Implant Practice US February/March 2015 Issue - Vol8.1 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

Challenging aspects of implant restoration Drs. Brenda Baker and David Reaney

Enhancing implant stability with osseodensification — a case report with 2-year follow-up Dr. Salah Huwais

Single implant-borne reconstruction in the esthetic area Dr. Daniel S. Thoma

Practice profile Dr. Justin Moody

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PRODUCT PROFILE

THE MAKING OF A

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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.

1 Implant practice

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.

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INTRODUCTION

Looking forward to 2015

t the time that I was asked to write the introduction for this issue of Implant Practice US, I was saddened to learn of the passing at age 85 of Dr. Per-Ingvar Brånemark in his hometown of Gothenburg, Sweden. There was an excellent article in the health section of The New York Times by Tamar Lewin on December 27, 2014, providing a short synopsis of this remarkable man, scholar, teacher, researcher, and inventor. How fortuitous it was that his initial experiment utilizing titanium chambers designed to study blood flow and bone healing unexpectedly could not be removed as they were fused to the bone. The term “osseointegration” was born from these experiments. Without Dr. Brånemark and his initial studies, this magazine might not exist, nor my scope of private practice, nor Cary A. Shapoff, DDS the millions of successfully treated patients restored with dental implants from the single-tooth replacement to the more complex full-arch fixed, removable, or hybrid-type restorations. Since Dr. Brånemark’s early studies and findings, dental implant surgical techniques and philosophies have evolved from the longer healing periods to immediate placement and provisionally loaded techniques now employed in specific clinical situations. Numerous former students and colleagues of Dr. Brånemark have added much to the knowledge base of the dental implant field. Restorative concepts, techniques and prosthodontic case design with intraoral scanners, and CAD/CAM abutment and crown design have also advanced the art and science of dental implant dentistry to new levels. All of us in the daily treatment of patients have the opportunity and responsibility to consider this replacement and reconstructive option in addition to the other conventional dental care approaches utilized to successfully maintain existing dentitions. My own experience in the field of dental implant surgery began in 1985, well after my formal periodontal residency training in 1975. My own implant knowledge base was developed from attending numerous courses and lectures and reviewing the literature. Self-evaluation of my techniques and outcomes from documentation and critical clinical evaluation has helped to hone my treatment concepts. Close-working relationships with my restorative colleagues have allowed us to focus on the esthetic desires and demands of our patient population while maintaining the biologically sound surgical principles and organized restorative responsibilities. Successful esthetic outcomes are a result of careful case analysis, development of wellorganized treatment plans, and keeping the end result in mind prior to performing irreversible surgical procedures. We now have the ability to plan our cases with three-dimensional radiographic surveys and provide precise surgical placement utilizing the imaging results combined with computer-generated surgical guides. Implant styles have certainly changed from the early fixture designs with machined implant collars to the variety of implant styles, fixture thread designs, and connections. Evidencebased variations to the platform design have been developed from platform-switched to those with specific microtextured surfaces that provide unique cellular bioactivity. Our dental implant knowledge is not a finite destination but rather a journey. We rely on a continuing educational stream in order to maintain our skills and develop new treatment methods. Graduate and postgraduate academic programs afford us the opportunity to develop clinical and research skills. The opportunity to expand and acquire additional knowledge on all aspects of implant dentistry can be gained from numerous sources. Implant Practice US and many other magazines and journals provide current, relevant technical and scientific articles as well as continuing education credits. The Internet has brought the dental implant world to our computers in the form of webinars, live-streaming seminars, and numerous international congresses and publications. As clinicians, our work is our signature. The ultimate goal is, therefore, to provide the patient with the most optimal functional and esthetic outcome with long-term success. Best wishes for a new year of success and fulfillment of your aspirations! Cary A. Shapoff, DDS Periodontist Diplomate and Past Director of the American Board of Periodontology 2 Implant practice

February/March 2015 - Volume 8 Number 1 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 GENERAL MANAGER | Adrienne Good Email: agood@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 | Kimberly Burke Email: kimberly@medmarkaz.com CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver Email: amanda@medmarkaz.com FRONT OFFICE MANAGER | Eileen Lewis Email: elewis@medmarkaz.com

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 Web: www.implantpracticeus.com www.medmarkaz.com SUBSCRIPTION RATES 1 year (6 issues) 3 years (18 issues)

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

Volume 8 Number 1

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TABLE OF CONTENTS

Case study

Practice profile

Justin Moody, DDS, DICOI, DABOI

Home-grown, high-tech dentistry

Implant insights

Options for patients with low bone volume Dr. Franck Renouard shares key insights from a presentation he gave at the Academy of Osseointegration (AO) 2014 Annual Meeting in a session called “Problem Solvers & Innovators” ....................................................... 22

Anterior implant esthetics Dr. Bernard Touati offers his insights into effective techniques and procedures for soft tissue management in the anterior region .......................................................26

Corporate spotlight Lending Club

Welcome to the “More Possibilities” Club

4 Implant practice

Volume 8 Number 1

ATLANTIS™ Conus Concept

Available for all major implant systems, the ATLANTIS Conus Concept allows for friction-fit, non-resilient prosthetic solutions for fully edentulous patients.

• Individually designed using the patented ATLANTIS VAD (Virtual Abutment Design) software for parallel abutments and margin levels as close to the soft tissue as possible. • Designed to fit SynCone caps, ensuring a tightly-seated final restoration and minimizing gaps and micro-movement. • Stable and comfortable implant-supported prosthesis designed for optimal access for oral hygiene.

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Stability of a fixed solution with the convenience of a removable prosthesis

NEW

TABLE OF CONTENTS

Continuing education Challenging aspects of implant restoration Drs. Brenda Baker and David Reaney explain various methods to restore function and esthetics to patients in need of implant restoration..............35

Materials & equipment.........................38 A conversation with... New You Smile (NYS) full mouth dental implant restorative system to launch in China ......................................................40

Practice management

Continuing education

Single implant-borne reconstruction in the esthetic area

Dr. Daniel S. Thoma outlines the treatment undertaken for a patient with fractured central incisors using ridge preservation

Guiding light Can your team rely on you when things seem dark? Laura Horton explains how effective leadership can be the light at the end of the tunnel ...................................................... 42

Abstracts

Treating soft tissue deformities around osseointegrated dental implants Dr. Maria Retzepi presents a selection of recent studies and published research..........................................44

Step-by-step

Assessing implant stability for loading Dr. Peter K. Moy discusses a product that helps determine proper implant loading time....................................48

Practice development Product profile How patients think Andy Smith presents patient-led insight to help improve your dental implant marketing............................46

6 Implant practice

Crystal® Ultra: a new hybrid nanoceramic ideal for implant cases Creative Dental offers two new flavors of implant restorations................... 50

Product profile

Introducing ATLANTIS Conus concept by DENTSPLY Implants ......................................................52

In memoriam

Professor Per-Ingvar Brånemark “Father of Modern Dental Implantology” May 3, 1929 – December 20, 2014 ......................................................53

Industry news ..............54

Volume 8 Number 1

GUIDED SURGICAL KIT Precision, Predictability & Performance

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PRACTICE PROFILE

Justin Moody, DDS, DICOI, DABOI Home-grown, high-tech dentistry

What can you tell us about your background? I grew up on a cattle ranch in Crawford, Nebraska, which is a small town in the very northwest corner of Nebraska. My family homesteaded this place somewhere around 1883. It’s amazing to think about the fact that no one else has owned this property prior to this — it even was part of the Louisiana Purchase! My sons are the sixth generation to have lived on the original homestead. After attending the University of Nebraska for undergraduate studies, I traveled south to dental school at the University of Oklahoma. It was a great place to study and an excellent clinical school. Upon graduation, my wife and I decided to move back to our hometown to raise our family, and in June of 1997, I joined my childhood dentist back home in Crawford Nebraska. I opened my first implantonly office in 2008 in Rapid City, South Dakota, and eventually moved with my family there full time in 2010. This is where I call home today.

Is your practice limited to implants? Yes, my practice is limited to the placement and restoration of dental implants and has been since 2008.

Why did you decide to focus on implantology? It took only a matter of months in private practice to realize that dentures, partials, and bridges were not the long-term solution. I could not see myself providing these services for the rest of my career when there were better solutions using dental implants.

How long have you been practicing, and what systems do you use? I began placing dental implants in 1998 after taking several courses throughout the country. It was very rewarding being the 8 Implant practice

only dentist offering implants for over 100 miles. The first system I used was Sterngold/ Sulzer, and I used it until I believe Zimmer Dental bought them sometime in the early 2000s. In 2007, I tried BioHorizons® dental implant systems and have been with them ever since.

What training have you undertaken? As with anything you do as a young dentist, you have the success that drives you, but it’s the failures that motivate you to become better for you and your patients. I went through the Misch International Implant Institute™, becoming a fellow and then one of Dr. Misch’s first masters. I also completed the Medical College of Georgia AAID Maxi-Course in Atlanta, Georgia, and every dental implant course I could get my hands on. Through this process of implant education, I realized I wanted more prosthetics and comprehensive dental education, so I completed the curriculum at the Kois Center in Seattle, Washington, and ultimately

became a Mentor at the Kois Center. It was this culmination of experience and education that inspired me to work on my credentials, becoming a Fellow, Master, and Diplomate in the International Congress of Oral Implantologists (ICOI), Fellow and Associate Fellow for the American Academy of Implant Dentistry (AAID), and ultimately a Diplomate in the American Board of Oral Implantology.

Who has inspired you? My father, David Moody. Since he is a rancher, he is part doctor/veterinarian, part engineer, and part superhero for doing the chores he does and working the hours he works. In dentistry, it’s Dr. Roger Plooster in Lincoln, Nebraska; he is my friend, my colleague, and my mentor in dentistry and especially implantology. Because he graduated from Crawford High School with my father, I have always known him, but when I graduated from dental school, he took me in as one of his own sons. He use to host what we called an “implant rodeo” — a day where three to four of us would gather in one of our offices and place dental implants on those who couldn’t afford it. We would do procedures that challenged us as a group, and I can’t tell you how valuable these days were. Volume 8 Number 1

WHAT KIND OF OPPORTUNITIES ARE IN YOUR WAITING ROOM? ENDO

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PRACTICE PROFILE

Top left: Father/son pheasant hunt Top right: Friday night lights for Dr. Moody’s oldest son, Aaron Lower left: Black Angus cattle on the Moody Ranch Lower right: Crawford, Nebraska, city limit sign

in CAD/CAM and the ability to provide ideal placement and restorations through guided surgery.

What are your top tips for maintaining a successful practice? What is the most satisfying aspect of your practice? Having a patient say, “Thank you.” It’s that simple!

practice. I have over 70 doctors in five states that have trusted their patients’ implant care to me. It’s an honor and a privilege to work with each and every one of them.

Professionally, what are you most proud of?

What has been your biggest challenge?

One day I received a thank-you note from a doctor whom I had trained. He said that dental implants have given his career a new start, and how he loves to go to work now. When you hear someone say that he/she considers you a mentor, that’s the moment when you sit back and realize that you made a difference in someone’s life. That’s what I am most proud of!

What would you have become if you had not become a dentist?

What do you think is unique about your practice? Without a doubt, it’s the fact that I am a general dentist with a referral-based

Educating the public about dental implants. So many people still to this day feel like dental implants are only for the rich. It is the standard of care, in my opinion, for the replacement of a missing tooth or teeth and should be offered to all our patients.

A farmer/rancher. It’s a great way of life.

What is the future of implants and dentistry? Digital. The future of implant dentistry is

The best tip I have is to keep it about the patient, doing what you feel is the right thing every time. It is not our right to be a doctor; it’s a privilege and an honor to have patients place their trust in you as a dentist.

What advice would you give to budding implantologists? Never stop learning! Take as many courses as you can, and provide your patients with the very best in care. Choose an implant system based upon science, not price. Treatment plan your cases using a CBCT — there is no substitution for knowing the whole story. And give back. We have the best profession in the world that allows for us to change someone’s life.

What are your hobbies, and what do you do in your spare time? I like to travel with my family, attend sporting events of all kinds, and hunt birds here in South Dakota. IP

Top 10 Favorites

Dr. Lewis Cummings, Dr. Pat Allen, Steve Boggan, and Dr. Moody in Dubai, United Arab Emirates 10 Implant practice

1. My friends and family 2. The Nebraska Cornhuskers 3. The Moody Ranch 4. Harley-Davidson® motorcycles 5. My i-CAT™ FLX CBCT (Imaging Sciences International) 6. BioHorizons® dental implants 7. Chicago Cubs and Wrigley Field 8. Sturgis® Motorcycle Rally™ 9. Teaching and mentoring fellow dentists 10. DEXIS™

Volume 8 Number 1

CORPORATE SPOTLIGHT

Lending Club Welcome to the “More Possibilities” Club

ending Club (NYSE: LC) is the world’s largest online credit marketplace. In addition to personal and business loans, the company provides quality, responsible options for people looking to finance elective medical procedures. “We combined Springstone’s decades of experience in patient lending with our technology and expertise to develop Lending Club Patient Solutions,” says Lending Club CEO Renaud Laplanche. “In doing so, we’re able to offer patients and providers a wider range of financing options, while keeping the application process as simple as possible.”

simple, user-friendly, and fast. Same-day treatment acceptance has gone up since incorporating Lending Club Patient Solutions into our treatment presentation — so much so that we have stopped offering any other financing options.” For more information, contact Lending Club Patient Solutions at 1700 West Park Drive, Suite 310, Westborough, MA 01581, 800-630-1663, or email solutions@lendingclub.com. IP

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“Same-day treatment acceptance has gone up since incorporating Lending Club Patient Solutions into our treatment presentation.”

Patients and the thousands of doctors participating in Lending Club Patient Solutions enjoy innovative payment options, high approvals, competitive rates, and exceptional customer service. The application process can be completed online within minutes, and applicants usually receive a response within seconds. As with other products offered through Lending Club, there’s no prepayment penalty, and there are no hidden fees. Says patient Larry Levandowski, “I needed a lot of dental work, well past any coverage I had. With the help of my dentist and Lending Club Patient Solutions, I had a financial solution within an hour that allowed me to get my teeth back to health.” Treatment providers also see benefits. “The difference in customer service alone is like night and day,” says Christina C., a treatment coordinator in Georgia. “They have lower practice fees and better approval rates, and the online application process is very 12 Implant practice

Launch of Small Business Loans: March 2014 Launch of Education and Patient Financing: April 2014 through the acquisition of Springstone Financial

Lending Club CEO Renaud Laplanche Volume 8 Number 1

Welcome to the more possibilities Club.

Introducing a new concept in patient ﬁnancing: More. More of what? More payment plan options, more flexibility, and more patient approvals. Which, at the end of the day, means you can treat more patients. Springstone Patient Financing,SM known for offering patient-friendly products and practices, has joined Lending Club, the world’s largest lending marketplace. As Lending Club Patient Solutions, we’ll provide True No-Interest Plans which avoid unwelcome surprises and offer higher approval rates, increased financing amounts – and much more. To learn how the new Lending Club Patient Solutions can help you do more for your patients, call 844-9DO-MORE (844-936-6673) or visit us at booth 3647 at the Chicago Midwinter Meeting.

