Implant Practice US April/May 2016 Vol 9, No 2 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews April/May 2016 – Vol 9 No 2

PROMOTING EXCELLENCE IN IMPLANTOLOGY Treatment of mandibular edentulism using conical interface abutments

Implant treatment in the esthetic zone Dr. Shakeel Shahdad

Drs. Lyndon F. Cooper and Ghadeer N. Thalji

Management of severe horizontal and vertical maxillary deficiency via tenting and sub-nasal augmentation with PRGF

Corporate profile Zimmer Biomet Institute

Dr. Pierre J. Tedders

Practice profile Dr. Nadim Z. Baba

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION CREDITS PER YEAR!

FREE: Become a #StraumannLegend straumann.us/StraumannLegend

BETTER. SIMPLER. STRONGER. Introducing the next generation of LOCATOR, the LOCATOR R-Tx™ Removable Attachment System– combining improved design, system simplicity, and DuraTec™ Coating toughness. DuraTec Titanium Carbon Nitride Coating is aesthetic, harder and more wear resistant.

Industry standard .050"/1.25mm* hex drive mechanism.

Dual retentive surfaces for engagement & narrower coronal geometry for easier seating of the overdenture.

50% increase in pivoting capability to 60° between implants.

Convenient all-in-one packaging.

Enhanced geometry to resist movement and anodized pink for improved aesthetics.

Experience the next generation LOCATOR R-Tx Removable Attachment System today! Please visit ZESTANCHORS.COM/RTX, call us at 800.262.2310, or contact your implant manufacturer for more information.

Available NOW for leading implant systems. *Excluding connections that utilize .048” hex drive mechanism. Please contact your implant company provider for more information. ©2016 ZEST Anchors LLC. All rights reserved. ZEST and LOCATOR are registered trademarks and DuraTec, LOCATOR R-Tx and R-Tx are trademarks of ZEST IP Holdings, LLC.

April/May 2016 - Volume 9 Number 2 EDITORIAL ADVISORS Steve Barter, BDS, MSurgDent RCS Anthony Bendkowsk,i 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

ooking back on the Academy of Osseointegration’s recent Annual Meeting, I am impressed with the level of collegiality among our profession, and the importance of it to the vitality of dentistry in the 21st century; and perhaps nowhere is it more vital than in implant dentistry. Collegiality is defined as the relationship between colleagues — those united in a common purpose. Whether we are specialists or general dentists, students or seasoned practitioners, living in the United States or across the pond, our shared goal is to enhance oral health Alan Pollack, DDS and make our patients smile. While technology has advanced to improve success rates and shorten healing times, there has also been an explosion of information regarding choices for implant surfaces, attachment types, restorative design, and materials. It’s not easy to navigate and identify the most relevant and up-to-date information and avoid the trap of being creatures of habit, continuing to do what we’re most familiar with. While very few of us are able to quote every clinical article in the past 5 years, it is imperative that we keep current with trends and best practices. And the best way to do that is through sharing both successes and problems with colleagues. In addition, we’re facing increasing issues of long-term and medically related complications, e.g., peri-implantitis and medication-related post-surgical and late bone complications. The plethora of decisions we face makes it evermore imperative that we understand the risks, as well as the differences, advantages, and disadvantages of each option. That’s why it’s so important for us to come together and participate in vetted programming and educational events we can trust. As a unified group of committed clinicians, we can gain new perspectives and challenge our old ways of thinking. We all, dentists and scientists across the spectrum of disciplines and backgrounds, need to teach, challenge, and critique one another; and we need to do it in an environment independent of outside influences. Collegiality also fosters a cross-fertilization of ideas — spanning not only specialties, but also generations. While at this year’s meeting, I was reminded of — and inspired by — the enthusiasm, fresh thinking, and familiarity with the literature our young members brought with them. I also saw how our more tenured members offered insights into how to evaluate the “latest and greatest” advances that come along. With the global implant dentistry market expected to double by 2018, it is increasingly important for all dentists involved in implant dentistry to work together to represent our field in the best light possible and to keep success rates high, and our patients safe and happy with our professional skills. The Academy of Osseointegration (AO) is an organization that connects us all and has led the way in implant dentistry since 1985. Together, we evaluate emerging research, technology and techniques, share best practices, and coordinate optimal patient care using timely, evidence-based information. (And, I’ll let you in on a little secret: We have quite a bit of fun doing it!) If you’re considering joining AO, more information about member benefits can be found at www.osseo.org. Your colleague, Alan Pollack, DDS President, Academy of Osseointegration

Dr. Ellis Paul, BDS, LDS, FFGDP (UK), FICD, editor-inchief 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

© FMC 2016. 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 9 Number 2

Dr. Pollack received his BA in Biology from Queens College, City University of New York, and his DDS degree from Columbia University School of Dental Medicine. He completed postgraduate programs in General Practice at Long Island Jewish Medical Center and in Periodontics at Columbia University. He served as a clinical assistant in the Department of Surgery at Memorial Sloan-Kettering Cancer Center from 1984 to 2003, and as an attending dentist at Beth Israel Medical Center from 1992 to 1998. Dr. Pollack has authored numerous publications in the dental literature and is a member of many professional organizations, including Omicron Kappa Upsilon, American Academy of Periodontology, American Dental Association, American Association for the Advancement of Science, First District Dental Society, and Northeastern Society of Periodontists. He is a Fellow of the International Team for Implantology and AO and has been an invited speaker at numerous national and international meetings. Dr. Pollack currently owns a private practice in New York City.

Implant practice 1

INTRODUCTION

A collegial profession

TABLE OF CONTENTS

Financial focus Living with the choices we make

Practice profile Nadim Z. Baba, DMD, MSD, FACP

Visualizing the transformation

Tony Robbins and Tom Zgainer discuss why you should understand how fees in your retirement plan investments will affect your future and that of your employees.................... 14

Case study Management of severe horizontal and vertical maxillary deficiency via tenting and subnasal augmentation with PRGF Dr. Pierre J. Tedders discusses a technique for grafting ridges requiring large areas of reconstruction .......................................................16

Clinical Using the All-on-4速 treatment concept to treat atrophied and over-treated jaws Dr. Reza Faridrad presents a case using the All-on-4 concept for insufficient bone in the posterior maxilla and mandible.......................22

Corporate profile

Zimmer Biomet Institute: education meets innovation

ON THE COVER Cover photo courtesy of Drs. Lyndon F. Cooper and Ghadeer N. Thalji. Article begins on page 27.

2 Implant practice

Volume 9 Number 2

OsseoSpeed™ Profile EV —A unique implant specifically designed for sloped ridges OsseoSpeed Profile EV is specially designed for efficient use of existing bone in sloped ridge situations. • Provides 360 degrees of bone preservation maintaining soft tissue esthetics • Can help to reduce the need for bone augmentation • Components designed to allow for accurate identification of the implant position throughout the treatment process OsseoSpeed Profile EV is an integral part of the new ASTRA TECH Implant System™ EV and is supported by the unique ASTRA TECH Implant System BioManagement Complex. For more information visit

www.jointheev.com

www.dentsplyimplants.com

Follow nature‘s contour

TABLE OF CONTENTS

Continuing education Continuing education Implant treatment in the esthetic zone Dr. Shakeel Shahdad presents a clinical case illustrating replacement of a maxillary canine with a narrow diameter implant in a hypodontia patient........................................33

Treatment of mandibular edentulism using conical interface abutments

Drs. Lyndon F. Cooper and Ghadeer N. Thalji present a simplified approach to divergent implant placement

Practice development Best of three

Implant insight In brief: the sausage technique Dr. Istvan Urban explains the processes and concepts behind his innovative — and less invasive — approach to bone regeneration

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

Product profile X-Guide® Dynamic 3D Navigation system Expand your control over the implant process...................................... 40

In the fifth article of his series, Toks Oyegunle looks at the three fundamental pillars of creating a winning marketing strategy............ 42

On the horizon

NATIONAL ACCOUNT MANAGER | Adrienne Good Email: agood@medmarkaz.com

Small diameter doesn’t mean small choices

NATIONAL ACCOUNT MANAGER | Michael Dunn Email: mdunn@medmarkaz.com

Dr. Justin Moody discusses his choice for small diameter implants............ 44

CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkaz.com

Materials & equipment.......................46

E-MEDIA PROJECT COORDINATOR | Michelle Kang Email: michellekang@medmarkaz.com

Meeting news............... 41 Industry news...............48

WEBSITE MANAGER | Anne Watson-Barber Email: anne@medmarkaz.com

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

4 Implant practice

$129 $319

Volume 9 Number 2

See the Engage in action on page 16! TM

UNMATCHED Primary Stability at Bone Level

The OCO Biomedical Engage™ implant provides unmatched primary stability and versatility at bone level. The patented implant body with its Bull Nose Auger™ tip, Mini Cortic-O™ threads and SLA surface provides the perfect support for all your restorative needs, whether they be a single restoration or a full mouth reconstruction. Available from 3.25 to 8mm in diameter, the Engage™ implant is a superior implant for all your clinical needs. With a simple two-step surgical protocol and dependable prosthetics, our immediate load system has been the implant of choice for thousands of practitioners around the world.

OCO Biomedical’s patented Bull Nose Auger™ tip

OCO Biomedical’s patented Mini Cortic-O™ threads

Our products are designed by dentists for dentists, just like you! To learn more about how OCO Biomedical can change the way you practice dentistry, call 1-800-228-0477 or email us at sales@ocobiomedical.com.

1-800-228-0477 Complete Implant Solutions

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

PRACTICE PROFILE

Nadim Z. Baba, DMD, MSD, FACP Visualizing the transformation

Working in my office

What can you tell us about your background?

When did you become a prosthodontist and why?

I received my DMD degree from the University of Montréal, Canada, in 1996. Following graduation, I moved to Boston to complete a Certificate in Advanced Graduate Studies in Prosthodontics and a master’s degree in Restorative Sciences in Prosthodontics from Boston University Goldman School of Dental Medicine. Years later, I became a Diplomate of the American Board of Prosthodontics and a Fellow of the American College of Prosthodontists (ACP). I currently serve as a Professor and Director of the Hugh Love Center for Research and Education in Technology at Loma Linda University School of Dentistry and maintain a part-time private practice limited to prosthodontics and implant dentistry in Glendale, California.

In dental school, I loved every discipline related to prosthodontics. I also had the chance to work with several instructors who were prosthodontists and came to realize that prosthodontics is what I would consider as a career path. Right after dental school in Montréal, I headed to Boston for my Prosthodontic training.

6 Implant practice

Is your practice limited solely to implants, or do you practice other types of dentistry? As a prosthodontist, I am a recognized expert when anything needs to be replaced in the patient’s mouth. I am a specialized dentist with advanced training in the treatment of crowns, bridges, implants, veneers, full dentures (conventional or CAD/CAM),

Dr. Nadim Z. Baba

partial dentures, snoring and sleep disorders, TMD or other jaw joint problems, and some other congenital conditions that affect the mouth. I am committed to improving patients’ results. Volume 9 Number 2

PRACTICE PROFILE

Do your patients come through referrals? Yes. Oral surgeons, periodontists, orthodontists, and general practitioners refer the majority of my patients. I also get patients referred by other satisfied patients who received their treatment in my office. As a prosthodontist, I am dedicated to the highest standards of care in the restoration and replacement of teeth, and for this reason, I maintain a close collaboration with all my referring colleagues during all the phases of treatment for the benefit of the patients.

How long have you been practicing implant dentistry, and what systems do you use? As a prosthodontist, I have been practicing implant dentistry for 20 years. I have worked with all the major implant systems between teaching at Loma Linda and working in my private practice. It basically depends on what my referrals use in their private practice. My office is located in a multi-specialty building and has three operatories, one designated for hygiene. I have an in-house laboratory operated by highly skilled dental technicians with tremendous amount of experience. A Dental Wings 7Series lab scanner (MontrĂŠal, Canada) was recently added to the state-of-of-the-art equipment already available in the lab. The office is paperless, and we use digital radiography and an in-house CBCT machine (Planmeca).

Putting a final touch to a denture and checking the quality of the finished laboratory work

What training you have undertaken? After completing my 4 years of dental school, I have trained for 3 additional years in prosthodontics followed by a masterâ&#x20AC;&#x2122;s degree in Restorative Sciences in Prosthodontics at Boston University Goldman School of Dental Medicine. I then challenged and successfully passed a rigorous four-part examination conducted by the American Board of Prosthodontics (ABP) to become a Diplomate of the ABP. Being affiliated with a teaching institution and attending specialty meetings such as the ACP, AAFP, AP, and others, I am at the cutting edge of technology and information.

Designing a framework for a fixed partial denture using CAD/CAM technology

Who has inspired you? Several of my instructors and colleagues inspired me through the years. In dental school, three of my faculty (Dr. P. Boudrias, Dr. C. Lamarche, and Dr. P. Milot), who were prosthodontists, had a great impact on my decision to choose prosthodontics as a specialty. At Boston University, I had the honor of being trained with Dr. Steve Volume 9 Number 2

With patient reviewing CBCT Implant practice 7

PRACTICE PROFILE

As a prosthodontist, I am committed to excellence and focused on providing all my patients with an exceptional quality and experience.

Top 10 favorites Graduation day at Loma Linda with Dr. Charles Goodacre on my right and Dr. George Zarb on my left

Morgano and other eminent faculty members who had a great impact on my visions and career. When I moved to Loma Linda to join the faculty, I had the privilege to work with my mentor, Dr. Charles Goodacre, who continues to be a role model and an inspiration to me. I feel blessed, lucky, and proud to have had the chance to know and work with each one of them in various stages of my professional career.

What is the most satisfying aspect of your practice? The most satisfying aspect of my practice is to visualize the transformation that patients go through during their smile makeovers and to see on their faces the degree of satisfaction and gratitude toward the work I accomplished.

Professionally, what are you most proud of?

innovative materials are used to provide patients with the finest dentistry can offer. The noncommercial, in-house laboratory, and highly skilled technicians utilize the latest technologies to design restorations of superior quality.

