Implant Practice US Winter 2023 Vol 16 No 4 by MedMark, LLC

Surgical strategies for preventing poor implant esthetics Dr. David Wong

Treatment of severely atrophic maxillae using the PATZI remote anchorage protocol: a case series Dr. Dan Holtzclaw

Corporate spotlight

Advanced Dental Implant Center

PROMOTING EXCELLENCE IN IMPLANTOLOGY

Full-Arch Growth Conference — close 20-30 arches monthly

Fontainebleau Miami Beach, Fl December 1st & 2nd

GROWTH CONFERENCE

implantpracticeus.com

FULL-ARCH

Winter 2023 Vol 16 No 4

Bringing World-Renowned Speakers to Dentistry

Oral Surgery / Periodontics n 4 CE Credits Available in This Issue*

erve for

ADVANCED

DENTAL IMPLANT CENTER THERE IS NO SUBSTITUTE One of the nation’s largest providers of dental implants. Nearly 50 years of time-tested results for 425+ dental practices with a focus on tooth replacement. Core expertise to serve dentists in: Marketing, Operations, Clinical Training, Real Estate, Human Resources, Lab, Information Technology, Recruiting, Accounting, Payroll and Call Center. Founder of the largest Group Purchasing Organization (GPO) in the dental industry. One of the largest Lab technician networks in the U.S. 30,000-square-foot, world-class implant training facility. More than 8 million patients served.

FOR PROVEN EXPERIENCE. “We are looking for doctors who are at the top of their game. You have been successful for a reason. We don’t want to change what you have built. Through affiliation with us, we help take both you and your practice to the next level, whatever your goals may be. Don’t entrust what you have worked hard for with the latest upstart in our industry.” - Dr. Dan Holtzclaw, Chief Clinical Officer

Scan the QR code or call (888) 537-2801 Proud to support the Advanced Dental Implant Center network

Let’s discuss what Affiliation could mean for you.

INTRODUCTION

Winter 2023 n Volume 16 Number 4 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

© MedMark, LLC 2023. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Endodontic Practice US or the publisher.

Implant dentistry — evolution and future

lthough the fundamental principles of implant dentistry remain unchanged, rapid advancements in technology and materials are transforming the field. This evolution presents a challenge for clinicians who must navigate a vast array of new options to determine the best course of treatment for their patients. As such, ongoing education is essential for every practitioner to stay up-to-date with the latest trends and advancements in contemporary implant dentistry. The inaugural implant symposium at Tufts aimed to discuss and disseminate knowledge about advances related to implant dentistry. It delivered insights about current and future technologies and developments. The implant symposium had great content, with expert key opinion speakers from different parts of the world — Australia, New Zealand, Netherlands, Italy, San Francisco, and more. The content was enriching, and speakers shared insights on the latest advancements in clinical dentistry and how to put them to use in practice. The goals of the symposium were not only to discuss and disseminate knowledge about the advances related to implant dentistry, but also to deliver insights about current and future technologies and developments like AI in implant dentistry. Participants learned to think critically about and fundamental principles of implant placement, and there was appreciation of critical evaluation of fundamental principles underpinning the procedures. Participants got in-depth information about: total solutions in immediate implants, biomechanical evidence-based principles, guided implant placement and predictable outcomes, immediate replacement in the esthetic zone, and prosthetic nightmares on implants. Other topics of discussion included: restoring immediate implant treatment solutions and biological and mechanical implant complications, soft tissue management around dental implants, implant rehabilitation of the atrophic maxilla, and biologically driven dental implant abutment design. The one-day symposium was held at Tufts University School of Dental Medicine (TUSDM) and was designed to bring together world-renowned clinicians to share their expertise on the latest implant-related topics, providing attendees with valuable insights, research, and evidence-based advances in implant dentistry to enhance their knowledge and improve their decision-making in everyday practice. The Speakers were oracles in the field of implant dentistry, namely, Dr. German Gallucci, Dr. Edmond Bedrossian, Dr. Tristan Staas, Dr. Giacomo Fabbri, Dr. Lawrence Brecht, Dr. Ekaterini Antonellou-Pantekidis, Dr. Mike Danesh-Meyer, Dr. Glen Liddelow, and Dr. Aldo Leopardi. There were post-symposium hands-on courses in various aspects of implant dentistry. Dr/A.Prof Shibani Sahni and Dean/Dr/Prof Nadeem Karimbux were thrilled to host this impactful and efficacious event in the heart of Boston at TUSDM and welcomed everyone to this exciting opportunity to learn and network with colleagues in the field. It was a remarkable event and a testament to Tufts being the leader of lifelong learning and distance education for dentists around the globe, to provide this invaluable platform for sharing knowledge, research, and advances in the field of implant dentistry.

Dr. Shibani Sahni is the Director Lifelong Learning and Distance Education, and an Assistant Professor in the Department of Comprehensive Care at Tufts University School of Dental Medicine. She started the Global Academy under the Continuing Education department and has been instrumental in bringing different dental education programs to various parts of the world including Australia and the Asia-Pacific region. She is passionate about seeing that the world’s dental professionals get access to the leading knowledge and hands-on techniques.

ISSN number 2372-6245

implantpracticeus.com

Volume 16 Number 4

TABLE OF CONTENTS

PUBLISHER’S PERSPECTIVE

Choose faith over fear Lisa Moler, Founder/CEO, MedMark Media............................... 6

COVER STORY

Full-Arch Growth Conference — close 20-30 arches monthly

8 CASE REPORT

Top implant clinicians will unite in Miami for The Closing Institute’s Symposium on December 1 and 2 Cover image of Molly Bloom, Mike Krzyzewski (Coach K), Bart Knellinger, Tim Grover, and Anthony Robles courtesy of The Closing Institute

CORPORATE SPOTLIGHT

Advanced Dental Implant Center There is no substitute for proven experience.

Implant Practice US

Volume 16 Number 4

Working as a team Drs. Iham Gammas and Haroutioun Kotchinian collaborate for more predicable surgical and restorative results .........................................................14

PRACTICE PROFILE

Dr. Kate Quinlin — collaboration for better dental care........................... 18

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TABLE OF CONTENTS

CONTINUING EDUCATION

Surgical strategies for preventing poor implant esthetics Dr. David Wong offers guidance on establishing soft tissue esthetics and stability to implants ............................................................... 20

TECHNOLOGY

Advances in alveolar bone regeneration: utilizing patient teeth for osseoinductive bone grafting Amit Binderman discusses converting extracted teeth into osseoinductive bone graft material............................................. 34 IMPLANT PERSPECTIVE

Five benefits of practicing rural dentistry

Dr. David Whitlock discusses the joys of practicing in a rural community....................................... 36

PRODUCT PROFILE

Flexible field of view and AI-powered efficiencies enhance diagnostic confidence Dr. Joe Mehranfar discusses his favorite features of the new DEXIS OP 3D LX.............................. 38 PRODUCT SPOTLIGHT

The advantages of immediate dental implants and YOMI robotic technology Dr. Chris Rothman talks about improving efficiency and precision in implant placement .............................................................. 40

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

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Implant Practice US

Volume 16 Number 4

PUBLISHER’S PERSPECTIVE

Choose faith over fear

’m sitting at my computer on a beautiful day, writing my winter message, and Billy Joel’s song, “Keeping the Faith” started playing. It started me thinking of the past and the future and how sometimes, it seems easier to stay “lost in let’s remember” than move forward and face an often scary unknown. One of my most meaningful mantras is “faith over fear.” It is so easy to keep to the same schedule, keep the same business protocols, and the same way of doing things, in a safe comfort zone. MedMark publications are meant to Lisa Moler Founder/Publisher, help you break out of that habit. We want you to not only MedMark Media read about the expanding opportunities for every aspect of your practice, but also to have the foresight to bring these innovations into your practice for your patients and your own success. After almost 2 decades of dental publishing, I have seen many advancements revolutionize dental specialties. I remember when dentists were wary of finding a new use for their darkroom space and welcoming digital imaging into the practice. Now, not only X-rays, but a myriad of digital technologies connect every aspect of the practice, from X-rays, to practice management, to marketing, and connecting with patients. Even AI has found its way to the dental office. AI is constantly evolving, so all of you brave “early adopters” should be excited about the prospects on that topic! No matter your specialty, innovations have transformed the way dental professionals practice — choices for clear aligner materials and 3D printing for orthodontists, new implant technologies for implant-focused dentists, and files and equipment to clean the root canal space for longer-lasting endodontic results. I have a personal involvement in many important breakthroughs affecting and saving the lives of those who suffer from sleep-breathing disorders. We have been honored all these years to bring new concepts and insights to our pages to bring you all of the latest clinical and business options. In our Winter issue, here are some articles that will help you to fulfill your ambitious and enlightened goals. Our Cover Story details the Full-Arch Growth Conference at the Closing Institute’s Symposium, a transformative event with celebrity speakers who will discuss how to cultivate your practices’ potential, bring out the best in your team, and help you to close high value implant cases. One CE, by Dr. Dan Holtzclaw, outlines the PATZI protocol that uses immediate loading and remote anchorage concepts developed over the past 35+ years that can accommodate nearly any situation in the atrophic maxillae. Our second CE, by Dr. David Wong, considers how to achieve long-term success for implants without sacrificing esthetics. In our case report, Drs. Ilham Gammas and Haroutioun Kotchinian show how restorative and implant dentists can work together for predictable surgical and restorative results. We can do the research, but you have to take the leap of faith. Billy Joel’s song has the right idea about honoring the past but propelling ourselves into the future: “You can get just so much from a good thing You can linger too long in your dreams Say goodbye to the oldies but goodies ‘Cause the good ole days weren’t always good And tomorrow ain’t as bad as it seems.” Don’t linger too long while others take initiative. Choose faith over fear to flourish personally and professionally! To your best success, Lisa Moler Implant Practice US

Volume 16 Number 4

Published by

Publisher Lisa Moler lmoler@medmarkmedia.com Managing Editor Mali Schantz-Feld, MA, CDE mali@medmarkmedia.com Tel: (727) 515-5118 National Account Manager Adrienne Good agood@medmarkmedia.com Tel: (623) 340-4373 Sales Assistant & Client Services Melissa Minnick melissa@medmarkmedia.com Creative Director/Production Manager Amanda Culver amanda@medmarkmedia.com Marketing & Digital Strategy Amzi Koury amzi@medmarkmedia.com eMedia Coordinator Michelle Britzius emedia@medmarkmedia.com Social Media Manager Felicia Vaughn felicia@medmarkmedia.com Digital Marketing Assistant Hana Kahn support@medmarkmedia.com Website Support Eileen Kane webmaster@medmarkmedia.com

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

COVER STORY

Full-Arch Growth Conference — close 20-30 arches monthly Top implant clinicians will unite in Miami for The Closing Institute’s Symposium on December 1 and 2

he Full-Arch Growth Conference is for dental professionals aiming to scale their full-arch production and master the art of closing. The upcoming Closing Institute Full-Arch Growth Conference is an unmissable opportunity. Hosted at the prestigious Fontainebleau Miami Beach Resort on December 1 and 2, this conference promises an iron-clad blueprint that will immediately boost implant sales.

On top of marketing, Progressive Dental created The Closing Institute to give doctors of all specialties and their teams the exact techniques to close high-dollar full-arch cases in volume. Their program is the only one of its kind in dentistry dedicated to coaching and training team members in sales mastery. Bart Knellinger, CEO and Founder of Progressive Dental and The Closing Institute, says, “We have seen that many clinicians want to do more full-arch immediate cases but don’t know how to do them at scale. This is why we created The Closing Institute. In my 15+ years of experience helping dental practices scale their dental implant production, we have seen that the doctor doesn’t have enough time, the practice gets too many unqualified patients, the team isn’t equipped with the tools needed to close price shoppers, workflows in the office are not optimized to do full-arch cases in volume, and much more.” High-performing practices have high-performing clinicians, but if the clinician is spending time and energy trying to close the case, they aren’t spending time and energy doing the cases

How The Closing Institute Full-Arch Growth Conference came about Progressive Dental is a company dedicated to dental practice growth; they have helped over 800 practices drastically scale their dental implant production. The company has been running dental implant marketing campaigns in nearly every major market in the country for the last 15 years. They have seen a lot of success and a lot of failures. The No. 1 opportunity that they have found in all those years that will make the biggest impact to a practice is team-based sales training.

The Closing Institute is bringing in some of the top speakers in the world to discuss vital concepts like leadership, mindset, entrepreneurship, and influence to add more value and different perspectives to dramatically impact your practice growth Implant Practice US

Volume 16 Number 4

COVER STORY

2022 Full-Arch Growth Conference had over 800+ attendees. This year’s will have 1,200 top implant clinicians and team members attending

Dr. James Fetsch tells the crowd about how he went from 5 arches per month to 20+ per month after attending his first Closing Institute event

— that’s why many run out of time! The treatment coordinator needs to be the quarterback of the consultation and the primary closer. This can lead to a time crunch and potential bottlenecks in patient care; that’s why the role of the treatment coordinator is pivotal. By delegating this critical aspect to the treatment coordinator, clinicians can optimize their time in surgery, ensuring a seamless and efficient workflow within the practice. The Closing Institute teaches doctors to utilize the Treatment Coordinator and Patient Advocate to scale their practice. Progressive Dental has clients that have been able to 10 times their ROI on their marketing spend because they train their teams to pre-qualify, handle, and close the leads they generate for them through marketing. “We have doctors that have gone from an $800,000 practice to a $3 million, or even $6 million dollar practice in just a few years,” says Knellinger.

