Implant Practice US Spring 2022 Vol 15 No 1 by MedMark, LLC

4 CE Credits Available in This Issue*

Spring 2022 Vol 15 No 1

Company spotlight Envista

Soft tissue laser dental surgery basics

Peter Vitruk, PhD, MInstP, CPhys

implantpracticeus.com

Creating the ultimate implant practice An interview with Simon Oh — DDS, FICOI

Practical considerations for utilizing Prescription Drug Monitoring Programs — a primer Nikki Sowards, PharmD; Michael O’Neil, PharmD; and Tyler Dougherty, PharmD

PROMOTING EXCELLENCE IN IMPLANTOLOGY

SEE BEYOND

Digital Workflow & Guided Surgery

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with These Best-Selling Titles from Arun K. Garg Arun K. Garg Dr Garg, a nationally recognized dental educator and surgeon, is considered the world’s preeminent authority on bone biology, bone harvesting, and bone grafting for dental implant surgery. He is the founder of Implant Seminars, a leading dental continuing education company, and the Garg Foundation in the Dominican Republic, which offers state-of-the-art dental treatment to the community free of charge.

Dermal Fillers for Dental Professionals When helping patients with their facial esthetics, why stop at teeth? This in-depth clinical manual covers everything you need to know to provide dermal ﬁller treatment. 208 pp; 645 illus; ©2021; ISBN 978-0-86715-830-4 (B8304); US $168

Autologous Blood Concentrates, Second Edition With a focus on the science, biology, and clinical applications of RPR, this book is the practical manual novices need and experienced clinicians value. 184 pp; 520 illus; ©2022; ISBN 978-1-64724-083-7 (B0837); US $120

Full-Arch Implant Rehabilitation The FAIR prosthesis is immediate, ﬁxed, esthetically pleasing, highly functional, inexpensive, and maintainable—a life-changing innovation in implant therapy. 120 pp (softcover); 440 illus; ©2019; ISBN 978-0-86715-809-0 (B8090); US $89

CALL: (800) 621-0387 (toll free within US & Canada) • (630) 736-3600 (elsewhere) FAX: (630) 736-3633 EMAIL: service@quintbook.com WEB: www.quintpub.com QUINTESSENCE PUBLISHING CO INC, 411 N Raddant Rd, Batavia, IL 60510

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INTRODUCTION

Spring 2022

Volume 15 Number 1

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

Standing out in a crowded marketplace

he future of implant dentistry has never been brighter. With that being said, it has also become very crowded with more dentists providing some form of dental implant care. So how does one stand out in a crowded marketplace? Let’s start by understanding the real problem: As a profession we haven’t truly made it easy and desirable for patients to choose dental implant therapy. We have only scratched the surface of potential. Let’s look at some numbers. • 36 million Americans do not have any teeth. • 120 million Americans are missing at least one tooth. • 20 million teeth are extracted each year. • 3 million dental implants were placed in the United States in 2021. This should beg the question, Why are so few implants being placed relative to the massive opportunity? As an industry, we should be turning our focus to solving the problem of making dental implants more accessible. So what can we do as a profession to help make dental implants more mainstream? • Reduce the time from tooth loss to replacement tooth. • Reduce the number of visits involved with completing dental implant therapy. • Reduce the overall cost of tooth replacement with dental implants.

Solutions to make implants more accessible I have found the best way to reduce the time from tooth loss to tooth replacement has been emphasizing immediate implant placement at the time of tooth extraction. Of course, this requires having a site that is free of infection and with adequate bone. Advances in implant geometry that promote primary stability have made immediate placement possible in many more cases. For those who have struggled with immediate placement due to difficulty keeping the osteotomy and/or implant on trajectory, I would like to suggest the use of guided surgery. With 3D CBCT coming down in cost, implant-planning software has become easier to use; and in-office 3D printing, guided surgery has become a viable, if not ideal, option for dental implant therapy. Another way to reduce time and visits is to take the final impression at the time of implant placement. With the emphasis on digital dentistry, it is now more feasible than ever to take your final impression at the time of implant placement. Combine this with CAD/CAM fabricated screw-retained restorations, and you have a real-time and cost saver. Truthfully, the price of dental implant care is not the issue — it’s the affordability. Too many dental offices are not utilizing and consistently offering patient financing. Implementing a financial menu that clearly spells out the costs and payment options for patients has been a game changer for our practice. Modern-day consumers (our patients) are looking for payment plans — so don’t make it difficult to do business with your practice. There is no magic bullet when it comes to increasing the volume of dental implants in your practice. Instead it requires a cumulative, intentional, patientcentric approach. The end result will be significant.

© MedMark, LLC 2022. 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 Endodontic Practice US or the publisher.

Tarun Agarwal, DDS, graduated dental school from University of Missouri at Kansas City in 1999. In 2001, he founded Raleigh Dental Arts with the goal of building the preeminent dental practice in the Raleigh area. He recently built a training center within the practice dedicated to sharing his expertise. He is a recognized speaker, author, and dental leader and has been featured on CBS, NBC, ABC, FOX, and News 14 Carolina.

ISSN number 2372-6245

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Volume 15 Number 1

TABLE OF CONTENTS

PUBLISHER’S PERSPECTIVE

Don’t just survive — thrive!

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

COVER STORY

Creating the ultimate implant practice An interview with Simon Oh — DDS, FICOI Cover image of Dr. Simon Oh courtesy of Ditron Dental USA.

CASE STUDY

Full arch CBCT-guided implant reconstruction Dr. Ara Nazarian treats a patient from start to finish in fewer appointments..................................13

TECHNIQUE

Computer-guided surgery to restore function and esthetics in partially and fully edentulous patients: the FAIR protocol Dr. Arun K. Garg discusses an alternative treatment for edentulous patients....................18

CASE REPORT

COMPANY SPOTLIGHT

Envista Implant Practice US

Volume 15 Number 1

Using digital technology to simplify anterior implant restoration Dr. Mark Ludlow discusses how adding efficiencies to this implant procedure led to a satisfying result............................... 21

The leading Oral Surgery partnership group

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Our family of brands

TABLE OF CONTENTS

CONTINUING EDUCATION CONTINUING EDUCATION

Soft tissue laser dental surgery basics Peter Vitruk, PhD, MInstP, CPhys, sheds some light on the many applications of lasers

PRODUCT INSIGHT

Same-day guided surgery with robotics Dr. Joe Griffin discusses how Yomi® robotic technology has transformed his practice............. 38

PRODUCT PROFILE

Panthera Dental CAD/ CAM Sub Implant™: a new approach (part 1) Marc Desjardins discusses a new implant that is adaptable to specific bone morphology.......... 40

*Paid subscribers can earn 4 continuing education credits per issue by passing the 2 CE article quizzes online at https://implantpracticeus.com/category/continuing-education/

www.implantpracticeus.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your inbox by registering for our eNewsletter CONNECT with us on social media Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

Implant Practice US

Volume 15 Number 1

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PUBLISHER’S PERSPECTIVE

Don’t just survive — thrive!

Published by

hen preparing my first message of 2022, I was looking for inspiration. I found a quote by author Richelle E. Goodrich, which said, “Revitalized, I find the strength to battle new tomorrows.” She added, “This year, I survived. Next year, I will thrive!” Revitalization is a key to continuing to grow and prosper in the coming years. It means to give new life or vitality. Here at MedMark, revitalization is exactly what we concentrate on every day — for our readers, and our authors and, ultimately, for our patients. For our spring issue, our page design has changed. That is part of our revitalization. Our articles and topics will conLisa Moler tinue to motivate. But you will also find: Founder/Publisher, MedMark Media • Easier-to-read bold headlines and a humanist, more legible typeface • More color and a fresh color palette with new accent colors • More reader-friendly text and column width • More bookshelf-friendly size — the publication now is easier to store for long-term reference In this issue, we feature a CE by Peter Vitruk titled “Soft tissue laser dental surgery basics” that explores how the soft tissue laser can be applied in dental surgery and implant procedures. Take the quiz and receive 2 CE credits! Our cover story is a conversation with Dr. Simon Oh. Find out how he intends to inspire other dentists to innovate implant procedures, and how Ditron Dental Implants help him achieve that goal. Dr. Ara Nazarian’s case study illustrates a full arch CBCT-guided implant reconstruction. The procedure can help clinicians position themselves as providers who can fulfill surgical and restorative needs as well as the patients’ desire for fewer appointments. While we all are laser-focused on succeeding and expanding our options this year, we also should remember the importance of practicing empathy and kindness. Stories of these past 2 years of the COVID-19 pandemic taught us all that everybody has a personal and professional story that has deeply impacted their lives. Some share these challenges with the world, and some prefer to keep it personal, but in the light of what we have all gone through, part of the revitalization of 2022 will be to recognize that we need each other’s support to move forward. There are many ways to practice kindness in the dental world. Be a mentor to another dentist who has questions on technique or materials that work for you. Motivate a colleague who is just starting out or is restarting. Use your social media to be an inspiration. Call peers and suggest they read an interesting article that will help move their practice forward. Tell a few people in your personal life that you are proud of them. Revitalization means so much, especially this year, and MedMark is proud to be a catalyst for positive change. For our readers, our articles and webinars can help you gain or change perspective and move in new directions. For manufacturers and innovators, our marketing services can bring you the attention you deserve and the recognition you seek. Our motto this year is “Renew in 2022!” With our combined experience and insights, we can stride into the future together. For this issue, we put a new spin on the quote at the beginning of this perspective. “Last year, I survived. This year, I will thrive!” To your best success, Lisa Moler Founder/Publisher, MedMark Media Implant Practice US

Volume 15 Number 1

Publisher Lisa Moler lmoler@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 Sales Assistant & Client Services Melissa Minnick melissa@medmarkmedia.com Creative Director/Production Manager Amanda Culver amanda@medmarkmedia.com Marketing & Digital Strategy Amzi Koury amzi@medmarkmedia.com Digital Marketing Assistant Hana Kahn support@medmarkmedia.com Webmaster Mike Campbell webmaster@medmarkmedia.com eMedia Coordinator Michelle Britzius emedia@medmarkmedia.com Social Media Manager April Gutierrez socialmedia@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 Rate 1 year (4 issues) $149 https://implantpracticeus.com/subscribe/

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being delivered to the site safely lifts the Schneiderian membrane. Case image courtesy of Dr. Philip M. Walton

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

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

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COVER STORY

Creating the ultimate implant practice An interview with Simon Oh — DDS, FICOI What can you tell us about your background? I grew up in Maryland where I received my Bachelors of Science from the University of Maryland. After graduating with honors from the University of Maryland Dental School, I trained in oral and maxillofacial surgery at Hahnemann University Hospital and St. Christopher’s Hospital for Children. During high school, I enjoyed lacrosse and wrestling. I played trumpet in a jazz band and guitar in a rock band called InciDental.

What originally attracted you to the implant specialty? Seeing a patient’s transformation from not having teeth to having a brand-new set in a day appeals to me. My most rewarding patients previously have been turned down by multiple other surgeons or dentists. The clinicians say the patients’ cases are impossible to treat because of issues with the amount of available bone, but now there are special implants for people with insufficient bone. These implants can be placed in the cheek (zygomatic implant), in the pterygoid bone, or in the nasal area. We can use these in concert to fill patients’ needs. It is unconventional, but we have gotten positive results. Dr. Ole Jensen, a Brånemark award-winning oral surgeon, is one of the pioneers of these techniques. A close friend of mine, Dr. Robert Mogyoros, was one of Dr. Jensen’s fellows. So now Dr. Mogyoros and I are the only two dentists in the Philadelphia market who place these special types of implants. Dr. Jensen also introduced me to Ditron Dental implants.

What prompted you to try Ditron Dental implants? Dr. Jensen is the founder of Ditron Dental USA. He told me that Ditron was dentist-driven, dentist-oriented as well as

Dr. Simon Oh received his Bachelors of Science at the University of Maryland — College Park in Physiology and Neurobiology. He then graduated with honors at the University of Maryland Dental School, where he achieved the highest national board scores in his class. After finishing his dental education, Dr. Oh furthered his training in Oral and Maxillofacial Surgery at Hahnemann University Hospital and St. Christopher’s Hospital for Children. Here he received extensive training in conditions ranging from impacted wisdom teeth and dental implants, to major facial reconstructive surgery. Dr. Oh is also a published author in the Journal of Maxillofacial Trauma. Today, Dr. Oh serves as Chief Clinical Officer of ProSmile, one of the largest DSOs in the USA. As a Fellow in the International Congress of Oral Implantologists, Dr. Oh has special interest in extramaxillary dental implant surgery, the All-on-X full mouth reconstruction concept, teeth in a day, and bone regeneration. Dr. Oh lectures and trains doctors on implant surgery on a regular basis. Disclosure: Dr. Oh is on the advisory board of Ditron Dental.

