Implant Practice US Winter 2018 Vol 11 No 4

clinical articles • management advice • practice profiles • technology reviews Winter 2018 – Vol 11 No 4 • implantpracticeus.com

PROMOTING EXCELLENCE IN IMPLANTOLOGY

PREDICTABLE

Same Day Teeth®/nSequence® Guided Prosthetics® protocol for immediate full-arch reconstruction Dr. Michael A. Pikos

n

PRECISE n

Primary stability: what does it mean?

Service profile Affordable Dentures & Implants

Corporate profile Planmeca Group

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION

CREDITS PER YEAR!

16

A comprehensive clinical review of plateletrich fibrin and its role in promoting tissue healing and regeneration: part 1 Drs. Johan Hartshorne and Howard Gluckman

PROACTIVE

Dr. Michael R. Norton

3D Guided Surgical and Restorative Workflow for Immediate Loading of Full Arches

To learn more, please visit nsequence.com or call 800.943.2314.

FULL-ARCH IMPLANT SOLUTIONS AHEAD

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LOCATOR R-Tx®

TWO PATHS. ONE DESTINATION. Patient REMOVABLE Prosthesis

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patient REMOVABLE overdenture Attachment System predicated on the award-winning and market-leading LOCATOR® design. BETTER. SIMPLER. STRONGER.

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Visit WWW.ZESTDENT.COM or call 800-262-2310.

©2018 Zest Anchors, LLC. All rights reserved. LOCATOR F-Tx, LOCATOR, LOCATOR R-Tx, Zest and Zest Dental Solutions are registered trademarks of ZEST IP Holdings, LLC.

Winter 2018 - Volume 11 Number 4

EDITORIAL ADVISORS Steve Barter, BDS, MSurgDent RCS Anthony Bendkowski, BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent Philip Bennett, BDS, LDS RCS, FICOI Stephen Byfield, BDS, MFGDP, FICD Sanjay Chopra, BDS Andrew Dawood, BDS, MSc, MRD RCS Professor Nikolaos Donos, DDS, MS, PhD Abid Faqir, BDS, MFDS RCS, MSc (MedSci) Koray Feran, BDS, MSC, LDS RCS, FDS RCS Philip Freiburger, BDS, MFGDP (UK) Jeffrey Ganeles, DMD, FACD Mark Hamburger, BDS, BChD Mark Haswell, BDS, MSc Gareth Jenkins, BDS, FDS RCS, MScD Stephen Jones, BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack, DDS, CertPerio, FCDS Samuel Lee, DDS David Little, DDS Andrew Moore, BDS, Dip Imp Dent RCS Ara Nazarian, DDS Ken Nicholson, BDS, MSc Michael R. Norton, BDS, FDS RCS(ed) Rob Oretti, BDS, MGDS RCS Christopher Orr, BDS, BSc Fazeela Khan-Osborne, BDS, LDS RCS, BSc, MSc Jay B. Reznick, DMD, MD Nigel Saynor, BDS Malcolm Schaller, BDS Ashok Sethi, BDS, DGDP, MGDS RCS, DUI Harry Shiers, BDS, MSc, MGDS, MFDS Harris Sidelsky, BDS, LDS RCS, MSc Paul Tipton, BDS, MSc, DGDP(UK) Clive Waterman, BDS, MDc, DGDP (UK) Peter Young, BDS, PhD Brian T. Young, DDS, MS CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day, BDS, VT Julian English, BA (Hons), editorial director FMC Dr. Paul Langmaid, CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul, BDS, LDS, FFGDP (UK), FICD, editor-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 2018. All rights reserved.

FMC is part of the specialist publishing group Springer Science+ Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproducedvw in any form whatsoever, including photocopies and information retrieval systems.

While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Implant Practice or the publisher.

I

mplant dentistry is unique in that it continues to evolve at a much faster rate than other forms of dentistry. The techniques, modalities, and designs regularly shift to address clinical needs such as primary and secondary stability concerns, peri-implantitis, accuracy, speed, and ultimately, patient demands.

It is in the area of patient expectations that many practitioners are seeing the most need for change. While optimal esthetic desires continue to perpetuate, the need for a more expeditious procedure is growing. This need is predicated by patients’ busy lifestyles, the constant onslaught of communication created by social media and other modalities, and the general busyness of the population overall. Recent reports indicate that Americans are finding themselves busier than ever, with data from the U.S. Bureau of Labor Statistics indicating that the average productivity of the American worker has increased 400% since 1950!

Less time can translate into a need for faster, more effective procedures. And for the partially or fully edentulous patients, or those who are terminally dentate, there is a need for a faster and more effective way to get a full arch replaced with implant-supported hybrid prosthetics.

Conventional methods require a laboratory technician to convert a denture chairside while a patient undergoes extractions, grafting, and other processes necessary to prepare the site for implants and the accompanying full-arch prosthetic. This time requirement can extend a procedure to more than 5 hours, while the patient remains in the chair. Oftentimes, the patient is sedated during the surgical portion of the procedure and then awakens to find that his/her teeth have been extracted and he/she is now edentulous. This can cause anxiety in a patient that may be exacerbated by prolonged time awaiting a provisional prosthetic to be fabricated by a technician.

Advancements in guided technology are now allowing for more complex procedures involving numerous implants and an entire arch to be conducted in a precise manner due to collaborative, comprehensive, yet convenient preplanning sessions. Patients typically prefer this type of dentistry because it can reduce time in the dental office from 4-6 hours per arch to 3-4 hours when performed properly.

Guided surgery workflows, pioneered by laboratories like nSequence® in Reno, Nevada, transform full-arch surgery into a precise, preplanned effort by having the surgeon, restorative dentist, and lab personnel participate in a comprehensive consult prior to the surgery, which allows for all parties to agree on the exact course of treatment to be taken. This collaborative approval also allows for fabrication of the provisional restoration — in this case, a PMMA prosthetic reinforced by an integrated metal bar, based on a set of clearly mapped diagnostics, readily available day of surgery. This adjustment allows for placement of the provisional within an hour of suturing after implant placement occurs. The patient is then given a set of teeth in a more expeditious manner and is able to be immediately loaded with immediate function for a more pleasing experience.

The need to freehand implant placement is sometimes unavoidable, as CBCT technology — while precise — is not entirely without error. There are instances where dehiscences or other bony defects may not be visible, and therefore, flap reflection during these types of cases may reveal an unexpected challenge. However, when possible, the conveniences allotted by preplanning a case and the ability to fabricate a provisional for the day of surgery are numerous. These benefits address the growing need to make implant dentistry — even more comprehensive cases — convenient for the busy patients or for the patients who do not want to endure long hours of post-surgical time in a dental office awaiting their new teeth.

Dr. Michael A. Pikos

Michael A. Pikos, DDS, is originally from Campbell, Ohio. He attended The Ohio State University where he graduated Summa Cum Laude and Phi Beta Kappa. He also graduated with honors from the Ohio State University College of Dentistry. Dr. Pikos completed an internship at Miami Valley Hospital and residency training in Oral and Maxillofacial Surgery at the University of Pittsburgh, Montefiore Hospital. He is a Diplomate of the American Board of Oral and Maxillofacial Surgery, Diplomate of the American Board of Oral Implantology/Implant Dentistry, Diplomate of the International Congress of Oral Implantologists, and a Fellow of the American College of Dentists. Dr. Pikos is the recipient of the 2006 Aaron Gershkoff Memorial Award from the American Academy of Implant Dentistry, and the 2015 Saul Schluger Memorial Award for Top Educator. Dr. Pikos has extensive experience in implant surgery and hard and soft tissue procedures. He also emphasizes interactive CT technology along with foundational principles of prosthetics and biomechanics that dictate the ultimate success of comprehensive implant rehabilitation. Dr. Pikos is founder and CEO of the Pikos Institute. Since 1990, he has been teaching advanced bone and soft tissue grafting courses with alumni who now number more than 3,700 from all 50 states and 43 countries. Dr. Pikos maintains a private practice, which is limited exclusively to implant surgery in Trinity, Florida.

ISSN number 2372-9058

Volume 11 Number 4

Implant practice 1

INTRODUCTION

Improving outcomes through preplanning and preparation

TABLE OF CONTENTS

Service profile Affordable Dentures & Implants

6

Making a difference for patients in need through best-in-class implant training

Case study A well-placed and integrated implant after proper atraumatic extraction and preparation of an extraction site Dr. Robert J. Mikhli discusses a technique for predictable and reproducible atraumatic extraction and socket preservation........................ 12

Case study Same Day Teeth®/nSequence® Guided Prosthetics™ protocol for immediate full-arch reconstruction

Corporate profile Planmeca Group

8

Dr. Michael A. Pikos describes a treatment plan for patients who request quick results........................18

A global leader in health care technology

ON THE COVER Cover photo courtesy of Dr. Michael A. Pikos.

Article begins on page 18.

2 Implant practice

Volume 11 Number 4

FULL-ARCH THERAPY ON FOUR IMPLANTS

THEIRS 1.

Place implant.

2. Use reamers to remove and reshape bone, or find a compromise in implant placement between the mesial-distal aspect of the bone.

OURS 1.

Place the OsseoSpeed Profile EV implant at an angle and see how the implant neck aligns with the anatomy.

3. Use every trick in the book to make it work.

Images for illustrative purposes only.

Another workaround made obsolete

by Dentsply Sirona Implants.

Tired of having to make bone disappear to align an angled implant to a flattened anatomy? Our SmartFix concept for the Astra Tech Implant System EV is designed with attention to detail that can help you avoid workarounds in complex restorations. The sloped design of the OsseoSpeed Profile EV implant allows the implant neck to naturally align to the anatomy when placed at an angle— eliminating the need to compromise with submerged implant placement and additional bone removal.

Di s cove r Den t spl y Si ron a i mpl an t s’ l i n e of fully ed entulous s olutions : S C R E W- R E TA INED | ATTACHM ENT-R ETAINE D | FRICTION-RE TAINE D

Implants

TABLE OF CONTENTS

Continuing education Continuing education Primary stability: what does it mean?

Dr. Michael R. Norton asks whether we really know what we’re measuring when assessing the solidity of implant placement...................................32

24

A comprehensive clinical review of platelet-rich fibrin and its role in promoting tissue healing and regeneration: part 1 Drs. Johan Hartshorne and Howard Gluckman examine the definition, development, biological characteristics, and function of PRF in all its many guises

Practice management Event recap What do gossip and gum disease have in common?

Cynthia Goerig discusses achieving an office environment based on teamwork ...................................36

Inaugural 3Shape Community Symposium.........44

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

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

Product profile

VP, SALES & BUSINESS DEVEL. | Mark Finkelstein Email: mark@medmarkmedia.com

Removable and fixed LOCATOR® Attachment Systems

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

Innovative advancements in full-arch implant solutions..........................39

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

Technology

On the horizon

Technology, techniques, and trends to look for in 2019

You don’t have to be a buccal plate extractor anymore!

Dr. Matthew Nichols discusses some trends that will change practice protocols in the future...................40

Dr. Justin Moody discusses a new tool for efficient tooth extraction before an immediate implant........................48

FRONT OFFICE ADMINISTRATOR | Melissa Minnick Email: melissa@medmarkmedia.com

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 | Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.implantpracticeus.com | www.medmarkmedia.com

SUBSCRIPTION RATES 1 year (4 issues) $149 | 3 years (12 issues) $399

4 Implant practice

Volume 11 Number 4

PREAT HELPS PROTECT YOUR GOALS

“Supporting restorative dentistry with more than parts….”

RESTORING CONFIDENCE

RESTORING VALUE

RESTORING PARTNERSHIP

www.PREAT.com • 800-232-7732 • info@PREAT.com

SERVICE PROFILE

Affordable Dentures & Implants Making a difference for patients in need through best-in-class implant training

A

ffordable Dentures & Implants (AD&I) affiliated Practice Owners and their dental and lab teams have the opportunity to participate in a weeklong Implant Training program, offered through Affordable Care, at Brighter Way Dental Clinic in Phoenix.

The training, which is offered several times a year, provides a lecture and live surgery experience that focuses on team building and teaching the surgical and restorative elements of implant dentistry.

The patients treated in the program are patients of Brighter Way Dental Clinic, which provides comprehensive dental care to the underserved, including homeless individuals, military veterans — many who do not receive dental benefits through the U.S. Department of Veterans Affairs — victims of domestic abuse, and immigrant parents of children treated at Brighter Way’s pediatric clinic. The downtown Phoenix dental clinic is located on the campus of one of the first centralized facilities in the United States that provides comprehensive shelter and supportive services for the homeless.

A group of Practice Owners from Affordable Dentures & Implants listen to Dr. Jase Hackney, Practice Owner, Affordable Dentures & Implants in Tampa, Florida, during live implant training at Brighter Way Clinic in Phoenix. Dr. Hackney serves as a member of the faculty for the training course.

“Our Mission is front and center in this training program as we work to provide a team environment for AD&I-affiliated doctors and staff to learn from some of the best faculty in the country while making a positive impact in the lives of people who would not have access to high-quality dental care,” explains Jim Smyros, Senior

Director of Operations, Implant Services, Affordable Care.

For practice ownership and career opportunities with Affordable Dentures & Implants, please visit info.affordabledentures. com/careers or call 888.837.3033. IP This information was provided by Affordable Care.

