Implant Practice US Winter 2019 Vol 12 No 4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews Winter 2019 – Vol 12 No 4 • implantpracticeus.com

Dr. Dipesh Parmar

Preserving and perfecting the gingival emergence profile Dr. Todd Liston

Peri-implantitis: cure and prevention Drs. Ashok Sethi, Thomas Kaus, and Naresh Sharma

Planning for success: reducing risks for peri-implant disease Dr. George A. Mandelaris

Improving osseous graft handling by incorporation of PRP to create “gummy bone” Drs. Arun K. Garg, Gregori M. Kurtzman, Renato Rossi Jr., and Maria del Pilar Rios

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*Contact Zimmer Biomet Dental for all claims. Unless otherwise indicated, as referenced herein, all trademarks are the property of Zimmer Biomet; and all products are manufactured by one or more of the dental subsidiaries of Zimmer Biomet Holdings, Inc. and marketed and distributed by Zimmer Biomet Dental and its authorized marketing partners. For additional product information, please refer to the individual product labeling or instructions for use. Product clearance and availability may be limited to certain countries/ regions. This material is intended for clinicians only and does not comprise medical advice or recommendations. Distribution to any other recipient is prohibited. This material may not be copied or reprinted without the express written consent of Zimmer Biomet Dental. ZB0702 REV A 01/19 ÂŠ2019 Zimmer Biomet. All rights reserved.

EDITORIAL ADVISORS Steve Barter, BDS, MSurgDent RCS Anthony Bendkowski, BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent

If there are no round teeth, then why are most healing abutments round?

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

ental implants have been placed and restored at an increased rate since their introduction to dentistry in the 1980s. The sophistication of the implant itself has emerged during that time period. In the armamentarium of implants, we have an unlimited variety of implants that are usable in every clinical situation the doctor encounters. As the implants themselves have been improved through the years, the restorative part of implant dentistry has not moved at the same pace in regard to making the tissue in the implant area look and feel as if the tooth had not been removed. Patients routinely complain that the implant feels fine, but they continually pack food around the implant due to the shape of the restoration Mark H. Blaisdell, DDS and the lack of the proper emergence profile. The critical part of restoring a dental implant ends with the clinician placing the proper abutment and a functional esthetic crown. Unfortunately, the gingival tissue is often left out of the restorative equation because there is no easy way to shape the tissue into the proper emergence profile. The best example of this is that nearly every implant company makes only round healing abutments. The question then needs to be asked, “If there are no round teeth, why do implant companies continue to make round healing abutments?” The emergence profile of a natural tooth is made to help keep food from packing around the tooth. Clinicians must have the proper anatomical tissue shape to restore the implant to the most esthetic and functional manner. Experienced clinicians are aware of the ideal emergence profile and wish to restore the tooth to that ideal, but with a round healing abutment, that is not possible without numerous patient visits and stretching tissue to a new shape. The best time to shape tissue is when the implant is placed and the healing abutment is the shape of the specific tooth that is being replaced with an implant. This allows the tissue to grow to the shape of the gingival cuff placed as the healing abutment. With the proper emergence profile, the restorative dentist is able to create an esthetic restoration for the patient that will not pack food and feel as if the tooth had not been removed. Dentists have waited over 30 years to have the emergence profile placed at the forefront of implant dentistry. With the advent of a tooth-specific, sculptable custom healing abutment, implant dentistry has finally moved forward in the preservation and shaping of gingival tissue to give optimal results for the patient. Dr. Mark H. Blaisdell

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.

Mark H. Blaisdell, DDS, is the cofounder and CEO of GCL Systems, and is a practicing restorative dentist. He graduated from Brigham Young University in 1976 with a degree in Zoology and moved to San Francisco, California, to complete his professional training at the University of the Pacific School of Dentistry. He received his dental degree in 1981 and moved to Bountiful, Utah, to start his dental practice. Dr. Blaisdell has been a member of the American Dental Association during his entire career and served in many leadership positions. He is a past President of the Utah Dental Association and a delegate to the American Dental Association representing Utah. He also served on the Council on Dental Benefits and Practice in Chicago at the headquarters of the American Dental Association. Dr. Blaisdell is currently the President of the American College of Dentists for the Utah Chapter and a member of both the Pierre Fauchard Dental Fraternity and the International College of Dentists. He practices in Bountiful, Utah.

ISSN number 2372-9058

Volume 12 Number 4

Implant practice 1

INTRODUCTION

Winter 2019 - Volume 12 Number 4

TABLE OF CONTENTS

Clinical Improving osseous graft handling by incorporation of PRP to create “gummy bone”

Publisher’s perspective Celebrating 15 years of growth and learning Lisa Moler, Founder/CEO, MedMark Media................................6

Drs. Arun K. Garg, Gregori M. Kurtzman, Renato Rossi Jr., and Maria del Pilar Rios discuss the benefits of using patient-derived autogenous blood concentrates mixed with particulate graft material

Technology Planning for success: reducing risks for peri-implant disease Dr. George A. Mandelaris discusses key tools to optimize positional accuracy and to avoid complications for patients with implants.................18

Case study

Preserving and perfecting the gingival emergence profile Dr. Todd Liston discusses an implant method that maintained soft tissue form and function and esthetics 2 Implant practice

ON THE COVER Cover image courtesy of Drs. Arun K. Garg, Gregori M. Kurtzman, Renato Rossi Jr., and Maria del Pilar Rios. Article begins on page 8. Volume 12 Number 4

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TABLE OF CONTENTS

Continuing education Managing the transition to an implant-supported dentition Dr. Dipesh Parmar details a case where the patient’s need to avoid a denture shaped the progression of treatment.................................... 22

Service profile ALPHAEON CREDIT ................................................. 32

Going viral

Continuing education Peri-implantitis: cure and prevention

Drs. Ashok Sethi, Thomas Kaus, and Naresh Sharma examine risk factors and management of this increasingly prevalent condition

IT companies and cybersecurity companies are not created equal Gary Salman sounds an alert: Don’t be held ransom to a data breach that could have been prevented........... 34

Product profile Optimize your implant workflow with 3Shape Implant Studio® .................................................36

Practice management On the horizon Comfort, function, or beauty? JoAn Majors, RDA, CSP , advises: Ask your patients the questions, and stay out of their way! ®

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

Preventing incision-line opening Dr. Justin D. Moody discusses solutions for a common postoperative complication................................ 40

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 4

TROUBLESHOOTING

Q & LOCATOR® ATTACHMENTS A Common calls received by the Technical Team at Preat. Q: The Retention Inserts are pulling out of the housing? A: The path of insertion is likely too divergent for standard inserts. Consider the extended range males (red, orange, green) which will accommodate a divergent implant between 10 and 20 degrees (40 degrees between implants). Standard LOCATOR® Replacement Males

Extended Range LOCATOR® Replacement Males

STANDARD RANGE:

Q: There is no retention with this OLD/EXISTING prosthesis. Why?

EXTENDED RANGE:

08529 Extra Light

08527 Light

08524 Regular

08558 Zero

08548 Extra Light

08915 Light

08547 Regular

Blue 1.5 lbs

Pink 3 lbs

Clear 5 lbs

Grey 0 lbs

Red 1 lbs

Orange 2 lbs

Green 4 lbs

0-10º of angulation

A4: If the position of the housing is out of alignment with the abutment, remove the nylon male, take a hot soldering tip and transfer heat into the housing (softening up the retaining acrylic), and pull the housing out of the prosthesis. Place a new black male into the housing, sandblast and prime, and go forward with normal chairside pickup procedures. Make sure to only put pressure over the attachment areas; pressure in the gingival supported areas will cause compression of gingiva and therefore a misalignment of attachment and abutment.

Over 10º of angulation up to 20º per implant

Q: There is no retention with this NEW prosthesis. Why? A1: Make sure you can see that the line of demarcation (undercut between retentive area of abutment line of demarcation and cuff height portion) is above the gingiva, allowing the housing and insert to engage with the abutment. LOCATOR® implant abutments should be ordered to the exact height of the gingival measurement. The LOCATOR® Implant abutment has a built in additional 1.5mm of height. This 1.5mm allows the male attachment to fully seat on to the the abutment. Please do not add 1.5mm to your measurements.

A1: Is the inside of the LOCATOR® abutment clean of debris? Plaque build up prevents the inserts from properly engaging with the abutment.

A2: Do you see any wear facets/gold TiN coming off of the abutment and the silver undercoating showing up? This is likely from worn/rough inserts making vertical striations into the abutment when the patient is biting it into place. To check retention, again use an impression coping to see if there is wear on the abutment. If no retention, you need a new abutment. Common causes for the vertical striations include: poor hygiene, denture cleaner, bruxism, and more.

A3: Finally, if there is retention, check for a reline. • Take a 0.5mm of thin/base plate wax and wrap it around the saddle area of the process A2: Try a housing or impression coping loaded with any nylon insert on the abutment. With finger pressure, is there retention? Is the housing making contact with the gingiva? A3: If there is retention with the impression coping/housing test, it is a high spot. Use indicating paste to check for acrylic high spots or alignment of the attachment.

• Replace the inserts with the black processing inserts • Seat the prosthesis back in the patient’s mouth and have them come into occlusion. • Remove the prosthesis and check for contact marks. • If there is no contact, that means there has been a loss of more than 0.5mm of supportive bone/tissue. Reline to compensate for what has been lost.

Contact Preat for all of your LOCATOR® needs! Abutments, Inserts, Impression Copings, Drivers, and more. 1-800-232-7732 or visit preat.com

PUBLISHER’S PERSPECTIVE

Celebrating 15 years of growth and learning

s the publisher of Implant Practice US, I have had so many opportunities to read, meet, and learn from “master teachers” — their wisdom comes from many fields, from dental KOLs to management gurus to technology and selfimprovement. One of the ways that I keep their tenets in mind is through collecting meaningful quotes — one of my greatest passions. Quotes from Wayne Dyer, Jim Rohn, Zig Ziglar, Marianne Williamson, and Tony Robbins reflect where I’ve been and what I’ve achieved in my half century on this earth. Each insight, opinion, and perspective has served as an integral part of my own personal growth, as well as the growth of each of MedMark Media’s publications. In the coming year, MedMark Media celebrates its 15th birthday! It’s Lisa Moler Founder/Publisher, MedMark Media been a growth experience, not only for me, but also a time of growth, learning, and building relationships among our readers, authors, and advertisers. This issue of Implant Practice US offers both clinical and management articles to extend your horizons, both clinically and in business. In CEs, Dr. Dipesh Parmar discusses using implants to restore edentulous arches and, in this case, for a patient who needed to avoid a denture. Dr. Ashok Sethi, et al.’s article educates on risk factors and preventative measures for peri-implant disease. Dr. George A. Mandelaris also discusses tools to avoid complications with this problematic inflammatory condition. In his case study, Dr. Todd Liston explores the predictability of maintaining and establishing the ideal soft tissue emergence profile. In our Practice Management column, JoAn Majors advises finding out more about patients’ wants, needs, and desires to devise the most customized treatment plan. Both the clinical and business sides of your practices must be nurtured to reduce your stress and increase your success. Fifteen years ago, MedMark Media’s home office was based here in my hometown of Scottsdale — my corporate headquarters was comprised of a makeshift office in my tiny second bedroom. My sole employee was a 17-year-old intern who found the job from a posting that one of my fellow publishing friends put up at one of the local colleges. I had a hopeful hunch that she would work out. Diving into contracts and paperwork, we shared a computer and a dream of producing a publication that mattered in the dental industry. Within that first year, my Arizona market held the top ranking out of about 12 markets at the time. And amazingly, 15 years later my first employee, Adrienne Good, is still a valued member of the much larger MedMark Media team that now has grown to include departments for editorial, production, advertising, and digital media. I am fortunate to be a part of this beautiful “dental world” and can honestly say that this industry and the amazing people I’ve met within it literally have saved my life. I found my niche, and for 15 years have been striving, along with my team, to help you find and cultivate your niches. We all continue to innovate and seek new ways to help our readers reach new personal and professional heights. Of course, as in any profession, there will be challenges, but we want to provide you with the tools to step back, take a deep breath, and think, “I got this.” Feel free to contact us to share your ideas and articles. Along the way, I have had so many conversations and learned that everyone has a unique way of looking at the world and overcoming obstacles. We start this 15th year with hope, appreciation, and the knowledge that every day is an opportunity for learning. Thank you for being a part of our journey. To your best success! Lisa Moler Founder/Publisher MedMark Media

