implant practice us jan-feb 2013 vol 6 no 1

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clinical articles • management advice • practice profiles • technology reviews

January/February 2013 – Vol 6 No 1

SonicWeld Rx™ — A novel replacement for traditionaltitanium mesh in particulate bone graftingDr. Lewis Cummings

Every picture tells a story: chlorhexidine conundrumDr. Eddie Scher Clinical Case: All-on-4™

and NobelGuide™ in anatrophic mandible

Drs. Paulo Malo, Armando Lopes, Mariana Nunes, André Rodrigues, Ana

Ferro, and Miguel De Araújo Nobre

P R O M O T I N G E X C E L L E N C E I N I M P L A N T O L O G Y

Straumann’s 2013 DentalImplant Complications Symposium

Corporate profileBIOMET 3i

PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!

Volume 6 Number 1 Implant practice 1

January/February 2013 - Volume 6 Number 1

EDITORIAL ADVISORSSteve Barter BDS, MSurgDent RCS Anthony Bendkowski BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent Philip Bennett BDS, LDS RCS, FICOI Stephen Byfield BDS, MFGDP, FICD Sanjay Chopra BDS Andrew Dawood BDS, MSc, MRD RCS Professor Nikolaos Donos DDS, MS, PhD Abid Faqir BDS, MFDS RCS, MSc (MedSci) Koray Feran BDS, MSC, LDS RCS, FDS RCS Philip Freiburger BDS, MFGDP (UK) Jeffrey Ganeles, DMD, FACD Mark Hamburger BDS, BChD Mark Haswell BDS, MSc Gareth Jenkins BDS, FDS RCS, MScD Stephen Jones BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack DDS, CertPerio, FCDS Samuel Lee, DDS David Little DDS Andrew Moore BDS, Dip Imp Dent RCS Ara Nazarian DDS Ken Nicholson BDS, MSc Michael R. Norton BDS, FDS RCS(ed) Rob Oretti BDS, MGDS RCS Christopher Orr BDS, BSc Fazeela Khan-Osborne BDS, LDS RCS, BSc, MSc Jay B. Reznick DMD, MD Nigel Saynor BDS Malcolm Schaller BDS Ashok Sethi BDS, DGDP, MGDS RCS, DUI Harry Shiers BDS, MSc, MGDS, MFDS Harris Sidelsky BDS, LDS RCS, MSc Paul Tipton BDS, MSc, DGDP(UK) Clive Waterman BDS, MDc, DGDP (UK) Peter Young BDS, PhD Brian T. Young DDS, MS

PUBLISHERLisa Moler Email: [email protected] Tel: (480) 403-1505

MANAGING EDITORMali Schantz-Feld Email: [email protected] Tel: (727) 515-5118

ASSISTANT EDITORKay Harwell Fernández Email: [email protected]

PRODUCTION MANAGER/CLIENT RELATIONSKim Murphy Email: [email protected]

NATIONAL SALES/MARKETING MANAGER Drew Thornley Email: [email protected] Tel: (619) 459-9595

NATIONAL SALES REPRESENTATIVE Sharon Conti Email: [email protected] Tel: (724) 496-6820

E-MEDIA MANAGER/GRAPHIC DESIGN Greg McGuire Email: [email protected]

PRODUCTION ASST./SUBSCRIPTION COORDINATOR Lauren Peyton Email: [email protected]

MedMark, LLC15720 N. Greenway-Hayden Loop #9Scottsdale, AZ 85260Tel: (480) 621-8955 Fax: (480) 629-4002Toll-free: (866) 579-9496 Web: www.endopracticeus.com

SUBSCRIPTION RATESIndividual subscription1 year (6 issues) $99 3 years (18 issues) $239

© FMC 2013. All rights reserved. FMC is part of the specialist publishing group

Springer Science+Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Implant Practice or the publisher.

Dear Readers:

Happy 2013! It seems like only yesterday that we were busily preparing to welcome 2012, but in fact, so much has happened in the dental profession and in our publications, that the time has just flown by. The positive momentum of the past year continues to propel us forward. We are happy to note that this year brings a fresh, contemporary look for the magazines. New design elements, an easy-to-read print style, and expanded page size are just a few of the exciting changes that you will find in this, and future issues.

Implant Practice US is growing and evolving to help you grow and evolve. We strive to keep up with current implant trends and to keep our readers up-to-date on the latest techniques and technology in the specialty. Our dentist-authors give of their time and expertise to share the methods that result in better dental care for patients. We are always seeking out new ideas and innovation in our clinical, technology and continuing education articles, and case studies. Our corporate profiles tell the stories of companies that facilitate innovation, and practice profiles share the insights and concepts that inspire practice excellence. And, practice management columns spotlight ways to improve the business aspects of the dental office that can make lives easier for the staff and the boss!

Besides our magazine, Implant Practice US also features a vital and continually changing website (www.medmarkaz.com/web) and e-newsletter with the latest industry news, articles, and information. Our social media mavens keep the action going on Facebook, Twitter, and LinkedIn. So whether you like to turn the pages or click the mouse, information can be in your lap or on your laptop!

Publishing a thought-provoking, diverse magazine with such high standards is a difficult task, but our authors, peer reviewers, editorial advisory board, advertisers, and columnists make it a smooth and enjoyable process. Our editors, sales and production staff, and I appreciate all of our authors and readers and value feedback as we continue to strive for excellence. Please feel free to call or email – we’d love to hear from you.

January is a time for resolutions. We strive to keep up the momentum so that we all can grow together in 2013.

All the best,

Lisa MolerPublisher

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ITICongress North AmericaChicago, USAApril 4 – 62013

5 Great Reasons to CONNECT with the ITI in Chicago.What puzzle pieces are you missing in your practice?

Attend the ITI Congress and complete your puzzle for a successful future.

1. GrowyourpracticerevenuebyattendingThursday’sPre-CongressPracticeManagementForumandlearnabout:Money,HowtoMakeit,HowtoGrowit&CaseAcceptance.

2. Learnfromtopinternationalexpertsandeducators: •UrsBelser:UniversityofGeneva,Switzerland •DanielBuser:UniversityofBern,Switzerland •DavidCochran:UniversityofTexasSanAntonio,USA •JocelyneFeine:McGillUniversity,Canada •Hans-PeterWeber:TuftsUniversity,USA •andmanymore

3. ConnectandbeapartofthelargestdentalNetwork;sharebestpracticesattheITICongressPartyonFridaytobenefittheNFED(NationalFoundationforEctodermalDysplasia)

4. ElevateyourskillintheTechnologyPodswithdemonstrationstaughtbyKeyOpinion LeadersintheTechnologyHall.(DigitalDentalPhotography,LOCATOR®Techniques, CementingonDentalImplants,ProvisionalFabrication,Augmentationtechniques andmore...)

5. TackleComplications–attendSaturday’s“ManagingPuzzleProblems”Sessionandapproachcomplicationswithconfidence.Theprogramwillstartwithcomplicationsfromtherestorativeandsurgicalaspectsintheestheticzone.

TheInternationalTeamforImplantology(ITI)isauniquenetworkthatunitesprofessionalsaroundtheworldfromeveryfieldofimplantdentistryandrelatedtissueregeneration.Notamember?Signuptodaytotakeadvantageofthehighestqualityeducationalsupportandawealthofbenefitstoenhanceprofessionalactivities.Findouthowyoucangeta$200discountontheITINorthAmericaCongressfee.

www.iti.org/congressnorthamerica

Do not wait, take advantage of the early bird rate which expires January 31st and save $100.

Connectivity in Implant Dentistry:Putting the Pieces Together.

Perhaps the best gift I have ever given myself was the pursuit of education. I remember the day I received my dental degree, knowing that a long journey was ahead. I had a plan, and my goal was simple: I would take continuing education courses that interested me and lay the foundation for my future success. It began with restorative treatment and included esthetics. At the same time, my self-confidence in endodontics was lacking, and I committed years to that discipline. Confident with the ability to heal and restore

ailing teeth, I set my sights on surgery. Unfortunately, dental school and residency could only prepare me so far. I yearned to understand the finer points of saving teeth with periodontal surgery, and when unable, then to extract those teeth. After 14 years of more education and honing my craft, I was awarded a Mastership in the Academy of General Dentistry.

Yet, even with that, I always knew there was one discipline in which I was lacking, and it was dental implants. I wasn’t simply interested in learning the science of restoring dental implants. I wanted much more. I sat through many weekend-warrior implant courses, often with a hands-on component using dentoform style models. But rubber and plastic models are a poor substitute for the real thing.

For me, the holy grail of dentistry was learning, understanding, and acquiring the wisdom to surgically place the implant in vivo. I had always felt that all other fundamentals had to be acquired, and at that time, I believed those elements were in my repertoire. With the groundwork laid out, and the foundation solid, I stood at the precipice, wanting to dive into the implant surgical arena. What held me back was fear. Fear of the unknown. Fear of those anatomical structures that haunted me, leading me to believe that with one wrong move, I would violate the maxillary sinus, the mental foramen, or the inferior alveolar nerve.

I knew those areas well enough, and frankly, they scared me. So, one day, I decided that it was time to overcome my anxiety and discover if those bugaboos were really a threat or just the primal fear they inject you with at the undergraduate level. I needed big time education. I sought something that was a commitment of time and funds, the two ingredients integral to any worthwhile venture. For me personally, I discovered and developed this talent (and continue to do so) in a “mini-residency.” Akin to the famed maxi-course, the location was Englewood, New Jersey, a 3-hour drive from my Baltimore home. It was a 6-month commitment of bimonthly lectures, participation, and over-the-shoulder live placement. And yes, there were lots of homework and tests. My teacher and mentor, Dr. John Minichetti, assembled an all-star cast of educators, and between his excellent teaching skills, guidance, and care, I began my journey.

I was thrilled when I learned not only the mechanics of implantology, but also all of the supporting pieces needed for success. I relearned how to extract a tooth, this time ensuring that the event was as atraumatic as possible. I discovered the art of bone grafting extraction sockets, and when they weren’t intact, then how to grow bone. I even deprogrammed my fear of those once dreaded anatomical sites, learning how to correct them (the sinus lift) or avoid them (the mandibular nerves). Once the course was complete, I was sent back into my world to begin this wonderful and exciting journey. Initially, I began cherry-picking my cases, staying within my comfort zone, and as my self-confidence grew, so did my treatment. Today, I am a proud recipient of the Associate Fellowship in the American Academy of Implant Dentistry. Yet, I am even more proud to be considered a kindred spirit with all of you, my fellow implantologists.

I look forward to continued discovery and collaboration in 2013!

Ian E. Shuman, DDS, MAGD

The best gift – education

4 Implant practice Volume 6 Number 1

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Implant-Ad-Dec2012:v 12/5/12 11:00 AM Page 1

TABLE OF CONTENTS

Through the keyholeDr. Scott Marshall Blyer: An affinity for accessibility and approachabilityA strong medical and surgical background, dedication to customer service, and a penchant for “pushing the envelope” keeps this clinician’s practice immersed in innovation

10

Corporate profileBiomet 3iSustainable esthetic treatment, comprehensive tissue management, accelerated therapy, and digitally-driven patient and practice management solutions

14

Case studyClinical Case: All-on-4™ and NobelGuide™ in an atrophic mandibleDrs. Paulo Malo, Armando Lopes, Mariana Nunes, André Rodrigues, Ana Ferro, and Miguel De Araújo Nobre explore an implant solution for extreme cases

28


ClinicalEvery picture tells a story:

chlorhexidine conundrum

Dr. Eddie Scher raises the alarm on

the potentially dangerous effects of

chlorhexidine digluconate

mouthwash ................................20

Customized impression of an

implant-supported fixed partial

denture in the esthetic zone

Dr. David Furze and Mr. Ashley

Byrne describe a method in which all

four maxillary incisors are replaced

with an implant-supported fixed

partial denture ............................22

Continuing educationSonicWeld Rx™ — A novel

replacement for traditional

titanium mesh in particulate

bone grafting

Dr. Lewis Cummings discusses an

improved method for particulate

bone grafting ..............................32

Secure bonding: implants and

overdentures

Dr. Ludwig Hermeler demonstrates

how to modify an existing

overdenture for use with implants

and secure it with direct intraoral

adhesion ....................................36

ImplPracAD2013F_Layout 1 12/14/12 6:01 PM Page 1

Abutments as individual as your patients

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The four features of the ATLANTIS BioDesign Matrix™

work together to support soft tissue managementfor ideal functional and esthetic result. This is the true value of ATLANTIS™ for you and your patients.

ATLANTIS VAD™ Designed from the fi nal tooth shape.

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Strong and stable fi t – customized connection for all major implant systems.

Soft-tissue Adapt™ Optimal support for soft tissue sculpturing and adaptation to the fi nished crown.

Natural Shape™ Shape and emergence profi le based on individual patient anatomy.

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Find out how ATLANTIS™ can bring simplicity and esthetics to your practice. Just take an implant-level impression, send it to your laboratory and ask for ATLANTIS today.

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TABLE OF CONTENTS


ResearchEarly loading versus immediate

loading: case examples

Drs. Alberto Maltagliati, Andrea

Ottonello, Giulio Raffaghello, and

Andrea Mascolo explore esthetics

and function of early and immediate

loading implants ...........................40

Step-By-StepBondBone®

Socket grafting made simple ........44

Product profileAseptico

Aseptico’s AEU-7000L-70V fiber optic

motor system ...............................46

Event previewStraumann’s 2013 Dental Implant

Complications Symposium

Providing Solutions for Your Practice

.....................................................48

Industry newsAribex acquired by the KaVo

Group

Aribex, the leader in portable X-ray

technology, joins the KaVo Group’s

portfolio of dental brands ..............50

AbstractsTreatment of peri-implant

diseases: a compilation of

systematic reviews

Dr. Maria Retzepi rounds up the

current thinking on an increasingly

important aspect of implant dentistry

.....................................................52

Practice managementKnow your liability as a business

owner

Dr. Robert M. Fleisher discusses

how to mitigate general liability risks

besides malpractice claims ...........54

Materials &equipment ......................56

Socket grafting made simple 44

What can you tell us about your background?I grew up in the streets and went to the school of hard knocks. My first experience with dental implants was getting my teeth knocked out after a mix-up of mistaken identity with the local crack dealer. Ok, none of that is true, but what is more boring than a being a dentist from Long Island? The genesis of my interest was after volunteering for an oral surgeon in college.

Is your practice limited to implants?In my practice, I perform the full scope of oral and maxillofacial surgery, although a large portion is dedicated to dental implants.

Why did you decide to focus on implantology?We actually chose each other. I was well trained in my residency in dental implants and continued my learning thereafter. Many of the dentists in my community have a high dental IQ and perform many simple cases themselves. The cases I was getting were cases that were complex, “hopeless,” and failing. It allowed me to push the envelope of science, and in many cases, be the hero doing what others deemed impossible. This excited me as a surgeon and a scientist.

How long have you been practicing, and what systems do you use?I graduated dental school in 2000 and residency in 2006. I have been in private practice for over 6 years. I have worked with many different systems. Straumann® is my personal preference, but Nobel is the most popular in my community, and therefore, my most commonly placed implant.

What training have you undertak-en?I graduated from the Pennsylvania

trusted me to care for them. I have visited my out-of-town patients after treatment in their hotels and even walked their dogs for them, and drove out of state to see a patient because she couldn’t come in. It is a tremendous responsibility to operate on someone, and it is a responsibility I do not take lightly. My accessibility and approachability to my family of patients is what I am most proud of. I have instilled this work ethic into my entire team.

