Implant Practice US Summer 2024 Vol 17 No 2

The Holtzclaw Extra Sinus Infratemporal Anchorage zygomatic implant protocol

Dr. Dan Holtzclaw

Dr. Steven Vorholt

Drs. Samuel Lee, et al.

The Nation’s Top Implant Practices will be at

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 Learn Advanced Strategies to Generate Full-Arch Leads

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Summer 2024 n Volume 17 Number 2

Editorial Advisors

Jeffrey Ganeles, DMD, FACD

Gregori M. Kurtzman, DDS

Jonathan Lack, DDS, CertPerio, FCDS

Samuel Lee, DDS, DMSc

David Little, DDS

Brian McGue, DDS

Ara Nazarian, DDS

Jay B. Reznick, DMD, MD

Steven Vorholt, DDS, FAAID, DABOI

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

Preparing for winter

Immediate-load FP3 full-arch implant therapy is one of the more gratifying aspects of dentistry. We completely revitalize masticatory function and restore their livelihood through their appearance — in 24 hours or less. It’s one of the few procedures in all of medicine and dentistry that tackles both form and function simultaneously. What more could you ask for?

Years ago, there was one major player on the market, and the rest were small operations and sole practitioner offices doing full arches on the side at premium cost to the patient. Today, the prevalence of implant-focused offices and groups is increasing fast and has gained the attraction of institutional financiers.

The number of ancillary products and services focused on full arch are also increasing, including marketing companies, labs, and implant companies. With respect to supply and demand, the increase in competition leads to a rush to the market and dwindling rates to attract patients and customers. Some of these organizations very respectably hold a strong stance on maintaining quality and integrity; however, this isn’t always the case.

Some marketing firms boast experience and results alongside competitive rates but fall short in several, if not most measurable, metrics. Some labs attract customers with competitive rates but have an overworked design team that lacks competency and fails to achieve clinically reasonable completion times. CE ventures are no different. My colleagues and I came across recent graduates offering CE courses in full arch implants only months after having taken one of their courses themselves. Unfortunately, a dentist only has the benefit of word-of-mouth to vet new companies in this space, and if they don’t, are forced to “try them out” often at the patients’ expense. Sadly for patients, most can only afford to have this done once. The use of dentist-only social media groups for this reason are invaluable.

What’s alarming are malpractice firms with more interest in dental implants. This may be a sign that failures are increasing, perhaps indicating a decreased priority for proper training. If this trend persists, I fear more trouble for my colleagues despite proper clinical protocols, as well as regulation by governing bodies, dental as well as medical. I recently read an article showing all the documented extraocular muscle injuries secondary to malpositioned zygomatic implants, some of which were documented in ophthalmology journals.

In the context of dental practices, with more clinicians performing full arches, many feel the need to lower their rates to gain market share, which has gained the sentiment of many as a “race to the bottom.” Is this warranted? Considering that the rate of edentulism in America is to 1 in 10 Americans (roughly 33M), making the total addressable market more than that figure with consideration to the terminal dentition population, I don’t believe we are near saturation.

There is no question the number of full arches in the U.S. is increasing quickly. Couple this with the natural failure rate of implants over time and a paradigm shift away from conventional dental treatment planning which drives the average All-on-X patient age down, and we will soon have an epidemic of revision cases on our hands. What does this mean for the future? An increase in interest in the remote anchorage approach as well as future novel approaches not just by dental professionals, but also vendors. More revisions mean more mess for patients and for doctors. Hence, in the words of Jon Snow of Game of Thrones, “Winter is coming.”

Dr. Simon Oh 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, he spent a few years training in Oral and Maxillofacial Surgery at Hahnemann University Hospital and St. Christopher’s Hospital for Children. Dr. Oh is a published author in the Journal of Maxillofacial Trauma, Annals of Medicine and Surgery, as well as textbooks. He served as the Chief Clinical officer of Prosmile, one of the largest DSOs in the U.S. Today, Dr. Oh serves as the Founder and Chief Dental Officer of Smart Arches Dental Implant Centers, a premiere technology-based implant-only DSO. Dr. Oh is also the Founder and President of ORCAA (Operation Re-Denulate Central America) where they provide free full arch implant treatment. Additionally, he is the Founder of the Smile Back Foundation, a public charity providing microvascular jaw reconstruction and cleft surgeries to the citizens of Guatemala. Dr. Oh has special interest in extra-maxillary implants.

COVER STORY

What comes after success

Dr. Josh Everts offers techniques on how to achieve fulfillment

Cover image of Dr. Everts courtesy of OMS360.

PUBLISHER’S PERSPECTIVE

My Rx for summer

Dentists often overwork and under-relax. Here is a prescription from Publisher Lisa Moler for continued mental and physical health this summer, and into the future.

RESEARCH

A novel approach to simplify dental implant osteotomy that collects autogenous bone using a single drill without water coolant

Dr. Samuel Lee, Thomas Sangwook Lee, and Michelle Kim study a way to collect autogenous bone from the osteotomy

Large Practice Sales Brings Multiple Bidders For The Highest Value in IDSO Partnerships

“I

CONTINUING EDUCATION

The Holtzclaw Extra Sinus Infratemporal Anchorage zygomatic implant protocol

Dr. Dan Holtzclaw delves into a technique for salvaging failed zygomatic implants ..................... 26

PRODUCT PROFILE

Glidewell introduces the Glidewell HT™ Implant System 32

Dr. Steven Vorholt discusses the importance of identifying and addressing implants that warrant removal

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My Rx for summer

How many times have you written prescriptions for your patients? Even after they leave your office, you strive to ease their pain, head off their infections, and get them back to healthy lives. I’m not a dentist, but I have played one for almost 20 years now! So, for this summer issue, it’s my turn to write a prescription — to encourage ongoing mental and physical health for our dedicated readers.

My Rx for a productive and rejuvenating summer

Lisa Moler Founder/Publisher, MedMark Media

Vitamin D: Take some time to get out in the sun and soak up the relaxing rays! Change out of your scrubs and breathe some fresh air — and don’t forget your hat and sunscreen. You will return to work revitalized and ready to tackle any patient.

Get moving: Even if you don’t have time to get to the beach or take a longer vacation, exercise is one of the best ways to relieve tension and clear your mind. The CDC recommends 150 minutes of moderate-intensity physical activity per week. You don’t even need to join a gym — a daily walk will keep that blood flowing. Breaking the time up into 30 minutes a day for 5 days is very doable and can become a healthy habit.

Give your mind some thought: Every day, take some time for mindful thought or meditation. It doesn’t have to be the same time every day, or even done in the same way. Just pick a comfortable spot, close your eyes, breathe deeply, and focus on your breathing. Picture the beach, a mountain trail, or any spot that brings you peace. Taking a few minutes can reduce stress, ease frustration, and open the door to serenity.

Read, watch television, or listen to music: Having a way to unwind first thing in the morning or before bed can calm your mind and body.

Eat healthy, but give yourself a treat: We all know the drill — eat healthy fruits, vegetables and grains, go big on the protein and low on fats and sugars. But, as with all things under heaven, there is a time for ice cream and cake too (in moderation).

Build a trusted team, in and out of the office: Having support people to boost you when you are sad and laugh with you when you are happy can make life a warmer, more welcoming place.

Forgive yourself! One of my main mantras throughout this journey of life is to give yourself a break. Everyone makes mistakes, and no matter what some people think, no one is perfect. Every mistake is an opportunity to learn from and grow.

Keep learning: Whether you are in the office or on vacation, take MedMark specialty publications with you! Keep learning new concepts so when you return to work, you can expand your patients’ options for care.

In this issue’s Cover Story, Dr. Josh Everts offers techniques to maximize efficiencies, optimize results, and alleviate stressors in your practice from his experience as an oral and maxillofacial surgeon and some help from a management support organization OMS360. The CE by Dr. Dan Holtzclaw explores his HESIAn technique, which was born out of necessity for the treatment and rescue of previously failed zygomatic implant cases. Dr. Steven Vorholt’s CE also gives guidance on understanding the importance of identifying and addressing failed implants promptly for optimal patient outcomes and maintaining the integrity of surrounding oral structures.

Even if your summer is busy with patients, there are plenty of ways to keep a healthy outlook on life. Journalist Charles Bowden once said, “Summertime is always the best of what might be.” Try a few of my Rx recommendations, and you will feel that endless summer in your hearts and minds for all future seasons.

To your best success, Lisa Moler

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What comes after success

Dr. Josh Everts offers techniques on how to achieve fulfillment

Success

Simply put, success is getting what you want. This often begins with a goal that started long ago, one that was inspired by a vision of something you desired. You then started on a journey, charting your path, planning the steps, and creating a course with your eyes focused on achievement. This invariably comes with hurdles and adaptations, each one gifting you with the experience, knowledge, and confidence to move forward. It feels good, and the more you do, the more you want to do. If not, if things unravel or fall short, then we adjust and modify the goal as we go. This is often mixed with setbacks and delays, but with persistence, it starts to build on itself. The momentum and inertia of eventual wins gives you what feels like a runner’s high. It is hard work and can be downright difficult, but the work gives you a sense of pride. You feel great and start to see yourself crossing the finish line. And then it happens. You wake up one day to realize that you have accomplished what you set out to do. You

Josh Everts, DDS, MD, is an oral and maxillofacial surgeon in private practice with multiple locations across Alabama and Georgia. He is also a founding doctor and board member for the specialty management support organization OMS360, where he brings his passion for systems and processes to help practices achieve growth by maximizing efficiencies, optimizing results, and alleviating stressors.

built a business, you hit your mark, and you are doing what you had always hoped you would do. Then you take stock of what you have achieved and decide if you have what you want or if you want more. Either way, the work is not done. Tomorrow is another day with more challenges and tasks and problems that wait for you.

