Implant Practice US November/December 2014 Issue - Vol7.6 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews November/December 2014 – Vol 7 No 6 (LODI)

Using new technology to efficiently create direct implant provisional restorations Dr. Ara Nazarian

Cement- versus screw-retained prosthetics: a comparison

WHEN SIZE OR BUDGET MATTERS,CHOOSE LODI

PROMOTING EXCELLENCE IN IMPLANTOLOGY

Drs. Brenda Baker and David Reaney

Practice profile

Steven E. Holbrook, DMD

Corporate profile Sirona

Company spotlight

MIS Implants Technologies

PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!

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

PRODUCT PROFILE

THE MAKING OF A

GOLD STANDARD ZESTâ&#x20AC;&#x2122;s LOCATORÂŽ Attachment represents a rare occurrence in the implant field. Never before have industry players, clinicians, and patients come together to universally recognize the merits of a restorative solution. It has allowed the LOCATOR to become the most globally recognized and trusted brand for overdenture restorations.

INDUSTRY WIDE SOLUTION ZEST recognizes, and is honored by, the commitment implant companies have made to make the LOCATOR Attachment compatible with their dental implants. In fact, the dental implant companies that collectively make up over 90% of the global implant market supply, partner with ZEST Anchors. Each has chosen the LOCATOR to be a part of the solutions they provide to you, their customer, and your patients.

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Volume 7 Number 4

CLINICIAN PREFERENCE LOCATOR’s unique low profile design, pivoting technology, durability, and ease-of-use has propelled it to be the preferred choice of clinicians worldwide for tissue supported, implant-retained overdentures. Clinicians have validated LOCATOR’s Gold Standard status with over 4 million units purchased - no other product can match its extensive clinical documentation, design accolades or number of satisfied patients.

PATIENT SATISFACTION Every day new patients begin a journey of being able to eat, laugh and speak with confidence again. Today, nearly two million patients are enjoying an improved quality of life by trusting their clinician to secure their restoration with LOCATOR.

TOGETHER WE CAN MAKE TOMORROW EVEN BETTER The trust and confidence placed in ZEST since its inception in 1972 is not taken lightly. It enhances our company’s commitment to clinicians, our implant company partners and your patients. Together we will continue to provide more options for the treatment of patients who suffer from the real-life problems associated with edentulisim. Stay close to ZEST for soon-to-be released innovations that can improve and expand the clinical solutions available within the LOCATOR Portfolio of products.

To experience for yourself how LOCATOR became the Gold Standard of resilient attachment systems, and for a listing of ZEST LOCATOR Partners, please visit zestlocator.com/8 or call 800-262-2310.

INTRODUCTION

Reflection on 2014

s the end of the year approaches, we often reflect on what we have done and what we would like to do next. This is a great time to be a dentist and especially to be practicing implant dentistry. Technology is the only thing that seems to move faster than time. I remember hearing that 2D digital sensors were part of a trendy digital revolution, and that too would pass. Well, I think the digital revolution is here to stay — it is still in its relative infancy, and every year brings new digital innovations that give us more tools to improve patient care. Today’s technology makes procedures safer for patients and increases our long-term treatment success while providing Justin Moody, DDS, DICOI, DABOI today’s implant dentist with the best in complication avoidance. Digital impressions are not just for getting rid of the mouth goop; this is a true timesaving technology. I recently watched my assistant gather data for an upcoming surgery. In a matter of minutes, she was able to take a 3D image with the i-CAT™ FLX and a digital impression using the 3Shape TRIOS® color scanner. By the time I entered the room, she had Tx STUDIO™ by Anatomage on the monitor, and I was able to treatment plan and order a surgical guide for delivery that same week. Now, that is efficient use of time, resources, and technology. But sometimes we get so wrapped up in the big stuff and the technology that we forget that it’s the small efforts that make the biggest differences. I recently received a lovely card from a patient thanking me for the life-changing work I did for her. Thinking to myself that her case was very simple, I remember she had lots of bone, and all I did was place two dental implants with LOCATOR® attachments to secure her denture. Simple for me, but it wasn’t simple to her. Implant dentistry is my passion for many reasons, but reactions like that make me realize how incredibly blessed we are in this era to have the privilege to treat our patients with such precise care thanks to innovative materials and equipment. Inside the pages of this publication, you will see many great products, techniques, and educational offers. Step into the technology ring and look around. You may even be able to take advantage of last minute tax benefits from buying technology yet this year, or maybe, you want to start the New Year out with a good implant continuing education course! Don’t be hesitant to take your practice and your profession to the next level. You, your staff, and your patients will be glad you did. I’m looking forward to seeing what’s on the horizon for 2015! Justin Moody, DDS, DICOI, DABOI Private practice at The Dental Implant Center in Rapid City, South Dakota Diplomate with the American Board of Oral Implantology Diplomate of the International Congress of Oral Implantologists Fellow and Associate Fellow of the American Academy of Implant Dentistry Adjunct Professor at the University of Nebraska Medical College

November/December 2014 - Volume 7 Number 6 EDITORIAL ADVISORS Steve Barter BDS, MSurgDent RCS Anthony Bendkowski BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent Philip Bennett BDS, LDS RCS, FICOI Stephen Byfield BDS, MFGDP, FICD Sanjay Chopra BDS Andrew Dawood BDS, MSc, MRD RCS Professor Nikolaos Donos DDS, MS, PhD Abid Faqir BDS, MFDS RCS, MSc (MedSci) Koray Feran BDS, MSC, LDS RCS, FDS RCS Philip Freiburger BDS, MFGDP (UK) Jeffrey Ganeles, DMD, FACD Mark Hamburger BDS, BChD Mark Haswell BDS, MSc Gareth Jenkins BDS, FDS RCS, MScD Stephen Jones BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack DDS, CertPerio, FCDS Samuel Lee, DDS David Little DDS Andrew Moore BDS, Dip Imp Dent RCS Ara Nazarian DDS Ken Nicholson BDS, MSc Michael R. Norton BDS, FDS RCS(ed) Rob Oretti BDS, MGDS RCS Christopher Orr BDS, BSc Fazeela Khan-Osborne BDS, LDS RCS, BSc, MSc Jay B. Reznick DMD, MD Nigel Saynor BDS Malcolm Schaller BDS Ashok Sethi BDS, DGDP, MGDS RCS, DUI Harry Shiers BDS, MSc, MGDS, MFDS Harris Sidelsky BDS, LDS RCS, MSc Paul Tipton BDS, MSc, DGDP(UK) Clive Waterman BDS, MDc, DGDP (UK) Peter Young BDS, PhD Brian T. Young DDS, MS CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com | Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com NATIONAL ACCOUNT MANAGER | Michelle Manning Email: michelle@medmarkaz.com NATIONAL ACCOUNT MANAGER | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver Email: amanda@medmarkaz.com BRAND COORDINATOR Jacqueline Baker Email: jbaker@medmarkaz.com

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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.

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Volume 7 Number 6

TABLE OF CONTENTS

Company spotlight MIS Implants Technologies

Prepared for today and the future of implant dentistry..............................15

Practice profile Steven E. Holbrook, DMD

Patients, staff, and family — it’s a wonderful life

Clinical

Full arch implant treatment Dr. Mark Willings and dental technician Steve Campbell describe how they worked in partnership to replace a patient’s “hated” denture................. 17

Clinical

Oral soft tissue laser ablative and coagulative efficiencies spectra Dr. Peter Vitruk delves into the science behind ablative soft tissue lasers .......................................................22

Corporate profile Sirona

Sirona continues to develop innovative products shaping the future of dentistry

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Volume 7 Number 6

NEW

without compromise The design philosophy of the ASTRA TECH Implant System EV is based on the natural dentition utilizing a site-specific, crown-down approach supported by an intuitive surgical protocol and a simple prosthetic workflow. • Unique interface with one-position-only placement for ATLANTIS patient-specific abutments • Self-guiding impression components • Versatile implant designs • Flexible drilling protocol The foundation of this evolutionary step remains the unique ASTRA TECH Implant System BioManagement Complex. For more information visit www.jointheev.com

www.dentsplyimplants.com

Simplicity

TABLE OF CONTENTS Case study

Using new technology to efficiently create direct implant provisional restorations Dr. Ara Nazarian discusses an easy and predictable solution for instant implant temporaries........................ 28

Continuing education Cement- versus screw-retained prosthetics: a comparison Drs. Brenda Baker and David Reaney look at the pros and cons of the two key retention methods at the heart of restoring implants...........................38

Continuing education Spread — don’t split

Dr. Sam Mohamed uncovers the processes behind an alternative method for increasing horizontal width in cases of alveolar bone resorption

Step-by-step

Easy-to-learn ridge split technique with HIOSSEN’s ESSET Kit ESSET (Easy Safe Stable Expanding and Tapping Kit) .............................43

Research

Retrospective study of the survival rates of a surface-treated external connection implant system Drs. Kwang-Bum Park, Myung-Hwan An, Sang-Taek Lee, Young-Jin Lee, Hyun-Jin Kim, Woo-Chang Noh, and Hyun-Wook An present their findings on the survival rates of the XPEED® implant system.............................. 44

Step-by-step

RevitaliZe™ Patient Solutions Restoring the edentulous arch John C. Minichetti, DMD, traces the steps to a fixed implant-supported prosthesis.......................................49 6 Implant practice

Product profile

NuOSS Granules A New Generation of Bone Regeneration ..................................52 ®

Product profile

Soft tissue incision, excision, ablation, coagulation with LightScalpel® No bleeding – No stitching – High productivity – Fast ROI .................. 54

Product profile

BioHorizons® Biologics Optimal choices to support predictable implant therapy.............56

IPUS viewpoint

Materials & equipment.........................60 On the horizon

The best gift for the holidays — technology Dr. Justin Moody suggests that now is the time to invest in practice-changing technologies...................................62

Industry news ..............64 Volume 7 Number 6

UNMATCHED Primary Stability at Bone Level

The OCO Biomedical Engage™ implant provides unmatched primary stability and versatility at bone level. The patented implant body with its Bull Nose Auger™ tip, Mini Cortic-O™ threads and SLA surface provide the perfect support for all your restorative needs, whether they be a single restoration or a full mouth reconstruction. Available in 3.25, 4.0, 5.0 and 6.0mm diameters in a variety of lengths, the Engage™ implant is a one of a kind, superior implant for all your clinical needs. With a simple two-step surgical protocol and dependable prosthetics, our immediate load system has been the implant of choice for thousands of practitioners around the world for the past 13 years. OCO Biomedical manufactures quality, patented dental implants for dentists around the world. Our American made products improve your patient care and practice performance.

OCO Biomedical’s patented Bull Nose Auger™ tip

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Half-Day Workshop Tuesday Dec. 2, 2:00 - 5:00pm Instructor: Dr. Charles Schlesinger

Introduction and Hands-On Placement of the OCO Biomedical Implant System Hands On!

OCO Biomedical’s patented Mini Cortic-O™ threads

The Mini Cortic-O™ threads works in conjunction with the Bull Nose Auger™ tip for immediate or early loading

Our products are designed by dentists for dentists, just like you! To learn more about how to work with our Patented Immediate Load Technology & Dual Stabilization® Implant Line, call 800-228-0477 or email us at sales@ocobiomedical.com.

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800-228-0477 Complete Implant Solutions

PRACTICE PROFILE

Steven E. Holbrook, DMD Patients, staff, and family — it’s a wonderful life

What can you tell us about your background? I was born and raised in Albuquerque, New Mexico. I graduated from Sandia High School and the University of New Mexico (UNM), so I am a “Lobo” for life. I attended Washington University School of Dental Medicine in St. Louis, Missouri, as one of two student scholars from the state of New Mexico. I always dreamed of returning to Albuquerque to practice dentistry, which is my avocation, not just my job. I have been living that dream since 1984. I have a “dream team” that makes dentistry not only rewarding, but fun. My office has been designed to provide maximum comfort and technology for my patients and staff. It is a pleasure to come to work every day. I strongly believe in continuing education, and to this end, I have achieved the following credentials and awards. I am board certified in implant dentistry as a Diplomate of the American Board of Oral Implantology. I am a Master in the Academy of General Dentistry (AGD) and a Fellow in the American Academy of Implant Dentistry (AAID). I also received the Lifelong Learning and Service Recognition Award from the AGD. Furthermore, in addition to participating in continuing education, I provide dental education for other dentists. I frequently speak on implantology for the AAID, AGD, and dental implant companies (Basic Dental Implants and Ossotanium™ Corporation). I mentor other dentists in an Albuquerque implant study club. I am also a reviewer for the Journal of Oral Implantology. I am active in local, regional, and national dental associations. I am currently serving as a Trustee for the AAID Board of Trustees. I am a past president of the New Mexico AGD and formerly the delegate from New Mexico to the national AGD Congress. I am a past chairperson for the national AGD Self-Instruction Committee and also 8 Implant practice

past president for the Western District of the AAID serving New Mexico, California, Oregon, Washington, Colorado, Arizona, Utah, Nevada, Wyoming, Montana, Hawaii, Alaska, and in Canada, British Columbia, and the Northwest Territories. I believe in giving back to the community. I volunteer my services to provide dental care to New Mexicans with limited incomes. I participate in the New Mexico Dental Association’s donated dental services programs for adults and for children. My staff and I also participated in the New Mexico Mission of Mercy. I am happily married to an attorney who is also my office manager. We have a daughter who graduated from UNM School of Law in 2013 and practices law in Albuquerque. Our daughter was also a Lobo as an

undergraduate. My parents and my brother also live in Albuquerque. Additionally, to make my family complete, I have a very energetic and spoiled yellow Labrador Retriever and a pampered cat. I have a great practice, a terrific staff, a fantastic family, and a wonderful life. My favorite movie is It’s a Wonderful Life!

When did you become a specialist and why? I was board certified in implant dentistry by the American Board of Oral Implantology in 2004. I found that I enjoyed the opportunity to give patients the option of replacing missing teeth with a more conservative and permanent solution than what was available with conventional dental treatment.

Is your practice limited solely to orthodontics/endodontics/implants, or do you practice other types of dentistry? The focus of my practice is comprehensive dental care, so we do provide all aspects of dental treatment, including both Volume 7 Number 6

PRACTICE PROFILE

restorative and surgical options for our patients. We also offer our patients esthetic enhancements such as Botox® and dermal fillers.

Why did you decide to focus on implants? Early on in my practice, I saw many patients who were unable to eat and chew comfortably due to ill-fitting dentures and partials. They were also embarrassed with their appearance and unable to maintain good health due to an inability to eat properly. I found that dental implants gave me the ability to provide restorations for these patients, which allowed them to eat comfortably, smile confidently, and maintain their health.

Do your patients come through referrals? Our most common referral sources are referrals from patients, physicians, and other dental professionals.

Tell us about your office. How long have you been practicing implantology, and what systems do you use? We built our current 2,886-square-foot, fully computerized state-of-the-art facility in 2006. The office has a large reception area, a large administrative area, five operatories, a sterilization area, a consultation room, a secondary consultation area, a laboratory, an imaging center, a staff break room, a laundry room, and a private office. The office was designed by Dr. Michael Unthank, a licensed dentist and architect, and decorated by my wife. It is my ideal office, and it is a pleasure for me to be able to work there every day. I have been placing and restoring dental implants for 29 years, so I have had experience with most implant systems on the market. I use the Ossotanium implant Volume 7 Number 6

system which features nanostructured titanium implants. These Biotanium™ implants provide a considerable advantage for my patients and my practice. These implants heal to the bone faster, are more biocompatible and are twice as strong as implants constructed from conventional titanium. These nanostructured implants are ideal for immediate loading. The Ossotanium system has excellent prosthetic variability. The system offers bone level, tissue level, one-piece, and mini implants.

What training have you undertaken? I have taken thousands of hours of continuing education courses. I have earned Diplomate status from the American Board of Oral Implantology, a Mastership in the Academy of General Dentistry, and a Fellowship in the American Academy of Implant Dentistry. I am a graduate of the Maxi-Course in Implant Dentistry at the Medical College of Georgia. I completed the Continuum at the Pankey Institute for Advanced Dental Studies, the Pacific Esthetic Continuum, and the Mini-Residency in Craniofacial Pain at the University of Florida. I also received the Lifetime Leadership and Service Award from the Academy of General Dentistry. I have served my profession as the President of the New Mexico Academy of General Dentistry, as the President of the Western District of the Academy of Implant Dentistry, as a reviewer for the journals General Dentistry and The Journal of Oral Implantology, and as the chairperson of the Self-Instruction Committee of the Academy of General Dentistry. I am also fortunate that I have been able to share my knowledge with others in my profession. I have lectured nationally and internationally on the subjects of Implant Dentistry, Occlusion, and Esthetics for the Academy of General Dentistry, the American Academy of Implant Dentistry,

Innova Corporation, Sybron Dental Specialties, Basic Dental Implants, and Ossotanium Corporation. I have taught hands-on courses in Implant Dentistry in Albuquerque since 2006 and have published articles on the subjects of implant dentistry and practice management.

Who has inspired you? I am inspired daily by Dr. L.D. Pankey, who believed that success in life is achieved by the balance of love, play, work, and worship. Adopting Dr. Pankey’s philosophy helps me keep my life in perspective. John Wooden, an award-winning basketball player and coach, said “Success is peace of mind that is a direct result of self-satisfaction in knowing that you made the effort to become the best of which you are capable.” This quote is important because there are failures that will occur in dentistry and in life so the most important thing that we can do is prepare as much as possible for every situation that we face. Cervantes in Don Quixote wrote that “The road is better than the inn.” It is easy to stay in our comfort zone, but I have found that the only time that we truly learn is when we venture outside our comfort zone. It is important to embrace new techniques and technologies in dental practice. Most importantly, I am inspired by my wife, who by her limitless courage in the face of life’s many challenges, lives in the present Implant practice 9

PRACTICE PROFILE with joy, humor, and kindness. She helps me be a better man, and I cherish every day with her.

What is the most satisfying aspect of your practice? The smiles, hugs, cards, and symbols of gratitude that I receive from my patients after completing their treatment.

Professionally, what are you most proud of? The relationships that I have developed with patients, employees, and colleagues. I have employees who have been with my practice for over 20 years and patients who have been with me since I opened my practice.

What do you think is unique about your practice? The focus of my practice is comprehensive dental care. The goal of my practice is to help our patients maintain their teeth for their lifetimes in optimal health, esthetics, function, and comfort according to their objectives and circumstances. When a patient has missing teeth, we replace them with those same objectives in mind. Our guiding principle is to do unto others as you would have them do unto you. I believe that every patient is a unique individual and needs to be treated as such. It is important take the time to discuss treatment options with our patients and allow them to make an informed decision regarding their treatment. In many cases, we are able to place immediate implants with immediate function. Patients can receive both surgical and prosthetic treatment without having to shuttle between offices.

10 Implant practice

What has been your biggest challenge? Achieving that balance of love, play, work, and worship in my life. I enjoy the practice of dentistry so much that I can easily devote too much time to it.

What would you have been if you didn’t become a dentist? I really cannot imagine a career that could have been as rewarding as the practice of dentistry. However, I do enjoy speaking, writing, and teaching.

What is the future of implant dentistry? I believe that nanostructured titanium implants are the future of implant dentistry as they have many advantages over conventional titanium implants in the areas of biocompatibility and strength while allowing us to shorten treatment time for our patients.

What are your top tips for maintaining a successful specialty practice?

DDS, advised — “Implant dentistry is a prosthetic discipline with a surgical component.” It is important to take advantage of mounted diagnostic casts and appropriate imaging techniques that complement a complete examination. This allows for proper diagnosis and treatment planning to optimize implant position for the best prosthetic result. In doing so, it is also important to remember Carl Misch’s advice that “an axiom of implant treatment is to provide the easiest, costeffective, most predictable treatment that will satisfy the patient’s needs and desires.” Take advantage of guided implant placement to provide optimal treatment for the patient with minimal postoperative discomfort.

