Implant Practice US October-November 2016 Vol 9 No 5 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

Full-mouth rehabilitation with implant-supported prostheses Drs. Vasileios Soumpasis, Stuart Kilner, Rajesh Vijayanarayanan, and Paul Coulthard

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October/November 2016 – Vol 9 No 5

Are short implants an acceptable alternative to sinus floor elevation in the posterior maxilla? Dr. Johan Hartshorne

Practice profile Dr. Jase Hackney

The use of Isolite® and Osstell to enhance implant placement: a case study Dr. Charles D. Schlesinger *Learn more about the InterActive™ System on back cover www.implantdirect.com 888-649-6425

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INTRODUCTION

Implant procedures — overcoming the fear

was honored to be asked to write this introduction for Implant Practice US. Initially, I thought about all of the aspects of implant dentistry that excite me — cone beam applications in diagnosis and treatment planning and their role in fabricating surgical guides. Then there’s the truly amazing use of platelet rich fibrin (PRF) in wound healing and in surgical applications, with the added bonus of being cost-effective for the patient. I could speak at length about the benefits of CO2 lasers and how I use them in implant surgeries. Yes, there are many technical subjects that are fascinating and topical, but I had this voice in the back of my head telling me to write about something else. Why is it that, with so much technology to assist us in making diagnosis easier and treatment planning more customized, there is so much FEAR on the part of many practitioners to take that first step and place implants? I have spoken to dentists over the last 16 years, both here and abroad, and have come to some conclusions concerning this. The first fear is fear of failure. This is understandable as no one likes to see anything fail in dentistry. Yet we see fractured crowns, failed endodontic procedures, failed bridges, collapsed orthodontic cases, and teeth lost after periodontal treatment is completed. Despite our best efforts, there will be failures in everything that we do. Yet we don’t stop providing those services because the successes are far more numerous than the failures. Our goal should be to provide the most beneficial treatment for our patients, and if something doesn’t work, we can try again or provide alternative solutions. Implants provide our patients with the best tooth replacement solution in the majority of cases, so we should always be willing to make them part of the discussion. The success rate for implants exceed that of traditional bridges over the long term. I urge dentists to consider an implant just as they would a bridge — don’t fear it; look forward to it! Your patients will thank you for offering them such a great solution. The second fear is the fear of our colleagues. Why should we fear criticism from our fellow professionals whether they are our local study club pals or the local specialists whom we refer to? Why is it, that in our culture, we are more likely to negatively critique the work of other dentists rather than support them and their efforts in providing care to their patients? In my experiences in over 38 years of practicing dentistry, I would estimate 95% of all dentists are good, ethical, conscientious, and caring, though they may have different skill levels. We each start at varying levels of confidence and experience, and we each grow throughout our careers. We change our procedures and methods as new techniques are developed, but we each do this at our own pace. I feel strongly that it doesn’t serve anyone’s best interest, be it a patient or a fellow practitioner, to criticize unconstructively. If you see a situation that you feel needs attention, then talk sincerely to the patient about a solution or talk to the previous dentist so that he/she may solve the problem for the patient. If a dentist of any caliber promotes discord between a patient and another doctor, then he is in the wrong for doing so. We can solve almost any problem if we work together. Dentistry is a great profession filled with great people. Perhaps you feel that your skills are better than other dentists’ skills. Rather than criticizing them, why not consider mentoring them? There is always a need for good teachers, mentors, and clinicians to help the new graduates and newly rejuvenated doctors who are trying to raise their skills. There are many different ways to place and restore implants, and they all work. There are hundreds of implants on the market today, and they all work. Every dentist who wishes to participate in implant dentistry should be encouraged, mentored, and given room to develop. If you’re already proficient at placing implants, how about helping another dentist learn this valuable skill? We all benefit when our profession is represented by people who refuse to sow discord and who generously share their talents. That’s how we’ll get rid of fear in dentistry. Jon M. Julian, DDS, received his Doctor of Dental Science degree from the University of Missouri at Kansas City Dental School in 1978 after doing his undergraduate work at the University of Kansas. He lived and practiced dentistry in McPherson, Kansas, from 1978-2011 when he relocated to South Carolina to open his new practice — The Dental Retreat at Mountain Park — in December of 2011. The facility not only houses his growing dental practice, but it is also where Dr. Julian holds a majority of his very popular Over the Shoulder/Hands-On Implant Courses.

2 Implant practice

October/November 2016 - Volume 9 Number 5

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 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 5

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TABLE OF CONTENTS

Corporate spotlight Zimmer Biomet Institutes Revolutionary learning facilities .......................................................16

Practice profile Jase Hackney, DMD, MICOI, FAAIP Making magical moments with implants

Clinical The use of IsoliteÂŽ and Osstell to enhance implant placement: a case study

Financial focus Is your 401(k) plan a ticking time bomb of personal and professional liability? Tom Zgainer discusses how small business owners may be overlooking a significant source of liability in their practices: their 401(k) plans

14 4 Implant practice

Dr. Charles D. Schlesinger discusses certain technologies to facilitate faster, more predictable treatment..............18

A conversation with... Goal of a lifetime Professor Niklaus P. Lang discusses the struggles of peri-implantitis, research surrounding biomaterials, and treatment protocols.........................22

Volume 9 Number 5

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TABLE OF CONTENTS

Continuing education Are short implants an acceptable alternative to sinus floor elevation in the posterior maxilla?

Continuing education

Full-mouth rehabilitation with implant-supported prostheses

Drs. Vasileios Soumpasis, Stuart Kilner, Rajesh Vijayanarayanan, and Paul Coulthard discuss the treatment of a patient in need of extensive restoration

Dr. Johan Hartshorne gives a critical appraisal of a systematic review into the evidence for avoiding longer implants in situations where augmentation techniques may be required......................................31

Technology Choosing the right implant impression material Dr. Matt Croley discusses adaptable impression materials.....................36

Practice development

Implant insights Problem solving In the second part of his series, Dr. Diyari Abdah discusses some very common implant problems and presents some ways to avoid them

.................................................42

Is your website really working? Ian McNickle, MBA, discusses how to convert website visitors into new patients......................................38

Three traits of successful implant treatment coordinators Charles Banh discusses how to increase implant potential with an implant treatment coordinator

.................................................40

On the horizon You can’t forget about the tissue Dr. Justin Moody discusses the importance of soft tissue evaluation

................................................. 44

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

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com GENERAL MANAGER | Alan Lobock Email: alobock@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com | Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez Email: celeste@medmarkaz.com MANAGER – CLIENT SERVICES | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkaz.com WEBSITE MANAGER | Anne Watson-Barber Email: anne@medmarkaz.com E-MEDIA PROJECT COORDINATOR | Michelle Kang Email: michellekang@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) $129 | 3 years (18 issues) $319

6 Implant practice

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PRACTICE PROFILE

Jase Hackney, DMD, MICOI, FAAIP Making magical moments with implants

Dr. Hackney in the on-site lab

What can you tell us about your background? I love practicing in Tampa — I grew up in Bradenton, not far from where I’m located today. I earned my undergraduate degree from the University of Florida and stayed in Gainesville to attend dental school, where I earned my Doctor of Dental Medicine in 2001. I served as an associate at two private practices located in North Port and Sarasota before coming to Tampa to buy my own practice in 2004. I chose to affiliate with Affordable Dentures & Implants® in 2007 and have been here ever since.

When did you become a specialist, and why? I had minimal exposure to implants while studying at the University of Florida College of Dentistry. My passion for performing surgery grew; and as an early career associate, if patients needing extractions walked through the door, I made sure to help them. 8 Implant practice

Dr. Hackney with dental assistant and Carestream CS 8100 cone beam imaging system Volume 9 Number 5

Is your practice limited solely to implants, or do you practice other types of dentistry? Like our name suggests, we also offer dentures, extractions, partials, and more. We can place implant crowns, implant bridges as well as administer basic bone grafting and crestal sinus lifts. My goal is to provide a range of tooth replacement solutions because every patient is unique.

Why did you decide to focus on implant dentistry? My staff and I educate every single patient on the benefits of implants. We see

every day the measurable improvement in an implant patient’s quality of life. It motivates me just seeing them realize in that moment how implants have changed their lives for the better.

Do your patients come through referrals? My practice has operated for almost a decade, so many implant patients do come in as referrals. I have also found that patients today often are implant savvy — they come in having done some research into the procedures and understand the lifelong benefits.

How long have you been practicing implant dentistry, and what systems do you use? My full leap into operating an implant practice began in 2011, and every year gets more exciting thanks in part to technological advancements. I now have 10 operatories and purchased a Carestream CS 8100 cone beam imaging system, which has helped advance my practice tremendously. While I don’t perform a lot of guided surgeries, being able to unlock that 3D view is paramount in treatment planning implant placement. And my patients love it too.

My favorite feature of the practice, though, is our in-house dental lab. It is a tremendous advantage for patients to not have to wait for an outside lab, and for me to directly interact with the lab technicians and follow my cases. Actually, our lab staff loves being able to speak directly with patients, too — it’s rewarding for them to see their hard work pay off. We recently invested in technology from Ivoclar Vivadent to offer the Ultimate Denture, made using high-pressure injection. Most patients are electing to pair their implants with this denture style since it provides such an accurate and precise fit. It’s really remarkable.

What training have you undertaken? I took an 8-month Implant Educators course through the University of Florida College of Dentistry and earned my fellowship in the International Congress of Oral Implantology. I was later able to pursue and earn a mastership in the same organization after attending Live Implant Training with Dr. Virgil Mongalo. There is a tremendous confidence benefit to exercising with live cases under instructor supervision. I also hold a fellowship with the American Academy of Implant Prostho-

Dr. Hackney and the Affordable Dentures & Implants team Volume 9 Number 5

Implant practice 9

PRACTICE PROFILE

I was able to nurture that passion even further once I began practicing at Affordable Dentures & Implants, due to the sheer volume of patients who needed extractions and tooth replacement. My interest in implants started growing around that same time because I saw how many of my patients struggled with their dentures, especially their lower denture. I spent several years placing mini dental implants and eventually progressed to traditional root-form implant placements several years ago. Now I’m doing what I love to do — helping implant patients every day.

PRACTICE PROFILE dontics, and completed the BioHorizons® TeethXpress® course under Dr. Justin Moody, another great mentor of mine. Dr. Moody also facilitates a wonderful implant study club, where practitioners can offer peer review and continue advancing their clinical skills.

Who has inspired you? Dr. Andy Burton, who owns and operates Affordable Dentures & Implants in Nashville, Tennessee, is a great inspiration whom I am fortunate to call a friend and colleague. Drs. Mongalo and Moody helped inspire me to build a successful implant practice, as did Jim Perry of Affordable Care. Dr. Michael Tischler has also given great advice on workflow improvement and is doing fascinating work within the world of full-arch zirconia prosthetics.

What is the most satisfying aspect of your practice? For me, it’s all about the patient who hasn’t smiled in 20 years. To get that person to smile again is a magical moment. Tying implants into that experience makes it even more rewarding since the prosthetic doesn’t move. And when our lab delivers an esthetically gorgeous overdenture, the patient looks like a million bucks. I wouldn’t trade that for the world.

Professionally, what are you most proud of? My practice grows by the month in implant volume, and so much of that is due to my staff. They’re kind, relatable, and know

Dr. Hackney adjusting a custom impression tray

how to balance the important educational message of implants with a sense of respect for the person sitting in the chair.

What do you think is unique about your practice? I am big on patient service, so that is a big focus for our whole team. The staff and on-site lab technicians share my vision for the patient experience — that they walk out with a beautiful new smile they love in a timely manner.

We don’t make false promises to the patient. We do what we say we’re going to do. That’s a matter of loyalty to the patients who have chosen us to help them make this monumental change in their lives. If a patient comes in with an issue with their prosthetic — even if it’s well past the 12-month service period — we’re going to take care of it for them.

What has been your biggest challenge? It’s not easy to make every patient happy. Some patients have trouble adapting to dentures. So I try to present a range of solutions and advise patience.

What would you have been if you didn’t become a dentist? You know, it’s funny — I would probably be fixing up old houses or automobiles. Having tools in hand and rolling my sleeves up aren’t so different from implant dentistry in some ways.

What is the future of implants and dentistry?

Dr. Hackney with Lab Technician William Bolivar 10 Implant practice

More than 180 million Americans are missing one or more teeth. It’s staggering. So I see implant services growing and becoming a realistic solution for more people. I’m able to keep my implant fees affordable because of the investment in the lab and pass that cost-saving advantage down to my patients. Volume 9 Number 5

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PRACTICE PROFILE

Dr. Hackney at a Tampa Bay Buccaneers football game with his wife, Nicole

Dr. Hackney with his daughter Lily, wife Nicole, and son Fletcher

Top 10 favorites 1. 2. 3. 4. 5. 6.

My wife and kids Taking 3D scans on my Carestream CS 8100 Skiing My A. Titan balloon for intracrestal sinus lifts Inshore fishing BioHorizons® tapered internal implants, ball abutments, and housings 7. ZEST Anchors® LOCATOR® system 8. ProSmiles Dental Studio in South Dakota for fixed single tooth crowns 9. My new Ultimate Denture 10. Tampa Bay Buccaneers football — go Bucs!

You’re going to see more treatment avenues open up, especially those that don’t harm virgin teeth like bridges. Implants are predictable, long-term treatment options — and patients already recognize it.

What are your top tips for maintaining a successful specialty practice? There’s nothing more valuable than hiring great staff — and keeping them happy. We have staff dinner outings and a quarterly bonus program based on implant volume. It comes back to sharing that vision for what a modern implant practice can be. Successful practices make patients happy by giving them options. Thirty years ago, edentulous patients didn’t have many choices. Today, there’s more choice than ever. Managing implant inventory is crucial. If a patient walks in and wants implants, I’m 12 Implant practice

not going to make them wait. Developing a good relationship with your implant manufacturer rep is key. I choose to place BioHorizons implants, and we keep what I need properly stocked — not overstocked.

