Implant Practice US June/July 2015 Issue - Vol8.3 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews June/July 2015 – Vol 8 No 3

Multiple idiopathic external cervical root resorption: a case report

The EVolution continues

PROMOTING EXCELLENCE IN IMPLANTOLOGY

Dr. Usman Hameed

Drs. George Pelekos and Nikos Mardas

Effectiveness of a superpulsed CO2 laser for removal of biofilm from three different types of implant surfaces: an in vitro study

Follow nature’s contour

Natural teeth or implants? Informing the decision-making process

Drs. Charles M. Cobb and Peter Vitruk

Practice profile Dr. Barry P. Levin

The new OsseoSpeed Profile EV To learn more, visit www.dentsplyimplants.com

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June/July 2015 - Volume 8 Number 3 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

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t was filled with the usual schedule of crowns, exams, and denture adjustments; so rarely do we provide lower dentures without a calendar of corrective follow-up appointments. However, this day included three patients for whom I have in the past trimmed, ground, or smoothed their conventional dentures to provide limited satisfaction. Today, they were scheduled, not for adjustment, but for continuing care; two with the dental hygienist. All three within the last year completed treatment with dental implants based upon their functional needs and the financial resources Mark Montana, DDS they chose to extend. The first patient had two implants placed into the anterior mandible, and her lower denture is now retained and stabilized by snap-in abutments. Today, she required replacement of the worn nylon components. The second patient received four implants and a fixed, screw-retained hybrid prosthesis for her lower jaw. The last was a man restored with four implants, four ATLANTIS™ Conus abutments (DENTSPLY Implants), and a metal-reinforced, resin prosthesis — a patient-removable design that functions with the stability of a fixed bridge. The latter fixed-removable concept is relatively new but owes its origin to both bar-in-bar implant bar designs as well as coping crowns used on teeth. The prosthesis functions like a fixed bridge but is retrievable by the patient, enabling unrestricted, excellent oral hygiene. The removable prosthesis is retained by friction fit and is placed and removed vertically, parallel to the axis of the abutments and, therefore, is not dislodged by chewing motion. Because the prosthesis is removable, it is possible to build better facial support and often improve phonetics compared to non-retrievable maxillary hybrids. These advantages come at a much lower cost and require less interarch space compared to bar-in-bar or fixed designs. As a CAD/CAM solution, each abutment is parallel to the other, milled precisely to fit within a standardized “telescopic” mate and within the confines of the prosthesis. Importantly, it fills a treatment gap between the simple snap-in overdentures and fixed implant bridges, both functionally and in terms of cost, to fully edentulous patients. For those suffering complete tooth loss, the consequences of their condition extend beyond the obvious. They also experience profound quality of life changes, including nutritional insufficiency and social withdrawal. Being unable to enjoy the same foods as their peers or perhaps being the last one eating often produces self-consciousness and avoidance of social meals. Denture patients are also burdened with escalating expenses in an attempt to remedy their circumstance, often trusting over-the-counter products rather than returning to their dentist for fear of even higher costs. For these reasons, they benefit the most from dental implant treatment, as we can offer recovery from these maladies with new technologies to meet the needs of almost any denture patient. Some can afford only two implants today, but with careful planning, two future implants may be placed and a fixed-removable solution delivered. Those with a fully implant-supported prosthesis no longer have pressure on the soft tissue nor lateral movement of the structure, eliminating sore spots and preserving the supporting bone. Their dental expenses shrink as replacement of abraded components is eliminated. Today, three people scheduled to invest in protecting a commitment toward improved quality of life. As more of my former denture patients benefit from their transition to overdentures, fixed hybrid prostheses, and now, fixed-removable bridges, their embrace of social interaction is rewarding, and their transformation in my practice is both gratifying to me and economical for them. This exciting new technology offers hope to many denture wearers and tremendous satisfaction for their dentists. A very good day indeed! How was yours? Mark Montana, DDS

$99 $239

© 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 3

Mark Montana, DDS, is a 1987 graduate of the University of Southern California (USC) School of Dentistry and completed his Certification in Advanced Prosthodontics at USC in 1989. He has been primarily involved in private practice in Tempe, Arizona, emphasizing fixed, removable, and implant prosthodontics. Dr. Montana has been involved in clinical instruction while attending USC and as a preclinical instructor at the Arizona School of Dentistry. He has lectured domestically and internationally on the topics of implant, fixed, and removable prosthodontics. He has served on several of his state’s dental committees. Dr. Montana’s memberships to professional organizations include the American College of Prosthodontists, the Academy of Osseointegration, the Academy of Fixed Prosthodontics, the Pacific Coast Society for Prosthodontics, and the American and Arizona Dental Associations.

Implant practice 1

INTRODUCTION

Today was a good day!

TABLE OF CONTENTS

Clinical Full arch implant restoration Dr. Paul Tipton discusses the advances in full arch implant restorations and presents a case study demonstrating how they can be applied to improve facial esthetics .......................................................17

Practice profile Barry P. Levin, DMD

Academics, sound science, and no shortcuts

Case study Replacement of a failed root canal of the second molar with a Straumann速 Roxolid速 SLActive速 Bone Level Tapered (BLT) Implant

Case study

A simplified guided surgical protocol: three mandibular implants

Dr. Brad McAllister offers hope to a patient with a hopeless tooth........... 30

Dr. Charles D. Schlesinger describes a unique two-drill protocol ON THE COVER Cover photo courtesy of Planmeca. Article begins on page 56.

2 Implant practice

Volume 8 Number 3

For all major implant systems

A stable and comfortable solution for edentulous patients

DENTSPLY Implants does not waive any right to its trademarks by not using the symbols ® or ™.

ATLANTIS™ Conus concept

ATLANTIS Conus concept allows for friction-fit, non-resilient prosthetic solutions for fully edentulous patients and is designed for optimal chewing function, sense of taste and oral hygiene.

www.dentsplyimplants.com

TABLE OF CONTENTS

Seeing the light Enhanced hemostasis and improved healing in CO2 laserassisted soft tissue oral surgeries Robert Levine, DDS, and Peter Vitruk, PhD, discuss CO2 laser efficiency in coagulation and healing.................. 34

Continuing education Natural teeth or implants? Informing the decision-making process Drs. George Pelekos and Nikos Mardas offer some considerations for all implant dentists to address when making their treatment choices

Continuing education

................................................. 38

Multiple idiopathic external cervical root resorption: a case report

Practice development

Dr. Usman Hameed takes a look at the unpredictable nature of some root resorption cases and argues the importance of flexibility in treatment planning

New horizons In the first of a new series, Toks Oyegunle explores how applying a simple yet effective marketing framework to your practice can help it thrive.......................................46

Product profile The SATURNO™ Narrow Diameter Implant System

.................................................48

Practice management Increase case acceptance by becoming a patient-centered practice and offering flexible payment options Marla Merritt discusses how to make treatment more affordable.............49

4 Implant practice

Step-by-step

On the horizon

Algisorb™ 100% organic bone grafting material

Complete 3D treatment planning software for implants Dr. Justin Moody discusses the latest

.................................................52

update to Tx STUDIO 5.4 .............54

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

Product profile Planmeca Romexis® software Open architecture, endless possibilities

.................................................56

Volume 8 Number 3

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PRACTICE PROFILE

Barry P. Levin, DMD Academics, sound science, and no shortcuts What can you tell us about your background? I attended Temple University School of Dentistry and completed my specialty training in periodontology and dental implant surgery at the University of Maryland in 1996. I have been in the same private practice for 19 years. I have also been teaching periodontal and implant surgery in the graduate periodontology program at the University of Pennsylvania (Penn) since 1996.

When did you become a specialist and why? In college, I originally thought I would become an orthopedic surgeon. The knowledge and skills required to regenerate alveolar bone necessary to perform proper implant placement falls into a similar line of thought. The use of growth factors, bone grafts, membranes, and so on, makes this field dynamic and always challenging. However, I finally decided to focus on dentistry, and I entered my perio residency immediately after graduating from dental school. I was always drawn to the surgical aspects of dentistry such as microbiology, pathology, and surgery. I was torn between oral maxillofacial surgery and periodontology. I felt periodontics gave me the best opportunity to be involved with my combined interests. Periodontitis is an infectious disease, often requiring antimicrobial and surgical therapy. The blend of keeping teeth via periodontal therapy and the regenerative nature of implant surgery was what sold me on periodontology as my career path.

Is your practice limited solely to implants, or do you practice other types of dentistry? While implant therapy is a key part of my practice, as a board-certified periodontist, my first goal is to help patients maintain their natural dentition in a state of health, function, and comfort. I perform nonsurgical and surgical periodontal therapy. This includes resective procedures such as crownlengthening and osseous surgery. It also includes regenerative therapy such as combining growth factors with bone grafts 6 Implant practice

and guided tissue regeneration (GTR) to regenerate lost attachment apparatus, and soft tissue augmentation for root coverage/ esthetics regularly. All of these procedures lend themselves directly to implant surgery. Often, hard and soft tissue augmentation is necessary either simultaneous or prior to implant placement. Having specialty training in periodontics makes this a seamless crossover. Having a strong background in regeneration makes adjunctive dental implant surgeries such as ridge augmentation, sinus grafting, and mucogingival procedures routine in my surgical specialty practice.

Why did you decide to focus on implant dentistry? During dental school, I spent a lot of time in the graduate periodontics clinic. I may hold the unofficial record for the number of periodontal surgical assists for a dental student. I saw the implementation of the surgical principles of Drs. BrĂĽnemark and Schroeder and the evolution of implant dentistry from a hospital-based to an office-based discipline

that was taking place in the early 1990s. The excitement this generated in the clinic was amazing. My periodontics training at Maryland under people such as Drs. Sylvan Feldman, Karl Zeren, Arnold Sindler, Paul Rosen, and John Bruno taught me how to make implant surgery an exciting and realistic career path. The meticulous attention to infection control, minimizing surgical trauma and technique was emphasized. Studying the literature and hearing pioneers such as Drs. BrĂĽnemark, Albrektsson, Buser, Nevins, Tarnow, and others present at Congresses inspired me to go beyond the didactic requirements of my graduate program, and I started reading textbooks pertaining to implant surgery, bone regeneration, and esthetics. This truly piqued my interest in making advanced surgical procedures a focus moving into private practice. I also felt how rewarding it is to improve patientsâ&#x20AC;&#x2122; quality of life by alleviating their dependence on removable prostheses and helping to provide them with permanent, esthetic solutions that had affected their self-esteem for many years in certain cases. Volume 8 Number 3

Yes. The majority of my patients are referred by restorative dentists. Having good relationships with restorative doctors is essential for the health of any surgical specialty practice and greatly impacts the overall positive experience and outcome for the patient. I am fortunate to work with some of the most talented restorative dentists in the Philadelphia area. We have created such a sense of familiarity with streamlined protocols that enhance treatment coordination and process. At the same time, however, more and more patients are being referred by other patients, or they discover my practice online. Overall patient experience and satisfaction is also so critical to the long-term success of a practice.

How long have you been practicing implant dentistry, and what systems do you use? I have worked with over 10 different implant systems over the 19 years I’ve been in practice, between working in the office and treating patients at Penn. My experience has led me to the point where I felt I needed one system that provided optimal surgical and restorative options, but with science backing all aspects. This is why I currently work exclusively with the ASTRA TECH Implant System™ EV by DENTSPLY Implants. Supporting the ASTRA TECH Implant System is a decades-long history of science and success, which is critical for me as a clinician

“Dr. Levin provided an expert and painless implant procedure and was so kind and understanding of my individual concerns. His staff follows his lead in patient care and satisfaction. Now, more than ever, I understand how important it is to see an experienced specialist trained in implant surgery.” – Beverly R., Elkins Park, Pennsylvania

looking to provide the most reliable and optimal outcomes for my patients.

What training have you undertaken? My periodontics specialty program provided me with years of formal implant training. Periodontics teaches the art of diagnosis, treatment planning, surgical technique, and wound healing. The importance of the literature, both classic and current, was a major point of emphasis. Supporting clinical decisions with sound scientific evidence is mandatory. I have continued my training by attending and teaching both didactic and hands-on courses at major Congresses such as the AAP, AO, EuroPerio, etc. Also, teaching at Penn alongside master clinicians like Drs. Louis Rose, Edwin Rosenberg, Arnold Weisgold, and others, I’ve collaborated and learned so much from sharing experiences with these true experts.

Who has inspired you? Personally, I grew up with a father who built a business from the ground up. He went to the Wharton School of Business at night for years while building a career and supporting his family. His work ethic was evident 7 days a week, and understanding that there is no substitute for hard work has rubbed off on me.

Professionally, I had the honor of being one of the four residents in Dr. Gerald Bowers’ last class before his retirement. Learning periodontology from one of the true legends was a privilege I cannot express in words. I went to Maryland because the program was renowned for having the regenerative emphasis on periodontal treatment. Dr. Bowers engrained in us the philosophy that all treatment must be based in sound science from the literature. Becoming board certified was a given, and I was proud to receive my acceptance as a Diplomate from Dr. Bowers. I was also inspired by Dr. Emanuel Tress. “Manny” brought me into his long-established practice right out of my residency. Not only did he give me an opportunity to build my own identity, but he taught me so many aspects about how to communicate with referring dentists, patients, and colleagues. I will be forever grateful for the opportunity Manny has given me. Teaching at Penn, I have not only become colleagues and friends with some of the “all stars” of periodontics and implant dentistry, but in subtle ways, I’ve been mentored by legends in our field. The knowledge these men have shared with me, both directly and indirectly, has been invaluable. Appreciating the path modern implantology has followed serves as a blueprint for the proper future direction of our field.

What is the most satisfying aspect of your practice? The most satisfying aspect of my specialty practice has to be the gratitude that patients show after their treatment is completed. When people come to you despondent about their oral health and appearance, and your therapy truly changes their attitude and outlook, you cannot help but feel tremendous satisfaction.

Front office under construction

Professionally what are you most proud of? Operatory in new office in Jenkintown, Pennsylvania Volume 8 Number 3

Front office after construction

I would have to say that I am most proud that I have built my practice “the right way.” There is immense pressure to take shortcuts Implant practice 7

PRACTICE PROFILE

Do your patients come through referrals?

PRACTICE PROFILE at every turn in private practice. Doing procedures people are not adequately trained to perform, using inferior, unproven products sold at discount prices, not basing treatment on sound science, etc., is everywhere. I am most proud that I stay within my specialty scope of practice, use only premium, solidlyresearched materials, and read multiple journals monthly. The treatment performed in my office is always based on this scientific approach. Shortcuts are simply not an option.

What do you think is unique about your practice? I think my practice is unique because I bring an academic approach to a private practice. I serve as an editorial board member of several peer-reviewed journals, including being the Implant Section Editor for Compendium. I regularly publish clinical research and case reports and lecture nationally and internationally. I bring this scientific approach to my patients each and every day. I spend the majority of my time in private practice. Relating proven treatment modalities to real-world patients is something I am most proud of. Because I present regularly and document procedures, I look at every procedure as if I am sitting in an auditorium, looking at my surgeries on a large screen. This is a compass for staying the course and trying to perform to the best of my ability. Also, with a brand-new, state-of-the-art office, we can offer cutting-edge technology while still maintaining the over 50-year tradition of patient care and a family atmosphere of the practice.

What has been your biggest challenge? I think the biggest challenge is making the public aware of why they should seek a specialist for implant care. Weekend courses, mini-residencies, and lack of regulations blur the lines for prospective patients. It’s very easy for under- or untrained dentists to appear qualified to perform care best rendered in a specialist’s practice. This can lead to less than ideal outcomes, and patients begin to fear implant therapy because they or someone they know has had bad experiences with implants. When a true team comprised of surgeon, restorative dentist, and lab technician work together, there can be success for everyone; and even more importantly, results can be predictable and optimal for the patient. This is the biggest challenge we face moving forward.

What would you have been if you hadn’t become a dentist? If I did not become a periodontist specializing in implants, I would probably be one of the three Levin Brothers in the family business. The fact that I chose dentistry as a career is good news for my two younger brothers, who are the two happiest people because of this. The forklift business is also better off for my choice, I’m sure!

What is the future of implants and dentistry? I think the future of implant dentistry is exciting, yet needs to be approached with caution. The vast amount of technology drives

Dr. Levin in his office

all fields to an extent. The emergence of threedimensional printing, CAD/CAM technologies, and tissue engineering will have major footprints on our field. The dentists 20 years from now may look at our patients’ radiographs and wonder what these metal screws are. The challenge we all face is knowing when certain technologies are safe, predictable, and proven scientifically. It is up to the peerreviewed journals, the researchers, and dental schools to exercise patience before touting biomaterials, techniques, and technologies. With that word of caution, I think the things we will accomplish in the future will be great! Regeneration of lost hard and soft tissue will always be at the forefront of my practice. Simply accomplishing osseointegration is no longer an acceptable endpoint. Inconspicuously blending dental implants and restorations within the partially edentulous patient’s dentition with long-term stability is our goal. For edentulous patients, giving them back a fully functional and esthetic dentition should always remain our focus. This is also one of the reasons that I am currently just finishing the construction on a brand-new office. The new office is designed around the integration of state-of-the-art technology and process efficiency for the highest level of patient comfort and treatment outcomes.

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

Dr. Levin with his staff 8 Implant practice

I think staying current with the science is crucial. For one to be a successful specialist, he/she must offer more than a “megadontist” can provide. We must use our specialty training as a platform to start “ahead of the curve.” Our background in surgery, wound healing, and science gives us this head start. Keeping open lines of communication with all members of the team is critical. Volume 8 Number 3

PRACTICE PROFILE The surgeon must understand the unique challenges our restorative colleagues face and how they manage specific situations. Being familiar with CAD/CAM technology, digital impression systems, and occlusion makes this communication most productive. If each team member understands and respects the other’s role, optimal treatment prevails. It is also very important for the specialist to maintain a modern, clean, and comfortable environment for patients. People need to feel that they are being cared for at an extremely high level when they see a specialist, with patient satisfaction being one of the best marketing strategies you can have.

What advice would you give to a budding implant dentist? Training is key. What a dental school curriculum can offer will always be limited. There is simply too much critical information and experience to serve as the “minimal requirements” for graduation. It is up to individuals to find their passion and pursue mastery appropriately. In my opinion, an ADA-certified residency is the best way to receive formal education in a particular area, without the bias of manufacturer-provided, private courses and in an adequate length of time to teach fundamental principles and learn the literature. After completing a graduate program, it is up to these individuals to continue their education for the duration of their careers. There are many opportunities to continue learning at major Congresses and smaller continuing education courses. Reading

peer-reviewed journals and collaborating with other doctors in person and online strengthen one’s knowledge.

