Implant Practice US - May/June 2014 Issue - Vol7.3 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews May/June 2014 – Vol 7 No 3

PROMOTING EXCELLENCE IN IMPLANTOLOGY

Practice profile Dr. Jeffrey Capes

Corporate spotlight OCO Biomedical

Corporate profile Straumann®

Do we need a radiographic guide? Dr. Michael D. Scherer

Immediate implant placement with immediate nonfunctional load using the BellaTek® Encode® Impression System Dr. Suheil M. Boutros

PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!

THIS IS NO TEMPORARY IMPLANT Hundreds of clinicians around the world have realized what sets the LOCATOR® Overdenture Implant (LODI) System apart from their past experiences with “mini” implants—sometimes perceived as temporary implants. LODI is a reliable and cost effective narrow diameter overdenture implant that performs like a standard implant.

Award winning LOCATOR Attachment your referrals rely on and are familiar with featuring dramatically reduced vertical height & patented pivoting technology Unique two-piece design for surgical placement & restorative flexibility

Narrow but right-sized at 2.9mm (and 2.4mm) LODI has a surface area very close to a 3.0mm standard implant

Aggressive thread design similar to standard implant diameter designs, providing increased primary stability

No screw access hole for implant strength

Proven RBM surface on the entire length of the implant, used for decades with dental implants

Self-tapping design for ease of insertion and increased implant stability

Discover the benefits of a narrow diameter implant that performs like a standard diameter implant. Add LODI to your armamentarium of implant options. www.zestanchors.com/LODI/31 or 855.868.LODI (5634).

May/June 2014 - Volume 7 Number 3 EDITORIAL ADVISORS Steve Barter BDS, MSurgDent RCS Anthony Bendkowski BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent Philip Bennett BDS, LDS RCS, FICOI Stephen Byfield BDS, MFGDP, FICD Sanjay Chopra BDS Andrew Dawood BDS, MSc, MRD RCS Professor Nikolaos Donos DDS, MS, PhD Abid Faqir BDS, MFDS RCS, MSc (MedSci) Koray Feran BDS, MSC, LDS RCS, FDS RCS Philip Freiburger BDS, MFGDP (UK) Jeffrey Ganeles, DMD, FACD Mark Hamburger BDS, BChD Mark Haswell BDS, MSc Gareth Jenkins BDS, FDS RCS, MScD Stephen Jones BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack DDS, CertPerio, FCDS Samuel Lee, DDS David Little DDS Andrew Moore BDS, Dip Imp Dent RCS Ara Nazarian DDS Ken Nicholson BDS, MSc Michael R. Norton BDS, FDS RCS(ed) Rob Oretti BDS, MGDS RCS Christopher Orr BDS, BSc Fazeela Khan-Osborne BDS, LDS RCS, BSc, MSc Jay B. Reznick DMD, MD Nigel Saynor BDS Malcolm Schaller BDS Ashok Sethi BDS, DGDP, MGDS RCS, DUI Harry Shiers BDS, MSc, MGDS, MFDS Harris Sidelsky BDS, LDS RCS, MSc Paul Tipton BDS, MSc, DGDP(UK) Clive Waterman BDS, MDc, DGDP (UK) Peter Young BDS, PhD Brian T. Young DDS, MS CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com NATIONAL ACCOUNT MANAGER | Michelle Manning Email: michelle@medmarkaz.com PRODUCTION MANAGER/CLIENT RELATIONS Adrienne Good Email: agood@medmarkaz.com PRODUCTION ASST./SUBSCRIPTION COORD. Jacqueline Baker Email: JBaker@medmarkaz.com

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 Web: www.implantpracticeus.com

ver the last few years, the landscape of private practice has changed dramatically with respect to dental implant treatment. The contributing factors are increasingly educated patients, discretionary income, patient demands, and the competitive nature of dentistry. Our patients are now better educated with respect to dental implants, and they are requesting implants as their treatment of choice for a missing tooth. The Internet has brought dental education and the promise of new treatment possibilities into their homes. The average implant candidate knows quite a bit more about implants and treatment than they did just a few years ago. Implant treatment has become mainstream, with frequent ads on radio and television. These ads, usually touting the virtues of “teeth in a day,” can muddy the conversational waters when a patient desires treatment. This type of advertising has certainly helped our profession, but at the same time put unrealistic expectations in our patients’ heads. Not every patient is a candidate for immediate restoration, and not every implant on the market can predictably provide the primary stability necessary to complete this type of treatment. Historically, implant treatment has been a tough sell, although those that desired and could afford the steep price would get them. Today, implant prices have come down considerably, and with the competitive nature of dentistry, we are seeing very low treatment costs. This shift from the high-dollar, premium treatment profile has been facilitated by lower implant product prices, faster and more efficient technology, and just good old-fashioned price wars between practitioners. Still, we see average implant treatment costs hovering in the $3,000-$3,500 range for placement and restoration of a single tooth. This is out of the reach of many patients, and statistically only about 30% of patients can afford treatment costs in this range. The other 70% either opt for a conventional crown and bridge, or forego treatment altogether. Dr. Gordon Christensen published data showing that average Americans would devote approximately 10% of their gross income to medical and dental expenses. Since the average salary in the United States is around $50,000 per year, that translates to about $5,000 for treatment expenses. Since most medical issues tend to supersede dental issues, we are vying for a much smaller slice of the pie. If you do the math, with traditional implant fees, we are lucky to get a single unit accepted as treatment. Add to the fact that since we are dealing with discretionary income, we now start to compete with other non-healthcare priorities in your patient’s life. They now have to make a decision: “Do I put an implant in an area where I lost a tooth — which, by the way, does not bother me — or do I buy a jet ski, or go on vacation?” So how do you get your patients to buy in? You must choose your implant system wisely. By utilizing a system that is affordable and has a simple, rapid surgical protocol with immediate-load capability, you will be able to provide the treatment that your patients desire and expect. You will find such a system with OCO Biomedical, as seen in our corporate profile in this issue. OCO’s extensive implant line utilizes a patented implant body coupled with a simple two-drill surgical protocol to provide a clinically proven answer to your implant treatment needs.

www.medmarkaz.com SUBSCRIPTION RATES 1 year (6 issues) 3 years (18 issues)

$99 $239

© FMC 2013. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Implant Practice or the publisher.

Volume 7 Number 3

Charles D. Schlesinger, DDS, FICOI Chief Operating Officer, OCO Biomedical Inc. Charles Schlesinger DDS, FICOI, completed his dental training at The Ohio State University College of Dentistry. After graduation, he completed a GPR at the VA San Diego Medical Center and then went on to become the Chief Resident at the VA West Los Angeles Medical Center. While in LA, he received extensive training in implantology, oral surgery, and complex restorative dentistry. Upon completion of his training, Dr. Schlesinger returned to San Diego where he ran a thriving dental practice for 14 years. During this time, he became an educator for various dental implant companies and has lectured across the U.S., Canada, the UK, and China. In 2012, he became the Director of Education and Clinical Affairs for OCO Biomedical and, in 2013, took on the position of Chief Operating Officer. Implant practice 1

INTRODUCTION

The true challenge of implant dentistry

TABLE OF CONTENTS

Corporate profile Straumann® 25 years of excellence in the U.S. ................................................... 12

Clinical A new implant material changes perceptions Dr. Paul Stone explains how Straumann’s Roxolid® narrow implant can be placed in more sites and requires less grafting, resulting in greater patient uptake.............. 16

Practice profile

Dr. Jeffrey Capes: A passion for the dental profession Dr. Capes discusses implant procedures and the importance of really caring for patients

Corporate spotlight OCO Biomedical Dedicated to bringing the next generation of implant technology to market

2 Implant practice

ON THE COVER Cover photo courtesy of Dr. Justin Moody. Article begins on page 46.

Volume 7 Number 3

TABLE OF CONTENTS

Case study Immediate implant placement with immediate nonfunctional load using the BellaTek速 Encode速 Impression System: restorative recommendations Dr. Suheil M. Boutros describes a technique that strives to create ideal esthetics and function ...................22 Immediate implant placement within your practice Dr. Ara Nazarian illustrates a simplified approach to an immediate dental implant .........................................26

AO recap Implant dentistry practitioners from 45 countries come together for the Academy of Osseointegration 2014 Annual

Do we need a radiographic guide?

Meeting ......................................30

Continuing education Do we need a radiographic guide? A review of the cone-beam computed tomography (CBCT) visualization and treatment planning for narrow-diameter implant overdentures Dr. Michael D. Scherer summarizes a contemporary approach using simple techniques to enhance visualization of restoration contour, separating soft tissues with simple techniques, and proposes that radiographic guides may no longer be necessary for implant overdenture therapy .........34 4 Implant practice

On the horizon Prevention and management of maxillary sinus complications in implant dentistry Drs. Ashok Sethi and Thomas Kaus summarize some of the complications that can arise when tackling the advanced techniques required by a sinus lift.........................................39

Product profile HIOSSEN.....................................44

Digital workflow, a guide to perfection Dr. Justin Moody discusses how digital technology creates a smoother implant process ............................46

News and views Dentists launch peer-to-peer platform to tackle industry reform ....................................................48

Diary .....................................54 Industry news ............56 Volume 7 Number 3

To succeed, you need technology that is well founded and documented in science. That is why we only deliver premium solutions for all phases of implant therapy, which have been extensively tested and clinically proven to provide lifelong function and esthetics. Moreover, with an open-minded approach, we partner with our customers and offer services that go beyond products, such as educational opportunities and practice development programs. Reliable solutions and partnership for restoring quality of life â&#x20AC;Ś because it matters.

www.dentsplyimplants.com

Patients rely on you in order to eat, speak, and smile with confidence. It can be said, you are actually restoring quality of life.

These products may not be regulatory cleared/released/licensed in all markets.

Restoring quality of life

PRACTICE PROFILE

Dr. Jeffrey Capes A passion for the dental profession

Dr. Jeff Capes and his staff at their annual Referral Christmas Celebration

What can you tell us about your background? I grew up in a small town where my dad, Dr. Johnny Capes, was a general dentist. What I remember best about that was spending time in his office and seeing him making people better. The other was the fact that my dad seemed to know everyone around town. I think that was what made me want to be in the health field. I went to college with the plan to go to medical school. Then, as fate would have it, I had my wisdom teeth removed by my dadâ&#x20AC;&#x2122;s friend, who was an oral surgeon, after my first year at college. I thought how cool was that experience? I ended up spending a lot of time with him in the summer, and that is when I knew I wanted to be an oral surgeon. So after spending time at the University of Georgia, I headed down to Augusta for dental school at the Medical College of 6 Implant practice

Georgia. Upon completing dental school, I attended Case Western Reserve University where I received not only my specialty training in Oral and Maxillofacial Surgery, but also my medical degree. So I guess in a roundabout way, I did go to medical school. When I finished my training, my wife and I knew we wanted to head back home to my Georgia roots. My goal was to find a place that would be similar to the experience I had seen with my father. We were very blessed to end up in southeast Georgia where I have been in solo practice for the last 16 years.

Is your practice implants?

limited

When I finished my residency and started my practice, I wanted to maintain a fullscope oral surgery practice. Over the past 16 years, it has developed into removal

of teeth, pathology, facial trauma, and reconstruction. The bulk of what we do surrounds the aspect of placing implants.

Why did you decide to focus on implantology? I had a very unique training at Case Western. We were fortunate to be involved in some large implant studies at that time. I was able to place a lot of implants and learn from some of the pioneers in the implant field at that time. I was at the beginning of what would be the future of dentistry. I saw the impact implants could have for our patients and I wanted to be a part of that.

Who inspired you? This is a tough question. I have been blessed that in many chapters of my life, there were key individuals who are responsible for where I am today. I certainly believe my Volume 7 Number 3

PRACTICE PROFILE

Dr. Jeff Capes’ office building (located on St. Simons Island, Georgia)

dad influenced me tremendously to go in the direction of dentistry. I was fortunate to do dental implant research for 3 years while in dental school. Dr. David Steflick, who is no longer with us, was a man who showed me passion, and the knowledge I gained from him and our research was amazing. I knew more about titanium and osseous integration in dental school than most do today. The reason for my unique experience at Case Western belonged to a pioneer in implant dentistry, Dr. Charles Babbush. He imparted a wealth of information and experience that had such an impact on me. But again, it was his passion for making a difference that influenced me the most. As the saying goes, “Find something in life that you’re passionate about, and do that!” I am blessed that this is what I do every day! Lastly, I would have never made it through the process and be where I am today if not for one person, my wife. People have no idea what it takes to survive 9 years of training. There were many times I wanted to give up. But she was always there by my side coming to the hospital, bringing me dinner, bringing our daughter so I could see her for 15 minutes. She is the strongest person I know. I am no one without her.

How long have you been in practice, and what systems do you use? I have been in practice coming up on 16 years. It is amazing how time flies by. During that time and in training, I have worked with most all implant systems. Since 2006,

Coastal Oral Surgery’s reception area

I have been using Implant Direct. It is an extraordinary company! In 2006, I made a trip to Las Vegas with a single purpose — to meet Dr. Gerald Niznick. After meeting with him, and looking at his systems and vision, I knew I was partnering with a company that was going to be a huge influence on the future of implant dentistry. And now 8 years later, I was right. But at the end of the day, the most important part of any implant system is the patient. The results we are able to give our patients using Implant Direct are why I use their system.

What training have you undertaken? Great question. For after all my training, you would say “I got it!” But a wiser man would admit not nearly enough to succeed! So when I started my practice, I committed myself to continuing to learn and teach. As a specialist, I knew that if I didn’t understand the restorative process, I was useless for my referrals. So I focused on the restorative aspects of implants. I also completed the process of becoming a Diplomate in the American Board of Implantology. For me it is very simple — learning never stops; you just have to go get it.

Professionally, what are you most proud of? Discovering a practice culture that is different from anything out there. As a specialist, I didn’t want to miss out on building relationships with both our patients and our referrals. We have developed a system that in simple terms allows us to do business with our friends. I am proud of what my staff has developed as a part of this. The culmination of this is that I now have a program specifically for oral surgeons to share what I have discovered. That is cool!

What do you think is unique about your practice? The simple answer is everything! In discussing this discovery with other specialists, it has become very clear that what we do is very unique. How we see that, is in what our patients (friends) tell us and in the letters we get from them. “This is the most unique doctor’s experience I have ever had.” “What a refreshing experience.” I guess just to sum it up, it is the whole experience. And at our office, we are not just about doing procedures; we are about taking care of people.

What is the most satisfying aspect of your practice?

What has been your biggest challenge?

As I said earlier, I am blessed that I get to wake up every morning and do what I love. But without a doubt, the most satisfying and humble aspect of my practice is the blessing of people who come to me and put their trust in me to help them. Without that, we do nothing.

Wow! I always tell my staff don’t let obstacles stop you; see them as opportunities. The reality was when I started in 1998, implants were still not part of regular dentistry. So when I opened, I was working with referring dentists who had very little experience. Placing an implant has no value if it can’t be restored. But this really became the

Volume 7 Number 3 Implant practice 7

PRACTICE PROFILE

Dr. Capes showing off his “big” catch of the day

Dr. Jeff Capes and his wife, Wendy

greatest opportunity. We all partnered together and I created a path of mutual learning that has worked very well. I am fortunate to work with so many talented dentists who provide amazing results for our patients.

What would you have become if you hadn’t become a dentist? That is easy. I would be a chef and own my own restaurant. This seems odd, but really both businesses are very similar. They are all about creating an experience! But don’t look for Doc’s Grill anytime soon!

What is the future of implants and dentistry? I always tell my patients I don’t have that crystal ball to tell the future. I have always been taught that He provides us with a lamp at our feet to show the path. Implants have revolutionized dentistry as we know it today. What we can provide for our patients is truly incredible! But what we must always remember and explain to our patients is that implants are not teeth. The future of implants really will be related to how we can better restore them and creating long-term success. We are just now beginning to see what can happen with implants over time; the future is how we react to it. I still believe that the team approach is the best long-term environment for our patients. It allows each team member to manage issues as they arise. Implants will be the future of dentistry as we know it. The field of dentistry is a wonderful profession. We must remember the opportunity we are given every day to change someone’s life. How important is a person’s smile? It is extremely important! 8 Implant practice

I think dentistry needs to take a hard look at who is in charge of patient care. We should never let corporate policies or insurance companies dictate how we take care of our patients. As the number of solo/ partner dental practices is decreasing, it will be interesting to see how dentistry is delivered in the future.