What advice would you give to a budding implant dentist?

Dr. Hackney and Lily fishing

Hands-on training is so important. Didactic training opportunities are great, but actually diving into live surgery is completely different. I have been fortunate to study under the eye of some really fantastic instructors. Try coming back from live instruction and settle on an easy case — one with lots of bone, great width, and height. Placing a single tooth system in the first upper or

lower molar is a highly predictable procedure, unlike anterior placements in the esthetic zone requiring more sensitive technique.

What are your hobbies, and what do you do in your spare time? I have children aged 2 and 4, so my hobby time is at a minimum! Still, I love to fish, hunt, and stay active in the gym or on the running trail. IP Volume 9 Number 5

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FINANCIAL FOCUS

Is your 401(k) plan a ticking time bomb of personal and professional liability? Tom Zgainer discusses how small business owners may be overlooking a significant source of liability in their practices: their 401(k) plans

lass-action lawyers seeking plaintiffs are reaching out to employees in businesses of all kinds with opportunistic letters that highlight how they have been harmed by excessive fees in their 401(k) plans. These letters encourage plan participants to join lawsuits against their employers for breach of their fiduciary obligation to provide a retirement plan that is set up for the sole benefit of the employees. While you are busy running your practice and offering a 401(k) as a benefit for your team, a recent ruling by the Supreme Court has officially started the clock on this ticking time bomb. Larger employers in a variety of industries are already under attack, and many others have paid to settle such suits. Smaller companies (under 100 employees), where excessive fees are most prevalent, are now also in litigation. Employee Benefit Advisor, an industry trade publication, recently prophesied that Tom Zgainer is CEO and founder of America’s Best 401k and has helped thousands of companies repair or rescue their retirement plans over the past 15 years. You can learn more at http://americasbest401k.com/feechecker-medmark.

14 Implant practice

an “onset of 401(k) lawsuits should prompt rigorous plan evaluations.” The 401(k) is a great piece of tax code, but the problem lies in the method by which 401(k) plans are sold — and the surprising number of hands in the retirement plan pie. Over the past 3 decades, 401(k) plan providers have been making big money through hidden or opaque fee arrangements. In fact, it took a full 30 years before the industry was required to disclose just how much they make on your plan! Only since 2012 are they now required to produce a fee disclosure document (known as a 408b2), that plan sponsors are required to review, articulate, and take action if necessary, yet the actual fees are often buried in fine print. This is why over 60% of Americans think they pay no 401(k) fees when nothing could

be further from the truth. So just how do plan providers make their money? Primarily by taking a cut of the fees charged by the mutual funds offered in the 401(k) plans they sell. And those fees directly subtract from your returns. Or if that’s not enough to wet their beaks, they layer on additional fees such as “asset management charges” or “contact asset charges.” And so we have a business model where nearly all the major plan providers are conflicted. They choose funds for your plan that charge hefty fees so that there is plenty to go around (or worse, they just sell you their own name-brand funds, which are more profitable for them). Did you think the funds were chosen because they were the best performing? Think again. They were probably chosen because the fund company will “pay to play”— which is why superior-performing, low-cost index funds tend to be a rarity in 401(k) plans. But it doesn’t stop there. The broker who sold the plan wants his cut. So he too will receive commissions from the funds or simply layer on additional fees. And let’s not forget the third-party administrator. They typically charge a fee directly to the employer, Volume 9 Number 5

Do fees really matter? Although the fees your plan charges might sound like small percentages, they have a massive impact over time. Fees subtract directly from your returns. John Bogle, founder of Vanguard, says that costs can cut returns by 66% over the course of our saving years. Said another way, simply controlling costs could double your future nest egg in size. The Department of Labor (DOL) says that hidden fees and backdoor payments in retirement plans are costing Americans over $17 billion annually. The head of the DOL, Secretary Thomas Perez, rightly stated, “The corrosive power of fine print and buried fees can eat away like a chronic illness at a person’s savings.”

It’s your problem At first glance, you might be thinking these issues and conflicts should be the

liability of the provider. After all, they sold you the plan. But ERISA rules make you, the employer, the fiduciary to the plan and to your employees. As the plan sponsor, it’s your job to make sure the plan is set up for the sole benefit of the employees. It’s your job to review and periodically benchmark your plan against other options. For many employers, this is alarming news, as running a business is already challenging enough. So where do you go from here? There are five key steps we advise all plan sponsors to take: 1. Benchmark your plan to determine how it compares to alternatives. A periodic benchmark is required by the DOL anyway, so it’s an exercise that can reap great rewards while also taking care of your duty as a plan sponsor. Beware that if you use a broker to do this, they will typically show other similar plan options where they will also make big commissions. As Warren Buffet says, “Never ask a barber if you need a haircut.” 2. Eliminate layers of fees wherever possible. The first and easiest way is to eliminate the use of a broker who is paid by commission. Brokers typically add little ongoing value short of

Costs can cut returns by 66% over the course of our saving years. Said another way, simply controlling costs could double your future nest egg in size.

bringing donuts to your office twice a year to keep everyone happy. Many employers were sold their plans by brokers who may also be personal friends. Breaking up is hard to do, but a personal relationship is not a defensible position with the Department of Labor. 3. Remove conflicts of interest. If you are using a plan where the provider is being paid by the mutual funds in the plan, they have an inherent bias to select more expensive funds or sell you their own name-brand proprietary funds. This is nearly always the case with plans offered by insurance companies, payroll companies, or mutual fund companies. You can simply ask your provider if they are “revenue sharing” with the mutual funds they offer. 4. Install a third-party fiduciary on your behalf. This is known as a 3(38) fiduciary, who will take over nearly all of the responsibilities and much of the liability of the plan sponsor. Their job is to make sure that the plan is continually operated in the best interests of the plan participants. This is a best practice adopted at many Fortune 500 companies but is rarely seen in small to midsize plans. 5. Look for a plan that has access to the lowest-cost index funds. Index funds consistently outperform nearly all actively managed mutual funds over the long term. One note of caution: Many providers don’t make money off these funds due to their rock-bottom fees, so they sometimes charge additional layers of fees, or they will say your plan isn’t big enough to qualify. Nonsense! Every 401(k) participant in America should have access to the same low-cost funds regardless of the balance in his/her company’s 401(k) plan. The 401(k) is an amazing retirement solution when there is alignment between the provider and the saver. It’s time that Americans wake up and take back their retirement plans from the providers that have been milking them for every dime they can get. It’s time for business owners to feel proud of the plans they offer, knowing that they will give themselves and their employees the absolute best chance at a successful retirement. IP

Check to see how your 401(k) plan compares to industry averages here: http://americasbest401k.com/fee-checker-medmark. Volume 9 Number 5

Implant practice 15

FINANCIAL FOCUS

but many will also accept a portion of the mutual fund fees. This often buys their loyalty to specific providers. The net result is an industry with layers upon layers of incestuous relationships that funnel excessive fees from your plan and puts numerous conflicts of interest in play — hence the lawsuits.

CORPORATE SPOTLIGHT

Zimmer Biomet Institutes Revolutionary learning facilities

quipped with the latest tools and advancements in implant and reconstructive dentistry as well as state-of-the-art audio and visual equipment, the newly renovated Zimmer Biomet Institute (ZBI) in Carlsbad, California, transforms the traditional classroom into a revolutionary learning facility. The Institute’s Simulated Patient Training Laboratory allows clinicians to practice real-life case scenarios, in their entirety, on one-of-a-kind, proprietary simulation patients. All Zimmer Biomet Institute courses and curriculums are developed and taught by either university-based faculties or worldclass educators; and while all courses meet standard objectives, every course taught at a ZBI is unique to the hosting faculty. Dental clinicians from around the world share their knowledge of scientific educational courses in restorative, surgical, and regenerative procedures. The Carlsbad facility features a newly enhanced 20,000-square-foot dental training center that houses a simulation lab, lecture room with live-streaming capabilities, a locker room with showers, café, and a tranquil outside seating area. Courses offered include case study reviews and simulation workshops (on lifelike mannequins). This provides optimal hands-on experience and support to clinicians as they strive to refine their clinical skills. “Having taught at all the Zimmer Biomet Institutes for the past 8 years, the new Institute surpassed all my expectations,” said renowned speaker and educator Monish

The SimLab is equipped with proprietary mannequins that are anatomically correct with realistic bone matrix, soft tissue, periodontal ligaments, live sinuses, and live nerves.

Bhola, DDS, MSD. “I can confidently say that the facility, the advanced surgical and restorative mannequins, and the advanced hands-on training, coupled with a worldclass support staff, offer the practitioner an experience unlike any other in the world. The opening of the new Carlsbad facility comes just on the heels of February’s reopening of the revamped Zimmer Biomet Institute in Parsippany, New Jersey. “Opening not one but two enhanced training centers this year shows our ongoing commitment

to providing increased and diversified opportunities for professional training,” said Ken Varner, the Director of Institutes for the dental division. Zimmer Biomet Institutes around the world host courses that range from basic restorative programs for clinicians who restore fewer than five implant cases each year to advanced cadaveric workshops designed for clinicians who are actively placing and restoring implants. There are also courses developed specifically for laboratory professionals. Additional Zimmer Biomet Institute locations are Bogotá, Columbia; Winterthur, Switzerland; and the global headquarters in Palm Beach Gardens, Florida. IP This information was provided by Zimmer Biomet. All references contained herein to Zimmer Biomet Dental refer to the Zimmer Biomet Dental Division.

Fast facts about Zimmer Biomet Institute, Carlsbad, California • • • • • • • • •

Dental training facility for clinicians and laboratory technicians Completely renovated, 20,000-sqaure-foot facility Will host 35 courses annually Inaugural course was a Digital Dentistry course for laboratory technicians held on August 19-20, 2016 Simulated patient training laboratory (SimLab) State-of-the-art lecture room equipped with live-streaming capabilities Café with 40-foot ceilings Locker room with showers Courses can be viewed at zimmerbiometdental.com/education

16 Implant practice

New Carlsbad facility expands education opportunities for the Pacific region Volume 9 Number 5

Accelerate your progress through innovative education. Powered by knowledge.

With a robust curriculum developed and taught by top innovators in

ZIMMER BIOMET INSTITUTE EAST • Parsippany, NJ New York, Metropolitan Area

ZIMMER BIOMET INSTITUTE EUROPE • Winterthur, Switzerland

dentistry, the Zimmer Biomet Institute is focused on bringing current and emerging dental procedures to you, your patients and your practice. From our Simulated Patient Training Laboratory and specialty courses in

ZIMMER BIOMET INSTITUTE SOUTH • Palm Beach Gardens, FL

ZIMMER BIOMET INSTITUTE WEST • Carlsbad, CA

implant and reconstructive dentistry to didactic seminars and hands-on training, the Zimmer Biomet Institute continues to transform modern dentistry. Call 1-800-342-5454 or 1-561-776-6700 to Learn. Do. Excel.® ZIMMER BIOMET INSTITUTE COLOMBIA • Bogotá, Colombia

To accelerate your progress, please schedule your next course at zimmerbiometdental.com/education All trademarks herein are the property of Zimmer Biomet or its affiliates unless otherwise indicated. Due to regulatory requirements, Zimmer Biomet’s dental division will continue to manufacture products under Zimmer Dental Inc. and Biomet 3i, LLC respectively until further notice. AD072 Rev. B 09/16. ©2016 Zimmer Biomet, All rights reserved.

ZIMMER BIOMET INSTITUTE CHINA • Shanghai, China

CLINICAL

The use of Isolite® and Osstell to enhance implant placement: a case study Dr. Charles D. Schlesinger discusses certain technologies to facilitate faster, more predictable treatment Introduction Implant treatment that results in the patient walking out within an hour with temporary teeth is a huge practice builder. Patients today are looking for immediate gratification and have read or heard about teeth in a day. In order to safely and predictably perform this type of service for your patients, you must have the correct armamentarium to facilitate rapid, safe, and accurate treatment.

Case report A 57-year-old female missing teeth Nos. 18 and 19 with a history of osteoporosis presented to the office. Currently, she was not taking any medications, yet had been on Fosamax for 1 week before discontinuing it due to GI distress. All other medical history was without issue.

Upon her intraoral exam, it was noted that tooth No. 14 had supra-erupted approximately 1 mm due to the missing opposing dentition. Enameloplasty would be carried out at the time of implant placement to create enough intra-arch space for the abutment and final restoration. A CBCT and panoramic radiograph (Vatech America) were taken (Figure 1) and the sites evaluated for treatment (Figure 2). Using the bone density function (Hounsfield units) in the native Vatech software (Figure 3), it was determined that the patient’s previous diagnosis of osteoporosis could be a factor. The use of CBCT density information is a great predictor of implant site bone density.1 After infiltrate anesthesia with 4% Septocaine® (Septodont) of the soft tissue in the area of tooth Nos. 18 and 19, an Isolite® (Isolite® Systems) was placed into

the patient’s mouth. The use of this device provides not only many benefits during restorative dentistry, but also huge advantages during implant surgery especially with the introduction of a sterile mouthpiece. Since we work with very small instruments such as drivers and very small components, an Isolite (Figure 4) with its ability to protect the trachea and esophagus — along with providing dual suction, a mouth prop, and very bright LED illumination — helps alleviate many of the dangers and potential issues we run into in implantology. The isolation and illumination make implant surgery much faster, as the tongue and fluids are no longer issues. Initial positioning of the osteotomy was carried out using a No. 8 round bur on a high-speed handpiece (Figure 5). Since I was planning to place two 5.0 mm diameter

Figure 2: Treatment planning on CBCT

Figure 3: Bone density determination

Figure 1: Preoperative pano

Charles Schlesinger, DDS, FICOI, is the founder and CEO of The C.D. Schlesinger Group, a dental implant consulting company. For the past 10 years, he has been an internationally renowned implant educator, teaching implantology based upon his years in private practice and his work as an implant company executive.

