Implant Practice US Fall 2019 Vol 12 No 3

clinical articles • management advice • practice profiles • technology reviews Fall 2019 – Vol 12 No 3 • implantpracticeus.com

CBCT as an interdisciplinary treatment-planning platform Dr. George A. Mandelaris

Dr. Rory McEnhill

Long-term case studies using a Laser-Lok® implant Dr. Cary A. Shapoff

Practice profile Dr. Andrew Howard

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Autogenous bone blocks and implant placement to reconstruct a large volume hard tissue defect Drs. Muhammed Abram and André van Zyl

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Fall 2019 - Volume 12 Number 3 EDITORIAL ADVISORS Steve Barter, BDS, MSurgDent RCS Anthony Bendkowski, BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent Philip Bennett, BDS, LDS RCS, FICOI Stephen Byfield, BDS, MFGDP, FICD Sanjay Chopra, BDS Andrew Dawood, BDS, MSc, MRD RCS Professor Nikolaos Donos, DDS, MS, PhD Abid Faqir, BDS, MFDS RCS, MSc (MedSci) Koray Feran, BDS, MSC, LDS RCS, FDS RCS Philip Freiburger, BDS, MFGDP (UK) Jeffrey Ganeles, DMD, FACD Mark Hamburger, BDS, BChD Mark Haswell, BDS, MSc Gareth Jenkins, BDS, FDS RCS, MScD Stephen Jones, BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack, DDS, CertPerio, FCDS Samuel Lee, DDS David Little, DDS Andrew Moore, BDS, Dip Imp Dent RCS Ara Nazarian, DDS Ken Nicholson, BDS, MSc Michael R. Norton, BDS, FDS RCS(ed) Rob Oretti, BDS, MGDS RCS Christopher Orr, BDS, BSc Fazeela Khan-Osborne, BDS, LDS RCS, BSc, MSc Jay B. Reznick, DMD, MD Nigel Saynor, BDS Malcolm Schaller, BDS Ashok Sethi, BDS, DGDP, MGDS RCS, DUI Harry Shiers, BDS, MSc, MGDS, MFDS Harris Sidelsky, BDS, LDS RCS, MSc Paul Tipton, BDS, MSc, DGDP(UK) Clive Waterman, BDS, MDc, DGDP (UK) Peter Young, BDS, PhD Brian T. Young, DDS, MS CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day, BDS, VT Julian English, BA (Hons), editorial director FMC Dr. Paul Langmaid, CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul, BDS, LDS, FFGDP (UK), FICD, editor-inchief Private Dentistry Dr. Chris Potts, BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers, BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

© FMC 2019. All rights reserved.

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

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

D

ental implants are now a major part of dentistry and should be thought of as a standard.

I won’t go so far as to suggest that they are standard-of-care (the definition of which is a bit of a gray area sometimes), but from a practice management standpoint, I will suggest that dental implants should be a standard offering to any patients who are missing teeth.

Taking it a step even further, I would suggest that dental implants are a key component of increasing practice production — the essential factor in the success of any dental practice.

As a quick review, osseointegrated implants had their birth in the early 1980s. By the 1990s, implant placement was becoming routine for oral surgeons, periodontists, and a very small segment of general dentists. Over time, dental implants have continually demonstrated high success rates, which motivated an increasing number of general dentists to refer patients for implant placement and to learn implant restorative dentistry. Today, dental implants for many practices are routine, and many dentists automatically recommend dental implants for missing teeth. The truth is that dental implants improve the quality of life for almost any patient and should now be thought of not only as a “standard” but also, in most cases, as the “ideal” treatment.

So why aren’t more patients receiving implants? The primary reason is the cost and lack of insurance coverage. Many more dental implants would be placed if they were less expensive to the patient. This dynamic needs to be offset by excellent case presentation that motivates patients to seek a surgical consult or accept dental implant treatment. Improved case presentation is the key to increasing the number of implants placed and restored and could allow the field of dental implants to grow exponentially.

Here are three recommendations to increase dental implant case acceptance.

1. Make a commitment for both dentists and hygienists to recommend dental implants to every edentulous patient. The practice should begin to think of dental implants as a “standard” that is automatically offered to patients and, in most cases, it should be recommended as the “ideal” treatment. Don’t think about cost as much as what is best for the patient. Very few patients would agree to have a less expensive hip replacement in order to save money.

Dental implants should become an automatic part of the practice culture. Everyone in the office (including the front desk) should understand them and be positive about the high quality they provide and the quality-of-life enhancement the patient will receive.

2. Identify three key benefits of dental implants, unique to each patient, and then repeat those benefits at least three times in the presentation. Adults learn in threes. Too many practices overemphasize the technical factors of implants rather than the benefits. You might choose to focus on comfort, convenience, retention, longevity, eating, smiling, the more natural feel, etc. Patients need to understand the benefits in order to make a decision, especially when they consider implants to be a complex or unfamiliar procedure.

3. Be sure that every patient knows, prior to hearing any fees, that there are several financial options including patient financing. As I’ve stated time and again in numerous seminars, “In the end it always comes down to money.” This is normal and to be expected. If the practice simply announces a very high fee for implant dentistry, that’s the last thing many patients hear. If you begin the fee discussion by letting patients know that there are several financial options available that will help them to afford treatment, they will be more open to accepting your recommendations.

Dental implants are a growth field but have the potential to grow exponentially faster.

The key is to begin to think of dental implants as a standard and often the ideal treatment. As this confidence grows within the culture of a practice, you can then implement excellent techniques, such as those described above, to increase dental implant case acceptance. In the world of win-win, the patient wins, and the practice wins.

Dr. Roger P. Levin

Roger P. Levin, DDS is the CEO and Founder of Levin Group, a leading practice management consulting firm that has worked with over 30,000 practices to increase production. A recognized expert on dental practice management and marketing, he has written 67 books and more than 4,000 articles and regularly presents seminars in the United States and around the world.

To contact Dr. Levin or to join the 40,000 dental professionals who receive his Practice Production Tip of the Day, visit www.levingroup.com, or email rlevin@levingroup.com.

ISSN number 2372-9058

Volume 12 Number 3

Implant practice 1

INTRODUCTION

Implants should be a standard

TABLE OF CONTENTS

Publisher’s perspective Turn your dreams into reality ..........................................................6

8

Practice profile Andrew Howard, DDS, PC Master Implant Dentist, LLC

Technology CBCT as an interdisciplinary treatment-planning platform Dr. George A. Mandelaris discusses how CBCT imaging is essential for practicing in an interdisciplinary treatment-planning model................ 20

Continuing education Autogenous bone blocks and implant placement to reconstruct a large volume hard tissue defect

Case report

14

Long-term case studies using a Laser-Lok implant ®

Dr. Cary A. Shapoff shares patient cases involving a surface treatment shown to attract a true, physical connective tissue attachment

Drs. Muhammed H. Abram and André van Zyl describe a case whereby one patient required complex tissue regeneration following a grinding disc injury.....................................24

ON THE COVER Inset cover image courtesy of Dr. George A. Mandelaris. Article begins on page 20.

2 Implant practice

Volume 12 Number 3

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TABLE OF CONTENTS Product profile Overcoming the great denture disappointment Finding an ideal endpoint means starting with an ideal LOCATOR®... 33

Product spotlight The DenMat implant maintenance kit Dr. Timothy Kosinski discusses tools that provide safe and efficient access around dental implants.................34

Going viral Have cyber criminals “implanted” malware into your network?

Gary Salman discusses how to take defensive measures to help protect your network and critical patient data...... 36

Product profile Novadontics software Make Novadontics the newest member of your dental team..........38

Continuing education

28

Single-tooth implant placement: achieving a biomimetic result in the esthetic zone

Dr. Rory McEnhill demonstrates the difficult process of providing an implant restoration that can offer outstanding esthetics for the long term

Product profile

Step-by-step

Sun Dental Labs Implants

GCL Systems™

Joey Cabral, CDT, discusses the many implant options available from Sun Dental Labs..........................42

Preserving and perfecting the gingival emergence profile

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Practice development Industry awards..........43

On the horizon

Dr. Roger P. Levin answers some questions that can help to expand an implant practice........................... 40

Dr. Justin D. Moody discusses the efficacy of immediate molar dental implants...................................... 48

The invisible dental implant patient

Industry news...............44

Immediate molar dental implants

www.implantpracticeus.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your inbox by registering for our eNewsletter

CONNECT with us on social media Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

4 Implant practice

Volume 12 Number 3

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PUBLISHER’S PERSPECTIVE

Turn your dreams into reality

R

ecently, I had the exciting experience of interviewing Shaquille O’Neal for our publications. Shaq’s sleep (and health) have been impacted over the years by his sleep apnea, and our discussion primarily focused on his journey to finding a solution. Fortunately, we also had time to delve into his philosophy of life, his path to fulfillment, and future goals. Two of his basic tenets of life resonated with me, so much so that I wanted to share them with you in this issue’s message.

First, Shaq noted that one of his favorite quotes is from Dwight D. Eisenhower, a former U.S. president and five-star general: “The greatest leaders are the ones smart enough to hire people smarter than them.” How true. While you bring the clinical knowledge to the practice, surrounding yourself with the Lisa Moler Founder/Publisher, MedMark Media best and the brightest opens up your world to ideas, insights, and talents beyond your own in other important areas. Thankfully, we have done that with the team at MedMark Media, and recommend that our readers should also take advantage of all of the experienced people who can expand your practice’s management, clerical, social media, and even clinical options in this very competitive specialty.

Second, Shaq developed his life’s mission from another concept that he learned from his mother. He had given her some material gifts, to which she responded, “‘I don’t want these, Baby; I love you very much. What have you done to brighten up someone else’s day?”

This reinforced what we try to practice every day. We know that taking care of business is our daily focus, but we also need to focus on taking care of others — and what better way than changing lives through our life’s calling! For me, it is improving dentists’ and patients’ health through bringing to light the important concepts and breakthroughs of our profession through our authors and advisors. You can expand patient care possibilities through CEs, our articles, webinars, DocTalk Dental videos, or any of the many educational options available in this quickly changing dental industry. While you’re at it, let your patients know how your practice is capable of changing or improving their lives! Use your social media, smartphones, and websites to spread the word.

We’d like to spread the word about a few articles in our Fall issue of Implant Practice US. Dr. Rory McEnhill gives a patient something to smile about after providing an implant restoration with outstanding long-term esthetics. Reviewing this patient’s soft tissue profile and tooth symmetry was satisfying after the challenging process leading to this implant-borne restoration. In their CE, Drs. Muhammed H. Abram and André van Zyl share their complex procedure where esthetics, function, and phonetics were restored for a patient who experienced major facial trauma. Dr. George A. Mandelaris contributes to our technology column with his article on CBCT as an interdisciplinary treatment-planning platform. And Dr. Cary A. Shapoff shares two treatment plans involving the establishment of a physical, connective tissue attachment to the surface of the Laser-Lok® implant.

While my interview with Shaq mainly focused on his nighttime sleep, we ended up discussing how to make every day count — a topic which always is our goal for all of you and your teams.

To your best success!

Lisa Moler Founder/Publisher MedMark Media

Published by

PUBLISHER Lisa Moler lmoler@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com VP, SALES & BUSINESS DEVELOPMENT Mark Finkelstein mark@medmarkmedia.com NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez celeste@medmarkmedia.com CLIENT SERVICES/SALES SUPPORT Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING STRATEGIST Matt Simpson emedia@medmarkmedia.com SOCIAL MEDIA & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com CONTENT MARKETING Lauren Nash emedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com

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

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PRACTICE PROFILE

Andrew Howard, DDS, PC Master Implant Dentist, LLC What can you tell us about your background?

I moved to Loveland, Colorado, from Indianapolis, Indiana, right after my General Practice Residency at Joseph Hospital in Denver in 1988. It was a small town with a population of about 40,000 at the time. I purchased a twooperatory practice and loved being so close to the mountains, the lifestyle, and recreational opportunities. I was shocked that so many of my patients had never heard of dental implants. External marketing by dentists was also almost unheard of. Against the advice of many local dentists, I started to advertise my dental implant services. This quickly allowed me to build a growing practice that was known for being able to handle the most difficult and challenging cases. I was also one of the first general dentists in northern Colorado to offer IV sedation and in-office CBCT scanning. In 2004, I decide to focus my practice on dental implants, full mouth reconstruction, and sedation dentistry. We became the Center for Advanced Dentistry. This involved building a new office with a dedicated surgical suite in addition to four other conventional dental operatories.

Why did you branch out to implant dentistry?

I am a general dentist and never wanted to restrict my scope of practice because I truly enjoy all aspects of dentistry.

Is your practice limited solely to implants or do you practice other types of dentistry?

Approximately 70% of my practice is surgical and restorative implant dentistry. The remaining 30% is mostly major restorative, sedation, and cosmetic dentistry.

Why did you decide to focus on implant dentistry?

I found it extremely frustrating to offer only removable dentures and partials for my patients who were missing most or all of their teeth. We would not accept such poor options for other medical concerns. A denture might alleviate their tooth pain but 8 Implant practice

Andrew Howard, DDS, PC

did nothing for their quality of life. I found implant dentistry to be very rewarding by the way it affected my patients’ overall satisfaction of life, health, and their confidence in social situations. It is amazing what an impact a beautiful, secure, and healthy smile can have on a person’s life.

Do your patients come through referrals?

Yes, our existing patients are our best referral source, but I also receive referrals from other general dentists and even specialists. We also do a very coordinated marketing campaign. My goal was to become known as the local expert in dental implants. We use a variety of marketing methods, including

giving live direct-to-patient seminars on a regular basis. This exposure keeps us “top of mind” when someone needs dental implants. It also provides a steady stream of pre-qualified patients that are ready for full mouth restoration with implant treatment. These have been highly instrumental in gaining expert status in our community.

Direct to public dental implant seminars have been our best return on investment of any marketing we have done.

