Vol. 6, No. 4 • Winter 2015
THE JOURNAL OF CLINICAL & PRACTICAL ORAL IMPLANTOLOGY
Immediate Loading in the Edentulous Mandible Implant-induced post-traumatic inferior alveolar nerve neuropathy Managing implant failure Metal-Free Replacement of a Maxillary First Premolar with a Zirconia Ceramic Implant Dental Implant Material and Design
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SPMP15403CA REV A DEC 2015
THE JOURNAL O F CLINICAL & PRACTICA L O RAL IMPLANTO LOGY
Vol. 6, No. 4 • Winter 2015
Contents 6 Guest Editorial Making It Happen in 2016 Nadean Burkett
8 Products and People 12 Immediate Loading in the Edentulous Mandible Dr. Jan Spieckermann and Dr. Ulrich Glase
20 Implant-induced post-traumatic inferior alveolar nerve neuropathy Tara Renton
28 28 Managing implant failure Naresh Sharma and Ashok Sethi
34 Metal-Free Replacement of a Maxillary First Premolar with a Zirconia Ceramic Implant: A Clinical Case Report Dr. Sammy Noumbissi
40 Dental Implant Material and Design Dr. Dan Hagi
46 Digital dental photography
(Part two)
Peter Gordon
50 Adlink
12 SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
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Publisher: Ettore Palmeri, MBA, AGDM, B.Ed., BA Palmeri Publishing Inc.
Vol. 6, No. 4 • Winter 2015
Advisory Board
Canadian Office: 35-145 Royal Crest Court, Markham, ON L3R 9Z4 Tel: 905-489-1970 Fax: 905-489-1971 Email: ettore@palmeripublishing.com Editor-in-Chief: Allen Aptekar, BSc., DMD editor@jcpoi.com Consulting Editor: David J. Stern, DDS Design & Layout: Tim Faller, Sophie Faller Publication Dates: Spring, Summer, Fall, Winter
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Dr. Allen Aptekar Editor-in-Chief
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Printed in Canada Canadian Publications Mail Product Sale Agreement 9386690 Spectrum Implants ISSN 2293-7897
Dr. Edy Braun
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Dr. Anastasios Irinakis
Dr. Sascha Jovanovic
Dr. Sonia Leziy
Dr. Craig M. Misch
Dr. Michael A. Pikos
Dr. Michael Razzoog
Dr. John Russo
Dr. Peter C. Shatz
Dr. Lee H. Silverstein
Dr. Bernard Touati
Spectrum Implants is published four times a year, and is distributed to dental practitioners across Canada and the United States. The journal is committed to better the knowledge of dental practitioners in discipline of dental implantology. All statements of opinion and supposed fact are published on the authority of the submitting author and do not necessarily express the views of the Spectrum Implants, CPOI Holdings Inc, the Editor(s), and the Editorial Board. The publisher disclaims any responsibility for loss or damage due to errors and omissions. Content of the Spectrum Implants does not constitute medical advice. The editor reserves the right to edit all copy submitted to the Spectrum Implants. Publication of an advertisement does not imply that Spectrum Implants endorses the claims therein. The publisher, Spectrum Implants, and CPOI Holdings Inc. disclaim responsibility for any injury to persons or property resulting from any ideas or products referred to in the articles or advertisements. Articles published express the viewpoints of the author(s) and do not necessarily reflect the views and opinions of the Editorial Board. All rights reserved. The contents of this publication may not be reproduced either in part or in full without written consent of the copyright owner.
Dr. Istvan Urban
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Dr. Hom-Lay Wang
Dr. Natalie Wong
Dr. Amr Zahran
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
Guided Surgery easy and predictable New innovations in guided implant surgery with the AVINENT® Implant System improve the patient experience, save you valuable chair time and offer the accuracy and simplicity that other systems cannot.
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Join us on the NEW “AVINENT Experiences” Blog! Go to www.avinentexperiences.com for a whole new way of looking at implantology!
Complete Root-to-Tooth™ Solutions The Aurum Group – All Under One Roof
Guest Editorial
Making It Happen in 2016 Nadean Burkett
What are your goals for 2016? We all know that the
• Expand your clinic’s footprint (multi-locations) Do more, be better, be different. In other words do more start of a new year brings with it retrospection and with less and expect a different result. But this strategy has opportunity for fresh new starts. proven to do one thing: commoditize dental services. From talking to many practitioners I find that their Dentistry is a business that has been based on trust and performance once again was less than what they had hoped respect between patient and their healthcare professional. for, but I have been hearing this over the past several years Over the past 20 years, many from all over North America. dentists, pushed by external Whether we consider the rising circumstances, have reversed expectations of practitioners the dentist — patient in terms of growth and return relationship 180 degrees. on investment or simply the They have done this year over year performance, by marketing promotional clearly the challenges of a solo offerings such as free whitening practitioner have multiplied Albert Einstein - Physicist & Philosopher or bleaching, discounted fees over the past few years. for new patient visits and The rising costs of capital restorative services (an implant for $600). The dental improvements, operating costs, the costs of attracting and profession has encouraged the commoditization of dentistry retaining patients, recruiting and retaining auxiliaries, by doing all of these things in retail settings where they are training and managing employees, promotion, technology sandwiched between the dollar store and a coffee house. integration, and other management responsibilities are It is a known fact that we tell people how to treat us by either pushed aside, ignored or take time away from clinical how we present ourselves and how we treat them. What do production. We hear this from GPs and specialists regularly, you think is the chance that your $25,000 treatment plan and with increasing frequency. will be accepted by a new patient who has just visited your The advice consultants usually suggest are : practice because you offered a new patient visit for $99? If • Decrease expenses you don’t see the correlation between discounting your fee • Become more efficient to attract new patients and their reluctance to pay $1,500 • Improve customer service to your patients for a crown, let alone the comprehensive treatment plan • Expand your services that will cost them $25,000 you are doomed to continue To me this advice sounds as if it is conflicting. Perhaps it the same pattern of behavior and will continue to get the is. I am certain every business student has learned the 2/3 same results. rule which states that we can only provide two of the I encourage you to start reviewing your 2015 financials following consistently: quality product/service, low cost, fast and strategies and to prepare for 2016 in a new way. Rather delivery. than only looking at your P & L report as your gauge of Other marketing consultants have also jumped into the determining your success or failure, consider your quality fray offering their advice with a multitude of suggestions: of life and culture of your practice (team morale) as well as • Build a web site presence, monitoring your patient satisfaction and loyalty. Patient • Invest in SEO (search engine optimization), satisfaction and loyalty can be quantified with the right KPIs • Sell homecare products (whitening kits, toothpaste, and reporting systems. Stop using “horse and buggy” electric toothbrushes, mouth rinses, etc), thinking to address today’s challenges. • Offer cosmetic services for children • Sell Invisalign
“We can’t solve problems by using the same kind of thinking we used when we created them.”
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SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
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Straumann® is expanding its portfolio of regenerative solutions to better meet customer needs. Now, Straumann® XenoGraft joins Straumann® AlloGraft, BoneCeramic™, and Emdogain™ to provide a single trusted source for dental implant and regeneration needs. NEW — Straumann® XenoGraft • Create a lasting scaffold for extended volume maintenance with this bovine derived natural bone substitute • Available sizes: 0.25g, 0.5g, 1.0g, 2.0g NEW SIZES — Straumann® AlloGraft • Choice of mineralized or demineralized cortical, mineralized cancellous, or mix of cortical/cancellous • Now available in 2.5cc size for mineralized cortical, cancellous, or mix To learn more about the new Straumann® Bone Regenerative portfolio visit www.straumann.ca
The Face Hunter 3D facial scanner — photorealistic visualization for more reliable restorative planning The Face Hunter 3D facial scanner by Zirkonzahn extends the digital workflow in fabricating dental restorations by an important additional step. A single click will digitize a face within three-tenths of a second. 3D digitization offers dentists, dental technicians, and patients a near-photorealistic preview of the definitive restoration, helping align the restoration with the patient’s physiognomy and adds a layer of reliability to the treatmentplanning process. Combined with a laptop computer, the Face Hunter is ready even for mobile use. SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
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MIS MGUIDE More than ever before, doctors are taking advantage of virtual implant planning and guided surgery in their everyday practices. MIS MCENTER facilities offer a wide range of quality digital dentistry services to assist doctors around the world in increasing both the efficacy and quality of the treatments they can offer their patients. When it comes to implant dentistry in the digital era, it’s all about simplicity and predictability. The MIS Digital Solutions Suite: Case planning is simplified by allowing the clinician to submit just two items, Dicom data plus a digital or traditional impression, and leaving software execution to MCENTER Specialists. Guided Surgery is simplified by a fully guided solution which guides all aspects of the surgery from pilot drilling to implant placement. Digital Impressions are simplified by our reusable scan post system which requires no spraying and can be used again and again. CAD restorations can be designed from the digital impression by MCENTER Specialists including: Ti bar, Ti custom abutment, Zirconia custom abutment and temporary restorations. CAM – MIS milling center utilizes FDA approved Titanium blanks for single units and can cater to all existing milled restorations. We offer all of these solutions a la carte, but customers who take advantage of the full suite of digital dentistry solutions are able to simplify their workflow. To learn more about MIS Implants visit our website at: www.mis-implants.ca. 1-877-633-0076 10
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
INNOVATIONS @ Implant Guided Surgery with SIMPLANT® Case planning is done online with screen sharing. You will receive SurgiGuide, final abutments and temporaries at the time of surgery.
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As a digitally advanced, innovative dental laboratory, Pro-Art can provide dentists with the support, knowledge and experience they need to achieve success for any restoration with any implant system and with their choice of material. Whether you are restoring a fixed case, a fixed detachable or an over-denture case, Pro-Art leads the way to success. To find out more about Prettau® Zirconia and Implant Guided Surgery call Pro-Art today.erial.