A Practice Owner’s Journey into Implants After 30 years in private practice, Dr. Saba Khalil, Practice Owner of Affordable Dentures & Implants (AD&I) in St. Louis, Missouri, had a successful career in general dentistry. “I started out in a General Practice Residency at the VA Medical Center, and gained extensive surgery experience and proficiency with dentures because of the patient population,” explains Dr. Khalil. “Then I transitioned to treating sleep apnea patients, but during my years in private practice, I never received implant placement training.”

He adds, “I had the background in surgeries and dentures, but I wanted to also expand into implants.” Nearly a year ago, Dr. Khalil became a new AD&I Practice Owner and took his first Implant Training course through Affordable Care. Fast-forward to today: Implants are part of Dr. Khalil’s practice for the first time in his 30-plus years in dentistry.

“I now talk with patients routinely about implants, and patients ask me about implants as well,” explains Dr. Khalil. “Implants are a key part of my growing practice because of the benefit, demand, and affordability of implants in the AD&I network.”

He adds, “Implants have provided me with an energy and excitement to work harder than ever for my patients. Joining the AD&I network was the best decision I could have made.”

Photo: Dr. Saba Khalil, Practice Owner, Affordable Dentures & Implants in St. Louis, Missouri, places his first implants during Affordable Care’s live implant training course at Brighter Way Clinic in Phoenix.

6 Implant practice

Volume 11 Number 4

CORPORATE PROFILE

Planmeca Group

Planmeca showroom in Helsinki, Finland

A global leader in health care technology

S

hiny white design and devices with colors from metallic silver to lime green, 3D-printed skulls of humans and pets in illuminated glass display cabinets, touchscreens surrounding the devices that look like they’re parts of a spaceship. This futuristic yet inviting pastel-colored scene is not part of a science fiction novel but is reality in a showroom in Helsinki, Finland. This showroom belongs to the Planmeca Group, a company that develops and manufactures cutting-edge Finnish health care technology.

Planmeca Group’s product range covers high-technology dental care equipment, world-class 2D- and 3D-imaging devices, comprehensive CAD/CAM and software solutions, mammography systems as well as dental instruments, supplies, and services.

President and founder of Planmeca, Heikki Kyöstilä, has seen his company and the industry evolve hand-in-hand. Fortyseven years ago, in 1971, Kyöstilä saw a market opportunity for manufacturing dental equipment after doing business for German companies in the same field and decided to start a company of his own. Today, the parent company of the group, Planmeca Oy, is the third-largest dental equipment manufacturer in the world and also the largest privately owned company in the field.

“It was all about hard work and an urge to put Finland on the map. And today, Planmeca is a global leader in health care technology,” said Kyöstilä.

8 Implant practice

Planmeca’s aim is to create functional, durable, and beautifully designed products that stand the test of time. Planmeca’s dental care units, X-rays, and software solutions are all designed and manufactured in Finland.

Using the latest technology and the best materials, products are tailored to meet the needs of dental professionals in different markets. Planmeca Group’s advanced mammography and orthopedic imaging products are manufactured by the group’s subsidiary Planmed Oy. Plandent Division of the group is the biggest dental supply and service chain in Northern Europe. The division consists of comprehensive dental supply houses, which offer innovative digital solutions and supply high-tech equipment manufactured by Planmeca. The division also offers a comprehensive selection of high-quality materials and instruments from the world’s leading manufacturers.

Over 98% of products manufactured by Planmeca are exported around the world.

Planmeca Group operates in over 120 countries, employing nearly 2,700 people worldwide.

Kyöstilä explains that a strong commitment to building customer relationships around the world and a passion for innovation guide everything the company does. Customers provide the company with the focus to consistently develop revolutionary technology and gain a deep

Heikki Kyöstilä, president and founder of Planmeca

understanding of the needs of dental and health care professionals. He believes these values have led them to where they are today — at the forefront of the dental industry.

Strong commitment to R&D The secret behind the success and never-ending innovation decade after decade is, according to Kyöstilä, a strong and unwavering commitment to R&D. “As a privately owned company, we are in control of our own destiny and able to make the long-term R&D commitments that are the driving force behind our innovations.

We also collaborate closely with health care professionals and leading universities. I firmly believe that this dedication to continuous development will enable us to make the work of dental professionals easier and more efficient for many years to come.”

Up to 10% of the company’s annual revenues are invested in R&D. Planmeca’s in-house R&D department employs 140 people: a mixed group of experts, including software, mechanics, and electronics engineers together with usability and industrial designers. Unrivaled scientific knowledge and in-depth understanding of clinical Volume 11 Number 4

A digital pioneer Already in the late 1990s, Planmeca realized that a shared software platform would be the logical next step, bringing diagnostics and treatment planning into a single workflow. Planmeca’s solution for this was, and still is, the ever-evolving Planmeca Romexis®, an all-in-one software connecting all of the equipment in a dental clinic.

Volume 11 Number 4

Planmeca USA, Inc. Planmeca USA, the North American Subsidiary of Planmeca, was launched in

1987 and the first to introduce the softwaredriven dental care unit concept in America.

For the past 31 years, Planmeca USA has lead the North American dental industry with advanced dental imaging systems starting with film based, then digital 2D, and now 3D-imaging equipment with patented SCARA (Selectively Compliant Articulated Robotic Arm) technology. Today, it is one of the most admired dental-imaging companies in North America.

Planmeca offers one of the most robust product lines in the world, which includes dental care units, dental lights, dental stools, dental cabinets, intraoral X-rays, intraoral sensors, 2D extraoral imaging, 3D imaging products, chairside milling units, and intraoral scanners.

“The U.S. is one of the most competitive regions in the dental industry. As a company, Planmeca USA is poised to solidify its position as a leader across several categories within the dental market. A strong product line, energized product launches, and an innovative pipeline will provide the company with upward momentum and exciting times for the U.S. division,” states President for Planmeca USA, Edwin J. McDonough.

Planmeca’s newest technology, Planmeca Viso™, has the capability of capturing the industry’s largest single scan volume covering the entire maxillofacial area. McDonough describes the technology — “the innovation that paves the way for the launch of Planmeca 4D™ Jaw Motion, a new exclusive

Implant practice 9

CORPORATE PROFILE

workflows are vital parts of the product development.

In 2011, Planmeca launched the concept of digital perfection. The company took digital imaging to the next level by enabling the combination of three different 3D datasets (photo, X-ray data, and digital impression) into one complete 3D model.

Planmeca was also among the forerunners to market the integration of CAD/CAM to dental treatment units. Due to the open-source STL file format of Planmeca’s CAD/CAM solutions, it is easy for dentists to connect with the rapidly growing computer-aided dental manufacturing community. The Planmeca FIT™ solution offers dentists a completely integrated and digital workflow with three simple steps — ultra-fast intraoral scanning, sophisticated design, and high-precision chairside milling. All of this is seamlessly integrated into Planmeca Romexis software.

CAD/CAM dentistry is an integral part of Planmeca today — a wide range of open architecture CAD/CAM solutions lets the dental professionals choose their preferred way to treat patients, improve workflow, and opens opportunities in growing the business scope. Planmeca’s newest intraoral scanner, Planmeca Emerald™, was designed on an open architecture platform and lets dentists offer more services by collaborating with laboratories or integrating additional equipment within their office.

CORPORATE PROFILE

Mill manufacturing line

X-ray production

specialty program, is the only CBCT integrated solution for tracking, recording, visualizing, and analyzing jaw movement in 3D in real-time.”

McDonough describes a company initiative that focuses on offering dentists specialty workflows, more treatment options, and ultimately better patient care through efficiency.

“With our current products and additions to the product portfolio, Planmeca can offer solutions to meet the needs of patients needing restorations, orthodontics, and even implants. Anticipating the needs of our clinicians is our number one priority. One area of dentistry that we will be exploring in the future is 3D printing. Planmeca Creo™ C5 is a new product tailored to meet the needs of our orthodontic partners and is primed to be a blockbuster for our CAD/CAM Division,” McDonough says.

All of Planmeca’s imaging, dental care units, and CAD/CAM products are built on open-architecture platforms. Designed with clinicians in mind, Planmeca’s upgradable, modular platform allows doctors to keep up with new technology by easily integrating the newest advances in hardware and software.

Elements of future growth Planmeca has stayed on the cuttingedge of dental products now for almost

1971

1979

1986

Planmeca OY The 1st dental unit founded in brought to market Helsinki, Finland

The 1st patient chair brought to market

1975 10 Implant practice

half a century. The plan is to stay on the cutting-edge in the future too. But what does the future of dentistry and health care technology look like? Kyöstilä sees a digital future ahead.

“We are living in an exciting era. Dentistry is at a crossroads; the digital revolution has already begun. In the future, dentistry will be completely digital, and 3D technology is going to transform the entire field. Software-driven innovations are now the heart of progress, and cloud services are reality.

This presents unforeseen opportunities, but also new challenges.”

“The industry is moving from products to services. In a completely digital dental workflow, it will be of paramount importance that all devices and software work together completely seamlessly. The future will not only be digital, but also increasingly mobile.

This reality is at the core of all Planmeca product development,” Kyöstilä explained.

When Kyöstilä describes his visions of the industry’s future, phrases like software, industrial internet, 3D printing, CAD/CAM, 3D, and even 4D keep coming up.

“It is our goal to design and manufacture high-end digital products that work together as smoothly as possible. To achieve this, we have been forerunners in building a rich ecosystem of devices, software, and

Planmeca introduces 1st microprocessor controlled dental chair

1983

2006

Launched a microprocessorcontrolled panoramic X-ray device

This information was provided by Planmeca Group.

2008

Launched all-in-one Planmeca Romexis software, Planmeca Clinic Management introduced Romexis

Cone Beam Volumetric Dental Unit with symmetrical Tomography system for 3D motorized movements dental imaging introduced enabling fully adaptable unit

2005

services. Our unrivaled product portfolio covers everything needed in a high-tech dental clinic: all 2D- and 3D-imaging modalities together with digital treatment centers, CAD/CAM systems, and software.”

“Software used to be something people received with the device they purchased, but now software is often the most important product. Software is the brains behind the products. We keep developing our software solutions and improving them constantly. This is all part of our goal to create the most powerful dental ecosystem in the market.”

“At Planmeca, we always operate with the future in mind. The possibilities with CAD/ CAM, 3D, and even 4D are endless. I strongly believe that Planmeca will guide dentistry into the future like no one else can.”

Planmeca USA has distribution in the United States and Canada servicing over 160 dealer locations throughout North America. Currently, Planmeca USA maintains 42 sales representatives in the field, one of the best management teams in the industry, and 40 technical support professionals with a total of over 135 employees supporting our North American distributors and doctors. IP

2007

Planmeca Digital Academy launched – education/ training

2016

2017

Planmeca Planmeca PlanMill 40 Emerald S launched launched

Full range of open Planmeca Romexis Planmeca Viso CAD/CAM solutions 4.0 – 1st software to and 4D Jaw to labs and dentists combine imaging Motion launched and CAD/CAM 2013 2018 workflow.

Volume 11 Number 4

Experience the Planmeca Difference No one understands the demands of the specialist like Planmeca. Colleagues and patients depend on your expert analysis and treatment. Like you, we know the smallest details matter.

Planmeca ProMax® 3D

Our Planmeca product line offers advanced technology to support the complete implant workflow:

•

3D imaging with high resolution options to capture detailed information

•

Fast and accurate full arch scanning with the ability to combine STL and DICOM files for accurate treatment planning

•

Comprehensive implant planning and guide design software for predictable outcomes

The small things form the big picture – delivering treatment and care your patients deserve.

Learn more about Planmeca solutions today.

630-529-2300

www.planmecausa.com

© Planmeca U.S.A. Inc. 11.2018. All Rights Reserved

Planmeca Romexis® Implant Guide Planmeca Emerald™

CASE STUDY

A well-placed and integrated implant after proper atraumatic extraction and preparation of an extraction site Dr. Robert J. Mikhli discusses a technique for predictable and reproducible atraumatic extraction and socket preservation Introduction As procedures and techniques in dentistry continue to progress, several treatment techniques should be well understood to achieve predictable and successful clinical outcomes. Atraumatic extractions and proper bone grafts in dentistry are critical to achieve desirable esthetic results as well as an adequate foundation for implant placement. As practitioners, we need to know what steps are essential to properly accomplish an atraumatic extraction and socket preservation, and what some of the preferred instruments and materials are recommended. The purpose of this article is to examine the proper technique for atraumatic extraction, review steps to achieve predictable and successful socket preservation, and to discuss recommended materials and instruments.

margins, and distal overhang on tooth No. 19. The patient desired a treatment plan that would remove tooth No. 17 immediately due to discomfort and persistent food

trap and restore or replace tooth No. 19. The evaluation for an implant, No. 19, was made utilizing a visual clinical assessment, digital radiographs, and 3D CBCT.

Case description A 62-year-old-female patient presented to the office with terminal case type III periodontitis1 with grade III mobility on tooth No.17 and terminal case type III periodontitis with grade II mobility, recurrent decay, open

Figure 1: Preoperative panoramic radiograph

Robert J. Mikhli, DDS, is a top-rated dentist offering dental implants and oral surgery at Precision Implant Care, located in Brooklyn, New York’s Midwood neighborhood. Dr. Mikhli utilizes state-of-the-art surgical approaches and technology to restore oral health and enhanced esthetics to patients with damaged, diseased, or missing teeth. Dr. Mikhli is praised for both for his exceptional skill and ability to put patients at ease, including those who have avoided going to the dentist for years. Originally from Cleveland, Ohio, Dr. Mikhli has made New York his home since attending Yeshiva University in Manhattan, where he graduated with a Bachelor of Arts in Economics. Dr. Mikhli continued his education at Stony Brook School of Dental Medicine, earning his Doctor of Dental Surgery. Following dental school, Dr. Mikhli completed a 1-year General Practice Residency at New York Hospital of Queens, followed by an additional 1-year fellowship in oral and maxillofacial surgery and implantology, also at New York Hospital of Queens. The fellowship program provided Dr. Mikhli with extensive training in both the surgical and prosthetic aspects of implant dentistry.