Dr. Simon Oh during implant surgery Implant Practice US

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COVER STORY

Dr. Oh speaking to a patient and reviewing patient imaging

There’s one implant insertion driver and one abutment driver. It’s a condensed kit that doesn’t take up a lot of space.

dentist-focused. Since I trusted his opinion before, I knew that the products he endorsed were ultimately focused on helping the patients, not just the company’s business bottom line. That was super appealing to me. Besides practicing dentistry, I also oversee a group of 80 practices as Chief Clinical Officer and Chief of Implantology of the largest DSO in the region, ProSmile. I deal with a lot of implant companies. I have noticed a disconnect — many times there are no doctors making upper-level decisions. The businesspeople making those decisions don’t understand the nuances and subtleties that really make a difference. To dentists, it’s about the patient. We’re not there to help the implant company become huge. We want to deliver products that are best for patients. When I am on advisory board conference calls with Ditron, I have noticed there are more dentists on the call than businesspeople. I can relate to these colleagues and talk shop about implants, and the engineers can hear us discuss our needs. We help determine the fundamental nuances in the implants that will make a difference to patient care.

Why is the single platform system important to you? I have a high-volume full-mouth implant practice. At that level, inventory is a headache. You can end up having a hundred types of implants with a hundred abutment pieces, and that really adds up. With Ditron, all implant sizes share a common platform — a single 2.45 mm platform regardless of the diameter of the implant. It’s convenient, easy to use, and less inventory. It’s simple and seamless. My assistants and associates don’t get confused because there is only one answer. The “bottom line” of the practice ultimately has benefited from it.

What advice would you give to dentists starting with implants? My best suggestion is to get a lot of hands-on training to promote muscle memory. You can see fancy PowerPoint programs and understand the philosophy but not have the clinical skill to place implants correctly. Find a mentor who can teach you oneon-one. Also, develop your skills in another country in a clinic in a philanthropic way. In the Dominican Republic, many impoverished people can’t afford implants or other dental work. The clinic provides free care, and the dentists pay the clinic because they are learning. You can place many implants that way.

What is your biggest challenge in educating implant specialists? My approach is never to be pushy. Ditron implants speak for themselves. For example, colleagues see me using a sensible, practical system that works. With the one-size platform, there are no random parts and pieces like a lot of other implant kits. implantpracticeus.com

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COVER STORY

What is the future of implants? At some point, I think we will be 3D-printing customized implants. Ultimately, we will be able to scan a patient’s jaw, view the exact anatomy of the tooth, extract that tooth, and print an implant that is an exact duplicate of the tooth. Also, the future may hold regrowing teeth from stem cells.

How did you first learn about Ditron Dental USA? I vetted the implants from a factual standpoint and did some background research. I started placing them on patients, waited 4 months, and was very pleased with the results. I was impressed with the Reverse Concave Neck (RCN) of the Ditron ULT™ Ultimate implant. The main issue with implants is crestal bone loss — the bone loss where the gums meet the bone. This is the smartest version of the type of implant that will eliminate or reduce crestal bone loss. It is based off of new information. The microthreads on the Reverse Concave Neck create implantto-bone contact that resists axial loads. The decreased pressure on the cortical bone and lack of vascular compression preserve the peri-implant marginal bone and soft tissue.

Ditron is known for precision manufacturing. Why is precision important with implants? Ditron was founded to supply components for the aerospace and automotive industries. For aerospace and high-performance vehicles, a couple of microns can make a difference. And that is the same with implants. Bacteria can be 0.5 microns or larger; viruses are 0.2 microns. That’s where precision gets vital. Food, saliva, and bacteria can get stuck in the smallest opening where it multiplies and seeps out right at the bone.

Does that relate to the implant/abutment junction and peri-implantitis?

shoulder, hip, and knee replacements) are contained inside the body. With dental implants, we don’t have that luxury as they are exposed to the oral cavity. So precision is important to minimize bacteria. MolecuLock™ technology on the ULT implant ensures a tight implant-abutment connection that reduces microgap and microleakage. It protects crestal bone and soft tissue from the risks of peri-implant disease.

How does Ditron provide initial stability for immediate load? The Double-Stressless Sharp Threads (DSST) have an apical-coronal incremental thickness and a descending concave profile between the threads. The threads and extra groove allow for greater initial stability. Immediate loading is dependent on the initial stability of the screw. Having an implant that provides predictable high torque is a must in a full-arch implant practice. Without it, we wouldn’t be able to deliver loaded teeth the same day.

What about costs? There are companies that are riding the wave of having a recognizable big name that people pay for, but in many cases, the products have not advanced. Ditron is an excellent, high-quality, precision product for a reasonable price.

What are your hobbies, and what do you do in your spare time? Right now my main hobby is making sure my 2-year-old daughter and 4-year-old son don’t injure themselves. I like to travel when it’s safe. I have a very exciting new hobby. A few dentist friends and I purchased a distillery in Harrisburg, Pennsylvania, and started a rum business. We launched in July. Called Klyr Rum, it is an American-made and extremely smooth silver rum.

What is your future goal clinically?

Peri-implantitis is definitely an issue. Most implant types (ie.

My main intention is to raise the bar clinically. If I am going to be an influencer, I want to do excellent work with innovative implants to inspire other dentists. Ditron is doctor-driven and receptive to dentists’ and patients’ needs. That’s refreshing. That’s why I became a part of the advisory board. Dr. Jensen is one of the fathers of implant dentistry, so just being a part of the Ditron team is a breath of fresh air and tremendous opportunity for me, and I am grateful for that. I believe that Ditron implants will make the future of implants even brighter with all the dentist-driven innovations to come. IP

Dr. Oh during implant surgery Implant Practice US

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SEE BEYOND

Visit DitronDentalUSA.com to learn more

COMPANY SPOTLIGHT

Envista

nvista is a global family of more than 30 trusted dental brands, united by a shared purpose: to partner with professionals to improve lives. Envista helps its partners deliver the best possible patient care through industry-leading products, solutions, and technology. Our comprehensive portfolio — including dental implants and treatment options, orthodontics, and digital imaging technologies — covers an estimated 90% of dentists’ clinical needs for diagnosing, treating, and preventing dental conditions as well as improving the human smile. The Envista portfolio of brands is dedicated to supporting, expanding, and improving how dental professionals care for their patients. Focused on innovation and the future of the digital landscape, we provide quality products and solutions for the dental office and beyond. Our history of innovation includes some of the most wellknown dental imaging brands and products in the market, including GENDEX™, i-CAT™, DEXIS™, NOMAD®, OP 3D™, and more. These core imaging tools have become mainstays in dental offices over the years, but as dentistry continues to evolve, it is necessary to grow with it. As we look to the future of digital dentistry, we must answer one key question: How can we best empower dental professionals with a simple, seamless, and accessible digital dentistry workflow? The answer is DTX Studio™ suite and X-Guide®. The DTX Studio suite and X-Guide workflow gives you freedom to do what you do best — focus on your patients. DTX Studio suite simplifies your interaction with scans and images for each patient, and X-Guide enables same-day guided surgery, making every appointment more focused and valuable for everyone. There are three key components to the DTX Studio suite + X-Guide workflow: DTX Studio Clinic (Image Acquisition and Diagnosis) sets a new standard for dental imaging software by truly connecting the various aspects of a modern dental professional’s daily work, allowing for greater focus on the specific patient’s needs and

X-Guide 3D-Navigated Implant Surgery (X-Guide® is a registered trademark of X-Nav Technologies)

driving continuity of care for every dental appointment. It serves as an open-image acquisition software for multi-brand imaging devices, allows for streamlined workflows with acquiring IOS datasets, and enables open import and export of the most-used dental industry file formats on both Windows and Mac. As a multimodality viewing software, DTX Studio Clinic intelligently combines 2D and 3D, X-Ray and optical datasets for an up-to-date imaging file in all stages of the diagnostic and treatment process. DTX Studio Implant (Implant Planning) plan implants for major implant systems according to the patient’s anatomy and prosthetic requirements during the first visit. Turn the plan into reality by using a surgical template or X-Guide 3D-navigated implant surgery. X-Guide (3D-Navigated Implant Surgery) is like a GPS for your drills and implants! X-Guide is a dynamic 3D navigation system that delivers real-time interactive guidance of drill position during surgery, giving you the ability to improve the precision and accuracy of implant position, angle, and depth. X-Guide is clinically proven to significantly improve accuracy, when compared to freehand implant placement. It also allows for direct visualization of the surgical site at all times, even in patients with limited mouth opening. The combination of DTX Studio suite and X-Guide is a real game changer for the implant industry. DTX Studio suite is not just another piece of dental software; rather it is a comprehensive digital workflow solution that simplifies and empowers the image acquisition, diagnostic, and treatment planning process. DTX Studio suite helps you build patient trust and gain case acceptance, while also enabling efficient communication with partners and driving predictable treatment outcomes. Now with the X-Guide workflow, you can truly enable same-day guided surgery and dynamically execute your implant plan without the need for surgical templates. At Envista, we are a partner for your practice, driven by a singular purpose of mind: to help you do what you do best — provide exceptional care for your patients. With the industry’s deepest expertise and broadest portfolio of innovative solutions, we meet a diverse range of needs for an equally diverse range of practices, doctors, and patients. There’s one thing our products and our people have in common — an unwavering focus on your success. IP

Comprehensive Imaging View in DTX Studio Clinic

This information was provided by Envista.

Implant Practice US

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CASE STUDY

Full arch CBCT-guided implant reconstruction Dr. Ara Nazarian treats a patient from start to finish in fewer appointments

hen a patient presents to your dental practice with questionable and/or non-restorable teeth requiring full-mouth extractions, the biggest concern is whether implants can be placed at the same surgical visit and, if so, whether patients will be able to walk out with fixed teeth. Having an implant within your practice, which allows you to load or progressively load so that these patients’ demands are met, lets you position your practice to a whole new level. Of course, certain parameters must be met in order to facilitate this type of treatment. This includes, but is not limited to, the quality and quantity of bone, the presence of infection, the patient’s health, and the skills of the dental provider. Additionally, the selection of the most appropriate materials for the most ideal situation must be met. A patient presented to my practice for a consultation wanting to restore her upper dentition to proper form and function (Figures 1 and 2). She complained of generalized discomfort in these upper teeth apparently due to advanced decay as well as some periodontal disease. Although her lower dentition would require definitive treatment in the future as well, the patient wanted to focus on her upper teeth at the moment.

The treatment plan was the further developed. Diagnostic model impressions were taken using Silginat® (Kettenbach USA) polyvinyl siloxane impression material, poured up and forwarded to the dental lab. These models were then mounted on an articulator (Stratos 100, Ivoclar Vivadent) for further analysis in order to meet the patient’s esthetic and functional needs. Financing options using a third-party payment option (Alphaeon Credit) were discussed with the patient. This discussion was a very important part of facilitating acceptance of her care, since it made the cost of treatment more feasible.

Figures 1 and 2: 1. Preoperative retracted frontal view. 2. Preoperative occlusal view

Planning The clinical evaluation included information regarding lip length and support, existing tooth position of the natural teeth, occlusion, restorative space, and phonetics. In addition, digital images of frontal, side, and occlusal views of the dentition as well as facial shots were captured with a Nikon D7200 (Photo Med). A CBCT scan and panoramic radiograph using the CS 8100 3D (Carestream Dental) (Figure 3) were taken to accurately capture the information needed to properly treatment plan this case ensuring the most ideal outcome, especially since the patient had discussed how disappointed she was with her existing smile. Dental implants were virtually planned, using the CS 3D-imaging software, in key positions in the maxillary arch (Figure 4).