What are your hobbies, and what do you do in your spare time? I enjoy the outdoors. My wife and I like spending time together at our cabin in the mountains of northern New Mexico. We enjoy hiking, watching the wildlife, fishing, and playing with Sunny (our yellow Labrador Retriever). We enjoy the beautiful landscape and cultural diversity of New Mexico, especially country western dancing. We both love to relax by the fire with a good book. We also enjoy attending UNM Lobo athletic events. IP

Remember to always treat others as you would have them treat you. Remember that as Steven Covey advised, “Always do first things first.” Always do a complete examination and diagnosis that includes diagnostic casts and necessary imaging prior to providing treatment for the Top 10 Favorites patient. This will help you avoid 1. My family and my faith possible surgical and prosthetic 2. Ossotanium™ implants complications. 3. Spending time in the mountains 4. PreXion imaging What advice would you give 5. Dancing with my wife to budding implantologists? 6. Guided implant placement Remember as Burton Melton, 7. Labrador Retrievers and Balinese cats 8. Esthetic Dental Arts laboratory 9. Hiking in Chaco Canyon 10. CoLab Dental Laboratory

Volume 7 Number 6

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CORPORATE PROFILE

Sirona Sirona continues to develop innovative products shaping the future of dentistry

or more than 130 years, Sirona has consistently spearheaded technological developments in dentistry beginning with the invention of the first electrically powered dental drill in 1887. As the world’s largest manufacturer of dental technology, Sirona develops, manufactures, and markets a complete line of dental products that drive improved workflow, a better patient experience, and ultimately increase the success of dentists who incorporate Sirona technology within their practices. Through Sirona’s robust product offering of CAD/CAM restoration systems (CEREC); digital intraoral, panoramic, and 3D imaging systems; dental treatment centers; handpieces; and hygiene systems, the company provides innovative solutions for dental practices, clinics, and laboratories.

Sirona executive team (left to right): Walter Petersohn, Executive VP of Sales; Rainer Berthan, Executive VP; Jeffrey T. Slovin, President and CEO; Ulrich Michel, Executive VP and CFO

Comprehensive 3D imaging In all dental disciplines, including implantology, endodontics, and orthodontics, there are numerous questions that can be answered far more easily using 3D X-ray CBCT. Sirona offers several 3D options that provide superior digital image quality at a low dose of radiation making for an efficient workflow and more concise communication with patients.

Sirona production site in Bensheim, Germany

GALILEOS® As the first 3D imaging solution developed by Sirona, GALILEOS® combines X-ray diagnostics, implant visualization, treatment planning, and patient communication in one tool. GALILEOS ComfortPlus, the highend CBCT unit with HD mode, includes a large field-of-view and integrated FaceScan technology. ORTHOPHOS® XG 3D — a hybrid approach ORTHOPHOS® XG 3D combines the advantages of 2D and 3D into one comprehensive unit. With an extensive selection of panoramic and cephalometric programs to choose from, the right 2D diagnostic images are now augmented with the ability to capture 3D X-ray. 12 Implant practice

Sirona Center of Innovation in Bensheim, Germany Volume 7 Number 6

Sirona, the dental technology and innovation leader, has served equipment dealers and dentists worldwide for more than 130 years. The company develops, manufactures, and markets a complete line of dental products, including CAD/CAM restoration systems (CEREC), digital intraoral, panoramic and 3D imaging systems, dental treatment centers, and handpieces. Sirona employs a workforce of more than 3,200 at 28 locations worldwide, and markets its products in over 135 countries on all continents. The United States is Sirona’s largest single market, followed by Germany, Western Europe, and Asia. The company was spun-off from the Siemens Medical Technology Division in 1997, and since 2006, has been listed on the US NASDAQ stock exchange (symbol: SIRO). In the last fiscal year (October 1, 2012, to September 30, 2013), Sirona reported revenues of $1.1 billion. Sirona develops and manufactures the majority of its products in Bensheim, Germany, the largest research, development, and production location in the dental industry. The company currently employs more than 290 scientists and, over the past seven years, has invested more than $350 million in R&D.

GALILEOS ComfortPlus

Patented integrated technology The practice of implantology is quickly spreading throughout dentistry. Sirona pioneered guided implantology through the integration of 3D X-ray and CAD/CAM technology. GALILEOS CEREC Integration (GCI) gives the clinician complete control over the entire implant process, starting with the planning and ending with the manufacture of highly accurate abutments and crowns. For years, clinicians have benefited from the comprehensive 3D digital diagnostic and treatment solutions provided by GALILEOS CBCT. The single, 14-second scan transforms a traditional dental office into a center capable of fast, efficient, and accurate implant placements. The increased Volume 7 Number 6

GALILEOS provides true motion in cone beam with the SICAT Function software solution

visualization changes the patient-clinician conversation, proving better treatment acceptance, more informed diagnoses, and efficient treatment planning. With the integration of CEREC for the design and fabrication of the implant abutment and esthetic crown, you can be confident that your treatment plan workflow — as well as the entire process from patient presentation to final restoration placement

— is completed smoothly and without complications. As the name suggests, GCI is all about the seamless collaboration and data sharing of systems and processes within the dental procedure. GCI allows simultaneous assessment of both the prosthetic and surgical situation, as well as both processes to be fully controlled and accomplished in the dental practice. Implant practice 13

CORPORATE PROFILE

The history of Sirona

CORPORATE PROFILE GCI’s step-by-step workflow To envision the GCI workflow from start to finish, consider the following steps: 1. During the first patient visit, an optical impression of the bite is taken with CEREC, and the prosthetic restoration is planned using the CEREC software. 2. The GALILEOS 3D scan begins diagnoses of the bone structure and integration of the prosthetic recommendation into the X-ray volume. The implant is planned simultaneously according to the surgical and prosthetic conditions. 3. Next, the surgical guide is ordered in the software, and the planning data is transmitted to SICAT (in the case of the SICAT OPTIGUIDE process). 4. During the second patient visit, the implant is placed using the surgical guide. In the case of immediate loading, it is restored directly with a CEREC temporary prosthesis. If necessary, patient-specific, customized abutments with CEREC can be created and incorporated in this session. 5. With immediately loaded implants, the temporary prosthesis is replaced by the final prosthesis, and the case is completed. With traditionally placed implants — after completion of the healing phase — the implant is provided with a temporary or final prosthesis (with CEREC) in this session. The benefits of GCI include faster and more reliable treatment with fewer complications resulting in higher patient satisfaction with the final outcome. With GCI, you are in complete control of all surgical and prosthetic parameters every step of the way.

Shaping the future through motion For the first time, GALILEOS provides true motion in cone beam with SICAT Function. SICAT Function is a revolutionary software solution with an integrated 3D workflow. With GALILEOS and SICAT Function, you can use patients’ 3D cone beam scan with their actual recorded jaw motion. This allows for the visualization and a movement-oriented treatment plan. The recorded jaw movement can be visualized and reproduced at any location in the dentition or mandible. With SICAT Function, in-depth patient information is at your fingertips. You’re now provided with an understanding of the condyle-fossa relationship during jaw movement, anatomically correct trajectory, visualization of the specific positioning of the trajectory in 3D, as well as a comparison 14 Implant practice

Sirona means solutions for dental practices, clinics, and laboratories. It is all part of our goal of constantly striving to find new ways of making the best much better and providing customers with the ultimate in dental products and services.

The recorded jaw movement with SICAT Function can be visualized and reproduced at any location in the dentition or mandible

to conventionally used axial points and the ability to evaluate the occlusion based on the integrated optical surface scans. Continuing investment in research and development (R&D) ensures that Sirona remains the industry leader in dental innovation and quality applications. Our focus on continuous improvement, supported by one of the largest R&D organizations, provides customers with the ultimate in dental products and services, now and well into the future.

The Sirona vision Sirona believes in providing dental practitioners with the tools they need to put and keep them ahead. From optimizing treatment workflow and patient communication, to creating modern practice management platforms, we’re constantly working to meet and exceed the expectations of our customers. Equally important is our commitment in the field of innovation. In the future, digital networking will play a fundamental role in dental practices, clinics, and laboratories — influencing everything from treatment to patient management. That’s why we place great emphasis on the research and

development of digital, network-capable dental technology. It is just one more way in which we are helping to build a stronger dental community prepared for all future challenges. Individuality is also a vital part of our company philosophy. Different markets have different needs, which is why our products are manufactured with features and functions tailor-made to suit their requirements. In offering dental practices, clinics, and laboratories a wide spectrum of individual solutions, we not only make work more effective but boost earnings as well. Consulting is another essential component of this service, and we work closely with dental dealers throughout the world, providing extensive support in marketing and sales promotions. To sum it all up — Sirona means solutions for dental practices, clinics, and laboratories. It is all part of our goal of constantly striving to find new ways of making the best much better and providing customers with the ultimate in dental products and services. For more information on Sirona, please visit www.sirona.com or call 800-659-5977. IP This information was provided by Sirona.

Volume 7 Number 6

Prepared for today and the future of implant dentistry

IS Implants Technologies has made its mark in the dental implant industry. Its humble beginnings laid down the strong foundation for MIS to become one of the leading global brands with innovative implant systems and related products. To understand how this has been achieved, it is important to understand the company’s philosophy and history. The first MIS implants were manufactured in 1995 in a small industrial park in northern Israel. They were able to use that original building for many years, but as their distributors and reach grew around the globe, they planned and built a far larger facility. With distributors in Europe, South and Central America, the United States, and Canada, the Israel corporate home is where everything still MIS Implants Technologies headquarters in northern Israel – a state-of-the-art facility begins, and activities are coordinated with those 60-plus distributors and subsidiaries. This new building itself houses hundreds of employees — from research and development, manufacturing, and quality assurance to warehousing, marketing, and the executive offices. The mission of MIS Implants Technologies is to simplify the practice of dental implantology. Doctors around the world recognize that the design of the MIS implants and surgical kits accomplish just that. MIS is dedicated to offering quality and service to its clients. This does not mean only in the design and manufacturing phases of the firm’s iproducts, but also in the type of relationships its distributors build with individual clients. MIS considers itself to be agile and innovative, responding to the needs of practitioners and moving forward with new products based on scientific research. The company’s implant systems Part of the quality assurance process at MIS Implants Technologies meet the needs of almost every dental implantologist (the majority of the company’s implantology. It is this combination of core and restorative doctor by implant systems are packvalues that has allowed this company to offering different connecaged with the appropriate grow steadily year after year. tions, body shapes, and final drill), MIS tries to simplify Mr. Idan Kleifeld holds the CEO posithread designs. The evolution at MIS Implants Technologies Ltd. in and improve the outcomes tion of their designs keeps Israel. He has an impressive background of dental implantology. To up with current research be more of a partner with with other manufacturing companies, all of and will continue to change which allowed him to transfer easily to MIS. the clinician, the MIS team Idan Kleifeld, CEO of MIS Implants Techas the practice of implantolaunches additional prodHis vision has helped MIS Implants to evolve nologies Ltd. continues to ensure that logy evolves. From superior ucts that serve to enhance into one of the world’s largest producers of significant efforts and resources are put toward research and production raw materials to packaging dental implants. the practice of dental

Volume 7 Number 6

Implant practice 15

COMPANY SPOTLIGHT

MIS Implants Technologies

COMPANY SPOTLIGHT Mr. Doron Peretz has and live surgery observation. been part of MIS since those This will give clinicians from all early days. He currently over the world an opportunity holds the title of Senior VP to see, firsthand, the operaof Sales and Marketing. He tions of this organization and has successfully expanded to get a better understanding the role of MIS Implants to of what makes the MIS team be more than just a manuso successful. facturer of dental implants. The MGUIDE stent and surgical kit also have unique He has been a champion features. The most impresof expanding product lines sive is the lack of keys (or and services from innovaDoron Peretz, Sr. VP of Sales and tive bone products such as “spoons”) to hold the guide in Marketing, has been with MIS since BondBone to two successful place. The MGUIDE surgical its infancy in 1995 world conferences held stent is designed to clip onto in Cancun, Mexico, and the undercuts of teeth to stay Cannes, France. Each of these conferences secure during the preparation of the ostehas brought experts in the field of implanotomy. Metal sleeves in the stent, along with tology to fabulous locations for lectures by the specially designed drills, determine the experts in their respective specialties, handsdepth to which the osteotomy is prepared. on workshops, and camaraderie among The other immediately noticeable difference the attendees. is the open framework of the stent, which Along with the rest of the manageallows for efficient irrigation and improved ment team in Israel, MIS leaders have set visibility over traditional stents. Imagine their sights high and continue the forward the increased confidence that a stent momentum of the company. They know that like this offers. the people they hire make a big difference At the helm of the U.S. subsidiary between MIS and other implant compais Mr. Motti Weisman who has held the nies. The MIS employees do truly work as a position of CEO at MIS USA since its team, even internationally, to deliver the best inception more than 12 years ago. He has product and service possible for their clients. helped to build the MIS brand through Newer entries into the market include the his dedication to the dental commuMCENTER with its MGUIDE guided surgical nity. With almost 50 reps throughout products and CAD/CAM 360 line of prodthe U.S., he has been able to provide ucts, which feature custom-milled solutions excellent customer service directly to for implant dentistry. the dental community. With almost There are MCENTERs located in the equal numbers of support personnel in United States, Germany, and Israel. The entire the home office, they strive concept of the MGUIDE differs from convento be true partners to the tional guided surgery applications in many doctors with whom they ways. To start out with, the surgeon does not interact every day. Mr. Weisman says, “We purchase the software. Each case is planned are in the middle of a digital with the doctor once the MCENTER specialrevolution in dentistry that ists have received the models (either digital or poured stone) and an STL file from CT imaging. will change and affect all A wax-up is developed for each arch, and the aspects of the science and case is then planned from the desired outcome art of dentistry.” The staff backward. This “top-down” planning helps to of the MCENTER in the U.S., along with assisting in the planning stage for guided assure the end result is what the patient and clinician desire. The case is charged out sepasurgery cases, also manufactures the stents rately or as part of a multi-case package. in-house in state-of-the-art 3D printers. In the last few months, MIS has Each stent is subject to a rigorous quality announced a new implantology training series assurance protocol prior to being sent to for doctors, which will be held at the corpothe surgeon. In addition to manufacturing rate headquarters in Israel. The first multiplethe stents, the 3D printers are also currently day course, which will be given in English, utilized to print digital models for MGUIDE will be held in February 2015. The curriculum case planning. will include (but is not limited to) treatment Another recent addition to the U.S. capaplanning, CT evaluation and anatomical bilities is the milling center, which doctors and labs can utilize to make custom abutconsiderations, soft tissue management ments with a pre-milled MIS interface as well around implants, surgical complications, 16 Implant practice

as hybrid zirconia abutments. The CAD/CAM milling machines are specific to the material being milled and highly efficient at producing high-quality end products. For education related to dental implantology, the Dental Implant Training Center (ditcusa.com) offers a variety of courses offering CE credits to doctors and staff members. Courses range from a basic introduction course to advanced bone grafts and sinus lift procedures. The newly launched MIS e-commerce site in the U.S. allows doctors to order their products online whenever they choose. This secure shopping site has been carefully built to make online ordering as simple as possible. The online store is well categorized with a strong search engine. Each product has excellent images with a magnifying feature available to zoom in for close-up viewing. Every order is reviewed to check on the compatibility of the products ordered to help avoid the shipment of unwanted products.

Artist’s rendition of the open design and specialized drill for the MGUIDE surgical stent Motti Weisman, CEO of MIS USA, embraces the digital advances in dentistry, acknowledging the changes and potential in all phases of dentistry

MIS USA has a strong presence at national specialty organization and local trade shows and is staffed by enthusiastic representatives who are always willing to speak to current or potential customers about the MIS products. As expected, the local representatives have experienced regional management to mentor and assist them. With the 20th anniversary year of MIS on the horizon, be ready for more innovative ideas and events to hit the implant industry. IP This information was provided by MIS Implants Technologies.

Volume 7 Number 6

Dr. Mark Willings and dental technician Steve Campbell describe how they worked in partnership to replace a patient’s “hated” denture

his article describes one of the cases treated with the ASTRA TECH Implant System™ EV during its “ambassador program” — a pre-launch evaluation of what the manufacturer calls the “latest step in the system’s continuous evolution.” Dr. Mark Willings was invited onto the program for the final testing stages of development, having used the ASTRA TECH Implant System for about 15 years. He placed 20 EV implants during the trial.

Diagnosis A female patient in her 60s was referred by her general dental practitioner, looking for a fixed replacement for her Valplast® partial upper denture, which she hated. Her last few remaining upper teeth were loose and failing. The initial diagnosis was denture intolerance and failing remaining natural teeth. The lower jaw also lacked posterior support, due to missing back teeth and chronic adult periodontitis. The patient had already dismissed the option of conventional dentures as she was struggling with the partial upper denture she had. The reason she sought our opinion was for fixed rehabilitation, and thus, implant treatment was the only consideration for her. The agreed treatment plan had five stages: 1. Maintaining the remaining upper teeth, while placing seven dental implants in the upper jaw 2. After integration, removal of all the remaining upper teeth, placement of abutments, and temporary acrylic bridgework

Figure 1: Initial dental panoramic tomography (DPT)

Figure 2: Postoperative dental panoramic tomography (DPT)

Mark Willings, BDS, MFGDP (UK), DipImpDent RCS (Eng), FFGDP (UK), is a partner in Dental Excellence at Harewood, a multidisciplinary dental center and educational facility in Leeds, England. He has many years of experience in dental implantology including bone grafting, sinus grafting, and full mouth rehabilitations. Steve Campbell, RDT, is the managing director of Ambridge Ceramics, one of the UK’s leading implant and cosmetic veneer dental laboratories. He is currently the technical representative for the Association of Dental Implantology and director of finance for the Dental Laboratories Association.

Figure 3: Postoperative DPT — lower implants in place. Remaining upper teeth extracted. Uni-abutments installed Volume 7 Number 6

Implant practice 17

CLINICAL

Full arch implant treatment

CLINICAL

Figure 4: CAD/CAM upper jaw

Figure 5: CAD/CAM image – Atlantis abutment in place

Figure 6: CAD/CAM image – Atlantis abutment

Figure 7: Lower jaw model with Atlantis abutments

Figure 8: Lower jaw model with bridgework

Figure 9: Upper acrylic transitional bridge

Figure 10: Abutments LR4 and LR6 installed

Figure 11: The Atlantis Isus framework try-in

Figure 12: Final bridgework construction

3. Provision of posterior support in the lower jaw with implant-borne bridges 4. Periodontal treatment to retain the remaining lower teeth 5. After healing and remodelling, fitting of definitive porcelain-bonded bridgework

bridgework. This was then fitted at the next clinical appointment. At the same time, the remaining upper teeth were extracted. The soft tissue was allowed to heal, and the bone was left to remodel for approximately 4 months. Pick-up impressions of the metal work in the lower jaw were taken to finalize the definitive porcelain-bonded bridgework. In the upper jaw, impressions were taken at abutment level and a mock-up made of the upper teeth.

As a whole, the results of the cases we treated during the trial were superb, with beautiful, esthetic restorations. In our opinion, the EV system gives great results across the board.

Surgical phase After completion of a diagnostic wax-up and CT scan, seven ASTRA TECH Implant System OsseoSpeed EV dental implants were placed in the upper jaw. Following initial soft tissue healing, a further four EV implants were placed in the lower jaw. The implants were allowed to integrate for 8 weeks. Then fixture head impressions were taken in the lower jaw for custom abutments to be fabricated. Temporary acrylic bridges were fitted for both LR4 to LR6 and LL4 to LL6. Once these were installed, the upper implants were exposed and fixture head impressions taken. The laboratory selected uni-abutments and manufactured temporary acrylic 18 Implant practice

Restoration Once we were satisfied with the tooth shape, morphology, position, and occlusion, the metal framework was fabricated. This was then tried in to ensure a passive fit. An Atlantis™ Isus metal framework was fabricated in milled cobalt chrome. Final bite registration was taken and recorded on the framework using pattern resin. This was returned to the laboratory for completion of the porcelain work. Finally, the bridge was secured into place.

Laboratory work The first stage of the laboratory work was to produce temporary bridges, according to pre-surgical bites and models. Then the cases were cast, and the multi-unit abutments needed to fabricate the bridgework were selected. A verification jig was produced, and the tooth set-up was finalized from all the information gathered when the temporary bridges were fitted. This ensured that an accurate impression was obtained, along with the confirmed final prosthetic envelope within which the final frameworks needed to be designed.