What do you think is unique about your practice?Certainly my training. With a strong medical and surgical background, it allows me to undertake cases where others may not. I also find myself thinking differently than most other implant surgeons, placing more importance on how the teeth fit to the face and the perioral structures. We also hold customer service as a top priority. Upon entering through our glass doors, our waterfall, marble and teak floors set up a serene environment. Our warm, welcoming


PRACTICE PROFILE

Dr. Scott Marshall BlyerAn affinity for accessibility and approachability

State University with a BS in nutritional biochemistry. I then went to Stony Brook dental school. I completed my 6-year oral and maxillofacial surgery training at Long Island Jewish Hospital. In the program, I earned a medical degree (MD) from Stony Brook, and completed a year of general surgery at North Shore University Hospital. I then did a fellowship in cosmetic surgery at Willow Bend Cosmetic Surgery Center in Plano, Texas.

Who has inspired you?On a personal level, my parents are responsible for who I am. My practice’s logo is a portrait of my deceased mother and is a constant reminder of the values she taught me. Professionally, Dr. Uday Reebye is a great friend and an amazing young surgeon who will change dental implantology as we know it. My list of people inspiring me is quite long. These are people who were not afraid to take chances, do the right thing by people, work hard, and who earned everything they have.

What is the most satisfying aspect of your practice?Like Frank Sinatra said, “I did it my way.” It is not the typical office in terms of patient care, ambiance, or services rendered. We don’t stand on ceremony and are very “down to earth.” I love offering different options to patients, and together make their expectations a reality.

Professionally, what are you most proud of?I have done pro bono work, taught, held fundraisers for breast cancer and MS in my community, but my biggest pride comes from my daily dedication to those who

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team will offer you a warm cup of coffee and a seat on our leather lounge chairs. We often send flowers after surgery, and even have a top-of-the-line full-service spa in the office.

What has been your biggest challenge?Trying to find the balance between family and professional life. I work essentially 7 days a week, and even when I am at home, it is difficult to get our profession off my mind. Different ideas are always racing through my mind.

What would you have become if you had not become a dentist?My father wanted me to be a chiropractor, my uncle a caterer, and my mother, the president. I love being creative and thinking of new ideas. I think I would have enjoyed a career in television marketing.

What is the future of implants and dentistry?In the titanium arena, immediate placement of CAD/CAM customized one-piece implants and crowns are the future. Zirconium implants are getting some buzz in the U.S., as we await long-term data. I am currently involved with research using stromal vascular fractions for implant site development, with promising early results. At some point, stem cells will probably replace implants entirely.

What are your top tips for main-taining a successful practice?Always be available. Maintain great communication with your referrals. Treat your patients like one of the family. Every patient gets my cell phone number and a call after surgery. With texting, it allows my patients to reach me at any time and is a welcoming security blanket for them.

What advice would you give to budding implantologists?Find yourself a mentor or someone you can turn to with a problem or question. It is unfortunate more people can’t work like colleagues rather than competitors. Don’t be a robot. Think before you act. The specialty must continue to evolve, so don’t listen to naysayers. If it makes sense biologically, give it a shot.

What are your hobbies, and what do you do in your spare time?I love the New York Knicks, Giants, and Penn State Football. In my spare time, I am always reading and writing scientific articles (yes, I am a nerd). I enjoy going to the gym, playing golf, and spending time with my family, fiancé, and my Daisy (my Chihuahua-Rat Terrier rescue; she’s delicious). With only 24 hours in a day, sleep is not overrated.

Dr. Blyer and his mother Dr. Blyer in action during a consultation

TOP FAVORITES

1. CVS gummy bears

2. Piezosurgery® unit — I love that little sucker

3. Daydreaming and getting a deep tissue massage

4. Making people happy

5. Waking up in the middle of the night and realizing I have another 2 hours of sleep left

6. When things work out

7. Lecturing/teaching

8. Sitting back with an interesting article and keeping up with current literature

9. Foundation bone graft material for socket preservation grafts: easy placement, compressible, no membrane needed, and converts to rock solid bone

10. Hand torquing to 40 Ncm..... ahhhhhh heaven!

IP

Main waiting room

Front desk

Dr. Blyer sponsoring the Carol Baldwin breast cancer fundraiser, 2011

Treatment room

Dr. Blyer’s office team

PRACTICE PROFILE

www.icoivegas2013.org

ICOI is an ADA CERP Recognized Provider. ADA CERP is a service

of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp.

ICOI is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from April 1, 2010 to March 31, 2014. Provider ID# 217378.

Founded in 1987 by a periodontist and an engineer who wanted to be more

responsive to dental needs, BIOMET 3i is now one of the largest dental implant companies in the world. Headquartered in Palm Beach Gardens, Florida, the company spans the globe with nearly 1,000 team members, 18 subsidiaries, and operations in more than 40 countries. Through sustainable aesthetic treatment, comprehensive tissue manage-ment, accelerated therapy and digitally-driven patient and practice management solutions, BIOMET 3i strives to enhance the lives of patients – one at a time.

Sustainable aesthetic treatment solutionsThe PREVAIL® Implant System with integrated platform-switching uses “The Science of Aesthetics” to deliver outcomes through tissue protection1, enhanced osseointegration,2-9 and crestal bone preservation2-6.

Comprehensive tissue manage-ment solutionsSuccessful patient outcomes begin with effective tissue management. BIOMET 3i provides a portfolio of site-specific options that are designed to achieve better results at crucial steps in the process – laying the foundation for successful Guided Bone Regeneration procedures.

Accelerated therapy solutionsBIOMET 3i provides patients with the option of immediate full arch rehabilitation in as little as one day* with DIEM®2. This innovative solution is designed to allow clinicians to differentiate their practices while increasing productivity and patient satisfaction.

BIOMET 3i


CORPORATE PROFILE

Digitally-driven patient and prac-tice management solutionsFor patients, too many dental visits over too long a period of time are barriers to implant dentistry being the treatment of choice. BIOMET 3i delivers a digital solution with a streamlined workflow from start to finish – the BellaTek® Encode® Impression System. The patented BellaTek Encode Impression System with intraoral scanning eliminates the need for impression copings, streamlining the process while improving the patient experience.

BIOMET 3i NanoTite™ Tapered Certain® PREVAIL® Implant

RegenerOss® Allograft

Endobon® Xenograft Granules

BIOMET 3i NanoTite™ Certain® PREVAIL® Implant

OsseoGuard Flex™ Membrane

OsseoGuard® Membrane

DIEM® 2

BellaTek® Encode® Impression System

The PREVAIL® Implant System

Please contact us at 561.776.6700 or visit us online at www.biomet3i.com to learn more.

† Aforementioned have financial relationships with BIOMET 3i LLC resulting from speaking engagements, consulting engagements and other retained services.

The key to achieving long-term sustainable aesthetic outcomes

is preservation of hard and soft tissues. The PREVAIL Implant

System’s unique features are designed for preservation.

Implants designed for primary stability with

two well-researched surface options for bone apposition

Optimized aesthetics with as little as 0.37mm of bone recession1

Higher seal strength as compared to the competitive average2,3

Seal integrity test was performed by BIOMET 3i on December 2011. Testing was done under testing standard ISO 14801. Five (5) BIOMET 3i PREVAIL Implant Systems and five (5) of three (3) competitors’ implant systems were tested. Bench test results are not necessarily indicative of clinical performance.

T issue ProTecT ion 7

enHAnceDosseoinTegrATion 1-6,8,9

cres TAl bonePreserVAT ion 1-5

preservationBY DESIGN™

1. Östman PO†, Wennerberg A, Albrektsson T. Immediate occlusal loading of NanoTite Prevail Implants: A prospective 1-year clinical and radiographic study. Clin Implant Dent Relat Res. 2010 Mar;12(1):39–47.

2. Baumgarten H†, Meltzer A†. Improving outcomes while employing accelerated treatment protocols within the aesthetic zone: From single tooth to full arch restorations. Presented at the Academy of Osseointegration, 27th Annual Meeting; March 2012; Phoenix, AZ.

3. Suttin Z†, Towse R†, Cruz J†. A novel method for assessing implant-abutment connection seal robustness. Poster Presentation 188: Academy Of Osseointegration, 27th Annual Meeting: 2012 March 1–3; Phoenix, Arizona. http://biomet3i.com/Pdf/Posters/Poster_Seal%20Study_ZS_AO2012_no%20logo.pdf. Testing done by BIOMET 3i, Palm Beach Gardens, FL; n = 20.

4. Byrne D, Jacobs S, O’Connell B, Houston F, Claffey N. Preloads generated with repeated tightening in three types of screws used in dental implant assemblies. J. Prosthodont. 2006 May–Jun;15(3):164-71.

5. Boitel N, Andreoni C, Grunder U†, Naef R, Meyenberg, K†. A three year prospective, multicenter, randomized-controlled study evaluating platform-switching for the preservation of peri-implant bone levels. Poster presentation P83: Academy of Osseointegration, 26th Annual Meeting: 2011 March 3–5; Washington DC.

6. Lin A, Wang CJ, Kelly J, Gubbi P, Nishimura I. The role of titanium implant surface modification with hydroxyapatite nanoparticles in progressive early bone-implant fixation in vivo. Int J Oral Maxillofac Implants. 2009 Sep–Oct;24(5):808–816.

7. Zetterqvist et al. A prospective, multicenter, randomized controlled 5-year study of hybrid and fully etched implants for the incidence of peri-implantitis. J Periodontol. April, 2010.

8. Östman PO†, Wennerberg A, Ekestubbe A, et al. Immediate occlusal loading of NanoTite™ Tapered Implants: A prospective 1-year clinical and radiographic study. Clin Implant Dent Relat Res. 2012 Jan 17. [Epub ahead of print]

9. Block MS†. Placement of implants into fresh molar sites: Results of 35 cases. J Oral Maxillofac Surg. 2011 Jan;69(1):170-4.

PREVAIL is a registered trademark of BIOMET 3i LLC. Preservation By Design and Providing Solutions - One Patient At A Time are trademarks of BIOMET 3i LLC. ©2013 BIOMET 3i LLC.


CORPORATE PROFILE

References

1. Zetterqvist L, et al. A prospective, multicenter, randomized controlled 5-year study of hybrid and fully etched implants for the incidence of peri-implantitis. J Periodontol. April, 2010.

2. Baumgarten H†, Meltzer A†. Improving outcomes while employing accelerated treatment protocols within the aesthetic zone: From single tooth to full arch restorations. Presented at the Academy of Osseointegration, 27th Annual Meeting; March 2012; Phoenix, AZ.

3. Suttin Z††, Towse R††, Cruz J††. A novel method for assessing implant-abutment connection seal robustness. Poster Presentation 188: Academy Of Osseointegration, 27th Annual Meeting: 2012 March 1–3; Phoenix, Arizona. http://biomet3i.com/Pdf/Posters/Poster_Seal%20Study_ZS_AO2012_no%20logo.pdf. Testing done by BIOMET 3i, Palm Beach Gardens, FL; n = 20.

4. Byrne D, Jacobs S, O’Connell B, Houston F, Claffey N. Preloads generated with repeated tightening in three types of screws used in dental implant assemblies. J. Prosthodont. 2006 May–Jun;15(3):164-71.

5. Östman PO†, Wennerberg A, Albrektsson T. Immediate occlusal loading of NanoTite Prevail Implants: A prospective 1-year clinical and radiographic study. Clin Implant Dent Relat Res. 2010 Mar;12(1):39–47.

6. Boitel N, Andreoni C, Grunder U†, Naef R, Meyenberg, K†. A three year prospective, multicenter, randomized-controlled study evaluating platform-switching for the preservation of peri-implant bone levels. Poster presentation P83: Academy of Osseointegration, 26th Annual Meeting: 2011 March 3–5; Washington DC.

7. Lin A, Wang CJ, Kelly J, Gubbi P††, Nishimura I. The role of titanium implant surface modification with hydroxyapatite nanoparticles in progressive early bone-implant fixation in vivo. Int J Oral Maxillofac Implants 2009 Sep–Oct;24(5):808–816.

8. Östman PO†, Wennerberg A, Ekestubbe A, et al. Immediate occlusal loading of NanoTite™ Tapered Implants: A prospective 1-year clinical and radiographic study. Clin Implant Dent Relat Res 2012 Jan 17. [Epub ahead of print]

9. Block MS†. Placement of implants into fresh molar sites: Results of 35 cases. J Oral Maxillofac Surg. 2011 Jan;69(1):170-4.

†Dr. Baumgarten, Dr. Block, Dr. Grunder, Dr. Meltzer, Dr. Meyenberg and Dr. Östman have financial relationships with BIOMET 3i LLC resulting from speaking engagements, consulting engagements and other retained services.

††Dr. Gubbi, Mr. Cruz, Mr. Suttin and Mr. Towse contributed to the above research while employed by BIOMET 3i.

World-class learning for dental cliniciansLocated in Palm Beach Gardens, Florida, the Institute for Implant & Reconstructive Dentistry (IIRD®) is a BIOMET 3i initiative for continuous learning and training for dental professionals. This state-of-the-art facility provides clinicians with the latest techniques and courses, empowering clinicians to provide outstanding patient care. The IIRD® was founded by Richard Lazzara, DMD, MScD, who passionately believes that education, evidence-based research and advanced techniques are essential in providing the best solutions to clinicians and patients.

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*Not all patients are candidates for immediate load procedures.

All trademarks herein are the property of BIOMET 3i LLC unless otherwise indicated.

For additional product information, including indications, contraindications, warnings, precautions, and potential adverse effects, see the product package insert and the BIOMET 3i website.

Want more information regarding BIOMET 3i? Please visit the company’s website at www.biomet3i.com or call 1-800-342-5454. Outside the US, please dial +561-776-6700.

This information was provided by BIOMET 3i.

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Back in 2005, I wrote an article warning colleagues about the possibility

of an allergic reaction to chlorhexidine digluconate (Figure 1). This is a compound used in many medical procedures, and of course, is also used as a mouthwash in dentistry. In the U.S., its use is controlled, but in the UK, we can still buy the mouthwash over the counter.

The right mouthwashThere is no question that this drug is very useful when performing surgery, as a pre- surgical rinse, and a follow-up mouthwash (Lambert, et al., 1997; Young, et al., 2002). It also has a major place in the treatment of different types of periodontal disease. In my 2005 article, I included Figure 2 to demonstrate the effect of changing from a chlorhexidine mouthwash to a hot saltwater mouthwash only. Figure 3 shows almost complete healing after 7 days. In that article, I warned colleagues that they must look out for any signs of allergic response when using this compound. However, at that time, there were very few cases reported in the literature.

FatalitiesSince then, there have been at least

two cases reported in the press, where chlorhexidine has been linked to a fatal anaphylactic reaction. The Daily Mail reported one such case on March 22, 2011 with the headline “Patient, 30, collapses and dies at dentist after suffering allergic reaction to mouthwash.” Another such case was reported on February 16, 2011, in the Whitehaven News, this time with the headline “Mouthwash linked to death of patient, 63.”

