Implant Practice US Spring 2020 Vol 13 No 1

clinical articles • management advice • practice profiles • technology reviews Spring 2020 – Vol 13 No 1 • implantpracticeus.com

PROMOTING EXCELLENCE IN IMPLANTOLOGY

How important is today’s digital lab?

Dr. Justin D. Moody

Clinician spotlight Sandy Chang, DMD

Corporate Profile Zimmer Biomet Dental

Considerations for guided immediate implant placement Dr. Steven Vorholt

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Spring 2020 - Volume 13 Number 1 EDITORIAL ADVISORS Steve Barter, BDS, MSurgDent RCS Anthony Bendkowski, BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent Philip Bennett, BDS, LDS RCS, FICOI Stephen Byfield, BDS, MFGDP, FICD Sanjay Chopra, BDS Andrew Dawood, BDS, MSc, MRD RCS Professor Nikolaos Donos, DDS, MS, PhD Abid Faqir, BDS, MFDS RCS, MSc (MedSci) Koray Feran, BDS, MSC, LDS RCS, FDS RCS Philip Freiburger, BDS, MFGDP (UK) Jeffrey Ganeles, DMD, FACD Mark Hamburger, BDS, BChD Mark Haswell, BDS, MSc Gareth Jenkins, BDS, FDS RCS, MScD Stephen Jones, BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack, DDS, CertPerio, FCDS Samuel Lee, DDS David Little, DDS Andrew Moore, BDS, Dip Imp Dent RCS Ara Nazarian, DDS Ken Nicholson, BDS, MSc Michael R. Norton, BDS, FDS RCS(ed) Rob Oretti, BDS, MGDS RCS Christopher Orr, BDS, BSc Fazeela Khan-Osborne, BDS, LDS RCS, BSc, MSc Jay B. Reznick, DMD, MD Nigel Saynor, BDS Malcolm Schaller, BDS Ashok Sethi, BDS, DGDP, MGDS RCS, DUI Harry Shiers, BDS, MSc, MGDS, MFDS Harris Sidelsky, BDS, LDS RCS, MSc Paul Tipton, BDS, MSc, DGDP(UK) Clive Waterman, BDS, MDc, DGDP (UK) Peter Young, BDS, PhD Brian T. Young, DDS, MS CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day, BDS, VT Julian English, BA (Hons), editorial director FMC Dr. Paul Langmaid, CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul, BDS, LDS, FFGDP (UK), FICD, editor-inchief Private Dentistry Dr. Chris Potts, BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers, BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

© FMC 2020. 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.

A

s we usher in a new decade, the outlook for the advance of digital technology in dentistry is gaining momentum. It seems like just yesterday I was completing surgical residency and starting in private practice. Digital technology was just entering mainstream medicine. CT scans were only available in the hospital or medical imaging center, and digital 2D radiography was just beginning to appear in physician practices. Impressions for study models were taken with alginate, polyvinyl, or rubber impression material, and the models were poured-up in plaster or stone. Sending a patient for a CT scan to plan implants was expensive, and the planning software was primitive. And since implants were placed freehand, the implant placement might need to be modified from its planned location anyway.

Now, cone beam CT systems are commonplace for evaluating dentofacial morphology, pathology, trauma, airway obstruction, and TMJ disease. Fully guided dental implant systems have improved the accuracy and success of implant surgery. Highly accurate surgical guides can now be printed in-office; restorations can be designed and milled chairside with CAD/ CAM systems; piezosurgical systems reduce the trauma and improve the outcome of bony reconstruction; and lasers can help treat pathology and reduce peri-implant disease. Dental appliances and models can be printed in the office in a few hours, or the data can be transmitted to a dental lab with quick turnaround.

As digital technology has become more commonplace, so has the ability of these systems to communicate and improve workflow. CAD/CAM data can be imported into CBCT implant planning software to plan implant placement based on a proposed final prosthetic plan. Conversely, information about virtually planned implants can be transferred to CAD/CAM software so that prostheses can be planned, and 3D printing and milling can be utilized to create the prosthesis before the surgery. With fully guided implant placement, the prosthesis can be delivered with minimal or no adjustment, leading to more efficient procedure times, enhanced recovery, and better overall outcomes.

Yet with new technologies come new challenges. The first is learning new techniques after having successful careers with techniques we learned and materials we used in dental school and residency training. At first, we may be unsure if these newer technologies are as good or as easy as those we have already experienced. We also worry about the time that it will take to master, or at least to become competent, in scanning, treatment planning, and clinical use.

From personal experience, I know that you have nothing to fear but fear itself. Even though most systems were designed by engineers, the refinement of the clinical workflow, user interface, and work product was done by clinicians. We also fear that our office staff will resist change. I have found that involving them in product evaluation and training actually gets them more excited about new technologies. The best way to move in to the 21st century of dentistry is to do it gradually. Start with a CBCT, which can be used for most of what we do as surgical specialists; and then with comfort and experience, add 3D printing and CAD/CAM to your arsenal.

As wonderful as they are, these technologies on their own do not make us better clinicians.

They are merely tools to improve our efficiency, accuracy, and success. Therefore, we must ensure that those of us with the credentials and the experience avail ourselves to the education of those who wish to expand their clinical horizons. For those starting on their implant surgical journeys, start with the basics and advance only to more complicated patients and procedures once you have the requisite clinical expertise. As I tell my students, it is not enough to “think” that you can treat a particular patient; you have to “know” that you can. That confidence comes from training and experience.

I like to compare 3D technology to cars’ GPS systems. I have driven from my house to my office and back thousands of times. Yet without using GPS, I don’t know about traffic, road closures, accidents, and other challenges to a smooth commute. Even though I have done thousands of implants, I still use CBCT, CAD/CAM and a surgical guide for every case. With GPS, I get where I am going faster, more efficiently, and with less stress. 3D technology does the same for me. Finally, remember, even though you have GPS, you still have to know how to drive. And you still need to know the rules of the road, so you don’t crash. Have a great 2020, and enjoy this first issue of the new decade.

Dr. Jay B. Reznick Jay B. Reznick, DMD, MD, is a Diplomate of the American Board of Oral and Maxillofacial Surgery. He received his undergraduate Biology degree from CAL-Berkeley, Dental degree from Tufts University, and his MD degree from the University of Southern California. He did his internship in General Surgery at Huntington Memorial Hospital in Pasadena and trained in Oral and Maxillofacial Surgery at L.A. CountyUSC Medical Center. Dr. Reznick is one of the founders of the website OnlineOralSurgery.com, which educates practicing dentists in basic and advanced oral surgery techniques. He is also a consultant to several manufacturers and suppliers of dental and surgical instruments and equipment, and is on the Editorial Advisory Boards of a number of dental journals. He is the Director of the Southern California Center for Oral and Facial Surgery in Tarzana, California.

ISSN number 2372-9058

Volume 13 Number 1

Implant practice 1

INTRODUCTION

Momentum for a new decade

TABLE OF CONTENTS

Practice profile Michael J. Hartman, DMD, MD

8

Publisher’s perspective Resolution or resolve? Time to take positive action in 2020!

Lisa Moler, Founder/CEO, MedMark Media................................6

From technician to technology-focused clinician

Clinician spotlight Sandy Chang, DMD Where art, science, and impact meet .......................................................15

Technology/case study

Corporate profile Zimmer Biomet Dental

12

High-frequency vibration for normalizing tooth mobility and improving bone for implant: a case study Dr. Matthew Hallas illustrates a case that utilized a new adjunctive therapy in implant care.................................18

ON THE COVER Cover image courtesy of Dr. Justin Moody.

Article begins on page 48.

2 Implant practice

Volume 13 Number 1

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TABLE OF CONTENTS Case report Considerations for guided immediate implant placement Dr. Steven Vorholt illustrates guided immediate implant surgery on teeth Nos. 19 and 18...............................21

Continuing education Partial extraction therapy: the socket shield technique and digital workflow Drs. Filipe Amante and Patrik Zachrisson describe the use of partial extraction therapy in a case of coronal fracture of a maxillary lateral incisor.................... 36

Product profile Cut the risk with guided surgery using 3Shape implant solutions

Continuing education Essentials for using CBCT in implant dentistry: technical considerations

26

Dr. Johan Hartshorne highlights technical aspects practitioners need to consider before adding a cone beam computed tomography unit to their practice

Dr. Sonia Leziy discusses the merits of guided surgery............................. 41

Practice management Marketing momentum On the horizon Compromise is the difference between a good leader and a dictator Dr. Christopher Hoffpauir discusses insights into providing feedback to employees...................................42

Your dental message — delivered

How important is today’s digital lab?

Dental marketer, Jackie Raulerson, offers insights into crafting engaging articles for dental publications

Dr. Justin D. Moody discusses the digital possibilities for minimally invasive surgery and precision placement

................................................. 44

................................................. 48

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

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PUBLISHER’S PERSPECTIVE

Resolution or resolve? Time to take positive action in 2020!

The New Year is a time for resolutions — which has led me to think of the true meaning of that word. Resolution is defined as “a firm decision not to do something.” That doesn’t sound so positive to me. I am more invested in the word resolve, defined as to “decide firmly on a course of action.” That’s more like it!

As leader of the MedMark team, our vision and our goals for 2020 are positive — we don’t want to “not do something”; we are going to take action on many exciting innovative, creative projects for our readers and advertisers. This year, on our media side, we continue to inform and educate through DocTalk videos and podcasts. We are especially excited about our new dental sleep medicine ZZZ Pack Podcast, which will bring news and views from some of the most knowledgeable sleep-focused Lisa Moler Founder/Publisher, MedMark Media dentists in the niche. Also, Dr. Rich Mounce will feature many of our most popular authors on his Dental Clinical Companion Podcast. In the past few years, I have been fortunate to help motivate our audience by interviewing some phenomenally inspiring people — Shaquille O’Neal, Tony Robbins, Simon Sinek, and Dr. Oz, and I will continue to connect you with those who can encourage you to expand your horizons.

Our print and digital articles continue to keep you on the cutting edge of clinical and practice management ideas and information. In this issue, for their CE, Drs. Filipe Amante and Patrik Zachrisson discuss a technique called “partial extraction therapy” for specific clinical circumstances that leaves a buccal fragment in situ, allowing for the preservation of the periodontal ligament, and an ideal soft, hard tissue volume preservation and vascularization. Dr. Johan Hartshorne’s CE aims to enhance understanding of the fundamental principles required for safe and effective use of CBCT technology — an imaging modality that increases diagnostic and communication capabilities, produces high-quality and accurate images, and is relatively easy to use. Dr. Matthew Hallas provides a case study on a new mode of therapy that uses high-frequency vibration for enhancing the integration of implants. In our Marketing column, Jackie Raulerson offers tips on writing articles in an organized and understandable way that both editors and readers will appreciate.

2020 has just started, and the opportunities to expand your practice potential are endless!

Along with our constant resolve to inform you through the written word of the most current technologies, products, services, and techniques, keep watching for us online and in person at major dental meetings and events across the United States. Please continue to contact us with your article ideas or if you want to take part in one of our online chats or podcasts. This year, “resolve” along with us to “embrace the exceptional.” Start the decade as we have — deciding firmly on a course of positive action based on solid science, facts, and innovation.

To your best success in 2020!

Lisa Moler Founder/Publisher MedMark Media

Published by

PUBLISHER Lisa Moler lmoler@medmarkmedia.com DIRECTOR OF OPERATIONS Don Gardner don@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 & DIGITAL STRATEGY Amzi Koury amzi@medmarkmedia.com EMEDIA COORDINATOR Michelle Britzius emedia@medmarkmedia.com SOCIAL MEDIA & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com

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

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PRACTICE PROFILE

Michael J. Hartman, DMD, MD From technician to technology-focused clinician What can you tell us about your background?

My path to becoming an Oral and Maxillofacial surgeon started initially in the dental laboratory. I spent 2 years working and training as a crown-and-bridge technician prior to starting dental school. That training allows me to evaluate implant cases from a dental technician’s standpoint to develop a true restoratively driven treatment plan.

When did you become a specialist and why?

I really enjoyed my oral surgery rotations in dental school, and my personality seemed to fit with the residents. I can honestly say I love my job and am very grateful to be an Oral and Maxillofacial surgeon.

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

Dental implants are a large part of our practice, but we also provide our referrals and their patients with other routine oral surgery procedures.

Why did you decide to focus on implant dentistry?

Having worked in the dental laboratory, I have a strong understanding of the restorative aspects of implant dentistry.

Focusing on implant dentistry has allowed me to combine my oral surgery training and restorative knowledge to improve outcomes for my patients.

Do your patients come through referrals?

A majority of our patients come from our referral network of general dentists and other specialists. We are very fortunate to have an ever-increasing amount of “word-of-mouth” referrals that come from patients pleased with their care.

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

I have been practicing for 11 years.

During this time, implant surgery has been a large part of the procedures I perform. I have 8 Implant practice

Dr. Hartman with his X-Guide™ (X-Nav Technologies) dynamic navigation systems

started Digital Provisionalization Technologies (DPT), a specialized dental laboratory, and integrated this into my practice. This entity fabricates patient-specific provisional components for surgeons using X-Guide™ (X-Nav Technologies) dynamic navigation and static surgical guides. I am well versed with the majority of the larger implant systems. This allows me to assist other surgeons utilizing DPT to streamline the use of the products into their practice. It also allows me to be flexible with referral preferences.

great daredevil of the 1970s. He lived life to the fullest and was always thinking of ways to push the limit.

In terms of implant dentistry, I am inspired by practitioners who are innovators with implementing new technology into their practice. Digital technology is changing the way we practice by allowing our implant cases to be planned and precisely executed in a restoratively driven manner.

What training have you undertaken?

The most satisfying aspect of my practice is caring for patients. I feel fortunate to live and work in the same community where I grew up. I enjoy caring for the people in my community and to have the opportunity to give back.

As mentioned earlier, my training started prior to dental school as a dental laboratory technician. After dental school, I completed a 6-year dual degree residency in Oral and Maxillofacial Surgery. I remain current with continuing education by attending the annual AAOMS and Dental Implant Conference meetings. I also try attend a weeklong course per year; in 2019, I attended the Digital Smile Design Course.

Who has inspired you?

I am inspired by people who show passion for life and their chosen craft. I am big reader of biographies. Believe it or not, one of my favorites is of Evel Knievel, the

What is the most satisfying aspect of your practice?

Professionally, what are you most proud of?

Professionally, I am most proud of starting my own practice, Hartman Oral and Maxillofacial Surgery in Mechanicsburg, Pennsylvania. We operate a 6,000 square foot standalone facility with five operatories outfitted to perform IV sedation, two consultation rooms, two post-op rooms, a film studio, a photo studio, and 15 staff Volume 13 Number 1

PRACTICE PROFILE

Dr. Hartman uses technology to deliver the best outcome for his patients

members, including a full-time CRNA to provide anesthesia.

We are also very pleased to have our new associate, David Sibley, DMD, join us as of January 2020. Dr. Sibley’s experience with zygomatic implants will now allow us to offer more treatment options for patient’s with severe resorption of the maxillary arch.

What do you think is unique about your practice?

Our practice is differentiated from others by our emphasis on implementing digital technology to improve patient outcomes. We are able to shorten treatment times, reduce cost, and often reduce the number of procedures for patients.

What has been your biggest challenge?

Personally, my biggest challenge is maintaining a healthy work/life balance.

I feel the biggest challenge in implant dentistry is establishing clear lines of communication between the surgeon, restoring doctor, and restoring lab technician. Our solution is to provide effective and clear communication. This is done by what I like to call “file sharing.” Since all of our implants are placed under some form of guidance, every patient has a preoperative work-up appointment. During this appointment, we acquire the necessary CBCT, intraoral scans, and 2D photos. In larger, more complex cases, we will also acquire a 3D facial scan. This allows us to plan in a restoratively driven manner. The idea of “file sharing” is to send our preoperative information to the restoring dental laboratory to assist in the restoration design. The technicians are the true artisans 10 Implant practice

in the process and should be given more information than an impression to guide them in the design and fabrication.

What would you have become if you had not become a dentist?

Well, that changes from time to time, but today if I weren’t an oral surgeon, I would like to be a part-time personal trainer and part-time CAD/CAM technician. Lately, I have been obsessed with the X,Y,Z coordinate system. LOL.

What is the future of implants and dentistry?

The future of implant dentistry is customized, patient-specific, provisional components for our implant cases. These components allow realistic emergence profiles to be contoured. With guided surgery, we can now design and fabricate the provisionals prior to the actual implant surgery.

The components can then be placed day of surgery with little to no adjustments. It is not uncommon in my practice to perform an extraction, immediate implant, and insertion of a lab-designed and fabricated provisional component all in under 1 hour.

What are your top tips for maintaining a successful specialty practice?

1. Stay current, and do not be afraid to invest in technology that you feel will enable you to improve your outcomes. Happy patients make a great referral base.

2. Surround yourself with quality people, and function as a team. This allows us to provide the best possible service to our patients. Our team members are the

Top favorites 1. Social Media: It connects our office with other dental professionals, and keeps us current.

2. X-Guide™ navigation: It has revolutionized my implant practice.

3. exocad DentalCAD and exoplan CAD/CAM software 4. NextDent 3D printer 5. Access to an in-house lab technician best asset to our practice, and they truly excel in their positions. We all contribute to the office culture and find many ways to have fun together.

3. Develop a solid social media campaign that displays your practice’s personality.

We have also been able to share our cases with dental professionals through a new, free continuing education platform named Implant Compare.

What advice would you give to a budding implant dentist?

Base your training and reading in science that follows evidence-based medicine. Have a vision, believe in it, and continue to pursue your goals.

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

When outside the office, I try and devote my time to my amazing wife and four boys.

I also enjoy reading and dedicate time for personal improvement by going to the gym every morning before work. This helps me mentally prepare for the day ahead. IP Volume 13 Number 1

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Tooth #15, set to be extracted

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Implant is placed. Note the histology showing mature osteocytes in lamellar bone formation.

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CORPORATE PROFILE

Zimmer Biomet Dental

Z

immer Biomet Dental offers dental professionals the kind of premium service and quality rarely found in today’s world of dentistry. As a leader in implant and restorative dentistry solutions, the company is committed to helping clinicians achieve exceptional outcomes for their patients by providing state-of-the-art solutions, world-class educational opportunities, and responsive, personalized service. The company’s comprehensive portfolio of products includes surgical solutions, regenerative materials for both hard- and soft-tissue applications, versatile prosthetic components for all types of implant restorations, and end-to-end digital dentistry solutions tailored for individual clinician’s needs.

Zimmer Biomet Dental is a division of Zimmer Biomet, one of the largest musculoskeletal companies in the world. The Dental division is headquartered in Palm Beach Gardens, Florida, with manufacturing facilities around the globe that produce treatment solutions for clinicians worldwide.

A market leader in regenerative solutions The company has partnered with a number of well-known regenerative-focused companies to become a market leader in the 12 Implant practice

regenerative space. They offer an extensive breadth of biomaterials for hard- and softtissue regeneration that includes allografts, xenografts, and synthetic bone substitutes; collagen barrier membranes; dental wound dressings; and a variety of surgical procedure kits. Among these solutions is the Puros® family of allografts, the No. 1 allograft in the North American dental market for rapid tissue regeneration. Puros allografts are processed using the proprietary Tutoplast® process, which has been successfully used for over 50 years to ensure the highest standard of tissue quality.