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

I have been placing and restoring implants for over 30 years. Today, I place mostly Volume 12 Number 3

e c i t c a r P t n a l p m I r u o Y w Gro s u t a t S t r e p x E d l i u B d n a

“The Complete Guide to Public Seminars for Dental Implants” The Key to More Implant Cases and “Local Expert” Status

● A step-by-step turn key system ● Everything you need to plan, promote, and deliver a professional high quality presentation

● Direct to patient seminars have one of the highest marketing ROI ● Provides a steady supply of high quality, pre-qualified patients ready for treatment

Visit masterimplantdentist.com for a complete source of implant practice growth products

Dr. Andrew Howard, DDS, FICOI andrew@masterimplantdentist.com

PRACTICE PROFILE BioHorizons®, Neodent® and MegaGen. However, at various times over the years, I have used most of the major systems.

What training have you undertaken?

I was fortunate to train in my residency under a world-renowned oral surgeon who was a pioneer in sinus augmentation and bone grafting. This sparked my initial enthusiasm for what was possible in implant dentistry. I took as much CE as possible and still do. I completed extensive training with Dr. Carl Misch and became a Fellow of the Misch Implant Institute and a Fellow of the International Congress of Oral Implantologists. I have also received vast amount of knowledge from Dr. Michael Pikos and the Pikos Institute. Dr. Frank Spear, Dr. John Kois, The Midwest Implant Institute®, and many others have also provided very valuable training.

Dr. Howard lecturing during a seminar

What are the most satisfying aspects of your practice?

1. The direct, tangible positive effects we can have on our patients’ lives.

2. The autonomy to have the style of practice and lifestyle that a fee-forservice implant practice provides.

3. Once I committed to being a “specialty general practice” and focus on implant dentistry, we no longer needed to worry about dental insurance. We submit insurance claims, but do not participate in any dental plans whatsoever.

4. It is very satisfying to focus entirely on what is best for the patient, and not worry about insurance coverage, or yearly maximums.

Professionally, what are you most proud of?

Being able to give back by providing dental care to those in need both locally and internationally, I have provided dental care on medical missions to Malawi, Haiti, and Mexico. These trips continually open your eyes to what we take for granted. I am proud to have written The Complete Guide to Public Seminars for Dental Implants. This guide explains all the steps from marketing to slides and scripts — everything to walk you through the first seminar and schedule highly motivated pre-screened implant patients. I am also very excited about my co-authorship of Second-Chance Smiles — The Patient’s Guide to Dental Implants.

When you give this to prospective patients, they will realize your expertise and learn 10 Implant practice

Dr. Howard’s practice — Center for Advanced Dentistry in Loveland, Colorado

about the process. All you need to do is add your bio, your philosophy, and background, and this information will be included in your book. We also are thrilled to offer a 2-day training course for your assistants in Denver, our Master Implant Dentist Live Course Dental Assistant Implant Training.

We developed this course because we believe that one of the greatest keys to rapid implant growth in your practice is a dedicated and trusted team.

What do you think is unique about your practice?

We work very hard to connect with each individual patient and find out what is most important to him/her so that we can find a solution that best meets his/her needs. We don’t prejudge patients and only suggest limited treatment options. It’s amazing how many patients will accept ideal long-lasting

full arch implants when presented properly.

We routinely have patients return after a year or more of “thinking about it” to begin comprehensive care.

What has been your biggest challenge?

Finding the balance between my professional interests and taking on personal goals and challenges.

What would you have been if you didn’t become a dentist?

An architect.

What is your top tip for maintaining a successful specialty practice?

Be confident without being arrogant.

Treat every consultation as a sincere conversation with a friend. Don’t want the treatment more than the patient does.

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PRACTICE PROFILE

Top 10 favorites 1. Traveling with my family 2. nSequence® guided surgery and immediate implant bridge 3. Digital implant work flow 4. Rock climbing and mountaineering 5. Propofol 6. My “Implant Concierge” 7. BioHorizons® implants 8. Running ultramarathons 9. Planmeca ProMax® CBCT scanner 10. Physics® forceps

Dental mission to Haiti

What is the future of implants and dentistry?

New materials and digital workflow will greatly streamline the process. Single units are already very efficient and profitable. However, there is a long way to go toward integrating the existing technology and making it user-friendly for full arch implants. Some dentists love spending hours basically being a digital lab tech. I prefer to use my time treating and talking to patients. In-office 3D printers and milling units are getting better and less expensive, but the labs need to step up their services and become more of a partner in making full-arch implant treatment fast and efficient. Dentists also need to have a better understanding of all the processes and the underlying technology.

What advice would you give to a budding implant dentist?

My favorite quote is from Czech playwright Vaclav Havel who said, “Seek out those in search of truth, and run from those that have found it.” Some of the voices in implant dentistry can be very dogmatic. After so many years of practice, I have seen many trends and changes. You need to be willing to see what works best in your hands and be able and willing to change your mind and 12 Implant practice

Mountaineering in Colorado

try new things. First and foremost, treat your patients as best as possible, and you will have them for your entire career. Many of them will be your best source of referrals.

Also, spend the time to train and create an “Implant Concierge” who is your treatment coordinator, financial coordinator, and ideally, your lead surgical assistant. This person is invaluable and needs to think, talk, and act as you do. This will close more implant cases than you can imagine. This not a role that I believe can be divided up among several

team members. The personal connection that this team member makes with your large case patients is critical to your success.

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

Mountain ultramarathons, rock climbing, and soccer. I clear my head best running on the mountain trails in Colorado. My wife Pam and I have three grown daughters with whom we enjoy traveling and spending time in the mountains. IP Volume 12 Number 3

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CASE REPORT

Long-term case studies using a Laser-Lok® implant Dr. Cary A. Shapoff shares patient cases involving a surface treatment shown to attract a true, physical connective tissue attachment Abstract Numerous published animal and human dental implant studies report crestal bone loss from the time of placement of the healing abutment to various time periods after restoration. The bone loss can result in loss of interproximal papilla and recession of crown margins. These case examples demonstrate the long-term results that can be obtained utilizing a variety of implant and abutment styles and sizes with the LaserLok® (BioHorizons®) microchannel collar design to preserve crestal bone and soft tissue esthetics. Case 1 involved extraction, socket grafting, 6-month delayed implant placement, and final restoration in 6 months.

This case was the first reported use of lasermicrochannel technology (Laser-Lok) and justified the continued use and documentation of numerous other case examples in a private practice setting.

Figures 1 and 2: Case 1 — 1. Tooth No. 9 prior to extraction. 2. Radiograph immediately after surgical placement of implant (1 mm LL collar) and 0.5 mm coverscrew

Figure 3: Baseline radiograph immediately after placement of final crown

Case 1 (Figures 1-5) First reported use of a Laser-Lok implant A 34-year-old female presented with external resorption at the level of the cementoenamel junction (CEJ) of tooth No. 9. Various treatment options were presented, and the patient elected extraction and dental implant placement. After atraumatic extraction, the socket anatomy did not allow for immediate placement with acceptable initial stability. The socket was grafted with allograft calcified bone and allowed to heal for 6 months. At that time, a dental implant with a 1 mm Laser-Lok microchannel collar

Figure 4: Bone level maintained on Laser-Lok collar 18 years after restoration

Figure 5: Clinical view — Laser-Lok implant restoration at 19 years after surgical placement

design was placed. A subepithelial connective tissue graft was also utilized on the adjacent tooth No. 10 for root coverage. Six months after placement, second-stage surgery was

Dr. Cary A. Shapoff, DDS, has been in private practice since 1977 in Fairfield, Connecticut, and a Diplomate of the American Board of Periodontology since 1981. He was elected as a Director of the American Board of Periodontology (2004-2010) and served as co-chairman (2009-2010). Dr. Shapoff also served as a Trustee of the American Academy of Periodontology (2015-2018). He has served as president of numerous dental and periodontal organizations on the local, state and regional levels and has lectured extensively throughout the United States, Canada, Europe, Australia, Middle East, and Asia on bone grafting, dental implant surgery, and periodontal treatment.

Dr. Shapoff has also written articles published in the Journal of Periodontology, International Journal of Periodontics & Restorative Dentistry, Compendium, Implant Practice US, and The Dental Guide, (Canada). A frequent lecturer on periodontics, bone grafting procedures, and dental implant surgery, Dr. Shapoff enjoys the opportunity to lecture to his dental colleagues around the world. Dr. Shapoff volunteered with Faith In Practice as a dental healthcare provider in Antigua, Guatemala (since 2014).

Disclosure: Dr. Shapoff is a consultant and lecturer for BioHorizons®.

14 Implant practice

performed, and the tooth was restored with a customized abutment and PFM crown.

Note the maintenance of excellent crestal bone levels on the Laser-Lok microchannel collar (within 0.5 mm of the implant/abutment interface) at 19 years post-restoration. The soft tissue margins have remained stable and exhibit excellent periodontal health.

Case 2 (Figures 6-10) A 45-year old female presented with non-restorable caries under existing crown on tooth No. 7. Treatment decision: Single tooth implant — immediate extraction, immediate placement with provisional loading utilizing BioHorizons Plus (platformswitched) implant (4.6 x 12 mm with 3.5 mm platform).

Volume 12 Number 3

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CASE REPORT

Figures 6 and 7: Case 2 — 6. Initial radiograph. 7. Radiograph following extraction, immediate implant placement (BioHorizons Plus) with provisional loading with PEEK abutment

Figure 10: Clinical photograph of final restoration with healthy and stable soft tissue on Laser-Lok microchannel implant abutment at 5 years. (Restoration by Dr. David J. Wohl, Fairfield, Connecticut)

Figure 8: Radiograph at placement of final crown on CAD/CAM-milled titanium Laser-Lok abutment

Figure 9: Case 2 — Radiograph at 5 years after restoration. Note stable crestal bone

Figures 11-13: Case 3 — 11. Initial radiograph (2012). 12. Radiograph of screw-retained provisional crowns with lexan plastic provisional abutments (four months after implant placement). Note interproximal bone levels at initial time of provisional restoration. 13. Radiograph 5 years after implant placement and restoration (2019)

Figure 14: Clinical view 5 years after final restorations.

(Restorations by Dr. Jeffrey O’Connell, Fairfield, Connecticut)

Case 3 (Figures 11-14) Two adjacent BioHorizons Laser-Lok dental implants (4.6 mm x 12 mm) A 52-year-old female patient presented with maxillary central incisors that were deemed non-restorable and replacements with dental implant restorations selected after discussing restorative options.

Figures 15 and 16: Case 4 — 15. Initial radiograph of nonrestorable tooth No. 9. Extraction and immediate implant placement with provisional loading. 16. Radiograph at 5 years post-restoration

Figure 17: Clinical photo (5-years post-restoration) demonstrating stable and healthy soft tissue around laser-microtextured implant and abutment. This was the first reported case utilizing the lasermicrotextured Ti-base CAD-CAM abutment

Cases 4 and 5 (Figures 15-23) Clinical use of laser-microtextured CAD-CAM abutments

Laser-Lok overview Laser-Lok microchannels are a proprietary dental implant surface treatment developed from over 25 years of research, initiated to create the optimal implant surface.

16 Implant practice

Figures 18-20: Case 5 — 18. Male, age 21, Initial radiograph of tooth No. 7 with mid-root horizontal fracture. Extraction with delayed placement after extraction socket bone grafting. 19. Radiograph at initial time of provisional loading. Note interproximal crestal bone levels. 20. Five-year post-restoration radiograph utilizing a BioHorizons 3.0 mm x 12 mm microchannel implant with Laser-Lok Ti-base abutment with a CAD-CAM abutment Volume 12 Number 3

Figure 21: Laser-Lok implant with SEM image at 39X showing the Laser-Lok zone

Figure 24: Colorized SEM of a dental implant harvested at 6 months with connective tissue physically attached and interdigitated to the Laser-Lok surface2

Unique surface characteristics Laser-Lok microchannels are a series of cell-sized circumferential channels that are precisely created using proprietary laser ablation technology. This technology produces extremely consistent microchannels that are optimally sized to attach and organize both osteoblasts and fibroblasts.15-25 The LaserLok microstructure also includes a repeating nanostructure that maximizes surface area and enables cell pseudopodia and collagen microfibrils to interdigitate with the LaserLok surface.

Virtually all dental implant surfaces on the market are grit-blasted and/or acid-etched.

These manufacturing methods create random surfaces that vary from point to point on the implant and alter cell reaction depending on where each cell comes in contact with the surface.10 While random surfaces have shown higher osseointegration than machined surfaces,11,26 only the Laser-Lok surface has been shown using light microscopy, polarized light microscopy, non-human and human

Figure 22: Laser-Lok at 800X exhibits consistently formed microchannels to organize and promote tissue growth2-10,16,17

Figure 23: The uniformity of the Laser-Lok microstructure and nanostructure is evident using extreme magnification

Figure 25: Colorized SEM of Laser-Lok microchannels showing superior osseointegration5

Figure 26: Colorized histology of a fully lased implant thread at 3 months showing complete bone attachment5

Table 1: In a 3-year multicenter prospective study, the Laser-Lok surface showed superior bone maintenance over identical implants without the Laser-Lok surface11 Volume 12 Number 3

Different from other surface treatments

Figure 27: Laser-Lok esthetic abutments Implant practice 17

CASE REPORT

Through this research, the unique Laser-Lok surface has been shown to elicit a biologic response that includes the inhibition of epithelial downgrowth and the attachment of connective tissue.2-10 This physical attachment produces a biologic seal around the implant that protects and maintains crestal bone health. The Laser-Lok phenomenon has been shown in post-market studies to be more effective than other implant designs in reducing bone loss.11,12,13,14,27

CASE REPORT

Figure 28: Histology of a Laser-Lok abutment on an RBT implant with a machined collar showing exceptional bone growth at 3 months6

histologic specimens, and scanning electron microscopy to also be effective for inhibiting epithelial downgrowth and formation of connective tissue attachment.2-10

The clinical advantage The Laser-Lok surface has been shown in several studies to offer a clinical advantage over other implant designs. In a prospective, controlled multi-center study, Laser-Lok implants, when placed alongside identical implants with a traditional surface, were shown at 37 months post-op to reduce bone loss by 70% (or 1.35 mm).11 In a retrospective, private practice study, Laser-Lok implants placed in a variety of site conditions and followed up to 3 years minimized bone loss to 0.46 mm.12 In a prospective, University-based overdenture study, LaserLok implants reduced bone loss by 63% versus NobelReplace™ Select.13

Latest discoveries The establishment of a physical, connective tissue attachment to the Laser-Lok surface has generated an entirely new area of research and development: Laser-Lok applied to abutments. This provides an opportunity to use Laser-Lok abutments to create a biologic seal and Laser-Lok implants to establish superior osseointegration15 — a solution that offers the best of both worlds. Alternatively, Laser-Lok abutments can support peri-implant health around implants without Laser-Lok. Multiple pre-clinical and clinical studies support both concepts.5-9 Laser-Lok abutments can inhibit epithelial downgrowth — physically attach connective tissue to protect and maintain crestal bone. Most recently, the combination of Laser-Lok abutments, implants, and platform switching was shown to regenerate crestal bone surrounding the implant.5 Cases 4 and 5 demonstrate the use of the Ti-base laser-microtextured abutments with the titanium base and the custom zirconia core abutment. These cases have maintained 18 Implant practice

Figure 29: Comparative histologies show the biologic differences between standard abutments and Laser-Lok abutments including changes in epithelial downgrowth, connective tissue, and crestal bone health6

exceptional crestal bone and excellent soft tissue contours during the 5-year followup period.