What are your top tips for maintaining a successful practice? I hate to repeat myself, but first of all, it is all about passion! If you aren’t looking for CE opportunities and participating in study clubs and local societies, are you passionate about what you are doing? We all go through peaks and valleys; just find ways to re-energize yourself. Be engaged with your practice. When I say practice, I mean your staff and anyone you work with to deliver care for your patients. I think way too many clinicians just show up. Your staff is your family, whether you like it or not. Start every day with a morning huddle. The single most important thing we can do is to start every day on the same page. Be humble. People come to us with pain or issues. We were not put here to judge. They put their trust in us; we should never take that for granted.

to do no harm. Our patients are not for us to experiment on. They deserve our very best every time. We all must continue to seek training that allows us to provide care for our patients. The best advice is to partner with a mentor that can guide them. Don’t go at it alone; there are plenty of people whom you can partner with that would love to help. Lastly, the rule I live by for all my patients, and it is what I tell them, “We can plan for life or we can plan for failure!” Don’t let patients dictate the care you provide for them.

What are your hobbies, and what do you do in your spare time? We all need downtime where no one is calling you doctor! I really enjoy just being outside whether golfing, working in the yard, or fishing. It is also nice to read and do non-dental stuff. I enjoy traveling with my wife Wendy, friends, and family. Recently, I have taken an interest in wines, which is so interesting. I recently went to Napa, which I highly recommend. Lastly, I am getting the opportunity to teach and share what I have learned. IP

Top Ten Favorites

What advice would you give a budding implantologist? First, you must define what that means. Implant dentistry is not recognized as a separate field or specialty of dentistry. So it is each individual’s responsibility and ethical obligation to determine what services related to implants he/she will provide. I think we must always remember

1. My wife and family 2. Making a difference in people’s lives and seeing someone smile! 3. Traveling 4. Teaching 5. Golf (especially my Ping driver) 6. Wine 7. Friends 8. My staff (which are my family) 9. My i-CAT® (Imaging Sciences International) 10. My iTero® (Align Technology, Inc.)

Volume 7 Number 3

CORPORATE SPOTLIGHT

OCO Biomedical Dedicated to bringing the next generation of implant technology to market

OCO company headquarters building, Albuquerque, New Mexico

OCO Biomedical, located in Albuquerque, New Mexico, has been constantly advancing the field of implantology since its inception. In 1976, Dr. Dave Dalise patented the O-Ball overdenture when he became frustrated that there was not a repeatable connection for the subperiosteal implants he had been placing. This prosthetic connection became the industry standard and revolutionized the way removable prosthetics are done. The O-Ball Company, which produced these attachments for the rest of the burgeoning implant industry, was born in 1977. Over the next 16 years, the company name changed to The O Company and continued to create new and innovative implant products, including subperiosteal, blade, and cylindrical implants. In 2001, the company changed its name to OCO Biomedical and revolutionized the industry again with the birth of the first 3.0-mm dual stabilization implant. Today, OCO Biomedical is on the cutting edge of implant design and technology, and we take great pride in the fact that all of our products are made domestically. OCO holds a U.S. patent for immediate-load technology; this is

Dr. Charles Schlesinger Master surgical kit

now incorporated into every one of our full-size implants, from the 3.0 up to the 6.0 diameter. Our implant line range is unprecedented by having diameters ranging from 2.2 mm through 6 mm, and covering the full spectrum, including onepiece, two-stage tissue level, and bone level implants.

A single master surgical kit is designed to place every implant in our inventory with a simple two drill protocol. This allows the practitioner to easily and quickly place dental implants in a fashion that allows for minimal post-op discomfort and outstanding and predictable immediateload results.

Volume 7 Number 3 Implant practice 9

CORPORATE SPOTLIGHT

Complete implant line

3.0

Immediate stabilization implant (ISI)

According to Charles Schlesinger, DDS, FICOI, the Chief Operating Officer of OCO Biomedical, “We continually strive to improve upon the original products that Dr. Dalise invented, as well as develop new products that will help our practitioners become better implantologists. Our success only comes through the success of our doctors, so our products are developed by practitioners for practitioners.” 10 Implant practice

Two-stage implant (TSI)

Esthetic Region Implant (ERI)

OCO Biomedical is committed to bringing the next generation of implant technology to market, year after year. Dr. Schlesinger says, “We strive for perfection in our product, and to keep our pricing affordable so as to allow every doctor to provide the best treatment to all of their patients. This is what motivates me to come into the office every day.” For the past 37 years, OCO Biomedical

Engage™ bone level implant

6 x 6 Macro implant

has been on the forefront of implant technology and development; the future will show our continued commitment not only to our users, but also to the patients they treat. IP This information was provided by OCO Biomedical.

Volume 7 Number 3

OCO BIOMEDICAL HOSTS FIRST ANNUAL

2014 DENTAL IMPLANT SYMPOSIUM TWO DAYS - ELEVEN LECTURES - A LIFETIME OF KNOWLEDGE

June 6 -7, 2014 Sandia Resort & Casino Albuquerque, NM

OCO Biomedical, a proven world leader in innovative, patented dental implant products, technology and education, proudly presents the 2014 OCO Dental Implant Symposium providing two full days of eleven information-packed lectures and Q&A sessions, to be held on Friday, June 6th from 8am to 5pm and Saturday, June 7th from 8am to 4 pm at the spectacular Sandia Resort & Casino in Albuquerque, New Mexico. Participants in this exciting, first annual OCO event will receive sixteen (16) hours of AGDPace CE Credits, competitively priced for both practitioners and staff; have the opportunity to network and gain knowledge from nationally recognized lecturers such as keynote speaker Dr. Howard Farran, DDS,MBA, founder/publisher of Dentaltown Magazine and other prominent speakers. Participants will learn immediate, practical, profitable skills in the most advanced methods of implantology, restorative dentistry, sinus elevation, and bone grafting. States OCO founder/president, Dr. David D. Dalise, DDS, “Since 1973, OCO has focused on developing, manufacturing and addressing the demanding needs of the dental industry. Our 2014 symposium will be a benchmark accomplishment showcasing not only the latest innovations in procedures and products but our commitment to the highest standards of practice and education as well.”

OUR SPEAKERS: Howard Farran, DDS, MBA – Dental Town Magazine Keynote Speaker

Steve Brown, DDS – Ft. Worth, TX SDI & Mini Implants in Your Practice

Joseph J. Chomiak Jr., DDS - Connellsville, PA Implant Prosthetic Treatment Options

Dave Dalise, DDS - OCO Biomedical

Affordable Yet Profitable Single Tooth Replacements

Eric Evans, DDS, MD - University of Cincinnati

Dental Implants in Patients Taking Anti-Resorptive Medication

Lary C. George Jr., DDS, MS - Heber Springs, AR The 4th Dimension of Implant Treatment Planning

Robert Heller, DDS - Midwest Implant Institute Synergy Between Implants & Prosthetics

Tim Kosinski, DDS - Bingham Farms, MI

$750 for doctors/practitioners; $450 for support staff/ personnel.

Perfecting Atraumatic Extraction, Socket Preservation & Implant Placement Today

Richard Leong Jr., DDS - Melbourne, FL

Incorporating Implants Into Your Practice & Practical Practice Management

Eric Smith, DDS - Las Lunas, NM

Restorative Experiences & the Implant CAD/CAM Connection

Pierre J. Tedders, DDS - Adrian, MI

Lateral Wall Sinus Augmentation: Perioperative Surgical Considerations

Call 1-800-228-0477 or visit our website: ocobiomedical.com for further information about this exciting event!

Designed and Manufactured in Albuquerque, NM

U.S. Patent: US 8,277,218,B2 ISO 13485:2003 CERTIFIED 0344

CORPORATE PROFILE

Straumann® 25 years of excellence in the U.S.

here are many factors to consider when choosing a dental implant system. What is the true value in working with a premium dental implant system? You may consider adding a value system as a way to increase profitability in certain cases, but do you realize that this could possibly pose a risk to your practice greater than any gain in saved cost? Aligning with a premium implant provider like Straumann® provides you with more than the peace of mind that comes with the demonstrated clinical success of the system — Straumann offers you a level of service and support that value systems cannot often provide — innovative marketing ideas, patient education, customer loyalty programs, and more. Why wouldn’t you consider this additional level of value?

Why dental professionals trust in our products Straumann has won the confidence of its customers with this promise: a strong foundation of scientific and clinical evidence supporting the specialization, reliability, and simplicity that define every Straumann solution. With more than 3,000 published peer-reviewed studies, along with what has been learned in over 60 years of research in various scientific fields, Straumann products have demonstrated their longterm effectiveness through research studies following good clinical practice. This reliability made the Straumann® Dental Implant System one of the most widely used systems in the world with more than 13 million implants sold. Straumann’s 31-year relationship with the International Team for Implantology (ITI®) unites more than 11,000 dental professionals from all fields of implant dentistry and dental tissue regeneration. An independent academic association, ITI actively promotes networking and exchange among its members at meetings, courses, and congresses with the objective of improving treatment methods and outcomes for the benefit of their patients.

12 Implant practice

“The advantage of using Straumann products is that both the doctor and patient can have peace of mind that a high quality product is being used.” – Dr. Edward Sielski, Periodontist, Williamsville, NY

Who we are Straumann® – a global leader in implant dentistry offering surgical, restorative, regenerative, and digital solutions for the dental and lab business — is a pioneer of innovative technologies. We are committed to Simply Doing MoreSM for dental professionals and patients. With world-class customer service, highly skilled technical support, and a team of experienced professionals readily available to you, our vision is to be the commercial partner of choice in implant, restorative, and regenerative dentistry. With its corporate headquarters in Basel, Switzerland and North American headquarters in Andover, Massachusetts, Straumann’s products and services are available in more than 70 countries. Having pioneered many influential technologies and techniques in dentistry, the company’s mission is to enable dental professionals to restore their patients’ dental function and overall oral health. At Straumann, philanthropy is an integral part of our culture. We have a rich history of supporting organizations that give back to the communities in which we live and work, particularly The National Foundation for Ectodermal Dysplasias (NFED). The NFED is a recognized leader among health-related nonprofit

organizations that provides comprehensive services to individuals affected by ectodermal dysplasias and their families; helps individuals and families benefit from early diagnosis and care, and leads research that could ultimately develop a cure. In addition to our corporate activities, we encourage our employees to volunteer and give back to their own communities.

Simply Doing MoreSM Straumann is not only a commercial partner for premium products, we strive to help you grow your practice. From a wide range of patient education materials to practice growth tools that are developed based on your needs, we will work with you every day to differentiate your practice. When you work with Straumann, you have a network of dental professionals who are by your side every day. We are committed to your success — and the esthetic results your patients demand.

Our history of innovation The number of innovations Straumann has produced continues to grow, from the SLA® implant surface in 1998 to the hydrophilic SLActive® implant surface in 2006, the Roxolid® material in 2009 to a new generation of small diameter implant — the Narrow Neck CrossFit®

Volume 7 Number 3

CORPORATE PROFILE

— in 2012. In April 2013, Straumann expanded the Roxolid implant offering — the first Titanium Zirconium alloy developed specifically for dental implantology — to all implant diameters and introduced the Loxim™ transfer piece that is designed to provide simplified handling during implant placement. This year, Straumann completes their portfolio with the introduction of the Standard Plus Short (SPS) Implant*, the shortest screw-type implant with an internal connection on the market.** Straumann’s dedication to innovation provides clinicians with the product solutions they need to meet the clinical demands in daily practice.

The Straumann® Dental Implant System — surgical and restorative solutions One system. One instrument kit. Various treatments. Maximum flexibility. Straumann offers a complete line of both Soft Tissue Level and Bone Level implants for flexibility and efficiency with SLA and SLActive surface technologies designed for treatment predictability and your choice of titanium grade 4 or Roxolid material. With characteristics such as double roughness treatment for greater boneto-implant contact, the SLA implant surface is designed to allow loading in as little as 6 weeks after implant placement in healthy patients with sufficient bone quality and quantity. The next generation in implant surface technology, SLActive, is

designed to deliver faster osseointegration to enhance confidence in all treatments, reducing healing time from 6 to 8 weeks to 3 to 4 weeks,1 and providing increased predictability in stability critical treatment protocols. The Roxolid implant material features higher tensile strength2 and faster osseointegration3 when compared to Straumann SLActive titanium implants. The Roxolid material enabled the design of the Straumann® Standard Plus Short (SPS) Implants.* Like the Roxolid 3.3 narrow diameter implant, the SPS Implants are a significant addition in our portfolio to offer less invasive options4 for tooth replacement. The SPS Implants utilize Straumann’s award-winning material and surface technologies, Roxolid and SLActive. The additional treatment options offered by the SPS Implant may result in a less invasive procedure, helping to increase the acceptance of implant treatment to patients. This year, all Straumann implant lines will come equipped with the Loxim transfer piece for simplified handling. Loxim is premounted to the implant, self-retained, and designed for clockwise and counterclockwise rotations with one-step implant insertion.

Excellent restorative outcomes – authenticity Precision is the hallmark of the Straumann product portfolio. From Bone Control Design® to the implant-abutment

connections, Straumann products are manufactured to exacting specifications. Look-alike implant and abutment systems attempt to copy the original manufacturer’s design, but cannot give assurance of equal precision or material quality. Compromises, such as a poor connection between the implant and abutment, can lead to complications. When it comes to long-term stability and excellent restorative outcomes, providing genuine Straumann components from our complete prosthetic portfolio is important. How do you know that you have an original Straumann component? You can eliminate all doubt with the Straumann Online Verification Tool and Laser Etched Titanium Abutments that enable you to confirm that you have purchased and received an original Straumann component.5

Straumann regeneration solutions Straumann offers a complete portfolio of oral tissue regeneration solutions for various treatment situations. Some of the most exciting research and development within the dental market is being conducted on regeneration, showing the body’s potential to rebuild lost structures. Straumann is on the forefront of this research with the use of the polyethylene glycol (PEG) technology in dental applications and more expansive research on enamel matrix derivative (EMD). With over 500 scientifically supported publications, including results over 10

Volume 7 Number 3 Implant practice 13

CORPORATE PROFILE years, Straumann® Emdogain™ is a protein-based gel designed to promote predictable regeneration of lost periodontal hard and soft tissue, helping to save and stabilize teeth. Clinicians have learned that treating gingival recession cases may be an important strategy in practice growth, and the use of Emdogain6 may decrease tooth sensitivity to hot and cold, support the regeneration of lost bone and tissue,7 and boost confidence by providing a more natural-looking appearance.8 Emdogain is easy to apply with prefilled syringes, it is convenient to use, and easily integrated into periodontal surgery. It’s available in three syringe sizes 0.3 ml, 0.7 ml, and the cost-effective, smaller volume 0.15 ml. Straumann® Bone Graft Solutions provide a choice of quality products designed to support the regeneration of the patient’s own vital bone. Straumann® AlloGraft is processed with LifeNet Health®’s proprietary and patented Allowash XG® technology, designed to remove and inactivate viruses and bacteria with a Sterility Assurance Level (SAL) of 10-6, and maintain the biomechanical and/ or biochemical properties of the tissue. Straumann delivers several AlloGraft products, each designed to meet a specific clinical and patient need.

On the cutting edge of digital dentistry What will shape the future of dentistry? Digitalization. Straumann’s complete digital package is designed for seamless connectivity to simplify workflows and offer interdisciplinary care amongst the treatment team. Straumann delivers full prosthetic digital workflows that encompass guided surgery, intraoral scanning, and CAD/CAM technology that are reliable, precise, and dedicated to the needs of clinicians and laboratory technicians.

