Implant Practice US April/May 2015 Issue - Vol8.2 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews April/May 2015 – Vol 8 No 2

PROMOTING EXCELLENCE IN IMPLANTOLOGY Implementing a contemporary, in-office complete digital workflow within a clinical implant practice Dr. Michael D. Scherer

Changing paradigms in implant dentistry: flapless implant dentistry Drs. Tony Aherne, Annika Meyer, and Stuart Aherne

Processing extracted teeth for immediate grafting of autogenous dentin Drs. Itzhak Binderman, Gideon Hallel, Casap Nardy, Avinoam Yaffe, and Lari Sapoznikov

Practice profile Dr. Li Luo Skelton

Corporate profile ACE Surgical Supply

PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!

PRODUCT PROFILE

THE MAKING OF A

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

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

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Volume 7 Number 4

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

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

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

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

The nuts and bolts and beyond of implant selection

ow do actively engaged, busy clinicians efficiently select a specific implant system or, expressed more broadly, an implant company? The answer to this question has changed considerably over the multi-decade history of implant dentistry. The contemporary implant company must address several categories of needs, both specific and comprehensive. Specific needs consist of the product line such as dental implants and prosthetic components. Comprehensive requirements include biomaterials, equipment, and continuing education that further the knowledge base and clinical application of the products.1,2 In these regards, an implant “partner,” which is a higher level of engagement and dedication to the practicing dentist, must be obliged to systematically and enthusiastically offer the following items.

The dental implant

Microscopic and macroscopic surface characteristics Endosseous dental implants are biomaterials, and the surface characteristics (texturing) of these implants should have a long-term history that includes consistency and quality control before, during, and after application of an industry-standard texturing process.3,4 As implant dentistry evolved from an exclusively submerged protocol to include immediate loading protocols, the demand for an implant body with enhanced primary stability has increased. The contemporary dental implant manufacturer must offer multiple features such as a tapered implant body, standard and enhanced thread patterns,5 platform-switched interfaces, and coronal micro-threads or grooved areas. Surgical straightforwardness It is important to have surgical equipment and protocols that are organized and understandable6 — for example, a hard bone and a soft bone protocol. Additionally, it is appropriate to have multiple implant lengths and diameters available to address a variety of scenarios.

The implant-abutment interface and prosthetic components

The ultimate goal of implantology is to provide an optimal and predictable restoration. To this end, a stable connection at the implant-abutment interface is primary. Additionally, a robust line of versatile prosthetic components (both pre-machined and customized CAD/ CAM) — which have been subjected to computerized software analysis (for example, finite element analysis [FEA], in vitro [desktop] testing); high levels of automated and visual inspection; and clinical documentation7 — must be the norm.

Website and personnel support

The ability to prospectively review an implant or material online as well as having knowledgeable company representatives as a consistent part of an implant practice is crucial. For the contemporary dental office, the additional convenience of online ordering is a benefit.

Value analysis

Individuals, institutions, and policymakers have increasingly turned their attention to how services are to be afforded, delivered, and cost-to-benefit considerations.8 Effectively reaching as many patients as possible is a creditable goal. In recent years, the price point of the implant industry has undergone a radical and welcome shift due to manufacturing technology advances that can achieve unprecedented efficiency without compromising quality.

Continuously renewed commitment to clinical education

In conclusion, when an implant, ancillary product, or company fulfills these obligations to the dental clinician, confidence in the relationship ensues, and invariably this bond of trust is recognized by our patients. A history of innovation and a continuously renewed commitment to clinical education further strengthens this trust. I personally choose Implant Direct because the company demonstrates these attributes as well as an understanding that nothing less will suffice and endure. References available upon request

Dr. John S. Cavallaro Jr. is a part-time Clinical Associate Professor at the College of Dental Medicine, Columbia University in New York City where he teaches postdoctoral residents the surgical and prosthetic aspects of Implant Dentistry as well as Implant Literature Review. Formerly, he taught these disciplines at NYU College of Dentistry for 25 years. He maintains a full-time private practice of surgical Implant Dentistry and Prosthodontics in Brooklyn, New York. He is a member of the American College of Prosthodontists and the Academy of Osseointegration and has authored/co-authored 40 peer-reviewed articles addressing various aspects of Implant Dentistry. Dr. Cavallaro is a lecturer and consultant for Implant Direct International.

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April/May 2015 - Volume 8 Number 2 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 CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver Email: amanda@medmarkaz.com FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com

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

Volume 8 Number 2

TABLE OF CONTENTS

New company spotlight Paradise Dental Institute to launch live implant training in the Bahamas .......................................................16

Practice profile Li Luo Skelton, DDS

Case study Osseodensification facilitates ridge expansion with enhanced implant stability in the maxilla: part II case report with 2-year follow-up Drs. Ann Marie Hofbauer and Salah Huwais offer another case study using a novel biomechanical site preparation

Optimizing dentistry and energy for new smiles

technique....................................... 18

Clinical Implementing a contemporary, in-office complete digital workflow within a clinical implant practice: intraoral scanning, virtual design, and 3D printing Dr. Michael D. Scherer summarizes a contemporary approach incorporating intraoral scanning into a dental implant practice, including integration with cone beam CT technology and in-office 3D printing, to enhance restorative visualization and surgical

Corporate profile

guide planning................................ 26

ACE Surgical Supply There from the start. ON THE COVER Cover photo courtesy of Dr. Michael D. Scherer. Article begins on page 26.

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Volume 8 Number 2

NEW

Simplicity The design philosophy of the ASTRA TECH Implant System EV is based on the natural dentition utilizing a site-specific, crown-down approach supported by an intuitive surgical protocol and a simple prosthetic workflow. • Unique interface with one-position-only placement for ATLANTIS patient-specific abutments • Self-guiding impression components • Versatile implant designs • Flexible drilling protocol The foundation of this evolutionary step remains the unique ASTRA TECH Implant System BioManagement Complex. For more information visit www.jointheev.com

www.dentsplyimplants.com

without compromise

TABLE OF CONTENTS

Implant insights Bisphosphonates: a class of drugs beyond match Dr. David Speechley delves into the surprising history behind bisphosphonates and the terrible legacy of “phossy jaw”.................... 48

Continuing education Changing paradigms in implant dentistry: flapless implant dentistry

Product profile Salvin® Renovix® Guided Healing Collagen Membrane ................................................. 50 CHAIRSIDE™ Product Portfolio

Drs. Tony Aherne, Annika Meyer, and Stuart Aherne examine the efficacy — and difficulty — of adopting a flapless approach to implant placement

Introducing a comprehensive kit designed for the efficient and accurate pickup of denture attachment housings.....................................52

Industry news ...................................................... 53

On the horizon If they all work … how do I choose? Dr. Justin Moody discusses his implant system of choice..........................54

Continuing education Processing extracted teeth for immediate grafting of autogenous dentin

Materials & equipment .......................................................56

Drs. Itzhak Binderman, Gideon Hallel, Casap Nardy, Avinoam Yaffe, and Lari Sapoznikov investigate an alternative use for extracted teeth

6 Implant practice

Volume 8 Number 2

2nd Annual International Dental Implant Symposium July 17 -18, 2015 Sandia Resort & Casino Albuquerque, NM

OCO Biomedical, a proven world leader in innovative, patented dental implant products, technology and education, proudly presents the 2015 OCO Dental Implant Symposium providing two full days of information-packed lectures and Q&A sessions, to be held on Friday, July 17th from 8 a.m. to 5 p.m. and Saturday, July 18th from 8 a.m. to 4 p.m. at the spectacular Sandia Resort & Casino in Albuquerque, New Mexico. Participants in this exciting OCO event will receive sixteen (16) hours of CE Credits, competitively priced for both practitioners and staff; have the opportunity to network and gain knowledge from nationally recognized lecturers and other prominent speakers.

PRE-REGISTER TODAY! Symposium Pre-Registration before May 1, 2015

$600. for doctors/practitioners; $300.00 for support staff/personnel. 00

1-800-228-0477

OUR SPEAKERS: Dr. Balwant Rai, DDS - Keynote Speaker Space Dentistry: New Vision

Dr. Thomas Mathew Bilski, DDS

Immediate Provisionals for the OCO Implant Aided by CBCT & CAD Design

Dr. Kelly Brown, DDS

7 Launching Lessons to Take Your Practice to the Next Level

Dr. Robert D’Orazio, DDS, FAGD, DABOI/ID Managing the Posterior Maxilla

Dr. Robert Heller, DDS

Utilization of the OCO Implant in the Maxilla

Dr. Mark Iacobelli, DDS, FAGD, FICD, MIIF

Tooth to Implant Transitions. Diagnosis, Treatment Planning Performing

Dr. Timothy F. Kosinski, DDS, MAGD

Perfecting Atraumatic Extractions & Grafting in Preparation for Dental Implants

Dr. Ara Nazarian, DDS

Simplifying Full Mouth Reconstructions with Guided Surgery

Dr. Vijay Parashar, BDS, DDS, MDSc

Cone Beam CT: Standard of Care for Dental Implants?

Dr. Rajiv Saini, Ph.D

Current Concept Review: Peri-implantitis

Dr. Peker Sandalli, DDS, Professor of Implantology 40 Years Experience in Oral Implantology & the Secret of Success

Dr. Pierre J. Tedders, DDS

Growth Factors/PRGF: Socket Preservation to Ridge Reconstruction

Dr. Andres Traverse, DDS

Immediate Placement of Small-Diameter Implants An Alternative Technique

NEW! 2015 Pre-Symposium Courses - Choose between (2) course options

The Implant Environment Diagnosis & Treatment Planning

Atraumatic Extraction & Socket Grafting

July 16th, 2015 8:00 a.m. - 5:00 p.m.

Dr. Robert D’Orazio, DDS, FAGD, DABOI/ID

Dr. Mark Iacobelli, DDS, FAGD, FICD, MIIF

Only $300.00

Call 1-800-228-0477 to Register! - 8 CE Credits

Only $300.00 Call 1-800-228-0477 to Register! - 8 CE Credits

PRACTICE PROFILE

Li Luo Skelton, DDS The ultimate connection — mind, body, and smiles What can you tell us about your background? I started treating TMJ patients at the only TMJ center in China, the oldest and top dental school. At the time, it was called Western China University of Medical Science but is now known as Sichuan University. I graduated at the end of 1982 and started my full mouth rehabilitation lifetime journey. I have approached dental care from many aspects — TMJ, removable orthodontics, full dentures, acupuncture and hypnosis, energy healing, neuro-linguistic programming (NLP), energy healing for allergy, pain, emotion, and body balance, mind and spiritual healing, art, church, and psychology. Then I explored full crown and bridge rehabilitation procedures by attending the Las Vegas Institute for Advanced Dental Studies (LVI) and studying for a full month. I have researched aspects of rehabilitation, including the Snap-On Smile®, mini implant Snap-on, fixed full mouth prosthetics, the Geneva full smile denture, and All-on-4™ and All-on-6 instant full mouth implant makeover. Now, I am focused on our New You Smile (NYS) full smile makeover system. I am proud to say that I have been a smile makeover seeker all my life! To me, a smile makeover creates a “new you.” It optimizes the patients’ energy and redirects their energy flow. It becomes a combination of the instant smile and a lifetime journey toward happiness and health. The smile is just the icing on the cake. Achieving a total life balance is like winning a gold medal in the Olympics. The outcome of the integration of all of this new dental technology is beauty, health, functionality, and love. For me, this is the beginning of an enriching, all-encompassing life adventure, which has prepared me to be a part of the innovation that is NYS.

When did you become a specialist, and why?

I have loved smiles since I learned how 8 Implant practice

to smile. To me, the smile is everything. Even though I am a general dentist, I have always strived to learn and try any technique to achieve a successful smile makeover. My quest for the full-scale smile makeover started 10 years ago. I estimate that all my gross income for those 10 years, which added up to millions of dollars, has all been devoted to serving, improving, and delivering affordable, yet high-value, beautiful full mouth smile makeovers. The NYS system is the realization of all those years and the combination of the study in all of those disciplines.

Is your practice limited solely to a certain specialty? My practice is focused on full mouth smiles and functional makeovers with our Allin-one location in Texas, which includes a dedication to dental implants, a surgical suite, a 3D imaging center, and an in-house, full service, high-tech dental lab. Now, we are the home base for the NYS system, which intends to accomplish the following: 1. Instant smile makeovers 2. Instant health and function makeovers 3. Instant occlusion and full body balance treatment makeovers 4. Lifetime smile and anti-aging maintenance Volume 8 Number 2

Soft from the syringe. Hard in the defect. Prep. Dispense. Shape. Placing bone graft has never been this easy. Once the coated granules of GUIDOR® easy-graft® are syringed into the bone defect and come in contact with blood, they change in minutes from a moldable material to a rigid, porous scaffold. • Designed for ease of use and predictability • 100% synthetic and fully resorbable • Ideal for immediate implants and socket preservation

easy-graft ® CLASSIC alloplastic bone grafting system

To learn more, call 877-484-3671 or visit GUIDOR.com/easy-graft/

This product should not be used in pregnant or nursing women. For additional product information, including indications, contraindications, precautions and potential adverse effects, see Instructions for Use (IFU) or visit GUIDOR.com/IFU/ *Source: Customer Survey (N=68), Sunstar Germany, February 2014. © 2014 Sunstar Americas, Inc. All rights reserved. GUIDOR is a registered trademark of Sunstar Suisse, SA. easy-graft is a registered trademark of Degradable Solutions AG.

GDR15006

of clinicians surveyed said they use GUIDOR easy-graft because in many cases no membrane is necessary.*

PRACTICE PROFILE Why did you decide to focus on rehabilitating smiles?

by preserving bone (getting rid of disease, placing dental implants and utilizing NYS occlusion, and addressing the root cause of the problems.) This leads to self-love and self-healing. 3. The whole smile total makeover that combines aspects of the body, mind, health, functions, emotions, and beauty. 4. The all-inclusive approach that integrates the following areas: dental (full month rehabilitation); medical (in aspects of breathing, the immune system, posture); mental (mindfulness, learning, mental engagement, and stress reduction); psychological (emotional); Eastern self-healing (habit changes); art (new smile); spiritual (self-awareness, self-love, and healing); lifestyle changes (these are the root cause changes), and preventive measures. 5. Dedicating ourselves to smiles for life with affordability as one of key standards and by leveraging and simplifying technology and creating a purposeful smile makeover Our practice is truly one-of-a-kind, advanced, and experienced.

General family dentistry and full mouth rehabilitation have a very different approach to diagnosis, treatment planning, treatment options, treatment processes, maintenance, and requirements for teamwork. It is comparable in construction terms to either undertaking a remodeling job or a full-scale total design, with demolition and total reconstruction. In many ways, the dental, medical, mental, emotional, and lifestyle changes that are necessary for the transformation translate into a total life makeover.

Do your patients come through referrals?

My patients come from referrals and marketing. I am a strong believer in marketing because the dental makeover is a part of educating patients. This is a must for a growing full mouth makeover clinic. Marketing is about education and motivation and finding patients who are suitable for our philosophy.

How long have you been practicing, and what systems do you use?

I have been practicing for about 10 years, but I have studied full mouth rehabilitation since I graduated from China 32 years ago, beginning with TMJ and orthodontic treatment. I use the NYS system — an all-integrating full mouth smile, health, and function-balancing makeover system.

Above: Dr. Skelton with a patient Below left: Patient pretreatment Below right: Patient posttreatment

Who has inspired you?

I have been inspired by my father, who is a most dedicated general surgeon, practitioner of traditional Chinese medicine, and an administrator of a hospital. I grew up in China, and one big advantage is that I have been raised to love heroes! My childhood heroes all have several aspects in common — they love people; they love what they do; they have a purpose; and they never quit despite any difficulty. They discover what they do best and put their soul into it! Their common characteristics, which I try to emulate are 10 Implant practice

Our holistic and technology-driven, affordable smile makeover.

What do you think is unique about your practice?

What training you have undertaken? I have studied dental implants: mini and conventional, All-on-4, full mouth rehabilitation, dental lab, TMJ, full smile and occlusion training in LVI, Dr. Dawson occlusion, CEREC® restoration, sedation, Geneva 2000™ full dentures, Lumineers®, Invisalign®, LANAP® lasers, Snap-On Smile®, Misch Implant 3D Guide and Design, just to name a few.

Professionally, what are you most proud of?

We are the home of the New You Smile! We also were just chosen as China Wisdom Angel’s first demo and training center.

What has been your biggest challenge? passion, giving, sacrifice, contribution, dedication, and the will to overcome difficulties. I never want to quit and will always try to find a way to achieve my goals.