Manufacture The case was esthetically challenging, as Volume 7 Number 6

STOP

Drilling Away Healthy Bone Presenting Densah™ Bur Technology*: The Innovation That Makes Osseodensification Possible

*Patent Pending

Introducing Densah Bur Technology for implant osteotomy preparation from Versah™ LLC. Densah Burs have a non-excavating proprietary flute design that, when rotating at 800 – 1500 rpm in reverse, densifies bone. This technique, known as Osseodensification, autografts bone along the entire length of the osteotomy through a hydrodynamic process with the use of irrigation. When rotating clockwise, Densah Burs also precisely cut bone. The result is a consistently cylindrical and condensed osteotomy leading to improved implant stability and potentially earlier loading. Rotating Counter Clockwise The Flute Back Rake Angle Creates Osseodensification

Osteotomy created with standard drills

Osteotomy created with Densah Bur cutting mode

Osteotomy created with Densah Bur Osseodensification

Rotating Clockwise The Flute Edges Precisely Cut Bone

To order the newest innovation in implant dentistry, contact a Versah Customer Service Professional at 844-711-5585 or visit www.versah.com

The Tip Design With The Flutes Facilitates Compaction Autografting

2500 West Argyle Street I Suite 300 I Jackson, MI 49202 I P: 517-796-3932 I Toll Free: 844-711-5585 I Fax: 844-571-4870

CLINICAL

Figure 13: Final bridgework

Figure 14: Upper abutments after soft tissue healing

Figure 15A: Final upper bridgework fitted

Figure 15B: Final upper bridgework fitted

Figure 16: Final lower bridges

Figure 17: An excellent end result was achieved

no pink ceramic was involved. The dimensions of the incisal length-to-width ratios, interdental shaping, and emergence profile needed careful consideration. The framework for the implant level bridge on the upper arch was produced using Atlantis Isus. The system provided the highest quality substructure for the ceramists to work on. This ensured a strong and passive foundation, which would serve the patient for many years to come (Mertens, et al., 2012). The lower arch was not suitable for direct screw-retained fixings due to the access holes coming through in the esthetic zone. Instead, four Atlantis CAD/CAM abutments were made. These were then milled and tapped in the laboratory to accept a metal framework that would be screw-retained onto the existing custom Atlantis abutments. This created a screw-retained bridge, but without the access holes coming through the buccal surfaces of the restoration. The final bridgework was produced by Jack Gleave of Ambridge Ceramics Ltd., North Yorkshire, England, using Creation ceramic. In our opinion, the ASTRA TECH Implant System EV is easy to use and genuinely seems to have been developed from the crown down. The technician can trust the system components to provide accurate information to create the ideal crown. 20 Implant practice

Figure 18: CT scan of end result

Conclusion The end result was excellent. Healing was uneventful, and the patient quickly recovered, following the surgical phase of the treatment. Aftercare involves meticulous attention and good oral hygiene with regular visits to the hygienist every 3 months (Yi, et al., 2001). The patient is delighted with both function and esthetics. She is very pleased to be without a denture and is happy to have function restored. Also, she does not have to worry

about a denture dropping or moving around. She can eat whatever she likes, smile with confidence, and has remarked: â&#x20AC;&#x153;I feel like I have my own teeth once again.â&#x20AC;? IP REFERENCES 1. Mertens C, Steveling HG, Stucke K, Petzl B, Meyer-Baumer A. Fixed implant-retained rehabilitation of the edentulous maxilla: 11-year results of a prospective study. Clin Implant Dent Relat Res. 2012;14(6): 816-827. 2. Yi SW, Ericsson I, Kim CK, Carlsson GE, Nilner K. Implantsupported fixed prostheses for the rehabilitation of periodontally compromised dentitions: a 3-year prospective clinical study. Clin Implant Dent Relat Res. 2001;3(3): 125-134.

Volume 7 Number 6

More than a treatment concept.

A smart portfolio with reduced complexity.

With a growing market of fully edentulous patients, the demand for immediate rehabilitation is increasing daily. Are you prepared to offer immediate rehabilitation with excellent esthetics and reliable long term results? The new Straumann Screw-Retained Abutments provide a wide range of prosthetic options for fixed edentulous and screw-retained restorations. More than a treatment concept, the Screw-Retained Abutments deliver a simple solution, excellent esthetics and longevity. To learn more contact your Straumann Territory Manager or visit www.straumann.us/SRA

CLINICAL

Oral soft tissue laser ablative and coagulative efficiencies spectra Dr. Peter Vitruk delves into the science behind ablative soft tissue lasers Introduction The much praised clinical benefits and ease of use of surgical and dental lasers are enjoyed by millions of patients and by tens of thousands of physicians, dentists, and veterinarians worldwide. State-of-the-art modern-day soft tissue lasers have made many soft tissue procedures much simpler and far more enjoyable for practitioners — consider bloodless laser blepharoplasty and laser frenectomy in Figures 1 and 2. The key to the success of soft tissue lasers is their ability to cut and coagulate the soft tissue at the same time. Present work is aimed to derive the wavelength-dependent differences in photo-thermal ablation and coagulation efficiencies for oral soft tissue pulsed dental Near-IR Diode, Mid-IR Erbium and IR CO2 lasers.1-24 Even though the soft tissue photothermal ablation has been extensively studied,5,6,17 there remains a discrepancy between (a) the widely proliferated notion about efficient Near-IR 800-1,100 nm laser ablation of the oral soft tissue,25,26 and (b) studies reporting the inefficient soft tissue Near-IR absorption/ablation.5,6,17,18 Indeed, the notions about “the key to the usefulness of the Nd:YAG is that this wavelength is highly absorbed in oral soft tissue”25, and “all currently available dental laser instruments and their emission wavelengths have indications for use for incising, excising … oral soft tissue surgery”26, contradict an observation5 illustrated here by Figure 3: “Lasers whose extinction length is 5 mm or more, and whose δ/α ratio [scattering to absorption ratio] is larger than 10, make Prior to co-founding LuxarCare in 2002 and LightScalpel in 2005, Peter Vitruk, PhD, MInstP, CPhys, held a variety of research and development positions around the globe. He was a Research Scientist with The Academy of Sciences in the former USSR and a Visiting Research Fellow with Heriot-Watt University in Edinburgh, United Kingdom (UK). He later worked as RF-excited CO2 Laser Programs Manager with Synrad, Inc., and then as Chief Scientist/Laser Designer with Luxar/ESC/Lumenis. He has authored 10 patents and over 20 articles on RF-excited CO2 gas laser plasma and resonator technology and is a Member of The Institute of Physics, London, UK. Author can be contacted at pvitruk@lightscalpel.com.

22 Implant practice

Figure 1: CO2 laser blepharoplasty in progress

Figure 2: CO2 laser frenectomy in progress

(Photo courtesy of Edward M. Zimmerman, MD, Pres. American Board

(Photo courtesy of Alan Winner, DDS, New York, New York)

of Laser Surgery, Las Vegas, Nevada)

Figure 3: Near-IR wavelengths 810 and 980 nm from commercially available dental diode lasers are highly scattered and weakly absorbed by the porcine soft tissue, resulting in slow and widespread photo-coagulation and no ablation

good coagulators but poor scalpels. Such wavelengths are all in the near-infrared (7001400 nm) region.” Another review article17 reports that “Using laser wavelengths where optical scattering is comparable to or dominant over tissue absorption is not conducive to precise ablation” directly relates to Near-IR wavelengths 800-1,100 nm. Furthermore, “Even in an idealized situation, application of high power laser [810 nm] light (e.g., 20 W) is necessary during several seconds, inducing tissue changes that extend further into the tissue than can be observed by the surgeon. An important complicating factor in the use of this highpower laser light, which penetrates deeply before being absorbed totally, is that it may reach vital structures in the vicinity of the

target tissue. These vital structures … may preferentially absorb near-infrared laser light because of different optical properties and may be heavily damaged before efficient tissue ablation at the surface initiated.”18 To address the preceding discrepancies, present work utilizes the known optical absorption coefficient spectra of the oral soft tissue’s four main chromophores — water,1,2 melanin,3,4 hemoglobin (Hb), and oxyhemoglobin (HbO2)4-6 (see Figure 4) — in order to analyze the photo-thermal ablation (or photovaporolysis5) and photo-thermal coagulation (or photopyrolysis5) efficiencies for the soft tissue dental lasers7 on the market today: Near-IR diodes at 808 - 1,064 nm; Mid-IR Erbium lasers at 2,780 nm and 2,940 nm; and IR CO2 laser at 9,300 nm and 10,600 nm. Volume 7 Number 6

CLINICAL

Optical model for epithelium and connective tissue (sub-epithelium) Besides the absorption coefficient spectra for the soft tissue’s main chromophores, their respective spatial distributions are taken into account through a simple twolayer optical model depicted in Figure 5: • The 100-300 µm thin8 epithelium layer with its optical absorption dominated by melanin and water. • The sub-epithelium medium (connective tissue, inclusive of lamina propria and submucosa9,10) with its optical absorption dominated by water and hemoglobin/oxyhemoglobin. 75% water content is assumed for both epithelium and sub-epithelium for convenience; adjusting water content within 70-100% range does not significantly alter main results and conclusions of this study. Figure 4: Optical absorption coefficient spectra at different histologically relevant concentrations of water, hemoglobin, oxyhemoglobin, and melanin based on data from references 1-6. Logarithmic scales are in use

Figure 5: Simplified optical model of oral soft tissue consisting of (1) water-melanin rich epithelium layer, and (2) waterhemoglobin-oxyhemoglobin rich sub-epithelium medium (connective tissue inclusive of lamina propria and submucosa)

Photo-thermal laser-tissue interaction: absorption, ablation, coagulation During photo-thermal laser-tissue interaction, the laser beam energy is absorbed (by tissue’s main chromophores-absorption centers) and heats the tissue inside the irradiated volume, which leads to elevated tissue temperatures that can result in tissue ablation and coagulation. Consider, as shown in Figure 6, a onedimensional approximation of a laser beam irradiating the tissue surface (at x=0) from the left (is graphically represented as a thin slice of a laser beam directed at the thin slice of the tissue), assuming pulse duration is essentially shorter than Thermal Relaxation Time discussed later. Incident laser beam intensity [W/cm2] is IB; laser light intensity Volume 7 Number 6

Figure 6: Simplified graphical representation of laser beam intensity attenuated inside the soft tissue

immediately below the tissue surface is I0. Accordingly, the reflectivity of tissue’ surface is (IB – I0)/IB, and the transmission is I0/IB. Inside the tissue, i.e., for x > 0, the laser light intensity is exponentially attenuated: I = I0 Exp [-x/A]

(1)

where 1/A is absorption coefficient from Figure 4 (or attenuation coefficient if light scattering is taken into account). Assuming that laser intensity I0 is greater than intensity Ia required (for a specific pulse duration t) to ablate the tissue locally, the tissue ablation takes place in 0 < x < xa referred to as the “ablation zone” in Figure 6. Immediately below the ablation zone the heat affected zone xa < x < xc is located, with the tissue temperature ranging from the very high Ta

(ablation temperature) at xa all the way down to the coagulation threshold temperature Tc at xc (i.e., Ta = 100ºC and Tc = 60ºC). Coagulation depth H = xc – xa, is defined by 60-100ºC temperature range19-22 inside the heat affected zone.

Light absorption and scattering in epithelium Since melanin is present in the epithelium layer while the hemoglobin is not, and since there is no melanin in hemoglobin-rich connective tissue (sub-epithelium), the optical properties of epithelium and sub-epithelium are analyzed separately and independently from each other. Similar to melanin content and pigmentation in human epidermis,3 the epithelium’s volume fraction of melanin pigmentation Implant practice 23

CLINICAL (presented in Figure 4) is estimated at approximately 2% (very light pigmentation), 13% (moderate), and 30% (dark). Optical absorption in epithelium at 800-1,100 nm Near-IR wavelengths is highly dependent on pigmentation but is relatively low due to very thin epithelium (100-300 µm8). Unlike Near-IR wavelengths, the Mid-IR wavelengths (Erbium lasers) and IR wavelengths (CO2 laser) exhibit close to 100% absorption in epithelium, which is of high value for predictable laser photo-thermal ablation of epithelium.11

Light absorption and scattering in sub-epithelium connective tissue Optical absorption depth spectrum for connective tissue (sub-epithelium) with 75% water and estimated 10% blood presence in the human soft tissue12 (containing hemoglobin (and/or oxyhemoglobin) at normal concentration of 150g/L5,6) is derived from absorption coefficient spectra (presented in Figure 4) for water1,2, hemoglobin and oxyhemoglobin4-6 and is presented in Figure 7. An estimate of the attenuation depth as an inverse of the sum of absorption coefficient3-6 and reduced scattering coefficient for whole blood (estimated through absorption to reduced scattering ratio from14), is presented as inset in Figure 7. Attenuation depth is a more accurate representation of laser energy penetration into the tissue for Near-IR wavelength where light scattering dominates over absorption.3-6,14 As can be seen from Figure 7, both Erbium lasers (approximately 3,000 nm) and CO2 lasers (approximately 10,000 nm) are highly efficiently absorbed by the soft tissue and, as will be shown, are efficient at cutting and ablating the soft tissue purely radiantly (non-contact). At the same time, diode lasers (approximately 1,000 nm) are highly inefficiently absorbed by the soft tissue, and therefore, cannot be used radiantly (non-contact) for cutting and ablating the soft tissue. Instead, Near-IR diodes are used as hot-tip contact thermal devices, whereas laser radiation heats the charred glass tip and then the heat from the charred tip is conducted into the soft tissue.

Thermal relaxation time Soft tissue ablation and coagulation efficiencies are influenced not only by absorption/attenuation spectra described in Figures 4 and 7, but also by laser pulse temporal characteristics and tissue’ thermal conductivity. The rate of how fast the irradiated tissue 24 Implant practice

Figure 7: Absorption (and estimated Near-IR attenuation) depth spectra of sub-epithelium (connective tissue). Logarithmic scale is in use

diffuses the heat away is defined through the thermal diffusion time, or Thermal Relaxation Time (presented in Figure 7) as TR = A2/K,16,17 where A is optical absorption (or Near-IR attenuation) depth discussed above. The physics behind thermal diffusivity process is similar to diffusion and Brownian motion first described in15. Coefficient K is tissue’s thermal diffusivity; K = λ /(ϱ C) ≈ 0.155 (+/-0.007) mm2/sec (derived from heat conductivity λ ≈ 6.2-6.8 mW/cm ºC ; specific heat capacity C ≈ 4.2 J/g ºC, and density ϱ ≈ 1 g/cm3 for liquid water for temperatures in 37-100ºC range23). For practical consideration of often used 0.4 mm laser beam diameter on the tissue, the Thermal Relaxation Time in Figure 7 is estimated approximately ≥1 sec for absorption (attenuation) depths in excess of 0.4 mm (i.e. when the 2-D radial heat conduction away from the axis of the beam takes place). Practical implications of Thermal Relaxation Time concept are simple and yet very powerful for appropriate application of laser energy. The most efficient heating of the irradiated tissue takes place when laser pulse energy is high and its duration is much shorter than TR. The most efficient cooling of the tissue adjacent to the ablated zone takes place if time duration between laser pulses is much greater than TR. Short laser pulse, depicted in Figure 6, allows for the most efficient ablation of the irradiated tissue with minimum coagulation and hemostasis underneath the ablated tissue. For instance, rapidly pulsed

Erbium and CO2 lasers are efficient at cutting with minimal coagulation in applications like char-free stage II implant uncovering, gingivectomy, frenectomy, biopsy, de-epithelization, fibroma excision, etc. The least efficient heating of the irradiated tissue takes place when laser pulse energy is low, and its duration is much longer than TR. The least efficient cooling of the tissue adjacent to the ablated zone takes place if time duration between laser pulses is much shorter than TR. For instance, long pulse and continuous wave (CW) CO2 lasers are less efficient cutters but provide for greater depth of coagulation for excising/incising in highly vascular and inflamed tissues like hemangioma.

Photo-thermal ablation efficiency Soft tissue photo-thermal ablation (or photovaporolysis5,6) is a process of vaporization of intra- and extra-cellular water.5,6,17 For a fixed laser beam diameter (or spot size), the volume of the tissue exposed to laser beam is proportional to the optical penetration (i.e. absorption or Near-IR attenuation as defined above) depth. The shorter the penetration depth — the less energy is required to ablate the tissue. The longer the optical penetration depth — the greater the volume of irradiated tissue, and therefore, more energy is required to ablate the tissue within the irradiated volume of tissue. The minimum energy density requirement to vaporize the irradiated soft tissue can be calculated from the spatial distribution Volume 7 Number 6

CLINICAL

of laser light intensity (1) inside the irradiated tissue (see Figure 6) for different wavelengths that are relevant to practical soft tissue dental Near-IR Diode, Mid-IR Erbium and IR CO2 lasers. Present analysis below covers conditions most suited for high efficiency photo-thermal ablation (pulse duration t ≤ TR) with minimum collateral damage to the surrounding tissue (pulse repetition rate f << 1/TR). Consider a laser beam pulse characterized by the following: 1) its duration t is less than Thermal Relaxation Time TR (for the thermal confinement of the laser energy within the irradiated tissue); and 2) its penetration (i.e., absorption or attenuation defined previously) depth A is uniquely defined by the laser wavelength and tissue properties; and 3) for the Near-IR wavelengths, the beam diameter is large enough so that its increase due to light scattering is negligible as it propagates through the tissue. Ablation depth is xa and coagulation depth is H = xa – xc, where the end of coagulation zone xc is where the tissue temperature Tc equals 60ºC. Let’s consider xa<<A conditions for which both the “blow-off” and “steady-state” ablation models described in17 apply. For laser beam intensity given by formula (1), the laser energy deposited into the unit volume of the tissue (during laser pulse duration t) is proportional to the rate of laser beam’ intensity’s change:

Figure 8: Soft tissue ablation threshold energy density spectrum. Logarithmic scale is in use

The key to the success of soft tissue lasers is their ability to cut and coagulate the soft tissue at the same time.

(4)

characterized by 100s-1,000s times greater photo-thermal ablation threshold energy densities than Mid-IR and IR wavelengths because of weak Near-IR absorption by the soft tissue’s chromophores. For the NearIR, the ablation threshold energy density is the lowest when the beam diameter is large enough so that its increase (due to scattering) is negligible as it propagates through the tissue. For very small Near-IR beam diameters, the ablation threshold energy density is significantly greater due to radial optical scattering as the beam propagates through the tissue. Figure 3 illustrates the high degree of scattering and predicted absence of tissue ablation at 810 and 980 nm. In sharp contrast to Near-IR wavelengths, the Mid-IR and IR wavelengths are highly energy efficient at ablating the soft tissue photo-thermally with very low ablation threshold intensities (see Figure 8) due to extremely small volumes of irradiated tissue because of extremely short absorption depths (see Figure 7).