In addition to working in private practice, Dr. Mikhli is a recognized expert in implantology, who lectures extensively on the topic to other dental professionals throughout the Tri-state area. He also runs an in-office mentorship program for general dentists, providing hands-on instruction in implant surgery. He is a member of the American Dental Association, Academy of General Dentistry, American Academy of Implant Dentistry, and Academy of Osseointegration.

Disclosure: The author declares that he has no financial interest in the products mentioned.

12 Implant practice

Figure 2: Terminal case type III periodontitis with grade II mobility, recurrent decay, open margins, and distal overhang on tooth No. 19 Volume 11 Number 4

CASE STUDY

Figure 3: Materials: allograft, chlorhexidine, HeliPLUG

Figure 4: Preparing allograft in bone bowl

Prior to surgery Proper patient consent was obtained verbally and in writing. Blood pressure was obtained. Written details of the procedure were sent to the referring provider.

Stage 1: atraumatic extraction and bone grafting (conducted in two visits — due to patient need) • Atraumatic extraction of tooth No. 17 • Atraumatic extraction of tooth No. 19 • Bone grafting for socket preservation site tooth No. 19 The patient was given 440 mg naproxen at the beginning of the procedure. Anesthetic included 20% benzocaine topical for L IA, LB. The total given was 3 carpules (1.7mL) of Septocaine® (Septodent USA), 4% with epinephrine 1:100,000, injected. Profound anesthesia was acquired.

Teeth Nos. 17 (first visit) and 19 (second visit) were extracted atraumatically with an extraction kit (Karl Schumacher) consisting of periotome, proximators, and elevators to sever periodontal ligaments from the socket to preserve surrounding bone. Teeth were sectioned and removed. The socket was thoroughly debrided of all granulomatous tissue, and remaining periodontal ligament fibers with curettes and flushed with 0.12% chlorhexidine gluconate. 2 cc’s of demineralized cortical/cancellous allograft (250-1000 microns) (Karl Schumacher) was placed into the socket; HeliPLUG® (Miltex-Integra) absorbable collagen wound dressing was placed for graft containment; 2 resorbable 14 Implant practice

Figure 5: Placement of allograft image 1

Figure 6: Allograft placement image 2

Figure 7: Allograft placement image 3

Figure 8: Placement of HeliPLUG wound dressing Volume 11 Number 4

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CASE STUDY

Figure 9: Demineralized cortical/cancellous allograft (250-1000 microns) (Karl Schumacher)

4-0 chromic sutures were placed. Postoperative instructions were given to the patient, and she was scheduled for 2-week post-up follow-up.

Stage 2: placement of implant • Preoperative radiograph to evaluate allograft • Placement of endosseous implant, site No. 19 The patient was given 440 mg naproxen at the beginning of the procedure. Anesthetic included 20% benzocaine topical for L IA, LB. The total given was 4 carpules (1.7mL) of Septocaine®, 4% with epinephrine 1:100,000, injected. Profound anesthesia was acquired.

Tissue was reflected to reveal the ridge.

An osteotomy performed into site No. 19, implant (Blue Sky Bio Max) 5.0 x 6 mm placed, 1-2 mm subcrestal and torque of 20N/cm was obtained. A cover screw was placed. Four resorbable 4-0 chromic sutures were placed. Postoperative instructions were given to the patient, and she was scheduled for 2-week post-up follow-up and subsequent surgical uncovering after 4 months of healing, and referred back to referring provider for abutment and crown placement.

Stage 3: completion (at referring provider) The final stage of the treatment plan, performed at the patient’s referring provider, was the placement of the abutment and crown.

Discussion There are numerous treatment possibilities for a tooth with a terminal prognosis.

16 Implant practice

Figure 10: Implant placement tooth No. 19 site

Atraumatic extractions and proper bone grafts in dentistry are critical to achieve desirable esthetic results as well as an adequate foundation for implant placement.

What course of treatment and when to begin treatment is a collaborative effort that involves the patient, the dental team, and the referring provider. Proper understanding of the techniques and materials is vital in achieving predictable and successful clinical outcomes.

The aforementioned treatment was initiated by the patient to resolve pain, discomfort, and food impaction while retaining at least one molar and maintaining proper occlusion.

With the proper atraumatic extraction and preparation of an extraction site, the prognosis for a well-placed and integrated implant is possible. Restorative-wise, as clinicians, we can bypass cantilevers and removable prosthetics with well-placed implants. From the perspective of a patient, restoring a single tooth, having the ability to still place dental floss between his/her teeth, not damaging a healthy proximal tooth, or not having a prosthesis that needs to be removed and inserted periodically are significant motivators to elect for the placement of a dental implant.

Conclusion Predictable and successful preparation of an area for implant placement is attainable with proper atraumatic extraction technique, proper socket preservation technique, and proper instruments and materials. Through a proper visual clinical exam,

digital radiographs, and a 3D CBCT scan to screen the patient, the treatment can be carefully planned for each specific patient.

When considering what the patients desire for their clinical outcome and understanding the most effective treatment modality to achieve the ideal outcome, the provider will need to determine the most effective way to educate the patients on the treatment path.

Effective communication, addressing the desires of the patient, while conforming to proper clinical technique, will increase case acceptance. The key to effective communication is to make sure patients know what to expect before and after the procedure from their perspective. Most patients do not want to discuss the procedure itself, but rather patients want to know what they will feel, see, hear, and taste during the visits, and what will happen when they get home.

Finally, make sure to provide a reasonable time line for surgical procedures. Although there can be additional clinical stages and patient visits, it has been the author’s experience that patients’ expectations are met and often exceeded when communication has been effective from the beginning. IP REFERENCE 1. Wiebe CB, Putnins EE. The periodontal disease classification system of the american academy of periodontology — an update. J Can Dent Assoc.2000;66(11):594-597.

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CASE STUDY

Same Day Teeth®/nSequence® Guided Prosthetics® protocol for immediate full-arch reconstruction Dr. Michael A. Pikos describes a treatment plan for patients who request quick results

T

his is a 59-year-old Caucasian female, Joanne, who presented to the office with chief complaint of “I hate my teeth; there are spaces, and they look bad.” Present medical history is essentially unremarkable.

Patient is a nonsmoker.

Clinical and CBCT evaluation revealed the following pertinent findings: Maxilla — Partially pneumatized sinuses without evidence of pathology was noted.

Teeth Nos. 3-13 are present with varying degrees of vertical bone loss present particularly with teeth Nos. 4, 5, 12, 13.

Mandible — Teeth Nos. 20-28 are present again in varying degrees of vertical bone loss present with spacing between several teeth. Remainder of oral as well as head and neck exam was within normal limits. In summary, diagnosis was consistent with Class II deep bite with splayed maxillary dentition secondary to collapse of vertical dimension and loss of posterior mandibular dentition and moderate-severe periodontal disease.

Joanne was given several treatment options that included serial extractions followed by root form implant placement for fixed work. This would also include restoration of existing teeth. Another option presented included serial extractions and RPD appliances. The third option was the Same Day Teeth® protocol for both arches. Joanne was very adamant about wanting “new teeth,” and thus, we proceeded with addressing both arches with the Same Day Teeth®/

Figure 1

nSequence® Guided Prosthetics™ protocol for immediate full-arch reconstruction.

Comprehensive evaluation and record taking was done followed by an online meeting with nSequence® along with our restorative and surgical team. Subsequently,

Michael A. Pikos, DDS, is originally from Campbell, Ohio. He attended The Ohio State University where he graduated Summa Cum Laude and Phi Beta Kappa. He also graduated with honors from the Ohio State University College of Dentistry. Dr. Pikos completed an internship at Miami Valley Hospital and residency training in Oral and Maxillofacial Surgery at the University of Pittsburgh, Montefiore Hospital. He is a Diplomate of the American Board of Oral and Maxillofacial Surgery, Diplomate of the American Board of Oral Implantology/ Implant Dentistry, Diplomate of the International Congress of Oral Implantologists, and a Fellow of the American College of Dentists. Dr. Pikos is the recipient of the 2006 Aaron Gershkoff Memorial Award from the American Academy of Implant Dentistry, and the 2015 Saul Schluger Memorial Award for Top Educator. Dr. Pikos has extensive experience in implant surgery and hard and soft tissue procedures. He also emphasizes interactive CT technology along with foundational principles of prosthetics and biomechanics that dictate the ultimate success of comprehensive implant rehabilitation. Dr. Pikos is founder and CEO of the Pikos Institute. Since 1990, he has been teaching advanced bone and soft tissue grafting courses with alumni who now number more than 3,700 from all 50 states and 43 countries. Dr. Pikos maintains a private practice, which is limited exclusively to implant surgery in Trinity, Florida.

Disclosure: Dr. Pikos is a paid consultant for NDX nSequence.

18 Implant practice

two-jaw surgery was proposed, and as you will see from the images, shown on page 20, the virtual treatment planning was accomplished followed by subsequent surgery at which time the conventional nSequence® Guided Prosthetics™ protocol was followed with appropriate bone foundation guides, surgical guides, and placement of implants via a fully guided approach. Subsequently, the maxillary and mandibular long-term fixed provisionals were placed. You will also note the 4-year follow-up with radiographs and clinical results. Five implants were placed in the maxilla followed by a full-arch zirconium hybrid final prosthesis, and four implants were placed in the mandible followed by a full-arch acrylic-wrap hybrid prosthesis.

Without question, we, as clinicians, were able to experience tremendous feedback from Joanne in that her quality of life Volume 11 Number 4

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Implant is placed lingually following extraction. OsteoGen® Strip will be used to fill gaps and to reinforce the buccal wall

The OsteoGen® Strip is a hydrophilic material that can be hydrated with patients blood and substantially compressed to fill a variety of defects

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Buccal plate is reinforced by feeding the OsteoGen® Strip downwards in between the implant and the buccal wall

OsteoGen® Strip is in place which reinforces the buccal wall while grafting the gaps between the buccal plate and the implant

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CASE STUDY

Figure 2: Virtual treatment planning — virtual corrections and additions

Figure 3: Original mounting

Figure 4: Optimal setup — preplanning prosthetic design

We, as clinicians, were able to experience tremendous feedback from Joanne in that her quality of life changed dramatically, and her self-image was transformed remarkably.

Figure 5: Optimal setup — preplanning prosthetic design with bone reduction

Figure 6: Virtual treatment planning maxilla

Figure 7: Virtual treatment planning mandible 20 Implant practice

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CASE STUDY

Figure 8

Figure 9

changed dramatically, and in fact, her selfimage was transformed remarkably as is true for so many of our patients treated with this wonderful technology.

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Figure 13: 4-year follow-up 22 Implant practice

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CONTINUING EDUCATION

A comprehensive clinical review of platelet-rich fibrin and its role in promoting tissue healing and regeneration: part 1 Drs. Johan Hartshorne and Howard Gluckman examine the definition, development, biological characteristics, and function of PRF in all its many guises

T

he introduction and development of platelet-rich fibrin (PRF) as a biomaterial has set in motion an exciting and promising era in the advancement of tissue healing and regeneration in the fields of implant dentistry, periodontology, oral surgery, and regenerative endodontics.

PRF is an autologous fibrin-based (membrane, matrix, or scaffold), living biomaterial, derived from human blood, also referred to as an optimized blood clot.

The key elements required to promote tissue healing and regeneration are the fibrin (serving as a supporting matrix), the platelets (rich in growth factors), cells (mostly the various populations of leukocytes, and stem cells for their antibacterial, neovascularization, and regenerative properties). These key elements are all active components of PRF. PRF can be easily prepared at chairside within a short period of time and provides the surgical wound area or defect not only with a matrix or scaffold permitting cell migration into the defect area, but also crucial biological signals or growth factors that can accelerate the wound healing and regeneration process.

The purpose of PRF technology is to extract from a patient’s blood sample these key elements and to prepare it in a clinically usable form such as a membrane or plug (A-PRF, L-PRF, or CGF) or injectable liquid (i-PRF). The function of PRF is to connect the various elements within the fibrin matrix with local tissues (bone and soft tissue) to accelerate neoangiogenesis within the tissue and to enhance its healing and regeneration potential.

Johan Hartshorne, BSc, BChD, MChD, MPA, PhD(Stell), FFPH RCP(UK), is a general dental practitioner working in Bellville, Cape Town, South Africa.

Howard Gluckman, BDS, MChD (OMP) (Wits) is a specialist in periodontics and oral medicine. He is director of The Implant and Aesthetic Academy, Cape Town, South Africa.

24 Implant practice

Educational aims and objectives

This article aims to review the scientific literature on platelet-rich fibrin (PRF) with the intent of answering several questions about its application in dental surgery.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 31 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify the composition and application of PRFs.

•

Analyze the available scientific literature on PRF regarding its definition and purpose in the clinical environment.

•

Realize aspects of the development and classification of platelet concentrate biomaterials.

•

Identify biological characteristics, composition, and function of key elements of PRF.

•

Read about how PRF evolved and developed to where it is today.

The PRF technique continues to develop because it is very easy to prepare, inexpensive, and allows the quick production of natural fibrin membranes, enriched with platelets and leukocytes, that can be used immediately in any clinical situation.

