Chairside Magazine Volume 15, Issue 2 by Glidewell

SPECIAL IMPLANT EDITION

Implant, Restorative and Esthetic Dentistry

vol. 15, iss. 2

10 THINGS

I Learned the Hard Way Dr. Jack Hahn p. 9

Guided Bone Regeneration 8 Steps to Successful Ridge Augmentation Dr. Randolph Resnik p. 31

4 Ways to Temporize Dental Implants Dr. T â&#x20AC;&#x2030; aylor Manalili p. 56

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PUBLISHER’S LETTER

Making Implant Treatment Affordable for More Patients

D As our goal was to improve the availability of implant treatment, we recognized that every aspect of the process would need to be simplified — from initial training, to treatment planning, to surgery and ultimately to seating the final restoration.

ental implant treatment can be one of the most life-changing services we offer in dentistry, and like so many of the dentists we serve, we believe these benefits should be available to every patient in need. But the reality is that, for many practitioners, providing dental implant treatment is perceived as out of reach — a notion that was reinforced for many years by overpriced implant components, unpredictable prosthetic designs, and uncertain case profitability. Starting nearly two decades ago, I sought to address these issues. By that time, our laboratory had already restored hundreds of thousands of implant cases, learning from the challenges and complexities that made implant treatment anything but straightforward. We used these insights to develop an implant manufacturing division — obtaining German-engineered machinery to fabricate our own prosthetic components in 2007, mini implants in 2011 and tapered implants in 2012. However, implantology is about far more than precision-manufactured components. As our goal was to improve the availability of implant treatment, we recognized that every aspect of the process would need to be simplified — from initial training, to treatment planning, to surgery and ultimately to seating the final restoration.

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We began seeking partners who had expertise in areas we lacked. We first connected with implant pioneer Dr. Jack Hahn, who has dedicated the last 50 years to making implant treatment more accessible to general dentists, including developing one of the most widely used implant systems in dentistry. Out of this partnership came the Hahn™ Tapered Implant System, which combines clinically proven features with contemporary innovation to meet the demands of modern implant dentistry. From there, we joined forces with the Misch International Implant Institute, the group of educators that has continually advanced the standards for dental implant training for more than 30 years. Not only has our company hosted some of their comprehensive courses in our state-of-the-art classroom facilities, but we also rely on Misch faculty and graduates to keep our engineers and laboratory technicians informed of the latest developments in implantology, ensuring that our efforts are focused on solving real challenges. Now, as implants have become the gold standard for the replacement of missing teeth, our company is firmly positioned to ensure the general dentist can participate. With our free and lowcost education opportunities, advanced surgical solutions, and full range of CAD/ CAM custom laboratory services, we offer clinicians everything they need to deliver this superior form of treatment simply and reliably, case after case. And better still, because we do all of this in-house at our California facilities, we’re able to keep costs down as we’re not reliant on third-party manufacturers, distributors or middlemen — savings we’re excited to pass on to our customers.

Sincerely,

Jim Glidewell, CDT President and CEO, Glidewell

TABLE OF CONTENTS

One hour of free CE is available for Dr. Hahn’s article. See page 16 for details.

One hour of free CE is available for Dr. Resnik’s article. See page 40 for details.

10 Things I Learned the Hard Way

A Simplified Clinical Protocol for the Fabrication of Full-Arch Implant Restorations

Guided Bone Regeneration: 8 Steps to Successful Ridge Augmentation

Dr. Taylor Manalili — Delivering the most life-changing implant restoration in dentistry doesn’t have to be a challenge.

Dr. Randolph Resnik — Take a look at the detailed step-by-step protocol for grafting bony ridge deficiencies in preparation for implant placement.

Dr. Jack Hahn — Discover the most important things to know about implantology from an implant pioneer who has been placing implants for 50 years.

Meeting High Esthetic Demands

5 Ways to Increase Implant Case Acceptance

Dr. Paresh Patel — More and more dentists are adding all-ceramic zirconia implants to their armamentarium — this case report illustrates why.

Dr. Roger Levin — Here are some simple strategies for improving case presentation and getting patients to say yes to implant treatment.

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One hour of free CE is available for Dr. Manalili’s article. See page 62 for details.

My First Immediate Load Full-Arch Implant Case

4 Ways to Temporize Dental Implants

When Are Overdentures the Right Treatment?

Dr. John Fish — Find out how rewarding immediately loading implants can be, and why one clinician is never going back to the acrylic hybrid denture after delivering his first monolithic zirconia full-arch implant restoration.

Dr. Taylor Manalili — Don’t miss these simple guidelines for deciding which lab-fabricated temporary solution is ideal for your implant case.

Dr. Timothy Kosinski — This simple, cost-effective solution is a great alternative for some patients who present with an unstable denture, especially in these common situations.

51 Tapered vs. Parallel-Walled Implants: Which Is the Better Design and Why? A recent study set out to determine which implant body design leads to higher primary stability — one of the most important success factors in implantology.

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ON THE WEB Here’s a sneak peek at additional Chairside® magazine content available online

ONLINE VIDEO PRESENTATIONS ■

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r. Taylor Manalili details a case in which a failed D implant is replaced, and reviews the clinician’s options for temporizing an implant site. on’t miss Dr. Roger Levin’s 11 critical steps for quickly D increasing production at your practice so you can better meet the challenges of today’s dental landscape.

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Based on feedback from clinicians and extensive R&D, Dr. Manalili presents a streamlined protocol for providing a fixed full-arch implant restoration. r. Paresh Patel demonstrates how all-ceramic zirconia D implants help address the most esthetically demanding cases.

ONLINE CE CREDIT Free CEUs are available online for the following articles featured in this issue: Dr. Randolph Resnik’s “Guided Bone Regeneration: 8 Steps to Successful Ridge Augmentation,” Dr. Jack Hahn’s “10 Things I Learned the Hard Way,” and Dr. Taylor Manalili’s “4 Ways to Temporize Dental Implants.”

chairsidemagazine.com Visit chairsidelive.com to view the latest episode of our weekly web series “Chairside Live.”

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EDITOR’S LETTER

Since shutdowns began in March, doctors have completed more than 10,000 CE courses and attendance for our weekly webinars has totaled more than 54,000.

hen doctors returned to their practices after the COVID-19 shutdown, many experienced a surge in production. In fact, for some practices, June and July were the most productive months on record. And based on the cases coming into the lab, implants were a major part of that pent-up demand. That’s not difficult to understand, because implants are the basis for some of the most life-changing treatment that we as dentists have the opportunity to provide.

This special implant dentistry issue of Chairside® magazine is part of the same effort. By putting together some of the country’s top implant mentors — including Drs. Randy Resnik, Jack Hahn, Tim Kosinski and Paresh Patel — we provide the most current and practice-proven clinical information available in the field of implant dentistry. From Dr. Resnik’s detailed review of guided bone regeneration, to Dr. Taylor Manalili’s practical discussion of implant provisionals, this issue is filled with practical information that will improve your clinical outcomes.

In the Publisher’s Letter, Jim talked about our implant mission at Glidewell: the drive to help make this treatment available to more patients. And a big part of that effort is providing clinical information to make doctors better prepared to render state-ofthe-art care, efficiently and profitably. Although we experienced a temporary interruption in our live courses and symposia, we have continued to provide these programs through our live webinars and on-demand courses. In fact, since shutdowns began in March, doctors have completed more than 10,000 CE courses and attendance for our weekly webinars has totaled more than 54,000.

On behalf of the team at Chairside magazine, I hope you enjoy the issue. We appreciate your support and hope that you find this issue — as well as our webinars, online courses and live hands-on courses — to be valuable in reaching your practice goals.

With kind regards,

Neil I. Park, DMD Editor-in-Chief chairside@glidewelldental.com

For our collection of online CE courses, visit education.glidewelldental.com. To register for one of our upcoming study club webinars, visit glidewelldental.com/studyclub.

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PUBLISHER Jim Glidewell, CDT EDITOR-IN-CHIEF Neil Park, DMD CLINICAL EDITOR Jack Hahn, DDS EXECUTIVE EDITORS Greg Minzenmayer, Eldon Thompson MANAGING EDITOR Bobbie Norton, RDA CREATIVE COORDINATOR Jennifer Gutierrez CONTRIBUTING COPYWRITERS/EDITORS Danny Evans, Ilona French, Chris Newcomb, Kiali Wong Orlowski, Brenda Paro, Keith Peters, Adam Pringle, Michelle Raddatz

JACK A. HAHN, DDS

VISUAL ARTS SUPERVISOR Joel Guerra GRAPHIC DESIGNERS/ILLUSTRATORS Dennis Lee, Phil Nguyen, Kelley Oh, Makara You WEB DEVELOPERS Adrian Barone, Meng-Jung Hsieh, Anna Kim, Caity Schoenfeld PHOTOGRAPHERS/VIDEOGRAPHERS James Kwasniewski, Sam Lea, Andrew Lee, David Manahan, Crystal Nguonly, Marc Repaire, Stanford J. Southall, Sterling Wright, Maurice Wyble AD REPRESENTATIVE Michael R. Martinez

Neither Chairside magazine nor any employees involved in its publication (“publisher”) make any warranty, expressed or implied, or assume any liability or responsibility for the accuracy, completeness, or usefulness of any information, apparatus, product, or process disclosed, or represent that its use would not infringe proprietary rights. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer or otherwise does not necessarily constitute or imply its endorsement, recommendation, or favoring by the publisher. The views and opinions of authors expressed herein do not necessarily state or reflect those of the publisher and shall not be used for advertising or product endorsement purposes. CAUTION: When viewing the techniques, procedures, theories and materials that are presented, you must make your own decisions about specific treatment for patients and exercise personal professional judgment regarding the need for further clinical testing or education and your own clinical expertise before trying to implement new procedures.

JOHN M. FISH, DDS Dr. John Fish earned his DDS from the University of North Carolina at Chapel Hill School of Dentistry. He completed postgraduate training at the Pankey Institute and is a graduate of the Kois Center and the Misch International Implant Institute. Dr. Fish owns a private practice in Hildebran, North Carolina, with a strong focus on implant dentistry. He has been placing dental implants since 1983 and has published articles in Dentistry Today and the Journal of Oral Implantology. Dr. Fish is a Diplomate of the American Board of Oral Implantology/ Implant Dentistry and a Fellow of the Misch Institute, AAID and AGD.

TIMOTHY F. KOSINSKI, DDS, MAGD Dr. Timothy Kosinski graduated from the University of Detroit Mercy School of Dentistry and received a Master of Science degree in biochemistry from Wayne State University School of Medicine. In addition to serving on the editorial review board of numerous dental journals, Dr. Kosinski has published over 180 articles and contributed to textbooks on the surgical and prosthetic phases of implant dentistry.

Chairside is a registered trademark of Glidewell.

Dr. Jack Hahn earned his DDS from The Ohio State University College of Dentistry. A pioneer in the field of implant dentistry, Dr. Hahn has been placing and restoring dental implants for 50 years, and he developed the original tapered implant design in the 1990s. Most recently, he oversaw the design of the Hahn™ Tapered Implant, which was created to streamline treatment and improve results. Dr. Hahn is also clinical editor of Chairside® magazine. He lectures to dentists around the world and maintains a private practice in Cincinnati, Ohio.

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CONTRIBUTORS TAYLOR MANALILI, DDS ROGER P. LEVIN, DDS Dr. Roger Levin is the CEO of Levin Group, Inc., a leading dental management consulting firm. Founded in 1985, Levin Group has worked with more than 30,000 dental practices. Dr. Levin is one of the most sought-after speakers in dentistry and is a leading authority on dental practice success and sustainable growth. He is a graduate of the University of Maryland School of Dentistry, and has authored 65 books and more than 4,000 articles on dental practice management and marketing.

PARESH B. PATEL, DDS

RANDOLPH R. RESNIK, DMD, MDS Dr. Randolph Resnik graduated from the University of Pittsburgh School of Dental Medicine and has earned specialty certificates in prosthodontics and oral implantology, as well as a Master of Dental Science. He was chief of staff and surgical director of the Misch International Implant Institute for over 15 years, and is currently the instituteâ&#x20AC;&#x2122;s director and primary lecturer. Dr. Resnik lectures in the U.S. and internationally, and has a practice in Pittsburgh focused on oral implantology.

Dr. Paresh Patel is a graduate of the University of North Carolina at Chapel Hill School of Dentistry and the Medical College of Georgia/AAID MaxiCourse. A clinical instructor who has placed more than 5,000 implants, Dr. Patel has published numerous articles in leading dental journals, is a Diplomate of the ICOI, and has worked extensively as a lecturer and clinical consultant on dental implants and prosthetics for several companies.

Dr. Taylor Manalili is director of clinical prosthodontics at Glidewell. Since joining Glidewell in 2018 as the companyâ&#x20AC;&#x2122;s first-ever Fellow, she has conducted clinical research and performed advanced restorative work, including implant placement, chairside restorations and fullmouth rehabilitations. Dr. Manalili earned her Doctor of Dental Surgery degree as well as a certificate in the advanced specialty of prosthodontics from Stony Brook University. Throughout her residency, Dr. Manalili served as a clinical instructor for predoctoral students, and provided lectures to students, residents and local dentists.

NEIL PARK, DMD Dr. Neil Park is vice president of clinical affairs for Glidewell. He received his DMD from Temple University School of Dentistry and practiced general dentistry in Florida before moving on to an accomplished career in the dental implant field, developing continuing education programs and implementing a predoctoral implant curriculum in universities throughout North America. In 2016, Dr. Park joined Glidewell, where he oversees clinical research as well as training and education programs for implant and restorative solutions.

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10 Things I Learned the Hard Way by J ack A. Hahn, DDS Implant Dentistry Pioneer and Private Practitioner — Cincinnati, Ohio

hings have changed a great deal since I began placing implants 50 years ago. Implant designs have evolved — and I’ve been fortunate enough to have had a hand in that. Implant restorations have advanced more than I could have imagined. The fact that you can restore an edentulous arch with unbreakable zirconia, with teeth and gingiva that look just like the real thing, continues to amaze me. It’s been great to see all this progress because, like many other dentists out there, I’ve seen time after time how implants can change the lives of patients, giving them back their smile, their ability to eat

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thousands of implantologists. Dr. Carl Misch was a friend of mine, and his dedication to teaching dentists how to place and restore implants based on scientific, literature-based principles is one of the biggest reasons implant dentistry is so successful and widely accepted today. The Hahn™ Tapered Implant (Glidewell; Irvine, Calif.) continues to serve as the official implant system of the Misch Institute, and I am honored that clinicians who attend their courses are taught to place implants following the simple surgical protocol I developed for the system with these very dentists in mind.