6 Implant practice

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 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

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Volume 12 Number 4

CLINICAL

Improving osseous graft handling by incorporation of PRP to create “gummy bone” Drs. Arun K. Garg, Gregori M. Kurtzman, Renato Rossi Jr., and Maria del Pilar Rios discuss the benefits of using patient-derived autogenous blood concentrates mixed with particulate graft material Introduction Clinically, there are situations where osseous grafting needs to be performed. This can vary from socket preservation following extraction, repair of bone loss at the furcation, filling voids between the socket walls and implant when immediate implants are planned, and treatment of exposed implant threads to sinus augmentation. These are managed by use of osseous particles, which can be allografts, autografts, xenografts, or even synthetic materials. The typical problem with particles is the potential for dispersement during the initial healing period. Although they may be rehydrated or wetted with various liquids such as saline, water, or anesthetic, these liquids do not hold the particles together and allow them to spread in the area during healing. This will lead to less volume of healed graft at the site desired and may compromise the intended results. Utilization of patientderived autogenous blood concentrates mixed with the particulate graft material improves graft handling during placement as well as maintenance at the intended site, eliminating dispersion potential. Autologous

blood concentrates are defined as the concentrated portion of the patient’s blood following centrifuging that contains growth factors, platelets, white blood cells (WBCs), and fibrin but does not contain the red blood cell (RBC) portion of the blood.

Benefits of using autogenous blood concentrates with osseous graft materials In the 1980s, several reports identified the pivotal role oxygen plays in wound healing.1-5 These studies were the first to recognize that growth factors promote healing related to the macrophage response to oxygen gradients, which secreted those wound-healing growth factors. Plateletderived wound-healing factor (PDWHF) was first introduced clinically6 and continued on to platelet-rich plasma (PRP) utilized for over 2 decades to initiate wound healing. Thrombinreleased platelets produce angiogenesis and collagen synthesis with fibrin eliciting a cellular exudate, followed by angiogenesis. In the early 1990s, Marx and Garg began work on using patient-derived blood as a fibrin source for use with osseous grafts to

improve product handling. This fibrin adhesive was first published in 1994.7 Platelets secrete growth factors (PDGFAA, PDGF-BB, and PDGF-AB) that stimulate mesenchymal stem cells to replicate, osteoblasts to replicate and produce osteoid, endothelial cells to replicate secreting basal lamina for new blood vessels, and fibroblasts to replicate producing collagen. Additionally, transforming growth factors (TGFß1 and TGFß2) and bone morphogenic protein (BMP) are present that stimulate matrix production and guide cell differentiation into bone. Other factors present in the autologous blood concentrates include vascular endothelial growth factor (VEGF), which supports new blood vessel development, and epithelial growth factor (EGF), which stimulates migration of the surrounding soft tissue to cover the area and form a basement membrane. Incorporation of autologous blood concentrates such as PRP into a particulate graft material provides growth factors to accelerate healing of the graft, stimulating the host cells adjacent to the graft to convert into native bone. More rapid closure of the soft

Arun K. Garg, DMD, is an internationally recognized dental educator and surgeon who, for more than 20 years, served as a full-time professor of surgery in the department of Oral and Maxillofacial Surgery and as director of residency training at The University of Miami Leonard M. Miller School of Medicine. He is considered one of the world’s preeminent authorities on bone biology, bone harvesting, and bone grafting for dental implant surgery. He also is a well-known lecturer and has authored nine published text books and a dental implant marketing kit, which has been translated into multiple languages and distributed worldwide. Dr. Garg can be reached at arun.implantseminars@gmail.com. Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA, is in private general dental practice in Silver Spring, Maryland, was a former Assistant Clinical Professor at University of Maryland in the Department of Restorative Dentistry and Endodontics, and a former AAID Implant Maxi-Course assistant program director at Howard University College of Dentistry. He has lectured internationally on the topics of restorative dentistry, endodontics and implant surgery, and prosthetics, removable and fixed prosthetics, and periodontics. Dr. Kurtzman has over 670 published articles globally, several ebooks, and textbook chapters. He has earned a Fellowship in the AGD, American College of Dentists (ACD), International Congress of Oral Implantology (ICOI), Pierre Fauchard, ADI, Mastership in the AGD and ICOI, and Diplomate status in the ICOI, American Dental Implant Association (ADIA), and International Dental Implant Association (IDIA). He is a consultant and evaluator for multiple dental companies. Dr. Kurtzman has been honored to be included in the top “Leaders in Continuing Education” by Dentistry Today, published annually since 2006, and was featured on the June 2012 cover. Dr. Kurtman can be reached at dr_kurtzman@maryland-implants.com Renato Rossi Jr., DMD, MSc, PhD, graduated from University of São Paulo - USP - Brazil in 1977 and Oral and Maxillofacial Surgeon and Implantology (USP University Hospital and Hospital Hermanos Ameijeiras Cuba). He obtained his MS and PhD in Pathology and Maxillofacial Surgery (USP - Brazil) and Postdoctoral Degree at the University of Havana, Cuba. He is currently dean of the School of Dentistry - USCS (Municipal University of Sao Caetano do Sul - Brazil), Director of Residency Training at the USCS University and UNIB University, and coordinator of the Laboratory of Research in Biomaterials - USCS University. He is the author of several books and research articles. In addition, Dr. Rossi Jr. is a scientific consultant for several biomaterials companies and lecturer regarding OMF, oral surgery, implantology, oral pathology, and autologous blood concentrates. Maria del Pilar Ríos Calvo, DDS, Esp. CAGS, MScD, PhD, graduated from Venezuela Central University UCV in 1990, specializing in CAGS. She earned an MS in Prosthodontics at Boston University in 1994 and a PhD at Santa Maria University, Venezuela in 2017. Dr. Pilar is currently the Chairwoman of the Master of Science in the dental implants program and an associate professor at Santa Maria University in Venezuela. She is also a full-time faculty at the Dr. Garg Implant Foundation in Santo Domingo, Dominican Republic in addition to being the President of the Venezuelan Branch of the International Dental Implant Association, IDIA, former Dean and Health Vice Chancellor at Santa Maria University in Venezuela, as well as President of the Venezuelan Prosthetic Society, Secretary of the Venezuelan Occlusal Society, and editor of the Journal of Implant Dentistry in the United States. Dr. del Pilar Ríos Calvo is author of several articles published in scientific journals an active member various scientific societies, and academies. Furthermore, she has been awarded for several research projects.

8 Implant practice

Volume 12 Number 4

CLINICAL • furcation repair (Figure 8) • grafting fill of defects on the lateral aspect of the ridge (Figure 9)

tissue using the patient’s own factors as that stimulating mechanism can be expected. The additional benefit is a gelatinous mass, termed “gummy bone,” that has improved handling without the dispersion issues found with graft particles mixed with saline or even allowed to absorb blood at the site (Figure 1). Gummy bone has a flexible putty-like consistency that can be cut to desired dimensions prior to placement and utilized in a variety of clinical graft situations, which include the following: • socket grafting (Figure 2) • filling voids around immediate implant placement (Figure 3) • lateral sinus augmentation (Figure 4) • crestal sinus augmentation (Figure 5) • lateral ridge expansion (Figure 6) • dehiscence repair at implant placement (Figure 7)

At the initiation of the surgical treatment, blood is drawn from the patient into red-top tubes. The red-top tubes are glass walled and contain no anticoagulant. These are then immediately centrifuged at 3,200 rpm for 3 minutes (about 600 gf) to create separation of the layers of the patient’s blood (Figure 10). Once centrifuging is complete, distinct layers present in the tube (Figure 11). For the purposes of creating gummy bone, the yellow layer, the plasma that is high in fibrin and platelets, will be used. The osseous graft particles that will be used are dispensed into a sterile dish

(Figure 12). The plasma liquid is withdrawn from the tube with a syringe and needle (Figure 13) and then dispensed into the dish containing the osseous graft material (Figure 14). This hydrates the dry graft particles and is allowed to sit for 10-12 minutes to coalesce into a gelatinous mass (Figure 15). Following the coalescence period, the gummy bone is formed and is ready for use (Figure 16). This does not need to be immediately used during the surgery and can sit in the dish until graft placement in the treatment process is ready. The gummy bone can be used as a single mass (Figure 17) when placing in large voids such as sinus augmentation or cut with scissors into smaller pieces (Figure 18) that can be incrementally placed into the surgical site. These pieces will adhere to each other when

Figure 1: The gummy bone has improved handling characteristics for placement in sites, eliminating the potential for particle dispersement during healing

Figure 2: Following extraction, gummy bone is placed into the socket for preservation of the site

Figure 3: Voids between the implant being placed and the extraction socket walls are filled with gummy bone prior to site closure

Figure 4: Gummy bone being placed into a lateral window sinus augmentation, allowing better placement against the medial, distal, and mesial walls of the elevated sinus

Figure 5: Gummy bone being introduced into the osteotomy where a crestal sinus elevation has been performed to increase the crestal height prior to implant insertion

Figure 6: Gummy bone being placed between the facial aspect of the ridge and the bone plate placed to widen the ridge to allow implant placement after healing

Figure 7: Placement of gummy bone over exposed implant threads at implant placement that will allow the osseous graft to remain where needed as the bone heals and prevent dispersement found when particulate graft is used alone

Figure 8: Placement of gummy bone into a furcation defect, allowing the graft to remain where placed and avoid dispersement potential typically observed with particulates rehydrated with saline

Figure 9: Placement of gummy bone to fill a defect in the anterior mandible apical to the existing teeth

10 Implant practice

Fabrication of “gummy bone”

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CLINICAL

Figure 10: Following phlebotomy, the patient’s blood is centrifuged at 3,200 rpm for 3 minutes (about 600 x gf)

Figure 11: Following centrifugation, the blood separates into several layers as outlined in the image above

Figure 13: The plasma (yellow liquid) is drawn out of the centrifuged tube with a syringe

Figure 14: The plasma is placed into the sterile dish containing the allograft particles

Figure 15: The plasma wets and rehydrates the allograft particles and is allowed to sit for 10-12 minutes before use

Figure 16: After 10-12 minutes, the fibrin within the plasma that had been mixed with the allograft particles forms a gelatinous mass referred to as “gummy bone”

Figure 17: Once the gummy bone is created, a gelatinous mass is formed that is easily carried to the desired site

Figure 18: The gummy bone can be cut into appropriately sized pieces depending on the clinical need

Fibrin from the autogenous blood concentrate has more favorable characteristics acting as “tissue glue” to hold the particulate graft into a pliable mass. This pliable material handles better, allowing easier shaping for the defect being treated with potential to increase width when needed that can not be easily accomplished with particulate bone when autogenous blood concentrates are not added. The added benefit of the platelets and associated growth factors stimulate angiogenesis, thus using the patient’s own systemic factors to aid in graft coalescence, organization, and maturation. Those practitioners, who are utilizing particulate graft materials in their treatment modalities, should consider incorporating autogenous blood concentrates like PRP to improve graft handling, eliminate particle dispersement during healing, and

stimulate regeneration via the growth factors that are now incorporated within the placed graft material. IP

they are placed into contact with each other or the surrounding tissues.