Acknowledgments Restorations for cases 1 and 4 by Jeffrey A. Babushkin, DDS (Trumbull, Connecticut). Restorations for cases 2 and 5 by David J. Wohl DDS, (Fairfield, Connecticut). Restorations for case 3 by Jeffery D. O’Connell, DMD (Fairfield, Connecticut). IP

REFERENCES 1. Implant success rate is the weighted average of all published human studies on BioHorizons implants. These studies are available for review in BioHorizons document number ML0130.

2. Nevins M, Nevins ML, Camelo M, Boyesen JL, Kim DM. Human histologic evidence of a connective tissue attachment to a dental implant. Int J Periodontics Restorative Dent.

2008;28(2):111-121.

3. Weiner S, Simon J, Ehrenberg DS, Zweig B, Ricci JL. The effects of laser microtextured collars upon crestal bone levels of dental implants. Implant Dent. 2008;17(2):217-228.

4. Shin SY, Han DH. Influence of a microgrooved collar design on soft and hard tissue healing of immediate implantation in fresh extraction sites in dogs. Clin Oral Implantsl Res. 2010;21(8):804-814.

5. Nevins M, Nevins ML, Gobbato L, et al. Maintaining interimplant crestal bone height via a combined platformswitched, Laser-Lok implant/abutment system: a proof-ofprinciple canine study. Int J Periodontics Restorative Dent.

2013;33(3):261-267.

6. Nevins M, Kim DM, Jun SH, et al. Histologic evidence of a connective tissue attachment to laser microgrooved abutments: a canine study. Int J Periodontics Restorative Dent.

2010;30(3):245-255.

7. Geurs NC, Vassilopoulos PJ, Reddy MS. Histologic evidence of connective tissue integration on laser microgrooved abutments in humans. Clin Adv Periodontics. 2011;1(1):29-33.

8. Nevins M, Camelo M, Nevins ML, Schupbach P, Kim DM. Connective tissue attachment to laser microgrooved abutments: a human histologic case report. Int J Periodontics Restorative Dent. 2012;32(4):385-392.

9. Nevins M, Camelo M, Nevins ML, Schupbach P, Kim DM. Reattachment of the connective tissue fibers to the lasermicrogrooved abutment surface. Int J Periodontics Restorative Dent. 2012;32(4):e131-e134.

10. Iglhaut G, Becker K, Golubovic V, Schliephake H, Mihatovic I. The impact of dis-/reconnection of laser microgrooved and machined implant abutments on soft- and hard-tissue healing. Clin Oral Implants Res. 2013;24(4):391-397.

11. Pecora GE, Ceccarelli R, Bonelli M, Alexander H, Ricci JL. Clinical evaluation of laser microtexturing for soft tissue and bone attachment to dental implants. Implant Dent.

2009;18(1):57-66.

12. Shapoff CA, Lahey B, Wasserlauf PA, Kim DM. Radiographic analysis of crestal bone levels on Laser-Lok collar dental implants. Int J Periodontics Restorative Dent.

2010;30(2):129-137.

13. Botos S, Yousef H, Zweig B, Flinton R, Weiner S. The effects of laser microtexturing of the dental implant collar on crestal bone levels and peri-implant health. Int J Oral Maxillofac Implants. 2011;26(3):492-498.

14. Bae HEK, Chung MK, Cha IH, Han DH. Marginal tissue response to different implant neck design. J Korean Acad Prosthodont. 2008;46(6):602-609.

15. Frenkel SR, Simon J, Alexander H, Dennis M, Ricci JL. Osseointegration on metallic implant surfaces: effects of microgeometry and growth factor treatment. J Biomed Mater Res. 2002;63(6):706-713.

16. Ricci JL, Grew JC, Alexander H. Connective-tissue responses to defined biomaterial surfaces. I. Growth of rat fibroblast and bone marrow cell colonies on microgrooved substrates. J Biomed Mater Res A. 2008;85(2):313-325.

17. Grew JC, Ricci JL, Alexander H. Connective-tissue responses to defined biomaterial surfaces. II. Behavior of rat and mouse fibroblasts cultured on microgrooved substrates.

J Biomed Mater Res A. 2008;85(2):326-335.

18. Soboyejo WO, Nemetski B, Allameh S, et al. Interactions between MC3T3-E1 cells and textured Ti6Al4V surfaces. J Biomed Mater Res. 2002;62(1):56-72.

19. Ricci J, Charvet J, Frenkel SR, et al. Bone response to laser microtextured surfaces. In Davies JE, ed. Bone Engineering.

Toronto, Canada: Em2 Inc.; 2000.

20. JC Grew, JL Ricci. Cytoskeletal organization in three fibroblast variants cultured on micropatterned surfaces.

Presented at the Sixth World Biomaterials Congress. May 15-20, 2000; Kamuela, HI. 21. JC Grew, SR Frenkel, E Goldwyn, T Herman, JL Ricci.

Cytological characteristics of 3T3 fibroblasts cultured on micropatterned substrates. Presented at the 24th Annual Meeting of the Society for Biomaterials. April 22-26, 1998; San Diego, CA. 22. JC Grew, JL Ricci, AH Teitelbaum, JL Charvet. Effects of surface microgeometry on fibroblast shape and cytoskeleton. Presented at the 23rd Annual Meeting of the Society for Biomaterials. April 30-May 4, 1997; New Orleans, LA. 23. Ricci JL, Rose R, Charvet JK, Alexander H, Naiman CS. Cell interaction with microtextured surfaces. Presented at the Fifth World Biomaterials Congress. May 29-June 2, 1996; Toronto, Canada.

24. Ricci JL, Charvet JK, Sealey R, et al. In vitro effects of surface roughness and controlled surface microgeometry on fibrous tissue cell colonization. Presented at the 21st Annual Meeting of the Society for Biomaterials. March 18-22, 1995; San Francisco, CA. 25. Boyan BD, Schwartz Z. Surface topography modulates osteoblast morphology. In Davies JE, ed. Bone Engineering.

Toronto, Canada: Em2 Inc.; 2000.

26. Wennerberg A, Albrektsson T. Effects of titanium surface topography on bone integration: a systematic review. Clin Oral Implants Res. 2009;20(suppl 4):172-184.

27. Nevins M, Leziy S, Kerr E, Janke U, et al. A Prospective Clinical and Radiographic Assessment of PlatformSwitched Laser-Microchannel Implants Placed in Limited Interimplant Spaces. Int J Periodontics Restorative Dent.

2017;37(1):33-38.

Volume 12 Number 3

Dental Sleep Practice is honored... to have been chosen again to sponsor the Sleep Apnea Symposium at the Greater New York Dental Meeting, Nov. 29-Dec. 4, 2019

Dental Sleep Practice will sponsor lectures each day from Sunday, December 1 through Wednesday, December 4. These seminars, taught by industry leaders who represent the top educators in sleep dentistry, will support dentists through practical sleep apnea education. DSP in partnership with the GNYDM will give you the facts and information you need to expand your practice in this growing and important field of dentistry.

Watch for more details this Summer:

www.GNYDM.com

Connect. Be Seen. Grow. Succeed.

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medmarkmedia.com

TECHNOLOGY

CBCT as an interdisciplinary treatment-planning platform Dr. George A. Mandelaris discusses how CBCT imaging is essential for practicing in an interdisciplinary treatment-planning model

I

t’s well understood that cone beam computed tomography (CBCT) greatly aids in implant planning and treatment. The accuracy it affords is undeniable, especially when it comes to avoiding surprises during surgery and when considering the final restoration.

However, CBCT allows implant surgeons to do even more for their patients. By adopting an interdisciplinary approach, doctors can reach across all disciplines to provide the full spectrum of care for their patients and address the core etiology of patient problems — and it all begins with a 3D scan.

CBCT is essential for practicing in an interdisciplinary treatment-planning model.

The multiple fields of view that the most advanced systems, such as the CS 9600 CBCT system (Carestream Dental) feature, give doctors flexibility in determining what

level of treatment planning is necessary for a patient. For example, a patient with a complex dentofacial disharmony skeletal malocclusion may be a good candidate for orthognathic surgery. In that case, a larger field of view — if not the largest — is necessary for planning; the CS 9600 offers 14 fields of view to cover all diagnostic needs.

CBCT also plays a role in risk assessment associated with orthodontic decompensation movements that would be needed to set the patient up for success and confidently judge the impact that such decompensation movements would have on the dentoalveolar structures. Is enough bone around the teeth present to accomplish the desired movements and not camouflage the patient? If not, do alternative applications of orthodontic therapy need to be considered,

Figure 1: Sagittal CBCT slice pre-SFOT

such as surgically facilitated orthodontic therapy (SFOT) in which the bone would be developed around the teeth to expand the orthodontic boundary conditions and optimize conditions for safe tooth movement?

Figures 1 and 2 demonstrate a Class II dentofacial disharmony malocclusion patient who was managed by SFOT. Note the before and after dentoalveolar bone volumes around the teeth. Also note that with expansion orthodontia (accomplished by SFOT and improving the orthodontic boundary conditions), the change in airway dimension at C2.

Figures 3-5 demonstrate 3D images of a patient with a Class III dentofacial disharmony malocclusion who was also managed with SFOT. Figure 3 demonstrates the pre-op condition; Figure 4 demonstrates the 3D rendering of placing the teeth in the

Figure 2: Sagittal CBCT slice at 15 months post-SFOT

George A. Mandelaris, DDS, MS, FACD, FICD, attended the University of Michigan from undergraduate through dental school. He completed a postgraduate residency program at the University of Louisville, School of Dentistry, where he obtained a certificate in the specialty of Periodontology as well as a Master of Science (MS) degree in Oral Biology. Dr. Mandelaris is a Diplomate of the American Board of Periodontology and Dental Implant Surgery and has served as an examiner for Part II (oral examination) of the American Board of Periodontology’s certification process. He is an Adjunct Clinical Assistant Professor in the Department of Graduate Periodontics at the University of Illinois at Chicago College of Dentistry (Chicago, Illinois) as well as the University of Michigan School of Dentistry, Department of Periodontics and Oral Medicine (Ann Arbor, Michigan). Dr. Mandelaris is a Fellow in both the American and International College of Dentists. Dr. Mandelaris is in private practice at Periodontal Medicine & Surgical Specialists, LTD, in Chicago, Park Ridge, and Oakbrook Terrace, Illinois. He limits his practice to periodontology, dental implant surgery, bone reconstruction, and tissue-engineering surgery.

Disclosure: Dr. Mandelaris serves as a key opinion leader for Carestream Dental.

20 Implant practice

Volume 12 Number 3

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Introducing the CS 9600 5-in-1 scanner for oral surgeons.

There’s nothing simple about oral and maxillofacial surgery. But now there is a simpler way for your staff to capture the high-quality images you need to achieve faster diagnoses and treatment plans. Learn more about this simply brilliant scanning solution at carestreamdental.com/CS9600.

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WORKFLOW INTEGRATION HUMANIZED TECHNOLOGY DIAGNOSTIC EXCELLENCE © 2019 Carestream Dental LLC. 18765 AL ALL PA 0719

TECHNOLOGY

Figure 3: Pre-op

Figure 4: Virtual final correct position for facial esthetics and function but in the non-augmented pre-op bone anatomy

final correct position for facial esthetics and function but in the non-augmented pre-op bone anatomy. Note the lack of facial bone volume to accomplish the movements safely.

The teeth are positioned outside the available bone envelope and cause iatrogenic risk to the periodontium, warranting such decompensation movements hazardous to the periodontium. If the bone volume is not augmented, the patient would settle for a compromised orthodontic result that would likely relapse. Figure 5 demonstrates the post-SFOT result of the patient with final tooth positions and the augmented bone volumes. Note that the teeth have not been compromised in the final outcome positions, and that the dentoalveolar bone volume has been augmented to allow such tooth movement to occur safely.

Once a 3D scan is taken, it can be mapped to a diagnostic software that can provide a 3D orthodontic treatment simulation to show the patient how the teeth need to be moved and into what position.

This eliminates guesswork and underscores informed consent at the highest level.

Patients better understand the scope of their problem as well as all the opportunities for

more optimal correction. The fact that the scope of treatment can be expanded also makes therapy more predictable and more stable. All team members benefit by having a patient more vested in their oral health care and better educated on what IDT therapy can provide for their long-term health.

Of course, orthognathic surgery and SFOT may seem like extreme examples. What about taking an interdisciplinary approach to planning and placing implants? Ultimately, implants are a restoratively driven process, and CBCT imaging aides with “top-down” planning. With today’s advanced technology, it’s not enough for the surgical specialist to simply place implants and assume the general dentist will figure out the restoration. Instead, CBCT allows the periodontist/ oral surgeon to keep the final crown at the forefront of planning and executing implant surgery, while building an excellent rapport with the restorative doctor so there are no surprises. What’s more, this prosthetically driven approach toward implant planning is also moving in a context that must also be biologically driven. With all the emerging problems of peri-implant diseases, we’re

Figure 5: Post-SFOT result with final for facial esthetics and function tooth positions and the augmented but in the nonaugmented pre-op bone volumes bone anatomy

learning more about who’s susceptible and how the treatments we perform at the chair influence how this disease develops. In many cases, problems can usually be traced back to the planning, and CBCT helps minimize that. Surgeons should not only be working closely with their referring doctors to achieve natural-looking and ideally placed prosthetics, but also be considering the long-term impact of implant placement and the inherent associated risks of patients developing periimplant disease.