Offering the full range of tooth replacement options, including implant placement, is increasingly important in addressing the needs of patients, many of whom seek out dental practices that can provide this service.

the foods they want, and their quality of life. While we’ve come awfully far, there have certainly been challenges along the way. I’ve been asked: “Jack, very few dentists have been doing implants as long as you have. What have you learned over the years that you can share with others?” To be honest, I’ve learned a lot the hard way, whether from placing, designing or restoring implants. These are the big 10 that come to mind.

1. I MPLANTS SHOULD BE PART OF EVERY GENERAL DENTIST’S PRACTICE These days, a lot of patients specifically seek out implant treatment. If they don’t get it from you, they’ll get it from someone else. I get new patients at my practice all the time because they know I do implants. And my existing patients are far more likely to accept implant treatment from me than they would if I were to refer them out to a specialist, though many dentists con-

tinue to refer out their more advanced cases. For basic tooth replacement, patients want implants from their general dentist — they don’t want to go anywhere else. More and more dentists are learning to place implants, and their patients and practices are better off as a result. Don’t miss out on what can be the most rewarding and valuable part of your career as a dentist.

2. I NVEST THE TIME UP FRONT TO GET GREAT TRAINING When I got started placing implants, there was very little training available. These days, dentists have access to an abundance of high-quality educational resources. Established in 1984, the Misch International Implant Institute continues to lead the way. I’ve had the honor of teaching courses for the institute, which offers a continuum that has served as the foundation for

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Glidewell is another great source of implant education, from entry-level classes to advanced courses on fullarch restoration. I’m proud to teach my “emergency” implant course for Glidewell Clinical Education, as it’s one of the most rewarding procedures in dentistry and makes a huge impact on patients who come to you with a broken tooth. Glidewell also offers free online education that is a great way to keep up with CE, whether you’re just getting started or exploring more advanced procedures.

3. N EVER EXTRACT A TOOTH WITHOUT GRAFTING THE SOCKET I’ve extracted thousands of teeth over the years, and I didn’t always graft the socket. I know now that I should have. There’s no better time to prepare the site for an implant and, the more bone you have, the easier it is to place the implant. Even in cases where the patient doesn’t want an implant, it’s a good idea to graft the site following an extraction. After you remove a tooth, bone loss occurs, which can require a more complex surgical procedure if the patient decides they want an implant later. Plus, bone loss can affect facial esthetics and make it difficult to provide a patient with a stable denture. So, it’s still in the patient’s best interest for you to graft the socket. And socket regeneration can be a straightforward procedure,

especially with the simplified bone grafting solutions available from Newport Surgical™. Cortico-cancellous allograft does the trick in a majority of cases, and if you want to learn more about grafting, check out the online and in-person courses available at glidewelldental.com/education.

4. D ON’T TRY TO SAVE TERMINAL DENTITION

Dr. Jack Hahn with the late Dr. Carl Misch in 2016. Dr. Hahn has taught for the world-renowned Misch International Implant Institute, which has educated over 6,000 dentists in implant placement and restoration based on research-based principles. The Hahn Tapered Implant serves as the official implant of the institute, and is used during the hands-on and clinical courses to teach dentists straightforward surgical protocols.

When a patient comes in with dentition compromised by severe caries and periodontal disease, our instinct as dentists is to do everything we can to save the teeth. I certainly tried whenever I could, but there were many cases where I shouldn’t have. For many of these patients, endodontic, periodontal and restorative treatment have a poor long-term prognosis because of the patient’s dental history and hygiene. Sometimes, a full-mouth extraction is the most conservative treatment, especially when you consider the cost of failed efforts to save teeth. When you encounter cases where “saving” terminal dentition is simply prolonging the inevitable, removing the teeth will provide a better outcome for the patient. Many of these patients are in pain, and the sooner you place implants, the sooner you can give them a restoration that fully restores dental function and esthetics — without wasting time and money on unsuccessful treatment along the way.

5. O FFER YOUR PATIENTS SAME-DAY TOOTH REPLACEMENT

Dr. Hahn teaching a course at the Glidewell Clinical Education training center. For information on his upcoming courses on extraction with immediate implant placement, visit glidewellcecenter.com.

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When a distraught patient comes to you with a broken, untreatable tooth, there is no better way to serve their needs than with an emergency implant. Extraction with immediate implant placement and loading is my favorite procedure because it takes someone with an urgent need — a broken anterior tooth is painful, compromises function and can be embarrassing — and makes them

Bone grafting can be essential to achieving a predictable outcome whether performing socket regeneration for future implantation or immediately placing an implant. Here, a fractured central incisor was removed, a Hahn Tapered Implant was placed, and the site was grafted with Newport Biologics™ Mineralized Cortico/Cancellous Allograft Blend material (Glidewell; Irvine, Calif.), which contributed to the esthetic final restoration.

whole again in a single appointment. Immediate implant placement has proven to be just as predictable as delayed placement, and has been shown to result in enhanced preservation of the hard and soft tissues.1,2 There are several key principles to observe when performing this procedure: 1. Remove the tooth atraumatically, taking great care to preserve the buccal plate. If the buccal plate is compromised, change your plan. This is a case where you graft the socket and wait for the site to heal. 2. Place the implant a safe distance from the facial plate of bone. To achieve this, I recommend posi-

tioning the initial osteotomy 2–3 mm away from the facial plate. I designed the Hahn implant with a pronounced thread pattern that engages the palatal or lingual wall, which keeps the implant from “walking” toward the facial during placement. 3. Fill the gaps between the implant and bone with cortico-cancellous allograft. 4. Don’t load the implant with a provisional crown unless you achieve high primary stability of 35–45 Ncm. Using an implant that has aggressive threads, like the Hahn Tapered Implant, will help with this.

The emergency implant has a “wow” factor for patients, who can’t believe they were able to have their tooth replaced in a single day, and often recommend your practice to their friends and family after having such an experience. If you’d like to learn more, I strongly suggest you attend my emergency implant course, which you can enroll in via glidewellcecenter.com.

6. USE TAPERED IMPLANTS I always struggled with positioning parallel-walled implants located in the anatomically restricted space of the anterior maxilla. It occurred to me that an implant with a tapered body, much like the contours of a natural tooth root, would be easier to position

This patient presented with terminal dentition due to extensive caries and advanced periodontal disease. After removing the patient’s remaining teeth, Hahn Tapered Implants were placed during the same appointment to support a fixed restoration, and healing abutments were delivered. Four months later, a monolithic zirconia full-arch restoration was delivered, providing the patient with renewed function, esthetics and quality of life.

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The patient presented with a horizontally fractured tooth #11 and was in a great deal of distress due to the esthetic issues this created. After extracting the tooth, a Hahn Tapered Implant was placed. The pronounced thread design eased placement 1 mm from the facial aspect of the extraction site. High primary stability of 45 Ncm was achieved, allowing for the placement of an immediate provisional crown.

within the available bone. To solve this problem, I designed the Replace® Select implant (Nobel Biocare; Yorba Linda, Calif.). That design went on to become one of the best-selling implants in dentistry, and the tapered design has helped me fit implants into sites where limited bone was available on countless occasions. Additionally, the tapered design has the effect of a wedge, thereby increasing primary stability of the implant, which is essential to a predictable outcome, particularly with immediate-loading cases. The Hahn Tapered Implant — my latest and best design — has exhibited a success rate of 99.2% in clinical study, in no small part due to the tapered body design. Check out the article on page 51 that

summarizes Dr. Christopher Resnik’s study on how the primary stability of a parallel-walled implant compares with that of a tapered implant.

7. A MACHINED IMPLANT COLLAR PRESERVES BONE I began designing and placing implants that include a machined collar nearly 35 years ago. When my patients from that era come back for recall, radiographs show an impressive amount of bone around the machined collar after all these years. Studies have shown that, compared to implants with a roughened collar, machined collars preserve the bone at a higher rate, which helps ensure you’re giving the patient an implant that will last them

their entire lives.3 This design feature is healthier for the bone as well as the soft tissue because the biofilm adheres less to the machined surface.3 Every implant I’ve designed since Steri-Oss has included a machined collar, and I’ve seen how my patients have benefited as they’ve come in for visits over the last few decades.

8. A HIGH PRICE DOESN’T EQUAL A BETTER IMPLANT When I partnered with Jim Glidewell to create the Hahn Tapered Implant, I quickly found that we shared a core philosophy: Treatment should be available to all who need it. Jim has dedicated his career to reducing the cost of high-quality restorative services so

DR. JACK HAHN’S TAPERED IMPLANT JOURNEY 2015

1986

Introduces Hahn Tapered Implant

1970

Developed the Steri-Oss Dental Implant System (purchased by Nobel Biocare)

1996

Developed Replace Select (first tapered implant)

Placed first dental implant

1980

Founded Midwest Implant Institute

Dr. Hahn developed the first tapered implant in 1996, and collaborated with Glidewell to launch the Hahn Tapered Implant in 2015, combining the tapered design with a pronounced thread pattern and other features that maximize primary stability and bone preservation.

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that more patients can receive care, and I was happy to follow this philosophy as I’ve always done my best to make implant treatment as affordable as possible for my patients. The implant itself includes the design features that produce the best results, based on my 50 years of clinical experience and observations. I’ve discovered what works and what doesn’t, and I’m happy to share the implant, which is the culmination of everything I’ve learned during my career, with my fellow clinicians at a price that helps grow the dental practice and expand patient access to care. You can pay more than twice as much for an implant I designed for Nobel, but you’re not going to get better results. And I’m happy that Glidewell offers 20% off all cases restored over Hahn implants, which does even more for making implants affordable for dentists and patients.

This longstanding patient (left) of more than three decades has had various implants placed over the years, including a Steri-Oss implant Dr. Hahn designed with a machined collar. Follow-up radiographs have consistently shown excellent crestal bone preservation around the machined collar of the implants placed in the maxilla, and the Steri-Oss implants have been functioning for nearly 35 years. Note the ample volume of bone above the platform of a Hahn Tapered Implant placed in the posterior (right).

9. HYBRID DENTURES BREAK — BRUXZIR® ZIRCONIA DOES NOT I’ve placed hundreds of acrylic hybrid full-arch restorations. Sometimes, I wish I hadn’t. Full-arch implant treatment is perhaps the most rewarding procedure in all of dentistry. When patients come to you with terminal dentition or a loose-fitting denture, you can give them a fixed restoration that fully restores form and function. It’s truly life-changing for these patients, but it’s an experience that is diminished when patients return to your office with a broken hybrid denture or a dislodged tooth in hand. I used to have to repair or replace these all the time, at a great cost to my practice — and to the patient’s time and satisfaction with the restoration. Now I just swap in a BruxZir® Implant Prosthesis, and I know it’s not going to break. Hybrid dentures also develop unpleasant odors and harbor all sorts of biofilm and residue. They’re incredibly hard for the patient to keep clean. The BruxZir Implant Prosthesis has none of those problems. It’s beautiful, the

Dr. Hahn formed a partnership with Glidewell President and CEO Jim Glidewell, CDT, to create the Hahn Tapered Implant. Shown here with the Hahn Tapered Implant in hand, Dr. Hahn and Glidewell found a shared philosophy in making high-quality implant treatment as affordable as possible for dentists and patients.

gingival areas and teeth look just like the real thing, and it’s easier for the patient to clean, which makes for a more pleasant chairside experience for the dentist. Most importantly, you’re not going to have a disappointed patient visit you with a damaged restoration. And you’ll have more new patients coming to your office thanks to recommendations from their friends.

10. T REAT PATIENTS WELL, AND THEY’LL STAY WITH YOU FOR LIFE In addition to being the best treatment option for a missing tooth,

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implants are a great way to grow your practice and retain your patients. As I mentioned earlier, implant designs have evolved a great deal, and I have patients return to see me who have restorations over various implants that show many years of evolution, from blade implants, to subperiosteals, to parallel-walled implants, to the modern tapered design I helped pioneer. The relationships I’ve developed with these patients are extremely valuable to me and have served as a cornerstone of my practice. The fact is that patients are loyal to dentists who give them the best

Dr. Hahn delivered numerous screw-retained hybrid dentures for his edentulous patients prior to the advent of the monolithic zirconia full-arch implant restoration. Now, when patients return to his office with a broken hybrid denture (left), he simply upgrades them to a BruxZir Implant Prosthesis (right), which avoids the damage that commonly occurs with acrylic appliances.

outcome possible. With implants, you give them the next best thing to a natural tooth, and patients will reward you by counting on you for their long-term dental needs. As always, dentistry has a great future ahead, but it shines brightest for those who embrace the best treatment options and technologies for the good of their patients and practices. CM

REFERENCES 1. Noelken R, Neffe BA, Kunkel M, Wagner W. Maintenance of marginal bone support and soft tissue esthetics at immediately provisionalized OsseoSpeed implants placed into extraction sites: 2-year results. Clin Oral Implants Res. 2014 Feb;25(2):214-20. 2. Valentini P, Abensur D, Albertini JF, Rocchesani M. Immediate provisionalization of single extraction-site implants in the esthetic zone: a clinical evaluation. Int J Periodontics Restorative Dent. 2010 Feb;30(1):41-51. 3. Gracis S, Llobell A, Bichacho N, Jahangiri L, Ferencz JL. The influence of implant neck features and abutment diameter on hard and soft tissues around single implants placed in healed ridges: clinical criteria for selection. Int J Periodontics Restorative Dent. 2020 Jan/Feb;40(1):39-48.

EARN CE CREDIT The patient, whom Dr. Hahn has been treating for several decades, has received implant restorations on many occasions to replace teeth lost due to fracture or decay. Placing implants is one of the best means of patient retention, as many people value the ability to receive the full circle of care from their general dentist. Note the various implant systems, all of which Dr. Hahn designed based on his clinical experience and observations over the last 50 years.

Earn free CE credit for this article. Scan the code or go to glidewelldental.com/1502-ce1 to enter your answers.