Figure 4: Isolite mouthpiece 18 Implant practice

Figure 5: No. 8 round bur Volume 9 Number 5

amount of keratinized tissue to allow access to the crestal bone. A punch technique was chosen in this case due to the sufficient quantity of keratinized tissue available to maintain a zone of keratinized tissue around the implant collar. If the patient had presented with insufficient tissue with the presence of unattached mucosa on the ridge, a full thickness periodontal flap would behave been elevated in order to reposition keratinized tissue to the buccal. Once this access is completed, a countersink (Figure 10) was utilized to not only allow the imbedded

tapered platform of the implant to seat passively, but also to assure the proper position of the restorative platform. The 1.8 mm pilot drill was used again to final depth, and then a 4.7 mm osteotomy former was used with an 8 mm depth stop (Figure 11) to create the final osteotomies for the implants. The unique step drill design of these osteotomy formers allows a two-step drilling protocol instead of the customary serial progression as is the case with other systems. The osteotomies were checked with a small curette to assure 360Â° bone support. TSI implants size 5.0 mm x 8 mm (OCO Biomedical) were chosen for the case. In posterior cases, my go-to implant

Figure 6: Purchase point in bone

Figure 7: 1.8 mm pilot bur to establish trajectory

Figure 8: Paralleling pins in place

Figure 9: 5 mm tissue punch

Figure 10: Countersink to establish the platform position Volume 9 Number 5

Figure 11: Final osteotomy former with stop Implant practice 19

CLINICAL

implants, the anterior implant center was positioned approximately 4.5 mm distal to the premolar (Figure 6). Once the soft tissue was penetrated and purchase point established on the crest, a 1.8 mm pilot bur was taken to a depth of 8 mm into soft tissue (Figure 7). A paralleling pin was placed, and the second access and pilot hole were drilled parallel to the first. A paralleling pin was placed to evaluate implant position and intra-implant distance (Figure 8). A guided 5 mm diameter tissue punch (Figure 9) was used to remove a specified

CLINICAL

Figure 12: TSI implant

Figure 13: Checking ISQ with an Osstell

Figure 14: Osstell reading

is the TSI (Figure 12). The dual stabilization that can be achieved will increase the chances of being able to load the implant immediately or early. The OCO implant is designed for immediate loading using Dual Stabilizationâ&#x201E;˘, an industry-unique design feature that biomechanically secures the tip and collar of the implant.2 While other implant companies boast their revolutionary surface treatments, OCO implants immediately â&#x20AC;&#x153;lockâ&#x20AC;? into the bone at placement. The tissue-level design lends itself to an easy and predictable restorative procedure and excellent crestal bone preservation. The implants were inserted and torqued into place. Neither implant attained a torque value greater than 35 N/cm upon seating. Literature shows great success and predictability in immediate loading with values greater than 40 N/cm. ISQ readings were taken with an Osstell IDX (Osstell, Gothenberg, Sweden; Columbia, Maryland). A smart peg was placed and reading taken (Figure 13). Implant No. 19 registered 70 in both the BL and MD directions and No. 18 had measurements of 75 BL and 80 MD (Figure 14). According to the literature, an ISQ of greater than 70 is an indication to immediately temporize.3 Though the seating torque 20 Implant practice

Figure 15: Solid crown and bridge abutments

was well below the minimum usually associated with enough primary stability to load early or immediately, it has been shown that ISQ is a predictable indicator of when to load or not.4 Since the Osstell quantifies the micromovement in a side-to-side manner, it is a more predictable manner to assess implant stability than torque alone.5 Since the ISQ value was as high as it was for both implants, the choice to immediately temporize was taken. Solid crown and bridge abutments of 4 mm tall were torqued into place at 30 N/cm (Figures 15 and 16) and then re-torqued after 5 minutes to accommodate for any pre-stretch of the abutment screw threads. The opposing occlusal surfaces were then reduced with a minimal amount of enameloplasty to create the proper clearance necessary for the intended restorative material.

Figure 16: Final radiograph Volume 9 Number 5

CLINICAL

Figure 17: Impression copings in place

A shade was taken, and impression copings were placed onto the implants and abutments (Figure 17). The final full arch impression was taken with VPS impression material. Light body was injected into the impression copings (Figure 18), and heavy body was extruded into the impression tray. An opposing impression was taken in alginate, and a blue-bite registration was also taken at this time. Acrylic temporaries were fabricated over acrylic copings. The copings assure a perfect margin and will prevent any soft tissue from migrating under the temporary and potentially causing an issue at the seat appointment. The temporaries were cemented with Improv® cement (Alvelogro). The restorative margins of the implants were only 1.0 mm-1.5 mm below the intended free gingival margins making cement cleanup an easy task and assured that it is complete not only at the temporary stage, but once the final crowns are delivered. The excess cement was removed and the final occlusion rechecked, and then the patient was dismissed. She will return in 1 month for delivery of her final restorations and completion of the case.

Figure 18: Impression

Conclusion This patient was able to get two implants placed and walk out with temporaries in approximately an hour. She will return to the office in approximately 2-4 weeks for the delivery of the final full contour zirconia restorations. Dentistry today is highly competitive, and the patients are highly demanding when it comes to dental treatment. Using technology such as Isolite and Osstell will make implantology safer, faster, and more predictable. The goal of any treatment is to provide dental treatment at the highest level and with the highest patient satisfaction. IP Volume 9 Number 5

Figure 19: Acrylic temporaries

REFERENCES 1. Salimov F, Tatli U, Kürkçü M, Akoğlan M, Oztunç H, Kurtoğlu C. Evaluation of relationship between preoperative bone density values derived from cone beam computed tomography and implant stability parameters: a clinical study. Clin Oral Implants Res. 2014;25(9):1016-1021. 2. Saini D. Dental Implants: Dual stabilization technology. IJBAR. 2015;6(02):196-198. 3. Kokovic V1, Jung R, Feloutzis A, Todorovic VS, Jurisic M, Hämmerle CH. Immediate vs. early loading of SLA implants in the posterior mandible: 5-year results of randomized controlled clinical trial. Clin Oral Implants Res. 2014;25(2):e114-119. 4. Schlesinger C. Torque versus RFA in implant placement. Implant Practice US. 2016;9(4):14-20. 5. Schlesinger CD. Immediately Loading Dental Implants: Doing it Right for Long-Term Success. Dent Today. 2016;35(5):84, 86-89.

Implant practice 21

A CONVERSATION WITH ...

Goal of a lifetime Professor Niklaus P. Lang discusses the struggles of peri-implantitis, research surrounding biomaterials, and treatment protocols How has the incidence of periimplantitis changed over the last 10 years? The incidence of new cases is, of course, dependent on the sales of dental implants, which have increased tremendously over the last 10 years. Consequently, we are placing more than a million implants worldwide each year, so the incidence of peri-implantitis will only increase.

What is the likelihood of the chances of an implant experiencing peri-implantitis within 10 years? Based on a systematic review, it will affect 10% of the implants and 20% of the patients — so every fifth patient will experience peri-implantitis within 10 years of their having an implant placed. This is unlikely to change unless we do something very specific regarding the maintenance of implants.

Do you have a preferred approach for the treatment of peri-implantitis? Definitely, yes: the cumulative interceptive supportive therapy (CIST) protocol. It starts as a maintenance program, and depending on the degree of pathology, additional therapies are added. This begins with mechanical debridement, then moves to antiseptic cleaning and to antibiotics, and finally to the surgical approach — which is why it is called a cumulative therapy. So we may do A; then if it’s more advanced, we will do A and B, then A, B, and C, and so on. So, you would only undertake a surgical approach once the initial phases have been completed, which are designed to eliminate the infection. Only then can you expect an optimal outcome of regenerative therapy. This whole system has been validated over the last 10 years in single studies, and there is now one prospective cohort study

that includes all of the four steps of the CIST protocol. We have randomized controlled trials of single steps of the protocols, but not all four.

What is your experience of using biomaterials as a part of the treatment process? There is an indication for using biomaterials as part of the CIST protocol. This comes once we have a disinfected area, and we would like to either level the lesions, so we can have access for cleansing in the future, or if the defect is self-contained, to regenerate it. I ask for three features from a biomaterial: The first is biocompatibility. Second, it must be osteoconductive. I don’t ask for osteoinduction because this arises from the limits of the defect; hence, in a self-contained defect, the biomaterial provides the scaffold, and this is very predictable. And the third feature is that it resorbs when it needs to but is replaced slowly. Through osteoconduction I would expect that bone would grow along with the bone graft particles and get in close contact with the implant, so there is some reosseointegration. This has been demonstrated in a study, but a moderately rough surface is required.

Based on your own experiences, what are the main causes/risk factors for peri-implantitis? There are very well-documented factors that increase the risk of peri-implantitis enormously. First: oral hygiene. A lot of people expect a lousy standard of oral hygiene and say, “Well, my patients just don’t clean better!” In my mind, if they don’t clean better, they don’t deserve high-end dentistry. The optimal level of oral hygiene, below which you can expect peri-implantitis, is not

Professor Niklaus P. Lang, DDS, MS, PhD, Dr Odont HC Mult Hon FRCPS (Glasgow), received his dental degree at the University of Berne in 1968 and his DrMedDent in 1970. After obtaining a master of science in periodontology from the University of Michigan, he returned to the University of Berne to earn his PhD in 1978. He is currently professor of implant dentistry at the University of Hong Kong in the area of oral rehabilitation. He has written numerous publications and spoken all around the world and is the former president of the International Team of Implantology (ITI). He is editor-in-chief of the journal, Clinical Oral Implants Research, and continually participates in clinical research.

22 Implant practice

known, but it’s clear that when you have only 10% of sites displaying plaque, then it’s under control. The second factor is patient compliance, not only with oral hygiene, but they must comply with the schedule of follow-up visits; the implant is, after all, a high-maintenance device, like a fancy car! Third is provision of a maintenance system. A lot of surgeons place the implant, send the bill, and that’s it! Maintenance is crucial; studies show that without maintenance, prevalence is up from 10% to 40%. A structured maintenance system, during which you perform diagnosis, looking first for peri-implant mucositis, followed by appropriate treatment, is crucial. The fourth factor is that periodontal treatment must have been completed successfully as these patients have tremendous reservoirs for pathogenic bacteria, which can jump over and feed into the peri-implant sulcus. We have shown in studies that the more residual pockets patients have, the greater the chance they have of developing peri-implantitis. The goal is to have a patient with good oral hygiene, who is compliant and who has been successfully treated for periodontitis. The final factor is that the prosthetic appliance must be cleansable and accessible to cleaning devices. If I was giving a talk on how to avoid peri-implantitis, these are the five factors that I would put my money on.

Does peri-implantitis threaten to reduce the use of dental implants as a treatment option? The answer is a philosophical one — no, but maybe it should. Volume 9 Number 5

Can you outline your own research in the area of peri-implantitis? I have worked on between 50 and 100 publications dealing with the topic, covering etiology, pathogenesis, diagnosis, and therapy of peri-implantitis. In Berne, we were the first group to look at the etiology and microbiology in 1987/1988 and have been doing so ever since. The most recent microbiological study was from 2014 and took place in Hong Kong with patients recruited from Shanghai. We were able to get people who had a healthy and diseased implant and a healthy and diseased tooth all in one mouth. It took us 3 years to recruit 27 cases. This study used the most modern microbiological diversity and molecular techniques, but peri-implantitis has been on my menu since 1986.

You recently spoke on the topic in London — what did delegates take away from this lecture? Hopefully, I conveyed the principle of diagnosis, so that when you place an implant, you know how to diagnose it in the future — not by taking a radiograph every couple of years but by probing. We also had consensus statements from the European Workshop on Periodontology 2012 where we discussed the monitoring of implants in great detail. It is a simple principle, but it has to be done! I also discussed the diagnosis and concept of maintenance. IP

A CONVERSATION WITH ...

Dentists will cope with peri-implantitis, or refer to another dentist, but they will not stop doing implants because implants bring them money! Good teeth that could be maintained are extracted these days, and this really has to do with ethics — which are not always at the highest premium in dentistry. It takes a while to develop peri-implantitis, maybe 5 to 10 years, during which time the dentist possibly has sold his/her practice, and someone else has to take care of it.

Take control of challenging cases. 3M™ Impregum™ Polyether Impression Material You need the precision standard when it comes to complex cases and moist environments. Implants and large restorations demand unfailing accuracy. The long working time, excellent flowability and hydrophilic properties of Impregum™ materials give you control over your toughest challenges. It’s simply a better way to make better impressions. FREE Impression Procedure Selection Guide www.3M.com/FreeSelectionWheel 3M and Impregum are trademarks of 3M or 3M Deutschland GmbH. Used under license in Canada. © 3M 2016. All rights reserved.

Implant practice 23

Volume 9 Number 5 Impregum_Implant_Practice_halfPg.indd 1

9/9/16 2:39 PM

CONTINUING EDUCATION

Full-mouth rehabilitation with implant-supported prostheses Drs. Vasileios Soumpasis, Stuart Kilner, Rajesh Vijayanarayanan, and Paul Coulthard discuss the treatment of a patient in need of extensive restoration

38-year-old male patient presented at the clinic suffering from an inability to feed himself properly for the last 20 years and a lack of confidence in social situations due to the current status of his dentition. Additionally, he was suffering from recurrent abscesses that were adding to his already lowered quality of life. The patient had visited other clinics, all of which only gave him the option of complete dentures, and he was seeking an implant-supported solution. The patient’s medical history was clear, apart from a smoking habit of 15 cigarettes per day. He was very anxious about dental treatment and had not had a dental appointment for the past 25 years. The last time the patient had visited his dentist, he had undergone extractions of his severely decayed maxillary and mandibular molars without sufficient anesthesia, which had left him with a dental phobia. As a teenager, his diet included a large amount of carbohydrates and a high intake of acidic foods. He had also neglected his oral hygiene in the intervening years. The patient was looking for a “return to normality” through restoration of his masticatory function and esthetic rehabilitation so that his appearance was appropriate for his age. As part of this return to normality, the patient expressed a desire to have fixed restorations. Before any examination was carried out, the patient was informed that no treatment

Vasileios Soumpasis, DDS, MSc, is a resident clinician at Evodental Heathrow. Stuart Kilner, BDS, is a resident clinician at Evodental Heathrow. Rajesh Vijayanarayanan, BDS, is an honorary clinical teaching fellow in dentistry within the Faculty of Medical and Human Sciences at the University of Manchester. He is the clinical director of Evodental. Paul Coulthard, BDS, MFGDP(UK), MDS FDSRCS, FDS(OS)RCS, PhD, is head of the School of Dentistry and professor of oral and maxillofacial surgery at the University of Manchester.