Straumann® Digital Solutions Straumann’s commercial partnerships with

leading digital technologies are designed to deliver seamless digital workflows to surgeons and laboratories. From intraoral scanning with Align’s Itero® and 3M™’s True Definition Scanners to 3D implant planning with coDiagnostiX treatment planning software by Dental Wings, Straumann® CARES® laboratories have an opportunity to offer digital workflow solutions across multiple platforms. From digital impressions to CAD design and the delivery of preoperative provisionals and final restorations, Straumann CARES laboratories are positioned to lead the entire dental team to the desired outcome for you and your patients. Straumann® CARES® CAD/CAM is an integrated prosthetic design system, including state-of-the-art scanner, CAD software, and a leading materials portfolio. Through alliances with industry leaders such as Ivoclar Vivadent®, 3M™ ESPE™, and Vident™, a VITA Company, Straumann offers high-performance ceramic materials for first-class esthetic restorations. Applications for a multitude of patient situations from customized abutments to screw-retained bar and bridge solutions are available. In 2014, commercial partnerships with 3Shape® and exocad® CAD Software expand access to Straumann’s centralized milling facility in Arlington, Texas for original customized abutments and tooth borne restorations. This growing network of dental laboratories offers additional options to surgeons and restorative dentists that insist on the quality of Original Straumann Components for their implants.

that the dental industry needs to provide more support. Straumann is stepping up to help hygienists turn new challenges into opportunities for themselves and their profession while providing the best possible oral health care for their patients. Our uncompromising commitment to producing only the finest regenerative, surgical, and restorative dental products on the market, now extends to support hygienists with continuing education credits, product training, and informative patient tools.

Commitment and support for Registered Dental Hygienists

For over 100 years, the public has come to know their registered dental hygienist as a trusted advisor and someone they can count on. A hygienist’s position is unique and like no other in the practice. The current trend of expanding the hygiene role shows no signs of slowing, and it’s clear

Today. Tomorrow. Together. Straumann invites you to grow with us. We are working on multiple initiatives that will help shape the future of dentistry. Dedication to research has allowed Straumann to deliver meaningful innovations that help clinicians improve the quality of care and life for patients.9 Straumann values the long-standing trust of customers, working with clinicians to help grow their practices through a variety of channels. From comprehensive continuing education courses designed to deliver the latest technologies and clinically relevant scientific information for surgical and restorative clinicians, office staff, and dental labs to customer loyalty programs, Straumann stands behind more than just their products — Straumann stands behind their customers. With a full pipeline of innovative technologies, products, services, and solutions to address the changing trends in dentistry, clinicians should want to choose Straumann as their commercial partner of choice. At Straumann, the future is today.

This information Straumann.

was

provided

References *Pending FDA 501(k) clearance. **As of April 22, 2014.

4. If a Guided Bone Regeneration (GBR) procedure can be avoided.

1. Compared to SLA.

5. Straumann recommends that you use only original Straumann prosthetic components to restore Straumann implants.

2. Norm ASTM F67 (states min. tensile strength of annealed titanium); data on file for Straumann® coldworked titanium and Roxolid® implants

6. In combination with coronally advanced flap.

3. Gottlow J, et al. Evaluation of a new titaniumzirconium dental implant: a biomechanical and histological comparative study in the mini pig. Clin Imp Dent Relat Res. 2012;14(4);538-545.

14 Implant practice

7. McGuire MK, Nunn M. Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue. Part 2: histologic evaluation. J Periodontol. 2003;74:1126-1135.

8. McGuire MK, Nunn M. Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue. Part 1: comparison of clinical parameters. J Periodontol 2003;74:1110-1125. 9. Academy of Osseointegration. What are the benefits of dental implants? Retrieved February 7, 2013. http:// www.osseo.org/FAQ4.htm. Accessed February 7, 2013.

Volume 7 Number 3

More than an implant.

A sense of trust.

Patients today are more aware of treatment options available for tooth replacement. Isnâ&#x20AC;&#x2122;t it important that you partner with an implant company that aligns with your philosophy and offers your patients peace of mind? The time-tested Straumann Dental Implant System has reported excellent long-term clinical results year after year and is designed for maximum flexibility with a minimum number of components. To learn more about the Straumann Dental Implant System, visit www.straumann.us/sdis

CLINICAL

A new implant material changes perceptions Dr. Paul Stone explains how Straumann’s Roxolid® narrow implant can be placed in more sites and requires less grafting, resulting in greater patient uptake

or many years, the two main dental implant materials available were either grade 4 pure titanium (with very strictly controlled minimal percentages of other elements) or a variety of titanium alloys of which titanium-aluminum-vanadium (TiAl6V4) was the most common. Both performed well enough in the clinical environment, with the grade 4 titanium exhibiting the better biological interaction with the neighboring bone and the titanium alloy having the greater strength. As time passed, and the expectations of clinicians and patients increased, the boundaries for the existing materials began to be pushed. Implants needed to be placed into narrower spaces, usually due to not only lack of bone width, but also reduced space between teeth (upper laterals, lower incisors, and small premolars). Another factor was to avoid more extensive bone grafting (Figure 1). While narrow implants were available (usually between 2.5 mm and 3.5 mm diameter), they came with guidelines as to when and how they should be used to reduce overloading issues and were accompanied by publications indicating (not surprisingly) higher fracture rates for the grade 4 titanium designs. There was often a reluctance to use one of the titanium alloys because, although stronger, publications indicated poorer cell integration (inhibition of osteoblast

Paul Stone, BDS (Hons) Lpool, FDS, RCS Ed, has been registered as a specialist oral surgeon since 2001 and has been involved with implant dentistry for more than 25 years. Dr. Stone is clinical director, Blackhills Clinic, Perthshire, Scotland. He is a part-time consultant and honorary senior clinical lecturer in oral surgery at Edinburgh University Postgraduate Dental Institute. Dr. Stone lectures both nationally and internationally, and has held senior positions on a number of representative bodies in both the UK and in Europe. Dr. Stone was chairman of the Royal College of Surgeons of Edinburgh Advisory Board in Implant Dentistry, president of the European Association of Osseointegration, president of the Association for Dental Implantology, and a member of the General Dental Council Working Group convened to revise the Implant Training Standards Guidelines for General Dental Practitioners. He is also a Fellow of the International Team for Implantology.

16 Implant practice

Figure 1: Conventional onlay bone graft augmentation

Figure 2: Implant material factors influencing treatment outcomes

Figures 3A and 3B: The first person to receive a Roxolid implant – 1-year (Figure 3A) and 3-year (Figure 3B) radiographs

differentiation), and there were concerns that in narrower diameters, the surface area available for cell attachment was even less.

New material Fortunately, the arrival of a new implant material (the first that was developed exclusively for dental implants) has begun to change some of our previously held concepts. The Swiss dental implant company Straumann has been at the

forefront of dental implants from the very beginning, and they looked at evidence from papers published over the last 15 years to develop an alloy of titanium (85%) and zirconium (15%) that is called Roxolid®. This new alloy also allows for preparation of the implant using the well-evidenced SLActive® surface technology, providing optimal surface texture and hydrophilicity with the highest rates of bone attachment (Figure 2). Blackhills Clinic was fortunate to Volume 7 Number 3

CLINICAL

Virtually everywhere

CS WinOMS Cloud Figures 4A: Reduced bone width with more palatal placement of narrower implant.

Everywhere your practice needs to be

Figures 4B: Labial over-contouring of implant crown to achieve required esthetics

have carried out the first-ever treatment in a human using this new implant as part of a pilot study. Our 3-year published results have confirmed that the “test” implants were stable and functional, and demonstrated good osseointegration and no mechanical failure (Figures 3A and 3B). The mean bone change in functional bone level over the 3 years was only 0.3 mm. All surviving implants and restorations were considered to be successful. Since this initial study, many more researchers have looked into this new material, and there is now increasing evidence that the material is not only stronger than grade 4 titanium (by up to 55% and similar to TiAl6V4 alloy),

Our CS WinOMS Cloud is a powerful practice management and imaging solution that makes data security simple and virtually worry-free. Access it any time, from any location using any computer or tablet device. • Greater flexibility with offsite and HIPAA-compliant storage, always equipped with the latest software • The best of CS WinOMS software with the benefits of a cloud environment • Ideal for single or multi-location practices with wireless Internet access via computer, tablet or iPad® • Minimal upfront cost with simple monthly installments

Call 800.944.6365 or explore it here carestreamdental.com © Carestream Health, Inc. 2014. WinOMS is a trademark of Carestream Health. iPad is a trademark of Apple, Inc., registered in the US and other countries. 10650 OM DI AD 0514

Volume 7 Number 3 Implant practice 17

CLINICAL

Figure 5A and 5B: Extreme example of wide diameter restoration on narrow implant (not Roxolid or treatment by author)

Figure 6: Reduced diameter Roxolid implants placed in a narrow bone ridge without the need for bone graft augmentation

but also exhibits better bone attachment at a cellular level. This means that for the first time, clinicians can have confidence in using reduced diameter implants, both mechanically and biologically. At Blackhills Clinic, we now have more than 5 years of experience with reduced diameter Roxolid implants and are in a position to comment on our findings and the implications. It is fair to say that previously, narrower implants were placed with some degree of skepticism, and patients were always warned of the increased risk of mechanical failure. This affected confidence could limit the number of treatment options available, often resulting in more bone graft augmentation to create adequate bone for the wider, stronger implants. With Roxolid, we can confidently explain to patients the nature of the new material and now find that bone grafting is required less frequently. Even where it is necessary, this is now often a straightforward, simultaneous procedure with significantly reduced morbidity, healing time, and cost to the patient. As well as the need for 18 Implant practice

This new alloy also allows for preparation of the implant using the well-evidenced SLActive速 surface technology, providing optimal surface texture and hydrophilicity. The reduced diameter allows for more favorable bone thickness around the implant than an equivalent regular diameter implant.

Volume 7 Number 3

Careful consideration Despite all the advantages of Roxolid, there needs to be some caution when using any reduced-diameter implant. The narrow size necessitates additional restorative considerations regarding the maintenance and appearance of the final restoration. A considerable over-contour or overhang can result from the abrupt change in diameter from the narrow implant head to the final restoration diameter (Figures 4A and 4B). This can adversely affect the final appearance, especially if the lip line is high or the oral mucosa is particularly thin, creating an unsightly shadow that can then look even worse if there is subsequent shrinkage of the labial soft tissues. The over-contouring can also cause problems with oral hygiene measures and with accurate peri-implant clinical probing assessments, preventing cleaning aids and metal periodontal probes from adapting to the sub-mucosal concavity. It is therefore important that careful consideration is given to the design, manufacture, and maintenance by all involved, and this includes the technician and patient (Figures 5A and 5B). In summary, Roxolid dental implants show better bone attachment than has been observed with grade 4 titanium or other alloys. Its increased strength means that there are more options for using this narrower implant in more sites and with the need for less grafting (Figure 6). Inevitably this results in a higher patient acceptance. The reduced diameter allows for more favorable bone thickness around the implant than an equivalent regular diameter implant that, in turn, gives better long-term, more predictable support for the overlying soft tissues. On the downside, the reduced diameter (rather than a particular material) means that care is needed when planning the use of any narrow implant, particularly with a more borderline case or where higher esthetic expectations are involved. IP

CLINICAL

less grafting, the narrower diameter also ensures that there is relatively more bone thickness surrounding the implant that, in turn, results in better long-term stability for both the bone and the overlying mucosa. A more predictable long-term esthetic result is one of the most desirable benefits from using Roxolid implants.

YOUR PRACTICE. OUR PASSION.

CS 1500

CS 9300 SELECT

RVG 6200 RVG 6100

INNOVATIVE design

Count on us for to keep your practice in the forefront.

INTEGRATED software for seamless workflow, office to operatory.

INTERACTIVE

products that And promote better patient relationships.

Visit www.carestreamdental.com or call 800.944.6365. ÂŠ Carestream Health, Inc. 2014. RVG is a trademark of Carestream Health. 10650 OM DI AD 0514

Share our Share our passion passionfor for your your practice practiceonline. online.

Volume 7 Number 3 Implant practice 19

The best decisions are based on facts. 2.9mm

Introducing the Neodent Implant System. The facts reveal that there has never been a better time to expand your patient pool and increase the proďŹ tability of your practice. The Neodent family of proven implants and prosthetics provides a quality solution at an affordable price, empowering you to make implant treatment available to a broader population of patients. Discover why over 30,000 dentists around the world have already purchased more than 5,000,000 implants. Neodent delivers both quality and value without compromise. Itâ&#x20AC;&#x2122;s a fact.

INNOVATIVE

Available Now

Neodent is the leading implant company in Latin America — the world's largest implant market in number of implants sold.

20 YEARS

Success Rate* 10 year open study, 3,578 patients.

150

We’ve provided quality implant solutions to clinicians like you for over 20 years.

Over 150 international scientiﬁc articles and publications have evaluated and recognized Neodent quality.

30,000

More than 30,000 clinicians around the globe already use our products.

CM Implant Line

96.5

We’re the 7th largest implant company in the world.

Smart Implant Line

Facility Implant Line

WS Implant Line

5,000,000 We’ve already sold over 5 million implants worldwide.

Abutments

For product, promotion information or to schedule an in person demonstration call us at 855-412-8883 or via email at: info@neodentusa.com www.neodentusa.com *All documented data on ﬁle at Neodent.

CASE STUDY

Immediate implant placement with immediate nonfunctional load using the BellaTek速 Encode速 Impression System: restorative recommendations Dr. Suheil M. Boutros describes a technique that strives to create ideal esthetics and function

mmediate implant placement has been advocated to minimize hard tissue loss following tooth extraction. On the other hand, immediate provisionalization enables the maintenance of the gingival architect for optimal esthetic emergence profile and eliminates the need for a removable provisional prosthesis while osseointegration is achieved. This case report describes a technique that enables the restorative team to create ideal esthetics and function following immediate placement and provisionalization. In addition, this case demonstrates the predictable outcome of using short implants in combination with CAD/CAM restorations.

Patient presentation This clinical presentation demonstrates the replacement of a congenitally missing maxillary left second premolar. A 40-yearold female presented with a primary retained maxillary left second molar that resulted in severe gingival recession. The patient was also missing the mandibular second premolars, first and second molars bilaterally. The patient did not have a medical or dental contraindication for implant therapy. Following the evaluation of the cone beam CT scan (Figure 1), the patient was given the option of extraction of the primary maxillary left second molar and immediate

implant placement along with mucogingival surgery to manage the mucogingival defect (Figure 2). Concurrently, the mandibular posterior teeth will be replaced with dental implants.

Surgical treatment At the surgical appointment, under intravenous conscious sedation using Midazolam (5 mg) and Fentanyl (100 mcg) along with the administration of local anesthesia, the primary retained maxillary left second molar was atraumatically extracted. The osteotomy was prepared in a type II-III bone. Bone taps were not used before the placement of a 4-mm diameter

Introduction Patients with congenitally missing teeth are seeking dental implant therapy more than conventional replacement due to the higher success rate. Generally, these patients have less than ideal alveolar bone width due to the absence of the permanent teeth. In addition, most retained primary teeth in the posterior regions have mucogingival defects. In these situations, incorporating the principles of periodontal plastic surgery along with the concept of immediate nonfunctional loading allows the development of a healthy and an esthetic emergence profile. Furthermore, with the utilization of the BellaTek速 Encode速 system, these implants can be restored with custom abutments that will provide the most optimal gingival contours and esthetics.

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

Suheil M. Boutros, DDS, MS, is a Diplomate of the American Board of Periodontology and a Diplomate of the American Board of Oral Implantology. He practices with Periodontal Specialists of Grand Blanc and is an Assistant Professor at the University of Michigan. He can be reached at www.PeriodonticsOnline.com The restoring dentist for this case Grzegorzewski, DDS, Burton, Michigan.

22 Implant practice

was

Larry

Volume 7 Number 3

osseointegration, healing was uneventful, and soft tissue healing was optimal (Figure 9). At the same time, the lower implants were uncovered, and Encode 4 x 4 x 5 mm healing abutments were placed (Figure 10). Two weeks later, the screw-retained restoration was removed by the restoring dentist, and an Encode 4 x 4 x 5 mm

removed, and the Encode abutment was placed. The fit and esthetics were verified clinically and radiographically (Figures 1822). The Gold-Tite® abutment screws were placed and tightened to 20 Ncm with a Biomet 3i Torque Indicating Rachet Wrench (Figure 23). The final crown was cemented with RelyX™ cement (3M™ ESPE™); excess cement was removed (Figure 22). At the

Figure 7

Figure 8

Figure 9

Figure 10

Figure 11

Figure 12

Figure 13

Figure 14

Figure 15

At the same surgical visit, six 4-mm diameter by 8.5-mm length Biomet 3i OSSEOTITE Certain Tapered Implants were placed in the posterior mandible along with the extraction of tooth No. 32 (Figure 8). The patient was given postsurgical instructions, including the use of 0.12% chlorhexidine gluconate (Peridex™, Proctor & Gamble) 3 times daily and was prescribed 500 mg of amoxicillin (every 6 hours for 7 days).

healing abutment was placed (Figure 11). A healing abutment level impression was taken using polyvinylsiloxane impression material (Figures 12 and 13). In the laboratory, an Encode master cast was fabricated, and the casts were mounted in an articulator on Adesso® Magnetic Mounting Plates (Ivoclar Vivadent Inc.). The mounted casts were then sent to the Biomet 3i PSP Department for scanning and milling of Encode abutments (Figure 14). The milled abutments were returned to the laboratory for the fabrications of the final crowns (Figures 15-17). The screw-retained restoration was

same time, the lower Encode abutments were seated and tightened to 20Ncm; the final splinted crowns were cemented in place using the same cement. Oral hygiene instructions were given, and the patient was seen for follow-up visits at 3 and 6 months, respectively.