QUESTIONS ON NEXT PAGE

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10 Things I Learned the Hard Way 1. Which of the following are benefits of grafting extraction sites? a. Prevention of bone loss b. Preparation of the site for future implant placement c. Avoiding a more complex surgical implant procedure d. All of the above e. None of the above 2. When a patient presents with dentition compromised by severe caries and periodontal disease, the dentist should always try to save the teeth. a. True b. False 3. Which of the following advantages do implants with a machined collar offer in comparison to implants with a roughened collar? a. Enhanced bone preservation b. Healthier soft tissue c. Biofilm adheres less to the machined surface d. All of the above e. None of the above

by Jack Hahn, DDS

6. What degree of primary stability is sufficient for immediate provisionalization? a. 35–45 Ncm b. 25–34 Ncm c. 46–55 Ncm d. None of the above 7. Immediate implant placement can result in enhanced preservation of the hard and soft tissues. a. True b. False 8. Monolithic zirconia full-arch implant restorations are less likely to fracture than acrylic hybrid dentures. a. True b. False 9. When immediately placing an implant in an extraction socket, the initial osteotomy should be positioned 2–3 mm from the facial plate.

4. The emergency implant procedure can be just as predictable as extraction with delayed implant placement. a. True b. False 5. Which of the following benefits does the tapered implant design offer?

a. True b. False 10. It is acceptable to move forward with immediate implant placement in cases where the buccal plate was compromised during tooth extraction. a. True b. False

a. H igh primary stability isn’t needed for immediate loading b. Fewer surgical steps c. E ase of positioning within sites where limited bone is available d. All of the above e. None of the above

To receive free CE credit for this article, go to glidewelldental.com/1502-ce1. Visit glidewelldental.com/education to access other free, on-demand CE courses. Or enroll in a hands-on course in a city near you. Register today!

Glidewell Education Center is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

The Glidewell Education Center is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or any other applicable regulatory authority, or AGD endorsement. The current term of approval extends from 3/1/2015 to 2/28/2021. Provider ID# 216789

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*Kerr M, Allen B, Park N. Clinical and radiographic evaluation of tapered implants with an aggressive reverse buttress thread and crestal microthreads: a retrospective study. For the full report, visit hahnimplant.com. †Discount offered only at Glidewell and cannot be combined with any other special offers. Case must include an implant-level or multi-unit abutment-level impression with a Hahn transfer coping or a digital scan with a Hahn Scanning Abutment. Impressions over cementable abutments are not eligible for discount. **Price does not include shipping or applicable taxes. Hahn is a trademark of Prismatik Dentalcraft, Inc. MKT-012679_2

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Meeting High Esthetic Demands by Paresh Patel, DDS Private Practitioner â&#x20AC;&#x201D; Lenoir, North Carolina

or anterior cases where uncompromised esthetics are required, dentists now have the option of using a 100% metal-free implant alternative, the ZERAMEXÂŽ XT Implant (Glidewell; Irvine, Calif.). These two-piece, all-ceramic zirconia implants offer a naturally white appearance and biocompatible tissue response that provide an optimal esthetic result, especially for patients who present with thin tissue biotypes. In the past, all-ceramic implants were mostly one-piece fixtures that, because of their design, required immediate loading. With the two-piece structure of ZERAMEX XT Implants, dentists can achieve excellent primary stability and have options for the timing of occlusal loading after the completion of the surgical procedure. Dentists will also find that the clinical technique, surgical protocol and shape of the ZERAMEX XT Implant share many similarities with a titanium implant, reducing the learning curve.

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Unlike a titanium implant, however, the natural esthetics of an all-ceramic implant allow clinicians to place implants in the esthetic zone without concern of gray showing through the soft tissue. For this reason, the all-ceramic implant makes for an excellent addition to the armamentarium of the modern dental practice. The following case report demonstrates how a ZERAMEX XT Implant served as the ideal restorative solution for treatment of an edentulous site in the anterior.

The natural esthetics of an all-ceramic implant allow clinicians to place implants in the esthetic zone without concern of gray showing through the soft tissue.

LEARN MORE Donâ&#x20AC;&#x2122;t miss Dr. Patelâ&#x20AC;&#x2122;s free online CE course on esthetic implant dentistry at chairsidemagazine.com

CASE REPORT

Figures 1a, 1b: The patient presented for treatment of an existing edentulous site in the area of tooth #9, which was lost traumatically during childhood. The tooth had a history of unsuccessful endodontic treatment and was extracted, with a flipper provided as a temporary restorative solution. The patient preferred implant surgery in place of a bridge or a new flipper, but required optimal esthetics due to the visibility of the implant site when she smiled. Because the implant site was located in the anterior and the soft tissue was visible when the patient smiled, an all-ceramic implant solution was selected to maximize esthetics. As a metal-free, two-piece 100% zirconia alternative, the ZERAMEX XT Implant was the right choice.

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Collar height 1.6mm Endosseous depth 8mm

Example dia. 4.2 x 8mm REGULAR Implant

ZERADRILL™ REGULAR dia. 4.2mm max. 15rpm

Optional for hard bone ZERADRILL™ Extension REGULAR max. 600rpm

ZERADRILL™ S8 (REGULAR 8mm) max. 600rpm

ZERADRILL™ S8 (SMALL 8mm) max. 700rpm

ZERADRILL™ Pilot dia. 2.3mm max. 800rpm

Rosedrill dia. 2mm max. 800rpm

1mm

Optionally, the implant can also be positioned 0.6mm supracrestal (instead of 1.6mm). The drill and threadcutter must be drilled 1mm deeper in this case.

Figure 2: On the day of surgery a local anesthetic was administered. After making a full-thickness flap at the implant site, I confirmed that the bone density and volume were adequate. I also confirmed that there was sufficient keratinized tissue around the implant site to proceed, and created the initial osteotomy using the ZERADRILL™ Pilot Drill included in the surgical kit.

Figure 5: For this particular case, the implant was positioned slightly above the bone crest (about 1.6 mm). It is not necessary or recommended to bury the ZERAMEX XT Implant below the bone level.

Figures 6a, 6b: Although good primary stability was achieved, I decided not to place a provisional crown on the day of the surgery. Instead, I placed a healing cap and then sutured the site to achieve primary closure. The patient was refitted with her previous partial appliance, including modifications to ensure it did not rest on the surgical site.

Figure 3: After using the pilot drill, I took a radiograph of the osteotomy site with a parallel pin in place in order to confirm the angulation. 4b

Figures 4a, 4b: After using the designated shaping drills to widen the osteotomy to accommodate a 4.2 mm x 10 mm ZERAMEX XT Implant, I used the handpiece to slowly seat the implant to the proper depth.

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Figure 9: The final restoration was completed successfully with delivery of the customized zirconia abutment and BruxZir Esthetic crown. No adjustments were needed. 7b

Figures 7a, 7b: After a five-month healing period, the patient returned for impressions. A closed-tray transfer coping was used, and impressions were sent to Glidewell, where a zirconia abutment was customized and a BruxZir® Esthetic Zirconia crown was fabricated to achieve optimal esthetics in the anterior.

CONCLUSION This case report demonstrates the straightforward surgical and restorative protocol for the ZERAMEX XT Implant. This treatment option has proven valuable in cases where the doctor wishes to provide the optimal esthetic solution, particularly in anterior cases with thin gingival biotype, where titanium implants often produce a gray shadowing. CM

10a - Before

All third-party trademarks are property of their respective owners. Products distributed by Glidewell Direct under exclusive agreement with Emerginnova.

Figures 8a, 8b: On the day of the final delivery, I removed the healing cap and noted excellent healing of the surrounding tissue. The zirconia abutment was attached to the implant with the carbon-fiber–reinforced polymer VICARBO® screw.

10b - After

Figures 10a, 10b: The patient was exceptionally pleased with the final result, with natural esthetics resulting from the use of the ZERAMEX XT Implant.

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A Simplified Clinical Protocol for the Fabrication of Full-Arch Implant Restorations Interview with Taylor Manalili, DDS Director of Clinical Prosthodontics for Glidewell â&#x20AC;&#x201D; Newport Beach, California

Recently, Dr. Taylor Manalili spearheaded efforts in Glidewellâ&#x20AC;&#x2122;s Clinical R&D department to streamline the clinical steps for full-arch implant restorations. Here, she details how the new, simplified workflow will produce more predictable results while saving doctors valuable chair time. Dr. Manalili also discusses how the lab has produced and made available step-by-step videos, instructions, checklists and other resources to help clinicians throughout the process.

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NEW!

The new BruxZir Esthetic Implant Prosthesis was launched in tandem with Glidewell’s streamlined step-by-step protocol for full-arch zirconia implant restorations. This new esthetic formulation offers optimized translucency and exceptional gingival and tooth anatomy — without the risk of fracturing the layered porcelain used in most premium full-arch restorations.

CHAIRSIDE ® MAGAZINE: We know you’ve been working extensively with the BruxZir® Implant Prosthesis since you joined Glidewell. Before we dive into the new and improved protocol you’ve developed with the Clinical R&D team, can you share your thoughts on the restoration itself? What distinguishes this implant solution from the other options out there? DR. TAYLOR MANALILI: As a prosthodontist working with acrylic hybrids and layered full-arch restorations, I would worry about the denture teeth dislodging or the material wearing down or fracturing. The strength and monolithic construction of the BruxZir Implant Prosthesis avoid all of that, so it’s been a major step forward in providing edentulous patients with a fixed restoration that will last. Dental zirconia also isn’t nearly as porous as the materials in hybrid restorations, so

biofilm buildup and the resulting odors are prevented. Also, we now have a new formulation fabricated from BruxZir Esthetic Zirconia, and I think that when you combine the durability of monolithic restorations with the beauty and lifelike translucency of anterior-grade zirconia, it really changes the game.

Our goal was to put in place a simplified, easy-to-follow procedure to help clinicians produce a predictable outcome, using as little chair time as possible.

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CM: As a key part of your work here as director of prosthodontics in the Clinical R&D department, you’ve been focusing on improving the restorative protocol for this type of implant restoration. How did this initiative come about? TM: It came about because restoring full-arch implant cases can be challenging. There’s a lot to take into consideration when fabricating this kind of restoration, and we really wanted to simplify things for clinicians. The position of the teeth within the restorative space is a vital determinant for the success of these full-arch cases. There are also some other important aspects that must be addressed, like achieving a precise full-arch impression, an accurate bite relationship, and a level restorative platform, so we want to give dentists the tools and clinical resources they need to accomplish all of that. Our goal was to put

In 2019, Dr. Taylor Manalili began leading Glidewell’s initiative to streamline the step-by-step protocol for the BruxZir Implant Prosthesis, with the goal of producing optimal restorative outcomes and saving clinicians valuable chair time. Here, she discusses prosthesis design and fabrication with Darius Raudys, CDT, general manager of the Implant department at Glidewell.

in place a simplified, easy-to-follow procedure to help clinicians produce a predictable outcome, using as little chair time as possible. CM: So what was the restorative protocol for this implant restoration before you began revising the process? Was it similar to what other labs do with screw-retained hybrid dentures? TM: It was similar, although ours has always included a CAD/CAM provisional implant prosthesis, which continues to be one of the most valuable clinical tools for ensuring an accurate final restoration. What we’ve done is put some steps in place that help determine where the teeth should go from the very beginning. We have found that by investing a little more time at the start, you can save a lot of time later in the process.

CM: What are the most important changes clinicians can expect? TM: Understanding where to place the teeth from the outset, and communicating that information to the lab, makes a huge difference, both esthetically and functionally. One key step in our new process is to have the dentist create a duplicate of the patient’s existing denture at the preliminary impression appointment, which helps the technician understand where to position the teeth, the midline and the incisal edges. This also helps us select the appropriate multi-unit abutments earlier on, which creates a level, equigingival restorative platform. This in turn allows for a smooth and efficient protocol at subsequent appointments. You don’t need to anesthetize the patient, you can correct implant angulation, and you don’t have to worry about tissue being in the way as you seat the wax rim, setup,

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provisional and final prosthesis. We now provide the custom tray and implant verification jig (IVJ) at the same appointment as the multi-unit abutments and wax rim. Previously, multi-unit abutments were selected after the wax rim appointment, which was creating issues with the bite in some cases. We’re seeing that the new process produces more accurate records and results in fewer try-ins. CM: How did you go about revising the protocol? TM: We developed and validated our new process in our clinical operatory, working with feedback we received from clinicians and our team in the Full-Arch Implant department. As we’ve refined the process, each case has gotten smoother, and we’re seeing better results in the full-arch BruxZir restorations we’ve produced

Based on clinical research spearheaded by Dr. Manalili, BruxZir Implant Prosthesis cases are now packaged in new boxes that include appointment-specific guides and checklists that help ensure a smooth, predictable restorative process.

for doctors since the new protocol was implemented a few months back. CM: What is Glidewell doing to familiarize clinicians with the new and improved process? TM: This has been one of our biggest areas of focus — giving dentists the clinical resources they need to achieve the best result possible. First, we created new shipping boxes, which include step-by-step guides as well as checklists of the items clinicians will need, receive and send back for each appointment. We’re also including checklists that help with evaluating the wax rim and try-in. This will help with the operatory setup for each appointment and knowing exactly what to expect. Additionally, we’ve made tutorial videos available online for the most

important parts of the restorative process. This includes tips and tricks for taking your bite registration, seating multi-unit abutments, and other essential procedures. Also, our technical advisor team is extremely knowledgeable and has been specially trained to assist with the clinical workflow and answer any questions dentists might have along the way. CM: The protocol includes a step for prescribing a bite splint if desired by the clinician. Do you typically prescribe bite splints for these types of cases? TM: Yes, I typically prescribe a CLEARsplint® (hard) or a Comfort H/S™ Bite Splint (hard/soft) in these cases. Full-arch implant patients have a lack of proprioception. If the patient has a history of parafunctional habits, this is cause for concern. Also, the bite splint

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will help reduce muscle activity, helping to protect the new prosthesis as well as the opposing dentition. While a guard can be provided for either arch, I tend to prescribe it for the arch with the restoration so I can have it fabricated and delivered with the definitive prosthesis at the same appointment, which is why we suggest prescribing one when you return the case prior to the final delivery appointment. CM: Where can dentists learn more about this new and improved protocol? TM: Everything I’ve discussed here is available at glidewelldental.com/bip, and our step-by-step guides include QR codes that lead directly to tutorial videos relevant to each appointment. I think dentists are going to have a great experience with the new process, and we certainly welcome feedback.

Dr. Manalili recommends providing a CLEARsplint or Comfort H/S Bite Splint for the arch being restored, especially for patients with parafunctional habits. Following the BruxZir Implant Prosthesis protocol, the bite splint is prescribed just prior to the final delivery appointment.