This is a TEAM event and you should attend with your Office Manager, Treatment Coordinator, and whoever is in charge of managing the inbound leads in order to fully benefit from the course

Master the art of influence, and close cases in volume

• How to implement the 10 - 10 - 10 consultation/sales process to drastically increase closing % • New cutting-edge digital workflows to increase profits, predictability, and quality • Lessons from world-renowned speakers on sales, leadership, mindset, and influence

Bart Knellinger’s vision for The Closing Institute’s Full-Arch Growth Conference is to provide doctors and their teams with the process, scripting psychology, and know-how to immediately increase their closing percentage. This conference is like no other event they have ever done. The Closing Institute is bringing in some of the top speakers in the world to discuss vital concepts like leadership, mindset, entrepreneurship, and influence to add more value and different perspectives to dramatically impact your practice growth. For dental practice owners and operators, two primary concerns consistently take precedence: delivering exceptional clinical outcomes to their patients and consistently meeting or surpassing daily production targets. At The Closing Institute Full-Arch Growth Conference, you will be trained on a step-by-step sales process to close “direct to public” leads in volume. Their 10-10-10 Sales Process will allow you to close exponentially more arches without increasing time, staff, or overhead. It is simply twice as efficient!

Top strategies for marketing and closing fullarch cases with keynote speaker Bart Knellinger, CEO and Founder of both Progressive Dental and The Closing Institute and the keynote speaker, will discuss topics such as the top mistakes practices make when marketing their full-arch services. Other main key takeaways from Bart are: • How to handle price shoppers • How to handle a negotiation • How to prequalify and triage leads • How to handle objections

Fueling growth and practice success with guest speakers

Key takeaways • Advanced strategies to generate full-arch leads • How to quickly pre-qualify and triage patients who are financially unqualified implantpracticeus.com

Although attendees will leave with the secrets to the process, the scripts, and the know-how, this still isn’t enough. This conference offers clinicians and their teams a fresh and transformative

Volume 16 Number 4

COVER STORY

perspective on the art of sales and influence, an experience that attendees will never forget. Experience a transformative event with celebrity speakers who will ignite your practices’ potential, cultivate growth, and unleash your team’s best. Their lineup of inspirational guests is set to empower and motivate, providing valuable insights and strategies for personal and professional development.

List of special guest speakers Mike Krzyzewski (Coach K) — Head Men’s Basketball Coach, Duke University (1980-2022) • A passionate, dynamic, and inspiring coach renowned for leading Duke University’s men’s basketball team. He also guided Team USA to three Olympic gold medals, making him a master motivator who pushes individuals to surpass their own expectations. • His lecture title is “ALL IN: Forging Winning Teams in Dentistry.” • Take away value-based leadership and practical strategies that attendees can implement with their practice and team to improve performance immediately. Tim Grover — Performance Coach to Champions, No. 1 New York Times Bestseller, and Global Keynote Speaker • A preeminent trainer, mentor, and advisor to iconic figures like Michael Jordan, Dwayne Wade, Charles Barkley, and many other celebrity athletes. • His lecture title is “Unleashing Team Excellence: Transforming Doctors, Champions, and Patient Care.” • Take away how to learn and focus on the things that do not come easy, do not come naturally, so doctors and their teams can dominate and win. Anthony Robles — An NCAA Wrestling Champion, National Wrestling Hall of Fame inductee, and the subject of the film “Unstoppable.” • Anthony overcame remarkable odds to win the 2010-11 NCAA individual wrestling championship in the 125pound weight class, despite being born with one leg. • His lecture title is “Redefining Limits: Overcoming Challenges and Maximizing Potential.” • Take away how to use your unique strengths to excel both in your career and personal life — redefine your limits, and maximize your potential in dentistry. Molly Bloom — Inspirational Speaker, Entrepreneur, and Bestselling Author of “Molly’s Game.” • Molly’s journey from a world-class skier to an entrepreneur who managed one of the world’s most exclusive, high-stakes underground poker games is truly inspiring. • Her lecture title is, “Empowering Success: Unveiling the Playbook For Growth.” • Take away Molly’s success playbook in becoming a dental professional whose potential is limitless. More speakers and special guest announcements to come!

Scale your practice with The Closing Institute’s 2-day Full-Arch Growth Conference This event is an exceptional opportunity to expand your practice through full-arch implant cases. Whether you’re a doctor, a Implant Practice US

Treatment Coordinators get the opportunity to role play directly with CEO and Founder of the Closing Institute, Bart Knellinger

Two top dental implant clinicians, Dr. Craig Miller from New Jersey and Dr. Barrie Matthews from Minnesota, attend Closing Institute events regularly to network and learn from other expert clinicians. Their teams love learning from other team members as well

treatment coordinator, an office manager, or a patient advocate, this event is for you. It promises to be the most valuable team event you’ve ever attended, poised to elevate your practice. Join top dental implant clinicians at the prestigious Fontainebleau Resort in Miami, Florida, where you’ll gain insights and expertise on mastering fullarch procedures that can truly transform lives. Don’t miss this chance to take your practice to the next level and make a lasting impact on your patients’ well-being.

About Progressive Dental Marketing Progressive Dental Marketing is a company that specializes in dental practice growth by attracting and closing high-value, big dental cases. They provide a turn-key solution to succeed with dental marketing, team motivation, sales training, and strategic business coaching. Progressive Dental is the only dental marketing company that can truly generate high-dollar leads and provide doctors with a sales system to ensure a high closing percentage and a phenomenal return on their investment. Progressive Dental is more than just a marketing company; they are a company dedicated to dental practice growth. Contact Progressive Dental Marketing by going to progressivedental.com or theclosinginstitute.com. You can also call at 727-888-6043. IP This article was provided by Progressive Dental Marketing.

10 Volume 16 Number 4

FULL-ARCH GROWTH CONFERENCE

The Closing Institute’s Full-Arch Growth Conference is an advanced CE course that will be held in Miami, FL. This event is about understanding the tremendous impact that Team Based Sales Training can have on all aspects of your practice, creating closers & leaders that prevail in every aspect of business.

LEARN PROVEN TECHNIQUES TO: • Acquire more leads and manage them effectively • Implement a sales process that will result in a massive increase in closing percentage and empower your Treatment Coordinator to improve drastically • Quickly pre-qualify and triage patients that are financially unqualified • Implement efficient, vertically integrated workflows based on your current volume and projected volume of cases • Present creative financing options to get patients with low credit scores qualified for funding • Dominate the 2nd opinion market • Gain insights from world-renowned speakers on Sales, Leadership, Mindset, and Influence that will dramatically impact your practice growth

 TOP IMPLANT CLINICIANS  TREATMENT COORDINATORS  OFFICE MANAGERS  PATIENT ADVOCATES Will Unite to Dominate Their Market With Full-Arch Dentistry.

SCALE YOUR PRACTICE

To 20, 30 Arches Per Month

This is Where Clinicians Receive Their Iron Clad Blueprint To Predictably Boost Their Implant Production.

CORPORATE SPOTLIGHT

Advanced Dental Implant Center There is no substitute for proven experience.

“T

rust and transparency.” me, including successful liquidity events. To this day, the affiliated Cameron Murray, President of Advanced Dental practice is thriving, and I’ve had more opportunities for myself as Implant Center, explains, “We are building relaa doctor than if I stayed running my own independent practice.” tionships with advanced implant doctors based on that solid One of the largest providers of dental implants foundation.” The Advanced Dental Implant Center Supported by Affordable Care, which is network is backed and supported by Affordthe nation’s largest dental support organiable Care, which is one of the nation’s zation (DSO) exclusively focused on tooth largest providers of dental implants. “We replacement, the Advanced Dental Implant have been at the forefront of tooth replaceCenter network is a rapidly-growing supment innovation for nearly 50 years,” says ported dental network within Affordable Murray. Care, comprised of general dentists with Founded in 1975, Affordable Care extensive implant experience, oral surserves more than 600 doctors in 425 dental geons, periodontists, and prosthodontists — practices across 43 states — all focused on all focused on delivering advanced dental tooth replacement. implant solutions to patients while leverag“We’ve seen a number of newly estabing Affordable Care’s long history of proven lished players trying to enter the implant innovation, expertise, service, and results. market because they think it’s a hot seg“With the number of new entrants in ment in dentistry, but they are really just the implant dentistry market that are trying Cameron Murray, President of Advanced chasing short-term financial gains for the to purchase and serve dental practices, it’s Dental Implant Center promoters, without understanding what it important now more than ever for dentists takes to operate and integrate the business to really take a critical look when affiliating for the benefit of dentists,” explains Murray. their dental practice,” explains Murray. “I “We have actually been doing it very well transparently talk with dentists on a daily for nearly 50 years, helping affiliated denbasis, and it’s pretty incredible to hear what tists achieve consistently strong financial they are being told. The bottom line is that returns.” financial stability, proven track record, and Murray adds, “When you look across depth of experience matter when looking the continuum of services provided to to affiliate. We understand this is an importdoctors by Affordable Care, the experience ant decision for doctors, and we help them behind those services is deep, with five carefully vet options because joining the decades of constant innovation. That is a latest upstart or private equity firm looking significant differentiator and advantage for to flip for a quick profit, may not be in their doctors who affiliate with the Advanced long-term best interest.” Dental Implant Center network.” He adds, “If the Advanced Dental The time-tested support and services Implant Center network is a good fit for all provided by Affordable Care to Advanced Dr. Dan Holtzclaw, Chief Clinical Officer of involved and provides dentists with what Advanced Dental Implant Center Dental Implant Center affiliated practices they need both financially and from a relaincludes: tionship perspective, then we do whatever • Clinical advancement: Led by a clinical leadership we can to help make it happen, and to help dentists work toward team of dentists with world-class implant experience, the goals they want to achieve by affiliating their practice.” a dedicated group is focused on building an engaged “I was in the exact same place as dentists who we talk doctor community through education and advancement, with,” shares Dr. Dan Holtzclaw, Chief Clinical Officer of including industry-leading CE training and mentorship Advanced Dental Implant Center. “I built and managed a sucprograms. Advanced Dental Implant Center-affiliated cessful fixed-arch clinic but was ready to expand to the next doctors and their associates have access to a top-notch, level professionally and explore more opportunities as an 30,000-square-foot training facility, supported by Affordimplant surgeon.” able Care and operated by The Pathway. At this ArizoHe explains, “I could have affiliated my practice with multiple na-based facility, an impressive array of live surgical DSOs or a new upstart, but I chose to affiliate with Affordable training and implant courses are led by leaders in the Care because they actually had the experience and results to show Implant Practice US

12 Volume 16 Number 4

CORPORATE SPOTLIGHT

field, including dentists from within the Advanced Dental Implant Center network. • Laboratory: With one of the largest networks of lab technicians in the U.S., a team of experienced laboratory professionals provide training and lab support for affiliated dental practices, especially practices that are looking to transition to a digital workflow. • Information Technology: Advanced IT services include world-class security solutions, enterprise network upgrades, and a dedicated team to provide practices with responsive IT support. • Finance: Accounting and financial management services help doctors manage their practices to achieve maximum financial performance. • HR/Recruiting: Dedicated team is focused on doctor and practice staff recruitment services to help attract and retain top talent and support clinic HR functions. • Marketing: Integrated marketing professionals and call center support leverage years of patient data from serving more than 8-million patients to provide marketing strategies and tactics that increase brand awareness and patient flow for advanced implant providers. • Operations: Dedicated integration and operations teams apply decades of experience working with private practices, fixed-arch specialty practices, and a range of DSOs to provide affiliated practices with on-the-ground support and operational insight to help drive continued growth and efficiency. • Real estate management: Experienced experts in de novo set-up, site selection, and lease management support lease negotiations and owner management. • Research and development: Multi-site clinical trial and pilot testing programs, including digital dentistry, engage affiliated doctors to help advance the latest dental technologies. • Staff training and development: Trainers focus on increasing the skills of practice dental staff to help make an impact inside clinics for dentists and their teams. • Supply chain: As the founder of the largest dental Group Purchasing Organization (GPO) in the U.S. that is focused exclusively on servicing dental practices, known as Sevaredent Sourcing Solutions, significant cost savings on clinic supplies and professional services are available to affiliated dentists. “Out of the different DSOs that were Dr. Peyman Raissi offering to affiliate with my practice, I felt the Advanced Dental Implant Center network, supported by Affordable Care, had the best reputation,” shares Dr. Peyman Raissi, who affiliated his My New Smile Dental practice and has maintained his local brand. “I had a blast building my practice from scratch and grew it to a level where I felt it was important to have a solid support group to take care of everything in the office except clinical care so I could practice what I love daily free of stress.” implantpracticeus.com

Advanced Dental Implant Center-affiliated doctors have access to a topnotch, 30,000-square-foot training facility with an impressive array of live surgical training and implant courses.

He adds, “I’m now part of something bigger, and ultimately, very happy with my decision to join an excellent community of clinicians across the nation.”

Building a legacy with you

As part of a community of more than 600 dentists, Advanced Dental Implant Center-affiliated doctors have the ability to continue to shape their legacy beyond serving patients inside their practice. “We help support dentists working toward their next phase, whatever that looks like for them, which can include serving as a mentor to other implant doctors and sharing their expertise through training events,” explains Dr. Holtzclaw. “The doctors who affiliate with us have been incredibly successful and have built their practices from the ground up. We don’t change what they have created.” He adds, “Doctors entrust us with their practice, and our team works to help take the practice to the next level, providing financial security for them and their families, and supporting their efforts to grow their legacy in our industry.” “We are building relationships with doctors that will last well beyond the transaction,” shares Murray. “When you affiliate with Advanced Dental Implant Center, you know who your partners will be for the long haul, because we are backed by a committed investor group, board, and management team with an unparalleled track record. If you are a doctor in the advanced dental implant space, we challenge you to ask yourself: ‘Why would I consider affiliating with anyone else?’ We welcome a transparent conversation so that you can find the right fit for your practice.” IP This information was provided by Affordable Care.

