Implant Practice US Spring 2021 Vol 14 No 1

clinical articles • management advice • practice profiles • technology reviews Spring 2021 – Vol 14 No 1 • implantpracticeus.com

PROMOTING EXCELLENCE IN IMPLANTOLOGY Company spotlight NovaBone Products ®

Oral hygiene and dental implant maintenance: part 1 Dr. Gregori M. Kurtzman and Debbie Zafiropoulos

A simple technique for creating a screw-retained immediate restoration after immediate implant placement Dr. Justin D. Moody

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A conversation with ...

Randolph R. Resnik, DMD, MDS, director of the Misch International Implant Institute

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DENTAL MOTOR S MOB ILE & P ORTAB LE DEN T I ST RY G LOBAL DENTAL CATALO G DENTAL EQUIPM ENT OEM

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 2021. 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.

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nnovative digital technologies are no longer a “need to have” but rather a “must have” in our daily implant procedures. In my experience, these advancements have had a substantial, positive impact on the safety and efficacy of my patients. Over the years, I’ve noticed that the use of the latest digital trends in my own practice has helped influence my patients’ trust and confidence that they’ll receive treatment and results that go above and beyond initial expectations. In my facility, specifically, we’ve taken full advantage of many digitalengineering solutions in the world of dental implants.

The evolution of dental implant-related technologies has considerably improved the safety, efficacy, efficiency, and scope of treatment available to patients. Patients with terminal dentition that require full-arch fixed hybrid prosthetics in particular have reaped the benefits from enhanced care as a result of digital diagnostic records, virtual planning, guided surgery, indexed prosthetics, and indexed 3D-printed prosthetics. Traditional visual facial analysis is augmented by digital photography and 3D photography to provide greater accuracy in the virtual-planning phase. Cone beam CT scans obtained in centric relation “CR” are the cornerstone of virtual planning. Intraoral dental scans or digital denture dual scans can be merged with cone beam CT data and 3D photography. Digital records are then transferred to virtual planning software such as exocad to develop the engineering and architecture of a functional and esthetic dental arch. Proper vertical dimension, occlusal plane orientation, and implant-to-prosthetic relationships are evaluated and modified using a virtual articulator.

It’s important to keep in mind that implant spacing, emergence position, and appropriate restorative space are integral to the final design. Bone-borne implant guides are registered and rigidly fixated to basal bone transfer concepts from the digital design to the surgical field. Base portions of the guide create a platform for appropriate bone reduction, vertical dimension, occlusal plane orientation, and prosthetic attachment. Implant guides registered to the base guide assure appropriate implant position and alignment to the prosthesis within the trabecular bone space. Ensuring proper placement of implants within trabecular bone stimulates anisotropic bone remodeling during integration and avoids stress-related bone loss.

The use of 3D printing has been a game changer in dental implantology. 3D-printed composite resin prosthetics are designed to permit indexed placement by attaching to the base guide during bonding to cylinder abutments. This provides for transferring the plan for arch form, vertical dimension, occlusal plane, and occlusal relationships using an efficient and accurate process. Advances in 3D printing permit the use of sophisticated composite resins with fiber-reinforced bases and micro-hybrid or zirconium-filled dental bridges. The greatest benefits of 3D-printed composite resin prostheses offer a lower cost, good wear resistance, strength, esthetics, Digital Records and the potential to be modified or repaired later on down CBCT-Oral Scan-Or Dual Scan the road.

Digital Photography Moving forward, I anticipate that many of the technologies will continue to evolve and give oral surgeons more Virtual Guide and Prosthetic Planning accuracy in their daily routines. By adding these cutting-edge solutions to my daily workflow, I’ve noticed how much more Guided Surgery time and cost efficiently I’m able to operate, and I’m excited to see what’s to come in the future.

Printed In summary, the digital flow outlined here eliminates dental Indexed models and leads to time and cost-efficient fixed implant-borne Prosthetics prosthetics.

Daniel B. Spagnoli, DDS, MS, PhD, completed his Oral and Maxillofacial Surgery (OMFS) residency at Louisiana State University (LSU) School of Dentistry and Charity Hospital. Dr. Spagnoli became certified by the American Board of Oral and Maxillofacial Surgeons and is a past Board examiner. Following his residency, he entered private practice in Charlotte, North Carolina, at University Oral and Maxillofacial Surgery, which eventually became the Carolinas Centers for Oral, Facial, Cosmetic & Dental Implant Surgery. While practicing in Charlotte, Dr. Spagnoli maintained academic affiliations with Louisiana State University and the University of North Carolina (UNC). The Charlotte practice became a training site for Oral and Maxillofacial Surgery residents initially from the UNC, and then and currently from LSU. Dr. Spagnoli has served as Director of Oral and Maxillofacial Residency Training at Carolinas Medical Center. He became the James Peltier Chairman of Oral & Maxillofacial Surgery and the Director of Dental School Hospital affairs at the LSU Health Science Center School of Dentistry. Dr. Spagnoli now brings his years of private practice and academic experience to a new practice — Brunswick Oral & Maxillofacial Surgery in Brunswick County, North Carolina.

ISSN number 2372-9058

Volume 14 Number 1

Implant practice 1

INTRODUCTION

Spring 2021 - Volume 14 Number 1

Contemporary digital workflow for efficient cost-effective implantborne full-arch hybrid prosthetics

TABLE OF CONTENTS

Publisher’s perspective Renewed energy in 2021 Lisa Moler, Founder/CEO, MedMark Media................................6

A conversation with ...

8

Dr. Randolph R. Resnik, director of the Misch International Implant Institute

Company profile Who we are: 3DISC ....................................................... 12

Case report High-frequency vibration to enhance socket preservation in anticipation of implant placement — case reports: part 2

Corporate spotlight

10

Drs. David W. Engen, Gregori M. Kurtzman, and Tarek El-Bialy illustrate five patient cases............................. 13

NovaBone Products ®

A diverse portfolio of osteostimulatory bone grafting products with a unique spin on delivery ON THE COVER Cover image courtesy of Glidewell. Article begins on page 8.

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TABLE OF CONTENTS Case report Rehabilitation of a patient with a severely resorbed maxilla using zygomatic dental implants and a novel prosthetic design for a full-arch zirconia rehabilitation Drs. Daniel F. Galindo and Caesar C. Butura and Michelle Boomer, CDT, treat a patient who had not visited a dentist in more than a decade.........18

Continuing education A simple technique for creating a screw-retained immediate restoration after immediate implant placement Dr. Justin D. Moody discusses an implant technique that achieves relievable and predictable results

Continuing education

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Oral hygiene and dental implant maintenance: part 1

Dr. Gregori M. Kurtzman, along with Debbie Zafiropoulos, discusses appropriate professional care and effective patient oral hygiene for maintenance of implants

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Practice management Practice development On the horizon “I’m not the doctor, but …”

JoAn Majors shows the power of the “preheat” when a well-trained team can instill confidence with implant patients ..........................................34

Medical insurance benefits can increase access to dental care Rose Nierman explores some intricacies of billing medical insurance ...................................................... 36

When implant design matters Dr. Justin D. Moody discusses how implant technology continues to evolve

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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

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Volume 14 Number 1

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PUBLISHER’S PERSPECTIVE

Renewed energy in 2021

S

o here we are in 2021. While the challenges of 2020 have not completely disappeared, we can definitely see healing and hope on the horizon. Personally, I am energized — looking forward to seeing all of you at in-person conferences and meetings, setting new goals, and finishing some that were put on hold.

What does this mean for MedMark and all of its publications? Since we thrive when you thrive, it means that we need you to share all of your thoughts with us. During the pandemic shutdowns, what ideas did you have for improving your office procedures and your clinical protocols when you returned?

What are you doing to make those plans into actions? How are Lisa Moler Founder/Publisher, MedMark Media you focusing your renewed energy into more thriving practices?

What were your challenges, and how are you going to make your practices more resistant to future forces that can get in the way of forward movement?

We want to be the publication that brings you new techniques, cutting-edge technologies, innovative products, and articles that start conversations about how your dental talents can change lives for the better. Because of our readers, people overcome life-threatening sleep disorders, teenagers can smile without being self-conscious, and adults can obtain some orthodontic, implant, and endodontic treatments that weren’t even an option when they were teens. As we discover and spotlight new products and techniques, patients will not think of their dentist as just doing a root canal or implant but as being synonymous with healing and overall good health.

In this issue of Implant Practice US, we have CE articles on oral hygiene and dental implant maintenance and a technique for creating a screw-retained immediate restoration after immediate implant placement. Another article explores the benefits of high-frequency vibration to enhance socket preservation before dental implants. For a patient who needed treatment of a severely resorbed maxilla, the full-arch zirconia rehabilitation was certainly a life-changer.

We greet 2021 with so much hope, ideas, and energy. The MedMark team is ready to help you reach positive goals that exceed your expectations. With articles written by experienced and knowledgeable dental leaders and advertisements from technology and service leaders that involve all areas of dentistry, we aspire to be part of your healing, a source of your inspiration, and a vehicle for your success!

All the best, 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, CDE mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com MANAGER CLIENT SERVICES/SALES Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING & DIGITAL STRATEGY Amzi Koury amzi@medmarkmedia.com WEBMASTER Mike Campbell webmaster@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 Toll-free: (866) 579-9496 www.medmarkmedia.com www.implantpracticeus.com SUBSCRIPTION RATES 1 year (4 issues) $149 3 years (12 issues) $399 Subscribe at www.medmarksubscriptions.com

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Volume 14 Number 1

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A CONVERSATION WITH ...

Dr. Randolph R. Resnik, director of the Misch International Implant Institute

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or more than 35 years, the Misch International Implant Institute (MIII) has set the standards for dental implant education. As a founding member, director, and primary lecturer of the MIII, Dr. Randolph Resnik provides us with an inside look at the MIII, its detailed, literature-based curriculum, and the success attendees have gained after graduation.

What is the Misch educational philosophy?

The Misch philosophy is based on integrating all aspects of implant dentistry, including the surgical, prosthetic, and maintenance disciplines, into easy-to-understand, comprehensive protocols. We teach literature-based, universally accepted classifications and procedures that allow clinicians to easily integrate into their practices.

I truly believe every general dentist should be placing dental implants and performing bone-grafting procedures. Implant dentistry is one of the fastest growing areas in medicine and is projected to continue at an increasing rate in the future. Therefore, general dentists just need to acquire a strong foundation of basic implant skills and time-proven principles that will allow their practices to go to the next level.

How does the MIII training directly impact graduates’ practices?

Our graduates become part of the Misch family, and many attendees acquire lasting relationships with our faculty and their fellow students. I am most proud of what our graduates accomplish after our training. In a recent graduate survey, which we conduct a year after students complete our program, Randolph R. Resnik, DMD, MDS, is a leading clinician, educator, researcher, and author in the field of prosthodontics and oral implantology. He received his dental degree, specialty training in Prosthodontics, Surgical Implantology Fellowship, and Master’s degree in Oral Implantology from the University of Pittsburgh.

He maintains faculty appointments at the Misch Institute (Director), University of Pittsburgh (Prosthodontics), Temple University (Periodontics and Oral Implantology), and Allegheny General Hospital (OMFS). In addition, he is an accomplished author, having published many research articles along with the two best-selling textbooks in implant dentistry by Elsevier: Avoiding Complications in Oral Implantology and the 4th edition of Contemporary Implant Dentistry.

8 Implant practice

Dr. Resnik assisting a doctor at the Hands-On Surgery course performing a lateral wall sinus augmentation

the results show a significant benefit to their practice: 98.5% of grads are placing implants, 97% of grads are performing bonegrafting procedures, and attendees report an average of 22.7% increase in office production in the first year after graduation. In addition, many graduates of our program easily become Diplomates and Board-certified in Oral Implantology.

Could you give us an overview of your courses?

The MIII provides courses in Surgery, Prosthetics, CBCT, Complications, and live Hands-On Surgery. Our goal is to provide the clinician with a well-rounded education that minimizes the possibility of complications. Each course is comprised of 2 to 3 days of didactic lectures and hands-on lab sessions. All PowerPoint slides are provided to the attendees in an easy-to-follow colored handout.

How would you explain your course curriculum?

I am a huge advocate for giving doctors as much information as possible. My belief is to expose doctors to every aspect of implant dentistry and, in addition, to build their skills

Randolph R. Resnik, DMD, MDS

in performing procedures they have never previously been exposed to. During each course, approximately 4 hours per weekend are dedicated to learning clinical procedures via hands-on labs. Attendees get extensive training in soft-tissue management — such as suturing, tissue stretching, reflecting tissue — along with flap design, exposing vital structures, and CBCT-guided procedures. In addition, we expose our doctors to freehand and fully guided implant surgery with respect to single, multiple, fully edentulous, and immediate-load implant protocols.

Our doctors are provided with step-by-step handouts, PowerPoint presentations, and a detailed video of each lab procedure.

Volume 14 Number 1

It is most beneficial if students are able to perform procedures they have just learned about in lecture. For instance, over the years, one of the most common complications doctors experience early in their learning curve is incision line opening.

Almost every weekend of our surgical program, we emphasize tissue stretching and incision procedures. Therefore, our doctors get very proficient at handling soft tissue, and this decreases their complications in their office and increases their procedural success rate. In fact, our faculty come in at night or early in the mornings to work with doctors one-on-one to increase their skill level with any particular procedure of interest.

Tell us about your supervised, hands-on surgery program.

Misch students are able to perform live surgery on patients for almost any type of

Volume 14 Number 1

implant or grafting procedure (extraction/ socket grafting, single and multiple implants, ridge augmentation, and crestal- or lateralwall sinus augmentation). The hands-on courses are given in Tampa, Florida, and state dental licenses are provided for all of our doctors. Doctors are allowed to select what type of procedures they would like to perform. Specific details are provided at misch.com.

What do you see in the future for implant dentistry?

I believe the outlook for the Misch Institute and implant education is excellent. I believe the demand for dental implants will only increase as more general dentists will become active in the surgical placement of implants. Currently, studies show that 80% to 90% of general dentists worldwide place implants; however, only 10% to 15% of general dentists in North America are involved in the surgical phase. A significant trend I am seeing is that more and more

general dentists are getting involved with implants; however, very few have formal training. Therefore, because our curriculum is tailored to the general dentist and is the most comprehensive in the industry, the Misch Institute will remain at the forefront of dental implant education.

What is your goal for the MIII graduating students?

My goal is for all of our graduates to integrate our protocols and classifications into their practices that will lead to their practices becoming more successful and profitable. My favorite saying is: “What is the difference between a good Implantologist and a great Implantologist? The answer is that a good Implantologist is very good at surgery; a great Implantologist knows when not to perform surgery.” Therefore, at the Misch Institute, we train our doctors to be successful and give them the knowledge that is needed to understand when it is not advisable to proceed with a procedure. IP

Implant practice 9

A CONVERSATION WITH ...

Why are these hands-on lab procedures so valuable?

