Implant Practice US Winter 2021 Vol 14 No 4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews Winter 2021 – Vol 14 No 4 • implantpracticeus.com

PROMOTING EXCELLENCE IN IMPLANTOLOGY Cortex Dental Implants Bringing fully digital implant technology to the U.S. market

Maintaining the ability to place anterior implants immediately using the socket shield technique Dr. Joshua Nagao

Special section Influencers/KOLs

Practice profile Jarron Tawzer, DMD

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION CREDITS PER YEAR!

Winter 2021 - Volume 14 Number 4

EDITORIAL ADVISORS Jeffrey Ganeles, DMD, FACD Gregori M. Kurtzman, DDS Jonathan Lack, DDS, CertPerio, FCDS Samuel Lee, DDS David Little, DDS Ara Nazarian, DDS Jay B. Reznick, DMD, MD Steven Vorholt, DDS Brian T. Young, DDS, MS

have placed over 2,000 implants as a full-time practicing general dentist, and I must have used almost every system under the sun. Not to “toot my own horn,” but I am very comfortable just picking up a new system, reading the catalog, reviewing the surgical and prosthetic protocol, and letting it rip. However, that was not the case when I first started out. After my implant residency at Boston University, I was free-handing all of my implants and planning on mostly 2D images. Some cases kept me up at night thinking about the bone anatomy, fretting over vital structures such as the sinus or nerve position, or considering how I could achieve the optimal implant positioning esthetically as well as ensure seamless and functioning future prosthetic results.

Fully guided implant surgery When free-handing implant surgery, you hope that you have prepped your osteotomy and placed your implant in the best possible position for the future restoration. Fully guided surgery takes a lot of the “hope” out of the equation. In fact, this has been an absolute game changer for me and my team. With this technology, an implant placement or restoration is one of the least stressful procedures that I perform in my day-to-day practice. It is not uncommon for patients to be in and out of the chair in 30 to 40 minutes, sometimes less. They will say, “Wow, that was fast!” or, “Wow, that was so much easier than I expected!”

The learning never ends 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)

I recently traveled to attend coursework at the Cortex Training Institute, just outside of Mexico City, Mexico. This state-of-the-art facility provides international live surgical training, using the latest in advanced digital-planning software. For these cases, we used TRIOS® with the future prosthetic in mind, and we placed Magix® implants fully guided on those same live patients within minutes just the very next day. No matter how skilled I become at performing (and teaching) guided surgery, I try to remain in “learning mode.” When it comes to digital dentistry, there are always new things to discover and that I can start implementing in my practice on Monday morning.

Mali Schantz-Feld, MA, CDE (Managing Editor)

The more you do, the more you find

Lou Shuman, DMD, CAGS

As you gain more experience with implants, you will also become more comfortable with treatment planning and removing the barriers that are preventing your patients from saying “yes.” Your patients trust you, and they want to stay in your office. If you have to refer out, they may not move forward with treatment. So, having a CBCT is a huge advantage. I also tend to seek out products and systems that can specifically help to reduce and avoid patient trauma, treatment complexity, and potential complications. This is especially helpful for those patients experiencing high anxiety or those with pre-existing medical conditions.

A shot of rejuvenation I speak to a lot of dental professionals about avoiding the “hamster wheel” that ultimately leads to burnout. Burned-out dentists aren’t as efficient and as productive as they used to be. Like aloe vera to sunburn or like a shot of espresso when you are tired, so implant dentistry can be to your dental career. Too many times, dentists get stuck in the monotony of doing the same old thing over and over — for 40 years. This is a one-way ticket to burnout. Adding high-value procedures like implants will lift your energy, increase your production, and ultimately generate more revenue for your practice. When you add a new modality to your practice, it reinvigorates you, your staff, and your patients. Adding implants doesn’t have to be intimidating or overwhelming. In fact, with the proper training, you and your staff may find placing implants to be one of the most fun and rewarding parts of your daily practice. You will feel it, your staff will feel it, and your patients will appreciate it. Dr. Eric M. Block © 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.

Eric M. Block, DMD, CAGS, FICOI, is a full-time practicing dentist in Acton, Massachusetts; a husband; and a father of two kids. He is on a mission to help dental professionals across the country overcome burnout and anxiety. He is the founder and CEO of online dental marketplace, DealsForDentists.com, and is the host of the popular Deals for Dentists Podcast. Dr. Block’s first book, titled The Stress-Free Dentist: Overcome Burnout and Start Loving Dentistry Again, is available now.

ISSN number 2372-9058

Volume 14 Number 4

Implant practice 1

INTRODUCTION

A shot of rejuvenation

TABLE OF CONTENTS

Publisher’s perspective With a gladiator’s determination Lisa Moler, Founder/CEO, MedMark Media................................ 6

Clinical

Practice profile Jarron Tawzer, DMD

Endless aspirations

Case study Immediate implant placement and reestablishing vertical dimension Dr. David Salmassy illustrates a complicated implant placement with the MPI™ Molecular Precision Implant by Ditron Dental USA.....................20

Implant insights Novel bone allograft offers superior surgical handling and adaptability

Cover story Cortex Dental Implants Bringing fully digital implant technology to the U.S. market

Dr. Arun K. Garg restores a severely resorbed alveolar buccal plate via guided-bone regeneration (GBR)

................................................. 22

ON THE COVER Cover image of Dr. Eric Block performing implant surgery with Magix by Cortex courtesy of Cortex Dental Implants. Article begins on page 12.

2 Implant practice

Volume 14 Number 4

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TABLE OF CONTENTS Continuing education The five best dental job interview questions to ask — and two to avoid — to build an outstanding team Ali Oromchian, JD, LLM, offers suggestions to find out about your potential new hires without legal concerns..................................... 30

Continuing education

Maintaining the ability to place anterior implants immediately using the socket shield technique Dr. Joshua Nagao discusses placing an implant when there is a thin buccal plate or risk of fenestration following an extraction

Influencers/KOLs special section Dr. Edward Goldin...................... 34 Dr. Robert W. Emery ................ 35 Dr. Georgios A. Kotsakis......... 36 Dr. Chris Farrugia...................... 37

Product debut

On the horizon

35Newtons® FirstPlug® Screw Channel Barrier..........................38

Digital Pathway to your new smile!

Industry news.................39

Dr. Justin D. Moody says the future of full-arch implant dentistry is now

..................................................40

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Volume 14 Number 4

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PUBLISHER’S PERSPECTIVE

With a gladiator’s determination

“I

am a gladiator! Winter is my season. This is my time. I will not be denied. … I will add more value than anyone else. … Give me your fears, give me your limitations, and I’ll give you results. I am a gladiator!” — Tony Robbins Welcome to our winter issue! The above inspirational message by Tony Robbins sums up how our MedMark team approaches your practices, your patients, and your future. Our goal is to add more value than anyone else. Through our publications, we inform you about trends in dentistry and provide articles that can help you grow clinically and professionally. Our CE articles educate you, and our webinars and podcasts bring amazing opportunities for growth. Our marketing expertise Lisa Moler spreads the word to audiences that are searching for insights Founder/Publisher, MedMark Media from leaders like you. This is your time, and we want to give you results! Throughout 2021, you have pushed past fears and muscled through limitations. We were courageous, creative, tenacious, and bold. Our focus was on not only getting back to normal, but also setting and surpassing new goals. We have heard of many triumphs since the beginning of 2021 — not just reopenings, but how you grew this year — with new technologies and techniques that improved patient care and expanded your capabilities. We are honored and thrilled to be a part of your continuing process. Our cover story shows how the recently launched Cortex Dental USA combines innovative implant designs with a digital interface. This gives clinicians the ability to plan and place more implants even in difficult patients. Our CE by Ali Oromchian, JD, LLM, discusses the art of the interview — how to build an outstanding team while avoiding legal pitfalls. Knowing what not to ask is often as important as asking the right questions! In his CE, Dr. Joshua Nagao defines the socket shield technique. He gives practical advice on how this can benefit patients who have a thin buccal plate or fenestration after an extraction. Dr. A. Kuritsyn and colleagues explain how guided bone regeneration facilitates good primary stability and bone quality during the implant process. This coming year is going to be exciting. We are renewed, rejuvenated, revitalized, and ready to take the dental arena by storm. Winter is OUR season, and we are picking up the momentum for 2022 — ready to face the new year with a gladiator’s determination to empower our dental community! To your best success, Lisa Moler Founder/Publisher MedMark Media

Published by

PUBLISHER Lisa Moler lmoler@medmarkmedia.com DIRECTOR OF OPERATIONS Don Gardner don@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA, CDE mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com NATIONAL ACCOUNT MANAGER 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 SALES ASSISTANT AND CLIENT SERVICES Melissa Minnick melissa@medmarkmedia.com

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Toll-free: (866) 579-9496 www.medmarkmedia.com www.implantpracticeus.com SUBSCRIPTION RATES 1 year (4 issues) $149 https://implantpracticeus.com/subscribe/

6 Implant practice

Volume 14 Number 4

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 4

Pictures/images

Disclosure of financial interest

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

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

Tables Ensure that each table is cited in the text. Number tables consecutively, and provide a brief title and caption (if appropriate) for each.

References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques. Aesthetic & Implant Dentistry. 2000;1(1):92-96. (Online) Author(s). Article title. Journal Name. Year; vol(issue#):inclusive pages. URL. Accessed [date].

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

Proofing Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity. Articles should be submitted to: Mali Schantz-Feld, managing editor mali@medmarkmedia.com

Reprints/Extra issues If reprints or additional issues are desired, they must be ordered from the publisher when the page proofs are reviewed by the authors. The publisher does not stock reprints; however, back issues can be purchased.

Or in the case of a Book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide. London: Martin Dunitz; 2001. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

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

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

Implant practice 7

PRACTICE PROFILE

Jarron Tawzer, DMD Endless aspirations What can you tell us about your background? I grew up in Idaho, Utah, New Jersey, and Oregon. I was born in the middle of two older sisters and two younger sisters. I fell in love with sports as a child and especially football. In high school, I realized that playing in the NFL was very unlikely, so I began focusing on scholastics. I met my wife in college, and she has traveled with me through countless states pursuing my education and CE addiction. I graduated from Oregon Health and Science University (OHSU). After my 3rd year, I had completed all my clinical requirements, which allowed me to attend and participate in the specialty clinics. I got vast exposure to orthodontics, periodontics, endodontics, and oral surgery. I quickly ruled out any desire to further my education in ortho or endo. I was not only intrigued in surgery, but also fascinated in the life-changing aspect of restorations. I knew which direction I needed to navigate and continue on that same journey today.

When did you become a specialist, and why? I am currently working on my credentialing as an Associate Fellow with the American Academy of Implant Dentistry and as a Diplomate with the American Board of Oral Implantology.

Is your practice limited solely to implants, or do you practice other types of dentistry? I own a general practice that I purchased in 2016. It has seven operatories and eight staff members. When I bought the practice, no implants were being placed or restored. Since then, I have transformed my practice to focus on dental implants and cosmetic dentistry. We place a large amount of implants each month and do so in a crowndown approach allowing esthetics and proper function to dictate implant placement

Why did you decide to focus on implant dentistry? Implants are inspiring in their concept and practicality. Dental implants replace 8 Implant practice

Dr. Tawzer’s main lobby finished June 2021

root structures that have been lost and successfully mimic our natural oral condition once integrated and restored correctly. They require surgical skills while maintaining restorative ideology. I never get bored when doing implant surgery or surgery in general.

Do your patients come through referrals?

Our practice does no marketing or advertising. Our patients are referred by friends or family.

How long have you been practicing implant dentistry, and what systems do you use? I have been placing implants since 2015. I have placed many implant brands in my quest to finding what I love. I have personally placed MIS, Straumann®, Nobel Biocare™, Hahn™, BioHorizons®, Implant Direct™, MegaGen, and Zimmer. I currently place mainly MegaGen AnyRidge® and BioHorizons® (both of which I love).

What training have you undertaken? My genesis of my training in implantology began my 4th year of dental school. I finished all my clinical requirements after my 3rd year.

Jarron Tawzer, DMD

Consequently, I began shadowing, assisting, and even participating in the placement of implants with the oral surgery residents. I became enamored with the placement and restoration of dental implants. Once practicing, I instantly began attending every implant CE course I could find. My training included Straumann courses, WhiteCap Institute, Implant Pathway, and various others. I am currently in the process of credentialing as an Associate Fellow with the American Academy of Implant Dentistry and as a Volume 14 Number 4

Who has inspired you? The list of inspirations in my dental journey are endless. Dr. Justin Moody (Implant Pathway), Dr. Courtney Dee Venable, and Dr. Josh Nagao are a few that continue to inspire me daily. All my fellow mentors/colleagues at Implant Pathway inspire me as they continue to move implantology in the right direction. I am a firm believer that to be the best, you have to surround yourself with the best.

What is the most satisfying aspect of your practice? Patient satisfaction. Without a doubt, seeing patients smile with gratitude is the most satisfying aspect of what I do. It is easy to get distracted in the administration, financials, and stress of running a large and successful practice. Changing lives and seeing results make the difference.

Tawzer Dental staff

Professionally, what are you most proud of? I am most proud of the reputation and trust we have developed in our community.

What do you think is unique about your practice? My practice is always evolving. I continually change and/or alter the way things are done with the goal of progression. If I try something, and it doesn’t work, I switch. If something fails, I try to examine why. If something succeeds fantastically, I consider why. Change and progression are vital to dental surgery and healthcare as a whole.

What has been your biggest challenge? My biggest challenge is the quest to be literate to the ever-changing technology

One of seven operatories. Each operatory is designed as a surgical suite

Curb front, designed with separate entrance and exit for patient privacy Volume 14 Number 4

Waiting area/reception Implant practice 9

PRACTICE PROFILE

Diplomate with the American Board of Oral Implantology.