13 Volume 16 Number 4

CASE REPORT

Working as a team Drs. Iham Gammas and Haroutioun Kotchinian collaborate for more predicable surgical and restorative results

his 77-year-old retired male sought dental treatment due to difficulty chewing and poor esthetics caused by missing teeth. His medical history revealed high blood pressure, an allergy to penicillin, and current medication with Losartan. His dental history indicated a lack of oral hygiene resulting in tooth decay and significant tooth loss. Previous dental treatments included fillings, extractions, and dentures, but the ill-fitting dentures caused discomfort while eating, speaking, and smiling. During the clinical examination, the patient displayed multiple missing, decayed, and broken teeth, along with severe wear on his remaining teeth. His high lip line and relatively good positioning of the remaining anterior teeth relative to his lips were noted. A comprehensive treatment plan was developed, which consisted of the following steps: • Extraction of teeth Nos. 3 and 11. • Placement of eight Ditron dental implants in the lower arch to support a full-arch fixed dental prosthesis. • Placement of three Ditron implants in the upper arch for single implant restorations. • Preparation of the upper arch by Dr. Kotchinian and final impression incorporating the three dental implants. • Upper arch fabrication using exocad software to merge preoperative full smile photos with the final impression, customizing the smile line based on the patient’s extraoral features. • Ideal restoration of the upper arch 2 months after surgery.

Iham Gammas, DMD, ABOI/ID Diplomate, was born and raised in Illinois and earned his dental degree from the Boston University School of Dental Medicine. He currently limits his private dental practice in Lowell, Massachusetts to implant dentistry. In addition, he is an itinerate implant dentist for several other clinics in the area performing revision surgery and advanced dental implant treatments. Dr. Gammas is board certified by the American Board of Oral Implantology, a Fellow of the AAID, and a Fellow and Master in the ICOI and IADI. He is also an active member of the Academy of Osseointegration. Haroutioun Kotchinian, DMD, completed his dental degree at Tufts University School of Dental Medicine where he graduated at the top of his class. Following his graduation from dental school, he further advanced his knowledge in general and advanced dentistry at the Newark Beth Israel Hospital, where he was exposed to endodontics, prosthodontics, and implantology. While living in New Jersey, he practiced for 5 years and was able to learn different digital workflows for esthetic and prosthetic outcomes. These workflows enabled him to see a case through with more clarity and fewer patient appointments. Most recently, Dr. Kotchinian completed the Boston maxicourse in implantology. Currently he works with Dr. Iham Gammas on complex FMR cases utilizing natural teeth and implants.

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Figure 1: Preoperative and postoperative pano

Surgical procedure — Dr. Iham Gammas This is a case of teamwork, as I performed the surgical aspect, and Dr. Kotchinian completed the restoration. We frequently do these types of full arch rehabilitations in tandem. The patient presented with a complete denture for the lower arch and upper arch where most of the teeth were salvageable except for teeth Nos. 3 and 11. The plan was to restore to 1st molar occlusion. Using the CBCT as a diagnostic, we were able to plan the case with more prosthetic predictability since it acted as another part of the final blueprint for the case. I plan all cases using a CBCT scan-based planning software. For my surgeries, I like to do full thickness incisions and flaps to fully expose the buccal and lingual surfaces of bone. This way I get a good feel for the surgical site, unrestricted views, and ultimately, a more fine-tuned placement of implants. This is especially important in thinner ridges. I am also in a better position to manipulate the soft tissue and am more prepared for a potential need for bone grafting. If a planned implant is in proximity to the mental foramina, I like to expose up to the foramina and keep a note of it. A nice piece of armamentarium that will make full-arch surgeries easier is the use of OptraGate by Ivoclar. This latex-free lip and cheek retractor allows for everything buccal to the surgical site be more out of the way throughout the procedure. This provides one less issue to struggle with and increases the chance that the clinician won’t nick lips or other tissue inadvertently. The implants were all placed freehand. The placement of the upper arch had sufficient landmarks to place the implants

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CASE REPORT

in a straightforward fashion. The placement of implants 3 and 11 were immediate placements. Depending on surgical technique and implant design, I have found that immediate implant placement can be done in most cases. Implant 3 was placed in the intraseptal bone, and 11 was placed engaging the lingual plate to allow for a screw-retained crown with an access hole at the cingulum. I frequently use Versah® Densah® burs to optimize the osteotomy. Even if I have sufficient bone width, I may use a Densah drill as a final drill before implant placement. When grafting, I nearly always use a placental membrane to cover the bone graft. I have been using BioXclude® (Snoais Medical), a resorbable placental membrane, for years, but there are other competing products to choose from. They provide ample amounts of growth factors and have antimicrobial activity, all in a convenient package. It makes for an outcome with a higher chance of success. For sites 3 and 11, I used a particulate cortical allograft to fill in the remaining socket, then tuck the membrane underneath the gingival margins and suture the flaps down to hold everything in place. For the lower arch, I used a few landmarks and measurements to get the implants in the proper positions and trajectory. First, I used the CBCT as a starting point to determine the spacing of implants in positions – 19, 20, 21, 23, 26, 28, 29, and 30. I use a Castroviejo caliper to ensure proper spacing when I am placing more than one adjacent implant. I then start with initial drill points and come back and recheck spacing. For the trajectory, I ensure that the drilling is in the direction of the opposing dentition. For example, in this case, I kept the anterior implant trajectories in line with lingual of the maxillary teeth. This can be confirmed as drilling proceeds with paralleling pins and having the patient slowly occlude. To keep the implants parallel to each other, I use the midline of the face as a type of fiduciary position, then keep the drill straight on while moving into the posterior osteotomies. As I move up in drill diameter, I start again with the anterior osteotomies then go posterior. I would keep on rechecking and correcting the parallelism, if needed, as I go on. Another technique is to place a parallel pin in the center of the ridge at the midline and use that to check parallelism. In this case, I used Ditron Ultimate™ implants for the following positions — 4.2x11.5 for all the lower implants, 5x8 for 3 and 14, and 4.2x16 for 11. I used this implant for the initial stability the threading design provides and because of the coronal convergence of the implant. This allows for less bone strain at the neck, a sort of platform switch, and anecdotally more soft tissue thickening. For suturing, my go-to is Glycolon™ 5-0 by Resorba®, a PGA-PCL copolymer resorbable monofilament suture that usually resorbs in around 3-4 weeks. I find it has sufficient tensile strength and less chance to retain plaque buildup.

patient, there are many different schools of thought from Kois, Spear, Pankey, and beyond. Many of them have similar principles, but use different terminology. My background came from Spear and the Esthetic, Function, Structure, Biology (EFSB) workflow. In this case, I spent most of the time in the Esthetic section to determine his ideal central display, central angulation, midline location, gingival levels, and buccal corridor. He had no functional habits that we needed to be concerned about. No jaw pain was present currently or in the past, and no TMD. He did have wear, but we attributed that to progressive tooth loss over time, and the stress that the remaining teeth had to incur as a result of that. In terms of Structure, we chose to use porcelain-fused-to-zirconia (PFZ) crowns because they are highly esthetic, and we need not worry about metal showing over time. Also PFZ crowns generally have higher value than E.max® crowns as they let less light travel through. This value resulted in a more natural look for our patient as his natural teeth were less translucent. As long as there is adequate thickness of the porcelain, chipping is becoming more rare. Lastly, addressing the patient’s biology, he had adequate bone and probing around the teeth for long term success. His gums were slightly red, but could be controlled through regular prophylaxis. Lastly, his teeth did not need endo as there were no large caries, and our preparation was planned as conservative/normal.

Restorative upper arch — Dr. Haroutioun Kotchinian The upper arch fabrication was accomplished using exocad software to merge preoperative full-smile photos with the final impression, customizing the smile line based on the patient’s extraoral features. Ideal restoration of the upper arch was noted 2 months after surgery. When looking to restore a full arch for a implantpracticeus.com

Figures 2 and 3: 2. Preoperative and postoperative photos; full-face smile. 3. Close-up preoperative and postoperative

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CASE REPORT

For cases such as this patient, we always take before photos at rest, full smile, and intraoral. In prepping the case, I first took a preop impression of his current teeth, because I liked the position of tooth No. 8 relative to his face. For an older patient, showing about 70%-80% tooth at a smile is adequate especially for our male patients. He did not want to be too “toothy.” In this particular case because we were going to stage the upper and lower restorations, Figure 4: Intraoral preoperative and postoperative images I simply took a blue-bite impression for his eventual temporaries. I prepped the case doing my best to prep each area of the teeth at the same time, to maintain ideal preps, and angulations. I prep in this order — incisal, buccal, mesial, distal, and lingual. Then I polish using a fine diamond, and extra polish with a slow speed polishing cup. Lastly, I gently pass a fine diamond 859L bur along the margins to open the gums slightly and remove any unsupported enamel. In preparing for my final impression, I first fabricate the temporaries, using them as custom retraction caps. I placed Hemoban (Dentsply Sirona) and GingiTrac® (Centrix) on the teeth and placed the temporaries over top of them. This allows me to retract the gums and control bleeding. Although packing cord is the ideal, I found in my experience that this helps save time and provide adequate retraction for a good impression. For the implants, we used open-tray impression copings. A PA was taken prior to the final impression. Figures 5-8: Progress photos during upper-arch rehabilitation For the final impression we use Aquasil® light body and heavy body in a knockout patented impression tray. Following the appointment, all this was sent to the lab which digitized the impressions. Using exocad, they were able to place the full smile photo over the preop and prepped scan. This allows us the freedom to design his case for his face without having him in the chair for multiple sessions with temporaries. I usually receive an exocad link which I can conveniently open on my iPhone®, and analyze for all the parameters we mentioned before. Then I give my feedback to the lab, and they make the necessary changes and send me a link for final approval. When we inserted his upper arch, there was no guessing as to how it was going to look. We knew the lengths we needed and Figure 9: Lower arch implants before final insertion of restoration, showing thick, keratinized tissue the spaces in the buccal corridor that needed to be filled, thanks to our digital design. The patient was very satisfied with this step, appearance and functionality. The patient received guidance on and was back to Dr. Gammas for his fixed hybrid. proper oral hygiene practices and was advised to schedule regular follow-up visits for ongoing maintenance and monitoring. Restorative lower arch — Dr. Iham Gammas In conclusion, full mouth rehabilitation following teeth The prosthesis was fabricated for the lower implants using extraction can significantly enhance the quality of life for patients traditional analog techniques, including a final impression, wax with extensive dental issues. The use of dental implants and bone bite, and creation of a PMMA try-in. The full-arch fixed dental grafting provides stability and durability for fixed dental prostheses, prosthesis was fabricated out of zirconia, and was delivered 4 restoring essential functions and esthetics. While reimbursement months after surgery. The patient was monitored during the heallimitations may exist in our community for such procedures, the ing phase, with adjustments made to the prosthesis as necessary. utilization of a digital workflow allows for accurate teeth design The full mouth rehabilitation yielded successful results for this patient, enabling him to regain his chewing function, speech, and without the need for traditional wax-ups and lab-fabricated proviesthetics. He reported improved comfort and satisfaction with the sionals, offering a positive experience for patients while ensuring new prosthesis, which closely resembled natural teeth in both the smooth operation of our dental office. IP Implant Practice US

16 Volume 16 Number 4

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

1 Tooth #15, set to be extracted.

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

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

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

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PRACTICE PROFILE

Dr. Kate Quinlin — collaboration for better dental care

elationships are key for periodontist Dr. Kate Quinlin — with her patients, her colleagues, and with her team at Cameo Dental Specialists, a fully integrated, multidisciplinary practice with five locations in and around Chicago, Illinois. Like many doctors, Dr. Quinlin said she can’t remember a time when she didn’t want to be a dentist, although she didn’t make the decision to specialize until she was in dental school. “I really loved surgery, but relationships with people are also very, very important to me, and periodontics nicely merges those things,” she said. Originally from Pittsburgh, Pennsylvania, Dr. Quinlin made the big decision out of high school to study at the University of Tennessee. She ultimately returned to the University of Pittsburgh for dental school, and then made her way to the Windy City for her periodontics residency at the University of Illinois-Chicago. After graduation, Dr. Quinlin joined a boutique periodontics practice in Chicago’s Lincoln Park neighborhood, led by an established doctor who quickly became a great mentor. As she continued to practice there over the next 4 years, she realized she felt very isolated. When an old friend from residency, endodontist Dr. Vladana Babcic Tal, sensed her discontent and presented her with an intriguing opportunity to join her team at Cameo, Dr. Quinlin leapt at the chance. Founded as Cameo Endodontics in 1979 by two brothers, the practice remained exclusive to endodontics until 2016 when the managing partners at the time, Dr. Rick Munaretto and Dr. Keith

Sommers, embraced a big vision and decided they could deliver a higher level of patient care by partnering under one roof with established oral and maxillofacial surgeon, Dr. Joe Baptist. Adding a periodontist was the next logical move — and Dr. Quinlin still considers herself lucky to have been in the right place at the right time to be the first. “It was terrifying, but I had a little experience on my side,” Quinlin said. “I was confident in my skills as a clinician, but I was nervous because I wanted the other doctors to trust me with their patients.” On her second day, one of the endodontists requested her perspective on a case, and she began to settle into the new environment. “Being able to work inside the integrated model allows me to have a wider knowledge base and to pull from that for any given case,” Dr. Quinlin said. “It gives me confidence in how I am treating the patient, and it gives patients confidence because all the doctors are in one place, communicating and collaborating. The advantages of having all the minds in one place is huge.” Today, Cameo has a team of 22 doctors, hailing from all three specialties. “I won’t ever practice another way,” Dr. Quinlin said. In 2022, Cameo joined Specialized Dental Partners (formerly US Endo Partners), a specialty dental service organization focused on revolutionizing oral health by partnering with periodontists, endodontists, and oral and maxillofacial surgeons to bring integrated care to practices in communities across the country. “The thing that stands out most to me about Specialized Dental Partners is the culture — egos don’t exist,” she said. “There is a hive mentality, which gives us strength from within. We are all working together to not only be successful within our own offices but also to let others stand on our shoulders to grow and maximize individual potential.” “It’s amazing for us as clinicians but even more so for our patients,” Quinlin said. Learn more at www.specializeddental.com. IP This information was provided by Specialized Dental Partners.

Implant Practice US

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Your future

without limits.