What would you have been if you had not become a dentist? If I did not become a prosthodontist, I would probably be a commercial pilot. I come from a family of six pilots from both sides of my parents. You could imagine what a family gathering would be when all these pilots meet together. They talk about airplanes all the time.

What are your hobbies, and what do you do in your spare time? In my spare time, I do some wood turning and collect die-cast cars. I enjoy going to

1. 2. 3. 4. 5. 6.

My family Willingness to share and be involved Humility and integrity Treatment based on science Lifelong learning Contemporary knowledge (i.e. digital dentistry) 7. Treat patients like you like to be treated 8. Evidence-based treatment 9. Respect people regardless of socioeconomic background 10. CAD/CAM technology

the Lakers basketball games with my kids, and I have a wonderful time with them. My daughter is 12 years old, and my son is 10 years old, and they both are very active and have a busy schedule between school and their extracurricular activities. They both play the piano, and I enjoy listening to them perform. Being a Mediterranean, I enjoy going to the beach all yearlong, and my whole family likes it too. IP

I am proud to be a board-certified prosthodontist. I am proud to give back to my specialty by serving on different committees of several specialty organizations. I also serve as a reviewer for two prosthodontic journals and as associate editor for the journal of Dental Traumatology. I am also proud to have published an evidence-based book on the diagnosis and treatment planning of the restoration of endodontically treated teeth published by Quintessence.

What do you think is unique about your practice? I am committed to excellence and focused on providing all my patients with an exceptional quality and experience. For that end, state-of-the-art equipment and 8 Implant practice

With my prosthodontic residents following a lecture by Professor Barakat and Dr. Aboujaoude during their visit from Lebanon Volume 9 Number 2

CHOOSE YOUR WORKFLOW TO THE $200 GUIDE

BUY OUR SOFT WARE

ORDER OUR SERVICES

[ PLAN YOUR OWN CASES ] [ SAVE MORE ON SURGICAL GUIDES ] [ GET HANDS-ON TRAINING WITH A DENTIST ]

[ SPEND LESS TIME ON YOUR COMPUTER ] [ NO SOFTWARE TRAINING OR LEARNING CURVE NEEDED ] [ EVALUATE THE SOFTWARE BEFORE YOU BUY IT ]

E V I S U L C X E ARE YOU A CBCT SCANNER OWNER?

CALL & ASK IF YOU QUALIFY FOR INSTANT ORDERING ORDER GUIDES & REPORTS DIRECTLY! NO 3RD PARTY IMPLANT PLANNING SOFTWARE NEEDED!

CORPORATE PROFILE

Zimmer Biomet Institute: education meets innovation

015 was a landmark year in the history of the dental industry. Zimmer Dental and Biomet 3i joined forces to become a leader in oral healthcare as the Zimmer Biomet dental division. Clinicians around the globe have since had access to a new level of customer service and extensive product portfolios that include a broad spectrum of surgical, restorative, regenerative, and digital dentistry solutions designed to improve the quality of life for patients. The Zimmer Biomet dental division is now uniquely positioned to provide continuing education programs that combine cadaveric and simulated patient training with didactic clinical presentations — all in one training center. Recognizing that education is critical to the advancement of dentistry, the dental division focuses on strengthening and enhancing the profession by offering industry-leading, scientific educational courses to dental clinicians from around the world through the Zimmer Biomet Institutes. The Zimmer Biomet Institutes in North America train more than 1,000 dental clinicians through more than 65 courses offered annually. General Manager of the Zimmer Biomet dental division, David Josza, remarked,

“The quality of the curriculum offered as well as the sophistication of the equipment and overall facility is outstanding. The simulation lab is the finest one I have ever experienced. It is impressive to see such a commitment made in the advancement of education in our field. I applaud the team at Zimmer Biomet.” — Howard Drew, DMD, professor, Rutgers School of Dental Medicine

“At an educational level, we strive to offer programs that complement skill sets and help clinicians achieve unprecedented levels of professional satisfaction and success, regardless of whether they are new to dental implantology or a seasoned practitioner.” In February, the dental division celebrated the grand reopening of the Zimmer Biomet Institute training center in Parsippany, New Jersey. The newly enhanced

20,000-square-foot dental training center provides professional educational courses for dental clinicians who are interested in restorative, surgical, and regenerative procedures. Training programs at this facility provide optimal hands-on experience and support to clinicians as they strive to refine their clinical skills. “We are thrilled to reopen our doors as the Zimmer Biomet Institute and excited

The newly enhanced 20,000-square-foot dental training center opened in February 10 Implant practice

Volume 9 Number 2

CORPORATE PROFILE

The new Zimmer Biomet Institute in Parsippany, New Jersey, features a state-of-the-art, proprietary simulation laboratory and a surgical laboratory for cadaveric workshops

to build on the foundation of our ability to provide dynamic professional training,” said Ken Varner, the Director of Institutes for the Zimmer Biomet dental division. “During our reopening in Parsippany on February 10, clinicians were able to see firsthand the bestin-class dental training offerings available in our new facility.” Courses offered at the new center include simulation workshops in a proprietary, stateof-the-art patient simulation laboratory. Reallife, simulated patient scenarios are reviewed and practiced during hands-on sessions with lifelike mannequins and anatomical models. This gives clinicians the unique opportunity to learn complicated implant procedures, including regenerative techniques, provisional and definitive restorations, and immediate implant loading. The simulation lab is equipped with all the tools and supplies that a clinician requires when treating a patient. Each learning station has a computer for accessing reference materials and simulated Volume 9 Number 2

patient materials, including radiographs, CT scans, and models that are specific for the exercises. The mannequins feature soft tissue and bone that have cortical and cancellous layers, soft-tissue lined sinuses, and wired inferior alveolar nerves. Ideal for clinicians skilled in basic implant surgery who want to refine their surgical knowledge and techniques, on-site cadaveric workshops enable clinicians to immediately implement what they’ve just practiced in the simulation lab on human tissue. Howard Drew, DMD, a professor at Rutgers School of Dental Medicine, attended a course at the new Parsippany Institute and commented, “The quality of the curriculum

offered as well as the sophistication of the equipment and overall facility is outstanding. The simulation lab is the finest one I have ever experienced. It is impressive to see such a commitment made in the advancement of education in our field. I applaud the team at Zimmer Biomet.” In addition to simulation and cadaveric training, didactic lectures and case reviews are given by guest speakers who travel from across the world to present on current and emerging procedures, technologies, and products. The Institute is equipped with advanced audio and visual technology, such as wireless projection and the ability to stream live presentations and demonstrations from Implant practice 11

CORPORATE PROFILE one training room to another and to various locations around the globe for an optimal educational experience. “Having lectured in many centers around the world, the Zimmer Biomet Institute offers a one-of-a-kind learning experience in a center designed specifically with clinicians’ needs in mind,” confirmed Harold S. Baumgarten, DMD. Courses range from a basic restorative program for clinicians who restore fewer than five implant cases each year to advanced surgical cadaveric workshops designed for clinicians who are actively placing and restoring implants. Depending on the course level, clinicians learn everything from basic dental implant restoration and associated techniques to advanced surgical procedures and the use of regenerative materials. Restorative topics include impression making, anterior esthetics, provisional restorations, fixed versus removable dentures, and full-arch restorations. Surgical topics range from soft-tissue grafting procedures, suturing techniques, sinus lifts, and socket

procedures to ridge augmentation. Courses typically last 2 to 3 days and are approved for continuing education credits. Building on the momentum from the New Jersey facility, plans are in order to meet the growing demand from clinicians and the expanding global business of dental implantology. Construction is in progress for two new facilities — one in Carlsbad, California, on target to open in the third quarter of 2016, and another in Shanghai, China, scheduled to open its doors by the end of this year. Plans are also being discussed to open a new Institute in Palm Beach Gardens, Florida, in 2017. In addition to keeping global education a priority, the Zimmer Biomet dental division, says Josza, will continue to focus its efforts on challenges faced by clinicians to meet patient expectations. “Implantology is about the solutions that you are ultimately offering clinicians so they can provide exceptional outcomes to patients. It’s not just what we make; it’s what we make possible.” As an affiliate of one of the largest musculoskeletal companies in the world,

the Zimmer Biomet dental division has access to the latest technology, talent, and resources to drive growth and accelerate the development of innovative solutions. Groundbreaking technologies such as the Zimmer® Trabecular Metal™ Implant, the 3i T3® Implant, the BellaTek® Encode® Impression System, and the Zimmer Dental 3.1 mmD Eztetic™ Implant System are a sampling of the comprehensive range of products that address clinicians’ daily clinical challenges. Collectively, the Zimmer Biomet dental division has conducted more than 175 preclinical and clinical research studies in the past 10 years, and there are more than 650 published articles on the surgical, restorative, and regenerative products. They have operations in 25 countries around the world and sell products in more than 100 countries. For more information on the Zimmer Biomet dental division, call 1-800-342-5454, or visit www.zimmerbiometdental.com. IP This information was provided by Zimmer Biomet Dental.

The Parsippany location is equipped with advanced audio and visual technology, including live-streaming capabilities 12 Implant practice

Volume 9 Number 2

Two worldwide leaders in oral health have a singular vision: You.

Zimmer Dental and Biomet 3i have joined forces. Together, the Zimmer Biomet dental division is pushing the boundaries of progress to help you achieve exceptional outcomes for your patients and your practice. With more than 62 years combined experience in the dental implant industry, Zimmer Biomet stands strong on its commitment to respond to ever-changing demands. Our visionary solutions, world-class educational opportunities, and unprecedented service are ready to move you beyond expectations. Join us in shaping the future of implant dentistry. Please contact us at 1-800-342-5454 for more information. www.zimmerbiometdental.com

ÂŠ2016 Zimmer Biomet. Due to regulatory requirements, Zimmer Biometâ&#x20AC;&#x2122;s dental division will continue to manufacture products under Zimmer Dental Inc. and Biomet 3i LLC respectively until further notice. AD069.

FINANCIAL FOCUS

Living with the choices we make Tony Robbins and Tom Zgainer discuss why you should understand how fees in your retirement plan investments will affect your future and that of your employees

s this article was written, the presidential campaign had officially started with the Iowa caucus now completed. In each of our states, we’ll soon enjoy the great individual privilege of choosing who we think will be the most suitable candidate in each party. When November 9 rolls around, and the results of the previous day’s election are confirmed, we’ll then have to live with the choices we made, or did not make, for the next 4 years. When it comes to our retirement planning, the choices we make today related to our investment options and their associated fees need to be made with a much longer time horizon in mind. Twenty to thirty years of life after active work has completed is now the norm. And if we intend to work another 10-25 years, the opportunity for the positive effects of compounding growth in your retirement savings will make all the difference in the quality of life we might enjoy in retirement. Different from what you might choose for yourself, be it a presidential candidate or a particular investment, if you are the sponsor of a retirement plan, your employees are counting on your decisions, and the ramifications of those choices good or bad. You are choosing for them, as they generally have no say so in the matter. And yet it’s their money, their future. It is a very significant responsibility often overlooked. We review hundreds of 401k plans per month, and while the employers are certainly well intentioned, so little is often understood regarding the effect of investment-related fees over time. A recent study found that the average total cost for a small business retirement plan declined to 1.46% over the past year, and that within this amount, the investment-related expenses typically borne by participants average 1.37%. This particular study defined small plans as those with 50 participants or $2.5 million in assets. However, if you own or work for a business that has fewer than 50 participants or Peak performance strategist Tony Robbins and Tom Zgainer, founder and CEO of America’s Best 401k, offer advice on growing retirement savings.

14 Implant practice

less than $2.5 million in plan assets, odds are you’re paying a substantial amount more in 401k fees. Plans in this demographic are defined as “micro” plans. It is not uncommon for the underlying investments in these plans to have expense ratios averaging between 1.50% and 2.50%. This has a major impact on retirement savings over time that can be difficult to decipher. Why is this important to you? While 1.00% may sound insignificant, the costs of your investments can have a staggering effect on your retirement savings over time. According to the Department of Labor (DOL), paying just 1 percentage point more in expenses over the course of 35 years could reduce a worker’s retirement savings by nearly 28%. For example, Bob is a participant in a plan offered by his employer with a 401k balance of $25,000 that earns 7% over the next 35 years. If Bob paid 0.50% in fees, even if he stopped making new contributions, his account would grow to $227,000 at retirement. But if he paid fees totaling 1.5%, the savings would rise to only $163,000, or 28% less. A startling statistic is that in a recent survey by the AARP, nearly 70% of participants in 401k plans believe they are paying no investment-related expenses or that their employer absorbs these fees. Nearly 40% of plan sponsors, the business owners bearing the fiduciary liability of the plan, who have chosen the providers and investments in the plan, do not know the average expense

ratios of the funds in the plan. Both figures are truly astonishing. A review of your own 401k fees and investment options should be a near-term action item. Plan sponsors are required by the Department of Labor to compare their current plans against alternatives on a regular basis to be sure all fees are reasonable and prudent. With the proliferation of lawsuits that exist — many very high-profile — recently in the news brought on by plan participants and almost always related to excessive fees or the use of proprietary funds in the 401k plan, it makes all sense to have a documented process and report of your findings in case a DOL examiner knocks on your door. We’ve made it easy for you to get a quick check to see how your plan compares to industry averages here: http://americasbest 401k.com/medmark. A couple of pieces of information are all we’ll need to complete the analysis. You’ll know right away if the path your retirement plan is heading is a place you’ll want to end up — or if a change will do you, and your employees who are counting on you, a world of good. Nothing is more important regarding your money than knowing how much you have, where it is, and if it is invested, how the costs of those investments will affect your future. Consider taking these steps for you, your family, and those you employ, who most likely do not even understand how your choices affect their future. IP Volume 9 Number 2

Oﬀer patient ﬁnancing for single implants at $99/month. 1

Give your patients the superior treatment they want with the affordable payment options they need. With premier implant financing through Lending Club Patient Solutions, the average patient can finance a single implant, including all restorative work, for $99/month.1 So you can: ■

Close more large cases

■

Present implants more conﬁdently

■

Help more patients move forward with treatment

Learn more about how to become one of our premier implant ﬁnancing providers. Visit: lendingclub.com/implants | Call: (844) 936-6673

1 $99

monthly payment assumes a 60-month term Extended Plan loan with an amount financed of $4,250 and an APR of 13.99%. Actual monthly payment amount and APR may vary based on amount financed, term and credit history. Subject to credit approval. Amount financed is based on an average single implant procedure cost of $4,250. Source: www.dentalimplantcostguide.com. © 2016 Lending Club Patient Solutions products and services provided through Springstone Financial, LLC, a subsidiary of LendingClub Corporation. Payment plans made by issuing bank partners.