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CASE STUDY

Enhancing implant stability with osseodensification — a case report with 2-year follow-up Dr. Salah Huwais discusses how osseodensification facilitates ridge expansion with enhanced implant stability Introduction The medical profession has, with certain exceptions, adapted commercially available instruments that have been developed for drilling other materials (Jackson, et al., 1989). For more than a decade, clinicians have been asking for improvement in bone drilling and preparation (Natali, et al., 1996). Standard drill designs used in dental implantology are made to excavate bone to create room for implant placement. They cut away bone effectively but typically do not produce a precise circumferential osteotomy. Osteotomies may become elongated and elliptical due to the chatter of the drills. In these circumstances, the implant insertion torque is reduced leading to poor primary stability and potential lack of integration. Furthermore, osteotomies drilled into narrow bone locations may produce dehiscence, buccally or lingually, which also reduces primary stability and will require an additional bone grafting procedure adding cost and healing time to treatment. When standard drills extract enough bone to let strains in the remaining bone to reach or exceed the bone micro-damage (MDX) threshold, the bone-remodeling unit (BMU) needs more than 3 months to repair the damaged area, so maintaining bone bulk will enhance healing and shorten the healing period (Frost, et al., 1998). Unlike traditional bone drilling technologies, osseodensification does not excavate bone tissue. Rather, it preserves bone bulk, so bone tissue is simultaneously compacted

Salah Huwais, DDS, maintains a private practice focusing on periodontics and surgical implantology in Jackson, Michigan. Dr. Huwais completed his periodontics and implantology surgical training at the University of Illinois at Chicago in 1997. He serves as an Adjunct Clinical Assistant Professor at the University of Minnesota, Dental Implant Program. Dr. Huwais has published in the Journal of Periodontology and lectures nationally and internationally on periodontal and surgical implantology procedures. He is a Diplomate of the American Board of Periodontology and the American Board of Oral Implantology. Dr. Huwais is the founder of Osseodensification and the inventor of the Densah™ Bur technology.

14 Implant practice

and autografted in an outwardly expanding direction to form the osteotomy. It is accomplished by using proprietary densifying burs. When the densifying bur is rotated at high speed in a reversed, non-cutting direction with steady external irrigation (Densifying Mode), a dense compacted layer of bone tissue is formed along the walls and base of the osteotomy (Meyer, Huwais, et al., 2014). The goal in implant placement is to achieve primary implant stability. It is well established that implant stability is critical for osseointegration (Albrektsson, et al., 1986, Meredith, et al., 1998). This is more important in recent days due to popular immediate/ early loading protocols being implemented into treatment by many clinicians. Removing bone bulk is contrary to achieving the primary stability desired. Implant primary mechanical stability is

directly related to surrounding bone quality and quantity. Maintaining and preserving bone during osteotomy preparation leads to increased primary mechanical stability, increased bone to implant contact (BIC), which then enhances implant secondary stability, and accelerates healing (Seeman, et al., 2008, Todisco, et al., 2005, Trisi, et al., 2009).

Case report Osseodensification facilitates mandibular ridge expansion and placement of two implants. The patient is a 62-year-old male presented with missing teeth Nos. 19, 20, and 21. Clinical and radiographic examination revealed a significant alveolar ridge resorption, which resulted in a Seibert Class I, ridge deficiency (Figure 1). The patient’s medical history was noncontributory.

Figure 1: Occlusal view of lower left edentulous area of missing teeth Nos. 19, 20, and 21 Volume 8 Number 1

STOP

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

*Patent Pending

Consistent osteotomies and densification are important to implant primary stability and to early loading.

Rotating Counter Clockwise The Flute Back Rake Angle Creates Osseodensification

Rotating Clockwise The Flute Edges Precisely Cut Bone Osteotomy created with standard drills

Osteotomy created with Densah Bur Cutting Mode

Osteotomy created with Densah Bur Densifying Mode

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

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CASE STUDY Treatment options with their potential risks and benefits were presented to the patient. A final treatment plan was finalized to utilize placement of two implants to receive two abutments for a fixed prosthesis to restore teeth Nos. 19, 20, and 21. Consent was given by the patient to utilize osseodensification site preparation for ridge expansion with immediate implant placement and possible additional buccal bone grafting if needed.

The lower left area was anesthetized using infiltration method with 1.8 ml 4% Septocaine® (Septodont) with 1:100,000 epinephrine. Once anesthetized, a crestal incision was done, and a full thickness flap was reflected to reveal 2.5 mm-3.0 mm crestal alveolar ridge width, which was confirmed by direct measurement (Figure 2). The site preparation for two implants in the areas of Nos. 19 and 21 began with site marking. Then, a 1.5-mm initial pilot

Figure 2: Full thickness flap reflected to reveal a significant alveolar ridge resorption

osteotomy was created with a pilot drill rotated at 1200 RPM in a clockwise rotation (CW) to a depth of 13 mm utilizing a highspeed surgical handpiece and a surgical motor (W&H) (Figure 3). Using paralleling pins, an X-ray was taken to confirm the angulation between the adjacent teeth and the implants. Once implant positions were confirmed, a horizontal ridge split to a 10-mm depth was created using Piezosurgery® (Piezosurgery Incorporated) to allow further buccal plate flexibility. Osseodensification with ridge expansion started with Densah™ Bur VT1525 (Versah™, LLC) rotating in a non-cutting counterclockwise (CCW) direction at 1200 RPM (Densifying Mode) to expand the osteotomy to 2.5 mm, utilizing a high-speed surgical handpiece and a surgical motor (W&H) (Figure 4). Then Densah™ Bur VT2535 (Versah, LLC) running in a non-cutting counterclockwise (CCW) direction at 1200 RPM (Densifying Mode), utilizing a high-speed surgical handpiece and a surgical motor (W&H), was used to expand osteotomies in the area of implant Nos. 19 and 21 (Figure 5). Mandibular osteotomies were expanded to 3.5 mm without any bone dehiscence, which then allowed for total implant length placement in autogenous bone without any thread exposure (Figure 6).

Figure 3: 1.5 mm/13 mm osteotomy was created utilizing 1.5-mm standard pilot drill

Figure 4: Osteotomy expansion to 2.5 mm was created utilizing Densah™ Bur VT1525 after horizontal relief split was created

Figure 5: Densah™ Bur VT2535 was used in Densifying Mode to expand and densify area of No. 19 implant

Figure 6: Osseodensification facilitated osteotomies expansion to 3.5 mm without any bone dehiscence or fenestrations

16 Implant practice

Volume 8 Number 1

1 2

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Diagnosis

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CASE STUDY Two 3.7/13 Tapered Screw-Vent implants (Zimmer®) were placed with an insertion torque of 40-50 Ncm. Both implants total lengths were covered with autogenous bone. Less than 1.0 mm crestal-buccal bone thickness in area of implant No. 21 was noted (Figure 7). Implant stability was measured with an (Osstell®) ISQ implant stability meter, which uses resonance frequency analysis. In this particular case, buccal-lingual ISQ readings in the areas of Nos. 19 and 20 were 78 and 49, respectively. Several studies have been conducted on resonance frequency analysis (RFA) measurements and the ISQ. They provided valid indication that accepted stability range is above ISQ 50 and

recommended loading at ISQ 67-68. Due to an ISQ reading of 49 in the mesial implant No. 21 and less than 1.0 mm of crestal-buccal bone thickness remaining after osseodensification, the decision was made to augment the buccal plate with a bone graft (Figure 8). Healing cover screws were placed and Puros Demineralized Bone Matrix (Zimmer®) was used as allograft to augment the mandibular buccal bone plate post implant placement. Full flap closure with mattress suture was achieved (Figures 9 and 10). Eight weeks post placement, implants were uncovered through shallow crestal incision. Healing abutments were placed.

Buccal-lingual ISQ readings obtained at week 10 were 76/72, 67 for implant Nos. 19 and 20, respectively. The implants’ high insertion torque with maintained gain in ISQ had allowed us to consider an early restorative phase initiation. Thus, at 10 weeks, when the ISQ reading reached ≥ 67, the patient was referred back to his restorative dentist for the restorative phase. Fourteen weeks post implant surgery, a fixed prosthesis retained by implants Nos. 19 and 21 was delivered. Supportive and follow-up care The patient returned in 1 year for clinical and radiographic follow-up. Examination

Figure 8: Allograft was used to augment buccal plate

Figures 7A-7C: Implants placed in area of Nos. 19 and 20 with insertion torque of 40-50 Ncm and ISQ reading of 49 and 78

Figure 10: Occlusal view — full flap coverage 18 Implant practice

Figure 9: Occlusal view — implants placed with cover screw and allograft

Figure 11: 8 weeks radiograph Volume 8 Number 1

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CASE STUDY

Figure 12B: 14 weeks occlusal view, post healing pre-restoration delivery

Figure 12A: 10 weeks ISQ values

Figure 14: 14 weeks post implant placement radiograph

Figure 15B: 1-year radiographic follow-up revealed maintained crestal bone level 20 Implant practice

Figure 13: 14 weeks post implant placement restoration

Figure 15A: 1-year follow-up clinical presentation, 1.0 mm soft tissue recession was noticed in area of implant No. 21

Figure 15C: 2-year radiographic follow-up revealed maintained crestal bone level Volume 8 Number 1

either block grafting or guided bone regeneration 2. Implant placement and healing phase (2-3 months) 3. Restorative phase The question remains, why do we build bone bulk to then extract it later and wait months for implants to heal? It is time to think about bone preservation to enhance its ability to heal faster, regardless of implant macro- or micro-geometry.

REFERENCES 1.

Jackson CJ, Ghosh SK. On the evolution of drill-bit shapes. Journal of Mechanical Working Technology. 1989;18(2):231-267.

Natali C, Ingle P, Dowell J. Orthopaedic bone drills-can they be improved? Temperature changes near the drilling face. J Bone Joint Surg Br. 1996;78(3):357-362.

Frost HM. A brief review for orthopedic surgeons: fatigue damage (microdamage) in bone (its determinants and clinical implications). J Orthop Sci, 1998;3(5):272-281.

EG, Huwais S. Osseodensification Is A Novel Implant Preparation Technique That Increases Implant Primary Stability By Compaction and Auto-Grafting Bone. American Academy of Periodontology. [abstract]. San Francisco, CA. 2014.

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.

Meredith N. Assessment of implant stability as a prognostic determinant. Int J Prosthodont. 1998;11(5):491-501.

Todisco, M, Trisi P. Bone mineral density and bone histomorphometry are statistically related. Int J Oral Maxillofac Implants. 2005. 20(6):898-904.

Seeman E. Bone quality: the material and structural basis of bone strength. J Bone Miner Metab. 2008;26(1):1-8.

Trisi P, Perfetti G, Baldoni E, Berardi D, Colagiovanni M, Scogna G. Implant micromotion is related to peak insertion torque and bone density. Clin Oral Implants Res. 2009;20(5):467-471.

Conclusion Osseodensification is a novel, biomechanical, non-excavation osteotomy preparation method. Unlike traditional drilling, osseodensification utilizes proprietary high-speed densifying burs to compact and autograft bone in its plastic deformation phase. The result is an expanded osteotomy with preserved and condensed bone tissue that maintains alveolar ridge integrity and allows for implant placement with enhanced stability. IP

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Volume 8 Number 1

Implant practice 21

CASE STUDY

revealed healthy hard and soft tissue with no sign of inflammation or infection. Radiographic examination revealed maintained crestal bone level and bone density. Clinical examination revealed slight soft tissue recession in the area of implant No. 21. This soft tissue height reduction is common post GBR or ridge augmentation procedures. Four months’ interval supportive periodontal treatment was initiated with yearly radiographic examination for implant Nos. 19 and 21. In this case, osseodensification utilizing the Densah™ Bur technology had facilitated ridge expansion with maintained alveolar ridge integrity, allowing for total implant length placement in autogenous bone with adequate primary stability. Despite compromised bone anatomy, osseodensification preserved bone bulk and promoted a shorter waiting period to the restoration. Ordinarilly, a case similar to this patient would progress through three phases of treatment over 30-50 weeks: 1. Ridge augmentation phase (6-9 months) to increase ridge width with

IMPLANT INSIGHTS

hen reading this article, it’s important to remember that the scenario we are putting forward involves patients with low bone volume (vertical and/or horizontal) and that we are faced with choosing between two options: either to carry out a bone graft in order to place long- and/or wide-diameter implants or to place short/narrow implants without having to carry out a bone graft.

What is the difference between short/narrow implants and longer/ wider ones with regards to competence and performance? To reply to this question, we have to define the difference between competence and performance. Competence is the sum of knowledge and experience that a practitioner has acquired during the course of his/her career to date. Performance is the people’s capacity to use their competence in a given situation. For example, very competent surgeons’ performance will be negatively affected if they are stressed, tired, or are battling with personal issues that are dominating their thoughts. The more complicated or complex the surgical procedure, the bigger the impact reduced performance will have upon the end result. To come back to our short/narrow implants, we can say that in order to place these implants, the practitioner must be competent, because these implants are often rather awkward to place due to low bone volumes. Still, for many practitioners, the use of these implants is a viable option. However, we have to say that bone grafting requires a greater degree of training and more extensive surgical experience. Likewise, if a practitioner’s performance is not

Dr. Franck Renouard graduated from the Dental University of Paris V in 1982. He has published several national and international articles and is the co-author of two textbooks — Risk Factors in Implant Dentistry: Simplified Clinical Analysis for Predictable Treatment and his new book on the Human Factors Concept, titled The Search of the Weakest Link. He is past president of the European Association for Osseointegration (EAO), is currently the visiting professor at the Liége Medicine Faculty in Belgium, and is in private practice in Paris limited to Oral and Implant Surgery.

22 Implant practice

Our profession’s goal is to offer reliable, simple treatments to the widest possible range of people. Professor Per-Ingvar Brånemark once said that a good treatment had to be “Simple, available, affordable.” That says it all, really. up to his/her usual standard, this will have less of an impact on short/narrow implants than on longer or wider implants placed with the help of bone augmentation procedures. To sum up, error, which is an integral part of all human endeavor, will have less significant consequences if short/narrow implants are involved.

What are the advantages of short/ narrow implants? Their main advantage is that they enable more practitioners to successfully take on cases they would previously not have had the skills to deal with. When there’s 7 mm of bone underneath a sinus, using short implants is an excellent alternative to the bone graft that would be required in order to place long implants. It’s the same with narrow implants and narrow alveolar ridges. Using these implants allows practitioners who have only limited surgical experience to work successfully with patients with narrow jawbones. An additional bonus with using narrow implants is that they make it easier to have adequate space between implants even when mesiodistal space is restricted. I often place two narrow implants when replacing premolars.