The ablation threshold energy density ETH spectrum is presented in Figure 8, where the Near-IR wavelengths 800-1,100 nm are

Near-IR 800-1,100 nm wavelengths (dental diodes’ operating wavelengths)

t dI/dx = - t I0 Exp [-x/A] / A = - t I / A

(2)

Laser energy absorbed by the tissue heats up the tissue. Soft tissue ablation (i.e., tissue’s water vaporization) intensity Ia at location x = xa can be derived from (2) as: ϱ ( C (Ta - Tb) + r ) = t Ia / A = t I0 Exp [-xa/A] / A (3) where Tb is body temperature at 37ºC, Ta is water boiling temperature is 100ºC, C =4.2 J/g ºC is specific heat capacity, r =2,260 J/g is latent heat of water evaporation [27], and ϱ =1 g/cm3 is water density. The greater the laser beam pulse energy density t I0, the deeper (i.e. greater xa) the ablation. In order to calculate from (3) the minimum (i.e. threshold) ablation energy density ETH of laser beam, we consider xa<<A conditions: ETH = t ITH = ϱ A ( C (Ta - Tb) + r )

Volume 7 Number 6

Spatial accuracy of photo-thermal ablation

are poorly absorbed by scarce melanin in epithelium and by low concentration hemoglobin and oxyhemoglobin in sub-epithelium connective tissue, which results in multimillimeter depth of laser energy penetration into the oral soft tissue. Such multi-millimeter ambiguity in tissue removal spatial accuracy at Near-IR wavelengths (also cited in5 as “poor scalpels” and in17 as “not conducive to precise ablation”) increases the collateral damage risk of overheating both soft and hard dental structures (enamel, dentin, implants, and bone) underneath the connective soft tissue if photo-thermal ablation is attempted. Such risk is referred to in18 as “vital structures … may be heavily damaged before tissue ablation at the surface initiated”; the 810 nm soft tissue absorption coefficient of 0.7 1/cm in18 makes its observations highly relevant to the present analysis where 10% blood absorbs at the rate of approximately 0.4 1/cm at 810 nm (see Figure 4). Unlike Near-IR wavelengths, the Mid-IR wavelengths (Erbium lasers) and IR wavelengths (CO2 lasers) exhibit much shorter absorption depths (see Figure 7), which makes Mid-IR and IR lasers far more spatially precise and safer in soft tissue ablative applications. Implant practice 25

CLINICAL Photo-thermal coagulation efficiency Coagulation occurs as a denaturation of soft tissue proteins that occurs in 60-100°C temperature range19-22 leading to a significant reduction in bleeding (and oozing of lymphatic liquids) on the margins of ablated tissue during laser ablation (and excision, incision) procedures. Since blood is contained within and transported through the blood vessels, the diameter of blood vessels B (estimated to range from 21 to 40 µm with average value of 31 µm – from measurements in human cadaver gingival connective tissue24) is a highly important spatial parameter that influences the efficiency of photocoagulation process. Photo-thermal coagulation is also accompanied by hemostasis due to shrinkage of the walls of blood vessels (and lymphatic vessels) due to collagen shrinkage at increased temperatures. Present analysis below covers conditions most suited for high efficiency photo-thermal ablation (pulse duration t ≤ TR) with minimum collateral damage to the surrounding tissue (pulse repetition rate f >> 1/TR). Laser light intensity, see Figure 6, is assumed at the ablation threshold ITH from (4), and xa<<A. For short laser pulses t << TR and for near-ablation threshold conditions (2)-(4) above, the coagulation threshold power density Ec = t Ic and coagulation depth H = xc – xa ≈ xc (for 60-100ºC temperature range inside the heat affected zone in Figure 6, i.e. Ta = 100ºC and Tc = 60ºC) is calculated from: ϱ C ( Tc - Tb ) = Ec / A = t I0 Exp [-xc/A] / A = (5) ETH Exp [-H/A] / A where body temperature Tb is 37ºC. For longer laser pulses closer to Thermal Relaxation Time (t ≈ TR), the thermal diffusion spreads the heat over an additional distance A, which accordingly increases the coagulation depth from (5). The coagulation depth value H relative to the blood vessel diameter B is an important measure of coagulation and hemostasis efficiency; and is presented in Figure 9 for B = 21-40 µm24, where absorption/attenuation depth A from Figure 7 is utilized to calculate H from (5). For H<<B (see Erbium laser wavelengths in Figure 9), optical absorption and coagulation depths are significantly smaller than blood vessel diameters; coagulation takes place on relatively small spatial scale and cannot prevent bleeding from the blood vessels severed during tissue ablation. For H>>B (diode laser wavelengths in Figure 9), optical absorption (Near-IR 26 Implant practice

Figure 9: Coagulation depth spectrum for ablation threshold conditions. Logarithmic scale is in use

attenuation), and coagulation depths are significantly greater than blood vessel diameters; coagulation takes place over extended volumes — far away from ablation site where no coagulation is required. Extended thermal damage zones for Near-IR irradiated soft tissue are documented in18; the 810 nm soft tissue absorption coefficient 0.7 1/cm in18 makes its observations highly relevant to present analysis with absorption coefficient of approximately 0.4 1/cm at 810 nm (see Figure 4). For H ≥ B (CO2 laser wavelengths in Figure 9), coagulation extends just deep enough into a severed blood vessel to stop the bleeding; the coagulation is more efficient then for the above two cases H<<B, and H>>B.

Near-IR diode and Nd:YAG laser soft tissue ablation and coagulation Near-IR diode laser light circa 1,000 nm is not used to optically ablate the oral soft tissue; instead, the diode laser optical energy is used to heat up the charred distal end of the fiber glass tip to 500-900ºC,28 which then heats up the soft tissue through heat conduction from hot glass tip: soft tissue is burned off (ablated) on contact with the hot charred glass tip, while the margins of the burn are coagulated. Unlike non-contact surgical lasers (such as CO2 or Erbium), the soft tissue ablative diodes are contact thermal non-laser wavelength-independent devices. When used in contact mode, the Nd:YAG laser may function as a hot tip cutting tool [6]. When used in non-contact mode, the

Nd:YAG laser’s 1,064 nm wavelength is a highly efficient coagulator, but a poor scalpel, as it is highly scattered and weakly absorbed by the soft tissue.5,6,17 The low absorption of the Nd:YAG wavelength may be attenuated (and, therefore, its cutting efficiency may be enhanced) by the use of very high peak power6 typical for free-running pulsed Nd:YAG lasers.

Summary and conclusions Ablation threshold intensity and coagulation depth spectra are derived from the absorption spectra of oral soft tissue’ main chromophores (water, melanin, hemoglobin, and oxyhemoglobin) for conditions most suited for high efficiency photo-thermal ablation (pulse duration t ≤ TR) with minimum collateral damage to the surrounding tissue (pulse repetition rate f << 1/TR). The nonlaser wavelength-independent thermal interaction between the soft tissue and diode’s charred hot glass tip was excluded from the scope of present analysis. Near-IR 800-1,100 nm diode wavelengths are shown to be highly energy inefficient and spatially inaccurate photothermal ablation tools with wide spread thermal damage. More measurement data on Near-IR reduced scattering coefficient are needed for more accurate calculations of the oral soft tissue photo-thermal ablation and coagulation properties in the Near-IR. Mid-IR Erbium laser wavelengths are shown to be highly energy efficient and spatially accurate photo-thermal ablation tool with poor coagulation efficiency. Coagulation Volume 7 Number 6

REFERENCES 1. Wieliczka DM, Weng S, Querry MR. Wedge shaped cell for highly absorbent liquids: infrared optical constants of water. Appl Opt. 1989;28(9):1714-1719. 2. Hale GM, Querry MR. Optical constants of water in the 200-nm to 200-microm wavelength region. Appl Opt. 1973;12(3):555-563. 3. Jacques SL. Origins of tissue optical properties in the UVA, visible, and NIR regions. In: Alfano RR, Fujimoto JG, ed. OSA TOPS on Advances in Optical Imaging Photon Migration, Volume 2. Optical Society of America; 1996:364–369. 4. Jacques SL. Optical properties of biological tissues: a review. Phys Med Biol. 2013;58(11):R37-R61. 5. Fisher JC. Basic laser physics and interaction of laser light with soft tissue. In: Shapshay SM, ed. Endoscopic Laser Surgery Handbook. New York, NY: Marcel Dekker; 1987:96-125. 6. Fisher JC. Qualitative and quantitative tissue effects of light from important surgical lasers. In: Wright CV, Fisher JC, eds. Laser Surgery in Gynecology: A Clinical Guide. Philadelphia, PA: Elsevier Health Sciences; 1993:58-81. 7. Convissar RA. Principles and Practice of Laser Dentistry. St. Louis, MO: Mosby Elsevier; 2011.

8. Prestin S, Rothschild SI, Betz CS, Kraft M. Measurement of epithelial thickness within the oral cavity using optical coherence tomography. Head Neck. 2012;34(12):1777-1781. 9. Squier CA, Brogden KA, eds. Human Oral Mucosa: Development, Structure, and Function. Chichester, West Sussex, UK: Wiley-Blackwell; 2011:14-16. 10. Squier CA, Finkelstein MW. Oral mucosa. In: Nanci A, ed. Ten Cate’s Oral Histology: Development, Structure, and Function. 7th ed. St. Louis, MO: Mosby Elsevier; 2007:319-57. 11. Esen E, Haytac MC, Oz IA, Erdoğan O, Karsli ED. Gingival melanin pigmentation and its treatment with the CO2 laser. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;98(5):522-527. 12. Alberts B, Johnson A, Lewis J, Raff M, Roberts K, Walter P. Molecular Biology of the Cell. 5th ed. New York, NY: Garland Science; 2007:Table 23-1. 13. Collier T, Arifler D, Malpica A, Follen M, Richards-Kortum R. Determination of epithelial tissue scattering coefficient using confocal microscopy. IEEE J of Quant Electronics. 2003;9(2):307-313. 14. Cheong WF, Prahl SA, Welch AJ. A review of the optical properties of biological tissues. IEEE J of Quant Electronics. 1990;26(12):2166-2185.

19. Pfefer TJ, Choi B, Vargas G, McNally KM, Welch AJ. Mechanisms of Laser-Induced Thermal Coagulation of Whole Blood In Vitro. Part of the SPIE Conference on Cutaneous Applications of Lasers: Dermatology, Plastic Surgery, and Tissue Welding. Proc SPIE. 1999;3590:20-31. 20. Barton JK, Rollins A, Yazdanfar S, Pfefer TJ, Westphal V, Izatt JA. Photothermal coagulation of blood vessels: a comparison of high-speed optical coherence tomography and numerical modelling. Phys Med Biol. 2001;46(6):1665-1678. 21. Mordon S, Rochon P, Dhelin G, Lesage JC. Dynamics of temperature dependent modifications of blood in the nearinfrared. Lasers Surg Med. 2005;37(4):301-307. 22. Pang P, Andreana S, Aoki A, Coluzzi D, Obeidi A, Olivi G, Parker S, Rechmann P, Sulewski J, Sweeney C, Swick M, Yung F. Laser energy in oral soft tissue applications. J Laser Dent. 2010;18(3):123-131. 23. Weast RC, ed. CRC Handbook of Chemistry and Physics. 61st ed. Boca Raton, FL: CRC Press; 1980-1981. 24. Yoshida S, Noguchi K, Imura K, Miwa Y, Sunohara M, Sato I. A morphological study of the blood vessels associated with periodontal probing depth in human gingival tissue. Okajimas Folia Anat Jpn. 2011;88(3):103-109.

15. Einstein A. Über die von der molekularkinetischen Theorie der Wärme geforderte Bewegung von in ruhenden Flüssigkeiten suspendierten Teilchen. Annalen der Physik. 1905;322(8):549-560.

25. Graeber J. Diode Lasers: A Primer. The Academy of Dental Therapeutics and Stomatology – Your Online Continuing Education Resource. IneedCE.com. http://www.ineedce. com/coursereview.aspx?url=2564%2FPDF%2F1401cei Graeber_rev3.pdf&scid=15269. Published January 2014. Accessed September 2014.

16. Svaasand LO. Lasers for biomedical applications. In: Driggers RG, Hoffman C, eds. Encyclopedia of Optical Engineering. New York, NY: CRC Press; 2003:1035-1041.

26. Coluzzi D. Fundamentals of lasers in dentistry, basic science, tissue interaction, and instrumentation. J Laser Dent. 2008;16(spec issue):4-10.

17. Vogel A, Venugopalan V. Mechanisms of pulsed laser ablation of biological tissues. Chem Rev. 2003;103(2):577-644.

27. Latent Heat. Encyclopedia Britannica. http://www.britannica.com/EBchecked/topic/331406/latent-heat. Accessed August 10, 2014.

18. Willems PW, Vandertop WP, Verdaasdonk RM, van Swol CF, Jansen GH. Contact laser-assisted neuroendoscopy can be performed safely by using pretreated ‘black’ fibre tips: experimental data. Lasers Surg and Med. 2001;28(4):324-329.

28. Romanos G. Diode Laser Soft-Tissue Surgery. Compend Contin Educ Dent. 2013;24(10):752-758. http://editiondigital.net/publication/?i=183287&p=38. Accessed August 2 2014.

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Volume 7 Number 6

Implant practice 27

CLINICAL

depth can be increased by pulse width/rate increase. IR CO2 laser wavelengths are shown to be highly efficient and spatially accurate photothermal ablation tool with excellent coagulation efficiency (close match between coagulation depth and oral soft tissue blood capillary diameters). Coagulation depth can be increased by pulse width/rate increase. IP

CASE STUDY

Using new technology to efficiently create direct implant provisional restorations Dr. Ara Nazarian discusses an easy and predictable solution for instant implant temporaries

lthough widely utilized in conventional crown and bridge applications, direct provisional restorations have traditionally been underused in implant therapy. Timeintensive surgical procedures may make the dentist reluctant to dedicate additional chair time to the proper fabrication of a “mere temporary.” This unfortunate attitude often ends up costing even more time and expense at subsequent appointments, and can cause the overall quality of the final restoration to suffer. Using new technologies that offer dental providers an easy and predictable way of efficiently creating a direct implant provisional contributes to the success of an implant case. Good Fit Technologies offers Instant Implant Dentures, a pre-set arrangement of denture teeth in a variety of shapes and shades, festooned and set in an adjustable denture base. Instant Implant Dentures (Good Fit) can be adapted and fitted in minutes to create immediate implant provisionals and hybrid implant dentures because the base material is made of a thermoplastic polymethyl methacrylate (PMMA) material. Placing the thermoplastic temporary into a water bath of 90-100°C for about 2-3 minutes will make the product moldable, but you can adjust that temperature and time to suit your needs. Hotter temperatures for longer times will make the temporary more moldable; cooler temperatures for shorter times will make it less moldable. So you just drop it in hot water to make the product moldable and then adapt it in the patient’s mouth or on a model, depending on if you Ara Nazarian DDS, DICOI, maintains a private practice in Troy, Michigan, with an emphasis on comprehensive and restorative care. He is a Diplomate in the International Congress of Oral Implantologists (ICOI). His articles have been published in many of today’s popular dental publications. Dr. Nazarian is the director of the Reconstructive Dentistry Institute. He has conducted lectures and hands-on workshops on esthetic materials and dental implants throughout the United States, Europe, New Zealand, and Australia. Dr. Nazarian is also the creator of the DemoDent patient education model system. He can be reached at (248) 457-0500 or at the website www. aranazariandds.com.

28 Implant practice

want to do a direct or indirect procedure (Note: the product will remain moldable for approximately 1-2 minutes after cooling to a temperature that is comfortable for use inside the patient’s mouth). After 1 or 2 minutes — or in seconds, if you dip it in cold water — the temporary will become very rigid with no shape distortion from the cooling. It is important to note that the templates can be reheated many times to achieve the proper fit on the model or in the mouth. Once set to the desired arch form, the provider may transfer the position of the abutments by relining the internal aspect of the temporary with bite registration material to identify where the temporary needs to be relieved. If reduction of the inner bevel is not necessary, one may use pink Triad® (Dentsply) to fill in the area. Once molded to the abutments and ridge, the temporary may be pulled off, making sure not to disrupt the material. After inspection, it may be cured with a hand curing light. With a lab acrylic bur, the receiving areas are enlarged slightly to allow a passive fit, and the rest of the temporary is trimmed to create a convex surface allowing for easy cleansability. Whether cemented or screw-retained, a provisional serves as the interim prosthesis while implants heal, and a definitive restoration is fabricated. But if its effectiveness is maximized, a provisional restorative prosthesis provides three principal benefits: 1. Protects the implants and underlying grafted sites: Long-term success of any implant-borne restoration depends heavily on the integration of the supporting implant. A proper provisional must, therefore, protect the surgical site from occlusal forces during the healing process, preventing micro-movement of the implant and any associated bone grafts. 2. Protects and forms the underlying gingival tissues: Along with preserving bone health, a provisional must protect its underlying gingival tissues. The provisional can also be used to shape the associated soft tissue during the maturation phase. The ability to manage and

sculpt the surrounding soft tissue leads to greater predictability in the seating of the final prosthesis. 3. Determines the size, shape, and shade of the final restoration: Beyond helping to establish the health and shape of the supportive tissues, a provisional restoration can act as the blueprint for the final prosthesis. The restorative dentist is therefore able to obtain a hands-on feel for the eventual solution using a working prototype in the actual oral environment. Dimensions and morphology can be precisely transferred to the laboratory via scan or impression for use in the fabrication of the final restoration, increasing the likelihood of patient acceptance during that final visit.

Case presentation When a patient presented to the practice with an upper complete denture and a failing lower dentition (Figure 1), a CBCT scan (i-CAT™, Imaging Sciences International) was taken to accurately treatment plan this case. The final treatment plan would consist of a fixed bridge for the lower arch on implants opposing a new full upper complete denture. SimPlant® software (Materialise Dental) was used through 3D Diagnostix virtual assistance to precisely plan the placement of six dental implants (Figure 2). Since high initial stability was necessary to deliver an immediate lower fixed provisional restoration, Engage™ (OCO Biomedical) dental implants were selected for this case because of their high initial stability for selective loading options.

Figure 1: Preoperative retracted view of existing dentition Volume 7 Number 6

One? Or two stage? Immediate? Early? Or delayed loading? Today patients want good looking teeth and they want them sooner rather than later. More patients are asking for early and immediate loading of their implants and patients who in the past might not have been candidates for implants are also asking to be treated. Reduce treatment time. If the initial mechanical stability is high enough a one-stage approach is often used together with immediate- or early loading. By measuring again before the final restoration, and comparing that value to the baseline value taken at placement, the decision whether to proceed or not is made quick and easy. Manage patients at risk. You will find Osstell ISQ especially valuable when treating patients with risk factors and implants at risk for failure due to poor integration. If osseointegration is not progressing as

www.osstell.com

expected Osstell gives you an early warning as a decreased ISQ-value. In this way Osstell helps you avoid the costs associated with premature loading of slow healing or failing implants. Osstell will also assist you in individualizing treatment plans for patients with risk factors, and treating them with higher predictability. With more than 600 articles published in scientific journals it is a proven scientific method as a guide to predictable surgical and restorative protocols. Now Osstell brings you and your patient new certainty.

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CASE STUDY Using the Mont Blanc® surgical handpiece and Aseptico® implant/oral surgery motor (AEU 7000) at a speed of 1200 rpm with copious amounts of chilled sterile saline, the sites for the implants were initiated with a 1.95 mm pilot drill provided in the 3D Diagnostix Guided Surgical Kit. Once the osteotomies were complete, an implant driver was used to place the dental implants (Figure 3) until increased torque was necessary. The ratchet wrench was then connected to the adapter and the implants torqued to final depths reaching a torque level

of about 45-50Ncm. Adequate implant fixation was further verified using an Osstell® ISQ implant stability meter (Osstell), which uses resonance frequency analysis as a method of measurement. Several studies have been conducted based on Resonance Frequency Analysis (RFA) measurements and the Implant Stability Quotient (ISQ) scale. They provide valid indications that the acceptable stability range lies above 55-60 ISQ. Temporary Peek abutments were handtightened to the implants (Figure 4) and a postoperative Panorex taken (Figure 5).