PRACTICE PROFILE

Dr. Jarron Tawzer and wife Whitney at Beaver Mountain Ski Resort

Top 10 favorites 1. Carestream IO scanner 2. Carestream CBCT 3. Penguin®/Osstell® ISQ 4. Acteon Piezotome® Cube 5. KaVo NOMAD™ intraoral X-ray 6. Aseptico implant motor 7. MegaGen AnyRidge® implants 8. Formlabs 3B printer 9. PRF centrifuge 10. DIT-USA Titanium PDL elevator set

Family picture

aspect of dentistry. Every day, implant dentistry is changing. New technology and materials are constantly evolving. It is a challenge to maintain and adapt to the advances. I feel an immense pressure to understand and learn new products, procedures, materials, protocols, and technology that all promise better results or ease of administration. Although many advancements accomplish what they claim, some do not.

What would you have been if you didn’t become a dentist? As the only boy in my family, I was destined to take over my father’s very successful construction business. Many thought I was insane for not continuing in the family business, but my heart was always rooted (no pun intended) in dentistry. Although dentistry has its ups and downs, I have never regretted my decision made long ago.

What is the future of implants and dentistry? I predict the future is to incorporate more technology and 3D printing. We have already implemented 3D printing of PMMA temporary prosthetics. I believe we will see many 10 Implant practice

Annual “doctors only” hunting trip

more products and equipment designed around immediate design and fabrication around implant prosthetics. I predict we will continue our advancement and incorporation of PRF/PRP membrane and graft. I would like more basic knowledge of implant dentistry among the general population. I still spend much of my time explaining basic concepts and fundamentals of dental implants that I hope will become more common knowledge in the future.

What are your top tips for maintaining a successful specialty practice? The top tips for maintaining a successful implant practice is to get educated and have

good results/treatment. Patients don’t usually complain about their bill if they love their results. I also believe good results can only come after a solid education and training.

What advice would you give to a budding implant dentist? Never stop learning and surrounding yourself with like-minded dentists. I would recommend starting with basic implant courses and advancing to more comprehensive implant placing courses. Every great implantologist that I associate with all began with their first implant placement.

What are your hobbies, and what do you do in your spare time? My wife and I have three daughters and one son. I love being outdoors. I love to ski, hunt, fish, and play outside with my kids. IP Volume 14 Number 4

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COVER STORY

Cortex Dental Implants Bringing fully digital implant technology to the U.S. market

ortex may not be a household name yet in the United States, but with the recent launch of Cortex USA, that appears likely to change this year. As a global leader in fully digital implant technology, the company, founded by a multinational consortium of dentists, surgeons, and engineers, combines innovative implant designs with a digital interface that takes the guesswork out of planning and placing implants. The result is the ability to plan and place more implants, even in difficult cases, with the confidence that the surgery will be a success. Cortex’s innovative tools and fully digital implant planning platform are part of the reason why it has established a strong foothold and sizable share in emergent markets around the world, and why in some regions, up to 90% of general dentists now offer in-house dental implant options to their patients. Having long been a favorite implant solution among dentists globally, as the firm enters the U.S. market, American dentists are now beginning to experience the speed and security that comes from implementing Cortex digital-guided surgery in their practice.

Figure 1: Dr. Eric Block performing implant surgery with Magix by Cortex

Engineering innovation improves outcomes Cortex manufactures all of its titanium implants and components in its 40,000-square-foot facility in Israel, which also serves as an international digital lab and training center. Cortex holds multiple patents for its unique and proprietary implant designs. In a series of force and torque tests performed by faculty at Goethe University in Frankfurt, Cortex’s patented conical connection showed no microgap between the implant and the abutment. This bold design approach has resulted in superior, long-lasting solutions built on a strong heritage of innovation and excellence. Cortex has also recently introduced the Magix™ self-drilling implant to global markets. Because Magix is self-drilling and self-tapping, it eliminates most of the traditional drilling sequence and can be hand-threaded almost all the way to final placement — conserving bone and reducing site trauma. The result is a faster, safer procedure that has proven to reduce postoperative complications and to ensure superior osseointegration. Magix is 12 Implant practice

Figure 2: Cortex Zero MicroGap Conical Connection (left) and Magix™ self-drilling implant (right)

FIgure 3: Cortex fully digital case planning for guided implant surgery Volume 14 Number 4

COVER STORY

Figure 4: Cortex digital implant planning

especially well-suited to patients who may have been delaying necessary treatment due to high-dental and -drill anxiety or in situations where a more complex procedure can be avoided because of its versatile body design and narrow apex.

A fully digital workflow yields improved outcomes in less time Cortex boasts a fully digital implant-

planning platform. From the first digital scan to the final placement, dentists can work in real-time with an in-house clinical staff and laboratory team to plan each and every Cortex implant case. AI-driven insights then reference thousands of similar cases performed worldwide, in order to assure the best patient outcomes. This end-to-end, integrated digital workflow, supported by a team of experts, ensures

that guided surgery with Cortex succeeds in diverse settings and patient groups, while reducing chairside procedural time by almost 50% versus other platforms.

An American footprint for a global firm The company’s new U.S.-based sales network and marketing team continues to expand, with representatives and clinical partners located in multiple markets, and a New Jersey-based customer care center. Thanks to careful inventory management and close coordination with a world-class supply chain team, Cortex USA has been able to avoid most typical supply interruptions and price increases even during a global pandemic. Leaning into this time of uncertainty, the company launched its American subsidiary with a new kind of business model in mind and with a focus on providing eyelevel support, expert clinical guidance, and cutting-edge digital resources to U.S. dental teams that want to enhance their skills and elevate their practice.

Meet the Cortex mentors Figure 5

Figure 6: Cortex Surgical Guide Volume 14 Number 4

Cortex USA insists that they do not work with “key opinion leaders,” in the most traditional sense. Rather, they have partnered with a growing roster of impressive clinical experts, who share the company’s vision and all serve on the team as on-call mentors for Cortex users. A group of resident clinical experts and network of digital lab partners assist in planning every Cortex case with a unique set of checks and balances navigating the entire work flow. Eric Block, DMD, CAGS, FICOI, The StressFree Dentist As the owner of Acton Dental Associates in Acton, Massachusetts, and author of the recently released book, The StressFree Dentist, Dr. Block has devoted his life Implant practice 13

COVER STORY to helping his peers overcome their stress, avoid burnout, and learn to enjoy everything that makes dentistry great. Dr. Block soon found that both his patients’ response to Magix and the ease and assurance in using guided surgery by Cortex to be a natural match for his stress-free approach. “When I use Magix, my patients are less stressed out about the surgery, and that makes the surgery more relaxing for me. The Cortex system is very unintimidating, and I plan everything I need digitally, including my surgical guide, which I print in the office overnight. That means there’s less time in the chair, way faster healing, and a completely next-level patient satisfaction with Cortex than with other systems. It’s great to see offices go from burnt-out to excited about Magix — most of them usually ask me to do another case with them right away.” Arturo Zarzar, DDS, MS, FAAIP, MAAIP, the International Educator Dr. Zarzar was born to teach, and he leads with both a genuine interest in his students and a strong passion for making a difference by helping to improve the quality of life for the underserved and underprivileged. As the founder and director of

Figure 7: Dr. Eric Block 14 Implant practice

the international Camarlengo Dental Institute (CDI), he’s taught hundreds of dentists around the world in live surgery and implant placement techniques. The 2022 CDI international live surgery training program will focus exclusively on Cortex digital case planning. “I have seen implant dentistry change lives,” Dr. Zarzar says. “It’s a wonderful feeling to empower dental teams and to help them bring such joy to their own communities through their work. Cortex guided surgery helps quickly accelerate that learning curve with a high level of confidence and competence. It’s the absolute best system I have used so far that can speak to a very wide range of users, both novice and expert alike. Simply put, the Cortex platform helps them become better dentists and prepares them for the future of standard care, which is fully digital case planning.”

Versatile enough for experts, reliable enough for novices Dr. Zarzar won’t train students using Magix until they’ve had the chance to learn with other implant systems. Why? “It’s too easy to use,” he explains. “I want them to learn how to do implants the conventional, harder way before they dive into a simpler, anatomic-biophysiological-maxillary friendly approach. It’s like how you teach people to use a conventional typewriter before you give them a computer. A dentist must first dominate the basics before starting with digital dentistry.” This combination of versatility and reliability is what makes Cortex an ideal product line for a busy, general dentistry practice. Even the most complex cases can now receive implant treatment in an office they

know from a dentist they trust. Meanwhile, general dentists can place implants secure in the knowledge that their work will be precise and long-lasting. “This is a different experience altogether for most dental implant teams,” affirms David Howlett, vice president of sales and marketing for the new Cortex USA business unit. “Cortex delivers a seamless, one-on-one support model that combines an advanced digital platform with real-time expert guidance, made available to all users. It meets an urgent need for dental practices that wish to accelerate their individual skillbuilding and to enhance their overall level of patient care, using globally-engineered solutions.” Expanding upon its already impressive product portfolio, Cortex will introduce a new branded intraoral scanner to global markets in late 2021, followed by an updated global AI reference library to provide virtual assistance and recommendations for every implant case. Cortex also has plans to break ground on multiple branded implant training facilities in the U.S. For more information about Cortex USA, call toll-free 866-GO-CORTEX, or email infoUS@cortex-dental.com. IP

Figure 8: Dr. Arturo Zarzar Volume 14 Number 4

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Surgical Kit CK-0060

CLINICAL

Guided bone regeneration (GBR) using InterOss®, an xenograft material in combination with autogenous bone blocks (puck technique) and autogenous bone chips Drs. A. Kuritsyn and M. Myroshnychenko, along with I. Borzenkova, discuss a clinical case with histological examination of obtained graft Purpose This case provides a histological examination of clinical cases demonstrating successful results during GBR. The main advantage of this approach is creation of the necessary osseous contour using an autogenous-derived round piece of bone block to hold and protect the augmentation. A combination of a mixture of InterOss® bovine bone (SigmaGraft) with autogenous bone chips in a 50-50 ratio followed by isolation with a resorbable collagen membrane (InterCollagen® Guide, SigmaGraft) makes it possible to obtain a high-quality augmentation. The results of the microscopic and morphometric examination of the biopsy specimen demonstrated the formation of a qualitative osteo-regeneration, proving the high efficiency of the treatment technique. This approach allows implants to be placed with sufficient primary stability and proven bone quality 4 months following GBR.

Abstract In most clinical situations for a successful and predictable treatment with dental implants, it is necessary to create an optimal volume of alveolar ridge. To accomplish this at the first stage or with immediate implant placement, bone grafting is performed in a horizontal, vertical direction. Guided bone regeneration (GBR) has been used in dentistry for over 30 years.1,15,17 A. Kuritsyn, PhD, is from Kharkiv National Medical University, Maxillofacial Department. He is the head doctor at the Dental Park Clinic in the Ukraine. M. Myroshnychenko, Doctor of Medical Science, is from the Kharkiv National Medical University. He is a Professor in the Pathological Anatomy Department. I Borzenkova is Head of the Pathological Anatomy Department at a public nonprofit organization of the Kharkiv District Council, Regional Clinical Hospital, Kharkiv, Ukraine. Disclosure: The authors have no direct relationship with SigmaGraft.

16 Implant practice

1A.

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Figures 1A-1C (left): The volume of bone in the area of the missing teeth (25 and 26) in the left upper jaw is insufficient for successful placement of dental implants with a long-term guaranteed result. It`s necessary to provide vertical bone grafting in the area of the maxillary sinus (sinus lifting) and horizontal bone grafting in the area of the vestibular bone wall of bone defect Figures 2A-2D (right): Figure 2A-2C. Clinicians used a trephine (with external diameter 9 mm) and piezosurgery for access to the sinus. 2D. The perforation of Schneiderian membrane was closed with resorbed suture material (Resorba Resolon 6-0)

Materials and methods The 37-year-old female patient is a nonsmoker without any bad habits and general pathologies. The volume of bone in the area of the missing teeth (upper left second premolar and first molar) was insufficient for placement of dental implants with a long-term guaranteed result (Figure 1). It was necessary to provide vertical bone grafting in the area of the maxillary sinus (sinus augmentation) and horizontal bone grafting in the area of the vestibular osseous defect with implant placement after 4 months of graft healing. CBCT controls were provided before and after each step of surgeries. Periodontal cleaning was provided for the patient and rinsing with chlorhexidine 0.2% before surgery. The operation was performed under local infiltration anesthesia (Ultracain® D-S forte, Sanofi U.S., Bridgewater, New Jersey) and intravenous sedation. A trephine with an external diameter of 9 mm was used along with piezosurgery for access to the sinus for sinus membrane elevation. The Schneiderian membrane of the maxillary sinus was elevated using curettes

for further bone grafting. A perforation of Schneiderian membrane was identified and closed with resorbable suture material (Resorba® Resolon™ 6-0 Osteogenics Biomedical, Lubbock, Texas) (Figure 2). InterOss bovine bone (size 0.25 mm1 mm) was mixed with autogenous bone chips in a 50-50 ratio graft and placed into the subantral sinus space for vertical bone graft.3,4,6,7 Autogenous bone chips were collected with a safe bone scraper (Geistlich Pharma, Princeton, New Jersey) from retromolar area of the mandible (Figure 3). The round autogenous blocks were harvested with a trephine from the line oblique external of the mandible. Splitting of the round block was accomplished with a diamond disk. The approximate width of round lamina (puck) was 1.5 mm-2 mm (Figure 4). The access to the sinus was closed with a round bone lamina (puck). The external diameter of trephine during access to the sinus was 9 mm, the same as the internal diameter of the puck. However, the puck was suitable for sinus closure (Figure 5). Volume 14 Number 4

3A.

CLINICAL

7A.

5. 4A.