Plan of actionSince then, the Medicines and Healthcare products Regulatory Agency (MHRA) has issued a Medical Device Alert dated October 25, 2012 (MDA/2012/075). It warns of the risk of anaphylactic reaction due to a chlorhexidine allergy. It gives the following action points, which I am quoting:• Be aware of the potential for ananaphylactic reaction to chlorhexidine• Ensurethatknownallergiesarerecordedin patient notes• Check the labels and instructionsfor use to establish if products contain chlorhexidine prior to use on patients with a known allergy• If apatientexperiencesanunexplainedreaction, check whether chlorhexidine was used or was impregnated in a medical device that was used• Report allergic reactions to productscontaining chlorhexidine to the MHRA• Further guidance on anaphylaxis isavailable from National Institute for Health andClinical Excellence, theResuscitation

Council, and the Association ofAnaesthetists of Great Britain and Ireland.

First aid trainingAs well as the above guidance, I would add that, in my view, it is essential for practices to keep all staff members fully trained in emergency procedures and first aid, including the treatment of anaphylactic shock. Adrenaline should be available in your emergency kit, and all practitioners should be able to recognize the symptoms of anaphylaxis, and be well-versed in how to treat it.

The patient backgroundFinally, prevention is better than treatment, and if the patient has a history of allergies, this must alert us immediately to potential problems. The Care Quality Commissionsuggests that medical histories are updated each time we see our patients: I believe that this is an excellent suggestion, as we can also check their allergy status at this time.

Every picture tells a story: chlorhexidine conundrum


CLINICAL

Dr. Eddie Scher raises the alarm on the potentially dangerous effects of chlorhexidine digluconate mouthwash

Figure 1: Acute allergic reaction due to chlorhexidine mouthwash

Eddie Scher, BDS, LDS, RCS, MFGDP, is a specialist in oral surgery and prosthodontics. He is a visiting professor of implantology at Temple University, Philadelphia, and is editor-in-chief of Implant Dentistry Today.

Figure 2: Changing the mouthwash to hot saltwater: improvement after 3 days

Figure 3: Improvement after 7 days of hot saltwater

RefeRences

Lambert PM, Morris HF, Ochi S. The influence of 0.12% chlorhexidine digluconate rinses on the incidence of infectious complications and implant success. J Oral Maxillofac Surg. 1997;55:25-30,Suppl 5.

Young MPJ, Korachi M, Carter DH, Worthington HV, McCord JF, Drucker DB. The effects of an immediately pre-surgical chlorhexidine oral rinse on the bacterial contaminants of bone debris collected during dental implant surgery. Clin Oral Impl Res. 2002;13:20-29.

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IntroductionWith the advances in implant surfaces and regenerative techniques, the survival rates of dental implants are quoted between 96% and 99%. As such, there has been a change in ethos of implant placement that should now be placed in a restoratively driven manner. The success of implant treatment is no longer merely based on the survival of the implant, but a greater influence is being placed on the esthetic result achieved. The most challenging of aspects of esthetic implant treatment lies within the soft tissue management. Treatment planning the replacement of multiple teeth in the esthetic zone may be considered to be complicated. The number and position of the implants to be placed should carefully consider the soft tissues and, in particular, obtaining the correct

papillary heights, an equivalent gingival height, and buccal soft tissue contour. This clinical report aims to document a technique of provisional restorations to condition the soft tissue, followed by a customized fixed partial denture (FPD) impression designed to give the technical team the correct emergence profiles of both the implant and pontic sites.

Clinical reportA 55-year-old female was referred for an implant consultation (Strand on the Green Dental Surgery, London, England). Her main complaints were continued loss of post crowns, poor esthetics of her resin-bonded FPD, and the loss of bone following the extraction of her upper right lateral incisor. The patient was a non-smoker and revealed no systemic medical

problems that would contraindicate implant therapy. On examination, she had failing restorations of her upper central incisors and her upper left lateral incisor. Bone resorption was clearly noted in the upper right lateral position. Occlusally, she was an incisal class 1 relationship and group function in lateral excursions. The unrestorable incisor teeth were removed without raising a mucoperiosteal flap, consistent with an early implant placement protocol. An immediate composite resin-bonded FPD with metal wings on both canines was modeled to support the interdental papilla and cemented using a glass ionomer cement (Fuji IX, GC). A 6-week healing period was followed by implant placement (Straumann® bone level 4.1 mm diameter, 12 mm length SLActive®, Straumann®) in the central incisor positions according to early implant protocol utilizing a surgical stent. The lateral incisor positions were not used for the implants due to the requirement of a block bone graft. The ridge was contoured using Straumann bone ceramic at both the implant and pontic sites, and a bilayered cross-linked collagen membrane (Bio-Gide®, Geistlich) in a two-layered technique. A further healing period of 3 months was observed prior to a second-stage surgical uncovering of the implants. Composite (Gradia® Direct, GC America, Inc.) was added to the palatal surfaces of both canines to return the patient to canine guidance. A closed-tray impression technique was taken in polyether (Impregum™ Penta™;

Customized impression of an implant-supported fixed partial denture in the esthetic zone


CLINICAL

Dr. David Furze and Mr. Ashley Byrne describe a method in which all four maxillary incisors are replaced with an implant-supported fixed partial denture

Figure 1: Pre-op

David Furze, BDS, MFDS RCS, qualified from Cardiff in 2000 and joined the Royal Army Dental Corp where he achieved the rank of Major. He has served in Germany, Brunei, Bosnia, and all over the U.K. He left the army in 2006 and has since been based in private practice. Dr. Furze has quickly increased his implant exposure by working in Ilkley, London, and Cornwall in implant referral practices. He is currently completing his MClinDent with Kings College London in Fixed and Removable Prosthodontics. He holds an honorary research contract at the Eastman Dental Institute and is currently awaiting several papers for publication. He has recently completed a month fellowship at the University of Bern, Switzerland, working alongside world-renowned implant surgeons. He has lectured nationally and internationally on both the surgical and restorative aspects of implant dentistry, including at the Royal College of Surgeons where he is involved in the teaching and examination of the IQE and MJDF examinations. Dr. Furze is a member of the ITI, the BDA, and SAAD (Society for the Advancement of Anaesthesia in Dentistry). His main area of interest is in implants in the esthetic zone, temporization of implants, customizing impressions, and bone regeneration techniques.

Ashley Byrne, RDT, BSc (Hons), graduated from Manchester Metropolitan University in 2001 and is co-founder and director of Byrnes Dental Laboratory in Oxfordshire, England. He has lectured across the U.K. and Europe on CAD/CAM technology and has been involved in the research and development of the Etkon CAD/CAM system from Straumann.

Figure 2: Surgical stent and implants in place with delivery system still attached

Figure 3: Bone ceramic with lots of blood covering implant and pontic site

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Figure 4: Membrane covering Figure 5: Provisional in situ Figure 6: Gingival contour with provisional removed

Figure 7: Provisional attached to primary cast Figure 8: Silicone impression of provisional Figure 9: Impression copings in situ


CLINICAL

3M™ ESPE™), and a composite provisional bridge was manufactured. Following 6 months of tissue conditioning, a customized FPD impression was taken. The procedure is summarized in Table 1. An irreversible hydrocolloid impression was taken of the provisional FPD in situ, and a full series of clinical photographs was emailed to the laboratory. From the customized implant FPD, impression two casts were constructed. The first was a soft tissue and the second a solid stone. An additional cast of the provisional FPD was used as a guide for the definitive case. The casts were mounted on a semi-adjustable articulator, using the previous lower to ensure the face bow recorded maintained constant. A customized an-terior guidance table was constructed using light-cured acrylic resin. A silicone

index of the current provisional was taken to aid in the design of the metal work ensuring correct support of the porcelain. Two gold cylinders (Straumann bone level regular crossfit) were screwed to the cast and cut down to fit within the index. The metal work was then waxed up allowing 1.5 mm of clearance for the porcelain. The wax was sprued and invested with a phosphate investment (Fujivest® premium, GC America, Inc.) using a 25% liquid to distilled water mix. The FPD was cast in Implant 58 alloy (Cendres Metaux, Biel/Bienne, Switzerland) and allowed to bench cool. The investment was removed, and the metal heat treated in accordance to the Cendres Metaux guidelines. The metal framework was then veneered with porcelain (GC Initial™, GC America, Inc.). The pontic and implant emergence were matched in the ceramic and consistent

on both the soft tissue and stone casts. The definitive FPD is tried in at a bisque bake stage and modifications made. The definitive FPD is then torqued to 35N and access holes filled with composite.

Discussion This use of provisional restorations to condition the tissue is now considered routine if the optimum esthetics are to be achieved. It would seem sensible to provide the technical team with every piece of information required. The use of customized impressions in single tooth replacement has been well documented, but extending the customized impression into the pontic site can further provide the technical team with accurate soft tissue information. The soft tissues collapse almost immediately following the removal of the provisional bridge. In customizing

Table 1

1. The provisional FPD is removed from the patient and replaced onto the initial cast. Care is taken to ensure that there is no contact of the pontics with the cast.2. A light-bodied, fast-setting addition silicone (Provil® Novo CD 2, Heraeus Kulzer) impression is then taken of the apical half of the provisional FPD.3. The provisional FPD is then removed and replaced in the patient.4. Open-tray impression copings are then inserted into the cast.5. Bis-acrylic temporary crown and bridge material, (Integrity®, Dentsply) is used to customize the impression copings to provide an exact replica of the provisional FPD.6. The FPD is removed from the patient, and the customized impression coping is immediately screwed into position supporting the soft tissue contour.7. An open-tray polyether impression is taken (Impregum Penta; 3M ESPE).

A video of the technique may be accessed via www.brynesdental.com.


CLINICAL

Figure 13: Final restoration with black diffuser

Figure 14: Final restoration with black diffuser

Figure 10: Impression Figure 11: Hard tissue cast

Figure 12: Soft tissue cast

the impression copings, the soft tissues are adequately supported while the impression material sets. This information is replicated on the master casts. The accuracy of the impression technique is shown by the immediate support of the soft tissues with no blanching of the tissues at any point. The extent of soft tissue management that may be achieved during this restorative phase is limited. It is regarded that the most important factor in achieving an esthetic result is the correct three-dimensional positioning of the implants. A correct wax-up and surgical stent are therefore required in all esthetic cases.

The choice of positioning the implants in these cases of replacing all the maxillary incisors is critical. The treatment outcome may have been greater if the implants had been placed in the lateral incisor positions. This configuration would remove the potentially hazardous position of placing two adjacent implants. In this case report, this would have required a lateral ridge augmentation procedure, and as such the central incisors sites were chosen. This esthetic risk is minimized as there will only be one midline papilla, and therefore, symmetry will not be altered in this case of placing two adjacent implants. In order to

give the best potential to create a midline papilla, the implants were placed more than 3 mm apart and were of a platform-switched design. This design appears to protect the crestal bone and the subsequent overlying tissue. This clinical report describes a simple, fast, and effective impression technique that accurately replicates the soft tissue emergence from the implant as well as the soft tissue sculpturing of the pontic site.

References available upon request.

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IntroductionEdentulous patients with extremely resorbed jaws have serious limitations when using a removable prosthesis: lack of retention, pain, masticatory and phonetic difficulties, lack of lip support, and loss of vertical dimension. The All-on-4™ concept (Nobel Biocare AB, Gothenburg, Sweden) enables the rehabilitation of extremely resorbed edentulous maxillae or mandibles, placing only four implants, avoiding complex surgical techniques such as bone graft procedures. The NobelGuide™ system (Nobel Biocare AB) allows not only a minimally invasive and simplified surgery, but also the previous planning of the exact position and direction of the implants in the 3D software. This results in a great advantage in “extreme cases.”

Case presentationA 61-year-old healthy female patient attended the private practice (Malo Clinic, Lisbon, Portugal) concerned with poor retention and lack of prosthetic stability due to the severely resorbed mandible. Her goal was to obtain an implant-retained fixed rehabilitation that fulfilled the functional and esthetical demands.

DiagnosisRadiological and clinical evaluations determined that all the inclusion criteria were fulfilled to perform an All-on-4™ surgery following the NobelGuide procedure. The radiographic examination – orthopantomography and CBCT – demonstrated bone availability of 8 mm in height and 5 mm in width between the mental foramina. The clinical evaluation determined an adequate keratinized gingival thickness, low smile line, and mouth opening capability over 40 mm. Because the jaw was completely edentulous, there were no teeth interfering with the surgical planning.

PlanningA new removable denture was manufactured, taking into account the esthetic and functional requirements of the patient, which was used as a radiographic guide. The DICOM files were converted to 3D images by the NobelClinician™ Software (Nobel Biocare AB), and the implants’ virtual planning followed the All-on-4™ concept.

A surgical guide was manufactured by Nobel Biocare according to the plan. The surgical template was used as a guide to obtain a stone cast and to make all the laboratory work. A surgical index was made with silicone (Silagum® Putty; DMG, Hamburg, Germany), and all prosthetic procedures were performed before surgery.

Surgical procedureFollowing the NobelGuide protocol, the surgical guide was stabilized with anchor pins using a surgical index. The surgery was performed following a similar protocol of the All-on-4™ conventional technique. NobelSpeedy™ Groovy RP 13 mm implants (Nobel Biocare AB) were placed in the posterior area, and NobelSpeedy™ Groovy RP 11.5 mm implants (Nobel Biocare AB) were placed in the anterior area according to a flapless approach. All implants were placed with an insertion torque over 50N/cm, and after the implant placement, the surgical guide was removed and the multi-unit abutments (Nobel Biocare AB) were connected using custom positioning guides. The full-arch acrylic resin (Heraeus Kulzer GmbH, Hanau, Germany) prosthesis was screwed on immediately, and occlusal adjustments were performed. The patient was enrolled in an implant maintenance program and instructed to eat a soft diet for 2 months. Oral hygiene appointments were performed postoperatively on day 10, on months 2, 4 and 6, and every 6 months

Clinical Case: All-on-4™ and NobelGuide™ in an atrophic mandible


CASE STUDY

Drs. Paulo Malo, Armando Lopes, Mariana Nunes, André Rodrigues, Ana Ferro, and Miguel De Araújo Nobre explore an implant solution for extreme cases

Paulo Malo, DDS, PhD, is the president of the Malo Clinic in Lisbon, Portugal.

Armando Lopes, DDS, is the director of implantology at the Malo Clinic.

Mariana Nunes, DDS, works in the department of implantology at the Malo Clinic.

André Rodrigues, DDS, works in the prosthodontic department at the Malo Clinic.

Ana Ferro, DDS, is the sub-director of implantology at the Malo Clinic.

Miguel De Araújo Nobre, RDH, MSc, is the director of oral hygiene at the Malo Clinic.

Figure 1: Extraoral preoperative frontal photograph Figure 2: Extraoral preoperative lateral photograph Figure 3: Intraoral preoperative photograph - mandible

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Figure 4: Evaluation of the mouth opening capability Figure 5: Preoperative orthopantomography Figure 6: 3D view of mandible

Figure 7: Computer planning NobelClinician Software™ Figure 8: Intraoral photograph with the radiographic guide and the radiographic index bite registration (Occlufast®, Zhermack SpA, Badia Polisione, Rovigo, Italy) in position before the CBCT according to the double scan technique

Figure 9: Surgical template - mandible

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Figure 13: Intraoral postoperative photograph Figure 14: Final orthopantomography (3-year follow-up)

Figure 15: Occlusal photograph of Malo Clinic acrylic bridge

Figure 16: Frontal intraoral photograph of Malo Clinic acrylic bridges

RefeRences

van Steenberghe D, Ericsson I, Van Cleynenbreugel J, Schutyser F, Brajnovic I, Andersson M. High precision planning for oral implants based on 3D CT scanning. A new surgical technique for immediate and delayed loading. Appl Osseoint Res. 2004;4:27-31.