“

I had never done a fixed full-arch implant restoration before my first BruxZir Implant Prosthesis case. I can’t say enough about how helpful and informative the lab was throughout the process. Everything was very straightforward, and each step went smoothly because I always knew exactly what I needed to accomplish clinically. The protocol Glidewell has developed helped simplify a complicated case and made it easy to get predictable results. There was nothing we had to do twice thanks to the instructions and help I received from the lab. Most importantly, the patient was extremely happy with the net result. –

”

Rafael Cardenas, DMD

East Providence, Rhode Island

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LEARN MORE Take Dr. Manalili’s free on-demand CE course on the full-arch implant restoration protocol at chairsidemagazine.com

Overview of the New Restorative Protocol Appointment

Appointment

Take preliminary impressions and duplicate the patientâ&#x20AC;&#x2122;s existing denture.

Seat multi-unit abutments, take final abutment-level impression, evaluate and adjust wax rim, and take bite registration.

Try in and verify the wax setup.

Seat and confirm the provisional implant prosthesis (patient wears provisional for 2â&#x20AC;&#x201C;4 weeks).

Deliver BruxZir Implant Prosthesis. CM

CLEARsplint is a registered trademark of Astron Dental Corporation.

To access the new step-by-step protocol, or learn more about the BruxZir Esthetic Implant Prosthesis, visit glidewelldental.com/bipe

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D C

Guided Bone Regeneration: 8 Steps to Successful Ridge Augmentation 1a

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2a 1a

2a 2a

3a2a

3a 3a

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by Randolph R. Resnik, DMD, MDS Director of the Misch International Implant Institute and Private Practitioner â&#x20AC;&#x201D; Pittsburgh, Pennsylvania

he ideal placement of dental implants is often compromised because of existing alveolar ridge deficiencies. The lack of available bone for proper implant placement 5a 5a 5a may be caused by many factors, including developmental 5a 5a anomalies, trauma and, most commonly, tooth extraction. It is widely accepted and documented in the literature that after a tooth is extracted, resorption of the alveolar bone occurs in both a horizontal and vertical dimension, which results in a compromised volume of bone.

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To reestablish the ideal bony contours and restore bony defects, effective bone augmentation techniques have been developed. The concept of guided bone regeneration (GBR) was introduced to the profession over 30 years ago and entails using a barrier membrane during the healing process to exclude certain nonideal cell types, thereby allowing the growth of slower-growing bone cells.1 Basically, osteoprogenitor cells, which differentiate into osteoblast bone-forming cells, are able to repopulate the graft site because of the mechanics of the exclusion membrane.2 Studies have shown that up to 40% of dental implant sites require GBR procedures as part of the patient’s rehabilitation.3 For success and predictability, clinicians must adhere to the factors and principles that are paramount to regenerating bony contours for implant placement. If implant placement is attempted in a deficient bony ridge, the function, support and esthetics may be compromised. A successful bone graft relies on the passage of various cellular components from the surrounding recipient site’s bony walls and vascular components into the developing graft site. The larger the distance from these bony surfaces to the peripheral graft components, the greater the challenge for angiogenesis and cells to migrate to the outer limits of the particulate graft. Therefore, bony defects are ideally treated according to the type of defect and the amount of bone growth required. In this article, a detailed step-by-step protocol will be discussed to provide clinicians with a strong foundation for predictable treatment planning and surgical intervention for the remediation of various bony deficiencies.

STEP 1: E VALUATE THE BONY DEFECT The first step in the bone regeneration process is to identify ideal and nonideal cases for GBR ridge augmentation surgery. The use of cone-beam computed tomography (CBCT) imaging, along with interactive CBCT treatment planning (e.g., nerve drawing, bone density measurements, defining bone graft requirements), is imperative in allowing the clinician to develop a definitive surgical and prosthetic treatment plan. Once the dimensions and volume of the intended bone graft have been determined, the clinician must be able to visualize the relationships between the bone volume and the ideal prosthesis. A careful review of the topography of the recipient graft site should include the bone levels around adjacent teeth, associated bony protuberances and concavities, the dimensions of the defect, the number of remaining bony walls if present, and the condition of the surrounding soft tissue.4

Bony defects may be identified in one of the following categories:

a. Small Depression Small depressions (less than 2.0 mm) occur most commonly on the buccal or lingual after implant placement. These defects, if left untreated, may contribute to dehiscence or fenestration of the bone, leading to exposure of the implant body. Usually, these bony deficiencies are grafted at the time of implant placement with graft material (e.g., allogenic bone or autogenous bone harvested from the implant osteotomy) and a membrane. These types of defects are predictable, especially if autogenous bone is used (Figs. 1a–1c).

Figures 1a–1c: Small depression defect: Compromised bony ridge width requiring grafting at time of implant placement (1a, 1b). The ideal source of autogenous bone is from the flutes of the surgical bur (1c).

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b. Concavity Defect A concavity-type defect is a horizontal deficiency greater than 2 mm. These bony defects have surrounding bone that may be utilized for graft support and A containment of graft material. B This is advantageous for space maintenance, which allows for more predictable graft healing. These depression-type bony defects are ideal for clinicians early in their learning curve for ridge augmentation procedures, as they are highly predictable (Figs. 2a, 2b). Depending on the sizeA and location of the deficiency, tenting screws may be required for space maintenance principles.

c. C onvex/Straight Bone Deficiency

d. Vertical (Height) Defects

Bony defects that require vertical height correction are highly complex Deficiencies that are straight/convex and should be reserved for clinicians are very prevalent, most commonly with advanced experience and skills in occurring after loss of the buccal plate complexD manipulation of hard and soft C or after an extended edentulous time tissue. Vertical defects are most comperiod. Because the defect occurs on monly the result of the loss of both an inclined plane, the concept of maincortical plates and will necessitate taining space to allow for undisturbed space maintenance in three dimenbone growth is challenging. Multiple, sions. As the vertical defect height stable tenting screws are necessary is increased, the crown-implant ratio to prevent micromovement, which becomes problematic with respect to is paramount for predictable bone esthetics and biomechanical factors. growth. In addition,B soft-tissue closure C D The limiting factor of these defects is more challenging, as special emis the interproximal bone level of the phasis must be used to reduce tissue adjacent teeth. Clinicians must underflap tension to obtain primary closure stand that it is not possible to increase of the surgical site. Care should be the bone level above the bone height exercised to minimize any pressure of the adjacent teeth (Figs. 4a, 4b). on the graft site from the provisional Unpredictable results occur if there or interim E prosthesis (Figs. 3a, 3b). is any compromise in maintaining space, preventing micromovement of the graft material, or achieving tension-free soft-tissue closure.

2a 3a

5a 3b 2b

Figures 2a, 2b: Concavity bony defect: Concave defect, which allows for predictable bone grafting procedures.

Figures 3a, 3b: Straight/convex bony defect: Width-compromised bony ridges are challenging graft sites due to the difficulty in preventing micromovement of the graft material and space maintenance.

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Figures 4a, 4b: Vertical height bone defects: Height-deficient ridges are the most difficult and least predictable to treat, as there are many limiting factors in the consideration of the graft.

e. Buccal-Lingual Defects Buccal-lingual bony defects, which often occur in the anterior maxilla or anterior mandible, are extremely challenging. These anatomic areas present technical challenges with respect to tissue release, space maintenance and graft containment. However, the most common difficulty with these types of defects is placement of tenting screws, as available bone is often insufficient to obtain fixation of these important holders of the graft space. These types of defects should also be limited to clinicians with extensive surgical and bone grafting experience (Figs. 5a, 5b).

STEP 2: FLAP DESIGN AND INCISION The flap design and incision are crucial steps in obtaining a predictable regenerative result. Ideally, complete access to the surgical site without compromising the integrity of the surrounding tissue should be obtained. As the incision location is planned, the anatomy of the adjacent papillae must be considered to minimize any compromise to the esthetics and function of the tissue postoperatively. The patientâ&#x20AC;&#x2122;s gingival biotype (thick vs. thin) and the amount of keratinized tissue are always evaluated. Failure to properly plan the incision and flap design during grafting may lead to complications, most commonly incision line opening, resulting in increased morbidity. The coronal incision is usually positioned on the crest of the ridge, with a more palatal position if the amount of existing attached tissue is compromised. Vertical release incisions are made on the buccal surface and extend to the mucogingival junction. Broad-based incisions are important to prevent interruptions in the vascular supply to the flap and to allow for elevation, retraction, repositioning and suturing without tension. It is imperative that a continuous full-thickness incision be made on bone through the tissue and the periosteum. Incisions

that are irregular may lead to maceration of the flap, which compromises the primary blood supply source (periosteal tissue layer). When incisions involve adjacent teeth, papillaesparing incisions should be completed, leaving a minimum of 1 mm of the papilla intact (Figs. 6a, 6b).

STEP 3: R EFLECTION AND RELEASE OF THE TISSUE

Tissue Reflection When exposing the recipient site, nontraumatic elevation of the tissue is required to obtain a full-thickness mucoperiosteal flap. This should include an uninterrupted release of the flap that includes the surface mucosa, submucosa and periosteum. As the tissue is reflected, the underlying bone should be scraped with a bone curette to remove any tissue. Ideally, a specialized periosteal elevator (e.g., 2/4 Molt Curette, Newport Surgicalâ&#x201E;˘ Implant and Bone Grafting Instrumentation Kit [Glidewell; Irvine, Calif.]) should be used with the curette edge resting on the bone to prevent tearing of the tissue flap (Fig. 7).

Figures 5a, 5b: Buccal-lingual bony defect: An hourglass type of ridge morphology is more complex, as grafting is indicated on the buccal and lingual aspects, and space maintenance and prevention of micromovement of the graft material are difficult.

Releasing Tissue Tension It is imperative that the flap has complete release of tension to prevent incision line opening. Excessive flap tension will compromise the blood supply to the tissue, which may lead to necrosis and eventual separation of the two edges of the flap closure, resulting in an incision line opening. When this occurs, soft-tissue ingrowth, bacterial contamination, and migration of graft particles may lead to compromised regenerative results. Flap tension is reduced by releasing the periosteal layer, allowing the elastic fibers of the underlying flap to stretch as the flap is drawn over the graft site. Stretching the tissue may be completed by either periosteal release incisions (shallow incisions with a scalpel blade in the periosteum)

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Figures 6a, 6b: Papillae-sparing incision depicting a broad-based design that maintains blood supply and prevents postoperative tissue recession.

or a blunt dissection (Metzenbaum scissors placed into the periosteal tissue layer and opened, resulting in stretching of the tissue fibers). Ideally, extension of the flap should extend at least 5 mm beyond the edge of the adjacent margin after the flap is released (Figs. 8a, 8b). Figure 7: Tissue reflection: Use of a 2/4 molt curette, which allows for nontraumatic soft-tissue exposure.

STEP 4: P REPARATION OF THE RECIPIENT SITE Soft-Tissue Removal For predictable bone regeneration to occur, all soft-tissue remnants must be removed from the bony recipient site. Soft-tissue fibers remaining on the host recipient bone will compromise the attachment of the newly regenerated bone to the underlying basal layer. Tenacious tissue may be removed with a sharp bone curette or a coarse acrylic bur (Fig. 9).

Decortication

Figures 8a, 8b: Periosteal release incisions with a No. 15 blade (8a), and broadbased tissue release with Metzenbaum scissors (8b).

Figure 9: Soft-tissue removal with No. 8 round carbide bur.

The decortication of the recipient site includes creating pilot holes into the cortical bone, which initiates the regional acceleratory phenomenon (RAP). RAP is the cellular process that stimulates and accelerates the healing rate of a graft site.5 Placing pilot holes into the cortical bone acts as a “noxious stimulus,” and the healing rate of a decorticated graft site has been shown to increase 2–10 times the normal healing rate.6 The holes create an open pathway to the underlying trabecular bone, where blood flow into the graft site will increase revascularization (angiogenesis) and allow for bone growth factors to readily enter the graft site. This acceleration is accomplished by the introduction of platelets to the area, which degranulate and release growth factors, including platelet-derived growth factor (PDGF) and transforming growth factor (TGF). The decortication process may be accomplished with the use of cross-cut fissure burs or small round burs that are used to perforate the cortical plate. Copious amounts of chilled saline should be used to prevent thermal trauma (Fig. 10).

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Figure 10: Decortication holes with a cross-cut fissure bur leading to the initiation of the RAP, allowing for faster and more predictable healing.

STEP 5: S PACE MAINTENANCE The concept of space maintenance to support the graft area is the key to success of the GBR process. The creation and continued structural support of the graft space is most commonly accomplished with membranes supported by tenting screws. If space maintenance is compromised in any way (i.e., loss of structural integrity or movement), then bone regeneration will be less predictable.

Tenting Screw Concept The use of specialized tenting screws has made the GBR process more predictable as the membrane is easily supported, thereby preventing collapse of the graft site. The design of tenting screws allows for the larger head of the screw to maintain vertical and horizontal support. This support system allows for the creation of a predictable and controlled final contour of the graft and the bone regeneration process to proceed in an unaltered manner. Bone fixation screws on the market today are most commonly non-resorbable titanium screws with aggressive thread designs, a wide head, and smooth neck contours for atraumatic tissue support. If the head of the screw perforates through the

Layer 2: Allograft

membrane, the vertical support will be decreased, and the particulate graft is subject to pressure and micromovement. When support is lost, the final volume and consistency of the matured ridge will be compromised.

Number of Tenting Screws The amount of support required to maintain the spatial dimensions of the graft site determines the number and positioning of the screws. Usually, multiple screws are anchored in the recipient site to form a dome over the graft site that replicates the dimensions of bone needed for ideal implant placement. Ultimately the tenting screws act as “tent poles” to support the membrane, decrease graft mobility, and relieve external pressure on the graft.7

Positioning of Tenting Screws The positioning of the screws should be planned in a manner that will result in a dome shape that is formed by the heads of the screws, which should match the intended contour of the final ridge form. The use of multiple screws in this technique creates very specific ridge forms that cannot be attained with unsupported membranes. Usually, screws are placed in a nonparallel fashion approximately 3–4 mm apart, which allows sufficient space for angiogenesis to occur. The location and trajectory of adjacent tooth roots must be determined to prevent screw placement near a tooth root. Ideally, intraoperative radiographs should be taken to verify ideal positioning in relation to tooth root position (Figs. 11a, 11b).

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11b

Figures 11a, 11b: Large-head tenting screw (11a); tenting screw positioning (11b).