Conclusion As discussed, one of the main challenges to osseous grafting is handling of the graft materials during both placement and the initial healing period. Particle dispersement is not uncommon with particulate materials as when wetted by nonhematological liquids; this limits site blood from infusing into the graft placed initially, allowing dispersement to occur. Placing the dry particles into the site to be grafted, allowing blood from the surrounding tissues to wet it, also limits holding the mass together. There may be limited bleeding from the bone’s surface and not penetrate throughout the graft placed from bleeding at the soft tissue. 12 Implant practice

Figure 12: Allograft (cortical, cancellous, or a mixture of the two) are dispensed from the bottle into a sterile dish

REFERENCES 1. Knighton DR, Silver IA, Hunt TK. Regulation of woundhealing angiogenesis-effect of oxygen gradients and inspired oxygen concentration. Surgery. 1981;90(2):262-270. 2. Knighton DR, Hunt TK, Scheuenstuhl H, et al. Oxygen tension regulates the expression of angiogenesis factor by macrophages. Science. 1983;221(4617):1283-1285. 3. Marx RE, Johnson RP. Studies in the radiobiology of osteoradionecrosis and their clinical significance. Oral Surg Oral Med Oral Pathol. 1987;64(4):379-390. 4. Hunt TK. The physiology of wound healing. Ann Emerg Med. 1988;17(12):1265-1273. 5. Marx RE, Ehler WJ, Tayapongsak P, Pierce LW. Relationship of oxygen dose to angiogenesis induction in irradiated tissue. Am J Surg. 1990;160(5):519-524. 6. Knighton DR, Hunt TK, Thakral KK, Goodson WH 3rd. Role of platelets and fibrin in the healing sequence: an in vivo study of angiogenesis and collagen synthesis. Ann Surg. 1982;196(4):379-388. 7. Tayapongsak P, O’Brien DA, Monteiro CB, Arceo-Diaz LY. Autologous fibrin adhesive in mandibular reconstruction with particulate cancellous bone and marrow. J Oral Maxillofac Surg. 1994;52(2):161-165; discussion 166.

Volume 12 Number 4

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CASE STUDY

Preserving and perfecting the gingival emergence profile Dr. Todd Liston discusses an implant method that maintained soft tissue form and function and esthetics Introduction Dental implants have changed the face of dentistry as much as any other technology in the last century. Since the discovery of osseointegration and the development of the modern-day dental implant, millions of lives have been enhanced with the ability to chew food and to function in a way that was not previously available. Significant research and development have been undertaken to allow bone to integrate more quickly and effectively with the dental implant. Despite achieving this very high level of success, the predictability of maintaining and establishing ideal soft tissue emergence profile has been far from successful, resulting in less-thanacceptable esthetic outcomes.

Background Traditional implant soft tissue management has been with round healing cuffs/abutments, but there are ironically no round teeth. The importance of gingival tissue manipulation to establish an ideal emergence profile has been discussed for years, and many Todd Liston, DDS, MS, is the cofounder and CSO of GCL Systems and a practicing oral maxillofacial surgeon. He received his bachelor’s degree from Weber State University, his Doctor of Dental Surgery degree from Virginia Commonwealth University/Medical College of Virginia, and completed a 4-year oral and maxillofacial surgical residency training program at The Ohio State University. He also passed a thorough written qualifying examination and rigorous oral certifying examination to become board-certified as a Diplomate of the American Board of Oral and Maxillofacial Surgery. He has served as president of the Utah Association of the Oral and Maxillofacial Surgeons as well as participated on multiple national and state committees. He is currently serving as a member and past chair of the Utah Dentist and Dental Hygienist Board. He has lectured locally and nationally on numerous surgical subjects, especially implant dentistry. The Liston family has provided service here at home and throughout the world. They have been active for years in the development and perpetuation of a dental/medical clinic in Northern Mexico.

techniques have been proposed or developed, which have fallen short to predictably preserve and perfect gingival tissue. This has been due to their inability to provide the dentist with three key elements: adaptability, durability, and dependability. The Gingival Cuff Links System™ was developed to meet all three elements.

and at all stages of the implant process (immediate and delayed). In all cases, the Cuff Link was either customized as a healing cuff and/or a provisional crown.

Case 1 (Figures 1-10)

Each Gingival Cuff Link™ core abutment is made of titanium specifically designed to fit with the implant manufactures’ implant design. The Gingival Cuff Link™ body is made of bisacrylic resin — the same material from which many temporary dental restorations are fabricated — can be easily sculpted by reduction using dental rotary instrumentation or 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™ was used in hundreds of cases, in all areas of the mouth,

Advanced resorption of the root of tooth No. 8 with resultant significant mobility and discoloration. Removal of the tooth is done and the site addressed with immediate implant placement and provisionalization using the Cuff Links System. • Preoperative photos and X-rays of the tooth No. 8 • Removal of tooth and implant placement • Chairside fabrication of a provisional restoration using a Cuff Links healing cuff • Bone grafting the surgical site • Placement of a subepithelial connective tissue graft • Shade correction of the provisional 3 weeks after implant placement using a flowable composite veneer.

Figure 1: Resorption of tooth No. 8 root requiring removal

Figure 2: Pink hue of tooth No. 8. Notice the high smile line

Figure 3: Implant placed into the area of tooth No. 8

Figure 4: Seated Cuff Links healing cuff

Materials and methods

Esthetic reconstruction of areas of missing teeth has been a been a passion of Dr. Liston. This desire has led him to be instrumental in the innovation and development of the Gingival Cuff Links System™, which provides the dentist with the ability to preserve and perfect the way the gum tissue forms around the dental implant. Disclosure: Dr. Liston is the developer of Gingival Cuff Links System™.

14 Implant practice

Volume 12 Number 4

CASE STUDY

Figure 5: Cuff Links healing cuff seated with the buccal “T” handle and palatal guide handle removed

Figure 6: Fabrication of the provisional crown using the Cuff Links system

Figure 7: Healing at 4 months

Figure 8: Soft tissue at 4 months. Notice the preservation and enhancement of the gingival form

Figure 9: Soft tissue healing at 4 months. Notice the enhanced buccal soft tissue thickness

Figure 10: Two-year follow-up. Veneers were placed on all anterior teeth

Case 2 (Figures 11-18)

Results

Decay under the crown of tooth No. 19 and fractured root of tooth No. 20 rendered them non-restorable. Removal of the teeth was done; immediate implant placement was accomplished; and soft tissue was managed with custom gingival healing cuffs using the Gingival Cuff Links System.

Immediately placed implant soft tissue emergence profile was able to be maintained or enhanced in 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, gingival recontouring using flap procedures was necessary, resulting

in longer healing time and not always as predictable results as with the immediate implant protocol. When multiple implants were placed adjacent to one other, the ability to maintain the interproximal papilla was predictable with immediate implant and provisional crown or custom-healing cuff placement. In all situations, the results were substantially better for each

Figure 11: Radiograph of the carious tooth No. 19 and fractured tooth No. 20

Figure 12: Implant placement into sockets of teeth Nos. 19 and 20 with recontouring of the peripheral bone margins of implant site 19.

Figure 13: Gingival Cuff Links seated on the implants. Note that the “T” handle is aligned parallel with the buccal surface of the adjacent teeth, verifying the correct rotational implant placement for this internal hex system

16 Implant practice

Volume 12 Number 4

Conclusion

Figure 14: Gingival Cuff Links aligned with opposing dentition

Management of the implant soft tissue is possible and predictable if anatomic support is provided. The Gingival Cuff Links System™ is fully sculptable to provide not only soft tissue form and function, but also esthetics when indicated. Ultimately the following benefits are realized by the implant team: • Surgeon: the ability to preserve and perfect the soft tissue emergence form and function • Restorative Dentist: the precise soft tissue profile for the optimal esthetic restoration • Laboratory Technician: the ability to fabricate the ideal esthetic and functional restoration • Patient: the implant treatment desired and deserved IP

Figures 15 and 16: 15. Sculpting of implant No. 20 Gingival Cuff Links being done with a 703 surgical bur using a surgical handpiece. Note the pink flowable composite on the lingual aspect to aid in retaining anatomic orientation. 16. Application of flowable composite to the customized gingival healing cuff to obtain a final surface

Figures 17 and 18: Soft tissue healing and emergence profile preservation at 3 months post implant placement Volume 12 Number 4

Implant practice 17

CASE STUDY

member of the implant team (Surgeon, Restorative Dentist, Laboratory Technician, Patient) than using the traditional method of a round healing abutment.

TECHNOLOGY

Planning for success: reducing risks for peri-implant disease Dr. George A. Mandelaris discusses key tools to optimize positional accuracy and to avoid complications for patients with implants

eri-implant disease is quickly emerging as one of the most problematic inflammatory conditions in clinical practice. Depending on the study, the prevalence of peri-implant disease is anywhere between 2.7% to nearly 47%.1,2 Doctors understand that risk factors for peri-implant diseases include a history of periodontitis; poor plaque control; smoking; diabetes, and genetic factors such as a positive interleukin 1 gene polymorphism (Figure 1). Interestingly, Monje, et al.,3 reported on 36 clinical cases of anterior implant positioning from an esthetic point of view. The esthetic outcomes were scored by a panel of periodontists with more than 20 years of experience. It was concluded that nearly 41% of the implants evaluated were determined to be in “too buccal” of a position compared to the ideal. We have known for a long time that facial implant positioning influences esthetic outcomes, so this is nothing new. What is new is the thought that such an offaxis position may in fact be considered a “trigger” to peri-implant disease. In the right environment, facial implant positioning can lead to unfavorable crestal bone remodeling/loss and subsequent gingival recession, which can trigger peri-implantitis. Therefore,

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 a Fellow in both the American and International College of Dentists. Dr. Mandelaris has published over 30 scientific papers in peer-reviewed journals and has authored eight chapters in seven different textbooks on subjects related to computer-guided implantology, CT/CBCT diagnostics, and surgically facilitated orthodontic therapy (SFOT). He is one of the recipients of the 2017 American Academy of Periodontology’s (AAP) Clinical Research Award, and he is the 2018 recipient of the Saul Schluger Memorial Award for Clinical Excellence in Diagnosis and Treatment Planning. Disclosure: Dr. Mandelaris serves as a key opinion leader for Carestream Dental.

18 Implant practice

Figure 1: Advanced periodontitis

the dirty little secret, which hasn’t been historically published as a contributing factor in initiating or facilitating the process of peri-implant diseases, includes iatrogenic factors that can be prevented in the surgical setting — namely, the implant positioning. If that’s the case, cone beam computed tomography (CBCT), virtual planning, and guided surgery are key tools that can set up doctors and patients for success to optimize positional accuracy and to avoid complications.

CBCT imaging If cases of peri-implant disease are influenced by improper placement, then it’s safe to assume the first step in avoiding this complication is ideal placement. Optimal implant positioning, however, is the result of proper imaging, excellent treatment planning, ideal surgical execution, and proper prosthetic contours. Right from the start, three-dimensional imaging, such as what the CS 9600 CBCT system (Carestream Dental) (Figure 2) provides, can give doctors a better understanding of the extent and location of

Figure 2: CS 9600 CBCT system (Carestream Dental)

remaining bone, the position of vital structures, marrow quality and vascular potential, as well as other regional anatomy characteristics paramount for surgical planning. From there, the implant team can make better decisions regarding the timing, sequencing, and overall treatment-planning strategies (surgical and prosthetic) to reduce the incidence of peri-implant disease. Alternatively, Volume 12 Number 4

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TECHNOLOGY when peri-implant disease is diagnosed, CBCT imaging can help plan surgery to resolve the disease, to regenerate hard/ soft tissue structures, or to finalize strategies when/how implants should be removed and replaced.