The purpose of this article — part 1 of a comprehensive review — is to analyze the available scientific literature on PRF regarding its definition and purpose in the clinical environment; development and classification of platelet concentrate biomaterials; and the biological characteristics, composition, and function of key elements.

Part 2 will look at preparation technique and optimizing the quality and benefits of PRF, while part 3 will address the clinical applications of PRF in implant dentistry, periodontics, oral surgery, and regenerative endodontics.

This article is intended to analyze the available literature on a number of questions: 1. What is platelet-rich fibrin (PRF)?

2. How did PRF evolve and develop to where it is today?

3. What are its biological characteristics and composition, and how do these key elements function within the clinical environment?

Figure 1: The blood concentrate after centrifugation has a visible yellow fibrin portion at the top and a red blood cell portion at the bottom

Introduction The prospect of having new therapies, biomaterials, and bioactive surgical additives available that will improve success and predictability of patient outcomes in soft and bone tissue healing and regeneration are key treatment objectives in implant dentistry, periodontology, and oral surgery.

PRF, a patient blood-derived and autogenous living biomaterial, is increasingly being investigated and used worldwide by clinicians as an adjunctive autologous biomaterial to promote bone and soft tissue healing and regeneration. The gold standard for in Volume 11 Number 4

vivo tissue healing and regeneration requires the mutual interaction between a scaffold (fibrin matrix), platelets, growth factors, leukocytes, and stem cells (Kawase, 2015).

These key elements are all active components of PRF and, when combined and prepared properly, are involved in the key processes of tissue healing and regeneration, including cell proliferation and differentiation, extracellular matrix synthesis, chemotaxis, and angiogenesis (neovascularization) (Dohan, et al., 2012; 2014).

An improved understanding of the development, biological, and physiological properties and characteristics of PRF in tissue healing and regeneration over the past 2 decades has led to more successful therapeutic applications, especially in the fields of implant dentistry, periodontology, and oral surgery.

Methodology, search strategy, and inclusion criteria An electronic MEDLINE®/PubMed® and Google Scholar search was performed for all articles on platelet-rich fibrin (PRF) and

platelet concentrates up to May 2016. The search was complemented by an additional hand search of selected journals in oral implantology, oral surgery, and periodontal, as well as grey literature.

The reference lists and bibliographies of all included publications were also screened for relevant studies. The search was limited to the English language. Randomized controlled trials (RCTs), controlled clinical trials (CCTs), case reports, case series, prospective, retrospective, and in vitro/in vivo studies were included in the narrative review. Animal studies were excluded from this review.

What is PRF? Definition PRF is an autologous fibrin-based (membrane, matrix, or scaffold), living biomaterial, derived from human blood (Ali, et al., 2016; Choukroun, et al., 2006; Tatullo, et al., 2012; Hauser, et al., 2013; Boora, et al., 2015), also referred to as an optimized blood clot (Öncu and Alaaddinoõglu, 2015).

In essence, PRF is a natural (autologous) composite biomaterial, consisting of fibrin,

Figure 3A: PRF clots transformed into membranes after compression in the PRF box Volume 11 Number 4

Figure 2B: PRF clot before compression

platelets, growth factors, and various cell types, including leukocytes and stem cells.

The blood concentrate, which is obtained after centrifugation (Figure 1), has three distinct layers: a red blood cell (RBC) base at the bottom, a PRF clot in the middle, and an acellular plasma (platelet-poor plasma [PPP]) supernatant layer at the top. The PRF clot is composed of two main parts observable with the naked eye: a fibrin yellow portion, constituting the main body, and a red portion located at the end of the clot (full of RBCs) (Figures 2A and 2B).

Between these two areas, a whitish layer called the “buffy coat” can be observed with the naked eye. PRF can be used directly as a clot (Figures 2A and 2B) or, after compression, as a membrane (Figures 3A and 3B) or plug (Figure 4).

Alternatively, the supernatant can be aspirated from the vacutube (i-PRF) and used in injectable form.

Purpose The purpose of PRF technology is to extract the essential elements that could be

Figure 3B: PRF membrane after compression of the clot in the box Implant practice 25

CONTINUING EDUCATION

Figure 2A: PRF clots before compression with distinct yellow fibrin portion at the top and a red blood cell portion at the bottom

CONTINUING EDUCATION used to improve healing and promote tissue regeneration from a patient’s blood sample (Clipet, et al., 2012), and to prepare it in a clinically usable form such as a membrane (A-PRF, L-PRF or CGF) or injectable liquid (i-PRF).

The key elements required to improve healing and to promote tissue regeneration are the fibrin (serving as a supporting matrix) (Kanayama, et al., 2016), the platelets (rich in growth factors), and cells (mostly the various populations of leukocytes, and stem cells for their antibacterial, neovascularization and regenerative properties) (Hauser, et al., 2013). The three-dimensional fibrin membrane is capable of mimicking the extracellular matrix in terms of its structure and creates the environment or scaffold for cells to function optimally during healing and regeneration. The fibrin matrix contains the platelets, leukocytes, growth factors, and stem cells that act naturally and in synergy to stimulate, improve, and accelerate tissue healing and to regenerate soft or bone tissue (Dohan, et al., 2014), including cell proliferation and differentiation, extracellular matrix synthesis, chemotaxis, and angiogenesis (Kawase, 2015).

The purpose of the PRF membrane is to connect the various elements within the fibrin matrix with local tissues (bone and soft tissue) to accelerate neoangiogenesis, thereby enhancing healing and regeneration.

The evolution and classification of patient blood-derived biomaterials Fibrin glue era Platelet-rich plasma (PRP) was first applied as a “glue” in surgical procedures in the 1970s (Mazor, et al., 2009) and is essentially identical to the present-day fibrin glue (Tisseel, Baxter, USA) (Simonpieri, et al., 2011; Tajim, et al., 2013), except that it prepared from platelet poor plasma (PPP) (Zhang, et al., 2012) and that several different protocols for this preparation now exist.

Fibrin glue is generally considered to have a positive effect on tissue repair and regeneration (Bölükbas, et al., 2013; Diss, et al., 2008); however, their use remains limited owing to the complexity and cost of production. The autologous fibrin glues (with or without platelets) were too complicated and time-consuming to prepare (Toffler, et al., 2010), and these techniques were therefore never widely developed.

Growth factor era: PRP and PRGF Breakthrough studies in the late 1990s and early 2000s identified PRP as a promising 26 Implant practice

Figure 4: PRF plug made from compression of the clot in the compression well

reservoir for growth factors that could facilitate wound healing and bone regeneration (Kanayama, et al., 2014; Ghetiu, et al., 2015; Peck, et al., 2011). Because of its liquid form, PRP has to be converted to a liquid form prior to clinical use. This conversion was achieved by adding bovine thrombin to PRP preparations to minimize the rapid diffusion of growth factors at the surgical site (Kawase, 2015; Choukroun, et al., 2006; Magremanne, et al., 2009).

The concept of “regeneration through growth factors” seduced many clinicians into using this product. However, the key role of fibrin was almost completely neglected for many years. The disadvantage of PRP preparation is that it is technique sensitive and time consuming (it requires at least 30 minutes).

The use of bovine thrombin for clotting the liquid preparation of PRP also raised the concern of transmission of unknown infections from bovine thrombin to recipients.

The term PRP was used to name all kinds of preparations and techniques without proper characterization of the content and architecture of the tested concentrate, leading to contradictory and controversial data.

This resulted in a state of confusion that led to the general feeling that PRPs are not so useful in the clinical setting (Zhao, et al., 2011; Del Corso, et al., 2012). Consequently, PRPs are slowly disappearing due to their complexity of use, cost of production, and mixed clinical results (Rao, et al., 2013). Plasma rich in growth factors (PRGF) was subsequently developed by Anitua and co-workers in 1999 (Öncü and Erbeyo, 2015; Simonpieri, et al., 2009a) and is characterized by the elimination of leukocytes to suppress their pro-inflammatory effect.

Fibrin and leukocyte era: Choukroun’s PRF In 2006, Choukroun and co-workers developed a novel technique with the aim of simplifying the PRP preparation protocol and eliminating xenofactors (bovine thrombin) (Ali, et al., 2016; Choukroun, et al., 2006; Simonpieri, et al., 2009b; Toeroek and Dohan, 2013; Vijayalakshmi, 2012; Hamzacebi, et al., 2015).

This led to the co-called “second generation platelet-derived biomaterials” designated as platelet-rich fibrin (PRF), or Choukroun’s PRF. Choukroun’s PRF is derived from the patient’s own blood and contains a variety of blood cells — including platelets, B- and T-lymphocytes, monocytes, stem cells, and neutrophilic granulocytes — as well as growth factors (Shilbli, et al., 2013; Inchingolo, et al., 2010).

Blood concentrate era Recently, numerous techniques using blood-derived concentrates have been developed to optimize the different ratios of platelets, growth factors, leukocytes, and other cells within the fibrin matrix (Choukroun, et al., 2006; Krasny, et al., 2011; Kim, et al., 2013).

A recent study showed that specific cell types are distributed differentially depending on the (cumulative) centrifugal force (Joseph, et al., 2014). This concept has paved the way for preparation of optimal PRF composite biomaterials to be tailored for specific clinical applications. Subsequently, various parties have developed their own centrifuges and kits and associated protocols with the view of improving and streamlining preparation protocols and furthering their commercial interests in PRF. Volume 11 Number 4

The future: stem cell and bone regenerative era Preparation and application of PRF is, and will in future, increasingly be focused on not only its healing properties, but also how to harness its bone and soft tissue regenerative potential. It is hypothesized that PRF can be a unique source/carrier of hematopoietic stem cells (HSCs) that can potentially play a major role in tissue regenerative dentistry (Del Corso and Dohan, 2013; Shah, et al., 2014).

Open access technique Although this technique is open access, the initial developers carefully optimized it in order to get the best possible and most reproducible fibrin clots, membranes, and clinical results (Nacopoulos, et al., 2014). The PRF technique (Ali, et al., 2016) continues to develop because it is very easy to prepare, inexpensive, and allows the quick production of natural fibrin membranes enriched with platelets and leukocytes (Choukroun, et al., 2006).

Classification of platelet concentrates Platelet concentrate preparations used in tissue healing and guided tissue regeneration therapy differ according to their preparation from a patient’s peripheral blood through adding chemicals, centrifugation speeds and times, and in the selection of supernatants and precipitates.

These variations can cause differences in fibrin network structures and in platelets, leucocyte, and growth factor content.

Volume 11 Number 4

The PRF technique continues to develop because it is very easy to prepare, inexpensive, and allows the quick production of natural fibrin membranes, enriched with platelets and leukocytes, that can be used immediately in any clinical situation.

The term PRP alone can therefore be nonspecific, because it does not define the actual preparation protocol. Recently, a full classification of platelet concentrate technologies was suggested (Tatullo, et al., 2012) that allowed classifying the main available techniques in four families depending on their leukocyte content and fibrin architecture: Pure platelet-rich plasma (P-PRP) Liquid suspension without leukocytes before activation can be activated and transformed into a gel form (P-PRP gel) — including Vivostat PRF®, Anitua’s PRGF, PRGF®-Endoret®, or E-PRP. Leukocyte- and platelet-rich plasma (L-PRP) Liquid suspension with leukocytes before activation can be activated and transformed into a gel form (L-PRP gel) — including Curasan, RegenLab® USA, Plateltex, SmartPReP, PCCS, or Magellan).

Pure platelet-rich fibrin (P-PRF) Solid fibrin material without leukocytes. includes FIBRINET® and Vertical Spine®.

Leukocyte- and platelet-rich fibrin Solid fibrin material with leukocytes. includes Choukroun’s PRF; Advanced PRF (A-PRF) and injectable i-PRF, (Duo Process, France); L-PRF (IntraSpin™, Intra-Lock International, Boca-Raton, Florida); and Concentrated Growth Factors (CGF).

How do the biological characteristics and composition of PRF function within the clinical environment?

Promoting tissue healing and regeneration is an important goal in surgical disciplines. This healing and reparation process is totally dependent on the initial mechanisms of hemostasis (Gamal, et al., 2016).

PRF technology draws on the following three fundamental principles and biological processes of hemostasis and wound healing (Shah, et al., 2015): • Principle one: The presence of a fibrin matrix at the surgical site acts as a scaffold for recruiting and migration of cells (epithelial, fibroblast,

endothelial) throughout the woundhealing and reparation process • Principle two: Platelets, neutrophil leukocytes, and monocytes within the fibrin matrix (release) secrete growth factors and chemotactic proteins that recruit epithelial, fibroblast, and endothelial cells to the surgical site to facilitate wound healing and reparation.

• Principle three: Angiogenesis (neovascularization) relies on a fibrin matrix (extracellular matrix) and stimulation of endothelial cell recruitment through growth factors (VEGF).

New blood vessels in the wound bed are essential for carrying oxygen and nutrients to sustain cell metabolism and regeneration.

The concept of generating a fibrin-based cell-seeded matrix solely by drawing blood and the slow polymerization process during centrifugation for 8 to 12 minutes is truly revolutionary in terms of clinical practicability and simplicity.

PRF can be easily prepared at the chairside within a short period of time and provides the surgical wound area or defect not only with a matrix or scaffold permitting cell migration into the defect area, but also provides the wound with crucial biological signals or growth factors, potentially accelerating the wound healing and regeneration process. The PRF membrane is therefore an ideal source of all key elements involved in the processes of tissue healing and regeneration (Choukroun, et al., 2006; Joseph, et al., 2014).