Figure 3: Preoperative panoramic radiograph

Ara Nazarian, DDS, DICOI, maintains a private practice in Troy, Michigan, with an emphasis on comprehensive and restorative care. He is a Diplomate in the International Congress of Oral Implantologists (ICOI). Dr. Nazarian has conducted lectures and hands-on workshops on esthetic materials, grafting, and dental implants throughout the United States, Europe, New Zealand, and Australia. Figures 4 and 5: 4. Planning with the CS 8100 3D. 5. Surgical guides and provisionals (Pittman Dental Lab)

Disclosure: Dr. Nazarian is the creator of the Reflector instrument.

implantpracticeus.com

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CASE STUDY

purity levels, and increases the success rate of bone-to-implant contact (BIC). Once the virtual plan was orchestrated and fully confirmed, the next appointment would be the planned surgery with all the necessary components for the guided surgical approach. The patient was appropriately sedated with IV medications, and local anesthesia was administered in both arches. The tissue was then reflected using the Reflector (GoldenDent™) instrument so that the bone-leveling surgical guide would be fully seated and fixed with its respectful retention screws (Figure 6 and 7). Following the positioning of the surgical guide, the maxillary teeth were atraumatically extracted utilizing the Physics Forceps® (GoldenDent). Once the appropriate bone leveling was accomplished with the surgical handpiece, the implant surgical guide (Figure 8) was positioned into the bone-leveling guide, and the sites for the implants were initiated with a designated pilot drill in the Adin Guided Surgery Drill Kit (Figure 9). Using precise orientation, depth, and direction, Adin’s Guided Surgical Kit provides fast, effective, and predictable preparation and placement of dental implants for dental practioners. It also features easy-to-follow layouts along with containing self-centering drills with built-in stoppers. The Adin Guide ActiveFlow™ Irrigation Technology unique design directs cooling saline through the guide, ensuring that irrigation reaches the bone and reducing the possibility for bone-heating throughout the procedure. Utilizing the Mont Blanc surgical handpiece and Aseptico surgical motor (AEU 7000) at a speed of 800 rpm with copious amounts of sterile saline, sequential drill preparation was initiated. Once the osteotomies were complete, the drivers in the Adin Guided Kit (Figure 10) were used to place the dental implants with precise timing so that the flat portion of the internal hex was positioned ideally for the receiving multiunit abutments.

A 3D virtual treatment plan was further developed from our planning with the CS 3D imaging (Carestream Dental) software and integrating it with the photos and models. A virtual online integrative meeting with the dental lab (Pittman Dental Lab) allowed for a comprehensive review of the assembled digital and clinical information formulating an optimal treatment plan, which would fulfill the necessary requirements for esthetics, form, and function. Within a short amount of time, the dental lab had fabricated all the necessary guides for positioning, leveling, drilling, and implant placement in addition to the PMMA provisional restorations and backup dentures (Figure 5). It is my belief that surgical guides in implant dentistry increase the predictability of treatment outcomes as well as making the clinician extremely efficient. In the past, implant placement routinely occurred by freehand technique, but this heightened the risk of damage to anatomic structures while lengthening the duration of the surgery. I personally feel surgical guides give clinicians more confidence to accurately place implants in every case whether you are a general practitioner or a specialist. Precision surgery reduces stress, decreases liability, and leads to a better outcome for the patient. The implants that would be utilized for this case were the Touareg™-OS Dental Implants (Adin Implant Dental System). The Touareg™ S & OS Spiral Implants are tapered with a spiral tap that condenses the bone during placement for immediate stability. There are two large variable threads and a tapered design for accurate implant placement, self-drilling, improved esthetics, and better load distribution. It features a special roundshaped apex that pushes the bone graft with minimal harm to anatomic structures. In addition, Touareg-OS implants feature Adin’s biocompatible and osseoconductive OsseoFix™ implant surface. This has proven to achieve the desired roughness levels for optimal osseointegration, attains the highest implant surface

Figures 6 and 7: 6. Positioning guide. 7. Maxillary bone-leveling foundation guide

Figure 9: Maxillary implant surgical guide

Figure 8: Adin Guided Dental Implant Kit

Figure 10: Touareg™-OS Dental Implant (Adin Implant Dental System)

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Figure 11: Maxillary temporary positioned on guide

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CASE STUDY

A baseline ISQ reading was taken of these implants utilizing the Penguin (Aseptico) RFA unit. Since the initial readings were all above 72, and the quality of bone after leveling was good, multiunit abutments (Adin) were tightened into the Touareg-OS (Adin) dental implants at 30 Ncm followed by temporary cylinders at 15 Ncm. Any residual areas around the implants or in the sockets were grafted with a cortical mineralized and demineralized bone-grafting material (GoldenDent) to optimize the area for regeneration. The prefabricated immediate provisional arch restorations with predrilled access openings were inspected before being trying-in. The maxillary provisional restoration was tried-in to verify a passive fit over the temporary abutments. Once confirmed, trimmed rubber dam pieces were placed to avoid the restoration (Figure 11) from locking on during the relining procedure with Rebase III Fast Set (Tokuyama) hard reline material. After the

Figure 12: Maxillary temporary

material polymerized, the immediate provisional restoration was removed and any access material removed with the Torque Plus (Aseptico) lab handpiece and acrylic bur (Komet). Once trimmed and polished, the provisional arch restoration was seated and tightened with a torque wrench at 15 Ncm (Figure 12). The access openings were filled ¾ of the way with Teflon® tape followed by Cavit™ (3M™) filling material. A few days later, the patient returned for her postoperative appointment with very little discomfort, swelling, or bruising. She was very pleased with her new upper fixed provisional restorations. The occlusion was further checked and adjusted to confirm there were no interferences in lateral or protrusive movements. Four months later, the patient presented for impressions for the definitive restoration. Using a heavy and light polyvinyl siloxane material (Panasil®, Kettenbach Dental) in a stock tray, an open tray impression was taken of the maxillary arch using transmucosal (Adin) impression posts (Figures 13 and 14). From

Figure 13: Transmucosal impression posts (Adin)

Figures 15 and 16: 15. Definitive hybrid restoration. 16. Monolithic hybrid restoration illustrating titanium frame

Figure 18: Postoperative occlusal view

Figure 14: Open tray impression (Kettenbach)

Figure 17: Postoperative retracted frontal view

Figure 19: Postoperative panoramic radiograph

Implant Practice US

Volume 15 Number 1

CASE STUDY

this impression, the dental lab fabricated a PMMA try-in of the proposed maxillary restoration for try-in and evaluation. Once tried-in, the restoration was evaluated for midline, incisal edge, and smile line. Bite relations was accomplished using Futar® Fast Bite (Kettenbach Dental) registration material. Within a couple weeks, the definitive restoration (monolithic zirconia on a titanium frame) was completed and delivered to the dental practice (Figures 15 and 16). When the patient returned, the hybrid restoration was inserted and torqued to the manufacturer’s suggested settings (Figures 17, 18, 19), and access openings were sealed with Teflon® followed by composite. The patient was instructed on how to clean and maintain her dental restoration In addition, we reviewed the importance of scheduled professional cleanings and overall oral health habits. With this new enhanced look, the patient was motivated to care for her investment (Figure 20).

Figure 20: Before-and-after facial view

type of service not only allows you to reduce the amount of visits for the patient, but also helps maintain the cost to patients since they are not seeing multiple dental providers. Most importantly, this enables the dental provider full control of the surgical and prosthetic outcome. Depending on the patients’ desires, the clinical conditions of the oral environment present, and the skills of the provider, a dentist may choose to extract teeth, level bone, and graft with guided dental implant placement within his/her dental practice. IP

Conclusion Having the ability to take a patient from start to finish in fewer appointments within your practice allows you to position yourself as a provider who can fulfill your patient’s surgical and restorative needs. With the proper training and appropriate materials, a dental provider may provide extraction, grafting, and implant placement within one appointment at one location. This

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Volume 15 Number 1

TECHNIQUE

Computer-guided surgery to restore function and esthetics in partially and fully edentulous patients: the FAIR protocol Dr. Arun K. Garg discusses an alternative treatment for edentulous patients

ration. The standard surgical protocol involves the placement of two or three implants in the traditional axial positions with no or minimal angulation, and two tilted posterior implants angled approximately 30 degrees distally to avoid anatomical barriers such as the maxillary sinus floor in the maxilla and the mental nerve in the mandible. In the edentulous maxilla, the tilted implants closely parallel the maxillary anterior sinus wall. For novice and expert surgeons alike, avoiding vital anatomy, particularly in patients with limited bone volume, is the primary rationale for using guided surgery when planning and placing implants. A computer-designed implant guide system allows the surgeon to plan implant placement while visualizing the surrounding anatomy. In the FAIR protocol, cone beam computed tomography (CBCT) scans are used to design each case. A three-dimensional stereolithographic (3D STL) model is then made based on the patient’s CBCT scan. Once the treatment plan has been finalized, a surgical guide is fabricated. In the maxilla, the implant surgeon must be thoroughly acquainted with the lateral piriform rim, the nasal floor, the incisive nerve and foramen, the anterior wall of the sinus, the crestal width, and the midline. The implants for mandibular

he introduction of digital imaging and planning tools in dentistry has dramatically changed the traditional workflow and expanded the range of treatment options available for patients with total or near-total edentulism. Studies have shown that wearing removable dentures can reduce patients’ quality of life, causing pain and areas of discomfort, chewing and speaking difficulties, slippage, reduced occlusal force, and poor oral sensation. The full-arch implant rehabilitation (FAIR) protocol provides a step-by-step procedure for restoring the edentulous (and nearly edentulous) maxilla and mandible to nearly natural function and esthetics. Modeled on the four-implant full-arch restoration concept pioneered by Malo, et al.,1–5 FAIR was developed using less costly materials and processes to offer an alternative treatment for edentulous patients with limited options. In contrast to conventional removable dentures, full-arch implant rehabilitation utilizing a digital workflow is a predictable treatment with less morbidity, less laboratory and clinical chair time, and a substantial increase in patient satisfaction. The FAIR treatment protocol has two parts: (1) a surgical procedure that concludes with placement of a provisional restoration accomplished within a single visit; and (2) following a short healing period, delivery of the definitive fixed prosthesis. The provisional prosthesis that is delivered on the day of surgery allows patients to consume soft foods during healing. The definitive prosthesis, which has a 95% success rate over 30 years, gives patients a natural esthetic appearance while imposing virtually no food restrictions. The ideal candidate for the FAIR protocol has ≤8 teeth per arch, moderate to advanced periodontal disease, limited finances, and the desire for a same-day fixed provisional restoArun K. Garg, DMD, completed both his engineering and dental degree at the University of Florida and subsequently, completed his residency training at 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 of Miami School of Medicine, and also served as Director of the Residency Training Program for 18 years. Currently, he is on the visiting faculty at the University of Florida College of Dentistry and has located his private practice for patient care in the Aventura area of Miami. Dr. Garg has authored eight textbooks, which have currently been translated into eight different languages, and has published well over 80 articles, and more than 12 book chapters. He is editor of a monthly newsletter, Dental Implantology Update, and serves on the editorial boards of four other leading journals.

Implant Practice US

Figures 1A-1D: In the FAIR protocol, the implants for mandibular rehabilitation follow the anterior loop of the mental nerve. A computer-designed implant guide system is used to ensure accurate implant placement during surgery. 1A. (above) Pins are inserted to keep the guide in. 1B. (left) The guide is used to create the osteotomies for the implants

Volume 15 Number 1

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TECHNIQUE

The FAIR protocol represents 30 years of clinical evolution, enabling skilled clinicians to provide edentulous or near-edentulous patients with the dental appearance and function they increasingly demand. Through this approach, fixed rehabilitation of the total arch is achieved without the complex surgeries, high-morbidity rates, high costs, and lengthy perioperative treatments traditionally associated with bone regeneration and grafting procedures. Interested Figures 1C and 1D: 1C. The implants are placed. 1D. The immediate full-arch prosthesis is tried-in readers can find more information about the FAIR protocol in the author’s step-by-step book, Full-Arch Implant rehabilitation follow the anterior loop of the mental nerve (FigRehabilitation, published by Quintessence (quintpub.com). IP ures 1A-1D). The clinician should take great care not only to identify the mental foramen but also to have an idea of the path REFERENCES of the anterior loop of the inferior alveolar nerve. The improved 1. Maló P, Rangert B, Dvarsater L. Immediate function of Branemark implants in the esthetic accuracy of CT-guided surgery has been well documented in zone: A retrospective clinical study with 6 months to 4 years of follow-up. Clin Implant the literature; in the FAIR protocol, it allows the clinician to feel Dent Relat Res. 2000;2(3):138-146. confident that the treatment plan has been followed, and the 2. Maló P, Rangert B, Nobre M. “All-on-Four” immediate-function concept with Brånemark System implants for completely edentulous mandibles: A retrospective clinical study. Clin implants are in the most appropriate locations. Implant Dent Relat Res. 2003;5(suppl 1):2-9. Fully edentulous cases may or may not require bone removal 3. Maló P, Friberg B, Polizzi G, et al. Immediate and early function of Brånemark System or a blood draw for applying platelet-rich plasma (PRP) therimplants placed in the esthetic zone: A 1-year prospective clinical multicenter study. Clin Implant Dent Relat Res. 2003;5(suppl 1):37-46. apies, but partially edentulous cases will involve both bone 4. Maló P, de Araujo Nobre M, Lopes A, Moss SM, Molina GJ. A longitudinal study of the removal and a blood draw as well as bone grafting and the use survival of All-on-4 implants in the mandible with up to 10 years of follow-up. J Am Dent of special socket-debriding burs. All implants are restored with Assoc. 2011;142(3):310-320. 5. Maló P, de Araujo Nobre M, Lopes A, Francischone C, Rigolizzo M. “All-on-4” immedistraight and angled multiunit abutments to support a provisional, ate-function concept for completely edentulous maxillae: A clinical report on the medium fixed, immediately loaded, full-arch prosthesis with survival (3 years) and long-term (5 years) outcomes. Clin Implant Dent Relat Res. 2012;14(suppl rates between 92% and 100%. 1):e139–e150.

