Implant Practice US - July/August 2014 Issue - Vol7.4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews July/August 2014 – Vol 7 No 4 (LODI)

Replacement of congenitally missing lateral incisors with Roxolid® SLActive® implants Dr. Robert Miller

WHEN SIZE OR BUDGET MATTERS,CHOOSE LODI

PROMOTING EXCELLENCE IN IMPLANTOLOGY

Using a narrow implant? Dr. Steve Barter

CBCT — not so incidental findings Dr. Randolph Resnik

The risks of dental implant placement in the edentulous anterior mandible Drs. Andrew Shelley and Richard Oliver

Two cases of immediate restoration of extracted maxillary anterior teeth using mini dental implants and CAD/CAM restoration Dr. Douglas Wright

Practice profile

Dr. Suheil Michael Boutros

PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!

Read more on the inside front cover

For more details, contact your preferred implant provider or ZEST Anchors at 855.868.LODI (5634) or visit www.zestanchors.com

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 ask for 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 Resorbable Blast Media (RBM) surface treatment 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).

July/August 2014 - Volume 7 Number 4

Impact of edentulism

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

Edentulism is considered a physical impairment, handicap, and a disability that impacts a patient’s health, nutritional balance, and quality of life.1 While the rate of edentulism has been declining throughout the past 3 decades, the subsequent increase in the United States and world population has resulted in an increase in the number of edentulous persons.2 The number of edentulous arches is expected to rise to 61 million in the year 2020, which represents approximately 10% of people in the U.S. having one edentulous arch or more.3 This will ultimately increase demand for implant overdenture therapy.

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 NATIONAL ACCOUNT MANAGER | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver Email: amanda@medmarkaz.com

First-choice standard of care The placement of two to four implants for retaining a complete denture is an effective treatment option with long-term successful outcomes of prostheses and implants.4 As compared to traditional complete dentures, implant overdentures have the following benefits:5-7 • Greater comfort and less pain • Enhanced chewing function, nutrition • Enhanced stability • Superior quality of life • Psychologically and emotionally superior

The implant is key, but attachment choice is critical! What do patients see every day when inserting and removing their dentures and cleaning the supragingival components? They see the portion that is holding the denture stable — the attachment! Attachment choice and its effect upon implant overdentures has been extensively studied. I use the Zest LOCATOR® because it has the lowest vertical height, enhanced long-term durability, dual retention, multiple levels of retention, and easy maintenance and interchangeability. It is unfortunate that some patients must be excluded from overdenture therapy due to a lack of sufficient bone to accommodate an implant greater than 3 mm without adjunctive treatment. Many patients refuse bone grafting, osteotomy enlargement, or ridge splitting due to the actual or perceived invasiveness of these procedures. Also, any additional procedures enhance the potential morbidity, introduce incremental risk factors, and prolong healing and treatment duration. Narrow diameter implants have been historically advocated for use in patients with inadequate bone volume and/or those who wish for minimally invasive therapy. While the onepiece ball and O-ring implant design is acceptable for certain indications, their tall prosthetic height, wear, and limited levels of retention present clinical challenges. The LOCATOR® Overdenture Implant (LODI) System provides a narrow diameter dental implant with a simple and efficient drilling protocol, proven Resorbable Blast Media (RBM) surface treatment, self-tapping design for increased primary stability, and a two-piece design that offers superior prosthetic and surgical flexibility. As a private practice Prosthodontist and an academic clinician, my patients who present with limited ridge width need a solution, one that I could feel comfortable with servicing over time in case attachment wear occurs, and one that allows me to fit the implant to the patient instead of the other way around. I have found tremendous growth of implant overdenture therapy in my clinical practice by being able to offer quality, affordable treatment using the Zest LODI System. Michael David Scherer, DMD, MS, FACP

PRODUCTION ASST./SUBSCRIPTION COORD. Jacqueline Baker Email: jbaker@medmarkaz.com

Dr. Michael Scherer is a full-time private practice prosthodontist in Sonora, California. He is currently an Assistant Clinical Professor at Loma Linda University, 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, implant dentistry, and digital technology with a special emphasis on implant overdentures. Dr. Scherer also maintains “LearnLODI” - an interactive YouTube channel on narrow diameter dental implant procedures.

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© 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 reproducedvw 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 4

REFERENCES 1.

World Health Organization. International Classification of Impairments, Disabilities and Handicaps. Geneva: World Health Organization; 1980.

Carlsson GE, Omar R. The future of complete dentures in oral rehabilitation. A critical review. J Oral Rehabil. 2010;37(2):143-156.

Douglass CW, Shih A, Ostry L. Will there be a need for complete dentures in the United States in 2020? J Prosthet Dent. 2002;87(1):5-8.

Naert I, Alsaadi G, Quirynen M. Prosthetic aspects and patient satisfaction with two-implant-retained mandibular overdentures: a 10-year randomized clinical study. Int J Prosthodont. 2004;17(4):401-410.

Awad MA, Rashid F, Feine JS, Overdenture Effectiveness Study Team Consortium. The effect of mandibular 2-implant overdentures on oral health-related quality of life: an international multicentre study. Clin Oral Implants Res. 2014;25(1):46-51.

Leles CR, Ferreira NP, Vieira AH, Campos AC, Silva ET. Factors influencing edentulous patients’ preferences for prosthodontic treatment. J Oral Rehabil. 2011;38(5):333-339.

Toman M, Toksavul S, Saracoglu A, Cura C, Hatipoglu A. Masticatory performance and mandibular movement patterns of patients with natural dentitions, complete dentures, and implant-supported overdentures. Int J Prosthodont. 2012;25(2):135-137.

Implant practice 1

INTRODUCTION

A paradigm shift in implant dentistry

TABLE OF CONTENTS

Case study

Practice profile

Dr. Suheil Michael Boutros: Dentistry from the heart

Replacement of congenitally missing lateral incisors with Roxolid® SLActive® implants Dr. Robert Miller treats a young patient with a durable esthetic restoration choice............................................. 18

Dr. Boutros’ full-time periodontics and implant surgery private practice is dedicated to helping edentulous patients restore functionality and improve confidence

Two cases of immediate restoration of extracted maxillary anterior teeth using mini dental implants and CAD/CAM restoration Dr. Douglas Wright illustrates two cases blending several techniques ....................................................... 23

Clinical 12 Single-surgery implant placement using maxillary sinus augmentation and allograft bone rings

Drs. Orcan Yüksel, Bernhard Giesenhagen, and Kris Chmielewski demonstrate a new method for reducing treatment time when augmenting the maxillary sinus ON THE COVER AlloGraft cover photo courtesy of Straumann. www.straumann.us 2 Implant practice

Volume 7 Number 4

TABLE OF CONTENTS

Implant insight

CBCT — not so incidental findings Dr. Randolph Resnik finds that 3D cone beam imaging shows incidental findings that become integral in the planning of a successful course of treatment ...................................28

Continuing education

The risks of dental implant placement in the edentulous anterior mandible Drs. Andrew Shelley and Richard Oliver examine how to prepare for the risk of hemorrhage when placing implants in the lower jaw

Continuing education A conversation on...

Product profile

Implant essentials

On the horizon

Using a narrow implant? Dr. Stephen Barter looks at clinical considerations in the use of narrow diameter implants............................36

Dental implant complications: systemic diseases and medication (part 1) Dr. Diyari Abdah offers an overview of implant complications with a look at how issues with patients’ general health can affect treatment............. 40

Understanding peri-implant diseases Dr. Michael Norton sheds some light on the fierce debate that continues to surround peri-implantitis................. 44

Research

A study on patients’ quality of life before and after implants Dr. Neil Patel outlines his findings after carrying out a study on patients’ well-being before and after they had implants placed..............................46

Straumann® Screw-Retained Abutment portfolio More than a treatment concept. A smart solution with reduced complexity...................................... 48

Digital is time-saving technology

Dr. Justin Moody discusses how efficient workflow creates efficiencies for planning and treatment...............50

Industry news ..............52 Diary .......................................56

4 Implant practice

Volume 7 Number 4

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.

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

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Restoring quality of life

PRACTICE PROFILE

Dr. Suheil Michael Boutros Dentistry from the heart What can you tell us about your background? I am a graduate of University of Detroit Mercy School of Dentistry in Detroit, Michigan, and earned my Master’s degree and specialty certificate in periodontics from the University of Minnesota School of Dentistry. I have been in private practice since 1996, with offices in Grand Blanc, Clarkston, and Flint, Michigan. In addition, I have been on the Dean’s faculty at the University of Michigan School of Dentistry in Ann Arbor, Michigan, since 2002.

The surgical suite during implant surgery at Dr. Boutros’ Grand Blanc office

Is your practice limited to implants? We offer the full scope of periodontal therapy, including regenerative therapy and periodontal plastic surgery, in addition to a strong emphasis on advanced bone grafting and dental implant surgery.

Why did you decide to focus on implantology? During my residency in the early 1990s, I witnessed the need for dental implants and the future of helping edentulous patients 6 Implant practice

restore their functionality and improve confidence. I became well trained in placing dental implants. Once I started in private practice, I continued to attend continuing education courses to further educate myself on the innovative improvements in the industry. At that time, I launched our own dental study club after seeing the need to further educate the dental professionals within our community.

How long have you been practicing, and what systems do you use? I have been in full-time private practice

limited to periodontics and implant surgery since 1996. Over the years, I have worked with several systems, but I mainly use Zimmer®, BIOMET 3i™ and a few Nobel Biocare®.

What training have you undertaken? After graduating from dental school, I completed 3 years of postgraduate studies in periodontics at the University of Minnesota where I earned a MS degree. Since I completed my residency, I have attended numerous continuing education courses, including hands-on courses. Volume 7 Number 4

PRACTICE PROFILE Now I present several hands-on courses as a faculty member at the Zimmer Institute and BIOMET Institute for Implant and Reconstructive Dentistry (IIRD). I have been involved with several implant organizations, and in addition to the American Academy of Periodontology, I am an active member of the Academy of Osseointegration and the American Academy of Implant Dentistry.

Who has inspired you? My father was a true inspiration in my life. He always encouraged me to work hard and to see every challenge as an opportunity to grow. I have carried the values he has instilled in me every day in business and my personal life. Of course, I would not be here today without the continuous support of my wife and our two children. Professionally, I value my mentors at the University of Minnesota and especially my graduate periodontology program director, Dr. James Hinrichs.

outcomes. We do a lot of volunteer work for the community and through a program called “Dentistry from the Heart.” I was able through a generous grant from BIOMET 3i to place multiple implants and restore patients’ function and esthetics.

Professionally, what are you most proud of? Recently, I was inducted as a Fellow of the Academy of Osseointegration, which is a great honor and recognition.

What do you think is unique about your practice? I am very proud of my great staff that has made our practice an elite practice. Our great relationship with our referring offices has made our office the go-to office in the

community. Also, our corporate partners, where I am a consultant for Zimmer Dental and lecturer and opinion leader for BIOMET 3i, makes our practice a progressive and a cutting-edge technology practice.

What has been your biggest challenge? Balancing between the busy professional life and family. Since I am on the faculty at the University of Michigan, I would like to find to more time to spend with the graduate students. Last, I want to continue to incorporate new technologies in our office.

What would you have become if you had not become a dentist? A physician, and more specifically, an orthopedic surgeon.

What is the most satisfying aspect of your practice? I love what I do! We treat every patient like a friend or a family member. Our patients become part of our family, and since we have a periodontal practice, we get to see long-term successful implant therapy

Zimmer Institute faculty

Dr. Boutros doing an implant consultation at his office, explaining the benefit of dental implants to a patient

The staff of Periodontal Specialists of Grand Blanc, Clarkston, and Flint, Michigan 8 Implant practice

Dr. Boutros receiving the AO Fellowship Award during the meeting in Seattle 2014. Pictured here are Dr. Stephen Wheeler, President of the AO, and Dr. Russell Nishimura, Vice President. Volume 7 Number 4

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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.

PRACTICE PROFILE What is the future of implants and dentistry?

Zimmer Implantology day as a keynote speaker in Frankfurt 2013

Definitely CAD/CAM restorations. In addition, I would say Zimmer Trabecular Metal implants. Because of their successful longterm history in orthopedics, treatment time has been reduced significantly, and made treatment possible in some of the medically compromised patients that otherwise would not be able to receive implant therapy.

What are your top tips for maintaining a successful practice? First, treat everybody the way you like to be treated. Second, maintain great communication and relationships with our referring offices and continue to grow our study club that allows us to update our referrals on the latest technologies and products.

What advice would you give to budding implantologists? BIOMET faculty at the Institute for Implant and Reconstructive Dentistry (IIRD)

Find a mentor if you are just starting out. Stay within your comfort zone, and always have an exit strategy. I can’t emphasize

enough the importance of diagnostic tools and treatment planning and taking more continuing education and hands-on courses. Last, have well-trained staff.

What are your hobbies, and what do you do in your spare time? Travel with my wife and our two children. I like to ski, swim, and boat. IP

Top 10 Favorites 1. Zimmer® Trabecular Metal™ Dental Implant 2. Immediate implant placement 3. Socket preservation 4. Ridge splitting 5. BIOMET 3i™ Bella Tek® Encode® impression and CAD/CAM restorations 6. Carestream CBCT/scan machine 7. Periodontal plastic surgery around implants 8. Family vacations 9. Lecturing both nationally and internationally 10. Seafood, especially in Italy

Dr. Boutros and his wife, Gada, in Venice, Italy 10 Implant practice

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CLINICAL

Single-surgery implant placement using maxillary sinus augmentation and allograft bone rings Drs. Orcan Yüksel, Bernhard Giesenhagen, and Kris Chmielewski demonstrate a new method for reducing treatment time when augmenting the maxillary sinus

n cases where sinus elevation treatment is indicated, a crestal bone height of less than 4 mm at the maxilla usually makes a two-stage protocol necessary. This two-stage protocol takes time for healing and the maturation of the grafting material and requires a second surgery for the implant placement. Prosthetic treatment can take place as much as 12-18 months after the first surgery. In many cases, complications — such as perforation of the Schneiderian membrane — can occur, which can delay treatment by another 3 to 6 months, or even render the whole treatment impossible. This article aims to present a new treatment option whereby the implant is fixed in the sinus with an allogenic bone ring (Botiss Biomaterials), held together with a 6-mm diameter membrane screw (Dentsply Implants). This technique has also been used by the authors in the three-dimensional reconstruction of maxillary and mandibular bone for many years with very good clinical results.

3. The implant must be correctly positioned for a successful prosthodontic rehabilitation. 4. The wound closure must be achieved using tension-free sutures. 5. No pressure should come from the prosthodontics to the soft tissue above the membrane screw: All contact should be avoided in this region during the healing phase (Figure 1).

Case report The 58-year-old woman presented, who had previously received a total removable denture,

Figure 1: Graphic shows the correct positioning in the sinus, the implant, and the membrane screw

Method The method presented here aims to combine the use of a bone block graft with implant placement in the maxillary sinus in a single-surgical procedure. The treatment protocol starts with the lateral window technique. After opening the sinus and lifting the membrane, some requirements must be met to achieve full treatment success: 1. The allograft bone ring must provide primary stability for the dental implant. The implants should preferably be 3.5-3.8 mm in diameter. 2. At the recipient site, the larger platform of the membrane screw head should be in close contact with the crestal bone to provide stability. The screw should also fix the implant rigidly within the bone ring itself.