CASE REPORT

Management of severe horizontal and vertical maxillary deficiency via tenting and sub-nasal augmentation with PRGF Dr. Pierre J. Tedders discusses a technique for grafting ridges requiring large areas of reconstruction

anagement of the comprehensive dental implant patient routinely requires guided-bone regenerative techniques. The benefits that the edentulous patient receives from an implant reconstruction can be life altering. Although depending on the specific patient, the duration of edentulism, the prosthetic, and utilization of the prosthetic, the alveolar and basal bone available for the reconstruction may range from sufficient to severe atrophy. Beyond the intraoral effects, these patients also suffer consequences of esthetics, decreased function, and psychological effects. Numerous predictable surgical protocols have been developed to manage the atrophic ridge. In those patients who have sufficient vertical height, with moderate to severe horizontal deficiency, an onlay graft via “tenting” procedure may be

most appropriate. This technique is useful in grafting ridges requiring large areas and may not result in the excessive facial remodeling of the implant as traditional block grafting. The following case will demonstrate the surgical procedure to overcome these types of deficiencies. The surgical plan includes a full periosteal flap reflection, nasal mucosal reflection, augmentation of the alveolar ridge, via onlay grafting with tenting to gain necessary width, and augmentation of the nasal cavity to gain height for the anterior implants utilizing Plasma Rich in Growth Factors (PRGF). The healing phase for this patient was 3 months prior to placing six root-form endosseous implants. This healing phase timing is appropriate when combining growth factors and the welldocumented initial stability of the OCO

Biomedical Engage™ implant with its Bull Nose Auger™ tip design.

Clinical case The patient presented with a chief complaint of ill-fitting maxillary complete denture. She reported that the fit and function of her maxillary prosthesis has negatively affected the quality of her life. The patient is ASA I with no contraindications to dentoalveolar surgery. Thorough clinical and radiographic examination reveals moderate to severe maxillary arch deficiency (Figures 1-3). Consideration was made for a traditional block-grafting procedure and combined block grafting with ridge splitting. Due to the size of the proposed graft and current known limitations to block grafting, the option was made for onlay grafting via a tenting procedure with sub-nasal elevation and augmentation with PRGF. A full thickness incision was made maintaining 3 mm of keratinized tissue to the facial of the incision line. Posterior superior vertical releasing incisions were made, and a full

Figure 2

Figure 1 Pierre J. Tedders, DDS, graduated from the University of Detroit-Mercy 1999 and received additional training at the University of Michigan/ VA Hospital general practice residency. He is a graduate of the Medical College of Georgia Maxi Course. Dr. Tedders has limited his practice to surgical and restorative dental implantology in southern and central Michigan. He is a Diplomate of the American Board of Oral Implantology/Implant Dentistry, an Associate Fellow of the American Academy of Implant Dentistry, and Educator for OCO Biomedical.

Figure 3 16 Implant practice

Volume 9 Number 2

nothing gets past

BREATHE A SIGH OF RELIEF Isolite comfortably obturates the throat, protecting against accidental aspiration and ingestion of instruments, materials, and debris without obstructing the airway. This is just one of the many ways Isolite provides total control of the oral environment, giving you stress-free, easy-to-use isolation and improving the dental experience for you, your team, and your patients.

LEARN MORE: 800 560 6066 www.isolitesystems.com

facebook.com/ISOLITESYSTEMS

youtube.com/ISOLITESYSTEMS

linkedin.com/COMPANY/ISOLITE-SYSTEMS

1605-JA2

CASE REPORT thickness reflection was completed exposing the facial alveolar and basal bone exposing the extent of the deficiency (Figure 4). Minimal alveoloplasty was completed followed by decortication, for regional acceleratory phenomenon aiding in angiogenesis (Figure 5), and bilateral reflection of the subnasal mucosa. Care is taken not to reflect the nasal mucosa as far posteriorly as the nasal cavity extends (reflection approximately 8-10 mm posteriorly) (Figure 6). Bone fixation screws (Salvin® Dental) were strategically fixed to the maxilla. The fixation screws serve to tent the collagen type I membrane and minimize the negative effects of compression from the muco-periosteum, peri-oral soft tissues, and musculature

(Figures 7 and 8). The fixation screws are approximated to slightly larger than the new proposed alveolar ridge — the final result ending with a minimum of 2 mm of bone to the facial and palatal of the dental implant. Approximately 64 cc of blood was drawn from the right antecubital fossa and prepped with 8 cc allograft (250 um-1000 um) for PRGF separated into “membrane” (Figure 10) and “graft” fractions. The allograft is osteoconductive, or serves as a scaffold for the predictable inflammatory response and remodeling. The PRGF increases the volume of localized growth factors, TGF-beta, and PDGF “inflammatory cytokines.” The growth factors accelerate the inflammatory cascade, the rate of angiogenesis, and further serves

as a filler. With the addition of growth factors, there is a significant decrease in reported postoperative complications. A type I collagen membrane was modified with tissue scissors and secured to the palatal tissue with 4-0 polyglycolic acid (PGA) sutures (Figure 11). The collagen membrane serves several functions: 1) the collagen membrane prevents epithelial migration into and displacing the graft and 2) contains the graft material. The PRGF and allograft “graft” were moderately condensed between the nasal floor and the nasal mucosa to a total height of approximately 15 mm from the alveolar crest. The graft was then moderately condensed to follow the new proposed facial-palatal ridge to

Figure 4

Figure 5

Figure 6

Figure 8

Figure 7

Figure 10 18 Implant practice

Figure 9

Figure 11

Figure 12 Volume 9 Number 2

Figure 13

PGA (Figure 16). The patient was prescribed a postoperative chemotherapeutic regimen, chlorhexidine rinse, an anti-inflammatory, and a narcotic pain reliever as needed. The patient was seen at 1 week, 2 weeks for suture removal (Figure 17), and 4 weeks to monitor the healing process. The patient then entered a total 12-week healing phase. At the 12-week time frame, the new maxillary arch was exposed using a full-thickness incision from right to left tuberosity with disto-vertical releasing incisions to gain access to the tenting screws for removal and implant placement. The remaining ridge demonstrated sufficient bone regeneration, to the head of the fixation screw, for the planned six 4.0 x 12 OCO Engageâ&#x201E;˘ implants (OCO Biomedical) (Figure 18). All tenting screws were removed, and minor alveoloplasty (Figure 19) was completed. Paralleling pins (Figure 20) were used to maintain parallelism for the placement of six 4.0 x 12 OCO Engage implants utilizing the simplified OCO Biomedical twodrill surgical sequence. The surgery was performed in a singlestage approach, and 5-mm tall trans-mucosal healing abutments were placed. For this specific surgery, the OCO Engage implant

Figure 14

was selected for its outstanding primary stability. The Engage is a bone-level implant with a variable self-taping thread pattern. The coronal micro threads increase the bone-toimplant surface contact, and combined with the Bull Nose Auger tip, provide the initial stability required for predictable success with a limited healing phase. The initial stability of the implants ranged from 40N/cm to 60N/cm of torque (sufficient for immediate load). The tissues were approximated with interrupted horizontal mattress sutures (Figures 21 and 22), and the patient was seen at the 2-week and 4-week postoperative visits. At the 3-month follow-up visit, the implants were torque tested to 35N/cm, and the patient was referred to her general dentist to complete the prosthetic phase of her treatment. The final prosthesis was a maxillary implant-retained overdenture. Note: In treatment planning of the implant overdenture, if the palate is to be removed out of the final denture, the implants must be splinted. The palate and the alveolar ridge provide the support and stability of the prosthesis. If individual locators are utilized, and the palate is removed, the prosthetic becomes an implantretained and implant-supported prosthesis, leading to potential progressive bone loss

Figure 16

Figure 15

Figure 17

Figure 18

Figure 19

Figure 20

Figure 21

Figure 22

Volume 9 Number 2

Implant practice 19

CASE REPORT

slightly overfill beyond the tenting screws to form the proposed new facial surface of the maxillary alveolus (Figure 11). The collagen membrane was then folded over and secured to contain the graft (Figure 12). With the entirety of the graft condensed and secured with the collagen type I membrane, the tissues do not approximate passively. The number one complication of a ridge reconstruction of width is suture line opening. Suture line opening exposes the underlying graft, and a negative inflammatory response follows, leading to excessive remodeling and potential infection (Figure 13). Horizontal periosteal releasing incisions and blunt dissection of the tissues was completed to allow for the tissues to approximate passively (Figure 14). Initially, 12 horizontal mattress sutures were utilized to approximate the tissues. The closure must be primary and tension free. Placing the horizontal mattress sutures at the mucogingival junction everts the tissues and releases the tension off the incision line. Further, multiple sutures must be used to prevent suture line opening due to suture failure during the phase of edema (Figure 15). Final incision line closure was completed with continuous interlocking suture with 4-0

CASE REPORT

Figure 24A

Figure 23

Figure 24B

Figure 25A

Figure 25D 20 Implant practice

Figure 25B

Figure 25E

Figure 25C

Figure 25F

around the implants. All implants can be seen on the postoperative pan (Figure 23). The patient presented for a 2-year postoperative evaluation on February 15, 2016. A clinical examination (Figure 24A) and CBCT were performed. All tissues remain firm, pink, and asymptomatic. The remaining maxillary ridge has maintained width and bone to the facial of the implants. (Note comparison photos preoperative Figure 24B and postoperative.) Figures 25C-25D demonstrate the augmented bone of the nasal cavity. Figure 25 shows the 2-year postoperative CBCT. Thorough knowledge and experience with the different ridge augmentation and bone manipulation techniques offer reconstructive options that directly improve the quality of life for our patient base. This case presented an onlay graft via a tenting procedure, which offers another option to obtain necessary bone quantity for implant placement. The procedure is relatively simple and may offer more predictable results to traditional block grafting. The patient is continuing her treatment with an immediate placement and immediate load transitional mandibular hybrid denture with five mandibular OCO implants in the A, B, C, D, and E positions in March 2016. Additionally, it has been highly recommended that an implant-retained and tissuesupported maxillary implant overdenture with a locator bar be fabricated. The patient stated that there has been a significant improvement in the quality of her life following her implant reconstruction. This was, and should be, the ultimate goal of our implant treatments. IP Volume 9 Number 2

GIVE YOUR DENTURE WEARING PATIENTS THE SECURITY THEY DESERVE WITH EVERY SMILE.

Same-Day Implants for Denture Patients Now it’s possible for you to offer reliable, predictable Small Diameter Implants to your patients who are denture wearers, right in your own office. The miniMARK® Dental Implant System is an affordable option for denture wearers. Precision engineered by ACE Surgical, it features the renowned LOCATOR® Attachment by Zest Anchors, the world’s most trusted name in securing implant-fixed dentures.

APRIL/MAY SPECIAL OFFER – PURCHASE 10 MINIMARK IMPLANTS AND RECEIVE A FREE SURGICAL KIT* For more information or to place an order, call 800.441.3100 or visit us online at www.minimarkimplant.com

Manufactured by

*Purchase any 10 miniMARK implants and receive a FREE MiniMARK surgical kit. This offer can not be combined with other miniMARK promotions. To receive the FREE kit on-line, please add at least 10 qualifying miniMARK implants and the miniMARK Surgical Kit (#09-2949-76) to your cart before checkout. Offer ends May 31, 2016. Limit one FREE kit per customer. miniMARK® is a registered trademark of ACE Surgical Supply Co., Inc. LOCATOR® is a registered trademark of Zest Anchors, LLC.

CLINICAL

Using the All-on-4® treatment concept to treat atrophied and over-treated jaws Dr. Reza Faridrad presents a case using the All-on-4 concept for insufficient bone in the posterior maxilla and mandible

t has been more than 20 years since the concept of All-on-4® (Nobel Biocare®) (Malo, Lopes, and De Araujo Nobre, 2011) has been introduced into the profession. The treatment of the resorbed edentulous jaws using a fixed implant-supported prosthesis (Malo, Lopes, and Costa, 2008) has always been a challenge for dentists. There are still debates among the profession about the credibility of this treatment modality. Needless to say, that there are other implant companies, such as Zimmer and Bredent (fast and fixed), following the similar philosophy. There is no doubt in my mind that the All-on-4 concept is the treatment of choice (both for me and my patients) when there is insufficient bone in the posterior maxilla and mandible (Rangert, et al., 2005; Malo, Rangert, and Nobre, 2005; Malo, Rangert, and Nobre, 2003; Malo, et al., 2011). Needless to say that the zygomatic implants and quad-zygoma options are available for more severely resorbed maxilla (when there is insufficient bone in the premolar and molar regions). These options will save time for both the patient and the operator without the need for bone-grafting procedures.

Poor planning and rushing into treatment is not uncommon among the profession when it comes to edentulous jaws. There are three types of failures: 1. Short-term — during and shortly after the procedure (e.g., bleeding, lack of primary stability, etc.) 2. Midterm — problems arising in the first few weeks (e.g., infection and mobility in the fixture, loosening of the internal hex screw, problems with the occlusion, poor esthetic results, etc.) 3. Long term — problems arising after a few months and years (e.g., periimplantitis and loss of hard and soft tissues, etc.).

Case study In this case, I have tried to illustrate how the All-on-4 concept helped me to treat a patient and give her teeth, smile, and, more importantly, chewing ability back. Her previous dentist (implantologist) had decided to treat the case in a staged manner using the immediate placement protocol.