Strangely enough, success seems to have diminishing returns. Even if you march a steady slope of success, the more you achieve, the more you need to succeed to feel the same satisfaction, often putting you at a combined effect of two heavy realizations: 1) after accomplishing more, you must do exponentially more and 2) significant dissatisfaction with your surroundings. This is the professional version of both the Hedonic Adaptation and the Diderot Effect.

With the Hedonic Adaptation, our expectations rise in tandem with our level of achievement. This has been referred to as “abundance denial” and describes the desensitization of circumstances that have previously brought us a sense of wellbeing. What was once a great accomplishment becomes something almost unnoticed or even expected. Similar to emotional dampening, it happens with commercial success as well, where the more you succeed, the harder you have to work to produce similar successes. There is no wonder this is also referred to as a treadmill and is a driving factor behind professional burnout.

Denis Diderot originally described the Diderot Effect as the overwhelming sense of inadequacy towards his current

possessions after receiving a new elegant dressing gown. Compared to his new shining acquisition, everything he owned seemed tawdry and did not live up to the style of his new standard. Diderot then replaces these previously adequate possessions with more costly ones. He states, “I was the absolute master of my old dressing gown, but I have become a slave to my new one.” As you master your profession, you also become a slave to its success or failure. This new success leads to a desire to acquire more wins, often in areas unrelated to the initial success. You feel pressured to have it all. It can even create dissatisfaction with your life as a whole in comparison to the success you have achieved in your work.

Have I ruined success for you? Don’t get me wrong, I am an Enneagram 3 Achiever (Enneagram is a system of analysis that represents the spectrum of possible personality types.) and would not be where I am today without my desire to succeed. It drives me and pushes me to work tirelessly at my craft and approach my life with a bend toward continuous improvement. I would venture to guess that if you are reading this, you too share my desire to succeed. I am not here to offer you a solution to this obsession. I will say that gratefulness is the key to appreciating your success and keeping your mind from skipping over what you have accomplished. Gratitude allows you to reflect and take stock of where you are in relation to where you have been and gives you a real perspective on what is happening around you. This is how you recognize that you are successful.

Although the daily practice of gratitude helps tremendously, it is not the full answer to the never-ending hunger to succeed. What I am suggesting, however, is what happens when you move past success and focus on fulfillment.

Fulfillment

Fulfillment is becoming who you have the potential to be. It is discovering what you truly love and setting out on a new path to become that truth. True fulfillment comes from progress, incremental improvements that build the foundation for greatness. I wish it were not true, but we are terrible predictors of what our future selves will find satisfying. Therefore, the pursuit of what we will be rather than what we will have offers a more likely environment for emotional highs.

“It is never too late to be the person you could have been.” — George Eliot

Let me back up and explain how we get to fulfillment in the first place. Maslow’s Hierarchy of Needs starts with the basic needs of physiology. In business, this starts with the things we need to survive. Our food and shelter show up as customers and cash flow. For this, we develop processes and systems to create the safety and security we need to move up. Then we focus on our teams — a culture of caring is how we feel we belong. This gives us a sense of respect for ourselves and those we have surrounded ourselves with. A real team. An actual business. A successful product.

Here is where it gets tricky. We are highly motivated to meet the lower level needs, and that motivation changes as we fill in deficiencies. Just because we have satisfied a need does not mean that we have optimized that need. It is not required to meet

Opportunity is missed by most people because it is dressed in overalls and looks like work.” — Thomas Edison

a need with maximal effect before we start looking to the next level. Once a need has been satisfied to a minimally acceptable level, we quickly turn our attention to the next level. And, as we progress up the triangle, our motivation actually diminishes for the lower levels. We even turn a blind eye to needs we have previously addressed. At a certain point, we “arrive” at a sufficient level at which our motivation almost disappears, and we then desire a certain degree of homeostasis. Amazingly enough, this happens before we get to the highest level of “self-actualization.”

I think many of us find ourselves here and don’t know how to proceed. I would argue that it often requires reflection and introspection. This gives us permission to return to the start and re-evaluate if our systems and processes need to be refined to build the foundation necessary to move up. Admitting you are discontented is the first step. Finding the source of the discontent is where the work begins. Identify inefficiencies and waste with an eye for making it easy — easy for your business and easy for your customer.

Most people are seeking a higher level of growth, but we become distracted in our pursuit. We learn the basics, satisfying each need with enough to be average, and then we look for the new great thing to propel us forward. It is almost as if the first few levels are “beneath” us, and continuing to focus our attention there might admit we are not any better than a professional just starting their journey. “Been there, done that.” I would argue that mastering the basics is actually the key to being ruthlessly effective. The basics might seem simple but that doesn’t mean they’re simplistic. Those who are achieving the best results probably don’t have some secret process or magical procedure. They merely understand the fundamentals better than others.

Unfashionable problems are undervalued. The most basic issues are often minimized because of their lack of appeal and mundane feel. The natural instinct is to follow the shining object and work on something flashing with high promise. But the other extreme is also true, and you can get bogged down in meaningless details. Don’t worry equally about everything. Doing good work is built on the basics of that work — small improvements of repeated activities. Stringing together small opportunities that lead to incremental advances will pay off like compounding interest. Each strength will build on the last and place distance between where you are now and where you were.

When it comes to fulfillment, there is no such thing as a quantum leap, only enthusiastic persistence. Passion and perseverance are a deadly combination. Focus on daily determination and resolve to put one foot in front of the other, walking away from the space you occupied previously and onward to a new future despite inevitable hardships. More specifically, you identify problems, make hypotheses, run experiments, collect data, and make changes to improve results. The results are real

progress. This is not about more money, more work, or even more recognition. Great caution should be had towards a focus on prestige and money alone. These should only be byproducts of the type of person you are becoming along the way and the value you are creating.

Mastery

It takes exponentially more effort to make changes the higher the level of change. This means you have to be very selective about the few things you choose to do that are worth doing. If they are worth doing, then they are worth doing better than average. This is how you work towards mastery.

The word “mastery” can have many meanings. I think a better word is “agency” — a sense of control that comes from your capacity to influence your own thoughts and behaviors. This gives you the confidence to handle a wide variety of new tasks and environments. You build this faith in your abilities by intentionally committing to a thoughtful future and acting in alignment with a set plan. This is balanced by a deliberate practice of focused thought that allows for affirming or adapting your course and further strengthening the sense of mastery. An agent is master of his domain who has decided who they will and will not become, and has set a course based on the things they can control to pursue greatness in their field.

“You don’t become great by trying to be great. You become great by wanting to do something, and then doing it so hard that you become great in the process.” — Randall Munroe

The most important determinant of mastery is diligence — shear willfulness balanced by discipline to be patient with the process and focus on the mundane. This does not happen without being earnest, defined as “resulting from or showing sincere and intense conviction.” Focus on what matters now, as well as what doesn’t. Intentionality.

Mastery is not only about getting better at your craft, but also about finding ways to eliminate the obstacles, distractions, and other annoyances that prevent you from working on your craft. Top performers find ways to spend as much time as possible on what matters and as little time as possible on what doesn’t. It

Learn to work harder on yourself than you do on your job. If you work hard on your job, you’ll make a living; if you work hard on yourself, you can make a fortune.” — Jim Rohn

is not someone else’s responsibility to create the conditions for success. You have to actively eliminate the things that don’t matter from your workload. If you haven’t figured out how to do that, you haven’t mastered your craft.

Community

This pursuit is a progression from who you are now to who you aspire to be. You make progress by being challenged by those around you. It is the bitter awareness of where you are and where you would like to be. This gap creates a dissonance — a feeling of discomfort, tension, weight. This discomfort is different from the previously described emptiness of meaningless successive accomplishments. This discomfort is one that knows you can be better and is excited about its prospects.

Identification of gaps and deficiencies also requires knowledge of blind spots. This is best accomplished through the vulnerability of strategic partnerships. It admits that you don’t know everything, which opens you up to learning what you don’t know. More commonly known as curiosity, it can feel a lot like vulnerability. It takes the humility to know that you don’t know it all and the teachable spirit to go looking for it.

Do not ignore the power of collaboration. The degree that great work happens in clusters suggests that one’s partners and associates often make the difference between doing great work and not. Ambitious people encourage more ambition in other ambitious people. Iron sharpens iron. I think the overwhelming difference in professional trajectory lies in those you choose as your close company. Be aware of character and commitment when choosing partners. You will multiply your impact, either good or bad, based on your team’s composition.

Beyond success

The stoics labeled those that embarked on this journey as “tryers” (proficientes). They took a theory, put it into practice, mastered a skill, and then taught those around them. This first requires you to realize imperfections and generate a desire to improve and to clear your mind of irrational beliefs. This desire often comes as a “wake up” where you see things in a different light. And most importantly, you use time to your advantage and develop a habit of trying.

I hope that this article has opened your eyes to how to achieve fulfillment by making incremental progress, mastery through enthusiastic focus, and community with strategic partners. Apply gratitude, introspection, persistence, diligence and collaboration. Know that it will be work, but work that fulfills our deepest desires. Work that takes us beyond success. This is a call not to have more or do more, but to be more. IP

A partnership with OMS360 will enable you to de-risk your investment, accelerate your growth, simplify your life, and unlock new opportunities for sustainable success, empowering you with innovative solutions, strategic insights, and comprehensive support every step of the way.

OMS360 provides comprehensive marketing support to drive increased patient volume at your practice

OMS360 cultivates Success with strategy and our operating system.

