Implant Practice US Summer 2021 Vol 14 No 2

clinical articles • management advice • practice profiles • technology reviews Summer 2021 – Vol 14 No 2 • implantpracticeus.com

PROMOTING EXCELLENCE IN IMPLANTOLOGY A conversation with ...

Isaac Tawil, DDS, MS

Oral hygiene and dental implant maintenance: part 2 Dr. Gregori M. Kurtzman and Debbie Zafiropoulos

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Dr. Jay Reznick

Dr. Ara Nazarian

BONE GRAFTING PUTTY

Using CBCT-guided technology to facilitate indirect sinus lift with immediate dental implant placement

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Summer 2021 - Volume 14 Number 2

EDITORIAL ADVISORS Jeffrey Ganeles, DMD, FACD Gregori M. Kurtzman, DDS Jonathan Lack, DDS, CertPerio, FCDS Samuel Lee, DDS David Little, DDS Ara Nazarian, DDS

I

remember 20 years ago leaving a Nobel Biocare Zygoma Implant training course thinking to myself, Not a chance; I am ever going to do that! Most patients faced with complete tooth loss at that time would be treated in my practice with conventional sinus augmentation, ridge augmentation, and root form implants. It seemed too invasive at the time without a real value proposition when compared to the systems and protocols that already worked in my hands. A big complaint among restorative dentists was that the surgical technique employed at that time resulted in excessive palatal emergence of the implant platform. This meant that the prostheses created were extremely thick and bulky on the palatal aspect, often interfering with speech and optimal hygiene. Our entire team didn’t see the real value in zygoma implants 20 years ago, particularly when immediate load wasn’t commonplace in the maxilla. We would just wait 6 to 9 months for grafts to consolidate before restoring ideally positioned implants.

Jay B. Reznick, DMD, MD

What is the Smart Zygoma method?

Steven Vorholt, DDS

The original zygomatic implant surgical techniques have been modified to a more extrasinus path for zygomatic implants using the ZAGA method. The anatomy-guided approach is a methodology that focuses on individual anatomic presentation to immediately rehabilitate the severely atrophic maxilla while minimizing the risk of maxillary sinus-associated complications and pathology. The relationship between the zygomatic buttress and the intraoral starting point of the implant will guide the zygoma implant to be positioned fully intrasinus or even completely extrasinus. The ZAGA approach promotes the placement of implants according to the individual anatomy of the patient.

The Smart Zygoma method combines a detailed presurgical planning and prototyping with the ZAGA approach to facilitate a predictable surgical and restorative procedure. To carry out the Smart Zygoma protocol, we start with a large field-of-view CBCT scan to enable complete assessment of the region. Careful planning is then carried out to position the zygomatic implant fixtures in ideal anatomic and prosthetic position. We ensure that the implants are optimized for maximum bone anchorage while avoiding critical anatomical structures.

The plan is exported to a 3D-modeling software for model preparation and then sent to our 3D printer where a medical-grade resin prototype is created. In about 30 minutes, we have a replica of the surgical plan. The prototype is cured, cleaned, and brought to the surgical field for use. The Smart Zygoma prototype is then used during surgery to triangulate visual reference points (such as the infraorbital foramen, pyriform aperture, zygomaticomaxillary suture, and zygomatic buttress) with the drill trajectory. When using this Smart Zygoma method, we can ensure a safer and more predictable outcome.

To those of you who perform a significant amount of full-arch or full-mouth implant surgery and have not incorporated zygoma implants yet, I encourage you to do so now.

New technology and the Smart Zygoma process doesn’t make the procedure any easier or less daunting, but it certainly can now be performed with a higher degree of safety with more precision and control.

If you restore full-arch or full-mouth cases, it’s time to consider referring these patients for a zygomatic implant workup in lieu of complex bone augmentation, knowing that your patients can have teeth immediately, and in most cases, with beautiful, functional smiles.

What a great time to be in dentistry. All the blessings, prosperity, and health in 2021 and for years to come.

Brian T. Young, DDS, MS

CE QUALITY ASSURANCE ADVISORY BOARD Bradford N. Edgren, DDS, MS, FACD Fred Stewart Feld, DMD Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA Justin D. Moody, DDS, DABOI, DICOI Lisa Moler (Publisher) Mali Schantz-Feld, MA, CDE (Managing Editor) Lou Shuman, DMD, CAGS

Dr. Brian Young

© MedMark, LLC 2021. All rights reserved.

The publisher’s written consent must be obtained before any part of this publication may be reproduced 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 US or the publisher.

Brian Young, DDS, attended the University of Florida for his undergraduate studies and the University of North Carolina at Chapel Hill where he earned his DDS. He completed his surgical training in periodontics and implant dentistry while completing a Master of Science degree at the University of Florida. He serves on the editorial review board for Implant Practice US and also served on the advisory board for North Florida Doctor. After teaching dental implants and bone grafting for a decade and private clinical practice for more than 12 years, Dr. Young joined practice with Dr. Nicholas Tawil to provide comprehensive dental implant reconstruction under one roof. Dr. Young is the Clinical Director at Natural Teeth Implant Center www.904implant.com.

Disclosure: Dr. Young did not receive financial compensation for this article.

ISSN number 2372-9058

Volume 14 Number 2

Implant practice 1

INTRODUCTION

Smart Zygoma protocol

TABLE OF CONTENTS

Publisher’s perspective The Roaring 20s Lisa Moler, Founder/CEO, MedMark Media................................ 6

A conversation with ...

Isaac Tawil, DDS, MS

8

Dr. Isaac Tawil discusses his practice’s focus on dental implantology and the role certain dental biomaterials play in his armamentarium

Case report Cost-effective same-day solutions for a failing dentition Dr. Ara Nazarian offers options to fit a patient’s lifestyle and budget............ 16

Clinical perspective Dental Mental Network

Case report

12

Dr. Brett E. Gilbert and Sue Jeffries discuss the importance of providing a safe space in support of dentists’ mental health................................... 19

Incision line opening: the good, the bad, and the ugly Dr. Steven Vorholt illustrates management of a common implant surgery postoperative complication ON THE COVER Cover image courtesy of NovaBone. Article begins on page 8.

2 Implant practice

Volume 14 Number 2

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TABLE OF CONTENTS

Continuing education Using CBCT-guided technology to facilitate indirect (crestal) sinus lift with immediate dental implant placement Dr. Jay Reznick introduces a novel, predictable, time-efficient, minimally invasive technique.........................28

Continuing education

21

Oral hygiene and dental implant maintenance: part 2 Dr. Gregori M. Kurtzman, along with Debbie Zafiropoulos, discusses in-office and at-home dental implant care

Industry news ....................................................... 35

Practice management Product profile

On the horizon

Billing medical for cone beam computed tomography (CBCT)

SMARTbase™ — for optimized esthetics (patent-pending)

Implant success and failure all at the same time

Rose Nierman says for patients and the practice it’s worth the effort to integrate medical billing .......................................................36

Douglas Wilkin, PhD, describes a system that achieves optimal outcomes for screw-retained restorations.....................................38

Dr. Justin D. Moody reflects on a patient’s 2-year-old implant............40

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

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4 Implant practice

Volume 14 Number 2

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PUBLISHER’S PERSPECTIVE

The Roaring 20s

Published by

H

ere comes summer — we’re already half way through the year, and many of hit the ground running into 2021 — a robust reboot of the “Roaring 20s!” During this past year, we have all had plenty of time to think about our personal and professional lives, what works and what needs to be changed. It’s definitely time to get back to business.

Here are some interesting and positive facts from an ADA Health Policy Institute survey collected in January.

• Patients are back! As of the week of January 18, patient volume was estimated at 80% of pre-COVID-19 levels, on average. Staffing in dental offices was at 99% of preCOVID-19 levels, and four out of five employee dentists Lisa Moler were being paid fully.

Founder/Publisher, MedMark Media • Dentists are realizing their worth! At the beginning of the year, nearly a third of dentists had raised fees. Those who needed some extra help were proactive, taking out loans, reducing their dental team hours, and changing suppliers to those more appropriate to their goals. Retirement rates have not changed due to COVID-19.

• Practices are ready to roar! The sector has recovered nearly fully in terms of hiring and employment. Based on vaccine rollout and perceptions, full recovery of dentistry is anticipated by the summer or fall.

Research and development continue to bring new products and techniques to dental specialties, and now, it’s time to figure out how to stay ahead in this very competitive marketplace. One valuable way is letting MedMark publications educate you about products, services, and techniques that can add to your armamentarium and boost your patients’ options. The more choices that patients have for treatment, the more ways that you can expand your practice’s scope and profits. This issue of Implant Practice US features part 2 of a CE by Dr. Gregori M. Kurtzman and Debbie Zafiropoulos on oral hygiene and dental implant maintenance and a CE by Dr. Jay Reznick on using CBCT technology to facilitate a sinus lift with immediate implant placement. In our cover story, we have a conversation with Dr. Isaac Tawil on the role of biomaterials in implantology, and Dr. Steven Vorholt illustrates the management of an incision line opening, a common postoperative complication of implant surgery.

Many aspects of traditional dentistry have changed over the past year, and clinicians were pushed to find ways to serve patients better while maintaining safe protocols. Applications like teledentistry, patient texting, and online consultations showed that you can stay connected to your patients and serve their needs with secure options. Patients have embraced new technologies and still want these benefits even as offices return to full business as usual.

Methods for scheduling fewer appointments and less chair time, while maintaining the personal connection with patients, have been created with more creativity and success that will continue into the future.

While 2020 started out as one of the most unusual in our lives, 2021 promises continued healing and the potential for great success. Let us help you get ready to roar into the future with high expectations!

To your best success, Lisa Moler Founder/Publisher MedMark Media

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

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6 Implant practice

Volume 14 Number 2

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

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

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

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

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

Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 14 Number 2

Pictures/images

Disclosure of financial interest

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

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

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

Tables Ensure that each table is cited in the text.

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

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

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

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

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

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

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

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

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

London: Martin Dunitz; 2001.

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

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

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

Implant practice 7

A CONVERSATION WITH ...

Isaac Tawil, DDS, MS Dr. Isaac Tawil discusses his practice’s focus on dental implantology and the role certain dental biomaterials play in his armamentarium As a general practitioner, what piqued your interest in dental implants and regenerative procedures?

As a private practice clinician, I often referred out many cases for dental implant therapy to local oral surgeons and periodontists. Many of these cases seemed simple enough; however, they required lengthy treatments. Often patients declined referrals due to length of treatment. Additionally, they did not want to be treated by another dentist.

As I joined dental implant associations and received didactic/surgical training, I learned more about simplifying dental implantology and digital dentistry, including guided surgery.

As my knowledge and experience grew, I challenged myself and my clinic to provide faster solutions to previously lengthy treatment modalities. With more time and experience, I took on larger and more complex cases requiring augmentations to existing alveolar bone.

What types of bone grafting procedures do you do in your clinical practice?

As the practice has a focus on implant therapy, a wide array of bone-grafting procedures is necessary. Sometimes the procedures are rather simple such as grafting an extraction socket for future placement of an implant. It is also common to correct dehiscence or fenestration-type defects at the time of implant placement. The more advanced procedures would include localized ridge augmentations to correct ridge deficiencies and sinus augmentations — both lateral window and crestal approaches.

As some implants may experience bone loss

Delivery of the NovaBone Putty to a graft site with the unique cartridge and dispensing gun combination

as a result of peri-implantitis, the ability to treat these implants and graft the defect has become a necessary treatment modality.

There is a plethora of bone grafting materials available to a practitioner.

Do you have a preference for a particular material, and why?

I use a variety of materials in the practice, and my selection really comes down to the indication. If I’m grafting a defect or deficiency in the esthetic zone, I may choose to use a material that doesn’t exhibit much resorption over time such as a mineralized

Isaac Tawil, DDS, MS, received his Doctor of Dental Surgery Degree from New York University College of Dental Surgery and a master’s degree in biology from Long Island University. Dr. Tawil is a MINEC Ambassador (Megagen International Network of Educators and Clinicians), a member of MINEC USA, sits on the Digital Dental USA Society board of directors, a Diplomate of the International Academy of Dental Implantology and the International Academy for Dental Facial Esthetics. He is a Fellow of the International Congress of Oral Implantology. Dr. Tawil is one of Dentistry Today’s top 225 leaders in CE, a faculty member of the Osseodensification Academy, Brighter Way Educational Director (Phoenix, Arizona), and Digital Director of Guided Smile.

Additionally, Dr. Tawil is an Ambassador for the Slow Dentistry initiative and a Fellow of the Advanced Dental Implant Academy. He is a recipient of the Pierre Fauchard Award and the Presidential Service Award for outstanding achievements in dentistry. He is the Founder and Co-Director of Advanced Implant Education, a Partner in TBS instruments, and Universal Shapers LLC. Dr. Tawil has held main podium sessions and hands on workshops worldwide and enjoys a private practice in Brooklyn, New York.

Disclosure: Dr. Tawil is a new product consultant for several dental companies, including NovaBone®.

8 Implant practice

Isaac Tawil, DDS, MS

allograft or xenograft. In other cases, such as an extraction socket where an implant will be placed in a delayed protocol, I want to use a material that turns over to vital bone in a reasonable time period, so the implant is placed in bone versus inorganic material. There are also some procedures such as a crestal sinus augmentation, where the handling characteristics and delivery system for the graft can play a key role in my choice of material.

Volume 14 Number 2

When choosing a procedure such as crestal sinus augmentation, a sufficient ridge height is required (e.g., > 4 mm). I prefer the crestal approach to sinus augmentation over the lateral window approach because the former is much less traumatic for the patient and in my experience has resulted in fewer complications. In these crestal approaches, we penetrate the maxillary ridge with crestal kits, osteotomes, or specialized burs (e.g., Densah® burs by Versah). We then need to find a way to atraumatically elevate the floor of the sinus and graft the site to produce sufficient bone volume for placement of a dental implant. NovaBone® makes a synthetic bioactive glass putty material that is really ideal for this indication. During insertion of this material, a form of hydrostatic pressure is created that naturally lifts the sinus and creates a dome of graft material that can surround the implant.

is the only company in the world that offers the delivery of bone-grating material in a cartridgebased system. The NovaBone Dental Putty also is radiopaque, so I can easily see the graft surrounding the dental implant on an intraoperative radiograph. This material also resorbs and turns over into host bone at rate the does not jeopardize the stability of the implant.

Do you use NovaBone graft materials in other procedures?

Yes. The NovaBone Dental Putty can also be used in extraction sockets, filling the gap of immediate implant placementpartial extraction therapy or for the treatment of peri-implant defects. The unique delivery system also proves helpful when addressing these defects in the posterior zone with compromised access. The putty material is also available in a standard syringe or clamshell packaging for those scenarios where the cartridge-based delivery may not

There are a number of allograft putties and other synthetic putties available on the market, so what makes the NovaBone material unique?

It has a lot to do with the delivery system and the material properties of this bone graft. The putty is available in cartridges that allow the material to be expressed using a dispensing gun provided by the company.

The cartridge has a slightly curved cannula that is 1.8 mm in diameter. This allows the material to be precisely expressed through the pilot hole that we’ve created in the maxillary ridge. Clinicians are familiar with this form of material delivery for other dental materials such as composites, but I believe NovaBone

Figure 1: NovaBone Dental Putty is widely used in the minimally invasive transcrestal approach to sinus augmentation

Figure 2: Clinical example of NovaBone Putty being injected for a transcrestal sinus augmentation Volume 14 Number 2

Figure 3: Another transcrestal clinical example. Note the precise delivery provided by the NovaBone Putty cartridge cannula Implant practice 9

A CONVERSATION WITH ...

So what kind of material would you use in a procedure such as a crestal sinus augmentation, and why?

