Implant Practice US December 2017/January 2018 Vol 10, No 6 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews December 2017/January 2018 – Vol 10 No 6

Planning an anterior esthetic implant case with innovative technologies Dr. Riley Clark

Is peri-implant maintenance therapy important for preventing periimplant disease? Dr. Johan Hartshorne

Integration of CAD/ CAM, 3D imaging, 3D printing, and guided implant surgery to treat a traumatic dental injury in a surgical practice Dr. Jay B. Reznick

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INTRODUCTION

Raising the bar for dental implant training

Dec. 2017/Jan. 2018 - Volume 10 Number 6 EDITORIAL ADVISORS Steve Barter, BDS, MSurgDent RCS

hen it comes to implant dentistry, I share a common philosophy with many colleagues that each case should begin with the end in mind. Success for patients seeking implant restorations depends on our ability to provide long-term functional and esthetic results. Today, this is easier than ever before. Innovative tools such as digital imaging and cone beam computed tomography (CBCT) 3D imaging enable dental professionals to diagnose and treat cases with precision. Guided surgical techniques allow for predictable placement of implant fixtures in the ideal position for prosthetic restorations. Additional technologies continue to be introduced at a rapid pace; something once considered state-of-the art moves quickly toward becoming standard of care in dental implant practice. After more than 25 years in private practice, I welcome the many advances we enjoy as providers of dental implant surgery. It is indeed an exciting time for our profession. The successes we have enjoyed have resulted in increased public demand. Naturally, this has catalyzed an increase in the number of dental professionals who are hoping to expand the focus of their practice to include implant services. This growing number of implant dentists requires increased concern to ensure that they are well prepared to provide these expanded services. Comprehensive dental implant treatment requires a wide range of skills. These span the entire process — from being able to provide a comprehensive pre-op evaluation of patients to the actual ability to perform the surgical techniques that have been planned in each case. These techniques include the extraction of teeth, hard and soft tissue augmentation, and placement of dental implant fixtures. In addition, the surgeon must be prepared to address complications that arise both during the operation and in postoperative recovery — namely, the extraction of teeth, bleeding, sinus pathology, infection, swelling, implant failure, and many others. Because of the wide range of skills needed to provide comprehensive surgical implant services, many discussions revolve around whether only ADA-recognized dental specialists — i.e., oral and maxillofacial surgeons, periodontists, and prosthodontists — should perform dental implant surgery. These specializations involve multiple years of hospital-based residency training, which provides invaluable experience in both patient evaluation and surgery. Working with attending faculty staff, the resident doctors learn to treat complications and interact with interdisciplinary departments in all phases of patient care. As a result, dental specialists are able to provide the highest standards of care in the delivery of dental implant surgery. As demand continues to increase, it is important that all new practitioners are prepared to meet a similar standard. The need for surgical training through continuing education has never been higher. Fortunately, advanced dental implant surgical training programs for general dentists have dramatically increased. The restorative dental community has long shown expertise in the diagnosis, treatment planning, and restorative phases of implant dentistry. Through participation in CE courses and national and international dental implant organizations, restorative dentists are acquiring additional surgical expertise that allows them to provide treatment in their practices. For example, the American Board of Oral Implantology (ABOI) is a bona fide credentialing organization that evaluates the standards of appropriate knowledge and experience to credential dentists in implant dentistry. Implant fellowships ranging from 1 to 2 years also provide a much needed opportunity for dental school graduates to receive advanced dental implant and surgical training. This increase in training opportunities has resulted in a stronger team approach among all dental health providers. The time seems right for our professional community to work towards implementation of new forms of mandatory hands-on experience beyond dental school. One possibility would be for all dental school graduates to serve a 1-year general practice residency if not entering a specialty or fellowship program. Each graduate should have the opportunity to work with trained mentors to not only practice existing skills, but also develop additional ones to better prepare for private practice. In this way, each dental school graduate gets to begin with the end in mind — to launch a lifelong commitment to continuing dental education. Joseph A. Leonetti, DMD, received his dental degree from the Tufts University School of Dental Medicine in 1983 and completed his anesthesia fellowship at the Medical College of Pennsylvania in 1984. He then completed his oral surgery internship and residency in oral and maxillofacial surgery at New York University Hospital System in 1987. Dr. Leonetti is a Diplomate of the American Academy of Oral and Maxillofacial Surgeons (AAOMS), the American Board of Oral Implantology (ABOI), and the American Dental Society of Anesthesiology (ADSA). He is also a Fellow of the American Academy of Implant Dentistry (AAID) and the International Congress of Oral Implantology (ICOI). Dr. Leonetti currently is in private practice in Paoli, Pennsylvania.

2 Implant practice

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

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

ISSN number 2372-9058

Volume 10 Number 6

IMPLANTING CONFIDENCE

WORKFLOW INTEGRATION I HUMANIZED TECHNOLOGY I DIAGNOSTIC EXCELLENCE

With open-format image files, implant planning has never been easier. Carestream Dental’s digital imaging and implant planning software simplifies your workflow, allowing you to easily scan your patients and plan the implant placement. Plus, integration with third-party surgical guide software makes placing implants easier than ever.

For more information, call 800.944.6365 or visit carestreamdental.com

TABLE OF CONTENTS

Case study

Retreatment of a dissatisfied overdenture wearer while addressing implant angulation and location, using the LOCATOR R-TxÂŽ attachment system

Dr. Anthony Prudenti discusses rehabilitation of a patient with ill-fitting maxillary and mandibular implant-retained overdentures

Case study Integration of CAD/CAM, 3D imaging, 3D printing, and guided implant surgery to treat a traumatic dental injury in a surgical practice Dr. Jay B. Reznick expands treatment options and optimizes results with methodical treatment planning .......................................................16

Case study

Planning an anterior esthetic implant case with innovative technologies Dr. Riley Clark discusses improved workflow due to digital technologies and a skilled lab

12 ON THE COVER Cover photo courtesy of Dr. Riley Clark. Article begins on page 12.

4 Implant practice

Volume 10 Number 6

Neither is the anatomy of your implant patients

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

It’s time to challenge conventional thinking

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Conventional vs innovative approach

OUR WORLD IS NOT FLAT

TABLE OF CONTENTS

Continuing education Continuing education Maxillary split-crest technique with immediate implant placement

Is peri-implant maintenance therapy important for preventing peri-implant disease?

Dr. Johan Hartshorne considers some pressing questions in his critical appraisal of a systematic review by Monje, et al.

Drs. Amr Zahran and Basma Mostafa present a case report detailing how careful use of implants in juvenile patients can yield positive results

................................................. 30 PUBLISHER | Lisa Moler Email: lmoler@medmarkmedia.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkmedia.com NATIONAL SALES DIRECTOR | Kristin Sammarco Email: kristin@medmarkmedia.com

On the horizon Practice development SEO: Scam or critical marketing service? part 2 Ian McNickle, MBA, discusses strategies to rank highly on Google and other search engines.............. 38

Patient comfort is the key to a positive experience Dr. Justin Moody discusses the gain of no pain....................................40

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6 Implant practice

Volume 10 Number 6

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CASE STUDY

Retreatment of a dissatisfied overdenture wearer while addressing implant angulation and location, using the LOCATOR R-TxÂŽ attachment system Dr. Anthony Prudenti discusses rehabilitation of a patient with ill-fitting maxillary and mandibular implantretained overdentures Abstract The rehabilitation of failing implantretained overdentures can be challenging. Working with implants that are placed in a less than ideal position, having a limited amount of prosthetic space, worn-down retentive mechanisms, or old attachments with no replacement parts could render restoring these cases a difficult task. This article describes the use of the new Locator R-TxÂŽ attachment system to rehabilitate a patient with maxillary and mandibular implant-retained overdentures.

Figure 1A: Pretreatment occlusal view of the mandible

Figure 1B: Pretreatment occlusal view of the maxilla

Introduction There are functional, psychosocial, and anatomic advantages of implant-retained overdentures for completely edentulous patients.1 There is an enormous amount of evidence in the literature in favor of the implant overdenture retained by two implants in the mandible as the first choice of treatment.2-4 However, there is disagreement on the treatment of choice for the maxillary implant overdenture. There is also no agreement among researchers regarding the ultimate number of implants to be used in the maxilla to retain an overdenture.4-7 However, the distribution and the number of implants have shown to have an effect on the overdentureâ&#x20AC;&#x2122;s survival.8 Several authors9-12 discussed the importance of having implants that are evenly spaced and distributed in such a way as to provide an increased anterior-posterior spread (A-P spread) and help distribute the load favorably on the implants. Considerations for fulcrum or the axis of rotation created at attachment sites have also been discussed. This article Anthony Prudenti, DDS, MS, was a Prosthodontics Resident at University of North Carolina at Chapel Hill, School of Dentistry and is currently in private practice in Long Island, New York. Disclosure: Dr. Prudenti has no financial interests in and is not a consultant for any of the products mentioned in this article.

8 Implant practice

Figure 2A: Pretreatment panoramic radiograph

describes the use of the new Locator R-Tx attachment system to rehabilitate a patient who was not satisfied with her existing maxillary and mandibular implant-retained overdentures.

Clinical report

A highly motivated 67-year-old Caucasian female presented to the clinic for the evaluation of her ill-fitting complete maxillary and mandibular overdentures (Figures 1A and 1B). Her desires were to have complete dentures that were more stable and retentive, while maintaining a palate-less design.

The patient has been a denture wearer since she was in her teens. She was treated a few years ago in an attempt to convert her dentures to implant-retained overdentures. However, complications ensued, leaving her unsatisfied with the dental treatment she received. Radiographic evaluation and review of the dental history indicated that the patient received bilateral window sinus augmentation and maxillary implant placement in the area of the maxillary right and left first and second molars (Figure 2). Two custom-made cast gold bars, each supported by two Volume 10 Number 6

CASE STUDY

Figures 2B and 2C: Pretreatment radiographs

Figure 3: Occlusal view of the placement of the maxillary anterior implants

implants, retained her maxillary overdenture, while two Locator abutments retained her mandibular overdenture. Following several months of service, both of the gold bars broke due to the large anterior cantilevers, and her maxillary denture was converted to a Locator-retained overdenture. The patient reported that her maxillary overdenture quickly became loose and had been unstable in the largely unsupported anterior region. The maxillary implant distribution that had been designed was insufficient for denture retention and stability. Denture stomatitis of the soft tissue was present under the maxillary denture and was mostly associated with the ill-fitting denture, poor oral hygiene, and the patient not removing her denture. Upon evaluation with the existing dentures in place, the patient exhibited a reduced occlusal vertical dimension, altered speech, and less than ideal esthetics. The panoramic radiograph demonstrated no obvious pathology. There was evidence of bilateral maxillary sinus augmentation and osseointegrated implants in position of teeth Nos. 2, 3, 14, and 15. Implants were identified as Straumann® tissue level (Straumann®). Volume 10 Number 6

Figure 4: Frontal view of the placement of the Locator R-Tx abutments

The four maxillary and two mandibular heavily worn Locator abutments appeared completely seated. Cone beam computed tomography (CBCT) images revealed the knife-edge anterior maxillary ridge with insufficient volume of bone for implant placement. After discussions with the referring periodontist, treatment plans based on clinical findings and radiographic examination were proposed to the patient. She consented to treatment that included maxillary anterior guided bone regeneration (GBR) and placement of implants in positions Nos. 7 and 10, and the fabrication of new maxillary and mandibular implant-retained overdentures. The surgical phase of therapy completed by the periodontist consisted of guided bone regeneration procedures in the maxillary anterior sextant. A mixture of allograft (Puros®, Zimmer Biomet Dental) and xenograft particulate (Bio-Oss®, Geistlich) with a titanium mesh and collagen membrane was used to perform the graft in an attempt to augment the bone both horizontally and vertically. Following a healing period of 9 months, two OsseoSpeed EV implants 4.8 x 6 mm were placed in the areas of teeth

Nos. 7 and 10 (ASTRA TECH Implant System™ EV, Dentsply Sirona) (Figure 3). Following implant placement and osseointegration, the Locator R-Tx removable attachment system was chosen due to the angulation and orientation of the available maxillary implants. The abutments were selected according to the measured tissue heights and implant diameters, then placed on the implants with the use of a standard hex driver (0.050”/1.25 mm) and torqued as per the manufacturer’s recommendation (Figure 4). Final impressions were made for the fabrication of the maxillary and mandibular overdentures. The maxillary overdenture was fabricated initially with a full acrylic palate for ease of initial seating. Denture attachment housings were placed on the abutments, and the overdentures were relieved at the abutment-housing sites until passive seating was achieved. The housings were picked up in the dentures intraorally with the use of attachment processing material (CHAIRSIDE®, Zest Dental Solutions). The black processing inserts in both the maxillary and mandibular overdentures were removed and replaced Implant practice 9

CASE STUDY

Figure 5A: Intaglio surface of the maxillary overdenture after the pickup of the denture attachment housings and placement of inserts

with a combination of gray (zero retention) and blue (low retention) retentive inserts. Then the acrylic in the palate area was removed from the maxillary overdenture. At the 7-week post-insertion visit, the two blue inserts in the mandibular prosthesis were replaced with pink (medium retention) inserts at the patient’s request. Two of three gray inserts in the maxillary prosthesis were replaced with blue inserts, leaving one gray insert in the most offangled implant at site No. 10, and blue inserts at the remaining five implant sites. Adequate retention and patient comfort were obtained, while allowing the patient’s dexterous ability to properly place and remove the prostheses (Figures 5A-5D).

