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7 2 For a complete list of our Bone Regeneration For products please visit For details see page Lending Club stability with Dr. Salah Huwais Salah Dr. 2-year follow-up Enhancing implant osseodensification Corporate spotlight — a case report with — a case report February/March 2015 – Vol 8 No 1 8 No Vol 2015 – February/March clinical articles • management advice • practice proﬁles • technology reviews technology • proﬁles practice • advice management • articles clinical Practice profile Justin Moody Dr. Challenging aspects of Challenging aspects of implant restoration Baker and Drs. Brenda David Reaney Single implant-borne in the reconstruction esthetic area Daniel S. Thoma Dr. PROMOTING EXCELLENCE IN IMPLANTOLOGY EXCELLENCE PROMOTING PAYING SUBSCRIBERS EARN 24 SUBSCRIBERS EARN 24 PAYING CREDITS CONTINUING EDUCATION PER YEAR! PRODUCT PROFILE

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INDUSTRY WIDE SOLUTION

ZEST recognizes, and is honored by, the commitment implant companies have made to make the LOCATOR Attachment compatible with their dental implants. In fact, the dental implant companies that collectively make up over 90% of the global implant market supply, partner with ZEST Anchors. Each has chosen the LOCATOR to be a part of the solutions they provide to you, their customer, and your patients.

1 Implant practice Volume 7 Number 4 CLINICIAN PREFERENCE

LOCATOR’s unique low proﬁ le design, pivoting technology, durability, and ease-of-use has propelled it to be the preferred choice of clinicians worldwide for tissue supported, implant-retained overdentures. Clinicians have validated LOCATOR’s Gold Standard status with over 4 million units purchased - no other product can match its extensive clinical documentation, design accolades or number of satisﬁ ed patients.

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February/March 2015 - Volume 8 Number 1 Looking forward to 2015 EDITORIAL ADVISORS Steve Barter BDS, MSurgDent RCS Anthony Bendkowski BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent Philip Bennett BDS, LDS RCS, FICOI t the time that I was asked to write the introduction for Stephen Byfield BDS, MFGDP, FICD Sanjay Chopra BDS Athis issue of Implant Practice US, I was saddened to learn Andrew Dawood BDS, MSc, MRD RCS Professor Nikolaos Donos DDS, MS, PhD of the passing at age 85 of Dr. Per-Ingvar Brånemark in his Abid Faqir BDS, MFDS RCS, MSc (MedSci) hometown of Gothenburg, Sweden. There was an excellent Koray Feran BDS, MSC, LDS RCS, FDS RCS Philip Freiburger BDS, MFGDP (UK) article in the health section of The New York Times by Tamar Jeffrey Ganeles, DMD, FACD Mark Hamburger BDS, BChD Lewin on December 27, 2014, providing a short synopsis of Mark Haswell BDS, MSc this remarkable man, scholar, teacher, researcher, and inventor. Gareth Jenkins BDS, FDS RCS, MScD Stephen Jones BDS, MSc, MGDS RCS, MRD RCS How fortuitous it was that his initial experiment utilizing titanium Gregori M. Kurtzman, DDS chambers designed to study blood flow and bone healing Jonathan Lack DDS, CertPerio, FCDS Samuel Lee, DDS unexpectedly could not be removed as they were fused to David Little DDS Andrew Moore BDS, Dip Imp Dent RCS the bone. The term “osseointegration” was born from these Ara Nazarian DDS experiments. Without Dr. Brånemark and his initial studies, this Ken Nicholson BDS, MSc Michael R. Norton BDS, FDS RCS(ed) magazine might not exist, nor my scope of private practice, nor Cary A. Shapoff, DDS Rob Oretti BDS, MGDS RCS Christopher Orr BDS, BSc the millions of successfully treated patients restored with dental Fazeela Khan-Osborne BDS, LDS RCS, BSc, MSc implants from the single-tooth replacement to the more complex full-arch fixed, removable, Jay B. Reznick DMD, MD Nigel Saynor BDS or hybrid-type restorations. Malcolm Schaller BDS Ashok Sethi BDS, DGDP, MGDS RCS, DUI Since Dr. Brånemark’s early studies and findings, dental implant surgical techniques Harry Shiers BDS, MSc, MGDS, MFDS and philosophies have evolved from the longer healing periods to immediate placement Harris Sidelsky BDS, LDS RCS, MSc Paul Tipton BDS, MSc, DGDP(UK) and provisionally loaded techniques now employed in specific clinical situations. Numerous Clive Waterman BDS, MDc, DGDP (UK) former students and colleagues of Dr. Brånemark have added much to the knowledge base Peter Young BDS, PhD Brian T. Young DDS, MS

of the dental implant field. CE QUALITY ASSURANCE ADVISORY BOARD Restorative concepts, techniques and prosthodontic case design with intraoral scan- Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC ners, and CAD/CAM abutment and crown design have also advanced the art and science Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales of dental implant dentistry to new levels. Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private All of us in the daily treatment of patients have the opportunity and responsibility to Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of consider this replacement and reconstructive option in addition to the other conventional Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St dental care approaches utilized to successfully maintain existing dentitions. referral implant surgeon My own experience in the field of dental implant surgery began in 1985, well after my formal periodontal residency training in 1975. My own implant knowledge base was developed from attending numerous courses and lectures and reviewing the literature. Self-evaluation of my techniques and outcomes from documentation and critical clinical evaluation has helped PUBLISHER | Lisa Moler to hone my treatment concepts. Close-working relationships with my restorative colleagues Email: [email protected] have allowed us to focus on the esthetic desires and demands of our patient population while GENERAL MANAGER | Adrienne Good Email: [email protected] maintaining the biologically sound surgical principles and organized restorative responsibilities. MANAGING EDITOR | Mali Schantz-Feld Successful esthetic outcomes are a result of careful case analysis, development of well- Email: [email protected] | Tel: (727) 515-5118 organized treatment plans, and keeping the end result in mind prior to performing irrevers- ASSISTANT EDITOR | Elizabeth Romanek Email: [email protected] ible surgical procedures. We now have the ability to plan our cases with three-dimensional EDITORIAL ASSISTANT | Mandi Gross radiographic surveys and provide precise surgical placement utilizing the imaging results Email: [email protected] combined with computer-generated surgical guides. NATIONAL ACCOUNT MANAGER | Michelle Manning Email: [email protected] Implant styles have certainly changed from the early fixture designs with machined implant NATIONAL ACCOUNT MANAGER | Kimberly Burke collars to the variety of implant styles, fixture thread designs, and connections. Evidence- Email: [email protected] based variations to the platform design have been developed from platform-switched to those CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver with specific microtextured surfaces that provide unique cellular bioactivity. Email: [email protected] FRONT OFFICE MANAGER | Eileen Lewis Our dental implant knowledge is not a finite destination but rather a journey. We rely Email: [email protected] on a continuing educational stream in order to maintain our skills and develop new treat- MedMark, LLC ment methods. Graduate and postgraduate academic programs afford us the opportunity 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 to develop clinical and research skills. The opportunity to expand and acquire additional Tel: (480) 621-8955 Fax: (480) 629-4002 knowledge on all aspects of implant dentistry can be gained from numerous sources. Implant Toll-free: (866) 579-9496 Web: www.implantpracticeus.com Practice US and many other magazines and journals provide current, relevant technical www.medmarkaz.com

and scientiﬁc articles as well as continuing education credits. The Internet has brought the SUBSCRIPTION RATES dental implant world to our computers in the form of webinars, live-streaming seminars, and 1 year (6 issues) $99 numerous international congresses and publications. 3 years (18 issues) $239 As clinicians, our work is our signature. The ultimate goal is, therefore, to provide the © FMC 2013. All rights reserved. FMC is part of the specialist patient with the most optimal functional and esthetic outcome with long-term success. publishing group Springer Science+ Business Media. The publisher’s written consent must be obtained Best wishes for a new year of success and fulﬁllment of your aspirations! before any part of this publication may be reproducedvw in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, Cary A. Shapoff, DDS the publisher cannot be held responsible for the accuracy of the Periodontist information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the Diplomate and Past Director of the American Board of Periodontology opinion of either Implant Practice or the publisher.

2 Implant practice Volume 8 Number 1 Long working time for you. Short setting time for them.

The material that gives you more control for accurate results … and improves the patient experience.

•฀฀All฀the฀working฀time฀you฀need—no฀stressful฀race฀ against฀the฀clock. Adequate working time is a factor for avoiding problems and for making good impressions. •฀฀The฀fastest฀intra-oral฀setting฀time฀on฀the฀market.1 Noticeably reduces chair time and stress for patients— without reducing the precision of your impression results. Available in Super Quick set (75 seconds) or ™ Regular set (2 minutes). Imprint 4 VPS Impression Material Learn more and redeem the Special Offer at: www.3MESPE.com/Imprint4 3M, ESPE, Imprint and Penta are trademarks of 3M or 3M Deutschland GmbH. Used under license in Canada. © 3M 2015. All rights reserved. All rights reserved. © 3M 2015. Used under license in Canada. Imprint and Penta are trademarks of 3M or Deutschland GmbH. ESPE, 3M, 3M ESPE internal data 1. TABLE OF CONTENTS

Case study Enhancing implant stability with osseodensification — a case report with 2-year follow-up Dr. Salah Huwais discusses how Practice proﬁle 8 osseodensiﬁcation facilitates ridge Justin Moody, DDS, DICOI, DABOI expansion with enhanced implant Home-grown, high-tech dentistry stability ...... 14

Implant insights Options for patients with low bone volume Dr. Franck Renouard shares key insights from a presentation he gave at the Academy of Osseointegration (AO) 2014 Annual Meeting in a session called “Problem Solvers & Innovators” ...... 22

Anterior implant esthetics Dr. Bernard Touati offers his insights into effective techniques and procedures for soft tissue management in the anterior region ...... 26 Corporate spotlight 12 Lending Club Welcome to the “More Possibilities” Club

4 Implant practice Volume 8 Number 1 www.dentsplyimplants.com the Available forallmajorimplantsystems, ATLANTIS convenience of aremovable prosthesis Stability of afixed solution with the solutions forfullyedentulouspatients. for friction-fit,non-resilientprosthetic ATLANTIS Conus Concept ™ ConusConcept allows • • • designed foroptimalaccessoralhygiene. prosthesis implant-supported Stable andcomfortable restoration andminimizinggapsmicro-movement. Designed tofitSynConecaps,ensuringatightly-seatedfinal and marginlevelsasclosetothesofttissuepossible. AbutmentDesign)softwareforparallelabutments (Virtual Individually designedusingthepatentedATLANTIS VAD NEW

Continuing education Challenging aspects of implant restoration Drs. Brenda Baker and David Reaney explain various methods to restore function and esthetics to patients in need of implant restoration ...... 35

Materials & equipment ...... 38

A conversation with... New You Smile (NYS) full mouth dental implant restorative system to launch in China Continuing education 30 ...... 40 Single implant-borne reconstruction in the esthetic area Dr. Daniel S. Thoma outlines the treatment undertaken for a patient with Practice management fractured central incisors using ridge preservation Guiding light Can your team rely on you when things seem dark? Laura Horton explains how effective leadership can be the light at the end of the tunnel ...... 42

Abstracts Treating soft tissue deformities Step-by-step Product profile around osseointegrated dental Assessing implant stability Introducing ATLANTIS Conus implants for loading concept by DENTSPLY Implants Dr. Maria Retzepi presents a selection Dr. Peter K. Moy discusses a product ...... 52 of recent studies and published that helps determine proper implant loading time...... 48 research ...... 44 In memoriam Professor Per-Ingvar Brånemark Practice development Product profile “Father of Modern Dental Implantology” How patients think Crystal® Ultra: a new hybrid nano- May 3, 1929 – December 20, 2014 Andy Smith presents patient-led ceramic ideal for implant cases ...... 53 insight to help improve your dental Creative Dental offers two new flavors implant marketing ...... 46 of implant restorations...... 50 Industry news ...... 54

6 Implant practice Volume 8 Number 1 GUIDED SURGICAL KIT Precision, Predictability & Performance

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Justin Moody, DDS, DICOI, DABOI

Home-grown, high-tech dentistry

What can you tell us about your background? I grew up on a cattle ranch in Crawford, Nebraska, which is a small town in the very northwest corner of Nebraska. My family homesteaded this place somewhere around 1883. It’s amazing to think about the fact that no one else has owned this property prior to this — it even was part of the Louisiana Purchase! My sons are the sixth generation to have lived on the original homestead. After attending the University of Nebraska for undergraduate studies, I traveled south to dental school at the Univer- sity of Oklahoma. It was a great place to study and an excellent clinical school. Upon graduation, my wife and I decided to move back to our hometown to raise our family, and in June of 1997, I joined my child- hood dentist back home only dentist offering became a Mentor at the Kois Center. It was in Crawford Nebraska. I implants for over 100 this culmination of experience and education opened my first implant- miles. The first system that inspired me to work on my credentials, only office in 2008 in I used was Sterngold/ becoming a Fellow, Master, and Diplomate in Rapid City, South Dakota, Sulzer, and I used it the International Congress of Oral Implanto- and eventually moved with until I believe Zimmer logists (ICOI), Fellow and Associate Fellow for my family there full time in Dental bought them the American Academy of Implant Dentistry 2010. This is where I call sometime in the early (AAID), and ultimately a Diplomate in the home today. 2000s. In 2007, I tried American Board of Oral Implantology. BioHorizons® dental Is your practice limited to implants? implant systems and have been with them Who has inspired you? Yes, my practice is limited to the place- ever since. My father, David Moody. Since he is a ment and restoration of dental implants and rancher, he is part doctor/veterinarian, part has been since 2008. What training have you undertaken? engineer, and part superhero for doing the As with anything you do as a young chores he does and working the hours he Why did you decide to focus on dentist, you have the success that drives works. In dentistry, it’s Dr. Roger Plooster implantology? you, but it’s the failures that motivate you in Lincoln, Nebraska; he is my friend, my It took only a matter of months in private to become better for you and your patients. colleague, and my mentor in dentistry and practice to realize that dentures, partials, and I went through the Misch International especially implantology. Because he gradu- bridges were not the long-term solution. I Implant Institute™, becoming a fellow and ated from Crawford High School with my could not see myself providing these services then one of Dr. Misch’s first masters. I also father, I have always known him, but when I for the rest of my career when there were completed the Medical College of Georgia graduated from dental school, he took me in better solutions using dental implants. AAID Maxi-Course in Atlanta, Georgia, and as one of his own sons. He use to host what every dental implant course I could get my we called an “implant rodeo” — a day where How long have you been practicing, hands on. Through this process of implant three to four of us would gather in one of our and what systems do you use? education, I realized I wanted more pros- offices and place dental implants on those I began placing dental implants in 1998 thetics and comprehensive dental education, who couldn’t afford it. We would do proce- after taking several courses throughout the so I completed the curriculum at the Kois dures that challenged us as a group, and I country. It was very rewarding being the Center in Seattle, Washington, and ultimately can’t tell you how valuable these days were.

8 Implant practice Volume 8 Number 1 WHAT KIND OF OPPORTUNITIES ARE IN YOUR WAITING ROOM?

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www.instrumentariumdental.com PRACTICE PROFILE

Top left: Father/son pheasant hunt Top right: Friday night lights for Dr. Moody’s oldest son, Aaron Lower left: Black Angus cattle on the Moody Ranch Lower right: Crawford, Nebraska, city limit sign

in CAD/CAM and the ability to provide ideal placement and restorations through guided surgery.