Figure 2: Panoramic X-ray before sinus lift

Orcan Yüksel, Dr med dent, is in private practice limited to dental implants in Germany. He is also on the editorial board of the journal Quintessence. Bernhard Giesenhagen, Dr med dent, is a renowned expert on bone grafting and lectures extensively. He is in private practice limited to dental implants in Germany. Dr. Chris Chmielewski, Msc, is an international speaker in implantology, esthetic treatment, and dental photography. He runs a private practice in Poland.

Figure 3: Lateral window technique used to open the maxillary sinus 12 Implant practice

Volume 7 Number 4

CLINICAL

followed by the extraction of both premolar and molar teeth at each site and further extractions in the frontal region. These extractions had contributed to a significant amount of bone loss in the maxilla. The preoperative radiograph (Figure 2) showed that a sinus graft would be necessary in order to place the six implants required for an implant-supported denture. The treatment was defined as a two-stage protocol. After discussing the need for general anesthesia, it became evident that the idea of a single operation was very attractive to the patient, and so a single-stage procedure was agreed upon. A lateral window was opened to the sinus (Figure 3). The height of the crestal bone was considered as 1-2 mm maximum. The Schneiderian membrane was lifted without any perforation. A 3.5 mm diameter osteotomy was prepared in the crestal bone (Figure 4). From the lateral window, a bone ring (Botiss) was then placed in the sinus. A 3.5 mm x 11 mm Ankylos® implant (Dentsply Implants) was inserted from the crest into the sinus through the bone ring (which measured 10 mm in length and 7 mm in diameter) (Figures 5 to 8). The bone ring was gently held in situ with forceps as the implant was inserted.

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Figure 4: Sinus lifted and osteotomy prepared for implant insertion. Note the very thin crestal bone

Many have waited for a redefined 2D/3D multi-functional system that was more relevant to their everyday work, that was plug-and-play and that was a strong yet affordable investment for their practice. With the CS 8100 3D, that wait is over. • Versatile programs and views (from 8 cm x 9 cm to 4 cm x 4 cm) • New 4T CMOS sensor for detailed images with up to 75 μm resolution • Intuitive patient placement, fast acquisition and low dose • The new standard of care, now even more affordable

LET’S REDEFINE EXPERTISE The CS 8100 3D is just one way we redefine imaging. Discover more at carestreamdental.com © Carestream Health, Inc. 2014. 10902 OM IN AD 0714

Figure 5: The Botiss maxgraft® bone ring is processed human allograft material Volume 7 Number 4

Implant practice 13

CLINICAL

Figure 6: The bone ring measures 10 mm in height, with an exterior diameter of 7 mm and an internal diameter of 3.5 mm

Figure 7: The bone ring is placed above the osteotomy after filling the back side wall of the sinus with a xenograft

Figure 8: The implant is completely inserted into the ring, so the crestal bone and the bone ring are touching

Figure 9: A membrane screw (6 mm in diameter, with a 1 mm pin height) is used to fix the implant and bone ring to the crestal bone

Figure 10: The cavity is filled with xenograft material

Figure 11: The lateral window is covered with a collagen membrane and fixed with titanium membrane fixation pins

14 Implant practice

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CLINICAL

A cover screw was attached to the implant once it sunk to 11 mm and the insertion adaptor removed. A membrane screw with a pin height of 1 mm was then fixed into the internal threads of the cover screw (Figure 9) until the implant/allograft membrane complex was tight. The cavity was filled with a small particulated xenograft (Cerabone®, Botiss Biomaterials) (Figure 10). The lateral window was covered with a collagene membrane (Jason®, Botiss Biomaterials ) and fixed with titanium membrane-fixation pins (Ustomed®) (Figure 11). The sinus implants were uncovered after 9 months (Figure 12), and 3 weeks later — after soft tissue healing and impression taking — a removable denture prosthesis was made.

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The treatment fulfilled all the patient’s expectations, and in a short time. The followup radiograph taken after 6 months of loading shows the perfect healing of the maxilla.

Everywhere your practice needs to be 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 Figure 12A: Gingival situation 9 months after sinus lift surgery, following reopening with sulcus former

• 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. 10902 OM IN AD 0714

Figure 12B: 3 weeks later — after soft tissue healing Volume 7 Number 4

Implant practice 15

CLINICAL

Figure 13: Follow-up X-ray after 6 months of loading shows the maxilla (and the mandibular with two rings on each side) healing well and success of augmentation procedure

The treatment fulfilled all the patient’s expectations, and in a short time. The follow-up radiograph taken after 6 months of loading shows the perfect healing of the maxilla (Figure 13).

Conclusion This technique allows for successful bone augmentation with maxillary sinus floor elevation. The authors believe the shortening of the treatment time and the avoidance of a second operation makes the bone ring technique unique in this type of indication. It is possible that unsuccessful sinus lifts where the Schneidarian membrane has been perforated could be dealt with at a single visit too, by using a collagen fleece in the sinus and bone rings without particulate material.

Allogenic graft material Autologous bone, representing the current “gold standard,” has certain limitations, with the availability of sufficient quantities of autologous bone from intraoral donor sites being restricted. The recent progress in the field of maxillofacial surgery and oral implantology means the need for a predictable and convenient bone grafting material has become increasingly essential. Although allografts are known to provide a well-established platform for inducing significant osseous regeneration, allogeneic bone tissue appears an adequate alternative. Approximately 40,000 U.S. citizens annually 16 Implant practice

This technique allows for successful bone augmentation with maxillary sinus floor elevation. The authors believe the shortening of the treatment time and the avoidance of a second operation makes the bone ring technique unique in this type of indication.

receive allogeneic grafts in the maxillomandibular region.

maxgraft® allograft maxgraft® is exclusively produced from the bone tissue of German, Swiss, and Austrian donors. All pure cancellous bone regeneration material (blocks and granules) originating from living donors are procured from certified procurement centers. All

donations from living donors are based on written consent from the patient and highly selective exclusion criteria. Certain risk factors for infectious diseases and internal diseases, as well as current or previous malignancies, are strictly excluded. Blood samples for serological testing are taken during the explantation of the donor bone tissue, which derives from femoral heads during total hip replacement. IP

REFERENCES 1. Dragoo MR, Irwin RK. A method of procuring cancellous iliac bone utilizing a trephine needle. J Periodontol. 1972;43(2):82-87. 2. Hiatt WH, Schallhorn RG. Intraoral transplants of cancellous bone and marrow in periodontal lesions. J Periodontol. 1973;44(4): 194-208. 3. Köndell PA, Mattsson T, Astrand P. Immunological responses to maxillary on-lay allogeneic bone grafts. Clin Oral Implants Res. 1996;7(4): 373-377. 4. Schallhorn RG, Hiatt WH. Human allografts of iliac cancellous bone and marrow in periodontal osseous defects. II. Clinical observations. J Periodontol. 1972;43(2): 67-81.

Volume 7 Number 4

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CASE STUDY

Replacement of congenitally missing lateral incisors with Roxolid® SLActive® implants Dr. Robert Miller treats a young patient with a durable esthetic restoration choice

19-year-old female presented for the replacement of her congenitally missing lateral incisors (Figures 1 and 2). She had recently completed orthodontic therapy, which included interceptive orthodontics in the mixed dentition stage to create appropriate space for lateral incisors. We were comfortable with placing implants at this stage as “serial cephs” depicted that jaw development has been completed (Figure 3). A CT scan was exposed to ensure adequate ridge dimension and proper root alignment for implant placement (Figures 4 and 5). Upon consultation with her restorative dentist, it was decided that the restoration of choice would be all ceramic with custommilled zirconia abutments. We chose to use two Straumann® Narrow CrossFit® Roxolid® Bone Level fixtures (Figure 6). The bone level implant is designed to provide the restorative dentist with the most restorative options, including custom-milled ceramic abutment that averts metal collar exposure or the potential for a dark hue at the gingival margin in patients with a thin tissue biotype. The Roxolid implant with its increased tensile strength, when compared to titanium, enables the surgeon to place a smaller diameter fixture that maximizes the amount of native bone buccal and palatal (lingual) to the fixture body.1 The SLActive hydrophilic surface was designed to reduce time needed for osseointegration, thereby speeding up healing times and increasing the confidence of the clinicians.2,3

Dr. Robert J. Miller, DMD, received his dental degree from Boston University Goldman School of Dentistry in 1984 and his Certificate for Advanced Graduate Study in periodontics from Boston University in 1986. Dr. Miller has maintained a private periodontal practice, Miller and Korn Periodontics and Implant Surgery, in Plantation, Florida, for over 27 years. He is an active member of a variety of different dental societies from the ADA to the AAP, and is a Fellow of the International Team for Implantology (ITI). He has a courtesy appointment with the Community Based division program at the University of Florida Hialeah Dental Clinic.

18 Implant practice

Figure 1: Preoperative view of 19-year-old female patient with congenitally missing lateral incisors

Figure 2: Panorex radiograph of depicting congenitally missing lateral incisors

The CT scan depicted an issue with the level of the osseous crest with respect to the adjacent teeth. Appropriate threedimensional placement for this patient necessitated the removal of 3–4 mm of (vertical) bone to accommodate the restorative abutment and allow for the development of the emergence profile of the restorations. This

additional room gives the laboratory technician adequate space for an esthetic restoration with appropriate dimensions and contours. Full thickness buccal and palatal flap elevation was necessary to visualize the osseous crest (Figure 7). Reduction of the ridge was accomplished with a round diamond bur and high-speed hand piece. Volume 7 Number 4

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CASE STUDY Fig. 5

Fig. 6

Figure 5: Cross section of lateral incisor position depicting appropriate buccal/lingual dimension for dental implant placement Figure 6: Cross section of appropriate implant placement that demonstrates the need for a custom-milled implant abutment due to angulation of the premaxilla Figure 3: Serial cephalometric radiographs confirming the cessation of jaw growth and ability to place dental implants

Figure 4: CT scan and volume rendering depicting proper root alignment for the placement of dental implants in the lateral incisor positions

Figure 7: Full thickness flap elevation illustrating the need for crestal reduction prior to the placement of dental implants

Figure 8: Implant placement in position No. 10 with fixture carrier after ridge reduction

Figure 9: Implant placement in position No. 7 with fixture carrier after ridge reduction

Figure 10: Healing abutments in place and suturing

Figure 11: Transitional appliance used to replace congenitally missing lateral incisors

Figure 12: Temporary acrylic removable prosthesis was adjusted and worn during osseointegration

Figure 14: Healing 3 months

Optimal positioning of the fixtures is 3 mm apical to the adjacent cemento-enamel junctions (Figures 8 and 9). Two 3.3 mm x 12 mm Straumann Roxolid NC Bone Level implants were placed with Straumann 3.6 mm x 3.5 mm healing abutments (Figure 10). The Hawley orthodontic retainer was adjusted and used as a provisional during the osseointegration phase (Figures 11 and 12). Healing was uneventful and was referred for restoration after 3 months of hard and soft tissue maturation (Figures 13 and 14). As planned, the final restoration was an all

Figure 13: Healing 1 week 20 Implant practice

Volume 7 Number 4

More than solid – Roxolid®.

Reducing invasiveness.

Patients today want their smile back fast with the least amount of complexity. Isn’t it important that your dental implant supplier provide solutions that align with the needs of your patients? With outstanding mechanical and hydrophilic properties, Roxolid® SLActive® Implants may allow you to use smaller diameters and reduce the need for complex GBR procedures. To learn more contact your Straumann Territory Manager or visit www.straumann.us/roxolid

CASE STUDY

Figure 15: Final prosthesis position No. 7 (1 year post-op)

Figure 17: Final prosthesis position No. 7 and No. 10 (1 year post-op)

Figure 16: Final prosthesis position No. 10 (1 year post-op)

ceramic restoration with a custom-milled zirconia abutment (Figures 15–18). The patient was ecstatic with her restorations. Having congenitally missing teeth has plagued her throughout her life. She was extremely self-conscious having to wear a removable appliance which she believed inhibited her ability to develop relationships. Upon completion, she had renewed self-confidence and reports that she is now socially active and is pursuing a career in sales. She believes that this has been a lifealtering event. Placement of dental implants for young adults has an added responsibility because the fact that the implant has to last their lifetime, which according to statistics is greater than 65 years. It is incumbent upon clinicians to choose a system that is based on sound clinical testing and will withstand the test of time. It is also important to choose a company that will be in business to stand by their products. The fabrication of anterior restorations that are indistinguishable from the existing teeth is one of the most difficult tasks that a dentist can undertake. Treatment planning from the restoration back includes having to choose the appropriate implant as well as the company. The Straumann Roxolid Bone Level implant fit the criteria that were necessary to ensure an esthetic restoration with the longevity necessary for this young adult. IP Thank you to Dr. Peter Wohlgemuth for the orthodontic therapy and Dr. Arthur Stanger for the prosthetics.

REFERENCES 1. Data on file. 2. From 6–8 weeks to 3–4 weeks compared to SLA®.

Figure 18: Final periapical radiographs No. 7 and No. 10 (1 year post-op) 22 Implant practice

3. Straumann SLActive® Scientific Overview (USLIT196).

Volume 7 Number 4

Dr. Douglas Wright illustrates two cases blending several techniques

oss of an anterior tooth always causes concern for the patient and the restorative dentist. Often, implant placement requires bone grafting procedures followed by lengthy healing between surgeries.1 Mini dental implants offer patients some distinct advantages to conventional implant therapy. They have been reviewed and found to be a successful way to restore missing single teeth as well as supports for removable prosthetics.2 The following cases are presented to provide an alternative treatment plan for consideration when facing the loss of an anterior tooth.

Case 1 A.M. is an 80-year-old man with controlled high blood pressure. He has crown restorations on all his anterior maxillary teeth. Tooth No. 7 had a history of endodontic treatment followed by two apicoectomies over the years. Finally, the core failed, and his crown came off. Because of the relatively short root length and endodontic treatment with a silver point, implant restoration was considered (Figure 1). A CBCT examination revealed over 20 mm of bone apical to tooth No. 7. A.M. was presented with the following treatment plan: 1. Atraumatic extraction of tooth No. 7 2. Placement of an MDL® implant 2.5 x 18 mm (Intra-Lock® International) 3. Immediate scan of the implant and restoration with CEREC® crown. A.M.’s health history was again reviewed. A review of the dental literature shows increased chances for implant failure in patients who smoke, have diabetes, and who have parafunction. In this author’s experience, patients who have kidney disease that includes metabolic bone disease should not be considered for implant treatment. A CBCT should reveal 2 mm of bone in all directions. Volume 7 Number 4

Figure 1: Center maxillary pretreatment X-ray of tooth No. 7

Figure 2: Postoperative X-ray (6 months post-op)

Anesthesia was provided using 1.8 ml of 4% Articaine with 1:200,000 epinephrine. The implant was placed through the bone at the apex of the extracted root. An IntraLock® 2.5 x 18 mm implant was immediately placed. Topical epinephrine provided via cotton pellets impregnated with epinephrine (EpiDri® Pellets by Pascal International) was used to stop bleeding. For inventory control purposes, our office only stocks the ball-type removable implants. To help CEREC take a better image, a very small amount of flowable composite resin was placed on the occlusal portion of the implant. This creates less

detail for CEREC and provides for an easier fit of the final crown. Once the images were loaded into CEREC, then crown fabrication could move forward. While the margin of the restoration can be placed on the neck of the implant, the apical portion of the crown should be sized to fit into the space created by the extracted tooth. Because the implant is placed through the apex area of an extracted tooth, the final restoration will have a less than ideal crown-to-root ratio. Every effort needs to be made to keep occlusal forces on this restoration at an absolute minimum to allow for complete healing.