Prosthetically directed virtual planning Although it’s becoming best practice to use CBCT when planning implants, most are still placed freehand. A CBCT scan may guide a doctor’s planning, but there are different factors on the day of surgery that can affect the placement. Therefore, once a 3D scan is captured, prosthetic-driven implant planning (PDIP), such as what can be accomplished with the Prosthetic-Driven Implant Planning Module (Carestream Dental), should make ideal treatment outcomes even more predictable. The key tenet of PDIP is ensuring implants are positioned in the ideal prosthetically directed position as possible. (Figure 3). Depending on how the prosthetics are planned, this infers an emergence trajectory through the cingulum so that a screwretained prosthesis can be accommodated. PDIP optimizes conditions so that modifiable triggers that happen iatrogenically, such as implants being positioned with too facial of an axial inclination, are negated as best as possible.

Figure 3: Prosthetically directed virtual planning

Surgical guides and dynamic surgical navigation Finally, doctors should implement their virtual plan on the day of placement with the aid of either computer-generated surgical guides or via the use of dynamic surgical navigation technology to optimize positional accuracy. Adopting guided-surgery protocols and/or dynamic surgical navigation — which allows for real-time verification and validation of positional accuracy and on-the-spot surgical transparency — can ensure that implants are placed in the best prosthetically directed position possible minimizing esthetic or peri-implant related complications (Figures 4A-4D). Even with today’s advantage of advanced digital technology for our patients, there is no substitute for an accurate diagnosis, well thought-out interdisciplinary treatment plan, and clinical expertise to deliver optimal results. Furthermore, instituting regular implant maintenance protocols in the post-restorative phase of treatment is more important than ever before. Properly contoured prosthetic restorations, high levels of self-performed plaque 20 Implant practice

Figures 4A-4D: A. Prosthetically directed implant planning using dynamic navigation software program (Navident). B. Trace registration technology (no fiducial) used in dynamic navigation surgery (Navident) to register regional anatomy to DICOM data set. C. Dynamic Navigation implant surgery (Navident) showing headtracker utilization for patient registration and drill tag in use. D. Target screen shown during dynamic navigation surgery. Real-time verification and validation of positional accuracy during implant surgery

control by patients, and critical scrutiny in evaluating the key indices of inflammation by dental professionals at every visit are the basic principles that must not be compromised to ensure our patients enjoy long term peri-implant health. With today’s population living longer and wanting to enjoy function and esthetics longer — i.e., maintaining a healthy smile, being able to eat the foods they want, etc. — the utilization of dental implants is on the rise. Through 3D imaging, proper planning, and thoughtful execution, doctors

can do their part to ensure that the incidence of peri-implant diseases doesn’t rise as well. IP REFERENCES 1. Lee CT, Huang YW, Zhu L, Weltman R. Prevalence’s of peri-implantitis and peri-implant mucositus: systematic review and meta-analysis. J Dent. 2017;62:1-12. 2. Monje A, Aranda L, Diaz KT, et al. Impact of maintenance therapy for the prevention of peri-implant diseases: a systematic review and meta-analysis. J Dent Res. 2016;95(4):372-379. 3. Monje A, Galindo-Moreno P, Canullo L, Greenwell H, Wang HL. Editorial: From early physiological marginal bone loss to peri-implant disease: on the unknown local contributing factors. Int J Periodontics Restorative Dent. 2015;35(6):764-765.

Volume 12 Number 4

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CONTINUING EDUCATION

Managing the transition to an implant-supported dentition Dr. Dipesh Parmar details a case where the patient’s need to avoid a denture shaped the progression of treatment

n pursuit of esthetic and functional perfection, clinicians often fail to see beyond these goals and fully appreciate the psychological impact that the removal of teeth has on our patients. The following case demonstrates how dental implants can be used to restore edentulous arches. The case is about not only the rehabilitation of a patient’s dentition, but also the management of her reluctance to lose her remaining teeth, the building of rapport and trust, the management of expectations, and ultimately, the restoration of a person’s confidence and ability to socially re-engage. The implant surgery and immediate prosthetic work was carried out by Dr. Manoj Parmar. The work related to the definitive prostheses was undertaken by Dr. Dipesh Parmar.

History and examination A 59-year-old retired teacher attended the practice, expressing her unhappiness with the appearance of her teeth and the psychosocial effect it was having on her. Eating was becoming increasingly difficult due to the lack of opposing teeth and the advanced mobility of the remaining units. Due to embarrassment, she had not visited a dentist for more than 5 years; however, the extreme lack of self-confidence eventually forced her to get her concerns addressed. She complained of no pain or discomfort from her teeth. Medically, she suffered from mild asthma that was controlled with salbutamol. No allergies were recorded. She was a nonsmoker,

Dipesh Parmar, BDS, graduated from the University of Birmingham (UK), obtaining numerous prizes and practices in Birmingham and focusing on minimally invasive esthetic reconstructions and orthodontic treatment. He has held a clinical lecturer teaching post at Birmingham Dental School and has won multiple awards at the UK Aesthetic Dentistry Awards, including Best Aesthetic Dentist UK 2018. He lectures at an international level on direct resin restorations. He has been awarded Diplomate status in orthodontic dentistry from the University of Warwick.

22 Implant practice

Educational aims and objectives

This clinical article aims to present a case study where the patient’s desire to avoid wearing a temporary denture formed a fundamental part of the treatment-planning process.

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: •

See diagnosis and treatment of a patient who was reluctant to wear dentures that resulted in effective but flexible treatment planning.

•

Note how the patient’s esthetic analysis affected treatment.

•

Identify some special tests that were conducted to help deduce the diagnoses.

•

Realize the role of CBCT imaging in diagnosis and treatment planning.

•

Recognize several post-extraction treatment options for this patient.

and her alcohol intake was minimal. Family history revealed early loss of teeth of teeth on her maternal side of the family. A diet history highlighted frequent sugar intake. Extraoral examination revealed nothing abnormal. Intraorally, the soft tissues were healthy. Her oral hygiene was graded as poor with evidence of generalized biofilm deposits and associated gingival inflammation and suppuration. She presented with medium-to-thick gingival biotype, and the BPE was recorded as 444/-44. Occlusal analysis proved to be difficult due to numerous missing units and the effects of the periodontitis on the remaining dentition. However, she presented with a Class II Division I incisor relationship on a Class I skeletal base. Due to the lack of teeth, lateral excursive movements had no alternative but to be canine-guided. Centric occlusion was not coincident with centric relation with the first contact between teeth 26 and 35. Most likely attributed to the lack of posterior support, she presented with an increased overjet and an increased and complete overbite. She had no history of parafunction; however, mobility and fremitus were present on all teeth. Esthetic analysis highlighted the following: • Midlines — unacceptable. Dental midline shifted to left

• Lip line — high • Smile line — discontinuous • Incisal edge position — central incisors and canines within normal limits. Lateral incisors unacceptable • Buccal corridor —unacceptable • Central incisor dimensions — acceptable (clinical crown only, roots excluded) • Tooth-to-tooth proportions — acceptable • Axial inclinations — unacceptable • Gingival esthetics — unacceptable due to effects of periodontitis • Connector heights — unacceptable • Embrasure form — unacceptable • Labial anatomy — within normal limits • Color — unacceptable

Special tests

The following special tests were conducted to help deduce diagnoses: Full-mouth detailed pocket charting was carried out, with bleeding indices, plaque indices, and mobility grading. All teeth scored either Grade 2 or 3 mobility. Thermal and cold pulp tests were carried out. Teeth UR6, UL3, UL6, LL4, and LL5 tested negatively. Percussion tests were also applied. Teeth UR6, UL3, UL6, LL4, and LL5 tested tender Volume 12 Number 4

Diagnoses Following thorough clinical and radiographic assessment, coupled with multiple special investigations, the following diagnoses were made: • Advanced generalized chronic periodontitis affecting all units • UR6 and UL6 — Asymptomatic perio-endo lesions with evidence of gross caries • LL4 and LL5 — Asymptomatic perioendo lesions • UL3 — Lost restoration and distal caries • UL7 — retained root remnant • Multiple missing units with resultant loss of function • Compromised esthetics

Treatment objectives and options The main objective of dental treatment for this patient was to re-establish form, function, and esthetics of her masticatory system. In addition, it was imperative to motivate the patient to improve her oral hygiene and rebuild her self-confidence and faith in dentistry. It was evident that the remaining teeth had very poor prognosis, and the most appropriate treatment plan to fulfil the objectives was full-mouth clearance followed by fixed or removable prostheses. The following post-extraction treatment options were discussed with the patient. Removable prostheses • Acrylic (with or without cobalt chrome) tissue-borne prostheses • Implant-supported overdentures Fixed prosthesis • Hybrid bridge on four or more implants (immediate or delayed loading) • Ceramic-metal bridge(s) on six or more implants The patient’s initial wishes were to have a fixed maxillary implant-retained ceramicmetal bridge and a conventional mandibular acrylic prosthesis. She wanted to achieve the best esthetic outcome in the upper arch and, due to the financial implications of this, was happy to accept a compromise solution for the lower arch. Further discussions took place regarding the use of dissimilar materials in opposing arches and that the full benefits of having a

fixed solution in the upper arch could not be attained while having a conventional prosthesis in the lower arch.

Planning Following detailed discussion, enhanced by the use of previous case studies, it was decided with the patient that the most appropriate plan would be extraction of the remaining teeth with provision of immediate replacement dentures (IRDs). This would be followed by a maxillary implant-retained hybrid bridge on four implants and a mandibular implant-supported overdenture on two implants.

Treatment Phase 1: Lower-arch clearance For the purposes of mental conditioning, it was planned to treat each arch separately starting with the lower at the patient’s request. Measurements were taken for the construction of a lower complete denture, which was fitted at the final visit immediately after the removal of all mandibular teeth. The granulation tissue from all the sockets was also curetted to facilitate optimal healing.

Figures 1-7: Patient at presentation Volume 12 Number 4

Implant practice 23

CONTINUING EDUCATION

to percussion in the apical direction. All other teeth responded positive to lateral percussion tests. Periapical radiographs were taken of the lower teeth to assess bone levels and apical pathology. Radiographic assessment highlighted 80%-100% bone loss on all mandibular teeth with evidence of vertical and crescentic bone loss patterns. Apical pathology was noted on UR6, UL3, UL6, LL1, LL4, LL5, and LR1. A maxillary CBCT scan was taken by the implant surgeon to allow assessment for implant treatment. The full series of British Academy of Cosmetic Dentistry (BACD)-recommended clinical photographs were taken. Figures 1-7 show a selection of these.

CONTINUING EDUCATION

Figure 8: A denture was created that could be converted into a temporary implant bridge or used as an immediate replacement denture

Figure 9: The implants were placed using a standard surgical technique following the Malo protocol

Figure 10: The denture was transferred to the mouth to check the position of the implants

Figure 11: Biomaterials were used to fill any remaining sockets, and the flap was sutured shut

Figure 12: Implants in the upper jaw were allowed to integrate for 3 months before the bridge was removed for impressions

Figure 13: A master abutment-level open tray impression was taken of the upper arch using monophase and light-bodied PVS impression materials

Figure 14: A verification jig was used to confirm the accuracy of the upper master impression

Figure 15: The jig did not seat fully

Figure 16: The rim was sectioned to allow passive seating of the two parts before being rejoined

At the follow-up appointments, the patient expressed her discontent with the poor retention and stability of the lower prosthesis, despite its relining with tissue conditioners. This reinforced not only the decision to have an implant-supported denture for the lower arch, but also her desire not to go through same process for the upper arch.