What are your top tips for maintaining a successful practice? The best tip I have is to keep it about the patient, doing what you feel is the right thing What is the most satisfying aspect practice. I have over 70 doctors in ﬁve states every time. It is not our right to be a doctor; of your practice? that have trusted their patients’ implant care it’s a privilege and an honor to have patients Having a patient say, “Thank you.” It’s to me. It’s an honor and a privilege to work place their trust in you as a dentist. that simple! with each and every one of them. What advice would you give to Professionally, what are you most What has been your biggest budding implantologists? proud of? challenge? Never stop learning! Take as many One day I received a thank-you note from Educating the public about dental courses as you can, and provide your a doctor whom I had trained. He said that implants. So many people still to this day patients with the very best in care. Choose dental implants have given his career a new feel like dental implants are only for the rich. an implant system based upon science, not start, and how he loves to go to work now. It is the standard of care, in my opinion, for price. Treatment plan your cases using a When you hear someone say that he/she the replacement of a missing tooth or teeth CBCT — there is no substitution for knowing considers you a mentor, that’s the moment and should be offered to all our patients. the whole story. And give back. We have the when you sit back and realize that you made best profession in the world that allows for a difference in someone’s life. That’s what I What would you have become if us to change someone’s life. am most proud of! you had not become a dentist? A farmer/rancher. It’s a great way of life. What are your hobbies, and what What do you think is unique about do you do in your spare time? your practice? What is the future of implants and I like to travel with my family, attend Without a doubt, it’s the fact that I am dentistry? sporting events of all kinds, and hunt birds a general dentist with a referral-based Digital. The future of implant dentistry is here in South Dakota. IP

Top 10 Favorites 1. My friends and family 2. The Nebraska Cornhuskers 3. The Moody Ranch 4. Harley-Davidson® motorcycles 5. My i-CAT™ FLX CBCT (Imaging Sciences International) 6. BioHorizons® dental implants 7. Chicago Cubs and Wrigley Field 8. Sturgis® Motorcycle Rally™ 9. Teaching and mentoring fellow dentists 10. DEXIS™ Dr. Lewis Cummings, Dr. Pat Allen, Steve Boggan, and Dr. Moody in Dubai, United Arab Emirates

10 Implant practice Volume 8 Number 1

CORPORATE SPOTLIGHT

Lending Club

Welcome to the “More Possibilities” Club

ending Club (NYSE: LC) is the world’s simple, user-friendly, and fast. Same-day Llargest online credit marketplace. In treatment acceptance has gone up since addition to personal and business loans, incorporating Lending Club Patient Solutions the company provides quality, responsible into our treatment presentation — so much options for people looking to finance so that we have stopped offering any other Lending Club’s commitment to radically elective medical procedures. financing options.” redefining consumer lending has attracted a “We combined Springstone’s decades For more information, contact Lending stellar team of innovators from the financial of experience in patient lending with our Club Patient Solutions at 1700 West Park services, technology, and consumer products technology and expertise to develop Drive, Suite 310, Westborough, MA 01581, industries. Lending Club Patient Solutions,” says 800-630-1663, or email solutions@lending- Headquarters: San Francisco Lending Club CEO Renaud Laplanche. club.com. IP “In doing so, we’re able to offer patients NYSE Listed: LC and providers a wider range of financing options, while keeping the application Established: 2006 process as simple as possible.” This information was provided by Springstone Financial. Founded By: Renaud Laplanche, CEO

First Personal Loan Facilitated: May 2007

“Same-day treatment acceptance has gone up Launch of Small Business Loans: March 2014

since incorporating Lending Club Patient Solutions Launch of Education and Patient Financing: April 2014 through the acquisition of into our treatment presentation.” Springstone Financial

Patients and the thousands of doctors participating in Lending Club Patient Solu- tions enjoy innovative payment options, high approvals, competitive rates, and exceptional customer service. The application process can be completed online within minutes, and applicants usually receive a response within seconds. As with other products offered through Lending Club, there’s no prepayment penalty, and there are no hidden fees. Says patient Larry Levandowski, “I needed a lot of dental work, well past any coverage I had. With the help of my dentist and Lending Club Patient Solutions, I had a ﬁnancial solution within an hour that allowed me to get my teeth back to health.” Treatment providers also see beneﬁts. “The difference in customer service alone is like night and day,” says Christina C., a treatment coordinator in Georgia. “They have lower practice fees and better approval rates, and the online application process is very Lending Club CEO Renaud Laplanche

12 Implant practice Volume 8 Number 1 Welcome to the more possibilities Club.

Introducing a new concept in patient fi nancing: More. More of what? More payment plan options, more fl exibility, and more patient approvals. Which, at the end of the day, means you can treat more patients. Springstone Patient Financing,SM known for offering patient-friendly products and practices, has joined Lending Club, the world’s largest lending marketplace. As Lending Club Patient Solutions, we’ll provide True No-Interest Plans which avoid unwelcome surprises and offer higher approval rates, increased fi nancing amounts – and much more. To learn how the new Lending Club Patient Solutions can help you do more for your patients, call 844-9DO-MORE (844-936-6673) or visit us at booth 3647 at the Chicago Midwinter Meeting.

© 2015 Lending Club Patient Solutions products and services provided through Springstone Financial LLC, a subsidiary of LendingClub Corporation. Patient plans made by issuing bank partners. lendingclub.com/providers CASE STUDY

Enhancing implant stability with osseodensiﬁcation — a case report with 2-year follow-up

Dr. Salah Huwais discusses how osseodensiﬁcation facilitates ridge expansion with enhanced implant stability

Introduction and autografted in an outwardly expanding directly related to surrounding bone quality The medical profession has, with certain direction to form the osteotomy. It is accom- and quantity. Maintaining and preserving exceptions, adapted commercially available plished by using proprietary densifying burs. bone during osteotomy preparation leads instruments that have been developed for When the densifying bur is rotated at high to increased primary mechanical stability, drilling other materials (Jackson, et al., 1989). speed in a reversed, non-cutting direction increased bone to implant contact (BIC), which For more than a decade, clinicians have been with steady external irrigation (Densifying then enhances implant secondary stability, and asking for improvement in bone drilling and Mode), a dense compacted layer of bone accelerates healing (Seeman, et al., 2008, preparation (Natali, et al., 1996). tissue is formed along the walls and base of Todisco, et al., 2005, Trisi, et al., 2009). Standard drill designs used in dental the osteotomy (Meyer, Huwais, et al., 2014). implantology are made to excavate bone to The goal in implant placement is to Case report create room for implant placement. They cut achieve primary implant stability. It is well Osseodensification facilitates mandib- away bone effectively but typically do not established that implant stability is critical for ular ridge expansion and placement of two produce a precise circumferential osteotomy. osseointegration (Albrektsson, et al., 1986, implants. Osteotomies may become elongated and Meredith, et al., 1998). This is more important The patient is a 62-year-old male elliptical due to the chatter of the drills. In in recent days due to popular immediate/ presented with missing teeth Nos. 19, 20, these circumstances, the implant insertion early loading protocols being implemented and 21. Clinical and radiographic exami- torque is reduced leading to poor primary into treatment by many clinicians. Removing nation revealed a significant alveolar ridge stability and potential lack of integration. bone bulk is contrary to achieving the primary resorption, which resulted in a Seibert Class Furthermore, osteotomies drilled into narrow stability desired. I, ridge deficiency (Figure 1). The patient’s bone locations may produce dehiscence, Implant primary mechanical stability is medical history was noncontributory. buccally or lingually, which also reduces primary stability and will require an additional bone grafting procedure adding cost and healing time to treatment. When standard drills extract enough bone to let strains in the remaining bone to reach or exceed the bone micro-damage (MDX) threshold, the bone-remodeling unit (BMU) needs more than 3 months to repair the damaged area, so maintaining bone bulk will enhance healing and shorten the healing period (Frost, et al., 1998). Unlike traditional bone drilling technologies, osseodensification does not excavate bone tissue. Rather, it preserves bone bulk, so bone tissue is simultaneously compacted

Salah Huwais, DDS, maintains a private practice focusing on periodontics and surgical implantology in Jackson, Michigan. Dr. Huwais completed his periodontics and implantology surgical training at the University of Illinois at Chicago in 1997. He serves as an Adjunct Clinical Assistant Professor at the University of Minnesota, Dental Implant Program. Dr. Huwais has published in the Journal of Periodontology and lectures nationally and internationally on periodontal and surgical implantology procedures. He is a Diplomate of the American Board of Periodontology and the American Board of Oral Implantology. Dr. Huwais is the founder of Osseodensiﬁcation and the inventor of the Densah™ Bur technology. Figure 1: Occlusal view of lower left edentulous area of missing teeth Nos. 19, 20, and 21

14 Implant practice Volume 8 Number 1 STOP Drilling Away Healthy Bone

Presenting Densah™ Bur Technology*: The Innovation That Makes Osseodensification Possible

*Patent Introducing Densah Bur Technology for implant osteotomy preparation from Versah™ LLC. Pending Densah Burs have a non-excavating proprietary flute design that, when rotating at 800 – 1500 rpm in reverse, densifies bone. This technique, known as Osseodensification, autografts bone along the entire length of the osteotomy through a hydrodynamic process with the use of irrigation. When rotating clockwise, Densah Burs also precisely cut bone. The result is a consistently cylindrical and densified osteotomy. Consistent osteotomies and densification are important to implant primary stability and to early loading.

Rotating Counter Clockwise The Flute Back Rake Angle Creates Osseodensification

Rotating Clockwise The Flute Edges Precisely Cut Bone Osteotomy created Osteotomy created Osteotomy created with standard drills with Densah Bur with Densah Bur Cutting Mode Densifying Mode

To order the newest innovation in implant dentistry, contact a Versah Customer Service Professional at 844-711-5585 or visit www.versah.com

The Tip Design With The Flutes Facilitates Compaction Autografting

2500 West Argyle Street I Suite 300 I Jackson, MI 49202 I P: 517-796-3932 I Toll Free: 844-711-5585 I Fax: 844-571-4870 www.versah.com Meet Us at the AO Meeting in San Francisco, March 12-14, 2015 - Booth #427

Treatment options with their potential risks The lower left area was anesthetized using osteotomy was created with a pilot drill and benefits were presented to the patient. infiltration method with 1.8 ml 4% Septocaine® rotated at 1200 RPM in a clockwise rotation A final treatment plan was finalized to utilize (Septodont) with 1:100,000 epinephrine. (CW) to a depth of 13 mm utilizing a high- placement of two implants to receive two Once anesthetized, a crestal incision was speed surgical handpiece and a surgical abutments for a fixed prosthesis to restore done, and a full thickness flap was reflected motor (W&H) (Figure 3). Using paralleling pins, teeth Nos. 19, 20, and 21. Consent was to reveal 2.5 mm-3.0 mm crestal alveolar an X-ray was taken to confirm the angulation given by the patient to utilize osseoden- ridge width, which was confirmed by direct between the adjacent teeth and the implants. sification site preparation for ridge expan- measurement (Figure 2). Once implant positions were confirmed, a sion with immediate implant placement and The site preparation for two implants horizontal ridge split to a 10-mm depth was possible additional buccal bone grafting if in the areas of Nos. 19 and 21 began with created using Piezosurgery® (Piezosurgery needed. site marking. Then, a 1.5-mm initial pilot Incorporated) to allow further buccal plate flexibility. Osseodensification with ridge expansion started with Densah™ Bur VT1525 (Versah™, LLC) rotating in a non-cutting counterclock- wise (CCW) direction at 1200 RPM (Densifying Mode) to expand the osteotomy to 2.5 mm, utilizing a high-speed surgical handpiece and a surgical motor (W&H) (Figure 4). Then Densah™ Bur VT2535 (Versah, LLC) running in a non-cutting counterclock- wise (CCW) direction at 1200 RPM (Densi- fying Mode), utilizing a high-speed surgical handpiece and a surgical motor (W&H), was used to expand osteotomies in the area of implant Nos. 19 and 21 (Figure 5). Mandib- ular osteotomies were expanded to 3.5 mm without any bone dehiscence, which then allowed for total implant length placement in autogenous bone without any thread Figure 2: Full thickness flap reflected to reveal a significant alveolar ridge resorption exposure (Figure 6).

Figure 3: 1.5 mm/13 mm osteotomy was created utilizing 1.5-mm standard pilot drill Figure 4: Osteotomy expansion to 2.5 mm was created utilizing Densah™ Bur VT1525 after horizontal relief split was created

Figure 5: Densah™ Bur VT2535 was used in Densifying Mode to expand and densify area Figure 6: Osseodensiﬁcation facilitated osteotomies expansion to 3.5 mm without any bone of No. 19 implant dehiscence or fenestrations

16 Implant practice Volume 8 Number 1 1 Patient Scan

2 Diagnosis

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5 CEREC® Integration CASE STUDY

Two 3.7/13 Tapered Screw-Vent implants recommended loading at ISQ 67-68. Buccal-lingual ISQ readings obtained at (Zimmer®) were placed with an insertion Due to an ISQ reading of 49 in the mesial week 10 were 76/72, 67 for implant Nos. torque of 40-50 Ncm. Both implants total implant No. 21 and less than 1.0 mm of 19 and 20, respectively. The implants’ high lengths were covered with autogenous bone. crestal-buccal bone thickness remaining insertion torque with maintained gain in ISQ Less than 1.0 mm crestal-buccal bone thick- after osseodensification, the decision was had allowed us to consider an early restor- ness in area of implant No. 21 was noted made to augment the buccal plate with a ative phase initiation. (Figure 7). Implant stability was measured bone graft (Figure 8). Thus, at 10 weeks, when the ISQ reading with an (Osstell®) ISQ implant stability meter, Healing cover screws were placed and reached ≥ 67, the patient was referred back to which uses resonance frequency analysis. In Puros Demineralized Bone Matrix (Zimmer®) his restorative dentist for the restorative phase. this particular case, buccal-lingual ISQ read- was used as allograft to augment the Fourteen weeks post implant surgery, a ings in the areas of Nos. 19 and 20 were 78 mandibular buccal bone plate post implant fixed prosthesis retained by implants Nos. and 49, respectively. Several studies have placement. Full flap closure with mattress 19 and 21 was delivered. been conducted on resonance frequency suture was achieved (Figures 9 and 10). analysis (RFA) measurements and the Eight weeks post placement, implants Supportive and follow-up care ISQ. They provided valid indication that were uncovered through shallow crestal The patient returned in 1 year for clinical accepted stability range is above ISQ 50 and incision. Healing abutments were placed. and radiographic follow-up. Examination

Figure 8: Allograft was used to augment buccal plate

Figures 7A-7C: Implants placed in area of Nos. 19 and 20 with insertion torque of 40-50 Ncm and ISQ Figure 9: Occlusal view — implants placed with cover screw and allograft reading of 49 and 78

Figure 10: Occlusal view — full ﬂap coverage Figure 11: 8 weeks radiograph

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Figure 12B: 14 weeks occlusal view, post healing pre-restoration delivery

Figure 12A: 10 weeks ISQ values Figure 13: 14 weeks post implant placement restoration

Figure 14: 14 weeks post implant placement radiograph Figure 15A: 1-year follow-up clinical presentation, 1.0 mm soft tissue recession was noticed in area of implant No. 21

Figure 15B: 1-year radiographic follow-up revealed maintained crestal bone level Figure 15C: 2-year radiographic follow-up revealed maintained crestal bone level