A CONVERSATION WITH ...

Figures 4 and 5: 4. The 1.8 mm cannula allows for precise placement of the putty for peri-implant defects. 5. Radiograph of an implant placed via the crestal approach. Note the dome of NovaBone Putty surrouding the implant and elevating the floor of the sinus

be necessary. The company also offers their material in a granule form — it’s the same basic bioactive glass technology, but in more of a particulate form with interconnected porosity. This form of the material holds dimension well and is preferred by some clinicians for indications such as localized ridge augmentation.

For those not familiar with bioactive glass materials, can you provide a simple primer?

Bioactive glass materials have been used in dentistry for several decades. Unlike some other parts of the world, the U.S. market seems more focused on allografts (cadaveric bone) or xenografts (bovine or porcine origin).

I never totally understood this, as materials, such as NovaBone, offer consistency, no risk of disease transmission, are visible on a radiograph, turn over into native bone, and are osteostimulatory — all are really important attributes for a bone graft material.

The NovaBone material consists of dual-sized particles of calcium phosphosilicate (CPS). The putty formulation adds polyethylene glycol and glycerin to provide the necessary binding of the particles and handling characteristics with the particles making up 70% by volume. Numerous in vivo studies have demonstrated that the CPS particles impart an osteostimulatory effect at the wound site. At the time of implantation, the graft does not harden like a cement but rather is adaptable to the defect space and provides a transient hemostatic effect.

Calcium and silicon ions are immediately released into the wound site that help stimulate the attraction of undifferentiated cells, ultimately resulting in a transformation and 10 Implant practice

proliferation of osteoblasts. Within days, the binder is absorbed, leaving a three-dimensional scaffold for bone regeneration. At this vascularized graft site, the smaller particles of CPS release calcium and phosphate ions that further contribute to bone formation. The larger particles of CPS remain in the wound site longer, providing ongoing release of calcium and phosphate ions and helping to ensure the graft does not lose volume prematurely. This stimulatory phenomenon is not found in many bone graft materials that only provide an osteoconductive or scaffolding capacity.

You make some compelling points for this particular synthetic graft material. Why do you think the market hasn’t shifted to such a material?

The answer is probably multifaceted.

Allografts are very popular in the United States because the bone is from another human being. That’s easy to explain to patients, and in general these grafts are highly biocompatible. The demineralized forms of allograft also demonstrate an osteoinductive effect, which is similar to NovaBone’s osteostimulatory effect albeit a slightly different mechanism of action. I think xenografts became popular because the inorganic content and structure are similar to human bone as well as a plethora of advertisements through dental journals, conferences, and social media promoting these materials. These grafts do have osteoconductive potential, and for some indications, their slow or nonresorbing characteristics can actually be a benefit. Some of the earlier synthetic graft materials introduced to the dental market

had a mixed success rate, and this may have poisoned the well a bit for synthetics in the U.S. The early sintered hydroxyapatites were essentially non-resorbable with limited vital bone at the graft site. There was a potpourri of various calcium sulfates and tricalcium phosphates (TCPs) produced in various ratios. Some of these resorbed too quickly, resulting in a disappointing volume of regenerated bone. Even the early forms of bioactive glass particles used in the treatment of periodontal defects could produce inconsistent results, especially if the graft was overpacked into the defect site. The more modern-day bioactive glass products, like those produced by NovaBone, have corrected for these historical deficiencies and nicely align with all the desirable characteristics for a dental bone graft material.

It seems that you also have a passion for teaching. Tell us a little about that.

Yes, I’ve had the good fortune to be able to lecture around the world on advanced dental implant procedures, often incorporating the latest dental technology. Through my private practice and Advanced Dental Education — the latter being an educational enterprise that I founded along with my partner, worldrenowned dental expert Dr. Scott Ganz — we are able to do hands-on and live surgical courses to impart my experience to others. I’m a big believer that didactic lectures alone do not adequately prepare a clinician to perform the gamut of dental implant procedures, so I offer educational venues and opportunities where clinicians can get some hands-on experience. Those interested can learn more at https://www.aiedental.com. IP Volume 14 Number 2

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1. Kotsakis GA, Mazor Z. A Simplified Approach to the Minimally Invasive Antral Membrane Elevation Technique Utilizing a Viscoelastic Medium for Hydraulic Sinus Floor Elevation. Oral Maxillofac Surg. 2015 Mar;19(1):97-101. 2. Mazor Z, Ioannou A, Venkataraman N, Kotsakis G, Kher U. Minimally Invasive Crestal Approach Technique for Sinus Elevation Utilizing a Cartridge Delivery System. Implant Practice. 2013;6(4):20-24. 3. Mazor Z, Ioannou A, Venkataraman N, Kotsakis G. A Minimally Invasive Sinus Augmentation Technique using a Novel Bone Graft Delivery System. Int J Oral Implantol Clin Res 2013;4(2):78-82.

Minimally Invasive Transcrestal Sinus Augmentation with NovaBone® Cartridge System1,2,3 Step 1: An osteotomy is prepared to less than 1 mm from the sinus floor.

Step 2: An osteotome is then used to gently fracture the bone at the apex of the osteotomy.

Step 3: The cannula from the cartridge tip can be pressed against the surface of the bone, and the putty can then be injected into the area, resulting in membrane elevation with hydraulic pressure from the putty.

Step 4: An implant may then be placed in the augmented area.

To order, call 1.888.796.1923 or go to osteogenics.com/NovaBone for product information

CASE REPORT

Incision line opening: the good, the bad, and the ugly Dr. Steven Vorholt illustrates management of a common implant surgery postoperative complication

I

ncision line opening is the most common postoperative complication that implant surgeons must handle. Being comfortable with the etiology, outcomes, and treatment is key for any implant surgeon whether he/ she is beginning the implant journey or is very experienced. In this article, I will showcase several examples of incision line opening seen at routine follow-up appointments, and how they are treated based on their presentation and patient history (Figures 1-5).

Incision line opening can have a multitude of causes. Increased risk has been noted in patients with smoking habits, diabetes, alcohol use, and obesity. Increased likelihood of incision line opening also can stem from iatrogenic causes such as poor incision design, poor suturing technique, lack of tension-free closure, and overextended temporary prosthetics. Use of pre- and postoperative chlorhexidine 0.12% rinse and an oral antibiotic loading dose have shown less likelihood of postoperative acute infections and more predictable healing.

The rule of thumb in most incision line opening cases is to wait and perform no treatment, inspect the area for secondary intention healing, relieve any temporary prosthetic, prescribe chlorhexidine rinse, and re-evaluate weekly as the wound continues to heal and close. Generally, you can expect some thinner tissue over the crest where the incision had opened and some minor early crestal bone loss around the affected implants.

Attempting to resuture at 1-2 weeks postoperatively is extremely difficult as the healing tissue edges are very friable and easily torn. Resuturing is most appropriate very shortly after surgery (1-2 days) or if the wound edges have fully healed but have not closed (2-3 weeks) (Figures 6-9). In the latter case, the wound edges have fully healed with keratinized tissue and are unlikely to close further. The wound edges must be freshened

Steven Vorholt, DDS, is a general dentist who focuses on dental implant surgery and restoration. He is currently the Clinic Director of the New Horizon Surgical Center in Tempe, Arizona. He is also the Implant Director for Implant Pathway and is faculty for NYU Langone’s AEGD program at the New Horizon Dental Center.

Dr. Vorholt is actively working towards his associate fellowship in the AAID and plans to continue toward his Diplomate in the ABOI. Dr. Vorholt will be a speaker at Implant Pathway’s “Implant Complications” course in Napa California, July 29-31 (Implantpathway.com).

12 Implant practice

Figures 1-5: This patient presented at his 10-day follow-up with the UL left incision line opened but healing via secondary intention. No treatment was performed except antibiotic rinses twice daily and weekly follow-ups to evaluate healing. At 5 months, the implants were uncovered (BioHorizons® Tapered Pro) and OD Secure abutment (BioHorizons) selected and placed for a maxillary overdenture. Note the tissue thickness/depth difference between the patient’s right and left sides — the left side with the previous incision line opening shows thinner tissue volume compared to the right side. Implants are all fully healed and integrated with good prognosis

Figures 6-9: At 3 weeks post-op from a lateral sinus augmentation, the patient still had a nonclosed incision line in the anterior maxilla. The edges were fully healed and had to be freshened with a coarse diamond to initiate fresh bleeding and exposure of the connective tissue. The fresh edges were then sutured with chromic gut for watertight primary closure. The patient healed uneventfully Volume 14 Number 2

CASE REPORT

to expose the connective tissue, often with a coarse diamond bur or fresh scalpel, and resutured with tension-free closure. This can be accomplished with primary closure, if possible, or with secondary intention healing and close follow-up.

The major concern of incision line opening is early implant exposure. Exposure of the cover screw to the oral environment can lead to early crestal bone loss, infection, and even loss of the implant. When the incision opens, but there is fresh new tissue granulating over the implant sites, no treatment is necessary. Gentle chlorhexidine rinses twice a day and a weekly re-evaluation are adequate. The tissue that heals over these areas is typically thinner than the patient’s biotype, and some minor crestal bone loss may be expected; but typically, it otherwise heals without issue. When a cover screw is partially or fully exposed to the oral environment, a decision must be made on how to treat the area. Surgical notes should be reviewed to confirm the primary stability and insertion torque from the day of surgery.

If within 2 weeks and if the insertion torque was adequate (> 32Ncm is a well-established benchmark), exchanging the cover screw for a low-profile healing abutment is suggested.

Figures 10 and 11: Patient presented at her 2-week follow-up with early implant exposure. Chart notes were consulted and noted insertion torque > 40Ncm for site Nos. 29 and 30. Both implants had healing abutments exchanged to allow the soft tissue drape to seal around the abutments and not leave a fistula above the cover screw for the remainder of healing

Figures 12-15: Patient presented at 2-week follow-up with a well-healed anterior site. Upon closer inspection, the incision was slightly open, and the cover screw was able to be easily located with a periodontal probe. This type of opening should be immediately treated to avoid an operculum open to the oral cavity during osseointegration. In this case, an Osstell RFA unit was used to gather ISQ data, and then a low-profile healing abutment was placed at 2 weeks Volume 14 Number 2

Implant practice 13

CASE REPORT

Figures 16-18: The use of L-PRF membranes to assist in soft tissue healing and closure in an immediate implant case for teeth Nos. 12 and 13. Primary closure was not attempted, and the use of L-PRF membranes helps to facilitate more predictable and expedient soft tissue healing (IntraSpin®, BioHorizons®)

Figure 19: Six implants placed between the mental foramen after alveoloplasty in an edentulous mandible

This allows the new granulating tissue to heal around the healing abutment and not have to close over a titanium cover screw, something that is unlikely to happen naturally.

Relieving any temporary prosthetic and patient home-care instructions to avoid the area is critical. Alternatively, the ISQ of the implant can be ascertained with an resonance frequency analysis (RFA) device like the Osstell® (Figures 12-15). An ISQ above 65 is a general benchmark to place a healing abutment.

This brings to light the importance of good primary stability in implant surgery even when not attempting single-stage surgeries.

The ability to exchange for a healing abutment at a 10-day follow-up when needed can save the surgeon and the patient time, money, and a guarded prognosis for the crestal bone health of the implant. When both torque and ISQ are inadequate for healing abutment placement, the wound should be monitored until the edges are healed or near closing when the wound edges can be freshened, and resuturing attempted with a membrane to help facilitate closure. A cytoplast PTFE membrane can be helpful to allow tissue coverage in situations like this. Alternatively, the clinician can turn to other adjunctive techniques to help soft tissue healing.

One important adjunctive tool that has become more and more influential in dental surgery has been the incorporation of platelet 14 Implant practice

Figure 20: Patient’s loose stitches

Figure 21: Four exposed implants exchanged for healing abutments

Figures 22 and 23: Restoration after using a scalpel blade to attempt bilayer closure

rich fibrin (PRF). PRF has been shown to increase soft tissue healing of wounds by placing dense concentrates of progenitor cells and clotting and tissue factors directly to the site (Figures 16-18). Empirically, I have seen much more predictable healing and speedy soft tissue healing when PRF is utilized. PRF can also be used to help treat incision line openings. Blood is drawn from the patient and spun using the PRF protocol and used to help pack the wound with PRF membranes. With the healing potential of the site increased, often I see impressive early healing or faster secondary intention healing.

Combining these techniques is sometimes necessary with more aggressive incision line openings. In severe cases of wound dehiscence, we relieve (or suggest not wearing altogether) the removable prosthesis, exchange cover screws for healing abutments, and utilize blood concentrates for increased soft tissue healing.

For this patient, we had to use all our techniques to encourage healing of a severe chronic open incision line. At no point in this process was the patient in any amount of discomfort or pain, but the intraoral presentation was genuinely concerning to the patient. The surgery included placement of six implants in between the mental foramen after alveoloplasty in an already edentulous mandible (Figure 19). Primary closure was obtained the day of surgery, but patient returned at 2 days for “loose stitches” (Figure 20). The next 6 weeks involved numerous attempts and techniques to close the incision line. The four exposed implants were exchanged for healing abutments, and the patient was instructed not to wear a lower prosthesis (Figure 21). When the patient presented 2 days postoperatively, I attempted to restore after using a scalpel blade to attempt bilayer closure (Figures 22 and 23). Chlorhexidine Volume 14 Number 2

CASE REPORT

Figure 24: Fully healed edge of the incision covered in keratinized tissue

Figures 25 and 26: Coarse diamond initiates fresh bleeding and secondary wound closure

Figure 27: Patient’s blood was drawn to make L-PRF membranes

Figure 28: L-PRF membranes tucked into incision line margins

Figure 29: Loosely sutured L-PRF membranes between healing abutments and wound edges

Figure 30: New soft tissue coverage of exposed bone and fresh granulating tissue over the wound

rinses were prescribed twice daily for gentle rinse.

The patient returned 2 weeks later with minimal tissue closure and some exposed bone. At this point, the edge of the incision had fully healed and was covered in keratinized tissue (Figure 24). The decision was made to freshen the edges of the flap with a coarse diamond to initiate fresh bleeding and secondary wound closure (Figures 25 and 26). At the same appointment, the patient’s blood was drawn to make L-PRF membranes that were tucked into the margins of the incision line (Figure 27 and 28). The L-PRF membranes were loosely sutured in between the healing abutments and wound edges (Figure 29).

The patient returned one week later with significant new soft tissue coverage of the exposed bone and fresh granulating tissue over the wound (Figure 30). The patient returned 6 months later and exhibited full soft tissue fill (Figure 31). A fragment of necrotic bone was noted between the two middle implants and removed with cotton pliers with no anesthesia (Figure 32). Final soft tissue healing around the implant platforms is seen (Figure 33) prior to selection of final overdenture abutments (OD Secure, BioHorizons) (Figure 34).

Takeaways

Figure 31: 6-month followup

Figure 32: Piece of necrotic bone removed from between teeth Nos. 23-26 with cotton pliers

Figure 33: Healed tissue circumferential for implant platforms with 3 mm thick keratinized tissue around each

Figure 34: Final overdenture abutments chosen and placed for fabrication of new denture

Volume 14 Number 2

Managing the most common implant surgery postoperative complication is an important skill set for every implant surgeon.

Understanding that most of the time the treatment necessary is to do nothing but observe, reassure the patient, and allow the body to heal is the first step. Knowing when and how to intervene is also vital. Allowing early implant exposure to go untreated can lead to more crestal bone loss, unesthetic restorations, or poorer long-term prognosis for the dental implants. Using the information from the date of surgery and/or the use of ISQ via RFA tools can help provide early intervention to avoid longer-term complications.