What is the most satisfying aspect of your practice?

We are the pioneers of 21st-century smile makeover dentistry, which involves technology and innovation. It encompasses: 1. Better engineering of the occlusion (NYS occlusion) that enhances airway, TMJ, posture, and total body skeletal balance 2. Preventive and anti-aging processes that preserve the foundation of smile

To help ourselves and our patients understand that a smile makeover is just like a life makeover — a lifetime and daily journey. But the rewards are instant and valuable over a patient’s whole lifetime. We have systemized and simplified our NYS system to be easy duplicable, and we continue to make huge improvements.

What would you have been if you didn’t become a dentist? A smile artist, innovator, and healer. That would still place me in the dental field!

What is the future of the specialty and dentistry? More and more people can have the Volume 8 Number 2

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

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

To learn more, visit www.hiossen.com or call 888.678.0001 Searching for talented people. Apply Now!

Made in the USA

PRACTICE PROFILE chance to have the smile they have always wanted. The technology and awareness of dentists in the full mouth rehabilitation field are continually making progress, The beautiful smile that we all wanted should be ours; it is no longer a dream, but the reality!

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

Top favorites

Dr. Skelton with her family

1. The right vision and leadership. Knowing yourself is a must. 2. Be the right kind of team player. 3. Choose the right system. 4. Choose the right products and services. 5. Have a passion and love to offer the right kind treatments to your patients. 6. Learning new processes and training is part of the passion.

What advice would you give to budding specialist? Truly know from your heart what you

12 Implant practice

love to do. Find your best talent and your resources. Combine all of those, creating a style that you know is your best. Perfect that and find help for the part that is not your strength. Learn your marketing style, and then, pray to God to send you the patients whom you can help the most!

What are your hobbies, and what do you do in your spare time? Shopping, fashion, makeup, good restaurants, movies, reading, traveling, and seminars. I am open to all kinds of pampering! IP

1. Dental implants: Ossotanium — customized implant service at a great price; a just like home relationship 2. OCO: easy to use, great price too 3. Ultra OralStone™ crown and bridge and denture material: simple and easy to use, affordable, and chairside repairable 4. Maxi-Temp®: nice temp 5. Turbo Temp™: nice hybrid bridge reline 6. Radical glaze: great for resin temp 7. Radical material: nice reline for NYS crown and bridge 8. Triad® temp white: great for chairside makeovers or stone model designs and temp relines 9. Triad® pink: great gum material 10. Palaseal: great denture glaze and resin temp bond 11. Pink Sil-tech®: a must for every smile makeover process

Volume 8 Number 2

CORPORATE PROFILE

ACE Surgical Supply There from the start. 1967 was a watershed year for the dental surgery community and the profession at large: The practice of oral surgery was rapidly transitioning to private practices across the United States. Yet the transition had left the profession with surgical products and instrumentation unsuitable for oral surgical procedures. Undaunted, and with many patients to treat, J. Edward Carchidi, DDS, went to work developing products that made sense for his private practice and his patients. This is how ACE Surgical Supply began. Word spread, and more oral surgeons sought Dr. Carchidi’s recast and customized dental surgical supplies. And they still do today.

“We didn’t have certain things, so we invented them.” Dr. Carchidi cited an emerging niche unrecognized by medical and traditional dental suppliers at the time. His entrepreneurial instincts surfaced — the specialized needs of oral surgeons would best be met by a fellow oral surgeon like himself, offering smartly modified products designed in his workroom for a fair price. The response was immediate and immense. Dr. C’s workroom gave way to an ever-expanding office, a loyal staff, and an official business name: ACE Surgical Supply. Forty-nine years later, ACE operates on this single enduring principle: How can we better serve oral surgeons and dental practitioners? The symbiotic relationship between oral surgeons and ACE was thereby established. Cultivating each business relationship has meant listening and re-examining everything from purchase quantities to core materials, thus assuring the most efficient purchasing strategies for managing a profitable practice. Affordability is central to patient retention. Our entire portfolio of products extends bestin-class competitive pricing — just one of the ways we’ve been instrumental in advancing oral healthcare.

Truly the complete solution ACE is proud to preserve our clients’ trust through decades of technological breakthroughs. Bone regeneration and dental implants are now established treatments. 14 Implant practice

The management team at ACE Surgical. Seated left to right: Christopher Carchidi and Craig Carchidi. Standing left to right: Tim Ritchey, Paul Caracciolo, David Dommel, Kerrin Sidibe, Michael Mancini, and John McKinnon

Starting as pioneers, today ACE is a bone regeneration leader, with a top-tiered spectrum of products: allograft, xenograft, and synthetics — predictable and proven products to reinforce patient trust. Our Infinity line of compatible, dental implant systems allows practitioners to place and restore the Infinity implants with the same confidence derived from their current systems without the added expenses.

“We’ll get it for you, for a better price.” The power of teamwork has been the trademark of ACE’s growth. Our team is family, literally, with relatives and longtime, permanent associates building our reputation every day. Our team anticipates customer needs with dedication and purposeful focus. We know our customers, the needs of their practices, and how to deliver the right products at the right price. All of our planning, decisions, and forecasting are based on customer needs. In fact, our current measured expansion further consolidates our corporate offices,

J. Edward Carchidi, DDS, Founder of ACE Surgical Supply

Volume 8 Number 2

ACE Production Technician working in one of the many clean room facilities at ACE Surgical Supply

warehouses, clean room facilities, and customer service center in order to better serve our customers. The nexus of our roots naturally extends outward to investigate important new therapeutics, instrumentation, and technologies. There is no end to our in-depth research for the development of new products and treatments for our clients and their patients. ACE is a formidable presence in the dental surgical world, not because of a series of acquisition and mergers, but because our customers brought us here. IP This information was provided by ACE Surgical Supply.

Infinity Dental Implant Systems â&#x20AC;&#x201D; committed to delivering a truly compatible implant solution

Volume 8 Number 2

Implant practice 15

CORPORATE PROFILE

ACE is a formidable presence in the dental surgical world ... because our customers brought us here.

NEW COMPANY SPOTLIGHT

Paradise Dental Institute to launch live implant training and annual conference in the Bahamas

aradise Dental Institute sets “sail” this July with the launch of a live surgery implant training program and annual working conference called Summers in Paradise at the Atlantis Resort and Casino, July 30-August 1, 2015. The working conference will explore the theme “Navigating the Past, Sailing to the Future” and the exciting but also challenging world of implant dentistry. The Institute, located in Nassau, Bahamas, will feature its faculty members as speakers or “captains” as well as guest speakers discussing topics from introductory to full mouth reconstruction surgery and prosthetics. Speakers will navigate traditional sound surgical practices of the past and sail to guided treatment planning and surgery, which are both the present and the future of dentistry. The working conference will allow dentists to diagnose, treatment plan, perform surgery, post-surgery management and complications, and deliver a final prosthesis, all in one morning! The interactive morning sessions will provide dentists who are new to and also experienced in implant dentistry a deeper understanding of when, why, and how.

The following are the preliminary ports of call: • Thursday, July 30: Introduction to Implants and Soft Tissue Grafting Captains: Dr. Rick Ferguson and Dr. Avi Schetritt • Friday, July 31: Predictable Impression Taking and Temporization Captain: Dr. Stace Lind • 7:00 p.m.-9:00 p.m.: Official Launch All-White Beach Party • Saturday, August 1: Guided and NonGuided Full Mouth Reconstruction Captains: Dr. Michael Pikos and Dr. Michael Tischler The conference features morning lectures from 8:00 a.m.-1:00 p.m. each day with breaks in between. Lunch and exhibit-only hours are from 1:00 p.m.-3:00 p.m. with a live calypso band playing, and a lunch featuring delicious local and American cuisine, and happy hour with the exhibitors, as it will be 5:00 p.m. somewhere!

After 3:00 p.m., guests can continue with happy hour or explore Atlantis! Friday night is the Official Launch with an all-white beach party and cultural entertainment. Dentists are encouraged to bring their families as Atlantis has something for everyone, and the group rate is available for 3 days before and 3 days after the conference for $226 per night, which includes spouses and children. The Institute and the Summer Conference is the brainchild of Founder and CEO Dental Technician Ms. Indira Darling, who partnered with Co-Founder and Clinical Director Dr. Derwin Munroe. The pair, who are both Bahamian born and American trained, will combine their love of dentistry and their beautiful country to launch the most comprensive implant training program with the philosophy, “No man is an island!” The institutute will provide dentists and all team members with the surgical, theoretical, clinical and business skills necessary to build a successful implant practice. To this end, our faculty is comprised of oral surgeons, ABOI board certified implant general dentists, hygenists, lab technicans, surgical assistants, and office managers. Our faculty will provide continued mentoring and support to dental teams as they begin or advance in implant dentistry. IP This information was provided by Paradise Dental Institute.

16 Implant practice

Volume 8 Number 2

CASE STUDY

Osseodensification facilitates ridge expansion with enhanced implant stability in the maxilla: part II case report with 2-year follow-up Drs. Ann Marie Hofbauer and Salah Huwais offer another case study using a novel biomechanical site preparation technique

n 1981, Dr. Albrektsson, a member of Dr. Brånemark’s team, stated that there are six factors for reliable osseointegration: implant material and design, its surface condition, bone status, surgical technique, and implant loading condition. (Albrektsson, et al., 1981). In 2004, 23 years later, he reemphasized the need for site preparation improvement, saying, “It seems probable that improvements in surgical technique will present good prospects for improving clinical results” (Albrektsson, et. al., 2004). Bone is a unique composite of protein molecules and mineral structure that form together contradictory properties: stiffness yet flexibility, lightness yet strength (Seemen, et al., 2008). As it is inhomogeneous (not uniformed), anisotropic (directionally independent), and viscoelastic, bone is flexible enough to absorb energy and change shape (deform) without failing, yet it is able to widen in compression and able to lengthen with tension. If load exceeds the bone’s ability to deform elastically, it can deform further and change permanently by plastic deformation (Matrin, et al., 2008). Ann Marie Hofbauer, DMD, received her dental degree at Southern Illinois University School of Dental Medicine in 1994 and her Certificate of Periodontics at the University of Illinois at Chicago College of Dentistry in 1997. She is a Diplomate of the American Board of Periodontology. Her private practice is limited to periodontology and implant dentistry.

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.

18 Implant practice

Bone behavior “strength” is directly related not only to its bulk of mineral density but also to its collagen integrity (Lang, et al., 2002). So, maintaining that bulk will determine the implant’s stability and its long-term success. Osseodensification is a novel biomechanical site preparation technique. It produces low plastic deformation due to its non-extraction site preparation method, which preserves the bone to enhance the host. It utilizes a multi-fluted Densifying Bur technology (Versah™, LLC) that creates and expands a pilot hole without excavating significant amounts of bone tissue through a unique, highly controllable, fast, and efficient procedure with minimal heat elevation. The taper design allows the surgeon to modulate pressure and irrigation, while providing a unique real-time haptic feedback that makes the Densifying Bur intuitive for every skilled implant surgeon. When the densifying bur is rotated at 800-1500 RPM in the counterclockwise non-cutting direction (Densifying mode), downward surgical pressure coupled with steady external irrigation creates a gentle compression wave inside the osteotomy that works with the fluting to generate a densified layer through compaction and autografting the surrounding bone while plastically expanding the bony ridge at the same time (Meyer, Huwais, et al., 2014). The Densifying Burs can also be rotated in the clockwise cutting direction (Cutting Mode) to cleanly cut bone if needed. This dual use capability allows for clinical versatility — it may enable the implant surgeon to autograft the maxillary sinus and efficiently expands any ridge in either jaw with enhanced implant stability. Our previous case report involved a ridge expansion and two implant placements in the mandible. This case report is about expanding an inadequate 3-mm ridge in

the maxilla to place a 4.2-mm implant with enhanced primary stability.

Case report: maxillary ridge expansion with implant placement The patient is a 65-year-old male presenting with missing tooth No. 6. Radiographic and clinical examination revealed a significant hard and soft tissue deficiency due to alveolar ridge resorption (Figures 1 and 2). Patient medical history was non-contributory. Dental history included surgical extraction of tooth No. 6 with socket preservation graft. Treatment options with their potential risks and benefits were presented to the patient. A final treatment plan was decided to utilize one implant placement for single crown restoration. Consent was given by patient to utilize osseodensification site preparation for ridge expansion with immediate implant placement and ridge augmentation if needed.

Figure 1: Hard and soft tissue deficiency in area of tooth No. 6

Figure 2: Significant loss in alveolar ridge due to buccal plate resorption post extraction and socket graft Volume 8 Number 2

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CASE STUDY The upper right anterior area was anesthetized using infiltration with 1.8 ml 4% Septocaine® (Septodont) with 1:100,000 epinephrine. Interproximal papillae were conserved. U-shaped incisions with extended vertical releases were made (Figure 3) to allow for Modified Roll Soft

Tissue Augmentation technique. A full thickness flap was reflected, and a 3.0-mm crestal alveolar ridge width was confirmed by direct measurement (Figure 4). A 1.7-mm initial pilot osteotomy was created to a depth of 13 mm utilizing a highspeed surgical handpiece and a surgical

Figure 3: U-shaped incision to allow for Modified Role Soft Tissue Augmentation

motor (W&H). The pilot drill was rotating at 1200 RPM in a clockwise (CW) rotation. Using the pilot drill as a paralleling pin, an X-ray was taken to confirm the angulation between the adjacent teeth and the implant. Once the correct position of the implant was confirmed, osseodensification was utilized using Densah™ Bur VT1828 (Versah™, LLC) running in a non-cutting counterclockwise (CCW) direction at 1200 RPM (Densifying Mode) with a bouncing motion to expand the osteotomy to 2.8 mm (Figure 5). Sequential use of Densah™ Bur VT2838 running in a non-cutting counterclockwise (CCW) direction at 1200 RPM (Densifying Mode) with a bouncing motion was utilized to expand the osteotomy to a 3.8-mm diameter (Figure 6). Osseodensification facilitated maxillary ridge expansion to form an osteotomy of 3.8-mm diameter without any buccal bone dehiscence (Figure 7), which allowed for total implant length placement in autogenous bone. One 4.2/13 Legacy2™ (Implant Direct™) was placed with an insertion torque

Figure 4: Alveolar ridge width after flap reflection measuring 3.0 mm

Figure 5: Densah™ Bur 1828 was used in Densifying Mode

Figure 6: Densah™ Bur 2838 was used in Densifying Mode

Figure 7: Osseodensification facilitated alveolar ridge expansion to form 3.8-mm osteotomy

20 Implant practice

Volume 8 Number 2

More than primary stability.

The new tapered standard.

Flexibility in challenging clinical and anatomical situations – the Straumann® Bone Level Tapered Implant: • Roxolid® material – Permits the use of smaller-diameter implants with the same clinical performance as regular-diameter titanium implants1 • SLActive® surface – Designed to maximize treatment success and predictability in stability critical treatment protocols • Apically tapered – Overcomes anatomical restrictions and is designed to enable placement in under-prepared sites • Crossfit® Connection – Delivers simplified handling and assurance that the abutment is seated properly straumann.us/blt

In combination with: 1 Benic GI, Gallucci GO, Mokti M, Hämmerle CH, Weber HP, Jung RE. Titanium-zirconium narrow-diameter versus titanium regular diameter implants for anterior and premolar single crowns: 1-year results of a randomized controlled clinical study. Journal of Clinical Periodontology 2013 Nov;40(11):1052–61. Epub 2013 Sep 8.

CASE STUDY > 50 Ncm (Figure 8). Implant stability was tested with an (OsstellÂŽ) ISQ implant stability meter. Buccal-lingual ISQ reading was 81. A healing abutment was placed, and the Modified Roll technique was used as soft tissue augmentation in the buccal of implant No. 6 site (Figure 11A).

Buccal-lingual ISQ readings were obtained weekly for 6 weeks. At 3 weeks post placement, ISQ reading for implant No. 6 was 67. Although many studies have suggested that implants with ISQ 67-68 have the stability needed for loading, our team chose to wait for further soft tissue maturation.