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Immediate Loading in the Edentulous Mandible surgical, prosthetic and laboratory procedures with screw-retained prosthetics Dr. Jan Spieckermann and Dr. Ulrich Glase Chemnitz, Germany
Implants Used Prosthetics Tooth
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
Implant type
n standard n fixed
Implant length Implant Ø
n bridge
Implant surface
n screw-retained
Tooth Implant type
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 SL
SL
SL
SL
SL
SL
Implant length
13.0 13.0 13.0
16.0 13.0 13.0
Implant Ø
4.3
4.3
3.8
3.8
4.3
4.3
P
P
P
P
P
P
Implant surface
n edentulous n Vario SR Abutment
Implant type: ROOT LINE (RL)/SCREW-LINE (SL) Implant surface: Promote® (P)/Promote® Plus (PP)
Information on patient and treatment Based on a clinical case seen at our dental practice, this case history describes the surgical, prosthetic and laboratory procedures for immediate implant placement with immediate loading in an edentulous mandible. The 62-year-old patient presented for a consultation at our dental practice. She reported a history of recurrent loosening of the circular metal-ceramic bridge in the mandible. The initial x-ray diagnosis revealed moderate atrophy of the mandible. The other teeth in her mandible exhibited horizontal and vertical bone resorption. After removing the bridge, the remaining teeth 34, 33, 32, 43, 44 showed periodontal deficiencies or caries damage. 12
Following comprehensive diagnostics, an overall treatment plan, including the maxilla, was proposed to the patient. However, only the mandibular restoration was performed. In the known protocols, the placement of 4 to 6 implants between the mental foramina in the anterior mandible is recommended. In this case, six Camlog® Screw-line Implants were used. It is important that the implants have a favourable primary stability when inserted. After implant placement, a longterm, immediately loaded, screw-retained provisional restoration was integrated. After a 3-month period of osseointegration and soft tissue healing, the definitive fixed prosthesis was fabricated. SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
Initial findings
Figure 1: Initial situation with recurrent loosening of the circular metal-ceramic bridge in the mandible.
Figure 2: Inadequate bridge in the mandible.
Figure 3: State after removal of the bridge. Caries-damaged residual teeth in the mandible, not worth being preserved.
Figure 4: OPG initial findings; moderate atrophy of the mandible, the remaining teeth in the mandible exhibit horizontal and vertical bone cavities.
Preoperative preparations
Figure 5: A wax-up was made preoperatively and transferred to a temporary dish.
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
Figure 6: Markings were made on a prepared open impression tray for use as a drilling orientation template.
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Implant placement
Impression
Figure 7: Six Camlog® Screw-Line Promote® implants were placed interforaminally. Check on implant position using parallelizing abutments. Cylindrical gingiva formers were integrated intraoperatively, and then the wound was sealed.
Figure 8: The postoperative x-ray check shows the proper position of the implants.
Figure 9: Postoperatively inserted open-tray impression posts.
Figure 10: Checking the open impression tray.
Figure 11: Open impression using polyether – (Impregum®). The prosthetic interim restoration was performed directly postoperatively.
Figure 12: Long-term temporary denture on PEEK abutments – model situation.
Prosthetic treatment – temporary prosthesis
Figure 13: During preparation of the long-term temporary bridge 35-45, the tooth positions were taken from a wax-up which had been created in advance.
Figure 14: Long-term temporary denture on PEEK abutments. A key aspect is the restoration's accuracy of fit which was checked clinically using the Sheffield test during insertion.
Figure 15: Long-term temporary denture 1 week postoperatively. Status before suture removal, moderate soft tissue edema.
Figure 16: Long-term temporary denture 16 weeks postoperatively.
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SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
Prosthetic treatment – definitive prosthesis
Figure 17: Soft tissue situation after removing the long-term temporary denture at 16 weeks postoperatively. A mucositis was detected in region 43 and treated locally. Otherwise, stable soft tissue conditions.
Figure 18: Due to the firm peri-implant soft tissue, a control OPG was taken after inserting the impression posts for open tray impression.
Dental laboratory
Figure 19: Camlog® Vario SR straight abutments on the model.
Figure 20: Camlog® Vario SR straight abutments on the model
Figure 21: Scaffold modeling.
Figure 22: Scaffold modeling.
Figure 23: Scaffold modeling.
Figure 24: Scaffold after casting and elaboration.
Figure 25: Scaffold.
Figure 26: The scaffold was checked in the mouth using the Sheffield test.
The scaffold was modeled with burnout plastic copings, modeling plastic and wax. To avoid tensions in the modeling, separations and new joining together were made using pattern resin. A special embedding procedure enabled casting to be tension-free. The scaffold was checked on the model and in the mouth using the Sheffield test. 16
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
Integration of definitive fixed prosthesis
Figure 27: Final screw-retained prosthesis after ceramic veneering.
Figure 28: Basal view of the final screwretained prosthesis after ceramic veneering.
Figure 29: After veneering, the restoration was tried in, checked for the ability to maintain hygiene and integrated definitively.
Figure 30: Intraoral diagnosis after integrating the final restoration.
Figure 31: Final restoration before closing the screw channels.
Figure 32: Final restoration after closing the screw channels.
Initial situation Conclusions
Figure 33: Initial diagnosis.
Figure 34: OPG initial diagnosis.
Final restoration
Figure 35: Intraoral diagnosis after integrating the final restoration.
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Immediate implant placement with immediate loading of implants constitutes a type of restoration much requested by patients due to the fast aesthetic and functional rehabilitation. But, besides the benefits for dentists such as conserving bone and soft tissue, it also harbors great risks. Strict indications along with the correct intraoperative therapeutic decision are basic pre-conditions for a successful outcome. The long-term temporary restoration should be integrated promptly; preferably on the day of implant placement, and should aim at reducing mechanical, infectious and chemical factors in the gingiva.
Figure 36: OPG after implantation in the mandible.
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
Immediate implant placement with immediate loading is a routine restoration in our dental practice but only performed according to very strict indications with intraoperative therapy decision. We always hold a detailed preoperative risk consultation and propose implant alternatives. Taking into account the strict indication and existing preconditions for immediate implant placement, in selected clinical situations, functional high-quality treatment results are possible in the edentulous mandible. The discussed screw-retained, long-term temporary restoration procedure constitutes a simple cost-effective option for rapid prosthetic restoration in the mandible. Besides, the short duration of treatment and reduced number of visits to the dentist, the benefits for the patient are, both, the immediate aesthetic functional rehabilitation, as well as the avoidance of removable dentures and their associated disadvantages during the healing phase. We generally note high acceptance from of our patients. n
Literature References Becker W, Becker BE , Huffstetlert S Early functional loading at 5 days for Brånemark implants placed into edentulous mandibles: a prospective, open-ended, longitudinal study. J Periodontol. 2003 May; 74(5): 695-702. Brånemark PI, Svensson B, van Steenberghe D Ten-year survival rates of fixed prostheses on four or six implants ad modum Branemark in full edentulism. Clin Oral Implants Res 1995; 6(4): 227-31. Dierens M, Collaert B, Deschepper E, Browaeys H, Klinge B, De Bruyn H Patient-centered outcome of immediately loaded implants in the rehabilitation of fully edentulous jaws. Clin Oral Implants Res. 2009 Oct; 20(10): 1070-7. Epub 2009 Aug 30.
Esposito M, Grusovin MG , Willings M, Coulthard P, Worthington HV Interventions for replacing missing teeth: different times for loading dental implants. Cochrane Database Syst Rev. 2009 Jan 21; (1): CD003878. Jemt T, Book K Prosthesis misfit and marginal bone loss in edentulous implant patients. Int J Oral Maxillofac Implants 1996; 11(5): 620-5. Li W, Chow J, Hui E, Lee PK, Chow R Retrospective study on immediate functional loading of edentulous maxillas and mandibles with 690 implants, up to 71 months of follow-up. J Oral Maxillofac Surg. 2009 Dec; 67(12): 2653-62. Ortorp A, Linden B, Jemt T Clinical experiences with laser-welded titanium frameworks supported by implants in the edentulous mandible: a 5-year follow-up study. Int J Prosthodont. 1999 Jan-Feb; 12(1): 65-72.
About the authors Dr. med. dent. Jan Spieckermann – Prosthetics After studying dentistry in Vienna and Greifswald, and subsequently graduating, Dr. Spieckermann worked as a scientific employee in the Department of Prosthodontics, Medical Faculty, Dresden University of Technology. After two years of working in the Swedish public health service, he then trained to be an Oral Surgeon in the dental practice of Dr. Glase-Dr. Berger in Chemnitz. Dr. Spieckermann is a qualified and trained specialist in prosthetics member of the German Society of Prosthodontics. Dr. med. Ulrich Glase – Surgery After studying dentistry in Plovdiv/Bulgaria, studying medicine and earning a doctorate in Jena, Dr. Glase completed his training as a specialist in OMF surgery at the Clinic for Oral, Maxillofacial and Plastic Surgery of the Friedrich Schiller University, Jena. After working as a senior physician in the Oral and Maxillofacial Surgery Department of the Chemnitz BKH, he opened his own practice in 1991. Since then, he has developed a special profile in the field of implant dentistry. Dr. Glase works as a consultant in implant dentistry
Striving for perfection and achieving excellence G
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Incisal Edge Dental Laboratory – Thomas Kitsos, RDT, Owner and Principal 3410 Yonge Street, Toronto, ON., M4N 2M9
T: 416.489.6533 TF: 1.877.INCISAL Fax: 416.489.6541 E-mail: incisaledge@on.aibn.com Website: www.incisaledge.ca
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
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Implant-induced post-traumatic inferior alveolar nerve neuropathy In the second part of her three-part series, Tara Renton looks at preventing and assessing dental implant-related nerve damage Prevention The etiology of permanent implant-related nerve injury can be attributed to direct damage to the inferior alveolar nerve (IAN) and/or its direct surroundings, such as the inferior dental canal (IDC), as shown in Figure 1. A significant search of the literature, for the ADI consultation paper on prevention, diagnosis and management of nerve injuries in relation to dental implants, showed a number of likely causes for this damage.
Inadequate preoperative planning and assessment Poor preoperative assessment and planning can result from a number of factors, not least of which are a lack of knowledge, and inadequate informed consent (all treatment options and the related risk/benefit for each option should be provided to the patient). Failure to identify existing preoperative neuropathy is another issue. Interestingly, 25% of edentulous patients present with a degree of altered IAN function, thus
Aims and objectives The aim of this article is to examine the prevention and assessment of implant-induced inferior alveolar nerve (IAN) neuropathy.