CORPORATE SPOTLIGHT

NovaBone® Products A diverse portfolio of osteostimulatory bone grafting products with a unique spin on delivery

N

ovaBone® Products was established in 2002 with a focus on developing biomaterials that harness the body’s natural healing process. The company, headquartered in Jacksonville, Florida, with manufacturing operations in Alachua, Florida, offers diverse product lines in both dental and orthopedics, including bioactive glass, collagen wound-healing products, and composite grafts.

The synthetic dental bone graft portfolio is based upon bioactive glass at its core. The active ingredient in all NovaBone bioactive glass products is calcium phosphosilicate.

This active ingredient has been shown in various studies to be osteostimulatory — meaning that the graft can assist in the proliferation and differentiation of bone-forming cells (osteoblasts). As the graft resorbs, calcium and phosphate ions are released into the wound site, which can help signal and recruit undifferentiated cells that later take on an osteoblast lineage.

The product line was expanded some years ago to include a putty form of the bioactive glass. Polyethylene glycol and glycerin are added to the bioactive glass particles to produce the putty consistency, with the bioactive glass particles still making up 70% of the putty by volume. The handling characteristics of the putty are much more desirable than a particulate graft alone as the putty can be shaped to the defect, does not wash out in the presence of blood or irrigation, and has excellent radiodensity to differentiate from the host bone in a radiograph. Initially, the putty offers a transient hemostatic effect.

As the binders/additives are more quickly resorbed by the body, it leaves a matrix that is supportive of angiogenesis and ultimate bone formation. There are over 50 technical publications and over 30 clinical publications in peer-reviewed journals that demonstrate the ability for NovaBone® Putty to regenerate bone across a range of defects, including peri-implant defects, localized ridge augmentations, extraction sockets, sinus augmentations, and periodontal defects.

The putty is available in traditional clamshell packaging as well as syringe configurations, but the real differentiator is the uni-dose cartridge configurations. NovaBone 10 Implant practice

Figure 1: The NovaBone Putty portfolio includes bulk material in a clamshell, syringes, and unique uni-dose cartridges expressed from a handheld dispenser

“NovaBone provides an ideal environment for bone formation by acting as a very stable but also temporary scaffold in a variety of clinical applications, which is later absorbed and replaced with additional vital bone, maximizing tissue quality and function.”

— Dr. Rodrigo Neiva, DDS, MS, Chair (Periodontics) University of Pennsylvania School of Dental Medicine

Putty is the only bone graft material that can be dispensed from a cartridge — similar to popular dental composite materials. At 1.8 mm, the cartridge cannula tip allows for precise delivery of the putty to the defect site. This is helpful when trying to place the graft in difficult to reach peri-implant defects or extraction sockets in the posterior region of the patient’s jaw. The uni-dose cartridge has also become hugely popular in the transcrestal approach to sinus augmentation as the graft material is more easily inserted through the osteotomy to the underside of the maxillary sinus. As the putty is expressed, it creates a form of hydraulic pressure that is able to safely lift the Schneiderian membrane upward, creating an augmented dome for subsequent placement of the dental implant.

This minimally invasive approach to sinus augmentation can be substantially less

traumatic to the patient in comparison to the traditional lateral window approach.

In addition to its market-leading delivery system, NovaBone Putty offers other considerations for the clinician user. First, it’s a synthetic material so is not subject to the variations in quality or consistency that sometimes are associated with allograft materials based on the condition of the underlying donor. The material offers a 4-year shelf life and requires no specialized storage conditions (e.g., refrigeration).

Second, the product is resorbable with most studies demonstrating 80%-90% of the graft being resorbed by the 6-month mark.

This is in contrast to many of the xenograft products that are sintered to the point of essentially creating a non-resorbable graft.

That sintering is a part of the manufacturing process to ensure the elimination of Volume 14 Number 1

CORPORATE SPOTLIGHT Figures 2 and 3: 2. NovaBone Putty is widely used in the minimally invasive transcrestal approach to sinus augmentation. 3. The 1.8 mm cannula allows for precise placement of the putty for peri-implant defects

“We have been working on peri-implant regeneration for years, and we have found that merely osteoconductive biomaterials are not consistently adequate for regeneration in these challenging situations.

Our preclinical findings with the use of calcium phosphosilicate morsels have shown that the osteostimulative properties of this graft can vastly increase the attachment of osteoblasts on implant surfaces, making it a great fit for peri-implantitis surgery.”

Figure 4: The NovaBone Granules offer larger particle size and interconnected porosity

any organic content in the graft that could result in disease transmission (e.g., mad cow disease). Such a process is unnecessary with NovaBone bioactive glass products as there is no organic content to remove. Finally, the NovaBone Putty has a unique osteostimulatory effect as previously described, which has not been validated to the same extent in other synthetic bone grafting materials.

Capitalizing on the success of the NovaBone Putty, NovaBone expanded the product line to include NovaBone® Morsels.

The morsels feature a larger particulate size, up to 1 mm, with interconnected porosity of 65% and pore sizes as large as 100 microns. In comparison to NovaBone Putty, the NovaBone Morsels provide more structural integrity, which some clinicians have Volume 14 Number 1

— Dr. George Kotsakis, DDS, MS, Associate Professor, Department of Periodontics, University of Texas Health Science Center at San Antonio (UTHSCSA) preferred for indications to include localized ridge augmentation and the treatment of peri-implantitis defects. The morsels are a crystalline version of the same calcium phosphosilicate active ingredient found in other NovaBone graft materials. This product is currently in clinical trials at the University of Texas Health Science Center in San Antonio to assess its performance in the treatment of bone defects associated with peri-implantitis.

Pre-clinical studies were encouraging and showed the material’s propensity to enhance the attachment of osteoblasts to titanium surfaces.

The NovaBone regenerative portfolio is rounded out by a series of collagen wound

dressings to include tape and plug configurations. As collagen is naturally hemostatic, these products have found a wide range of applications to include extraction sockets, repairs to a tear of the Schneiderian membrane in a sinus augmentation procedure, and short-term containment of bone grafting materials. NovaBone has a number of products in its product development pipeline that capitalize on its core competency with collagen and bioactive glass implantable biomaterials.

The NovaBone bone grafting portfolio is distributed exclusively in the United States and Canada by Osteogenics Biomaterials (www.osteogenics.com). IP Implant practice 11

COMPANY PROFILE

Who we are: 3DISC

Company overview Founded in 2007, 3DISC started off as an R&D company but quickly matured into an agile American manufacturer and global provider of digital-imaging solutions for dental practices. Fourteen years later, 3DISC is a privately owned company with headquarters based in the United States and France with a diverse team of digital experts curated from a variety of high-tech backgrounds for one mission — to pioneer the digital dentistry landscape of tomorrow. Our goal is to deliver relevant clinical benefits to doctors through inclusively digital solutions, specifically intraoral scanners. When dental clinics choose 3DISC, they’re taking digital beyond; they can trust our commitment to the continuous innovation of our solutions that will help bring simplicity to their workday and empower doctors to provide the highest quality treatment to their patients. That’s why we created the Heron IOS.

Solution overview The Heron™ IOS is a digital 3D-imaging solution bringing simplicity to the beauty of

12 Implant practice

“The Heron has arrived, and it has set a new bar for all other scanners. The choices among optical scanners have become vastly overwhelming. In its inception clinicians demanded quality scans and simplified workflow. The Heron from 3DISC not only has those qualities but is unsurpassed in ergonomics and accessibility.

Finally, we have a comfortable lightweight scanner that feels like it belongs in the palm of your hand.” – Isaac Tawil, DDS, MS your work as a medical professional. One of the most ergonomic and easy-to-use scanners on the market, the Heron weighs in at 150 grams with a compact, streamlined design for more efficient scanning and increased patient comfort. For an allinclusive price, the Heron IOS is presented as a turnkey solution that takes less than 10 minutes to unbox and set up — including a pre-calibrated scanner, three autoclavable tips, and optimized acquisition PC equipped with HeronClinic Software. Using the HeronClinic Software, your team can easily navigate the intuitive, user-friendly interface to meet all your restorative, orthodontic, and implant needs. With clear workflows and a cloud platform, the Heron IOS makes it easier than ever to create or browse patient cases, scan, and share with your labs.

Our team is committed to providing superior service and support, so you can trust that when you introduce a Heron IOS into your practice, we will be there providing thorough in-office training as well as a variety of online resources. Our optimized acquisition PC automatically deploys software

updates as they are released to ensure that you always have the latest as well as instant remote access capabilities when you have questions or need help.

Why go digital?

Digital impressions have a number of advantages over traditional techniques. The increased accuracy of a digital impression results in fewer lab remakes and better-fitting crowns and appliances. Intraoral scanners (IOS) are also faster and more cost-efficient for users, while being less intrusive and uncomfortable for patients. Traditional impression taking methods may be triedand-true, but the reliability and performance intraoral scanning for digital impressions have increased dramatically in recent years.

Switching to intraoral scanning has never been easier or more reliable than it is today.

The Heron IOS is a fast and easy-to-use system that provides reliable and accurate results every day — take advantage of this technology in your own practice today. IP This information was provided by 3DISC.

Volume 14 Number 1

Drs. David W. Engen, Gregori M. Kurtzman, and Tarek El-Bialy illustrate five patient cases Introduction

Case report No. 1

Part 1 of this series discussed considerations for ridge and socket preservation in preparation for implant placement. The treatments used for these patients involve a novel approach applying high-frequency vibration (HFV) to stimulate bone growth.

Orthopedically and dentally, the literature demonstrates that when bone is stimulated with HFV during healing, osteoblastic activity increases, and denser more organized bone results. When applied to extraction sockets during the healing phase in anticipation of implant placement, higher quality and quantity of bone is present to accommodate the planned implant when compared to sites that were not treated with HFV. This HFV protocol is implemented by the patient at home using a 5 minute routine daily making compliance easy. Part 2 of this series reviews five patient cases using this innovative method.

A 73-year-old male presented with an abscessed, nonrestorable lower-left first molar (tooth No. 19) with a vertical root fracture (VRF) on the mesial root (Figure 1).

Surgical extraction was performed, and a post-extraction CBCT was acquired (Figure 2). The socket was intact. The patient returned 4 months postsurgically, and a pre-implant CBCT was acquired (Figures 3 and 4). The ridge had adequate buccallingual width to permit implant placement with sufficient buccal and lingual thickness of bone between the planned implant and the periosteum. Bone had filled in everywhere but the mesial-buccal socket, which was filled with granulation tissue (Figure 5). The granulation tissue was removed, a 6.0 mm x 11 mm implant was placed, and the void was grafted with mineralized bone putty and covered over with a collagen membrane. The implant was still able to be done single stage

(Figure 6). The patient was instructed to use the VPro™ HFV oral device with a bite plane utilized daily for 5 minutes post-extraction during the 4-month healing period. Density

Figure 1: Failing previously endodontically treated lower-left first molar

David W. Engen, DDS, MSD, is a Board-certified periodontist in private practice in Spokane, Washington. He has a master’s degree in bone physiology, as well as dual training in both Periodontics and Orthodontics. He is a graduate of Indiana University School of Dentistry and received his specialty training there as well. His master’s thesis was observing bone micro-damage around dental implants in the alveolar bone of dogs treated with various bisphosphonates.

Gregori M. Kurtzman, DDS, is in private general dental practice in Silver Spring, Maryland, and a former Assistant Clinical Professor at University of Maryland in the department of Restorative Dentistry and Endodontics, and a former AAID Implant Maxi-Course assistant program director at Howard University College of Dentistry. He has lectured internationally on the topics of Restorative dentistry, Endodontics and Implant surgery and prosthetics, removable and fixed prosthetics, Periodontics, and has over 750 published articles globally, as well as several ebooks and textbook chapters. He has earned a Fellowship in the AGD, American College of Dentists (ACD), International Congress of Oral Implantology (ICOI), Pierre Fauchard, ADI, Mastership in the AGD and ICOI and Diplomat status in the ICOI, American Dental Implant Association (ADIA), International Dental Implant Association (IDIA). A consultant and evaluator for multiple dental companies, Dr. Kurtzman has been honored to be included in the “Top Leaders in Continuing Education” by Dentistry Today annually since 2006 and was featured on the June 2012 cover. He can be reached at dr_kurtzman@maryland-implants.com

Figure 2: Immediate post-extraction CBCT axial view of the extraction site demonstrating the void created by extraction of the failing molar

Tarek El-Bialy, BDS MS PhD, is a tenured full-time professor of orthodontics and biomedical engineering at the University of Alberta, Canada. He received a BDS from Tanta University, Egypt, in 1987 and completed a Master’s degree in Orthodontics at Tanta University, Egypt. He received a law degree from Tanta University in 1994. He has successfully completed a certificate of specialty in Orthodontics, Master’s Degree in Oral Sciences and a PhD in Bioengineering at the University of Illinois at Chicago in 2000 and 2001. In addition, he completed an Executive Masters of Business and Administration (EMBA) at the University of Alberta, Canada in 2012. In addition, he recently (June 2019) received a doctoral degree from university of Bonn, Germany. A significant part of Dr. El-Bialy’s work was devoted to repair of orthodontically induced root resorption and biomechanics. Dr. El-Bialy is a fellow of the Royal College of Dentists of Canada (RCDC) and Diplomat of the American Board of Orthodontics. In addition, he is a senior research fellow, von Humboldt Foundation, Germany, since 2013. He also is the director of orthodontics at the RCDC board of directors. Dr. El-Bailey was the past president of the Alberta Society of Orthodontists.

Disclosure: Dr. David Engen received no compensation, nor has any financial interest in the HFV device. He received five VPro™ units from Propel Orthodontics at no charge. Patients paid full price for the extraction, but no charge for either the HFV or the CBCT scans.

Volume 14 Number 1

Figure 3: 4-month postsurgical CBCT demonstrating bone-fill in the extraction socket Implant practice 13

CASE REPORT

High-frequency vibration to enhance socket preservation in anticipation of implant placement — case reports: part 2

CASE REPORT

Figures 4 and 5: 4. 4-month postsurgical CBCT coronal slice demonstrating bone-fill in the extraction socket.

5. 4-month postsurgical healed extraction socket upon flapping demonstrating complete bone-fill

Figure 6: Immediate post-implant placement radiograph demonstrating dense organized bone in contact with the implant and filling what was the extraction socket

Table 1: Density readings on the CBCT for extraction site (Pre HFV) and the same spot following healing (Post HFV) with change in resulting density with HFV usage (% change).

Pre HFV* Case #

Post HFV*

% Mean Change in Density Following

Max

Min

Mean

Max

Min

Mean

1

230

-83

42.17

529

80

286.78

+580%

2

287

-117

42.07

362

171

86.98

+107%

3

81

-508

-216.39

730

45

608.98

+381%

4

-947

-984

-969.70

540

108

329.52

+134%

5

-991

-1000

-999.89

387

24

256.43

+126%

Healing and HFV**

* Hounsfield units ** Values rounded to 1.0

was measured on the CBCT in Hounsfield units at an area in the extraction socket for the immediate extraction CBCT and again in the same spot on the post-healing CBCT, indicating an increase in density of the healed clot, which was present in the socket initially (Table 1). For standardization, an area on the socket wall was compared at initial CBCT, and post-CBCT was measured for standardization on the patient indicating similar density values to bone outside the socket before-and-after use of HFV (Table 2). The large osseous defect resulting from the VRF of the mesial root at the 4-month postoperative appointment bone-fill had occurred with a small residual area at the mesial root that permitted the planned implant placement.