Figure 8: 4.2/13-mm implant was placed in area of tooth No. 6

Figure 10: Implant placement radiograph

Figures 9A-9B: Ridge expansion with no dehiscence allowed for total implant length placement in autogenous bone with ISQ = 81

Figure 11A: Modified Roll technique was used as soft tissue augmentation in the buccal of implant No. 6 site

Figures 11B-11D: Three weeksâ&#x20AC;&#x2122; healing revealed ISQ 67 reading 22 Implant practice

Volume 8 Number 2

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No Interest for 6, 12, 18 or 24 months, after that 22.98% variable APR. Interest will be charged to your account at the standard variable APR of 22.98% (based on the Prime Rate) from the end of the promotional period on the remaining balance if the purchase balance is not paid in full within the promotional period. Minimum monthly payments for this plan during the promotional period will be the greater of: the amount of the purchase divided by the number of months in the promotional period (rounded up to the nearest $1.00); or $5. Required minimum purchase of $499 for the 6-month plan; $999 for the 12-month plan; $1,499 for the 18-month plan; $2,499 for the 24-month plan. Lending Club Patient Solutions Credit Accounts are offered by Comenity Capital Bank who determines qualiﬁcations for credit and promotion eligibility. Minimum Interest Charge is $1.00 per credit plan. Standard variable APR of 22.98%. 2 Rates range from 3.99% to 19.99% APR. Terms available based on amount ﬁnanced and credit history. All Extended Plan loans made by NBT Bank, N.A. member of FDIC Equal Housing Lender. Please visit lendingclub.com/healthcare for current rate information. © 2015 Lending Club Patient Solutions products and services provided through Springstone Financial LLC, a subsidiary of LendingClub Corporation. Payment plans made by issuing bank partners. lendingclub.com/providers. 1

CASE STUDY

Figures 12A-12C: Six weeksâ&#x20AC;&#x2122; healing revealed ISQ 79/83 reading

Figures 13A-13B: Final restoration of single crown restoration was delivered with adequate buccal ridge anatomy

Figures 14A-14B: One-year follow-up revealed maintained buccal anatomy 24 Implant practice

Figure 15: One-year radiographic follow-up revealed maintained crestal bone level

Figure 16: Two-year follow-up revealed maintained crestal bone level Volume 8 Number 2

Supportive and follow-up care The patient returned at 1 year for clinical and radiographic follow-up. Examination revealed healthy hard and soft tissue with no sign of inflammation or infection. The patient maintained buccal bone anatomy, and adequate coronal bone level was evident. The 2-year radiograph taken by the patient’s restorative dentist demonstrated no change in alveolar bone height (Figure 16).

Discussion In this case, osseodensification utilizing Densah™ Bur technology has facilitated ridge expansion in the maxilla with maintained alveolar ridge integrity, allowing for

Prosthetic Materials & Solutions

total implant length placement in autogenous bone with adequate primary stability. Despite compromised bone anatomy, osseodensification preserved bone bulk and promoted a shorter healing period. According to Trisi, et al., 2009, immediate implant loading can be recommended when insertion torque value (ITV) is at least 45Ncm, and ISQ is at least 68. Ossseodensification technique can be recommended to enhance primary stability and possibly allow for earlier loading due to higher ITV and ISQ.

REFERENCES

Conclusion Osseodensification utilizing the Densah™ Bur technology produces stronger osteotomy for any implant. It preserves the bone to enhance the host. This allows for clinical versatility, which may facilitate enhanced implant stability and efficient expansion of any ridge in either jaw. IP

Albrektsson T, Brånemark PI, Hansson HA, Lindström J. Osseointegrated titanium implants. Requirements for ensuring a long-lasting direct bone-to-implant anchorage in man. Acta Orthop Scand. 1981;52(2):155-170.

Albrektsson T, Wennerberg A. Oral implant surfaces: Part 1— review focusing on topographic and chemical properties of different surfaces and in vivo responses to them. Int J Prosthodont. 2004;17(5):536-43.

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

Martin TJ, Seeman E. Bone remodelling: its local regulation and the emergence of bone fragility. Best Pract Res Clin Endocrinol Metab. 2008;22(5):701-722.

Lang TF, Guglielmi G, van Kuijk C, De Serio A, Cammisa M, Genant HK. Measurement of bone mineral density at the spine and proximal femur by volumetric quantitative computed tomography and dual-energy X-ray absorptiometry in elderly women with and without vertebral fractures. Bone. 2002;30(1):247-250.

Meyer E, 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.

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.

Scan the code to view a video of the procedure, or visit http://www.versah.com/ osseodensification-with-ridge-deficiency/

Your Total Solution Provider

Implant

Fabrication

Scan Body

Biodenta has established its position within the dental field on the concept of the Total Solution Provider. This is a systems based approach to dentistry. Our two main product groups are Dental Implant System (DIS) and Digital Dentistry System (DDS). We believe that the future belongs to those who successfully can integrate these modules in a smart and efficient way. Our mission is to help clinicians to do this through advancements in products, workflows, and clinical procedures. Biodenta stands for the highest Swiss quality and precision. Our staff collaborates with dental professionals and specialists from other industries on a daily basis in order to improve products and solutions for increased reliability, predictability, and simplicity. We invite you to learn more about Your Total Solution Provider and how we can work together to improve implant dentistry.

Planning and Design

Digital Impression

www.biodenta.com/learnmore Volume 8 Number 2

Implant practice 25

CASE STUDY

At 6 weeks post placement, ISQ reading was increased substantially to 79/83. This increase in stability allowed us to start the restorative phase. The patient was referred back to his restorative dentist for final restoration at 6 weeks. Final restoration of a single crown was delivered with adequate buccal ridge anatomy (Figure 13).

CLINICAL

Implementing a contemporary, in-office complete digital workflow within a clinical implant practice: intraoral scanning, virtual design, and 3D printing Dr. Michael D. Scherer summarizes a contemporary approach incorporating intraoral scanning into a dental implant practice, including integration with cone beam CT technology and in-office 3D printing, to enhance restorative visualization and surgical guide planning Synopsis/abstract Intraoral optical scanning (IOS) technology is not new to clinical practice; however, the integration of this technology has been slow because it is often viewed as challenging, cumbersome, and with a cost that is out of the reach of most clinicians. This article seeks to describe a contemporary, yet affordable, approach to integrating IOS into dental implant practice including digital superimposition with cone beam CT radiography, computerized surgical guide fabrication, and 3D printing models for using in a private practice setting.

Introduction Technological innovation and implementation of contemporary digital techniques in methods and materials in clinical practice is both exciting and challenging for private practice practitioners. In busy dental implant practices, it is easy to justify utilizing conebeam computed tomography (CBCT) for treatment planning. Taking the next step of including optical image fusion with the CBCT scans for the purposes of fabricating computerized surgical guides and immediate restorations is a big one for many. In this author’s experience, the biggest barrier to Michael D. Scherer, DMD, MS, FACP, is an Assistant Clinical Professor at Loma Linda University in California, a Clinical Instructor at University of Nevada, Las Vegas (UNLV), and maintains a practice limited to prosthodontics and implant dentistry in Sonora, California. He is a fellow of the American College of Prosthodontists and has published articles related to implant dentistry, clinical prosthodontics, and digital technology with a special emphasis on implant overdentures. As an avid technology and computer hobbyist, Dr. Scherer’s involvement in digital implant dentistry has led him to develop and utilize new technology with CAD/CAM surgical systems, implement student-facilitated CBCT implant planning, and outside-of-the-box radiographic imaging concepts. Dr. Scherer has served as the director of the implant dentistry curriculum at UNLV and is actively engaged in guided surgical placement and prosthetic restoration of implants in private practice. Dr. Scherer also maintains “LearnLODI” and “LearnLOCATOR” — interactive YouTube channels on standard and narrow diameter dental implant procedures.

26 Implant practice

taking this step is the lack of confidence that the systems will work because they are either too confusing, cumbersome, or expensive. The reality is that these systems have been around for years but are just now becoming rapidly embraced by clinicians. Machining and reductive-style CAD/CAM technology like CEREC® (Sirona Dental USA) has been available to private practice practitioners since 1987.1 This technology was exciting because at its implementation, both computers and the Internet were in their infancy, yet a private dental office could make a photograph of a tooth preparation, and minutes later, mill an esthetic ceramic restoration. At the publication of this article, almost 30 years later, it is interesting that approximately 14,000 U.S. and 24,000 worldwide dentists utilize this technology within their offices.2 While this may seem like a large figure, when comparing the total number of dentists in each respective group, these figures represent an implementation of 8% in the United States (186,000 total dentists) and 1% worldwide (1.8 million total dentists).2-4 The most likely reason for this low implementation rate? The high initial cost. At approximately $100,000 USD, the high cost of this technology can be a substantial barrier, not to mention having to qualify for a loan, paying interest on the practice loan, and yearly software updates. Finally, this technology makes a clinician change the way he/she practices including the types of materials used (PFM versus ceramics) and daily routine (prep/temp versus prep/design/cement final ceramics). The important question to ask is, How can we implement contemporary technology that’s accessible to more dentists by having a lower initial investment and also one that fits into a clinician’s everyday schedule and flow? The purpose of this clinical article is to describe implementation of intraoral scanning and three-dimensional (3D) printing into a private clinical implant dental practice.

Intraoral scanning Intraoral optical scanning (IOS) technology was first popularized with the introduction of the CEREC system and has progressed parallel to the development of this system.1 Standalone intraoral scanning units, however, were not introduced until around 2006, and the technology has rapidly become popularized due to the lower cost of the scanning units compared to the CAD/ CAM machining systems. In addition, the growing segment of dentists placing implants with the help of CBCT and computerizedguided surgery has created a demand to incorporate optical scanning. While conventional impression techniques are an accurate way to reproduce the details necessary to fabricate surgical guides and indirect restorations, they are also technique-sensitive, cumbersome, and can also be subjected to laboratory error. Intraoral

Figure 1: Chairside intraoral optical scanner (3M™ True Definition Scanner, 3M ESPE) Volume 8 Number 2

tissues. If a capture error is found with this conventional technique, the only recourse is to remake the impression. With intraoral scanning, the clinician can scan and capture a segment of the dentition, stop for a moment to complete the scan, and then scan an additional segment. These multiple segments can be joined together to form a single image (Figure 3). This approach is valuable for mandibular scans, where the tongue can difficult to control; with patients with high saliva production; and with patients who tire easily from staying open. Additionally, for crown and bridge applications, a second scan can be joined to the first scan if a margin was missed (Figure 4). This technology, known as image fusion or superimposition, is especially exciting because it allows for joining of tooth/tissue optical scans and CBCT radiological scans.5

Image fusion and joining optical and CBCT scans CBCT imaging utilizes multiple twodimensional (2D) radiographic slices that virtually join together to form a 3D image

to facilitate viewing. Historically, the 3D image was used only for visual reference, and clinicians traditionally relied upon a 2D interpretation of bone volumes to analyze for proper implant placement (Figure 5). This approach serves an important function giving substantially more information than a periapical or panoramic radiograph; however, it relies upon the clinician estimating implant placement during surgical procedures with assistance of a model-based standard surgical guide. CBCT-based surgical guides allow for precise drilling at the angle, depth, and position based on the virtual-planned implant positions versus estimation of these parameters during surgical procedures with model-based surgical guides. Implementing optical scanning into an implant practice is facilitated by optical fusion technologies allowing visualization of a tooth/tissue optical scan virtually on a CBCT radiograph. A challenge of visualizing a 3D rendering of an arch with CBCT alone is problems related to artifacts induced by metallic objects such as crowns or amalgam fillings, inadequate soft tissue visualization,

Figure 2: As the scanner optically reads the tooth and tissue contours, visual display of the images on the computer monitor give the clinician instantaneous feedback

Figure 3: Multiple intraoral scans can be captured and joined together to form a single image, allowing for easy reproduction of detail in challenging patients

Figure 4: Joining together multiple scan attempts is extremely beneficial for having to refine and recapture crown margins

Figure 5: Traditional implant planning techniques involve a 2D interpretation of the 3D CBCT scan

Volume 8 Number 2

Implant practice 27

CLINICAL

scanning uses optical imaging technology, including making multiple image scans of the teeth/tissues and then mathematically calculating the differences between images to generate a 3D image. One system, the 3Mâ&#x201E;˘ True Definition Scanner (3M ESPE), uses a technology called â&#x20AC;&#x153;active wavefront samplingâ&#x20AC;? in which distances between objects on the scan coincides to a focal length of the lens (Figure 1). Upon focusing the video-feed image, the difference between the focused and non-focused image is calculated, and distances are reported as a 3D image. Live image acquisition is acquired and displayed on a computer monitor, giving instantaneous feedback on accurately capturing all of the details of teeth and tissues (Figure 2). The optical impression technique is in contrast to that of conventional impression techniques using impression materials such as polyvinylsiloxane (PVS), where a series of viscosities are mixed together and placed onto teeth/tissues and held in one place until fully polymerized. After polymerization, the impression is removed and examined for accurate representation of the teeth/

CLINICAL and digital tresholding controls (Figure 6). Overlay of an optical scan on the CBCT allows for overcoming of these limitations of conventional CBCT visualization and greatly enhances visualization of dental arches in relation to bone volumes (Figure 7). The workflow of image fusion begins with initial planning of an implant procedure (Figure 8). While this initially seems complicated to many clinicians, it is easy to do once completed successfully a few times. First, an intraoral optical scan is made of

the arch (Figure 9). This often takes approximately 3-4 minutes to complete, and depending upon dental regulations within various communities, can be delegated to a dental assistant. The scan is uploaded and processed into a stereolithography data file (STL), which is the 3D optical image file, similar to a JPG or GIF format that is used for 2D photographic images. Second, a CBCT scan of the patient is made with cotton rolls placed to separate the occlusal surfaces and tissues (Figure 10). The CBCT

Figure 6: CBCT images are subject to artifact scattering due to metal artifacts such as amalgam restorations, crowns, implants, and posts making interpretation of implant-tooth position more difficult

Figure 8: Workflow outlining the steps to generate a superimposition of an optical image on a CBCT scan

28 Implant practice

Figure 7: Same patient as depicted in Figure 6, however, an optical image of the dentition is overlaid on the CBCT scan, giving the ability for a clear and precise interpretation of the dental structures surrounding the proposed implant site

Figure 9: Intraoral scan of a patient immediately after tooth preparation for proposed implant sites Nos. 3, 4, 5, and 10

Figure 11: An implant is initially placed in the planning software (Invivo, Anatomage) according to best fit within the bone volume

scan digital imaging and communications in medicine (DICOM) files are opened in a dental implant planning software (Invivo, Anatomage), and a dental implant is tentatively planned according to best fit within the bone volume (Figure 11). The implant plan (.INV file) and optical scan (.STL file) are uploaded to a central processing server where the images are fused together (Figure 12). Alternatively, some software packages allow for the clinician to perform image fusion without having to send it to a

Figure 10: Tooth and soft tissue separation is achieved by strategically placing cotton rolls around the teeth in the following orientation: 3 buccal, 2 lingual, 2 occlusal

Figure 12: The planning file (INV) and optical scan (STL) are uploaded to a central server for image processing Volume 8 Number 2

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CLINICAL central server (Blue Sky Plan速, Blue Sky Bio) (Figure 13). The final plan with image-fused scans is downloaded and checked to ensure that the proposed implant trajectory is within the desired restorative contours. A virtual restoration can be created, allowing for a more precise positioning of the implant to the proposed restorative plan (Figure 14). Proposed guide sleeve positions are verified, and a computerized surgical guide is finalized by uploading the final, verified planning file (.INV) through the central server (Figure 15). The guide is tried in, and the implant is placed (Figure 16).

In-office 3D printing Until just a few years ago, 3D printing remained in the realm of large dental laboratories and facilities that can own and operate large and expensive equipment necessary to adequately print for dental models. Similar

Figure 13: Some software packages allow for the user to superimpose optical images on CBCT scans (Blue Sky Plan, Blue Sky Bio)

Figure 14: Virtual restorations can be easily visualized and planned with superimposed optical images

Figure 16: The surgical guide is tried in, and the implant is placed 30 Implant practice

Figure 15: Changes are made to the planning file and uploaded to the central server for guide fabrication

Figure 17: Reasonably priced, consumer-grade, 3D printers (Form 1+, Formlabs) can be utilized in dental offices to fabricate models of teeth, edentulous ridges, and alveolar surfaces Volume 8 Number 2

CS 9300

INTELLIGENT CHOICE LOW-DOSE SCANS TRUE 2D PAN FAST, ACCURATE 3D IMAGING The CS 9300 lets you focus on a specific area of interest, whether it’s zooming in on a maxillary exposure using the 5x5cm scan or shooting a 17x13.5cm scan for orthognathic surgery. So you get the options you need to limit radiation exposure and maximize image quality, and it’s simple to share the images with your referrals. • 3D images - now at a dose up to 85% lower than panoramic imaging1 • Dedicated 2D digital panoramic imaging in 14 seconds • Comprehensive implant planning software and implant library

LET’S REDEFINE OMS Call 800.944.6365 today, or visit www.carestreamdental.com/OMS © Carestream Health, Inc. 2015. 12272 OM 93 AD 0415 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 Low-Dose 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%.