7B.

6A.

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4B. 7C.

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Figure 3A-3C (left): Filling of subantral space of sinus for vertical bone graft. Clinicians used a mix of InterOss bovine bone with autogenous bone chips for bone graft. Autogenous bone chips were collected with safe bone scraper from retromolar area of mandible. Figures 4A-4C (right): Taking round blocks with trephine from linea oblique externa mandibula. Splitting of round block with diamond disk. Width of round lamina (puck) 1.5 mm-2 mm

8A.

8B.

8C.

Figures 8A-8C: 8B. 4 months after surgery bone graft. 8C. 4 months after bone graft

The next surgical step was formation of a new bony contour in the area of the horizontal defect. Round bone plates (pucks) were used for GBR. Pucks were fixed with microscrews (Jeil Medical Corporation, Seoul, Republic of Korea) at the required distance from the jaw, depending on the need to repair the defect (Figure 6). Filling of the defect around and under the installed round bone plates was performed using a mix xenograft (InterOss) and autogenous bone chips in the same ratio and previously mixed (Figure 3). The bone-grafted area was covered with a resorbable collagen membrane (InterCollagen Guide, size 30 x 40 mm) which was fixated with titanium pins (Figure 7).5,8,9,12,13 The main advantage of the collagen membrane is its ability to stretch. The membrane isolates the graft from soft tissue and maintains the shape of the new bony contour. The difference with the approach presented from Urban’s Sausage technique5 is that the new bony contour is supported by the round bone plates. This protects the area from muscle activity and chewing function and maintains a given shape during the healing phase of treatment.3,13,16 Volume 14 Number 4

7D.

Figure 5 (top left): Closing of access to sinus with round bone lamina (puck). External diameter of trephine during access to sinus is same as internal diameter of puck. However, the puck is exactly suitable for closing of sinus. Figures 6A and 6B (bottom left): Formation of a new bone contour in the aria of horizontal defect using round bone plates (pucks) for GBR. Pucks were fixed with screws at the required distance from the jaw, depending on the need to repair the defect. Figures 7A-7D (right): 7A and 7B. Filling the defect around and under the installed round bone plates using mix of xenograft and bone chips (50%50%). Figures 7C and 7D. Fixing of collagen membrane with pins. The main advantage of the membrane is its ability to stretch. The membrane isolates the graft from soft tissue and maintains the shape of the new bone contour. The difference of our approach from the Sausage technique of Dr. Urban is that the main factor in holding the new bone contour is round bone plates. These will protect muscle activity, chewing function, and maintain a given shape

10A.

10D.

10B.

10E.

10C.

10F.

Figure 9: Average density of grafted area is 905 (Hounsfield units)

The site is closed in two steps using mattress sutures and interrupted sutures without tension utilizing resorbable sutures (Resorba®Glycolon™ 6.0, Osteogenics) and Resorba Resolon 5.0 sutures. The sutures were removed after 14 days. Postoperative antibiotic administration was performed with amoxicillin at 1g each twice per day for 10 days. Following healing, the next surgery was performed 4 months post osseous grafting (Figure 8). After flap elevation, the screws and pins were removed, and implants were placed. Implants were NeoBiotech IS III, 4.0 mm x 10 mm (Pasadena, California) in the second premolar

Figure 10A-10C (left): 4 months after bone graft. Figures 10D-10F (right): Preparations of beds for implants with trephines for histological examination of bone formation using InterOss bovine bone in combination with auto bone chips after 4 months. 10E. Implant placement. 10F. Cores of bone for histological examination

area and a 4.5 mm x 10 mm implant at the first molar. The second molar was extracted during second surgery as it was deemed of poor prognosis. The width of the augmented bone was measured following site exposure, and volume and density of bone was checked with CBCT before implant placement. Implant practice 17

CLINICAL Osteotomy preparation was initiated using the trephine (diameter 2.5/3.5). This allowed removal of bone cores for histological examination (Figure 10).

Histological examination The resulting bone material was placed into a 10% solution of neutral formalin (pH 7.4) for 24 to 48 hours, decalcified, following generally accepted technique, and embedded in paraffin. From the paraffin blocks, serial sections with a thickness of 4-5 mm were made, stained with a hematoxylin and eosin picrofuchsin solution according to van Gieson. The slides were studied using an Olympus BX-41 microscope (Japan). The implants were exposed 2 months after implant placement with soft tissue management. A full gingival graft (FGG) from the palate was used for creation of sufficient keratinized tissue.

Results • CBCT examination before bone graft and 4 months after: In the area of the missing second premolar, a measuring of bone showed a height of 11 mm and width of 4.6 mm before surgery. Following surgery, the resulting height was 13 mm and width of 9.6 mm. • Average density of the grafted area was 905 (Hounsfield units). • Primary stability during inserting of the implants was acceptable with insertion torque of 35 Ncm at the second premolar and 25 Ncm at the first molar site. • CBCT 1 year after prosthetic placement showed a stable level of bone tissue around the implants, absence of inflammation in the maxillary sinus, and bone tissue of the alveolar process (Figure 11).

Results of histological examination Observational microscopy revealed osteo-regeneration, characterized by the presence of bone trabeculae, with connective and adipose tissues between them. The average value of the specific volume of bone trabeculae was 65.9%, connective tissue — 22.5%, and adipose tissue — 11.6%. The bone trabeculae were located chaotically and had different sizes. Some of the bone trabeculae formed anastomoses between themselves. The bone trabeculae were uniformly pink in color, which indicated good mineralization. Osteocytes were found within the trabeculae. On the surface of some osteoid trabeculae, osteoblasts were identified that had a polygonal shape and sharply basophilic cytoplasm. A few large multinucleated osteoclasts were found on the periphery of some osteoid trabeculae. 18 Implant practice

11A.

12.

14.

11B.

13.

15.

Figure 11A and 11B (left): CBCT 1 year after prosthetic placement. Figure 12 (middle top): Microscopic structure of the formed osteo-regenerate represented by 1) the bone trabeculae, 2) connective, and 3) adipose tissues. Hematoxylin and eosin staining × 40. Figure 13 (middle botton): Bone trabeculae are uniformly pink in color. 1) In the thickness of the trabeculae, osteocytes are determined. 2) On their surface – osteoblasts. 3) Hematoxylin and eosin staining, × 200. Figure 14 (right top): Connective tissue is defined between the bone trabeculae with the presence of polymorphic cellular in titration and vessels. Hematoxylin and eosin staining × 200. Figure 15 (right bottom): Dark red connective tissue fibers 1) between the bone trabeculae. Picrofuchsin according to van Gieson staining × 200

Connective and adipose tissues with the presence of vessels and polymorphic cell infiltration — represented mainly by lymphocytes, histiocytes, macrophages, and few cells of fibroblast series — were determined between the bone trabeculae. Connective tissue fibers were thinned in some fields of view, thickened in other fields that had a pink color when stained with hematoxylin and eosin, or dark red when stained with picrofuchsin according to van Gieson.18 Adipocytes of adipose tissue, when stained with hematoxylin and eosin, looked like roundoval colorless voids with the clear boundaries. The nuclei in adipocytes were localized at the periphery of the cells.

Conclusion The combination between xenograft and autogenous bone chips in a 50-50 ratio with round split blocks (pucks) allows achievement of enough volume and quality of bone for successful implantation. Round split blocks have a clear advantage for creating a new hard osseous ridge contour in comparison with PTFE membranes or titanium mesh. The results of the survey microscopy and morphometric examination of the biopsy specimen indicate the formation of high-quality osteo-regeneration, which proves the high efficiency of the treatment. This approach allows implants to be placed with sufficient primary stability and proven bone quality 4 months after GBR. IP REFERENCES 1. Buser D. 20 Years of Guided Bone Regeneration in Implant Dentistry (2nd edition). Quintessence Publishing: USA; 2009. 2. Khoury F, Hanser T. Mandibular bone block harvesting from the retromolar region: a 10-year prospective clinical study. Int J Oral Maxillofac Implants. 2015;30( 3): 688-697. 3. Khoury F, Hanser T. Three-dimensional vertical alveolar ridge augmentation in posterior maxilla: a 10-year clinical study. Int J Oral Maxillofac Implants. 2019; 34( 2) :471-480. 4. Simion M, Fontana F, Rasperini G, Maiorana C. Long-term

evaluation of osseointegrated implants placed in sites augmented with sinus floor elevation associated with vertical ridge augmentation: a retrospective study of consecutive implants with 1- to 7-year follow-up. Int J Periodontics Restorative Dent. 2004;24(3):208-221. 5. Urban IA, Jovanovic SA, Lozada JL. Vertical ridge augmentation using guided bone regeneration (GBR) in three clinical scenarios prior to implant placement: a retrospective study of 35 patients 12 to 72 months after loading. Int J Oral Maxillofac Implants. 2009; 24(3):502-510. 6. Fontana F, Santoro F, Maiorana C, et al. Clinical and histologic evaluation of allogeneic bone matrix versus autogenous bone chips associated with titanium-reinforced e-PTFE membrane for vertical ridge augmentation: a prospective pilot study. Int J Oral Maxillofac Implants. 2008;23(6):1003-1012. 7. Lee EY, Kim ES, Kim KW. Vertical augmentation of maxillary posterior alveolar ridge using allogenic block bone graft and simultaneous maxillary sinus graft. Maxillofac Plast Reconstr Surg. 2019;36(5):224-229. 8. Buser D, Witteneben J, Bornstein MM, et al. Stability of contour augmentation and asthetic outcomes of implantsupported single crowns in the esthetic zone: 3-year results of a prospective study with early implant placement postextraction. J Periodontol. 2011;82(3):342-349. 9. Kang DW, Yun PY, Choi YH, Kim YK. Sinus bone graft and simultaneous vertical ridge augmentation: case series study. Maxillofac Plast Reconst Surg. 2019;16(41):36. 10. Urban IA, Montero E, Monje A, Sanz-Sánchez I. Effectiveness of vertical ridge augmentation interventions: A systematic review and meta-analysis. J Clin Periodontol. 46(Suppl 21):319-339. 11. Khoury F, Happe A. Soft tissue management in oral implantology: A review of surgical techniques for shaping an esthetic and functional peri-implant soft tissue structure. Quintessence Int. 2000;31(7):483-499. 12. De Stavola L, Tunkel J. Results of vertical bone augmentation with autogenous bone block grafts and the tunnel technique: A clinical prospective study of 10 consecutively treated patients. Int J Perio Restorative Dent. 2013;33(5):651-659. 13. Khoury F, Tunkel J. Bone augmentation and soft tissue management. In: Khoury F, Antoun H, Missika P (eds.) Bone Augmentation in Oral Implantology. Berlin, London: Quintessence; 2006. 14. Khoury F, Keller P, Keeve PL. Stability of grafted implant placement sites after sinus oo r elevation using a layering technique: 10-year clinical and radiographic results. Int J Oral Maxillofac Implants. 2017;32(5):1086-1096. 15. Esposito M, Grusovin MG, Felice P, et al. Interventions for replacing missing teeth: horizontal and vertical bone augmentation techniques for dental implant treatment. Cochrane Database of Systematic Reviews. 2009. 16. Felice P, Esposito M, Scarano A, et al. A comparison of two techniques to augment maxillary sinus with the lateral approach: no grafting procedure vs an organic bone placement. Preliminary histological and clinical outcomes of a randomized controlled clinical trial. Clinical oral Implants Research. 2009;20:973(Abs 261). 17. Parma-Benfenati S, Tinti C, Albrektsson T, Johansson C. Histologic evaluation of guided vertical ridge augmentation around implants in humans. Int J Perio Restorative Dent. 1999:424-37. 18. Khalid AL. Eponyms in the dermatology literature linked to stains used in skin biopsies. Our Dermatology Online. 2013; 4(4):569-572.

Volume 14 Number 4

The macroporosity structure facilitate the osteogenesis and angiogenesis

The microporosity structure improve the attachment of bone-related cells on the scaﬀolds surface

Structure facilitating the interactions between scaffolds and cells Microporosity plays a significant role in enhancing the osteconduction of scaffolds

Office: (714) 525-0114

SigmaGraft, Inc.

Toll Free: (888) 499-0114

575 Sally Place

E-mail:info@sigmagraft.com

Fullerton CA 92831, USA

www.sigmagraft.com

CASE STUDY

Immediate implant placement and reestablishing vertical dimension Dr. David Salmassy illustrates a complicated implant placement with the MPI™ Molecular Precision Implant by Ditron Dental USA

atients don’t come to dentists just for implants. They come to us for teeth and smiles. Some want to use those smiles to improve their life. This female patient, MC, is 30 years old and had a history of traumatic dental experiences that resulted in an extreme dental phobia. She had not seen a dentist in almost a decade, and her teeth deteriorated to a state of disrepair, broken off at the gum line. Her grandmother, already a patient of the practice, brought her to the office, asking me to “fix my grandbaby.” MC rarely spoke and never smiled. We took digital photographs and sent them to ROE Dental Laboratory in Cleveland, Ohio, for a PreVu™ Smile Simulation. This simulation allows us to show the patient his/ her projected new smile at the outcome of treatment (Figure 2). Seeing the enhanced new smile before the implant procedure is like test-driving your new set of teeth. After

viewing her Smile Simulation, MC and her grandmother accepted treatment, and we continued the process — taking traditional impressions, making models, and making the required measurements. We captured the proper and necessary intraoral photographs and CBCT imaging. When the initial process was completed, we had a long-distance case-planning conference with ROE Dental Laboratory to

design the placement of the implants. From the chart records and the CBCT, we elected to use the CHROME GuidedSMILE process to fabricate a virtual prosthesis for the patient. The surgical and prosthetic guides were fabricated so that we could position the actual teeth with a high degree of accuracy. All information was input into the computer based on the bite registration and the models that we sent. MC’s dentition had some

Figure 1A: Imaging — the panoramic image produced from the CBCT

Figure 1B: Intraoral photo — pre-op of MC’s upper jaw David Salmassy, DMD, completed his undergraduate studies with honors at Carroll College in Helena, Montana, receiving a Bachelor of Arts degree with minors in mathematics and chemistry. He attended the University of California at Davis Medical School where he completed research in molecular genetics for his honors thesis. He received his DMD degree at Oregon Health Sciences University. Dr. Salmassy completed his surgical residency in Oral and Maxillofacial Surgery at the University of California at San Francisco. During his training, he also completed 1-year medical training in general surgery and training in anesthesiology. He practices exclusively in Auburn, California, and is part of the medical staff of Sutter Auburn Faith Hospital. Disclosure: Dr. Salmassy is not compensated by Ditron Dental USA and is not an officer, director, employee, or consultant for the company.