Seventy-year-old Mrs. TB was referred to me for a second opinion in 2012. Mrs. TB was treated by a visiting implantologist from California, in Belgium in 2008. The patient presented to me with fixedbridge restorations fitting over the 14 fixtures (unknown manufacturer), seven in the maxilla and seven in the mandible. The halitosis and poor plaque control around the fixtures with readily bleeding soft tissue around those fixtures was a horrible experience. The patient was distressed, and she was in a lot of pain and discomfort. Her chief complaint, not surprisingly, was pain, bleeding, and not being able to chew and eat properly. Nearly all the fixtures were exposed, and the bone loss was well past the first thread (Figures 1-5). There was no mobility in the bridges, but I noticed that the UL1 was looking out of place, and its shade was not matching the rest of the porcelain work. It became clear that this part was soldered onto the bridge separately. The bruxism took its toll, and the sign of it was evident on the worn down ceramic of the lower bridge occlusally (Figure 6).

The success of All-on-4 The success and survival rate of the All-on-4 treatment has been assessed by many clinicians (Malo, et al., 2011; Malo, et al., 2011) and research groups.

Reza Faridrad, Dip Dent (lst), MSc (OMFS), MFDS RCS (Eng), qualified in 1995 and has 3 years of postgraduate education in oral and maxillofacial surgery at Eastman Dental Institute. He was awarded a prestigious master’s degree from UCL in 2001. He has 4 years’ hospital experience in oral and maxillofacial surgery and orthodontics in London (UCH), Liverpool (Aintree Hospitals), Gloucester, and Cheltenham general hospitals. Dr. Faridrad has allocated his time to dental implant treatments, mentoring, visiting surgeons, and accepts referrals for complex cases as well as dealing with failed dental implant treatments. Contact Dr. Faridrad by emailing rfaridrad@gmail.com, or visit www.angeldentalimplant centre.co.uk.

Figure 1: Extraoral appearance during smiling (when the patient presented to us) 22 Implant practice

Volume 9 Number 2

CLINICAL

Figure 2: Extensive loss of alveolar bone and soft tissue (3 years postoperative)

Figure 4: Extensive hard and soft tissue loss on upper anterior and left side of the maxilla

Figure 3: Extensive hard and soft tissue loss on upper anterior and right side of the maxilla

Figure 5: Lack of space in the vestibular sulcus due to fixtures positioned too far buccally. Note the lack of soft tissue available to cover the fixtures

An Orthopantomogram (OPG) X-ray and CBCT examinations revealed severe bone loss on the upper fixtures with poor planning for placement. It has been confirmed with the patient that these fixtures were positioned immediately in the extraction sockets for the upper left canine and premolars. In the mandible, the LR5 fixture was perforated and inserted in the right inferior dental nerve canal, and the patient already had anesthesia of the right lower lip. During all the visits the patient had with her dentist (implantologist), she was always reassured that the numbness would be temporary, that the implants and restorations were in a very good shape with minimal bone loss around them, and the dentist was actually very happy with the result.

Treatment plan

Figure 6: Sign of bruxism over the porcelain restorations Volume 9 Number 2

After agreeing to the proposed treatment plan, on the day of surgery, the patient had all the fixed bridgework and 14 implant fixtures removed under IV sedation. This procedure took around 7 hours as one of the upper and two of the lower fixtures were Implant practice 23

CLINICAL

Figure 7: Existing lower abutments after removal of the lower fixed bridge

Figure 8: Seven fixtures after removal of the abutments (system unknown to us)

Figure 9: Two fixtures removed using trephine as osseointegration made it impossible to unscrew the fixtures

osseointegrated, and some of the heads of the internal hex screws were blunted and were already damaged. They were impossible to be undone. The high-speed handpiece, trephine, forceps, and implant removal kit were used in order to remove all the previous restorations (Figures 7-10). The alveolar ridge was reduced and trimmed according to the All-on-4 protocol. The fixtures (four upper and four lower) were inserted in the position LR4-5 area and angled away from the mental foramen and previously perforated ID canal. Needless to say, that the patient had some improvement in her numb lip, and she described it as “less heavy” (Figure 19).

Figure 12: Upper and lower temporary acrylic fixed bridges 24 Implant practice

Figure 10: Mandible post removal of all seven fixtures

Figure 11: Taking impressions from the four NobelActive® implants inserted according to the All-on-4 principles

Figure 13: More space and flexibility in the lower labial vestibular region Volume 9 Number 2

CLINICAL

Figures 14-16: No more gaps or space between the restoration and soft tissues

Figure 17: Upper temporary acrylic fixed bridge

All the created sockets and damaged ridges were augmented with Bio-Oss速 (Geistlich), covered using Geistlich bilayer GBR membrane, and primary closure was achieved using Vicryl速 (Ethicon) undyed suture material. After taking impressions, the temporary bridges were made by the technician on site and fitted. The vertical height and occlusion were checked and adjusted. This part of the job took approximately 6 hours. The patient was experiencing less soreness and bleeding from the soft tissue over the ridge as her erosive lichen planus appeared to be less symptomatic; although the condition affected all her mouth, it stayed unchanged on her buccal mucosa and pharyngeal areas. There was obvious improvement over the ridges and floor of the mouth (Figures 12-18 and Figure 20). The final bridges were made and fitted 6 months later, and the patient has fully recovered from her previous experience and managed to eat and chew effectively (after 8 years) with minimal flare-ups from her inflamed oral soft tissues. The bleeding index from the soft tissues around the fixtures was minimal, and the halitosis issue was also resolved (Figures 21-27). Volume 9 Number 2

Figure 18: Lower temporary acrylic fixed bridge

Figure 19: Preoperative Orthopantomogram (OPG)

Figure 20: Postoperative OPG Implant practice 25

CLINICAL

Figure 22: Occlusal view of upper fixed PBM bridge

Figure 21: Final upper porcelain fixed bridge restoration opposing the lower composite fixed bridge

Figure 23: Occlusal view of lower fixed bridge

Figures 24-25: Right and left lateral view. Restorations in maximum intercuspation position

Figure 26: Final restorations in situ

Conclusion The All-on-4 concept for total rehabilitation is clinically effective but challenging. The survival rates of the implants and restorations is high according to the short-, medium-, and long-term studies. The All-on-4 can be offered routinely to most patients in need of a complete edentulous rehabilitation. The use of NobelGuide (Nobel Biocare®) for computer planning can simplify the treatment if the patient is totally edentulous. IP

Figure 27: Smiling with final restorations in situ

REFERENCES 1. Malo P, de Araújo Nobre M, Lopes A, Moss SM, Molina GJ. A longitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up. J Am Dent Assoc. 2011;142 (3):310-320. 2. Maló P, de Araújo Nobre M, Lopes A, Francischone C, Rigolizzo M. “All-on-4” immediate-function concept for completely edentulous maxillae: a clinical report on the medium (3 years) and long term (5 years) outcomes. Clin Implant Dent Relat Res. 2012;14Suppl.:e139-150. 3. Malo P, Lopes I, De Araújo Nobre. The All-on-4 concept. In: Babbush CA, Hahn JA, Krauser JT. Dental Implants: The Art and Science. Maryland Heights, Missouri: Saunders Elsevier;2011:435-447. 4. Malo P, Lopes I, Costa R. Oral fixed rehabilitation of atrophic jaws. In: Francischone CE. Osseointegration and multidisciplinary treatment. Sao Paulo, Brazil: Quintessence Editora Itda;2008:Chapter 13. 5. Malo P, Rangert B, Nobre M. All-on-4 Immediate function concept with Brånemark system implants for completely edentulous mandibles: a retrospective clinical study. Clin Implant Dent Relat Res. 2003;5(5 Suppl 1):2-9. 6. Malo P, Rangert B, Nobre M. All-on-4 immediate-function concept with Brånemark System implants for completely edentulous maxillae: a 1-year retrospective clinical study. Clin Implant Dent Relat Res. 2005;(7 Suppl 1):S88-S94. 7. Rangert B, Aparicio C, Malevez C, Bedrossian E, Renouard F, Malo P, Calandriello R. Graftless rehabilitation of the atrophied maxilla – tilted implants, short implants and immediate function. In: Jensen OT. The Sinus Bone Graft. Denver, Colorado: Editorial Quintessence, SL; 2005:296-320.

26 Implant practice

Volume 9 Number 2

Drs. Lyndon F. Cooper and Ghadeer N. Thalji present a simplified approach to divergent implant placement

ental implant therapy for the edentulous mandible is highly successful when measured at the level of the dental implant. When component and prosthetic complications are considered, recent systematic reviews suggest that component and prosthesis complications occur frequently. Many of these complications are related to prosthesis design and have been attributed to the cantilever designs that impose significant bending moments and stress on the prostheses and components. The intentional divergence of implants from mutually parallel placement restricted to the parasymphyseal mandible has been proposed (Malo, et al., 2003) and has been recently substantiated by a retrospective evaluation revealing greater than 98% implant success (Malo, et al., 2011). The distal displacement of the terminal implants supporting mandibular implantsupported fixed dentures (ISFD) requires the use of abutments that geometrically reconcile the nonparallel arrangement of the implants and permit relative parallelism of the abutments. The aim of this case report is to illustrate the alternative use of conical interface abutments to simplify the construction of mandibular ISFD supported by four implants with intended divergence.

Educational aims and objectives

This article aims to illustrate the alternative use of conical interface abutments to simplify the construction of mandibular implant-supported fixed dentures (ISFD) supported by four implants with intended divergence.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 32 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize that the use of conical-design abutments permits the intentional displacement of implants in nonparallel orientations without adding complexity to the required components for restoration. •

Realize that the placement of abutments of strength and utility enables the clinical management of the prosthesis at a tissue or supratissue level.

•

Recognize the option of a simplified approach to divergent implant placement.

•

Identify the process of implant placement for a patient with a complicated type of edentulous mandible.

Diagnosis and treatment plan A 57-year-old male presented for treatment of mandibular edentulism. Clinical examination revealed a non-restorable, carious maxillary left canine and first premolar tooth and the linguoversion of the maxillary left lateral incisor (Figures 1A-1C). After discussion of options for treatment of mandibular

Figure 1A: Pretreatment frontal view with prostheses

Lyndon F. Cooper, DDS, PhD, is the associate dean for research and head of the department of oral biology at the University of Illinois at Chicago. He formerly served as program director of advanced prosthodontics and Stallings distinguished professor at the University of North Carolina. He is a past president of the American College of Prosthodontists. Ghadeer N. Thalji, BDS, PhD, is an assistant professor at the Department of Prosthodontics at the University of Iowa. She is a Diplomate of the American Board of Prosthodontics.

Figure 1B: Pretreatment maxillary occlusal view Volume 9 Number 2

Figure 1C: Pretreatment mandibular occlusal view Implant practice 27

CONTINUING EDUCATION

Treatment of mandibular edentulism using conical interface abutments

CONTINUING EDUCATION

Figures 2A-2C: 2A.Clinical charting of pretreatment dental condition. 2B. Preoperative panoramic X-ray. 2C. Periapical X-ray of tooth No. 12 demonstrating non-restorable carious lesion

Figure 4A: Laboratory putty mold of the processed mandibular denture

Figure 3: Frontal view of the waxed denture teeth try-in

Figure 4B: Mandibular denture along with its duplicate from radiopaque resin produced within the putty mold

Figures 5A-5C: 5A. Oblique view of the proposed implant position within the mandible as viewed in the segmented and formatted image using Facilitateâ&#x201E;˘ software (Dentsply Implants). 5B. Frontal view of the proposed implant positions using Facilitate software. 5C. A lateral left side view of the proposed implant positions demonstrating the distal angulation of the terminal implants

edentulism that included a conventional denture, an implant-retained overdenture, and an implant-supported fixed prosthesis, the patient selected rehabilitation by four implants supporting a mandibular ISFD constructed of titanium alloy and resin veneer. Treatment planning was performed using information gathered from the clinical chart, mounted radiographs, and the panoramic radiograph (Figures 2A-2C). A diagnostic waxing was performed to reveal the proposed restoration of the maxillary left lateral incisor and replacement of the maxillary right first 28 Implant practice

premolar using a fixed dental prosthesis. A mandibular denture setup was waxed to characterize the position of teeth for the proposed interim denture and final prosthesis (Figure 3). The Class III skeletal relationship was adapted to a Class I tooth arrangement. After reviewing treatment and obtaining informed consent, additional diagnostic measures for the surgical treatment were performed. The mandibular denture was flasked and processed in heat polymerizing resin (LucitoneÂŽ 199, Dentsply) using a conventional compression technique.

Thereafter, the mandibular denture was duplicated using a radiopaque resin (Biocryl-X radiopaque acrylic resin, Great Lakes Orthodontics) polymerized in a custom laboratory putty mold (Figures 4A-4B). A cone beam CT image was made of the patient wearing this radiographic template, and the DICOM files were imported into planning software (Dentsply Implants). Four implants were located within the parasymphyseal mandible and in relationship to the visualized denture teeth (Figure 5A). The implant selection and placement was performed to account for primary stability and osseointegration, restorative dimension, and minimal cantilever length for the available distribution of the implants. The targeted planning goal was to assure that there were at least four implants of >10 mm length, >10 mm of restorative dimension, and >10 mm of anterioposterior implant distribution (English 1990; Rangert, et al., 1989) to permit a cantilever of one premolar and one molar tooth (approximately 15 mm). Achieving these Volume 9 Number 2

Figure 6B: Osteotomies performed in preparation for placement of four OsseoSpeed™ TX implants

Figure 6C: Implant placement of a 4.0 mm x 11.0 mm OsseoSpeed™ TX dental implant at site No. 21

Figures 7A-7B: 7A. Conical interface abutments (Uni Abutments, Dentsply Implants) hand torqued in place at the time of implant surgery. Note that the 4 mm length makes access to the restorative interface directly accessible. The angular correction necessary is provided by the 20º interface design. 7B. Schematic drawing reveals the construction of components using conical seal design abutments (b) within the 4.0 mm implant (c). The 4 mm abutment easily traverses the 2 mm-3 mm of mucosa and reveals a circular interface that supports the 20º interface for the bridge cylinder (a).The bridge screw (d) attaches the prosthesis to the abutment

goals required distal angulation (Figure 5B) of the terminal implants and an alveoloplasty to assure adequate restorative dimension.