Discussion

Figure 5B: Intaglio surface of the mandibular overdenture after the pickup of the denture attachment housings and placement of inserts

The patient presented with four implants placed too close together in the posterior area of the maxilla, providing a very small A-P spread with a great anterior cantilever. This implant position made the patient’s old dentures unstable and non-retentive because of the unfavorable biomechanics. The patient maintained her desire for a maxillary prosthesis with an open palate. Given the large prosthetic space, an alternative treatment plan would have been the fabrication of custom-milled titanium bars to retain the maxillary overdenture. However, the close proximity of the maxillary implants would necessitate long cantilevers to accommodate the addition of retentive mechanisms to the bar. The patient was deterred from this bar treatment option due to her past negative experience with broken bars and also the associated higher prosthetic costs. In order to improve the A-P spread and stabilize the prosthesis with a palate-less

design, the decision was made to place two implants anteriorly. The guided bone regeneration procedure in the maxillary anterior sextant provided limited available bone volume after bone grafting and dictated the resulting implant positions, which were less than ideal. The buccal inclination of the anterior implants created a divergence between the anterior and the posterior implants, narrowing the choice of individual retentive mechanisms that could be used in order to obtain a path of insertion for the maxillary prosthesis. The Locator R-Tx removable attachment system was selected because of the pivoting capability that allows it to be used with nonparallel implants. In this particular case, given the posterior position of the implants and the patient’s limited dexterity, it would have been difficult for the patient to maintain adequate hygiene with bar attachments, hence the choice of individual retentive mechanisms. In addition, the author believes that the simplicity of this treatment solution will be beneficial for the longevity of the overdenture prosthetic care, along with the simplified patient access for hygiene. IP REFERENCES 1. Koka S, Baba N, Ma SY. The Benefits of implant overdentures. In: Goodacre CJ, Naylor WP, eds. Implant Overdentures: From Diagnosis to Maintenance. Version 1.0, 2016, published by FOR.org http://www.for.org/. Accessed November 22, 2017. 2. Feine JS, Carlsson GE, Awad MA, et al. The McGill Consensus Statement on Overdentures. Montreal, Quebec, Canada. May 24-25, 2002. Int J Prosthodont. 2002;15(4):413-414. 3. Thomason JM, Feine J, Exley C, et al. Mandibular two implant-supported overdentures as the first choice standard of care for edentulous patients — the York Consensus Statement. Br Dent J. 2009;207(4):185-186. 4. Roccuzzo M, Bonino F, Gaudioso L, Zwahlen M, Meijer HJ. What is the optimal number of implants for removable reconstructions? A systematic review on implant-supported overdentures. Clin Oral Implants Res. 2012;23(suppl 6):229-237. 5. Slot W, Raghoebar GM, Vissink A, Meijer HJ. A comparison between 4 and 6 implants in the maxillary posterior region to support an overdenture; 1-year results from a randomized controlled trial. Clin Oral Implants Res. 2014;25(5):560-566. 6. Raghoebar GM, Meijer HJ, Slot W, Slater JJ, Vissink A. A systematic review of implant-supported overdentures in the edentulous maxilla, compared to the mandible: how many implants? Eur J Oral Implantol. 2014;7(suppl 2):S191-S201. 7. Roccuzzo M, Bonino F, Gaudioso L, Zwahlen M, Meijer HJ. What is the optimal number of implants for removable reconstructions? A systematic review on implant-supported overdentures. Clin Oral Implants Res. 2012;23(suppl 6):229-237. 8.

Şahin S, Cehreli MC, Yalçın E. The influence of functional forces on the biomechanics of implant-supported prostheses — a review. J Dent. 2002;30(7-8):271-282.

9. Mericske-Stern RD, Taylor TD, Belser U. Management of the edentulous patient. Clin Oral Implants Res. 2000;11(suppl 1):108-125. 10. Benzing UR, Gall H, Weber H. Biomechanical aspects of two different implant-prosthetic concepts for edentulous maxillae. Int J Oral Maxillofac Implants. 1995;10(2):188-198. 11. Kiener P, Oetterli M, Mericske E, Mericske-Stern R. Effectiveness of maxillary overdentures supported by implants: maintenance and prosthetic complications. Int J Prosthodont. 2001;14(2):133-140.

Figures 5C and 5D: Frontal view of patient smile 10 Implant practice

12. Lee DJ. Performance of attachments used in implantsupported overdentures: review of trends in the literature. J Periodontal Implant Sci. 2013;43(1):12-17.

Volume 10 Number 6

light years beyond ‘frozen peas’ ®

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.

CASE STUDY

Planning an anterior esthetic implant case with innovative technologies Dr. Riley Clark discusses improved workflow due to digital technologies and a skilled lab

hen patients opt for implant-supported prosthetic rehabilitation, their questions focus most frequently on prosthetic implications, not the implant surgery. Questions arise, such as: “Am I going to leave surgery with teeth? What will the teeth look like? How will the teeth function?” Fortunately, a digital workflow allows implantologists to give patients not only predictable surgical outcomes but also a familiar temporary on the day of surgery. With today’s technology and with a good lab, the implant dentist can not only plan the ideal implant position relative to osseous boundaries but also complement those implants with milled abutments and provisionals. Perhaps the most compelling aspect is that these processes can occur days before the surgery even happens. Nothing highlights this technology and its potential better than an anterior esthetic case as will be demonstrated in this review. A 44-year-old male presented with complaints of pain and pressure around an existing bridge from teeth Nos. 6-10. The patient received recommendations from colleagues to seek out treatment at WhiteCap Institute due to its capabilities in using technology to plan for immediate placement of dental implants and provisional crowns. After a clinical exam, decay was found on tooth No. 6, which was supporting the bridge. The tooth would need to be extracted. The

Figure 1: CS 8100 3D 8x9 FOV at 150µ

patient worked in a highly visible position and was hesitant to settle for teeth that weren’t perfect and did not like the idea of a long span bridge involving more abutment teeth. He opted for an implant-supported bridge using three implants. A CBCT scan was captured with a CS 8100 3D system (Carestream Dental) (Figure 1), and a digital impression was taken with a CS 3600 intraoral scanner (Carestream Dental) (Figure 2). The patient’s CBCT (DICOM) file was merged with the STL file produced by the CS 3600 using Carestream Dental’s Prosthetic-Driven Implant Planning module (Figures 3-4).

Figure 2: Digital impression taken with a CS 3600 intraoral scanner

Riley Clark, DMD, completed his bachelor’s degree in biological sciences at Portland State University and then moved to Cleveland, Ohio, for his DMD program at Case Western Reserve University. Shortly after graduation, he attended advanced training in anesthesia. Professionally, Dr. Clark takes great pride in optimizing clinical efficiencies and digital workflows. He spends the majority of his time in private practice doing full-mouth dental implant rehab. He also teaches and mentors at WhiteCap Institute. He acts as a consultant to WhiteCap Dental Lab and Milling, where he focuses on full-mouth treatment sequencing and digital workflows in preoperative procedures and final restorative procedures. Dr. Clark is passionate about dentistry and transforming patients’ lives through their smiles with dental implants. Disclosure: Dr. Clark is a key opinion leader for Carestream Dental.

Figure 3 12 Implant practice

Figure 4 Volume 10 Number 6

CASE STUDY

The implant position was then digitally planned (Figures 5-6). These files were exported to WhiteCap Dental Lab and Milling, which utilizes 360imaging® software to plan and fabricate surgical guides (Figure 7). Implant locations are shown through the simulated surgical planning software (Figures 8-9). This data was merged with prosthetic planning software (exocad) (Figure 10) from which an immediate fixed provisional bridge was designed (Figures 11-12). The interface of these technologies allows not only precise implant placement planning, but also the fabrication of capable and esthetic temporaries.

Figure 5

Figure 6

Treatment On the day of the surgery, blood was drawn and processed following the Endoret® (prgf®) protocol (BTI®). An IV line was placed, and the patient sedated to a light/moderate level; 4% Septocaine® 1:100k epi was administered to the anterior maxilla for local anesthesia. The first task was to section the bridge between teeth Nos. 6 and 7 and then between teeth Nos. 7 and 10. Abutment teeth Nos. 6, 7, and 10 were extracted following an atraumatic protocol in order to preserve the buccal plate and other periodontal tissues. The lateral incisors were extracted quickly and uneventfully. However, tooth No. 6 needed to be sectioned to remove it with minimal pressure and trauma to its supporting structures (Figure 13). The sectioning of single-rooted teeth is helpful for atraumatic exodontia when traditional

Figure 8

Figure 10 Volume 10 Number 6

Figure 7

Figure 9

Figure 11

Figure 12 Implant practice 13

CASE STUDY

Figure 13

Figure 14

Figure 15

Figure 16

Figure 17

Figure 18

Figure 19

methods prove fruitless. A small periapical cyst was discovered on tooth No. 7. A fair amount of time was spent between irrigation and manual/rotary debridement to remove any cystic remnants. Often a rotary instrument, such as a Lindemann bur, at the apical end of the extraction is the best approach for apical debridement. At that point, the surgical guide was placed, and proper fit was confirmed (Figure 14). A fixation pin in the anterior portion was placed to add extra stability to the guide during drilling. The designated drilling sequence was followed with a special focus to not oversize the osteotomy. Immediate placement of implants requires distinct attention during drilling to achieve primary stability. Without initial stability, the implants would have needed to follow a two-stage protocol, and no fixed temporary could have been indicated the day of surgery. After the osteotomy drilling, the surgical guide was removed, and a 50/50 mixture of bovine bone and cadaver bone that had been embedded in the PRGF mixture was placed into the extraction areas, mainly against the 14 Implant practice

Figure 20

Figure 21

buccal plate. Then the surgical guide was seated, and the three implants were placed through the surgical guide using a special mount to ensure proper position within the guide (Figure 15). Initial stability was achieved on every implant. The surgical guide was removed, and supplemental bone grafting was performed where needed. Tooth No. 10 had a special task Figure 22 to ensure that the rotational component of the implant was ideal for a 17ยบ multi-angled abutment. The abutment fibrin membranes were placed around the was tried in; the angle was slightly off, so temporary abutments. the implant was rotated 10ยบ to 15ยบ; and the A luting agent was used to adhere the abutment was tried in again (Figure 16). The PMMA bridge to the abutments. Small new angle fit the profile we were hoping to holes and voids were filled in. The occluachieve. Lab-prepped temporary cylinders sion was checked and the bite adjusted to were placed direct to implants on teeth Nos. avoid anterior collision with the temporary 6 and 7. No. 10 cylinder was placed on the (Figures 19-21). multi-unit abutment following the corrected The out-of-town patient returned the 17ยบ angle, maximizing parallelism between following day for a post-op visit to check all abutments (Figure 17). bite and initial patient response (Figure 22). At that point, it was confirmed that After 3 months of healing, the patient the PMMA temporary could fit passively will return to have another digital impression over all three abutments (Figure 18). After taken with the CS 3600 for the restorative confirming a good fit and occlusion, PRGF phase. IP Volume 10 Number 6

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CASE STUDY

Integration of CAD/CAM, 3D imaging, 3D printing, and guided implant surgery to treat a traumatic dental injury in a surgical practice Dr. Jay B. Reznick expands treatment options and optimizes results with methodical treatment planning

he clinical practice of dentistry has changed significantly in the past 10 years due to the advances in digital technology. These changes not only have influenced change in restorative dentistry, but also have changed how things are done in surgical practice. A patient may present with multiple injuries and problems requiring treatment following a traumatic incident. By utilizing digital imaging and CAD/ CAM, treatment options can be more easily evaluated to determine the one that will optimize results.

Case report An otherwise healthy 40-year-old woman was involved in a rear-end motor vehicle accident on a Sunday afternoon. The air bags did not deploy. She flew forward; and despite wearing a seatbelt and shoulder restraint, her face hit the steering wheel. There was no loss of consciousness. She was seen in the office the following morning Jay B. Reznick, DMD, MD, was one of the first North American adopters of fully guided, prosthetically based implant surgery and was the first specialist in the United States to integrate CBCT and CAD/ CAM in his practice. He has taught dentists about basic and advanced implant dentistry, surgery, and 3D digital technology for the last 2 decades. Dr. Reznick has published extensively in the dental and medical literature, and founded the educational website OnlineOralSurgery.com. He lectures frequently at dental meetings and educational conferences, as well as teaches live training courses to dentists from all over the world. Dr. Reznick is a Diplomate of the American Board of Oral and Maxillofacial Surgery. He received his undergraduate Biology degree from CAL-Berkeley, Dental degree from Tufts University, and his MD degree from the University of Southern California. He did his internship in General Surgery at Huntington Memorial Hospital in Pasadena and trained in Oral and Maxillofacial Surgery at LA County + USC Medical Center. Dr. Reznick is also a consultant to a number of manufacturers and suppliers of dental and surgical instruments and equipment, and is on the editorial advisory boards of a number of dental journals. He is the Director of the Southern California Center for Oral and Facial Surgery in Tarzana, California. Disclosure: Dr. Reznick is a consultant and key opinion leader for Dentsply Sirona.