Maló P, Rangert B, Nobre M. All-on-Four immediate-function concept with Branemark System implants for completely edentulous mandibles: a retrospective clinical study. Clin Implant Dent Relat Res. 2003;5(Suppl 1):2-9.

Maló P, Nobre M, Lopes A. The use of computer-guided flapless implant surgery and 4 implants placed in immediate function to support a fixed denture: preliminary results after a mean follow-up period of 13 months. J Prosthet Dent. 2007;97:S26-S34.

between 1 and 5 years of follow-up, without registering any signs or symptoms of peri-implant pathology, or presence of significant marginal bone resorption (radiographically confirmed).

Final prosthetic protocolSix months after surgery, a Malo Clinic acrylic bridge was manufactured, finalizing the rehabilitation, and fulfilling functional, phonetic, and esthetic requirements. A titanium-acrylic resin implant-supported fixed prosthesis (NobelProcera titanium framework; Nobel Biocare AB)

Figure 10: 30° non-engaging multi-unit abutment guides Figure 11: Surgical index Figure 12: Pre-made removable denture converted into screw-retained fixed acrylic resin complete prosthesis

with acrylic resin prosthetic teeth (Heraeus Kulzer GmbH) was connected. In this final bridge, the occlusion was adjusted according to the patient’s natural dentition: bilateral anteroposterior harmonious contacts more pronounced in the posterior teeth, anterior group incisor protrusive guide, and lateral canine excursive guide. A final orthopantomography was made after fitting of the final rehabilitation. The clinical and radiographic parameters remained stable during the 5-year follow-up.

ConclusionWhen there is a suitable patient selection and a good surgical planning, the use of the All-on-4™ and NobelGuide presents advantages. The time required to perform the surgery is reduced when compared with other methods, making it more convenient to the patient. As this is a flapless procedure, the patient’s well-being is maximized by ensuring greater comfort and minor edema in the oral region. For the surgeon, this technique presents as a precise and predictable approach. This case shows that the rehabilitation of atrophic mandibles with immediate fixed bridges is possible using the All-on-4™ concept. The NobelGuide planning decreases the surgical risks, adding to the known advantages the possibility of using it on extreme cases.

IntroductionEdentulous patients with extremely resorbed jaws have serious limitations when using a removable prosthesis: lack of retention, pain, masticatory and phonetic difficulties, lack of lip support, and loss of vertical dimension. The All-on-4™ concept (Nobel Biocare AB, Gothenburg, Sweden) enables the rehabilitation of extremely resorbed edentulous maxillae or mandibles, placing only four implants, avoiding complex surgical techniques such as bone graft procedures. The NobelGuide™ system (Nobel Biocare AB) allows not only a minimally invasive and simplified surgery, but also the previous planning of the exact position and direction of the implants in the 3D software. This results in a great advantage in “extreme cases.”

Case presentationA 61-year-old healthy female patient attended the private practice (Malo Clinic, Lisbon, Portugal) concerned with poor retention and lack of prosthetic stability due to the severely resorbed mandible. Her goal was to obtain an implant-retained fixed rehabilitation that fulfilled the functional and esthetical demands.

DiagnosisRadiological and clinical evaluations determined that all the inclusion criteria were fulfilled to perform an All-on-4™ surgery following the NobelGuide procedure. The radiographic examination – orthopantomography and CBCT – demonstrated bone availability of 8 mm in height and 5 mm in width between the mental foramina. The clinical evaluation determined an adequate keratinized gingival thickness, low smile line, and mouth opening capability over 40 mm. Because the jaw was completely edentulous, there were no teeth interfering with the surgical planning.

PlanningA new removable denture was manufactured, taking into account the esthetic and functional requirements of the patient, which was used as a radiographic guide. The DICOM files were converted to 3D images by the NobelClinicianTM Software (Nobel Biocare AB), and the implants’ virtual planning followed the All-on-4TM concept.

A surgical guide was manufactured by Nobel Biocare according to the plan. The surgical template was used as a guide to obtain a stone cast and to make all the laboratory work. A surgical index was made with silicone (Silagum® Putty; DMG, Hamburg, Germany), and all prosthetic procedures were performed before surgery.

Surgical procedureFollowing the NobelGuide protocol, the surgical guide was stabilized with anchor pins using a surgical index. The surgery was performed following a similar protocol of the All-on-4™ conventional technique. NobelSpeedy™ Groovy RP 13 mm implants (Nobel Biocare AB) were placed in the posterior area, and NobelSpeedy™ Groovy RP 11.5 mm implants (Nobel Biocare AB) were placed in the anterior area according to a flapless approach. All implants were placed with an insertion torque over 50N/cm, and after the implant placement, the surgical guide was removed and the multi-unit abutments (Nobel Biocare AB) were connected using custom positioning guides. The full-arch acrylic resin (Heraeus Kulzer GmbH, Hanau, Germany) prosthesis was screwed on immediately, and occlusal adjustments were performed. The patient was enrolled in an implant maintenance program and instructed to eat a soft diet for 2 months. Oral hygiene appointments were performed postoperatively on day 10, on months 2, 4 and 6, and every 6 months

Clinical Case: All-on-4™ and NobelGuide™ in an atrophic mandible


CASE STUDY

Drs. Paulo Malo, Armando Lopes, Mariana Nunes, André Rodrigues, Ana Ferro, and Miguel De Araújo Nobre explore an implant solution for extreme cases

Paulo Malo, DDS, PhD, is the president of the Malo Clinic in Lisbon, Portugal.

Armando Lopes, DDS, is the director of implantology at the Malo Clinic.

Mariana Nunes, DDS, works in the department of implantology at the Malo Clinic.

André Rodrigues, DDS, works in the prosthodontic department at the Malo Clinic.

Ana Ferro, DDS, is the sub-director of implantology at the Malo Clinic.

Miguel De Araújo Nobre, RDH, MSc, is the director of oral hygiene at the Malo Clinic.

Figure 1: Extraoral preoperative frontal photograph Figure 2: Extraoral preoperative lateral photograph Figure 3: Intraoral preoperative photograph - mandible

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Figure 4: Evaluation of the mouth opening capability Figure 5: Preoperative orthopantomography Figure 6: 3D view of mandible

Figure 7: Computer planning NobelClinician Software™ Figure 8: Intraoral photograph with the radiographic guide and the radiographic index bite registration (Occlufast®, Zhermack SpA, Badia Polisione, Rovigo, Italy) in position before the CBCT according to the double scan technique

Figure 9: Surgical template - mandible

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CASE STUDY

Figure 13: Intraoral postoperative photograph Figure 14: Final orthopantomography (3-year follow-up)

Figure 15: Occlusal photograph of Malo Clinic acrylic bridge

Figure 16: Frontal intraoral photograph of Malo Clinic acrylic bridges

RefeRences

van Steenberghe D, Ericsson I, Van Cleynenbreugel J, Schutyser F, Brajnovic I, Andersson M. High precision planning for oral implants based on 3D CT scanning. A new surgical technique for immediate and delayed loading. Appl Osseoint Res. 2004;4:27-31.

Maló P, Rangert B, Nobre M. All-on-Four immediate-function concept with Branemark System implants for completely edentulous mandibles: a retrospective clinical study. Clin Implant Dent Relat Res. 2003;5(Suppl 1):2-9.

Maló P, Nobre M, Lopes A. The use of computer-guided flapless implant surgery and 4 implants placed in immediate function to support a fixed denture: preliminary results after a mean follow-up period of 13 months. J Prosthet Dent. 2007;97:S26-S34.

between 1 and 5 years of follow-up, without registering any signs or symptoms of peri-implant pathology, or presence of significant marginal bone resorption (radiographically confirmed).

Final prosthetic protocolSix months after surgery, a Malo Clinic acrylic bridge was manufactured, finalizing the rehabilitation, and fulfilling functional, phonetic, and esthetic requirements. A titanium-acrylic resin implant-supported fixed prosthesis (NobelProcera titanium framework; Nobel Biocare AB)

Figure 10: 30° non-engaging multi-unit abutment guides Figure 11: Surgical index Figure 12: Pre-made removable denture converted into screw-retained fixed acrylic resin complete prosthesis

with acrylic resin prosthetic teeth (Heraeus Kulzer GmbH) was connected. In this final bridge, the occlusion was adjusted according to the patient’s natural dentition: bilateral anteroposterior harmonious contacts more pronounced in the posterior teeth, anterior group incisor protrusive guide, and lateral canine excursive guide. A final orthopantomography was made after fitting of the final rehabilitation. The clinical and radiographic parameters remained stable during the 5-year follow-up.

ConclusionWhen there is a suitable patient selection and a good surgical planning, the use of the All-on-4™ and NobelGuide presents advantages. The time required to perform the surgery is reduced when compared with other methods, making it more convenient to the patient. As this is a flapless procedure, the patient’s well-being is maximized by ensuring greater comfort and minor edema in the oral region. For the surgeon, this technique presents as a precise and predictable approach. This case shows that the rehabilitation of atrophic mandibles with immediate fixed bridges is possible using the All-on-4™ concept. The NobelGuide planning decreases the surgical risks, adding to the known advantages the possibility of using it on extreme cases. IP

With the increased predictability of tissue augmentation and implant

dentistry, it is commonplace to design a final prosthesis from the ideal restorative position rather than simply from where bone is available. Though hard tissue can be regenerated in a variety of defects, its position must be statically maintained during the revitalization period. Traditionally, large particulate bone grafts have been stabilized with a titanium mesh and fixation screw system. Although effective, complications with mesh exposure during healing, and with its inevitable removal, are often encountered. The desire to eliminate factors such as these has led to the development and introduction of a resorbable, rigid fixation system for particulate bone grafting. The following is a case study demonstrating the use of the SonicWeld Rx™ system to increase the ridge within an edentulous site prior to implant replacement. A 49-year-old male presented with a significant buccal osseous defect resulting from the longstanding loss of the mandibular right first molar and second premolar (Figures 1A-1C) with an implant-supported restoration planned as the final prostheses. Given the volume of bone loss

in the molar site and the desire to minimize postoperative morbidity, an allogenic particulate bone graft using freeze-dried bone allograft (FDBA) was chosen for defect regeneration. Though particulated FDBA has proven successful for osseous regeneration1, lateral ridge augmentation often requires rigid, three-dimensional support as the graft mineralizes. This support must be resilient enough to withstand the compressive forces of the overlying soft tissue flap and potential traumatic contact during mastication. Historically, titanium mesh has served as the primary material from which to create three-dimensional, rigid membranes for guided bone regeneration2,3. Titanium mesh offers the advantages of being biocompatible and malleable, easily conforming to defect dimensions. Following manipulation, fixation of the mesh is often required to prevent micromovement during graft maturation. This fixation is often accomplished with the placement of screws or tacks through the mesh into the host bone. This containment and fixation

provide rigid stability for the particulate graft, allowing for bony regeneration in a variety of defects. Though successful in space maintenance, a significant drawback to titanium mesh is the requirement of a second surgical procedure for removal following graft ossification. Often, the overlying soft tissue may partially encase the mesh framework making removal complicated, requiring generous flap access. Additionally, if the titanium mesh becomes exposed during the healing process, complications may arise.4 To overcome drawbacks associated

SonicWeld Rx™ — A novel replacement for traditional titanium mesh in particulate bone grafting


CONTINUING EDUCATION

Dr. Lewis Cummings discusses an improved method for particulate bone grafting

Lewis Cummings, DDS, MS, received his dental degree from the University of Texas Health Science Center at San Antonio. While there, he received the Horace Wells Anesthesiology Award and the Annual Student Award for outstanding achievement in Periodontics from the American Academy of Periodontology. He did his residency at the University of Nebraska Medical Center in Lincoln, where he completed a Master’s Degree in Oral Biology and received his certificate in periodontics. While in Lincoln, Dr. Cummings began to research tissue engineering and has since lectured nationally on the topic. Additionally, Dr. Cummings has advanced his dental implant training by attending the Misch International Implant Institute. Currently, he holds associate professor positions with both the University of Texas Dental School at Houston and the University of Nebraska Medical Center in Lincoln, teaching soft tissue grafting and dental implants in the post-graduate programs. He is also an instructor with the Center for Advanced Dental Education in Dallas, Texas and the Rocky Mountain Dental Institute in Denver, Colorado.

Educational aims and objectivesThe aim of this article is to introduce the reader to an alternative to traditional titanium mesh.

Expected outcomesCorrectly answering the questions on page 35, worth 2 hours of CE, will demonstrate the reader can:• Realize the advantages and disadvantages of titanium mesh in particulate bone grafting.• Describe the need for a resorbable, rigid fixation system for particulate bone grafting in certain cases.• See the various steps involved in the SonicWeld Rx system.

Figure 1A: Preoperative ridge defect Figure 1B: Preoperative ridge defect

Figure 1C: Occlusal view of osseous ridge defect

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with titanium mesh, a resorbable, rigid fixation system has been introduced. The SonicWeld Rx system of resorbable fixation pins and membranes eliminates the need for device removal once healing is complete. The system is comprised of fixation pins and rigid membranes composed of a 50:50 blend of D- and L-isomers of polylactic acid that are broken down over time through hydrolysis. For device placement, an ultrasonic vibrating handpiece is employed that generates frictional heat, allowing the transformation of the solid polymer pins to a temporary liquefied state for insertion at the surgical site. This transformation allows for the engagement of the partially liquefied pin into the ever-narrowing recipient preparation created in the host bone. During this process, a minimal elevation in temperature is created, but only for very short periods of time where the two hard surfaces are in contact.5

After the placement of SonicPin Rx’s, the membrane is cut to the shape desired, and the same frictional heat process is used to weld the two together. The heat created between the two solid pieces of polymer

creates a “spot weld” in the specific location and secures the membrane to the pin. Vertical augmentation can be accomplished by bringing the coronal edge of the membrane to the desired future height of bone. This same technique can be employed in sites where a lingual osseous defect is present. For this case, local anesthetic was ad-ministered, and a traditional full-thickness mucoperiosteal flap was elevated for access to the surgical site. Using rotary instruments, superficial decortication of the edentulous molar site was performed in the area to be augmented (Figure 2).

Three 2.1 x 4 mm SonicPin Rx’s were placed using the SonicWeld Rx protocol (Figures 2 and 3) to stabilize the membrane used for graft containment. For this case, a pin was placed in the interdental space between the lower right premolars, on the mesial of the second molar, and at the apex of the augmentation site. A 12 mm x 30 mm foil was trimmed and welded to the pinheads using the standard protocol (Figure 4). Once welded, the membrane creates a three-dimensional containment system for the particulated bone graft. Following rehydration of FDBA (MinerOss®, BioHorizons® Osteotech) and application

Figure 2: Perforation holes and SonicPin Rx placement Figure 3: SonicPin Rx placement Figure 4: Coronal edge of membrane containing FDBA

Figure 5: Buccal view of coronal edge of membrane containing FDBA

Figure 6: Acellular dermal matrix overlying the grafted site Figure 7: Incision closure using 6.0 polypropylene and 4.0 PTFE suture

To overcome drawbacks associated with titanium mesh, a resorbable, rigid fixation system has been introduced. The SonicWeld Rx system of resorbable fixation pins and membranes eliminates the need for device removal once healing is complete.



of platelet rich plasma, the graft was inserted into the recipient preparation (Figure 5). Once the defect was completely filled with particulate graft, the entire area was covered with an acellular dermal matrix graft (Figure 6). The dermal matrix, rehydrated with platelet rich plasma, was utilized for graft containment and augmentation of the overlying gingiva. Complete and passive site closure was obtained using a combination of 4.0 PTFE and 6.0 polypropylene sutures (Figure 7). A traditional post-surgical protocol was followed for 7 days consisting of anti-inflammatory and antibacterial agents, with the patient being instructed to not masticate in the area.