Tell us some details about your practice. My private practice has recently opened a new location in Jenkintown, Pennsylvania, with eight operatories, three designated for hygiene. Two operatories are set up for evaluations and nonsurgical procedures, and three operatories are equipped for surgical treatment, including IV sedation, administered by a physician. We have had digital radiography for 10 years and in-house CBCT for 8 years. This new facility has a state-ofthe-art sterilization center and private consultation room for comfortable explanations and Q & A appointments for our patients. My office manager, Jennifer Scamuffa, runs the practice. She is a member of the American Association of Dental Office Managers and manages the daily business of the practice as well as performs patient consultations. The team consists of two dental hygienists, three surgical assistants, and two front

desk team members. We have little to no turnover, and I am the third-longest tenured member of the team. Our patients truly appreciate the same faces they see at every visit and share recipes, borrow books, and share pictures of the children and grandchildren with our crew. Relationships are very important in our practice. I am extremely proud to be able to provide state-of-the science specialty care in this brand-new facility while carrying over a half-century tradition of patient comfort and friendships to our new office.

What are your hobbies, and what do you do in your spare time?

My hobbies include continuing a 30-plus year weightlifting habit. My youngest son has begun training with me, and this has re-invigorated my passion for fitness. I also help coach his travel basketball team with my wife. She played basketball in high school, and I am really enjoying the role of mentor and coach of 10 great 5th grade boys. All three of my kids lead pretty active lives. My 16-year-old daughter and 14-yearold son are both active in theater and music, and I really enjoy seeing them perform. Running to soccer and basketball games, school plays, and concerts fills time pretty well during the Top 10 favorites academic year. 1. Bone and dermal allografts I have always loved the Jersey 2. Digital photography shore (not the one on TV). We try 3. rhBMP-2 and rhPDGF-BB ® to spend as much family time as 4. Piezosurgery possible in the summer at the 5. CBCT and planning software beach. I have always wanted my 6. X-otomes and periotomes kids to have that love of the shore 7. Loupes with illumination that my parents instilled in me. IP 8. Resorbable mesh for ridge augmentation 9. ASTRA TECH Implant System™ EV 10. Peace

Dr. Levin with his family

10 Implant practice

Dr. Levin and his son, David, with legendary Hall of Fame coach John Chaney, who ran a practice for the team this season Volume 8 Number 3

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CASE STUDY

A simplified guided surgical protocol: three mandibular implants Dr. Charles D. Schlesinger describes a unique two-drill protocol

lthough implants have been, and will continue to be, placed freehand, technology has brought guided surgery into the hands of any doctor who may want to utilize it. The use of CT-guided surgery can increase accuracy and predictability of implant placement but also drastically cut down the time of actual surgery. Buser and colleagues point out that successful esthetic outcome can only be achieved with an ideal implant position in all three dimensions.1 They describe proper implant position as a zone within the buccolingual, mesiodistal, and apicocoronal dimensions rather than a specific point. By positioning the implant within these comfort zones, it is predictable to achieve a functional and esthetic outcome.2 Guided surgery systems are either designed for a specific implant type/ company or generic kits that work with multiple systems. A variety of software is available to treatment plan; virtually place the implants, and then allow the fabrication of a surgical guide to be used with specific guided surgical instrumentation. For this case, I utilized a surgical system with a unique two-drill protocol to simplify the surgical phase of treatment.

Figure 1: Pre-op oral photo

Figure 2: Maxillary arch

Figure 3: Mandibular arch

Clinical case A 54-year-old female with an unremarkable medical history presented to the clinic with the complaint of â&#x20AC;&#x153;I do not like my teeth.â&#x20AC;? Upon both radiographic and intraoral evaluation, it was determined that the patient had extensive decay and chronic periodontal Charles Schlesinger, DDS, FICOI, completed his dental training at The Ohio State University College of Dentistry. After graduation, he completed a GPR at the VA San Diego Medical Center and then went on to become the Chief Resident at the VA West Los Angeles Medical Center. While in Los Angeles, he received extensive training in implantology, oral surgery, and complex restorative dentistry. Upon completion of his training, Dr. Schlesinger returned to San Diego where he ran a thriving dental practice for 14 years. During this time, he became an educator for various dental implant companies and has lectured across the United States, Canada, the United Kingdom, and China. In 2012, he became the Director of Education and Clinical Affairs for OCO Biomedical, and in 2013, took on the position of Chief Operating Officer.

12 Implant practice

Figure 4: Pre-op panorex

disease confined to the maxillary arch. The panorex showed a pneumatized sinus on the left and multiple periapical radiolucencies associated with failing endodontic treatment. The mandibular arch was healthy with no signs of pathology beyond incisal wear

and would require only implant placement to replace teeth Nos. 28, 29, and 30 (Figures 1, 2, 3, and 4). The treatment was to be carried out in two phases. The initial surgical phase would include complete edentulation of the maxillary Volume 8 Number 3

antibiotic therapy for an additional 5 days post-op.

Surgical Phase I

Maxillary arch The maxillary arch was edentulated, and the sockets were grafted with OsteoGen® Plugs (Impladent Ltd.). OsteoGen Plugs are made up of a mixture of OsteoGen and Type 1 collagen. A lateral approach (Caldwell-Luc) sinus elevation was carried out on the left side in preparation for implants at Phase II. The site was grafted with pure OsteoGen particulate. Three 2.5 mm x 12 mm SDI implants (OCO Biomedical) were placed to help retain the upper denture during the healing phase. The interim maxillary denture was tried in and the occlusion adjusted. A soft reline material (Mucopren®, Kettenbach USA) was used to provide retention around the O-Ball abutments of the implants. Housings with O-Rings will be retrofitted a few weeks down the line once healing of the soft tissues has been established.

Due to the multiple periapical radiolucencies, the patient was placed on 300 mg of clindamycin 3 times a day starting 3 days before surgery and will continue the

Mandibular arch Implant sites Nos. 28, 29, and 30 were treatment planned using a Vatech PaX-i3D

Figure 5: Guided surgical treatment plan

CBCT (Vatech USA). The treatment plan was devised using coDiagnostiX imaging software (Dental Wings, Montreal, Quebec), and the guide was fabricated by 3DDX (Figures 5, 6, and 7). The lower arch was anesthetized with a local infiltration of Septocaine® with epinephrine 1:100,000 (Septodont). Once profound anesthesia was established, the surgical guide (3DDX) was tried into place. Openings within the guide allow visualization and verification of complete seating (Figure 8). The case was treatment planned for three 4.0 mm x 10 mm TSI implants (OCO Biomedical) and the use of the OCO Biomedical Guided Surgery System for placement. This system is unique in that it is the only two-drill protocol system on the market and drastically simplifies the surgical procedure since only one key is used per implant size (Figure 9). The double-ended key has the pilot on one side and the final osteotomy former on the other (Figure 10). The 4.0 key is placed into the guide sleeve, and the 1.8 mm pilot drill is taken to full length. The digital treatment plan called for the use of a 20-mm length bur

Figure 6: Occlusal view of treatment plan

Figure 9: OCO Biomedical Guided Surgery System

Figure 7: Completed 3DDX guide Volume 8 Number 3

Figure 8: Guide seated on mandibular arch

Figure 10: Double-ended key for each implant diameter Implant practice 13

CASE STUDY

arch, including lateral sinus elevation on the left side and grafting of the sockets and a bony defect associated with the area of the left lateral incisor. Three small diameter implants — SDIs (OCO Biomedical) — would be placed to provide increased retention for the interim full upper denture. Guided placement of three implants in the mandibular fourth quadrant was also to be carried out at this initial phase of treatment. Definitive implants on the maxillary arch at Phase I were contraindicated due to the extensive pathology associated with the previously mentioned issues. An immediate maxillary denture will be worn for 4 months until the healing phase is completed, and definitive implants can be placed in the maxillary arch. This treatment will be featured in a future article. This article will focus on the surgical treatment of the mandibular arch.

CASE STUDY for all three implant locations (Figure 11). Once the pilot holes were completed, a 4.0 guided tissue punch was used in each location (Figure 12). The guide was then removed to allow access to remove the tissue plugs with a No. 8 round bur on a surgical high-speed handpiece (Figure 13). Since tissue level implants were being utilized, a countersink was now used to allow the imbedded tapered platform

Figure 11: 1.8 mm pilot taken to full length

of the TSI implant to be placed into the crestal bone to allow for the patented body of the implant to attain dual stabilization (Figure 14). This countersink also allows for placement when the crestal bone has an irregular topography by removing the proper amount of bone that is needed to allow for complete seating of the implant. When using bone level ENGAGEâ&#x201E;˘ implants (OCO Biomedical), this step is not necessary. Once the countersink procedure is completed, the guide is replaced, and the opposite side of the key (final osteotomy side) is inserted into the guide sleeve. With internal irrigation, the final internally irrigated osteotomy former (3.6 mm) is taken to the 20-mm length as indicated by the treatment plan (Figure 15). The guide is then removed; the implant osteotomies are checked for integrity 360 degrees around and flushed with sterile saline. The sites are now ready to receive their implants.

Figure 12: Tissue punch used through guide

Figure 14: Use of countersink 14 Implant practice

4.0 mm x 10 mm OCO Biomedical TSI implants were placed using a handpiece and implant driver set to 40N/cm (Figure 16). Usually, the TSI implant has a gold titanium nitride (TiN) finish, but these implants were prototypes with an internal hex configuration and were not put through the TiN process. A torque driver is applied, and the implants were fully seated with the following torque values. An Osstell (Osstell, Gothenburg, Sweden) unit was used to get an ISQ reading on each implant:

Table 1: ISQ Reading Implant site

Torque value

ISQ value

65N/cm

40N/cm

55N/cm

Figure 13: Removing tissue tags with a HS No. 8 bur

Figure 15: Final osteotomy former

Figure 16: Delivery of implant Volume 8 Number 3

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CASE STUDY

Figure 17: Final post-op panorex

Figure 18: Solid crown and bridge abutments in place

Figure 19: Completed immediately loaded temporaries

With both sufficient insertion torque values and ISQ readings, the choice to immediately load was taken. The post–op panorex shows well-positioned implants ready for restorations (Figure 17); 4.0 mm solid crown and bridge abutments were torqued to 30N/cm on each implant. Five minutes later, they were re-torqued to accommodate for any pre-stretch that may have occurred (Figure 18). Acrylic copings were placed, and acrylic resin temporaries were made using a thermoform matrix of the wax-up and Visalys® Temp temporary material (Kettenbach USA) (Figure 19). Once the occlusion was adjusted and the interproximal embrasure spaces were contoured, the temporary was cemented using Improv® temporary cement (MS Biologics) (Figure 20). The patient was dismissed with postoperative instructions and will return to the clinic in 1 week for a follow-up exam. Final impressions could have been taken at this time due to the outstanding primary stability, but the choice to delay restoration for a few months was chosen by the patient for financial reasons. 16 Implant practice

Figure 20: Final temporization of case

The use of CT-guided surgery can increase accuracy and predictability of implant placement but also drastically cut down the time of actual surgery. Conclusion Guided surgery can drastically decrease the amount of time a surgery takes along with increasing the accuracy and safety of dental implant placement. By utilizing CBCT and guide technology, it is possible to provide the very best treatment to our patients while maximizing our production and decreasing the stress of implant surgery. IP

REFERENCES 1. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants. 2004;19(suppl):43-61. 2. Norkin FJ, Ganeles J, Zfaz S, Modares A. Image guided implant surgery in today’s clinical practice. Inside Dentistry. 2013;9(12):44-48.

Volume 8 Number 3

Dr. Paul Tipton discusses the advances in full arch implant restorations and presents a case study demonstrating how they can be applied to improve facial esthetics

or many years, the holy grail of implant prosthodontics has been a passive fit of the bridge framework onto titanium implants. The original Br책nemark protocol (1981) relied heavily on this goal to ensure a long-lasting restoration and longevity of the implants. While a passive fit may have been achieved on many traditional acrylic on gold, screw-retained restorations, several further difficulties were encountered achieving the same passive fit with a porcelain-fused-tometal (PFM) bridge. Jemt (1996) stated that, in fact, none of the prostheses he tested presented a completely passive fit. His study indicated that a certain biologic tolerance for misfit may be present in most restorations and, in conclusion, that an absolute passive fit was impossible to attain for a traditional screwretained restoration.

Impression techniques Carr (1991) and Hsu (1993) have shown that full arch impression techniques using either pickup or transfer style impression copings are also inaccurate. Many hours have been spent in sectioning frameworks from an inaccurate case, picking up these sections in the mouth prior to soldering in an attempt to achieve an adequately fitting framework (see Figure 6 in the case study). Shiffleger (1985) showed that large onepiece castings are not accurate and that these need to be sectioned and soldered for a more accurate casting. Furthermore, as soon as porcelain is added onto the framework, Bridger (1981) showed that the framework will distort, leading to further inaccuracies in the fit. These inaccuracies tend to be larger when they are more posterior in the arch.

Professor Paul Tipton, BDS, MSc, DGDP UK, is a specialist in prosthodontics, visiting professor of restorative and cosmetic dentistry at the City of London Dental School, and president of the British Academy of Restorative Dentistry (BARD). The founder of Tipton Training (www.tiptontraining.co.uk), he currently practices at his clinics in Manchester, Watford, and London.

Volume 8 Number 3

Passive fit

Maintenance

Misch (1995) suggested that a cementretained implant-supported prosthesis offers several advantages when compared to screw-retained, in that the superstructure may be more passively attached. The cement-retained restoration may offer a better chance of a passive fit in some areas of the implant abutment crown interface. However, because of the distortion previously described during impression techniques, casting and then porcelain application, spacers often need to be incorporated under the framework to achieve adequate fit, leaving large cement spaces in the posterior areas of the bridge. Alternatively, by means of a fit checker, the internal aspects of the bridge can be adjusted to achieve adequate fit with the same result of open cement margins and loss of retention. In order to achieve retrievability of the restoration, the cemented prosthesis is usually cemented with a soft cement. Unfortunately, one of the problems of the softer cement is that of cement washout. Anecdotally, other clinicians have maintained that this can then lead to excess stress being placed on certain abutments and implants due to cement washout under the crowns on top of other abutments. Again, this leads to potential problems with overstressing of implants.

Porcelain is a very brittle material and has the potential to fracture under parafunctional and/or impact loading. Cibirka (1992) recommended acrylic as the veneering material for a full arch bridge because of its dampening effect; however, this has been questioned by Davis (1988), as porcelain has been shown to be more beneficial under static loading. Changing from a screw-retained design of restoration with access holes in the center of the occlusal and palatal surfaces to a cement-retained restoration will increase the strength of the final porcelain-fused-to-metal bridge. However, there is still the potential for fracture or cracking during long-term function. Should this occur, then it might be impossible to retrieve this from the mouth and repair the porcelain in the laboratory due to the contamination of the porcelain by saliva. This contamination makes the porcelain more liable to explode while in the furnace. Very often, reshaping of the bridge or composite repair have been the only options to maintain the bridge long-term in function, again with loss of form, function, and esthetics. The alternative, which is both time-consuming and expensive, is stripping the porcelain and remaking it on the same framework.

Esthetics

Case study

The female patient was referred from her A further problem that has been GP in Brighton. She required a full makeover, observed with the large porcelain-fused-toincluding dental and facial changes (Figure 1). metal full arch bridge is that of less than ideal esthetics. It is a daunting task for the technician to build pink porcelain to restore the lost soft tissues combined with the need to restore functioning prosthetic teeth at the same time. A technician only has a limited number of firings available to build up this final fixed restoration prior to the porcelain becoming too translucent and Figure 1: Preoperative smile losing its natural color. Implant practice 17

CLINICAL

Full arch implant restoration

CLINICAL As can be seen from the photos, she was suffering from advanced periodontal disease to the upper teeth and lower incisors together with an unattractive smile. She had a severe Class II division I jaw relationship with a deep fold under the lower lip. She was overclosed with the lower third of the face shorter than middle and upper thirds (Figures 2 and 3). In conjunction with the implant surgeon, orthodontist, and oral maxillofacial surgeon, the treatment plan was to first correct the Class II jaw relationship with the combination of provisional upper restorations, orthodontics (Figure 4), and orthognathic surgery via a sagittal split procedure in the mandible to advance it to a Class I relationship. She was then to be restored with implants and crown

and bridgework to an increased vertical dimension to improve the facial esthetics. The upper teeth were extracted and bone grafting done from the hip to onlay the maxilla and inlay the sinuses. Eight upper and two lower implants were then placed (Figure 5).

In the mandible, a chin implant was placed to eliminate the fold under the lower lip. The lower jaw was then restored with bridgework on the implants and crowns on the side and posterior teeth (Figures 7 and 8). The final result was cosmetic in that the patient made it known from the outset

Figure 2: Upper jaw showing periodontally involved teeth, mobility pocketing, bone loss, and poor esthetics

Figure 3: Lower jaw showing periodontally involved lower anterior teeth with bone loss, mobility, and poor esthetics

Figure 4: Upper fixed prototypes with ortho retention ready for orthognathic surgery

Figure 5: Orthognathic surgery completed, implants, and immediate loading in the upper jaw

Figure 7: Definitive crown and bridgework in the lower jaw; patient requested bleach shade

Figure 6: Try-in of upper implant abutments and resin coping pickups of the teeth for lower implants Figure 8: Try-in of pink PFM bridge on abutments in the upper jaw against lower implant-supported anterior bridge and crowns in the lower jaw 18 Implant practice

Volume 8 Number 3

CLINICAL

Figure 9: Fit of upper definitive — Dr. Peter Wöhrle bridge

that she wanted a white even setup with no esthetic elements (Figures 9 and 10). The aims and objectives of the treatment plan were all executed according to standard occlusal and prosthodontic principles. IP

Figure 10: Final smile — bleach shade REFERENCES 1. Bridger DV, Nicholls JL. Distortion of ceramometal fixed partial dentures during the firing cycle. J Prosth Dent. 1981;45(5):507-514.

5. Hsu CC, Millstein PL, Stein RS. A comparative analysis of the accuracy of implant transfer techniques. J Prosth Dent. 1993;69(6):588-593.

2. Carr AB. Comparison of impression techniques for a fiveimplant mandibular model. Int J Oral Maxillofac Implants. 1991;6(4):448-455.

6. Jemt T, Book K. Prosthesis misfit and marginal bone loss in edentulous implant patients. Int J Oral Maxillofac Implants. 1996;11(5):620-625.