Bringing PRF into your practice at the day of surgery or as an adjunct to help wound dehiscence treatment can be a great tool to have in your back pocket as well. IP Implant practice 15

CASE REPORT

Cost-effective same-day solutions for a failing dentition Dr. Ara Nazarian offers options to fit a patient’s lifestyle and budget Introduction In today’s economy, we have seen dramatic changes in lifestyle, health, and income. Because of this, we have seen patients delay dental treatment until it ultimately becomes very painful. Although patients may want full mouth dental implant reconstructions with fixed restorations, this may not always be something that fits into their budget. As dental providers, we need to offer our patients a variety of different treatment options in order to restore their dentition to proper form and function. This article focuses on the steps involved in providing denture and overdenture treatment in addition to extractions, grafting, and dental implant placement.

Case description A patient presented to my practice for a consultation wanting to restore his smile.

He complained of generalized discomfort in his teeth due to the caries and periodontal disease that was readily apparent (Figures 1-4). Previously, the patient had teeth removed, one at a time, when there was severe pain or infection. However, this time he wanted to have a “game plan” and be proactive in any suggested treatment that would fit into his budget. He had already been informed by a few dental providers that he would probably need all his remaining teeth removed due to his advanced periodontal disease so he was aware that this might be the case.

Planning At the consultation appointment, the patient was informed that we would require a CBCT to assist us in accurately diagnosing his dental conditions (Figure 5). Using the CS 8100 3D (Carestream Dental), a CBCT was taken so that we would be able to identify

Ara Nazarian, DDS, DICOI, maintains a private practice in Troy, Michigan, with an emphasis on comprehensive and restorative care. He is a Diplomate in the International Congress of Oral Implantologists (ICOI). He has conducted lectures and hands-on workshops on aesthetic materials, grafting, and dental implants throughout the United States, Europe, New Zealand, and Australia.

16 Implant practice

Figure 2: Retracted preoperative frontal view

Figure 1: Preoperative smile view

not only the areas of infection and decay, but also the areas of remaining bone for dental implant placement. Since the patient had expressed his concern about cost, our goal was to not only find a treatment modality that would restore esthetics and function cost economically, but also provide a treatment that could potentially be upgraded in the future.

Preliminary impressions for immediate dentures were obtained using Silginat® (Kettenbach), a cost-effective elastomeric polyvinyl siloxane (PVS) impression material.

Orthodontic retractors were utilized in order to observe the patient was accurately biting in centric occlusion (CO) when capturing the bite registration with fast-setting Futar® (Kettenbach) bite material. Photographs of the patient’s smile and midline were acquired in order to properly inform the dental laboratory of any changes that were desired, including tooth position, tooth size, and arch form for the immediate dentures.

All risks, benefits, and alternatives were fully described to the patient, and any questions were fully answered. Upon listening to the various treatment options, the patient decided to have all his remaining teeth extracted and those sites grafted. The patient would be getting a complete denture in the upper arch whereas in the lower arch, he would be getting an overdenture retained by four dental implants.

Figure 3: Maxillary occlusal view

Figure 4: Mandibular occlusal view

In order to assist the patient with this investment, financing options using a thirdparty payment option (Alphaeon Credit) was discussed. This consideration was a very important part of facilitating acceptance of his care since it made the cost of treatment more economical.

Once anesthesia was acquired (Figure 6), we started removing the teeth in the maxillary arch using the Physics Forceps® (Goldendent) (Figure 7). Since the Physics Forceps act like a Class I lever, the only force applied with the beak is on the lingual aspect of the tooth.

With the beak positioned at the lingual cervical portion, the soft bumper is placed on the buccal alveolar ridge at the approximate Volume 14 Number 2

within the sockets was removed using a curette (Goldendent), and any sharp areas of the alveolar crest were smoothed with a bone bur (Goldendent). OsteoGen® plugs (Goldendent) were placed in each socket to facilitate bone growth within the sockets over a 4- to 5-month period for future implant placement if the patient desired. Using resorbable sutures, the OsteoGen plugs were further stabilized and the tissue sutured (Figure 8).

Figure 6: Maxillary arch anesthetized

Figure 7: Physics Forceps used for extractions

The immediate maxillary denture was tried in to confirm a passive placement as well as a visual inspection of the patient’s midline (Figure 9). Once this was confirmed, and the immediate denture was fully seated, a self-cured, silicone-based soft reline material (Sofreliner Tough® Medium, Tokuyama Dental) was used to line the inner aspects. According to the manufacturer, Sofreliner Tough is designed to provide long-lasting consistent relief with outstanding durability for up to 2 years, superb stain and odor resistance, and excellent adhesion to the denture.

The GoldenForce Forceps (Goldendent) in the lower arch (Figure 10) were used to remove any remaining teeth in the lower arch (Figure 11). The remaining sockets were curetted to further remove any debris or granulation tissue.

Once the sockets were curetted and irrigated with surgical saline, the necessary drilling steps were followed for the preparation of osteotomies in the placement of Touareg® OS (Adin) dental implants (Figure 12). This implant was utilized because it is uniquely designed for immediate function for all bone types, with optimal implant-abutment seating, minimal horizontal bone stress and retention-screw loading stress.

Since the patient was interested in upgrading to a lower FPD restoration in the future, additional implants were placed in key position areas as compared to traditional placement of just two or four dental implants for an overdenture. Two 3.50 mm x 13.0 mm Touareg OS (Adin) dental implants and four Touareg-OS (Adin) 4.20 mm x 10 mm (Figures 13 and 14) were torqued down to the desired depth at approximately 50Ncm. The Touareg OS Spiral Implant (Adin) is a tapered implant with a spiral tap that

Figure 8: Area grafted and sutured

Figure 9: Try-in of immediate denture

Figure 10: Mandibular arch anesthetized

Figure 11: GoldenForce used for extractions

Figure 12: Touareg OS (Adin) dental implants

Figure 13: Dental implant ready for insertion

Figure 5: CBCT using Carestream CS8100

Volume 14 Number 2

Implant practice 17

CASE REPORT

location of the mucogingival junction. While the beak grasps the tooth, the bumper acts as the fulcrum providing leverage and stability for the beak. Extraction is accomplished with slight wrist movement rotation in the buccal direction for about 30 to 60 seconds depending on the length and curvature of the roots.

Once the teeth in the maxillary arch were removed, any granulation tissue remaining

CASE REPORT

Figure 14: Dental implants placed

Figure 17: Overdenture housings picked up using Futar Bite

condenses the bone during placement for immediate stability. It has two large variable threads and a tapered design for accurate implant placement, self-drilling, and better load distribution.

Once fully torqued down, four 5 mm height Zest Locators® were inserted within the implants using the Zest tool. Using a torque wrench with the appropriate adapter, the Zest Locators were tightened to 30Ncm. Now that the internal aspect of the dental implants was sealed, bone-grafting putty material (Goldendent) was injected and packed in any remaining voids in the bone (Figure 15). Using resorbable sutures, primary closure was accomplished around the locations of the implants (Figure 16). In order to avoid tearing the sutures during the pickup procedure of the Zest housings, small strips of C-fold towel were used to cover any exposed areas of the sutures.

Since the bone had been leveled with the guide, there were no interferences detected between the denture base and attachments in the anterior portion of the immediate denture. Using Tokuyama® Rebase II Chairside Hard Denture Reline (Tokuyama Dental), the female components of the Zest Locators would be picked up. Since this material is methyl methacrylate-free, it doesn’t have a strong odor or taste in addition to very minimal heat generation.

The first step in the pickup process was to brush a thin coat of Rebase II adhesive included in the Rebase II kit (Tokuyama Dental) into the area of the overdenture 18 Implant practice

Figure 15: Locators tightened and graft material placed

Figure 16: Mandibular tissue sutured

Figure 18: Panorex and retracted views

Figure 20: Before-and-after smile view

Figure 19: Postoperative smile view

attachments. This would enhance the chemical retention between the denture base and the hard reline/pickup material. KY® lubricant was applied to the surrounding surfaces of the denture to prevent unwanted adherence of excess material. Once the powder and liquid of Rebase II material was mixed, it was then placed into a plastic dispensing syringe and injected into the internal anterior portion of the lower immediate denture as well as on to the receptor attachments.

The prosthesis was held in position by the patient biting together in centric occlusion bite captured previously with Futar (Kettenbach) bite material (Figure 17). After approximately 3 minutes, the overdenture with the incorporated retention caps was removed, and any excess material was removed with a trimming bur. The bite of

the upper immediate denture with soft reline opposing the lower overdenture was verified and any interference eliminated. The patient was instructed to return in a week for a follow up. In 3 to 4 months following his surgery, we would do an indirect reline of both upper denture and lower overdenture to compensate for any settling of bone and tissue. The patient was very pleased with the final outcome of his treatment (Figures 18-20) and actually referred several patients to the practice.

Conclusion As we see more patients presenting with dental issues requiring full mouth edentulation, we need to offer a variety of different treatment modalities to accommodate their esthetic and functional needs in addition to fitting their budget. Overdentures, which can later be upgraded to fixed restorations with additional dental implant therapy, are a great treatment option for these patients. IP Volume 14 Number 2

Dr. Brett E. Gilbert and Sue Jeffries discuss the importance of providing a safe space in support of dentists’ mental health

“W

hen we are looking for compassion, we need someone who is deeply rooted, able to bend, and, most of all, we need someone who embraces us for our strengths and struggles. We need to honor our struggle by sharing it with someone who has earned the right to hear it. When we’re looking for compassion, it’s about connecting with the right person at the right time about the right issue.” — Brene Brown, The Gifts of Imperfection All around the world, organizations and individuals are raising awareness about the scope of our mental health crisis. And it is definitely a crisis. More than 300 million people worldwide deal with depression, making it the leading cause of disability.1 Every 40 seconds, a life is lost to suicide.2 As The Guardian put it in a headline last year: “World in mental health crisis of ‘monumental suffering,’ say experts.”3 Dental Mental Network is predicated on the belief that dentistry’s discussion on mental health and wellness must transform from awareness to action. We are creating a first-of-its-kind platform, a safe space unique to dentistry. In this place, the profession will openly and eagerly denounce the existing culture of distress and develop methodologies that provide timely and appropriate mental wellness support and resources.

The goal is to break through all stigmas surrounding mental health awareness, illness, and suicide. Dental Mental Network is a community of dental professions committed

to supporting one another, being supported, and providing a safe space filled with kind, wholehearted, and empathetic colleagues.

The mental health of dentists remains an important and largely unspoken issue.

Job-related stressors, bullying, treatment error, traumatic patient experiences, and perfectionism lead to dentist depression and burnout. Shame — a universal emotion that contributes to low self-esteem, depression, eating disorders, violence, and addiction — underscores these factors. Dentistry can feel isolating, and perfectionism leads to self-beat-down, self-judgment, and a feeling of being trapped in the office. Dentists routinely feel high levels of stress related to

Brett E. Gilbert, DDS, graduated from the University of Maryland Dental School in 2001 and completed his postgraduate training in Endodontics from the University of Maryland Dental School in 2003. He is currently a Clinical Assistant Professor in the Department of Endodontics at the University of Illinois at Chicago College of Dentistry and on staff at Amita Health Resurrection Medical Center in Chicago. He is a past-president of the Illinois Association of Endodontists. Dr. Gilbert is Board-certified, a Diplomate of the American Board of Endodontics. He was named a top ten young dental educator in America by the Seattle Study Club in 2017. In 2019, he was named to Academic Keys Who’s Who in Dentistry Higher Education. In 2019, he founded an endodontic specialty program at the Chicago Dental Society Foundation Clinic to provide free endodontic services to those in need. He is the founder of Access Endo, a global online education platform devoted to Endodontics and personal development. In 2020, he won the People’s Choice Award as the Top Instructor of 2020 for Endodontics by Course Karma. Dr. Gilbert lectures nationally and internationally on clinical endodontics. Dr. Gilbert is a partner in U.S. Endo Partners and has a full-time private practice limited to endodontics in Niles, Illinois.

He is the Director of Intellectual Wellness for the Dental Mental Network.

Sue Jeffries, BSDH, RDH, began her dental career in 1983 when she joined the U.S. Navy as a Dental Technician. During her 20year Navy career, she assisted in all dentistry phases, managed several Naval Dental Centers, and completed her dental hygiene degree. Upon retiring, Jeffries began practicing dental hygiene full-time and continues to practice as a guest hygienist. In 2018, she completed a Bachelor of Science degree in Oral Health Promotion at O’Hehir University. Her true passion is advocating for mental health awareness and eradicating its stigma. As cofounder of Dental Mental Network, a 501c3 charitable organization serving dentistry, Jeffries works tirelessly toward that end.

Volume 14 Number 2

clinical struggles, financial concerns, and the requirement of being at the dental chair working to generate any income.

Most dentists are idealists who always knew that their calling was to become a doctor who can help others to heal. The decision to enter the profession of dentistry is often chosen early in adulthood, before a true understanding of interests and other life events have started. Most enter dental school with an incomplete understanding of what the reality of the lifestyle will be like. No one warns them about the hidden pitfalls and mind-altering stressors of practicing — the costs that leave practice owners and clinicians emotionally wasted and professionally destitute. Sadly, too many students graduate from dental school with PTSD — forever changed and profoundly affected.

Humans are fallible.

Because dentists are human, accidental errors, practice management mishaps, and financial disasters occur. Although unintended, these errors and accidents can negatively impact patients, families, and staff, leading to the clinician’s adverse mental and emotional effects. These effects include burnout, loss of focus, poor work performance, post-traumatic stress disorder, depression, guilt, embarrassment, anxiety, fear, and even suicide.

The pervasive climate of perfectionism and individual blame in dentistry plays a Implant practice 19

CLINICAL PERSPECTIVE

Dental Mental Network

CLINICAL PERSPECTIVE significant role in these adverse effects.

Many practice owners lack any personal and administrative support, further cause for diminished mental well-being.

Dentists often feel trapped due to the amount of time and finances already sacrificed. They often feel chained to their dental chair, unable to generate income when not performing procedures. They also believe there is nothing they or anyone else can do about it. Support is not substantive in dentistry’s current system, a system that merely wants you to get through.

Dentists have human problems outside of the office. They, too, experience relationship issues, money troubles, custody battles, and deaths in their own families. Still, many dentists are working long, stress-filled hours focused on strangers’ well-being, leaving little to no time to sort through their own issues.

Dentists are notorious for pouring from an empty cup, always concerned with the wellbeing of others while grossly lacking in their own self-care. Shame fills this vacuum, as well as thoughts such as “What is wrong with me?” “Why am I the one this happens to?” “Why am I broken?” Shame thrives on secrecy, is insidious, and intensifies by the day. It is imperative that dentists let it out and share their shame stories. But the question is, with whom?

It’s distressing for us as clinicians and caregivers to feel paralyzed and powerless when a problem is so immense and overwhelming; after all, we are in the business of healing and making things better. That’s why moving from a general big-picture understanding to actionable measures that encourage mental well-being is the best use of this moment in time. People want and need support to take action: 91% of Americans say their emotional well-being has been hurt by ignoring or not recognizing their warning signs of overstressing.4 Our goal is to assist our fellow professionals in recognizing the warning signs of mental health issues. This will help our colleagues to obtain the support they need and facilitate the improvements they need to make. Even in difficult times, everyone should have the opportunity to elevate to living the lives they deserve, not merely the lives they settle for.

Changing the “disease model” of mental health care A critical examination of the prevailing “disease-model” of mental health care would reveal the necessity for a novel alternative to the notion that psychological distress is a symptom of an illness and should be treated as such. How we care for people with mental 20 Implant practice

Dentists are notorious for pouring from an empty cup, always concerned with the well-being of others while grossly lacking in their own self-care. health problems is mainly ineffective — a new approach is needed.