Douglas Wright, DDS, graduated from the University of Maryland in 1985. After serving 4 years in the United States Navy, Dr. Wright operated a private practice in Maryland. After 10 years in practice, he joined the staff at the Washington DC Veterans Administration Medical Center. Now, Dr. Wright is in private practice in Harrisonburg, Virginia. He is married to Karen Wright and has three children; Nicholas, Julia, and Rosemary.

Implant practice 23

CASE STUDY

Two cases of immediate restoration of extracted maxillary anterior teeth using mini dental implants and CAD/CAM restoration

CASE STUDY at the site of the crown/post-and-core failure. Anesthesia was provided using Articaine and epinephrine. Tooth No. 8 was atraumatically extracted (Figure 8), and an Intra-Lock 2.5 x 18 mm implant was placed into the bone apical to tooth No. 8 (Figure 9). Placement of this implant was completed with very little torque generated. Because the torque during placement was so small, the 2.5 x 18 mm implant was backed out, and an Intra-Lock MILO™ 3.0 x 17 mm implant was placed at the same site. Torque was immediately improved. Again, bleeding was controlled with epinephrine pellets, and the area was scanned. The restoration was designed to fill in the site of the extraction (Figures 10, 11, and 12). IPS e.max (Ivoclar Vivadent) was used as the restorative material. Both restorations were cemented with SEcure® resin cement by Parkell.

Figure 3: Postoperative photo of tooth No. 7

Photos taken months after placement show gingival healing around the tooth mimicking a normal gingival contour (Figure 3).

Case 2 J.B. is an 88-year-old woman with a history of crown treatment to her anterior maxillary teeth (Figure 4). Over the years, she has had implants placed when she lost teeth. She has had good experience as a dental implant patient in the past (Figure 5). Tooth No. 8 had a history of endodontic treatment with repeated failure of post and core causing secondary root decay (Figure 6). Treatment options were discussed. J.B.

was adamant that she wanted immediate placement of a fixed restoration, and she did not want to wear an interim partial denture. J.B.’s health history was reviewed. She did not have a history of bisphosphonate use, but she did take medication for hypertension and has an artificial knee. She was given amoxicillin as an antibiotic prophylaxis prior to her visit for surgery. She reported a history of smoking, but she quit smoking in 1975. On the day of treatment, a small fluctuant lesion was noted at the distal buccal portion of the gingival crest (Figure 7). Investigation of this area after anesthesia revealed that this abscess was probably from food impaction

Figure 7: Small fluctuant lesion

Figure 8: Extraction Figure 4: Pretreatment photo

Figure 5: CBCT scan 24 Implant practice

Figure 6: Pretreatment X-ray of tooth No. 9

Figure 9: An Intra-Lock 2.5 x 18 mm implant was placed into the bone apical to tooth No. 8 Volume 7 Number 4

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CASE STUDY

Figure 10: CEREC constructed restoration

Figure 11: CEREC constructed restoration

Figure 12: IPS e.max CEREC-created restoration try-in

Figure 14: 1 week post-op of tooth No. 9

Photographs provided by Daniel Emmerman of DBE Photography.

Figure 13: Light curing the final restoration

Photographs of both patients show excellent healing of the surgical sites with implant-retained crowns. Some authors refer to these restorations as “crontics” because they have the qualities of both crowns and oval-shaped pontics. Numerous authors have noted that resin cement trapped under the gum can cause implant failure.3 Because of this, great care is taken to make certain only enough cement is used to coat the implant and fill the space in the IPS e.max restoration. Super Floss® (Oral-B®) is used at delivery before light curing to make absolutely sure that no excess cement remains outside the crown. In the evaluation stage of these cases, it is surprising to see how much bone is available apical to the maxillary incisors. In both of these cases, implants longer than 17 or 18 mm could have been used. Perhaps implant manufacturers can take a look at this and consider making implants that are 21 or even 25 mm in length. Having a greater amount of implant to engage bone would improve the crown-to-root ration in these cases. There is some indication in the literature that insertion torque between 30 and 50 Ncm at placement provides adequate stability for immediate use of the implant.4 In case No. 2, it was evident that there was insufficient torque to insure successful placement of the implant. I confirmed this with a hand-held torque wrench. I set the 26 Implant practice

torque on the wrench at 20 Ncm and had no trouble advancing the implant, meaning the torque needed to advance the implant was less than 20 Ncm. For this reason, I selected a wider implant to achieve greater torque during placement and greater stability. Here are rules to follow for the successful restoration of an immediate implant after extraction: 1. Get a complete health history. Review it at least twice. Make certain there is nothing that can prevent normal healing. 2. Use a CBCT scan. Because of the triangular shape of the bone in this region of the skull, it is extremely difficult to see exactly how much bone is

available for implant placement using a two-dimensional panoramic or periapical X-ray. 3. Keep occlusal forces light on the final restoration to allow for osseous integration. 4. Keep a complete inventory of implants on hand in case the clinical situation dictates a change in size of the implant. Mini dental implants are fulfilling the demands of our patients for an immediate, cost-effective means to provide dental care. The preceding two cases are presented to highlight an innovative way to blend several accepted techniques to provide immediate and lasting restorations to our patients. IP

REFERENCES 1. Shapoff, C. Tackling a challenging esthetic clinical situation. Implant Practice US. 2014;7(1):14-17. 2. Shatkin TE, Shatkin S, Oppenheimer BD, Oppenheimer AJ. Mini dental implants for long-term fixed and removable prosthetics: a retrospective analysis of 2514 implants placed over a five-year period. Compend Contin Educ Dent.2007;28(2):92-99. 3. Gapski R, Neugeboren N, Pomeranz AZ, Reissner MW. Endosseous implant failure influenced by crown cementation: a clinical case report. Int J Oral Maxillofac Implants. 2008;23(5):943-946. 4. Grandi T, Garuti G, Guazzi P, Tarabini L, Forabosco A. Survival and success rates of immediately and early loaded implants: 12-month results from a multicentric randomized clinical study. J Oral Implantol. 2012;38(3):239-249.

Volume 7 Number 4

IMPLANT INSIGHT

CBCT — not so incidental findings Dr. Randolph Resnik finds that 3D cone beam imaging shows incidental findings that become integral in the planning of a successful course of treatment

n an article in Implant Practice US, entitled “CBCT and Implants: the new era in treatment planning and diagnosis” (October 2013, Vol. 6, No. 5), I discussed 3D cone beam imaging (CBCT) and its clinical benefits for treatment planning and placement of dental implants. The information obtained from a scan of the patient’s 3-dimensional anatomy may significantly impact the predictability of the implant procedure. Information about anatomical landmarks, such as the inferior alveolar nerve, maxillary sinus, nasal cavity, and mandibular lingual concavities, help the implant dentist to prudently plan treatment. In addition to these vital structures, there are anatomic variants that may be visible on 3D scans that may not be evident with 2D radiography. Recent studies show that the average scan contains approximately 3.2 incidental findings per CBCT scan.1 Thus, the following case study reveals the importance of identifying and understanding “incidental” findings, which may impact future dental implant planning. A 55-year-old male presented to my office for evaluation and treatment alternatives for an ill-fitting maxillary complete denture. His medical history was unremarkable with no known allergies. My office obtained an i-CAT® FLX (Imaging Sciences International) scan for evaluation of future implants. Two incidental findings were noted: (1) Both maxillary sinuses were completely radiopaque. (2) The lateral wall of the maxillary sinus depicted a large intraosseous anastomosis.

Randolph Resnik, DMD, MDS, is a specialist in Prosthodontics and Oral Implantology. He received his dental degree from the University of Pittsburgh School of Dental Medicine. Upon his graduation from dental school, he continued his training at the University of Pittsburgh by receiving a specialty degree in Prosthodontics. Dr. Resnik then furthered his postgraduate education at the University of Pittsburgh by completing a fellowship in Oral Implantology and then receiving a Masters degree in Radiology for his research on dental implants. In addition to his practice in Pittsburgh, he teaches at two universities and is the surgical director of the world famous Misch International Implant Institute. Dr. Resnik is a paid consultant for Imaging Sciences.

28 Implant practice

The information obtained from a scan of the patient’s 3-dimensional anatomy may significantly impact the predictability of the implant procedure. Axial Image depicting completely opacified maxillary sinuses

Panoramic image depicting significant bone loss with associated opacified sinuses

Right coronal view depicting intraosseous anastamosis

Left coronal view depicting intraosseous anastamosis

The presence of bilateral radiopaque sinuses is consistent with significant maxillary sinus disease; however, the patient was completely asymptomatic. This presented the opportunity for me to refer the patient to an otolaryngologist (ENT). Besides the obvious advantages to treating sinus pathology before any implant or bone grafting procedures involving the maxillary sinus, there exists an additional benefit. By having the patient treated and cleared for

future procedures in the maxillary sinus with an ENT, the implant dentist has the ability to form a relationship with an ENT physician that will be crucial if postoperative complications develop. In this particular case, the ENT performed a procedure termed functional endoscopic sinus surgery (FESS), which entails placing an endoscope through the maxillary sinus ostium. With this treatment, the ostium is opened, and the sinus is cleaned to reduce Volume 7 Number 4

...with the i-CAT FLX, I am confident that the radiation is minimal and within the limits of ALARA. Using my system’s low-dose setting (QuickScan+), I can take a full-dentition 3D scan with a dose comparable to a 2D panoramic X-ray. As a result, it is well within a safe range if I need to repeat a scan after an implant is placed or to evaluate healing of a bone graft. In this case study, the importance of a CBCT scan is easily seen. Without a radiographic exam of this type, the patient’s pathologic maxillary sinuses may have gone

undetected, thus placing the patient at an increased morbidity for procedures in this area. Additionally, the patient was able to be treated with sinus bone grafting and future implants for a fixed maxillary prosthesis. Besides performing a quality implant procedure, CBCT is integral in helping my patients. Whether working with an ENT, or sharing my scans with a referring dentist, I would not want to work without 3D imaging, its details, and capacity for low radiation dose. This patient now trusts that I am interested in more than his teeth — his quality of life has improved, and now I am more ready to improve the quality of his dentition through implants as well. IP

REFERENCES 1. Price JB, Thaw KL, Tyndall DA, Ludlow JB, Padilla RJ. Incidental findings from cone beam computed tomography of the maxillofacial region: a descriptive retrospective study. Clin Oral Implants Res. 2012;23(11):1261-1268. 2. Ludlow JB, Walker C. Assessment of phantom dosimetry and image quality of i-CAT FLX cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2013;144(6):802-817.

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Volume 7 Number 4

Implant practice 29

IMPLANT INSIGHT

the pathology present. After a course of antibiotics, the patient was cleared for future bone grafting and dental implant treatment. The other finding, the intraosseous anastomosis, presented as a large radiolucent concavity in the lateral wall of the maxillary sinus. This particular anatomic variant is a relatively new finding in the dental implant literature, which represents an anastomosis of posterior superior artery and the infraorbital artery. So, why is this important? In a lateral sinus graft, a window is made on the lateral aspect of the maxillary sinus where this anastomosis is present. Preoperatively seeing this variant on the CBCT scan allows the clinician to prepare for possible excessive bleeding during this procedure. In some instances, bleeding from this area is very significant. Having an i-CAT scan allows me to view all areas of concern. And with the i-CAT FLX, I am confident that the radiation is minimal and within the limits of ALARA. Using my system’s low-dose setting (QuickScan+), I can take a full-dentition 3D scan with a dose comparable to a 2D panoramic X-ray.2

CONTINUING EDUCATION

hile tooth loss in industrialized countries is in decline, the population is rising at the same time — and with it, the proportion of people over the age of 65. This means that there will remain a significant number of edentulous individuals in the population. Many edentulous patients struggle to function, leading to a decline in their quality of life (Thomason, et al., 2009). This is particularly true of lower complete dentures where looseness and discomfort are common. The placement of two dental implants in the anterior mandible allows methods of additional retention to be used to support complete lower dentures (Figure 1). In the

Educational aims and objectives

The aim of this article is to inform readers of the risks of implant placement in the anterior edentulous mandible and to discuss risk management strategies.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 34 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Revisit relevant anatomy of the symphyseal region. • Understand the options available for preoperative imaging. • Be presented with an emergency protocol for severe hemorrhage.

Figures 1A and 1B: A complete lower overdenture supported by two dental implants

Andrew Shelley, BDS, MSc, MFGDP(UK), DPDS, MGDS, RCSEd, FDS, RCSEd, FFGDP(UK), Dip Rest Dent RCS Eng, is a specialist in prosthodontics and is in practice in Manchester. He is an examiner for the Royal College of Surgeons of Edinburgh and a former tutor at the University of Manchester School of Dentistry. Dr. Shelley has a special interest in imaging and is a co-author of the FGDP(UK)’s selection criteria in dental radiography. Richard Oliver, BDS, BSc, PhD, FDS, RCPS Glasg, FDS(OS), RCPS Glasg, is a specialist in oral surgery and formerly senior lecturer and consultant in oral surgery at the University of Manchester School of Dentistry. He is an examiner for the Royal College of Surgeons and Physicians of Glasgow. Dr. Oliver has a special interest in dental implant education and the treatment of challenging cases.

30 Implant practice

York and in the McGill consensus documents, implant-supported overdentures are regarded as the first choice of treatment for the edentulous mandible (Thomason, et al., 2009; Feine, et al., 2002). Nevertheless, the placement of dental implants in the edentulous anterior mandible is not without its risks (Figure 2). On the lingual surface of the anterior mandible is an anastomosis of vessels arising from both the sublingual artery — which is a branch of the lingual artery — and the submental artery, which is a branch of the facial artery. In addition there are perforating branches through the mandible from branches of the inferior alveolar artery. There is, therefore, a rich plexus of arteries just lingual to where we wish to place our

Figure 2: Placement of a dental implant in the edentulous mandible to support an overdenture

osteotomies when placing implants to support a complete lower overdenture. Alveolar resorption can leave the anterior mandible very shallow, narrow, or knifeedged, and there is often a natural lingual Volume 7 Number 4

Fig. 4

Figure 3: This cone beam CT image of the midline of an edentulous mandible demonstrates the bony canals through which communicating arteries pass Figure 4: Panoramic radiograph with 5-mm ball bearing markers

concavity. Therefore, there is a significant risk of perforation through the lingual surface. The consequences of perforation and trauma to these vessels may be dramatic and serious since a severe hemorrhage spreading from the sublingual space can cause elevation of the tongue and threaten the airway. One such case was reported in the UK in 2009 (Pigadas, et al.), but a search of the literature reveals that at least 20 other cases have been reported. Some of these cases are reported as “potentially fatal” or even “near fatal.” Many of the patients in these reports were fortunate enough to be in a situation where an emergency tracheotomy could be performed to save the patient’s life. Nevertheless, there are also anecdotal reports of fatalities. We cannot know how many cases remain unreported.