“The thing that stands out most to me is the culture — egos don’t exist. We are all working together to not only be successful within our own offices, but also to let others stand on our shoulders to grow and maximize individual potential.” Dr. Kate Quinlin, Periodontist, Cameo Dental Specialists | Partner and believer since 2022

Specialized Dental Partners is proud to champion periodontists like Dr. Kate Quinlin, and the more than 300 premier specialists that make up our growing network. Since our start in 2018, we’ve been laser-focused on partnering with the best clinicians and strongest practice teams in the country. That commitment to excellence has yielded a powerhouse community of periodontists, endodontists and oral surgeons, working together to create a future without limits. You deserve a champion, too. Come join our community of specialists today.

The Champion of Specialists Scan to learn more about our Partnership opportunity for Periodontists

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Surgical strategies for preventing poor implant esthetics Dr. David Wong offers guidance on establishing soft tissue esthetics and stability to implants Introduction Replacing missing anterior teeth with dental implants can make a huge positive impact on a patient’s self-image, beauty, and confidence; however, poor implant esthetics can have the opposite effect, leaving patients ashamed to smile. The treatment to recover from poor implant esthetics can be a long, arduous, expensive, and painful process. Often, attempts to correct implant appearances still leave the patient unsatisfied. This article and case study is aimed at identifying the causes and contributing factors to poor implant esthetics and offer keys for long-term success.

5 key points 1. Poor implant esthetics are often due to poor gingival form and/or poor tissue quality. 2. Implant esthetics are influenced by implant position and depth. 3. Common gingival defects surrounding implants include poor gingival levels, lack of interdental papillae, or inadequate soft tissue contour. 4. The quality of implant esthetics tends to decrease over time. 5. Surgical techniques are available to help establish and stabilize the peri-implant soft tissue during implant therapy.

Abstract Avoiding poor implant esthetics involves careful evaluation, planning, and execution. Whether an implant is planned before or after a tooth is extracted, the endpoint of any esthetic implant-supported restoration requires proper management of the hard and soft tissues. It is not merely enough to place a dental implant in a restorable position or even to provide a properly

David Wong, DDS, is a board-certified periodontist in fulltime private practice in Tulsa, Oklahoma. He received his undergraduate education and dental training at the University of Oklahoma. He then went on to complete a 3-year residency in periodontics at the University of Missouri-Kansas City. He is a Diplomate of the American Board of Periodontology and holds teaching positions at the University of Oklahoma College of Dentistry and Penn Dental Medicine Periodontic Program. He is a published author in several peer-reviewed dental journals and has also reached a mainstream audience in media such as Fox News and the Wall Street Journal. Dr. Wong presently resides in Tulsa with his wife and three children.

Implant Practice US

Educational aims and objectives

This self-instructional course for dentists aims to identify the causes and contributing factors to poor implant esthetics and offers keys for long-term success.

Expected outcomes

Implant Practice US subscribers can answer the CE questions by taking the quiz online at implantpracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify some factors influencing implant esthetics. • Recognize how biology influences tissue behavior. • Realize the role of tissue response to surgery and restorative procedures. • Identify the five risk factors associated with peri-implant soft tissue dehiscences (PSTDs). • Observe a case study where the clinician was faced with esthetic challenges. CREDITS

2 CE

contoured restoration with the correct shade and other important elements. The importance of the surrounding soft tissue should be addressed during the course of dental implant therapy as this is the esthetic variable that is most prone to change over time. Esthetic issues such as soft tissue dehiscences, apical migration of the gingival margin, or loss of papillae height are best anticipated and addressed prior to the delivery of the final restoration. This paper will examine some common surgical strategies to establish soft tissue esthetics and stability over time.

Factors influencing implant esthetics Implant esthetics are influenced by a number of factors: 1. implant position 2. existing gingival level 3. tissue response to surgery and restorative procedures 4. management of the restoration with the abutment and crown 5. time1

Implant position A “restoratively driven” approach to implant placement is often preferred for the best esthetic outcome, which allows for proper abutment and crown design. This can be challenging in areas of severe periodontal destruction, tooth position, ridge

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atrophy, or the patient’s anatomy. Nevertheless, whether an implant is placed in a fresh extraction socket or a healed site, extremely poor positioning cannot be overcome with surgical or restorative procedures.2,3

Existing gingival levels A dental implant and restoration cannot be esthetically pleasing by itself. The appearance and alignment of the adjacent teeth should complement each other to develop a pleasing smile. Often, orthodontics or more comprehensive restorative care is necessary to develop the symmetry, soft tissue architecture, and uniformity necessary for the desired esthetic outcome.

Figure 1: Over time, gingival recession is a common change observed in patients with implants

Tissue response to surgery and restorative procedures

Prosthetic design

While it may be simple to perform procedures such as extractions, bone grafting, implant surgery, abutment/crown delivery, etc., it is important to remember that the patient’s biology and wound healing will influence the final outcome. It is impossible to entirely predict how patients will respond to surgery, but their clinical presentation provides some clues. For example, the periodontal phenotype and presence of keratinized tissue are two clinical parameters that surgeons can use to predict future tissue behavior.4,5,6,7 The interproximal height of bone is another important observation to make.8 The periodontal phenotype is often described as either thick or thin. To tell the difference, a common technique is transgingival probing4 where a periodontal probe is inserted into the facial sulcus of a tooth. If the probe is visible through the tissue, the phenotype is thin. If it is not visible, it is considered thick. Thin phenotypes are associated with longer, triangular-shaped teeth with a highly scalloped gingival architecture. There tends to be less keratinized tissue and thinner facial bone, leaving teeth prone to bony dehiscences and fenestrations. Thinner phenotypes tend to respond to insult or injury with gingival recession. Thicker phenotypes tend to be associated with shorter, squareshaped teeth, often surrounded by thicker bands of keratinized tissue which is considered more resistant to gingival recession.9 The flatter gingival architecture of thick phenotypes generally makes implant esthetics more straightforward compared to the thin phenotype.10,11,12 Keratinized tissue around implants is also considered an important part of implant esthetics because like thicker periodontal phenotypes, this tissue is less prone to recession. It is also considered helpful for maintaining implant health in regards to decreasing plaque retention, bleeding, and inflammation.13,14 When surveyed, patients tend to prefer the appearance of keratinized tissue versus non-keratinized tissue.15 The interproximal height of bone (IHB),8 which is the interdental bone height on the mesial and distal side of an implant, is critical to esthetics because it is a key determinant of the presence or absence of papillae and the so-called “black triangles.” To maximize the chances of proper papillae formation/preservation, it is recommended that the IHB is 5 mm or less from the interproximal contracts. The keys to maintaining the IHB are conservative extraction, implant, and regenerative procedures when possible and utilizing methods such as orthodontic extrusion whenever appropriate. implantpracticeus.com

Soft tissue esthetics around implants are influenced by the abutment and crown design. Compared to tooth-supported crowns, implant-supported crowns tend to have a flatter or concave subgingival profile16,17 to allow for thicker facial tissue and more stable gingival levels.

Implant esthetics over time The facial soft tissue changes around implants in the esthetic zone are being studied more as there is now ample data to compare various treatment strategies observed over time. The most common change observed with implants over time is the presence of gingival recession (Figure 1), now called “peri-implant soft tissue dehiscences (PSTDs).”18 In 2000, Small, et al., reported after a 1-year longitudinal prospective study that 80% of implants exhibited approximately 1 mm of recession after the abutment was connected to the implant.19 A study by Cardaropoli, et al., in 2006 found a similar result with the average recession being 0.6 mm at 1 year.20 More recently, Tavelli, et al., in 2022 reported on 176 implants, and 56.8% of them had recession, and 43.2% did not have any noticeable recession. There were five risk factors associated with PSTDs: 1. Time in function 2. Implants next to each other 3. Bony dehiscence 4. Thin facial tissue 5. Less keratinized mucosa width.18 Finally, when comparing gingival recession on implants placed in fresh extraction sockets (immediate placement) versus implants placed in a delayed approach, Parvini, et al. (2022), reported increased recession on the immediately placed implants after 12 months (0.37 mm).21 Meanwhile, the delayed placement group exhibited a facial tissue gain of 0.83 mm. Immediate implant placement typically shows the greatest variability in the occurrence of recession with reports ranging from 9% to 41% having at least 1 mm of recession, 1 to 3 years after placement.22,23

Implications for implant treatment Given the knowledge available regarding soft tissue changes around implants, an increased focus is being placed on the preservation and protection of the facial plate24,25,26,27 improving facial tissue thickness when necessary (i.e., thin phenotypes)7, and the timing of implant placement (immediate versus delayed;

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Figures 2A-2C: Patient’s initial presentation. Notice the ridge collapse at No. 8

serial extraction).11,28 Below is a case study detailing the various techniques available with this hard and soft tissue development philosophy in mind.

Case Study This 24-year-old white male patient Figure 2D: CBCT of site No. 8 with proposed implant position initially presented for an implant consultation to replace his upper central incisors, tooth Nos. 8 and 9. Both teeth had a history of trauma and subsequent root canal therapy; however, No. 8 was recently extracted after a second traumatic event, and No. 9 was deemed endodontically hopeless (Figures 2A and 2B). This case posed several challenges. Esthetically, the patient had malpositioned teeth and uneven gingival levels. His periodontal phenotype was thin, and he had adequate keratinized mucosa present in the maxilla but much less in the mandible. When considering implant esthetics, specifically, labial ridge atrophy was observed in the No. 8 site (Figure 2C); fortunately, the ridge width was still adequate for proper implant placement (Figures 2D). The other implant challenge was addressing hopeless tooth No. 9. With the thin phenotype and long, tapered tooth Figure 2E: The patient was referred to an orthodontist for treatment prior to morphology, papillae preservation and the stability of the facial surgery tissue was a major concern. There was no loss of the interproximal height of bone, so with tooth No. 9 still present, the proper To counteract the tendency of anterior implants to develop surgical strategy and timing was crucial to ensure preservation soft tissue dehiscences (PSTDs), each implant site was managed of the tissues. The final challenge was patient management. He differently, since tooth No. 8 was a healed site, and tooth No. 9 self-reported that he is “rough with his teeth” which has resulted was still present. Tooth No. 8 was treated with an implant and a in his present situation. simultaneous connective tissue graft to address the facial ridge Implant esthetics is influenced by four main factors: 30 atrophy. Tooth No. 9 was treated with the “socket shield” tech1. existing gingival levels nique, which is a form of root submergence where a thin facial 2. implant position portion of the root (the root shield) is left attached to the facial 3. response of the tissues to dental/surgical procedures 1 plate in order to avoid any loss of facial bone and tissue. 4. management of the tissue with the crown/abutment The sequence of treatment was the following: The patient agreed that orthodontics and two implants was 1. Referred to orthodontist for evaluation and treatment the ultimate goal. prior to commencement of any implant-related surgery Considering the esthetic risk of two implants side-by-side, a (Figure 2E). serial extraction (aka as “one by one”) approach,11,28 was taken 2. Placed implant No. 8 with the addition of a connective in order to preserve the midline papilla and the interdental bone tissue graft and healing abutment (Figures 2F-2H). With between the implants. In this case, tooth No. 8 was treated with this technique, a soft tissue allograft such as an acellular an implant first, followed by extraction and treatment of tooth dermal graft material may also be used.3 No. 9 approximately 3 months later. Both implants were placed 3. After 3 months, removed tooth No. 9 utilizing the “socket in positions to both accommodate screw-retained restorations as shield”25,26,27 approach and grafted the socket (Figures well as to allow thicker facial bone to avoid future bony dehis29 2I-2K). cences (more lingual position). Implant Practice US

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Figure 2F-2H: Implant No. 8 was placed with a connective tissue graft first

Figures 2I-2K: After 3 months, tooth No. 9 was removed utilizing the “socket shield” approach, and the socket was grafted

Figure 2L: A surgical guide was used to place implant No. 9

Figures 2M and 2N: Implant positions and radiograph

Figures 2O-2Q: Uneven gingival levels were corrected with provisional crowns

4. After 3 months of healing of the grafted socket of tooth No. 9, a surgical guide (which was also used for tooth No. 8) was used to place implant No. 9 (Figures 2L and 2M). 5. Implant No. 9 was allowed to heal for 4 months, and both sites Nos. 8 and 9 were evaluated (Figures 2N-2P). The facial gingival thickness and keratinized tissues were satisfactory; however, recession and a mucogingival deficiency had developed on tooth Nos. 24-25 post-orthodontically. 6. The gingival levels between tooth Nos. 8-9 were uneven; this was corrected through the provisional restorations (Figures 2Q and 2R). implantpracticeus.com

7. After addressing the recession on tooth Nos. 24-25 with a free gingival graft, final restorations were placed on tooth Nos. 8 and 9, making desired changes from the patient (Figures 2S and 2T). Figure 2T is 4 years posttreatment.

Conclusions Implant esthetics requires a lot of consideration and planning to achieve the desired result. While there are many approaches available, especially in the case presented, it is important to understand how biology influences tissue behavior. The present focus is on maximizing tissue thickness, minimizing bone loss

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Figure 2R: Nos. 8 and 9 were both screw-retained crowns

Figures 2S and 2T: 4 years posttreatment. The gingival recession on Nos. 24-25 has been corrected as well

after extraction, placing implants away from the facial plate, and tissue management using the abutments and crowns. Other surgical strategies such as immediate implant placement or perhaps even a single implant to replace both teeth8 are other options that were considered. No matter the treatment plan, one must always treat to their ability and take advantage of interdisciplinary approaches such orthodontics, periodontics, and restorative dentistry (in this case) whenever appropriate. IP REFERENCES 1.

Cooper LF. Objective criteria: guiding and evaluating dental implant esthetics. J Esthet Restor Dent. 2008;20(3):195-205.

Nisapakultorn K, Suphanantachat S, Silkosessak O, Rattanamongkolgul S. Factors affecting soft tissue level around anterior maxillary single-tooth implants. Clin Oral Implants Res. 2010 Jun;21(6):662-670.

Park JB. Increasing the width of keratinized mucosa around endosseous implant using acellular dermal matrix allograft. Implant Dent. 2006 Sep;15(3):275-281.