20 Implant practice

Figure 2: Shows Smile Simulation before and after

Figures 3 and 4: 3. Surgical guide mount has been affixed to the upper jaw after removal of bone. Also shows the bite plane used to secure the teeth in place. We have to ensure that is fixed first before going to the implant placement. 4. Implant surgical guide with a guide sleeve and the guide holes in preparation for implant placement Volume 14 Number 4

Figure 5: Using the surgical guide sleeves in the placement of the upper left posterior implant

components and the teeth, maintaining bone — an integral part of a successful implant. The design features on the MPI include the unique Spherical Helix Chamber, which captures blood and bone fragments for assisted osseointegration, and the beveled collar, which shifts the dental implantabutment junction inward away from the coronal bone, allowing you to achieve a platform-switching configuration that prevents coronal bone resorption. Additionally, the MPI offers an expanding tapered dental-implant body with a selftapping progressive double-thread design, which gradually condenses the boneenhancing initial stability. The double threads result in an efficient insertion rate of 2.2 mm per revolution of the dental implant. The MPI implant also has a single platform — one 2.45 mm dental implantabutment internal hexagon connection for all diameters. This is huge for my office. It simplifies the restorative platform and provides a consistency and interchangeability of parts. That means there are fewer parts and pieces to keep track of and less inventory to maintain. It is easier to swap pieces out because

it is one-size-fits-all, whether I use straight or angled abutments. The surgery went according to plan. First, we extracted 11 of MC’s teeth — Nos. 3, 5, 6, 7, 8, 9, 10, 11, 13, 14, and 15. This implant procedure was “life changing” for MC. When she returned for her post-op photos, she described a conversation that she had with her 15-year-old son after surgery. She said, “He kept staring at me. He didn’t realize that I didn’t have any teeth before. I didn’t smile, and I didn’t show him that I didn’t have any teeth. Now that he sees me talk like a normal person, and he sees teeth, he says it’s amazing.” She continued, “They are so beautiful. This is my biggest milestone in life other than having my children.” For me, implants are not just about speech, phonetics, appearance, and function, although those are all very important. We give a person back hope, self-esteem, and self-worth. The main reason that MC wanted her implants was her desire to return to the workforce. Before her surgery, she wouldn’t smile. In her post-op photo, she is beaming. It is very rewarding to see my patients get the smile of their dreams. IP

Figure 6: Surgical guide in place showing the placement of the implants through the guide

Figures 7 and 8: 7. Guide platform for placement of the prosthesis showing the multi-unit abutments in place. 8. The prosthesis on the guide platform and the alignment of the multi-unit abutments with the computer preplanned and pre-positioned access holes in the prosthesis

Figures 9 and 10: 9. Temporary cylinders attached to the multi-unit abutment. 10. Prosthesis in place and guide tubes in preparation for the placement of the bonding

Figures 11 and 12: 11. Bonding agent applied to the outside of the temporary cylinders to pick up the actual position of the teeth in the arch. 12. Closure sutures around healing sleeves

Figure 13: Immediately after returning the prosthetics to the mouth, attaching them to the multi-unit abutments Volume 14 Number 4

Figures 14 and 15: 14. Facial photograph showing the net increase in the vertical dimension and occlusion. There is a cotton tip applicator with a mark on the nose and a mark on the chin. The upper mark is the pre-op vertical dimension, and the lower mark is the postop vertical dimension. The VDO increased from 62 to 70. 15. MC 4 days after placement Implant practice 21

CASE STUDY

complicated aspects. Because her upper teeth were broken off so badly, her bite had become over closed. As a result, she had lost much of her vertical dimension, which needed to be reestablished. We needed to open up her bite 8 mm. MC also needed a bone reduction. Since she needed proper vertical dimension and height for the actual prosthesis, the apical end of the appliance had to be between 13 mm to 15 mm. Hence, we needed to reduce the bone to accommodate for these measurements. We chose the MPI™ Molecular Precision Implant System by Ditron Dental USA. The precision fit of the components and tight tolerances are very important to the long-term success of treatment. The implants’ MolecuLock™ technology uses a biomechanical dental implant-abutment seal designed to reduce microgaps. Microgaps are reduced to less than 0.05 microns, which eliminate microleakage and bacterial penetration. This is critical for a patient who does not have direct access to hygiene under a prosthesis. Also, the better the tolerance, the better the fit. This facilitates a lack of movement of the

IMPLANT INSIGHTS

Novel bone allograft offers superior surgical handling and adaptability Dr. Arun K. Garg restores a severely resorbed alveolar buccal plate via guided-bone regeneration (GBR)

llogeneic bone is favored by many implant surgeons for its convenience and unlimited availability, obviating the need for a second surgical procedure to harvest bone. Bone allografts are obtained from human cadavers through tissue banks that screen, process, and store them under highly sterile conditions. Because they are freezedried, the risk of antigenicity or disease transmission associated with cadaver bone is significantly reduced. Freeze-dried bone allografts are osteoconductive and osteoinductive and have the capacity to stimulate bone growth in areas where resorption has occurred and implants are needed. A variety of configurations are commercially available, including particulates, blocks, putty, and strips designed for extraction socket grafting, ridge and sinus augmentation, bone augmentation around implants, and repair of bony defects. Recently, a new freeze-dried bone allograft material was introduced by OsteoLife Biomedical in a form that provides superior handling and easy adaptability to any defect morphology. Allogeneic Bone Fluff™ is a novel allograft with a proprietary patented 100% freeze-dried bone allograft (FDBA) configuration. When dry, Fluff has the unique consistency of a cotton ball, making it extremely easy to pick up and deliver to the surgical site. When it is hydrated, Fluff handles like a putty and provides cohesion and volume without any of the extraneous carriers that are added to other putty materials commonly used in dentistry. The consistency holds together throughout the procedure without any breakdown or disintegration. Fluff combines the enhanced regenerative capacity of FDBA while maximizing the exposure of growth factors to cortical bone. It can be hydrated with sterile saline, Arun K. Garg, DMD, completed his engineering and dental degrees at the University of Florida and completed his residency at the University of Miami/Jackson Memorial Hospital. Dr. Garg served as a full-time Professor of Surgery in the Division of Oral/ Maxillofacial Surgery at the University Residency of Training Miami School of Medicine and as Director of the Program for 18 years. Disclosure: Dr. Garg is a volunteer clinical advisor for Osteolife Biomedical.

22 Implant practice

platelet-rich plasma, or the surgeon’s biologic solution of choice and yields highly predictable results. The following case demonstrates the unique properties of this innovative bone grafting material.

Case report A 55-year-old woman who underwent extraction of her six maxillary anterior teeth 5 years earlier secondary to tooth decay presented with a request for a fixed restorative solution. Her medical history was unremarkable with the exception of hypertension, which was well controlled with medication. The clinical exam revealed deep concavities at the buccal aspect of the maxilla. Cone beam CT showed minimal residual cortical bone particularly in the cervical region, ranging from 0.5 mm to 3.8 mm of the available width. A treatment plan was developed to restore the severely resorbed alveolar buccal plate via guided-bone regeneration (GBR) using allogeneic Bone Fluff and cortical bone particles hydrated with PRP and covered with a slow-resorbing collagen membrane. After a 6-month healing period, two implants would be placed in the maxillary canine positions, followed by 4 months of healing, leading to delivery of a six-unit fixed anterior prosthesis. The plan was accepted by the patient who then provided her written informed consent. Following local anesthesia of the buccal and palatal maxilla using 2% xylocaine with 1:100,000 epinephrine, a 15C blade was used to make a midcrestal incision from the mesial of the left first premolar to the mesial of the right lateral incisor. Intrasulcular incisions were made around the left and right and premolars along with release incisions at the base of the papillae of the second premolars. A full-thickness flap was elevated buccally and palatally to expose the anterior maxilla from the piriform rim to the apex of the palatal plate. Debridement of the graft site with a Molt curette and a No. 8 diamond bur under saline irrigation was followed by decortication of the buccal plate at the apical level of the bone with a No. 701 carbide bur. Meanwhile, cortical allogeneic Bone Fluff, which comes in the physical form of a cylinder (Figure 1), was sectioned into small pieces and hydrated with PRP to achieve a fluffy

Figure 1

Figure 2

Figure 3

cotton ball-like consistency and combined with a particulated cortical bone allograft. Once activated, the composite graft was applied to the vertically deficient buccal ridge (Figure 2) and then covered with a collagen membrane that had been soaked in liquid PRP to improve its handling and increase the number of growth factors at the graft site. The membrane was carefully adapted under the palatal flap and fixated with two screws. The flap was repositioned, and the site was closed with multiple single interrupted sutures and one horizontal mattress suture using 5-0 monofilament nylon suture material. Postoperative CBCT slices showed an immediate increase in the width of the ridge in the cervical region from 7.3 mm to 8.5 mm and in the central area from 11.1 mm to 12.1 mm (Figure 3). Allogeneic Bone Fluff™ is packaged in quantities of 1cc and 3cc and can be ordered direct from OsteoLife Biomedical (www.osteolifebiomedical.com). IP Volume 14 Number 4

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ne of the most frequent challenges in implant dentistry is maintaining the ability to place an implant immediately when there is a thin buccal plate or fenestration following an extraction, especially in the anterior segments. After an extraction, a cascade of events occurs that eventually leads to, at minimum, some resorption of the alveolus around the site. In the event of the complete loss of the buccal plate during an extraction, a contraindication to immediate placement is created. This makes the ability to maintain the anatomical structures around the extraction site an important skill for any practitioner who is currently placing implants. One advanced treatment method that has shown significant success in combating this scenario is the socket shield technique.1 This technique, first described in literature by Hürzeler,2 involves bisecting the root of a tooth and preserving a portion in areas of thin bone to maintain the periodontium and bundle bone of the site. Preservation of these structures will aid in preventing the collapse of the bone vertically and horizontally, inhibiting apical migration of the tissues, and helping the practitioner avoid additional grafting (both hard and soft tissue) procedures in the future, shortening overall treatment time for the patient.3 The following is a case report highlighting the step-by-step procedure that can lead to a successful socket shield.

Dr. Joshua Nagao, DDS, earned his dental degree from The Ohio State University, graduating first in his class clinically. While in Ohio, he received advanced surgical training working with a prominent oral surgeon in the area. Dr. Nagao is particularly passionate for dental surgery, including implant placements, sedation dentistry, and complex reconstructions. He is a faculty member and mentor at Implant Pathway, which focuses entirely on the surgical placement of dental implants. Dr. Nagao is an Associate Fellow in the AAID and is currently undertaking the process of becoming a Diplomate in the ABOI. Disclosure: Dr. Nagao does not have any financial interests in any of the products or brands mentioned in this article.

24 Implant practice

Educational aims and objectives

This self-instructional course for dentists aims to discuss placing anterior implants immediately using the socket shield technique when there is a thin buccal plate or fenestration following an extraction.

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: •

Define the socket shield technique

•

Recognize when the socket shield technique would benefit preservation and maintenance of bone after extraction.

•

Identify materials for utilization of the socket shield technique.

•

View digital planning that will benefit the socket shield technique.

•

Identify the poncho technique and its effect on periodontal tissues, overall patient discomfort, and site healing time.

Figure 1: Intraoral retracted of initial patient presentation

Figure 2: Initial panoramic radiograph

Patient presentation and history

cavity. Symptoms were limited to flossing. The tooth was diagnosed as nonrestorable due to the extent of the resorption.4 The diagnosis of the tooth was discussed with the patient, and it was mutually decided that having the tooth extracted and replaced with a dental implant would give him the best long-term prognosis of the site. As the patient is a dentist, he was adamant that he have a fixed temporary prosthesis for the site.

The patient presented as a 44-year-old white male who happens to be a dentist. His overall health is impeccable with no underlying medical conditions, medications, or other contraindications to surgical treatment. The patient reported that when he was 25 years old, he was involved in a baseball accident where he was head-butted during a game. Tooth No. 9 was subluxated with corresponding broken alveolus but was able to be retained after being reset and splinted. Subsequent radiographs had shown initial signs of external resorption, but the tooth had been asymptomatic until recently. The patient had noticed sensitivity during flossing, which started “a few years ago.” Pre-op CBCT and periapical radiograph show significant expansion of the resorption and exposure of the canal space to the oral

Treatment plan The plan for the case was to perform the socket shield technique on tooth No. 9, removing the clinical crown, sectioning the tooth, extracting the palatal portion of the root, and leaving the buccal segment to maintain the buccal plate. With a history of resorption, it was very likely that at least some portions of the tooth could be ankylosed to Volume 14 Number 4

temporization. If, for any reason, the tooth was unable to be used as a provisional, records were taken so that an Essix-style retainer could be fabricated. The patient was to receive the standard pharmacology protocol of 2g amoxicillin 1 hour prior6 and thorough rinse with chlorhexidine immediately prior to beginning to the procedure. Supplemental medications including 30mg Torodol and 8mg Dexamethasone would be given via IV access.