Acknowledgments

3. Cibirka RM, Razzoog ME, Lang BR, Stohler CS. Determining the force absorption for restorative materials used in implant occlusal surfaces. J Prosth Dent. 1992;67(3):361-364.

7. Misch CE. Screw-retained versus cement-retained implantsupported prostheses. Pract Periodontics Aesthet Dent. 1995;7(9):15-18.

The author would like to thank John Wibberley and Martin Fletcher from Waters Edge Dental Laboratory for their help in this case.

4. Davis DM, Rimrott R, Zarb GA. Studies on frameworks for osseointegrated prostheses: part 2. The effect of adding acrylic resin or porcelain to form the occlusal superstructure. Int J Oral Maxillofac Implants. 1988;3(4):275-280.

8. Schiffleger BE, Ziebert GJ, Dhuru VB, Brantley WA, Sigaroudi K. Comparison of accuracy of multiunit one-piece castings. J Prosth Dent. 1985;54(6):770-776.

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Implant practice 19

CLINICAL

Effectiveness of a super-pulsed CO2 laser for removal of biofilm from three different types of implant surfaces: an in vitro study Charles M. Cobb, DDS, MS, PhD, and Peter Vitruk, PhD, quantify implant surface decontamination parameters Abstract Background: As dental implants become a routine part of dental practice, so too will the prevalence of peri-implant diseases. Inherent to the treatment of peri-implant disease is the removal of microbial biofilms from the implant surface. Currently, there is no standardized protocol for application of any treatment modality directed at implant surface decontamination. In this in vitro study, we report on the effectiveness of a super-pulsed CO2 laser (10.6 μm wavelength), delivering an average fluence of 6.3 to 113 J/cm2, to remove biofilm from three different types of implant surface topographies. Methods: Sixty-six implants representing three distinctly different surface topographies were used to prepare 132 specimens yielding 44 of each surface type. A 48-hour mixed species biofilm was established on the surface of each specimen. Controls consisted of untreated specimens while

Charles M. Cobb, DDS, MS, PhD, graduated from the University of Missouri-Kansas City (UMKC), School of Dentistry in 1964. He received a Certificate of Specialty in Periodontics and a Master of Science degree in Microbiology, both from UMKC in 1966. Following two years of active duty with the U. S. Navy, Dr. Cobb returned to school at Georgetown University, graduating in 1971 with a PhD in Anatomy (emphasis in microanatomy). After graduation from Georgetown, he held teaching and research positions at Louisiana State University and the University of Alabama in Birmingham. Dr. Cobb devoted 15 years to full-time private practice in periodontics and 20 years to academics. He is a Diplomate of the American Board of Periodontology, has published over 200 peer-reviewed articles, and presented over 200 programs at regional, national, and international meetings. He recently concluded 1 year as the Interim Director of the Graduate Periodontics Program at UMKC. Lastly, Dr. Cobb retired from the U. S. Army Reserves with the rank of Colonel and is one of the few Reservists to be inducted into the Order of Military Medical Merit. Peter Vitruk, PhD, MInstP, CPhys, is founder of LightScalpel, LLC, a member of the Science and Research Committee, Academy of Laser Dentistry, a member of the faculty of California Implant Institute and the faculty of Global Laser Oral Health, LLC. Disclosure: Dr. Cobb reports no conflicts of interest related to this study. Dr. Vitruk is Founder of Luxarcare, LLC; Aesculight, LLC; and LightScalpel, LLC.

20 Implant practice

treated specimens were irradiated at eight different laser energy density (or fluence) levels ranging from 6.3 to 113 J/cm2. Outcomes were measured by SEM examination and CFU counts of residual microbes following treatment at each fluence. Results: Biofilms ranged in thickness from 5 to 15 μm. An average fluence of 19 J/cm2 was sufficient to achieve 100% ablation of the biofilm on hydrophilic sandblasted and acidetched surface specimens (SA). However, to achieve 100% ablation of biofilm on HA and highly crystalline, phosphate enriched titanium oxide (PTO) surfaced implants required an average fluence of 38 J/cm2. Conclusions: In this in vitro model, a 10.6 μm wavelength super-pulse CO2 laser using parameters that produce an average fluence of 38 J/cm2 will achieve 100% ablation of biofilms grown on implant specimens of varying topographies.

saline-soaked cotton pellets,8-11 air-polishing with sodium bicarbonate,12 diode,13 Nd:YAG,13 Er:YAG,14 Er,Cr:YSGG,15 and CO2 lasers.16 In addition, various adjunctive combinations with flap surgery and/or regenerative therapies have also been investigated.8-10, 17,18 None of the prescribed methods of implant surface decontamination has been shown to be superior in the management of periimplantitis. Part of the problem relates to the fact that there are no standardized protocols for any treatment modality directed at implant surface decontamination, including use of the CO2 laser. Thus, the purpose of this in vitro project was to establish the minimum fluence at which complete microbial decontamination can be achieved using a super-pulsed CO2 laser on each of three different, but common, implant surface topographies.

Introduction

Implants Three implants types were selected that collectively represented a range of topography and surface roughness (Figure 1). The implants’ surfaces were as follows: 1. hydroxyapatite (HA) plasma-sprayed (Steri-Oss® HA Coated Surface, Steri-Oss Inc.) 2. a highly crystalline, phosphate enriched titanium oxide surface produced by spark anodization (PTO) (NobelReplace™ Groovy, Nobel Biocare® USA) 3. hydrophilic sandblasted and acidetched surface (SA) (Straumann® SLActive® Surface, Straumann USA, LLC)

As the placement of dental implants increases and becomes a routine part of dental practice so too will the prevalence rate of peri-implant diseases.1 Some reports suggest the radiographic evidence of periimplant bone loss may reach 30% to 35% while others report a lower rate, ranging from 10% to 20%.2-7 The treatment of periimplantitis, at some point, requires removal of all microbial biofilms from the exposed implant surface that, in turn, allows for optimal healing of host bone, osseous regeneration techniques, and overlying soft tissues. Various methods of implant surface decontamination have been suggested, including use of tetracycline or sterile A.

Materials and methods

Figure 1: Untreated implant surfaces with no biofilm: (1A) HA plasma-spray coated. (1B) Untreated PTO. (1C) Untreated SA. Original magnification of x1,000; bar = 20 µm (1A); and x2,000; bar = 10 µm (1B, 1C) Volume 8 Number 3

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CLINICAL From a total of 66 intact implants (22 of each surface type), two specimens measuring 1.0 mm (thickness) x 1.6 mm x 4.0 mm were cut from each 4.8 mm or 5.0 mm x 10 mm implant using a low-speed diamond saw (Buhler IsoMet® saw, Buhler). Specimens were cleaned of residual debris from the cutting process by sonication for 1 minute and rinsing twice, using sterile water. All implant specimens were sterilized by UV light exposure for 60 minutes19 and then stored in sterile 48-well flat-bottomed cell culture dishes (Falcon® Cultureware, BD Biosciences) until inoculated and incubated with broth-containing bacteria. A total of 44 specimens of each implant surface type were divided as follows: • one untreated negative control (no biofilm for SEM), one untreated positive control (with biofilm for SEM), and one specimen from each of the eight laser treatment groups, all examined by SEM • two untreated positive controls from each surface type to establish a baseline CFU count • four treated specimens of each surface type from each of the eight different laser treatment groups used for CFU counts. Biofilm Four supragingival plaque samples were obtained from each of five private practice periodontal patients exhibiting moderate and/or severe chronic periodontitis (i.e., ≥ 5 mm probing depth with bleeding on probing and radiographic evidence of interproximal bone loss). Samples were obtained during scaling and root planing appointments using a McCall 13S/14S curette. The technique and purpose of the plaque sampling was explained in detail to the volunteer patients. All patients signed an informed consent according to the Helsinki Declaration.20 Plaque samples were pooled in 100 ml of broth media (Terrific Broth, Invitrogen®/ Life Technologies) and homogenized by vortex agitation for 1 minute. The pooled plaque sample was then incubated in a 150 ml roller bottle using a standard roller bottle apparatus under microaerophilic conditions at 37ºC for 48 hours. Following incubation, the 100 ml sample was agitated by vortex for 1 minute and then divided into four equal aliquots of 25 ml each. Fresh broth media was then added to each 25 ml aliquots, adjusting each to an absorption density of 1.0 (λ 630 nm) yielding four tubes of equal bacterial densities that were again agitated by vortex for 30 seconds. The resulting tubes of mixed bacteria were used as the 22 Implant practice

Figure 2: Drawings depicting (2A) repeat gating of SuperPulse modes with longer pulses ( ≥ 10 msec) at lower frequencies (≤ 30 Hz); (2B) movement of the laser beam over the biofilm adhering to the implant surface; and (2C) schematic of experimental protocol

stock sample for inoculation of the implant specimens. The inoculum contained approximately 106 microbes per ml. Immediately prior to inoculating implant specimens with the bacteria-ladened broth, they were immersed for 2 hours in fetal bovine serum (Gibco® Fetal Bovine Serum, Life Technologies), which was diluted 1:1 in 25% sterile physiological saline. Preconditioning with fetal bovine serum served as a surrogate for GCF and salivary proteins that implants would normally acquire in situ. Using a 48-well sterile culture dish, three implant specimens of each surface type were placed in a single well and covered with 1.0 ml of stock solution (i.e., broth media) containing bacteria. The “inoculated” implants were then incubated on a shaker table (low setting for gentle agitation) at 37ºC in a microaerophilic environment for 48 hours. The resulting biofilm attached to the implant specimens ranged in thickness from 5 to 15 μm. Laser The laser used in this project was a Super-Pulsed CO2 laser (10,600 nm) (Luxar NovaPulse LX-20SP CO2 laser, LightScalpel, LLC). The laser handpiece LightScalpel PN

LS9002-07 was fitted with a 0.8 mm spot size diameter ceramic delivery tip LightScalpel PN LS9005-01 (86% of beam energy contained within 0.8 mm diameter, 100% of energy contained within 1 mm diameter). The eight different fluence levels were determined by using the parameters listed in Table 1 (laser settings “A” through “H”). All laser settings were for SuperPulse mode (peak power > 50 W, pulse widths under 800 μsec, and pulse repetition rates of 150Hz. SuperPulse modes were further gated (“Repeat” gate settings, Table 1 and Figure 2A) with longer pulses (≥ 10 msec) at lower frequencies (≤ 30 Hz). The pulse-width and pulse-rate settings of SuperPulse mode allow for thermal confinement of the laser energy deposited into 5-15 μm thick water-rich biofilm as will be discussed below. A previous study21 determined that when manually using a CO2 laser to “paint” a flat surface, the typical rate of irradiation exposure is 4 mm/second. Thus, as all specimens measured 4 mm in length and 1.6 mm in width, each of two non-overlapping sweeps of the laser beam was of 1-second duration. Volume 8 Number 3

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CLINICAL The laser handpiece was stabilized at a fixed 2 mm distance over the target surface by use of an adjustable-angle clamp attached to an L-shaped base support stand. Implant specimens were placed on a glass microscope slide that, in turn, was positioned on a variable speed motorized microscope stage, allowing passage of the specimen under the laser beam at the prescribed rate of 4 mm/ second. This arrangement also allowed for minimal overlapping of exposed surfaces during the second pass required to cover the 1.6 mm width using the 0.8 mm diameter beam delivery tip (Figure 2B). Following laser treatment of the implant specimen surface, the edges of the specimen were irradiated using a continuous beam and 6 Watts. This was to ensure that bacteria attached to the edges were ablated. Thus, only residual bacteria from the treated surface, if any, contributed to CFU counts. Immediately following laser treatment, one specimen of each surface type from each treatment group was selected for SEM evaluation and immersed in fixative. The remaining three specimens were immersed in sterile broth media and processed for CFU counts. A summary schematic of the experimental protocol is presented in Figure 2C. Colony-forming units All laser treated implant specimens, including the eight untreated positive control specimens (with biofilm), were processed in a sterile laboratory hood in the following manner: 1. One implant specimen from each laser treatment group was randomly selected for SEM evaluation. 2. The remaining implant specimens were each immersed in 10 ml of fresh broth media and vigorously agitated by vortex for 2 minutes followed by

1 minute of sonication. 3. Serial dilutions were made from the supernatant (1:10,000 and 1:100,000). Aliquots of 0.1 ml from each of the two dilutions were plated manually in triplicate using a spiral platter onto non-selective blood agar plates (Sigma-Aldrich) supplemented with hemin (5 mg/ml), menadione (1 mg/ml), and 5% sterile sheep blood. Plates were incubated under microaerophilic conditions at 37ºC for 72 hours. Following incubation, the total number of CFU/ml was determined for each plate using an electronic colony counter system (Scienceware® Electronic Colony Counter System, Bel-Art Products). All counts were converted assuming a dilution of 1:100,000 and recorded as the average number of CFUs/ml. There was no attempt to subculture or identify recovered microbes other than by SEM morphotype. Scanning Electron Microscopy Specimens dedicated to SEM evaluation were immersed in ice-cold fixation consisting of 2.5% gluteraldehyde in 0.1 M cacodylate buffer at pH 7.4 for 2 hours. Following fixation, specimens were rinsed 3 times in 0.1 M cacodylate buffer (pH 7.4) for 5 minutes per rinse. Following the buffer rinse, specimens were dehydrated in a series of graded ethanol solutions (20% to 100%) at 5-minute intervals, followed by immersion in hexamethyldisilazane for 30 minutes. Each specimen was then affixed to an aluminum stub and stored in a desiccator overnight, followed by sputtercoating with approximately 20 nm of goldpalladium. Specimens were examined in a XL30 ESEM-FEG scanning electron microscope (FEI Corp., North America NanoPort) at various magnifications ranging from x80

up to x4,000. Magnifications of 2,000x and 4,000x were used to identify residual microbes by morphotype, i.e., coccus, short, medium, and long rods, fusiform, spirochete-like, and curved rods. Statistical analysis Regardless of implant surface topography, total decontamination of the implant surface is the clinical goal when treating periimplant disease. Thus, the CFU data were log transformed to obtain only the main effect for each level of laser treatment. Descriptive statistics are presented for raw data and logtransformed CFUs. The measured outcome of laser treatment is the percentage reduction in CFU counts, assuming the baseline count of untreated implant specimens to represent 100%.

Results The 48-hour biofilm that developed on the implant specimens ranged in thickness from 5 to 15 μm and was dominated by microbial morphotypes that were typically associated with a supragingival biofilms of natural teeth, i.e., cocci, short and medium length rods (Figure 3A). The morphologic character and thickness of the biofilm was consistent for all implant specimens regardless of the surface topography. Table 1 summarizes the laser setting parameters and the results of the bacterial reduction, as well as the calculated depth of the laser ablation. It should be noted that 100% bacterial reduction was achieved at a fluence of 19 J/cm2 (laser setting “D”) per passage of the laser beam for the SA implant surface and for both the HA and PTO implant surfaces the bacterial reduction was 96.3% and 96.6%, respectively. At a fluence of 38 J/cm2 (laser setting “E”) or greater per pass, 100% of the biofilm was ablated and 100%

Table 1: Laser parameters used and percentage of bacterial reduction for each implant specimen surface type Laser Setting #

Laser Display Power (W)

Repeat Gate Pulse Rate (Hz)

Repeat Gate Pulse Width (sec)

Average Fluence per Pass (J/ cm2)

SuperPulse Rate (Hz)

SuperPulse Fluence (J/ cm2)

Ablation Depth per SuperPulse pulse (μm)

Ablation Depth per Pass at 4mm/s (μm)

% Bacterial Reduction for HA implant

% Bacterial Reduction for PTC implant

% Bacterial Reduction for SA implant

0.01

6.3

150

2.29

53.6

59.0

71.4

0.01

9.4

150

3.44

2.1

4.8

62.4

71.4

69.3

0.01

150

3.44

2.1

7.2

83.3

87.0

92.4

0.01

150

3.44

2.1

9.6

96.3

96.6

100

0.01

150

4.59

7.4

100

0.015

150

4.59

7.4

100

0.02

150

4.59

7.4

104

100

0.02

113

150

6.88

18.1

254

100

24 Implant practice

Volume 8 Number 3

CLINICAL bacterial reduction was measured regardless of the type of implant surface. Use of per pass beam fluence of 6.3. 9.4, and 14 J/cm2 (laser settings “A-C”) achieved incomplete biofilm ablation and bacterial A.

reduction, ranging from a low of 53.6% up to 92.4% with little variation between implant surface types (Table 1). SEM examination of specimens treated with a fluence of ≤ 14 J/cm2 revealed the presence of residual B.

microbes (incomplete biofilm ablation) within surface depressions (Figures 3B and 3C). At a beam fluence of 38 J/cm2 (laser setting “E”), it was noted that the HA surface exhibited evidence of melting (Figure 3D), whereas the PTO and SA surfaces showed no surface alterations at any of the higher fluence exposures, i.e., 38, 56, 75, and 113 J/cm2.