REfEREncEs

1. Rummelhart JM, Mellonig JT, Gray JL, Towle HJ. A comparison of freeze-dried bone allografts and demineralized freeze-dried bone allografts in human periodontal osseous defects. J Periodontol. 1989;60:655-663.

2. Assenza B, Piattelli M, Scarano A, Iezzi G, Petrone G, Piattelli A. Localized ridge augmentation using titanium micromesh. J Oral Implantol. 2001;27(6):287-292.

3. Malchiodi L, Scarano A, Quaranta M, Piattelli A. Rigid fixation by means of titanium mesh in edentulous ridge expansion for horizontal ridge augmentation in the maxilla. Int J Oral Maxillofac Implants. 1998;13(5):701-5.

4. Miyamoto I, Funaki K, Yamauchi K, Kodama T, Takahashi T. Alveolar ridge reconstruction with titanium mesh and autogenous particulate bone graft: computed tomography-based evaluations of augmented bone

quality and quantity. Clin Implant Dent Relat Res. 2012;14(2):304-11.

5. Pilling E, Mai R, Theissig F, et al. An experimental in vivo analysis of the resorption to ultrasound activated pins (Sonicweld) and standard biodegradable screws (ResorbX) in sheep. Br J Oral Maxillofac Surg. 2007;45:447.

Following 4 months of uneventful healing (Figures 8A-8C), the site was reentered for implant placement. At this time, the particulate bone graft was clinically well integrated with the host bone, and excellent density was noted clinically (Figure 8). Minimal access was necessary at the reentry, as the SonicWeld Rx graft containment system did not have to be removed and was breaking down by hydrolysis. Two implant osteotomies were prepared to receive a 3.8 mm diameter and 4.6 mm diameter BioHorizons® tapered internal hex implants with the Laser-Lok® surface (Figure 9). Given the good bone density and adequate torque placed on the implants during insertion, healing

abutments were placed, preventing the need for a future uncover surgery. The site was then closed with absorbable sutures, and a traditional post-implant placement protocol was followed by the patient for the first week. Following an additional 4-month healing period to allow for proper implant integration, the patient returned to his restorative dentist to begin fabrication of the final restoration. By utilizing the resorbable system and eliminating the need for a second procedure for mesh removal, the patient’s experience was enhanced, and the operator’s chair time was reduced, while an excellent quality of bone was regenerated.

Figures 8A-8C: Four-month reentry compared to preoperative ridge width Figure 9: Implant placement with healing abutment

Visit www.implantpracticeus.com

Email [email protected]

call 1.866.579.9496

With the increased predictability of tissue augmentation and implant

dentistry, it is commonplace to design a final prosthesis from the ideal restorative position rather than simply from where bone is available. Though hard tissue can be regenerated in a variety of defects, its position must be statically maintained during the revitalization period. Traditionally, large particulate bone grafts have been stabilized with a titanium mesh and fixation screw system. Although effective, complications with mesh exposure during healing, and with its inevitable removal, are often encountered. The desire to eliminate factors such as these has led to the development and introduction of a resorbable, rigid fixation system for particulate bone grafting. The following is a case study demonstrating the use of the SonicWeld Rx™ system to increase the ridge within an edentulous site prior to implant replacement. A 49-year-old male presented with a significant buccal osseous defect resulting from the longstanding loss of the mandibular right first molar and second premolar (Figures 1A-1C) with an implant-supported restoration planned as the final prostheses. Given the volume of bone loss

in the molar site and the desire to minimize postoperative morbidity, an allogenic particulate bone graft using freeze-dried bone allograft (FDBA) was chosen for defect regeneration. Though particulated FDBA has proven successful for osseous regeneration1, lateral ridge augmentation often requires rigid, three-dimensional support as the graft mineralizes. This support must be resilient enough to withstand the compressive forces of the overlying soft tissue flap and potential traumatic contact during mastication. Historically, titanium mesh has served as the primary material from which to create three-dimensional, rigid membranes for guided bone regeneration2,3. Titanium mesh offers the advantages of being biocompatible and malleable, easily conforming to defect dimensions. Following manipulation, fixation of the mesh is often required to prevent micromovement during graft maturation. This fixation is often accomplished with the placement of screws or tacks through the mesh into the host bone. This containment and fixation

provide rigid stability for the particulate graft, allowing for bony regeneration in a variety of defects. Though successful in space maintenance, a significant drawback to titanium mesh is the requirement of a second surgical procedure for removal following graft ossification. Often, the overlying soft tissue may partially encase the mesh framework making removal complicated, requiring generous flap access. Additionally, if the titanium mesh becomes exposed during the healing process, complications may arise.4 To overcome drawbacks associated




Dr. Lewis Cummings discusses an improved method for particulate bone grafting

Lewis Cummings, DDS, MS, received his dental degree from the University of Texas Health Science Center at San Antonio. While there, he received the Horace Wells Anesthesiology Award and the Annual Student Award for outstanding achievement in Periodontics from the American Academy of Periodontology. He did his residency at the University of Nebraska Medical Center in Lincoln, where he completed a Master’s Degree in Oral Biology and received his certificate in periodontics. While in Lincoln, Dr. Cummings began to research tissue engineering and has since lectured nationally on the topic. Additionally, Dr. Cummings has advanced his dental implant training by attending the Misch International Implant Institute. Currently, he holds associate professor positions with both the University of Texas Dental School at Houston and the University of Nebraska Medical Center in Lincoln, teaching soft tissue grafting and dental implants in the post-graduate programs. He is also an instructor with the Center for Advanced Dental Education in Dallas, Texas and the Rocky Mountain Dental Institute in Denver, Colorado.

Educational aims and objectivesThe aim of this article is to introduce the reader to an alternative to traditional titanium mesh.

Expected outcomesCorrectly answering the questions on page 35, worth 2 hours of CE, will demonstrate the reader can:• Realizetheadvantagesanddisadvantagesoftitaniummeshinparticulate bone grafting.• Describetheneedforaresorbable,rigidfixationsystemforparticulate bone grafting in certain cases.• SeethevariousstepsinvolvedintheSonicWeldRxsystem.

Figure 1A: Preoperative ridge defect Figure 1B: Preoperative ridge defect

Figure 1C: Occlusal view of osseous ridge defect

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ING

ED

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ION


with titanium mesh, a resorbable, rigid fixation system has been introduced. The SonicWeld Rx system of resorbable fixation pins and membranes eliminates the need for device removal once healing is complete. The system is comprised of fixation pins and rigid membranes composed of a 50:50 blend of D- and L-isomers of polylactic acid that are broken down over time through hydrolysis. For device placement, an ultrasonic vibrating handpiece is employed that generates frictional heat, allowing the transformation of the solid polymer pins to a temporary liquefied state for insertion at the surgical site. This transformation allows for the engagement of the partially liquefied pin into the ever-narrowing recipient preparation created in the host bone. During this process, a minimal elevation in temperature is created, but only for very short periods of time where the two hard surfaces are in contact.5

After the placement of SonicPin Rx’s, the membrane is cut to the shape desired, and the same frictional heat process is used to weld the two together. The heat created between the two solid pieces of polymer

creates a “spot weld” in the specific location and secures the membrane to the pin. Vertical augmentation can be accomplished by bringing the coronal edge of the membrane to the desired future height of bone. This same technique can be employed in sites where a lingual osseous defect is present. For this case, local anesthetic was ad-ministered, and a traditional full-thickness mucoperiosteal flap was elevated for access to the surgical site. Using rotary instruments, superficial decortication of the edentulous molar site was performed in the area to be augmented (Figure 2).

Three 2.1 x 4 mm SonicPin Rx’s were placed using the SonicWeld Rx protocol (Figures 2 and 3) to stabilize the membrane used for graft containment. For this case, a pin was placed in the interdental space between the lower right premolars, on the mesial of the second molar, and at the apex of the augmentation site. A 12 mm x 30 mm foil was trimmed and welded to the pinheads using the standard protocol (Figure 4). Once welded, the membrane creates a three-dimensional containment system for the particulated bone graft. Following rehydration of FDBA (MinerOss®, BioHorizons® Osteotech) and application

Figure 2: Perforation holes and SonicPin Rx placement Figure 3: SonicPin Rx placement Figure 4: Coronal edge of membrane containing FDBA

Figure 5: Buccal view of coronal edge of membrane containing FDBA

Figure 6: Acellular dermal matrix overlying the grafted site Figure 7: Incision closure using 6.0 polypropylene and 4.0 PTFE suture

To overcome drawbacks associated with titanium mesh, a resorbable, rigid fixation system has been introduced. The SonicWeld Rx system of resorbable fixation pins and membranes eliminates the need for device removal once healing is complete.



of platelet rich plasma, the graft was inserted into the recipient preparation (Figure 5). Once the defect was completely filled with particulate graft, the entire area was covered with an acellular dermal matrix graft (Figure 6). The dermal matrix, rehydrated with platelet rich plasma, was utilized for graft containment and augmentation of the overlying gingiva. Complete and passive site closure was obtained using a combination of 4.0 PTFE and 6.0 polypropylene sutures (Figure 7). A traditional post-surgical protocol was followed for 7 days consisting of anti-inflammatory and antibacterial agents, with the patient being instructed to not masticate in the area.

REfEREncEs

1. Rummelhart JM, Mellonig JT, Gray JL, Towle HJ.Acomparisonoffreeze-driedboneallograftsanddemineralizedfreeze-driedboneallograftsinhuman periodontal osseous defects. J Periodontol. 1989;60:655-663.

2.AssenzaB,PiattelliM,ScaranoA,IezziG,PetroneG,PiattelliA.Localizedridgeaugmentationusingtitaniummicromesh. J Oral Implantol. 2001;27(6):287-292.

3. Malchiodi L, Scarano A, Quaranta M, Piattelli A. Rigid fixation by means of titanium mesh in edentulous ridge expansionforhorizontalridgeaugmentationinthemaxilla. Int J Oral Maxillofac Implants. 1998;13(5):701-5.

4. Miyamoto I, Funaki K, Yamauchi K, Kodama T, Takahashi T. Alveolar ridge reconstruction with titanium mesh and autogenous particulate bone graft: computed tomography-based evaluations of augmented bone

quality and quantity. Clin Implant Dent Relat Res. 2012;14(2):304-11.

5. Pilling E, Mai R, Theissig F, et al. An experimental in vivo analysis of the resorption to ultrasound activated pins (Sonicweld) and standard biodegradable screws (ResorbX) in sheep. Br J Oral Maxillofac Surg. 2007;45:447.

Following 4 months of uneventful healing (Figures 8A-8C), the site was reentered for implant placement. At this time, the particulate bone graft was clinically well integrated with the host bone, and excellent density was noted clinically (Figure 8). Minimal access was necessary at the reentry, as the SonicWeld Rx graft containment system did not have to be removed and was breaking down by hydrolysis. Two implant osteotomies were prepared to receive a 3.8 mm diameter and 4.6 mm diameter BioHorizons® tapered internal hex implants with the Laser-Lok® surface (Figure 9). Given the good bone density and adequate torque placed on the implants during insertion, healing

abutments were placed, preventing the need for a future uncover surgery. The site was then closed with absorbable sutures, and a traditional post-implant placement protocol was followed by the patient for the first week. Following an additional 4-month healing period to allow for proper implant integration, the patient returned to his restorative dentist to begin fabrication of the final restoration. By utilizing the resorbable system and eliminating the need for a second procedure for mesh removal, the patient’s experience was enhanced, and the operator’s chair time was reduced, while an excellent quality of bone was regenerated. IP

Figures 8A-8C: Four-month reentry compared to preoperative ridge width Figure 9: Implant placement with healing abutment

Visit www.implantpracticeus.com

Email [email protected]

call 1.866.579.9496

1. Though hard tissue can be regenerated in a variety of defects, its position must be statically maintained during _________.a. the patient’s childhoodb. the year prior to treatmentc. the revitalization period d. a period of retention

2. Traditionally, large particulate bone grafts have been ______ with a titanium mesh and fixation screw system.a. stabilized b. removedc. resorbedd. liquefied

3. Though particulated FDBA has proven successful for osseous regeneration, lateral ridge augmentation often requires rigid, three-dimensional support as the graft _____.a. breaks downb. mineralizesc. elevatesd. rehydrates

4. This (rigid, three-dimensional) support must be resilient enough to withstand ______.a. the pull of the titanium meshb. the compressive forces of the overlying soft tissue flap

c. potential traumatic contact during masticationd. both b and c

5. Historically, _______has served as the primary material from which to create three-dimensional, rigid membranes for guided bone regeneration.a. particulated FDBAb. polylactic acidc. titanium mesh d. L-isomers

6. The SonicWeld Rx system of resorbable fixation pins and membranes ______device removal once healing is complete.a. eliminates the need for b. increases the need forc. helps to facilitated. ensures

7. For device placement, an ultrasonic vibrating handpiece is employed that _____, allowing the transformation of the solid polymer pins to a temporary liquefied state for insertion at the surgical site.a. causes gingival movementb. encases the meshc. dispenses polylactic acidd. generates frictional heat

8. The heat created between the two solid pieces of polymer creates a ______ in the specific location and secures the membrane to the pin.a. reduction in temperatureb. decorticationc. “spot weld” d. vertical augmentation

9. ______ can be accomplished by bringing the coronal edge of the membrane to the desired future height of bone.a. Decorticationb. Vertical augmentation c. Malleability d. Flap access

10. Given ______placed on the implants during insertion, healing abutments were placed, preventing the need for a future uncover surgery.a. the good bone densityb. adequate torquec. absorbable suturesd. both a and b


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The secure hold of full dentures, particularly in the lower jaw, decreases

with age. This is essentially due to progressive jaw atrophy in connection with soft tissue changes and reduced salivation. Implants can help to remedy this. In many cases, the existing restoration can still be used if connecting elements, such as locators, provide a reliable connection between the implants and the functional overdenture. To allow such attachments to be bonded in at chairside, Voco has developed the Quick Up set that makes the clinical workflow both simple and safe for the dentist. Dental implants were originally developed for use in edentulous jaws. As patients become increasingly older, the natural changes in the edentulous alveolar ridge, and, in particular in the lower jaw, result in a deterioration in the hold of the denture. A firm bite can be recreated using various types of implants (one-piece, two-piece, mini-implants). The existing restoration can often be used, but is modified for the connection between the implants and the denture. This is where the attachments, which are precisely aligned to the implant system, come into play. These are bonded into the basis of the denture at the chairside. Thanks to this method, the workflow can be handled internally at the practice, the costs and time required are significantly reduced, and the patient is spared the otherwise unavoidable waiting time due to external laboratory work. Direct intraoral adhesion ensures the maximum possible accuracy. The Quick Up set by Voco (Figure 1) includes all of the necessary components for safe and simple luting.• Fit TestC andB, a low-viscosity liquidcontrol silicone

Secure bonding: implants and overdentures



Dr. Ludwig Hermeler demonstrates how to modify an existing overdenture for use with implants and secure it with direct intraoral adhesion

Dr. Ludwig Hermeler, Med Dent, qualified at the Westfälische Wilhelms Universität Münster in 1988 and established his own practice in Rheine, Germany in 1991. He has had articles published on the subjects of esthetic dentistry, bleaching, implantology, and endodontics. He is a member of the German Association of Oral Implantology (DGOI).