Allogenic bone is the most ideal bone substitute used today for GBR techniques. Allografts are available in many different preparations, with the most common being freezedried bone allograft (FDBA) and demineralized FDBA (DFDBA). The recommended graft material (e.g., Newport Biologics™ Mineralized Cortico/Cancellous Allograft Blend [Glidewell]) should be hydrated with sterile saline (0.9% sodium chloride) or platelet-rich fibrin (PRF) and then gently condensed into the recipient site. Small increments of material should be added into the site, and a bone-packing instrument, such as the Bone Carrier and Spoon included with the 12-piece Newport Surgical Implant and Bone Grafting Instrumentation Kit (Glidewell), should be utilized to condense the material to avoid air spaces (Figs. 12a, 12b).

STEP 6: P LACEMENT OF THE BONE GRAFT When placing graft material into a bony defect, a systematic layered approach should be utilized, depending on the size and location of the graft site.

Layer 1: Autograft The first layer of the GBR graft is composed of autogenous bone. Autogenous bone is usually indicated in any bony defect that requires horizontal bone growth of greater than 3 mm or in all cases of vertical regeneration. In smaller defects of less than 3 mm, autogenous bone is optional. Autogenous bone is typically harvested from any accessible region of cortical/cancellous bone present in the oral cavity (tuberosity, ramus or symphysis). The small autograft particulate pieces are placed directly on the host bone surrounding the bone screws. Graft particles are transferred from the surgical bowl to the graft site and placed underneath the tenting screw heads with cotton forceps or a molt curette.

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12b

Figures 12a, 12b: Newport Biologics Mineralized Cortico/Cancellous Allograft Blend (12a); graft material added to recipient site (12b).

STEP 7: S ELECT AND PLACE THE BARRIER MEMBRANE Barrier membranes are generally used in guided bone regeneration procedures to act as a biological and mechanical barrier against the invasion of fibrous tissue into the developing graft site. Most membranes will allow for the migration of the slowermigrating bone-forming cells into the defect sites. During the bone regeneration process, there is a competition between soft-tissue and bone-forming cells to invade the surgical site. In general, soft-tissue cells migrate at a much faster rate than bone-forming cells. Therefore, the primary goal of barrier membranes is to allow for selective cell repopulation and to guide the proliferation of various bone-forming cells during the healing process. This will allow for angiogenesis and the migration of osteogenic cells that replace the blood clot with woven bone, which eventually transforms into load-bearing lamellar bone. If a barrier membrane is not utilized, lack of isolated space maintenance will result in soft-tissue integration and compromised bone growth.

Types of Membranes Barrier membranes in GBR procedures are usually classified as either resorbable or non-resorbable. Resorbable membranes (e.g., collagen) are the most commonly used membranes for GBR techniques. Resorbable membranes are cost-effective, easy to use and naturally biodegradable, and have varying resorption rates. For ridge augmentation procedures, a longer-acting collagen barrier such as the Newport Biologics Resorbable Collagen Membrane 4–6 (Glidewell) is recommended. These cross-linked membranes are ideal for containing the graft, especially for grafts that require longer healing periods (Figs. 13a–13c). In contrast, non-resorbable membranes are bio-inert materials, which

are less advantageous because they require a second surgical procedure for removal. Dense polytetrafluoroethylene (d-PTFE) membranes are the most commonly used material with or without titanium reinforcement (e.g., CytoSurg™ Non-Resorbable PTFE Membrane [Salvin Dental Specialties; Charlotte, N.C.]). Although they exhibit excellent biocompatibility, superior mechanical strength and increased rigidity, and generally achieve more favorable space maintenance than unsupported resorbable membranes, they are associated with increased incision line opening and increased complications.

Sizing and Positioning of Membranes The size of the membrane must be large enough to completely cover and extend approximately 2–3 mm beyond the graft site. The barrier membrane may be fixated prior to the placement of graft material with bone tacks. The initial fixation may be completed either apically or on the lingual aspect of the ridge. Fixation of the membrane before placing the particulate graft ensures that the membrane will not move after the graft material is added.

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13b

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Figures 13a–13c: Newport Biologics Resorbable Collagen Membrane 4–6 (13a); maxillary anterior graft site (13b); collagen membrane positioned over graft site (13c).

Final Positioning and Stabilization of the Membrane After the graft material, in one or two layers, is positioned, the membrane is stretched over the graft site. The membrane should be of sufficient size to totally encompass the entire graft. The goal of the membrane fixation is to prevent any movement, which could negatively affect the wound healing. In most cases, the final fixation is on the palatal aspect of the ridge with two tacks. Additional fixation can be used as needed in large graft sites to limit membrane movement. Alternatively, in some cases, the edges of the membrane may be tucked beneath the flap margins at the time of closure to provide stabilization without bone tacks (Fig. 14).

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Figure 14: Newport Biologics Resorbable Collagen Membrane fixated with bone tacks. In some cases, the membrane can be fixated on one side apically or lingually prior to bone graft placement.

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Figure 15: Platelet-rich fibrin (PRF) growth factor placed over the barrier membrane. PRF can also be mixed with the bone graft material for increased bone healing results. See more details about PRF procedures in Dr. Resnik’s article, “Enhancing Bone Regeneration with the Use of Platelet Concentrates” (Chairside® Vol. 15, Issue 1).

Bone Growth Factors Bone growth factors may be used in combination with barrier membranes A B A to enhance the formation and mineralization of bone, especially in larger cases. In addition, bone growth factors may induce undifferentiated mesenchymal cells to differentiate into bone cells that trigger a cascade of intracellular reactions for the release of additional bone growth and cell-enhancing factors. The two most common bone growth factor techniques utilize blood concentrates (platelet-rich fibrin) and recombinant human bone morphogenetic protein-2. Multiple clinical studies have shown increased soft-tissue healing, enhanced healing of grafted bone, promotion of angiogenesis, and faster wound healing with the use of bone growth factors (Fig. 15).8

STEP 8: E NSURE PROPER CLOSURE The final closure of the bone graft site is a crucial step in the bone grafting procedure. Most importantly, a tensionfree flap adaptation is the key to predictable and consistent results. If incision line opening occurs, the morbidity of the procedure will increase.

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Figures 16a–16e: Examples of completed ridge augmentation for the five bone defect types discussed: small depression (16a), concavity (16b), straight/convex (16c), vertical (16d), and buccal-lingual (16e).

Therefore, meticulous principles 1a 1a should be adhered to with respect to a tension-free flap design, ideal suture technique, and close postoperative evaluation of the surgical site. The suture selected should be made from a material that has high tensile strength, ideally polyglycolic acid (PGA) (absorbable), such as the REDISORB® PRO (Glidewell), or PTFE (nonabsorbable). Specific attention must be directed to proper approximation of the mar-

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gins of to confirm there 2athe flap 2a 3a is no overlapping of the tissue flaps or bone graft material present within the margins. Most commonly, horizontal mattress and interrupted sutures are used to close the graft site. One of the primary advantages of using the horizontal mattress sutures is the ability to “evert” the tissue margins. By everting the margins of the flap

4a5a

outward, the connective tissue layers will be approximated against each other. Additional interrupted sutures may be used to approximate all edges of the wound. The vertical incisions may be closed with 4-0 chromic, such as the REDIGUT® Chromic Pro 4-0 (Glidewell), as they may greatly reduce the post-op formation of tissue scars.

REFERENCES 1. Dahlin C, Linde A, Gottlow J, Nyman S. Healing of bone defects by guided tissue regeneration. Plast Reconstr Surg. 1988 May;81(5):672-6. 2. Retzepi M, Donos N. Guided bone regeneration: biological principle and therapeutic applications. Clin Oral Implants Res. 2010 Jun; 21(6):567-76. 3. Bornstein MM, Halbritter S, Harnisch H, Weber HP, Buser D. A retrospective analysis of patients referred for implant placement to a specialty clinic: indications, surgical procedures, and early failures. Int J Oral Maxillofac Implants. 2008 Nov-Dec;23(6):1109-16.

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CONCLUSION To obtain optimal function and esthetics in implant dentistry, the hard and soft tissues need to be present in adequate volume and quality. The guided bone regeneration technique has been shown to be very successful and predictable in augmenting these tissues. The correction of alveolar bony ridge deficiencies, once thought to be difficult or impossible, should be in every clinician’s procedural arsenal (Figs. 16a–16e). However, these procedures are technique-sensitive, and therefore all procedural steps must be strictly followed. In this article, a GBR ridge augmentation protocol has been discussed in eight procedural steps that allow for predictable bone grafting (Figs. 17a–19b).

4. Resnik R. Misch’s Contemporary implant dentistry. 4th ed. St. Louis: Mosby; 2020. 5. Frost HM. The regional acceleratory phenomenon: a review. Henry Ford Hosp Med J. 1983;31(1):3-9. 6. Melcher AH, Accursi GE. Osteogenic capacity of periosteal and osteoperiosteal flaps elevated from the parietal bone of the rat. Arch Oral Biol. 1971 Jun;16(6):573-80.

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Figures 18a, 18b: Straight/convex-type bone defect (18a), and final post-healing image revealing bone growth in height and width ideal for future implant placement (18b).

7. Caldwell GR, Mealey BL. A prospective study: alveolar ridge augmentation using tenting screws, acellular dermal matrix and combination particulate grafts. A thesis for Master of Science in Periodontics — University of Texas Health Science Center at San Antonio Graduate School of Biomedical Sciences. May 2013. 8. Laney WR. Glossary of oral and maxillofacial implants. Berlin: Quintessence Publishing Co Ltd; 2007. 212 p. REDISORB and REDIGUT are registered trademarks of Myco Medical Supplies, Inc.

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Figures 19a, 19b: Very challenging vertical defect (19a) and final post-healing image depicting horizontal and vertical bone growth to the level of the adjacent teeth (19b). CM

Earn free CE credit for this article. Scan the code or go to glidewelldental.com/1502-ce2 to enter your answers.

QUESTIONS ON NEXT PAGE

Figures 17a, 17b: Concavity-type defect (17a) and final post-healing image depicting bone growth to the level of the tenting screws (17b).

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Guided Bone Regeneration: 8 Steps to Successful Ridge Augmentation 1. A small depression bony defect is defined as a defect of less than _______, which most commonly exists on the buccal or the lingual after implant placement. a. b. c. d. e.

0.5 mm 1.0 mm 1.5 mm 2.0 mm 2.5 mm

2. A concavity type of defect is usually greater than 2 mm and is highly predictable because of the existing surrounding bone, which is used for graft material support. a. True b. False 3. When designing a papillae-sparing incision around adjacent teeth for a GBR procedure, ideally a minimum of _______ of the papilla should be left intact. a. b. c. d. e.

0.5 mm 1.0 mm 1.5 mm 2.0 mm 2.5 mm

6. The tenting screws used for the space maintenance concept are advantageous for which of the following? a. b. c. d. e.

Supporting the membrane Decreasing graft mobility Relieving external pressure on the graft All of the above None of the above

7. What is the ideal type of bone substitute to use for guided bone regeneration procedures? a. Mineralized cortico/cancellous allograft b. Xenograft c. Alloplast d. Calcium phosphate e. Bioactive glass 8. Soft-tissue cells migrate at a slower rate than bone-forming cells. a. True b. False 9. Which of the following is the most ideal barrier membrane to prevent invasion of fibrous tissue?

4. Which of the following is NOT a complication from incision line opening? a. b. c. d. e.

by Randolph R. Resnik, DMD, MDS

Soft-tissue ingrowth Bacterial contamination Migration of graft particles Compromised regenerative results All of the above are complications

5. Decortication of the recipient grafting site will initiate what phenomenon, which accelerates the healing rate of the graft site? a. Membrane exclusion b. Angiogenesis c. Regional acceleratory d. Osteoblast acceleration e. Remodeling

a. Expanded polytetrafluoroethylene (e-PTFE) b. Platelet-rich fibrin c. Fast-resorbing collagen tape d. Recombinant human bone morphogenetic protein-2 e. Cross-linked collagen membrane 10. To prevent incision line opening, what is the MOST ideal suture material to use because of its high tensile strength? a. Chromic gut b. Polyglycolic acid (PGA) c. Plain gut d. Prolene e. Silk

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5 Ways to Increase Implant Case Acceptance by Roger P. Levin, DDS Founder and CEO, Levin Group, Inc. â&#x20AC;&#x201D; Owings Mills, Maryland

mplant treatment is one of the most life-enhancing services that dentistry can offer. Dental implants are also an area of tremendous potential growth for your practice and, given their convenience and permanence, are seen as the best option by most edentulous patients. However, a surprising number of patients do not accept implant treatment when it is presented. Rather than looking at this as a negative, practices should view these patients as opportunities for boosting production.

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FIVE REASONS WHY PATIENTS REJECT THE DENTAL IMPLANT OPTION There are five main reasons why patients reject dental implants. I believe that it’s important to understand these reasons so that you can properly design a case presentation process that motivates and encourages patients to accept treatment.

Implant case presentations don’t highlight the lifestyle benefits. Dental implant patients always have other treatment options, including doing nothing, getting partial or full dentures, or restoration via crown & bridge. This means that the patient must make a choice between treatments that have varying impacts. Case presentations that focus more on lifestyle benefits — comfort, ease of cleaning, preservation of bone and facial structures, and self-confidence, to name just a few — than implant materials and procedures will help patients see implants as the best choice.

Implant restoration and recovery takes time. Implant dentistry involves surgery followed by a restorative procedure. This means more time will be dedicated to implant treatment and patients will have to spend more time away from work, their children or other important responsibilities.

Patients take time to decide and then make no decision. Many implant cases are lost because the patient loses motivation or interest following a treatment presentation for which no follow-up appointment occurs.

Dental implants are perceived as expensive. Implants are expensive relative to the typical day-to-day expenditures that most people face. They are also expensive because there is often little to no insurance coverage. This forces patients to choose between implants or other personal expenses that may be more pressing.

Dental implants are surgical. Implants are perceived to be more painful than dentures or crown & bridge restorations. Many patients fear surgical procedures, while others simply do not want to deal with the inconvenience and healing required.

Learn 10 personal things about each new patient you see. Taking note of their family dynamics and some of their hobbies will make future conversations with them flow very easily.

There are other factors that can come into play in a patient’s decision not to receive dental implants, but those listed above are the most prevalent. And there is one other barrier to case acceptance that should be understood: the number of patients who never seek a dental implant consult. According to the Levin Group Data Center, 35% of patients referred by general dentists to a specialist for implant consultation fail to make an appointment. This would indicate that these patients don’t fully understand or appreciate the benefits of implant dentistry and don’t have the motivation or incentive to find out.