Learn FAIR from the Master Full-Arch Implant Rehabilitation Arun K. Garg, DMD The full-arch implant rehabilitation (FAIR) protocol is one of the newest implant therapy innovations to treat the edentulous or nearly edentulous patient. This book describes how the FAIR protocol works, who it should be used for, and methods to implement it successfully for different patients. Step-by-step procedures are described with detailed clinical photographs documenting every stage from initial assessment to prosthesis delivery. 120 pp (softcover); 440 illus; ©2019; ISBN 978-0-86715-809-0 (B8090); US $89

(800) 621-0387 (toll free in US & Canada) • (630) 736-3600 (elsewhere) • www.quintpub.com

Implant Practice US

Volume 15 Number 1

1/22

CASE REPORT

Using digital technology to simplify anterior implant restoration Dr. Mark Ludlow discusses how adding efficiencies to this implant procedure led to a satisfying result

On clinical and radiographic examination, I noted the previously discussed endodontic findings, along with the patient’s esthetic complaint. I also observed several potential challenges in this case, which include a high-smile line, blunted gingival papilla, thin buccal plates, and a bony defect at site No. 8.

mplant therapy in the maxillary anterior region is always challenging from both a functional and an esthetic perspective. Tooth proportions, smile line, occlusion, soft tissue contour, and bone volume can all affect the degree of difficulty. However, with careful planning and a robust implant system, it is possible to achieve predictable success in these cases. The case presented demonstrates how digital technologies facilitate a complex anterior implant restoration.

Introduction By establishing a standardized digital workflow — from diagnosis, to planning, to the creation of customized prosthetics — we can significantly improve outcomes and offer more efficient treatment strategies. In my own practice, I routinely use a combination of CBCT radiography, digital impressions (Primescan intraoral scanner, Dentsply Sirona), and implant planning software (Simplant, Dentsply Sirona) to diagnose and plan each case. I also use various in-house CAD/CAM fabrication technologies to create either temporary and/or final restorations. However, in more complex cases, it is necessary to use more refined or specialized components, such as custom abutments, surgical guides, or edentulous superstructures (Atlantis, Dentsply Sirona). The following case outlines the care of a patient whose failing maxillary central incisors were replaced with single dental implants, custom abutments, and zirconia restorations.

Figure 1A: Initial situation —The two anterior teeth restored with crowns only fit incongruently into the dental arch. The high-smile line reinforces this impression

Case history A 64-year-old female presented to the clinic as a referral from her general dentist for evaluation of teeth Nos. 8 and 9. Many years ago the patient sustained trauma to her upper anterior teeth, which required both central incisors to be treated with root canal therapy and single crowns. However, her general dentist recently diagnosed both central incisors with internal root resorption during a recall examination. Additionally, the patient reported dissatisfaction with the color of her existing crowns, stating that they do not match the adjacent teeth.

Figures 1B and 1C: 1B. The radiograph clearly shows internal resorption in the root canals. 1C. Validation also using cone beam computed technology (CBCT). The internal resorptions are clearly visible. Both teeth were therefore classified as not worth preserving

Mark Ludlow, DMD, is the Section Head of Implant Dentistry, Digital Dentistry, and Removable Prosthodontics at the University of Utah School of Dentistry. He completed his dental training at the University of Connecticut and received his MS in prosthodontics from the University of North Carolina. As a practicing and teaching prosthodontist, Dr. Ludlow’s passion is in the development and integration of digital technology in the practice of everyday implant and restorative dentistry.

Figures 2A and 2B: 2A. Initial scan of the original situation as it is visualized in the CEREC SW. It was interesting to note that the row of teeth from 6 to 11 was not in occlusion. 2B. The shape of the crown should be maintained according to the patient’s wishes. This scan enabled us to create a model copy for the planned restoration

Disclosure: Dr. Ludlow is s a key opinion leader for Dentsply Sirona.

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Volume 15 Number 1

CASE REPORT

However, the patient’s thick gingival biotype, shallow anterior occlusion, and square tooth form were identified as more favorable factors. Given the severity, I recommended extraction and implant replacement of teeth Nos. 8 and 9. The DCM files from the CBCT scan and the STL files from the intraoral scan were exported and combined in Simplant planning software to confirm our diagnoses, to generate a prosthetically driven treatment strategy, and to order a surgical guide/ template. The patient’s bone volume and gingival biotype were well suited for immediate implant placement, assuming an intact buccal plate following extraction. Further, assuming adequate primary stability can be achieved at implant placement, the plan is to immediately provisionalize both sites. Following finalization of the treatment plan, I ordered and received the surgical guide, the custom abutments, and a core file to design and fabricate PMMA provisional crowns prior to the surgery. On the day of surgery, I carefully extracted teeth Nos. 8 and 9 to preserve the buccal plate, and curetted and irrigated each

Figures 3A and 3B: 3A. Little space and little buccal stability for the implant in region 8. 3B. The situation is similar in region 9, where the extraction process was to preserve the thin buccal lamella

Figure 6: Surgical guide created by Atlantis with the planning data

socket. Next, the surgical guide was seated, and the osteotomies prepared with each drill passing through the guide. Implants 8 and 9 (4.2 Astra Tech Implant System EV, Dentsply Sirona) were then placed through the guide. However, the primary stability was not sufficient for immediate loading. Therefore, cover screws were placed in each implant, and the sites were grafted with demineralized allograft and collagen membranes. A bonded temporary restoration was fabricated with multilayered PMMA directly in the practice using the inLab software and the inLab MC X5. The custom abutment and PMMA provisional will be saved for use in the second-stage procedure. After 4 months of healing, the sites were uncovered, and osseointegration was confirmed. The previously fabricated Atlantis custom abutments were inserted along with the PMMA provisional crowns to facilitate tissue shaping over the next 6 to 8 weeks. Once the soft tissue contours were acceptable, the temporary crowns were removed, and an abutment level scan was made with Primescan. This final intraoral scan was merged

Figures 4 and 5: 4. Implant planning in Simplant — Here data from the CBCT can be matched with data from the scan to determine the correct position of the implant. 5. In order to be able to provide the patient with a screw-retained crown, an angled abutment was planned. Otherwise, the end of the screw channel would have been in the visible crown area

Figure 7: Careful extraction of tooth No. 9

Figure 8: Placement of the surgical guide for accurate insertion of the implants

Figure 10: Final position of the implants

Figure 9: Inserting at tooth No. 8

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Volume 15 Number 1

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Clinical Case Example Clinical images courtesy of German Murias DDS, ABOI/ID

1 Tooth #15, set to be extracted.

Two Slim OsteoGen® Plugs are in place. Suture over top of socket to contain Plug. Do not suture through Plug. No membrane is required.

Remove the entire pathologic periodontal 2 ligament and flush socket twice. Use #6 carbide bur, make holes through the Lamina Dura to trabecular bone and establish Regional Acceleratory Phenomenon.

OsteoGen® is a low density bone graft and the OsteoGen® Plugs will show radiolucent on the day of placement.

Insert Large or Slim sized OsteoGen® Bone Grafting Plugs and allow blood to absorb.

The collagen promotes keratinized soft tissue coverage while the OsteoGen® crystals resorb to form solid bone. In this image, a core sample was retrieved.

As the OsteoGen® crystals are resorbed and replaced by host bone, the site will become radiopaque.

8 Implant is placed. Note the histology showing mature osteocytes in lamellar bone formation. Some of the larger OsteoGen® crystals and clusters are slowly 9 resorbing. Bioactivity is demonstrated by the high bone to crystal contact, absent of any fibrous tissue encapsulation.

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CASE REPORT

Figures 11 and 12: 11. Since the required primary stability could not be achieved with immediate implant placement, the alveoli were closed with bone-grafting material and sealed with a double vertical suture for papilla preservation. 12. Reentry after 2 months — restoration with abutments (gold titanium alloy)

Figures 14A and 14B: 14A. Control X-ray after seating the abutments. 14B. Control X-ray after seating the crowns

Figure 13: Restoration with a long-term temporary restoration, which already represented a clearly visible improvement in terms of esthetics

Figures 15A and 15B: 15A. Final situation with a happy patient smile. 15B.The final restoration seamlessly blends into the dental arch

with the design files of the original abutments to allow fabrication of the final restorations. The advantage of this technique is that the original abutments are not needed to be removed, and no additional effort is needed to expose/capture the margin line. The temporary crowns were also scanned and were used as a guide for the contours of the final restorations. Two zirconia screw-retained crowns were designed and fabricated to match the shade of the adjacent teeth. However, when attempting to insert the final restorations, I noticed the shade was slightly off. As a trained dental technician, I took this as a challenge. I then milled multiple sets of zirconia crowns and customized them differently for the patient to get the perfect shade and fit. Once the case was completed, the patient was very satisfied with the outcome.

Discussion This case highlighted many of the challenges commonly found in anterior implant therapy. However, with careful planning, the right tools, and precise execution, optimal results were achieved. Further, the technologies and materials utilized in this case allowed us to react to the clinical situation and to make the correct intraoperative decisions for optimal outcome. Intraoral scanning is an essential part of this workflow. The accuracy of Primescan is reflected in the precise fit of both the surgical guide and the final restorations. Primescan is an invaluable tool in both the diagnosis and monitoring of dental disease as well as in patient education and communication. Scan data can easily be exported to planning software, laboratories, or CAD/CAM devices. Implant Practice US

Simplant gives the clinician the ability to view 3D data from any CBCT scanner, create virtual wax-ups, and plan cases using its extensive implant library. For those situations requiring guided surgery, Simplant makes it easy to order precise surgical guides for practically any implant system available today. Further, the link between Simplant and Atlantis allows the design and fabrication of custom abutments, based directly off the surgical planning. This digital workflow streamlines the entire process of implant therapy. All steps are coordinated to avoid compatibility issues. Even if primary stability cannot be achieved initially during implant insertion, and closed healing is advisable, the fabricated abutments can be used as intended in the restorative restoration. Patients also appreciate the difference of a digital workflow. The ability to illustrate problems, discuss treatment options, and actively involve patients in the decision-making process are vital to patient education and provider trust. Further, the reduction in chair time has an extremely positive effect on patient perception. Taken together, these differences contribute to better case acceptance and ultimately case success.

Conclusion The patient was very satisfied with both the process and the result. She was particularly impressed by the appearance of the provisional restorations, and at first, she thought they were the definitive restorations. Her husband stated that he “couldn’t imagine how we could do better,” but through the leveraging of digital tools, we were able to achieve even better results, and now the patient can smile confidently again. IP Volume 15 Number 1

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CONTINUING EDUCATION

Soft tissue laser dental surgery basics Peter Vitruk, PhD, MInstP, CPhys, sheds some light on the many applications of lasers Laser light absorption by the biological tissues — ablative and nonablative lasers The key to the success of lasers in soft tissue surgery is their ability to (a) cut and (b) coagulate the soft tissue at the same time. Not all laser wavelengths are suitable to comply with both requirements. To understand how laser light cuts and coagulates the soft tissue, one must consider how the laser light is absorbed and scattered by the soft tissue.1-3 Most commercially available dental lasers fit into three wavelength categories: • Near-infrared circa 1,000 nm (810-1,064 nm diodes and 1,064 nm Nd-laser) • Mid-infrared circa 3,000 nm (2,790 and 2,940 nm Er-lasers) • Infrared circa 10,000 nm (9,300 and 10,600 nm CO2 lasers) The absorption spectra of oral soft tissue are summarized in Figure 1 along with Ablation Thresholds and Coagulation Depths for popular soft tissue dental lasers. Because near-infrared (Near-IR) photons are weakly absorbed (1,000-10,000 times weaker than CO2 and Erbium), dental diodes are not used to cut soft tissue with photons. Instead, dental diodes cut soft tissue thermomechanically with hot charred glass tips, whereas the tip-tissue contact time defines the depths of its thermal impact. These diode laser wavelengths, however, are scattered much stronger than they are absorbed, resulting in a strong and widespread Near-IR halo of light underneath the irradiated surface of the soft tissue.3 These Near-IR diode laser wavelengths are referred to as nonablative, as opposed to ablative Erbium and CO2 laser wavelengths, which are weakly scattered but strongly absorbed by the soft tissue. Mid-IR Erbium laser wavelengths are highly energy-efficient and spatially accurate photothermal ablation tools, but with an insufficient depth of coagulation (significantly less than blood capillary diameters). IR CO2 laser wavelengths are highly efficient and spatially accurate photothermal ablation tools with good coagulation efficiency due to a close match between coagulation depth and oral soft tissue blood capillary diameters.