The combination of the fibrin membrane for a scaffold, leukocytes, stem cells, and growth factors are collectively involved in the key biological processes of tissue healing and regeneration, including cell proliferation and differentiation, extracellular matrix synthesis, chemotaxis, and angiogenesis (neovascularization) (Kawase, 2015; Vijayalakshmi, 2012; Bansal and Bharti, 2013).

Fibrin matrix The slow polymerization mode confers upon the fibrin matrix its favorable physiologic architecture, loaded or seeded with Implant practice 27

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Choukroun further modified his PRF to produce A-PRF (leukocyte-enriched, advanced type) and i-PRF (injectable PRF) (Joseph, et al., 2014; Barone, et al., 2014) by reducing the centrifuge speed — minimizing leukocyte infiltration into the red blood cell fraction. Both A-PRF and i-PRF preparations are characterized by platelets, leukocytes, and circulating stem cells, and endothelial cells concentrated in the fibrin clot.

Leukocytes are enriched in A-PRF and L-PRF (Choukroun’s original protocol used

by Prof. Ehrenfest), to exploit their antibacterial and osteoconductive activity (Kawase, 2015). In 2006, Sacci developed another preparation called CGF (concentrated growth factors). CGF is produced using a centrifuge device that has a programmed spin cycle (Medifuge, Silfradent®) (Krasny, et al., 2011). The different centrifugation speed permits the isolation of fibrin matrix that is markedly larger, denser, and richer in growth factors as compared to PRF.

CONTINUING EDUCATION platelets, leukocytes (B- and T-lymphocytes), monocytes, and neutrophilic granulocytes, and mesenchymal stem cells, which is required to support and enhance the healing process (Ali, et al., 2016; Choukroun, et al., 2006; Hauser, et al., 2013; Shilbli, et al., 2013; Inchingolo, et al., 2010; Barone, et al., 2014).

The strong three-dimensional fibrin network functions as an “adhesive” scaffolding material for endothelial cells involved in angiogenesis (new blood vessel formation) to adhere to, proliferate, and concentrate at the site of wound healing and tissue regeneration (Kawase, 2015; Thorat, 2011; Pradeep, et al., 2012).

Additionally, the fibrin matrix functions as an “adhesive” carrier for growth factors and matrix glycoproteins, and controls their release and sustains their bioactivity for ≥ 7 days (Kanayama, et al., 2016; Nacopoulos, et al., 2014; Pradeep, et al., 2012; Troiano, et al., 2016; Pradeep and Sharma, 2011).

It is these growth factors (i.e., vascular endothelial growth factor [VEGF]) that attract endothelial cells into the fibrin to stimulate formation of new blood vessels (Pradeep, et al., 2012). In the field of tissue healing and regeneration, vascularization plays a crucial role as it ensures a continuous supply of nutrients to, and the removal of waste products from, the scaffold and the implanted or wound region.

It is theorized that the overall quality and quantity of fibrin fibers, in addition to growth factors (GF), may potentially affect the potency and efficacy of PRF, both directly and indirectly, in tissue healing and regeneration (Kawase, 2015).

A recent study concluded that age could potentially play a significant role in altering fibrin network patterns and hence, its interaction with platelets, thus influencing the quality of the PRF clot expected treatment outcomes (Gupta, et al., 2014).

Platelets Platelets in the fibrin matrix play a crucial role, not only in hemostasis, but also in the wound-healing process. Platelets are distributed throughout the entire clot and merged within the fibrin-rich scaffold or mesh like a cement (Panda, et al., 2014). After activation, they become trapped within the fibrin matrix and immediately start releasing growth factors (Inchingolo, et al., 2010; Krasny, et al., 2011).

Platelets are important reservoirs for growth factors since they release high concentrations of these biologically active 28 Implant practice

The prospect of having new therapies, biomaterials, and bioactive surgical additives available that will improve success and predictability of patient outcomes in soft and bone tissue healing and regeneration are key treatment objectives in implant dentistry, periodontology, and oral surgery.

proteins that support recruitment of cells from the surrounding host tissue, and stimulate growth and cell morphogenesis, thus promoting bone and soft tissue healing (Joseph, et al., 2014; Pradeep, et al., 2012; Lekovic, et al., 2012; Joseph, et al., 2012). Entrapped platelets release a broad spectrum of cytokines, chemokines, growth factors, and other mediators that facilitate angiogenesis and tissue healing and regeneration.

With these different growth factors, adhesion molecules, and other mediators, platelets have the ability to initiate and modulate host immune responsiveness through recruiting and influencing leukocytes, neutrophils, monocytes, and endothelial cells, as well as lymphocytes to sites of tissue damage or infection.

Upon stimulation, platelets actively participate in pathogen detection, capturing, and sequestration. They can even induce the death of infected cellular targets (Joseph, et al., 2014; Bajaj, et al., 2013).

Release of growth factors After platelets are activated, they start releasing high concentrations of growth factors (Inchingolo, et al., 2010; Panda, et al., 2014). The PRF membrane stays intact for at least 7 days and releases continuously large quantities of growth factors (such as transforming growth factor-β 1 [TGFβ β1], plateletderived growth factor-AB [PDGF-AB], vascular endothelial growth factor [VEGF]), and key coagulation and healing matrix proteins or cytokines (thrombospondin-1, fibronectin, vitronectin, osteocalcin, osteonectin) (Kanayama, et al., 2016; Joseph, et al., 2014; Nacopoulos, et al., 2014; Patil, et al., 2014; Ranganathan and Chandran, 2014; Desarda, et al., 2013).

A recent study showed that Choukroun’s new formulation of PRF called advanced PRF (A-PRF) had a more gradual release of growth factors up to a 10-day period. A-PRF stimulated significantly higher growth factor release over time when compared to standard PRF and may prove clinically beneficial

for future regenerative procedures (Sambhav, et al., 2014).

It is generally accepted that growth factors have an essential role in influencing processes of healing and tissue regeneration, including angiogenesis, chemotaxis, cell proliferation and differentiation, and the synthesis and degradation of extracellular matrix proteins (matrix remodeling) (Joseph, et al., 2014; Nacopoulos, et al., 2014; Pradeepet, et al., 2012b; Lekovic, et al., 2012; Simonpieri, et al., 2011; Dohan, 2009).

Platelets are not the only blood cells that release growth factors, but leukocytes and erythrocytes also contain TGF-β1 and VEGF (Dohan, et al., 2009; Moraschini, et al., 2015). The presence of these growth factors (TGF-β and VEGF) are important for stimulating cell proliferation, matrix remodeling, and angiogenesis during healing processes and tissue regeneration (Dohan, 2009; Del Corso, et al., 2009; Keceliet, et al., 2015).

In vitro studies suggest PRF is capable of increasing osteoblast attachment, proliferation, and simultaneously upregulating collagen-related protein production. These actions in combination could potentially effectively promote bone regeneration (Rajaram, et al., 2015).

Leukocytes Leukocytes are the cells of the immune system that are involved in protecting the body against infections or foreign bodies.

Different types of leukocytes are concentrated in the fibrin matrix, namely lymphocytes (T-lymphocytes, B lymphocytes), monocytes, and neutrophilic granulocytes.

Leukocyte-enriched PRF (A-PRF and L-PRF) is reported to be an ideal provider of leukocytes (Joseph, et al., 2014). Leukocytes are enriched in A-PRF and L-PRF, primarily to exploit their antibacterial and osteoconductive actions (Kawase, 2015). Most leukocytes are found in the first 25%-30% proximal part of the clot (Joseph, et al., 2014). The leukocytes enmeshed into the dense fibrin network are alive and functional as an immune node that is able to stimulate defense mechanisms Volume 11 Number 4

Neutrophilic granulocytes Neutrophilic granulocytes are considered to be early inflammatory cells due to their phagocytic capacity, participating in the process of wound debridement and revascularization (Aroca, et al., 2009; Aleksic, et al., 2010). Macrophages also support cell proliferation and tissue restoration following injury through expression of VEGF, PDGF, FGF, TGF-α, and TGF-β, and other biologically active molecules (e.g., BMP-2) (Jankovic, et al., 2010; 2012).

Neutrophils also facilitate trafficking of monocytes into the wound to phagocytize inflammatory remnants (necrotic and apoptotic cells) (Aroca, et al., 2009; Agarwal, et al., 2013). A recent study found that changing the centrifugation protocol in terms of centrifugation time and speed leads to a different distribution pattern for neutrophilic granulocytes (Joseph, et al., 2014). Accordingly, a higher presence of these cells might be able to influence the differentiation of host macrophages and macrophages within the clot after implantation. It is therefore hypothesized that A-PRF might influence bone and soft tissue regeneration, especially through the presence of monocytes/macrophages and their growth factors. However, the relevance and feasibility of this tissue-engineering concept has to be proven through in vivo studies (Joseph, et al., 2014).

Monocytes Monocytes are in essence the “vacuum cleaners” of the body. They migrate into the

REFERENCES 1. Agarwal K, Chandra C, Agarwal K, Kumar N. Lateral sliding bridge flap technique along with platelet rich fibrin and guided tissue regeneration for root coverage. J Indian Soc Periodontol. 2013;17(6):801-805.

2. Aleksić Z, Janković S, Dimitrijević B, et al. The use of plateletrich fibrin membrane in gingival recession treatment. Srp Arh Celok Lek. 2008;136(3-4):95-103.

3. Ali S, Bakry SA, Abd-Elhakam H. Platelet-rich fibrin in maxillary sinus augmentation: a systematic review. J Oral Implantol. 2015;41(6):746-753.

4. Aroca S, Keglevich T, Barbieri B, Gera I, Etienne D. Clinical evaluation of a modified coronally advanced flap alone or in combination with a platelet-rich fibrin membrane for the treatment of adjacent multiple gingival recessions: a 6-month study. J Periodontol. 2009;80(2):244-252.

5. Bajaj P, Pradeep AR, Agarwal E, et al. Comparative evaluation of autologous platelet-rich fibrin and platelet-rich plasma in the treatment of mandibular degree II furcation

Volume 11 Number 4

wound or inflamed area after the influx of neutrophils, where they then become macrophages (Gupta, et al., 2015). The macrophages collect and remove all the dead, necrotic, bacterial, or foreign particles in the wound site. This function is essential for healing and regeneration of tissue.

Monocytes also have a beneficial effect on healing and tissue regeneration bone growth, the production of vascular endothelial growth factor (VEGF), and neovascularization (Gamal, et al., 2016; Shah, et al., 2015). This process, however, needs to be validated through histochemical and histological studies.

Mesenchymal stem cells (MSC) It is hypothesized that PRF may be a unique source or carrier of hematopoietic stem cells (HSCs) that potentially may be of major importance in bone regenerative procedures. Recently, studies highlighted the differentiation potential of HSCs (Del Corso and Dohan, 2013). Ling He and co-workers were also able to show that different cell types, such as rat osteoblasts, could differentiate and proliferate when cultured on the leukocyterich PRF (L-PRF) (Shah, et al., 2014). Stronger focus will in future be placed on the up-regulation of MSC and osteoblasts in bone healing, osseointegration, and in particular, guided bone regenerative procedures.

Conclusion The introduction of PRF as an autologous biomaterial has set in motion an exciting and promising era in the advancement of tissue healing and regeneration in the fields of implant dentistry, periodontology, oral surgery, and regenerative endodontics. PRF is an autologous fibrinbased (membrane, matrix or scaffold), living biomaterial, derived from human blood,

defects: a randomized controlled clinical trial. J Periodont Res. 2013;48(5):573-581.

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10. Choukroun J, Diss A, Simonpieri A, et al. Platelet-rich fibrin

also referred to as an optimized blood clot.

The key elements required to promote tissue healing and regeneration are the fibrin (serving as a supporting matrix), the platelets (rich in growth factors), and cells (mostly the various populations of leukocytes, and stem cells for their antibacterial, neovascularization, and regenerative properties).

These key elements are all active components of PRF. The purpose of PRF technology is to extract these key elements from a patient’s blood sample and to prepare it in a clinically usable form such as a membrane (A-PRF, L-PRF or CGF) or injectable liquid (i-PRF) that can be used immediately in any clinical situation to improve healing and to promote tissue regeneration.

The concept of generating a cellseeded fibrin matrix, solely by drawing the patients’ own blood and centrifugation for 8 to 14 minutes is truly revolutionary in terms of clinical practicability, as it can be made easily at chairside in a short period of time. More importantly, the use of PRF enables local delivery of a fibrin matrix, cells, growth factors, and proteins that provide unique biological properties and cues for promoting new blood vessel formation and potentially accelerating wound healing and tissue regeneration, while at the same time reducing morbidity due to its antibacterial and anti-hemorrhagic effects, with virtually no risk of rejection.

The future of PRF and its applications in clinical dentistry, especially in the field of soft tissue and bone regeneration, has enormous therapeutic implications, but developing and strengthening its role in dentistry is dependent on its coherence and scientific clarity. Independent and robust scientific studies are needed to validate and standardize PRF processes and that will enhance therapeutic outcomes. IP

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J Periodontol. 2009;80(11):1694-1697.

14. Del Corso M, Vervelle A, Simonpieri A, et al. Current knowledge and perspectives for the use of platelet-rich plasma

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(Toeroek and Dohan, 2013; Panda, et al., 2014). Leukocytes living in the fibrin matrix are also involved in the production of significant amounts of growth factors, particularly TGFβ1 (Kanayama, et al., 2016; Troiano, et al., 2016; Patil, et al., 2014; Dohan, 2009; Eren and Atilla, 2014).