STAFFING AND RECRUITING

OMS360’s full suite of recruiting services will alleviate the stress, burden and time spent during a new hire process.

A novel approach to simplify dental implant osteotomy that collects autogenous bone using a single drill without water coolant

Dr. Samuel Lee, Thomas Sangwook Lee, and Michelle Kim study a way to collect autogenous bone from the osteotomy

Abstract

This study investigates a novel approach to dental implant osteotomy, aiming to simplify the procedure by employing a single drill without the use of water coolant. Traditional methods involve multi-step drilling with saline irrigation to manage heat generation and preserve tissue integrity. However, these approaches can introduce complications and inconvenience. In contrast, the proposed single-drill protocol eliminates the need for multiple steps and irrigation. This new approach allows

Samuel Lee, DDS, DMSc, is an innovator with a passion for teaching and developing new technologies. Dr. Lee obtained two doctorate level degrees: Doctor of Medical Science and a specialty degree in Periodontology from Harvard University, as well as his Doctor of Dental Surgery from UCLA. He invented the “Crestal Window Sinus Grafting Technique,” and owns the patent on various sinus and surgical instruments. He also introduced a new method of dental radiography that uses ultra-low dosage radiation and allows for angulation correction, enhancing 3D imaging capabilities. As the Founder and Director of the International Academy of Dental Implantology, he focuses his career on teaching and doing research. Among many other distinguished achievements, he has trained over 10,000 dentists worldwide in implant dentistry, developed a new method of dental x-ray, and designed advancements to surgical tools. He travels internationally, lecturing on his sinus techniques and TADs to surgical specialists, general dentists, and dental schools.

Thomas Sangwook Lee is a researcher at The International Academy of Dental Implants. He is a predental student at Santa Fe Christian School. His goal is to become a dental implant surgeon. He holds patents on a unique thermosensor for oral surgery.

Michelle Kim is a researcher at The International Academy of Dental Implants. She is a predental student at University of California, San Diego. Her goal is to become a dental implant surgeon.

surgeons to collect autogenous bone from the osteotomy. Using thermal cameras, the study assesses the temperature changes during osteotomy and evaluates the safety and efficacy of this innovative approach. The study encompasses three key aspects:

1. An examination of the effects of various drilling techniques on bone temperature,

2. An exploration of the relationship between drill dimensions and thermal conductivity

3. A retrospective analysis of the success rate of the single-step osteotomy without coolant in a clinical setting. Findings indicate that the single-step osteotomy protocol, when executed with precision, can maintain bone temperatures below critical levels without the need for water coolants. This innovative approach offers potential benefits in terms of surgery simplification and reduced patient and operator stress, particularly in complex dental procedures. The study underscores the importance of new drill technologies that collect bone while simplifying surgery and improving the efficiency and safety of dental implantation.

Introduction

Disclosures: Dr. Samuel Lee is the inventor of Newton Implant System. Thomas Lee is the inventor of Thermal Detector for Implant Osteotomy.

Eriksson, et al., established 47 degrees Celsius as the critical temperature at which bone cells necrose in a rabbit model when drilled for more than one minute.1 Furthermore, 44 degrees Celsius (111.2 Fahrenheit) is recognized to be the threshold at which necrosis does not seem to occur. To maintain cell viability during oral implantation, many clinicians advocate for multistep drilling combined with saline coolant. In this article, we aim to explore the use of a single-drill protocol as an alternative technique for oral implantation that eliminates the need for multi-drilling protocols and saline irrigation. This is because the conventional multi-step drilling protocol can lead to increased complications such as contamination and inconvenience by showing it does not result in necrosis in the cell and does not generate heat when kept below 44 degrees Celsius (111.2 Fahrenheit), which is where necrosis seems to occur. This is because while water coolants like saline irrigation assist in reducing temperatures, they can also introduce complications such as choking, laryngospasm,9 saliva contamination, and loss of bone from the drill.

Figure 11 is more volatile and does not follow the trends Figures 5 and 6 follow. However, this is likely because heating for 1 second is so short that it did not have much of an effect on the temperature of the shank. The differences between the different widths of drills in Figure 11 are not statistically significant, so a trend cannot be established.

The findings within part 2 help establish the general trends between the thermal conductivity of drills and the temperatures of the shank of drills in relation to their tips. These findings can help estimate the heat of the tip of drills in 10.0 mm length in different time intervals. However, more analysis and additional models are recommended for data on different types of drills.

3. Part 3: Patient data on one-step osteotomy

A retrospective study of 267 patients from September 1, 2020 to October 10, 2023, in a dental implant institute in San Diego received 979 dental implants (585 in the maxilla, Figure 8) and 394 in the mandible (Figure 9) using a one-step (single) osteotomy technique without water coolant. As seen in Figure 10, the success rate of these implants outperforms compared to the traditional dental implant success rates reported by Papaspyridakos et al., (2012).8

Discussion

Part one of the study presents a comprehensive comparison of various drilling techniques against a critical temperature threshold of 44 ° C/ 111.2° F. All other methods, except for the piezo technique, both with and without irrigation, remained below this critical temperature. Consequently, the study indicates that conducting a single-step osteotomy without irrigation at speeds below 1000 rpm for short durations not exceeding three seconds effectively maintains bone temperatures below potentially hazardous levels within the pig model. In order to further ensure low thermal damage, lower speed can be employed, suction placed near the osteotomy (Figure 6A), and use of a new sharp instrument (drill). Figures 4A, 4B, and 8 show both multi-step and one-step osteotomy without water coolant. These groups all showed lower temperatures than thermal damage temperature (44 ° C/ 111.2° F). Therefore, water coolants are not necessary if the surgeon employs the precautions mentioned above.

Hollow drills offer implant surgeons the following advantages:

1. They reduce frictional heat by removing bone particles away from the osteotomy into the center of the drill.

2. They collect autogenous bones to be used for grafting. The best use of a step hollow drill is without coolant, as the irrigant can wash away the bone particles.

Interestingly, the hollow drills offered lower temperatures when used at higher speeds at 1000 rpm versus 150 rpm, as seen in Figure 8. This is true when pumping the drill up and down as it cools down from rotating air. The bone collected from this

Figures 13A and 13B: Success rate of one-step drilling protocol without coolant. Thermal damage leads to early failure (within the first few weeks); therefore, most failures in these studies are not due to thermal damage

Figure 12A

Figure 12B

hollow drill is used to augment the dental implant, as seen in Figures 15 to Figure 18.

In the study, an up-and-down motion was used to decrease contact time between the drill tip and the bone and to measure the temperature of the tip. This technique is recommended especially when not using saline irrigation to cool down the drill to prevent reaching the critical thermal damage temperature.

If a surgeon does not employ up-anddown motion without irrigation, the tip of the drill might exceed the critical temperature since the thermal camera can only detect the surface temperature (shank or bone surface). In Part 2 of our study, we aimed to find the ratio between the tip and the shank of the drill. Our result suggests that there is a statistical trend between the diameter of the drill (Figures 10-12) of 10.0 mm length drills and their thermal conductivity when heated for 3 seconds or 5 seconds. The authors hypothesized these trends to be a result of the ratio between the surface area of a drill and the volume of the drill. However, further research is suggested to find statistical validity for that hypothesis. In this study, there was no notable trend when heated for 1 second. The authors believe this to be the case because 1 second is likely not enough time for heat to travel to the drill’s shank. As a result, the trends found within our study cannot be applied to cases in which the drill is heated for less than 3 seconds.

One-step osteotomy without irrigation simplifies the surgery and reduces surgical time. It reduces stress for the operator and the patient. In addition, it allows the surgeons to collect autogenous bone from the osteotomy, which in turn, can be used in complex cases involving sinus lift or vertical ridge augmentation. Most osteotomies ended in 5 seconds due to a simplified approach to dental implantation. There are three very important requirements to achieve a successful “one” drilling protocol.

1. In order to ensure sharpness of the drill, our group recommends a new drill for each surgery. Repeated use of drill and autoclave processes have been known to dull the drills.

2. Fully guided surgery is highly recommended. When using a step protocol, there is no guiding pin involved,

nor is there any subsequent drilling to rescue malangulation of the osteotomy.

3. Implant morphology should accommodate bone density. For maxillary bone, a smaller pitch and wider crystal body is recommended. For mandibular bone, a higher pitch and narrower crystal body is indicated. The pointed apex allows self-tapping of the implant without bottoming out in case the surgeon wishes to place the fixture deeper. This study shows that the success rate is over 97% on both maxilla and mandible. Long-term follow-up (> 5 years) is not available, but should thermal necrosis happen, it is within weeks after implantation. Therefore, if the failure resulted from thermal damage during osteotomy, we can observe it within 6 months of follow-up. The authors believe that a single drill without coolant results in faster surgery and less stress for the patient and the operator. This can be attributed to a higher success rate, especially if the procedure involves more complicated bone morphology needing sinus lift or ridge augmentation, the use of autogenous bone collected from the hollow drill gives an unparalleled advantage to surgical healing as autogenous bone is the gold standard. For example, the case in Figure 10 involves a sinus lift. Since the osteotomy was simple, the surgeon was able to concentrate more on sinus grafting. Furthermore, the autogenous bone collected from the hollow drill mixed with FDBA resulted in faster healing. As discussed earlier, in a maxilla with minimal bone height, it is critical to use an implant with a higher pitch and a larger crystal body to achieve good initial stability.