20 Implant practice Volume 8 Number 1 CASE STUDY

revealed healthy hard and soft tissue with either block grafting or guided bone REFERENCES no sign of inflammation or infection. Radio- regeneration 1. Jackson CJ, Ghosh SK. On the evolution of drill-bit shapes. Journal of Mechanical Working Technology. graphic examination revealed maintained 2. Implant placement and healing phase 1989;18(2):231-267. crestal bone level and bone density. Clinical (2-3 months) 2. Natali C, Ingle P, Dowell J. Orthopaedic bone drills-can they examination revealed slight soft tissue reces- be improved? Temperature changes near the drilling face. 3. Restorative phase J Bone Joint Surg Br. 1996;78(3):357-362. sion in the area of implant No. 21. This soft The question remains, why do we build 3. Frost HM. A brief review for orthopedic surgeons: fatigue tissue height reduction is common post GBR bone bulk to then extract it later and wait damage (microdamage) in bone (its determinants and clinical implications). J Orthop Sci, 1998;3(5):272-281. or ridge augmentation procedures. Four months for implants to heal? It is time to think months’ interval supportive periodontal treat- 4. EG, Huwais S. Osseodensification Is A Novel Implant about bone preservation to enhance its ability Preparation Technique That Increases Implant Primary ment was initiated with yearly radiographic to heal faster, regardless of implant macro- or Stability By Compaction and Auto-Grafting Bone. American examination for implant Nos. 19 and 21. Academy of Periodontology. [abstract]. San Francisco, micro-geometry. CA. 2014. In this case, osseodensification utilizing 5. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The the Densah™ Bur technology had facilitated Conclusion long-term efficacy of currently used dental implants: A ridge expansion with maintained alveolar review and proposed criteria of success. Int J Oral Maxil- Osseodensification is a novel, bio- lofac Implants. 1986;1(1):11-25. ridge integrity, allowing for total implant mechanical, non-excavation osteotomy 6. Meredith N. Assessment of implant stability as a prognostic length placement in autogenous bone with determinant. Int J Prosthodont. 1998;11(5):491-501. preparation method. Unlike traditional adequate primary stability. Despite compro- 7. Todisco, M, Trisi P. Bone mineral density and bone histo- drilling, osseodensification utilizes proprie- morphometry are statistically related. Int J Oral Maxillofac mised bone anatomy, osseodensification Implants. 2005. 20(6):898-904. tary high-speed densifying burs to compact preserved bone bulk and promoted a shorter 8. Seeman E. Bone quality: the material and structural basis waiting period to the restoration. and autograft bone in its plastic deforma- of bone strength. J Bone Miner Metab. 2008;26(1):1-8. Ordinarilly, a case similar to this patient tion phase. The result is an expanded oste- 9. Trisi P, Perfetti G, Baldoni E, Berardi D, Colagiovanni M, otomy with preserved and condensed bone Scogna G. Implant micromotion is related to peak inser- would progress through three phases of tion torque and bone density. Clin Oral Implants Res. treatment over 30-50 weeks: tissue that maintains alveolar ridge integ- 2009;20(5):467-471. 1. Ridge augmentation phase (6-9 rity and allows for implant placement with months) to increase ridge width with enhanced stability. IP

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Volume 8 Number 1 Implant practice 21 IMPLANT INSIGHTS

Options for patients with low bone volume

Dr. Franck Renouard shares key insights from a presentation he gave at the Academy of Osseointegration (AO) 2014 Annual Meeting in a session called “Problem Solvers & Innovators”

hen reading this article, it’s important Wto remember that the scenario we are putting forward involves patients with low Our profession’s goal is to offer reliable, simple treatments bone volume (vertical and/or horizontal) and that we are faced with choosing between to the widest possible range of people. two options: either to carry out a bone graft in order to place long- and/or wide-diameter Professor Per-Ingvar Brånemark once said that a good implants or to place short/narrow implants without having to carry out a bone graft. treatment had to be “Simple, available, affordable.”

What is the difference between That says it all, really. short/narrow implants and longer/ wider ones with regards to competence and performance? To reply to this question, we have to up to his/her usual standard, this will have implants). Narrow implants generally require define the difference between competence less of an impact on short/narrow implants at least 4 mm to 5 mm of alveolar ridge width. and performance. Competence is the sum than on longer or wider implants placed with Another limitation for narrow implants is of knowledge and experience that a prac- the help of bone augmentation procedures. biomechanical in nature. Although all relevant titioner has acquired during the course of To sum up, error, which is an integral part of literature is very encouraging with regard to his/her career to date. Performance is the all human endeavor, will have less significant this approach, given the extent of our knowl- people’s capacity to use their competence consequences if short/narrow implants are edge about it at this moment in time, it is not in a given situation. For example, very involved. a good idea to use this type of implant to competent surgeons’ performance will be replace single molars or canines in patients negatively affected if they are stressed, tired, What are the advantages of short/ exhibiting canine-protected occlusion. or are battling with personal issues that are narrow implants? Perhaps we should also be wary of adopting dominating their thoughts. The more compli- Their main advantage is that they enable this approach when faced with patients who cated or complex the surgical procedure, the more practitioners to successfully take on grind their teeth. bigger the impact reduced performance will cases they would previously not have had There are also esthetic considerations. have upon the end result. To come back to the skills to deal with. When there’s 7 mm When bone resorption starts having an our short/narrow implants, we can say that in of bone underneath a sinus, using short esthetic impact, a bone graft is needed. In order to place these implants, the practitioner implants is an excellent alternative to the this scenario, it would be better to use stan- must be competent, because these implants bone graft that would be required in order dard length implants. are often rather awkward to place due to low to place long implants. It’s the same with bone volumes. Still, for many practitioners, narrow implants and narrow alveolar ridges. What is the rationale behind the use of these implants is a viable option. Using these implants allows practitioners the use of short/narrow versus However, we have to say that bone grafting who have only limited surgical experience to longer implants? What are the key requires a greater degree of training and work successfully with patients with narrow considerations guiding any such more extensive surgical experience. Like- jawbones. An additional bonus with using decision? wise, if a practitioner’s performance is not narrow implants is that they make it easier to Once again, when we talk about the use have adequate space between implants even of long-/wide-diameter implants, this means when mesiodistal space is restricted. I often having to carry out a bone graft before or Dr. Franck Renouard graduated from the Dental place two narrow implants when replacing during the placing of implants. Choosing University of Paris V in 1982. He has published several national and international articles and is premolars. from these two options involves taking three the co-author of two textbooks — Risk Factors in criteria into account: Implant Dentistry: Simplified Clinical Analysis for Are there limitations to the use of 1. To what extent is the outcome of the Predictable Treatment and his new book on the Human Factors Concept, titled The Search of the short/narrow implants? treatment predictable? Weakest Link. He is past president of the European Association The first limitation is obviously bone 2. What is the incidence of complica- for Osseointegration (EAO), is currently the visiting professor at volume. I think that you need at least 6 mm tions and adverse events of the treat- the Liége Medicine Faculty in Belgium, and is in private practice in Paris limited to Oral and Implant Surgery. for the maxilla and 8 mm for the mandible ment? (What are the consequences (above the inferior dental nerve for short of the complications that I may

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encounter on implementing a given Table 1 procedure?) 3. How feasible is the procedure? (Am Short/narrow implants Bone graft + long/wide-diameter implants I capable of carrying out this procedure and managing any complica- Predictability Good Good tions that may arise from it?) We can summarize these three criteria Incidence of complications/ Low Signiﬁcant in Table 1. adverse events

What human factors interfere with Feasibility Good Poor* this decision-making process? Often practitioners are influenced by * Poor feasibility means that a practitioner needs extensive experience in order to regularly carry out successful bone grafts and to be able to deal effectively with complications arising from these grafts analytical biases and biases affecting how they make decisions. It is quite remarkable that in 2014, dentists persist in thinking that our way of thinking and we reject informa- situation, we can say that placing short and/or the longer the implant, the better its chances tion that challenges it, even when this data is narrow implants represents less of a risk than of long-term success, despite the wide- substantial and reliable. This is a very human carrying out a bone graft and placing long spread availability of scientific data to the reaction, but it prevents us from making and/or wide-diameter implants. Assessing contrary. This is known as confirmation bias. progress. the differences between the two approaches Once we have made our minds up about requires more than simply an examination something, we find it very difficult to change Is the risk of complications higher of their respective success rates. It is also them. We exhibit the same tendency when with short/narrow implants? important to consider the consequences of we only consider information that confirms If we take a broad perspective on the failure, which are often more serious when bone grafts are involved. This relates to the incidence of complications and adverse events. This criterion was mentioned earlier. “Science, Collaboration and Clinical Excellence for 30 Years,” The major risk we run when using narrow is the theme of the 30th Annual Meeting of the Academy of implants is implant fracture, but seemingly Osseointegration this is a very rare occurrence.

The 30th Annual Meeting of the Academy of Osseointegration (AO), will What do you think the future holds be held March 12-14, 2015, at the Moscone West Convention Center in San for short/narrow implants? Francisco. The intense, 3-day learning session for dental professionals will offer I am convinced that more and more cutting-edge insights and continuing education from the field’s most noted practitioners will start regularly using short researchers and clinicians. or narrow implants. This is part and parcel Among this year’s top new features are “Morning with the Masters,” a of a wider movement toward simpler daybreak education session, a symposium presented in English by seven protocols. Our profession’s goal is to offer prominent speakers from South Korea, and a record number of electronic reliable, simple treatments to the widest posters where, for the first time, AO-member research will be presented on possible range of people. Professor Per- large flat-screen TV monitors instead of cardboard and paper. Ingvar Brånemark once said that a good “We continue to explore and add innovative features to ensure this event is treatment had to be “Simple, available, fresh, engaging, and educational,” said Joseph Gian-Grasso, DMD, president affordable.” That says it all, really. of the Academy of Osseointegration. “We’re confident that all of our attendees — no matter where they are in their career — will enjoy a truly memorable What type of patients are these experience and take home knowledge that they can begin applying at their implants particularly helpful for? practices Monday morning.” These implants are particularly helpful for The event’s keynote speaker will be notable facial plastic surgeon, Daniel patients exhibiting low levels of bone volume Alam, MD, who was a member of the multidisciplinary team of doctors and who are not suitable candidates for a bone surgeons at the Cleveland Clinic that performed the first near-total face trans- graft, either for medical reasons, for financial plant in the United States. His address will focus on the power of the team in reasons, or because they are afraid of what rebuilding health and well-being, and will highlight the critical importance of they see as major surgery. IP different disciplines collaborating to support a patient’s medical, surgical, and emotional needs to make them whole again. That message will be supported throughout the meeting. There will also be numerous opportunities to network and socialize, including REFERENCES 1. Nisand D, Renouard F. Short implant in limited bone volume. at the President’s Reception, which will be held at The Exploratorium. To view the Periodontol 2000. 2014; 66(1):72-96. meeting schedule and register, visit http://www.osseo.org/futureMeetings.html. 2. Renouard F, Charrier JG. Ewenn éd. The search for the weakest link. An introduction to the Human Factors. 2011. 3. Sohrabi K, Mushantat A, Esfandiari S, Feine J. How successful are small-diameter implants? A literature review. Clin Oral Implants Res. 2012;23(5):515-525.

24 Implant practice Volume 8 Number 1 More than an implant. A sense of trust.

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Anterior implant esthetics

Dr. Bernard Touati offers his insights into effective techniques and procedures for soft tissue management in the anterior region

n the following article, I will do my best And not just in two dimensions! Table 1: Major factors affecting to explain the main factors influencing I We also have to remember that our work hard and soft tissue remodeling hard and soft tissue remodeling around will not be evaluated by the two-dimensional implants and make suggestions on how to photographic images we use to document around implants achieve optimal integration in the esthetic the treatment, but in the homes, on the Anatomically related zone. Among other aspects of treatment, streets, and at the workplaces where our • Tissue biotype I will cover diagnostics, treatment planning patients go about their day-to-day lives. • Thickness of bone plates and risk assessment, ideal 3D bone-level Thus, we need to achieve three-dimensional • Thickness of soft tissue implant placement, the relevance of good integration. We need to have the scalloping, • Lack of attached gingiva hard tissue volume and architecture, as well the volume, the papillae, the texture, the as the importance of thick and stable soft color, and the absence of scars that are Surgically related • Implant 3D position tissue in the transmucosal zone. characteristic of healthy, natural teeth. • Flap elevation or flapless surgery When we deal with dental implants in Five major factors • Soft tissue augmentation the anterior region, we are looking for more • Bone desiccation The main factors that influence tissue than osseointegration. We — dentists and • Countersinking remodeling around implants can be orga- patients alike — are looking for optimal soft • Bone compression nized into five categories: anatomical, • Extraction technique tissue integration. We are looking for the surgical, implant, patient, and prosthetic perfect pink score. (see Table 1). In the anterior region, esthetic perfection Implant-related Among the anatomical considerations • Design (macro, micro) is not a choice, but an obligation. Patients are the tissue biotype, the thickness of the • Surface properties want their peri-implant soft tissues to mimic bone plates, the thickness of the soft tissue, • Type of connection the soft tissue around natural teeth. There and the lack of attached gingiva. I can testify • Built-in platform shifting or equivalent are, of course, many differences between from experience that the tissue biotype and teeth and implants. When we produce resto- the thickness of the tissue are critical to Patient-related rations based on natural teeth, the gingiva optimal outcomes. • Hygiene is only dealing with the margin of the crown. Surgical factors include the three-dimen- • Maintenance We locate our margin at the gingival or intra- sional positioning of the implant, the choice • Tobacco • Healing sulcular level, but not transmucosally. between a flap or flapless approach, and the When we deal with implants, on the other kind of soft tissue augmentation that has hand, we need to take into consideration the been carried out. Other factors include bone Prosthetics-related • Final abutment design desiccation, countersinking, bone compres- mucosal barrier, and the mucosal barrier is • Type of abutment connections quite different on implants than on teeth for sion, and (last but not least), the extraction • Provisional abutment: biomaterial, design a variety of reasons. technique used. • Immediate provisionalization The problem is that when we want to do Implant design is also important, of • Submergence profile something transmucosally — for the abut- course. The design of the neck, the surface • Emergence profile • Restoration anatomy ment or at the neck of the implant — we properties of the implant, and the type of connection can all be decisive. Questions • Possible excess cement and retention need the soft tissue to adhere to the pros- • Occlusion, excessive load that become interesting in this context thetic surface of the implant. This is different include “Do we have platform shifting avail- than working with natural teeth because it able?” Or, “Can the implant be maneuvered which they are made, the abutment’s surface involves many biological factors. To achieve during insertion, when necessary, in order to properties, connection, and fit are all impor- harmonious soft tissue integration, we obvi- ensure optimal placement?” tant factors that contribute to success. ously have to take into account all the biolog- We also need to remember that every Abutment connections — and discon- ical, functional, and esthetic factors. patient has a specific set of characteristics nections — need to be taken into consid- that influences remodeling. Do they smoke? eration as well as choices concerning Do they have good healing potential? immediate provisionalization and the Dr. Bernard Touati is past president of the European Academy of Esthetic Dentistry, and Immune factors need to be considered, as submergence profile, emergence profile, a member of the American Academies of well as the patient’s willingness and ability to and the restoration anatomy. We need to Restorative Dentistry and Esthetic Dentistry. He maintain good oral hygiene. be careful about deleterious excess cement practices in Paris, France, and lectures around (if we have not chosen screw retention, of the world on practical and innovative dental There are also a great number of pros- procedures. thetic factors that impact remodeling. The course) and must take into account good final abutment design, the biomaterial from occlusion to prevent excessive load.