24 Implant practice

Educational aims and objectives

This article aims to present a case study illustrating full-mouth rehabilitation with implant-supported prostheses.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 30 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize a possible treatment technique for a patient with dental phobia and issues related to dental treatment avoidance. • See possible implant treatment for a patient with large bone defects and destruction of the alveolar bone architecture. • Visualize a plan for full-mouth rehabilitation via a fixed full-arch implant-supported prosthesis for the upper and lower jaws. • Identify various aspects of the surgical phase that affect implant placement success. • View treatment planning and implementation for restoration of a patient’s masticatory function and facial and tooth esthetics.

Figure 1: Patient at presentation — extraoral examination

would be undertaken without him stopping smoking, as smoking makes healing problematic and treatment outcomes unpredictable. The patient agreed to this because it would also create a better environment for his young child.

Examination A clinical and radiological examination was carried out to assess the patient’s suitability for rehabilitation with dental implants. There was no obvious facial asymmetry, and the patient’s lymph nodes, TMJ, and soft tissues all appeared normal. Screening for oral cancer was negative. The lateral profile view revealed the patient had a skeletal Class I maxillomandibular relationship, taking under consideration he

had no occluding teeth. The patient’s smile line was low. The patient had sufficient mouth opening (50 mm), his arch forms were elliptical, and his gingival biotype was moderate to thick. On his upper jaw, he had decayed retained roots from UL6 to UR6 and on his lower jaw from LL5 to LR5. His BPE score for all sextants was 2. Apart from caries, signs of erosive wear were also evident, supporting the tooth surface loss that leads to a total bite collapse and resulting in a significant decrease of the occlusal vertical dimension that was not compensated for by the alveolar bone. The determination of the occlusal class could not be completed due to the severely decayed remaining dentition. Volume 9 Number 5

were also found on the mandible, but these were not as extensive as those in the maxilla. In the mandible, although the height of the alveolar bone was sufficient, its width and shape made implant placement challenging, and potential sites were very specific. Due to the large bone defects and destruction of the alveolar bone architecture, potential implant sites in the maxilla

were again limited. Furthermore, the left sinus cavity appeared pneumatized. The quality of the alveolar bone seemed adequate for implant placement, taking into consideration the Hounsfield unit measurements of the CBCT scan and observing its overall appearance. The pterygoid plates and their access through the maxillary tuberosity were also evaluated.

Figure 2: Patient at presentation â&#x20AC;&#x201D; intraoral examination

Figure 3: A 3D CBCT scan was performed to evaluate bone level and quality Volume 9 Number 5

Implant practice 25

CONTINUING EDUCATION

In order to provide the patient with an accurate diagnosis and to evaluate bone levels and quality for potential implant placement, a 3D CBCT scan was performed (Figure 3). The scan revealed the presence of large bone defects on the maxilla around the apices of the decayed roots, confirming the history of recurrent abscesses. Periapical lesions

CONTINUING EDUCATION Diagnosis The patient was provided with the following diagnosis: • Severe caries • Generalized chronic plaque-induced gingivitis • Severe generalized tooth surface loss due to erosion • Acquired tooth loss due to caries • Chronic AP with periapical lesions and recurrent abscesses in several sites in the oral cavity • Loss of occlusal vertical dimension (OVD)

Treatment planning

protocols have been proven to have high success rates (Gokcen-Rohlig, et al., 2010; Penarrocha-Diago, et al., 2011; Soydan, et al., 2013) when followed by the fitting of fullarch prostheses that involve splinting the implants through a rigid metal framework (Degidi, 2009), and when the implants are placed with high primary stability through bicortical fixation. Thorough degranulation of the extraction sockets and bone defects would be carried out before implant placement. An alveoplasty would also be done before and after placement in order to create an ideal platform around the implant heads, helping placement and facilitating future oral hygiene.

The rehabilitation of the maxilla and mandible required the occlusal vertical dimension (OVD) to be increased in order to restore the esthetics and allow for the bulk of the restorative materials used to fabricate the full-arch implant-supported prostheses. For that reason, wax rims on acrylic bases were made to be fitted over the retained roots to properly record the jaw relationships. By positioning the length of the wax rim, the midline, smile line and canine line, and parallelizing the occlusal level with the interpapillary line and camper plane — as would be done for complete dentures — we were able to assess the facial esthetics and select

A plan was made for full-mouth rehabilitation via a fixed full-arch implant-supported prosthesis for the upper and lower jaws. The patient was not willing to undergo bone grafting, due to the high costs and unpredictability of the outcome, or zygomatic implants, again due to the expense. The classic All-On-4® treatment modality was not feasible due to insufficient bone in the anterior maxilla. Therefore, should the pterygoid implants be unable to engage successfully in cortical bone, a complete upper denture would be offered to the patient. The palatally positioned implants would be placed into fresh extraction sites with loading scheduled to take place 7 days after the surgery. These

Figure 4: The decision was made to place five implants in each jaw 26 Implant practice

Volume 9 Number 5

A facebow recording was then taken to transfer the upper working cast to the semiadjustable articulator. Implants were then placed in the mandible, with alveoplasty and gingivoplasty being carried out as in the upper jaw, and occlusal registration being taken before suturing. The desired occlusal vertical dimension (OVD) had been measured at an earlier appointment, so a rigid acrylic base with a wax rim was adjusted to fit on the healing cups of the lower implants and an interocclusal registration record was taken in RAP at the desired OVD. After suturing, a plaster impression was taken for the mandible and the maxilla. On the day, it was decided to create a provisional upper full-arch prosthesis that would be screwed on three implant abutments

and be supported by all five (Figure 5), by adjusting the rigid try-in with the insertion of restorative cylinder abutments and relining with PMMA in the clinic’s laboratory (rather than intraorally). This approach was taken to boost the patient’s confidence, in light of his previous traumatic experiences, and to reassure him for the outcome of the treatment. After the fit of the maxillary provisional prosthesis, an OPG radiograph (Figure 6) was taken to confirm full seating of the metal framework interfaces on the multi-unit abutments. The screws were torqued to 25 Ncm, and a light-body silicone material was used to fill the screw access holes. The patient was given his postoperative medication, reminded of his instructions, and sent home when the clinical team felt he could be dismissed.

Figure 5A: Implants placed in the maxilla

Figure 5B: Implants placed in the mandible

Surgical phase Local anesthetic was administered, after which the retained roots were extracted, and a full-thickness mucoperiosteal flap was elevated. Thorough degranulation and irrigation with sterile saline solution followed. As planned, an alveoplasty was carried out before and after implant placement in order to create the platform that would later accommodate the full-arch profile prosthetics. All implants in the maxilla were placed with a torque of 50 Ncm in D3 (Misch classification) bone, apart from the pterygoids that were torqued to 45 Ncm. In the mandible, all implants were placed to a torque of 50 Ncm. All multi-unit abutments were tightened to 35 Ncm. A gingivoplasty was carried out after the multi-unit abutments had been placed in order to remove any excess soft tissue. Before suturing the maxilla, a rigid try-in was seated on the healing cups so the esthetics of the maxillary dentition could be checked. Volume 9 Number 5

Figure 6: A full-arch upper provisional prosthesis was fabricated in the lab and screwed to three of the five abutments

Figure 7: Immediate postoperative OPG Implant practice 27

CONTINUING EDUCATION

appropriate teeth based on the patient’s facial characteristics. A relationship record was taken of the patient’s jaw in retruded axis position (RAP). A facebow was used to transfer the cast of maxillary dentition to a semi-adjustable articulator. The shade of the teeth was also decided at this stage. The lab put together a diagnostic wax-up on the rigid acrylic bases in order to reproduce the desired function and esthetics. A restoratively driven surgical plan was followed in order to place the optimum number of implants to eliminate cantilevers. Because of this, and given the condition of the alveolar bone, it was decided that five implants would be placed in each jaw. The sites chosen for the maxilla can be seen in Figure 4. Due to the patient’s previous traumatic experience, it was decided that oral sedation would be administered, and the whole procedure would happen under local anesthetic. Additionally, antibiotics and pre- and postoperative non-steroidal anti-inflammatories (NSAIDs) were prescribed. The decision was made not to use corticosteroids to control any swelling, as the efficiency of the surgical procedure and its completion in optimum time (an hour and a half for the maxilla and 1 hour for the mandible) was expected. The surgeon was highly experienced at performing under these strict conditions, and as a result of his experience, ability, and precision, guided surgery was not used.

CONTINUING EDUCATION

Figure 8: Clinical situation at 7 days following placement and provisionalization

Figure 9: The final metal-acrylic restoration

Definitive prostheses The patient returned to the clinic 7 days after implant placement for the fit of his definitive upper and lower fixed full-arch prostheses, which had been fabricated in the clinic’s laboratory. On examination, and after removal of the maxillary provisional prosthesis, the soft tissues showed good healing, and the patient didn’t complain of excessive pain, discomfort, or swelling. No bruising was evident. One healing cup had loosened in the mandible, and the patient had removed it. The fit of the cobalt chrome-PMMA profile full-arch prosthesis followed. Because of the inherent rigidity of the plaster impression and the high precision of the CAD/CAM milled metal framework, a passive fit was secured. The screws were tightened to 25 Ncm, and an OPG radiograph was taken (Figure 10) to ensure full seating of the prosthesis on the multi-unit abutments. After full seating of the prosthesis was observed on the OPG, the screw access holes were filled with a silicone material. The patient’s occlusion, comfort, esthetics, and phonetics were evaluated and a soft food, 28 Implant practice

Figure 10: An OPG was taken to ensure full seating of the prosthesis on the multi-unit abutments

slow-chewing protocol was advised to be followed for the next 5 months.

Review Review appointments were scheduled for 4 weeks, 4 months, and 6 months after the surgery. Postoperative soft tissue healing and maxillary soft tissue shrinkage were evaluated at the 4-week appointment. Because

of the importance of avoiding micromovement of the implants, any reline of the maxillary prosthesis would not be made before 4 months had passed, though a slight lisp was noticeable at this time. The patient’s adaptation to the new vertical dimension was already successful, and pronunciation of the f, v, and s sounds was perfect. The patient was very satisfied with the comfort of the prosthesis and already Volume 9 Number 5

CONTINUING EDUCATION

Figure 11: Final prostheses in place

Figure 12: Final result

happy with the reduced bulk compared to the provisional one. At the 4-month review, the upper full-arch prosthesis was relined, and the phonetic seal was restored. The patient maintained very good oral hygiene, but the self-cleansing design of the highly polished prosthetics helped secure a high level of hygiene. At the 6-month follow-up, the prosthesis was removed from the patient’s mouth in order to confirm osseointegration of the implants, and another radiograph was taken. The patient was then signed off and his maintenance protocol initiated. He was instructed to attend the clinic for an examination every 12 months. Volume 9 Number 5

The patient’s satisfaction was at the highest level; and the restoration of his masticatory function and facial and tooth esthetics were very pleasing and life-changing. The absence of cantilevers (Francetti, et al., 2015), the self-cleansing surfaces of the prostheses, the appropriate spacing between implants, their anchorage in dense cortical/ basal bone, and their splinting with a rigid metal framework 7 days after placement (Degidi, et al., 2009), combined with a soft, slow-chewing diet for the first 5 months, and the establishment of a mutually protected occlusal scheme were factors that secured a positive treatment outcome in the short term, but also reassured us for its mid- and long-term prognosis. IP

REFERENCES 1. Degidi M, Nardi D, Piattelli A. Immediate rehabilitation of the edentulous mandible with a definitive prosthesis supported by an intraorally welded titanium bar. Int J Oral Maxillofac Implants. 2009;24(2):342-347. 2. Francetti L, Rodolfi A, Barbaro B, Taschieri S, Cavalli N, Corbella S. Implant success rates in full-arch rehabilitations supported by upright and tilted implants: a retrospective investigation with up to five years of follow-up. J Periodontal Implant Sci. 2015;45(6):210-215. 3. Gökçen-Röhlig B, Meriç U, Keskin H. Clinical and radiographic outcomes of implants immediately placed in fresh extraction sockets. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(4): e1-7. 4. Peñarrocha-Diago MA, Maestre-Ferrín L, Demarchi CL, Peñarrocha-Oltra D, Peñarrocha-Diago M. Immediate versus nonimmediate placement of implants for full-arch fixed restorations: a preliminary study. J Oral Maxillofac Surg. 2011;69(1): 154-159. 5. Soydan SS, Cubuk S, Oguz Y, Uckan S. Are success and survival rates of early implant placement higher than immediate implant placement? Int J Oral Maxillofac Surg. 2013;42(4): 511-515.

Implant practice 29

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 V9.5 SOUMPASIS REF: IP V9.5 HARTSHORNE

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Full-mouth rehabilitation with implant-supported prostheses SOUMPASIS, ET AL. 1.