Are there limitations to the use of short/narrow implants? The first limitation is obviously bone volume. I think that you need at least 6 mm for the maxilla and 8 mm for the mandible (above the inferior dental nerve for short

implants). Narrow implants generally require at least 4 mm to 5 mm of alveolar ridge width. Another limitation for narrow implants is biomechanical in nature. Although all relevant literature is very encouraging with regard to this approach, given the extent of our knowledge about it at this moment in time, it is not a good idea to use this type of implant to replace single molars or canines in patients exhibiting canine-protected occlusion. Perhaps we should also be wary of adopting this approach when faced with patients who grind their teeth. There are also esthetic considerations. When bone resorption starts having an esthetic impact, a bone graft is needed. In this scenario, it would be better to use standard length implants.

What is the rationale behind the use of short/narrow versus longer implants? What are the key considerations guiding any such decision? Once again, when we talk about the use of long-/wide-diameter implants, this means having to carry out a bone graft before or during the placing of implants. Choosing from these two options involves taking three criteria into account: 1. To what extent is the outcome of the treatment predictable? 2. What is the incidence of complications and adverse events of the treatment? (What are the consequences of the complications that I may Volume 8 Number 1

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IMPLANT INSIGHTS encounter on implementing a given procedure?) 3. How feasible is the procedure? (Am I capable of carrying out this procedure and managing any complications that may arise from it?) We can summarize these three criteria in Table 1.

What human factors interfere with this decision-making process? Often practitioners are influenced by analytical biases and biases affecting how they make decisions. It is quite remarkable that in 2014, dentists persist in thinking that the longer the implant, the better its chances of long-term success, despite the widespread availability of scientific data to the contrary. This is known as confirmation bias. Once we have made our minds up about something, we find it very difficult to change them. We exhibit the same tendency when we only consider information that confirms

Table 1 Short/narrow implants

Bone graft + long/wide-diameter implants

Predictability

Good

Incidence of complications/ adverse events

Low

Significant

Feasibility

Good

Poor*

* Poor feasibility means that a practitioner needs extensive experience in order to regularly carry out successful bone grafts and to be able to deal effectively with complications arising from these grafts

our way of thinking and we reject information that challenges it, even when this data is substantial and reliable. This is a very human reaction, but it prevents us from making progress.

Is the risk of complications higher with short/narrow implants? If we take a broad perspective on the

“Science, Collaboration and Clinical Excellence for 30 Years,” is the theme of the 30th Annual Meeting of the Academy of Osseointegration The 30th Annual Meeting of the Academy of Osseointegration (AO), will be held March 12-14, 2015, at the Moscone West Convention Center in San Francisco. The intense, 3-day learning session for dental professionals will offer cutting-edge insights and continuing education from the field’s most noted researchers and clinicians. Among this year’s top new features are “Morning with the Masters,” a daybreak education session, a symposium presented in English by seven prominent speakers from South Korea, and a record number of electronic posters where, for the first time, AO-member research will be presented on large flat-screen TV monitors instead of cardboard and paper. “We continue to explore and add innovative features to ensure this event is fresh, engaging, and educational,” said Joseph Gian-Grasso, DMD, president of the Academy of Osseointegration. “We’re confident that all of our attendees — no matter where they are in their career — will enjoy a truly memorable experience and take home knowledge that they can begin applying at their practices Monday morning.” The event’s keynote speaker will be notable facial plastic surgeon, Daniel Alam, MD, who was a member of the multidisciplinary team of doctors and surgeons at the Cleveland Clinic that performed the first near-total face transplant in the United States. His address will focus on the power of the team in rebuilding health and well-being, and will highlight the critical importance of different disciplines collaborating to support a patient’s medical, surgical, and emotional needs to make them whole again. That message will be supported throughout the meeting. There will also be numerous opportunities to network and socialize, including at the President’s Reception, which will be held at The Exploratorium. To view the meeting schedule and register, visit http://www.osseo.org/futureMeetings.html.

situation, we can say that placing short and/or narrow implants represents less of a risk than carrying out a bone graft and placing long and/or wide-diameter implants. Assessing the differences between the two approaches requires more than simply an examination of their respective success rates. It is also important to consider the consequences of failure, which are often more serious when bone grafts are involved. This relates to the incidence of complications and adverse events. This criterion was mentioned earlier. The major risk we run when using narrow implants is implant fracture, but seemingly this is a very rare occurrence.

What do you think the future holds for short/narrow implants? I am convinced that more and more practitioners will start regularly using short or narrow implants. This is part and parcel of a wider movement toward simpler protocols. Our profession’s goal is to offer reliable, simple treatments to the widest possible range of people. Professor PerIngvar Brånemark once said that a good treatment had to be “Simple, available, affordable.” That says it all, really.

What type of patients are these implants particularly helpful for? These implants are particularly helpful for patients exhibiting low levels of bone volume who are not suitable candidates for a bone graft, either for medical reasons, for financial reasons, or because they are afraid of what they see as major surgery. IP

REFERENCES 1. Nisand D, Renouard F. Short implant in limited bone volume. Periodontol 2000. 2014; 66(1):72-96. 2. Renouard F, Charrier JG. Ewenn éd. The search for the weakest link. An introduction to the Human Factors. 2011. 3. Sohrabi K, Mushantat A, Esfandiari S, Feine J. How successful are small-diameter implants? A literature review. Clin Oral Implants Res. 2012;23(5):515-525.

24 Implant practice

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IMPLANT INSIGHTS

Anterior implant esthetics Dr. Bernard Touati offers his insights into effective techniques and procedures for soft tissue management in the anterior region

n the following article, I will do my best to explain the main factors influencing hard and soft tissue remodeling around implants and make suggestions on how to achieve optimal integration in the esthetic zone. Among other aspects of treatment, I will cover diagnostics, treatment planning and risk assessment, ideal 3D bone-level implant placement, the relevance of good hard tissue volume and architecture, as well as the importance of thick and stable soft tissue in the transmucosal zone. When we deal with dental implants in the anterior region, we are looking for more than osseointegration. We — dentists and patients alike — are looking for optimal soft tissue integration. We are looking for the perfect pink score. In the anterior region, esthetic perfection is not a choice, but an obligation. Patients want their peri-implant soft tissues to mimic the soft tissue around natural teeth. There are, of course, many differences between teeth and implants. When we produce restorations based on natural teeth, the gingiva is only dealing with the margin of the crown. We locate our margin at the gingival or intrasulcular level, but not transmucosally. When we deal with implants, on the other hand, we need to take into consideration the mucosal barrier, and the mucosal barrier is quite different on implants than on teeth for a variety of reasons. The problem is that when we want to do something transmucosally — for the abutment or at the neck of the implant — we need the soft tissue to adhere to the prosthetic surface of the implant. This is different than working with natural teeth because it involves many biological factors. To achieve harmonious soft tissue integration, we obviously have to take into account all the biological, functional, and esthetic factors.

Dr. Bernard Touati is past president of the European Academy of Esthetic Dentistry, and a member of the American Academies of Restorative Dentistry and Esthetic Dentistry. He practices in Paris, France, and lectures around the world on practical and innovative dental procedures.

26 Implant practice

And not just in two dimensions! We also have to remember that our work will not be evaluated by the two-dimensional photographic images we use to document the treatment, but in the homes, on the streets, and at the workplaces where our patients go about their day-to-day lives. Thus, we need to achieve three-dimensional integration. We need to have the scalloping, the volume, the papillae, the texture, the color, and the absence of scars that are characteristic of healthy, natural teeth.

Five major factors The main factors that influence tissue remodeling around implants can be organized into five categories: anatomical, surgical, implant, patient, and prosthetic (see Table 1). Among the anatomical considerations are the tissue biotype, the thickness of the bone plates, the thickness of the soft tissue, and the lack of attached gingiva. I can testify from experience that the tissue biotype and the thickness of the tissue are critical to optimal outcomes. Surgical factors include the three-dimensional positioning of the implant, the choice between a flap or flapless approach, and the kind of soft tissue augmentation that has been carried out. Other factors include bone desiccation, countersinking, bone compression, and (last but not least), the extraction technique used. Implant design is also important, of course. The design of the neck, the surface properties of the implant, and the type of connection can all be decisive. Questions that become interesting in this context include “Do we have platform shifting available?” Or, “Can the implant be maneuvered during insertion, when necessary, in order to ensure optimal placement?” We also need to remember that every patient has a specific set of characteristics that influences remodeling. Do they smoke? Do they have good healing potential? Immune factors need to be considered, as well as the patient’s willingness and ability to maintain good oral hygiene. There are also a great number of prosthetic factors that impact remodeling. The final abutment design, the biomaterial from

Table 1: Major factors affecting hard and soft tissue remodeling around implants Anatomically related • Tissue biotype • Thickness of bone plates • Thickness of soft tissue • Lack of attached gingiva Surgically related • Implant 3D position • Flap elevation or flapless surgery • Soft tissue augmentation • Bone desiccation • Countersinking • Bone compression • Extraction technique Implant-related • Design (macro, micro) • Surface properties • Type of connection • Built-in platform shifting or equivalent Patient-related • Hygiene • Maintenance • Tobacco • Healing Prosthetics-related • Final abutment design • Type of abutment connections • Provisional abutment: biomaterial, design • Immediate provisionalization • Submergence profile • Emergence profile • Restoration anatomy • Possible excess cement and retention • Occlusion, excessive load

which they are made, the abutment’s surface properties, connection, and fit are all important factors that contribute to success. Abutment connections — and disconnections — need to be taken into consideration as well as choices concerning immediate provisionalization and the submergence profile, emergence profile, and the restoration anatomy. We need to be careful about deleterious excess cement (if we have not chosen screw retention, of course) and must take into account good occlusion to prevent excessive load. Volume 8 Number 1

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IMPLANT INSIGHTS Given all these factors — and I have only listed the main ones in the table — I have constructed a roadmap for optimal integration in the esthetic zone.

Diagnose, plan, and assess To plan for a successful anterior solution, we need to assess risk factors via threedimensional visual inspection, probing, and employing radiographs. Visually, we can see deformities such as concavities. Probing, we can see where the bone is, and we can also probe at the level of the adjacent teeth to assess the periodontium. Cone beam computed tomography (CBCT) is an invaluable three-dimensional tool. When connected to software like NobelClinician® (Nobel Biocare®), it provides us with an enormous amount of information that is useful in the decisionmaking process. It shows us, for example, whether we have a thin buccal plate or a thick one. And this makes a very big difference. The volume and architecture of the site also become clear when using this sort of software. The thickness of the soft tissue can also be assessed via CBCT. When the patient wears radiographically transparent lip retractors during the imaging process, the resulting CBCT image renders the soft tissue in light gray. Should we then want to harvest some soft tissue from the palate, for example, this technique allows us to objectively measure the tissue available. It also lets us assess whether the patient has a thick or thin biotype. A delicate biotype will ordinarily require connective tissue grafting, but a thick one generally indicates stable tissue that is forgiving of minor mistakes. When facing thin and moderate soft tissue situations, we need to be more invasive and start considering soft tissue enhancement, grafting procedures, and so on.

Ideal implant placement The first thing to consider is where the implant is going to be placed. Positioning is critical because even a little deviation can impact the esthetic outcome. The real problem is the transversal plane. We want to insert our implant more toward the palatal, because if we leave too much inclination, we run the risk of reducing the thickness of the buccal plate, which in almost all cases is already very thin. The more an implant allows you to play with its position — in order to put it in solid bone — the better suited it is to situations like these. With a little extra room between the buccal plate and the implant, you will have space to fill in later with bone augmentation material. 28 Implant practice

Ensuring hard tissue volume and architecture At this point, we are dealing with where the bone is, and how to make the most of it. Again, we really do need to keep in mind how thin the buccal plate ordinarily is. Natural teeth have Sharpey’s fibers, a blood supply to the periodontium, stimulation, and even though there may not be much (if any) cortical bone on the buccal, the soft tissue still stays in place. With an implant, on the other hand, we run the risk of fenestration through this thin bone if we position implants with the same orientation as natural incisor roots. The buccal socket wall is predominantly composed of bundle bone (while the lingual one has more lamellar bone). The lack of stimulation and function in the absence of Sharpey’s fibers may explain the remodeling of this buccal wall. The buccal plate often quickly collapses when we extract a tooth — partly because it is thin, and partly because it is mostly composed of bundle bone. Because an implant does not have a periodontium and therefore lacks vascularization, we have a ready explanation as to why we have more remodeling on the buccal side as opposed to the lingual side. In 60% of anterior cases, buccal bone plates are less than 0.5 mm thick (and we really need 2 mm to get the job done). If we remember these values, we will understand the entire strategy of slightly angulating the implant in the anterior aspect. When building a multiple unit anterior restoration on natural teeth, we still have soft tissue, and the soft tissue is quite stable. But once anterior teeth are extracted, we will almost certainly have to reorient “the root,” inserting the implant palatally. The good news is that with CBCT — especially when used in conjunction with planning software — the right position can be objectively assessed first, making sure that a gap exists between the implant and the buccal plate. This way we can take steps to thicken the buccal bone plate zone and, thus, provide a safe situation for the future. The key factors for good esthetic results at anterior extraction sites are the integrity of the buccal plate and the thickness of the soft tissue. If those two parameters are promising, implant treatment is more likely to succeed. Of course, in terms of the three-dimensional architecture of the soft tissue and recapturing interdental papillae, the health of the periodontium of the adjoining teeth is important, and probing gives us solid information.

Bone grafting We can use bone augmentation materials in the “jumping gap” (i.e., the

osteogenic “jumping distance,” which is the gap between the implant body and the alveolar wall). In cases with a large defect, guided bone regeneration can be carried out. Adding connective tissue on top of this brings greater thickness to the tissue, which provides greater mechanical resistance and leads to increased blood supply. In cases where there is no buccal bone post-extraction, a complete socket must first be re-created, which provides a favorable situation for the insertion of an implant and is well within widely-practiced, well-accepted reconstructive protocols.