Table 2: Reference reading for cortical bone adjacent to the extraction Pre and Post HFV Case #

Pre HFV*

Case report No. 2

Post HFV*

Max

Min

Mean

Max

Min

Mean

1

1175

313

818.80

1163

631

910.08

2

1483

835

1125.62

1196

947

1067.64

3

1142

689

971.30

1225

702

1147.32

4

1044

384

781.68

1137

569

891.71

5

1193

256

681.43

955

232

549.45

* Hounsfield units

Figures 7 and 8: 7. Previously endodontically treated lower-right second molar presenting with a vertical root fracture necessitating extraction. 8. Immediate post-extraction CBCT demonstrating the extraction socket with thin buccal wall 14 Implant practice

A 66-year-old female presented with a painful vertical root fracture, nonrestorable lower-right second molar (tooth No. 31) (Figure 7). Surgical extraction was performed, and a post-extraction CBCT was acquired (Figure 8). The socket was intact but with a thin buccal wall following extraction. The patient was instructed to use the VPro™ HFV oral device daily for 5 minutes post-extraction during the 4-month healing period. The patient returned 4 months later, a pre-implant CBCT was acquired, and the socket presented with osseous fill of sufficient density to retain an implant (Figure 9). A 6.0 mm x 8 mm implant was placed (Figure 10). Density was measured on the CBCT in Hounsfield units at an area in the extraction socket for the immediate extraction CBCT and again in the same spot on the post-healing CBCT, indicating an increase in density of the healed clot that was present in the socket initially (Table 1). For standardization, an area on the socket wall was compared at initial CBCT, and post-CBCT was measured for standardization on the patient indicating similar density values to bone outside the socket before-and-after Volume 14 Number 1

Case report No. 3 A 67-year-old female presented with a lower first molar (tooth No. 19) decayed to the core and nonrestorable (Figure 11). After surgical extraction was completed, a postextraction CBCT was taken (Figure 12). The socket was intact. The patient was instructed to use the VPro™ HFV oral device daily for 5 minutes post-extraction during the 4.5-month healing period. The patient returned 4.5 months later, and a pre-implant CBCT was taken (Figure 13). Sufficient bone was present at the healed extraction socket to accommodate implant placement with sufficient bone thickness on the buccal and lingual between the planned implant and periosteum (Figure 14). A 6.0 mm x 11 mm implant was placed (Figure 15). Density was measured on the CBCT in Hounsfield units at an area in the extraction socket for the immediate extraction CBCT and again in the same spot on the posthealing CBCT, indicating an increase in density of the healed clot that was present in the socket initially (Table 1). For standardization, an area on the socket wall was compared at initial CBCT, and a post-CBCT was measured for standardization on the patient, indicating similar density values to bone outside the socket before-and-after use of HFV (Table 2).

Sufficient osseous fill was achieved with maintenance of the crestal aspects of the extraction socket permitting a wider implant to be placed following the initial healing period.

Figure 9: 4-month postsurgical CBCT demonstrating bone-fill of the extraction socket

Figure 10: Immediate post-implant placement radiograph demonstrating dense organized bone in contact with the implant and filling what was the extraction socket

Figure 11: Lower-left first molar with recurrent caries on the distal and buccal rendering the tooth nonrestorable Figure 12: Immediate post-extraction axial view demonstrating intact socket walls at the lower-left first molar site

Case report No. 4 A 63-year-old female presented with an abscessed and nonrestorable lower-left first molar (tooth No. 19) (Figure 16). The patient had a significant history of long-term use of bisphosphonates. An article by expert panelists of the American Dental Association Council on Scientific Affairs notes: “Bisphosphonates may carry a potential for severe suppression of bone turnover that may impair some of bone’s biomechanical and reparative properties.” However, the article continues, “The dentist, knowing the patient’s health history and vulnerability to oral disease, is in the best position to make treatment recommendations in the interest of each patient.”1 Surgical extraction was performed, and the socket was lined with granulation tissue that was curetted out to uncover the boney walls of the socket. The buccal plate was noted to be fully intact. A post-extraction CBCT was acquired (Figure 17). The patient was instructed to use the VPro™ HFV oral device daily for 5 minutes post-extraction during the Volume 14 Number 1

Figure 13: 4.5-month post-extraction CBCT axial view demonstrating complete socket bone-fill at the lower-left first molar site

Figure 14: Site has been flapped to expose the crest for implant placement 4.5 months post-extraction demonstrating bone-fill of the socket

Figures 15 and 16: 15. Immediate post-implant placement radiograph demonstrating dense bone in contact with the implant surface and fill of the extraction socket. 16. A lower-left first molar with an endo-perio lesion and nonrestorable tooth requiring extraction

6-month healing period. When the patient returned 6 months later, a pre-implant CBCT was acquired (Figure 18). There was a large hole where the socket had been. Density was measured on the CBCT in Hounsfield units at

an area in the extraction socket for the immediate extraction CBCT and again in the same spot on the post-healing CBCT indicating an increase in density of the healed clot that was present in the socket initially (Table 1).

Implant practice 15

CASE REPORT

use of HFV (Table 2). HFV allowed maintenance of the thin buccal wall without loss of height or thickness while yielding a dense vital socket fill ready for implant placement.

CASE REPORT For standardization, an area on the socket wall was compared at initial CBCT, and post-CBCT was measured for standardization on the patient indicating similar density values to bone outside the socket before-and-after use of HFV (Table 2). The socket was degranulated, grafted with a porcine xenograft (RegenerOSS® Xenograft, Zimmer Biomet) and covered with a pericardium membrane. Patients on longterm bisphosphonate drugs have osseous circulation issues that have been reported to potentially lead to osteonecrosis, and bone healing can be a challenge in this population.

HFV aided in some socket fill and avoided potential osteonecrosis. Placement of graft material in the extraction socket of these patients at time of extraction combined with use of HFV may have yielded a higher volume of socket fill, then just leaving the clot to organize and convert to bone.

Figure 17: Immediate post-extraction CBCT of the extraction socket demonstrating a large defect

Figure 19: Maxillary left canine presenting with external cervical resorption necessitating extraction

Case report No. 5 A 58-year-old female presented with deep distal decay and a nonrestorable maxillary left canine (tooth No. 11) (Figure 19). Surgical extraction was done, and a post-extraction CBCT was acquired. The patient was instructed to use the VPro™ HFV oral device daily for 5 minutes post-extraction during the 4-month healing period. The patient returned 4 months postsurgically, and pre-implant CBCT was acquired. Local anesthetic was administered, and the planned implant site was flapped to expose the prior extraction socket. The socket was filled with bone that felt dense when contacted with the periosteal elevator and appeared similar in density to adjacent bone (Figure 20). An osteotomy was performed, and a 3.5 mm x 11 mm implant was placed into the site with a healing abutment to allow osteointegration before the restorative phase would be initiated (Figure 21). Density was measured on the CBCT in Hounsfield units at an area in the extraction socket for the immediate extraction CBCT and again in the same spot on the posthealing CBCT indicating an increase in density of the healed clot that was present in the socket initially (Table 1). For standardization, an area on the socket wall was compared at initial CBCT and post-CBCT was measured for standardization on the patient indicating similar density values to bone outside the socket before-and-after use of HFV (Table 2). Healing demonstrated complete fill of the extraction socket with dense organized vital bone having converted over from the clot left in the socket following extraction.

Conclusion The pandemic and shutdown lead to delays in treatment before the patients were able to return for follow-up and implant 16 Implant practice

Figure 18: CBCT taken at 6 months post-extraction following socket grafting with bovine bone due to insufficient healing caused by bisphosphonate long-term use to permit implant placement

Figure 20: Site has been flapped 4 months post-extraction demonstrating socket bone-fill and site ready for implant placement

placement. Improvement in the osseous quality and density is typically observed with 3 months usage of the VPro. Kurtzman, et al., has noted that HFV, “has demonstrated an ability to increase bone density, stimulate growth factors increasing osteoblastic activity and angiogenesis accelerating graft conversion to host bone to allow earlier implant placement.”2 Four of the five cases presented in this article demonstrated dense bone at each extraction socket at uncovery of the healed ridge in anticipation of implant placement. The one case that required subsequent grafting was in a patient who was on long-term bisphosphonate medication, which affects osseous circulation, and some osseous fill occurred at the end of the initial healing but not sufficient for implant placement. Of the cases presented, three of the

Figure 21: Immediate post-implant placement radiograph demonstrating dense bone in contact with the implant surface and healing abutment placement

sockets received no graft material and were allowed to fill with a clot and heal naturally, aided by the HFV during the healing period.

Those sockets demonstrated complete bone-fill with dense vital bone after the 4- to 6-month healing period, supporting that HFV has a positive impact on osseous healing and organization. For cases that were similarly followed without the use of HFV, significant increases in bone-fill and site density were noted in the HFV patients in comparison. IP REFERENCES 1. Expert panel recommendations: American Dental Association Council on Scientific Affairs. Dental management of patients receiving oral bisphosphonate therapy. J Am Dent Assoc. 2006;137(8):1144-1150.

2. Kurtzman GM, Horowitz RA, Hallas MB, El-Bialy T. Improving osseous conditions around teeth and implants utilizing high frequency vibration. [awaiting publication]

Volume 14 Number 1

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CASE REPORT

Rehabilitation of a patient with a severely resorbed maxilla using zygomatic dental implants and a novel prosthetic design for a full-arch zirconia rehabilitation Drs. Daniel F. Galindo and Caesar C. Butura and Michelle Boomer, CDT, treat a patient who had not visited a dentist in more than a decade Introduction Historically, reconstruction of the severely atrophic maxilla has required multiple grafting procedures to restore lost soft and hard tissues.1,2 The most common approach involves iliac crest harvesting, but it brings inherent surgical risks and possible complications, as well as unpredictable success and resorption rates.3-6 Treatment of the severely resorbed maxilla has been expanded to include the use of dental implants inserted into the zygomatic process while allowing for immediate function.7-11 Zygomatic dental implants prevent the need for extensive grafting with the insertion of implants into a denser and more stable bone.

This clinical report summarizes the management of a patient with severe resorption of the maxilla due to a failed previous dental implant treatment and long-term use of a maxillary complete denture. In this case, a single-surgery graftless approach was used with the placement of four zygomatic dental implants and a monolithic full-arch zirconia prosthesis. The patient was diagnosed and treated at the ClearChoice Dental Implant Center in Phoenix, Arizona.

Chronic edentulism Edentulism is defined as the loss of natural teeth and is an important global public health issue due to its high prevalence

(over 10% in adults aged ≥ 50 years) and associated disability.12-14 Edentulism has a direct effect on facial appearance, nutrition, and the ability to eat, speak, and socialize.15 An individual who has become edentulous has reached this dental endpoint condition usually as a result of either periodontal disease or dental caries. Dental caries is the main cause of edentulism in individuals under 45 years of age,16 while periodontal disease is the primary cause of tooth loss in the older population.17 Edentulism creates a lifelong steady state of disability that can be a burden for the duration of a person’s life.18

Failed dental implant treatment Implant-supported restorations offer a predictable treatment for tooth replacement. The success rate for dental implants is high. Nevertheless, implant failures that require implant removal occur and have been reported.19 Implant removal can compromise the planned functional and esthetic outcome for a patient and usually involves further cost and additional procedures.

Predictors for dental implant success and failure are usually classified into patientrelated factors (such as general health status, smoking habits, quantity and quality of bone, oral hygiene, and periodic professional maintenance, among others), dental implant characteristics (diameter and length, connection

Daniel F. Galindo, DDS, FACP, received his dental degree from Universidad Javeriana School of Dentistry. He then pursued specialty training at the University of Rochester Eastman Dental Center, where he earned a certificate in prosthodontics. He has served as Assistant Professor in the Department of Prosthodontics and Operative Dentistry at the University of Connecticut School of Dental Medicine. Dr. Galindo earned his Board Certification from the American Board of Prosthodontics, is a Diplomate of the American Board of Prosthodontics, and a Fellow of the American College of Prosthodontists.

Caesar C. Butura, DDS, FAOMS, obtained his degree from Columbia University School of Dental and Oral Surgery, and he completed the 4-year Oral and Maxillofacial Surgery program at the University of Illinois Medical Center in Chicago. He also served as Assistant Clinical Professor at the University of Illinois Oral and Maxillofacial Surgery Department. Dr. Butura received his Board certification from the American Board of Oral and Maxillofacial Surgeons, is a Diplomate of the American Board of Oral and Maxillofacial Surgeons, Fellow of the American Association of Oral and Maxillofacial Surgeons and International Association of Oral and Maxillofacial Surgeons, and is a member of the Academy of Osseointegration and International College of Implantologists.

Michelle Boomer, CDT, is a Dental Technician at ClearChoice Dental Implant Center of Phoenix, Arizona.

Disclosure: Both Drs. Galindo and Butura work at ClearChoice Dental Implant Centers of Phoenix and Chandler, Arizona.

18 Implant practice

type, surface finish and/or coating, and loading protocol, among others), implant placement, prosthetic design, and clinician experience.20,21

Restorative options for failed implants in the edentulous maxilla A patient with maxillae that have been previously treated with dental implants that have failed posttreatment has limited treatment alternatives. Maxillary complete dentures are still commonly used for the restoration of edentulous patients. However, a limited residual alveolar ridge creates significant retention and resistance problems and, as a result, these prostheses have poor patient acceptance, as well as compromised function and esthetics.

Zygomatic dental implants have been used for the past two decades to treat patients with severely resorbed maxillae.

Professor Brånemark introduced the first zygomatic implants in 1988 in the management of patients with maxillofacial defects, and they became available to the dental profession in the late 1990s.22 The most common protocol involved placing at least two zygomatic implants, one in each posterior sextant, with additional conventional implants in the anterior maxilla. All implants were then splinted together to support a screw-retained hybrid fixed-detachable prosthesis.

Traditional and contemporary restorative options for the edentulous maxilla The traditional method for restoring a fully edentulous arch consisted of fabricating the prothesis by securing teeth to a metal framework using acrylic resin.23 Depending on the patient’s form, function, and habits, the denture teeth would wear, chip, or fracture.24,25 The acrylic resin could also deteriorate, while fractures to the titanium framework were also a possibility. Technological advancements led to the development Volume 14 Number 1

reducing the risk of breakage and avoiding chipping. Esthetics can be enhanced with the application of feldspathic pink porcelain or stains to re-create the architecture of the gingival tissues.

The design process for the zirconia restoration requires computerized enlargement of the dimensions of the pattern prior to the milling process in order to compensate for linear sintering shrinkage of zirconia by approximately 15%–30%.36 The sintering process comprises three phases: heating, sintering, and cooling, during which the milled structure shrinks to match the size of the original scanned pattern.37 When using zirconia as the prosthetic material to reconstruct atrophic edentulous maxillae, the height of the prosthesis might be greater than the thickness of the sintered zirconia puck, ruling out zirconia as the restorative material.