Figure 15: Simplified osteotomy makes the surgery easier, allowing surgeons to have more time for more complex procedures such as sinus bone grafting. Autogenous bone collected from the hollow drill makes the bone heal faster

Figures 14A and 14B: 14A. The number of dental fixtures placed in maxillary bone using the one-step drill and no coolant in the maxilla and their follow-up to 3 years. 14B. The number of dental fixtures placed in mandibular bone using a one-step drill and no coolant in the maxilla and their follow-up to 3 years

Figures 16A-B: 16A. 2-year follow-up after “one-step” drilling protocol to install a Newton Dental Implant (San Diego, California), 4.5 mm x 13 mm with a simultaneous sinus lift. 16B. 3-year follow up

Figure 11 shows 3-year follow-up showing bone preservation without any bone loss.

Another challenge in implant dentistry is vertical ridge augmentation. By utilizing the “one-drill” protocol, the surgeon simplifies the installation of the dental implant, thereby giving more time to the bone augmentation procedure. Again, the autogenous bone collected from the drill is reused with FDBA in these challenging cases. Autogenous bone gives osteogenic and osteoinductive properties. However, it is not very osteoconductive as bone particles are very small. Therefore, mixing with FDBA supplements this mixture very well since FDBA is good osteoconduction. Figure 17 shows vertical bone loss due to periodontal abscess. Upper centrals are extracted, and a “one-drill” protocol with guided surgery has been performed. Autogenous bone mixed with FDBA bone is used to augment before the insertion of a dental implant. Newton Implant (San Diego, California) 4 mm x 13 mm fixtures are placed with excellent torque due to their sharp apical shape and aggressive thread design. 3 year follow-up shows excellent bone maintenance and healthy peri-implant tissues, as seen in Figure 18.

Conclusion

A traditional multi-step drilling protocol with saline coolant has been used for decades as proposed by the original Brånemark Protocol. However, using the new one-drill protocol with a new hollow drill, computer-planned and guided, and innovative dental implant design helps oral implantologists to minimize surgical time and reduce stress to our patients. In addition, the hollow drill allows autogenous bone collection, which can be used in complex procedures such as vertical and horizontal ridge augmentations as illustrated in this article.

REFERENCES

1. Eriksson RA, Albrektsson T. The effect of heat on bone regeneration: an experimental study in the rabbit using the bone growth chamber. J Oral Maxillofac Surg. 1984 Nov;42(11):705-711.

2. Moritz AR, Henriques FC. Studies of Thermal Injury: II. The Relative Importance of Time and Surface Temperature in the Causation of Cutaneous Burns. Am J Pathol. 1947 Sep;23(5):695-720.

3. Lundskog J. Heat and bone tissue. An experimental investigation of the thermal properties of bone and threshold levels for thermal injury. Scand J Plast Reconstr Surg. 1972;9:1-80.

4. Eriksson RA, Albrektsson T, Magnusson B. Assessment of bone viability after heat trauma. A histological, histochemical and vital microscopic study in the rabbit. Scand J Plast Reconstr Surg. 1984;18(3):261-268.

5. Eriksson AR, Albrektsson T. Temperature threshold levels for heat-induced bone tissue injury: a vital-microscopic study in the rabbit. J Prosthet Dent. 1983 Jul;50(1):101-107.

6. Eriksson AR, Albrektsson T, Albrektsson B. Heat caused by drilling cortical bone. Temperature measured in vivo in patients and animals. Acta Orthop Scand. 1984 Dec;55(6):629-631.

7. Bonfield W, Li CH. The temperature dependence of the deformation of bone. J Biomech. 1968 Dec;1(4):323-329.

8. Papaspyridakos P, Chen CJ, Singh M, Weber HP, Gallucci GO. Success criteria in implant dentistry: a systematic review. J Dent Res. 2012 Mar;91(3):242-248.

9. Kim JY, Chae M, Lee J. Operative hysteroscopy intravascular absorption syndrome caused by massive absorption of 0.9% saline as the distention/irrigation medium. Korean J Anesthesiol. 2013 Dec;65(6 Suppl):S44-46.

Figure 17: Preoperative X-ray showing vertical bone loss on upper centrals

Figure 18: 3-year follow-up after “one-drill” protocol and Newton Dental Implant placed. Notice healthy tissue around the implant and preservation of coastal bone. This successful vertical ridge augmentation is attributed to autogenous bone collected from the “one-step” hollow drill

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From removal to renewal: a comprehensive look at extracting and replacing failed dental implants

Dr. Steven Vorholt discusses the importance of identifying and addressing implants that warrant removal

Each year, millions of dental implants are placed worldwide, offering patients a reliable solution for replacing missing teeth and restoring oral function. With an impressive survival rate of around 98%, dental implants have revolutionized modern dentistry, providing long-lasting benefits to countless individuals. However, even with such high success rates, a small percentage of implants may encounter complications, leading to failure and necessitating removal. Considering the staggering volume of implants placed annually — even a 2% failure rate translates to a substantial number of cases requiring intervention. Timely removal of failed implants is crucial to prevent further complications and preserve oral health. When left untreated, failed implants can become sources of infection, leading to bone loss, tissue damage, and potentially compromising neighboring teeth. Therefore, understanding the importance of identifying and addressing failed implants promptly is paramount in ensuring optimal patient outcomes and maintaining the integrity of the surrounding oral structures.

When a dental implant is exhibiting signs of failure, prompt removal is imperative to prevent additional harm to the alveolar process, adjacent teeth or implants, and to ensure the patient’s health and comfort. Common indicators of implant failure include pain, dull sounds upon percussion, purulence, radiographic evidence of bone loss and radiolucency, as well

Steven Vorholt, DDS, graduated with a dental degree from The Ohio State University in 2013. Shortly after graduation, Dr. Vorholt started a private practice in the Columbus area. Immersing himself in as much continuing education as possible, he quickly developed a great passion for dental implant surgery. After building a successful general practice in Ohio, Dr. Vorholt followed his passion and moved to Arizona in 2020 to accept a full-time position with Implant Pathway helping to educate over 1,000 dentists place over 15,000 implants on their paths with implant dentistry

Dr. Vorholt is a Fellow of the American Academy of Implant Dentistry and is a Board-certified Dental Implantologist, earning his Diplomate from the American Board of Oral Implantology in 2021. He finds teaching other doctors how to successfully incorporate implant dentistry into their own practices to be his proudest professional endeavor. Dr. Vorholt currently resides and practices in Santa Barbara, California where he focuses solely on full mouth rehabilitation with dental implants in an entirely digital workflow at Santa Barbara Dentures and Implants.

Disclosure: Dr. Vorholt reports no conflicts of interest with the products mentioned in this article.

Educational aims and objectives

This self-instructional course for dentists aims to delve into the complexities of removing failed dental implants, explore the reasons behind implant failure, observe the surgical techniques involved in extraction, and identify the critical aspects of post-removal rehabilitation.

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:

• Recognize early signs of implant failure.

• Identify risk factors that predispose patients to implant failure.

• View failed implants as opportunities for learning and improvement.

• View implant removal as a staged process, involving preoperative assessment, surgical intervention, and postoperative rehabilitation. Recognize the significance of postremoval rehabilitation techniques.

as mobility. However, the necessity for implant removal extends beyond infection and failure. Instances where implants are poorly positioned for restoration, previously integrated implants requiring extraction for full arch implant treatment, or rare but severe patient allergies to dental implants also warrant removal. The simplest dental implants to remove are those that fail to osseointegrate. Typically, these implants display mobility and can be extracted using rongeurs or forceps alone. Alternatively, the insertion driver can be utilized, and the implant can be reversed out. However, caution must be exercised when dealing with infected and mobile implants near the maxillary sinus to prevent inadvertent displacement into the sinus cavity. While attempts to retrieve dislodged implants through the osteotomy may be successful, more complex cases may necessitate a Caldwell-Luc approach into the lateral wall of the sinus. To mitigate this risk, it is advisable to refrain from using instruments that exert apical pressure on the implant. Instead, an open tray impression coping or fixed guided carrier can be meticulously engaged

into the connection, providing a more secure grip for successful implant removal (Figures 1A-1E).

When dealing with integrated implants that require removal, the initial approach should prioritize conservatism. In cases where osseointegration needs to be broken, employing the insertion driver in reverse, aiming for approximately 60Ncm, can yield success, particularly in the posterior maxilla or implants with considerable crestal bone loss. However, it’s crucial to exercise caution and refrain from applying maximum torque in reverse, as these drivers are typically not designed to withstand torque exceeding 80Ncm. Exceeding this threshold can lead to stripping or fracturing of the driver.

If attempts to reverse-torque the integrated implant are unsuccessful, the next step involves considering a fixture removal kit. Salvin Dental offers a popular kit, and similar options are available in the market. This kit typically includes a reverse-threaded tap, which is inserted into the implant connection and engaged in a counterclockwise direction until it cold welds into the implant. This allows the counterclockwise force to be transferred to the entire fixture. Such kits often come with longer torque wrenches, enabling forces of up to 120Ncm, and are suitable for most implants in the maxilla and posterior mandible. The implant fixture tap will be ankylosed into the implant body and unable to be removed without reversing paired vice grips, and can be expensive to replace.

However, potential complications with this technique include fracture of the fixture removal tip or flowering of the dental implant (Figures 2A-2B). Surgeons should be mindful of the material and thickness of the implant being removed. Commercially pure titanium and implants with thinner connection walls are more susceptible to flowering compared to alloy implants with larger platform switches. Understanding these factors is crucial for minimizing complications and ensuring successful implant removal and may force a surgeon to consider skipping the fixture removal tap in favor of a trephine removal technique.