The most recent addition to the company’s regenerative portfolio is a new line of non-resorbable membranes and sutures.

The OsseoGuard® non-resorbable product line includes dense PTFE (polytetrafluoroethylene) membranes in reinforced and non-reinforced variants, as well as a titanium mesh and PTFE sutures. OsseoGuard membranes are specifically engineered to eliminate bacterial infiltration into the surgical site while preventing tissue from growing into the bone cavity.

“Zimmer Biomet Dental is very excited to provide advanced barrier membranes and sutures to our customers for ridge augmentation and other relevant procedures,” said

Indraneel Kanaglekar, Vice President and General Manager, Zimmer Biomet Dental.

“As a market leader in dental regenerative solutions, it is important that we keep diversifying and growing our available solutions in order to address the specific needs and preferences of clinicians.”

Two new procedure kits specifically intended for sinus lift (crestal and lateral approach) procedures were also recently introduced into the portfolio.

Staying competitive in the digital age Digital dentistry is more than a trend. It is becoming a standard of care for dental practices and laboratories in order to develop workflow efficiency, simplify implant dentistry, increase accuracy, and improve patient outcomes.

Zimmer Biomet Dental was ahead of this curve when they pioneered the BellaTek® Encode® Impression System over a decade ago. Recently, the company has been busy expanding its global footprint in the rapidly growing market for digital restorative dentistry solutions with the goal of delivering end-to-end digital solutions. This includes investing in technology and creating partnerships to better meet the increasing Volume 13 Number 1

Volume 13 Number 1

CORPORATE PROFILE

market demands. The company’s digital armamentarium includes solutions ranging from intraoral scanning technology to open architecture CAD/CAM systems and patientspecific abutments.

In October 2019, Zimmer Biomet Dental launched a family of new products and solutions into its BellaTek portfolio.

Certain® BellaTek Express and Certain BellaTek Flex Abutments are TiBase-type solutions for cement- or screw-retained applications with an angled screw access channel for better accessibility and improved esthetics. These new products offer efficiency to a CAD/CAM single- or multi-unit implant restorative workflow with the flexibility of adjusting the abutment at four different heights for better crown adhesion, and added strength with thicker abutment walls on wider implant platforms diameters.

Certain and External Hex Digital Analogs are newly designed and manufactured with laser precision to accurately replicate implant placement in a 3D-printed model or a stone model.

Carbon 3D printers, with a reputation for innovation, precision, and accuracy, were added to the BellaTek production facility.

By incorporating this technology, Zimmer Biomet Dental can provide their dental lab customers with a fully digital workflow by taking a laboratory’s scan or stone model, designing and printing a 3D model, and shipping back the model with a digital analog placed, along with a Certain BellaTek Abutment, Express, or Flex Abutment.

In September 2019, the company also announced exciting news of a multinational distribution agreement with Align Technology Inc. for the award-winning iTero® Element family of intraoral scanners. Align is known worldwide for the Invisalign® system, the most advanced clear aligner system in the world, and iTero intraoral scanners and services. The agreement expanded distribution of iTero from Europe to the US, Canada, and Japan.

“Zimmer Biomet is committed to offering best-in-class solutions and technology tailored to dental professionals’ needs, and this partnership with Align Technology to complement our portfolio of fully digital solutions is another important step in that direction,” said Pedro Malha, President, Zimmer Biomet Dental and CMF&T. Together, the iTero Element scanner family and Zimmer Biomet’s dental solutions will deliver multiple digital workflows

Together, the iTero Element scanner family and Zimmer Biomet’s dental solutions will deliver multiple digital workflows for dental professionals and laboratories, enabling efficient businessto-business collaboration and offering patients an optimal treatment experience.

Intraoral scanners help patients visualize their potential new smiles and feel more engaged about their treatment

for dental professionals and laboratories, enabling efficient business-to-business collaboration and offering patients an optimal treatment experience.

“We are excited to be partnering with Zimmer Biomet to demonstrate our companies’ commitment to supporting dental professionals on their journey to digital dentistry,” said Yuval Shaked, Senior Vice President and Managing Director, iTero Scanner and Services.

Strong commitment to education A key differentiator in the evolution to a digital practice and dental ecosystem is clinical education. Through this partnership, the iTero scanner becomes the preferred intraoral scanner used in the U.S. and European Zimmer Biomet Institutes, which train thousands of dental professionals annually in an interactive learning environment with the ultimate goal of improved clinical outcomes. Having digital technologies Implant practice 13

CORPORATE PROFILE

Zimmer Biomet prides itself on offering education in multiple learning platforms that cater to individual learning styles, convenience, and accessibility while focusing on current and emerging topics in implant and restorative dentistry. as commonplace in training facilities will accelerate learning, increase confidence, and broaden adoption for clinicians interested in digital workflows.

Medical education as a whole remains an extremely important part of Zimmer Biomet’s global business.

Zimmer Biomet prides itself on offering education in multiple learning platforms that cater to individual learning styles, convenience, and accessibility while focusing on current and emerging topics in implant and restorative dentistry. The company is not just advancing digital dentistry; it is advancing digital training through digital education platforms. Recently, the company launched an education application that includes prerecorded lectures, live webcasts, technique videos, registration portals for Zimmer Biomet Institute courses, and product information and resources.

“As everything in our lives becomes more digital, education is being consumed via various digital platforms,” Kanaglekar says.

“Personally, when I need to work on something in my home, I watch instructional videos on YouTube. Similarly, if a dentist wants to learn about our products (i.e., the features, how to use them clinically, and the science behind them), we want that information to be available at their fingertips.”

Zimmer Biomet’s Complimentary Dental Education App

In addition to virtual learning, dental professionals can visit one of six Zimmer Biomet Institutes around the world for didactic and hands-on workshops on diverse treatment topics for varying skill levels. Flagship USA institutes in Carlsbad, California, and Parsippany, New Jersey, feature stateof-the-art, proprietary Simulated Patient Training Laboratories for clinicians to learn surgical and restorative techniques. The New Jersey facility also has a cadaver laboratory.

Also offered through Zimmer Biomet Institute is the Zimmer Biomet Institute PathwayZ™ Series, which offer two unique educational program formats — zbipathwayZ

Self-Study Series and zbipathwayZ LIVE Group Series. The zbipathwayZ Self-Study Series begins with an introduction to implant therapy to start restorative clinicians on the road to competency with theory, knowledge acquisition, and technique review, followed by skill development at Zimmer Biomet Institute. Launched last year, Series 2 of the zbipathwayZ Self-Study Series is focused on Full Arch Therapy, and Series 3 is an Introduction to Regeneration with an emphasis on socket preservation for restorative clinicians.

The local, regionally based zbipathwayZ LIVE Group Series offers interactive education and comprehensive training led by an experienced thought leader in implant restorative dentistry. The program focuses on patient education and identification of candidates for implant therapy, through diagnosis, treatment planning, and fabrication of provisional restorations through definitive restorations.

Visit www.zimmerbiometdental.com to learn more about Zimmer Biomet Dental’s solutions and upcoming educational opportunities. IP Contact Zimmer Biomet Dental for references to all claims.

Zimmer Biomet Institute’s Simulated Patient Training Laboratory in New Jersey 14 Implant practice

This information was provided by Zimmer Biomet Dental.

Volume 13 Number 1

CLINICIAN SPOTLIGHT

Sandy Chang, DMD Where art, science, and impact meet

D

r. Sandy Chang easily fell into a role within the healthcare industry. “I guess it was just something I grew up with,” she says.

Quite right. She was born into it, as her father, uncles, both sets of grandparents, and many of her extended family members were all doctors.

The medical field made sense, but identifying the specific course was something that Dr. Chang was thoughtful about.

Like most people in the midst of choosing a career path, she looked to what came naturally to her and what she enjoyed.

Two subjects stood out — art and science — disciplines customarily envisioned at opposite ends of the spectrum with people easily gravitating toward one over the other. Not Dr. Chang. She was adamant on choosing both.

“In elementary and middle school, I was always good at science and always interested in it, and that extends itself and makes sense,” Dr. Chang says. Simultaneously, she could be found excelling in both visual and performing arts as a watercolorist, an oil painter, and a violinist.

Dr. Chang was accepted into the pre-med program at Virginia Commonwealth University. She explored her options there,

Fourteen years into her dental career, Dr. Sandy Chang has happily arrived at Affordable Dentures & Implants

while still keeping her love of the arts and science front and center.

Discussions with college friends led her to consider dentistry. Upon attending a local dental conference, however, her consideration was solidified after seeing incredible before-and-after photos of dental patients. The visual transformations struck her, and she knew then that she had found what she was looking for — a career in the surgical aspect of dentistry. The surgical sector calls for an artistic individual as much as a scientific one, where, as she puts it, she “could make an impact.” Delivering a

Dr. Chang treats one of her patients, just one of the countless whom she helps “walk through this journey” Volume 13 Number 1

meaningful impact on a daily basis, however, took time.

The University of Pennsylvania School of Dental Medicine welcomed Dr. Chang, where she earned her Doctor of Dental Medicine degree. Upon graduation, she continued on to San Antonio for a 3-year Prosthodontics Certificate Program at the University of Texas Health Science Center. From there, she settled in Manhattan, New York, where she worked as an associate dentist in private practice for 8 years. It was during this time that she reflected on what was next.

“I wasn’t interested in academia so that left two options: open my own private practice or be an associate,” Dr. Chang recalls. Through research, Dr. Chang stumbled upon a third option: Affordable Dentures & Implants (AD&I).

AD&I practices have treated over 7 million patients to date and is supported

by Affordable Care, the leading U.S. dental support organization in tooth replacement services. The company provides full business management services to its affiliated dentists, like Dr. Chang, as well as 100% clinical autonomy. The fact that AD&I dentists focus solely on dental surgery, not general dentistry, is also what sold her.

“Being a dentist for 14 years now, the majority of what I did was more general dentistry, cosmetic fillings, veneers, crowns, but what I love most is being able to be a part of that transformation,” Dr. Chang explains.

This is where the impact she was seeking had finally come — Not to mention, artistic expression as well.

Implant practice 15

CLINICIAN SPOTLIGHT

Her role as an AD&I-affiliated dentist provides both the time and opportunity for continuing education, prompting learnings that she can apply within her practice that further her impact.

“With dentures, I get to be the sculptor,” she continues, “I’m able to create a smile and design it with each patient.”

Dr. Chang is able to make an impact many times over thanks to a few factors.

For one, her entire day consists of dentistry.

And that’s it. There’s no business to tend to.

No accounting, invoicing, or tax filings for her to worry about. Ever.

The entire business side of her practice is run by Affordable Care’s Support Center, leaving her to see more patients, and she prefers it that way.

“Being able to focus just on dentistry is how I can make sure I’m providing the best care for my patients, and that’s ultimately why I’m here.”

Her role as an AD&I-affiliated dentist provides both the time and opportunity for continuing education, prompting learnings

that she can apply within her practice that further her impact. Upon becoming an AD&Iaffiliated Practice Owner, Dr. Chang attended the Live Implant Training Course at the Brighter Way Institute in Phoenix, Arizona. This training with top dental implant specialists expanded her clinical competence while widening her network, as she and other attending dentists from AD&I connected and benefited from sharing valuable ideas and techniques.

Her large network of connections didn’t cease when the training did. With 300-plus AD&I affiliated dentists, there is always someone to reach out to.

“I can pick up my phone and call one of my AD&I colleagues — a benefit of being part of a network of educated dentists. We can always learn from one another.”

The streamlined process, which is the AD&I way, helps Dr. Chang complete multiple

transformations each and every day. The on-site labs, which AD&I is known for, allow Dr. Chang and her team to connect with one another on each individual case in person, in real time. Dr. Chang’s practice can, therefore, take their patients from initial consultation to deliveries in a matter of hours as opposed to a month or more, which happens when roles, processes, and materials are outsourced.

Dr. Chang and her practice make an impact quickly and often, upwards of 10, sometimes 20 transformations each day.

“I’m lucky that I’m in a field where it’s very direct in the positive impact we make.

It’s instant gratification and tangible results, which aren’t common in jobs these days.

Now you can say, ‘Hey, I made a difference in someone’s life, and I was able to meet that person.’”

When that person brings a mirror up to his/her face for the first time is the moment of impact. The power of that moment is something that Dr. Chang and her team feel right alongside the patient.

“It’s heartwarming to know that you’re part of this important journey. It’s amazing really because this is when you see patients for the first time. It’s not just their smiles that change; it’s more than that,” she says.

Patients arrive embarrassed, uncomfortable, and nervous, heads down, hands covering their mouths, with very little to say.

Yet once Dr. Chang and team fulfill their roles and unveil the sculpture they have scientifically and artistically created, patients come alive. They are no longer hiding. Impact is made and felt by all. IP

Dr. Chang works hand in hand with her team and believes the enjoyment everyone feels at work is because “there’s meaning in what [they] do each day”

This information was provided by Affordable Dentures & Implants.

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Volume 13 Number 1

Your Career in Implant & Surgery Awaits...

Do you have a passion for implants and surgery? Our team at Affordable Dentures & Implants does!

When you join us as an affiliated practice owner or associate dentist, you get to focus on the procedures you love most, and you can leave the stress of all the business operations to us.

It’s time to flex your surgical muscles and join a clinically-led organization that has all the industry-leading training you crave. From live implant training, to changing patient smiles every day, joining the AD&I network allows you to do more of what you love!

Currently we’re offering a $10K sign-on bonus for practice owners in the following locations: Minneapolis, MN St. Cloud, MN Boise, ID Olympia, WA Springfield, OR Columbus, OH Valdosta, GA

Visit careers.affordabledentures.com or call (888) 837-3033 to speak with a recruiter today.

TECHNOLOGY/CASE STUDY

High-frequency vibration for normalizing tooth mobility and improving bone for implant: a case study Dr. Matthew Hallas illustrates a case that utilized a new adjunctive therapy in implant care

I

n dentistry, we routinely encounter patients requiring implants and restorations where the underlying causes such as disease and improper forces have impacted contributing factors to treatment success. This can often relate to the patients’ bone: loss of bone height, reduced bone density, defects, and tooth mobility. To restore these patients to the desired esthetics and function, we first need to gain control of the disease and improve overall oral health. However, bone quality and tooth mobility remain an ongoing challenge.

Recently a new, noninvasive mode of therapy using high-frequency vibration (HFV) has been made available. In preclinical studies, HFV has demonstrated the following abilities: • to increase bone volume and preserve alveolar bone width and height1 • to significantly increase osteoblasts and fibroblasts in the periodontal ligament (PDL)2

Figure 1: Pretreatment panoramic

• to enhance the integration of implants3 • to increase naturally produced growth factors — for example, bone morphogenetic protein (BMP), platelet-derived growth factor (PDGF)4 This case study focuses on a patient using the VPro™ (Propel Orthodontics), a noninvasive, high-frequency vibration, oral device with a bite plane used for 5 minutes per day post-extraction to improve bone for future implants, while significantly reducing tooth mobility and improving overall oral health.

Initial presentation A 60-year-old healthy nonsmoking female presented for surgical and restorative consultation regarding her failing maxillary left dentition. The patient’s chief complaint was fear that a removable dental appliance was her only restorative option due to the extensive breakdown of her teeth. Following

an initial discussion, the dentist performed and completed a comprehensive dental examination of her hard and soft tissues that included an occlusal exam, periodontal charting, mobility analysis, and temporomandibular joint evaluation. The patient’s maxillary left quadrant examination revealed vertical root fractures on teeth Nos. 12 and 14 with periapical abscesses, resulting in non-restorability of No. 12-x-14 fixed bridge work (Figures 1 and 2). Additionally, tooth No. 15 presented with a large mesialocclusal amalgam with distal-occlusal fracture, (+)2 mobility, and a periodontal probing depth range of 3 mm-7 mm. Generalized moderate plaque and calculus accumulations, posterior interproximal food impaction, and generalized bleeding on probing were also noted.

Treatment planning The patient desired to phase her treatment plan with initial treatment of the maxillary

Figure 2: Pretreatment PA of teeth Nos. 12-15

Matthew Hallas, DMD, joined Bay Lakes Center for Complex Dentistry after several years working with University Associates in Dentistry in Chicago, Illinois. His extensive training in the specialty of prosthodontics gives him advanced skills and knowledge of the latest technologies and utilization of dental materials, including all ceramic restorations, CAD/ CAM restorations, and computer-guided implant surgery. Additionally, Dr. Hallas is an active lecturer for dental study groups and continuing education programs, which keeps him on the leading edge of new developments in the field of prosthodontics.

Disclosure: Dr. Hallas does not have a financial arrangement with any of the companies mentioned in this article.

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left quadrant followed by completion of the maxillary right quadrant at a future date. The following treatment options were discussed with the patient.

Option 1: Removal of teeth Nos. 12 and 14 with hard tissue augmentation, implant

Figure 4: Post-healing flap reflection prior to implant placement

placement at Nos. 12 and 14 sites, implantsupported fixed bridge work with abutments at Nos. 12 and 14, and core buildup tooth No. 15 with a crown.

Option 2: Removal of teeth Nos. 12, 14, and 15 with hard tissue augmentation,

implant placement at No. 12 and 14 sites, and implant-supported fixed bridge work with abutments at Nos. 12 and 14.

The first option was chosen with the understanding that following removal of teeth Nos. 12 and 14 and an adequate amount of

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Volume 13 Number 1

Legacy™ IMPLANT SYSTEM

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Implant practice 19

TECHNOLOGY/CASE STUDY

Figure 3: Mirror image prior to flap reflection

TECHNOLOGY/CASE STUDY healing, that there would be a reduction in the amount of probing depths and mobility on tooth No. 15 to support a restoration with a favorable long-term prognosis.

Surgical phase part 1 Extractions with hard tissue augmentation The patient was premedicated with amoxicillin 500 mg (2 g presurgery followed by 875 mg BID for 7 days, an oral antibacterial rinse (CHG 0.12%), and an NSAID — all starting 1 hour prior to surgery. Local infiltration of the hard and soft tissue in the maxilla was completed at site Nos. 11 through 15 with 2% lidocaine with 1:100,000 epinephrine. Routine dental extractions of teeth Nos. 12 and 14 were completed, and thorough curettage and irrigation of the sites were completed. Maintenance of the buccal plates was accomplished using a minimally traumatic approach. Hard tissue augmentation was completed using a CollaPlug® Absorbable Collagen Wound Dressing (Integra LifeSciences Corp.) technique utilizing creos™ allo.gain corticocancellous 0.25-1.00 mm (Nobel Biocare) and Miltex by Integra HeliPLUG®. Following completion of the procedures, postoperative instructions were given, and a VPro device (Propel Orthodontics) was delivered with instructions to use 5 minutes per day for 8 weeks.

Surgical phase part 2 Implant placement treatment planning Following 4 months of healing, the patient was re-evaluated for implant placement at site Nos. 12 and 14 (Figures 3 and 4). Clinical examination with cone beam CT was completed and revealed tooth No. 15 presented with 1 mm-4 mm probing depths and no clinical sign of mobility (Figures 5A and 5B). Potential future implant sites Nos. 12 and 14 have adequate soft and hard tissue volume for implant placement as originally treatment planned.