CBCT serves as a vehicle of high transparency; the surgeon can see what’s needed at every level so that every discipline can contribute to the overall outcome of the patient. This underscores the team approach, long-term outcome stability, and predictability associated with complex interdisciplinary treatment. Interdisciplinary treatment planning goes beyond just a pretty smile and a good bite; it’s about also developing a stable, healthy periodontium; a healthy, stable TM joint relationship; a good airway, and, in the end, sustainable oral health conditions for the lifetime of the patient. IP

Stay Connected Between Issues Like us on Facebook at facebook.com/ImplantPractice/ Watch our DocTalk Dental videos at doctalkdental.com Check out our Webinars at implantpracticeus.com/webinars Connect. Be Seen. Grow. Succeed. www.medmarkmedia.com

22 Implant practice

Volume 12 Number 3

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CONTINUING EDUCATION

Autogenous bone blocks and implant placement to reconstruct a large volume hard tissue defect Drs. Muhammed H. Abram and André van Zyl describe a case whereby one patient required complex tissue regeneration following a grinding disc injury

I

njuries to the maxillofacial region resulting from the use of angle grinders are often disfiguring. They can negatively influence phonetics and masticatory function as well as self-esteem. This article presents a case report wherein autogenous bone blocks followed by dental implant placement were used to reconstruct a large volume hard tissue defect caused by a grinding disc injury.

Introduction Penetrating injuries are those that violate the soft and hard tissues by an object that forcefully enters the body. In the maxillofacial region, these injuries may either be isolated or any combination of contusions, abrasions, lacerations, dentoalveolar fractures, luxations in their several forms (lateral, intrusive, extrusive), subluxations, dental tissue lesions, and avulsions (Rodriguez and Guerrero, 2010; Koyuturk and Kusgoz, 2008).

In their study, Bastone, et al. (2000), found that males experienced significantly more facial trauma than females with male:female ratios ranging from 1.3-2.3:1.

Most traumatic dental injuries are unintentional with the most dominating causes being falls, collisions, and being struck by an object (Glendor, 2009).

This article presents an unusual case of reconstruction of the dentoalveolar structures, carried out one year after an injury caused by a broken disc from an angle grinder.

Case report A 35-year-old male presented to the Department of Periodontics and Oral Medicine, University of Pretoria, with a request to

Muhammed H. Abram, BDS(Wits), PDD(Clinical Dentistry)(Stell), DipOdont(Oral Surgery)(UP), MChD(OMP)(UP), is a specialist in periodontics and oral medicine. He practices in Johannesburg, South Africa.

André W van Zyl, BChD, MChD(OMP)(Stell), is a specialist in periodontics. He is head of the Department of Periodontics and Oral Medicine at the University of Pretoria in South Africa.

24 Implant practice

Educational aims and objectives

This article aims to describe the complex restorative and placement procedure required in a case resulting from major facial trauma.

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: •

Identify surgical protocols applied in this case.

•

Identify the characteristics and causes of penetrating injuries in the maxillofacial region.

•

Recognize the phases to treatment planning a case such as this.

•

Realize some statistics related to traumatic injuries as a result of work-related injuries.

•

Recognize autogenous onlay block grafting from intraoral sites as a predictable treatment modality for reconstruction of large volume alveolar bone defects.

Figure 1: Anterior facial view

replace his missing upper right canine and first premolar with a fixed restoration.

He reported having an accident 1 year previously: An angle grinder disc had snapped and cut into his face.

The patient had sustained a full thickness laceration through the right upper and lower lips. He also sustained a dentoalveolar fracture, with traumatic luxation of the upper right canine and first premolar. The loss of teeth negatively influenced his phonetics and masticatory function, as well as his self-esteem.

A comprehensive medical and dental history was taken. This was followed by extraoral and intraoral examination.

Extraoral examination revealed a vertically orientated scar, about 4 cm in length, extending across both the upper and lower lips from the inferior aspect of the right nasal

Figures 2A-2B: 2A. Intraoral right labial view. 2B. Occlusal view

ala (Figure 1). Intraoral examination revealed a healthy periodontium and no dental disease.

A large volume hard and soft tissue defect was noted in the first quadrant between the UR5 and UR2 (Figure 2).

A cone beam computed tomography (CBCT) scan was done as an adjunctive diagnostic aid. This scan revealed the presence of a mini-plate and screws in the region of the healed fracture and graphically demonstrated the hard tissue defect that Volume 12 Number 3

Figure 5: Placement of bone blocks horizontally and vertically

existed in both the vertical and horizontal dimensions (Figure 3). Reduced bone height along the proximal surfaces of teeth UR5 and UR2 was noted.

Treatment planning The patient was assessed by a periodontist and a prosthodontist. Teeth UR5 and UR2 were not considered suitable abutment teeth for a four-unit bridge. The hard tissue defect precluded the ideal three-dimensional placement of dental implants to replace teeth UR4 and UR3.

Augmentation of the site with autogenous bone blocks, followed by a healing period of 4 to 6 months, and then placement of dental implants was considered to be the treatment of choice.

The treatment protocol was based on a consensus statement of the third ITI conference (Chen, et al., 2009), which states that “Augmentation utilizing autogenous blocks with or without membranes results in higher gains in ridge width and lower complication rates than use of particulate materials with or without membranes.” The surgical SAC assessment was graded as complex and the Volume 12 Number 3

CONTINUING EDUCATION

Figure 3: 3D reconstruction of CBCT

Figure 4: Use of the piezoelectric instrument

Figure 6: Use of a surgical stent

restorative SAC assessment as advanced (Dawson, et al., 2009).

Bone augmentation surgery

prefabricated surgical stent (Figure 6) was used as a guide for the ideal three-dimensional placement of the implant fixtures (Figure 7).

Under local anesthesia and sedation, bone blocks were harvested from the right external oblique ridge and ascending ramus of the mandible. A piezoelectric knife was used to harvest the bone (Figure 4).

One bone block was fixed to the lateral aspect and a second bone block to the superior aspect of the deficient residual ridge using bone screws (Figure 5). Guided bone regeneration was performed by covering the bone blocks with anorganic bovine bone mineral and a collagen membrane as described by von Arx and Buser (2006). Tension-free primary closure was obtained with 5-0 nylon sutures. Postoperative medication included a chlorhexidine mouthwash, antibiotics, antiinflammatories, and analgesics.

Dental implant surgery Following a healing period of 4 months, the bone screws were removed and Straumann® bone level implants were inserted in teeth UR4 and UR3 positions. A

Figure 7: Periapical radiograph showing implants at UR4 and UR3 Implant practice 25

CONTINUING EDUCATION

Figure 8: Surgical exposure of implants

Closure screws were placed and primary closure obtained, and a further 2 months of healing was allowed.

Implant exposure The implants were exposed 2 months later utilizing the roll-back technique (Figure 8).

Osseointegration of the implants was verified with a RFA monitoring instrument, yielding an adequate Implant Stability Quotient (ISQ) reading at implant level and healing abutments placed.

Prosthodontic phase Following a further healing period of 2 weeks, implant-level impressions were taken and temporary acrylic restorations manufactured. A period of 2 months was allowed for soft tissue training to optimize the emergence profiles of the crowns. Screwretained porcelain-fused-to-metal crowns were subsequently manufactured (Figure 9).

Figure 9: Final restorations on day of placement

removable partial dentures and bonded or cementable fixed bridges. With increasing patient demands, the use of removable partial dentures is rarely the option of choice as a definitive solution. Clinical follow-ups of teeth supplied with single crowns or included as abutments in bridge works have indeed demonstrated that pulp tissue necrosis is not a rare complication and may affect 10%-20% of the observed teeth over a 10- to 15-year period (Bergenholtz and Nyman, 1984).

Survival rate of implants placed in horizontally augmented bone is high (Chen, et al., 2009). Nevins, et al. (1998), in a systematic review, found that implants placed in regenerated bone had similar survival rates to implants placed in native bone.

In the repair of alveolar bone defects, intraoral donor sites offer a number of advantages. The proximity of the recipient and donor sites makes it ideal for outpatient

implant surgery because less operative and anesthetic time is required. There is also no cutaneous scar, and patients report reduced morbidity and discomfort compared with extraoral locations (Schwartz-Arad and Levin, 2005; Gungormus and Yavuz, 2002).

REFERENCES

9. Koyuturk AE, Kusgoz A. Multiple dentoalveolar traumatic injury: a case report (3 years follow up). Dent Traumatol.

2008;24(4):e16-e19.

Conclusion The use of autogenous onlay block grafting from intraoral sites is a predictable treatment modality for reconstruction of large volume alveolar bone defects. Esthetics, function, and phonetics can be restored following trauma to the anterior maxilla by guided bone regeneration and dental implant placement.

Acknowledgments The authors would like to thank Dr. Ashana Harrypersad, Department of Prosthodontics, University of Pretoria for the outstanding prosthodontic work. IP

Discussion Traumatic injuries as a result of workrelated injuries occur frequently, with the most common sites injured by angle grinders being the head and face (Rodriguez and Guerrero, 2010; Black, et al., 2000; Carter, et al., 2008; Senthilkumaran, et al., 2010; Telmon, et al., 2001).

Injury occurs when a disc shatters while rotating during use. Human error by unskilled or untrained workers and mechanical failure have been cited as being some of the most common causes (Rodriguez and Guerrero, 2010; Carter, et al., 2008). Dental trauma constitutes a significant health issue among adults with 15.5% reporting a history of injury to the mouth or teeth (Locker, 2007).

Various treatment modalities have been used to replace lost anterior teeth, including 26 Implant practice

1. Back DL, Espag M, Hilton A, Peckham T. Angle grinder injuries. Injury. 2000;31(6):475-476.

2. Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: a review of the literature. Aust Dent J. 2000;45(1):2-9.

3. Bergenholtz G, Nyman S. Endodontic complications following periodontal and prosthetic treatment of patients with advanced periodontal disease. J Periodontol.

1984;55(2):63-68.

4. Carter LM, Wales CJ, Varley I, Telfer MR. Penetrating facial injury from angle grinder use: management and prevention.

Head Face Med. 2008;4:1.

5. Chen ST, Beagle J, Jensen SS, Chiapasco M, Darby I. Consensus statements and recommended clinical procedures regarding surgical techniques. Int J Oral Maxillofac Implants. 2009;24(suppl):272-278.

6. Dawson A, Chen S, Buser D, et al. In: Dawson A, Chen S, eds. The SAC Classification in Implant Dentistry. Berlin, Germany: Quintessence Publishing Co; 2009.

7. Glendor U. Aetiology and risk factors related to traumatic dental injuries — a review of the literature. Dent Traumatol.

2009;25(1):19-31.

8. Güngörmüş M, Yavuz MS. The ascending ramus of the mandible as a donor site in maxillofacial bone grafting. J Oral Maxillofac Surg. 2002;60(11):1316-1318.

10. Locker D. Self-reported dental and oral injuries in a population of adults aged 18-50 years. Dent Traumatol.

2007;23(5):291-296.

11. Nevins M, Mellonig JT, Clem DS 3rd, Reiser GM, Buser DA. Implants in regenerated bone: long-term survival. J Periodontics Restorative Dent. 1998;18(1):34-45.

12. Rodriguez JH, Guerrero JS. Maxillofacial penetrating injury by a grinding disc: a case report. J Calif Dent Assoc.

2010;38(11):811-813.

13. Schwartz-Arad D, Levin L. Intraoral autogenous block onlay bone grafting for extensive reconstruction of atrophic maxillary alveolar ridges. J Periodontol. 2005;76(4):636-641.

14. Senthilkumaran S, Balamurgan N, Arthanari K, Thirumalaikolundusubramanian P. Penetrating head injury from angle grinder: a cautionary tale. J Neurosci Rural Pract.

2010;1(1):26-29.

15. Telmon N, Allery JP, Scolan V, Rouge D. Fatal cranial injuries caused by an electric angle grinder. J Forensic Sci. 2001;46(2):389-391.

16. von Arx T, Buser D. Horizontal ridge augmentation using autogenous block grafts and the guided bone regeneration technique with collagen membranes: a clinical study with 42 patients. Clin Oral Implants Res. 2006;17(4):359-366.

Volume 12 Number 3

REF: IP V12.3 ABRAM/VAN ZYL

FULL NAME

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 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.

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

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Autogenous bone blocks and implant placement to reconstruct a large volume hard tissue defect ABRAM/VAN ZYL

1. _________ are those that violate the soft and hard tissues by an object that forcefully enters the body. a. Penetrating injuries b. Bruxism injuries c. Bite lacerations d. Surgical injuries 2. In the maxillofacial region, these injuries may either be isolated or any combination of contusions, abrasions, ________, subluxations, dental tissue lesions, and avulsions. a. lacerations b. dentoalveolar fractures c. luxations in their several forms (lateral, intrusive, extrusive) d. all of the above 3.

4.

Most traumatic dental injuries are _________ with the most dominating causes being falls, collisions, and being struck by an object. a. self-inflicted b. unintentional c. untreatable d. undetectable (For the patient described in this case report) A cone beam computed tomography (CBCT) scan was done ____________.