Fu J, Lee A, Wang HL (2011) Influence of tissue biotype on implant esthetics. Int J Oral Maxillofac Implants. 26:499–508

Fu JH, Su CY, Wang HL. Esthetic soft tissue management for teeth and implants. J Evid Based Dent Pract. 2012 Sep;12(3 Suppl):129-142.

Jung RE, Sailer I, Hämmerle CH, Attin T, Schmidlin P. In vitro color changes of soft tissues caused by restorative materials. Int J Periodontics Restorative Dent. 2007 Jun;27(3):251-257.

Kan JYK, Yin S, Rungcharassaeng K, Zucchelli G, Urban I, Lozada J. Facial implant gingival level and thickness changes following maxillary anterior immediate tooth replacement with scarf-connective tissue graft: A 4-13-year retrospective study. J Esthet Restor Dent. 2023 Jan;35(1):138-147.

Salama H, Salama MA, Garber D, Adar P. The interproximal height of bone: a guidepost to predictable aesthetic strategies and soft tissue contours in anterior tooth replacement. Pract Periodontics Aesthet Dent. 1998 Nov-Dec;10(9):1131-1141; quiz 1142. Magne P, Belser U. Bonded porcelain restorations in the anterior dentition. A biomimetic approach. Chicago: Quintessence; 2002.

10. Kao RT, Fagan MC, Conte GJ. Thick vs. thin gingival biotypes: a key determinant in treatment planning for dental implants. J Calif Dent Assoc. 2008 Mar;36(3):193-198. 11. Khoury G, Chamieh F, Fromentin O. One-by-one immediate dental implants: A papillae preservation concept for adjacent implants in a compromised periodontal case. Clin Case Rep. 2020 Aug 20;8(12):2664-2672. 12. Kois JC, Kan JY. Predictable peri-implant gingival aesthetics: surgical and prosthodontic rationales. Pract Proced Aesthet Dent. 2001 Nov-Dec;13(9):691-698; quiz 700, 721-722. 13. Chung DM, Oh TJ, Shotwell JL, Misch CE, Wang HL. Significance of keratinized mucosa in maintenance of dental implants with different surfaces. J Periodontol. 2006 Aug;77(8):1410-1420. 14. Warrer K, Buser D, Lang NP, Karring T. Plaque-induced peri-implantitis in the presence or absence of keratinized mucosa. An experimental study in monkeys. Clin Oral Implants Res. 1995 Sep;6(3):131-138. 15. Bonino F, Steffensen B, Natto Z, Hur Y, Holtzman LP, Weber HP. Prospective study of the impact of peri-implant soft tissue properties on patient-reported and clinically assessed outcomes. J Periodontol. 2018 Sep;89(9):1025-1032. 16. Gomez-Meda R, Esquivel J, Blatz MB. The esthetic biological contour concept for implant restoration emergence profile design. J Esthet Restor Dent. 2021 Jan;33(1): 173-184.

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Figure 2U: 5 years posttreatment 17. Rompen E, Raepsaet N, Domken O, Touati B, Van Dooren E. Soft tissue stability at the facial aspect of gingivally converging abutments in the esthetic zone: a pilot clinical study. J Prosthet Dent. 2007 Jun;97(6 Suppl):S119-125. 18. Tavelli L, Barootchi S, Majzoub J, Chan HL, Stefanini M, Zucchelli G, Kripfgans OD, Wang HL, Urban IA. Prevalence and risk indicators of midfacial peri-implant soft tissue dehiscence at single site in the esthetic zone: A cross-sectional clinical and ultrasonographic study. J Periodontol. 2022 Jun;93(6):857-866. 19. Small PN, Tarnow DP. Gingival recession around implants: a 1-year longitudinal prospective study. Int J Oral Maxillofac Implants. 2000 Jul-Aug;15(4):527-532. 20. CCardaropoli G, Lekholm U, Wennström JL. Tissue alterations at implant-supported single-tooth replacements: a 1-year prospective clinical study. Clin Oral Implants Res. 2006 Apr;17(2):165-171. 21. Parvini P, Müller KM, Cafferata EA, Schwarz F, Obreja K. Immediate versus delayed implant placement in the esthetic zone: a prospective 3D volumetric assessment of peri-implant tissue stability. Int J Implant Dent. 2022 Nov 25;8(1):58. 22. Chen ST, Buser D. Clinical and esthetic outcomes of implants placed in postextraction sites. Int J Oral Maxillofac Implants. 2009;24 Suppl:186-217. 23. Chen ST, Buser D. Esthetic outcomes following immediate and early implant placement in the anterior maxilla--a systematic review. Int J Oral Maxillofac Implants. 2014;29 Suppl:186-215. 24. Agnini A, Salama MA, Salama H, Garber D, Agnini AM. Surgical veneer grafting: compensation for natural labial plate remodeling after immediate implant placement. J Cosmetic Dent. 2017 Winter; 32(4):70-85. 25. Gluckman H, Du Toit J, Salama M. The Pontic-Shield: Partial Extraction Therapy for Ridge Preservation and Pontic Site Development. Int J Periodontics Restorative Dent. 2016 May-Jun;36(3):417-423. 26. Gluckman H, Salama M, Du Toit J. Partial Extraction Therapies (PET) Part 1: Maintaining Alveolar Ridge Contour at Pontic and Immediate Implant Sites. Int J Periodontics Restorative Dent. 2016 Sep-Oct;36(5):681-687. 27. Gluckman H, Du Toit J, Salama M, Nagy K, Dard M. A decade of the socket-shield technique: a step-by-step partial extraction therapy protocol. Int J Esthet Dent. 2020;15(2):212-225. 28. Funato A, Salama MA, Ishikawa T, Garber DA, Salama H. Timing, positioning, and sequential staging in esthetic implant therapy: a four-dimensional perspective. Int J Periodontics Restorative Dent. 2007 Aug;27(4):313-323. 29. Rojas-Vizcaya F. Biological aspects as a rule for single implant placement. The 3A-2B rule: a clinical report. J Prosthodont. 2013 Oct;22(7):575-580. 30. Seibert JS, Salama H. Alveolar ridge preservation and reconstruction. Periodontol 2000. 1996 Jun;11:69-84.

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Continuing Education Quiz Surgical strategies for preventing poor implant esthetics WONG

1. It is not merely enough to place a dental implant in a restorable position or even to provide a properly contoured restoration with the correct shade and other important elements. a. True b. False

2. Implant esthetics are influenced by implant position, _______, and time. a. existing gingival level b. tissue response to surgery and restorative procedures c. management of the restoration with the abutment and crown d. all of the above

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.

3. Often, orthodontics or more comprehensive restorative care is necessary to ________ necessary for the desired esthetic outcome. a. develop the symmetry b. develop the soft tissue architecture c. develop the uniformity d. all of the above

Expiration Date: November 15, 2026

4. While it may be simple to perform procedures such as extractions, bone grafting, implant surgery, abutment/crown delivery, etc., it is important to remember that the patient’s ________ will influence the final outcome. a. biology b. wound healing c. personality d. both a and b 5. (With transgingival probing) If the probe is visible through the tissue, the phenotype is ________. a. thin b. thick c. flat d. more resistant to gingival recession 6. When surveyed, patients tend to __________. a. prefer the appearance of non-keratinized tissue versus keratinized b. prefer the appearance of keratinized tissue versus non-keratinized tissue c. have no preference regarding keratinized or non-keratinized tissue d. none of the above 7. The interproximal height of bone (IHB), which is the interdental bone height on the mesial and distal side of an implant, is critical to esthetics

AGD Code: 690 Date Published: November 15, 2023

2 CE CREDITS

because it is a key determinant of the presence or absence of papillae and the so-called _______. a. “gray areas” b. “triangular territories” c. “black triangles” d. “soft tissue issues” 8. To maximize the chances of proper papillae formation/preservation, it is recommended that the interproximal height of bone (IHB) is _______ or less from the interproximal contracts. a. 1 mm b. 3 mm c. 5 mm d. 6 mm 9. Compared to tooth-supported crowns, implant-supported crowns tend to have a ________ gingival profile to allow for thicker facial tissue and more stable gingival levels. a. flatter or concave b. thicker or concave c. flatter or convex d. thicker or convex 10. The most common change observed with implants over time is the presence of gingival recession, now called “peri-implant soft tissue dehiscences (PSTDs). a. True b. False

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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Treatment of severely atrophic maxillae using the PATZI remote anchorage protocol: a case series Dr. Dan Holtzclaw discusses a systematic algorithm that allows for real-time modifications during surgery Introduction Treatment of the atrophic maxilla was once thought impossible,1 but advances in dental implant technology and surgical techniques over the past 30 years have significantly remedied this situation. In 1985, Tulasne performed the first placement of root-form pterygoid implants which used remotely located dense pterygomaxillary bone for restoration of compromised posterior maxillae.2 This was soon followed by Brånemark who in 1987 utilized dense bone of the zygoma to further facilitate restoration of atrophic maxillae.3 While these protocols afforded new treatment options for severely resorbed maxillae, prosthetic restoration of these early remote anchorage implants often resulted in bulky prosthetics that compromised patient comfort and speech.4-9 These issues were improved when Stella and Warner introduced the extramaxillary zygomatic implant “slot” technique at the turn of the millennium 13 years later.10 This protocol lateralized placement of zygomatic implants, thus eliminating excessive palatal platform positioning associated with the original Brånemark protocol. Bothur next proposed use of multiple fixtures per zygoma to completely eliminate the need for bone grafting in severely atrophic maxillae.11 In 2003, Malo, et al., published the first paper documenting use of the All-On-4™ protocol for restoration of edentulated maxillae with immediate loading.12 Over the ensuing decade, Aparicio, et al., published a series of studies that culminated in the development of the Zygomatic Anatomy Guided Approach (ZAGA) which refined placement of zygomatic implants further improving prosthetic restoration of the atrophic maxillae.13-17 In 2018, Holtzclaw introduced the Pterygoid Fixated Arch Stabilization (PFAST) protocol employing immediately loading of pterygoid implants to eliminate prosthetic cantilevers which

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 more than 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.

Implant Practice US

Educational aims and objectives

This self-instructional course for dentists aims to discuss dental implant treatment of the atrophic maxilla following the PATZI protocol.

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: • Use the PATZI protocol to make rapid treatment decisions for the treatment of severely atrophic maxillae following a logical and systematic algorithm. • Recognize that multiple different implant fixtures are readily available for treatment of severely atrophic maxillae. • Recognize that the PATZI protocol offers a systematic algorithm for rapidly planning the treatment of severely atrophic maxillae. • Identify situations in which the PATZI protocol allows for real-time alterations of planned surgical treatment based on intrasurgical outcomes. • Recognize that the PATZI protocol may result in an infinite number of remote anchorage implant combinations to treat any atrophic maxilla.

2 CE CREDITS

were often associated with problems that sometimes arose from the All-On-4™ protocol.18 The purpose of this paper is to highlight continued advancements in treatment of edentulated and atrophic maxillae with introduction of the PATZI protocol: (P)terygoid, (A)nterior (T)ilted (Z)ygomatic (I)mplants.

PATZI protocol concept The PATZI protocol is a systematic algorithm for rapid treatment planning of atrophic maxillae which allows for real-time modifications during the surgical procedure.20 PATZI employs immediate loading and remote anchorage concepts developed over the past 35+ years to produce a near infinite combination of dental implant setups to accommodate nearly any situation that may present in atrophic maxillae. PATZI starts with attempted placement of pterygoid implants to employ their numerous

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benefits of cantilever elimination, maximizing anterior-posterior spread, and increasing composite torque value.18-21 If pterygoid implants are successfully placed, the algorithm next proceeds to achieve anterior support. Anterior prosthetic support may be attained with standard axial, nasopalatine, piriform rim, or transnasal fixtures.12,22-24 If anterior support is achieved, PATZI now proceeds to achieve mid-maxillary support via tilted implants which may be of either traditional or trans-sinus varieties.12,25 If pterygoid or mid-maxillary Figure 1: Presurgical 3D rendering of patient Figure 2: Presurgical CBCT image (axial view) of left tilted implants are not successful, PATZI with severe maxillary atrophy prelacrimal recess with Simmen Class 3 status calls for placement of a posteroinferior zygomatic implant. Alternatively, failure to achieve placement of an anterior implant necessitates placement of an anterosuperior zygomatic implant. In the event that multiple zygomatic implants are required in a single malar process, the presence or absence of a pterygoid implant will influence the configuration of the zygomatic fixtures: parallel versus “A-Frame.”20 If a pterygoid implant is present, the zygomatic implants can be placed in a parallel configuration. While parallel zygomatic implants have the disadvantage of an anteriorly located posterior prosthetic platform, they have the benefits of more superior malar real estate for the placement of a second zygomatic Figure 3: According to PATZI protocol, a pterygoid Figure 4: A pair of zygomatic implants were implant and eliminate the possibility implant was placed first and achieved high insertion placed on the right side of Case 1 as (A) and (T) of for collision with the anterosuperior torque of 45+ Ncm PATZI were not satisfied zygomatic fixture. The shortcomings of the posteriorly located posteroinferior trauma and several failed prior treatment attempts. The patient’s zygomatic implant are offset by the pterygoid implant which medical history was unremarkable. Presurgical radiographic maximizes AP spread and eliminates prosthetic cantilever. If a evaluation revealed a deficient premaxilla with minimal subpterygoid implant is not successfully placed, zygomatic implants nasal bone precluding the placement of standard, nasopalatine, are placed in an A-Frame setup with the posteroinferior fixture and piriform-rim dental implants. Evaluation of the prelacrimal placed in a more posterior position. Placement in this manner recesses revealed radiopaque bone suggestive of dense quality distalizes the prosthetic platform of the posteroinferior zygomatic and measurements consistent with Simmen 2 classification on implant, shortening the resultant cantilever of the restoration. the left and Simmen 1 on the right.31 In the mid-maxilla, both Alternatively, the A-Frame setup brings the posteroinferior maxillary sinuses were severely pneumatized but appeared zygomatic implant apex closer to the orbit, thus reducing availradiolucent with minimal thickening of the Schneiderian memable real estate for the anterosuperior zygomatic fixture and branes. Evaluation of coronal CBCT slices suggested patent increases the risk of implant collision. The PATZI protocol is osteomeatal complexes bilaterally. The zygomas presented employed to the left and right sides of the maxilla independently. radiopacity consistent with dense bone, but were constricted The remainder of this article presents a series of cases that in height compared to average measurements reported in pubdemonstrate the applicability of the PATZI protocol for treatment lished literature.32-36 Posteriorly, minimal subantral bone was of atrophic maxillae. noted bilaterally, and the pterygomaxillary complexes contained radiopaque bone of standard dimensions. Case 1 Following the induction of general endotracheal anestheA 42-year-old female patient was referred to the author for sia with an anesthesiologist, local anesthesia was provided treatment of a severely atrophic maxillae which had a history of implantpracticeus.com