Establishing thick and stable soft tissue All of this brings us to the soft tissue. It needs to be thick and stable, especially in the transmucosal zone; stability makes for good esthetics. Post-extraction remodeling is inevitable. Today, there is no magical way to totally counteract the post-extraction remodeling — it’s biological — but it can be compensated for. One way to compensate for it is to thicken the soft tissue and also to regenerate the bone, when necessary. A connective tissue pouch can be used, both horizontally and vertically. Mucosal enhancement can be realized through connective tissue graft(s). Not least of all, we can manipulate the soft tissue via subtle changes in the design of the prosthetics. First, we want to see some concavity transmucosally at the abutment level and/ or platform switching in order to thicken the mucosa, creating a virtual “o-ring” of soft tissue. On the other hand, proximally, the prosthetic restorations need to display some convexity in order to gently push the tissue and to keep the interdental papillae. The vertical position of the implant in relation to the mucosa is very important. This makes it possible for us to play with the emergence profile and then shape the marginal mucosa with the emergence bulk. Adding composite material incrementally, we can guide the marginal mucosa very successfully. This careful step-by-step process takes a substantial amount of time, but gives beautiful results. IP This article is a condensed version of a lecture given by Dr. Touati at the Nobel Biocare Global Symposium in New York City last June. It originally appeared in Nobel Biocare News (Vol. 16, No. 1, 2014) and appears with permission. Dr. Touati’s full lecture can be found by visiting the website www. for.org/video-insights and searching for “Bernard Touati.” Volume 8 Number 1

CONTINUING EDUCATION

Single implant-borne reconstruction in the esthetic area Dr. Daniel S. Thoma outlines the treatment undertaken for a patient with fractured central incisors using ridge preservation

52-year woman presented with pain in her two central incisors. The patient had fractured both central incisors in her youth. They were subsequently restored with two porcelain-fused-to-metal crowns (Figure 1). At the day of the first examination, CBCT analysis and clinical inspection revealed that tooth UR1 was endodontically treated and had increased periodontal pocket depths with bleeding on probing. Several treatment options were discussed following the tooth’s extraction: 1. Crown UL1 with a cantilevered UR1 2. Fixed dental prostheses UR2 to UL1 3. Implant placement at UR1 and new crown UL1 A decision was taken to opt for the third treatment modality, which included the replacement of tooth UR1 with a dental implant.

Educational aims and objectives

This article aims to demonstrate the benefits that using ridge preservation techniques can bring to challenging cases in the esthetic zone.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 34 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • See where regeneration techniques can be applied. • Understand how these techniques can impact treatment time. • Learn when to apply these techniques in practice.

According to Jung and colleagues (2013), a ridge preservation procedure allows bone volume to be maintained by 80% over 6 months. For that reason, a ridge preservation procedure was defined as being appropriate for optimizing the clinical situation, including the hard and soft tissue aspects.

The treatment (Figure 2) consisted of placement of a collagen sponge consisting of 10% collagen and deproteinized bovine bone mineral (DBBM) granules, and a soft tissue punch. The bone substitute material was placed within the extraction socket flush with the bone crest on the buccal side, and

Pre-surgical phase A full wax-up for teeth UR1 and UL1 was performed on casts by the dental technician to optimize the esthetic outcome prior to implant therapy. This wax-up was transferred to a mock-up that was tried-in intraorally.

Surgical phase Two weeks later, tooth UR1 was carefully extracted without damaging the surrounding tissues and leaving the papillae intact. The epithelium at the extraction socket was removed using a diamond bur. Subsequently, the height of the buccal and palatal bone plate was measured with a periodontal probe. This revealed that, while on the buccal side the bone plate was almost fully present, the palatal height was reduced by 40%.

Figures 1A-1B: Patient at presentation

Daniel S. Thoma, PD Dr Med Dent, is an associate professor at the Clinic for Fixed and Removable Prosthodontics and Dental Material Science, Center for Dental and Oral Medicine and CranioMaxillofacial Surgery in the University of Zurich. He is a specialist in reconstructive dentistry and received the Hans-R Mühlemann Research Prize from the Swiss Society of Periodontology (SSP) in Switzerland. Pascal Müller was the dental technician in this case.

Figures 2A-2C: Extraction site 30 Implant practice

Volume 8 Number 1

Due to the fact that guided bone regeneration (GBR) on the palatal side cannot be performed predictably, a longer healing time was discussed with the patient. Four months later, a second CBCT was taken (Figure 6), and again, the implant position was defined using digital planning software (SMOP Swissmeda AG, Switzerland). A

digital scan of the initial clinical situation was matched and superimposed with the CBCT data in the planning software. At this point, the height of the palatal and buccal bone plates returned to a regular height. Bone regeneration had taken place, and the former extraction socket was completely filled with bone substitute material and newly formed

Figures 2D-2E: Ridge preservation carried out at extraction site

Figure 3A-3D: Gingival graft taken from the palate and sutured over the extraction socket

Figures 4A-4B: Provisional restorations placed

Figure 5: CBCT at 6 weeks showing a dehiscence or at least immature bone substitute material at the palatal aspect with an ideal position Volume 8 Number 1

Implant practice 31

CONTINUING EDUCATION

exceeding the palatal bone plate by roughly 4 mm and to a level of 3 mm below the mucosal margin. Subsequently, a free gingival graft (FGG) with a thickness of 3 mm and a diameter of 8 mm was harvested at the palate. This FGG was sutured on top of the extraction socket using non-resorbable sutures (Figure 3) in keeping with the method described by Jung, Siegenthaler, and H채mmerle (2004). The crown on tooth UL1 was removed and replaced with a provisional restoration including a cantilever to replace tooth UR1 (Figure 4). Six weeks later, the clinical situation was healthy, and the former extraction socket was completely closed. A CBCT was taken to assess the bone dimension and to decide whether or not implant placement could be performed. The CBCT revealed that, with an ideal implant position, a dehiscence defect at the palatal aspect would be present.

CONTINUING EDUCATION

Figures 6A-6D: Second CBCT taken at 6 months

bone. This allowed implant surgery planning and the production of a surgical stent for guided surgery. On the day of implant placement, a full thickness flap was elevated, and a dental implant (Bone Level, Straumann速) was placed using guided surgery, and a surgical guide printed using a three-dimensional printer. The implant was placed in an ideal position, vertically and horizontally (Figure 7). In order to compensate for an expected loss of volume on the buccal side, GBR with DBBM and a resorbable collagen membrane was performed to optimize the contour (Figure 8). Primary wound closure was obtained. Three months later, the clinical situation revealed a slight loss of the buccal contour. According to a recent clinical study on 16 patients, GBR may contribute for up to 57% of the volume, whereas soft tissue augmentation compensates the remaining 43% of the volume deficiency (Schneider, et al., 2011). Soft tissue volume augmentation surgery was performed using a classic approach (Figure 9). The patient agreed to be part of an ongoing clinical study comparing autogenous soft tissue grafts to a prototype three-dimensional collagen matrix. For that purpose, a split thickness flap was elevated, a pouch on the buccal aspect of the implant site prepared, and a three-dimensional collagen matrix inserted and sutured in place.

Figures 7A-7D: Implant placed using guided surgery

Figures 8A-8B: Guided bone regeneration was carried out to compensate for an expected loss in volume

Figures 9A-9D: Soft tissue augmentation carried out to address slight loss of buccal contour 32 Implant practice

Volume 8 Number 1

CONTINUING EDUCATION

Again, primary wound closure was obtained. Three months later, abutment connection was performed using a U-shaped incision, and the preparation of a small flap was placed underneath the buccal flap. Following an impression with a standardized impression post, a healing abutment was inserted.

Prosthetic phase After 1 week, a provisional implantborne reconstruction with a full contour on the buccal side and a concave contour within the soft tissues was inserted (Figure 10). Within two to three appointments, flowable composite was added to the transmucosal part of the provisional restoration (at the implant site) to aim for a more convex contour and to create the emergence profile, mimicking one of the neighboring contralateral teeth UL1. After a healing period of 3 months, an individual impression post was prepared, and an impression was taken for implant UR1 and tooth UL1. The dental technician fabricated a try-in wax-up, which was inserted during the following appointment. Subsequently, an all-ceramic reconstruction based on a zirconia abutment (Cares®, Straumann) for implant UR1 and an all-ceramic single crown for tooth UL1 were prepared by the dental technician (Figure 11). The implant-borne reconstruction was screw-retained and inserted with an insertion torque of 35Ncm. The access hole was closed with composite. The all-ceramic crown on tooth UL1 was cemented with a resin cement. One week later, the patient was recalled for the follow-up examination. The clinical situation was healthy; no bleeding on probing was observed. The final outcome was judged as being esthetically pleasing, and the patient scheduled for a regular maintenance program.

Figures 10A-10B: Healing abutments removed and provisional placed

Figures 11A-11D: Final restoration wax-up and framework

Final outcome The final outcome of the case (Figure 12) was considered to be excellent from an esthetic and functional point of view, and the patient was satisfied with the results. The ridge preservation procedure performed at the day of tooth extraction allowed for further optimal implant position and enhanced the clinical situation on the hard and soft tissue level, but prolonged the overall treatment time. GBR and soft tissue volume augmentation contributed almost equally to the volume obtained at the end of the treatment. The reconstructions manufactured by a skilled dental technician were based on allceramic materials, which, in this clinical situation, demonstrated high long-term survival and success rates. IP Volume 8 Number 1

Figure 12: Final restoration

REFERENCES 1.

Jung RE, Philipp A, Annen BM, Signorelli L, Thoma DS, Hämmerle CH, Attin T, Schmidlin P. Radiographic evaluation of different techniques for ridge preservation after tooth extraction: a randomized controlled clinical trial. J Clin Periodontol. 2013;40(1):90-98.

Jung RE, Siegenthaler DW, Hämmerle CH. Postextraction tissue management: a soft tissue punch technique. Int J Periodontics Restorative Dent. 2004;24(6): 545-553.

Schneider, D, Grunder U, Ender A, Hämmerle CH, Jung RE. Volume gain and stability of peri-implant tissue following bone and soft tissue augmentation: 1-year results from a prospective cohort study. Clin Oral Implants Res. 2011;22(1):28-37.

Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part I. Technique and wound healing. Compend Contin Educ Dent. 1983;4(5):437-453.

Implant practice 33

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Single implant-borne reconstruction in the esthetic area

Challenging aspects of implant restoration

The contact forces, including the preload, ________ to the torque experienced by the implant complex. a. are the first response b. are the last response c. is not a necessary response d. may be detrimental

The design of the screw head has an impact on the ability to apply the preload. __________ do not allow enough preload to be applied. a. Slotted screws b. Square screws c. Hexagonal screws d. Triangular screws

The insertion torque should not exceed 30Ncm, especially for immediate load implants, as higher insertion torques above 50Ncm can generate high compressive stresses to the peri-implant tissues, causing ___________. a. blood supply deficiency b. bone necrosis during the osseointegration phase c. early implant failure (usually within the first month after placement) d. all of the above

There is always a _____ between the top of the implant and the undersurface of the abutment due to the tolerance during manufacturing. a. perfect fit b. small mismatch in fit c. very tight fit d. clamping torque

(In screw fracture) The worst case scenario is that _______ once osseointegration has occurred. a. the implant would have to be removed surgically b. the site would be allowed to heal c. a new implant would be placed and restored d. all of the above

Mucositis lesions can show apical progression after _______ of plaque buildup around implants. a. 1 month b. 2 months c. 3 months d. 6 months

THOMA

According to Jung and colleagues (2013), a ridge preservation procedure allows bone volume to be maintained by ______ over 6 months. a. 25% b. 30% c. 55% d. 80% The CBCT revealed that, with an ideal implant position, a ______ at the palatal aspect would be present. a. dehiscence defect b. mucosal margin c. proteinized bone placement d. contour Due to the fact that guided bone regeneration (GBR) on the palatal side cannot be performed predictably, _______ was discussed with the patient. a. an additional surgery b. a longer healing time c. another type of implant d. the use of resorbable sutures According to a recent clinical study on 16 patients, __________ may contribute for up to 57% of the volume, whereas soft tissue augmentation compensates the remaining 43% of the volume deficiency. a. proteinized porcine bone mineral (PPBM) b. the gingival graft c. guided bone regeneration (GBR) d. a collagen implant The patient agreed to be part of an ongoing clinical study comparing autogenous soft tissue grafts to a prototype three-dimensional collagen matrix. For that purpose, _____. a. a split thickness flap was elevated b. a pouch on the buccal aspect of the implant site was prepared c. a three-dimensional collagen matrix was inserted and sutured in place

34 Implant practice

d. all of the above 6.

Three months later, abutment connection was performed using a _______, and the preparation of a small flap was placed underneath the buccal flap. a. U-shaped incision b. Book incision c. Y-shaped incision d. none of the above

BAKER/REANEY

After ________, a provisional implant-borne reconstruction with a full contour on the buccal side and a concave contour within the soft tissues was inserted. a. 1 week b. 2 weeks c. 3 weeks d. 4 weeks Within two to three appointments, flowable composite was added to the transmucosal part of the provisional restoration (at the implant site) _______, mimicking one of the neighboring contralateral teeth UL1. a. to prevent tooth migration b. to aim for a more convex contour c. to create the emergence profile d. both b and c

A(n) ____ insertion torque may occur during implant placement in high-density bone tissue. a. low b. high c. unstable d. transformative

The material of the screw must be stretched to ______ of its elastic limit, which means that the screw will return to its original length as the torque is released and the two components are clamped together. a. 25% b. 40% c. 55% d. 80%

After a healing period of _____, an individual impression post was prepared, and an impression was taken for implant UR1 and tooth UL1. a. 2 weeks b. 1 month c. 2 months d. 3 months

10. The implant-borne reconstruction was screwretained and inserted with an insertion torque of _______. a. 15Ncm b. 20Ncm c. 35Ncm d. 60Ncm

If the screw _____, adequate preload will not be achieved, which means that the screw will not be stretched to its full potential, and repeated screw loosening will occur. a. is tightened with a torque driver b. is not slotted c. is tightened by hand d. is cemented in

10. Any movement (of the implant) would indicate _________. a. possible lack of osseointegration of the fixture b. possible failure of the cement bond between the superstructure and the retainer c. screw failure by fracture or loosening d. all of the above

Volume 8 Number 1

CE CREDITS

IMPLANT PRACTICE CE

Drs. Brenda Baker and David Reaney explain various methods to restore function and esthetics to patients in need of implant restoration

mplant dentistry has revolutionized the way we restore function and esthetics to patients who, historically, would have needed removable prosthetics or less mechanically favorable fixed prosthetics. However, it is not always smooth sailing, and we need to be aware of some of the possible pitfalls and issues.

Try-in and torquing of implants There is confusion between the torque load delivered to the implant complex, the initial force transformation and stress developed within the system during the implant complex assembly, and how the clamping forces at the interfaces and the preload stress impact the implant prior to external loading. The application of any external load to the implant complex must be preceded by the assembly of the abutment onto the implant, achieved by tightening the abutment screw to create a stable screw joint and, thus, form the implant complex. It is the first step in preparing the assembled implant complex to transfer loads. Accuracy, with respect to the applied load, is critical in the determination of load transfer to and through the complex to the bone. The dynamic nature of the implant complex assembly generated by a certain magnitude of torque loading is essential for understanding the response of any implant system to external loading. The contact forces, including the preload, are the first response to the torque experienced by the

Educational aims and objectives

This article aims to explain the various methods to restore function and esthetics to patients in need of implant restoration.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 34 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize the pitfalls and issues to restoring function and esthetics in certain types of patients. • Be able to monitor peri-implant tissues. • Identify the maintenance protocols after restoration has taken place.

implant complex. The insertion torque should not exceed 30Ncm, especially for immediate load implants, as higher insertion torques above 50Ncm can generate high-compressive stresses to the peri-implant tissues, causing blood supply deficiency and bone necrosis during the osseointegration phase, as well as early implant failure (usually within the first month after placement) (Trisi, et al., 2009). A high insertion torque may occur during implant placement in high-density bone tissue. Under high stresses, significant changes impair the formation of new blood vessels, causing hypoxia in the peri-implant tissues, thus inhibiting bone formation and

favoring the formation of cartilage and connective tissue.

