Implant Practice US September/October 2014 Issue - Vol7.5 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews September/October 2014 – Vol 7 No 5

Dr. Adam Patel

Practice profile

Dr. Michael D. Scherer

Corporate profile LightScalpel

Lateral sinus augmentation: a safer technique

Drs. Gregori M. Kurtzman and Douglas F. Dompkowski

NEW components for

The role of piezosurgery in implant dentistry

fixed screw-retained full-arch restorations.

PROMOTING EXCELLENCE IN IMPLANTOLOGY

Company spotlight Anatomage

READ MORE ON PAGES 10 & 11

PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!

THIS IS NO TEMPORARY IMPLANT Hundreds of clinicians around the world have realized what sets the LOCATOR® Overdenture Implant (LODI) System apart from their past experiences with “mini” implants—sometimes perceived as temporary implants. LODI is a reliable and costeffective, 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 (2.4mm option available) LODI has a surface area very close to a 3.0mm standard implant Aggressive thread design similar to standard implant diameter designs, providing increased primary stability

No screw access hole for implant strength

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

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

Discover the benefits of a narrow diameter implant that performs like a standard diameter implant. Add LODI to your armamentarium of implant options. www.zestanchors.com/lodi/31 or 855.868.LODI (5634). Introducing the CHAIRSIDE Attachment Processing Material you have been waiting for. Try CHAIRSIDE with your first case FREE! Contact us for details.

NEW!

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

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com CHIEF OPERATING OFFICER | Andrea Hood Email: andreah@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 PRODUCTION ASST./SUBSCRIPTION COORD. Jacqueline Baker Email: jbaker@medmarkaz.com

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requently, I am asked why I use the implant systems I use. Why do I spend so much for one implant when I can easily save lots of money using an implant with “nearly equivalent design” made by another company? The answer is simple and unequivocal; it is not just the implant component, but all that comes with it that determines my choice. OK. So what comes with that “Porsche” implant? What am I paying for, and is it worth it? I believe I absolutely get my money’s worth because I get three critical advantages that I am more than willing to pay for: Dr. Alan E. Fetner support, quality, and technology. It is therefore, not just about the implant, but really about what the implant company can offer as a whole. Support is not about calling a company when there is a problem with a component, but rather, support is a partnership with a local representative and a company that share my goals of achieving and sustaining optimum results. Support is working with a representative that helps keep the whole surgical/restorative process working smoothly between my practice, the laboratories, the implant company, and most importantly, the restorative practices that I work with. Quality is a critical feature of any implant system, but a difficult thing to judge by examining the product. Can we really determine if the surface of the implant was properly researched and manufactured? How about the fit of the components or the accuracy of the drills? Some of the problems associated with quality issues may not be manifest for years, including potential loss of bone, loosening of parts, or even complete failure of the implant. Good companies guarantee the quality of their implants and components. Complete support with guarantees is just good business. How well a company stands behind its products is a critical benefit and a testament to the integrity of that company. It is also one that instills confidence that we can pass on to our patients. The industry-leading companies have provided remarkable technologies that have changed my perspective from being a dentist who simply places an implant to a dentist who considers the implant as part of a much broader procedure — from digital planning to implant placement, and eventually, to the final restoration. Every year, I incorporate more of what is offered, and I rely on the companies to provide these innovations. I also rely on them to fully support the development of the dentists whom I work with. Advances such as the integration of cone beam technology with intraoral scanners to create workflows allow the level of care and convenience my patients and referrers have come to expect. I may not use all the technology offered, but I like to know it is there if it is needed and when I am ready to embrace it. Similarly, when you get behind the wheel of a Porsche, you may not use a whole lot of what the car has to offer, but it is great to know that it is there when you need it. Wow! Two Porsche references in one editorial. I realize that the implant systems I use are high quality and not cheap; but then again, so is the level of care that I provide my patients and the standard by which I partner with my treatment team. I also know that there’s a lot of technology under the hood, and I am just beginning to tap the potential. It is just a matter of putting the pedal to the metal AND having a great pit crew. Dr. Alan E. Fetner Diplomate, American Board of Periodontology Fetner & Hartigan, Periodontics and Implant Dentistry Jacksonville, Florida

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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 5

Alan E. Fetner, DMD, practices periodontics and implant dentistry in Jacksonville, Florida, with his wife, Dr. Mary Hartigan, and their son, Dr. Michael Fetner. He received both his dental degree and specialty degree from the University of Florida. For the past 29 years, he has maintained a part-time faculty position in the Department of Periodontics at the University of Florida and the past 20 years with Florida State College Hygiene School. He is currently involved in dental research with emphasis on the placement of implants subcrestally. Dr. Fetner has presented over 150 programs in the United States, Canada, and Europe primarily on periodontal therapy in the general practice and advanced implant therapy. Dr. Fetner is a member of the ADA, the American Academy of Periodontology, AO, Florida Association of Periodontists, and PEERS NA. Dr. Fetner is a Fellow of the American College of Dentists.

Implant practice 1

INTRODUCTION

September/October 2014 - Volume 7 Number 5

So much more than just the implant…

TABLE OF CONTENTS

Company spotlight

Anatomage Shaping and defining industry standards.........................................16

Practice profile

Michael D. Scherer, DMD, MS, FACP

Inspired in Sonora

Clinical

Lateral sinus augmentation: a safer technique Drs. Gregori M. Kurtzman and Douglas F. Dompkowski illustrate an approach that can avoid complications ....................................................... 19

Case report

Corporate profile LightScalpel

Advancing flexible fiber CO2 lasers since 1991

2 Implant practice

Cone beam computed tomography-monitored guided bone regeneration following teeth extractions in the anterior maxilla of a 15-year-old patient for future implant placement: a case report Drs. Spyridon I. Vassilopoulos and Michael Mastoris treat a case involving a frequent phenomenon during childhood .......................................27

Volume 7 Number 5

TABLE OF CONTENTS

Continuing education Implant-induced post-traumatic inferior alveolar nerve neuropathy Dr. Tara Renton discusses nerve injury .......................................................38

“Tech”-nique

Socket preservation technique with NuOss® XC Self-expanding Bone Graft Composite Dr. Frank Kung explains a streamlined approach to socket preservation ...................................................... 40

Technology

Continuing education

The role of piezosurgery in implant dentistry Dr. Adam Patel details the huge potential of piezosurgery for improving the predictability and ease of dental implant treatment

Cone beam CT applications in oral surgery Dr. Bart Silverman discusses the benefits of an added dimension in imaging...........................................44

Step-by-step

LightScalpel® Soft tissue incision/excision/ablation/ coagulation with LightScalpel®.........50

Step-by-step

Product profile

Salvin® Renovix® Guided Healing Collagen Membrane ..................................................... 54

Product profile

Implant Direct IQity Impression Technique™ with InterActive™ and Legacy™4 Implants ...................................................... 51

OCO Biomedical’s gateway to complete implant dentistry solutions The 3.0 and ISI One-Piece Implant System ...........................................56

Brand spotlight

Step-by-step

Planmeca PlanScan™ Complete System It’s a new day for same-day dentistry ...................................................... 52 4 Implant practice

Industry news ..............59 On the horizon

Digital impressions in the digital office Dr. Justin Moody discusses how to make the best impression on patients .......................................................60

Notable milestones........................62

ZEST Anchors introduces CHAIRSIDE® — A new and unique attachment processing material ......................................................58

Volume 7 Number 5

Patients rely on you in order to eat, speak, and smile with confidence. It can be said, you are actually restoring quality of life. 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 lifeâ&#x20AC;&#x201D;because it matters.

www.dentsplyimplants.com

Restoring quality of life

PRACTICE PROFILE

Michael D. Scherer, DMD, MS, FACP Inspired in Sonora

What can you tell us about your background? I grew up in Fort Lauderdale and Duck Key, Florida, the youngest of four children of a medical surgeon father and adoption attorney mother. I received my bachelor’s degree from the University of Miami and dental degree from Nova Southeastern University. While in dental school, I met my future wife in the anatomy lab, and we have become quite the dental couple! During this time, I received several awards for clinical and academic dentistry, including being able to present an implant case poster at the Astra World Congress in 2008 with my wife. After graduating from dental school, I went to practice in the Florida Keys with Dr. Fred Troxel, a recognized restorative and implant dentist. Fred taught me an incredible amount about dentistry and practice 6 Implant practice

management while giving an opportunity to cement my desires to be intimately involved with implant dentistry with an emphasis on implant overdentures. I returned to dental school, enrolling in a Prosthodontics program at Ohio State University, and did everything I could to absorb the “fire hose of information” in a residency program. Under the tutelage of Drs. Julie Holloway, Wayne Campagni, Ed McGlumphy, Ernest Svensson, and Robert Seghi, I was able to develop and publish foundational research on implant overdentures. Soon after graduating as a Prosthodontist, I became a dual faculty member at the University of Nevada, Las Vegas (UNLV) and Loma Linda University. While at UNLV, I took over a pre-doctoral implant program that was doing a trickle of cases and opened up the floodgates, as my goal was to get every

student to restore implant cases and, for those who had an interest, to place standard and narrow diameter implants. The dental students at UNLV are a special group, and throughout my tenure they were thrilled about learning as much as possible about implant dentistry. My greatest academic reward was knowing that in UNLV’s first 9 years, two students enrolled into Prosthodontics residency programs, but during my 2 years as faculty, we had three people enroll in 1 year! While my wife was studying at Loma Linda’s Orthodontics program, I became involved with the Prosthodontics program. It is such a pleasure being able to teach side by side with amazing faculty, Drs. Matthew Kattadiyil and Charles Goodacre. I began practicing in Sonora, California, after a practice opportunity became available from a retiring implant dentist. After Volume 7 Number 5

PRACTICE PROFILE

Dr. Scherer maintains an on-site laboratory

previously practicing in a more rural environment in Florida, I have fallen in love with the foothills of the Sierra Nevada mountain range as it allows me to focus on comprehensive restorative and implant dentistry.

Is your practice limited to implants? Since I am in a more rural environment, I have decided that limiting my practice to only implant dentistry would not be the best fit for my community. While my principle focus is on implant dentistry, specifically full arch restoration with fixed or removable restorations, I feel it is important in my area to be able to provide comprehensive Prosthodontics and be able to provide specialized services to patients and to assist other dental providers in challenging cases.

Why did you decide to focus on implantology? Implant Dentistry is exciting. People come to my office asking for implants because they know it will change their lives. When I was in dental school, I was told by faculty that people don’t come in asking for implants; they come in asking for teeth. I find that this has changed significantly over the years. People are now coming to my office because of my credentials, clinical experience, and reputation within the community.

Dr. Scherer, his wife Melissa, and the team in Sonora strive for an amazing patient experience!

What training have you undertaken? After 3 years in Prosthodontics residency training, I keep my skills active by constantly challenging myself with implant dentistry courses at the American College of Prosthodontists meetings, American Academy of Implant Dentistry, and International College of Oral Implantologists. I stay active in the teaching and training side of implant dentistry, specifically toward full arch restorative options such as Zest LOCATOR® Overdenture Implants, and Biomet 3i DIEM® 2. Through my experiences at courses, a huge amount of lateral learning occurs. I believe collaboration with other professionals, faculty members, and dental students/residents greatly enhances my learning and training.

Who has inspired you? On a personal note, my family is my biggest inspiration. My father passed

away too early while I was in college. I am constantly motivated by knowing that he is keeping an eye on me and making sure that I push myself to excel. I would not be here without the support of my wife, Melissa, who constantly inspires me to be the best that I can be. On a professional level, I am inspired by Dr. Wayne Campagni, my mentor and friend. Dr. Campagni has constantly challenged me to think about the literature and how I justify my clinical decisions. As a truly inspiring individual who has served in several graduate director roles, I am beyond fortunate to have been able to work with Dr. Campagni.

What is the most satisfying aspect of your practice? The best part of my practice is the resounding welcome that I received from people of Sonora and the professional community! The community has given me

How long have you been practicing, and what systems do you use? I have been practicing for over 7 years and have almost every major implant system in the marketplace. In my own office, I use Biomet 3i™ standard diameter implants for my fixed cases and Zest Anchors narrow diameter LOCATOR® Overdenture Implant System (LODI) implants for my overdenture cases. 8 Implant practice

Dr. Scherer is actively involved in teaching and leading CE courses throughout the country Volume 7 Number 5

Professionally, what are you most proud of? I am most proud of my board certification in Prosthodontics, an honor that is shared by only a small group within Prosthodontics. I am also very proud of my continued development of research and educational materials for implant overdenture available for dentists.

What do you think is unique about your practice? I provide a thorough, comprehensive approach to clinical dentistry that not only focuses on complete mouth health, but also imparts a high level of trust with my patients. I want patients to walk out of their initial appointment believing that our office is on the cutting edge of diagnosis, treatment planning, and options in implant dentistry.

What has been your biggest challenge? By far the biggest challenge has been to manage clinical, professional, and family time. I am very active within education, professional development, research, and clinical dentistry.

What would you have become if you had not become a dentist? A marine biologist or ecologist. I spent countless hours in research in the Florida Everglades, coral reef, mangrove ecosystems, and pine forests. I love the outdoors and biological research.

What is the future of implants and dentistry? The future is absolutely in giving full arch restorative options that are affordable, minimally invasive, and highly effective for patients. Even though the rate of edentulism has been decreasing, because of the baby boom, the amount of edentulous arches is expected to rise over the next 10 years. The future of implant dentistry will be providing treatment for these patients, and those who are better equipped for providing this treatment will be poised for success.

What are your top tips for maintaining a successful practice? The Number 1 tip is to engage with your community and to establish relationships with your patients that facilitate a high level of trust. In a small community, trust is paramount to success. Clinically, I maintain a successful practice by providing services that are unique within my area. With the assistance of the InPlace™ marketing campaign from Zest Anchors, I have grown my implant overdenture

practice significantly. Since I am able to offer LOCATOR® narrow diameter implants for my patients, I can provide minimally invasive surgical options for the older population within my community. Patients come in because I market specifically toward this treatment, and since I offer both removable and fixed full arch treatment options, many choose removable and some choose fixed, helping me continue to grow my practice.

What advice would you give to budding implantologists? The biggest thing that I can tell young clinicians is that they need to know how to make really high-quality dentures before they launch into full arch implantology. Many dental schools are reducing pre-clinical and clinical exposure of students for removable prosthodontics, which is a slippery slope. You cannot effectively treat full arch implant patients without knowing how to make a good denture. Additionally, narrow diameter implant overdentures have been a tremendous practice growth tool, and patients are seeking out my office because we offer this solution.

What are your hobbies, and what do you do in your spare time? Education is my passion. I maintain the YouTube channels “LearnLOCATOR” and “LearnLODI” where I post informational video content for implant overdentures. I love working with other clinicians and bringing new and informative content that is challenging the traditional paradigm of implant education. During my free time, our two Shih Tsu puppies keep us very busy! IP

Top 10 Favorites 1. Sonora, California, and my team 2. Zest Chairside® attachment processing material 3. Zest LOCATOR® implant attachments 4. Zest LOCATOR® Overdenture Implant System (LODI) 5. Biomet 3i™ dental implants 6. YouTube 7. Pumpkin and Flower — our Shih Tsu puppies 8. The Florida Keys 9. Fried grouper sandwiches 10. Fishing, anywhere! Dr. Michael Scherer, his wife Melissa, Pumpkin, and Flower Volume 7 Number 5

Implant practice 9

PRACTICE PROFILE

such a warm welcome that I feel they know that I can help the residents of Tuolumne County. As a result, I feel that this level of commitment enables me to have a longlasting and trusting relationship with my patients.

New components for

fixed screw-retained full-arch restorations.

Our aim is to support you in providing prosthetic components which help you to meet your patients’ specific needs. Increasing patient expectations are challenging dental professionals to find new treatment options Patients suffering from impending loss of teeth or edentulism are no longer willing to compromise - and they don’t have to. When removable dentures are not the preferred option, dental professionals are challenged to provide a fixed denture that is stable, esthetic and fully functional. In addition to this, patients want to have the solution quickly and working in a short time.

SHAPING YOUR PATIENTS’ QUALITY OF LIFE

First Phase: Optimization of the Straumann® Bone Level Prosthetic line In the initial phase, the prosthetic portfolio for screw-retained full arch restorations is optimized, introducing the new Straumann® Screw-Retained Abutment Portfolio and combining it with the scientifically proven Straumann Bone Level Implant line.

When it comes to treating edentulous patients, Straumann offers a broad range of options: removable or fixed, budgetfriendly or premium, straightforward or complex. However, treating edentulous patients is more than just combining different technical components: these patients are looking for a solution to enhance their current situation. They want to be able to chew and enjoy food, feel self-confident and attractive, and avoid any pain. Therefore, dental professionals actually improve their edentulous patients’ quality of life when they treat them successfully – high quality and scientific evidence are just one part of the equation.

The sleek abutment design offers increased prosthetic flexibility for fixed screw-retained restorations, even in challenging clinical situations where tilting the implant is necessary. Furthermore, Straumann® will introduce new custom-milled framework components for final fixed prostheses (on implantas well as on abutment-level). Benefit from outstanding product properties Roxolid® SLActive® implants. Roxolid SLActive is Straumann’s outstanding material/surface combination. Roxolid has been specifically designed for the use in dental implantology and offers high mechanical strength.1 This allows dental professionals to use reduced diameter implants preserving bone and reducing invasive grafting procedures. In combination with the SLActive surface, Straumann implants offer increased predictability even in challenging protocols2,3 and faster osseointegration for reduced healing times from 6 – 8 weeks down to 3 – 4 weeks in all indications.4 Fixed screw-retained restorations with the new Straumann Screw-retained prosthetics and CARES® custom-milled frameworks Straumann ScrewRetained Abutments were designed to achieve excellent esthetic and functional results. The abutment dimensions allow for fixed screw-retained full arch

REFERENCES Norm ASTM F67 (states min. tensile strength of annealed titanium). Data on file for Straumann coldworked titanium and Roxolid® Implants. 2 Oates TW, Valderrama P, Bischof M, Nedir R, Jones A, Simpson J, Toutenburg H, Cochran DL. Enhanced implant stability with a chemically modified SLA surface: a randomized pilot study. Int J Oral Maxillofac Implants. 2007 SepOct;22(5):755-60. 3 Bornstein MM, Wittneben JG, Brägger U, Buser D. Early loading at 21 days of non-submerged titanium implants with a chemically modified sandblasted and acid-etched surface: 3-year results of a prospective study in the posterior mandible. J Periodontol. 2010 Jun;81(6):809-18. doi: 10.1902/jop.2010.090727. 4 Compared to Straumann SLA. 1

restorations according to the patients’ individual clinical situation, even in cases where tilted implants are inevitable. Furthermore, the portfolio allows conventional immediate temporization. For final dentures, Straumann® CARES® Visual will provide custom-milled frameworks on implantas well as abutment-level. Straumann Screw-Retained Abutments The new Straumann Screw-Retained Abutments are designed to provide flexibility when treating edentulous patients with Straumann Bone Level implants. These new abutments are available with different angulations and gingiva heights (see list below). The abutment connector can be used for either multi or single-unit restorations; it has the same geometry throughout all platforms which allows for a small component portfolio.