Our mental health and well-being depend primarily on the society in which we live, what happens to us, and how we learn to make sense of and respond to our life events. To proceed, we must recognize that distress is usually an understandable human reaction to life’s challenges, especially episodes of abuse, neglect, and inequity. In response to these, practical support rather than prescription medication should become the new norm. Renouncing labels, considering our life circumstances, and documenting our emotional response in a simple and easily understood format, should become our latest recording.

The time for revolutionizing mental healthcare is now. This revolution starts with an unmitigated shift from how we view mental health solely as a biological disease to view it through a social and psychological lens.

We need to replace unfounded diagnoses with practical, scientific, and understandable alternatives. Instead of treating so-called disorders, we should help people solve the issues leading to distress in their lives.

Addressing the cause versus just treating symptoms is critical to a progressive change in how society views and responds to mental illness.

A terrific start to a new approach would be to ask people for straightforward descriptions of their problems, using their own words. Our social conditions generally shape our psychological health and well-being, so we need to work collectively in creating a vastly more humane society. A priority for all humans should be safeguarding our fellow men, women, and especially children from abuse, neglect, and inequality while developing healthier communities.

Shame can be addressed and overcome through acknowledgment, vulnerability, and compassion.

Attempting to share a shameful story with friends and family can cause you to feel worse and even more beaten-up afterward due to self-blame for not explaining the shame adequately.

Dentistry can integrate positive strategies by promoting kindness, supportive

environments, and constructive rather than negative feedback. Constructive feedback, mentorship, and a collectively supportive and judgment-free resource group are desperately needed to support dentists in a safe space. This space allows for sharing and being free to show vulnerability without worry of recourse, reprimand, or concerns about a negative effect on reputation.

Forging meaningful and tangible connections with others is how we overpower our shame. Shame cannot survive interpersonal relations predicated on understanding and trust. Author Brene Brown aptly summarized the burden of sharing our issues with others.

She said, “If we share our shame story with the wrong person, they can easily become one more piece of flying debris in an already dangerous storm. We want a solid connection in a situation like this — something akin to a sturdy tree firmly planted in the ground.”

Allowing others to view you as imperfect will strengthen your bond and result in relationships that will likely last longer than the other relationships you have.

By joining Dental Mental Network, you can take action by joining this community and showing up to help support yourself, your family, and all dental professionals around the world. We welcome you and are here to support you.

If you would like to join the network or make a donation to allow us to continue to provide support to those we serve, please email: sue@dentalmentalnetwork.com. IP REFERENCES 1. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. 2018. https://www.thelancet.com/ journals/lancet/article/PIIS0140-6736(18)32279-7/fulltext.

Accessed January 20, 2021.

2. World Health Organization. World Mental Health Day 2019 — Focus on Suicide Prevention. www.who.int/news-room/ events/detail/2019/10/10/default-calendar/world-mentalhealth-day-2019-focus-on-suicide-prevention. Published October 20, 2019. Accessed January 20, 2021.

3. “World in Mental Health Crisis of ‘Monumental Suffering’, Say Experts.” The Guardian. www.theguardian.com/ society/2018/oct/09/world-mental-health-crisis-monumental-suffering-say-experts. Published October 20, 2019.

Accessed January 20, 2021.

4. Khidekel M. The COVID-19 pandemic has made spotting our mental health warning signs more critical than ever.

Thrive Global. https://thriveglobal.com/stories/mentalhealth-learn-to-spot-recognize-stress-warning-signsmicrosteps/?utm_source=Recirc. Published May 1, 2020.

January 20, 2021.

Volume 14 Number 2

Dr. Gregori M. Kurtzman, along with Debbie Zafiropoulos, discusses in-office and at-home dental implant care

I

mplant maintenance requires both professional services (routine recall appointments) as well as good home care by the patient to minimize issues related to biofilm accumulation and the resulting peri-mucositis that can result. Cleaning of implants and their prosthetics need different approaches than natural teeth and their prosthetics.

Professional cleaning of instrumentation: an overview Instruments made of metal such as stainless steel should be limited to use on natural teeth and not to probe or scale dental implants. The rationale for this well-documented conclusion is that the hardness of this metal can cause scratches, contamination, or a galvanic reaction at the implantabutment interface.1,2 Ideally, hand periodontal scalers for cleaning dental implants can be made of plastic, Teflon™, gold-plated, or wood (Figures 1 and 2).3,4 When using gold-plated curettes, the manufacturer recommends not sharpening these hygiene instruments, as the gold surface could be chipped exposing the hard metal underneath this coating. Stainless steel scaling instruments may abrade the implant surface, stripping off any surface treatment such as hydroxyapatite (HA) as the instrument’s hardness is greater than the titanium alloy the implant is fabricated from (Figure 3).

Other cleaning armamentarium contraindicated for use with dental implants are air

Educational aims and objectives

This self-instructional course for dentists aims to show information and techniques regarding maintenance of implants for both in-office and at-home processes.

Expected outcomes

Implant Practice US subscribers can answer the CE questions by taking 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 different instrument materials that reduce damage to dental implants.

•

Realize the positive role disclosing solutions can make on biofilm education.

•

Recognize the importance of implant education for patients with implants.

•

Identify some characteristics of air-polishing technology.

•

Identify some at-home care products that have benefits for dental implants.

powder abrasive units, flour or pumice for polishing, and sonic and ultrasonic scaling units.5,6 Ultrasonic, piezo, or sonic scaler tips may mar the implant’s surface leading to microroughness and plaque accumulation. The stainless steel tip may also lead to gouging of the implant’s polished collar (Figure 4). However, some clinicians advocate using a sonic instrument with a plastic sleeve over the tip for scaling dental implants.

Air powder polishing units may also damage the implant surface and should be avoided during hygiene appointments (Figure 5).

Even the use of baking soda powder in these units may strip off any surface coating on the implant. Additionally, the air pressure may detach the soft tissue connection with the coronal of the implant possibly leading to emphysema. Titanium or titanium alloy surfaces of dental implants can be polished

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 sought-after 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.

Volume 14 Number 2

Figure 1: Plastic curettes for scaling dental implants and demonstration of the implant surface after use. Note: No alteration to surface of the implant

Figure 2: Plastic scaler used for recall maintenance

Figure 3: Demonstration of surface alteration of implant surface after use of stainless steel scalers. Note: Alteration to surface texture

Figure 4: Demonstration of gouging of the implant surface that may occur following use of an ultrasonic scaler Implant practice 21

CONTINUING EDUCATION

Oral hygiene and dental implant maintenance: part 2

CONTINUING EDUCATION using a rubber cup along with a nonabrasive polishing paste or a gauze strip with tin oxide.

Improving implant recall prophy maintenance with disclosing solution Why disclose?

Dental healthcare professionals often equate the use of disclosing solution as undesirable as it can be time-consuming, difficult to manage, limited to pediatric patients, or merely utilized in an academic clinical setting. However, the application of disclosing solution as part of preventive maintenance workflow is an essential step in identifying biofilm and is beneficial for both the patient and clinician.

While disclosing solutions have been tucked away in our operatory cabinets, products have improved over the years, which has simplified the application process and aligns vital patient education with the oralsystemic link and, subsequently, improving patient compliance. Medical science has well documented the impact oral biofilm has on long-term dental implant health and stability, which indicates that facilitating biofilm management strategies in implant maintenance protocols is a critical component of the dental hygiene process of care.7-9

Figures 5 and 6: 5. Demonstration of surface alteration of the implant surface following application of a traditional air polisher and baking soda. Note: Change in surface texture. 6. GC Tri-Plaque ID Gel® (GC America, Alsip, Illinois)

Figures 7 and 8: 7. HurriView II® two-tone preloaded disclosing solution applicator (Beutlich Pharmaceuticals, Bunnell, Florida).

8. Disclosing application sticks are snapped to activate, and the solution is applied via the cotton tip

Oral and systemic health Medical scientific evidence continues to correlate the influence of pathogenic oral biofilm on noncommunicable systemic diseases. Embracing the understanding that preventive dental care and patient education have on reducing the impact of active disease, managing disease, and preventing disease through dental biofilm disruption is necessary for periodontal and peri-implant health. The periodontal pathogen, P gingivalis, has been linked to many noncommunicable diseases such as cardiovascular disease, diabetes, Alzheimer’s, rheumatoid arthritis, kidney disease, erectile dysfunction, chronic inflammation, and increased risk for some cancers.10-16 Since 42% of Americans have periodontitis, dental professionals need to recognize this scientific evidence to implement protocols in prevention that meet the needs of this type of patient and adopt a comprehensive methodology to preventive dental care.17

Dental implant patient education Dental implant patients require maintenance that extends beyond traditional preventive protocols. Dental professionals have a responsibility to recognize the importance of technologies and clinical workflows 22 Implant practice

Figures 9 and 10: 9. EMS Dental GBT Biofilm Discloser. 10. Gel solution can be applied with an applicator brush or toothbrush, and the viscosity lends itself to minimal mess. (Courtesy of Shavonne R. Healy, MSDH, RDH)

tailored for implant maintenance to aide in the disruption of oral biofilm and its associated inflammation for implant health and success. As patient compliance ranks as the most significant barrier to improving patients’ oral health, disclosing solution lends the ability for dental professionals to educate patients of the areas where self-care efforts require improvement. The use of disclosing agents will allow dental professionals the opportunity to inform patients of the consequences of biofilm dysbiosis to dental and systemic health, personalize home care to the specific needs of the patient, and demonstrate the efficacy of home care recommendations through a hands-on approach to gain an understanding of the disease process induced by patient noncompliance.18,19

Disclosing application The application of disclosing solution has improved for ease of use and the ability to identify different maturity levels of bacteria.

Contemporary disclosing solutions come

in gel form, pre-loaded applicators, and presoaked sponges (Figures 6-9). The gel solution form may be applied with a cotton applicator, applicator brush, or toothbrush (Figures 10 and 11).

Once the disclosing solution is applied, have the patient rinse, and then review the results. Educating patients to the different colors that result related to the age and virulence of bacteria enables an understanding of periodontal and peri-implant disease etiology.

Performing home care instructions before debridement helps patients visualize the biofilm removal process and efficacy.

After the demonstration, have the patient perform the given instructions and coach as needed. Once education and home care instructions are complete, then debridement procedures can begin. This small shift in the clinical workflow will ensure that critical patient education is routinely included in maintenance appointments, thus leading to improved patient outcomes and increased implant health and success.

Volume 14 Number 2

Figures 12-14: 12. Before disclosing application. (Courtesy of Melissa Obrotka, BA, RDH). 13. After disclosing application, the GC America gel identifies new biofilm as red/pink, mature biofilm as dark blue/purple, and acid-producing biofilms light blue. (Courtesy of Melissa Obrotka, BA, RDH). 14. After guided biofilm therapy has been completed. (Courtesy of Melissa Obrotka, BA, RDH)

Furthermore, when applying the Guided Biofilm Therapy (GBT) eight-step protocol to implant maintenance, debridement outcomes improve as the clinician has a roadmap for biofilm and calculus removal via disclosing solution (Figures 12-14). The GBT protocol allows for more thorough care, less labor-intensive work for the clinician, and a minimally invasive approach to maintaining dental implant surface integrity.20

Improving oral biofilm in-office removal via air polishing Air polishing with glycine powder may be considered as a better method to remove plaque from dental implant because glycine is less aggressive than sodium bicarbonate powder. Moreover, the use of glycine powder seems to have an active role on the inhibition of bacterial recolonization of implants in a short test period (24 hours).21 Other studies indicate that glycine powder assists in the reduction of bleeding upon probing after nonsurgical therapy. This is a key point that would entice the clinician/patient communication of utilizing noninvasive therapy to reduce bleeding.22 In the past few years, indications for the use of the air-polishing technology have been expanded from supragingival use (airflow) to subgingival air polishing (PERIOFLOW) by the development of new low-abrasive glycine-based powders and devices with a subgingival nozzle. Several studies on the subgingival use of air polishing have been completed. In June of 2012, during the Europerio 7 Congress in Vienna, a consensus conference on mechanical biofilm Volume 14 Number 2

management took place aiming to review the current evidence from the literature on the clinical relevance of the subgingival use of air polishing and to make practical recommendations for the clinician.23 Their consensus concluded that: • Oral disease is caused by biofilm.

• Mechanical bacterial biofilm management is essential to longevity.

• Air-polishing devices are effective in removing supra and subgingival biofilm and stain.

• Air-polishing devices shorten the treatment time.

• Air polishing diminishes root sensitivity compared to stainless steel curettes.

In order for the restorative clinician (dentist) and the maintenance therapist (hygienist) to successfully collaborate in the long-term health and stability of the prothesis, it is imperative that they first identify any risk factors that inhibit a successful procedure through all steps. Understanding the integrity of the implant surface is key to long-term maintenance of the implants intraorally, and optimized in-office therapies can be provided by the dental practitioners (dentists and hygienists) and the patient during at home maintenance protocols. The goal is to minimize iatrogenic damage to the implant surface which can happen with the use of metal hand or ultrasonic instruments and diminish pathogenic biofilm adhesion to the implant surfaces that are supracrestal and the prosthetics. Once this is established, the patient should be enrolled in long-term biofilm therapy to ensure preventive management

of the implant and prosthesis. The GBT Compass optimizes the patient/clinician appointment time in a synchronized manner to enhance assessment, patient motivation and home care protocols as well as more effective, noninvasive biofilm therapy with both patient and clinician comfort (Figure 15).

Traditional air polishers use higher pressure as discussed previously, but units have been developed that utilize very low air pressure so the potential issues encountered and reported with the older units are not observed in the newer implant specific air polishers. When it comes to the opportunity to use Airflow (EMS, Nyon, Switzerland), one of the benefits is the use of erythritol powder. In the past, air polishers have been limited to bicarbonate or glycine. While each powder has its limitations, the use of erythritol has overwhelming attributes that contribute to its safe and comfortable application. Erythritol is a polyol (sugar alcohol) that has a smaller particle size of 14µm in comparison to sodium bicarbonate (40µm) or glycine (25µm). Due to the smaller particle size and decreased abrasiveness, the advantages of erythritol in GBT therapy allows the clinician to comfortably deliver supra and subgingival airflow therapy with increased comfort to the patient without damaging the cementum. Usage around implants that lie surpracrestally allow more thorough removal of biofilm on the surfaces without the potential for roughening the exposed titanium and becoming a future biofilm accumulation area (Figure 16). Additionally, airflow is able to reach areas not easily accessible between the inferior surface of the prosthesis and the Implant practice 23

CONTINUING EDUCATION

Figure 11: Disclosing solution on presoaked sponges are applied with cotton pliers. (Courtesy of EMS Dental)

CONTINUING EDUCATION soft tissue (Figure 17). Erythritol’s hardness factor and smaller particle size also allows the clinician to remove more stain with less powder volume than glycine which cuts down on per treatment costs. Additionally, erythritol has been shown to have an antimicrobial inhibition factor for S gordonii and P gingivalis.24 Based on the most recent marketing reports, dental implants and prosthesis market is expected to reach $13.01 billion USD by 2023, up 6.5% from an estimated $9.50 billion in 2018. Key factors driving the growth of this market include the growing geriatric population and corresponding dental disorders, including the rising incidence of tooth decay and edentulism across the globe, growing dental tourism in emerging markets, and increasing government expenditure on oral healthcare.25

PERIOFLOW®

Figure 15: The GBT Compass steps for guided biofilm therapy involving the dentist, hygienist, and patient

Figure 16: Airflow being utilized with erythritol powder in the EMS Airflow unit

Peri-implantitis has been defined as an emerging public health issue. According to recent scientific data and depending on the clinical and radiographic criteria that are adopted, it can affect from 20% to 40% of subjects restored with dental implants.