Common complications (Goodacre, et al., 2003) Screw loosening There are two main reasons why screw loosening occurs: Incorrect torque Torque drivers should always be used to tighten screws. The correct preload must be applied to the screw. The material of the screw must be stretched to 80% of its elastic limit,

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.

Figure 1: Anterior tooth esthetics are critical. Color data with shade tabs against various teeth will help guide the laboratory Volume 8 Number 1

Implant practice 35

CONTINUING EDUCATION

Challenging aspects of implant restoration

CONTINUING EDUCATION

Figure 2: Minimal space is evident anteriorly for esthetic functional reconstruction

which means that the screw will return to its original length as the torque is released, and the two components are clamped together. If the screw is tightened by hand, adequate preload will not be achieved, which means that the screw will not be stretched to its full potential, and repeated screw loosening will occur. If the screw is over-tightened and exceeds the elastic limit, it will become plastic and not return to its original length. There will also be no tension placed into the system. Thus, loosening of the screw will occur and may cause eventual fracture. The design of the screw head has an impact on the ability to apply the preload. Slotted screws do not allow enough preload to be applied. However, square and hexagonal screws allow the preload to be transmitted through the screw, and either can be used. A screw can loosen where the abutment underlying the crown becomes loose, yet the crown remains cemented. Always replace abutment screws that have loosened repeatedly or are damaged. The crown may not detach from the abutment easily. If the crown will not separate, it may be possible to cut a hole in the crown to expose the screw access hole underneath. The access hole may not be in the center of the abutment and can be difficult to locate. Considerable cutting of the crown can damage the underlying abutment and possibly lead to eventual replacement of the entire assembly. It is also possible to cut through the interproximal contacts and unscrew the whole assembly. Then, the abutment can be relocated onto the implant and the screw torqued down. A new impression can be fabricated to construct a new restoration. Mismatch between the diameter of the implant and the width of the crown that the final prosthesis replaces 36 Implant practice

Figure 3: The irregularity of the occlusal plane is clearly illustrated when the patientâ&#x20AC;&#x2122;s mouth is partially open

There is always a small mismatch in fit between the top of the implant and the undersurface of the abutment due to the tolerance during manufacturing. Forces are applied that cause a small amount of movement between the component parts during function. If applied forces fall outside the diameter of the implant, the movement between the component parts is magnified, and the screw is more likely to become loose. The diameter of the implant should match the diameter of the tooth that is being replaced as closely as possible. When considering multiunit cases, the correct number of implants should be chosen to allow even distribution of the forces. Components should be chosen from the same manufacturer, or the use of customized abutments specifically tailored for each clinical scenario may prove to be even more accurate. Screw fracture Kim and colleagues found that screw fracture occurs as a result of overloading an implant by occlusal forces (2005). The abutment screws become loose and eventually fracture. Incorrect preload may also create ultimate screw fracture. Over-tightening of the screw may eventually cause fracture, and occlusal overload caused by excessive cantilever design should be avoided. The forces applied to the prosthesis should be controlled, and it is important to avoid damaging the internal thread of the implant. The worst case scenario is that the implant would have to be removed surgically, the site be allowed to heal, and then a new implant placed and restored once osseointegration has occurred. The design of the superstructure should be carefully planned as this could cause fracture of the screw. If the screw cannot be removed, it may have to be drilled out in order to salvage the implant.

Then, a cemented post and abutment can be made with an impression of the internal surface of the implant, and a new superstructure fabricated. Fracture of the superstructure This can occur in either porcelain or resin, as found by Molin and Karlsson (2008) and Larsson and colleagues (2006). If the occlusion has not been designed properly, or the interface between the veneering material and the underlying metal framework is placed under stress, then material fracture can occur. The framework must be made rigid enough to support the veneering material. Extensive cantilevering can increase the risk of fractures, as can parafunction. The occlusion should be checked in lateral excursions to ensure that there are no interferences. If a crown needs to be removed, then it is possible to either unscrew the component â&#x20AC;&#x201D; if it is screw-retained â&#x20AC;&#x201D; or ease it off if it is cement-retained after having used a temporary cement. If acrylic resin is too thin, it too will fracture when loaded, and the alignment of the screw access hole, when using a screw-retained restoration, should be in the central fossa of the restoration to allow adequate thickness of porcelain or acrylic. Inflammation and peri-implantitis Cochran reported that during maintenance, gingival inflammation can be detected. It may either be mucositis, which is reversible without evidence of bone loss or peri-implantitis (2002). Most frequently, mucositis is caused by abutment loosening. The loosening of the abutment enables bacterial infiltration. Lindhe and Meyle found that if the mucositis caused by abutment loosening goes undetected, it can result in peri-implantitis Volume 8 Number 1

CONTINUING EDUCATION

(2008). Mucositis lesions can show apical progression after 3 months of plaque buildup around implants. In order to detect abutment loosening, look for abutment separation on the radiograph — seen as a dark line between the components and prosthesis mobility. Abutment loosening can result in uncomfortable pressure on the prosthesis if gingival tissue has overgrown into the opened junction. The excess soft tissue must be removed before the abutment or prosthesis can be tightened back into place. Treatment of peri-implantitis involves inflammation control and modifying the exposed implant surface.

Occlusal evaluation The occlusal status of the implant and its prosthesis must be assessed routinely at every maintenance appointment. Occlusal overload can cause a variety of problems, including loosening of abutment screws, implant and prosthetic failure (Zarb and Schmitt, 1990). Occlusal contact patterns should be assessed, as well as the mobility of the implant and opposing dentition. Successful implants should not be clearly mobile. A failing implant is not mobile until all or most of the bone has been lost. Abnormal occlusal loading will negatively affect the various parts of the implantsupported prosthesis. Hence, premature contacts or interferences should be identified and corrected to prevent occlusal overload. There should be light centric contact with no contacts in lateral excursions (Engleman, 1996). Lundgren and Laurell believe that shim stock should be able to be held only with hard-clenched teeth (1994). Possible bruxism and parafunctional activities must be evaluated as excessive concentrated forces can result in rapid and significant peri-implant bone loss. If a failed implant is connected to a multi-unit prosthesis, it may mask evidence of mobility.

Maintenance protocols (Lang, Wilson, and Corbet, 2000) These should be customized for the individual patient. There is insufficient data on exact recall intervals, methods of plaque and calculus removal, and appropriate antimicrobials for maintenance around implants. Before implant placement, the patient’s ability for home care and motivation must be assessed, and the patient must understand his/her role in caring for the implant. Volume 8 Number 1

Figure 4: These implants show excellent tissue health around the abutments

The patient’s motivation and skill in undertaking oral hygiene measures may influence prosthetic design. Importantly, if the patient is unable to achieve adequate oral hygiene, then this should be a possible contraindication to implant placement. It is essential to monitor peri-implant tissues at regular intervals so that disease can be noted early in treatment if possible. The maintenance appointment should include evaluation of: • Presence of plaque and calculus and oral hygiene • Clinical appearance of peri-implant tissue and deposit removal from implant/prosthesis surface • Occlusal status and stability of prostheses and implants • Probing depths and presence of exudates or bleeding on probing • Patient comfort and function

• Possible need for antimicrobials • Re-evaluation of present maintenance intervals that may be altered depending on the clinical situation • Mobility Any movement would indicate possible lack of osseointegration of the fixture, possible failure of the cement bond between the superstructure and the retainer, or screw failure by fracture or loosening. If an abutment is loose, then the microgap widens, which can result in the formation of a fistula. By using the recommended torque settings, biologic considerations of the peri-implant areas, and adhering to certain biomechanical principles governing abutment and restoration shapes and sizes, we can avoid much heartache through careful planning so that we have content patients with favorable lifelong outcomes.

REFERENCES 1.

Cochran DL. Tampa and convenient diseases. [newsletter]. Academy of Osseointegration News. 2012;23(4):1, 13.

Engelman MJ. Occlusion in: Clinical decision making and treatment planning in osseointegration. Chicago: Quintessence;1996.

Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications with implants and implant prostheses. J Prosthet Dent. 2003;90(2):121-132.

Kim Y, Oh TJ, Misch CE, Wang HL. Occlusal considerations in implant therapy: clinical guidelines with biomechanical rationale. Clin Oral Implants Res. 2005;16(1):26-35.

Lang NP, Wilson TG, Corbet EF. Biological complications with dental implants: their prevention, diagnosis and treatment. Clinical Oral Implants Res. 2000;11(Suppl 1):146-155.

Larsson C, Vult von Steyern P, Sunzel B, Nilner K. All-ceramic two- to five-unit implant-supported reconstructions. A randomized, prospective clinical trial. Swed Dent J. 2006;30(2):45-53.

Lindhe J, Meyle J, Group of European Workshop on Periodontology. Peri-implant diseases: Consensus Report of the Sixth European Workshop on Periodontology. J Clin Periodontol. 2008;35(8 Suppl):282-285.

Lundgren D, Laurell L. Biomechanical aspects of fixed bridgework supported by natural teeth and endosseous implants. Periodontol 2000. 1994;4:23-40.

Molin MK, Karlsson SL (2008) Five-year clinical prospective evaluation of zirconia-based Denzir 3-unit FPDs. Int J Prosthodont. 2008;21(3):223-227.

10. Trisi P, Perfetti G, Baldoni E, Berardi D, Colagiovanni M, Scogna G. Implant micromotion is related to peak insertion torque and bone density. Clinical Oral Implants Res. 2009;20(5):467-471. 11. Zarb GA, Schmitt A. The longitudinal clinical significance of ossseointegrated dental implants: the Toronto study. Part III: Problems and complications encountered. J Prosthet Dent. 1990;64(2):185-194.

Implant practice 37

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Planmeca rolls out Cloud Service product Dental equipment manufacturer Planmeca Oy developed Planmeca Romexis® software as an open architecture platform, making it compatible with most software operating systems and dental equipment. Now, Planmeca has taken this technology to a new level with Planmeca Romexis® Cloud Service, which works with Planmeca Romexis software so dentists can access and share diagnostic images from any imaging unit. Planmeca Romexis Cloud Service lets dental professionals communicate with colleagues and transfer images and key case information securely, quickly, and seamlessly. This brings new possibilities to the dental practice, such as providing access to specialists from remote general practitioners, giving rural dentists the same referral base as any dentist in a large metropolitan area. Other features of the Planmeca Romexis Cloud Service include: • All treatment plan elements are automatically added, including annotations and measurements. • Virtual patient cases include 2D X-ray images and photos, CBCT volumes, and 3D photos. • Images and reports are easily shared with patients. For more information, visit http://www.planmecausa.com.

Sunstar introduces GUIDOR® easy-graft® Alloplastic Bone Grafting System

ZEST Anchors introduces a healing cap for the popular LOCATOR® Overdenture Implant (LODI) System ZEST Anchors has expanded the popular LODI System by offering a healing cap for delayed loading protocols. Patients’ unique and individual needs are at the core of new product development for ZEST Anchors. With the introduction of the healing cap for the LODI System, clinicians can now offer a variety of treatment protocols for delayed or immediate loading in all bone types. The new LODI healing cap, a smooth, non-engaging cap, is available for 2.4 mm and 2.9 mm diameter LODI Implants in 3 mm and 4 mm cuff heights and is ideal during healing. The LODI System offers clinicians a trusted treatment alternative for their edentulous patients’ unique scenarios, which consist of anatomical limitations, the unwillingness or inability to endure an invasive bone grafting procedure, or financial limitations. The LODI System, incorporating narrow diameter implants with a detachable LOCATOR Attachment, is an ideal solution for these patients. For more information, visit http://www.zestanchors.com/.

38 Implant practice

Sunstar Americas announces a new extension to its guided bone regeneration portfolio with the introduction of GUIDOR® easy-graft® CLASSIC Alloplastic Bone Grafting System. Designed with technology that enables the material to be syringed directly into a bone defect, GUIDOR easy-graft is the first bone grafting material that hardens into a stable, porous scaffold in minutes and may reduce the need for a dental membrane.1 Cleared for a wide range of indications, GUIDOR easy-graft is a fully resorbable bone grafting material ideally suited for socket preservation after tooth extraction and implant packing. The easy handling of GUIDOR easy-graft originates from its unique combination of materials. Comprised of coated synthetic granules in a syringe and a liquid activator, the material hardens into a stable, porous scaffold in minutes when in contact with fluids such as blood. This brief delay allows practitioners time to pack and shape the material to the contours of the defect before hardening occurs. For more information, visit www.GUIDOR.com, or call Sunstar at 1-877-484-3671.

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A CONVERSATION WITH...

New You Smile (NYS) full mouth dental implant restorative system to launch in China

t Ossotanium headquarters in Albuquerque, New Mexico, MedMark General Manager, Adrienne Good, met with dental professionals and representatives from Angel Dentistry in China to watch a live full mouth implant restoration performed by Dr. Li Luo Skelton and partner Dr. Luis Galvan from New You Smile Center® in San Antonio, Texas, using an innovative new material. The patient, Dianna Lamb, is Adrienne’s mother, a denture wearer who never wore her bottom denture because she had very little bone to enable it to fit properly. In this interview, Adrienne delves into the development of this new material, Ultra OralStone™ by Nouvelle Ere, a breakthrough implant-optimized dental prosthesis. This material, which combines shock-absorbing strength, nano-resin hardness, affordability, ease, and flexibility of design, enables the possibility of creating dental fixtures from affordable implant dentures to high-end, full mouth, implant-based smile makeovers. This material’s highly anticipated launch in China is expected to revolutionize the field of dentistry worldwide.

Interviewees

• Mr. Shijun Li – President, CEO Angel Dentistry • Tao Xu, DMD, PhD – Professor and former Dean of Peking University School and Hospital of Stomatology • Li Luo Skelton, DDS – Owner of New You Smile

Adrienne Good (AG): Dr. Xu, as a Professor and former Dean of Peking University School and Hospital of Stomatology, can you offer some background on why this new material is important and insight into its launch in China?

Dr. Tao Xu: China’s economic growth has increased demand for oral health services and quality of life. However, there is a shortage of dental services due to the ratio of dental professionals to the large population. As the aging population gradually grows in the country, based on the third oral health epidemiological survey in China in 2005, there are still a lot of treatment requirements for seniors — for the estimated 98.4% who suffer with caries, for the 68% who experience periodontal conditions resulting in bleeding, for the 88.7% with calculus, and AL > 4 mm at 40 Implant practice

71%. The need for treatment of the edentulous jaw was also found in both adult and senior populations. While increasing services for these needs could improve the situation, application of new technology would also help improve the outcome of treatment. Dental professionals should continue seeking the best possible approach to serve the patients and the society for a better quality of life.

patients are left without access to quality care, increasing demand for materials optimized for full mouth restoration. There are issues that prevent catering to these patients with current technology. Materials available on the market have not been able to satisfy explosive demands, creating a “bottleneck,” which is further aggravated by our evergrowing and aging population.