This self-instructional course for dentists aims to discuss how the soft tissue laser can be applied in dental surgery and implant procedures.

Expected outcomes

Implant Practice US subscribers can answer the CE questions by taking the quiz online at implantpracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize how different types of lasers are absorbed by biological tissues. • Recognize that efficient decontamination of the implant surfaces can be achieved without heating or damaging the implant. • Realize how the depth of the incision is controlled with the laser, so the clinician can adjust technique for a very wide range of applications. • Identify how laser light can affect safe decontamination of the implant surfaces. • Realize how the laser affects the depth of coagulation/hemostasis. • Observe how CO2 laser surgery can result in reduced scarring and reduced postoperative pain.

2 CE CREDITS

SuperPulse and Thermal Relaxation Time Thermal Relaxation Time (TRT) is a measure of how fast the irradiated tissue diffuses the heat into the adjacent tissues.3,4 The most efficient heating of the irradiated tissue takes place when the laser pulse duration is shorter than the TRT. The most efficient cooling of the tissue adjacent to the ablated zone takes place if the time duration between laser pulses is greater than the TRT. Such laser pulse design in CO2 lasers is referred to as SuperPulse,3 depicted in Figure 2. SuperPulse minimizes the amount of heat that is diffusing away from the cutting/ablation zone to the adjacent healthy tissue.

SuperPulse CO2 laser removal of biofilms from dental implant surfaces Efficient decontamination of the implant surfaces can be achieved by the SuperPulse CO2 laser beam5,6 without heating or damaging the implant7,8 for the following reasons: • This 10,600 nm wavelength is highly efficiently absorbed by water-rich bacterial biofilms on the implant surface (Figure 1).

Peter Vitruk, PhD, MInstP, CPhys, is a member of The Institute of Physics, United Kingdom, and a founder of the American Laser Study Club (www.americanlaserstudyclub. org), and LightScalpel, LLC (www.lightscalpel.com), both in the United States. Dr. Vitruk can be reached at 1-866-589-2722 or pvitruk@lightscalpel.com.

Implant Practice US

Educational aims and objectives

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CONTINUING EDUCATION

• The short pulse duration of the SuperPulse allows for highly efficient confinement of the lasergenerated heat inside the biofilm without thermal conduction of heat away into the implant (Figure 2). • SuperPulse’s high peak power allows for fast vaporization (ablation) of biofilms since the laser-generated heat inside the biofilm is sufficient for vaporizing it. The SuperPulse 10.600 nm CO2 laser treatment with an average fluence in excess of 40 J/cm2 provides a 100% removal of an in vitro biofilms of approximately 10 μm thickness grown on titanium and titanium-oxide implant specimens with a moderately rough surface topography.6 Such CO2 laser irradiation of the titanium implant surface during open flap procedures allows for high success outcomes9 when treating peri-implantitis as illustrated in Figure 3.

Figure 1: Spectra of (a) Absorption Coefficient, 1/cm, (b) Thermal Relaxation Time, TRT, msec, (c) short pulse Ablation Threshold Fluence, Eth , J/cm2 and (d) short pulse Photothermal Coagulation Depth, H, mm, at histologically relevant concentrations of water, hemoglobin (Hb), oxyhemoglobin (HbO2) in sub-epithelial oral soft tissue. Logarithmic scales are in use

Implant-Safe Lasers — Implant-Safe SuperPulse CO2 Laser settings

Safe decontamination of implant surfaces with laser light can be achieved if the laser energy is efficiently reflected off the implant surface after the diseased tissue and biofilms are vaporized (ablated) from the implant surface.6-8 This condition is easily met for titanium implants.6-8 As illustrated in Figure 4, the 10.6 micrometer CO2 laser wavelength is highly reflected (>90%) from titanium.10 Diode, Nd-laser, and Er-laser wavelengths are not as efficiently reflected and produce 3 to 4 times greater rate of the implant heating than the CO2 laser for a comparable dose of laser energy. This property makes the CO2 laser wavelength the safest available wavelength for peri-implantitis treatment. Titanium implants (Biomet 3i NanoTite™ NIITP4310 and Biomet 3i Osseotite™ IFNT510 — all are trade names and trademarks of Biomet) have been demonstrated8 to safely handle a SuperPulse CO2 laser’s average fluence in 320 J/cm2 –360 J/ cm2 range, which are much greater fluence values than those proven efficient for biofilm ablation (> 40 J/cm2).6 It has been also demonstrated in the same study8 that SuperPulse CO2 laser irradiation of these implants produces significantly less heat when compared to the diode laser wavelengths.

Figure 2: SuperPulse explained: High-peak power and short laser pulse duration maximize soft tissue removal rate and keep adjacent tissue cool

Soft tissue surgery and incision/ablation depth with laser beams

Figure 3: Radiograph images illustrating successful peri-implantitis treatment involving SuperPulse CO2 laser decontamination of implant surface before placing bone graft.10 Treatment protocol includes detoxication mechanical piezo scaling, air abrasion (resorbable hydroxyapatite), chemical (sodium hypochlorite 40% + sterile water 60%), local antibiotics (tetracycline) and CO2 laser detoxication, bone graft, allograft with PRF, and sticky bone. Final radiograph 10-months following the procedure. (Images provided courtesy of Mike Shulman, DDS)

For the ablative CO2 and Erbium lasers, the power density of the focused laser beam is equivalent to the mechanical pressure that is applied to a cold steel blade.11 Greater laser fluence (i.e., greater power density and slower hand speed) results in a greater depth and rate of soft tissue vaporization. More specifically, as illustrated in Figure 5, the depth of incision is proportional to implantpracticeus.com

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Figure 4: Titanium surface absorption spectrum derived from titanium surface reflectivity at a normal angle of incidence10

Figure 5: Laser tissue incision with focused (0.25 mm spot size) laser beam; incision depth is 0.3-0.4 mm for 2 W SP F1-6 at 3-4 mm/sec hand speed. Defocused beam (> 1 mm spot size) with reduced fluence does not incise but coagulates the tissue. The handpiece is pen-sized, autoclavable, and uses no disposables

Figure 7: This highly venous tongue-tie is released with a CO2 laser on a 51-year-old patient, avoiding puncturing large blood vessels inside the tongue-tie.13 (Images provided courtesy of Martin Kaplan, DMD)

Figure 6: Closed-flap sulcular debridement with a CO2 laser beam delivered through a hollow tapered ceramic perio tip.12 Crest of the sulcus is deepithelialized 2-3 mm around the neck of each tooth to ensure that bacteria embedded in tissue are evaporated. De-epithelialization is performed on the buccal, then on the lingual side. After crestal de-epithelialization is complete, the distal end of the laser perio tip is inserted into the sulcus and is slowly moved around the tooth circumference while engaging the laser. Damp gauze is used to clear the tip if tissue clogs it up. The tip moves slowly in order to transfer as much energy as possible into the sulcus to evaporate anything biological in this site. (Image provided courtesy of Ben Sutter, DMD)

laser beam average power and inversely proportional to laser beam spot size and the surgeon’s hand speed. Understanding how the depth of the incision is controlled through power, spot size, and hand speed, a skilled dental surgeon can easily adjust the technique for a very wide range of applications. When decontaminating the dental implant surfaces described earlier, the depth of the biofilms removed is under 20 micrometers. During the closed-flap sulcular debridement with the CO2 laser, the diseased epithelium can be removed12 with similar micrometer-range precision and accuracy as illustrated in Figure 6. In certain popular soft tissue applications — e.g., lingual frenectomy13 — the skilled laser user can carefully debride the fibrous tissue even from around blood vessels if need be to Implant Practice US

Figure 8: (left) Surgical site immediately after a lingual CO2 laser frenectomy.11 Fascia and fibrous tissues are vaporized without puncturing very large blood vessels inside the tongue anatomy. (right) Completely healed, scar-free tongue — 4 weeks after the CO2 laser lingual frenectomy. (Images provided courtesy of Cara Riek, DNP, RN, FNP-BC, IBCLC)

fulfill the complete release of restrictions without puncturing the exposed blood vessels as illustrated in Figures 7 and 8.

Depth of coagulation/hemostasis with laser beams Coagulation occurs as a denaturation of soft tissue proteins that takes place in the 60°C to 100°C temperature range3 leading Volume 15 Number 1

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to a significant reduction in bleeding (and oozing of lymphatic liquids) on the margins of ablated tissue. Photothermal coagulation is also accompanied by hemostasis due to shrinkage of the walls of blood and lymphatic vessels due to collagen shrinkage at increased temperatures. Since blood is contained within and transported through the blood vessels, the diameter of blood vessels B (20-40 µm from measurements in human cadaver gingival tissue16) is a highly important spatial parameter in considering the efficiency of photothermal coagulation. For diode laser wavelengths, optical absorption (Near-IR attenuation) and coagulation depths are significantly greater than blood vessel diameters; coagulation takes place over extended volumes, extending far beyond ablation margins where no coagulation is required.3,11,17 For pulsed lasers (e.g., SuperPulse CO2 and free-running pulse Erbium lasers) the coagulation depth is proportional to the absorption depth of light in the soft tissue. The depth of coagulation/hemostasis can be extended by longer and lower power laser pulses, which allow the heat to diffuse away from the irradiated superficial depths into the deeper regions of the target tissue. 3,11 For Erbium laser wavelengths, the optical absorption depth and the coagulation depth are significantly smaller than blood vessel diameters (Figure 1); coagulation takes place on a relatively small spatial scale and cannot prevent bleeding from the blood vessels severed during efficient tissue ablation.3,11

For CO2 laser wavelengths (Figure 1), sub-100 µm5,7 coagulation extends just deep enough into a severed blood vessel to stop the bleeding; the coagulation and hemostasis are more efficient than for Erbium laser wavelengths.3,11 Figures 6-10 illustrate great hemostasis and coagulation on surgical margins during and immediately after the CO2 laser surgery.

Reduced scarring and reduced postoperative pain following CO2 laser surgery18

Both the reduced scarring and postoperative pain can be partially explained by the optimal coagulation/hemostasis depth on CO2 laser surgical margins. Several studies have found the reduced presence of contractile myofibroblasts — cells accountable for postoperative scarring — in CO2 laser surgical wounds when compared to scalpel surgery, which explains the lesser postoperative scarring following CO2 laser surgery. Also, decreased extravasation of blood and lymphatic fluids into the CO2 laser wound space impedes the release of inflammatory mediators. This results in less edema around the wound then following conventional surgery and delayed minimal inflammatory response. It may also account for the reduced immediate postoperative pain after CO2 laser surgery. Despite the abundant published case studies and research as well as anecdotal reports regarding reduced pain following CO2 laser surgery, the exact mechanism behind it remains to be explained.

Figure 9: Immediate postoperative image (right) indicates excellent hemostasis and coagulation during mucocele removal with a CO2 laser.14 (Images provided courtesy of Robert Levine, DDS)

Figure 10: Intraoperative image (left) indicates excellent hemostasis and coagulation during fibroma removal with a CO2 laser.15 The 4 weeks postoperative image (right) indicates excellent scar-free healing. (Images provided courtesy of Robert Levine, DDS)

Figure 11: Unlike the 10,600 nm CO2 laser, the 810 nm near-IR diode laser cannot cut soft tissue photothermally at comparable values of laser fluence

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Nonablative lasers and nearinfrared diode hot glass tip

Understanding how the depth of the incision is controlled through power, spot size, and hand speed, a skilled dental surgeon can easily adjust the technique for a very wide range of applications.

As previously explained and further illustrated in Figure 11, the near-IR laser wavelengths of diode lasers are weakly absorbed by the soft tissue and cannot radiantly ablate/vaporize the soft tissue3,11,17-21 (except for high melanin content epithelium). Since diode Near-IR laser wavelengths are not suitable for the oral soft-tissue cutting, there is a different technique of non-optical (non-radiant) tissue cutting with the so-called “hot tip,”19-21 as illustrated in Figure 12. A critical component of such hot tip-tissue interaction is the creation of the optically dark char deposit on the very end of the glass tip. The diode laser optical energy is then used to heat the charred glass fiber’s tip up to 1,000ºC to 1,500ºC.19-21 The hot glass tip heats soft tissue through heat conduction (i.e., heat diffusion) from (and through) hot glass tip to (and through) the soft tissue. Charred glass tip diode lasers perform as non-laser wavelength-independent ablation thermal devices with coagulation depths in the range 250-1,000 µm22 (similarly to electrocautery where soft tissue is cut by the hot metal tip). The cutting speed of the charred hot glass tip is limited by its disintegration at elevated temperatures (up to 1,500ºC), thus raising concerns about biocompatibility19 of the burnt tip’s cladding chemicals and thermally fractured glass. Degradation of the char on glass tip surface creates the “optically leaky” tip with a reduced tip temperature, and increased risk of Near-IR induced sub-surface thermal necrosis20 as well as mechanical tearing of the tissue by the cold glass’ sharp edges, which may result in both deep thermal trauma and excessive superficial bleeding as illustrated in Figure 13.

