Implant Practice US Spring 2019 Vol 12 No 1

clinical articles • management advice • practice profiles • technology reviews Spring 2019 – Vol 12 No 1 • implantpracticeus.com

PROMOTING EXCELLENCE IN IMPLANTOLOGY

Overcoming the struggle with fixed implant hybrid cases Dr. Tarun Agarwal

The microbiology of peri-implantitis Dr. Aneel Jabbar

Full arch restorations with 3Shape TRIOS® IOS Dr. Dean Vafiadis

A comprehensive clinical review of platelet-rich fibrin and its role in promoting tissue healing and regeneration: part 2 Drs. Johan Hartshorne and Howard Gluckman

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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

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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.

Dental implant education — what you and your patients deserve

I

n 1987, by the grace of God, I graduated from dental school.

I’ve witnessed many transitions in dentistry during my school years and so, so many since. In 1984, we were not wearing gloves, and masks were optional. Composites were one shade and a two-mix system, and implants were in their infancy (for modern times). I remember the first video (yes, we had Beta or VHS) I watched on the placement of a sub-periosteal implant and thought to myself, No way, this will never work — and what time is my next amalgam?

Fast-forward to today where implant dentistry is an integral part of my practice and should be an integral part of every dentist’s practice whether restorative, surgical, or both. Every U.S.-trained dentist graduates from school with basic knowlSteven A. Enea, DDS edge of all the disciplines of dentistry; however, surgical implantology has only recently come into the routine of the general practice. I for one applaud this development.

If you are restoring implants, then you know the pain of trying to restore an implant that was well integrated but lacked restorative vision. Besides the obvious shortcomings in function and/or esthetics, now you sometimes have to tell the patient that the “Chiclet®” in the front of his/her mouth looks the way it does because of the extreme angle and shallow placement of the implant. You can imagine how things go after that. Thankfully, many new materials, techniques, protocols, and equipment are constantly being created to help prevent issues such as this.

With the benefits come the challenges — it is almost daunting to keep up with this technological explosion, but also exhilarating. The popularity of 3D scanners has taken implantology to a level of predictability not seen before with 2D radiography. Root-form implants boast a success rate of 98%. In 2000, L-PRF was showing some incredible healing properties at a surgical clinic in France, and it has now become one of the most popular trends in dentistry.

The development of different types of allograft and xenograft materials has given the provider ways to graft without donor sites. These developments, which are not all inclusive, have helped make the discipline of implantology more accessible and predictable.

My advice for any dentist, new or seasoned, who may be restoring an occasional implant or not restoring at all, is to seek out dental implant education on both the surgical and restorative sides. There are so many excellent resources to gain that keeping educated becomes a little overwhelming. My recommendation would be to take a hands-on course with live patients that is steeped in the didactics. You will not regret this. Even if you don’t plan to place implants, you will be better prepared for the scenario above and have a better understanding of why and how implants are placed as they are. You will even notice that your patients have a different attitude when coming in to have a tooth replaced with an implant versus a Class II restoration! They are motivated, happy to be there, and willing to do what it takes to get their tooth/teeth back. Studying and practicing implantology has changed the way I do dentistry. It has added a new dimension that allows me to offer my patients a predictable, long-lasting way to replace missing teeth and restore their dentition that is on the cutting edge of dentistry. After all, isn’t that what our patients deserve?

Steven A. Enea, DDS

Steven A. Enea, DDS, received his dental degree from the University of Missouri-Kansas City. In 1990, he entered the U.S. Navy, where he served as the Dental Department head aboard the USS Seattle AOE3, Force Dental Officer for the U.S. Antarctic Program, and was assigned as the Dental Officer for the Blue Angels. In 2001, Dr. Enea exited the Navy for private practice. He then went into the Air Force Reserves in 2006 and has served as the Surgeon General Dentist at Peterson AFB, and is now Officer in Charge of Dental at Buckley AFB for the Colorado Air National Guard. Dr. Enea is on faculty with Implant Pathways.

ISSN number 2372-9058

Volume 12 Number 1

Implant practice 1

INTRODUCTION

Spring 2019 - Volume 12 Number 1

TABLE OF CONTENTS

Case report Full arch restorations with 3Shape TRIOSÂŽ IOS

6

Dr. Dean Vafiadis outlines his steps for full arch restoration

Continuing education A comprehensive clinical review of platelet-rich fibrin (PRF) and its role in promoting tissue healing and regeneration: part 2 Drs. Johan Hartshorne and Howard Gluckman discuss the optimization and application of PRF — along with its benefits and limitations.................18

Case report

12

Overcoming the struggle with fixed implant hybrid cases Dr. Tarun Agarwal discusses the learning curve and subsequent revelations gained regarding the implant process ON THE COVER Cover images courtesy of Dr. Tarun Agarwal.

Article begins on page 12.

2 Implant practice

Volume 12 Number 1

TABLE OF CONTENTS

Continuing education The microbiology of peri-implantitis

Going viral

28

Dr. Aneel Jabbar explores whether the microbiology of peri-implantitis is similar to or distinct from chronic periodontitis

The four pillars of cybersecurity for the dental practice Gary Salman, CEO of Black Talon Security, discusses the reasons for protecting against cyberattacks to your patient files.......................... 32

Product profile

On the horizon

Are your patients having a hard time understanding?

Kilgore International, Inc................34

Digital workflow is different for everyone

Industry news...............36

Dr. Justin Moody discusses how a digital workflow can make your practice more efficient, predictable, and reliable.................................. 40

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4 Implant practice

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CASE REPORT

Full arch restorations with 3Shape TRIOS® IOS Dr. Dean Vafiadis outlines his steps for full arch restoration Introduction Full arch restoration for patients can be treatment planned and fabricated in many different ways. Utilizing IOS 3ShapeTRIOS® scanning technology has made these treatments much easier and more accurate for mounting, fabrication, and delivery of the restoration.1,2 Using new software, file sharing, and file merging will allow the clinician and laboratory to get ideal positions of teeth, implant abutments, final restorations, and occlusal morphology to the ideal positions that are best for each patient.

This is a case report of a patient who presented with periodontal disease on the maxillary and mandibular arch. Many teeth had Class II and Class III mobility. Pocket depth ranged from 5 mm to 10 mm on many teeth. The patient had a traumatic experience with her previous dental office and had not visited a dentist in more than 7 years. Most of the lower teeth were hopeless and could not be saved. Based on patient’s needs of function, esthetics, and traveling schedule, three options were presented at her consultation visit (Figures 1-3).

Option 1 • Extract all teeth, immediate placement of 5-6 implants on the mandible and maxilla.

• Immediate provisional in occlusion.

• Final restoration would be a zirconia fixed-hybrid prosthesis.

Option 2 • Sequentially extract teeth while keeping the provisional restoration to hold the occlusal vertical dimension (OVD).

• Maintain teeth with perio-prostho concept and maintain tissue levels for better natural gum tissue.

• Keep teeth that were stable to hold the provisional.

Figure 2

Figure 1

Dean C. Vafiadis, DDS, is a program director of the Full Mouth Rehabilitation CE course at NYU College of Dentistry (NYUCD). He has been on faculty at NYUCD since 1993. He currently practices in New York City, New York, where he is the president of the New York Smile Institute — a multi-specialty practice for esthetics, CAD/CAM, and implant dentistry. He currently uses CEREC®, TRIOS®, E4D, and 3M™ True Definition Scanners in his office. He has lectured around the world and has given over 300 all-day courses on esthetics, implants, and CAD/CAM technologies.

• Final restoration would be splinted zirconia-ceramic crowns and bridges.

Option 3 • Extract all teeth and place immediate complete dentures to reduce finances.

• Final restoration would be complete upper and lower dentures.

Treatment The patient chose option 2, and treatment proceeded as follows.

Methods and materials Digital diagnostic scans were made. A CBCT scan was taken, and a diagnostic wax-up was fabricated for ideal provisional to new OVD position. Strategic extraction of teeth Nos. 17, 20, 21, 23, 24, 25, 26, 28, 29, and 31 was performed. After extractions were performed, a provisional restoration was placed at a new occlusal vertical dimension based on the jaw position that was analyzed with the CT scan (Figure 4).

This allowed the clinician to restore OVD and give the patient ideal mandibular movement. This would also reduce the occlusal forces to the provisional and natural teeth during the healing phases.3 The provisional restoration was made from teeth Nos. 19 to 30. Teeth remaining were 19, 22, 27, and 30. The teeth were retaining the provisional and were root-planed and scaled to have ideal periodontal healing during the splinted provisional therapy. This will also allow for cross-arch stability of the provisional and restore the new OVD position with canine guidance occlusion.

Figure 3

Disclosure: Dr. Vafiadis is a consultant for: 3Shape, Henry Schein®, Ritter Implants, MegaGen Implants, BioHorizons® Implants, Zimmer Biomet Implants, and ROE Dental Laboratory.

Figure 4 6 Implant practice

Figure 5 Volume 12 Number 1

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CASE REPORT

Figures 6-8: Occlusion scan for full arches

Internal connection implants (Ritter™ Implants, San Antonio, Texas) were placed in sites 20, 21, 23, 25, 26, 28, and 29.

While the implants were healing, the provisional restoration maintained the newly restored vertical dimension and sealed the dental tubules of the existing remaining mandibular teeth with dentin- bonded solution (ExciTE®, Ivoclar Vivadent®, Amherst, New York). After 5 months of healing, the implants were uncovered, and healing caps were replaced for 3 weeks. Tooth No. 19 was loose and was extracted. An additional implant No. 30 was placed and allowed to heal for 4 months. The provisional was removed after all implants were osseointegrated, digital scan bodies were placed (Core3dcentres®, Las Vegas, Nevada) for the posterior implants, and standard impression copings were placed on the anterior implants. Radiographs were taken to ensure correct position on the implant fixtures.

A 3Shape TRIOS scanner was used to scan the full arch of the mandible in addition to maxillary provisional (Figures 5 to 10).

Three individual occlusion scans were merged together in one consistent file. The first scan was with posterior right provisional used as stops in place so that ideal OVD was scanned. A second scan was with the posterior left provisional in place. The third scan was for the anterior teeth in ideal OVD position. These scans were merged instantaneously with the software to produce ideal

Figure 13 8 Implant practice

Figures 9-10

Figures 11-12: Laboratory connection

OVD position of maxillary and mandibular arches (Figures 11 and 12).

Files were imported into 3Shape implant software, and abutment design was initiated.

Implants on the posterior left and right, as well as anterior implant abutments, were designed for ideal position and distribution mesially and digitally (Figure 13).

A separate scan of the provisional can be seen in purple color, merged and overlaid to anatomical position mesially and distally, so that the clinician can approve or edit designs as needed (Figure 14).

This also allows the clinician to evaluate individual alignment and interproximal position, which ultimately allows the patient

Figure 14 Volume 12 Number 1

Orange is the New Gold Standard Would you recommend your implant system to a colleague? Recently we had our Net Promoter Score (NPS) measured relative to other implants. NPS is a simple metric to see if your customers would recommend you.

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CASE REPORT

Figure 15

access to clean the pontic sites. This is a critical step in the quality control of full arch implant cases. This step can save many “try-in” visits because of the accuracy and visualization of final designs. This also gives excellent communication between the lab technician and the clinician. In addition, more detailed analysis of the CAD/CAM abutments was made circumferentially around each abutment-tissue emergence profile. The emergence profile formula published by Goldstein, Vafiadis, and Kim, regarding the tissueabutment-bone displacement was used to idealize the gingival levels of the abutments around the tissue of the implant.4 The XYZ axis is used to determine the ideal emergence design to avoid displacement and blanching of the tissues. Further input of a zirconia frame as designed by the technician and approved by the clinician shows proper position restorations and pontic sites. The esthetic outcome, porcelain overlay, and ideal OVD can be evaluated by the technician and the clinician. This will also minimize patient visits since the clinician can make the changes before final fabrication (Figures 15 and 16).

Delivery of final abutments and coping try-in was performed on the second restorative visit. A PVS pickup impression was made of all the zirconia copings.

A new vertical dimension record was made as well as a new face-bow transfer record to allow for ideal articulation virtually (Figure 17).

At the third restorative visit, the final design of all ideal anatomic forms of lower teeth and implants becomes a very easy and quick try-in bisque-bake visit with minimal occlusion adjustments. At the fourth restorative visit, patient acceptance for shade and shape of teeth, final stain, and glaze is performed and temporary cement is placed (Figures 18 and 19).

Temrex is used to cement all implant and teeth restorations. Final OVD is confirmed, and ideal occlusal guidance and emergence profile is evaluated. A 4-week postoperative 10 Implant practice

Figure 16

Figure 17

Figure 18

evaluation is performed, and final cementation of all restorations is completed using Temrex (Temrex Corp., Freeport, New York) on implants and Durelon™ (3M ESPE) on teeth.

Discussion The accuracy of the 3Shape TRIOS scanner can be realized fully when full arch restorations are being fabricated. The accuracy of the printing technology has also been improved to 16 microns (Stratasys Objet Eden206VS).5,6 3Shape software allows for ideal porcelain library to be imported and merged in matter of seconds. This allows for ideal position of anatomy emergence profile, occlusal contour, and esthetic position. The provisional overlay “purple” view was a significant advantage to show the clinician and technician the proper alignment of abutment position, posteriorly and anteriorly. The accuracy of these procedures for implant restorations can be seen by using the 3Shape TRIOS scanner. The verification of impressions and records are very consistent when using scanning technology and virtual articulation. The provisional cement was used on the implant restorations, and after 36 months in service, there has been no complication except for increased tartar in the posterior lingual areas of the anterior teeth. The patient is currently on a 3-month maintenance protocol for hygiene. There have been no failures or prosthetic complications or screw loosening up to this point.