Prosthetic treatment Three months following implant placement, the patient was seen for evaluation of

Follow-up and maintenance The patient was seen for a follow-up visit at 3 months (Figure 23), and at 6 months post placement; the gingival tissues were healthy, and the esthetic outcome was well maintained (Figures 24-25). Currently, the patient is placed on a 6-month recall

Volume 7 Number 3 Implant practice 23

CASE STUDY

by 13-mm length Biomet 3i™ OSSEOTITE® Tapered Certain® Implant. A PreFormance® Post was used to support a resin-bonded screw-retained restoration (Figures 3-5). Following the seat of the provisional restoration, the flap was coronally advanced using Ethicon 4-0 Vicryl™ suture without the use of a free connective tissue graft (Figures 6-7).

CASE STUDY

Figure 16

Figure 17

Figure 19

Figure 18

Figure 20

Figure 22

Figure 23

Figure 21

Figure 24

to properly maintain the implants and the restorations. At 1-year post restoration, the bone level around all implants is well maintained (Figure 26).

Clinical relevance

Figure 25

24 Implant practice

Figure 26

With patientsâ&#x20AC;&#x2122; increasing demand for immediate implant placement and immediate provisionalization, it is possible to create soft tissue symmetry and health around implant-supported crowns through the use of properly shaped provisional restoration, while allowing the patient to function, feel, and look esthetically pleasing during the osseointegration period. This case also demonstrated that the combination of short implants and the very precise CAD/CAM restoration can achieve a very predictable long-term functional and esthetic outcome. IP Volume 7 Number 3

The

Encode Impression System ®

The BIOMET 3i patented BellaTek® Encode Impression System is the gateway to creating a customized solution for you and your patients. This eliminates the need for impression copings and streamlines the process for beautiful aesthetic outcomes.

Optimization By Design® • A more efficient workflow and less inventory to stock provide a vehicle for practice growth. • Create and select aesthetic BellaTek Patient Specific Abutments available in titanium or with titanium nitride coating. • No need to remove the healing abutment, preserving tissue and resulting in aesthetic outcomes.

For more information, please contact your local BIOMET 3i Sales Representative today! In the USA: 1-888-800-8045 Outside the USA: +1-561-776-6700 Or visit us online at www.biomet3i.com BellaTek, BellaTek design, Encode and Optimization By Design are registered trademarks of BIOMET 3i. Providing Solutions One Patient At A Time is a trademark of BIOMET 3i LLC. ©2014 BIOMET 3i LLC. All trademarks herein are the property of BIOMET 3i LLC unless otherwise indicated. This material is intended for clinicians only and is NOT intended for patient distribution. This material is not to be redistributed, duplicated, or disclosed without the express written consent of BIOMET 3i. For additional product information, including indications, contraindications, warnings, precautions, and potential adverse effects, see the product package insert and the BIOMET 3i Website.

AD020

CASE STUDY

Immediate implant placement within your practice Dr. Ara Nazarian illustrates a simplified approach to an immediate dental implant

oday, we see more patients presenting to the office with endodontically treated teeth that have failed for one reason or another due to fracture, recurrent caries, or periodontal problems. In the past, the common dental treatment would be to prepare the adjacent teeth for a three-unit bridge. However, with implant therapy increasingly gaining popularity among patients and providers, the request to have implant treatment has increased. It is my opinion that implant tooth replacement is the standard of care, and that every general practitioner needs to learn how to replace missing teeth using this modality at some level. This article focuses on a case where a fractured tooth was extracted, and a dental implant was placed immediately using a simplified approach. A 58-year-old male patient presented to my practice with a fractured tooth No. 4 (Figure 1) that was previously restored with a root canal, post/core, and crown. Since the tooth had just recently fractured, there was no periapical lesion present that would contradict dental implant placement (Figure 2). In addition, the patient’s medical history was non-contributory. Different options available to restore the area were discussed with the patient as well as any risks, benefits, and alternatives. The patient decided to have an implant placed immediately after the extraction of tooth No. 4. The area was anesthetized using

Ara Nazarian, DDS, is a graduate of the University of Detroit-Mercy School of Dentistry. Upon graduation, he completed an AEGD residency in San Diego California, with the U.S. Navy. He is a recipient of the Excellence in Dentistry Scholarship and Award. Currently, he maintains a private practice in Troy, Michigan, with an emphasis on comprehensive and restorative care. His articles have been published in many of today’s popular dental publications. Dr. Nazarian also serves as a clinical consultant for the Dental Advisor, testing and reviewing new products on the market. He has conducted lectures and handson workshops on esthetic materials and techniques throughout the United States. Dr. Nazarian is also the creator of the DemoDent patient education model system. He can be reached at (248) 457-0500 or at www.demo-dent.com.

26 Implant practice

Figure 1: Clinical view of fractured tooth No. 4

1.8 ml 4% Septocaine® (Septodont) with 1:100,000 epinephrine. Once anesthetized, the Physics Forceps (Golden Dental Solutions) was placed and pressure slowly applied using only wrist movement toward the buccal. Approximately within 60 seconds, the force built up and released at which point the tooth disengaged from its socket (Figure 3). Once the tooth was extracted, a curette was used to clean out the socket of any fibrous tissue. The site for the implant was begun with a #557FG surgical bur in a high-speed surgical handpiece and surgical motor (Aseptico, AEU 7000). By using the highspeed surgical handpiece, I was able to control the initial penetration through the floor of the socket with total control. The location was centered facial-lingually as well as mesial-distally. Since the tooth being replaced was a premolar, and there was sufficient bone width and height, a 4 mm x 12 mm OCO Biomedical TSI dental implant was selected. A 1.8 mm pilot drill was placed into the site and advanced to a depth of 12 mm measuring from the height of bone. Since the dental implant was being placed immediately into the socket, it was important to engage the bone apical to the socket for immediate fixation. Ideally, I prefer to place immediate implants 3 mm apical to the socket if the anatomy permits. Using the pilot drill as a paralleling pin, an X-ray was taken to check the angulations between the adjacent teeth within the maxilla. Once the position was confirmed, the final drill was used to shape the osteotomy for the implant. DBM bone putty (Maxxeus) was placed into the osteotomy

Figure 2: Preoperative X-ray of No. 4

Figure 3: Extraction of tooth No. 4

and displaced to the lateral walls with a curette. Once complete, a 4 mm x 12 mm TSI OCO Biomedical threaded implant (Figure 4) was placed into the osteotomy using an implant finger driver until increased torque was necessary. The ratchet wrench was then connected to the adapter and the implant torqued to final depth reaching a torque level of 55 Ncm. A 3 mm healing abutment was hand-tightened to the implant (Figure 5) and the tissue sutured. A postoperative radiograph was made of the implant and the healing abutment. The implant was evaluated clinically after 1 week. The patient stated he had no post operative discomfort or swelling. When the patient returned 4 months later, the healing abutment was removed (Figure 6) and the implant tested with an Osstell® ISQ implant stability meter, which uses resonance frequency analysis as a method of measurement. Several studies have been conducted based on resonance frequency analysis (RFA) measurements and the Implant Stability Quotient (ISQ) scale. They provide valid indications that the acceptable stability range lies above 55 ISQ. In this particular case, the ISQ meter Volume 7 Number 3

CASE STUDY

Figure 4: OCO Biomedical TSI Implant

read 76 (Figure 7), which was far above the guidelines. A solid stock abutment of 4-mm height was tightened into the implant and then retightened to insure proper seating (Figure 8), and an X-ray taken. An impression was taken of the implant and abutment using a tissue retraction impression pickup (TRIP) from OCO Biomedical Company. The TRIP was tried on to the TSI implant and abutment to check clearance for a triple tray impression. It was important to make sure the TRIP displaced the gingiva and snapped over the collar of the implant to ensure proper seating. Since there was enough clearance and a tooth present on either side of the implant, a triple tray (EXACTA Dental Products) was used with a heavy and light-bodied polyvinyl siloxane impression material (Take-One Advance, Kerr). Once the impression material was set, it was removed from the mouth picking up the TRIP, and a 4.0 mm marginal collar was snapped into the impression and sent to the lab for pour up. From this pour up, the marginal collar would reproduce the margin of the implant, and the pour up would replicate the abutment so that the final PFM crown restoration would be fabricated. When the patient returned for the seating appointment, the PFM crown was placed on the abutment with its margins on the implant, and another X-ray was taken to verify an accurate fit. Since there were no open margins, and the contacts and occlusion were good, the crown restoration was seated using Nexusâ&#x201E;˘ RMGI (Kerr) cement (Figure 9). Once the cement reached its gel stage, it was quickly cleaned off, and any excess quickly and easily removed (Figure 10). The patient was very pleased with the end result and was surprised at how atraumatically the dental implant was placed at the same time of the extraction. Today, patients like to get all their services performed under one roof. They 28 Implant practice

Figure 5: Placement of implant and graft material

Figure 6: 4 months postoperative view

Figure 7: Osstell reading of implant

Figure 8: Abutment placed into implant

....With therapy increasingly gaining popularity among patients and providers, the request to have implant treatment has increased. It is my opinion that implant tooth replacement is the standard of care, and that every general practitioner needs to learn how to replace missing teeth using this modality at some level.

Figure 9: Crown seated onto implant

Figure 10: Postoperative X-ray of implant

know, trust, and feel comfortable with their general dentist and usually prefer him or her to perform dental procedures necessary to reach optimum dental health. I am not advocating general dentists offer procedures they are not comfortable with or not properly trained for. However, it is my opinion that general dentists should

implement single posterior implants into their practices. General dentists interested in offering implant treatment should pursue postgraduate implant training in placement and restoration if they want to meet the demands of todayâ&#x20AC;&#x2122;s society at www. aranazariandds.com. IP

Volume 7 Number 3

G N I H T T E S N E O B B E H T NEXT TO

eoi

n co r p ora

tio

abe

cular bon

l ne

gro

th*

r Metal M at

Tr a

ula

ria

™

ng wth + Bone I

Artistic Rendering

I am the Zimmer® Trabecular Metal™ Dental Implant, the first dental implant to offer a mid-section with up to 80% porosity—designed to enable bone INGROWTH as well and ONGROWTH. Through osseoincorporation, I harness the tried-and-true technology of Trabecular Metal Material, used by Zimmer Orthopedics for over a decade. My material adds a high volume of ingrowth designed to enhance secondary stability.... and I am Zimmer.

Visit TrabecularMetal.zimmerdental.com to view a special bone ingrowth animation and request a Trabecular Metal Technology demo. www.zimmerdental.com ©2013 Zimmer Dental Inc. All rights reserved. * Data on file with Zimmer Dental. Please check with a Zimmer Dental representative for availability and additional information.

AO RECAP

Implant dentistry practitioners from 45 countries come together for the Academy of Osseointegration 2014 Annual Meeting

ore than 2,000 clinicians attended the 29th Annual Meeting of the Academy of Osseointegration (AO), which took place from March 6-8 in Seattle. With the theme of “Real Problems, Real Solutions,” the event featured presentations from internationally renowned speakers offering their experience and expertise in the diagnosis, treatment, and use of the latest techniques and technologies to correct dental implant problems and prevent future complications. The conference, which recorded the fourth largest attendance in its history, included 624 international attendees representing 45 countries and more than 1,100 exhibitors that showcased products and services to support implant dentistry. “As a GP who only places about 75 implants a year, it is invaluable for me to get to be a part of AO where I can get the best level of education possible,” said Dr. Dean Daniele, General Practitioner, Kamloops, Canada. “We are so lucky that no matter how many implants we perform, we get to come together and learn.”

Annual meeting kicks off with Implant Retreatment Symposium Thought leaders in the field of implant dentistry kicked off the AO Annual Meeting on Thursday with its Opening Symposium. Past, present, and future clinical challenges — especially as related to patients presenting with issues related to implants that are at least 25 years old — were the focus of the sessions. Educational events on Thursday also included the Corporate Forums, 36 industry-hosted presentations, which highlighted recent innovations from a collection of the industry’s leading companies. Approximately 75 new AO members — who reflected the increased professional diversity experienced by AO in recent years — were introduced to the organization at a special New Member Breakfast meeting on the Annual Meeting’s opening day. More than 120 clinicians gathered 30 Implant practice

at The Pike Brewing Company Thursday evening for AO’s first-ever Young Clinicians’ Reception.

Day 2 features International Symposium and high-flying fun This year’s Annual Meeting featured an exciting innovation: AO’s first-ever International Symposium dedicated to one country: Japan. The Symposium, which took place the second day of the conference on Friday, was met with enthusiastic feedback from both international and U.S. attendees. “I was very happy to present at the first-ever International Symposium dedicated to one country — and I was also very happy that the AO selected Japan,” said presenter Dr. Tomohiro Ishikawa. “We are very honored. I hope this opportunity will be impactful to further build the relationship between AO and Japan, and our countries.” Also taking place on Friday were targeted sessions focused on surgery, restoration, and clinical innovations. Day 2 ended with the AO President’s Reception held at Seattle’s Museum of Flight — attended by more than 1,300 meeting attendees, leaders, exhibitors, and guests. “It was an absolutely amazing evening that truly celebrated all that AO has accomplished together over the past year,” said Dr. Stephen Wheeler, 2013-14 AO President, whose term concluded at the Annual Meeting. “I was honored to see so many new faces from around the world, as well as to spend time with longtime friends and colleagues who work so hard to make this event a success and to help AO achieve the premier status we enjoy today.”

Annual meeting concludes with optimism and energy The Closing Symposium, which took place on its final day, Saturday, was well attended and forward-looking with its topic, “Our Better Future.”

Presenters addressed advances in important topics such as digital dentistry, implant prosthodontics, as well as biotechnology, and the future. Also on Saturday was a program for the allied staff, “Real Problems, Real Solutions in the Business of Implant Dentistry,” which was attended by representatives from practices specializing in periodontics, oral surgery, prosthodontics, and general dentistry.

Record number of clinicians presented original research and clinical cases During the conference, a record number of more than 250 clinicians presented their original research and clinical cases of interest in the field of implant dentistry. AO awarded seven of these clinicians for best abstract poster presentations. To view the winning abstracts, please visit http://www. osseo.org/2014_review.html. “Research at the AO Annual Meeting squarely focused how science supports clinicians who are fully committed to providing an evidence-based approach to treatment to ensure the best outcome for their patients,” said Dr. Lyndon Cooper, the meeting’s scientific program chair who also presented research. “Presentations ranged from digital planning, new esthetic techniques and prevention strategies to molecular strategies and stem cell biology. Abstract presentations explored original scientific and clinical research, clinical innovations, and case presentations that could help shape the future of implant dentistry.”

Highlights of AO’s Annual Business Meeting Dr. Joseph Gian-Grasso, a periodontist from Philadelphia, Pennsylvania, was elected to serve as President of AO. Dr. Gian-Grasso will serve with the 2014-2015 AO Board of Directors, also named during the meeting. “I am honored to continue AO’s commitment to establishing a nexus where Volume 7 Number 3

unmatched speed and precision.

The affordable and portable mixing unit The lightweight Pentamix™ Lite Automatic Mixing Unit swivels for easy carrying, so you can have the convenience, speed and precision of automixing in every operatory.

The fastest VPS impression material Imprint™ 4 VPS Impression Material reduces stress with its fast intra-oral setting time, and provides flexibility and accuracy with a long working time—giving you greater control.

Fastest intra-oral setting time 1

75 sec.

without compromising working time or control.

NEW!