The PERIOFLOW® device (EMS Dental) provides a flexible nozzle and lightweight body providing a minimally invasive treatment of periodontal pockets with a uniform trilateral powder spray (Figure 18). The flexible tip can be inserted atraumatically into the sulcus (Figure 19). Three outlets at the tip provide comfortable decontamination of the tissue, the implant, and the base of the sulcus with erythritol powder delivered with warmed water with the PERIOFLOW handpiece as part of GBT therapy. It’s ideal for supportive periodontal therapy (SPT), primary and secondary prevention, as well as implant maintenance and nonsurgical treatment of peri-implantitis and periodontitis.

Home care Figure 17: Airflow to remove biofilm under the prosthesis that may not be accessible with other methods in the office

Figure 18: PERIOFLOW tip demonstrating multidirectional flow of the warmed water and powder 24 Implant practice

Figure 19: PERIOFLOW tip introduced subgingivally to debride biofilm from a pocket associated with an implant

Dental implants require special home care. Clinicians should discourage the use of normal OTC toothpastes, because their ingredients can damage the implant surfaces. Fluoride, pH-value, abrasives, and bad oral hygiene can all affect the prosthesis by affecting the implant and prosthesis surfaces, increasing their biofilm adhesion, and thus contributing to peri-mucositis that may progress to peri-implantitis. Ideal medicaments should be recommended based on the patient’s risk factors, commitment to optimized home care protocols and other comorbidities. Ideally the product should not be abrasive, maintain a neutral pH-value, Volume 14 Number 2

Volume 14 Number 2

Figures 20 and 21: 20. Plastic-coated interproximal brush applied around implant abutments and under the superstructure for home care maintenance. 21. ImplantClean brush

Figures 22 and 23: 22. A single implant with crown present on the maxillary premolar with marginal inflammation indicating patient difficulty home care associated with this area of the mouth. (Courtesy of Salvatore DeRicco, DDS). 23. ImplantClean brush allowing better access to subgingival biofilm causing the marginal inflammation and associated bleeding. (Courtesy of Salvatore DeRicco, DDS)

Figures 24 and 25: 24. Following 3 weeks of home care with the ImplantClean brush, resolution of the marginal inflammation has occurred, and an absence of bleeding is noted. (Courtesy of Salvatore DeRicco, DDS). 25. Improved access for home care on the lingual posterior with the ImplantClean brush. (Courtesy of Shavonne R. Healy, MSDH, RDH)

Figure 26: Demonstration of the ImplantClean brush under the flange of the hybrid allowing home biofilm care in an area that is not easily accessible using traditional brushes

Figure 27: Access under a cantilever portion of the hybrid with the ImplantClean brush that would not be accessible with a regular toothbrush

instruction on their use and then diligent daily use by the implant patient. Specialized manual toothbrushes have been developed that are designed to access those areas that a traditional manual or electric toothbrush may not be able to access. This becomes particularly difficult for the patient with a hybrid prosthesis.

As with natural dentition, adjunctive cleaning aids such as flossing are still valuable. As with dentated patients, an implant

patient’s home care requirements should be individually tailored according to each patient’s needs. Individual needs are based on the location and angulation of the dental implants, the position and length of transmucosal abutments, the type of prosthesis, and the dexterity of each patient.

The other popularized type of cleansing device is the use of oral irrigators with or without the addition of antimicrobial solutions. Also, oral rinses with antimicrobial Implant practice 25

CONTINUING EDUCATION

and minimal amount of fluoride to prevent damaging the implant.

Patients should be taught the modified bass technique of brushing using a mediumsized head, soft-bristled toothbrush. The use of intradental brushes should be used by implant patients after being shown their proper use. The plastic-coated wire brush is the only type to be used with dental implants to clean and not scratch the implant surface (Figure 20).

A challenge with home care with regard to partially or fully edentulous implant prosthetics is difficulty for the patient to access the surfaces that can harbor biofilm. Traditional toothbrushes do not permit access to these areas specifically between the fixed prosthesis and gingival tissue and on the lingual aspects. A modified specialty toothbrush designed to access areas that are difficult to clean with a traditional brush, the ImplantClean™ Brush (www.implantclean. com) permits easier home care for the patient in those areas in and around the prosthetics (Figure 21). The angulation of the bristles allows better penetration into the sulcus around single-unit restored implants (as well as around non-splinted natural teeth) to remove subgingival biofilm (Figure 22-24).

Lingual aspects of the posterior teeth, especially those with wider emergence profiles compared to the implant’s diameter or under cantilever pontics are easier to access (Figure 25). The increased frequency of hybrid prosthetics presents challenges to the patient regarding home care. These prostheses often have cantilever posterior pontics and are adapted to flat ridges creating potential food traps and biofilm accumulation areas.

The angulation of the bristles in relation to the handle on the ImplantClean Brush allow better cleaning between the inferior aspect of the hybrid and the soft tissue, with the bristles being able to pass through fully to the lingual aspect of the arch (Figure 26). The inferior aspect of the posterior cantilevers can be accessed either from the lingual (Figure 27) or buccal giving the patient a choice as to which is easier when cleaning that aspect of the bridge.

It is difficult to get a patient to brush longer, but if we can improve efficiency in the time they actually brush, we can improve the quality of their home care. Electric toothbrushes have been advocated as a daily mode of tooth cleansing with natural teeth and they improve home care with implants too. These devices may be a rotary, circular, or sonic type. The key to the effectiveness of these home-care instruments is proper

CONTINUING EDUCATION properties such as Listerine or chlorhexidine have been widely advocated throughout the literature.31-33

Conclusion During the early years of dental implantology, the emphasis for long-term success of osseointegrated implants was the surgical phase of dental implantology. In the years that followed, the emphasis for success had switched from a purely surgical influence to focusing more on the proper fixture placement, which would be dictated by the prosthetic and esthetic needs of each particular case.

The dental professional has recognized professional implant maintenance and diligent patient home care as two critical factors for the long-term success of dental implants.

The microbiota and clinical presentation of peri-implantitis is the same as periodontitis around a natural tooth. Elimination of oral biofilm is key to preventing peri-mucositis that can progress to peri-implantitis with potential loss of the implants. This falls on both the dental professional at recall appointments and the patient via good home care. IP

REFERENCES 1. Speelman JA, Collaert B, Klinge B. Evaluation of different methods to clean titanium abutments. A scanning electron microscopic study. Clin Oral Implants Res. 1992;3(3):120-127.

2. Louropoulou A, Slot DE, Van der Weijden F. Influence of mechanical instruments on the biocompatibility of titanium dental implants surfaces: a systematic review. Clin Oral Implants Res. 2015;26(7):841-850.

3. Louropoulou A, Slot DE, Van der Weijden FA. Titanium surface alterations following the use of different mechanical instruments: a systematic review. Clin Oral Implants Res. 2012;23(6):643-658.

4. Gantes BG, Nilveus R. The effects of different hygiene instruments on titanium surfaces: SEM observations. Int J Periodontics Restorative Dent. 1991;11(3):225-239.

15. Rodríguez-Lozano B, González-Febles J, Garnier-Rodríguez JL, et al. Association between severity of periodontitis and clinical activity in rheumatoid arthritis patients: a casecontrol study. Arthritis Research & Therapy. 2019;21(27).

16. Singhrao S. K., Olsen I. Assessing the role of Porphyromonas gingivalis in periodontitis to determine a causative relationship with Alzheimer’s disease. J Oral Microbiol.

2019;11(1):1563410.

17. Eke PI, Thornton-Evans GO, Wei L, et al. Periodontitis in US Adults: National Health and Nutrition Examination Survey 2009-2014. J Am Dent Assoc. 2018;149(7):576-588.

18. Huang J, Yao Y, Jiang J, Li C. Effects of motivational methods on oral hygiene of orthodontic patients: A systematic review and meta-analysis. Medicine (Baltimore).

2018;97(47):e13182.

5. Rapley JW, Swan RH, Hallmon WW, et al. The oral hygiene instruments and materials on titanium implant abutments.

Int J Oral Maxillofac Implants. 1990;5(1):47-52.

19. Peng Y, Wu R, Qu W, et al. Effect of visual method vs plaque disclosure in enhancing oral hygiene in adolescents and young adults: a single-blind randomized controlled trial. Am J Orthod Dentofacial Orthop. 2014;145(3):280-286

6. Unursaikhan O, Lee JS, Cha JK, et al. Comparative evaluation of roughness of titanium surfaces treated by different hygiene instruments. J Periodontal Implant Sci. 2012;42(3):88-94.

20. Louropoulou A, Slot DE, Van der Weijden F. The effects of mechanical instruments on contaminated titanium dental implant surfaces: a systematic review. Clin Oral Implants Res. 2014;25(10):1149-1160.

7. Heitz-Mayfield, LJA, Salvi, GE. Peri-implant mucositis. J Clin Periodontol. 2018; 45(suppl 20):S237-S245.

8. Schwarz, F, Derks, J, Monje, A, Wang, HL. Peri-implantitis. J Clin Periodontol. 2018; 45(suppl 20):S246-S266.

9. Lasserre JF, Brecx MC, Toma S. Oral Microbes, Biofilms and Their Role in Periodontal and Peri-Implant Diseases. Materials (Basel). 2018;11(10):1802.

10. Aguilera EM, Suvan J, Buti J, et al. Periodontitis is associated with hypertension. A systematic review and metaanalysis. Cardiovasc Res. 2020;116(1):28-39.

11. Zeng XT, Xia LY, Zhang YG, et al. Periodontal Disease and Incident Lung Cancer Risk: A Meta-Analysis of Cohort Studies. J Periodontol. 2016;87(10)1158-1164.

12. Jacob JA. Study Links Periodontal Disease Bacteria to Pancreatic Cancer Risk. JAMA 2016;315:2653-2654.

13. Oğuz F, Eltas A, Beytur A, et al. Is there a relationship between chronic periodontitis and erectile dysfunction? J Sex Med. 2013;10(3):838-843.

14. Wahid A, Chaudhry S, Ehsan A, et al. Bidirectional Relationship between Chronic Kidney Disease and Periodontal Disease. Park J Med Science. 2013;29 (1):211-215.

21. Cochis A, Fini M, Carrassi A, et al. Effect of air polishing with glycine powder on titanium abutment surfaces. Clin Oral Implants Res. 2013;24(8):904-909.

22. Schwarz F, Becker K, Renvert S. Efficacy of air polishing for the non-surgical treatment of peri-implant diseases: a systematic review. J Clin Periodontal. 2015;42(10):951-959.

23. Sculean A, Bastendorf KD, Becker C, et al. A paradigm shift in mechanical biofilm management? Subgingival air polishing: a new way to improve mechanical biofilm management in the dental practice. Quintessence Int. 2013;44(7):475-477.

24. Hashino E, Kuboniwa M, Alghamdi S, Yaet al. Erythritol alters microstructure and metabolomic profiles of biofilm composed of Streptococcus gordonii and Porphyromonas gingivalis. Mol Oral Microbiol. 2013;28(6):435-451.

25. MarketsandMarkets™ report: Dental Implants and Prosthesis Market by Type (Dental Implants, Bridge, Crown, Abutment, Dentures, Veneers, Inlay & Onlays), Material (Titanium, Zirconium, Metal, Ceramic, Porcelain Fused to Metal), Type of Facility, and Region. Global Forecast to 2023.

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Volume 14 Number 2

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AGD Code: 690 Date Published: May 24, 2021 Expiration Date: May 24, 2024

Oral hygiene and dental implant maintenance: part 2 KURTZMAN/ZAFIROPOULOS

1. Instruments made of ______ should be limited to use on natural teeth and not to probe or scale dental implants. a. metal such as stainless steel b. plastic c. Teflon™ d. wood 2. _________ as part of preventive maintenance workflow is an essential step in identifying biofilm and is beneficial for both the patient and clinician. a. Recommendation of specific toothpaste b. The application of disclosing solution c. The use of dental floss d. Air polishing 3. The periodontal pathogen, ________, has been linked to many noncommunicable diseases such as cardiovascular disease, diabetes, Alzheimer’s, rheumatoid arthritis, kidney disease, erectile dysfunction, chronic inflammation, and increased risk for some cancers. a. Staphylococcus b. Eubacterium c. P gingivalis d. Veillonella 4. Since ______ of Americans have periodontitis, dental professionals need to recognize this scientific evidence to

Volume 14 Number 2

implement protocols in prevention that meet the needs of this type of patient and adopt a comprehensive methodology to preventive dental care. a. 26% b. 42% c. 64% d. 75% 5. The use of glycine powder seems to have an active role on the inhibition of bacterial recolonization of implants in a short test period (_______). a. 6 hours b. 12 hours c. 18 hours d. 24 hours 6. (Regarding air polishing) _______ is a polyol (sugar alcohol) that has a smaller particle size of 14μm in comparison to sodium bicarbonate (40μm) or glycine (25μm). a. Erythritol b. Calcium carbonate c. Calcium sodium phosphosilicate d. Feldspar 7. Based on the most recent marketing reports, dental implants and prosthesis market is expected to reach _______ USD by 2023, up 6.5% from an estimated $9.50 billion in 2018.

a. $11.20 billion b. $13.01 billion c. $16.02 billion d. $20.1 billion 8. _______ can affect the prosthesis by affecting the implant and prosthesis surfaces, increasing their biofilm adhesion, and thus contributing to peri-mucositis that may progress to peri-implantitis. a. Fluoride b. pH-value c. Abrasives and bad oral hygiene d. all of the above 9. ______ do/does not permit access to the areas specifically between the fixed prosthesis and gingival tissue and on the lingual aspects. a. Flossing b. Traditional toothbrushes c. Dental cleanings d. Interdental brushes 10. Individual (brushing and flossing) needs are based on the ________ and the dexterity of each patient. a. location and angulation of the dental implants b. position and length of transmucosal abutments c. type of prosthesis d. all of the above

Implant practice 27

CE CREDITS

IMPLANT PRACTICE CE

CONTINUING EDUCATION

Using CBCT-guided technology to facilitate indirect (crestal) sinus lift with immediate dental implant placement Dr. Jay Reznick introduces a novel, predictable, time-efficient, minimally invasive technique Introduction Ridge resorption begins immediately after a tooth is removed. In the posterior maxillary arch, this bone loss is compounded by pneumatization of the maxillary sinus into the edentulous space. Even when ridge preservation is performed, the residual alveolar ridge may be deficient for dental implant placement due to inferior expansion of the sinus floor. This can be managed by sinus augmentation, either by a lateral or crestal approach. Many techniques have been developed for the crestal sinus lift utilizing various osteotomes, bone compactors, and drilling systems with control devices to limit depth of penetration toward the sinus floor to avoid tearing of the sinus membrane. This report describes a unique technique that utilizes CBCT-guided surgery to develop a controlled osteotomy to accomplish a crestal sinus lift.

Once teeth have been removed, the bony resorption process begins. Lack of functional stresses on the alveolar bone leads to a decrease in density at the extraction site and its surrounding bone.1,2 In the maxillary posterior region, there are two opposing forces at work that can severely compromise the alveolar ridge volume in the site where a dental implant is to be placed. Alveolar ridge resorption has been well documented and is greatest in the first 3 to 6 months following tooth removal. Two-thirds of the resorption

Educational aims and objectives

This self-instructional course for dentists aims to discuss a CBCT-guided technology to facilitate indirect (crestal) sinus lift with immediate dental implant placement.

Expected outcomes

Implant Practice US subscribers can answer the CE questions by taking 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 history and variations in the technique of sinus lift and bone grafting for facilitating dental implant placement.