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Figure 5: A transnasal implant was placed on the left side of Case 1 to satisfy (A) of PATZI. Note the implant traverses the lateral nasal wall to engage the dense bone at the confluence of the inferior concha, lateral nasal wall, and frontal process of the maxilla

intraorally. Supplemental local anesthesia was administered extraorally at both infraorbital nerves and malar prominences. A full-thickness mucoperiosteal flap was elevated to bilaterally expose the piriform aperture, infraorbital nerve, malar prominence, and hamular notch. As the maxillary arch was already severely atrophic, no bone adjustments were required to obtain prosthetic space. Following the PATZI protocol, a 4.2 mm x 18 mm pterygoid implant was placed on the patient’s right side achieving high insertion torque of 45+ Ncm. On this same side, no bone was available for anterior or mid-maxillary implant placement, thus eliminating the possibility of implant placement according to (A) and (T) in the PATZI. Accordingly, the protocol called for placement of multiple zygomatic implants in the right malar prominence. As a pterygoid implant had been successfully placed in the right pterygomaxillary region, a parallel zygomatic setup was employed. On the patient’s left side, a 4.2 mm x 18 mm pterygoid implant was placed in a similar fashion to the contralateral side in accordance with the PATZI protocol. As PATZI next calls for anterior implant support (A), a transnasal implant was attempted as bone in the left prelacrimal recess appeared adequate. The left nasal mucosa was reflected superiorly to the inferior concha and a 3.8 mm x 24 mm was placed with insertion torque exceeding 45Ncm. With pterygoid and anterior support achieved on the left side satisfying (P) and (A) of PATZI, mid-maxillary support was sought with tilted implants to satisfy (T). With no adequate bone to support tilted implants, a posteroinferior zygomatic implant was placed. With composite torque value exceeding 350+ Ncm, the maxillary arch was immediately loaded with a transitional restoration. The procedure completed without incident, and the patient was pleased with the outcome (Figures 1-6). Implant Practice US

Figure 6: Postsurgical 3D rendering of Case 1 following placement of 2 pterygoid, 3 zygomatic, and 1 transnasal implants according to the PATZI protocol

Case 2 A healthy 83-year-old female patient presented to our clinic seeking full-mouth implant rehabilitation. She had been edentulous in the maxilla for more than a decade, and her mandibular prosthetic work had recently begun to deteriorate. Presurgical radiographic evaluation revealed a premaxilla with mixed amounts of alveolar atrophy. The right anterior maxilla had bone of adequate thickness for a smaller diameter implant while the left side had severe atrophy. Moderate pneumatization of the maxillary sinuses was evident with relatively radiolucent subantral bone suggesting low density. The pterygomaxillary complexes suggested areas of dense bone in the pyramidal processes and pterygoid pillars with the right side appearing more robust than the left. Anesthesia and flap reflection were carried out in a similar fashion to that of Case 1 in this article. Following the PATZI protocol, a 4.2 mm x 18 mm pterygoid implant was first placed with 45+ Ncm insertion torque on the patient’s right side. With (P) of PATZI satisfied, anterior (A) implants were attempted next. The neurovascular bundle of the nasopalatine canal was enucleated and a 4.2 mm x 10 mm implant was placed with 45+ Ncm torque. Additional support for the patient’s anterior right side was achieved with a 4.2 mm x 13 mm implant that engaged the dense bone of the piriform rim. With minimal subantral bone remaining, a tilted implant was not possible. With (T) of PATZI not satisfied, mid-maxillary support was achieved with a right posteroinferior zygomatic implant. This zygomatic implant was placed in the inferior aspect of the zygoma to preserve the possibility of placing a second zygomatic implant if ever needed in the future. With the patient’s right side adequately supported, attention was now turned to

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Figures 7 and 8: 7. Presurgical panoramic radiograph of Case 2 . 8. According to PATZI protocol, a pterygoid implant was placed first and achieved high insertion torque of 45+ Ncm

Figures 9 and 10: 9. To satisfy (A) of PATZI, a nasopalatine implant was placed in the anterior sextant. 10. Atrophy of the alveolar ridge on the left side of Case 2 precluded implants to satisfy (A) and (T) of PATZI. Accordingly, multiple zygomatic implants would be required to accommodate the protocol

the left maxilla. Following PATZI, a left pterygoid implant was attempted first but without success. With the (P) of PATZI unsatisfied, algorithm progression next dictated attempts at anterior implant placement. With bone thickness as low as 0.8 mm in the anterior left maxilla, placement of standard, nasal rim, and piriform rim implants was not possible. Evaluation of the patient’s prelacrimal recess revealed a Simmen Class 3 relationship to the nasolacrimal duct, but minimal bone thickness of only 0.9 mm precluded placement of a transnasal implant. Failure to satisfy (A) of PATZI called for placement of an anterosuperior zygomatic implant. With minimal bone in the patient’s mid-maxilla, (T) of PATZI was also unsatisfied with inability to place a tilted implant. As tilted implant placement was not possible, a posteroinferior zygomatic implant was indicated. With the additional consideration that (P) of PATZI was also unsatisfied on the patient’s left side, zygomatic implants in an “A-Frame” configuration were required to maximize AP prosthetic spread. With a composite torque value exceeding 350 Ncm, the patient’s maxilla was immediately restored with a transitional restoration which was matched to fit an implant supported restoration in the mandible. The patient healed uneventfully and was pleased with the outcome (Figures 7-12). implantpracticeus.com

Figure 11: To satisfy PATZI, note that multiple zygomatic implants have been placed on the patient’s left side due to the condition noted in Figure 10

Figure 12: Multiple zygomatic implants were placed in an “A-Frame” fashion in the left zygoma of Case 2 since no left pterygoid implant was able to satisfy (P) of PATZI

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Figures 13 and 14: 13. Presurgical panoramic radiograph of Case 3 showing pneumatized maxillary sinuses and localized areas of periapical infection. 14. Presurgical panoramic radiograph of Case 3 showing severe bone loss at the left canine. This may preclude placement of dental implants in this area with possible deleterious effect on (T) of the PATZI protocol

Case 3 A 52-year-old male presented for full arch immediate implant treatment of the maxilla and mandible. Presurgical radiographic analysis revealed multiple missing teeth and localized areas of infection in the remaining dentition. Infection around the left maxillary canine was particularly concerning as a significant amount of bone was missing in this area. Both maxillary sinuses were pneumatized posteriorly, but the pterygomaxillary complexes demonstrated dense bone of standard dimensions. The mandible contained multiple missing teeth and exhibited a horizontal periodontal bone loss pattern similar to that of the maxilla. Following the administration of intravenous sedation, local anesthetic was applied intraorally, and an incision was employed from the left to right maxillary tuberosity. Figures 15 and 16: 15. According to PATZI protocol, a pterygoid implant was placed Following elevation of a full thickness mucoperiosteal flap, first and achieved high insertion torque of 45+ Ncm. 16. Since (T) of PATZI was not all teeth were removed and their sockets degranulated. satisfied on the patient’s left side due to the large osseous defect associated with Following the PATZI protocol, a pterygoid implant was the left maxillary canine, a zygomatic implant was placed to satisfy (Z) first placed on the patient’s right side with extremely high with extremely high documented success.12,26-30 While standard insertion torque. With (P) of PATZI satisfied, an anterior implant All-On-4™ style implant treatment has been a readily accepted was next placed in the area of the right lateral incisor, and a protocol, it is not applicable to all maxillary situations such as tilted implant was next placed in the right premolar region to those with severe atrophy. The PATZI protocol employs a comaccommodate (T). On the patient’s left side, the process repeated bination of standard and remote anchorage implant techniques with a pterygoid implant placed first. With (P) of PATZI accomto tackle any situation that may present in the atrophic maxilla. modated, an anterior implant was placed in the socket of the left Additionally, this systematic algorithm allows for rapid treatment central incisor. The large amount of bone loss associated with the planning and the option for real-time changes based on intrasurleft maxillary canine and the pneumatized left maxillary sinus gical outcomes. PATZI is an advanced protocol that requires the precluded placement of a tilted implant. With (T) of PATZI unsatuser to have full command of complex surgical techniques such isfied, the algorithm called for placement of a posteroinferior as pterygoid, zygomatic, and transnasal implants. Without these zygomatic implant. Using the extrasinus slot technique, a 4.2 implant styles, PATZI cannot be employed. IP mm x 42.5 mm zygomatic fixture was placed with extremely high insertion torque. With a cumulative torque value of 300+ REFERENCES Ncm, the maxilla was immediately restored with a transitional 1. Linkow L. A Dynamic Approach to Oral Implantology Maxillary Implants. North Haven, restoration. The mandible was subsequently treated in a similar Connecticut: Glarus; 1977. fashion to the maxilla. The patient healed uneventfully and was 2. Balshi TJ, Lee HY, Hernandez RE. The use of pterygomaxillary implants in the partially edentulous patient: a preliminary report. Int J Oral Maxillofac Implants. 1995 Jan-Feb; satisfied with the outcome (Figures 13-18). 10(1):89-98.

Conclusion Immediately loaded full arch treatment has a 20-year history Implant Practice US

Parel SM, Brånemark PI, Ohrnell LO, Svensson B. Remote implant anchorage for the rehabilitation of maxillary defects. J Prosthet Dent. 2001 Oct;86(4):377-381.

Lopes A, de Araújo Nobre M, Ferro A, Moura Guedes C, Almeida R, Nunes M. Zygomatic

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Figures 17 and 18: 17. Postsurgical panoramic radiograph of Case 3 showing PATZI satisfied by 2 pterygoid, 2 standard anterior, 1 tilted, and 1 zygomatic implant. 18. Postsurgical 3D rendering of Case 3 showing PATZI satisfied by 2 pterygoid, 2 standard anterior, 1 tilted, and 1 zygomatic implant

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.

21. Jensen OT, Adams MW, Butura C, Galindo DF. Maxillary V-4: Four implant treatment for maxillary atrophy with dental implants fixed apically at the vomer-nasal crest, lateral pyriform rim, and zygoma for immediate function. Report on 44 patients followed from 1 to 3 years. J Prosthet Dent. 2015 Dec;114(6):810-817.

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.

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):7378. Epub 2018 Aug 3.

22. Urban I, Jovanovic SA, Buser D, Bornstein MM. Partial lateralization of the nasopalatine nerve at the incisive foramen for ridge augmentation in the anterior maxilla prior to placement of dental implants: a retrospective case series evaluating self-reported data and neurosensory testing. Int J Periodontics Restorative Dent. 2015 Mar-Apr;35(2):169-177. 23. Lorean A, Mazor Z, Barbu H, Mijiritsky E, Levin L. Nasal floor elevation combined with dental implant placement: a long-term report of up to 86 months. Int J Oral Maxillofac Implants. 2014 May-Jun;29(3):705-708.

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.

24. Camargo VB, Baptista D, Manfro R. Implante transnasal (Técnica Vanderlim) como opção ao segundo implante zigomático. Coppedê A. Soluções clínicas para reabilitações totais sobre implantes sem enxertos ósseos. 2019:198–214. São Paulo: Quintessence.

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.

25. Jensen OT, Cottam J, Ringeman J, Adams M. Trans-sinus dental implants, bone morphogenetic protein 2, and immediate function for all-on-4 treatment of severe maxillary atrophy. J Oral Maxillofac Surg. 2012 Jan;70(1):141-148.

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. Maló P, Rangert B, Nobre M. “All-on-Four” immediate-function concept with Brånemark System implants for completely edentulous mandibles: a retrospective clinical study. Clin Implant Dent Relat Res. 2003;5 Suppl 1:2-9. 13. Aparicio C, Ouazzani W, Aparicio A, Fortes V, Muela R, Pascual A, Codesal M, Barluenga N, Franch M. Immediate/Early loading of zygomatic implants: clinical experiences after 2 to 5 years of follow-up. Clin Implant Dent Relat Res. 2010 May;12 Suppl 1:e77-82. 14. Aparicio C, Manresa C, Francisco K, Ouazzani W, Claros P, Potau JM, Aparicio A. The long-term use of zygomatic implants: a 10-year clinical and radiographic report. Clin Implant Dent Relat Res. 2014 Jun;16(3):447-459. 15. Aparicio C, Manresa C, Francisco K, Claros P, Alández J, González-Martín O, Albrektsson T. Zygomatic implants: indications, techniques and outcomes, and the zygomatic success code. Periodontol 2000. 2014 Oct;66(1):41-58. 16. Quintana R, Aparicio C. ¿Qué indicaciones tienen y qué resultados nos ofrecen los Implantes Cigomáticos? (What are then indications of the zygomatic fixture and what results do they offer us?) Cient Dent. April 2008;5(1):73-84 (Spanish). 17. 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. 18. Holtzclaw D. Pterygoid Fixated Arch Stabilization Technique (PFAST): A Retrospective Study of Pterygoid Dental Implants used for Immediately Loaded Full Arch Prosthetics. J Implant Adv Clin Dent. 2018;10(7):6-17.