Readers will: • Learn some of the primary causes for iatrogenic IAN damage • See how these can be avoided • Understand how to assess patients in the case of possible IAN trauma.
reinforcing the recommendations on the necessity of preoperative neurosensory evaluation (Wismeijer et al 1997). Inadequate planning in positioning the implant is a major, multifactorial contributor to nerve injury. Clinicians must consider many different areas when planning placement.
Figure 1: Possible aetiology of nerve injury. The nerve injury may be due to direct mechanical trauma by the preparation bur or implant (A), extrusion of debris into the canal (B), the but most likely due to haemorrhage caused by preparation which continues after implant placement and results in nerve ischemia (C). Many drill systems have a drill longer than the implant (D+E)
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SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
Bone assessment Both the quality and quantity of bone need assessment — see EAO and soon-to-be-released ADI radiographic guidelines.
Implant location The location must be ideal for restoration while avoiding possible compromises — always avoid planned proximal placement of implant near the IDC, and especially near the mental foramen region whenever possible. Always question the actual need for the implant and other practical treatment options for the patient.
Know where the nerve is Clinicians must be aware of local nerve risk factors when assessing the position of the IAN (mental loop, characteristics of IAN position in various sites of mandible). Be familiar with the patient’s anatomy, use cross-sectional imaging, thorough measurements, and CBCT imaging where necessary and/or where bone levels require more intimate localization of the IDC.
Parasymphyseal zone high risk When placing implants in proximity to the mental foramen, the clinician must take into consideration the anterior loop of the nerve, as well as the available bone above the mental foramen. Attempting to place a fixture below the level of the foramen will increase risk. Additional 3D scanning, that the clinician is able to interpret, may be required for these cases where alternative sites for mandibular implants are, either not available, or optimal for restoration. Recent papers give a comprehensive overview of clinical assessment for patients undergoing implant treatment (Juodzbalys et al 2010 1;2).
Figure 2: CBCT highlighting accessory canals and IAN damage not identified preoperatively
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
The accuracy of estimating the position of the IDC, based on plain films or CT scans, is highlighted in the radiographic assessment section. There is no consensus that CBCT scanning or tomography effectively reduces IAN damage, but strict guidelines do exist enforcing the use of tomography and scanning, if required to better assess the IDC when plain radiography is inadequate. Identifying accessory branches, after implant placement, is too late (Figure 2).
Mental loop Many papers have highlighted the difficulty in assessing the particularly complex region of the mental foramen. Extreme caution and explicit planning should be undertaken in this region (Greenstein and Tarnow 2006). Inaccuracies in the assessment of the mental loop are described based on plain film radiography (Figure 3) (Uchida et al 2007).
Safety zone Perforation of a canal surrounding the IDC — or even direct perforation — means there is a risk of damage to the nerve (Figure 1). There is limited evidence for appropriate distance between the implant and the IDC to prevent nerve damage (Misch and Crawford 1990). The minimum distance (from above the lamina dura, above the IDC, on plain and 3D radiographic imaging) should be estimated from clinical data and biomechanical analyzes. Basa & Dilek (2011) investigated the IDC lamina dura density and thickness of bone surrounding the IDC in order to use the area to engage dental implants. This does seem a high-risk strategy when intending to prevent damage to the IAN. Many authors suggest that a 2mm safety zone and implant length of 7mm should be sufficient in routine cases
Figure 3: Radiograph of extended mental loop Courtesy of Dr David R Nelson BDS, MSc (ImpDent)
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Figure 4: DPT illustrating a case with bilateral IAN injury resulting from inadequate safety zone provision.
Figure 5: ‘Smart’ local anaesthetic practice optimising prevention of LA related nerve injury when undertaking implant surgery
(Greenstein and Tarnow 2006; Guan et al 2009) and, within a recent reported cohort of 30 patients with implant nerve injury, 94% had had implants placed that were longer than 10mm (Renton et al 2012).
Commission 2004) gives the following general guidance: • No radiographs should be selected unless a history and clinical examination have been performed. ‘Routine’ radiography is unacceptable practice • When referring a patient for a radiographic examination, the dentist should supply sufficient clinical information (based on a history and clinical examination) to allow the practitioner taking clinical responsibility for the X-ray exposure to perform the justification process • Clinicians should decide if a patient requires crosssectional imaging on the basis of the clinical examination, the treatment requirements and information obtained from conventional radiographs • The technique chosen should provide the required diagnostic information with the least amount of radiation exposure to the patient • ‘Standard’ imaging modalities are combinations of conventional radiographs • Cross-sectional imaging is applied to those cases where more information is required after appropriate clinical examination and standard radiographic techniques have been performed. The literature related to the use of CBCT in dental implantology is extensive. This is not surprising as implant treatment planning has been the most frequent use of conventional CT in dentistry. Studies on geometric accuracy for linear measurements — of obvious importance in implant planning — have shown high accuracy, although one study gave a poorer figure. Two previous papers (Harris et al 2002; Harris et al 2012) have made specific recommendations regarding radiographic assessment of patients undergoing dental implant therapy.
Implant selection Short implants (under 8-10mm) simplify procedures and minimize morbidity. The use of shorter implants is recommended as a means to mitigate risk and increase the safety zone, with the specific aim of placing implants with a safety zone of 2-4mm (Greenstein and Tarnow 2006; Malo et al 2007). Clearly, the extent of the required safety zone will be a function of the operators’ surgical experience: experience in radiographic interpretation, and surgical access. Clinicians must have an awareness that certain prep drills are up to 1.5mm longer than the placed implant.
Radiographic assessment All radiographic imaging should enhance your knowledge on risk assessment in the area of interest, with minimum radiation (Figure 4). Long-cone periapicals and panoramic investigations are, thus, the first choice but, if the IDC is difficult to identify, then 3D imaging may be required (Figure 2). Reducing CBCT exposure is possible and advised — the clinician does not require ‘HD’ high-radiation images to ascertain sufficient information about bone quantity, density and nerve position. The European Guidelines on Radiation Protection in Dental Radiology (Harris et al 2002) did not include any comment on CBCT. They did, however, describe criteria for use of ‘cross-sectional imaging’ (at that time, spiral tomography and conventional CT). More recently, however, the EAO guideline (European 22
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
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The clinician should be able to read the CBCT themselves. Clinicians using the more sophisticated CBCT and CT scans must be appropriately radiographically trained to avoid errors in planning and maximize the benefit.
Surgical procedures Local anaesthesia (LA) Avoid inferior dental blocks by using the buccal infiltration technique, which allows the patient to advise you if pain is emanating from drilling or implant placement proximal to the IAN. Neuropathy may be related to local anaesthetic injections, particularly if conventional inferior dental blocks (IDBs) are used. It is estimated that nerve injury in relation to IDBs occurs in about one out of every 14,000 occasions with 25% being persistent permanent injuries. Pain on injection may indicate a higher risk of nerve injury. Avoidance of these injuries is simple — by using buccal infiltration anaesthesia (either lidocaine or articaine) (Heller and Shankland 2001) — and it is becoming routine practice for orthodontic extraction of premolars and restorative treatment of premolars and molars in adults using articaine local anesthetic infiltrations, rather than inferior alveolar nerve blocks. Thus far, there is limited clinical evidence for avoiding inferior alveolar nerve blocks using articaine, or indeed lidocaine, infiltrations for mandibular dentistry and oral surgical procedures using articaine infiltrations (Meechan 2011) (Figure 5).
Flap design Flap design depends upon the region of the mouth. Posteriorly, avoid the lingual nerve (bucco-crestal incision), in a resorbed mandible with exposed inferior alveolar nerve (buccal incision) and, anteriorly, avoid the mental nerve (crestal incision). Good management of soft tissue is imperative for implant surgery success (Cranin 2002). Avoiding direct damage to the mental nerve and its multiple branches splaying out into the lower lip tissues is essential, thus, a full understanding of the local anatomy is imperative (Gershenson et al 1986).
Surgical guides Surgical guides should be used, as set out by Chan et al (2013).
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Use intraoperative radiographs CT-based intraoperative navigation has been recommended to minimize nerve damage (Gaggl et al 2001). One hundred test drillings were carried out on 10 standardized acrylic lower jaw models with the aid of a navigation system. An average drilling depth of 6.23mm, and a mean distance of 0.14mm to the IDC (s=0.05) was found. Eleven cases showed perforation of the upper border of the canal. The average penetration of the IDC was 0.19mm. In contrast, Burstein et al (2008) recommended using intraoperative periapical radiographs during the drilling sequence as an inexpensive and reliable tool, allowing the operator to confidently adjust the direction and depth of the implant during the placement. Most importantly, it helps to avoid the risk of injury to the IAN especially in those cases with limited vertical alveolar bone. No incidents of postoperative paraesthesia were noted in 21 implants that authors placed.
Drill stops There is no published evidence relating to using drill stops for preventing injury to the inferior alveolar nerve and canal. However, several practitioners already apply the ‘Summers’ drill stop technique — used for augmentation of the sinus — (Checchi et al 2010). Direct or indirect damage to the IDC and/or IAN may be caused by: • Haematoma • Drill damage • Thermal damage from the drill overheating bone, causing bone destruction with implant surgery • Chemical damage — adjunctive chemical irrigates • Implant damage to the IDC and or IAN • Unpredictable anatomy (especially proximal to mental foramen) • Poor surgical technique Ultimately, poor planning will undoubtedly lead to most intraoperative surgical errors. Wrong measurements, and allowing an inadequate safety zone, will result in the most severe types of injuries, caused by implant drills and implants themselves (Lamas et al 2008; Khawaja and Renton 2009). Many implant drills are slightly longer (for drilling efficiency) than their corresponding implants. Implant drilllength varies and must be understood by the surgeon, because the specified length may not reflect an additional millimetre in the so-called ‘y’ dimension (Alhassani and Alghamdi 2010).
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
resistance of spongy bone. This can lead to slippage of the drill even by experienced surgeons (Worthington 2004). Recognition of intraoperative neural symptoms is crucial.