16 Implant practice

Figure 1: At initial presentation, the patient was found to have palatal displacement of the maxillary central incisors, as well as loss of tooth No. 7

Figure 2: A cone beam CT scan demonstrated avulsion of tooth No. 7 and a dentoalveolar fracture associated with the maxillary central incisors

for examination. The impact resulted in the avulsion of the maxillary right lateral incisor and palatal displacement of the two maxillary central incisors with fracture of the facial alveolar bone (Figure 1). The two central incisors were mobile and exquisitely tender and

were in crossbite. Other than a few bruises and scrapes, her clinical exam was unremarkable. In order to make a clinical decision regarding treatment options, we needed to have accurate information to guide us. Three-dimensional cone beam CT (CBCT) Volume 10 Number 6

Volume 10 Number 6

CASE STUDY

imaging allows us to evaluate the patient’s skeletal and dental anatomy, spatial relationships, and the extent of injury or pathology. Utilizing this technology, it was evident that tooth No. 7 had been completely avulsed, with no residual root fragments remaining. The alveolar bone on the facial aspect of teeth Nos. 7 through 9 had also been fractured by the force of the impact against these teeth (Figure 2). The treatment plan required reduction of the displaced teeth with splinting to allow the dentoalveolar fractures to heal and replacement of the avulsed tooth. Ideally, we would like to replace the lost lateral incisor as soon after the injury as possible. We know that for maintenance of the alveolar ridge, soft tissue contours, and interdental papillae, there is no better material than a dental implant along with a bone graft placed between the fixture and alveolar bone.1,2 The soft tissue outcome is further improved if a provisional restoration can be placed at the time of fixture placement.2,3 In order to plan for implant placement, there needs to be a blueprint. Following the principles of “prosthetically driven” implant planning, the ideal final prosthesis is designed, and then the implant fixture position is determined. The bony and soft tissue anatomy is assessed, and if there is a need for augmentation or modification, it is determined at the planning stages, rather than at surgery. Ordinarily, when a plan is being developed to replace a missing tooth, the arch form of the adjacent teeth can be used as a reference to design the ideal final prosthesis. In this case, the adjacent central incisors had been traumatically displaced, and if used for determining arch form, the crown of the right maxillary lateral incisor would be incorrectly positioned. In addition, taking standard dental impressions was not practical in this case due to patient discomfort. In order to manage all these challenges, a fully digital workflow is ideal. We began by obtaining an optical impression of the patient’s maxillary dental arch, using a CEREC® Omnicam (Dentsply Sirona). Because the patient was unable to bring her teeth into occlusion, the mandibular arch image and digital bite relationship were not recorded. In the CEREC software, a prosthetic proposal was developed, guided by the ideal position of the final restoration, which will be finalized 4 months after implant placement (Figure 3). Since the maxillary central incisors were in crossbite due to the recent trauma, they were “mentally repositioned” to represent the true dental arch form in order to plan the proposed prosthesis for the missing lateral incisor.

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Implant practice 17

CASE STUDY The optical impression and digital prosthetic proposal were then exported using an integration file. In GALILEOSÂŽ Implant software (Dentsply Sirona), the optical impression and proposal were imported and then superimposed over the cone beam CT image. Using the digitally proposed final restoration as the blueprint for the final prosthetic result, the ideal position, angulation, and depth for the implant fixture were determined (Figure 4). From this image, it could be seen that about half of the apical dimension of the fixture would be located in solid alveolar bone, allowing for good primary mechanical stabilization. However, because of the fracture of the facial alveolar plate, a decision was made to delay placement of a prosthesis until the implant had fully osseointegrated at about 16 weeks after fixture placement. It is essential to use 3D imaging not only for implant planning, but also for placing the implant fixture as precisely and accurately as possible. This is especially true in the anterior esthetic zone. In order to accomplish this objective, the technique of fully guided surgery was utilized. With this workflow, a surgical guide is created from the planning software. Depending on the case, the guide may be milled or 3D-printed. Critical to the success of this guide is a channel into which a metal guide sleeve, or tube,

is inserted. The guide tube is specific for the particular implant system being used. For implant systems that are fully guided, a specific drilling system is used. Within that system are drills and drill guides that are designed to fit within the drill tubes in the surgical guide. This sleeve-in-a-sleeve technique allows for precise control of the position, angulation, and depth of each osteotomy and of the implant placed.

Figure 3: An optical impression was obtained and used to create a digital proposal for the final restoration. This is used to plan the ideal implant placement

Figure 4: The Planning Report shows the planned implant placement based on the prosthetic plan

Figure 6: The stereolithographic (STL) file was as loaded into the 3D printer to fabricate the surgical guide 18 Implant practice

In this particular case, an Astra Tech Implant Systemâ&#x201E;˘ EV 3.6 mm x 15 mm straight-walled fixture was selected in order to maximize primary mechanical stability into the traumatized site. The EV-guided surgery system uses a sleeve, which fits directly on the drill (sleeve-on-drill), thus eliminating the need to use a drill key (aka handle, drill guide, spoon) (Figure 5). Following the consultation appointment, the treatment plan, based

Figure 5: Closeup view of the Astra Tech Implant System EV-guided surgery kit, showing the sleeve-on-drill concept

Figure 7: The completed surgical guide that contains the master tube, which is specific for the implant system being used Volume 10 Number 6

CASE STUDY on the final prosthetic result, was finalized, and the treatment plan and optical scan were uploaded to SICAT (Dentsply Sirona; Bonn, Germany). Approximately 18 hours later, a printable stereolithographic file for the surgical guide was available (Figure 6). This was remotely sent to a 3D printer (CELRobox), and printing of the surgical guide was begun. Once the surgical guide printing had been completed, the build platform was removed, the surface smoothed and polished, and the guide tube was inserted, making the guide ready to use (Figure 7). The patient presented for surgery on Tuesday morning, less than 24 hours after initial consultation, examination, and treatment planning. The site of the avulsed tooth was debrided and irrigated, and then the implant surgical guide, which had been produced from all digital data at the time of initial examination, was used to prepare the osteotomy and to place the implant fixture into the planned site at the proper angle and depth for ideal restoration (Figure 8). Once the implant had been delivered, a cover screw was placed, and allogeneic freeze-dried calcified cancellous bone powder (SymbiosÂŽ, Dentsply Sirona) was placed between the fixture and socket walls, and into the facial bony defect. A collagen barrier was sutured over the implant and graft, and then stabilized with sterile cyanoacrylate tissue glue (PeriAcrylÂŽ, Glustitch). The displaced maxillary central incisors were then reduced into their correct anatomical position, which was verified by bringing the patientâ&#x20AC;&#x2122;s teeth into full occlusion. The teeth and surrounding fractured alveolar bone were stabilized using an Erich arch bar, which went from the maxillary right first premolar to the left canine, using 26 gauge stainless steel wire (Figure 9). Finally, maxillary and mandibular polyvinyl siloxane (PVS) impressions were taken of both arches to allow the lab to fabricate a removable prosthesis for the missing lateral incisor. This was able to be quickly fabricated, so that the patient was able to leave the office with the provisional appliance in place. A postoperative panoramic radiograph was taken in addition to periapical images of the central incisors (Figure 10). The implant placement was as planned, and the incisors were well situated in their sockets. The patient was seen for periodic followup, and at 6 weeks, the arch bar was removed. The surgical sites healed well, and the central incisors remained asymptomatic. Radiographically, there was no change in this region (Figure 11). At approximately 16 weeks after surgery, second-stage surgery 20 Implant practice

Figure 8: The position of the master tube in the surgical guide controls the position, angulation, and depth of each osteotomy and fixture placement

Figure 9: An Erich arch bar with circumdental 26 gauge stainless steel ligatures was used to stabilize the displaced dentoalveolar segment

Figures 10 and 11: 10. At the 6-week follow-up visit, the displaced teeth showed no significant periapical changes and remained asymptomatic. 11. At 14 weeks, the implant was osseointegrated, and the displaced teeth were stable and asymptomatic Volume 10 Number 6

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CASE STUDY

Figure 12: The implant was exposed at 16 weeks using a papilla-sparing crestal incision, and the flap was repositioned against the healing abutment

Figure 13: Two weeks after exposure, the patient was referred to her general dentist for prosthetic restoration of the implant

was performed to remove the implant cover screw and to place a transgingival healing abutment. A papilla-preserving crestal incision was made at the lateral incisor site (Figure 12). The central incisors continued to remain stable and symptomatic. Once the incision had healed, the patient was then referred to her general dentist for prosthetic restoration of the implant (Figure 13).

Discussion In this case, we were able to, by utilizing a fully digital workflow, replace a traumatically avulsed maxillary lateral incisor tooth 22 Implant practice

with a dental implant less than 48 hours after injury. The final prosthetic plan was developed, and this digital blueprint was used to determine the ideal implant position. Using a custom surgical guide and fully guided technique, the implant fixture was placed exactly as planned in order facilitate ideal prosthetic restoration. Prior to this technology being available, dental implant placement would have been performed using a freehand technique, with the final result being dependent on the experience and skill of the surgeon. Studies have shown that the occlusal

implant position can be off as much as 3.0 mm laterally and 9.9º in angulation from the planned position.4 This can lead to aberrant fixture placement, which could lead to the implant being placed too far facially or at an angle that complicates restoration. Even very experienced surgeons placing implants freehand cannot compare with the accuracy of guided surgery.5 One of the major impediments to the widespread acceptance of guided surgery for immediate implant placement has been the turnaround time between treatment planning and surgical guide availability, which has typically been anywhere from 1 to 3 weeks, depending on the software and laboratory being used. This is usually not acceptable when a patient presents with an acute problem, such as a fractured maxillary incisor, which requires removal and replacement. Therefore, most surgeons still prefer freehand implant placement in this situation, rather than delay treatment. Utilizing digital technology, we were able to treat this patient very predictably and successfully in a time-sensitive manner. Because the variables of ridge volume and anatomy were known prior to surgery, the treatment plan did not need to be modified during the procedure, and the implant was placed in the ideal location for restoration. Through methodical treatment planning, using all the data available, we were able to sequence the implant placement, reduce the fracture with stabilization, and fabricate a provisional prosthesis while making efficient use of our surgical time and providing optimal patient care. IP

REFERENCES 1. Tarnow DP, Chu SJ, Salama MA, et al. Flapless postextraction socket implant placement in the esthetic zone: part 1. The effect of bone grafting and/or provisional restoration on facial-palatal ridge dimension — a retrospective cohort study. Int J Peridontics Restorative Dent. 2014;34(3):323-331. 2. Cooper LF, Reside GJ, Raes F, et al. Immediate provisionalization of dental implants placed in healed alveolar ridges and extraction sockets: a 5-year prospective evaluation. Int J Oral Maxillofac Implants. 2014;29(3):709-717. 3. Chu SJ, Salama MA, Garber DA, et al. Flapless postextraction socket implant placement, part 2: The effects of bone grafting and provisional restoration on the peri-implant soft tissue height and thickness — a retrospective study. Int J Peridontics Restorative Dent. 2016;35(6):803-809. 4. Vercruyssen M, Cox C, Coucke W, Naert I, Jacobs R, Quirynen M. A randomized clinical trial comparing guided im plant surgery (bone- or mucosa-supported) with mental navigation or the use of a pilot-drill template. J Clin Periodontol. 2014;(7):717-723. 5. Vermeulen J.. The accuracy of implant placement by experienced surgeons: guided vs freehand approach in a simulated plastic model. Int J Oral Maxillofac Implants. 2017; 32(3):617–624.

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Planning an anterior esthetic implant case with innovative technologies Dr. Riley Clark

Is peri-implant maintenance therapy important for preventing periimplant disease? Dr. Johan Hartshorne

Integration of CAD/ CAM, 3D imaging, 3D printing, and guided implant surgery to treat a traumatic dental injury in a surgical practice Dr. Jay B. Reznick

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CONTINUING EDUCATION

Is peri-implant maintenance therapy important for preventing peri-implant disease? Dr. Johan Hartshorne considers some pressing questions in his critical appraisal of a systematic review by Monje, et al.

his article aims to provide a critical appraisal of a systematic review: Monje A, Aranda L, Diaz KT, Alarcón MA, Bagramian RA, Wang HL, Catena A. Impact of maintenance therapy for the prevention of periimplant diseases: a systematic review and meta-analysis. J Dent Res. 2016;95(4):372-379. The research originated from the Department of Periodontics and Oral Medicine at the University of Michigan’s School of Dentistry, based in Ann Arbor, Michigan.

Summary This systematic review concluded, within its limitations, that implant therapy must not be limited to the placement and restoration of dental implants, but also the implementation of peri-implant maintenance therapy (PIMT) to potentially prevent biologic complications and hence to increase the long-term success rate. Although it must be tailored to a patient’s risk profiling, the findings suggest reason to claim a minimum recall PIMT interval of 5 to 6 months. Additionally, it must be stressed that even with the establishment of PIMT, biologic complications might still occur. Thus, patient-, clinical-, and implant-related factors must be thoroughly explored.

Educational aims and objectives

This article aims to discuss Monje, et al.’s (2016) systematic review and meta-analysis of the impact of maintenance therapy on the prevention of peri-implant diseases.

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: •

Realize the outcomes and conclusions of this systematic review.