Educational aims and objectivesThe aim of this article is to show a reliable and effective procedure for the adhesion of implants to overdentures at the chairside.

Expected outcomesCorrectly answering the questions on page 39, worth 2 hours of CE will demonstrate that the reader can:• See the benefit that a reliably secured overdenture can have for patients.• Learn one protocol for achieving this through dental implant treatment.• Gain a better knowledge of the process of intraoral adhesion at the chair side.

Figure 1: The Quick Up set (Voco)

• Quick Up adhesive, a bonding agentbetween the denture material and Quick Up• QuickUp,aself-curinglutingcompositein the color of the denture base (gingiva colored)• QuickUpLC,alight-curing,alsogingivacolored, luting composite for amendments/ corrections after the luting of attachments with the self-curing material Quick Up.

Case studyInitial clinical situation: Two OsseoSpeed™ TX implants (Astra Tech) with a diameter of 3.5 mm were inserted in parallel alignment in the atrophied jaw of a 77-year-old male patient. Around 4 months later, they were

exposed following a complication-free period of healing and osseointegration. The fit of the margins and the base of the existing lower jaw dentures are fully functional, the hold is to be enhanced using locators because of jaw atrophy. Figure 2 shows measurement of the height of the mucosa using an abutment depth gauge (Astra Tech). The retentive part of the locator abutments selected according to height should be located supragingivally with sufficient spacing. Placement of the finished overdenture is easier for the patient if the locator secondary components are at the same horizontal height.

CONTINUINGEDUCATION


The abutments are screwed in and tightened to 25Ncm (Figure 3). The resilience spacers, which serve to compensate for mucosal resilience, are positioned on the locator abutments, and then, the locator metal matrices are placed on the locator abutment analogues (Figure 4). Using Quick Up, attachments are secured chairside in three simple steps.

Step one: preparationUsing a felt-tip pen (alternatively, articulating paper, occlusion spray, or similar can be used), the position of the locator metal matrix can be transferred to the denture base by simple copying (Figure 5). The marked areas are relief-ground only enough to enable the denture to be easily inserted over the implants with attached secondary components. Large-scale relief-grinding,and the creation of drainage channels is not necessary when using Quick Up. As well as the clinical check, with the control and covering silicone Fit Test CandB,thecorrectrelief-grinding issimplyshown in the denture base (Figure 6). Fit TestCandBcanalsobeusedinparticularto block out and protect undercut interface areas between the implant and gingiva. The slim, angled cannulae ensure simple and delicate application. Figure 7 shows the applied silicone

Figure 2: Initial situation and measuring of the gingival height for the correct locator height

Figure 3: Placement of the selected locator abutments in the OsseoSpeed TX implants

Figure 4: Resilience spacers and metal matrices in position

Figure 6: Checking of the space required in the denture base using the Fit Test C and B

Figure 7: Covering of the vestibular face of the abutment

Figure 5: Determining the position with a felt-tip pen for copying in the denture base

Figure 9: Visible ditchings upon removal from the mouth

Figure 10: Polymerization of Quick Up LC

Figure 8: Filling of the openings up to two-thirds full, using self-curing Quick Up



for demonstration purposes; as there were no undercuts, it was not required and removed again.

Step two: lutingThe prepared denture base is wetted with the Quick Up adhesive. The overdenture openings intended for the attachments are filled two-thirds full (i.e., not completely) with Quick Up (Figure 8). The denture is reinserted, and correct occlusion is checked without exerting too much pressure on the soft tissue. After a Quick Up curing time of 3-1/2 minutes, the lower dentures can be removed from the mouth. The locator abutments are now bonded into the base both securely and precisely.

Step three: corrections and polishingSince the ground openings in the denture are deliberately not completely filled with Quick Up, ditchings (Figure 9) are evident. These can be filled under visual inspection with the light-curing Quick Up LC andpolymerized (Figure 10). With finishing and polishing, successful adhesion with Quick Up (Figure 11) is concluded. On the locator abutment, the black working insert is exchanged for a locator insert with the desired bond strength – here, initially blue (680g retention force) – and the resilience spacers are removed (Figure 12). Handling is practiced together with the patient, optimal oral hygiene (including

the use of Solostix and chlorhexidine gel) is shown, and the necessary frequent recalls are arranged. Weeks later, a happy patient, who can bite powerfully again, comes to the follow-up session (Figure 13).

ConclusionsWith the Quick Up method – whereby firstly self-curing Quick Up material, followed by light-curingQuickUPLCisusedtolutetheattachments, and secondary components – disastrous adhesion to the implant in the mouth is avoided. The Quick Up components included in the set have been specially designed and combined to enable the simple and safe luting of attachments at the chairside.

Figure 12: Placement of the desired locator insert in the metal matrix using the insertion instrument Figure 13: Trouble-free and close fit of the finished lower prosthesis

Figure 11: Polishing of the denture after bonding in

IP

1. The secure hold of full dentures, particularly in the lower jaw, ______ with age.a. increasesb. decreases c. never changesd. retains its original fit

2. This (change in the hold of full dentures) is essentially due to progressive jaw atrophy in connection with _______.a. soft tissue changesb. bruxation c. reduced salivationd. both a and c

3. In many cases, the existing restoration can still be used if connecting elements, such as locators, provide a ________between the implants and the functional overdenture.a. reliable connection b. modified restorationc. supragingival spaced. higher mucosa

4. A firm bite can be recreated using various types of implants, (__________).a. one-pieceb. two-piecec. mini-implantsd. all of the above

5. (In the case study) The retentive part of the locator abutments selected according to heightshould be located _________.a. below the gingival marginb. supragingivallyc. with sufficient spacingd. both b and c

6. Placement of the finished overdenture is easier for the patient if the locator secondary components are _______ horizontal height.a. at the same b. at a differentc. at the maximumd. not measured by

7. (In this case) The abutments are screwed in and tightened to_____.a. 10Ncmb. 15Ncmc. 25Ncm d. 30Ncm

8. The resilience spacers, which _______ mucosal resilience, are positioned on the locator abutments, and then, the locator metal matrices are placed on the locator abutment analogues.

a. greatly increaseb. greatly decreasec. serve to compensate for d. determine

9. (In step one: preparation) Using _______ (alternatively, articulating paper, occlusion spray, or similar can be used), the position of the locator metal matrix can be transferred to the denture base by simple copying.a. an explorer tipb. a felt-tip pen c. the resilience spacerd. Quick Up adhesive

10. (In step two: luting) After a Quick Up curing time of ______, the lower dentures can be removed from the mouth.a. 2 minutesb. 3-1/2 minutes c. 4 minutesd. 4-1/4 minutes

Secure bonding: implants and overdentures

IMPLANT PRACTICE CEC

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Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $99. To receive credit, complete the 10-question test by circling the correct answer, then either:

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Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the ma-terials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

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Approved PACE Program ProviderFAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement12/1/2012 to 11/30/2016Provider ID# 325231

Introduction“Immediate loading” is a favorite way to maintain appropriate anatomic and topographic proportions between dental arches, to maintain the contact with periodontal tissues, and for the “occlusal/contact memory”.1-2 An edentulous area that remains this way for a long period of time may modify and even preclude the possibility of recreating an occlusion that is esthetic, functional, always predictable, and similar to the original.3 The concept of “primary stability,” torque wrench, osseointegration, and adequate/suitable denture, are the fundamental factors for immediate and long-distance clinical results.4-5 With immediate loading, the management of peri-implant soft tissues can lead to a long-term predictability with 30-year old case-studies;6-7 moreover, the waiting time for osseointegration allows for modulation/mediation of some human mistakes not managed in the early loading phases in the 72-hour prosthetic technique.8 The use of autologous fibrin glue in the same surgery increases the neoangiogenesis and the healing factors’ activity, also obtaining a better predictability regarding soft-tissue management.9-10

Aim of the studyThe aim of this study was to demonstrate the concept of middle and long-term esthetic and functional predictability differentiating: - full arch implant restoration, cemented technique, with loading after 60-90 days (early loading)- full arch implant restoration, screwed technique, with loading after 72 hours (immediate loading) since fixture insertion.

Materials and methodsA retrospective analysis was conducted of patients undergoing implant therapy with a load time period shorter than the standard; the inclusion criteria was a follow-up period of over 2 years. Included in the study were

Early loading versus immediate loading: case examples


RESEARCH

Drs. Alberto Maltagliati, Andrea Ottonello, Giulio Raffaghello, and Andrea Mascolo explore esthetics and function of early and immediate loading implants

Figure 1A: Initial OPG

Alberto Maltagliati, DDS, earned his dental degree from the University of Genoa, in Italy. He has taught at the University of Genoa and the University of Chieti. Andrea Ottonello, DDS, PhD, received his degree from the University of Genoa, and also earned a PhD at the same university. He has been a visiting PhD student and obtained a Fellowship in Periodontology at the Department of Periodontics and Oral Medicine at the University of Michigan, and is now a professor in Periodontology at the University of Genoa.

Giulio Raffaghello, DDS, graduated from the University of Pavia, Italy, and attended a course in endodontics. He is in private practice, with Dr. Mascolo, DDS, in research activities.

Andrea Mascolo, DDS, has a Master in Oral Surgery from the University of Pisa, Italy. He qualified for Implantology at the Brånemark Clinic, Gothenburg, Sweden and attended the Summer School Clinical Implantology Periodontology at the University of Heidelberg, Germany. He is founder and an active member of the Computer Aided Implantology (CAI) Academy and has been a Professor at the University of Genoa since 2001. He is a speaker and author in Italy and abroad, and is an international peer reviewer. He maintains a private practice in Novi Ligure, Italy, devoted to minimally invasive surgical procedures on compromised patients. He is UK GDC registered, and is an expert in periodontics and implantology in private clinics.

Figure 1B: Intra surgery: extractions and inserting fixtures

Figure 1C: Immediately after surgery: taking impression Figure 1D: Detail

Figure 1E: Immediately after restoration Figure 1F: OPG check after surgery

Case 1

233 implants, of which 110 were in the jaw and 123 were in the maxilla: 18 patients, eight male and 10 female, received early loading treatment; two patients were under 50 years old, seven were under 60 years old, and the last nine were under 70 years old. Some patients presented systemic conditions: three were affected by heart disease, and one patient was affected by diabetes. In this patients’ group, we had 10 totally edentulous patients and eight only one arch edentulous patients. Thirteen patients, seven male and six female, received immediate load treatment; eight patients were under 60 years old and five were under 70 years old. Two patients presented with heart disease. In this patients’ group, we had eight totally edentulous patients and five only one arch edentulous patients. For the patients selected, two kinds of implants were used: Intra-Lock® International (Boca Raton, FL) and Tekka In-Kone® (Brignais, FR/EU), with a length from 4 to 13 mm. One hundred and seven implants were fitted with the finished prosthesis with a cemented technique after 60-90 days (early loading); 126 implants were fitted with the finished prosthesis with screwed technique after 72 hours (immediate loading). The chosen technique was opercular and flapless, with the insertion of the implants at least 1 mm under the crestal bone level, to avoid the conic reabsorption peri-implant process. The impression was taken with the pick-up technique with polyvinyl siloxane (Identium® Kettenbach GmbH & Co. KG., Eschenburg, Germany). In the following 36 hours, we tried on the structure. Pick-up impression technique cemented. The prosthesis in metal-ceramic was cemented after 72 hours from implant placement. Autologous fibrin glue was used with PRF methodic to increase peri-implant connective tissue formation and manage inflammation and healing, and accelerate vascularization by the growth factors (i.e. VEGF, PDGF) contained in the buffy coat. All clinical cases have been monitored radiographically with the same machine 12 and 24 months after the loading date. The same doctor monitored all the clinical cases performing a periodontal probe after 6, 12, 18, and 24 months.

Case examplesCase 1 (Figures 1A-1F)A 60-year-old female patient presented

with a totally edentulous maxilla and previous maxillary sinus augmentation before implant restoration, with three 3I™ implants with external hexagon supporting a mandibular overdenture. It was decided that the best course of action was immediate loading with cemented technique adding five Intra-Lock CT 4 mm implants and using the previous implants. The technique chosen was the opercular one, flapless, with the insertion of the implants at least 1 mm under the crestal bone level, to avoid the conic reabsorption peri-implant process. The impression was taken with the pick-up technique with polyvinyl siloxane. In the following 36 hours, the structure was tried on and cementation of the prosthesis in metal-ceramic took place 72 hours after surgery.

Case 2 (Figures 2A-2F)A 45-year-old female patient was affected by chronical periodontitis. The treatment involved immediate loading at the maxilla with eight Intra-Lock CT implants 4 mm; we maintained first and second superior left molars for inter arch occlusal contacts. The prosthetic technique included a posterior

region flat-one bridge with composite filling with screwed technique, with the intercanine area in metal-ceramic. Multiple extractions were performed with maintenance of vestibular and interproximal cortical, and insertion of six Tekka In-Kone implants, which we chose for the excellent esthetic profile given by the switch-platform that reduces prosthetic spaces, increasing the peri-implant connective tissue. Implant insertion 2 mm under the cortical bone allows for peri-implant bone regeneration. Pick-up impression technique cemented. The prosthetic restoration was in metal-ceramic cemented after 72 hours from implant placement.

ResultsAfter 18 months, we report a 2 mm conical peri-implant reabsorption on six implants loaded after 72 hours in parafunctional patients, having natural teeth opposing prosthetic full-arch rehabilitations. No reabsorption was noticed in patients with upper and lower full-arch restorations.11-12 Two implants in the maxilla (first left molar and first right molar in the same patient), both loaded after 72 hours (immediate

Figure 2A: Fixture insertion: operculum Figure 2B: Immediately after surgery: taking impression

Figure 2C: Impression: parallelism between fixtures Figure 2D: Abutment inserted immediately after surgery

Figure 2E: Restoration cementation Figure 2F: OPG

Case 2


RESEARCH

ReFeRenCes

1. Cochran DL, Morton D, Weber HP. Consensus statements and recommended clinical procedures regarding loading protocols for endosseous dental implants. Int J Oral Maxillofac Implants. 2004:109-13.

2. Nkenke E, Fenner M, Vairaktaris EG, Neukam FW, Radespiel-Tröger M. Immediate versus delayed loading dental implants in the maxillae minipigs. Part II: histomorphometric analysis. Int J Oral Maxillofac Implants. 2005;20(4):540-6.

3. Sabattini B. Tecniche ricostruttive e rigenerative dei mascellari atrofici. Torino: TU.E.OR.; 2007:298-301.

4. Nkenke E, Fenner M. Indications for immediate loading of implants and implant success. Clin Oral Implants Res. 2006;7(2):19-34.

5. Lorenzon G. Implantologia funzionale dalla osteointegrazione alla fisiointegrazione. Martina; 2010:4-123.

6. Balshi SF, Allen FD, Wolfinger GJ, Blashi TJ. A resonance frequency analysis assessment of maxillary and mandibular immediately loaded implants. Int J Oral Maxillofac Implants. 2005;20(4):428-34.