Digital planning Cross-section viewing of the CBCT allowed visualization of the thin buccal plate of tooth No. 9, confirming the decision to perform socket shield. The location of the implant was planned to the lingual aspect of the ridge as to allow space for grafting material as well as to keep the implant from touching the shield itself. The access opening of the implant was designed to be placed in the area of the cingulum to ensure the final prosthesis could be screw-retained. Once the planned location was satisfactory, a

maxillary arch intraoral scan was merged with the CBCT data in Blue Sky Plan® software. The software was used to create a surgical guide with the intention of creating the osteotomy with the guide and placing the implant freehand. Once digitally designed, the guide was printed using a SprintRay Pro 95 resin printer.

Procedure Preoperatory preparation Prior to beginning the procedure, treatment was overviewed with the patient, including risks, materials that would be used, and the timeline for healing. Consent for treatment was given, including specific consent for the use of biologics as indicated. The patient did not report any moral or religious aversion to any biologic materials. Preoperative records were taken that included intraoral photos and a sextant impression for temporary fabrication if needed. IV moderate sedation was utilized for the comfort of the patient.

Figures 3-5: 3. Periapical radiograph clearly showing the extent of the resorption present in tooth No. 9. 4. Cross section of CBCT where the intraoral cavity is in communication with the pulp space of the tooth to the lingual. 5. Digitally planning the implant position to reflect maximum bone stability and position of the access to the lingual to allow a screw-retained prosthesis

Crown removal and socket shield Approximately 3 ml of 4% septocaine with 1/100,000 epinephrine was administered to the anterior segment of the maxilla for local anesthesia. Once adequate anesthesia was achieved, the clinical crown of the tooth was sectioned from the root with the Acteon Piezotome Cube using the SL1 tip from the sinus lift kit. This tip, a flat diamond blade, was chosen because of its thin nature, which allowed minimal loss of coronal structure while offering effective cutting. This instrumentation also allowed atraumatic removal of the crown without damage to surrounding tissues or teeth.7 The entirety of the clinical crown was removed and set aside for temporization. The remaining root was leveled to the gingival level with the same instrumentation. Upon removal of the clinical crown, the MegaGen PET kit was used to perform the socket shield. First, the CBCT data was used

Figures 6 and 7: These images highlight the use of the Acteon Piezotome Cube for sectioning the clinical crown from the root. They also illustrate the ability to perform this portion of the procedure virtually trauma-free in regards to the surrounding tissues

Figure 8: This image shows the end result of removing the clinical crown that was set aside for temporization

Volume 14 Number 4

Implant practice 25

CONTINUING EDUCATION

the surrounding bone, so careful attention would have to be paid to remove as much of the existing root structure atraumatically. An Acteon Piezotome® Cube would also be used throughout the procedure to ensure atraumatic removal of the root sections. It was also crucial to remove as much of the root as possible as resorption could continue over time, even in sections of the tooth that currently did not exhibit resorption. A Straumann® BLX implant would be placed immediately in the area after performing the guided osteotomy. This implant was specifically chosen for a number of reasons — the primary being the aggressiveness of the thread pattern, which would contribute to a high primary stability.5 The buccal gap would be grafted with allograft sticky bone made with leukocyte- and platelet-rich fibrin (L-PRF) from the patient’s blood. Once placed, the initial stability of the implant would be checked with both torque value and Implant Stability Quotient (ISQ) and, if deemed stable, would be immediately loaded using the patient’s clinical crown for

CONTINUING EDUCATION

Figure 9: Result after use of No. 1 and 2 drills from the kit

Figures 10: Sectioning the tooth in to buccal and lingual sections. Resulting view after additional sectioning of the lingual portion into mesial and distal halves

Figure 12: The full shield once the palatal root was extracted and prior to any modification or trimming

Figure 13: Resulting site and buccal fragment following complete extraction of the lingual portions

Figure 14: Use of the No. 4 final smoothing bur

Figure 15: Crestal trimming and beveling with the No. 5 bur

Figure 16: Resulting final shape and S-curve bevel of shield

Figure 17: Fully seated resin printed guide

to measure the canal length. The Nos. 1 and 2 burs were then used to widen the canal space and allow for further instrumentation. Shaper diamonds (long shank diamonds with labeled measurements) were used to section the tooth along the long axis from mesial to distal, effectively creating two sections of tooth — a buccal and a lingual segment. The lingual portion was then further sectioned into mesial and distal halves for easier access for elevation. The lingual portions were elevated with great care to keep all pressure off the buccal segment, as displacement or mobility of that segment indicates abortion of the procedure and potentially ridge preservation only. Both lingual segments were retrieved with luxators and spade elevators only. The fragment of the buccal root that remained was thinned significantly and formed into a crescent shape with the round diamonds in the kit. Smoothing was then

completed with a finer cylindrical diamond. Once adequately thin (Han, et al., recommend less than 1.5 mm thickness8), the crestal portion of the buccal fragment was reduced in height to the surrounding bone level in an S-curve shape with the end cutting diamond (No. 5 bur). This shape creates a bevel on the lingual slope that offers an improved emergence profile, which is beneficial for the surrounding soft tissue.9

26 Implant practice

Osteotomy, grafting, and implant placement Upon completion of the shield preparation, the fabricated guide was used to create an initial pilot osteotomy. The osteotomy was completed and was expanded in a typical fashion under heavy irrigation and was left undersized to aide in primary stability. Typically, the implant is then placed and the “jump space” or buccal gap grafted, but the operator prefers to graft prior to placing the implant. The buccal portion of

Figure 11: Process of extracting the lingual halves atraumatically using luxators and spade elevator

Figure 18: Sticky bone complex made with Genate Blend™ and PRF collected from patient’s blood

the extraction site/osteotomy complex was grafted with BioHorizons® Genate Blend™, which is a 70% cortical, 30% cancellous allograft blend. This material was hydrated with PRF liquid to create sticky bone and other blood tubes used to create PRF membranes for later use. The implant was then placed with the implant motor to 40 Ncm and finished by Volume 14 Number 4

Figure 19: Final result from packing bone. Note the amount of space left for the implant to avoid excessive pressures when placing

Figures 20 and 21: Placement of the Straumann® BLX implant into the osteotomy

Figure 22: Placed TiBase and resulting emergence profiles

Figure 23: Scan abutment placed and shade selected in case a milled temp needed to be created

Figure 24: Space created in clinical crown for placement over titanium cylinder

Figure 26: Titanium cylinder opaqued and clinical crown picked up with minimal amount of flowable

Figure 27: Temporary complex picked up. Shown prior to cleaning and further manipulation

Figure 25: Occlusal view of adjusted crown placed over titanium cylinder to visualize orientation prior to pickup Volume 14 Number 4

“sealed” against the tissue.12 This technique has been reported to help maintain periodontal tissues, reduce overall patient discomfort, and accelerate site healing.13 The prosthetic screw was tightened to approximately 20 Ncm, and the access was filled with Gingitech™. Protrusive and excursive movements were checked for and completely eliminated.

Postoperative recommendations and follow-up care The patient was thoroughly instructed on care for the site, and avoidance of any function on the tooth was stressed. As the patient lived in a different state than the practitioner, he was left responsible for monitoring the area and reporting any abnormal healing or problems. Follow-up radiographs were taken of the area after 4 months of healing. The ISQ was taken in the patient’s office,

Implant practice 27

CONTINUING EDUCATION

Temporization A TiBase® and scan body were placed to create a milled temporary as a backup if the tooth itself could not be used or needed esthetic improvement. A titanium cylinder was placed and trimmed to an appropriate height. White opaquer was used to block out the underlying metal from showing through the prosthetic. A hole was created in the lingual aspect of the patient’s clinical crown approximating the path of draw of the titanium cylinder. This was widened and adjusted until the clinical crown was able to be placed in a natural position.

Once the position of the crown was acceptable, flowable composite was used to pick up the cylinder inside the hollowed tooth. A minimal amount of material was used to avoid displacement into the surgical site. The entire temporary complex (titanium cylinder and picked-up crown) was removed and cleaned thoroughly. Flowable composite was then used to approximate an ideal emergence profile, which included an S-curve profile on the buccal, which has shown to promote tissue health.11 Diamond burs and 3M™ Sof-Lex™ disks were used to complete the finishing of the temporary, and polishing cups were used to achieve a gloss finish. A “poncho technique” was used by folding a PRF membrane in half and placing the prosthetic screw completely through the membrane. Utilization of the PRF membrane in this manner allows the temporary to be

hand until the operator was satisfied with the position, depth, and stability. Resonance Frequency Analysis was then used to measure the ISQ via the Osstell Beacon. As the ISQ value was greater than 70, immediate load was considered appropriate.10

CONTINUING EDUCATION

Figures 28-30: 28 and 29. Temporary after adding flowable composite to create profile and finishing and polishing. 30. Temporary complex with PRF “poncho” prior to placement

Figure 32: Final PA of implant position and temporary prosthesis

Figure 31: Final position of placed temporary removed from all interferences. Tooth No. 8 was slightly adjusted after this photo to shorten the overall length slightly for esthetics

Figures 33 and 34: CBCT slice views and global position view of the final placement

and maintained levels over 70, indicating final restoration was appropriate. Photos were also taken by the patient in his office and reviewed. The gingival tissue showed a significant improvement from the preoperative condition. As the patient was referred to the surgical provider for placement only, he returned to his general dentist for final restoration.

Conclusion Expansion of a provider’s skill set to include advanced procedures like the socket shield can be an effective way to make treatment more predictable, faster, and less invasive. This procedure is something that a practitioner can effectively achieve with a solid surgical knowledge base, skill set, and the correct instrumentation. IP

REFERENCES 1. Kumar P, Kher U. Shield the socket: Procedure, case report and classification. J Indian Soc of Periodontol. 2018;22(3):266-272. 2. Hürzeler M, Zuhr O, Schupbach P, et al. The socket-shield technique: a proof-of-principle report. J Clin Periodontol. 2010;37(9):855-862.

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Figures 35 and 36: Comparing the gingiva preoperative (35) to postoperative (36) 4 months after healing. Note the improvement in the inflammation, specifically at the mesial line angle of the margin 3. Blaschke C, Schwass D. The socket-shield technique: a critical literature review. Int J Implant Dent. 2020;6(1):52.

8. Han C, Park K, Mangano F. The Modified Socket Shield Technique. J Craniofacial Surg. 2018;29(8):2247-2254.

4. Pinto L. External root resorption: diagnosis and treatment. clinical case report. J Dent Health Oral Disord Ther. 2018;9(2):160-164.

9. Kher U, Tunkiwala A. Surgical technique for socket shield procedure. Clin Dent Reviewed. 2020;4(1).

5. Menini M, Bagnasco F, Calimodio I, et al. Influence of Implant Thread Morphology on Primary Stability: A Prospective Clinical Study. Biomed Res Int. 2020;5:1-8. 6. Roca-Millan E, Estrugo-Devesa A, Merlos A, et al. Systemic Antibiotic Prophylaxis to Reduce Early Implant Failure: A Systematic Review and Meta-Analysis. Antibiotics (Basel). 2021;10(6):698. 7. Tsirlis A, Eliades A, Georgopoulou-Karanikola T, Vasiloudi M. A technique for atraumatic root extraction, immediate implant placement and loading in maxillary aesthetic zone. Oral Surg. 2014; 8(2):102-110.

10. Osstell®. 2021. The evidence-based Osstell ISQ Scale. [online] Available at: https://www.osstell.com/clinical-guidelines/the-osstell-isq-scale/. Accessed October 22, 2021. 11. Schoenbaum T, Swift E. Abutment Emergence Contours for Single-Unit Implants. J Esthet Restor Dent. 2015;27(1):1-3. 12. Cunha D, de Oliveira M, Ferreira H, Pinheiro A, Senna P. Poncho technique to seal fresh socket with platelet-rich fibrin in immediate loaded implant. Clin Oral Implants Res. 2018;29:388-388. 13. Sohn D, Kim H. Simplified Ridge and Extraction Socket Augmentation using Sohn’s Poncho Technique. J Implant Advanced Clin Dent. 2018;10(2):16-36.

Volume 14 Number 4

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $149; call 866-579-9496 or visit https://implantpracticeus.com/subscribe/ to subscribe today.