AG: What is the global trend in dentistry?

AG: What has your company done to innovate in this area?

Mr. Shijun Li (SL): there are three main components: 1. Prevention 2. Patients demanding better treatment due to advanced technology 3. Both therapeutic and esthetic benefits

AG: What is your vision of the future of dentistry?

SL: The implant market has moved to a new era in advancement and technology making it the “era of the lifetime total makeover with or combined with dental implants.” Research demonstrates that more people are in need of full mouth implant rehabilitation instead of just one or two implant placements. Full mouth restoration is beneficial to the following types of patients: • Patients who have missing teeth • Patients who suffer from periodontal disease • Patients who have suffered traumatic injuries or accidents • Patients who aim to improve their appearance • Patients who suffer from skeletal malocclusion The inadequacies of current technology have created a vacuum effect in which

SL: The challenge of full mouth restoration is that most implant-supported prostheses made with acrylic are too brittle and can break easily. In dealing with precious metals for a crown, the costs can quickly become very expensive, and it is difficult for lab technicians to manipulate these materials. Another downside is that these materials provide no stress relief for the underlying bone. Angel Dental has made an effort to introduce a full mouth implant restoration system to overcome the challenges identified previously. The material in the new implant system is flexible enough to ensure that it reduces direct pressure on the implants and the bone while being of exceptional strength and durability, eliminating the need for metal substructure. This new material has a longer longevity and greater overall strength compared to existing materials while at the same time restoring function to the patient’s smile and reducing the chances for further bone loss down the road.

AG: I know that you have had many years of experience in dental management, and that the material is approved by the FDA. Dr. Li Skelton has been placing this material in patients in her San Antonio practice for over 2 years, Volume 8 Number 1

SL: As the CEO of China Angel Dental, I have personally followed up with results and patients post-surgery. I think it is the right time to introduce this full restoration implant system. Its unique features have significantly improved the industry, and some may say it is a clinical and technical revolution! As dental leaders, we decided to collaborate with the inventor

of Ultra OralStoneâ&#x201E;˘, Dr. Li Skelton, to build a new company, Wisdom Angelâ&#x201E;˘ Science and Technology, Inc., in China. At the end of this year, we are going to launch this system in China. This will bring benefits to the many of our denture-wearing senior population.

done with a dental implant system that can easily serve the many individuals in need. We are proud to serve patients with an instant and customized smile makeover that is made up of preserving bone foundation, and is affordable, functional, and a lifetime solution.

AG: Dr. Skelton, how do you see this product making an impact worldwide?

AG: What are some benefits to the patients?

Dr. Li Luo Skelton: The New You Smile Implant Makeover System is an all-in-one total integrated system, starting with education, and then creating a new culture where the power of a smile is brought back to patients, from the U.S. to China. This system is great for patient education, home and healing systems for all treated patients, marketing, R&D, materials, dental labs, training opportunities, and multidisciplinary modern dentistry applications. Our mission is to help patients improve their quality of life with a Opening ceremony of the Guangxi Wisdom Angelâ&#x201E;˘ Science and Techhealthy and functional smile. This is nology Inc. (China).

Volume 8 Number 1

SL: Basic dentures are uncomfortable and can easily break. Given the opportunity to use our system, patients would find increased comfort levels with a solid product that will not break. We offer better quality material at a lower price for the greatest possible accessibility to our products and services.

AG: When can doctors in the United States expect to take advantage of this system?

SL: After the system launches in China, we will welcome clinicians in other countries to collaborate in launching this system in other parts of the world. Please go to www. oralstone.com for more information on the material and advances in the U.S. market. IP

Implant practice 41

A CONVERSATION WITH...

and her patients are very satisfied. Tell me more about your experience working with Dr. Skelton and future plans.

PRACTICE MANAGEMENT

Guiding light Can your team rely on you when things seem dark? Laura Horton explains how effective leadership can be the light at the end of the tunnel

ome say leadership is in your bones — you either have it or you don’t. I firmly believe leadership is a skill that needs to be worked on frequently. Skills can be taught, and therefore, people who are automatically put into a position of leadership can work on those skills, whether it is a practice manager who has been promoted from a dental nurse or an associate dentist who is now a partner or sole owner. Practice owners and managers often struggle to become leaders for two reasons: 1. They do not have the time to lead. 2. They like to be in control. If either of these apply to you, then it is likely your leadership isn’t as strong as it could be.

Invest in your team Successful leaders share their compelling visions, but if you do not have time to plan the vision of your business, how can you share it? How do you know if it is compelling if you can’t get your team to provide ideas and ask questions? A compelling vision is communicated with a team, creating excitement. Every team member will be right behind you because they will be able to see where they are heading and will want to be a part of it. Practice owners need one day a week to work on their business. However, this doesn’t mean writing treatment plans or doing admin — you should already have a support network to help you with those aspects! Successful leaders get to know their team. I do not agree with business owners who do not intentionally get to know their teams. It is vital to know what similarities they share with you, such as background, schooling, and family upbringing, or what common interests you have, such as hobbies, films, or television shows. We all know the importance of building relationships with patients, but this is often forgotten within a team that works together every day. While you may know your nurse very well, what happens to the other team Laura Horton has worked in dentistry for 15 years and is passionate about treatment coordination and team development. To find out more, visit the website at www.laurahortonconsulting.co.uk.

42 Implant practice

members you aren’t interacting with when you are being a dentist? Successful leaders bring out the best in others; they do not dictate to their team members what they should be doing, and how they should be doing it. They ask them how they wish to get to the end goal. Is there any way the leader can help a team member complete a new task by providing advice or training? Are there any worries they have completing this new task? The leader should be approachable, and all members of the team must be able to go to him/her without feeling that they are wasting their time or looking stupid.

Taking control Successful leaders trust in others. You may say you trust your team, but do your actions display this? If all team members were asked, anonymously, if they trusted you, what do you think they would say? Trust takes time to build up, but can very quickly be taken away. The most vital thing you can do here is to ask your team members for honest feedback — whether or not they all feel you trust them. Ask them to provide you with an example, whatever their response.

Handing out tasks Successful leaders also delegate. Delegation is most often misunderstood. It is not about handing out a task and never seeing the completion of it. There is nothing worse than wondering if something has been done and what the finished result may be. Delegation is about sharing tasks with team members, giving them a deadline and reviewing the task together. Delegating to your team helps to motivate and build trust. You need to ensure you are organized and know who has been delegated what. After all, delegated tasks are still your responsibility.

Training team members Successful leaders train others. Increasing your team’s skills to take on new tasks is a great use of your time as a leader. Everyone in your team knows you are busy, so when you set time aside to train them and give them new skills, they will appreciate it. You may not be the one running the training; you could send them on courses

Leading from the front • Share your vision for the business with your team to help build trust. • Take the time to get to know each person in your team. • Follow up on all tasks that you have delegated to team members. • Take the time to train your staff. • Ensure your team knows when your practice has achieved results. or identify others who already have these skills to train them. A key example of this is cross-training your dental-assisting team to be able to work with every dentist, and training him/her to be able to carry out front desk duties such as handling new patient phone calls. Successful leaders have the right team around them, so surround yourself with likeminded people. This is extremely important in a dental setting. If, as a leader, you have a passion for customer service and providing every patient with an amazing experience on every visit, yet you have a team member who thinks “this is a waste of time,” then you have a problem. In his 2001 book, Good to Great, Jim Collins stated that it is vital to get the right people on the bus and in the right seats.

The end goal Successful leaders achieve results for the business. For everyone in your team to look up to you, and respect you as a leader, he/ she needs to see you have done all of this and gained results for the business, too. You have worked hard on the vision, connected, and trained to bring out the best in your team —but have you, as a team, gotten the results you planned for? Feedback is vital. When your team sees you have helped the practice achieve results, that is when you become a successful leader with a team that respects you, rather than being a team that follows you because it has to. IP Volume 8 Number 1

ABSTRACTS

Treating soft tissue deformities around osseointegrated dental implants Dr. Maria Retzepi presents a selection of recent studies and published research Efficacy of soft tissue augmentation around dental implants and in partially edentulous areas: a systematic review. Thoma DS, Buranawat B, Hämmerle CH, Held U, Jung RE (2014). Journal of Clinical Periodontology 41(suppl) 15: S77–S91 The aim of this systematic review was to evaluate the efficacy of different soft tissue augmentation procedures in terms of increasing the width of peri-implant keratinized mucosa, and gain in soft tissue volume around implants and in partially edentulous areas. The authors conducted a Medline search for human clinical trials (case studies, cohort studies, controlled trials) with a follow-up of at least 3 months reporting on augmentation of keratinized mucosa or gain in soft tissue volume around implants or partially edentulous areas. Nine clinical studies were included with a total of 283 patients and 375 sites treated for gain of keratinized tissue around the implants. The authors reported that: • An apically positioned flap/vestibuloplasty combined with a graft material (free gingival graft/subepithelial connective tissue graft/collagen matrix) resulted in an increase of keratinized tissue by 1.4 mm–3.3 mm for an observation period up to 48 months. • An apically positioned flap plus autogenous graft was the best documented and most successful method of increasing the peri-implant keratinized mucosa width. • The combination of an apically positioned flap with collagen matrix demonstrated less keratinized tissue

Maria Retzepi, DipDS, PhD, MSc, CertClinSpec (Perio), is a registered specialist in periodontics and honorary clinical lecturer in periodontology at the UCL Eastman Dental Institute. She currently works in specialist private practice in central London.

44 Implant practice

gain, but also significantly reduced patient morbidity and surgery time compared to an apically positioned flap, and combined with autogenous graft based on two randomized controlled clinical trials. • All studies found shrinkage of the augmented grafts, which may result in a decrease in width of keratinized tissue of more than 50% within a couple of months. The results were more favorable for the autogenous grafts (59.7% shrinkage) compared to collagenous matrix grafts (67.2% shrinkage) at 30 days postoperatively. A total of 295 patients and 320 sites treated for augmentation of soft tissue volume around implants or in partially edentulous areas were included in 11 studies. The authors reported that: • Autogenous (subepithelial connective tissue) grafts should be considered as the treatment of choice, as they were the best documented method for soft tissue volume gain at implant and partially edentulous sites. • Three studies used casts to evaluate the soft tissue volume over time and reported that the mean augmented thickness following autogenous grafting ranged between 0.55 mm and 1.18 mm. One randomized controlled clinical trial reported superior results following grafting of alveolar defects with subepithelial connective tissue graft (159 mm3 volume gain) compared to free gingival graft (104 mm3 volume gain). • Soft tissue substitutes for gain of soft tissue volume currently lack clinical data. • Shrinkage of the augmented sites should be expected, with autogenous grafts being reported to shrink by more than 40% in two studies. Shrinkage data were not available on soft tissue substitutes. • From an esthetic point of view, at immediate implant sites, better papilla

fill and higher marginal mucosal levels were obtained using subepithelial connective tissue grafts compared to non-grafted sites.

Soft tissue augmentation procedures for mucogingival defects in esthetic sites Levine RA, Huynh-Ba G, Cochran DL (2014). International Journal of Oral and Maxillofacial Implants 29(suppl):155–185 The objective of this systematic review was to evaluate the esthetic outcomes of soft tissue procedures performed and soft tissue deficiencies present around maxillary anterior implants. A Medline database search was performed, which led to 123 full-text articles for further evaluation. A total of 18 studies were finally included in the present systematic review, the vast majority of which were case series, with only one randomized controlled clinical trial identified. The included studies were grouped according to the intervention performed on the peri-implant soft tissues. The authors reported that, overall, six therapeutic modalities have been studied in terms of addressing peri-implant soft tissues deficiencies. These include the connective tissue graft with a Volume 8 Number 1

results are common in the treatment of a dental implant for facial gingival recession. The authors concluded that the available literature on the effectiveness of soft tissue procedures in promoting the esthetic parameters around dental implants was based on very limited literature support. Furthermore, the available studies were lacking long-term follow-up, a large number of patients, and were subject to inclusion bias.

A novel surgical-prosthetic approach for soft tissue dehiscence coverage around single implant Zucchelli G, Mazzotti C, Mounssif I, Mele M, Stefanini M, Montebugnoli l (2013). Clinical Oral Implants Research 24: 957–962 This prospective case series study aimed to evaluate soft tissue coverage and patient esthetic satisfaction of a novel surgicalprosthetic approach to soft tissue dehiscences around single endosseous implants in the esthetic region. Twenty patients with buccal soft tissue dehiscence around single implants in the

esthetic area were enrolled. The treatment protocol included removal of the implantsupported crown, reduction of the implant abutment, coronally advanced flap combined with connective tissue graft and final restoration. The soft tissue coverage was evaluated 1 year after the final restoration, and the unrestored contralateral tooth, which did not present recession, served as a reference. The study also evaluated patient satisfaction 1 year after the treatment. One year after treatment, the mean soft tissue dehiscence coverage was 96.3%. Complete coverage was achieved in 75% of the treated sites. The increase in buccal soft tissue thickness amounted to 1.54 ± 0.21 mm and correlated significantly with the thickness of the connective tissue graft at the time of the surgery. Furthermore, esthetic analysis demonstrated a significant improvement in the visual analogue scale (VAS) score, (median, 3.8; 95% CI, 2–4 at baseline compared to 8.0; 95% CI, 8–10 at 1 year [median]). The authors concluded that the combined prosthetic-surgical technique was effective in addressing buccal soft tissue deformities around single dental implants. IP

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Implant practice 45

ABSTRACTS

coronally advanced flap (seven studies), the connective tissue graft in combination with an envelope flap or pouch (three studies), the free gingival graft (three studies), the acellular dermal matrix with a coronally advanced flap (one study), the pediculated connective tissue graft (two studies), and the injection of hyaluronic acid (one study). The data indicated that the periodontal plastic surgery procedures performed around dental implants gave good initial results, partly owing to the inflammation involved in the healing process. As such, in virtually all cases, significant recession occurred as healing resolved and the tissues matured. The authors have further reported that immediate implant placement is associated with an alarmingly high incidence of mucosal recession in the range of 20% to 40%, and that several case studies have shown that, with immediate implant placement, there is a benefit in augmenting both the buccal gap and using a connective tissue graft to thicken the buccal tissue for biotype conversion. Furthermore, it was reported that the available literature indicated that unpredictable esthetic

PRACTICE DEVELOPMENT

How patients think Andy Smith presents patient-led insight to help improve your dental implant marketing

fter years working inside the implant industry, swapping over to the patient side of the fence has proved highly illuminating. Establishing a website to assist implant patients and respond to their questions has given me interesting insight into how they think and what it is that they are really looking for. A robust patient survey, our own site analytics, and hours spent talking to patients have challenged many of the assumptions implant providers have about what motivates implant patients. Here, I will outline some of the key lessons that we all need to take on board if we are to please more of our patients more of the time.