7. Grotowski T, Dal Carlo L, Garbaccio D. Carico funzionale immediato di impianti a vite bicorticale di Garbaccio post-estrattivi immediati – studio multicentrico prospettico su 15 anni di esperienza impianto protesica. Chrurgia Orale; 2007.

8. Glauser R, Sennerby L, Meredith N, Rée A, Lundgren A, Gottlow J, Hämmerle CH. Resonance frequency analysis implants subjected immediate or early functional occlusal loading. Successful vs. failing implants. Clin Oral Implants Res. 2004;15(4):428-34.

9. Grotowski T. Syncrystallization - technique for joining dental implants. Physical and clinical observation in 17-year old. Magazyn Stomatologiczny (Polonia). 2007;6:58-69.

10. Linkow L. The Legends of Implant Dentistry. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2010.79-172.

11. Jokstad A, Carr AB. What is the effect on outcomes of time-to loading of fixed or removable prosthesis placed on implant(s)? Int J Oral Maxillofac Implants. 2007;22(suppl):19-48.

12. Diotallevi P, Moglioni E, Pezzuti E,Pierazzini A, Pasqualini ME, Floris P. Correlazioni biomeccanico-radiologiche nel riassorbimento osseo perimplantare. Studio comparativo su 47 soggetti. DoctorOS. 2007;18(2).

13. Klineberg I, Kingston D, Murray G. The bases for using a particular occlusal design in tooth and implant-borne reconstructions and complete dentures. Clin Oral Implants Res. 2007;18(3)151–167.

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loading), failed. Results confirmed an augmentation in short-term esthetics in the immediate loading technique within 24 months, with a physiological maintenance of the inter-implant papilla and a good trophism of the periodontal tissues.

Every technique used needed a good mid- and long-term predictability and repeatability, and with both methods we can assure esthetics and function.13

ConclusionsFinally, in our opinion, supported from

the recorded data, the immediate loading technique (full-arch with screwed technique) represents the current “gold standard” in implant prosthetic restoration, because it reduces intraoperatory time and increases wound healing, in hard and soft tissues, with excellent patient compliance.IP

Socket preservation has become a hot topic for specialists and general

practitioners alike. The amount of bone loss following extractions can be greatly reduced by placing bone graft material immediately post extraction. BondBone® is a unique biphasic calcium sulfate bone augmentation material that can be used for this purpose as a stand-alone product. The term “bi-phasic” refers to the combination of hemihydrate and dihydrate calcium sulfate particles in this product. BondBone does not need a catalyst to set and will set in the presence of blood and saliva. Once BondBone has been hydrated with sterile saline, the pre-set seed particles initiate the setting process. The entire setting process takes 3-5 minutes to occur. In bony defects larger than 10 mm, BondBone can be used as part of a composite graft. This is done by mixing BondBone with a particulate graft material of the clinician’s choice at a ratio of 2:1 BondBone to particulate graft. This allows the paste that is formed to become cementable in the site. Depending on the particulate graft material used, the resorption time of the composite graft could be extended. BondBone used alone has been shown to fully resorb within 3-4 months after placement. Following extraction, the following steps should be followed in a simple socket preservation procedure using BondBone as a stand-alone product.

Socket grafting made simple


STEP-BY-STEP

BondBone®

Figure 1: Simulated canal injected with ink

1. Follow normal post-extraction protocol, which includes fully debriding the socket of all granulation tissue. This will ensure that good bone-to-product contact will be achieved. BondBone begins to set immediately after the hydration process is started. It will fully set within 2-3 minutes after hydration so it is important not to hydrate the BondBone until the graft site is fully prepared.

3. Slowly push down on the BondBone driver to express all of the excess liquid and to compress the BondBone in preparation for placement into the socket. Push down until you feel resistance.

2. Prepare the BondBone in the driver in which it is packaged. Remove the outer small tip, and place the tip of a long, sterile needle filled with sterile saline into the driver. Holding the driver horizontally, slowly express the saline into the driver at a 1:1 ratio of saline to BondBone. Continue until you see a couple of drops of saline drip out of the driver. Remove the needle from the driver.

7. Hydrate gauze with sterile saline, and place the gauze over the graft. Have the patient bite down, and relax for 2 minutes. This will allow the graft to set completely and bond to the bone.

8. After the BondBone is set, cut and place a membrane of choice over the graft, and suture into place.

This information was provided by MIS Implants Technologies, Inc.

www.misimplants.comPhone: 866-797-1333Email: [email protected]

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4. Remove the second tip from the driver. You will notice excess moisture at the opening of the driver. Remove the excess moisture by gently blotting the end of the driver on a piece of sterile gauze.

5. Extrude the BondBone directly into the extraction socket. Slightly overfill the socket just above the crest of the ridge.

6. Take dry gauze, and place it over the BondBone graft while applying pressure to the graft with your thumb. This draws out any excess moisture from the graft.

All Aseptico-branded products are built in the United States, fully regulatory

compliant to U.S. and international manufacturing and safety standards.

AEU-7000L-70V fiber optic motor systemThe AEU-7000L-70V fiber optic motor system is designed for many specialties, including implant, endo, restoration, and oral surgery. Features include a powerful, 40K rpm, autoclavable micromotor with LED illumination. An advanced handpiece calibration system automatically detects the properties of individual implant or endo contra angles for highly accurate speed, torque, and efficiency results at the time of treatment. Adjustable torque up to 80 Ncm ensures compatibility with most implant systems available. Dr. Ara Nazarian, the director of the Reconstructive Dentistry Institute in Troy, Michigan, and noted lecturer says, “The AEU-7000 Aseptico motor with corresponding Mont Blanc handpiece has always performed exceptionally well.” He continues, “I have used the AEU-7000 for root canals, drilling for implants, leveling bone, augmentation procedures, and wisdom teeth removal. Most importantly, when doing large cases, the last thing you want is your surgical motor not working properly. I always rely on Aseptico motors for consistent reliability and superb performance.” The firm’s dedication to customer service is another advantage. Dr. Nazarian says, “Having the very best trained staff and service department, I have found that when I have had a question or needed any assistance when setting up my units, Aseptico fulfilled my needs beyond my expectations. I am so pleased with my Aseptico AEU-7000 units that I recommend them to all my students at the Reconstructive Dentistry Institute as well as at my lectures at various dental societies and conferences.” Dr. Paresh Patel, co-founder of the American Academy of Small-Diameter Implants and clinical instructor at the Reconstructive Dentistry Institute, has used the Aseptico AEU-7000 motor/handpiece for 3 years. He says, “As a wet-fingered dentist whose practice focuses

on extractions, implant placement, and overdentures, the Aseptico unit is one thing I would not want to practice without.” He describes, “My old unit, from another manufacturer, became obsolete as newer versions were released. With Aspetico’s upgradeable software, it is as easy as inserting a flash card into the unit to get the latest features activated.” For more control, Dr. Patel’s preference is to place implants with the surgical motor. He says, “With a push of the button on the foot pedal, I can switch from the implant drill speed preset to the implant placement mode preset. This kind of efficiency reduces our chair time when placing multiple implants. There are six fully programmable buttons. The real advantage for our practice and patients is the ability to change the display name. No longer do I have to look at every part of the screen to see if the speed, torque, water flow, and other variables are correct. If the display says ‘implant placement,’ I know all my individual preferences are set and ready for me to use. This powerful unit has unbelievable torque when it comes to bone leveling or any oral surgery procedure. With 80 Ncm available, smooth, chatter- and vibration-free bone shaping and cutting is possible.” “Once the implants are fully seated, the Aseptico motor is still going to be put to work,” says Dr. Patel. With the ability to handle just about any attachment, I am able to place a straight E-type nose cone on the motor, and relieve dentures, and create space for our overdenture housings with ease. The need to step out of the operatory and into the lab is no longer necessary. A quick push on the foot pedal

to activate another preset is all that is needed. Adjustable torque to grind away metal is available with this unit.” Dr. Patel notes that his assistant, Shannon, likes the easy-to-load irrigation pump when she is setting up for implant cases. She points out that the built-in dynamometer calibrates the motor and each handpiece. “So if you ask the motor to give you 1500 rpm at 40 Ncm, that is what you are ensured to get, and it will even tell you the efficiency,” she says. “This is huge for us, as it lets me know if my handpiece is in need of offsite maintenance.” The LED illumination is also an advantage where the overhead light or head-mounted light has difficulty lighting up the surgical field. The LED is built into the motor so no bulbs or cables are necessary. The clinician can even control the intensity of the LED and save it to any preset. “On a personal note,” says Dr. Patel, “I am glad that Aesptico motors are manufactured in the U.S. The ability to connect with highly trained staff by phone was most appreciated when I needed to set up my first unit 3 years ago. If you are looking to purchase a high quality American made motor, then you should consider the Aesptico AEU-7000. With the ability to handle implant, endo, oral surgery, and restorative attachments, you can have it all.” For information about Aseptico’s full range of motors, handpieces, and accessories, visit www.Aseptico.com, call 866-244-2954 or 425-487-3157, or e-mail [email protected].

This information was provided by Aseptico.

Aseptico’s AEU-7000L-70V fiber optic motor system


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On Friday, March 23, 2012, 400 dental professionals joined Straumann

and the Center for Advanced Implant Training for the first annual Dental Implant Complications Symposium in New York City. This event, highlighting Dr. Stuart Froum’s book of the same title, featured nine top Key Opinion Leaders in the dental industry who spoke on a variety of topics including Medical-Legal Concerns, Treatment Planning, Peri-implantitis, Prosthetic Complications, Surgical Handling of Esthetic Implant Failure Complications, Soft Tissue Complications, and Sinus Complications. In 2013, this highly-regarded event will be held on Friday, May 17 in San Francisco, California, with returning speakers as well as new field experts. The much anticipated presenters are: Drs. Stuart J. Froum, Paul S. Rosen, Ronald E. Jung, Dean Morton, Kirk L. Pasquinelli, Sang-Choon Cho, and moderater Ray C. Williams. The 2012 program attendees spoke highly of the presentations: Dr. Jennifer Hirsch Doobrow noted,

“Thank you for organizing an exceptional symposium. I truly gained an invaluable wealth of knowledge and cannot thank you and the entire panel of speakers enough for sharing your pearls of wisdom with all in attendance.” Dr. Jay Freedman concurred, “Course was amazing. Engaging speakers and was able to apply things I learned the next day I was in my office! As a restorative dentist who works in the same office as my surgical team, I have always enjoyed learning the surgical end so that it can enhance my ability to communicate the complete treatment to patients during case presentations.” Dr. Joseph E. Gian-Grasso added his congratulations to the symposium team, along with his intention of learning more at the next session. “I will certainly be in San Francisco next year.” Stuart J. Froum, DDS, also shared his personal feedback about the Symposium: “The Second Annual Implant Complications Symposium, which will take place in San Francisco on May 17, 2013 promises to continue what the first symposium

began. This will be a program like the first, which will present the latest evidence-based information for the prevention and treatment of implant complications. The latest techniques will be shown and discussed with examples of how to avoid common and uncommon pitfalls that can occur to anyone placing or restoring implants. The speakers are ‘world class,’ and even the most experienced clinicians will come home with practical solutions to problems that may arise during and after treatment. It’s a meeting you don’t want to miss.” Four hundred people attended the sold-out event in 2012, and there were more than 100 people on the waiting list, so those who are interested in attending in 2013 should register early. Visit http://straumann.cvent.com/DIC2013 for complete details and to register. See the Straumann ad in Implant Practice US to receive $20 off your registration.

This information was provided by Straumann.

Straumann’s 2013 Dental Implant Complications Symposium


EVENT PREVIEW

Dental Implant Complications: Providing Solutions for Your Practice will be held on Friday, May 17, 2013 in San Francisco, California

Images were provided by Alexander Mangold

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INDUSTRY NEWS

In November 2012, Aribex, a worldwide leader in portable and handheld X-ray

products, was acquired by the KaVo Group, an affiliation of leading global dental equipment brands. Aribex, best known for the NOMAD™ handheld and portable X-ray systems, will continue to be the center of excellence for the portable X-ray business. Handheld and portable X-ray systems are the fastest growing segment in intraoral X-ray systems, and Aribex’s innovative prod-ucts are supported by strong patents, intel-lectual property, and a robust new product pipeline. Aribex NOMAD X-ray systems are now used in clinical, remote, and mobile facilities throughout the world, from pro-fessional offices to humanitarian missions. The NOMAD significantly decreases costs

and provides hundreds of safe, high-quality images on a single battery charge. “We are thrilled to be joining forces with the KaVo Group, a world class dental organization that shares common values and a passion for future success. The KaVo Group combines over 500 years of dental experience with leading global brands and will certainly bolster Aribex’s ability to further accelerate the adoption of handheld X-ray technology,” says Ken Kaufman, President of Aribex. The KaVo Group consists of market-leading brands such as KaVo, Gendex, DEXIS®, i-CAT®, Instrumentarium, SOREDEX, Pelton & Crane, and Marus. With the acquisition of Aribex, the KaVo Group will reinforce its global imaging

footprint and commitment to market-leading innovation. “We enthusiastically welcome the Aribex team and look forward to further acceleration and expansion of the portable X-ray market,” says Henk van Duijnhoven, Senior Vice President, Dental. “The synergies across our platform are immense from integrated R&D, advances in workflow, technology integration, and a passion to advance the quality of care that our health care providers deliver. We also share a passion for serving our dealer partners with excellence.”

This information was provided by the KaVo Group.

Aribex acquired by the KaVo GroupAribex, the leader in portable X-ray technology, joins the KaVo Group’s portfolio of dental brands

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Non-surgical therapy for the management of peri-implantitis: a systematic reviewMuthukuru M, Zainvi A, Esplugues EO, Flemmig TF (2012). Clinical Oral Implants Research. 23(Suppl 6): 77-83.

The aim of this systematic review was to evaluate the efficacy of non-surgical treatment modalities employed for the management of peri-implantitis. The authors included randomized controlled clinical trials that assessed non- surgical treatment of peri-implantitis with a minimum follow-up period of 3 months. Following application of the inclusion criteria, nine clinical studies were identified and included in this systematic review. The use of Er:YAG laser treatment adjunctively to submucosal debridement has been reported to result in greater reduction in bleeding on probing scores compared to submucosal debridement with adjunctive submucosal irrigation with chlorhexidine digluconate. Likewise, submucosal glycine powder air polishing has been demonstrated to reduce bleeding on probing scores to a greater extent than submucosal irrigation with chlorhexidine digluconate, when used as an adjunct to submucosal debridement with hand instruments. No differences in terms of clinical effectiveness have been found when submucosal glycine powder air polishing was compared with Er:YAG laser treatment.Locally delivered antibiotics (minocycline microspheres or doxycycline hyclate) as an adjunct to submucosal debridement have resulted in greater reduction in bleeding on probing scores and in probing pocket depths compared to submucosal debridement with adjunctive submucosal

irrigation with chlorhexidine digluconate. It should be noted that no progressive peri-implant bone loss has been found following any of the assessed treatments over a maximum observation period of 12 months. In addition, only two studies reported implant survival rates, which were 100% over a 6-month follow-up period. The authors concluded that the available evidence neither supported nor refuted the clinical efficacy of submucosal debridement using curettes or ultrasonic scalers alone and that it was insufficient to indicate whether any of the assessed non-surgical treatments arrested peri-implant bone loss. It was therefore suggested that long-term randomized controlled trials are needed to assess the efficacy of non-surgical therapy on progressing peri-implant bone loss, on implant survival rates, as well as on measures of oral health-related quality of life.