•

Realize the greater accuracy of alveolar ridge height measurement that can be achieved when using cone beam CT (CBCT) as the imaging modality.

•

Identify other devices and instruments that have been used to minimize risk of tearing the sinus membrane in both lateral wall and crestal sinus lift techniques.

•

Realize the benefit of a surgical guide based on the prosthetic plan to determine optimal location for implant placement as well as improving accuracy of the osteotomy position.

•

Read about a patient whose treatment reflects the author’s chosen technique.

occurs within the first few months. Bone of the alveolar ridge diminishes both in width and height.3,4 It has also been demonstrated that immediate ridge preservation grafting of the extraction site significantly reduces the amount of alveolar volume reduction in the first 6 months.5,6,7 From the maxillary second premolar to the second molar, once a tooth has been removed from this region, the process of pneumatization of the sinus begins. This is variable from patient to patient and has been shown by Sharan and Madjar8 that this is most problematic in patients who have a superiorly curving sinus floor above

Jay Reznick, DMD, MD, is a Diplomate of the American Board of Oral and Maxillofacial Surgery. He received his undergraduate Biology degree from CAL-Berkeley, Dental degree from Tufts University, and his MD degree from the University of Southern California. He did his internship in General Surgery at Huntington Memorial Hospital in Pasadena and trained in Oral and Maxillofacial Surgery at L.A. County- USC Medical Center.

Dr. Reznick was one of the first North American adopters of fully guided, prosthetically based implant surgery and was the first specialist in the United States to integrate CBCT and CAD/CAM in his practice. He has taught dentists about basic and advanced implant dentistry, surgery, sleep apnea and snoring, and 3D digital technology for the past 2 decades. Dr. Reznick has published extensively in the dental and medical literature. He lectures frequently at dental meetings and educational conferences as well as giving live training courses to dentists from all over the world. Dr. Reznick is one of the Founders of the website OnlineOralSurgery.com, which educates practicing dentists in basic and advanced oral surgery techniques. He is also a consultant to a number of manufacturers and suppliers of dental and surgical instruments and equipment, and is on the Editorial Advisory Boards of a number of dental journals. Dr. Reznick is the Director of the Southern California Center for Oral and Facial Surgery in Tarzana, California. He can be reached at jay@onlineoralsurgery.com.

Disclosure: Dr. Reznick is a speaker and key opinion leader for Dentsply Sirona. He has no financial relationship with any of the companies mentioned in the article.

28 Implant practice

the extracted tooth, for the second-premolar and first-molar teeth, and when the sinus appeared to already be pneumatized around the roots.9 Even before dental implants were mainstream dentistry, ridge atrophy and expansion of the sinus have made prosthetic restoration of the edentulous maxillary arch more difficult. In order to reduce the bone loss caused by pneumatization of the sinus, Boyne in 1960, in a lecture to U.S. Navy postgraduate dental students10 suggested bone grafting to the floor of the maxillary sinus in order to increase the inter-arch distance in longstanding edentulous patients. The technique of sinus lift and bone grafting for facilitating dental implant placement was first described

by Tatum at the Alabama Implant Congress meeting in 1976. In 1980, Boyne and James published their technique.11 This was essentially a modification of the maxillary wall osteotomy described by George Caldwell and Henry Luc in the 19th century, used to gain access for treating sinus disease, except that the Schneiderian membrane was elevated from the sinus floor to create a pocket for bony regeneration and subsequent dental implant placement.12 This technique, known as the “lateral wall“ or “open” sinus lift, has been used now for decades and has a very Volume 14 Number 2

Volume 14 Number 2

into the final osteotomy and then tapped superiorly with the final osteotome to elevate the sinus floor and membrane. Additional bone graft is pushed through the osteotomy with the final osteotome to the desired volume increase, and the implant is then inserted into place. They concluded that it was imperative to use a guide, especially when the volume of alveolar ridge bone is limited.

All of the preceding methods planned the osteotomies by measuring the height of the alveolar ridge from a two-dimensional radiograph and drilling just short of the sinus floor. Much greater accuracy of alveolar ridge height measurement can be achieved when using cone beam CT (CBCT) as the imaging modality.22 Checchi, et al., compared the Cosci and Summers techniques by treating 15 bilaterally partially edentulous patients with each technique in a split-mouth design.

Patients were treatment-planned based on CBCT, although no mention was made as to why this was chosen over two-dimensional images.23 Thomas and Bindra emphasized the use of CBCT imaging to evaluate the ridge height and width, as well as the anatomy of the sinus above the implant site. They again described use of “careful drilling without perforation of the sinus floor” to prepare the osteotomy using sequentially wider drills.

They did not use any bone graft placed in the sinus floor, but placed a collagen plug to protect against microtears of the membrane as it was elevated.24 Other devices and instruments have been used to minimize risk of tearing the sinus membrane in both lateral wall and crestal sinus lift techniques. The balloon sinus lift is generally used through the crestal approach.25 A catheter with an elastic balloon at the tip is introduced into the sinus once the bony floor has been penetrated. The balloon is filled with sterile saline and is used to gently lift the sinus membrane from the sinus floor using hydraulic pressure. Bone graft is then introduced through the osteotomy prior to implant placement. Troedhan, et al., introduced a technique using a piezosurgery unit and a specially designed set of tips and reported their results on 404 patients.26 After drilling with a pilot drill to 2 mm below the sinus floor, the osteotomy is widened with the calibrated diamond tips and deepened to the sinus floor. Finally. A “trumpet” tip is used to elevate the sinus membrane and to create a space for a bone graft and the implant. In a human cadaver study, none of the 150 specimens showed perforation of the membrane using this technique.27 All these techniques have shown similar success rates no matter which protocol is used.

Now that CBCT has become the de facto standard of care for dental implant planning,

many clinicians have developed crestal sinus lift techniques that exploit the dimensional accuracy of the 3D image compared to a 2D radiograph and its ability to assess sinus anatomy and health.22 A surgical guide based on the prosthetic plan helps to determine optimal location for implant placement, as well as improving accuracy of the osteotomy position. Chasioti, et al., reported on a staged technique utilizing these principles and concluded that despite the knowledge, time, and effort needed to plan and use a guide, the final prosthetic outcome is more predictable and successful.28 Attanasio, et al., used a series of manual screw-tapered bone expanders through a flapless crestal approach to create the implant osteotomy and atraumatically lift the sinus membrane.

Surgery was planned using implant planning software, merging the CBCT data with an intraoral optical scanning image to create a prosthetically based surgical guide.

They proposed that this type of flapless, guided technique leads to better accuracy, and decreased surgical time and patient discomfort.29 Solano, et al., reported a case of transcrestal sinus lift and implant placement using CBCT, CAD/CAM technology and implant planning software to determine optimal implant diameter, length, and placement. They used a printed surgical guide to drill to 1 mm below the sinus floor, followed by penetration of the sinus floor and elevation of the Schneiderian membrane with specially designed rotary instruments. A corticocancellous allograft was placed, followed by the implant fixture, which was delivered to the proper depth using a guided-surgery kit.30 In these guided-surgery cases, the pilot and subsequent drills were utilized to approach but not perforate the sinus floor. This was done by subtracting 1 mm – 2 mm from the alveolar crest height and stopping the drills at that depth.

There has not been a case reported where the drilling of the osteotomies to the proper depth was completely controlled by the surgical guide and guided-surgery drills.

The novel technique that follows, developed by the author, allows for controlled osteotomy to within 0.5 mm of the sinus floor, via a flapped or flapless, fully guided technique.

Case report A 65-year-old woman presented with pain and swelling associated with tooth No. 14.

She had been seen by an endodontist, who determined that the tooth was most likely fractured and was not able to be saved. She was referred by her dentist for removal of the tooth and subsequent replacement with an implant-supported prosthesis. Her medical history was remarkable for HPV-related Implant practice 29

CONTINUING EDUCATION

high success rate with a low morbidity.13 It is most useful when there is less than 5 millimeters of residual bone between the sinus floor and maxillary alveolar ridge crest,14,15 or when multiple implants will be placed in the posterior atrophic maxilla.

The lateral wall technique of sinus lift was popular among oral and maxillofacial surgeons, but rarely used by other dental practitioners due to the technical aspects of the procedure. In order to create a less invasive procedure with reduced morbidity, a new technique was introduced by Robert Summers at the 1993 Academy of Osseointegration meeting16 utilizing a pilot drill via a crestal approach, driven 1 millimeter short of the sinus floor. Calibrated tapered osteotomes were then applied in sequence of increasing diameter in order to shave bone and push it toward the end of the osteotomy, and then up-fracture a 1 mm thick section of the sinus floor. This would elevate the sinus membrane to develop a space for placement of additional bone graft and a dental implant.

This technique is best suited when 5 mm or greater height of crestal bone is present, allowing simultaneous implant placement at the time of sinus lift.

Over the years, there have been many modifications of Summers’ technique developed to reduce the risk of perforation of the sinus membrane via crestal approach. Pontes used a connective tissue graft taken from the hard palate to cushion the Summers No. 2 sinus floor elevator when up-fracturing the bone at the superior end of the osteotomy.16 Various “sinus lift” surgical kits have been created to simplify the crestal sinus lift.17,18 Bernardello, et al., described using Cosci’s technique19 with 3.1 mm diameter drills of various lengths from 2 mm to 12 mm, based on the ridge height measurement to prepare the osteotomy. These drills had a non-fluted tip that prevented perforation of the sinus membrane by abrasive removal of the bony sinus floor. The final drill length was selected to stop 1 mm below the sinus floor. An intraoral radiograph with a parallel pin was used to verify the depth. Next, a “lifting drill” that was 1 mm longer than the measured crest height was used to perforate the sinus floor.

A self-tapping implant of approximately 3.5 mm to 3.75 mm diameter was then inserted into the osteotomy.20 Drew, et al., described using a surgical guide made from study models and a diagnostic wax-up to direct the initial osteotome, as well as subsequent osteotomes of increasing diameter, tapped 1 mm – 2 mm inferior to the sinus floor.21 Their reason for using a guide was that they felt that subsequent osteotomies could deviate from the path of the initial instrument. Bone graft material was placed

CONTINUING EDUCATION pharyngeal carcinoma in her 30s, mild hypothyroidism, and allergy to penicillin. She was taking Synthroid® and Lipitor®. The patient complained of tenderness and mild buccal swelling in the area of tooth No. 14. Clinical examination revealed minor swelling and erythema in the buccal vestibule, and a 9 mm probing depth around the mesiobuccal root. The limited field-of-view CBCT image, sent by the endodontist, showed significant radiolucency involving all three roots and furcation, a thinning of the sinus floor, and edema of the sinus membrane apical to tooth No. 14 (Figure 1). No definitive perforation of the bony sinus floor was noted (Figure 2).

Tooth No. 14 was removed 2 weeks later.

The patient was started on clindamycin 300 mg QID and chlorhexidine 0.12% oral rinse BID, both begun 2 days before surgery.

There was a significant amount of fibrous and granulation tissue, which was sent for microscopic evaluation. This was thoroughly debrided and irrigated with sterile saline until only healthy bone remained in the extraction site. The bony sinus floor showed no perforations when examined clinically. The socket was packed with about 1.5 cc of mineralized and demineralized cortico-cancellous granules (Symbios® Allograft, Dentsply Sirona) until the bony defect was completely filled to the crest. This was covered by a 12 x 24 mm d-PTFE membrane (Symbios® OsteoShield®, Dentsply Sirona), which was trimmed to be 1 mm from each adjacent tooth and tucked between the buccal and lingual bone plates and a 5 mm deep fullthickness mucoperiosteal flap. This barrier was held in place with three PTFE sutures (Cytoplast™, Osteogenics) (Figure 3). The clindamycin was continued for 1 week and the chlorhexidine rinse for 2 weeks after the procedure. Sutures were removed after 2 weeks (Figure 4), and the barrier membrane was removed 6 weeks after surgery (Figure 5). Healthy granulation tissue was present under the membrane and fully epithelialized over the next 8 weeks.

At 4 months’ post-extraction, the grafted extraction site was fully healed, and a periapical radiograph showed good bony volume preservation and adequate bone density for dental implant planning (Figure 6). A CBCT (GALILEOS, Dentsply Sirona) and CAD/CAM optical scan (CEREC Omnicam, Dentsply Sirona) were obtained to facilitate planning for fully guided implant surgery at the site of tooth No. 14. The optical image was used to create a digital wax-up (prosthetic proposal) estimating the size, shape, and position of the final restoration. This information was merged with the CBCT image in order to determine the optimal location, angulation, and depth of the implant fixture to be placed. Measurement of 30 Implant practice

Figure 1: CBCT image demonstrating significant periapical pathology around the mesiobuccal and distolingual roots

Figure 2: CBCT image demonstrating significant periapical pathology involving the interradicular furcation region as well as an intact maxillary sinus floor

Figure 3: Post-extraction ridge preservation graft demonstrating PFTE membrane and sutures in place

Figure 4: Clinical appearance of grafted extraction site at 6 weeks with healthy soft tissues

Figures 5 and 6: 5. Appearance of grafted extraction site immediately following removal of the PFTE membrane. 6. Periapical radiograph of grafted extraction site No. 14 at 16 weeks demonstrating adequate bony regeneration and density

the alveolar ridge height on the CBCT image showed about 6.75 mm distance between the crest of the ridge and the bony sinus floor (Figure 7). The implant system chosen was the Astra Tech Implant System EV (Dentsply Sirona). The shortest wide diameter (4.8 mm) implant available in that system is 6 mm in

height. The drills used for the System EV osteotomy are 1.0 mm longer than the implant fixture. Therefore, despite the successful ridge preservation graft, even with placing the shortest implant, the drills would most likely perforate the sinus floor and possibly the Schneiderian membrane as well. This Volume 14 Number 2

necessary at only one implant site, an indirect (crestal) sinus lift was treatment planned.

Traditional techniques use either two- or three-dimensional imaging to measure the residual ridge height, and the osteotomy is

Figure 7: CBCT measurement of residual alveolar ridge at 18 weeks showing dense bone at the graft site and about 6.74 mm alveolar ridge height at the proposed implant site

Figure 8: “Surgical Plan” for a 4.8 mm x 11 mm dental implant to be placed at site No. 14

Figure 9: Planning Report for implant to be placed at tooth No. 14 site Volume 14 Number 2

planned to stop about 1 mm short of the sinus floor. This is done using marked drills, osteotomes, or special rotary instruments to control the depth of penetration. This author has developed a simplified technique, taking advantage of CBCT-guided protocols for controlling the depth, angulation, and position of sequentially wider drills used to prepare the osteotomy. The sinus floor is up-fractured using either an osteotome or a piezo-surgery tip. The technique is applicable whether an open flap or tissue punch is used to expose the osteotomy site. An extensive search of the English language literature failed to find a similar method described.

Using SICAT Implant software (SICAT GmbH, Bonn, Germany), an Astra Tech Implant System EV was planned with the ideal 4.8 mm diameter by 11 mm long straight implant with the occlusal end at bone level. The optical scan of the maxillary arch and the digital prosthetic proposal were loaded into the planning software and merged with the CBCT image. These images were used to fine-tune the position, angulation, and depth of this implant fixture (Figure 8). This plan is saved and called the “Surgical Plan,” and the planning report (Figure 9) is used to direct the surgical staff as to which implant system, size, and diameter will be used so that all necessary components are ready for surgery. In order to plan the crestal osteotomy to stop 0.5 mm – 1.0 mm inferior to the sinus floor, the implant length is shortened in the planning software so that the series of osteotomy drills will stop at the desired depth, keeping in mind that the drills will cut to 1 mm beyond the planned implant apex. In this case, a 6 mm long implant was selected and positioned so that the fixture apex is 1 mm – 2 mm below the sinus floor.