Preventing hemorrhage Naturally, implant dentists will seek to prevent this occurrence and protect their patients from a potentially life threatening situation. So what can be done? Anatomy It is, of course, important to be aware of the form of the mandible in advance. There are several sources of information. First, preoperative palpation of the area will give some indication of the size and shape of the mandible, although this is limited. At the time of surgery, it is possible to raise a periosteal flap and explore the form of the anterior mandible with, for example, a periosteal elevator. Nevertheless, in itself, this risks damage to arteries on the lingual surface. Perforating arteries can enter the symphyseal bone through lingual foramina. Such Volume 7 Number 4

foramina are most often at the midline but can be more widely distributed. The diameter of the sublingual artery at this point has been reported to be up to 1.8 mm in diameter, and anastomoses may cause a copious blood flow if damage occurs. Such exploration of the area should therefore be conducted with caution, avoiding the midline if possible. A cone beam computed tomography (CBCT) image of an edentulous mandible at the midline clearly demonstrates significant foramina, which carry perforating arterial branches (Figure 3). Some clinicians may place a metal retractor against the lingual bone to protect the soft tissues against accidental perforation of the lingual plate when preparing an osteotomy. If this is done, retraction should be no deeper than necessary to protect the soft tissues and should avoid the midline where perforating branches are common. Imaging Radiography plays an important part in the preoperative assessment of the form of the anterior edentulous mandible, and a number of views are available. A panoramic radiograph will give a twodimensional view of the mandible but little information about the crucial cross-sectional form. Use of ball bearings at the potential implant sites will give useful planning information and a reference diameter from which to take measurements (Figure 4). A panoramic view can be supplemented with a lateral cephalometric image, which will give a superimposition of the anterior mandible in cross-section. Nevertheless, a convenient alternative in the practice situation is the transymphyseal view, in which a periapical radiograph is used extraorally to give a similar

image to the lateral cephalogram at a lower effective dose (Shelley and Horner, 2008). This is illustrated in Figure 5. Three-dimensional views such as conventional and computed tomography are available, although in dentistry, the availability of CBCT has largely replaced other

Figure 5: The transymphyseal X-ray view Implant practice 31

CONTINUING EDUCATION

Fig. 3

CONTINUING EDUCATION three-dimensional views. CBCT machines are now becoming commonly available in practices and specialist imaging centers. CBCT views will give a true cross-sectional image at exactly the site of the proposed dental implant. Nevertheless, there are reasons not to take CBCT images just as there are reasons to take them. Individual machines vary, but while the effective radiation dose to the patient is something like one-tenth of that of medical CT, it is still around 10 times that of a panoramic view, and we have a professional duty to keep radiation dose as low as reasonably practical. Furthermore, while it may seem like a reasonable assumption, there is presently no evidence to support the suggestion that the availability of three-dimensional images is helpful in preventing damage to the lingual vessels (Shelley, at al., 2013). Therefore, research does not presently exist to help us choose the most appropriate balance between effective dose to the patient and availability of comprehensive images. You might expect dentists to be in broad agreement as to which views are appropriate for the preoperative imaging of the anterior edentulous mandible prior to dental implant placement. This is not the case. A recent survey of UK dentists revealed a chaotic pattern of prescription of views for this situation (Shelley, et al., 2013). Most dentists began with either a panoramic view or a CBCT view. From the results of this first view, some dentists prescribed supplementary views and some did not. The prescription pattern was similar for both a difficult and a relatively easy case. Surprisingly, a small number of dentists prescribed no radiographs at all. One reason for confusion might be that existing guidelines are conflicting. For example, the latest guidelines of the European Association of Osseointegration (EAO) were issued in 2012 and state: “If the clinical assessment of implant sites indicates that there is sufficient bone width, and the conventional radiographic examination reveals the relevant anatomical boundaries and adequate bone height and space, no additional imaging is required for implant placement.” Conversely, in the same year the American Association of Oral and Maxillofacial Radiologists (AAOMR) issued guidelines that read: “AAOMR recommends that cross-sectional imaging be used for the assessment of all dental implant sites and that CBCT is the imaging method of choice for gaining this information.” 32 Implant practice

Figure 6: Delayed presentation of hematoma in the floor of the mouth

Figure 7: Life-threatening hematoma in the floor of the mouth (image reproduced by kind permission of the British Dental Journal)

Implant length Choice of implant length may be important. In a review of the literature, Kalpidis and Setayesh (2004) report an association between the use of longer implants in the anterior edentulous mandible and the occurrence of dangerous bleeding episodes. At the same time, the use of shorter implants in mandibular bone can be very successful. In the case of implant placement in the anterior mandible, therefore, it may be sensible to reconsider the concept

of bicortical anchorage and use of long implants.

Hemorrhage in practice So what would it be like if there is trauma to a lingual vessel, and what can be done as an emergency measure? In some cases, the bleeding will be very slow, and a contained swelling may develop over 24 hours. An example is shown in Figure 6. This patient’s airway was not endangered. On the other hand, bleeding can be rapid and dramatic. In Figure 7, you can Volume 7 Number 4

Emergency protocols If you encounter a hemorrhage in the floor of the mouth, we believe a sensible protocol

Recommended reading

The following articles present detailed discussion of this issue, including a description of relevant anatomy: • Kalpidis CD, Setayesh RM. Hemorrhaging associated with endosseous implant placement in the anterior mandible: a review of the literature. J Periodontol. 2004;75(5):631-645. • Flanagan D. Important arterial supply of the mandible, control of an arterial hemorrhage, and report of a hemorrhagic incident. J Oral Implantol. 2003;29(4):165-173. • Isaacson TJ. Sublingual hematoma formation during immediate placement of mandibular endosseous implants. J Am Dent Assoc. 2004;135(2):168-172.

Conclusions

Crucially, when placing implants in the edentulous anterior mandible, a thorough understanding of anatomy and awareness of the potential for a fatal hemorrhagic episode is possibly the best protection. for the practice situation is as follows. First, take immediate action. Do not wait. Take two large gauze pads. Place one in the floor of the mouth at the site of the bleeding and the other extraorally on the other side of the floor of the mouth. Then apply pressure to the floor of the mouth by squeezing the pads together with your fingers and thumb. A mouth prop on the opposite side of the mouth may be helpful to maintain opening. Telephone the emergency services, and explain that you have a patient who has a bleed in the floor of the mouth and that the airway is endangered. Intubation, if it is appropriate, will then be carried out by those with appropriate training and experience.

In conclusion, the risk of a potentially fatal hemorrhage in the floor of the mouth following dental implant placement in the edentulous mandible seems to be under recognized. While it is unlikely that an implant practitioner will encounter this, many cases have been reported in the literature, and the potential certainly exists. The use of implants that are as long as possible in order to establish bicortical anchorage should be discouraged in the edentulous anterior mandible. Preoperative diagnostic imaging is probably important, but evidence is still emerging to help us choose the appropriate views for different cases, and current guidelines are conflicting. Until such evidence emerges, it seems sensible practice to prescribe CBCT images for challenging cases such as the more atrophic mandibles. Protection of the lingual soft tissue with a metal retractor, when preparing an osteotomy, may be a sensible precaution, but operators should be aware of the possible presence of perforating arteries, especially near the midline. It is also wise to discuss a simple emergency protocol with the team and ensure that appropriate materials are available. Crucially, when placing implants in the edentulous anterior mandible, a thorough understanding of anatomy and awareness of the potential for a fatal hemorrhagic episode is possibly the best protection. IP

REFERENCES 1. Feine JS, Carlsson GE, Awad MA, Chehade A, Duncan WJ, Gizani S, Head T, Heydecke G, Lund JP, MacEntee M, Mericske-Stern R, Mojon P, Morais JA, Naert I, Payne AG, Penrod J, Stoker GT, Tawse-Smith A, Taylor TD, Thomason JM, Thomson WM, Wismeijer D. The McGill consensus statement on overdentures. Mandibular two-implant overdentures as first choice standard of care for edentulous patients. Gerodontology. 2002;19(1):3-4. 2. Pigadas N, Simoes P,Tuffin JR. Massive sublingual haematoma following osseo-integrated implant placement in the anterior mandible. Br Dent J. 2009;206(2):67-68. 3. Shelley A, Horner K. A transymphyseal X-ray projection to assess the anterior edentulous mandible prior to implant placement. Dent Update. 2008;35(10):689-694. 4. Shelley AM, Glenny AM, Goodwin M, Brunton P, Horner K. Conventional radiography and cross-sectional imaging when planning dental implants in the anterior edentulous mandible to support an overdenture: a systematic review. Dentomaxillofac Radiol. 2014;43(2). 5. Shelley AM, Wardle L, Goodwin M, Brunton P, Horner K. A questionnaire study to investigate custom and practice of imaging methods for the anterior region of the mandible prior to dental implant placement. Dentomaxillofac Radiol. 2013;42(3). 6. Thomason JM, Feine J, Exley C, Moynihan P, Müller F, Naert I, Ellis JS, Barclay C, Butterworth C, Scott B, Lynch C, Stewardson D, Smith P, Welfare R, Hyde P, McAndrew R, Fenlon M, Barclay S, Barker D. Mandibular two implant-supported overdentures as the first choice standard of care for edentulous patients – the York Consensus Statement. Br Dent J. 2009;207(4):185-186.

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see a massive hematoma that is displacing the tongue and endangering the patient’s airway. In the hospital situation, you are likely to be surrounded by the appropriate facilities, equipment, and personnel to avoid the worst happening. But what would you do in practice? It has been suggested that the arteries can be tied off to stem the bleeding. However, few of us would feel confident to do this in an emergency situation, if at all. Furthermore, a damaged artery will retract and be more difficult to identify. Searching in the floor of the mouth for an artery to tie off in the presence of an actively expanding hematoma is only likely to worsen the situation and precipitate a deeper crisis. Even the most experienced maxillofacial surgeons are likely to regard this as unwise. In a hospital, it is most likely that the airway will be protected by intubation with a nasotracheal or orotracheal airway. However, as a hemorrhage extends to endanger the patient’s airway, intubation will become more difficult and may become impossible. Does this mean that dentists who place implants in the practice situation should be trained to intubate patients at an early stage? The remaining alternative is an emergency tracheotomy — so should that also form part of training for implant practitioners? Even the most thorough training in this regard is unlikely to be accompanied by significant practical experience. Therefore, if an implant practitioner were called upon to do this, he or she would be carrying out an unfamiliar procedure, in an emergency situation, for the first time. Further, intubation and emergency tracheotomy, in the hands of the inexperienced, have the potential to turn urgency into crisis. On balance, therefore, the authors of this article believe that it is not appropriate for most dentists to attempt intubation or tracheotomy in the practice situation in other than the most extreme of circumstances.

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The risks of dental implant placement in the edentulous anterior mandible

Using a narrow implant? BARTER

SHELLEY 1.

In the York and in the McGill consensus documents, implant-supported overdentures are regarded as ______ of treatment for the edentulous mandible. a. the first choice b. the second choice c. an unusual choice d. the worst choice Alveolar resorption can leave the anterior mandible ______, and there is often a natural lingual concavity. a. very shallow b. narrow c. knife-edged d. all of the above

The consequences of perforation and trauma to these vessels may be dramatic and serious since a severe hemorrhage spreading from the sublingual space _____. a. can cause elevation of the tongue b. can threaten the airway c. can weaken the bone d. both a and b

Perforating arteries can enter the symphyseal bone through ____. a. ovale foramen b. rotundum foramen c. lingual foramina d. lingual frenum

The diameter of the sublingual artery at this point has been reported to be up to ____ in diameter, and anastomoses may cause a copious blood flow if damage occurs. a. 1.2 mm b. 1.5 mm c. 1.8 mm d. 2.0 mm

6. _____________ image of an edentulous mandible at the midline clearly demonstrates significant foramina, which carry perforating

34 Implant practice

arterial branches. a. A cone beam computed tomography (CBCT) b. A 2D radiograph c. A tomogram d. An intraoral photograph 7.

10.

_______ will give a two-dimensional view of the mandible but little information about the crucial cross-sectional form. a. A lateral cephalometric image b. A panoramic radiograph c. A CBCT d. Transillumination Conversely, in the same year the American Association of Oral and Maxillofacial Radiologists (AAOMR) issued guidelines that read: â&#x20AC;&#x153;AAOMR recommends that crosssectional imaging be used for the assessment of all dental implant sites and that ____ is the imaging method of choice for gaining this information.â&#x20AC;? a. CBCT b. a panoramic radiograph c. a conventional 2D X-ray d. a cephalogram On balance, therefore, the authors of this article believe that it is not appropriate for most dentists to attempt _____ in the practice situation in other than the most extreme of circumstances. a. to apply pressure b. intubation c. tracheotomy d. both b and c The use of implants that are as long as possible in order to establish bicortical anchorage should be _____ in the edentulous anterior mandible. a. the first choice b. encouraged c. discouraged d. a good alternative

Reducing the diameter of a dental implant will have the effect of also reducing the thickness of the material used and a consequent reduction in the ______ of the implant body. a. tensile strength b. cost c. fixture design d. ridge lap

It follows that as implant diameter is reduced, there will also be an inevitable ______. a. reduction in the component size b. increased risk of abutment or screw failure c. need for an angled abutment d. both a and b

When considering the placement of an implant in a site with reduced gap width, the issue of _________ is vital in avoiding both biological and prosthetic/esthetic complications. a. previous in vitro and in vivo research b. maintaining critical tooth-implant distances c. load dissipation d. whether to allow acid etching

Using a narrow implant in an unsuitably small space is risky. Often, using another solution, such as _____, may provide a better outcome. a. a splinted implant b. a conventional or resin-retained bridge c. a cantilever from a regular implant d. both b and c

Another situation where a narrow implant may be useful is in _____, where a reduction in alveolar ridge height may be required in order to achieve the necessary ridge width for implant placement. a. the overdenture situation b. rapid osseointegration c. the addition of surface topography d. placement of a resin-retained bridge Reduction in height of the ridge can result in the implant emergence being in the floor of the mouth, with ________.

a. limited attached mucosa b. complications in maintenance of the prosthesis c. complications in comfort of the prosthesis d. all of the above 7.