Material

TAN

Implant compatibility

CrossFit® connection

Abutment features

Ø 3.5 mm and Ø 4.6 mm platform, three angulations (0°, 17° and 30°), three gingiva heights (1 mm, 2.5 mm, 4 mm)

4 Straumann® Bone Level Implants placed in the maxilla, 2 posterior hilted with RC 30° Straumann® Screw-Retained Abutments, 2 anterior abutments NC straight.

For full product portfolio see NAMLIT 1024

Straumann® CARES® custom-milled frameworks on implant – as well as on abutment-level The Straumann CARES frameworks are designed for treating edentulous patients and satisfying high demands in reliability and esthetics.

Material

Titanium Gr 4 and coron® (CrCo)

Implant compatibility

Straumann Soft Tissue Level RN & WN synOcta® connection and Straumann Bone Level NC & RC CrossFit connection, available on 2-10 Implants

Abutment compatibility

Straumann Screw-Retained Abutment, available on 2 – 10 Abutments

To learn more contact your Straumann Territory Manager or call 800/448/8168

© Straumann USA, LLC 2014. All rights reserved. Straumann® and/or other trademarks and logos from Straumann® that are mentioned herein are the trademarks or registered trademarks of Straumann Holding AG and/or its affiliates. All rights reserved.

CORPORATE PROFILE

LightScalpel — Advancing flexible fiber CO2 lasers since 1991 www.LightScalpel.com / 1-866-589-2722 LightScalpel legacy

LightScalpel’s mission and vision

LightScalpel finds its roots in the revolutionary flexible CO2 laser fiber and all-metal CO2 laser tube technologies since it was introduced to dentists by Luxar Corporation in 1991 as the first ever soft tissue surgical CO2 laser, designed specifically for a small office environment. Over 12,000 dentists, physicians, and surgeons worldwide enjoy the many praised clinical benefits and ease of use of the flexible fiber CO2 laser (see bloodless laser Stage II implant uncovering in Figure 1 and bloodless laser frenectomy in Figure 2). In 2002, following the sale of Luxar to a large multinational corporation, its former principals, Paul Diaz, MSc, EE, and Dr. Peter Vitruk, PhD, started LuxarCare LLC, whose mission was to provide total support for Luxar laser owners with affordable accessories and reliable repairs. Started in Dr. Vitruk’s garage in Seattle, Washington, and working with nothing more than extensive laser technology knowledge, LuxarCare has grown to become an exclusive accessory and repair provider for all Luxar lasers in North America. Many dentists in the United States are still using lasers that they purchased in 19911993. No other laser company in the world has a longer history and more consistent track record of keeping surgical lasers in business since the early 1990s. In the mid-2000s, the LuxarCare owners set their eyes on creating the next “Best in Class” dental and surgical laser. Soon, the LightScalpel brand was born.

LightScalpel’s founders defined and charted the course to provide a superior customer experience focusing on: • Latest in laser-tissue interaction science • U.S.-based laser technology, manufacturing, and customer service excellence • Dedication to laser training and education

The CO2 laser wavelength is the most efficient wavelength for soft tissue laser dentistry due to its unparalleled absorption by oral soft tissue. Robert A. Convissar, DDS New York, New York

LightScalpel team Gathering together many talented and experienced former Luxar Design and Manufacturing Engineers, LightScalpel founders, Drs. Vitruk and Diaz, took on the challenge of designing and building the next generation of dental CO2 surgical lasers. LightScalpel scientists, engineers and technicians share 300-plus years of combined experience of leadership in laser dentistry, surgery, and medicine. Launched in 2013, LightScalpel lasers feature re-engineered flexible fibers and handpieces, as well as further enhanced reliability and longevity of its rugged allmetal laser tube technology. At the same time, LightScalpel continues to focus on LuxarCare’s founding principles of exceptional customer service and technical support.

CO2 is the gold standard for laser technology, for soft tissue procedures … [diodes] are inefficient compared to the speed of CO2 … CO2 simply cuts and ablates tissue much faster. Does the laser pay for itself in terms of the vast amount of time it’s saving me, the lack of needing second appointments and follow-ups? Absolutely. Take troughing for example — the laser quickly eliminates 15-20 minutes of cord-packing time. Multiply that out — having done crowns for over 20 years with the laser — efficiency is a huge cost saver for me.

Wavelength matters: soft tissue ablation and coagulation

Alan Winner, DDS New York, New York

The highest order priority of the LightScalpel mission was a review of laser-tissue

Figure 1: Stage II implant uncovering with Luxar CO2 laser (Photo courtesy of Stuart Coleton, DDS, White Plains, New York) 12 Implant practice

Testimonials

Figure 2: Luxar CO2 laser soft tissue dental procedure frenectomy in progress (Photo courtesy of Alan Winner, DDS, New York, New York) Volume 7 Number 5

interaction science. Presented in Figure 3 is the modern-day understanding1 of how different laser wavelengths interact with the main chromophores (absorption centers) in the oral soft tissue for the three wavelength groups of practical dental lasers: • circa 1,000 nm (diodes and Nd:YAG laser) • circa 3,000 nm (Erbium lasers) • circa 10,000 nm (CO2 lasers) As illustrated in Figure 3, wavelengths circa 10,000 nm are 1,000-plus times superior to 800-1,100 nm wavelengths for soft tissue ablation. At the same time, the wavelengths circa 10,000 nm are 10-plus times superior to wavelengths circa 3,000 nm for soft tissue coagulation. Naturally, LightScalpel’s choice was the CO2 laser as the only wavelength that delivers excellent ablation with simultaneous coagulation (unobtainable with either diodes or Erbium wavelengths).

CORPORATE PROFILE

Figure 3: Optical absorption coefficient spectra at different histologically relevant concentrations of water, hemoglobin (Hb), oxyhemoglobin (HbO2), and melanin. Logarithmic scales are in use

Figure 4: Titanium optical absorption spectrum

LightScalpel fiber and handpieces The 1.75 meter extended reach of the LightScalpel fiber allows for convenient positioning of the laser in relation to both patient and dentist, making it ideal for a dental office. The LightScalpel flexible fiber and handpieces (Figure 5) provide the clinician with the most natural “scalpel-like” feel. The fiber is durable, light, maneuverable, and offers high precision for unparalleled focus ability of the laser beam.

LightScalpel top performance and lowest cost maintenance: all-metal laser tube

The laser enables us to achieve some really dramatic results for soft tissue. By sealing blood vessels, lymphatic vessels and nerve endings, my laser enables me to operate with a dry surgical field; meanwhile, the clinical benefits of reduced pain, minimal bleeding, and faster recovery for my patients cannot be stressed enough … The CO2 wavelength is far superior for the soft-tissue surgeries I’m doing.

The LightScalpel proprietary all-metal

Mark Docktor, DDS Hoboken, New Jersey

Wavelength matters: implants The future of dentistry is unthinkable without implants. Naturally, the next step in evaluating the appropriate laser wavelength for the needs of modern-day and future dentists was the study of laser-implant interaction properties. Presented in Figure 4 is the absorption spectrum of titanium,2 the most common implant material. Once again, LightScalpel’s choice for the CO2 laser wavelength is based on solid scientific foundation and assures that implants are affected (heated) approximately 4 times less than at diode and Nd:YAG wavelengths (circa 1,000 nm) and approximately 3 times less than at Erbium laser wavelengths (circa 3,000 nm). Volume 7 Number 5

Figure 5: LightScalpel laser fiber, autoclavable handpieces, and laser console Implant practice 13

CORPORATE PROFILE

It’s so much easier with the flexible fiber waveguide… Using the waveguide, particularly inside the mouth… it’s like having a pencil in your hand. You just can’t do that with articulated arms … Relative to CO2, there is simply a greater zone of necrotic tissue damage with electrocautery … The laser has paid for itself a hundredfold. I use it every day… Figure 6: LightScalpel laser tube (left) versus imported antiquated glass tube CO2 laser tube (right). Stuart Coleton, DDS White Plains, New York

The flexible fiber waveguide is essential to the work that I do. With my flexible waveguide and my contraangle tip, there’s no place in the mouth I can’t reach! Every area of the mouth is accessible, and that’s a fantastic advantage. The SuperPulse wave configuration works much faster and creates much less tissue damage. I use SuperPulse for almost all of the “cutting” procedures, like gingivectomies and frenectomies – it’s a big advantage to have it… in general, the SuperPulse is a great advancement in CO2 lasers.

Figure 7: Stage II implant uncovering with LightScalpel CO2 laser (Photo courtesy of Grant Selig, DDS, Las Vegas, Nevada)

Steven A Guttenberg, DDS, MD Washington, DC

CO2 laser tube (Figure 6) lasts for up to 45,000 hours (7-plus years), is inexpensively rechargeable, capable of handling extreme shocks and vibrations, and is easily pulsed and air-cooled under the heaviest operating conditions.

LightScalpel-assisted soft tissue oral surgery The LightScalpel installed base in dentistry is rapidly growing, thanks to LightScalpel’s price point being more than $20,000 below competitive offerings (from overseas), and thanks to the unprecedented versatility of its handpieces and controls. Figures 7 and 8 illustrate some of the LightScalpel’s applications that allow it to boost profitability (as reported by dental practices using LightScalpel) because of performing soft tissue procedures much quicker and virtually bloodless. Without 14 Implant practice

Figure 8: LightScalpel CO2 laser fibroma removal (Photo courtesy of Robert Levine, DDS, Scottsdale, Arizona)

LightScalpel, many soft tissue procedures would be referred out (and revenues lost), or much longer time would be spent (and vital efficiencies and profits lost because of the bleeding and suturing) on such procedures performed with a blade. IP

REFERENCES 1. Jacques SL. Optical properties of biological tissues: a review. Phys Med Biol. 2013;58(11):R37-61. 2. Derived from Wolfe WL, Zissis GJ. The Infrared Handbook. Office of Naval Research, NAVY, Wash. DC, 1985;7-81.

This information was provided by LightScalpel.

Volume 7 Number 5

COMPANY SPOTLIGHT

Anatomage Shaping and defining industry standards

natomage was founded in 2004. This year, the company is celebrating 10 years of bringing innovative technology to the healthcare industry. During this decade, the medical solutions company has been experiencing robust and consistent growth. Anatomage is headquartered in downtown San Jose, California, the capital of Silicon Valley. Thriving in a place where innovation is a part of the culture, Anatomage’s products have been featured globally on TED, BBC, CBC, Japanese Fuji TV, and PBS due to their originality and positive impact. Anatomage’s avant-garde approach has made the company a technical leader, shaping and defining the industry standards. With representatives in more than 20 countries, Anatomage is poised to maintain its robust growth into the next decade. Anatomage is committed to offering high quality products and services that satisfy its customers. The company prides itself on having strong relationships with customers and creating a high-caliber support team with whom customers enjoy working. Anatomage is composed of biologists, medical specialists, and engineers from top schools across the country, all of whom represent the best of their respective fields. Establishing strong ties through successful relationships, collaborating with researchers, and helping build curricula at many prominent universities have been Anatomage’s priorities since its inception. Anatomage is dedicated not only to making the most innovative products, but also to creating the highest quality experiences. At the beginning of 2014, Anatomage expanded into a 25,000-square-foot office space, including an on-site gym, multiple meeting rooms, and a large multipurpose classroom. Doctors recently had the opportunity to take courses in the new space, which received abundant compliments and excellent reviews. Anatomage is looking forward to hosting many more instructional programs for its customers and employees. The company has a history of highly attended, well-reviewed users’ group meetings and study clubs. These educational opportunities are an excellent way for new or experienced doctors to expand their 16 Implant practice

knowledge, increase their skills, and meet the Anatomage staff. With a personal approach to customer support, Anatomage offers the opportunity for doctors to work with the same surgical and application specialists. Each support member has a strong technical or clinical background and is highly trained. Doctors will often work with the same specialist regularly on a variety of cases and software features. Anatomage employees enjoy company events ranging from the annual Iron Chef Competition to white water rafting on the American River. The incredibly talented team members enjoy creating impromptu

performances in their new music room outside of business hours. Employees can often be found giving back to the community through Relay for Life benefiting the American Cancer Society or One Warm Coat, among others. Anatomage products are used in tens of thousands of clinics and hospitals both in the United States and internationally. The company has established partnerships with leading radiology equipment companies that bundle Anatomage’s software with their scanning equipment as their exclusive imaging solution. Anatomage’s current product offering includes its award-winning Invivo5 radiology software, image-guided surgical devices, surgical instruments, and educational display equipment.

Invivo5 Invivo5.3 is the latest edition to the InVivoDental software lineage. The highquality visualizations and myriad of diagnostic tools have brought Invivo5 to the top of the global market. This innovative software

“Once in a while you come across a company or product that is head and shoulders above its competition. Anatomage is such a company, and Invivo5 is such a product . . . What also makes Anatomage great are the people working for the company . . . Anatomage is a great company to work with because it provides superior product and superior customer service to its clients. I highly recommend Anatomage to anybody searching for a guided dental implant surgery solution.” – Dr. Vladimir Polyakov, Anatomage Guide User

Volume 7 Number 5

COMPANY SPOTLIGHT is used by implantologists, oral surgeons, general dentists, orthodontists, and periodontists. The software opens Medical CT, MRI, Dental CBCT, and any other medical images in the standard DICOM format without the need for file conversions. These medical images are quickly displayed as interactive three-dimensional volumes for clinical diagnosis and demonstration. Invivo5 features restoration-driven implant planning with full CAD/CAM integration. Furthermore, the large restoration library has many crown morphologies to choose from.

“The goal for Anatomage is to stay focused on clinically oriented innovation that can be easily used by the doctor. We are very excited to see that many doctors are adopting the new technology and incorporating it into their everyday practice routine. That’s what motivates us.” – Dr. Jack Choi, CEO of Anatomage Jack Choi arrived in Silicon Valley, California, during the “dot-com” rush. With a PhD in Engineering from Carnegie Mellon University and the dream of owning a business, this modern-day “49er” started laying the groundwork for Anatomage.

Collage Anatomage’s most recent innovation, Collage, is an ingenious approach to patient image management. This unique patient image management software can manage all patient images, 2D and 3D, seamlessly. Collage’s side-by-side image viewing option supports 3D and 2D image data at the same time. The single, server, or cloud-based software supports many image formats including jpg, dcm, and stl files, among others. Collage allows for quick and easy access to all the patient images in a single unified location for efficient image management.

long and rigorous clinical-testing period before coming to the market. The fully digital process involves no preprocessing and guide delivery with fast turnaround times. Immediately plan implants directly in Invivo5 and educate patients with powerful educational images and simulations. Anatomage Guides are compatible with other implant manufacturer guide kits for easy adoption into any office.

Anatomage Table The Anatomage Table is a virtual dissection table for anatomy education. Universities, simulation centers, and hospitals worldwide have adopted the Anatomage technology for their anatomy and procedural demonstrations. The pre-installed pathology cases

expose students to clinical images early in their studies, and the high-resolution regional anatomy scans allow instructors to highlight difficult to see anatomical landmarks. Example gross anatomy cases are fully labeled for self-assessment, and instructors can even load their own clinical cases for additional educational use. Anatomage’s vision for the future is full of innovations that will shape the next generation of medical care. With dedication to developing seamless workflows and eliminating unnecessary steps, Anatomage has the vision of optimizing the process while increasing the quality of healthcare. IP This information was provided by Anatomage.

Anatomage Guide Anatomage proudly offers the most refined solution for guided surgery. With a low flat rate and high reliability, Anatomage Guide has been steadily and rapidly growing in popularity. Anatomage Guide went through a

18 Implant practice

Volume 7 Number 5

Drs. Gregori M. Kurtzman and Douglas F. Dompkowski illustrate an approach that can avoid complications Introduction The posterior maxilla presents with a common problem clinically following tooth extraction or crestal bone loss resulting in loss of osseous height sufficient to place implants. Resorptive patterns in some patients along with sinus enlargement result in minimal bone that can accommodate implant placement. Maxillary sinus augmentation over the past 18 years with various bone graft materials has become routine treatment. Numerous studies have reported highly successful implant survival rates when placed into the augmented sinus.¹-3 Transalveolar sinus floor elevation, also referred to as subantrial augmentation, was first described by Tatum4 and later modified by Summers.5-7 This technique utilized a series of osteotomes with a mallet to create an osteotomy and subsequent infracturing of the sinus floor while elevating the Schneiderian membrane. Following manipulation, the space created in the sinus is augmented with various bone particulate graft materials, increasing the volume of bone available for implant placement. Various studies have reported that when 5 mm of residual alveolar bone is present, simultaneous implant placement can be performed to achieve adequate primary stability.6,8,9 But when less than 5 mm of residual alveolar bone height is available, a delayed two-stage approach has been recommended.10,11 The most common complication of the lateral sinus elevation approach is typically tearing of the Schneiderian membrane, which could allow

for bacterial contamination or loose particles to gain access to the sinus cavity. A safer lateral window approach sinus augmentation procedure will be discussed using specialized safe cutting end drills with vertical stoppers for osseous window formation and subsequent membrane elevation (Lateral Approach-Sinus Kit (LASK), HIOSSEN).

Materials and methods The LASK provides dome drills, core drills, metal stoppers, a side wall drill, and a bone separator tool (Figure 1). The dome drill is a unique osseous drill allowing removal of the lateral wall of the maxillary sinus while collecting autogenous bone to be added to the material to be placed into the sinus. Macro- and micro-cutting blades provide excellent cutting of the lateral wall without tearing of the sinus membrane. These dome drills, available in both 5.0 and 7.0 mm in diameter, are run at 1,200 to 1,500 rpm with irrigation in an implant surgical handpiece. Metal depth control stoppers are provided that fit on the dome drills, limiting depth of penetration (0.5, 1.0, 1.5, 2.0, 2.5, and 3.0 mm) and are used sequentially to safely expose the sinus membrane. The core drill, also available in 5.0 and 7.0 mm diameter differs from the dome drill in that the center does not cut, with bone removal resulting in a core of bone being left over the sinus. This bony lid may be elevated with the sinus membrane still attached becoming the new “roof” to the sinus with osseous augmentation being placed below

it. This particular drill follows the same design of the CAS-Kit (crestal augmentation sinus) drills and are utilized at 1,200-1,500 rpm. The metal drill stoppers also fit these drills, allowing controlled sequential depth preparation. The bone separator tool is utilized to separate the osseous core created with the core drill if removal is desired and is based on the practitioner’s preferred technique. The side wall drill may be used to enlarge the osseous window created by the dome drill if desired. The tip of this drill is smooth and designed to safely push the sinus membrane away from the cutting portion of the drill, which starts 1 mm from the safe end. Osseous cutting is performed at 1,500 rpm, using the side of the rotating drill to enlarge the osseous window. The CAS-Kit metal drill stoppers may be placed on this drill to limit accidental penetration too far into the sinus and tearing of the membrane during this drill’s use. As with the other drills in this kit, irrigation is needed during its use. Gregori M. Kurtzman, DDS, DICOI, DADIA, is in private general practice in Silver Spring, Maryland, and is a former Assistant Clinical Professor at the University of Maryland, Baltimore College of Dentistry, Department of Endodontics, Prosthetics and Operative Dentistry. He has lectured both nationally and internationally on the topics of restorative dentistry; endodontics and implant surgery and prosthetics; removable and fixed prosthetics; and periodontics and has over 360 published articles. He is privileged to be on the editorial board of numerous dental publications, a consultant for multiple dental companies, and a former Assistant Program Director for a university-based implant maxi-course. He has earned Fellowship in the AGD, AAIP, ACD, ICOI, Pierre Fauchard Academy, and Academy of Dentistry International; Mastership in the AGD and ICOI; and Diplomate status in the ICOI and American Dental Implant Association (ADIA). Dr. Kurtzman has been honored to be included in the “Top Leaders in Continuing Education” by Dentistry Today annually since 2006. He can be contacted at dr_kurtzman@maryland-implants.com. Douglas F. Dompkowski, DDS, is in private practice limited to periodontics and implant dentistry in Bethesda, Maryland. He is the course director for the AIC Advance Surgical course in Implant Dentistry and is a former Assistant Clinical Professor at the University of Maryland, Baltimore College of Dentistry, Department of Periodontics. He has lectured both nationally and internationally on the topics of Implant surgical procedures, sinus augmentation, and periodontics. Dr. Dompkowski has co-authored numerous articles on implant dentistry. He can be contacted at dompkowskidds@verizon.net.