Discussion

Figures 3A-3D: High magnification SEM photographs. 3A. 72-hour in vitro biofilm growth on SA implant surface (Average thickness of biofilm for all implant specimens was ≈ 10 μm with a range of ≈ 5-15 μm. Original magnification x5,000; bar = 5 μm). 3B. HA implant surface showing residual microbes following laser treatment using a fluence of 14 J/cm2 per pass of the laser beam. Original magnification of 4,000x; bar = 5 μm. 3C. PTO implant surface following laser treatment using a fluence of 14 J/cm2 per pass of the laser beam. Arrows indicate residual cocci and short rod microbes lying within surface depressions. Original magnification of 5,000x; bar = 5 μm. 3D. HA plasma-sprayed coated implant surface exhibiting evidence of surface melting (arrows) following treatment using a fluence of 38 J/cm2 per pass of the laser beam. Original magnification of 250x; bar = 100 μm

Figure 4: Absorption depth, Thermal Relaxation Time, and ablation threshold fluence spectrum for biofilm with assumed 85% water content 26 Implant practice

Efficient bacterial reduction can be achieved by ablating the bacterial biofilm off the implant surface without heating nor damaging the implant if: 1. Laser energy is efficiently deposited into the biofilm. 2. Laser-generated heat inside the biofilm is confined to the biofilm and is not thermally conducted away into the body of the implant (which acts as a highly efficient heat sink). 3. Laser-generated heat inside the biofilm is sufficient for vaporizing the biofilm. The first condition (efficient laser energy deposition into the biofilm) is met when laser absorption depth is comparable to the biofilm’s thickness. Figure 4 presents absorption depth and thermal relaxation time spectra22 for a biofilm assumed to have a water content of 85%.23 The absorption depth of a 10.6 µm wavelength CO2 laser wavelength is about 14 µm, which is well within the range of the biofilm thickness observed in this study, i.e., range of 5 to 15 µm. The second condition of thermal confinement of laser energy within the irradiated biofilm is met when the laser pulse duration is shorter than Thermal Relaxation Time (TRT), also presented in Figure 4. TRT defines the rate of how fast the irradiated tissue diffuses the heat away as defined through the thermal diffusion time: TRT = A2/K,24,25 where A is optical absorption depth discussed above. The physics behind thermal diffusivity process is similar to diffusion and Brownian motion first described by Einstein in 1905.26 Coefficient K is the tissue’s thermal diffusivity; K = λ /(ϱ C) ≈ 0.155 (+/-0.007) mm2/sec (derived from heat conductivity λ ≈ 6.2-6.8 mW/cm ºC; specific heat capacity C ≈ 4.2 J/g ºC, and density ϱ ≈ 1 g/cm3 for liquid water for temperatures in 37ºC-100ºC range).27 For 10 µm thick 80%-90% waterrich biofilm at 10,600 nm wavelength, the TRT is approximately 700 µsec. Therefore, a SuperPulsed CO2 laser with pulses under 800 µsec are highly efficient at confining the heat generated by the laser pulse within the biofilm thickness during the laser pulse. The third condition of efficient biofilm vaporization (or ablation) is met when laser Volume 8 Number 3

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CLINICAL fluence during the SuperPulse pulse exceeds laser ablation threshold Eth25,28 presented in Figure 4. The more efficiently the laser energy is absorbed (Erbium and CO2 lasers), the lower is the ablation threshold. The less efficient the laser energy is absorbed (diode and Nd:YAG lasers), the higher is the ablation threshold. The ablation threshold at the 10.6 µm CO2 laser’s wavelength for a biofilm with an assumed 85% water content equals approximately 3 J/cm2. Laser settings “B-H” from Table 1 with fluence over 3 J/cm2 fit the ablative requirements. During each SuperPulse pulse, the ablation depth δ is given by the formula δ = A (E – Eth) / Eth for the steady state ablation conditions,25 where A is the absorption depth and Eth is the ablation threshold fluence, and E is the fluence during the SuperPulse pulse. Ablative laser settings “B-D” in Table 1 (with fluence over 3 J/cm2) allow for an ablation depth of approximately 2-18 µm per pulse; multiple pulses stacked on top of each other allow for deeper ablation depths (proportional to number of pulses). Bacterial reduction depends on how much of the bacterial biofilm is ablated as illustrated in Figure 5. Bacterial reduction of 100% can be achieved only through complete laser ablation of the biofilm; the sub-ablative laser setting “A” with 2.29 J/ cm2 is seen as the least efficient. As also observed in this study, plasmasprayed hydroxyapatite HA implant surface is susceptible to melting and heat-induced cracking at an average fluence greater than 19 J/cm2 and certainly at the 38 J/cm2 as noted in this study. This can be explained through high absorption of the 10,600 nm light by the hydroxyapatite29 exposed after the bacterial biofilm was ablated. In contrast, the PTO and SA surfaces did not exhibit adverse surface interactions even at higher fluences up to 113 J/cm2, which can be explained by high reflectivity of titanium (> 90%) at 10,600 nm.30

Figure 5: Bacterial reduction vs. calculated ablation depth for 10 μm thick biofilm with an assumed 85% water content

predictable method of surface decontamination in the treatment of peri-implantitis. IP REFERENCES 1.

Roccuzzo M, Bonino F, Aglietta M, Dalmasso P. Tenyear results of a three arms prospective cohort study on implants in periodontally compromised patients. Part 2: Clinical result. Clin Oral Implants Res. 2012;23(4):389-395.

Renvert S, Lindahl C, Rutger-Persson G. The incidence of peri-implantitis for two different implant systems over a period of thirteen years. J Clin Periodontol. 2012;39(12):1191-1197.

Fardal O, Grytten J. A comparison of teeth and implants during maintenance therapy in terms of the number of disease-free years and costs – an in vivo internal control study. J Clin Periodontol. 2013;40(6):645-651.

Gruica B, Wang HY, Lang NP, Buser D. Impact of IL-1 genotype and smoking status on the prognosis of osseointegrated implants. Clin Oral Implants Res. 2004;15(4):393-400.

Koldsland OC, Scheie AA, Aass AM. Prevalence of periimplantitis related to severity of the disease with different degrees of bone loss. J Periodontol. 2010;81(2):231-238.

Mombelli A, Müller N, Cionca N. Epidemiology of periimplantitis. Clin Oral Implants Res. 2012;23(Suppl 6):67-76.

Schmidt EC, Papadimitriou DEV, Caton JG. Surgical management of peri-implantitis: A clinical case report. Clin Adv Periodontics. 2014;4(1):31-37.

Aljateeli M, Fu JH, Wang HL. Managing peri-implant bone loss: current understanding. Clin Implant Dent Related Res. 2012;14(Suppl 1):e109-e118.

Conclusion An average fluence of 19 J/cm2 delivered by a SuperPulse 10.6 μm wavelength CO2 laser is sufficient to achieve a 100% ablation of an in vitro biofilm of approximately 10 μm thickness grown on implant specimens with a moderately rough surface topography. A similar reduction on HA or highly crystalline, phosphate enriched titanium oxide surfaces required an average fluence of 38 J/cm2. The HA surface implant specimens also exhibited surface melting and heat crazing at an average fluence of 38 J/cm2. The SuperPulse 10.6 μm wavelength CO2 laser may provide a 28 Implant practice

Da Silva JD, Kazimiroff J, Papas A, Curro FA, Thompson VP, Vena DA, Wu H, Collie D, Craig RG. Outcomes of implants and restorations placed in general dental practices: A retrospective study by the Practitioners Engaged in Applied Research and Learning (PEARL) Network. J Am Dent Assoc. 2014;145(7):704-713.

10. Froum SJ, Froum SH. Rosen PS. Successful management of peri-implantitis with a regenerative approach: A consecutive series of 51 treated implants with 3- to 7.5-year followup. Int J Periodontics Restorative Dent. 2012;32(1):11-20. 11. Heitz-Mayfield LJ, Salvi GE, Mombelli A, Faddy M, Lang NP. Anti-infective surgical therapy of peri-implantitis. A 12-month prospective clinical study. Clin Oral Implants Res. 2012;23(2):205-210. 12. Vouros JD, Papadopoulos C, Menexes G, Konstantinidis A. Laser and air-abrasive therapies in the nonsurgical treatment of peri-implantitis: A systemic review. J Implant Adv Clin Dent 2014;6:21-36. 13. Goncalves F, Zanetti AL, Zanetti RV, Martelli FS, AvilaCampos MJ, Tomazinho LF, Granjeiro JM. Effectiveness of 980-mm diode and 1064-nm extra-long-pulse neodymiumdoped yttrium aluminum garnet lasers in implant disinfection. Photomed Laser Surg. 2010; 28(2):273-280.

14. Yamamoto A, Tanabe T. Treatment of peri-implantitis around TiUnite-surface implants using Er:YAG laser microexplosions. Int J Periodontics Restorative Dent. 2013;33(1):21-30. 15. Schwarz, F, Nuesry E. Bieling K. Herten M., Becker J. Influence of an erbium, chromium- doped yttrium, scandium, gallium, and garnet (Er,Cr:YSGG) laser on the reestablishment of the biocompatibility of contaminated titanium implant surfaces. J Periodontol. 2006;77(11): 1820-1827. 16. Romanos GE, Nentwig GH . Regenerative therapy of deep peri-implant infrabony defects after CO2 laser implant surface decontamination. Int J Periodontics Restorative Dent. 2008;28(3):245-255. 17. Schwarz F, Sahm N, Iglhaut G, Becker J. Impact of the method of surface debridement and decontamination on the clinical outcome following combined surgical therapy of peri- implantitis: a randomized controlled clinical study. J Clin Periodontol. 2011;38(3):276-284. 18. Schwarz F, John G, Mainusch S, Sahm N, Becker J. Combined surgical therapy of peri-implantitis evaluating two methods of surface debridement and decontamination. A two-year clinical follow up report. J Clin Periodontol. 2012; 39(8):789-797. 19. Sharma A. An ultraviolet-sterilization protocol for microtitre plates. J Exp Microbiol Immunol. 2012;16:144-147. 20. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013(20);310:2191-2194. 21. Spencer P, Cobb CM, McCollum MH, Wieliczka DM. The effects of CO2 laser and Nd:YAG with and without water/ air surface cooling on tooth root structure: Correlation between FTIR spectroscopy and histology. J Periodontol Res. 1996;31(7):453-462. 22. Jacques SL. Optical properties of biological tissues: a review. Phys Med Biol. 2013;58(11):R37-61. 23. Zhang XQ, Bishop PL, Kupferle MJ. Measurement of polysaccharides and proteins in biofilm extracellular polymers. Water Sci Technol. 1998;37:345-348. 24. Svaasand LO. Lasers for biomedical applications. In: Driggers RG, ed. Encyclopedia of Optical Engineering. New York, NY: Marcel Dekker; 2003:1035-1041. 25. Vogel A, Venugopalan V. Mechanisms of pulsed laser ablation of biological tissues. Chem Rev. 2003;103(2):577-644. 26. Einstein A. Über die von der molekularkinetischen Theorie der Wärme geforderte Bewegung von in ruhenden Flüssigkeiten suspendierten Teilchen. Annalen der Physik. 1905;322(8):549-60. 27. Weast RC, ed. CRC Handbook of Chemistry and Physics. 61st ed. Boca Raton, FL: CRC Press; 1980-1981. 28. Vitruk P. Oral soft tissue laser ablative and coagulative efficiencies spectra. Implant Practice US. 2014;7(6):22-27. 29. Duplain G, Boulay R, Bélanger PA. Complex index of refraction of dental enamel at CO2 laser wavelengths. Appl Opt. 1987; 26(20):4447-4451. 30. Wolfe WL, Zissis GJ. The Infrared Handbook. Washington DC: Office of Naval Research, NAVY, 1985:7-81.

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CASE STUDY

Replacement of a failed root canal of the second molar with a Straumann® Roxolid® SLActive® Bone Level Tapered (BLT) Implant Dr. Brad McAllister offers hope to a patient with a hopeless tooth

50-year-old female presented with hopeless tooth No. 18 (Figure 1). Her medical and dental history were uneventful. This previously root canaled tooth was hopeless due to deep decay and extensive furcation involvement (Figures 2 and 3). In planning a size for placing an immediate Straumann® Roxolid® SLActive® Bone Level Tapered (BLT) Implant, a crosssectional view was employed to measure the distance to the inferior alveolar nerve (Figure 4). Approximately 3 mm of bone was observed apical to the tooth root and superior to the nerve. The patient initiated a 1-week course of antibiotic therapy, which included 500 mg of amoxicillin 3 times per day, the day prior to

her surgery. After local anesthetic was administered, a localized flap was elevated, and the tooth was sectioned and extracted taking care to preserve the buccal plate of bone. The socket was degranulated, curetted, and rinsed with sterile saline prior to initiating any implant osteotomy preparation. The osteotomy was underprepared in diameter and the Straumann® Roxolid® SLActive® BLT implant (10 mm x 4.8 mm RC) was inserted with a torque of 35Ncm (Figure 5). The BLT implant design easily allowed for ideal placement and excellent initial stability. A wider

diameter healing abutment was placed along with a mineralized allograft (Figure 6). The site was sutured to a tension-free primary closure with Vicryl® (Ethicon) 4-0 suture (Figure 7). A digital radiograph was taken to evaluate implant and bone graft placement (Figure 8).

Figure 1: Female patient presented with hopeless tooth No. 18

Figure 2: CBCT of tooth No. 18 showing root canal, deep decay, and extensive furcation

Brad McAllister, DDS, PhD, is a Diplomate of the American Board of Periodontology, a Diplomate of the International Congress of Oral Implantologists, and a Fellow of the International Team for Implantology. He is also Assistant Professor at the Department of Periodontology, Oregon Health and Sciences University. He practices at Periodontal Associates in Tualatin, Oregon (www.portlandimplantdentistry.com), and he can be reached at mcallister@portlandimplantdentistry.com. Dr. McAllister did not receive any compensation from Straumann for this article.

30 Implant practice

Figure 3: CBCT of tooth No. 18 showing deep decay and extensive furcation

Figure 5: Immediate placement of the 4.8 mm x 10 mm Straumann® Roxolid® SLActive® Bone Level Tapered Implant

Figure 4: CBCT of tooth No. 18 and the inferior alveolar nerve

Figure 6: Placement of a wide-diameter healing abutment along with a mineralized allograft Volume 8 Number 3

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

Figure 7: Site sutured

Figure 8: Digital radiograph to evaluate implant and allograft placement

Since the inferior alveolar nerve positioning was not clear, a CBCT was taken to verify implant position relative to the inferior alveolar nerve (Figures 9 and 10). It was observed that nearly 2 mm of clearance was present. Initial healing was uneventful as shown in the 1-month healed clinical presentation (Figure 11).

Figure 9: CBCT of tooth No. 18 showing implant position relative to the inferior alveolar nerve

Following 4 months of healing, the final restoration of a screw-retained gold abutment with a crown consisting of porcelain fused to metal was fabricated and torqued to 35Ncm (Figures 12 and 13). The radiographic evaluation showed ideal restoration contours and excellent radiographic bone healing (Figure 14). IP

Figure 10: CBCT of tooth No. 18 showing implant position.

Figure 11: One-month post-op image shows uneventful initial healing

Figure 12: Four-months post-op with a screw-retained crown

Figure 13: Four-months post-op with a screw-retained crown 32 Implant practice

Figure 14: Digital radiograph of tooth No. 18 showing ideal restoration contours and excellent osseointegration Volume 8 Number 3

Watch laser surgery videos

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SEEING THE LIGHT

Enhanced hemostasis and improved healing in CO2 laser-assisted soft tissue oral surgeries Robert Levine, DDS, and Peter Vitruk, PhD, discuss CO2 laser efficiency in coagulation and healing Introduction The key to successful applications of soft tissue lasers and their advantages over other surgical tools is their ability to accurately cut and efficiently coagulate the soft tissue at the same time. However, not all lasers are efficient at both cutting and coagulating. Some laser wavelengths (such as those of Erbium lasers) are great at cutting but are not as efficient at coagulating.1 Other wavelengths (such as those of diode lasers) are efficient coagulators but are poor scalpels.2 There are also lasers (such as the CO2 laser) that are efficient at both cutting and coagulating the soft tissue.1 The key to understanding how the laser light cuts and coagulates is through the wavelength-dependent nature of laser light’s absorption by the soft tissue, as presented in Figure 1 for the three wavelength groups of practical dental lasers that are on the market today: • circa 1,000 nm (diodes and Nd:YAG laser) • circa 3,000 nm (Erbium lasers) • circa 10,000 nm (CO2 lasers)

Photo-thermal ablation and laser pulsing The most efficient soft tissue laser ablation (and incision and excision) is a process of vaporization of intra- and extracellular water heated by the laser light within the irradiated soft tissue. Water vapors, rapidly Robert Levine, DDS, is director of Laser Dentistry, Arizona School of Dentistry & Oral Health and founder of Global Laser Oral Health, LLC, a designer of online laser dentistry training programs for academia, general dentists, and hygienists.

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

steaming out of the intensely laser-heated soft tissue, carry with them cellular ashes and other byproducts of this fast boiling and vaporization process. Because of weak absorption (Figure 1) and strong scattering by the soft tissue,2 the near-infrared diode and Nd:YAG laser wavelengths circa 1,000 nm are highly inefficient and spatially inaccurate photo-thermal laser ablation tools.2 Because of very strong absorption by the soft tissue, mid-infrared Erbium (circa 3,000 nm) and infrared CO2 laser (circa 10,000 nm) wavelengths are highly efficient and spatially accurate laser ablation tools.1,2 The rate of how fast the irradiated tissue diffuses the heat away is defined by Thermal Relaxation Time TR, 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.1

Photo-thermal coagulation Coagulation occurs as a denaturation of soft tissue proteins that occurs in 60º-100°C temperature range1 leading to a significant reduction in bleeding (and oozing of lymphatic liquids) on the margins of ablated tissue during laser ablation (and excision/incision) procedures. Since blood is contained within and transported through the blood vessels, the diameter of blood vessels B (estimated to range from 21 to 40 µm)3 is a highly important spatial parameter that influences the efficiency of photocoagulation process. Photo-thermal coagulation is also accompanied by hemostasis due to

shrinkage of the walls of blood vessels (and lymphatic vessels) due to collagen shrinkage at increased temperatures. The coagulation depth H (for 60º-100ºC temperature range inside the ablation margins) was shown in Figure 1 to be proportional to the absorption depth A (an inverse of absorption coefficient presented in Figure 1) and is presented in Figure 2. The coagulation depth H relative to the blood vessel diameter B is an important measure of coagulation and hemostasis efficiency. For H<<B (see Erbium laser wavelengths in Figure 2), optical absorption and coagulation depths are significantly smaller than blood vessel diameters; coagulation takes place on relatively small spatial scale and cannot prevent bleeding from the blood vessels severed during tissue ablation. For H>>B (diode laser wavelengths in Figure 2), optical absorption (Near-IR attenuation) and coagulation depths are significantly greater than blood vessel diameters; coagulation takes place over extended volumes. For H ≥ B (CO2 laser wavelengths in Figure 2), coagulation extends just deep enough into a severed blood vessel to stop the bleeding. In another words, the CO2 laser’s excellent coagulation efficiency is due to the close match between the photothermal coagulation depth of approximately 50 µm,4 and oral soft tissue blood capillary diameters of approximately 20-40 µm.3 The key to the success of the soft tissue CO2 laser is its ability to cut and coagulate the soft tissue simultaneously.