Trephine drills are widely recognized as one of the most aggressive techniques for dental implant removal, offering a high level of predictability. However, they can complicate immediate replacement with a new implant due to the widening of the osteotomy during the removal process. These drills function similarly to core sample drills, cutting a cylindrical section of bone surrounding the integrated dental implant to remove the entire plug of integrated bone and implant. It’s worth noting that it’s often unnecessary to take the trephine drill to full depth. Instead, a step-wise approach is recommended, drilling incrementally to depths such as half, two-thirds, and three-quarters of the implant length. This strategy helps avoid removing more bone than necessary. It’s important to exercise caution when using trephines near vital anatomy, as implants close to critical structures may be contraindicated for trephine use or limited to a depth that does not encroach on vital structures such as the mandibular lingual plate or mandibular nerve canal. This ensures patient safety and minimizes the risk of complications during the removal process.

Figures 1A-1E: Removing an infected implant near the sinus floor using a guided carrier that engages in the implant allows for more controlled removal to avoid iatrogenic displacement into the sinus

Figures 2A and 2B: A potential complication is fracturing of the fixture removal drill inside the implant body when removing integrated implants

After the removal of a dental implant, the decision to immediately replace it with another implant should be approached similarly to the decision-making process for placing immediate implants after tooth extraction. Several factors must be considered, including the available bone volume to ensure primary stability of the new implant, the establishment of an appropriate restorative position for future implant restoration, and ensuring adequate space from vital structures.

Furthermore, thorough removal and debridement of the osteotomy site, as well as any infected tissue or bone surrounding the previous implant, are crucial steps in the process. This is akin to the approach taken during immediate implant placement around a chronically infected or periodontally involved tooth. By meticulously cleaning the site and ensuring the removal of any diseased tissue, optimal conditions for successful implant osseointegration and long-term stability can be achieved.

Case

examples

Simple removal with reverse torque

During the uncovering phase of a lower overdenture case, a posterior implant was observed to display early crestal bone loss.

To address this issue, the implant was carefully removed using reverse torque with the insertion driver, minimizing additional bone removal. Subsequently, the osteotomy site was meticulously cleaned to ensure removal of any debris or infected tissue. A new implant, wider and deeper than the previous one, was then placed into the same osteotomy site.

During the healing process, the newly placed implant was buried, while the other integrated implants were utilized to support the overdenture prosthesis. This allowed for the replacement implant to integrate successfully without bearing load during the initial healing period. Once the replacement implant had fully integrated, it could be uncovered and incorporated into the prosthetic restoration, ensuring optimal function and stability of the overdenture. This approach enabled the successful management of early crestal bone loss while maintaining the integrity of the implant-supported overdenture (Figures 3A-3H).

Implant removal with fixture removal kit

In a case where a patient presents for edentulation of the maxillary arch and requires a conventional denture with a single integrated implant at site No. 9, the surgical approach may vary

Figures 3A-3H: Most implants that are failed or infected can be removed by using the insertion driver in reverse, and is the least traumatic of removal options. Replacement of the dental implant follows the same rationale used for immediate implants after tooth extraction. Clean any infection, assess bone volume and quality, and place implant if appropriate

depending on factors such as implant brand compatibility. In this scenario, if the implant being removed is of a different brand and line than what the surgeon typically has access to, the insertion driver reversal technique may not be feasible.

Instead, the surgeon may opt to use a fixture removal kit, which is universal and not dependent on the implant’s connection type. These kits typically include fixture removal tips of various sizes (narrow, regular, wide) to accommodate different implant dimensions.

During the procedure, the appropriate-sized fixture removal tip is selected based on the size of the implant. In cases where the widest available tip is not sufficient, a pro tip suggests that the surgeon can modify narrower tips by cutting off the ends to convert them into larger widths.

The chosen fixture removal tip is then turned counter-clockwise into the implant connection until it cold welds into place. Subsequently, a long, non-breaking torque wrench is attached, and the implant is gently removed in a counter-clockwise direction using a non-invasive technique. This method allows for the safe and effective removal of the implant without compromising surrounding bone or tissue (Figures 4A-4D).

Identifying signs of implant failure sets the stage for timely intervention, safeguarding against further complications and preserving oral health.”

Trephine removal for full arch revision

In a case where a patient presented with a completely failing lower fixed arch necessitating revision surgery, the majority of implants were successfully removed using traditional reverse torque techniques due to bone loss and infection. However, implant No. 19 posed a challenge as it was integrated and resistant to atraumatic removal methods.

To address this issue, a trephine drill from Meisinger USA was selected, ensuring it was just large enough to fit over the implant diameter. Depth markers on the trephine drill allowed for precise depth control, and a preoperative CBCT scan was consulted to ensure a safe distance from the inferior alveolar nerve (IAN).

Carefully utilizing the trephine drill to half the length of the implant while maintaining control over the depth avoids any complications with vital structures. Subsequently, reverse torque was successfully achieved using the insertion driver, allowing for the safe removal of the integrated implant.

Following the successful removal of implant No. 19, the surgery proceeded with a traditional All-on-4 revision approach. This case highlights the importance of utilizing appropriate tools and techniques to address challenging scenarios in implant dentistry, ensuring optimal outcomes for the patient (Figures 5A-5E).

Figures 4A-4D: Implant removal via the fixture removal drill technique (Salvin) engages the implant body in a reverse threaded design to reverse torque the implant body at high torque (~100Ncm)

Conclusion

In the realm of implant dentistry, the journey from removal to renewal embodies both challenge and opportunity. As we’ve explored the intricate process of addressing failed dental implants, it becomes evident that each case presents a unique puzzle, demanding a tailored approach for optimal resolution.

The pivotal role of early recognition cannot be overstated. Identifying signs of implant failure sets the stage for timely intervention, safeguarding against further complications and preserving oral health. Moreover, embracing failed implants as learning opportunities propels us towards continuous improvement, refining our strategies and enhancing patient care.

Surgical techniques, ranging from conservative to aggressive, offer a spectrum of options for implant removal. Yet, it’s the artful application of these techniques, guided by patient-specific considerations, that truly defines success. From the delicate precision of trephine drills to the strategic finesse of fixture removal kits, each tool in our arsenal serves a purpose, sculpting the path towards restoration.

Crucially, the journey doesn’t end with removal. Post-removal rehabilitation emerges as a cornerstone, fostering an environment conducive to successful implant osseointegration and long-term stability. Through meticulous debridement and thoughtful preparation, we lay the groundwork for the next phase of the patient’s journey – renewal.

In our case examples, we’ve witnessed the transformative power of these principles in action, guiding patients from complication to resolution, from uncertainty to confidence. It’s a testament to the artistry and science of modern implant dentistry, where innovation meets compassion in pursuit of patient well-being.

As we navigate the complexities of implant management, let us remain steadfast in our commitment to excellence. By staying attuned to emerging technologies, sharing insights within our professional community, and nurturing a culture of continuous learning, we equip ourselves to meet the evolving needs of our patients with unwavering skill and dedication.

In the end, it’s not merely about extracting and replacing failed dental implants — it’s about revitalizing smiles, restoring function, and enriching lives. It’s about embracing the journey, with all its challenges and triumphs, and forging ahead with confidence, knowing that each step brings us closer to our shared goal: the pursuit of dental excellence and patient well-being.

Figures 5A-5E: In instances of integrated implants, the trephine technique is used to cut circumfrentially around an implant body to allow easier implant removal. Care must be taken around vital anatomy and when utilizing trephines IP

REFERENCES

1. Young L, Brown T, Lamont TJ. A comparison of techniques for the explantation of osseointegrated dental implants. Evid Based Dent. 2020 Dec;21(4):126-127.

2. Roy M, Loutan L, Garavaglia G, Hashim D. Removal of osseointegrated dental implants: a systematic review of explantation techniques. Clin Oral Investig. 2020 Jan;24(1):47-60.

3. Tafuri G, Santilli M, Manciocchi E, Rexhepi I, D’Addazio G, Caputi S, Sinjari B. A systematic review on removal of osseointegrated implants: un update. BMC Oral Health. 2023 Oct 13;23(1):756.

4. Stajčić Z, Stojčev Stajčić LJ, Kalanović M, Đinić A, Divekar N, Rodić M. Removal of dental implants: review of five different techniques. Int J Oral Maxillofac Surg. 2016 May;45(5):641-648.

5. Solderer A, Al-Jazrawi A, Sahrmann P, Jung R, Attin T, Schmidlin PR. Removal of failed dental implants revisited: Questions and answers. Clin Exp Dent Res. 2019 Aug 21;5(6):712-724.

Continuing Education Quiz

From removal to renewal: a comprehensive look at extracting and replacing failed dental implants

VORHOLT

1. With an impressive survival rate of around _______, dental implants have revolutionized modern dentistry, providing long-lasting benefits to countless individuals.

a. 70%

b. 78%

c. 88%

d. 98%

2. When left untreated, failed implants can become sources of infection, leading to _______.

a. bone loss

b. tissue damage

c. potentially compromising neighboring teeth

d. all of the above

3. When dealing with integrated implants that require removal, the initial approach should prioritize conservatism.

a. True

b. False

4. In cases where osseointegration needs to be broken, employing the insertion driver in reverse, aiming for approximately ______, can yield success, particularly in the posterior maxilla or implants with considerable crestal bone loss.

a. 40Ncm

b. 50Ncm

c. 60Ncm

d. 70Ncm

5. However, it’s crucial to exercise caution and refrain from applying maximum torque in reverse, as these (insertion) drivers are typically not designed to withstand torque exceeding _______.

a. 60Ncm

b. 70Ncm

c. 80Ncm

d. 90Ncm

6. If attempts to reverse-torque the integrated implant are unsuccessful, the next step involves considering _______.

a. a fixture removal kit

b. rongeur

c. forceps

d. insertion driver

7. Fixture removal kits often come with longer torque wrenches, enabling forces of up to _______, and are suitable for most implants in the maxilla

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

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.