Figure 1: Lateral Approach-Sinus Kit (LASK) Volume 7 Number 5

Implant practice 19

CLINICAL

Lateral sinus augmentation: a safer technique

CLINICAL Case report A 32-year-old male presented with the desire for implant placement in the posterior maxillary right quadrant which had been missing the first molar for an extended period of time. The result of long-term loss of the tooth resulted in drifting of the second molar into the space, which was corrected orthodontically prior to implant surgery. Radiographically, enlargement of the maxillary sinus was noted with insufficient height in the molar region for implant placement (Figure 2). Resorption was noted compromising the width of the ridge at the buccal leading to a mild concavity (Figure 3). Sinus augmentation was discussed to assist in achieving the patientâ&#x20AC;&#x2122;s desired treatment

goal of implant placement and restoration with a fixed crown. Following administration of local anesthetic, a crestal lingual incision was made with vertical releasing incisions at the mesial and distal aspect of the site, and a full thickness flap was elevated, leaving the attached gingiva undisturbed on the adjacent teeth (Figure 4). Elevation of the flap extended superiorly to expose the lateral wall of the maxillary sinus up to the inferior aspect of the zygoma (Figure 5). A 0.5 mm wide dome drill was placed onto the surgical handpiece with a 0.5 mm drill

stopper (Figure 6). This would allow initiation of the window without the possibility of excessive penetration and subsequent damage to the sinus membrane. The initial dome drill is placed onto the surgical handpiece with the selected drill stop. The dome drill with stopper was placed on the lateral sinus wall at a height more superior then the current height of the available bone as measured radiographically (Figure 7). This is done to ensure that the window created has

Figures 2A and 2B: CBCT radiograph pretreatment demonstrating insufficient osseous height for implant placement without sinus augmentation in the molar region

Figure 3: Buccal concavity evident as a result of long-standing loss of the first molar, compromising the width of the site

Figure 4: A trapezoidal-shaped flap was created with a scalpel with the crestal incision placed to the palatal aspect of the ridge

Figure 5: Lateral aspect of the maxillary posterior following elevation of a full thickness flap

Figure 6: Dome drill with 0.5 mm stopper placed on the surgical handpiece

Figure 7: Lateral sinus approached initiated with the dome drill and a 0.5 mm drill stopper

20 Implant practice

Volume 7 Number 5

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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.

CLINICAL

Figure 8: The initial dome drill created an outline into the bony wall

Figure 9: Lateral sinus approached continued with the dome drill and a 1.0 mm drill stopper

Figure 10: Bone is collected from the dome drill to be utilized to augment the graft to be placed

Figure 11: Following each dome drill, the site is examined for identification of the underlying membrane which will appear darker as bone is removed over it

Figure 12: Lateral sinus approached continued with the dome drill and a 1.5 mm drill stopper

Figure 13: Lateral sinus approached continued with the dome drill and a 2.0 mm drill stopper

Figure 14: Lateral wall of the maxillary sinus following sequential use of the dome drill with increasing stopper depth demonstrating no damage to the sinus membrane after bone removal

elevated the membrane circumferentially. When maximum depth has been achieved with the 0.5 mm drill stopper present, the drill stopper is changed to a 1.0 mm stopper, and drilling is continued (Figure 8). The drill stopper is sequentially increased while checking for membrane exposure. Lateral drilling continues stepping up to the next drill stop (Figure 9). Bone collected on the dome drills is removed from the drill and placed into a sterile dish to be added to the graft to be placed, adding the hostâ&#x20AC;&#x2122;s osteopotential 22 Implant practice

cells to the graft (Figure 10). As bone is removed over the sinus membrane, the area changes in color from the light color of the bone (ivory) to darker gray as the dark sinus begins to show clinically at the window (Figure 11). Final window creation is made with the dome drill, in this particular case with a 2.5-mm drill stopper (Figure 13). Some patients may require deeper drilling, which is dependent on thickness of the lateral maxillary sinus wall. The intact sinus membrane

is noted with no bone over the membrane at the window that has been created on the lateral wall (Figure 14). Additionally, host bone is collected from the dome drill. Sinus curettes are utilized to start the sinus membrane elevation at the inferior aspect, teasing the membrane from the osseous wall of the sinus interiorly (Figure 15). Following elevation of the membrane, the membrane should be intact and free of visible tears that may prevent graft distribution within the sinus during initial healing Volume 7 Number 5

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CLINICAL

Figure 15: A curette is utilized to separate the sinus membrane from the bone of the maxillary sinus, elevating it superiorly from the inferior floor to the medial wall

Figure 16: Lateral window completed demonstrating the intact sinus membrane following use of the dome drills and stoppers

Figure 17: A collagen membrane is placed into the sinus over the elevated membrane to help confine the graft to be placed should a micro tear be present in the elevated sinus membrane

Figure 18: Osseous graft material was mixed with the patient’s donor bone collected from the dome drills and was gently packed into the sinus

(Figure 16). It is important that the elevation also include the medial wall of the sinus so that it fills a volume great enough that the implant, when placed, will be surrounded by bone. Failure to elevate the medial aspect may result in the implant, when placed, having no osseous contact, which may decrease clinical success following loading. Additionally, the authors advise elevation to a greater height then the implant length to be placed when a delayed fixture placement is to be performed. This will allow for possible graft settling during healing that may yield less height than was planned. An absorbable extracellular membrane (DynaMatrix®, Keystone Dental) is inserted into the sinus to act as protection, containing the graft material and thickening the sinus membrane, and sealing any micro tears that might be present (Figure 17). The resorbable membrane is cut to size and placed into the sinus dry using the patient’s blood in the site to wet it as it is placed. Once wetted with blood, the resorable membrane becomes sticky, gluing itself to the sinus membrane. Regenaform® cortical cancellous bone chips (Exactech®) and SureOss®, a freezedried cortical allograft (HIOSSEN) were used 24 Implant practice

Figure 19: The elevated sinus area has been completely packed with osseous graft material

Figure 20: Implant placement following osseous graft healing demonstrating the new sinus height achieved

in a 50:50 ratio in a sterile dappen dish and mixed with the autogenous bone collected from the dome drill. The osseous graft mixture was carried to the oral cavity, introduced into the elevated sinus, and gently condensed with a large plugger, pushing the mixture to the medial wall and filling in a lateral direction until the entire cavity was filled (Figure 18). The process was repeated in the cavity anterior to the septa. Sufficient osseous graft was placed till the sinus was augmented to be flushed with the outer aspect of the lateral sinus wall at the window that had been created (Figure 19).

Following sinus grafting, the site was prepared, and an implant (4.5 x 10 mm, ETIII, HIOSSEN) was placed at the site. A low profile cover screw was used to allow primary closure of the flap. The radiograph shows initial graft placement and the elevation achieving a site that can accommodate implant placement at this surgical appointment (Figure 20). A long-term resorbable membrane (DynaMatrix) was cut to extend beyond the outline of the lateral window and placed over the osseous graft that had been placed into the sinus (Figure 21). The flap was Volume 7 Number 5

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CLINICAL

Figure 22: The flap was repositioned and closed with a horizontal mattress and interrupted sutures

Figure 21: A resorbable membrane was placed over the bony sinus window to limit soft tissue ingrowth into the graft during the healing phase

repositioned and initially closed with a horizontal mattress suture using a 5-0 Cytoplastâ&#x201E;˘ suture material, (Osteogenics Biomedical) to achieve primary closure of the Figures 24A and 24B: CBCT demonstrating new volume of bone achieved following flap without tension, sinus augmentation and implant placement, which is ready for restoration of the implant and then the crest was closed with interrupted that had been placed into the sinus, integrasutures (Figure 22). This suture serves to resist soft tissue tension that may result due tion of the implant, and seating of the healing to inflammation and the resulting swelling abutment on the fixture (Figure 23). A CBCT following surgery. Additional sutures are was taken to check the graft and implant placed to close the incision line using a integration, and the implant was ready to be restored (Figure 24). simple interrupted technique. The patient returned 8 months after implant placement. Soft tissue in the site on Conclusion the lateral aspect demonstrated no inflamEmphasis has moved to the use of a mation, and incision lines were not discerncrestal approach to sinus elevation when additional osseous height is required for ible on the gingiva. The implant was exposed implant placement. This approach works using a disposable tissue punch, and the cover screw was replaced by a healing abutwell when at least 5 mm of osseous ment. A radiograph was taken to check and height is present for immediate implant verify the organization of the osseous graft placement. Yet, when less bone height is

Figure 23: Implant following 8 months of healing and exposure to place a healing abutment, demonstrating blending of the grafted sinus with the surrounding native bone

present, a lateral window approach may be the preferred technique to increase crestal height and geometric volume so that implant fixtures may be placed. The lateral sinus augmentation approach can be challenging as tearing of the sinus membrane often necessitates abandoning the procedure and re-entry at a later date after the membrane has healed. Previous techniques involved use of diamonds or carbides in a high-speed handpiece or the use of peizo surgical units. These approaches had potential for membrane damage (burs in a high speed) or were very slow (peizo). The LASK from HIOSSEN utilizes specially designed drills that greatly minimize tearing of the membrane and improve the safety of the procedure. IP

REFERENCES 1. Blomqvist JE, Alberius P, Isaksson S. Two-stage maxillary sinus reconstruction with endosseous implants: A prospective study. Int J Oral Maxillofac implants. 1998;13(6):758-766. 2. Valentini P, Abensur DJ. Maxillary sinus grafting with anorganic bovine bone: A clinical report of long-term results. Int J Oral Maxillofac Implants. 2003;18(4):556-560. 3. Tong DC, Roux K, Drangsholt M, Beirne OR. A review of survival rates for implants placed in grafted maxillary sinuses using META analysis. Int J Oral Maxillofac Implants. 1998;13(2):175-182. 4. Tatum OH Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am. 1986;30(2):207-229. 5. Rosen PS, Summers R, Mellado JR, Salkin LM, Shanaman RH, Marks MH, Fugazzotto PA. The bone-added osteotome sinus floor elevation technique: multicenter retrospective report of consecutively treated patients. Int J Oral Maxillofac Implants. 1999;14(6):853-858. 6. Summers RB. A new concept in maxillary implant surgery: the osteotome technique. Compendium. 1994;15(2):152-162. 7. Summers RB. The osteotome technique: Part 3â&#x20AC;&#x201D;Less invasive methods of elevating the sinus floor. Compendium. 1994;15(6):698-710. 8. Emmerich D, Att W, Stappert C. Sinus floor elevation using osteotomes: a systemic review and meta-analysis. J Periodontol. 2005;76(8):1237-1251. 9. Toffler M. Osteotome- mediated sinus floor elevation: a clinical report. Int J Oral Maxillofac Implants. 2004;19(2): 266-273. 10. Peleg M, Mazor Z, Chaushu G, Garg AK. Sinus floor augmentation with simultaneous implant placement in the severely atrophic maxilla. J Periodontol. 1998;69(12):1397-1403. 11. Peleg M, Mazor Z, Garg AK. Augmentation grafting of the maxillary sinus and simultaneous implant placement in patients with 3 to 5 mm of residual alveolar bone height. Int J Oral Maxillofac Implants. 1999;14(4):549-556.

26 Implant practice

Volume 7 Number 5

Drs. Spyridon I. Vassilopoulos and Michael Mastoris treat a case involving a frequent phenomenon during childhood Backround Tooth loss after trauma is a frequent phenomenon during childhood, especially in the anterior maxillary area. Periapical lesions left untreated for a prolonged period of time can provoke an extended resorption of the labial plate, complicating future implant placement.

years previously. Clinical examination revealed that teeth Nos. 21 and 22 were non-vital with degree III mobility and purulence associated to deep probing pocket depths of > 11 mm mesiodistally. Preoperative radiographical

examination utilizing cone beam computed tomography (CBCT) (Accuitomo, J.Morita, Japan) showed a U-shaped periapical lesion extending 0.5 mm away from the floor of the nasal cavity (Figures 1B and 1C). The patient

Introduction Tooth loss after trauma is a frequent phenomenon during childhood and adolescence. Periapical lesions following tooth necrosis and other post-traumatic complications left untreated for a prolonged period of time can provoke an extended resorption of the labial plate of the alveolar ridge. When dental implants are included in the treatment plan, augmentation procedures of the resorbed buccal plate may be required in order to achieve initial stabilization of the implant in an anatomically appropriate location, especially in the anterior maxillary area, where implants have to satisfy both the long-term functional stability of the prosthetic restoration and the increased esthetic demands of the patient.1

Figure 1A: Initial clinical situation

Case report A 15-year-old, systematically healthy, regular smoker male, was referred to the practice by his pediatric dentist in October 2010 (Figure 1A). His chief complaints were swelling on the maxillary left labial area, accompanied by mobilization of teeth Nos. 21 and 22, and pain on percussion. Patient stated that he had an accident during a basketball game 5 Dr. Spyridon I. Vassilopoulos is a lecturer at the Department of Periodontology, Dental School, National and Kapodestrian University of Athens in Athens, Greece. Dr. Michael Mastoris is an oral radiologist in private practice in Athens, Greece.

Volume 7 Number 5

Figures 1B and 1C: Preoperative radiographical examination (CBCT: Accuitomo, J.Morita, Japan) revealed a periapical lesion in contact with the floor of the nasal cavity Implant practice 27

CASE REPORT

Cone beam computed tomography-monitored guided bone regeneration following teeth extractions in the anterior maxilla of a 15-year-old patient for future implant placement: a case report

CASE REPORT was instructed to follow a smoking cessation program prior to any surgical intervention. Because of the increased possibility of root fractures or cracks on either or both of the involved teeth, a diagnostic, full thickness mucoperiosteal flap was elevated in advance of root canal therapies (Figure 1D). After meticulous degranulation of the defect, apical cracks were spotted, and both teeth were extracted (Figure 2A). Possible remnants of inflammation in addition to the insufficient soft tissue volume overlying the extremely resorbed buccal part of the alveolar ridge led to the delay of any bone regeneration attempt until complete wound healing was achieved. A temporary Rochette-type bridge was delivered to the patient in order to satisfy his increased functional, phonetic, and esthetic needs. Seven weeks later, the uneventfully healed soft tissues were depressed buccally, indicating the extension of the underlying bone loss (Figure 2B). A bone augmentation surgical procedure was performed starting with infiltration of local anesthetic (4% articaine, 1:100,000 epinephrine) and, subsequently, elevation of full thickness buccal and palatal flaps extending from cuspid to cuspid with vertical releasing incisions buccally. The exposed bone defect was grafted with a mixture of allograft mineralized cortical and cancellous chips (MinerOss®, BioHorizons) (Figure 2C). A resorbable collagen membrane (OsseoGuard®, Biomet 3i) was trimmed and carefully adapted over the grafted site (Figure 2D), and then stabilized under the flaps without the need of tucking or suturing. In order to achieve full coverage of the regenerative materials, the site was closed with mucosal advancement flap using releasing incisions of the periosteum, as necessary. Mattress sutures were placed to secure the

Figure 1D: Almost complete loss of bony support and apical cracks were spotted intra-surgically

Figure 2B: Wound healing 7 weeks later. Insufficient soft and hard tissue bucco-palatal dimensions

Figure 2C: 7 weeks later, a bone augmentation surgical procedure was performed. The bone defect grafted with allograft granules (MinerOss®, BioHorizons) 28 Implant practice

Figure 2A: Both teeth were extracted

Figure 2D: Application of a collagen membrane (OsseoGuard®, Biomet 3i™) with a modification of a double-layered technique Volume 7 Number 5

CASE REPORT

Figure 3A: Primary wound closure

membrane under the flap and reduce the tension of the flap, while a second superficial layer of simple interrupted sutures facilitated primary closure of the surgical wound (Figure 3A). The patient was given medication consisting of amoxicillin, (500 mg, q.i.d/7 days), nimesulide, (100 mg, b.i.d/5 days), and chlorhexidine gluconate mouth rinse (0.12%, b.i.d/21 days). Six months post-surgically, the patient returned for evaluation. Clinical examination revealed complete soft tissue restoration bucco-palataly (Figure 3B). CBCT and handwrist films were also obtained. Although more than adequate bone dimensions were noted, confirming the success of the buccal bone augmentation (Figures 3C and 3D), the nearly complete radial epiphyseal closure in conjunction with patientâ&#x20AC;&#x2122;s chronological age (15, 8/12 years old) dictated the delay of implant placement.

Comments The loss of bone volume after tooth extraction, according to Schropp, et al. (2003)2, amounts 5-7 mm horizontally (approximately 50% of the original alveolar bone with) and only 1 mm vertically, within the first 10 months. In the case of more extended horizontal alveolar bone crest deficiencies caused by tooth necrosis or other untreated post-traumatic complications, simultaneous implant placement should be avoided since there is not enough bone to achieve both primary implant stability and an optimal prosthetic-driven implant positioning. Under these circumstances, a staged protocol, which will address the lateral bone augmentation first and the implant placement in a second stage, is highly recommended.3 Furthermore, for the growing patient, this â&#x20AC;&#x153;waitingâ&#x20AC;? period of 6-8 30 Implant practice

Figure 3B: Occlusal view of complete soft tissue restoration 6 months later

Figures 3C and 3D: 6 months postoperatively; more than adequate bone dimensions were measured with CBCT examination

months until adequate maturation of the regenerated bone occurs, can spare the time needed for the completion of growth. Bone augmentation procedures can be applicable during growth, since the regenerated bone will follow the developing pattern of the growing maxilla. Implants placed into regenerated bone show similar success rate with implants placed into pristine bone.4 Even in severely resorbed alveolar ridges, guided bone regeneration techniques utilizing allografts and/or xenografts in conjunction with bioabsorbable or nonresorbable barrier membranes can create an osteoconductive scaffold, providing volume enhancement and effective site development for successful bone remodeling and future implant placement. Avoiding the second surgical trauma in order to obtain an autologous bone block graft from the donor

site may be beneficial for the young patient since it reduces the operative time needed and the post-surgical discomfort.5 In order to evaluate the total amount of bone loss and osseous destruction in three dimensions, cone beam computed tomography (Accuitomo, J.Morita, Japan) examination of that area was performed. The anatomic area to be scanned was restricted, so that only the region of interest was examined, resulting in a radiation dose similar to a panoramic radiograph. This major advantage offers the possibility of repeating the examination, especially in young patients, in order to evaluate the outcome of the surgical procedure and the quality/quantity of newly formatted bone as well as the blending of the grafting material.6 For the growing child or adolescent, early implantation is not recommended, Volume 7 Number 5

of the maxilla continues beyond the age at which transverse and sagittal growth cease. To prevent implant infraocclusion or buccolingual disharmony or, even more, a potential interfering with growing pattern of the jaws,8 it is advisable to delay implant placement until the age of 17 or 18 years for girls and somewhat later for boys.9 IP

Acknowledgments: This case report was awarded with J. Morita prize “Case report’’ at the 23rd Congress of the International Association of Paediatric Dentistry, June 2011, Athens, Greece. Conflict of interest: Authors have declared no conflict of interest.