Figure 19 Note: When these implants were scanned, we were using an older type of scan bodies. The current scan bodies that are being recommended today are the 3Shape scan bodies and Biodenta scan bodies for all implant systems. IP

REFERENCES 1. Nedelcu,R Persson AS. Scanning accuracy and precision in 4 intra-oral scanners: an in vitro comparison based on 3-dimensional analysis. J Prosthet Dent.

2014;112(6):1461-1471.

2. Fukazawa S. Odaira C, Kondo H. Investigation of accuracy and reproducibility of abutment position by intraoral scanners. J Prosthodont Res. 2017;61(4):450-459.

3. Bachhav VC. Aras MA. Altering occlusal vertical dimension in functional and esthetic rehabilitation of severely worn dentition. J Oral Health Res. 2010;1(1):2-7.

4. Goldstein G. Vafiadis D. Kim J. Finding Z: a mathematical method for predicting tissue position after implant abutment restoration placement. J Prosthet Dent.

2014;112(2):322-324.

5. Sami T. Goldstein G. Vafiadis D. Malvin J. The accuracy of four intraoral scanners. Third place ACP award. Poster presented at: Digital Poster Session at the 48th Annual Session of the American College of Prosthodontists.

October 31 - November 3, 2018; Baltimore, Maryland.

6. Patzelt SB, Emmanouilidi A, Stampf S, Strub JR, Att W. Accuracy of full-arch scans using intraoral scanners. Clin Oral Investig. 2014;18(6):1687-1694.

Volume 12 Number 1

CASE REPORT

Overcoming the struggle with fixed implant hybrid cases Dr. Tarun Agarwal discusses the learning curve and subsequent revelations gained regarding the implant process

A

s a general dentist practice owner, I am constantly looking for new options to add to my practice to help patients and increase revenue. About 10 years ago, I made a firm decision to add dental implants — it’s a decision I haven’t looked back from.

As that journey progressed, I felt it time to tackle my first full-arch implant case (about 3 to 4 years into my implant journey). Truthfully, I was not sure what I was doing, so I enlisted the help of an oral surgeon and sent the patient for a consult. The rest, as they say, is history.

That first case was a total disaster on so many levels. Looking back, it was the best thing that could have happened to me!

Patient confusion I sent the patient to the surgeon without discussing fees and the process. About 6 months later, the patient returned to me with five implants in her maxillary jaw and asked when she would get her teeth. I proceeded to make up a restorative fee, and the patient said “I already paid the surgeon.” I called the surgeon, and he advised me that she had paid for the surgery. So to keep the patient happy, I was in a dilemma. I thought, What do I do now? Just wanting to get a few cases under my belt, I agreed to restore the case for the lab cost — to which the patient reluctantly agreed. And I was off to the races.

Tarun Agarwal, DDS, graduated dental school from University of Missouri at Kansas City in 1999. In 2001, he founded Raleigh Dental Arts with the goal of building the preeminent dental practice in the Raleigh area. He recently built a training center within the practice dedicated to sharing his expertise. He is a recognized speaker, author, and dental leader and has been featured on CBS, NBC, ABC, FOX, and News 14 Carolina.

To learn more about Dr. Agarwal’s workflow and watch a live case “over the shoulder,” you can get more information about attending Dr. Agarwal’s 3D Edentulous workshop with 3D Dentists in Raleigh, North Carolina, by visiting www.3D-Dentists. com/edentulous.

12 Implant practice

Restorative nightmare Being a novice at implants, I quickly realized this situation was nothing like taking a one- or two-unit dental implant impression. There were preliminary impressions, verification impressions, trial bites, trial screwed-in setups, material considerations, prosthetic space considerations, and hygiene-design considerations. As a result, I spent four appointments just getting a final working impression, only to discover that due to implant positioning, we needed to place multi-unit abutments (MUA) to correct angulations. Now, every time I am doing a try-in, I am fiddling with these MUAs and making sure they are on correctly. Finally, we got done, and the result wasn’t exactly hygienic (due to lack of bone reduction) nor esthetic. Luckily, “the patient was happy.”

Probably, she was just tired of the long and drawn-out process.

Team bias What I wasn’t aware of during all of this was how the team was watching and making notes. They basically had decided to never allow us to do a case like this again. It sent a “mentality message” that is critically important to successful integration of any new procedure. This has the biggest effect on success in your practice.

At the conclusion of treatment, I must have seen this patient for 15 visits and felt stressed and stupid at each visit. Even if I was paid my full fee, it would have been a loss. To make matters worse, I didn’t estimate the lab bill properly — I didn’t know to plan for MUA costs, impression component costs, and other miscellaneous items.

I was tempted to give up before I even really got started. But I felt there had to a better way. Frankly, I was too stubborn to give up.

So I went to my classic playbook — how could I leverage technology to make this better. What I found has turned out to be amazing and practice-changing. Over the years, workflow has morphed and improved

— from both simply my having done more cases and improvements in digital technologies. In this case presentation, I would like to offer an overview the process from beginning to end.

Partners for patient outcome I follow a pretty simple philosophy of teamwork for ideal patient outcomes. This allows me to leverage various areas of expertise to achieve maximum efficiency and minimize stress. The three team members follow.

1. Restorative dentist The restorative dentist is the “conductor of the orchestra.” After all, patients don’t really come for dental implants; they come for a smile. So the restorative outcome has to be kept in mind prior to committing to surgery.

2. Surgical dentist The surgical dentist is the person performing the surgery and coordinating the optimal level of sedation for patient comfort. This person will ensure efficient surgery following the plan and any postoperative follow-ups.

3. Dental laboratory The dental laboratory is a key component to make this actually happen. The lab is tasked with designing the diagnostics, designing the guide, and fabricating the actual restorations.

Technology has certainly reached a point where the general dentist can be all or a few of these components. The depth at which the general dentist is involved is dependent on comfort, surgical skill, and the patient’s medical condition.

Diagnosis and case acceptance Today, diagnosis starts during the consultation. Our treatment coordinator sits with the patients to discover their needs, take a preset series of digital photographs, and a 3D CBCT. She then sends the full-face photo to our laboratory partner for smile simulation Volume 12 Number 1

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CASE REPORT

Figure 1

Figure 2

Figure 3

Figure 5

Figure 4

and reviews demonstration models with the patient. At this point, I meet the patient, assess his/her condition, answer any questions, and begin the diagnostic virtual planning. By the end of our consultation visit, the patient has a clear answer of what options exist and what his/her new smile will look like (after the simulation is completed and shown to patient), and I will have a clear idea of the involvement of his/her surgery. Our treatment coordinator then sits with the patient to review the game plan and begins the discussion of how to make this affordable for the patient.

Once the patient accepts treatment and firm financial arrangements are in place, the diagnostic records are transferred to our skilled laboratory for final planning and guide fabrication. I provide the laboratory an initial implant plan and approve the final

plan through remote session. The laboratory also provides me with a comprehensive list of all implant components that are necessary for this case and sends the final guides to the office.

Figure 6

Figure 7

14 Implant practice

Surgery and immediate teeth At this point, I have walked through surgery virtually and am very familiar with the potential pitfalls. All materials are set aside in order to maximize efficiency, and the patient is sedated (we choose to use a surgical center with MD anesthesiologist providing nasal intubation). The guide is fitted over the teeth and tacked into place. Guided bone reduction is completed to create proper prosthetic space and develop ideal hygienic contours. The implant guide is placed, and the dental implants are guided into place ensuring adequate primary stability.

A conversion-milled prosthetic has been prefabricated and fits on top of the foundation guide to allow for immediate loading of the implants with a strong and hygienic provisional prosthetic. The bite is verified, and an immediate postoperative panoramic X-ray is taken.

Honestly, this part has become straightforward, and the average case takes about 90 minutes per arch. I have full confidence the implants are being placed in the proper position to best support the final prosthetic.

The patient is scheduled for a 1-week followup and 3-month follow-up.

Final restorative After allowing for integration, I begin fabricating the final restorative. As a restorative dentist, this is where my life has been made easier — due to better planning, guided surgery, immediate conversion, and leveraging digital technologies.

Figure 8 Volume 12 Number 1

NAVIGATING THE OVERDENTURE STUD ATTACHMENT MAZE Indications for stud attachments:

• Improving quality of life with only two implants in lower arch, functional capacity increased from 10% to 60% • Allows independent servicing of attachments • Provides retention and improved prostheses stability

Locator

• Lowest profile, 2.73mm x 5.5mm • 8 different retention levels • Self-aligning function 40° • Nylon male stays in contact with abutment, housing pivots around nylon male, to reduce abutment wear

O-Rings

• 6mm x 4.5mm tall • 2 retention levels • Minimal angulation correction, 10° • The most resilient attachment system, protects weaker abutments

Clix

• Small size, 4 x 4mm • 3 different retention levels • Angle correction up to 30° • Great for patients with hygiene issues • Female makes patient pleasing audible Clix when engaged for security and confidence.

• Ideal for anterior maxillae

Locator R-Tx

• Low profile, 3.1mm x 5.6mm • 4 different retention levels • Self-aligning function 60° • Nylon male stays in contact with abutment, housing pivots around nylon male, to reduce abutment wear

Magnets

• 2.4mm x 3.9mm • One retention level per size • No path of insertion; corrects up to 48° of divergence • Ideal for patients with limited dexterity Images courtesy of PREAT Corporation Technical Team

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CASE REPORT

Figure 9

Figure 10

Figure 13

Figure 12

Figure 14

Figure 15

Figure 16

Figure 17

Figure 18

Figure 19

16 Implant practice

Figure 11

The first step is a preliminary implant level impression by actually scanning the conversion prosthetic with analogs in place and also digitally capturing the bite and opposing dentition.

The lab then makes necessary esthetic design changes and bite modifications and prints a prosthetic implant verification jig tray (iJIG), which is screwed into the mouth in pieces. A panoramic X-ray is taken to verify complete seating of each component and luted together using bis-acryl. A tissue impression is then taken with light body PVS injected under the iJIG. In a single visit, we have completed the verified impression, bite records, esthetic verification, and tissue impression. The next step is a final trial smile to verify fit, function, esthetics, and phonetics. Once verified, the lab is instructed to fabricate the final restoration.

Thanks to leveraging digital technologies and putting the right partners in place, what was once complicated and unpredictable has become enjoyable, profitable, and predictable. If you have felt the same frustrations and have given up on these types of cases, or feel that you and your surgical specialist aren’t on the same page, know that modern solutions exist to age-old problems. IP

Volume 12 Number 1

IMPLANTING CONFIDENCE

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For more information, call 800.944.6365 or visit carestreamdental.com

CONTINUING EDUCATION

A comprehensive clinical review of platelet-rich fibrin (PRF) and its role in promoting tissue healing and regeneration: part 2 Drs. Johan Hartshorne and Howard Gluckman discuss the optimization and application of PRF — along with its benefits and limitations

P

latelet-rich fibrin (PRF), a patient bloodderived 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. PRF technology has grabbed the attention of clinicians because it is derived from the patients’ own blood; is readily available; is easy to prepare; can be produced immediately at the chairside; is easy to use; and widely applicable in dentistry, while being financially realistic for the patient and the clinician, and with virtually no risk of a rejection reaction (foreign body response).

The 3D architecture of the fibrin matrix provides the PRF membrane with great density, elasticity, flexibility, and strength that are excellently suited for handling, manipulation, and suturing.

Optimal PRF membrane quality and treatment success is dependent on quick collection of blood and transfer to the centrifuge (2 minutes as per Choukroun); use of proper centrifugation protocol; maturation of the clot for 4 to 8 minutes before use; preparation of the membrane using a standardized preparation technique; and appropriate conservation of the membrane before use.

The PRF can be used as a membrane (A-PRF or L-PRF), liquid or injectable form (i-PRF), plug or the membrane can be cut in fragments, and applied either in standalone therapies (i.e., plug, filler, or protective barrier); additive therapies (i.e., added or mixed to bone substitutes); or used in combination therapies with other biomaterials (i.e., protective barrier in GBR procedures).

Educational aims and objectives

This article aims to describe the key aspects of preparing and optimizing PRF, as well as its benefits and limitations.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 27 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Define the PRF preparation technique.

•

Identify currently used centrifugation protocols.

•

Realize techniques for optimizing the quality of PRF.

•

Identify the physical handling and application of PRF.

•

Recognize the benefits and limitations of PRF.

At present, very little is understood about PRF generated from patients with coagulation disorders or patients on medications that affect blood clotting (heparin, warfarin, or platelet inhibitors).

Its lack of rigidity and fast degradation (biodegradability) may limit its application as a sole barrier membrane in GTR procedures.

One of the clinical limitations to deal with is the heterogeneity in the quality of platelets and blood components of various PRF protocols.

At this stage in time there is not a single RCT or CCT to compare the effectiveness of A-PRF or L-PRF protocols. Furthermore, in vitro studies that claim superiority or inferiority of a specific PRF preparation have yet to be validated by independent clinical trials.

Standardized and optimized PRF preparation protocols and their effectiveness still have to be validated through independent robust randomized controlled clinical trials.

The purpose of this review (part 2 of 3) is to analyze the available literature on PRF relating to: • PRF preparation technique • Optimizing the quality of PRF • The physical handling and application of PRF • The benefits and limitations of PRF An improved understanding of these aspects will facilitate the clinicians’ ability to enhance the therapeutic applications of PRF in the fields of implant dentistry, periodontology, and oral surgery.

Figure 1: Drawing blood from a patient using a sterile 10 ml vacutainer just before or during surgery

Figure 2: The tubes should always be balanced by opposing tubes to equilibrate centrifugation forces and prevent vibrations during the centrifugation process

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.

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Figure 4: Extracting the PRF clot from the tube with a sterile tweezer

Figure 5: The fibrin clot is separated from the red blood cell fragment using a scissor

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 dental implantology, 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 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 (neo-vascularization) (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 periodontology, as well as gray literature. The Volume 12 Number 1

Figures 6A-6B: 6A. The PRF clots are placed in the Box grid (Process, France) or Xpression Kit (Intra-Lock, Boca Raton, Florida) and covered with the lid. 6B. The PRF membranes are ready for use after 2 minutes

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.