AGD Code: 690

Date Published: June 30, 2024

Expiration Date: June 30, 2027

and posterior mandible.

a. 100Ncm

b. 120Ncm

c. 130NCm

d. 140Ncm

2 CE CREDITS

8. _________ and implants with thinner connection walls are more susceptible to flowering compared to alloy implants with larger platform switches.

a. Stainless steel

b. Commercially pure titanium

c. Cobalt-chromium

d. Nickel-chromium alloys

9. It’s important to exercise caution when using trephines near vital anatomy, as implants close to critical structures may be contraindicated for trephine use or limited to a depth that does not encroach on vital structures such as the mandibular lingual plate or mandibular nerve canal.

a. True

b. False

10. After the removal of a dental implant, the decision to immediately replace it with another implant should be approached similarly to the decision-making process for placing immediate implants after tooth extraction, considering _______.

a. the available bone volume to ensure primary stability of the new implant

b. the establishment of an appropriate restorative position for future implant restoration

c. ensuring adequate space from vital structures

d. all of the above

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.

The Holtzclaw Extra Sinus Infratemporal Anchorage zygomatic implant protocol

Dr. Dan Holtzclaw delves into a technique for salvaging failed zygomatic implants

Background

To afford patients with severe maxillary atrophy the opportunity for dental implant treatment without major bone grafting procedures, anchorage into the malar process was proposed as early as the mid-1980s.1 The original Brånemark protocol called for bilateral zygomatic implants anchored into the mid-body of the zygoma via an intrasinus approach.2,3 This approach, however, was not without problems, including:

1. palatal positioning of zygomatic fixture platforms which caused discomfort and speech issues for some patients

2. high rates of maxillary sinusitis in certain patients which some clinicians felt was related to the 100% perforation rate of the Schneiderian membrane with the intrasinus path of the zygomatic implant

3. decreased visualization of the osteotomy drills with the intrasinus path

4. oroantal fistula formation secondary to degradation of thin palatal bone at the platform position when using intrasinus paths

5. unusual prosthetic configurations with extensive palatal extensions.4-9

To address these concerns, Stella and Warner proposed a modification to the original Brånemark intrasinus protocol whereby a “slot” was made in the external wall of the maxillary sinus allowing for more lateral “extrasinus” positioning of the zygomatic implant.10 This lateral positioning resulted in a more favorable prosthetic position of zygomatic implant platforms, thus reducing many of the palatal emergence issues associated with the original Brånemark protocol. Additionally, the authors noted that substitution of the lateral slot for the window needed with the intrasinus protocol allowed for better surgical visualization and improved the speed of the procedure.

While some clinicians in the early 2000s focused on better positioning of zygomatic implant platforms, others questioned the need for the additional bone grafting procedures which were

Dan Holtzclaw, DDS, MS, is Chief Clinical Officer of Advanced Dental Implant Centers and Director of Fixed Arch Services at Affordable Care, LLC, Morrisville, North Carolina. He is a Diplomate of the American Board of Periodontology and Diplomate of the International Congress of Oral Implantologists. Dr. Holtzclaw has published over 60 articles in peer reviewed journals in addition to multiple textbooks. He served as the Editor-In-Chief of the Journal of Implant and Advanced Clinical Dentistry for 13 years in addition to serving as an editorial board member and/or editorial reviewer for several other dental journals.

Disclosure: Dr. Holtzclaw is the creator of the HESIAn protocol.

Educational aims and objectives

This self-instructional course for dentists discusses a novel new treatment technique for failed zygomatic implant cases.

Expected outcomes

Implant Practice US subscribers can answer the CE questions by taking the quiz online at implantpracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can:

• Realize some evolutionary history of zygomatic implants.

• Identify some challenges associated with zygomatic implants.

• Identify various changes to zygomatic protocols over time. Recognize the indications for HESIAn zygomatic implant technique.

• Observe the technique for using the HESIAn zygomatic protocol.

• Recognize some benefits of using the HESIAn zygomatic implant technique.

• Recognize some risks of using the HESIAn technique.

2 CE CREDITS

required for many patients treated with the original Brånemark zygomaticus protocol. As these additional bone grafting procedures often produced higher failure rates for conventional dental implants in addition to increased treatment time, cost, and morbidity for patients, the concept of using multiple fixtures per zygoma in lieu of bone augmentation was considered. As an alternative to Brånemark’s original zygomatic implant protocol, in 2003, Bothur, et al., proposed a graftless procedure utilizing at least two zygomatic implants anchored into each zygoma.11 This protocol eliminated the need for additional bone grafting procedures to provide an enhanced patient experience and improve overall survivability of prostheses supported in this manner.

In 2011, Aparicio, et al., proposed a refinement of the zygomatic implant process with the “ZAGA” (Zygoma Anatomy Guided Approach) protocol.12 Rather than simply being a new technique, as was the case with previous movements from from intrasinus to extrasinus methods, The ZAGA concept considered patient specific anatomy to use a variety of zygomatic implant positions and/or specific implant fixtures for treatment. A decade later, Holtzclaw and Gonzalez introduced another full arch protocol that incorporated zygomatic implants for improved prosthetic outcomes.13 Like ZAGA, the PATZi (Pterygoid, Anterior, Tilted, Zygomatic, implants) protocol utilized a combination of implant styles to treat atrophic maxillae based upon patient-specific anatomy. The PATZi protocol, however, allowed clinicians

to rapidly alter their treatment approach in real-time based on instrasurgical conditions that may arise during treatment.

As the fourth decade of treatment with zygomatic implants quickly approaches, the evolution of this treatment modality continues to advance, expanding the scope of treatment for those afflicted with severely atrophied maxillae. In this article, the author introduces the HESIAn zygomatic implant protocol: (H)oltzclaw (E)xtra (S)inus (I)nfratemporal (An)chorage.

Technique description

The HESIAn technique was born out of necessity for the treatment and rescue of previously failed zygomatic implant cases. Survival/success means the implants are osseointegrated with no mobility, infection, radiolucency, and are able to support their intended function for prosthetic support. Failure of a zygomatic implant can often lead to large defects of the malar process that can complicate the placement of additional implants (Figures 1-3).13 In many of these cases, adequate bone remains in the dorsal zygoma as it approaches the temporal process since zygomatic implant fixtures are not often placed here with initial treatment (Figure 4). Depending on the resultant defect from a failed zygomatic implant, preparation and approach to reach this area can be complicated. Often, previously placed zygomatic fixtures may have significantly altered lateral sinus wall

anatomy or destroyed it completely (Figure 5). Additionally, failing zygomatic fixtures frequently produce sinusitis and create situations where placement of another implant through the sinus is discouraged.14-17 With this in mind, the HESIAn technique avoids the lateral sinus wall and the sinus in most cases.

The HESIAn zygomatic implant technique requires modifications compared to existing zygomatic implant protocols. While the standard zygomatic implant traverses the zygomatic buttress or just anterior to this anatomic feature, the HESIAn zygomatic implant is located dorsal to the buttress and crosses the anterior third of the infratemporal fossa (Figure 6). As such, incision design must be modified with posterior vertical releasing incisions moved to a more dorsal position closer to the pterygoid implant. Additionally, the more posterior location of the HESIAn zygomatic implant requires more extensive tissue dissection to achieve unimpeded clearance in the infratemporal fossa (Figure 7). This is critical for both effectiveness and safety with anatomic structures such as the buccal fat pad and ptergygoid venous plexus being propinquitious (near) to this area.13 Furthermore, the ventral portion of the masseteric tendon must be dissected and stripped to expose additional malar real estate for engagement of the HESIAn zygomatic implant fixture (Figure 8).

Once adequate exposure of the surgical site has been achieved with the aforementioned preparatory modifications,

Figure 1 (left): 3-dimensional CBCT rendering of patient with a failed zygomatic implant. Note the resultant defect in the malar process. Figure 2 (center): CBCT coronal slice showing large bony defect resulting from a failed zygomatic implant. Figure 3 (right): CBCT sagittal slice showing large bony defect resulting from a failed zygomatic implant. Note that there is minimal room for an additional zygomatic implant

Figure 4 (left): 3-dimensional CBCT rendering showing typical malar engagement location of standard zygomatic implants (purple shaded area) versus location of HESIAn zygomatic implants (red shaded area). Figure 5 (center): Large bony defect in lateral sinus wall and residual alveolar ridge resulting from a failed zygomatic implant. Figure 6 (right): 3-dimensional rendering showing a HESIAn zygomatic crossing the anterior third of the infratemporal fossa just dorsal to the zygomatic buttress

osteotomy creation commences. While zygomatic implant platform positioning typically occurs at the second premolar or first molar with traditional techniques,1,18,19 HESIAn protocol produces platform positions at either the second or third molar position (Figure 9). Osteotomy preparation begins by selecting platform position on the residual alveolar ridge according to the patient’s specific condition. The extrasinus barrel bur is then positioned at this point and crosses the infratemporal fossa in a position dorsal to the zygomatic buttress (Figure 10). The tip of the barrel bur should touch the medial aspect of the malar process in line with the desired apical exit point of the HESIAn zygomatic implant. Depending on the depth of the residual alveolar ridge, the barrel bur is advanced to a point whereby the bur is either level to the adjacent bone or not fully into the maxillary sinus.