Conclusion This case demonstrates the VPro highfrequency vibration device helped improve overall oral health by improving blood flow and circulation, while helping maintain quality bone for implants and normalizing mobility.

At this phase of treatment, the patient had normalized mobility and normalized probing depths of 1 mm-4 mm.

Tooth mobility remains a challenge in restorative dentistry as well as periodontics.

20 Implant practice

Figures 5A-5B: CBCT of teeth Nos. 12-14

While antibiotics, scaling, planing, or laser treatments can decrease the progress of mobility, they do not usually improve the existing mobility.5 In studies, high-frequency vibration has demonstrated a significant increase in biological activity in growth factors4 and a substantial increase in fibroblast PDL.2 It is hypothesized that this stimulation of PDL fibroblasts, along with improved bone volume and density, leads to a stabilizing of mobile teeth.6 The effects of HFV on bone has been extensively studied in orthopedics and orthodontics.7 These data show the HFV has an

anabolic effect through activation of osteoblasts to stimulate bone growth and improve bone density.2,8 High-frequency vibration has also been demonstrated to relieve oral pain and improve blood flow to tissues.4,9,10 The HFV VPro device is noninvasive, requires only 5 minutes of daily use at home, and provides a phone app for tracking usage, which can help overall patient compliance.

While only a case study and more studies are needed, high-frequency vibration may offer a new adjunctive therapy in implant care and a new primary treatment for mobile teeth. IP

REFERENCES 1. Alikhani M Khoo E, Alyami B, et al. Osteogenic effect of high-frequency acceleration on alveolar bone. J Dent Res. 2012;91(4):413-419.

2. Judex S, Pongkitwitoon S. Differential efficacy of 2 vibrating orthodontic devices to alter the cellular response in osteoblasts, fibroblasts, and osteoclasts. Dose Response. 2018;16(3):1-8.

3. Akca K, Sarac E, Baysal U, et al. Micro-morphologic changes around biophysically-stimulated titanium implants in ovariectomized rats. Head Face Med. 2007;3:28.

4. Alansari S, Antiqu MI, Gomez JP, et al., The effects of brief daily vibration on clear aligner orthodontic treatment. J World Fed Orthod. 2018;7(4):134-140.

5. Shaddox L and Walker C. Treating chronic periodontitis: current status, challenges, and future directions. Clin Cosmet Investig Dent. 2010; 2:79-91.

6. Shipley T, Farouk K, El-Bialy T. Effect of high-frequency vibration on orthodontic tooth movement and bone density. J Orthod Sci. 2019;8:15.

7. Cerciello S, Rossi S, Oliva F, et al. Clinical applications of vibration therapy in orthopaedic practice. Muscles Ligaments Tendons J. 2016;6(1):147–156.

8. Alikhani M, Alansari S, Hamidaddin MA, et al. Vibration paradox in orthodontics: Anabolic and catabolic effects. PLoS One. 2018;13(5):e0196540.

9. Shipley T, Brigham G, Sparaga J, Nicozisis J. Effects of a 120Hz high-frequency acceleration device on orthodontic discomfort.

Preprints 2018, 2018100557 (doi: 10.20944/preprints201810.0557.v1).

10. Baxter A. Vibration for chronic pain. Practical Pain Management. 2019;19(2):60-63;67.

Volume 13 Number 1

CASE REPORT

Considerations for guided immediate implant placement Dr. Steven Vorholt illustrates guided immediate implant surgery on teeth Nos. 19 and 18

B

oth immediate implant placement and fully guided implant placement are becoming more popular options for surgical approaches. Combining the two is a winwin and allows a shortened treatment timeline while still maintaining complete control for the best restoratively driven placement.

Dentists investing in new digital technologies in-house can predictably and quickly plan, design, and execute guided immediate implant surgeries where precision is crucial. Implementing a digital workflow can make implant surgeries more efficient, more profitable, and more predictable. Digital imaging technologies allow for unparalleled visualization and foresight, while in-house 3D-printing and CAD/CAM solutions bring the restorative portion under the same roof.

Cone beam computed tomography (CBCT) and digital intraoral scanning systems simplify treatment planning and help avoid surgical complications in advance. Rather than separating the surgical and restorative aspects of the treatment, combining the CBCT and the intraoral scan of the patient’s dentition leads to restoratively driven implant placement and makes the entire process more predictable.

Planning alone is only as good as the clinician’s surgical skills. Knowing the location of possible complications is a huge advantage, but using surgical guides further minimizes risk. Using the combined radiographs and models to design a surgical stent, which can be 3D-printed and used during surgery, and designing the surgical stent based on the planned ideal position on the computer from start to finish mean more control and confidence at the actual surgery. Bringing the digital placement of the implant into the operatory allows your surgeries to be performed with more control and confidence.

Placing the implant exactly as planned makes the restorative portion of the treatment very straightforward. In-office CAD/ CAM systems allow the dentist to take digital impressions, design the final prosthesis, and fabricate it without outsourcing.

Volume 13 Number 1

Figure 1: Initial presentation PA. Patient reported intermittent pain on the LL. Tooth No. 19 has gross recurrent decay and had to be directly restored once before. Determined tooth to be nonrestorable and require extraction. Note the mesial root socket’s parallelism to No. 20 — a good candidate for immediate implant placement into the molar socket

Figure 2: Intraoral presentation. No. 19 metal crown over 10 years old; No. 18 been missing over 5 years; and the third molar is still present and in function. Good remaining width of ridge in the lower quadrant thanks to the presence of third molar

This workflow is impressive to patients and is more efficient and cost-effective for the dental team. Often this process can even be accomplished during the day of surgery to further speed up the treatment timeline.

In conclusion, new digital technologies and techniques help establish an optimized workflow for in-house surgeries and restorations. The following case highlights how I’ve used immediately guided digital protocols for the surgery and final restoration.

Case presentation and review A healthy 69-year-old Caucasian male patient presented at a regular hygiene exam with a recent history of “on-and-off pain” from the lower left quadrant (Figure 2). The patient’s health history detailed controlled high blood pressure, controlled gastric reflux, and a history of arthritis.

Routine bitewing radiographs and periapical radiographs (Figure 1) revealed gross recurrent decay along the distal margin of a previously directly repaired metal crown margin. Food was occasionally getting trapped under the gum distal to the tooth and causing irritation. The tooth was deemed nonrestorable due to caries extending to the bone level and the margin of the decay being on the distal root. A recommendation was made to have the tooth removed and replaced with a dental implant. An alginate

Figure 3: Lower full arch alginate taken and digitally scanned with Shining 3D DS-EX Desktop Scanner

impression of the lower jaw was taken and scanned using the Shining 3D® DS-EX desktop scanner (Shining 3D®, San Francisco, California), and a 11 x 10 cm CBCT was exposed with a Dentsply Sirona Orthophos SL 3D (Dentsply Sirona, Charlotte, North Carolina) machine.

The digitized model (Figure 3) was loaded in the Blue Sky Bio (Libertyville, Illinois) digital Steven Vorholt, DDS, is a general dentist who focuses on dental implant surgery and restoration. He is currently the Implant Director at the New Horizon Surgical Clinic in Tempe, Arizona.

He is also full-time faculty at Implant Pathway and faculty for NYU’s AEGD Program at New Horizon Dental Clinic. Dr. Vorholt is actively working toward his associate fellowship in the AAID and plans to continue toward his Diplomate in the ABOI.

Implant practice 21

CASE REPORT

Figure 4: No. 19 digitally extracted and new model made for implant surgical guide design

Figure 5: Implants planned for edentulous second molar site and immediate first molar

Figure 6: Implant planning overlaid over CBCT scan data

Figures 7A and 7B: A. Implant planning overlaid over digitally altered final model. B. Implant surgical guide is designed in Blue Sky Plan and exported for 3D printing

Figure 8: Digital treatment plan sagittal view showing planned parallelism of implants and mesial root socket placement

implant planning software Blue Sky Plan.

Tooth No. 19 was digitally extracted (Figure 4) to allow for the design of a surgical guide for the immediate placement. The patient had been missing tooth No. 18 for over 5 years and was encouraged to replace both teeth in one surgical appointment. Implants were planned in the software to be restoratively driven and parallel (Figures 5-7A). The mesial root space of tooth No. 19 was parallel to the root of tooth No. 20 and was utilized in the planned location of the 5.0 x 13 mm Blue Sky Bio Bio|Max dental implant. Figure 7 shows the use of the native bone apical to the mesial root socket for added initial stability. Tooth No. 18 was planned for a 5.0 mm x 8 mm Blue Sky Bio Bio|Max implant into the healed ridge of the second molar space. Tooth No. 17 later had enameloplasty performed on the mesial surface to accommodate two screwretained restorations.

The digital plan for the implant locations is viewed utilizing the parallel root space of tooth No. 19 and the healed site for tooth No. 18 (Figures 8 and 9). A longer implant for tooth No. 18 (Figure 10) could have been used, but I have found no advantage of additional length past 8 mm in a healed site and wanted to avoid a longer “wag” factor being introduced into the system, which could amount to the

Figure 9: Digital treatment plan coronal view of No. 19 — 5.0 x 13 mm Blue Sky Bio Bio|Max dental implant

Figure 10: Digital treatment plan coronal view of No. 18 — 5.0 x 8mm Blue Sky Bio Bio|Max dental implant

No. 18 implant being difficult to restore if the dense lingual cortical plate or the distal root socket of No. 19 interfered with the guided placement. The guide was exported (Figure 7B) and printed on a MoonRay S 3D Printer (SprintRay, Los Angeles, California) using FDA-approved surgical guide resin. Initial treatment plan to being ready for surgical appointment was less than 24 hours.

Tooth No. 19 was atraumatically removed by sectioning the roots and utilizing luxators and elevators to remove the two roots independently of each other (Figure 11). The

guide seat was confirmed for fit and stability (Figure 12) and an intrasulcular incision for envelope flap one tooth mesial and distal to the surgical site. Implant No. 18 was placed first, and a Penguin RFA device was used to record the implant stability quotient (ISQ) of 76 (Figure 13). The osteotomy was completed for tooth No. 19 and corticocancellous 50:50 allograft mix (Maxxeus™ Dental, Kettering, Ohio), mixed with fusion bone binder (Woodland Hills Pharmacy, Woodland Hills, California), was placed in the socket for No. 19 (Figure 14). The guide

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Volume 13 Number 1

CASE REPORT

Figures 11 and 12: 11. Midcrestal and envelope flap after atraumatic extraction of first molar.

12. Confirm seat of 3D-printed surgical guide. Guide designed in Blue Sky Plan (Blue Sky Bio) and printed on a MoonRay S 3D Printer (SprintRay)

Figure 13: Second molar implant placed into healed ridge first. Platform is exposed on the mesial to the distal socket space of first molar.

Will be filled with graft material. ISQ taken with Penguin RFA device measured at 76

Figure 14: Graft material placed into mesial socket of the first molar. Maxxeus Dental 50:50 corticocancellous allograft 0.5-1.0 mm particle size. Mixed with Fusion Bone Binder (Woodland Hills Pharmacy)

Figures 15 and 16: 15. Final implant drill ran in reverse at 50 rpm with no irrigation to gently push the graft out of the osteotomy and condense on socket walls. Implant placed with ISQ measured at 78 with Penguin RFA Device. 16. Pericardium membrane (Maxxeus Dental) tucked under flap and secured with PTFE 3-0 sutures utilizing a continuous double interlocking technique

Figure 17: Final placement PA. Graft material can be viewed filling the distal socket as well as covering the molar in the mesial socket of the first molar. Figure molar implant is parallel to second premolar, and second molar implant splits the difference between third molar and first molar path of draw

Figure 18: Post-op CBCT sagittal slice. Compare to Figure 8

Figure 19: Post-OP CBCT coronal slice for first molar immediate implant. Compare to Figure 9

Figure 20: Post-OP CBCT coronal slice for second molar healed ridge implant. Compare to Figure 10

was replaced, and the final osteotomy drill run at 50 rpm in reverse without water to push the graft material apical and outward from the osteotomy (Figure 15). The 5.0 x 13 mm BSB Bio|Max implant was placed and

ISQ recorded at 78. Both implants torqued out >30Ncm and had cover screws placed.

A large pericardium long-term resorbable membrane was tucked under the flap, and 3-0 PTFE suture material was used in a

continuous double-interlocking design to approximate the flap (Figure 16).

Immediate post-op PA (Figure 17) and 5 x 5 cm quadrant CBCT was exposed (Figures 18-20) showing guided placement to be very

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Implant practice 23

CASE REPORT

Figure 21: Two-week healing check, membrane still well secured, and secondary intention well underway for the immediate implant site. Patient reports no discomfort since surgery

Figure 24: PA at placement of transmucosal healing abutments

close to the ideal planned placement. Implant No. 19 was placed 2 mm subcrestal to the remaining buccal plate of No. 19, and No. 18 was placed 1 mm subcrestal to the healed ridge. Figure 19 shows adequate distance between the implant and the inferior alveolar nerve (IAN) canal and midcrestal placement. Post-op instructions were given to the patient, and he was released. The surgical appointment lasted 1 hour.

The patient was seen for a 2-week follow-up and suture removal (Figure 21), and he reported mild discomfort for the first 2 days. The patient also reported that OTC ibuprofen was enough to mask any discomfort, and that he had not experienced any problems since. Pericardium membrane was still intact and buried under the flap; PTFE sutures were removed; and the patient was rescheduled for 4 months for uncovery and transmucosal healing abutment placement.

The patient returned 4½ months after original surgery date for uncovery. Tissue was fully healed and pericardium membrane 24 Implant practice

Figures 22 and 23: 22. Five months’ uncovery visit initial presentation. 23. Uncovery and placement of transmucosal healing abutments. Three simple interrupted gut sutures to allow interproximal soft tissue to granulate in additional keratinized gingiva.

Implant No. 19 ISQ measured at 81 (from 78) and No. 18 ISQ measured at 84 (from 76) with Penguin RFA Device

Figures 25 and 26: 25. Three weeks of healing with transmucosal healing abutments — final tissue photo. 26.

CEREC scan caps placed on Blue Sky Bio 1.8 mm collar tibase. Scanned with CEREC Bluecam (Dentsply Sirona)

Figures 27 and 28: 27. Due to slight implant placement angulation differences, the distal contact of No. 19 is planned parallel to the implant path of draw for No. 18. No. 19 will be seated first, and then No. 18 path of draw will be parallel to the contacts on the distal of No. 19 and mesial of No. 17. CEREC’s software allows direct control of these contours. 28. Another view of the distal contact of No. 19 using CEREC’s grid mode in the design software

was resorbed (Figure 22). The midcrestal incision was made, and No. 19 required bone profiling (Blue Sky Bio Bone Profile Kit) to get the healing abutment to fully seat. Transmucosal healing abutments were placed, and three interrupted gut sutures were used (Figures 23-24).

Two weeks after uncovery, the patient returned for final digital impressions. Healing abutments were removed (Figure 25), and the healthy keratinized gingiva surrounding the implants was visualized. Blue Sky Bio 1.8 mm collar tibases were placed on the implants, and Sirona Scan Caps were placed Volume 13 Number 1

Figure 32: Immediate post-seat PA showing broad contact between implants and full-seated tibase

Figure 31: Immediate post-seat intraoral photo

Figure 34: One-year follow-up PA showing final bone levels

Figure 33: One-year follow-up occlusal photo

Final thoughts

Figure 35: One-year follow-up left excursive movements Volume 13 Number 1

Dental implant surgery can be made more efficient, more profitable, and more predictable with the use of digital technologies and digital-planning software.

From the initial treatment planning, the surgical appointment, and through the final restoration, this entire process took place in-office with no outsourcing of materials or costs. IP Implant practice 25

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Figures 29 and 30: 29. No. 18’s mesial contact broad and parallel to No. 19. 30. Buccal view of final restorations

for digital impression (Figure 26). An impression was taken with CEREC Bluecam (Sirona Dentsply) with 4.5.1 software, healing abutments were replaced, and the patient was rescheduled for final delivery 3 days later.

The scan was loaded in CEREC 4.5.1 software to design the screw-retained implant crowns. The distal contour of No. 19 was made parallel to the angulation of the No. 18 implant (Figure 27) to facilitate screw-retained restorations. The No. 19 implant crown was placed first and the No. 18 crown placed second. Contacts were refined (Figures 28 and 29) to be broad, long, and parallel to the insertion angulation of No. 18. The buccal view was compared to ensure it fits the patient’s occlusion (Figure 30).

Three days later, the patient returned for delivery of two screw-retained IPS e.max® crowns (Ivoclar Vivadent, Amherst, New York). The crowns were luted to the tibases outside the mouth with RelyX® Luting cement (3M ESPE, St. Paul, Minnesota) and cleaned of excess before insertion. Both crowns were inserted and contacts verified (Figure 31). Final seat PA (Figure 32) confirmed full seating of the implant crowns and good crestal bone levels at 5 months. Note the distal contour of No. 19 paralleling the implant insertion angulation of No. 18 just like the plan in CEREC software. The ability for the practitioners to design this themselves allows increased flexibility for restoring sideby-side implant restorations.

One-year follow-up photos and periapical radiograph (Figures 33 and 34) show that tissue is very healthy, the patient has reported no problems or food traps, and bone levels have been maintained. The crestal bone can be seen to possibly have condensed further after 1 year of loading the implants. The excursive occlusion is checked at each hygiene recall appointment (Figure 35) to account for occlusion changes to the remaining dentition that can affect implant contacts.

CONTINUING EDUCATION

Essentials for using CBCT in implant dentistry: technical considerations Dr. Johan Hartshorne highlights technical aspects practitioners need to consider before adding a cone beam computed tomography unit to their practice

T

he development of inexpensive X-ray tubes, high-quality detector systems, and powerful personal computers has paved the way for commercially available and affordable 3D cone beam computed tomography (CBCT) imaging systems for dental practices.

This article is the first of a series providing clinicians with an overview of technical considerations relating to basic elements of CBCT hardware, types and characteristics of different CBCT units, the fundamental principles of the CBCT imaging workflow chain, and the benefits and limitations of incorporating a CBCT unit into your practice. It also aims to provide some guidelines and recommendations on what factors must be considered when purchasing a CBCT unit.

These technical considerations are intended to enhance the practitioner’s understanding of the fundamental principles required for safe and effective use of this technology. CBCT technology is increasingly being introduced into the dental practice setting due to its invaluable diagnostic and communication capabilities, high quality and accurate images, ease of use, and suitability.

Introduction Intraoral and extraoral 2D radiographic imaging procedure (periapical, lateral cephalometric, and panoramic), traditionally used for preoperative dental implant diagnostics and treatment planning, suffer from the same inherent limitations common to all planar 2D projections — namely, magnification, distortion, superimposition, and misrepresentation of structures (Scarfe and Farman, 2008).

Although numerous efforts have been made toward developing 3D radiographic imaging — such as stereoscopy, tuned aperture computed tomography, and multidetector computed tomography (MDCT) — the use of these advanced CT imaging techniques Johan Hartshorne, BSc, BChD, MChD ,MPA, PhD(Stell) FFPH. RCP(UK) is a general dental practitioner at Intercare Medical and Dental Centre, Tyger Valley, South Africa.