How is PRF prepared, and how can I use it?

Blood drawing A major advantage of PRF is that it has a simple preparation protocol. Blood is drawn from the patient using a sterile 10 ml vacutainer (two to 12 tubes) just before or during surgery (Figure 1).

Dental clinicians have the following options for drawing blood: • Doing it themselves (venepuncture courses are available) • Asking an anesthetist or sedationist when using general anesthesia or conscious sedation for procedures • Contracting the services of a qualified nurse The tubes with collected blood samples are immediately (within 2 minutes after collecting the blood sample) placed in the centrifuge and processed using a single centrifugation step. The clinical success of the PRF protocol is dependent on a quick collection of blood and its transfer to the

centrifuge because blood will automatically start to coagulate after 1-2 minutes and make it difficult to obtain the required clot quality (Ali, et al., 2016). Failure to accomplish the quick preparation of PRF could cause a diffuse polymerization of fibrin, which is not ideal for tissue healing.

Centrifugation The tubes should always be balanced by opposing two tubes to equilibrate the centrifugation forces and to prevent vibrations during the centrifugation process (Figure 2).

At the end of the centrifugation spin, the caps for A-PRF or L-PRF (not i-PRF) are removed and the tubes placed in a sterile tube holder (Figure 3). The blood sample with the clot is allowed to rest/mature for approximately 4-8 minutes before extracting the clot from the tube. (Figure 4) The centrifugation process activates the coagulation process and separates the blood sample into three different layers: an acellular plasma at the top of the tube; a strongly polymerized fibrin clot is formed in the middle; and blood cells (red corpuscle base) are gathered at the bottom of the tube.4,5,6 Currently used centrifugation protocols There are various centrifugation processing protocols that are currently being used.

• Original Choukroun’s PRF protocol (standard protocol): 3,000 rpm/ 10 minutes Implant practice 19

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Figure 3: At the end of the centrifugation spin, the A-PRF or L-PRF caps are removed and the tubes placed in a sterile tube holder. (i-PRF caps are not removed)

CONTINUING EDUCATION • Dohan Ehrenfest’s group (leukocyteand platelet-rich fibrin [L-PRF]): 2,700 rpm/12 minutes • Choukroun’s advanced PRF (A-PRF), enriched with leukocytes: 1,300 rpm/ 8 minutes • Choukroun’s i-PRF (solution/gel): 700 rpm/3 minutes Effect of centrifugation protocols on the optimum fibrin clot:cell ratio Current data shows that there is a differential distribution of red blood cells, platelets, and leukocytes in the PRF clot depending on the centrifugal force used (Hauser, et al., 2013). The clinical efficacy of different centrifugation protocols, however, still needs to be independently validated with controlled clinical trials.

In vitro studies showed that a longer centrifugation protocol (2,700 rpm) produces a denser (stronger) fibrin clot with less interfibrous space containing less cells compared to the shorter centrifugation protocol of A-PRF (1300 rpm) that produced a less dense fibrin clot with a looser inter-fibrous structure containing more cells (Hauser, et al., 2013).

Dohan and co-workers (2010) found in their in vitro studies that the original L-PRF protocol produces larger clots and membranes, and a more intense release of growth factors than the modified A-PRF protocol. Based on the findings of their studies they suggested that centrifuge characteristics and protocols may have a very significant impact on the cell, growth factors, and fibrin architecture of a PRF clot and membrane.

In contrast, another recent in vivo study showed that Choukroun’s new formulation of PRF (A-PRF) had a more gradual release of growth factors, up to a 10-day period and stimulated significantly higher growth factor release over time when compared to Choukroun’s standard PRF (Öncu and Alaaddinoõglu 2015).

The latter investigators concluded that A-PRF may prove clinically beneficial for future regenerative procedures. The clinical effectiveness and implications of above-mentioned findings still have to be validated through robust randomized controlled clinical trials.

Effect of test tube type and compression on clot quality Research data suggests that the type of vacutube that is used (i.e., dry glass or glasscoated plastic tubes) and the compression process of the clot (forcible or soft) do not seem to influence the architecture of this autologous biomaterial.

20 Implant practice

Figures 7A-7B: 7A. Punching a hole in a PRF membrane. 7B. Draping a punched membrane over a healing abutment

However, both parameters could influence the growth-factor content and the matrix properties of the product (Tatullo, et al., 2012). The influence of these preparation factors requires further analysis, and their effect on the clinical efficacy needs to be validated with good quality clinical trials.

Preparation of PRF membranes Each fibrin clot concentrates most platelets (97%) and more than half of the leukocytes from a 9 ml blood harvest (Tatullo, et al., 2012, Clipet, et al., 2012, Kanayama, et al., 2016).

The PRF clot is removed from the tube with a sterile tweezer. The fibrin clot is separated from the red blood cell fragment, approximately 2 mm below the dividing line, using a scissor (Figure 5).

The section of the blood clot attached to the fibrin clot contains the stem cells.

The PRF clots are placed in the Box grid (Process, France) or Xpression™ Kit (IntraLock, Boca Raton, Florida) and covered with the lid. The PRF membranes are ready for use after 2 minutes.

It provides a three-dimensional matrix of platelets, leukocytes, and growth factors.

A PRF membrane remains usable many hours after preparation, as long as the PRF is prepared correctly and conserved in physiologic conditions.

Moreover, the use of the PRF Box, a user-friendly and inexpensive tool, allows for standardized preparation of homogeneous PRF membranes with a higher growth factor content, avoids the dehydration or death of the leukocytes living in the PRF clot, and also prevents the shrinkage of the fibrin matrix architecture (Mazor, et al., 2009; Simonpieri, et al., 2011; Tajim, et al., 2013).

The concept of “the optimal PRF scaffold or composites,” tailored for specific clinical applications, is still in a process of virtual development. Further clinical trials are required to validate this concept, and what centrifugal force and time is required to get

the optimum PRF composite biomaterial for specific clinical applications.

At this stage in time there is not a single RCT or CCT to compare the effectiveness of any of the above-mentioned PRF (A-PRF or L-PRF) protocols. Furthermore, in vitro studies that claim superiority or inferiority of a specific PRF preparation have not been validated by independent clinical trials. Therefore, based on these facts, no preference or distinction is made between any of the above-mentioned PRF preparation protocols (A-PRF or L-PRF) in this review.

Practical guidelines for optimizing the quality of PRF PRF is a living biomaterial that requires a good knowledge and skills on how to produce, prepare, conserve, and use it most effectively and efficiently (Ali, et al., 2016; Tatullo, et al., 2012; Zhang, et al., 2012). Incorrect use could lead to damaged, dry product leading to inconsistent clinical results (Bölükbas, et al., 2013). The most critical factor affecting the success of PRF in healing and regenerative therapy is the quality of PRF preparations.

Following are some practical guidelines how to optimize the quality of PRF, increase clinical efficiency and consistency, and how to prevent common mistakes.

Limit centrifuge vibration during PRF preparation Centrifuge rotational speed and subsequent vibrations have been shown to have a direct impact on the architecture and cell content of a PRF clot (Diss, et al., 2008).

The Dohan group have hypothesized that the type/make of centrifuge machine has an effect on rotational speed and vibrations. The latter, however, has not been validated with clinical trials.

Vibrations can be limited through following the following rules: • Always make sure that the centrifuge tubes are filled equally (1 cm from the top).

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Figures 9A-9B: 9A. Collagen membrane placed over bone graft. 9B. PRF membrane placed above a GBR membrane as interposition barrier to promote soft tissue healing

• Always balance the rotor properly.

Every tube must have a balance or opposing tube (Figure 2).

• Do not balance with a vacutube filled with water: The distribution of the densities will be incorrect and cause unnecessary vibration.

• If properly balanced and used, the rotor should accelerate smoothly and with a constant change in the pitch of the motor sound.

• Any vibrations or unusual sounds should cause the cessation of operation immediately by the operator.

• Initial vibrations with start of centrifugation can be reduced by holding your hand on the lid.

• Never leave the centrifuge until you are certain that it has reached its operating speed and is functioning properly. All rotors go through a minor vibration phase when they first start.

There will be a minor flutter when the rotor reaches this vibration point — do not confuse this with a serious vibration caused by imbalance.

Patients receiving anticoagulants At present, very little is understood about PRF generated from patients with coagulation disorders or patients on medications Volume 12 Number 1

that affect blood clotting (heparin, warfarin, or platelet inhibitors). When patients are on any type of anticoagulant therapy, they have a longer coagulation time, therefore, it is suggested to centrifuge blood for longer periods, or increase the waiting time after centrifugation (approximately 5-10 minutes).

However, there is no data available to support this recommendation.

Standardized and efficient preparation of PRF The PRF box (Box grid or Xpression Kit) was designed to collect and transform up to 16 PRF clots into membranes in sterile conditions and to conserve them in a clean and wet environment before use (Figure 6A).

The box also contains compression wells and maces to compress the PRF clots into dense PRF cylinders, easy to use for filling cavities (such as extraction sockets).

It is suggested that gentle pressure is used to prevent squeezing out all of the plasma contained in the original PRF clots (Toffler, et al., 2010). Compressing the clot too hard or too long results in shrinkage of the fibrin network, release of growth factors, dehydration, and damage of leukocyte content (Simonpieri, et al., 2011). PRF membranes or plugs are ready for use within 2 minutes after compression

Conservation of the PRF membrane PRF is a blood-derived living tissue and must be handled carefully to keep its cellular content alive and stable. Conserve the PRF clot in its centrifugation tube. As long as the serum has not been flushed away from the clot, the growth factor content remains stable. It is a good way to gain 5 to 15 minutes (Simonpieri, et al., 2011). PRF membranes remain usable many hours after preparation, as long as the PRF is prepared correctly and conserved in physiologic conditions (Clipet, et al., 2012; Simonpieri, et al., 2011; Tajim, et al., 2013).

The PRF Box, a user-friendly and inexpensive tool, guarantees the adequate preparation of homogeneous PRF membranes with a higher growth factor content, avoids dehydration or death of the leukocytes living in the PRF clot, and also prevents shrinkage of the fibrin matrix architecture.

Optimal preparation and selection For the standardization of PRF preparations and to preserve platelets and growth factors, it is suggested not to squeeze out all of the plasma contained in the original PRF clots (Toffler, et al., 2010). Platelets are not equally distributed inside and on the surface of the PRF clot. Therefore, in a clinical situation, when growth factors provided by platelets are expected and desired, the platelet-rich region adjacent to the red thrombus should be used (Toffler, et al., 2010).

Therefore, always place the part of the clot closest to the thrombus closest to the grafting site. This part of the clot contains the highest concentration of platelets and stem cells required for bone regeneration. Thus, it is necessary to preserve a small RBC layer at the PRF clot end to collect as many platelets Implant practice 21

CONTINUING EDUCATION

Figures 8A-8B: 8A. i-PRF added to particulate bone. 8B. i-PRF transforms the graft material into an easy-to-handle gel consistency

of clots in the Box grid (Figure 6B) or plug well (cylinder).

The serum exudate collected in the bottom of the box can be used for a longer conservation of the membranes and is ready to be mixed with a bone biomaterial for grafting. This standardized approach also allows an increase in the total growth factors release of the PRF membrane itself (Simonpieri, et al., 2011).

The exudate in the bottom of the box is rich in proteins (Vitronectin and Fibronectin).

This solution can be recovered with a syringe and used to hydrate biomaterials, flush the surgical site, wet the implant surface, and to preserve harvested autogenous bone blocks, rather than using saline.

CONTINUING EDUCATION and leukocytes as possible. This part of the procedure is done with scissors and remains operator-dependent (Bölükbas, et al., 2013).

Optimizing and preserving growth factor release For the standardization of PRF preparations as a grafting material for tissue regeneration, PRF membranes should always be preserved in a wet serum environment (Toffler, et al., 2010). The compression procedure of the clots into membranes is performed with a gentle, slow, and homogeneous pressure to prevent squeezing out all the serum contained in the original PRF clot (Bölükbas, et al., 2013; Toffler, et al., 2010; Kanayama, et al., 2014).

This will ensure that the final membrane always remains homogeneously wet and soaked with serum. This gentle method thus avoids extracting and losing a significant amount of extrinsic-incorporated platelet growth factors (Clipet, et al., 2012). Significant amounts of growth factors are released during the first 20 minutes after preparation (Mazor, et al., 2009). PRF membranes should therefore be used as quickly as possible after preparation.

However, this release is considerably less significant when forcible extraction is avoided. In physiologic conditions, the main release occurs after several hours (Mazor, et al., 2009), and PRF can be used a long time after preparation, as long as the material is conserved in the adequate conditions.

Figure 10A: PRF used in a clot form

Figure 10B: PRF used in membrane form

Figure 10C: PRF applied as injectable liquid

Figure 10D: PRF used in a plug form

Figure 10E: PRF membrane cut to use as used fragments

Figure 10F: PRF membrane cut in fragments to mix with bone particulate

10B), injectable liquid (i-PRF) (Figure 10C), plug (Figure 10D), or the membrane can be cut up in fragments (Figures 10E and 10F).

PRF can either be applied in stand-alone, additive, or in combination therapies.

PRF can also be used as a protective barrier membrane to seal off and promote healing of oroantral communications following extractions (Magremanne, et al., 2009); to close a palatal connective tissue harvesting site (Zhao, et al., 2011); or as sole grafting material in sinus floor elevations (Kanayama, et al., 2014; Del Corso, et al., 2012; Rao, et al., 2013; Öncü and Erbeyo 2015; Simonpieri, et al., 2009; Simonpieri, et al., 2009) or as a vestibuloplasty wound bandage (Figure 12).