In order to provide the patient with an accurate diagnosis and to evaluate bone levels and quality for potential implant placement, a __________. a. 3D CBCT scan was performed b. 2D digital radiograph was taken c. a panoramic X-ray was taken d. a manual examination was done

Therefore, should the pterygoid implants __________, a complete upper denture would be offered to the patient. a. be too expensive for the patient b. be unable to engage successfully in cortical bone c. preclude bone grafting d. be too large for the area of concern

The palatally positioned implants would be placed into fresh extraction sites with loading scheduled to take place ___ days after the surgery. a. 3 b. 5 c. 7 d. 10

Thorough degranulation of the extraction sockets and bone defects _________ implant placement. a. would be carried out before b. would be carried out after c. would not be an option d. would hinder rehabilitation after An alveoplasty would also be done _______ in order to create an ideal platform around the implant heads, helping placement and facilitating future oral hygiene. a. only before b. only after c. before and after placement d. only if there are complications during preparation The rehabilitation of the maxilla and mandible required the occlusal vertical dimension (OVD) to be _______ in order to restore the esthetics and allow for the bulk of the restorative materials

30 Implant practice

Are short implants an acceptable alternative to sinus floor elevation in the posterior maxilla? HARTSHORNE

used to fabricate the full arch implant-supported prostheses. a. decreased b. increased c. tapered d. regranulated 7.

By positioning the length of the wax rim, _____, and parallelizing the occlusal level with the interpapillar line and camper plane — as would be done for complete dentures — we were able to assess the facial esthetics and select appropriate teeth based on the patient’s facial characteristics. a. the midline b. the smile line c. the canine line d. all of the above

All implants in the maxilla were placed with a torque of ___ in D3 (Misch classification) bone, apart from the pterygoids that were torqued to 45 Ncm. a. 35 Ncm b. 40 Ncm c. 50 Ncm d. 60 Ncm

After full seating of the prosthesis was observed on the OPG, the screw access holes were filled with a silicone material. The patient’s occlusion, comfort, esthetics, and phonetics were evaluated and a soft food, slow-chewing protocol was advised to be followed for the next ______. a. 2 weeks b. 30 days c. 60 days d. 5 months

10. Because of the importance of avoiding micromovement of the implants, any reline of the maxillary prosthesis would not be made before _______ had passed, though a slight lisp was noticeable at this time. a. 2 weeks b. 1 month c. 4 months d. 5 months

Implant treatment options for rehabilitation of the posterior maxilla are dictated by _______. a. the available alveolar bone height b. type of bone c. interarch space d. all of the above

Available data indicates _______ associated with the use of shorter implants. a. less morbidity b. greater patient acceptance c. more morbidity d. both a and b

Clinical choice of the most appropriate implant therapy modality should be based on assessment of the residual alveolar bone height, width, and sinus morphology with _______, current scientific evidence, surgical skills, and experience of the surgeon, and the patient’s preferences. a. a cone beam computed tomography (CBCT) scan b. an endoscopic view c. a 2D film radiograph d. a tomogram

The single study that assessed surgical time and costs (Thoma, et al., 2015) showed that surgical time increased by ____ when a SFE procedure was performed compared to just using a short dental implant. a. 30% b. 50% c. 70% d. 86%

For the patient, _____ also play(s) an important role when making choices between treatment options. a. costs b. limiting surgical interventions c. associated discomfort d. all of the above

Implant surface roughness and _______ the diameter of the implant for achievement of sufficient primary stability at time of implant placement may contribute to the long-term survival of the implant and prosthesis. a. decreasing b. increasing c. monitoring d. none of the above

Alveolar bone height will often fall short of the optimum _____ in the posterior maxilla due to alveolar bone loss and sinus pneumatization. a. 6 mm b. 8 mm c. 10 mm d. 12 mm

Sinus floor elevation (SFE) procedures, however, are associated with an increased risk of complications, _______, and require advanced skills. a. higher patient morbidity b. longer treatment time c. costs d. all of the above

There were ___ statistically significant differences in marginal bone level changes between short implants and longer implants with SFE. a. some b. substantial c. no d. two

10. Short implants can be a successful minimally invasive treatment alternative to placing longer implants with SFE in cases where the alveolar bone height in the posterior maxilla is _____ or more. a. 2.5 mm b. 3.5 mm c. 4 mm d. 5 mm

Volume 9 Number 5

CE CREDITS

IMPLANT PRACTICE CE

Dr. Johan Hartshorne gives a critical appraisal of a systematic review into the evidence for avoiding longer implants in situations where augmentation techniques may be required

his article aims to provide a critical appraisal of a systematic review: Thoma DS, Zeltner M, Hüsler J, Hämmerle CH, Jung RE. EAO Supplement Working Group 4 – EAO CC 2015 Short implants versus sinus lifting with longer implants to restore the posterior maxilla: a systematic review. Clin Oral Implants Res. 2015;26 Suppl 11:154-169. The article was accepted for publication on April 13, 2015, and was first published online on May 21, 2015. The research originated from the Clinic for Fixed & Removable Prosthodontics and Dental Material Science Center at the University of Zurich, Switzerland.

Educational aims and objectives

This article aims to critically analyze a systematic review and its findings in relation to the use of short implants over longer implants and sinus lift procedures.

Expected outcomes

Realize if short implants are comparable to longer implants with sinus floor elevation (SFE) in terms of morbidity and surgically related complications.

•

Realize if short implants comparable to longer implants with SFE in terms of clinical and radiographic outcomes.

•

Identify some key factor in clinical decision-making for increasing implant and prosthesis success rates, minimizing complications and morbidity, and improving patient acceptance with implant therapy.

•

Realize some ways to avoid complications and disadvantages associated with SFEs.

Summary The outcomes of this systematic review demonstrated high implant and reconstruction survival rates for short implants and sinus floor elevation (SFE) with simultaneous placement of longer implants. Both treatment options are safe and predictable for implant therapy in the posterior maxilla. Biological complications are frequent, but mainly associated with SFE. The increased biological complications, costs, and surgical time associated with SFE with longer implants, favor the use of shorter dental implants in the posterior maxilla.

Critical appraisal conclusion The evidence suggests the use of short implants (5 mm to 8.5 mm long) as an alternative to SFE with longer implants (of 10 mm or more) for rehabilitation of the posterior maxilla. The outcomes indicate that there are less intraoperative complications when short implants are used.

Johan Hartshorne, BSc, BChD, MChD, MPA, PhD (Stell), FFPH RCP (UK), is visiting professor at the department of periodontics and oral medicine, University of Pretoria, South Africa. Disclaimer: Dr Hartshorne is trained in clinical epidemiology, biostatistics, research methodology, and critical appraisal of research evidence.

Volume 9 Number 5

There is limited evidence that less postoperative complications with short implants and prosthesis will occur after loading compared to longer implants with SFE. The evidence presented should be interpreted and applied with caution because studies are limited, not all the important outcomes were measured, and the duration of follow-up was less than 18 months.

Implications for clinical practice Implant treatment options for rehabilitation of the posterior maxilla are dictated by the available alveolar bone height, type of bone, and interarch space. The evidence suggests that both short implants or SFE with longer dental implants can be recommended for implant therapy in the posterior maxilla presenting with limited alveolar bone height, provided careful case selection and evidence-based clinical protocols are followed. Where short implants are indicated, the best way to compensate for reduced implant surface and to ensure best possible primary stability is to use a wider diameter (4 mm-6 mm) implant. Until more evidence is available, it would be prudent for clinicians to: • avoid placing short implants in single free-end case

• follow a two-stage implant surgery approach • allow for longer periods of osseointegration • avoid immediate loading • consider splinting of prosthesis Clinical choice of the most appropriate implant therapy modality should be based on assessment of the residual alveolar bone height, width, and sinus morphology with a cone beam computed tomography (CBCT) scan, current scientific evidence, surgical skills and experience of the surgeon, and the patient’s preferences. Following a good surgical protocol and excellent oral hygiene maintenance program are fundamental elements in achieving a successful and predictable outcome. Clinical question Are short implants comparable to longer implants with SFE in terms of • morbidity and surgically related complications? • Clinical and radiographic outcomes?

Review methodology Search strategy An electronic MEDLINE® (PubMed®) search was performed for controlled clinical Implant practice 31

CONTINUING EDUCATION

Are short implants an acceptable alternative to sinus floor elevation in the posterior maxilla?

CONTINUING EDUCATION studies, published from January 1990 up to October 31, 2014, comparing short implants (8 mm or less) (Group A) to longer implants (greater than 8 mm) with lateral window sinus floor elevation (SFE) (Group B) for rehabilitating the posterior maxilla. The search was limited to the English, German, Italian, and French languages. The search was complemented by an additional hand search of the selected papers and reviews published between 2011 and 2014. Reference list of all included publications were screened for relevant studies. Inclusion criteria Eligible studies were selected based on the following inclusion criteria: • Human trials with a minimum amount of 20 patients • Randomized controlled trials (RCT) or controlled clinical trials (CCT) • Short implants with an intrabony length of 8 mm or less • SFE in combination with longer implants with an intrabony length of greater than 8 mm • Screw-type implants with a moderately rough surface • Implants placed within the alveolar bone and the augmented sinus floor • Patients needed to be examined clinically Data extraction Two authors independently screened the titles and abstracts derived from the search. Eligible articles were then obtained in full text. Disagreements regarding eligibility of studies and data extraction between authors were resolved by discussion and consensus. Cohen’s Kappa coefficient was calculated to measure agreement between the two readers. The primary outcomes were survival rates of implants and reconstructions. Secondary outcomes included complication rates for implants and reconstructions, radiographic bone levels, as well as patientrelated outcome measures, surgical time, costs, and the feasibility to perform the two procedures. Method of analysis and quality assessment Two reviewers independently evaluated the methodological quality of all included studies using the Cochrane Collaboration’s tool for assessing risk of bias in randomized trials. Any disagreement was discussed until consensus was achieved. Survival rates with corresponding 95% confidence 32 Implant practice

intervals (95% CI) were calculated with implants as unit.

Main results Eight RCTs comparing short implants with longer implants with SFE met the eligibility criteria. The studies were wellconducted with respect to randomization, allocation, data collection, and reporting, thus resulting in a low risk for selection, attrition, and reporting bias. All of the studies presented with a high risk of performance bias due to a lack of blinding of patients and surgeons. Four studies had a high risk of bias from blinding of outcome assessment (detection bias). Surgeons placed implants in specialized clinical settings. A total of 406 implants were placed in 217 patients with a mean age of 54 years. One hundred and ninety seven implants were placed in the short implant group (Group A) and 209 implants in the longer implant group with SFE (Group B). The length of the short implants varied between 5 mm and 6 mm, with diameters of either 4 mm, 5 mm, or 6 mm. The length of longer implants ranged between 10 mm and 15 mm. Lateral window SFE in Group B was performed simultaneously with implant placement. Based on the pooled analyses of longer follow-ups (five studies, 16-18 months), the

survival rate of longer implants with SFE amounted to 99.5% (95% CI: 97.6-99.98%) and for shorter implants 99.0% (95% CI: 96.4-99.8%). For shorter follow-ups (three studies, 8 to 9 months), the survival rates of longer implants were 100% (95% CI: 97.1-100%) and for shorter implants 98.2% (95% CI: 93.9-99.7%). Complications were predominantly sinus floor membrane perforations. Patient reported outcomes — i.e., morbidity, surgical time, and costs — were generally in favor of shorter dental implants.

Conclusion The analysis demonstrated predictably high implant and reconstruction survival rates for both groups. Given the higher number of biological complications, increased morbidity, costs, and surgical time of longer dental implants with SFE, shorter dental implants may represent the preferred treatment alternative. The authors declared that no funding was provided for the elaboration of this study nor was there potential conflict of interest with respect to the authorship and/or publication of this review.

Commentary Background and importance Alveolar bone height will often fall short of the optimum 10 mm in the posterior maxilla due to alveolar bone loss and sinus Volume 9 Number 5

Are the results valid? The individual studies presented with various methodological limitations that could potentially increase risk of bias and thus affect the validity of the evidence. Inadequate blinding of participants and investigators, short follow-up time, small sample sizes, and a calculation of sample sizes based on secondary outcomes contributed toward a high risk for bias. Heterogeneity or group imbalances such as using different study designs, assessment tools, differing implant diameters, splinting of reconstructions within and between groups may also potentially affect the estimate of the outcome. The authors did not report whether tests for heterogeneity were conducted. Overall, the limited number of studies, variation in study design, heterogeneity, and limitations in research methodology among individual studies could potentially result in Volume 9 Number 5

The high survival rates should be interpreted with caution due to the relatively short follow-up observation period.

increased risk of bias that may affect the estimates of effect and thus affect the validity of the evidence. What are the key findings? The pooled survival rates for shorter implants were similar to that of longer implants with SFE. Due to heterogeneity in observation periods, no meta-analysis was conducted for the eight studies combined. The metaanalysis of the pooled data for short-term (8 to 9 months) (three studies) and longer term (16-18 months) (five studies) showed high implant and reconstruction survival rates for both the short implant group as well as with longer implants with SFE. The high survival rates should be interpreted with caution due to the relatively short follow-up observation period (maximum 18 months). Although the survival results were consistent throughout individual studies, the confidence intervals were wide, indicating that the estimate of survival of implants was lacking precision. This could be ascribed to the limitations in the research methodology. In all of the studies, except one, the differences between the two groups with respect to complication rates were statistically insignificant. More intraoperative biological complications were observed in the longer implant group, the most frequent complication being sinus floor membrane perforation. The data in this review suggests that the risk of complications increased by threefold with sinus floor elevation procedures. There were no statistically significant differences in marginal bone level changes between short implants and longer implants with SFE. Available data indicates less morbidity and greater patient acceptance associated with the use of shorter implants. Comparison between the two groups is difficult because only four studies reported patient-related outcome data. To complicate matters further, different assessment tools were used. Qualitative analysis of descriptive statistics were further hampered due to small sample sizes, different study designs,

and variations in intervention within same populations (i.e., number of implants placed). The single study that assessed surgical time and costs (Thoma, et al., 2015) showed that surgical time increased by 50% when a SFE procedure was performed compared to just using a short dental implant. It can be inferred that increased surgical time may be associated with the increase in morbidity, complication rate, and negative patientrelated outcomes. Shorter implants accounted for only half the costs compared to longer implants with SFE. Although the availability of data was limited, patient-reported outcomes, morbidity, costs, and surgical time were all in favor of shorter dental implants. Most of the studies included in the review did not report on all the secondary outcomes. Only three studies reported on changes in marginal bone levels, and four provided data on patient-related outcome measures. The four studies reporting on patient-related outcome lacked standardization in methods and criteria, thus ruling out an appropriate comparative analysis. Important patient-related outcomes such as postoperative pain or discomfort, morbidity, the impact on quality of life, surgical time, and costs were largely not reported on. Secondary outcomes were only reported on descriptively and not subjected to metaanalysis. No data was provided on initial alveolar bone height, alveolar ridge width, type of bone, systemic conditions, smoking habits, periodontal health, parafunctional habits, sinus morphology, and interarch relations. These variables may be critical to clinical decision-making. The evidence reported in this review supports that of a previous systematic review â&#x20AC;&#x201D; namely, that there is not enough evidence to show whether SFE techniques are more or less successful in reducing the implant and prosthetic failures when compared to simply using short implants up to 1 year after loading, and that there were fewer complications when short implants were used without SFE (Esposito, et al., 2014). Implant practice 33