Figure 2: Virtual treatment plan from 3DDX

Figure 3: Engage implant (OCO Biomedical)

Once confirmed, a blend of cortical mineralized and demineralized bone grafting material (Maxxeus) was placed in any residual areas of the extractions sites and the tissue sutured. Soon afterward, a carbide bur was used to trim the abutments, so that they would have adequate draw for the fabrication of the provisional restoration. A medium-size Instant Implant Denture was selected for the lower arch and placed into a water bath of 90-100°C for about 2-3 minutes, making the product moldable. In its thermoplastic state, the temporary was shaped to the appropriate width of the patient’s lower arch (Figure 6). Once set to the desired arch form, the temporary was allowed to cool. Since the internal aspect of the Instant Implant Denture already had adequate clearance in this particular case, no adjustment was necessary to seat the temporary. Instead, pink Triad material was used to fill in the area after application of a bonding agent (Triad) (Figures 7 and 8). The temporary was further molded (Figure 9) and seated on to the abutments. The patient

Figure 4: Temporary PEEK abutments

Figure 5: Panorex X-ray of implants placed

Figure 6: Forming the Instant Implant Denture

Figure 7: Application of a bonding agent

30 Implant practice

Volume 7 Number 6

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CASE STUDY

Figure 8: Adaptation of pink Triad material

Figure 9: Pink Triad material molded to temporary

Figure 10: Position of abutments transferred to temporary

Figure 11: Healed gingival tissue around temporary abutments

Figure 12: Completed Instant Implant Denture

Figure 13: Stock abutment preparations

Figure 14: Instant Custom Tray with Take 1 Advanced

was instructed to bite until the proper vertical dimension was acquired. The temporary was then pulled off making sure not to disrupt the Triad material (Figure 10). Once inspected for accuracy, the Triad material was cured with a hand curing light (Demi Plus, Kerr). With a lab acrylic bur, the receiving areas were enlarged slightly to allow a more passive fit and spacer for temporary cement. The temporary was then trimmed and polished to create a smooth convex surface for easy cleansability before seating (Figure 11). Esthetics, phonetics, and bite of the provisional were evaluated and documented. The patient was very pleased with 32 Implant practice

the esthetics of this provisional restoration. She was instructed about its care and use in eating, speaking, and biting. Approximately 16 weeks after implant placement, the patient returned for the final prosthetic phase of her treatment. The gingival tissue around the implants was very healthy (Figure 12), so the temporary abutments were removed and the implants evaluated. Each implant was tested with the OsstellÂŽ ISQ implant stability meter (Osstell). Since all six dental implants were well integrated, stock abutments were placed and tightened to the manufacturers recommended torque level. Using a carbide

prosthetic bur in a high-speed handpiece, the stock abutments were prepared using copious amounts of water irrigation to prevent overheating. Once ideal parallelism and distinct margins were achieved (Figure 13), a full arch impression would be taken using the Instant Custom Trays. Adapted and fitted in a matter of minutes, this instant thermoplastic tray was used to take a full arch polyvinylsiloxane impression (Take 1â&#x201E;˘ Advancedâ&#x201E;˘, Kerr) (Figure 14). Bite relations as well as instructions for size, shape, and color for the full arch porcelain fused to metal restoration were forwarded to the dental laboratory. Volume 7 Number 6

while preserving or enhancing the condition of the peri-implant and gingival tissues. They provide patients with natural-looking temporaries at any stage of implant treatment and

serve as an excellent prototype by which to evaluate shade and contours, leading to greater patient acceptance and a superior definitive restoration. IP

Conclusion Instant Implant Dentures can play a valuable role in managing clinical situations to ensure success with the final implant prosthesis. They can be used to evaluate esthetic, phonetic, and occlusal function prior to delivery of the final implant restorations,

Volume 7 Number 6

Figure 15: Seated FPD restoration

Implant practice 33

CASE STUDY

Within 3 weeks, the definitive restoration was tried in and radiographs taken to insure complete seating. Once confirmed, the FPD restoration was cemented with Premier速 Implant Cement (Premier) and allowed to set (Figure 15). Premier Implant Cement is a non-eugenol resin cement that features a unique, two-stage cure that makes seating the restoration and removing excess cement quick and easy. The rigid final set and low solubility in oral fluids provide an excellent marginal seal and superior retention. Once seated and cleaned, a Panorex X-ray was taken of the final cement-retained FPD restoration. The patient was very pleased with the result and commented on how much more confident she felt with this new enhanced smile.

CONTINUING EDUCATION

Spread — don’t split Dr. Sam Mohamed uncovers the processes behind an alternative method for increasing horizontal width in cases of alveolar bone resorption

he surgical placement of dental implants is governed primarily by the nature and design of the final restoration and, secondarily, by the morphology and quality of the alveolar bone. Resorption of the alveolar bone may make implant placement difficult, if it is possible at all. Following extraction, if no socket preservation is carried out, the alveolar bone undergoes progressive resorption, resulting in reduced width and height. Around 50% of bone width and height is lost in the 6to 12-month period following extraction. As a consequence, restoratively driven dental implant positioning often entails augmentation of the alveolar ridge and adjacent structures. There are various surgical techniques to augment alveolar ridges with reduced width, but these carry a risk of increased morbidity and can also result in increased expense and longer treatment times — all of which are factors that can affect the acceptance of treatment by some patients. Techniques for the management of resorbed alveolar ridges include the following: • Onlay grafting • Segmental osteotomy • Vertical distraction • Sinus floor augmentation • Major reconstruction • Ridge-splitting or bone expansion These techniques present a number of surgical and prosthetic challenges: • Inadequate tissue to cover the grafted area. • Incorrect emergence profile in the presence of undercuts. • Autogenous bone requires an additional surgical site. • Small diameter implants could be used: However, if less than 1.5 mm Hossam (Sam) Mohamed, BChD (Hons), is the principal of Wolds Dental Studio in Lincolnshire, England. A graduate of the Tatum Institute of Dental Implantology in the United Kingdom, he has been placing and restoring dental implants for more than 15 years, and he has also studied for a diploma in implant dentistry in Lille, France. Dr. Mohamed is currently the postgraduate dental tutor for Grimsby and a clinical teacher at the Bristol Implant Education Centre. He can be contacted by email at sammohamed864@gmail.com.

34 Implant practice

Educational aims and objectives

The aim of this article is to demonstrate how the ridge-spreading technique can be a valuable tool for managing resorbed alveolar bone simply.

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: • Learn the simple technique of ridge-spreading in suitable cases. • Be familiar with ridge-spreading instruments. • Understand how this technique can simplify implant placement and increase predictability as well as reducing expense and treatment time.

of bone surrounds the implant, the risk of bone loss is greater; therefore, in areas where there is height deficiency, width becomes a more critical factor.

Horizontal augmentation Alveolar bone splitting and immediate implant placement have been proposed for patients with atrophy of the maxilla in the horizontal dimension. Many lateral augmentation techniques have been successfully adopted for the management of horizontal ridge defects. It is well established that implant placement must be restoratively driven and not bone driven. If one fails to achieve the necessary modifications in bony defects prior to implant placement, then esthetic and/or functional failure is inevitable. Augmentation techniques using autografts or allografts have proven to be successful in highly resorbed ridges, but they have several drawbacks, including invasiveness, the need for an additional donor site, graft resorption, membrane exposure to infection, and delaying of implant placement for grafting maturation. Hence, employing such techniques in moderate horizontal ridge defects (less than 4 mm) is not necessary. More non-invasive techniques — like ridge expansion and ridge spreading — could be carried out easily, without much trauma to the patient.

mm, augmentation of the alveolar ridge using a ridge-splitting and bone expansion technique is a viable option to allow for implant placement within the restorative envelope. The 3 mm of bone should have at least 1 mm of trabecular bone sandwiched between the cortical plates. That will ensure 1.5 mm of bone (cortical and cancellous) on either side of the split ridge and allow the bone to spread and maintain a good vascular perfusion. Several ridge-splitting techniques have been developed in the past few decades, such as the split crest osteotomy and the ridge expansion osteotomy, along with numerous modifications to these techniques. The criteria for bone expansion and spreading are as follows: • Ridge width not less than 3 mm. • Adequate zone of keratinized tissue. • If there is a combined height and thickness deficiency, the esthetic demands must be minimal. • Full flaps are not usually necessary if undercuts are minimal.

Ridge-splitting When the buccolingual/palatal bone width is 3 mm or greater but less than 6

Figure 1: The ridge-splitting technique Volume 7 Number 6

Figure 5: The alveolar ridge was measured using a ridge mapper

Dr. Hilt Tatum Jr. advocated the ridgesplitting technique back in the 1970s to treat mainly horizontal defects in atrophic maxilla. The technique described by Tatum involved the use of osteotomes of varying thicknesses; these were driven using a mallet to produce gradual splitting and expansion of the alveolar ridge, which allows simultaneous implant placement (Figures 1 to 4). This technique, employed mainly in the maxilla, relied on the visco-elastic properties of the maxillary bone and required no more than a crestal incision without flap reflection. This allowed the periosteum to remain intact, which maintained the perfusion of the cortical plates and minimized (or eliminated) cortical plate fracture. The author used this technique successfully for many years. The main disadvantage of this technique is that the mallet application is very disturbing to the patient (unless sedated). In very few cases, some patients reported symptoms of transient vertigo, which resolved within two days. This technique is also very difficult to utilize in the mandible as the cortical plates are denser and more likely to fracture.

Bone spreading The bone spreading technique (also known as expansion without splitting) involves Volume 7 Number 6

Figure 6: Initial osteotomy carried out using a 2-mm drill to predetermined implant length

the insertion of non-cutting tapered bone spreaders in the initial (pilot) osteotomy. This is typically performed at a torque of 50Ncm at an insertion speed of 100rpm with copious irrigation in gradually increasing diameters to the predetermined implantation depth. There is a lack of adequate research on this technique. However, as it does not involve sharp trauma, in contrast with the technique described by Tatum, and there is less risk of fracture of the cortical plates. Bone-spreading kits are available from a number of manufacturers. The kit is designed to produce gradual spreading of thin ridges by gradually introducing the â&#x20AC;&#x153;ridge spreadersâ&#x20AC;? in the initial osteotomy, increasing its diameter and allowing the implant to be placed. Care must be taken with the speed and the torque as described above. If resistance is encountered, the spreading osteotome should be reversed out and the osteotomy recapitulated with a 2-mm drill with copious irrigation and a pumping action to remove bone debris. A typical spreading kit consists of the following: 1. A bone saw 2. Expanders 3. A ratchet and ratchet adapter 4. A bone bur 5. A ridge-splitting chisel

The bone saw is used to create the first split in the crestal cortical bone if required as illustrated. The ridge-splitting chisel is then used to widen the crestal split, thus creating a space for the pilot drill, if needed. The ridge spreaders are of varying diameters and are introduced as described above to produce gradual spreading and widening of the osteotomy diameter to allow the placement of the relevant implant. The ratchet could be used to drive the spreaders if the space is restricted or if resistance is encountered. However, the force should be extremely gradual to avoid overheating of the bone and possible fracture of the cortical plates.

Case study A 35-year-old healthy female nonsmoker attended after the loss of the upper left central and lateral incisors, following the failure of her post-retained crowns around 3 years ago. The alveolar ridge displayed no labial undercuts. However, it was around 3.5 mm in width in the coronal 4-5 mm as measured by a ridge mapper (Figure 5). It was decided to use ridge spreaders to expand and preserve the alveolar bone as opposed to drilling. Implant practice 35

CONTINUING EDUCATION

Figures 2, 3, and 4: The ridge-splitting technique advocated by Hilt Tatum Jr. in the 1970s â&#x20AC;&#x201D; osteotomes driven into the bone with a mallet to expand the alveolar ridge and allow simultaneous implant placement

CONTINUING EDUCATION

Figure 7: Bone spreaders were used to expand the osteotomy

Figure 8: Expanded osteotomy

Figure 9: Osteotomy after expansion by bone spreaders

A flap was raised, and the ridge thickness and topography were examined closely; a cleft in the crest was noted palatally at the UL2. The initial osteotomy was carried out using a 2-mm drill to the predetermined implant length, as the bone density was low (D3). The same process was repeated for UL1 (Figures 5 and 6). The bone spreaders were then used to expand the osteotomy as shown in Figures 7 to 10. A width of 4 mm was easily achievable for UL2 and 5 mm for UL1 sites (Figures 11 to 13).

Figure 10: Expanded osteotomy

Figure 11: A width of 4 mm was achievable for UL2 and 5 mm for UL1 sites

Figure 12: A width of 4 mm was achievable for UL2 and 5 mm for UL1 sites

Figure 13: A width of 4 mm was achievable for UL2 and 5 mm for UL1 sites

Conclusion With the introduction of short and wide implants and the bone spreading technique, many cases with width deficiencies could potentially be treated without grafting. When bone density is low, spreading rather than drilling is generally more advisable due to the compacting effect of the spreading technique, which helps improve primary stability. Avoiding grafting techniques can help reduce treatment times and complexity — reducing prices while helping predictability and success rates to rise. IP 36 Implant practice

REFERENCES 1. Aghaloo TL, Moy PK. Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? Int J Oral Maxillofac Implants. 2007;22(suppl):49-70. 2. de Wijs FL, Cune MS. Immediate labial contour restoration for improved esthetics: a radiographic study on bone splitting in anterior single-tooth replacement. Int J Oral Maxillofac Implants. 2007;12(5):686-696. 3. Flanagan D. Cortical bone spreader osteotome and method for dental implant placement. J Oral Implantol. 2002;28(6):295-296. 4. Garber D, Belser UC. Restoration-driven implant placement with restoration-generated site development. Compend Contin Educ Dent. 1995;16(8):796-804. 5. González-García R, Monje F, Moreno C. Alveolar split osteotomy for the treatment of the severe narrow ridge maxillary atrophy: a modified technique. Int J Oral Maxillofac Surg. 2011;40(1):57-64. 6. Oh TJ, Shotwell JL, Billy EJ, Wang HL. Effect of flapless implant surgery on soft tissue profile: a randomized controlled clinical trial. J Periodontol. 2006;77(5):874-882. 7. Rammelsberg P, Schmitter M, Gabbert O, Lorenzo Bermejo J, Eiffler C, Schwarz S. Influence of bone augmentation procedures on the short-term prognosis of simultaneously placed implants. Clin Oral Implants Res. 2012;23(10): 1232-1237.

Volume 7 Number 6

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1. The surgical placement of dental implants is governed primarily by the nature and design of the final restoration, and secondarily, by the ____ of the alveolar bone. a. morphology b. quality c. sensitivity d. both a and b 2. ________________ may make implant placement difficult, if it is possible at all. a. Extraction b. Palatal bone width c. Resorption of the alveolar bone d. An atrophic maxilla 3. Following extraction, if no socket preservation is carried out, the alveolar bone undergoes progressive resorption, resulting in ______. a. bone expansion b. reduced width

Volume 7 Number 6

c. reduced height d. both b and c 4. Around 50% of bone width and height is lost in the ______ month period following extraction. a. 1- to 2 b. 3- to 4 c. 6- to 12 d. 16- to 18 5. Alveolar bone splitting and immediate implant placement have been proposed for patients with atrophy of the maxilla in the ______. a. vertical dimension b. horizontal dimension c. third dimension d. trabecular ridge 6. If one fails to achieve the necessary modifications in bony defects prior to implant placement, then _____ failure is inevitable.

a. vascular b. esthetic c. functional d. both b and c 7. When the buccolingual/palatal bone width is 3 mm or greater but less than 6 mm, augmentation of the alveolar ridge using a ridge-splitting and bone expansion technique is ____ to allow for implant placement within the restorative envelope. a. a viable option b. the least favorite option c. a risky tactic d. the only option 8. _______ advocated the ridge splitting technique back in the 1970s to treat mainly horizontal defects in atrophic maxilla. a. Per-Ingvar Brånemark b. Dr. Matts Andersson c. Dr. Gerald Levinson d. Dr. Hilt Tatum Jr.

9. The bone spreading technique (also known as expansion without splitting) involves the insertion of non-cutting tapered bone spreaders in the initial (pilot) osteotomy. This is typically performed at a torque of ____ at an insertion speed of 100rpm with copious irrigation in gradually increasing diameters to the predetermined implantation depth. a. 20Ncm b. 30Ncm c. 40Ncm d. 50Ncm 10. The ratchet could be used to drive the spreaders if the space is restricted or if resistance is encountered. However, the force should be extremely gradual to avoid _______. a. overheating of the bone b. possible fracture of the cortical plates c. transient vertigo d. both a and b

Implant practice 37

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Cement- versus screw-retained prosthetics: a comparison Drs. Brenda Baker and David Reaney look at the pros and cons of the two key retention methods at the heart of restoring implants

oth cement- and screw-retained prostheses have been validated in clinical studies, and each type of restoration has particular advantages and disadvantages. Historically, screw-retained prostheses were widely used, as restorations could be retrieved for evaluation of the underlying implants and repair of any possible complications. Cemented restorations are now widely used as more esthetic restorations can be created. While they are not as readily retrieved as a screw-retained prosthesis, cementing restorations with provisional cement allows a degree of retrievability. The cement chosen is the controlling factor in the retention attained; either temporary cement or a mixture of temporary cement and petroleum jelly (reduced strength) can be used to cement implant-supported prostheses. The lack of screw holes in cemented prostheses provides a design that enhances the physical strength of porcelain and acrylic resin, resulting in less fracture. The occlusal surface is devoid of screw holes, and as such, the occlusion can be developed so that it responds to axial loading. Cement-retained implant prostheses provide easier access to the posterior of the mouth, reduced costs, reduced complexity of components, reduced complexity of laboratory procedures, and reduced clinical chairside time. There is some evidence that cement-retained fixed prostheses have fewer prosthodontic

Brenda Baker, BDS (Hons), MSc, graduated from Sydney University with honors and completed a master’s degree in conservative dentistry from Eastman Dental College. She has taught in the prosthetic faculty at Sydney University and pursued a preventively oriented career in private practice. Throughout her career, Dr. Baker has had a commitment to continuing education in a variety of disciplines, including prosthodontics, periodontics, and pain management, and is currently director of clinical education for Southern Cross Dental. David Reaney, BDS (Edin), DGDP(UK), MClinDent (Prosthodontics), graduated with distinction from the University of Edinburgh. He has held the position of clinical lecturer at the School of Dentistry, Royal Victoria Hospital in Belfast and is currently in private practice in Moy, Northern Ireland. Dr. Reaney is general manager of Southern Cross Dental.

38 Implant practice

Educational aims and objectives

The aim of this article is to compare cement- and screw-retained prostheses.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 42 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify the different types of abutments that are available. • Be familiar with the advantages and disadvantages of techniques for retaining prosthetics. • Recognize the importance of a stable implant/abutment connection.

complications after delivery. It is generally simpler to correct a misaligned implant with a cemented restoration. With screw-retained restorations, if the implant is misaligned, the screw access hole may be in a variety of locations (Jacobs and O’Connell, 2011). On a posterior tooth, the screw access hole may obliterate much of the occlusal anatomy. With a screw-retained prosthesis, once the retaining screw has been tightened, the access hole is filled with a resin material. During function, this material wears and stains, and periodically needs replacement. The screw access hole may represent 50% or more of the occlusal surface of a posterior tooth, so the correct occlusal contacts must be built into the resin restoration at the chairside. A screw access hole on an anterior implant-supported prosthesis may mean that the alignment of the implant is such that the screw access is to be placed buccally or near the incisal edge. In that case, access holes may be filled with tooth-colored resin in the provisional restoration, but the final restoration would warrant a cement-retained prosthesis. Whereas cement-retained prostheses are constructed using conventional prosthodontic procedures, screw retention requires extreme care because of the small retaining screw, which may be lost in or outside the mouth. Drivers used to tighten the retaining screws may be difficult to align in the posterior areas of the mouth. These retaining

screws, being smaller than the abutmentto-implant screws and typically placed with lower torque (10Ncm compared to 32Ncm), are also liable to loosen, which has been well documented in many clinical studies. A minimum of 7 mm from the implant head to the opposing tooth is advised for adequate retention of a cement-retained restoration. A screw-retained prosthesis may be provided with 4 mm of interocclusal space. Excess cement can be difficult to clear from the subgingival margin of a restoration, which can lead to persistent inflammation of the tissue. It is important that cemented restorations are designed with the prosthesisabutment interface no more than 2-3 mm subgingivally, so that excess cement may be readily removed.

Occlusal and loading concepts related to design The selection of screw retention or cement retention as an attachment mechanism impacts on the occlusion of the restoration. Implants ideally placed under the central fossa or stamp cusps of posterior teeth represent the best opportunity to generate axial loading. Clinical experience suggests that this goal is often not attained, and thus, offset loading occurs. Screws or screw holes in the occlusal surfaces of teeth disrupt the occlusal surfaces. The area where the screw hole exists may be a critical area when one attempts to generate an optimal occlusion. Volume 7 Number 6

Features of cement- and screwretained restorations Table 1 compares some of the key features of cement- and screw-retained restorations. One of the keys to successful long-term implant restorations is the stability of the implant/abutment connection. The type of finish on screws can have a significant effect on the tension induced by a given torque. Implant manufacturers have altered the material in the screws as well as the surface of abutment screws in an effort to prevent or minimize screw loosening. Martin and colleagues (2001) tested the rotational angles in implant/abutment connections with various abutment screws and preloads. They found that the abutment screws with enhanced surfaces reduced the coefficient of friction and produced greater rotational angles and preload values than screws made from conventional gold and titanium alloys.