Figure 12: The “Initiated” (i.e., charred per manufacturer’s instruction by burning corkwood on contact at 1 watt) glass tip of the 810 nm near-IR diode laser at 3 watts

ANSI Z136.3 Standard for Safe Use of Lasers in Health Care Laser Institute of America (LIA) has originally developed and now regularly updates the Laser Safety regulations (ANSI Z136.3 Standard for Safe Use of Lasers in Health Care - 2018 Edition23), which are mandatory for implementation by all laser users in mitigating laser beam and non-beam hazards. The most important top-level Laser Hazard mitigation measures are typically well understood and properly implemented by the majority of the surgical laser users — i.e., Laser Safety Officer (LSO) appointment, Laser In Use Sign, and Laser Safety Goggles Administration. Additionally, the ANSI Z136.3 Standard defines laser plume as one of the non-beam laser hazards since it contains viral, bacterial, and other cellular and aerosolized particulates, gaseous toxic compounds, etc. ANSI Z136.3 Standard specifies safety measures to mitigate the laser plume hazards, i.e., the mandatory use of Local Exhaust Ventilation (LEV) device — for example, wall suction devices in dental offices (aka high-volume evacuation devices and mobile/ portable smoke evacuators in physicians’ and veterinarians’ offices) — equipped with a proper filter (with ANSI Z136.3 Standard’s defined filtration at 0.12 μm at 99.999% efficiency) and with wide aperture suction nozzle held as close as possible to Implant Practice US

Figure 13: Excessive and deep thermal damage (from a charred hot glass tip) and excessive bleeding (from a cold glass tip when char wears out) both taking place during the same infant frenectomy surgery with a diode glass charred tip20

the surgical site (no further than 2 inches per the CDC24 — Figure 14) to safely remove laser plume. According to ANSI Z136.3(2018), the use of N95 is preferred over surgical masks, but only in addition to laser plume evacuation. It is important to emphasize that in surgical laser uses that do not utilize water sprays, laser plume can be safely removed according to and in compliance with ANSI Z136.3 Standard. However, users of dental lasers that utilize water sprays should Volume 15 Number 1

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Figure 14: Proper positioning of the high-speed suction nozzle —no farther than 2 inches from the surgical site, according to the CDC and ANSI Z136.3. (Images provided courtesy of Leonard Kundel, DMD; Paul Rubin, DMD; Mike Shulman, DDS; Ben Sutter, DMD; Richard Winter, DDS; Soroush Zaghi, MD; and Edward Zimmerman, MD)

be aware that ANSI Z136.3 Standard does not address the safe removal of the laser plume dispersed by the water spray.25 IP

13. Kaplan M, Vitruk P. Soft tissue 10.6 micrometers CO2 laser orthodontic procedures. Orthodontic Practice US. 2015;6(6):53-57.

REFERENCES

15. Levine R, Vitruk P. Enhanced hemostasis and improved healing in CO2 laser-assisted soft tissue oral surgeries. Implant Practice US. 2015;8(3):34-37.

Jacques SL. Origins of tissue optical properties in the UVA, visible, and NIR regions. In: Alfano RR, Fujimoto JG (ed.) OSA TOPS on Advances in Optical Imaging Photon Migration. Optical Society of America. 1996.

Jacques SL. Optical properties of biological tissues: a review. Phys Med Biol. 2013; 58(11):R37-61.

Vitruk P. Oral soft tissue laser ablative and coagulative efficiencies spectra. Implant Practice US. 2014;7(6):19-27.

Vogel A, Venugopalan V. Mechanisms of pulsed laser ablation of biological tissues. Chem Rev. 2003;103(2):577-644.

Romanos GE, Ko HH, Froum S, Tarnow D. The use of CO2 laser in the treatment of peri-implantitis. Photomed Laser Surg. 2009;27(3):381-386.

Cobb CM, Vitruk P. Effectiveness of a super-pulsed CO2 laser for removal of biofilm from three different types of implant surfaces: an in vitro study. Implant Practice US. 2015;8(3):20-28.

Linden E, Vitruk P. SuperPulse 10.6 µm CO2 laser-assisted, closed flap treatment of peri-implantitis. Implant Practice US. 2015;8(4):34-38.

Linden E, Vitruk P. Implant-safe settings for SuperPulse 10.6 micrometers CO2 laser-assisted, closed flap peri-implantitis treatment. Implant Practice US. 2015;8(6):26-28.

Shulman M. CO2 Laser Peri-Implantitis Treatment Results. https://www.youtube.com/ watch?v=bV8dfT6I17g&list=PL4ROT89t1sVtyFCoK6Gls4E0xqKlSOvbm&index=70

14. Levine R, Vitruk P. Laser Mucocele Removal in Pediatric Patients. Dentaltown. 2016;17(9):10-111.

16. Yoshida S, Noguchi K, Imura K, Miwa Y, Sunohara M, Sato I. A morphological study of the blood vessels associated with periodontal probing depth in human gingival tissue. Okajimas Folia Anat Jpn. 2011;88(3):103-109. 17. Willems PWA, Vandertop WP, Verdaxsasdonk RM, van Swol CFP, Jansen GH. Contact laser-assisted neuroendoscopy can be performed safely by using pretreated ‘black’ fibre tips: Experimental data. Lasers Surg Med. 2001;28(4):324-329. 18. Glazkova A, Vitruk P. CO2 Laser Surgery Post-Operative Pain and Healing: A Partial Literature Review. Dental Sleep Practice. Winter 2019:28-34. 19. Vitruk P. Laser Education, Science and Safety – A review of dental laser education standards. Dentaltown. 2017;17(6):62-67. 20. Vitruk P. Hot Glass Tip Diode Frenectomies ARE NOT Laser Frenectomies. Dental Sleep Practice US. Summer 2019;48-50. 21. Romanos GE. Diode Laser Soft-Tissue Surgery. Compend Contin Educ Dent. 2013;34(10):752-757 22. Vitruk P, Levine R. Hemostasis and Coagulation with Ablative Soft-Tissue Dental Lasers and Hot-Tip Devices. Inside Dentistry. 2016;12(8):37-42. 23. The Laser Institute of America. American National Standards Institute - ANSI Z136.3. Safe Use of Lasers in Health Care. https://www.lia.org/resources/laser-safety-information/laser-safety-standards/ansi-z136-standards/z136-3. Accessed January 21, 2022. 24. 24. Centers for Disease Control and Prevention. Control of Smoke From Laser/Electric Surgical Procedures. 1996. DHHS (NIOSH) Publication Number 96-128. Accessed January 21, 2022. https://www.cdc.gov/niosh/docs/hazardcontrol/hc11.html.

10. Wolfe WL, Zissis GJ. The Infrared Handbook. Office of Naval Research. 1985:7-81. 11. Riek C, Vitruk P. Incision and Coagulation/Hemostasis Depth Control During a CO2 Laser Lingual Frenectomy. Dental Sleep Practice. spring2018;32-38.

25. Vitruk P. ANSI Z136.3 Standard Doesn’t Cover Safe Removal of Laser Plume Dispersed by Water Spray. Dent Today. 2020. https://www.dentistrytoday.com/standard-doesnt-cover-safe-removal-of-laser-plume-dispersed-by-water-spray/. Accessed January 21, 2022.

12. Sutter BA. Identification and Laser Eradication of Oral Cavity Spirochetes. Case Study. JALSC. 2018;1(1):4-13. https://www.youtube.com/watch?v=GboQ3Y7h0eQ&list=PL4 ROT89t1sVtyFCoK6Gls4E0xqKlSOvbm&index=40. Accessed January 21, 2022.

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Continuing Education Quiz Soft tissue laser dental surgery basics VITRUK

Because _________ photons are weakly absorbed, dental diodes are not used to cut soft tissue with photons. a. near-infrared b. mid-infrared c. infrared d. none of the above

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 866579-9496, or visit https://implantpracticeus.com/subscribe/ to subscribe today. n To receive credit: Go online to https://implantpracticeus.com/continuingeducation/, click on the article, then click on the take quiz button, and enter your test answers.

Near-IR diode laser wavelengths are referred to as _______. a. non-ablative b. ablative c. weakly scattered d. strongly absorbed

AGD Code: 135 Date Published: February 15, 2022

________ is a measure of how fast the irradiated tissue diffuses the heat into the adjacent tissues. a. Absorption coefficient b. Thermal Relaxation Time (TRT) c. Ablation Threshold d. Photothermal Coagulation Depth

Expiration Date: February 15, 2025

The most efficient cooling of the tissue adjacent to the ablated zone takes place if the time duration between laser pulses _______ the TRT. a. is greater than b. is equal to c. is less than d. diminishes Efficient decontamination of the implant surfaces can be achieved by the SuperPulse CO2 laser beam without heating or damaging the implant because ________ . a. This 10,600 nm wavelength is highly efficiently absorbed by water-rich bacterial biofilms on the implant surface. b. The short pulse duration of the SuperPulse allows for highly efficient confinement of the laser-generated heat inside the biofilm without thermal conduction of heat away into the implant. c. SuperPulse’s high peak power allows for fast vaporization (ablation) of biofilms since the laser-generated heat inside the biofilm is sufficient for vaporizing it. d. all of the above The SuperPulse 10.600 nm CO2 laser treatment with an average fluence in excess of 40 J/cm2 provides a ________ removal of an in vitro biofilms of approximately 10 μm thickness grown on titanium and titaniumoxide implant specimens with a moderately rough surface topography. a. 36% b. 65% c. 83% d. 100%

2 CE CREDITS

Coagulation occurs as a denaturation of soft tissue proteins that takes place in the ________ temperature range leading to a significant reduction in bleeding (and oozing of lymphatic liquids) on the margins of ablated tissue. a. 10-30°C b. 40-55°C c. 60-100°C d. 125-200°C

The ______ can be partially explained by the optimal depth of coagulation/ hemostasis on CO2 laser surgical margins. a. reduced scarring b. reduced postoperative pain c. decreased coagulation d. both a and b

Several studies have found the reduced presence of ___________ – cells accountable for postoperative scarring — in CO2 laser surgical wounds when compared to scalpel surgery, which explains the lesser postoperative scarring following CO2 laser surgery. a. fibroblasts b. contractile myofibroblasts c. cytokines d. matrix metalloproteinases

10. Since diode Near-IR laser wavelengths are not suitable for the oral soft-tissue cutting, there is a different technique of non-optical (non-radiant) tissue cutting with the so-called _______. a. “burned tip” b. “scorched end” c. “hot tip” d. “searing instrument”

To provide feedback on 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.

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Practical considerations for utilizing Prescription Drug Monitoring Programs (PDMP) — a primer Nikki Sowards, PharmD; Michael O’Neil, PharmD; and Tyler Dougherty, PharmD; discuss how prescription drug monitoring programs play an important role in monitoring controlled substances Introduction Although not first-line therapy, prescription opioids play an important role in the management of acute dental pain. However, all medications carry risks, which in the case of opioids can lead to misuse, physiologic dependence, and diversion. Additionally, opioid use disorder may lead to overdose and death. According to the CDC, from 1999 to 2019, an estimated 247,000 deaths in the United States were attributed to overdoses involving prescription opioids.1 In dental practice, the majority of opioids prescribed are immediate-release formulations with a higher potential for misuse and diversion.2 Data also suggests that dentists prescribe more opioids than considered necessary

Educational aims and objectives

This self-instructional course for dentists aims to present an overview of prescription drug monitoring programs (PDMPs) and their considerations for use in dental practice.