Postoperative care Postoperative care should attend to: • Early postoperative recognition of neuropathy (homecheck) within six to 12 hours after local anaesthetic has worn off (usually at three and a half hours) • Prompt management of neuropathy (removal of implant if indicated) • Acute phase • Late phase • Early or late postoperative infection. Figure 6: Mapping the extraoral neuropathic area within the inferior alveolar nerve dermatome
An insufficient safety zone will cause complications that could otherwise have been avoided (Kraut and Chahal 2002). Even after measuring the available bone accurately, nerve injury can occur as a result of over penetration of the drill (direct intraoperative mechanical trauma) owing to low
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Assessment The patient may often complain of pain and numbness simultaneously. They must be seen, reassured and, if urgent, treated. Ascertain a history (confirming a history of trauma) and identify specific risk factors including intense pain with LA or implant preparation. Elicit the pain experience, altered sensation and anaesthesia, ask about functional aspects (teeth-brushing,
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kissing, and so on), then provisionally assess the psychological distress of the patient. Clinical confirmation of focal neuropathy must be confirmed (i.e. the either hypoaesthetic or hyperaesthetic change in sensation within the dermatome of the injured sensory nerve). Remember that we are looking at sensory, rather than motor changes, as the facial nerve is not involved. First, map the area of altered sensation and record it (photo or pictorially) (Figure 6). Once the area is mapped, you can then compare the relative mechanosensory function of the neuropathic region with the normal unaffected side (unless you have bilateral nerve injury). Simple tests confirming nerve injury include: • Pain to touch (allodynia) • Pain with thermal changes particularly cold (thermal allodynia) • Decreased subjective function (hypoaesthesia) • Increased two-point discrimination • Decreased sharp-blunt discrimination, but most patients present with hyperalgesia (increased in pain with painful stimulus). If the neuropathic area is less than 30%, and the patient is not too distressed, reassurance and review is indicated. Urgent management may be indicated for patients with severe pain and larger neuropathic areas, which is hugely impactful on the patient. n
About the author Professor Tara Renton BDS MDSc PhD FDS RCS FRACDS (OMS) FHEA is a chair of oral surgery at King’s College London. A specialist in oral surgery, she has a particular interest in trigeminal nerve injuries and pain and has developed a national clinical service for patients suffering from these ailments. She is the national adviser for oral surgery, a council member for the British Association of Oral Surgeons (BAOS) and is an elected member of the RCS England Dental Faculty Committee.
References Alhassani AA, AlGhamdi AS (2010). Inferior alveolar nerve injury in implant dentistry: diagnosis, causes, prevention, and management. J Oral Implantol 36(5): 401-7 Ba a O, Dilek OC (2011) Assessment of the risk of perforation of the mandibular canal by implant drill using density and thickness parameters. Gerodontology Sep;28(3): 213-20 Burstein J, Mastin C, Le B (2008). Avoiding injury to the inferior alveolar nerve by routine use of intraoperative radiographs during implant placement. J Oral Implantol 34(1): 34-8 Chan PW, Chik FF, Pow EH, Chow TW (2013). Stereoscopic technique for conversion of radiographic guide into implant surgical guide. Clin Implant Dent Relat Res 15(4): 613-24 Checchi L, Felice P, Antonini ES, Cosci F, Pellegrino G, Esposito M (2010). Crestal sinus lift for implant rehabilitation: a randomised clinical trial comparing the Cosci and theSummers techniques. A preliminary report on complications and patient reference. Eur J Oral Implantol 3(3):221-32
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Cranin AN (2002). Implant surgery: the management of soft tissues. J Oral Implantol. 2002;28(5):230-7 Gaggl A, Schultes G, Kärcher H (2001). Navigational precision of drilling tools preventing damage to the mandibular canal. J Craniomaxillofac Surg 29(5): 271-5 Gershenson A, Nathan H, Luchansky E (1986). Mental foramen and mental nerve: changes with age. Acta Anat (Basel). 126(1):21-8 Greenstein G, Tarnow D (2006) The mental foramen and nerve: clinical and anatomical factors related to dental implant placement: a review. J Periodontol 77: 1933-43 Guan H, van Staden R, Loo YC, Johnson N, Ivanovski S, Meredith N (2009) Influence of bone and dental implant parameters on stress distribution in the mandible: a finite element study. Int J Oral Maxillofac Implants 24(5):866-76 Harris D, Buser D, Dula K, Gröndahl K, Haris D, Jacobs R, Lekholm U, Nakielny R, van Steenberghe D, van der Stelt P (2002). European Association for Osseointegration. E. A. O. guidelines for the use of diagnostic imaging in implant dentistry. A consensus workshop organized by the European Association for Osseointegration in Trinity College Dublin. Clin Oral Implants Res;13: 566–570 Harris D, Horner K, Gröndahl K, Jacobs R, Helmrot E, Benic GI, Bornstein MM, Dawood A, Quirynen M (2012). EAO guidelines for the use of diagnostic imaging in implant dentistry 2011. A consensus workshop organized by the European Association for Osseointegration at the Medical University of Warsaw. Clin Oral Implants Res. Heller AA, Shankland WE 2nd (2001). Alternative to the inferior alveolar nerve block anesthesia when placing mandibular dental implants posterior to the mental foramen. J Oral Implantol 27(3): 127-33 Juodzbalys G, Wang HL, Sabalys G (2010) 2. Anatomy of Mandibular Vital Structures. Part I: Mandibular Canal and Inferior Alveolar Neurovascular Bundle in relation with Dental Implantology. J Oral Maxillofac Res 1(1):e2 Juodzbalys G, Wang HL, Sabalys G (2010) 2. Anatomy of Mandibular Vital Structures. Part II: Mandibular Incisive Canal, Mental Foramen and Associated Neurovascular Bundles in Relation with Dental Implantology. J Oral Maxillofac Res 1(1):e3 Khawaja N, Renton T (2009). Case studies on implant removal influencing the resolution of inferior alveolar nerve injury. Br Dent J 206: 365-70 Kraut RA, Chahal O (2002). Management of patients with trigeminal nerve injuries after mandibular implant placement. J Am Dent Assoc 133(10): 1351-4 Lamas Pelayo J, Peñarrocha Diago M, Martí Bowen E, Peñarrocha Diago M. Intraoperative complications during oral implantology. Med Oral Patol Oral Cir Bucal 1;13(4): E239-43 Malo P, de Araujo Nobre M, Rangert B (2007). Short implants placed one-stage in maxillae and mandibles: a retrospective clinical study with 1 to 9 years of follow-up. Clin Implant Dent Relat Res 9: 15-21 Meechan JG (2011).The use of the mandibular infiltration anesthetic technique in adults.J Am Dent Assoc 142 Suppl 3:19S-24S. Review Misch CE, Crawford EA (1990). Predictable mandibular nerve location – a clinical zone of safety. Int J Oral Implantol 7: 37-40 Renton T, Dawood A, Shah A, Searson L, Yilmaz Z (2012). Postimplant neuropathy of the trigeminal nerve. A case series. Br Dent J 212(11): E17 Uchida Y, Yamashita Y, Goto M, Hanihara T (2007).Measurement of anterior loop length for the mandibular canal and diameter of the mandibular incisive canal to avoid nerve damage when installing endosseousimplants in the interforaminal region. J Oral Maxillofac Surg 65(9):1772-9 Wismeijer D, van Mass M, Vermeeren J, Kalk W (1997). Patient’s perception of sensory disturbances of the mental nerve before and after implant surgery: a prospective study of 110 patients. Br J Oral Maxillofac Surg 35: 254–259 Worthington P (2004). Injury to the inferior alveolar nerve during implant placement: a formula for protection of the patient and clinician. Int J Oral Maxillofac Implants. 19(5): 731-4
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Managing implant failure Naresh Sharma and Ashok Sethi look at how to deal with the management of a patient after implant failure Aims and objectives This article aims to present an understanding of the management of a patient after implant failure.
Readers will: • See the clinical issues that can result from implant failure • Learn one method for addressing these issues • Understand some of the causes of implant failure.
T
he loss of implants invariably results in extensive bone loss. The management of these patients is very challenging both in terms of the clinical work as well as managing the disappointment that results from such an event.
This article describes the treatment carried out to manage a patient who was referred following the loss of implants. The loss of implants resulted in a deficiency, which was inadequate for the satisfactory restoration of the patient. The remaining ridge height measured 6mm, however, the buccolingual discrepancy between the ideal tooth position and implant site was 8mm. All the various options for the retreatment were discussed with the patient. It was clear that the replacement of the lost hard and soft tissues was required. Replacement by means of prosthetic means was discussed. The patient expressed a preference for the biological replacement of the tissues, and the emergence of individual teeth directly from the soft tissues. The patient was clearly concerned about the predictability of the procedure that was being proposed. This was particularly the case as implants placed previously had failed. 28
Figure 1: Extraoral view of patient following the loss of the implants as well as supporting bone. The increased nasolabial angle is indicative of the amount of bone loss that has taken place.
Figure 2: Three-dimensional view (CBCT) of the patient on completion of healing of the soft tissues following the loss of implants
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
Figure 4: Intraoperative view of the bone graft in situ showing the correction of the vertical and horizontal deficiencies
Figure 3: Cross-sectional view of CBCT in the region of the central incisor showing the vertical and the 8mm horizontal discrepancy, resulting in the loss of lip support. Without a bone graft, the position of the implants would therefore also be several millimetres palatal to the ideal tooth position. Please note that only 6mm of ridge height remains
The additional costs involved were also to be accepted by the patient. The treatment proposed required an autogenous on-lay bone graft in order to reconstruct the lost tissues. The extent of the tissue loss required obtaining the graft from an extra oral source. The high predictability of autogenous bone was discussed with the patient, and a decision made to proceed with the treatment as proposed (Bell et al, 2002; Sethi and Kaus, 2001; Misch and Dietsh, 1991; Misch and Dietsh, 1994).
Treatment sequence
Figure 5: Cross-sectional view of the CBCT scan taken prior to implant placement showing the reconstructed ridge
Figure 6: Interactive planning is seen being carried out using the Simplant program on the three-dimensional CBCT scan image. The reconstructed ridge and the simulated position of the implants is visible. This will then be transferred to the clinical site
Bone graft The size of the bone graft required was estimated based on position of the teeth required to provide the patient with good aesthetic and functional outcome. The graft was harvested from the iliac crest, and transplanted simultaneously to the deficient ridge. It was closely adapted to the deficient ridge and secured in place using fixation screws. Soft tissue closure without tension was carried out (Figures 1-4).