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CLINICAL

Figure 18: Workflow of integrating intraoral scanning and in-office 3D printing

to the previous example of in-office CAD/ CAM, the high cost of this equipment has been a critical factor limiting the integration into private clinical practices. Recently, 3D printing has become more accessible to practitioners due to the rapid development of consumer-grade stereolithography (SLA) printers such as the Form 1+ (Formlabs, Somerville, Massachusetts) (Figure 17). These consumer-grade printers, often costing just a few thousand dollars, are a significant departure from the currently available dental laboratory printers, which can cost almost 10-20 times more than a consumer-grade printer. The workflow for 3D printing begins with an intraoral optical scan of the dentition, and generation of a STL file and results in a 3D printed model (Figure 18). While some intraoral scanners do not allow for exporting of open STL file, this author uses a scanner that easily converts an intraoral optical scan into an open STL (3M™ True Definition Scanner, 3M ESPE). The STL file is opened in a digital-modeling software (netfabb basic, netfabb GmbH, Lupburg, Germany) where missing parts of the scan can be filled in, and a base can be added. Alternatively, software that comes with a 3D printer will allow for automatic processing of an STL file to make it ready for printing (Figure 19) (Proform, Formlabs). A variety of colors and physical properties are available with some offering printing accuracy of between 25-200µm. Greater accuracy prints require more time, often up to 2-4 hours per dental model, because they are printing in thinner layers that require more layers to fabricate a dental model. The STL file is imported into the printer software, and the resin tank is filled with liquid resin. The 32 Implant practice

Figure 19: 3D printing software allows for orientation and preparation for printing

Figure 20: In-office 3D printed models allow for a variety of applications, including provisional models, surgical guide fabrication, and study models

dental model is printed and can be used to work with planning, designing, and fabricating surgical guides (Figure 20). Following printing of the surgical guide, metal sleeves are incorporated in to the resin guide using a vacuum-forming processing, completing the fabrication process.

CBCT interpretation and intraoral scanning, a paradigm shift in practice is rapidly occurring. The proposed workflow in this article describes just one of the many potential implementation strategies for this exciting technology. IP Disclosure: Dr. Michael Scherer is a clinical consultant

Conclusion While originally out of the reach of many, contemporary digital techniques are being implemented into private practices, allowing a seamless, digital approach to everyday dentistry. Intraoral scanning, especially with being able to easily export open STL files, allows for the full digital control, whether simply for restoration visualization or for being able to fabricate guides. In-office 3D printing, while still a relatively new technology, is rapidly becoming part of everyday private practice. With advanced in dental implant

to Zest Anchors, BIOMET 3i™ , and Keystone Dental.

REFERENCES 1. Mörmann WH. The evolution of the CEREC system. J Am Dent Assoc. 2006;137(suppl):7S-13S. 2. Puri S. A CAD/CAM picture is worth a thousand words. CERECdoctors.com Magazine. 2009;Q2:46-47. 3. Yamalik N, Ensaldo-Carrasco E, Cavalle E, Kell K. Oral health workforce planning part 2: figures, determinants and trends in a sample of World Dental Federation member countries. Int Dent J. 2014;64(3):117-126. 4. Dentists working. WorldMapper Web site. http://www.worldmapper.org/display.php?selected=218#. Published 2004. 5. Scherer MD. Presurgical implant-site assessment and restoratively driven digital planning. Dent Clin North Am. 2014;58(3):561-595.

Volume 8 Number 2

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Ablation and sulcular debridement utilizing the CO2 laser for denture-induced gingival hyperplasia Drs. Joel L. Rosenlicht and Peter Vitruk discuss gingival hyperplasia and peri-implant pocket treatment using a CO2 laser Introduction The term gingival hyperplasia refers to excess gingival tissue growth. It can be caused by numerous factors, most common being periodontal disease, poor oral hygiene, medications, smoking, and ill-fitting denture prostheses.1,2 The treatment of hyperplasia includes elimination of the causing factors and surgical removal of the lesion.1 If the cause persists, the tissue becomes more fibrous over time and can ulcerate and cause further pathology. This article presents a case report of the surgical removal of gingival hyperplasia along with the sulcular debridement for periimplantitis using the flexible fiber CO2 laser with a variety of dental and surgical laser handpieces. Hyperplasia can be treated conservatively (by improving oral hygiene) or surgically (by scalpel, electrosurgery, carbon dioxide [CO2], Er:YAG, Nd:YAG, and diode lasers).1-3 The greatest disadvantage of the conventional scalpel is intraoperative hemorrhage and the need to suture the wound (patient discomfort).4 The CO2 laser in the case described in this article did not require sutures and allowed the surgeon to perform vestibuloplasty with a palatal mucosal graft during the same visit. Electrosurgery was not an option in the case described in this article because of the close proximity to the titanium implants.5 Joel L. Rosenlicht, DMD, an oral and maxillofacial surgeon, is past president of the American Academy of Implant Dentistry (AAID) and past president of the American College of Oral and Maxillofacial Surgeons (ACOMS). He is a Diplomate of the American Board of Oral and Maxillofacial Surgery (ABOMS) and of the American Board of Implant Dentistry (ABOI). Peter Vitruk, PhD, MInstP, CPhys, is founder of LightScalpel, LLC. He is a member of the The Institute of Physics and of the Science and Research Committee, Academy of Laser Dentistry. He is also on the faculty of the California Implant Institute and Global Laser Oral Health, LLC. Dr. Vitruk can be reached at 1-866-589-2722 or pvitruk@LightScalpel.com.

34 Implant practice

The CO2 laser is an excellent tool for removal of gingival hyperplasia because of its ability to induce hemostasis, speed, lack of the need for sutures, and excellent healing with reduced wound contraction without scar tissue resulting in healthy pliable tissue.6-8 In comparison with scalpel wounds, healing in the CO2 laser-treated wounds is characterized by a higher fibroblastic proliferation with young fibroblasts actively producing collagen. Only a small number of myofibroblasts (the cells responsible for wound contraction) are found in the CO2 laser-treated wounds compared with scalpel wounds.9,10 Thus, diminished wound contraction and reduced possibility of scar tissue formation are attributed to the insignificant amount of myofibroblasts. In addition, the CO2 laser can be effectively used for sulcular debridement due to its bactericidal properties along with the safety of the 10,600 nm wavelength around titanium implants.11-13

Figure 1A: Articulated arm (left) and flexible fiber (right) dental soft tissue 10,600 nm CO2 lasers. (Photo courtesy of LightScalpel, LLC)

Soft tissue laser surgery The CO2 laser is a “what you see is what you get” surgical soft tissue cutting laser with minimal collateral thermal effects sufficient for sealing blood vessels, lymphatics, and nerve endings; the surface bacteria are efficiently destroyed on incision/ ablation margins. The current generation dental CO2 laser technology features a small foot-print, compact unit with flexible hollow fiber beam delivery (Figure 1A), and a variety of straight and angled handpieces (Figure 1B). The handpieces are pen-sized, disposable-free, autoclavable, and easily adapted to switching between (1) incision with coagulation, (2) superficial ablation with coagulation, or (3) coagulation modalities. CO2 laser photo-thermal ablation and coagulation Soft tissue photo-thermal ablation is a process of vaporization of intra- and extracellular water near the surface where the laser beam intensity is at its maximum (Figure 2). For a fixed laser beam diameter (or spot

Figure 1B: CO2 laser surgical and dental handpieces with tipless and tip-retainer nozzles. (Photo courtesy of LightScalpel, LLC)

size), the volume of the tissue exposed to the laser beam is proportional to the optical penetration (i.e., absorption or Near-IR attenuation as defined earlier) depth. The shorter the penetration depth — the less energy is Volume 8 Number 2

the close match between the photo-thermal coagulation depth of approximately 50-100 µm14 and oral soft tissue blood capillary diameters of approximately 20-40 µm.15 Thermal Relaxation Time The rate of how fast the irradiated tissue diffuses the heat away is defined by Thermal Relaxation Time, which equals approximately 1.5 msec for 75% water rich soft tissue irradiated by 10,600 nm CO2 laser. Practical implications of the Thermal Relaxation Time concept are simple and yet very powerful for appropriate application of laser energy. The most efficient heating of the irradiated tissue takes place when laser pulse energy is high, and its duration is much shorter than TR. The most efficient cooling of the tissue adjacent to the ablated zone takes place if time duration between laser pulses is much greater than TR. Such laser pulsing is referred to as SuperPulse and is a must-have feature of any state-of-the-art soft tissue surgical CO2 laser that minimizes the depth of coagulation.

Figure 2: Simplified graphical representation of laser beam intensity attenuated inside the soft tissue

Figure 3: Titanium surface optical absorption spectrum derived from Wolfe and Zissis17 Volume 8 Number 2

Laser beam spot size Just as the sharpness of the steel blade defines the quality and the ease of the cut, the size of the laser beam focal spot defines the quality of the laser cut. The smaller (or sharper) the focal spot of the beam, the narrower and the deeper the incision. Just as a dull blade cannot produce a quality incision, an oversized laser beam spot cannot produce a precise and narrow incision. For a rapid switch from cutting to just photo-coagulation, the laser beam can be defocused either by selecting a larger spot size or by simply moving the handpiece away from the tissue by approximately 10 mm and “painting” the “bleeder” for enhanced hemostasis. Laser power density and depth of ablation Consider a steel blade: Regardless of how sharp the blade is, there will be no interaction between the blade and the tissue unless mechanical pressure is applied to the blade, forcing it through the tissue surface. For a laser scalpel, the power density of the focused laser beam is equivalent to the mechanical pressure that is applied to a cold steel blade: the greater the laser power density, the greater the depth and the rate of soft tissue removal. Controlling thermal effects The SuperPulse setting (see preceding explanation) minimizes the amount of the heat transfer from the cutting/ablation zone to surrounding tissue; it results in minimal char on the margins of the cut, facilitating better healing and reduced postoperative scarring of the surgical wounds. For a superior hemostasis effect through photo-coagulation by laser light, turning the SuperPulse mode off is recommended; such a capacity of the CO2 laser is especially useful for procedures involving highly vascular tissues and patients with coagulation disorders or undergoing anticoagulant therapy. Laser-implant interaction In a recent study on CO2 laser removal of biofilms from implant surfaces,16 both titanium and titanium oxide (the most common implant materials) are reported to be unaffected when treated by high power 10,600 nm CO2 laser. Figure 3 presents the absorption spectrum of the titanium surface. It illustrates that titanium implants, when treated by the CO2 laser, are affected (heated) approximately 4 times less than with diode and Nd:YAG wavelengths (circa 1,000 nm) and approximately 3 times less than with Erbium laser wavelengths (circa 3,000 nm). Implant practice 35

SEEING THE LIGHT

required to ablate the tissue. The longer the optical penetration depth — the greater the volume of irradiated tissue, and therefore, more energy is required to ablate the tissue within the irradiated volume of tissue. The 10,600 nm CO2 laser is highly energy efficient at ablating the soft tissue photo-thermally with very low ablation threshold intensities due to extremely small volume of irradiated tissue because of extremely short absorption depth around 15 µm.14 The coagulation zone is located immediately below the ablation zone (Figure 2). Coagulation occurs as a denaturation of soft tissue proteins that occurs in a 60°-100°C temperature range leading to a significant reduction in bleeding (and oozing of lymphatic liquids) on the margins of ablated tissue during laser ablation (and excision/ incision) procedures. The coagulation depth value relative to the blood vessel diameter is an important measure of coagulation and hemostasis efficiency. For CO2 laser, its excellent coagulation efficiency is due to

SEEING THE LIGHT A case report Patient The 66-year-old female patient presented for discomfort and pain, associated with her full arch mandibular implant-supported prosthesis. The patient had had the prosthesis for 10 years. Over that period of time, a significant amount of gingival hyperplasia developed around and between the implants along with a decrease in vestibular depth (Figure 4). Hyperplastic tissue around one of the implants was inflamed with 5 mm of pocket depth and some circumferential bone

Figure 4: Gingival hyperplasia – immediate pre-op view. The applicator with topical points at the inflamed tissue with the deep pocket around one of the implants

loss (cotton swab in Figure 4 points at the involved implant). It was decided to perform the following procedures utilizing the CO2 laser: (1) ablation of gingival hyperplasia, including the inflamed peri-implant tissue; (2) sulcus sterilization around the involved implant; and (3) vestibuloplasty with a palatal free gingival mucosal graft. Vestibular release and hemostasis for the palatal graft donor and recipient sites were done with the CO2 laser. The focus of this article is only on the reduction of gingival hyperplasia and sulcus sterilization immediately preceding the vestibuloplasty.

Figure 5: Tissue ablation with the LightScalpel straight tipless handpiece in progress. Note lack of bleeding

Figure 6: Ablation of the inflamed peri-implant gingival tissue. Note the small beam spot size on the target tissue

Figure 7: The tipless angled handpiece provided better access for ablation around implant 36 Implant practice

Figure 8: Last touch-ups of the hyperplasia ablation

Laser equipment and settings LightScalpel LS-2010 — the 20-watt carbon dioxide laser — (LightScalpel, LLC, Woodinville, Washington) was used with the following settings: 2-4 watts SuperPulse, F1 repeat pulse modes 3-8. Three handpieces were used during the procedure: a fixed spot tipless handpiece, an angled tipless handpiece, and an angled tip retainer handpiece with ceramic perio-focusing tip. All three of the handpieces had the laser beam spot size of 0.25 mm (the smallest available). Surgical procedure Topical anesthesia was applied to the site (Figure 4). Then local anesthesia was administered by infiltration (2% lidocaine with 1:100,000 epinephrine). Ablation of hyperplastic tissue was performed on the gingival tissue between the implants (Figure 5). The straight tipless handpiece was held at a 3-5-mm nozzle-to-tissue distance (Figure 5). The surgeon’s hand quickly moved in overlapping strokes as though “erasing” the excess tissue. Depending on the tissue amount and thickness, a number of passes were required to remove the hyperplasia from the gingiva. After the hyperplastic tissue was vaporized in the spaces between implants, the inflamed tissue around the implant was ablated (Figure 6). The traces of carbonized ashes were rinsed off, and the surgical area was blotted off with damp gauze pad to ensure better penetration of the laser energy. In order to gain better access to the lingual part of the peri-implant tissue, the surgeon switched to the angled tipless handpiece (Figure 7). Once the inflamed tissue was removed and the surgical site rinsed off, touch-up ablation was performed to finish the hyperplastic tissue reduction between the implants (Figure 8). For sulcular debridement, the surgeon switched to the angled handpiece with a ceramic periodontal tip (Figure 9). The laser power was reduced to 2 watts in the SuperPulse mode with repeat pulsing F1-3 mode.

Figure 9: Angled handpiece with a ceramic perio tip Volume 8 Number 2

SEEING THE LIGHT

Figure 10: The perio tip was slowly moved inside the peri-implant pocket during the sulcular debridement procedure

The periodontal tip was placed into the depth of the pocket and tracked slowly circumferentially around the implant to ablate the diseased tissue and eliminate the bacterial load within the pocket. Approximately 8-10 seconds were spent on both the buccal and lingual areas, with the tip smoothly gliding around the implant to ensure the laser energy reached all aspects of the peri-implant pocket (Figure 10). After the peri-implant pocket treatment was finished, the pocket was thoroughly irrigated, and all residual intrasulcular material within the pocket was removed with implant curettes to make sure that all granulation tissue and residual epithelium had been eliminated. The handpiece with the perio tip was then replaced by the tipless angled handpiece. Defocusing the laser was used to achieve hemostasis inside the peri-implant pocket where mild hemorrhage occurred from the mechanical debridement. Finally, the walls of the sulcus were smoothed out with the laser. The surgical area was rinsed off, and the procedure was completed (Figure 11 shows the surgical site immediately postoperatively). The patient was ready for the next stage of the surgery — vestibular tissue release and vestibuloplasty, which by doing so may contribute to the continued long-term success of this 10-year old prosthesis. Postoperative assessment The use of the laser for the tissue reduction, sulcular debridement, and vestibuloplasty effectively reduces postoperative pain and discomfort by the sealing off and ablation of the exposed tissue. This reduces postoperative complaints of swelling and bleeding and minimizes the need for excessive postsurgical analgesia. The patient’s prosthesis Volume 8 Number 2

Figure 11: Immediate postoperative view

was immediately reinserted following the procedure and function restored.