Abutment selection Abutments are components that attach directly to the head of the implant and extend through the gingiva and into the oral cavity. For fixed prostheses, the abutment acts as a substitute for the missing coronal tooth structure. A variety of abutments are available, which allow the restorative dentist the ability to provide a functional and esthetic Volume 7 Number 6

Table 1: Summary of features of cement- and screw-retained restorations Feature Retrievable Esthetics Correction of misaligned implant Ease of insertion Retention at minimal occlusal height Passive fit Maintenance

Cement-retained Not easily Excellent Usually Conventional methods Marginal Yes Minimal

restoration. Some abutments are designed to be prepared directly in the mouth (or milled in the laboratory), similar to conventional crown preparations. Other abutments are customized in the laboratory and cast to their final shape. With both of these techniques, the final restoration is cemented onto the finished abutment. In other designs, factory-prefabricated abutments are used, and the prosthesis is screwed directly onto the abutment. Abutment selection depends on many clinical factors, and it is often not possible to make this selection until after second-stage surgery maturation of the soft tissues has occurred. In difficult situations, it is best to wait until the working cast has been made and mounted on an articulator before choosing the abutment. The abutment must take account of the position and angulation of the implant, the height and thickness of the surrounding soft tissues, the interocclusal space, and the type of restoration to be placed. Additional considerations include the height of the lip line, the occlusal scheme, and the position of the tooth in the arch. The primary objective must always be proper support of the surrounding tissues and optimal morphology to support the restoration without impairing hygiene maintenance. These goals can be easily achieved if the abutment is custom-made, but for the purpose of complete analysis of all available options, the clinician is presented here with the spectrum of current possibilities.

Abutment types UCLA abutment The UCLA abutment is a very versatile abutment (Lewis, et al., 1992). It may be used to produce a customized abutment for a cemented restoration or as a screwretained restoration. The abutment consists of a machined gold cylinder with a plastic sleeve that can be shaped to allow the construction of a custom abutment. The abutment and restorative coping are incorporated into one unit, reducing the number of interfaces and components in the restored implant pillar.

Screw-retained Yes Variable Sometimes Difficult in posterior areas Excellent Questionable Moderate

The abutment sleeve is then waxed up in the laboratory to the shape of a core that fits the particular tooth it is replacing, and can also be shaped to compensate for any misalignment of the implant. This abutment design allows for a wide range of tooth sizes and angulations to be accommodated, but with a machined-fitting surface to ensure accurate fit of the abutment on the implant. The UCLA abutment may correct problems of implant angulation by up to 30째. This feature helps provide an esthetic restoration by creating a substructure with a good emergence profile and contours that accurately follow the gingival tissue. The finished abutment is screwed down directly onto the implant, and a coronal restoration is cemented onto the post. The UCLA abutment gives the laboratory the scope to produce an optimum abutment and save clinical time, especially in challenging cases. The UCLA abutment comes in two designs with either a hexagonal or nonhexagonal fitting surface to engage the head of the implant. The hexagonal UCLA abutment makes for a non-rotational design that allows it to be used for single-unit restorations. The non-hexagonal version does not engage the hexagonal top of the implant and can be used for multiple-unit restorations. The machined collar on the UCLA abutment is 1 mm high and so can be used where there is minimal soft tissue height above the implant head. In an esthetic area, however, if there is a risk of metal showing through thin gingival tissue, an alternative abutment may be required. Many dentists cement fixedimplant prostheses with temporary luting cement, so the restoration may be removed at some later date. This would be important if the abutment screw were to break or get loose. Then a new screw could be placed without having to remake the prosthesis. Despite the flexibility of the UCLA abutment, the overall cost of the restoration can be high. The abutment must be purchased, and there is a laboratory charge for waxing and casting the abutment. The final restoration must then be fabricated on the finished abutment. The UCLA can also be made Implant practice 39

CONTINUING EDUCATION

With cement-retained implant restorations, all of the anatomic surfaces of all of the teeth are present to develop protrusive and lateral protrusive relationships. Screwretained implant prostheses may lack the proper anatomy on the cuspids and central incisors for the smooth transition into protrusive and lateral protrusive movements, and thus, anterior guidance may be compromised. Many factors interact in a complex manner to produce a load at the boneimplant interface. Offset loading is one factor that can be controlled with prosthetic design. The bone-implant interface appears able to survive with some degree of offset loading; however, there appears to be an increase in the incidence of prosthetic complications such as screw loosening and breakage. As such, prudent control of offset loading is suggested through prosthetic design. The ability to generate vertical or axial loading may be compromised when the choice is made to use screw-retained implant restorations. Cement-retained implant prostheses are able to vertically load the prosthetic head of the implant.

CONTINUING EDUCATION

Figure 1: The need for an exquisite junction between the abutment and the implant crown is paramount for both screw- and cement-retained prostheses

Figure 2: An abutment in place, showing the screw

to make a screw-retained prosthesis. The abutment is waxed up to the full contour of the final restoration and may be cut back for porcelain if required. Hence, the abutment and restoration are in one piece, and they are retained by an abutment screw. With this type of restoration, the positioning of the implant is critical since the screw access hole should pass through the cingulum area of an anterior tooth or the central fossa of a posterior tooth. Poor placement of the implant may lead to abnormally shaped cingulum areas or access holes that affect the occlusal morphology of posterior teeth, leading to a poor occlusal relationship. Preparable abutments A range of implant abutments is available that can be prepared with cutting burs to the desired shape. A cement-retained prosthesis may then be made over the prepared abutments. Preparable abutments may be used for single crown or multiple units. Preparable abutments are most effective where the implant placement is favorable, and so there is minimal preparation to be completed on the abutment. The preparation of the abutment may be completed intraorally by the dentist or in the laboratory by the technician. Direct preparation of the abutment in the mouth is completed using the same principles as tooth preparation. A silicone matrix of the fully contoured wax-up is useful as a guide to abutment preparation. Preparable abutments are available with different collar heights to suit the thickness of soft tissue present above the implants. The abutments may be made of metal (usually pure titanium) or ceramic, which is used in critically esthetic areas. Titanium abutments Titanium abutments may be covered with a gold-colored titanium nitride coating that improves esthetics (Sadeq, et al., 2003). 40 Implant practice

Figure 3: Zirconia abutments combine strength with esthetics, with no grayness at the gingival margins

The gold color is less likely than a titaniumcolored abutment to cast a gray shadow at the gingival margin. The abutment is normally machined with a 6° taper and has a prechamfered margin. It is available straight or pre-angled to correct for misalignment of the implant. The abutment has a flat side to prevent rotation of the final restoration. Ceramic abutments Ceramic abutments may be made of zirconia or alumina (aluminium oxide) (Lesmes and Lasterl, 2011). The ceramic allows for light reflection in a similar way to natural teeth and leads to less darkening of thin gingival tissue than is the case with metal. The ceramic abutment may be preferred if a translucent material is used for the definitive prosthesis (Christensen, 2008). The zirconia abutment has a machined titanium interface that fits onto the implant. The margins of the abutment can be prepared to follow the uneven contours of the gingival tissue. The hardness of the material can make these abutments difficult to prepare

intraorally. The implant position should be as close to ideal as the abutment cannot accommodate changes in angulation. Prefabricated conical abutments: screw-retained prostheses The conical abutment is one of several pre-machined abutments that are used for screw-retained restorations. It has a side wall taper of 15° with hexagonal sides to resist rotation of the restoration, where needed. Other tapered abutments are angulated from 25° to 35° to correct for the difference in orientation between implant and restoration. While the use of misaligned implants is sometimes unavoidable, it should be minimized as non-axial forces on implants and abutments are more likely to cause complications and failures. If possible, the clinician should avoid lateral excursions on teeth that have angulated abutments. Angled abutments facilitate restoration of implants placed with buccolingual or mesiodistal misalignment (Cavallaro and Greenstein, 2011). A 15° angulation of a prefabricated abutment can create parallelism between adjacent Volume 7 Number 6

Machined abutments: cement-retained prostheses Different machined abutments are available for use with cemented prostheses. These abutments are designed for minimal modification and so can be used only where implant placement is ideal, and there is ample space for the prosthesis. A parallel-sided hexagonal abutment can be used for single restorations — the crown can be fabricated directly onto a gold or ceramic coping that is machined to fit onto the abutment. Tapered abutments are generally used for multi-unit prostheses and may be straight or angulated. Prefabricated abutments are not commonly used due to their lack of flexibility. Standard abutment The original abutment for the external hex implant was the standard abutment. This two-piece abutment consists of a cylinder and a screw. Its purpose was to provide a restorative platform above the soft tissue level. The standard abutment requires a Volume 7 Number 6

minimum of 2 mm of tissue height and is available up to 7 mm high. Standard abutments now have few indications. They may be used for the fabrication of full-arch, fixed hybrid prostheses. For this purpose, a secondary cylinder, which is screwed onto the standard abutment, is incorporated into the prosthesis framework. The standard abutment may also act as the platform for some overdenture attachments. One disadvantage of the standard abutment is that the collar has a uniform height and so does not follow the natural contours of the gingival margin. It is thus difficult to achieve an appropriate emergence profile and acceptable esthetics. As with other intermediate-type abutments, it requires the cost and complexity of a second restorative component and screw. Custom-machined abutments The trend toward impressing the implant and reproducing it in the laboratory, rather than using a registration of a prefabricated, stock abutment placed on top of the implant, has hugely increased the flexibility of implant prosthodontics and created a new standard for esthetic implant restorative dentistry. Advances in CAD/CAM have made it possible to manufacture precision custom abutments. Once an impression of the implants is obtained, the CAD/CAM system allows for the design of individual abutments by computer or the scanning of an abutment wax-up. The specifications are then transmitted to a centralized facility, and a metal or ceramic abutment is machined and then returned to the local laboratory. The advantage of this approach is that the abutment can take into account implant angulation, tissue height, and the size and contour of the final restoration. As it is a onestep process, the custom-machined abutment eliminates the need to buy a stock abutment and then modify it in the laboratory. The centralization of the manufacturing process means that the abutments can be produced with an accurate fit. Greater angulation correction issues of more than 15° are well controlled by the custom-made components. Another option is to construct a final custom abutment based on the use of a special twopiece healing abutment (Drago, 2007). The healing abutment has codes embedded on its occlusal surface containing the information needed to create the final abutment. It provides the position of the implant hex, the soft tissue height, and the implant platform diameter.

A simple conventional elastomeric impression is made of the healing abutment, thus ensuring reproduction of the coded area. The master cast is scanned in a CAD/CAM laboratory where an abutment is designed and milled. A crown can then be made and sent to the dentist for issue. This system eliminates the need for implant-level impressions and simplifies the restorative technique.

Conclusion The current aim of implant design is to address situations prone to failure such as cases of low bone quality or of concomitant systemic disease. There are more than 1,300 dental implant types available worldwide, each with differing properties (size, shape, and surface). Emerging developments are based mainly on modification of either chemical or mechanical properties of an implant. With the expansion of routine implant restoration, from the edentulous arch to the partially edentulous arch and to single-tooth replacement, a broader array of restorative abutments and components have been necessary, compared to implant treatments limited to the edentulous mandible. Accordingly, implant manufacturers have expanded abutment choices substantially. The practice of implant-level impression taking can be traced directly to the UCLA abutment concept, from which a number of abutment options have evolved. The trend toward impressing the implant and reproducing it in the laboratory, rather than using a registration of a prefabricated stock abutment on top of the implant, has greatly increased the flexibility of implant prosthodontics and created a new standard for esthetic implant restoration. IP

REFERENCES 1. Christensen GJ. Selecting the best abutment for a single implant. J Am Dent Assoc. 2008;139(4):484-487. 2. Cavallaro J Jr, Greenstein G. Angled implant abutments: a practical application of available knowledge. J Am Dent Assoc. 2011;142(2):150-158. 3. Drago C. Implant Restorations: A Step-By-Step Guide. 2nd ed. London: Wiley-Blackwell; 2007. 4. Jacobs SH, O’Connell BC. Dental Implant Restoration: Principles and Procedures. Berlin: Quintessence; 2011. 5. Lesmes D, Laster Z. Innovations in dental implant design for current therapy. Dent Clin North Am. 2011;55(4):649-661. 6. Lewis SG, Llamas D, Avera S. The UCLA abutment: a fouryear review. J Prosthet Dent. 1992;67(4):509-515. 7. Martin WC, Woody RD, Miller BH, Miller AW. Implant abutment screw rotations and preloads for four different screw materials and surfaces. J Prosthet Dent. 2001;86(1):24-32. 8. Sadeq A, Cai Z, Woody RD, Miller AW. Effects of interfacial variables on ceramic adherence to cast and machined commercially pure titanium. J Prosthet Dent. 2003;90(1):10-17.

Implant practice 41

CONTINUING EDUCATION

abutments. Additionally, correcting an implant trajectory with a 15° angled abutment can shift a restoration about 1.0-1.5 mm at the occlusal aspect, and a 25° abutment can move it 2.0-2.5 mm. When using angled abutments to achieve a good prosthetic result, the clinician should leave sufficient running room to ensure a gradual emergence profile of the restoration. Running room is the vertical distance from the implant’s prosthetic platform to the free gingival margin. The clinician uses this distance to make the transition from the smaller diameter, circular shape of the implant’s coronal aspect to the larger cross-sectional shape of the tooth being restored. In the esthetic zone, it is imperative that correction of angulation issues be combined with sufficient running room (sufficiently deep placement of the implant). Prefabricated abutments are made with a range of collar heights to accommodate the subgingival position of the implant. Selection of the collar height will allow the margin of the restoration to be placed just below the gingival margin so the emergence profile of the final restoration can be improved. However, the abutment collar is uniform in height and does not follow the natural contours of the tissue. The screw-retained prosthesis requires a minimum of 4 mm of interocclusal space from the implant to the occlusal or incisal edge of the final restoration. Angulated abutments require more interocclusal space.

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Cement- versus screw-retained prosthetics: a comparison BAKER

1. The cement chosen is the controlling factor in the retention attained; _________ can be used to cement implantsupported prostheses. a. temporary cement b. mixture of temporary cement and petroleum jelly (reduced strength) c. glass ionomer permanent cement d. both a and b 2. Cement-retained implant prostheses provide easier access to the posterior of the mouth, _____, and reduced clinical chairside time. a. reduced costs b. reduced complexity of components c. reduced complexity of laboratory procedures d. all of the above 3. With a screw-retained prosthesis, once the retaining screw has been________, the

42 Implant practice

access hole is filled with a resin material. a. tightened b. loosened c. removed d. repaired 4. The screw access hole may represent ____ or more of the occlusal surface of a posterior tooth, so the correct occlusal contacts must be built into the resin restoration at the chairside. a. 10% b. 30% c. 42% d. 50% 5. They [Martin and colleagues (2001)] found that the abutment screws with enhanced surfaces reduced the coefficient of friction and produced greater rotational angles and preload values than screws made from ____. a. stainless steel

b. conventional gold c. titanium alloys d. both b and c 6. _____ are components that attach directly to the head of the implant and extend through the gingiva and into the oral cavity. a. Crowns b. Copings c. Abutments d. Analogues 7. Selection of the collar height will allow the margin of the restoration to be placed ____ the gingival margin so the emergence profile of the final restoration can be improved. a. just above b. just below c. even with d. all of the above 8. The screw-retained prosthesis requires a minimum of _____ of interocclusal space from

the implant to the occlusal or incisal edge of the final restoration. a. 1 mm b. 2 mm c. 3 mm d. 4 mm 9. The advantage of this approach (custom-machined abutment) is that the abutment can take into account ______of the final restoration. a. implant angulation b. tissue height c. the size and contour d. all of the above 10. The current aim of implant design is to address situations prone to failure such as cases of _______. a. low bone quality b. concomitant systemic disease c. occlusion of the original tooth d. both a and b

Volume 7 Number 6

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IMPLANT PRACTICE CE

ESSET (Easy Safe Stable Expanding and Tapping Kit)

n development for over a decade, the introduction of HIOSSEN’s ESSET Kit is the solution for successful implant placement when presented with insufficient horizontal bone volume without the use of bone grafts. The ESSET Kit focuses on the visco-elastic properties of bone tissue and the elasticity coefficient of the alveolar bone. The new ESSET Kit is the ideal implant solution for patients with narrow alveolar ridges. Easy-to-follow steps safely and predictably allow practitioners to split and expand the crestal bone, preparing the site to accept dental implants with minimal patient discomfort or complications. Specialized tools minimize bone fracture, and initial implant stability is enhanced by tapping of the basal bone base. Moreover, the split and expanded bone process provides an ample

supply of bone-forming cells for quicker integration and reduced recovery time. To begin, the practitioner will need to modify the crest to form at least 3-4 mm of the horizontal bone (Figures 1A and 1B). It is recommended to use crest remover 7.0 with an rpm of 1,200–1,500 for successful modification. Then create an indentation where the implant is to be placed, and mark the implant placement location using the initial lance drill. With the implant placement location identified, the area can now be drilled using the 1.8 mm twist drill (Figure 2). The site is now prepared for the practitioner to perform a full-depth vertical cut using the ESSET Kit’s 13 Saw (Figure 3). After the initial vertical cut, horizontal splitting along the crestal bone can now be executed from distal to mesial direction. If

Figures 1A and 1B

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

Volume 7 Number 6

needed, additional splitting can be performed around the proximal tooth using the ESSET Kit 7 Saw. The bone is now ready for expansion using the SET drill sequentially at full depth (Figure 4). The sequence of the SET drill for bone expansion is as follows: 1.6/2.8, 2.2/3.6, 2.7/4.1, and 3.1/4.5. Recommended rpm for expansion is 25-35 rpm. Using the drill extension before applying high amounts of torque is suggested, as excessive torqueing can pose a risk of locking the handpiece. Place the implant taper fixtures (Figure 5). Normal bone density will work well using a 4.5 mm fixture; however, the 4.0 mm fixture works best in hard bone density cases. After placing the healing abutment, the site is now ready to be sutured (Figure 6). The healing abutment should ultimately be 2 mm higher than the height of the gingiva. Compared to conventional ridge splitting methods (i.e., mallets and chisels) the ESSET Kit’s specialized tools safely and predictably split and expand the crestal bone, preparing the site to readily accept dental implants. The patient will experience a significant reduction in recovery time, with the process ensuring minimal bone fracture and high initial stability, while the practitioner will be able to save time and money using a simple, safe, and predictable procedure with an easy-to-use ridge split technique. Each ESSET Kit contains all the components needed for each unique case: • Crest removers (2) 5.0, 7.0 diameter 29, 45 length • Twist drills (3) 1.8 diameter 8.5, 10, 11.5 length • Saws (3) 7.0, 10.0, 13.0 diameter 0.3 blade thickness • SET drills (4) 8.5, 10. 11.5 length 1.6/2.8, 2.2/3.6, 2.7/4.1, 3.1/4.5 diameter • Mount extension • Torque wrench • Depth gauge IP This information was provided by HIOSSEN.