Implant placement and impressions The healing of the graft was carefully monitored clinically by observing the changes of the contours of the soft tissues. Radiographs were used to monitor the changes in the trabecular pattern of the bone. .At the appropriate time, a second CBCT scan was taken to permit planning of the implant positions (Sethi, 1993) (Figures 5 and 6). SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
Implants were inserted at three months in sites dictated by tooth position. On seating of the implants, impressions using an open tray technique were taken for transfer to the laboratory. This allowed the laboratory to design and fabricate the abutments using CAD/CAM technology (Procera). At the same time, temporary restorations and the metalwork were constructed so that these could be fitted at the next stage (Figures 7-11).
Implant exposure and abutment attachment The implants were exposed using a crestal incision and the abutments attached at the same time. The transitional restorations (temporary) were fitted and the soft tissues closed around the restorations to create the desired emergence profile (Sethi and Kaus, 2012). 29
Figure 7: Intraoperative view of the implants in situ. Impression posts can be seen attached to the implants to transfer implant position to the laboratory using an open tray technique. This permitted the technician to design the abutments and transitional restorations in time for the next stage
Figure 8: Computer-aided design of the abutments was carried out based on the information transferred to the laboratory at first-stage surgery
Figure 10: Labial view of the transitional restorations on the costs constructed from impressions taken at the time of implant insertion
Figure 9: Design of the transitional restorations was carried out based on the original diagnostic preview. The tooth position determined during the diagnostic phase was transferred to the transitional restorations supported by the abutments
Figure 11: The metalwork fabricated on the abutments designed and fabricated using CAD/CAM Technology (Procera)
Figure 14: Extraoral postoperative view showing the definitive restorations. Excellent lip support health has been provided by the reconstructed ridge
Restoration Figure 12: Intraoral periapical radiographs showing the implants on the left-hand side following restoration by individual crowns
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Figure 13: Intraoral periapical radiographs showing the implants on the right-hand side following restoration. Excellent bone levels can be seen
The restorative phase involved the picking up of the metalwork constructed from impressions taken at first-stage surgery. Jaw registration was carried out, and face bow records taken. An incisor guidance table was fabricated based on the transition restorations construction from the original diagnostic. Porcelain was then fused to the metalwork. The shape and position of the final restoration was dictated by the original diagnostic preview. The restorations SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
were fitted using temporary soft cement to permit the restoration to be retrieved in case access to the abutments was needed or in order to repair the restorations.
Follow-up
A CONICAL CONNECTION IMPLANT MAKE IT SIMPLE
Regular monitoring is carried out by a dental hygienist at three monthly intervals. The patient is initially reviewed annually and then every two years. Monitoring to ensure that there are no soft tissue changes is carried out using photographs. Bone levels are monitored using periapical radiographs (Figures 12-14).
Minimising failure
Platform Switching
Micro Rings
Increase in the use of implants to restore partially dentate and edentulous patients will invariably result in an increase in failure. The loss of hard and soft tissues that are caused by these failures need to be repaired but will require more elaborate procedures. Fortunately, the techniques available in modern dentistry make it possible for us to restore such compromised patients. Though implant losses are sometimes inevitable in spite of the high survival rates reported, every effort should be made to minimise failure. Several factors are responsible; some of these are patient related and others are operator related. It is important, therefore, that clinicians ensure that they have adequate training prior to embarking on this very rewarding field of dentistry. n
About the authors Dual Thread Design
Naresh Sharma BChD MGDS (RCSEng) FFGDP MSurgDent (RCSEng) DipImpDent (RCSEng) is an oral surgeon and co-director of PID Academy, which offers implant training to dentists and dental technicians. Ashok Sethi BDS DGDP MGDS (RCS Eng) FFGDP DUI (Lille) is a specialist in oral surgery and prosthodontics and co-director of PID Academy.
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References Bell RB, Blakey GH, White RP, Hillebrand DG, Molina A (2002). Staged reconstruction of the severely atrophic mandible with autogenous bone graft and endosteal implants. J Oral Maxillofac Surg 60: 11351141 Misch CE, Dietsh F (1991). Autogenous bone grafts for endosteal implants – indications and failures. Int J Oral Implantol 8: 13-20 Misch CE, Dietsh F (1994). Endosteal implants and iliac crest grafts to restore severely resorbed totally edentulous maxillae – a retrospective study. J OralImplantol 20: 100-110 Sethi A (1993). Precise site location for implants using CT scans: a technical note. Int J Oral Maxillofac Implants 8: 433-438 Sethi A, Kaus T (2001). Ridge augmentation using mandibular block bone grafts: preliminary results of an ongoing prospective study. Int J Oral Maxillofac Implants 16: 378-88 Sethi A, Kaus T (2012). Practical implant dentistry. The science and art. London, Quintessence Publishing Co Ltd
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
More than primary stability. The new tapered standard.
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In combination with: 1 Benic GI, Gallucci GO, Mokti M, Hämmerle CH, Weber HP, Jung RE. Titanium-zirconium narrow-diameter versus titanium regular diameter implants for anterior and premolar single crowns: 1-year results of a randomized controlled clinical study. Journal of Clinical Periodontology 2013 Nov;40(11):1052–61. Epub 2013 Sep 8.
Metal-Free Replacement of a Maxillary First Premolar with a Zirconia Ceramic Implant: A Clinical Case Report Introduction and Background Fixed, functional, safe and aesthetic replacement of dentition with dental implants has long been a challenge and, for more than four decades, titanium and titaniumalloy implants have been, and continue to be, the mainstream and most used material in implant dentistry. Thanks to the stability of the TiO2 layer (oxide layer) on their surface, titanium alloys are exceptionally resistant to the oxidative effects of corrosion, but they are not 100% immune to corrosive attack. The number of manufacturers has increased, and manufacturing protocols have also evolved leading to a variety of alloys of dental implants, as a result, these changes have led to the modification in the percentage of titanium and the insertion of new components in the alloys. Most dentists, today, are trained to use and offer titanium and titanium-alloy dental implants which are all metal. Increasing reports1,3 of sensitivity to titanium and titaniumalloy dental implants, with responses ranging from local soft tissue irritation to spontaneous unexplainable implant failure2, joint pain, skin irritation, fatigue, and even bone necrosis, have been made. Many of the implant-related health problems have been attributed to the oxidation/corrosion events that occur in the presence of bodily fluid, material fatigue4, stress, galvanism5, exposure to the harsh oral environment, material wear and any combination of all these factors.
Figure 2: Pre-Op 3D view from CBCT
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Dr. Sammy Noumbissi
Figure 1: Pre-Op intraoral
A well investigated phenomenon in orthopedics, and to a lesser extent in the dental literature, byproducts released by implants under corrosion attack6 will spread to other distant organs via lymphatics7 and blood stream to the spleen, liver and, in some instances, cross the blood-brain barrier. Such by-products have been shown to induce metal toxicity, and present severe challenges to the implant recipient’s immune system and general health. In recent years, both for aesthetic and functional reasons, there has been a paradigm shift in the types of materials used for
Figure 3: Pre-Op axial view from CBCT
Figure 4: Coronal view pre-op
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
implantation and restoration of dental implants. Bioceramics and other truly bioinert and biocompatible non-metals materials are rapidly replacing metal alloys, and polycrystal zirconia, also know as zirconium dioxide (ZrO2), has emerged as the material of choice9 because it is an inert bioceramic which has excellent biomechanical properties, does not conduct heat, and does not allow galvanic activity8. Unlike titanium zirconia, it is not susceptible to corrosion attack in the oral environment. Alumina-toughened zirconia (ATZ), and yttria-stabilized tetragonal zirconia polycrystal (Y-TZP), are the bioceramic materials of choice in use today for manufacturing ceramic implants.
Case Report A 27 year-old female presented with a missing maxillary left first premolar. The tooth which, according to the patient, had two rounds of root-canal therapy was extracted six weeks prior at another clinic in an emergency situation (Figure 1). Medical and dental histories were taken and clinical and a radiographic exam was performed as well. Clinical observation of the edentulous space suggested a defect in the buccal bone, and this finding was confirmed by the examination of the 3D (Figure 2), axial (Figure 3) and coronal slices (Figure 4) from the CBCT. The patient was informed that there was a chance that the implant would not be placed during the first surgery, and that the chances of immediate fixed temporization of the implant would be minimal. The treatment was established, and would consist of ridge augmentation, implant placement, interim prosthetics and permanent-fixed prosthetics. A review of the medical history revealed that patient reported no sensitivity to metals but preferred to have a tooth replaced with metal-free biomaterials. During the surgical planning phase, the acquired CBCT was reviewed and it was observed that tooth #12 was birooted (Figure 4), and there was enough interradicular bone width and height to obtain adequate initial stability immediately after placement. Based on the radiographic data using the InVivo treatment planning software, it was determined that a one-piece Y-TZP zirconia implant (Zirkolith
Figure 7: Implant protective/Essix appliance
Figure 5: Virtual implant planning Figure 6: Zirkolith Evo 4.0 X 12mm
AG) 4.0mm diameter, with a 4.8 mm platform by 12mm length (Figure 5), would be the most adequate size for the site and replacement of tooth #12 (Figure 6).
Ridge Augmentation and Implant Placement Surgery In preparation of implant placement, impressions were also made in order to fabricate an implant protective device and a temporary crown (Figure 7) for the patient to wear during the implant integration into the bone. At the time of surgery, the patient was administered local anesthetic. A total of five carpules of lidocaine 2% with 1/100.000 epinephrine were administered, by infiltration, only in the areas extending distal of tooth #11 to mesial of tooth #14, both buccally and palatally. An intra-sulcular incision was made, and it extended from mesial of tooth #14 to mesial of tooth #11. A mucoperiosteal flap was raised, the bone was exposed, and the four-walled defect socket was visualized (Figure 8). The osteotomy was performed under sequential drilling using profuse irrigation, starting with a Loma Linda drill. This initial drill was positioned in a manner that the interradicular bone was engaged in a slightly palatal position, but emerging buccally at the coronal level (Figure 9). The following steps of the drill sequence were done in accordance with the Zirkolith surgical kit workflow for the selected implant configuration. During the initial phases of the osteotomy, it was subjectively determined that the bone was type II quality and, hence, favorable for
Figure 8: Buccal bone defect
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
Figure 9: Ostetomy
35
Figure 12: Collagen membrane
Figure 10: Exposed buccal threads
Figure 11: Bone Graft
good primary stability of the implant. The implant was inserted at a speed of 20rpm, and a torque of 40 Ncm, two third of the buccal threads were exposed (Figure 10), and the stability of the implant was measured with a Periotest™ and recorded at a value of -3.6. Bone graft, using mineralized cancellous bone (PUROS, Zimmer AG), was placed to cover the exposed threads (Figure 11), and a resorbable collagen membrane (Figure 12) was placed. Two sutures were placed mesial and distal of the implant platform, and the temporary crown was provisionally cemented to the implant abutment. Three weeks later, the sutures were removed (Figure 13).