1. Patient to undergo hygiene therapy to remove all plaque deposits, arrest active disease, and reduce periodontal inflammation. 2. Take a CBCT scan of the upper arch with a radiographic stent to assess bone levels for implant planning. 3. Remove any teeth that were infected or unsavable. 4. Construct an upper full denture that would be converted into a temporary implant bridge or used as an IRD if immediate loading was not possible (Figure 8). 5. Create a copy of the denture in clear acrylic to be used as a surgical guide. The CBCT revealed that there was sufficient bone for the placement of four implants. Arrangements were then made for the extraction of the UL3 due to advanced apical pathology, followed by impressions

to begin the construction of the upper complete IRD. To reduce the risk of accidental extraction of the incisors while taking impressions, the teeth were splinted using flowable composite, and the embrasures were occluded using temporary inlay material, which was subsequently easily removed. The periodontal treatment reduced the inflammation of the gingivae. Once the dentures were fabricated, the next phase was surgery. The complete denture was made to full sulcus depth and full palatal coverage to allow seating once the teeth were removed. However, the flanges were hollowed-out apical to the teeth to facilitate easier removal of the flange when converting the denture to a bridge. The surgical stent mirrored the design of the denture with the addition of a channel cutout along the occlusal surfaces of the

Phase 2: Upper-arch planning and treatment In order to respect the patientâ&#x20AC;&#x2122;s decision not to have a clearance and an IRD, the treatment plan had to be revised. Although still in agreement for the definitive prosthesis to be a hybrid bridge, the only way to avoid an IRD was to extract the teeth, place the implants, and immediately load with a temporary bridge all on the same day. To enable us to do this, the following plan was created: 24 Implant practice

Volume 12 Number 4

anterior wall of the maxillary sinus was not violated. Once the implants were placed, angled abutments were placed on top and adjusted to make all four emergence profiles as parallel as possible while still being within the prosthetic envelope. Once positions were confirmed, the abutments were torqued to 35 Ncm as recommended by the implant system. Two 30° angled abutments were used for the posterior implants, and two 15° angled abutments were used for the anterior implants. The denture was lined with red beading wax on the fit surface. It was then transferred in to the mouth and seated until the abutments indented the wax indicating the position of the implants (Figure 10). Holes were then cut in the denture in these positions. Temporary metal cylinders were attached to the abutments and the fit of the denture checked over them. Biomaterials were used to fill any remaining sockets and voids in the bone with subsequent closure of the flap with 4.0 Vicryl® (Ethicon®) sutures (Figure 11). Cold-cured chairside acrylic was used to tack the denture onto the temporary cylinders. The cylinders were then unscrewed from the abutments and removed with the denture, which was sent to the lab with the lower denture and bite registration for finishing and conversion into a temporary bridge. Healing caps were placed over the abutments while the bridge was being prepared at the laboratory.

When the bridge was returned, the healing caps were removed and the temporary bridge was seated and torqued down to finger pressure. Access holes were occluded with PFTE tape and temporary inlay material. The final occlusion was checked and adjustments made to ensure evenly distributed contacts conforming to the appropriate occlusal scheme. The patient was reviewed a week later with evidence of healing. The bridge was removed along with remaining sutures. The prosthesis was cleaned, and the patient was provided with a water flosser to help with hygiene.

Figure 17: A cast metal framework was constructed

Figures 18: A passive fit was confirmed

Figures 19: A second try-in was conducted after the first showed the teeth were too short, built onto the metal framework for more thorough assessment

Phase 3: Lower-arch implant placement Approximately a month after the upperarch surgery, the patient was invited back to have two implants placed in the lower arch. Following local anesthesia, two individual flaps were raised to allow implant placement. Holes were cut in the denture, which in turn was used as a surgical guide to help make the osteotomies in the correct positions and angulation. Cover screws were placed and the flap closed to allow submerged healing. The patient continued to wear the lower denture during the healing period. Phase 4: Final prosthesis A period of 3 months was allowed for complete integration of the implants before continuing with the prosthetic phase of the treatment. The lower implants were exposed and the cover screws replaced with healing

Figures 20-22: Final prosthesis Volume 12 Number 4

Implant practice 25

CONTINUING EDUCATION

teeth to set the prosthetic profile within which the implants would be placed. It was stressed to the patient that in the event that primary stability was not achieved, she would need to wear the full denture until osseointegration was optimal. Following local anesthesia, the remaining upper teeth were separated and extracted. The denture was tried in and checked for fit, following which occlusion was checked against the lower denture and adjusted accordingly. The transition zone between the prosthesis and the gingivae was checked, albeit with difficulty due to the anesthesia. A crestal incision was made approximately from UR6 to UL6 with small relieving incisions at either end. A full thickness flap was raised to expose the ridge. Sufficient ridge width was present as predicted from the CBCT. A large round bur was used to flatten the ridge, which also would move the transition line further apically, allowing it to be better hidden by the upper lip. The extraction sockets were thoroughly curetted. A pilot osteotomy was made in the midline to facilitate the positioning of the Malo implant guide that facilitates the placement of the implant at the correct angulation. The surgical guide was repeatedly located to ensure that implants were placed within the prosthetic envelope. The implants were placed using a standard surgical technique following the Malo protocol (Figure 9). Peri-treatment periapical radiographs were taken to ensure the

CONTINUING EDUCATION abutments. The upper bridge was removed (Figure 12), followed by upper and lower primary impressions for fabrication of custom acrylic trays. The bridge was then replaced following retorquing of the abutments. A master abutment-level open tray impression was taken of the upper arch using monophase and light-bodied PVS impression materials (Figure 13). A lower implant-level master impression was taken in heavy-bodied and light-bodied PVS impression materials. The increased viscosity of the silicone putty allows for a muco-displacing impression to be taken, which in turn would result in a snug fit of the overdenture to the ridge. Wax occlusal registration rims were used to record centric relation at the desired vertical dimension as per conventional full denture construction, followed by a facebow transfer. A verification jig was used to confirm the accuracy of the upper master impression (Figures 14-16). The verification jig did not seat fully; thus, the rim was sectioned close to the implant where the discrepancy was, which allowed passive seating of the two parts. These were then rejoined using acrylic resin and returned to the lab for repositioning of the analogue on the master cast. A cast metal framework was constructed (Figure 17) and tried intraorally with a passive fit being confirmed (Figure 18) as it was on the model. A try-in of both upper and lower prostheses was undertaken, and the teeth proved to be too short. The patient also requested more irregularity in the positioning of the teeth. A second try-in with longer teeth was conducted (Figure 19); however, on this occasion the try-in was built onto the metal framework to allow accurate assessment of the occlusion, esthetics, and phonetics. The position of the transitional line was also evaluated and confirmed not to be visible when the patient force-smiles. The patient consented to progress to the definitive restorations (Figures 21-22). The temporary prostheses were removed, and the final bridge was fitted with access holes sealed with polytetrafluoroethylene (PTFE) tape and composite resin. Kerator® abutments were placed onto the lower implants, and the matrices were cold-cured into the lower denture. Written and verbal implant maintenance advice was provided to the patient. Figures 23 to 27 show the final result.

Conclusion Full-mouth clearance cases can be extremely challenging, not only in terms of 26 Implant practice

Figures 23-27: Final result

the surgical and restorative skills required to rehabilitate the patient, but also the management of patient expectations to deliver a result that exceeds the patient’s expectations as opposed to falling short of them. This was a truly rewarding case for the clinician but a life-changing one for the patient. IP

REFERENCES 1. Thomason JM, Feine J, Exley C, et al. Mandibular two implant-supported overdentures as the first choice standard of care for edentulous patients — the York Consensus Statement. Br Dent J. 2009;207(4):185-186. 2. Chee W, Jivraj S. Treatment planning of the edentulous mandible. Br Dent J. 2006;201(6).:337-347.

5. Del Fabbio M, Bellini CM, Romeo D, Francetti L. Tilted implants for the rehabilitation of edentulous jaws: a systematic review. Clin Implant Dent Relat Res. 2012;14(4):612-621. 6. Gallucci GO, Benic GI, Eckert SE, et al. Consensus statements and clinical recommendations for implant loading protocols. Int J Oral Maxillofac Implants. 2014; 29(suppl):287-290. 7. Jivraj S, Chee W. Transitioning patients from teeth to implants. Br Dent J. 2006;201(11):699-708. 8. Jivraj S, Chee W, Corrado P. Treatment planning of the edentulous maxilla. Br Dent J. 2006;201(5):261-279. 9. Malo P, Rangert B, Nobre M. All-on-4 immediate function concept with Brånemark System implants for completely edentulous maxillae: a 1-year retrospective clinical study. Clin Implant Dent Relat Res. 2005;7(suppl):S88-S94. 10. Malo P, de Araújo Nobre M, Lopes A, Francischone C, Rigolizzo M. “All-on-4” immediate-function concept for the completely edentulous maxillae; a clinical report on the medium (3 years) and long-term (5 years) outcomes. Clin Implant Dent Relat Res. 2012;14(suppl 1):e239-e150.

3. Chiapasco M. Early and immediate restoration and loading of implants in completely edentulous patients. Int J Oral Maxillofac Implants. 2004;19(suppl):76-91.

11. Schimmel M, Srinivasan M, Herrmann FR, Müller F. Loading protocols for implant-supported overdentures in the edentulous jaw: a systematic review and meta-analysis. Int J Oral Maxillofac Implants. 2014;29(suppl):271-286.

4. Crespi R, Vinci R, Capparé P, Romanos GE, Gherlone E. A clinical study of edentulous patients rehabilitated according to the “all on four” immediate function protocol. Int J Oral Maxillofac Implants. 2012;27(2):428-434.

12. Stoker GT, Wismeijer D. Immediate loading of two implants with a mandibular implant-retained overdenture: a new treatment protocol. Clin Implant Dent Relat Res. 2011;13(4):255-261.

Volume 12 Number 4

REF: IP V12.4 PARMAR

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.

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Managing the transition to an implant-supported dentition PARMAR

1. (For this patient, for the Phase 2 treatment in upper arch planning and treatment) The patient was to undergo hygiene therapy to __________. a. remove all plaque deposits b. arrest active disease c. reduce periodontal inflammation d. all of the above 2. (For this patient, for the Phase 2 treatment in upper arch planning and treatment the imaging plan was to) Take a ______ of the upper arch with a radiographic stent to assess bone levels for implant planning. a. 2D digital radiograph b. panoramic X-ray c. CBCT scan d. transilluminated image 3. (For this patient) The implants were placed using a standard surgical technique following the ________. a. Malo protocol b. Dhal protocol c. Linkow protocol d. Lew protocol 4. (For this patient) Once positions were confirmed, the abutments were torqued to _______ as recommended by the implant system.

Volume 12 Number 4

a. b. c. d. 5.