26 Implant practice

Educational aims and objectives

This clinical article aims to present an overview of CBCT technology and suggest guidelines to follow when incorporating it into an implant practice.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 35 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify the basic elements of CBCT hardware, the fundamental principles of the associated workflow, and the practical benefits and limitations of this technology.

•

Identify the characteristics of the X-ray source in a CBCT unit.

•

Identify various types of CBCT units available in dentistry.

•

Realize the steps in the workflow of image capture.

•

Define the Ray-sum technique.

•

Recognize some limitations of CBCT.

•

Realize some benefits of implementing CBCT.

has been unavailable or limited for most dental practitioners because of cost, physical complexity and size, and high-radiation dose considerations (Scarfe and Farman, 2008).

The development of inexpensive X-ray tubes, high-quality detector systems, and powerful PCs has paved the way for commercially available and affordable 3D CBCT imaging systems, small enough to be used in dental practice (Scarfe et al, 2006).

Since its introduction for the maxillofacial region by Italian co-inventors Attilio Tacconi and Piero Mozzo in 1998, CBCT imaging has become an important and established diagnostic tool for the clinical assessment and treatment planning of patients needing dental

implants (Sato, et al., 2004; Kobayashi, et al., 2004; Hatcher, et al., 2003). The value of CBCT imaging as a diagnostic tool has also been reported for various other fields of dentistry, such as oral-maxillofacial surgery, dental traumatology, endodontics, temporomandibular joint, periodontology, orthodontics, and forensic odontology (Scarfe and Farman, 2008; Alamri, et al., 2012).

The widespread use of CBCT scanners, however, has resulted in several concerns for clinicians regarding: • Indications, justification, and optimization of CBCT exposures • Training to optimize safe and effective use of CBCT in the clinical setting • Quality assurance of CBCT scanners It is, therefore, important for clinicians to have a full understanding of the technical principles of dental CBCT imaging to purchase the correct machine, and using it correctly and effectively to reap the full benefit, while minimizing radiation-related patient risk (Schulze, et al., 2011).

CBCT imaging hardware Figure 1: Basic elements of CBCT imaging hardware — X-ray source on the left, image detector or sensor on the right, and the gantry or rotating platform that connects the X-ray source and the detector

CBCT imaging hardware consists of three basic elements: • X-ray source (X-ray generator) • Image detector (sensor) Volume 13 Number 1

Figure 3: Conversion of incoming X-ray photons to an electrical signal by the image detector

• Gantry (C-arm or rotating platform) that connects the X-ray source and the detector (Figure 1).

X-ray source An X-ray beam is generated in a tube containing an electrical circuit with two oppositely charged electrodes (such as cathode and anode) separated by a vacuum (Figure 2). The cathode is composed of a filament that gets heated when an electric current is applied, inducing the release of electrons through thermionic emission.

Because of the high voltage between the cathode and anode, these released electrons will be accelerated toward the anode, colliding with it at high speeds at a location called the focal spot. Ideally, this focal spot is point-sized, but typical focal spots in CBCT are 0.5 mm wide; the size of the focal spot is one of the determinants of image sharpness (Pauwels, et al., 2015). The energy generated through this collision is mainly lost as heat, but a small part is converted into X-rays through bremsstrahlung. (Editor’s note: According to the Merriam-Webster dictionary, bremsstrahlung is “the electromagnetic radiation produced by the sudden deceleration of a charged particle in an intense electric field (as of an atomic nucleus).”

X-rays are emitted in all directions, but absorption within the anode and the tube housing results in a beam emerging from the tube perpendicular to the electron beam. The anode surface is slightly tilted to maximize the outgoing X-ray beam through the exit window of the tube (Pauwels, et al., 2015).

A lead alloy collimator is used to block X-rays not passing through the scanned volume or region of interest (ROI), thus reducing patient exposure.

Most CBCT systems have multiple, predefined field-of-view (FOV) sizes, so a collimator will have several pre-defined openings according to the FOV sizes (Pauwels, et al., Volume 13 Number 1

Figure 4: The X-ray source and reciprocating image detector synchronously moves 180° to 360° around the patient’s head

Figure 5: Head restraint mechanism to minimize movement and limit motion artifacts during the 3D-scanning process

2015); thus, collimation of the X-ray beam by adjustment of the FOV limits the radiation to the ROI only. Furthermore, collimation defines the width and height of the primary X-ray beam, and size of the reconstructed FOV. The cone-shaped X-ray beam has two primary characteristics: quality and quantity. Quality refers to the overall energy of the photons in the X-ray beam. Factors that affect (increase or decrease) X-ray beam quality are peak kilo voltage (kVp), filtration, and the type of waveform used. Quantity refers to the number of photons in the X-ray beam.

When the number of photons increases, beam intensity increases, affecting X-ray beam quantity. This is affected by change in tube anode current (mAs), kVp, filtration, and changes in distance from the tube.

Beam hardening refers to the process in which the quality (energy) of an X-ray beam is increased by removing lower energy photons with appropriate filtration. Exposure can be controlled either automatic or manual adjustment of kVp or mAs.

detectors (also referred to as “sensors”) used in contemporary CBCT units: either a charge-coupled device with a fiber-optic image intensifier detector or an amorphous silicon flat-panel detector. During the initial introduction of CBCT, most units were constructed with the large, bulky imageintensifier detectors.

Most CBCT scanners have nearly all transitioned to the smaller, flat panel linear array detectors (Abromovitch and Rice, 2014). Besides being less bulky and having a smaller footprint, the flat panels have minimal distortion of the image dimensions at the periphery of an image display, a higher dose efficiency, a wider dynamic range, and can be produced with either a smaller or larger FOV8; hence, these units are considered to generate better data volume sets.

Image detector X-ray detectors convert the incoming X-ray photons to an electrical signal and are a crucial component of the imaging chain (Figure 3). There are two types image

Gantry Most dental CBCT systems have a fixed C-shaped rotating platform or gantry with the X-ray source and the image detector mounted on opposite sides of the C-arm or gantry (Figure 4). During a CBCT scan, the C-arm or gantry performs a partial (180°) or full rotation (360°), in which the X-ray source and reciprocating area detector synchronously move around the patient’s head (Figure 4).

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Figure 2: Basic elements of a CBCT X-ray source

CONTINUING EDUCATION Some CBCT devices offer the opportunity to select a partial rotation with a reduction of radiation dose to the patient (Pauwels, et al., 2015). The patient’s head is stabilized during the rotation process with a head restraint device, while capturing multiple 2D images at different intervals, also known as “basis” images of the FOV. These series of basis images are referred to as projection data or data volume (Pauwels, et al., 2015).

The head restraint mechanism (Figure 5) is used to minimize movement and to limit motion artifacts during the 3D scanning process (Scarfe and Farman, 2008).

Figure 6: Different types of CBCT units categorized according to orientation of the patient during image acquisition. (left) Seated patient position. (middle) Standing patient position. (right) Supine patient position

Types of CBCT machine There are several different dental CBCT machines that vary in their design, footprint, detector configurations, and protocol selection features. CBCT machines can be categorized according to orientation of the patient during image acquisition (Figure 6) and the scan volume, also referred to as FOV-irradiated (Scarfe and Farman, 2008) (Figure 7).

Patient orientation There are three types of CBCT gantries that can scan patients in different positions (Figure 6): seated, standing, and supine.

Each has advantages and disadvantages.

Scanners allowing for standing patient positioning are usually more accommodating for wheelchairs (Figure 8) and occupy no more space than a panoramic radiography device.

However, some standing units may not be able to be adjusted to a height to accommodate wheelchair-bound patients.

Seated units, on the other hand, are more comfortable. However, fixed seats may not allow scanning of physically disabled or wheelchair-bound patients. Additionally, scanners with a built-in chair or table occupy a larger space. CBCT scanners that require the patient to lie supine occupy a larger surface area and may not be accessible for patients with physical disabilities.

Scan volume or field of view CBCT machines can also be categorized according to the available FOV or selected scan volume height as follows (Figure 7): • Localized region: approximately 5 cm or less (such as dentoalveolar and temporo-mandibular joint) • Single arch: 5 cm to 10 cm (such as maxilla or mandible) • Interarch: 7 cm to 10 cm (such as mandible and superiorly to include the inferior concha) 28 Implant practice

Figure 7: CBCT units can also be categorized according to scan volume or FOV irradiated

Figure 8: Scanners allowing for standing patients are usually more accommodating for wheelchairs

Figure 9: Image workflow stages of a 3D CBCT scanner

• Maxillofacial: 10 cm to 15 cm (such as mandible and extending to Nasion) • Craniofacial: greater than 15 cm (such as from the lower border of the mandible to the vertex of the head).

The FOV is an important parameter that defines a CBCT imaging protocol. It represents collimation of the beam size to a predetermined area. Adjusting the FOV determines the size of anatomic coverage, image resolution, and patient radiation dose. In general, clinicians should select the smallest FOV that provides adequate anatomic coverage and adequate image resolution (www.sedentexct.eu/files/radiation_protection_172.pdf). For most units, a smaller FOV is acquired using a smaller voxel size and thus has higher spatial resolution.

Additionally, the reduced scatter radiation with a smaller FOV also contributes to improved image quality. Typically, the radiation dose decreases with a smaller FOV size (Mallya, 2015). FOV limits depend on the

detector size and shape, beam projection geometry, and the ability to collimate or not.

It is desirable to limit the FOV to the smallest volume that can accommodate the ROI.

Image workflow: 3D CBCT scanner CBCT image production workflow consists of four stages: • Acquisition • Detection • Reconstruction • Display of the image (Scarfe and Farman, 2008) (Figure 9) Acquiring the scan Depending on the type of cone beam imaging system used, the subject may be positioned in a standing, sitting, or supine position, with the head or area of interest placed at the center of the CBCT system.

After situating the patient, the head is stabilized with a restraint mechanism and chin rest to minimize movement during scanning.

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Figure 10: Pixel is the basic 2D image picture element, while a voxel is 3D picture element and represents the smallest individual volume element of a 3D scan

variation in reported cone-beam unit dosimetry (Scarfe and Farman, 2008).

Depending on the mAs, a 180° rotation protocol can lead to a slight or more pronounced increase in noise than in a 360° protocol. A partial rotation and reduced sampling associated with shorter scan time tends to decrease overall image quality due to the amount of noise associated with reduced mAs (Pauwels, et al., 2015).

More projection data from a 360° rotation protocol provides more information to reconstruct the image; allowing for greater spatial and contrast resolution; increasing the signal-to-noise ratio, producing “smoother” images; and reducing metallic artifacts.

However, more projection data usually necessitate a longer scan time, a higher patient dose, and longer primary reconstruction time. In accordance with the “as low as reasonably achievable” (ALARA) principle, the number of basis images should be minimized to produce an image of diagnostic quality (Scarfe and Farman, 2008).

size can vary from 0.12 mm to 0.4 mm. The lower pixel-size image takes more exposure time (20 to 40 seconds) and more radiation.

It is very susceptible to movement distortion. Thus, even though small pixelsize images lend more definition to smaller object areas, the risk of movement distortion makes it impractical for most applications. Therefore, imaging subtle pathology, such as caries, root fractures, or periodontal bone loss, is not practical due to movementrelated distortion.

Detecting the image During scan rotation, a divergent pyramidal or cone-shaped source of ionizing radiation is directed through the middle of the ROI (fulcrum), and the transmitted attenuated radiation is projected onto the detector on the opposite side (Figure 4). The X-ray source emits X-ray photons. The scintillator in the detector absorbs the X-ray photons and converts them into light. The photodiode array in the amorphous silicon panel absorbs the light and converts it into an electronic charge (Pauwels, et al., 2015).

Each photodiode represents a pixel or 2D picture element (Figure 10). The electronic charge at each pixel is read out by low-noise electronics to provide digital data. This data is transmitted to, and collected at, a dedicated computer.

The pixel size of the detector is the principle determinant of the voxel size (3D picture element) (Figure 10). Detectors with small pixel size capture fewer X-ray photons per voxel and result in more noise. In CBCT, pixel

Reconstructing the image In a single rotation, the detector can generate anywhere between 150 to 600 high-resolution 2D basis images. The basis images, each with more than one million pixels with 12 to 16 bits of data assigned to each pixel, is transferred to a processing computer for reconstruction using software programs incorporating sophisticated algorithms, including back filtered projection to construct a 3D image, also known as a volumetric data set (Scarfe, et al., 2006).

The most widespread form of 3D-filtered back projection in CBCT uses the Feldkamp-Davis-Kress algorithm (Pauwels, et al., 2015). Reconstruction time is usually less than 3 minutes for standard resolution scans (Scarfe and Farman, 2008) and is dependent on the quality of the software and computer hardware. Once the basis images are reconstructed, they can be recombined into a single digital 3D image or volumetric data set for visualization by the clinician.

Figure 11: The 3D volumetric data set is a compilation of all available voxels presented to the clinician (stage 2) and presented to the clinician in real-time onscreen as secondary reconstructed 2D cross-sectional images in three orthogonal planes (axial, sagittal, and coronal) (stage 3)

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The frame rate, speed of rotation, FOV, and completeness of the trajectory arc are set manually or automatically to get the image desired.

The X-ray source produces a coneshaped beam of ionizing radiation that passes through the center of the ROI in the patients’ head to the X-ray detector on the other side. A single partial or full rotational scan from the X-ray source takes place, while the reciprocating detector moves synchronously with the scan around a fixed fulcrum within the ROI (Scarfe and Farman, 2008).

This fulcrum acts as the center of the final acquired volume imaged. During the scan rotation, each projection image is made by sequential image capture of the attenuated X-ray beam by the detector.

While rotating, the X-ray source emits radiation in a continuous or pulsed mode, allowing 2D projection radiographs or basis images (Scarfe and Farman, 2008). In a single rotation, the detector can generate between 150 to 600 high-resolution 2D basis images (Pauwels, et al., 2015). The series of basis images are referred to as projection data. Typical rotation times range between 10 and 40, although faster and slower scan protocols exist.

Technically, the easiest method of exposing the patient is to use a continuous beam of radiation during the scan rotation and allow the X-ray detector to sample or capture single images of the attenuated X-ray beam in its trajectory. However, continuous radiation emission does not contribute to the formation of the image and results in greater radiation exposure to the patient (Abromovitch and Rice, 2014).

In most contemporary units, the X-ray beam exposure is pulsed to coincide with the detector sampling. Pulsed X-ray beam exposure at intervals allows time between basis image acquisition for the signal to be transmitted from the detector area to the data storage area and the detector to rotate to the next site or angle of exposure. Hence, the X-ray tube does not generate X-rays for the entire rotational cycle, meaning radiation exposure time is markedly less than scanning time (Abromovitch and Rice, 2014).

The total scan time is equivalent to exposure time, where the X-ray tube allows only continuous exposure. In comparison, for CBCT scanners using pulsed exposure, the exposure time is markedly less than scan time; thus, pulsed X-ray beam generation is preferable as it results in less radiation dosage to the patient. Pulsed X-ray beam exposure is a major reason for considerable

CONTINUING EDUCATION The voxel is the smallest individual volume element in the 3D environment and determines the spatial resolution of the image (Figure 10). They are cubic in nature and equal in all dimensions (isotropic). When viewed as a digital image, the pixel size controls the resolution. The smaller pixel size yields a higher resolution image and, conversely, the larger the pixel size, the lower the resolution or quality of the image.

Displaying and manipulating the image CBCT technology provides a complete digital model at the end of the process. The software also provides the clinician with a relatively large choice of display formats, allowing for 2D, 3D, and panoramic views of the mouth and head, along with other viewing options to help focus on areas of interest.

The default presentation of the 3D volumetric data set is a compilation of all available voxels presented to the clinician in real time on screen, as secondary reconstructed 2D cross-sectional images in three orthogonal planes (axial, sagittal, and coronal) for visualization and manipulation (Figure 11).

Axial planes are a series of slices from top to bottom in the volume. Sagittal planes are a series of 2D slices from left to right, and coronal planes are a series of 2D slices from front to back. Each panel of the display software presents one of a series of contiguous images in that plane. Each image is inter-relational, such that the location of each image in the sequence can be identified in the other two planes.

CBCT data should be considered as a volume to be explored from which selected images are extracted.

Optimizing image data Technically, four stages are recommended to provide an efficient and consistent systematic approach to optimize CBCT image display before interpretation namely: • Reorientation • Optimization • Viewing • Formatting the data Reorientation One of the advantages of CBCT is the resultant volumetric data set can be reoriented in all three planes using PC-based software. Initial adjustment of the volumetric data set should include reorientation, such that the patient’s anatomic features are realigned symmetrically according to three orthogonal reference planes, namely axial or horizontal 30 Implant practice

Figure 12: The volumetric data can be reorientated, so the region of interest is realigned symmetrically in three orthogonal planes: axial or horizontal plane (top to bottom views) (upper left); sagittal (right to left or mesial to distal) (upper right); coronal or frontal plane (front to back or buccal to lingual) (lower right); and 3D rendering is lower left for real-time visual and dimensional assessment

plane (top to bottom cross sections), coronal or frontal plane (front to back cross section), and sagittal plane (right to left or buccal to lingual cross sections) (Figure 12).

This stage is particularly important for aligning subsequent cross-sectional, transaxial images perpendicular to the structure of interest, such as to visualize single tooth pathology, or to measure the maximal height and width of the residual alveolar ridge in an edentulous segment for implant site assessment.

Data can be reoriented so the patients’ anatomic features are realigned. Cursordriven measurement algorithms provide the clinician with an interactive capability for real-time dimensional assessment and pre-implant treatment planning in all three planes. On screen measurements provide dimensions free from distortion and magnification. Basic image enhancement includes magnification.

Optimize Great variability can exist in the overall density and contrast of orthogonal images between CBCT units, and within the same unit depending on patient images and scan parameters selected. Therefore, to optimize image presentation and facilitate diagnosis, it is often necessary to adjust contrast (window) and brightness (level) parameters to favor bony structures.

Although CBCT proprietary software may provide for window and level presets, it is advisable these parameters are optimized for each scan. After these parameters are set, further enhancements can be performed by the application of sharpening, filtering, and edge algorithms.

The use of these functions must be weighed against the visual effects of increased noise in the image. After these adjustments, secondary algorithms (such as annotation, measurement, and magnification) can be applied with confidence.

Viewing Because there are numerous component orthogonal images in each plane, it is impractical to display all slices on one display format. Therefore, it is necessary to review each series dynamically by scrolling through the consecutive orthogonal image “stack.”

This is referred to as a “cine” or “paging” mode. This review process will be described in greater detail in part two of this series.

CBCT software programs allow scrolling through the stack of images. A cursor represented by two crossing lines indicates the precise localization in virtual space. The data set can also be rotated, panned or zoomed to allow visualization of the ROI — at any angle, scale, or position. It is recommended scrolling be performed cranio-caudally (from head to toe) and in reverse, slowing down in areas of greater complexity (inferior alveolar nerve, maxillary sinus). This scrolling process should be performed at least in the coronal and axial planes. Viewing orthogonal projections at this stage is recommended as an overall survey for disease and establish the presence of any asymmetry.