REFERENCES 1. Schwartz-Arad D, Levin L, Ashkenazi M. Treatment options of untreatable traumatized anterior maxillary teeth for future use of dental implantation. Implant Dent. 2004; 13(2):120-128. 2. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single-tooth extraction: a clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent. 2003;23(4):313-323. 3. Behr M, Driemel O, Mertins V, Gerlach T, Kolbeck C, Rohr N, Reichert TE, Handel G. Concepts for the treatment of adolescent patients with missing permanent teeth. Oral Maxillofac Surg. 2008;12(2):49-60. 4. Oesterle LJ, Cronin RJ Jr, Ranly DM. Maxillary implants and the growing patient. Int J Oral Maxillofac Implants. 1993;8(4):377-387. 5. McAllister BS, Haghighat K. Bone augmentation techniques. J Periodontol. 2007:78(3);377-396. 6. Lofthag-Hansen S, Thilander-Klang A, Ekestubbe A, Helmrot E, Grondahl K. Calculating effective dose on a cone beam computed tomography device: 3D Accuitomo and 3D Accuitomo FPD. Dentomaxillofac Radiol. 2008;37(2):72-79. 7. Thilander B, Odman J, Lekholm U. Orthodontic aspects of the use of oral implants in adolescents: A 10-year follow-up study. Eur J Orthod. 2001;23(6):715-731. 8. Odman J, Grondahl K, Lekholm U, Thilander B. The effect of osseointegrated implants on the dento-alveolar development. A clinical and radiographic study in growing pigs. Eur J Orthod. 1991;13(4):279-286. 9. Heij DG, Opdebeeck H, van Steenberghe D, Kokich VG, Belser U, Quirynen M. Facial development, continuous tooth eruption, and mesial drift as compromising factors for implant placement. Int J Oral Maxillofac Implants. 2006;21(6):867-878.

OUR SCIENCE YOUR CHOICE

OPTECURE • Intra-operative flexibility1 • Resists migration1

• 100% lot tested for sterility

• Optimal DBM concentration1,2 • 3D Matrix for bone cell • 100% lot tested in-vivo for migration osteoinductivity 1. Data on file at Exactech. 2. Keller T, et al. Carriers may change osteoinductivity of human demineralized bone in the athymic mouse. The 32nd annual Meeting and Exhibition of the American Academy of Dental Research. 2003 Mar.

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WWW.EXAC.COM | 1-866-284-9690 Implant practice 31

CASE REPORT

since osseointegrated implants behave like ankylosed teeth, jeopardizing the longterm esthetic and functional outcome of the implant supported restoration, particularly in the anterior maxillary area. Thilander, et al.,7 followed 15 adolescents (13 to 19 years old) with 27 implants for a period of 10 years. Mean infraocclusion of the implants was 1.0 mm (range 0.1 to 2.2 mm), possibly causing marginal bone loss around the adjacent teeth. A clear correlation was recorded between body length growth and the extent of implant infraocclusion after 3 years of loading. Interestingly, from the fourth year on, the relative infraocclussion increased (mean of 0.5± 0.6 mm) despite the fact that no further length growth or craniofacial alterations could be measured. Growth of the maxilla in a vertical direction occurs as a combined result of suture growth; bone remodeling in the orbits, the nasal cavity, and the maxillary sinuses; and continued teeth eruption. Vertical growth

CONTINUING EDUCATION

The role of piezosurgery in implant dentistry Dr. Adam Patel details the huge potential of piezosurgery for improving the predictability and ease of dental implant treatment

iezosurgery was first introduced in 1988. Its development was encouraged by the need for high levels of precision and safety in bone surgery compared with that achieved by standard bur and saw instruments (Landes, et al., 2008). Piezosurgery as a technique spread because of its ease of use and safety. The piezoelectric effect occurs when an electric current is passed around a stack of crystals, and they start to vibrate at a precise frequency. The piezoelectric instrument produces a modulated ultrasonic frequency of 24 to 29kHz, and a microvibration amplitude between 60 and 200 mm/sec (Sortino, et al., 2008). The amplitude of these microvibrations allows a clean, precise, and controlled cut of bony structures without causing destruction of soft tissue (including nerves, blood vessels, and oral mucosa) (Eggers, et al., 2004). Since its introduction, piezosurgery has established an important role in various aspects of dentistry and dental implantology (Table 1). This article will discuss the role of piezosurgery in these areas, including its advantages and disadvantages.

Properties and characteristics The piezosurgery unit provides three different power levels (endo, perio, and cortical/spongious), the highest of which is used in bone surgery. The amplitude of the working tip ranges from 60 to 200, mm/sec, with variable ultrasonic frequencies (Beziat, et al., 2007). A distinctive characteristic of piezosurgery is its ability to distinguish tissue hardness. It will act only on mineralized structures and, thus, will not cut or damage soft tissues. This occurs due to cessation of the surgical action when the scalpel comes into contact with demineralized structures (Robiony, et al., 2007). Piezosurgery can be advantageous when exact cutting of thin bones is required. Adam Patel, BDS, MFDS, RCS, Ed MFDS, RCPSG, graduated from the University of Liverpool (England) in 2008 and embarked on a multitude of postgraduate courses in restorative, prosthodontics, and oral surgery. He is currently in the final year of an MSc in implantology at the University of Manchester. Dr. Patel is also a visiting clinician in several practices nationwide.

32 Implant practice

Educational aims and objectives

The aim of this article is to discuss the role of piezosurgery in implant cases and to explore the advantages and disadvantages.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 37 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Define the properties and characteristics of piezosurgery. • Identify the osseous response during piezosurgery. • Recognize how piezosurgery is involved in guided bone regeneration. • Realize the role of piezosurgery during a sinus lift. • Realize how piezosurgery is used in Le Fort I osteotomies.

The modulated ultrasonic vibrations allow controlled cutting of bony structures. Delicate bony structures can be cut easily and with great precision. However, it is only of limited use in cutting highly dense bone and in regions with limited access (Eggers, et al., 2004). Because of its micrometric and selective cut, the piezosurgery unit produces safe and precise osteotomies without any osteonecrotic damage (Robiony, et al., 2004). Due to its cavitational effect on physiological solutions such as blood, piezosurgery creates an effectively bloodless surgical site that makes visibility in the working area much clearer than with conventional bone-cutting instruments (González-García, 2007). The digital modulation of the oscillation frequencies and the high-flow irrigation system of the piezosurgery unit minimizes overheating of the bone during osteotomies (Robiony, et al., 2007). Unlike conventional burs and micro saws, piezosurgery inserts do not become hot either, which again reduces the risk of postoperative necrosis and helps maintain vitality of adjacent tissue (Horton, et al., 1975).

In comparison with traditional rotary instrumentation, piezosurgery requires much less hand pressure. This leads to enhanced operator sensitivity and control, allowing the clinician to develop a better “feel” and precision for the cutting action because of the microvibration of the cutting tip (Seshan, et al., 2009). Osseous response Microscopic examination of bone fragments acquired during piezosurgery (Figure 1) have shown viable cells on the bony surfaces with no signs of coagulative necrosis (Robiony, et al., 2007). Research has shown a more favorable osseous response, with less bone damage when compared with diamond or carbide burs (Vercellotti, et al., 2005). A study by Preti, et al. (2007), concluded that piezoelectric bone surgery is more effective in stimulating implant osteogenesis, promoting more osteoblastic activity around the implant sites compared to sites prepared conventionally with drills. Another study comparing piezosurgery with carbide and diamond burs to cut

Table 1: Uses of piezosurgery in implant dentistry • Bone grafting procedures • Bone harvesting (chips) • Distraction osteogenesis • Ridge expansion • Sinus lifts • Le Fort I osteotomies

• Surgically assisted rapid maxillary expansion (SARME) • Implant site preparation • Relocation of a malpositioned implant • Nerve transpositions • Atraumatic tooth extraction • Peri-mucositis/peri-implantitis and calculus removal

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experimental osteotomies showed conventionally treated surgical sites lost bone level by day 14, compared to those treated by piezosurgery — which actually gained bone level. The study concluded that piezosurgery provides more favorable osseous repair and remodelling compared to burs when surgical ostectomy and osteoplasty procedures were performed (Landes, et al., 2008). A study examined the recovery process of dogs that had gone through osteotomies with various techniques. In this study, the clinical and histological aspects of three surgery techniques — scalpel, piezosurgery, and low-speed bur — were analyzed. The recovery process after scalpel and piezosurgery were similar. However, a difference was observed in the recovery of bone tissue treated by a bur, as it produced degeneration of cellular elements along the edges, persistence of fibrovascular tissue, and a reduced reaction of osteoblasts and osteoclasts (Sortino, et al., 2008). Healing By applying the same surgery protocol and measurement methods, the study also compared rotary and piezosurgery with regards to time taken to complete surgery and postoperative healing. The average time of surgery was 25.83% higher in the piezosurgery group compared with rotary. The facial swelling and trismus at 24 hours post surgery with piezosurgery were respectively 40.06% and 25.3% lower compared with rotatory osteotomy technique. The results of the comparative study showed that piezosurgery reduces the postoperative facial swelling and trismus, although increases the time of surgery (Sortino, et al., 2008). Disadvantages One key disadvantage of piezosurgery is Volume 7 Number 5

the time involved: The piezoelectric scalpel requires repeated application to the bone to progressively deepen the cut and complete the osteotomy. This increased preparation time inevitably carries financial implications, so slightly higher costs may be involved. Piezosurgery usage in areas of highly dense cortical bone may have limited cutting strength and may not function as effectively as burs, and thus may not be suitable for all implant site preparations.

Bone grafting There is a range of techniques available to manage deficient alveolar ridges. These include: • Block bone grafting • Guided bone regeneration • Distraction osteogenesis • Ridge expansion

Block bone grafting The correct positioning of implants, in accordance with prosthodontic and functional principles, can be compromised by bone volume or density. The aim of augmentation is to reconstitute the original hard tissue contours as far as possible (Gellrich, et al., 2007). Atrophic alveolar ridges should be restored by bone augmentation so as to allow optimal implant positioning within the prosthetic envelope (Muñoz-Guerra, et al., 2009). Various resources for bone grafting exist, including the use of allografts, xenografts, and alloplastic materials. However, autologous bone is still regarded as the gold standard with respect to intended bone quantity, quality, and an uneventful healing phase with reliable outcome (Gellrich, Figure 2: Chin block graft being harvested from the anterior mandible et al., 2007). Piezosurgery can be

Implant practice 33

CONTINUING EDUCATION

Figure 1: Microscopic examination of bone fragments acquired during piezosurgery shows viable cells on bony surfaces with no signs of coagulative necrosis

used effectively in autogenous block bone grafting procedures. Autogenous grafts can be harvested from both intra- and extraoral sites. The most common intraoral sites include the mandibular ramus and symphysis, where delicate structures exist. One of the most significant advantages of piezosurgery over conventional burs and saws is its selective cut. This means that bone can be cut with relative ease while soft tissue, including nerves, blood vessels, and mucosal tissues, remain unharmed, even if they come into direct contact with the cutting tip (Stübinger, et al., 2006). In comparison with surgical burs and microsaws, piezosurgery requires only a feather-light touch, allowing better operator sensitivity and control. As a result, the clinician develops a better feel and precision for the cutting action, can feel the transition from cortical to cancellous bone, and produces precise and clean cuts up to one centimeter deep. Consequently, the operator minimizes trauma and waste to the adjacent bone, creating grafts of optimum dimensions. Figure 2 demonstrates a chin block graft being harvested from the anterior mandible. Because piezosurgery does not traumatize the bone, it prevents the considerable bone necrosis often caused by surgical burs and microsaws (Vercellotti and Pollack, 2006). Histological research has shown a clear lack of postoperative cellular damage to the resection edges, bony matrix, or bone marrow. There is also evidence of the presence of vital osteoblasts near the cut section of bone — meaning that bone cut with piezosurgery stays vital, and any bone chips that are harvested will contain vital osteoblasts as well as bone matrix, which, in turn, will increase healing rate. In addition, less periosteal stripping occurs when using piezosurgery, so there is subsequently less postoperative pain and swelling, and wound healing is improved (Landes, et al., 2008). The risk of postoperative necrosis is further reduced

CONTINUING EDUCATION because piezosurgery inserts do not get hot (Vercellotti and Pollack, 2006). The overall patient experience may be less traumatic, with reduced donor and recipient site morbidity â&#x20AC;&#x201D; and fewer complaints about vibration compared to with conventional burs and microsaws. Guided bone regeneration Piezosurgery is also very useful for harvesting bone chips, which Figures 3A and 3B: Ridge expansion is the surgical widening of a bone ridge in the mouth to allow for the placement of dental implants are produced at the optimum grain size for effectiveness and remain on possible due to its micrometric and linear Sinus lifts the bone surface ready for collection. vibrations, and cause minimal damage to Atrophy of the maxilla and progressive Two surgical tips are available for removal of hard and soft tissues (Vercellotti, 2000). pneumatization of the maxillary sinus can cortical bone, eliminating the need for bone The use of piezosurgery can permit ideal compromise implant placement in the postetraps. These bone chips can be used alone osteotomy preparation without flap damage, rior maxilla. Atrophy can lead to inadequate or in combination with other graft material for providing abundant vascularization that leads height, width, and quality of bone restricting guided bone regeneration purposes. to successful new bone formation. Furtherideal implant positioning and risking perforaLandes, et al. (2008), assessed bone more, it is possible to get direct visibility over tion of the sinus floor (MuĂąoz-Guerra, et al., chips collected using piezosurgery and entire osteotomies. The only minor limita2009). There can often be as little as a few conventional burs and found no difference tion is the slightly longer time required for millimeters of bone between sinus and the in the detrimental effect on the viability and the operation. oral cavity. differentiation of cells, but found piezosurgery Piezosurgery can be used as an alterwas more economical in regard to quantity Ridge expansion native or adjunct to standard instrumentaof bone harvested. Ridge expansion is the surgical widening tion during a sinus lift procedure (Figure 4). of a bone ridge in the mouth to allow for The sinus is accessed through a window Distraction osteogenesis the placement of dental implants (Figure prepared in the lateral wall of the sinus, Distraction osteogenesis is a method of 3). It can allow for a shortened treatment conventionally made using a diamond bur regaining both hard and soft tissue without time and eliminates the issue of donorand then infracturing of the bony window. grafting. It is the biological process of new site morbidity, as grafting is not required. However, a round piezosurgery tip may bone formation through the application of Piezosurgery was originally designed for be used to prepare the window instead, graduated tensile stress by incremental augmentation in implant surgery, including which brings the advantage of being able traction. With ridges that require four to five sinus lifts and procedures such as ridge to touch the sinus lining without tearing millimeters of vertical height augmentation, expansion (Eggers, et al., 2004). It can be it. This eliminates the need to leave a thin or where the overlying soft tissue does not used to cut the crestal and proximal facial layer of bone around the window and tap it support osseous augmentation, distraction cortices in a precise and tactile controlled osteogenesis is a useful treatment alternain (and thus further reduces the chance of manner. Motorized osteotomes are then tive, with piezosurgery being an effective tool perforation). used to widen the split ridge and create for distraction osteotomies (Lee, et al., 2007). A blunt inverted cone tip can then be space. This technique allows for the expanWhen performing distraction osteoused to raise the sinus lining, reducing sion of narrow, anatomically limiting, atrogenesis in certain areas, it is critical to the risk of damage to the membrane even phic ridges, creating space for immediate complete the osteotomies delicately, because further. In cases of sinus lift, studies have placement of implants. The facial and lingual they are performed close to dental and perishown it can reduce the membrane perfocortices provide necessary support with odontal structures, and to soft tissues that ration rate from 30% with the conventional vital osteocytes for osteogenesis (Kelly and provide vascularization. The advantage is approach to 7% with the piezosurgery Flanagan, 2013). that we can osteotomize as precisely as (Wallace, et al., 2007).

Figures 4A, 4B, and 4C: Lateral sinus window cut using piezosurgery followed by gradual lifting of the Schneiderian membrane and subsequent particulate sinus grafting 34 Implant practice

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In severely atrophic alveolar ridges, both the maxilla and mandible can present a jaw discrepancy, with a skeletal Class III tendency and a loss of vertical dimension that may hinder treatment with dental implants (Muñoz-Guerra, et al., 2009). Severe atrophy of the edentulous maxilla can cause insufficient bone volume and an unfavorable vertical, transverse, and sagittal relationship, due to the tri-dimensional resorption pattern of long-term maxillary edentulism (MuñozGuerra, et al., 2009). Maxillary sinus augmentation and onlay grafting procedures can allow the correction of bone defects, but are often insufficient to correct severe maxillary retrusion and increased interarch distance. Le Fort I osteotomies allow for forward or downward repositioning of the maxilla to correct intermaxillary vertical and transverse discrepancies (Bell, et al., 1977). Correction of osseous deficiencies using this technique permits ideal implant placement and creates a more natural soft tissue profile that impacts on the overall prosthodontic outcome. The precise nature of piezosurgery provides exact, clean, and smooth cut geometries (Stübinger, et al., 2005). This is an extremely important attribute, considering an atrophic maxilla is likely to present with a thin and fragile bone structure that may increase the risk of accidental fracture. The application of piezosurgery in these instances is advocated over other mechanical instruments because it minimizes the chances of accidental damage (Muñoz-Guerra, et al., 2009). The risk to critical anatomical structures, such as the palatine nerve and artery, is also minimized because the surgical action stops when the piezosurgery insert comes into contact with demineralized structures (Robiony, et al., 2007). However, it must be noted that the success rate of implants placed in a reconstructed maxillae following a Le Fort I technique and bone grafting is significantly lower than that of implants placed in an edentulous, but non-reconstructed, maxillae (Chiapasco, et al., 2007). Piezosurgery has also been used in various other craniofacial surgical procedures in addition to Le Fort osteotomies, including calvarian bone grafting and mandibular sagittal splits (Beziat, et al., 2007).

well-established procedure to correct maxillary transverse discrepancies. Piezosurgery can be used to carry out the surgical aspect of this technique and carries the same surgical advantages as those mentioned previously within this article.

Implant site preparation Piezosurgery is efficient at preparing implant site osteotomies due to its selective cut, micro-streaming, and cavitational effects, which preserve and maintain the soft tissue — essential for the overall healing and esthetics of the implant (Sortino, et al., 2008). Micro-streaming is the continuous whirling movement of fluid created by a vibrating insert that favors a mechanical action of debris removal. Intraoperative visibility is enhanced with piezosurgery by the implosion of gas bullae into blood vessels during the osteotomy, which have a hemostatic effect — the cavitational phenomenon (Sortino, et al., 2008). Primary implant stability and osseointegration are directly indicative of implant prognosis. Primary implant stability can provide an early indication of future osseointegration. A recent study by Baker, et al. (2012), has suggested that there are no statistically significant differences between primary implant stability provided by using the piezosurgery in comparison with a conventional rotary unit. However, due to the study being ex vivo in nature and the relatively small sample size, further studies are recommended. In a minipig model, bone healing at intervals of 1, 2, 4, and 8 weeks in sites prepared with piezosurgery was compared to sites prepared with conventional drills. The study (Preti, et al., 2007) concluded that piezosurgery was more effective in stimulating implant osteogenesis, promoting more osteoblastic activity around the implant sites compared to sites prepared conventionally with drills. Another randomized control trial suggested that piezosurgery implant site

preparation has the potential to modify biological events during the osseointegration process, resulting in a limited decrease of implant stability quotient values and in an earlier shifting from a decreasing to an increasing stability pattern in comparison with traditional drilling technique (Stacchi, et al., 2013).