Volume 12 Number 3

a. b. c. d.

as the only form of imaging because the patient refused other imaging as an adjunctive diagnostic aid although it showed no additional information to other forms of imaging

5. (For the patient described in this case report) The hard tissue defect _______ the ideal three-dimensional placement of dental implants to replace teeth UR4 and UR3. a. precluded b. included c. required d. augmented 6. Augmentation of the site with autogenous bone blocks, followed by a healing period of _________, and then placement of dental implants was considered to be the treatment of choice. a. 1-2 months b. 3 months c. 4-6 months d. 8 months to 1 year 7. The treatment protocol was based on a consensus statement of the third ITI conference, which states that “Augmentation utilizing autogenous blocks with or without membranes results in ________

ridge width and lower complication rates than use of particulate materials with or without membranes.� a. higher gains in b. decreased c. compromised d. degraded 8. A ________ was used to harvest the bone. a. bone curette b. piezoelectric knife c. scalpel d. low-speed twist drill 9. Postoperative medication included ________, and analgesics. a. a chlorhexidine mouthwash b. antibiotics c. anti-inflammatories d. all of the above 10. Dental trauma constitutes a significant health issue among adults with _____ reporting a history of injury to the mouth or teeth. a. 15.5% b. 24.6% c. 47.2% d. 64.1%

Implant practice 27

CE CREDITS

IMPLANT PRACTICE CE

CONTINUING EDUCATION

Single-tooth implant placement: achieving a biomimetic result in the esthetic zone Dr. Rory McEnhill demonstrates the difficult process of providing an implant restoration that can offer outstanding esthetics for the long term Background This patient presented with a missing UR2. He was a young man and had already worn a flipper denture and an adhesive bridge. Neither of these treatment options had brought him any satisfaction. In addition, they had been unpredictable with the denture breaking and the adhesive bridge debonding.

This patient’s key clinical features were: • Upper anterior gap UR2 • Huge hard tissue volume defect • Good gingival biotype despite some volume loss • Good interarch space The patient was referred to the practice in order to deal with the functional and esthetic issues relating to his missing upper right lateral incisor. Examination of his dentition highlighted that everything was healthy and that the sole and primary focus of his treatment would be to provide a biomimetic approach to restore the UR2 site back to its original state. This would involve hard tissue grafting as well as soft tissue bulking.

The patient was very clear about what he wanted to achieve. He wanted a predictable, long-term esthetic solution that would be fixed and permanent. Despite his reticence toward denture and adhesive bridges, we discussed their merits again. However, due to his age, he was willing to undertake the more complex solution, which was to provide the implant. He understood that this would involve bone harvested from the chin and grafted, connective tissue graft, and implantation. He understood the time scale would be approximately 8 to 9 months and was happy to wear an Essix retainer for this period of time.

The patient attended for a primary hygiene appointment to ensure optimum gingival health prior to surgery. We had

Rory McEnhill BDS(QUB), MSc(U Man), MFGDP(UK), is practice principal of Blue Sky Dentistry, an award-winning practice in Northern Ireland.

28 Implant practice

Educational aims and objectives

This clinical article aims to discuss a case where complex procedures were used to provide an esthetic implant-borne restoration in order to meet high patient expectations.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 32 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify the treatment-planning process involved in providing this patient with a biomimetic restoration.

•

Identify several potential options for this patient’s treatment.

•

Realize the treatment objectives.

•

Realize the steps for the implant placement and connective tissue graft.

•

Realize the protocols followed for the restorative phase.

•

Identify some necessary plans for this patient’s future care.

Figures 1-4: Patient at presentation

assessed from the CT scan that a concurrent implant and bone graft was not possible, as the hard tissue defect was too large, and the implant would have been placed outside the protective environs of the bony envelope.

The bone graft was carried out using the Khoury technique using a tunnel flap. The implant was then placed 3 months later, and a connective soft tissue graft was carried out at the same time. Following 3 months of further healing, an apically repositioned flap

was used to expose the implant, and a series of temporary crowns was used to sculpt the soft tissue, prior to a final screw-retained implant crown being fabricated.

Examination and assessment The patient had no significant medical history or dental issues beyond the missing UR2. He had lost this tooth 5 years previously: He had a post crown that endured a root fracture, which was responsible for the Volume 12 Number 3

bony destruction. Preoperative radiographs highlighted his excellent bone health generally. In the UR2 position, the bone levels could be seen to be diminished. A subsequent CT scan highlighted the bone quality at the donor site and also the size of the defect in the recipient site. A diagnosis of missing upper right lateral incisor with associated hard and soft tissue volume loss was made.

Treatment discussion and planning The patient was insistent on having an implant-based solution. He wanted to restore this site to what it was pre-tooth loss. Ideally, he wanted the implant to be indistinguishable from his natural teeth.

He understood that the treatment plan would be an involved, complex one but due to his age was very happy to invest his time, effort, and finances into fixing the issue definitively.

The patient was offered several options for treatment: 1. New permanent denture 2. Adhesive bridge

3. Conventional cantilevered bridge 4. Implant with hard/soft tissue grafting He confirmed his desire to go for the fourth option.

This patient was an ideal candidate for treatment. He was very motivated and ambitious with regard to the final result. He was willing to undergo difficult treatments to achieve the ideal esthetic result.

The treatment objectives were therefore: • To restore the upper right lateral incisor • Biomimetic reinstitution of hard/soft tissues • Perfect color match of implant restoration

Treatment Following the initial consultation, where the patient’s hopes and expectations were established, he was referred to the in-house hygienist. Impressions were taken for a temporary adhesive bridge that the patient could wear during treatment. Due to the fact that a bone graft was to be carried out,

Figure 8: The bone plate was fixed in place using a 1 mm bone screw Volume 12 Number 3

Figure 6: A vertical relieving incision was made to expose the UR2 site and establish the size of the defect

Figure 7: An autogenous bone plate was harvested from the patient’s chin

no direct pressure was to be applied to the healing graft site. A CT scan was also taken of the upper and lower jaws at this point too.

These views allowed us to assess the donor and recipient sites.

The chin was decided on as the donor site, due to the thickness of the soft tissue there, making gum recession less likely. The incisors were short, and the incisal branch of the inferior dental nerve was not close, meaning that paresthesia of the incisors was

Figure 9: The graft site was closed using Vicryl sutures Implant practice 29

CONTINUING EDUCATION

Figure 5: Preoperative radiograph

CONTINUING EDUCATION unlikely. In addition, this patient retained his lower wisdom teeth diminishing the retromolar/ramus sites as less attractive. The palate was also considered, but the roots were uncomfortably close to the palatal side, as well as the palate being relatively shallow.

The long-term paresthesia of the incisive papillae was a negative aspect too.

The UR2 site was exposed with one vertical relieving incision with the intention of carrying out a tunnel graft. The site defect was measured, and this value was used to guide us in the harvesting of the chin block.

The bone was harvested using a micro saw, ensuring that the bony window was cut with beveled edges. This allowed us to tap the bone plate out with a chisel. Collagen was placed into the defect. Internal 6.0 VicrylÂŽ sutures and external Vicryl interrupted sutures were used to close the donor site up.

The graft was then cut in half lengthways using the Khoury technique. This produced two rectangular bone blocks, one of which was used as the new buccal plate and the other which would be used to fill in the gap between the defect and the new buccal plate.

To achieve this aim, a safe bone scraper was used to thin out the samples.

The principal reason for the success of the Khoury technique is the large surface area of the graft, as opposed to a bone block, which has a low surface area. Angiogenesis consequently occurs much more rapidly, and osteoclastic activity is thus dramatically reduced as the grafted bone is revascularized rapidly.

In addition, the harvested bone has a high osteoinductive and osteogenic capacity.

The autogenous bone plate is then trimmed and adjusted to fit the defect intimately, the rough edges are rounded, and

Figure 10: Radiograph showing graft and bone screw in place

Figure 11: The UR2 site was left to allow for healing and revascularization

Figure 12: An implant was placed into the regenerated ridge 30 Implant practice

a 1.0 mm bone screw was used to fix the plate into position. The harvested cancellous/ cortical bone was packed into the defect to fill up the remaining voids. The soft tissue was then reflected back and sutured up with 4.0/6.0 Vicryl. The graft was left for 3 months to mature prior to implant placement.

Implant placement and connective tissue graft A full thickness flap with two vertical relieving incisions was carried out to expose the graft. The graft was massively revascularized and was red and oozing blood. The bone screw was removed, and the width of the ridge was now 8 mm. Ideally, at least 2 mm of buccal bone and 2 mm of palatal bone are required for predictable long-term implant placements. In this case, there was 3 mm of buccal bone once we had placed a MegaGen

Figure 13: Once healing was complete, impressions were taken to plan the screw-retained temporary and final restoration Volume 12 Number 3

CONTINUING EDUCATION

Figure 14-16: An excellent final esthetic result was achieved

Figure 17: The patient was an ideal candidate — willing to undergo difficult treatments to achieve the ideal result

AnyRidge® 3.5 x 11.5 mm implant. To bulk up the tissue volume, a connective tissue graft was harvested from the palate, and this was packed into the site and the flap closed over.

The site was allowed to heal for 3 months.

Restorative phase After 3 months of implant integration and soft tissue healing, an apically repositioned flap was carried out to improve the buccal soft tissue bulk further. A sulcus former was placed, and the soft tissue was left to heal for 1 month.

Open-tray impressions were taken to fabricate a screw-retained temporary restoration. This was due to the fact that the soft tissue needed to be sculpted further. The temporary crown had a bulbous buccal emergence profile to effect apical movement of the soft tissue. Following this process, a new open-tray impression was taken, and a porcelain screw-retained crown was fabricated and torqued into position.

The 1- and 3-month review appointments were held to assess a number of Volume 12 Number 3

potential issues and to assess that the patient was cleansing the site effectively.

In addition, photos were taken at the 1- and 3-month appointments for our clinical records.

The patient was informed of the importance of maintaining gingival health and was advised to attend with his hygienist quarterly.

Conclusion This was a very demanding case. To provide biomimetic dentistry is a high tariff treatment.

The treatment was very successful on a number of fronts. The goal to achieve a biomimetic result has been achieved with hard and soft tissue redevelopment being very successful. The implant has been restored with a porcelain restoration that is an excellent color match and blends in very harmoniously.

Plans for future care include: • Implant monitoring appointments • Biannual hygiene appointment with his GDP.

Figure 18: Radiograph showing implant in situ

In terms of the clinical issues, this was a case that worked out due to good clinical planning. A methodical treatment plan allowed us to develop this case systematically. By putting in the hard and soft tissue foundations and tissue sculpting with temporary restorations, we were able to achieve an excellent result.

With regard to the final esthetics, the author feels that the final result is very satisfying, as the soft tissue profile and tooth symmetry are all harmonious and blend well into this patient’s smile. IP

REFERENCES 1. Khoury F, Antoun H, Missika P. Bone augmentation in oral implantology. Quintessence, UK; 2006.

2. Kuchler U, von Arx T. Horizontal ridge augmentation in conjunction with or prior to implant placement in the anterior maxilla: a systematic review. Int J Oral Maxillofac Implants.

2014;29(suppl):14-24.

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

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

4. Ritter RG. Multifunctional uses of a novel ceramic-lithium disilicate. J Esthet Restor Dent. 2010;22(5):332-341.

5. Tonelli P, Duvina M, Barbato L, et al. Bone regeneration in dentistry. Clin Cases Miner Bone Metab. 2011; 8(3):24-28.

Implant practice 31

REF: IP V12.3 MCENHILL

FULL NAME

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 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.

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

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

EMAIL

TELEPHONE/FAX

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

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Single-tooth implant placement: achieving a biomimetic result in the esthetic zone McENHILL

1. (For the patient mentioned in this article) We had assessed from the ________ that a concurrent implant and bone graft was not possible, as the hard tissue defect was too large, and the implant would have been placed outside the protective environs of the bony envelope. a. 2D radiograph b. visual inspection c. CT scan d. transilluminated image 2. The bone graft was carried out using the Khoury technique using a ________. a. tunnel flap b. crestal flap c. punch approach d. palatal-lingual approach 3. (After the bone graft was carried out) The implant was placed _______, and a connective tissue graft was carried out at the same time. a. 1 month later b. 3 months later c. 4 months later d. 6 months later 4. Due to the fact that a bone graft was to be carried

32 Implant practice

out, ________ was to be applied to the healing graft site. a. direct pressure b. no direct pressure c. excessive pressure d. a topical steroid 5. (For this patient) The ________ was decided on as the donor site, due to the thickness of the soft tissue there, making gum recession less likely. a. palate b. earlobe c. chin d. hip 6. The bone was harvested using a ________, ensuring that the bony window was cut with beveled edges. a. chisel b. Charriere saw c. micro saw d. ribbon saw 7. Ideally, at least _______ of buccal bone and 2 mm of palatal bone are required for predictable long-term implant placements. a. 1 mm

b. 2 mm c. 3 mm d. 4 mm 8. To bulk up the tissue volume, a connective tissue graft was harvested from the _______, and this was packed into the site and the flap closed over. a. chin b. palate c. hip d. ear 9. After 3 months of implant integration and soft tissue healing, a/an _________ was carried out to improve the buccal soft tissue bulk further. a. double pedicle flap b. partial thickness flap c. full thickness flap d. apically repositioned flap 10. The patient was informed of the importance of maintaining gingival health and was advised to attend with his hygienist ________. a. monthly b. bimonthly c. quarterly d. yearly

Volume 12 Number 3

CE CREDITS

IMPLANT PRACTICE CE

Finding an ideal endpoint means starting with an ideal LOCATOR®

T

oday there are 75 million baby boomers.

By the year 2030, the number of baby boomers 65 and older will have doubled, with 10,000 new boomers crossing daily into retirement age. This is important because as the retirement age population grows, so will the demand for dentures. However, studies suggest there is low patient satisfaction with denture therapy. One of the reasons for the gaps in patient satisfaction is the poor perception most people have of conventional dentures. Unfortunately, this reputation has been earned. Almost every patient fitted with conventional dentures will eventually experience some combination of facial collapse, food entrapment, soreness, ulcers, and angular cheilitis. Equally troubling is the inability of dentures to perform the primary function for which teeth exist — the chewing of food.

Another shortcoming of dentures is their inability to deliver a satisfactory emotional experience. As the physical shortcomings reveal themselves, patients may become self-conscious and fearful of experiencing a retention failure at an inopportune time.

Many also report a feeling of “fullness” in their mouth and unpredictable vocalization when wearing their dentures.

Just as implantology has offered a superior alternative to traditional crown-andbridge procedures, so too has it improved the performance of denture treatment. The inclusion of implants in denture therapy to treat edentulous patients has changed the denture landscape. Implant-retained overdentures provide stability and a predictable level of retention that exponentially improves the quality of life of millions of patients.