Surgical treatment Four implants (OsseoSpeed™ TX, 4.0S x 11mm at the LL4, LR2, and LR4 sites, and a 3.5S x 11mm Dentsply Implants at the LL2) were placed in the parasymphyseal mandible. Under local anesthesia, a mucoperiosteal flap was elevated from the left molar region to the right molar region of the mandible. An alveoloplasty was performed from the left premolar region to the right premolar region with removal of approximately 4 mm of crestal bone (Figure 6A). This resulted in the exposure of a mandibular alveolar crestal shelf of approximately 5 mm-6 mm in buccolingual width and afforded an additional 3 mm of restorative dimension. Using the radiographic template with appropriately oriented 2.5 mm diameter guides drilled for surgical orientation, 2.0 mm osteotomies were placed to 4 mm-5 mm depth through the template. After affirming the proper orientation of the four osteotomies, each osteotomy was sequentially enlarged to 11.0 mm x 3.7 mm for sites Volume 9 Number 2

LL4, LR2, and LR4 and 11.0 mm x 3.2 mm for the LL2 according to the implant manufacturer’s recommended protocol (Figure 6B). Subsequently, 11.0 mm x 4.0 mm or 11.0 mm x 3.5S implants were placed into each osteotomy with primary stability (Figure 6C). Next, a conical interface abutment (Uni-Abutment, Dentsply Implants) was placed with hand torque into each of the four implants, and the mucosa was sutured circumferentially to each of the abutments (Figures 7A-7B). On each of the 20º conical interface abutments, machined-titanium temporary cylinders (Dentsply Implants) were placed with hexed bridge screws using finger pressure only. The access chambers of the cylinders were filled with VPS impression material to exclude acrylic resin. The complete denture was relieved to accommodate the temporary cylinders but with the full extension of the flanges intact. Upon closure, the coincidence of the denture maximum intercuspation at centric relation confirmed that the temporary cylinders did not displace the denture orientation. At that position, each of the four temporary cylinders was incorporated into the denture

Figures 8A-8B: 8A. Occlusal view of the mandibular master cast incorporating the 20º conical interface analogues. 8B. Right lateral view of the mounted master cast. Note the angulation of the abutment accounts for the intended nonparallel nature of the implant orientation

using autopolymerizing acrylic resin with a rubber dam placed beneath the cylinders to protect the surgical site. The conversion prosthesis was then refined by removal of the flanges and eliminating the cantilever extension beyond the mesial cusps of the first molar. The prosthesis was delivered using four hex bridge screws, and the access holes were filled with VPS material.

Restorative treatment After 8 weeks of healing, the patient returned for an impression of the abutments to construct the final prosthesis. First, an inter-occlusal record using the existing interim prosthesis at centric relation was taken. Then, the interim conversion prosthesis was removed, the stability of the implants and abutments was verified, and an impression of the implant abutments made at the level of the 20º conical interfaces using a stock tray and VPS impression material. Implant practice 29

CONTINUING EDUCATION

Figure 6A: Alveoloplasty procedure performed on the mandibular alveolar crest shelf

CONTINUING EDUCATION

Figure 9: Verification index fabricated on the master cast using GC pattern resin. After intraoral try-in and evaluation, the index confirmed the correct inter-implant orientation within the master cast. This step is essential to subsequent CAD/CAM manufacture of the framework

Figures 10A-10B: 10A. The master cast and the denture are both scanned in preparation for the design of the framework. This permits accurate orientation of the framework relative to tooth position as revealed in this rendering from the Cagenix AccuFrame® software. 10B. Cross-sectional representation reveals “Y” framework design visualized using Cagenix AccuFrame software

Figure 11: Diagramatic representation of the extent of divergence that is accommodated by 20º conus abutments. Note that at 40º of divergence, the bridge screw access would be lingual to the incisors (anterior) and within the first molar (posterior). Less divergence (20º-25º) is easily accommodated and readily restored with a short ( ~10 mm ) cantilever.

The master cast was poured to incorporate 20º conical interface analogues without a soft tissue moulage (Figures 8A-8B). A verification index was fabricated using four impression copings and acrylic resin (GC Pattern Resin™) (Figure 9). The verification index was tested clinically to confirm the accuracy of the master cast. The interim conversion prosthesis and the interocclusal record were used to mount the mandibular master cast in correct relationship to the maxillary cast. A shade was taken for fabrication of the final prosthesis using nanohybrid composite/resin teeth (SR Phonares® II, Ivoclar Vivadent®).

Laboratory procedures The fabrication of the mandibular prosthesis required CAD/CAM design and milling of a titanium alloy bar. For this process, the dentist must provide the laboratory or milling center with a) a master cast, b) a verification index that confirmed the position of the analogues in the cast, c) a copy of the mandibular denture, or an impression of the existing conversion prosthesis. No articulator is required for the CAD/CAM design and manufacture of the milled framework. The design of the framework should take account of the position of the teeth and should address concerns of imposed function. In this case, the framework design utilizes an effective “Y” design to provide resistance to deformation and strength (Figures 10A-10B). The regions of the 30 Implant practice

Figures 12A-12B: 12A. Frontal view of waxed teeth try-in of the ISFD on the master cast. 12B. Frontal view of the waxed teeth try-in demonstrating screw access hole through the facial aspect of left lateral incisor

framework distal to the screw access areas are bolstered to account for known stresses that accumulate in this area of cantilever bars. Note that the design is within the contours of the scanned denture and should not interfere with the prosthetic teeth. The distal inclination of the implants does not impede the use of simple abutments as these abutments possess 20º conus interfaces for the framework. In most cases, displacement of the implants leading to access screws exiting the first or second premolar region involves approximately 25º of angulation between the two implants and is easily reconciled by 40º of mutual angulation between two 20º conus interface abutments (Figure 11). There exists no need for an angled abutment component. There is no need to assess the fit of the framework due to the accuracy of manufacture and the provision of the verification index.

Upon delivery of the framework, it is transferred to the articulator and nanohybrid composite/PMMA teeth (SR Phonaris II, Ivoclar Vivodent) were arranged in baseplate wax for try-in and final evaluation (Figure 12A). In this particular case, one implant was placed facial to the anterior tooth plane. This is attributable to the conversion of a skeletal Class III relationship to a Class I dental relationship. One approach to solving the interference of the screw access with the esthetic aspects of the incisor tooth is to construct the acrylic veneer prosthesis with the denture tooth deleted from the position of the offending screw access during processing. This approach was taken in design and implementation of prosthesis construction (Figure 12B). Metal frameworks for implant-supported fixed dentures typically require opaquing of the metal color. This can be done using

Figures 13A-13B: 13A. Frontal view of the anodized Cagenix AccuFrame Plus framework. 13B. Left lateral view of the anodized Cagenix AccuFrame Plus framework Volume 9 Number 2

Figures 15A-15C: 15A. Frontal view of the processed ISFD mounted with the left lateral incisor tooth. 15B. Frontal view of the processed ISFD mounted without the left lateral incisor tooth. 15C. The processed ISFD along with the lateral incisor tooth

Figure 16A: Frontal view of the ISFD definitive prosthesis in CR

different methods that include adhesive and non-adhesive application of materials. Another innovative approach is the anodization of the titanium alloy metal substrate to a pink hue (Figures 13A-13B). This technology is commercially available (AccuFrame® Plus, Cagenix™, Memphis, Tennessee) and was applied in this instance. Following tooth try-in and acceptance by the patient, the fabrication of the ISFD was completed by conventional processing that included tinting of the acrylic resin base using white, red, and melanin shading acrylics (Kayon® denture stain kit, Englewood, New Jersey). Just prior to flasking of the prosthesis, the lateral incisor tooth interfering with bridge screw access was removed from the wax-up (Figure 14). The interface between the tooth and the baseplate wax was refined, and then the waxed denture was finally flasked in plaster. The acrylic resin base and teeth were polymerized and de-flasked, and the prosthesis without the lateral incisor tooth was revealed (Figures 15A-15C). The lateral incisor tooth was easily fit to the recipient acrylic resin housing the screw access, and the entire prosthesis was finally polished.

Delivery and follow-up care The processed denture was delivered using four bridge screws tightened to 15Ncm. Prior to closing the screw access and placement of the lateral incisor tooth, an occlusal photograph was made and given to the patient. All hex bridge screws were covered with cotton pellets. The lateral Volume 9 Number 2

Figure 16B: Frontal view of the ISFD definitive prosthesis in protrusion

Figure 16C: Right lateral view of the ISFD definitive prosthesis in CR

Figure 16D: Left lateral view of the ISFD definitive prosthesis in CR

Figure 16E: Occlusal view of the ISFD definitive prosthesis

incisor tooth was fit into the recipient acrylic resin housing and bonded into place using ProTech Plus® self-cure hard reline and repair acrylic resin (ProTech Professional Products). The screw access hole exiting the pink denture resin was filled with pinkfibered triad resin (Dentsply), and the screw access holes exiting the premolar teeth were filled with shade A3.5 composite resin (Kerr, Orange, California). These surfaces were covered with Vaseline®, smoothed with a gloved finger, and then light polymerized in order to avoid polishing. The occlusion was verified using articulating paper visualization and bilaterally symmetric contacts in centric occlusion as demonstrated using shimstock (Figures 16A-16E).

Summary The use of conical-design abutments permits the intentional displacement of implants in nonparallel orientations without adding complexity (additional screws, specific angled components, or custom abutments) to the required components for restoration. The 20º configuration illustrated here offers resistance along the abutment/ prosthesis interface that contributes to stability of bridge screws. The use of CAD/CAM manufacture of frameworks does not preclude the use of individual abutments in construction. The placement of abutments of strength and utility enables the clinical management of the prosthesis at a tissue or supratissue level. IP

REFERENCES 1. Maló P, Rangert B, Nobre M. “All-on-Four” immediate-function concept with Brånemark System implants for completely edentulous mandibles: a retrospective clinical study. Clin Implant Dent Relat Res. 2003;5 Suppl 1:2-9. 2. Malo P, de Araújo Nobre M, Lopes A, Moss SM, Molina GJ. A longitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up. J Am Dent Assoc. 2011;142(3):310-320. 3. English CE. Critical A-P spread. Implant Soc. 1990;1(1):2-3. 4. Rangert B, Jemt T, Jörneus L. Forces and moments on Branemark implants. Int J Oral Maxillofac Implants. 1989;4(3):241-247.

Implant practice 31

CONTINUING EDUCATION

Figure 14: Occlusal view of the waxed ISFD with the analogues embedded in type III gypsum product (Microstone, Whipmix) prior to flasking

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2012 to 11/30/2016 Provider ID# 325231

REF: IP V9.2 COOPER

CONTINUING EDUCATION BROUGHT TO YOU BY

FULL NAME

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 24 CE credits for only $99. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Implant Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

To provide feedback on this article and CE, please email us at education@medmarkaz.com Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

TELEPHONE/FAX

Please allow 28 days for the issue of the certificates to be posted.

Treatment of mandibular edentulism using conical interface abutments COOPER/THALJI

1. The intentional divergence of implants from mutually parallel placement restricted to the parasymphyseal mandible has been proposed and has been recently substantiated by a retrospective evaluation revealing greater than _________ implant success. a. 35% b. 50% c. 78% d. 98% 2. ___________ was made of the patient wearing this radiographic template, and the DICOM files were imported into planning software. a. A cone beam CT image b. A 2D digital image c. A cephalometric image d. A transilluminated image 3. The implant selection and placement were performed to account for _________ for the available distribution of the implants. a. primary stability and osseointegration b. restorative dimension c. minimal cantilever length d. all of the above 4. After _______ of healing, the patient returned for

32 Implant practice

an impression of the abutments to construct the final prosthesis. a. 2 weeks b. 4 weeks c. 6 weeks d. 8 weeks 5. (For this case) The master cast was poured to incorporate _____ conical interface analogues without a soft tissue moulage. a. 10ยบ b. 20ยบ c. 30ยบ d. 40ยบ 6. For this process (CAD/CAM design and milling of a titanium alloy bar), the dentist must provide the laboratory or milling center with _____, or an impression of the existing conversion prosthesis. a. a master cast b. a verification index that confirmed the position of the analogues in the cast c. a copy of the mandibular denture d. all of the above 7. _____ is required for the CAD/CAM design and manufacture of the milled framework. a. An articulator b. No articulator

c. An X design d. Opaquing 8. The processed denture was delivered using four bridge screws tightened to _______. a. 10Ncm b. 15Ncm c. 20Ncm d. 30Ncm 9. The use of conical-design abutments permits the intentional displacement of implants in ______ orientations without adding complexity (additional screws, specific angled components, or custom abutments) to the required components for restoration. a. parallel b. nonparallel c. straight d. angled 10. The placement of abutments of _______ enables the clinical management of the prosthesis at a tissue or supratissue level. a. articulation b. strength c. utility d. both b and c

Volume 9 Number 2

CE CREDITS

IMPLANT PRACTICE CE

Dr. Shakeel Shahdad presents a clinical case illustrating replacement of a maxillary canine with a narrow diameter implant in a hypodontia patient

mplants are now considered a predictable choice to replace missing teeth; nevertheless, replacement in the esthetic zone remains a challenge. In addition to the challenges posed by the various clinical scenarios, our patients have high expectations; they demand optimal functional and esthetic outcomes. An ideal implant restoration has to re-create gingival esthetics, and for a clinician, the pink esthetics remain the most challenging aspect of the treatment. In recent years, we have become more critical in objectively assessing the outcome with newer indices. Furhauser and colleagues (2005) recommended the “pink esthetic score” (PES) as a means of objectively assessing gingival esthetics in implant restorations, especially single-tooth implants. Besides papillae, the PES combines the height, contour, color, and texture of the peri-implant soft tissues. Achieving an ideal esthetic outcome in implant restorations requires a meticulous approach. The different stages of treatment

Educational aims and objectives

This article aims to discuss an implant method of replacing a tooth in the esthetic zone.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 36 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify a method of preoperative assessment for implant placement. • Recognize a method to deliver a restoration that esthetically fulfills the objectives of treatment. • Recognize a method to deliver a restoration that functionally fulfills the objectives of treatment. • See how to fulfill a specific need by using narrow diameter implant to replace a canine tooth.

are important, and a thorough preoperative assessment underpins the process. To ensure an optimal outcome, the following factors are important: • Three-dimensional surgical placement • Esthetic hard tissue grafting • Careful soft tissue handling during second-stage surgery • Soft tissue sculpting with a provisional restoration • Utilizing a technique that aids creation of an optimal definitive restoration. In

this article, a clinical case illustrating replacement of a maxillary canine with a narrow diameter implant is presented in a hypodontia patient.