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74. Zhao JH, Tsai CH, Chang YC. Clinical and histologic evaluations of healing in an extraction socket filled with plateletrich fibrin. J Dent Sci. 2011;6(2):116-122.

Volume 11 Number 4

The FMC is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing 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 12/1/2016 to 11/30/2018.

Provider ID# 325231

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $149; call 866-579-9496 or visit www.implantpracticeus.com to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Implant Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

REF: IP V11.4 HARTSHORNE/GLUCKMAN

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

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

EMAIL

TELEPHONE/FAX

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

Your CE certificate(s) will be emailed to the address you provided above. Please add medmarkmedia.com to your Approved Senders List in your email account. You may need to check your junk/spam folder for your certificate email.

A comprehensive clinical review of platelet-rich fibrin and its role in promoting tissue healing and regeneration: part 1 HARTSHORNE/GLUCKMAN

1. PRF is an autologous fibrin-based (membrane, matrix, or scaffold), living biomaterial, derived from __________, also referred to as an optimized blood clot. a. human blood b. bovine blood c. synthetic blood d. none of the above 2. The key elements required to promote tissue healing and regeneration are the fibrin (serving as a supporting matrix), the platelets (rich in growth factors), cells (mostly the various populations of leukocytes, and stem cells for their ________ properties). a. antibacterial b. neovascularization c. regenerative d. all of the above 3. PRF can be easily prepared _______ and provides the surgical wound area or defect not only with a matrix or scaffold permitting cell migration into the defect area, but also crucial biological signals or growth factors that can accelerate the wound healing and regeneration process. a. at chairside within a short period of time b. in a hospital lab over several weeks

Volume 11 Number 4

preparation protocol and eliminating xenofactors (bovine thrombin). a. Choukroun b. Joseph c. Kanayama d. Zhao

c. in a desktop incubator d. by the patient at home 4. PRF can be used ________. a. directly as a clot b. after compression as a membrane c. after compression as a plug d. all of the above 5.

The purpose of the PRF membrane is to connect the various elements within the fibrin matrix with local tissues (bone and soft tissue) to accelerate neoangiogenesis, thereby _____ healing and regeneration. a. enhancing b. slowing c. differentiating d. having no real effect on

6. The disadvantage of platelet-rich plasma (PRP) preparation is that it is technique-sensitive and timeconsuming (it requires at least _______). a. 15 minutes b. 30 minutes c. 1 hour d. 1.5 hours 7. In 2006, _______ and co-workers developed a novel technique with the aim of simplifying the PRP

8.

In 2006, Sacci developed another preparation called _______. a. A-PRF (leukocyte-enriched, advanced type) b. i-PRF (injectable PRF) c. CGF (concentrated growth factors) d. P-PRP (pure platelet-rich plasma)

9. This healing and reparation process (of tissue) _______ the initial mechanisms of hemostasis. a. is totally independent of b. is totally dependent on c. can interfere with d. can stop 10. The presence of these growth factors (TGF-β and VEGF) are important for _______ during healing processes and tissue regeneration. a. stimulating cell proliferation b. matrix remodeling c. angiogenesis d. all of the above

Implant practice 31

CE CREDITS

IMPLANT PRACTICE CE

CONTINUING EDUCATION

Primary stability: what does it mean?

Dr. Michael R. Norton asks whether we really know what we’re measuring when assessing the solidity of implant placement

T

he term of the day is “primary stability.”

We have to get good primary stability, don’t we? After all, we don’t want our implant to fail — so primary stability is key, isn’t it? But have you ever stopped to consider what exactly we mean by that? What is primary stability?

The simplest answer is that primary stability is an implant that feels tight in bone.

Like a carpenter, you need to know that the screw in the wall is big enough and tight enough to support the heavy picture you are about to hang on it. But bone is not wood, and we are not carpenters.

So perhaps we can be more clinical about things and say that primary stability is an objective measure of tightness for which we use insertion torque. But how does insertion torque measure tightness, and does it correlate to implant success?

Torque or stability?

In order to understand torque, the clinician first needs to appreciate the fact that it is a measure of rotational friction — the friction between the implant and the surrounding bone as the implant is screwed into place.

This friction will increase as the difference between the osteotomy diameter and the implant diameter increases or, to put it another way, as the compression of the bone increases. That can occur at the microscopic level by the application of surface roughness, or at the macroscopic level through the adoption of tapered implants and an aggressive thread design.

Of course, we also have a need to appreciate the viscoelasticity of bone (or lack thereof) and the difference between dense cortical lamellar bone and the more yielding spongiosa or cancellous bone. Either way, a high insertion torque equates to a high compression of the bone, and bone is not Michael R. Norton, BDS, FDS RCS(Ed), is the 31st president of the Academy of Osseointegration and associate editor of the International Journal of Oral & Maxillofacial Implants. He is a past president and honorary life member of the Association of Dental Implantology. He runs a private practice in Harley Street, London, limited to implants and reconstructive dentistry.

32 Implant practice

Educational aims and objectives

The aim of this article is to discuss the term “primary stability” and how the clinical understanding of this concept is changing.

Expected outcomes

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

Identify the factors influencing primary stability and how they impact on implant stability in the long term.

•

Define the concept of primary stability.

•

Define the characteristics of torque.

•

Realize differences between axial and rotational stability.

wood — it is a living vital tissue that responds negatively to high compressive pressure, as seen during orthodontic movement.

The net result is resorption and remodeling to better support the contours of induced stress. High isometric strain, as induced with high insertion torque, is in this sense very destructive, but while this does not impede osseointegration, it has been clearly shown to delay healing and reduce the bone-to-implant contact compared to bone that is subject to lower levels of compression.

Nonetheless, there remains a sense that high insertion torque reduces risk of failure. But this is an illusion. Most experienced implant surgeons will tell you an implant that is a spinner (insertion torque of

lower than 10Ncm) still has the capacity to osseointegrate, and many researchers have shown that torque is in fact a poor predictor of success.

Furthermore, the clinician cannot compare torque measurements over time to determine if stability is increasing or decreasing; surely, any valuable objective measure of stability must be able to inform with regard to longitudinal changes in stability so that the clinician can determine if an implant has gained or lost stability during the early osseointegration phase.

At a time when early loading, progressive loading, and immediate loading are all prescribed with increasing regularity, there is a greater need to appreciate subtle changes in stability over time.

Volume 11 Number 4

Perhaps another point to reflect on is that occlusal functional load is rarely, if ever, rotational. Rotational forces do of course occur, as we see with the loosening of abutment screws, for example, but this is not due to direct rotational forces — rather, it is the combination of lateral forces applied from different vectors.

So what is the rational basis for concern with rotational stability, when we all understand from the history of dentistry that the most destructive forces are lateral, horizontal forces, especially those applied through parafunction? Surely, then axial primary stability of an implant counts for greater importance than rotational stability.

Axial stiffness is much to do with the congruence of the osteotomy with regard to the implant diameter and geometry as well as the density of bone, but perhaps contrary to intuition, it has absolutely nothing to do with rotational friction. Consequently, an implant that has low rotational stability can achieve high axial stiffness.

For example, imagine that an implant has been placed in dense cortical bone (Type 1 bone) using a bone tap to cut a thread within the bone exactly to match that of the implant, within an idealized osteotomy. The fit is perfect, but due to the bone tap, there is no rotational compression: The implant is a spinner. Such an implant would yield a high axial stiffness due to its precise fit within the osteotomy and due to the dense quality of the bone.

Conversely, an implant in soft bone under high compression with high initial insertion torque may quickly demonstrate a reduced axial stiffness as the bone undergoes stress release through its viscoelastic properties, and subsequent resorption and the density of bone fail to provide the enhanced axial stiffness desired.

The two examples above lend weight to the question as to whether the implant with lower insertion torque might not actually be preferable to the implant with higher insertion torque. The answer to this question lies in the histology of healing bone in the two scenarios described, which constitutes the different healing pathways adopted by the bone in response to the presence or absence of compression.

It has been very well documented in numerous studies that under the influence of high insertion torque, there is a wider zone of dead or dying cells, a decreased expression of protein biomolecules for bone formation, reduced cell proliferation, the presence of Volume 11 Number 4

At a time when early loading, progressive loading, and immediate loading are all prescribed with increasing regularity, there is a greater need to appreciate subtle changes in stability over time.

Figure 1: Histological section from Trisi, et al. (2011), showing microfracture (arrowed) through the dense cortical bone adjacent to an implant inserted with high insertion torque

microfractures, reduced vascularization and bone deposition, and ultimately a reduced interfacial stiffness with a lower bone-toimplant contact.

In contrast, the most notable feature of bone healing around implants where there is no bone compression is rapid neo-bone formation and a more rapid osseointegration.

Resonance frequency analysis Again, no one is saying that high insertion torque prevents osseointegration. It is about quality of osseointegration and thresholds of insertion torque needed to achieve optimal stability.

To this end, this author has worked tirelessly over the past 6 or 7 years to try to identify what represents the threshold for optimal insertion torque with respect to ensuring a highly predictable axial stability at the lowest value of torque as well as from the perspective of the bone, ensuring that the minimum isometric strain builds within the bone-inducing microfractures and delayed healing.

There is much work yet to be done, but we are now homing in on precise values.

In my most recent published work (Norton 2017), implants that achieved the very lowest of insertion torques were monitored for axial stiffness, changes in axial stiffness, and successful osseointegration.

All implants in the study osseointegrated, and implant stability quotient (ISQ) values obtained even at the lowest of insertion

torques were in the mid to high 60s, which is generally considered clinically stable, increasing to around 80 after a short 12-week period for osseointegration.

Perhaps the most remarkable finding in this study was the variability in axial stiffness for implants below 10Ncm, which was high and differed starkly to those placed with 15Ncm-20Ncm whose variability and standard deviation were extremely small. This is the first insight into a possible threshold for insertion torque at around 10Ncm-15Ncm. This value is far lower than one could possibly imagine, but it reinforces what this author has always believed and lectured on for many years — that an insertion torque above 25Ncm does not add any clinical value.

This is due to the fact that 25Ncm is well above any level of torque that can be achieved manually, and no one can differentiate between an implant inserted with 25Ncm or one inserted with 50Ncm. Indeed, 25Ncm exceeds the threshold above which it is possible to appreciate differences in tightness.

So the next time you place an implant, in the absence of an ability to measure ISQ, limit your torque to 20Ncm or 25Ncm and feel confident that not only will your implant osseointegrate, but through respecting the bone you will achieve a higher quality of osseointegration, with more rapid healing, and a higher bone-to-implant contact.

We’re not in the game of primary stability; we are in the game of secondary stability — so let’s get there as fast as possible. IP

REFERENCES 1. Trisi P, Todisco M, Consolo U, Travaglini D. High versus low implant insertion torque: a histologic, histomorphometric, and biomechanical study in the sheep mandible. Int J Oral Maxillofac Implants. 2011;26(4):837-849.

2. Norton MR. The influence of low insertion torque on primary stability, implant survival and maintenance of marginal bone levels – a closed-cohort prospective study. Int J Oral Maxillofac Implants. 2017;32(4): 849-857.

Implant practice 33

CONTINUING EDUCATION

Axial versus rotational stability

The FMC is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing 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 12/1/2016 to 11/30/2018.

Provider ID# 325231

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $149; call 866-579-9496 or visit www.implantpracticeus.com to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Implant Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

REF: IP V11.4 NORTON

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

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

EMAIL

TELEPHONE/FAX

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

Your CE certificate(s) will be emailed to the address you provided above. Please add medmarkmedia.com to your Approved Senders List in your email account. You may need to check your junk/spam folder for your certificate email.

Primary stability: what does it mean?

NORTON

1. The simplest answer is that _______ is an implant that feels tight in bone. a. primary stability b. rotational fraction c. insertion torque d. none of the above 2. In order to understand _______, the clinician first needs to appreciate the fact that it is a measure of rotational friction — the friction between the implant and the surrounding bone as the implant is screwed into place. a. stability b. torque c. viscoelasticity d. isometric strain 3. Of course, we also have a need to appreciate the viscoelasticity of bone (or lack thereof) and the difference between dense cortical lamellar bone and the more yielding _______ bone. a. spongiosa b. cancellous c. sesamoid d. both a and b 4. The net result (of high insertion torque) is ________ to better support the contours of induced stress. a. viscoelasticity b. resorption c. remodeling

34 Implant practice

d. both b and c 5. High isometric strain, as induced with high insertion torque, is in this sense very destructive, but while this does not impede osseointegration, it has been clearly shown to ________ compared to bone that is subject to lower levels of compression. a. delay healing b. reduce the bone-to-implant contact c. accelerate healing d. both a and b 6. Most experienced implant surgeons will tell you an implant that is a spinner (insertion torque of lower than ______ ) still has the capacity to osseointegrate, and many researchers have shown that torque is in fact a poor predictor of success. a. 5Ncm b. 8Ncm c. 10Ncm d. 14Ncm 7. Perhaps another point to reflect on is that occlusal functional load is _______ rotational. a. rarely, if ever b. always c. frequently d. never 8. Axial stiffness is much to do with the congruence of the osteotomy with regard to _______, but perhaps

contrary to intuition, it has absolutely nothing to do with rotational friction. a. the implant diameter b. geometry c. the density of bone d. all of the above 9. It has been very well documented in numerous studies that under the influence of _______, there is a wider zone of dead or dying cells, a decreased expression of protein biomolecules for bone formation, reduced cell proliferation, the presence of microfractures, reduced vascularization and bone deposition, and ultimately a reduced interfacial stiffness with a lower bone-to implant contact. a. low insertion torque b. high insertion torque c. axial stiffness d. a bone tap 10. So the next time you place an implant, in the absence of an ability to measure ISQ, limit your torque to ________ and feel confident that not only will your implant osseointegrate, but through respecting the bone you will achieve a higher quality of osseointegration, with more rapid healing, and a higher bone-to-implant contact. a. 5Ncm to 10Ncm b. 12Ncm to 15Ncm c. 20Ncm or 25Ncm d. 30Ncm to 35Ncm

Volume 11 Number 4

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PRACTICE MANAGEMENT

What do gossip and gum disease have in common?