CONTINUING EDUCATION

pneumatization. Clinicians are consequently faced with the challenge of optimizing success and limiting complications when placing implants where there is reduced alveolar ridge height and poor bone quality (type IV) in the rehabilitation of the posterior maxilla. In cases presenting with reduced alveolar bone height in the posterior maxilla, SFE procedures using either a lateral or crestal approach have traditionally been the treatment of choice to increase bone height to allow the placement of dental implants of optimal length (10 mm or more). SFE procedures, however, are associated with an increased risk of complications, higher patient morbidity, longer treatment time, and costs and require advanced skills. In order to avoid the complications and disadvantages associated with SFEs, the use of shorter dental implants (less than 10 mm in length) has been advocated as an alternative treatment option. Simultaneously, implant texture and design have been improved to compensate for situations with compromised bone quality and quantity. The survival rates, complications and patient-related outcomes of short implants in the posterior maxilla have never been compared to those of longer implants in combination with SFE for the same indications. The literature comparing the two treatment options in well-designed controlled clinical trials was scarce for many years, but more recent evidence suggests that both treatment options are reliable and predictably successful (Esposito, et al., 2012; Gulje, et al., 2014).

CONTINUING EDUCATION How are the results of this review applicable in clinical practice? Increasing implant and prosthesis success rates, minimizing complications and morbidity, and improving patient acceptance and satisfaction with implant therapy are key factors in clinical decision-making. For the patient, costs, limiting surgical interventions, and associated discomfort also play an important role when making choices between treatment options. Considering that SFE requires more treatment time, greater costs, have more complications and more advanced surgical skills, the use of shorter dental implants may open dental implant therapy to a broader spectrum of clinicians, and subsequently, a broader patient population may benefit from this treatment option. Clinicians may elect to use short implants in cases where SFE are contraindicated (such as chronic sinusitis, abnormal sinus morphology, or smoking), provided there is adequate alveolar bone volume (5 mm or more). Implant surface roughness and increasing the diameter of the implant for achievement of sufficient primary stability at time of implant placement may contribute to the long-term survival of the implant and prosthesis (Javea, Romanos, 2015). Proper case selection is essential to achieve a predictable and successful outcome, irrespective of which choice of treatment is selected. CBCT is critical tool for proper case selection and treatment planning. Important factors that must be considered include: • patient-related factors (systemic conditions smoking habits, periodontal health, para-function) • biological factors (residual alveolar bone height, alveolar bone width, bone quality, and sinus morphology) • surgical considerations (one or two stages, skills of the surgeon) • prosthetic considerations (splinted or not)

longer implants with SFE in cases where the alveolar bone height in the posterior maxilla is 5 mm or more. Using short implants in the posterior maxilla with reduced alveolar ridge height has several advantages for the patient, including less surgical intervention and intraoperative complications, reduced waiting periods for treatment completion, and reduced costs. It may also render implant treatment accessible to a larger pool of patients. The evidence presented in this systematic review offers modest evidence for placement and restoration of short implants provided that clinicians understand the limitations, indications, and risk factors thereof. However, the results from this review should be interpreted with caution due to the lack of good quality studies and longer follow-up. SFE may still be the procedure of choice for surgeons who do not elect to use short implants or when short implants are contraindicated. The use of short implants is promising, but there are still many unanswered questions that require more research. First, we do not know what the longterm success rates of short implants are from a biological and prosthetic perspective.

Second, what is the optimum bone-toimplant contact surface (implant geometry, length, and width) that will ensure the best primary and secondary stability, and a predictable and successful osseointegration? Further controversies include whether short implants should be used single or two-stage, should longer time for healing and bone maturation be allowed before loading, and whether prostheses on short implants should be splinted. IP REFERENCES 1. Esposito M, Cannizzaro G, Soardi E, Pistilli R, Piattelli M, Corvino V, Felice P. Posterior atrophic jaws rehabilitated with prostheses supported by 6mm-long, 4mm-wide implants or by longer implants in augmented bone. Preliminary results from a pilot randomized controlled trial. Eur J Oral Implantol. 2012;5(1):19-33. 2. Esposito M, Felice P, Worthington HV. Interventions for replacing missing teeth: augmentation procedures of the maxillary sinus. Cochrane Database of Syst Rev. 2014;13(5). 3. Gulje FL, Raghoebar GM, Vissink A, Meijer HJ. Single crowns in the resorbed posterior maxilla supported by either 6-mm implants or by 11-mm implants combined with sinus floor elevation surgery: a 1-year randomized controlled trial. Eur J Oral Implantol. 2014;7(3):247-255. 4. Javed F, Romanos GE. Role of implant diameter on long- term survival of dental implants placed in the posterior maxilla: a systematic review. Clin Oral Investig. 2015;19(1):1-10. 5. Thoma DS, Haas R, Tutak M, Garcia A, Schincaglia GP, Hämmerle CH. Randomized controlled multicenter study comparing short dental implants (6mm) versus longer dental implants (11-15mm) in combination with sinus floor elevation procedures . Part I: demographics and patientreported outcomes at 1 year of loading. J Clin Periodontol. 2015;42(1):72-80.

Clinical resolution Today, both patients and practitioners demand simplified, minimally invasive, affordable, and predictable approaches to increase acceptance and success of implant therapy. Restoring the edentulous maxilla with dental implants is challenging due to reduced residual alveolar bone and proximity of the maxillary sinus. Short implants can be a successful minimally invasive treatment alternative to placing 34 Implant practice

Volume 9 Number 5

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TECHNOLOGY

Choosing the right implant impression material Dr. Matt Croley discusses adaptable impression materials

mpression taking is a critical and yet commonly overlooked function of a busy dental practice, and choosing the right impression material for each case can be challenging. While it’s certainly true that the type of material you choose doesn’t completely dictate the accuracy of the impression (many human factors are involved here too), selecting the appropriate impression material for each case is an important part of the process that can help ensure the best clinical outcomes and a more efficient practice. Especially in larger practices, honing in on the right materials for your cases can also help limit the amount of inventory you carry. Generally, I utilize a go-to material for what I like to call “everyday impressions,” and a second for more challenging cases that require the finest detail or longer working times, such as implant cases.

Choosing impression material Almost all patients will need an impression at some point for diagnostic purposes — standard procedures that happen in your practice on a daily basis. For these “everyday” cases, I utilize a vinyl polysiloxane (VPS) material because it allows for sufficient time to load and seat the impression tray. Many clinicians utilize an alginate for similar cases, but it’s important to remember that alginate needs to be poured immediately if you want an accurate result. It also limits the options for multiple pours, and the material’s viscosity can mean that the accuracy of soft tissue areas could be compromised.

VPS Impression Material from 3M, also has one of the shortest intraoral setting times on the market. This means my patients are able to get out of the chair faster and with a better overall experience. I also recommend the use of an intraoral syringe because I can prepare for cases by prefilling up to 12 hours in advance without the material setting, allowing me to be more efficient during practice hours. In my practice, we use the 3M™ Intra-oral Syringe. Another benefit over an alginate material is that VPS materials are not mixed by hand, which reduces steps, waste, and cleanup time.

working time. The long working time allows the material to flow into tough spots to capture fine details for precision impressions. A final feature of Impregum™ Polyether material that I appreciate is its unique snapset behavior. Impregum™ Polyether will not start setting before the working time ends, and when it does, it does so immediately. It allows constant flow behavior during the entire working time. Flowability, long working time, and moisture control are the three key reasons I choose Impregum™ for many of my implant impression cases.

Impression taking for challenging cases

A 66-year-old female patient presented with pain in tooth No. 3. An X-ray confirmed that the tooth had been previously endodontically treated with a root canal and a crown. Several treatment options were discussed to address the pain, including retreatment of the root canal, removal of the tooth, a three-unit bridge, or a single-unit crown over implant. The patient selected the single-unit crown over implant because it offered maximum predictability and strength over time. The patient was referred to an oral surgery practice for tooth removal and bone grafting. After 3 months of healing time, the patient returned to the oral surgeon for placement of a Nobel Biocare® Replace Select™ 5.0 mm tapered implant. After 4 months and ample time for osseointegration and healing time, the patient returned for impressions and to discuss a final treatment plan (Figure 1). Because strength

For cases that offer bigger challenges or the need for finer precision (which, in my practice, comes up quite often), I turn to a polyether material — 3M™ Impregum™ Polyether Impression Material. This class of impression material offers superior moisture tolerance for void-free impressions, even in wet environments.1 We all know that the mouth presents a constantly moist environment, regardless of steps taken to reduce wetness with air, cotton rolls, and more. Impregum™ offers high precision due to the inherent hydrophilic composition of the material. This makes the material very forgiving when sulcus control is challenging due to blood and saliva contamination around the margin. Another advantage of a polyether material is sustained flowability throughout a long

Case presentation

Taking better “everyday” impressions VPS materials offer the kind of accuracy that you might need for diagnostic and preliminary casts, and they can be poured later if the lab can’t get to it in a timely manner. With a VPS material, there’s no “stressful race against the clock.” The material I utilize in my practice, Imprint™ 4 Matt Croley, DMD, is a graduate of the University of Kentucky College of Dentistry. He maintains a general dental practice in Lexington, Kentucky. Disclosure: Dr. Croley has no financial interests in the products mentioned in this article.

Figure 1: Preoperative view of tooth No. 3 36 Implant practice

Volume 9 Number 5

Figure 3: Analog for abutment

Figure 4: Cast with final restoration

Conclusion

Figure 5: Occlusal view of the cast with the final restoration

Figure 6: Final restoration shows excellent marginal fit

With nearly 10 years of clinical experience with polyether impression material, I’ve continued to see satisfactory results, minimal retakes, and very few crown/restoration remakes, allowing me to maintain efficiency while providing the best possible patient outcomes. While VPS impression material has a place in my practice for indications such as preliminary impressions and dentures, polyether impression materials continue to be key for the majority of my impression-taking needs. In the end, it really comes down to which material works most predictably in your hands, and how “tricky” or involved a particular case may be, and I appreciate having both materials on hand to ensure that I can easily adapt to the right material for the right case. IP

REFERENCE

Figure 7: Final seated restoration on tooth No. 3 Volume 9 Number 5

1. Walker MP, Petrie CS, Haj-Ali R, Spencer P, Dumas C, Williams K. Moisture effect on polyether and polyvinylsiloxane dimensional accuracy and detail reproduction. J Prosthodont. 2005;14(3):158-163.

Implant practice 37

TECHNOLOGY

Figure 2: Impression of tooth No. 3 with light body and heavy body polyether impression material (Impregum™ Soft Quick Step, 3M)

was a priority over esthetics based on the positioning of the affected tooth, the final treatment plan included a screw-retained crown with UCLA abutment, which would also minimize the risk for peri-implantitis. Impressions were taken with Impregum™ Soft Polyether Impression Material from 3M (Figure 2). This particular impression material was selected because it offers excellent moisture tolerance in wet environments, and the flowability continues even with a longer working time. The rigidity of the material makes it excellent for use in a tray, while the flowability helps for flowing around the implant impression post. To prevent distortion, the impression tray should be removed by first loosening it on the opposite side of the implants (moved slowly with an up-anddown and side-to-side motion) with the area to be restored being removed last. The impressions were then shipped to the lab, models were created (Figures 3-5), and the final restoration was received. The patient returned for final seating, and few minimal occlusal adjustments were made, with the initial restoration showing excellent marginal fit (Figures 6-7). Once the abutment was torqued to 35 Ncm, a cotton pellet was placed over the abutment and the access opening filled with Filtek™ Supreme Ultra Universal Restorative. Despite a tight interocclusal space, the accuracy of the impression-taking process led to a restoration with excellent fit.

PRACTICE DEVELOPMENT

Is your website really working? Ian McNickle, MBA, discusses how to convert website visitors into new patients

he world of websites and online marketing can be confusing. Dentists and their staff often feel as though their website could be doing more for them, but aren’t quite sure how to determine this or what to do about it. The goal of this article is to help you understand how to get more value and new patients from your website.

The goal of online marketing Online marketing is primarily concerned with the following two objectives: 1. Driving traffic to the website 2. Converting that traffic to take the actions you want them to take Driving traffic to your website is achieved by the use of search engine optimization (SEO), pay-per-click (PPC) paid ads, social media, review sites (Google+, Yelp, Facebook, Healthgrades®, etc.), and other methods. Once people arrive at your website, you’ll want them to take action to contact your office via phone call, email, or filling out an appointment request form. These actions are called “website conversion.” The ultimate marketing goal of the website is to drive new patients to the

Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a co-founder and partner at WEO Media, winner of the 2016 Cellerant “Best of Class” Technology Award for Dental Marketing and Dental Websites. If you have questions about any marketing-related topic, please contact Ian McNickle directly at ian@ weomedia.com, or by calling 888-246-6906. For more information, you can visit www.weodental.com.

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practice. This is achieved by maximizing both traffic and website conversion. The focus of this article will be on website conversion, and our next article will focus on driving traffic.