Clinical case A 32-year-old male patient presented with a congenitally missing maxillary lateral incisor. Specialist orthodontic treatment had been completed elsewhere without any restorative interdisciplinary planning.

Figure 1: Preoperative view. The UL3 is in place of the UL2 and modified with a composite resin Shakeel Shahdad, BDS, MMedSc FDS, RCSEd FDS (Rest Dent), RCSEd, DDS, is a consultant and honorary clinical senior lecturer in restorative dentistry at The Royal London Dental Hospital and Barts and The London School of Medicine and Dentistry, Queen Mary University of London. He is a specialist in restorative dentistry, periodontics, prosthodontics, and endodontics. He also works at Specialist Dental Services, a specialist referral practice at 7 Wimpole Street, London, England.

Volume 9 Number 2

Figure 2: Adequate mesiodistal space at coronal level to replace the UL3 Implant practice 33

CONTINUING EDUCATION

Implant treatment in the esthetic zone

CONTINUING EDUCATION The UL3 was positioned in the UL2 space, and a pontic space was present in the UL3 area (Figure 1). A diminutive right lateral incisor was present. The overall dentition was minimally restored, and the pontic space mesiodistally was adequate for a canine width tooth (Figure 2). However, the interradicular space was limited and inadequate for replacement of this tooth with an average diameter implant, ideally suited for a canine tooth (Figure 3). After a detailed discussion, the patient ruled out a resin-retained bridge and preferred to have the tooth replaced with a dental implant. Direct composite buildup was carried out to optimize the diminutive right lateral incisor and reshape the UL3 as the UL2. A narrow diameter, tissue-level type, Straumann速 Roxolid速 hydrophilic implant (3.3 mm diameter NNC) was placed in an

ideal three-dimensional position for a screwretained single-tooth restoration. Submerged healing was allowed for 6 weeks followed by implant exposure surgery.

Figure 3: Post-orthodontic radiograph demonstrating limited interradicular space

Figure 5: Soft tissue sculpting is carried out over a few visits by modifying the provisional crown

Figure 7: The shape of the impression coping does not correspond to the shape of the subgingival emergence. To facilitate the technician, impression coping should be customized 34 Implant practice

After a period of provisionalization to allow peri-implant soft tissue molding (Figures 4-6), impression coping was customized to facilitate the dental technician (Figures 7 and 8) to

Figure 4: A screw-retained provisional restoration is inserted for soft tissue sculpting. Note the discrepancy in the gingival height between the provisional restoration and the adjacent teeth

Figure 6: The emergence of the restoration mimics a natural tooth, and the implant is ready for impression for a definitive crown

Figure 8: A hard-setting silicone bite registration material (Stone Bite速, Dreve Dentamid GmbH) is used directly in the mouth to capture the detail of the subgingival emergence Volume 9 Number 2

Figure 10: Postoperative view. The final restoration, fulfilling all the pink and white esthetic criteria

Figure 11: Two-year follow-up. The imperceptible restoration despite malpositioned UL3 in the UL2 space

achieve an ideal emergence in the definitive restoration (Figure 9).

Conclusion

Figure 13: Radiograph at 2 years, demonstrating wellmaintained bone levels

While the success of osseointegration is now an established fact, the challenge for clinicians is to deliver restorations that esthetically fulfill the objectives of treatment. This clinical case demonstrates how careful assessment and treatment planning can be predictably controlled to fulfill the treatment objectives. A narrow diameter implant was used to replace a canine, which is now feasible to do predictably with the advent of stronger dental implant materials. Despite the non-ideal orthodontic result, the final esthetic outcome with the dental implant and reshaping of teeth with directly bonded composite restorations yielded a great result for this patient (Figures 10 and 11). IP

REFERENCES

Figure 12: Definitive screw-retained restoration â&#x20AC;&#x201D; the contours of which should snugly fit the subgingival emergence. The restoration should be neither over- nor under-contoured Volume 9 Number 2

1. FĂźrhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek G. Evaluation of soft tissue around single-tooth implant crowns: the pink aesthetic score. Clin Oral Implants Res. 2005;16(6):639-644. 2. Jemt T. Regeneration of gingival papillae after single-implant treatment. Int J Periodontics Restorative Dent. 1997;17(4):326-333. 3. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the height of inter-implant bone crest. J Periodontol. 2000;71(4):546-549.

Implant practice 35

CONTINUING EDUCATION

Figure 9: Customized impression coping is incorporated within the impression, and an ideal working cast can be created

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2012 to 11/30/2016 Provider ID# 325231

REF: IP V9.2 SHAHDAD

CONTINUING EDUCATION BROUGHT TO YOU BY

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

TELEPHONE/FAX

Please allow 28 days for the issue of the certificates to be posted.

Implant treatment in the esthetic zone SHAHDAD

1. An ideal implant restoration has to recreate gingival esthetics, and for a clinician, the ________ remain the most challenging aspect of the treatment. a. black triangle b. pink esthetics c. contour d. texture 2. Furhauser and colleagues recommended the _________ as a means of objectively assessing gingival esthetics in implant restorations, especially single-tooth implants. a. “pink esthetic score” (PES) b. “gingival zenith score” (GZS) c. “gingival scaffold score” (GSS) d. “melanin pigmentation score” (MPS) 3. Besides papillae, the PES combines the ______ and texture of the peri-implant soft tissues. a. height b. contour c. color d. all of the above 4. To ensure an optimal outcome, the following factors are important: • _____ surgical placement a. two-dimensional b. three-dimensional

36 Implant practice

c. manual d. sculpted 5. (In this case) __________ was carried out to optimize the diminutive right lateral incisor and reshape the UL3 as the UL2. a. Amalgam buildup b. Laboratory fabricated buildup c. Direct composite buildup d. None of the above 6. (In the clinical case) Submerged healing was allowed for _________ followed by implant exposure surgery. a. 2 weeks b. 4 weeks c. 6 weeks d. 8 weeks 7. After a period of provisionalization to allow _____, impression coping was customized to facilitate the dental technician to achieve an ideal emergence in the definitive restoration. a. peri-implant soft tissue molding b. hard tissue grafting c. hard tissue sculpting d. the patient to become accustomed to the implant

8. While the success of __________ is now an established fact, the challenge for clinicians is to deliver restorations that esthetically fulfill the objectives of treatment. a. the digital impression b. osseointegration c. tissue grafting d. tissue sculpting 9. A _________ was used to replace a canine, which is now feasible to do predictably with the advent of stronger dental implant materials. a. narrow diameter implant b. wide diameter implant c. supraperiosteal implants d. standard implants 10. Despite the _________, the final esthetic outcome with the dental implant and reshaping of teeth with directly bonded composite restorations yielded a great result for this patient. a. screw-retained restoration b. poor PES score c. texture of the soft tissue d. non-ideal orthodontic result

Volume 9 Number 2

CE CREDITS

IMPLANT PRACTICE CE

StraumannÂŽ Bone Level Tapered Implant

It is not a trick. It is legendary science.

Discover the magic of the tapered standard.

Designed for excellent primary stability thanks to an apically tapered implant with groundbreaking material and surface technology for maximizing predictability. The Bone Level Tapered Implant â&#x20AC;&#x201C; the new tapered standard. Engineered in Switzerland, home of Straumann.

FREE implant.* FREE abutment.* For more information visit straumann.us/StraumannLegend

Material *Eligible Customers: Offer only valid for customers of US and Canada who have not purchased Straumann BLT implants in the last 18 months. Limit one implant and one healing abutment per customer. Additional qualifications may be required.

Surface

IMPLANT INSIGHTS

In brief: the sausage technique Dr. Istvan Urban explains the processes and concepts behind his innovative — and less invasive — approach to bone regeneration You are widely known for developing the “sausage technique.” Can you explain a little of the theory behind this procedure? Prior to the sausage technique, we had to utilize more autogenous bone blocks, which is a pretty invasive procedure. The sausage technique is minimally invasive compared to this, which is one of the biggest advantages. Now, we can utilize particulate bone graft composed of 50% of autogenous bone scrapings and a xenogeneic bone graft. So by mixing these two together, we need to harvest much less autogenous bone. One big advantage is that the xenogeneic bone graft maintains the volume of the regenerated crest, whereas the autogenous blocks tended to resorb over time, often meaning you had to repeat the procedure. We have more than 10 years of experience with this technique, which shows it is very stable. Why is it called the sausage technique? Well, simply put, it’s because we use a native collagen membrane, which we stretch out with mini-tacks to completely immobilize the bone graft. Using the membrane in this way, like a skin, looks like a little sausage and achieves a very stable bone graft. This membrane beautifully allows the blood vessels to permeate through from the periosteum and the host bone and will resorb in around 4 to 6 weeks. The term sausage technique is not a medical term; rather, it is a technical term to highlight to the clinician that immobilizing the bone graft with the collagen membrane is central to the technique.

How important are the properties of the materials that you use for this technique? They are very important. Let’s talk about the bone graft — Bio-Oss® (Geistlich) is the most well-studied graft material on the planet. It is very successful because it has

Istvan Urban, DMD, MD, PhD (Budapest), is assistant professor at the implant dentistry program at Loma Linda University, California. He also has a private practice in Budapest, Hungary.

38 Implant practice

the structure of native human bone, which allows for connection between the graft and the host bone. The other important property is that it is dimensionally stable — it does not resorb too quickly. Allograft, for example, has poor dimensional stability, so we cannot use it for this technique. The membrane again is native and, again, is very well studied. We know from the research that capillaries from the periosteum can pass through the membrane, which allows for nutrient transfer and vascularization, but at the same time, it does not allow for the ingrowth of soft tissue cells. So it excludes what needs to be excluded and allows what is required for good bone formation.

You have developed a technique that uses a strip of autogenous tissue harvested from the palate, which sits alongside a strip of 3D collagen matrix to gain keratinized tissue. How does this work? We know that keratinized tissue (KT) is really important around implants, but developing it can be quite an invasive procedure. You have to harvest large quantities of soft tissue from the patient’s palate using a free gingival graft (FGG), which is painful for the patient, and often the outcome can be esthetically poor. I consider this new approach to be a little bit like tissue engineering: What we are doing is utilizing a collagen matrix, which is designed to stabilize the blood clot of the periosteal bed and allow the soft tissue cells of the neighboring tissues to migrate and to form within the matrix. If we just use the collagen matrix, we can get some KT, but sometimes we need more than 2 mm-3 mm — after bone grafting, for example, we might need 5 mm or more KT because the mucogingival line has been distorted. In these cases, we can harvest a very thin FGG, which is a source of cells, and position it apically to the collagen matrix — providing cell ingrowth into the collagen matrix. A big advantage of this technique is that harvesting this thin strip of autograft causes

only a negligible amount of pain — something that was observed in our study. Out of 20 patients involved in the study, 19 didn’t recognize the wound from the ministrip graft that was harvested from the palate, which is a very big improvement compared to the FGG, or connective tissue graft. The other thing we see is that since the matrix is collecting cells from palate and cells from the strip of autograft, it is more esthetically pleasing than the FGG. So we have less morbidity, less potential for bleeding, better-looking soft tissue, and very good attached KT. Now, in a new study — to be published soon — we can demonstrate using histology that we are really developing KT with this technique.

You have recently become a board member at the Osteology Foundation. Can you tell us a little bit about your role? For me, it is an honor to be a board member of the Osteology Foundation. I think it’s a great foundation, and the work on the communication committee is really exciting. The foundation already communicates well with dentists, and I think most dental practitioners know and like the major symposiums. But there is still room to develop and reach out to dental communities and communicate, not only through the symposiums, but also throughout the year. For example, if you have a group of dentists running a study club, the Osteology Foundation can support them with speakers, by helping to develop research protocols and ensuring they have a platform where they can communicate with each other, with the Osteology Foundation and with other study clubs. To have a platform where we could standardize documentation and make it easier to evaluate cases would be a big step and would help to promote education, science, and communication between dentists.

Can you tell me a little more about your involvement with this organization and your lecture at the symposium in April? I am lecturing on vertical ridge augmentation at the International Osteology Volume 9 Number 2

Figure 1: Occlusal view of the posterior maxilla showing the thin bone crest

Figure 2: View of the lateral window

Figure 3: Application of the bone graft particles

Figure 4: The membrane is applied and secured using fixation pins

Symposium 2016 in Monaco. The vertical defect is probably the most advanced defect, but is probably a little over-mystified, and I think it can be treated by most specialists. I will talk about the biology of this defect, the biomaterials that should be utilized — what we use and get good results with. I will also talk about the completely resorbed maxilla and utilizing GBR to regenerate in a vertical and horizontal direction — which is very exciting because we are just publishing a study that shows 15 years of follow-up with Volume 9 Number 2

Figure 5: View of the augmented bone crest with three implants in position

this indication, which was not an indication before GBR. So I am really looking forward to April, as it is one of my favorite congresses.