Handling the PRF: clinical application PRF membranes are easy to drape over a surgical or augmented site. The elastic consistency of the PRF membrane also allows the clinician to punch a hole in the membrane to drape over a healing abutment before suturing the flap (Ghetiu, et al., 2015) (Figures 7A and 7B). Mixing autogenous bone or bone substitutes (allografts) with i-PRF (PRF lquid) for use in GBR procedures transforms particulate bone into an easy to handle gel consistency (Figures 8A and 8B).

PRF liquid (i-PRF) can be injected above, or PRF (A-PRF or L-PRF) membrane placed above the GBR or GTR membrane (Figures 9A and 9B) to act as an interposition barrier to protect and stimulate the bone compartment, and as a healing membrane in order to improve the soft tissue healing and remodeling, and thus avoid soft tissue dehiscence (Peck, et al., 2011; Inchingolo, et al., 2010).

Using PRF: physical application PRF (A-PRF or L-PRF) can either be used as a clot (Figure 10A), membrane (Figure 22 Implant practice

Stand-alone therapies Typical stand-alone therapies include using the fibrin plug or membrane as a filler material in extraction sockets (Figure 11) to prevent complications and to enhance socket healing (Choukroun, et al., 2006).

Volume 12 Number 1

Figure 12: PRF membrane used as a vestibuloplasty wound bandage

Figure 13: PRF membrane fragments to mixed with bone particulate

Additive therapies PRF (membrane or liquid) can be added or mixed to bone substitutes (Figure 13) such as xenograft or biphasic calcium phosphate (BCP) to enhance the formation of new bone (Toeroek and Dohan 2013). Research suggests that bone healing is more effective when PRF is mixed with autogenous bone or bone substitutes such as DBBG and BCP in bone augmentation or GBR procedures (Vijayalakshmi 2012). However, there is limited evidence to support this as a clinical guideline.

Combination therapies The PRF membrane is typically used in combination with other biomaterials in bone augmentation and grafting sites as a graft material or barrier membrane (Hamzacebi, et al., 2015) (Figures 9A and 9B). The purpose of PRF is to activate and facilitate the healing and regenerative capacity of the host tissue, by providing a strong fibrin scaffold, major growth factors, and allowing space for tissue regeneration. Using PRF as a protective barrier on bone graft sites helps avoid perforations of the weakened gingival tissues and prevent associated contamination of the bone graft below.

Key biological function of a PRF membrane PRF membranes are not comparable to heterologous resorbable collagen or nonresorbable (i.e., dPTFE) membranes. PRF membranes belong to a completely different category of membrane, namely natural autologous membrane (Shilbli, et al., 2013). A PRF membrane is as natural as the host tissue, while heterologous membranes are considered as foreign bodies by the host tissues and interfere with the natural tissue healing process. A PRF membrane can be used for three purposes: Bioactive barrier A PRF membrane is a blood clot prepared in an optimized form that is rich Volume 12 Number 1

Figure 14: PRF membrane used as a protective and regenerative barrier for intrabony defect

in cells and growth factors, and acts as a natural bioactive barrier, allowing interaction with the tissues below and above it. This interaction with tissues facilitates natural tissue regeneration (NTR) and healing (Inchingolo, et al., 2010). PRF will undergo quicker remodeling (biodegradation) in situ than a resorbable collagen membrane, but will also promote a strong induction on the periosteum/gingival tissue due to the slow release of growth factors and other matrix proteins (Krasny, et al., 2011; Kim, et al., 2013).

Competitive interposition barrier GTR membranes are cell-proof barriers against soft tissue invagination, whereas PRF membranes allow cells to migrate through it, thus allowing new blood vessel formation that will facilitate regenerative and healing interactions between the tissues below and above the PRF membrane. The PRF membrane is a highly stimulating matrix, attracting cell migration and differentiation preferentially, and also reinforcing the natural periosteal barrier.

The hard and soft tissues migrate and interact within the PRF matrix. The PRF matrix becomes the interface between the tissues and therefore avoids the migration of the soft tissues deeper within grafted defect or augmented site. This biological characteristic is referred to as a competitive barrier (Krasny, et al., 2011). However, it is important to recognize that using PRF as a competitive barrier does not have the graft stability or space maintenance characteristics of a normal collagen membrane, and therefore cannot be recommended for use as such.

Protective barrier and healing booster PRF membranes are frequently used for the protection of the grafted area and as a healing booster for the soft tissues above the grafted defects or augmented sites (Inchingolo, et al., 2010). The purpose of the PRF membrane is not only to protect the blood clot and/or the graft material, like in the GTR concept, but also to promote the induction of a strong and thick periosteum and gingiva.

This boosted periosteum functions as a true Implant practice 23

CONTINUING EDUCATION

Figure 11: PRF membrane used as a filler material in a socket

CONTINUING EDUCATION barrier between the soft tissue and bone compartments, and constitutes probably the best protection and regenerative barrier for the intrabony defects (Inchingolo, et al., 2010) (Figure 14).

What are the benefits of PRF? PRF has increasingly grabbed the attention of clinicians worldwide because this biomaterial is of natural origin (autologous/ derived from the patients’ own blood); can be produced chairside; is easy to make, readily available; easy to use within the daily clinical routine; widely applicable in dentistry, while being financially realistic for the patient and the health care system (Joseph, et al., 2014).

The following major advantages support the clinical use of PRF in tissue repair and regeneration processes.

Natural (autologous) biomaterial Regenerative therapies are now shifting away from using allogenic and xenogeneic biomaterials to autologous biomaterials.

While other membranes are considered as foreign bodies by the host tissues and interfere with the natural tissue healing process, a PRF membrane is as natural as the host tissue with virtually no risk of infection, immune or a rejection reaction (foreign body response) (Hauser, et al., 2013; Kanayama, et al., 2014; Barone, et al., 2014).

Easy and efficient to use Preparing PRF is easy, fast, and userfriendly to use within the daily clinical routine (Kanayama, et al., 2014; Inchingolo, et al., 2010; Nacopoulos, et al., 2014; Del Corso and Dohan 2013; Shah, et al., 2014). PRF is prepared on-site (in the clinical setting) simply by drawing blood from the patient for immediate use, thus reducing patient waiting time.

Currently used protocols for the preparation of autologous PRF are standardized and easy for clinicians and clinical assistants to use. Furthermore, there is no limitation on quantity of PRF membranes required.

In comparison with a natural blood clot, a PRF membrane is a solid material, has a strong fibrin architecture, and easier to handle and to position (Kanayama, et al., 2014; Barone, et al., 2014). Fibrin threedimensional architecture provides the PRF membrane with great density, elasticity, flexibility, and strength (Ali, et al., 2016; Del Corso and Dohan 2013) that is better suited for manipulation and suturing (Hauser, et al., 2013). The elastic consistency of the PRF membrane allows the clinician to punch it to allow for placing it 24 Implant practice

The 3D architecture of the fibrin matrix provides the PRF membrane with great density, elasticity, flexibility, and strength that are excellently suited for handling, manipulation, and suturing.

around a healing or prosthetic abutment or even suture it.

Increased clinical performance Recent studies have shown that, compared with previous generation PRP, PRF exhibits a greater expression and concentration of growth factors and matrix proteins, which are released more slowly due to the three-dimensional architecture of the adhesive glycoproteins in the fibrin, which results in significantly better performance (Mazor, et al., 2009; Simonpieri, et al., 2011; Gamal, et al., 2016).

Moreover, A-PRF shows a more gradual release of growth factors, up to a 10-day period, and stimulated significantly higher growth factor release over time when compared to Choukroun’s standard PRF (Öncu and Alaaddinoõglu 2015).

Safety Blood is drawn from the patient, and there is therefore reduced donor site morbidity. PRF rarely causes complications such as membrane exposure; an unwanted outcome that has been observed in cases using biodegradable barrier membranes (Shah, et al., 2015). A further advantage of PRF is the extremely low risk of infection.

Moreover, no in vitro cytotoxicity effects have been detected whatever the quantity of PRF used (Sharma and Pradeep 2011; 2011; Pradeep, et al., 2012).

Increased healing potential PRF increases the predictability of wound healing and regeneration potential of tissues (Zhao, et al., 2011; Bansal and Bharti 2013; Thorat 2011; Pradeep, et al., 2012; Troiano et al 2016; Pradeep and Sharma 2011; Gupta, et al., 2014; Panda, et al., 2014).

Reduced morbidity A clinical advantage of PRF as a graft material is related to avoidance of a donor site and risk of morbidity, thus resulting in a decrease in patient discomfort,

post-surgical pain, and bleeding after operation (Kanayama, et al., 2014; Panda, et al., 2014). PRF is not only a platelet concentrate but also an “immune node” that is able to stimulate defense mechanisms.

It is even likely that the significant inflammatory regulation noted on surgical sites treated with PRF is the outcome of retrocontrol effects from cytokines trapped in the fibrin network and released during the remodeling of this initial matrix (Kanayama, et al., 2016). Furthermore, evidence suggests that the content of platelet alpha granules might have a bactericidal effect, mediated by molecules called thrombocidines that may have an important contribution toward reducing postoperative infections (Lekovic, et al., 2012; Joseph, et al., 2012). The antihemorrhagic properties of PRF are also advantageous and convenient during surgical procedures (Ghetiu, et al., 2015).

Cost-benefit ratio PRF has an outstanding potential costto-benefit ratio. A platelet-rich fibrin (PRF) membrane is a readily available and inexpensive biomaterial that is beneficial in implant dentistry, oral surgery, and periodontal procedures (Bajaj, et al., 2013).

The ease of preparation and cost-effectiveness of PRF membrane offers a huge advantage over other commercially available membranes (Patil, et al., 2014). It is widely applicable in dentistry, while being financially realistic for the patient and the healthcare system. PRF is currently the safest and most economical choice for patients and clinicians for improving healing and tissue (soft tissue and bone) regeneration outcomes.

It can spare the patient from additional operating field (second-surgery morbidity) and also save cost through avoiding use of alloplastic or xenogenic membranes and reduce the quantity of synthetic grafting materials (Thorat 2011). It is also an economical alternative to expensive recombinant growth factors when used in conjunction with osseous grafts.

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No contraindications PRF membranes have no contraindications: they can be used in all kinds of patients, especially in patients with systemic conditions where healing is compromised (i.e., diabetics and smokers), or in surgically compromised situations (damaged flap). In these situations, PRF will promote soft tissue healing and stimulate the healing of a damaged flap and reduce the risks of flap necrosis after a surgery. It is a common point that all fibrin-based products (platelet concentrates) are frequently used for 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;17:801-805.

2. Aleksić Z, Janković S, Dimitrijević B, et al. The use of platelet-rich fibrin membrane in gingival recession treatment. Srp Arh Celok Lek. 2010;38:118.

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

6. Barone A, Ricci M, Romanos GE, Tonelli P, Alfonsi F, Covani U. Buccal bone deficiency in fresh extraction sockets: a prospective single cohort study. Clin Oral Implants Res. 2015;26(7):823-830.

7. Bansal C, Bharti V. Evaluation of efficacy of autologous platelet-rich fibrin with demineralized freeze dried bone allograft in the treatment of periodontal intrabony defects.

J Indian Soc Periodontol. 2013;7(3):361-366.

8. Bolukbasi N, Ersanli S, Keklikoglu N, Basegmez C, Ozdemir T. Sinus augmentation with platelet-rich fibrin in combination with bovine bone graft versus bovine bone graft in combination with collagen membrane. J Oral Implantol.

2015;41(5):586-595.

9. Boora P, Rathee M, Bhoria M. Effect of Platelet Rich Fibrin (PRF) on Peri-implant Soft Tissue and Crestal Bone in OneStage ImplantPlacement: A Randomized Controlled Trial.

J Clin Diagn Res. 2015;9(4):ZC18-ZC21.

10. Choukroun J, Diss A, Simonpieri A, et al. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part V: histologic evaluations of PRF effects on bone allograft maturation in sinus lift. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 101:299-303.

11. Choukroun J, Diss A, Simonpieri A, et al. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part IV: clinical effects on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;101(3):e56-e60 12. Clipet F, Tricot S, Alno N, et al. In vitro effects of Choukroun’s platelet-rich fibrin conditioned medium on 3 different cell lines implicated in dental implantology. Implant Dent.

2012;21:51-56.

13. Del Corso M, Sammartino G, Dohan EDM. Clinical evaluation of a modified coronally advanced flap alone or in

Volume 12 Number 1

stimulation of angiogenesis and to reduce the risk of flap necrosis in many general surgery applications (Ranganathan and Chandran 2014; Desarda, et al., 2013).

Open access and widely applicable The PRF technique is open access and thus can be widely developed and used in private practice without commercial considerations (Inchingolo, et al., 2010). The clinical applications of PRF in other fields of dentistry, such as endodontics, are also increasing exponentially.

Limitations The rapid use of PRF without delay or short handling time may be a potential limitation. Lack of rigidity and fast degradation (biodegradability) (Sambhav, et al., 2014; Simonpieri, et al., 2011; Dohan 2009) may limit its application in GTR procedures.

combination with a platelet-rich fibrin membrane for the treatment of adjacent multiple gingival recessions: a 6-month study. 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 (PRP) and platelet-rich fibrin (PRF) in oral and maxillofacial surgery part 1: Periodontal and dentoalveolar surgery. Curr Pharm Biotechnol. 2012;13(7):1207-1230.

15. Del Corso M, Dohan EDM. Immediate implantation and peri-implant Natural Bone Regeneration (NBR) in the severely resorbed posterior mandible using Leukocyte- and Platelet-Rich Fibrin (L-PRF): a 4-year follow-up. POSEIDO. 2013;1(2):109-116.

16. Desarda HM, Gurav AN, Gaikwad SP, Inamdar SP. Platelet rich fibrin: a new hope for regeneration in aggressive periodontitis patients: report of two cases. Indian J Dent Res. 2013;24:627-630.