Over the years, overdentures were secured with several different attachment concepts. While providing more retention, the performance was still not optimal, leaving doctors and patients wanting more. Most solutions also require precise placement of implants to align with the attachment system. This is not always possible based on competing factors in the patient’s anatomy.

These competing requirements made the placement of implants for use with overdentures complex, highly technique-sensitive, and costly for patients.

Volume 12 Number 3

However, that changed with the introduction of the Zest LOCATOR®.

The LOCATOR is a super-gingival attachment system that allows the doctor or patient to easily seat his/her overdenture without the need for complete accurate alignment of the dental implants. In other words, it allows the dentist or patient to easily seat the overdentures on the implants. This offers patients many of the performance and stability benefits of permanent options with the hygienic convenience of a removable — all at a more affordable price point.

“The LOCATOR systems let us overcome so many of the shortcomings in conventional dentures,” says Dr. Nadim Z. Baba, DMD, MSD, FACP, a practicing prosthodontist, teacher, and President of the American College of Prosthodontists. He began using the LOCATOR system in 1997.

“The genius of the system is in the flexibility it provides. The system is self-aligning.

Other systems need to be 100% aligned for the abutment to be seated. If the person seating the appliance isn’t perfect with the abutments, the denture is not going to fit.

With the Zest LOCATOR, even if the person is a little bit off, they’ve been designed in a way that they will find and guide the denture to the right location. This means the patients can seat the dentures on their own, which is especially relevant for those who are elderly and may have lost some dexterity.”

From a clinical standpoint, the selfaligning feature also means that the implants do not need to be perfectly aligned when they are placed. In fact, the new LOCATOR R-Tx systems will allow for 60 degrees of divergence between the implants. This can be especially helpful for patients where bone volume may be reduced, or there is an unfavorable anatomical landscape.

Dr. Baba points out that the LOCATOR brand name has become a little too successful for its own good. The word LOCATOR has become shorthand for “overdenture abutment attachment” in the profession, even though Zest makes the only actual LOCATOR. He says it’s a distinction worth noting.

“LOCATOR has been on the market for so long because it’s been proven successful.

Clinical case and photographs courtesy Anthony Prudenti, DDS

Other companies have tried to create their own version of a LOCATOR. The scientist in me forces me to try out these new systems when they are introduced. But there’s been nothing that compares to Zest LOCATOR when it comes to quality and clinical outcomes. I ask myself, “Why would I consider switching if what I’m using is working?”

Baba continues, “The other thing that sets LOCATOR apart is the service. The Zest team is there for you. They satisfy their customers no matter what. They have an excellent product, and they’re confident about it. Honesty, integrity, quality — these are all traits that Zest displays.

On a personal level, being able to change people’s lives in this way is so rewarding.

It’s changed so many lives for the better. It changes the way people eat and the way they live and function in public.”

From a financial standpoint, the use of a Zest LOCATOR with an overdenture can offer practices a recurring source of patient recall, with patients needing to be seen for installation, continuing hygiene, and maintenance of the attachment system.

With the baby boomers moving into their golden years, the demand for dentures is on the rise. The uncomfortable truth is that conventional dentures often disappoint patients. However, implant-retained overdentures and implant-retained removable partial dentures using the Zest LOCATOR can offer a rewarding outcome for the patient and practitioner alike. Because arriving at the ideal clinical endpoint means starting with the ideal physical LOCATOR. IP This information was provided by Zest Dental Solutions®.

Implant practice 33

PRODUCT PROFILE

Overcoming the great denture disappointment

PRODUCT SPOTLIGHT

The DenMat implant maintenance kit Dr. Timothy Kosinski discusses tools that provide safe and efficient access around dental implants

T

he option to restore patient health, function, and esthetics with dental implants has become an integral part of dental practices. The surgical and prosthetic applications have become rather routine, and long- term prognoses have improved with CBCT diagnosis and planning. Taking a “tooth-down” approach ensures that the dental implants are not only placed in available hard tissue, but also ideally positioned to maximize the final esthetic and functional result. There are many factors to consider when an implant does not heal as expected. The patient’s general health, habits, and medication may affect implant integration and stability of soft tissue. Uncontrolled medical conditions, the outcomes of surgical procedures, changes in body chemistry, and hormonal issues can result in poor healing around implants.

Sometimes there is no obvious reason why an implant becomes unhealthy. There is one constant — if the patient is not committed to long-term care at home and in the office, the chance for failure will rise.

Involving patients in the continuing care of an implant is a cornerstone of successful dental practices. The peri-implant interface is different than periodontal physiology, and there must be attached connective tissue on the facial aspect of dental implants. Along the implant-tissue interface are fibers running parallel to the bone. Inflammation around the implant will progress apically more quickly than it will around a natural tooth, underscoring the importance of frequent in-office evaluation. Infected mucosa can create significant negative peri-implant issues such as accelerated bone loss and discomfort.

Taking precautions to prevent these issues includes proper, thorough home care and

the patient’s commitment to consistent in-office physical and radiographic evaluation. Working as a team ensures that plaque, calculus, and debris will be minimized between in-office evaluations.

When implementing in-office assessment and maintenance of the dental implant, focus should be on the peri-implant tissue margin, implant body, and the implant abutment interface. To effectively and safely remove biofilm and hard deposits, implant-compatible instruments are required to maximize efficiency and thoroughness. The metal that hygiene curettes are fabricated from is important, as we prefer not to scratch the surface of the titanium fixture and create a greater plaque trap.

The DenMat implant maintenance kit is a comprehensive set of instruments, which allow safe and efficient access around dental implants that may have bone loss and or gingival recession. The kit consists of essential instrument designs such as a UC Rule universal curette. The UC Rule is similar to a Barnhardt 5/6, which is commonly used in hygiene departments. It is versatile and particularly good for wide-based posterior implants. The “toe” works well for horizontal strokes under larger implant restorations. The Mini Langer-Pattison Curette is a universal curette used for implants with bone loss and narrow spaces. It is especially good for larger crown or crown and bridge prostheses. The mini is often used for fixed hybrid and fixed screw-retained zirconia bridges. Try this curette using horizontal strokes under implant-retained crowns, as

Stephanie Pajot, RDH, treating a patient

if scaling under the cemento-enamel junction of a natural tooth. The posterior sickle scaler is a popular universal scaler design among hygienists and is perfect for shallow pockets and heavier supra-gingival calculus.

Lastly, the Nebraska-Langer combination scaler has an anterior curette on one end and a universal scaler on the other. This is our favorite for a singular implant.

The DenMat implant treatment instrument design is versatile and allows for effective plaque and calculus removal. The titanium nitrite-coated instruments minimize scratching of the titanium surfaces. Adding the DenMat implant maintenance kit to the office treatment protocol adds a tool that can assist in raising retention and overall health rates for implant success. IP

Timothy Kosinski, DDS, MAGD, received his doctorate from the University of Detroit Mercy Dental School and his Masters in Biochemistry from Wayne State University School of Medicine, Detroit. He is an Affiliated Adjunct Clinical Professor at the University of Detroit Mercy School of Dentistry and associate editor of the Academy of General Dentistry (AGD) journal. He is a Diplomate of the American Board of Oral Implantology/Implant Dentistry, the International Congress of Oral Implantologists, and the American Society of Osseointegration.

Disclosure: Dr. Kosinski is a key opinion leader for DenMat.

34 Implant practice

Volume 12 Number 3

Improve your implant maintenance protocol with Hartzell Titanium!

VS Titanium-coated. Implant-compatible.

Increase tactile sensitivity and protect surrounding tissue with precision titanium-coated scalers and curettes, carefully selected for full coverage of any implant size, shape or position.

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Call to order today! 800-433-6628 | denmat.com/hartzell Implant Maintenance Kit (1) 5-Instrument Cassette

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(1) UC Rule 3/4 Curette Wide-based implants (1) 1/2 Mini-Pattison Langer Curette & (1) 3/4 Mini-Pattison Langer Curette Bulbous crowns in posterior of maxillary and mandibular arches, and narrow-based implants (1) 1/2 SAMJ Narrow Sickle Scaler Hadar Bars for overdentures and posterior implants (1) 128 Straight Sickle/5 Mini Pattison-Langer Curette Screw tops and mini implants

Š2019 Den-Mat Holdings, LLC. All rights reserved.

801357600 07/19CM

GOING VIRAL

Have cyber criminals “implanted” malware into your network?

Gary Salman discusses how to take defensive measures to help protect your network and critical patient data

I

t seems that you can’t turn on the TV or visit your favorite news website without reading about how cyberattacks and ransomware are crippling businesses and healthcare entities across the United States.

Unfortunately, dental practices are now becoming the victims of similar attacks. We often hear dentists say, “Why would they want to come after my practice?” Your practice is being targeted because of the vast amount of data you store. In addition, we are now seeing scenarios where dental practices are targeted because their IT company or even their accountant’s office was hacked, and the criminals then used this data to attack or target their practices. It is important to understand that the days of simply relying on firewalls and antivirus software to keep hackers out of your network are over.

If these devices were so effective at protecting your data, there would be no data breaches. With the continued sophistication of hackers, they can now deliver payloads that completely disable your antivirus software and allow unauthorized access to your network.

Cybercriminals are targeting practices through phishing or spear phishing campaigns. The hackers will send blanket or targeted emails to you and your staff with the intent of getting someone to either click on something or give up the credentials to your network or email system. We have seen many instances where a practice’s email system gets hacked, and the hackers then send out emails to the practice’s patients with malware attached to them. The debilitating effects of a cyberattack include loss of productivity and business continuity, lack of trust by your patients and referrals, and negative PR in the community where you worked so hard to build your reputation.

Imagine opening an email and clicking on what appears to be an invoice and then

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.

36 Implant practice

Make sure to take defensive measures to help protect your network and critical patient data. getting hit with ransomware or malware.

Hackers are also breaking in through vulnerabilities (“unlocked doors and windows” on your network) or, even worse, through your IT vendor. You can no longer rely solely on your IT company to protect your network. IT companies are not cybersecurity companies. You need the knowledge and expertise of a specialist in cybersecurity to help ensure the security of your network.

Hackers can scan your network for vulnerabilities in a matter of minutes and then identify and exploit these vulnerabilities in order to gain access. This approach in the dental space is much more common than you may imagine. The FBI and Department of Homeland Security posted a bulletin in the Fall of 2018 warning IT vendors that Advanced Persistent Threat Actors (APTs) are targeting IT firms in order to exploit their information to

attack their clients. Since your IT vendor typically stores your IP address, user name, and password in their database, a breach will give the cybercriminal the “keys to your castle.”

Make sure to take defensive measures to help protect your network and critical patient data. It is important to work with a qualified cybersecurity company that can: 1. Perform an audit of your existing policies and procedures 2. Provide you with quarterly vulnerability scans of your network 3. Conduct live employee training to educate your staff on the latest threats and learn how to prevent them 4. Have penetration testing conducted on your network You don’t have to be the next victim of a cyberattack if you take action NOW. IP Volume 12 Number 3

It’s Time To Think Differently

It Takes a Team to Win the Ba le The number one mistake OMS prac ces make...relying on their “IT Guy” for cybersecurity. Cybersecurity is a specialized industry that employs highly trained and cer fied individuals who work in conjunc on with your “IT Guy” to secure your network. Your prac ce and pa ent data is vulnerable to a ack, unless preventa ve measures are put in place to mi gate risk.

Black Talon Security is proud to be the only OMSNIC Preferred Cybersecurity Partner. We secure over 400 dental offices and 8,000+ devices. Stop by our booth (#645) at the AAOMS Annual Mee ng to see why so many of your colleagues have decided to engage with Black Talon to secure their prac ces.

“We understand that it is our responsibility to protect our pa ent’s data and your services are now a necessity to protect this sensi ve informa on from hackers. We have all worked too hard to build our prac ce and reputa on to have it destroyed by one wrong click of an a achment in an email.” Gordon L. Brady, DMD - Oral Surgery Associates & Dental Implant Centers

Cybersecurity | HIPAA Compliance | PCI Scanning | Forensics | Breach Response blacktalonsecurity.com | 800-683-3797

PRODUCT PROFILE

Novadontics software Make Novadontics the newest member of your dental team

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ovadontics software gives you unparalleled dental technology built specifically to improve your dental practice management. With industry-leading business, clinical, and front-office tools, including electronic prescriptions, monthly business metrics, mobile computing, quality continuing dental education, third-party products, and more, our technology enables you and your team to improve patient care while growing your business.

Elevate your patient management Because we recognize the challenges and concerns you face in making a choice about the dental therapy options available for your patients, we created a technologyenabled, data-driven process to ensure that you have all the necessary information at your fingertips to ensure a stress-free process and perfect outcome. We call our proprietary method Digital Treatment Optimization™.

Our cutting-edge technology provides a smart checklist via app and desktop applied through data and technology-driven, cloudbased software that streamlines and foolproofs the implant treatment process. This proprietary treatment approach enables clinicians to perform complicated procedures in a predictable fashion.

Anytime, anywhere mobile EMR access Revolutionary Cloud-based Technology built to help manage your practice anytime, anywhere and sync changes to any device for up-to-date real time information.

Conveniently chart on-the-go whenever and wherever. Novadontics innovative iPad®

application enables its users to work from any location. With a swipe of a finger, you can quickly review patient charts, review notes, and refill prescriptions.

Chart faster and more accurately with Nova Intellechart™. Created by a dentist for dentists, Nova Intellechart is setting the standard for cloud-based EMR technology.

Grow your referral network with Nova Shared Care™ Import or share clinical information with other dental care providers, locally or across the country. Easily locate practices already in the Novadontics Shared Care Community. Compare multiple diagnostic images from multiple practices in a secure, HIPAAcompliant environment.

Streamlined support Novadontics offers extensive support network via online and onsite intervention for all activities ranging from consultations and treatment planning to in-office surgical, prosthodontic, and lab services.

User-friendly Operational Dashboard Our new Operational Dashboard provides real-time, actionable insights into the most important financial and operational metrics for your practice. The innovative Operational 38 Implant practice

Dashboard will help your practice answer critical questions related to collections and production with easy-to-read and understand charts and graphs.

Online Novadontics Academy More than 1,000 dentists are using our comprehensive resource of 200-plus lectures, 100-plus clinical videos, 5 certificate courses, and more.