Improve your website conversion rate Far too many dental practices use common, templated websites with stock photos and stock content. This does not differentiate you from other practices and does not reflect the unique personality of your practice. In addition, the calls to action are often poorly implemented. Instead, consider implementing the following items to improve your website conversion: • A custom website design should properly reflect your practice. • Phone number should be easy to find at the top of every page in large font. • Appointment request button (or form) should be easy to find on every page and be located further up the page (not at the bottom). • Use actual photos of the practice, staff, and equipment with minimal use of stock photos. • Write unique content that is specific to your treatment philosophy and approach. • Embed an overview video of the practice on the home page to help

communicate who you are/your personality, what is unique about your practice, highlight technology and training, etc.

Track and optimize results over time In order to properly track conversion, we always recommend using a phone call tracking number that routes to your actual office phone. Using a tracking number will allow you to more accurately understand how many calls are coming from your website. We also recommend recording the phone calls for training purposes. Dental practices that want to get the most from their online marketing efforts should make it a regular monthly activity to review website traffic and conversion. Plotting these trends over time will allow practices to understand if their activities to increase traffic are working, if their conversion rate is getting better or worse, and to determine the return on investment (ROI) for this portion of their marketing.

Marketing consultation If you have questions about your website, social media, or online marketing, you may contact WEO Media for a consultation to learn more about the latest industry trends and strategies. The consultation is FREE if you identify yourself as a reader of this publication. IP

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com Volume 9 Number 5

Targeting Perfection Dynamic navigation for freehanded dental implant placement See for yourself how freehanded guided surgery aids more accurate implant placement. Navident tracks the drill and the patient’s jaw, providing real-time tactile guidance and visual feedback. “The Navident system is the next leap forward in CBCT based implantology. The ability to verify and validate, in real time, positional accuracy of osteotomy site preparation and implant positioning is unlike anything that has ever been available before outside a research center. Every day and every case now closes with me knowing (and having a medicolegal record of proof) that I am providing the most accurate and precise implant placement for my patients and referring doctors to maximize functional and esthetic prosthetic outcomes. In a discipline that Compatible with any implant type, drill system and all CBCTs currently on the market

depends largely on precision and accuracy, there should be and can be no more excuses.” George A. Mandelaris, DDS, MS, FACD, FICD Diplomate, American Board of Periodontology

Try Navident’s precision guidance for yourself. Call 1-844-NAVIDENT or email info@claronav.com (628-4336)

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PRACTICE DEVELOPMENT

Three traits of successful implant treatment coordinators Charles Banh discusses how to increase implant potential with an implant treatment coordinator

ou’ve heard it before: The implant part of your practice operates as a separate, smaller entity within your overall business. It’s a practice within your practice. As that implant practice grows in volume, the responsibilities and work increase exponentially, not linearly. Additionally, that work is highly specialized and often operates totally separate from the other tasks in the office. I have been very lucky to work with surgeons who are talented both with their hands and also in their business sense. Many of these surgeons place 1,000s of implants a year both in a solo practice and group practice setting. While there are many variables that separate these extremely successful surgeons, they all have one thing in common: They have an extremely competent implant treatment coordinator (ITC) whose sole job is to grow and manage the implant practice. I have isolated three elements that make these implant treatment coordinators superstars. These are the skills that separate.

1. They are experts in implants. Superstar ITCs know which implants are used in a particular situation and why. They have memorized all the available sizes of that system and are masters of your implant inventory. An exceptional ITC is up-to-date on current surgical literature and procedures such as immediate anterior implants, hybrid procedures, and surgical planning. They should have a close relationship with Charles Banh is the owner of the implant consulting firm The Practice Within, LLC. He is an instructor, speaker for various dental companies, and executive coach. For the past decade, he has been involved in the implant field serving as director of sales at Anatomage and also as a territory representative for BIOMET dental implants. The company focus is on-site systems implementation and mentoring of implant treatment coordinators and surgical staff for the purpose of building implant production in the surgical office. For more information, please visit www.thepracticewithin. com, or email charles@thepraticewithin.com.

40 Implant practice

your implant sales representatives and stay current on all products. How to accomplish this: Invest in your implant treatment coordinator. Take him/her to conventions and CE. This staff member should have a surgical rotation with you where you can tutor him/her on technique, instrumentation, and reasoning.

2. They have a foundation of prosthetic knowledge and are a resource to your referrals. Your ITC should be such an expert on prosthetic procedures and parts that your referrals would rather call your ITC instead of the implant sales representative or even you! This is an absolute critical skill. For example, ITCs should know open- and closed-tray impression technique and which parts are used in which situations (single units versus bridges). Superstar ITCs can go chairside to your referral’s office to walk him/her through an implant impression; elite ITCs go chairside for implant crown seatings when necessary to help troubleshoot any potential problems. Your ITC should have your main lab technician’s cell phone and have a working relationship with him/her. Why is this so important? Having your referrals contact your ITC with these questions saves you time to focus on production-creating activities; your ITC becomes a rep for your office at the disposal of your referrals, which creates value. Here’s something your restorative doctor may not tell you: “I don’t like when you use this particular implant system because I don’t like working with the company/rep.” Restorative doctors usually won’t tell you until you notice their referral pattern slipping. By that time, it may be too late. If your ITC is a prosthetic master, then you are no longer a slave to situations that are out of your control (like your favorite rep switching companies, which forces you to look for another system). How to accomplish this: Again, invest in your ITC with continuing education. Also,

pick your favorite, most experienced referral, and have your ITC spend a few days shadowing that person doing implant restorative procedures.

3. Amazing implant treatment coordinators have a consultative sales mentality. This boils down to a few abilities. First of which, your ITC should not blink when presenting a $60,000 double-arch hybrid treatment plan because he/she fully understands and believes in the treatment he/she is presenting. Your ITC should be carrying out 90% of the implant consultation and cover the following: • medical history • alternative options to an implant • timeline for a single- or two-stage implant • restorative timeline • common questions about bone grafts • fielding any other questions At this time, you should be able to come into the room, make a quick diagnosis, finalize the treatment option, and then leave the ITC to carry out financial arrangements. Maximizing implant production means decentralizing your command of the office and allowing your staff to absorb tasks. How to accomplish this: Create a script for your implant consultation. Your ITC should shadow your consultation style and memorize keywords and phrases that you like to use. You should role-play consultations with your ITC, and last, observe his/ her initial consults to ensure he/she follows your script. These three skills take time and require your investment. The upfront cost and effort it takes to get an individual in your office to this level will pay dividends. The unseen benefit is the increased implant potential that your office can realize with an amazing implant treatment coordinator as the captain of your implant practice. IP Volume 9 Number 5

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Are short implants an acceptable alternative to sinus floor elevation in the posterior maxilla? Dr. Johan Hartshorne

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Clinical articles enhanced by high quality photography Analysis of the latest groundbreaking developments in implant dentistry

Predictable implant therapy Torque versus RFA at implant placement: a case study

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IMPLANT INSIGHTS

Problem solving In the second part of his series, Dr. Diyari Abdah discusses some very common implant problems and presents some ways to avoid them

his article will focus on some of the very common problems in the process of implant placement.

Not placing the right number or size of implants Failure to respect occlusal considerations, combined with too few implants to take a large occlusal load, can lead to failure. This can happen very quickly and is a cause for many inquiries from unhappy patients who have spent a lot of time and money thinking that they had a solution to their problem and yet find out that everything failed. Of course, with that goes the trust in the initial dentist who delivered the treatment. Common sense dictates that we start the entire treatment-planning process with the end result in mind. This is why we utilize study models, correct radiographs/CT scans, three-dimensional modeling, diagnostic wax-ups, and occlusal analysis. All these elements are important factors here. Think where the occlusal forces might be highest, and plan what you need in those areas to support the restoration(s). Then, based on the available bone and anatomical structures, you can plan your implant case with or without grafting where needed. We should never compromise the positioning of an implant because we don’t want to (or don’t have the right skills) to carry out a grafting procedure (to enhance the bone/ soft tissue profile), or because the patient refused a graft. Unfortunately, sometimes this happens as the dentist tries to be “accommodating” to the patient’s requirements. That’s like a pilot flying according to the passenger’s technical requirements. It is all about how the information is presented to the patient.

Diyari Abdah, MSc ImpDent, is a cosmetic and implant dentist in private practice in Cambridge, England. He deals with all aspects of implant dentistry and grafting techniques, and has been actively promoting dental implants among GPs for the last 12 years through lecturing, workshops, articles, and mentoring programs. Dr. Abdah is a visiting academic at the University of Warwick on the implant MSc program and runs a successful mentoring program that emphasizes avoiding and solving problems in implant dentistry.

42 Implant practice

When the right procedure has to be done for the right reason, an executive decision has to be made to thoroughly explain to the patients, giving them all the necessary information about why we have to do what we have to do. If this is done satisfactorily, presenting the information in a logical and easily understood manner, then most patients will put up very little resistance. Remember, they trust you, and that’s why they are there in the first place.

Paying attention While on the subject of occlusion and its importance in implant dentistry, one major problem could be not paying attention to the lateral forces when restoring implants, as this can be fatal for the implants in the long run. This is not just an issue for the restorative dentist, but also for the surgeon who places the implants. The surgeon often gives little room for the restorative dentist to maneuver and restore correctly. One example is when the implant is placed at an angle because of the bone, but because of this, the restoration has to be less than ideal and subsequently will fail when in use after some time. Good communication between the surgeon and the restoring dentist, together with the laboratory technician, is of utmost importance for the overall success of every case. In planning any case, we must always be mindful of the need to maintain a favorable occlusal scheme if it is to be a longterm success. The starting point is a correctly fabricated wax-up (or a digital scan), which takes into consideration the correct occlusal table for the restoration — without any sharp or high cusps — and minimizes the negative effects of lateral/excursive movements on the implant. Creating correct vertical dimension is critical, together with correct angulation of the implants and the restorations, to minimize bending moments on the components. For dentures, a customized occlusion should be adapted and tested to improve the long-term prognosis of the implant-denture interface. If implants and natural teeth are part of a functioning dental arch, the natural teeth should meet the opposing dentition prior to

the implants. Remember that a foreign structure (like implants) in bone reacts differently to forces than natural teeth. In conclusion, occlusal biomechanical stress (forces) is a critical factor in the longterm prognosis of any implant case. The higher the number of implants that have to be placed, the more mindful of their correct positioning and alignment we have to be. Over the years, many placement sequences and positioning have been suggested to avoid unwanted torque forces, thus distributing the forces in a favorable way. Among these suggestions is to always use the longest and widest implants (when possible) in a nonlinear way, but not too close to each other, that can be favorably restored in a functional and esthetic manner. Although more research has recently been done on shorter implants (and some literature encourages their use when there is insufficient bone height), they are still under scrutiny by some, and more research is needed in this area before we can give up on traditional sinus and vertical ridge augmentations. Mixed results suggest the need for sticking to known standards, especially for the beginners among us. In certain cases of restoring the posterior maxilla with shorter implants, it would have been easier to perform a sinus augmentation and subsequent long implant than a very short implant initially with subsequent thread exposure problems. Remember, the exposure of only two to three threads of a very short implant results in 50% or more bone loss around that implant!

Dealing with bone dehiscence and alveolar bone irregularities It is critical to observe and note the bone contour prior to surgery, ideally through a CBCT scan and 3D modeling of the jaw. Although some clinicians use CBCT scans for almost every case, the majority of surgeons still try to get a feel for the buccal bone contour through observation, simple palpation, and possible ridge mapping, especially in cases of one or two implants. Being equipped with the right knowledge and know-how in dealing with these defects makes all the difference in making the case a Volume 9 Number 5

Conclusion Treating our patients with dental implants can be very rewarding, but it should not be taken lightly. Implant dentistry combines many disciplines, and just one mistake can have negative consequences later. Thorough planning, using all the diagnostic tools available to us, is the best way to avoid mishaps and achieve the desired results. Above all, be curious and critical. Learn everything you can from others and your own cases — and be prepared to change things when they don’t work. IP Volume 9 Number 5

IMPLANT INSIGHTS

potential success. Preoperative wax-ups can indicate the ideal positioning of implants and indicate the need for any bone augmentation, but CBCT scans and 3D digital models can demonstrate this even more accurately. It is important to note that it is more predictable to place an implant in the native bone, despite its uneven topography (provided the quality and quantity of the bone is good) than in a block graft that may resorb because of a disturbed blood supply. Bone resorption can happen after an extraction (before placing an implant) as part of socket remodeling or after the implant has been placed and is in function. Both require much attention, but the treatment approach can be different. Avoiding resorption after extraction can be achieved by applying one of the many socket preservation techniques in the literature. This can be done easily; there is little excuse for resorption to occur. Planning and sequencing implant placement after extraction can also reduce the incidence of post-extraction bone resorption, and this too has been documented extensively in the literature. Dealing with bone dehiscence after placement is another issue. The principles are the same, but the approach is different. If the cause is infection, the etiology has to be identified and treated accordingly to prevent further bone loss. If the cause is parafunction, and no infection is involved, then the implant surface has to be cleaned, HA graft applied to aid soft tissue adherence, and the source of the parafunction eliminated. Performing a ridge-splitting procedure and/or block grafts can enhance the overall thickness in the case of a very thin ridge. However, the easiest way can sometimes be flattening the edge of the ridge to gain a platform for the implant placement — height permitting. Apical bone perforations (fenestration) can also be noted sometimes in the maxilla, and these require bone grafting, sometimes combined with guided bone regeneration.

Designed for Easy Placement Once the coated granules of GUIDOR® easy-graft ® are syringed into the bone defect and come in contact with blood, they change in approximately one minute from a moldable material to a rigid, porous scaffold. • Designed for ease of use and predictability • 100% synthetic and fully resorbable • Ideal for ridge preservation and filling voids around immediate implant placements This product should not be used in pregnant or nursing women.