25 Ncm 35 Ncm 40 Ncm 45 Ncm

Two 30° angled abutments were used for the posterior implants, and _______ angled abutments were used for the anterior implants. a. two 30° b. two 15° c. one 15° and one 30° d. two 20°

6. (At the conclusion of Phase 2) The prosthesis was cleaned, and the patient was provided with a _________ to help with hygiene. a. soft toothbrush b. hard toothbrush c. water flosser d. conventional waxed floss 7. (To begin Phase 3) Approximately _________ after the upper arch surgery, the patient was invited back to have two implants placed in the lower arch. a. 2 weeks b. 1 month c. 6 weeks d. 2 months

8. (To begin Phase 4) A period of ________ was allowed for complete integration of the implants before continuing with the prosthetic phase of the treatment. a. 2 weeks b. 1 month c. 2 months d. 3 months 9. (During Phase 4) A master abutment-level open tray impression was taken of the upper arch using ________ impression materials. a. monophase and light-bodied PVS b. heavy-bodied and light-bodied PVS c. monophase and heavy bodied PVS d. alginate 10. Full-mouth clearance cases can be extremely challenging, in terms of _________. a. the surgical skills required to rehabilitate the patient b. the restorative skills required to rehabilitate the patient c. the management of patient expectations to deliver a result that exceeds the patient’s expectations as opposed to falling short of them d. all of the above

Implant practice 27

CE CREDITS

IMPLANT PRACTICE CE

CONTINUING EDUCATION

Peri-implantitis: cure and prevention Drs. Ashok Sethi, Thomas Kaus, and Naresh Sharma examine risk factors and management of this increasingly prevalent condition

rapid increase in the incidence of peri-implantitis has been reported. Prevalences up to 56% at patient level have been reported for periodontitis susceptible patients (Donos, et al., 2012; Heitz-Mayfield, et al., 2014; Monje, et al., 2016). However, incidences as low as 1% at implant level have also been reported (Monje, et al., 2016). This clearly indicates that there are various risk factors that influence the incidence of peri-implantitis. These factors include known risk factors that predispose to periodontal disease such as poor oral hygiene, smoking, genetic susceptibility, and diabetes. Other factors may be considered iatrogenic such as poor implant placement where the implant is not wholly submerged in bone. Other factors may be related to the implant. Modern implants are now produced with a rough surface to encourage contact osteogenesis (Figure 1) — in other words, direct deposition of bone by osteoblasts onto the implant surface (Davies 1998). This has considerable advantages such as rapid integration permitting reduced healing times and higher success rates. However, if the implant surface is exposed to bacteria, colonization and formation of biofilms are more likely to lead to peri-implantitis. Other factors influencing the presence of bacteria in the peri-implant sulcus are determined by the leakage of bacteria from the abutment implant connection as well as the space between the prosthesis and the abutment. This is especially the case for

Educational aims and objectives

This clinical article aims to discuss some of the risk factors and preventative measures for peri-implant disease.

Expected outcomes

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

Understand how careful treatment planning can minimize the occurrence of peri-implantitis.

•

Recognize some strategies for treatment of the disease.

•

Realize some of the reasons for resective treatment.

•

Identify some characteristics of the ideal implant surface and how to achieve those goals.

•

Identify some essential features of the implant abutment connection for a positive implant protocol.

Ashok Sethi, BDS, DGDP, MGDS (RCS Eng), FFGDP, DUI (Lille) is a specialist in oral surgery and prosthodontics. Thomas Kaus, Dr. med dent (Germany), Dip Implant Dent (RCS Eng). Naresh Sharma, BChD, MGDS, RCS (ENG) M. Surg. Dent. F.F.G.D.P. (UK), has a Diploma In Implant Dentistry RCS (Eng) and is a specialist in oral surgery. Disclosure: The authors conceived and taught the Diploma in Implant Dentistry at the Royal College of Surgeons, and have now set up PID Academy (www.PID-Academy.org) where clinical facilities are available, which are fundamental for training sound and competent clinicians.

28 Implant practice

Figure 1: Scanning electron microscopic (SEM) image a rough implant surface with osteoblasts in direct contact permitting direct bone deposition (contact osteogenesis)

screw-retained prostheses (Cosyn, et al., 2011; Gross, et al., 1999). The conical connection, however, is reported to be tight enough to prevent bacterial contamination (Figure 2) (Mairgunther and Nentwig, 1992; Sethi and Kaus, 2002).

Treatment of peri-implantitis A broad range of therapies have been put forward for the treatment of peri-implantitis. They essentially involve the removal of the biofilm and subsequent maintenance of the area with adequate oral hygiene Volume 12 Number 4

protocols. The decision-making process will involve factors such as level of bone loss and the implant location. Three strategies are normally considered. Resective treatment Resective treatment involves the removal of the bacterial biofilm as well as any infected surrounding soft tissues. Some form of implant surface modification to remove any rough surfaces and/or threads is also deemed necessary (referred to as an implantoplasty). The aim of this is to re-establish direct soft tissue contact onto the implant surface. The disadvantage of this technique is exposure of the implant or abutment, which may prove to be an issue in the esthetic zone. Regenerative therapy Regenerative therapy is considered when the defect morphology permits it. Hard tissue regeneration may be attempted, which is fraught with the risk of recurrence and is challenging, often requiring the covering of the implant during the healing phase. Retreatment In circumstances where excessive bone loss has taken place and is progressive, retreatment may be considered. It is essential to identify the cause of the peri-implantitis prior to considering retreatment. This is most likely to involve bone grafting.

Prevention of peri-implantitis There are a few general considerations regarding the successful prevention of periimplantitis. From the outset, it is clear that all the systemic factors need to be favorable. Volume 12 Number 4

Figure 3: SEM image of a titanium surface with hemidesmosomal soft tissue attachment

In the case of immediate implants, the rough surface permits the direct attachment of bone to the implant within the extraction socket where the blood clot has been contained. The treatment of periodontal disease prior to implant therapy is therefore prudent. Ideally the removal of all sources of contamination should be implemented. Predisposing factors such as smoking should also be brought under control. Susceptible patients should be informed and be aware of the risks and willing to maintain a high degree of hygiene. However, specific strategies also exist for the prevention of the disease. These strategies should be aimed at creating an environment where the risk of implant infection is reduced. They relate to choice of technique, implant/ component features, and design of the restoration. Implant The ideal implant surface has been determined to be a rough surface to promote contact osteogenesis. Surgical strategy, therefore, should be aimed at positioning the rough implant surface below the crestal bone to permit bone to grow over it, minimizing the risk of bacterial contamination. This, therefore, has to be coupled with components that prevent

the harboring of bacteria at the implant-abutment junction. It should be clear that the implant should be placed within healthy bone, which may have been reconstructed. In the case of immediate implants, the rough surface permits the direct attachment of bone to the implant within the extraction socket where the blood clot has been contained. Abutment The essential feature of the implant abutment connection is to be tight enough to prevent leakage. It should also be stable under functional load to avoid deformation and therefore leakage. The feature, which has been well tried in the engineering world and borne out by scientific investigation, is the tapered or conical connection. Therefore this non-indexed connection can be fabricated to a high degree of accuracy by a lathe and be produced to an accuracy that prevents microleakage. It has been suggested that the attachment of the abutment at the time the permucosal entry is created may be of benefit. This means that the definitive abutment is Implant practice 29

CONTINUING EDUCATION

Figure 2: SEM image of a cross section through the implant and abutment showing no gap, thus preventing microleakage (Ankylos implant system, Dentsply Sirona)

CONTINUING EDUCATION attached at the time of implant placement in the case of an immediate implant. If a staged approach is used, then the abutment is attached at the time of implant exposure. The aim is to establish a hemidesmosomal connection between the abutment surface and the surrounding soft tissues (Figure 3). The protocol outlined above would therefore provide two levels of protection â&#x20AC;&#x201D; the bone over the implant and the direct connection of the soft tissue to the abutment (Figure 4-6). Type of restoration The design of the restoration should be such that access for cleaning is provided. Overhangs and large, adversely contoured flanges should be avoided. The ideal material to penetrate the soft tissues must be biocompatible (either titanium or zirconium oxide). This is often compromised in the esthetic zone by having an intra-sulcular margin to establish the ideal esthetic emergence profile. Screw-retained restorations have the disadvantage of leakage as a result of the inherent space between the component parts. Cement retention eliminates this but adds the additional risk of excess cement being intruded below the gingival margin when an intra-sulcular margin is required for esthetic purposes. The introduction of conical retention, eliminating cement and screws, promises to offer a solution and will be verified as time goes on.

Figure 4: Periapical radiograph taken immediately postoperatively of an Ankylos implant placed immediately into the extraction socket with the definitive abutment (zirconium oxide) in situ. Note the subcrestal placement of the implantabutment connection and the extraction socket. Subcrestal placement can only be recommended if a tight, conical, microleakage-free connection is present

Figure 5: Postoperative radiograph taken 4 years after placement. A close adaptation of the soft tissues by hemidesmosomal attachment to the zirconium oxide abutment prevents bacterial infiltration offering a primary line of defense against peri-implantitis. Note the growth of bone over the implant. This provides a secondary line of defense against peri-implantitis. This is only possible if there is no microleakage between the implant and the abutment

Conclusion Implant treatment is often the choice for the replacement of missing or failing teeth. High success rates have been reported, and the recent observations of an increased rate of peri-implant disease must be addressed. Proper understanding of the biology of healing is fundamental to safe practice of implant dentistry. Appropriate training in this field is essential. The protocols outlined are considered fundamental to achieving longterm stability. IP

Figure 6: Four-year postoperative clinical view demonstrating healthy peri-implant tissues

REFERENCES 1. Cosyn J, Van Aelst L, Collaert B, Persson GR, De Bruyn H. The peri-implant sulcus compared with internal implant and suprastructure components: a microbiological analysis. Clin Implant Dent Relat Res. 2011;13(4):286-295. 2. Davies JE. Mechanisms of endosseous integration. Int J Prosthodont. 1998;11(5):391-401. 3. Doos N, Laurell L, Mardas N. Hierarchical decisions on teeth vs. implants in the periodontitis-susceptible patient: the modern dilemma. Periodontol 2000. 2012;59(1): 89-110. 4. Gross M, Abramovich I, Weiss EI. Microleakage at the abutment-implant interface of osseointegrated implants: a comparative study. Int J Oral Maxillofac Implants. 1999;14(1):94-100. 5. Heitz-Mayfield LJ, Needleman I, Salvi GE, Pjetursson BE. Consensus statements and clinical recommendations for prevention and management of biologic and technical implant complications. Int J Oral Maxillofac Implants. 2014;29(suppl):346-350. 6. MairgĂźnther R, Nentwig GH. Das Dichtigkeitsverhalten des Verbindungssystems beim zweiphasigen NM-Implantat. [The tightness behavior of the connection system of the 2-phase Ankylos implant]. Z ZahnĂ¤rztl Implantol. 1992;8:50-53. 7. Monje A, Aranda L, Diaz KT, et al. Impact of Maintenance Therapy for the Prevention of Peri-implant Diseases: A Systematic Review and Meta-analysis. J Dent Res. 2016;95(4):372-379. 8. Sethi A, Kaus T. An implant that does not smell - The Ankylos Implant. Irish Dentist. July 2002.

30 Implant practice

Volume 12 Number 4

REF: IP V12.4 SETHI/KAUS/SHARMA

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

TELEPHONE/FAX

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

Peri-implantitis: cure and prevention SETHI/KAUS/SHARMA

1. Factors (that influence the incidence of periimplantitis) include known risk factors that predispose to periodontal disease such as ________ and diabetes. a. poor oral hygiene b. smoking c. genetic susceptibility d. all of the above 2. This (the surface of modern implants) has considerable advantages such as rapid integration permitting ________ and higher success rates. a. reduced healing times b. elongated healing times c. formation of biofilm d. complete elimination of healing time 3. If the implant surface is exposed to bacteria, ______ is/are more likely to lead to peri-implantitis. a. use of a conical connection b. colonization and formation of biofilms c. removal of biofilm d. direct soft tissue contact 4. The decision-making process (to decide upon which therapy to apply for the treatment of periimplantitis) involves factors such as _______.