CO2 laser oral soft tissue surgery

Figures 1 and 2 indicate that wavelengths circa 10,000 nm are >1,000 times superior to wavelengths circa 1,000 nm for soft tissue ablation and >10 times superior to wavelengths circa 3,000 nm for soft tissue coagulation and hemostasis. The 10,600nm 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.1,2 Volume 8 Number 3

SEEING THE LIGHT

Figure 1: Optical absorption coefficient spectra at different histologically relevant concentrations of water, hemoglobin (Hb), oxyhemoglobin (HbO2), and melanin. Logarithmic scales are in use

Hemostasis and tissue healing In comparison with conventional scalpel, the use of the CO2 laser in oral soft tissue surgeries offers several benefits. Among these benefits are cutting in a non-contact mode (which helps to avoid mechanical trauma to the tissue) and without bleeding or the need for sutures, precise tissue removal, and minimized postoperative pain, edema, and inflammation. The use of a CO2 laser on the oral soft tissue has no known contraindications or side effects.5 A substantial body of peerreviewed literature describes the excellent hemostatic capacity of the CO2 laser as a useful instrument for oral surgery in patients with hemorrhagic disorders or undergoing antithrombotic therapy (Figures 3A-3B).5-8 Due to the hemostatic ability of the CO2 laser, intraoral surgical wounds often can be left to heal by secondary intention without placing sutures or dressing (as in Cases 3, 5, 7, and 8 described in this article).10 For example, the patient in Case 1 (Figures 3A-3C) wanted to have a vascular lesion (capillary hemangioma

Figure 2: Coagulation depth spectrum for pulsed laser ablation; TR is Thermal Relaxation Time.1,2 Logarithmic scale is in use

on the lip) removed. The risk of intraoperative hemorrhage was elevated by the fact that the patient had been taking blood thinning agents for his atrial fibrillation condition. In addition, the lesion was located in the area where successful cosmetic outcome was important; therefore, it was crucial to have good visualization of the operatory field. Efficient intra-operative hemostasis provided by the CO2 laser allows for more precise and accurate tissue removal due to the improved visibility of the surgical field (Figure 3B).9 In this case, the CO2 laser enabled the clinician to achieve the best results in a short period of time. No sutures were placed, and a thin layer of char was created to protect the surgical site. The recovery was uneventful. Figure 3C shows the completely healed surgical site at 1 month postoperatively. Figures 4A-4B, 5A-5B, 6A-6C, 7B-7C, and 8A demonstrate the enhanced hemostasis ensured by the LightScalpel CO2 laser. In Case 2, the patient had the vestibular extension procedure performed, and the

hemorrhage was very well controlled, enabling the clinician with utmost precision. In Case 3, the bloodless excisional biopsy of fibroma was performed. Case 4 is a stage II implant uncovering procedure. This surgery requires both special accuracy and the well-controlled depth of laser energy penetration as well as enhanced hemostasis. No blood was present at any point. The implant was uncovered in approximately 30 seconds. In connection with implant uncovering, it should be mentioned that the recent study on the 10,600 nm CO2 laser removal of biofilm from titanium implant surfaces11 reported that this laser wavelength does not affect titanium or titanium oxide (most common implant materials) and is therefore safe to use around implants. Case 5 shows a LightScalpel CO2 laser lingual frenectomy in a 7-year-old patient. Surgery is performed in a highly vascularized area where bleeding was well controlled. Finally, Case 6 is the ablation of the inflamed operculum. Figure 8A demonstrates the immediately postoperative view with excellent hemostasis.

Case 1: Removal of the capillary hemangioma of the lip

Figure 3A: Pre-op view of the capillary hemangioma of the lip. The lesion is a 5 x 5 mm round, slightly exophytic nodule with smooth surface and bluish-purple in color

Volume 8 Number 3

Figure 3B: Intra-op view. After the lesion had been ablated, the laser was defocused, and the hemangioma bed was coagulated until bleeding and oozing stopped. Hemostasis was easily achieved, which was especially important in this patient who was undergoing anticoagulant therapy for atrial fibrillation

Figure 3C: One month post-op view. Note complete healing with excellent esthetic outcome

Implant practice 35

SEEING THE LIGHT Case 2: Laser-assisted vestibular extension

Figure 4A: Superficial laser marking for the planned incision

Figure 4B: Intraoperative view. Note clear surgical field with unobstructed visibility

Figure 4C: Healed surgical site

Figure 5B: Excision of the fibroma mass is complete. No sutures were needed. The wound was left to heal by secondary intension

Figure 5C: Follow-up exam at 14 days after the surgery. Note the clean healing of the buccal mucosa. The recovery was uneventful

Figure 6A: Laser beginning implant uncovering. Laser ablation was performed from center toward periphery in a circular spiral motion

Figure 6B: Tissue ablation in progress. Note the absence of blood in the surgical field

Figure 6C: Implant uncovered after 30 seconds of laser ablation

Similar to its effect on smaller blood vessels, the CO2 laser coagulates lymphatic vessels on the margins of the incision, which results in minimal postoperative swelling and edema, and ultimately, improved, less painful healing. Lymphatic vessels regenerate successively in approximately 8 to 10 days after capillary-vessel proliferation.12 Among the most prominent benefits of CO2 laser treatment are minimized wound contraction and scarring.10,13-16 Healing of CO2 laser-irradiated wounds is characterized by a more prominent fibroblastic proliferation, with young fibroblasts actively producing collagen. Compared to scalpel wounds, CO2 laser-induced wounds contain only a small number of myofibroblasts (cells responsible

for wound contraction).16-18 According to Basu, et al.,19 and Tambuwala, et al.,20 healing of the CO2 laser-irradiated wounds involves the appearance of a fibroserous membrane 72 hours postoperatively. This membrane replaces the superficial necrotic layer of the laser-treated area. An epithelial covering of the wound starts to form from the periphery toward the center after two weeks and is thinner and parakeratotic in comparison with the epithelium that forms after scalpel resection. This could account for the excellent esthetic outcome of all CO2 laser treatment, with no fibrosis or scarring, and soft, pliable residual tissue. Figures 3C (capillary hemangioma of the lip), 4C (mandibular vestibuloplasty), 5C

(excisional biopsy of fibroma), and 8B-8C (operculectomy) depict beautiful healing of the CO2 laser surgical sites where the wound was left to heal by secondary intention. In the case of capillary hemangioma, the lack of scarring was important for esthetic reasons; in the case of vestibuloplasty, the absence of scarring was significant to preserve functionality; in the case of fibroma excision, smooth tissue ensured that the patient would not continue check biting and that the lesion would not reoccur. Reduced wound contraction â&#x20AC;&#x201D; combined with decreased lateral tissue damage, less traumatic surgery, more precise control of the depth of tissue damage, and excellent hemostatic ability â&#x20AC;&#x201D; makes the CO2 laser a

Case 3: Excisional biopsy of fibroma

Figure 5A: Intra-op view. Traction suture put through the lesion to maintain tension. The lesion was circumscribed and undermined with the laser

Case 4: Stage II implant uncovering

36 Implant practice

Volume 8 Number 3

Figure 7A: Pre-op view of a restrictive frenum attached to the tip of the tongue

Figure 7B: Intra-op view

Figure 7C: Immediately post-op view

Figure 8A: Immediately pre-op view. The case was originally approached with scalpel by an oral surgeon. This pre-op photo is taken 2 days after scalpel surgery.

Figure 8B: Immediately post-op view. Hemostasis was achieved, and the wound was left to heal by secondary intention

Figure 8C: 1 week post-op view. Patient was pain- and discomfort-free even during mastication. Healing progressed very well. Note the absence of swelling or inflammation

safe and efficient alternative to the conventional scalpel. Strauss, et al.,21 and Deppe, et al.,22 report that the healing process with CO2 laser surgery is faster and less painful than after cryosurgery or electrosurgery. It should be mentioned, however, that the healing process for surgical laser wounds may be somewhat prolonged in comparison with surgical scalpel wounds. This delay in healing is believed to be caused by the sealing of blood vessels and lymphatics that subsequently requires neovascularization for healing. Typical intraoral healing takes 2 to 3 weeks for wounds that, if treated with a scalpel, normally would take 7 to 10 days.5, 22 At the same time, Lambrecht, et al.,12 reported a slightly shorter delay of just 3 to 10 days. The key to minimizing the healing time is through minimizing the thermal damage on the margins of laser incision/ablation (e.g., utilizing the SuperPulse CO2 laser settings).

tissue surgery. In combination with the laser’s ability to cut in a non-contact mode, the risks of complications typically associated with outpatient treatment are reduced. The enhanced hemostatic capacity and improved healing with minimal to no scarring make the CO2 laser especially well suited for oral soft tissue surgery.

9. Kotlow LA. Lasers in pediatric dentistry. Dent Clin North Am. 2004;48(4):889-922.

Case 6: Operculectomy

Conclusion The 10,600 nm CO2 laser is an efficient and spatially accurate photo-thermal ablation tool with excellent coagulation efficiency due to the close match between coagulation depth and oral soft tissue blood capillary diameters. The highly precise cutting with minimal collateral damage to the adjacent healthy tissue, good visibility of the operating field and, reportedly, relatively minimal postoperative pain make the CO2 laser an optimal surgical solution to the oral soft Volume 8 Number 3

Acknowledgments Authors greatly appreciate the support and contribution from Anna Glazkova, PhD, in preparing this material for publication. IP This article is sponsored by LightScalpel, LLC. (www.LightScalpel.com, 1-866-589-2722)

REFERENCES 1. Vitruk P. Oral Soft Tissue Laser Ablative & Coagulative Efficiencies Spectra. Implant Practice US. 2014;7(6):22-27. 2. Vogel A, Venugopalan V. Mechanisms of pulsed laser ablation of biological tissues. Chem Rev. 2003;103(2):577-644. 3. 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. 4. Convissar RA. Principles and Practice of Laser Dentistry. St. Louis, MO: Mosby Elsevier 2011. 5. Gama SK, de Araújo TM, Pinheiro AL. Benefits of the use of the CO2 laser in orthodontics. Lasers Med Sci. 2008;23(4):459-465. 6. Coleton S. Lasers in surgical periodontics and oral medicine. Dent Clin North Am. 2004;48(4):937-962. 7. Monteiro LS, Mouzinho J, Azevedo A, Câmara MI, Martins MA, La Fuente JM. Treatment of epulis fissuratum with carbon dioxide laser in a patient with antithrombotic medication. Braz Dent J. 2012;23(11):77-81. 8. Tuncer I, Ozçakir-Tomruk C, Sencift K, Cöloğlu S. Comparison of conventional surgery and CO2 laser on intraoral soft tissue pathologies and evaluation of the collateral thermal damage. Photomed Laser Surg. 2010;28(1):75-79.

10. Zaffe D, Vitale MC, Martignone A, Scarpelli F, Botticelli AR. Morphological, histochemical, and immunocytochemical study of CO2 and Er:YAG laser effect on oral soft tissues. Photomed Laser Surg. 2004;22(3):185-189. 11. 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; Feb. 5-7, 2015; Palm Springs, CA. 12. Lambrecht JT, Stübinger S, Hodel Y. Treatment of intraoral hemangiomas with the CO2 laser. J Oral Laser Appl. 2004;4:89-96. 13. Zeinoun T, Nammour S, Dourov N, Aftimos G, Luomanen M. Myofibroblasts in healing laser excision wounds. Lasers Surg Med. 2001;28(1):74-79. 14. Mason C, Hopper C. The use of CO2 laser in the treatment of gingival fibromatosis: a case report. Int J Paediatr Dent. 1994;4(2):105-109. 15. Wang X, Ishizaki NT, Matsumoto K. Healing process of skin after CO2 laser ablation at low radiance: a comparison of continuous-wave and pulsed mode. Photomed Laser Surg. 2005;23(1):20-26. 16. 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. 17. 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. 18. Fisher SE, Frame JW, Browne RM, Tranter RM. A comparative histological study of wound healing following CO2 laser and conventional surgical excision of canine buccal mucosa. Arch. Oral Biol. 1983;28(4):287-291. 19. Basu MK, Frame JW, Rhys Evans PH. Wound healing following partial glossectomy using the CO2 laser, diathermy and scalpel: a histological study in rats. J Laryngol Otol. 1988;102(4):322-327. 20. Tambuwala A, Sangle A, Khan A, Sayed A. Excision of oral leukoplakia by CO2 lasers versus traditional scalpel: A comparative study. J Maxillofac Oral Surg. 2014;13(3):320-327. 21. Strauss RA, Fallon SD. Lasers in contemporary oral and maxillofacial surgery. Dent Clin North Am. 2004;48(4):861-888. 22. Deppe H, Horch HH. Current status of laser applications in oral and cranio-maxillofacial surgery. Med Laser Appl. 2007;22(1):39-42.

Implant practice 37

SEEING THE LIGHT

Case 5: Lingual frenectomy in a 7-year-old patient

CONTINUING EDUCATION

Natural teeth or implants? Informing the decision-making process Drs. George Pelekos and Nikos Mardas offer some considerations for all implant dentists to address when making their treatment choices

eeth constitute an important part of the human body that are responsible for many different functions like mastication and phonetics, while also important for maintaining acceptable facial cosmetics. Tooth loss is thus a devastating life event with significant psychological side effects for the patient, meaning that tooth extractions should be considered as a last resort treatment (John, et al., 2007). The dental community has traditionally focused its efforts in the management of periodontal, pulpal, traumatic, or carious pathologies (Avila, et al., 2009) in order to preserve — and when necessary, rehabilitate — natural teeth. When conservative restorative approaches for the treatment of all these pathologies fail, and tooth extraction is unavoidable, prosthodontic replacement of teeth should be considered to restore lost function and esthetics. In the case of single tooth loss or partial edentulism, fixed partial dentures (FPD) appeared to be a promising prosthodontic treatment modality. A low incidence of complications and high survival rate of conventional bridgework have been reported in the literature for the first 5 years of function over up to a 20-year period (Svanborg, et al., 2013). Other alternatives, especially in cases of multiple missing teeth, are removable partial dentures (RPD) that can also improve appearance, mastication, prevent undesirable tooth movement, and improve occlusal load (Davenport, et al., 2000; Shugars, et al., 1998). However, the survival of periodontally compromised teeth is negatively associated with the use of RPDs when compared with no treatment or the use of an FPD (Aquillino, et al., 2001; Yamazaki, et al., 2013). Complete dentures that rely on the volume of the residual alveolar ridge and Dr. George Pelekos, MSc, MClinDent, is a specialist in periodontics in London, England. Dr. Nikos Mardas, DiplDS, MS, PhD, is a specialist in periodontics and a senior clinical lecturer in periodontology and program coordinator of the MSc and MClinDent in periodontology at the Eastman Dental Institute in London, England.

38 Implant practice

Educational aims and objectives

This article aims to provide the reader with topics for consideration when assessing the suitability of dental implants as a treatment protocol.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 41 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify how to balance an appreciation of success rates. • Recognize alternative treatment options. • Consider esthetic considerations. • Realize possible complications when deciding on a course of action.

mucosa for retention have been used for years as the standard prosthetic solution in case of full edentulism, with high level of patient satisfaction especially in the upper jaw (Larking, et al., 2004). However, a lot of patients are not satisfied with lower complete dentures because of their poor retention, increased denture mobility, and compromised chewing function (Feine, et al., 2002). Historically, the development of osseointegrated implants (Brånemark, et al., 1977; Schroeder, et al., 1981) came as a response to this problem; therefore, the first dental implants were used to increase the retention of dentures in lower jaw. Today, implant-supported restorations are often considered the treatment of choice in most of the cases of partial or full edentulism (Salvi, et al., 2001). The wide acceptance of implant dentistry changed the paradigm in everyday clinical practice where treatment for retention of natural teeth is often challenged by “new trends in implant industry.” There is a strong impression among clinicians that teeth extraction and their substitution with dental implants is superior to their preservation with other conservative treatments in terms of survival and complications rates (Donos, et al., 2012), although such an impression is not necessarily always based on scientific evidence. When clinicians face the dilemma of whether to retain/restore a compromised tooth or replace it with an implant, their personal experience, access to technology, postgraduate education in combination with

local factors (periodontal, endodontic, restorative) together with patient-related parameters should guide the final decision (Tepper, et al., 2003; Kao, et al., 2006; Donos, et al., 2012). Clinical decisions should also be based on the best available evidence regarding the predictability and effectiveness of each the suggested treatment protocols. Systematic reviews (Egger and Smith, 1997), where the majority of the studies assessed are randomized controlled clinical trials (RCTs) present usually the highest level of evidence (Glasziou, et al., 2004). However, for several clinical scenarios, an evidence-based decision-making process may not always be possible since in prosthetic dentistry there are hardly any RCTs addressing whether an implant-supported restoration is superior to a tooth-supported restoration (Pjetursson, et al., 2007). In such a case, dentists involved in implant dentistry should take into consideration well-documented evidence from other disciplines like periodontics (Lundgren, et al., 2008) or endodontics (Iqbal, et al., 2008) regarding the longevity and complication rate of periodontally and endodontically affected teeth following treatment. The following questions quite often need to be addressed during treatment planning:

Endodontic treatment versus implants Root canal treatment is most often a treatment of necessity to alleviate symptomatic pathology and reduce the risk for tooth loss. Volume 8 Number 3

Natural teeth versus implants as abutments for fixed partial dentures A direct comparison between teeth and implants as abutments for fixed partial dentures (FPDs) is currently very difficult because most of the available clinical studies are retrospective cohort studies without stringent inclusion criteria, characterized by high levels of heterogeneity and bias. Nevertheless, a series of systematic reviews (Pjetursson, et al., 2004; Tan, et al., 2004) reported 10-year survival rates of 85% to 95% for conventional tooth-supported FPDs. In another systematic review (Pjetursson, et al., 2007) comparing tooth and implantsupported FPDs by the use of metaanalysis, the survival rate was 89.2% and 86.7%, respectively, for tooth and implantsupported prostheses, indicating equal long-term outcomes for teeth and implants as abutments for FPDs. Similar survival rates (up to 90% over 10 years) were reported from studies where teeth with reduced but healthy periodontal tissues were used as abutments in cross arch bridges (Laurell, et al., 1991; Lulic, et al., 2007). Despite the limitations of these studies, it can be concluded that periodontally healthy teeth present high survival rates that are comparable to those of dental implants (Tomassi, et al., 2008) and can serve as reliable abutments for FPDs. It should be mentioned, however, that most of Volume 8 Number 3

the implant data in these systematic reviews was related to implant systems and surfaces that are not extensively used anymore.

Treatment of periodontal disease versus dental implants Current clinical evidence has positioned implants as one of the first choices of treatment for partially or fully edentulous patients and has influenced the decision to extract periodontally affected teeth, which in a number of cases may be treatable (Greenstein, et al., 2007). It has been suggested that “proactive” or “strategic extractions” will prevent further bone destruction in a potential future implant site (Kao, et al., 2008). However, this approach is not supported by the current evidence considering that, otherwise, tooth extraction will result in resorption of alveolar bone that cannot be completely controlled even with alveolar ridge preservation techniques (Mardas, et al., 2010) or immediate implant placement (Sanz, et al., 2010). The concept of early extraction of periodontally involved teeth and their replacement with dental implants is therefore of questionable value since is not supported by evidence (Donos, et al., 2012) but rather on “clinicians’ belief” that implants are better than teeth in terms of the following:

Survival rates of teeth following treatment of periodontal disease Severe periodontal disease has an overall prevalence of approximately 10% in the industrial countries (Hugoson, et al., 2008). Poor plaque control and smoking are well-established risk factors for developing periodontitis (Lee, et al., 2010). Similarly, residual pocketing is a significant risk factor for periodontal disease progression and tooth loss even after periodontal treatment (Matuliene, et al., 2008). On the other hand, long-term, follow-up studies have demonstrated that treatment of periodontal disease could successfully arrest disease progression and minimize further tooth loss, according to Tonetti and colleagues (2000).