Although there is an ongoing debate regarding the amount of buccal/labial bone necessary to provide long-term stability of the peri-implant soft tissues, most authors regard the minimum to be _____. a. .5 mm b. at least 1 mm c. 2 mm d. 3 mm

It should also not be forgotten that postextraction alveolar ridge resorption is in an apico-lingual direction, and the placement of an implant ______ will almost certainly result in an implant that is more lingually positioned than will be ideal. a. nearer to the mesial surface b. in the center of a resorbed ridge c. abutting the adjacent tooth d. with an angled abutment

However, using a narrower diameter implant may allow the center of the implant to be brought _____ and still leave the correct distance between tooth and implant for a better esthetic outcome. a. closer to the gingiva b. higher on the ridge c. closer to the tooth d. into ridge-lap position

10. If neither clinician nor patient can disrupt the biofilm that will inevitably form on an implant collar (tissue level implant) or abutment (bone level implant), then a risk of ____ will inevitably be present. a. screw fracture b. reduced ridge width c. peri-implant disease d. ridge remodeling

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Using a narrow implant? Dr. Stephen Barter looks at clinical considerations in the use of narrow diameter implants

he replacement of missing teeth with dental implants is commonly regarded as a treatment protocol supported by a strong evidence base. There is a growing trend in dental implant therapy to simplify treatment protocols, reducing the need for expensive and time-consuming procedures with higher levels of morbidity; this may be particularly so in elderly patients, or those with medical conditions where the level of surgical intervention would preferably be minimized. It has been suggested that the use of reduced diameter implants would minimize the need for bone augmentation, therefore, simplifying treatment and reducing cost. Such narrow implants may be useful in situations of reduced interdental width, allowing preservation of critical distances between adjacent implants or indeed between implants and neighboring teeth, as well as offering other potential advantages. However, there are many other considerations to be made regarding the differences between the use of regular and narrow diameter implants. It is important that such factors are weighed with individual patient- and site-specific risk factors in order to obtain predictability of long-term, patient-centered outcomes. For the purpose of this article, the factors to be assessed when considering the use of narrow diameter implants will be divided into the following: • Biomechanical • Surgical • Prosthetic • Maintenance

Biomechanical considerations The biocompatibility, physical strength, and surface chemistry of an implant material Stephen Barter, BDS, MSurgDent, RCS, specialist in oral surgery established Perlan Specialist Dental Centre in 2007. This specialist referral practice is well-known for providing expertise in dealing with cases of all levels of complexity with a philosophy of comprehensive planning, combined with empathy to the patient’s needs. Dr. Barter is a member of the Royal College of Surgeons of England; a fellow of the Straumann Clinic, University of Berne, Switzerland; a member of the Association of Dental Implantology; a member of the British Association of Oral Surgeons; a member of the European Association of Osseointegration; and a fellow of the International Team for Implantology.

36 Implant practice

Educational aims and objectives

The aim of this article is to access individual patient- and site-specific risk factors in order to obtain predictability of long-term, patient-centered outcomes for cases with narrow diameter implants.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 34 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify biomechanical considerations of implants. • Discuss surgical considerations when considering the placement of an implant in a site with reduced gap width. • Recognize prosthetic considerations and a restorative-driven approach. • Realize maintenance considerations for both the doctor and the patient. • Recognize the benefits and risks of narrow diameter implants.

will all have an impact on the successful clinical performance of the implant in real-life conditions. There is a large body of documented long-term evidence for regular diameter implants (3.75 mm to 4.1 mm diameter) used in widely varying applications with a fracture rate of approximately 0.02% (Sánchez-Peréz, et al., 2010). However, there is a less extensive availability of scientifically substantiated treatment protocols for the use of narrow diameter implants (less than 3.5 mm diameter), with most studies being observational with limited follow-up. Reducing the diameter of a dental implant will have the effect of also reducing the thickness of the material used and a consequent reduction in the tensile strength of the implant body. This has been shown to reach a level where there is a significant risk of fracture of the implant under normal occlusal loads (Allum, et al., 2008). Figure 1 shows a fractured implant, even with the titanium-aluminium-vanadium (Ti-Al-V) alloys

commonly used. This alloy is less biocompatible in cell culture studies (Thompson and Puleo, 1996), although the clinical relevance of this fact remains a topic of discussion. There will also be a reduced surface area for osseointegration, resulting in less boneto-implant contact and, therefore, a reduced surface area of bone to which loading on the implant is transferred. It has been suggested that there is consequently a higher cortical bone strain, and that this may increase the possibility of crestal bone resorption (Ding, et al., 2009), which may have esthetic and biological impact reducing the predictability of the long-term outcome. Splinting narrow implants may reduce the cortical bone strain (Jofre, et al., 2010) dependent on other factors, such as prosthesis design, implant length, and a multitude of individual patient/ site-related factors. It follows that as implant diameter is reduced, there will also be an inevitable reduction in the component size and an increased risk of abutment or screw failure.

Figure 1 Volume 7 Number 4

Figure 3

Figure 4

Figure 5

The material used in these components then becomes a more important factor, as does the accuracy of component fit (Figure 2). The importance of using the correct components for a given implant system to achieve the manufacturer’s design and performance specification cannot be understated — using a cheaper copy component carries a significant risk of complications. The use of an internal connection is common due to the favorable load dissipation, but this, of course, also comes with a reduction of the implant wall thickness, with a concomitant risk of fracture. A novel implant material is now available in the form of a titanium-zirconium alloy (Roxolid®, Straumann®). Previous in vitro and in vivo research has shown that this material is strong and very biocompatible, with osseointegration performance that equals or exceeds other implant materials (Kobayashi, et al., 1995; Gottlow, et al., 2010). The homogenous crystalline structure of the alloy allows both sandblasting and acid-etching to produce the degree of surface topography and chemical properties proven to be highly effective in producing rapid osseointegration. Human trials have demonstrated the safety and efficacy of this clinical performance Volume 7 Number 4

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Figure 2

of this implant, which appears to offer a potential for risk reduction in the previously mentioned complications. There are data including a randomized controlled clinical trial and other human studies (Al-Nawas, et al., 2011; Barter, et al., 2012).

Surgical considerations When considering the placement of an implant in a site with reduced gap width, the issue of maintaining critical tooth-implant distances is vital in avoiding both biological and prosthetic/esthetic complications. A narrow implant may facilitate a more favorable and esthetic outcome (Figures 3 and 4). The same issue may arise in an extended edentulous space in a patient with diminutive teeth, where the use of narrow diameter implants allows the proper implant-toimplant and implant-to-tooth distance (Figure 5). However, we should not forget that implants are merely one option for the replacement of missing teeth, and that other options are available. Using a narrow implant in an unsuitably small space is risky (Figure 6). Often, using another solution, such as a conventional or resin-retained bridge or a cantilever from a regular implant, may provide a better outcome (Figure 7).

Figure 6

Figure 7

Another situation where a narrow implant may be useful is in the overdenture situation, where a reduction in alveolar ridge height may be required in order to achieve the necessary ridge width for implant placement. This Implant practice 37

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Figure 8

is particularly so in the anterior mandible, where the residual ridge can frequently be knife-edged. Reduction in height of the ridge can result in the implant emergence being in the floor of the mouth, with limited attached mucosa and complications in both maintenance and comfort of the prosthesis (Figure 8). Although there is an ongoing debate regarding the amount of buccal/labial bone necessary to provide long-term stability of the peri-implant soft tissues, most authors regard the minimum to be at least 1 mm. Normal ridge remodeling after tooth extraction often means that this is not the case, with a consequent need for augmentation. It has been suggested that narrow implants may offer a solution in the avoidance of such augmentation, with benefits in terms of reduced morbidity and better health economics. However, the very choice of a narrow implant infers a reduced ridge width in such a situation, and the maintenance of a minimum 1-mm buccal bone wall remains a basic requirement; this may mean that augmentation is still required (Figure 9). It should also not be forgotten that post extraction alveolar ridge resorption is in an apico-lingual direction, and the placement of an implant in the center of a resorbed ridge will almost certainly result in an implant that is more lingually positioned than will be ideal (Figure 10). The basic tenet of restoration-driven implant placement, the correct positioning of the implant in relation to the already planned prosthesis (whatever this may be), is well established in contemporary implant therapy; it is no longer acceptable to simply place an implant in the available bone and then figure out how to restore it. The margins for error when placing implants into small edentulous spaces or into narrow bony ridges are inevitably reduced, and the need for an accurate surgical template becomes increasingly relevant.

Prosthetic considerations The use of a restoration-driven approach also requires the selection of the implant platform according to the proposed restoration: 38 Implant practice

Figure 9

Figure 10

Figure 11

Figure 12

Figure 13

a wide platform for a molar tooth and a reduced platform for a small tooth, such as a maxillary lateral incisor or lower incisors. This is not just the case in a single tooth gap, but also in extended edentulous spaces where, for example, an implant has to be placed for a small tooth next to a natural tooth. Using a regular diameter implant, but respecting the critical distance between the tooth and the implant, may result in an unfavorable emergence profile (Figure 11). However, using a narrower diameter implant may allow the center of the implant to be brought closer to the tooth and still leave the correct distance between tooth and implant for a better esthetic outcome (Figures 12 and 13).

Apart from the aforementioned risk of implant or component fracture, the most common complication of an implant placed in a more lingual position is the need for a â&#x20AC;&#x153;ridge-lapâ&#x20AC;? design in the prosthesis in order to attain the correct appearance. While this is often not challenging from the technical viewpoint, there will be a degree of cantilever that may, given the smaller component size, lead to screw loosening or fracture. Any requirement for angled abutments in order to achieve the correct prosthetic position may increase the risk of such complications (Figures 14 and 15). The availability of reduced diameter implants with internal connections means Volume 7 Number 4

Maintenance considerations The ridge-lap design, of course, brings issues of access for maintenance for both the clinician and patient. Access for probing of peri-implant bone levels may also be problematic if a normal size crown is placed on a reduced diameter implant, as the emergence profile from the fixture head can be acute. The importance of probing the peri-implant tissues as part of a regular maintenance regime is well established in the scientific literature. If probing is difficult, then access

Figure 14

Figure 15

for preventive maintenance may be impossible. If neither clinician nor patient can disrupt the biofilm that will inevitably form on an implant collar (tissue level implant) or abutment (bone level implant), then a risk of periimplant disease will inevitably be present. Conversely, the use of a reduced diameter implant to maintain the critical distances between implants and teeth or between adjacent implants can be very useful in designing and constructing a prosthesis that can be properly and easily cleaned by the patient. Mini-implants (less than 3 mm diameter) are generally of one-piece design, as to use an internal connection would render the implant wall thickness too thin. Such implants are only documented in a limited manner for the edentulous jaw. Long-term data and success rates for single tooth non-load bearing anterior region are not available. Despite the fact that thousands of such implants are documented in different studies, no reports are available on the success rate (as opposed to survival) or the long-term performance of these implants. Because such implants are of one-piece design, there is little flexibility in the future use of the implants as the patients’ age and their oral health needs change. There is no opportunity to change the abutment or remove the abutment to “put the implant to sleep” if the patient becomes unable to manage his/ her prosthesis. The author, therefore, advises caution in their use. Therefore, it can be seen that there are many considerations to be made in the planning process regarding prosthesis design that will impact on the surgical approach, need for augmentation, likely incidence of technical complications, and the maintenance of periimplant tissue health. Consequently, to omit or restrict preoperative planning and seek to “simplify” treatment by merely selecting a narrow implant is inappropriate and carries a risk of failure in one or more aspects. It is

well-known that proper preoperative planning and appropriate implant selection is important and that inadequacy or omission of this step in the treatment process is a major factor in litigation.

Conclusions When considering implants as a treatment option for our patients, we should ask for evidence that the implant has been tested and that clinical trials have been performed to support the use of the implant in the clinical situation under consideration. Albrektsson, et al., (2007) remarked on the rapid expansion of implant choices: “In many cases, commercial hype has replaced the careful scientific approach once represented by the early pioneers of osseointegration. In fact, we cannot solely blame the involved commercial bodies, since oral implants nowadays are routinely placed by clinicians who obviously do not ask for clinical results before testing these various systems, perhaps acceptable if implant changes are small but not so after substantial changes in implant design (and implant material, remark of the present authors) or recommended handling of it. Unfortunately, control bodies such as the Food and Drug Administration have placed oral implants in their category 2a where clinical pre-trials are deemed unnecessary. Europeans have followed suit in their CE marking procedure that neither asks for any clinical pre-trials before introducing novel implants on the market.” There is little evidence in peer-reviewed scientific literature that can be used to support the use of implants of less than 3.0 mm diameter; there is evidence that the use of such implants can carry an increased risk of technical and biological complications. There are now some data that show promising results for the use of implants between 3.0 mm and 3.3 mm with careful consideration of the relevant site- and patient-specific risk factors. IP

REFERENCES 1. Al-Nawas B, Brägger U, Meijer HJ, Naert I, Persson R, Perucchi A, Quirynen M, Raghoebar GM, Reichert TE, Romeo E, Santing HJ, Schimmel M, Storelli S, ten Bruggenkate C, Vandekerckhove B, Wagner W, Wismeijer D, Müller F. A double-blind randomized controlled trial (RCT) of Titanium-13Zirconium versus Titanium Grade IV small-diameter bone level implants in edentulous mandibles-results from a 1-year observation period. Clin Implant Dent Relat Res. 2012;14(6):896-904. 2. Allum SR, Tomlinson RA, Joshi R. The impact of loads on standard diameter, small diameter and mini implants: a comparative laboratory study. Clin Oral Implants Res. 2008;19(6):553-559. 3. Albrektsson T, Gottlow J, Meirelles L, Ostman PO, Rocci A, Sennerby L. Survival of NobelDirect implants: an analysis of 550 consecutively placed implants at 18 different clinical centers. Clin Implant Dent Relat Res. 2007;9(2):65-70. 4. Barter S, Stone P, Brägger U. A pilot study to evaluate the success and survival rate of titanium–zirconium implants in partially edentulous patients: results after 24 months of follow-up. Clin Oral Implants Res. 2012;23(7):873-881. 5. Ding X, Zhu XH, Liao SH, Zhang XH, Chen H. Implant-bone interface stress distribution in immediately loaded implants of different diameters: a three-dimensional finite element analysis. J Prosthodont. 2009;18(5):393-402. 6. Gottlow J, Dard M, Kjellson F, Obrecht M, Sennerby L. Evaluation of a new titanium-zirconium dental implant: a biomechanical and histological comparative study in the mini pig. Clin Implant Dent Relat Res. 2012;14(4):538-545. 7. Jofre J, Cendoya P, Munoz P. Effect of splinting mini-implants on marginal bone loss: a biomechanical model and clinical randomized study with mandibular overdentures. The Int J Oral Maxillofac Implant. 2010;25(6):1137-1144. 8. Kobayashi E, Matsumoto S, Doi H, Yoneyama T, Hamanaka H. Mechanical properties of the binary titanium-zirconium alloys and their potential for biomedical materials. J Biomed Mater Res. 1995;29(8):943-950. 9. Sánchez-Pérez A, Moya-Villaescusa MJ, Jornet-Garcia A, Gomez S. Etiology, risk factors and management of implant fractures. Med Oral Patol Oral Cir Bucal. 2010;15(3):e504 508. 10. Thompson GJ, Puleo DA. Ti-6Al-4V ion solution inhibition of osteogenic cell phenotype as a function of differentiation timecourse in vitro. Biomaterials. 1996;17(20):1949-1954.

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that there is no longer a need to consider the use of one-piece implants with the preparation of an integral abutment in the mouth, which is technically less satisfactory even though there is no risk of an abutment/screw loosening. The lack of prosthetic flexibility associated with such implant designs can cause technical and biological complications.