To provide feedback on this CE, please email us at education@medmarkmedia.com Legal disclaimer: Course expires 3 years from date of publication. The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

n To receive credit: Go online to https://implantpracticeus.com/continuing-education/, click on the article, then click on the take quiz button, and enter your test answers. AGD Code: 690 Date Published: November 30, 2021 Expiration Date: November 30, 2024

Maintaining the ability to place anterior implants immediately using the socket shield technique NAGAO

1. The socket shield technique, first described in the literature by Hürzeler, involves ________. a. bisecting the root of a tooth and preserving a portion in areas of thin bone to maintain the periodontium and bundle bone of the site b. repositioning the sinus floor c. using bone graft material to build up the ridge (alveolar process) prior to implant placement d. replacing an entire set of upper or lower teeth on only four dental implant posts 2. (For this patient) It was crucial to _________ as resorption could continue over time, even in sections of the tooth that currently did not exhibit resorption. a. remove the entire root b. remove as much of the root as possible c. retain as much of the root as possible d. remove a portion of the clinical crown 3. To perform the socket shield technique, first, the _______ was used to measure the canal length. a. 2D radiograph b. digital photograph c. CBCT data

Volume 14 Number 4

d. gutta percha 4. (For this patient during sectioning of the tooth) The fragment of the buccal root that remained was thinned significantly and formed into a ________ with the round diamonds in the kit. a. crescent shape b. round shape c. flat surface d. small convex shape 5. The buccal gap would be grafted with allograft sticky bone made with _______. a. mesenchymal stem cells b. calcium phosphate c. leukocyte- and platelet-rich fibrin (L-PRF) from the patient’s blood d. allograft bone 6. The location of the implant was planned to the lingual aspect of the ridge as to ________. a. allow space for grafting material b. keep the implant from touching the shield itself c. keep the implant in contact with the shield d. both a and b 7. The access opening of the implant was designed to be placed in the area of the

________ to ensure the final prosthesis could be screw-retained. a. nasopalatine canal b. cingulum c. mesial marginal ridge d. distal marginal ridge 8. Prior to beginning the procedure, treatment was overviewed with the patient, including _________. a. risks b. materials that would be used c. the time line for healing d. all of the above 9. A _______ was used by folding a PRF membrane in half and placing the prosthetic screw completely through the membrane. a. “poncho technique” b. “napkin technique” c. “tension flap” d. “scaffold technique” 10. The ISQ was taken in the patient’s office and maintained levels over _____, indicating final restoration was appropriate. a. 40 b. 50 c. 60 d. 70

Implant practice 29

CE CREDITS

IMPLANT PRACTICE CE

CONTINUING EDUCATION

The five best dental job interview questions to ask — and two to avoid — to build an outstanding team Ali Oromchian, JD, LLM, offers suggestions to find out about your potential new hires without legal concerns

hen you’re in the position of leading a company or charged with hiring a team to run a practice, you want to make sure you’re hiring the best possible candidates. However, when your business is a dental practice, it’s not only your financial success that’s a concern, but also people’s dental health and overall well-being. That’s why the job interview is essential to master — it‘s the key to bringing in candidates who can make your practice thrive. It can also be the roadblock that results in the construction of a lackluster team. To build a practice that consistently brings in loyal patients and provides quality care, start by focusing on the dental job interview. If you can master this first step in the teambuilding process, you’ll continue to build a solid foundation as your team grows. It’s essential to ensure the interview process is fair, nondiscriminatory, and most of all, legally compliant to avoid getting yourself and your practice in legal hot water. Keep reading to learn about the essential questions you should focus on during a job interview and which questions you should legally avoid.

Why the dental job interview matters The hiring process has always mattered for a dental practice. Choosing the right people to staff your team can make for a group of employees who work well together and help keep patients happy. Choosing the wrong people can make for an unpleasant Ali Oromchian, JD, LLM, is the founding attorney of the Dental & Medical Counsel, PC law firm and is renowned for his expertise in legal matters pertaining to dentists. Oromchian has served as a key opinion leader and legal authority in the dental industry with dental CPAs, consultants, banks, insurance brokers, and dental supplies and equipment companies. He serves as a legal consultant for numerous dental practice management firms that rely on his expertise for their clients’ businesses. He is also recognized as an exceptional speaker and educator who simplifies complex legal topics and has lectured extensively throughout the United States. To contact the author, please email ao@dmcounsel or visit www.hrforhealth.com. Disclosure: Mr. Oromchian is cofounder and Chief Executive Officer of HR for Health in the San Francisco Bay Area.

30 Implant practice

Educational aims and objectives

This self-instructional course for dentists aims to demonstrate the importance of the interview process in the dental industry to find quality hires.

Expected outcomes

Realize the importance of the hiring process and the regulations associated with it.

•

Recognize which questions dental professionals should avoid in the interview process.

•

Identify key questions to ask to find quality hires for dental practices.

and stressful environment both for colleagues and the patients they serve.1 However, the hiring process, including the job interview, is more important than ever because there is currently a shortage of dental job applicants post-COVID-19. In fact, according to ADA News from the American Dental Association, more than 80% of practices attempting to hire staff are currently finding the process either very challenging or extremely challenging.2 More than half of dental professionals even consider recruiting their most challenging HR issue.3 This means that dental practice owners or hiring managers are focusing on making their practice a desirable place to work. While a cohesive, kind, and qualified team may convince a candidate to join a practice, a disjointed, improperly trained, or unhappy team may turn someone away. Make clear in the interview process that you care about your team members and the overall culture at the practice. Allow team members to engage in open communication with candidates to ensure they receive an accurate picture of what to expect regarding the work environment and the role itself. Approaching interviews in this manner will yield more success and help you find the right, motivated, and qualified candidates you need to serve your patients.

The best dental job interview questions to ask candidates Now that you understand the importance of acing interviews in the dental

industry, let’s see which interview questions are the right ones to ask. To begin, start by making a checklist of the technical skills and soft skills (i.e., personal attributes needed for success such as time management and teamwork) desired as well as the level of experience and competencies you need. This makes it quick and easy to hone in on which candidates are options to consider, and which are not. You’ll also want to leverage the expertise of an HR specialist to manage the process of hiring a new team member for your practice. HR specialists are experts in interviewing and hiring, and they can ensure your process is legally compliant and effective. They can also identify both promising signs and red flags in a candidate that you may have overlooked due to a lack of interviewing or hiring experience. It’s also important to keep in mind that you can take time during the interview process to express interest in a job candidate and to make a potential new employee feel welcomed. The dental job interview is both a screening and recruiting process: You want to assess whether or not the candidates meet the requirements of the job description and if they are a good fit (i.e., they display those soft skills you desire). Once you have established that, you can determine if it is appropriate to engage them in further discussions that help attract the candidate to the role and your practice. The best job interview questions to ask a candidate for your dental practice follow. Volume 14 Number 4

How do you envision dentistry as we move into the future? This is an open-ended question. However, it can show you whether candidates see potential growth in the field, and if they’ve considered ways their position might change down the road. In a dental job interview, you don’t just want to know if someone has the right skills to perform day-to-day tasks. You want to see if candidates are thinking about a long-term career with your practice — or at least in the field. The answer candidates give to this question also gives you insight into the candidates’ ability to think creatively, to genuinely understand issues in the dental field and, more importantly, understand new ways dental professionals might be able to help solve those problems. Static thinkers can keep a practice static. Dynamic thinkers can help ensure that a practice continuously evolves, staying on the cutting edge of what dentistry has to offer. Finally, in a job interview, you want to see if the candidates are planning to be in the field for a long time, or whether the job you’re offering is just a stepping-stone. You want to boost retention as much as possible and minimize turnover, so candidates who Volume 14 Number 4

haven’t considered the future of dentistry might be giving a sign that you’re not in their long-term plans. How do you stay on top of the latest trends and news in the dental field? Similar to the previous question, this inquiry shows whether candidates are invested in the field and show the concrete ways they are doing so. To provide the best dental care possible, you need employees who are interested in how the industry is changing and improving. Again, dental job candidates who are thinking about the future of dentistry are likely to want to have a job in the field in the future. Those who are not may be thinking of this job as a temporary position on the way to doing something else. It’s important to keep an eye on this because it may be a sign that hiring them will lead to turnover, which is very disruptive and expensive for a dental team. According to a recent survey, 27% of employees in the dental industry will leave within 2 years of being hired.3 Have you previously worked in a stressful work environment? If so, can you describe a time when you performed well despite the stress you experienced? It’s no secret that working in a dental office can be stressful. This question can help identify if candidates are prepared for the stress that comes from working in a practice and how they might handle that stress. You want your candidates to demonstrate their competence and ability to remain calm when things get difficult. This is especially important because patients look to dental staff to calm them down when they’re scared or stressed. The professionals around them should be able to stay calm and avoid compounding stress in the office environment. Asking about stress management is also a window into your candidates’ emotional intelligence — a generally important quality to have when you’re working with patients and other team members. Have you experienced any failures in your career, and if so, how did they help you grow? This is another question that asks about the candidates’ weaknesses in a dental job interview — and it also allows you to see what mistakes they’ve made and, more importantly, how they have reacted when faced with a failure. You want new team members who can overcome any challenge, and who won’t get defeated if things become difficult.

This particular question gives some insight into creative thinking because candidates may reveal that they were able to come up with a clever solution to help improve their professional “failure.” Creative staff members are always exciting and motivating to have around, coming up with innovative solutions and forward-thinking ideas, which can help keep a practice growing and evolving as time passes.

Dental job interview questions to avoid asking any candidate The preceding questions are essential to ask in any dental job interview, as they allow you to examine candidates beyond their qualifications and achievements. The candidates can give you an idea of their quickthinking and problem-solving abilities as well as how they will interact with patients and colleagues. However, there are also some questions that you should never ask in an interview because they could get you or your practice in trouble. Many questions may seem harmless enough on the surface, but in reality they could be discriminatory or even illegal. Certain questions can also make your practice seem unappealing, which could drive away potentially great candidates in an already tough hiring market. So how do you avoid certain questions, while still finding out what you need to know about candidates? When interviewing dental practice candidates, make sure all questions are fair, nondiscriminatory, and solely based on experience or other job-related factors. Several questions that you should never ask in job interviews with dental candidates follow. What’s your current salary? While you can discuss salary in an interview if a candidate brings it up, it’s important to be aware of the state you’re located in, as many states have laws/restrictions around salary inquiries. Never, under any circumstances, should you ask the candidates what they make at their current job. Not only does it put the candidate in a weird position (allowing their potential employer to manipulate their offer based on what they currently make), but it’s a risky question legally, since many states prohibit it. If your candidates directly share their salary with you, that’s fine — but you’ll want to take note of the fact that they actively shared that info without being asked. Take this opportunity to redirect the conversation toward the topic of salary range for the particular role the candidates are interviewing for. You want to proceed Implant practice 31

CONTINUING EDUCATION

Why did you decide to work in the field of dentistry? Your field is a particular one: It has its perks and its drawbacks, and it offers very specific hours, benefits, and challenges. When you’re interviewing candidates, ask why they’re drawn to this particular field. This will give you insight into what they’re passionate about doing, how they want to spend their time, and how deep their knowledge of the field is. It is with these questions that you can get the candidates to talk about their education and previous dental work experience. All of the candidates’ experience should demonstrate purposeful steps toward making a decision to have a career in dentistry. When your candidates answer, listen for the qualities you are seeking. Do they align with the values expected of all employees at the practice? Do they like helping people? Do they have empathy for those in pain? Are they fascinated by the human body and innovative technologies being developed to help it? Alternatively, are they mostly focused on the paycheck? This is a question that reveals candidates’ true values and motivations and gives you insight into whether they’re in it for the same reason as the rest of your team. This can give you a clue into whether everyone’s values will align for a cohesive culture and shared interests.

CONTINUING EDUCATION cautiously and ensure your knowledge is up-to-date regarding salary questions. You don’t want to violate a law before you’ve ever even decided whether you want to make a candidate an offer.

Table 1: Interview questions to avoid and legal alternatives

Tell me more about yourself [insert personal protected information here]. A lot of personal information is legally protected in the professional realm. Candidates and employees are not allowed to be asked about certain topics, since they might be discriminated against based on these answers. These topics include things such as disabilities (including pregnancy), age, previous medical history, marriage status, and more. Essentially, job interviews should be strictly professional and should be solely focused on the job duties/competencies required for the role and candidates’ professional experience — both in the past and their goals for the future. Avoid all personal topics if possible unless a candidate brings something up — then you can simply listen and attempt to redirect the conversation. Following these guidelines ensures you won’t risk discriminating against candidates based on personal or protected information they shared with you. How much longer do you plan to work before you retire? While on the surface it makes sense to ask this question — after all you don’t want to hire someone and get them trained just so they can leave you a few years later — this could get you into serious trouble. Instead try asking “What are your long-term career goals?” This will help you understand where candidates see themselves in the future and hopefully give you an idea of if they plan to retire soon.

How to hone your dental job interview questions for interviews that work again and again Now that you understand what questions you should and shouldn’t ask during a dental job interview, you can get to work creating a standard list of questions for each position at your practice. After all, the questions shouldn’t vary based on the person — the answers will be what makes a candidate stand out and seem hirable. Once you’ve created a set list of questions for each position, you should return to that list every time you have to interview new candidates for that job to ensure consistency with your hiring process and to avoid claims of discrimination. The questions should be a good tool for revealing who you will hire, and who is not the best fit for your practice.4 If you 32 Implant practice

What not to ask

What to ask instead

Are you a U.S. citizen? What is your birthplace or national origin?

Are you authorized to work in the U.S.?

How long have you lived here?

What is your current address and phone number?

What religion do you practice?

What days are you available to work?

Which religious holidays do you observe?

Are you able to work with our required schedule?

How much longer do you plan to work before you

What are your long-term career goals?

retire? Do you have or plan to have children, or are you pregnant?

Are you available to work overtime on occasion? Can you travel?

If you get pregnant, will you continue to work, and will you come back after maternity leave?

What are your long-term career goals?

Do you have kids?

What is your experience with “x” age group?

We’ve always had a man/woman do this job. How do you think you will stack up?

What do you have to offer our company?

How do you feel about supervising men/women?

Tell me about your previous experience managing

Do you have any disabilities, handicaps, or mental conditions? What is the nature or severity of your disability?

Are you able to perform the specific duties of this position?