Long-term prognosis of implantsupported restorations in comparison to teeth-supported restorations Management of patients with advanced periodontal disease, which includes extraction and replacement of teeth with a hopeless prognosis, will be followed with a restorative phase usually involving tooth-supported or implantsupported FPDs or alternatively removable

partial dentures RPDs. As mentioned previously, long-term follow-up studies have confirmed comparable survival rates of teeth and implants as abutments for FPDs in patients with advanced periodontal breakdown.

Better cost-benefit ratio Implant-supported prostheses are more expensive than other prosthodontic alternatives (Lewis, et al., 1998), the maintenance of periodontally involved teeth (Pretzl, et al., 2009), or efforts to save endodontically compromised teeth (Iqbal, et al., 2008). Therefore, their overall economic effectiveness has yet to be proven, considering that implants are inaccessible economically to a significant number of patients who would need them (Zimmer, et al., 1992).

Esthetic result Quite often, periodontally compromised teeth present esthetic considerations for both the patient and the clinician due to gingival recession resulting in a clinical crown elongation, the loss of interdental papillae, and drifting or extrusion of teeth with reduced periodontium. The decision whether to conserve or extract esthetically compromised teeth depends on the patient’s smile line, gingival biotype, local bone availability, but most of all, the patient’s expectations regarding the final esthetic outcome. Tooth extraction for esthetic reasons may be recommended if the prosthetic restoration (either implant- or tooth-supported) will significantly improve the esthetic outcome and satisfy the patient’s expectations (Donos, et al., 2012). Predictable and pleasing esthetic outcomes could be achieved in several cases of single-tooth replacement with a dental implant when tissue support provided by the adjacent natural teeth is preserved (Belser, et al., 2004). However, the esthetics following replacement of multiple missing teeth with dental implants in the anterior maxilla may be unpredictable, and esthetic failures (poor emergence profiles, loss or distortion of the papillae, and exposure of the metallic implant components) are common (Goodacre, et al., 2003). Therefore, extraction of periodontally compromised teeth for esthetic reasons should be considered only under the condition that the future implant-supported restoration could predictably provide an improved esthetic outcome.

Reduced complication rate for implants in comparison to teeth The comparison of clinical outcomes between teeth treated for periodontal disease Implant practice 39

CONTINUING EDUCATION

Successfully treated endodontically involved teeth present high survival rates (up to 97%) (Salehrabi, et al., 2004; Imura, et al., 2007) that are comparable to those for a single crown implant restoration (Noack, et al., 1999; Jung, et al., 2012). When comparing these two treatment modalities, the clinician should be able to estimate both the endodontic and the restorative prognosis of a tooth (John, et al., 2009). Clinical factors, such as the presence/ size of a periapical lesion or the necessity of repetition of an older failing root canal treatment have been negatively related with prognosis of those teeth (Stoll, et al., 2005). Furthermore, the experience of the operator seems crucial since specialists in endodontics were reported to have higher success (up to 98% in a 5-year period) than general practitioners (Alley, et al., 2004). Although there is lack of RCTs directly comparing the two treatment principles (Friedman, et al., 2002; Eckert, et al., 2005), endodontically treated teeth as well as dental implants are valuable treatment options that should be equally considered, in a cost benefit analysis, before any clinical decision making for tooth extraction.

CONTINUING EDUCATION and dental implants, which very often have been placed in healthy dentitions not previously affected by periodontal disease, should be based on implant success rather than survival rates. Implant survival rate refers to the proportion of implants still in place at a certain time without considering biological and/or technical complication, function, or clinical value. From a clinical point of view, survival rates are not always representative of success, since the risk of biological, technical, and mechanical complications in implantsupported restorations is not presented. Treatments of all these complications require extra time, increased cost and morbidity, and may result in lower patient satisfaction levels with implant treatment. Biological complications are mainly related to peri-implant mucositis describing “the presence of inflammation in the mucosa of an implant with no signs of loss of supporting bone” or peri-implantitis describing “the inflammation of the mucosa characterized by loss of supporting bone” (Lindhe, et al., 2008). In a recent systematic review, Zitzmann and colleagues (2008) reported that the prevalence of peri-mucositis was approximately 80% on the subject and 50% on the implant level while the prevalence of peri-implantitis varied between 28% and 56% on a patient level and 12%-43% on an implant level. Similarly, technical complications in fixed partial dentures (loosening of occlusal screw, porcelain chipping, loss of retention, fracture of implant component) for implant-supported reconstructions was 39% as compared to 16% for tooth-supported reconstruction (Bragger, et al., 2011).

Conclusion The notion that “implants survive longer than teeth,” as sometimes suggested in implant companies’ marketing, has no scientific support. Periodontally compromised but successfully treated teeth in well-maintained patients present comparable long-term survival rates of more than 90%. Implant therapy in periodontally or endodontically affected dentitions should include proper diagnosis and treatment for the remaining natural teeth when possible and a patient assessment of all the related risk factors for periodontal/periimplant diseases. Such risk estimation should always be considered in any implant treatment planning and should include a general health and oral hygiene assessment, an evaluation of periodontal disease control, and a detailed cost-benefit analysis based on patients’ expectations. IP 40 Implant practice

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Aquilino SA, Shugars DA, Bader JD, White BA. Ten-year survival rates of teeth adjacent to treated and untreated posterior bounded edentulous spaces. J Prosthet Dent. 2001;85(5):455-460.

Belser U, Buser D, Higginbottom F. Consensus statements and recommended clinical procedures regarding esthetics in implant dentistry. Int J Oral Maxillofac Implants. 2001;19(suppl): 73-74.

Brånemark PI, Hansson BO, Adell R, Breine U, Lindström J, Hallén O, Ohman A. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scand J Plast Reconstr Surg Suppl. 1977;16:1-132.

Brägger U, Hirt-Steiner S, Schnell N, Schmidlin K, Salvi GE, Pjetursson B, Matuliene G, Zwahlen M, Lang NP. Complication and failure rates of fixed dental prostheses in patients treated for periodontal disease. Clin Oral Implants Res. 2011;22(1):70-77.

Cho-Yan Lee J, Mattheos N, Nixon KC, Ivanovski S. Residual periodontal pockets are a risk indicator for periimplantitis in patients treated for periodontitis. Clin Oral Implants Res. 2012;23(3):325-333.

De Backer H, Van Maele G, De Moor N, Van den Berghe L. An up to 20-year retrospective study of 4-unit fixed dental prostheses for the replacement of 2 missing adjacent teeth. Int J Prosthodont. 2008;21(3):259-266.

Davenport JC, Basker RM, Heath JR, Ralph JP, Glantz PO. The removable partial denture equation. Br Dent J. 2000;189(8):414-424.

10. Donos N, Laurell L, Mardas N. Hierarchical decisions on teeth vs. implants in the periodontitis-susceptible patient: the modern dilemma. Periodontol 2000. 2012;59(1):89-110. 11. Eckert SE, Choi YG, Sánchez AR, Koka S. Comparison of dental implant systems: quality of clinical evidence and prediction of 5-year survival. Int J Oral Maxillofac Implants. 2005;20(3):406-415. 12. Egger M, Smith GD, Phillips AN. Meta-analysis: principles and procedures. BMJ. 1997;315(7121):1533-1537 13. Feine JS, Carlsson GE, Awad MA, Chehade A, Duncan WJ, Gizani S, Head T, Heydecke G, Lund JP, MacEntee M, Mericske-Stern R, Mojon P, Morais JA, Naert I, Payne AG, Penrod J, Stoker GT, Tawse-Smith A, Taylor TD, Thomason JM, Thomson WM, Wismeijer D. The McGill consensus statement on overdentures. Mandibular two-implant overdentures as first choice standard of care for edentulous patients. Gerodontology. 2002;19(1):3-4. 14. Friedman S, Mor C. The success of endodontic therapy--healing and functionality. J Calif Dent Assoc. 2004;32(6):493-503. 15. Glasziou P, Vandenbroucke JP, Chalmers I. Assessing the quality of research. BMJ. 2004;328(7430):39-41. 16. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications with implants and implant prostheses. J Prosthet Dent. 2003;90(2):121-132. 17. Greenstein G, Greenstein B, Cavallaro J. Prerequisite for treatment planning implant dentistry: periodontal prognostication of compromised teeth. Compend Contin Educ Dent. 2007;28(8):436-446, 447, 470. 18. Holm-Pedersen P, Lang NP, Müller F. What are the longevities of teeth and oral implants? Clin Oral Implants Res. 2007;18(suppl 3):15-19. 19. Hugoson A, Koch G. Thirty year trends in the prevalence and distribution of dental caries in Swedish adults (19732003). Swed Dent J. 2008;32(2):57-67. 20. Iqbal MK, Kim S. A review of factors influencing treatment planning decisions of single-tooth implants versus preserving natural teeth with nonsurgical endodontic therapy. J Endod. 2008;34(5):519-529. 21. Imura N, Pinheiro ET, Gomes BP, Zaia AA, Ferraz CC, Souza-Filho FJ. The outcome of endodontic treatment: a retrospective study of 2000 cases performed by a specialist. J Endod. 2007;33(11):1278-1282. 22. John V, Chen S, Parashos P. Implant or the natural tooth--a contemporary treatment planning dilemma? Aust Dent J. 2007;52(suppl 1):S138-S150.

27. Lewis DW. Optimized therapy for the edentulous predicament: cost-effectiveness considerations. J Prosthet Dent. 1998;79(1):93-99. 28. Lindhe J, Meyle J, Group D of European Workshop on Periodontology. Peri-implant diseases: Consensus Report of the Sixth European Workshop on Periodontology. J ClinPeriodontol. 2008;35(suppl 8):282-285. 29. Lundgren D, Rylander H, Laurell L. To save or to extract, that is the question. Natural teeth or dental implants in periodontitis-susceptible patients: clinical decision-making and treatment strategies exemplified with patient case presentations. Periodontol 2000. 2008;47:27-50. 30. Mardas N, Chadha V, Donos N. Alveolar ridge preservation with guided bone regeneration and a synthetic bone substitute or a bovine-derived xenograft: a randomized, controlled clinical trial. Clin Oral Implants Res. 2010;21(7):688-698. 31. Matuliene G, Pjetursson BE, Salvi GE, Schmidlin K, Brägger U, Zwahlen M, Lang NP. Influence of residual pockets on progression of periodontitis and tooth loss: results after 11 years of maintenance. J Clin Periodontol. 2008;35(8):685-695. 32. Mojon P, Thomason JM, Walls AW. The impact of falling rates of edentulism. Int J Prosthodont. 2004;17(4):434-440. 33. Noack N, Willer J, Hoffmann J. Long-term results after placement of dental implants: longitudinal study of 1,964 implants over 16 years. Int J Oral Maxillofac Implants. 1999;14(5):748-755. 34. Pjetursson BE, Brägger U, Lang NP, Zwahlen M. Comparison of survival and complication rates of tooth-supported fixed dental prostheses (FDPs) and implant-supported FDPs and single crowns (SCs). Clin Oral Implants Res. 2007;18(suppl 3):97-113. 35. Pjetursson BE, Tan K, Lang NP, Brägger U, Egger M, Zwahlen M. A systematic review of the survival and complication rates of fixed partial dentures (FPDs) after an observation period of at least 5 years. Clin Oral Implants Res. 2004;15(6):667-676. 36. Pretzl B, Wiedemann D, Cosgarea R, Kaltschmitt J, Kim TS, Staehle HJ, Eickholz P. Effort and costs of tooth preservation in supportive periodontal treatment in a German population. J Clin Periodontol. 2009;36(8):669-676. 37. Salehrabi R, Rotstein I. Endodontic treatment outcomes in a large patient population in the USA: an epidemiological study. J Endod. 2004;30(12):846-850. 38. Salvi GE, Lang NP. Changing paradigms in implant dentistry. Crit Rev Oral Biol Med. 2001;12(3):262-272. 39. Sanz M, Cecchinato D, Ferrus J, Pjetursson EB, Lang NP, Lindhe J. A prospective, randomized-controlled clinical trial to evaluate bone preservation using implants with different geometry placed into extraction sockets in the maxilla. Clin Oral Implants Res. 2010;21(1):13-21. 40. Schroeder A, van der Zypen E, Stich H, Sutter F. The reactions of bone, connective tissue, and epithelium to endosteal implants with titanium-sprayed surfaces. J Maxillofac Surg. 1981;9(1):15-25. 41. Sjögren P, Halling A. Randomised controlled trials and publication trends in periodontal research during 19802000. J Clin Periodontol. 2002;29(12):1112-1117. 42. Svanborg P, Längström L, Lundh RM, Bjerkstig G, Ortorp A. A 5-year retrospective study of cobalt-chromium-based fixed dental prostheses. Int J Prosthodont. 2013;26(4):343-349. 43. Shugars DA, Bader JD, White BA, Scurria MS, Hayden WJ Jr, Garcia RI. Survival rates of teeth adjacent to treated and untreated posterior bounded edentulous spaces. J Am Dent Assoc. 1998;129(8):1089-1095. 44. Stoll R, Betke K, Stachniss V. The influence of different factors on the survival of root canal fillings: a 10-year retrospective study. J Endod. 2005;31(11):783-790. 45. Tan K, Pjetursson BE, Lang NP, Chan ES. A systematic review of the survival and complication rates of fixed partial dentures (FPDs) after an observation period of at least 5 years. Clin Oral Implants Res. 15(6):654-666. 46. Tepper G, Haas R, Mailath G, Teller C, Zechner W, Watzak G, Watzek G. Representative marketing-oriented study on implants in the Austrian population. I. Level of information, sources of information and need for patient information. Clin Oral Implants Res. 2003;14(5):621-633. 47. Tomasi C, Wennström JL, Berglundh T. Longevity of teeth and implants - a systematic review. J Oral Rehabil. 2008;35 (suppl 1):23-32.

24. Kao RT. Strategic extraction: a paradigm shift that is changing our profession. J Periodontol. 2008;79(6):971-977.

48. Yamazaki S, Arakawa H, Maekawa K, Hara ES, Noda K, Minakuchi H, Sonoyama W, Matsuka Y, Kuboki T. A retrospective comparative ten-year study of cumulative survival rates of remaining teeth in large edentulism treated with implant-supported fixed partial dentures or removable partial dentures. J Prosthodont Res. 2013; 57(3):156-161.

25. Larking P. Dental implants ; patient selection, patient satisfaction, and cost factors. Evidence based review. Evidence Based Healthcare Advisory Group. 2004;1-64.

49. Zimmer CM, Zimmer WM, Williams J, Liesener J. Public awareness and acceptance of dental implants. Int J Oral Maxillofac Implants. 1992;7(2):228-232.

26. Laurell L, Lundgren D, Falk H, Hugoson A. Long-term prognosis of extensive polyunit cantilevered fixed partial dentures. J Prosthet Dent. 1991;66(4):545-552.

50. Zitzmann NU, Berglundh T. Definition and prevalence of peri-implant diseases. J Clin Periodontol. 2008;35(suppl 8):286-291.

23. Kao RT. The challenges of transferring evidencebased dentistry into practice. J Evid Based Dent Pract. 2006;6(1):125-128.

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Natural teeth or implants? Informing the decision-making process

Multiple idiopathic external cervical root resorption: a case report

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Tooth loss is thus a devastating life event with significant psychological side effects for the patient, meaning that tooth extractions should be considered ________. a. as a last resort treatment b. as soon as is practical c. at the patient’s request d. only with general anesthesia The dental community has traditionally focused its efforts in the management of _____ in order to preserve — and when necessary, rehabilitate — natural teeth. a. periodontal or pulpal pathologies b. traumatic pathology c. carious pathology d. all of the above

In the case of ________, fixed partial dentures (FPD) appeared to be a promising prosthodontic treatment modality. a. complete edentulism b. single tooth loss c. partial edentulism d. both b and c A low incidence of complications and high survival rate of conventional bridgework has been reported in the literature for the first ____ years of function over up to a 20-year period. a. 2 b. 5 c. 10 d. 15 Other alternatives, especially in cases of ____, are removable partial dentures (RPD) that can also improve appearance, mastication, prevent undesirable tooth movement, and improve occlusal load. a. already existing implants b. patients with poor oral hygiene c. multiple missing teeth d. none of the above

Volume 8 Number 3

10.

Complete dentures that rely on the volume of the residual alveolar ridge and mucosa for retention have been used for years as the standard prosthetic solution in case of full edentulism, with high level of patient satisfaction especially in ______. a. the lower jaw b. the upper jaw c. non-compliant patients d. the elderly However, a lot of patients are not satisfied with lower complete dentures because of their ____. a. poor retention b. increased denture mobility c. compromised chewing function d. all of the above

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Root resorption is the loss of dental hard tissues through _______ cell action. a. osteoclastic b. intercalary c. osteogenic d. osteoblastic Resorption can be classified as _______. a. internal b. external c. homeostatic d. both a and b

c. sufficient width d. thermal insensitivity 7.

Usually, most teeth require _____ as patients usually present in the later stages of the lesion progression or when there are symptoms. a. filing b. extraction c. root canal d. bonding

In the cases of _______, restorations of the resulting edentulous areas will be either with bridges, dentures or dental implants. a. the need for a more temporary solution b. singular tooth loss c. burnout d. multiple tooth loss

Successfully treated endodontically involved teeth present high survival rates (_____) that are comparable to those for a single crown implant restoration. a. estimated at 67% b. approximately 75% c. 82% d. up to 97%

_____ usually has traumatic or infective etiology. a. Colonized tubules b. External resorption c. Internal resorption d. Cementoiditis

The decision whether to conserve or extract esthetically compromised teeth depends on the patient’s smile line, gingival biotype, local bone availability, but most of all, _______. a. the brand of implant that will be used b. the patient’s insurance c. the patient’s expectations regarding the final esthetic outcome d. the patient’s plaque control

Common features of external cervical root resorption include: ________ on teeth affected or normal appearance. a. “White spot” lesions b. “Pink spot” lesions c. Gum dehiscence d. Discolored margins

There are links to polymorphism in the IL1-beta gene, which is a proinflammatory cytokine involved in _________. a. inflammatory responses b. osteoclast formation c. bone resorption d. all of the above

10.