Clinical report A 68-year-old male patient visited our office with a chief complaint of embarrassment due to his dental condition and a strong desire to replace his existing maxillary complete denture. The patient had not seen a dentist in more than 10 years and had terminated any dental care due to frustration with his oral condition. His medical history was noncontributory, and his vital signs were within normal limits.

Examination The patient was not under the care of a physician. He was extremely reserved and skeptical regarding dental implant treatment.

Figure 1: Pretreatment frontal view

Figure 2: Maxillary occlusal view Volume 14 Number 1

Extraoral examination Extraoral examination revealed a symmetrical phase with significant reduction on lower-third facial height due to wear of occlusal surfaces of his existing complete denture. His opening and range of motion were within normal limits and presented no symptomatology of his stomathognathic system.

Intraoral examination The intraoral examination revealed an edentulous maxilla and a partially dentate mandible. The patient presented with a Class III malocclusion resulting from the severe resorption of his maxilla.

Radiographic examination A cone beam computed tomography (CBCT) revealed severe atrophic of his maxillary residual ridge and severely pneumatized maxillary sinuses. Evaluation of his zygomatic processes bilaterally revealed adequate dimensions for use as anchorage for dental implants.

Diagnosis 1.

2.

3.

4.

5.

6.

Edentulous maxillary arch Partially dentate mandibular arch Class III malocclusion Severely atrophied maxilla Bilateral sinus pneumatization Poorly fitting maxillary complete denture

Treatment plan 1. Placement of four dental implants anchored in the zygomatic arches (two per arch) with immediate function procedures through a full-arch fixed acrylic prosthesis.

2. After healing, fabrication of a full-arch fixed zirconia prosthesis.

3. Follow-up with the patient every 4 months.

4. Treatment for replacement of mandibular missing teeth was presented in the form of a removable partial

Figure 3: Preoperative panoramic radiograph Implant practice 19

CASE REPORT

of CAD/CAM-fabricated milled frameworks incorporating different forms of retention to prevent debonding of denture teeth and/ or acrylic resin.26 In specific instances of known parafunction or for patients in need of a higher demand of esthetics, individual ceramic crowns were luted to the metal frameworks, and the gingival portion was reconstructed with pink porcelain rather than acrylic resin.27 These reconstruction procedures were rather expensive, timeconsuming, and unavailable to the majority of the population due to cost. In general with both types of reconstructions, complications such as fractured or debonded acrylic resin teeth, wear of opposing incisal and occlusal surfaces, ceramic chipping, difficulty in shade matching of acrylic and pink ceramic, lack of passive fit, and extensive repair work after framework fractures led to the search of biomaterial options.

Zirconium oxide is a material that has shown increased popularity in contemporary dentistry.28,29 Several studies have demonstrated the physical, mechanical, biological and chemical properties of this material.30,31 Fixed dental prostheses are produced by directly firing veneering porcelain onto a one-piece CAD/CAMdesigned and milled zirconia substructure.32,33 However, fracture or chipping of the veneering ceramic34 and of the zirconia substructure have been reported.35 To overcome these problems, CAD/CAM restorations milled from blocks of monolithic zirconia have been introduced as an alternative for implant-supported full-arch reconstructions,

CASE REPORT denture, but the patient decided to evaluate the outcome of maxillary arch treatment prior to committing to dental care in the mandible.

Presurgical phase Following review of the CBCT radiograph, severe maxillary atrophy was noted.

The patient rejected the treatment option of bilateral sinus grafting and opted for the use of four zygomatic dental implants to retain a fixed full-arch prosthesis. Impressions were made, a wax rim fabricated, and casts were articulated on a semi-adjustable articulator.

Teeth were selected and set on a wax rim and evaluated for esthetics, phonetics, and occlusion.

The setup was processed in heat-polymerized acrylic resin to fabricate a maxillary complete denture that would be modified into a fixed provisional prosthesis. The prosthesis was duplicated in clear acrylic resin to fabricate a surgical guide.

Figure 4: Postoperative panoramic radiograph

Surgical phase The patient was brought to the suite and placed into a semi-supine position with all the appropriate monitors. Following indicated treatment preparation, incisions were made from the distal tuberosity to the anterior midline and reflections on the anterior lateral parts of the maxilla. Laterally, the refection was taken to the zygomatic process and further to the zygomatic notch. Anteriorly, the inferior orbital nerve and inferior orbital rim were identified and were used as anatomical markers. Slot osteotomies were made in the lateral maxillary walls with a No. 8 round bur under NS irrigation. The sinus membrane was cauterized to minimize bleeding, and through the slot it was reflected from the lateral and superior walls of the sinus. The anterior implant site was now prepared starting in the premaxilla (area of 6/7) using a standard drill sequence under NS irrigation and direct vision. The apical portion of the drill was visualized below the inferior orbital nerve as it exited the superior portion of the zygomatic body. A 50 mm NobelZygoma implant was placed under direct vision to a torque value of 45+ Ncm. The posterior osteotomy was now developed in the second premolar region under direct vision using a sequenced drilling technique to accommodate a 35 mm implant with insertion torque value over 45 Ncm. The left maxilla was addressed with the same technique and same length implants with torque values over 45 Ncm. The right anterior zygomatic implant was covered with a 1 X 2 cm AlloDerm™ graft which was secured to the periosteum with 3.0 chromic gut suture.

20 Implant practice

Figure 5: Base and coronal segments before joining together

Closure of the incision site was completed in a watertight interrupted fashion using 3.0 chromic gut suture.

Figure 6: Luting of base and coronal segments (note multiunit coping on base segment)

Prosthodontic phase Primary stability of dental implants placed into zygomatic arches was achieved due to high insertion torque. Impression copings were connected over each abutment, and a vinyl polysiloxane (VPS) rigid impression material was used to make an open tray impression. Accuracy of the impression was confirmed prior to pouring of a master cast.

Temporary titanium copings were connected to the abutments, and the denture was relieved accordingly to provide proper fit over primary supporting areas. Self-polymerizing urethanedimethacrylate resin (Quick Up®, VOCO GmbH) was used to connect the copings to the prosthesis. Upon polymerization, the prosthesis was removed and rigidity of the connection confirmed prior to sending the case to the dental laboratory for conversion to a fixed-detachable prosthesis. The interim fixed prosthesis was seated, fit and occlusion confirmed, and a panoramic radiograph obtained to confirm adequate seat.

Definitive prosthesis Following 2 months of healing, a CBCT was obtained. The patient was satisfied with the esthetics and occlusion achieved with

the interim prosthesis. A definitive impression was made using a verification jig and VPS impression material. The master cast was poured and mounted on the semi-adjustable articulator. Teeth were set for a wax try-in; esthetics, occlusion, and maxillomandibular relationships were confirmed. Upon approval from the patient, the setup was processed using heat-cured acrylic resin. The acrylic resin pattern was tried once again to confirm passive fit, hygienic contours, esthetics, and occlusion.

The height of the acrylic resin pattern presented a challenge as it was greater than the thickness of the zirconia puck. In order to address this limitation, a segmental approach was taken. The original pattern was scanned and then processed digitally to create two distinct segments. The base segment of the prosthesis would seat directly on the four multi-unit abutments through titanium copings luted to the zirconia structure. The coronal portion of this segment had two multi-unit abutments luted and a vertical extension 4 mm in height and 4 mm in width to provide mechanical retention to the second segment. The second segment Volume 14 Number 1

had two titanium copings that would provide mechanical retention to the base segment in addition to the channel to allow cementation of both segments into one piece. Both segments were milled in using the XTCERA system and milled in Zirconia YZ (XTCERA, Zubler USA) and layered with DC Ceram™ 9.2 (Gingiva on Zirconia, Ceramay GmbH & Co.) feldspathic porcelain.

The prosthesis was seated intraorally and prosthetic screws torqued according to manufacturer’s recommendations. Radiographs were obtained to verify a passive fit of the prosthesis.

Home care instructions were given to the patient and the use of a water flosser explained. The patient was instructed to return for regular examinations every 4 months.

Conclusion Edentulism is a chronically debilitating condition that affects patients physically and emotionally. This case demonstrates the management of a chronically edentulous patient using zygomatic dental implants and a novel approach for the fabrication of the definitive zirconia prosthesis.

Acknowledgment The authors wish to acknowledge the assistance of Rob Dinker, CDT from Integrity Dental Services for his contributions to the design of the final prosthesis. IP

Figure 8: Intraoral view of maxillary prosthesis in occlusion

Figure 10: Posttreatment frontal view maxillae employing for zygomatic fixtures in an immediate loading system – A 30-month clinical and radiographic follow-up. Clin Implant Dent Relat Res. 2007;9(4):186-96.

7. Branemark P-I, Grondahl K, Worthington P. Osseointegration and Autogenous Onlay Bone Grafts: Reconstruction of the Edentulous Atophic Maxilla. Chicago: Quintessence; 2001.

8. Bedrossian E. Stumple L, Beckely M, et al. The zygomatic implant: Preliminary data on treatment of severely resorbed maxillae – A clinical report. Int J Oral Maxillfac Implants.

2002; 17:861-865.

9. Branemark P-I, Grondahl K, Ohrnell L, et al. Zygomatic fixture in management of advanced atrophy of the maxilla: Technique and long-term results. Scand J Plast Reconstr Surg Hand Surg. 2004;38(2):70-85.

10. Aparicio C, Ouazzani W, Garcia R, et al. A prospective clinical study on titanium implants in the zygomatic arch for prosthetic rehabilitation of the atrophic edentulous maxilla with a follow-up of 6 months to 5 years. Clin Implant Dent Relat Res. 2006;8(3):114-122.

11. Butura CC, Galindo DF. Combined Immediate Loading of Zygomatic and Mandibular Implants: A Preliminary 2-Year Report of 19 Patients. Int J Oral Maxillofac Implants.

2014;29(1):e22-e29.

1. Kahnberg KE, Henry PJ, Hirsch JM, et al. Clinical evaluation of the zygoma implant: 3-year follow-up at 16 clnics. J Oral Maxillofac Surg. 2007;65(10):2033-2038.

2. Farzad P, Andersson L, Gunnarsson S, et al. Rehabilitatoin of the severely resorbed maxillae with zygomatic implants: An evaluation of implant stability, tissue conditions, and patient’s opinion and after treatment. Int J Oral Maxillofac Implants. 2006;21(3):399-404.

3. Seiler JG III, Johnson J. Iliac crest autogenous bone grafting: Donor site complications. J South Orthop Assoc.

2000;9(2):91-97.

4. Arrington ED, Smith WJ, Chambers HG, et al. Complications of iliac crest bone graft harvesting. Clin Orthop.

1996.;329:300-309 5. Nystrom E, Legrell PE, Forssell A, et al. Combined use of bone grafts and implants in the severely resorbed maxilla.

Postoperative evaluation by computed tomography. Int J Oral Maxillofac Surg. 1995;24:20-25.

6. Duarte LR, Filho HN, Francischone Ce, et al. The establishment of a protocol for the total rehabilitation of atrophic

Volume 14 Number 1

Fixture Clinical Procedures (1st ed). Gothenburg, Sweden: Nobel Biocare AB; 1998.

23. Rojas-Vizcaya F. Full zirconia fixed detachable implantretained restorations manufactured from monolithic zirconia: clinical report after two years in service. J Prosthodont. 2011; 20(7):570-576.

24. Purcell BA, McGlumphy EA, Holloway JA, et al. Prosthetic complications in mandibular metal-resin implant-fixed complete dental prostheses: a 5- to 9-year analysis. Int J Oral Maxillofac Implants. 2008;23(5):847-857.

25. Bozini T, Petridis H, Garefis K. A meta-analysis of prosthodontic complication rates of implant-supported fixed dental prostheses in edentulous patients after an observation period of at least 5 years. Int J Oral Maxillofac Implants. 2011;26(2):304-318.

26. Örtorp A, Jemt T. Clinical experiences of computer numeric control-milled titanium frameworks supported by implants in the edentulous jaw: a 5-year prospective study. Clin Implant Dent Relat Res. 2004;6(4):199-2099.

27. Lang BR, Malo P, Guedes CM, et al. Procera All Ceram Bridge. Appl Osseointegration Res. 2005;4:13-21.

28. Guess PC, Att W, Strub JR. Zirconia in fixed implant prosthodontics. Clin Implant Dent Relat Res. 2012; 14:633-645.

12. Norderam G, Davidson T, Gynther G, et al. Qualitative studies of patients’ perceptions of loss of teeth, the edentulous state and prosthetic rehabilitation. Acta Odont Scand.

2013;71(3-4):937-951.

29. Kanat B, Çömlekoğlu EM, Dündar-Çömlekoğlu M, et al.

Effect of various veneering techniques on mechanical strength of computer-controlled zirconia framework designs. J Prosthod. 2014;23:445-455.

13. Peltzer K, Hewlett S, Yawson AE, et al. Prevalence of loss of all teeth (edentulism) and associated factors in older adults in China, Ghana, India, Mexico, Russia and South Africa. Int J Environ Res Public Health. 2014;11(11):11308-11324.

30. Papaspyridakos P, Lal K. Immediate loading of the maxilla with prefabricated interim prosthesis using interactive planning software, and CAD/CAM rehabilitation with definitive zirconia prosthesis: 2-year clinical follow-up. J Esthet Restor Dent. 2010;22:223-232.

14. Tyrovolas S, Koyanagi A, Panagiotakos DB, et al. Population prevalence of edentulism and its association with depression and self-rated health. Sci Rep. 2016;6:1-9.

15. Felton DA. Complete Edentulism and Comorbid Diseases: An Update. J Prosthodont. 2016;25(1):5-20.

REFERENCES

Figure 9: Occlusal view of maxillary prosthesis

16. Meier T, Deumelandt P, Christen O, et al. Global Burden of Sugar-Related Dental Diseases in 168 Countries and Corresponding Health Care Costs. J Dent Res. 2017;96(8):845-884.

17. Dye, Bruce A. Global Periodontal Disease Epidemiology. Periodontol 2000. 2012;58(1):10-25.

18. Jin LJ, Lamster IB, Greenspan JS, et al. Global Burden of Oral Diseases: Emerging Concepts, Management and Interplay with Systemic Health. Oral Diseases.

2016;22(7):609-619.

19. Esposito M, Grusovin MG, Coulthard P, et al. A 5-year follow-up comparative analysis of the efficacy of various osseointegrated dental implant systems: a systematic review of randomized controlled clinical trials. Int J Oral Maxillofac Implants. 2005;20(4):555-568.

20. Levin L, Schwartz-Arad D. The effect of cigarette smoking on dental implants and related surgery. Implant Dent. 2005;14(4):357-361.

21. Nitzan D, Mamlider A, Levin L, et al. Impact of smoking on marginal bone loss. Int J Maxillofac Implants. 2005;20(4):605-609.

22. Brånemark PI. Surgery and fixture installation. Zygomaticus

31. Pozzi A, Holst S, Fabbri G, Tallarico M. Clinical reliability of CAD/CAM cross-arch zirconia bridges on immediately loaded implants placed with computer-assisted/templateguided surgery: a retrospective study with a follow-up between 3 and 5 years. Clin Implant Dent Relat Res. 2015;17(suppl 1):e86-e96.