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Given all these factors — and I have only Ensuring hard tissue volume and osteogenic “jumping distance,” which is listed the main ones in the table — I have architecture the gap between the implant body and the constructed a roadmap for optimal integra- At this point, we are dealing with where alveolar wall). In cases with a large defect, tion in the esthetic zone. the bone is, and how to make the most of guided bone regeneration can be carried it. Again, we really do need to keep in mind out. Adding connective tissue on top of this Diagnose, plan, and assess how thin the buccal plate ordinarily is. Natural brings greater thickness to the tissue, which To plan for a successful anterior solu- teeth have Sharpey’s fibers, a blood supply provides greater mechanical resistance and tion, we need to assess risk factors via three- to the periodontium, stimulation, and even leads to increased blood supply. dimensional visual inspection, probing, and though there may not be much (if any) cortical In cases where there is no buccal bone employing radiographs. Visually, we can see bone on the buccal, the soft tissue still stays post-extraction, a complete socket must first deformities such as concavities. Probing, we in place. With an implant, on the other hand, be re-created, which provides a favorable can see where the bone is, and we can also we run the risk of fenestration through this situation for the insertion of an implant and probe at the level of the adjacent teeth to thin bone if we position implants with the is well within widely-practiced, well-accepted assess the periodontium. same orientation as natural incisor roots. reconstructive protocols. Cone beam computed tomography The buccal socket wall is predominantly (CBCT) is an invaluable three-dimen- composed of bundle bone (while the lingual Establishing thick and stable soft sional tool. When connected to software one has more lamellar bone). The lack of tissue like NobelClinician® (Nobel Biocare®), it stimulation and function in the absence of All of this brings us to the soft tissue. It provides us with an enormous amount of Sharpey’s fibers may explain the remodeling needs to be thick and stable, especially in information that is useful in the decision- of this buccal wall. the transmucosal zone; stability makes for making process. It shows us, for example, The buccal plate often quickly collapses good esthetics. whether we have a thin buccal plate or a when we extract a tooth — partly because Post-extraction remodeling is inevitable. thick one. And this makes a very big differ- it is thin, and partly because it is mostly Today, there is no magical way to totally ence. The volume and architecture of the composed of bundle bone. Because an counteract the post-extraction remodeling site also become clear when using this sort implant does not have a periodontium and — it’s biological — but it can be compen- of software. therefore lacks vascularization, we have a sated for. One way to compensate for it is to The thickness of the soft tissue can also ready explanation as to why we have more thicken the soft tissue and also to regenerate be assessed via CBCT. When the patient remodeling on the buccal side as opposed the bone, when necessary. wears radiographically transparent lip retrac- to the lingual side. A connective tissue pouch can be used, tors during the imaging process, the resulting In 60% of anterior cases, buccal bone both horizontally and vertically. Mucosal CBCT image renders the soft tissue in light plates are less than 0.5 mm thick (and we enhancement can be realized through gray. Should we then want to harvest some really need 2 mm to get the job done). If we connective tissue graft(s). soft tissue from the palate, for example, this remember these values, we will understand the Not least of all, we can manipulate the technique allows us to objectively measure entire strategy of slightly angulating the implant soft tissue via subtle changes in the design the tissue available. in the anterior aspect. When building a multiple of the prosthetics. It also lets us assess whether the unit anterior restoration on natural teeth, we First, we want to see some concavity patient has a thick or thin biotype. A deli- still have soft tissue, and the soft tissue is quite transmucosally at the abutment level and/ cate biotype will ordinarily require connective stable. But once anterior teeth are extracted, or platform switching in order to thicken the tissue grafting, but a thick one generally indi- we will almost certainly have to reorient “the mucosa, creating a virtual “o-ring” of soft cates stable tissue that is forgiving of minor root,” inserting the implant palatally. tissue. On the other hand, proximally, the mistakes. When facing thin and moderate soft The good news is that with CBCT — prosthetic restorations need to display some tissue situations, we need to be more invasive especially when used in conjunction with convexity in order to gently push the tissue and start considering soft tissue enhance- planning software — the right position can and to keep the interdental papillae. ment, grafting procedures, and so on. be objectively assessed first, making sure The vertical position of the implant in that a gap exists between the implant and relation to the mucosa is very important. Ideal implant placement the buccal plate. This way we can take steps This makes it possible for us to play with The first thing to consider is where the to thicken the buccal bone plate zone and, the emergence profile and then shape the implant is going to be placed. Positioning thus, provide a safe situation for the future. marginal mucosa with the emergence bulk. is critical because even a little deviation The key factors for good esthetic results at Adding composite material incrementally, can impact the esthetic outcome. The real anterior extraction sites are the integrity of we can guide the marginal mucosa very problem is the transversal plane. We want to the buccal plate and the thickness of the successfully. insert our implant more toward the palatal, soft tissue. This careful step-by-step process takes a because if we leave too much inclination, If those two parameters are promising, substantial amount of time, but gives beau- we run the risk of reducing the thickness of implant treatment is more likely to succeed. tiful results. IP the buccal plate, which in almost all cases Of course, in terms of the three-dimensional is already very thin. architecture of the soft tissue and recapturing This article is a condensed version of a lecture The more an implant allows you to play interdental papillae, the health of the peri- given by Dr. Touati at the Nobel Biocare Global with its position — in order to put it in solid odontium of the adjoining teeth is important, Symposium in New York City last June. It originally bone — the better suited it is to situations like and probing gives us solid information. appeared in Nobel Biocare News (Vol. 16, No. 1, these. With a little extra room between the 2014) and appears with permission. Dr. Touati’s full buccal plate and the implant, you will have Bone grafting lecture can be found by visiting the website www. space to fill in later with bone augmentation We can use bone augmentation for.org/video-insights and searching for “Bernard material. materials in the “jumping gap” (i.e., the Touati.”

28 Implant practice Volume 8 Number 1

CONTINUING EDUCATION

Single implant-borne reconstruction in the esthetic area

Dr. Daniel S. Thoma outlines the treatment undertaken for a patient with fractured central incisors using ridge preservation

52-year woman presented with pain in Aher two central incisors. The patient had Educational aims and objectives fractured both central incisors in her youth. This article aims to demonstrate the benefits that using ridge preservation techniques can They were subsequently restored with two bring to challenging cases in the esthetic zone. porcelain-fused-to-metal crowns (Figure 1). At the day of the first examination, CBCT Expected outcomes Implant Practice US subscribers can answer the CE questions on page 34 to analysis and clinical inspection revealed that earn 2 hours of CE from reading this article. Correctly answering the questions will tooth UR1 was endodontically treated and demonstrate the reader can: had increased periodontal pocket depths • See where regeneration techniques can be applied. with bleeding on probing. • Understand how these techniques can impact treatment time. • Learn when to apply these techniques in practice. Several treatment options were discussed following the tooth’s extraction: 1. Crown UL1 with a cantilevered UR1 2. Fixed dental prostheses UR2 to UL1 According to Jung and colleagues The treatment (Figure 2) consisted of 3. Implant placement at UR1 and new (2013), a ridge preservation procedure allows placement of a collagen sponge consisting crown UL1 bone volume to be maintained by 80% over 6 of 10% collagen and deproteinized bovine A decision was taken to opt for the months. For that reason, a ridge preservation bone mineral (DBBM) granules, and a soft third treatment modality, which included procedure was defined as being appropriate tissue punch. The bone substitute material the replacement of tooth UR1 with a dental for optimizing the clinical situation, including was placed within the extraction socket flush implant. the hard and soft tissue aspects. with the bone crest on the buccal side, and

Pre-surgical phase A full wax-up for teeth UR1 and UL1 was performed on casts by the dental technician to optimize the esthetic outcome prior to implant therapy. This wax-up was transferred to a mock-up that was tried-in intraorally.

Surgical phase Two weeks later, tooth UR1 was carefully extracted without damaging the surrounding Figures 1A-1B: Patient at presentation tissues and leaving the papillae intact. The epithelium at the extraction socket was removed using a diamond bur. Subsequently, the height of the buccal and palatal bone plate was measured with a periodontal probe. This revealed that, while on the buccal side the bone plate was almost fully present, the palatal height was reduced by 40%.

Daniel S. Thoma, PD Dr Med Dent, is an associate professor at the Clinic for Fixed and Removable Prosthodontics and Dental Material Science, Center for Dental and Oral Medicine and Cranio- Maxillofacial Surgery in the University of Zurich. He is a specialist in reconstructive dentistry and received the Hans-R Mühlemann Research Prize from the Swiss Society of Periodontology (SSP) in Switzerland. Pascal Müller was the dental technician in this case. Figures 2A-2C: Extraction site

30 Implant practice Volume 8 Number 1 CONTINUING EDUCATION

exceeding the palatal bone plate by roughly 4 Due to the fact that guided bone regenera- digital scan of the initial clinical situation was mm and to a level of 3 mm below the mucosal tion (GBR) on the palatal side cannot be matched and superimposed with the CBCT margin. Subsequently, a free gingival graft performed predictably, a longer healing time data in the planning software. At this point, (FGG) with a thickness of 3 mm and a diam- was discussed with the patient. the height of the palatal and buccal bone eter of 8 mm was harvested at the palate. Four months later, a second CBCT was plates returned to a regular height. Bone This FGG was sutured on top of the taken (Figure 6), and again, the implant posi- regeneration had taken place, and the former extraction socket using non-resorbable tion was deﬁned using digital planning soft- extraction socket was completely ﬁlled with sutures (Figure 3) in keeping with the method ware (SMOP Swissmeda AG, Switzerland). A bone substitute material and newly formed described by Jung, Siegenthaler, and Hämmerle (2004). The crown on tooth UL1 was removed and replaced with a provisional restoration including a cantilever to replace tooth UR1 (Figure 4). Six weeks later, the clinical situation was healthy, and the former extraction socket was completely closed. A CBCT was taken to assess the bone dimension and to decide whether or not implant placement could be performed. The CBCT revealed that, with an ideal implant position, a dehiscence defect at the palatal aspect would be present. Figures 2D-2E: Ridge preservation carried out at extraction site

Figure 3A-3D: Gingival graft taken from the palate and sutured over the extraction socket

Figures 4A-4B: Provisional restorations placed

Figure 5: CBCT at 6 weeks showing a dehiscence or at least immature bone substitute material at the palatal aspect with an ideal position

Volume 8 Number 1 Implant practice 31 CONTINUING EDUCATION

Figures 6A-6D: Second CBCT taken at 6 months

bone. This allowed implant surgery planning and the production of a surgical stent for guided surgery. On the day of implant placement, a full thickness flap was elevated, and a dental implant (Bone Level, Straumann®) was placed using guided surgery, and a surgical guide printed using a three-dimensional printer. The implant was placed in an ideal position, vertically and horizontally (Figure 7). In order to compensate for an expected loss of volume on the buccal side, GBR with DBBM and a resorbable collagen membrane was performed to optimize the contour (Figure 8). Primary wound closure was obtained. Three months later, the clinical situation revealed a slight loss of the buccal contour. According to a recent clinical study on 16 patients, GBR may contribute for up to 57% of the volume, whereas soft tissue augmentation compensates the remaining 43% of the Figures 7A-7D: Implant placed using guided surgery volume deficiency (Schneider, et al., 2011). Soft tissue volume augmentation surgery was performed using a classic approach (Figure 9). The patient agreed to be part of an ongoing clinical study comparing autogenous soft tissue grafts to a prototype three-dimensional collagen matrix. For that purpose, a split thickness flap was elevated, a pouch on the buccal aspect of the implant site prepared, and a three-dimensional collagen matrix inserted and sutured in place. Figures 8A-8B: Guided bone regeneration was carried out to compensate for an expected loss in volume

Figures 9A-9D: Soft tissue augmentation carried out to address slight loss of buccal contour

32 Implant practice Volume 8 Number 1 CONTINUING EDUCATION

Again, primary wound closure was obtained. Three months later, abutment connection was performed using a U-shaped incision, and the preparation of a small ﬂap was placed underneath the buccal ﬂap. Following an impression with a standardized impression post, a healing abutment was inserted.

Prosthetic phase After 1 week, a provisional implant- borne reconstruction with a full contour Figures 10A-10B: Healing abutments removed and provisional placed on the buccal side and a concave contour within the soft tissues was inserted (Figure 10). Within two to three appointments, flowable composite was added to the transmucosal part of the provisional restoration (at the implant site) to aim for a more convex contour and to create the emergence profile, mimicking one of the neighboring contralateral teeth UL1. After a healing period of 3 months, an individual impression post was prepared, and an impression was taken for implant UR1 and tooth UL1. The dental technician fabricated a try-in wax-up, which was inserted during the following appointment. Subsequently, an all-ceramic reconstruction based on a zirconia abutment (Cares®, Straumann) for implant UR1 and an all-ceramic single crown for tooth UL1 were prepared by the dental technician (Figure 11). The implant-borne reconstruction was screw-retained and Figures 11A-11D: Final restoration wax-up and framework inserted with an insertion torque of 35Ncm. The access hole was closed with composite. The all-ceramic crown on tooth UL1 was cemented with a resin cement. One week later, the patient was recalled for the follow-up examination. The clinical situation was healthy; no bleeding on probing was observed. The final outcome was judged as being esthetically pleasing, and the patient scheduled for a regular maintenance program.

Final outcome The ﬁnal outcome of the case (Figure 12) was considered to be excellent from an esthetic and functional point of view, and the patient was satisﬁed with the results. The ridge preservation procedure performed at Figure 12: Final restoration the day of tooth extraction allowed for further optimal implant position and enhanced the clinical situation on the hard and soft tissue level, but prolonged the overall treatment time. GBR and soft tissue volume augmentation contributed almost equally to the volume REFERENCES obtained at the end of the treatment. 1. Jung RE, Philipp A, Annen BM, Signorelli L, Thoma DS, Hämmerle CH, Attin T, Schmidlin P. Radiographic evaluation of different techniques for ridge preservation after tooth extraction: a randomized controlled clinical trial. J Clin Periodontol. 2013;40(1):90-98. The reconstructions manufactured by a 2. Jung RE, Siegenthaler DW, Hämmerle CH. Postextraction tissue management: a soft tissue punch technique. Int J skilled dental technician were based on all- Periodontics Restorative Dent. 2004;24(6): 545-553. ceramic materials, which, in this clinical situ- 3. Schneider, D, Grunder U, Ender A, Hämmerle CH, Jung RE. Volume gain and stability of peri-implant tissue following bone and soft tissue augmentation: 1-year results from a prospective cohort study. Clin Oral Implants Res. 2011;22(1):28-37. ation, demonstrated high long-term survival 4. Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part I. Technique and success rates. IP and wound healing. Compend Contin Educ Dent. 1983;4(5):437-453.

Volume 8 Number 1 Implant practice 33 CE CREDITS IMPLANT PRACTICE CE

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Single implant-borne reconstruction in the esthetic area Challenging aspects of implant restoration THOMA BAKER/REANEY

1. According to Jung and colleagues (2013), a d. all of the above 1. The contact forces, including the preload, 6. The design of the screw head has an impact ridge preservation procedure allows bone ______to the torque experienced by the on the ability to apply the preload. ______volume to be maintained by ______over 6 6. Three months later, abutment connection was implant complex. do not allow enough preload to be applied. months. performed using a ______, and the prepara- a. are the first response a. Slotted screws a. 25% tion of a small flap was placed underneath the b. are the last response b. Square screws b. 30% buccal flap. c. is not a necessary response c. Hexagonal screws c. 55% a. U-shaped incision d. may be detrimental d. Triangular screws d. 80% b. Book incision c. Y-shaped incision 2. The insertion torque should not exceed 30Ncm, 7. There is always a _____ between the top of the 2. The CBCT revealed that, with an ideal implant d. none of the above especially for immediate load implants, as implant and the undersurface of the abutment position, a ______at the palatal aspect would higher insertion torques above 50Ncm can due to the tolerance during manufacturing. be present. 7. After ______, a provisional implant-borne generate high compressive stresses to the a. perfect fit a. dehiscence defect reconstruction with a full contour on the buccal peri-implant tissues, causing ______. b. small mismatch in fit b. mucosal margin side and a concave contour within the soft a. blood supply deficiency c. very tight fit c. proteinized bone placement tissues was inserted. b. bone necrosis during the osseointegration d. clamping torque d. contour a. 1 week phase b. 2 weeks c. early implant failure (usually within the first 8. (In screw fracture) The worst case scenario 3. Due to the fact that guided bone regenera- c. 3 weeks month after placement) is that ______once osseointegration has tion (GBR) on the palatal side cannot be d. 4 weeks d. all of the above occurred. performed predictably, ______was discussed a. the implant would have to be removed 8. Within two to three appointments, flowable with the patient. 3. A(n) ____ insertion torque may occur during surgically composite was added to the transmucosal a. an additional surgery implant placement in high-density bone tissue. b. the site would be allowed to heal part of the provisional restoration (at the implant b. a longer healing time a. low c. a new implant would be placed and site) ______, mimicking one of the neighboring c. another type of implant b. high restored contralateral teeth UL1. d. the use of resorbable sutures c. unstable d. all of the above a. to prevent tooth migration d. transformative 4. According to a recent clinical study on 16 b. to aim for a more convex contour 9. Mucositis lesions can show apical progres- patients, ______may contribute for up c. to create the emergence profile 4. The material of the screw must be stretched sion after ______of plaque buildup around to 57% of the volume, whereas soft tissue d. both b and c to ______of its elastic limit, which means that implants. augmentation compensates the remaining the screw will return to its original length as the a. 1 month 43% of the volume deficiency. 9. After a healing period of _____, an individual torque is released and the two components are b. 2 months a. proteinized porcine bone mineral (PPBM) impression post was prepared, and an impres- clamped together. c. 3 months b. the gingival graft sion was taken for implant UR1 and tooth UL1. a. 25% d. 6 months c. guided bone regeneration (GBR) a. 2 weeks b. 40% d. a collagen implant b. 1 month c. 55% 10. Any movement (of the implant) would indicate c. 2 months d. 80% ______. 5. The patient agreed to be part of an ongoing d. 3 months a. possible lack of osseointegration of the clinical study comparing autogenous soft 5. If the screw _____, adequate preload will not be fixture tissue grafts to a prototype three-dimensional 10. The implant-borne reconstruction was screw- achieved, which means that the screw will not b. possible failure of the cement bond collagen matrix. For that purpose, _____. retained and inserted with an insertion torque be stretched to its full potential, and repeated between the superstructure and the a. a split thickness flap was elevated of ______. screw loosening will occur. retainer b. a pouch on the buccal aspect of the a. 15Ncm a. is tightened with a torque driver c. screw failure by fracture or loosening implant site was prepared b. 20Ncm b. is not slotted d. all of the above c. a three-dimensional collagen matrix was c. 35Ncm c. is tightened by hand inserted and sutured in place d. 60Ncm d. is cemented in