Pentamix Lite ™

Automatic Mixing Unit

Imprint 4 ™

Pentamix™ Lite Starter Kit: $1,400 Includes: 4 Penta™ Refill Cartridges, 1 bag of Penta™ Mixing Tips, and the Pentamix Lite unit ($1,200 MSRP)

Learn more and find the Special Offer at:

www.3MESPE.com/PentamixLite

VPS Impression Material

AO RECAP

Figure 1: Implant dentistry professionals gathered at the Welcome Reception to kick off the meeting

Figure 2: Attendees discuss original research and clinical cases of interest at the AO Annual Meeting, which had a record number of scientific posters

Figure 3: International attendees listened to sessions with headsets for English-to-Japanese translation

specialists and generalists from around the world can come together to learn and stay up-to-date on the rapidly advancing clinical research and innovations in the dental implant and tissue engineering industries,” said Dr. Gian-Grasso. “Having been with AO for nearly 30 years, I have grown to truly appreciate its unique role, the commitment of its board of directors, and the enthusiasm 32 Implant practice

of its members to provide the best patient care possible.” Tomas Albrektsson, MD, PhD, ODhc, Gothenburg, Sweden, a close co-worker with Dr. Per-Ingvar Brånemark in the development of osseointegrated dental implant treatment in the 1980s, also was presented the Nobel Biocare Brånemark Osseointegration Award. The award is

given annually by the Osseointegration Foundation to honor an individual whose impact on implant dentistry is exemplary in any or all of the Foundation’s mission categories: research, education, and charitable causes. IP

Volume 7 Number 3

CONTINUING EDUCATION

Do we need a radiographic guide? A review of the cone-beam computed tomography (CBCT) visualization and treatment planning for narrow-diameter implant overdentures Dr. Michael D. Scherer summarizes a contemporary approach using simple techniques to enhance visualization of restoration contour, separating soft tissues with simple techniques, and proposes that radiographic guides may no longer be necessary for implant overdenture therapy Synopsis/Abstract Treatment planning for implant overdentures can be challenging because of the interplay between bone volumes, angulation, and denture base contour requirements. Narrow-diameter overdenture implants, while having an easy and predictable surgical protocol, often are placed without regard to restorative goals because of the difficulty and added expense of fabricating a radiographic guide. Simple techniques are available to enhance visualization of complete dentures during cone-beam computed tomography (CBCT) imaging. This article aims to illustrate the use of soft tissue separation techniques and assessment of CBCT scans for narrowdiameter overdenture implants.

Educational aims and objectives The aim of this article is to review radiographic assessment of implant sites for narrow diameter implants and illustrates methods of visualization of restorative plans without radiographic guides. Expected outcomes Implant Practice US subscribers can answer the CE questions on page 38 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Understand the role of cone-beam imaging for traditional radiographic interpretation of implant sites for narrow-diameter implants. • Recognize the ability of contemporary imaging techniques to separate soft tissues and minimize the need for a radiographic guide. • Effectively create a virtual implant plan and request a computerized surgical guide to allow for surgical placement of implants based upon the virtual plan.

Introduction Radiographic visualization of the alveolar ridge bone volume, current tooth position, and the definitive restorative plan are necessary steps in the treatment sequence and planning of implant positions and final restoration contours. Proper positioning of the narrow-diameter implant body is critical to the success of the surgical procedure, initial and definitive prosthetics, and longterm maintenance of both the implant and

Michael D. Scherer, DMD, MS, is a fulltime private practice prosthodontist in Sonora, California. He is currently an Assistant Clinical Professor at Loma Linda University in California, a former Assistant Professor in Residence at University of Nevada, Las Vegas (UNLV), and a fellow of the American College of Prosthodontists. He has published articles related to clinical prosthodontics and implant dentistry and completed a master’s degree related to implant overdentures with multiple publications pending. Dr. Scherer has served as the director of the implant dentistry curriculum at UNLV and is actively engaged in guided surgical placement and prosthetic restoration of implants in private practice. Disclosure: Dr. Michael Scherer receives occasional reimbursement for speaking engagements on behalf of ZEST Anchors.

34 Implant practice

Figure 1: Mini Dental Implants placed in the interforaminal area of the edentulous mandible

Figure 3: The patient was unable to close her lips completely and reported soreness while chewing and speaking

Figure 2: Radiographic appearance shows that the implants are well integrated

Figure 4: The overdenture was excessively thick due to attempting to accommodate height of the implant and housings

restoration. The implant position not only is dependent upon location of sufficient bone volume, but also must satisfy esthetic, biomechanical, and functional requirements. While narrow-diameter implants, such as the ZEST LOCATOR® Overdenture Implant System (LODI), offer flexible and predictable surgical placement protocols, many clinicians often plan implant

Figure 5: The housings were removed from the intaglio of the denture and adjusted until the patient was comfortable at the proposed vertical dimension

positions solely based upon radiographic appearance of bone volumes with the assumption that the surgical procedure is the prime directive of implant therapy. Critical to treatment planning procedures, it requires a thorough evaluation of the current or proposed restoration space. Proper evaluation of threedimensional restorative space is essential Volume 7 Number 3

Figure 7: CBCT scan made with a patient wearing a barium sulfate replica of the complete denture, allowing the clinician to measure prosthetic space in addition to bone volume measurements

during treatment evaluation for implant restorations. This restorative space is bound by the proposed occlusal plane, denture-bearing tissues of the edentulous ridge, and oro-facial tissues.1 The space is also controlled by the patient’s neutral zone, which is the region balanced by the inward force of lips and cheeks and that of the outward force of the tongue.2 Proper control of this balance is largely dependent upon the buccolingual position of the teeth and denture base contour.3 Inadequate attention to analyzing the restorative space may lead to problems such as an over-contoured prosthesis, compromise in the neutral zone, fractured teeth and/or denture bases, artificially opened occlusal vertical dimension, and the need to perform additional surgical procedures.4-6 The purpose of this article is to outline essential steps and techniques involved in proper radiographic assessment of sites for narrow-diameter overdenture implants to avoid potential treatment planning complications. Additionally, this article aims to describe contemporary 3D imaging using soft tissue separation techniques to visualize restorative plans without having to utilize a radiographic guide.

Case report: inadequate restoration treatment planning for overdenture implants Patients who are treated without regard to restorative space have difficulty with adapting to the bulkiness of their restoration. An example of a patient seen by this author is shown in Figures 1-5. This patient had four 3M ESPE Mini Dental Implants (MDI), (3M, St. Paul, Minnesota) placed approximately 5 years prior to presenting to the author for evaluation (Figures 1 and 2). The patient expressed no pain or dysfunction with her implants; however, she hasn’t been able to wear

Figure 8: Barium sulfate mixed with acrylic resin shrinks and potentially could result in the radiographic appearance of ill-fitting radiographic guide. Arrows indicate areas of tissue-prosthesis misfit

her mandibular denture since the implants were placed. She expressed concerns that she was unable to speak effectively and felt strained with both dentures in her mouth (Figure 3). Frustrated, she decided to leave her denture out of her mouth and has accommodated to not wearing the denture. Diagnostic procedures were completed, and a clinical assessment showed that her vertical dimension was opened beyond her comfort level. This was a result of the previous clinician attempting to accommodate the height of the tall implants, housings, and acrylic resin within the denture borders (Figure 4). The housings were removed, the denture adjusted until her vertical dimension was adequate, and the determination was that she had to have the implants removed (Figure 5) Unfortunately, lack of restorative assessment, lack of effective radiographic visualization, and insufficient attention to fundamentals of complete denture fabrication resulted in an outcome that was less than optimal.

CBCT scanning and treatment planning

implant

The use of cone-beam computerized tomography (CBCT) has gained popularity as it allows for three-dimensional evaluation as opposed to traditional two-dimensional radiographic techniques. CBCT allows proper visualization of critical anatomical structures and provides a superior amount of information.7-9 CBCT software packages also allow for interpretation of Digital Imaging and Communications in Medicine (DICOM) files via volumetric or surface rendering technology. Figure 6 illustrates a CBCT scan of a patient wearing complete dentures without the use of a radiographic template. While the volume, width, and height of bone can be properly determined for position of

Figure 9: Radiographic appearance of a patient wearing a complete denture using soft tissue separation techniques. Arrows illustrate the visualization of occlusal anatomy and denture base contours that allow the clinician to measure bone volumes with regard restoration outline

a narrow-diameter implant (LODI, ZEST Anchors, Escondido, California) within the bone, it is not possible to fully identify the proper implant position relative to the planned restorative goal. Various methods of radiographic visualization methods have been described in the literature with many reports and techniques described involving duplicating the existing or proposed restoration and fabricating a radiographic guide.10-16 Radiographic guides can reliably act as tooth or restoration outline markers indicating incisal edge position, buccolingual position aides, and denture base contour (Figure 7). Additionally, these markers may potentially act as a fiducial marker allowing for accurate representation of the final restorative goals by ensuring adequate radiographic determination for narrow-diameter implant placement. By using these as a template for planning, critical anatomical features are identified, and dental implants may be digitally planned. Traditional radiographic visualization for fully edentulous patients typically involves the use of duplicating the patient’s existing complete denture and fabricating a barium sulfate and acrylic resin replica of various radiodensities.11,13,15,16 The method of duplication most likely calls for the use of an irreversible hydrocolloid (alginate) or a polyvinylsiloxane (PVS) impression. It requires laboratory components, and generally requires two clinical appointments. While visualization can be achieved with this approach, some practitioners choose not to fabricate radiographic guides because of the extra steps and costs involved. Laboratories typically charge between $50–$200 for fabrication of a radiographic guide in addition to approximately $50 worth of impression material used, dental gypsum, and packing material needed to ship the

Volume 7 Number 3 Implant practice 35

CONTINUING EDUCATION

Figure 6: Typical radiographic appearance of a patient wearing complete dentures without soft tissue separation techniques. This technique permits the clinician to measure bone volumes for implants

CONTINUING EDUCATION duplicate index of the patientâ&#x20AC;&#x2122;s denture. As mentioned, a second clinical appointment is necessary to fit the prosthesis prior to the CBCT scan. Even after guide fabrication and adjustments in the mouth, as well as considering that acrylic resin has a shrinkage of up to 21%, there is a possibility of the radiographic guide not adequately fitting the soft tissues.18 Prosthetic space, angulation, and height adjustments in relation to bone volumes are possible with the addition of barium sulfate. Figure 8 illustrates a CBCT scan of a patient wearing an ill-fitting barium sulfate/acrylic resin radiographic guide. This method allows for the clinician to visualize the restorative contours in addition to the bone volume measurements previously depicted, however, due to the aforementioned, can be a challenging method of radiographic visualization. Clinical procedures that reduce cost and complexity, yet still allow for achieving an appropriate clinical outcome, are always of interest to private practitioners. It is the opinion of the author that with the current cone-beam software packages in conjunction with digital technology, distinct radiographic templates are rapidly becoming unnecessary.

Figures 10A and 10B: Shows the cross-section radiographic appearance of a barium sulfate radiographic guide (Figure 10A). Shows a complete denture using soft tissue separation techniques (Figure 10B)

Figure 11: CBCT scan made with a patient wearing complete denture with cotton rolls separating the tissues away from the acrylic resin, allowing the clinician to measure prosthetic space in addition to bone volume measurements

Figure 12: For mandibular arches: cotton rolls placed buccal and lingual to the denture to separate the cheeks and tongue, and two also placed on the occlusal surface to enhance the radiographic appearance of occlusal anatomy

Figure 13: Cotton rolls can also be placed to separate soft tissues away from a clear surgical guide

Figure 14: For maxillary arches: cotton rolls placed buccal to the denture, tongue pulled away from the palate, and cotton rolls used to separate the occlusal surface

Figure 15: Radiographic appearance of the patient from Figure 14 showing occlusal anatomy, denture base outline, and palate contour of the maxillary complete denture

Case report: soft tissue separation techniques for narrow-diameter overdenture implants Air space on a CBCT image is represented by dark space, and the patient volume is represented by shades of grey to bright white points. The Hounsfield unit (HU) scale is a relative measurement of the radiodensity of an object within a CT scan, indirectly providing amounts of gray within an image. Radiodensity of cortical bone (1700 HU) allows it be easily visible on CBCT radiographs as compared to air (-1000 HU) and tissues (50 HU).19 Typical radiographic techniques do not permit visualization of soft tissue contours separate from acrylic denture resin. The comparison of tissue radiodensity and that of acrylic denture resin (70 HU) makes it more difficult to discern the differences between the two.19 Figure 9 illustrates a CBCT radiograph of a mandibular complete denture with soft tissue and occlusal separation. Looking at this radiographic representation of the denture contour, it is easy to see all of the major factors related to essential treatment planning: tooth position, denture base contour, and occlusal morphology. Comparing the radiographic appearance of the barium sulfate replicate of the complete 36 Implant practice

denture to that of just the complete denture reveals a similar appearance (Figures 10A and 10B). Narrow-diameter implant overdenture (LODI, ZEST Anchors, Escondido, California) treatment planning with measurement-based CBCT analysis is facilitated with this simple yet intuitive approach for fully edentulous patients (Figure 11). Separation of soft tissues during CBCT scans is a very simple technique that creates negative air space, which contrasts with objects that are not radiopaque, such as acrylic resin. Multiple methods have been employed by this author; however, the simplest and most readily available technique is to place a combination of cotton rolls around the denture prior to the CBCT scan. In most mandibular narrow-

Figure 16: Some software packages (Invivo, Anatomage, San Jose, California) offer several visualization modes that facilitate visualization of the complete denture in addition to the bone volume

diameter overdenture implant cases where the patient is wearing a complete denture, seven cotton rolls are placed: two on the lingual, two on the occlusal, and three in the buccal vestibule (Figure 12). The Volume 7 Number 3

Figure 18: Preoperative maxillary arch showing a wellhealed alveolar ridge and firm keratinized tissues

lingual cotton rolls are used to keep the tongue away from the lingual slope of the complete denture; the occlusal cotton rolls permit visualization of the occlusal surface details; and the buccal cotton rolls keep the cheeks and lips away from the denture surface. If the clinician wishes to have a duplicate denture made for the purposes of a surgical guide, cotton rolls can also be applied in a similar fashion around a clear surgical template (Figure 13). Alternatively, a single extended length cotton roll can take the place of multiple individual cotton rolls. For maxillary narrow-diameter overdenture implant cases where the patient is wearing a complete denture, five cotton rolls are placed: two on the occlusal and three in the buccal vestibule (Figure 14). During the CBCT scan, the patient is instructed to keep the tongue away from the palate. By employing these techniques, dark areas corresponding to air space are created on the CBCT volume-enhanced visualization of the occlusal surfaces of denture teeth, tongue anatomy, and palate (Figure 15). With some CBCT software packages (Invivo, Anatomage, San Jose, California), special rendering modes will permit visualization of bone volume and the complete denture without secondary CBCT scans or complicated techniques (Figure 16). Based upon these simple techniques, the clinician can easily visualize restoration plans in relation to bone volumes in 3D. Angulation, depth, and position of implants can be modified based upon this visualization, which greatly enhanced treatment planning for narrow diameter overdenture implants. The virtual treatment plan allows for fabrication of a 3D-printed model and a computerized guide (Anatomage Guide, Anatomage, San Jose, California) with special metal sleeve inserts that permit placement using implant osteotomy drills (Figure 17). After ensuring complete adaptation of the surgical guide to the alveolar ridge, anchor

pins assist in stabilizing the surgical guide during implant osteotomy preparation. Implants are placed with precision through the surgical guide, and LOCATOR Implant abutments are attached to the implants (Figures 18-19). Using the computerized guide to place narrow-diameter implants allows the clinician to precisely place the implants, to minimize surgical trauma, and to ensure that the preoperative virtual plan is transferred from the computer screen to the surgical procedure (Figure 20).