Cynthia Goerig discusses achieving an office environment based on teamwork

D

entists want to look forward to going to the office. And although they wish they could just perform dentistry and not have to deal with all of the business aspects of running a practice, they realize that a typical day may include glitches that need their attention before the first patient arrives.

When team member drama is involved, there may be tension and hushed whispers,

and the doctor may be visited by multiple team members who update him with the latest gossip, suggesting who is to blame and who did something wrong. Many times the practice owner knows he/she needs to address the situation but doesn’t, hoping it will go away. Throughout the day, similar distractions pop up, as well as scheduling and patient issues, and by the end of the

Cynthia Goerig, Master Teacher and Executive Coach, has been developing leaders and coaching dental executives for more than 15 years. She is the founder of Legacy Life Consulting and CEO of Endo Mastery. Legacy Life Consulting, Home of Inner Legacy Seminars, was created to bridge the gap between clinical mastery and leadership excellence for dental specialists. Personal Leadership is taught in seminars, executive coaching, and team programs. Legacy’s unique method is taught in small groups where doctors uncover patterns that prevent them from effectively leading their practice. For a consultation or program availability, please contact David Stamation, Chief Operating Officer, at 208-946-3894 or email: david@legacylifeconsulting.com

36 Implant practice

day, the dentist could feel drained and exhausted, privately wishing he/she could just do dentistry and feel the satisfaction of completing cases.

What do gum disease and gossip have in common? It is an infection that can spread without being noticed, and when left to fester, puts the patient or practice at risk and is expensive to treat.

Gossip is a very expensive production killer. The negative energy is off-putting to the rest of the staff and the patients, and creates unnecessary frustration and stress for the doctor. Gossip damages relationships, manipulates emotions, creates competition, causes drama in the workplace, and affects the bottom line. In one Volume 11 Number 4

WHERE CLINICAL MASTERS BECOME LEADERSHIP EXPERTS Results from attending our course: n

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Specializing in referral-based dental practices Legacy Life Consulting - Home of Inner Legacy Seminars SEMINARS | EXECUTIVE COACHING | TEAM PROGRAMS

PRACTICE MANAGEMENT

Envision an office environment based on teamwork with everyone working in the best interests of the patient — a team that looks forward to going to work; one with camaraderie, support, and problem solving.

case, an endodontic office was burdened with gossip and a team openly at war with each other. When this was addressed, production increased 36%, slightly better than the doctor’s prediction.

Gossip fosters an environment of blaming A little-known fact: people who gossip are terrified of conflict.

When there is a culture of blaming, people do not take responsibility to solve problems. They would rather make someone

else wrong for fear they will get in trouble.

People will look to find fault in why something doesn’t work and manipulate your time in convincing you who is to blame.

Now imagine …

Envision an office environment based on teamwork with everyone working in the best interests of the patient — a team that looks forward to going to work; one with camaraderie, support, and problem solving. A culture of celebration is pronounced around the success of the day and a team that

Step One Answer the following questions: 1. What is your vision for how people treat each other in the office?

2. What is your vision for how the team will treat patients?

3. Pick three to five words to describe the daily environment or culture of the office. (examples — focused, supportive, fun, friendly, professional, caring, etc.)

Step Two Call a team meeting, and schedule it for 30 minutes.

Step Three At the meeting ...

1. Share your answers from questions 1-3. Explain why this is important to you, coming from an authentic and vulnerable place, and ask for their help in achieving it. People respond when they feel they are needed to help create the new vision.

2. Create a “no gossip” rule. Explain why there is no gossip, and how it will reinforce the culture you want.

3. In closing the meeting, ask if everyone can get behind this and agree by raising his/her hand. When people physically act, like raising their hand, in front of everyone, they feel like they have a choice and are more likely to follow through.

38 Implant practice

rallied to close the office and prepare for the next day.

Imagine not having to remind your team members what they are supposed to do that they already knew, and that it was taken care of. They know the objectives and goals, and are invested in the vision — not only sharing it, but also owning it.

Envision that the team felt safe at work, knowing that if something goes wrong, the whole team will help.That they don’t criticize or judge each other; instead, they look for the strengths in each other and improve upon their weaknesses.

Finally, imagine when leaving the office, the team thanks the doctor and each other, leaving everyone energized, proud of the team and the work they do. In short time, the practice becomes known as one of the best to work for.

The good news is that you are a few steps away from this possibility. (See the steps in the red box.)

The most effective way for a change in a practice to occur is for the leader to model it. I recommend printing out your three to five words that describe the environment you want to cultivate (from question 3) and review them daily.

Inspire your team to make the change, model it, and become the office that everyone wants to work for. IP

Volume 11 Number 4

Innovative advancements in full-arch implant solutions

Z

est Dental Solutions® has been the leader of innovative restorative solutions for edentulous patients since 1977. They pioneered the first pivoting, self-aligning LOCATOR® Attachment System that quickly became the gold standard in patient removable overdentures.

Building on 17 years of clinical success, they launched the next-generation worldclass attachment system, the LOCATOR R-Tx® Removable Attachment System. In 2016, Zest initiated yet another paradigm shift in implant dentistry with the introduction of the LOCATOR F-Tx® Fixed Attachment System, making Zest Dental Solutions your one source for all full-arch implant solutions: fixed and removable.

The LOCATOR R-Tx Removable Attachment System is the fourth generation of patient removable technology that relies on the same restorative techniques as its predecessor, LOCATOR. It combines progressive design features, enhanced benefits, and System simplicity for clinicians and patients alike. The LOCATOR R-Tx features a new DuraTec® Abutment Coating that is 30% harder and offers more than 25% greater wear resistance. In addition, the new coating reduces surface roughness by approximately 65% compared to Zest’s already industryleading titanium nitride coating and features a pink gingiva tone for maximum esthetics.

The narrower coronal geometry of the Abutment, together with the dual engagement of the Retention Inserts on the outside of

LOCATOR F-Tx® Fixed Attachment System Volume 11 Number 4

the Abutment, allows patients to easily align and properly seat their overdentures, thus preventing potential deformation of the Inserts that could lead to premature wear. It now treats up to 30° angle correction with a single set of redesigned Retention Inserts with straightforward retention values — zero, low, medium, and high — and uses a standard .050"/1.25 mm hex drive mechanism.

And now ordering is easy with convenient, all-in-one packaging, providing all of the necessary components for the case with one part number. Zest strongly believes that the LOCATOR R-Tx is a better, simpler, and stronger System and has implemented a 100% Satisfaction Guarantee to prove it.

The revolutionary LOCATOR F-Tx Fixed Attachment System offers a new option for edentulous patients. LOCATOR F-Tx is fixed for the patient, only removable by the clinician. It does not require prosthetic screws, screw access channels, or cement, therefore maintaining prosthesis integrity, preserving esthetics, and reducing chair time. The unique spherical geometry of the Abutment and innovative “snap-in” Attachment work like a ball and socket, allowing the Denture Attachment Housing to snap into place and pivot 360° into the desired position, eliminating the need for angled abutments, as well as treating up to 20° of angle correction from one common vertical. PEEK Retention Balls are threaded into the Denture Attachment Housing using finger-tight pressure and come in three levels of retention: low, medium, and high. The System is packaged and sterilized in one convenient vial that includes the Abutment, Denture Attachment Housing with pre-inserted black Processing Ball, a replacement black Processing Ball, a low, medium, and high Retention Ball, and two Blockout Spacers. It uses a single, simple Tool that quickly seats and removes the LOCATOR F-Tx prosthesis expediting patient visits. During maintenance visits, Retention Balls are replaced extraorally, enhancing patient comfort.

In addition, this versatile System is the only immediate treatment solution available today that can rescue a

LOCATOR R-Tx® Removable Attachment System

patient’s existing fixed-hybrid prosthesis after replacing an implant in as little as one patient visit. The LOCATOR F-Tx Abutment is picked up chairside, ensures a passive fit, and works in harmony with the existing screw-retained abutments. This cost-effective solution eliminates the need to fabricate a new prosthesis and additional lab fees. Simple modifications to the patient’s existing prosthesis, together with the flexibility of the System, allows it to be easily incorporated alongside the remaining screw-retained abutments, saving both clinicians and patients substantial time, money, and frustration.

No matter which road your full-arch implant case takes, you can turn to Zest Dental Solutions, the company you know and trust.

About Zest Dental Solutions Zest Dental Solutions is a global leader in the design, development, manufacturing, and distribution of diversified dental solutions for a continuum of patient care from the preservation of natural teeth to the treatment of total edentulism. The company’s product portfolios consist of Zest Anchors, Danville Materials, and Perioscopy with global distribution through OEMs, dealer/distributor networks, as well as a domestic retail sales operation for the Zest Anchors Portfolio. Zest Dental Solutions’ corporate headquarters is in Carlsbad, California, with satellite operations in Anaheim and Escondido, California. IP This information was provided by Zest Dental Solutions®.

Implant practice 39

PRODUCT PROFILE

Removable and fixed LOCATOR® Attachment Systems

TECHNOLOGY

Technology, techniques, and trends to look for in 2019 Dr. Matthew Nichols discusses some trends that will change practice protocols in the future

A

s the end of each year approaches, it’s helpful to look back at the technology and techniques that have furthered the evolution of implantology — and it’s just as exciting to think about what the future holds for the oral surgery specialty. Below are just a few of the trends that I think will drive implant planning and placement in 2019.

Technology

Smart CBCT I was trained to use cone beam computed tomography (CBCT) about halfway through my degree in the mid-2000s. Where we’ll see advancements in 2019 is in “smart” CBCT. Much like the smart technology we think of that makes our daily lives easier (devices that intuitively adapt to their environment; respond to our voices; or predict our desires based on previous interactions), we’ll see similar advancements in our practices.

Touchscreens will be incorporated with the system so a computer screen and mouse will become optional. Built-in video cameras will aid with patient positioning as well as facial scanning. Quality control features will either autocorrect mistakes or alert users before the scan is taken. Most important, advancements in technology will keep radiation dose at a minimum for patients, and scan times will be faster than ever. We’ve seen a trend toward all-in-one systems, and future CBCT systems will continue in this direction, with multiple fields of view and upgradable options for cephalometric imaging to appeal to all specialists.

Matthew Nichols, DDS, was born and raised in Tullahoma, Tennessee. After graduating from Tullahoma High School in 2000, he completed his undergraduate training at Lipscomb University in 2004. Dr. Nichols graduated from the University of Tennessee College of Dentistry in 2008. Postgraduate training in Oral and Maxillofacial Surgery was obtained at Vanderbilt University Medical Center. Dr. Nichols received his certificate in Oral and Maxillofacial Surgery in 2012. Dr. Nichols began practicing in Manchester, Tennessee, in July 2012. He is board certified by the American Board of Oral and Maxillofacial Surgeons. He is a member of the American Association of Oral and Maxillofacial Surgeons, Tennessee Society of Oral and Maxillofacial Surgeons, and the American Dental Association. Dr. Nichols maintains active training in CPR, ACLS, and PALS. Disclosure: Dr. Matthew Nichols is a Key Opinion Leader of Carestream Dental.

40 Implant practice

Figure 1: Prosthetic-Driven Implant Planning (PDIP) Module

Implant planning software With new research confirming that virtually planning implants increases their angular accuracy during surgery,1 we’ll see further advancements in software that help doctors virtually plan and place implants. The rise of the “crown-down” approach to implant planning is also driving demand for intuitive planning software that leads to greater predictability in the success of the implant and final restoration.

Additionally, software that can automatically merge STL files from an intraoral scanner with the DICOM files of a CBCT system, such as the Prosthetic-Driven Implant Planning (PDIP) Module, will give an added layer of confidence in planning — not to mention a powerful communication tool for patients.

3D printing Three-dimensional printing has exploded in popularity across all industries, and oral surgery is no exception. Aiding in the spread of this technology is a significant decrease in the cost of buying a printer — as low as $3,000 instead of $25,000 as in years past.

For example, since bringing 3D printing in-house a year and a half ago, I have printed all my own surgical guides. I’m able to do so for approximately $30 a guide, rather than $400-$500; it’s more cost-effective for my practice and also protects my patients from any surprise lab fees that may be passed

Figure 2: Surgical guide

down to them. By cutting out the middleman, I can also collaborate directly with the referring GP. Based on the number of phone calls I receive from colleagues asking about my 3D-printing workflow, we’ll see more doctors of all specialties bring 3D printing in-house.

Techniques Guided surgery Many of the technological advancements above make new techniques possible. As such, we’ll see more doctors take advantage of guided implant surgery. If virtual implant planning increases the accuracy of implant planning and placement, as previously mentioned, then using a restrictive drill guide increases the angular and depth accuracy even more. Surgical guides also allow doctors to take a flapless approach, with means less healing time for patients. The predictability of guided surgery will even help doctors save on supplies. In the past, I would have to order five to six implants to ensure I’d be covered during surgery. In 2019, an Volume 11 Number 4

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TECHNOLOGY implant will be virtually placed from a digital implant library, and the necessary implant will be ordered for the day of surgery. In addition to the advanced software and 3D printing that will make guided surgery prevalent in the coming year, surgical navigation systems will also aid with accuracy and safer surgeries.