34 Implant practice Volume 8 Number 1 CONTINUING EDUCATION

Challenging aspects of implant restoration

Drs. Brenda Baker and David Reaney explain various methods to restore function and esthetics to patients in need of implant restoration

mplant dentistry has revolutionized the Iway we restore function and esthetics Educational aims and objectives to patients who, historically, would have This article aims to explain the various methods to restore function and esthetics to needed removable prosthetics or less patients in need of implant restoration. mechanically favorable fixed prosthetics. Expected outcomes However, it is not always smooth sailing, Implant Practice US subscribers can answer the CE questions on page 34 to and we need to be aware of some of the earn 2 hours of CE from reading this article. Correctly answering the questions will possible pitfalls and issues. demonstrate the reader can: • Recognize the pitfalls and issues to restoring function and esthetics in certain Try-in and torquing of implants types of patients. • Be able to monitor peri-implant tissues. There is confusion between the torque • Identify the maintenance protocols after restoration has taken place. load delivered to the implant complex, the initial force transformation and stress developed within the system during the implant implant complex. The insertion torque should favoring the formation of cartilage and complex assembly, and how the clamping not exceed 30Ncm, especially for immediate connective tissue. forces at the interfaces and the preload load implants, as higher insertion torques stress impact the implant prior to external above 50Ncm can generate high-compressive Common complications loading. The application of any external load stresses to the peri-implant tissues, causing (Goodacre, et al., 2003) to the implant complex must be preceded blood supply deficiency and bone necrosis by the assembly of the abutment onto the during the osseointegration phase, as well Screw loosening implant, achieved by tightening the abut- as early implant failure (usually within the first There are two main reasons why screw ment screw to create a stable screw joint month after placement) (Trisi, et al., 2009). loosening occurs: and, thus, form the implant complex. It is the A high insertion torque may occur during first step in preparing the assembled implant implant placement in high-density bone Incorrect torque complex to transfer loads. tissue. Under high stresses, significant Torque drivers should always be used to Accuracy, with respect to the applied changes impair the formation of new blood tighten screws. The correct preload must be load, is critical in the determination of load vessels, causing hypoxia in the peri-implant applied to the screw. The material of the screw transfer to and through the complex to the tissues, thus inhibiting bone formation and must be stretched to 80% of its elastic limit, bone. The dynamic nature of the implant complex assembly generated by a certain magnitude of torque loading is essential for understanding the response of any implant system to external loading. The contact forces, including the preload, are the first response to the torque experienced by the

Brenda Baker, BDS (Hons), MSc, graduated from Sydney University with honors and completed a master’s degree in conservative dentistry from Eastman Dental College. She has taught in the prosthetic faculty at Sydney University and pursued a preventively oriented career in private practice. Throughout her career, Dr. Baker has had a commitment to continuing education in a variety of disciplines, including prosthodontics, periodontics, and pain management and is currently director of clinical education for Southern Cross Dental.

David Reaney, BDS (Edin), DGDP(UK), MClinDent (Prosthodontics), graduated with distinction from the University of Edinburgh. He has held the position of clinical lecturer at the School of Dentistry, Royal Victoria Hospital in Belfast and is currently in private practice in Moy, Northern Ireland. Dr. Reaney is general manager of Southern Cross Dental. Figure 1: Anterior tooth esthetics are critical. Color data with shade tabs against various teeth will help guide the laboratory

Volume 8 Number 1 Implant practice 35 CONTINUING EDUCATION

Figure 2: Minimal space is evident anteriorly for esthetic functional reconstruction Figure 3: The irregularity of the occlusal plane is clearly illustrated when the patient’s mouth is partially open

which means that the screw will return to its There is always a small mismatch in Then, a cemented post and abutment can original length as the torque is released, and fit between the top of the implant and the be made with an impression of the internal the two components are clamped together. undersurface of the abutment due to the surface of the implant, and a new super- If the screw is tightened by hand, adequate tolerance during manufacturing. Forces structure fabricated. preload will not be achieved, which means are applied that cause a small amount of that the screw will not be stretched to its movement between the component parts Fracture of the superstructure full potential, and repeated screw loosening during function. If applied forces fall outside This can occur in either porcelain or resin, will occur. If the screw is over-tightened and the diameter of the implant, the movement as found by Molin and Karlsson (2008) and exceeds the elastic limit, it will become plastic between the component parts is magnified, Larsson and colleagues (2006). If the occlu- and not return to its original length. There will and the screw is more likely to become loose. sion has not been designed properly, or the also be no tension placed into the system. The diameter of the implant should match the interface between the veneering material and Thus, loosening of the screw will occur and diameter of the tooth that is being replaced as the underlying metal framework is placed may cause eventual fracture. The design of closely as possible. When considering multi- under stress, then material fracture can the screw head has an impact on the ability unit cases, the correct number of implants occur. The framework must be made rigid to apply the preload. Slotted screws do not should be chosen to allow even distribution enough to support the veneering material. allow enough preload to be applied. However, of the forces. Components should be chosen Extensive cantilevering can increase the square and hexagonal screws allow the from the same manufacturer, or the use of risk of fractures, as can parafunction. The preload to be transmitted through the screw, customized abutments specifically tailored occlusion should be checked in lateral excur- and either can be used. for each clinical scenario may prove to be sions to ensure that there are no interfer- A screw can loosen where the abut- even more accurate. ences. If a crown needs to be removed, then ment underlying the crown becomes loose, it is possible to either unscrew the compo- yet the crown remains cemented. Always Screw fracture nent — if it is screw-retained — or ease it replace abutment screws that have loosened Kim and colleagues found that screw off if it is cement-retained after having used repeatedly or are damaged. The crown may fracture occurs as a result of overloading an a temporary cement. not detach from the abutment easily. If the implant by occlusal forces (2005). The abut- If acrylic resin is too thin, it too will fracture crown will not separate, it may be possible to ment screws become loose and eventually when loaded, and the alignment of the screw cut a hole in the crown to expose the screw fracture. Incorrect preload may also create access hole, when using a screw-retained access hole underneath. The access hole ultimate screw fracture. Over-tightening of restoration, should be in the central fossa of may not be in the center of the abutment the screw may eventually cause fracture, the restoration to allow adequate thickness and can be difficult to locate. Considerable and occlusal overload caused by exces- of porcelain or acrylic. cutting of the crown can damage the under- sive cantilever design should be avoided. lying abutment and possibly lead to eventual The forces applied to the prosthesis should Inflammation and peri-implantitis replacement of the entire assembly. be controlled, and it is important to avoid Cochran reported that during main- It is also possible to cut through the damaging the internal thread of the implant. tenance, gingival inflammation can be interproximal contacts and unscrew the The worst case scenario is that the detected. It may either be mucositis, which whole assembly. Then, the abutment can implant would have to be removed surgically, is reversible without evidence of bone loss be relocated onto the implant and the screw the site be allowed to heal, and then a new or peri-implantitis (2002). Most frequently, torqued down. A new impression can be implant placed and restored once osseo- mucositis is caused by abutment loosening. fabricated to construct a new restoration. integration has occurred. The design of the The loosening of the abutment enables superstructure should be carefully planned bacterial infiltration. Mismatch between the diameter of the as this could cause fracture of the screw. If Lindhe and Meyle found that if the muco- implant and the width of the crown that the screw cannot be removed, it may have to sitis caused by abutment loosening goes the final prosthesis replaces be drilled out in order to salvage the implant. undetected, it can result in peri-implantitis

36 Implant practice Volume 8 Number 1 CONTINUING EDUCATION

(2008). Mucositis lesions can show apical progression after 3 months of plaque buildup around implants. In order to detect abutment loosening, look for abutment separation on the radiograph — seen as a dark line between the components and prosthesis mobility. Abut- ment loosening can result in uncomfortable pressure on the prosthesis if gingival tissue has overgrown into the opened junction. The excess soft tissue must be removed before the abutment or prosthesis can be tightened back into place. Treatment of peri-implantitis involves inﬂammation control and modifying the exposed implant surface.

Occlusal evaluation The occlusal status of the implant and its prosthesis must be assessed routinely at every maintenance appointment. Occlusal Figure 4: These implants show excellent tissue health around the abutments overload can cause a variety of problems, including loosening of abutment screws, The patient’s motivation and skill in • Possible need for antimicrobials implant and prosthetic failure (Zarb and undertaking oral hygiene measures may • Re-evaluation of present mainte- Schmitt, 1990). Occlusal contact patterns influence prosthetic design. Importantly, if nance intervals that may be altered should be assessed, as well as the mobility the patient is unable to achieve adequate depending on the clinical situation of the implant and opposing dentition. oral hygiene, then this should be a possible • Mobility Successful implants should not be contraindication to implant placement. It is Any movement would indicate possible clearly mobile. A failing implant is not mobile essential to monitor peri-implant tissues at lack of osseointegration of the fixture, until all or most of the bone has been lost. regular intervals so that disease can be noted possible failure of the cement bond between Abnormal occlusal loading will negatively early in treatment if possible. the superstructure and the retainer, or screw affect the various parts of the implant- The maintenance appointment should failure by fracture or loosening. supported prosthesis. Hence, premature include evaluation of: If an abutment is loose, then the microgap contacts or interferences should be iden- • Presence of plaque and calculus and widens, which can result in the formation of tified and corrected to prevent occlusal oral hygiene a fistula. overload. There should be light centric • Clinical appearance of peri-implant By using the recommended torque contact with no contacts in lateral excur- tissue and deposit removal from settings, biologic considerations of the sions (Engleman, 1996). implant/prosthesis surface peri-implant areas, and adhering to certain Lundgren and Laurell believe that • Occlusal status and stability of pros- biomechanical principles governing abut- shim stock should be able to be held only theses and implants ment and restoration shapes and sizes, we with hard-clenched teeth (1994). Possible • Probing depths and presence of can avoid much heartache through careful bruxism and parafunctional activities must be exudates or bleeding on probing planning so that we have content patients evaluated as excessive concentrated forces • Patient comfort and function with favorable lifelong outcomes. can result in rapid and significant peri-implant bone loss. REFERENCES If a failed implant is connected to a 1. Cochran DL. Tampa and convenient diseases. [newsletter]. Academy of Osseointegration News. 2012;23(4):1, 13. multi-unit prosthesis, it may mask evidence 2. Engelman MJ. Occlusion in: Clinical decision making and treatment planning in osseointegration. Chicago: Quintessence;1996. 3. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications with implants and implant prostheses. J Prosthet of mobility. Dent. 2003;90(2):121-132. 4. Kim Y, Oh TJ, Misch CE, Wang HL. Occlusal considerations in implant therapy: clinical guidelines with biomechanical rationale. Maintenance protocols Clin Oral Implants Res. 2005;16(1):26-35. 5. Lang NP, Wilson TG, Corbet EF. Biological complications with dental implants: their prevention, diagnosis and treatment. (Lang, Wilson, and Corbet, 2000) Clinical Oral Implants Res. 2000;11(Suppl 1):146-155. These should be customized for the 6. Larsson C, Vult von Steyern P, Sunzel B, Nilner K. All-ceramic two- to five-unit implant-supported reconstructions. A randomized, prospective clinical trial. Swed Dent J. 2006;30(2):45-53. individual patient. There is insufficient data 7. Lindhe J, Meyle J, Group of European Workshop on Periodontology. Peri-implant diseases: Consensus Report of the on exact recall intervals, methods of plaque Sixth European Workshop on Periodontology. J Clin Periodontol. 2008;35(8 Suppl):282-285. and calculus removal, and appropriate anti- 8. Lundgren D, Laurell L. Biomechanical aspects of fixed bridgework supported by natural teeth and endosseous implants. Periodontol 2000. 1994;4:23-40. microbials for maintenance around implants. 9. Molin MK, Karlsson SL (2008) Five-year clinical prospective evaluation of zirconia-based Denzir 3-unit FPDs. Int J Prosthodont. Before implant placement, the patient’s 2008;21(3):223-227. ability for home care and motivation must be 10. Trisi P, Perfetti G, Baldoni E, Berardi D, Colagiovanni M, Scogna G. Implant micromotion is related to peak insertion torque and bone density. Clinical Oral Implants Res. 2009;20(5):467-471. assessed, and the patient must understand 11. Zarb GA, Schmitt A. The longitudinal clinical significance of ossseointegrated dental implants: the Toronto study. Part III: his/her role in caring for the implant. Problems and complications encountered. J Prosthet Dent. 1990;64(2):185-194.

Volume 8 Number 1 Implant practice 37 MATERIALS lllllllllllll& lllllllllllll Planmeca rolls out Cloud Service product Dental equipment manufacturer Planmeca Oy developed Planmeca Romexis® software as an open architecture platform, EQUIPMENT making it compatible with most software operating systems and dental equipment. Now, Planmeca has taken this technology to a new level with Planmeca Romexis® Cloud Service, which works with Planmeca Romexis software so dentists can access Surgeon-focused, patient-driven Exactech Dental and share diagnostic images from any imaging unit. Planmeca launches 0.5cc Optecure and Optecure+ccc Romexis Cloud Service lets dental professionals communicate with colleagues and transfer images and key case information Exactech Dental has expanded the Optecure® product line to securely, quickly, and seamlessly. This brings new possibilities to include a dry-engineered allograft in .5cc sizes. Optecure Dental the dental practice, such as providing access to specialists from is an engineered bone graft for reconstruction and augmentation remote general practitioners, giving rural dentists the same referral of deﬁcient maxillary and mandibular alveolar ridges and dental base as any dentist in a large metropolitan area. intraosseous defects. Its room temperature convenience facili- Other features of the Planmeca Romexis Cloud Service tates rapid mixing with normal saline, water for injection, whole include: blood, or autogenous bone graft (ABG). With cortical cancel- • All treatment plan elements are automatically added, lous bone chips, Optecure+ccc also provides a 3D matrix for including annotations and measurements. osteoconductivity. The convenience, constituents, and robust • Virtual patient cases include 2D X-ray images and photos, handling properties make Optecure the optimal cure for clinicians’ CBCT volumes, and 3D photos. concerns about bone graft performance. • Images and reports are easily shared with patients. For more information, visit www.exac.com/dental, or call For more information, visit http://www.planmecausa.com. 866-284-9690. Sunstar introduces GUIDOR® easy-graft® Alloplastic Bone Grafting System

Sunstar Americas announces a new extension to its guided bone regeneration portfolio with the introduction of GUIDOR® easy-graft® CLASSIC Alloplastic Bone Grafting System. Designed with technology that enables the material to be syringed directly into a bone defect, GUIDOR easy-graft is the first bone grafting material that hardens into a stable, porous scaffold in minutes and may reduce the need for a dental membrane.1 Cleared for a wide range of indications, GUIDOR easy-graft is a fully resorbable ZEST Anchors introduces a healing cap for bone grafting material ideally suited for socket preservation after ® the popular LOCATOR Overdenture Implant tooth extraction and implant packing. (LODI) System The easy handling of GUIDOR easy-graft originates from its unique combination of materials. Comprised of coated synthetic ZEST Anchors has expanded the popular LODI System by granules in a syringe and a liquid activator, the material hardens offering a healing cap for delayed loading protocols. Patients’ into a stable, porous scaffold in minutes when in contact with unique and individual needs are at the core of new product devel- fluids such as blood. This brief delay allows practitioners time to opment for ZEST Anchors. With the introduction of the healing pack and shape the material to the contours of the defect before cap for the LODI System, clinicians can now offer a variety of hardening occurs. treatment protocols for delayed or immediate loading in all bone For more information, visit www.GUIDOR.com, or call Sunstar types. The new LODI healing cap, a smooth, non-engaging cap, at 1-877-484-3671. is available for 2.4 mm and 2.9 mm diameter LODI Implants in 3 mm and 4 mm cuff heights and is ideal during healing. The LODI System offers clinicians a trusted treatment alternative for their edentulous patients’ unique scenarios, which consist of anatomical limitations, the unwillingness or inability to endure an invasive bone grafting procedure, or financial limitations. The LODI System, incorporating narrow diameter implants with a detach- able LOCATOR Attachment, is an ideal solution for these patients. For more information, visit http://www.zestanchors.com/. 1. Data on file with the company