Relocation of malpositioned implants Implant relocation (Figure 5) is a relatively new surgical technique used to move integrated implants along with their surrounding bone into a more desired position. Inadequately positioned implants can either be left as “sleeper” implants, if their support is not essential for rehabilitation, or surgically removed and then replaced. The disadvantage of surgically removing the implant is that bony defects may be created, which compromise the ideal placement of another implant. Another option is to surgically remove the implant with its surrounding bone into a more appropriate position. This peri-implant osteotomy can be accomplished by using conventional burs, saws, or piezosurgery (Stacchi, et al., 2008). The advantage of using piezosurgery for this procedure is that maximum intraoperative control can be maintained to ensure a precise cut and minimal bone ablation. In addition, the healing response is likely to be more favorable in comparison to cuts using burs or saws (Preti, et al., 2007).

Nerve transpositions Piezosurgery can be used for nerve lateralization or transposition procedures. The precise and selective surgical cut of piezosurgery is extremely important when performing surgery close to nerves such as the inferior alveolar nerve. Eriksson, et al. (2006), reported that an interruption of the structures of a nerve would result in proliferation of axons, a patho-physiological cause of paresthesia and dysesthesia.

Surgically assisted rapid maxillary expansion Surgically assisted rapid maxillary expansion (SARME) is another Volume 7 Number 5

Figures 5A and 5B: Introduction of the piezosurgery tip (5A) and implant site post-explantation (5B) Implant practice 35

CONTINUING EDUCATION

Le Fort I osteotomies

CONTINUING EDUCATION An in vitro study compared piezosurgery with conventional bur surgery for transposition of the inferior alveolar nerve to assess the effects on both soft and hard tissues. The study concluded that piezosurgery was more invasive to the bone than a conventional diamond bur, but the amount of injury was much lower than when using a conventional rotary bur (Metzger, et al., 2006).

Atraumatic tooth extraction When an implant is to be placed into a socket or area where a tooth is to be extracted, it is imperative to ensure minimal trauma to the surrounding bone to maintain as much bone as possible for integration of the implant. Piezosurgical extraction consists of cutting the fibers of the periodontal ligament with vibrating tips of up to 10 mm in depth. The teeth can then be mobilized with an elevator. This method can be very useful with teeth that are ankylosed. Extractions performed in this way can be atraumatic, and render subsequent implant placement more predictable and easier compared to using burs (Blus and SzmuklerMoncler, 2010).

Peri-mucositis, peri-implantitis, and calculus removal Piezosurgery can be used in the treatment of peri-implantitis. It can be used for soft tissue debridement to remove the secondary flap after incision through retained periosteum. Using a thin tapered tip and altering the power setting, the piezosurgery device can also be used to debride the field of residual soft tissue and for root surface scaling to ensure thorough removal of calculus. The piezosurgery system also allows removal of calculus from titanium osteosynthetic material quickly. Debris and infected bone can be removed from implant surfaces without damaging the implant. This feature can also be beneficial when hard tissue has ingrown into screw slots, as it allows safe removal without damaging the screw itself to allow for screwdriver application (Robiony, et al., 2007).

Conclusion Before the widespread use of piezosurgery for osteotomies is accepted, possible side effects such as thrombogenesis or impaired blood circulation need to be examined. An area of particular concern is the poorly vascularized mandible, where thrombosis of its intraosseous vessels may lead to obvious clinical problems of reossification of the osteotomy gap (Landes, et al., 2008). 36 Implant practice

Long-term follow-up in larger patient numbers will prove whether seldom, yet serious, complications such as hemorrhage, aseptic necrosis, and facial nerve palsy may occur with smaller incidence compared with conventional techniques (Landes, et al., 2008). As this article demonstrates, however, there is an important role for piezosurgery in various clinical scenarios within dental implant treatment. Piezosurgery can benefit the operator by allowing clear-cut precise

osteotomies to be performed in a clear bloodless field without the risk of damaging soft tissues and nerves. The use of piezosurgery can equally benefit the patient by reducing postoperative swelling and trismus and speed up the recovery process. In addition, the lack of osteonecrosis caused by piezosurgery and the positive effects on bone healing and osteogenesis mean that piezosurgery is a valuable tool to have within your dental implant armamentarium. IP

REFERENCES 1. Baker JA, Vora S, Bairam L, Kim HI, Davis EL, Andreana S. Piezoelectric vs. conventional implant site preparation: ex vivo implant primary stability. Clin Oral Implants Res. 2012;23(4):433-437. 2. Bell WH, Buche WA, Kennedy JW III, Ampil JP. Surgical correction of the atrophic alveolar ridge. A preliminary report on a new concept of treatment. Oral Surg Oral Med Oral Pathol. 1977;43(4):485-498. 3. Beziat JL, Vercellotti T, Gleizal A. What is piezosurgery? Two years experience in craniomaxillofacial surgery. Rev Stomatol Chir Maxillofac. 2007;108(2):101-107. 4. Blus C, Szmukler-Moncler S. Atraumatic tooth extraction and immediate implant placement with Piezosurgery: evaluation of 40 sites after at least 1 year of loading. Int J Periodontics Restorative Dent. 2010;30(4):355-363. 5. Chiapasco M, Brusati R, Ronchi P. Le Fort I osteotomy with interpositional bone grafts and delayed oral implants for the rehabilitation of extremely atrophied maxillae: A 1-9-year clinical follow-up study on humans. Clin Oral Implants Res. 2007;18(1):74-85. 6. Eggers G, Klein J, Blank J, Hassfeld S. Piezosurgery: an ultrasound device for cutting bone and its use and limitations in maxillofacial surgery. Br J Oral Maxillofac Surg. 2004;42(5):451-453. 7. Eriksson L, Hillerup S, Reibel J, Persson S, Brun A. Traumatic changes of the inferior alveolar nerve and Gasserian ganglion after removal of a mandibular third molar: report of a case. J Oral Maxillofac Surg. 2006;64:(12)1821-1825. 8. Gellrich NC, Held U, Schoen R, Pailing T, Schramm A, Bormann KH. Alveolar zygomatic buttress: A new donor site for limited preimplant augmentation procedures. J Oral Maxillofac Surg. 2007;65(2):275-280. 9. González-García A, Diniz-Freitas M, Somoza-Martín M, García-García A. Piezoelectric bone surgery applied in alveolar distraction osteogenesis: a technical note. Int J Oral Maxillofac Implants. 2007;22(6):1012-1016. 10. Horton JE, Tarpley TM Jr, Wood LD. The healing of surgical defects in alveolar bone produced with ultrasonic instrumentation, chisel, and rotary bur. Oral Surg Oral Med Oral Pathol. 1975;39(4):536-546. 11. Kelly A, Flanagan D. Ridge expansion and immediate placement with piezosurgery and screw expanders in atrophic maxillary sites: two case reports. J Oral Implantol. 2013;39(1):85-90. 12. Landes CA, Stübinger S, Rieger J, Williger B, Ha TK, Sader R. Critical evaluation of piezoelectric osteotomy in orthognathic surgery: operative technique, blood loss, time requirement, nerve and vessel integrity. J Oral Maxillofac Surg. 2008;66(4):657-674. 13. Lee HJ, Ahn MR, Sohn DS. Piezoelectric distraction osteogenesis in the atrophic maxillary anterior area: a case report. Implant Dent. 2007;16(3):227-234. 14. Metzger MC, Bormann KH, Schoen R, Gellrich NC, Schmelzeisen R. Inferior alveolar nerve transposition — an in vitro comparison between piezosurgery and conventional bur use. J Oral Implantol. 2006;32(1):19-25. 15. Muñoz-Guerra MF, Naval-Gías L, Capote-Moreno A. Le Fort I osteotomy, bilateral sinus lift, and inlay bone-grafting for reconstruction in the severely atrophic maxilla: a new vision of the sandwich technique, using bone scrapers and piezosurgery. J oral Maxillofac Surg. 2009;67(3):613-618. 16. Preti G, Martinasso G, Peirone B, Navone R, Manzella C, Muzio G, Russo C, Canuto RA, Schierano G. Cytokines and growth factors involved in the osseointegration of oral titanium implants positioned using piezoelectric bone surgery versus a drill technique: a pilot study in minipigs. J Periodontol. 2007;78(4): 716-722. 17. Robiony M, Polini F, Costa F, Zerman N, Politi M. Ultrasound bone cutting for surgically assisted rapid maxillary expansion (SARME) under local anaesthesia. Int J Oral Maxillofac Surg. 2007;36(3):266-269. 18. Robiony M, Polini F, Costa F, Vercellotti T, Politi M. Piezoelectric bone cutting in multipiece maxillary osteotomies. Technical note. J Oral Maxillofac Surg. 2004;62(6):759-761. 19. Seshan H, Konuganti K, Zope S. Piezosurgery in periodontology and oral implantology. J Indian Soc Periodontol. 2009;13(3): 155-156. 20. Sortino F, Pedullà E, Masoli V. The piezoelectric and rotatory osteotomy technique in impacted third molar surgery: comparison of postoperative recovery. J Oral Maxillofac Surg. 2008;66(12):2444-2448. 21. Stacchi C, Costantinides F, Biasotto M, Di Lenarda R. Relocation of a malpositioned maxillary implant with piezoelectric osteotomies: a case report. Int J Periodontics Restorative Dent. 2008;28(5):489-495. 22. Stacchi C, Vercellotti T, Torelli L, Furlan F, Di Lenarda R. Changes in implant stability using different site preparation techniques: twist drills versus piezosurgery. a single-blinded, randomized, controlled clinical trial. Clin Implant Dent Relat Res 15(2):188-197 23. Stübinger S, Kuttenberger J, Filippi A, Sader R, Zeilhofer HF. Intraoral piezosurgery: preliminary results of a new technique. J Oral Maxillofac Surg. 2005;63(9):1283-1287. 24. Stübinger S, Robertson A, Zimmerer KS, Leiggener C, Sader R, Kunz C. Piezoelectric harvesting of an autogenous bone graft from the zygomaticomaxillary region: case report. Int J Periodontics Restorative Dent. 2006;26(5):453-457. 25. Vercellotti T. Piezoelectric surgery in implantology: a case report — a new piezoelectric ridge expansion technique. Int J Periodontics Restorative Dent. 2000;20(4):358-365. 26. Vercellotti T, Nevins ML, Kim DM, Nevins M, Wada K, Schenk RK, Fiorellini JP. Osseous response following resective therapy with piezosurgery. Int J Periodontic Restorative Dent. 2005;25(6):543-549. 27. Vercellotti T, Pollack AS. A new bone surgery device: sinus grafting and periodontal surgery. Compend Contin Educ Dent. 2006;27(5):319-325. 28. Wallace SS, Mazor Z, Froum SJ, Cho SC, Tarnow DP. Schneiderian membrane perforation rate during sinus elevation using piezosurgery: clinical results of 100 consecutive cases. Int J Periodont Rest Dent. 2007;27(5):413-419.

Volume 7 Number 5

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The role of piezosurgery in implant dentistry PATEL 1.

Piezosurgery as a technique spread because of its _____. a. ease of use b. safety c. low cost d. both a and b The piezoelectric effect occurs when an electric current is passed around ____, and they start to vibrate at a precise frequency. a. a stack of crystals b. a standard bur c. a diamond bur d. a non-mineralized structure A distinctive characteristic of piezosurgery is its ability to distinguish _____. a. bone structure b. osseous response c. tissue hardness d. osteoblastic activity Piezosurgery can be advantageous when exact cutting of _____ is required. a. thin bones b. non-mineralized structures c. nerves d. a malpositioned implant Due to its cavitational effect on physiological solutions such as blood, piezosurgery creates an effectively ______ that makes visibility in the working area much clearer than with conventional bone-cutting instruments. a. bacteria-free surgical area b. bloodless surgical site c. depressurized surgical site d. desensitized surgical site The recovery process after scalpel and piezosurgery were similar. However, a difference was

Volume 7 Number 5

observed in the recovery of bone tissue treated by a bur, as it produced ______. a. degeneration of cellular elements along the edges b. persistence of fibrovascular tissue c. a reduced reaction of osteoblasts and osteoclasts d. all of the above 7.

______ is still regarded as the gold standard with respect to intended bone quantity, quality, and an uneventful healing phase with reliable outcome. a. A xenograft b. Autologous bone c. An allograft d. Alloplastic bone

Because piezosurgery does not traumatize the bone, it prevents the considerable _____ often caused by surgical burs and microsaws. a. nerve damage b. blood loss c. bone necrosis d. psychological trauma

In addition, less periosteal stripping occurs when using piezosurgery, so there is subsequently ___________. a. less postoperative pain b. less postoperative swelling c. wound healing is improved d. all of the above

10.

Piezosurgical extraction consists of cutting the fibers of the periodontal ligament with vibrating tips of up to ____ in depth. a. 5 mm b. 10 mm c. 15 mm d. 20 mm

Implant-induced post-traumatic inferior alveolar nerve neuropathy RENTON 1.

In the author’s experience, if injury persists for more than ______, with more than 50% of the dermatome affected (i.e., the neuropathic area extends over more than half the extraoral distribution of the inferior alveolar nerve, including the vermillion [lip, lip skin, and chin skin]), recovery is unlikely. a. 1 week b. 2 weeks c. 4 weeks d. 6 weeks

A report illustrated that early removal of implants (________) may maximize neuropathy resolution; however, the evidence remains weak. a. within 2 hours b. within 30 hours c. within 1 week d. within 2 weeks

The suggested protocol, based upon the available evidence, is as follows: The treating clinician must contact the patient between _____ after surgery (home check) to establish any persistent neuropathy after LA has resolved. a. 6 and 24 hours b. 36 to 48 hours c. 3 and 4 days d. 5 and 7 days

(Part of the suggested protocol continues) Initiate medical management: ________. a. magnesium (400 mg, BID) b. high-dose oral NSAIDs (600-800 mg ibuprofen PO QDS) c. GMP prescription for prednisolone on a 5-day “step-down” dose (50-40-30-20-10 mg PO) d. both b and c

After 3 to 7 days, nerve injury is likely ______, and therapeutic management is indicated. a. to be resolved b. to be permanent

c. to be significantly healed d. to have no further effect on the patient 6.

Management options for post-traumatic neuropathy will depend upon the _______. a. mechanism b. duration of injury c. the patients’ wishes d. all of the above

A key concern is disability associated with ______ a. altered sensation, severe discomfort, pain or numbness b. a large neuropathic area c. interference with eating, drinking, and so on d. all of the above

Any planned treatment must address the patient’s concerns appropriately. The aims of treatment would ideally provide the following: Improved sensation: treatment _____ normal sensation in the neuropathic area, general sensory area (such as mechanosensory function), or special sensory areas (such as taste). a. will never fully restore b. will definitely fully restore c. will have no effect on d. will completely eliminate

If there is a persistent large neuropathic area (more than ____ of the dermatome), then a severe nerve injury is present. a. 10% b. 20% c. 30% d. 40%

10.

Systemic agents for pain include ____________. a. tricyclic antidepressants (such as amitriptyline and nortriptyline) b. anti-epileptics (pregabalin or gabapentin) c. Versatis d. both a and b

Implant practice 37

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IMPLANT PRACTICE CE

CONTINUING EDUCATION

Implant-induced post-traumatic inferior alveolar nerve neuropathy Dr. Tara Renton discusses nerve injury

revention is better than cure in all instances of iatrogenic nerve damage — but when it happens, it is crucial that clinicians take the appropriate steps to manage the condition. Management of local anesthetic (LA)-related injuries is essentially by counseling and medication for pain, if it is present. The patient should be reassured and given their realistic expectations of recovery, with an explanation of why they are not regularly warned about this complication. However, in the author’s experience, if injury persists for more than 6 weeks, with more than 50% of the dermatome affected (i.e., the neuropathic area extends over more than half the extraoral distribution of the inferior alveolar nerve, including the vermillion [lip, lip skin, and chin skin]), recovery is unlikely. Empirically, the incidence of neuropathic pain also seems high in this cohort (Renton and Yilmaz, 2012). The neuropathic pain can be managed using anti-epileptic drugs if the pain is neuralgic, tricyclic antidepressants if the pain is constant and burning in nature, or external LA patches if the lip is very sensitive to touch or change in temperature. In most cases, the nerve injury is more likely to be related to the mandibular implant. Once the injury has happened, there are two phases for managing dental implant-related nerve injuries: • Acute phase (within 30 hours) • Late phase

Acute phase management There may be a limited window to maximize nerve injury resolution in relation to dental implants. A report illustrated that early removal of implants (within 30 hours) may maximize Professor Tara Renton, BDS, MDSc, PhD, FDS, RCS, FRACDS (OMS), FHEA, is a chair of oral surgery at King’s College London. A specialist in oral surgery, she has a particular interest in trigeminal nerve injuries and pain and has developed a national clinical service for patients suffering from these ailments. She is the national adviser for oral surgery, a council member for the British Association of Oral Surgeons (BAOS), and an elected member of the RCS England Dental Faculty Committee.

38 Implant practice

Educational aims and objectives

The aim of this article is to present some protocols for managing implant-induced inferior alveolar nerve neuropathy.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 37 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify the difference between acute and late phase intervention. • Be given some recommendations for managing nerve injuries. • Recognize key concerns faced by patients with permanent neuropathy.

neuropathy resolution; however, the evidence remains weak (Khawaja and Renton, 2009). The suggested protocol, based upon the available evidence, is as follows: • The treating clinician must contact the patient between 6 and 24 hours after surgery (home check) to establish any persistent neuropathy after LA has resolved. This builds on the relationship of the clinician with the patient, which should have started with good consent process. • Confirm the presence of neuropathy. If the neuropathy affects most of the dermatome, even if it is not associated with severe neuropathic pain, then nerve injury must be suspected. • Say “sorry” — this is not an admission of guilt. • Additional scanning or radiography is not essential. • Initiate medical management: high-dose oral NSAIDs (600-800 mg ibuprofen PO QDS) and a GMP prescription for prednisolone on a 5-day “step-down” dose (50-40-30-20-10 mg PO). This is not for patients with contraindications for steroids or NSAIDs. • Patients can also be advised to take vitamin B complex (1, 3, 6, and 12) — there is no evidence base for this as yet, but it is commonly recommended after sports injuries. • Prompt removal of the implant to maximize potential resolution of the injury is advised. • Review the patient, and report to the CQC. (Editor’s note: In the United

Kingdom this is the Care Quality Commission.) There are no reports relating to neuropathy being resolved by backing the implant up or replacing it with a shorter implant, so these options are not recommended. The most important thing to do is manage the patient’s expectations and, if appropriate, gain informed consent for any further procedures. With continued dialogue throughout this adverse event, the patient’s ability to cope will be significantly improved.