17. Diss A, Dohan DM, Mouhyi J, Mahler P. Osteotome sinus floor elevation using Choukroun’s platelet-rich fibrin as grafting material: a 1-year prospective pilot study with micro threaded implants. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105:572-579.

18. Dohan EDM, de Peppo GM, Doglioli P, Sammartino G. Slow release of growth factors and thrombospondin-1 in Choukroun’s platelet-rich fibrin (PRF): a gold standard to achieve for all surgical platelet concentrates technologies.

Growth Factors. 2009;27(1):63-69.

19. Dohan EDM. How to optimize the preparation of leukocyteand platelet-rich fibrin (L-PRF, Choukroun’s technique) clots and membranes: introducing the PRF Box. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;110(3):275-278; author reply 8-80 20. Dohan EDM, Bielecki T, Mishra A, Borzini P, Inchingolo F, Sammartino G, Rasmusson L, Evert PA. In search of a consensus terminology in the field of platelet concentrates for surgical use: platelet-rich plasma (PRP), platelet-rich fibrin (PRF), fibrin gel polymerization and leukocytes. Curr Pharm Biotechnol. 2012;13(7):1131-1137.

21. Dohan EDM, Andia I, Zumstein M, Zhang C-Q, Nelson R. Pinto NR, Bielecki T. Classification of platelet concentrates (Platelet-Rich Plasma-PRP, Platelet- Rich Fibrin-PRF) for topical and infiltrative use in orthopedic and sports medicine: current consensus, clinical implications and perspectives. Muscles Ligaments Tendons J. 2014;4(1):3-9.

22. Eren G, Atilla G. Platelet-rich fibrin in the treatment of localized gingival recessions: a split-mouth randomized clinical trial. Clin Oral Invest. 2014;18(8):1941-1948 23. Gamal AY, Abdel Ghaffar KA, Alghezwy OA. Crevicular Fluid Growth Factors Release Profile Following the Use of Platelets Rich Fibrin (PRF) and Plasma Rich Growth Factors (PRGF) in Treating Periodontal Intrabony Defects (Randomized Clinical Trial). J Periodontol. 2016;87(6):654-662.

24. Ghetiu A, Sirbu D, Topalo V, et al. Tissue engineering with

PRF can be considered a healing biomaterial that can be utilized in regenerative surgical procedures to fasten healing, but its application as a barrier membrane in GBR is doubtful due to its poor mechanical properties (Patil, et al., 2014).

Owing to the fact that PRF is an autologous product, the availability of this biomaterial in larger amounts is also a concern.

One of the clinical limitations to deal with is the heterogeneity in the quality of platelets and blood components. At present, very little is understood about PRF generated from patients with coagulation disorders or patients on medications that affect blood clotting (heparin, warfarin, or platelet inhibitors).

Conclusion The therapeutic use of PRF for accelerating tissue healing and regeneration has

Platelet-Rich-Fibrin in Oral region. Clin Oral Impl Res. 2015;26(suppl 12):205 25. Gupta SJ, Jhingran R, Gupta V, et al. Efficacy of plateletrich fibrin vs. enamel matrix derivative in the treatment of periodontal intrabony defects: a clinical and cone beam computed tomography study. J Int Acad Periodontol.

2014;16(3):86-96.

26. Gupta G, Puri K, Bansal M, Khatri M, Kumar A. PlateletRich Fibrin-Reinforced Vestibular Incision Sub periosteal Tunnel Access Technique for Recession Coverage. Clin Adv Periodontics. 2015;5:248-253.

27. Hamzacebi B, Oduncuoglo B, Alaaddinogl EE. Treatment of peri-implant bone defects with platelet-rich fibrin. Int J Periodont Restorative Dent. 2015;35(3):415-422.

28. Hauser F, Gaydarov N, Badoud I, et al. Clinical and histological evaluation of postextraction platelet-rich fibrin socket filling: a prospective randomized controlled study. Implant Dent. 2013;22(3):295-303.

29. Inchingolo F, Tatullo M, Marrelli M, et al. Trial with PlateletRich Fibrin and Bio-Oss used as grafting materials in the treatment of the severe maxillary bone atrophy: clinical and radiological evaluations. Eur Rev Med Pharmacol Sci. 2010;14(12):1075-1084.

30. Jankovic S, Aleksic Z, Milinkovic I, Dimitrijevic B. The coronally advanced flap in combination with platelet-rich fibrin (PRF) and enamel matrix derivative in the treatment of gingival recession: a comparative study. Eur J Esthet Dent. 2010;5:260-273.

31. Jankovic S, Aleksic Z, Klokkevold P, et al. Use of plateletrich fibrin membrane following treatment of gingival recession: a randomized clinical trial. Int J Periodontics Restor Dent. 2012;32(5):41-50.

32. Joseph RV, Raghunath A, Sharma N. Clinical effectiveness of autologous platelet rich fibrin in the management of infrabony periodontal defects. Singapore Dent J. 2012;33(1):5-12.

33. Joseph VR, Sam G, Amol NV. Clinical evaluation of autologous platelet rich fibrin in horizontal alveolar bony defects.

J Clin Diagn Res. 2014;8(11) ZC43-ZC47.

34. Kanayama T, Sigetomi T, Sato H, Yokoi M. Crestal approach sinus floor elevation in atrophic posterior maxilla using only platelet rich fibrin as grafting material: A computed tomography evaluation of 2 cases. J Oral Maxillofac Surg Med Path. 2014;26(4):519-525.

35. Kanayama T, Horii K, Senga Y, Shibuya Y. Crestal Approach to Sinus Floor Elevation for Atrophic Maxilla Using PlateletRich Fibrin as the Only Grafting Material: A 1-Year Prospective Study. Implant Dent. 2016;25(1):32-38.

36. Kawase T. Platelet-rich plasma and its derivatives as promising bioactive materials for regenerative medicine: basic principles and concepts underlying recent advances.

Odontology. 2015;103(2):126-135.

Implant practice 25

CONTINUING EDUCATION

Affordability and cost-effectiveness PRF is a simple and inexpensive biomaterial to use (Kanayama, et al., 2014; Shah, et al., 2014). The initial investment for producing PRF preparations is potentially affordable for most private practices to invest in (Simonpieri, et al., 2011).

CONTINUING EDUCATION increasingly grabbed the attention of clinicians worldwide because this biomaterial is of natural origin (autologous/derived from the patients’ own blood); PRF technology is readily available; is easy to prepare; can be produced immediately at chairside; is easy to use; and widely applicable in dentistry, while being financially realistic for the patient and the clinician, and with virtually no risk of a rejection reaction (foreign body response).

The three-dimensional architecture of fibrin provides the PRF membrane with great density, elasticity, flexibility, and strength that are excellently suited for handling, manipulation, and suturing.

Optimal PRF membrane quality and treatment success is dependent on quick collection of blood and transfer to the centrifuge; use of proper centrifugation protocol; maturation of the clot for 5 minutes before use; preparation of the membrane using a

standardized preparation technique; and appropriate conservation of the membrane before use.

The PRF can be used as a membrane (A-PRF or L-PRF), gel (i-PRF), plug, or the membrane can be cut in fragments and applied either in stand-alone therapies (i.e., plug, filler, or protective barrier); additive therapies (i.e., added or mixed to bone substitutes); or used in combination therapies with other biomaterials (i.e., protective barrier in GBR procedures).

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 adverse events. Consequently, the benefits of PRF in wound and bone healing,

its antibacterial and antihemorrhagic effects, the low risks with its use, and the availability of easy and low-cost preparation methods should encourage more clinicians to adopt this technology in their practices for the benefit of their patients One of the clinical limitations to deal with is the heterogeneity in the quality and quantity of platelets and blood components due to use of different PRF preparation protocols. At this point in time there is not a single RCT or CCT to compare the effectiveness of any of the PRF (A-PRF or L-PRF) protocols. Furthermore, in vitro studies that claim superiority of inferiority of a specific PRF preparation have not been validated by independent clinical trials.

PRF preparation protocols (A-PRF and L-PRF) and the clinical effectiveness thereof still have to be validated and standardized through independent robust randomized controlled clinical trials. IP

37. Keceli HG, Kamak G, Erdemir EO, Evginer MS, Dolgun A. The Adjunctive Effect of Platelet-Rich Fibrin to Connective Tissue Graft in the Treatment of Buccal Recession Defects: Results of a Randomized, Parallel-Group Contolled Trial.

J Periodontol. 2015;86(11):1221-1230.

Hydroxyapatite Graft for the Treatment of 3-Wall Intrabony Defects in Chronic Periodontitis: A Randomized Controlled Clinical Trial. J Periodontol. 2011;82(12):1288-1296.

and metronidazole during complex maxillary rehabilitations using bone allograft. Part I: a new grafting protocol. Implant Dent. 2009;18(2):102-111.

51. Pradeep AR, Rao NS, Agarwal E, Bajaj P, Kumari M, Naik SB. Comparative evaluation of autologous platelet-rich fibrin and platelet-rich plasma in the treatment of 3-wall intrabony defects in chronic periodontitis: a randomized controlled clinical trial. J Periodontol. 2012;83(12):1499-1507.

63. Simonpieri A, Del Corso M, Sammartino G, Dohan Ehrenfest DM. The relevance of Choukroun’s platelet-rich fibrin and metronidazole during complex maxillary rehabilitations using bone allograft. Part II: implant surgery, prosthodontics, and survival. Implant Dent. 2009;18(3):220-229.

39. Krasny K, Kaminski A, Krasny M, et al. Clinical use of allogeneic bone granulates to reconstruct maxillary and mandibular alveolar processes. Transplant Proc.

2011;43(8):3142-3144.

52. Pradeep AR, Bajaj P, Rao NS, Agarwal E, Naik SB. PlateletRich Fibrin Combined With a Porous Hydroxyapatite Graft for the Treatment of 3-Wall Intrabony Defects in Chronic Periodontitis: A Randomized Controlled Clinical Trial. J Periodontol. 2017;88(12):1288-1296.

64. Simonpieri A, Choukroun J, Del Corso M, Sammartino G, Dohan EDM. Simultaneous sinus-lift and implantation using micro threaded implants and leukocyte- and plateletrich fibrin as sole grafting material: a six-year experience.

Implant Dent. 2011;20(1):2-12.

40. Lekovic V, Milinkovic I, Aleksic Z, et al. Platelet-rich fibrin and bovine porous bone mineral vs. platelet-rich fibrin in the treatment of intrabony periodontal defects. J Periodontal Res. 2011;47:409-417.

53. Rajaram V, Thyegarajan R, Balachandran A, Aari G, Kanakamedala A. Platelet Rich Fibrin in double lateral sliding bridge flap procedure for gingival recession coverage: An original study. J Indian Soc Periodontol. 2015;19(6):665-670.

65. Tajima N, Ohba S, Sawase T, Asahina I. Evaluation of sinus floor augmentation with simultaneous implant placement using platelet- rich fibrin as sole grafting material. Int J Oral Maxillofac Implants. 2013;28:77-83.

41. Magremanne M, Baeyens W, Awada S, Vervaet C. Solitary bone cyst of the mandible and platelet rich fibrin (PRF). Rev Stomatol Chir Maxillofac. 2009;110(2):105-108.

54. Ranganathan AT, Chandran CR. Platelet-rich fibrin in the treatment of periodontal bone defects. J Contemp Dent Pract. 2014;15(3):372-375.

42. Mazor Z, Horowitz RA, Del Corso M, et al. Sinus floor augmentation with simultaneous implant placement using Choukroun’s platelet-rich fibrin as the sole grafting material: a radiologic and histologic study at 6 months. J Periodontol. 2009;80:2056-2064.

55. Rao SG, Bhat P, Nagesh KS, et al. Bone Regeneration in Extraction Sockets with Autologous Platelet Rich Fibrin Gel. J Maxillofac Oral Surg. 2013;12(1):11-16.

66. Tatullo M, Marrelli M, Cassetta M, Pacifici A, Stefanelli LV, Scacco S, Dipalma G, Pacifici L, Inchingolo F. Platelet Rich Fibrin (P.R.F.) in reconstructive surgery of atrophied maxillary bones: clinical and histological evaluations. Int J Med Sci. 2012;9:872-880.

38. Kim JS, Jeong MH, Jo JH, Kim SG, Oh JS. Clinical application of platelet-rich fibrin by the application of the Double J technique during implant placement in alveolar bone defect areas: case reports. Implant Dent. 2013;22(3):244-249.

43. Moraschini V, dos Santos EBP. Use of Platelet-Rich Fibrin Membrane in the Treatment of Gingival Recession: a Systematic Review and Meta-Analysis. J Periodontol.

2016;87(3):281-290.

44. Nacopoulos C, Dontas I, Lelovas P, et al.. Enhancement of bone regeneration with the combination of platelet-rich fibrin and synthetic graft. J Craniofac Surg.

2014;25(6):2164-2168.

45. Öncü EA, Erbeyoğlu AA. Enhancement of immediate implant stability and recovery by platelet-rich fibrin. Clin Oral Impl Res. 2017;27. doi: 10.11607/prd.2505 46. Panda S, Jayakumar ND, Sankari M, Varghese SS, Kumar DS. Platelet rich fibrin and xenograft in treatment of intrabony defect. Contemp Clin Dent. 2014;5(4):550-554.

47. Panda S, Ramamoorthi S, Jayakumar ND, Sankari M, Varghese SS. Platelet rich fibrin and alloplast in the treatment of intrabony defect. J Pharm Bioallied Sci. 2014;6:127-131.

48. Patil PA, Kumar R V, Kripal K. Role and Efficacy of L- PRF matrix in the Regeneration of Periodontal Defect: A New Perspective. J Clin Diagn Res. 2014;8:ZD03-ZD05 49. Peck MT, Marnewick J, Stephen L. Alveolar ridge preservation using leukocyte and platelet-rich fibrin: a report of a case. Case Rep Dent. 2011; 345048 Platelet-Rich 50.