Trends

Figure 3: Carestream Dental’s CS 9600 system

Figure 4: With metal artifact reduction (MAR)

Figure 5: Without metal artifact reduction (MAR) 42 Implant practice

Greater collaboration among specialties Open communication among doctors will lead to more efficient treatment and faster turnaround times (in healing, having implants restored, receiving appliances, etc.) for patients. Again, it’s all possible thanks to advancements in technology. I’m able to share the full version of my CS 3D Imaging software with referrals, so they can see exactly what I see when discussing a patient’s case. Open systems, in general, also make it easier to export and share files.

Since I serve a small rural community, many doctors send their patients to me for CBCT imaging, especially orthodontists, rather than sending them to a hospital.

We’ll also see more multispecialty practices as referral relationships evolve into business partnerships. With more equipment being designed to handle several workflows — such as intraoral scanners that can be used for restorations, orthodontics, and implant-borne restorations, and CBCT systems that are ceph-ready — several different specialists can benefit from technology used in one multidiscipline practice.

In 2019, there will be no reason to work in a silo since working across specialties will benefit doctors and patients so much more.

“2019” comes early As previously mentioned, I was trained on CBCT in school and have never practiced without it. However, I recognize that the technology behind 3D imaging systems and software keeps evolving, which can be daunting to some. Fortunately, I recently had the opportunity to implement one of the newest CBCT systems on the market: Carestream Dental’s CS 9600 system. This new system features smart technology to aid oral surgeons and their teams in providing exceptional care. For example, a built-in SmartPad guides my team in positioning patients and previewing images. Smartautomated technology incorporates much of what we know about medical imaging — photographic scout, radiographic scout, etc. — so the team can capture a smaller area more effectively, or a larger area more easily, with fewer retakes. The system can also detect and visually indicate if the wrong accessory is inserted for the selected procedure and recommends the appropriate one.

Multiple fields of view give me more options to handle any clinical situation, even capturing the frontal sinus (16 cm x 17 cm).

At the same time, I can capture a post-op image using the 4 cm x 4 cm FOV at just slightly more dose than a PA. The metal artifact reduction (MAR) algorithm also significantly reduces metal artifacts to help confirm diagnosis and reduces risk of misinterpretation. As we enter 2019, my team and I are eager to discover even more ways this innovative system can benefits our patients.

No one can say for certain what the future holds for oral surgery, but there’s no doubt the right technology has given me more certainty about the future of my patients’ oral health. As that technology aids with new techniques for better surgery and fuels industry trends, we’re sure to see even more advancements in 2019 that will change the way we practice and, ultimately, change our patients’ lives. IP 1. 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.

Volume 11 Number 4

AUTHOR GUIDELINES Implant Practice US is a peer-reviewed, quarterly 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 11 Number 4

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 43

EVENT RECAP

Inaugural 3Shape Community Symposium

3

Shape kicked off its Inaugural Community Symposium on Thursday, October 4, 2018, at the Arizona Biltmore, a Waldorf Astoria Resort, in Phoenix, Arizona. The beautiful weather and Squaw Peak Terrace were an ideal complement to the outdoor evening welcome reception.

Attendees were treated to a formal welcome Friday morning by 3Shape co-founders co-CEO Tais Clausen and Vice President of Product Strategy Rune Fisker.

This standing-room-only presentation was brimming with excitement as new releases and updates were revealed, the first of which was the new 3Shape TRIOS® AI scan. This advanced artificial intelligence (AI) makes intraoral scanning easier than ever. AI scan improves the speed of digital impressiontaking by automatically removing soft tissue while you scan. Delivering a cleaner-looking scan, it saves a step for the experienced dental professional and removes clutter for novice users. The releases kept coming with higher capacity batteries for the 3Shape TRIOS Wireless intraoral scanner and 3Shape Patient Excitement Apps. Among the apps: the 3Shape TRIOS Smile Design app, which allows the clinician to design new teeth/smiles on a photo-realistic image of the patient for improved patient acceptance; the 3Shape Treatment Simulator app, which can compare an intraoral scan of the patient to the simulated results of orthodontic treatment to drive case acceptance; and the 3Shape TRIOS Patient Monitoring app, which enables clinicians to compare patient intraoral scans between visits to monitor changes and share with the patient.

The newly revealed features and upgrades were on par with the Symposium’s theme, “Changing Dentistry Together.”

After a clinically driven keynote address

by Dr. Lyndon Cooper, participants were encouraged to take a deep dive into digital dentistry with general session lectures, master classes, and hands-on classes. Ranging from tips and tricks to aligner workflow to maximizing efficiency using 3Shape systems in your laboratory, the hands-on sessions held many gems. Senior Clinical Product Manager Morten Ryde really delivered in the Tips and Tricks for Optimal TRIOS Scanning class.

Users of all levels found value in his insights about scan depth (12 mm from first contact), implant body scanning (circle around it), edentulous patient scanning (start with the alveolar ridge), etc. The 2-day Symposium schedule of courses held interest for everyone.

44 Implant practice

3Shape co-founder and co-CEO Tais Clausen speaks about the company’s history during the welcome presentation

The hands-on courses provided attendees with opportunities to perfect their skills

During course breaks, attendees could visit one of several 3Shape Genius Bars where a 3Shape expert in your specialty would provide one-to-one product advice and technical help. Also, a cozy exhibit hall held several booths with additional handson opportunities with event sponsors and 3Shape brand partners.

The stellar 2-day event exceeded expectations. 3Shape’s digital dentistry experts displayed their innovative culture and shined in every aspect. Save the date for next year’s 3Shape Community Symposium, September 12-14, 2019.

About 3Shape

The 3Shape Genius Bar stations gave clinicians a chance to speak one-to-one with an expert in their field

3Shape is changing dentistry together with dental professionals across the world by developing innovations that provide superior dental care for patients. Its portfolio of 3D scanners and CAD/CAM software solutions includes the multiple award-winning 3Shape TRIOS intraoral scanner, the upcoming 3Shape X1 CBCT scanner, as well as marketleading scanning and design software solutions for both dental practices and labs.

Two graduate students founded 3Shape in Denmark’s capital, Copenhagen, in the year 2000. Today, 3Shape has over 1,400 employees serving customers in over 100 countries from an ever-growing number of 3Shape offices around the world. 3Shape’s products and innovations continue to challenge traditional methods, enabling dental professionals to treat more patients more effectively. Visit www.3shape.com to learn more. IP Volume 11 Number 4

Implant Practice US

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INDUSTRY NEWS Cellerant announces the Best of Class Technology Award winners for 2018 The Cellerant Best of Class Technology Award Winners for 2018 are: CELLERANT • 3D Systems NextDent 5100 BEST OF CLASS • 3Shape TRIOS® MOVE TECHNOLOGY AWARD • DEXIS and Simplifeye 2018 DEXvoice • AdDent Calset Composite Warmer and CoMax • LED Dental VELscope® Vx Composite Dispenser • MMG ChairFill by MMG • Bien-Air iOptima INT Fusion • Bien-Air TORNADO • Orascoptic EyeZoom™ • DDS Rescue • Orascoptic Spark™ • Dentrix G7 • Shofu EyeSpecial C-III • DEXIS FS Ergo by KaVo • Simplifeye Amplify • Digital Doc LUM G2 • Ultradent Gemini® 810 + • Garrison Dental Solutions 980 Diode Laser Composi-Tight® 3D Fusion™ • WEO Media The selection process relies on an expert panel of dentists recognized as thought leaders and educators. The panel includes Drs. Paul Feuerstein, John Flucke, Marty Jablow, Pamela Maragliano-Muniz, Chris Salierno, and Lou Shuman. Over the course of each year, the panel members seek out and conduct research on potentially practice-changing technologies, with deliberations on nominees and final voting taking place in February. Panelists are precluded from voting in any category where they have consulting relationships. The entire selection process is conducted and managed on a not-for-profit basis.

For more information, visit cellerantconsulting.com/bestofclass.

Ultradent pledges $25,000 for Hurricane Florence and Hurricane Michael relief efforts In response to the catastrophic devastation caused by Hurricane Florence and the most recent damage caused by Hurricane Michael, Ultradent Products, Inc., has pledged $25,000 to All Hands and Hearts Smart Response. These funds will be used to aid in the rescue, relief, and rebuilding efforts of those affected by the storms. In addition to these donations, Ultradent is offering to help dentists whose practices have been damaged by these hurricanes. Ultradent has offered any dentist whose office has sustained substantial physical damage by Hurricanes Florence or Michael $500 worth of free consumable product, plus 40% off all consumable products, and 15% off all equipment purchases exceeding the initial $500 on that order. Through this offer, Ultradent hopes to provide some aid in the rebuilding efforts of the dental community.

To find out more about Ultradent’s disaster relief efforts, please visit www.ultradent.com/relief.

46 Implant practice

Dentsply Sirona launches Dentistry.com to connect dentists to new patients Dentsply Sirona announced the launch of Dentistry.com, the only digital platform built exclusively to connect patients to dentists.

Created with consumers in mind, the free online community is dedicated to improving the state of dental health by increasing the number of new patients who go to the dentist and accept treatment. Positioned as “The New Destination for Dentistry,” the platform features a search engine for patients that supports filtering by a number of criteria, including insurance network — one of the top ways patients choose a dentist. Additionally, the site will house a comprehensive directory of dental practices across the country.

Dentists joining the Dentistry.com community will be able to “claim their practice” during the Dentsply Sirona World meeting.

This allows dentists to manage their own page on the site where they can list information about themselves, their practice, and other relevant information that would assist in patient acquisition and retention. During the meeting, dentists who sign up will receive a complimentary practice profile that increases their online presence, offers access to national and local audiences, improves website SEO, and helps dentists connect with more new patients by listing services, insurance plans, hours and more.

For more information, please visit www.dentistry.com.

Edwin J. McDonough appointed the President of Planmeca USA, Inc. Edwin J. McDonough has been appointed the President of Roselle, Illinois-based Planmeca USA and will lead the Planmeca subsidiary in North America, which is the most significant market for the Planmeca Group. McDonough joins Planmeca from McDonough Medical Products Corporation, where he served as Chief Executive Officer. He has a proven track record of successfully leading and developing several healthcare technology corporations, such as Progeny and GENDEX, both specializing in dental imaging equipment.

For more information, visit www.planmecausa.com.

Volume 11 Number 4

ON THE HORIZON

You don’t have to be a buccal plate extractor anymore!

Dr. Justin Moody discusses a new tool for efficient tooth extraction before an immediate implant

O

ne of the fundamental skill sets for implant dentistry is the ability to remove teeth while preserving bone, particularly the buccal plate. This is vital to the preservation of bone volume, especially when immediate dental implants are planned. It can be frustrating, even to the most skilled surgeon to encounter paper-thin buccal plates and stubborn teeth such as large canines.

When extracting a tooth for a potential immediate implant placement, it is critical to keep two things in mind to optimize your chances for a positive outcome. First and foremost is buccal bone preservation. This is essential for long-term crestal bone maintenance, osseointegration, and immediate implant stability. Also of importance is minimizing the disruption of healthy soft tissue. In general, soft tissue and bone have a symbiotic relationship. When we see

Acteon® Piezotome® handpiece

Acteon® Piezotome® Cube

Extracted tooth No. 6 showing no bone was removed with the tooth

Extraction of tooth No. 6 for an immediate dental implant. The thin tip is worked down the PDL of the tooth 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®. Dr. Moody has no contract or financial interest in Acteon®.

48 Implant practice

Extraction site showing no loss of bone and minimal soft tissue trauma allowing for the best opportunity for healing and implant success

healthy keratinized gingiva, we will most likely find good bone underneath. Preserving the papilla and soft tissue architecture at the extraction site will contribute to a more predictable and positive long-term outcome.

In my experience, I have found that elevation is the key to atraumatic tooth removal.

While this technique minimizes bone and soft tissue trauma, there are still some situations where the bone is so paper thin that it seems like there is no way to avoid loss of at least part of the buccal plate.

Earlier this year, I had the opportunity to try the Acteon® Piezotome® Cube ultrasonic technology for atraumatic tooth extraction.

Ultrasonic instruments are far less traumatic for the patient then traditional elevators and forceps. At the same time, they are superior at preserving the bone that is essential for ridge preservation and immediate implant placement. The instruments are inserted between the cementum and periodontal ligament (PDL). The tips then widen the ligament space with minimal bone loss and loosen the tooth so that there is little to no luxation required for delivery of the tooth. The frequency modulation is controlled for soft tissue preservation, resulting in better tissue recovery after the surgery. The linear thin tips provide smooth cutting, and the irrigation flow reaches the end of the tip regardless of the orientation, thereby reducing the risk of overheating the bone. I am convinced that this technology will lead to a dynamic shift in how we will remove teeth in the future and encourage you to give it a try! IP Volume 11 Number 4

confidence in compromised sites

Tapered Short Implants BioHorizons Tapered Short implants are available in 6 and 7.5mm lengths, offering a solution for cases with limited vertical bone height and minimizing the need for bone grafting. The implant design features an aggressive thread profile and tapered body for primary stability, even in compromised situations. A platform-switched, dual-affinity, Laser-LokÂŽ surface offers crestal bone retention and a connective tissue attachment for flexible placement in uneven ridges.

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

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