Once the channel is created into the residual alveolar ridge, a sharp marking drill is laid into the channel and advanced until it touches the medial aspect of the malar process. It is very important to note that this is done without the drill running. The curvature of the medial zygoma creates the potential for the drill to slip, and using a sharp marking drill reduces the risk of this happening. With the sharp marking drill firmly embedded into

the channel created in the alveolar ridge, it is advanced through the medial aspect of the bone until it penetrates the lateral aspect (Figure 11). It is important to achieve full drill penetration for the following reasons:

1. visualization of implant exit point which prevents collision with preexisting anterosuperior zygomatic implants, avoidance of preexisting defects from failed implants, and confirmation that the implant apex will not end up in the infratemporal fossa

2. bicortical anchorage for maximum implant stability

3. ability to adjust the timing of final multi-unit abutment positioning without bottoming out of the implant.

During the drilling process, it is important to protect the tissues of the dissected infratemporal fossa from being tangled up with the advancing drill. Failure to do so may result in premature exposure of the buccal fat pad and/or violation of the pterygoid venous plexus.

Once the initial marking drill has safely penetrated the lateral zygomatic cortex, subsequent drills are used to widen the osteotomy (Figure 12). It is important to note that due to the posterior positioning of the zygomatic implant fixture with the HESIAn

Figure 7 (left): Adequate dissection of the anterior third of the infratemporal fossa must be accomplished prior to HESIAn zygomatic implant osteotomy preparation. Figure 8 (center): Scalpel being used for sharp dissection and stripping of the anterior masseteric tendon. Figure 9 (right): HESIAn zygomatic implants will typically produce screw access holes in the second or third molar location of a prosthesis

Figure 10 (left): Barrel diamond bur being used to create initial trough for a HESIAN zygomatic implant. This bur typically engages the second or third molar area of the residual alveolar ridge. Figure 11 (center): Sharp marking drill being used to penetrate the malar process. Note how the drill sits in the trough created by the barrel diamond bur, crosses the anterior third of the infratemporal fossa to engage the medial aspect of the zygoma, and completely penetrates through the bone. Figure 12 (right): Short zygomatic drills used to complete the HESIAn zygomatic implant osteotomy

technique, implant systems with longer drills will not work. The dense nature of the posterior malar process precludes underdrilling the osteotomy to less than adequate diameter.

With typical extrasinus zygomatic implant osteotomy preparation, measurement for fixture length is recommended to be performed at the most inferior aspect of the oblique exit point minus 2.5 mm to account for the multi-unit abutment. With the HESIAn protocol, however, the author has found that this measurement protocol often results in shorter than desired platform positions. As such, the author recommends not to subtract 2.5 mm from the apical exit measurement when using HESIAn.

After osteotomy preparation, it is important to thoroughly irrigate the medial and lateral aspects of the posterior malar process. In most instances, the HESIAn protocol does not typically penetrate the maxillary sinus so intrasinus irrigation is not required. The appropriately sized zygomatic implant is then placed into the slot preparation of the alveolar ridge and advanced through the anterior third of the infratemporal fossa until it reaches the HESIAn osteotomy at the medial aspect of the malar process. With firm palatal pressure to ensure intimate contact with the residual alveolar ridge, the zygomatic implant is advanced to engage the bone of the posterior zygoma. Due to the oblique nature of the osteotomy preparation, the author has found that up to 10 mm of bone to implant engagement is achieved (Figure 13) with extremely high insertion torque.

The unique position of HESIAn zygomatic implants often results in shorter fixture lengths ranging from 30 mm to 45 mm. The oblique angulation of these implants often requires multiunit abutments ranging from 45 degrees to 60 degrees when a zero degree fixture is utilized (Figure 14).

Results

To date, the author has used the HESIAn protocol for 20 immediately loaded zygomatic implant fixtures with zero failures. Mean follow-up time for these procedures is 8.4 months (range 2 to 24 months). With every HESIAn zygomatic fixture placed, insertion torque exceeded 45 Ncm, which is the maximum measurement for the manufacturer’s wrench used in these procedures. To date, there have been zero instances of gingival recession with HESIAn

Figures 13A and 13B: 13A. HESIAn zygomatic implants may engage 10 mm or more of dense malar process near the jugale. 13B. Location of the jugale

fixtures. Because these implants do not enter the maxillary sinus, there have been zero cases of maxillary sinusitis associated with HESIAn zygomatic implants of this paper.

Discussion

Figure 14 (left): Patient treated with quad zygomatic implants with HESIAn fixtures used to maximize anterior-posterior prosthetic spread. Figure 15 (right): 3-dimensional CBCT rendering showing a HESIAn zygomatic implant (yellow arrow) being used to avoid a large defect in the malar process (red arrow) which resulted from a failed zygomatic implant. Note that the HESIAn zygomatic implant has an exit point comparable to the preexisting pterygoid implant on the contralateral side of the arch (green arrow)

Zygomatic implants have nearly 40 years of documented use in rehabilitation of atrophic maxillae.1-3 Systematic reviews and meta-analyses indicate that zygomatic implants have high long-term survival rates comparable to conventional fixtures. A recent publication by Moraschini, et al., evaluated 18 studies encompassing 5,434 dental implants (2,972 zygomatic and 2,462 conventional fixtures).20 With a mean follow-up of 91.5 months, zygomatic implants had a 96.5% survival rate. Roper, et al., found similar results in their systematic review and meta-analysis where 1,349 zygomatic implants had a 96.2% survival rate at 6 years.21 In both studies, maxillary sinusitis was the most commonly documented compliation with a prevalence of 14.2% at 5 years.21 Although zygomatic implants have a high survival rate, their failure can be catastrophic for severely atrophic maxillae. For many cases such as those treated with quad zygomatic fixtures, the loss of even one fixture may render the prosthetic unusable.22 When this occurs, resultant defects often limit bone available for replacement fixtures. The HESIAn protocol is a technique that has been used by the author to salvage a number of failing zygomatic implant cases (Figure 15). To avoid defects from these failed fixtures, the HESIAn zygomatic implant typically engages zones B3 or C3 according to the classifications of Wang and Hung.23,24 While these zones have lesser thickness than other areas of the zygoma, they are still typically thick enough to achieve high insertion torque as evidenced in the findings of this study. This is aided by the oblique dorsosuperior insertion plane of the HESIAn zygomatic implant which increases bone to implant contact over the horizontal measurements that were used in determining bone thickness of the aforementioned anatomic studies. In most cases, HESIAn zygomatic implants will engage up to 10 mm of bone. In

situations of anatomic defects secondary to failing zygomatic implants, the dorsal engagement of HESIAn zygomatic implants affords the clinician additional bone to engage as zones L2, L3, Lb, and Lc are the longest parts of the malar process according to the anatomic studies.23,24 Furthermore, these dorsal locations near the jugale have been found to be 16.6% denser than areas such as the mid-body of the zygoma.25

In addition to securing alternative anchorage sites for failed zygomatic implants, the HESIAn protocol produces prosthetic results that eliminate cantilevers. Most zygomatic implant treatments that do not employ PATZi or pterygoid implants have posterior platform positions at either the second premolar or first molar and subsequent prosthetic cantilevers.1,18,19 Davo’s 2024 study evaluating patients treated with quad zygomatic implants, for example, reported that cantilevers were present in 75% of prostheses.22 In the 14 patients treated with HESIAn zygomatic implants for this retrospective study, there were zero prosthetic cantilevers.

Cantilever elimination can be benficial for zygomatic implants as noted by the Ishak series of finite element analysis studies for malar fixtures.26-28 In this trio of studies, Ishak, et al., note that longer cantilevers produced higher stresses within the body of zygomatic implants. Additionally, these authors note that distal zygomatic implant platform positions further away from points of maximum occlusal load, which typically occur in the posterior maxilla, result in a near 2-fold increase of stress within loaded prostheses. As HESIAn zygomatic implants have platforms that typically exit at the second or third molar, they address these concerns of the Ishak studies by both eliminating cantilevers and having posterior platform exit points in the area of maximum occlusal force generation. The posterior exit point of HESIAn zygomatic implants does generate possible interference with positioning of pterygoid implants and this should be taken into consideration when planning cases.

Conclusion

The (H)oltzclaw (E)xtra (S)inus (I)nfratemporal (An)chorage (HESIAn) zygomatic implant protocol continues the near 40-year evolution of malar fixture treatment for atrophic maxillae. This technique is intended for either the rescue of failed zygomatic implant cases or maximizing anterior-posterior (AP) prosthetic spread in patients where pterygoid implants are not an option. The HESIAn protocol for zygomatic implants is highly advanced and should only be attempted by clinicians with significant experience placing malar fixtures. Long term follow-up and additional controlled studies further evaluating use of HESIAn zygomatic implants are warranted by the promising findings of this retrospective study.

REFERENCES

1. Brånemark PI, Gröndahl K, Ohrnell LO, Nilsson P, Petruson B, Svensson B, Engstrand P, Nannmark U. Zygoma fixture in the management of advanced atrophy of the maxilla: technique and long-term results. Scand J Plast Reconstr Surg Hand Surg. 2004;38(2):70-85.

2. Parel SM, Brånemark PI, Ohrnell LO, Svensson B. Remote implant anchorage for the rehabilitation of maxillary defects. J Prosthet Dent. 2001 Oct;86(4):377-81.

3. Aparicio C. Brånemark P, Keller EE, Olivé J. Reconstruction of the premaxilla with autogenous iliac bone in combination with osseointegrated implants. Int J Oral Maxillofac Implants.1993;8:61-67.