REFERENCES 1.

Convissar RA, Sawisch TJ, Strauss RA. Laser-enhanced removable prosthetic reconstruction. In: Convissar RA. Principles and Practices of Laser Dentistry. St. Louis, MO: Mosby;2011:93-113.

Follow-up exam The patient was seen 1 week after the surgery. Healing was uneventful, and the patient was pleased with the outcome. Typically, the tissue reduction site is well healed within 7-10 days and the vestibuloplasty site within 2-3 weeks.

de Arruda Paes-Junior TJ, Cavalcanti SC, Nascimento DF, Saavedra Gde S, Kimpara ET, Borges AL, Niccoli-Filho W, Komori PC. CO2 Laser Surgery and Prosthetic Management for the Treatment of Epulis Fissuratum. ISRN Dent. 2011;2011:282361. doi: 10.5402/2011/282361.

Namour S. Atlas of Current Oral Laser Surgery. Boca Raton, FL: Universal Publishers. 2011;139-171.

Sawisch TJ. Oral surgery for the general practitioner: ablation/ vaporization techniques and procedures – clinical scenarios. In: Convissar RA. Principles and Practices of Laser Dentistry. St. Louis, MO: Mosby; 2011:93-113.

Convissar RA, Gharemani EH. Laser treatment as an adjunct to removable prosthetic care. Gen Dent. 1995;43(4):336-341. Points out that the CO2 laser, unlike the conventional scalpel, allows gradually, cell layer at a time, removing precisely the right amount of tissue.

Zeinoun T, Nammour S, Dourov N, Aftimos G, Luomanen M. Myofibroblasts in healing laser excision wounds. Lasers Surg Med. 2001;28(1):74-79.

Strauss RA, Fallon SD. Lasers in contemporary oral and maxillofacial surgery. Dent Clin North Am. 2004;48(4):861-888.

Wlodawsky RN, Strauss RA. Intraoral laser surgery. Oral Maxillofac Surg Clin North Am. 2004;16(2):149-163.

Grbavac RA, Veeck EB, Bernard JP, Ramalho LM, Pinheiro AL. Effects of laser therapy in CO2 laser wounds in rats. Photomed Laser Surg. 2006;24(3):389-396.

10.

de Freitas AC, Pinheiro AL, de Oliveira MG, Ramalho LM. Assessment of the behavior of myofibroblasts on scalpel and CO2 laser wounds: an immunohistochemical study in rats. J Clin Laser Med Surg. 2002;20(4):221-225.

Conclusion The CO2 laser was efficiently used for the hyperplastic gingival ablation and sulcular debridement. The ability of the CO2 laser to achieve hemostasis proved especially important for the procedures described in this article for the following reasons: • The laser maintained the dry bloodless operatory field with excellent visibility. • Ability to see ensured precise tissue removal with very little collateral damage to the surrounding unaffected tissues. • No sutures were required reducing overall surgery time. • Patients report less post-op pain and swelling, thus less analgesia is necessary. • With bactericidal effects, many at-risk implants can be treated early, before too much of the supporting bone is lost. IP

Acknowledgments The authors greatly appreciate the support and contribution from Anna Glazkova, PhD, in preparing this material for publication.

11. Kato T, Kusakari H, Hoshino E. Bactericidal efficacy of carbon dioxide laser against bacteria-contaminated titanium implant and subsequent cellular adhesion to irradiated area. Lasers Surg Med. 1998;23(5):299-309. 12. Deppe H, Horch HH, Henke J, Donath K. Peri-implant care of ailing implants with the carbon dioxide laser. Int J Oral Maxillofac Implants. 2001;16(5):659-667. 13. Deppe H, Horch HH, Greim H, Brill T, Wagenpfeil S, Donath K. Peri-implant care with the CO2 laser: In vitro and in vivo results. Med Laser Application. 2005;20(1):61-70. 14. Vitruk P. Oral soft tissue laser ablative & coagulative efficiencies spectra. Implant Practice US, 2014;7(6):22-27. 15. Yoshida S, Noguchi K, Imura K, Miwa Y, Sunohara M, Sato I. A morphological study of the blood vessels associated with periodontal probing depth in human gingival tissue. Okajimas Folia Anat Jpn. 2011;88(3):103-109. 16. Cobb CM, Vitruk P. Microbial Decontamination of Three Different Implant Surfaces Using a SuperPulse CO2 (10,600 nm) Laser: An In Vitro Study. Presented at the Academy of Laser Dentistry Meeting. Palm Springs, February 5-7, 2015. 17. Wolfe WL, Zissis GJ. The Infrared Handbook. Washington DC: Office of Naval Research, NAVY, 1985;7-81.

This article is sponsored by LightScalpel, LLC. (www.LightScalpel.com, 1-866-589-2722)

Implant practice 37

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Changing paradigms in implant dentistry: flapless implant dentistry Drs. Tony Aherne, Annika Meyer, and Stuart Aherne examine the efficacy — and difficulty — of adopting a flapless approach to implant placement

mplant placement using conventional surgical techniques (in a two-stage approach) is, in most cases, a rather invasive procedure. It involves the raising of a mucoperiosteal flap and implant placement into the osteotomy site (Adel, 1985). Examining this procedure from a general point of view, it has changed little over the years (Höockl, 2011). The advantages of good visibility of the site and the ability to correct peri-implant defects are countered by the major disadvantage of resultant bone loss. This is due to interruption of the blood supply to the periosteum (Kleinheinz, 2005). Flapless procedures have been developed as an atraumatic approach, which allow good preservation of the existing hard and soft tissues (Kan, 2000, Lee, 2008). The limited surgical trauma is suggested to minimize bleeding at the time of the procedure and postoperative complications such as swelling and pain (Stoll, 2011). This results in improved postoperative comfort and accelerated recuperation of the implant site. In addition, it minimizes the amount of resultant scar tissue, particularly if it is used with a transgingival approach. Promises from the dental industry that sophisticated planning systems are the universal remedy to efficiency and the gateway to success with flapless procedures are elusive. The inherent blindness of the flapless technique demands sound surgical experience and profound planning,

Educational aims and objectives

This article aims to discuss a flapless approach to implant placement and illustrate the difficulties and potential benefits of the technique.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 42 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize the importance of careful case selection and technique when adopting a freehand flapless approach. • See advantages and disadvantages of flapless procedures. • Identify materials and methods needed for a specific technique for a flapless procedure. • Realize the reason for the tissue-punch technique. • Realize the reason for the mini-incision technique.

especially when using the soft tissue-punch technique. A traditional comprehensive surgical education is thus an essential advantage when starting flapless. With a careful selection of cases, freehand flapless implant placement is possible and leads to good results.

Case presentation A 19-year-old female was referred in as a result of a horizontal fracture of the apical area of the root of the right central incisor. This was the result of a sporting accident (Figures 1 and 2). Extraction was planned together

Tony Aherne, BDS, NUI DRD RCS Ed MDS, is a former secretary, treasurer, and executive council member of the European Academy of Aesthetic Dentistry. A founder of the Irish Academy of Aesthetic Dentistry, he has a practice in Cork, Ireland, specializing in implant dentistry and prosthodontics. Annika Meyer, DDS, graduated from the Humboldt University of Berlin and earned her doctorate at the Charite Berlin in Germany. She completed vocational training in the Berlin area and the University of Münster (Department of Periodontology). Stuart Aherne, BDS, is a graduate of the University of Wales College of Medicine and completed his vocational training in Cardiff. He is a partner in a private specialist prosthodontic and implant practice in Cork, Ireland.

Figures 1 and 2: Preoperative situation — fracture of the apical root section of a central incisor in a 19-year-old female 38 Implant practice

Volume 8 Number 2

planned from the time of extraction. The area had been carefully probed and measured during extraction surgery; models of the presurgical condition gave information about

the clinical distances and axis, which were needed to consider. A tissue punch was used to expose the implant site as a punch diameter that is

Figures 3 and 4: Careful extraction of the fractured segment. Note the use of the periotome

Figure 5: The socket augmented with a xenograft material and sealed with a membrane sutured into position

Figure 6: The socket augmented with a xenograft material and sealed with a membrane sutured into position

Figures 7 and 8: Healing of the site prior to implant placement Volume 8 Number 2

Implant practice 39

CONTINUING EDUCATION

with delayed placement of the implant until the patient had completed her university examinations. The extraction was carried out carefully using periotomes, preserving as much of the hard and soft tissue architecture as possible (Figures 3 and 4). The area was augmented with a xenograft material (Geistlich). It was then supported with a membrane, which was sutured in place (Sereline) (Figures 5 and 6). Healing was allowed to take place for 8 months, and a bonded temporary composite was placed (Figures 7 and 8). The temporary was designed so that its pontic carefully reached into the extraction socket. The apical end was constantly adapted to the remodeling process. Implant placement took place with a flapless procedure. A CBCT scan was not used as the implant placement had been carefully

CONTINUING EDUCATION minimally smaller than the implant diameter has a positive effect on healing (Lee, 2008) (Figures 9 and 10). A predetermined drilling sequence took place using implant drills (Thommen Medical) (Figure 11). Implant placement subsequently took place with a chairside conditioned superhydrophilic implant surface, which has been shown to enable improved homogeneous

protein absorption to allow for a safer osseointegration (Vasak, 2013; Held, 2013; Calvo Guirado, 2010; Tugulu, 2009; 2010) (Figure 12). A healing abutment was placed to allow for transgingival healing (Figure 13). A composite chairside temporary was bonded to the adjoining central incisor (Figure 14). Implant recovery took place after 10

weeks. A chairside temporary crown was then placed (Figure 15). This procedure did not require a local anesthetic and demonstrated good gingival harmony. The temporary crown will be left in place for a period of time to encourage further papillary development (Figure 16). The temporary crown was carefully contoured so that the tissues were supported and to

Figure 9: Tissue punch for exposure of implant site

Figure 10: Exposed implant site in preparation for osteotomy

Figure 11: Drilling to a predetermined sequence into the osteotomy site

Figure 12: Placement of conditioned implant into a predetermined position

Figure 13: Exposed healing abutment to allow for transgingival healing

Figure 14: Chairside composite bonding so that there is no occlusal pressure on the healing abutment

40 Implant practice

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CONTINUING EDUCATION

provide space for any potential increase in height of the papilla.

Discussion Flapless implant surgery gains high patient acceptance and popularity. It also offers important advantages for the elderly and medically compromised patients. In the early stages of the development of the flapless technique, it was recommended to inexperienced surgeons. It has, however, now become clear that it is a very techniquesensitive procedure, as false assessment may lead to bone perforation or incorrect implant positioning. Careful planning seems to be the key element in the success of the flapless approach, and this aspect has not changed with the accessibility of planning systems. It is, therefore, only a technique that can be recommended to highly experienced implant surgeons who can do the appropriate case selection. The tissue-punch technique should only be used with a sufficient amount of keratinized tissue around the defined implant placement area and when no bone augmentation is necessary. In areas of doubtful primary stability of the implant (posterior maxillary region), the miniincision technique is a flapless alternative to the punch technique (Choi, 2010). Flapless procedures carried out carefully with good planning can lead to very high success rates with less bleeding at the time of implant placement and fewer postoperative complications, together with an increasing demand from patients for less invasive procedures. IP

Figure 15: The temporary was contoured to support the soft tissues

Figure 16: Space has been provided to provide any potential increase in height of the papillae

REFERENCES 1.

Adell R, Lekholm U, Brånemark PI, Lindhe J, Rockler B, Eriksson B, Lindvall AM, Yoneyama T, Sbordone L. Marginal tissue reactions at osseointegrated titanium fixtures. Swed Dent J Suppl. 1985;28:175-181.

Calvo-Guirado JL, Ortiz-Ruiz AJ, Negri B, López-Marí L, Rodriguez-Barba C, Schlottig F. Histological and histomorphometric evaluation of immediate implant placement on a dog model with a new implant surface treatment. Clin Oral Impl Res. 2010;21(3):308-315.

Choi BH, Jeong SM, Kim J, Engelke W. Flapless Implantology. London: Quintessence; 2010.

Held U, Rohner D, Rothamel D. Early loading of hydrophilic titanium implants inserted in low-mineralized (D3 and D4) bone: one year results of a prospective clinical trial. Head Face Med. 2013;9:37.

Höckl K, Stoll P, Bach G, Bähr W, Stoll V. Flapless implant surgeryand its effect on peri- implant soft tissue. Implants. 2011;4:6-17.

Kleinheinz J, Büchter A, Kruse-Lösler B, Weingart D, Joos U. Incision design in implant dentistry based on vascularization of the mucosa. Clin Oral Implants Res. 2005;16(5):518-523.

Kan JY, Rungcharassaeng K, Ojano M, Goodacre CJ. Flapless anterior implant surgery: a surgical and prosthodontic rationale. Pract Periodontics Aesthet Dent. 2000;12(5):467-474, 476.

Lee DH, Choi BH, Jeong SM, Xuan F, Kim HR. Effects of flapless implant surgery on soft tissue profiles: a prospective clinical study. Clin Implant Dent Relat Res. 2011;13(4):324-329.

Stoll V, Stoll P, Bach G, Bähr W, Höckl K. How reliable is immediate implant insertion after tooth extraction? Implants. 2011;1:14-17.

10. Tugulu S, Löwe K, Scharnweber D, Schlottig F. Preparation of superhydrophilic microrough titanium implant surfaces by alkali treatment. J Mater Sci Mater Med. 2010; 21(10):2751-2763. 11. Vasak C, Busenlechner D, Schwarze UY, Leitner HF, Munoz Guzon F, Hefti T, Schlottig F, Gruber R. Early bone apposition to hydrophilic and hydrophobic titanium implant surfaces: a histologic and histomorphometric study in minipigs. Clin Oral Implants Res. 2014;25(12):1378-1385.

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Implant practice 41

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Changing paradigms in implant dentistry: flapless implant dentistry

Processing extracted teeth for immediate grafting of autogenous dentin

AHERNE, ET AL.

The advantages of good visibility of the site and the ability to correct peri-implant defects are countered by the major disadvantage of __________. a. resultant bone loss b. black triangle c. remodeling d. super-hydrophilia

Flapless procedures have been developed as a(n) _________, which allow good preservation of the existing hard and soft tissues. a. universal remedy b. atraumatic approach c. easy approach d. traumatic approach The limited surgical trauma is suggested to ________ at the time of the procedure and postoperative complications such as swelling and pain. a. totally eliminate bleeding b. eliminate pain c. minimize bleeding d. totally eliminate scar tissue Promises from the dental industry that sophisticated planning systems are the universal remedy to efficiency and the gateway to success with flapless procedures are ______. a. elusive b. totally true c. totally untrue d. against comprehensive surgical education The inherent blindness of the flapless technique demands _____, especially when using the soft tissue-punch technique. a. sound surgical experience b. profound planning c. LED lighting in the operatory d. both a and b

42 Implant practice

It (flapless implant surgery) also offers important advantages for ________. a. those who need bone augmentation b. the elderly c. medically compromised patients d. both b and c It has, however, now become clear that it is a very ______, as false assessment may lead to bone perforation or incorrect implant positioning. a. time-consuming procedure b. technique-sensitive procedure c. expensive procedure d. stressful experience Careful planning seems to be the key element in the success of the flapless approach, and this aspect ______ with the accessibility of planning systems. a. has changed b. has not changed c. has been revolutionized d. has attracted inexperienced practitioners The tissue-punch technique should only be used with a sufficient amount of keratinized tissue around the defined implant placement area and when ________. a. there is insufficient papilla b. the patient is less than 40 years old c. bone augmentation is necessary d. no bone augmentation is necessary

10. In areas of doubtful primary stability of the implant (posterior maxillary region) ______ technique is a flapless alternative to the punch technique. a. the transgingival b. the mini-incision c. the bilateral d. the fenestration

BINDERMAN, ET AL.

In their review, Horowitz, et al., stated that less ridge resorption occurs when alveolar ridge preservation procedures are used, compared to leaving fresh alveolar sockets without placing graft material. If performed inadequately, the resulting deformity can be a considerable obstacle to the ________ results. a. esthetic b. phonetic c. functional d. all of the above

However, fresh autogenous bone graft is still considered the gold standard since it exhibits bioactive cell instructive matrix properties and is ________, in spite of the need for harvesting bone and possible morbidity resulting from it. a. non-immunogenic b. non-pathogenic c. immunogenic d. both a and b

It is, therefore, not surprising that dentin, which comprises more than _______ of tooth structure, can serve as native bone grafting material. a. 30% b. 45% c. 50% d. 85%

It is evident that transplanted teeth that are ankylosed in the jawbone undergo replacement resorption over _______ years. a. 1 to 2 years b. 2 to 4 years c. 5 to 8 years d. 9 to 12 years

In addition, it is well documented that avulsed teeth that are implanted back into their sockets undergo firm reattachment to bone, which is formed directly on root dentin or cementum, leading to ______. a. ankylosis b. decay

c. mobility d. dentin damage 6.