Three problems propel people towards implants A recent survey we conducted confirmed that three different health issues trigger patients to consider implants; 45% of respondents confirmed that they had missing or broken teeth, while 28% were looking to replace dentures or bridges. The third major group (17%) were interested in implants because they were suffering from gum disease and loosening teeth. While these groupings won’t surprise clinicians, they do highlight that not every implant patient is the same. They don’t all have the same problem, and each is exploring an implant solution from an individual perspective. It also serves to remind us that, while many will be having their first major dental treatment, others will have already spent many hours in the dentist’s chair. There is so much scope to market to these groups differently, but they tend to get lumped together.

health. While patients might be on their own individual implant research journey, many of their initial behaviors are the same — and most begin online. You only need to look at the monthly number of Google searches around “dental implant” (18,100 on average per month) to know that, first, lots of people are searching and, second, that most start their journey by typing “dental implant” or something similar into Google. The web has created a new tribe of “researchers,” and it’s surprising how diligent they are. We found that only 10% were on their first research foray, 26% had already done some research and were looking for a trustworthy practitioner, and a further 26% had already been to see a clinician and were considering their treatment recommendation. This is interesting because it shows how modern behaviors are bleeding into dentistry. Just as people use online recommendation services to minimize risk when selecting a tradesman, so people are looking to really ensure that they are making the right choices when investing significant money in something like dental implant treatment.

Researchers want reassurance and references The cost and complexity of dental implant treatment means it is hardly surprising that the most visited pages on our site are the pages on cost (“Why can’t I get a price for something I want over the phone?”), the Charter (a set of principles to help people interrogate the quality of their implant providers), and the FAQs. Researchers are really keen to amass information so that they can make good

choices, and it’s up to us as an industry to help them do so. The only way to neutralize misleading “cheap implant” ads on Google is to work together to generate alternative information that will help people make good choices for the long-term. Reassuringly, once people have been encouraged to ask searching questions of their providers, obtaining an experienced, qualified clinician becomes their key priority. This is followed in second place by the avoidance of future problems, and in third, by quality of outcome. Giving patients the right reassurance upfront relegates cost down the list as a priority (although it will always be important). Not surprisingly, the importance of an open and flexible discussion around treatment options is also important to researchers: having done their homework, they don’t want to be railroaded into a single solution. Feedback from other patients is also influential: in the world of TripAdvisor® and OpenTable®, patient cases work as “references” for clinicians, giving potential patients reassurance that problems like theirs can be resolved. They can have an impact on their choice of practitioner.

Patients don’t care about what we care about This insight around patient priorities is interesting because it clashes with what many practitioners are currently doing. Instead of showing how years of experience and expertise have generated case after case of satisfied customers, many practices wax lyrical about their practice — which is further down on the list of priorities for patients.

Patients know more than we’d like to think The trend towards self-diagnosis, the influx of medical web content, and the boom in innovative apps and devices seen across the health sector are also impacting oral

Andy Smith has held senior executive positions in both Straumann® and BIOMET 3i™ across several different European countries. He now leads the way in patient referrals from the Internet in the United Kingdom and the United States.

46 Implant practice

Volume 8 Number 1

Prosthetic Materials & Solutions

opportunity to position themselves around the things that really matter: expertise, experience, and evidence of good results.

Your website is not enough This final insight brings us full circle to the point about Google searches. No matter how

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Implant practice 47

PRACTICE DEVELOPMENT

Yes, ambiance and friendly staff are nice to have (and caring staff, in particular, will be referenced by satisfied clients in reviews), but they won’t convert researchers on their own. Those practices marketing their “contemporary space” and “spa-style waiting area” are missing the point — and wasting an

sexy your website is, it — and any expensively produced films on it — will be wasted if they simply languish in the digisphere. I was looking recently at a beautiful practice video that must have cost thousands to make, without registering that it had only received around 30 views in 2 years. These days, most practices have grasped the importance of a digital presence, but the rules of the web have evolved once again. People researching implants don’t start their journey by typing in their postal code; they start with a question or a search term, so you cannot rely on your website popping into their eyeline. Now, to be part of their conversation, you need to be generating content that responds to their needs, and you must be making this content easily available. These days, content is now much more important than a website; pushing out blogs, articles, and case studies will always trump the sexiest of practice pages, and video is king. We all need to respond to these changes to feed the appetites of this new breed of “researcher” patients, showing them that we truly understand the implant journey they are on. IP

STEP-BY-STEP

Assessing implant stability for loading Dr. Peter K. Moy discusses a product that helps determine proper implant loading time

ver the years, there have been many developments in the field of implant dentistry that help to improve clinical outcomes, such as new implant surfaces, innovations in implant design and components, and advanced grafting products and techniques for site development. We now see success and survival rates that consistently exceed 95% and are attributable to these state-ofthe-art implant technologies, clinical Figure 1: Osstell® ISQ device expertise, case selection, and patient compliance. At this point, we have routinely used Historically, when root-form implants were the Osstell ISQ for over 10 years to identify first placed, they were submerged during implant stability and to monitor osseointegraosseointegration. Later, non-submerged tion. By providing an objective and reproimplants with delayed loading became the ducible guide for my decisions concerning typical protocol and shortened treatment loading protocols, this technology has helped times. Today, patients want well-functioning, my restorative referrals avoid potential lost natural-looking restorations and prostheses as revenue due to implant failures associated soon as possible following surgery. As a result, with improper healing periods and to optipatients are increasingly demanding shorter mize the clinical outcome of implant treattreatment times, and patients who historically ment for patients. Osstell ISQ is reliable would not have been candidates for implant and clinically proven, with more than 500 treatment due to compromised bone and published articles supporting the underlying other risk factors are requesting implants. technology and the use of implant stability Therein lies the dilemma since some quotient (ISQ) measurements to assess patients’ clinical condition (for example, implant stability and osseointegration. porosity of the recipient bone bed, limited Basically, the Osstell ISQ uses magnetic bone volume, or medical conditions) resonance to measure implant stability and lengthens the bone reparative process, the degree of osseointegration at implant which requires longer healing periods. sites. Unlike the traditional method of This makes it crucial to be able to objecassessing implant stability and osseointetively measure primary implant stability and gration by measuring torque, which could osseointegration. be hard to objectively quantify and could The majority of my implant cases are on occasion negatively influence stability, now early loading cases. A minority is the Osstell ISQ method is completely nonimmediate loading, and delayed loading is invasive and objective. now performed only when immediate or Using this method, a small, high-precision early loading are not advisable. The Osstell® metal rod (the SmartPeg™) is attached by technology provides me with an invaluable screwing it into the internal thread of the objective measurement of primary implant implant or the implant-abutment complex. stability and the progression of osseointegraNext, the Osstell ISQ probe is placed in tion over time. That helps me decide the time close proximity to the SmartPeg and emits of optimum loading. magnetic pulses that cause the SmartPeg to Peter K. Moy, DMD, is an Oral and Maxillofacial Surgeon in Los Angeles, California.

48 Implant practice

resonate. The resonance varies depending on the lateral stability of the implant and the rigidity of osseointegration, and is interpreted using resonance frequency analysis (RFA). Therefore, a comparison can be made between the readings obtained immediately

Figure 2: SmartPeg in position with RFA in progress

following implant placement (baseline) and those obtained at a given moment during osseointegration. In this way, the degree of osseointegration can be determined. In addition, any observed decreases in ISQ from one time point to another can indicate potential problems and enable early intervention. Showing the readings to patients also helps involve them in their treatment. I have found that most patients appreciate this information and understand the decision on when to load their implants. Readings above 55 ISQ have been validated to indicate an acceptable degree of implant stability for loading.

Figure 3: Acceptable reading of 84 shown ISQ

Osstell ISQ helps prevent failures and the associated costs for the office and patients. Overall, the main advantages for my office and patients are the quality assurance that we have been able to implement into implant protocols, the ability to reduce treatment time through earlier loading, and the ability to manage implant risk. Osstell ISQ has become my personal guide in determining the appropriate time to load patients’ implants, and now I use it for every implant case. IP This article was provided by Osstell.

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PRODUCT PROFILE

Crystal® Ultra: a new hybrid nanoceramic ideal for implant cases Creative Dental offers two new flavors of implant restorations

he employees put a sign on Scott Atkin’s door, “mad scientist at work.” Atkin refers to his research lab as a sort-of test kitchen for every machine, material, or process ever conceived for dentistry. As CEO of Creative Dental Laboratory, Atkin has been pushing dental technology into new frontiers for over 35 years. Creative was an early adopter of CAD/CAM, among the first to mill Zirconia copings; and in 2009, Atkin was the very first person ever to mill full contour Zirconia crowns using CAD/CAM. And, most importantly, Creative shared their technologies with other labs by co-founding Dental Laboratory Milling Supplies (DLMS) in 2007 to distribute advanced dental CAD/ CAM supplies worldwide. Today, according to independent market research, DLMS’ Crystal® Zirconia is the number one selling Zirconia offered by the largest U.S. labs, providing a unique combination of unparalleled strength, beauty, and translucency.

FDA approves Crystal® Ultra, a new hybrid nano-ceramic

Recently, the FDA approved Atkin’s newest material, Crystal® Ultra, which is a hybrid nano-ceramic that actually “bends and flexes” in the mouth. With more than a million restorations seated worldwide and dozens of labs participating in U.S. trials, Crystal® Ultra has been one of the most anticipated dental science advances in the past decade.

At a conference recently, Atkin held up a thin bar of Crystal® Ultra and bent it. “There is no other ceramic on Earth that can do this,” he said. “Crystal® Ultra flexes in the mouth as the patient chews, absorbing shock, making it the only dental material with mechanical properties similar to human dentin.”

Implant dentistry is the greatest beneficiary

Crystal® Ultra was originally engineered for minimally invasive and cosmetic dentistry because of its opalescent chameleon-like esthetic qualities, absolutely disappearing 50 Implant practice

in the mouth as an inlay, onlay, or veneer. But its greatest utilization today is in implant dentistry. After implants are placed, there is no periodontal ligament that surrounds the roots to absorb shock and give the patients nerve feedback when they bite. That’s why older ceramic implant restorations tend to crack or break under pressure after just a few years in the mouth, and it is why some are concerned that Zirconia might be less-than-forgiving if supported by only four implants. With Crystal® Ultra, the material takes the abuse and doesn’t pass the impact to the bone.

No more bars — the Goldilocks effect

In the past, most full arch hybrid restorations were made of acrylic denture materials supported by a titanium bar, commonly called an All-on-4™ when done with four implants. Atkin offers, “That is like reinforcing gummy bears with a toothpick, and so we tend to see up to 90% repair or failure rates within 5 years of placement.” Most denture techs are used to repairing and replacing acrylic dentures, but patients who spend tens of thousands of dollars on a permanent solution are expecting — a permanent solution. For several years, Creative has been offering highly esthetic full arch Zirconia restorations as a permanent alternative, but some dentists and patients complain that Zirconia feels too hard, with a clacky sound as you bite down and chew. Since acrylic is too soft, Atkin had a Goldilocks’ moment when he started making monolithic full arch restorations out of Ultra. “Not only are they beautiful,” offered Atkin, “but they feel great in the mouth; the closest material we have to the feel of natural teeth; the most pleasant bite experience a patient will ever have; and because they are nonporous and super-stain resistant, they stay clean!”

The science of flex

The magic sauce behind Crystal® Ultra is a perfect 70/30 blend of silanated glass and advanced polymers. The 30% polymer matrix gives the material its elasticity, and silanizing causes the ceramic to bond chemically to the polymers giving the material its strength. In the past 2 years, others have also developed ceramic hybrids, such as 3M Ultimate, and Vita Enamic®, but these other hybrids can’t be used for bridges or full arches.

Ultra overtaking Zirconia in 2015

Atkin says that today about half of his full arch restorations are made of Crystal® Zirconia and half are Ultra-based, and to make the decision to test Ultra ultra-simple, he offers both at the same $2,495 allinclusive price. “In 2015, I expect Ultra to tip the scale,” indicated Atkin, “because patients absolutely love how it looks and feels.” As a result of both of these materials, Atkin believes that titanium bar-supported “gummy bear teeth” are a thing of the past. He offers to personally create a test Ultra restoration, either a single or bridge or full arch, for every new implant dentist who inquires, explaining the features and benefits and taking the dentist through the simple process step-by-step. To learn more, call Scott Atkin at 480-948-0456, or visit www.CreativeDentalAZ.com or www. CrystalUltra.com. With Crystal® Ultra and other modern advances in placing implants, Atkin believes that many more dentists will be entering the lucrative implant dentistry field in coming years, and he wants to be there to support them with advanced materials and advanced techniques.

About Creative Dental Laboratory

Creative Dental Laboratory, Inc. was founded in Scottsdale, Arizona, in 1980 by Scott Atkin, who received his degree in dentistry from the Royal Dental Hospital in London before going on to a master’s program where he became a Registered Master Dental Technician. In his lab in Arizona, Atkin invented CAD/CAM-based full contour Zirconia and 3D transition shading, and after significant research on translucency, he created SinteringOvens.com to offer revolutionary high-speed, high-temp ovens that will sinter Zirconia in short cycles while achieving maximum translucency, strength, and luster. IP This information was provided by Creative Dental Laboratory, Inc.

Volume 8 Number 1

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No More Bars! $ Complete Full Arch Restoration

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8 Year Warranty full arch w/ 4 ti-bases, bite block, diagnostic setup, setup try-in, implant verification jig, reset, and final restoration

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Creative stands behind our CAD/CAM monolithic implant restorations with an unheard of 8-year warranty against cracks, breakage or failure.

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Your choice of two leading materials. Unlike acrylic at <50 MPa, both are very strong and super stain resistant. Crystal Zirconia, at 1250 Mpa, is the strongest super-translucent zirconia available on the market today. Crystal Ultra is a high-luster 490 MPa hybrid ceramic that bends and flexes giving it a gentle bite and making it kinder on implants. Ultra is easy to adjust or add to without removal.

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PRODUCT PROFILE

Introducing ATLANTIS Conus concept by DENTSPLY Implants

he dynamic growth in implant dentistry has greatly enhanced the position of implant-supported restorations in prosthetic dentistry. As this growth continues, it offers exciting opportunities for advanced fixed and removable implant-supported options that contribute to even better patient satisfaction. Implant-level attachments used with overdentures accounted for 82% of the total United States and European attachment market in 2013. The U.S. and European attachment market grew 3.5% to 1.5 million units sold in 2013. This growth trend is predicted to continue through 2020**. With this in mind, overdenture solutions can offer an ideal growth opportunity within the dental practice. Studies show that a dissatisfied patient will tell eight to 10 people, while a satisfied patient will tell two to three people. Providing your denture patients with the optimized function and convenience of an implantsupported restoration can directly impact the number of satisfied patients that you create. Within the options of advanced patientspecific implant-supported restorations, DENTSPLY Implants is pleased to introduce ATLANTIS Conus concept as the newest addition to its digital solutions portfolio. Available for all major implant systems, ATLANTIS Conus concept provides a frictionfit, non-resilient prosthetic restoration for fully

edentulous patients. The patient-specific solution is a uniquely designed, conicalshaped abutment with corresponding caps that incorporates an implant-borne prosthesis while being removable like an overdenture. ATLANTIS Conus Abutments are individually designed using the patented ATLANTIS VAD (Virtual Abutment Design) software to ensure that all abutments are parallel to each other, that their restorative margin are as close to the soft tissue as possible, and that they are positioned in relation to the space needed for the final restoration. In addition, ATLANTIS Conus Abutments are designed to fit SynCone caps that ensure a tightly seated final restoration, minimize gaps and micro-movement, and provide: • A cost-effective and comfortable implant-supported prosthesis designed for optimal access for oral hygiene. • A solution that eliminates the need for design or manual adjustments often associated with dentures (e.g., pain of pressure of ill-fitting dentures and atrophy as a result of inactivity or pressure requiring relining of existing denture), allowing you to save time and increase profitability. • Stable but removable solution that offers the comfort of a fixed restoration.