Finally, can you tell us a little bit about your institute in Budapest and your courses? We have a regeneration institute, which I think is the only institute in the world dealing specifically with bone and soft tissue regeneration. The most popular course is a 3-day

course on advanced bone and soft tissue regeneration where we teach the sausage technique, vertical ridge augmentation, and also techniques for comprehensive soft tissue reconstruction of these defects. The course includes live surgery and handson with cadavers. We now also have the “Regenerator Program,” which is over three sessions and covers everything in regeneration from the extraction socket and single tooth defect to the vertical ridge defect and comes with a university certification. IP Implant practice 39

IMPLANT INSIGHTS

Clinical case: combined sinus and horizontal ridge augmentation using the sausage technique

PRODUCT PROFILE

X-Guide® Dynamic 3D Navigation system Expand your control over the implant process

he X-Guide® Dynamic 3D Navigation system is designed to elevate the surgeon’s control and precision over the entire implant process, including planning and placement. The X-Guide system utilizes the surgeon’s plan to provide turnby-turn guidance during live surgery, giving the ability to visualize precise movements of the handpiece during osteotomy and implant delivery for more exact placement — it’s like GPS for the drill. X-Guide is: • Impressively easy • Remarkably accurate • Incredibly consistent

“The X-Guide system fills the final gap of digital dentistry. Dynamic 3D navigation allows the dentist to use all the 3D digital information at their fingertips in real-time to immediately plan and place implants.” — Dr. Robert W. Emery, Diplomate of the American Board of Oral and Maxillofacial Surgeons

X-Nav X-Guide

to assist in precisely guiding the surgical implant. The result — the clinician can consistently achieve a more desirable functional and esthetic outcome.

plus new, patent-pending X-Point™ navigation technology — the first, single-view guidance of implant position, angle, and depth. Compatible with most cone beam 3D systems, surgeons do not have to stop at precise planning anymore — now they can place in remarkable detail as well. With the X-Guide system in the dental practice, same-day guided surgery can be a reality for more patients.

Easy navigation for better control Patent-pending X-Point technology makes it easy to look at the screen and concentrate on one dynamic focus point

Confident planning

X-Guide live navigation with CBCT cross-sections

Use the robust X-Guide implant planning software to plan all factors of the ideal implant location. Visualize the placement of virtual teeth for better esthetic planning. If using an intraoral scanner, go a step further with six simple clicks, and register the intraoral scan to plan an ideal restorative outcome with opposing teeth in occlusion.

Precise placement The X-Guide system makes it easy to be exact by providing robust treatment software

About X-Nav Technologies, LLC X-Nav Technologies is a medical device company in Lansdale, Pennsylvania, that develops surgical products for the dental market that advance patient care while improving doctor productivity. For more information, call 267-436-0420, or visit www.x-navtech.com. IP This information was provided by X-Nav Technologies, LLC.

X-Guide X-Point Target axial view

X-Guide implant plan with intraoral scan 40 Implant practice

Robust X-Guide implant planning Volume 9 Number 2

Dr. Ed Zuckerberg will present the closing keynote address at AAID’s 2016 Annual Educational Conference to be held in New Orleans, beginning on October 26, 2016. His presentation, entitled “Social Media Marketing for Dentists-What You Need to Know Now!” will take place on Saturday, October 29, 2016, from 11:00 a.m. until noon. Dr. Zuckerberg’s presentation will highlight the importance of having an active social media presence and discuss the various platforms, with emphasis on Facebook. Techniques to increase followers and promote engagement will be highlighted. The process for creating a social media marketing budget will also be reviewed, along with a discussion of techniques for efficient use of advertising dollars. For more information, visit http://www.aaid.com/Annual_ Conference/index.html.

Registration is now open for Carestream Dental’s new Global Oral Health Summit Global Oral Health Summit, hosted by Carestream Dental, is 2016’s new comprehensive educational event that brings dental, orthodontic, and OMS professionals together under one roof, November 10-13, 2016, at Caesars Palace, Las Vegas. The Global Oral Health Summit takes the place of Carestream Dental’s three separate Users’ Meetings of the past and is open to all oral health care professionals, both doctors and staff. The Summit opens with keynote speaker Laura Schwartz, former White House director of events. Then attendees obtain CE credits while attending educational sessions hosted by some of the oral health care industry’s most respected names. Speakers include Dr. Craig Misch of the Misch International Implant Institute; Dr. Tom Pitts of Ortho Classic; Dr. John Khademi; Dr. Ben Burris; Dr. Kanyon Keeney; Dr. David Little; and Dr. Mark Setter, to name just a few of the 20 scheduled clinical key opinion leaders. At the User’s meeting, different tracks are available to CS SoftDent, CS PracticeWorks, CS WinOMS, and CS OrthoTrac users so that attendees can participate in the classes most relevant to them. Plus, new this year, “super-users” of the software step into the role of trainer and share the tips and tricks they’ve picked up over the years that make their practices run so smoothly. For more information and to register, visit www.carestream dental.com/globalsummit. Use #GOHS16 on Twitter and like the Global Oral Health Summit Facebook page to stay up-to-date with all the latest news.

Volume 9 Number 2

Sir Richard Branson to deliver keynote address during SIROWORLD event Dentsply Sirona Inc. has enlisted business magnate and Virgin Group founder Sir Richard Branson to speak at SIROWORLD in Orlando, Florida, August 11-13, 2016, at the Rosen Shingle Creek Resort in Orlando, Florida. Branson, who is listed on the Forbes “World’s Billionaires” list, will engage the SIROWORLD audience with his tale of success, technological innovations, philanthropic efforts, and the conflicts and triumphs of his journey. SIROWORLD is Dentsply Sirona’s 3-day educational event in which thousands of attendees are expected to gather to attend inventive breakout sessions, benefit from copious networking opportunities, and relish in the astonishing entertainment planned throughout the event. Also, The Grammy Award-nominated band, OneRepublic, will perform during the inaugural SIROWORLD annual event. Dentsply Sirona is also elated to welcome Connie Podesta — therapist, comedienne, award-winning author, and former TV/ radio personality — to the already robust lineup of celebrity entertainers speaking at the 3-day educational festival. Register at www.siroworld.com.

OCO Biomedical announces open registration for their second quarter 2016 world-class, AGD-Pace accredited, 2-day, hands-on “Introductory Implant Planning and Placement” courses OCO Biomedical, Inc., a proven global leader in world-class dental technology, training, and instrumentation, has announced open registration for their 2016 second quarter “Introductory Implant Planning and Placement” courses. These fast-paced, information-packed dental implant classes, presented by highly qualified, industry-recognized clinical instructors, will be offered throughout the year in numerous locations nationwide. According to OCO, this value-priced, in-depth, 2-day implant dentistry introductory course forms the core of OCO’s nationwide educational program. The comprehensive, accelerated course structures provide practitioners, on all levels, the opportunity to gain extensive knowledge that can be immediately implemented into practice. The company’s seminar-style training focuses on The OCO Advantage: A Complete Dental Implant Solutions Approach, a successful, clinically-proven methodology created and developed by OCO Founder and President, Dr. David Dalise, and OCO Chief Operating Officer and Director of Clinical Affairs, Dr. Charles Schlesinger. To enroll or for further information about The Next Generation of Dental Implant Training, register for the 2016 OCO Biomedical International Dental Implant Symposium, order the print Product Catalog, call OCO Biomedical at 1-800-228-0477, or visit www. ocobiomedical.com.

Implant practice 41

MEETING NEWS

Zuckerberg to speak at AAID Annual Conference

PRACTICE DEVELOPMENT

Best of three In the fifth article of his series, Toks Oyegunle looks at the three fundamental pillars of creating a winning marketing strategy

f we assume you want increased sales and profit from your dental practice, then what exactly must you do to create a marketing strategy that will help your business to thrive? Before we get into the strategy, here’s a quick recap: This is the fifth article in a six-part series developed to help dentists improve the marketing of their practices. In this series, I am using my “triple M” profitable marketing framework as a tool to clarify exactly what needs to be done to significantly improve your marketing efforts. Over the last few issues, we have delved into the details of this framework separately: What they are, how they work, and how you can profitably apply the framework to your practice. This article will present an overview of all the individual components and how they all fit together. The three basic aspects you need to understand and implement properly are market, message, and media.

Market Simply put, your market represents the universe of current and potential patients. However, who really represents your perfect target market? If we are unclear what we are aiming for, it will be difficult to hit the target! In line with this, I introduced the concept of the “perfect patient avatar”: a detailed

Toks Oyegunle is a leading business coach and an awardwinning entrepreneur. The Harvard Business School alumnus is the founder of Thriving Practices: profitable marketing solutions; experience-based, technology driven.

42 Implant practice

profile of the best patient you can attract to your practice based on the criteria you believe your patients should exhibit. The idea of the demographics and psychographics of your market was explored as a key component of the perfect patient avatar, as this is the only way you can truly understand your market. This detailed level of patient understanding is critical to you being able to attract the best patients effortlessly to your practice because you will know how they think and what they truly want from your practice and why. To understand your patients better, I suggested you analyze your patient database by separating them into three distinct groups: • Best patients • Average patients • Worst patients On one hand, this exercise helps you appreciate your best patients more and figure out ways to give them a delightful experience. On the other hand, it makes it very clear which patients need to be fired from your practice and why. Never be scared to lose problem patients — especially the ones you are sure that you cannot satisfy or convert to become your best patients. It will give you more time and energy to serve your best patients better — and that is always a good idea!

Message Your message is the core essence of your communication with your market. This becomes increasingly easier once it is clear

who your perfect patient is because you can intentionally craft your marketing message to speak directly to the patient’s wants and needs you have already identified. This is why we started by developing a “perfect patient avatar,” and I still strongly advise you to do this for your practice if you are serious about increasing your profit dramatically. Next, identify your unique selling point (USP). This is usually a phrase or sentence that clearly summarizes and explains the key benefits you provide to your patients over your competition. Think of it as a simple marketing message that you can use to communicate with a lead that will easily convert them into a patient. If you’ve not yet developed your USP, the following questions will help you: 1. What are your core strengths? 2. What are patients’ biggest needs? 3. What are patients’ biggest wants? 4. Why will patients choose you over others? Remember, your USP does not need to be cast in stone; it is a dynamic communication tool you will use to easily attract the right patients to your practice on a regular basis. The goal here is to create a message that makes you stand out in an already crowded marketplace. So, start now and put your USP together with the knowledge that you can always change it whenever you want.

Media I gave the following definition of media to ensure you are thinking about your options Volume 9 Number 2

results while decreasing/stopping adverts that do not bring results. You are a small business and simply cannot afford to do the big adverts that large companies do with little or no way to measure the effectiveness of your advertising spending. This testing process will take time, but once you get it right, you will be able to predict the response you will get from certain media with some level of accuracy. This is the feedback you need to plan your advertising investment accordingly.

Never be scared to lose problem patients — especially the ones you are sure that you cannot satisfy to convert to become your best patients.

The basic three

However, if you get this right, you should soon see considerable growth in the sales of your services and products. The following questions will help you to understand what media you should use for profitable marketing: 1. Who are your perfect patients? 2. What media do they use? 3. What media should you use? Once you decide on the ideal media for your practice, you need to test each option carefully by starting small and only increasing your adverts in the media where you get

We have clarified exactly what you need to do to increase your profit by improving your marketing, and it is captured by this simple formula: “Right market x right message x right media = increased practice profit.” Once you get your market right, your message right, and your media right, you will be shocked by the rapid transformation that will happen to your practice. Once you manage to get the three basics right, increased profit will happen naturally as you will be optimized for growth. IP

DON’T BE FOOLED BY IMITATIONS Only PIEZOSURGERY® by Mectron is powered by patented dual wave technology

Seamless, efficient and precise bone cutting with reduced bleeding.

Maximum respect of soft tissues including sinus membrane and nerves.

Int J Oral Maxillofac Surg 2011; 40: 451–457

J Oral Maxillofac Surg 2008; 66:593-596

BMP-4

Days

Increased BMP release for faster bone healing and osseointegration. J Periodontol 2007; 78:716-722

Over 80 inserts for maximum surgical versatility in a wide variety of clinical applications.

“I use Piezosurgery® for almost all surgical procedures; it reduces my surgical stress while improving patient outcomes. This equals fun for me and it is evidence-based.” Robert Levine, Periodontist, Philadelphia, PA

USE THE REAL PIEZOSURGERY® FOR EVIDENCE-BASED RESULTS +1 888 877 4396 Volume 9 Number 2

info@piezosurgery.us

www.piezosurgery.us Implant practice 43

PRACTICE DEVELOPMENT

the right way: “Media — any platform that enables you to effectively communicate your marketing message and positively influence your target market.” Once again, I want you to take a moment to consider the many different platforms that you may use to communicate your marketing message and positively influence all the potential patients out there to come to your practice instead of the competition. We explored the different media options available to you in the market and considered the merits of some over the others. What is the right media for you to use for the profitable marketing of your practice? Do not underestimate the importance of this question; understanding what media to use, and why, will provide you with invaluable information regarding where you should regularly advertise your practice. It is probably the most important question you can ask regarding your use of media. If you get the answers wrong, you will probably incur considerable advertising costs with relatively few results to show for it. I am sure some of you have already had this experience.

ON THE HORIZON

Small diameter doesn’t mean small choices Dr. Justin Moody discusses his choice for small diameter implants

n the beginning of implant dentistry, clinicians’ only choices for small diameter implants were one-piece titanium implants of variable sizes ranging from maybe 1.9 mm to 3.2 mm. The downside to these small diameter, or what many refer to as miniimplants, was that they were one piece, which meant that they had to be loaded immediately. It was this lack of restorative options that kept many from using them and truthfully what caused them to get a

Figure 1: Zirconia hybrid abutment to a 3.0 BioHorizons Ti-Base created by ProSmiles Dental Studio

bad rap. The argument was so heated that online forums and discussion boards had to create second columns for the “mini” implant people. As time has passed, I have found myself placing narrower implants for preservation of buccal bone and soft tissue maintenance. Today is a different story all together as we now have 3.0 mm two-piece implant options with full restorative options and anatomically correct implant bodies; the tapered body allows for better positioning in the anterior for those missing lateral incisors and lower anteriors. This is significant as we can provide the patient with exactly what they need, not just what we can do, if we are limited by the implant or restorative options. We can elect to submerge the implant in a traditional two-stage procedure with a cover screw when the situation calls for it. When the need calls for immediate provisionals and loading, the 3.0 is well equipped to handle most any situation.