In a recent review, Malmgren stressed that in ankylosed teeth that are treated by _______, the alveolar ridge is maintained in the buccal/ palatinal direction, while vertical height is even increased. a. root canal b. decoronation c. transplantation d. extraction

Since the mineralized dentin is very _______ in comparison to cortical bone or most biomaterials, the esthetic and structure pattern of the alveolar crest and mucoperiosteum is maintained for years. a. slowly remodeled b. quickly remodeled c. flexible d. pliable

Teeth and jawbone have a high level of affinity, having a similar _______. a. healing time b. chemical structure c. composition d. both b and c

Therefore, the authors and others propose that extracted nonfunctional teeth or periodontally involved teeth ______. a. should be discarded at the same time b. should be restored immediately c. should not be discarded any more d. should be monitored before further treatment

10. Extracted teeth can become autogenous dentin, ready to be grafted within _______ after extraction. a. 15 minutes b. 6 hours c. 2 days d. 1 week

Volume 8 Number 2

CE CREDITS

IMPLANT PRACTICE CE

Drs. Itzhak Binderman, Gideon Hallel, Casap Nardy, Avinoam Yaffe, and Lari Sapoznikov investigate an alternative use for extracted teeth

ooth extraction is one of the most widely performed procedures in dentistry, and it has been historically well documented that it can induce significant dimensional changes of the alveolar ridge. In their review, Horowitz, et al. (2012), stated that less ridge resorption occurs when alveolar ridge preservation procedures are used, compared to leaving fresh alveolar sockets without placing graft material. If performed inadequately, the resulting deformity can be a considerable obstacle to the esthetic, phonetic, and functional results. In dentistry, allogeneic bone and synthetic mineral materials are the main source for grafting in bone. However, fresh autogenous bone graft is still considered the gold standard since it exhibits bioactive cell instructive matrix properties and is non-immunogenic and non-pathogenic, in spite of the need for harvesting bone and possible morbidity resulting from it. It is well-known that jawbones, alveolar bone, and teeth develop from cells of the neural crest and that many proteins are common to bone, dentin, and cementum (Donovan, et al., 1993; Qin, et al., 2002). It is, therefore, not surprising that dentin, which comprises more than 85% of tooth structure, can serve as native bone grafting material. Interestingly, Schmidt-Schultz and Schultz (2005) found that intact growth factors are conserved even in the collagenous extracellular matrix of ancient human bone and teeth.

Dr. Itzhak Binderman works at the department of oral biology, School of Dental Medicine and Department of Bio-Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel. Dr. Gideon Hallel is in private practice in Tel Aviv. Dr. Casap Nardy works in the departments of maxillofacial surgery at Hebrew University of Jerusalem. Dr. Avinoam Yaffe works at the Hadassah Faculty of Dental Medicine, Hebrew University of Jerusalem. Dr. Lari Sapoznikov is in private practice in Tel Aviv.

Volume 8 Number 2

Educational aims and objectives

This article aims to demonstrate an application that uses freshly extracted teeth as an autogenous grafting material in implant patients.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 42 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify the procedure involved in processing extracted teeth into graft material. • Realize the potential benefits this material offers to clinicians placing implants. • See how to prepare for immediate grafting teeth without root canal fillings, which have been extracted due to advanced periodontal bone loss or other reason. • See how autogenous dentin particulate can serve as a superior grafting matrix for augmenting bone in maxillary sinuses.

Methods for processing bovine dentin into particulate and sterile grafting material for preserving of alveolar bone have been described and used in several animal studies (Fugazzotto, et al., 1986; Nampo, et al., 2010; Qin, et al., 2014). It is, therefore, evident that teeth can become grafts that are slowly and gradually replaced by bone (Hasegawa, et al., 2007). Currently, all extracted teeth are generally considered clinical waste and, therefore, are simply discarded. Recently, however, several studies have reported that extracted teeth from patients, which undergo a process of cleaning, grinding, demineralization, and sterilization, can be a very effective graft to fill alveolar bone defects in the same patient (Kim, et al., 2010; Kim, et al., 2011; Murata, et al., 2011). However, this procedure is extremely time-consuming since the graft is only ready several hours or days after extraction. This article, therefore, aims to present a modified procedure that employs freshly extracted teeth in a clinical setting by recycling them into bacteria-free particulate autogenous mineralized dentin for immediate grafting. A Smart Dentin Grinder® (SDG) (KometaBio) was devised, which grinds and sorts extracted teeth into dentin particulate of a specific size. A chemical cleanser is then applied to process the dentin particulate into a bacteria-free graft over the course of about 15-20 minutes.

This novel procedure is indicated mainly in cases when teeth are extracted because of periodontal reasons and for partially or totally impacted teeth. Teeth that have undergone root canal fillings should not be employed in this procedure because of the risk of contamination by foreign materials. On the other hand, crowns and fillings can be reduced, and the clean dentin of the tooth crown can be processed for immediate grafting.

Method: from extraction to grafting particulate dentin Teeth without root canal fillings, which have been extracted due to advanced periodontal bone loss or other reasons, such as wisdom teeth extraction or orthodontic indications, can be prepared for immediate grafting. Immediately after extraction, restorations like crowns and fillings should be cut off or removed. Carious lesions and discolored dentin, or remnants of periodontal ligament (PDL) and calculus should be reduced by tungsten bur (Figures 1A and 1B). The authors have found that high-speed tungsten carbide burs are most efficient for this process. The roots could be split in case of multi-rooted teeth. Clean teeth, including crown and root dentin, are dried by air syringe and put into the grinding sterile chamber of the newly designed Smart Dentin Grinder (Figure 2A). The SDG can grind the roots in 3 seconds Implant practice 43

CONTINUING EDUCATION

Processing extracted teeth for immediate grafting of autogenous dentin

CONTINUING EDUCATION and then uses the vibrating movement of the grinding chamber to sieve any particles smaller than 1,200µm into a lower chamber that collects particles between 300µm and 1,200µm (Figure 2B). Particles smaller than 300µm fall into a waste drawer, as this fine particulate is not considered to be an efficient size for bone grafting. This grinding and sorting protocol is repeated to grind the remaining teeth particles left in the grinding chamber, still collecting particles between 300µm and 1,200µm. The particulate dentin from the drawer is immersed in basic alcohol for 10 minutes, in a small sterile glass container. The basic alcohol cleanser consists of 0.5M of NaOH and 30% alcohol (v/v) for defatting, dissolving all organic debris, bacteria, and toxins of the dentin particulate. Figure 3 shows the efficiency of the cleanser to dissolve all the organic debris from dentin particulate, including dentin tubules. The scanning electron microscope (SEM) picture shows open and clean tubules after 10 minutes of cleanser treatment (Figure 3C). After decanting the basic alcohol cleanser, the particulate is washed twice in sterile phosphate-buffered saline (PBS). The PBS is decanted, leaving wet particulate dentin ready to graft into freshly extracted sockets, alveolar bone defects, or in procedures involving augmenting the maxillary sinus. The process from tooth extraction until grafting takes approximately 15-20 minutes. It should be noted that the efficiency of selecting the dentin particulate of specific size for grafting is more than 95%. It is also obvious that the volume of the particulate dentin is more than twice of the original root volume. Alternatively, the wet particulate can

be put on a hot plate (140ºC) for 5 minutes to produce dry, bacteria-free particulate autologous dentin that can serve for immediate or future grafting procedures.

Results: clinical evaluation Over a period of 2 years, more than 100 dentists have employed the present procedure for preparing autogenous dentin

Figures 1A-1C: From extraction to clean particulate: 1A. Tooth after extraction, debris, and calculus. 1B. Same tooth after reducing debris with tungsten carbide bur. 1C. Particulate dentin after grinding and sorting. The particulate dentin size is 300µm-1200µm

Figures 2A-2B: Smart Dentin Grinder and drawer with particulate dentin of 300µm-1200µm size ready for cleanser treatment: 2A. Smart Dentin Grinder and sorter. 2B. Drawer that collects particulate dentin after grinding and sorting. The size of particles in this drawer is 300µm-1200µm

Figures 3A-3C: 3A. Scanning electron microscope (SEM) x750 of particulate dentin when cleanser is added. 3B. SEM x750 of particulate dentin at 3 minutes after treatment with cleanser. 3C. SEM x750 of particulate dentin at 10 minutes after treatment with cleanser. Note the wide-open tubuli openings. Bacteriological tests revealed no bacteria growth at this point

44 Implant practice

particulate from extracted teeth for immediate grafting in the same patient. It should be noted that teeth that underwent root canal treatment were discarded. When intact teeth were processed, the enamel and cementum were included. Figures 4 to 7 show a number of typical case presentations where teeth were extracted and processed into bacteria-free particulate

Figures 4A-4D: Extraction sites at LR8 filled with particulate dentin prepared from extracted tooth by the Smart Dentin Grinder procedure: 4A. Clinical view of the extraction site. 4B. X-ray of impacted tooth LR8. 4C. After extracting the LR8, particulate of extracted tooth was prepared and placed in extraction site. 4D. By 4 months, the particulate and newly formed bone completely restored the void next to the distal root of tooth LR7 Volume 8 Number 2

Figures 5A-5I: Periodontally involved teeth at LR7, LR8, LL6, LL7, and LL8 with extensive alveolar bone loss. Immediately after extraction, only teeth LR8 and LL8 were employed for particulate dentin and immediately used to augment the extraction sites: 5A. X-ray before extraction of LR7 and LR8. 5B. LR8 before mechanical cleaning. 5C. LR8 after cleaning with tungsten carbide. 5D. Particulate dentin after cleanser treatment, ready to graft. 5E. After 2 months, two implants were inserted in the augmented extraction sites. 5F. Radiograph at 2 years – note dense bone and lack of bone loss next to implant. 5G. X-ray showing bone loss around teeth LL6-LL8. 5H. Three implants were placed, 2 months after grafting with particulate dentin from tooth LL8. 5I. One year later, note the bone density and bone level with no signs of bone loss next to implants

Wisdom tooth extraction A total of 16 wisdom teeth, including partially impacted, horizontally impacted, and caries-affected teeth, were processed using the SDG procedure during this study. Figure 4 shows a horizontally impacted LR8 tooth that was in close proximity to the distal root surface of the LR7, creating a deep void. The surgically extracted LR8 exposed the distal root surface of the LR7, almost denuded from bone tissue. The LR8 was processed immediately into the particulate graft, which totally filled the extraction site (Figure 4C). Healing and recovery after the surgical procedure and grafting took place without complications. A follow-up after 4 months revealed a normal pattern of marginal gingiva around the LR7. Probing was normal: 1 mm-2 mm in depth. On the X-ray distal to the LR7, new bone and particulate dentin was integrated into bone, completely restoring the extraction site and distal bone support of the LR7 (Figure 4D).

Periodontal extractions A further 37 teeth were extracted because of poor periodontal attachment, bone loss, and mobility. Figure 5 illustrates the case of a 56-year-old male patient with a localized, advanced periodontal condition in posterior parts of the mandible. The LR7 and LR8 were extracted, and the granulation tissue was removed exposing bone tissue walls. The LR7 had a root canal filling and was therefore discarded. The LR8 was processed into particulate dentin by the SDG device and prepared for immediate grafting in the extraction sites. The grafting of one tooth produced sufficient volume of particulate dentin to overfill the extraction site of both sockets. A Choukroun PRF (platelet rich fibrin) membrane was prepared from the patient’s blood (Cieslik-Bielecka, et al., 2012) to cover the graft. The mucoperiosteum was sutured to the PRF, avoiding tension of tissues. Improved healing was achieved because of the PRF membrane. Approximately 2 months later, two implants were placed, followed by a cemented bridge of LR7-LR8 crowns. After 2 years, clinical and X-ray follow-up revealed very radiopaque bone integrated into implants, most possibly consisting of bone-dentin but producing a very solid support for implants (Figure 5). A similar Volume 8 Number 2

Figures 6A-6F: 6A. Periodontally involved tooth UL6. 6B. Alveolar bone after extraction – note the oroantral opening. 6C. The UL6 after extraction and cleaning. 6D. After preparation of particulate from tooth UL6, the socket was grafted and the oroantral opening filled with particulate dentin. 6E. After 2 months, 8.3 mm height of bone was achieved with a high density of dentinbone. 6F. After 3 months, three implants were placed, and immediate solid anchorage was achieved

procedure was performed in the same patient’s lower left jaw. X-rays showed bone loss around the LL6-LL8 (Figure 5G). Two months after grafting with the particulate dentin from tooth LL8, three implants were inserted (Figure 5H), and 1 year later, the bone density and bone level with no signs of bone resorption at the crest after restoration could be observed (Figure 5J).

Sinus lifts Autogenous dentin particulate can serve as a superior grafting matrix for augmenting bone in maxillary sinuses, as presented in the next case. The patient presented with alveolar bone loss, with infrabony pockets that extended into the maxillary sinus of tooth UL6 (Figure 6). The UL6 was extracted, cleaned, and processed into bacteria-free particulate dentin (Figure 6D). An immediate grafting of the extraction socket was performed, and the tract into the sinus was occluded by the particulate dentin.

Closure of the wound and sutures of mucoperiosteum flap was performed. Healing was normal, and 3 months later, an alveolar ridge of minimum 8.3 mm height was achieved, allowing placement of three implants. It should be noted that one molar — the UL6 — produced at least 2 cc of particulate dentin, which allowed augmentation of the extraction socket and part of the sinus. Moreover, we found that autogenous dentin grafting allowed the placement of implants after 3 months in the upper jaw because the new bone that was integrated with particulate dentin produced a solid support for implants. Loading of implants followed. During preparation of the site for implant placement, a core of bone was recovered from the grafted socket site. The histology revealed new bone integrated with grafted dentin, producing a bone-dentin interface and connectivity (Figure 7). Implant practice 45

CONTINUING EDUCATION

autogenous tooth dentin for immediate grafting in same patient.

CONTINUING EDUCATION Discussion More than 40 years ago, autogenous teeth were routinely transplanted into extraction sockets when possible. It is evident that transplanted teeth that are ankylosed in the jawbone undergo replacement resorption over 5 to 8 years (Sperling, et al., 1986). In addition, it is well documented that avulsed teeth that are implanted back into their sockets undergo firm reattachment to bone, which is formed directly on root dentin or cementum, leading to ankylosis (Andersson et al, 1989). An ankylosed root is continuously resorbed and replaced by bone, eventually resorbing the entire root, while the alveolar process is preserved during this period and later. In a recent review, Malmgren (2013) stressed that in ankylosed teeth that are treated by decoronation, the alveolar ridge is maintained in the buccal/palatinal direction, while vertical height is even increased (Park, et al., 2007). Our results reveal similar interaction between the mineralized dentin and osteogenic cells that attach and produce mineralized bone matrix directly on the dentin graft. A tooth bank in Korea provides a service that prepares autogenic demineralized dentin matrix graft in block or granular types (Kim, et al., 2011; Murata, et al., 2011; Kim, 2012), delaying the grafting procedure from several hours to several days and, therefore, requiring an additional surgical session. Although demineralized dentin exposes matrix-derived growth and differentiation factors for effective osteogenesis, the newly formed bone and residual demineralized dentin are too weak to support implant anchorage. In contrast, the SDG procedure allows preparation of bacteria-free particulate dentin from freshly extracted autologous teeth, ready to be employed as autogenous graft material immediately. Mineralized dentin particles have the advantage of maintaining mechanical stability, allowing early loading after grafting in fresh sockets and bone defects. Moreover, in spite of its delayed inductive properties (Yeomans and Urist, 1967; Huggins, et al., 1970), the mineralized dentin is firmly integrated with newly formed bone, creating a solid site for anchorage of dental implants. In fact, our clinical data indicates that implant insertion and loading can be performed in both lower and upper jaws 2 to 3 months after dentin grafting. Since the mineralized dentin is very slowly remodeled (Yeomans and Urist, 1967; Kim, et al., 2014; Andersson, 2010) in comparison 46 Implant practice

Figures 7A-7B: 7A. A histology section (trichrome stain) of a core of bone tissue that was drilled out from upper jaw 3 months after grafting with autogenous dentin. 7B. A higher magnification of the dentin-bone interface. Note how the dentin with its tubules (D) is surrounded by newly formed bone matrix (B)

to cortical bone or most biomaterials, the esthetic and structure pattern of the alveolar crest and mucoperiosteum is maintained for years. Teeth and jawbone have a high level of affinity, having a similar chemical structure and composition. Therefore, the authors and others (Kim, et al., 2011; Murata, et al., 2011; Kim, 2012) propose that extracted nonfunctional teeth or periodontally involved teeth should not be discarded any more. Extracted teeth can become autogenous dentin, ready to be grafted within 15 minutes after extraction. We consider autogenous dentin as the gold standard graft for socket

preservation, bone augmentation in sinuses, or filling bone defects.