Volume 12 Number 4

a. b. c. d.

level of bone loss implant location the patientâ&#x20AC;&#x2122;s ability to pay for extra services both a and b

5. ________ involves the removal of the bacterial biofilm as well as any infected surrounding soft tissues. a. Regeneration b. Hemidermal treatment c. Resective treatment d. Tissue-plasty 6. (During resective treatment) Some form of implant surface modification to _______ is also deemed necessary (referred to as an implantoplasty). a. roughen the surface and/or threads b. avoid direct soft tissue contact onto the implant surface c. remove any rough surfaces and/or threads d. loosen the abutment connection 7. The aim of resective treatment is to ________. a. re-establish direct soft tissue contact onto the implant surface b. avoid direct soft tissue contact onto the implant surface

c. ensure no issues occur in the esthetic zone d. avoid the need for a high level of hygiene 8. (Since the treatment of periodontal disease prior to implant therapy is prudent, and ideally the removal of all sources of contamination should be implemented) Predisposing factors such as _______ should also be brought under control. a. drinking through a straw b. smoking c. eating citrus fruits d. chewing ice 9. The ideal implant surface has been determined to be _______ to promote contact osteogenesis. a. a smooth surface b. a rough surface c. stainless steel d. a slippery surface 10. The feature (of the abutment), which has been well tried in the engineering world and borne out by scientific investigation, is the ________. a. octagonal connection b. tapered or conical connection c. hexagonal connection d. non-conical connection

Implant practice 31

CE CREDITS

IMPLANT PRACTICE CE

SERVICE PROFILE

ALPHAEON CREDIT What are we? In 2014, ALPHAEON CREDIT began delivering on our promise to help doctors help more patients by providing an improved patient-financing solution. Initially, we worked solely with plastic surgeons, ophthalmologists, and dermatologists. In 2019, due to patient demand, we began offering our program to dentists as well.

Why are we different? We offer a credit card with special financing plans, including deferred interest and longer-term with interest plans. That does not make us unique. What makes us unique is our ability to provide: • A line of credit that is exclusive to four medical specialties, increasing the likelihood that your patients have funds available when they need them and have not spent their funds elsewhere.

ALPHAEON CREDIT booth at the Yankee Dental Congress

ALPHAEON CREDIT has the ability to provide superior credit limits, so your patients can finance the full cost of their care easily and feel more comfortable pursuing higher-cost treatment plans. • Stronger approval rates, so your patients can move forward with the treatment and care you recommend. • Superior credit limits, so your patients can finance the full cost of their care easily and feel more comfortable pursuing higher-cost treatment plans. • An improved experience for your team with a dedication to customer service and a special hotline that rings to every employee’s cellphone, including the President’s, where you can always speak to someone immediately without waiting, 24-7, 365 days a year. • Rates that are often lower for the doctor and the patient. 32 Implant practice

How do we do it?

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We partnered with Comenity Capital Bank, which is the bank behind many favorite branded credit cards, including Ann Taylor, Cost Plus World Market, IKEA, J. Crew, Kay Jewelers, Pottery Barn, Restoration Hardware, Sephora, Victoria’s Secret, and more. With Comenity Capital Bank’s experience and our focus limited to only four medical specialties reducing exposure for our lending partner, we’re able to deliver on our differentiators. We understand what is important to doctors, their teams, and patients and provide an improved patient-financing solution.

Enrolling with ALPHAEON CREDIT is easy. There are no application or enrollment fees, no monthly activity fees, and no cost for marketing materials. The enrollment form takes only a couple of minutes to complete and can be found at www.myalphaeoncredit. com/enroll. If you have questions about our patientfinancing program, please call 949-2844580, or email us at dental@alphaeon.com. We look forward to showing you the ALPHAEON difference! IP This information was provided by ALPHAEON CREDIT.

Volume 12 Number 4

YOUR WORD OF THE YEAR

alphaeon noun

\al-fee-on\ n 1: a better option for patient financing 2: a company ready to make a dentist’s job easier 3: a way to help more patients

TOUGH TO SAY. TERRIFIC TO USE. ALPHAEON CREDIT has been the go-to patient financing option for dermatologists, ophthalmologists, and plastic surgeons for over five years. Now the program is available for dentists as well.

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GOING VIRAL

IT companies and cybersecurity companies are not created equal Gary Salman sounds an alert: Don’t be held ransom to a data breach that could have been prevented

ansomware is a type of malicious software, or malware, that is designed to deny access to a computer system and/ or data until a ransom is paid. An entirely new class of ransomware is being deployed by cybercriminals that encrypts your data, steals your patient records, and creates a “backdoor” for a future attack. It is typically spread through phishing emails, attachments, infected websites, or through hackers injecting it into your network. It is important to understand that for ransomware to hold you hostage, there must be existing software or network vulnerabilities in your system. In our experience, these vulnerabilities have been present in every dental practice due to the fact that IT companies do not have the technology or credentials to properly identify these risks. Ransomware can be devastating to your practice both from a financial and PR standpoint (including the loss of your patients’ and referral trust). Recovery of data is a difficult process and may require the assistance of a reputable cybersecurity specialist. In addition, the HIPAA Privacy Rule (See 45C.F.R. 164.400-414) and many state laws require the practice owner to prove, with low probability, that electronic protected health information (ePHI) was neither accessed nor stolen by the cybercriminal. A forensics investigation performed by a cybersecurity company is the only way to determine whether or not ePHI was compromised. One of the biggest mistakes that we see practices make is relying on their IT company for cybersecurity and believing that “my IT guy does this.” Every dentist and specialist we have worked with who has been the victim of a data breach also had an IT company that they thought was protecting them. As the owner of the practice, understanding your risk should be a top priority for protecting 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.

34 Implant practice

Once cybercriminals have this information (the “keys to your castle”), it’s easy for them to gain access to your network and compromise the data in your practice. your data. It is important to remember that IT companies are not cybersecurity companies and do not have the same knowledge and/ or expertise as a specialist in cybersecurity. Many cloud-based practices have a false sense of security when it comes to this new cyber threat. In August 2019, one of the most devastating ransomware attacks on a medical records backup service impacted more than 400 dental practices across the United States. While using cloud-based software can be more secure, there is always the concern of malware moving from your local network into the cloud or vice versa. This attack was launched not only against a cloud-based software, but also through its managed service provider (MSP)/IT vendor. We have recently been involved in data breaches with several practices where the IT vendors were the initial targets. Cybercriminals know that IT companies store user names and passwords to their clients’ data. Once they have this information (the “keys to your castle”), it’s easy for them to gain access to your network and compromise the data in your practice. 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 data, there would be no data breaches. With the continued sophistication of cybercriminals, they can now deliver payloads that completely disable your antivirus software and allow unauthorized access to your network. Make no mistake: As practicing dentists, you are actively being targeted by cybercriminals with

the intent of stealing your valuable patient data. Your patient records include all of the information that a cybercriminal needs for identity theft. A single patient record sells for as much as $50 on the “dark web” (the black market for hackers). In addition to identity theft, hackers are extorting practitioners for ransom payments. Black Talon Security has been involved in breach cases with ransoms ranging from $4,000 to $1.4 million.

Predictive threat intelligence Black Talon Security is now deploying the next generation of advanced cybersecurity tools. At the 2019 American Association of Oral and Maxillofacial Surgeons (AAOMS) meeting in Boston, we introduced Predictive Threat Intelligence (PTI). This new gamechanging technology will help us identify the “unlocked doors and windows” on your network on a real-time basis. This is a significant development for your cyber defense as this automated tool acts as a “news feed” to alert us to the latest vulnerabilities that could affect various devices on your network. Our new PTI tool knows vulnerabilities that have been successfully exploited by hackers worldwide and provides us with an instant alert should one of these vulnerabilities ever appear on your network. Being proactive: Educating doctors and staff members about current threats has significantly reduced the number of cyberattacks in practices by more than 75%. Don’t fall victim to these cybercriminals, and don’t think this will never happen to you. It’s not IF it will happen to you, but WHEN. IP Volume 12 Number 4

Cybersecurity Threats Are Real... It is Time to Think Diﬀerently

Your Team + Your IT Company + Black Talon = Cybersecurity A mistake we believe dental prac ces make...relying solely on their IT Company for cybersecurity. Cybersecurity is a specialized industry that employs highly trained and cer ﬁed individuals who work in conjunc on with your IT company to secure your network. Your prac ce and pa ent data may be vulnerable to a ack, unless preventa ve measures are put in place to mi gate risk. The cost of a cybera ack o�en runs into the hundreds of thousands of dollars. IT companies in the dental industry are now partnering with us to enhance the security of their business and their clients. WE BELIEVE IT NOW TAKES A TEAM TO PROTECT YOUR NETWORK. “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

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Optimize your implant workflow with 3Shape Implant Studio®

Shape Implant Studio® is an open implant planning software solution that enables you to develop an implant surgical plan as well as digitally plan the implant placement presurgery. The innovative solution also allows you to design customized surgical guides for printing in-house or send your designs to your preferred manufacturing partner.

Start your workflow with best-inclass technology When you plan your implant treatment digitally, your workflow begins with a digital impression. While Implant Studio is an open solution that accepts any .STL file, why not start your workflow with a fast and highly accurate scan using the award-winning 3Shape TRIOS® intraoral scanner? U.S.based practitioner, Dr. David Wohl says that with 3Shape TRIOS, his “delivery time has been cut by two-thirds.”

Plan any implant treatment In the software, Implant Studio combines your surface impression with a CBCT scan. This provides you with full clinical insight for planning your treatment. You can plan any implant treatment in Implant Studio, from single units to full edentulous cases. As an open solution, Implant Studio enables you to choose from more than 100 implant and sleeve libraries, your preferred manufacturing options, as well as seamlessly connect with manufacturing partners in an integrated workflow or export your cases for use with any CAD/CAM solution. With 3Shape Implant Studio, it’s up to you.

Guided surgery for a great patient experience The flexibility of the workflow also extends to the design and production of

36 Implant practice

surgical guides. Design tooth-, mucosa-, or bone-supported1 surgical guides in Implant Studio for a less invasive and more comfortable treatment experience for the patient.2 Dr. Simon Kold from Denmark says, “Implant Studio allows me to reduce allocated appointment times for complete surgery from 90 to 30 minutes, while providing a much better patient experience and more accurate results.” Aside from reducing your chair and healing time, the treatment precision and efficiency of guided surgery can also translate into greater confidence and predictability when handling complex cases. Canadian practitioner, Dr. Sonia Leziy says, “Because I’ve pre-planned the outcome in Implant Studio and use surgical guides, I can now treat 20%-25% more patients and am far more relaxed in surgery. To me, it’s a stressfree environment.”

Restore implants easily If you are also restoring implants, 3Shape provides you with all the tools you need. Compared to conventional implant impressions, implant scanning with TRIOS is faster3 and less complex. Implant scanning after surgery also allows for the easy capture of the emergence profile to ensure high-quality restorations. U.S.-based Dr. Peter Hunt says, “With implant scanning, the whole process is becoming so predictable. It’s contributing to a much more effective workflow, much more predictable, more precise, and it feels safer and more comfortable.”

To enable the precise position and orientation recording of an implant with an intraoral scanner, we recommend using 3Shape scan bodies. 3Shape scan bodies are made of durable titanium to ensure accuracy throughout their up-to-100-use lifetime and are available for all major implant systems.

Choose an open system to optimize your implant workflow When it comes to digital implantology and CAD/CAM solutions, there are plenty of choices out there. Among these, 3Shape provides you with an open, seamlessly integrated system for developing your implant surgical plan and the design and production of customized surgical guides. For more information or to start your free trial, please call +1-908-867-0144, visit us at www.3shape.com/implantstudio, or email Sales.US@3shape.com. Visit us at Booth 2626 at the Greater New York Dental Meeting, happening December 1-4, 2019. IP This information was provided by 3Shape.

REFERENCES 1. Bone-supported guides are not cleared by the FDA for clinical use in the U.S. Coming in 2020. 2. Pozzi A, Tallarico M, Marchetti M, Scarfò B, Esposito M. Computer-guided versus free-hand placement of immediately loaded dental implants: 1-year post-loading results of a multicentre randomised controlled trial. Eur J Oral Implantol. 2014;7(3):229-242. 3. Joda T, Lenherr P, Dedem P, Kovaltschuk I, Bragger U, Zitzmann NU. Time efficiency, difficulty, and operator’s preference comparing digital and conventional implant impressions: a randomized controlled trial. Clin Oral Implants Res. 2017;28(10):1318-1323.