32. Guess PC, Att W, Strub JR. Zirconia in fixed implant prosthodontics. Clin Implant Dent Relat Res. 2012;14(50:633-645.

33. Kanat B, Cömlekoglu EM, Dündar-Çömlekoglu M, et al.

Effect of various veneering techniques on mechanical strength of computer-controlled zirconia framework designs. J Prosthodont. 2014;23:445-455.

34. Larsson C, Vult von Steyern P, Nilner K. A prospective study of implant-supported full-arch yttria-stabilized tetragonal zirconia polycrystal mandibular fixed dental prostheses: three-year results. Int J Prosthodont. 2010;23(4):364-369.

35. Sadid-Zadeh R, Liu PR, Aponte-Wesson R, et al. Maxillary cement retained implant supported monolithic zirconia prosthesis in a full mouth rehabilitation: a clinical report. J Adv Prosthodont. 2013;5:209-217.

36. Reich S, Wichmann M, Nkenke E, et al. Clinical fit of all-ceramic three-unit fixed partial dentures, generated with three different CAD/CAM systems. Eur J Oral Sci. 2005;113(2):174-179.

37. Marinis A, Aquilino SA, Lund PS, et al. Fracture toughness of yttria-stabilized zirconia sintered in conventional and microwave ovens. J Prosthet Dent. 2013;109(3):165-171.

Implant practice 21

CASE REPORT

Figure 7: Finalized maxillary prosthesis with segments joined together

CONTINUING EDUCATION

Oral hygiene and dental implant maintenance: part 1 Dr. Gregori M. Kurtzman, along with Debbie Zafiropoulos, discusses appropriate professional care and effective patient oral hygiene for maintenance of implants Introduction Implant usage has become a common treatment modality in dentistry as a predictable long-term replacement of single teeth or full arches demonstrating restoration success.1-3 As the number of patients selecting dental implants as a treatment option continues to grow, the dental team must accept the challenges of maintaining these sometimes complex restorations.

Those maintenance challenges also involve the patients and their home care.

Proper monitoring and maintenance are essential to ensure the longevity of the dental implant and its associated restoration through a combination of appropriate professional care and effective patient oral hygiene.4,5 So, maintaining implants is a double-edged sword with the dental team and patient both contributing to its long-term success or failure.

The value of using conventional periodontal parameters to determine peri-implant health is not clearly evident in the literature.6-8 Therefore, it is paramount that the dental implant team understands the similarities and distinctions between the dental implant and natural tooth. Subsequently, by examining the similarities and differences between a natural tooth and a dental implant, basic guidelines can be provided for maintaining the long-term health of the dental implant.

Direct anchorage of alveolar bone to a dental implant body provides a foundation to support a prosthesis and transmits

Educational aims and objectives

This article aims to show the dental team’s challenges of maintaining implants and involving patients in the home care process.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 27 or take the quiz online at implantpracticeus.com to earn 2 hours of CE from reading this article.

Correctly answering the questions will demonstrate the reader can: •

Identify some causes of peri-implant diseases.

•

Realize the similarities and distinctions between the dental implant and natural tooth to provide basic guidelines for maintaining the long-term health of the dental implant.

•

Realize how hygiene treatment, especially in certain areas, is integral to maintaining the implant.

•

Realize scheduling needs for a hygiene re-care schedule depending upon the reason for and timing of the implant.

•

Realize some differences in the connection of natural teeth or implants to the surrounding tissues for assessment of periodontal health.

occlusal forces to the alveolar bone. This is the definition of osseointegration.9,10 With the common acceptance of dental implants today as a viable and routine treatment option for the restoration of a partially edentulous or fully edentulous mouth, the dental team is faced with maintaining and educating those patients.

Recently, the focus of implant dentistry has changed from obtaining osseointegration, which is highly predictable, to long-term maintenance and health of the peri-implant hard and soft tissues. This can be achieved through appropriate professional care, patient cooperation, and effective home care.11-14 Since frequently the tooth or teeth are lost due to a lack of patient maintenance, the goal is to prevent old habits from

Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA, is in private general practice in Silver Spring, Maryland. He is a former Assistant Clinical Professor at University of Maryland in the department of Restorative Dentistry and Endodontics and a former AAID Implant Maxi-Course assistant program director at Howard University College of Dentistry. He has lectured internationally on the topics of restorative dentistry, endodontics, implant surgery and prosthetics, removable and fixed prosthetics, and periodontics. Dr. Kurtzman has over 750 published articles globally. He has earned Fellowship in the AGD, ACD, ICOI, Pierre Fauchard, ADI, Mastership in the AGD and ICOI, and Diplomate status in the ICOI and American Dental Implant Association (ADIA). A consultant and evaluator for multiple dental companies, Dr. Kurtzman has been honored to be included in the “Top Leaders in Continuing Education” by Dentistry Today annually since 2006. He can be reached at dr_kurtzman@maryland-implants.com Debbie Zafiropoulos, EFDA, RDH, is the CEO of the OralED Institute, a Partner in Education for the Wellness Dentistry Network, an instructor with MoradoASC, and certified GBT Trainer for EMS-NA. Zafiropoulos works with top corporate companies in health, creating and delivering live and online educational programs to a worldwide audience. As a soughtafter key opinion leader and author, she is determined to deliver programs of forward motion in prevention, science, and technology. In 2016, Zafiropoulos was a recipient of the SUNSTAR Award of Distinction. In 2017, she was recognized as one of the Top 25 Women in Dentistry for her advances in research and prevention of HPV-related oral cancer.

22 Implant practice

re-emerging that could lead to periodontal issues around the implant and its potential loss. Patients must accept the responsibility for being co-therapists in maintenance therapy, so the dental team essentially must screen the potential implant patient.

Peri-implant challenges Peri-implant diseases are prevalent, and prevalence of peri-implantitis increases over time. These might not be highly associated since the instances are influenced by distinct variables, which can include changes in the patient’s systemic health, the patient’s medications, and changes in the patient’s home care or ability to maintain oral hygiene.15 Periimplant disease affects a significant number of implants. It is important to understand the difficulties in diagnosis of these diseases and risk factors, so that they may be modified to reduce the potential for disease occurrence or progression. Diagnosis and treatment planning based on a risk-benefit analysis should be performed subsequent to a comprehensive medical, dental, head-andneck, psychological, temporomandibular disorder, and radiographic examination.16 Convincing evidence exists that bacterial plaque not only leads to gingivitis and periodontitis,17,18 but also can induce the development of peri-implantitis.10 Thus, personal oral hygiene must begin at the time of dental Volume 14 Number 1

Volume 14 Number 1

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implant placement and should be modified using various adjunctive aids for oral hygiene to effectively clean the altered morphology of the peri-implant region before, during, and after implant placement. For instance, interproximal brushes can penetrate up to 3 mm into a gingival sulcus or pocket and may effectively clean the peri-implant sulcus.11 In addition to mechanical plaque control, chlorine dioxide has been demonstrated to reduce both plaque, gingival indices, and bacterial counts in the oral cavity without the potential issues with other rinses.12 Hygiene with dental implants is so tedious and critical to their long-term success that the patient and dental professional must exercise considerable effort. During the maintenance visit, the dental professional should concentrate on the peri-implant tissue margin, implant body, prosthetic abutment to implant collar connection, and the prosthesis.13 Clinical inspection for signs of inflammation — i.e., bleeding on probing, exudate, mobility, probable pockets, and a radiographic evaluation of the peri-implant bony housing — still remains the standard mode for evaluating the long-term status of endosseous dental implants. For instance, successful and stable endosseous dental implants exhibit no mobility. However, if there is clinically perceptible mobility, then subsequent to radiographic evaluation of the implant and its surrounding bony housing, the abutment retaining screw14 and/or prosthetic abutment collar interface should be examined for looseness or breakage.

All these modes of clinical assessment are used routinely, except for periodontal probing around peri-implant tissues that appear to be in a state of good health. The baseline data and data from subsequent re-care visits should be recorded in the daily progress notes to properly assess the periimplant status longitudinally.

Subsequent to a thorough intraoral examination, unless there is visual evidence of soft tissue changes, i.e., inflammation of peri-implant tissue with even slight attachment loss or mucositis, and routine probing of the peri-implant tissue should not be performed.

Usually during the first year subsequent to restoring dental implants, a 3-month re-care schedule should be implemented, especially if the patient lost teeth because of periodontal disease. However, if after 12 months, the patient’s implants are stable and peri-implant tissues are healthy, then a

Figure 1: Comparison of crestal gingival fiber orientation

Recently, the focus of implant dentistry has changed from obtaining osseointegration, which is highly predictable, to longterm maintenance and health of the peri-implant hard and soft tissues. This can be achieved through appropriate professional care, patient cooperation, and effective home care.

4-6 month re-care regimen can be implemented.15 However, be cognizant of each patient’s level of home care effectiveness, systemic health, and periodontal status of the peri-implant tissue when determining these re-care intervals.

With dental implant patients, the dental professional must evaluate the prosthetic components for plaque, calculus, and the stability of the implant abutment. Radiographs of dental implants should be taken every 12 to 18 months during these maintenance visits.16,17 For dental implant restorations that are screw-retained, the dental professional needs to remove the prosthesis at least once a year to more easily assess the status of the peri-implant’s hard and soft tissues, the existence of acceptable mobility of the prosthetic components or the implant fixture itself, and the patient’s level of home care effectiveness.18 Remember that the presence of any symptoms of infection, radiographic evidence of peri-implant bone

loss, and/or neuropathies may be indicative of an ailing or failing implant.19 Inflammation at the gingival marginal tissue may be the first indication of initiation of peri-implantitis even in the absence of bleeding. Yet the periodontal complex around healthy natural teeth and implants are not similar.

Implants versus natural teeth It is essential to understand the periodontal relationship between the gingiva and the structure it attaches to, whether it is a natural tooth or an implant (Figures 1 and 2). The fiber orientation of the gingival cuff around a natural tooth has those fibers attaching perpendicular to the long axis of the tooth (Figure 3). This fiber orientation acts as a barrier when a periodontal probe is inserted into the periodontal sulcus. The probe tip advances apically until the tip contacts the perpendicular fibers, resistance is felt, and the tip is halted from further apical progression without increased force on the Implant practice 23

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Figure 2: Microscopic comparison of gingival fiber orientation (natural tooth on left, implant on right)

instrument. This orientation is not found around implants. With an implant, the gingival fiber orientation is parallel to the implant’s long axis (Figure 4). When the periodontal probe is inserted into the periodontal sulcus around an implant, the probe tip advances, passing between the fibers of the gingival cuff until the crestal bone is contacted by the instrument’s tip, preventing it from further advancement (Figure 5). Due to the difficulty of defining a probing depth associated with peri-implant health, radiographic evaluation may be considered in the daily practice as a more predictable method for evaluation of the periodontal health of the implant.20-23 During re-care appointments, periimplant periodontal probing should be performed where signs of infection are present — i.e., exudate, swelling, bleeding on probing, inflamed peri-implant soft tissue, and/or radiographic evidence of peri-implant alveolar bone loss. Lastly, periodontal probing of dental implants could damage the weak epithelial attachment around dental implants, possibly creating a pathway for the ingress of periodontal pathogens by inoculating them from saliva or biofilm deeper apically into the gingival tissue of the cuff.24,25 The use of probing depth and bleeding on probing assessments may lead to over-diagnosis and possibly to overtreatment of assumed biofilm-mediated peri-implantitis lesions.26 Due to the lack of a soft tissue physical stop to the tip of the probe related to fiber orientation, depth on probing will be higher around implants even when healthy tissue is present and should not assume that a probing of 6 or greater indicates a periodontal issue. Those probings can be used in comparison at future 24 Implant practice

Figure 3: Gingival fibers between two natural teeth showing orientation perpendicular to the long axis of the tooth

Figure 4: Gingival fibers between two implants showing orientation parallel with the long axis of the implants

Figure 5: Gingival fiber orientation around a natural tooth provides a natural stop to advancement of the periodontal probe (left).

The lack of physical stop related to the fiber orientation around an implant allows the periodontal probe to continue apically until the crestal bone acts as a physical stop (right) Volume 14 Number 1

Figure 6: Plastic periodontal probe being used on an implant to check probing depth when the signs of peri-mucositis are present.

periodontal issues, especially in the absence of gingival inflammation being evident.

The peri-implant mucosal seal may be a less effective barrier to bacterial plaque than the periodontium around a natural tooth, tissue attachment.30-33 There is less vasculature in the gingival tissue surrounding dental implants compared to natural teeth. This reduced vascularity concomitant with paralleloriented collagen fibers adjacent to the body of any dental implant make dental implants more vulnerable to bacterial insult.34 Peri-implant inflammation (mucositis) is a result of biofilm accumulation that disrupts the host-microbe homeostasis at the implant-mucosa interface.

This results in an inflammatory lesion, but this is a reversible condition at the host level. The clinical implication is, therefore, that optimal biofilm removal is a prerequisite for prevention and management of peri-implant mucositis.24 With all of these reasons in mind, personal home care and consistent professional oral hygiene maintenance have proven to be critical to the success and longevity of dental implants. This is especially true in an environment with adjacent natural teeth, which if affected by periodontal disease, could act as a reservoir for pathogenic bacteria — i.e., gram-negative anaerobic rods — and seed the peri-implant sulcus.25-29 The physical characteristics of the periimplant soft tissue are the focus of all patient oral hygiene instruction. The presence or absence of keratinized tissue in this critical area has not been unequivocally documented to state that peri-implant tissues are more vulnerable to the ingress of pathogenic bacteria with or without keratinized tissue being present around dental implants.

However, the ability of the patient to maintain

Figure 7: Damage to the surface of the implant caused by a stainless steel instrument contacting the surface Volume 14 Number 1

good oral hygiene around dental implants at home is facilitated by the presence of keratinized tissue surrounding the implants.

Thus, if no keratinized tissue is around an implant, and if a pull from a frenum or a chronic peri-implant mucositis exists, then placement of a soft tissue autogenous or alloplastic connective tissue graft is recommended to facilitate proper mechanical oral hygiene maintenance.30-32 There is still no specific criteria for obtaining clinical data around dental implants that would allow proper monitoring, and detection of early possible failure of osseointegrated implants has not been clearly defined. Presently, the presence of mobility is the best indicator for diagnosis of implant failure. As opposed to natural teeth, dental implants exhibit minimal clinically undetectable movement because of the absence of a periodontal ligament.33,34 Therefore, healthy implants should appear nonmobile, even in the presence of periimplant bone loss, if an adequate amount of supporting alveolar bone still exists.35,36 When monitoring the health of the periimplant soft tissues, the practitioner should be cognizant of changes in soft tissue color, contour, and consistency. The presence of a fistulous tract could indicate the presence of a pathologic process or implant fracture.

When noted in a partially edentulous arch, tracing the fistula tract with a gutta-percha cone inserted into the fistula prior to taking a radiograph will help determine if the infection resulting in the fistula is associated with the implant or the adjacent natural tooth.