Disclosure The Smart Dentin Grinder is distributed by Kometa Bio. Drs. Itzhak Binderman and Lari Sapoznikov helped to develop the Smart Dentin Grinder and have shares in Kometa Bio Ltd., the company responsible for distributing the device. Drs. Gideon Hallel, Casap Nardy, and Avinoam Yaffe have no conflict of interest. They participated actively in providing clinical cases and their follow-ups. IP

REFERENCES 1.

Andersson L, Bodin I, Sรถrensen S. Progression of root resorption following replantation of human teeth after extended extraoral storage. Endod Dent Traumatol. 1989;5(1):38-47.

Andersson L. Dentin xenografts to experimental bone defects in rabbit tibia are ankylosed and undergo osseous replacement. Dent Traumatol. 2010;26(5):398-402.

Cieslik-Bielecka A Choukroun J, Odin G, Dohan Ehrenfest DM. L-PRP/ L-PRF in esthetic plastic surgery, regenerative medicine of the skin and chronic wounds. Curr Pharm Biotechnol. 2012;13(7):1266-1277.

Donovan MG, Dickerson NC, Hellstein JW, Hanson LJ. Autologous calvarial and iliac onlay bone grafts in miniature swine. J Oral Maxillofac Surg. 1993;51(8):898-903.

Fugazzotto PA, De Paoli S, Benfenati SP. The use of allogenic freeze-dried dentin in the repair of periodontal osseous defects in humans. Quintessence Int. 1986;17(8):461-477.

Hasegawa T, Suzuki H, Yoshie H, Ohshima H. Influence of extended operation time and of occlusal force on determination of pulpal healing pattern in replanted mouse molars. Cell Tissue Res. 2007;329(2):259-272.

Horowitz R, Holtzclaw D, Rosen PS. A review on alveolar ridge preservation following tooth extraction. J Evid Based Dent Pract. 2012;12(suppl 3):149-160.

Huggins C, Wiseman S, Reddi AH. Transformation of fibroblasts by allogeneic and xenogeneic transplants of demineralized tooth and bone. J Exp Med. 1970;132(6):1250-1258.

Kim YK, Kim SG, Byeon JH, Lee HJ, Um IU, Lim SC, Kim SY. Development of a novel bone grafting material using autogenous teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(4):496-503.

10. Kim SG, Kim YK, Lim SC, Kim KW, Um IW. Histomorphometric analysis of bone graft using autogenous tooth bone graft. Implantology. 2011;15:134-141. 11. Kim YK. Bone graft material using teeth. J Korean Assoc Oral Maxillofac Surg. 2012;38:134-138. 12. Kim YK, Kim SG, Yun PY, Yeo IS, Jin SC, Oh JS, Kim HJ, Yu SK, Lee SY, Kim JS, Um IW, Jeong MA, Kim GW. Autogenous teeth used for bone grafting: a comparison with traditional grafting materials. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;117(1):e39-45. 13. Malmgren B. Ridge preservation/decoronation. J Endod. 2013;39(suppl 3):S67-72. 14. Murata M, Akazawa T, Mitsugi M, Um IW, Kim, KW, Kim YK. Human dentin as novel biomaterial for bone regeneration. In: Pignatello R, ed. Biomaterials - Physics and Chemistry. Croatia: InTech; 2011: 127-140. 15. Nampo T, Watahiki J, Enomoto A, Taguchi T, Ono M, Nakano H, Yamamoto G, Irie T, Tachikawa T, Maki K. A new method for alveolar bone repair using extracted teeth for the graft material. J Periodontol. 2010;81(9):1264-1272. 16. Park CH, Abramson ZR, Taba M Jr, Jin Q, Chang J, Kreider JM, Goldstein SA, Giannobile WV. Three-dimensional micro-computed tomographic imaging of alveolar bone in experimental bone loss or repair. J Periodontol. 2007;78(2):273-281. 17. Qin C, Brunn JC, Cadena E, Ridall A, Tsujigiwa H, Nagatsuka H, Nagai N, Butler WT. The expression of dentin sialophosphoprotein gene in bone. J Dent Res. 2002;81(6):392-394 18. Qin X, Raj RM, Liao XF, Shi W, Ma B, Gong SQ, Chen WM, Zhou B. Using rigidly fixed autogenous tooth graft to repair bone defect: an animal model. Dent Traumatol. 2014;30(5):380-384. 19. Schmidt-Schultz TH, Schultz M. Intact growth factors are conserved in the extracellular matrix of ancient human bone and teeth: a storehouse for the study of human evolution in health and disease. Biol Chem. 2005;386(8):767-776. 20. Sperling I, Itzkowitz D, Kaufman A, Binderman I. A new treatment of heterotransplanted teeth to prevent progression of root resorption. Endod Dent Traumatol. 1986;2(3):117-120. 21. Yeomans JD, Urist MR. Bone induction by decalcified dentin implanted into oral, osseous and muscle tissues. Arch Oral Biol. 1967;12(8):999-1008.

Volume 8 Number 2

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IMPLANT INSIGHTS

Bisphosphonates: a class of drugs beyond match

Dr. David Speechley delves into the surprising history behind bisphosphonates and the terrible legacy of “phossy jaw”

he year was 1669 when German scientist Hennig Brand first discovered the philosopher’s stone — or so he thought. His experiment had started with ingredients that included sand and more than 50 buckets of urine, and the process had taken 2 weeks to complete; but the product of his labor was a substance that glowed in the dark. Nothing like this had ever been seen before, so he really did believe he had discovered something with magic properties. Calling his discovery phosphorus (meaning “bringer of light” in Greek), scientists all over Europe were soon engaged in trying to unlock the magic properties of this wondrous substance, with eminent people such as Robert Boyle giving demonstrations in the United Kingdom to his fellow scientists. Today, we know that phosphorus is a non-metallic element, essential for life that is present in bone as well as both DNA and RNA. Its modern uses include pesticides, pyrotechnics, steel production, armaments, and pharmaceuticals; but back in the 17th century, its practical use was limited.

A darker side In 1831, the Frenchman Charles Sauria invented a “strike-anywhere” match, the head of which contained a mixture of white phosphorus, potassium chlorate, gum, and David Speechley, BDS, DMI, RCS Edin, PG Dip (Implant Dentistry) Msc, is a principal partner of Glencairn Dental Practice in England and a director of the ICE Foundation, an organization dedicated to implant training and treatment.

48 Implant practice

starch. These matches ignited when rubbed on a rough surface, and the match industry was born. Founded in 1850, the Bryant and May match company rose in importance and, by 1861, had become one of England’s largest employers, operating from the largest industrial complex in Britain, situated in the Bow area of London. The workforce ran into the thousands and was largely made up of women, mostly young. Conditions were atrocious with workrelated deaths commonplace. The workers suffered from abdominal pain, liver and kidney damage, central nervous system disturbances, and phossy jaw. Phossy jaw was a dreadful condition typified by necrosis of the jawbones, eroding away the lower face, leading to an agonizing death. Many young workers imbibed such quantities of phosphorus from the working environment that reportedly girls as young as 13 in the cold winter nights had mandibles that could be clearly seen glowing through their skin. Figure 1 is an image from the mid1850s, of a man suffering from phossy jaw. Figure 2 is his mandible postmortem.

Figure 1

Yesterday’s poison

Figure 2

By 1888, the workforce was so discontented that they marched on Parliament. Nearly 1,500 workers withdrew their labor, and Bryant and May was forced to take note. Dentists employed to research the condition of phossy jaw concluded that the condition was brought about by phosphorus

poisoning, and that the severity of the condition was related to how closely the workers worked to the cauldrons containing the noxious chemicals and over what time scale. The dentists concluded that the symptoms were time- and dose-related. Volume 8 Number 2

Today’s wonder drug Today, bisphosphonates are a class of drugs that prevent the loss of bone mass. They are used to treat metabolic disorders of bone, including Paget’s disease, osteoporosis, osteogenesis imperfecta, and more life-threatening conditions such as multiple myeloma, primary bone malignancies, and metastases from other malignancies, including breast and prostate. Their mode of activity is preventing bone remodeling: The bisphosphonate molecule enters the osteoclast cell and brings about apoptosis. The dead cell gives up its contents, including the unchanged bisphosphonate molecule, which can go on to enter another cell. The half-life of this drug is therefore long, with authors recording figures of around 10 years.

Applications Bisphosphonates are the only drugs effective in prolonging life of those suffering from hypercalcaemia of malignancy, although this remains a terminal condition, and their life-extending properties are limited. Osteitis deformans (Paget’s disease of bone) is a relatively common condition in which the cycle of bone turnover is disrupted. This can cause bones to become weakened and deformed, and results in symptoms that may include pain and deformity. It is the second most common metabolic disorder of bone after osteoporosis. Volume 8 Number 2

The condition shows familial tendencies and is most widespread in the U.K. (the north west in particular), but it occurs in countries that have experienced migration from the U.K. as well – most notably the United States, Australia, New Zealand, and South Africa. The onset of Paget’s disease is agerelated; 1%-2% of white adults who are over 55 years of age have Paget’s disease, rising to 5%-8% for white people who are over the age of 80. The causes of Paget’s disease are not fully established, but it seems that two rogue genes are implicated and a viral trigger, which may be the measles virus. One theory is the mutated genes RANKL and SQSTM1 cause the measles virus to remain in the body following infection, lying dormant for decades before being reactivated and attacking the osteoclast cells, causing them to malfunction. The decline in the incidence of both measles and Paget’s disease could therefore be related. Until the 1960s, treatment of Paget’s disease was limited to hormonal treatment and surgery to correct bony deformities, including the removal of lumps and bumps impinging on nerves causing neurological disturbances. It is said the sciatic nerve, with its long tortuous path, is particularly vulnerable, and people suffering repeated bouts of sciatica should be tested for Paget’s. Serum alkaline phosphatase (SAP) remains the definitive blood test, and diagnosis may happen when a person is having a blood test for another unrelated condition, since most sufferers have little or no symptoms. Today, bisphosphonates taken either orally or by infusion are the drugs of choice in the treatment of people experiencing the bony symptoms of Paget’s disease. These drugs work by suppressing the actions of the osteoclasts — since osteoclastic activity triggers osteoblastic activity, the bone remodeling process is inhibited and bone density maintained. The dosage typically used makes it likely that these people may well be suitable for implant placement, but liaison with the clinician treating the condition should be consulted prior to considering dental implantation.

Taking bisphosphonates Oral bisphosphonates should be taken on an empty stomach to aid absorption. They should be taken while standing, or sitting upright, and taken with water, refraining from food for approximately 2 hours. Common side effects include diarrhea and nausea. More rarely, side effects may

include a tingling sensation in the arms or legs, as well as changes in mental states (such as confusion), hair loss, headaches, and glossitis. In recent times following the trend in the U.S., the oral route is becoming less popular, giving way to infusions.

Osteoporosis In the last 15 years or so, bisphosphonates have become the drugs of choice for the treatment of osteoporosis, a condition in which the bone mineral density is reduced beyond certain limits, the diagnosis being made by dual energy X-ray absorptiometry (DEXA) scanning. We must consider when the loss of bone mineral density — something that occurs with increasing age in both sexes, but most notably in post-menopausal women — ceases to be physiological and becomes pathological, and also what the consequences of not treating this condition may be. DEXA scans measure bone mineral density and are reported as T-scores, comparing the patients’ bone mineral density with the optimal peak mineral density for their gender, or as Z-scores when comparison is drawn with individuals of the same age, weight, ethnicity, and gender. The latter may be more useful as it allows for changes, which are known to occur with aging. Osteoporotic fracture is common, expensive, and associated with increased morbidity and mortality. The incidence of osteoporosis-related fracture reported annually in the U.S. is greater than the risk of stroke, breast cancer, and heart attack combined. Statistical analysis reveals that approximately one in two women and one in four men over the age of 50 will suffer osteoporosis-related fractures in their remaining lifetime. In 2005, osteoporosis was responsible for more than 2 million fractures in the U.S., with up to 38% of people who suffered hip fracture attributed to osteoporosis dying within 12 months. These figures are compelling evidence for why we should be treating osteoporosis. When it comes to the treatment of malignant bone disease, be it primary bone malignancy or metastatic spread, bisphosphonates are effective in reducing the risk of pathological fracture and confining tumor cells. The dosage used in these patients tends to be elevated in both dose and potency when compared with the treatment of other conditions, and the effect in the mouth where bone turnover is rapid may be profound. IP Implant practice 49

IMPLANT INSIGHTS

Today, we know the mechanism of the condition; the white phosphorus was reacting with water, carbon dioxide, and amino acids within the bodies of the workers to produce amino bisphosphonate. These poor unfortunates were imbibing uncontrolled doses of bisphosphonates and suffering bisphosphonate-related osteonecrosis (BRON — though there are a number of acronyms for this condition). Bisphosphonate-related osteonecrosis of the jaw is today defined as: • Current or previous treatment with bisphosphonates • Exposed bone in the maxillofacial region persisting for more than 8 weeks • No history of radiotherapy to the jaws (American Association of Oral and Maxillofacial Surgeons, 2006) The poisonous effects of bisphosphonates were clearly now well established — but as history has shown time and again, yesterday’s poison is tomorrow’s wonder drug, and bisphosphonates have been no exception.

PRODUCT PROFILE

Salvin® Renovix® Guided Healing Collagen Membrane

he Renovix® Guided Healing Collagen Membrane from Salvin Dental is getting excellent reviews from doctors using it for pre-implant grafting procedures, including socket preservation, ridge augmentation, and sinus lifts. It combines the ability to drape and conform to the specific anatomy of a grafted defect, while maintaining structural integrity and elasticity. This combination of ideal handling characteristics helps make grafting procedures easier and more predictable. When it comes to selecting the perfect membrane for guided bone and tissue regeneration, there are many choices. Yet most clinicians are still looking for the ideal barrier that combines the best handling and performance characteristics. Some collagen membranes remain stiff even after being hydrated, making it difficult to place over a ridge and conform to the shape of the defect. Other membranes have no memory and resemble wet tissue paper, making it extremely difficult to manipulate during surgery. Renovix® was originally created for use in repairing pediatric cardiac defects. Cardiac surgeons needed a resorbable membrane to protect the surgical site without migration, and to have it crosslinked in a way that significantly reduced the chance of an inflammatory response. Based on these specific requests, the material used for Renovix® was developed. Renovix® is fabricated from Type 1 porcine collagen, known to be one of the purest forms of collagen available. It is cross-linked with polysaccharide, a naturally occurring sugar, with excellent biocompatibility. The combined performance and handling characteristics of this membrane, along with specific requests from many implant surgeons, encouraged Salvin Dental to introduce Renovix® for guided bone-regeneration procedures. Case reports and clinical documentation are an important part of the decisionmaking process when determining how regenerative products will perform. Steve Wallace, DDS, MHS, from Wilmington, North Carolina, has used Renovix® in over 25 cases as a guided regeneration barrier after extraction and grafting of maxillary first and second molars in preparation for implant placement. Dr. Wallace made the following statement detailing his clinical experience with Renovix®: “Primary flap closure over maxillary molar extraction sites is always difficult to achieve. I have been using Renovix® as my barrier over these 50 Implant practice

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

Elastic handling

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

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

Volume 8 Number 2

Everything For Your Implant Practice But The Implants®

Enhancing Care For Your Patients™

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

Socket Graft Without Primary Closure

Grafted Extraction Socket

Renovix® Placed Double Layer

Mineralized Cortical / Cancellous

Sutured Without Primary Closure

16 Week Post-Op Mature Tissue Closure

16 Week X-Ray Ideal Bone Formation

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

Socket Graft Without Primary Closure

Grafted Extraction Socket

Renovix® Draped Over Surgical Site

Mineralized Cancellous

Sutured Without Primary Closure

4 Week Post-Op Mature Tissue Closure

16 Week X-Ray Ideal Bone Formation

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

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

PRODUCT PROFILE

CHAIRSIDE™ Product Portfolio Introducing a comprehensive kit designed for the efficient and accurate pickup of denture attachment housings

t is no secret that for more than 40 years, ZEST Anchors has been developing innovative products for overdenture applications. This dedication has led to product solutions that have enhanced outcomes for both clinicians and patients alike. ZEST Anchors is continuing this innovative path with the CHAIRSIDE™ Product Portfolio — a series of dental tools and materials that provide an end-to-end solution for implant-retained overdenture modification and processing. The first product ZEST Anchors introduced in the CHAIRSIDE Portfolio was CHAIRSIDE Attachment Processing Material — a pickup material designed for ease of use and predictability when processing Denture Attachment Housings and other attachment components into overdentures. Continuing to refine the efficiency and accuracy of the process, ZEST Anchors is pleased to introduce the latest advancement in the CHAIRSIDE Portfolio — the CHAIRSIDE Denture Prep & Polish Kit — all the instruments dental professionals need for the efficient and accurate pickup of Denture Attachment Housings. The CHAIRSIDE Product Portfolio, united with the LOCATOR® Attachment System,

“The CHAIRSIDE Denture Prep & Polish Kit is well organized, which makes it easy for me to navigate through the denture preparation steps. The custom Recess Bur significantly cuts down on the time it takes me to create the appropriately sized recess for the LOCATOR denture attachment housings.” — Charles Mastrovich, DDS, Escondido, California

LOCATOR® Overdenture Implant System and SATURNO™ Products, provide clinicians with innovative solutions for implantretained overdentures from a convenient and trusted source — ZEST Anchors.