IMPLANT ESSENTIALS

ystemic diseases can have an immediate and long-term effect on the healing process and prognosis of dental implants, but there are some solutions to the problems they pose. The first rule is to be critical in case selection. Plan the entire case in a specific manner according to the patient’s medical history, and do not apply universal methods of treatment — different individuals may need altered treatment plans according to their individual medical needs. A well thought-out and thorough medical history form can save the clinician and the patient from dealing with complex failures later. However, some cases yield unexpected outcomes (both good and bad) despite thorough planning and execution of the treatment model. Sometimes the case starts to fail even before the surgeon is aware of it. Understanding medical conditions and pharmacological implications and interactions is critical for any implant surgeon, and this knowledge needs continuous updating. Every surgery performed, every flap raised, every implant placed, every graft done, and every case restored has to be planned and performed to make it successful and safe for the patient. This article will try to cover some of the main systemic disorders that can influence implant therapy — but further reading is strongly suggested to gain more knowledge and come closer to treating these cases more predictably.

Osteoporosis Osteoporosis is a decrease in the mineral density of normally mineralized skeletal bone. The assumption that osteoporosis is a risk Diyari Abdah, MSc, ImpDent, is a cosmetic and implant dentist in private practice in Cambridge, England. He deals with all aspects of implantology and grafting techniques, and has been actively promoting dental implants among GPs for the last 12 years through lecturing, workshops, articles, and mentoring programs. Dr. Abdah is a visiting academic at the University of Warwick on the implant MSc program and runs a successful mentoring program that emphasizes avoiding and solving problems in implant dentistry.

40 Implant practice

factor for dental implants is based on the idea that all bone types in the body are similarly affected by decreased bone metabolism. However, the literature suggests that not all bone types are affected in the same way. Of interest here is that maxilla and mandibular bone mass or density are affected by a diminished bone metabolism, which some suggest is not in line with the rest of the body. There is not enough evidence suggesting that high failure rates of dental implants or complications are related directly to osteoporosis. However, the long-term risk (greater than years) escalates when these patients are treated with bisphosphonates. Oral bisphosphonates are used to treat osteoporosis and osteopenia, and the risk of bisphosphonate-induced osteonecrosis in the jaw is lower for oral bisphosphonates compared to intravenous therapy. The process of bone remodeling is different from one area to another; cortical bone remodels differently than trabecular bone. The latter is affected more by metabolic changes, and thus is lost at an annual rate of 1.2% in pre-menopausal females (which increases dramatically after menopause), compared to 0.7% in males. One fact remains constant, and that is that osteoporotic patients heal as satisfactorily as healthy patients when they have a bone fracture. Consequently, bone healing after implant placement in these patients is comparable to healthy patients. In conclusion, osteoporotic patients can also benefit from dental implants, and they can initially heal as well as healthy patients. However, if rapid peri-implant bone loss is noted — with no sign of peri-implant disease — after the implant has been in use for some time, the occlusion should be assessed again, and a referral made to the endocrinologist for an updated bone density assessment and re-evaluation of their medication.

Cancer therapy Chemotherapy and/or radiation therapy of the head and neck for treating cancer

can often affect these areas in terms of host defense. Implant therapy is contraindicated when the patient is actively going through chemo- or radiotherapy. High-dose radiation of the head and neck can decrease vascularity of the oral bone, which continues even after the radiation has stopped. The literature suggests that the rate of implant failure is higher in irradiated bone; however, the failure rate reduces when the dose is below 45 Gy. Surgical resection of oral tumors can lead to a limited amount of bone, making it very difficult to place dental implants even after grafting procedures. These are factors that can increase the failure risks and need to be looked at thoroughly at the treatment planning stage. The literature shows that implant failure rates are usually higher in the maxilla (17.4%) compared to the mandible (4.4%). In previously irradiated bone, most implant failures occur less than 4-years post placement. In general, the average survival rate of dental implants in irradiated bone (preor post-implant placement) is approximately 76%. Implant surgeons and patients should therefore expect lower survival rates if the patient has received radiation therapy. A major negative effect of radiotherapy is osteoradionecrosis (ORN), which is usually treated with hyperbaric oxygen therapy to increase tissue vascularity and promote angiogenesis. This has led to improved implant survival rates and lower complications in some reports, although not every study shows the same positive results. No conclusive recommendation can therefore be made in this regard. In conclusion, any dental implant surgery should be delayed while the patient is under chemo- or radiotherapy. Only once the acute phase of chemotherapy has diminished, should one consider such treatment, as during chemotherapy, the risk of hemorrhage, infection, mucositis, and ulceration is much higher. Antibiotic prophylaxis is usually considered if the patient has had chemotherapy in the immediate past. The surgeon should Volume 7 Number 4

IMPLANT ESSENTIALS

always consult the patient’s oncologist before planning any implant therapy, especially when radiation therapy was performed, to establish the areas of radiation and the dose used. If the planned site for the implant placement falls outside the radiation area (i.e., a non-radiated zone of the mouth), an implant success rate comparable with a healthy patient can be predicted. A cancer patient can be a high risk for potential infections, hence why any periodontal diseases, caries, and inflammatory conditions have to be eliminated as soon as possible. Also, consultation with the patient’s oncologist should include projected patient survival, as in some cases the patient can survive for many years postcancer treatment.

Diabetes Diabetic patients with good glycemic control can, in theory, be treated like healthy patients when it comes to dental implant therapy. However, one has to be mindful of the changes that occur in the body when the patient is diabetic and bear these in mind when treating with dental implants. Diabetes, in general, is associated with micro- and macrovascular diseases, an increased risk of infection, and delayed or altered wound healing, which can lead Volume 7 Number 4

to postoperative complications. When implants are placed in a partially edentulous diabetic patient with periodontally involved dentition, the risk of complications is higher because diabetes is a key risk factor for periodontal disease. This could lead to alteration in the way the implant restorations are loaded over time, with subsequent failures as a result. The clinician has to perform a thorough periodontal examination in the rest of the dentition with a view to treating and managing any periodontal problems before implant therapy in order to minimize the risks of implant failure later on. Studies have shown that trabecular bone volume is more negatively affected by diabetes (especially type 1) than cortical bone. It is therefore more likely that osseointegration will be negatively affected in areas of predominantly cancellous bone, such as the maxilla.

Areas such as the front region of the mandible with majority cortical bone seem to be less affected. Studies in animal models have also indicated that in type 2 diabetes, there is no significant difference in osseointegration or trabecular bone around implants between diabetic and non-diabetic subjects. In type 1 diabetes, when insulin therapy is used to control the disease, bone-to-implant contact increases significantly, indicating the importance of good glycemic control for osseointegration. In conclusion, a good knowledge of the patient’s medical history and good glycemic control are critical when planning surgery on diabetic patients. Risk factors, such as infections and postoperative healing, can depend on how well or how poorly the patient is managing the disease. It is agreed that diabetic patients are at a higher risk of infection (during and after surgery). The use of prophylactic antibiotics has been universally adopted by clinicians to prevent postoperative complications. Chlorhexidine mouth rinse has also shown to increase survival rates in both diabetic and non-diabetic patients when used postoperatively. It is important that the whole dental team can recognize the signs when the patient seems unwell or about to go into hypoglycemia, as it can be a life-threatening situation. A full knowledge of patients’ medications, when they took them last, and when they last ate, is important to have before starting surgery. Implant practice 41

IMPLANT ESSENTIALS Valvular prosthesis placement Valvular heart disease does not directly affect dental implant outcome; however, there is a major need for preventing potential infective endocarditis. As the cardiac tissue can be damaged in these patients, especially valves, the risk of bacteria-induced infective endocarditis can be high. Preoperative rinses with chlorhexidine can be beneficial together with antibiotic prophylaxis. If any infection persists around dental implants in these patients, necessary steps need to be taken very quickly, such as removing the implants (the infection) under stringent conditions. Patients with valvular prosthesis placement must be vigilant with their oral hygiene to prevent infection.

Myocardial infarction Patients with cardiovascular disease (CVD) can manifest any form of these conditions: hypertension, vascular stenosis, coronary artery disease, atherosclerosis, and congestive heart failure. These, in turn, can have a negative effect on blood and oxygen supply to the surgical site, thus affecting healing. Ischemic heart disease (coronary artery disease) can manifest itself as angina or myocardial infarction (MI). This can cause severe pain in the jaws, neck, and left arm, and most deaths occur within the first 12 hours. If the patient survives MI, recovery can take months and up to a year; therefore, it is suggested that any planned implant surgery should be delayed by 6 to 12 months, as it may endanger the patient’s overall health. Some studies suggest that a very wellhealed and recovered patient with no further risk of ischemia can undergo surgery by 6 weeks after the event. This has to be in close consultation with the patient’s physician, and a thorough assessment and consent has to be put in place. Protocols to follow in these cases include the following: • Blood pressure and heart monitoring • Administration of oxygen • Preoperative pain medication • Stress management • Deep anesthesia • Premedication with nitrate In general, the two main key factors are pain control and stress management. The surgeon must have knowledge of all the patient’s medications, such as anticoagulants and thrombolytic therapies, and understand the risks and benefits of considering implant therapy against interrupting these medications.

Stroke An interruption in blood flow to the brain tissue can result in diminished levels of oxygen 42 Implant practice

and glucose levels, resulting in neuronal ischemia and neurologic symptoms, and can lead to irreversible brain tissue damage.

Understanding medical conditions and pharmacological implications and interactions is critical for any implant surgeon, and this knowledge needs continuous updating. The four different phenomena, based on their duration, have been described as follows: • Transient ischemic attack • Reversible ischemic neurologic defect • Stroke in evolution • Completed stroke In general, strokes are classified as ischemic and hemorrhagic types based on original pathogenesis. The oral manifestations of strokes include altered or loss of feeling and unilateral paralysis of the face, loss of control over oral structures, leading to increased oral secretion, gag reflex, and an inability to speak clearly. Dysphagia-related problems (trouble

swallowing) can also lead to poor fit of appliances due to weight loss. In addition, oral hygiene is negatively affected, resulting in caries, and periodontal problems. Deferring any implant therapy for the first 6 months is good practice since stroke patients have to cope with a lot during the initial phase of recovery, and their stress and lack of motivation can affect implant therapy greatly. A preoperative assessment of hemostasis is necessary in patients taking oral anticoagulants. Surgeons have widely accepted that atraumatic surgical techniques should be considered, together with topical hemostatic agents to control bleeding, rather than interrupting the anticoagulation. For international normalized ratios (INR — a measure of blood coagulation) greater than 3.5 and more complex surgery, the patient’s doctor should be consulted prior to performing any surgery. Dental surgeons should be mindful that interaction between oral anticoagulants and certain dental medications (such as metronidazole, tetracycline, and erythromycin) can increase INR. Prescribing alternatives and close monitoring of INR while on certain medication is vital for these patients. This is not an exhaustive list — the next part of this series will continue reviewing systemic diseases, but further reading is strongly advised on any of these topics. IP

REFERENCES 1. Ardekian L, Gaspar R, Peled M, Brener B, Laufer D. Does low dose aspirin therapy complicate oral surgical procedures? J Am Dent Assoc. 2000;131(3): 331-335. 2. Beikler T, Flemmig T. Implants in the medically compromised patient. Crit Rev Oral Biol Med. 2003;14(4): 305-316. 3. Casap N, Nimri S, Ziv E, Sela J, Samuni Y. Type 2 diabetes has minimal effect on osseointegration of titanium implants in Psammomys obesus. Clin Oral Implants Res. 2008;19(5): 658-664. 4. Collela G, Cannavale R, Pentenero M, Gandolpho S. Oral implants in radiated patients: a systematic review. Int J Oral Maxillofac Implants. 2007; 22(4): 616-622. 5. Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, Gewitz MH, Shulman ST, Nouri S, Newburger JW, Hutto C, Pallasch TJ, Gage TW, Levison ME, Peter G, Zuccaro G Jr. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA. 1997;277(22): 1794-1801. 6. Froum SJ, ed. Dental Implant Complications, etiology, prevention, and treatment. UK: Blackwell Publishing ;2010. 7. Heersche JN, Bellows CG, Ishida Y. The decrease in bone mass associated with age and menopause. J Prosthet Dent. 1998;79(1): 14-16. 8. Hwang D, Wang HL . Medical contraindications to implant therapy, part I: absolute contraindications. Implant Dent . 2006;15(4): 353-360. 9. Little JW, Falace DA, Miller GS, Rhodus NL, eds. Dental management of the medically compromised patient. St. Louis, MO:Mosby; 2002:417-28. 10. Madrid C, Sanz M. What impact do systemically administered bisphosphonates have on oral implant therapy? A systematic review. Clin Oral Implants Res. 2009;20(Suppl 4): 87-95. 11. Mealey BL, Ocampo GL Diabetes mellitus and periodontal disease. Periodontol. 2000; 44: 127-153. 12. Mori H, Manabe M, Kurachi Y, Nagumo M. Osseointegration of dental implants in rabbit bone with low mineral density. J Oral Maxillofac Surg. 1997; 55(4): 351-361. 13. Olson JW, Shernoff AF, Tarlow JL, Colwell JA, Scheetz JP, Bingham SF. Dental endosseous implant assessments in a type2 diabetic population: a prospective study. Int J Oral Maxillofac Implants. 2000;15(6): 811-818. 14. Purcell PM, Boyd IW. Bisphosphonates and osteonecrosis of the jaw. Med J Aust. 2005;182(8): 417-418. 15. Rice PJ, Perry RJ, Afzal Z, Stockley IH. Antibacterial prescribing and warfarin: a review. Br Dent J. 2003;194(8): 411-415. 16. Roberts HW, Mitnitsky EF. Cardiac risk stratification for postmyocardial infarction dental patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91(6): 676-681. 17. Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL. Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. J Oral Maxillofac Surg. 2004;62(5): 527-534. 18. Schoen PJ, Raghoebar GM, Bouma J, Reintsema H, Vissink A, Sterk W, Roodenburg JL. Rehabilitation of oral function in head and neck cancer patients after radiotherapy with implant-retaimed dentures: effects of hyperbaric oxygen therapy. Oral Oncol. 2007; 43(4): 379-388. 19. Whitney JD. The influence of tissue oxygen and perfusion on wound healing. AACN Clin Issues Crit Care Nurs. 1990;1(13): 578-584.

Volume 7 Number 4

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A CONVERSATION ON...

Understanding peri-implant diseases Dr. Michael Norton sheds some light on the fierce debate that continues to surround peri-implantitis

Is the current definition of periimplantitis a good place to start? It is. It’s also the most difficult place to start, because depending on which body you talk to, it’s defined differently. You could say the simplest definition is an inflammation in and around the area of a dental implant, and just leave it at that. However, other people go further and describe it by the presence of bone loss, pus, or bleeding. Of course, it may simply be that it’s a scale, and that peri-implantitis is an inflammatory disease, which at its least aggressive, presents with inflammation followed by bleeding, followed by pus, followed by all of those, plus bone loss. Some people define peri-implant mucositis as separate from peri-implantitis, where the former is the inflammatory component and the latter is the infective component, which means the presence of pus. But while periimplantitis could be strictly defined as inflammation, I think we can say that peri-implantitis is an inflammation with an overlying infection and bone loss. There was a recent European workshop on periodontology looking into this, with my good friend Professor Tord Berglundh, who is probably one of the names at the forefront of this area. He would argue that peri-implantitis is defined as follows: an implant with 2.5 mm of bone loss; a pocket depth of greater than 6 mm; bleeding on probing; and the presence of pus.