These implants are now included in most treatment planning software for use in case design and for fabrication of surgical guides. Cone beam CT machines like the Carestream 8100 3D allow for real-time virtual implant placement as well as easy integration with guide manufacturers like Implant Concierge™. How do you choose a small diameter implant? The BioHorizons® Laser-Lok® tapered internal 3.0 is my implant of choice. Not only do these implants have the LaserLok surface treatment that has shown great bone and soft tissue attachment, but with the reverse buttress thread design, they have amazing initial stability. When I looked at the full line of prosthetic products such as the ability to make hybrid abutments on titanium bases, stock esthetic abutments, and screw retained crowns, it was a no-brainer for me. As technology continues to advance, I’m looking forward to even more options for my patients and my practice. IP

Figure 2: Shaded hybrid abutment sealed with composite

Figure 5: Treatment planning using the Carestream 8100

Figure 3: Layered zirconia crown from ProSmiles Dental Studio

Figure 4: Surgical guide treatment planning and fabrication using Implant Concierge

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.

Figure 6: Cross-sectional planning on the Carestream 8100 44 Implant practice

Volume 9 Number 2

no more

compromises

The Tapered Internal family of dental implants provides excellent primary stability, maximum bone maintenance and soft tissue attachment for predictable results. All implant diameters from 3.0 to 5.8 can be placed with the same instrument kit providing you surgical convenience and flexibility to choose the ideal implants for each patientâ&#x20AC;&#x2122;s needs. With all these features, you no longer have to accept the clinical compromises that come with other implant systems.

restorative ease

universal surgical kit

45Â° conical internal hex connection creates a robust, biologic seal and is color-coded for quick identification and component matching

intuitive color-coded instrumentation used to place all BioHorizons tapered implants*

connective tissue attachment Laser-Lok uniquely creates a physical connective tissue attachment and biologic seal

bone attachment Laser-LokÂŽ microchannels achieve superior osseointegration

For more information, contact BioHorizons Customer Care: 888.246.8338 or shop online at www.biohorizons.com

Made in the USA

*Tapered Plus, Tapered Tissue Level, Tapered Internal and Tapered 3.0 SPMP13154 REV E MAY 2015

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT Zimmer Biomet’s dental division unveils new 3.1 mmD Eztetic™ dental implant Zimmer Biomet’s dental division has announced its new 3.1 mmD Eztetic™ Implant, manufactured by Zimmer Dental, and accompanying surgical and restorative components, offering a strong, esthetic solution for narrow anterior sites. The 3.1mmD Eztetic Implant is designed to offer improvements over similar commercially available implants, particularly in the areas of strength and primary stability. When compared to select competitive implants of similar diameters, the Eztetic Implant achieved a 43% higher fatigue strength.1 In addition, the implant performed exceptionally well in insertion torque and torsional yield strength testing.1 For the first time, three concepts have been combined to create a precise implant-abutment connection designed to reduce micromovement and microleakage. This unique connection consists of a conical interface, platform switch, and Double Friction-Fit™ technology designed to make strong narrowdiameter implants indicated for all anterior areas. The Eztetic implant-abutment connection, along with a Contour Abutment profile, is designed to provide space for soft tissue and esthetic emergence of the restoration. In addition, a wide range of userfriendly restorative options are available, including abutments for cement-retained, custom, and overdenture restoration. For more information, visit www.zimmerdental.com/eztetic. 1. Data on file

Expanding digital dentistry capabilities and options available through Henry Schein’s ConnectDental® Henry Schein®, Inc., will offer BruxZir® NOW milling blocks, which enable practitioners to offer patients high-strength, authentic BruxZir Solid Zirconia restorations in one visit. BruxZir NOW milling blocks produce restorations that can be designed and fabricated in-office, and are available in 14 shades that correspond to the VITA® Classical shade system. According to Prismatik Dentalcraft, Inc., a wholly owned subsidiary of Glidewell Laboratories, finished BruxZir NOW crowns feature flexural strengths of greater than 800 Mpa. BruxZir NOW, combined with the TS150™ Chairside Milling Solution from IOS Technologies, Inc., a wholly owned subsidiary of Glidewell Laboratories, also offered through Henry Schein, provides practitioners with the ability to deliver in-office one-visit crown services to their patients. Henry Schein also offers the BruxZir NOW blocks to dental laboratories to provide technicians with a zirconia restoration that requires less processing time. Practitioners interested in BruxZir NOW can also call Henry Schein Dental at 1-800-645-6594, or visit www.henryschein.com.

46 Implant practice

Sani-Soak Ultra from Enzyme Industries Sani-Soak Ultra is an anticorrosive enzymatic cleaner that can be used as an ultrasonic cleaner and/or an evacuation system cleaner. Sani-Soak Ultra is designed to brighten and extend the life of instruments, is nontoxic, and is safe to use on burs and instruments. It is available in Cool Mint or Lemongrass Lavender scent. Sani-Soak Ultra is available in a quart or gallon bottle or a 64-count box of 0.5 oz uni-dose packets. The quart bottle has a built-in “tip and measure” cup, and it yields 64 gallons of cleaner. In an investigation, dental scalers and probes were heavily contaminated with organic soil prior to undergoing processing in an ultrasonic cleaner. The amount of challenge debris on instruments was far greater than what would be expected in clinical settings. After contaminated instruments were processed in an ultrasonic unit for 10 minutes, rinsed, and subsequently visually observed, it was found that Sani-Soak Ultra Enzymatic Cleaner System effectively removed the extensive dried material in >99% of soiled test samples. An entire research report on Sani-Soak UItra can be viewed at www.enzymeindustries.com/sanisoakultra/.

DENTSPLY International introduces the CELTRA® DUO zirconia-reinforced lithium silicate (ZLS) Block DENTSPLY International Inc. is offering the new CELTRA® DUO (ZLS) high-strength glass ceramic milling block. The fully crystalized CELTRA® DUO (ZLS) block contains high-glass content and features a zirconia-reinforced lithium silicate microstructure, resulting in a balance of durability, translucency, and opalescence for a beautiful natural-looking restoration. In addition, CELTRA® DUO (ZLS) is the only material that can be processed in two different ways, providing the clinician complete control for each individual restorative case. CELTRA® DUO is a threefold functional zirconia-reinforced lithium silicate (ZLS) block indicated for single unit restorations, including crowns, inlays, onlays, and veneers. The blocks possess the unique capacity to be processed in two ways — either milled and polished, or milled and fired. This dual pathway component renders complete clinician control in determining the appropriate solution to apply for each individual restorative case. Moreover, CELTRA® DUO (ZLS) can be processed by dry fire, eliminating the need for glaze. The ZLS microstructure is composed of fine-grained lithium crystallites that contain high-glass content and an exceptional balance of opalescence, fluorescence, and translucency, resulting in a natural-looking yet exquisite restoration. Additionally, the 10% zirconia reinforces the glass matrix without clouding while yielding high flexural strength properties to provide a robust, easily polished block with detailed margins. CELTRA® DUO (ZLS) can be conveniently utilized with the same milling units used for all-ceramic restorations, including the inLab® MC XL. For additional information, or to place an order, visit www. dentsplyceltra.com, or call 855-7-CELTRA.

Volume 9 Number 2

Implant 601 Guided Implant Surgery June 17, 2016 705 Columbus St. Rapid City, SD

Implant 501 Full Arch Immediate Load and Restorative Solutions June 18, 2016 705 Columbus St. Rapid City, SD

With today’s technology we can not only virtually plan the perfect case but now can deliver the perfect placement through the use of a surgical guide. Learn how to go from consultation to fully guided surgery in as little as 4 days. This course features cone beam CT, digital impression scanners, treatment planning software, guide design and surgical protocol. It sounds easy, that’s because it is and I will show you how from start to finish.

This course is about the all on 4 technique and beyond. We will show you how to treatment plan, set fees, billing, surgical protocol as well as the denture conversion. Past doctors that have taken this course have seen some of the biggest increases in revenue from incorporation teeth express.

8 hours ADA/AGD CE credits • $1125.00 • Lunch provided • e-mail Justin: justin@ justinmoodydds.com, Kendra: kendra@justinmoodydds.com or call 888-484-0355

8 hours ADA/AGD CE credits • $1125.00 • Lunch provided • e-mail Justin: justin@ justinmoodydds.com, Kendra: kendra@justinmoodydds.com or call 888-484-0355 South Dakota Dental Implant Center (SDDIC) is an ADA CERP provider. CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/goto/cerp. Approval Term: 5/1/2015 through 6/30/2019 South Dakota Dental Implant Center (SDDIC) is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 4-1-2015 to 3-31-2019. Provider #: 342679

a higher standard

Locally owned and operated for all your full arch zirconia needs

10-year warranty



109 New York St. Rapid city, SD 57701



(605) 791-0652



prosmilesdentalstudio.com

INDUSTRY NEWS ZEST Anchors expands dental portfolio with acquisition of Danville Materials

Misch International Implant Institute and Glidewell Laboratories announce educational partnership

ZEST Anchors, Inc., a global leader in the design and manufacturing of overdenture attachments, announced the acquisition of Danville Materials, LLC, a leading manufacturer of restorative consumables and small equipment for the dental market from Inverness Graham Investments. ZEST is a portfolio company of Avista Capital Partners, a leading private equity firm. “For more than 40 years, ZEST has been a global leader and pioneer of overdenture treatment technologies focused on improving the lives of edentulous patients, including the market leading LOCATOR® Attachment System,” said Steve Schiess, ZEST’s CEO. “The acquisition of Danville will enable ZEST to expand its broad range of treatment solutions to patients caring for their natural teeth, as well. Danville’s high-quality line of dental consumables, market leading micro-etching and air abrasion products, and unique offerings, including Perioscopy, will strongly complement the clinical solutions available at ZEST today.”

The Misch International Implant Institute and Glidewell Laboratories announced a partnership in continuing education that will introduce the Hahn™ Tapered Implant as the exclusive dental implant system used in the institute’s courses. As part of this collaboration, the Misch Institute will relocate its West Coast programs to the Glidewell International Technology Center in Newport Beach, California. For more information on Misch International Implant Institute course offerings, visit http://www.misch.com, or call 248-6423199. Additional information on the Hahn Tapered Implant can be found by visiting http://www.hahnimplant.com or calling 800-407-3379.

Darby Dental Supply announces national service agreement with Dental Fix Rx Darby Dental Supply, LLC, all-telesales distributor of dental products, recently formed a partnership with Dental Fix Rx, to bring dental equipment service and repair to their customers. “We have listened closely to our customers as they discussed their business needs,” reported Scott Walsh, Vice President of Sales at Darby Dental Supply. “Partnering with expert technicians at Dental Fix RX provides the services that our customers want and need, while allowing us to continue to offer products at more competitive pricing without carrying the fixed expense of an in-house team of service technicians.” David Lopez, CEO for Dental Fix Rx, a nationwide company with 200+ franchises specializing in the repair and installation of dental equipment added, “Customer service is one of the key factors in Dental Fix Rx’s success. Darby is a very customer-centric organization, and we see a lot of synergies here that will help both businesses grow in this changing economy.” For more information about all Darby services and products, visit www.darby.com. For more information about Dental Fix Rx franchises and services, visit www.dentalfixrx.com.

Merger of leading U.S. dental lab solution providers Digital Dental Lab, based in Laguna Hills, California, and Dental Laboratory Milling Supplies, based in Scottsdale, Arizona, have merged in order to offer a comprehensive suite of CAD/ CAM solutions for digital dentistry. The merger brings together the leading brands of Crystal® zirconia, Dental Mill machines, and SinterMax ovens. The new combined company will be known as Digital Dental and will be headquartered in Scottsdale. The companies develop advanced technologies and materials, which enable dental labs to use computer-aided design to create stronger and higher quality dental restorations (crowns, bridges, and dentures). The newly combined company is the only American-made provider of materials and milling machines in the dental lab industry. The combined company also includes a “Center for Excellence” advanced dental milling research and training laboratory in Scottsdale. For more information, visit http://www.digitaldentallab.com/

Share your good (implant) news! Submit your press release for consideration to managing editor Mali Schantz-Feld via email at Mali@medmarkaz.com.

48 Implant practice

Volume 9 Number 2

Save Time and Money by the Bundle NEW!!

& $ 425* Bundle includes u Hahn™ Tapered Implant u Hahn™ Tapered Implant Titanium Healing Abutment and Impression Coping or Scanning Abutment u Choose from a BruxZir ® Solid Zirconia Crown with Inclusive® Custom Implant Abutment or BruxZir Screw-Retained Implant Crown

BruxZir Solid Zirconia, the world’s most prescribed zirconia restoration, now comes as a complete tooth replacement solution. For about the same price as a crown and custom abutment, everything needed to replace a missing tooth is included. The bundle provides convenience and predictable treatment costs, and reduces the need to keep a supply of implants and prosthetic components on hand. not include shipping or applicable taxes. Inclusive is a registered trademark of Glidewell Laboratories. *Price does Hahn Tapered Implant is a trademark of Prismatik Dentalcraft, Inc. Price is valid only in the U.S.

For more information

877-708-7972

www.glidewelldental.com

Hahn implants and components are manufactured in our Irvine, California, facility.

3034532_1.0 ECO #3034511

Introducing TM

simply the smarter case approach

This new versatile system enables you to easily tailor case treatment and coordinate with restorative partners. Simply pair a mount-free implant with one of the treatment-specific prosthetic SMART PACKS. Both the implant and SMART PACK include the necessary components for that treatment phase – which means you not only know treatment costs upfront but can also practice more efficiently. Choose the smarter case approach. TAKE BACK YOUR TIME Order by case, not component so you can focus on the dentistry

ELIMINATE SURPRISES Know your costs upfront by having all the components – the right components – at the start

AVOID CONFUSION Have all your components conveniently in one place for easy team communication & coordination

Legacy™ Internal Hex Connection Compatible with Zimmer, BioHorizons®, MIS®1

SMART PACK Mount-free Implant

InterActive™ 12° Conical Hex Connection Compatible with NobelActive™1

Start transforming your practice. Call to ask about the special INTRO OFFER!

RePlant® & ReActive® Internal Tri-Lobe Connection Compatible with NobelReplace™

simply crown & bridge

simply fixed

simply removable

simply digital

simply à la carte

www.implantdirect.com | 888-649-6425 1 Some limitations apply. Call for details. Promotion valid for new customers only, limited to single use and cannot be combined with other offers. Expires June 30, 2016. All trademarks are property of their respective companies.