38 Implant practice Volume 8 Number 1 NEW!

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New You Smile (NYS) full mouth dental implant restorative system to launch in China

t Ossotanium headquarters in AAlbuquerque, New Mexico, MedMark General Manager, Adrienne Good, met with dental professionals and representatives from Angel Dentistry in China to watch a live full mouth implant restoration performed by Dr. Li Luo Skelton and partner Dr. Luis Galvan from New You Smile Center® in San Antonio, Texas, using an innovative new material. The patient, Dianna Lamb, is Adrienne’s mother, a denture wearer who never wore her bottom denture because she had very little bone to enable it to fit properly. In this interview, Adrienne delves into the 71%. The need for treatment of the edentu- patients are left without access to quality development of this new material, Ultra lous jaw was also found in both adult and care, increasing demand for materials opti- OralStone™ by Nouvelle Ere, a breakthrough senior populations. While increasing services mized for full mouth restoration. There are implant-optimized dental prosthesis. This for these needs could improve the situation, issues that prevent catering to these patients material, which combines shock-absorbing application of new technology would also help with current technology. Materials available strength, nano-resin hardness, affordability, improve the outcome of treatment. Dental on the market have not been able to satisfy ease, and flexibility of design, enables the professionals should continue seeking the explosive demands, creating a “bottleneck,” possibility of creating dental fixtures from best possible approach to serve the patients which is further aggravated by our ever- affordable implant dentures to high-end, and the society for a better quality of life. growing and aging population. full mouth, implant-based smile makeovers. This material’s highly anticipated launch in AG: What is the global trend in AG: What has your company done China is expected to revolutionize the field dentistry? to innovate in this area? of dentistry worldwide. Mr. Shijun Li (SL): there are three main SL: The challenge of full mouth restora- components: tion is that most implant-supported pros- Interviewees 1. Prevention theses made with acrylic are too brittle and • Mr. Shijun Li – President, CEO Angel 2. Patients demanding better treatment can break easily. In dealing with precious Dentistry due to advanced technology metals for a crown, the costs can quickly • Tao Xu, DMD, PhD – Professor and 3. Both therapeutic and esthetic become very expensive, and it is difficult former Dean of Peking University benefits for lab technicians to manipulate these School and Hospital of Stomatology materials. Another downside is that these • Li Luo Skelton, DDS – Owner of AG: What is your vision of the future materials provide no stress relief for the New You Smile of dentistry? underlying bone. SL: The implant market has moved to Angel Dental has made an effort to intro- Adrienne Good (AG): Dr. Xu, as a new era in advancement and technology duce a full mouth implant restoration system to a Professor and former Dean of making it the “era of the lifetime total make- overcome the challenges identified previously. Peking University School and over with or combined with dental implants.” The material in the new implant system is flex- Hospital of Stomatology, can you Research demonstrates that more people ible enough to ensure that it reduces direct offer some background on why are in need of full mouth implant rehabili- pressure on the implants and the bone while this new material is important and tation instead of just one or two implant being of exceptional strength and durability, insight into its launch in China? placements. eliminating the need for metal substructure. Dr. Tao Xu: China’s economic growth has Full mouth restoration is beneficial to the This new material has a longer longevity and increased demand for oral health services following types of patients: greater overall strength compared to existing and quality of life. However, there is a • Patients who have missing teeth materials while at the same time restoring func- shortage of dental services due to the ratio • Patients who suffer from periodontal tion to the patient’s smile and reducing the of dental professionals to the large popula- disease chances for further bone loss down the road. tion. As the aging population gradually grows • Patients who have suffered traumatic in the country, based on the third oral health injuries or accidents AG: I know that you have had epidemiological survey in China in 2005, there • Patients who aim to improve their many years of experience in are still a lot of treatment requirements for appearance dental management, and that the seniors — for the estimated 98.4% who suffer • Patients who suffer from skeletal material is approved by the FDA. with caries, for the 68% who experience peri- malocclusion Dr. Li Skelton has been placing odontal conditions resulting in bleeding, for The inadequacies of current technology this material in patients in her San the 88.7% with calculus, and AL > 4 mm at have created a vacuum effect in which Antonio practice for over 2 years,

40 Implant practice Volume 8 Number 1 A CONVERSATION WITH...

and her patients are very satisfied. of Ultra OralStone™, Dr. Li Skelton, to build a done with a dental implant system that can Tell me more about your experience new company, Wisdom Angel™ Science and easily serve the many individuals in need. We working with Dr. Skelton and future Technology, Inc., in China. At the end of this are proud to serve patients with an instant plans. year, we are going to launch this system in and customized smile makeover that is made SL: As the CEO of China Angel Dental, I China. This will bring benefits to the many of up of preserving bone foundation, and is have personally followed up with results and our denture-wearing senior population. affordable, functional, and a lifetime solution. patients post-surgery. I think it is the right time to introduce this full restoration implant system. AG: Dr. Skelton, how do you see AG: What are some benefits to the Its unique features have significantly improved this product making an impact patients? the industry, and some may say it is a clinical worldwide? SL: Basic dentures are uncomfortable and technical revolution! As dental leaders, Dr. Li Luo Skelton: The New You Smile and can easily break. Given the opportu- we decided to collaborate with the inventor Implant Makeover System is an all-in-one nity to use our system, patients would find total integrated system, starting with increased comfort levels with a solid product education, and then creating a new that will not break. We offer better quality culture where the power of a smile material at a lower price for the greatest is brought back to patients, from the possible accessibility to our products and U.S. to China. services. This system is great for patient education, home and healing AG: When can doctors in the United systems for all treated patients, States expect to take advantage of marketing, R&D, materials, dental this system? labs, training opportunities, and SL: After the system launches in China, multidisciplinary modern dentistry we will welcome clinicians in other countries applications. to collaborate in launching this system in Our mission is to help patients other parts of the world. Please go to www. Opening ceremony of the Guangxi Wisdom Angel™ Science and Tech- improve their quality of life with a oralstone.com for more information on the nology Inc. (China). healthy and functional smile. This is material and advances in the U.S. market. IP

Volume 8 Number 1 Implant practice 41 PRACTICE MANAGEMENT

Guiding light

Can your team rely on you when things seem dark? Laura Horton explains how effective leadership can be the light at the end of the tunnel

ome say leadership is in your bones — members you aren’t interacting with when Leading from the front Syou either have it or you don’t. I firmly you are being a dentist? believe leadership is a skill that needs to be Successful leaders bring out the best • Share your vision for the business worked on frequently. in others; they do not dictate to their team with your team to help build trust. Skills can be taught, and therefore, people members what they should be doing, and who are automatically put into a position of how they should be doing it. They ask them • Take the time to get to know each leadership can work on those skills, whether it how they wish to get to the end goal. Is there person in your team. is a practice manager who has been promoted any way the leader can help a team member from a dental nurse or an associate dentist complete a new task by providing advice who is now a partner or sole owner. or training? Are there any worries they have • Follow up on all tasks that you have Practice owners and managers often completing this new task? The leader should delegated to team members. struggle to become leaders for two reasons: be approachable, and all members of the 1. They do not have the time to lead. team must be able to go to him/her without • Take the time to train your staff. 2. They like to be in control. feeling that they are wasting their time or If either of these apply to you, then it is looking stupid. • Ensure your team knows when your likely your leadership isn’t as strong as it practice has achieved results. could be. Taking control Successful leaders trust in others. You Invest in your team may say you trust your team, but do your or identify others who already have these Successful leaders share their compel- actions display this? If all team members skills to train them. A key example of this ling visions, but if you do not have time to were asked, anonymously, if they trusted is cross-training your dental-assisting team plan the vision of your business, how can you you, what do you think they would say? Trust to be able to work with every dentist, and share it? How do you know if it is compelling takes time to build up, but can very quickly training him/her to be able to carry out front if you can’t get your team to provide ideas be taken away. The most vital thing you can desk duties such as handling new patient and ask questions? do here is to ask your team members for phone calls. A compelling vision is communicated honest feedback — whether or not they all Successful leaders have the right team with a team, creating excitement. Every team feel you trust them. Ask them to provide you around them, so surround yourself with like- member will be right behind you because with an example, whatever their response. minded people. This is extremely important they will be able to see where they are in a dental setting. If, as a leader, you have a heading and will want to be a part of it. Handing out tasks passion for customer service and providing Practice owners need one day a week to Successful leaders also delegate. Dele- every patient with an amazing experience on work on their business. However, this doesn’t gation is most often misunderstood. It is not every visit, yet you have a team member who mean writing treatment plans or doing admin about handing out a task and never seeing thinks “this is a waste of time,” then you have — you should already have a support network the completion of it. There is nothing worse a problem. In his 2001 book, Good to Great, to help you with those aspects! than wondering if something has been done Jim Collins stated that it is vital to get the Successful leaders get to know their and what the finished result may be. right people on the bus and in the right seats. team. I do not agree with business owners Delegation is about sharing tasks with who do not intentionally get to know their team members, giving them a deadline and The end goal teams. It is vital to know what similarities reviewing the task together. Delegating to Successful leaders achieve results for the they share with you, such as background, your team helps to motivate and build trust. business. For everyone in your team to look schooling, and family upbringing, or what You need to ensure you are organized and up to you, and respect you as a leader, he/ common interests you have, such as know who has been delegated what. After all, she needs to see you have done all of this hobbies, films, or television shows. delegated tasks are still your responsibility. and gained results for the business, too. You We all know the importance of building have worked hard on the vision, connected, relationships with patients, but this is often Training team members and trained to bring out the best in your team forgotten within a team that works together Successful leaders train others. —but have you, as a team, gotten the results every day. While you may know your nurse Increasing your team’s skills to take on new you planned for? very well, what happens to the other team tasks is a great use of your time as a leader. Feedback is vital. When your team sees Everyone in your team knows you are busy, you have helped the practice achieve results, so when you set time aside to train them and that is when you become a successful leader Laura Horton has worked in dentistry for 15 years and is passionate give them new skills, they will appreciate it. with a team that respects you, rather than about treatment coordination and team development. To find out more, visit the website at www.laurahortonconsulting.co.uk. You may not be the one running the being a team that follows you because it training; you could send them on courses has to. IP

42 Implant practice Volume 8 Number 1

ABSTRACTS

Treating soft tissue deformities around osseointegrated dental implants

Dr. Maria Retzepi presents a selection of recent studies and published research

Efficacy of soft tissue augmentation gain, but also significantly reduced around dental implants and in patient morbidity and surgery time partially edentulous areas: a compared to an apically positioned systematic review. flap, and combined with autogenous Thoma DS, Buranawat B, Hämmerle CH, graft based on two randomized Held U, Jung RE (2014). Journal of Clinical controlled clinical trials. Periodontology 41(suppl) 15: S77–S91 • All studies found shrinkage of the augmented grafts, which may result The aim of this systematic review was in a decrease in width of keratinized to evaluate the efficacy of different soft tissue of more than 50% within a tissue augmentation procedures in terms of couple of months. The results were increasing the width of peri-implant keratin- more favorable for the autogenous ized mucosa, and gain in soft tissue volume grafts (59.7% shrinkage) compared around implants and in partially edentulous to collagenous matrix grafts (67.2% areas. shrinkage) at 30 days postoperatively. The authors conducted a Medline search A total of 295 patients and 320 sites for human clinical trials (case studies, cohort treated for augmentation of soft tissue studies, controlled trials) with a follow-up of volume around implants or in partially eden- at least 3 months reporting on augmentation tulous areas were included in 11 studies. The fill and higher marginal mucosal levels of keratinized mucosa or gain in soft tissue authors reported that: were obtained using subepithelial volume around implants or partially edentu- • Autogenous (subepithelial connective connective tissue grafts compared lous areas. tissue) grafts should be considered to non-grafted sites. Nine clinical studies were included with as the treatment of choice, as they a total of 283 patients and 375 sites treated were the best documented method Soft tissue augmentation procedures for gain of keratinized tissue around the for soft tissue volume gain at implant for mucogingival defects in esthetic implants. and partially edentulous sites. sites The authors reported that: • Three studies used casts to evaluate Levine RA, Huynh-Ba G, Cochran DL • An apically positioned flap/vestibulo- the soft tissue volume over time and (2014). International Journal of Oral and plasty combined with a graft mate- reported that the mean augmented Maxillofacial Implants 29(suppl):155–185 rial (free gingival graft/subepithelial thickness following autogenous connective tissue graft/collagen grafting ranged between 0.55 The objective of this systematic review matrix) resulted in an increase of mm and 1.18 mm. One random- was to evaluate the esthetic outcomes of keratinized tissue by 1.4 mm–3.3 ized controlled clinical trial reported soft tissue procedures performed and soft mm for an observation period up to superior results following grafting of tissue deficiencies present around maxillary 48 months. alveolar defects with subepithelial anterior implants. • An apically positioned flap plus connective tissue graft (159 mm3 A Medline database search was autogenous graft was the best docu- volume gain) compared to free performed, which led to 123 full-text arti- mented and most successful method gingival graft (104 mm3 volume gain). cles for further evaluation. A total of 18 of increasing the peri-implant keratin- • Soft tissue substitutes for gain of soft studies were finally included in the present ized mucosa width. tissue volume currently lack clinical systematic review, the vast majority of which • The combination of an apically data. were case series, with only one randomized positioned flap with collagen matrix • Shrinkage of the augmented sites controlled clinical trial identified. demonstrated less keratinized tissue should be expected, with autoge- The included studies were grouped nous grafts being reported to shrink according to the intervention performed on by more than 40% in two studies. the peri-implant soft tissues. The authors Maria Retzepi, DipDS, PhD, MSc, CertClinSpec (Perio), is a Shrinkage data were not available on reported that, overall, six therapeutic modali- registered specialist in periodontics and honorary clinical lecturer soft tissue substitutes. in periodontology at the UCL Eastman Dental Institute. She ties have been studied in terms of addressing currently works in specialist private practice in central London. • From an esthetic point of view, at peri-implant soft tissues deficiencies. These immediate implant sites, better papilla include the connective tissue graft with a

44 Implant practice Volume 8 Number 1 ABSTRACTS

coronally advanced flap (seven studies), the results are common in the treatment of a esthetic area were enrolled. The treatment connective tissue graft in combination with dental implant for facial gingival recession. protocol included removal of the implant- an envelope flap or pouch (three studies), The authors concluded that the available supported crown, reduction of the implant the free gingival graft (three studies), the acel- literature on the effectiveness of soft tissue abutment, coronally advanced flap combined lular dermal matrix with a coronally advanced procedures in promoting the esthetic param- with connective tissue graft and final resto- flap (one study), the pediculated connective eters around dental implants was based on ration. The soft tissue coverage was evalu- tissue graft (two studies), and the injection of very limited literature support. Furthermore, ated 1 year after the final restoration, and the hyaluronic acid (one study). the available studies were lacking long-term unrestored contralateral tooth, which did not The data indicated that the periodontal follow-up, a large number of patients, and present recession, served as a reference. plastic surgery procedures performed around were subject to inclusion bias. The study also evaluated patient satisfaction dental implants gave good initial results, 1 year after the treatment. partly owing to the inflammation involved A novel surgical-prosthetic approach One year after treatment, the mean soft in the healing process. As such, in virtually for soft tissue dehiscence coverage tissue dehiscence coverage was 96.3%. all cases, significant recession occurred as around single implant Complete coverage was achieved in 75% of the healing resolved and the tissues matured. Zucchelli G, Mazzotti C, Mounssif I, treated sites. The increase in buccal soft tissue The authors have further reported that imme- Mele M, Stefanini M, Montebugnoli l (2013). thickness amounted to 1.54 ± 0.21 mm and diate implant placement is associated with Clinical Oral Implants Research 24: 957–962 correlated significantly with the thickness of the an alarmingly high incidence of mucosal connective tissue graft at the time of the surgery. recession in the range of 20% to 40%, and This prospective case series study aimed Furthermore, esthetic analysis demonstrated a that several case studies have shown that, to evaluate soft tissue coverage and patient significant improvement in the visual analogue with immediate implant placement, there is esthetic satisfaction of a novel surgical- scale (VAS) score, (median, 3.8; 95% CI, 2–4 a benefit in augmenting both the buccal gap prosthetic approach to soft tissue dehis- at baseline compared to 8.0; 95% CI, 8–10 at and using a connective tissue graft to thicken cences around single endosseous implants 1 year [median]). The authors concluded that the buccal tissue for biotype conversion. in the esthetic region. the combined prosthetic-surgical technique Furthermore, it was reported that the available Twenty patients with buccal soft tissue was effective in addressing buccal soft tissue literature indicated that unpredictable esthetic dehiscence around single implants in the deformities around single dental implants. IP