Have you had any recent or past illnesses or

Are you able to perform the essential functions of this job with or without reasonable accommodations?

operations?

teams.

already have a set list of questions, but realize you need to change up some of them, you can tweak the questions you already have. You don’t need to toss out the entire interview and start over! Here are some examples of questions that might seem discriminatory, but are actually useful — and fine to ask once tweaked. • “Do you have children?” might turn into “Are you able to meet the attendance requirements of this position?” After all, managers or bosses aren’t interested in whether a person has kids or not; they are wondering if there are life situations that will interfere with a candidate’s work regularly. • “How old are you?” can be shifted to “Are you over the age of 18?” You don’t need to know how old someone is for them to do the job; you only need to know that it’s legal for them to work for you. • “Are you religious?” can be shifted to “Are you available on weekends?” No boss needs to know potential team members’ religion. Bosses may only worry about religion because people who practice religion may be unavailable at certain times. So, ask about

the issue directly as it pertains to the requirements of the position — “Are you going to be available on weekends?” If they say yes or no, it doesn’t matter why. It just informs you about whether they have the availability to be at the practice on the days and at the times you need them to be there. Avoiding an expensive lawsuit and gaining peace of mind is easy when you follow the guidelines already discussed. IP REFERENCES 1. Wojcik S. Destress in the office with these 4 Tips for dental practices. HR for Health. https://www.hrforhealth.com/ blog/destress-in-the-office-with-these-4-tips. Published April 20, 2021. Accessed October 21, 2021. 2. Versaci MB. Understaffed and ready to hire, dentists face applicant shortages as they emerge from COVID-19 pandemic. ADA News. https://www.ada.org/en/publications/ada-news/2021-archive/june/dentists-face-applicantshortages-as-they-emerge-from-covid-19-pandemic. Published June 9, 2021. Accessed October 21, 2021. 3. HR for Health. Unnecessary Risk: The State of Human Resources Compliance in Dentistry. A Special Report on Private Practices, Dental Groups, & DSOs [white paper]. HR for Health: 2021. https://f.hubspotusercontent40. net/hubfs/5014795/DSO%20Whitepaper%202021.pdf Accessed October 21, 2021 4. Wojcik S. Provide Your New Dental Hire with 4 Essential Documents to Prevent Getting Sued [blog]. https://www. hrforhealth.com/blog/four-essential-new-dental-hire-documents. Published September 2, 2021. Accessed October 21, 2021.

This article is intended to provide general information and is not intended as legal advice.

Volume 14 Number 4

n To receive credit: Go online to https://implantpracticeus.com/continuing-education/, click on the article, then click on the take quiz button, and enter your test answers. AGD Code: 550 Date Published: November 30, 2021 Expiration Date: November 30, 2024

The five best dental job interview questions to ask — and two to avoid — to build an outstanding team OROMCHIAN

1. According to ADA News from the American Dental Association, more than _____ of practices attempting to hire staff are currently finding the process either very challenging or extremely challenging. a. 40% b. 66% c. 80% d. 92% 2. More than ______ of dental professionals even consider recruiting their most challenging HR issue. a. one-quarter b. half c one-third d. three-quarters 3. To begin, start by making a checklist of the _______ desired as well as the level of experience and competencies you need. a. technical skills and soft skills b. religion c. lowest salary d. attractiveness 4. With the question “How do you envision dentistry as we move into the future?” The answer candidates give to this question gives you insight into the candidate’s ability to _______. a. think creatively b. genuinely understand issues in the

Volume 14 Number 4

dental field c. understand new ways dental professionals might be able to help solve those problems d. all of the above 5. According to a recent survey, 27% of employees in the dental industry will leave within ______ of being hired. a. 6 months b. 1 year c. 2 years d. 5 years 6. Many questions may seem harmless enough on the surface, but in reality they could be _______. a. discriminatory b. illegal c. too difficult to answer d. both a and b 7. When interviewing dental practice candidates, make sure all questions are ______. a. fair b. nondiscriminatory c. solely based on experience or other job-related factors d. all of the above 8. Avoid all personal topics if possible unless a candidate brings something up

— then you can simply _______. a. tell the applicant a similarly personal bit of information about yourself b. listen and attempt to redirect the conversation c. realize that since the applicant started the topic, you can ask more personal questions d. stop the interview, and do not offer the candidate the job even if he/she is qualified 9. Now that you understand what questions you should and shouldn’t ask during a dental job interview, you can get to work creating a _______ for each position at your practice. a. list of questions depending on the applicant’s gender b. standard list of questions c. list of questions depending on the applicant’s age d. list of questions depending on where the applicant lives 10. Instead of “How old are you?” which may be construed as discriminatory, a more useful question would be __________. a. “Are you over the age of 18?” b. “How old are your children?” c. “What is your religion?” d. “Are you planning to have more children?”

Implant practice 33

CE CREDITS

IMPLANT PRACTICE CE

INFLUENCERS

SPECIAL SECTION

Edward Goldin, DDS Tell us a little about your background. I have been on the faculty at New York University (NYU) postgraduate prosthodontics program for 12 years and am trained in prosthodontics and implant surgery. I graduated from Columbia University College of Dental Medicine and did my postgraduate prosthodontics training and implant fellowship at NYU. My family practice was started by my grandfather in the 1930s. My father continued in the 1960s, and I joined in 2000. Now my daughter, a senior in high school, is talking about studying dentistry. She would be fourth generation!

How does someone achieve the status of key opinion leader/ influencer? First, you really have to love what you’re doing. When you go into the office every day looking forward to the next case, I think it brings you to a level where you can create excitement in other people. Influencers should be able to talk about their subject in a way that makes others excited about it as well. I teach residents at NYU. I see their cases as challenges and puzzles to solve. They see my enthusiasm when I get to treatment plan a new case.

You must have many choices of implant brands. Why have you chosen Ditron Dental implants as your implants of choice? For me to consider switching, the implant

must be not only less expensive than what I am currently using, but also better quality. I also look for a track record of successful osseointegration. I like implants with a simple connection. The implant should have many prosthetic options like angulated abutments, straight abutments, overdenture, or fixed components.

What features of Ditron Dental implants do you consider most valuable? Placing as many immediate-load and full-arch immediate-load implants as I do, primary stability is critical. For example, when I extract a fractured tooth, I want to do immediate implant placement and immediate provisionalization. The Ditron implant’s aggressive threads ensure that I will have good primary stability even when I place it into an extraction socket. Also, the implant’s geometry provides a uniform dental implantto-bone contact. I need to be confident that implants are going to be able to be loaded at the time of placement. Ditron implants have a simple and reliable internal hex connection. There is one 2.45 mm dental implant-abutment internal hexagon connection for all diameters. Ditron’s research found that platform-switching achieved with the implant-abutment connection prevents coronal bone resorption and promotes soft-tissue growth. The components fit together really tightly, preventing microleakage. Ditron calls that “MolecuLock™ biomechanical dental

To Learn More To learn more about Ditron Dental USA, schedule your virtual meeting today by visiting: DitronDentalUSA.com/lunchandlearn

34 Implant practice

implant-abutment seal.” It was designed to reduce microgaps to less than 0.5 microns — too narrow for bacteria to penetrate. Also, the aggressive thread design, called Double Stressless Sharp Thread (DSST), preserves the vascularity of the osteotomy and maintains the peri-implant marginal bone and soft tissue.

What advice do you have on how to keep current on the trends and changes in this rapidly evolving dental sector? Keep up with the current journals and monitoring social media is an important part of staying current. Teaching at NYU and being involved with the residents helps me to learn. When they bring me information, it forces me to research and find out more. I recently heard about new stackable guides — some technologies didn’t even exist 5 years ago. I also am on the clinic floor treating patients with the residents. So every student’s experience with me is different because we focus on a particular patient’s treatment. Today I treatment-planned a fullmouth implant case. Another patient had a congenitally missing tooth, and another needed dentures. The hope is that over the 3 years, each student will learn how to approach all of those types of cases — that is the goal of the prosthodontics residency.

Volume 14 Number 4

Dr. Robert W. Emery How do you relieve the stress of a busy practice/speaking schedule? The key is enjoying what you’re doing — whether it’s speaking, running a business, a dental practice, or a medical device company. I am a partner and team member in a group of really great people. The key to reducing stress is forming a good group of people, respecting their thoughts, learning from them, and problem-solving as a group.

What is a fun fact about you? My family is the most fun thing about my life. I always wanted children. I was married for more than 30 years. Then my wonderful wife passed away. I have since remarried, and now have two children. It’s loads of fun and also one of the most challenging things I’ve ever done. Anyone who has kids understands that. At my age, having a 6-month-old and a 22-month-old makes life exciting again.

How does someone achieve the title of KOL/influencer? First, you have to be able to be comfortable taking a risk. Second, you have to be comfortable socioeconomically. That does not mean you need to be wealthy. You need to be comfortable that your business is not going to be financially destroyed by your decisions. Third, you must believe in your message. For example, I believe in X-Nav, DTX Studio™, and the software programs that I work with, and the people I work with. So, they are really easy to talk about. You also need to be evidence-based and comfortable with the literature. I read extensively. And I am critical of my own decisions. I compare current and past literature, and if it all balances with my own decisions, then it’s easy to share that.

How does someone build/keep credibility in a world of many opinions?

How do you keep current on the trends and changes in this rapidly evolving dental sector? Prior to COVID, I enjoyed going to meetings. I talked to people whom I respected and then walked around to vendors. New ideas are hidden away at meetings in areas where not many people are paying attention. Read some of the less prominent articles in the literature and abstracts. I read science magazines that are unrelated to dentistry. I look at the trends. Right now, augmented reality (AR) and artificial intelligence (AI) are big deals. I try to relate concepts to what I am seeing in dental literature.

What do you think will be the most exciting development in the future of implants in the next 5 years? The next 20 years? In the next 5 years, AR and AI are going to affect dentistry. I look at some of the software already written by Nobel and DTX

software. Virtual treatment plans that put the teeth in place use amazing software. Obviously, X-Nav and X-Guide dynamic navigation are very powerful. I can actually operate on patients while keeping my head up and having proper ergonomic posture. As dentists understand the technology more, it’s going to create a giant change in their life. In general dentistry, clinicians will be able to cut preps for crown and bridge work and perform procedures that will be more efficient for their patients and easier for them. Robotics will shift from those with very large, almost industrial arms into smaller robots that consistently learn people’s habits. For example, if a smaller robot arm has AI, it can actually learn the dentist’s habits. This would allow it to become a perfect assistant. It is going to take time, but this is the future. Robots that perform simple tasks can make our lives better and easier. You can already see that with a company like X-Nav. I think that’s super exciting.

Learn More Learn more about the benefits of integrating DTX Studio implant planning with X-Guide navigation for a complete dental implant solution! Scan the QR code below or visit https://www.dtxstudio.com/en-us/x-guide.

You have to be evidence-based and outcome-based. If the literature is consistent and supports your message, that is key to credibility. Also, be willing to admit if something is wrong. Do your own research. Look at the questions and the clinical problems to solve those problems. Some of the best KOLs consistently do quality research or write quality articles that are based on the science. You also need to be a good teacher. Volume 14 Number 4

Implant practice 35

SPECIAL SECTION

INFLUENCERS

SPECIAL SECTION

Georgios A. Kotsakis, DDS, MS Tell us about your background I received my DDS from the University of Athens and then practiced in Athens, Greece. I completed my residency in Periodontics and MS in Science at the University of Minnesota when starting my peri-implantitis research. Now I am an Associate Professor of Periodontics, UT Health San Antonio, and Director of the ITI Scholarship Center. I am a Diplomate of the American Board of Periodontology and serve as a Graduate Faculty member in the Graduate School of Biomedical Sciences, UT Health San Antonio, and as an Affiliate Associate Professor in Global Health at the School of Public Health, University of Washington. At UT Health San Antonio, I direct the NIH-funded Translational Periodontal Research Lab conducting research on the biological mechanisms underlying peri-implant bone loss and developing novel treatments for dental and biomedical implants. I serve as an Associate Editor for BMC Oral Health, Frontiers in Oral Health, and as an editorial review board member for multiple prestigious dental journals. I practice Periodontics in the UT Health San Antonio intramural clinics with a focus on implant complications and peri-implantitis.

How do you relieve the stress of a busy practice/speaking schedule? The best stress reliever is chatting with my little ones after a long day at my practice. Toddlers have such amazing viewpoints about what’s important in life. My kids have helped me learn that the moment I walk through my home door, along with my shoes, I also remove any work-related stressful thoughts.

How does someone achieve the status of KOL/influencer? Being a KOL to me means that you have a passion for constantly asking “why,” and “how can we improve,” and sharing evidence-based answers to these questions with the community.

How do you build and keep credibility in a world of many opinions? It’s all about putting the time and effort to investigate the rigor and credibility of your opinions. Opinions are often empirical or based on someone’s perception of what may be true. However, because medicine and dentistry are driven by biology, all opinions must be put to the test through the scientific process to ensure their credibility. That’s the foundation of evidence-based dentistry.

As a researcher, where is your current focus regarding implants and regenerative products? My main research focus is on periimplantitis prevention and management. Dental implants are extremely successful, but there are no contingencies available when complications occur. We are actively pursuing the best treatment strategies for bone regeneration around diseased implants. Our team at UT Health San Antonio is currently conducting the first ever clinical trial on whether mechanical dental treatments may negatively affect peri-implant bone regeneration through the production of implant-derived titanium particles. We are assessing how osteostimulative bioactive synthetic biomaterials can restore implant surface cytocompatibility to allow

To Learn More To learn more about NovaBone® Dental Putty, visit https://osteogenics.com/.

36 Implant practice

re-osseointegration. This critical evidence will help us develop evidence-based guidelines for peri-implantitis treatment.

How do you keep current on the trends and changes in this rapidly evolving dental sector? I am part of the implantology literature reviews in our Periodontics residency programs, discuss new literature information during treatment planning, and constantly screen articles that concern our main research lines to stay up to speed.

What stands out as unique among the plethora of dental implant products and regenerative materials? Because regenerative materials have made great improvements in biological efficacy, a new area of interest is the enhancement of the delivery system to broaden or optimize biomaterial applications. For example, we recently leveraged the second-generation putty form of a bioactive alloplastic biomaterial that enables it to be dispensed from a uni-dose cartridge — much like some of the restorative materials commonly used in the dental office. By optimizing the cannula diameter to fit precisely at the 2.8 mm osteotomy, we leveraged this differentiated method of delivery to develop a simplified crestal sinus augmentations technique based on the hydraulic pressure distributed through the putty (NovaBone® Dental Putty) to the Schneiderian membrane. The expression of the material through the pilot hole creates a type of hydraulic pressure that elevates the Schneiderian membrane without trauma. This technique has now become a mainstream approach for simple, effective, and safe crestal floor elevation with excellent long-term data. Volume 14 Number 4

Dr. Chris Farrugia How do you relieve the stress of a busy practice/speaking schedule? Sometimes that is easier said than done! I believe that stress occurs only when your life is out of balance. Work is balanced by play, so for me, it’s a matter of creating sufficient time for recreation to balance out the time spent practicing, speaking, and teaching.

five-plus years. From a surgical/prosthetic perspective, I look for the in-office production of scan-based, same-day, custom CAD/ CAM implants in the short term. Further out, I think there will be some very exciting surgical/restorative solutions to edentulism based on advances in our understanding and utilization of stem cells.