Volume 12 Number 4

3Shape Implantology Open and efficient implant solutions

Visit 3Shape at GNYDM Booth #2626

Whether you are restoring or placing implants, working in-house or with partners, 3Shape provides you with the solutions for more efficient implant workflows.

Scan

Plan

Design

Combine surface and CBCT scans in Implant Studio for full clinical insight.

Plan prosthetic driven implants for optimal esthetics, fit and function.

Design customized surgical guides and screw-retained provisional crowns.

Integrate to in-house printers or send-to-lab in a flexible open system.

Explore more at go.3shape.com/implantology

PRACTICE MANAGEMENT

Comfort, function, or beauty? JoAn Majors, RDA, CSP®, advises: Ask your patients the questions, and stay out of their way!

his is actually how we do it. I’m serious. We have mastered the soft skills in this area, and what we know is that when we use them and follow the systems in place, the patients will tell us exactly what they want. It’s up to us to know what to ask and when to ask — also, to learn that at that moment, the best thing to do is to zip our lips! Be empathetic, listen, and stay engaged because if you understand the subtle art of asking questions, your patients will have more significant outcomes, and so will you. After all, dental providers LOVE predictability. If you believe the studies that 93% of communication is nonverbal, then you’ll understand that it is not about asking yes-and-no questions like a robot in a medical office. It is about asking specific questions and observing — very carefully. It’s been my experience that many of us love the art of interviewing new patients to learn more so that our doctor can come in as the hero — mainly because we have worked as a detective, finding out more about patients’ wants, needs, and desires. In our practice and the practices I work with, we believe this is serving our patients in a big way. Potentially, they are not as nervous. It can often seem more like a casual conversation with the team member. Patients also don’t mind telling a team member or even asking his/her opinion about implant treatment because (with all due respect — remember, I am married to a dentist). It’s not the fat-cat doctor but someone who might have a different insight. Better yet, the person JoAn Majors, RDA, CSP®, is a registered dental assistant, published author, and has earned the designation of certified speaking professional from the National Speakers Association. Her vast career in dentistry spans 3 decades. Her biggest block of business is speaking and training specialists and teams along with their referring practices and teams on the skills that matter. JoAn even developed an aftercare program that consists of online short video training that is executed through a monthly meeting with team leads. She is founder and content creation specialist for The Soft Skills Institute, LLC, a nationally recognized AGD PACE provider of seminars and workshops. JoAn’s happy place is at the front of the room, inspiring today’s total team to appreciate the significance of soft skills to create greater value for all types of care and in every relationship that they want to keep. The time is now; the choice is yours! To learn more or see her in action, visit www.joanmajors.com

38 Implant practice

patients are speaking to won’t necessarily make their house note with the treatment discussed today. Don’t turn your nose up and act as though this doesn’t happen. I live in the real world, and many times this is the mindset of a patient. We’ve all had a patient say something like this. If you have ever heard me speak or read my work, you know I share that in our office. We have a rule. It’s pretty simple. Until we have a want, need, or desire, our doctor will not tip the chair back! It may sound strange, and it’s been my experience that after teaching at the Misch International Implant Institute for almost 16 years working with multiple doctors in many countries, (not to mention functioning as the comprehensive care coordinator in my husband’s practice) this absolutely works. My husband is (in my humble opinion) ridiculously smart. He has some incredible hands and the best part — he’s not an egomaniac. He is just a competent practitioner because after 35-plus years in practice, he knows when to say when. This being said, we are about systems. Systems create success and predictability. He loves predictability. (Side note: Because some will wonder, I never worked in his office until after I sold my software company and had a break between opportunities.) We don’t have some

strange sense of worth. We do have a way of working together that is certain. Creating soft skill systems around this is what makes it scalable, teachable, and duplicable. We want a want, need, or desire. We work as a team on the initial phone call and initial encounter with a team member to learn what that is. We don’t believe a doctor’s best and highest use of time is “fishing” for this information. We are both convinced with my experience and history that I am absolutely the best person to do this fact-finding part of the patient interview. I also believe that team members WANT to do more, and when trained in systems to do so, they will knock your socks off with what they can uncover versus what you might have time to discover. You don’t have to agree with me. I’m okay with this. You need to understand that you should ask more questions because if you don’t agree, honestly, you don’t understand the concept and or the context. When interviewing a patient interested in implant treatment, it often involves a partial or full arch option. I love and have a standard setup when doing this fact-finding portion of the appointment. One of the things we have done is to involve the patients early in the interview. It’s often before a doctor exam because I am just educating what might be Volume 12 Number 4

Majors.” I’ll move perhaps a standard instrument pack off the bracket table. I’ll take a pen, and I’ll write on the bracket cover. I call this “Planned Spontaneity,” not covered here because this is another article! I’ll write Comfort, Function, Beauty. Then I’ll give the patient the pen and ask him/her to rate these 1-3 as far as most important to least important to his/her desired outcome with the treatment. Then I listen and watch. That is when the magic happens! Talk about a want, need, or desire. When patients share that they are most interested in eating because they haven’t been able to enjoy a meal in years, they are quick to put that No. 1 by function. Others (a recent female patient) didn’t pass-go or collect $200 to say as fast as she could, “It’s about beauty. I don’t want another embarrassing episode where I am out of town looking for super glue to put this back in!” You need to get a system down that allows patients to be able to share what’s on their mind and not get caught up on sharing what’s on yours. What they might want or need or desire from

this implant treatment that they are inquiring about at this very moment. Again, we love systems, and systems create predictability. My guess is that you’ll never look at a bracket cover again the same way! I certainly hope not. Just because a concept is new to you or seems strange doesn’t discount the fact that it might actually be working. We are pretty innovative with how we seek to understand what our patients want. I love creating systems that support today’s busy practice and align with today’s team members mindsets. The truth is, most of us want to be more valued. Unless someone is willing to share their “magic,” it’s up to you, and you feel as though you are on your own. Let me assure you, I’ve had some fantastic mentors, and most of them shared with me, “JoAn, always give your best stuff away, and they will come back.” I’ve been sharing my best for years in seminars and the written word. I’ll continue to do this in the hope that you can change the outcome for one patient. That’s the one it is supposed to happen for today! See you on the road. IP

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PRACTICE MANAGEMENT

available for them with THEIR wants, needs, and desires in mind. I’ll say something like this: “I’m not the doctor, but in instances like this when someone is interested in replacing teeth with dentures or partials, even implants, I have the opportunity to work with you and help you understand more about this treatment and also more about what you believe you want. Allowing you to have additional information at the time our doctor orders X-rays, reviews medical history, helps you know more about your treatment options. Does this make sense?” After a “yes” from the patient, we are off to the races! We have some standard questions and a system for this interaction with the patient. My husband and many of my surgeon clients call it “magic.” I’m here to say; it’s a system. Once we have entered into the conversation about the patients, it is amazing how they open up and share more and often many different details that what might have been shared prior. When the timing is right, and I have seen the visual cues I am looking for, I do something that is trademark “JoAn

S .A Drs Naresh and

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Volume 12 Number 4

Implant practice 39

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ON THE HORIZON

Preventing incision-line opening Dr. Justin D. Moody discusses solutions for a common postoperative complication

ast week I had the privilege of mentoring doctors at the New Horizon Dental Institute in a live surgical course. Over the course of 2 days, more than 900 teeth were removed, 28 alveoloplasties were performed, and 245 dental implants were placed either as full arch or single units. As all of these patients will return for postoperative appointments and eventual restorative treatment here at the Institute by Dr. Heather Wilson and her team, she will confirm that incision-line opening is by far the most common postoperative complication that they will see. This leads me to ask the question, “Why?” I believe that several factors play a part in incision-line opening. First and foremost is the skill set and experience of the surgeon. In dental school, many dentists perform a very limited amount of surgical procedures and, therefore, do not become proficient in suturing skills. Without practice and experience, confidence is low, and dentists are far less likely to perform these procedures when they enter into private practice. Another very important factor is technique. It is my observation that many dentists will just pull the tissue tight with sutures and dismiss the patient, thinking that this is successful only to find the patient back in the chair a few days later with a wide open incision. It is important that the flap edges re-approximate tension-free in order for primary closure to occur. This can be accomplished by reducing the bone level with alveoloplasty or by tissue elongation procedures. When these steps are taken, the occurrence of incision-line opening can be greatly reduced.

An important clinical observation to note is the significant difference in healing when platelet-rich fibrin (PRF) is used in the closure of incisions as compared to those sites that did not have PRF. The team at New Horizon has noted over and over again that the sites that were sutured over L-PRF heal much faster, with less inflammation, and with far less incision-line opening. This technology from Intra-Lock® International has changed postoperative follow-up visits from dreaded to anticipated!

Figures 2 and 3: 2. Growth factors from the patients own blood captured using the IntraSpin. 3. L-PRF prepared in the Expression by Intra-Lock to be mixed with MinerOss® 50/50 allograft by BioHorizons

Figure 4: Full arch of extractions, implant placement, and sockets grafted with the MinerOss/L-PRF mixture

Figure 5: Closure of full arch incision using 4-0 PGA sutures

Figure 6: Lower full arch just 4 days post-op having used L-PRF (Surgery by Dr. Wade Pilling)

Regardless of the complexity of the procedure, from a simple socket graft to a full arch reflection of tissue, it is important that you take your time to manage the soft tissue and achieve primary closure. Learn and practice good suturing techniques. Consider getting training on the use of biological growth factors such as L-PRF. By simply focusing on effective suturing, you will see a large decrease in your surgical complications. IP

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.

40 Implant practice

Figure 1: IntraSpin™ L-PRF machine by Intra-Lock

Volume 12 Number 4

don’t be fooled.

chairside system for the production of Leukocyte- and Platelet-Rich Fibrin

choose an FDA-cleared medical device for the production of L-PRF® no anticoagulant, heating, pipetting, second spin, chemical additives or expensive consumables • simple & economical1 • quality guarantee • quick three-step processing protocol • up to 80% reduction in undesirable vibrations2 • high quality German engineering and manufacturing For more information, contact BioHorizons Customer Care: 888.246.8338 or shop online at www.biohorizons.com 1.Intra-lock.com/scientific-literature.html. IntraSpin® and L-PRF® are trademarks of Intra-Lock® International Inc. 2. David M. Dohan Ehrenfest, Nelson R. Pinto, Andrea Pereda, Paula Jiménez, Marco Del Corso, Byung-Soo Kang, Mauricio Nally, Nicole Lanata, Hom-Lay Wang & Marc Quirynen (2017): The impact of the centrifuge characteristics and centrifugation protocols on the cells, growth factors, and fibrin architecture of a leukocyte- and platelet-rich fibrin (L-PRF) clot and membrane, Platelets, DOI: 10.1080/09537104.2017.1293812 SPMP18276 REV C FEB 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 CALIFORN OCEANSIDE, CALIFORNIA Session 2: February 7 and 8, 2020 Session 3: March 6 and 7, 2020

2020 CITIES

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

ATLANTA, GEORGIA

Georgia

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

salt lake city

FAST TRACK: SPRING II Sessions 2-4: May 11 - 15, 2020

Utah

SALT LAKE CITY, UTAH

Presented by Drs. Justin Moody and Wade Pilling

chicago

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

Illinois

FAST TRACK: SUMMER Sessions 2-4: June 15 - 19, 2020 CHICAGO, ILLINOIS Session 2: August 28 and 29, 2020 Session 3: September 18 and 19, 2020

2020 SCHEDULE

tempe Arizona INSTRUCTOR

SESSION FOUR: LIVE SURGERY 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

oceanside atlanta

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

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

New York

California

Presented by Drs. Jumoke Adedoyin and Daniel Fenton

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

new city

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

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.

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