•

Recognize the clinical implications for patients considering implant therapy.

•

Identify some biological complications of peri-implant mucositis and peri-implantitis.

•

Realize the importance of implementation of peri-implant maintenance therapy (PIMT) to prevent potential biologic complications and increase the long-term success rate.

•

Identify some patient-, clinical- (surgical and restorative), and implant-related risk factors that should be considered to increase the long-term success rate of implants.

Critical appraisal conclusion Within the limitations of the present systematic review, the results suggest that regular PIMT reduces the rate of peri-implant mucositis and peri-implantitis, and that 5 to Johan Hartshorne, BSc, BChD, MChD, MPA, PhD (Stell), FFPH.RCP (UK), is visiting professor at the department of periodontics and oral medicine, University of Pretoria, South Africa. Disclosure and disclaimer: Dr. Johan Hartshorne is trained in clinical epidemiology, biostatistics, research methodology, and critical appraisal of research evidence. This critical appraisal is not intended to, and does not, express, imply, or summarize standards of care, but rather provide a concise reference point for dentists to aid in understanding and applying research evidence from referenced early view or prepublished articles in top-ranking scientific publications and to facilitate clinically sound decisions as guided by their clinical judgment and by patient needs.

24 Implant practice

6 months should be considered a minimum recall interval for PIMT to prevent peri-implant disease. The findings also show that a history of periodontitis significantly increased the incidence of peri-implant disease and suggested more stringent follow-up maintenance at shorter intervals. In addition, patient-, clinical- (surgical and restorative), and implant-related risk factors must be thoroughly considered to potentially prevent biologic complications and hence increase the long-term success rate of implants. Although the results presented in this review are considered as low-level evidence, it has given us a better understanding of the importance of regular preventive care

in preventing biological complications and increasing the longevity of implant restorations.

Implications for clinical practice This review holds a number of implications for clinical practice. It suggests that patients considering implant therapy should be adequately informed of the following: • Risks for peri-implant disease • Importance of maintaining proper oral hygiene • Need for long-term regular follow-up and professional maintenance care • Need to identify early signs of the disease and to develop preventive treatment strategies, particularly for those at high risk. Volume 10 Number 6

Clinical question What is the impact of PIMT upon the incidence of biologic complications (such as mucositis and peri-implantitis)?

Review methodology This review methodology was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines (Moher, et al., 2009). Volume 10 Number 6

Although the results presented in this review are considered as low-level evidence, it has given us a better understanding of the importance of regular preventive care.

The Newcastle-Ottawa Scale (NOS) (Wells, et al., 2011) was used to evaluate the methodological quality of non-randomized trials included studies. Electronic and manual literature searches were conducted by three independent reviewers in several databases, including Medline, Embase, the Cochrane Central Register of Controlled Trials, and Cochrane Oral Health Group databases for articles published up to June 2015 without language restriction. Electronic screening of the gray literature was conducted according to the Assessment of Multiple Systematic Reviews (AMSTAR) guidelines (Shea, et al., 2009). Additionally, a manual search of periodontics-related journals was done. Randomized or non-randomized clinical trials, prospective, or retrospective cohort studies or case series studies involving humans with a sample size of at least 10 subjects and a minimum follow-up time of 6 months were eligible. Implants had to meet the criteria of rough surface, with or without a smooth surface collar. Studies included in the meta-analysis had to give a clear description of PIMT intervals and biologic complications. Participants in the studies were patients with mandibular and/or maxillary complete or partially edentulous healthy subjects in need of dental implants to restore oral function. The test group were subjects receiving PIMT at regular recall intervals after implant placement for treatment of peri-implant disease. The control group received no regular PIMT or a longer interval compared to the test group. The primary outcomes measured were the incidence of peri-implant mucositis and peri-implantitis at implant and patient level. Secondary outcomes measured were implant survival and implant failure rates. Three reviewers independently screened and extracted the data from studies. In case of disagreement, consensus was reached by

discussion with a fourth reviewer. In case of unclear data, authors were contacted to provide the data. A multivariate negative binomial regression was used to examine potential effects of PIMT on the incidence of peri-implant disease, implant success and failure rates.

Main results Thirteen clinical trials were included in the qualitative analysis and 10 clinical trials in the quantitative analysis. Implant level For mucositis, a history of periodontal disease showed negative effects (z = -8.12, P < 0.001; lower mucositis with larger number of patients with history of periodontitis). Moreover, PIMT interval was shown to significantly influence the incidence of mucositis at this level (z = 8.64, P < 0.001). Significant effects of treatment (z = -19.04, P < 0.001), history of periodontitis (z = -14.64, P < 0.001; increased periimplantitis with larger number of patients with history of periodontitis), and mean PIMT (z = -29.31, P < 0.001) were obtained for periimplantitis. Additionally, a significant effect was found for the intervals of PIMT on the incidence of peri-implantitis at this level (z = -5.26, P < 0.001). Patient level For mucositis, there were significant effects of treatment (z = -14.36, P < 0.001), history of periodontitis (z = -5.83, P < 0.001; lower mucositis with larger number of periodontal disease patients), and mean PIMT interval (z = -21.07, P < 0.001; lower periimplantitis with larger interval). PIMT range did show an influence on mucositis at this level (z = -3.07, P = 0.002). For peri-implantitis, the same negative binomial model was applied. Significant effects of treatment (z = -16.63, P < 0.001), history of periodontal disease (z = 3.79, P < 0.001; increased Implant practice 25

CONTINUING EDUCATION

The review makes a number of other points, going on to state that preventing peri-implant disease and that maintaining the peri-implant tissues in health is the responsibility of both the patient and the dental team. Preventive care should be aimed at eliminating bacterial plaque through meticulous oral hygiene practices and professional mechanical debridement. Modifiable risk factors, such as periodontitis, uncontrolled diabetes, and smoking should be managed before implant placement. Patients with a high-risk profile should be followed up at more frequent intervals to monitor and maintain peri-implant tissue health. Implant position, design, and the placement of prosthetic superstructures should be planned so that they will facilitate proper personal cleaning and professional monitoring and maintenance therapy. Clinicians placing implants should ensure that there is adequate attached and unmovable keratinized soft tissue surrounding the implant to facilitate peri-implant health. Establishing a radiographic baseline at the time of implant placement is key to monitoring peri-implant bone stability. Prosthetic components and superstructures should fit properly to avoid microgaps for biofilm adherence and excess cement at submucosal restorative margins. Implant position, design, and placement of prosthetic superstructures should be planned so that they will facilitate proper personal cleaning and professional monitoring and maintenance therapy. Establishing a clinical (periodontal probing) and radiographic baseline at final prosthesis placement is key to early diagnosis and proper intervention of periimplant inflammation. Debridement of the implant-supported restoration must be directed at three components: the prosthesis, the abutment, and the implant fixture, should its surface become exposed to the oral cavity.

CONTINUING EDUCATION peri-implantitis with larger number of patients with history of periodontal disease), and mean PIMT (z = -3.94, P < 0.001) were observed. In addition, PIMT interval demonstrated a significant effect on the incidence of periimplantitis at this level (z = -26.51, P < 0.001). Mean PIMT had a statistically significant effect on implant survival rate (z = -7.88, P < 0.001) and implant failure rate (z = -30.59, P = 0.001). PIMT interval significantly influenced the incidence of mucositis (at implant level only) (z = 8.64, P < 0.001) and periimplantitis (z = -5.26, P < 0.001). History of periodontitis also showed a statistically significant effect on implant failure rate (z = 38.03, P < 0.001). Results suggest that 5 to 6 months is a reasonable interval for PIMT.

Conclusion Within the limitations of the present systematic review, it can be concluded that implant therapy must not be limited to the placement and restoration of dental implants, but to the implementation of PIMT as well in order to potentially prevent biologic complications and hence heighten the long-term success rate. Although implant treatment must be tailored to a patient’s risk profiling, the findings suggest reason to claim a minimum recall PIMT interval of 5 to 6 months. Additionally, it must be stressed that even in the establishment of PIMT, biologic complications might occur. Hence, patient-, clinical-, and implant-related factors must be thoroughly explored. The authors declared that no funding, either directly or indirectly, was provided for the elaboration of this study nor was there potential conflict of interest with respect to the authorship and/or publication of this review.

Commentary Background and importance Peri-implant soft tissue healing and health differs significantly from that of natural teeth. Key characteristics of peri-implant soft tissues are deeper probing depth, weaker connective tissue attachment, reduced vascular supply, and more pronounced inflammatory tissue response, making the implant more vulnerable to bacterial accumulations and other external stimulations (Belibasakis, 2014; Wang, et al., 2015). Biological complications of peri-implant 26 Implant practice

The findings show that a history of periodontitis significantly increases the incidence of peri-implant disease.

tissues — namely, peri-implant mucositis and peri-implantitis — are a frequently encountered problem, characterized by the inflammatory destruction of the tissues surrounding the implant as a result of biofilm formation on the prosthesis, the abutment, and the implant fixture, should its surface become exposed to the oral cavity (Belibasakis 2014). Microbial colonization in the form of dental plaque biofilms and the host inflammatory response in the periimplant tissues have been considered as the critical etiological factors for the development of peri-implant diseases (Mombelli and Lang, 1998). However, several other etiological factors and risk indicators, such as a history of periodontitis, excess cement, smoking, diabetes, absence of keratinized mucosa, implant characteristics, and occlusal overload could also increase the incidence of peri-implant diseases (Figuero, et al., 2014). The diagnostic criteria for peri-implant diseases are mainly clinical and radiographic (Mombelli and Lang, 1998). Peri-implant mucositis is a reversible inflammatory process characterized by inflamed or erythematous peri-implant mucosa and bleeding with probing with no evidence of loss of the supporting bone (Mombelli and Lang, 1998; Heitz-Mayfield and Lang, 2010). Peri-implantitis, on the other hand, is characterized by both soft tissue inflammation and progressive loss of supporting bone leading to the formation of a peri-implant pocket (of greater than 5 mm), bleeding or suppuration on probing, and, radiographically, a characteristic symmetrical “saucershaped” bone destruction (or “crater”) around the implant (Mombelli and Lang, 1998; Heitz-Mayfield and Lang, 2010). Peri-implant diseases are common following implant therapy (Atieh, et al., 2013). Recent systematic reviews estimate that the frequency of peri-implant mucositis was 63.4% of participants and 30.7% of implants, and that of peri-implantitis were 18.8% of

participants and 9.6% of implants. A higher frequency (36.3%) of occurrence of periimplant diseases was recorded for smokers (Atieh, et al., 2013). Another meta-analysis estimated a weighted mean prevalence of peri-implant mucositis and peri-implantitis of 43% (CI: 32%-54%) and 22% (CI: 14%-30%), respectively (Derks and Tomasi, 2015). Emerging evidence shows that there is an increased risk for conversion of peri-implant mucositis to peri-implantitis in undiagnosed patients or in patients who are not receiving supportive therapy (Costa, et al., 2012). A recent study suggested that periimplantitis is a common condition and that several patient- and implant-related factors influence the risk for moderate/severe periimplantitis (Derks, et al, 2016). Peri-implantitis is a progressive chronic inflammatory process that, if not diagnosed and/or treated appropriately and promptly, may lead to gradual destruction of the supporting bone, and potentially implant loss (Carcuac and Berglundh, 2014). With an increasing number of dental implants being placed annually and the fact that periimplant diseases’ prevalence increases with the number of years an implant is in function (Roos-Jansaker, 2007), one can expect that peri-implant disease will increasingly become a significant challenge to clinicians, threatening the success and longevity of dental implant therapy. Tarnow (2016) places this nicely in perspective with the following quote from his article: “In addition, because at least 10% of all implants being placed this year will have peri-implant disease after 10 years, it makes us realize how important this is. “The estimate that one million implants were placed last year worldwide should serve as an eye-opener. If, conservatively, 10% of all implants will have this problem, then 100,000 per year will need our attention. It should also be mentioned that life in the mouth is a hostile environment for both teeth and implants. We therefore will see Volume 10 Number 6

Are the results valid? The present systematic review had major limitations affecting the quality and validity of the evidence presented. Overall, the primary studies included in the study were based upon convenience samples of limited sample size, questionable study design producing low-level evidence, an unclear or high risk for bias, and therefore may not provide a true reflection of the effect of PIMT on peri-implant disease. Furthermore, follow-up time and PIMT interval range analyzed varied considerably and may not accurately demonstrate its true impact on the incidence of periimplant disease. The number of studies and sample sizes were too small to analyze the effect of extraneous variables (such as smoking, systemic conditions, bone quality, implant location, peri-implant mucosal dimensions, Volume 10 Number 6

implant design and surface characteristics, number of implants, placement protocols, loading protocols, follow-up period, and type of prosthesis) on the incidence of periimplant disease. These confounding variables could affect the reliability of the evidence presented. In view of the previously mentioned limitations, caution should therefore be exercised when interpreting the data and extrapolating directly from the findings to daily implant practice. What are the key findings? An incidence rate ratio (IRR) is a relative measure of the effect (peri-implant disease) of a given exposure (PIMT) or the approximation of the relative risk of a non-exposure to PIMT. IRR is calculated by dividing the incidence of peri-implant disease among the exposed population (PIMT) by the incidence among the non-exposed population (no-PIMT). Subjects receiving PIMT had 0.9369 times the rate (risk) of having mucositis and 0.7056 times the rate of having peri- implantitis at implant level compared to subjects not receiving PIMT. (Rate ratios are often interpreted as if they were risk ratios â&#x20AC;&#x201D; for example, subjects receiving PIMT had 0.9369 times the risk of getting mucositis compared to subjects not receiving PIMT, but it is more precise to refer to the ratio of rates rather than risk.) PIMT intervals had a significant effect on the incidence of mucositis at implant level and peri-implantitis at implant level and patient level. The findings of this review suggest 5 to 6 months to be a reasonable interval for PIMT. History of periodontitis significantly increased the incidence of mucositis and peri-implantitis at both implant and patient level. Mean PIMT and periodontitis showed significant effects on implant failure rate. The systematic review showed that PIMT has a positive impact on peri-implant tissue health as well as implant survival rate. The results of this study lend further support to findings of previous studies that long-term maintenance care and frequency of maintenance visits are essential to reduce the risk of peri-implantitis, and to enhance implant survival (Atieh, et al., 2013; Gay, et al., 2015). The finding that history of periodontitis increases the incidence of periimplantitis is also in agreement with a recent study suggesting that susceptibility confers higher risk of implantitis (Derks, et al., 2016).