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INCREASING IMPLANT CASE ACCEPTANCE There is no standardized approach that will guarantee case acceptance. Each patient is a unique individual who will react to different forms of educational and motivational psychology. However, there are certain standard aspects of implant case presentation that will enhance the process and increase case acceptance. Here are five:

Make the patient your friend. We teach a concept called the “Golden 10,” which means that you learn 10 personal things about each new patient and continue to get updates from current patients. There’s a tremendous affinity that occurs as a relationship moves from a professional level to a personal level. By learning 10 personal things about each patient, you’re creating much stronger relationships. The simple technique of creating a more personal relationship builds a higher level of trust that will help encourage the patient to be more open to learning about dental implants and accepting treatment.

Dedicate time in a quiet setting to talk to the patient. Dental practices are often chaotic environments — and even more so with the advent of COVID-19. However, implant case presentation requires a calm and relaxed environment in which the patient and doctor (or treatment coordinator) can have a full conversation about the recommendation. Ideally, there will be an uncluttered consult room where the doctor and patient can sit down uninterrupted. Your body language is important as well. We recommend sitting eye-level with the patient so that you are engaging as equals, leaning back in a relaxed manner to express that you are completely focused on the patient, not crossing your arms or legs, leaning forward at times to create an additional sense of connection, and smiling even when wearing a mask. Patients detect these cues, and they feel

To facilitate a “case conversation,” make sure to stop talking and involve the patient in the conversation after approximately every 12 sentences.

more comfortable thinking through the decision of whether to accept dental implants.

Have a conversation, not a presentation. Levin Group is teaching a relatively new concept that we call “case conversation.” Rather than the doctor or treatment coordinator doing all the talking, the case presentation should be more of a conversation. A simple rule for facilitating this is that after approximately every 12 sentences you should stop talking and involve the patient in the conversation. This can include asking the patient if they’re following what you’re saying or if it is interesting to them. By involving the patient

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in the conversation, you create engagement, and engagement creates more interest, trust and commitment. Patients who have a higher level of participation in case presentations feel like they’re more involved in the process, and they tend to become comfortable accepting treatment.

Highlight time, comfort and longevity. These are some of the most important factors that can impact a patient’s decision about getting implants. The case presentation conversation should include an explanation of the amount of time that implants will take, both surgically and restoratively, and

how the patient’s comfort will be maintained. The reality is that dental implant treatment today takes less time than it did in the past, and comfort can be maintained at a reasonably high level. This needs to be communicated to patients to give them the confidence and reassurance to accept treatment. Confidence is vital in guiding the patient’s decision-making about implants, and addressing the time and comfort factors to the satisfaction of the patient is critical to piquing their interest in treatment. Along with time and comfort, longevity is high on the list of important factors that influence the patient’s decision. When choosing implants, patients undergo a surgical procedure that requires time and money, so they want the end result to last. The doctor or treatment coordinator must be proactive in explaining the high rates of implant longevity and that, for many people, implants will last the rest of their lives. This makes the patient’s time and comfort investment seem minimal compared to the lifetime benefit of excellent oral health, comfort and esthetics.

Cost: the final frontier. Cost is always the final factor in patient decision-making. Other than the rare wealthy patient, you can expect that most people will consider fees and payment options as a major part of their decision on dental implants. But, as the old business adage goes, “It’s not how much it costs — it’s how they have to pay for it.” Therefore, the doctor or treatment coordinator needs to be very skilled and follow excellent scripting in presenting financial options to patients.

SUMMARY

Whether the treatment involves a single tooth or a BruxZir® Implant Prosthesis, emphasize to patients that implants are a long-lasting option that justifies their time and comfort investment.

One effective strategy, which is also effective as a post-COVID–19 practice success plan, is to offer interest-free financing. Companies like CareCredit® (Synchrony Financial; Stamford, Conn.) have different levels of interest-free financing that make it easier for patients to accept treatment. When patients know this, they become more open-minded during an implant case conversation. Other options can include a discount for payment up front, a multiple-appointment payment plan or traditional patient financing. Working with patients to identify the best option will go a long way toward helping the patient come to a positive decision about dental implants. When presenting financial options, you should be relaxed, comfortable and confident that you’ll find a solution with the patient to make treatment affordable. A positive, helpful and caring attitude will show people that you’re doing your best to give them the opportunity to pursue a treatment that is in their best interest.

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Implant dentistry is an outstanding option for patients who are missing teeth, and it can provide improved quality of life. Unfortunately, not all patients understand implant dentistry even if they’ve heard about it or seen it on television commercials. The good news is that creating a case conversation in which the patient is engaged and becomes educated about implant dentistry will help to shape the patient’s expectations and confidence. Addressing the five points previously listed will help you to view each patient as an individual who needs a customized conversation to generate confidence as well as a financial option that allows them to afford treatment. CM

LEARN MORE Check out Dr. Levin’s tips for quickly boosting production at your practice at chairsidemagazine.com

My First Immediate Load Full-Arch Implant Case with John M. Fish, DDS Private Practitioner â&#x20AC;&#x201D; Hildebran, North Carolina

r. John Fish, a general dentist with a strong focus on implantology, takes pride in offering his patients a comprehensive range of implant treatment options at his practice in Hildebran, North Carolina. Here, he discusses how much implantology has changed since he began placing implants in the 1980s, the benefits of immediate loading in full-arch indications, and his recent experience providing his edentulous patients with the BruxZirÂŽ Implant Prosthesis, which has helped simplify his clinical workflow while avoiding the prosthetic wear and fractures common to other types of full-arch restorations.

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CHAIRSIDE® MAGAZINE: Thanks for joining us today to discuss fullarch implant treatment and your recent experience with the BruxZir® Implant Prosthesis. To start, can you talk about how long you’ve been practicing dentistry and what led you to pursue this profession? DR. JOHN FISH: I’ve been practicing dentistry for more than 30 years. My dad was an orthopedic surgeon and he loved his job, but I also saw that he had a lot of sleepless nights and he was on call a lot. I wanted to follow my father’s footsteps, but I thought that dentistry might be a better choice for me as far as work-life balance and autonomy were concerned, when compared with medicine. So midway through college I decided that I wanted to go to dental school, and I ended up at the University of North Carolina at Chapel Hill School of Dentistry. CM: You’ve been placing implants since 1983. What inspired you to learn to place implants back then, when implants weren’t as mainstream as they are today? JF: Coming out of dental school, I bought a practice that offered implants to its patients. I looked at several practices, but this one really jumped out at me because I was very excited about the possibilities that implant dentistry had to offer. The practice was owned by Dr. Paul Homoly, who has since become a renowned leader in dental implantology and had a significant nationwide following even back then. And he was selling this little practice in Hildebran, which is just west of Hickory, North Carolina. He was very generous with his time and taught me many very useful things, both clinical and managerial. I worked with him for eight or nine months, and this gave me a really accelerated introduction to dentistry and implant treatment. Back in those days, root-form implants were not really the thing — it was more endosseous blades, ramus

frames and subperiosteals. So I placed a lot of those early designs at a time when implant dentistry was quite controversial, really. Then the Brånemark implants came on the scene a few years after I started and, of course, now everything’s gravitated toward root-form implants. CM: So did you receive most of your initial implant training from Dr. Homoly? JF: I had zero experience or exposure to implants coming into dentistry because it was not taught in dental school. Implants were basically heresy back then, in 1982–83. So everything I learned early on was from Paul, who was placing implants every day. And of course, I embraced continuing education very early in my career. I got involved in the AAID and I became an Associate Fellow. I also joined the Dental Implant Associates of North Carolina, and we’d have live-surgery meetings. There were oral surgeons in the group as well as general dentists. There were probably 15 or 20 of us, and the group hung together for about

20 years. I got a lot out of that and formed a lot of strong mentor relationships with more experienced dentists. Of course, these days, implant programs are more readily available. However, even back then I got involved with the Misch Implant Institute, though I had completed quite a few cases even before I went to see Dr. Carl Misch. I remember meeting Carl at the annual AAID meeting in Washington, D.C., in 1988. He said, “Come to my institute — I promise you’ll love it, and I promise you’ll get a lot out of it.” He was right. There was nobody quite like him — God rest his soul. He was amazing. CM: How long have you been doing full-arch implant treatment, and what types of restorations have you worked with over the years? JF: I probably did my first full-arch porcelain fused to metal implant restoration in 1984. I’ve done hundreds of implant overdentures, but doing fixed full-arch cases — to me that’s the pinnacle of dentistry. I’ve

As an experienced implantologist of over 30 years, Dr. John Fish has witnessed time and again how offering implant treatment in the general practice can benefit patients. He recently began prescribing the BruxZir Implant Prosthesis for his edentulous patients, and has seen dramatic improvement in the restorative workflow as well as the durability and esthetics of his full-arch restorations.

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Dr. Fish recently placed five mandibular implants for a patient who requested a permanent solution for terminal dentition. He opted to place and immediately load five Hahn Tapered Implants with a fixed provisional denture. After the implant sites healed, Hahn Multi-Unit Abutments were connected to the implants and elevated the restorative platform above the soft tissue, thereby simplifying the fabrication of the immediate provisional denture as well as the final restoration.

certainly done quite a few acrylic hybrid dentures, where you’ve got acrylic and denture teeth fused to a bar. When I used to do full-arch cases, any issues I experienced tended to be on the prosthetic end of things. It has gradually evolved, and with the advent of monolithic zirconia, we can provide this type of restoration with much more confidence, without worrying that the denture teeth will wear down or the porcelain or acrylic will break, chip off or delaminate.

My dental implant practice has culminated with full-arch zirconia implant restorations, and that’s been within the last three years or so. I’ve never seen a BruxZir Zirconia restoration chip, crack or fail in the seven years since I started working with the material. It’s a game changer. From single units up to full-arch implant restorations, BruxZir has to be the most successful dental material ever. It has revolutionized dentistry.

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And doing a full-arch PFM on implants is way more labor-intensive — it’s just painfully slow going. There are just so many more layers and steps compared to the greatly streamlined workflow of doing a BruxZir Implant Prosthesis. My next frontier is the immediate loading of full-arch cases, where you send the patient home on the day of surgery with a fixed, converted denture. Even back in the ’90s, Dr. Misch’s research showed that immediately loading a

converted full-arch provisional denture was more predictable than doing one or two implants and loading them on the day of surgery, so the idea is not new. I’ve done a couple of those and picked up some great tips and tricks from my friend Dr. Paresh Patel at the full-arch implant course he teaches for Glidewell Clinical Education. He really helped build up my confidence that I should be doing immediate provisional implant dentures routinely. It’s a huge jump to go from placing the implants and waiting for them to heal to immediately loading a converted denture, so I’ve been grateful for the guidance and expertise provided by Dr. Patel. It makes such a positive impact on the lives of patients when they can leave your office with fixed teeth on the same day you place the implants. CM: Can you talk about any notable cases you’ve recently restored with the BruxZir Implant Prosthesis? JF: Sure. He had been a regular patient of mine for a number of years, and his lower teeth were failing at a pretty rapid rate due to periodontal disease. So we talked about all the options, and he finally decided it was time to move forward with replacing his terminal dentition. The patient had some esthetic and functional concerns, so a fixed implant restoration fabricated from BruxZir Zirconia was an ideal solution. He’s a huge guy — a bodybuilder, in fact — so the high strength and durability of monolithic zirconia was also important. Prior to the surgical appointment, we had a temporary denture specifically made for conversion to a fixed appliance after placing implants. We took out his remaining lower teeth and immediately placed five Hahn™ Tapered Implants (Glidewell; Irvine, Calif.). I positioned the three anterior implants axially, and I angled the posterior implants mesially to avoid the inferior alveolar canal. I freehanded the surgical procedure, and it came out really well. We connected three straight

multi-unit abutments to the anterior implants and two angled 17-degree multi-unit abutments to the posterior implants. Then, we prepared holes in the denture, did the pickup procedure with the temporary cylinders, reshaped it, and sent him home with the fixed, converted denture in place. This was my first immediate load fixed full-arch restoration on multi-unit abutments. As I mentioned earlier, this was a procedure I learned at Dr. Patel’s course at Glidewell. It was something I took home with me and was able to put it into practice within a few weeks. The patient is kind of a quiet guy, but it was obvious that he was really happy to leave there with fixed teeth. After three months, we removed the converted denture, took impressions, and began restoring the case. We tried in the setup and everything looked good, so we sent it in to get it copy-milled. Glidewell sent us a provisional implant prosthesis to make sure everything was perfect. We seated the provisional and made sure

he could clean it and liked the way it looked. We let him wear it for three weeks and there were no adjustments needed, so then it was a simple phone call to have the final prosthesis milled from BruxZir Zirconia. The final delivery appointment went very quickly because the patient and I both knew exactly what to expect thanks to the provisional. Like I said, the patient is not the most verbal guy, but when I handed him the mirror, he said, “I like it a lot,” and we could tell that he was very happy. This workflow totally changed my outlook on full-arch implant treatment. This was just a huge leap for me, and when I see what can be done now with so much less effort and so much more benefit for the patient, it’s totally reenergized the way I practice dentistry. CM: We’ve actually made multi-unit abutments a standard part of our restorative protocol for the BruxZir Implant Prosthesis, whether the dentist loads the implants on the

The denture converted to a fixed appliance (left) on the day of surgery was duplicated and sent to Glidewell to begin the restorative process. A provisional implant prosthesis (middle) was provided by the lab so the function, occlusion and esthetics could be confirmed by the doctor and patient. After a three-week “test drive,” the patient indicated that he was happy with the design and the final BruxZir Implant Prosthesis (right) was milled from monolithic zirconia.

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day of surgery or waits until the implant sites have healed. How has your experience been with multiunit abutments? JF: They help tremendously in these cases because it elevates everything above the gingival tissue. When you get the multi-unit abutments in place at the beginning of treatment, it makes the try-ins, the provisional and the delivery of the final restoration an easier experience for the dentist and the patient. This particular patient was something of a dental phobic, and we only had to sedate him once. After placing the implants and connecting the multi-unit abutments, each subsequent visit went smoothly because we could easily attach the try-ins and didn’t have to worry about impinging on his gingiva. So just from the patient’s standpoint, he would tell you that he doesn’t remember one bit of pain or discomfort through the whole procedure. It’s phenomenal. CM: How often are you prescribing the BruxZir Implant Prosthesis for your full-arch cases? JF: If I’m going to do a fixed full-arch, that’s my go-to restoration — period.