Fibrin

26 Implant practice

Combined

With

a

Porous

56. Sambhav J, Rohit R, Ranjana M, Shalabh M. Platelet rich fibrin (PRF) and -tricalcium phosphate with coronally advanced flap for the management of grade-II furcation defect. Ethiop J Health Sci. 2014;24(3):269-272.

57. Shah M, Deshpande N, Bharwani A, et al. Effectiveness of autologous platelet-rich fibrin in the treatment of intra-bony defects: A systematic review and meta-analysis. J Indian Soc Periodontol. 2014;18(6):698-704.

58. Shah M, Patel J, Dave D, Shah S. Comparative evaluation of platelet-rich fibrin with demineralized freeze-dried bone allograft in periodontal infrabony defects: A randomized controlled clinical study. J Indian Soc Periodontol.

2015;19(1):56-60.

59. Sharma A, Pradeep AR. Treatment of 3-wall intrabony defects in patients with chronic periodontitis with autologous platelet-rich fibrin: A randomized controlled clinical trial. J Periodontol. 2011;82(12):1705-1712.

60. Sharma A, Pradeep AR. Autologous platelet-rich fibrin in the treatment of mandibular degree II furcation defects: a randomised clinical trial. J Periodontol. 2011;82:1396-1403.

61. Shilbli JA, Blay A, Tunchel S, Roth L, Nardagam G, Cassoni A, Rodriques JA. Treatment of peri-implantitis using L-PRF and ER,CR:YSGG laser in the esthetic zone: Longitudinal aspects. In: Complex situations on Implant Dentistry: Specialized Clinical Solutions. Eds: EHO Rosetti and WC Bonachela. VM Vultural, Sao Paulo; 2013.

62. Simonpieri A, Del Corso M, Sammartino G, Dohan Ehrenfest DM. The relevance of Choukroun’s platelet-rich fibrin

67. Thorat MK, Pradeep AR, Pallavi B. Clinical effect of autologous platelet-rich fibrin in the treatment of intrabony defects: a controlled clinical trial. J Clin Periodontol.

2011;38:925-932.

68. Toeroek R, Dohan EDM. The concept of Screw- Guided Bone Regeneration (S-GBR). Part 3: Fast Screw- Guided Bone Regeneration (FS-GBR) in the severely resorbed preimplant posterior mandible using allograft and Leukocyte- and Platelet-Rich Fibrin (L PRF): a 4-year follow-up.

POSEIDO. 2013;1(2):93-100.

69. Toffler M, Toscano N, Holtzclaw D. Osteotome-mediated sinus floor elevation using only platelet-rich fibrin: an early report on 110 patients. Implant Dent. 2010;19:447-456.

70. Troiano G, Laino L, Dioguardi M, et al. Mandibular Class II Furcation Defects Treatment: Effects of the Addition of Platelet Concentrates to Open Flap. A Systematic Review and Meta-analysis of RCT. J Periodontol. 2016; 87(9):1030-1038.

71. Vijayalakshmi R, Rajmohan CS, Deepalakshmi D, Sivakami G. Use of platelet rich fibrin in a fenestration defect around an implant. J Indian Soc Periodontol. 2012;16(1):108-112.

72. Zhang Y, Tangl S, Huber CD, Lin Y, Qiu L, Rausch-Fan X. Effects of Choukroun’s platelet-rich fibrin on bone regeneration in combination with deproteinized bovine bone mineral in maxillary sinus augmentation: a histological and histomorphometric study. J Craniomaxillofac Surg.

2012;40(4):321-328.

73. 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 12 Number 1

REF: IP V12.1 HARTSHORNE/GLUCKMAN

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A comprehensive clinical review of platelet-rich fibrin (PRF) and its role in promoting tissue healing and regeneration: part 2 HARTSHORNE/GLUCKMAN

1. A major advantage of PRF is that it has a simple preparation protocol. Blood is drawn from the patient using a sterile _______ vacutainer (two to 12 tubes) just before or during surgery. a. 5 ml b. 10 ml c. 15 ml d. 20 ml 2. The tubes with collected blood samples are immediately (within _______ after collecting the blood sample) placed in the centrifuge and processed using a single centrifugation step. a. 2 minutes b. 6 minutes c. 10 minutes d. 15 minutes 3. Based on the findings of their studies, they (Dohan and co-workers, 2010) suggested that centrifuge characteristics and protocols may have a very significant impact on the ______ of a PRF clot and membrane. a. cell b. growth factors c. fibrin architecture d. all of the above 4. In contrast, another recent in vivo study showed that Choukroun’s new formulation of PRF (A-PRF)

Volume 12 Number 1

had a more gradual release of growth factors, up to a _______ period and stimulated significantly higher growth factor release over time when compared to Choukroun’s standard PRF (Öncu and Alaaddinoõglu 2015). a. 3-day b. 10-day c. 16-day d. 30-day 5

The section of the blood clot attached to the fibrin clot contains the ______. a. intra-fibrous structure b. collagen c. stem cells d. inter-fibrous structure

6. Moreover, the use of the PRF Box, a user-friendly and inexpensive tool, allows for ______. a. standardized preparation of homogeneous PRF membranes with a higher growth factor content b. avoids the dehydration or death of the leukocytes living in the PRF clot c. prevents the shrinkage of the fibrin matrix architecture d. all of the above 7. Centrifuge rotational speed and subsequent vibrations have been shown to have _______ the architecture and cell content of a PRF clot.

a. b. c. d.

a direct impact on no impact on only slight impact on none of the above

8. PRF membranes or plugs are ready for use within _______ after compression of clots in the Box grid. a. 2 minutes b. 4 minutes c. 6 minutes d 10 minutes 9. For the standardization of PRF preparations and to preserve platelets and growth factors, it is suggested _______ all of the plasma contained in the original PRF clots. a. to squeeze out b. not to squeeze out c. to vibrate d. to shrink 10. Research suggests that bone healing is more effective when PRF is mixed with autogenous bone or bone substitutes such as ________ in bone augmentation or GBR procedures. a. A-PRF b DBBG c. BCP d. both b and c

Implant practice 27

CE CREDITS

IMPLANT PRACTICE CE

CONTINUING EDUCATION

The microbiology of peri-implantitis Dr. Aneel Jabbar explores whether the microbiology of peri-implantitis is similar to or distinct from chronic periodontitis

D

ental implants have become an increasingly favored treatment modality over the past few decades, with rapid evolution of dental implant designs, surgical protocols, and bone grafting techniques. As clinicians, we find that not only are many patients having dental implants placed, but there are also many patients with existing dental implants that require maintenance.

Implant challenges One of the challenges in implant dentistry today is the management of peri-implantitis, a bacterial-driven inflammatory disease that results in progressive bone loss around dental implants. It is the main long-term biological complication associated with treatment, with Mombelli, et al., (2012), suggesting a 20% prevalence in individuals at 5 to 10 years following placement.

A recent literature review by this author investigated the bacteria involved in periimplantitis. A holistic appreciation of the surgical, prosthetic, and biological risk factors is required in the diagnosis and management of peri-implantitis. Therefore, understanding the microbiology of the failing site is merely one small part of a multifactorial and multifaceted disease process.

Given that clinicians may utilize topical or systemic antimicrobials in addition to surgical intervention as part of their treatment protocol, it is essential that such antimicrobials are selected based on knowledge of the microbes they are targeting.

Periodontitis and peri-implantitis have historically been seen as analogous: the difference simply being the subject of the Aneel Jabbar BDS, MJDF RCS (Eng), MSc qualified from the University of Bristol in 2010. In 2012, he joined the Royal College of Surgeons with the MJDF postgraduate qualification. He gained a master’s degree in dental implantology from the University of Bristol. He has also received a number of prizes in the field of dental implants, most recently having won the 2017 Congress Poster Prize at the Association of Dental Implantology (ADI) Members’ National Forum. Dr. Jabbar enjoys providing all aspects of dentistry for his patients and has a special interest in dental implants. He is a member of the Association of Dental Implantology and the International Team for Implantology.

28 Implant practice

Educational aims and objectives

This article aims to discuss the bacteria involved in peri-implantitis and the management of the disease.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 30 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Demonstrate an understanding of the microbiology of peri-implantitis and chronic periodontitis.

•

Realize the difference in some microbe detection techniques.

•

Identify some complex organisms commonly detected in peri-implantitis.

•

Recognize growing evidence that peri-implantitis has its own, unique microbial signature that is distinct to chronic periodontitis.

•

Recognize the need for management of peri-implantitis, which may entail implementing certain testing protocols from which a suitable antimicrobial can be carefully selected.

Table 1: A summary of the techniques used to analyze and identify microbes Technique

Advantages

Disadvantages

Culture and microscopy

Can visualize bacterial community and superstructures (i.e, rods, filaments)

Time-consuming Limited scope of bacteria that can be cultured

DNA-DNA hybridization (checkerboard)

A molecular technique that does not require sample bacteria to be alive Less time-consuming

Selection bias as DNA probes must be preselected Technique sensitive – risk of false positives due to low specificity

16S rRNA sequencing

Uses polymerase chain reaction to rapidly amplify genomic data Provides a broader picture of the microbiome than above methods 16S region is sufficiently variable to allow species identification

May not detect less prevalent species in a sample

16S pyrosequencing

Shares the advantages of 16S rRNA sequencing over other methods Large sampling depth, which means less prevalent species in a sample can also be detected

Short read lengths can make high-resolution bacterial identification difficult

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CONTINUING EDUCATION

Table 2: A list of microbe groups and the frequency of studies reporting their detection in peri-implantitis Microbe group

Frequency of reporting in literature

Red complex

15

Orange complex

25

Other periodontal complexes (yellow, green, purple, blue)

8

Eubacterium spp.

4

Staphylococcus spp.

6

Enterics

3

Candida spp.

3

disease — tooth or dental implant. This is partly true, but not entirely. While the clinical parameters that both present with can be similar, there are differences reported in the host response, the rate, and pattern of bone loss.

Historically, the microbes involved in peri-implantitis were believed to be the same as those involved in chronic periodontitis.

Recent studies, however, have suggested that the answer may be slightly more nuanced than this.

Literature review A literature search was conducted involving MEDLINE®/PubMed® and Web of Science databases to gather clinical studies that investigated the microbiology of peri-implantitis, using appropriate search terms and applying inclusion and exclusion criteria to filter the results. The selected studies were reviewed and quality assessed using published guidelines on the analysis of observational studies (Strobe). A total of 25 clinical studies between 1987 and 2015, involving 1,392 participants, were obtained.

With advancements in technology, microbe detection techniques have evolved to yield more information about the microbial profile of a plaque sample, and this is reflected in the diverse number of techniques used in the studies obtained (Table 1). The results obtained in the studies depended heavily on the technique used, with newer molecular techniques (such as 16S pyrosequencing) being well-equipped to detect most, if not all, bacterial species in a sample.

In comparison, older techniques — such as DNA-DNA hybridization or bacterial culture and microscopy — were far more limited in their scope.

Volume 12 Number 1

Figure 1: Diagram of bacterial complexes associated with chronic adult periodontitis, as adapted from Socransky, et al., (1998).

The pathogens most associated with bone loss and bleeding on probing form the “red complex,” while the “orange complex” is less strongly associated with clinical parameters. The other complexes are found in periodontitis but have no significant association with clinical parameters

Socransky, et al., (1998), described pathogens associated with chronic periodontitis as working together symbiotically in specific groups, or complexes (Figure 1). Red and orange complex organisms — strongly and moderately linked to bleeding on probing and bone loss in chronic periodontitis, respectively — were commonly detected in peri-implantitis in this review (Table 2).

In addition to this, a number of studies detected non-periodontal opportunistic pathogens at the failing dental implant site, such as Staphylococcus spp., Candida spp., and Pseudomonas aeruginosa.

When assessing the studies that compared chronic periodontitis and periimplantitis in a split mouth design and used the most current microbe detection technique (16S pyrosequencing), the majority of studies found a significant difference in the overall microbial profiles of the two pathologies.

These findings suggest that the red and orange complex microbes linked to chronic periodontitis are also strongly linked to periimplantitis. Yet, simultaneously, there is growing evidence that peri-implantitis has its own, unique microbial signature that is distinct to chronic periodontitis. The role of non-periodontal opportunistic species (such as Staphylococcus spp.), and whether or not they play a part in the acute pathological process, is not entirely clear.

Implications on management In the words of one author, the microbiology of peri-implantitis and chronic periodontitis should be viewed as “fraternal” instead of identical (Robitaille, et al., 2015).

In clinical practice, it seems apparent that if we view peri-implantitis as somewhat distinct to chronic periodontitis in terms of its microbiology, then it may encourage us to reflect more on the types of antimicrobials we prescribe — should we choose to use them.

As a crude example, P. aeruginosa, which some studies detected in peri-implantitis, is known to be resistant to chlorhexidine, amoxicillin, and metronidazole, the agents most commonly prescribed for dental infections.

Future management of peri-implantitis may involve obtaining a swab from the peri-implant pocket to send for molecular analysis, on which basis a suitable antimicrobial can be carefully selected. This will help to ensure that antimicrobial therapies are effective in complementing surgical intervention. IP REFERENCES 1. Mombelli A, Müller N, Cionca N. The epidemiology of periimplantitis. Clin Oral Implants Res. 2012;23(Suppl 6): 67-76.

2. Robitaille N, Reed DN, Walters JD, Kumar PS. Periodontal and peri-implant diseases: identical or fraternal infections?

Mol Oral Microbiol. 2016;31(4):285-301.

3. Socransky SS, Haffajee AD, Cugini MA, Smith C, Kent RL Jr. Microbial complexes in subgingival plaque. J Clin Periodontol. 1998;25(2):134-44

Implant practice 29

REF: IP V12.1 JABBAR

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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.

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The microbiology of peri-implantitis JABBAR

1.