Exclusive savings Novadontics offers tremendous capital equipment and products savings for up to 50% off from world-leading manufacturers such as Nobel Biocare™, Geistlich®, Salvin®, Piezosurgery®, Omnia LLC, Osstell LLC, Brasseler USA®, and others. We support our members by leveraging the power of many for your independent practice. We offer you better cost control, better revenue management, and better representation.

For more information or to start your free trial, please call 888-838-NOVA, visit us at www.novadontics.com, or email team@novadontics.com.

Visit us at Booth 217 at the 68th AAID Annual Conference in Las Vegas, Nevada, happening October 23 to 26, 2019. IP This information was provided by Novadontics.

Volume 12 Number 3

PRACTICE DEVELOPMENT

The invisible dental implant patient Dr. Roger P. Levin answers some questions that can help to expand an implant practice Question: How can I identify more potential implant patients for my practice?

Answer: There probably aren’t many people who haven’t heard about dental implants or have a basic understanding of their benefits. This is vastly different than in 1985 when implants were relatively new, and a great deal of time was spent trying to prove to specialists and general dentists that dental implants were a viable service that would be successful. There was a great deal of debate as to the best type of implant, implant coating, and other biological factors. And while there still may be some deliberation over what type of implant is most successful, dental implants are now widely accepted.

Given that, your focus should now be on reaching the “invisible implant patient.” This is the patient who, despite already knowing that dental implants are successful and can enhance the quality of life, never presents for a consult and may not even visit a dentist regularly. These patients may be from a lower, middle, or even upper socioeconomic background. And as insurance patients, they haven’t been exposed to implants through their coverage and fear that the implants are too expensive or painful.

When thinking about your approach to this type of patient, it may help to consider this analogy. In the 1940s, orthodontic care was only for the rich, as an orthodontic case at that time rivaled the cost of a new car. When dental insurance began to cover orthodontics, it became more and more mainstream and is now considered a rite of passage for anyone desiring a great smile regardless of their income bracket.

Roger P. Levin, DDS is the CEO and Founder of Levin Group, a leading practice management consulting firm that has worked with over 30,000 practices to increase production.

A recognized expert on dental practice management and marketing, he has written 67 books and over 4,000 articles and regularly presents seminars in the U.S. and around the world.

To contact Dr. Levin or to join the 40,000 dental professionals who receive his Practice Production Tip of the Day, visit www. levingroup.com, or email rlevin@levingroup.com.

40 Implant practice

Third molars in oral surgery are another good example of how a new dental service became a go-to dental treatment. Third molars were deemed to be unhealthy and prone to significant infection; however, they caused a much more complex and painful extraction for adult patients. As insurance coverage broadened to cover an increasing number of patients, the number of third molar cases expanded as well. Third molar removal is now considered a biological health necessity.

There is a slightly increasing amount of insurance coverage for dental implants; however, it is nowhere near the coverage of orthodontic care or third molar removal. This is why there are still so many invisible implant patients. So how do we begin to access the invisible implant patient in an interdisciplinary care environment?

• Give all edentulous patients an implant consultation. The cost of implants or knowledge of the patient’s background should not be considered a factor. Every edentulous patient should be encouraged to undergo an implant consultation. This would include treatment design, cost, length, options, recovery, pain management, and fees. Having a consultation anytime a patient is missing teeth should be thought of as normal and automatic protocol whether the patient

is currently interested in implants or not.

Only with knowledge and education can a patient who is not currently interested in dental implants become more informed and decide to accept implant treatment today or possibly in the future.

• Explain the benefits of implants over other procedures. Invisible implant patients don’t know enough to ask about implants and are often not presented with an implant option. These patients should know that dental implants are long-lasting and give patients a quality of life that they cannot get from any other dental treatment for missing teeth. Partial dentures are known to weaken the adjacent natural teeth that provide support for the dentures, and dentures overall do not look or feel natural, are prone to causing gum disease from trapped food, and must be consistently removed and cleaned.

• Promote convenience. People will pay to have their lives made easier. If you think your patients can’t afford implants, simply ask yourself how many people you know who do not have cable, Internet, cell phone service, and a flat screen television. There are almost none. Most people find the money to pay for whatever they really want. They may prefer taking a cruise over getting Volume 12 Number 3

Volume 12 Number 3

United States. Six months seems to be a fantastic time frame that patients like and it usually fits their budget. However, there are some patients who may need much longer-term payment plans and will choose loan options for payment.

Whatever the option, patient financing can completely change their view of accepting dental implants.

• Educate all patients about dental implants whether they need them or not. Provide a complimentary first implant exam for any patient to learn more about dental implants. Many patients have aging parents or friends who complain about missing teeth. Patients who are educated about dental implants will educate others who may benefit from implant treatment.

• Provide consistent, long-term marketing to patients who have had implant consultations. Many invisible implant patients desire dental implants, but they put it off for some time in the future. However, they may never get

around to it unless they receive some type of reminder. Practices should contact patients periodically by email or text to remind them about the benefits of implants.

• Infuse energy and enthusiasm in case presentation. As dental implants become more common, the case presentations tend to become more robotic.

Having a treatment coordinator who can enthusiastically explain the benefits of dental implants can go a long way toward motivating the invisible implant patient to accept treatment.

Summary All new dental services must go through a stage of gaining legitimacy both within the profession and with early adopter patients. As that service becomes more mainstream, it will take deliberate marketing strategies to excite, energize, and motivate potential patients. Use the strategies outlined here to reach and motivate the invisible implant patients and grow your implant production. IP

Implant practice 41

PRACTICE DEVELOPMENT

implants, but you won’t know until you present it to them. When discussing implant treatment with patients, it’s best to focus on how implants will improve their quality of life through the convenience they offer. Explain that dental implants last for many years, stay in their mouth, are taken care of like natural teeth, and that most of the time they probably won’t notice they have them.

That’s a level of convenience that many people are willing to pay for.

• Offer various payment options. Offer a 5% discount for paying in full by cash or check prior to treatment. Accept payment by credit cards, a shortterm monthly payment plan, or patient financing. Companies like CareCredit® have different financing options, and one of our favorites is the 6-month interestfree option. The practice will give up approximately 6% of its fee (only 1% more than the discount we suggested that they pay upfront anyway), and patients get 6 months to pay if it’s a case in the

PRODUCT PROFILE

Sun® Dental Labs Implants Joey Cabral, CDT, discusses the many implant options available from Sun Dental Labs

O

ur Suntech® custom implant abutments are made of titanium grade 5 ELI (Extra-Low Interstitial). We guarantee our abutments for life. In order to accommodate the needs of each individual patient, our Suntech custom implant abutments provide optimal soft tissue contours; this will ensure an excellent emergence profile while providing optimal placement of the margin below the gingival crest. We also have the option of up to a 30-degree angle abutment for patients who have angulation issues with the placement of their implant, which will allow us to shape the custom abutment as needed depending on the location in the dental arch, so an implant placed in the molar region will be shaped as such. Sun Dental® is a digital lab. We have the ability to send digital images for approval before milling of the abutment if requested. We believe communication is key in achieving the best results for our customer and ultimately the patient.

A great alternative in the esthetic zone is a Suntech® hybrid custom abutment.

This is a zirconia abutment custom-milled to fit on a titanium base and fabricated to be one piece. Suntech hybrid abutments work very well with our Suntech translucent zirconia products, SunCeram® ST or SunCeram® HT, e-max®. It can also be made in the shade requested. Sun Dental Lab is compatible with many popular systems in use today such as Biomet 3i, Astra Tech,

Joey Cabral, CDT, has over 30 years’ experience in dental technology, as well as a Certification in removable prosthodontics and a Certification in implant technology. He is the Implant Manager at Sun Dental Labs.

42 Implant practice

Suntech® Implant Abutments

We believe communication is key in achieving the best results for our customer and ultimately the patient.

Nobel Biocare™, Zimmer, BioHorizons®, Straumann®, CAMLOG®, and many more. If there is an implant that is not in our library, we will order the proper abutment and prep it as needed for the restoration. This will allow for the best contour of the crown. We provide many choices that the restorative dentist can choose from after fabrication of the abutment.

If restorative dentists would like a screwretained restoration, they will have the choice of many different restorative options such as porcelain to non-precious, porcelain to semi-precious, Suntech full-contour zirconia, Suntech Layered Zirconia, e-max pressed crown, or SunCeram 3D multilayered zirconia. Screw-retained provisional restorations allow for the creation of a seamless and cement-free transition from the head of the implant to the free gingiva margin. The screw-retained approach also allows for easy access and manipulation of the emergence profile should the need arise. Three

components are needed to fabricate a screwretained provisional restoration: abutment, clinical screw, and a provisional tooth shell.

We have found in some cases that a cement-retained restoration will provide optimal esthetic results when the direction of the access hole is to the buccal. Utilizing Sun Dental Labs for your custom abutment and restorative needs will also eliminate the need for stock abutment inventory. We accept traditional impressions with a transfer abutment, and we also accept digital submissions. Please contact us at Sun Dental Lab (https://www.sundentallabs.com/support/), so we can supply you with the scan body for the library that we utilize. We also supply a full range of analogs.

Sun Dental Lab is a Certified Dental Laboratory. Our implant department is managed by an Implant-certified Dental Technician along with many other certified, qualified, and experienced technicians in other departments here to serve your technical needs. IP Volume 12 Number 3

INDUSTRY AWARDS

Cellerant announces the 2019 Best of Class Technology Award winners

C

ellerant Consulting Group has announced the 2019 Cellerant Best of Class Technology Award winners. “We are entering a new era in dentistry — one that will change how we diagnose, treat, and manage our patients and practices,” said Dr. Lou Shuman, CEO of Cellerant and founder of the Best of Class Technology Awards. “This was a breakthrough year in product and services technologies. The panel spent hundreds of hours in close discussion reviewing and analyzing the corporate landscape. Pay close attention to our winners as they are truly leading the way to provide you what is best in today’s contemporary practice.”

The 2019 Cellerant Best of Class Technology Award Winners are: • 3Shape TRIOS® • Apteryx XVWeb® + 3D Module • Bausch OccluSense® • Bien-Air iOptima INT • Bien-Air Tornado • BlueLight Analytics • Carestream CS 9600 • DDS Rescue • Dentsply Sirona Primescan • DEXIS™ Titanium by KaVo • Exocad ChairsideCAD • Garrison Dental Solutions ComposiTight® 3D Fusion™ Sectional Matrix System • Ivoclar Vivadent® Bluephase® G4 • MMG™ Fusion ChairFill • Orascoptic™ EyeZoom™ • Patient Prism® • Schein ONE OmniCore™ • Shofu EyeSpecial C-III • SICAT • SleepArchiTx™ • Tokuyama OMNICHROMA • Ultradent Gemini® 810 + 980 • Ultradent VALO™ Grand • Vista Dental Products Phasor™ • WEO Media Out of all 25 winners, 14 are winning the award for the first time. “The Cellerant Best of Class Award creates an even playing field for dental manufacturers,” said Chris Salierno, DDS, Cellerant Best of Class panel member.

“Major players stand next to start-ups, and their technologies compete on innovation and disruption rather than marketing budgets and branding.”

Volume 12 Number 3

The Cellerant Best of Class Technology Award is the only award of its kind, as it is covered by every major dental journal in North America and is presented at the American Dental Association’s Annual Meeting.

This year winning products will be showcased at the 2019 ADA FDI World Dental Congress, which will be held in San Francisco from September 5–7. Attendees will have the unique opportunity to experience the Best of Class technologies firsthand at the ADA meeting, as well as hear the panel members lecture on these products at the Digital Future of Dentistry Technology Expo.

The expo also features free continuing education taught by the leading experts in technology integration and social media.

More information can be found online at ada.org/meeting.

About the Cellerant Best of Class Technology Award Since the inaugural presentation in 2009, the Best of Class Technology Awards have grown to occupy a unique space in dentistry by creating awareness in the community of manufacturers that are driving the discussion as to how practices will operate now and in the future.

The 2019 Cellerant Best of Class Technology Award is selected by a panel of the most prominent technology leaders in dentistry: Paul Feuerstein, DMD, technology editor for Dentistry Today; John Flucke, DDS, technology editor for Dental Products Report; Marty Jablow, DMD, known as America’s technology coach; Pamela Maragliano-Muniz, DMD, editor-in-chief of Inside Dental Hygiene; Chris Salierno, DDS, editor-in-chief of Dental Economics; and Lou Shuman, DMD, CAGS, founder and creator of the Best of Class Technology Award.

Over the course of each year, the panel members seek out and conduct research on potentially practice-changing technologies, with deliberations on nominees and final voting taking place in February. Panelists are precluded from voting in any category where they have consulting relationships.

The entire selection process is conducted and managed on a not-for-profit basis.

About Cellerant Consulting Group Founded and led by CEO Lou Shuman,

DMD, CAGS, Cellerant provides strategic dental market insights, clinical expertise, implementation resources, and support to accelerate growth for client dental companies. Cellerant services include new concept incubation, clinical product evaluation, product development, continuing education program development and CE sponsorship, strategic branding and marketing, online marketing, content marketing, and dental media relations management. As an orthodontist and former owner of a 10-doctor multi-specialty private group practice, Dr. Shuman guides clients to offer products that engage dental customers and provide sustained differentiation. Cellerant operates under a unique model that merges leading voices in clinical product evaluation and strategic partner companies to provide a menu of services from one easily accessible network.

For more information on the Cellerant Best of Class Awards and the 2019 Award Winners, go to cellerantconsulting.com/ bestofclass. IP Implant practice 43

INDUSTRY NEWS Glidewell Dental kicks off exciting leadership program geared toward women in dentistry

Carestream Dental announces new partner program for independent software vendors

Glidewell Dental, an industry-leading provider of dental laboratory services, products, technologies, and clinical education, has officially launched Guiding Leaders, a dynamic leadership development program for women in dentistry. Glidewell kicked off Guiding Leaders with a 2-day training course in Irvine, California, with a group of 13 female dentists and one Fellow participating in the program’s premiere year. Guiding Leaders empowers practicing women clinicians to become influential voices in dentistry by providing them with elite training from top industry professionals. The 12-month program, which covers a range of topics, including practice management, effective communication, and principles of finance, began with a session from facilitator Jo Schaeffer-Crabb of the Arbinger Institute discussing the importance of developing an outward mindset. Glidewell plans to continue Guiding Leaders next year with a new group of participants with the goal of building an ongoing community of women who provide support and guidance to each other while mentoring newer professionals in coming years.