It has all the advantages in terms of workflow, patient satisfaction, durability and quality. And they’re just utterly gorgeous. When I put the prosthesis in patients’ hands, they’re always amazed at the beauty. I don’t imagine I’ll ever deliver a PFM or acrylic hybrid denture for these types of cases again. CM: Do you find a lot of value in the provisional implant prosthesis? JF: It’s huge. It gives the patient a chance to test-drive the restoration, and it’s an exact replica of what we’re proposing for the final restoration. I wouldn’t think of going straight from the approved setup to the final restoration. It’s a very valuable intermediate step and basically allows the patient not only to preview the looks, but also an opportunity to function with it during real life. I wouldn’t do a case without it, and I’m glad it’s part of the service Glidewell provides. CM: You mentioned that you did the restoration over Hahn implants — have you found that those work well in full-arch indications? When did you start using Hahn?

The final BruxZir Implant Prosthesis was delivered, completing a streamlined, predictable clinical workflow. The patient was extremely happy with the look and feel of the monolithic zirconia restoration, which affords the high strength needed to avoid prosthetic complications and does a great job of addressing the long-term needs of the patient.

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JF: They work well in any indication. I’ve had great success doing everything from single units, to 3-unit bridges, to full arches. It’s a very versatile implant I can use anywhere, in just about any application. And the Hahn system offers a cost-effective approach due to the relatively low cost of the implants, the improved workflow and the 20% lab discount I receive for implant restorations through Glidewell. I can offer implant treatment with confidence at a significantly lower price point than I could before, which makes it easier for patients to accept treatment. I started using the Hahn implant in 2015. I was attending a dental meeting in Las Vegas. Dr. Carl Misch, who was the creator of the BioHorizons implant I was using at that time, was there promoting the Hahn system as a more cost-effective alternative. I switched over pretty quickly after hearing Carl talk about the Hahn system, and my practice really transformed when I began using the Hahn implant and started working a lot with Glidewell. CM: What general advice can you offer to any dentists out there who are considering switching to or learning how to provide monolithic zirconia full-arch implant restorations? JF: First of all, I’d suggest leaning heavily on Glidewell, which pioneered this type of restoration and has a well-established reputation. They’ve been refining the restorative workflow for full-arch cases for years, and they have a great technical support team in place that can provide you with any help you need in restoring these cases. I’d also suggest taking advantage of Glidewell as a tremendous educational resource and attending one of their courses on full-arch implant treatment. Dr. Patel’s course was great, and it really opened my eyes to a lot of possibilities. CM

R&D CORNER

Tapered vs. Parallel-Walled Implants: Which Is the Better Design and Why? An inside look at new research conducted by Dr. Christopher Resnik, a prosthodontist based in Winter Park, Florida

he design of the dental implant body â&#x20AC;&#x201D; or macrostructure â&#x20AC;&#x201D; is the key design feature in achieving primary stability, which is the main prerequisite for achieving successful osseointegration of dental implants. This is particularly critical in areas of poor bone quality (D4 bone), which are associated with increased morbidity and lower success rates. Despite the importance of this design feature, there have been few studies comparing the performance of tapered implants vs. parallel-walled implants in poor-quality bone.

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Figure 1: Dr. Christopher Resnik (second from right) joined by his sister, Allison, and parents, Randolph and Diane Resnik, while receiving his Diplomate status from the International Congress of Oral Implantologists.

To address this knowledge gap, Dr. Christopher Resnik recently conducted a study to examine whether tapered or parallel-walled dental implants provide greater primary stability. Due to the increasing popularity of immediate loading of dental implants, which relies on initial stability, he set out to determine if there is a specific implant design that can be used to increase clinical success. Dr. Resnik is a prosthodontist in private practice in Winter Park, Florida, and recently graduated from the specialty training program in prosthodontics at the University of Pittsburgh, where he conducted this study. His father, Dr. Randolph Resnik, is the director of the Misch International Implant Institute, which has set the standards for dental implant education for over 30 years.

Dr. Christopher Resnikâ&#x20AC;&#x2122;s new study, which has been accepted for publication, is the first of its kind, and its findings have important implications for clinicians. Here, weâ&#x20AC;&#x2122;ll discuss implant body design and present a summary of this exciting new research.

DISCUSSION Implant Body Design Implant designs include cylindrical and threaded types. However, implants with a threaded design predominate due to their increased surface area, which allows for increased bone-implant contact (BIC) and more predictable integration. Increased BIC is associated with superior primary stability and minimal micromotion, which is paramount to success.1

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Figure 2: Cylindrical dental implant.

R&D CORNER diameter. Therefore, they are less likely to perforate the cortical plates when osseous undercuts are present in the regional anatomy. In addition, they are ideal for implant sites with compromised space between tooth roots.

Figure 4: The design of the Hahn Tapered Implant, shown above, is advantageous in anatomically constricted sites, as well as in sites planned for immediate loading. Clinical photo courtesy of Dr. Jack Hahn

inadequate bone volume, and in sites planned for immediate loading.

STUDY SUMMARY It was hypothesized that placement of tapered implants in poor-quality bone would demonstrate a higher degree of initial stability than parallel-walled implants placed in the same medium. This, in turn, could lead to greater osseointegration and implant success. To determine which type of implant provides greater primary stability, Dr. Resnik collaborated with Grant Bullis, vice president and general manager of the Manufacturing division at Glidewell, to fabricate a parallel-walled prototype implant to compare with the Hahn Tapered Implant. In all other characteristics, the implants were identical, including the same titanium alloy, implant length and diameter (4.3 x 13.0 mm), implant collar, and thread design. The only difference between the tested implants was the macrostructure: tapered vs. parallel.

Figures 3a, 3b: Threaded implant: Parallelwalled design (3a) vs. tapered implant (3b).

Primary Stability and Osseointegration

Threaded implants may be either parallel-walled (equal diameter along the entire implant body) or tapered (decreasing diameter toward the apex, similar to a tooth root). Tapered implants divert forces toward the apex, making this type of implant more desirable for immediate placement and immediate loading.2 Tapered implants have also been shown to distribute occlusal forces to adjacent bone more favorably than parallel-walled implants.3

Primary stability is the initial mechanical fixation of a dental implant immediately after placement within the bone. Primary stability of the dental implant is crucial in obtaining osseointegration.4 This stability directly affects the rigidity and resistance to movement of the dental implant before the initiation of the bone remodeling and healing process. Studies have shown that micromovement greater than 150 µm is detrimental to osseointegration.5 Therefore, prevention of micromovement is essential in averting early implant failures.

Dr. Jack Hahn is recognized for pioneering the first tapered implant in the 1990s and for developing the Hahn™ Tapered Implant in 2015. Tapered implants require less bone volume at the apex due to the decreased apical

The tapered design has been shown to provide greater lateral compression of the bone during insertion.6 This could lead to an increase in primary stability, favoring tapered implants to be used in sites with poorer bone quality or

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Figure 5: For the study, the lab fabricated test implants with identical design characteristics. The only difference was the wall design, with the tapered-body Hahn Tapered Implant (left) and parallel-body prototype (right).

Figure 6: Resonance frequency analysis recording using Penguin RFA.

Type

Tapered Implant Parallel-Walled Implant

Mean ISQ Score 67.1

64.8

Figure 7: ISQ results for tapered vs. parallel-walled implants. The study concluded that tapered implants achieve significantly greater primary stability.

Twenty-four tapered and parallel-body dental implants were placed fully guided with a drill press into a poorquality bone medium (balsa wood). The primary stability of each implant was evaluated using resonance frequency analysis with the Penguin RFAÂŽ (Glidewell; Irvine, Calif.). Implant stability quotient (ISQ) scores, which correlate to primary stability, were calculated and compared for each implant. The mean ISQ value for tapered implants was 67.125 +/- 1.974, and the

ISQ value for parallel-walled implants was 64.813 +/- 0.93. The study concluded that tapered dental implants reach a statistically significant greater primary stability in poor-quality bone than parallel-walled implants.

CONCLUSION Implant body design is of critical importance to the success of implant treatment, particularly in sites with poor bone density. Although past studies have been conducted to evaluate different implant designs, this study is believed to be the first to compare a parallel-body implant vs. a tapered implant with all other variables of implant design kept identical. The study found that tapered implants provide greater primary stability than parallel-walled implants. This is important because primary stability is a key prerequisite for successful osseointegration. With the popularity of immediate loading protocols in implant dentistry, the implant surgeon can increase predictability and success by selecting a tapered implant. CM

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REFERENCES 1. Watzak G, Zechner W, Ulm C, Tangl S, Tepper G, Watzek G. Histologic and histomorphometric analysis of three types of dental implants following 18 months of occlusal loading: a preliminary study in baboons. Clin Oral Implants Res. 2005 Aug;16(4):408-16. 2. Morris HF, Ochi S, Crum P, Orenstein IH, Winkler S. AICRG, part 1: a 6-year multicentered, multidisciplinary clinical study of a new and innovative implant design. Oral Implantol. 2004;30(3):125-33. 3. Glauser R, Sennerby L, Meredith N, RĂŠe A, Lundgren A, Gottlow J, HĂ¤mmerle CH. Resonance frequency analysis of implants subjected to immediate or early functional occlusal loading: successful vs. failing implants. Clin Oral Implants Res. 2004 Aug;15(4):428-34. 4. Albrektsson T. Direct bone anchorage of dental implants. J Prost Dent. 1983 Aug;50(2):255-61. 5. Szmukler-Moncler S, Salama H, Reingewirtz Y, Dubruille JH. Timing of loading and effect of micromotion on bone-dental implant interface: review of experimental literature. J Biomed Mater Res. Summer 1998;43(2):192203. 6. Atieh MA, Alsabeeha N, Duncan WJ. Stability of tapered and parallel-walled dental implants: a systematic review and meta-analysis. Clin Implant Dent Relat Res. 2018 Aug;20(4):634-45. Penguin RFA is a registered trademark of Integration Diagnostics Sweden AB.

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4 Ways to Temporize Dental Implants These provisional solutions are designed to support your patient’s oral health — and provide an efficient, simple clinical protocol for your implant cases.

by Taylor Manalili, DDS Director of Clinical Prosthodontics for Glidewell — Newport Beach, California

hen I am asked about my favorite way to provisionalize dental implants, I have one answer on standby: “It depends.” How many teeth need to be restored? Is the implant stable? How long will the patient be wearing the provisional? These are just some of the factors that inform my clinical decision-making. Ultimately, I want to provide temporization results that will best serve my patient’s oral health — in the healing phase and for the final implant restoration. I’m always aware of the time factor, too. That’s why I often prescribe lab-fabricated solutions to temporize dental implants, rather than enduring the time and inconvenience of trying to create temporaries chairside. Let’s look at four options.

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1. S CREW-RETAINED BIOTEMPS® PROVISIONALS For single-unit implant cases, screw-retained BioTemps® Provisionals are my go-to solution. Why? Because my driving concern in the temporization stage is to ensure esthetic gingival contours, whether I want to retain the current position of the gingiva or guide the soft tissue into an ideal emergence profile. When it comes to implant cases in the esthetic zone, we are all acutely aware of the challenges and importance of managing the soft tissue. Fortunately, BioTemps Provisionals enable predictable results. It’s also important not to rush this pivotal step. For patient comfort, predictable final esthetics and ease of communication with the lab, goals for the soft tissue need to be fully realized before advancing to the final restoration.

Figure 2: For this case, I prescribed a screw-retained BioTemps provisional, which was fabricated prior to the implant surgery. This step can also simplify the final restoration, as Glidewell automatically saves the BioTemps design file. The BioTemps design can be used to fabricate the final restoration after any necessary adjustments are made.

Case Report

Figure 3: BioTemps Provisionals are far more efficient than the chairside temporaries that we’re all familiar with, and immediate loading is possible if the implant achieves sufficient primary stability. For this case, using a BioTemps provisional enabled me to guide the soft tissue to establish an ideal emergence profile. Also, it is worth noting that BioTemps Provisionals can be made as screw-retained or cementable restorations.

Figures 1a, 1b: This patient was missing tooth #4. To achieve a predictable, esthetic and functional restorative outcome, I used the Digital Treatment Planning (DTP) and surgical guide fabrication services from Glidewell. These services consistently enable accurate placement and allow me to save precious time. The lab’s DTP team identifies the optimal positioning of the implant and creates a restorative-driven treatment plan, complete with a tooth-supported surgical guide for precise implant placement.

Figure 4: This buccal view of tooth #4 shows the BioTemps provisional in place with nicely healed tissue and papillae — something that I never take for granted when temporizing dental implants. The smooth surface of BioTemps Provisionals is conducive for healthier tissue like that shown in the above photo, as BioTemps Provisionals accumulate lower levels of biofilm compared to chairside acrylic temporaries. For this case, I am planning to prescribe BruxZir® Full-Strength Zirconia for the final screw-retained restoration.

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2. C EMENT-RETAINED BIOTEMPS PROVISIONALS When multiple sites — implants and natural teeth — need to be provisionalized, BioTemps Provisionals remain my answer. In this case report, you’ll see how I placed a dental implant at tooth #9 and immediately temporized teeth #8–11 with splinted BioTemps Provisionals.

Case Report

Figure 3: With the splinted BioTemps Provisionals, I was able to immediately temporize the surgical sites and adjacent teeth on the day of surgery, and proactively manage the tissue.

Figure 1: This patient desired more esthetic restorations for a full smile makeover spanning teeth #4–13. Teeth #9 & #10 were non-restorable due to vertical root fractures.

Figure 4: At one month post-op, the soft tissue looked great, and the patient remained comfortable. The esthetic BioTemps Provisionals empowered the patient to smile with confidence during the healing and osseointegration phase for the dental implant.

Figure 2: After extraction, I grafted using Newport Biologics™ Cortico/Cancellous Allograft Blend (Glidewell; Irvine, Calif.). As the patient had a thin tissue biotype, I chose to place a ZERAMEX® XT Implant at site #9. The white all-ceramic implant would help avoid metal showing through the thin facial gingiva.

SAVE NOW Take advantage of our special offers on implant provisionals at glidewelldental.com/ temporaries-offer

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3. SMILE TRANSITIONS™ COSMETIC APPLIANCE Fully transforming a smile is often a complex process that takes place over many months. But before the process can begin, there’s the crucial step of gaining patient acceptance. And one of my favorite motivational tools for smile makeovers is the Smile Transitions™ cosmetic appliance. Prescribing a Smile Transitions appliance is an easy, affordable way to give the patient a preview of the cosmetic possibilities. The patient can instantly see dramatic improvements in the shape and shade of the teeth, without any tooth preparation or cementation.