Surgical therapy for the control of peri-implantitisRenvert S, Polyzois I, Claffey N (2012). Clinical Oral Implants Research. 23(Suppl 6): 84-94.

The aim of this systematic review was to evaluate the effectiveness of different surgical treatment modalities in the management of peri-implantitis. The review was based on 26 clinical studies investigating surgical procedures for the treatment of peri-implantitis lesions with a minimum population of seven patients. Overall, the authors suggested that there was marked heterogeneity with regards to the study designs and case definitions for peri-implantitis employed by the clinical trials included in this review, which limited the potential to generalize the reported results. A case series and a controlled clinical trial have reported that the performance of access flap surgery with removal of granulation tissue and implant surface decontamination was successful in reducing the plaque index, the bleeding on

probing, the suppuration and the probing depths, and in arresting the bone loss on 58% of affected implant sites over 5 years. Resective surgery alone or combined with implant surface modification (implantoplasty) has also demonstrated effectiveness in treating patients with peri-implantitis. Interestingly, although systemic antibiotics have been used adjunctively to surgical treatment in most studies, no trials have actually evaluated the additional benefit from systemic administration of antibiotics, and therefore, at present, there is no scientific evidence to support one approach over the other. The clinical trials included in the present review have indicated overall that it is possible to obtain defect fill of peri-implantitis defects following surgical treatment with concomitant placement of autogenous bone or deproteinized bovine bone mineral. However, the authors reported that, at present, there is no evidence to support that the placement of membranes adjunctively to bone grafting procedures provides any additional defect fill. Two clinical studies have reported that the decontamination of the implant surfaces with a CO2 laser or Er:YAG laser, in combination with augmentive or resec-tive procedures, constitutes an effective modality for treating peri-implantitis de-fects. However, the adjunctive use of laser treatment has not demonstrated additional benefits and, as such, it is suggested that the use of lasers as an adjunct to surgical treatment needs to be further elucidated before any firm conclusions can be drawn. Overall, the authors stated that surgical therapeutic modalities for the management of peri-implantitis constitute a predictable method for treating peri-implant disease, and that the obtained clinical outcomes can be retained long-term. Systematic review of quality of reporting, outcome measure-ments, and methods to study

Treatment of peri-implant diseases: a compilation of systematic reviews


ABSTRACTS

Dr. Maria Retzepi rounds up the current thinking on an increasingly important aspect of implant dentistry

Maria Retzepi, DipDS, PhD, MSc, CertClinSpec(Perio), is a registered specialist in periodontics and honorary clinical lecturer in periodontology at the UCL Eastman Dental Institute. She currently works in specialist private practice in central London, England.

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efficacy of preventive and therapeutic approaches to peri- implant diseasesGraziani F, Figuero E, Herrera D (2012). Journal of Clinical Periodontology. 39(Suppl 12): 224-244.

The aim of this systematic review was to evaluate the quality of reporting and the methodology of clinical research on preventive and therapeutic approaches forthe treatment of peri-implant diseases such as peri-implant mucositis and peri-implantitis. The authors conducted a search for randomized and controlled clinical trials reporting on preventive or therapeutic interventions in patients with peri-implantitis or peri-mucositis. The reporting and the methods were evaluated through an analysis of the risk of biases and quality score. Following application of the inclusion criteria, 32 trials were included in this review. Of these, seven focused on prevention, six

on therapeutic treatment of peri-mucositis, 10 on non-surgical treatment of peri-implantitis, and nine on surgical treatment of peri-implantitis. In terms of trials evaluating preventive treatment, the use of triclosan/copolymer mouthwash, and 1% chlorhexidine gel inside the internal part of the implant during abutment placement after 6 months, was related with improved clinical and microbiological parameters. Clinical studies evaluating topical application of chlorhexidine for the treatment of peri-mucositis have reported no adjunctive beneficial effect. Furthermore, trials evaluating different plaque control regimes indicated a superior performanceof an essential oils mouthrinse and of a triclosan/copolymer-containing toothpaste, when compared with a sodium fluoride toothpaste. Regarding the non-surgical treatment of peri-implantitis, no additional benefits were found in a 6- to 12-month follow-up, with the use of different debridement

approaches such as air abrasion, ultrasonic scaling or Er:Yag lasers in peri-implantitis lesions. However, a significant improvement on probing pocket depths has been consistently observed in clinical trials testing local application of antibiotics against scaling alone. All trials evaluating the effectiveness of surgical treatment for peri-implantitis lesions reported some improvements of clinical conditions. However, complete resolution of peri-implantitis has not been reported and, furthermore, significant differences among different surgical treatment modalities have not been reported by studies with a higher quality value. The authors stated that, overall, the current literature on peri-mucositis and peri-implantitis prevention and treatment offers limited potential to extract clinically applicable information, and that the quality of methods and reporting guidelines in clinical methodology should be encouraged.


PRACTICE MANAGEMENT

As small business owners, a category in which most of us as dentists fall, there

are many rules and regulations we must follow. One area of importance that is rarely discussed has to do with our general liability to protect our patients, our staff, and our personal assets. Let’s explore other areas of risk aside from malpractice claims that may help keep you out of trouble.

Innocent chores – major riskMany practitioners find it convenient to have an employee run chores for them. These tasks range from making bank deposits to picking up supplies to transferring patient charts from one office to another. Some utilize the services of their assistants,

secretaries, and office managers rather often. If possible, it is best to avoid any and all of these types of requests. Here is a scenario involving an auto accident that takes place every day in one city or another all around the country. Mary is riding to the bank to make your daily deposit when a dog runs into her path (hopefully she wasn’t texting). She veers off the street, onto the curb at the school bus stop where she kills three children, and four others are paralyzed to varying degrees; an unimaginable tragedy! The families will sue Mary, and since she was acting as your agent when the accident occurred, they will sue you as well and win.

There is much temptation to use others to run chores, but try to do them yourself if at all possible. If an employee does have to run errands, make sure he/she has a valid license and automobile insurance of his/her own. Make sure whoever runs chores for you is responsible, not driving under the influence or distracted by his/her cell phones. You must make sure you have liability insurance as well since, as noted, you will be sued, too. Purchasing an umbrella liability policy provides a large amount of coverage for little cost. Your umbrella policy should be between 5 and 10 million dollars. Get as much coverage as you can reasonably afford to protect yourself as best as you can in an unreasonable climate. Your umbrella policy is usually applicable to your home and offices as well, giving you an extra boost of protection against a lawsuit.

Personal liabilityWhile your homeowner’s and automobile insurance policies protect you from most personal injury claims, the bigger worries are the catastrophic claims that require the umbrella policy noted above. People slip and fall all the time. They often try to find

Robert Fleisher, DMD, graduated from Temple University School of Dental Medicine in 1974 and received his certificate in endodontics from The University of Pennsylvania in 1976. He taught at Temple University and The University of Pennsylvania and is now a member of the Affiliate Attending Staff – Albert Einstein Medical Center, Philadelphia, Department of Dental Medicine, Division of Endodontics, Philadelphia, Pennsylvania. Dr. Fleisher is the

founding partner of Endodontics Limited, P.C., one of the larger endodontic practices in the United States. After retiring from practice, he now devotes his time to writing about practice management, aging and health issues, and fiction with a medical bent.

You can read about all of Dr. Fleisher’s methods to improve bedside manner in his book Bedside Manner - How to Gain Your Patients’ Respect, Love & Loyalty. www.bedsidemanner.info. Dr. Fleisher can be reached at: [email protected].

Know yourliability as a business ownerDr. Robert M. Fleisher discusses how to mitigate general liability risks besides malpractice claims

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an excuse for their misfortune by blaming others and exaggerating the claim. There are some protective measures that will keep your personal and business properties less risk-prone, and reduce the chance for a fall in the first place. Tour your properties periodically to look for potential problems like defective pavements, potholes, loose carpeting, defective waiting room chairs, sharp edges, heavy objects on flimsy shelving, and any potential threats to the safety of visitors to your home and practice. Parking lots should be well lit and properly paved with safe and easy access to your building. Periodically have a serviceman check the stability of your overhead lights and X-ray equipment. Equipment falling onto your patient can result in considerable damage and grief for all involved. If you practice in a colder climate, make sure that icy conditions are managed appropriately with application of salt or sand, snow is removed in a timely manner, and any water that may result in slippery surfaces is attended to. Assign someone on your staff to be in charge of safety, and make sure that he/she develops a list that documents that he/she is doing the inspections regularly. Discuss your accident prevention program with your staff, and stress the importance of safety. Make sure you have a protocol in place to manage emergencies, whether it’s from a slip and fall, or a medical emergency related to patient care. Rather than running around in panic mode, each person should have a responsibility that allows for attending to the patient and a prompt call for emergency personnel. During an emergency, it is not the time to run around looking for your emergency kit or checking the dates on the contents. With a well-run emergency program in place, there should be no sign of panic, and most other patients in your office will not realize that an emergency has occurred until the ambulance pulls up to your door. Having periodic emergency drills will allow you to handle most emergency problems in a professional and discreet manner. The last thing you want is chaos, considering there will likely be several witnesses to what took place during an emergency. You don’t want the plaintiff to show the jury how you were not prepared, and the resultant panic delayed timely and appropriate care resulting in further injury.

Vicarious liabilityAnyone who works for you can pose a threat by any and all of his/her actions. This is called vicarious liability – liability incurred due to the actions of others. These actions can include having your secretary or assistant making suggestions for managing postoperative pain to an associate who provides patient care. The rationale for vicarious liability is based on the legal concept respondeat superior. This model was developed many years ago and means that the master is responsible for the acts or omissions of the servant. This states that you are responsible for the negligent actions of your staff members, including associates and possibly even independent contractors who offer services in your practice. To reduce your liability, it is imperative to define and control all work-related procedures, and supervise all staff

members. Make sure you script exactly what you want your staff to tell patients regarding postoperative care and sequelae as well as any instructions you have auxiliary staff provide to patients. Having written handout information is the best way to make sure you control instructions to patients, and it makes it much easier for your staff to learn the exact contents of the handouts. This allows them to offer the same instructions verbally when queried by the patient. A patient who sees your associate, the independent contractor, will likely sue you as well if a claim of malpractice arises unless you inform the patient of the independent status. Without this notification, the patient has good reason to believe that the associate is an employee under the supervision of the owner of the practice, and therefore, making the owner liable for the actions of the associate. A notification of the independent status of the associate, on the patient registration/informed consent form that the patient signs, will help to reduce your vulnerability from the actions of the independent

Make sure you have a protocol in place to manage emergencies, whether it’s from a slip and fall, or a

medical emergency related to patient care.

contractor. However, remember you are going to be held responsible for any of your regular associates if the plaintiff can prove that you should have been aware of the poor quality of the associate’s work. How hard is it to subpoena several charts of patients your associate worked on to show a pattern of poor quality? Get rid of anyone who doesn’t practice quality care. Make sure you have vicarious liability insurance coverage. Require a certificate of insurance from all professional employees, and make sure you check yearly that they have paid up policies. You should be listed as an additional insured on their policy just as your associates should be listed as an additional insured on your policy. Examine all educational credentials of any employees requiring licensure, and make sure they have valid licenses. Check references on job applications to make sure they are legitimate. Get

written permission to contact an applicant’s references, and have the applicant sign a release form authorizing former employers to provide references. Call all the names on the reference list, not just the top ones. Any question you ask a reference must abide by all non-discrimination laws. It’s easy to be lazy about hiring, but the liability consequences can be enormous. Do your homework! Protect yourself by employing these ideas. They will help make you bulletproof to lawsuits. Many people and lawyers are just waiting for the opportunity to file a claim. Don’t let yourself remain vulnerable. Most of all, consult with your lawyer and insurance agent to help you properly institute the ideas contained herein.

This article is an excerpt from Dr. Fleisher’s soon to be published, From Waiting Room to Courtroom – How Doctors Can Avoid Being Sued.

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DEXIS connects with the all-new Dentrix Developer Program and with Dentrix® users

DEXIS, LLC, whose premier product is the only digital X-ray system that fully integrates with Dentrix, is now a member of the Dentrix Developer Program, created for those companies that want to develop specific Dentrix G5 Connected applications. Both the DEXIS® Digital Imaging System and the DEXIS® Integrator™ for DENTRIX® have also been accepted into the Dentrix MarketPlace program. The Dentrix MarketPlace online portal provides a central location for users to easily review and select technologies that are associated with their Dentrix program and which ultimately enhance their practices. The DEXIS Digital Imaging System with its award-winning Platinum Sensor and the feature rich DEXIS® Imaging Suite software provides clinicians with the best image quality, most comfortable sensor, and fastest workflow. For more information on DEXIS Imaging Suite and the DEXIS® Platinum Sensor, and to learn about DEXIS imaging solutions, visit www.dexis.com.

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PREAT Corporation introduces the new Hader Alignment Housing

Dental professionals now have a choice between the popular Horix/Hader thin housings and the new knurled Hader Alignment Housings. The alignment groove on top of the Alignment Housing provides an easy way to maintain clip alignment, assure that the clips have not rotated prior to processing, and maintain a parallel path of insertion/draw. The Alignment Housings work with all retentions of Hader clips.

For more information, or to place an order, contact www.preat.com, 800-232-7732.

The Wand® STA® All-Injection System

Ideal for pediatric dentistry, endodontics, implant, and general dentistry, the Wand® STA® All-Injection System allows clinicians to gently, precisely, and quickly administer most injections (PDL, block, palatal, etc.) without the fear or anxiety of traditional syringes. Single tooth injections eliminate numbness of the cheek, lips, or tongue for a more pleasant experience during and after the procedure. Doctors can perform bilateral dentistry during a single visit! The Wand® STA® is made in the USA and provides real-time audio and visual guidance.

For more information, call 866-244-2954 or visit www.Aseptico.com.

RGP signs license to produce Relax and Hydro armrests

RGP has long been selling its articulating armrests, and under a newly signed license agreement, RGP owns the rights to manufacture the armrests. According to Sales Manager, Jason DeCosta, “The Relax arm is a two-dimensional armrest that moves with you to accept the weight of your arm off your back, neck and shoulder. It allows the user to hold a mirror or retract for long periods while alleviating the tension and strain usually associated with longer procedures. The Hydro arm is a three-dimensional armrest designed to provide ‘full range-of-motion’ for the dominant-instrument arm.” Visit RGP’s web site at: www.rgpdental.com; call: 800-522-9695 x5534, or fax: 401-254-0157.

CareCreditSM announces free practice management CD featuring Dr. Rhonda Savage

CareCredit is offering a complimentary educational audio CD, Accountability = Energized Teams and Satisfied Patients, featuring Dr. Rhonda Savage, chief operating officer of Miles Global, a practice management and consulting firm exclusively serving dentists. In this audio program, Dr. Rhonda Savage shares how accountability “done right” can improve communications, efficiency and help the practice run smoother. Practices that currently accept CareCredit can request a copy of this complimentary audio CD by contacting their Practice Development Team at 800-859-9975. Practices that have yet to add CareCredit as a payment option can call 800-300-3046, ext. 4519 to request their complimentary copy.

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implant practice us jan-feb 2013 vol 6 no 1

Documents

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msc gareth jenkins bds

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msurgdent philip bennett