Does the ongoing debate make it difficult to know how widespread the issue is? I think everyone can agree that if there’s bone loss and pus, then you’ve got periimplantitis. But when you try to be more precise than that, it influences how you evaluate prevalence. If, for example, you’re somebody who says “all implants that bleed on probing have peri-implantitis,” probably 100% of implants have it. But if you say “only Michael Norton BDS FDS RCS(Ed) is a registered specialist in oral surgery who runs a practice dedicated to reconstructive implant dentistry on London’s Harley Street.

44 Implant practice

implants with a pocket greater than 6 mm, bleeding on probing, pus, and bone loss,” then the prevalence might go down to 20%, or less. Interestingly, Berglundh seems to think that the prevalence is quite high, but others have questioned this. In one study published just 4 years ago, prevalence was stated to vary between 11% and 15%, at different levels of severity.

Is it extensive enough that dentists need to start considering it distinct from periodontitis? Well, periodontitis is a disease of teeth, not of implants — but one of the problems we have is that we try to use indices and markers that establish whether a tooth has gum disease, and relate them to dental implants. For example, if you’ve got a 6-mm pocket around a tooth, there’s no question that that’s disease. It’s not even a matter for debate. But if you have a 6-mm pocket around an implant, it may only denote thick mucosa. It may have no bearing on the disease status of that implant, so there are

many healthy implants that will have 6-mm pockets around them. It’s obviously still a very hot topic; the reason being, of course, that it’s frightening the life out of everyone. If every implant ever placed is going to get peri-implantitis, then the profession has a big problem. I have to say that I don’t think that’s going to be the case at all because I myself have been placing implants for more than 20 years, and while I do see peri-implantitis, it doesn’t dominate my daily practice.

So what are the key risk factors? I think the ones that most people are agreed on are smoking and a predisposition to periodontal disease, and of course, a lack of oral hygiene motivation. If you’re a patient who has a predisposition to periodontal disease, and you continue smoking, and you don’t clean your implants very well, then probably within 5 years your implants will start to show the early signs — or even the late signs, depending on how susceptible you are — of peri-implant disease. However, there are many smokers in the world who Volume 7 Number 4

Is peri-implantitis a largely preventable condition then? I don’t think we can say that yet, but I think we are clear that there are ways to reduce the risk. The major bacterial reservoirs in a patient’s mouth need to be removed, which means extracting the most periodontally affected teeth. The patient needs to be put into a regular periodontal maintenance program, and you need a good thickness of peri-implant bone, ideally a minimum of 1 mm or more, around the entire circumference of the implant. If you have these preconditions, then I think you can dramatically reduce the risk of peri-implant disease, but you may not eradicate it.

If dentists do come across it in practice, how do they treat it? There are no formally established treatments. In a broad context though, treatment will involve debridement, decontamination, and then either one of two options. The first is pocket elimination, which basically means exposing the metal into the mouth. The alternative approach is grafting and repair, which means attempting to re-establish a hard tissue mass around the now decontaminated implant that is exposed outside the envelope of bone. Pocket elimination is probably the healthier option, but it’s also the most unsightly because patients are left with exposed metal screws visible in their mouth. Volume 7 Number 4

The inevitable desire is to use guided bone regeneration techniques and try and repair the damage instead. I actually believe that pocket reduction is the less invasive option though, insofar as once you’ve debrided and decontaminated the implant, all you’re then doing is sewing up the soft tissues. With the graft and repair, you’ve still got a lot more surgery to do. You have to do the bone graft, protect it, and then you have to try and get the soft tissues to go back around the graft and the implant. It’s a much more technically demanding technique.

feel they can’t charge for it. Yet it’s very time consuming, and they may not be availing themselves of the latest technology or knowledge to treat the case. If they refer the patient, they don’t have to use up their chair time — the patient gets the benefit of going to an expert, and the expert can charge for his/her time because he/she didn’t place the implants in the first place. So, everyone’s a winner. To enhance this service, I have employed a therapist, Diana Bloom, in my practice, who I’m training up in the non-invasive treat-

Professor Tord Berglundh, who is probably one of the names at the forefront of this area, would argue that peri-implantitis is defined as follows: an implant with 2.5 mm of bone loss; a pocket depth of greater than 6 mm; bleeding on probing; and the presence of pus.

So how do dentists choose between these approaches? I think the answer to that is a lot of dentists really don’t know how to handle it. I’m afraid there are a lot of passive treatments being undertaken — non-surgical approaches like mechanical debridement. These techniques can work over the short-term, but patients who get maintained this way for long periods end up with significantly more bone loss, as these treatments do not always eradicate the disease process. To this end, I set up a center for the treatment of peri-implant disease a few years ago, and we are now regularly getting referrals specifically to treat it.

Does that suggest awareness of the problem is growing? I think so. It’s interesting that most dentists won’t treat periodontal disease themselves — they’ll refer it. I’m starting to feel that that’s going to happen with implants too. Part of the problem with treating periimplant disease is that as the primary provider of those implants, most dentists

ments we have in place. Eventually, it’s my hope that she will be the first recipient of these referrals, and she will make the decisions with me as to whether these patients remain under passive treatment or progress to surgery. One of the problems we have is that we try to use indices and markers that establish whether a tooth has gum disease, and relate them to dental implants.

Seeing the light Dr. Norton’s practice is the only European center in an ongoing clinical study to examine the efficacy of lasers in the treatment of peri-implantitis. He explains, “We’re using an Er:YAG laser designed by Morita Corporation specifically for treating periimplant disease, which shows that people are investing time and money into the problem. The laser not only kills local bacteria but also sterilizes the surface of the implant in the process.” He continues, “We’ve treated about 10 patients so far, and we need 20, so there is still a way to go yet — but if it proves to be effective, I suspect we will be doing a lot more of it.” IP Implant practice 45

A CONVERSATION ON...

actually don’t get gum disease because they don’t have the predisposition or the genetic susceptibility to it. I would argue that it’s the same with implants for those people, so smoking may not be a risk factor in patients who have a genetic resistance to gum disease. My personal view is the patient’s genetic susceptibility plays a key role — so a history of periodontal disease is a higher risk factor because it indicates susceptibility. Nonetheless, the vast majority of patients who get implants have lost their teeth by definition, and therefore, the greater proportion of those patients probably had periodontal disease. So, if all those patients are a high risk for peri-implant disease, why are we not seeing more of it? Obviously, the susceptibility to periodontal disease — even if it is transferable — is not linear. In other words, you may be susceptible to periodontal disease, but that may not make you susceptible to periimplant disease. There are so many “howevers” in all this.

RESEARCH

A study on patients’ quality of life before and after implants Dr. Neil Patel outlines his findings after carrying out a study on patients’ well-being before and after they had implants placed

ral health changes, such as tooth loss, can have a profound effect on a patient’s quality of life (McGrath and Bedi, 2002). Many patients find it difficult to come to terms with tooth loss, being less confident about themselves and more inhibited in daily activities (Davis, et al., 2000). The partial and fully edentulous condition has negative impacts on ability to chew, speech, and appearance (Walton and MacEntee, 2005). Population-based studies have commonly shown that satisfactory oral health is achieved with the presence of a minimum of 20 teeth, or a particular number of contacting posterior pairs of teeth (Sheiham, et al., 2001; Shimazaki, et al., 2001). However, this is only on a functional level with the patient’s psychological well-being not taken into account. Furthermore, the wider availability of prosthetics and advances in dental materials have made well-aligned, esthetically pleasing teeth more attainable and are now widely promoted in the media as to what society considers to be an acceptable standard for dental appearance (Sheiham, et al., 2001). Consequently, there may be increasing pressure for patients to replace lost teeth and obtain an appearance that is closer to celebrities in the media. Compared to other dental disciplines, implant dentistry has enjoyed far more progressive development in recent years. Patients too are becoming more aware of dental implants and the benefits they can offer.

Figure 1: Preoperative stage

Neil Patel, BDS(Hons), MSc(Dist), MFDS, RCSEd, MJDF, RCSEng, is an NIHR academic clinical fellow and specialist registrar in oral surgery at Manchester Dental Hospital. He was awarded Best Young Dentist in the north west 2013 and went on to win Best Young Dentist in the UK. Dr. Patel has completed his membership exams of the Faculty of Dental Surgery at the Royal College of Surgeons in Edinburgh and completed a Masters Degree in oral and maxillofacial surgery. Dr. Patel has research interests in dental implantology, pain and anxiety management, and stem cell research. He has published and presented his work on an international level.

Figure 2: Postoperative stage 46 Implant practice

Volume 7 Number 4

The paucity of information reporting the influence of implant therapy, especially carried out in primary care, promoted the basis for this study. The aim of this study was to assess changes in oral health quality of life following dental implant treatment. A total of 150 consecutive patients had implants placed at the Evodental Implant Center (a primary care dental practice specializing in implant therapy). They were asked to complete an Oral Health Impact Profile (OHIP) questionnaire reprinted from Gary Slade’s (1997) Measuring Oral Health and Quality of Life. This questionnaire is designed to measure patient perceptions of the impact of oral health issues on their lives. It is a scaled index consisting of 49 statements. The OHIP was given to patients at their initial consultation and at a 6-month followup after restoration of the implants. In order to determine whether statistically significant improvements had occurred in oral health quality of life following treatment, the paired sample t-test was employed.

therapy has a positive affect on oral health quality of life as determined by the participants’ answers for the OHIP. Long-term follow-up is, however, required to provide an understanding of continuing benefits from dental implant therapy. The study has also highlighted the benefits of using surveys to monitor patient outcomes. Patient-targeted questionnaire use is encouraged as part of the compliance framework of the Care Quality Commission in England (Busby, et al., 2012). Furthermore, patient-reported outcome

measures are gaining increasing popularity. Reliable patient surveys have the potential to improve the performance of any organization if results are acted upon. Patient responses to these oral health-related questionnaires provide clinicians with valuable information about the effectiveness of their therapies on functional capacity and well-being, areas in which patients are most interested and familiar. IP A copy of the Oral Health Impact Profile used for this survey is available upon request.

REFERENCES 1. Busby M, Burke FJ, Matthews R, Cyrta J, Mullins A. Measuring oral health self perceptions as part of a concise patient survey. Br Dent J. 2012;213(12):611-615. 2. Davis DM, Fiske J, Scott B, Radford DR. The emotional effects of tooth loss: a preliminary quantitative study. Br Dent J. 2000;188(9):503-506. 3. McGrath C, Bedi R. Measuring the impact of oral health on life quality in two national surveys — functionalist versus hermeneutic approaches. Community Dent Oral Epidemiol. 2002;30(4):254-259. 4. Meadows LM, Verdi AJ, Crabtree BF. Keeping up appearances: using qualitative research to enhance knowledge of dental practice. J Dent Educ. 2003;67(9):981-990. 5. Sheiham A, Steele JG, Marcenes W, Lowe C, Finch S, Bates CJ, Prentice A, Walls AW. The relationship between dental status, nutrient intake, and nutritional status in older people. J Dent Res. 2001;80:408-413. 6. Shimazaki Y, Soh I, Saito T, Yamashita Y, Koga T, Miyazaki H, Takehara T. Influence of dentition status on physical disability, mental impairment, and mortality in institutionalized elderly people. J Dent Res. 2001; 80(1):340-345. 7. Walton JN, MacEntee MI. Choosing or refusing oral implants: a prospective study of edentulous volunteers for a clinical trial. Int J Prosthodont. 2005;18(6):483-488.

Results From the 150 patients recruited, 107 returned for a 6-month follow-up and successfully completed the OHIP for a second time. Therefore, data can only be used from this group’s first and second OHIP answers. This sample of 107 patients included 48 male and 59 female patients, with an age range of 24 to 82 years. Thirty-nine patients were totally edentulous. Multiple implants were placed in 70 patients, and the remaining 37 each had a single implant placed. At the preoperative assessment, areas that scored the lowest on the OHIP, and therefore signified the greatest effect on quality of life, were dissatisfaction with appearance, food catching under dentures, and negative feelings of self-consciousness. Six months after restoration of the implants, there was a significant improvement in every component of the OHIP (p < 0.001). Categories where patients benefited the most after implant therapy included improvement in appearance, improvement in feelings of self-consciousness, and improved fit of dentures. Edentulous patients showed the greatest increase in OHIP scores, thus benefiting the most from implant therapy.

Discussion This study has shown that quality of life is affected by oral health. Dental implant Volume 7 Number 4

Implant practice 47

RESEARCH

The study

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screw-retained restorations. A sleek profile designed for optimal tissue management, various angulations and gingival heights offer the flexibility to provide an individual solution for edentulous patients. The Screw-Retained Abutments are designed to achieve excellent esthetic and functional results. The abutment dimensions allow for fixed screw-retained full arch restorations according to the patients’ individual clinical situation, even in cases where tilted implants are inevitable. The new Straumann Screw-Retained Abutments are designed to provide flexibility when treating edentulous patients with Straumann® Bone Level

From treatment planning and implant placement to final restorations, the treatment process is seamless for the patient.

implants. Furthermore, the portfolio allows for the possibility of conventional immediate temporization. “By listening to our customers and developing a solution with reduced complexity, it is ultimately the patients who win, and that is exciting for all involved,” said Gino DeSimone, Vice President, Dental Division, United States. To patients with hopeless dentition, the combination of the Straumann Dental Implant System and the NEW Screw-Retained Abutment is the optimal choice for simplified, full arch rehabilitation. To learn more about the Screw-Retained Abutment portfolio, contact your Straumann Territory Manager or visit the company’s website at www.straumann.us/sra. IP REFERENCES 1. Norm ASTM F67 (states min. tensile strength of annealed titanium); data on file for Straumann® cold-worked titanium and Roxolid® implants 2. Compared to SLA® 3. Benic GI, Gallucci GO, Mokti M, Hämmerle CH, Weber HP, Jung RE. Titanium-zirconium narrow-diameter versus titanium regular-diameter implants for anterior and premolar single crowns: 1-year results of a randomized controlled clinical study. J Clin Periodontol. 2013;40(11):1052–1061. doi: 10.1111/jcpe.12156. Epub 2013 Sep 8.

This information was provided by Straumann. 48 Implant practice

Volume 7 Number 4

AUTHOR GUIDELINES Implant Practice US is a peer-reviewed, bimonthly publication containing articles by leading authors from around the world. Implant Practice US is designed to be read by specialists in Periodontics, Oral Surgery, and Prosthodontics.