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To learn more, visit http://us.GUIDOR.com/easy-graft/ or call 1-877-484-3671. Instructions for Use (IFU), including indications, contraindications, precautions and potential adverse effects, are available at http://us.GUIDOR.com/IFU/. © 2016 Sunstar Americas, Inc. All rights reserved. GDR16071 09162016v1 The trademarks GUIDOR, easy-graft and BioLinker are owned by Sunstar Suisse, SA.

Implant practice 43

ON THE HORIZON

You can’t forget about the tissue Dr. Justin Moody discusses the importance of soft tissue evaluation

oday in implant dentistry, we are starting to see the true importance of soft tissue architecture, not only at the time of implant placement, but also for the longterm esthetic survival of the restoration. In my practice, I have seen the changes in soft tissue manipulation or lack thereof, and I can tell you that we all learn from our mistakes and experiences. When I first started placing implants nearly 20 years ago, I only used a twostage technique and always uncovered my implants with an incision not removing any tissue. As time continued, I started to look at less invasive techniques such as a tissue punch or laser; this was often less traumatic to the patient, but what about the tissue? Those techniques remove the most valuable thing we have — keratinized tissue. It is important to note that there are some instances, like in the posterior maxilla where the tissue is already super thick, that you can use these methods. However, in the esthetic zone, where tissue is king, and the papilla rules, we need all that we can get. I was recently teaching a guided-surgery course where I was showing a case involving a flap being laid first prior to the guide. A doctor raised his hand and said, “That’s exactly why

Figure 1: Edentulous mandible with thin biotype and total lack of keratinized tissue

Figure 2: Thin unattached non-keratinized tissue

Figure 3: Adequate ketatinized tissue and soft tissue drape

Figure 4: BioHorizons® Tapered PLUS platform switching designed for increased soft tissue volume.

Figure 5: Screw-retained crown using authentic BioHorizons TiBase with Laser-Lok® Image 6: Layered zirconia screw-retained crown from ProSmiles Dental Studio 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®.

44 Implant practice

I am learning about guides so that I don’t ever have to make a flap again.” It was then that I knew we needed to discuss this. The long-time edentulous mandible is one of the areas in which we see a total lack of keratinized tissue. It is here that I get the most emails asking what to do when a locator abutment is coming out of paper-thin tissue, and the patient is complaining of pain and discomfort. Many times, this patient has

adequate bone, and we jump straight into the placement, not thinking of the long-term effects of the absence of tissue. The referral to a periodontist may seem like a case killer, but in the long-term, it could be the difference between seeing the patient once every 6 months for re-care or every week with a problem. Soft tissue evaluation during the implant workup is a must; it just makes life easier! IP Volume 9 Number 5

why choose BioHorizons Laser-Lok implants? improved crestal bone maintenance reduced probing depths conventional implant

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Tapered Laser-Lok family Developed from over 25 years of research, the unique Laser-Lok surface has been shown to elicit a biologic response that includes the inhibition of epithelial downgrowth and the attachment of connective tissue.1 This physical attachment produces a biologic seal around the implant that protects and maintains crestal bone health. The Laser-Lok phenomenon has been shown in post-market studies to be more effective than other implant designs in reducing bone loss.2

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1. M Nevins et al. Int J Periodontics Restorative Dent. Vol. 28, No. 2, 2008. 2. S Botos et al. Int J Oral Maxillofac Implants. 2011; 26:492-498. SPMP16251 REV A AUG 2016

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT 3Shape Abutment Designer receives 510(k) clearance The United States FDA has issued a 510(k) clearance for 3Shape Abutment Designer, a functionality within 3Shape Dental System CAD/CAM software. The 510(k) clearance covers all implant cases being designed using 3Shape Dental System software. A 3Shape Abutment Designer and/or Implant Bridge and Bars license is needed to use the functionality. The FDA 510(k) clearance for 3Shape Abutment Designer is unique in that it marks the first time a stand-alone CAD/CAM software has received clearance under the FDA’s new product code PNP - Abutment design software for dental laboratories. 3Shape Abutment Designer is part of 3Shape’s larger eco-system of CAD/ CAM dental design software. Implant libraries integrated with 3Shape software will need to apply individually to receive 510(k) clearance. In the United States, 3Shape Abutment Designer can only be used with libraries with documented 510(k) clearance. 3Shape creates 3D scanning and CAD/CAM software solutions. A privately owned company, 3Shape has over 700 employees with a product-development force of more than 275 professionals. Offices and service centers located in the Americas, Asia, and Europe serve customers in more than 100 countries. Company headquarters are in Copenhagen, Denmark. For more information, visit www.3shape.com.

Danaher Corporation Awards scholarships to three children of dental platform associates The 2016 Danaher Scholarship Program presented a total of $225,000 to students this year. Nearly 400 students applied to the program this year. Of the 36 university-bound women and men selected — chosen based on a combination of academic achievement, extracurricular activity involvement, and moral character — three are children of Danaher dental platform associates. Administered by Scholarship Management Services on behalf of Danaher, each student will receive between $5,000 and $8,000 to put toward tuition. Since its inception more than a decade ago, the Danaher Scholarship Program has awarded more than $2 million in scholarship dollars to deserving students. Among Fortune 500 companies, the Danaher scholarship program stands out: It ranks in the top 25% of companies for its total distribution and in the top 10% for individual award amounts.

46 Implant practice

Osstell partners with W&H to bring innovative and integrated solution to dental implant procedures The global leader in implant stability measurement, Osstell, has announced its partnership with the Austrian family-run dental company, W&H Dentalwerk Bürmoos GmbH. The collaboration will focus on bringing innovative all-in-one solutions to support dental implant clinicians in their everyday practice. The first result of this partnership is now being introduced in the form of W&H’s latest generation surgical device, Implantmed, where an integrated Osstell ISQ module is available. This unique combination of technologies allows a new standard to be set in the global dental industry, while giving users significant benefits in terms of functionality and optimum efficiency during treatment, and thereby helping clinicians improve patient confidence and comfort. W&H is known in the global dental market as a leading manufacturer of dental precision instruments and devices. Innovative prowess and outstanding quality have been at the heart of the company for over 125 years, as have lasting collaborative partnerships. For W&H, the collaboration enables the integration of a new innovative functionality — called “W&H Osstell ISQ module” — to the new generation of its Implantmed surgical device. The integration of the proprietary Osstell Implant Stability Quotient (ISQ) technology in the new Implantmed device allows the user to benefit from non-invasive monitoring of osseointegration. Knowing the right time to load an implant is becoming increasingly complex due to all the key parameters and risk factors that need to be considered for each patient. The ISQ measurements allow clinicians working with implants to make decisions based on reliable and objective stability values when determining the course of treatment for each patient. This procedure can be used to measure primary implant stability, observe osseointegration on the basis of secondary stability readings, and determine the best possible time for loading the implant, thereby helping to prevent failures and ensuring high quality. The W&H Osstell ISQ module is available as an option and can also easily be retrofitted for use on one of the new generation of Implantmed devices. To learn more about Implantmed, visit http://www.wh.com/ en_global/dental-products/oralsurgery-implantology/surgicaldevices/implantmed/. For more information about Osstell, please visit Osstell.com.

Volume 9 Number 5

Dr. Justin Moody and his faculty will mentor and guide you down the implant pathway. You’ll learn... ✔

Live Implant Surgery and Restorations Done by YOU

✔ Patient Selection, Medical History and Pharmacology ✔ Treatment Planning and Case Acceptance ✔ Surgical Implant Placement

✔ Ridge Preservation and Bone Grafting ✔ Guided Implant Surgery

✔ Complications When It Don’t Go Right

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DO YOU KNOw how to TREATMENT PLAN and deliver implant dentistry TO YOUR PATIENTS?

Diplomate - American Board of Oral Implantology Diplomate, Master and Fellow - International Congress of Oral Implantologists Fellow and Associate Fellow - American Academy of Implant Dentistry Master and Fellow - Misch International Implant Institute Adjunct Professor - University of Nebraska Medical Center Mentor - Kois Center

Learn more at justinmoodydds.com

MATERIALS & EQUIPMENT i-CAT™ introduces i-CAT FLX V-Series, the first line of upgradable dedicated 3D CBCT machines with the full award-winning i-CAT FLX technology i-CAT™, a brand of the KaVo Kerr Group, has launched the i-CAT FLX V-Series, the industry’s first fully upgradable solution. This dynamic system offers three fields of view (FOV), enhanced lowdose and ultra-low-dose 3D imaging, and dedicated 2D traditional panoramic capabilities at a price point starting at under $90,000. The i-CAT FLX V-Series enables clinicians to support current or incorporate new treatment offerings, such as airway analysis, with an imaging solution that can grow as their practice evolves. Features include: • A solution that can grow as a practice’s diagnosis and treatment offerings expand i-CAT. • FLX V-Series provides the option of upgrading the field-ofview based on the types of procedures performed today and in the future, such as: o i-CAT FLX V8 – 8x8, 2D pan o i-CAT FLX V10 – 10x16, 2D pan o i-CAT FLX V17 – 17x23, 2D pan • Enhanced low-dose and ultra-low-dose scanning, using i-CAT QuickScan and QuickScan+ protocols, allows practitioners to take complete 3D images at a radiation dose comparable to a 2D panoramic image. • The i-PAN™ feature allows technicians to take a quick 2D pan using the same high-quality sensor that is used to acquire 3D scans. That, coupled with software used to enhance overall 2D image quality, dentists and specialists can confidently use their i-CAT FLX V-Series for both 2D and 3D imaging. • Utilizing i-CAT PureScan™ technology and full-size sensor, i-CAT FLX V-Series scanners utilize full-beam scanning and maximize the use of the large sensor to capture a 3D scan. This provides more anatomical information without compromising image quality compared to other smaller sensors. • Open software architecture seamlessly integrates the easyto-use SmartScan STUDIO™ with touch screen interface with orthodontic programs, CAD/CAM systems, and practice management systems, providing a comprehensive practice workflow solution for all-sized practices. For more information about the i-CAT FLX V-Series, including a product brochure, access to either webinars, or to schedule demos, please visit http://info. i-cat.com/flxvseries_vbpr.

48 Implant practice

New innovations from Carestream Dental enhance workflow in the OMS practice Carestream Dental’s newest intraoral scanner, the CS 3600, is designed with oral and maxillofacial surgeons in mind, with an implant-borne restorative workflow, fast scanning to save on chair time, and an open system for easy sharing of files. The implantborne restorative workflow of the CS 3600 is designed specifically for handling implant scanning, supported abutments, and scan bodies. A dual scan mode allows the user to scan the same implant region of interest twice — once with the scan body in place and one without — to capture more precise data. Also, the scanner’s software allows for split-screen viewing for side-by-side comparison of the digital impressions with and without the scan bodies/abutments in place. The CS 3600 also features high-speed continuous scanning to significantly reduce the time it takes to acquire a digital impression. Unsteady hands or fidgeting patients have no impact on successive views; users simply continue to scan in a smooth motion. Continuous scanning contributes to faster, easier dualarch acquisition and, ultimately, more accurate digital impressions. Because the CS 3600 is part of an open system, it is compatible with other open implant planning and surgical guide software programs. Open .STL files also make it easier to quickly share data with referrals and labs. Collaborating on implants is also simplified — a digital impression can be taken at the OMS practice; the case is submitted digitally to a lab; and the final restoration can be sent directly to the referring GP. This also means the patient doesn’t have to make multiple trips between the surgeon and dentist. The CS 3600 also features an Intelligent Matching System that “auto-locates” holes in the data set that need to be filled in while scanning. The scanner comes with a normal and a side-oriented tip; the tips are rounded, interchangeable, and autoclavable, so users can capture scans in hard-to-reach areas while considering patient comfort and safety. Stunning full HD 3D color impressions make for easier diagnosis and enhanced communication with patients, referrals, and labs. The CS 3600 is not connected to a trolley or proprietary computer and is easy to carry from operatory to operatory. For more information, call 800-944-6365 or visit www. carestreamdental.com.

Volume 9 Number 5

Referrals Simplified Securely and easily send electronic referrals

Save time & stay compliant

Streamline communication among dental colleagues

Call: 415.749.1444 Visit: RecordLinc.com

PATIENT PORTAL

REFERRALS

SCHEDULING

INTEGRATION

MESSAGING

eFORMS

InterActive™ Nobel Biocare® Compatible* Simply Smarter Conical Connection

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

Simply Smarter Restorations

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

Neck Matched to Major Diameter • Seals opening at crest of ridge reducing need for bone grafting

Simply Smarter Surgery

Domed Apex • Less aggressive apex reduces risk during insertion of implant diverging from path created by drilling

Matched Concave Transgingival Profile on Abutments & Components • Shape soft tissue for improved esthetics Compatible Abutments with Longer Hex/Shorter Bevel • Reduce the need to confirm seating with X-rays Two Color-coded Implant Platforms for Four Implant Diameters & Six Lengths • Restore more implants with a smaller prosthetic inventory and easily identify the correct size

Apical 1/3rd Tapers 2º • Slight body taper increases initial stability without over-compression and facilitates self-tapping insertion in dense bone Micro-threads and Grooves • Micro-grooves and micro-threads to increase stability as well as reduce stress in crestal bone area

Packaging Options

All-in-1 Packaging

Includes implant, cover screw, healing collar & new fixture-mount – $225 SBM

NEW simplyInterActive includes mountfree implant, cover screw & 3mm healing collar – $195 SBM, $175 if SMART PACK purchased at same time

AAID Booth# 810 ADA Booth# 3437 GNY Booth# 3313 AAOMS Booth# 415

Plastic simplyfixed Ball SMART PACK simplycrown & bridge Laboratory Straight 15° Angled Gold/ Zirconia Temporary LOCATOR® Abutment Contoured Contoured Plastic Abutment Abutment Abutment Abutment Straight Angled SMART PACK

*Nobel Biocare® NP & RP compatible. All trademarks are property of their respective companies. Measurements based upon 4.3mm diameter, 13mm length implants. Dimensions can vary. All prices shown in USD. Pricing and product availability subject to change without notice. Not all products shown are available in all countries.