Formatting CBCT software provides three basic nonorthogonal display formatting options for 3D volumetric data: • Multiplanar reformatted images (linear and curved oblique) Volume 13 Number 1

reformation. PC-based or third-party software facilitates dynamic interaction with the clinician to provide task-specific display modes useful in dentistry (Figure 2).

Multiplanar reformatting Because of the isotropic nature of image acquisition, the volumetric data set can be sectioned non-orthogonally to provide nonaxial 2D planar images, referred to as multiplanar reformatting (MPR).

In an MPR window, axial, coronal, and sagittal orthogonal planar views are related through intersection lines or crosshairs, allowing for straightforward orientation and navigation (Pauwels, et al., 2015). MPR A, C and S indicate intersection lines corresponding with axial, coronal, and sagittal planes, respectively.

MPR modes can be viewed in three basic formats namely, linear oblique, curved planar,

Figure 13: Ray-sum image (upper right) and volume rendering image (lower left)

Figure 14: Example of serial transaxial images Volume 13 Number 1

and serial trans-axial reformations (Scarfe, et al., 2006): • Linear oblique technique creates nonaxial 2D images by transecting a set or “stack” of axial images. Several anatomic structures are not particularly well visualized and represented as displayed in orthogonal planes, and oblique reformatting can be useful in these instances. Oblique images are most often used to transect and evaluate specific structures, such as the mandibular condyle, temporomandibular joint (TMJ), and impacted third molars (Scarfe, et al., 2006).

• Curved oblique technique for planar reformation creates non-axial 2D images by aligning the long axis of the imaging plane with a specific anatomic structure. This mode is useful in displaying the dental arch, providing familiar panorama-like thinslice images (Figures 12 and 13).

Images are undistorted, so measurements and angulations made from them have minimal error (Scarfe, et al., 2006). Panoramic MPR reconstructions are useful for jaw evaluation. Such reconstructions must be thick enough to include the entire mandible to avoid missing disease.

• Serial trans-axial technique produces a series of stacked sequential crosssectional images orthogonal to the oblique or curved planar reformation.

Images are usually thin slices (1 mm thick) of known separation or interval (1 mm apart). Resultant images are useful in the assessment of specific morphologic features — such as alveolar bone height and width for implant site assessment, the inferior alveolar canal in relation to impacted mandibular molars, condylar surface and shape in the symptomatic TMJ, or evaluation of pathological conditions affecting the jaws (Scarfe, et al., 2006). Cross-sectional images are optimal for examining teeth and alveolar bone (Figure 14).

Ray-sum technique The ray-sum technique is used to produces images of increased sliced thickness. The slice thickness of orthogonal or MPR images can be “thickened” by increasing the number of adjacent voxels included in the display. This creates an image slab that represents a specific volume of the patient, referred to as a ray-sum (Figure 13).

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• Ray-sum images (Figure 13) • Volume rendering (indirect or direct) (Figure 13) or serial trans-axial (Figure 14).

Each image display option should be selected on visualizing specific anatomic features or functional characteristics of the volumetric data set. These images can be used to highlight specific anatomic regions and diagnostic tasks. Overall, selection should be based on applying thin sections to show detail and thicker sections to demonstrate relationships.

Protocols incorporating FOV scan exposure parameters and display modes should be applied selectively to highlight anatomic features or functional characteristics within a specific diagnostic task. Most volumetric data sets can be sectioned non-orthogonally to provide multiple or a series nonaxial 2D images, referred to as multi-planar

CONTINUING EDUCATION The thickness of the slab is usually variable and determined by the thickness of the structure to be imaged. Full-thickness perpendicular ray-sum images can be used to generate simulated projections, such as a panoramic X-ray or lateral cephalometric images. This mode can be used to generate simulated panoramic images by increasing the slice thickness of curved planar reformatted images along the dental arch to 25 mm to 30 mm, comparable to the in-focus image layer of panoramic radiographs (Figure 13).

In contrast to conventional radiographs, these ray-sum images are without magnification and parallax distortion. However, this technique uses the entire volumetric data set, and interpretation is negatively affected by “anatomic noise” – the superimposition of multiple structures – also inherent in conventional projection radiography. Unlike conventional radiographs, ray-sum images are without magnification and undistorted (Sato, et al., 2004).

Volumetric rendering Volumetric rendering techniques, also referred to as 3D renderings (Figures 12 and 13), allow the visualization of 3D data by selective display of voxels. This can be achieved by direct volume rendering providing a volumetric surface reconstruction with depth, or indirect volume rendering, most commonly as a maximum intensity projection (MIP). MIP is used to demonstrate high intensity structures by providing a “pseudo” 3D reconstruction.

For simplicity, some viewer software has set pre-defined threshold values for different anatomical structures. From different threshold values result in different forms of 3D surface rendering, thus 3D rendering is for visualization purposes, not for diagnosis and analysis. A variety of 3D image qualities with varying render times can be provided by the visualization software (Pauwels, et al., 2015).

Exporting data CBCT produces two data products: the volumetric image data from the scan and the image report generated by the operator.

All these images are saved in the digital imaging and communication in medicine (DICOM) format.

CBCT data can be exported in the non-proprietary DICOM file format standard and imported into task-specific thirdparty diagnostic and planning software to facilitate virtual implant placement, and/or create diagnostic and surgical implant guidance stents – and assist in the CAD/CAM of implant prosthetics.

32 Implant practice

Benefits of implementing CBCT Diagnostics and communication CBCT provides superior diagnostic and patient communication capabilities. Patients are amazed by the technology, and it gives them a far greater understanding of any dental problems they may be having. Seeing things in 3D greatly increases patient understanding of the problem and location.

Large monitors in front of the patient allow them to sit with the clinician and co-diagnose problems and do virtual treatment planning.

Superior images The potential benefits of using CBCT in dentistry for assessment and diagnosis of pathologies, and pre-surgical planning is undisputed. Experience has shown CBCT imaging is superior to conventional 2D images in demonstrating the location and extent of pathology, the quantity and quality of bone, and the spatial relationships of an object relative to critical anatomical structures (Adibi, et al., 2012).

It provides clear images of highly contrasted structures and is extremely useful for analyzing bone.

No image distortion and high accuracy CBCT volumetric data is isotropic, which means all three dimensions of the image voxels are the same. This makes it possible to reorient the images to fit the patient’s anatomic features and perform real-time measurements without distortion (Adibi, et al., 2012).

High image resolution and quality Image voxels sizes (a 3D cuboid unit of images) can be generated, ranging from 0.125 mm to 0.4 mm in dimension, which contributes to its superior image resolution and quality. The resolution obtained with CBCT often exceeds the highest-grade multi-slice CT (Adibi, et al., 2012).

X-ray beam limitation and reduced radiation dose Reducing the size of the irradiated area by collimation of the primary X-ray beam to the FOV minimizes the radiation dose. Most CBCT units can be adjusted to scan small regions of interest for specific diagnostic tasks. Others are capable of scanning the entire craniofacial complex when necessary.

The smaller the FOV, the greater the resolution, and lesser radiation dose exposure for the patient (Adibi, et al., 2012).

Reduced size, expense and difficulty of use Compared to conventional CT equipment, the compact size and cost of CBCT

makes it ideal and suitable for the dental office setting. Another advantage is CBCT software for use in planning implants is usually much easier to use and far more useful than software available with CT (Adibi, et al., 2012; Tyndall, et al., 2012).

Easy reorientation Because the CBCT volumetric data set is isotropic, the entire volumetric data set can be reoriented in all three reference planes using PC-based software, so the patient’s anatomic features are realigned.

Aligning reference planes perpendicular to the structure of interest facilitates visualization of single-tooth pathology, vital anatomical structures, and allows accurate measurement of the residual alveolar ridge in an edentulous segment for preimplant site assessment (Adibi, et al., 2012).

Reformatting and display ability Reconstruction of CBCT data is performed natively via PC. This provides the clinician with the opportunity to use chairside image display, real-time analysis and task-specific MPR modes. Moreover, a CBCT image can be reconstructed in many formats with which the oral care provider is already familiar. For instance, a CBCT image can be reformatted to panoramic, cephalometric, or bilateral multiplanar projections of the temporomandibular joint. These images, in turn, can be annotated, assessed, and measured for diagnostic and treatment planning purposes.

In addition, cursor-driven measurement algorithms allow the clinician to do real-time dimensional assessment (Adibi, et al., 2012).

Rapid scan time Because CBCT acquires all basis images in a single rotation, scan time is rapid (10 to 70 seconds). Although faster scanning time usually means fewer basis images from which to reconstruct the volumetric data set, motion artifacts due to subject movement are reduced.

Lower radiation dose than CT Risks have also been noted in the radiation dose needed, although it is generally believed the radiation dose of CBCT is significantly lower than a conventional CT (Schulze, et al., 2004). The effective dose of radiation required for conventional fan beam CT (average range 36.9 to 50.3 microsievert [µSv]) is reduced by up to 98%, compared with the effective radiation dose for CBCT (average range for mandible 1320µSv to 3324µSv; average range for maxilla 1031µSv to 1420µSv).

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Medicolegal reassurance CBCT is increasingly seen as the standard of care in many fields of dentistry. Using a CBCT correctly will eliminate risks and complications and play an essential role in preventing medicolegal litigation.

Positive return on investment Reimbursement drives adoption in new technologies. Investing in this technology provides increased opportunities for superior diagnostics, while increasing the standard of care in all fields of dentistry.

Limitations of CBCT Requires expertise Referral to an oral maxillofacial radiologist may be indicated for need of expertise and because a proper monitor, ambient lighting, and equipment settings may be available only in a specialist radiologist environment (Adibi, et al., 2012).

Expense CBCT is more expensive than classic 2D radiologic assessments. However, the counterarguments is 2D radiologic assessments do not have the diagnostic and treatment planning capabilities and benefits CBCT has.

Increased radiation dose CBCT units from different manufacturers vary in dose by as much as 10-fold for an equivalent FOV examination (Bornstein, et al., 2014). As most devices exhibited effective doses in the 50ÂľSv to 200ÂľSv range, it can be stated CBCT imaging results in higher patient doses than standard radiographic methods used in dental practice for dental therapy, but significantly lower than a conventional MDCT (Schulze et al, 2004; Bornstein et al, 2014).

The effective radiation dose for a CBCT is 2 to 4 times greater than for a cephalometric X-ray, 3 to 6 times greater than a panoramic X-ray, and 8 to 14 times greater than a periapical X-ray. The effective radiation dose of CBCT can be affected to an order of magnitude by patient size, FOV, ROI, and resolution. A careful selection of all these parameters is needed to optimize diagnostic information and reduce the patient’s radiation exposure (www.camosci.cz/public/files/ pages/00000202_basicprinciplesforuseofdentalconebeamct.pdf).

Volume 13 Number 1

Investing in this technology provides increased opportunities for superior diagnostics, while increasing the standard of care in all fields of dentistry.

In general, imaging parameters (such as kV, mAs, and FOV size) has an impact on the effective radiation dose, as well as image quality parameters (spatial resolution, contrast, noise, and artifacts) (Pauwels, et al., 2015).

In terms of exposure, the most straightforward imaging parameter is FOV size, as larger FOVs increase radiation dose to the patient. Significant dose reduction can be achieved by reducing the FOV to the actual ROI (Bornstein, et al., 2014). In addition, larger FOVs increase the relative amount of scattered radiation reaching the detector, leading to an increase in noise and artifacts.

Therefore, FOVs should always be kept as small as possible, covering only the ROI. (Pauwels, et al., 2015; www.sedentexct.eu/ files/radiation_protection_172.pdf).

Learning curve Using CBCT requires new competencies from the clinician, and the value of information obtained is interpretation sensitive. This requires training and new knowledge from the clinician.

Poor soft tissue contrast One major disadvantage of CBCT is it can only demonstrate limited contrast resolution. If the objective of the examination were hard tissue only, then CBCT would not be a problem. However, CBCT is not sufficient for soft tissue evaluation as it provides limited resolution to deeper (inner) soft tissues. MRI and CT are better for soft tissue imaging (Adibi, et al., 2012).

Imaging artifacts Artifacts are any distortions or errors in the image unrelated to the subject being studied. Such image artifacts can be inherently related to the image acquisition and reconstruction process of the CBCT machine, or patient related (such as metal artifacts or motion artifacts) (Adibi, et al., 2012).

Metal artifacts are the result of high X-ray absorption by high-density objects. These contribute to image quality degradation and can lead to inaccurate or false diagnosis. It is important to note a CBCT user has little influence on metal artifacts, as increasing exposure settings do not improve the appearance of metal artifacts substantially enough to

justify increased radiation dose (Pauwels, et al., 2015).

Depending on the amount of motion during image acquisition, slight blurring or severe artifacts may occur. Due to the relatively long scan times in CBCT, motion is an important issue. Any movement artifacts affect the whole dataset and the whole image. Motion artifacts can be controlled by the CBCT user by using a head restraint device with long scan times and selecting a protocol with a short scan time for patients at risk for excessive motion.

Bone density and grayscale CBCT is commonly used for the assessment of bone quality primarily for preimplant treatment planning. Traditionally, bone quality has been based on bone density, estimated through the use of Hounsfield units derived from MDCT data sets. However, due to crucial differences between MDCT and CBCT, the use of quantitative greyscale values (GV) for assessment of bone density with CBCT is complicated.

Experimental and clinical research suggest the qualitive use of GV in CBCT to assess bone density should be avoided at this stage. Scientific literature suggests a paradigm shift in bone quality assessment from a density-based analysis to structural evaluation (Pauwels, et al., 2015).

Considerations and guidelines for purchase The number of CBCT devices available on the market has increased substantially, and new models are developed and released on a continuous basis. There are more than 50 types of CBCT models available, including multimodal types for additional panoramic and/or cephalometric imaging, and cheaper primary panoramic machines with a small FOV 3D button (Jacobs and Quirynen, 2014).

These devices exhibit a wide variability in terms of capabilities and crucial exposure parameters (Pauwels, et al., 2011). Additionally, 3D radiographic technology is continuously evolving and improving. Each dentist has to identify what he or she wants from the device, then pitch this purchase toward the strong points of the available brands that meet the needs. A good place to start is to consult with other users and suppliers of CBCT devices.

Implant practice 33

CONTINUING EDUCATION

Improved clinical outcomes and reduced risk of complication The diagnostic and treatment planning capabilities of CBCT contributes toward improved clinical outcomes, lesser risks and complications for the patient, thus increased patient satisfaction.

CONTINUING EDUCATION Decision-making when purchasing a CBCT machine is primarily based on four parameters: needs and benefits, hardware capabilities, software capabilities, and cost considerations.

Needs and benefits Critical questions a potential buyer must ask is: why do I need a CBCT device? What benefits do I expect my patients will get from having a CBCT machine? CBCT machines are generally used for diagnostics and treatment planning in dental implantology, endodontics, oral and maxillofacial surgery, and orthodontics.

CBCT machines can also be integrated with CAD/CAM and/or digital printer devices for fabrication of surgical guides, prosthodontics, and orthodontic appliances.

Potential purchasers also need to understand acquisition of this technology has a learning curve on how to use the device, and learning how to interpret and read images requires time, effort, and experience.

Therefore, check the manufacturer has a technical support service, and get more than one opinion before buying. An important guideline is to get an easy-to-use machine.

Patients appreciate the convenience of having a CBCT machine in your office, and that it will improve diagnosis, the outcome of treatment and reduce treatment complications.

Hardware capabilities What type of machine should I get, and what features should it have? CBCT machines can be categorized according to: design of the device or orientation of the patient during image acquisition or the scan volume, also referred to as the FOV irradiated (Scarfe and Farman, 2008).

The first decision is to make sure there is sufficient space available to accommodate the footprint of a sitting, standing, or supine CBCT machine in the practice. A basic CBCT machine should have the capability to allow for a small FOV for a single tooth clinical situation (5x5 FOV), a full upper or lower jaw (5x10 FOV), or to view the upper and lower jaw simultaneously (10x10 FOV). Additionally, most dentists require a CBCT machine should at least have the capability to take panorex X-rays (also referred to as multimodal capability). If you are doing orthodontic treatment, your CBCT device should preferably have a 2D cephalometric X-ray capability. Oral and maxillofacial surgeons require an extended field of view (full skeletal 3D view) to manage trauma, orthognathic, and TMJ cases.

Software capabilities Three important guidelines CBCT has 34 Implant practice

to comply with are the software must have all the required tools and be easy to use; it should be compatible with the office management software; and it must be compatible with optical scanners.

Features or software capabilities (characteristics) that should be looked for or considered are: • Automatically converts DICOM files • Imports STL files • Nerve mapping • Implant site measurement tools • Virtual implant library • Implant abutment library • Prosthetic planning • Cephalometric tracing • Airway space analysis • Surgical guide fabrication • Radiology reporting capability (Scherer, 2014).

Return on investment Is the return on investment worth the purchase price? The current cost of a cone beam device is high, though purchasing a CBCT machine that has a multimodal functionality helps to pay for the machine. Thus, when observing the high financial outlay for a cone beam device, prudent practitioners should determine how often they would use the device in their practices.

It is easy to multiply the number of images anticipated in a typical month of practice by the individual image fees to see if the return on investment is worth the expense. The various fee levels and frequency of use will make this analysis different for each practice. But a word of caution related to any high-cost technology — when practitioners have such devices, there is a tendency to overuse them for financial reasons, which is unethical practice.

Besides costs of a CBCT unit, having inadequate space for a machine, and having to learn and maintain additional software and hardware — a major emerging barrier for acquiring a CBCT unit — relates to skills and competencies required for interpretation of images (Friedland, 2009).

Conclusion The development of inexpensive X-ray tubes, high-quality detector systems, and powerful PCs has paved the way for commercially available and affordable 3D CBCT imaging systems. Over the past decade, CBCT has revolutionized dentomaxillofacial radiology by providing 3D imaging for the dental setting, overcoming the major limitations of traditional 2D intraoral, panoramic, and cephalometric radiographs.

Despite the lack of universal standards of care for dentistry, 3D CBCT imaging

capabilities for diagnostics, pre-surgical planning, and improving treatment outcome in dental implantology is rapidly moving toward being the standard of care. As with any emerging technology, dental professionals need adequate theoretical and practical training to use CBCT effectively and safely.

Finally, dentists have an ethical duty to preserve the health of their patients and prevent or limit risks, and always seek the best treatment in such a way the benefits will always exceed the risks. The quest begins with the radiographic assessment that requires the least amount of radiation dose to treat the patient appropriately. IP

REFERENCES 1. Adibi S, Zhang W, Servos T, O’Neil P. 2012; Cone beam computed tomography in dentistry: what dental educators and learners should know. J Dent Educ.

2012;76(11):1437-1442.

2. Abromovitch K, Rice DD. Basic principles of cone beam computed tomography. Dent Clin N Am. 2014; 58(3):463-484.

3. Alamri HM, Sadrameli M, Alshalhoob MA, Sadrameli M, Alshehri MA. Applications of CBCT in dental practice: a review of the literature. Gen Dent. 2012;60(5):390-400.

4. Bornstein MM, Scarfe WC, Vaughn VM, Jacobs R. Cone beam computed tomography in implant dentistry: a systematic review focusing on guidelines, indications, and radiation dose risks. Int J Oral Maxillofac Implants.