Bleeding There is controversy in the literature as to the accuracy and significance of bleeding

Figure 8: Damage to the surface of the implant caused by a titanium instrument contacting the surface Implant practice 25

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recall appointments to indicate if crestal bone has moved in an apical direction.

Commercially available plastic probes should be used when investigating the crevicular depth around dental implants that are presenting with signs of peri-mucositis (Figure 6). These plastic probes will not potentially damage the implant’s surface as a metal probe (stainless steel) may mar the surface creating biofilm accumulation points that may lead to peri-mucositis subgingivally (Figure 7). Titanium probes are available, but although they are less hard then stainless steel, may still damage the implant’s surface (Figure 8). The probing depth around dental implants may be related closely to the thickness and type of mucosa surrounding the implant. A healthy peri-implant sulcus has been reported to range from 1.3 mm to 3.8 mm, which is greater than those depths reported for natural teeth.27 In essence, the best indicator for evaluating an unhealthy site would be probing data gathered longitudinally.28,29 So, routine probing of dental implants is not predictable in identifying

CONTINUING EDUCATION upon probing around dental implants. Presently, the literature advocates the use of bleeding on probing as an indicator of periimplant disease, as it may present prior to histologic signs of inflammation or concurrently with other signs of implant failure — i.e., bone loss. However, as previously mentioned, routine probing is not recommended. As stated, mobility is a clear sign of implant failure and may be present with or without the presence of bleeding.

Radiographic evaluation Radiographic interpretation is one of the most useful clinical parameters for evaluating the status of an endosseous dental implant. Invasion of biologic width, predictable remodeling, or so-called saucerization, is an average marginal bone loss of 1.0 mm - 1.5 mm during the first year following prosthetic rehabilitation followed by an average of 0.2 mm of vertical bone loss every subsequent year.38,39 Thus, progressive bone loss around a dental implant that exceeds these averages may be indicative of an ailing or failing implant. Lastly, during radiographic evaluation, no evidence of a peri-implant radiolucency should be found, because such a rarefaction usually indicates infection or failure to osseointegration. Two-dimensional radiographs will not allow visualization of the buccal/facial and lingual crestal bone heights. 3D (CBCT) radiographic analysis may be required to properly evaluate bone levels when suspected or confirmed periimplantitis is present, as the buccal/facial bone being less dense typically is resorbed prior to the interproximal bone.

Conclusion Understanding the differences in the soft tissue attachment and the connection to the osseous bed housing the natural tooth or implant helps in maintaining those longterm. Natural teeth and implants, although providing identical functions allowing the patient to eat, have some differences in their connection to the surrounding tissues.

Natural teeth have a fiber orientation at the gingival connection that acts as an effective barrier to bacteria in the biofilm from progressing apically, whereas the fiber orientation around implants does not provide that same bacterial restrictive factor. Routine periodontal probing of natural teeth as discussed can accurately identify periodontal disease related to that physical stop created by the perpendicular fibers at the base of the periodontal sulcus. Routine probing of 26 Implant practice

implants is inaccurately related to the lack of a physical stop allowing the periodontal probe to progress through the tissue past the apical extent of the gingival cuff until a hard barrier, the crestal bone is encountered.

This will give a false sense that periodontal issues are present around the implant, and appropriate treatment is needed to address that. Although mobility in a natural tooth can allow the tooth to function and be maintained unless it reaches pathologic levels, any mobility noted with an implant indicates it is failing and needs to be removed.

How those implants need to be maintained both by the dental practitioners (dentists and hygienists) and patients to ensure long-term survival will be addressed in part 2. IP

15. Lee CT, Huang YW, Zhu L, Weltman R. Prevalences of periimplantitis and peri-implant mucositis: systematic review and meta-analysis. J Dent. 2017;62:1-12.

16. Meffert RM. Contemporary Implant Dentistry. Misch CE (ed).

St. Louis, Mo: Mosby Year Book; 1993.

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2019;45(2):127-131.

18. Valm AM. The Structure of Dental Plaque Microbial Communities in the Transition from Health to Dental Caries and Periodontal Disease. J Mol Biol. 2019;431(16):2957-2969.

19. Harvey JD. Periodontal Microbiology. Dent Clin North Am. 2017;61(2):253-269.

20. Rösing CK, Fiorini T, Haas AN, et al. The impact of maintenance on peri-implant health. Braz Oral Res. 2019;33(suppl 1):e074.

21. Weyant RJ. Characteristics associated with the loss and peri-implant tissue health of endosseous dental implants.

Int J Oral Maxillofac Implants. 1994;9(1):95-102.

22. Heitz-Mayfield LJA, Salvi GE. Peri-implant mucositis. J Periodontol. 2018;89(suppl 1):S257-S266.

23. Nevins M, Langer B. The successful use of osseointegrated implants for the treatment of the recalcitrant periodontal patient. J Periodontol. 1995;66(2):150-157.

24. Lang NP, Wetzel AC, Stich H, Caffesse RG. Histologic probe penetration in healthy and inflamed peri-implant tissues. Clin Oral Implants Res. 1994;5(4):191-201.

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28. Karoussis IK, Müller S, Salvi GE, et al. Association between periodontal and peri-implant conditions: a 10-year prospective study. Clin Oral Implants Res. 2004;15(1):1-7.

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30. Artzi Z, Tal H, Moses O, Kozlovsky A. Mucosal considerations for osseointegrated implants. J Prosthet Dent.

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31. Thoma DS, Alshihri A, Fontolliet A, et al. Clinical and histologic evaluation of different approaches to gain keratinized tissue prior to implant placement in fully edentulous patients. Clin Oral Investig. 2018;22(5):2111-2119.

32. Thoma DS, Naenni N, Figuero E, et al. Effects of soft tissue augmentation procedures on peri-implant health or disease: a systematic review and meta-analysis. Clin Oral Implants Res. 2018;29(suppl 15):32-49.

33. Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factors contributing to failures of osseointegrated oral implants. (I). Success criteria and epidemiology. Eur J Oral Sci. 1998;106(1):527-551.

34. Quirynen M, van Steenberghe D, Jacobs R, Schotte A, Darius P. The reliability of pocket probing around screwtype implants. Clin Oral Implants Res. 1991;2(4):186-192.

10. Albrektsson T, Wennerberg A. On osseointegration in relation to implant surfaces. Clin Implant Dent Relat Res. 2019;21(suppl 1):4-7.

35. Papaioannou W, Quirynen M, Nys M, van Steenberghe D.: The effect of periodontal parameters on the subgingival microbiota around implants. Clin Oral Implants Res. 1995;6(4):197-204.

11. Warrer K, Buser D, Lang NP, et al. Plaque-induced periimplantitis in the presence or absence of keratinized mucosa: an experimental study in monkeys. Clin Oral implant Res. 1995;6(3):131-138.

36. de Waal YC, Winkel EG, Meijer HJ, Raghoebar GM, van Winkelhoff AJ. Differences in peri-implant microflora between fully and partially edentulous patients: a systematic review. J Periodontol. 2014;85(1):68-82.

12. Kerémi B, Márta K, Farkas K, Czumbel LM, Tóth B, Szakács Z, Csupor D, Czimmer J, Rumbus Z, Révész P, Németh A, Gerber G, Hegyi P, Varga G. Effects of Chlorine Dioxide on Oral Hygiene - A Systematic Review and Meta-analysis. Curr Pharm Des. 2020;26(25):3015-3025. doi: 10.2174/1381612 826666200515134450. PMID: 32410557.

37. Wang Q, Meng HX. Zhonghua Kou Qiang Yi Xue Za Zhi. [Research Progress in Microbiological Characteristics of Peri-Implant Disease] [Article in Chinese] 2017;52(12):773-776.

13. Balshi TJ. Hygiene maintenance procedures for patients treated with the tissue-integrated prothesis (osseointegration). Quintessence. 1986;17(2):95-102.

38. Gholami H, Mericske-Stern R, Kessler-Liechti G, Katsoulis J. Radiographic bone level changes of implantsupported restorations in edentulous and partially dentate patients: 5-year results. Int J Oral Maxillofac Implants.

2014;29(4):898-904.

14. Albrektsson T, Wennerberg A. On osseointegration in relation to implant surfaces. Clin Implant Dent Relat Res. 2019;21(suppl 1):4-7.

39. Del Fabbro M, Ceresoli V. The fate of marginal bone around axial vs. tilted implants: a systematic review. Eur J Oral Implantol. 2014;7(suppl 2):S171-S189.

Volume 14 Number 1

REF: IP V14.1 KURTZMAN, ET AL. REF: IP V14.1 MOODY

FULL NAME

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Oral hygiene and dental implant maintenance: part 1

A simple technique for creating a screw-retained immediate restoration after immediate implant placement

KURTZMAN, ET AL.

MOODY

1.

2.

3.

4.

Direct anchorage of alveolar bone to a dental implant body provides a foundation to support a prosthesis and transmits occlusal forces to the alveolar bone.

This is the definition of ________. a. osseointegration b. allograft c. bony housing d. gingival fiber orientation Long-term maintenance and health of the periimplant hard and soft tissues can be achieved through _______. a. appropriate professional care b. patient cooperation c. effective home care d. all of the above Interproximal brushes can penetrate up to ______ into a gingival sulcus or pocket and may effectively clean the peri-implant sulcus. a. 3 mm b. 4 mm c. 5 mm d. 6 mm In addition to mechanical plaque control, ______ has been demonstrated to reduce plaque, gingival indices, and bacterial counts in the oral cavity without the potential issues with other rinses. a. ozone b. peroxide c. chlorine dioxide d. gluconates

6.

7.

8.

9.

10.

5.

Usually during the first year subsequent to restoring dental implants, a ______ re-care schedule should be implemented, especially if the patient lost teeth because of periodontal disease. a. 1-month b. 3-month c. 4-month d. 6-month

Volume 14 Number 1

With dental implant patients, the dental professional must evaluate the prosthetic components for plaque, calculus, and the stability of the implant abutment. Radiographs of dental implants should be taken every ________ during these maintenance visits. a. 2 to 3 months b. 6 to 8 months c. 12 to 18 months d. 24 to 26 months

1.

When monitoring the health of the peri-implant soft tissues, the practitioner should be cognizant of changes in soft tissue ______. a. color b. contour c. consistency d. all of the above ______ analysis may be required to properly evaluate bone levels when suspected or confirmed peri-implantitis is present, as the buccal/facial bone being less dense typically is resorbed prior to the interproximal bone. a. 2D radiographic b. 3D (CBCT) radiographic c. digital photographic d. visual

c. 82

dentistry is to restore the patient to normal contour,

d. 90

function, _______, and health. a. comfort

2.

6.

The space that is often created between the buccal

b. esthetics

plate and the facial surface of the dental implant is

c. speech

called the “gap” or _________.

d.

a.

“plug distance”

b.

“graft distance”

For this patient [a 46-year-old male], once we

c.

“jump distance”

________, a pharmacology protocol was given of

d.

“provisional distance”

all of the above

2g Amox4, 4mg Decadron, 600mg ibuprophen with

A. healthy peri-implant sulcus has been reported to range from _______, which is greater than those depths reported for natural teeth. a. 0.2 mm to 1.2 mm b. 1.3 mm to 3.8 mm c. 4.0 mm to 4. 5 mm d. 4.6 mm to 5.3 mm There is ______ vasculature in the gingival tissue surrounding dental implants compared to natural teeth. a. less b. more c. equal d. much greater

Dr. Carl Misch stated that the goal of modern

a chlorhexidine rinse. a.

7.

obtained verbal and written consent

b. discussed the general treatment with the

3.

4.

We know that when the gap distance is ______, you can reliably just leave it, and the blood clot will allow for adequate bone formation.

patient

a.

2 mm or less

c.

called the patient’s spouse for approval

b.

2 mm or more

d.

observed that the patient was amenable to our

c.

3 mm or more

plan

d.

4 mm or more

Viewing tooth No. 9 within the CBCT software allows

8.

I usually see the patients back in ______ to check

us to visualize _______.

occlusion and excursions once they are no longer

a.

the cross section of the root within the alveolar

numb and have had a chance to start the healing

bone

process.

b.

existing buccal bone width

a.

c.

available bone apical to the existing root

b. 1 week

d.

all of the above

c.

14 days

d.

21 days

24/48 hours

Implant platform was in an ideal position _______ below the adjacent cemento-enamel junc-

9.

In _______, the patients return for a post-op check.

tion (CEJ) and slightly subcrestal of the buccal

a.

1 week

plate.

b.

2 weeks

a.

1.0 mm-1.5 mm

c.

3 weeks

b.

2 mm-3 mm

d.

4 weeks

c.

4 mm-5 mm

d.

none of the above

10.

After the post-op check, if they are symptom-free, I will recall them at _______, and this appointment

5.

(For this patient) With an ISQ of ______, we were

is scheduled for final impression/scanning.

able to confirm that this implant should be a good

a.

2 months

candidate for an immediate provisional restoration.

b.

3 months

a. 25

c.

4 months

b. 54

d.

6 months

Implant practice 27

CE CREDITS

IMPLANT PRACTICE CE

CONTINUING EDUCATION

A simple technique for creating a screw-retained immediate restoration after immediate implant placement Dr. Justin D. Moody discusses an implant technique that achieves relievable and predictable results

W

hen teeth come to the end of their functional life, clinicians are asked to make decisions based upon the situation they present. The use of an immediate dental implant in many cases is the best treatment for true tooth replacement. To achieve repeatable and predictable results, clinicians must take into account a number of factors (Table 1) that will relate to its shortand long-term success. Case selection1 is without a doubt the primary ingredient for good clinical outcomes.

Educational aims and objectives

This article aims to show the process for making a simple screw-retained immediate restoration on an immediate implant.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 27 or take the quiz online at implantpracticeus.com to earn 2 hours of CE from reading this article.

Correctly answering the questions will demonstrate the reader can: •

Realize some factors that relate to long- and short-term implant success.

•

Identify some preparations for temporary restorations.

•

Recognize the benefit of CBCT in the implant process.

•

Identify “gap distance” and considerations for different types.

•

Identify possible pharmacology protocol.

Table 1: Factors that relate to long- and short-term implant success 1. Desired prosthetic outcome 2. Health risk factors 3. Soft tissue biotype 4. Esthetic risk factors 5. Potential parafuctional habits 6. Residual buccal bone post extraction 7. Available bone volume beyond the apex of the extraction 8. Pathology 9. Implant selection 10. Implant stability 11. Implant platform position 12. Temporary prosthesis

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 speaker for BioHorizons®.

28 Implant practice

Figure 1: Retracted anterior photo of non-restorable tooth No. 9

Dr. Carl Misch stated that the goal of modern dentistry is to restore the patient to normal contour, function, comfort, esthetics, speech, and health.2 To achieve this goal with implant dentistry at the time of tooth loss, the fabrication of a temporary prosthesis is often imperative for preservation of both hard and soft tissue as well as any esthetic concerns.

Creating a simple and efficient way to deal with the temporization of an immediate dental implant is key to making these spontaneous procedures flow smoothly in your office. Let’s walk through a case and the process for making a simple screw-retained immediate restoration on an immediate implant.