Late phase management After 3 to 7 days, nerve injury is likely to be permanent, and therapeutic management is indicated. With patients presenting with late postoperative inferior alveolar nerve (IAN) neuropathy, the author no longer removes the implant (and based on anecdotal evidence, nor do some other specialists), as it appears to be of little value in reversing nerve damage and its associated symptoms. Management options for post-traumatic neuropathy will depend upon the mechanism, duration of injury, and the patients’ wishes. Management options include the following: • Reassurance and review • Medical management (the early intervention for minimizing neural inflammation steroids or NSAIDs protocol is not evidence-based) and pain management, or management of depression • Counseling • Surgery The clinician must discern exactly what he/she is trying to treat the patient for. Is it Volume 7 Number 5

Possible management tools The timing of intervention and the mechanism of injury are paramount in decision making when it comes to treating trigeminal nerve injuries. Table 1 shows when surgical intervention is indicated. Volume 7 Number 5

Table 1: Indications for surgical intervention Cause of injury

Surgical intervention

Known or suspected sectioned or damaged nerves

Immediate exploration and repair

Endodontics

Within 24-48 hours

Implant

Within 24-48 hours

Wisdom teeth (inferior alveolar nerve injury)

Within 2 weeks

Wisdom teeth (lingual nerve injury)

Within 3 to 6 months

Local anesthetic nerve injuries (LN or IAN)

Therapeutic management only

Orthognathic nerve injuries

Therapeutic management only

Mandibular fracture nerve injuries

Therapeutic management only

Surgical exploration can involve immediate repair, if the nerve section is known, and removal of the implant within 24 hours (ideally). Exploration of IAN injuries is no longer indicated for injuries older than 1 week. Counseling is the most useful tool for managing patients with permanent sensory problematic nerve injuries. Medical symptomatic therapy is indicated for patients with pain or discomfort, and for patients with anxiety or depression in relation to chronic pain. Due to the extensive side effects of chronic pain medication, less than 8% of patients remain on medication. Topical agents for pain include Versatis patches and topical lidocaine 5% (12 hours on, 12 hours off) (Khawaja and Renton, 2009; Renton and Yilmaz, 2012). Systemic agents for pain include tricyclic antidepressants (such as amitriptyline and nortriptyline) and anti-epileptics (pregabalin or gabapentin).

None of these interventions “fix” the patients, but the aim is to manage their symptoms as best as possible — although often, this is still not very satisfactory. Iatrogenic nerve injury has a significant and unpleasant effect on our patients. Most will experience not only pain but altered sensation and numbness too. There are some key messages that all dentists carrying out implant dentistry in particular should take to heart: • Most iatrogenic nerve injuries cause neuropathic pain as well as altered sensation and numbness. • Improve your consent! • All nerve injuries are avoidable. • Most IAN injuries in relation to implant dentistry are permanent and cannot be “fixed.” • Improving preoperative planning, operative execution, and postoperative care can minimize and hopefully prevent these injuries. IP

REFERENCES 1. Alani A, Bishop K, Djemal S, Renton T (2012) Update on Guidelines for Selecting Appropriate Patients to Receive Treatment with Dental Implants: Priorities for the NHS-the position after fifteen years. Br Dent J in press 2012 2. Başa O, Dilek OC. Assessment of the risk of perforation of the mandibular canal by implant drill using density and thickness parameters. Gerodontology. 2011;28(3): 213-220. 3. Bavitz JB, Harn SD, Hansen CA, Lang M. An anatomical study of mental neurovascular bundle-implant relationships. Int J Oral Maxillofac Implants. 1993;8(5): 563-567. 4. Khawaja N, Renton T. Case studies on implant removal influencing the resolution of inferior alveolar nerve injury. Br Dent J. 2009;206(7): 365-370. 5. Pogrel MA, Bryan J, Regezi J. Nerve damage associated with inferior alveolar nerve blocks. J Am Dent Assoc. 1995;126(8): 1150-1155. 6. Pogrel MA, Kaban LB. Injuries to the inferior alveolar and lingual nerves. J Calif Dent Assoc. 1993;21(1): 50-54. 7. Pogrel MA, Thamby S. Permanent nerve involvement resulting from inferior alveolar nerve blocks. J Am Dent Assoc. 2000;131(7): 901-907. 8. Renton T, Dawood A, Shah A, Searson L, Yilmaz Z. Post-implant neuropathy of the trigeminal nerve. A case series. Br Dent J. 2012;212(11): E17. 9. Renton T, Yilmaz Z. Profiling of patients presenting with posttraumatic neuropathy of the trigeminal nerve. J Orofac Pain. 2011;25(4): 333-344. 10. Renton T, Yilmaz Z. Managing iatrogenic trigeminal nerve injury: a case series and review of the literature. Int J Oral Maxillofac Surg. 2012;41(5): 629-637. 11. Torrente-Castells E, Gargallo-Albiol J, Rodríguez-Baeza A, Berini-Aytés L, Gay-Escoda C. Necrosis of the skin of the chin: a possible complication of inferior alveolar nerve block injection. J Am Dent Assoc. 2008;139(12):1625-1630.

Implant practice 39

CONTINUING EDUCATION

poor mechanosensory function (continually the focus of many surgical studies) — or more pertinently, should it be what the patient is complaining of? Based on my research, the patients will often complain that they are struggling to cope, or to do certain things. A key concern is disability associated with: • Altered sensation, severe discomfort, pain or numbness • A large neuropathic area • Interference with eating, drinking, and so on Many patients find accepting or coping with even minimal iatrogenic nerve injuries very difficult. This may be due to the unexpected nature of the injury, uninformed consent, poor postoperative management, and a lack of information. Any planned treatment must address the patient’s concerns appropriately. The aims of treatment would ideally provide the following: • Improved function (treatment will not restore function completely) • Improved sensation: treatment will never fully restore normal sensation in the neuropathic area, general sensory area (such as mechanosensory function), or special sensory areas (such as taste) • Reduced pain or altered sensation Escalating a patient from intermittent pain to persistent pain would be a negative outcome, as would causing a patient to have discomfort or pain when previously they had only anesthesia. As previously highlighted, the management will depend on the mechanism and the duration of the nerve injury and the patient’s complaints. Many injuries have limited benefit from surgical intervention and should be managed symptomatically. Earlier intervention is required for endodontic, implant, and third molar-related nerve injuries, as discussed. If there is a persistent large neuropathic area (more than 40% of the dermatome), then a severe nerve injury is present. If pain and/or hypersensitivity are present, these will often be the main precipitating factors of difficulty with daily function. These symptoms may not be best treated using surgical intervention; however, the patient’s inability to cope with disability is often a driving factor for seeking treatment.

“TECH”-NIQUE

Socket preservation technique with NuOss® XC Self-Expanding Bone Graft Composite Dr. Frank Kung explains a streamlined approach to socket preservation

he rationale for the socket preservation technique is based on the knowledge that an average of 40%-60% of original alveolar bone height and width is expected to be lost after tooth extraction with the greatest loss happening within the first 2 years.1 The goal of socket preservation is to prevent this bone loss, minimize the need for future augmentation procedures, and maximize functional and esthetic results. In implantology, the use of materials after extraction to preserve these alveolar dimensions is fast approaching a “standard of care.” The socket preservation technique begins with an atraumatic tooth extraction, during which care is used to ensure that the surrounding bone and soft tissue are preserved, with specific attention paid to the delicate buccal plate. After extraction, granulation tissue is removed, and good bleeding is established with minor perforation of the socket wall if necessary. A suitable bone grafting material is placed into the prepared socket. Traditional bone grafting particulates have been widely used due to their success and availability. As well, the use of dental bone grafting putty has proven popular with its ease of placement when compared to particulate materials. The following case report highlights a unique patent-pending expandable bone grafting composite with a unique three-dimensional matrix. A 62-year-old male patient, nonsmoker, without any history of systemic disease presented to the dental office complaining of tooth pain. Inspection and periapical radiograph (Figure 1A) confirmed an apical fracture of the upper left central incisor. Surgical extraction was planned, and the patient was Frank Kung, BDS, DDS, graduated from the College of Dental Medicine at Kaohsiung Medical University in Taiwan, and he did a general dentistry residency at Taipei Veterans General Hospital in Taiwan. He also graduated from Dental School at the UT Health Science Center at San Antonio and took the Advanced Dental Education program at University of California, San Francisco. Currently, he is in private practice in Austin, Texas.

40 Implant practice

Figure 1A

Figure 1B

Figure 1C

prescribed an antibiotic for 1 week prior to scheduled surgery. At the time of surgery, an atraumatic extraction was performed, and a curette was used to remove granulation tissue and prepare the socket for graft placement. A unique one-step composite graft (NuOss® XC Socket, ACE Surgical Supply) was chosen as the material for the socket preservation procedure. In contrast to the use of a grafting particulate, no membrane was used for graft containment due to the self-expanding composite nature of the material and the subsequent containment of the bone mineral particles within the composite graft matrix. NuOss XC Socket bone grafting composite is comprised of 80% anorganic bovine bone and 20% type I bovine collagen. The proprietary formulation of NuOss XC allows for syringe delivery of the material in a non-hydrated compressed form, which quickly expands to fill the defect upon contact with blood. In this expanded form, the composite material provides a

Figure 2

Figure 3

three-dimensional matrix that optimizes the spacing of the bone mineral, allowing improved vascular access into the grafted site. NuOss XC Socket requires no special handling and is stored at room temperature. Volume 7 Number 5

â&#x20AC;&#x153;TECHâ&#x20AC;?-NIQUE

Figure 4

After the product was delivered to the site via a pre-loaded syringe, mattress sutures were used to ensure that the material was not dislodged, and the patient was sent home, continuing on a regimen of antibiotics for 1 week. Subsequent follow-up visits showed continued healing and maintenance of the extraction socket dimensions. Upon re-entry of the site in preparation for implant placement, the bone was found to be of sufficient quality and quantity for optimal placement in this critical esthetic zone. A 4.0 mm x 11.5 mm was placed into the previously grafted site. The 24-month follow-up shows the maintenance of the socket dimensions, successful osseointegration of the implant fixture, and full function of the prosthetic. Importantly, coronal bone level has been maintained as well. NuOss XC Socket allowed for a streamlined approach to the socket preservation technique. A simple one-step graft delivery, with no need for pre-hydration, and the placement and fill of the socket were ideally achieved. The unique composite of collagen and natural bone mineral combines two highly proven and desirable materials into one easy-to-use graft. NuOss XC Socket is available in two sizes and is ideal for singlerooted teeth. It is also available in NuOss XC Sinus, a format ideally suited for use in sinus lift procedures allowing for precise placement of the graft without concerns of graft loss due to membrane perforations. IP

Figure 5

Figure 6

Figure 7

Figure 8

REFERENCES 1. Wang HL, Kiyonobu K, Neiva RF. Socket Augmentation: rationale and technique. Implant Dent. 2004;13(4):286-296.

Volume 7 Number 5

Figure 9 Implant practice 41

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Intended Use Number

• Expanding composite material allows for placement in a compressed form with self-expansion to fill the entire defect upon hydration • Simple implantation technique • Composite nature of the material enhances graft stability and minimizes particulate migration • Optimizes spacing between particulate to allow for bone ingrowth • NuOss XC is available in both socket and sinus forms

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NuOss® XC Sinus

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Elevation of maxillary sinus floor.

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TECHNOLOGY

Cone beam CT applications in oral surgery Dr. Bart Silverman discusses the benefits of an added dimension in imaging

t present, one can go into a cardiologist’s office with chest pain and — within minutes — a non-invasive, threedimensional scan can be taken so the doctor can actually look at the great vessels and structures supplying the heart. The cardiologist can see details so intricate, they were previously seen only through the intraarterial insertion of a camera. Think about the treatment afforded to a patient with this state of the art technology; it is limitless. Now imagine in the future if we can use this same technology in the field of oral and maxillofacial surgery. Imagine seeing a patient’s jaw structure, surrounding nerves, and actual anatomy without any magnification or distortion prior to placing dental implants. Imagine the three-dimensional treatment-planning capabilities. Imagine if you could see the bony structure many times prior to actually bringing the patient in for surgery. You would be providing a terrific service for your patient, as treatment plans could be very specifically designed for that particular patient without having to generalize as “in most cases we do this.” Your surgery time as well as the patient’s postoperative swelling and discomfort would be greatly reduced. Imagine also in the future if you could use this three-dimensional technology to see where a patient’s mandibular nerve canal lies in reference to a lower third

Bart W. Silverman, DMD, is in private practice limited to oral and maxillofacial surgery in New City, New York, and is an attending physician at Westchester County Medical Center, Department of Oral and Maxillofacial Surgery, and Nyack Hospital, Department of Dentistry. He is also a Clinical Associate Professor at New York Medical College. He lectures nationally on several different implant systems and is president of the Bi-State and Hudson River Implant Study Clubs. He is a past president of the Rockland County Dental Society and previously served on the Board of Governors of the Ninth District Dental Society. Dr. Silverman graduated summa cum laude from Fairleigh Dickinson University in 1982 and received his doctorate in Dental Medicine in 1986 from Fairleigh S. Dickinson Jr. College of Dental Medicine, where he was a member of the Omicron Kappa Upsilon Honor Society. He completed his Oral and Maxillofacial Surgical residency at Westchester County Medical Center in 1989 and was Chief Resident during his final year. Dr. Silverman is currently a Diplomate of the American Board of Oral and Maxillofacial Surgery.

molar that needs to be removed. The information obtained could be priceless. Well, the future is here today. We now have the ability to obtain a cone beam computed tomography (CBCT) scan of a patient performed by a unit solely made for dentistry. In the past, if we wanted to send a patient for a CT scan, the only option we had was to have them go to a hospital or radiology facility for a medical grade CT. These scans exposed patients to high doses of radiation and often produced a low resolution scan that made treatment planning a challenge. The cost, price, and radiation have made this somewhat prohibitive. Now, with the advent of an in-office cone beam scanner, we can deliver high-resolution, low-dose scans packaged with software that is specific for the field of dentistry. The footprint of these newer machines is no greater than the size of a panorex unit, which easily fits in most offices. In contrast to a medical-grade CT scan, where patients would have to lie down and remain perfectly still for the whole scan, patients comfortably stand or sit when the cone beam CT scan is performed. There are many advantages of having an in-office machine. The ease of being able to walk the patient to a part of your office and take a scan for them is great. No longer do you have to give the patients a prescription for a study and hope that they get it done, nor do you have to spend the time tracking down the scan. Think of the benefit of being able to do the scan, developing a treatment plan specific for the patient, reviewing the plan, and then scheduling the surgery all in the same visit.

Figure 1 44 Implant practice

Ever since Wilhelm Roentgen’s accidental — but momentous — discovery of X-rays in 1896, innovative imaging technologies have continued to dramatically improve health care. Digital radiography started in the field of dentistry with Dr. Francis Mouyen, a French dental student who developed it in 1982. Cone beam CT (CBCT) started around 2000 with the early adoptors being some dental schools, surgeons, and radiologists. Now one can hardly pick a dental journal without seeing two to three articles about the exciting technology of three-dimensional scanning. The increase in demand for imaging in the oral surgical practice has increased because of the need for better correlation between surgical placement and prosthetic restorability of dental implants as well as improved surgical techniques, which require three-dimensional visualization of the dental anatomy. We no longer have to treat three-dimensional patients based upon twodimensional diagnostic means; rather we can develop three-dimensional treatment plans to treat our three-dimensional patients.

Cone beam CT: What is it? Cone beam CT is a three-dimensional radiographic tool that can be used to obtain anatomically accurate information. This information, in turn, can help identify possibilities and limitations of treatment as well as provide us with a powerful communication tool to be utilized with our patients and referring doctors. In the past, say, in the posterior maxilla, when two-dimensional radiographs were obtained, you had superimposition of adjacent roots, posts, gutta percha, the zygomatic buttress, and floor of the maxillary

Figure 2 Volume 7 Number 5

TECHNOLOGY

sinus. It is almost like a series of window panes superimposed on top of each other. As dentists, we had to use our mind’s eye to pull out the structures we did not want to see and try to visualize only what we needed to see. With cone beam CT, on the other hand, we can pull out the window pane we want to see and clearly visualize the desired structures. A cone beam CT gives you an exact one-to-one representation of the clinical situation. When using a panorex radiograph, it is almost like when we were in elementary school and took a globe and unfolded it and laid it out on a table and made a map. Inherently, there is a degree of elongation or magnification built into the process. This does not happen with cone beam CT.

THE WAIT IS OVER

How does it work? Just like any other scan, the patient stands or sits by the machine, and the operator lines up the machine using a series of laser lines. The machine then rotates around the patient 360 degrees, and a cone beam of radiation is emitted against some type of imaging plate. The scans typically take less than 30 seconds. A primary reconstruction is obtained, and a series of DICOM files are formed. These DICOM files can be reconstructed and viewed as in the standard axial, saggital, coronal, or transaxial cuts, as with conventional CAT scans. The images can also be reconstructed to form 3D images. Once performed, a computer monitor is used to view the images.

Available systems There are quite a few systems now available for use in the field of dentistry and oral surgery. With the advent of the newer scanners particularly made for dentistry, clinicians can have higher resolution scanners with less radiation. The scanners also now have software that is made specifically for dentistry. The scans are a lot faster, and reconstruction times have been greatly reduced.