Submitting articles

Implant Practice US requires original, unpublished article submissions on implant topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Implant Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 7 Number 4

Pictures/images

Disclosure of financial interest

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

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

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

References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques. Aesthetic & Implant Dentistry. 2000;1(1):92-96. (Online) Author(s). Article title. Journal Name. Year; vol(issue#):inclusive pages. URL. Accessed [date]. Or in the case of a Book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide. London: Martin Dunitz; 2001. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

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

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

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

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

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

Implant practice 49

ON THE HORIZON

Digital is time-saving technology Dr. Justin Moody discusses how efficient workflow creates efficiencies for planning and treatment

veryone is talking about digital workflow these days, but what does that really mean? Technology changes by the second. It seems like every time I buy something, a new version is coming out the next day, or an upgrade is available the minute it is installed. If we sit on the sidelines waiting for the perfect time to jump in, that time will never come. I remember when it was a big deal to be a paperless office, and then the cutting-edge dentists had digital sensors and CAD/CAM. Digital technology has come a long way — with technologies that include integrative and interactive software, digital impressions, and cone beam 3D imaging. Digital workflow is all of those things and more. It is the ability to use digital technology to make ourselves more efficient. How do we measure efficiency? We can measure it in seconds, minutes, hours — it’s all about time. As dentists, we only have so much time in a work day to see patients, and our efficiency is contingent upon how effectively we spend that time. The price of technology only seems high if you are only looking at the price tag. We must educate ourselves as to what this technology can actually do for the practice. In my practice, I think of digital workflow as many products from many manufacturers working together in my system to make my job easier and faster. Let me give you just one example of how this works for me every day. I see new patients for dental implant consultations; they have either filled out their paperwork online or on an iPad® at

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.

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Virtual implant and restoration placement

my office after they have been instructed to arrive 15 minutes early. Now in my system, patients are taken back to my consultation room, and we talk about their vision of what they want — 100% of the time, this involves a CBCT scan from my i-CAT® FLX (Imaging Sciences International) machine, which no longer needs data entry, as it gets this from my Dentrix Chart, and my DEXIS integrator sends the info to the CBCT unit with one click of the mouse. Approximately 2-3 minutes later, I can treatment plan my cases in Tx STUDIO™ for patients to see and discuss. Once they commit to care, then it’s a matter of taking a digital impression with my 3Shape TRIOS® Color, Pod, and digital clinical photo series. I can now schedule patients for surgery, having gathered all the necessary information to create models, virtual wax-ups, surgical guides, and immediate provisionals. I am able to do this in one visit. Many of the steps are a team effort, and patients are getting the very best in care quickly and efficiently. That is time savings; that is how to be more profitable, and it’s also fun. With digital workflow, you can work smarter and let the technology work harder for you. IP

3D rendering of planned segment of implants

i-CAT FLX Volume 7 Number 4

INDUSTRY NEWS Save the date for #AO2015

Planning for the 2015 Annual Meeting — Academy of Osseointegration’s 30th anniversary — is already underway. The AO event will take place in San Francisco March 12-14, 2015, where the focus will be on the power of collaboration to advance the art and science of dental implant therapy. Here are a few glimpses at what’s in store for next year. The Opening Symposium will feature teams of doctors presenting on how they manage patients together for optimal results. The keynote speaker will be Dr. Daniel Alam, MD, who was a member of the multi-disciplinary team of doctors and surgeons at Cleveland Clinic that performed the first neartotal face transplant in the United States. He will speak to the critical importance of different disciplines coming together to support a patient’s medical, surgical, and emotional needs to make him/her whole again. Dr. Daniel Alam, MD AO also will take a look at what Keynote Speaker for the 2015 the Academy has learned throughout Annual Meeting its 30-year history and summarize current recommendations to address the most challenging conditions in implant dentistry. AO has enlisted some of the foremost authorities in both surgical and restorative dentistry to share their knowledge and views to support this initiative. Dr. Steve Eckert, editor-in-chief of The International Journal of Oral & Maxillofacial Implants (JOMI) also will choose and present six JOMI articles that will change the way clinicians practice implant dentistry. The meeting’s goal will be to take what the profession has learned and show how it can be applied in new ways to solve clinical conditions and dilemmas. This will be done via top-notch surgical and restorative tracks, as well as a “Morning with the Masters” for which AO has put together an outstanding group of experts to a give attendees pearls that can be used in the office on Monday morning. Keeping with AO tradition, the Closing Symposium promises not to disappoint. It will be an interactive session where attendees can vote on keypads to give their opinion on various treatment options for presented cases. A panel of experts will also discuss and debate the options. “It is important in any dynamic organization to build on its past and chart the way for its future,” said Dr. Dr. Donald Clem III, DDS Donald Clem, Chair of AO’s 2015 Chair of the 2015 Annual Meeting Annual Meeting. “Ultimately, patient safety and benefit must be based on sound evidence — that’s what the Academy is all about and our Annual Meetings are as well.” To learn more about AO membership, please visit http://www. osseo.org/NEWmembership.html.

52 Implant practice

LED Imaging partners with The University of Tennessee Health Science Center College of Dentistry to provide students with advanced imaging technology The university recently installed LED Imaging’s premier digital extraoral imaging system Students, residents and faculty at the University of Tennessee (UT) Health Science Center College of Dentistry will now have access to new, sophisticated oral and maxillofacial imaging technology due to a partnership between the UT College of Dentistry and LED Imaging, a new division of LED Dental. Residents and dental students will receive hands-on training with the RAYSCAN α – Expert, a multi-function digital imaging system, as part of their clinical training. This partnership demonstrates LED Imaging’s commitment to providing revolutionary technology to the dental industry and enhancing the education offered to the dentists and dental specialists of tomorrow. The RAYSCAN α – Expert features 3D cone beam computed tomography (CBCT), panoramic, and cephalometric capabilities. The system, developed by Ray Co., Ltd., a subsidiary of Samsung, secures the images practitioners need to make fast and accurate diagnoses. The RAYSCAN α – Expert’s 3D images are captured using an optimal 9 cm x 9 cm field of view, while its CMOS and Direct Deposition Cesium Iodide (CsI) Detector ensure practitioners can quickly capture high-quality, 16-bit DICOM images at a low radiation dose. To minimize error from patient positioning and movement, the system’s focal trough is stabilized and controlled through Adaptive Moving Focus technology. The RAYSCAN α – Expert’s exclusive noise-reduction algorithms enhance image quality by removing image noise that could otherwise blur the image. The RAYSCAN α – Expert, which utilizes a wireless remote control for patient positioning, helps teach students the techniques for proper patient positioning for panoramic, cephalometric and CBCT image acquisition. Additionally, green, blue, yellow, and red LED illumination indicates the status of the unit to the students at a glance: ready, standby, exposure, and emergency, respectively. This ensures they are able to capture images effectively and efficiently for more accurate diagnoses. Founded in 1878, the UT College of Dentistry maintains a four-year dental program totaling approximately 360 students. More than 75 percent of the dentists practicing in Tennessee were educated and trained at the UT College of Dentistry in Memphis.

About LED Dental LED Dental is a wholly owned subsidiary of LED Medical Diagnostics Inc. Founded by the creator of the award-winning VELscope® tissue fluorescence visualization technology, LED Dental now also features the LED Imaging division that provides dentists and oral health specialists with advanced diagnostic imaging products and software. LED Dental products seamlessly integrate into dental practices. To learn more about LED Imaging, visit www.led-imaging. com. To learn more about the UTHSC College of Dentistry, visit www.uthsc.edu/dentistry.

Volume 7 Number 4

Own the New Piezosurgery

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INDUSTRY NEWS Carestream Dental partners with Zimmer Dental Inc. to strengthen education for clinicians at Zimmer Institute’s four facilities

has direct subsidiary operations in Australia, Canada, China, France, Germany, Israel, Italy, and Spain, with a global network of distributors worldwide. For more information about the Zimmer Institute, call 1-800-854-7019 or visit www.zimmerdental.com.

Partnership offers practitioners hands-on experience with the CS 9300 multi-modality imaging system

About Carestream Dental

Carestream Dental has entered into a partnership with Zimmer Dental Inc., a leading provider of dental oral rehabilitation products, and the Zimmer Institute, a world leader in the educational field of oral rehabilitation. The partnership involves the placement of Carestream Dental’s CS 9300, an all-in-one extraoral imaging system that supports a wide range of clinical applications for different oral health specialties, at the Zimmer Institute located in Parsippany, New Jersey. As a leader in implantology educational programs, the Zimmer Institute provides an interactive learning environment to enhance training. With four locations, the Zimmer Institute has served the needs of more than 6,000 clinicians globally over the last 9 years. Over the past few years, 3D imaging has become an important tool to the modern dental practice. Imaging systems, like the CS 9300, provide enhanced images through advanced cone beam computed tomography (CBCT) that allow practitioners to uncover critical information that cannot be detected when relying solely upon 2D imaging. In addition to improved diagnoses and treatment planning, practitioners who have taken advantage of 3D imaging systems have discovered an improvement in doctorpatient communication, as patients are more likely to comprehend their diagnosis when the clinician can point out the problem on a more realistic 3D image rather than a static 2D image. Sharing the CS 9300 with the Zimmer Institute’s students gives them the advantage as they enhance and refine their skills. The dental industry is rapidly changing, and it’s vital that students have the opportunity to work hands-on with the latest technology so that they can more accurately diagnose and treat patients in the future. Dr. Maurice Salama, an industry-leading dental implantologist who serves as an instructor at the Zimmer Institute, described the Zimmer Institute’s facility and training capabilities — “The utilization of both high-tech mannequin and cadaver labs, along with Carestream Dental’s CS 9300 CBCT imaging system and software, provides a very dynamic and robust educational opportunity for all attendees. This combination of Carestream Dental’s diagnostic 3D imaging and the Zimmer Institute’s cutting-edge facility and products is the new template for dental implant education. I am most pleased by their collective collaboration with LIVE courses and their support of the digital educational platform provided by DentalXP.”

About Zimmer Dental Inc. Zimmer Dental Inc. provides a comprehensive portfolio of innovative implant technologies designed to meet a broad range of clinical needs. Zimmer Dental continues to be a market leader in the development of world-class implantology products, practice partnerships and educational programs — all focused on empowering clinicians and revolutionizing implant dentistry. Headquartered near San Diego in Carlsbad, California, Zimmer Dental

54 Implant practice

Carestream Dental provides industry-leading imaging, CAD/ CAM, software and practice management solutions for dental and oral health professionals. With more than 100 years of industry experience, Carestream Dental products are used by seven out of 10 practitioners globally and deliver more precise diagnoses, improved workflows, and superior patient care. For more information or to contact a Carestream Dental representative, call 800-944-6365 or visit www.carestreamdental.com.

Instrumentarium Dental™ unveils the OP300 Maxio delivering 3D scans up to 5 times lower dose than 2D pans

The latest addition to the Orthopantomograph® line reduces radiation exposure to patients with the all-new Low Dose Technology™ while further expanding 3D field-of-view options. Instrumentarium Dental extends its extraoral product line with the new, feature-rich OP300 Maxio Pan/Ceph/3D. The latest addition introduces new and larger fieldsof-view for dental and maxillofacial imaging, and a revolutionary Low Dose Technology (LDT) delivering quality-optimized Cone Beam 3D scans with very low radiation dose, up to 5 times lower* than traditional 2D panoramic images. Low Dose Technology provides quality-optimized images with a very low radiation dose across all fields-of-view. Low Dose Technology is ideal for dose sensitive applications such as pediatric patients, follow-up imaging, or implant planning. The new expanded 3D field-of-view of the OP300 platform extends to 13 x 15 cm. This covers both mandibula and maxilla to include airways and the upper cervical spine, or sinus area. The OP300 Maxio provides offers several targeted field-of-views as small as 5 x 5 cm to optimize the cone beam scan for single site implants or localized diagnostics, while keeping the patient dose at a reduced level. The OP300 Maxio delivers a state-of-the-art end-user software experience with the new Invivo 5.3. The enhanced software is now capable of combining digital impressions and CBCT scans for improved accuracy in treatment planning, as well as new restoration tools to improve communication between dental professionals and labs. For more information, visit www.instrumentariumdental.com. *OP300 Maxio Dosimetry Report, Prof. John B. Ludlow, April 2014. Based on a 5 x 5 cm 3D scan with LDT. Source: http://aim.ndc-inc.com/LinkClick.aspx?fileticket=iBSo8TaVtKo%3D&tabid=744&mid=2310

Volume 7 Number 4

DIARY

lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll

EVENTS

ICOI Summer Implant Prosthetic Symposium August 21 – 23, 2014 Chicago, IL http://icoi.org/meetings-courses.php American Association of Oral and Maxillofacial Surgeons 2014 September 8 – 13, 2014 Honolulu, HI http://www.aaoms.org/annual_meeting/ 2014/index.php American Academy of Periodontology 2014 September 19 – 22, 2014 San Francisco, CA http://www.perio.org/meetings/am/index.html ADA 2014 October 9 – 14, 2014 San Antonio, TX http://www.ada.org/en/meeting American Academy of Implant Dentistry 2014 November 5 – 8, 2014 http://www.aaid.com/index.html

CE EVENTS

Place the OCO Biomedical Dual Stabilization™ Line of Dental Implants http://www.ocobiomedical.com July 12, 2014 • Charleston, SC July 26, 2014 • Tallahassee, FL August 9, 2014 • Phoenix, AZ August 16, 2014 • Cleveland, OH

56 Implant practice

Place the OCO Biomedical Dual Stabilization™ Line of Dental Implants with LIVE SURGERY August 2 – 3, 2014 Albuquerque, NM http://www.ocobiomedical.com

Ostrow School of Dentistry of USC Complications Associated with Implant Therapy Drs. Bach Le and Baldwin W. Marchack July 12, 2014 https://dent-web02.usc.edu/ce/course_ calendar.asp

Diagnosis and Treatment Planning in the Esthetic Zone – Part II Dr. Saj Jivraj https://implanteducation.net/ True Restoratively Driven Implant Dentistry Through 3D Planning Dr. Scott Ganz http://www.i-cat.com/events/webinars/ CBCT: An Indispensible Technology for the Implant Placement Dr. Steven Guttenberg http://www.i-cat.com/events/webinars/

Ostrow School of Dentistry of USC Immediate Full-Arch Provisional Restorations with Dental Implants Drs. Bach Le and Baldwin W. Marchack July 13, 2014 https://dent-web02.usc.edu/ce/course_ calendar.asp

Treating Denture Patients Shouldn’t Be Aggravating! Simple and Profitable Techniques to Stabilize Loose Dentures with Narrow Diameter Implants Dr. Michael Scherer http://forms.coronapro.com/BIpQ1sU4

Hands-On Workshop: 3D Imaging Software Jordan Reiss July 25, 2014 El Segundo, CA http://www.carestreamdental.com/us/en

Indication Specific Implants: Immediate Molar Replacement With Ultra-Wide Diameter Implants Dr. Michael J. Will http://www.dtstudyclub.com/

Small Diameter Implant Workshop Dr. Jerry D. Martin August 9, 2014 Salt Lake City, UT http://intra-lock.com/index.php?option=com_ content&task=view&id=153&Itemid=284

Sinus Elevation and Immediate Implant Placement in Severely Resorbed Maxillae by Using mp3 and Compacting Technique Dr. Patrick Palacci http://www.dtstudyclub.com/

WEBINARS

Diagnosis and Treatment Planning in the Esthetic Zone – Part I Dr. Saj Jivraj https://implanteducation.net/

Implant Dentistry: A Structured Approach to Treatment Planning of Advanced Clinical Cases Utilizing Modern Digital Technologies Dr. Roland Jung http://www.dtstudyclub.com/

Volume 7 Number 4

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