Nikki Sowards, PharmD, earned her Doctor of Pharmacy degree in 2012 from the University of Tennessee College of Pharmacy in Memphis, Tennessee. She completed a PGY-1 Pharmacy Practice residency in Knoxville, Tennessee. Dr. Sowards joined South College School of Pharmacy as an Assistant Professor in 2013. In 2015, Dr. Sowards worked as a Director of Hospital Pharmacy in Knoxville, Tennessee. Dr. Sowards is currently an Assistant Professor of Pharmacy Practice at South College School of Pharmacy. She practices at Blount Memorial Hospital where she focuses on pharmacy operations and pharmacy management. Michael O’Neil, PharmD, received his Doctor of Pharmacy from the University of North Carolina at Chapel Hill, North Carolina. Dr. O’Neil has extensive experience in pain management, substance misuse, and medication diversion. Dr. O’Neil was editor and lead author for the American Dental Association’s book titled The ADA Practical Guide to Substance Use Disorders and Safe Prescribing, published in 2015. Dr. O’Neil has served as a consultant for prescription drug misuse and diversion for several entities including the Federal Drug Enforcement Agency. He is currently Professor and Chair of Pharmacy Practice at South College School of Pharmacy in Knoxville, Tennessee. Tyler Dougherty, BA, PharmD, BCACP, received his Bachelor of Arts degree in Biochemistry from Maryville College in 2011 and his Doctor of Pharmacy degree from the University of Tennessee College of Pharmacy in 2015. He completed a postgraduate residency at South College School of Pharmacy in 2016. Dr. Dougherty is a Clinical Community Pharmacist and Assistant Professor of Pharmacy Practice where he specializes in community pharmacy practice and teaches ethics and pharmacy law. Dr. Dougherty is an invited speaker for healthcare professionals teaching ethics and law with emphasis on medication management.

implantpracticeus.com

Expected outcomes

Implant Practice US subscribers can answer the CE questions by taking the quiz online at implantpracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify key components of the PDMP. • Outline steps to access the state’s PDMP. • List reasons how utilizing the PDMP can protect dental practices. • List limitations to the PDMP. • Complete a query utilizing the PDMP to evaluate a patient’s controlled substance record. CREDITS

2 CE

for managing postprocedural acute pain.3 Over the past 10 years, many medical and dental boards as well as professional organizations have recommended or required routine use of prescription drug monitoring programs (PDMPs). The American Dental Association recommends dentists register and utilize their state’s PDMP to promote the safe and appropriate use of controlled substances.4 Currently, all 50 states have implemented a PDMP, and dental practitioners may access the following link for more information related to their state PDMP: https://www.pdmpassist. org/State.5,6 Dental practitioners must be fully knowledgeable of their own state’s PDMP. This article will serve as a primer and

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give a general overview for dental practitioners to optimize utilization of their state’s PDMP.

Use of the PDMP by dental practitioners Historically, data has indicated that out of 805 members of the National Dental Practice-Based Research Network, only half of respondents reported having accessed a PDMP. Both lack of awareness and lack of knowledge regarding its use were the most common reasons cited for not using the database. Of those individuals who did report utilizing the PDMP, 33.5% indicated that their usage led them not to prescribe an opioid, while 25.5% reported usage led them to prescribe fewer opioid doses. Figure 1: An example report from the Tennessee Controlled Substance Monitoring Database of dispensed Overall, the findings of this research controlled substances for a mock patient did suggest that a majority of dentists do find the PDMP helpful in their decision-making regarding the prescribing of controlled substances. Table 1: Commonly Used Names and Acronyms for PDMPs Many states now mandate prescribers access the PDMP prior CSD Controlled Substance Database to prescribing controlled substances in defined circumstances.4

PDMP basics Prescription Drug Monitoring Programs (PDMPs) store outpatient controlled prescription medication information and are designed to track these prescriptions through an internet-accessed database maintained at the state level. Classes of controlled substances required to appear in the PDMP are determined by individual states. Of note, PDMPs are commonly referred to in a variety of ways depending on the state of origin. Table 1 lists commonly used terminologies that are equivalent to the PDMP. The main components of the PDMP include tracking of a patient’s prescribed controlled prescriptions, prescriber tracking of prescriptions utilizing their DEA number, and surveillance/ monitoring systems to detect trends and allow for statistical analysis. Controlled substances dispensed by community pharmacies and outpatient clinics are entered into the patient’s prescription record. When these prescriptions are dispensed, information associated with the prescription is uploaded to the PDMP at a time determined by the state with many pharmacies and clinics uploading at the immediate point-of-sale or dispensing. The PDMP report contains the patient’s name, date of birth, any addresses associated with that patient, and any prescriptions for controlled substances that have been dispensed by a pharmacy or outpatient clinic. Specific information typically available for each prescription follows: • medication name • medication strength • quantity filled • number of days’ supply • the prescriber’s DEA number • the date the prescription was written Implant Practice US

CSMP

Controlled Substance Monitoring Program

CSMD

Controlled Substance Monitoring Database

CSMPD

Controlled Substance Monitoring Program Database

PMP

Prescription Monitoring Program

PDMP

Prescription Drug Monitoring Program CSMD=CSMP=CSMPD=PMP=PDMP

• the prescription number • the pharmacy that filled the prescription. Some PDMPs are more advanced and may contain additional information such as total daily morphine milligram equivalents (MME), dispensed naloxone, and payment type.6,7 Figure 1 represents a typical report generated from the state of Tennessee PDMP. This database is maintained by the Tennessee Board of Pharmacy, which is a division of the State’s Public Health Department.8 It is critical for practitioners to recognize that information uploaded to the PDMP comes directly from pharmacies or outpatient clinic records. Medication information is entered into the pharmacy’s or clinic’s computers by a variety of personnel. None of this data is ever validated prior to being uploaded to the PDMP other than by personnel entering the data. Any entry errors by practitioners, pharmacists, technicians, or staff get uploaded to the database. Therefore, it is critical to recognize that the PDMP report is not evidence of a crime and should be used only as a starting point to verify potential concerns or “red flags” found in the report. The PDMP ultimately serves to inform clinical practice and improve prescribing. When utilized in a timely manner, PDMPs can prevent dangerous combinations of medications, limit preVolume 15 Number 1

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scribing of unnecessary or duplicate prescriptions, and prevent doctor shopping as well as other types of medication diversion.

Accessing PDMPs Accessing PDMPs requires the prescriber to register with the state organization responsible for managing the database. Like most internet-based restricted sites, passwords are initially assigned by the regulating body and can be changed to a more convenient password later by the user. The database should only be accessed to evaluate a specific provider’s patient records “near time” of the scheduled appointment unless the prescriber is investigating potential fraud or diversion. Information provided in the PDMP must be handled the same as other patient information, which requires following all requirements of The Health Insurance Portability and Accountability Act (HIPAA).9 Accessing the PDMP to ascertain information about friends, families, other practitioners, or patients not part of the prescriber’s immediate practice is usually considered a violation of state and federal law that may result in prosecution. Prescribers are not usually obligated to provide patients with a copy of their PDMP report. However, if a copy of the report is placed in a patient’s medical record, the patient or insurance agencies may have access to the report. Additionally, caution should be used when placing the PDMP report in the chart since it potentially may contain another patient’s information depending on how the patient’s information was queried. Access to the PDMP is restricted to prescribers, pharmacists, the DEA, and law enforcement entities executing a warrant or who are part of a defined drug task force. However, most states allow the PDMP registered user to grant access to PDMP records to a limited number of users in the practice. In most cases this requires the user to use the registrant’s password. Ultimately, the PDMP registrants are responsible for any queries by any allowed users that use their password even if it is not for legitimate purposes. When “allowed users” leave the practice, passwords must be changed immediately to prevent misuse of the database. Some states now identify “allowed users” through special registrations linked to the PDMP registrant or allow support staff to have their own login code.10 Many medical practices and pharmacies have a separate login to the state’s PDMP that is often utilized by everyone in the practice. It is key that every licensed user use his/her own login to access the PDMP. Multiple users put the practice and individual login owners at risks for violations made by individuals using the facility’s login information inappropriately. Many patients live in areas that border multiple states, allowing patients to access practitioners and pharmacies in different states. Some states’ PDMPs provide a link to other nearby states’ PDMP. To date, there is not a single, nationally controlled PDMP that integrates all patient information for all 50 states.

For example, a patient named “Michael O’Neil” should not be entered as “Mike O’Neil” or vice versa. To avoid missing records that may have been entered using an abbreviated name, a more advanced search can be easily performed by using only the first initial of the patient’s first name and his/her last name. Caution is warranted when this method is used since any person named “O’Neil” whose first name starts with the letter “M” and has the exact birthdate will appear in the results. Spellings and datesof-birth must be exact; otherwise, they will not be found in the report. Dental practitioners should also be vigilant for the potential for multiple patients who have the same last name and date of birth. The timeline of the search is also required. For practitioners treating an active patient, searches generally only need to go back 6 months to 1 year because practitioners are making a real-time clinical decision. When investigating patients for potential fraud or diversion, longer time periods may be warranted. Although patient addresses can be entered, patients frequently move, and listing a specific address in the query may limit the findings in the report. Errors entered into patient profiles that end up in the PDMP usually requires a formal request to the PDMP managing agency to correct the misinformation. Simply changing the information in the patient profile will not change the information in the PDMP. Once the PDMP report has been generated for the designated patient and the defined timeline, select the most recent prescription listed, and track on the timeline any medications within the same medication class. Look for any potential “red flags.” Repeat this process for any additional medications.

Identifying and evaluating “red flags” A “red flag” may be defined as any observation that provokes the user of the PDMP to evaluate the need, safety, or legitimacy of a prescribed medication. Identifying a “red flag” does not mean to immediately refuse to prescribe, but rather to ask questions and verify information before prescribing. Ultimately, refusing to prescribe often becomes a common action by the prescriber if controversial information is identified and verified.11

Table 2: Common Potential “Red Flags” Patients traveling extremely long distances between dental practicehome-pharmacy Early refills Utilizing multiple prescribers (emergency medicine, dental practices, hospitals, private practices) Out-of-state patients Random, escalating-de-escalating doses of opioids or benzodiazepines Common “cocktails” consisting of opioids, benzodiazepines, muscle relaxants, and sedative hypnotics

Querying the PDMP After logging into the PDMP, the patient’s name and date of birth must be entered. Ideally this information should come from a government-issued identification such as a driver’s license, but this sometimes is not possible. The patient’s proper name should be used. Nicknames or abbreviated names should be avoided. implantpracticeus.com

Morphine-Equivalent Daily Doses (MEDD) exceeding 90 mg/day Patients presenting “old” dental injuries as “new” injuries Utilizing only cash payments for medications

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When reviewing the PDMP, general observations that may be identified as “red flags” include the following: early medication refills, duplicate medications, utilization of multiple pharmacies or multiple providers, extremely long distances traveled from a patient’s home-pharmacy-dental practice, persistent use of similar medications, including random escalating-de-escalating doses, variation in products, and concerning medication combinations, also commonly referred to as “cocktails.” Table 2 lists common “red flags” that may require further questioning.11,12

Limitations to the PDMP Equally as important to the information provided in the PDMP is the information not found in the PDMP that potentially impacts prescribing. The PDMP report will not reflect any verbal changes that have been communicated to the patient such as increasing usage of a prescription. As previously mentioned, errors may occur when prescriptions are processed then uploaded to the database. Because Veterans Administration Medical Center patients receiving medical care are under federal regulation, prescriptions for controlled substances, including methadone and buprenorphine products, are not required to be reported to the PDMP. However, some Veterans Administration Medical Centers do voluntarily report to the PDMP. The PDMP does not usually contain patient diagnosis for the medications prescribed. Finally, all PDMPs are subject to the variety of connectivity issues that commonly occur with accessing information through an internet connection.

Reporting suspected diversion or fraud behavior When suspicious findings in the PDMP have been confirmed to be attempts to divert controlled substances or commit fraud, most states require reporting to a specific drug enforcement agency. This may include the dental practitioner’s local police department, regional drug task force, or regional DEA office. The DEA requires the reporting of any suspicious activities surrounding controlled substances. Regardless, specific information

including the time, date, patient’s name, address, date of birth, suspected illegal activity, medications indicated, and the verification process used to confirm the information in the PDMP should be reported. All information collected surrounding the suspected case should be documented in the patient’s medical record.13

Best practices Recommendations to help optimize a dental practitioner’s use of the PDMP include: • Logging in to the PDMP often to stay familiar with passwords and to stay current with any PDMP changes. • Training staff to run the PDMP report and to have the report ready for review when your patients arrive. • Maintain positive relations with local pharmacies and law enforcement since they are frequently the first to identify potential problems and can help protect your practice. • Evaluate PDMP reports every 6 months with your office manager using your DEA registration number to identify fraudulent prescriptions that have been issued using your DEA number. • Evaluate the PDMP for any brand new patient requiring a controlled substance.

Summary In summary, PDMPs are an effective tool for detecting and deterring controlled substance fraud and diversion. Querying the PDMP requires exact name and date of birth. “Red flags” require further questioning and verification before prescribing or refusing to prescribe since information contained in the PDMP is not evidence of a crime. Sharing of PDMP login passwords should be limited. Although there are some limitations to PDMP, most information is accurate. Dental practitioners prescribing controlled substances should access the PDMP to stay familiar with their passwords and to be kept up-to-date on major changes to their state’s PDMP. Confirmed suspicions or fraud or diversion must be reported per state and federal laws. IP

REFERENCES 1.

Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2020. http://wonder.cdc.gov. Accessed 1/7/22

McCauley JL, Hyer JM, Ramakrishnan VR, et al. Dental opioid prescribing and multiple opioid prescriptions among dental patients: administrative data from the South Carolina prescription drug monitoring program. J Am Dent Assoc. 2016;147(7):537-544.

Maughan BC, Hersh EV, Shofer FS, et al. Unused opioid analgesics and drug disposal following outpatient dental surgery: a randomized controlled trial. Drug Alcohol Depend. 2016;168:328-334.

McCauley JL, Gilbert GH, Cochran DL, et al. Prescription Drug Monitoring Program Use: National Dental PBRN Results. JDR Clin Trans Res. 2019;4(2):178-186.

Herion P, office GP, Marshall Cof J. Missouri becomes 50th state to introduce Prescription Drug Monitoring Database. KOMU 8. https://www.komu.com/news/state/missouri-becomes-50th-state-to-introduce-prescription-drug-monitoring-database/article_6e944f90-c7b8-11eb-a6ff-8742499b65dd.html. Published June 7, 2021. Accessed January 7, 2022.

State PDMP Profiles and Contacts. https://www.pdmpassist.org/State. Accessed January 7, 2022.7. Appriss, Inc. - Tennessee state government - tn.gov. https://www.tn.gov/content/dam/ tn/health/healthprofboards/csmd/TNDataCollectionManual.pdf. Accessed January 7, 2021.

Image Courtesy Tennessee Department of Public Health.

Health Insurance Portability and Accountability Act of 1996 (HIPAA). Centers for Disease Control and Prevention. https://www.cdc.gov/phlp/publications/topic/hipaa.html#:~:text=The%20Health%20Insurance%20Portability%20and,the%20patient’s%20consent%20or%20knowledge. Published September 14, 2018. Accessed January 7, 2022.

FAQ’s. https://www.tn.gov/health/health-program-areas/health-professional-boards/csmd-board/csmd-board/faq.html. Accessed January 7, 2022.

10. Prescription Medication Diversion: Detection and Deterrence. J Calif Dent Assoc. 2019;47(3):180-181. 11. O’Neil M, Winbigler B, Sowards A. Detection and Deterrence of Substance Use Disorders and Drug Diversion in Dental Practice. In: The ADA Practical Guide to Substance Use Disorders and Safe Prescribing. 143-149; 2015:144-147. 12. Suspicious orders report system (sors). https://www.deadiversion.usdoj.gov/sors/index.html#:~:text=On%20October%2023%2C%202019%2C%20DEA,115%2D271). Accessed January 7, 2022.

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CONTINUING EDUCATION

Continuing Education Quiz Practical considerations for utilizing Prescription Drug Monitoring Programs (PDMP) — a primer SOWARDS/O’NEIL/DOUGHERTY

1. According to the CDC, from 1999 to 2019, an estimated _________ deaths in the United States were attributed to overdoses involving prescription opioids. a. 50,000 b. 134,000 c. 247,000 d. 456,000

2. Currently, ________ have implemented a PDMP. a. 16 states b. 34 states c.. 46 states d. all 50 states

AGD Code: 157 Date Published: February 15, 2022 Expiration Date: February 15, 2025

3. Of those individuals who did report utilizing the PDMP, ________ indicated that their usage led them not to prescribe an opioid, while 25.5% reported usage led them to prescribe fewer opioid doses. a. 33.5% b. 52% c. 65% d. 71%

2 CE CREDITS

ally considered a violation of state and federal law that may result in prosecution. a. friends and families b. other practitioners c. patients not part of the prescriber’s immediate practice d. all of the above

4. The main components of the PDMP include tracking of a patient’s prescribed controlled prescriptions, prescriber tracking of prescriptions utilizing their _______ , and surveillance/monitoring systems to detect trends and allow for statistical analysis. a. Social Security number (SSN) b. DEA number c. driver’s license number d. Employee Identification Number (EIN)

8. For practitioners treating an active patient, searches generally need to go back _______ because practitioners are making a real-time clinical decision. a. 6 months to a year b. 2 to 3 years c. 4 to 5 years d. 6 to 10 years

5. It is critical for practitioners to recognize that information uploaded to the PDMP comes directly from _______. a. pharmacies or outpatient clinic records b. the patient c. the insurance company d. the pharmaceutical manufacturer

9. A “red flag” may be defined as any observation that provokes the user of the PDMP to evaluate the _____ of a prescribed medication. a. need b. safety c. legitimacy d. all of the above

6. When utilized in a timely manner, PDMPs can prevent _________. a. dangerous combinations of medications b. limit prescribing of unnecessary or duplicate prescriptions c. prevent doctor shopping as well as other types of medication diversion d. all of the above

10. As part of “best practices” process: Evaluate PDMP reports every ______ with your office manager using your DEA registration number to identify fraudulent prescriptions that have been issued using your DEA number. a. 3 months b. 6 months c. 9 months d. 12 months

7. Accessing the PDMP to ascertain information about _______ is usu-

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Volume 15 Number 1

PRODUCT INSIGHT

Same-day guided surgery with robotics Dr. Joe Griffin discusses how Yomi® robotic technology has transformed his practice

have been a general dentist in private practice for 22 years and have been placing implants for 18 years. I began utilizing haptic robotics to place implants in late 2019 using Yomi® robotic technology. My practice became the first in the state of Tennessee to adopt robotics for dental implant surgery, and I now place 250 to 300 implants per year robotically. Adopting dental robotics has transformed my practice.

Same-day guided surgery Robotics allows me to provide same-day guided surgery to my patients. When the patient comes in, we place a splint that attaches either to the patient’s existing dentition for single implants or to the patient’s bone using small self-tapping screws for fully edentulous cases. A fiducial array is Figure 1: Patient with splint and patient tracker arm attached to the splint, and a CBCT attached during a robot-assisted single implant scan is taken. procedure A three-dimensional implant placement plan for the case is done skiving, minimizing the amount of tissue on this scan and uploaded to the reflected, which saves time and pain for the robot. The fiducial is removed from patient and allows me to do cases more minthe splint and replaced by a patient imally invasively. Currently, an entire guided tracker arm that is attached to the non-sedated case from patient in-the-door to robot. This arm tracks the motion patient out-the-door takes less than 45 minFigure 2: Robotic surgery platform with robotic utes. The osteotomy and implant placement of the patient so that the robotic arm, patient tracker arm, and planning station for six implants on a full-arch, edentulous plan and the 3D haptic volumes case took 30 minutes initially, and now is around 20-25 minutes. move as the patient moves. The patient tracker arm ensures that the robot is synced with the patient’s mouth for the entirety of the procedure, and that the implant plan is carried out with Other advantages accuracy and precision. When I am ready to begin drilling, In addition to same-day guided surgery, using robotics proI hold the handpiece to move in an apical-coronal direction vides accurate placement without the time, cost, and intraoral being constrained by the robotic software to stay on long axis obstruction of plastic guides. There is full visualization and easy of the planned implant position. Finally, as I am preparing the irrigation with robotics. I can also change my plan intraoperosteotomy, the robotic arm physically stops me at the planned atively at any time for any reason, which is not possible with osteotomy depth. The same level of control is provided during preprinted plastic surgical guides. With robotics, I can choose from many different implant systems, and there are no additional implant placement. The physical haptic guidance prevents drill drill sleeves or other restrictions. Joe Griffin, DDS, completed his undergraduate degree from the University of Tennessee (UT) Knoxville. He received his Doctor of Dental Surgery degree from UT Memphis where he graduated with honors. He has subsequently received extensive specialized training in implant fixture placement and advanced bone-grafting procedures from the Midwest Implant Institute 1-year externship program on implant placement. Dr. Griffin received training at the Medical University of South Carolina in advanced soft tissue and bone grafting and completed a residency in conscious sedation at the University of Alabama at Birmingham. He also received an oral and IV sedation certification from the Tennessee State Board of Dentistry. Dr. Griffin currently practices at Cornerstone Dental Arts in Knoxville, Tennessee.

Patient perspective Carol Dunlap, RDA, is the Implant/Robotics Coordinator at my practice. She said: “Patients really get excited to know they are having implants placed with the robot. It has been a very positive experience for our patients, and they really do grasp the value of greater accuracy. Patients have been on board and have embraced dental robotics just as we have in the office.” IP This information was provided by Neocis.

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Your surgical skills

Our precise guidance

Set your practice apart with our revolutionary robot-assisted dental implant placement system. Have you met Yomi® ? As the first and only FDA-cleared, robot-assisted dental implant placement system, Yomi helps guide you through every step of your implant procedures. It’s top-of-the-line technology that can take your talent and practice to the next level. Bring us your bold vision, and we’ll bring you the confidence to execute it. You Yomi.

The future of dental surgery | yomirobot.com Yomi® is the first and only FDA-cleared robot-assisted dental surgery system. Yomi is a computerized navigational system intended to provide assistance in both the planning (pre-operative) and the surgical (intra-operative) phases of dental implantation surgery. The system provides software to preoperatively plan dental implantation procedures and provides navigational guidance of the surgical instruments. Yomi is intended for use in partially edentulous and fully edentulous adult patients who qualify for dental implants. More info at neocis.com/ifu © 2021 Neocis, Inc. NEOCIS and YOMI are registered trademarks of Neocis, Inc. All rights reserved. LB-0375-01 RA

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PRODUCT PROFILE

Panthera Dental CAD/CAM Sub Implant™: a new approach (part 1) Marc Desjardins discusses a new implant that is adaptable to specific bone morphology

ince the arrival of conventional screw implants, subperiosteal implants have been relegated to the status of antiques! Frankly, their success rate, both surgically and prosthetically, was absolutely not comparable to the screw implants of today. In previous years, the clinician had to be satisfied with prefabricated parts that often did not match the patient’s bone morphology. No auxiliary part was available for making the prosthetic part, no impression transfers, no abutments or implant replicas. The shape of these implants — often blade-shaped or with abutments that were too thin or too long — made it very difficult to achieve an accurate master model. Too often breakage occurred during the mold release. The fabrication of the prosBilateral CAD/CAM Sub Implant™ case — images of Panthera 3D Viewer for design validation and CBCT thesis was also problematic. scan after the surgery Today different treatment plans can be considered in a situation of the prosthesis in the laboratory is therefore carried out in a where the patient’s mandible has a severely vertically atrophied completely conventional manner, ensuring absolute confidence posterior alveolar bone. Some treatment plans are indicated by in the final result. the type of implant and the patient’s bone morphology. Others This unique system is designed and manufactured from the are adequate but are sensitive to the technique of the surgeon CBCT scan of the patient and based on the optimal prosthetic and require two surgeries. Only one meets all the criteria nectreatment plan decided before the design of the implant. Once essary for a predictable success — the CAD/CAM Sub Implant™ developed by Panthera Dental. Panthera Dental receives it, the design is done in Panthera’s Using proven 3D imaging and printing technologies, the proprietary software and then manufactured in Grade 23 6AL 4V ELI titanium and sandblasted to optimize osseointegration. CAD/CAM Sub Implant from Panthera adapts perfectly to the This process eliminates inaccuracies because no impressions of specific bone morphology of each patient and can be placed in a single surgical phase. The abutments are always parallel to the bone can be as precise. As a result, the procedure is done each other and offer a wide range of prosthetic components. quickly and requires only one surgery. Impression copings are available for open- or closed-impression Several solutions are available to the dental technician trays. Of course, replicas complete the system. The conception depending on the patient’s particular situation — fixed, cemented, or completely removable prosthesis. In some cases, structures can even be manufactured and delivered simultaneously, reducing the waiting time and the number of appointments. Marc Desjardins, TPAD (Technologue en Prothèses et The Panthera CAD/CAM Sub Implant is the modern alternaAppareils Dentaires), Senior Technical Advisor for Panthera tive solution for patients with lack of bone in the posterior area Prosthetic Division, has been a member of the College of Dental Technicians in the province of Quebec, Canada, and without sacrificing their healthy anterior teeth and their quality a laboratory director since 1977. He has more than 40 years of life. In addition, the production of the prosthesis is part of a of experience in the field. Founder of Laboratoire Lafond, normal, conventional process that becomes a key element in the Desjardins et Associés, a laboratory recognized and respected for the quality confidence of the dentist and patient. IP of its work, Desjardins defines himself as a visionary person with respect to new technologies in the dental industry. This information was provided by Panthera Dental.

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