Restorative Four months after implant placement, based on clinical examination and after determining adequate implant stability with the Periotest™ (Figure 14), it was decided that, for functional and aesthetic purposes, both the implant and tooth #13 would be restored with a porcelain-fused-tozirconia (PFZ) crowns. Conventional impressions using a pick-up impression cap (Figure 15) of the implant and adjacent prepped tooth were made with light and medium body polyvinylsiloxane impression material (Figure 16), and a stone model made (Figure 17). Once the crown was received from the dental laboratory, the challenge was to bond two ceramics, namely the abutment and the crown together, in a predictable manner on the implant. The intaglio of the crown was decontaminated with Ivoclean (Ivoclar), and the abutment cleaned with alcohol. Both abutment and crown were, then, primed with Z-Prime (Bisco) (Figure 18) and finally bonded with resin-modified glassionomer cement. The patient was satisfied with the aesthetic and functional outcome of this top-to-bottom metal free 36
Figure 13: Provisional crown
tooth replacement (Figure 19). Three years later, the patient returned for additional dental procedures, implant #12 and tooth #13 were evaluated, and the red aesthetics had improved, since initial crowns delivery (Figure 20).
Conclusion Dental implants have been a Figure 14: Periotest very successful and predictable option to replace missing teeth. Titanium and titanium alloys have long been considered the gold standard of materials for dental implantation. It is now well known and documented that metal alloys, including titanium, will, over time, be oxidized in the body or oral environment, and the products of this oxidation/corrosion can cause metal toxicity, spontaneous aseptic implant failure, and other systemic health problems in the host. Over time, more procedures have been performed, thereby, exposing a greater number and genetically-diverse group of people to titanium and its alloys. Studies and clinical observations have been made, SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
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Figure 15: Impression cap on abutment
Figure 16: Impression
Figure 17: Model
Figure 18: Cleaning and priming materials
Figure 19: Immediate post crown delivery
Figure 20: Three years post op
and reported of, various responses to the alloys from the patients, but also about the materials’ response over time to the environment in which they are placed and required to function. The search for alternative, more stable and less toxic materials, has been ongoing and, today, whether it is for restorative or direct implantation, bioceramics, especially zirconia, is an acceptable and proven material in dental implantology. It is, therefore, necessary that clinicians attune themselves to this evolution, as it appears our patients have also evolved in terms of their health and dental care choices and expectations. n
About the author Dr. Sammy Noumbissi obtained his Doctorate in Dental Surgery from Howard University in Washington DC. He then attended Loma Linda University where he received three years of formal training in Implant Dentistry which culminated with a certificate and a Master of Science degree in Implant Dentistry. He has published abstracts and articles in peer reviewed dental journals namely the Journal of Dental Research, the Journal of Oral Implantology and the Journal of Implant and Clinical Dentistry. He lectures nationally and internationally across the globe in metal free dental implantology. He is a member of the editorial board of the Journal of Implant and Advanced Clinical Dentistry and a reviewer for the Journal of Oral Implantology. Dr. Noumbissi practices in Silver Spring, Maryland USA.
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References 1:
Evrard L. et al. Allergies to dental metals. Titanium: a new allergen. Rev Med Brux. 2010 Jan-Feb;31(1):44-9.
2:
Siddiqi A et al. Titanium allergy: could it affect dental implant integration? Clin Oral Implants Res. 2011 Jul;22(7):673-80.
3:
Chaturvedi TP. An overview of the corrosion aspect of dental implants (titanium and its alloys). Indian J Dent Res. 2009; 20(1):91-8.
4:
Anders S. Zirconia as a biomaterial for odontological applications Effects of composition and manufacturing processes on fracture resistance. Umeå University Odontological Dissertations, Series No 114
5:
Gettens et al. Electrical Implications of Corrosion for Osseointegration of Titanium Implants. J Dent Res. 2011 90(12):1389-1397.
6:
Lugowski SJ et al. Release of metal ions from dental implant materials in vivo: Determinations of Al, Co, Cr, Mo, Ni, V, and Ti in organ tissue. J Biomed Mater Res 1991;25:1443-58.
7:
Weingart D. Titanium deposition in regional lymph nodes after insertion of titanium screw implants in maxillofacial region. Int J Oral Maxillofac Surg. 1994; 23 :450-2.
8:
Lee S. et al. Peri-implant and systemic release of metallic elements following insertion of a mandibular modular endoprosthesis in Macaca fascicularis. Acta Biomater. 2009 Nov; 5(9):3640-6.
9:
C. Piconi, G. Maccauro. Review Zirconia as a ceramic biomaterial. Biomaterials 1999 (20): 1 -25.
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
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Dental Implant Material and Design The glorious past and the road to a tremendous future
I
t has been more than 30 years since the Toronto Osseointegration Conference, and over 50 years since the work of Professor Per-Ingvar Brånemark. In that time frame, we have seen an explosion in the field of dental implantology. Many facets of our knowledge-base and understanding of the field evolved during that time, as well as fundamental developments in material science. Our implant designs have evolved, our surface treatments have evolved, our surgical techniques and prosthetic protocols too have evolved, and so have the materials we use.
Dr. Dan Hagi DDS, FAGD, FICOI, (a)FAAID, FIADFE
The original two-stage machined implants made of surgical commercially-pure titanium, used by the mavericks of implantology, are nearly extinct in the modern dental implant marketplace. Instead we are faced with a myriad of alloys, designs, connector geometries, all with substantial literature attesting to similar survival rates. Thanks to evolution in materials, we now have a surge in ceramic implants that are made of increasingly stronger materials, and that feature new designs and material characteristics that simplify and enhance long-term outcomes in tooth replacement. How do we choose? What is best and most successful? Where is the future of implant design and material heading? Is the age of metals in the mouth over? In order to see the future, the best place to look is the past. History repeats itself and in dentistry, as in many other scientific pursuits, one needs to learn from that past. Figure 1: Greenfield Basket implant
Titanium Implants The history of titanium in dentistry is familiar to us all. Many lessons were learned from past experiences, until one got to the success that Dr. Brånemark had reported. The first documented metal dental implant was the Greenfield crib or basket implant system presented in 1913.1 This iridioplatinum implant, restored with an attached gold crown, showed evidence of osseointegration and lasted for a number of years.1
Figure 3: Pin implant
40
Figure 4: Panoramic radiograph of historic dental implants
Figure 5: Original Brånemark implant
Figure 2: Spiral implant
Figure 6: Exposed metal
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
Figure 7: Tissue recession around the implants in the anterior
Figure 7a: Fully edentulous tooth replacement – exposed metal
In the 1930’s Drs. Alvin and Moses Strock, utilized orthopedic screw fixtures made of Vitallium (chromiumcobalt alloy). These early implants were inserted in both humans and dogs to restore individual teeth. The brothers were acknowledged for their work in selecting a biocompatible metal to be used in the human dentition.2 Formiggini and Zepponi developed a post-type endosseous implant in the 1940’s. The spiral stainless steel design of the implant allowed bone to grow into the metal.2 Dr. Perron Andres from Spain modified Formiggini’s spiral design to include a solid shaft in the construction.2 The design was successful and fused with the bone. Various implant designs expanded in the 1960’s. Dr. Cherchieve crafted a double-helical spiral implant made of cobalt and chromium.3 These were screw-shaped singlepiece implants. The spiral shaft was further enhanced during this decade by Dr. Giordano Muratori by the addition of internal threading to the shaft of the implant.2 The basic spiral design was turned into a flat plate with various configurations by Dr. Leonard Linkow in 19634,5 and by 1967, there were two variations of the blade implant and the subperiosteal design making it possible to place it in either the maxilla or the mandible.4,5 In the early 1970’s, Dr. Roberts began the development of the Ramus Blade endosseous implant. This implant was made of surgical-grade stainless steel.2 All these materials saw a degree of success, as did the various designs. None of them withstood the test of time in a predictable manner. If was not until 1978, when Dr. P. Brånemark presented a two-stage threaded titanium rootform implant; he developed and tested a system using pure titanium screws which he termed fixtures.6 These fixtures were first placed in his patients in 1965. Dr. Brånemark’s first patient had severe deformities of the jaw and chin, congenitally-missing teeth and misaligned teeth. Four implants were inserted into the mandible. These implants integrated within a period of six months and remained in place for the next 40 years.7 A careful implantation protocol was also introduced. The original Brånemark implant was SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
Figure 8: Sapphirre crystal implants
created as a cylindrical one; later, tapered forms appeared. Many other types of implants were introduced after the Brånemark implant which included the ITIsprayed implant, the Stryker implant, the IMZ implant and the Core-Vent implant.11,12 It took over 40 years of metal implantology for the “ideal” metal and implant design for the support of teeth to emerge. The success Dr. Brånemark had was attributed to the physical and chemical attributes of Titanium as well as a strict protocol for treating the
Figure 8a: Glass implant
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Figure 10: Ceraroot histology
Figure 11: CeraRoot Ceramic Implant System
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Figure 14: Lateral incisors Titanium vs. ceramic
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completely edentulous patients.8,9 These concepts of treating the completely edentulous were used in the 80’s and beyond to attempt to restore the partially edentulous. This is where the profession found problems. Two-piece metal-made implants showed increasing amounts of tissue recession and bone disease that, although did not detrimentally affect outcomes in the completely edentulous, were disastrous in the highly demanding partially-edentulous SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
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patients. Poor performance in thin biotypes, lacking tissue contours and the prevalence of hard and soft tissue periimplant disease, as well as prosthetic complications, meant that implant design had to change to solve these problems. A way to deal with those problems was altering the design of the implants. Abutment connection geometry, surface modifications, abutment materials are all attempts to overcome the challenges that present themselves in using two piece titanium implants in the partially edentulous patients.