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Volume 8 Number 1 Implant practice 45 PRACTICE DEVELOPMENT

How patients think

Andy Smith presents patient-led insight to help improve your dental implant marketing

fter years working inside the implant health. While patients might be on their own choices, and it’s up to us as an industry to Aindustry, swapping over to the patient individual implant research journey, many of help them do so. The only way to neutralize side of the fence has proved highly their initial behaviors are the same — and misleading “cheap implant” ads on Google illuminating. most begin online. You only need to look is to work together to generate alternative Establishing a website to assist implant at the monthly number of Google searches information that will help people make good patients and respond to their questions has around “dental implant” (18,100 on average choices for the long-term. given me interesting insight into how they per month) to know that, first, lots of people Reassuringly, once people have been think and what it is that they are really looking are searching and, second, that most start encouraged to ask searching questions of for. A robust patient survey, our own site their journey by typing “dental implant” or their providers, obtaining an experienced, analytics, and hours spent talking to patients something similar into Google. qualified clinician becomes their key priority. have challenged many of the assumptions The web has created a new tribe of This is followed in second place by the avoid- implant providers have about what motivates “researchers,” and it’s surprising how dili- ance of future problems, and in third, by implant patients. Here, I will outline some of gent they are. We found that only 10% were quality of outcome. Giving patients the right the key lessons that we all need to take on on their first research foray, 26% had already reassurance upfront relegates cost down the board if we are to please more of our patients done some research and were looking for a list as a priority (although it will always be more of the time. trustworthy practitioner, and a further 26% important). had already been to see a clinician and were Not surprisingly, the importance of an Three problems propel people considering their treatment recommendation. open and flexible discussion around treat- towards implants This is interesting because it shows how ment options is also important to researchers: A recent survey we conducted modern behaviors are bleeding into dentistry. having done their homework, they don’t want confirmed that three different health issues Just as people use online recommendation to be railroaded into a single solution. trigger patients to consider implants; 45% services to minimize risk when selecting a Feedback from other patients is also of respondents confirmed that they had tradesman, so people are looking to really influential: in the world of TripAdvisor® and missing or broken teeth, while 28% were ensure that they are making the right choices OpenTable®, patient cases work as “refer- looking to replace dentures or bridges. The when investing significant money in some- ences” for clinicians, giving potential patients third major group (17%) were interested in thing like dental implant treatment. reassurance that problems like theirs can be implants because they were suffering from resolved. They can have an impact on their gum disease and loosening teeth. Researchers want reassurance and choice of practitioner. While these groupings won’t surprise references clinicians, they do highlight that not every The cost and complexity of dental implant Patients don’t care about what we implant patient is the same. They don’t treatment means it is hardly surprising that care about all have the same problem, and each is the most visited pages on our site are the This insight around patient priorities is exploring an implant solution from an indi- pages on cost (“Why can’t I get a price for interesting because it clashes with what many vidual perspective. It also serves to remind something I want over the phone?”), the practitioners are currently doing. Instead of us that, while many will be having their first Charter (a set of principles to help people showing how years of experience and exper- major dental treatment, others will have interrogate the quality of their implant tise have generated case after case of satis- already spent many hours in the dentist’s providers), and the FAQs. fied customers, many practices wax lyrical chair. There is so much scope to market to Researchers are really keen to amass about their practice — which is further down these groups differently, but they tend to get information so that they can make good on the list of priorities for patients. lumped together.

Patients know more than we’d like to think The trend towards self-diagnosis, the inﬂux of medical web content, and the boom in innovative apps and devices seen across the health sector are also impacting oral

Andy Smith has held senior executive positions in both Straumann® and BIOMET 3i™ across several different European countries. He now leads the way in patient referrals from the Internet in the United Kingdom and the United States.

46 Implant practice Volume 8 Number 1 PRACTICE DEVELOPMENT

sexy your website is, it — and any expen- sively produced films on it — will be wasted if they simply languish in the digisphere. I was looking recently at a beautiful practice video that must have cost thousands to make, without registering that it had only received around 30 views in 2 years. These days, most practices have grasped the importance of a digital presence, but the rules of the web have evolved once again. People researching implants don’t start their journey by typing in their postal code; they start with a question or a search term, so you cannot rely on your website popping into their eyeline. Now, to be part of their conversation, you need to be generating content that responds to their needs, and you must be making this content easily available. These days, content is now much more important than a website; pushing out blogs, Yes, ambiance and friendly staff are nice opportunity to position themselves around articles, and case studies will always trump to have (and caring staff, in particular, will be the things that really matter: expertise, expe- the sexiest of practice pages, and video referenced by satisfied clients in reviews), but rience, and evidence of good results. is king. We all need to respond to these they won’t convert researchers on their own. changes to feed the appetites of this new Those practices marketing their “contem- Your website is not enough breed of “researcher” patients, showing them porary space” and “spa-style waiting area” This final insight brings us full circle to the that we truly understand the implant journey are missing the point — and wasting an point about Google searches. No matter how they are on. IP

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Volume 8 Number 1 Implant practice 47 STEP-BY-STEP

Assessing implant stability for loading

Dr. Peter K. Moy discusses a product that helps determine proper implant loading time

ver the years, there have been Omany developments in the field of implant dentistry that help to improve clinical outcomes, such as new implant surfaces, innovations in implant design and components, and advanced grafting products and techniques for site development. We now see success and survival rates that consistently exceed 95% and are attributable to these state-of- the-art implant technologies, clinical Figure 1: Osstell® ISQ device Figure 2: SmartPeg in position with RFA in progress expertise, case selection, and patient compliance. At this point, we have routinely used following implant placement (baseline) and Historically, when root-form implants were the Osstell ISQ for over 10 years to identify those obtained at a given moment during first placed, they were submerged during implant stability and to monitor osseointegra- osseointegration. In this way, the degree of osseointegration. Later, non-submerged tion. By providing an objective and repro- osseointegration can be determined. In addi- implants with delayed loading became the ducible guide for my decisions concerning tion, any observed decreases in ISQ from typical protocol and shortened treatment loading protocols, this technology has helped one time point to another can indicate poten- times. Today, patients want well-functioning, my restorative referrals avoid potential lost tial problems and enable early intervention. natural-looking restorations and prostheses as revenue due to implant failures associated Showing the readings to patients also helps soon as possible following surgery. As a result, with improper healing periods and to opti- involve them in their treatment. I have found patients are increasingly demanding shorter mize the clinical outcome of implant treat- that most patients appreciate this informa- treatment times, and patients who historically ment for patients. Osstell ISQ is reliable tion and understand the decision on when to would not have been candidates for implant and clinically proven, with more than 500 load their implants. Readings above 55 ISQ treatment due to compromised bone and published articles supporting the underlying have been validated to indicate an accept- other risk factors are requesting implants. technology and the use of implant stability able degree of implant stability for loading. Therein lies the dilemma since some quotient (ISQ) measurements to assess patients’ clinical condition (for example, implant stability and osseointegration. porosity of the recipient bone bed, limited Basically, the Osstell ISQ uses magnetic bone volume, or medical conditions) resonance to measure implant stability and lengthens the bone reparative process, the degree of osseointegration at implant which requires longer healing periods. sites. Unlike the traditional method of This makes it crucial to be able to objec- assessing implant stability and osseointe- tively measure primary implant stability and gration by measuring torque, which could osseointegration. be hard to objectively quantify and could The majority of my implant cases are on occasion negatively influence stability, now early loading cases. A minority is the Osstell ISQ method is completely non- Figure 3: Acceptable reading of 84 shown ISQ immediate loading, and delayed loading is invasive and objective. now performed only when immediate or Using this method, a small, high-precision early loading are not advisable. The Osstell® Osstell ISQ helps prevent failures and the metal rod (the SmartPeg™) is attached by associated costs for the office and patients. technology provides me with an invaluable screwing it into the internal thread of the objective measurement of primary implant Overall, the main advantages for my office implant or the implant-abutment complex. and patients are the quality assurance that stability and the progression of osseointegra- Next, the Osstell ISQ probe is placed in tion over time. That helps me decide the time we have been able to implement into implant close proximity to the SmartPeg and emits protocols, the ability to reduce treatment time of optimum loading. magnetic pulses that cause the SmartPeg to through earlier loading, and the ability to resonate. The resonance varies depending manage implant risk. Osstell ISQ has become Peter K. Moy, DMD, is an Oral and Maxillofacial on the lateral stability of the implant and the Surgeon in Los Angeles, California. my personal guide in determining the appro- rigidity of osseointegration, and is interpreted priate time to load patients’ implants, and using resonance frequency analysis (RFA). now I use it for every implant case. IP Therefore, a comparison can be made between the readings obtained immediately This article was provided by Osstell.

48 Implant practice Volume 8 Number 1 You have the know-how. Now get the know-when.

More patients are asking for early and immediate This is especially valuable for more predictable outcomes loading of their implants and patients who in the when treating risk patients. Osstell offers the only past might not have been candidates for implants objective quality assurance system that gives you an are also asking to be treated. Correctly assessing early warning if osseointegration isn’t progressing as implant stability and osseointegration is key in expected. With an objective ISQ-value, it’s easy to explain either situation. treatment planning and healing times to your patients Osstell does this for you in an accurate and objective and collegues. way, helping you make optimal implant loading You already have the experience and decisions. Measure at placement for a baseline value the judgement. Now Osstell brings and again before final restoration to assess the degree you and your patient new certainty. of osseointegration.

Advancing Implant Diagnostics www.osstell.com

Visit us at AO in San Francisco, CA! March 12th - 14th - Booth #336 PRODUCT PROFILE

Crystal® Ultra: a new hybrid nano- ceramic ideal for implant cases

Creative Dental offers two new ﬂavors of implant restorations

he employees put a sign on Scott in the mouth as an inlay, onlay, or veneer. TAtkin’s door, “mad scientist at work.” But its greatest utilization today is in implant Atkin refers to his research lab as a sort-of dentistry. After implants are placed, there is no test kitchen for every machine, material, or periodontal ligament that surrounds the roots process ever conceived for dentistry. to absorb shock and give the patients nerve As CEO of Creative Dental Laboratory, feedback when they bite. That’s why older Atkin has been pushing dental technology ceramic implant restorations tend to crack or into new frontiers for over 35 years. Creative break under pressure after just a few years in was an early adopter of CAD/CAM, among the mouth, and it is why some are concerned the first to mill Zirconia copings; and in 2009, that Zirconia might be less-than-forgiving if Atkin was the very first person ever to mill full supported by only four implants. With Crystal® Ultra overtaking Zirconia in 2015 contour Zirconia crowns using CAD/CAM. Ultra, the material takes the abuse and doesn’t Atkin says that today about half of his And, most importantly, Creative shared their pass the impact to the bone. full arch restorations are made of Crystal® technologies with other labs by co-founding Zirconia and half are Ultra-based, and to Dental Laboratory Milling Supplies (DLMS) No more bars — the Goldilocks effect make the decision to test Ultra ultra-simple, in 2007 to distribute advanced dental CAD/ In the past, most full arch hybrid restora- he offers both at the same $2,495 all- CAM supplies worldwide. Today, according tions were made of acrylic denture materials inclusive price. “In 2015, I expect Ultra to tip to independent market research, DLMS’ supported by a titanium bar, commonly called the scale,” indicated Atkin, “because patients ® Crystal Zirconia is the number one selling an All-on-4™ when done with four implants. absolutely love how it looks and feels.” Zirconia offered by the largest U.S. labs, Atkin offers, “That is like reinforcing gummy As a result of both of these materials, Atkin providing a unique combination of unparal- bears with a toothpick, and so we tend to believes that titanium bar-supported “gummy leled strength, beauty, and translucency. see up to 90% repair or failure rates within bear teeth” are a thing of the past. He offers 5 years of placement.” Most denture techs to personally create a test Ultra restoration, ® FDA approves Crystal Ultra, a new are used to repairing and replacing acrylic either a single or bridge or full arch, for every hybrid nano-ceramic dentures, but patients who spend tens of new implant dentist who inquires, explaining Recently, the FDA approved Atkin’s thousands of dollars on a permanent solu- the features and benefits and taking the dentist ® newest material, Crystal Ultra, which is a tion are expecting — a permanent solution. through the simple process step-by-step. To hybrid nano-ceramic that actually “bends and For several years, Creative has been offering learn more, call Scott Atkin at 480-948-0456, flexes” in the mouth. With more than a million highly esthetic full arch Zirconia restorations or visit www.CreativeDentalAZ.com or www. restorations seated worldwide and dozens of as a permanent alternative, but some dentists CrystalUltra.com. ® labs participating in U.S. trials, Crystal Ultra and patients complain that Zirconia feels too With Crystal® Ultra and other modern has been one of the most anticipated dental hard, with a clacky sound as you bite down advances in placing implants, Atkin believes science advances in the past decade. and chew. Since acrylic is too soft, Atkin had that many more dentists will be entering the a Goldilocks’ moment when he started making lucrative implant dentistry field in coming years, monolithic full arch restorations out of Ultra. and he wants to be there to support them with “Not only are they beautiful,” offered Atkin, advanced materials and advanced techniques. “but they feel great in the mouth; the closest material we have to the feel of natural teeth; About Creative Dental Laboratory the most pleasant bite experience a patient will Creative Dental Laboratory, Inc. was ever have; and because they are nonporous founded in Scottsdale, Arizona, in 1980 At a conference recently, Atkin held up a and super-stain resistant, they stay clean!” by Scott Atkin, who received his degree in ® thin bar of Crystal Ultra and bent it. “There is dentistry from the Royal Dental Hospital in no other ceramic on Earth that can do this,” The science of flex London before going on to a master’s program ® ® he said. “Crystal Ultra flexes in the mouth as The magic sauce behind Crystal Ultra where he became a Registered Master Dental the patient chews, absorbing shock, making is a perfect 70/30 blend of silanated glass Technician. In his lab in Arizona, Atkin invented it the only dental material with mechanical and advanced polymers. The 30% polymer CAD/CAM-based full contour Zirconia and properties similar to human dentin.” matrix gives the material its elasticity, and 3D transition shading, and after significant silanizing causes the ceramic to bond chemi- research on translucency, he created Sintering- Implant dentistry is the greatest cally to the polymers giving the material its Ovens.com to offer revolutionary high-speed, beneficiary strength. In the past 2 years, others have high-temp ovens that will sinter Zirconia in ® Crystal Ultra was originally engineered also developed ceramic hybrids, such as short cycles while achieving maximum trans- ® for minimally invasive and cosmetic dentistry 3M Ultimate, and Vita Enamic , but these lucency, strength, and luster. IP because of its opalescent chameleon-like other hybrids can’t be used for bridges or esthetic qualities, absolutely disappearing full arches. This information was provided by Creative Dental Laboratory, Inc.