2014;29(Suppl):55-77.

5. Friedland B. Medicolegal issues related to cone beam CT. Semin Orthod. 2009;15(1):77-84.

6. Hatcher DC, Dial C, Mayorga C. Cone beam CT for presurgical assessment of implant sites. J Calif Dent Assoc.

2003;31(11):825-833.

7. Jacobs R, Quirynen M. Dental cone beam computed tomography: justification for use in planning oral implant placement. Periodontology 2000. 2014;66(1):203-213.

8. Kobayashi K, Shimoda S, Nakagawa Y, Yamamoto A. Accuracy in measurement of distance using limited cone-beam computerized tomography. Int J Oral Maxillofac Implants.

2004;19(2):228-231.

9. Mallya SM. Evidence and professional guidelines for appropriate use of cone beam computed tomography. J Calif Dent Assoc. 2015;43(9):512-520.

10. Pauwels R, Araki K, Siewerdsen JH, Thongvigitmanee SS. Technical aspects of dental CBCT: state of the art. Dentomaxillofac Radiol. 2015;44(1):20140224.

11. Pauwels R, Jacobs R, Singer SR, Mupparapu M. CBCTbased bone quality assessment: are Hounsfield units applicable? Dentomaxillofac Radiol. 2015;44(1):20150238.

12. Pauwels R, Jilke Beinsberger J, Collaert B, et al. Effective dose range for dental cone beam computed tomography scanners. Eur J Radiol. 2011;81(2): 267-271.

13. Sato S, Arai Y, Shinoda K, Ito K. Clinical application of a new cone-beam computerized tomography system to assess multiple two-dimensional images for the preoperative treatment planning of maxillary implants: case reports. Quintessence Int. 2004;35(7):525-528.

14. Scarfe WC, Farman AG. What is cone-beam CT and how does it work? Dent Clin N Amer. 2008;52(4):707-730.

15. Scarfe WC, Farman AG, Sukovic P (2006). Clinical applications of cone-beam computed tomography in dental practice. J Can Dent Assoc 72(1): 75-80.

16. Scherer MD. Presurgical implant-site assessment and restoratively driven digital planning. Dent Clin N Am. 2014;58(3):561-595.

17. Schulze D, Heiland M, Thurmann H, Adam G. Radiation exposure during midfacial imaging using 4- and 16-slice computed tomography: cone beam computed tomography systems and conventional tomography. Dentomaxillofac Radiol. 2004;33(2): 83-86.

18. Schulze R, Heil U, Bruellemann DD, et al. Artefacts in CBCT: a review. Dentomaxillofac Radiol. 2011;40(5):265-273.

19. Tyndall DA, Price JB, Tetradis S, et al. Position statement of the American Academy of Oral and Maxillofacial Radiology on selection criteria for the use of radiology in dental implantology with emphasis on cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol.

2012;113(6):817-826.

Volume 13 Number 1

REF: IP V13.1 HARTSHORNE

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Essentials for using CBCT in implant dentistry: technical considerations HARTSHORNE

1. Intraoral and extraoral 2D radiographic imaging procedure (periapical, lateral cephalometric, and panoramic), traditionally used for preoperative dental implant diagnostics and treatment planning, suffer from the same inherent limitations common to all planar 2D projections — namely, ______, and misrepresentation of structures. a. magnification b. distortion c. superimposition d. all of the above 2. (To produce a CBCT) The X-ray source produces a _________ of ionizing radiation that passes through the center of the ROI in the patients’ head to the X-ray detector on the other side. a. cone-shaped beam b. fan-shaped beam c. parabolic beam d. particulated beam

c. Fanned d. Amorphous 4. More projection data from a _____ rotation protocol provides more information to reconstruct the image; allowing for greater spatial and contrast resolution; increasing the signal-to-noise ratio, producing “smoother” images; and reducing metallic artifacts. a. 180° b. 260° c. 300° d. 360° 5. In accordance with the _____ principle, the number of basis images should be minimized to produce an image of diagnostic quality. a. “radiation exposure accumulation” (REA) b. “radiation source distance” (RSD) c. “as low as reasonably achievable” (ALARA) d. “electromagnetic radiation spectrum” (ERS) 6.

3. _______ X-ray beam exposure at intervals allows time between basis image acquisition for the signal to be transmitted from the detector area to the data storage area and the detector to rotate to the next site or angle of exposure. a. Continuous b. Pulsed

Volume 13 Number 1

The _______ is the principle determinant of the voxel size (3D picture element). a. pixel size of the detector b. rotational cycle c. volumetric data set d. algorithm

7. The _____ is the smallest individual volume element

in the 3D environment and determines the spatial resolution of the image. a. photodiode b. voxel c. milliampere seconds (mAs) d. kilovoltage peak (kVp) 8. The software also provides the clinician with a relatively large choice of display formats, allowing for _____ views of the mouth and head, along with other viewing options to help focus on areas of interest. a. 2D b. 3D c. panoramic d. all of the above 9. Axial planes are a series of slices from ________ in the volume. a. left to right b. front to back c. top to bottom d. none of the above 10. Reducing the size of the irradiated area by ______ minimizes the radiation dose. a. a faster scan time b. collimation of the primary X-ray beam to the FOV c. increasing the FOV d. using maximum intensity projection (MIP)

Implant practice 35

CE CREDITS

IMPLANT PRACTICE CE

CONTINUING EDUCATION

Partial extraction therapy: the socket shield technique and digital workflow Drs. Filipe Amante and Patrik Zachrisson describe the use of partial extraction therapy in a case of coronal fracture of a maxillary lateral incisor

T

he usage of osseointegrated dental implants to replace missing or hopeless teeth is currently regarded as one of the best treatment options in dentistry worldwide. Since the technique was presented to the world by Brånemark several decades ago, implant dentistry has progressed immensely, fueled by an active and continuous research that has instigated the materials, methods, and techniques to evolve.

Years of experience and clinical data have proven that the peri-implant complex plays an essential role on the short- to long-term stability of implant restorations. Furthermore, the literature has shown that respecting and preserving this delicate and crucial area is essential to achieving long-term success and predictability in implant dentistry.

Following the extraction of a tooth, there is a reorganization of the periodontal area affecting soft and hard tissue volume and irrigation. Numerous publications have confirmed that, following tooth loss, there is a dimensional transformation that takes place on the alveolar ridge contour (Amler, et al., 1960; Schropp, et al., 2003; Araújo and Lindhe, 2005; Fickl, et al., 2008a), which is particularly noticeable in the anterior zone.

Furthermore, the resulting soft and hard tissue deficiencies can interfere with optimal implant positioning and affect the overall esthetic outcome and long-term prognosis of implant-supported prostheses (Hurzeler, et al., 2010).

Filipe Amante, LMD, MSc, is in private practice in London and Cambridgeshire. He has completed extensive postgraduate training in implant dentistry, oral surgery, and digital and cosmetic dentistry in Brazil, Portugal, UK, and Italy. Dr. Amante has been shortlisted for numerous professional awards, including Best Young Dentist (2017, 2018, and 2019) and Digital Rookie (2018, 2019).

Patrik Zachrisson, LEG,TDL KI Swe, is the owner of Wensleydale Dental Practice and Wensleydale Dental Laboratory. He is vice president of the International Digital Dentistry Academy (IDDA) and visiting assistant professor at College of Medicine and Dentistry, Birmingham.

36 Implant practice

Educational aims and objectives

This clinical article aims to describe the surgical processes and key principles of partial extraction therapy and present a case illustrating the application of this technique.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 40 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify the protocols, supporting evidence, and indications of partial extraction therapy (PET).

•

Realize some clinical approaches that attempt to address the unpredictability of the soft and hard tissue deficiencies that can interfere with optimal implant positioning and esthetics.

•

Observe this approach that allows the preservation of the periodontal ligament and avoids the disruption of the periodontal dynamics, allowing an ideal soft, hard tissue volume preservation and vascularization.

•

Realize the benefits for PET for specific clinical cases.

•

Observe a case that used PET to treat a coronal fracture of a maxillary lateral incisor, followed by an implant.

The immediate placement of dental implants following dental extraction and several guided-bone regeneration (GBR) techniques have been described and used for many years, but despite all the advances in bone augmentation and periodontal surgery, there is still an element of unpredictability when the entire tooth element is removed.

Approaches such as soft and hard tissue augmentation procedures, immediate provisionalization, flapless implant placement, a more palatal placement of the implant, and the use of platform switching (Baumer, et al., 2015) have been used to attempt to address this unpredictability. Despite the positive effects of these techniques, it is widely accepted that an optimal esthetical result can be reached in only specific cases (Khzam, et al., 2015), as the tissue changes cannot be entirely prevented or compensated for (Esposito, et al., 2012; Chen and Buser, 2014; Lin, et al., 2014).

The marked alterations after tooth extraction appear to be attributable to the loss of the periodontal ligament and the consecutive trauma, particularly at the buccal bone plate (Araújo and Lindhe, 2005).

In the past decade, several clinicians and researchers have suggested that, in specific clinical circumstances upon immediately placing a dental implant, rather than

extracting the entire hopeless tooth, it may be beneficial to leave a buccal fragment in situ through partial extraction therapy (PET) or the “root membrane technique.”

This approach allows the preservation of the periodontal ligament and therefore avoids the disruption of the periodontal dynamics, allowing an ideal soft, hard tissue volume preservation and vascularization.

Several in vivo and in vitro studies have shown encouraging results to support this approach. In 2010, Hürzeler, et al., described the socket shield technique (SST) with an article that involved the histological evaluation in a beagle dog. The protocol involved the partial extraction of the tooth, leaving a buccal fragment in situ (shield), followed by the immediate placement of a dental implant.

The results showed no resorption of the root fragment and also new cementum formed on the implant surface. Furthermore, there was noted excellent buccal soft and hard tissue preservation and clinically successful osseointegration of the implant. Bäumer, et al.

(2015), conducted a pilot study that concentrated on the histological, clinical, and volumetrical observation of the alveolar ridge and implant after a similar protocol. The results were equally promising and concluded that the periodontal ligament of the tooth segment remained healthy; there were minor volumetric Volume 13 Number 1

Figure 2: Preoperative CBCT scan and implant planning

Figure 4: Implant placement

Figure 5: Socket shield and implant in situ

Figure 7: Intraoral view at 3-months postoperative

Figure 8: Intraoral view at 3-months postoperative — healing collar removed

change of the ridge contour, and there was evident direct bone-to-implant contact.

Since then, an exponential number of clinical case reports have emerged, with promising results and with longer follow-ups that have observed the clinical appearance and stability of the peri-implant soft and hard tissues, as well as evaluating the volumetric changes of the affected buccal contours in the long term.

The results available so far seem to suggest that the PET may reduce the extent of treatment and decrease patient stress and pain (HĂźrzeler, et al., 2010).

Furthermore, the technique has additional advantages: There is no added cost for materials; comorbidity is reduced; it can be applied in the presence of apical pathology; and it requires reduced surgical intervention (Chen, 2013). Despite the encouraging results and the potential benefits highlighted by the literature, PET should only be considered suitable for specific clinical cases.

Baumer, et al. (2015), in a 5-year followup clinical study, defined the following

exclusion criteria for the SST: teeth with present/past periodontal disease; teeth with vertical root fractures on the buccal aspect; teeth with horizontal fractures at/below gum level; teeth with other pathologies affecting the buccal part of the root, for example, external or internal resorptions, except apical pathology; heavy smokers; lack of neighbor teeth; bad oral hygiene; and lack of capacity to provide valid consent.

The aim of this article is to describe the use of the PET in a case of a coronal fracture of a maxillary lateral incisor. A dental implant was immediately placed and later on restored with a crown fabricated in-house using a digital workflow.

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Clinical case The patient, a 63-year-old male, was referred by his GDP for a consultation in view to replace his fractured upper left lateral incisor. The tooth was fractured at gum level after having had a root canal treatment and a crown for several years. The GDP had previous discussed different replacement

Figure 3: Surgical hemi-section of root

Figure 6: Socket shield and implant in situ with healing collar

Figure 9: Periapical radiograph at 3-months postoperative

options such as bridges and dentures, but the patient was adamant he would like to have the tooth replaced with a dental implant.

He was fit and healthy, did not take any medication, and had previously been a regular attender to the dental practice. He presented with a considerably restored dentition, good oral hygiene, no evidence of other active decay or periodontal disease, didn’t smoke, and reported consuming alcohol sporadically.

After discussing the different treatment options, the patient agreed to have a sequence of clinical records taken including a CBCT scan, upper and lower alginate impressions (for study models and a surgical guide), and a maxillary silicone putty/ wash impression (for a temporary bonded Implant practice 37

CONTINUING EDUCATION

Figure 1: Preoperative intraoral view

CONTINUING EDUCATION Maryland bridge), as well as a sequence of intraoral and extraoral photographs.

The implant treatment planning protocol followed at the author’s practice involves the formulation of an extensive and thorough document that encompasses all of the information gathered during the preliminary stages of treatment and is sent to the patient in advance to allow an appropriate time for the information to be read, assimilated, and hopefully fully understood. The patient was presented with two clinical scenarios: a more traditional approach that included the complete removal of the condemned tooth followed by either an immediate or delayed implant placement (possibly involving bone and/or soft tissue augmentation procedures), or the partial removal of the tooth with the immediate placement of the implant without resorting to raising a flap as described by the SST. After some deliberation, the patient decided to go ahead with the latter approach, as it was less invasive and more conservative. He confessed that he found the prospect of having a flapless surgical procedure and a better esthetic final outcome quite appealing, despite being aware that this technique wasn’t as documented as the more traditional alternative. The surgical appointment was subsequently booked, and on the day, the patient was given the opportunity of asking questions about the procedure and risks involved, and the consent form was signed.

No new complaints or medical changes were reported preoperatively, and the patient was given a prophylactic dose of antibiotics — 3g of amoxicillin 1 hour before the procedure. (There were no reports of allergies or hypersensitivity to any medication.)

The patient was then anesthetized having received two cartridges of Septanest (articaine) (Septodont) that were infiltrated buccal and palatally. A strict standardized sterilization protocol was then followed to prepare the patient and the surgical room, including the placement of sterile draping on all of the working surfaces, and the usage of sterile gowns and hats on clinical staff and patient.

The patient was then disinfected extraorally and intraorally with a 0.20% chlorhexidine + PVP-VA and hyaluronic acid solution, and the surgical procedure started with the section of the retained root. This is a very delicate process that starts with the mesiodistal hemi-section of the root, effectively separating it in buccal and palatal fragments.

Some of the literature advises the usage of slow handpiece burs similar to the ones used in re-root canal treatment, prior to the root hemi-section, particularly in cases of 38 Implant practice

Figures 10A and 10B: Intraoral view at 3-months postoperative with scan body in situ

Figure 11: Final crown prior to fit

Figure 12: Final crown fitted (or in situ)

single canal teeth (there are presently PET bur kits available specifically for this purpose).

In this instance, it was opted to carefully remove the palatal fragment, but in certain cases the osteotomy can be performed directly through the palatal fragment and, once completed, the removal of the proximal/ palatal fragments can take place.

It is of utmost importance to ensure that there is no pressure exerted on the buccal shield upon removing the unwanted portions of the tooth, as it is essential not to disturb the buccal periodontal area, which is critical for the success of the technique. The osteotomy was then performed with a periapical X-ray taken with a parallel pin to confirm the correct angulation and dismiss any other possible problems, and a 4.5 x 11.5mm Osstem TSIII implant was inserted with a torque of approximately 35Ncm. The position of the implant in the socket followed the original pathway of the root parallel to the neighboring teeth and slightly more palatally to ensure that there was no direct contact with the socket shield. The gap between the implant and the socket shield will then be filled with a blood clot, and there is usually no need to use bone augmentation materials or membranes; in this particular case, a portion of collagen sponge (PARASORBA®, RESORBA®) was used.

Some authors believe that using an enamel matrix protein (Emdogain®, Straumann®) can be applied in this gap and help initiate the process of new cementum formation, which could aid in the prevention of root resorption on the long term (Baumer, et al., 2017). A healing cap was placed along with one single suture 6-0 Prolene® (Ethicon) and,

as planned, a bonded Maryland bridge was ready to be fitted on the day to adequately provisionalize the area.

The technicians were instructed to construct the bridge with an anatomy that would not exert unwanted pressure on the underlying soft tissue, and the patient was very happy with the result at that stage.

The patient was given comprehensive postoperative instructions, including rinses with 0.12% chlorhexidine mouthwash 3 times per day for the first week, and advised to take paracetamol and/or ibuprofen 3 times per day for the first 72 hours. The patient was reviewed after a week and reported no postoperative discomfort.

Clinically, the soft tissue and temporary bridge were looking fine, with no evidence of inflammation or other ill symptoms. Eleven weeks after this, the patient returned in order to assess the osseointegration of the implant and the appearance of the surrounding soft tissues.

A periapical X-ray view showed a favorable outcome with a satisfactory presence of bone around the implant and in between the threads, and also that the soft tissue volume remained stable and healthy looking.

The patient reported no discomfort and had been quite happy with the temporary bonded bridge that was subsequently removed.

A Ti-Base was then fitted and a digital impression taken using the CEREC Omnicam (Dentsply Sirona). An IPS e.max® (Ivoclar Vivadent) crown was made in-house, stained, characterized accordingly, and fitted to the Ti-Base, and was fitted that same day.

A periapical view confirmed the engagement of the implant fixtures, and the crown Volume 13 Number 1

19. Guarnieri R, Giardino L, Crespi R, Romagnoli R. Cementum formation around a titanium implant: a case report. Int J Oral Maxillofac Implants. 2002;17(5):729-732.

20. Helsham RW. Some observations on the subject of roots of teeth retained in the jaws as a result of incomplete exodontia. Aust Dent J. 1960;5(2):70-77.

21. Herd JR. The retained tooth root. Aust Dent J. 1973;18(3): 125-131.

22. Hurzeler MB, Zuhr O, Schupbach P, et al. The socket-shield technique: a proof-of-principle report. J Clin Periodontol.

2010;37(9):855-862.

Figure 13: Extraoral picture of final result

Figure 14: Intraoral view at 12-month follow-up

was torqued to 25Ncm as per the manufacturer’s advice, and the palatal access covered with flowable composite following the placement of some Teflon tape to protect the screw access.

The occlusion was checked and no adjustments were necessary. The patient was then instructed in regard to the oral hygiene (regular visits to the hygienist were recommended) and was advised to return for a review appointment. After 12 months, the patient was again reviewed and reported no problems. Furthermore, the volume of soft tissue seemed to have been maintained, and there were no evidence of pain, inflammation, mobility, or other ill symptoms.

for both patient and clinicians. The authors agree that further clinical data needs to emerge for this technique to be regarded as a more mainstream approach but, nonetheless, the current state of the art suggests that this technique may become increasingly used in the future of implant dentistry. IP

Conclusion The privilege of being a dentist and to be able to make a difference in people’s lives comes with a great burden and a constant responsibility to keep our skills updated to ensure we provide the best possible care to our patients. The ongoing clinical and scientific research in dentistry is continuously providing us with new and improved treatment options to help our patients in the best possible way, and it is our mission as modern dentists to keep updated with the innovations in our field.