Uses of cone beam CT in oral and maxillofacial surgery Implants The uses of cone beam CT in the oral and maxillofacial practice are almost limitless. Probably the number one use for cone beam CT for an oral and maxillofacial surgeon would be for implants. A cone beam CT can be used to determine the quantity and quality of the patient’s bone in order to assess the possibility and feasibility of implant placement. One can determine the amount of bone above the nerve canal or Volume 7 Number 5

CS 8100 3D 3D IMAGING IS NOW AVAILABLE FOR EVERYONE 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

Implant practice 45

TECHNOLOGY below the maxillary sinus, which can significantly reduce surgical morbidity. The clinician can assess bone morphology before taking a patient to surgery. The degree of accuracy from these scans is so high that very precise surgical guides can be fabricated. This can increase accurate implant placement and allow for ease of prosthetic restorability. Surgical time is greatly reduced, and this is translated into less swelling and postoperative discomfort for the patient. By having this data set, the surgeon can reformat the DICOM files into different views many times prior to the procedure. This allows the surgeon to visualize the patient’s jaw structure before the actual surgery in order to potentially reduce unwanted results and untoward implant placement. A surgeon now can look at the patient’s bone and develop a treatment plan that is very specific for that particular patient. No longer do we have to generalize about what we may do at the time of surgery and then actually determine the exact plan once we open up the surgical site. We can now confidently say to our patients exactly what their treatment plan will be. We also know how much time to set aside and can determine exactly what the patient’s cost will be based upon the exact treatment plan we will perform. At the same time, we are building confidence with our patients. Imagine if you went to a cardiologist and he or she said to you, “We have the technology to see and plan exactly what we’ll do to treat your chest pain, but we don’t need to do that. We can open you up, and if this vessel is occluded, we will do this. If this vessel is open, but this other one is blocked, depending upon the blockage, we may take a leg vein graft, or not, etc.” You would run out of there. Once implants are placed, positioning can be confirmed by a follow-up cone beam CT scan. One must evaluate the potential gain versus the increase in radiation from a subsequent scan. TMJ uses A great use for cone beam CT is in the field of temporomandibular joint (TMJ) problems. Using this technology, one can assess morphological changes as well as see arthritic changes in the joint and surrounding bony structures. This is an improvement over diagnosing fractures of the TMJ using two-dimensional plane films, as hairline or greenstick fractures are difficult to visualize on many occasions. Also difficult to determine has been the position 46 Implant practice

of the fractured condylar segment whether it is medial or lateral. On the other hand, superior positioning of the condyle into the middle cranial fossa following a severe motor vehicle accident can be very easily seen with the use of CBCT. Impacted teeth Probably the second biggest use for cone beam CT in the oral surgery field is impacted teeth. For those of us who — after determining the position of an impacted maxillary canine — had to start drilling palatally after starting buccally, you can really appreciate the embarrassment of not performing a cone beam CT scan. Multiple periapical radiographs taken at different positions and various angles in order to try to three-dimensionally locate the teeth are no longer necessary, as exact position of impacted teeth can be determined preoperatively. Surgical treatment plans and access can also be determined quickly and efficiently. By having an exact plan before starting the procedure, surgical time will be reduced. By reducing surgical time, we are ultimately reducing the time patients are under anesthesia as well as swelling. Patients will heal faster, and these surgical outcomes can translate into additional referrals from our patients and referring doctors. Juxtaposition of third molar roots with the inferior alveolar canal can also be determined. When discussing the risks of surgery, particularly paresthesia, a surgeon can be very specific with their patients and their patients’ family members. You can visualize the position of the impacted tooth within the alveolar bone and its location relative to the adjacent teeth and surrounding neurovascular structures. This may also help determine if it is wise to remove asymptomatic third molars and whether it is prudent to remove these teeth in the office or hospital settings. There was a great study performed by Park and Choi1 where they looked at the cortical integrity of the inferior alveolar canal as a predictor of paresthesia after third molar extraction. The prevalence of paresthesia was higher where third molar to inferior alveolar canal continuity was disrupted. The frequency of nerve damage increased with the number of cone beam CT image slices showing loss of cortical continuity. By using a cone beam CT, surgeons can help plan their surgeries and educate their patients on a realistic risk-versus-benefit situation.

Surgical orthodontic uses Of course, an obvious use in oral surgery in conjunction with orthodontics is in orthognathic surgery. The cephalometric view (if the scanner has a full-field view or a cephalometric arm) can be used to analyze each case, and the cone beam CT component can be used once a treatment plan is decided upon to evaluate the patient’s bone morphology and determine if there are any anatomical limitations to the proposed treatment. The surgeon can also look at the patient’s bone anatomy where the proposed osteotomies will be performed, in order to see if they are conducive to the planned surgery. Temporary anchorage devices, or TADS, are used to aid the orthodontist in tooth movements where there may be lack of posterior anchorage or in patients that are — or would be — non-compliant with an external head gear. Three-dimensional volumes give a much better view of the special relations of adjacent roots in suggested TAD placement areas than a 2D periapical radiograph. Three-dimensionally, the colleagues can discuss movement of adjacent teeth prior to TAD placement to help insure optimum positioning for the patient and less risk of placement into the roots of the adjacent teeth. Sleep apnea Oral nasal airways can be measured, and three-dimensional volumes can be determined using cone beam CT technology. Appliances can be fabricated and, after a certain time frame, evaluated based on a subsequent scan to see if the airway measurements or volumes have changed. Now, there can be a concrete method used to determine the effectiveness of surgical or non-surgical therapies. Pathology and trauma With cone beam CT scans, a surgeon can take a look at a lesion, such as a fairly large jaw cyst, before the patient even comes into the surgical suite. This technology allows surgeons to see if the buccal and lingual cortices are intact as well as to evaluate teeth or nerve canal displacement if any impacted teeth are associated with the lesion. If a primary reconstruction with bone grafting is planned, an exact measurement of the bony volume that needs to be replaced can be determined and planned for ahead of time. All of this planning ahead of time allows you to be more confident in your surgical approach and allows for a Volume 7 Number 5

Surgical endodontic uses Think of the last time a patient presented to your office with an alveolar swelling opposite his/her maxillary first molar: A periapical radiograph is taken and demonstrates a periapical lesion associated with what looks like only the MB root of a previously endodontically treated tooth. A sulcular or vestibular incision is made, thereby exposing the periapical area. Not only is the MB root affected, but you must chase the periapical pathology back to the palatal root, only to find out this was the cause of the abscess. If a focused-field cone beam CT was performed preoperatively, one could then review the volume and see on the coronal and sagittal slices where the pathology is emanating from. You can use the axial views and see if the pathology extends into the sinus or not. A more definitive treatment plan can be determined to better treat the patient. Is it best to have the canals retreated, or to perform an apicoectomy or to remove the tooth, bone graft, and place an implant? Diagnosis and treatment planning When we decide to pursue a career in dentistry, one of the first things we have to do is take a dental admission test. As future dentists, we are tested on our Volume 7 Number 5

TECHNOLOGY

quicker surgery, which translates into less surgical swelling and discomfort for our patients. In evaluating an odontoma, it is beneficial to see where it extends and what other structures may be involved when planning the case. With tooth avulsions, luxations, fractures or other dentoalveolar trauma, a highresolution, three-dimensional focused-field volume would aid your diagnosis better than a two-dimensional periapical radiograph. You can now visualize alveolar fractures and no longer have to feel along the alveolar ridge for movement when you palpate the involved dentition. With maxillofacial trauma, one cone beam CT scan can be obtained, and the DICOM files can then be reviewed, obviating the need for four or potentially five other X-rays. Radiation to the patient is limited. Once the DICOM files are taken, they can be reconstructed many times without subjecting the patient to more and more radiographs. The cone beam CT can also be performed postoperatively, which can allow the surgeon the ability to immediately see if the fractured bones and fixation were performed adequately.

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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 • 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

Implant practice 47

TECHNOLOGY

Figure 3

Figure 5

Figure 4

Figure 6

three-dimensional perception. Those of us who excel are admitted into a dental school. We then spend 4 years looking at two-dimensional radiographs in order to treat three-dimensional patients. Aside from not making sense, if one can see problems three-dimensionally, it certainly can change our treatment plans. This patient came to our office with a cystic area seen superiorly to an impacted mandibular left third molar on a periapical radiograph taken by his general dentist. I took a panorex radiograph to fully visualize the tooth (Figure 3). We then decided to obtain a cone beam CT scan of the area to see if the cystic area affected the buccal or lingual plates of the bone before we performed a biopsy. If one looks at the cone beam CT transaxial view (Figure 4), not only does the tooth extend

Figure 9 48 Implant practice

Figure 7

most of the vertical portion of the mandible, but also the whole buccal lingual width. If you decided to remove this tooth based upon the two-dimensional panorex, you would be in for a huge awakening when you found out there was no bone on the buccal or lingual when you were removing the tooth, thereby leaving the jaw in a severely weakened state. In the following case, I received a call from an orthodontist about a patient we had treated several years earlier (Figure 5). He reported that the cyst that I removed had recurred. As it was an eruption cyst, I didnâ&#x20AC;&#x2122;t think it was possible. The orthodontist then sent over a copy of the panorex he had taken. It appeared to demonstrate a large radiolucency of the right mandibular ramus. A cone beam CT scan (Figure 6) was taken to help delineate the borders of the lesion

Figure 10

Figure 8

before removal or marsupialization was performed. The cone beam scan showed no right ramal expansion or bone thinning, as would be expected. The triplanar views actually demonstrated a bowing of the cortex (Figures 7 and 8). A follow-up MRI yielded no soft tissue tumors as well. If a cone beam was not used to validate the suspected lesion, unnecessary surgery would have been performed. In this last case, the patient had presented from his orthodontist with a series of three panoramic radiographs taken 2 years apart. The orthodontist was concerned about the non-eruption of the maxillary left second molar (Figure 9). Reviewing the two dimensional radiographs, I didnâ&#x20AC;&#x2122;t know why the tooth did not erupt. It was decided to do a cone beam radiograph (Figures 10 and 11).

Figure 11 Volume 7 Number 5

TECHNOLOGY

Figure 12

Figure 13

Upon review of the cone beam scan, one can see the reason for the unerupted maxillary left second molar was its fusion to the impacted maxillary left third molar. Computer-generated surgical guides The use of cone beam CT in the fabrication of computer-generated surgical guides is probably one of the most exciting uses for this technology. In the past, our planning of multiple-placed implants would involve

taking a panoramic radiograph with an acrylic tray with some gutta percha placed. Now, surgical-guided techniques allow the fabrication of computer generated guides through the use of cone beam CT to allow prosthetically driven implant placements (Figures 12 and 13).

As you can see, there are many uses for a cone beam CT scanner in the oral surgical field. It seems as every day, more and more uses come about. It has definitely changed the way we practice. I question if we would be able to provide the same care for our patients without it. IP

REFERENCE 1. Park W, Choi JW, Kim JY, Kim BC, Kim HJ, Lee SH. Cortical integrity of the inferior alveolar canal as a predictor of paresthesia after third-molar extraction. J Am Dent Assoc. 2010;141(3): 271-278.

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Volume 7 Number 5

Implant practice 49

STEP-BY-STEP

Soft tissue incision/excision/ ablation/coagulation with www.LightScalpel.com / 1-866-589-2722 LightScalpel handpieces are autoclavable, durable, and ergonomic, with straight and angled nozzles. They are designed for high-speed soft tissue incision/excision/ablation with simultaneous coagulation of the margins.

Ceramic tip for intra-sulcular ablation/coagulation

Flexible laser fiber Provides the clinician with the most natural “scalpel-like” feel. The fiber is durable, light, maneuverable, and offers high precision.

Angled tipless handpiece for incision/excision/ablation/coagulation

Stage II IMPLANT UNCOVERING with LightScalpel angled tipless handpiece 1. Healed implant site ready for uncovering

2. Tissue ablation begins in the center above the implant and continues in a circular spiraling motion

3. Implant uncovered after ablation

Photographs courtesy of Grant Selig, DDS, Las Vegas, Nevada

Incision/excision/ablation with focused laser beam

Nozzle-to-tissue distance 1-3 mm maintains 250 µm focal spot on the tissue

Coagulation depth of the margins < 100 µm Width of incision < 250 µm Depth of incision is proportional to irradiance [Joules/cm2]

Coagulation with defocused laser beam

Nozzle-to-tissue distance 6-9 mm maintains 500-800 µm focal spot on the tissue

Coagulation depth is 100-300 µm, depending on exposure time

This information was provided by LightScalpel.

50 Implant practice

Volume 7 Number 5

STEP-BY-STEP

IQity Impression Technique™ with InterActive™ and Legacy™4 Implants

ritical to implant treatment success is the transference of the threedimensional spatial position of the implant platform from the mouth to the dental laboratory technician in order to create the final restoration. While the digital workflow is gaining popularity to assist in this treatment process, there still remains the need to have an accurate method for traditional impressioning. Implant Direct’s InterActive™ conical connection implants (shown) and Legacy™4 internal hex connection implants, both feature a new patent-pending fixturemount. The mount is designed to provide the accuracy of an open-tray transfer with the simplicity of a closed-tray transfer via the IQity Impression Technique™. To begin, fully seat implant, ensuring the correct indexing of flat surface of fixture-mount. Occlude screw access hole to prevent ingress of impression material (Figure 1). Inject impression material around the entire fixture-mount (Figure 2). Fill impression tray with heavier body impression material than that used around the fixture-mount. Make a full arch impression, and allow the material to set (Figure 3). Remove impression tray from the mouth and confirm that the colored top portion of fixturemount is retained within impression material (Figure 4). Attach fixture-mount to an implant analog, and insert into impression (Figure 5). Snap assembly securely and accurately to the fixture-mount top located within the impression. This process creates an implant-level impression. Alternatively, an abutment replica may be inserted into the impression to create an abutment-level impression (Figure 6). IP

This information was provided by Implant Direct.

Volume 7 Number 5

Implant practice 51

BRAND SPOTLIGHT

Planmeca PlanScan™ Complete System It’s a new day for same-day dentistry

lanmeca’s CAD/CAM solutions, driven by E4D Technologies, provide everything clinicians need to deliver better dentistry. Create and design digital models with Planmeca CAD/CAM. Share cases with Planmeca Romexis Cloud. And bring designs to life with the precision of the renowned Planmeca PlanMill 40.

Planmeca PlanScan™ The world of CAD/CAM dentistry has been evolving for 30 years. Now it’s time for a leap. Introducing the Planmeca PlanScan, driven by E4D Technologies – the innovative, technologically advanced, ultra-fast intraoral CAD/CAM system for restorative dentistry. Super easy Everything about the Planmeca PlanScan makes restorative dentistry quicker and easier — from intuitive computer-guided image capture to plug-and-play technology that gives dentists the freedom to scan at multiple Planmeca PlanScan workstations. And, of course, it’s powder-free.

Super portable The Planmeca Scan and Design Center is a complete restorative design system with laptop convenience. Super intuitive Planmeca PlanCAD® software creates a custom restoration for every patient.

Super accurate Planmeca PlanScan is the only intraoral scanner in the world with blue laser technology. Its smaller wavelength (450 nm) is more reflective, resulting in sharper images. Its ability to capture fine details allows for more clinically precise prosthetics. Super fast With video-rate scanning and Thunderbolt™* connectivity to the Planmeca PlanCAD laptop, Planmeca PlanScan captures and processes data almost as quickly as you move your hand – even with full-arch cases.

Planmeca PlanCAD™ Planmeca PlanCAD guides the practitioner through the process with rich graphics and easy-to-follow navigation. The system automatically positions and shapes the selected tooth template to match the central grooves, cusp heights and marginal ridges of the actual proximal dentition. 52 Implant practice

Super convenient Add same-day crowns, inlays, onlays and veneers to the menu of services and fabricate restoration designs quickly and conveniently with the PlanMill 40, featuring wireless connectivity and Smart Mill touchscreen operation. Dual spindles simultaneously mill the latest metal-free materials (by leading manufacturers) on both sides of the restoration, with custom milling paths calculated for micron-precise accuracy. What’s more, the automatic tool changer selects the appropriate bur and replaces worn burs automatically.

Planmeca Romexis®

*Thunderbolt is a trademark of Intel Corporation in the U.S. and/ or other countries

Planmeca PlanMill 40™

Fast scanning and robust design tools allow you to complete single-unit to full-arch capture. ICE™

Left: before. Right: dentistry by E4D Technologies and Dr. Charles Schof.

Super modern Together with Planmeca Romexis software, the system supports an ideal digital treatment workflow. The open STL file format enables the clinician to seamlessly integrate and collaborate with other systems as well as export case files to any third party for review or completion. Scan the upper and lower jaw and buccal view, and send the case easily to a partner lab through Planmeca Romexis Cloud service. The scan software is included so it all comes together with Planmeca Romexis. IP This information was provided by Planmeca.

Volume 7 Number 5

ø8 x 8cm

• Features comprehensive implant planning module with a library of realistic implant models from over 30 manufacturers • Versatile volume sizes for single impaction to full dentition, and beyond • Measuring and annotation tools assist in safe and accurate treatment planning • Optional SmartPan allows 2D and 3D images to be taken with the same sensor

For a free in-office consultation, please call

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PLANMECA

PRODUCT PROFILE

Salvin® Renovix® Guided Healing Collagen Membrane

he Renovix® Guided Healing Collagen Membrane from Salvin Dental is getting excellent reviews from doctors using it for pre-implant grafting procedures, including socket preservation, ridge augmentation, and sinus lifts. It combines the ability to drape and conform to the specific anatomy of a grafted defect, while maintaining structural integrity and elasticity. This combination of ideal handling characteristics helps make grafting procedures easier and more predictable. When it comes to selecting the perfect membrane for guided bone and tissue regeneration, there are many choices. Yet most clinicians are still looking for the ideal barrier that combines the best handling and performance characteristics. Some collagen membranes remain stiff even after being hydrated, making it difficult to place over a ridge and conform to the shape of the defect. Other membranes have no memory and resemble wet tissue paper, making it extremely difficult to manipulate during surgery. Renovix® was originally created for use in repairing pediatric cardiac defects. Cardiac surgeons needed a resorbable membrane to protect the surgical site without migration, and to have it crosslinked in a way that significantly reduced the chance of an inflammatory response. Based on these specific requests, the material used for Renovix® was developed. Renovix® is fabricated from Type 1 porcine collagen, known to be one of the purest forms of collagen available. It is cross-linked with polysaccharide, a naturally occurring sugar, with excellent biocompatibility. The combined performance and handling characteristics of this membrane, along with specific requests from many implant surgeons, encouraged Salvin Dental to introduce Renovix® for guided bone-regeneration procedures. Case reports and clinical documentation are an important part of the decisionmaking process when determining how regenerative products will perform. Steve Wallace, DDS, MHS, from Wilmington, North Carolina, has used Renovix® in over 25 cases as a guided regeneration barrier after extraction and grafting of maxillary first and second molars in preparation for implant placement. Dr. Wallace made the following statement detailing his clinical experience with Renovix®: “Primary flap closure over maxillary molar extraction sites is always difficult to achieve. I have been using Renovix® as my barrier over these 54 Implant practice

grafted sites to exclude soft tissue ingrowth. I have seen that Renovix® remains intact up to 13 weeks and consistently promotes soft tissue closure over it with minimal inflammation.” When it is first removed from its sterile packaging, Renovix® is transparent and fairly rigid. Once hydrated, Renovix® becomes opaque, making it easy to identify when brought into the surgical field, and very easy to manipulate. Doctors have said that they get their best results when trimming it after it has been hydrated. Renovix® is very thin, yet has remarkable tensile strength. This characteristic provides several clinical advantages. First and foremost, it can easily be tacked or sutured to the surgical site if needed. Next, it can be tucked into small tunnel incisions using a micro periosteal elevator without concern that the instrument will easily puncture through the membrane. Finally, the fact that Renovix® is thin and resilient enables the clinician to elevate smaller flaps, leaving more of the periosteum and blood supply undisturbed for faster healing and less patient discomfort. James Woodyard, DMD, MS, from Newburgh, Indiana, made the following statement regarding his experience with Renovix®: “The thinness and excellent tensile strength of Renovix® allows me to create small tunnel incisions and tuck it under the tissue without tearing the membrane. With thicker membranes that I used in the past, I had to create large full-thickness flaps, and many of the other thin membranes had a tendency to tear when I tried to tuck them. When I decrease the size of the flap elevated and exposure of bone, I decrease postoperative swelling, pain, bone loss, and discomfort for the patient. The less invasive I can be, the less complications I have. I

Elastic handling

Conforms to the surgical site when hydrated Photo: Dr. Steve Wallace, DDS, MHS – Wilmington, NC

am extremely pleased with the results that I have seen when using Renovix®.” Renovix® is available in three different sizes and is individually packaged sterile for immediate use. Many doctors like 15 mm x 25 mm size because it will typically fully cover a grafted extraction socket from the buccal to the opposing lingual plate, maintaining full coverage over the ridge, without having to select a larger size. This unique size reduces waste and saves money by often eliminating the need to select the next larger size. For more information about Renovix®, check out the product video on the company’s website at www.salvin.com, or contact the team of experts at Salvin Dental at 800-5356566. They’ll take great care of you! IP This information was provided by Salvin Dental.

