Tạp chí Implant tháng 10 2013 vol 6 no5

Tạp chí implant tháng 10 2013 Vol 6 No5

PAYING SUBSCRIBERS EARN 24

CONTINUING EDUCATION CREDITS

SO MUST YOUR IMPLANT CHOICE

It’s a fact – denture patients commonly have narrow ridges and will require bone grafting before standard implants can be placed Many

of these patients will decline grafting due to the additional treatment time or cost For these patients, the new narrow diameter LOCATOR Overdenture Implant System (LODI) may be the perfect fi t Make LODI your new go-to implant for overdenture patients with narrow ridges

or limited fi nances and stop turning away patients who decline grafting Your referrals will love that LODI features all the benefi ts of the LOCATOR Attachment system that they prefer, and that all of the restorative components are included.

©2013 ZEST Anchors LLC All rights reserved ZEST and LOCATOR are registered trademarks of ZEST IP Holdings, LLC.

grafting Your referrals will love that LODI features all the benefi ts of the LOCATOR Attachment system that they prefer, and that all of the restorative components are included.

2.5mm

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Discover the benefi ts that LODI can bring to your practice today

by visiting www.zestanchors.com/LODI/31 or calling 855.868.LODI (5634)

Cuff Heights

Diameters

Volume 6 Number 5 Implant practice 1

October 2013 - Volume 6 Number 5

EDITORIAL ADVISORS

Steve 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

Paul Tipton BDS, MSc, DGDP(UK)

Clive Waterman BDS, MDc, DGDP (UK)

Peter Young BDS, PhD

Brian T Young DDS, MS

CE QUALITY ASSURANCE ADVISORY BOARD

Dr Alexandra Day BDS, VT

Julian English BA (Hons), editorial director FMC

Dr Paul Langmaid CBE, BDS, ex chief dental officer to the Government

for Wales

Dr Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private

Dentistry

Dr Chris Potts BDS, DGDP (UK), business advisor and ex-head of

Boots Dental, BUPA Dentalcover, Virgin

Dr Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St

referral implant surgeon

PUBLISHER | Lisa Moler

Email: lmoler@medmarkaz.com Tel: (480) 403-1505

MANAGING EDITOR | Mali Schantz-Feld

Email: mali@medmarkaz.com Tel: (727) 515-5118

ASSISTANT EDITOR | Kay Harwell Fernández

Email: kay@medmarkaz.com Tel: (386) 212-0413

EDITORIAL ASSISTANT | Mandi Gross

Email: mandi@medmarkaz.com Tel: (727) 393-3394

DIRECTOR OF SALES | Michelle Manning

Email: michelle@medmarkaz.com Tel: (480) 621-8955

NATIONAL SALES/MARKETING MANAGER

Drew Thornley

Email: drew@medmarkaz.com Tel: (619) 459-9595

PRODUCTION ASST./SUBSCRIPTION COORD

© 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.

The implant world is rapidly evolving Final restorative seating of cases with a more natural look with scalloped tissues is the newest, fastest growing trend in implantology The implant field has progressed: we no longer discuss modification

of the implant surface to promote osseointegration; more focus is on the soft tissues surrounding the implant The focus is now on maintaining tissue height, contour, and esthetics by using surgical techniques or by using implant surface modifications such as Laser-Lok® (BioHorizons®) or platform switching

“This is clearly the focus of implant dentistry today Crestal bone preservation at the head of the implant Platform switching, slopping shoulder, laser microchannels and microgrooves are the predominant macro and micro geometries currently discussed,”

according to Maurice Salama, DDS

Implants have been shown to be successful in the treatment of multiple restorative needs: replacing single teeth, multiple teeth, or a full mouth of teeth with fixed or removable restorations Technology and research have improved to modify the surfacing

of the implant to help increase bone-to-implant contact, decrease healing times, and improve the long-term restorability of implants Initial research was first focused on the integration of titanium to bone, and long-term followup was needed to show if this therapy was a good treatment option for patients Today, we have over 50 years of research to show that implants integrate with bone and have long-term success rates

We also have the benefit of state-of-the-art technology, like CBCT imaging, and improved surgical techniques, such as guided surgery, to remove much of the guesswork from procedures, and aid in the success rates of implant therapy and placement Due to this paradigm shift in the implant world from simply getting implants to work to emphasizing esthetic outcomes, there has been a change in the focus of implant dentistry from osseointegration to peri-implant esthetics

Proper soft tissue development is of the utmost importance to today’s clinicians, because it improves both the peri-implant esthetics of the final case and also the long-term stability of implants Prior to implant placement, the soft tissue can be modified, using one of many techniques, to promote proper tissue contour