The PET has now been documented for more than a decade. The results obtained are incredibly promising and have been increasingly supported by clinical data that is constantly emerging. However, it is of utmost importance that each clinical case is individually assessed, namely in regard to the case selection and — very importantly – the experience and clinical confidence of the dental surgeon performing the procedure.

The concepts of preservation, diminished comorbidity and ideal esthetic outcomes that are defended by the PET are very attractive, but if the case selection and technical completion of the technique are not adequate, this can be a recipe for disaster.

For this particular clinical case, the PET proved to be extremely helpful, and the results achieved were quite rewarding Volume 13 Number 1

23. Jahangiri L, Hessamfar R, Ricci JL. Partial generation of periodontal ligament on endosseous dental implants in dogs. Clin Oral Implants Res. 2005;16(4):96-401.

24. Kan JY, Rungcharassaeng K. Proximal socket shield for interimplant papilla preservation in the esthetic zone. Int J Periodontics Restorative Dent. 2013;33(1):e24-31.

25. Lagas LJ, Pepplinkhuizen. JJFAA, Bergé SJ, Meijer GJ. Implant placement in the aesthetic zone: the socket-shieldtechnique. Ned Tijdschr Tandheelkd. 2015;122(1):33-36.

26. Langer L, Langer B, Salem D. Unintentional root fragment retention in proximity to dental implants: a series of six human case reports. Int J Periodontics Restorative Dent.

2015;35(3):305-313.

27. Malmgren B. Decoronation: how, why, and when? J Calif Dent Assoc. 2000;28(11):846-854.

REFERENCES 1. Al Dary H, Al Hadidi A. The socket shield technique using bone trephine: a case report. Int J Dent Oral Sci. 2015;5(001):1-5.

2. Amante LF, Mamede DM. The socket shield technique: a conservative approach in Implant Dentistry. Implant Dentistry Today. 2018;12(3):33-38.

3. Abadzhiev MN, P Velcheva P. Conventional immediate implant placement and immediate placement with socketshield technique – which is better. Int J Clin Med Res. 2014;1(5):176-180.

4. Araujo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol. 2005;32(2):212-218.

5. Baumer D, Zuhr O, Rebele S, Schneider D, Schupbach P, Hurzeler M. The socket-shield technique: first histological, clinical, and volumetrical observations after separation of the buccal tooth segment – a pilot study. Clin Implant Dent Relat Res. 2015;17(1):71-82.

6. Buser D, Warrer K, Karring T. 1990; Formation of a periodontal ligament around titanium implants. J Periodontol.

2015;61(9):597-601.

7. Chen C, Pan Y. Socket shield technique for ridge preservation: a case report. J Prosthodont Implantol. 2013;2(2):16-21.

8. Cherel F, Etienne D. Papilla preservation between two implants: a modified socket-shield technique to maintain the scalloped anatomy? A case report. Quintessence Int. 2014;45(1):23-30.

9. Fickl S, Zuhr O, Wachtel H, Stappert CF, Stein JM, Hurzeler MB. Dimensional changes of the alveolar ridge contour after different socket preservation techniques. J Clin Periodontol.

2008a;35(10):906-913.

10. Fickl S, Zuhr O, Wachtel H, Bolz W, Huerzeler M. Tissue alterations after tooth extraction with and without surgical trauma: a volumetric study in the beagle dog. J Clin Periodontol. 2008b;35(4):356-363.

11. Filippi A, Pohl Y, von Arx T. Decoronation of an ankylosed tooth for preservation of alveolar bone prior to implant placement. Dent Traumatol. 2001;17(2):93-95.

12. Glocker M, Attin T, Schmidlin PR. Ridge preservation with modified ‘socket-shield’ technique: a methodological case series. Dent J. 2014;2(1):11-21.

13. Gluckman H, Du Toit J, Salama M. The socket-shield technique to support the buccofacial tissues at immediate implant placement. Int Dent Afr Ed. 2015;5(3):6-14.

14. Gluckman H, Salama M, Toit JD. Partial extraction therapies (PET) part 1: maintaining alveolar ridge contour at pontic and immediate implant sites. Int J Periodontics Restorative Dent. 2016;36(5):681-687.

15. Gluckman H, Salama M, Toit JD. Partial extraction therapies (PET) part 2: procedures and technical aspects. Int J Periodontics Restorative Dent. 2017;37(3):377-385.

16. Gray JL, Vernino AR. The interface between retained roots and dental implants: a histologic study in baboons. J Periodontol. 2004;75(8):1102-1106.

17. Groenendijk E, Staas TA, Graauwmans FE, et al. Immediate implant placement: the fate of the buccal crest. A retrospective cone beam computed tomography study. Int J Oral Maxillofac Surg. 2017;46(12):1600-1606.

28. Mitsias ME, Siormpas KD, Kotsakis GA, et al. The root membrane technique: human histologic evidence after five years of function. Biomed Res Int. 2017; doi: 10.

1155/2017/7269467 29. Mitsias ME, Siormpas KD, Kontsiotou-Siormpa E, et al. A step-by-step description of PDL-mediated ridge preservation for immediate implant rehabilitation in the esthetic region. Int J Periodontics. Restorative Dent.

2015;35(6):835-841.

30. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Br Med J. 2009;339:b2535 31. Nayyar J, Clarke M, O’Sullivan M, Stassen LF. Fractured root tips during dental extractions and retained root fragments.

A clinical dilemma? Br Dent J. 2015;218(5):285-290.

32. Ong CT, Ivanovski S, Needleman IG, et al. Systematic review of implant outcomes in treated periodontitis subjects. J Clin Periodontol. 2008;35(5):438-462.

33. Parlar A, Bosshardt DD, Unsal B, et al. New formation of periodontal tissues around titanium implants in a novel dentin chamber model. Clin Oral Implants Res. 2005;16(3):259-267.

34. Pietrokovski J, Massler M. Alveolar ridge resorption following tooth extraction. J Prosthet Dent. 1967;17(1):21-27.

35. Saeidi Pour R, Zuhr O, Hürzeler M, et al. Clinical benefits of the immediate implant socket shield technique. J Esthet Restor Dent. 2017;29(2):93-101.

36. Salama M, Ishikawa T, Salama H, Funato A, Garber D. Advantages of the root submergence technique for pontic site development in esthetic implant therapy. Int J Periodontics Restorative Dent. 2007;27(6):521-527.

37. Sapir S, Shapira J. Decoronation for the management of an ankylosed young permanent tooth. Dent Traumatol.

2008;24(1):131-135.

38. Siormpas KD, Mitsias ME, Kontsiotou-Siormpa E, Garber D, Kotsakis GA. 2014; Immediate implant placement in the esthetic zone utilizing the ‘root-membrane’ technique: clinical results up to 5 years postloading. Int J Oral Maxillofac Implants. 2008;29(6):1397-1405.

39. Schropp L, Wenzel A, Stavropoulos A. Early, delayed, or late single implant placement: 10-year results from a randomized controlled clinical trial. Clin Oral implants Res. 2013;25(12):1359-1365.

40. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following singletooth extraction: a clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent.

2003;23(4):313-323 41. Tonetti MS. Risk factors for osseodisintegration. Periodontol 2000. 1998;17:55-62 42. Tonetti MS. (1999) Determination of the success and failure of root-form osseointegrated dental implants. Adv Dent Res. 13:173-180 43. Troiano M, Benincasa M, Sánchez P, Calvo-Guirado J. Bundle bone preservation with Root-T-Belt: case study.

Ann Oral Maxillofac Surg. 2014;2(1):7 44. Wadhwani P, Goyal S, Tiwari S, et al. Socket Shield Technique: A new concept of ridge preservation. Asian J Oral Health Allied Sci. 2013;2015;5(2):55-58.

Implant practice 39

CONTINUING EDUCATION

18. Holbrook SE. Model-Guided flapless immediate implant placement and provisionalization in the esthetic zone utilizing a nanostructured titanium implant: a case report. J Oral Implantol. 2016;42(1):98-103.

REF: IP V13.1 AMANTE-ZACHRISSON

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Partial extraction therapy: the socket shield technique and digital workflow AMANTE-ZACHHRISSON

1. Since the technique (usage of osseointegrated dental implants) was presented to the world by _________ several decades ago, implant dentistry has progressed immensely, fueled by an active and continuous research that has instigated the materials, methods, and techniques to evolve. a. Brånemark b. Greenfield c. Hunter d. Chercheve 2.

3.

4.

Approaches such as soft and hard tissue augmentation procedures, _______, and the use of platform switching have been used to attempt to address this unpredictability (related to overall outcome, long-term prognosis and esthetics). a. immediate provisionalization b. flapless implant placement c. more palatal placement of the implant d. all of the above The marked alterations after tooth extraction appear to be attributable to the loss of the periodontal ligament and the consecutive trauma, particularly at the ______. a. lingual plate b. buccal bone plate c. apical third d. none of the above In the past decade, several clinicians and researchers have suggested that, in specific clinical circumstances upon immediately placing a dental implant, rather than

40 Implant practice

extracting the entire hopeless tooth, it may be beneficial to leave a buccal fragment in situ through _______, or the “root membrane technique.” a. partial attachment therapy (PAT) b. buccal ridge contour therapy (BRCT) c. partial extraction therapy (PET) d. platform switching therapy (PWT) 5.

6.

7.

In 2010, Hürzeler, et al., described the ____ with an article that involved the histological evaluation in a beagle dog. a. canine socket technique (CST) b. socket shield technique (SST) c. cementum formation technique (CFT) d. buccal reduction technique (BRT) The results available so far seem to suggest that the ______ may reduce the extent of treatment and decrease patient stress and pain. a. partial extraction therapy (PET) b. particulated socket shield technique (PSST) c. Baumer shielded technique (BST) d. stent-guided surgeries It is of utmost importance to ensure that ______, as it is essential not to disturb the buccal periodontal area, which is critical for the success of the technique. a. constant forceful pressure is exerted on the buccal shield upon removing unwanted portions of the teeth b. no anesthesia is given c. there is no pressure exerted on the buccal shield upon removing the unwanted portions of the tooth d. the tooth is not disinfected

8.

The patient was given comprehensive postoperative instructions, including rinses with 0.12% chlorhexidine mouthwash ______, and advised to take paracetamol and/or ibuprofen 3 times per day for the first 72 hours. a. once a day for the first 24 hours b. 3 times per day for the first week c. 2 times a day for 2 weeks d. once a day for 6 months

9.

(For this patient) A periapical view confirmed the engagement of the implant fixtures, and the crown was torqued to _______ as per the manufacturer’s advice, and the palatal access covered with flowable composite following the placement of some Teflon tape to protect the screw access. a. 15Ncm b. 25Ncm c. 35Ncm d. 40Ncm

10. The concepts of preservation, diminished comorbidity and ideal esthetic outcomes that are defended by the PET are very attractive, but _______ . a. if the case selection and technical completion of the technique are not adequate, this can be a recipe for disaster b. it is the patient’s choice that will determine whether this technique can be used c. clinicians should wait until this technique becomes less costly before implementing into their practices d. in the final analysis, only esthetic outcomes should be the deciding factor when choosing this technique

Volume 13 Number 1

CE CREDITS

IMPLANT PRACTICE CE

Dr. Sonia Leziy discusses the merits of guided surgery Over the past 3 years, your view on guided surgery has gone from a “mixed opinion” to “extremely positive.” What’s changed?

Dr. Sonia Leziy: Intraoral scanning, combined with the CBCTs that we take, has opened the opportunity for me to go back to fully guided surgery. What I found in the past 3 years is that I now prefer to not consider nonguided surgery and clearly see that type of surgical approach is less accurate and more time-consuming than a fully guided approach.

It has become my norm to plan and execute guided surgery, other than in cases where there is inadequate space to place a static guide (restricted opening and access).

My principal reasons as to why it is so important for me to do guided surgery is that I’m an experienced clinician — and I think I do good work; I have good hand/eye coordination. However, the brain sometimes does not connect too well with the hand. We do make mistakes — all of us, regardless of our level of experience. Limited access, challenging patients and surgical sites, and restricted intra-arch space are among some of the factors that strengthen why guided protocols are so important.

Guided surgery takes the mistakes out of my hands Guided surgery takes the mistakes out of my hands during the clinical event, and that is important because I can sit at my computer in a non-stressful environment and make all the decisions there — I can carefully develop the treatment plan and envision the prosthetically driven outcome.

What I’ve also found is that because I am going into surgery with a guide, my surgeries are faster. I am more efficient in my use of operatory time and have been able to reduce the surgical time. In some cases, I have been able to do more conservative surgery. Therefore, I’m also far more relaxed in surgery. To me it’s now a stress-free environment.

Eliminating the need for secondary delivery appointments Probably one of the other very important aspects is that I’ve always been a strong believer in “guide tissues from the moment of surgery,” which means I build in some kind of transitional solution, whether it is a custom-healing abutment coupled with a bonded PMMA bridge or a full restoration, single or multiple in many cases. The insertion of a transitional component at the time of extraction/implant placement is important for tissue anatomy, patient function, and patient esthetics. Where I was previously making provisional components chairside or impressing at the time of surgery for lab-generated components to be delivered at a follow-up appointment, prefabricated components eliminate the time required to make transitional components and eliminate the need for secondary delivery appointments in many cases.

Interestingly, intraoral scanning has become an integral component to my recession documentation, helping me track gingival recession/tooth wear and NCCL stability. I also believe that it is a powerful and more accurate method to monitor the

outcomes of treatment used to address these conditions.

Do you trust digital workflows?

Dr. Sonia Leziy: That’s a good question, because in my first 6 months of guided surgery, I would prep with my initial pilot drill, then remove the guide and place a direction indicator, and take a radiograph to verify two-dimensionally my progress throughout the surgery. Was I preparing the osteotomy as it was planned? Looking at how direction indicators fit through the guide — I did that for months and months, stopping and radiographing throughout a procedure. I don’t do this anymore. I basically place the guide, assess its stability, and verify its fit through my inspection windows. I have complete confidence in the concept and in the quality of the guides that can be printed, based on my TRIOS scan and excellent CBCT quality.

The guides fit impeccably all the time.

Compared to the old days, is there a big difference?

Dr. Sonia Leziy: Night and day, apples and oranges. I can’t go backward.

I don’t understand today how even experienced clinicians still say, “I have a lot of experience, so I don’t need to do guided surgery”; that makes no sense to me. From what would be considered the simplest cases, which are single-teeth cases to fully edentulous, the standard of care is moving toward guided surgery. IP This information was provided by 3Shape.

Sonia Leziy, DDS, received her dental degree from McGill University. She completed her postgraduate degree in periodontics at the University of British Columbia, Canada. Dr. Leziy is a Fellow of the Royal College of Dentists of Canada, a Fellow of the International Congress of Oral Implantologists, and a member of the British Columbia Society of Periodontists, the Canadian Academy of Periodontists, the American Academy of Periodontists, and the American Academy of Esthetic Dentistry (AAED). She co-mentors the Vancouver Implant Periodontal and Prosthetic Study Group (VIP), which focuses on total treatment solutions from diagnosis to final restoration.

Dr. Leziy is the VP of Clinical Affairs for the Seattle Study Club. She is a member of the editorial boards of the journals Spectrum Dialogue, the Journal of Esthetic and Restorative Dentistry, the International Journal of Perio and Restorative Dentistry, and section editor for Aegis’ Inside Dentistry. She maintains a Clinical Associate position at the University of British Columbia. Dr. Leziy has been recognized among the top clinicians in CE in North America by Dentistry Today for more than a decade. She has published extensively on implant esthetics and lectures nationally and internationally on the subject of implants and advanced esthetics/periodontal plastic surgery. Dr. Leziy maintains a full-time interdisciplinary private practice in Vancouver, Canada.

Volume 13 Number 1

Implant practice 41

PRODUCT PROFILE

Cut the risk with guided surgery using 3Shape implant solutions

PRACTICE MANAGEMENT

Compromise is the difference between a good leader and a dictator Dr. Christopher Hoffpauir discusses insights into providing feedback to employees

“Y

ou’re unhappy. I’m unhappy too. Have you heard of Henry Clay? He was the Great Compromiser. A good compromise is when both parties are dissatisfied, and I think that’s what we have here.” — Larry David, Curb Your Enthusiasm Taking corrective action in the workplace is an uncomfortable but necessary skill to cultivate. Whether you are the boss who needs to address a concern or the employee who is faced with the realization that your performance has been under some scrutiny, the bottom line is that both the boss’s and employee’s openness to the change can create a positive or negative outcome.

To the employee Corrective action in the workplace is not a personal attack and not the employer’s attempt to tear down or upset you. Corrections are an opportunity — a sign that your employer believes in you and wants to mentor you into becoming the valuable employee that he/she believes you can be. Sadly, many employees respond to constructive criticism either by becoming covertly hostile and apathetic or by quitting.

But really listening and implementing suggestions shows that the boss’s insights and the business are important to you. Your flexibility and cooperation are qualities that the boss will recognize and appreciate.

To the employer Developing a corrective conversation with anyone about work performance isn’t pleasant. Because we are all human, taking

the time to correct and guide the employees to become better team members usually comes with the “cost of stomach lining” — it’s uncomfortable. We lose sleep over finding the right words and worry about the effect of those words on the employee. But taking the time to discuss potential problems with employees shows that you deeply believe in their potential and want to help them reach it. It’s what good leaders do.

First, you need to discover what is causing a particular problem. Look for the true basis for the issue. Do employees not understand their tasks? Is more training needed? Are the employees resistant to change or training?

Do they think doing it your way will not give the results required? Are they afraid that they can’t meet the standards set in the office?

Are they covertly hostile? (If an employee is just hostile, he/she needs to be fired because a person who refuses to be led ultimately will be toxic in the workplace.)

How to elicit change “Compliment-sandwich” technique One of my favorite tips for correcting employees is to use the “complimentsandwich” technique. Most employees will already be expecting a problem when they are called in for a conference. You can ensure that team members are in a receptive mood to receive instruction if you compliment them on something they are doing well before addressing the problem.

Then introduce the problematic situation very gently and positively. Refer to the following example as a model.

Christopher Hoffpauir, DDS, was born in Lafayette, Louisiana. Poor experiences at the dentist led him to a path of dental phobia. In 2002, a severe dental infection changed his life. Seeing firsthand what a difference proper dental care can make in someone’s life, Dr. Hoffpauir decided to go back to school in pursuit of a degree in dentistry.

Returning to school at 30 years old and years of work experience in various fields gave him a different perspective than that of most students. He graduated Magna Cum Laude from University of Houston Clear Lake with a BS in Biology with a focus on Molecular and Cellular studies, and his DDS from the University of Texas School of Dentistry in 2012. In 2013, Dr. Hoffpauir opened a new startup practice in Alvin, Texas, where he continues to practice today. He has a special interest in utilizing the latest technology to offer the best possible care to patients, with a focus on helping patients with dental phobia overcome their fears. Dr. Hoffpauir is creator/sole owner of The Business of Dentistry, a dentist-only Facebook group with more than 20,000 members.

Disclosure: Dr. Hoffpauir is an owner or partner in the following businesses: Modento, 4G Dental Lab, Dentira, PK Performance, Dentalogic, DocHoff Investments, Dream Makers Industries, Get Practice Growth, Infinity 3rd Coast BJJ, and nFoldAI Inc.