Ceramic Implants Ceramics were first introduced into dental implantology as coatings onto metal-based endosseous implants in an effort to improve osseointegration. Materials such as hydroxyapatite(HA), tricalcium phosphate (TCP) and fluorapatite (FA) have all been used as coatings to enhance the biological response of bone.13,14,15 These coatings proved not entirely successful as the bond with the metal substructure was not predictable. Dr. Sandhaus in the mid-60’s developed a crystallized bone implant whose composition was mainly aluminum oxides.16 The 1970’s brought in the placement of vitreous carbon implants by Grenoble17, both showed poor results due to the brittle nature of the material. In 1975 Schulte and Heimke introduced the Tubingen implant made of high-purity alumina ceramic.18 The twopiece wide design was fraught with mechanical problems of material fracture (alumina oxide is a brittle material) and superstructure failure caused by the cemented restorative metal pins. However, what was observed was that a failure to integrate, resulted in neither acute nor chronic periimplant osteomyelitis. Tissue reacted better to these ceramic materials than it did to metals. McKinney, Koth, and Steflik’s group have conducted numerous studies on the single-crystal sapphire endosseous dental implant, Bioceram®, in the early 1980’s.19 However, these had a poor survival rate and, although some survived for 15 plus years, the implants had barely a 50% survival rate. In 1987 the Sigma implant (Sandhause, Incermed) was introduced as the first Zirconia dental implant system.20 Since then, about 15 different Zirconia dental implant systems have been introduced to the market with many more coming. The material has proven to osseointegrate, have high fracture-resistance, be very tissue-friendly and be able to solve many challenges of the partially-edentulous, that have previously been extremely difficult to manage with two-piece titanium. In 2003 a system designed to be the ideal tooth 44
replacement was introduced. The CeraRoot (Oral Iceberg, Granoliers, Spain) implant system encompassed the “Tooth Replacement Concept” with a system employing five unique tooth root shapes (with an additional two shapes introduced in 2015) designed to replace the root and trans-gingival part of the tooth with a one-piece y-TZP dental implant. The evolution of ceramics in implant dentistry has spanned the course of nearly 40 years, with early learning leading to better and better solutions. Much like the pioneers of titanium, we have finally arrived at a material that is well suited for replacement of teeth. The history of dental implants is a glorious voyage. Clinicians used materials ranging from coral sea-shells, ivory, chromium-cobalt, to iridium and platinum and stainless steel. Implant designs started as wires and spirals, evolving to blades and helical one-piece creations; and finally to endosseous two-piece titanium root forms. As time marches on in the dental implant research, the materials, forms, and surface coatings have been refined and restructured to allow the consumer the very best in tooth replacement choices for their present and future needs. The late Dr. Brånemark famously commented that “no one should have to die with their teeth in a glass of water beside their bed”. The titanium standard, as the foundation for treatment of the completely edentulous, highly-disabled patients, is unchallenged at this time. Today’s pioneers take this mantra further. No one should have to compromise the aesthetic and biologic longevity of their smile for the sake of a strong, healthy, and functional mouth. Thanks to the continued evolution of our field, patients no longer have to bear the consequences of metals in their mouths, loosening screws, abutment fractures or high rates of peri-implant disease. We now have materials and implant designs that more naturally mimic teeth and, as such, ceramic tooth replacement is becoming a viable and accepted treatment option for the partially-edentulous, or soon-to-be partially-edentulous patient. n
About the author Dr. Dan Hagi received his dental training at the University of Toronto and now maintains a multidisciplinary implant and rehabilitative practice in Thornhill, Ontario. He is an associate Fellow of the American Academy of Implant Dentistry(AAID), a Fellow of the International Congress of Oral Implantology(ICOI), a Fellow of the Academy of General Dentistry(AGD) and the Misch International Implant Institute. His private practice focuses on metal free, minimally invasive rehabilitation and aesthetic smile design. His focus on ceramic materials has led him to gain valuable experience in the utilization of Zirconium Oxide materials as a restorative material as well as the use of Zirconium Oxide dental implants. He is a lecturer and mentor as well as a consultant on emerging metal-free materials and techniques.
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
References 1.
Greenfield EJ. Implantation of artificial crown and bridge abutments. Int J Oral Implant. 1991;7(2):63–8.
2.
Linkow LI, Dorfman JD. Implantology in dentistry: A brief historical perspective. N Y State Dent J. 1991;57(6):31–5.
3.
Cherchieve R. Considerazioni fisiologiche e pratiche su una osservazione originale di un impianto endosseo. Inform Dent. 1959;24:677–80.
4.
Linkow LI. Intraosseous implants utilized as fixed bridge abutments. J Oral Implant Transplant Surg. 1964;10:17–23.
5.
Linkow LI. The radiographic role in endosseous implants interventions. Chron Omaha District Dent Soc. 1966;29:304–11.
6.
Brånemark PI, Zarb G, Albrektsson T, editors. Chicago: : Quintessence Publishing; 1985. Tissue-integrated prostheses: Osseointegration in clinical dentistry.
7.
Brånemark PI, Hansson BO, Adell R , et al. Osseointegrated implants in the treatment of the edentulous jaw: Experience from a 10-year period. Scand J Plast Reconstr Surg. 1977;16:1–132.
8.
Brånemark PI. Osseointegration and its experimental background. J Prosthet Dent. 1983;50 (3):399–410. [PubMed]
9.
Osteointegration: Associated Branemark Ossointegration Centers 2010. Available from: http://www.branemark.com/Osseointegration.html.
10. Leventhal, Gottlieb S. (1951). "Titanium, a metal for surgery". J Bone Joint Surg Am 33–A (2): 473–474. 11. Driskell TD, editor. The stryker precision implant system Root form series McKinney RV Endosteal dental implants. Mosby Year Book. 1991;81 12. Kirsch A, Ackermann KL. The IMZ osseointegrated implant system. Dent Clin North Am. 1989;33(4):733–91. 13. Wen X, Wang X, Zhang N. Microsurface of metallic biomaterials: A literature review. J BioMed Mater Eng. 1996;6:173–89. 14. Albrektsson T, Jacobsson M. Bone-metal interface in osseointegration. J Prosthet Dent. 1987;57:5–10. 15. Schroeder A, van der Zypen E, Stich H, Sutter F. The reactions of bone. connective tissue and epithelium to endosteal implants with titanium sprayed surfaces. J Maxillofac Surg. 1981;9:15–25. 16. Sandhaus S. Tecnica e strumentario dell’impianto C..S. (Crystalline Bone Screw). Informatore Odonto-Stomatologico. 1968;4:19–24. 17. Markle DH, Grenoble DE, Melrose RJ. Histologic evaluation of vitreous carbon endosteal implants in dogs. Biomater Med Dev Artif Organs. 1975;3(1):97–114. 18. Schulte W, Heimke G. [The Tubinger immediate implant] Quintessenz. 1976;27:17–23. 19. Steflik DE, Koth DL, McKinney RV Jr. A clinical and statistical analysis of human clinical trails with the single crystal sapphire endosteal dental implant: two year results. J Oral Implantol. 1984;11(4):500-15. 20. Andreiotelli M, Kohal RJ. Fracture strength of zirconia implants after artificial aging. Clin Implant Dent Relat Res. 2009;11(2):158-66. 21. Bacchelli, B., Giavaresi, G. Franchi, M. et al. Influence of a zirconia sandblasting treated surface on peri-implant bone healing: an experimental study in sheep. Acta Biomater. 2009. 5:2246–2257. 22. Akagawa, Y., Ichikawa, Y. Nikai, H. and Tsuru, H. Interface histology of unloaded and early loaded partially stabilized zirconia endosseous implant in initial bone healing. J Prosthet Dent. 1993. 69:599–604. 23. Akagawa, Y., Hosokawa, R. Sato, Y. and Kamayama, K. Comparison between freestanding and tooth-connected partially stabilized zirconia implants after two years' function in monkeys: a clinical and histologic study. J Prosthet Dent. 1998. 80:551–558.
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24. Dubruille, J. H., Viguier, E. Le Naour, G. Dubruille, M. T. Auriol, M. and Le Charpentier, Y. Evaluation of combinations of titanium, zirconia, and alumina implants with 2 bone fillers in the dog. Int J Oral Maxillofac Implants. 1999. 14:271–277. 25. Schultze-Mosgau, S., Schliephake, H. Radespiel-Tröger, M. and Neukam, F. W. Osseointegration of endodontic endosseous cones: zirconium oxide vs titanium. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000. 89:91–98. 26. Kohal, R. J., Weng, D. Bächle, M. and Strub, J. R. Loaded custommade zirconia and titanium implants show similar osseointegration: an animal experiment. J Periodontol. 2004. 75:1262–1268. 27. Hoffmann, O., Angelov, N. Gallez, F. Jung, R. E. and Weber, F. E. The zirconia implant-bone interface: a preliminary histologic evaluation in rabbits. Int J Oral Maxillofac Implants. 2008. 23:691–695. 28. Depprich, R., Zipprich, H. Ommerborn, M. et al. Osseointegration of zirconia implants: an SEM observation of the bone-implant interface. Head Face Med. 2008. 4:25. 29. Depprich, R., Ommerborn, M. Zipprich, H. et al. Behavior of osteoblastic cells cultured on titanium and structured zirconia surfaces. Head Face Med. 2008. 4:29. 30. Sennerby, L., Dasmah, A. Larsson, B. and Iverhed, M. Bone tissue responses to surface-modified zirconia implants: a histomorphometric and removal torque study in the rabbit. Clin Implant Dent Relat Res. 2005. 7(suppl 1):S13–S20. 31. Minamizato, T. Slip-cast zirconia dental roots with tunnels drilled by laser process. J Prosthet Dent. 1990. 63:677–684. 32. Kohal, R. J., Klaus, G. and Strub, J. R. Zirconia-implant-supported allceramic crowns withstand long-term load: a pilot investigation. Clin Oral Implants Res. 2006. 17:565–571. 33. Silva, N. R., Coelho, P. G. Fernandes, C. A. Navarro, J. M. Dias, R. A. and Thompson, V. P. Reliability of one-piece ceramic implant. J Biomed Mater Res B Appl Biomater. 2009. 88:419–426. 34. Kohal, R. J., Papavasiliou, G. Kamposiora, P. Tripodakis, A. and Strub, J. R. Three-dimensional computerized stress analysis of commercially pure titanium and yttrium-partially stabilized zirconia implants. Int J Prosthodont. 2002. 15:189–194. 35. Blaschke, C. and Volz, U. Soft and hard tissue response to zirconium dioxide dental implants—a clinical study in man. Neuroendocrinol Lett. 2006. 27(suppl 1):69–72. 36. Oliva, J., Oliva, X. and Oliva, J. D. Five-year success rate of 831 consecutively placed zirconia dental implants in humans: a comparison of three different rough surfaces. Int J Oral Maxillofac Implants. 2010. 25:336-344. 37. Pirker, W. and Kocher, A. Immediate, non-submerged, root-analogue zirconia implant in single tooth replacement. Int J Oral Maxillofac Surg. 2008. 37:293–295. 38. Oliva, J., Oliva, X. and Oliva, J. D. Ovoid zirconia implants: anatomic design for premolar replacement. Int J Periodontics Restorative Dent. 2008. 28:609–615. 39. Wenz, H. J., Bartsch, J. Wolfart, S. and Kern, M. Osseointegration and clinical success of zirconia dental implants: a systematic review. Int J Prosthodont. 2008. 21:27–36.