Implant practice 43

STEP-BY-STEP

Easy-to-learn ridge split technique with HIOSSEN’s ESSET Kit

RESEARCH

ince the concept of osseointegration was introduced by Brånemark in the 1960s, implants have been widely recommended in the arena of dental treatment with high success rates being reported (Brånemark, et al., 1969; Rosenberg, et al., 2004; Hämmerle, et al., 2002; Bahat, 2000). Many authors claim one prerequisite for successful osseointegration is initial stability (Martinez, et al., 2001) after implant placement, which depends on the surface characteristics and morphology of the implant and the bone density of the surgical site (Meredith, 1998; Barewal, 2003). At any given time, a number of surface treatment methods are being researched to facilitate rapid, strong osseointegration. Many studies have been performed on implant success rates, and a number of different factors are known to be involved in the long-term success of implants.The height of the marginal bone in particular has been found to be a very important factor in determining the functional and esthetic success of implants, meaning maintaining appropriate height of marginal bone is a prerequisite for a satisfactory long-term result. After Schnitman, et al. (1979), presented their criteria for implant success, and many other criteria followed (Smith and Zarb, 1989; Misch, 1998; Buser, et al., 1999),

Kwang-Bum Park, DDS, PhD, is director of the MIR dental hospital in Daegu, Korea. Myung-Hwan An, DDS, PhD, practices at the MIR dental hospital in Daegu, Korea. Sang-Taek Lee, DDS, PhD, practices at the MIR dental hospital in Daegu, Korea. Young-Jin Lee, DDS, PhD, practices at the MIR dental hospital in Daegu, Korea. Hyun-Jin Kim, DDS, PhD, practices at the Kimhyunjin Dental Clinic, Korea. Woo-Chang Noh, MS, works at MegaGen Implant. Hyun-Wook An, MS, practices at the Department of Periodontology, School of Dentistry, Kyungpook National University.

44 Implant practice

but the most widely used in modern practice are arguably the criteria proposed by Albrektsson, et al., in 1986. These criteria detail no implant mobility, no translucency on radiographs, no symptoms such as pain or numbness, and bone resorption of 1.5 mm or less in the first year following prosthetic connection, 0.2 mm or less per year following that, and a minimum 85% success rate at 5 years and 80% at 10 years. Recently, various types of implants have been introduced to the market, and the advancement of implant systems and procedures have helped the success rate rise to as much as 95% or higher as suggested by many papers in the last decade. This article will discuss the outcome of a study conducted into the success rates of the ExFeel® External implant system, an external connection-type implant using the XPEED® surface and sold by MegaGen. Using hydroxyapatite, the XPEED surface is treated with resorbable blast media (RBM) that increases the affinity to bone, followed by infiltration of Ca2+ into the surface to form a calcium titanate nano-structure. Of late, many in vivo and in vitro studies have been performed on titanium with Ca2+ ion on the surface. Park, et al. (2009), reported that the nano-structure formed by Ca2+ treatment enhances osteoconductivity. Lee, et al. (2011), reported that the XPEED surface treatment improves apatite formation, loosening torque, and bone to implant contact (BIC). The XPEED surface treatment is continually advancing, but the reality is that a new implant surface meets resistance due to lack of verification on its long-term safety. The objective of this study was therefore to retrospectively examine the survival rate, and at the same time verify the usefulness, of the ExFeel External implant system by analyzing the patients treated with the implant system in terms of distribution of gender, age, implant location, additional surgery, and final prosthetic type.

Materials and methods Study subjects The study includes 111 patients who had implant surgery performed at Daegu MIR Dental Hospital, Suncheon MIR Dental Hospital, or Kimhyunjin Dental Clinic in Korea from August 2010 and were followed up for 2 to 3 years until March 2013. The average age of the patients was 55.2 years old, of which 67 were men and 44 were women. A total of 237 implants were placed: 127 of them in men and 110 in women, with 74 in the maxilla and 163 in the mandible. Study materials The study looked at the externallyconnected straight-type ExFeel system with XPEED surface. The implant is available in diameters of 3.3 mm, 3.75 mm, 4 mm, 4.5 mm, 5 mm, and 5.5 mm and in lengths of 7 mm, 8 mm, 10 mm, 11 mm, and 13 mm. In this study, 4 mm or 5 mm diameter implants with a length of 10 mm were placed. Study method Using medical charts of patients, the following was looked into: 1. Gender of patients, implant distribution, and locations 2. Bone quality of implant site and primary stability 3. Placement timing and the use of guided bone regeneration 4. Implant survival rate An oral examination and radiograph test were also carried out on all the patients, and their smoking status was also checked.

Results Demographics and implant distribution A total of 237 ExFEEL external fixtures were placed on 111 patients. Out of these, 127 implants (53.6%) were placed in 67 men (60.4%) and 110 (46.4%) in 44 women (39.6%). In men, seven out of the 127 implants placed failed and 120 (94.48%) succeeded. In women, four out of 110 implants placed failed, and 106 (96.36%) survived — women Volume 7 Number 6

RESEARCH Table 1: Localization of inserted implants Site

Central incisor

Lateral incisor

Canine

1st premolar

2nd premolar

1st molar

2nd molar

Total %

Maxilla

74 (31.2%)

Mandible

163 (68.8%)

Total

104

237

Table 2: Implant distribution according to bone quality Bone density

Total

Success

Fail

15 (93.74%)

106

102 (96.22%)

86 (94.5%)

23 (95.83%)

Figures 1A and 1B: Survival rate by patient gender and arch. A. gender B. arch

Table 4: Graft type

Table 3: Placement timing showed some 1.9% higher survival rate than men (Figure 1A). Out of 237 implants in total, 74 (31.2%) were placed in the maxilla and 163 (66.8%) in the mandible as twice more implants were placed in the mandible than the maxilla concentrating on left and right molar regions (Table 1). In the maxilla, six out of 74 inserted implants failed, and 68 (91.89%) survived; and in the mandible, five out of 163 inserted implants failed, and 158 (96.93%) survived, with about 5% better survival rate in the mandible than the maxilla (Figure 1B). Bone quality and primary stability The bone quality of implant patients was categorized according to Lekholm classification. In the order of frequency, type II (106), type III (91), type IV (24), and type 1 (16) were observed (Table 2). Placement timing and guided bone regeneration In terms of implant placement timing, 189 implants were placed in healed ridges, 28 were immediately placed, and 20 placed with a delayed approach in the order of frequency. In 28 cases of immediate placement, five cases failed. All 20 delayed cases (100%) survived, and of the 189 cases placed in healed ridges, six failed (Table 3). In 74 guided bone regeneration (GBR) cases, five failed. Of the 34 socket regeneration cases, three failed, and all 28 sinus lift cases survived. Of the 101 cases carried out without GBR, three failed (Table 4). Survival analysis A total of 237 implants were placed, and 226 of them were still surviving at 3 months 46 Implant practice

Graft type

Success

Fail

Placement timing

Success

Fail

GBR

69 (93.24%)

Immediate

23 (82.14%)

Socket BR

31 (91.17%)

Delayed

20 (100%)

Sinus BR

28 (100%)

Healed ridge

183 (96.82%)

Non-GBR

98 (97.02%)

Table 5: Failure rates by stage Time

Implant at start of interval

No. of failed implants

Survival implant

Survival rate in the interval

Cumulative survival rate (%)

Before loading

237

226

95.35

Loading to 3m

226

100

95.35

3m to 1y

226

100

95.35

1y to 2y

226

100

95.35

2y-

226

100

95.35

following the placement. Of these surviving implants, all 226 of them went on to survive for more than 2 years (Table 5). Analysis of failed implants There were 11 implants that did not meet the survival criteria, including one osseointegration failure with occlusal problems, three due to smoking and drinking, one burned because of bone quality, two lost by infection, and four loosened after immediate placement or failure to integrate (Table 6).

Discussion A number of in vivo and in vitro studies have recently been conducted on titanium with Ca2+ ion surfaces. The subject of this particular study was the ExFeel External implant system manufactured by the Korean company, MegaGen.

It has an external abutment connection, and features self-tapping threads and cutting edges for good primary stability. Using hydroxyapatite, the surface is treated with resorbable blast media (RBM) with the aim of promoting affinity to bone followed by infiltration of the Ca2+ ion into the surface to form a calcium titanate nano-structure (Park, et al., 2009). The survival rate of implants was defined as the ratio of implants remaining in the mouth and not removed due to failure at the time of the study. The criteria for implant failure was taken to include mobile implant fixtures, translucency on radiograph around the implant during healing, a failure to osseointegrate as determined by the fixture rotating when the healing abutment was connected, uncontrolled pain, infection, and neurological Volume 7 Number 6

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RESEARCH abnormalities (Cochran, et al., 2002; SeongLeon and Young-Kyun, 2010). The most widely used implant success criteria by Albrektsson, et al. (1986), also treats the year following implant placement as a critical timescale. The loading of the implant is reflected in the 1-year data; most prostheses would be completed within a year of placement (Carr, et al., 2003). Survival table analysis was used in this study based on the assessment of cumulative survival rate (CSR). To assess the cumulative survival rate with 95% confidence level, the data is usually analysed for a duration of 5 years with assessment performed every year. This method is used in many studies to assess CSR of implants (Cutler and Ederer 1958; Chuang, et al., 2001). In many studies assessing implants, a modified survival table is applied depending on follow-up period, implant placement, or prosthesis criteria. For this study, it was modified in units of 5 months to assess the 1-year CSR. In this study, all 111 subjects treated with the ExFeel implant were included, and 11 implants failed before loading, resulting in 95.3% survival rate. There were no failures of any kind for 2 years after the loading. Therefore, all the failures can be attributed to lack of initial stability. As to the composition of subjects, male subjects were 20% more than females in number. Implants and patients were evenly distributed among patients in their 20s and under, and in the 50s, but there were more male patients and more implants placed in men among patients in their 30s, 40s, and 60s. Increasing numbers of implants and patients were observed in men in their 40s and in women in their 50s. By implant location, there were 2.2 times more implants placed in the lower jaw than the upper jaw, and most in the posterior region (about 95% of all the implants) than the anterior region. A greater rate of tooth loss in the lower posterior is thought to be the reason for this, as demonstrated in the study by Meskin, Brown, et al.,1988. There were 11 implants that did not meet the survival criteria, including one osseointegration failure with occlusal problems, three due to smoking and drinking, one burned because of bone quality, two lost by infection, and four loosened after immediate placement or failure to osseointegrate. Among these were three cases of osseointegration failure and five cases of infection by food, drinking, or smoking. Thus the main causes of the failure include infection, drinking, smoking, and lack of osseointegration. As reported by Chuang, 48 Implant practice

Table 6: Analysis of failed implants Site No.

Fixture size

Ext socket

Graft type

Density

5 x 10

Healed

GBR

5 x 10

Immediate

GBR

5 x 10

Immediate

Socket BG

5 x 10

Healed

Without BG

5 x 10

Immediate

Socket BG

4 x 10

Healed

GBR

4 x 10

Healed

GBR

5 x 10

Healed

GBR

5 x 10

Immediate

Without BG

5 x 10

Healed

Without BG

5 x 10

Immediate

Socket BG

et al. (2001), it is thought that systemic conditions of a patient, such as diabetes, age, osteoporosis, smoking, and radiation therapy, influence implant survival rate.

Conclusion This study was performed in a short period of time — less than 2 years — and it analyzed survival rates instead of success

rates. The shortcoming of the study lies in the lack of data on prosthetic complications. Despite these constraints, the study showed a 95.35% short-term survival rate of ExFeel implants with an XPEED-treated surface, which would indicate the implant can be chosen and used as a stable option. However, a long-term study with more implants is called for. IP

REFERENCES 1.

Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: a review and proposed criteria of success. Int J Oral Maxillofac Implants. 1986;1(1):11-25.

Bahat O. Brånemark system implants in the posterior maxilla: clinical study of 660 implants followed for 5 to 12 years. Int J Oral Maxillofac Implants. 2000;15(5):646-653.

Barewal RM, Oates TW, Meredith N, Cochran DL. Resonance frequency measurement of implant stability in vivo on implants with a sandblasted and acid-etched surface. Int J Oral Maxillofac Implants. 2003;18(5): 641-651.

4. Brånemark PI, Adell R, Breine U, Hansson BO, Lindström J, Ohlsson A. Intra-osseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg. 1969;3(2):81-100. 5. Buser D, Mericske-Stern R, Dula K, Lang NP. Clinical experience with one-stage, non-submerged dental implants. Adv Dent Res. 1999.13:153-161. 6.

Carr AB, Choi YG, Eckert SE, Desjardins RP. Retrospective cohort study of the clinical performance of 1-stage dental implants. Int J Oral Maxillofac Implants. 2003;18(3):399-405.

Chuang SK, Tian L, Wei LJ, Dodson TB. Kaplan-Meier analysis of dental implant survival: a strategy for estimating survival with clustered observations. J Dent Res. 2001;80(11):2016-2020.

Cochran DL, Buser D, ten Bruggenkate CM, Weingart D, Taylor TM, Bernard JP, Peters F, Simpson JP. The use of reduced healing times on ITI implants with a sandblasted and acid-etched (SLA) surface: early results from clinical trials on ITI SLA implants. Clin Oral Implants Res. 2002;13(2):144-153.

Cutler SJ, Ederer F. Maximum utilization of the life table method in analyzing survival. J Chronic Dis. 1958;8(6):699-712.

10. Finne K, Rompen E, Toljanic J. Clinical evaluation of a prospective multicenter study on 1-piece implants. part 1: marginal bone level evaluation after 1 year of follow-up. Int J Oral Maxillofac Implants. 2007;22(2):226-234. 11. Friberg B, Henningsson C, Jemt T. Rehabilitation of edentulous mandibles by means of turned Branemark System implants after one-stage surgery: a 1-year retrospective study of 152 patients. Clin Implant Dent Relat Res. 2005;7(1):1-9. 12. Hämmerle CH, Jung RE, Feloutzis A. A systematic review of the survival of implants in bone sites augmented with barrier membranes (guided bone regeneration) in partially edentulous patients. J Clin Periodontol. 2002;29 Suppl 3:226-231; discussion 232-3. 13. Lee SY, Yang DJ, Yeo S, An HW, Ryoo KH, Park KB. The cytocompatibility and osseointegration of the Ti implants with XPEED® surfaces. Clin Oral Implants Res. 2012;23(11):1283-1289. 14. Martinez H, Davarpanah M, Missika P, Celletti R, Lazzara R. Optimal implant stabilization in low density bone. Clin Oral Implants Res. 2001;12(5): 423-432. 15. Meredith N. Assessment of implant stability as a prognostic determinant. Int J Prosthodont. 1998;11(5):491-501. 16. Meskin LH, Brown LJ. Prevalence and patterns of tooth loss in the employed adult and senior populations, 1985-1986. J Dent Educ. 1988;52(12):686-691. 17. Misch CE. The implant quality scale: a clinical assessment of the health-disease continuum. Oral Health. 1998;88(7):15-20, 23-25; quiz 25-26. 18. Park JW, Kim HK, Kim YJ, An CH, Hanawa T. Enhanced osteoconductivity of micro-structured titanium implants (XiVE S CELLplus) by addition of surface calcium chemistry: a histomorphometric study in the rabbit femur. Clin Oral Implants Res. 2009;20(7):684-690. 19. Penarrocha M, Carrillo C, Boronat A, Marti E. Early loading of 642 Defcon implants: 1-year follow-up. J Oral Maxillofac Surg. 2007;65(1):2317-2320. 20. Rosenberg ES, Cho SC, Elian N, Jalbout ZN, Froum S, Evian CI. A comparison of characteristics of implant failure and survival in periodontally compromised and periodontally healthy patients: a clinical report. Int J Oral Maxillofac Implants. 2004;19(6):873-879. 21. Schnitman PA, Shulman LB. Recommendations of the consensus development conference on dental implants. J Am Dent Assoc. 1979;98(3):373-377. 22. Seong-Yeon Lee, Young-Kyun Kim. Retrospective clinical study of tapered form dental implant system. The Journal of the Korean Academy of Implant Dentistry. 2010;29(2):20-25. 23. Smith DE, Zarb GA. Criteria for success of osseointegrated endosseous implants. J Prosthet Dent. 1989;62(5):567-572.

Volume 7 Number 6

Restoring the edentulous arch John C. Minichetti, DMD, traces the steps to a fixed implant-supported prosthesis

atients often present to the office with compromised dentitions. RevitaliZe™ Patient Solutions (Zimmer Dental) shall enable the dentist to provide patients with a fixed implant-supported prosthesis in an economical, predictable, and efficient manner. Not only should this be a permanent

solution to failing dentitions, but clinicians may provide their patients with full-arch, immediate-load, screw-retained provisional restorations while allowing the implants to fully integrate. Surgical protocols should allow the surgeon to place implants in positions to avoid critical anatomic structures.

The preoperative CBCT scan illustrates a hopeless maxillary dentition with low maxillary sinuses. The postoperative radiograph shows implant placement angled to avoid the maxillary sinus while increasing the anterior-posterior spread for better occlusal load distribution (Figures 1-2).

Figure 3

Figure 4 Figure 1

Implant placement: The osteotomies are prepared using the appropriate drilling sequence based upon the bone quality of the implant site. The goal is to achieve an adequate insertion torque to allow for immediate loading. The hex on the fixture mount/ transfer is used to align the implant correctly for the Angled Tapered Abutments (Figure 3).

Seating the Abutments

Figure 2 John C. Minichetti, DMD, Director of Implant and Reconstructive Dentistry of Englewood, in Englewood, New Jersey, has years of experience in cosmetic dentistry, implantology, and prosthetic reconstruction.

Volume 7 Number 6

Utilization of Tapered Abutments, straight or angled (15º or 30º), should allow the prosthetic screws to be positioned within the prosthesis. The Delivery Tool is used to carry and seat the Angled Tapered Abutments. The 1.25 mm Hex Driver is used to tighten the abutment screws. The Delivery Tools are then removed. Care should be taken as they disengage quickly from the abutment (Figure 4). Implant practice 49

STEP-BY-STEP

RevitaliZe™ Patient Solutions

STEP-BY-STEP Any excess resin should be removed and voids filled. The flanges and palate of the denture are removed and the borders rounded to facilitate hygiene. The provisional restoration is finished and polished. The provisional restoration is placed on the Tapered Abutments and the Coping Screws tightened. Radiographs are taken to verify complete seating (Figures 7-8).

Figure 5

Figure 12

Bar design and fabrication: The case is scanned on the Zfxâ&#x201E;˘ Evolution Scanner. A virtual design of the bar is created based on the tooth set-up. Once the design is approved, the bar is precision-milled from a solid puck of titanium (Figures 11-12).

Figure 9 Figure 6

Provisionalization: The provisional can be fabricated utilizing the patientâ&#x20AC;&#x2122;s existing denture or a new immediate denture. It is modified to help create a screw-retained provisional restoration (Figures 5-6). Healing Caps are threaded onto the Tapered Abutments and the tops marked with a Thompsonâ&#x20AC;&#x2122;s Stick. The denture is triedin. Ink marks indicate where holes should be drilled through the denture. Temporary Titanium Copings are mounted on the Abutments and are picked up in the denture using resin material with a brush-bead technique. Once the resin has set, the coping screws are loosened and the denture removed. The intaglio surface of the denture is inspected.

Figure 10

Final restoration: A final impression is made and a soft tissue master model poured (Figure 9). An acrylic verification jig is fabricated and tried-in to help assure an accurate master model (Figure 10). The master model, verification jig and trial setup are sent to the Zimmer Zfx Milling Center with the Zimmer Zfx Bar Order Form.

Figure 13

Figure 14

Final Delivery

Figure 7

Figure 11

The trial setup is transferred to the bar and tried-in. Once all adjustments are made, the prosthesis is processed, finished, and polished. The fixed-detachable restoration is seated on the Tapered Abutments and the Prosthetic Screws tightened. Occlusal adjustments are made as needed (Figure 13). A radiograph is taken to ensure complete seating (Figure 14). The screw access openings are sealed and the patient placed on a recall schedule. IP This article was provided by Zimmer Dental.

Figure 8 50 Implant practice

Volume 7 Number 6

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

eoi

n co r p ora

tio

abe

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gro

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ria

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NuOSS® Granules A New Generation of Bone Regeneration

uOss® natural cancellous (spongiosa) and cortical bone matrix is produced by the removal of organic components from bovine bone. Due to its natural porous structure, NuOss is physically and chemically comparable to the mineralized matrix of human bone. The proprietary manufacturing process of NuOss allows for maintenance of the naturally occurring bone mineral structure, including macro and micro structures. Due to this trabecular architecture with interconnecting macro and micro pores, the ingrowth of new bone and associated vascularization at the site of grafting is optimized. NuOss may be used with autogenous bone where there is an insufficient quantity of bone to fulfill the needs of the proposed surgical procedure. Oral and Maxillofacial Surgeon Dr. John Guariglia of Suffolk Oral Surgery Associates, LLP, of Brentwood, Stony Brook, Smithtown, and Holbrook, New York, has been using NuOss for approximately 10 years for a myriad of applications, “from implants to socket preservation, to bone regeneration procedures. I also use it for treating pathology such as tumors and cysts. Depending upon the lesion, I enucleate it, mix NuOss with alloOss® allograft and platelet-rich plasma and pack the defect.”