One of the challenges in implant dentistry today is the management of peri-implantitis, a _______ inflammatory disease that results in progressive bone loss around dental implants. a. bacterial-driven b. trauma-driven c. viral d. nontreatable

2. It (peri-implantitis) is the main long-term biological complication associated with treatment, with Mombelli, et al., (2012), suggesting a ______ prevalence in individuals at 5 to 10 years following placement. a. 5% b. 20% c. 40% d. 60% 3. A holistic appreciation of the ______ risk factors is required in the diagnosis and management of peri-implantitis. a. surgical b. prosthetic c. biological d. all of the above 4. Given that clinicians may utilize _______ in addition to surgical intervention as part of their treatment protocol, it is essential that such antimicrobials are

30 Implant practice

selected based on knowledge of the microbes they are targeting. a. DNA microbials b. topical antimicrobials c. systemic antimicrobials d. both b and c 5.

6.

While the clinical parameters that both (periodontitis and peri-implantitis) present with can be similar, there are differences reported in the _______. a. host response b. rate of bone loss c. pattern of bone loss d. all of the above Socransky, et al., (1998), described pathogens associated with _______ as working together symbiotically in specific groups, or complexes. a. chronic peri-implantitis b. chronic periodontitis c. P. aeruginosa d. none of the above

7. Red and orange complex organisms — _______ linked to bleeding on probing and bone loss in chronic periodontitis, respectively — were commonly detected in peri-implantitis in this review. a. strongly b. moderately

c. which were not d both a and b 8. When assessing the studies that compared chronic periodontitis and peri-implantitis in a split mouth design and used the most current microbe detection technique (16S pyrosequencing), the majority of studies found _______ in the overall microbial profiles of the two pathologies. a. no difference b. a slight difference c. a significant difference d. few variations 9. In the words of one author, the microbiology of peri-implantitis and chronic periodontitis should be viewed as _______ (Robitaille, et al., 2015). a. “fraternal” instead of identical b. “identical” instead of fraternal c. unique d. totally non-opportunistic 10. Future management of peri-implantitis may involve _______, on which basis a suitable antimicrobial can be carefully selected. a. studying red microbes only b. studying only orange complex microbes c. obtaining a swab from the peri-implant pocket to send for molecular analysis d. using culture and microscopy

Volume 12 Number 1

CE CREDITS

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Doctors receive 60% to 90% of the value of their practice, in cash, at favorable tax rates and the balance in retained practice ownership, which increases in value with growth.

Doctors are paid a negotiated salary under contract for three or more years, plus quarterly profit distributions from their retained ownership in the practice.

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GOING VIRAL

The four pillars of cybersecurity for the dental practice Gary Salman, CEO of Black Talon Security, discusses the reasons for protecting against cyberattacks to your patient files

O

ver the past 20 years, an evolution in computer technology has taken place in the dental practice. Computers were previously used only for basic recordkeeping and billing. Then came the progression from billing to appointment scheduling, digital radiography, charting, and now, to digital dentistry. As the amount of data stored in systems has increased, so have the frequency and sophistication of cyberattacks.

The days of simply relying on a firewall and antivirus software to protect the practice’s network and patient data are over. The reality is, if these devices were so effective at protecting networks from breaches, there would be no data breaches.

Cyberattacks have shifted dramatically in the past 12 to 18 months, and now, more than ever before, hackers are setting their sights on healthcare entities. The frequency and severity of these attacks have increased, and practices of all sizes are being impacted.

These ransomware and malware attacks can shut down and compromise networks, resulting in an inability to access patient records and loss of revenue.

Dentists must consider the scope of their data and understand that they have one of the highest risk databases in the dental community — children’s records. Many dentists may think that since they don’t

Gary Salman, is Chief Executive Officer, Black Talon Security, Katonah, New York (www.blacktalonsecurity.com). He has more than 26 years of dental technology and IT experience.

32 Implant practice

store “medical records” in their system, they don’t have to worry about protecting patient records. In the eyes of Health and Human Services (or the parent of a child), it does not matter if you are a cardiologist, a dentist, or a laboratory. If you have any patient data in your system, everyone must follow the same rules to protect these records. In addition, if a practice were to have a data breach, the HIPAA Breach Notification Rule requires practices to notify every patient of record that a breach has occurred. Imagine the negative PR that a practice would encounter in its local community and the uncomfortable conversations with the parents of the minors whose data was compromised. In addition, Identity Theft Monitoring would need to be offered to all affected minors. Health and Human Services (HHS) and the Office of Civil Rights (OCR) are just two of the reporting agencies a practice will have to work with; 49 out of the 50 states now have equal or more stringent breach notification rules. Also, if a practice treats patients from multiple states, it may be required to report to all the states in which it treat patients. A data breach is about patient trust, and once it has been broken, it’s very difficult to regain that trust.

When we ask dentists what they do for cybersecurity, they often say, “My IT company handles that.” IT companies are not cybersecurity companies. IT organizations typically partner with a cybersecurity company to independently audit its work.

It is extremely critical to understand that IT companies cannot audit their own work.

It takes the expertise and knowledge of a cybersecurity company to help ensure the security of the network.

In speaking with numerous dentists, it is apparent that ransomware attacks have been impacting this community. The unfortunate mistake that practitioners make is that they have their IT company “clean it up and restore their data.” What if, as part of or prior to the attack, a practice’s data was stolen from their network and is being bought and sold on the Dark Web (the black market of hackers), and the practice did not report the breach to the Office of Civil Rights (OCR)?

The practice could be subject to massive fines for the lack of reporting. If a dentist’s office falls victim to a ransomware attack or other possible breach, there are steps that the practice and its IT company must follow to determine if electronic protected health information (ePHI) was compromised. This often involves hiring a forensics company and working with a cybersecurity company to harden the practice’s infrastructure. What we have typically seen is that if you were the victim of an attack once, you will mostly likely be a victim again because of vulnerabilities in your network that enabled the attack vector or payload to infiltrate your system. To recover from the attack, you cannot simply restore your data and hope for the best.

To secure your network and combat against these sophisticated attacks, a dentist needs to implement four key pillars of cybersecurity. These pillars are Cybersecurity Audit, Cybersecurity Awareness Volume 12 Number 1

GOING VIRAL

Training, Vulnerability Scanning, and Penetration Testing.

Cybersecurity Audit During this audit, a cybersecurity company works closely with the practice and its IT company to understand the complete landscape of the practice’s IT footprint. The cybersecurity company asks questions regarding where and how data is stored, what protocols are in place to protect the data, and how it is accessed. Are there remote team members? Does the practice contract with a billing company that “logs in” to the practice’s network? Do doctors leave the office with devices that store ePHI, leaving the practice exposed if the device is stolen or lost? Is ePHI transmitted and stored using encryption technologies to protect the data?

Cybersecurity Awareness Training As part of the HIPAA Security Rule, covered entities (i.e., your practice) are required to undergo cybersecurity awareness training to help mitigate the risk of human error and minimize the chances of being exposed to an attack. Recent data points to a 50%-75% reduction in cyberattacks against healthcare entities that properly train their staff.

Perhaps the most vulnerable components of a network are the people using it — the dentist and staff. Social engineering, often referred to as “hacking the human,” is the most prominent threat vector impacting practices and is often the least discussed. As advancements are made in security, hackers begin to rely increasingly on humans making mistakes. For example, most ransomware attacks are initiated via spear phishing, which is designed to fool an email recipient into opening an email that appears to be coming from someone he/she knows or trusts. An email may be sent to the staff, purporting to be from the dentist, asking them to open an attachment or click on a link to update or download something. Once they initiate the action, an executable file may run, which is a ransomware attack. The ransomware typically encrypts the current computer and then searches the network for other machines.

Once it finds the server, depending on the complexity and lethality of the attack, the ransomware will encrypt most of, or all of, the files on the server. This results in the files becoming inaccessible to anyone unless the user pays the ransom to the hackers to have the data decrypted. This is typically done using a cryptocurrency such as Bitcoin or Monero. Often, however, the files Volume 12 Number 1

The days of simply relying on a firewall and antivirus software to protect the practice’s network and patient data are over.

are not returned and, if they are returned, a time bomb attack may be set up that will impact the files again shortly thereafter. The hacking should be reported to law enforcement authorities.

Vulnerability Scanning For a ransomware or a network breach to occur, a network typically needs to have vulnerabilities. Examples of vulnerabilities include unpatched operating systems, outdated equipment, weak passwords, open ports on computers or firewalls, unsecure network protocols, and improperly configured firewalls. Cybersecurity firms deploy very sophisticated tools and technologies to search for “open doors and windows” on your network that hackers use to exploit.

These tools gather information on your network and run tests against the devices searching for vulnerabilities. This data is then turned over to the practice’s IT company for remediation purposes, and the IT company can effectively lock the “doors and windows.”

Cybersecurity companies invest heavily in best-in-class vulnerability scanning technologies that can detect thousands of vulnerabilities on a practice’s network. Testing should be performed quarterly or whenever network devices are upgraded, modified, or added.

Penetration Testing The final cybersecurity pillar is penetration testing, which utilizes a “white-hat hacker” (ethical hacker) who uses the same tools, techniques, and protocols that a cyber-criminal would use to try and “break into” your network. Unlike a vulnerability scanner, an ethical hacker has the capacity to problemsolve during the testing. For instance, a vulnerability scanner will get to a locked “window”

and not know how to progress. Essentially, it stops and moves on to something else. A hacker, based on his/her experience, will see that the “door” is locked but may run a certain script to pop the door open. Ethical hackers use their experience to exploit networks in a way an automated tool simply cannot. After ethical hackers finish their testing, they turn their findings over to your IT company so they can mitigate the risks.

The Cost of a Breach The U.S. Department of Health and Human Services has strict guidelines in place regarding what is required to protect patient records. In the event of a data breach, the Office of Civil Rights will be notified and will conduct an investigation into the breach.

They will want to see proof that the practice has complete HIPAA documentation in place and has provided HIPAA and cybersecurity training, and will ask what has been done to harden the practice’s network.

You have spent years to become a dentist, growing and building your practice, your reputation, and your patient’s trust. The risk of a data breach is real, and you should not be passive. You need to take a proactive approach to secure your network before this happens to you. Practitioners who have experienced data breaches all say the same thing: “This is one of the worst things that can happen to you.” The financial and social impact on your practice is debilitating. The cost for mitigating a breach can run into the hundreds of thousands of dollars and may result in a significant loss of patient trust.

Fortunately, if a practice implements sound cybersecurity solutions, trains its staff, and puts a hyper focus on security, almost all attacks can be thwarted. IP Implant practice 33

PRODUCT PROFILE

Are your patients having a hard time understanding?

D

o you find yourself discussing the same procedure multiple times a day, every day? One of the most common complaints we hear is the time it takes to explain a procedure or treatment process, after which the patient still does not fully understand.

Established in 1955, Kilgore International is proud to bring you the finest dental models and medical-related items used in the training of future health professionals, case presentations, and in-office staff training.

A few top-selling models

What we offer We offer a wide variety of demonstration models. Our patient education models were all designed and created by the needs of the doctors. We take ideas and turn them into reality for doctors who wish there was an easier way to describe a procedure or treatment.

Our patient education line includes models for: • Implants, single tooth, or overdenture • Periodontal disease • Cracked teeth • Crown and bridges • Orthodontic • Endodontic procedures

LOC-4 – Overdenture mandible (4 Locators)

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KPEK – Kilgore Patient Education Kit

HWB-6 – Hybrid overdenture on 6 implants

Visit our website at www.Kilgore International.com. Go to the patient education section to see our wide variety of models. If you have an idea for an implant model, contact us, and we can customize to your needs.

model to evaluate and play with. If you don’t like it, send it back at no charge. We do this because we guarantee you will enjoy our models. Our demonstration models will pay for themselves the first time you use them in a presentation!

Why our products work Allowing the patients to visualize and hold the model in their hands will give them a better conception of the procedure or treatments. Our demonstration models will not only save you time but will also leave the patients feeling more comfortable by fully understanding what procedures will take place. Treatment presentations are the most important conversations you will have with your patients to increase your acceptance rate. Our patient education models will allow you to fully optimize your case presentations!

Overdenture model customization In 2017, Kilgore International, Inc. purchased Dental Models & Designs of Garfield, New Jersey. We moved all operations to Coldwater, and we now manufacture all of our own dental implant training models, as well as surgical models for patient and student education. We specialize in custom implant models for patient education. We have the capability to customize the perfect implant model to meet your needs!

34 Implant practice

Our offer to you!

Use the coupon code IMPLANT10 at www.KilgoreInternational.com to receive 10% off of your entire purchase. This offer is only valid for our patient education models.

Our guarantee All of our products are sold on a net 30-day payment period. We send you the

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If you have any questions or would like to see any samples, please contact Logan Graybill at Logan@Kilgoreinternational.com or 517-279-9000 any time! IP

This information was provided by Kilgore International.

Volume 12 Number 1

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INDUSTRY NEWS Season of giving from PREAT In the season of giving, PREAT Corporation generously donated to several non-profit organizations throughout the month of December. Organizations included the San Luis Obispo County Noor Foundation providing free dental care to the uninsured in the surrounding communities, the Little Lighthouse Foundation for families with children diagnosed with chronic diseases, and participated in their annual company shopping trip of gifts for three local families to the non-profit CALM of Santa Barbara County.

For information, visit www.preat.com, or call 800-232-7732.

Ruben Arebalo named Vice President of PREAT Corporation

American Academy of Periodontology installs new president and officers in Vancouver

PREAT Corporation has announced the promotion of Ruben Arebalo as Vice President.

He has 15 years of dental laboratory experience with 11 years of digital design and edentulous, full-arch case planning skills. A graduate from the University of La Verne, Arebalo is frequently sought out for technical advice and implant identification and is recognized as an expert in attachments and implantology. He joined PREAT Corporation in 2008, was named Senior Technician in 2010, was promoted to General Manager in 2014, and is now Vice President.