Conclusion Proper visualization of bone volumes and restorative plans for narrow-diameter overdenture implants is critical and requires careful preoperative assessments. While narrow-diameter overdenture implants, such as the ZEST Anchors LODI System, are an excellent treatment option for patients with narrow ridges because of the flexible surgical placement protocol, it is critical to properly plan implant placement

Figure 19: Narrow-diameter implants (ZEST LODI) placed with the assistance of a computerized surgical guide

Figure 20: One-week healing illustrating the benefit of a computerized surgical guide to allow for precise implant placement with minimal tissue trauma

around restorative goals. Visualization of bone volume and restorative plans is facilitated with CBCT imaging and simple techniques using cotton rolls to separate soft tissues and enhance the visualization of a complete denture. While barium sulfate and other radiopaque materials may still have a place in implant dentistry, it is the opinion of this author that use of these materials is no longer necessary for restorative visualization and treatment planning for narrow-diameter overdenture implants. IP

References 1. Ahuja S, Cagna DR. Classification and management of restorative space in edentulous implant overdenture patients. J Prosthet Dent. 2011;105(5):332-337. 2. Beresin VE, Schiesser FJ. The neutral zone in complete dentures. J Prosthet Dent. 1976;36(4):356-365. 3. Cagna DR, Massad JJ, Schiesser FJ. The neutral zone revisited: from historical concepts to modern application. J Prosthet Dent. 2009;101(6):405-412. 4. Lee CK, Agar JR. Surgical and prosthetic planning for a two-implant-retained mandibular overdenture: a clinical report. J Prosthet Dent. 2006;95(2):102-105. 5. Bidra AS. Consequences of insufficient treatment planning for flapless implant surgery for a mandibular overdenture: a clinical report. J Prosthet Dent. 2011;105(5):286-291.

10. Engelman MJ, Sorensen JA, Moy P. Optimum placement of osseointegrated implants. J Prosthet Dent. 1988;59(4):467-473. 11. Israelson H, Plemons JM, Watkins P, Sory C. Bariumcoated surgical stents and computer-assisted tomography in the preoperative assessment of dental implant patients. Int J Periodontics Restorative Dent. 1992;12(1):52-61. 12. Pesun IJ, Gardner FM. Fabrication of a guide for radiographic evaluation and surgical placement of implants. J Prosthet Dent. 1995;73(6):548-552. 13. Basten CH, Kois JC. The use of barium sulfate for implant templates. J Prosthet Dent. 1996;76(4):451-454. 14. Takeshita F, Tokoshima T, Suetsugu T. A stent for presurgical evaluation of implant placement. J Prosthet Dent. 1997;77(1):36-38.

6. Porwal A, Sasaki K. Current status of the neutral zone: a literature review. J Prosthet Dent. 2013;109(2):129-134.

15. Kopp KC, Koslow AH, Abdo OS. Predictable implant placement with a diagnostic/surgical template and advanced radiographic imaging. J Prosthet Dent. 2003;89(6):611-615.

7. White SC, Heslop EW, Hollender LG, Mosier KM, Ruprecht A, Shrout MK. Parameters of radiologic care: An official report of the American Academy of Oral and Maxillofacial Radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91(5):498-511.

16. Oh WS, Saglik B. A simple method to duplicate a denture for an implant surgical guide. J Prosthet Dent. 2008;99(4):326-327.

8. Benavides E, Rios HF, Ganz SD, An CH, Resnik R, Reardon GT, Feldman SJ, Mah JK, Hatcher D, Kim MJ, Sohn DS, Palti A, Perel ML, Judy KW, Misch CE, Wang HL. Use of cone beam computed tomography in implant dentistry: the International Congress of Oral Implantologists consensus report. Implant Dent. 2012;21(2):78-86. 9. Dreiseidler T, Mischkowski RA, Neugebauer J, Ritter L, Zรถller JE. Comparison of cone-beam imaging with orthopantomography and computerized tomography for assessment in presurgical implant dentistry. Int J Oral Maxillofac Implants. 2009;24(2):216-225.

17. Mecall RA, Rosenfeld AL. The influence of residual ridge resorption patterns on implant fixture placement and tooth position. 2. Presurgical determination of prosthesis type and design. Int J Periodontics Restorative Dent. 1992;12(1):32-51. 18. Mojon P, Oberholzer JP, Meyer JM, Belser UC. Polymerization shrinkage of index and pattern acrylic resins. J Prosthet Dent. 1990;64(6):684-688. 19. Mah P, Reeves TE, McDavid WD. Deriving Hounsfield units using grey levels in cone beam computed tomography. Dentomaxillofac Radiol. 2010;39(6):323-335.

Volume 7 Number 3 Implant practice 37

CONTINUING EDUCATION

Figure 17: 3D-printed model of the maxillary arch and computerized surgical guide for the patient illustrated in Figure 16

CE CREDITS

IMPLANT PRACTICE CE Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2012 to 11/30/2016 Provider ID# 325231

REF: IP V7.3 SCHERER REF: IP V7.3 SETHI

CONTINUING EDUCATION BROUGHT TO YOU BY

FULL NAME

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 $99. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Implant Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

To provide feedback on this article and CE, please email us at education@implantpracticeus.com Legal disclaimer: 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.

TELEPHONE/FAX

Please allow 28 days for the issue of the certificates to be posted.

Do we need a radiographic guide? SCHERER

Prevention and management of maxillary sinus complications in implant dentistry SETHI

1. Narrow-diameter overdenture implants, while having an easy and predictable surgical protocol, often are placed without regard to restorative goals because of _______. a. the difficulty b. added expense of fabricating a radiographic guide c. prosthetic space insufficiency d. both a and b 2. Proper positioning of the narrow-diameter implant body is critical to the success of ______. a. the surgical procedure b. initial and definitive prosthetics c. long-term maintenance of both the implant and restoration d. all of the above 3. This (three-dimensional) restorative space is bound by the proposed ____. a. occlusal plane b. denture-bearing tissues of the edentulous ridge c. oro-facial tissues d. all of the above 4. The space is also controlled by the patient’s ______, which is the region balanced by the inward force of lips and cheeks and that of the outward force of the tongue. a. oral commissure b. velum palatinum c. neutral zone d. stratified squamous non-keratinized epithelium 5. Proper control of this balance is largely dependent upon the _____. a. barium sulfate mixed with acrylic resin replica b. buccolingual position of the teeth c. denture base contour d. both b and c

38 Implant practice

6. ______ allows proper visualization of critical anatomical structures and provides a superior amount of information. a. two-dimensional film X-rays b. CBCT c. intraoral photographs d. visual examination 7. Radiographic guides can reliably act as _____ indicating incisal edge position, buccolingual position aides, and denture base contour. a. a shade guide b. acrylic resin replica c. tooth or restoration outline markers d. none of the above 8. Even after guide fabrication and adjustments in the mouth, as well as considering that acrylic resin has a shrinkage of _____, there is a possibility of the radiographic guide not adequately fitting the soft tissues. a. up to 21% b. 25%-30% c. 40%-45% d. 65% 9. The ______ scale is a relative measurement of the radiodensity of an object within a CT scan, indirectly providing amounts of gray within an image. a. Röntgen radiation b. Hounsfield unit (HU) c. nanometer d. Klein–Nishina 10. Typical radiographic techniques ____ visualization of soft tissue contours separate from acrylic denture resin. a. permit b. do not permit c. are excellent for d. have no effect on

1. ________ is one of the most predictable sites for augmentation. a. The maxillary sinus b. The maxillary incisor area c. The maxillary cuspid area d. The mandibular arch 2. The creation of bone under the sinus lining requires the sinus lining ____. a. to be excised b. to be elevated without perforation c. to be surgically augmented d. to be treated with topical steroids for several weeks 3. The surrounding walls of the maxillary sinus must have osteogenic potential, which is commonly assumed to exist when there is an excess of _____ of bone thickness. a. 1 mm b. 2 mm c. 3 mm d. 4 mm 4. In addition to a proper medical history, it is appropriate to take a history of _____. a. sinus disease b. predisposition to colds and sinusitis c. a history of any operations that might have been carried out d. all of the above 5. _______ can, therefore, guide the surgeon in avoiding potential complications. a. Proper preoperative imaging b. Informing the patient of the risks c. Premedicating every patient d. Placing a space maintainer

6. A small perforation (2-5 mm) can be managed by using ______ to prevent displacement of any particulate material into the sinus cavity. a. extra sutures b. direct pressure c. A collagen membrane d. An allograft 7. A large tear (greater than 10 mm) is best managed by _____. a. a collagen membrane b. removing particulate material c. aborting the procedure d. flattening the elevated lining 8. Hemorrhage can be controlled by ______. a. metronidazole b. pressure c. the use of a local anesthetic with a vasoconstrictor d. both b and c 9. Prevention of infection using _____is the desired way forward. a. proper aseptic technique b. antibiotic prophylaxis c. a vasoconstrictor d. both a and b 10. (In the case of communication between the oral cavity and the sinus) ______may be used to close the communication. a. Connective tissue underlay b. A rotational connective tissue pedicle flap from the palate c. The traditional buccal advancement flap d. All of the above

Volume 7 Number 3

Drs. Ashok Sethi and Thomas Kaus summarize some of the complications that can arise when tackling the advanced techniques required by a sinus lift

he maxillary sinus is one of the most predictable sites for augmentation (Tatum, 1986; Tatum, et al., 1993). It is essentially a cavity within bone. The creation of bone under the sinus lining requires the sinus lining to be elevated without perforation (Sethi and Kaus, 2005; 2012). This produces a cavity within bone, which can be repaired by a normal healing process similar to the one that takes place following extraction. A space maintainer, preferably one that resorbs over a desired period of time, greatly facilitates this process and prevents the elevated sinus lining from relapsing. The surrounding walls of the maxillary sinus must have osteogenic potential, which is commonly assumed to exist when there is an excess of 2 mm of bone thickness. Otherwise, autogenous bone may be indicated (Figures 1-4). The anatomical location of the maxillary sinus and its proximity to vital structures reinforce the need for careful and methodical planning for the prevention of complications.

Educational aims and objectives This clinical article aims to highlight some of the complications that can occur when augmenting the maxillary sinus region for implant treatment. Expected outcomes Implant Practice US subscribers can answer the CE questions on page 38 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • See some preoperative protocols to follow. • Learn some techniques for managing common complications. • Understand the impact that failing to identify and manage the risks can have on the patient.

Figure 1: Intraoperative view of lateral wall window into the maxillary sinus on inhalation. The window has moved inward indicating an intact lining

Figure 2: Intraoperative view of lateral wall window into the maxillary sinus on exhalation. The window has moved outward indicating an intact lining

Thomas Kaus, Dr Med Dent (FRG), Dip Imp Dent (RCS), is a former assistant professor at the Universities of Toronto and TŸbingen. He currently works in private practice in both Canada and in the UK. Thomas has extensive teaching experience in implant dentistry and has implemented postgraduate courses on implantology in Germany.

Figure 3: Clinical view of the sinus on completion of placing a xenograft

Figure 4: DPT radiograph demonstrating well-contained graft material within the sinus. This indicates a nonperforated lining

Drs. Sethi and Kaus are joint authors of the book Practical Implant Dentistry, which is now into its second edition, and has been translated into 10 different languages. Together with Dr. Naresh Sharma, they are the founders of PID Academy, providing comprehensive practical courses in a custom-built training and surgical facility in Yorkshire, England, which includes hands-on surgical experiences.

This article will identify some of the complications that can occur with this process, provide protocols for avoiding these complications, and demonstrate some techniques for managing them. The aim is to improve the predictability

of this technique, which is essential for the management of the posterior maxilla where the sinuses have enlarged, leaving insufficient bone for the placement of implants (Aghaloo and Moy, 2007; Lee, et al., 2010).

Ashok Sethi, BDS, DGDP (UK), MGDS RCS (Eng), DUI (Lille) FFGDP (UK), is a registered specialist in oral surgery and in prosthodontics. His practice is totally dedicated to implants. A pioneer in surgical and restorative implant dentistry for more than 30 years, he is a founding member and past president of the Association of Dental Implantology (ADI) and has been elected by it as an honorary life member.

Volume 7 Number 3 Implant practice 39

CONTINUING EDUCATION

Prevention and management of maxillary sinus complications in implant dentistry

CONTINUING EDUCATION Adequate training Any clinician undertaking sinus graft surgery must be adequately trained and recognize the risks associated with this form of surgery. It is also appropriate for the clinician to be confident about managing any complications that may occur. Training should follow the normal accepted protocol of observation, treatment under supervision, and finally unsupervised treatment of patients once the appropriate skills have been acquired.

that may result from some of the anatomical variations that have been previously listed (Stern and Green, 2012). The presence of pathology can be detected and addressed before the surgery (Lee, et al., 2010).

can be made. Careful surgery using suitable instruments will minimize the risks of perforation or tear of the sinus lining (Hernandez-Alfaro, et al., 2008).

Intraoperative complications

The integrity of the sinus lining can be confirmed by the movement of the sinus lining in harmony with the patient’s inhalation and exhalation while breathing normally during the procedure once the

The risk of complications can be minimized by carrying out appropriate imaging and proper planning. A decision about whether or not the septum should be negotiated

Managing perforations and tears

Avoiding complications Preoperative management Complications can be avoided or minimized through proper treatment planning. This should include a thorough clinical examination, detailed history taking, and appropriate preoperative imaging.

History taking In addition to a proper medical history, it is appropriate to take a history of sinus disease, predisposition to colds and sinusitis, as well as a history of any operations that might have been carried out (Figure 5). This is useful in determining whether the patient needs an opinion of an ENT surgeon prior to treatment. Preoperative imaging Preliminary imaging using periapical radiographs and dental pantomograms (DPTs) is very informative. Three-dimensional imaging using cone beam computed tomography (CBCT) scans is considered to be essential for proper preoperative diagnostics (Neugebauer, et al., 2010) (Figure 6). The identification of several anatomical structures is vital for the safe treatment of patients. Some of these are listed here: • Lateral wall thickness • Medial and anterior extensions of the sinus (Figures 7 and 8) • Volume of the sinus • Blood vessels within the lateral wall of the sinus (Figure 10) • Thickened lining or pathology (Figure 12) • Volume of bone available • Density of bone available • Presence of septa and roots in the floor of the sinus (Figure 9) • Previous surgery (such as endoscopic surgery) to clean the sinuses, resulting in nasoantral antrostomy (Figure 5). Proper preoperative imaging (MaestreFerrin, et al., 2011) can, therefore, guide the surgeon in avoiding potential complications 40 Implant practice

Figure 5: Cross-sectional view of CBCT scan showing a nasal antrostomy in the middle meatus (red arrow) previously carried out to remove pathology from the maxillary sinus

Figures 6A-6B: CBCT scan provides excellent information in three dimensions. The SimPlant® software demonstrates the four windows that are commonly used to investigate the three-dimensional morphology. These are as follows: Figure 6A: Cross-sectional image Figure 6B: Axial view Figure 6C: A panoramic view showing a slice through the maxilla, which is 1 mm thick Figure 6D: Three-dimensional view, which is reconstructed from the data gathered

Figure 7: Cross-sectional view of the CBCT showing the medial extension of the sinus excavating well under the nasal cavity. This information is only available on a threedimensional investigation

Figure 8: Axial view of the CBCT demonstrating the excavation by the maxillary sinus beyond the canines up until the lateral and possibly central incisor regions

Figure 9: Three-dimensional view looking down into the maxillary sinus. The septa, as well as the irregularities created by the protrusion of the roots of the maxillary teeth, can be seen (same case as in Figures 6A-6D)

Figure 10: Three-dimensional view of the internal surface of maxillary sinus showing the groove created by a branch of the maxillary artery. The excavation of the maxilla by the expanding maxillary sinus has exposed the artery, which would normally lie within the body of the maxilla Volume 7 Number 3

Bleeding Bleeding from a vessel within the lateral wall of the sinus is best managed by waiting for the bleeding to cease through natural processes. Local anesthetic incorporating vasoconstrictors may be helpful in this. This may be also be assisted using an intravenous injection of Tranexamic acid to prevent the hemolysis of the clot.

Figure 11: Intraoperative view of a highly vascularized lateral wall of the maxillary sinus. Numerous minor vessels can be seen within the groove created for access to the sinus cavity. A larger vessel is visible running along the inferior border of the groove

Figure 12: Cross-sectional image of a CBCT scan showing excessive pathology, which has eliminated the entire maxillary sinus. Dense radiopaque debris can also be seen, which was identified as gutta percha and excess endodontic cement

Figure 13: The pathological tissue was removed and sent for histopathological examination. Inflammatory and multinucleated cells were seen with no signs of neo-plastic changes

Figure 14: Coronal view of a CT scan taken on prescription from an ENT surgeon demonstrating extensive inflammatory changes typical of pansinusitis affecting all the sinuses

Postoperative complications Some of the complications that may occur immediately postoperatively include the following: Hemorrhage This can be controlled by pressure and the use of a local anesthetic with a vasoconstrictor. Infection Prevention of infection using proper aseptic technique and antibiotic prophylaxis is the desired way forward. However, should an infection occur, it should be managed with antibiotics. Amoxicillin and metronidazole should be prescribed for patients who are not allergic to penicillin. A swab should be taken to identify the organism, as well as its sensitivity to the antibiotic. The antibiotic should be

Figure 15: Intraoperative view of a small perforation in the maxillary sinus lining. Such a small perforation can be managed using a collagen membrane to prevent extrusion of the graft material into the sinus (with permission from Quintessence International)

Figure 16: Intraoperative view showing two small holes drilled in the bone above the superior aspect of the window to enable this torn sinus lining to be sutured. The procedure is demonstrated in Figure 17 (with permission from Quintessence International)

changed if the organism is not sensitive to the antibiotics prescribed. Clindamycin should be considered as an alternative antibiotic for patients who are sensitive to penicillin. If the antibiotics do not clear the infection within 2 weeks, removal of the graft is indicated.