4. Lopes A, de Araújo Nobre M, Ferro A, Moura Guedes C, Almeida R, Nunes M. Zygomatic Implants Placed in Immediate Function through Extra-Maxillary Surgical Technique and 45 to 60 Degrees Angulated Abutments for Full-Arch Rehabilitation of Extremely Atrophic Maxillae: Short-Term Outcome of a Retrospective Cohort. J Clin Med. 2021 Aug 16;10(16):3600.

5. Stella JP, Warner MR. Sinus slot technique for simplification and improved orientation of zygomaticus dental implants: a technical note. Int J Oral Maxillofac Implants. 2000 Nov-Dec;15(6):889-893.

6. Aleksandrowicz P, Kusa-Podkańska M, Grabowska K, Kotuła L, Szkatuła-Łupina A, Wysokińska-Miszczuk J. Extra-Sinus Zygomatic Implants to Avoid Chronic Sinusitis and Prosthetic Arch Malposition: 12 Years of Experience. J Oral Implantol. 2019 Feb;45(1):73-78.

7. Aparicio C, Polido WD, Zarrinkelk HM. The Zygoma Anatomy-Guided Approach for Placement of Zygomatic Implants. Atlas Oral Maxillofac Surg Clin North Am. 2021 Sep;29(2):203-231.

8. Aparicio C, Manresa C, Francisco K, Aparicio A, Nunes J, Claros P, Potau JM. Zygomatic implants placed using the zygomatic anatomy-guided approach versus the classical technique: a proposed system to report rhinosinusitis diagnosis. Clin Implant Dent Relat Res. 2014 Oct;16(5):627-642.

9. Aparicio C, Ouazzani W, Hatano N. The use of zygomatic implants for prosthetic rehabilitation of the severely resorbed maxilla. Periodontol 2000. 2008;47:162-171.

10. Stella JP, Warner MR. Sinus slot technique for simplification and improved orientation of zygomaticus dental implants: a technical note. Int J Oral Maxillofac Implants. 2000 Nov-Dec;15(6):889-893.

11. Bothur S, Jonsson G, Sandahl L. Modified technique using multiple zygomatic implants in reconstruction of the atrophic maxilla: a technical note. Int J Oral Maxillofac Implants. 2003 Nov-Dec;18(6):902-904.

12. Aparicio C. A proposed classification for zygomatic implant patient based on the zygoma anatomy guided approach (ZAGA): a cross-sectional survey. Eur J Oral Implantol. 2011 Autumn;4(3):269-275.

13. Holtzclaw D Remote Anchorage Solutions for Severe Maxillary Atrophy: Zygomatic, Pterygoid, Transnasal, Nasal Rim, Piriform Rim, Nasopalatine, and Trans-Sinus Dental Implants. Austin, Texas: Zygoma Partners; 2023.

14. Lan K, Wang F, Huang W, Davó R, Wu Y. Quad Zygomatic Implants: A Systematic Review and Meta-analysis on Survival and Complications. Int J Oral Maxillofac Implants. 2021 Jan-Feb;36(1):21-29.

15. Chrcanovic BR, Abreu MH. Survival and complications of zygomatic implants: a systematic review. Oral Maxillofac Surg. 2013 Jun;17(2):81-93. Chrcanovic BR, Abreu MH. Survival and complications of zygomatic implants: a systematic review. Oral Maxillofac Surg. 2013 Jun;17(2):81-93.

16. Chrcanovic BR, Albrektsson T, Wennerberg A. Survival and Complications of Zygomatic Implants: An Updated Systematic Review. J Oral Maxillofac Surg. 2016 Oct;74(10):1949-1964.

17. Fiamoncini, E. S., Guimarães, G. M. M. M. de F., Alcalde, L. F. A., Mello, M. Of A. B., Ferreira Júnior, O., de Carvalho, P. S.S. P. Complications in the use of zygomatic implants for the treatment of atrophic maxillary rehabilitation: literature review. Journal of Multidisciplinary Dentistry. 2020;10(1), 41–45.

18. Tuminelli F, Balshi T. Zygomatic implants: Position statement of the American College of Prosthodontists 2016. https://www.prosthodontics.org/about-acp/position-statement-zygomatic-implants/ (Accessed May 16, 2024).

19. Hirsch JM, Ohrnell LO, Henry PJ, Andreasson L, Brånemark PI, Chiapasco M, Gynther G, Finne K, Higuchi KW, Isaksson S, Kahnberg KE, Malevez C, Neukam FW, Sevetz E, Urgell JP, Widmark G, Bolind P. A clinical evaluation of the Zygoma fixture: one year of follow-up at 16 clinics. J Oral Maxillofac Surg. 2004 Sep;62(9 Suppl 2):22-29.

20. Moraschini V, de Queiroz TR, Sartoretto SC, de Almeida DCF, Calasans-Maia MD, Louro RS. Survival and complications of zygomatic implants compared to conventional implants reported in longitudinal studies with a follow-up period of at least 5 years: A systematic review and meta-analysis. Clin Implant Dent Relat Res. 2023 Feb;25(1):177-189.

21. Brennand Roper M, Vissink A, Dudding T, Pollard A, Gareb B, Malevez C, Balshi T, Brecht L, Kumar V, Wu Y, Jung R. Long-term treatment outcomes with zygomatic implants: a systematic review and meta-analysis. Int J Implant Dent. 2023 Jul 5;9(1):21.

22. Davó R, Fan S, Wang F, Wu Y. Long-term survival and complications of Quad Zygoma Protocol with Anatomy-Guided Approach in severely atrophic maxilla: A retrospective follow-up analysis of up to 17 years. Clin Implant Dent Relat Res. 2024 Apr;26(2):343-355.

23. Wang H, Hung K, Zhao K, Wang Y, Wang F, Wu Y. Anatomical analysis of zygomatic bone in ectodermal dysplasia patients with oligodontia. Clin Implant Dent Relat Res. 2019 Apr;21(2):310-316

24. Hung KF, Ai QY, Fan SC, Wang F, Huang W, Wu YQ. Measurement of the zygomatic region for the optimal placement of quad zygomatic implants. Clin Implant Dent Relat Res. 2017 Oct;19(5):841-848.

25. Kato Y, Kizu Y, Tonogi M, Ide Y, Yamane GY. Internal structure of zygomatic bone related to zygomatic fixture. J Oral Maxillofac Surg. 2005 Sep;63(9):1325-1329.

26. Ishak MI, Abdul Kadir MR, Sulaiman E, Abu Kasim NH. Finite element analysis of different surgical approaches in various occlusal loading locations for zygomatic implant placement for the treatment of atrophic maxillae. Int J Oral Maxillofac Surg. 2012 Sep;41(9):1077-1089.

27. Ishak MI, Kadir MR, Sulaiman E, Kasim NH. Finite element analysis of zygomatic implants in intrasinus and extramaxillary approaches for prosthetic rehabilitation in severely atrophic maxillae. Int J Oral Maxillofac Implants. 2013 May-Jun;28(3):e151-160

28. Ishak M, Rosli M, Jamalludin M, Termizi S, Khor C, Nawi M. Biomechanical assessment of different surgical approaches of zygomatic implant placement on prosthesis stress. 1st Int Conference on Science, Engineering, and Technology (ICSET) 2020. IOP Conf Series: Materials Science and Engineering. 932 (2020) 012108: 1-8.

Continuing Education Quiz

The Holtzclaw Extra Sinus Infratemporal Anchorage zygomatic implant protocol HOLTZCLAW

1. The original ________ protocol called for bilateral zygomatic implants anchored into the mid-body of the zygoma via an intrasinus approach.

a. Brånemark

b. ZAGA

c. Gershoff

d. Ring

2. Rather than simply being a new technique, as was the case with previous movements from intrasinus to extrasinus methods, the ________ considered patient specific anatomy to use a variety of zygomatic implant positions and/or specific implant fixtures for treatment.

a. PATZI concept

b. ZAGA concept

c. slot positioning protocol

d. Brånemark intrasinus protocol

3. The HESIAn technique was born out of necessity for the treatment and rescue of previously failed zygomatic implant cases.

a. True

b. False

4. Survival/success (for implant procedures) means the implants are osseointegrated with ________ and are able to support their intended function for prosthetic support.

a. no mobility

b. no infection

c. no radiolucency

d. all of the above

5. The HESIAn technique _______ the lateral sinus wall and the sinus in most cases.

a. avoids

b. utilizes

c. significantly alters

d. always involves

6. HESIAn protocol produces platform positions at _______.

a. second premolar

b. first molar

c. either the second or third molar position

d. the sinus wall

7. (During osteotomy preparation) Depending on the depth of the residual alveolar ridge, the barrel bur is advanced to a point whereby the bur is _______.

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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.

AGD Code: 690

Date Published: June 30, 2024

Expiration Date: June 30, 2027

a. level to the adjacent bone

b. not fully into the maxillary sinus

c. fully into the maxillary sinus

d. both a and b

8. One of the reasons that it is important to achieve full drill penetration is: the visualization of implant exit point which ________.

a. prevents collision with preexisting anterosuperior zygomatic implants

b. avoids preexisting defects from failed implants

c. confirms that the implant apex will not end up in the infratemporal fossa

d. all of the above

9. With typical extrasinus zygomatic implant osteotomy preparation, measurement for fixture length is recommended to be performed at the most inferior aspect of the oblique exit point minus ________ to account for the multi-unit abutment.

a. 1.5 mm

b. 2.5 mm

c. 3.5 mm

d. 4.5 mm

10. The unique position of HESIAn zygomatic implants often results in shorter fixture lengths ranging from ________ .

a. 5 mm to 10 mm

b. 12 mm to 25 mm

c. 30 mm to 45 mm

d. 50 mm to 55 mm

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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