For information, call www.preat.com, or visit 800-232-7732.

The American Academy of Periodontology installed Richard T. Kao, DDS, PhD, as its president during its 104th Annual Meeting in Vancouver, British Columbia. Other newly appointed officers include President-Elect Bryan J. Frantz, DMD, MS, of Scranton, Pennsylvania; Vice President James G. Wilson, DMD, of Tampa, Florida; as well as Secretary and Treasurer Christopher Richardson, DMD, MS, of Richmond, Virginia.

In addition to maintaining a private practice in Cupertino, California, Dr. Kao is a Clinical Professor in the Department of Orofacial Sciences at the University of California San Francisco and an Adjunct Clinical Professor of Periodontology at the University of the Pacific.

Dr. Kao obtained his Doctor of Dental Surgery degree, certificate in periodontics, and PhD from the University of California. His academic endeavors have resulted in winning two prestigious R. Earl Robinson Periodontal Regeneration Awards, the publication of over 40 scientific articles and 30 book chapters, and service awards from various professional organizations. Dr. Kao’s past work in organized dentistry includes service as a trustee for the California Dental Association and past president of the California Society of Periodontists.

For more information, visit https://www.perio.org/.

Carestream Dental welcomes new leadership for the Americas Region Carestream Dental is pleased to announce two new regional leaders.

Jeremy Thomas has been appointed as general manager of the Americas Region. In this role, he oversees the design and execution of Carestream Dental’s imaging and software growth strategies for marketing and sales in North and South America. He has held several high-level leadership roles at MedWorld Advisors, ATL Technology, and Kulzer Dental, where most recently he served as president. In addition to his business experience, Thomas has worked in several global roles managing country heads and executives in Central and South America, the United States, and Canada.

Jeff Farmer has been appointed the director of marketing and business development for the Americas. He brings with him a strong background in the medical device industry, having held leadership positions with Kimberly-Clark Healthcare, Invenio Healthcare, and most recently, Medtronic.

For more information, visit carestream dental.com, or call 800-944-6365.

36 Implant practice

Ultradent donates $10,000 to humanitarian medical and dental education charity Ultradent Products, Inc., announced a donation of $10,000 toward a Humanitarian Medical and Dental Education Fund started by the Adams, Gladwell, Durham Foundation based in Salt Lake City, Utah.

The money will go toward providing professional medical and dental education to underserved populations through online lectures and handson training provided to students through virtual reality programs.

Ultradent supports hundreds of humanitarian efforts every year, worldwide. This includes donations toward major disaster relief efforts as well as smaller, individually run humanitarian missions.

To learn more about Ultradent’s humanitarian efforts, please visit ultradent.com/company/humanitarian.

Volume 12 Number 1

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 12 Number 1

Pictures/images

Disclosure of financial interest

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

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

Any commercial or financial interest will be acknowledged in the article.

Tables Ensure that each table is cited in the text.

Number tables consecutively, and provide a brief title and caption (if appropriate) for each.

References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques.

Aesthetic & Implant Dentistry. 2000;1(1):92-96.

(Online) Author(s). Article title. Journal Name. Year; vol(issue#):inclusive pages. URL. Accessed [date].

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

Proofing Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity.

Articles should be submitted to: Mali Schantz-Feld, managing editor mali@medmarkmedia.com

Reprints/Extra issues If reprints or additional issues are desired, they must be ordered from the publisher when the page proofs are reviewed by the authors.

The publisher does not stock reprints; however, back issues can be purchased.

Or in the case of a Book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide.

London: Martin Dunitz; 2001.

Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011.

Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

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

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

Implant practice 37

INDUSTRY NEWS Planmeca announces new dental unit

BioHorizons® adds the IntraSpin™ system, the only FDA-cleared medical device for the production of PRF

The new Planmeca Compact™ i5 dental unit has been built around five central themes — design, well-being, cleanliness, intelligence, and evolution. All of these principles are carried through in every detail of the dental unit, resulting in a perfect combination of functionality, durability, comfort, safety, and esthetics. Planmeca Compact i5 can be easily connected to a network in order to produce valuable data. With Planmeca’s intelligent software solutions, clinics can track and follow their patient flow, optimize their capacity through real-time information, and monitor the use of their equipment. Furthermore, the dental unit’s smart sign-in system allows fast access to personalized dental unit settings with a flash of a card.

For more information, visit https://www.planmeca.com/.

BioHorizons® announced the addition of the IntraSpin™ system to its product portfolio. The IntraSpin system is the only FDA-cleared medical device for the chairside production of platelet-rich fibrin (PRF). PRF is increasingly being used in grafting procedures to enhance the healing process. The IntraSpin’s simple, three-step protocol produces a thin, compressed layer of leukocyte plateletrich fibrin (L-PRF™) that is strong, pliable and suitable for surgical manipulation and suturing. The L-PRF matrix can act as a carrier for particulate bone material to improve handling characteristics.

For more information, visit biohorizons.com.

OraCare launches Implant Post-Op Care System, designed to help prevent peri-implantitis — the No. 1 cause of implant failure Oracare has launched the new Implant Post-Op Care System, a simple solution to protect implants from the No. 1 cause of failure — peri-implantitis. The main ingredients in the OraCare system are activated chlorine dioxide, aloe, and xylitol, which provide efficacy without causing staining and calculus buildup. This integrated system provides an in-office gel and a take-home patient rinse. The gel is for the doctor to use in-office immediately following implant placement, but it can also be used around an existing failing implant. The rinse is for the patient to use at home during the 30- to 34-day healing time. This will keep the area clean during this critical time. For long-term implant maintenance, OraCare also provides a daily health rinse that patients start using once the healing process ends. With similar ingredients, the rinse provides the extended protection implants need.

For more information, visit https://www.oracareproducts.com/ implant-care.html.

38 Implant practice

Glidewell Laboratories utilizes high-precision digital technology to help dentists provide restorative-driven implant treatment Glidewell Laboratories announced that it is now offering digital treatment planning (DTP) and surgical guide fabrication to implant dentists. Pairing the dental lab’s restorative expertise with threedimensional treatment planning technology, the new DTP service is devoted to helping clinicians perform implant surgery with maximum safety and predictability while maintaining a prosthetically driven approach throughout treatment. The result of years of extensive R&D, this new Glidewell Laboratories service firmly establishes the industryleading dental lab in virtually every aspect of implantology. Cases, including a full-arch CBCT scan and a digital or physical impression, can be digitally uploaded via the My Account feature at glidewelldental. com or shipped to the lab. Available for most major guided surgery systems, the DTP service at Glidewell Laboratories combines data conversion, digital treatment planning, and surgical guide fabrication as one streamlined, affordable service.

For more information, call 866-497-3692, or visit glidewelldental.com/dtp.

Volume 12 Number 1

IMPLANT PATHWAY 2019

IMPLANTS DONE RIGHT ———————

Implant Pathway is a continued education continuum that focuses entirely on the surgical placement of dental implants. Implant Pathway was founded and is directed by one of the most credentialed Implantologists in the country, Justin D. Moody, DDS Our continuum is divided into four sessions and can be designed to fit your schedule— Session One (Implant History, Rationale and Treatment), Session Two (Single Implants, Ridge Preservation and Grafting), Session Three (Implant Restoration and Guided Surgery Success) and Session Four (Two Days of Live Clinical Implant Surgery).

LEARN MORE ABOUT OUR COURSES www.ImplantPathway.com

CALL US (888) 309-2423

E-MAIL US info@implantpathway.com

OUR CONTINUUM

SESSION FOUR: LIVE SURGERY

THE ADVANCED CONTINUUM

The core of our continuum is made up of four sessions, and includes online modules, lectures, hands-on training, questions and answers, and concludes with two days of live surgery.

Two full days of live surgery from the New Horizon Dental Center in Phoenix, Arizona. Each doctor places an average of 15 implants per Session Four.

Introducing our Advanced Continuum, feautring additional courses that will take your implant education to the next level.

———————

Earn 20, 52 or 76 CE Credits by taking Session One, Sessions 1-3 or Sessions 1-4, respectively.

Session One: Online Twenty one-hour modules, on-demand videos and quizzes.

Houston, Texas Session 2: February 8 and 9, 2019 Session 3: March 8 and 9, 2019 Chicago, Illinois Session 2: April 26 and 27, 2019 Session 3: May 17 and 18, 2019 Seattle, Washington Session 2: June 21 and 22, 2019 Session 3: July 19 and 20, 2019

———————

March 13 - 15, 2019 April 10 - 12, 2019 June 12 - 14, 2019 August 7 - 9, 2019 October 9 - 11, 2019 December 11 - 13, 2019

FAST TRACK ———————

After completing Session One: Online, complete Sessions Two through Four in only one week in Phoenix, Arizona. Exclusive Session 4 for Fast Track registrants only.

Fast Track: Spring April 29 - May 3, 2019 Fast Track: Summer August 19 - 23, 2019 Fast Track: Fall September 9 - 13, 2019

INSTRUCTOR

Fast Track: Fall November 11 - 15, 2019

———————

All courses (except Complications) are held at the New Horizon Dental Center in Tempe, Arizona.

Soft Tissue Grafting March 15 and 16, 2019 Presented by Dr. Lewis Cummings Hands-On / Live Patient Demonstration Restorative Solutions March 28 - 30, 2019 Live Patient Training Restorative Solutions June 6 - 8, 2019 Live Patient Training Complications July 12 and 13, 2019 Located in Denver, Colorado Restorative Solutions October 31 - November 2, 2019 Live Patient Training Sinus Grafting September 26 - 28, 2019 Live Patient Training

Justin D. Moody, DDS is an internationally known dentist, entrepreneur, instructor and speaker in the fields of dentistry, practice management, technology and Implantology. Dr. Moody has practices in Nebraska and South Dakota and has made a name for himself as one of the leading Continued Education providers in the United States.

Dr. Moody knows how important dental continuing education is as well as the need for mentoring and hands-on training. His conversational, real-life approach solidifies his educational philosophy. Dr. Moody is also the host of the Dentists, Implants and Worms podcast. Learn more about Dr. Moody by visiting JustinMoodyDDS.com and DentistsImplantsandWorms.com. #ImplantsDoneRight #ImplantPathwayLeadsTheWay #LearnByDoing JUSTIN D. MOODY, DDS

ON THE HORIZON

Digital workflow is different for everyone Dr. Justin Moody discusses how a digital workflow can make your practice more efficient, predictable, and reliable

P

eople talk about digital workflow as though it’s the same for every dentist; the fact is that it is truly different for every office and every clinician. Many of us have cone beam CT, which is often the first piece of the digital workflow puzzle as we use this information for diagnostic assessment, virtual implant placement, and even surgicalguide design and fabrication. When planning implant surgery, we should always start with the final prosthetic outcome in

Figure 1: Single implant scan using the BioHorizons® scan body and the 3Shape TRIOS® intraoral scanner

Figure 2: Screw-retained crown designed by Jeremy Herbert at ProSmiles Dental Studio

Figure 4: Digital design of upper full-arch zirconia bridge by ProSmiles Dental Studio with implant analogs

Figure 3: Upper full-arch scan of the BioHorizons multi-units for a complete zirconia bridge using the 3Shape TRIOS intraoral scanner

mind. The use of surgical guides and their design keeps this as a number one priority.

The ability to create screw-retained restorations, full-arch solutions with access on the lingual side of the incisal edges, while maximizing the available bone allows for more predictable long-term results.

Justin D. Moody DDS, DABOI, DICOI, is a Diplomate in the American Board of Oral Implantology, Diplomate in the International Congress of Oral Implantologists, Honored Fellow, Fellow, and Associate Fellow in the American Academy of Implant Dentistry, and Adjunct Faculty at the University of Nebraska Medical Center. He is an internationally known speaker, founder of the New Horizons Institute Non-Profit Clinic, and Director of Implant Education for Implant Pathway.

You can reach him at justin@justinmoodydds.com.

Disclosure: Dr. Moody is a paid consultant for BioHorizons® and ProSmiles Dental Studio. He has no affiliation with 3Shape.

40 Implant practice

Some offices may not place the dental implants, but the restoration of such often starts with digital intraoral scanning with direct submission to either an in-office mill or electronically to the laboratory. IOS systems are more accurate than traditional analog impressions, in my opinion, and I think if you were to ask any full digital lab, they would tell you the same. Today’s dental laboratories are digital from the moment the case comes in — regardless if it’s digitally scanned or if the dentist sends the impression and it is then digitized. It is here that digital lives, and innovation truly happens, from 3D printing and 5-axis milling all from a digital design team that has the talent literally at their fingertips. Find a laboratory that understands the technology you have in your office, and listen to their recommendations on how to best utilize that. My

Figure 5: Proposed upper full-arch zirconia bridge to be shared with the dentist to ensure that the case is progressing according to plan and design

go-to in this world are Nick and Jeremy Herbert at ProSmiles Dental Studio — they are without a doubt my partner in implant dentistry.

As you can see, the digital workflow is truly different for each office and for each patient. What I do know is when you start to put all these pieces together, you begin to develop a workflow that not only saves you time (which is money) but also makes the outcome more efficient, predictable, and reliable. Go digital — what are you waiting for? IP Volume 12 Number 1

stability where it counts Tapered Immediate Molar Tapered IM implants offer a solution for molar extraction sockets. Available in 7 and 8mm diameters, the implant design features deep aggressive threads for compressive bone loading and primary stability. The reduced collar diameter ensures the implant does not deviate from its intended placement location in extraction sites. The platform-switched, dual-affinity Laser-LokÂŽ surface offers crestal bone retention and connective tissue attachment for flexible placement.

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

Not available in all countries. SPMP18304 REV A OCT 2018

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To learn more: stop by and speak with the ALPHAEON CREDIT team at CMW #829 and AO #1125, call (949) 284-4507, or visit www.myalphaeoncredit.com/implants.

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