Such risk estimation should always be considered in any implant treatment planning and should include ________. a. a general health and oral hygiene assessment b. an evaluation of periodontal disease control c. a detailed cost-benefit analysis based on patients’ expectations d. all of the above

Common features of external cervical root resorption include: Time from discovery of initial lesion to involvement of other teeth can vary from months to ____ years. a. 3 b. 6 c. 9 d. 12

Counseling the patient about the condition and its unknown etiology is important, and ______ is essential. a. use of a removable prosthesis only b. recommendation for immediate implant placement c. long-term management d. a short-term, quick fix

Periodontal surgery may be required to expose the repair to be able to maintain ________ in the area. a. oral hygiene b. proper height

Implant practice 41

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Multiple idiopathic external cervical root resorption: a case report Dr. Usman Hameed takes a look at the unpredictable nature of some root resorption cases and argues the importance of flexibility in treatment planning

oot resorption is the loss of dental hard tissues through osteoclastic cell action. In the primary dentition, this can be desirable, allowing roots to resorb and the exfoliation of teeth. But in the permanent dentition, these effects are undesirable and can lead to potential loss of the affected teeth. The process is thus deemed to be pathological (Patel and Ford, 2007). Resorption can be classified as internal or external. Internal resorption usually has traumatic or infective etiology (Bakeland, 1992). Etiological factors for external resorption can include trauma, inflammation, tooth re-implantation, tumors, cysts, impacted teeth, orthodontic tooth movement, abnormal occlusal loads, certain dental treatments, or systemic disease (Bakeland, 1992). A diagnosis of idiopathic root resorption is usually considered after excluding the known factors. Biologically, it is thought to be caused by damage to or loss of the cementoid layer on the root surface. This allows the osteoclast cells to attach to and resorb the root surface. Microorganisms from the gingival sulcus, or from bacteria colonizing the tubules, may then provide further stimulus for the resorption to continue (Patel and Ford, 2007; Nanci and Bosshardt, 2006). The case study in this article will consider multiple idiopathic external cervical root resorption (MIECRR) and the difficulties that may be posed in its management.

Case study Presentation This 21-year-old female patient attended in between her routine recall appointment complaining of “tooth sensitivity” from the

Usman Hameed, BDS, graduated from Manchester University in 2007 and currently practices at Standish Street Dental Practice in Lancashire, United Kingdom. He is a member of the Royal College of Surgeons and has a certificate in implant dentistry. In 2009, he returned to Manchester University as a clinical teaching fellow in restorative dentistry and has moved on to mentoring on a Master’s degree in dental implantology. His special interests are minimally invasive dentistry, implant placement, and restoration. He is currently working toward attaining a master’s degree in restorative dentistry.

42 Implant practice

Educational aims and objectives

This article aims to present a case study highlighting the difficulty of managing and rehabilitating multiple idiopathic external cervical root resorption.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 41 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Be aware of the unpredictable nature of multiple idiopathic external cervical root resorption. • Realize the importance of a flexible approach to treatment in these cases. • Visualize treatment for a specific patient with type of idiopathic external cervical root resorption. • Identify some common features of external cervical root resorption. • Identify some options for restorability and maintenance of lesions when managing patients with multiple idiopathic external cervical root resorption (MIECRR).

Figure 1A: Clinical appearance of LL2 and LL3 at presentation

Figure 1B: Lingual appearance of LL2 and LL3 at presentation

lower anterior mandibular area. It was mainly to cold and lasted as long as the stimulus was present. She had also become aware of a pink appearance to the teeth but did not feel any tenderness on biting. The patient had mild asthma but otherwise was fit and well. She took no medications apart from inhalers for asthma (which she only took when involved in sports activities) and had no known allergies. The patient was a regular attender, a nonsmoker, and drank below her limits of alcohol consumption. There was no recent trauma to report, nor had the patient had any form of teeth whitening. She had orthodontic treatment completed more than 6 years before presentation. Comprehensive extraoral and intraoral examinations were carried out, which revealed a fully dentate arch with some restorations in her molars and upper incisors. She

Figure 1C: Periapical radiograph of LL2 and LL3 showing the extent of the external cervical root resorption Volume 8 Number 3

had fixed retainers on her upper and lower anterior teeth. The patient’s physical appearance was a normal, incisal Class III with an anterior open bite and the LR3 in crossbite. There was gingival swelling around the LL2 and LL3 with the classic “pink spot” lesions of external cervical root resorption (Figure 1). The teeth were sensitive to cold, not tender to percussion. Periapical radiographs show the extent of the lesions on the LL2 and LL3 (Figure 1).

Figure 2B: Radiograph at 3 months after grafting

Figure 2C: Radiograph at implant placement

Diagnosis and planning The LL3 and LL2 teeth were deemed unrestorable, and after discussion of all the options, the patient decided on dental implants. An implant was to be placed in the LL3 area, and a cantilever implant-retained bridge would be placed to replace the LL2 and LL3. The patient had a high lower lip line and medium tissue biotype. Due to the extent of the lesions and location of the teeth in the arch, the patient was pre-warned that the bone levels may not be ideal, and grafting of the area may be required following extraction. Treatment The teeth were extracted atraumatically, revealing a significant buccal bone dehiscence. Bone grafting was carried out with a xenograft bone substitute and membrane, followed by soft tissue closure. The patient had a hypersensitive gag reflex and did not want a denture. A temporary pull-down splint with acrylic teeth was made for the immediate postoperative phase before a chairside temporary bonded bridge (using fiber-reinforced ribbon) was made as the occlusion was favorable. The pontic lengths were kept short to maintain as much soft tissue as possible. The implants were placed at 12 weeks following bone grafting. Radiographs throughout treatment were all good. At 12 weeks following implant placement, a Volume 8 Number 3

Figures 3A-3D: Radiographs of teeth affected with external cervical root resorption

temporary bridge was placed to shape the soft tissues, and once their condition was satisfactory, an open-tray impression was taken for a titanium abutment and zirconia bridge.

Upon taking a radiograph to check the seating of the abutment, there was an incidental finding of cervical radiolucencies on the LL4 and LL5 (Figure 3). There were no clinically visible signs or symptoms. Full Implant practice 43

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Figure 2A: Temporary chairside bridge made freehand with resin-reinforced ribbon

CONTINUING EDUCATION

Figure 4A: Implant-retained bridge at fit appointment

mouth radiographs were subsequently taken, which showed cervical radiolucencies on teeth LR6, LR3, LR2, LL1, LL4, and LL5. A provisional diagnosis of multiple cervical external root resorption was made. A specialist referral was made, though the patient was due to travel soon after for 3 months and would not see the specialist until her return. The patient’s general medical practitioner conducted blood tests to rule out any systemic imbalances before she embarked on her travels, which all came back normal (Liang, et al., 2003). The bridge design was modified to become a screw-retained zirconia bridge with a titanium abutment. It was fitted as a temporary measure until her return. The patient was made aware that her condition made it difficult to predict its progression and was aware of the guarded prognosis to several teeth. Due to her travel plans, the decision was made to extract the LL4 and fill the LL5 before her departure. The LL5 cavity was mechanically cleaned and restored with GIC due to its extension subgingivally (Al-Momani and Nixon, 2013; Heithersay, 2007). Upon her return, the restorative specialist confirmed the diagnosis of idiopathic external cervical root resorption, and at the time of writing, the plan is to allow the condition to stabilize or “burnout” and then consider her options for dental rehabilitation.

Discussion Few cases of multiple idiopathic external cervical root resorption exist in the literature. It appears to be a progressive condition, and 44 Implant practice

Figure 4B: Occlusal view showing screw access cavity sealed with composite. Note in both pictures, no clinical signs of resorption are visible on the LL4 and LL5. Compare with the resorption in Figure 1

there has been no detectable frequency for its occurrence, regions affected in the dentition, or whether single/multiple quadrants are involved (Liang, et al., 2003). It has been reported to most frequently affect medically unremarkable younger females, and some of the reported cases had hormonal abnormalities (Nanci and Bosshardt, 2006). Common features of external cervical root resorption include (Liang, et al., 2003; Heithersay, 2007; Patel, et al., 2009): • “Pink spot” lesions on teeth affected or normal appearance • Asymptomatic, or with thermal sensitivity in late stages • Normal gingival appearance or chronically inflamed gingival appearance

• Pocketing can localized to the lesion, and the cavity can be probed if there are supragingival margins. Unlike caries, the probe does not stick — lesions are hard and smooth to probe • Commonly incidental finding on radiographs • Radiographically, lesions begin at the mesial or distal cementoenamel junction with a scalloped margin, which can undermine the enamel and spread down the root surface • Time from discovery of initial lesion to involvement of other teeth can vary from months to 9 years • Absence of periapical inflammation as pulp is not usually involved Volume 8 Number 3

CONTINUING EDUCATION

Figure 5A: LL4 tooth, when extracted, showed extent of resorption, meaning tooth could not be extracted in one piece

• Root canal appears intact on radiographs • Initial radiolucent lesion due to granulomatous infiltration of lesion • Later stages may have radiopaque flecks as the fibro-osseous nature of lesion develops When managing patients with MIECRR, the long-term restorability and maintenance of the lesions need to be considered. There have been many described techniques from surgical exposure and debridement then restoration with glass ionomer, composite, or MTA (Al-Momani and Nixon, 2013; Nikolidakis, 2008). Periodontal surgery may be required to expose the repair to be able to maintain oral hygiene in the area (Nikolidakis, 2008). Usually, most teeth require extraction as patients usually present in the later stages of the lesion progression or when there are symptoms. In the cases of multiple tooth loss, restorations of the resulting edentulous areas will be either with bridges, dentures, or dental implants. There is limited evidence on the impact of MIECRR on implant osseointegration (Dewan and Fairbrother, 2014). There are links to polymorphism in the IL1-beta gene, which is a proinflammatory cytokine involved in inflammatory responses, osteoclast formation, and bone resorption (Maria, et al., 2010; Urban and Mincik, 2010; Bolhari, et al., 2013). However, some evidence has illustrated those with this genotype showed no association with the failure of dental implants or increased incidence of peri-implantitis (Rogers, et al., 2002; Hultin, et al., 2002). A familial pattern has been described in some Volume 8 Number 3

Figure 5B: LL5 tooth, showing the extent of resorption on the mesial aspect of the tooth. Typical resorptive lesion is caries-free with hard dental tissue at base of cavity and thin undermined enamel on superior cavity periphery

cases (Neeley and Gordon, 2007; Sarvaria and Meyer, 1989).

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Al-Momani Z, Nixon PJ. Internal and external root resorption: aetiology, diagnosis and treatment options. Dent Update. 2013;40(2):102-104, 111-112.

Conclusion

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Bolhari B, Meraji N, Nosrat A. Extensive idiopathic external root resorption in first maxillary molar: a case report. Iran Endod J. 2013;8(2):72-74.

Dewan K, Fairbrother K. Multiple Idiopathic External Apical Root Resorption: A Literature Review. Dent Update. 2014;41(7):586-595.

Heithersay GS. Management of tooth resorption. Aust Dent J. 2007;52(suppl 1):S105-S121.

Hultin M, Gustafsson A, Hallström H, Johansson LA, Ekfeldt A, Klinge B. Microbiological findings and host response in patients with peri-implantitis. Clin Oral Implants Res. 2002;13(4):349-358.

Liang H, Burkes EJ, Frederiksen NL. Multiple idiopathic cervical root resorption: systematic review and report of four cases. Dentomaxillofac Radiol. 2003;32(3):150-155.

Maria R, Mantri V, Koolwal S. Internal resorption: A review and case report. Endodontology. 2010;22:100-108.

In cases such as this, no definitive treatment can be formulated at the outset as the disease is progressive. The priority is to assess the extent of the ECRR and the restorative prognosis of each tooth. Counseling the patient about the condition and its unknown etiology is important, and longterm management is essential. If multiple teeth are lost, then the only options may be a removable prosthesis or implant-retained prosthesis. Initially, this case appeared to be localized external cervical resorption — however, it progressed into a case of multiple external cervical root resorption. The importance of good planning, which allows flexibility when it comes to the longterm dental rehabilitation, is crucial. This case was restored with a screw-retained implant prosthesis, which will allow the implant fixture to be used when or if future implant restoration is considered as part of a bigger dental rehabilitation treatment plan. Furthermore, it will reduce the surgical treatment required by the patient. It would be considered prudent to screen family members as appropriate to diagnose any cases of root resorption in its early stages and hopefully improve the restorative prognosis of their teeth. IP

10. Nanci A, Bosshardt DD. Structure of periodontal tissues in health and disease. Periodontology 2000. 2006;40:11-28. 11. Neely AL, Gordon SC. A familial pattern of multiple idiopathic cervical root resorption in a father and son: a 22-year follow-up. J Periodontol. 2007;78(2):367-371. 12. Nikolidakis D, Nikou G, Meijer GJ, Jansen JA. Cervical external root resorption: 3-year follow-up of a case. J Oral Sci. 2008;50(4):487-491. 13. Patel S, Ford TP. Is the resorption external or internal? Dent Update. 2007;34(4): 218-220, 222, 224-226, 229. 14. Patel S, Kanagasingam S, Pitt Ford T. External cervical resorption: a review. J Endod. 2009;35(5):616-625. 15. Rogers MA, Figliomeni L, Baluchova K, Tan AE, Davies G, Henry PJ, Price P. Do interleukin-1 polymorphisms predict the development of periodontitis or the success of dental implants? J Periodontal Res. 2002;37(1):37-41. 16. Saravia ME, Meyer ML. Multiple idiopathic root resorption in monozygotic twins: case report. Pediatr Dent. 1989;11(1):76-78. 17. Urban D, Mincik J. Monozygotic twins with idiopathic internal root resorption: A case report. Aust Endod J. 2010;36(2):79-82.

Implant practice 45

PRACTICE DEVELOPMENT

New horizons

In the first of a new series, Toks Oyegunle explores how applying a simple yet effective marketing framework to your practice can help it thrive

ave you ever wondered how some dental practices always seem to naturally thrive? How do they manage to constantly grow their business and attract the best clients? If you want to have a thriving dental practice with a constant stream of profitable clients showing up regularly, you need to dramatically improve your practice marketing — and this is where this series of articles comes in. The goal is simple: to help you increase the profitability of your practice using a proven marketing framework that is easy to understand and apply to your practice. To get maximum benefit from this series, I would advise you use a journal to write your thoughts and answers to the questions that will come up about your practice over this series.

The magic number I recommend an approach that I call the “triple M” marketing framework. This

Toks Oyegunle is a leading business coach in the United Kingdom who enjoys helping dentists achieve success using proven techniques and strategies.

46 Implant practice

is a simple but extremely effective tool that helps us to simplify, understand, and apply the fundamental principles of “thriving dental practice marketing.” The framework involves initially identifying the right market and then crafting and communicating the right message to the right market using the right media and methods — effectively, efficiently, and profitably.

Market Who really represents your perfect target market? If we are unclear what we are aiming for, it will be difficult to hit the target. Have you analyzed your patient database to understand how many of them are perfect, as opposed to average or bad patients? A very helpful exercise is to develop what I call your “perfect patient avatar.” This is a detailed description of who you believe your perfect patient should be. You will need to consider the demographic aspects and also the psychographic aspects here. If you haven’t done this before, or you simply haven’t reviewed yours in a while, then these coming articles will explain who your perfect patients should be — and more importantly, what goes into making them your perfect patients.

Message What marketing message are you communicating to your target market? This can be tricky because, if you are not clear who your perfect patient is, it is possible that you may be saying the right thing to the wrong person, or even worse, the wrong thing to the wrong person. What is your unique selling point (USP)? Are you a general dentist that really should be a specialist or a specialist that happens to be in the wrong niche? For your practice to really thrive, you must use your marketing message to attract the perfect patients — and repel the wrong ones!

Media What media choices are you using to communicate your marketing message to your target market? Are you clear on why you use each one? Your media choice should be based on a detailed understanding of who represents your target market. This understanding helps you to know what media these perfect patients use so you can target them effectively. For example, traditionally, many dentists would advertise in the Yellow Pages or similar directories Volume 8 Number 3

Profit How profitable is your dental practice now? You should already know how profitable your practice is. If not, a quick look at your books or call to your accountant will tell you. Get the exact number, and write it down in your journal: It really is the best indication of the effectiveness of your current marketing efforts. How profitable do you want your dental practice to be? Knowing how profitable you want your practice to be in future is a more challenging question, as it is currently a desire, a goal that you must set for yourself now, and work toward achieving over a period of time. I would strongly urge you to consider the following: If there were no limitations to your potential, what would the ideal profit from your practice be? Think about this question, and come up with a figure.

If you want to have a thriving dental practice with a constant stream of profitable clients showing up regularly, you need to dramatically improve your practice marketing. Remember that your desired practice profit goal must be SMART (specific, measurable, achievable, relevant, and time-bound). An example you may find helpful while developing your desired profit may be: “I, Dr. Smith, will increase the profit of Smiles by Smith by 25% within the next 12 months.”

Getting from A to B For some dentists, the answer to both questions will be the same or very similar. If this is true for you, then I must congratulate you. You are already at the peak of your desired financial success, at least from your practice anyway. For others, however, there

will be a gap between your answers. Your answer to the first question tells you where you currently are — let’s call this point A. Yet your answer to the second tells you where you really want to be — let’s call this point B. Now you have a journey to get from point A to B. There are two ways to do this: increase your revenue and/or reduce your costs. My goal is to empower you with the knowledge, tips, and strategies that will help you on this journey by increasing your revenue by improving your marketing. Over the course of the month, think about the following questions, as they will focus your attention on the areas that need improvement in order to achieve the profitability you desire: 1. What target market do you attract and why? 2. What marketing message do you communicate? 3. What media do you use to communicate to the market? Your answers will help you to review what your current marketing efforts are and, more importantly, how effective they have been. IP

Soft from the syringe. Hard in the defect. 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 ridge preservation

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Volume 8 Number 3

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Implant practice 47

PRACTICE DEVELOPMENT

religiously, but their perfect patients may actually be avid readers of the Financial Times, meaning they can probably be reached more effectively through these alternative media choices.