The vertical position can be adjusted, but the implant position and angulation remain unchanged. (Figure 10). This treatment plan, the “Guide Plan,” is uploaded to the SICAT Portal for design of the surgical guide. This “tricks” the surgical guide designer in to thinking that a short implant will be placed without violation of the sinus floor. A stereolithographic (STL) file is available within 2 to 3 days if there are no issues, and this is used to print the surgical guide on a 3D printer (Form 3, Formlabs). The appropriate guide sleeve is then placed into the printed guide (Figure 11).

The patient presented for surgery the following week. Consent forms were reviewed, and the patient signed giving authorization for treatment. Approximately ½ cc of articaine HCl 4% with 1:100,000 epinephrine (Septodont USA) was infiltrated into the crest of the ridge at the tooth No. 14 site. There were adequate ridge volume and keratinized gingiva to use a flapless (tissue Implant practice 31

CONTINUING EDUCATION

situation necessitated bony augmentation of the floor of sinus above tooth No. 14 for a dental implant to be successfully placed.

Because the residual ridge height is greater than 5 mm and augmentation is

CONTINUING EDUCATION punch) approach.31 The surgical guide was placed, and following the “Guide Plan,” the AstraTech Implant System EV guided surgical kit (Figure 12) was used to prepare the osteotomy to the final diameter (4.5 mm) and approximately 0.6 mm below the left maxillary sinus floor. The surgical guide was removed, and a depth probe was used to verify that the sinus floor was intact. Approximately 0.2 cc of DBX putty demineralized bone matrix (MTF Biologics) (Figure 13) was placed into the osteotomy from a 1 cc syringe and pushed toward the sinus floor with an offset sinus floor elevation osteotome with a concave tip whose outer diameter was 4.2 mm. The bone putty acts as a cushion between the osteotome and the sinus floor and sinus membrane. Using light staccato contact with a surgical mallet, the bony sinus floor was up-fractured, and the Schneiderian membrane was lifted.

The patient’s nasal bridge was stabilized to reduce the risk of post-procedural benign paroxysmal positional vertigo by dampening the vibration which can cause the otoconia in the inner ear from being dislodged and causing this complication.32,33,34 Once the sinus floor had been penetrated, the remainder of the contents of the bone putty syringe were injected through the osteotomy toward the sinus floor. The surgical guide was then replaced, and the 4.8 mm x 11 mm implant fixture was delivered to the osteotomy to the planned depth (“Surgical

Plan”). The bone remaining in the osteotomy is pushed toward the sinus floor as the implant is advanced. The guide was then removed, the position and depth of the implant visually verified, and a 3.5 mm tall healing abutment (HealDesign™ EV, Dentsply Sirona) was placed to 15 Ncm of torque. A postoperative radiograph was taken to confirm the implant position and depth (Figure 14).

Healing was uneventful, and at 4 months’ post-placement, the implant was prosthetically restored. At the 6-month follow-up exam, the implant was stable without any signs of peri-implant disease. Radiographically, the bone level was unchanged from that at the time of placement. The implant apex was surrounded by bone (Figure 15).

Discussion Since Summers first described the crestal sinus lift (Summers technique) in 1994,15 many clinicians have attempted to make the procedure more efficient and less likely to injure the delicate sinus membrane.

There have also been many commercially available “crestal sinus lift” kits designed for this purpose. These kits are designed with either depth control attachments or marks, or drills with 1 mm incremental increase of length in order to control the depth of penetration of rotary instruments. These may not take into consideration the variable contour of the alveolar crest or the sinus floor, especially where there has been bony resorption.

The use of 3D CBCT imaging has significantly improved our diagnostic ability due to

Figure 10: Close-up view demonstrating placement of a 4.8 mm x 6 mm dental implant with its apex located 1.6 mm below the bony sinus floor. When using the Astra Tech Implant System EV guided-surgery kit, the osteotomy will stop 0.6 mm from the sinus floor

Figure 11: Surgical guide which was printed in the office using the sterolithographic file (STL) based on the “Guide Plan” upload

Figure 12: Astra Tech Implant System EV standard guided-surgery kit

Figure 13: Demineralized bone matrix (DBX) putty in preloaded 1 cc syringe. This is used to inject the bone putty into the osteotomy and below the sinus membrane

Figure 14: Immediately postoperative image of placed No. 14 dental implant fixture

32 Implant practice

Figure 15: Radiograph of the restored implant 6 months after delivery of the prosthetic crown Volume 14 Number 2

Volume 14 Number 2

paroxysmal positional vertigo (BPPV) as a result of using a mallet against an osteotome to lift the bony sinus floor.32,33,34,35 When the osteotome method is used, an assistant places a thumb and forefinger over the bridge of the nose in order dampen the vibration from the mallet. This was found to be quite effective, and only one case of mild, self-limiting BPPV has been reported over the many years this technique has been used.

Conclusion With this technique, no special drills, stops, or other devices are needed beyond the standard guided-surgery kit specific to the implant system being used. This author has performed this procedure on average 6 to 8 times per month over the past 10 years, with only 16 failures during the 4-month integration period. There is no significant learning curve to this protocol. Knowing the measurement of the drill length increment beyond the implant apex in the guided-surgery system being used is all that is necessary to plan the position of the “Guide Plan” fixture in the implant planning software so that the drills reach to 0.5 mm to 1.0 mm below the sinus floor. The clinician’s method of choice may be used to lift the sinus floor and graft under the Schneiderian membrane. This unique method is predictable, time-efficient, minimally invasive (especially if done flapless), comfortable for the patient, and has a high success rate. IP

REFERENCES 1. Hansson S, Halldin A. Alveolar ridge resorption after tooth extraction: A consequence of a fundamental principle of bone physiology. J Dent Biomech. 2012;3.

2. Wolff J. Das Gesetz der Transformation der Knochen. Berlin, Germany: August Hirschwald ;1892.

3. Tan WL, Wong TLT, Wong MCM, Lang NP. A systematic review of post-extraction alveolar hard and soft tissue dimensional change in humans. Clin Oral Implants Res. 2012;23(suppl 5):1-21.

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

2003;23(4):313-323.

5. Weng D, Stock V, Schliephake H. Are socket and ridge preservation techniques at the day of tooth extraction efficient in maintaining the tissues of the alveolar ridge? Systematic review, consensus statements, and recommendations of the first DGI Consensus Conference in September 2010, Aerzen, Germany. European J Oral Implantology.

2011;4:59-66.

6. Mardas N, Trullenque-Eriksson A, MacBeth N, Petrie A, Donos N. Does ridge preservation following tooth extraction improve implant treatment outcomes: a systematic review: Group 4: therapeutic concepts and methods. Clin Oral Implants Res. 2015;26(suppl 11):180-201.

7. Avila-Ortiz G, Elangovan S, Kramer KW, Blanchette D, Dawson DV. Effect of alveolar ridge preservation after tooth extraction: a systematic review and meta-analysis. J Dent Res. 2014;93(10):950-958.

8. Sharan A, Madjar D. Maxillary sinus pneumatization following extractions: a radiographic study. Int J Oral Maxillofac Implants. 2008;23:1;48-56.

9. Cavalcanti MC, Guirado TE, Sapata VM, et al. Maxillary sinus floor pneumatization an alveolar Ridge resorption after tooth loss: a cross-sectional study. Braz Oral Res. 2018;32(e64):1-10.

10. Tasoullis G, Yao SG, Fine JB. The maxillary sinus: challenges and treatments for implant placement. Compend

Contin Educ Dent. 2011;32(1):10-19.

11. Tatum OH. Lecture presented to the Alabama Implant Congress. Clinical Implant Dentistry and Related Research.

1976.

12. Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg.

1980;38(8):613-616.

13. Riben C, Thor A. The maxillary sinus membrane elevation procedure: augmentation of bone around dental implants without grafts — A review of a surgical technique. Int J Dent.

2012; 2012.

14. Block MS. Improvements in the crestal osteotome approach have decreased the need for lateral window approach to augment the maxilla. J Oral Maxilofac Surg. 2016;74(11): 2169-2181.

15. Rosen PS, Summers R, Mellado JR, et al. The bone-added osteotomes sinus floor elevation technique: multicenter retrospective report of consecutively treated patients. Int J Oral Maxillofac Implants. 1999;14(6)853-858.

16. Summers RB. A new concept in maxillary implant surgery: the osteotome technique. Compendium. 1994;15(2): 152-160.

17. Pontes FSRAEF, Zuza EP, de Toledo BEC. Summers’ technique modification for sinus floor elevation using a connective tissue graft. A case report. J Int Acad Periodontol. 2010; 12(1):27-30.

18. Koerner KR, Chong D. Simplified sinus lift surgery. Dent Today. 2013;32(12):56-60.

19. Lin M. Controlled technique for indirect sinus grafting with simultaneous implant placement. Oral Health. 2013. https:// www.oralhealthgroup.com/features/controlled-techniquefor-indirect-sinus-grafting-with-simultaneous-implantplacement-mark-lin-bsc/. Accessed April 7, 2021.

20. Cosci F, Luccioli M. A new sinus lift technique in conjunction with placement of 265 implants: A 6-year retrospective study. Implant Dent. 2000;9(4):363-368.

21. Bernadello F, Righi D, Cosci F, et al. Crestal sinus lift with sequential drills and simultaneous implant placement in sights with < 5 millimeters of native bone: a multicenter retrospective study. Implant Dent. 2011;20(6):439-444.

22. Tyndall DA, Price JB, Tetradis S, Ganz SD, Hildebolt C, Scarfe WC. Position statement of the American Academy of Oral and Maxillofacial Radiology on selection criteria for the use of radiology in dental implantology with emphasis on cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;113(6):817–826.

23. Drew HJ, Chiang T, Simon BI. The osteotome technique: modifications to the original approach. Inside Dentistry.

2007;3(10):58-65.

24. Checci L, Felice P, Antonini ES, et al. Crestal sinus left for implant rehabilitation: a randomized clinical trial comparing the Cosci and the Summers techniques. A preliminary report on the complications and patient preference. Eur J Oral Implantol. 2010;3(3):221-232.

25. Thomas TJ, Bindra AS. Internal sinus membrane elevation in patients with less than 5 millimeters residual bone height.

Compend Contin Educ Dent. 2018;39(5):e13-e16.

26. Abadzhiev M. Alternative sinus lift techniques - literature review. Journal of IMAB Annual – Proceeding (Scientific Papers), Book 2. 2009;23-27.

27. Troedham A, Kurrek A, Wainwright M, et al. The transcrestal hydrodynamic ultrasonic cavitational sinus lift: results of a two-year prospective multicenter study on 404 patients, 446 sinus lift sites and 637 inserted implants. Open J Stomatol.

2013;3:471-484.

28. Troedham A, Kurrek A, Wainwright M, Jank S. Schneiderian membrane detachment using transcrestal hydrodynamic ultrasonic cavitational sinus lift: a human cadaver head study and histologic analysis. J Oral Maxillofac Surg.

2014;72(8): 1503.e1-1503.e10.

29. Chasioti E, Sayed M, Drew H. Novel techniques with the aid of a staged CBCT guided surgical protocol. Case Rep Dent. 2015;2015.

30. Attanasio F, Bortolini S, Carbone D, Pacifici A. Flapless cone beam computed tomography — guided implant surgery with contextual transcrestal sinus lift augmentation using new bone compactor tools. Case Rep Dent. 2020;2020.

31. Solano N, Ortega A, Gutiérrez P, Ortega A, et al. Use of a surgical guide for flapless transcrestal maxillary sinus floor elevation and immediate placement of dental implant: a case report. Res Rep Oral Maxillofac Surg. 2020;4(1):033.

32. Greenstein G, Cavallero S. The clinical significance of keratinized gingiva around dental implants. Compendium of Contin Educ Dent. 2011;32(8):24-31.

33. Ackay H, Ulu M, Kelebek S, Aladag I. Benign paroxysmal positional vertigo following sinus floor elevation in a patient with antecedents of vertigo. J Maxillofac Oral Surg.

2016;15:(suppl 2):351-354.

34. Peñarrocha M, Garcia A. benign paroxysmal positional vertigo as a complication of interventions with osteotome and mallett. J Oral Maxillofac Surg. 2006;64(8) 1324.

35. Saker M, Ogle O. Benign paroxysmal positional vertigo subsequent to sinus lift via closed technique. J Oral Maxillofac Surg. 2005;63(9):1385-1387.

Implant practice 33

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more accurate information.22 Implant planning software based on these images has improved our ability to compare variations of implant size and position in order to optimize our treatment results. Sinus lift techniques, whether performed via a crestal incision (indirect) or an open lateral wall (open) approach have allowed clinicians to place implants in atrophic posterior maxillae. The ideal candidate for an indirect (crestal) sinus lift needs only one or two adjacent posterior maxillary teeth to be replaced, has a concave sinus floor with surrounding walls,13 no bony septae near the edentulous space,9 and at least 5 mm of alveolar ridge height.14 Most of the techniques described use blunt- or concave-ended osteotomes, drills or other cutting instruments with stops to carefully approach the bony sinus floor to about 1 mm.19,23,24 If the alveolar ridge is irregularly shaped, or if the floor of the sinus is convexly curved, the selection of the correct-length instrument may be unclear.

A number of authors have reported using a CBCT-generated surgical guide to facilitate crestal sinus lift. In 2007, Drew, et al., used a surgical guide to direct tapered osteotomes, following the technique of Summers16 at the surgical site to up fracture the sinus floor.21 Attanasio, et al., described using a flapless, guided technique using a series of manual screw-tapered bone expanders to develop the osteotomy. The surgical guide was created by integrating information from a CBCT and intraoral optical scanner.29 Solano, et al., reported on a similar technique using a fully guided flapless crestal approach through a surgical stent designed by the merger of CAD/CAM and CBCT technology.

The osteotomy was created using a specially designed surgical kit used for indirect sinus lift procedures only.30 All reported good results with simultaneous implant placement and emphasized the use of a surgical guide for accuracy and efficiency.

The technique reported here is unique in that it utilizes a prosthetically based treatment plan derived from the integration of CBCT, optical scanning, and state-of-theart planning software to design a surgical guide that is used for preparation of the osteotomy using rotary instruments, followed by implant placement. The custom guide facilitates precision in the position, angulation, and depth of each drill. The drilling depth can be planned so that the distance from the tip of the drill to the sinus floor can be precisely controlled. The up-fracture of the sinus floor can then be completed by a single osteotome or using a piezosurgical device.