Case Report

Figures 2a, 2b: To help the patient visualize what his completely transformed smile could look like, I prescribed a Smile Transitions cosmetic appliance (2a). The Smile Transitions appliance also was beneficial in the interim for restoring the vertical dimension. If no changes to the vertical dimension are needed, the lab can fabricate a Smile Transitions appliance that includes occlusal cutouts, upon request (2b).

Figures 1a, 1b: This patient was edentulous in the area of teeth #4–12 and had a collapsed vertical dimension. The restorative treatment plan to provide full function and an esthetic smile was going to be a lengthy process.

Figures 3a, 3b: The Smile Transitions cosmetic appliance also provided an immediate temporization solution after placing the patient’s dental implants. During the healing and osseointegration period, the posterior teeth were kept to retain the Smile Transitions appliance. The patient enjoyed the daily preview of his more esthetic smile. And I appreciated knowing that the Smile Transitions cosmetic appliance — milled from acetal resin — would be a durable solution as the rest of his treatment progressed.

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4. ESSIX RETAINER Sometimes, primary stability is inadequate and immediate loading is not indicated. For instance, when placing an implant in the maxillary posterior, with Type 3 or Type 4 bone, immediate loading is less predictable. Typically, I prefer to put on a cover screw and do a full soft-tissue closure. Then, with the implant buried, I can temporize the site with an Essix retainer from Glidewell. An Essix retainer is the easiest of these four implant temporization options. Glidewell fixes a denture tooth in the Essix retainer to maintain the edentulous space and provide an esthetic temporary tooth replacement.

Case Report

Figures 3a, 3b: Although the missing tooth was a second premolar, the area showed when the patient smiled. The esthetics of the Essix retainer made it an excellent choice for this case.

CONCLUSION Figure 1: This patient sought treatment due to discomfort caused by a failing implant at site #13, which had been restored several years ago. I removed the existing implant, from an unfamiliar implant system, and replaced it with a Hahnâ&#x201E;˘ Tapered Implant (Glidewell). The lower pitch and deeper thread pattern of the Hahn Tapered Implant are two of the many qualities that I like about the Hahn Tapered Implant System. This photo is from the healing and osseointegration phase, following placement of the Hahn Tapered Implant.

Knowing all your options is essential for predictably temporizing dental implants across a range of case needs. These four lab-fabricated options are just one indicator of how, with the right dental laboratory by your side, implant dentistry can be simpler and safer. CM

EARN CE CREDIT

Figure 2: I chose to prescribe an Essix retainer from Glidewell for this patient, as maintaining the space during the healing phase is an important factor. The Essix retainer can help prevent supraeruption of the opposing dentition and prevent rotation or drifting of the adjacent teeth.

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Earn free CE credit for this article. Scan the code or go to glidewelldental.com /1502-ce3 to enter your answers.

QUESTIONS ON NEXT PAGE

4 Ways to Temporize Dental Implants 1. Which of the following considerations are important when determining how to provisionalize an implant? a. b. c. d. e.

6. It is important to achieve the goals for the soft tissue before advancing to the final restoration.

he number of implants and teeth to be restored T The primary stability of the implant(s) Esthetic demands All of the above None of the above

2. Management of both the soft tissue and surrounding dentition is important throughout the healing phase. a. True b. False 3. Digital treatment planning and guided surgery can allow you to fabricate a provisional restoration prior to implant surgery, allowing for more predictable results and less chair time. a. True b. False 4. Soft-tissue management is the only reason we want to provisionalize implants. a. True b. False 5. What are the benefits of having a lab-fabricated provisional restoration compared to a chairsidemade acrylic provisional? a. b. c. d. e.

by Taylor Manalili, DDS

a. True b. False 7. Esthetics, function and vertical dimension can be tested utilizing a provisional restoration, which also helps protect the healing implant sites. a. True b. False 8. Management of the edentulous space is a significant factor in implant planning and the provisionalization phase. a. True b. False 9. Implant location, esthetic demands, gingival biotype and primary stability are factors to consider when selecting a method of provisionalization. a. True b. False 10. When the soft-tissue emergence is critical, a fixed provisional restoration is the most predictable way to achieve a successful clinical outcome. a. True b. False

Less chair time Lower levels of biofilm accumulations Smoother surface to promote healthier soft tissue All of the above None of the above

To receive free CE credit for this article, go to glidewelldental.com/1502-ce3. Visit glidewelldental.com/education to access other free, on-demand CE courses. Or enroll in a hands-on course in a city near you. Register today!

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When Are Overdentures the Right Treatment? by Timothy F. Kosinski, DDS, MAGD Private Practitioner â&#x20AC;&#x201D; Bingham Farms, Michigan

hen a patient visits your office with terminal dentition or an unstable, poorly fitting denture, dental implants are typically the best long-term solution. Providing superior function, prosthetic stability and quality of life, dental implant treatment offers a vast improvement over traditional complete dentures.1â&#x20AC;&#x201C;3 Depending on the patientâ&#x20AC;&#x2122;s health, anatomy and financial circumstances, a fixed full-arch implant restoration is ideal for some patients, while a removable implant overdenture is well suited for others. Here, I will explore the implant overdenture, common situations in which it is prescribed and a case report that illustrates a simplified restorative workflow.

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An implant overdenture is an implant-retained prosthesis that restores function and stability by attaching to two or more implants. Unlike the fixed full-arch restoration, most implant overdentures are soft-tissue supported and can be removed by the patient for cleaning. Although fixed restorations usually provide superior stability and function, here are some common situations where implant overdentures should be considered: 1. Patients with limited finances — Implant overdentures typically require fewer implants and can be offered to patients at a reduced cost compared to fixed implant restorations. In certain situations, the patient’s existing complete denture can be retrofitted to the implants, reducing costs even further. 2. Limited bone in the edentulous arch — When the patient doesn’t have enough bone volume to support the number of implants in the correct positions needed to provide adequate anterior-posterior (A-P) spread for a fixed restoration, an implant overdenture is an excellent solution. 3. Grafting procedures are contraindicated — When bone augmentation is needed to facilitate placement of the implants for a fixed restoration, but the patient cannot receive bone grafting due to health or financial reasons, an implant overdenture is a great alternative. 4. Patients who like their dentures but want more stability — Some patients prefer their removable dentures but experience problems with retention. An implant overdenture solves this problem and offers the same esthetics as traditional dentures. 5. A palateless maxillary appliance is desired by the patient — With an adequate number and positioning of implants, maxillary overdentures can be horseshoeshaped, addressing the concerns some patients have with regard to comfort, speech and taste.

CASE REPORT The following case report illustrates a straightforward clinical workflow for delivering a Locator® Overdenture (Glidewell; Newport Beach, Calif.) — a removable appliance that seats over Locator Abutments connected to the implants. Denture caps are embedded in the overdenture and provide retention by seating over and engaging the Locator Abutments. By stabilizing the prosthesis, these retentive devices improve function and chewing efficiency. Our patient is a middle-aged female who presented with a chief complaint of ill-fitting, unstable maxillary and mandibular conventional dentures. We discussed several options, including relining her existing dentures, fabrication of new conventional dentures, implant-retained overdentures and

The Locator Overdenture provides increased retention for the patient’s denture via retentive caps that seat over the Locator Abutments connected to the implants.

fixed implant-supported prostheses. The patient opted for implant placement and restoration with a Locator Overdenture — which would provide an effective, economical means of addressing the patient’s needs and improving prosthetic stability and dental function.

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Figure 3: CBCT analysis demonstrating horizontal and vertical mandibular bone loss. Based on the available bone, we decided to place four implants in the maxilla and four in the mandible to support implant-retained overdentures.

Figures 1a, 1b: Preoperative smile and intraoral image of patient’s existing maxillary and mandibular complete dentures. The patient’s dentures no longer fit or functioned well and the upper denture was cracked, leading the patient to consider treatment that provided more retention, stability and chewing force, while eliminating the acrylic on the maxillary palate for enhanced comfort and taste.

Figure 4: Postoperative panoramic radiograph illustrating the strategic placement of eight Hahn™ Tapered Implants (Glidewell) in the edentulous arches.

GO ONLINE 2b

Figures 2a, 2b: The edentulous ridges exhibited significant bone loss, especially in the mandible. Note the sore spot on the right side of the patient’s maxillary arch from the cracked, unstable denture. After discussing treatment options with the patient, she selected overdentures as an affordable means of increasing her chewing efficiency and function while maintaining the esthetics she had grown accustomed to with her conventional dentures.

For information on mini implant overdentures — a removable implant solution that can stabilize dentures in one simple appointment — check out Dr. Raymond Choi’s blog post on Smile Bulletin, the new blog from Glidewell. glidewelldental.com/company/blog

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Figures 5a, 5b: Four months after placing implants, implant-level impressions were made and sent to the lab, where Locator Abutments were chosen according to the height of the soft tissue. At the next appointment, Locator Abutments were connected to the implants, which extended 1.5â&#x20AC;&#x201C;2 mm above the mucosa. This allowed for seating of the prostheses without impingement of the soft tissue.

Figure 6: Wax rims were produced by the lab and tried in to establish proper vertical dimension of occlusion (VDO), record the jaw relationship, and confirm lip support and other aspects of the prosthetic design. Placing two anterior teeth on the wax rim helped accurately capture the midline.

Figures 7a, 7b: The lab created wax setups and designed the overdentures to improve lip support, esthetics and function. The metal housings for the Locator Attachments were cured into the denture bases to stabilize and retain the appliances during try-in.

Figure 8: The trial denture setups were seated in the patientâ&#x20AC;&#x2122;s mouth and the VDO, esthetics, occlusion, phonetics and midline were carefully evaluated. After making minor adjustments, the setups were returned to the lab for processing of the final overdentures.

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Figures 9a, 9b: The final Locator Overdentures were produced by the lab based on the approved wax setups. Note the use of metal substructures to maximize the strength of the prostheses. Figure 11: The final smile of our patient, who was extremely happy with her stabilized overdentures and now enjoys renewed dental function, comfort and quality of life.

CONCLUSION

Figure 10: Before delivering the final implant overdentures, the Locator Abutments were torqued to 35 Ncm on the Hahn Tapered Implants. Then, the implant-retained overdentures were seated and the occlusion, esthetics and function were confirmed. The restorations provided the patient with outstanding stability and retention using the Locator attachment system.

As more patients turn to implant treatment as the optimal solution for the edentulous arch, itâ&#x20AC;&#x2122;s important that doctors consider the full range of restorative options. While the fixed full-arch restoration provides the best possible outcome, for many patients, the removable implant overdenture is an excellent alternative that addresses the issues associated with traditional complete dentures and is indicated in many patient situations. Locator is a registered trademark of Zest Dental Solutions.

REFERENCES 1. Yunus N, Masood M, Saub R, Al-Hashedi AA, Taiyeb Ali TB, Thomason JM. Impact of mandibular implant prostheses on the oral health-related quality of life in partially and completely edentulous patients. Clin Oral Implants Res. 2016 Jul;27(7):904-9. 2. Hyland R, Ellis J, Thomason M, El-Feky A, Moynihan P. A qualitative study on patient perspectives of how conventional and implant-supported dentures affect eating. J Dent. 2009 Sep;37(9):718-23. 3. Geckili O, Bilhan H, Mumcu E, Dayan C, Yabul A, Tuncer N. Comparison of patient satisfaction, quality of life, and bite force between elderly edentulous patients wearing mandibular two implant-supported overdentures and conventional complete dentures after 4 years. Spec Care Dentist. 2012 Jul-Aug;32(4):136-41.

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Chairside Pickup of Locator Housings Len Conner, CDT Director of Education and Clinical Affairs at Zest Dental Solutions

In the standard protocol for the Locator Overdenture, the Locator housings are processed into the overdenture by the dental lab. However, some doctors may prefer to pick up the Locator housings intraorally. The following presentation, courtesy of Len Conner, CDT, director of education and clinical affairs at Zest Dental Solutions, illustrates the straightforward clinical procedure for intraoral pickup.

Step 1: After seating the appropriate Locator abutments and tightening them to the recommended torque, place the white blockout spacer over each abutment.

Step 4: Apply fit-check marking paste to the intaglio surface of the denture. Seat the overdenture over the Locator housings. Then, remove the overdenture and relieve the marked areas with an acrylic carbide bur. Remove enough material so that the overdenture seats over the Locator housings passively without making contact, adding undercuts for mechanical retention.

Step 7: Remove the denture from the mouth. Verify that the housings have been securely processed into the overdenture. Fill voids with additional processing material and light-cure. Remove any excess material with an acrylic cutting carbide bur.

Step 8: Depending on the desired retention and the patientâ&#x20AC;&#x2122;s ability to remove the prosthesis, remove the black nylon processing caps and replace them with either the clear, blue or pink nylon caps.

Step 2: Snap the Locator housings with the black nylon processing caps over the blockout spacers and abutments.

Step 3: Make sure the metal housings are fully seated.

Step 6: Seat the denture over the housings and onto the tissue. Have the patient close into light occlusion and hold while the material sets.

Step 5: After drying the metal housings, apply a small amount of processing material on top of and around the circumference of each cap. Then, partially fill the relieved areas of the denture with processing material.

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Step 9: Instruct the patient on insertion and removal of the final overdenture. CM

A Stable Denture Your Patients Can Smile About Locator ® Overdentures from Glidewell are a simple, cost-effective implant solution for restoring comfort and function for your denture patients. • Implant retention stabilizes denture and preserves ridge • Customized prosthetic design ensures secure fit • Improved functionality with lifelike esthetics • Predictable implant lab fees and no hidden costs

List Price

655

Includes two Locator Abutments, Processing Kits and final overdenture.

Made in USA * Price does not include shipping or applicable taxes and varies if original equipment manufacturer (OEM) components are requested or required for the chosen implant system. Locator is a registered trademark of Zest Dental Solutions.

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Chairside Magazine Volume 15, Issue 2

Articles inside

When Are Overdentures the Right Treatment?

4 Ways to Temporize Dental Implants

Tapered vs. Parallel-Walled Implants: Which Is the Better Design and Why?

My First Immediate Load Full-Arch Implant Case

5 Ways to Increase Implant Case Acceptance

Guided Bone Regeneration: 8 Steps to Successful Ridge Augmentation

A Simplified Clinical Protocol for the Fabrication of Full-Arch Implant Restorations

Meeting High Esthetic Demands

10 Things I Learned the Hard Way

Editor's Letter

Publisher's Letter