History and examination A 46-year-old male in reported good health presents to the clinic with the crown of tooth No. 9 in his hand. He states that he had broken this tooth in college playing basketball and has had a root canal and several crowns over the years. He reports no pain or symptoms, but his desire is to leave today with a tooth replacing the lost one, as he is a real estate agent and says no one will take him seriously without a front tooth.

Medically, he is unremarkable, reports taking no medications, addresses any medical issues early with his physician, and sees his general dentist every 6 months for Volume 14 Number 1

Figures 3 and 4: 3. CBCT generated pano from Acteon X-Mind Prime showing Tooth No. 9. 4. Cross-section slice of non-restorable tooth No. 9 using the Acteon AIS Software

hygiene. Clinically, he presents with lost PFM crown on tooth No. 9 containing a metal post-and-core buildup. The root of the tooth has significant decay to the bone level, and after review of the periapical radiograph, a diagnosis of a nonrestorable tooth was made. We discussed the treatment options available to him today, and we both agreed that the replacement of this tooth with a dental implant would provide the best longterm prognosis.

He has a thick biotype (>2 mm) and a low lip line at maximum smile, lending himself to a lower esthetic risk for the case. After a review of his dental history, centric relation of his bite, and the minimal wear to his existing teeth, it was determined that he may be at a low risk for parafunctional habits.3 We talked about the removal of his tooth and placement of a dental implant depending upon several key indicators that will only be known once we remove the tooth.

I discussed with the patient that if we are not able to maintain enough bone at the crest of the ridge after the extraction, we may need to graft the site prior to dental implant placement. He also understood that if the implant did not have adequate stability at the time of placement, he would be fitted with an alternative temporary prosthesis that day.

Treatment plan It was decided that our plan was the extraction of tooth No. 9, placement of an immediate dental implant, and temporization via a screw-retained provisional crown. Once we obtained verbal and written consent, a pharmacology protocol was given of 2g Amox4, 4mg Decadron, 600mg ibuprophen with a chlorhexidine rinse. While these medications will be used 1 hour prior to surgery, there is plenty to do as we need to prepare our temporary restorations — placement of the patient’s lost crown back into the tooth, and taking of upper and lower PVS impressions, bite registration, shade selection, and Volume 14 Number 1

Figure 5: Virtual placement of dental implant using the Acteon AIS Software

Figure 6: Separation of the soft tissue from the tooth to be extracted with a No. 15 scalpel blade

clinical photos. Impressions were poured in snap stone and trimmed, and a vacuumform stent was made. We are now prepared for any scenario that comes up. If we need to graft, or the implant is not of adequate stability, we can use the old crown in the stent as an Essix appliance, or we can use the stent to make a custom screw-retained provisional.5

CBCT 3D planning: Figures 2-5 Viewing tooth No. 9 within the CBCT6 software allows us to visualize the cross section of the root within the alveolar bone, existing buccal bone width, and available bone apical to the existing root. Virtual treatment planning allows for implant selection and placement utilizing the available bone while maintaining as close to ideal bone width and position as possible. Implant selection is important for immediate implants as there are several features that we are looking for. First is an

Figure 7: Extraction of tooth No. 9 using forceps

aggressive thread pattern, which will allow for good initial implant stability. Second is platform switching, which will allow us to place the implant more subcrestal for a better emergence profile and microchannels such as Laser-Lok®7 by BioHorizons®, which has a dual affinity for bone and soft tissue attachment. For the implant in this case, I selected a 4.6 mm x 15 mm BioHorizons tapered PRO8.

Treatment Surgical: Figures 6-15 The anterior maxilla was anesthetized using articaine with 1:100,000 epi. A No. 15 scalpel blade around the tooth allows full release of the soft tissue without any releasing incisions or disruption of the papilla.

With the adjacent teeth being PFM crowns, the luxation and elevation of the tooth will be Implant practice 29

CONTINUING EDUCATION

Figure 2: PA radiograph of tooth No. 9

CONTINUING EDUCATION

Figure 8: Retracted image of extraction site following removal of tooth No. 9

Figure 9: Initial pilot osteotomy with the BioHorizons 2.0 mm drill

Figure 11: Showing the platform position as it relates to the adjacent teeth within the socket

Figure 12: Measuring the depth of the implant platform with a periodontal probe

Figure 10: Placement of a BioHorizons Tapered Plus dental implant into the prepared tooth No. 9 site

Figure 13: Initial stability of the implant being measured with ISQ, pictured is the Penguin peg

Figure 14: ISQ value taken using the Penguin cordless device

Figure 15: Temporary screw-retained crown to be fabricated on this BioHorizons PEEK abutment

Figure 16: Temporary crown formed by using the vacuumformed stent

Temporary prosthesis: Figures 15-20 I placed a PEEK plastic abutment on the implant and hand-tightened it using the 050 driver. The clinician must be careful that the abutment is fully seated; the downside to PEEK polymer material is that you cannot verify it using a radiograph. The upside to placing a platform-switched implant is that the platform is narrower than the implant diameter allowing for the seating to be visually checked. A vacuum-formed stent is seated on the teeth and used as a prep

guide allowing the clinician to see if reduction is needed to allow for thickness of temporary material. The PEEK abutment can be adjusted with a course diamond or a carbide.

After that, I placed a rolled Teflon flag into the abutment and allowed it to extend out the top 2 mm-3 mm; this will be visible through the temporary material and allow for ease of access location and removal. Once set up, the screw channel can be accessed with a carbide bur. Then the Teflon is removed, the screw loosened, and the crown teased off

difficult in order not to damage these existing crowns. This is an ideal situation for the use of technology9 such as Piezotome®Cube to help remove the tooth without luxation against the adjacent teeth and maximum retention of the buccal plate The tooth was removed; the socket was curetted well and rinsed with sterile saline. With our final restoration planned for a screw-retained crown, we would like to see the screw access slightly inside or palatal to the incisal edge. Even if we end up under the edge or slightly facial, we may still be able to do a screw-retained crown with an angled screw channel. Otherwise, we will make a custom abutment and cement-retained crown.

Using a 2.0 started drill, the palatal plate was pierced, and the drill was directed to allow for the proper emergence and to get apical of the extraction site to find solid bone, which will help the stability. The osteotomy was widened according to standard drilling protocol while omitting the final drill in the sequence to allow for more stability. Implant platform was in an ideal position 2 mm-3 mm below the adjacent cemento-enamel junction (CEJ) and slightly subcrestal10 of the buccal plate. The implant motor was set at 40Ncm and hit the torque limit before it was in the final position. Using the hand ratchet, I was able to finish placement the final 1 mm approximately to the desired depth.

Although a good initial torque was reached, it is always a good idea to get an implant stability quotient (ISQ)11 for the implant. With an ISQ of 82, we were able to confirm that this implant should be a good candidate for an immediate provisional restoration.

30 Implant practice

Volume 14 Number 1

Figure 20: Placement of a BioHorizons BioPlug into the buccal gap between the bone and the implant

Figure 19: Removal of temporary crown on peek abutment with small hemostats

Figure 18: Temporary crown material was used in the vacuum stent to form the temporary crown

with a set of hemostats. If the crown does not immediately release, there may be temporary crown material in an undercut. If this occurs, simply remove this with a needle diamond or carbide bur. Once removed, all blood is cleaned from the abutment and screw channel, the PEEK abutment is bonded, flowable composite is used to make the emergence from the PEEK platform to the contact points, and then finish with contour and polish.

Gap distance The space that is often created between the buccal plate and the facial surface of the dental implant is called the “gap” or “jump distance.”12 We know that when this distance is 2 mm or less, you can reliably just leave it, and the blood clot will allow for adequate bone formation. When this distance gets beyond 2 mm, the gap should be grafted.

In the past, I have used cancellous allograft material but have been having great success by placing a collagen plug into this area to allow for clot formation and excellent healing/ bone growth. I will do this once I remove the temporary crown and immediately follow up with a stock healing abutment, which will keep the soft tissue from slumping into the site during completion of the temporary provisional.

Occlusion: Figures 23-28 At this point, I removed the stock abutment, rinsed the hex of the implant with chlorhexidine, and seated the screw-retained temporary prosthesis, being careful not to over contour and blanch the tissue too much.

Volume 14 Number 1

Figure 21: Occlusal image of the implant and BioPlug placement

Figure 22: A stock 3.5 mm x 3 mm wide BioHorizons healing abutment was used to hold the tissue while the temporary crown is fabricated

If the blanching does not go away in a matter of minutes, the clinician should remove and recontour. The abutment is hand-tightened, and occlusion and excursions are checked.

Then sit the patient up and first adjust the CR position — it is critical not to miss the end-to-end position. You will see in Figure 26 only the temp is hitting in forward protrusive in end-to-end, adjusted the restoration to be slightly out of occlusion and out of function

Figure 23: PA radiograph was taken of the healing abutment and final implant placement

as seen in Figure 27. Teflon was placed over the hex, and the access was filled with bonded composite and polished.13 Implant practice 31

CONTINUING EDUCATION

Figure 17: Teflon® tape placed into the screw access channel to keep temporary material from flowing into the screw hex

CONTINUING EDUCATION

Figure 24: Flowable composite was added to the temporary crown to full contour

Figure 25: Temporary crown was tried-in to check for any soft tissue impingements and gingival countours

Figure 26: Occlusion and excursions are checked, an extrusive interference was noted

Figure 27: The incisal edge of the temp was reduced to remove the interference

Figure 28: A Meisinger latch angle polishing wheel was used for the final contour

Follow-up: Figures 29-30 I usually see the patients back in 24/48 hours to check occlusion and excursions once they are no longer numb and have had a chance to start the healing process. Be sure to follow up to ensure that they are taking all of the pharmacology protocol you have given them. In 2 weeks, the patients return for a post-op check. Sometimes you may have needed to place a suture through the papilla, and this is when I would remove them.

If they are symptom-free, I will recall them at 4 months, and this appointment is scheduled for final impression/scanning. My checklist for this appointment is first a periapical radiograph, which is used to determine any crestal bone loss, removal of temporary prosthesis, and ISQ acquisition. Based upon the results, I will proceed directly with a scan body and replacement of the temporary.

Conclusion Understanding the risk factors associated with immediate dental implants and provisional restorations is a guide to good case selection. Developing systems to treat your implant patients can help these procedures smoothly flow into your schedule and provide timely and needed treatment for your patients. This case completed with a very grateful and appreciative patient. IP REFERENCES 1. Daniel Buser, Vivianne Chappuis, Urs Belser, Stephen Chen. Implant placement post extraction in esthetic single tooth sites. Periodontol. 2017;73(1):84-102.

32 Implant practice

Figure 30: Final retracted image of the finished temporary crown No. 9 7. Farronato D, Mangano F, Briguglio F, et al. Influence of Laser-Lok on immediate functional loading of implants in single-tooth replacement: a 2-year prospective clinical study. Int J Periodontics Restorative Dent. 2014;34(1):79-89.

Figure 29: Final PA radiograph of the implant and temporary crown; the PEEK material is not radiopaque, and the flowable composite is often more opaque 2. Carl Misch. Contemporary Implant Dentistry. 3rd ed. St. Louis, MO: Mosby Elsevier; 2007.

3. Chitumalla R, Kumari K, Mohapatra A, et al. Assessment of survival rate of dental implants in patients with bruxism.

Contemp Clin Dent. 2018;9(suppl 2):S278-S282.

4. Greenstein G, Tarnow D. Effectiveness of antibiotics to reduce early implant loss in systemically healthy patients.

Compend Contin Educ Dent. 2020;41(2):102-110.

8. Saito H, Chu S, Zamzok J, et al. Flapless Postextraction Socket Implant Placement: The Effect of a Platform SwitchDesigned Implant on Peri-Implant Soft Tissue Thickness — A prospective study. Int J Periodontic Restorative Dent.

2018;38(suppl):s9-s15.

9. Blus C, Moncler S. Atramatic tooth extraction and immediate implant placement with piezosurgery: evaluation of 40 sites after at least 1 year of loading. Int J Periodontics Restorative Dent. 2010;30(4):355-363.

10. Guirado J, Lopez P, Sanchez J, et al. Crestal bone loss related to immediate implants in crestal and subcrestal position: a pilot study in dogs. Clin Oral Implants Res. 2014;25(11):1286-1294.

11. Monje A, Ravida A, Wang H, Helms J, Brunski J. Relationship between primary/mechanical and secondary/ biological implant stability. Int J Oral Maxillofac Implants.

2019; 34(suppl):s7-s23.

5. Siadat H, Alikhasi M, Beyabanaki E. Interm Prosthesis Options for Dental Implants. J Prosthodont. 2017;26(4): 331-338.

12. Pluemsakunthai W, Le B, Kasugai S. Effect of buccal gap distance on alveolar ridge alteration after immediate implant placement: A microcomputed tomographic and morphometric analysis in dogs. Implant Dent. 2015;24(1):70-76.

6. Jacobs R, Salmon B, Codari M, Hassan B, Bornstein M. Cone beam computed tomography in implant dentistry: recommendations for clinical use. BMC Oral Health.

2018;18(1):88.

13. Martin W, Pollini A, Morton D. The influence of restorative procedures on esthetic outcomes in implant dentistry: A systemic review. Int J Oral Maxillofac Implants. 2014;29 (suppl):142-154.

Volume 14 Number 1

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PRACTICE MANAGEMENT

“I’m not the doctor, but …”

JoAn Majors shows the power of the “preheat” when a well-trained team can instill confidence with implant patients

W

ith implant dentistry or any “want to” treatment with a larger fee, the words, “I’m not the doctor, but …,” can have a powerful impact on innocently “preheating” anything from bone economics to fees from a well-trained team member sharing critical information.

In my husband’s dental practice, we try to avoid hiring “staff members.” We choose to treat our dental team as “colleagues” or “stakeholders,” and they, in turn, understand that expectations are high, and the rewards are high as well. My husband routinely shares that he expects his “colleagues” to bring their brains to work. When one of us shares, “I’m not the doctor, but I have seen Dr. Majors do some amazing things in instances just like this. May I share that with you?” patients are open to the next part of this conversation.

They are in charge of where it goes from this point forward.

We know from our practice experience and the training that we offer at the Misch International Implant Institute that misunderstandings concerning implant treatment can still run rampant with patients. My team and I have witnessed this over the past 2 decades as we would “secret shop” the practices whose doctors were at the Institute for clinical training. Before I ever offer our implant team training, we do our research.

We discover that, in some practices, if no existing system to answer questions consistently is in place, no dependable answers are offered to our shopper each year. Instead, teams inevitably offer the same “unpredictable” responses to our questions.

Patients’ expectations are at their highest at the initial phone call and initial visit. If we meet and exceed them at that time, we have room for error afterward.