PRODUCT PROFILE

The SATURNO™ Narrow Diameter Implant System ZEST Anchors, the trusted manufacturer of LOCATOR® and end-to-end solutions in the resilient implant-retained overdenture market, has released a new angle on o-ball implants — the SATURNO™ Narrow Diameter Implant System. SATURNO is a narrow diameter, O-Ball implant designed as a permanent solution for overdenture retention. Engineered with straight and innovative 20° angled O-Ball implant options, SATURNO incorporates many unique features not found with mini O-Ball implants currently on the market today. These features include: 1. a 20° Angled O-Ball Implant option that allows for placement following the natural slope of the maxillary ridge. This ZEST Anchors innovation diminishes O-Ball facial emergence, a problem that could produce areas of thin denture acrylic and compromise denture strength and/or esthetics 2. patented, pivoting O-Ring technology that allows for passive denture seating when convergent/divergent implants are present. With passive seating, patients will experience easier prosthesis insertion/removal, and less wear on their O-Rings 3. a proven RBM surface on the entire length of the implant 4. progressive threads provide increased primary stability 5. a self-tapping feature for ease of implant insertion Each SATURNO Implant is available in the clinician’s choice of 20° Angled or Straight O-Ball implant options; in 2.0 mm, 2.4 mm, or 2.9 mm diameters; 10 mm, 12 mm, or 14 mm lengths; and cuff heights in 2 mm or 4 mm. The value-conscious packaging also includes a Restorative Component Vial with the Attachment Housing and Block-Out Spacer for processing the overdenture. ZEST is offering a SATURNO Narrow Diameter Implant System product special for clinicians who want to start offering this unique solution to their edentulous patients. Please call 800-262-2310, or visit www.zestanchors. com to get started today! IP

3 1 2

This information was provided by ZEST Anchors.

48 Implant practice

Volume 8 Number 3

Marla Merritt discusses how to make treatment more affordable

oes your practice offer flexible payment options to your patients? Most do not. As a result, the dental industry as a whole is missing out on hundreds of thousands of dollars in recommended but unaccepted cases each year. Recently, I have visited with several orthodontic and dental practices. The purpose of

Marla Merritt, Director of Marketing and Sales for OrthoBanc, LLC, has over 22 years of experience in the promotion and sales of risk management services and payment solutions. Her background includes 12 years working for an Equifax affiliate in Chattanooga, Tennessee, where she helped banks, credit unions, and other industries implement risk assessment models into their lending policies. Ms. Merritt is currently with OrthoBanc where she leads the teams that are responsible for sales/marketing, customer setup, training, and customer service. OrthoBanc currently serves over 2,000 providers and has managed payments for over 1.3 million responsible parties. Ms. Merritt secured EXHIBITOR Magazine’s Sizzle Award and also its All-Star Award for two of her highly successful, city-themed trade-show marketing campaigns.

Volume 8 Number 3

my visits has been to discuss the financial policies and fee presentation procedures in these practices. It has been an eye-opening exercise. Here is what I have observed while in dental practices: Treatment Coordinator: Mr. Patient … Here is the treatment you need, and the total price will be about $5,500. Here is the information for a company that will provide you with financing. If you do not qualify, payment in full will be due at the time of treatment. Patient: I know that I need this done. Can we work out some sort of office payment plan? Treatment Coordinator: I’m sorry. We don’t offer an office payment plan, but here is the information you will need to see if you qualify for financing. At this point, the patient often walks out the door with sticker shock. Many will never come back to that practice again. Many will shop around to see if they can get a better price or a more flexible payment option.

Others will determine that they just can’t afford treatment. What I have observed in orthodontic practices, however, has been a much different story. Those fee presentations go something like this: Treatment Coordinator: Mr. Patient … We look forward to working with you and giving you an even more beautiful smile. We typically ask for $1,000 up-front and then let you pay $225 per month interest free for 20 months. Does this work for you? Patient: Not really. I will have to think this over and get back with you. Treatment Coordinator: What part of this doesn’t work? Is it the up-front cost? How much do you think you could afford to pay up-front? We can work with you. At this point, the Treatment Coordinator and the patient engage in dialogue where they work together to come up with something that works for both parties. Practices that are very good at this dialogue are often Implant practice 49

PRACTICE MANAGEMENT

Increase case acceptance by becoming a patientcentered practice and offering flexible payment options

PRACTICE MANAGEMENT able to secure an appointment to begin treatment. The July 1995 issue of Dental Economics magazine carried the headline “Cash or Credit? A Flexible Policy Maximizes Your Cash Flow.” As far back as 20 years ago, consultants were pointing out that it is important for a dental practice to offer flexible payment plans — yet most practices still maintain a “cash only” policy. Let’s explore why this is still happening. Practices that offer only third-party financing or cash up-front (known as a “cash only” practice), enjoy a 100% collection rate and maintain very low accounts receivable. On the surface, this seems like the perfect solution. However, if we dig a little deeper, the picture looks quite different. First of all, these practices are giving up as much as 10% of their treatment fees to these thirdparty finance companies when patients choose this over true “cash” up-front. Many practices will inflate fees to account for this, making treatment even more out of reach for numerous patients. Another thing that happens to these “cash only” practices is that they leave behind tens of thousands of dollars in unscheduled production each year. Patients walk away. Many of these are patients who need treatment, who want treatment, and who could afford treatment if only they were offered more flexible payment options. I am not telling you anything that you didn’t already know. Most specialty dentists realize that being a “cash only” practice creates low case acceptance and a dependency on insurance, but the alternative leaves them even more apprehensive. “I am not going to offer payment plans because I do not want to take the risk of having delinquent payments or nonpayment. Also, taking on patient delinquency opens me up to poor compliance, lawsuits, and a referral pipeline of other nonpaying patients.” This is the argument that I have heard from many dentists. For 20 years, dental practices have chosen what they consider to be the lesser of two evils. By having a “cash only” practice, they have avoided the headaches involved with offering office payment plans and chasing down missed payments. They have also missed the opportunity for higher case acceptance and increased profitability. Is there a third choice? Is there a solution that allows for high case acceptance and production, a great collection rate, an efficient schedule, and a high rate of the right kind of patient referrals? 50 Implant practice

Now more than ever before, it is important to build a patient-centered reputation. Offering a flexible payment policy that makes your treatment affordable is a key factor in building that reputation.

Dental Consultant, Paul Zuelke, recently said, “Stable people with excellent credit can be trusted to keep their financial agreements and should be allowed, when necessary, low and even $0 down payments with fairly longterm payment plans.” There are two important things to notice about this statement. First of all, Zuelke refers to “stable people with excellent credit.” How do you assess if a person is stable and has excellent credit? Fortunately, technology makes that one easy. Credit grades and payment plan recommendations can be obtained in a matter of seconds using an office computer and the Internet. Check out www.getzacc.com to learn a little more about how this can work in your practice. The next key point I want to highlight is Zuelke’s mention of “when necessary.” The reason I want to dwell on these two words is because the assumption is that you know when a flexible payment plan is necessary. In my observations, dental practices are not delving into these important conversations with responsible parties to determine what they can reasonably afford up-front and as a monthly payment. When handled properly, these conversations can be the key to great case acceptance. It is critical, first of all, to have a system in place that allows you to quickly identify the maturity, stability, and credit worthiness of any person. Second, it is important that you have a well-trained, pleasant Treatment Coordinator that will work with patients to determine a payment plan that is appropriate for both parties. Once you have these two things in place, you can design payment plans that work for your low-risk patients. You will begin to enjoy increased case acceptance, a more predictable flow of monthly income for your practice, and improved profitability.

Before I conclude this article, I want to address two other concerns often expressed to me by dentists who consider offering flexible payment options. The first concern is in response to my comparison of dental and orthodontic practices. The argument can be made that the risk is inherently less in an orthodontic practice because the patient is making payments while receiving ongoing treatment. This is a very valid point, and it is the reason that utilizing a credit assessment tool is so important for a dental practice. People who have a good credit rating can be counted on to pay all their bills, including their dental bills. These are the people who have earned the opportunity for a flexible payment plan. The second concern that I often hear relates to what happens after a payment plan is established. Many practices operate with a staff that is at capacity and cannot take on the added burden of managing monthly payment plans. To address this concern, I strongly recommend electronic drafting for all monthly payments. There are a variety of sources that can handle electronic payment drafting. Check out www.dentalbanc.com to learn about a drafting company that also follows up with responsible parties if a payment fails for any reason. In the last 12 months, dental practices have observed a decline in the number of patients that have dental insurance. It is forecasted that there will be an additional 50% decline in the next 3-5 years due to the Affordable Care Act. Now more than ever before, it is important to build a patientcentered reputation. Offering a flexible payment policy that makes your treatment affordable is a key factor in building that reputation. IP Volume 8 Number 3

5-DAY LIVE PATIENT SURGICAL EXTERNSHIP

Baja California, Mexico Key Educational Objectives: - Implement step-by-step implant surgical protocols on live patients under the direction of Dr. Louie Al-Faraje and staff. - Place multiple implants (10-15 implants) and assist with multiple implants on live patients. - Gain the surgical experience to safely place implants with predictability. - Learn to manage surgical complications which may possibly arise while placing implants. - Level II (covering advanced bone grafting procedures) and All-on-Four programs are offered in addition to level I program.

The program is provided 4 times a year. For dates and tuition fee please visit our website

Tuition includes: 40 CE Units, all materials and implants, daily continental breakfast, lunch, dinner and course certificate.

STEP-BY-STEP

Algisorb™ 100% organic bone grafting material

one grafting materials should always attempt to imitate the properties of autogenous bone. Therefore, the best choice is a natural product that is both biocompatible and immunocompatible as well as osteoconductive. Aligsorb™, a 100% organic bone grafting material, is the first and only natural biological product on the market based on plant origin. The algae-derived product is very similar to human bone. All algae-derived (phycogenic) materials demonstrate a high specific porosity up to 1.1 cm3/g. Their unique interconnecting porous structure, a “honeycomb-like” channel system, and their specific chemistry is decisive for the high in vivo bioactivity of the phycongenic materials that results in complete bone remodeling and resorption. Histological studies show that the apatite material undergoes a mainly cellular successive bone resorption and simultaneous remodeling (creeping substitution) where the product is completely degraded and replaced by newly formed bone. A few months after augmentation, the apatite granules are incorporated into a young, newly formed vascularized bony tissue. Letters P, A, R symbolize the three main advantages of Algisorb P for Porosity: Algisorb has a honeycomblike interconnecting porosity that provides for efficient osteoconduction and fast, new bone formation. A for Absorption: The high absorptive pore structure of Algisorb guarantees moldability, ease of handling, and stability within the site. R for Resorption: Histological studies of Algisorb (Ewers, et al., 1987; Ewers and Schumann 1994; Schopper, et al., 2003) report almost total resorption of the material with simultaneous substitution by new bone within 2 to 3 years. This process is commonly known as creeping substitution. Due to the unique porosity, the high absorption capacity, the presence of an immense amount of cell chambers, and the positive resorption kinetic (which allows for future biomechanical loading of the bone), Algisorb is a true bone-conducing and regenerative material. 52 Implant practice

Clinical Case Socket grafting, socket fill in the maxilla with phycogenic algae-derived hydroxyapatite, and dental implants Patient: 61-year-old female

Figure 1: Panorex after tooth extraction with local infection

Figure 2: Intraoperative situation 2 weeks after tooth extraction and after socket grafting with phycogenic apatite

Figure 3: Covering with collagen membrane

Figure 4: Panorex 5 months later shows the complete filling of the alveolar defect with newly formed bone

Figure 5: Primary wound healing with a perfect mucosa level, which means perfect ridge preservation, enabling insertion of a dental implant, which was inserted 5 months later

Figure 6: Dental X-ray 1 year after socket grafting and after implant surgery

Algisorb is sold in .5ml, 1ml, and 2ml vials and is available exclusively in the United States through Osseous Technologies of America. For further information, as well as a comprehensive listing of the Osseous

Technologies of America’s (OTA), product line, please visit www.osseoustech.com, or call 866-901-5050. IP This information was provided by Osseous Technologies of America.

Volume 8 Number 3

OCO Biomedical hosts world-class AGD-PACEaccredited dental implant event

DEXIS™, a brand of the KaVo Kerr Group, has released the DEXcam™ 4 intraoral video camera designed for patient communication and case documentation. This new easy-to-use camera includes a higher resolution sensor, dual capture buttons, one-touch focus, and a detachable cord — all contained within an aluminum housing. DEXcam 4 seamlessly integrates with DEXIS™ imaging software. This next generation intraoral camera focuses on these key benefits: • High-resolution, color-correct images • Enhanced image quality and zoom mode allowing for clearer communication with patients • Improved ergonomics for both left and right-handed users • Greater ease-of-use resulting from the motor-driven onetouch focus • Easy sharing in multi-operatory practices with the quick disconnect cable • Robust and chemical-safe aluminum construction For more information, call 888-883-3947, or visit http:// www.dexis.com/dexcam4.

OCO Biomedical, Inc., has announced its 2015 OCO International Dental Implant Symposium at the Sandia Resort and Casino, Albuquerque, New Mexico, on Friday, July 17 and Saturday, July 18 from 8 a.m. to 4 p.m. both days. Attendees will receive 16 AGD-PACE-accredited CEU credits. In addition, OCO is also offering two separate full-day pre-symposium implantology courses that will run simultaneously from 8 a.m. to 5 p.m. on Thursday, July 16, at the same venue as the Symposium. Attendees will receive eight AGD-Pace-accredited CEUs for each session and a $300 discounted rate. This year’s diversified program will feature a robust roster of internationally acclaimed, industry-recognized speakers who will present “hot topics” in implant dentistry during this powerpacked, 2-day special event. The keynote speaker, Balwant Rai, DDS, from Amsterdam, The Netherlands, will discuss “Space Dentistry: New Vision.” For more information call 1-800-228-0477, or visit www. ocobiomedical.com.

Volume 8 Number 3

Implant practice 53

INDUSTRY NEWS

DEXIS™ unveils DEXcam™ 4 next generation intraoral camera

ON THE HORIZON

Complete 3D treatment planning software for implants Dr. Justin Moody discusses the latest update to Tx STUDIO 5.4

y most powerful tool when treatment planning dental implant cases is the software I use for virtual placement and fabrication of surgical guides. This digital workflow allows me to combine the data I get from my i-CAT™ FLX CBCT scanner and the 3Shape TRIOS® digital impression solution. The ability to merge the CBCT scan and the actual patient’s digital impression is so important for creating natural emergence of the restoration while ensuring the implant is in sound bone for long-term survival and esthetics. Surgical guides fabricated from this information allow for site-specific ideal implant placement, which leads to ideal restorations.

Figure 1: Parallel virtual implant placement with custom patient-specific abutment design

Figure 2: Virtual Implant placement and positioning for ideal prosthetic position

This whole process just got so much better and easier with the release of Tx STUDIO™ 5.4 by Anatomage. In addition to its already existing capabilities for accurate implant planning and extraordinary restorative planning capabilities, Tx 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. Disclosure: Dr. Moody is a paid speaker for BioHorizons and i-CAT. He has no ties to 3Shape or Anatomage.

54 Implant practice

Figure 3: Sinus graft volume estimate feature

STUDIO 5.4 also offers new and improved tools. Useful treatment planning and patient communication features allow me to present my case and showcase the technology chairside. This “wow factor” resonates across to the patient in the form of trust and confidence as well as the benefit to my practice by increased case acceptance. New to this version is the sinus graft feature, which allows for estimated volumetric measurements; this feature allows for more detailed planning and information leading to smoother surgical appointments. Also new is the ability to parallel groups of implants and the placement of virtual pontics and bridges, allowing for more restorative control. This is made easier and more predictable by having control of the

Figure 4: BioHorizons® fully guided surgery using an Anatomage Guide

abutment design and contour under the planned crowns and bridges. With every updated version I always think to myself, How can they improve on this yet again? That is why I am always looking to the horizon for what’s next — exciting times indeed. IP Volume 8 Number 3

PRODUCT PROFILE

Planmeca Romexis® software Open architecture, endless possibilities

echnology in dentistry is evolving. With an ever-growing platform and so many options in the industry, it’s time for a software platform that features all-in-one capabilities and open architecture, allowing you to choose the best technology for your practice. Built on an open architecture software platform, Planmeca Romexis offers best-inclass integration, providing users with the freedom to use third-party products for a customizable workflow built to fit the needs of any office. TWAIN protocol and DICOM compliance, as well as full support for Windows and Mac OS operating systems, make Planmeca Romexis an ideal fit for any practice.

Your all-in-one software solution Planmeca Romexis is the first software in the world to combine 2D and 3D imaging with complete CAD/CAM workflow and even extended connectivity with Planmeca dental units. Planmeca Romexis software offers these capabilities and more — IO scanning and restorative design, ceph analysis and tracing, orthodontic tasks with Ortho Studio, and Planmeca ProFace true 3D facial photos for case presentations that are more detailed than ever.

plans. Easy mouse-driven navigation means no complicated keyboard combinations to remember: Your necessary functions are in front of you, clearly marked, and ready to use.

Secure image sharing from anywhere Share files from wherever you are with the innovative Planmeca Romexis Cloud, a secure transfer service for Planmeca Romexis users and their partners. The service is easy to use and seamlessly integrated into Planmeca Romexis, saving you even more time and cost by eliminating DVDs and other physical processes.

Exceptional usability

Efficient clinic management

With Planmeca Romexis, versatile applications are easy to use with intuitive features that make it simple to view, edit, and enhance images, as well as create detailed treatment

For larger practices with multiple operatories, Planmeca Romexis also offers its Clinic Management module for an innovative link between software and equipment,

Planmeca 3DMax 3 x 3D = CBCT + ProFace + impression scan 56 Implant practice

making it possible to remotely monitor your unit functions, access user-specific presets from any unit, proactively manage unit maintenance for decreased downtime, and more.

A future-proof investment Planmeca Romexis software offers a complete workflow engineered with the flexibility to adapt to you and your patients’ evolving needs. Planmeca Romexis leads the world in image capture and diagnostics for superior treatment planning with the ability to upgrade and make your investment future-proof. Open file architecture and true modularity means you can add technology as you need it, ensuring your practice won’t be left behind as dental technology continues to advance. IP This information was provided by Planmeca.

Planmeca 3Ds large view image Volume 8 Number 3

Create your virtual patient - with just one software

Planmeca ProMax 3D

Planmeca Romexis® software oﬀers the most sophisticated tools to meet the needs of modern implantology. With tools such as an implant library featuring realistic models from over 40 diﬀerent manufacturers, the most sophisticated tools are just a few mouse clicks away.* * Implant library is available as an optional feature. Please see your local sales representative for more details.

For a free in-oﬃce consultation, please call 1-855-245-2908 or visit us on the web at www.planmecausa.com

www.planmecausa.com

PLANMECA USA INC. 100 North Gary Avenue, Suite A, Roselle, IL 60172, P.630.529.2300

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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.

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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 September 30, 2015. Price comparisons based upon US list prices for comparable items as of January 2015. All trademarks are property of their respective companies.