26. Soto-Penaloza D, Zaragozí-Alonso R, Penarrocha-Diago M, Penarrocha-Diago M. The allon-four treatment concept: Systematic review. J Clin Exp Dent. 2017 Mar 1;9(3):e474-e488. 27. Maló P, de Araújo Nobre M, Lopes A, Ferro A, Nunes M. The All-on-4 concept for fullarch rehabilitation of the edentulous maxillae: A longitudinal study with 5-13 years of follow-up. Clin Implant Dent Relat Res. 2019 Aug;21(4):538-549. 28. Tironi F, Orlando F, Azzola F, Vitelli C, Francetti LA. Implants Placed with the All-On-4 Technique: A Radiographic Retrospective Study on 156 Implants with a 5- to 14-Year Follow-up. Int J Periodontics Restorative Dent. 2023 Sep-Oct;43(5):606-613. 29. de Araújo Nobre M, Lopes A, Antunes E. The 10 Year Outcomes of Implants Inserted with Dehiscence or Fenestrations in the Rehabilitation of Completely Edentulous Jaws with the All-on-4 Concept. J Clin Med. 2022 Mar 31;11(7):1939. 30. Maló P, Araújo Nobre MD, Lopes A, Rodrigues R. Double Full-Arch Versus Single FullArch, Four Implant-Supported Rehabilitations: A Retrospective, 5-Year Cohort Study. J Prosthodont. 2015 Jun;24(4):263-270. Simmen D, Veerasigamani N, Briner HR, Jones N, Schuknecht B. Anterior maxillary wall and lacrimal duct relationship - CT analysis for prelacrimal access to the maxillary sinus. Rhinology. 2017 Jun 1;55(2):170-174. 31. 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. 32. 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. 33. Rigolizzo MB, Camilli JA, Francischone CE, Padovani CR, Brånemark PI. Zygomatic bone: anatomic bases for osseointegrated implant anchorage. Int J Oral Maxillofac Implants. 2005 May-Jun;20(3):441-447. 34. Saltagi MZ, Schueth E, Nag A, Rabbani C, MacPhail ME, Nelson RF. The Effects of Age and Race on Calvarium, Tegmen, and Zygoma Thickness. J Craniofac Surg. 2021 Jan-Feb 01;32(1):345-349.

19. Holtzclaw D. Pterygoid Dental Implants: The Art and Science. Austin, Texas: DIA Management Services; 2020.

35. Nkenke E, Hahn M, Lell M, Wiltfang J, Schultze-Mosgau S, Stech B, Radespiel-Tröger M, Neukam FW. Anatomic site evaluation of the zygomatic bone for dental implant placement. Clin Oral Implants Res. 2003 Feb;14(1):72-79.

20. 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.

36. Nkenke E, Hahn M, Lell M, Wiltfang J, Schultze-Mosgau S, Stech B, Radespiel-Tröger M, Neukam FW. Anatomic site evaluation of the zygomatic bone for dental implant placement. Clin Oral Implants Res. 2003 Feb;14(1):72-79.

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31 Volume 16 Number 4

CONTINUING EDUCATION

Continuing Education Quiz Treatment of severely atrophic maxillae using the PATZI remote anchorage protocol: a case series HOLTZCLAW

1. In 1985, ________ performed the first placement of root-form pterygoid implants which used remotely located dense pterygomaxillary bone for restoration of compromised posterior maxillae. a. Tulasne b. Brånemark c. Linkow d. Balshi 2. These issues were improved when _______ introduced the extramaxillary zygomatic implant “slot” technique at the turn of the millennium 13 years later. a. Bothur b. Stella and Warner c. Malo d. Aparicio

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: November 15, 2023 Expiration Date: November 15, 2026

2 CE CREDITS

3. In 2003, Malo, et al., published the first paper documenting use of the _______ for restoration of edentulated maxillae with immediate loading. a. Zygomatic Implant Slot Technique b. Zygomatic Anatomy Guided Approach c. All-On-4™ protocol d. Pterygoid Fixated Arch Stabilization protocol

7. While parallel zygomatic implants have the disadvantage of an anteriorly located posterior prosthetic platform, they have the benefits of more superior malar real estate for the placement of a second zygomatic implant and eliminate the possibility for collision with the anterosuperior zygomatic fixture. a. True b. False

4. The ________ is a systematic algorithm for rapid treatment planning of atrophic maxillae which allows for real-time modifications during the surgical procedure. a. Brånemark protocol b. Zygomatic Anatomy Guided Approach (ZAGA) c. PATZI protocol d. Multiple Fixtures Per Zygoma protocol

8. If a pterygoid implant is not successfully placed, zygomatic implants are placed in a/an ________ with the posteroinferior fixture placed in a more posterior position. a. A-Frame setup b. parallel setup c. root-form set up d. none of the above

5. PATZI starts with attempted placement of pterygoid implants to employ their numerous benefits of cantilever elimination, _______. a. maximizing anterior-posterior spread b. increasing composite torque value c. eliminating the need for bone grafting d. both a and b

9. The A-Frame setup brings the posteroinferior zygomatic implant apex closer to the orbit, thus _______. a. reducing available real estate for the anterosuperior zygomatic fixture b. increasing the risk of implant collision c. achieving anterior support d. both a and b

6. (With the PATZI protocol) Anterior prosthetic support may be attained with ________ or transnasal fixtures. a. standard axial b. nasopalatine c. piriform rim d. all of the above

10. PATZI is an advanced protocol that requires the user to have full command of complex surgical techniques such as pterygoid, zygomatic, and transnasal implants. a. True b. False

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TECHNOLOGY

Advances in alveolar bone regeneration: utilizing patient teeth for osseoinductive bone grafting Amit Binderman discusses converting extracted teeth into osseoinductive bone graft material

lveolar bone regeneration is a crucial element of dental and maxillofacial surgery, particularly for patients requiring dental implants or corrective procedures due to traumatic injuries, periodontal defects, bone loss, or congenital anomalies. Traditional bone grafting methods have been employed to promote bone regrowth, but they often come with numerous limitations — including inflammation at the graft site (foreign material reaction), which hampers healing and impedes regeneration. Many traditional graft materials do not resorb, preventing the conversion of the site into native bone. On the other hand, some materials resorb too rapidly, failing to offer sufficient support for the longevity of newly formed tissue (woven bone). In certain instances, grafting material is susceptible to infection and soft tissue invagination into the graft itself. Furthermore, most materials do not integrate effectively with surrounding bone or dental implants, making them unpredictable when immediate placement is required. Although these limitations may not be critical in some cases such as sinus grafting, they significantly affect alveolar bone regeneration procedures, at times yielding unpredictable outcomes. Moreover, these materials are heavily reliant on the overall health condition of the patient — compromised patients like diabetics, smokers, and those on medication do not respond well to many materials, hindering successful bone regeneration. Practitioners who rely on autologous bone, considered as the gold standard, resort to bone harvesting. However, these techniques often necessitate a secondary harvesting site, resulting

Amit Binderman holds an MBA degree in International Business from the University of California, Berkeley, and an Undergraduate degree in Physics and Chemistry from TelAviv University, Israel. Prior to KometaBio, Amit built a dental implant company which was later sold. He then worked with various medical device companies and tech companies where he held VP Sales and VP Business Development positions. With KometaBio, Amit focuses on educating dentists from around the world on autologous regenerative solutions as a way of providing more predictable and higher standard of care to patients through the innovations that the company brings. The Smart Dentin Grinder®, KometaBio’s flagship product, enables dentists to repurpose extracted teeth into bioactive autologous grafts. Amit also oversees the scientific and clinical initiatives aimed at advancing autologous applications. Disclosure: Amit Binderman is CEO of KometaBio Inc.

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Figures 1A-1B: 1A. (left) Dentin graft after processing ready for use. 1B. (right) Dentin graft controlled for size coming out of trays

in potential patient discomfort, morbidity, and increased costs. Furthermore, harvested bone frequently fails to provide sufficient volume for the required procedure. Nevertheless, from a biological standpoint, autologous tissue is superior. Autologous tissue possesses osseoinductive and osseoconductive properties, facilitating both bone regeneration and the necessary scaffold for supporting regenerated bone until it matures into lamellar bone.

A novel approach

In the past 15 years, a promising concept has been developed by biotechnology company, KometaBio Inc. (www.kometa bio.com) — the conversion of patient teeth into autologous dentin grafts. This solution harnesses the osseoinductive regenerative potential of human teeth. This concept involves converting extracted teeth into osseoinductive bone graft material, offering a personalized and biocompatible option for alveolar bone regeneration. Given the high similarity in composition between teeth and bone, coupled with the attraction of progenitor cells by dentin, grafts derived from teeth exhibit profound bioactivity. The process begins with the extraction of the patient’s natural tooth, a routine procedure performed by dentists and oral surgeons. The extracted tooth then undergoes mechanical and chemical cleansing to eliminate bacteria, infections, and any restorations such as composites, fillings, or endo materials (Figures 1A-1B). The tooth is subsequently pulverized into controlled particle sizes, presenting a user-friendly putty-like format (Figure 2).

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TECHNOLOGY

The resulting acellular scaffold retains the architectural and compositional traits of natural bone, making it an ideal substrate for bone regeneration (Figure 3). A tooth, rich in HA mineral, collagen fiber type I, growth factors, and BMPs, presents an excellent graft material, further enhanced by its autologous nature. The HA scaffold gradually resorbs, the collagen contributes to graft osseoinductive properties, and growth factors accelerate healing by attracting progenitor cells and signaling M2 macrophages, fostering osteoblastic activity. A dental assistant or doctor can transform any extracted tooth into an autologous dentin graft within 7-8 minutes chairside, following this protocol. Upon implanting the Dentin Graft, a favorable microenvironment encourages osteogenic cell migration to the site. These cells then differentiate into osteoblasts, the bone-forming cells responsible for synthesizing the bone tissue’s extracellular matrix. This process mirrors natural bone formation, resulting in the gradual development of functional alveolar bone. Over time, the Dentin Graft slowly resorbs, revealing more collagen and growth factors, ultimately replacing the dentin with native bone after approximately 10-14 months. The newly formed bone maintains its dimensional integrity as lamellar bone (Figure 3).

Figure 2: Placement of dentin particulate around implants

Advantages of Autologous Dentin Graft

The use of patient teeth for osseoinductive bone grafting presents several notable advantages over traditional grafting methods: 1. Predictability: The most significant advantage of using an autologous graft, like dentin grafts, is the enhanced predictability of treatment success. Studies indicate minimal loss in height and width after grafting with dentin grafts, maintaining horizontal and vertical dimensions close to the original level. 2. Biocompatibility: As the graft material originates from the patient’s body, the risk of immune rejection and adverse reactions is significantly reduced, promoting biocompatibility and hastening the natural site healing process with minimal inflammation. 3. Reduced morbidity: Unlike autologous bone, which demands a secondary surgical site for bone harvesting, teeth-derived grafts negate the need for additional invasive procedures, minimizing donor site morbidity and patient discomfort. 4. Enhanced regenerative potential: The inherent osseoinductive properties of teeth-derived grafts facilitate the natural bone formation process, resulting in robust and functional bone regeneration. 5. Sustainability: Repurposing extracted teeth for bone grafting offers a sustainable approach that recycles biological material that would otherwise be discarded. 6. Soft tissue invagination prevention: Autologous dentin grafts demonstrate reduced risk of soft tissue invagination into the graft site, potentially eliminating the need for barrier membranes. 7. Patient acceptance: Patients, informed about the autologous use of their own extracted teeth, often view grafting procedures more favorably, increasing their willingness to undergo the procedure. 8. Cost efficiency: Dentin grafts offer a cost-effective graft option, with a single tooth generating between 1cc 2.5cc of grafting material. implantpracticeus.com

Figure 3: Components of a tooth versus bone show them to be very similar in composition

Figure 4A-4B: 4A. (left) Bone defect prior to extraction. 4B. (right) 3 year follow up after dentin grafting

Scientific support

Over the past two decades, more than 120 studies have explored the characteristics and clinical aspects of dentin grafting. These studies have compared autologous dentin grafts with conventional grafts and examined specific indications. The common thread across this research is the consistent achievement of alveolar bone regeneration and maintenance over time through dentin grafting.

Conclusion

Bone grafting is increasingly prevalent in dentistry, whether for extraction socket rehabilitation, alveolar bone reconstruction, or implant success enhancement. The predictability of grafting outcomes plays a pivotal role. Opting for the best available options, particularly a matrix capable of inducing bone formation and acting as a long-term scaffold, is crucial. Extracted teeth present a perfect candidate for such a matrix. While teeth have long been used as an alternative graft material, the advances by KometaBio have streamlined their controlled and efficient utilization. IP

35 Volume 16 Number 4

IMPLANT PERSPECTIVE

Five benefits of practicing rural dentistry Dr. David Whitlock discusses the joys of practicing in a rural community

racticing dentistry in a rural setting is my chosen way to practice in today’s dental landscape. I didn’t come to this conclusion without a lot of headache and heartache, but for me, the choice was undeniable. I have been practicing in a rural setting for almost 4 years, and I will never go back to “big- city” dentistry. First, let’s define the term “rural.” Definitions can vary depending on who you’re talking to. Fort Collins, population 150,000, was once the “smallest” place we had ever lived. By no means is Fort Collins a rural community. They have a Costco! That’s criterion number one. (If you have a Costco, you are not rural!) Most people will define rural based on population size. My current town has a population of approximately 25,000 people. Others will define rural based on geography — how isolated you are from a major city. We are 2 hours from the closest major airport and city. A third criteria would be based on the socioeconomics of the people in the area. Aspen, Colorado has a population of just under 7,000 people, and it’s almost a 4 hour drive to the closest major city, Denver. According to the U.S. Census Bureau, the median household income for Aspen from 2017-2021 was $89,625. Many would not consider Aspen as a rural community. Some stark contrasts are apparent when I compare practicing rurally and practicing in an urban/suburban setting. The following are the five main benefits to practicing in a rural community.

plan under the sun because you have to compete with every other dentist within a mile radius of your office. When patients have multiple options, more times than not, they are going to choose based on price. That’s a no-win for everyone involved. There are rural communities throughout the country that are in desperate need of providers. These are the situations that foster success not only professionally, but financially as well.