Using terms such as titanium rod, metal post, or screw-like thing in the bone is very commonly heard by our secret shoppers. Most of the time, if left on their own and without additional information, team members do the best they can with what they know. The problem is everyone knows or has heard (and regurgitates) something different. This inconsistent message is not one of authority and offers little confidence to a patient. Having clear-cut systems to

JoAn Majors, RDA, CSP®, CVP, is the content creation specialist and cofounder of The Soft Skills Institute, LLC, a National AGD PACE provider. She has earned a CSP — Certified Speaking Professional — the highest global designation for a professional speaker from the National Speakers Association and is also a Certified Virtual Presenter. Published in over 25 magazines and newsletters, her first book on implants has trained thousands of implant teams. She holds the team-training faculty position for the world-renowned Misch International Implant Institute. She offers her signature Soft Side of Implant Dentistry training program through the Institute and privately to groups and DSOs followed by virtual and online implementation modules, available on any device anywhere.

She offers scalable and affordable training to meet the needs of today’s busy providers and teams. JoAn’s platform voice and writing voice are similar to her storytelling style. She is a member of multiple organizations and associations and serves on the advisory board for DeW Life magazine. An ambassador to select dental companies, she still serves weekly as the Comprehensive Care Coordinator in her husband’s practice. Finally, JoAn also works with organizations on strategic messaging that resonates with doctors and teams in today’s COVID-19 climate. To learn more or see her in action, visit www.joanmajors.com.

34 Implant practice

support these types of treatment is how you can measure your success. The late Dr. Carl Misch often asked an audience, “What good is all the clinical training if no one chooses the treatment?” The truth is, the team can pull patients in or push them away when it comes to implant dentistry.

If getting them into your chair matters, you might want to lean in about now.

The title of this piece, “I’m not the doctor, but …” is frequently used in our practice and for those whom we train. We know that the patient’s perception of the team member is different from the “rich” doctor. For years, we have witnessed a patient turning to a team member when the doctor walks out of a room, asking some form of, “What did she/he say?” or “What would you do?”

This is not uncommon, just not commonly addressed. For me, it’s my lane and where our training specializes. Having systems to set up the team, and ultimately the patient, for success makes treatment acceptance predictable. Systems don’t fail; people do.

Plug good people into sound systems, and you’ll all experience more confidence.

Volume 14 Number 1

Volume 14 Number 1

Having clear-cut systems to support these types of treatment is how you can measure your success. The late Dr. Carl Misch often asked an audience, “What good is all the clinical training if no one chooses the treatment?” The truth is, the team can pull patients in or push them away when it comes to implant dentistry. and is in no way confused with “selling” anything at that point.

“Ms. Needmore Time, I’m not the doctor, but helping you understand what might be possible today with implant treatments is my role. Would it be okay if I show you models of some of these options? This way, when you meet Dr. Wonderful in a bit, you’ll understand more about the treatment options that she/ he will discuss designed to meet your needs and desires.”

We approach this with much curiosity to learn their wants and educate them about treatment options with implants. We are intentional and very specific that we won’t know the patient’s particular options until Dr. Wonderful has seen the CT Scan that she/ he ordered. It is not uncommon for a trained team member to spend 45 minutes to an hour sharing types of implant treatments, removable and nonremovable options, and understanding the types of bone in the face, and why bone is significant. They have much more confidence when the doctor comes in, and we often hear, “I feel like I know so much more now; I hope I still have enough bone.”

It’s the ultimate preheat for this type of treatment. The facts are now the facts and not confused with the misconception that the doctor is looking for more types of treatment to increase the fee. The doctor looks at bone width, height, and quality, as the patient is leaning in, hopeful of their answers. Don’t

confuse the education piece. No one is diagnosing but the doctor. When patients have been appropriately interviewed on the phone (this is a system) and are interested in implants, we share what will happen next.

They expect the comprehensive care coordinator to help them understand what might be possible today with implant treatment. There are personality types who don’t need or want this extra time. It’s generally the “D” or dominant style — one of four styles originated from William Marston’s DISC® model — that can make decisions quickly and want only the bottom line to do it. The rarest type, dominant personalities form approximately 9% of the worldwide population.

We’ve proven over the many years when we do this training, that the more patients comprehend before the doctor looks at a CT scan or their potentially terminal dentition, the more the treatment acceptance increases.

My second favorite chapter in my implant book is “Information versus Excuses.” If you tell me before, it’s information; if you tell me after, no matter what it is, it is an excuse!

Give your patients information, and trust the process and systems. I’m not the doctor, but in instances like this, I’ve witnessed many doctors love a team member who is willing to be an educated colleague when it comes to implant dentistry!

See you on the road or on the web! IP Implant practice 35

PRACTICE MANAGEMENT

Find the systems that support your great people, and success will be yours.

One of the early chapters in my implant book addressed the standard answer we share with audiences (and our patients) about how to describe an implant when someone asks. It’s not the be-all-end-all for all patients, but 98% of the time, it answers their question and leaves them feeling more confident rather than getting mixed messages from everyone on the team. It gets more complicated for a specialty practice. It’s the reason my most significant block of speaking business in the past 15 years has been educating the referring and specialists’ practices along with their teams at the same time. Having a group that works together with all saying, “An implant is a man-made root and a man-made tooth or teeth that are fit on top to replace your teeth,” creates consistent results and gives a patient confidence in the practice(s).

It also allows us to go into our common lingo about dentures, “A denture does not replace teeth because teeth have roots.”

Systems support your team, and your case acceptance goes up when they can confidently speak the same language and assure patients they’re in the right place.

In our practice and many we work with, the doctors realize that patients respond well to and believe a confident team member. We are not mini-robots who push buttons, clean instruments, and become transactional. We are educated and bring our brains to work!

We are transformational and become a vital part of treatment acceptance. Our doctors can’t be the only ones learning, and they also can’t afford to spend an hour, sometimes two, just going through possible scenarios with implant treatment and post-care. A team member often covers the education of the implant process(es) available today, and many times that comes long before the diagnosis. It’s the education piece we believe people have a right to know and understand

PRACTICE DEVELOPMENT

Medical insurance benefits can increase access to dental care Rose Nierman explores some intricacies of billing medical insurance

A

n all-too-common situation that we see daily — your patient is in urgent need of extractions, bone grafting, and implants.

As you review the treatment plan, you advise your patient that his dental plan will reimburse for a small portion of the care at $1,500. Your patient is deciding whether he can afford treatment, and you are struggling to think of any avenue to help the patient afford this necessary treatment.

Has your practice considered checking medical insurance benefits? Today it is quite common for medical insurers to reimburse for extractions, bone grafts, frenectomies, sleep apnea appliances, TMD orthotics, oral surgeries, and other procedures. Many dental practices have incorporated a system to successfully bill medical insurance to increase access to care. Also, billing medical may be a requirement if you bill to dental, since many dental plans require that you bill surgeries to the medical plan before they process the dental claim.

There are some differences in medical versus dental billing, but there are also similarities that you can hang your hat on. Let’s explore some of the intricacies of billing medical insurance.

Register as out-of-network provider Most dental practices that bill medical function as out-of-network providers. While it is possible to become an in-network provider with medical insurers, it can be a

Rose Nierman is a leading expert in crosscoding and medical billing in dentistry. She made it her mission to help dentists get paid by medical insurance, and in 1988, she founded Nierman Practice Management (NPM) for dentists to incorporate a SOAP report (DentalWriter) system to successfully bill medical insurance. NPM educates practices to become successful cross-coders through the online medical billing course for dentists, Nierman CE Plus, and offers medical billing services for dentistry. For more information, contact Nierman Practice Management at contactus@dentalwriter. com or 1-800-879-6468.

36 Implant practice

lengthy process for dental practices, so it makes sense to start with out-of-network billing with your usual and preferred fees for services. I recommend that you contact the prominent medical insurers including United Healthcare, Cigna, Aetna, and “the Blues” to register as an out-of-network provider.

Registration forms can typically be found on the insurer’s website.

One of the main questions we receive at our “Cross-coding: Medical Billing in Dentistry” CE seminar is, “If we are in-network with dental insurance, does the in-network status automatically apply to medical insurers?” The answer is “typically no.” Although this is not unheard of, the dental network status will not typically carry over into the medical arena.

Why? The coverage criteria will determine if a medical insurer considers a service medically necessary.

Familiarity with medical policies

ICD-10 (diagnosis) coding

Become familiar with the coverage criteria for the types of services you provide.

Example: Subjective Complaints Medical Policy Oral implants may be covered when trials of mandibular prosthesis have failed, and there is evidence of problems caused by inability to wear a mandibular dental prosthesis. These may include, but are not limited to, malnutrition, diet limited to soft foods, persistent pain, mucosal hypertrophy due to instability, and upper intestinal problems.

Example: Bone Graft Medical Policy Coverage may be available for oral surgery procedures under either medical or dental plans. Necessity and appropriateness will be determined through review of corresponding diagnostics and a rationale of medical necessary. Need for bone graft used in conjunction with apicoectomies, extractions, and/or implants will be based on a clinical scenario in which normal healing cannot be expected.

Every medical claim requires at least one diagnosis code and allows for up to 12.

When more than one ICD code is reported, the code representing the main condition, disorder, or trauma is listed first, with symptoms and secondary conditions to follow.

For example, code K08.23 reports severe atrophy of the mandible. Report symptoms such as jaw pain, difficulty masticating, stomatitis, or dysphagia (oral phase) (ICD R13.11) secondarily.

CPT (procedure) codes Every medical claim requires at least one procedure code and allows for up to six. There is certainly no shortage of codes Volume 14 Number 1

PRACTICE DEVELOPMENT available! Here are some common procedure codes used for surgical services: • CPT 21215 Mandibular bone graft (includes obtaining graft) • CPT 99070 Specific supplies and materials (i.e., allogenic grafting material) • CPT 21248 Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder); partial — three or fewer implants • CPT 20680 Removal of implant due to complications, deep • CPT 20670 Removal of implant; superficial (e.g., buried wire, pin, or rod) In addition to billing for oral surgery, sleep appliances, Botox, etc., be sure to crosscode and bill imaging such as a panorex view or CBCT (preauthorization may be required for advanced imaging).

SOAP reports Your documentation to the medical insurer shows when treatment is a medical need. The medical insurer requires clinical notes to process claims and preauthorization requests, referred to as SOAP notes: Subjective Objective Assessment Plan Effective dental practices are medically documenting care in this format. Utilizing a dedicated questionnaire for oral surgery, obstructive sleep apnea, and TMD cases

Jon and Rose Nierman present a cross-coding/medical billing CE seminar

supports medical documentation for the “subjective” portion of the SOAP note.

How can your dental practice gather the information from the patient that is needed to bill medical? Start with the questions that show the treatment is medically necessary. Pain, functional impairment, digestive problems, and a diet limited to soft food are common examples of conditions that changes the realm from “dental in nature” into “medical in nature.” Nierman Practice Management has created a dedicated questionnaire of medical necessity, which is available to readers of Implant Practice US. For a large portion of dental offices, the ability to cross-code and bill a patient’s medical insurance for necessary procedures

isn’t simply a way to improve their bottom line. It’s an important factor in the practice’s ability to thrive in the current economy.

Medical billing support necessary for success Don’t go at it alone. If there was only one piece of advice I could offer, it would be to secure a support team that has your team’s back throughout the medical billing process. Having that support team to turn to who can answer questions and help navigate the world of medical billing is priceless.

Medical billing success starts with education, grows with implementation of repeatable systems, and is refined by continuing to gather the knowledge you need to level up your success. IP

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Volume 14 Number 1

2021 CITIES

Alabama

BIRMINGHAM, ALABAMA Session 2: Sept 10-11, 2021 Session 3: Oct 14-15, 2021

ADDITIONAL IMPLANT COURSES Sinus Augmentation: October 20-22, 2021 Digital Restorative Solutions: April 15-17, 2021 Advanced Fast Track: April 19-23, 2021 Conscious Oral Sedation: April 30 - May 1, 2021 CBCT Tx Planning/Complications: - NAPA, CA - July 29-31, 2021

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AUSTIN, TEXAS Session 2: May 14-15, 2021 Session 3: June 4-5, 2021

SESSION FOUR: LIVE SURGERY - TEMPE, AZ March 24-26 July 14-16 April 28-30 August 25-27 June 23-25 November 3-5

Texas

Illinois

CHICAGO, ILLINOIS Session 2: July 23-24, 2021 Session 3: August 13-14, 2021

FAST TRACK: WINTER Sessions 2-4: December 6-10, 2021

Austin

learn by doing

INSTRUCTOR

2021 SCHEDULE

live patient implant education

Justin D. Moody, DDS Founder & Clinical Director

Dr. Justin Moody is an internationally known dentist, entrepreneur, instructor and speaker in the fields of dentistry, practice management, technology and Implantology. Dr. Moody has practices in Nebraska and South Dakota and has made a name for himself as one of the leading Continued Education providers in the United States. D Dr. Moody knows how important dental continuing education is as well as the need for mentoring and hands-on training. His conversational, real-life approach solidifies his educational philosophy.

register online at

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

#implantsdoneright

ON THE HORIZON

When implant design matters Dr. Justin D. Moody discusses how implant technology continues to evolve

S

ince the beginning of my implant journey, I have heard many people say, “All implants work the same.” I find this to be true only to the point of asking the human body to make a physical attachment (osseointegration) to a foreign object (the dental implant). In 1998, when I bought my first dental implant system, it was a machined smooth dental implant with holes through the threads in hopes the bone with would grow in them, locking the implant in place. The human body is really amazing as most of these implants did great initially. It was the best we had at the time.

Now that I am no longer eligible for the new dentist discounts, I am seeing these original cases back, and this is when I am so glad that technology continues to evolve.

Bone loss down to the first thread was the norm and taught in textbooks. Today textbooks are discussing zero bone loss. This is why implant design matters today.

Having placed many brands of dental implants, a few design aspects became important to me. These features are not necessarily in order of importance.

• Tapered design to mimic the root of the tooth • Aggressive threads to provide initial stability for immediate loading • Platform switching to aid in soft tissue bulk • Restorability of anterior implants • Surface treatment at the collar to help preserve crestal bone.

Having seen many of these features in the BioHorizons® line, I started placing them in 2007. Now, all of these characteristics are together in the Tapered Pro Series,

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®.

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Figures 1-3: The BioHorizons Tapered Pro features unique Laser-Lok microchannels to create connective tissue attachment and retain crestal bone allowing for better control of the esthetic outcomes. Tapered body and aggressive threads provide primary stability

Figure 4: Laser-Lok microchannels

Figure 5: The BioHorizons Tapered Pro series

Figure 6: A BioHorizons 4.6 x 12 Tapered Pro with wide healing abutment

and that has been a clinical win for me and my clinics.

Over the last several years, we rarely see crestal bone loss. I attribute this to several factors such as the platform switching and Laser-Lok® microchannels. For stability, we saw an increase in initial torque values and ISQ values with the new thread design and helical cutting apex. Combine this with good surgical technique, and you should have a system in your hands that is reliable and predictable.

There is no substitute for prosthetic and surgical knowledge and education. This is a

Figure 7: CEREC scan body for the BioHorizons Tapered Pro to provide same day restoration

Figure 8: CEREC Primescan used to create this same day screw retained restoration

must prior to investing in an implant system that is right for you. Never stop learning because in my next article, you will see how that has applied to me recently. Cheers! IP Volume 14 Number 1

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

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

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

#AreYouAPro Not all products are available in all countries.

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