Non-conversion of graft material If the graft material does not convert, bone will fail to form as a result. This can be caused by a very thin sinus wall with no osteogenic potential (Figure 18). The first indication of this is the radiographic appearance (DPT), where no condensation of the graft is noted

Volume 7 Number 3 Implant practice 41

CONTINUING EDUCATION

sinus lining has been elevated from the floor and walls (Figures 1 and 2). â&#x20AC;˘ A small perforation (2-5 mm) can be managed by using a collagen membrane to prevent displacement of any particulate material into the sinus cavity (Figure 15) â&#x20AC;˘ A small tear (5-10 mm) is best managed by suturing the sinus lining and using the supplementary membrane to contain the particulate material within space created by the elevated lining (Figures 16 and 17) â&#x20AC;˘ A large tear (greater than 10 mm) is best managed by aborting the procedure. However, prior to closing the wound, it is better to eliminate the cause of the tear. For instance, a septum that has been difficult to negotiate and has resulted in a tear should be flattened to reduce the chances of the same problem occurring on re-entry 3 months later. It is also important to carefully document the position of the opening into the sinus, so that the overlying tissue can be incised. This then minimizes the risk of tears at the second operation.

CONTINUING EDUCATION

Figure 17: Diagram illustrating the suturing of sinus lining with a small tear to the lateral wall of the maxillary sinus wall (with permission from Quintessence International)

Figure 18: Cross-sectional view of very thin maxillary sinus with severely compromised osteogenic potential

between the radiograph taken immediately postoperatively and the one taken prior to implant insertion. At the time of implant insertion, the graft material will appear unchanged. Finally, failure of the implant will take place.

Oroantral fistula or communication Infection, or the failure of an implant, may result in communication between the oral cavity and the sinus. Closure of the fistula can be carried out using a number of techniques. However, it is essential to ensure that the sinus is not infected, and that there is no exudate. Connective tissue underlay, a rotational connective tissue pedicle flap from the palate (Figure 19), or the traditional buccal advancement flap may be used to close the communication.

Summary The avoidance of complications in this critical area is recommended. Appropriately managing the complications that can occur as part of a sinus lift procedure can make the region available for predictable augmentation procedures. But failing to identify and appropriately deal with these risks can result in harm to the patient. IP 42 Implant practice

Figure 19: Diagram demonstrating the closure of an oroantral fistula using a rotational pedicle connective tissue flap (with permission from Quintessence International)

References Aghaloo TL, Moy PK. Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? Int J Oral Maxillofac Implants. 2007;22(suppl):49-70.

Sethi A, Kaus T. Practical Implant Dentistry. Diagnostic, Surgical, Restorative and Technical Aspects of Aesthetic and Functional Harmony. London: Quintessence Publishing Co Ltd; 2005.

Hernández-Alfaro F, Torradeflot MM, Marti C. Prevalence and management of Schneiderian membrane perforations during sinus-lift procedures. Clin Oral Implants Res. 2008;19(1):91-98.

Sethi A, Kaus T. Practical Implant Dentistry. The Science and Art. London: Quintessence Publishing Co Ltd; 2012.

Lee WJ, Lee SJ, Kim HS. Analysis of location and prevalence of maxillary sinus septa. J Periodontal Implant Sci. 2010;40(2):56-60. Maestre-Ferrín L, Carrillo-García C, Galán-Gil S, Peñarrocha-Diago M, Peñarrocha-Diago M. Prevalence, location, and size of maxillary sinus septa: panoramic radiograph versus computed tomography scan. J Oral Maxillofac Surg. 2011;69(2): 507-511.

Stern A, Green J. Sinus lift procedures: an overview of current techniques. Dent Clin North Am. 2012;56(1):219-233. Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am. 1986;30:207229. Tatum OH Jr, Lebowitz MS, Tatum CA, Borgner RA. Sinus augmentation. Rationale, development, longterm results. N Y State Dent J. 1993;59(5):43-48.

Neugebauer J, Ritter L, Mischkowski RA, Dreiseidler T, Scherer P, Ketterle M, Rothamel D, Zöller JE. Evaluation of maxillary sinus anatomy by cone-beam CT prior to sinus floor elevation. Int J Oral Maxillofac Implants. 2010;25(2):258-265.

Volume 7 Number 3

PRODUCT PROFILE

HIOSSEN ET III SA Implants • Ideal conditions allow for immediate and early loading • Optimal body design allows for greater primary stability and facilitates easy path change • A number of different threads help prevent bone necrosis and reinforce fixture strength and stability • Backed by extensive research and development* • Available in a wide variety of sizes Manufactured with pure titanium metal and equipped with a sandblasted and acidetched (SA) surface, the ET III SA Implant (ET III) is HIOSSEN’s most popular implant on the market. Ideal for surgical placement in the upper or lower jaw arches, the ET III provides many benefits for both the clinician who places the implant as well as the patient who receives a well-fitted, reliable implant. The ET III is backed by extensive research and development based on a large number of implants created for the HIOSSEN line.* Providing convenient placement and initial stability, the optimal body design of the ET III features a number of different open-thread designs that help to prevent bone necrosis, reinforce fixture strength and stability, and facilitate easy path change. The corkscrew thread design provides both self-tapping and path-correcting ability while delivering smooth insertion and feel. The SA surface treatment of the ET III employs the pluri-potential capacity of osteoblastic cells to shorten bonehealing time, provide early cell response, and improve secondary attachment force and integration with the bone. In fact, ET III yields ideal conditions for immediate and early loading after 6 weeks of placement. Moreover, integrated platform switching of the ET III creates an environment for a wide range of esthetic options. The internal hex design of the ET III is available in four different diameters: 3.5, 4, 4.5, and 5 mm, and includes packaging for no-mount fixtures and pre-mounted fixtures (fixture + mount + cover screw). The ET III has two types of abutment connection specifications: the Mini Connection for the 3.5 fixture, and the Standard Connection for other diameters. Unlike the Mini Connection that must 44 Implant practice

be used with a separate abutment, the Standard Connection can be used with the same abutment for fixtures more than 4.0, regardless of the diameter. With each ET III implant, HIOSSEN provides clinicians a complete implant package. HIOSSEN offers not only the ET III implant, but an extensive choice of surgical instruments, tools, and the most advanced and thorough implant training courses possible. *Documentation available upon request

About HIOSSEN, Inc. HIOSSEN, Inc. was established in Pennsylvania in 2006 as a subsidiary of Osstem Implant. HIOSSEN produces a wide variety of implants at state-of-the-art manufacturing facilities located in Fairless Hills, Pennsylvania. The company’s quality

implants are available and exported to more than 20 different countries throughout Europe and Asia. HIOSSEN strives to improve implant quality by carefully monitoring the market and gathering feedback from leading clinicians. All ideas and opinions are analyzed with rigorous scientific tests and incorporated into the research and development process. HIOSSEN’s philosophy is to be close to customers in order to provide them the best service possible. Therefore, HIOSSEN continues to open branches in major cities across the country. Currently, HIOSSEN maintains branch offices in 10 cities including New York, Los Angeles, Chicago, Phoenix, Philadelphia, Washington D.C., Dallas, San Francisco, Atlanta, and Seattle. Moreover, HIOSSEN hosts a variety

of systematic education programs to study dental implants and educate professional dental surgeons in upgrading their expertise as implantologists. HIOSSEN has a unique and specialized training center equipped with state-of-the-art facilities, a renowned faculty, and systematic curriculum management. Currently, more than 100,000 dentists have benefited from these courses. In addition, HIOSSEN hosts an online education site. Thousands of clinical videos are posted, providing dentists the opportunity to learn from fellow clinicians. The online forum also provides a place to discuss and find better solutions for more advanced cases. HIOSSEN is constantly searching for competitive and innovative technologies. Recently, the company acquired a 3D

software company in order to make the surgical process easier and more predictable. In the future, HIOSSEN will provide an updated and accurate surgical guide program to assist its many users. In an effort to become the world’s leading dental implant provider, HIOSSEN’s never-ending commitment to customer service and technology will continue to be the foundation of the company. For more information, visit www.hiossen.com, or call 888-678-0001. IP This information HIOSSEN.

was

provided

Volume 7 Number 3

Precision. Performance. Perfection. THAT’S THE POWER OF 3.

ET III SA IMPLANT Precision • Single-pitch micro thread for reinforced fixture strength. • Open thread prevents bone necrosis. • Corkscrew thread provides powerful self-threading ability, maintains implant path and facilitates easy path change. Performance • Sand-blasted, acid-etched surface encourages osteoblastic cell development, shortens healing time and improves attachment force. Perfection • Simplified surgical sequence and intuitive taper kits provide confident placement and predictable results.

To learn more, visit www.hiossen.com or call 888.678.0001

ON THE HORIZON

Digital workflow, a guide to perfection Dr. Justin Moody discusses how digital technology creates a smoother implant process

n today’s implant dentistry, we can’t just be good; we have to strive to be perfect, especially in the esthetic zone. Digital imaging and impressions along with treatment planning software have the digital workflow refined to save time while giving the clinician the peace of mind that the placement will be as close to ideal as possible. When I first started down this dental implant path, cone beam CT was expensive and rare, digital impressions were struggling to make a single tooth crown, and the treatment planning software was nonexistent. Now, here I am today talking about how this can all be done efficiently and effectively, literally in a matter of minutes. It is so important to be able to gather all the necessary information in one visit, treatment plan the case, and gain case acceptance in one visit while scheduling the surgery in that same visit. Let me guide you through the workflow for a dental implant case in today’s digital office. The patient comes in for a consultation regarding missing teeth Nos. 8 and 10, and a cone beam 3D image is taken with my i-CAT® FLX (Imaging Sciences International). An advantage to this unit is its QuickScan+ setting that allows for a fulldentition 3D scan at a lower dose than a panoramic image. In a matter of minutes, I can open Tx STUDIO™ designed by Anatomage, treatment plan the case, and present my recommendation to the patient for case acceptance. After the patient says “yes” to treatment, I will use my 3Shape TRIOS® Color scanner to take a full arch impression. Developing a surgical guide that is tooth-borne is literally a matter of

Figure 1: Implant position via Anatomage

Figure 2: BioHorizons fully guided surgical kit that accommodates all their product line in one kit

Figure 3: Tooth-borne guide with color-coded sleeves to match the BioHorizons kit

Justin Moody, DDS, DICOI, DABOI, is a Diplomate with the American Board of Oral Implantology and with the International Congress of Oral Implantologists, Fellow and Associate Fellow of the American Academy of Implant Dentistry, Adjunct Professor at the University of Nebraska Medical College, and Founder and Director of the Rocky Mountain Dental Institute. He is an international speaker and is in private practice at The Dental Implant Center in Rapid City, South Dakota. He can be reached at justin@rockymountaindentalinstitute. com or at drjustinmoody.com.

46 Implant practice

clicks at this point using Anatomodel by Anatomage. Then I fill out the form, upload the treatment planning file from Tx STUDIO, upload the DICOM i-CAT image, upload the STL file from the digital impression, and click submit. My surgical guide is in my hands in a matter of days. BioHorizons® has developed, in my opinion, the most user-friendly, fully guided surgical kit on the market today. Seamless

integration with Anatomage for the guide and the Tapered Plus platform switched dental implant with Laser-Lok® gives me the absolute best chance for perfection both surgically and prosthetically. Today’s technology is truly time-saving through increased efficiency, making our practices more profitable and, most important, giving us the ability to provide better care for our patients — that is what is truly important. IP Volume 7 Number 3

News and views

Dentists launch peer-to-peer platform to tackle industry reform

mid findings by the Consumer Financial Protection Bureau and a Joint Congressional Staff Report, dentists are uniting to usher in better practices. Recognizing that the centralized management and financing operations of dental practices must be reformed, Dental Equities, LLC, intends to help tackle a continuous financial problem within the dental industry. According to a recent Joint Congressional Investigation led by Senators Grassley and Baucus, certain group dental clinics in corporate environments have placed control of their operations in the hands of large dental management service organizations, thereby putting profits above responsible patient care. Moreover, on December 10, 2013, the Consumer Financial Protection Bureau entered a Consent Order against a well-known industry leader in patient financing, preventing it from further deceptive enrollment practices. Executives of Dental Equities, collaborating with several leaders of

48 Implant practice

industry in their respective fields, will inform and showcase how Dental Equities intends to reshape the future of dentistry at its first annual meeting on June 21, 2014 in Newport Beach, California. This event will follow a company-sponsored continuing education symposium featuring a live global broadcast. Dental Equities was recently formed to promote a unique approach to affordable patient financing, to spread the important message of high-quality dental care, and to train dentists how to better service their patients. Dental Equities’ mission is to elevate the professionalism of younger dentists, enable dentists to remain independent, engage collaboration of fellow colleagues, and make quality dental care more affordable and accessible. The members of Dental Equities’ Board of Managers and other advisors of Dental Equities have extensive expertise and the dedication to assist Dental Equities to move forward with its vision. They believe that the challenges faced by each healthcare profession can be

overcome only by its professionals merging their clinical knowledge and business experience while taking action with the guidance of experts in law, accounting, and finance.

About Dental Equities, LLC Dental Equities, LLC, is a private equity limited liability company founded and led by Dr. Kianor Shah, its Chairman. Dental Equities, LLC provides a decentralized peer-to-peer platform where dental professionals unite administratively, academically and financially for the benefit of patients as well as dental professionals — without borders. Many of Dental Equities, LLC’s members and advisors have been engaged as professional consultants and business owners in dental practices and sophisticated finance across the United States. For more information, please visit www.DentalEquities.com. IP This information was provided by Dental Equities, LLC.

Volume 7 Number 3

14-DAY CONTINUOUS FELLOWSHIP PROGRAM IN IMPLANT DENTISTRY

San Diego, CA August 4-17, 2014 Key Educational Objectives

Hands-on Sessions:

Surgery-related topics: Surgical anatomy and physiology, patient evaluation for implant treatment, risk factors, vertical and horizontal spaces of occlusion, bone density, implant surgical placement protocols, computer guided implant placement and restoration, immediate load techniques, mini implants, bone grafting before, during and after implant placement, alveolar ridge expansion using split-cortical technique, guided bone regeneration, sinus lifting through the osteotomy site and the lateral window, block grafting, BMP-2 / ACS graft with titanium mesh. Prosthodontics-related topics: Impression techniques, restorative steps for implant crown and bridge, implant prosthodontics for the fully edentulous patients, high-water design, bar-overdenture, CAD/CAM designs, biomechanical principles, biomaterials, implant occlusion and more.

Hands-on workshops will be provided on models and pig jaws.

LIVE Surgeries:

Selected LIVE surgical procedures will be performed during the program.

Tuition:

14-Day Certificate Tuition ............ $9,900 Limited availability. Call today! Tuition includes: 112 CE units, hands-on workshop, live surgeries, two quintessence textbooks, manual and course certificate.

Faculty:

Dr. Louie Al-Faraje, Dr. James Rutkowski, Dr. Philip Kroll, Dr. Christopher Church, Renzo Casellini, CDT and more.

Easy online registration at www.implanteducation.net

or call 858.496.0574

IMPLANT INSIGHT

The importance of clinical guidelines AO Immediate Past President Dr. Stephen L. Wheeler discusses some timely information for clinicians to apply in their practices

s dental implants become more mainstream, proper training and standards are more important than ever. It’s important that specialists and general dentists involved in implant dentistry work together to represent the field in the best light possible. The Academy of Osseointegration (AO) seeks to ensure that those offering implant reconstruction to their patients have the training and background to provide excellence in their care. It is critical to follow evidence-based clinical guidelines focused on achieving the best possible patient outcomes.