2. Lower cost of living

1. The level of competition I have practiced in heavily populated areas where there are literally five dentists on every block. There simply aren’t enough patients to go around. If you practice in an area where competition is either low or nonexistent, your ability to produce is greatly increased. This sounds so simple, yet so many dentists turn a blind eye to this fact. Personally, I previously have naively disregarded the competition level in other places I’ve practiced. I was told in dental school that you can simply decide where you want to live, practice there, and you’ll be just fine. That is absolutely not true. Competition matters. It matters if you don’t have enough people to work on. It matters if you have to drastically reduce your fees or be encumbered by every insurance

David Whitlock, DDS, graduated dental school from Virginia Commonwealth University in 2007. He has since practiced in Phoenix, Arizona; Dallas/Fort Worth, Texas; Fort Collins, Colorado; and Raleigh, North Carolina, before settling in eastern Kentucky. Dr. Whitlock has been married for over 20 years and is the proud father of three daughters and two sons. He is passionate about rural dentistry and the opportunities that exist for dentists in rural communities. You can connect with Dr. Whitlock through his website: www.ruralpractices.com.

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The largest expense of any adult/family is housing. Whether you’re renting or buying, housing is less expensive in rural areas. When I moved from Colorado to Kentucky, my house payment was cut in half while only sacrificing a few hundred square feet from my Colorado home to my Kentucky home. Gas is cheaper. Groceries are cheaper. Utilities are cheaper. Also, (and this is purely anecdotal), when one has less “shopping” options in town, you are more likely to spend less money. When all the factors are considered, you can decrease your home’s “overhead” by thousands of dollars per month by living in a rural community. The amount of stress that can be alleviated from knowing that your monthly take-home pay doesn’t have to be an astronomical number each month makes practicing dentistry a little more enjoyable. Instead of fretting over the implant patient that didn’t show up, you’re happy to have a little extra time to surf the web. That one broken appointment won’t make or break your month.

3. Work/life balance Dentistry is hard work. Dealing with the general public is difficult. Dealing with staffng issues is difficult. Even if you’re an associate with no ownership responsibilities, you still have to deal with patients and staff. We all need to find ways to get out of the office and de-stress. Working in a rural community

36 Volume 16 Number 4

IMPLANT PERSPECTIVE

gives you that opportunity. The vast majority of rural practices still operate Monday through Thursday from 8 a.m. to 5 p.m. I work on Fridays, and I’m the outlier. Evenings and weekends seldom need to be covered. Working 4 to 5 days per week provides opportunities to get out of the office and pursue passions that reinvigorate us. It provides down time to simply relax and recharge for another day/week. It provides time to spend with family at ball games, swim meets, or orchestra concerts. It provides time to work on that side hustle that you’re passionate about. Again, dentistry is hard on us physically and mentally. We all need breaks. Practicing rurally gives us those breaks.

4. Opportunity to get involved in the community where you practice This might sound like a nightmare to some of you. My biggest fear when I decided to practice in a small town was running into patients in public — that awkward exchange of me knowing who they are but them not knowing who I am is so uncomfortable to me. That being said, getting involved in the community where you practice is so very rewarding. In a big city, dentists are a dime a dozen, but in a small community, you stand out. You’re a healthcare provider. Your donation to a school sports team actually makes a difference. The board seat that you can hold for whatever local organization you are passionate about can enact real change that helps your community. A couple of decades ago, the elected mayor in our town also was a local dentist! I have enjoyed being able to contribute to the sports teams that my

kids have played on over the past few years. I have also enjoyed getting involved in community events like homecoming parades, 5k races, and community outreach that help improve our community and those who live here.

5. Career fulfillment Not only do you have the opportunity to do more dentistry, but you have the ability to choose the type of dentistry you want to do. You can narrow your scope of practice and focus solely on placing implants, treating children, or treating sleep apnea. More importantly, you can also eliminate procedures that might cause you more stress than you want to deal with. Personally, I have never been proficient at molar endo. In the past I’ve done it, mostly because I “needed” the production, but it was never very profitable to me because I wasn’t very fast at it. Plus, I always felt guilty if one I did failed. When I transitioned to a rural practice, I decided I would refer out all my molar endo to the specialist. It has made my life so much easier. I love seeing a crown on my schedule where the endo was done by someone else. Not only can you narrow your focus, but you can extend your career in a rural environment. Less wear and tear from working long hours can extend your career by years, if not close to a decade. Rural dentistry has been ignored for far too long. The benefits of practicing in a rural area far outweigh the drawbacks, in my opinion. You can practice the way you want with little/ no competition in an environment that is cheaper to live in. Sounds like a win-win to me. IP

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37 Volume 16 Number 4

PRODUCT PROFILE

Flexible field of view and AI-powered efficiencies enhance diagnostic confidence Dr. Joe Mehranfar discusses his favorite features of the new DEXIS OP 3D LX

ver the course of my 19-plus years career, I’ve placed over 10,000 implants and over 1,000 full arches. Behind every one of those surgeries is a patient, and behind every patient, there must be a plan. My priority is to make the correct diagnosis the first time around so that we can create the appropriate treatment plan to give our patients the best possible prognosis. Cone beam technology is our most powerful tool in achieving this goal, and my CBCT technology of choice has long been the DEXIS ORTHOPANTOMOGRAPH™ OP 3D™. Recently, I had the opportunity to add a third OP 3D machine to our practice: the new OP 3D LX. This addition has increased our diagnostic confidence and workflow efficiencies even more.

M. Joe Mehranfar, DMD, MS, received a BS in biology and a master’s degree in microbiology and in environmental science from Southern Illinois University at Edwardsville. Dr. Mehranfar started his passion for dental implants in 2002 when he was a second-year dental student at Temple University School of Dentistry. He would travel to his dental instructor’s practice to watch and learn more about dental implants. While in dental school, he also attended a dental implant training course at UCLA. This fueled his love for dental implants. Dr. Mehranfar was the director of dental implant education at the Brighterway Clinic in Phoenix. Today, he is Clinical Director at Dental Hearts which specializes in helping the over 400,000 veterans in Arizona and those that have trouble affording conventional dental implant fees. Also, he is Clinical Director at Implant Education Company which trains U.S. licensed dentists on live implant surgery. Dr. Mehranfar was formerly an Adjunct Assistant Professor at Midwestern University College of Dental Medicine in Glendale and A. T. Still University School of Dentistry and Oral Health in Mesa. Dr. Mehranfar was awarded a Mastership from the American Academy of Implant Prosthodontics. He is a member of the Board of Directors of the American Academy of Implant Prosthodontics. Dr. Mehranfar is Chairperson-Elect of the implant division of the American Dental Education Association and a recipient of their Pierre Fauchard Award for excellence. He is also a member of the Board of Directors of the Central Arizona Dental Society. Dr. Mehranfar has placed over 10,000 implants and mentored hundreds of U.S. licensed dentists on dental implant surgery. Dr. Mehranfar’s practice extends to general dental offices throughout Phoenix, where he performs implant surgery for individual dentists. His own practice in Phoenix is limited to surgical and prosthodontic implant treatment.

Implant Practice US

FOV flexibility expands the possibilities In my implant practice, we typically need to review larger areas like the sinuses, maxilla, mandible, airway, and ostiomeatal complex. The OP 3D LX offers a 15x20 maxillofacial complex, the largest field of view (FOV) yet from this series, that captures an expansive diagnostic area with a single scan. This saves my team the time needed to stitch together multiple images, while also ensuring no data is lost to stitching. Fewer scans also mean less radiation exposure and chair time for patients, which they certainly appreciate. This large field of view is particularly useful for post-surgical diagnostic and treatment planning. But the OP 3D LX also provides 12x15 and 10x10 FOV options that allow you to focus on a particular area with greater clarity and detail. This flexibility is particularly beneficial post-surgery, allowing us to find any potential issues and ensure the treatment is going according to plan. Along with over 96 customizable FOV options and four resolutions, the OP 3D LX can be easily configured to take panoramic, cephalometric, 2D and 3D images of the craniomaxillofacial complex including the ear, nose, throat, TMJ, and airway regions. This exceptional versatility makes the OP 3D LX machine ideal not only for oral surgery, but for a wide range of practices including endodontists, periodontists, orthodontists, oral radiologists, and general practitioners.

38 Volume 16 Number 4

PRODUCT PROFILE

AI-powered efficiencies drive digital workflow In addition to its flexibility, my team also appreciates the supreme ease of use, intuitiveness, and digital workflow efficiencies of the OP 3D LX. Because the machine integrates smoothly with DTX Studio™ Clinic software, my team can take advantage of the software’s AI-enabled features that automate a wide range of previously time-consuming and labor-intensive manual tasks. A large percentage of our patient population is at the end stage of tooth disease. Using the OP 3D LX with DTX Studio Clinic integration, we’re able to automate the annotation of mandibular nerve canals for greater accuracy, efficiency, and confidence in treating these patients. The 2D AI-findings capabilities will assist in visualization of decay, bone loss, and periapical pathologies. This will aid in proper diagnosis and treatment planning which in return will aid in better long-term prognosis for our patients. My team additionally leverages DTX Studio’s MagicAssist™ with AI-assisted auto set-up of 3D X-rays. This feature makes it much easier and faster for us to find and review carious lesions, signs of periodontal disease, and other abnormalities for treatment planning. These automated efficiencies allow my team to spend more time interacting with patients instead of a screen, managing and manipulating images.

Better visibility makes for better planning Our OP 3D machines have always delivered the consistently high-quality images we need to diagnose and treat patients with confidence. Our new OP 3D LX machine offers several enhancements that take that image quality to the next level. These include new implant planning tools that increase the visibility of internal metal structures and existing implants and a noise-reduction filter that minimizes artifacts for clear images. The machine also features a new patient head support that enables us to stabilize the patient and scan without interfering with the patient’s soft tissue profile.

Powering your practice productivity In the past year alone, my practice completed over 4,000 scans in our consult room and over 2,000 in our surgery room using our OP 3D machines. With the addition of our OP 3D LX, we fully expect to significantly exceed those numbers. For any practice seeking a flexible, versatile, and intuitive CBCT machine that will drive the efficiency of your digital workflow, support your practice productivity, and increase your diagnostic confidence, I highly recommend the OP 3D LX. Your team as well as your patients will thank you. IP ORTHOPANTOMOGRAPH™ OP 3D™ is a trademark of PaloDEx Group Oy. DTX Studio™ Clinic is a trademark of Nobel Biocare. All Rights Reserved. This article was provided by DEXIS.

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39 Volume 16 Number 4

PRODUCT SPOTLIGHT

The advantages of immediate dental implants and YOMI robotic technology Dr. Chris Rothman talks about improving efficiency and precision in implant placement

ver the past decade, dental implant technology has advanced significantly, improving oral health and dental procedures. One of the latest breakthroughs making an impact in my own practice is the use of YOMI robotic technology in combination with dental implants for immediate placement after tooth extraction. This new approach is enhancing patient experience, improving treatment outcomes, and promoting overall oral health. Traditionally, dental implants required multiple steps, including tooth extraction, implant placement, and a waiting period for osseointegration. However, it’s now possible to streamline the process and provide same-day tooth replacement in certain cases. Education and access to new technology is critical to ensuring the best possible patient care and outcomes. As a partner with HighFive Healthcare, a collaborative group of practices across the country, we are fully supported to make these clinical decisions concerning patient care and enabled to access the newest technologies available. With the YOMI robot’s precise movements, I can more accurately position the dental implant during surgery, ensuring optimal alignment and stability. This means my patients can leave the office with an implant and possibly a crown on the same day as their extraction, reducing the timeline and surgical procedures.

Bone preservation The loss of a tooth can lead to the degradation of the underlying bone over time due to lack of stimulation. While traditional dental implants mitigate this concern by promoting osseointeChristopher M. Rothman, DDS, is a founder of Alabama Oral and Facial Surgery and a HighFive Healthcare Board Member. He received his degrees from the University of Alabama and the University of Tennessee, Memphis. He performed his residency in Oral and Maxillofacial Surgery at University Hospital at the University of Cincinnati. He served as National Chairman of the American Association of Oral and Maxillofacial Surgeons Residents Organization, is Board Certified by the American Board of Oral and Maxillofacial Surgery, and the National Dental Board of Anesthesiology.

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gration, the process still involves some bone loss during the waiting period. Placing the implant immediately following tooth extraction ensures that the bone receives the necessary stimulation to maintain its volume and density, effectively preserving the overall bone structure. Utilizing this proactive approach contributes to long-term oral health of my patients by preventing bone resorption and subsequent changes in facial appearance.

Enhanced precision The YOMI robotic technology has revolutionized dental implant surgery by introducing an unprecedented level of precision and predictability. The robot assists me in real-time, adhering to the predetermined treatment plan with sub-millimeter accuracy, reducing human error. This ensures that the implant is placed in the optimal position for function and esthetics, reducing the risk of complications, such as nerve injury or sinus perforation. My patients benefit from a more comfortable and efficient procedure, as well as greater peace of mind, knowing that their treatment is guided by state-of-the-art technology.

Improved patient experience Dental procedures can be pretty stressful for patients. By reducing the number of visits and shortening the treatment timeline, my patients experience less disruption to their daily lives. Additionally, the minimally invasive nature of the procedure, enhanced by robotic precision, leads to reduced postoperative discomfort and faster recovery times. It’s a combination that leaves everyone smiling.

A healthy future The combination of dental implants and robotic technology for immediate implant placement is a significant leap forward in modern dentistry. This approach addresses functional and esthetic needs while also offering long-term benefits by preserving bone and improving overall treatment outcomes. I’m confident technology will continue to shape the field of dentistry, and my patients can look forward to more efficient, precise, and patient-centric procedures that enhance their oral health and their quality of life. IP

40 Volume 16 Number 4

You handle the teeth.

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