50 Implant practice Volume 8 Number 1 No More Bars! $ Complete Full Arch Restoration 2495 Try One Today! Call 480.948.0456 8 Year Warranty

full arch w/ 4 ti-bases, bite block, Creative stands behind our diagnostic setup, setup try-in, implant CAD/CAM monolithic implant verification jig, reset, and final restoration restorations with an unheard of 8-year warranty against cracks, breakage or failure.

CrystalZirconia.com CrystalUltra.com

Your choice of two leading materials. Unlike acrylic at <50 MPa, both are very strong and super stain resistant.

Crystal Zirconia, at 1250 Mpa, is the strongest super-translucent zirconia available on the market today.

Crystal Ultra is a high-luster 490 MPa hybrid ceramic that bends and flexes giving it a gentle bite and making it kinder on implants. Ultra is easy to adjust or add to without removal.

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Introducing ATLANTIS Conus concept by DENTSPLY Implants

he dynamic growth in implant dentistry edentulous patients. The patient-specific Thas greatly enhanced the position of solution is a uniquely designed, conical- implant-supported restorations in prosthetic shaped abutment with corresponding caps dentistry. As this growth continues, it offers that incorporates an implant-borne prosthesis exciting opportunities for advanced fixed and while being removable like an overdenture. removable implant-supported options that ATLANTIS Conus Abutments are individually In addition, the friction-retained SynCone contribute to even better patient satisfaction. designed using the patented ATLANTIS VAD caps are part of the SynCone concept, Implant-level attachments used with over- (Virtual Abutment Design) software to ensure a proven solution that has been used dentures accounted for 82% of the total United that all abutments are parallel to each other, since 2001. States and European attachment market in that their restorative margin are as close to There are two treatment choices avail- 2013. The U.S. and European attachment the soft tissue as possible, and that they are able with ATLANTIS Conus Abutments. Both market grew 3.5% to 1.5 million units sold positioned in relation to the space needed options provide clinical and patient flex- in 2013. This growth trend is predicted to for the final restoration. ibility in turnaround times and economical continue through 2020**. With this in mind, In addition, ATLANTIS Conus Abutments situations: overdenture solutions can offer an ideal are designed to fit SynCone caps that ensure • Immediate restoration (intraoral) growth opportunity within the dental prac- a tightly seated final restoration, minimize chairside pickup of SynCone caps tice. Studies show that a dissatisfied patient gaps and micro-movement, and provide: in an existing appliance. will tell eight to 10 people, while a satisfied • A cost-effective and comfort- • Indirect (laboratory process) with or patient will tell two to three people. Providing able implant-supported prosthesis without a framework fabricated in an your denture patients with the optimized designed for optimal access for oral existing or completely new denture. function and convenience of an implant- hygiene. o With framework permanent solution supported restoration can directly impact the • A solution that eliminates the need for o Without framework temporary number of satisfied patients that you create. design or manual adjustments often solution Within the options of advanced patient- associated with dentures (e.g., pain In the clinical case below, the ATLANTIS specific implant-supported restorations, of pressure of ill-fitting dentures and Conus solution was selected for surgical DENTSPLY Implants is pleased to introduce atrophy as a result of inactivity or and restorative simplicity considerations. It ATLANTIS Conus concept as the newest pressure requiring relining of existing was also a cost-effective treatment for satis- addition to its digital solutions portfolio. denture), allowing you to save time fying the patient’s requirements for stability, Available for all major implant systems, and increase profitability. restored function and esthetics, and easy ATLANTIS Conus concept provides a friction- • Stable but removable solution that hygiene maintenance. This was a long-term, fit, non-resilient prosthetic restoration for fully offers the comfort of a fixed restoration. temporary solution based on the patient’s existing denture, requiring no new supporting framework. Comparison with other retention systems As with all ATLANTIS solutions, ATLANTIS Ball Locator ATLANTIS Conus concept Conus concept is backed by a comprehensive warranty* for your peace of mind. Hygiene maintenance Easy Easy Easy In addition to patient-specific prosthetic

Resilient/Soft tissue pressure Yes Yes No solutions for all major implant systems, DENTSPLY Implants offers comprehensive Replacement of retention Complicated Easy Not required as virtually solutions for all phases of implant therapy, elements wear-free including digital treatment planning, regen- Compensation of angular Slight correction Slight correction Possible to angulate abut- erative solutions, implant systems, restora- placed implants of nonparallel of nonparallel ments up to 30 degrees tions, and practice development services. implants possible implants possible For restorative versatility, workflow efficiency and flexibility, and design options that go beyond CAD/CAM — choose ATLANTIS™. For more information, contact your local DENTSPLY Implants representative, or visit www.dentsplyimplants.com. IP

Silicone sleeves placed under the New complete upper denture was Final result *Subject to full terms and conditions. SynCone caps to ensure that no pickup adjusted for access to the abutments ** iData Research material would engage an undercut and copings Case images courtesy of Dr. Arnold Rosen, DDS, MBA This information was provided by DENTSPLY Implants.

52 Implant practice Volume 8 Number 1 IN MEMORIAM

Professor Per-Ingvar Brånemark

“Father of Modern Dental Implantology” May 3, 1929 – December 20, 2014

rofessor Per-Ingvar Brånemark has Ppassed away after a long illness at the age of 85. He leaves behind a legacy — the discovery that titanium could be tolerated by the body to provide an anchor for prosthetic devices — that has touched millions of lives.

Visionary Hailed by the modern world as a visionary, the young Professor Brånemark nevertheless struggled to gain acceptance for the concept that he would go on to term “osseointegration.” The young orthopedic surgeon faced opposition by the medical establishment in his native Sweden for almost 20 years. The Toronto Osseointegration Confer- ence in 1982 would change that, providing a forum to bring the concept to the international community, and kickstarting a tidal wave of new research and clinical investi- gation. Since then, the influence of titanium implants has spread across the globe, not only revolutionizing dentistry but benefiting a huge breadth of other medical and veterinary fields as well. Professor Brånemark’s work earned him a vast array of awards and plaudits from insti- tutions all over the world. He held more than 30 honorary positions across Europe and the United States and counted the Swedish Society of Medicine’s Söderberg Prize among some of his most significant honors. The Academy of Osseointegration (AO) continues to honor the life Inspiration and legacy of Professor Brånemark who was an Honorary Fellow of AO. But those who met him were just as “Professor Brånemark was a giant, brilliantly scientific intellect, touched by his enthusiasm as by his shrewd embodied in an equally large compassionate heart. His caring focus mind. A gifted leader and teacher, he more was always on the patient,” said Dr. Edward Sevetz Jr. Past President, than earned his title as the father of dental Academy of Osseointegration. “His breakthrough discovery of osseo- implants after a career that saw him inspire integrated titanium benefits patients throughout the world, and will forever countless young scientists and dentists. His benefit mankind.” dedication to the impact and potential of the “Professor Brånemark’s work genuinely transformed the dental land- field he discovered is neatly summed up in scape and the smiles of millions of people across the globe,” said AO his often-quoted comment: “No one should President Dr. Joseph Gian-Grasso. “It is because of him that the Academy have to die with their teeth in a glass of water of Osseointegration exists, and today we honor his memory and monu- beside their bed.” mental legacy. As an organization, we aspire to encompass his passion Professor Brånemark is survived by his and to continue his lifelong work to enhance oral health globally.” wife, Barbro, his three children, and four grandchildren. IP

Volume 8 Number 1 Implant practice 53 INDUSTRY NEWS

The California Implant Institute offers a range of OCO Biomedical presents “Exploring the Implant implant courses Treatment Modality”: The Next Generation of Dental Implant Training • 4-Day Live Patient Surgical Course (Rosarito, Baja California, Mexico): March 18-21, 2015 and June 24-27, 2015 OCO Biomedical, Inc., will present power-packed, 2-day, • 1-Year Fellowship Program (San Diego, California) starting AGD-Pace Accredited Courses called “Exploring the Implant April 15, 2015 Modality” on February 20-21, 2015, in Fort Lauderdale, Florida, • Advanced Hard and Soft Tissue Grafting with Cadaver and on February 27-28, 2015, in Irving, Texas. These value- Program (Honolulu, Hawaii): April 24-26, 2015 priced, in-depth, 2-day implant dentistry introductory courses • 14-Day Continuous Fellowship Program (San Diego, Cali- form the core of OCO’s nationwide launch of OCO 2015: The fornia): August 3-16, 2015 Next Generation of Dental Implant Training. For more information, visit www.implanteducation.net. These 16 CE unit AGD-Pace accredited courses are designed for either experienced implantologists or for dentists looking to expand their practice by implementing implant treatment modali- Independent study recognizes extreme low dose ties. Attendees will become familiar with the implant surgical kit capabilities of Carestream Dental’s CS 9300 Low and the necessary prosthetic components for start-up. The Dose Mode basics of bone regeneration and grafting, an integral part of endosseous implants, will be taught. The company’s seminar- Recent studies have confirmed that the CS 9300 family of style training focuses on The OCO Advantage: A Complete Dental cone beam computed tomography (CBCT) systems can provide Implant Solutions Approach, a successful, clinically proven meth- 3D exams at up to 85% lower dose than traditional 2D panoramic odology created and developed by OCO Founder and President, imaging. The research, conducted by John Ludlow, DDS, of the Dr. David Dalise, and OCO Chief Operating Officer and Director University of North Carolina’s School of Dentistry, Chapel Hill, of Education and Clinical Affairs, Dr. Charles Schlesinger. found that 3D images captured using the Low Dose Mode for a Additional 2015 training also offered by OCO Biomedical in 5x5 cm adult exam provides an effective dose of just 3 micro- numerous locations nationwide include Exploring the Implant sieverts (µSv).1 Treatment Modality with Cadavers (16 CE units) and Advanced Cadaver Grafting and Implantology Training (16 CE units). Dose-saving algorithms and noise reduction processing For more information, call OCO Biomedical at 1-800-228-0477, enables the new Low Dose Mode to drastically reduce the dose or visit www.ocobiomedical.com. and scanning time of the CS 9300 — between 73% and 95% as compared to standard acquisition mode2 — while maintaining diagnostic image quality. Low Dose Mode is available for 17x11 Global Dental Science partners with Good Fit cm down to 5x5 cm scans and covers multiple applications such Technologies as implant planning; follow-up exams for orthognathic, maxillofacial surgery, or implant; analyzing skeletal symmetry; assessing Global Dental Science (GDS), creators of AvaDent® Digital airways; evaluating impacted teeth and supernumeraries; and Dentures, has partnered with Good Fit Technologies to be the pediatric examinations. exclusive distributor of Good Fit™ Denture Tray products in North An additional benefit of the new Low Dose Mode is that America and Europe. existing units in the CS 9300 family can easily be retrofitted with Good Fit Technologies manufactures a variety of moldable the module, so that doctors denture trays that simplify and shorten the denture fabrication can ensure they’re treating process, including the “All-in-One Denture Tray,” the “All-in-One their patients with the lowest Implant Tray,” and the “Immediate Denture Tray.” These trays dosage possible. can be adapted and fitted in minutes to create custom impres- For more information, sion trays, bite blocks, and stents right in the dental clinic. They call 1-800-944-6365, or visit allow for fast, accurate impressions and measurements, enabling www.carestreamdental.com. dentists to get all the information required for complete denture fabrication in a single clinical visit. 1. Based on studies conducted by John AvaDent Digital Dentures’ revolutionary technology brings the B. Ludlow, University of North Carolina, School of Dentistry: Dosimetry of CS precision, speed, and profitability of digital process automation 8100 CBCT Unit and CS 9300 Low- to removable dentistry using Computer-Aided Engineering (CAE). Dose Protocol, August 2014; Dosim- etry of the Carestream CS 9300 CBCT AvaDent makes it possible for providers to offer a precise fitting unit, June 2011. 85% reduction (3µSv) denture with superior bio-hygienics and esthetics and, for the first found in 5x5 cm adult exams; exact dose reduction varies based on field time ever, create a treatment plan for full mouth rehabilitation all of view and ranges from 0% to 85%. within a digital environment. 2. Based on study conducted by John Ludlow, University of North Carolina, For more information, call 855-AVADENT (282-3368), or go School of Dentistry, Dosimetry of CS 8100 CBCT Unit and CS 9300 Low- to www.avadent.com. For information about Good Fit™ denture Dose Protocol, September 2014. products, call 617-973-5136, or visit www.goodfit.com.

54 Implant practice Volume 8 Number 1

INDUSTRY NEWS

Gendex announces new website launch

Gendex, a leader in dental imaging, stands by its promise to be Always by Your Side with its newly designed website, Gendex. com. The new website allows you to simplify your imaging search on any device whether on a phone, tablet, or laptop. The brand new Gendex website connects you to the entire product family with ease. Explore digital intraoral sensors, panoramic X-ray, Cone Beam 3D, PSP, imaging software and more. Take a 360 degree product tour, or check out the enhanced support section — all at your ﬁngertips, faster, and easier. Gendex is dedicated to improving your practice and advancing patient care through comprehensive solutions and exceptional support. The new Gendex.com is a testament to the ﬁrm’s commitment.

LED Medical Diagnostics officially opens new Atlanta training facility and support center

LED Medical Diagnostics Inc. officially announced the opening of its new training and support facility in Atlanta, Georgia, which has been in use since October 15, 2014. LED Dental Inc., a wholly owned Canadian operating subsidiary of LED Medical, has completed a 20-person training room, which is equipped with Wi-Fi and wireless high-resolution displays for customers, installers, and employees. The training facility includes a lead- lined laboratory for X-ray emission from intraoral and extraoral units and a fully functional RAYSCAN Alpha - Expert dental imaging system, with 3D cone beam computed tomography J. Morita USA introduces AdvErL Evo (CBCT) as well as panoramic and cephalometric capabilities. A dedicated LAN for testing within various types of dental clinic J. Morita USA has introduced AdvErL Evo, an Er:YAG laser networks, including commonly used operating systems and prac- effective for a wide variety of applications on both hard and soft tice management software, is also available. On-site technical tissue and clinically ideal for periodontal treatment. AdvErL Evo support staff members manage a 12-hour, 5-day-a-week call eliminates the vibration of a high-speed handpiece, providing center. In addition, the training facility includes conference and a comfortable laser treatment option. Its wavelength is readily board rooms for meetings with current and potential customers. absorbed by water and efficiently vaporizes soft tissue. This unit For more information, visit www.leddental.com. offers a wide variety of tip options, adding to its versatility, with an extensive selection for periodontic procedures. Applications include removal of subgingival calculus, diseased, infected, ® inflamed, and necrosed soft tissue within the periodontal pocket, DEXIS™ and TeamSmile demonstrate teamwork in bringing dental care to underserved children subgingival calculus, and granulation tissue from bony defects. It may also be applied for soft tissue curettage, sulcular debride- TeamSmile®, a unique national dental outreach program, gains ment, and osseous crown lengthening. continued support from DEXIS™, a brand of the Kavo Kerr Group, Most notably, AdvErL Evo has been studied and recognized for the 7th consecutive year. Since the inception of the TeamSmile clinically in the effective treatment of peri-implantitis, a challenging program in 2007, DEXIS has been a proud supporter through its disease leading to bone loss around an implant. With use of donation and maintenance of its digital imaging systems, DEXIS™ AdvErL Evo, a method has been found to regenerate tissue and Platinum sensors, CariVu™ caries detection, and DEXcam™ permanently remove bacteria with a low-heat treatment process. intraoral cameras, as well as financial contributions. TeamSmile Information about this study, and other peer-reviewed clinical partners with dental professionals and athletic organizations to articles, can be found at www.morita.com/usa/laser. In terms bring together athletic role models and underserved children in of patient benefits, AdvErL Evo is virtually painless. There is far communities across the country at events held throughout the less trauma compared to other laser types, as vaporization is year. These events allow the children to obtain free screening and concentrated at the surface of the tissue. The energy does not treatment and also learn about the importance of their overall penetrate and damage deep layers of tissue, nor does it disperse health. DEXIS has rededicated efforts to assist TeamSmile with widely to the adjacent area around the irradiation target. company volunteers, on-site systems, and funding. For more information, call 877-JMORITA (566-7482), or visit For more information about DEXIS, visit www.dexis.com. www.morita.com/usa/laser.

56 Implant practice Volume 8 Number 1 Save Time and Money by the Bundle

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