How are the results of this review applicable in clinical practice? Are these interventions feasible? The findings of this study, although very low-level evidence, remain very clinically relevant to daily implant practice. Early diagnosis and identifying risk factors during treatment planning and throughout therapy, together with regular long-term follow-up are fundamental principles in preventing disease and selecting appropriate treatment protocols. Long-term maintenance care at more frequent intervals for high-risk groups is essential to reduce the risk of peri-implant disease. Patients receiving implant treatment must be duly informed on the risk for periimplant diseases and the need for regular preventive care (Atieh, et al., 2013; Jepsen, et al., 2015). It is important that implant placement and prosthetic reconstructions need to allow proper personal cleaning, diagnosis by probing, and professional plaque removal (Jepsen, et al., 2015). Peri-implant mucositis is a reversible condition; therefore, early diagnosis is imperative for initiating preventive care. Patient-administered mechanical plaque control alone should be considered the current standard of care for preventing and managing peri-implant mucositis (Jepsen, et al., 2015). Treatment of periimplant mucositis usually includes mechanical debridement of biofilm and calculus either by professional intervention and/or by home-use oral hygiene techniques, with or without the adjunctive use of antimicrobials. Based on the available data, it seems that the nonsurgical therapy of peri-implantitis is not effective in disease resolution because only limited improvements in the main clinical parameters have been reported, and there is a clear tendency for disease recurrence. It is therefore recommended to consider advanced therapies, such as surgical intervention, when nonsurgical periimplant surgery is unable to achieve significant improvements in the clinical parameters (Figuero, et al., 2014; Heitz-Mayfield, et al., 2014; Robertson, et al., 2015). Treatment of peri-implantitis should be tailored to the severity of the lesion, which ranges from mechanical debridement to implant removal. Several nonsurgical and surgical treatment alternatives exist, and there is little consensus on superior treatment methods. For more detailed nonsurgical and surgical treatment protocols, readers can Implant practice 27

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more peri-implantitis on implants as they spend more time in the mouth. This is just like teeth.â&#x20AC;? Therefore, as the number of implants placed per year continues to increase, it is becoming increasingly important for the clinician to ensure that patients are properly informed and that they are receiving appropriate, regular long-term supportive treatment to ensure that their implants remain disease-free. Recent evidence indicates that without a regular maintenance program, including clinical reevaluation, plaque control, oral hygiene instruction, and other professional preventive measures, the benefits provided by dental implants cannot be maintained on a long-term basis, and biological complications such as peri-implant mucositis and/or peri-implantitis may result (Smeets, et al., 2014; Tonetti, et al., 2015). To date, current approaches to implant maintenance are empirical with no evidencebased guidelines or protocol for prevention of peri-implant diseases. Additionally, there is currently no reliable evidence to identify the most effective intervention for treating peri-implantitis (Esposito, et al., 2012). If the clinician is better able to identify and understand the etiology, pathogenesis, and characteristics of peri-implant disease, prevention and management can be performed more effectively. The present systematic review aims at assessing the impact of maintenance therapy on the incidence of peri-implant diseases.

CONTINUING EDUCATION refer to the following clinical literature: Figuero, et al., 2014; Heitz-Mayfield, et al., 2014; Robertson, et al., 2015; Heitz-Mayfield and Mombelli, 2014; Lang, et al., 2004. Do benefits outweigh the potential harms and costs? “Peri-implant disease is not an easy, predictable disease to treat once it is past the mucositis level into the bone. Therefore, the key is prevention based on proper implant design, proper placement, and correct contours for ease of hygiene. This, along with meticulous maintenance care by both the dentist and the patient, will mean that we won’t ‘revisit’ these implants.” (Tarnow, 2016) Furthermore, treatment of peri-implantitis can be inconvenient and uncomfortable for the patient, and appropriate treatment is demanding in terms of resources and costs. Thus, as the global number of individuals who undergo implant-retained restorative therapy increases, peri-implantitis will increasingly become a major and growing problem in dentistry (Derks, et al., 2016). It is best to prevent peri-mucositis, which is the precursor of peri-implantitis. Long-term regular follow-up and maintenance care is key to preventing peri-implant disease. Early diagnosis will ensure that appropriate therapy is initiated to reverse periimplant mucositis. Additionally, long-term maintenance care, especially for high-risk groups, is essential to reduce the risk of periimplantitis and subsequent implant failure.

Studies included in the meta-analysis had to give a clear description of PIMT intervals and biologic complications.

To summarize, prevention incurs less risk of peri-implant disease, discomfort, emotional stress, and costs associated with surgical treatment protocols associated with managing peri-implantitis or ultimate removal of a failed implant.

Clinical resolution Within the limitations of the present systematic review, the results support the fundamental principle that dental implants necessitate regular long-term attention to peri-implant maintenance through rigorously employed regular professional follow-up and patient self-management. This review has highlighted the importance of proper oral hygiene, and more stringent follow-up care is suggested, with recall intervals every 5 to 6 months. The findings show that a history of periodontitis significantly increases the incidence of peri-implant disease — meaning clinicians should pay particular attention to patients with periodontal disease, with regard to periodontal therapy and adherence to regular periodontal maintenance.

REFERENCES 1. Atieh MA, Alsabeeha NH, Faggion CM Jr, Duncan WJ. The frequency of peri-implant diseases: a systematic review and meta-analysis. J Periodontol. 2013;84(11):586-1598. 2. Belibasakis GN. Microbiological and immuno-pathological aspects of peri-implant diseases. Arch Oral Biol. 2014;59(1):66-72.

In addition, patient-, clinical- (surgical and restorative), and implant-related factors must be thoroughly considered to potentially prevent biologic complications and hence increase the long-term success rate of dental implants. Although the results presented in this review are low-level evidence, it has given us a better understanding of the importance of regular preventive care in preventing biological complications and increasing the longevity of implant restorations. Future research should focus on quality study design and adherence to standardized guidelines for diagnostic criteria for measuring outcome parameters, and especially patient-reported outcomes. Well-designed studies with attention to inclusion criteria and larger sample sizes will allow for analysis of treatment outcomes at multivariable level to identify sources of heterogeneity. Further investigations should also focus on optimal ways for treating periimplant mucositis and peri-implantitis that can provide evidence-based therapeutic protocols for peri-implant disease. IP

13. Jepsen S, Berglundh T, Genco R, et al. Primary prevention of peri-implantitis: managing periimplant mucositis. J Clin Periodontol. 2015;42(suppl 16):152–157. 14. Lang NP, Berglundh T, Heitz-Mayfield LJ, Pjetursson BE, Salvi GE, Sanz M. Consensus statements and recommended clinical procedures regarding implant survival and complications. Int J Oral Maxillofac Implants. 2004;19(suppl):150-154 .

3. Carcuac O, Berglundh T. Composition of human peri-implantitis and periodontitis lesions. J Dent Res. 2014;93(11):1083–1088.

15. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Ann Int Med. 2009;151(4): 264-269.

4. Costa FO, Takenaka-Martinez S, Cota LO, Ferreira SD, Silva GL, Costa JE. Peri-implant disease in subjects with and without preventive maintenance: a 5-year follow-up. J Clin Periodontol. 2012;39(2):173-183.

16. Mombelli A, Lang NP. The diagnosis and treatment of peri-implantitis. Periodontol 2000. 1998;17:63-76.

5. Derks J, Schaller D, Håkansson J, Wennström JL, Tomasi C, Berglundh T. Effectiveness of implant therapy analyzed in a Swedish population: prevalence of peri-implantitis. J Dent Res. 2015;95(1):43-49. 6. Derks J, Tomasi C. Peri-implant health and disease. A systematic review of current epidemiology. J Clin Periodontol. 2016;42(suppl 16):158-171. 7. Esposito M, Grusovin MG, Worthington HV. Interventions for replacing missing teeth: treatment of peri-implantitis: Cochrane Database Syst Rev. 2012;CD004970. 8. Figuero E, Graziani F, Sanz I, Herrera D, Sanz M. Management of peri-implant mucositis and peri-implantitis. Periodontol 2000. 2014;66(1):255-273. 9. Gay IC, Tran DT, Weltman R, et al. Role of supportive maintenance therapy on implant survival: a university-based 17 years retrospective analysis. Int J Dent Hyg. 2016;14(4):267-271. 10. Heitz-Mayfield LJ, Lang NP. Comparative biology of chronic and aggressive periodontitis vs. peri-implantitis. Periodontol 2000. 2010;53:167-181. 11. Heitz-Mayfield LJA, Mombelli A. The therapy of peri-implantitis: a systematic review. Int J Oral Maxillofac Implants. 2014;29(suppl):325-345. 12. Heitz-Mayfield LJ, Needleman I, Salvi GE, Pjetursson BE. Consensus statements and clinical recommendations for prevention and management of biologic and technical implant complications. Int J Oral Maxillofac Implants. 2014;29(suppl):346-350.

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17. Robertson K, Shahbazian T, MacLeod S. Treatment of peri-implantitis and the failing implant. Dent Clin N Am. 2015;59(2):329-343. 18. Roos-Jansaker AM. Long time follow-up of implant therapy and treatment of peri-implantitis. Swed Dent J Suppl. 2007;(188)7-66. 19. Shea BJ, Hamel C, Wells GA, et al. AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews. J Clin Epidemiol. 2009;62(10):1013-1020. 20. Smeets R, Henningsen A, Jung O, Heiland M, Hammächer C, Stein JM. Definition, etiology, prevention and treatment of peri-implantitis—a review. Head Face Med. 2014;10:34. 21. Tarnow DP. Increasing prevalence of peri-implantitis: How will we manage? J Dent Res. 2016;95(1):7-8. 22. Tonetti MS, Chapple IL, Jepsen S, Sanz M. Primary and secondary prevention of periodontal and peri-implant diseases: Introduction to, and objectives of the 11th European Workshop on Periodontology consensus conference. J Clin Periodontol. 2015; 42(suppl 16):1–4. 23. Wang Y, Zhang Y, Miron RJ. Health, maintenance, and recovery of soft tissues around implants. Clin Implant Dent Rel Res. 2015; 18(3):618-634. 24. Wells GA, Shea B, O’Connell D, Peterson J, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of non-randomized studies in meta-analyses. Ottawa Hospital Research Institute. 2011;http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed November 9, 2017.

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Is peri-implant maintenance therapy important for preventing peri-implant disease? HARTSHORNE

1. Although it must be tailored to a patient’s risk profiling, the findings suggest reason to claim a minimum recall PIMT interval of ________. a. 1 to 2 months b. 2 to 4 months c. 5 to 6 months d. 7 to 8 months 2. The findings also show that a history of periodontitis ________ the incidence of peri-implant disease and suggested more stringent follow-up maintenance at shorter intervals. a. significantly increased b. only slightly increased c. had no effect on d. decreased 3. In addition, __________ risk factors must be thoroughly considered to potentially prevent biologic complications and hence increase the long-term success rate of implants. a. patient-related b. clinical-related (surgical and restorative) c. implant-related d. all of the above 4. Prosthetic components and superstructures should fit properly to avoid _________. a. microgaps for biofilm adherence

Volume 10 Number 6

b. excess cement at submucosal restorative margins c. unmovable keratinized tissue d. both a and b 5. Peri-implant soft tissue healing and health _______ that of natural teeth. a. differs only slightly from b. differs significantly from c. is equal to d. has absolutely no correlation to 6. ________ has/have been considered as the critical etiological factors for the development of peri-implant diseases. a. Time-related factors b. Microbial colonization in the form of dental plaque biofilms c. The host inflammatory response in the periimplant tissues d. both b and c 7. ________ is a reversible inflammatory process characterized by inflamed or erythematous periimplant mucosa and bleeding with probing with no evidence of loss of the supporting bone. a. Peri-implant mucositis b. Peri-implantitis c. Periodontitis

d. Necrotizing periodontal ligament disease 8. Tarnow (2016) places this nicely in perspective with the following quote from his article: “In addition, because at least _____ of all implants being placed this year will have peri-implant disease after 10 years, it makes us realize how important this is.” a. 5% b. 10% c. 25% d. 35% 9. Peri-implant mucositis _____; therefore, early diagnosis is imperative for initiating preventive care. a. is a reversible condition b. is a permanent condition c. is a life-threatening condition d. can only be treated by clinician-administered treatment 10. (Tarnow noted) “Peri-implant disease is not an easy, predictable disease to treat once it is past the mucositis level into the bone. Therefore, the key is prevention based on _________.” a. proper implant design b. proper placement c. correct contours for ease of hygiene d. all of the above

Implant practice 29

CE CREDITS

IMPLANT PRACTICE CE

CONTINUING EDUCATION

Maxillary split-crest technique with immediate implant placement Drs. Amr Zahran and Basma Mostafa present a case report detailing how careful use of implants in juvenile patients can yield positive results

his case report presents a divergent approach in which a modified split-crest technique was applied using a piezoelectric tip, one drill, and tapered implants. The split-crest surgery was performed with immediate placement of two tapered selftapping dental implants in the anterior maxilla of a 13-year-old female patient. The patient had lost four of her maxillary anterior teeth as a result of an accident at 9 years old, with subsequent severe alveolar ridge resorption, leading to an average buccopalatal ridge width of less than 4 mm. At 6 months postoperatively, the average increase of the alveolar ridge width was evaluated using cone beam computed tomography (CBCT) and found to be 1.92 ± 0.04 mm. The stability of the implants was also evaluated at 6 months, using the Periotest M (PTM) system. The two implants were found to have PTM values of -2.3 and -2.8, indicating good osseointegration. After 2 years, the PTM values were -2.4 and -2.8, with a 100% survival rate of the two osseointegrated implants. The implants were restored using a polyetheretherketone (PEEK) bridge, providing both satisfying function and esthetics to the patient.