Volume 7 Number 5

Everything For Your Implant Practice But The Implants®

Enhancing Care For Your Patients™

Guided Healing Collagen Membrane • Resorbable Porcine Collagen Membrane For Guided Tissue & Bone Regeneration • Optimal Mechanical & Elastic Handling Characteristics • Biocompatibility With No Inflammatory Response • Easily Sutured Or Tacked Over Your Surgical Site • Easily Cut & Shape To Your Desired Size • Compare To Ossix™ Or Bio-Gide® Ossix™ is a registered trademark of Johnson & Johnson Bio-Gide® is a registered trademark of Geistlich

Socket Graft Without Primary Closure

Grafted Extraction Socket

Renovix® Placed Double Layer

Mineralized Cortical / Cancellous

Sutured Without Primary Closure

16 Week Post-Op Mature Tissue Closure

16 Week X-Ray Ideal Bone Formation

Surgery & Photos: Dr. James Woodyard, Periodontist, Newburgh, IN

Socket Graft Without Primary Closure

Grafted Extraction Socket

Renovix® Draped Over Surgical Site

Mineralized Cancellous

Sutured Without Primary Closure

4 Week Post-Op Mature Tissue Closure

16 Week X-Ray Ideal Bone Formation

Surgery & Photos: Dr. Steve Wallace, Periodontist, Wilmington, NC

Salvin Dental Specialties, Inc Toll Free (US & Canada) 800-535-6566 • www.salvin.com Phone 704-442-5400 • Fax 704-442-5424 • Email: orders@salvin.com 3450 Latrobe Drive • Charlotte, NC 28211 • USA © 2014 Salvin Dental Specialties, Inc. All Rights Reserved. REV. 01-2014

PRODUCT PROFILE

OCO Biomedical’s gateway to complete implant dentistry solutions The 3.0 and ISI One-Piece Implant System

rior to 2002, when implant dentistry practitioners were confronted with the challenges of patients who had single or several missing teeth, removable prosthetics and/or compromised bone quality, the choices were limited to using small diameter implants similar in design to wood screws. OCO Biomedical Inc. founder and inventor, David D. Dalise, DDS, responded to these challenges by creating and introducing the revolutionary, one-piece 3.0 mm immediately stabilizing implant. He developed trendsetting, patented protocols, procedures, and technology to provide simple, affordable, and almost pain-free implant solutions. After the clinically proven success of the 3.0, which incorporated orthopedic biomedical engineering principles to provide greater stabilization using shorter devices, the dental industry’s perception of implant placement and performance was transformed. This transformation was due to the unprecedented stability and innovative immediateload characteristics of this implant. Dalise then further developed and advanced the 3.0’s properties, i.e., wider diameter implants with the same characteristics and functionality; thus, the introduction of the one-piece ISI 3.25 mm, 4 mm, and 5 mm diameter implants. Being a one-piece configuration confirmed the patented claims of the system being designed for immediate or early loading. The two-piece TSI and ERI implant lines followed to accommodate different areas and provide for a wide variety of abutments to satisfy clinician preferences and various clinical situations. For the bone-level practitioner, the Engage™ implant line was developed. These

implants have all the initial stability characteristics of the ISI, TSI, and ERI lines less the Embedded Tapered Platform™. The platform-switched design uses the universal internal hex implant/abutment interface and offers unchallenged initial stability with the option of immediate or early loading after most placements.

Features and benefits of the 3.0 mm and the ISI One-Piece Implant System • Innovative, clinically tested, patented implant design with an unprecedented success rate • The Machined Embedded Tapered Platform™ is titanium-nitride coated for the best possible esthetic outcome and hygiene • Proprietary SLA surface treatment is applied to the superior strength Ti-TAL4V ELI titanium alloy • Simple, flapless placement protocols that enable the patient to receive an implant, final impression, and a temporary crown in one office visit, thus eliminating the need for multiple return appointments • Implant of choice by dentists throughout the USA: The 3.0 mm Mini, selected as one of the Top 25 Implant Products by Dentistry Today (June 2014) for small interdental spaces or denture stabilization

The Technology The Bullnose Auger™ Tip pulls bone up and around the tip of the implant; thus, condensing it around the apex with tension. At the same time, the Embedded Tapered Platform™, with a diameter greater than the

body of the implant, extends down through the cortical bone at the crest. This creates further tension throughout the length of the implant affecting exceptional initial stability, effectively creating dual stabilization. In orthopedic terms, this would be considered “osseous fixation.” This technology allows predictable, flapless, direct procedures because the Embedded Tapered Platform™ overcomes irregular bone-level situations at the crest of the ridge. For further information on OCO Biomedical’s 3.0 mm implant, the ISI OnePiece Implant System, as well as a comprehensive listing of the complete OCO product line, the recently updated 2014-15 catalog is available in print and online. AGD/PACE accredited course schedules and upcoming special events are also listed. Visit www.ocobiomedical.com.

About OCO Biomedical Inc. Established in 1977 and headquartered in Albuquerque, New Mexico, OCO Biomedical Inc. is a privately-owned dental implant company. In addition to the company’s vast network of practitioners using OCO products in the United States, the company has an international network of distributors located in Asia, Central and South America, Europe, and the Caribbean. OCO Biomedical Inc. is a proven world leader in creating and supplying patented, brand-name dental implant products, technology, and AGDPace CE accredited education and training in North America. OCO Biomedical Inc. is the implant company that provides complete implant solutions allowing practitioners to effectively serve their patients while simultaneously building practice performance. IP This information was provided by OCO Biomedical Inc.

56 Implant practice

Volume 7 Number 5

Give Your Practice A Lift

SINUS LIFT COMBO Your dental implant success, in part, is dependent on the bone quantity and quality at the implant location. Most practitioners agree, one of the more challenging locations for dental implants is the maxillary posterior, where there is often insufficient bone quantity due to the sinus cavity. Sinus lift surgery can rectify this problem by raising the sinus floor and increasing the vertical bone height for the placement of dental implants. Most patients experience only minimal discomfort from this procedure.

•DD-Sinus Lift Kit •HeliTAPE ™

Collage Resorbable Membrane - 2.5cm x 7.5cm - 10 pack

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The OCO Biomedical DD-Sinus Lift™ Kit, combined with our bone products provide you with a more predictable sinus lift surgery: improving your patient care and practice performance.

OCO Improves Your Dentistry

See it for yourself. Check out our DD-Sinus Lift™ Kit animation at: www.ocobiomedical.com/products/ dd-sinus-lift-kit

800-228-0477

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Complete Implant Solutions

STEP-BY-STEP

ZEST Anchors introduces CHAIRSIDE® — A new and unique attachment processing material

EST Anchors LLC (ZEST), the manufacturer of the trusted LOCATOR® Attachment and LOCATOR Overdenture Implant (LODI) systems, introduces the company’s newest product for overdenture cases — CHAIRSIDE® Attachment Processing Material. ZEST has a long history of producing superior overdenture products, and clinicians will find that CHAIRSIDE Attachment Processing Material is no different. CHAIRSIDE is designed for ease of use and predictability when processing attachment components into overdentures, including ZEST’s LOCATOR and SATURNO™ Denture Caps. Clinician input contributed to a formulation that has the most sought-after handling characteristics, which requires no primer, and is self-curing — all at a reduced cost per case.* “CHAIRSIDE Attachment Processing Material by ZEST Anchors is a game-changer!” said Dr. Michael Scherer of Sonora, California. “ZEST has developed a material that is perfect for processing attachments... It’s so easy to use, no messy primer is required, and the material offers dual-curing flexibility (self or light), thereby making the time I spend connecting the denture caps to the overdenture highly efficient and effective.” ZEST is convinced that clinicians will quickly realize the benefits CHAIRSIDE will bring to their practices — to prove it, please call 800-2622310, or visit www.zestanchors.com to learn about the company’s money-back guarantee when using CHAIRSIDE with the first overdenture case. IP

1. Place a White Block Out Spacer Ring around each abutment and press it down to the tissue. Place a Denture Cap with a Black Processing Male onto each abutment and press down firmly to ensure engagement of the abutment.

2. Apply fit check marking paste inside the denture. Insert it into the mouth over the Denture Caps. Mark the areas where the denture will need to be relieved to allow space for the caps to be picked up.

3. Relieve the areas marked with an acrylic bur. Try in the denture to verify that the Denture Caps are not in contact with the acrylic in any area. Cut lingual/palatal vent windows in the denture to visualize full seating and for excess material to vent. Cut an undercut below the intaglio surface of each Denture Cap relief area for mechanical retention.

4. Dry the Denture Caps. Apply a small amount of CHAIRSIDE Material around the circumference of each cap. Place CHAIRSIDE Material into the relief areas of the denture and seat it over the caps and onto the tissue. Have the patient close into light occlusion and hold while the CHAIRSIDE Material sets. The set time of the material from the time the material is mixed is five (5) minutes. The working time for the material is two (2) minutes, fifteen (15) seconds.

5. Disengage the denture from the abutments and remove from the mouth. Verify that the Denture Caps have been securely processed into the denture. Fill any voids; light cure and polish the denture. The material will bond to itself and will cure within 30 seconds with light application.

6. Place the denture in the mouth and press down to engage the males on the attachment system.

*Compared to the leading brands.

This information was provided by ZEST Anchors, LLC.

58 Implant practice

Volume 7 Number 5

University of Planmeca to showcase company’s imaging products and provide meeting space for dentists Planmeca USA has opened the University of Planmeca, a new multipurpose facility where clinicians can earn continuing education credits and see demonstrations of the latest Planmeca imaging units, core equipment, and other products for their operatories, adjacent to its main North American plant in northwest suburban Roselle, Illinois. The University of Planmeca is a unique 10,000-square-foot space that features room for 60 students in a Wi-Fi setting complete with comprehensive audiovisual capabilities for virtually any classroom setting. “We established the University of Planmeca to meet the need for dentists to pursue continuing education to keep up with the latest in dental imaging issues. We also wanted a state-of-theindustry showroom to demonstrate our best-in-class imaging units and operatory furniture,” said Planmeca USA President Bob Pienkowski, who added that the space is ideal for clinicians, dealers’ sales representatives, study clubs, and dental associations to hold their regular meetings and receive training on Planmeca imaging units. In addition to product demonstrations, the location offers to host educational programs or develop customized training courses on issues pertinent to dental imaging professionals. “The University of Planmeca is more than just a new space for dentists; it represents an opportunity for the dental industry to meet, learn, and plan for the dental practice of the future,” Pienkowski said. The showroom portion of the facility includes five operatories highlighting different imaging equipment, each with a unique specialty focus, Pienkowski noted. “Dentists need to see our imaging units to appreciate the seemless engineering, small footprint and elegant design — U.P. allows them to do just that,” Pienkowski said. Dentists interested in making an appointment to see the facility can do so by contacting their local sales rep at www.planmeca.com/na/how-to-buy. For more information, visit www.planmecausa.com, or find the company on Facebook at www.facebook.com/ PlanmecaUSA.

The California Implant Institute presents a 4-day, level I or level II comprehensive live patient surgical externship course in Baja California, Mexico Level I course Attendees of the level I course will implement step-by-step implant surgical protocols on live patients under the supervision of Dr. Louie Al-Faraje and faculty. The 4-day course will include 8 hours of lectures on diagnosis and treatment planning of implant cases (around 2 hours each morning). Each attendee will place 8-12 implants and assist with multiple implants on live patients. Alveoloplasty, flap designs, and suturing techniques are among the topics covered in level I curriculum. Course participants will increase their knowledge and skill in the areas of flap design, implant placement, bone grafting, and suturing techniques. All patients are carefully selected by the California Implant Institute faculty, and CT scans are provided for all patients. During the last program, 15 participants placed over 170 implants, including immediate and computer-guided placements and performed multiple bone grafting procedures.

Level II course Attendees of the level II course will increase their knowledge and skill level in the areas of advanced implant surgical techniques, including lateral-window sinus lifting, maxillary and mandibular ridge expansions, All-on-4®, CT graft, and block grafting. Level II participants will work also with Piezotome units that are available at each level II working station.

Next course scheduled The live patient surgical externship in Mexico is provided 4 times a year. Complete information on the externship, can be found on the California Implant Institute website, www.implanteducation.net, by calling 858-496-0574 or email: info@implanteducation.net Each of the level I and level II programs offers 32 CE credits.

Academic Director Louie Al-Faraje, DDS, is a private practitioner as well as the founder and director of the California Implant Institute, which conducts a 1-year fellowship program in implant dentistry. He is a fellow of the American Academy of Implant Dentistry and a Diplomate of the International Congress of Oral Implantologists and the American Board of Oral Implantology. He is the author of three Quintessence textbooks and is on the editorial board of Journal of Oral Implantology (JOI).

Volume 7 Number 5

Implant practice 59

INDUSTRY NEWS

Chicago-area dental equipment company builds education and sales center

ON THE HORIZON

Digital Impressions in the digital office Dr. Justin Moody discusses how to make the best impression on patients

here was a time when dentists were asked about about digital X-rays, and their responses were, “Won’t catch on,” or “I’d never be able to afford that.” Now, the numbers of digital offices are growing steadily. Recently, I have been asking my colleagues about digital impressions, and the answers are nearly the same. In my opinion, history will repeat itself again; the move to digital impressions has been somewhat slower in part due to the very rapidly changing technology that creates the fear of buying a product when you think the next version will debut shortly thereafter. I have said in the past that technology is only worth the investment if it can truly make your life more efficient; hence, more profitable. Sometimes we get caught up in how new treatment options can make us more money, but we must always remember the most important part of our practice — the patient. I have found that my patients not only want this technology, but will embrace it, and tell the world about it. When impressions are involved, shorter clinical appointments, no gooey impression material, and less remakes are what the patient understands and is now demanding it in today’s world. In my offices, the 3Shape Trios® intraoral scanner and the PlanScan™ (Planmeca E4D Technologies) are an integral part of my daily digital workflow. When placing implants in the esthetic zone, every patient in my office receives an i-CAT® FLX (Imaging Sciences International) 3D image as well as a full arch digital impression. With this data, I am able to treatment plan the case, present the treatment options to the patient, and fabricate models and surgical guides in one patient visit. Using Tx STUDIO™ from Anatomage, I am able to seamlessly merge these digital 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, and Adjunct Professor at the University of Nebraska Medical College. 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@justinmoodydds.com or at www.justinmoodydds.com.

60 Implant practice

3Shape Trios

Digital impression of scan body

Milling of zirconia crowns Full arch zirconia bridge

data for guided surgery, which is more efficient and safer for the patient. My use of digital impressions does not stop there; we use it to scan implants via scan bodies for digital communication with the laboratory. It is here that this technology has made the biggest difference in my practice — the ability to take a digital impression of an implant scan body and then to send this to a lab for fabrication of a patient-specific abutment or crown is simply amazing. Implant manufacturers such as BioHorizons® have helped this process speed up with their willingness to share files about their products and provide the laboratories with items such as titanium bases with Laser-Lok® for the custom abutment.

Patient specific zirconia abutment to a TiBase

The quality of the work I get back from ProSmiles Dental Studio and the speed at which the technology makes this happen are things that I would not give up in my practice. And I haven’t even touched on its use with real teeth. Don’t sit on the fence, and wait for the technology to stabilize because it won’t. Buy it, embrace it, and use it. You won’t be sorry. IP Volume 7 Number 5

NOTABLE MILESTONES llllllllllllllllllllllllllllll

NOMAD® reaches a new milestone: 15,000 handheld units shipped In July, Aribex®, Inc., worldwide leader in handheld X-ray technologies announced the sale of their 15,000th NOMAD® handheld X-ray system. Since its creation in 2004, NOMAD has quickly climbed to the top of the intraoral X-ray market and recently became a proud brand of the KaVo Kerr Group. The device’s breakthrough technology has revolutionized intraoral X-ray, and now it has become mainstream in the world of dentistry. NOMAD requires no walls, no installation, and no space-reducing cabinets. This leaves the staff free to arrange their operatories in the most effective workflow for them. Because operators are fully shielded from radiation while using NOMAD, they also have the freedom to stay with patients when taking X-rays, which minimizes retakes and expedites the X-ray process. In addition to heightened workflow, flexibility is an influencing factor in choosing NOMAD. It allows dental offices to have one NOMAD for multiple operatories, cutting equipment costs, and opening up ways to take X-rays more conveniently. Oral surgeons and endodontists are now able to take NOMAD with them into procedures and take X-rays under anesthesia. Often the convenience and comfort of using NOMAD causes dental staff to replace their older, working wall mounts in favor of NOMAD, and it has changed their office. NOMAD has proven itself to be a revolutionary technology in the dental world, and the over 15,000 units shipped are a testament that this device is finding itself in the mainstream of dentistry. For more information, visit www.kavokerrgroup.com.

62 Implant practice

Noor Foundation’s dental clinic receives muchneeded digital imaging technology DEXIS® has donated a DEXIS Platinum intraoral digital sensor, DEXIS Imaging Suite, and related image management software to the Noor Foundation’s Dental Clinic, a volunteer-based, nonprofit organization that provides free dental services for those in its community who might otherwise go without care. DEXIS provided the Noor Foundation’s charity clinic with robust digital imaging hardware and software. This donation allows the clinic to operate with leading technology that can help the volunteer healthcare providers improve and streamline patient care. DEXIS is an industry leader in developing high-quality digital imaging solutions for the dental community. Since its introduction to the United States in 1997, DEXIS has become the most highly awarded intraoral digital X-ray system with numerous awards from dental researchers and well-respected dental publications. The company has a strong history of supporting national and international outreach programs, including Give Kids A Smile®, TeamSmile®, and Mission of Mercy®. DEXIS is a member of the KaVo Kerr Group. KaVo Kerr Group is a global portfolio of leading dental brands that share common values of Trust, Experience, Choices, Quality, and Smart Innovation. For more information about DEXIS, visit www.dexis.com.

BruxZir® Solid Zirconia surpasses 5 years of clinical use Glidewell Laboratories announced that BruxZir® Solid Zirconia crowns and bridges have successfully passed the 5-year mark in clinical usage and have reached this important milestone with over 5-million units prescribed by U.S. dentists. Even as BruxZir Solid Zirconia passed the 1-year and 2-year marks with good results from respected clinical studies, many dentists expressed the desire to see how the material might perform over extended years of clinical service before they would elect to utilize it within their own practices. Now, 5-years later, BruxZir Solid Zirconia is one of the most prescribed brands of full-contour zirconia restorations, a status owed to the countless dental and laboratory professionals who have adopted the material into their workplaces. As a result of its strength and unique vital translucence, BruxZir Solid Zirconia has revolutionized the landscape of dentistry by replacing bilayer restorations with a high-strength, esthetic monolithic option. Glidewell Laboratories is a privately owned corporation that has more than 43 years of history as a provider of high-quality restorations to dental practitioners nationwide. Its newly developed CAD/CAM processing capabilities are recognized as among the most advanced in the industry. To view a selection of clinical videos, CE courses, products, and services, visit the Glidewell Laboratories website, http://www.glidewelldental.com.

Volume 7 Number 5

Address the Implant Complexities You Face Everyday with...

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September/October 2014 – Vol 7 No 5

The role of piezosurgery in implant dentistry Dr. Adam Patel

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Dr. Michael D. Scherer

Corporate profile LightScalpel

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

PROMOTING EXCELLENCE IN IMPLANTOLOGY

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

Clinical articles enhanced by high quality photography

CBCT — not so incidental findings

Real-life profiles of successful implant practices Technology reviews of the latest products

Anatomage