AO clinical guidelines In 2008, AO published its first set of clinical guidelines focused on dental implants. The purpose of the guidelines was to establish guidance based on the provision of patient care and the results of AO’s 2006 Consensus Conference on the State of the Science on Implant Dentistry. In 2010, AO updated the guidelines to provide an update and expansion of its recommendations for safe and effective implant dentistry. The Academy’s “Guidelines for the Provision of Dental Implants and Associated Patient Care,” which were published in The International Journal of Oral & Maxillofacial Implants (JOMI), are available to download in their entirety via AO’s home page at www.osseo.org.

Highlights of AO’s guidelines include: • Training: Whether a specialist or general dentist, AO is determined to underscore the importance of adequate training in the surgical and/or prosthodontic aspects of implant dentistry. Training pathways now exist through monospecialty training programs, as well as a wide variety of courses offered through institutions both in the United States and abroad, and by private individuals and companies. Training must be comprehensive enough to not only meet legal standards of care, but also to ensure optimal patient outcomes and maintain a positive public image of implant dentistry. At minimum, clinicians who place, restore and/or maintain dental implants should be well50 Implant practice

versed in implant dentistry techniques, technologies, and best practices for basic to complex cases; diagnosis and clinical care plans; patient selection and education; surgical protocols; minimizing risk and treating complications; ethical considerations; and maintenance and long-term management. In addition, because the field of implant dentistry is always advancing and changing, clinicians must be committed to ongoing training and education. • Legal standard: The law holds that any practitioner (generalist or specialist) undertaking any surgical and/or prosthodontic procedure, particularly one deemed to be of a complex nature, should do so to the same standard of care expected of a specialist; or in the case of a specialist, to a standard equal to a reasonable body of his/her peers. In particular, the ability of a practitioner to predict, recognize, and treat complications arising from treatment is of paramount importance. • Therapeutic goal: Implant dentistry should be a restoratively driven therapy whereby the therapeutic goal determines the treatment plan and subsequent surgical placement of dental implants. Assisting in the ongoing maintenance of the remaining intraoral and perioral structures and tissues remains part of the therapeutic goal. • Pretreatment considerations: It is important to emphasize that the need for a dental implant is a prosthodontic diagnosis and the prescription of a dental implant is part of a restorative treatment plan. This will involve a number of stages, which can be distilled into the following headings: • Appropriate medical and dental history • Thorough intra- and extraoral examination • Appropriate radiographic examination and any other relevant investigations • Provision of a comprehensive report, treatment plan (including schedule), and estimate of treatment cost • Diagnostics: The following aids are recommended for use in reaching a presurgical diagnosis to assist in determining the complexity of the case

as well as the number, location, type, and angulation of the implants and abutments to be placed: • Mounted diagnostic casts • Imaging techniques • Radiographic guides and templates • Computerized planning software • The at-risk patient: Possible contraindications to implant therapy and risk factors for implant failure include smoking, diabetes, periodontal disease, osteoporosis, and certain types of radiotherapy. • Implant placement: The surgical approach should be based on the pretreatment evaluation and the type of implants and/or graft procedure to be utilized. The surgical risk should be assessed and classified according to the Surgical Classification System (scale 1 to 4) as set out in the “Parameters of Patient Care” document of the American Association of Oral and Maxillofacial Surgeons (AAOMS). • Grafting procedures: For the purposes of classification, grafting can be categorized as dentoalveolar or anatomical. • Postoperative management: It is a central requirement in all patient care documents that a patient be provided appropriate instructions for postoperative care. These instructions may be verbal, but a written, individualized instruction sheet is recommended with information on bleeding, pain control, swelling, the need for antibiotics, the use of chlorhexidine or similar mouthwashes, etc. • Prosthodontic considerations: Implant dentistry is a restoratively driven therapy, and as such, the prescription of implants will have been taken in light of all other prosthetic considerations — including an evaluation of the preexisting condition of teeth adjacent to edentulous spans, alternative methods of tooth replacement, and the condition of the soft tissues, which may be critical to the anticipated results. • Management of implant and periimplant tissues: Periodic evaluation of implants is a requisite component of patient care. The responsibility to Volume 7 Number 3

Please visit us at the AO, Booth #1027!

Own the New Piezosurgery

速

for as low as

*$276

per month!

*On Approved Credit - US Dentists only - Special 3.98% Interest Arrangement with Highland Capital Corp.

IMPLANT INSIGHT perform this evaluation falls on the providing clinician(s). In the case of a team approach, an agreement should be in place as to whether one or both members of the team (i.e., surgeon and/ or prosthodontist or general dentist) will follow the patient. • Recall appointments: The appointment should involve a careful examination of the suprastructure, the surrounding peri-implant tissues, and an assessment made of the patient’s oral hygiene. Considerations recommended by the American Academy of Periodontology (AAP) in the evaluation of implants at recall follow: • Oral hygiene status • Clinical appearance of peri-implant tissues

52 Implant practice

• Bleeding on probing and/or presence of exudate • Pocket probing depths and alveolar bone level • Radiographic appearance of implant, peri-implant bone, and alveolar bone levels relative to the implant abutment junction • Stability of prostheses and assessment of occlusal screws or cement • Assessment of veneering material for presence of fractures • Occlusal assessment • Patient comfort and function • Assessment of appropriate maintenance intervals • Outcomes assessment: The desired outcome of successful implant therapy is not only the achievement

of the therapeutic goal, but also the maintenance of a stable, functional, and esthetically acceptable tooth replacement for the patient. While AO’s guidelines provide information and recommendations, they are not intended to be all-inclusive. Clinicians also should consider recommendations set out in comparable documents offered by other specialist bodies and organizations. As with any specialty, new studies and recommendations regarding implant dentistry are always evolving. As such, AO constantly evaluates emerging research, technology and techniques to ensure its members have the most important and timely information to apply in their practices. IP

Volume 7 Number 3

DIARY

lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll

CE Events Making Successful Clinical Decisions in Anterior Esthetic and Implant Therapy Dr. Henry Salama May 8, 2014 Flower Mound, TX www.ritterdentalusa.com/en Mastering Glenoid Exposure, the Reverse Shoulder and Proximal Humerus Fractures Dr. Curtis Noel and Dr. Greg Gilot May 16, 2014 Cleveland, OH www.exac.com Implant Surgical Placement and Tissue Grafting Workshop May 16 – 17, 2014 Dallas, TX www.piezosurgery.us Place the OCO Biomedical Dual Stabilization Line of Dental Implants May 17, 2014 Kansas City, MO www.ocobiomedical.com Place the OCO Biomedical Dual Stabilization Line of Dental Implants May 31, 2014 Austin, TX www.ocobiomedical.com Advanced Implant Reconstruction Techniques Dr. Dan Cullum June 5 – 7, 2014 Coeur d’ Alene, ID www.piezosurgery.us/Default.aspx

54 Implant practice

Mastering Glenoid Exposure, the Reverse Shoulder and Proximal Humerus Fractures Dr. Curtis Noel and Dr. Greg Gilot June 6, 2014 Philadelphia, PA www.exac.com Soft Tissue Grafting Around Teeth and Implants Dr. Paul A. Fugazzotto June 6 – 7, 2014 Milton, MA www.piezosurgery.us/Default.aspx Implant Complications: Cause and Prevention Dr. Carl Misch June 21, 2014 Newport Beach, CA www.dentistrycampus.com How to Boost Case Acceptance With Patient Advance Dr. Kianor Shah June 21, 2014 Newport Beach, CA www.dentistrycampus.com Simplification and Rationalization in Implant Dentistry Dr. Charles Zahedi June 21, 2014 Newport Beach, CA www.dentistrycampus.com

Webinars Mini Dental Implants in Partial Denture Applications Dr. Raymond Choi May 14, 2014 solutions.3m.com/wps/portal/3M/en_US/3MESPE-NA/dental-professionals Sinus Elevation and Immediate Implant Placement in Severely Resorbed Maxillae by Using MP3 and a Compacting Technique Dr. Patrick Palacci www.dtstudyclub.com Bone Augmentation and Sinus Grafting Procedure from Science to Practice. Part 3 Dr. Kiril Dinov www.dtstudyclub.com Implant Dentistry: A Structured Approach to Treatment Planning of Advanced Clinical Cases Utilizing Modern Digital Technologies Dr. Roland Jung www.dtstudyclub.com Restoring Deep Caries — Bulk Fill, Liners, and Dentin Bonding Dr. David Clark solutions.3m.com/wps/portal/3M/en_US/3MESPE-NA/dental-professionals

Esthetics Implant Restoration Dr. George Freedman June 21, 2014 Newport Beach, CA www.dentistrycampus.com

Volume 7 Number 3

2014 MDI Certification and Expanded Indications Training Seminars Event Seminar Date Day 1 Certification June 12 Day 2 Expanded June 13 Day 1 Certification June 13 Day 2

Changing patients’ lives. Building doctors’ practices.

Learn how to effectively integrate 3M™ ESPE™ MDI Mini Dental Implants into your practice by attending the seminar that best meets your needs. Attend one or both days.

Expanded

June 14

Location Orlando, FL Orlando, FL Louisville, KY Louisville, KY

Day 1 Certification June 27

Austin, TX

Day 1 Certification June 27

Baltimore, MD

Day 1 Certification July 18

Hartford, CT

Day 1 Certification Aug. 1

Cleveland, OH

Day 1 Certification Aug. 8 Day 2 Expanded Aug. 9

Kansas City, MO Kansas City, MO

Day 1 Certification Aug. 15

Boise, ID

Day 1 Certification Aug. 15 Day 2 Expanded Aug. 16

San Diego, CA San Diego, CA

Day 1 Certification Sept. 12 Day 2 Expanded Sept. 13

Indianapolis, IN Indianapolis, IN

Day 1 Certification Sept. 19

Atlanta, GA

Day 1 Certification Sept. 19 Day 2 Expanded Sept. 20

Dallas, TX Dallas, TX

Day 1 Certification Sept. 19 Day 2 Expanded Sept. 20

Denver, CO Denver, CO

Day 1 Certification Sept. 26

Memphis, TN

Day 1 Certification Sept. 26

Phoenix, AZ

Day 1 Certification Oct. 10 Day 2 Expanded Oct. 11

St. Paul, MN St. Paul, MN

Day 1 Certification Oct. 17

Houston, TX

Day 1 Certification Oct. 17

Seattle, WA

Day 1 Certification Oct. 24

St. Louis, MO

For more information or to enroll today visit

3MESPE.com/ImplantSeminars

MDI Certification Seminar — 7 CE Credits DAY 1: Learn how market leading 3M ESPE MDIs can help you offer a solution to patients who may be contra-indicated for conventional implant treatment. The focus of this seminar is on the surgical placement protocol and full dentures. Includes hands-on experience. MDI Expanded Indications Training Seminar — 7 CE Credits DAY 2: Build on your knowledge from the certification course with the focus on: • Removable partial dentures, maxillary dentures and single tooth restorations • Addressing challenging cases This course is for doctors who have completed the certification course or have experience placing mini implants.

3M ESPE Customer Care: 1-800-634-2249 Certification Seminar Tuition: $595; Expanded Indications Training Seminar Tuition: $495; or Both for $995 For more information or to enroll contact 3M ESPE Customer Care. 3M and ESPE are trademarks of 3M or 3M Deutschland GmbH. Used under license in Canada. © 3M 2014. All rights reserved.

MDI

Mini Dental Implants

INDUSTRY NEWS Ritter Dental co-sponsors The DentalXP implant lecture series

Neodent announces launch in the United States

Ritter Dental USA’s Implant Division is co-sponsoring a nationwide series of dental implant lectures presented by Dr. Maurice Salama, Dr. Henry Salama, and other distinguished DentalXP “XPerts.” The next Ritter/DentalXP event will be on May 8 in Dallas, Texas. Dr. Henry Salama, will present his popular and timely lecture “Making Successful Clinical Decisions in Anterior Esthetic and Implant Therapy: Success by Design.” This 2.5 CEU course takes an interdisciplinary team approach to help restorative dentists, surgeons, orthodontists, and laboratory technicians make the right decisions when treating an esthetically-demanding patient. DentalXP is dentistry’s fastest growing online dental education website, with visitors from over 140 countries. Included in the content are online lectures, online educational videos, articles, product information, and online courses. For more information, visit www.DentalXP.com. Seating for the May 8th event is limited. You can register by calling Ritter Dental USA toll-free at 855-807-8111.

Neodent, Latin America’s leading dental implant company, made its high-quality, cost-effective dental implant system available to U.S. dental professionals at the beginning of March. Its range of products will be available through direct sales representatives in various U.S. cities, and the company’s new U.S. base/service center in Andover, Massachusetts. Neodent specializes in the design, development, and manufacture of dental implants and related prosthetic components. The U.S. expansion will be led by Anthony J. Susino, who for the past 8 years has been with Straumann and most recently held the position of Vice President and Head of Strategic Projects in North America. For more information, call Neodent USA, Inc., at 855-4128883 or visit www.neodentusa.com.

LED Dental Ltd. Announces New Brand Initiative and Logo LED Dental Ltd. announced its new brand initiative to further the company’s goal of providing advanced imaging technologies to dental and specialty practices in the United States and Canada. A wholly-owned subsidiary of LED Medical Diagnostics Inc., LED Dental announces the launch of a new product division known as “LED Imaging” to reflect the company’s movement further into the dental imaging category. This news comes shortly on the heels of the company’s recent expansions of its senior leadership team, including appointing key industry leaders Lamar Roberts and Dr. Jeffrey Brooks to the positions of president and vice president of imaging, respectively. The branding initiative will include a new logo to further unify the business under the LED Imaging name. Backed by an experienced senior leadership team, led by Dr. David Gane, the entire company is dedicated to a premium level of service and support before, during, and after products are sold. For more information, call 888-541-4614 or visit www.leddental.com.

BIOMET 3i™ completes successful Research & Technology Forum in Tokyo BIOMET 3i has just completed its successful Research & Technology Forum in Tokyo, Japan. The event, which was well-attended, featured 18 world renowned speakers from the United States, Europe, and Asia. Dr. Dennis Tarnow opened the meeting that covered topics such as sustainable esthetics, bone preservation, and treatment/diagnosis of peri-implantitis. Along with the latest in clinical outcomes and treatment, key BIOMET 3i Solutions that include the 3i T3® Implant and the BellaTek® Encode® Impression System were also highlighted. For more information about BIOMET 3i, visit www.biomet3i. com or contact the company at 800-342-5454.

56 Implant practice

Enter to Win a Free ErgoSure™ stool with DentalEZ® Group’s “#MYERGOSURE” Facebook sweepstakes DentalEZ® Group, a supplier of innovative products and services for dental health professionals worldwide, has announced its #MYERGOSURE Sweepstakes. Currently running on the DentalEZ Group Facebook page, the sweepstakes provides all participants a chance to win a free ErgoSure™ operator or assistant stool. DentalEZ Group Facebook fans can simply visit the DentalEZ Facebook page at facebook.com/dentalezgroup and click on the “#MYERGOSURE SWEEPSTAKES” tab. An online registration entry form will appear, and dental professionals will be prompted to complete the form as instructed. The sweepstakes runs from April 3, 2014 through June 30, 2014.

CAD/CAM customized abutments with Straumann® original implant connections now available to 3Shape Dental System™ users 3Shape, a global leader in 3D scanners and CAD/CAM software solutions and Straumann, a global leader in implant, restorative and regenerative dentistry, have released new software capabilities that enable users of 3Shape’s Dental System™ to design and order customized zirconia or titanium abutments with Straumann original implant connections. The two companies have worked together to integrate Straumann® CARES® libraries in 3Shape’s Dental System software, enabling dental technicians to use the 3Shape Dental System to design abutments and a range of high-quality customized prosthetics — including cobalt chromium alloy (coron®), zirconium dioxide (zerion®), and various full-contour materials. These can be ordered with an original Straumann connection from Straumann’s global production facilities. For more information about Straumann, visit www.straumann. us or www.straumann.us/connectivity, and to learn more about 3Shape, visit www.3shapedental.com.

Volume 7 Number 3

IQity™ - Simply Smarter Impression Technique • The ease of a closed-tray impression • The accuracy of an open-tray impression • The versatility to create impression at either implant-level or abutment-level