This author has used piezosurgery (Piezotome® Cube, Acteon) over the past few years to reduce the risk of postoperative benign

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AGD Code: 730 Date Published: May 24, 2021 Expiration Date: May 24, 2024

Using CBCT-guided technology to facilitate indirect (crestal) sinus lift with immediate dental implant placement REZNICK

1. Ridge resorption _______ after a tooth is removed. a. begins immediately b. seldom begins c. begins several months after d. begins several years after 2. Many techniques have been developed for the crestal sinus lift utilizing various _______ with control devices to limit depth of penetration toward the sinus floor to avoid tearing of the sinus membrane. a. osteotomes b. bone compactors c. drilling systems with control devices d. all of the above 3. Alveolar ridge resorption has been well documented and is greatest in the first ______ following tooth removal. a. 1 to 2 months b. 3 to 6 months c. 7 to 12 months d. 14 to 20 months 4. Even before dental implants were mainstream dentistry, _______ has/have made prosthetic restoration of the edentulous maxillary arch more difficult. a. ridge atrophy b. expansion of the sinus

34 Implant practice

c. lack of patient compliance d. all of the above 5. Lateral wall, or open sinus lift, is most useful when there is _______ of residual bone between the sinus floor and maxillary alveolar ridge crest, or when multiple implants will be placed in the posterior atrophic maxilla. a. less than 2 millimeters b. less than 4 millimeters c. less than 5 millimeters d. more than 5 millimeters 6. Much greater accuracy of alveolar ridge height measurement can be achieved when using ____ as the imaging modality. a. cone beam CT (CBCT) b. 2D digital X-rays c. a panoramic X-ray d. MRI 7. The technique reported here is unique in that it utilizes a prosthetically based treatment plan derived from the integration of _______ to design a surgical guide that is used for preparation of the osteotomy using rotary instruments, followed by implant placement. a. CBCT b. optical scanning c. state-of-the art planning software

d. all of the above 8. This author has used piezosurgery (Piezotome® Cube, Acteon) over the past few years to reduce the risk of _______ as a result of using a mallet against an osteotome to lift the bony sinus floor. a. infection at the implant site b. postoperative benign paroxysmal positional vertigo (BPPV) c. sinus problems d. tingling in the natural teeth 9. Knowing the measurement of the drill length increment beyond the implant apex in the guided-surgery system being used is all that is necessary to plan the position of the “Guide Plan” fixture in the implant planning software so that the drills reach to _____ below the sinus floor. a. 0.5 mm to 1.0 mm b. 1.5 mm to 2.5 mm c. 3.0 mm to 3.5 mm d. 4.0 mm to 5.0 mm 10. (When using the author’s technique) ____ may be used to lift the sinus floor and graft under the Schneiderian membrane. a. Dr. George Caldwell’s method only b. Dr. Robert Summers’ method only c. The clinician’s method of choice d. Dr. Leonard Linkow’s method only

Volume 14 Number 2

CE CREDITS

IMPLANT PRACTICE CE

Anatotemp has incorporated the Anatotemp SC® anatomic dental implant healing abutment and scan body library into the 3Shape dental implant laboratory and model creator software.

Anatotemp has become the off-the-shelf solution for creating ideal emergence profile, and now its second generation, Anatotemp SC is both an anatomic healing abutment and digital scan body in one component. With Anatotemp SC, there is no need to remove the healing abutment and place an impression post or scan body.

Anatotemp SC performs both functions, saving the implant clinician four steps and at least one appointment. 3Shape is a global leader in digitally driven dental implant planning and laboratory software and is utilized by a vast number of dental implant clinicians and dental laboratories worldwide.

For more information, visit www.anatotemp.com

AO announces new Fellowship and AO Certificate in Implant Dentisty recipients Seven individuals were recognized as achieving Fellowship status in the Academy of Osseointegration (AO) during the Opening Symposium of its 2021 Virtual Annual Meeting. Fellowship is obtained by demonstrating a commitment to the field of osseointegration. Reflecting the importance of science and service embodied in its founding principles, AO established a Fellow membership category to honor members who have excelled in both academics as well as service to the Academy. The newest AO Fellows include: Riad Almasri, DDS, in private practice, Dallas, Texas, and adjunct faculty member at Nova Southeastern University College of Dental Medicine; Joseph Y. K. Kan, DDS, MS, a professor in the Department of Implant Dentistry at Loma Linda University; and Gustavo Mendonca, DDS, MSc, PhD, a clinical associate professor of dentistry at the University of Michigan School of Dentistry, Ann Arbor, Michigan.

Four AO members have been recognized as recently earning the AO Certificate in Implant Dentistry. They are Yuen Lok Loretta Ching, BDS, MSD, assistant clinical professor, Department of General Dentistry, School of Dentistry, Loma Linda University; Jorge Mauricio Hervas, DDS, MS, who is in private practice and holds faculty positions at Nova Southern University; Robert H. Sattler, DMD, a general practitioner in a family private practice in Southampton, Pennsylvania, and Amerian D. Sones, DMD, MS, prosthodontist and AO Board of Directors Vice President.

Volume 14 Number 2

Dentsply Sirona invites innovative female dental experts to apply for this year’s Smart Integration Award Dentsply Sirona’s second Smart Integration Award competition is now open for entries. The competition underlines Dentsply Sirona’s commitment to the advancement of women in dentistry by showcasing and honoring their novel treatment concepts and ideas for the future. These include, for example, ideas on how to improve the treatment experience for patients during diagnosis and therapy or on how optimally networked and efficient workflows could look in the practices and dental labs of tomorrow. The award celebrates the achievements of women in dentistry. This year for the first time, not only female dentists but also female dental technicians are invited to apply by June 28, 2021, with their ideas for collaboration between the practice and the dental lab. A jury of Dentsply Sirona executives and renowned external experts will evaluate the entries. The award ceremony is scheduled for the end of the year 2021.

For more information, visit www.dentsplysirona.com.

GreenMark Biomedical Inc. secures FDA clearance for LumiCare™ Caries Detection Rinse GreenMark Biomedical Inc. has secured regulatory clearance from the U.S. Food and Drug Administration to market its LumiCare™ Caries Detection Rinse as a 510(k) Class II Medical Device. GreenMark’s LumiCare™ rinse enhances visualization of carious lesions (cavities and pre-cavities) by targeting and illuminating sub-surface porosities in enamel, thereby aiding in the detection of caries. The technology utilizes bioresorbable starch-based nanoparticles, which degrade due to enzymes in saliva by the time the patient is ready to leave the dental office.

For more information, visit www.greenmark.bio.

Enhanced visualization of dental caries is the first commercial application of startup venture’s nanotechnology platform

Implant practice 35

INDUSTRY NEWS

Anatotemp SC® teams with 3Shape to provide streamlined digital dental implant workflow

PRACTICE MANAGEMENT

Billing medical for cone beam computed tomography (CBCT) Rose Nierman says for patients and the practice it’s worth the effort to integrate medical billing

D

id you know that it is possible to bill medical insurance for CBCT? Many dental practices bill medical insurance for sleep apnea appliances, oral surgeries, TMJ orthotics, and diagnostic imaging services.

Medical billing in a dental office is a necessity, not a nicety

Due to dental insurance’s newer edicts to send specific diagnostic and surgical claims to medical insurers first, a basic level of medical billing knowledge in a dental office is a necessity, not a nicety. When the patient has medical coverage, patients are eager to utilize the benefit, and rightfully so!

The dental practice can benefit from medical billing for CBCT and bone grafting as charges for these procedures are commonly “left on the table” when dental coverage falls short. Medical billing can help to fill in gaps in coverage.

According to medical policies, CBCT may be supported for presurgical planning when plain x-rays alone are insufficient. If a panorex or 2D image is needed, preauthorization is typically not required.

Dental practices encounter many conditions daily that potentially demonstrate that CBCT or other imaging is medically necessary.

Dental to medical codes and policies for imaging

Some common indications for medical necessity • Partial or complete bony impactions, bony defects • Cysts, osteoitis, and jaw-related infections • Proposed implant placement near the inferior alveolar nerve or maxillary sinus • Proposed implant placement where there may be inadequate bone • Dental implants related to tooth loss from injury, trauma, or jaw pathology • TMJ disorder

Cross-codes from dental to medical for a panorex (CPT 70355) and computerized bilateral tomography (CPT 76102) are available. Another common dental to medical cross code is CT Scan, Maxillofacial (CPT 70486).

To reimburse for imaging, the medical insurer needs to know what condition or symptoms are present. To process a claim, medical carriers will need an ICD-10 diagnosis code — for example, ICD K01.1, for impacted teeth.

At Nierman Practice Management (NPM), we are frequently asked, “What is the first step to getting started with medical billing?”

According to Courtney Snow, teaching faculty at NPM’s Medical Billing in Dentistry Courses, “Once you examine the patient and have assigned codes, the first step is always to verify benefits with a patient’s medical plan. The great news is that you can find out in advance if a service is covered

Rose Nierman is a leading expert in crosscoding and medical billing in dentistry. For 30 years, Ms. Nierman has educated thousands of dental practices in medical billing and created the leading software system, DentalWriter™, which transforms specific questionnaire and exam data into medical necessity narrative reports and medical claims. Nierman Practice Management’s course CrossCoding: Medical Billing in Dentistry is available live or online. NPM’s Medical Billing Service streamlines medical reimbursement for dental practices. Contact Nierman Practice Management at contactus@dentalwriter. com, or call 1-800-879-6468.

36 Implant practice

The first step to integrate medical billing

by the patient’s medical plan!” Many dental practices find that a little bit of help goes a long way in helping patients receive lifechanging treatments, so it can be worth the effort. An area where NPM can help is by teaching offices not only the codes, but also the documentation needed for coverage.

With CBCT, dental implants, and obstructive sleep apnea being the fastestgrowing areas in dentistry, dental practices need to have all the possible tools in their toolbox to help patients make decisions to move forward with recommended treatment.

Offering financing options and checking into medical benefits make it far easier for patients to accept treatment. These strategies used in conjunction with patient motivation are highly effective ways to increase Figure 1: Medical insurance sample policy for potential indications oral surgery case acceptance. IP for imaging reimbursement Volume 14 Number 2

PRODUCT PROFILE

SMARTbase™ — for optimized esthetics (patent-pending) Douglas Wilkin, PhD, describes a system that achieves optimal outcomes for screw-retained restorations

T

he introduction of SMARTbase™ Engaging Ti-base Abutment System from Implant Direct allows clinicians to achieve optimal outcomes for screw-retained restorations. SMARTbase abutments are a new generation of titanium abutments (also known as Ti-bases) designed with ease of use in mind and offer a number of features that aid in allowing clinicians to achieve the most esthetically pleasing restoration.

What is SMARTbase?

SMARTbase is Implant Direct’s Engaging titanium abutment. SMARTbase abutments can be utilized in both digital and conventional workflows. Numerous benefits have been incorporated into the design — all developed to manage and facilitate restoration and to ease placement by the clinician.

Soft tissue management One of the main features is the proprietary SMARTbase Dual Hue anodization.

This feature combined with the SMARTbase Concave Profile enables management of both the shape and color of soft tissue. The SMARTbase abutment has a gold anodized stem, permitting the utilization of a translucent restoration material. In addition, the pink anodized-titanium base provides for superior blending with the gingival tissue removing the chance of any traditional gray coloring showing through the tissue, as may occur with other Ti-bases. The concave profile is standard on all SMARTbase abutments.

This profile mimics that of healing abutments, allowing for optimal tissue management. The concave profile allows for improved healing of the gingival cuff, adding an additional layer of protection against abutment visibility.

SMARTbase in tissue illustration

Size management SMARTbase has multiple collar heights and profile options available to ensure you get just the right size. The abutments are available in numerous heights and widths, encompassing practically every foreseeable restorative circumstance.

Position management Implant-supported crowns have traditionally been designed to be placed in a two-step procedure: First, the abutment is attached to the implant, and then the crown is cemented onto the abutment. This process can limit the esthetic possibilities of the restoration, especially within the posterior region, though admittingly, esthetics may not be as important in this region. Using SMARTbase helps overcome this issue.

With SMARTbase, the position of the screw-access hole is no longer an issue.

An additional feature of SMARTbase is the elongated screw-access channel incorporated into the abutment wall. This channel allows for off-angle differential placement of the screw-access hole within the crown, allowing this access hole to be repositioned if necessary. This can readily provide a muchneeded benefit for anterior restorations.

The SMARTbase Tool Access Postiion management 38 Implant practice

This feature in the abutment wall allows for a discrete screw-access cavity; this cavity

SMARTbase group

in the restoration can be placed up to 25° off-axis. This feature allows for numerous access points from the restoration to the screw-access cavity. The screw-access opening within the restoration must no longer be placed in contiguous line with the screw channel. For anterior teeth, this often would create an access hole within the labial surface.

With SMARTbase, the access hole can be placed at any angle of up to 25° off-axis.

This allows access to the abutment screw from any number of positions, allowing for improved esthetics, especially in the anterior region as the opening can be hidden on the lingual side of the prosthesis.

Does this system require special tools?

In short, yes. The off-axis characteristic of SMARTbase requires unique tools produced specifically to engage this abutment system.

The design of the SMARTbase together with these SMARTbase tools provides the freedom to reposition the screw-access channel from 0° to 25° and allows greater accessibility in the posterior region where space can be limited. IP This information was provided by Implant Direct.

Volume 14 Number 2

SMARTbase

TM

Beauty Done Better ADD A TOUCH OF BEAUTY TO YOUR DIGITAL AND TRADITIONAL WORKFLOWS

Ü Off-Axis Engagement: Improved Aesthetics and Greater Accessibility Ü Seamless Blend for a Natural Look Ü Available in a Variety of Cuff Heights and Widths Ü Simplify with Pre-Assembled “Floating Screw” Option

PATENT PENDING

CONFIDENCE YOU CAN AFFORD

TM

Copyright ©2021 All Rights Reserved. Product images are not necessarily to scale. Implant Direct, the Implant Direct logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Implant Direct. In order to improve readability, Implant Direct does not use TM/® in the running text. Implant Direct does not waive any right to the trademark or registered mark and nothing herein shall be construed to the contrary. For prescription use only. Caution: Federal (United States) law restricts this device to sale by or on the order of a licensed dentist. See Instructions For Use for full prescribing information, including indications, contraindications, warnings, and precautions. In an effort to protect patient care, Implant Direct strongly encourages responsible training and knowledge prior to the integration of new surgical and non-surgical techniques. AD-0011 Rev 06

www.implantdirect.com | 888-649-6425

ON THE HORIZON

Implant success and failure all at the same time Dr. Justin D. Moody reflects on a patient’s 2-year-old implant

S

eems everyone has a specific criterion for what success and failure looks like.

Some judge it on the implant health, others on the soft tissue condition, and yet others on the prosthetic outcome. Truth is that it should be a view of all three of these criteria, and the overall status can be several outcomes.

I recently took care of a patient from one of my referral doctors. Having placed this implant over 2 years ago, he sent the patient my way as he was unable to remove the screw from the TiBase and was afraid to strip the hex. The first issue is that we had a debonded zirconia crown from a stock TiBase, and my first thought is always why.

What was the “why” here? After 2 years, you would not expect this to happen. The answer is that the patient was eating some very sticky candy, so I will take this as the “why,” considering there were minimal cantilevers, and the position of the implant seemed to be good. Prosthetic failure for sure.

Next, we removed the screw and the TiBase from the mouth. The doctor was having an issue as there was debris inside the hex not allowing the driver to fully seat.

Once removed, we cleaned the internal hex with chlorhexidine and placed a healing abutment to allow the soft tissue to be impression-ready for the referring dentist. So we have a soft tissue win here as the biotype is thick with no disease.

Finally, let us look at the bone levels on the PA. After 2 years, we can see that bone has grown up over the platform switch bevel of this BioHorizons® Tapered Plus implant.

This is also a win as the bone levels have actually improved from the time of placement.

What’s next? Can we possibly prevent

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®.

40 Implant practice

Figure 1: BioHorizons Tapered Plus platform-switched implant in function for 2.5 years. Notice the bone levels and the growth all the way to the platform

Figure 2: Crown has debonded, and the TiBase is left in place

Figures 3 and 4: 3. Soft tissue biotype is nearly ideal at 3 mm thick with an absence of any pathology or disease. 4. BioHorizons wide healing abutment placed to restore the emergence of the soft tissue to allow for an ideal future impression

Figure 5: The image shows that the crown has come apart from the TiBase, and the screw was removed without damage to the implant. All new components are needed from this point forward

this from reoccurring? Yes, one solution that was suggested was a new screw-retained crown, this time with a full titanium abutment and full contour zirconia bonded to it.

Perhaps we should view or categorize our success and/or failures differently going forward to more accurately represent what is going on. IP Volume 14 Number 2

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

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

#AreYouAPro Not all products are available in all countries.

SPMP19231 REV A JUL 2019