Recess bur

Undercut bur

Vent hole bur

Trim bur

Grind bur

Polisher

52 Implant practice

The NEW CHAIRSIDE Prep & Polish Kit: A comprehensive kit consisting of recess, trim, undercut, grind, and vent burs, as well as a polisher, all of which are designed to address the most frequent overdenture preparation requirements. A unique to the market CHAIRSIDE Recess Bur, specifically designed by ZEST Anchors, that quickly and easily prepares the exact size recess for the LOCATOR and SATURNO Denture Attachment Housings (Denture Caps). • CHAIRSIDE Recess Bur — precise recess preparation • CHAIRSIDE Undercut Bur — optimized housing retention • CHAIRSIDE Vent Hole Bur — simple vent-hole creation • CHAIRSIDE Trim and Grind Burs — efficient post-pickup prosthesis adjustment • CHAIRSIDE Polisher — finishing and polishing IP This information was provided by ZEST Anchors.

Volume 8 Number 2

Brasseler USA® and Ivoclar Vivadent® have partnered in order to provide new innovations in dental procedural solutions. Specifically, Brasseler USA’s Innovations team collaborated with the experts at Ivoclar Vivadent to develop a specialized Crown & Bridge/Veneer Preparation System as well as a Chairside Finishing and Polishing system specifically designed to work with Ivoclar Vivadent’s popular IPS e.max® restorative material. Starting in March 2015, the new systems were available to dental professionals exclusively through Brasseler USA. Ivoclar Vivadent’s IPS e.max products have garnered leadership in the ceramic restorative material market through superior performance. Extremely versatile, IPS e.max can be pressed as thin as .3 mm and is very durable, with strength between 360 and 400 MPa. IPS e.max restorations are strong and highly esthetic, making them ideal for both anterior and posterior cases. Precise preparation and finishing are made seamless when Brasseler USA’s instrumentation is utilized. For more information on the new procedural systems, contact a dedicated Brasseler USA representative, or visit BrasselerCADCAM.com.

Dr. Balwant Rai, is Keynote Speaker for the 2015 OCO Biomedical International Dental Implant Symposium, July 17-18, in Albuquerque, New Mexico OCO Biomedical has announced Associate Professor Balwant Rai, BDS, MS — founder of Curriculum Aeronautical and Space Dentistry and the Editor-in-Chief of three journals and program director at the Kepler Space Institute — as the Keynote Speaker for the 2015 OCO Biomedical International Dental Implant Symposium presenting “Space Dentistry: New Vision.” OCO’s Symposium roster also includes Rajiv Saini, PhD, MDS, Associate Professor Department of Periodontology, Loni Maharashtra, India, who will present “Current Concept Review: PeriImplantitis,” Andres Traverse, DDS, Burlington, Ontario, Canada, who will address “Immediate Placement of Small-Diameter Implants — An Alternative Technique,” and Peker Sandalli, DDS, Professor of Implantology, Istanbul, Turkey, who will cover “40 Years’ Experience in Oral Implantology and the Secret of Success.” Participants will receive 16 hours of AGD-Pace CE credits and learn skills in the most advanced methods of implantology, restorative dentistry, sinus elevation, and bone grafting. OCO also will showcase the latest product and technology developments, and highlight the OCO Complete Implant Dentistry Solutions Approach and the company’s cutting-edge curriculum. To register or for further information, call 1-800-228-0477 or visit www.ocobiomedical.com.

Volume 8 Number 2

New Morita products debut J. Morita USA announced the R600T laser tip, a new treatment option accessory for the AdvErL Evo Er:YAG laser, and a new microsurgical blades product line. Morita’s AdvErL Evo laser is effective for a broad range of applications on both hard and soft tissue and is clinically ideal for periodontal treatment. This unit offers a wide variety of tip options, now 20 tips in total, with three new tips just added to the product line. Feather Microsurgical Blades have also been added to J. Morita USA’s product line. They are made of high-quality stainless steel with a two-step grinding process that produces ultrasharp cutting edges. The round and tapered shape is specifically designed for dental surgery and offers easy handling. Feather blades allow surgical precision with a very fine incision and are thus ideal for microsurgery and use with a microscope. For more information, call 877-JMORITA (566-7482), or visit www.morita.com/usa.

Osstell presents new platform for objective implant stability assessment Osstell has introduced Osstell IDx. It displays the ISQ measurements in an intuitive and easily interpreted way. It is easier than ever to assess implant stability and the degree of osseointegration, ensuring that implants are stable enough for final restoration. Ostell IDx also facilitates the communication with patients or the restorative dentists, concerning the treatment plans. Furthermore, with the Osstell IDx the company introduced the associated online service Osstell Connect. Implant stability data and results are automatically stored directly in the device and in the Osstell Connect service. It makes collaborations with colleagues easier; enables data backup, remote service, and support; and allows the user to analyze implant and treatment data through various platforms. For more information, visit osstell.com.

Sirona releases SIDEXIS 4 This intuitive software and new features such as patient timeline and lightbox for gathering and displaying images sets a new standard in clinical diagnosis and patient care. This innovative software with a sleek modern look has improved dentists’ ability to diagnose and treatment plan and — perhaps most importantly — effectively communicate their findings to patients who are then more likely to accept recommended treatment. What was previously hidden in the menu bar is now clearly visible in workflow icons arranged to match typical clinical procedures. In addition, the software readily accepts images obtained by intraoral, panoramic, and cephalometric X-rays; 2D and 3D CBCT systems; intraoral cameras; FaceScanner; and more. For more information, visit www.Sirona.com.

Implant practice 53

INDUSTRY NEWS

Brasseler USA® and Ivoclar Vivadent® collaborate to provide new innovations in dental and laboratory procedural solutions

ON THE HORIZON

If they all work … how do I choose? Dr. Justin Moody discusses his implant system of choice

t has been a long time since I have heard someone say, “I’m not sure dental implants work.” Now, more people pose questions such as “What system do you place?” or “Why do you like the system you have chosen?” I think this has been an incredible evolution. Personally, I am excited about the fact dental implants are, for the most part, considered the standard of care for a missing tooth or teeth! Looking back on my short 17-year career, I have seen many changes in the world of dental implants. In the beginning, I was more influenced by marketing and my local sales rep, but today my choice in dental implants is driven by science and research. Having used other implant systems, I feel my decision to place BioHorizons® implants is a good one. When working in the esthetic zone, we cannot be satisfied with an implant that just works — it has to be perfect, and this is where you must rely on science, every time. That is why I use the BioHorizons Tapered PLUS dental implant. It has all the proven features of platform shifting for bone and soft tissue maintenance along with the LaserLok® surface allowing for a true soft tissue connection not only to the implant but also to the underside of the abutment. BioHorizons has many features and products that provide a complete system. Having a two-piece 3.0 mm tapered dental implant with Laser-Lok and all the restorative choices makes total sense. The challenge was always maximizing esthetics with titanium abutments. BioHorizons makes a titanium base with Laser-Lok for zirconia

Justin Moody, DDS, DICOI, DABOI, is a Diplomate of the American Board of Oral Implantology and of the International Congress of Oral Implantologists, Fellow and Associate Fellow of the American Academy of Implant Dentistry, and Adjunct Professor at the University of Nebraska Medical College. He is an international speaker and is in private practice at The Dental Implant Center in Rapid City, South Dakota. He can be reached at justin@justinmoodydds.com or at www.justinmoodydds.com. Dr. Moody is a paid consultant for BioHorizons.

54 Implant practice

18 months post prosthetic X-ray using a DEXIS™ Platinum sensor

Extreme magnification showing the Laser-Lok microchannels and underlying nanostructure

Tapered family of implants include a 3.0, platformmatched and platform-switched versions

Only surface shown to achieve a connective tissue attachment

Screw-retained, full-contour zircona crown with an Authentic Connection Ti-Base from BioHorizons made by ProSmiles Dental Studio

hybrid abutments. Labs such as ProSmiles Dental Studio are able to make beautiful ceramic abutments and restorations using BioHorizons Authentic Connection prosthetic components that have superior fit and reliability. Other features include one surgical kit

for the entire tapered product line, implant sizes and lengths that make sense, a full range of prosthetic options, bone and soft tissue regeneration products, all with great customer care and made in the United States. Now that’s a system, and the reason why I chose BioHorizons. IP Volume 8 Number 2

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT Taub Products’ ZERO-G bio implant cement kit available TAUB Products is marketing its ZERO-G dual-cure implant cement in a kit that contains two 7.0 gram filled syringes and 20 auto-mixing tips. The cement is recommended for intermediate to long-term cementation of implant-retained restorations and for traditional crown and bridge restorations. It can be cured with light in as little as 20 seconds, which allows for complete margin curing. Working time for self-curing is 1 minute and 45 seconds, and complete set time is 2 minutes and 30 seconds. ZERO-G provides excellent radio-opacity for good visualization after cementation, facilitating simple and easy cleanup, and allowing for diagnostic examination upon follow-up. The new implant cement is retentive, which allows easy removal of the restoration, as well as excess cement. Its unique color provides great contrast to gingival tissue, enhancing easy visualization. For more information on TAUB products, call 800-828-2634, or visit www.taubdental.com.

3Shape Implant Studio™ users can now access BIOMET 3i™ implants 3Shape has announced that dental professionals can now access BIOMET 3i™ family of implants in connection with 3Shape Implant Studio™. Dentists, implantologists, and dental technicians access implant systems, like BIOMET 3i, when using Implant Studio™ software to assist in their implant planning. Users who wish to benefit from this opportunity should contact their 3Shape distributor for more information on how to access these libraries. For more information about BIOMET 3i, visit www.biomet3i.com or contact the company at 800-342-5454. For further information regarding 3Shape, refer to www.3shape dental.com.

LED Medical Diagnostics launches new RIOSensor Intraoral Radiography System LED Medical Diagnostics Inc. has announced that its subsidiary, LED Dental, has officially launched the new RIOSensor Intraoral Radiography System from RAY Co., Ltd. (“RAY”), a spin-off of Samsung Electronics, in the USA and Canada. Boasting true resolution of >20 line pairs/mm, the RIOSensor provides image quality that is among the best in the industry. Built to deliver exceptional precision, RIOSensor images enhance the clinician’s ability to improve radiographic diagnosis through a variety of custom filters to optimize sharpness and contrast for endodontics, periodontics, and caries diagnosis. For more information, visit www.leddental.com.

56 Implant practice

Straumann® introduces a new tapered implant designed for immediate placement and loading Straumann® has launched the new Bone Level Tapered (BLT) Implant in conjunction with Straumann® Pro Arch, their new treatment solution for screw-retained full arch restorations. Building on the clinically proven features of the Straumann® Bone Level Implant, the Straumann BLT Implant introduces the powerful combination of Roxolid®, SLActive®, Bone Control Design®, CrossFit® Connection, and Consistent Emergence Profiles®. The tapered design of the Straumann BLT Implant body helps overcome anatomical restrictions such as converging tooth roots and concave jaw structures. It’s well suited for one- and two-stage procedures with reduced intra-procedural times. A full thread at the implant tip allows for early engagement of the threads; the three cutting notches enable placement in an underprepared osteotomy. The Straumann BLT Implant design delivers flexibility in challenging clinical and anatomical situations. Straumann — a single trusted source for dental implant and regeneration needs — also introduced Membrane Flex™, which joins Membrane Plus™, XenoGraft, AlloGraft, BoneCeramic™, and Emdogain™. For more information, visit www.straumann.us.

Carestream Dental announces release of Logicon Caries Detector 5.1 Carestream Dental’s latest release of Logicon Caries Detector 5.1 further automates the detection process and produces improved displays of caries sites, making exams and diagnoses even more efficient than in the past. Logicon 5.1, the only commercially available FDA-approved computer-aided radiographic caries diagnosis software, is a unique and clinically proven tool that helps practitioners detect and treat interproximal caries at an early stage, enabling minimally invasive treatments. Studies show that Logicon more than doubles dentists’ capability to find early caries in the dentin over traditional visual diagnostic methods.* For more information about Logicon 5.1, RVG sensors or any of Carestream Dental’s innovative products, call 800-9446365, or visit www.carestreamdental.com. * Tracy, Kyle D., “Utility and effectiveness of computer-aided diagnosis of dental caries.” General Dentistry 59-2 (2011): 136-144.

BruxZir™ Shaded 16 CAD/CAM blocks now available for use with Sirona’s CEREC® solutions Glidewell Laboratories released BruxZir™ Shaded 16 blocks compatible with CEREC® and inLab® MC XL milling machines, the dental CAD/CAM solutions from Sirona Dental Systems. Henry Schein® will exclusively distribute the new blocks, available in both 20 x 19 and 40 x 19 sizes. BruxZir™ Shaded 16, the series of preshaded zirconia blocks matching all 16 VITA Classical shades, is an iteration of the BruxZir™ Solid Zirconia line, the most prescribed brand of solid zirconia restorative material. Known for its superior strength and unique vital translucence, the addition of inLab®compatible BruxZir™ Shaded 16 blocks to the BruxZir portfolio will deliver consistency and complete shade penetration to dental technicians implementing Sirona’s CEREC® and MC XL milling machines. With the significant market penetration of Sirona CAD/CAM systems, distribution of blocks consistent with the machines’ specifications ensures a wide new audience for the benefits provided. For more information, visit http://www.glidewelldental.com.

Volume 8 Number 2

SWISH™

simply brilliant Straumann®-compatible1 design

SwishPlus™

NEW SwishTapered™

Tissue- or Bone-Level Implant with Internal Octagon Connection

Tissue-Level Implant with Internal Octagon Connection

All-in-1 Packaging

includes implant, cover screw, healing collar & carrier/transfer – $150 SBM $435 TRUE SAVINGS for Straumann Customers we dare to compare

NEW SwishActive™

Bone-Level Implant with 12° Conical Hex Connection

With 1 surgical tray, All-in-1 Packaging and 1 price at any level, the simplicity of the Swish™ Implant System is evident. The design enhancements combined with Straumann-compatibility1 are what make it truly brilliant. Each implant body design promotes self-tapping, initial stability and reduced crestal bone stress The NEW SwishActive also features a platform-shifting conical hex connection with six indexing positions for precise prosthetic placement. Matched transgingival profiles on prosthetics allow for consistent soft tissue management throughout treatment. All this with TRUE SAVINGS of $435 compared to Straumann. Now that’s simply brilliant.

Your SMART START: 6 straight abutment kits FREE with purchase of 20 implants 1

www.implantdirect.com | 888-649-6425

SwishPlus and SwishTapered fully compatible with Straumann tissue level implants, with some restrictions for 3.3mm and 5.7mm diameter implants. SwishActive surgically compatible with Straumann drills with exception of profiling drills and Bone-Level Tapered drills. Promotion valid for new customers only and cannot be combined with other offers. Promotion expires June 30, 2015. Price comparisons based upon US list prices for comparable items as of January 2015. All trademarks are property of their respective companies.