42 Implant practice

“Henry, I wanted to tell you what a great job you did on that project for our new patient last week. I really appreciate all of your hard work. I also wanted to talk about an opportunity. I’ve been following your progress very closely, and I noticed that there is a task that you are doing that you can do an even better job at than you are doing currently. I have such high expectations for you, and I think you are an amazing team member. I just wanted to share this with you and see if we can work together on it.”

Remember to add corrective action or task that you would like to see improved.

Then return to complimenting.

“Henry, I’m glad that we got to chat. I’ll check back with you next week to see what progress you’ve made, but don’t hesitate to let me know if you need any help. By the way, before you get back to work, I wanted to say thank you. You make the hard parts of being the boss a lot easier because you are always so willing to improve.”

Compliment at the beginning, deal with the problem, and then compliment at the end.

Conflict resolution When a conflict involves two or more employees, the situation can easily turn into a “he said/she said.” In this case, usually neither person hears what is being said, but each is filtering it through his/her own experience or feelings. The boss needs to make an effort to hear both sides correctly and let both sides know that they are valued. Refer to the following example as a model.

“You both are too important to me, and you are both too important to this team to let some misunderstanding come between you or decrease your effectiveness.”

I invite them to calmly take turns telling each other their version of the situation. I emphasize that when this meeting is finished, and we all go back into the office, the problem will stay behind in the meeting room.

In a conflict like this, there is usually some bickering. To maintain decorum, each person must be given the opportunity to state his/ her side of the story without interruption. It Volume 13 Number 1

is very important that the team members explain what happened in facts only.

Emotion in relaying the event can derail the entire process. The team members will get a chance to address their emotions after both sides have finished telling their version of what happened.

The following dialogue shows how a boss can moderate: Employee No. 1 tells her side of the story.

Moderator asks employee No. 2: “How does what she said make you feel?”

Moderator asks employee No. 2: “OK, what do you remember happening?”

Employee No. 2 tells his side of the situation.

Moderator asks employee No. 1: “How does what he said make you feel?”

Moderator: “Now that we all know how both of you feel, what compromise do you both propose to make sure this problem doesn’t happen again?

I like to remind the two employees of Henry Clay’s definition of a compromise, which introduces this article.

All team members should feel as though their contributions are celebrated by those above and around them. This helps people to achieve greatness. However, if both parties are unable to reach an amicable compromise, the boss needs to intervene and say what needs to be done. This may include reprimands, corrective training, or even firing the one or both team members. The important thing here is to give the team members the chance to find a workable solution themselves before going from “moderator” to “boss.”

The job of moderator often falls to the office manager — and should. If that person is already embroiled in the situation or is a friend to one of the people in the conflict, one or both employees may become distrustful or expect a biased outcome.

In this case, the owner will need to step Volume 13 Number 1

in and act as moderator. It is important to note that even in the perfect mediation, no one will ever be 100% correct or happy.

(Remember Henry Clay?) The goal is not to make everyone happy; the goal is to fix the problem.

An important part of correcting employees, both for clarity and legal reasons, is keeping a record of the intervention. In my office, I record all talks on Zoom, and the recording becomes a part of the employee’s record. It is advantageous to record the interview because if the employee gets hostile or upset and claims it is because of something that you said, you can both can go back and listen to the recording and listen to the actual words used.

(Remember we talked about words being filtered through our emotions?) Employees should sign a form as part of the intake or hiring process that states that they submit to this policy. If they don’t sign, they have already shown that they are unwilling and should not be hired. A sample dialogue follows Boss: Why did you get upset?

Employee: You just said I suck at my job.

Boss: I actually didn’t say that. Let’s listen to the recording and see why I might have come across that way. (Taking ownership of the misunderstanding from the first sign of trouble will assure the employee and ensure that they are in a receptive frame of mind). I can see where you could have taken what I said that way. But now that you pointed that out, let me rephrase that because I did not mean to imply that you suck at your job; I said that there are some procedures that you are doing that need to be improved.

Note the lesson here. Apologizing for how employees interpreted what you said doesn’t cost you anything. It doesn’t make you wrong and them right. It may, however, keep a situation from escalating and lead to improved performance.

Sadly, in some cases, immediate dismissal is the only recourse. Here are a

few instances that should result in this worstcase scenario: • In a medical or dental office, taking shortcuts with the sterilization process, or anything that might endanger the patient, is a dramatic departure from employee training and procedures under the law.

• Screaming or cursing at the boss or even a coworker is disrespectful.

Epithets should not be used against anyone in the office, much less the person who signs the paychecks.

• Drama is not allowed in my office, so much so that my new hire paperwork states that if someone brings drama into my office he/she will be fired immediately. I determine what “drama” means.

• An employee who refuses to sign an action plan or written warning or is dismissive of the proposed corrective action and indicates that he/she isn’t willing to change should be fired immediately.

Sleep well Working together efficiently can affect every aspect of your business, from the front office to the operatory. Taking the time to correct and guide team members usually does so at the “cost of stomach lining.” As bosses, we lose sleep over formulating the right words to improve an uncomfortable situation. But if we deeply believe in our team members’ potential, this is the way to help them strive for a better outcome.

It’s what good leaders do. Many of us can approach confrontation calmly; others will sweat through it or perhaps even become somewhat abrasive when put on the defensive. However, in the final analysis, remember that true leaders take their employees’ failures as their own — and we share in all of the triumphs and victories too. IP Implant practice 43

PRACTICE MANAGEMENT

Apologizing for how employees interpreted what you said doesn’t cost you anything. It doesn’t make you wrong and them right. It may, however, keep a situation from escalating and lead to improved performance.

MARKETING MOMENTUM

Your dental message — delivered Dental marketer, Jackie Raulerson, offers insights into crafting engaging articles for dental publications

W

hen you have some great cases and experiences and want to share your success with colleagues via an article, providing comprehensive information in the best format can be a challenging but very achievable goal. The adage, “You only get one chance at a first impression,” applies to the written word just as much as a face-toface meeting. To properly show the many aspects of your successful treatment plan, you need to be familiar with the steps to present it well. You’ve worked too hard to perfect your clinical skills to let them be obscured by missing information. Ensure that your message is delivered in an organized and understandable form.

Developing a clear message is critical to your achievement as an author. To skillfully present findings and treatment plans to patients, your case presentation and information should be clear, concise, and tailored for your audience.

Publishers understand that you are foremost a clinician, not a writer by trade.

However, to construct an article, you need to harken back to the basic formulas that you learned in college for constructing an essay.

After my 20-year clinical career as a dental assistant, hygienist, and office manager, I worked for dental manufacturers in an editorial/marketing role. As part of my duties, I had the pleasure of assisting doctors and other dental professionals in delivering their messages. For a case report or practice management article, the process is basically the same. In my experience, the areas where I found I was able to lend the most assistance and guidance was in structure, written content management, and supportive images.

Here are some tips that I hope you will find helpful in your writing journey.

Jackie Raulerson, RDH, has been in the dental clinical field for 20 years and in dental development and marketing for 17 years. Working with both manufacturers and dental professionals, she helped to establish a strong editorial and social media presence for several global companies. Raulerson now operates her own business to help both dental sectors accomplish their marketing needs. She can be reached at jackie@yourmessagedelivered.net.

44 Implant practice

Decide on a style This will be dictated depending on the type of article. Case studies need a more straightforward, clinical approach to the language and content. Continuing education (CE) articles need to explain or elaborate on a technique, innovative treatment, or technology. CE articles also are written in a formal tone and often must start with an abstract — a paragraph that summarizes the whole article and contains objectives/purpose, materials and methods, and results. The CE must contain citations/references to substantiate your information with another authoritative source. Depending upon the amount of credits offered for your CE, you may need to formulate a quiz. For a nonclinical style article, you can be more conversational. This gives you more of an opportunity to let your personality shine through. These kinds of articles can be enjoyable to write for you and interesting for readers.

the good news is, you already know how to do this. Approach your article as you did your patient’s treatment, moving from one step to the next, from one visit to the next.

Clinical articles should include introduction/objectives, diagnosis, treatments in order of occurrence, and conclusion. For nonclinical articles, an outline will also help you to stay on track. Here, the outline should include introduction/objectives or problem to solve and steps you took to solve the issue in order of occurrence, and conclusion.

Generate steppingstones/stages of information As your outline comes together, you will probably notice that your content is automatically dividing into sections. Before each section, a subhead, or short phrase, can allow for separation and an easier read. Each stage of advancement builds on the story, which can keep the reader involved.

Create an outline

Use concise language

To begin any type of article, you need to have a clear direction and path. An outline will help you stay on track to move through the process of generating a cohesive flow of information and ideas rather than jumping around.

You must be deliberate in this process. And

Wordiness can stall the reader’s attention and ultimately cause his/her mind to wander.

After all, you are putting lots of time and effort into your presentation and want to engage the reader all the way to the end. As you reread your content, look for places where Volume 13 Number 1

Move from the general to the specific For each section, the first sentence or few sentences should set up the topic for that section. For example, if you are discussing treatment, start with what was accomplished with this step of the treatment, and then break down the process. For example, “My treatment recommendation was surgical intervention. To start, I began with the exposure of tooth No. 5, which was impacted. Then I moved to …”

Deliver the proper details Offer basic yet concise details for each section. For example, “The patient came to my office and had a problem with anterior crowding that needed treatment” is not detailed enough. A better approach would be, “The 14-year-old female patient presented with anterior crowding. I set a course of treatment that included …”

Another example, “I was able to move the teeth into correct position,” would be better as “I was able to move teeth Nos. 6 through 11 into correct position.”

When describing what you did, usually a publication will allow you to mention product names, especially if the brand or type of product was integral to the successful outcome of treatment. When mentioning product names, it is best to first state the general product group and then the product name. For example, “As part of diagnosis phase, I recommended a 3D radiographic scan (enter product name, followed by a comma and manufacturer name, city, and state of the company headquarters) …” The exact information that must be included may be indicated by the publisher’s guidelines.

Develop a compelling bio Most articles require a short biographical paragraph of the author, some as little as 30 words. While you may have 300 words about yourself on your website, you will need to edit down the word count for an article. Most bios will give your educational background, affiliations, and milestones. Choose the most important items that you want your readers to know about yourself, as well as those that make sense for the information you are presenting. Group items in a shortened format as needed. For example, if you belong to your local, regional, state, and national organizations, and you also take many CE courses during the year, you can offer, Volume 13 Number 1

Figure 1: When space is limited, or images will appear in a smaller size, cropping is a good option to show the most important aspect of the image. On the left is a full screenshot. On the right is a cropped version showing just of the area of interest to your reader. (Images courtesy of Kaveh Ghaboussi, DMD)

To skillfully present findings and treatment plans to patients, your case presentation and information should be clear, concise, and tailored for your audience.

Figure 2: Using the appropriate tool in the imaging software can better show desired anatomy or features. On the left is a typical 3D X-ray sagittal view. On the right, the airway tool has been applied, clearly calling out the airway space. (Images courtesy of Robert Kaspers, DDS)

Figure 3: It is important to dry the teeth prior to camera images. On the left is an image where much saliva is present, obscuring the view. On the right, the tooth is dry, and the image is more readable. (Images courtesy of KaVo Kerr) Implant practice 45

MARKETING MOMENTUM

you have repeated information. Then decide on the best place for that info, and do not repeat unless it is for emphasis or as part of your summary/conclusion.

MARKETING MOMENTUM “Dr. is a strong proponent of organized dentistry and continuing education.”

Make sure your pictures are worth 1,000 words Now that we have covered the written word, let’s move on to supporting images.

What I have learned clinically is that images we look at may not be the best in terms of composition and angulation and maybe even dose when it comes to radiation; however, they give us the information we need for our particular task. For example, your hygienist may take a bitewing X-ray where there is some overlap, which can happen due to many factors. However, clinically, if you are only interested in the contact point of two particular teeth for this appointment, that area is clearly shown. On the other hand, although the X-ray may meet clinical needs, it may not be the right resolution or position for a textbook or clinical article.

For case presentation in articles, it is imperative that the images meet or are very

close to what I like to call “marketing standards.” That is, they are crisp, clear, and presented at the right angle. When they meet all of these criteria, they visually tell the story of the case. This is especially important when showing newer technologies that others may not be familiar with; for example, 3D camera or radiographic images. Your readers need to know at a glance what they’re looking at, what you’re explaining, and how important it is to the case.

Most publishers have guidelines on what size and resolution is required for images.

Proper resolution ensures that images will not pixelate when enlarged for print. While high resolution and size is less important for web use, print is another story entirely.

Captions for images can be a summary of the text in the article, or they can have their own message. In the case of the latter, you can offer more information to your reader without creating redundancy. It’s also important to note that most readers will skim article images and captions before reading the

Figure 4: When taking camera images for case study articles, it is helpful to take several and then pick the best one. On the left is an image where the camera wand slightly moved, causing a blurry image. On the right is the same tooth captured with a still wand. (Images courtesy of KaVo Kerr)

entire article, so it is best to create compelling captions.

Ask for help Editors understand that you are under the time constraints of a busy practice, so they want to save you time and revisions by creating publisher’s guidelines. Typically, these guidelines specify the length, layout, and number of images you can submit for your article. They also share how to add and format references, if needed.

If you are new to the writing process, you may want to ask a colleague to review your article before submitting. Of course, he/she should be someone whose opinion you value, and who will be honest in his/her assessment.

While the publication’s editors will usually edit the text, references, and captions in your article, they may offer additional help if you are unsure about another aspect of your article. Since editors are often extremely busy during article due dates, don’t wait to the last minute. Most are happy to help during the writing process.

You can also seek the assistance of freelance writers that specialize in the dental field. You can find qualified writers through groups such as the American Medical Writers Association or marketing companies that employ writers who are experienced in the dental field.

When it comes to supportive images, often the manufacturer of the imaging product you use (cameras, scanners, X-ray) can offer clinical assistance. This is one activity I really enjoyed when working for imaging companies. Given my clinical background and software proficiency, I was able to help dentists find the best image, best viewing mode, and angulation to tell their stories. I was also able to help with resolution issues. You can begin by asking your product sales representative to make a recommendation within his/her company for someone who can offer a helpful hint or necessary graphic; typically, this is the Clinical Advisor or Product Developer.

If you would like to learn more about image screen capture, resolution, and size, YouTube offers an abundance of information.

One video that I found helpful without information overload is “The Confusing Concept of Image Resolution” at https://youtu.be/ XqWFfTrorRQ.

Go forth and share!

Figure 5: Saving an image in the correct resolution ensures better quality when displayed in the article. On the left is an X-ray saved in lower resolution (72dpi); the right is a higher resolution (300dpi), shows more details. (Image courtesy of KaVo Kerr) 46 Implant practice

I hope that this information will give you more confidence in sharing your clinical and professional experiences. You can do this! As in dentistry, it all starts with a plan. IP Volume 13 Number 1

AUTHOR GUIDELINES Implant Practice US is a peer-reviewed, quarterly publication containing articles by leading authors from around the world.

Implant Practice US is designed to be read by specialists in Periodontics, Oral Surgery, and Prosthodontics.

Submitting articles Implant Practice US requires original, unpublished article submissions on implant topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education.

Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Implant Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available.

Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses.

Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 13 Number 1

Pictures/images

Disclosure of financial interest

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

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

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

Tables Ensure that each table is cited in the text.

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

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

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

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

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

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

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

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

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

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

London: Martin Dunitz; 2001.

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

Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

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

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

Implant practice 47

ON THE HORIZON

How important is today’s digital lab?

Dr. Justin D. Moody discusses the digital possibilities for minimally invasive surgery and precision placement

I

n the past, I have talked about how nearly every dental laboratory is digital in some way. Last month I had just finished a guided surgery case that made implant dentistry seem way too easy, so I decided to go and check out the lab that fabricated it. What I found is far beyond just a digital scan, beyond a computer screen, or the fancy 3D-printed models.

True digital workflow exists in today’s premier labs; they embrace it, and when you talk with the technicians, you would find that they actually thrive on it. Jeremy Herbert at ProSmiles Dental Studio is the CAD/CAM department supervisor and captain of the U.S.S. Molar, their new digital design center. He walked me through the process for making a surgical guide. It’s truly all digital, all virtual, and 100% amazing, in my opinion. Many times the fabrication of immediate-loaded restorations that were placed with a guide can be done at the same time of guide manufacture, and this saves the office time and patient visits, and is just cool to see. Virtual articulators that help make the connection from the patient to the 3D screen are no longer theory but reality.

I personally use the Kois Facebow, which allows the information to be transferred to the CAD/CAM software. This wasn’t even talked about years ago when I first learned from Dr. John Kois.

Surgical guide cases arrive at the lab in two parts — the .dcm file from the CBCT and the .stl file from the surface scan. Jeremy and his team of design artists take these files and merge them using surgical guide software, and

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 (nonprofit clinic), and Director of Implant Education for Implant Pathway. You can reach him at justin@justinmoodydds.com.

Disclosure: Dr. Moody is a paid consultant for BioHorizons® and ProSmiles Dental Studio.

48 Implant practice

Figure 1: Jeremy Herbert in his element at ProSmiles Dental Studio. He is at the helm of the U.S.S. Molar Design Center!

Figure 2: ProSmiles Dental Studio Design team at their ugly sweater Christmas party!

Figure 3: Cone Beam CT data merged with virtual implant placement and proposed surgical guide

Figure 4: Prosthetically driven treatment planning starts with the final product in mind, true teamwork between the dentist and the lab

with guidance from the treating doctor, they prepare a concept guide based on their desired outcome. Once the doctor has signed off on the guide design, it goes to the 3D-printing department for fabrication, processing, and Figure 5: Surgical guide concept approved by dentist and finishing. Many of the guides require metal ready for 3D printing. Guide will literally be in the hands of sleeves specific for the guided kits. The use the surgeon in a matter of hours of only authentic OEM parts is critical for the proper seating, positioning, and placement of the planned implants.

The final product is packaged up with the guide protocol sheets and overnighted to the final destination. How long does all this take? This mainly depends upon the doctor providing all the data as soon Figures 6 and 7: 6. 3D-printed models mounted to the Panadent articulator with as possible, providing a clear the help of the Kois Facebow. Getting the right data is key to prosthetic success restorative plan, and timely with the lab. 7. The use of authentic OEM parts such as these from BioHorizons® will help ensure accuracy and pinpoint placement of the dental implant review of the concept for proof.

Normally this can take just days exciting — there’s better treatment done with in the lab, and as technology improves, so minimally invasive surgery and precision placedoes the turnaround times and the quality of the product. Today’s implant dentistry is so ment for prosthetically driven results! IP Volume 13 Number 1

predictable, immediate results Tapered Pro Implants “The design of the Tapered Pro implants allows me to use the system for a range of treatment protocols, from single implants to complex immediate loading cases. The thread design and primary stability from the implants makes my immediate cases much more predictable�.

Dr. Arshiya Sharafi, DDS For more information, contact BioHorizons Customer Care: 888.246.8338 or visit us online at www.biohorizons.com

#AreYouAPro Not all products are available in all countries.

SPMP19231 REV A JUL 2019

2020 CITIES INSTRUCTOR Justin D. Moody, DDS

2020 SCHEDULE

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.