Dr. Guariglia explains that NuOss is his bone regeneration material of choice because “It is a great value; it adheres to the instruments, and it is NuOss® 50x magnification very easy to use. Also, it’s available in all sizes I need for a majority of my procedures.” NuOss® features: The results from NuOss are quick and Handling: The structure of NuOss aids effective. Dr. Guariglia describes, “For in particulate hydration and delivery of the example, I grafted bone for a patient 2 product to the defect. months ago, and now, his implants show Particle Distribution: NuOss maximizes maximum torque. No complaints. I was the distribution of the preferred particle sizing able to place implants in these grafts in 2 within desired ranges. months, and I have solid bone to work with. Particle Structure and Porosity: NuOss That shows me that NuOss permits solid maintains the high porosity and trabecular bone growth.” structure of natural mineralized bone and maximizes the potential for angiogenesis.

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52 Implant practice

Volume 7 Number 6

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cancellous & cor tical granules ACE NuOss® natural anorganic bovine bone matrix is one of the most reliable bone substitutes used by dental professionals around the world. NuOss cancellous and cortical granules are physically and chemically comparable to the mineral matrix of human bone and are available in a variety of vial volumes, and in a preloaded delivery syringe. To learn more about the NuOss family of products and to take advantage of this amazing offer, visit our website www.acesurgical.com or call 800-441-3100

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54 Implant practice

Volume 7 Number 6

PRODUCT PROFILE

BioHorizons® Biologics Optimal choices to support predictable implant therapy

t’s no secret that predictable implant treatment planning often begins with proper soft and hard tissue regeneration to facilitate sufficient initial implant stability. Historically, aside from implants and related prosthetic components, implant companies rarely provided adjunct products to support other major steps in treatment. In 1998, BioHorizons began distribution of Grafton® Demineralized Bone Matrix (DBM) and became one of the first dental implant companies to feature a regenerative product line. Since the launch of Grafton DBM, BioHorizons has added a variety of key biologics products to Cortical chips provide Cancellous chips have support soft and hard tissue regenerstructure for space increased surface area for ation. AlloDerm® Regenerative Tissue maintenance bone forming cells to deposit Matrix (RTM) is the market leader in soft tissue alternatives with 118 Features of the MinerOss family of bone peer-reviewed published studies in dental grafts include: since 2000. MinerOss® cortical and cancel• MinerOss cortical and cancellous lous chips was the first blended allograft chips offers a unique blend to form an particulate offered in implant dentistry in osteoconductive scaffold providing 2004. MinerOss is now distributed in over volume enhancement and effective 35 countries. site development.

• MinerOss Cancellous allograft particulate launched in 2012, and MinerOss Cortical particulate launched in 2013. • MinerOss X family of xenografts, an anorganic bovine bone mineral matrix that is physically and chemically comparable to the mineral structure of human bone, launched in 2014. The ability to offer complete solutions from first surgery to final restoration provides clinicians with a streamlined approach to implant practice management. BioHorizons is recognized as a global leader for scientifically proven tissue regeneration solutions.

About BioHorizons BioHorizons, Inc., a majority-owned subsidiary of Henry Schein, Inc. (NASDAQ: HSIC), is a leading dental implant and biologics company located in Birmingham, Alabama. The company has a broad product offering, including dental implants, surgical planning software and tissue regeneration solutions for the replacement of missing teeth. BioHorizons products are available in 85 markets around the world. For more information, visit www.biohorizons.com. IP

This information was provided by BioHorizons.

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IPUS VIEWPOINT

Treatment of the edentulous maxilla Dr. Tara Aghaloo explains why the Academy of Osseointegration took up the important topic of the edentulous maxilla at a recent Scientific Summit. Why is treatment of the edentulous maxilla a current hot topic? Treatment of the edentulous maxilla is such a hot topic today, because many things have changed, and many things have stayed the same. A comprehensive diagnostic work-up followed by careful treatment planning is still the most important aspect of treating edentulous patients, no matter how complicated the surgery or restorative procedures are. We have patients who are able to receive fixed prostheses on implants in a number of hours; we have new digital tools to give us significantly improved views of our patients’ bone quality and quantity, vital structures, and potential pathology; and we have a tremendous selection of new prosthetic and surgical materials to aid in making almost every patient a candidate for dental implants.

What makes the clinical management of the edentulous maxilla so complex and controversial? This topic is controversial because treatment is often seen as “one size fits all.” What I mean is that some clinicians want to give everyone immediately loaded fixed prostheses on tilted implants; other clinicians want to perform bone augmentation to place implants into a classically healed ridge; and still others are somewhere in between. The issue is that technology is advancing so rapidly that we don’t have time to evaluate the techniques and materials that we are utilizing in an objective way. In other words, by the time we have long-term studies on one technique or material, new and likely better ones have become available. However, this does not excuse the profession from researching these new technologies before we widely offer them to our patients. Herein lies the controversy.

Tara L. Aghaloo, DDS, MD, PhD, is a Professor in Oral and Maxillofacial Surgery at the UCLA School of Dentistry. She is also a member of the Board of Directors, Academy of Osseointegration.

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It is apparent that technology will continue to improve to provide us with enhanced diagnostic tools, improved materials to augment deficient tissues via less invasive procedures, better prosthetic options for both provisional and final restorations, and implants can be loaded sooner and can be used in more compromised sites. Why are clinical practice guidelines so important for dentistry? Clinical practice guidelines are so important for dentistry, especially for implant dentistry, because there are so many ways to manage specific clinical situations. Some treatment options require advanced training and skill, and should not be performed by less experienced clinicians, at least not without the proper training. At the Academy of Osseointegration (AO) Summit in August, AO brought together over 120 of the world’s leading scientists and clinicians in implant dentistry, including representatives from the American Association of Oral and Maxillofacial Surgeons, the American Academy of Periodontology, and the American College of Prosthodontists to propose up-to-date Clinical Practice Guidelines (CPGs) for management of the edentulous maxilla. These guidelines, which are in progress, are based on a systematic review of the current dental literature, clinical information, and accepted approaches to the treatment of the edentulous atrophic maxilla. They are intended to provide practicing clinicians with current thoughts and recommendations for several topics, including the role of bone augmentation for implant site development, the role of implant design and surgical approaches, the role of advanced imaging for more minimally invasive procedures, the role of tissue engineering in hard and soft tissue reconstruction, and an interdisciplinary approach to prosthetic management of the edentulous maxilla. The guidelines can also

be used as an educational tool to assist dentists in treatment choices, to improve the quality and efficiency of patient care, and to explain treatment options to patients.

What are some key diagnostic criteria to consider when weighing treatment options? When evaluating different treatment options, we must consider maxillary/mandibular ridge relationship, quality and quantity of available hard and soft tissue, lip support, ability to maintain adequate oral hygiene, presence of pathology, and evidence of parafunctional habits.

How have advances in imaging/ technology impacted the diagnosis/ treatment of the edentulous maxilla? Advanced imaging, mostly referring to cone-beam CT (CBCT) scans, is essential in both the diagnostic and treatment phase of treating patients with an edentulous maxilla. Not only can it help us determine if there is adequate bone for implant placement, visualize maxillary anatomy, and diagnose the degree of osseous atrophy, but it can help identify anatomic variations and the presence of pathology. Utilizing CBCT scans to digitally plan an implant case before it is actually performed on a patient is an extremely valuable tool, both for the novice and experienced clinician. Having a “test run” on each individual patient, where potential difficulties or challenges can be identified and overcome, cannot be overstated. This can help determine Volume 7 Number 6

What are some treatment options that should be considered? Treatment options that should be considered for the edentulous maxilla were covered very well in the recent AO Summit. After discussing the patientâ&#x20AC;&#x2122;s chief complaint, doing a complete history, physical exam, diagnostic casts, and appropriate radiographs, these options can be discussed. A complete maxillary denture is always an option, especially if it is well made and can meet the esthetic, phonetic, and functional requirements. If it cannot, a prosthesis utilizing implants should be considered. A removable implant-assisted overdenture is an option that has been shown to increase a patientâ&#x20AC;&#x2122;s satisfaction and quality of life. However, this treatment option requires surgery, increased cost, and must be

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evaluated regularly for maintenance, repair, and/or replacement. Another option is an implant-supported fixed prosthesis, which generally requires more complicated surgery and increased cost. Again, if this is the option that fits the esthetic, prosthetic, and functional requirements of an individual patient, and the clinician and patient are willing to undergo regular maintenance, repair, or replacement, then the fixed prosthesis should be chosen. At this stage, it is extremely important to consider the training and skill of the treating clinician. If there is an option that may be considered for a patient, but the treating clinician is not comfortable with it, that patient should be referred to another clinician who can provide those options. Clinicians should not perform procedures or recommend treatment options that they have not had the training or skills to perform.

How important is patient communication in treatment planning? Patient communication is the most vital

aspect involved in diagnosis and treatment planning. We have to remember why patients seek our consultation: They want teeth! It is up to us to inform them of their attributes and limitations to achieving their chief goal. Whether it is a complicated medical history, inadequate available bone, unrealistic expectations, or financial limitations, any treatment performed will fail without proper communication.

What does the future look like for the management of the edentulous maxilla? The future is extremely bright in management of the edentulous maxilla, whether it is severely atrophic or not. It is apparent that technology will continue to improve to provide us with enhanced diagnostic tools, improved materials to augment deficient tissues via less invasive procedures, better prosthetic options for both provisional and final restorations, and implants can be loaded sooner and can be used in more compromised sites. IP

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IPUS VIEWPOINT

position or angulation of implants, number of implants, prefabricated surgical guides, or provisional and sometimes final prosthesis fabrication. The role of advanced imaging will only continue to increase in the future.

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT Densah™ Bur Technology introduced Introducing Densah™ Bur Technology for implant osteotomy preparation from Versah™ LLC. Densah Burs have a non-excavating proprietary flute design to precisely cut bone when turning clockwise and densify bone when rotated in reverse. This technique, known as Osseodensification, autografts bone along the entire length of the osteotomy through a hydrodynamic process with the use of irrigation. The result is a precise, condensed osteotomy leading to improved implant stability and potentially earlier loading. For more information, visit http://www.versah.com.

Straumann® now offers one of the most complete portfolios for bone regeneration Straumann® is expanding its portfolio of regenerative solutions. Now, Straumann® XenoGraft and Straumann® Membrane Plus™ join Straumann® AlloGraft, BoneCeramic™, and Emdogain™ to provide a single trusted source for dental implant and regeneration needs. NEW – Straumann® XenoGraft • This bovine-derived natural bone substitute creates a lasting scaffold for extended volume maintenance. Available sizes: 0.25g, 0.5g, 1.0g, 2.0g. NEW – Straumann® Membrane Plus™ • This barrier provides soft tissue support and space maintenance for bone regeneration. Available sizes: 10x20 mm, 15x20 mm, 20x30 mm. NEW SIZES – Straumann® AlloGraft • Choice of mineralized or demineralized cortical, mineralized cancellous, or mix of cortical/cancellous. Now available in 2.5cc size for mineralized cortical, cancellous, or mix. These new offerings provide customers with a total solution for patient satisfaction and practice success. To learn more about the new Straumann® Bone Regenerative portfolio, visit www. straumann.us/bone.

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DEXIS™, manufacturer of the highly awarded DEXIS™ digital X-ray system, has released its Mac-based dental imaging software DEXIS has launched DEXIS™ Mac, a new software that integrates the true functionality of Apple products that Mac users crave with the functionality of the renowned DEXIS imaging system. To better serve loyal Mac users, this new software combines the tried-and-true workflow that DEXIS users appreciate into a native Mac platform that requires no parallels. DEXIS Mac is compatible with the award-winning single-sized DEXIS™ Platinum sensor, which provides images of remarkable quality and efficient workflow. This software is 100% Mac-oriented — providing the quintessential DEXIS imaging experience along with the flair of the Mac platform. For more information, visit www.dexis.com.

A new Blue Hader Rider for significantly worn Hader Bars PREAT Corporation has introduced a new Blue Hader Clip to service patients with worn Hader Bars. The Blue Hader “salvage” clips have a much smaller internal diameter to compensate for wear on the bar, but will fit inside both the Traditional Metal Housings and Alignment Housings. The Hader Insertion Tool allows quick and easy placement to increase prosthesis retention and patient satisfaction. All components are manufactured to stringent ISO13485:2012 quality standards and made in the USA. For more information, visit www.preat.com or call 800-232-7732.

The new i-CAT™ FLX MV delivers i-CAT quality in a model that fits a wide range of dental practices i-CAT™, a brand member of the KaVo Kerr Group, has launched the i-CAT FLX MV (medium field-of-view) for general dentists and specialists who place and restore implants, perform oral surgery, periodontics, prosthodontics, endodontics, and oral surgery with greater confidence and lower radiation. The innovative features of the i-CAT FLX MV will deliver greater clarity, ease-of-use, and control for those clinicians who need a medium field of view and a range of image sizes to fit a variety of needs. From scan to plan to treat, i-CAT FLX MV offers these features to seamlessly provide information and control: • Medium field-of-view captures up to both arches and the temporomandibular joints in 3D. • Visual iQuity™ advanced image technology provides i-CAT’s clearest 3D and 2D images. • Provides lower dose scan options, including QuickScan+. • Easy-to-use SmartScan STUDIO™ touchscreen allows for selection of the appropriate scan for each patient. • Capture traditional 2D panoramic images with i-PAN. • Integration with CAD/CAM programs. For more information, visit www.i-cat.com.

Volume 7 Number 6

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ON THE HORIZON

The best gift for the holidays — technology Dr. Justin Moody suggests that now is the time to invest in practice-changing technologies

t’s crazy to think that Thanksgiving, Christmas, and the New Year are just mere days away. Many of us are looking forward to the start of the New Year, while some of us have not given up on 2014 just yet. Throughout my columns this year, we have talked about how technology is here to stay in implant dentistry; we have reviewed the features of today’s dental implants and discussed various ways that we can change people’s smiles and lives. With the knowledge that the demand for dental implants is not slowing down, there is still time to take that leap into the world of technology to make placement easier, and more efficient. You cannot just sit on the fence and wait for a lull to happen to add these innovations; you have to pick a time; and just do it! Sure, you will feel that the minute you buy that cone beam CT machine, it will be replaced by an updated model, or that the implant company has a better surface treatment coming soon, or that software just can’t provide all of the applications that you need. These may all carry some truth, but upgrades and updates to technology are a fact of life and will be undergoing changes for the rest of your career. I was lucky enough to have just returned from Silicon Valley where I visited the headquarters of medical technology firm, Anatomage. This company is not just listening to the needs of the implant doctor, but is also trying to make a difference in the way we practice. I predict that the categories of accuracy and efficiency will make the biggest strides in 2015. The ability to gather

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.

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3Shape Implant Studio

Anatomage Guide

all the needed data to diagnose, treatment plan, and execute in one appointment is making implant dentistry safer, more efficient, and downright fun again. Cone beam CTs, digital impresi-CAT Treatment Studio sions, surgical guides, and move forward. So if you want a tax-related the delivery of dental implants using a purchase, give an early Christmas present surgical guide made by Anatomage and fully compatible with the BioHorizons® surgical to yourself, or some technology to get the kit in as little as 48 hours excites me and New Year off to a good start. Embrace it; keeps me on the edge of my chair as we use it; and have fun! IP Volume 7 Number 6

INDUSTRY NEWS BIOMET 3i™ has introduced its Smile Therapy™ Campaign to clinicians and laboratories Smile Therapy consists of a trio of system solutions to help dental professionals and their patients achieve beautiful, confident and healthy smiles. The solutions include the following: • Smile Beautifully with Sustainable Aesthetic Solutions — A comprehensive portfolio of surgical and restorative treatment options with SureSeal™ Technology to assist in achieving long-term aesthetic results. • Smile Confidently with Full Arch Rehabilitation Solutions — These solutions are designed to work in synergy to provide comprehensive dental implant therapy for partially edentulous and edentulous patients, as well as those with failing dentition. • Smile Healthy with Peri-Implant Health Management Solutions — These solutions include a comprehensive portfolio focused on prevention, diagnosis, and treatment of peri-implant disease. For more information about BIOMET 3i™, visit www.biomet3i. com, or contact the company at 800-342-5454; outside the United States, call 561-776-6700.

Pride Institute grants “Best of Class” honor to CariVu™ Pride Institute has presented DEXIS™ CariVu™ with the Best of Class Technology Award for 2014 as a product that demonstrates excellence in its category. CariVu technology benefits the patient by detecting caries accurately without ionizing radiation. This unique caries detection device is compact, portable, and uses patented transillumination technology to support the identification of occlusal, interproximal, and recurrent carious lesions and cracks. CariVu images are easily compared to intraoral radiographs and camera images within the DEXIS software. This unit functions unlike any other product in its category — and with truly unmatched technology, delivers an impressive accuracy rate of 99%*. For more information, visit www.DEXIS.com * Data on file

For the second consecutive year, the i-CAT™ FLX cone beam 3D system is honored by the Pride Institute i-CAT™, a brand of the KaVo Kerr Group, has been recognized in 2014 with the Pride Institute’s “Best of Class” Technology Award for excellence in its category for the second consecutive year. i-CAT FLX was differentiated from the competition for its unique characteristics that create value for the dental practice. i-CAT FLX features clinical control over radiation dose and scan size along with comprehensive treatment tools that benefit both general dentists and specialty practices. Its QuickScan+ provides for a full-dentition 3D scan at a dose comparable to a traditional 2D panoramic x-ray.*+ The i-CAT FLX allows for clinical control over scan size, resolution, modality and dose, while the updated Tx STUDIO™ software provides even more integrated surgical and orthodontic treatment tools to help dentists deliver the best care. For more information, visit www.i-cat.com.

Candy Ross elected to ADA Foundation Executive Committee as Vice President of Grants Candy Ross, Director of Industry and Professional Relations, Dental Technologies, North America for KaVo Kerr Group, was elected Vice President of Grants of the ADA Foundation (ADAF) Executive Committee during the ADAF board meeting on Tuesday, September 16. She has served on the Board of Directors for the ADAF for the last year and a half. Described as “dentistry’s premier philanthropic and charitable organization,” the ADAF is active in providing educational grants, including dental student scholarships and affiliated dental scholarships; a variety of grants related to access to care and oral health outreach, including grants related to Give Kids A Smile®; and charitable assistance through its Disaster Assistance Grant Program and Relief Grant Program. The ADAF also provides funding for the Dr. Anthony Volpe Research Center (formerly the Paffenbarger Research Center) in Gaithersburg, Maryland. For more information about the ADAF, visit www.adafoundation.org.

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* Ludlow JB, Walker C. Assessment of phantom dosimetry and image quality of i-CAT FLX cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2013;144(6):802-817. +

Image quality is proportional to dose.

Nobel Biocare to join Danaher dental platform Danaher Corporation has entered into a definitive transaction agreement to acquire Nobel Biocare Holding AG. Nobel Biocare will be a cornerstone of the dental platform. With this acquisition, Danaher will have an unmatched position in dental implants with Nobel Biocare in the premium segment and the Implant Direct joint venture in the value segment; the company plans to further invest in both these segments. Nobel Biocare will operate as a stand-alone company within Danaher’s dental platform, maintaining its own brand and identity. Implant Direct will remain as a stand-alone joint venture with no change in its go-to market strategy. For more information, visit www.kavokerrgroup.com.

Volume 7 Number 6

IQity Impression Technique™ Patent pending fixture-mount design provides:

• The ease of a closed-tray impression • The accuracy of an open-tray impression • The versatility to create impression at either implant-level or abutment-level