Comparison with other retention systems Ball

Locator

ATLANTIS Conus concept

Hygiene maintenance

Easy

Resilient/Soft tissue pressure

Yes

Replacement of retention elements

Complicated

Easy

Not required as virtually wear-free

Compensation of angular placed implants

Slight correction of nonparallel implants possible

Possible to angulate abutments up to 30 degrees

Silicone sleeves placed under the SynCone caps to ensure that no pickup material would engage an undercut

New complete upper denture was adjusted for access to the abutments and copings

Final result

Case images courtesy of Dr. Arnold Rosen, DDS, MBA

52 Implant practice

In addition, the friction-retained SynCone caps are part of the SynCone concept, a proven solution that has been used since 2001. There are two treatment choices available with ATLANTIS Conus Abutments. Both options provide clinical and patient flexibility in turnaround times and economical situations: • Immediate restoration (intraoral) chairside pickup of SynCone caps in an existing appliance. • Indirect (laboratory process) with or without a framework fabricated in an existing or completely new denture. o With framework permanent solution o Without framework temporary solution In the clinical case below, the ATLANTIS Conus solution was selected for surgical and restorative simplicity considerations. It was also a cost-effective treatment for satisfying the patient’s requirements for stability, restored function and esthetics, and easy hygiene maintenance. This was a long-term, temporary solution based on the patient’s existing denture, requiring no new supporting framework. As with all ATLANTIS solutions, ATLANTIS Conus concept is backed by a comprehensive warranty* for your peace of mind. In addition to patient-specific prosthetic solutions for all major implant systems, DENTSPLY Implants offers comprehensive solutions for all phases of implant therapy, including digital treatment planning, regenerative solutions, implant systems, restorations, and practice development services. For restorative versatility, workflow efficiency and flexibility, and design options that go beyond CAD/CAM — choose ATLANTIS™. For more information, contact your local DENTSPLY Implants representative, or visit www.dentsplyimplants.com. IP *Subject to full terms and conditions. ** iData Research This information was provided by DENTSPLY Implants.

Volume 8 Number 1

IN MEMORIAM

Professor Per-Ingvar Brånemark “Father of Modern Dental Implantology” May 3, 1929 – December 20, 2014

rofessor Per-Ingvar Brånemark has passed away after a long illness at the age of 85. He leaves behind a legacy — the discovery that titanium could be tolerated by the body to provide an anchor for prosthetic devices — that has touched millions of lives.

Visionary Hailed by the modern world as a visionary, the young Professor Brånemark nevertheless struggled to gain acceptance for the concept that he would go on to term “osseointegration.” The young orthopedic surgeon faced opposition by the medical establishment in his native Sweden for almost 20 years. The Toronto Osseointegration Conference in 1982 would change that, providing a forum to bring the concept to the international community, and kickstarting a tidal wave of new research and clinical investigation. Since then, the influence of titanium implants has spread across the globe, not only revolutionizing dentistry but benefiting a huge breadth of other medical and veterinary fields as well. Professor Brånemark’s work earned him a vast array of awards and plaudits from institutions all over the world. He held more than 30 honorary positions across Europe and the United States and counted the Swedish Society of Medicine’s Söderberg Prize among some of his most significant honors.

Inspiration But those who met him were just as touched by his enthusiasm as by his shrewd mind. A gifted leader and teacher, he more than earned his title as the father of dental implants after a career that saw him inspire countless young scientists and dentists. His dedication to the impact and potential of the field he discovered is neatly summed up in his often-quoted comment: “No one should have to die with their teeth in a glass of water beside their bed.” Professor Brånemark is survived by his wife, Barbro, his three children, and four grandchildren. IP

Volume 8 Number 1

The Academy of Osseointegration (AO) continues to honor the life and legacy of Professor Brånemark who was an Honorary Fellow of AO. “Professor Brånemark was a giant, brilliantly scientific intellect, embodied in an equally large compassionate heart. His caring focus was always on the patient,” said Dr. Edward Sevetz Jr. Past President, Academy of Osseointegration. “His breakthrough discovery of osseointegrated titanium benefits patients throughout the world, and will forever benefit mankind.” “Professor Brånemark’s work genuinely transformed the dental landscape and the smiles of millions of people across the globe,” said AO President Dr. Joseph Gian-Grasso. “It is because of him that the Academy of Osseointegration exists, and today we honor his memory and monumental legacy. As an organization, we aspire to encompass his passion and to continue his lifelong work to enhance oral health globally.”

Implant practice 53

INDUSTRY NEWS The California Implant Institute offers a range of implant courses • 4-Day Live Patient Surgical Course (Rosarito, Baja California, Mexico): March 18-21, 2015 and June 24-27, 2015 • 1-Year Fellowship Program (San Diego, California) starting April 15, 2015 • Advanced Hard and Soft Tissue Grafting with Cadaver Program (Honolulu, Hawaii): April 24-26, 2015 • 14-Day Continuous Fellowship Program (San Diego, California): August 3-16, 2015 For more information, visit www.implanteducation.net.

Independent study recognizes extreme low dose capabilities of Carestream Dental’s CS 9300 Low Dose Mode Recent studies have confirmed that the CS 9300 family of cone beam computed tomography (CBCT) systems can provide 3D exams at up to 85% lower dose than traditional 2D panoramic imaging. The research, conducted by John Ludlow, DDS, of the University of North Carolina’s School of Dentistry, Chapel Hill, found that 3D images captured using the Low Dose Mode for a 5x5 cm adult exam provides an effective dose of just 3 microsieverts (µSv).1 Dose-saving algorithms and noise reduction processing enables the new Low Dose Mode to drastically reduce the dose and scanning time of the CS 9300 — between 73% and 95% as compared to standard acquisition mode2 — while maintaining diagnostic image quality. Low Dose Mode is available for 17x11 cm down to 5x5 cm scans and covers multiple applications such as implant planning; follow-up exams for orthognathic, maxillofacial surgery, or implant; analyzing skeletal symmetry; assessing airways; evaluating impacted teeth and supernumeraries; and pediatric examinations. An additional benefit of the new Low Dose Mode is that existing units in the CS 9300 family can easily be retrofitted with the module, so that doctors can ensure they’re treating their patients with the lowest dosage possible. For more information, call 1-800-944-6365, or visit www.carestreamdental.com. 1. Based on studies conducted by John B. Ludlow, University of North Carolina, School of Dentistry: Dosimetry of CS 8100 CBCT Unit and CS 9300 LowDose Protocol, August 2014; Dosimetry of the Carestream CS 9300 CBCT unit, June 2011. 85% reduction (3µSv) found in 5x5 cm adult exams; exact dose reduction varies based on field of view and ranges from 0% to 85%. 2. Based on study conducted by John Ludlow, University of North Carolina, School of Dentistry, Dosimetry of CS 8100 CBCT Unit and CS 9300 LowDose Protocol, September 2014.

54 Implant practice

OCO Biomedical presents “Exploring the Implant Treatment Modality”: The Next Generation of Dental Implant Training OCO Biomedical, Inc., will present power-packed, 2-day, AGD-Pace Accredited Courses called “Exploring the Implant Modality” on February 20-21, 2015, in Fort Lauderdale, Florida, and on February 27-28, 2015, in Irving, Texas. These valuepriced, in-depth, 2-day implant dentistry introductory courses form the core of OCO’s nationwide launch of OCO 2015: The Next Generation of Dental Implant Training. These 16 CE unit AGD-Pace accredited courses are designed for either experienced implantologists or for dentists looking to expand their practice by implementing implant treatment modalities. Attendees will become familiar with the implant surgical kit and the necessary prosthetic components for start-up. The basics of bone regeneration and grafting, an integral part of endosseous implants, will be taught. The company’s seminarstyle training focuses on The OCO Advantage: A Complete Dental Implant Solutions Approach, a successful, clinically proven methodology created and developed by OCO Founder and President, Dr. David Dalise, and OCO Chief Operating Officer and Director of Education and Clinical Affairs, Dr. Charles Schlesinger. Additional 2015 training also offered by OCO Biomedical in numerous locations nationwide include Exploring the Implant Treatment Modality with Cadavers (16 CE units) and Advanced Cadaver Grafting and Implantology Training (16 CE units). For more information, call OCO Biomedical at 1-800-228-0477, or visit www.ocobiomedical.com.

Global Dental Science partners with Good Fit Technologies Global Dental Science (GDS), creators of AvaDent® Digital Dentures, has partnered with Good Fit Technologies to be the exclusive distributor of Good Fit™ Denture Tray products in North America and Europe. Good Fit Technologies manufactures a variety of moldable denture trays that simplify and shorten the denture fabrication process, including the “All-in-One Denture Tray,” the “All-in-One Implant Tray,” and the “Immediate Denture Tray.” These trays can be adapted and fitted in minutes to create custom impression trays, bite blocks, and stents right in the dental clinic. They allow for fast, accurate impressions and measurements, enabling dentists to get all the information required for complete denture fabrication in a single clinical visit. AvaDent Digital Dentures’ revolutionary technology brings the precision, speed, and profitability of digital process automation to removable dentistry using Computer-Aided Engineering (CAE). AvaDent makes it possible for providers to offer a precise fitting denture with superior bio-hygienics and esthetics and, for the first time ever, create a treatment plan for full mouth rehabilitation all within a digital environment. For more information, call 855-AVADENT (282-3368), or go to www.avadent.com. For information about Good Fit™ denture products, call 617-973-5136, or visit www.goodfit.com.

Volume 8 Number 1

INDUSTRY NEWS Gendex announces new website launch Gendex, a leader in dental imaging, stands by its promise to be Always by Your Side with its newly designed website, Gendex. com. The new website allows you to simplify your imaging search on any device whether on a phone, tablet, or laptop. The brand new Gendex website connects you to the entire product family with ease. Explore digital intraoral sensors, panoramic X-ray, Cone Beam 3D, PSP, imaging software and more. Take a 360 degree product tour, or check out the enhanced support section — all at your fingertips, faster, and easier. Gendex is dedicated to improving your practice and advancing patient care through comprehensive solutions and exceptional support. The new Gendex.com is a testament to the firm’s commitment.

LED Medical Diagnostics officially opens new Atlanta training facility and support center LED Medical Diagnostics Inc. officially announced the opening of its new training and support facility in Atlanta, Georgia, which has been in use since October 15, 2014. LED Dental Inc., a wholly owned Canadian operating subsidiary of LED Medical, has completed a 20-person training room, which is equipped with Wi-Fi and wireless high-resolution displays for customers, installers, and employees. The training facility includes a leadlined laboratory for X-ray emission from intraoral and extraoral units and a fully functional RAYSCAN Alpha - Expert dental imaging system, with 3D cone beam computed tomography (CBCT) as well as panoramic and cephalometric capabilities. A dedicated LAN for testing within various types of dental clinic networks, including commonly used operating systems and practice management software, is also available. On-site technical support staff members manage a 12-hour, 5-day-a-week call center. In addition, the training facility includes conference and board rooms for meetings with current and potential customers. For more information, visit www.leddental.com.

DEXIS™ and TeamSmile® demonstrate teamwork in bringing dental care to underserved children TeamSmile®, a unique national dental outreach program, gains continued support from DEXIS™, a brand of the Kavo Kerr Group, for the 7th consecutive year. Since the inception of the TeamSmile program in 2007, DEXIS has been a proud supporter through its donation and maintenance of its digital imaging systems, DEXIS™ Platinum sensors, CariVu™ caries detection, and DEXcam™ intraoral cameras, as well as financial contributions. TeamSmile partners with dental professionals and athletic organizations to bring together athletic role models and underserved children in communities across the country at events held throughout the year. These events allow the children to obtain free screening and treatment and also learn about the importance of their overall health. DEXIS has rededicated efforts to assist TeamSmile with company volunteers, on-site systems, and funding. For more information about DEXIS, visit www.dexis.com.

56 Implant practice

J. Morita USA introduces AdvErL Evo J. Morita USA has introduced AdvErL Evo, an Er:YAG laser effective for a wide variety of applications on both hard and soft tissue and clinically ideal for periodontal treatment. AdvErL Evo eliminates the vibration of a high-speed handpiece, providing a comfortable laser treatment option. Its wavelength is readily absorbed by water and efficiently vaporizes soft tissue. This unit offers a wide variety of tip options, adding to its versatility, with an extensive selection for periodontic procedures. Applications include removal of subgingival calculus, diseased, infected, inflamed, and necrosed soft tissue within the periodontal pocket, subgingival calculus, and granulation tissue from bony defects. It may also be applied for soft tissue curettage, sulcular debridement, and osseous crown lengthening. Most notably, AdvErL Evo has been studied and recognized clinically in the effective treatment of peri-implantitis, a challenging disease leading to bone loss around an implant. With use of AdvErL Evo, a method has been found to regenerate tissue and permanently remove bacteria with a low-heat treatment process. Information about this study, and other peer-reviewed clinical articles, can be found at www.morita.com/usa/laser. In terms of patient benefits, AdvErL Evo is virtually painless. There is far less trauma compared to other laser types, as vaporization is concentrated at the surface of the tissue. The energy does not penetrate and damage deep layers of tissue, nor does it disperse widely to the adjacent area around the irradiation target. For more information, call 877-JMORITA (566-7482), or visit www.morita.com/usa/laser.

Volume 8 Number 1

Save Time and Money by the Bundle BruxZir ™ Implant Bundle $395* includes

• Inclusive® Tapered Implant • Inclusive® Titanium Healing Abutment and Impression Coping • Choose from a BruxZir ® Solid Zirconia Crown with Inclusive® Custom Implant Abutment or BruxZir Screw-Retained Implant Crown

BruxZir Solid Zirconia, the world’s most prescribed zirconia restoration, now comes as a complete tooth replacement solution. For about the same price as a crown and custom abutment, everything needed to replace a missing tooth is included. The bundle provides convenience and predictable treatment costs, and reduces the need to keep a supply of implants and prosthetic components on hand. *Price does not include shipping or applicable taxes.

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Price comparisons based upon US list prices for comparable items as of January 2015. All trademarks are property of their respective companies. Promotion is valid for new customers only and cannot be combined with other offers.