If C.P. titanium or a titanium alloy has more than 85% titanium content it will form a titanium biocompatable titanium oxide surface layer or veneer that encloses the other metals preventing them from contacting the bone.[56]
45
Digital dental photography (Part two) Peter Gordon continues his guide to consistent photography by demystifying your camera’s settings and suggesting a standardized approach
O
ne of the main objectives of dental photography is to take consistent views, which can be defined as the same area, reproduced at the same size, on a regular basis. (Figure 1)
identically, but not all have their own (or even third party) range of macro lenses or suitable flash units. While dentists will have to familiarize themselves with their own equipment, these settings should be easy to find on most DSLRs. The author recommends the following settings as a good basic starting point.
Consistent views are particularly important for things like accreditation, but even if you do not require them specifically, the basic camera set-up is identical. These procedures must be carried out prior to use. The most popular digital single-lens reflex (DSLR) cameras in the UK are Canon and Nikon, though there are a number of other good quality brands available. Most can be set up
Digital cameras have a variety of shooting modes that allow the user to choose from a selection of pre-programmed settings geared to specific types of photography. These modes are usually selected on DSLRs via a dial somewhere on the camera body itself. Many of them are represented by an image or icon, but there are some — the ‘letter modes’ — that allow the user to change settings more specifically. It is these that a dental user should turn to when setting
Camera mode
Figure 1: Photographing the same area at a consistent size is one of the main aims of dental photography (images courtesy of Dr Ken Harris)
46
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
up the system. These letter modes are detailed here, though some of the terms are explained further below: • Automatic — Sometimes represented by a green box icon, the camera sets everything automatically; just ‘point and shoot’ • P — Programmed auto. The camera will generally choose the highest shutter speed to avoid camera shake and, by default, will select the appropriate aperture according to other preset conditions (such as sensitivity) • S or TV — Shutter priority. The user chooses the shutter speed and the camera automatically sets the correct aperture • A or AV — Aperture priority. The user chooses the aperture and the camera automatically sets the correct shutter speed. The suggested setting for clinical photography • M — Manual. The user chooses every single setting manually. Aperture priority mode is the author’s recommended setting for clinical photography.
ISO value
• • • •
Cloudy Fluorescent Tungsten Electronic flash (the choice for clinical work) • Custom (where the operator knows the source color temperature and selects appropriately). As electronic flash will invariably be the source of illumination, the WB should be set to the ‘flash’ position, which is generally indicated by a lightning icon.
Auto Daylight Cloudy Tungsten Fluorescent Flash Custom Figure 2: A typical selection of white balance icons. Clinical photography should always be carried out with flash and the camera set accordingly
Image quality
The ISO (International Standards Organisation) speed or value may seem like jargon but is in fact very simple — it sets the sensitivity of the sensor to light. It can range from 100 to as high as 6,400 in some digital cameras, though a range of between 200 and 800 is most widely adopted in general photography. The lower the number, the less light-sensitive the sensor — but the image will typically be higher in quality. Higher ISO speeds are used in low-light conditions. For clinical photography, the author recommends an ISO of 200.
Digital cameras always allow the user to set image quality, which dictates how much of the information hitting the sensor is used within the image. The option to change or check this is usually hidden within a settings menu on the camera. Image quality in digital cameras is a little difficult to define but, in simple terms, can offer three basic levels: fine, normal, and basic. The highest quality (fine) will use 100% of available pixels; normal will use 75% and basic 50%. There is, therefore, more detail in a fine image, which allows it to be enlarged further before it ‘breaks up’ or pixelates.
White balance
File type
Sensors are not as good as the human eye, which generally recognizes colors irrespective of their illumination source, and compensates accordingly (except in extreme circumstances). Digital sensors cannot do this, so changing the camera’s white balance (WB) allows the photographer to compensate manually for the colour temperature by choosing the most appropriate setting (Figure 2).
Your camera should have the option to take raw and jpeg images simultaneously. Though raw files (discussed in more detail in the previous article) will take up even more space, shooting in this fashion is recommended. The jpeg images can be used easily for most purposes, while the raw images can be set aside and archived for the audit trail, academy accreditation, or other requirements as needed.
A typical choice is as follows: • AWB (automatic white balance, which leaves the camera to assess the situation automatically) • Sunshine • Shadow SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
Shutter speed and flash synchronisation The shutter speed (or exposure) is the amount of time the sensor is exposed to the light when the camera shutter opens. It is generally measured in fractions of a second. 47
A typical range on most DSLRs is 1/2000 second to half (1/2) a second. The exposure is successively halved at each change (eg, 1/2000s to 1/1000s, to 1/500s and so on).
At-a-glance settings:
Electronic flash
Mode: A or AV (aperture priority)
The duration of an electronic flash is much shorter than most exposure times, so for an accurate exposure the flash must fire when the sensor is fully exposed. This is referred to as the flash synchronization speed and varies from make to make (1/60 sec for most Nikons and 1/200 sec for most Canons). Most auxiliary flash power units are mounted in the camera’s hot-shoe. With Nikon, this will automatically set the flash sync speed, but this is not the case with Canon. Depending on the model, there are currently two methods of setting it for use in the AV aperture priority mode. It cannot be set on the Canon 1200D and the M (manual)
Aperture: f22 — all intra- and perioral views f8 — full faces and profiles
Aperture The aperture is the hole that controls the amount of light reaching the sensor. It is variable in diameter. The size of the aperture is referred to by ‘f’ numbers, usually called ‘f-stops’. While these numbers appear numerically unrelated, moving from one f-stop to another doubles or halves the size of the hole (and thus the amount of light hitting the sensor). The smaller the number, the larger the hole (Figure 3). Aperture is, simultaneously, one of the most important and the most misunderstood aspects of photography. It controls something called ‘depth of field’, which is the range in depth of the photograph (from front to back) that appears in focus (Figure 4). In close up work, this is small enough that it can be measured in millimetres.
ISO: 200 Shutter speed: Automatic with Nikon cameras but ensure flash sync is enabled with Canon models White balance (WB): Flash (lightning icon) setting requires that the user pre-sets the shutter and changes the aperture as necessary.
Depth of field will be discussed fully in a later article, but suffice it to say that the clinical operator only needs to remember two f-numbers to keep their photography in focus. An aperture of f22 should be selected for all intra- and perioral- views, and an aperture of f8 for all full faces, profiles etc.
Other settings A number of other terms may crop up when learning your way around your camera. These are largely irrelevant to clinical photography but it helps to understand what they mean.
Burst mode Most cameras will take single or multiple shots as required. Taking a series of shots in quick succession is referred to as burst mode or continuous shooting. Settings here will often be referred to as ‘S’ (single shots), ‘CL’ (continuous low — perhaps two to three shots a second), or ‘CH’ (continuous high — as many as seven to ten shots per second). The clinical user will typically only need the default setting of single shots.
Live-view
Figure 3: Aperture is measured in ‘f-stops’. The smaller the f number, the larger the hole
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The live-view setting allows the operator to use the rear screen as a viewfinder, just as compact cameras do. Though it is now available on most DSLRs, it comes with certain performance limitations (slower focusing, battery drain, and the difficulty of keeping a DSLR steady at arm’s length), which mean using it in a clinical setting is not generally recommended.
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
Fig. 4a
Fig. 4b
Figure 4: A demonstration of the effect of aperture on depth of field. Figure 4a was taken at a large aperture (f4) and Figure 4b at a small aperture (f22)
Bracketing shots
About the author
It is possible to take a sequence of three or five images in quick succession with degrees of over- and under-exposure either side of the ‘correct’ setting. In a standardized clinical setup, this should not be necessary, but referral to the camera manual is recommended if the user feels it is useful.
Peter Gordon LDSRCS DGDP(UK) is one of the most experienced dental photographers. He was in private practice from 1969 until 1998, when he joined the Dental Reference Service, introducing photography there with great success. Together with Philip Wander, he is the author of Dental Photography (published by the BDJ in 1987). Peter was a BDA adviser between 1991 and 1996, and has lectured worldwide on clinical photography. He is currently a director of Photodent, a company that helps dental teams achieve the finest results in dental photography.
Summary You can take steps towards good clinical photography before you even take your first picture. Making sure that your camera is set up correctly (see the box ‘At a glance’) is half the battle. n
Solution provider for dental implants! dentallabs.com www.smiletech 0.3372 77 Fax: 905.94 Tel: 905.940.33 90 81 8. 35 Toll Free: 1.888. 0B1 arkham ON L3R Ave., Unit 9, M th 14 3980
SmileTECH supports all premier dental implants Maher Andrawes, RDT Member of the American Academy of Cosmetic Dentistry (AACD) Graduate of Las Vegas Institute (LVI) and Dawson Centre for Advanced Dental Study
SPECTRUM Implants — Vol. 6 No. 4 — Winter 2015
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