For more information, please visit glidewelldental.com.

Carestream Dental is seeking to partner with independent software vendors that share its mission of transforming dentistry, simplifying technology, and changing lives. The new Carestream Dental Partner Program invites outside vendors to submit their solutions for integration with Carestream Dental’s care management platform, CS OrthoTrac, CS PracticeWorks, CS SoftDent, and CS WinOMS practice management solutions. With the new Carestream Dental Partner Program, third-party vendors now have a more direct way to submit their software modules to be reviewed and approved by Carestream Dental. These modules may include patient engagement, revenue cycle management, data and analytics, and even clinical functionality. Most important, the new program ensures consistency and quality across Carestream Dental’s third-party software add-ons. Once approved and properly integrated, Carestream Dental Partners will receive a seal to display on their websites to both proudly acknowledge their partnership with Carestream Dental.

To learn more about the program, call 800-944-6365, or visit carestreamdental.com.

CS 3600 intraoral scanner tested to have highest accuracy in latest implantology study When it comes to placing implants, accuracy matters, and the CS 3600 intraoral scanner was found to give the most accurate results during a new study, “Trueness and Precision of Five Intraoral Scanners in the Impressions of Single and Multiple Implants: A Comparative In-Vitro study.” With few peer-reviewed studies evaluating the clinical efficacy of intraoral scanners in implantology, these latest findings from Drs. Francesco Guido Mangano, Uli Hauschild, Giovanni Veronesi, Mario Imburgia, Carlo Mangano, and Oleg Admakin compared the trueness and precision of five intraoral scanners and determined which have both accurate and consistent results. According to the study, the CS 3600 had the best accuracy, while having the fewest triangles making up the meshes in all applications. To put the scanners to the test, 10 scans were performed by a single digital dentistry expert per indication per intraoral scanner with a zigzag technique in the same environmental conditions.

Two maxilla plaster models were used as a reference: one partially edentulous and one totally edentulous.

To learn more, visit carestreamdental.com.

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DenMat introduces implant service offerings DenMat Holdings, LLC, has expanded its line of high-quality, end-to-end laboratory services to include custom implant abutments and screw-retained crowns and bridges. The addition of implant services enables oral health professionals to prescribe a custom-tailored restorative solution for virtually any patient — be it simple or complex — from DenMat Laboratory. DenMat offers three custom abutment options, three implant crown options, and three screw-retained restorative options. These implant offerings are compatible with most major implant systems on the market today.

Custom titanium abutments include free anodization. Turnaround time for screw-retained restorations is 5 days, while custom abutments and crowns require 10 days.

Visit denmat.com/laboratory to learn about DenMat Implant Services in more detail.

Volume 12 Number 3

INDUSTRY NEWS

DenMat launches study club dedicated to professional excellence DenMat Holdings, LLC, announced its DenMat Study Club: a dental community dedicated to excellence. The Study Club will meet monthly at DenMat headquarters in Lompoc, California, with its inaugural meeting held on June 20, 2019. This first Study Club featured a presentation called “High Tech Innovations in Endodontics” featuring Stephen Buchanan, DDS, FICD, FACD. DenMat is proud to offer several engaging lectures as part of its DenMat Study Club through 2019. This exciting series will feature presentations on dental implants, esthetics, soft tissue management, restorative dentistry, social media marketing, dental sleep medicine, digital dentistry, and much more. Each informative Study Club gathering will be led by respected and well-known industry leaders .

For more information, please visit https://www.denmat.com/ education/study-club.

3Shape Dental System 2019 software now available 3Shape announced the release of the 2019 version of its industry-leading design software for labs, 3Shape Dental System 2019. The new and improved 3Shape Dental System 2019 includes significantly enhanced solutions for designing and producing dentures, splints, and clear aligners as well as improvements to core workflows. Powerful advancements to 3Shape’s denture design software and new possibilities within materials and manufacturing make it highly profitable for labs to produce dentures digitally. New features such as, teeth-in-blocks, optimized try-in denture workflow, and improved TRIOS integration and alignment, serve to reduce labor time, production costs, and improve efficiency. 3Shape Dental System and 3Shape Smile Design smile libraries are based on real people’s smiles and are included in corresponding coffee-table book meant for patients and dental practices. Patients can leaf through the book and choose a desired smile. Labs can then create the restoration chosen from the book using the matching library in 3Shape Dental System. 3Shape Dental System 2019 is now up to 10 times faster to start new cases, re-open previously designed cases, and for the import and export of material settings. Dental System offers design proposals with just one click, beautiful gingiva for implant bridges, and new superior function using the patient’s real jaw motion.

For more information, visit https://www.3shape.com/en.

Volume 12 Number 3

Denta-Cool Is launching first-of-a-kind intraoral cryotherapy device Denta-Cool™, a revolutionary cryotherapy device designed to effectively reduce oral pain and swelling for dental patients, launched its product on the North American market in April 2019.

Denta-Cool is a therapeutically designed intraoral mouthpiece that engages with the entire oral cavity to provide cooling and reduce discomfort for dental patients who suffer from pain and swelling after dental surgery. Denta-Cool is now available to specialists in the dental and maxillofacial industry and can be reused by patients at home after refreezing. Cryotherapy, or cooling of the mouth, teeth, root surfaces and gums, during or after dental treatment has been proven to significantly reduce the patients’ discomfort and has helped manage post-operational dental pain and swelling. DentaCool compliments the established post-surgical recovery regimen and might help decrease the amount of prescribed opioids dental patients require to take after surgery for pain relief. The intraoral thermo scans showed that the Denta-Cool mouthpiece engaged the entire oral cavity and comfortably cooled it for up to 30 minutes.

Learn more at www.denta-cool.com.

Implant practice 45

STEP-BY-STEP

GCL Systems™ Preserving and perfecting the gingival emergence profile

D

ental implants have changed the face of dentistry as much as any other technology. Since the discovery of osseointegration and the development of the dental implant, millions of lives have been enhanced with the ability to chew food and function in a way that was not previously available. Significant implant research and development have been undertaken to allow bone to integrate more quickly and effectively. Despite achieving this very high level of success, the predictability of maintaining and establishing the ideal soft tissue emergence profile has resulted in less than acceptable esthetic outcomes.

Traditional implant soft tissue management has been with round healing cuffs/abutments, but ironically, there are no round teeth.

The importance of gingival tissue manipulation to establish an ideal emergence profile has been discussed for years, and many techniques have been proposed or developed but fallen short of the goal of predictably preserving and perfecting gingival tissue. The shortfalls of the alternative approaches and devices arise from the failure to satisfy three key elements required of an ideal solution: adaptability, durability, and dependability. The Gingival Cuff Links System™ was developed to meet all three elements.

Each Gingival Cuff Link™ core abutment is made of titanium specifically designed to fit with the implant manufacturer’s implant design. The Gingival Cuff Link™ body is made of bisacrylic resin, which is the same material from which many temporary dental restorations are fabricated and can be easily sculpted by reduction using dental rotary instrumentation or by addition using flowable composite or bisacrylic. The body is molded to 11 different emergence profiles to assist in establishing and maintaining a natural soft tissue emergence for every tooth.

The Gingival Cuff Links System™ has been used in hundreds of cases, in all areas of the mouth, and at all stages of the implant process (immediate and delayed). In all cases, the Gingival Cuff Link was either customized as a healing cuff and/or a provisional crown.

Clinical case This patient presented with advanced resorption of the root of tooth No. 8 with resultant significant mobility and discoloration. Removal of the tooth was done, and the site addressed with immediate implant 46 Implant practice

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placement and provisionalization using the Gingival Cuff Links System™.

Results The immediately placed implant soft tissue emergence profile was able to be maintained or enhanced in the nearly all cases using the Gingival Cuff Links System™ either as a gingival healing cuff or a provisional crown. In delayed or second-stage surgery protocols, emergence-profile maintenance with Gingival Cuff Links was superior to round healing caps; however, some gingival recontouring using flap

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procedures was necessary affecting healing times and predictability relative to immediate protocols. When multiple implants were placed adjacent to each other, the ability to maintain the interproximal papilla was predictable with immediate implant and provisional crown or customized-healing cuff placement.

In all situations, the results were substantially better for each member of the implant team (surgeon, restorative dentist, laboratory technician, patient) than using the traditional method of a round healing abutment. IP This information was provided by GCL Systems.

Volume 12 Number 3

ON THE HORIZON

Immediate molar dental implants Dr. Justin D. Moody discusses the efficacy of immediate molar dental implants

T

he benefits of properly placed immediate dental implants into single-rooted extraction sites in the esthetic zone have been well documented for several years now. In the anterior maxilla, the preservation of ridge dimension and the stability of the soft tissue architecture are paramount for a successful true tooth replacement solution. Many times this can be achieved without the use of bone-grafting materials.

This makes the service more cost-effective to the patient while being more surgically conservative, which, in my opinion, is usually better in the esthetic zone.

Replacement of molars has always been a struggle to be done at the time of extraction for many reasons. First, due to the morphology of molar teeth, the bone is rarely in a position post-extraction where the dental implant can be placed in the perfect prosthetic position.

Today’s immediate molars are wider and come in a variety of sizes to accommodate the sites and allow for primary stability of the fixture engaging the walls of the extraction site. The key to the prosthetic success is the placement of the implant; it must be made subcrestally so that the emergence profile is closest to that of the tooth that was lost. Second, there is very little opportunity to get primary closure over a molar extraction site, which has always made grafting the site challenging to say the least. With the placement of the immediate molar and its affinity for good initial stability, the placement of a healing abutment at the time of implant placement greatly increases our ability to get a soft tissue seal over the implant.

Biology still dictates when a site is a good candidate for an immediate molar. Having 1.5 mm or more of bone all around the implant, especially on the buccal, will lead to reliable long-term success. Choosing an implant that 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 Horizon Dental Center (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.

48 Implant practice

Figure 1: BioHorizons® guided surgery kit and immediate molar supplemental bur block. There is one final drill for each implant size

Figure 2: Final BioHorizons drill. The height of the drill is the depth of the final osteotomy, making the system simple and efficient

Figure 3: BioHorizons 8x10.5 mm immediate molar implant, which comes in 7 mm and 8 mm width and 7.5 mm, 9 mm, and 10.5 mm in length

Figure 4: Fully seated BioHorizons immediate molar. Key to the placement is being slightly subcrestal

Figures 5 and 6: 5. The BioHorizons immediate molar has both Laser-Lok technology and its new aggressive thread pattern for maximum stability. 6. Good implant placement still starts with an adequate amount of bone all the way around the implant.

Post-op CBCT shows good bone volume encompassing the implant

was designed for this application through science will further add to the potential for immediate molar success. I have been using the BioHorizons® immediate molar since its release; the tread pattern is deep, providing good initial stability and a 5.7 mm platform that is compatible with my current BioHorizons surgical and prosthetic kits — the only addition is a final drill that is sized to the

implant. It also has Laser-Lok® technology, which has a dual affinity for bone and soft tissue, making integration and soft tissue management predictable.

Immediate molar implants have their place in dental treatment, providing you use good common sense and follow the biological principals for integration and soft tissue management. IP Volume 12 Number 3

predictable, immediate results introducing Tapered Pro Immediate implant treatment requires predictability. Tapered Pro implants have been developed based on over 10 years of tapered implant success. The unique design elements provide a predictable solution for immediate treatment.

design features include: • tapered body and aggressive threads provide primary stability • end cutting, self-tapping thread design for controlled implant placement in challenging sites • reduced collar diameter preserves vital bone • unique Laser-Lok microchannels create connective tissue attachment and retain crestal bone, allowing better control of esthetic outcomes

For more information, contact BioHorizons Customer Care: 888.246.8338 or shop online at www.biohorizons.com Not all products are available in all countries.

SPMP19213 REV A JUN 2019

NEW CITY, NEW YORK

Presented by Drs. Adam Kimowitz and Bart Silverman

Session 2: January 31 and February 1, 2020 Session 3: March 13 and 14, 2020

2020 CITIES

FAST TRACK: WINTER I Sessions 2-4: January 13 - 17, 2020

Georgia

FAST TRACK: SPRING Sessions 2-4: March Ma 9 - 13, 2020

salt lake city

SALT LAKE CITY, UTAH

Utah

Presented by Drs. Justin Moody and Wade Pilling

Session 2: June 5 and 6, 2020 Session 3: July 10 and 11, 2020

chicago

FAST TRACK: SUMMER Sessions 2-4: June 15 - 19, 2020

Illinois

ILLINOIS CHICAGO, CHIC Session 2: August 28 and 29, 2020 Session 3: September 18 and 19, 2020

tempe Arizona

2020 SCHEDULE

INSTRUCTOR

FAST TRACK: FALL Sessions 2-4: September 21 - 25, 2020

ADDITIONAL IMPLANT COURSES Complications: July 31 and August 1, 2020 Full Arch Guided: January 10 and 11, 2020 Restorative Solutions: April 2 - 4, 2020 Restorative Solutions: June 25 - 27, 2020 Restorative Solutions: November 5 - 7, 2020 May 28 - 30, 2020 Sinus Grafting: G Soft Tissue Grafting: September 11 and 12, 2020

oceanside atlanta

ATLANTA, GEORGIA Session 2: April 3 and 4, 2020 Session 3: May 1 and 2, 2020

SESSION FOUR: LIVE SURGERY SURGE March 25 - 27, 2020 April 15 - 17, 2020 June 10 - 12, 2020 July 29 - 31, 2020 September 9 - 11, 2020 October 21 - 23, 2020 December 2 - 4, 2020

New York

California

OCEANSIDE, CALIFORNIA CALIFORN Session 2: February 7 and 8, 2020 Session 3: March 6 and 7, 2020

FAST TRACK: WINTER II Sessions 2-4: December 7 - 11, 2020

new city

Justin D. Moody, DDS Founder & Clinical Director

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

register online at

implantpathway.com Questions? Call us at (888) 309-2423