Introduction Tooth loss as a result of trauma or congenital absence presents a major problem in young individuals. It causes functional impairment in addition to psychological disturbances (Wang, et al., 2015). Missing teeth in youth have been reported to have a negative impact on individuals’ emotional condition, social relations, and speech; smiling; and overall performance (Brahmin 2005). In such cases, oral rehabilitation is

Professor Amr Zahran, BDS, MDS, PhD, is a professor of periodontology at the department of periodontology, Faculty of Oral and Dental medicine, Cairo University, Cairo, Egypt. Basma Mostafa, BDS, MDS, PhD, is assistant professor of oral medicine and periodontology in the department of surgery and oral medicine, National Research Centre, Cairo, Egypt.

30 Implant practice

Educational aims and objectives

This article aims to presents a divergent approach in which a modified split-crest technique was applied to treatment of a 13-year-old girl and both the positive and challenging aspects of treatment on younger patients.

Expected outcomes

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

Realize the various functional and psychological effects of missing teeth on young patients’ lives.

•

Recognize some of the distinctive and significant differences between treating pediatric and adult patients.

•

Recognize some procedures that may be necessary to provide adequate bone for implant placement.

•

Realize some of the notably different aspects of the use of implants in youth from adults.

•

Realize some of the advantages and disadvantages of placing dental implants on young patients.

mandatory, even before reaching complete skeletal and dental maturation. The removable partial denture has been considered as the first treatment option in such conditions due to its ease of construction and relatively lower cost. However, certain drawbacks are associated with this treatment modality such as a high incidence of caries, periodontal problems, and increased residual alveolar bone resorption. In addition, its removable nature is not favored by many patients. Another recommendation for replacing the missing teeth is the resin-bonded bridge. It has been reported that this type of bridge has satisfying survival rates with debonding as a major concern. These solutions have led many authors to discuss the use of implants in young patients (Mishra 2103). The success and predictability of dental implant placement in adults requires optimum quality and quantity of alveolar bone. Proper treatment planning, as well as correctly performed surgery, is essential. In addition, appropriate prosthetic restoration with good oral hygiene maintenance is also needed. The same factors are also necessary for successful dental implants when placed in children, adolescents, or young adults in certain cases.

The distinctive and significant difference between treating pediatric and adult patients is that the outcome and success of treatment is highly influenced by the craniofacial growth and dentoalveolar development. Implants present for several years during facial growth can be embedded, relocated, or displaced during the growth of the jaws. The changes that occur as the adolescent grows should be compensated for by continuous design adjustment (Shah, et al., 2013; Percinoto, et al., 2001). The most important target when using dental implants in growing patients is the preservation of bone. In cases of partially missing teeth, the insertion of dental implants can change the load mechanism to which bone is subjected and hence retard its resorption. Tooth loss as a result of trauma can affect the availability of sufficient bone volume for placing dental implants in many young healthy individuals due to the subsequent alveolar bone resorption following tooth extraction (Op Heij, et al., 2003; Sharma and Vergervik, 2006). Various procedures may be necessary to provide adequate bone for implant placement. Bone augmentation with autogenous bone or any other grafting materials can be used. Guided bone regeneration (GBR) procedures using barriers and bone expansion or splitting techniques have been adopted for management of such volume deficiencies. Many of Volume 10 Number 6

Case report This 13-year-old girl was referred to the first author’s private clinic. She was healthy

Tooth loss as a result of trauma or congenital absence presents a major problem in young individuals. It causes functional impairment in addition to psychological disturbances.

with a normal medical history documented by the Cornell Medical Index Questionnaire (Brodman, et al., 1951). She had been involved in a bicycle accident at 9 years old and subsequently lost four of her upper anterior teeth. She had been wearing a partial denture since the accident and was not satisfied with having a removable prosthesis. The patient found her partial denture inconvenient and struggled with an inability to pronounce certain words. Her removable prosthesis required frequent removal for cleaning purposes following eating, and she was often teased for this. She was afraid to participate in various sporting activities for fear of dislodging the denture, which had a negative impact on her social life. Clinical intraoral examinations revealed the absence of the maxillary anterior teeth with presence of severely atrophic ridge (Figure 1). Radiographic examination showed severe loss of the bone width at the edentulous area (Figure 2). Wrist carpal radiographs and multiple cephalometric radiographs were taken and performed with superimposed orthodontic tracings to assess the degree of skeletal maturity of the jaw bones. No changes occurred over a period of 6 months, leading to the assumption that bone growth was nearly complete. (It was also evident that the

Figure 1: Preoperative intraoral photograph showing the four missing upper anterior teeth with the maxillary ridge deficiency Volume 10 Number 6

patient was very similar physically and in height to her mother.) The study protocol was reviewed and approved by the ethical committee at the Faculty of Oral and Dental Medicine of Cairo University. Clinically, the edentulous site demonstrated insufficient bucco-palatal ridge width (less than 4 mm) with more than 10 mm of residual bone height and sufficient vertical intermaxillary arch space upon centric occlusion. No local or systemic conditions that might contraindicate minor oral surgeries were detected. Oral habits that might endanger the osseointegration process, such as smoking or parafunctional habits, were not recorded. The patient and her mother were fully informed about the associated risks of the procedures. The mother, as the responsible guardian, signed an informed consent form to document her approval.

Methods A preoperative evaluation was carried out that included a visual examination and palpation of the entire oral and paraoral tissues. Study casts were prepared to evaluate the intermaxillary space and type of occlusion. The buccopalatal alveolar ridge width at the implant site was measured using a bone caliper. Periapical and panoramic radiographs were taken for the recipient sites.

Figure 2: Preoperative CBCT showing the deficient maxillary alveolar ridge width measurements Implant practice 31

CONTINUING EDUCATION

the drawbacks of using GBR — the invasiveness, potential need for a supplementary donor site, resorption of grafting materials, membrane collapse, exposure to infection, and delaying of implant installation for grafting maturation — have also been associated and recorded with using of autogenous grafts and membranes (Sharma and Vergervik, 2006; Schropp, et al., 2003; Aghaloo and Moy, 2007; McAllister and Haghighat, 2007; Machtei 2001). Accordingly, there has been some discussion of applying noninvasive techniques of ridge splitting and expansion that do not subject the patient to much trauma. Several of these ridge-split techniques have been discussed in recent years, including the split-crest osteotomy, ridge expansion osteotomy, and frequent modifications of those techniques (Guirado, et al., 2005). This case report differs from the norm in performing a modified split-crest technique followed by immediate implant placement in a young patient to manage the atrophic maxillary ridge. The first author has previously described a modified approach of this technique within which expansion of the alveolar ridge and immediate implant placement are combined in a single process. Several instruments, including a piezoelectric tip and one tapered osteotomy drill, are essential to this technique. In this case, the tapered implants were positioned into the determined osteotomy sites within the split channel. This placement was used to expand the bone during seating of the implants (Zahran, et al., 2016). To the authors’ knowledge, this is the first case reporting the application of these approaches at such a young age.

CONTINUING EDUCATION

Figure 3: Bone channel created by piezosurgery

Figure 4: Immediate postoperative photograph showing placed implants with expansion of bone

Figure 5: Six-month postoperative CBCT showing the increase in ridge width and the implant in place

CBCT was performed on the assigned sites for the study in order to determine the buccopalatal alveolar ridge width at the implant sites preoperatively.

Surgical procedures The patient was anesthetized locally by infiltration anesthesia. A palatal subcrestal incision was created for the surgical site. Two oblique releasing incisions were then made on the buccal aspect. Dissection of the full thickness mucoperiosteal flap was performed to provide complete exposure of the alveolar bone. Using a piezoelectric surgery unit (VarioSurg, NSK â&#x20AC;&#x201D; using the SG1 tip), a horizontal crestal cut was created along the crest of the bone (Figure 3). The cut extended through the cortical bone to reach the spongy bone. The depth of the horizontal cut was approximately the same length of the implant to be inserted. Two vertical cuts were then created, and these were connected to the horizontal crestal cut. After ridge splitting, the osteotomy site was prepared using the new OsteoCareâ&#x201E;˘ 3.25 mm Ultra drill, and two 32 Implant practice

Figure 6: Re-entry after 6 months showing bone growth

OsteoCare Maxi Z flat-end 3.75 mm x 10 mm dental implants were placed (Figure 4), and their positions were confirmed by immediate postoperative periapical radiographs. Careful seating of these tapered implants into the bone was performed until all exposed threads were submerged and the platform remained flush with the crestal bone; then cover screws were inserted into the implants. This positioning of the implants created expansion through deformation between the split bony plates. Closure of the flap was performed using interrupted sutures with a 4-0 black silk suture material (Assut sutures). Postoperative patient management 1. Augmentin (Medical Union Pharmaceuticals) 1g tablets were prescribed twice daily for 5 days. 2. Analgesics (Brufen, Khaira Pharmaceuticals and Chemical Industries) were prescribed 200mg 3 times per day for 5 days. 3. Oral hygiene recommendations were provided, including the use of a soft toothbrush.

Second-stage surgery After a healing period of 6 months, postoperative periapical radiographs as well as CBCT scans were taken (Figure 5), and the clinical and radiographic increase of the alveolar ridge width were recorded. Surgical re-entry was then undertaken in order to assess the success of the modified split-crest technique and to position the healing collars on the newly-exposed implants (Figure 6). The Periotest M (Medizintechnik Gulden) was used to test implant stability at 6 months (Figure 7) before cementation of the bridge, and again at 2 years postoperatively. Prosthetic procedures Two weeks after fixation of the healing collars, indirect impressions were taken using OsteoCare impression transfers for the open-tray transfer technique. Impressions were given to the dental laboratory for construction of milled Peek bridge (Najeeb, et al., 2016). After fixation of the abutments, the final bridge was cemented using zinc polycarboxylate cement (Figure 8). Volume 10 Number 6

Figure 7: Six-month postoperative photograph showing the fixed healing collars to the implants with the use of the Periotest M to confirm osseointegration

Figure 8: Photograph showing the cemented PEEK bridge

Radiographic follow-up Standardized periapical radiographs (Figures 9A and 9B) using the parallel technique, as well as panoramic radiographs and CBCT, were undertaken preoperatively, immediately postoperatively (within the first 24 hours), at 6 months, and after 2 years. CBCT scans were used to evaluate the total gain in alveolar ridge width in the buccopalatal dimension. They were also used to assess the stability of the marginal bone around the implant after the procedure and to record the postoperative ridge width. The raw data obtained from the CBCT scan was imported into bespoke third-party software for secondary reconstruction and further clinical interpretation. The results recorded from each of the data sets were compared. The preoperative image was fused to the postoperative image by manual registration through landmarks in the cranium. Accurate registration (superimposition) was automatically performed by the software. Each image (primary and secondary) was color-coded for identification. First, key point measurements were recorded onto the primary image. The measurements on the primary image were held, and the primary image was removed to leave the secondary image. New measurements were then recorded on the secondary image in the identical plane, direction, and cut as that of the primary image to ensure standardization. The obtained data was then presented.

Results

Figure 9A: Six-month postoperative periapical radiograph showing implants in place Volume 10 Number 6

Figure 9B: Two-year postoperative periapical radiograph showing implants in place

Two self-tapping titanium dental implants were placed in a 13-year-old female patient during the split-crest procedure. The diameter of the two inserted implants was 3.75 mm with a length of 10 mm. Wound healing was normal around all the positioned implants without any signs of infection, suppuration, or mucositis at the peri-implant area. Initial pain and minor swelling was noted. These conditions were completely resolved by the 10th day postoperatively. Implant practice 33

CONTINUING EDUCATION

Clinical follow-up The patient underwent immediate postoperative, 6-month, and 2-year postoperative examination and evaluation. The examination and evaluation criteria included review for the presence of peri-implant infection, any complaint of local pain at the site of implant insertion, and any complaint of neuropathies or paraesthesia. In addition, the patient was clinically evaluated for implant mobility.