What is a fun fact about you? Basketball was one of my favorite sports in high school. You would not guess this about someone that is a little over six feet in height, but I led the city of Pensacola in goaltending my senior year!

How does someone achieve the title of KOL/influencer? I think the designation of KOL/Influencer is achieved only by someone who has both accumulated enough knowledge through his/her own personal professional journey and has the willingness and time to share that knowledge with others, thereby influencing the professional journey of others.

How do you build/keep credibility in a world of many opinions? Credibility can only be built on honesty. There are some straightforward things that can facilitate building credibility: Keep it real, understand that you don’t know everything, be willing to say “I don’t know but I’ll find the answer,” and understand that any question may have multiple valid answers.

How do you keep current on the trends and changes in this rapidly evolving dental sector? Dentistry is evolving and changing at a tremendous pace. Materials, techniques, and technologies advance at an ever-accelerating rate. I’ve found that the only way to keep current is by voracious reading, maintaining a professional curiosity, always asking questions, and participating in as many CEs as you can.

Sign Up Today Surgical and surgical/prosthetic services are some of the most important aspects in the practice of dentistry. These services have a huge, direct impact on the quality of life of our patients. In addition to gaining the knowledge to provide these services, dentists must also learn how to be properly compensated for them while making them affordable for their patients. That is why a course like Medical Billing for the Surgical Dental Practice is critical to the success of dentists who perform these procedures in their practice. Sign up at https://thevivosinstitute.com/summit-club/ or learn more about Billing Intelligence Service at www.vivosbis.com.

What do you think will be the most exciting development in the future of implants in the next five years? The next 20 years? I think there will be many astonishing developments in dentistry in the next Volume 14 Number 4

Implant practice 37

SPECIAL SECTION

INFLUENCERS

PRODUCT DEBUT

35Newtons® FirstPlug® Screw Channel Barrier

hen Drs. Alexander Shor and Jim Janakievski met in graduate school at the University of Washington, they discovered many common interests. They shared a passion for landscape photography and a love of nature. As dental clinicians, they also faced many of the same challenges. Both had a profound interest in the field of implant dentistry. They realized that no ideal material specifically created for use as a screw channel barrier was available. The management of screw channels is critical in the life cycle of an implant restoration, and existing options present many limitations. For that reason, they cofounded 35Newtons®, and along with it, the FirstPlug® system — a medicalgrade polytetrafluoroethylene (PTFE) screw channel barrier and instruments. The company’s name was chosen for its meaningful significance to the implant process — the most common torque value for connecting a restoration to an implant is 35Ncm. Dr. Janakievski, a Tacoma, Washington-based periodontist, said, “Over the years, collaborating on patient care has helped us identify numerous clinical challenges. With the goal of creating a better workflow for clinical practice, we have worked together to develop solutions to overcome these obstacles.” Dr. Shor, a Seattle-based prosthodontist, concurred: “We needed an option that was elegant, usable, and affordable — all of these are very important factors.”

A medical-grade solution One of the most compelling reasons for creating the FirstPlug® system was the need the product met for quality standards for medical products. FirstPlug® properties are superior to commonly used materials and have been optimized for safe and efficient use in the dental office. “Many dentists are creative problem solvers and are lacking suitable alternatives; some have undoubtedly resorted to the local hardware store for an answer,” said Dr. Janakievski. “PTFE is the right material, but we feel strongly that implants and other sensitive dental procedures call for a medicalgrade option.” With FirstPlug®, there is no longer a need for industrial pipe thread tape (aka, Teflon™), cotton pellets, gutta percha, or silicone. And FirstPlug® can be autoclaved. FirstPlug® is made from PTFE that is made in the U.S.A. Material selection for covering implant abutment screws is important to limit leakage, which has been shown to negatively impact peri-implant tissues. “None of the common materials 38 Implant practice

The FirstPlug® system is a medical grade PTFE screw channel barrier and instruments

and techniques in use today were developed specifically for this procedure, and all have their drawbacks,” said Dr. Janakievski. For example, cotton pellets provide an ideal substrate for pathogenic oral flora to flourish, while gutta percha can be difficult to remove. “The ideal barrier material provides a good seal to limit leakage, is pliable, biologically inert, and easily retrievable,” said Dr. Shor. Every detail in the FirstPlug® system has been engineered to fit the clinical application. The cylindrically shaped plug seats easily in the screw channel without rolling or twisting. The patented medical-grade PTFE has the right compression characteristics for packing and sealing the screw access chamber, as well as sufficient stiffness to support the overlying restorative materials. The accompanying instrument set includes a Barrier Plugger™ for efficient packing of the PTFE plug, as well as a Barrier Excavator™ for easy removal when uncovering the screw to remove temporaries or replace a restoration. Dentists who have used the system have provided positive feedback. Some of the most popular features of FirstPlug® follow: • Efficient dispensing system saves chair time • Easy to pack and remove • Dense and strong material • A solid foundation for the overlying restorative material

• Avoids waste • Medical-grade material inspires confidence in safety and quality • Dedicated placement and removal instruments (Barrier Plugger™ and Barrier Excavator™) In addition to the optimized physical characteristics of the medical-grade PTFE material, FirstPlug® is manufactured, assembled, and packaged under strict medical-device protocols and quality systems. “Of course, FirstPlug® users appreciate the added convenience, efficiency, and clinical benefits,” said Dr. Shor. “But first and foremost, we hear from our dentists that sealing implant access channels with a medical-grade material, made in medical-class conditions, offers invaluable peace of mind.” In fact, 100% of dentists who tried FirstPlug® said they would use it in their own mouth should they require a dental implant restoration. 35Newtons® is bringing a much needed upgrade to the clinically sensitive task of filling access channels in screw-retained restorations. Drs. Janakievski and Shor are educators, speakers, and published authors who are focused on clinical excellence and innovation. That focus on clinical excellence for their own practices led to the development of FirstPlug®. Dr. Shor said, “We designed this product for ourselves. We were our own first customers.” Dr. Janakievski added, “We tested different versions, and when we were confident with the design, we knew we had to make it available to all of our colleagues.” Visit www.35newtons.com for more information. IP This information was provided by 35Newtons®.

Volume 14 Number 4

Panthera Dental welcomes Pierre Cantin to its team

Nobio Ltd., innovators in antimicrobial nanotechnologies, announced that John Scott has joined the company as Chief Commercial Officer. Scott, an experienced executive leader in the dental industry, will head up the company’s North American operations supporting Nobio’s award-winning infinix™ family of antimicrobial composites. As the industry’s only FDA-cleared antibacterial composite, infinix has been shown to significantly reduce demineralization, which is part of the decay process. The infinix line of advanced restorative materials was also recently selected as a Cellerant Best of Class Technology Award recipient for the second year in a row. For more information, visit www.nobio.com and www.infinix. com.

Panthera Dental has welcomed Pierre Cantin as Vice-President of Strategic Partnerships. His role will be to forge new collaborations and to be responsible for strategic partnership and international business development. Pierre Cantin has more than 25 years of experience in business development, business networking, and new market development. Panthera Dental is committed to designing and manufacturing state-of-the-art products using proprietary CAD/CAM processes, smart manufacturing, and superior quality materials to provide the highest quality outcomes. The company strives to deliver peerless solutions to dental, medical, and sleep professionals to improve patients’ quality of life worldwide. For more information, visit www.pantheradental.com.

Enhanced ultrafiltration technology makes dental office water safer

New developments at Dentsply Sirona Dentsply Sirona announced the official launch of DS Implants — its newly transformed and innovative business. DS Implants will harmonize successful brands such as Simplant, OSSIX, Axeos, Primescan, Atlantis, and MIS. Dentsply Sirona will also launch three new workflows to provide new solutions for dental professionals with a new way of practicing implantology. The workflows include a single tooth signature workflow, partial multiple tooth replacement signature workflow, and a full arch signature workflow — all addressing unique patient problems and offering efficient and reliable solutions. As part of the revamp, Dentsply Sirona is launching DS PrimeTaper, an integrated new implant system that offers excellent long-term stability, is easy to handle, and enables an efficient treatment workflow. Dentsply Sirona is also starting a clinical and registry study at Dentsply Sirona World. The registry study has been initiated aiming to involve more than 500 clinicians, placing over 2,500 implants for long-term follow-up. This will serve as a powerful tool to create scientific evidence and market insights from the daily use of the product by the clinician. For more information, visit www.dentsplysirona.com/en-us.

Volume 14 Number 4

Toppen Dental, an innovator in dental office disinfection and water treatment solutions, announces the launch of its UltraSafe™ ultrafiltration platform. UltraSafe provides a chemical-free answer to keeping dental unit water lines in compliance with CDC and ADA recommendations, protecting patients and staff from waterborne microorganisms known to cause disease. UltraSafe incorporates Toppen’s proprietary Energized Fiber Matrix™ (EFM™) technology that imparts an electro-adhesive charge to a specially adapted nanofiber filtration structure. The charged nanofibers form a barrier membrane that removes microorganisms, including bacteria, viruses, and fungi from dental office water. UltraSafe with EFM has been incorporated into a range of dental products. The line includes UltraSafe Micro Straws for chairside bottles and UltraSafe In-Line Cartridges, which can be connected directly to dental chair water lines. The UltraSafe Whole Office System treats multioperatory practices at the point of entry, offering staff convenience, practice efficiency, and significant cost savings. For more information, visit toppendental.com.

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INDUSTRY NEWS

John Scott joins Nobio as Chief Commercial Officer

ON THE HORIZON

Digital Pathway to your new smile! Dr. Justin D. Moody says the future of full-arch implant dentistry is now

o when you turn 50 (asking for a friend), you start to reflect a little where you were and where you are today in your career. Not so many years ago, I listened to presentations on the future of implant dentistry. For the most part, I just shrugged it off and said, “I’ll wait.” The wait is over! IOS systems are more accurate today, more available, and in some instances less expensive. I was recently at Dentsply Sirona World in Las Vegas where this technology was on display for all to see. Prior to recent years, the thought of being able to capture the vertical dimension, implant positions, and bite was unheard of. Having the great fortune of working with Dr. August De Oliveira has opened my eyes to the future of full-arch implant dentistry. Dr. De Oliveira began teaching these techniques at Implant Pathway — it’s dialed in, real, and repeatable. Using the Primescan™ from Dentsply Sirona makes this a very doable procedure for virtually anyone in the office. The key to the scanning is the use of liquid rubber dam material on the attached

Figure 1: Upper scan of the converted denture in place using the liquid rubber dam material to form the “squiggles”

Figure 2: Upper and lower implants scanned using the Dentsply Sirona Primescan showing the jaw relation after being aligned

Figure 3: Use of the Imetric photogrammetry domino scan posts to orient the implants

Figure 4: Dr. August De Oliveria using the Imetric to record the implant positions

Figure 5: Using the manual orientation feature of the Primescan to show how the 2 scans become overlaid 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 does not have any affiliation with Dentsply Sirona. He is a paid consultant for ProSmiles Dental Studio.

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Figure 6: Delivered upper and lower PMMA arches fabricated in one visit from ProSmiles Dental Studio

gingiva with what Dr. De Oliveira calls “squiggles.” This is the fiduciary marker that is used to orient the maxilla to the mandible so that the vertical dimension of occlusion (VDO) is captured as well as the bite. The technique calls for the scanning of the treatment prosthesis — in this case, the upper- and lower-converted dentures. It involves the scanning of the bite and then the scanning of the upper and lower arches without the prosthesis in place but rather the multi-unit caps, which are the scan bodies.

The Primescan allows the alignment of these to reflect what is in the mouth. We also scan the implants with the Imetric photogrammetry system to verify the implant positions. With this technique, we should be able to go from impression/scan to polymethyl methacrylate (PMMA) and then to the final if all works out. Imagine a full-arch world where we can go from impressions, to PMMA, to final in three appointments with no wax. It’s here. Thank you, Dr. August De Oliveira, for your willingness to share this. IP Volume 14 Number 4

CONELOG® PROGRESSIVE conical performance at bone level

CONELOG® connection benefits: • long conus for reduced micromovements1 • superior positional stability in comparison to other conical systems2,3 • easy positioning with tactile feedback • integrated platform switching • “vertical fit feature” designed to minimize vertical discrepancy during workflow

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

1. Hogg WS, Zulauf K, Mehrhof J, Nelson K. The Influence of Torque Tightening on the Position Stability of the Abutment in Conical Implant-Abutment Connections. Int J Prosthodont. 2015 Sep-Oct;28(5):538-41. 2. Schwarz F, Alcoforado G, Nelson K, Schaer A, Taylor T, Beuer F, Strietzel FP. Impact of implant–abutment connection, positioning of the machined collar/microgap, and platform switching on crestal bone level changes. CAMLOG Foundation Consensus Report. Clin. Oral Impl. Res. 2014; 25(11): 1301-1303. 3. Semper-Hogg, W, Kraft, S, Stiller, S et al. Analytical and experimental position stability of the abutment in different dental implant systems with a conical implant–abutment connection. Clin Oral Invest (2013) 17: 1017.

Not all products are available in all countries. BioHorizons® is a registered trademark of BioHorizons.

SPMP21097 REV A MAY 2021