CONTINUING EDUCATION Osseointegration was clinically and radiographically checked and proven to be successful. The success criteria were a lack of mobility as checked by the Periotest M, and the absence of radiographic radiolucency at the bone-implant interface. The 2-year follow-up period showed the continued success of the treatment with no further bone loss as revealed radiographically. The preoperative bone width at the site of the first implant measured 3.72 mm. This changed after 6 months postoperatively to be 5.61 mm. The bone width gain was 1.89 mm. At the area where the second implant was inserted, the bone width was 3.70 mm, which changed after 6 months to 5.65 mm. The bone width gain was 1.95 mm. The average bone width preoperatively was 3.71 ± 0.014 mm, which changed to 5.63 ± 0.028 mm after 6 months, showing a significant ridge width bone gain of 1.92 ± 0.042 mm with a p-value 0.0001. The two implants were successfully osseointegrated when clinically assessed at 6 months postoperatively. The degrees of implant stability measured by Periotest M were -2.3 and -2.8 for the two implants after 6 months postoperatively. After 2 years, the Periotest M values were -2.4 and -2.8. After the prosthesis was loaded, speech and pronunciation improved. Oral function was efficiently restored with high patient satisfaction within a limited time period. The 2-year follow-up reported no apparent vertical discrepancy between the implants and the adjacent natural teeth (Figure 10). The patient reported positive psychological consequence following the implant restoration and bridge fixation. At the end of the 2-year follow-up period, 100% success and survival rates were recorded.

Discussion The success and predictable long-term outcomes of dental implants in restoring partially edentulous cases in adults have been the base for many clinicians to broaden their application and use for younger patients who have lost their teeth as a result of agenesis and/or trauma (Shah, et al., 2013). Implant-supported prostheses can provide the essential requirements for proper function and esthetics (Tiedemann, et al., 2014). The use of implants in youth differs notably from adults. Special attention must be given to the growth pattern of the young because a diversity of changes occurs in the dentition and jaws of these individuals (Mishra, et al., 2013). In adult patients, the 34 Implant practice

Figure 10: Two-year postoperative photograph showing no discrepancy of occlusion

The success and predictable long-term outcomes of dental implants in restoring partially edentulous cases in adults have been the base for many clinicians to broaden their application and use for younger patients who have lost their teeth as a result of agenesis and/or trauma.

use of osseointegrated dental implants is frequently the treatment of choice as their performance is independent from adjacent teeth. Meanwhile, implant placement in young individuals involves the risk of position relationship problems due to the “ankylosed” nature of the implant. The implants placed in young individuals might not follow the dentoalveolar development. This nature could lead to infra-occlusion of the ankylosed implant with possible periodontal, occlusal, and esthetic consequences in the future. On the other hand, reviewing the concept that has been established by various studies that alveolar remodelling and growth does not end at puberty and that vertical discrepancy between a single dental implant and its neighboring natural teeth may possibly still occur in adulthood encouraged us to insert

the dental implant in our young 13-year-old patient (Mishra, et al., 2013; Bernard, et al., 2004; Jemt, et al., 2006). It was documented that the delay of dental implant insertion in youth does not essentially exclude future complications. The placement of dental implants in young patients can provide both functional and psychological benefits. The ankylosed implant is fixed into the alveolar bone and, therefore, might provide the patient with more natural sensation. On top of this, the security that a fixed prosthesis provides has a tremendous psychological benefit for the patient (Spriggs, et al., 2007), as occurred in this case with our female patient, who was happy and satisfied with her fixed restoration. Papers have been published reporting the use of dental implants in the anterior Volume 10 Number 6

Where maxillary teeth are nonexistent, alveolar ridge development will be defective, and the maxilla will remain underdeveloped — both in the sagittal and vertical planes — causing inappropriate upper to lower jaw relationships (Ribeiro-Junior, et al., 2009). This was the condition in this case, which presented an average deficient ridge width of 3.71 ± 0.014 mm. Many treatment modalities have been implemented for augmenting and correcting this defective alveolar bone (Aghaloo and Moy, 2007; McAllister and Haghighat, 2007). The modification of the split-crest technique previously discussed by Zahran, et al., 2016, was applied in this case and combined with immediate placement of tapered implants to expand the bone, as an alternative to the use of ridge expanders or osteotomes. The tapered implants used in this case are more controllable during the expansion procedure, easing the bone plates apart gradually and minimizing the risk of fracturing the buccal plates. The two implants were successfully osseointegrated as revealed by the Periotest M values, and the supporting alveolar bone was also preserved. This case is unusual in that, to the authors’ knowledge, it is the first attempt in performing the split-crest technique at such a young age. The obtained results of the current report revealed an average bone gain of 1.92 ± 0.042 mm after 6 months postoperatively, without the use of any bone grafting

REFERENCES 1. Aghaloo TL, Moy PK. Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? Int J Oral Maxillofac Implants. 2007;22(suppl):49-70. 2. Brahmin JS. Dental Implants in Children. Oral Maxillofacial Surg Clin N Am. 2005;17:375-381. 3. Brodman K, Erdmann AJ Jr, Lorge I, et al. The Cornell Medical Index-Health Questionnaire. JAMA. 1951;145(3):152-157. 4. Bernard JP, Schatz JP, Christou P, Belser U, Kiliaridis S. Long-term vertical changes of the anterior maxillary teeth adjacent to single implants in young and mature adults. A retrospective study. J Clin Periodontol. 2004;31(11):1024-1028. 5. Chiapasco M, Ferrini F, Casentini P, Accardi S, Zaniboni M. Dental implants placed in expanded narrow edentulous ridges with the Extension Crest Device. A 1-3-year multicenter follow-up study. Clin Oral Implants Res. 2006;17(3):265-272. 6. Guirado JLC, Yuguero MR, Carrión del Valle MJ, Zamora GP. A maxillary ridge-splitting technique followed by immediate placement of implants: a case report. J Implant Dent. 2005;14(1):14-20. 7.

Holtzclaw DJ, Toscano NJ, Rosen PS. Reconstruction of posterior mandibular alveolar ridge deficiencies with the piezoelectric hinge-assisted ridge split technique: a retrospective observational report. J Periodontol. 2010;81(11):1580-1586.

8. Jemt T, Ahlberg G, Henriksson K, Bondevik O. Tooth movements adjacent to single-implant restorations after more than 15 years of follow-up. Int J Prosthodont. 2006;20(6):626-632. 9. Kramer FJ, Baethge G, Tschernitschek H. Implants in children with ectodermal dysplasia: a case report and literature review. Clin Oral Implants Res. 2007;18(1):140-146. 10. Machtei EE. The effect of membrane exposure on the outcome of regenerative procedures in humans: a meta-analysis. J Periodontol. 2001;72(4):512-516. 11. McAllister BS, Haghighat K. Bone augmentation techniques. J Periodontol. 2007;78(3):377-396. 12. Mishra SK, Chowdhary N, Chowdhary R. Dental implants in growing children. J Indian Soc Pedod Prev Dent. 2013;31(1):3-9. 13. Najeeb S, Zafar MS, Khurshid Z, Siddiqui F. Applications of polyetheretherketone (PEEK) in oral implantology and prosthodontics. J Prosthodont Res. 2016;60(1):12-19.

Volume 10 Number 6

materials or barrier membranes to block the defective space. These results were similar to many studies performed on adults that have reported satisfactory ridge bone gain without the use of grafting materials with a high success and survival rates. Chiapasco, et al., 2006, reported a final mean bone gain of 4 mm and Holtzclaw, et al., 2010, showed a mean bone gain of 4.03 mm. Meanwhile, Sohn, et al., 2010, reached a bone gain of 2.7 mm. Zahran, et al., 2016, revealed a total mean bone gain of 2.93 mm, also after 6 months, which is in line with the present work done. Implant placement in our 13-year old patient allowed us to track her growth, the prognosis, and the positions of the inserted implants in the 2-year follow-up period, which revealed no apparent vertical discrepancy between the implants and the natural teeth.

Conclusion This case study illustrates a novel treatment option with 2-year follow-up in which a modified split-crest technique was applied with immediate implant placement, which successfully osseointegrated. Adequate alveolar bone width gain was achieved, with a proper restoration of function and esthetics. This applied treatment modality provides an encouraging therapeutic option in management of deficient maxillary ridges in young individuals. IP

14. Op Heij DG, Opdebeeck H, van Steenberghe D, Quirynen M. Age as compromising factor for implant insertion. Periodontol 2000. 2003;33:172-184. 15. Percinoto C, Vieira AE, Barbieri CM, Melhado FL, Moreira KS. Use of dental implants in children: a literature review. Quintessence Int. 2001;32(5):381-383. 16. Prachar P, Vanek J. Tooth defects treated by dental implants in adolescents. Scr Med (Brno). 2003;76:5-8. 17. Ribeiro-Junior PD, Padovan LE, Gonçales ES, Nary-Filho H. Bone grafting and insertion of dental implants followed by Le Fort advancement for correction of severely atrophic maxilla in young patients. Int J Oral Maxillofac Surg. 2009;38(10):1101-1106. 18. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single-tooth extraction: a clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent. 2003;23(4):313-323. 19. Shah RA, Mitra DK, Rodrigues SV, Pathare PN, Podar RS, Vijayakar HN. Implants in adolescents. J Indian Soc Periodontol. 2013;17(4):546-548. 20. Sharma AB, Vargervik K. Using implants for the growing child. J Calif Dent Assoc. 2006;34:719-724. 21. Shaw WC. Problem of accuracy and reliability in cephalometric studies with implants in infants with cleft lip and palate. Br J Orthod. 1977;4(2):93-100. 22. Sohn DS, Lee HJ, Heo JU, Moon JW, Park IS, Romanos GE. Immediate and delayed lateral ridge expansion technique in the atrophic posterior mandibular ridge. J Oral Maxillofac Surg. 2010;68(9):2283-2290. 23. Spriggs AL, Iannotti RJ, Nansel TR, Haynie DL. Adolescent bullying involvement and perceived family, peer and school relations: commonalities and differences across race/ethnicity. J Adolesc Health. 2007;41(3):283-293. 24. Tiedemann Svendsen M, Henningsen E, Hertz JM, Vestergaard Greisen D, Bygum A. A retrospective study of clinical and mutational findings in 45 Danish families with ectodermal dysplasia. Acta Derm Venereol. 2014;94(5):531. 25. Wang WCW, Suinaga LT, Klenise S, Paranhos, Cho SC. Replacing Missing Teeth with Dental Implants in Pubescent Patients: A Case Report. Open Journal of Pediatrics. 2015;5:207-212. 26. Zahran A, Mostafa B, Hanafy A, Darhous M. A modified split-crest technique using piezoelectric surgery and immediate implant placement in the atrophic maxilla. JIACD. 2016;8(4):36-44.

Implant practice 35

CONTINUING EDUCATION

mandibular area at 5 years of age with affirmative successful treatment results (Wang, et al., 2015). Prachar and Vaneek (2003) also presented the results of using both cylindrical or screw implants in youths aged 15-19 years. With the various measures performed, the success rate was constantly higher than 96% over the 5-year study period. These studies are in line with this case report, which shows 100% success and survival rates of the two inserted implants over the 2-year follow-up period. On the other hand, Shaw (1977) has previously mentioned that the dramatic growth changes that occur in infancy and early childhood are not conducive to the maintenance of dental implants. Other researchers have suggested that treatment with implants must be postponed until the age of 13 years (which is in line with this case), since an implant placed at the age of 7 or 8 may not be in a favorable location when the patient is 16. These researchers concluded that the benefits of implant use in growing patients are as important as the concerns for their premature use (Kramer, et al., 2007). The presence of a maxilla with deficient bone is a challenging issue in the use of dental implants for replacing missing teeth. Following tooth extraction as a result of trauma, a continuing alveolar bone resorption process is present, which leads to alveolar bone deficiency.

REF: IP V10.6 ZAHRAN/MOSTAFA

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

TELEPHONE/FAX

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

Maxillary split-crest technique with immediate implant placement ZAHRAN/MOSTAFA

1. Tooth loss as a result of ________ presents a major problem in young individuals. a. trauma b. congenital absence c. periodontitis d. both a and b 2. Missing teeth in youth have been reported to have a negative impact on individuals’ emotional condition, _______, and overall performance. a. social relations b. speech c. smiling d. all of the above 3. The distinctive and significant difference between treating pediatric and adult patients is that the outcome and success of treatment is highly influenced by the ________. a. patients’ psychological maturity b. craniofacial growth c. dentoalveolar development d. both b and c 4. Implants present for several years during facial growth can be _____ during the growth of the jaws. a. embedded

36 Implant practice

b. relocated c. displaced d. all of the above 5. The most important target when using dental implants in growing patients is the _______. a. preservation of bone b. the carious areas c. patient’s emotional condition d. periodontal condition 6. Implant placement in young individuals involves the risk of position relationship problems due to ________. a. non-compliance of younger patients b. the “ankylosed” nature of the implant c. poor osseointegration of grafts at younger ages d. patients’ poor hygiene habits 7. With the various measures performed (in studies by Wang, et al., and Prachar and Vaneek), the success rate was constantly higher than ____ over the 5-year study period. a. 25% b. 46% c. 67% d. 96%

8. Other researchers have suggested that treatment with implants must be postponed until the age of ___ years (which is in line with this case), since an implant placed at the age of 7 or 8 may not be in a favorable location when the patient is 16. a. 10 b. 11 c. 12 d. 13 9. The tapered implants used in this case are more controllable during the expansion procedure, _______. a. and are the only implants indicated for patients under 13 b. easing the bone plates apart gradually c. minimizing the risk of fracturing the buccal plates d. both b and c 10. The obtained results of the current report revealed an average bone gain of 1.92 ± 0.042 mm after 6 months postoperatively, ________. a. without the use of any bone grafting materials or barrier membranes to block the defective space b. using only autogenous bone c. using guided bone regeneration d. using allograft only

Volume 10 Number 6

CE CREDITS

IMPLANT PRACTICE CE

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

Submitting articles Implant Practice US requires original, unpublished article submissions on implant topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Implant Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 10 Number 6

Pictures/images

Disclosure of financial interest

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

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

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

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

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

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

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

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

(Multiple) Doe JF, Roe JP

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

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

Implant practice 37

PRACTICE DEVELOPMENT

SEO: Scam or critical marketing service? part 2 Ian McNickle, MBA, discusses strategies to rank highly on Google and other search engines

n part 1 of our series, we defined SEO, and how it works at a high level. The primary takeaway from part 1 was that search engines evaluate your website and online presence on a monthly basis, so it is important to have an ongoing and robust online marketing program in order to be rewarded by Google. As a reminder, Google has over 200 variables it evaluates when assigning search rankings to websites. I normally group the most important variables into five major categories: 1) website code, 2) website content, 3) incoming links to the website, 4) online reviews, and 5) social media. In part 2 of our SEO series, we will explore these five major categories, so each practice will be able to understand what they need to do (or what their SEO company should be doing) in order to rank highly on Google and other search engines.

Category No. 1 — website code There are literally dozens of things Google (and other search engines) look for in your website code, but we will focus on our discussion on the primary items: title tag, description tag, image tags, and keyword tags. Each of these items should be properly implemented on your website in order to tell Google what it wants to know about your business. Remember Google reads your code; so if you don’t put the right information in your website code, Google likely will not rank your site well in search results. Ask your website or SEO company to install these elements in your website code and to contain the primary keywords you want to rank for (type of practice, primary services, etc.). If you are paying for SEO and these basic items are not done, then you are certainly not getting real SEO. Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a Co-Founder and Partner at WEO Media, winner of the 2016 and 2017 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.weomedia.com.

38 Implant practice

Category No. 2 — website content The main factor you’ll want to make sure is that your website has unique content. Search engines give very little credit to websites with duplicate content (i.e., content that also resides on other websites in addition to your website). Your SEO company should write entirely unique content for all pages on your website in order to get the best search results. Most companies say they’re doing SEO, but don’t even do this fundamental step, so make sure your SEO company is doing this critical item in the SEO process.

Category No. 3 — incoming links to your website When another website has a link on it that links back to your website that is considered an incoming link (or backlink) to your website. Search engines reward websites with lots of incoming links. Think of it like a popularity contest online; the more links pointing to your website, the better because Google will consider websites with numerous incoming links to have more valuable information and will rank them higher in search results. In general, more links are good, and links from websites with lots of traffic are even better.

Category No. 4 — online reviews In the dental industry, the four most important online review sites are Google, Yelp, Healthgrades, and Facebook. Google is always the most important, but they are all very important. Search engines place a high level of importance on the number of reviews, and how recently the reviews are posted. It is wise to implement some sort of program to generate online reviews. Our company offers a service called WEO Reviews, but other services exist. The main point is to have a strategy to generate new patient reviews on these four major review sites on an ongoing basis. In addition to helping your SEO performance, the other major benefit is improved online reputation.

Category No. 5 — social media Obviously, social media is a huge topic, but for the purposes of SEO, we’ll just focus on a couple of items. In general, it is helpful to have ongoing posts on your social media pages, but what really helps SEO performance is when people actually engage with your posts by commenting, sharing, retweeting, reposting, etc. Social media engagement can be a strong SEO factor. Facebook is the most important social media site in the dental industry, so focus most of your efforts there, although other sites can have significant importance as well.

Is your SEO working? If you are working with an SEO company with the goal of driving new patients, then their recommended program should have all five of these categories covered as part of their strategy. In my experience, the majority of SEO companies do not properly implement a comprehensive SEO program covering these five categories and often don’t do nearly as much as they should be doing. In part 3 of our series, we will discuss questions to ask when interviewing SEO companies, and how to spot scams (and low-end SEO services).

Marketing consultation If you have questions about your website, SEO, 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 6

2018 schedule SESSION 1:

SESSION 2:

Begin with the basics through sixteen one-hour modules, available online and on-demand 24/7.

Learn how to place dental implants into abundant bone reliably, predictably and efficiently. This course is packed with hands on exercises designed to prepare you for implant placement, flap design and suturing.

Online Only

✔ Implant rationale ✔ Dental and Medical history ✔ Pharmacology ✔ Implant design ✔ Radiology for dental implants ✔ Bone quality ✔ Anatomy for dental implants ✔ Grafting materials ✔ Restorative options ✔ Consults, records and photos ✔ Surgical setup ✔ Post operative follow-up ✔ Pricing dental implants ✔ Staffing, team and business building NEW! ✔ Marketing your dental practice NEW!

Hands-On Training

Session One: Online Only - Twenty one-hour modules, on-demand videos. - Online access granted upon registration. Seattle, Washington - Session 2: February 9 and 10, 2018 - Session 3: March 9 and 10, 2018

✔ Single tooth implant placement ✔ Incision and flap designs for the implant surgical site ✔ Suturing rationale for predictable success ✔ Surgical tooth extraction techniques ✔ Ridge preservation grafting techniques and materials ✔ Implant placement for the edentulous mandible ✔ Hands-on training with one-on-one mentorship ✔ Questions and answers with Dr. Moody and his faculty

Raleigh, North Carolina - Session 2: April 6 and 7, 2018 - Session 3: May 18 and 19, 2018

20 CE Credit Hours

16 CE Credit Hours

Chicago, Illinois - Session 2: June 8 and 9, 2018 - Session 3: July 13 and 14, 2018

SESSION 3:

SESSION 4:

✔ Uncovery of the dental implant, soft tissue and healing ✔ Implant impression techniques ✔ Implant restorations ✔ Key implant restorations for the edentulous maxilla ✔ Fabrication of the implant retained denture ✔ Guide fabrication and use of guided kit ✔ Immediate dental implant placement criteria for success ✔ Uncovery of the dental implant, soft tissue manipulation and healing times ✔ Implant impression techniques ✔ Implant restorations ✔ Key implant restorations for the edentulous maxilla ✔ Fabrication of the implant retained denture

Put your dental implant education to the test by helping the very people that need it the most. Perform live implant placement and restorations on patients in Phoenix, AZ.

16 CE Credit Hours

24 CE Credit Hours

Hands-On Training

Arizona Live Surgery

✔ Preoperative case work up of each patient using CBCT ✔ Implant placement on multiple patients over 2 days ✔ At least one edentulous mandible of implants for a removable denture ✔ Restorative experience of uncover, healing abutment placement and soft tissue manipulation ✔ Patient management and post operative recaps of cases

Phoenix, Arizona - Session 4: April 25 - 27, 2018 - Session 4: June 20 - 22, 2018 - Session 4: September 5 - 7, 2018 - Session 4: November 28 - 30, 2018 AND Introducing

Justin MOODY, dds Implant PATHWAY fOUNDER

Dr. Justin Moody is an internationally known dentist, entrepreneur, instructor and speaker in the fields of dentistry, practice management, technology and implantology. Dr. Moody has practices in Nebraska and South Dakota and is the founder of Implant Pathway, a leading Midwest dental CE provider. Dr. Moody knows how important dental continuing education is as well as the need for mentoring and hands-on training. His conversational, real-life approach solidifies his educational philosophy.

My Clinical Pathway (MCP) is an ADA CERP provider. CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/goto/cerp. Approval Term: 5/1/2015 through 6/30/2019

Dallas, Texas - Session 2: September 13 and 14, 2018 - Session 3: October 12 and 13, 2018

My Clinical Pathway (MCP) is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 4-1-2015 to 3-31-2019. Provider #: 342679

IMPLANT PATHWAY: FAST TRACK One week intensive training in Phoenix, AZ. Exclusive Session 4 for Fast Track registrants only.

Session 1: Online Only Session 2: November 5, 2018 Session 3: November 6, 2018 Session 4: November 7 - 9, 2018

REGISTRATION Register online at www.implantpathway.com or give us a call at (888) 309-2423. Student and New Dentist discounts available, e-mail austin@implantpathway.com.

Session 1: $2,332 Sessions 1-3: $6,996 Sessions 1-4: $16,995 / $150 per assistant

ON THE HORIZON

Patient comfort is the key to a positive experience Dr. Justin Moody discusses the gain of no pain

s dentists, I think we sometimes forget the fear that people feel when being treated at the dental office. Since we are so focused on presenting the case and what we can do for patients’ various dental conditions, often their comfort is just an afterthought. Dental implants and oral surgery are perhaps the most frightening procedures you could hear about, especially in today’s age, when we have YouTube® Figure 1: Primary closure is so important for getting the case and all the other social media platforms off to a good start adding to the overload of information and possible misinformation that instills even more apprehension. The power of social media reaches well beyond the promotion of our practices. Just this week, I had scheduled a bi-lateral sinus augmentation graft after meticulous patient education — only to have the patient call the next day to cancel. When asked why he was no longer coming Figure 3: Drs. Justin Moody, Mike Freimuth, and Danny Domingue providing in, the patient said he watched hands-on leadership at Implant Pathway Live Surgery Course the procedure on YouTube and decided it was not for him. Fear of the dentist is as real as the dental pain itself. Many of us think it’s just the anesthetic injection, but in all actuality, for most, it’s experiencing the pain of the procedure. As dentists really get a pass on the needle (our patients know it’s coming), it is uncomfortable for just a short time. There is no substitution for profound anesthesia during the case — get good at it, and use it. Even with this said, many still need some form of sedation to get over their initial fears. We can handle this at the office, but what about the postoperative pain?

Figure 2: Pharmacology will make you look like a rock star in your patients’ eyes — minimal swelling and pain should be one of your goals

Figure 4: Adequate alveoloplasty to provide for adequate restorative space for the final restoration

Figure 5: Postoperative cone beam CT taken to check implant placement Justin Moody, DDS, DICOI, DABOI, is a Diplomate of the American Board of Oral Implantology and of the International Congress of Oral Implantologists, Fellow and Associate Fellow of the American Academy of Implant Dentistry, and Adjunct Professor at the University of Nebraska Medical College. He is an international speaker and is in private practice at The Dental Implant Center in Rapid City, South Dakota. He can be reached at justin@justinmoodydds.com or at www.justinmoodydds.com. Disclosure: Dr. Moody is a paid speaker for BioHorizons®.

40 Implant practice

Good sound surgical principles and tissue manipulation go a long way in minimizing postoperative pain. So many of my cases are more complex and require large tissue reflections, multiple osteotomies, and extensive suturing. I have found that the use of a proper pharmacology protocol prior to implant treatment makes an even bigger difference. Prophylactic antibiotics have been shown to reduce infections, and a short-term dose

of a steroid such as Decadron will decrease swelling, which in turn will decrease pain. A NSAID will block alternate inflammation pathways that the steroid didn’t, and all of these will make you look like a rock star. Since implementing this regimen in my practice, more of my patients have had a positive experience and ultimately have left more positive social media reviews. Better to be known as the painless dentist! IP Volume 10 Number 6

better science, better implants is osseointegration enough? Only the Laser-Lok surface has been shown using light microscopy, polarized light microscopy and scanning electron microscopy to also be effective for soft tissue attachment. 1,2

Colorized SEM shows connective tissue physically attached to the Laser-Lok surface.1

Colorized SEM of Laser-LokÂŽ microchannels shows superior osseointegration3

interact at

laser-lok.com 1. Human Histologic Evidence of a Connective Tissue Attachment to a Dental Implant. M Nevins, ML Nevins, M Camelo, JL Boyesen, DM Kim. International Journal of Periodontics & Restorative Dentistry. Vol. 28, No. 2, 2008. 2. Histologic evidence of a connective tissue attachment to laser microgrooved abutments: a canine study. M Nevins, DDS, DM Kim, DDS, DMSc, SH Jun, DDS, MS, K Guze, DMD, P Schupbach, PhD, ML Nevins, DMD, MMSc. Accepted for publication: IJPRD, Vol 30, No. 3, 2010. 3. Maintaining inter-implant crestal bone height via a combined platformswitched, Laser-LokÂŽ mplant/abutment system: A proof-of-principle canine study. M Nevins, ML Nevins, L Gobbato, HJ Lee, CW Wang, DM Kim. Int J Periodontics Restorative Dent. Volume 33, Number 3, 2013. SPMP17297 REV A OCT 2017

The Power is On January 2018

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