There are different ways of improving the peri-implant tissue It can be achieved

by grafting with soft tissue or alloderm, modifying the amount of keratinized tissue with various surgical techniques, or developing the soft tissue scallop/papilla around an anterior tooth before making the final crown

The long-term esthetic success of an implant is dependent upon maintenance of the implant by the doctor to help avoid infection that could lead to failure of the implant This

is done by properly placing implants in the correct position, and secondly, by properly restoring implants Clinicians should always avoid concave pontics, ridge-lapped crowns, and open contacts These make it hard for patients to clean and maintain, ultimately leading to complications such as peri-implantitis Getting the patients invested in the hygienic care of their implant can also help mitigate potential issues before they become big problems that can threaten the success of the implant

Integration of implants has proven to be successful long term, but in a still-developing field, there remains a need for more research to develop the soft tissue around implants Dentists placing implants need to be more concentrated on how to properly develop tissue in order to avoid complications in the future Using what we learned yesterday, and focusing on research today, will give us better outcomes tomorrow

Daniel Domingue, DDS, FICOI, MICOI, DICOI, ASAAID, FAAID, DABOIMentor/Lecturer: Rocky Mountain Dental Institute, Denver, ColoradoLecturer: Implants in Black and White, Lafayette, Louisiana

Shifting trends: osseointegration

to peri-implant esthetics

Practice profile 6

Dr Robert J Miller: Setting the bar high

This clinician discusses the true joy of treatment success and his recipe for

delivering high quality care in a predictable fashion.

Dr Dean Vafiadis delves into the use

of a coded healing abutment 12

Restoring the edentulous maxilla

Dr Ross Cutts discusses a cost effective way to restore the edentulous upper arch 20

Bridge construction in the anterior tooth area of the maxilla

Dr Steffen Wolf juggles esthetic requirements to produce pocket- friendly results for a patient with very particular needs 26

Continuing

education

Missing lateral incisors:

overcoming the problem of

insufficient space

Dr Ian Hallam presents a case study

providing a solution for a patient who

does not wish to undergo orthodontic

treatment, using narrow implants 34

Dental rehabilitation of a

6-year-old boy with a rare tumor of the

mandible

Drs T Nyunt, K George, H Chana,

and G.I Smith discuss treatment and

maintenance of an unusual

pediatric case 40

On the horizon

“Lok”-ed and loaded

Dr Justin Moody explores Laser-Lok

implant technology 44

Technology

CBCT and implants: the new era in

treatment planning and diagnosis

Dr Randolph Resnik discusses the

benefits of 3D imaging in a modern

implant practice 46

Industry news

Osteogenics Biomedical to

host 2014 Global Bone Grafting

Symposium in Scottsdale, Arizona

World-renowned speakers showcase

latest in bone grafting techniques,

materials, and research 48

The big debate

Drs Michael Norton and Julian Webber discuss — implants or endodontics? 50

Practice development

Apply current tax laws to improve patient care

Bob Creamer explains Section 179 and Bonus Depreciation 54

Practice management

Growing the money tree

William H Black, Jr discusses the financial advantages of having a good plan in place 56

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We invite you to join us on our journey to redefi ne implant dentistry.

For more information, visit www.dentsplyimplants.com.

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by providing high quality and groundbreaking oral healthcare solutions that create value for dental professionals, and allows for predictable and lasting implant treatment outcomes, resulting in enhanced quality of life for patients.

What can you tell us about your

background?

I am a graduate of Hobart College in

Geneva, New York where I earned a BS in

Chemistry I received my DMD at the Henry

M Goldman School of Dentistry at Boston

University I also did my residency in

Periodontics at Boston University, receiving

a CAGS (Certificate of Advanced Graduate

Study) I have been in private practice since

1986 in Plantation, Florida

Is your practice limited to

implants?

No, we also offer all phases of periodontal

therapy, including regenerative therapy,

mucogingival surgery, and anterior esthetic

procedures When I was a resident, implant

dentistry was still not widely accepted and

was not part of the curriculum As a result

of my early training, when confronted with

a compromised tooth, my instinct is to try

save it I believe that this is an advantage,

as comprehensive treatment has to include

salvaging teeth whenever it is appropriate

Why did you decide to focus on

implantology?

I received my first training in implant

placement in 1987 This course changed

the way I viewed dentistry For the first time,

there was a predictable option for tooth

replacement Taking this course opened

my eyes to what I perceived as cutting

edge and the future of dentistry With this

in mind, I ultimately dedicated myself and

my practice to providing state-of-the-art

implant therapy to my patients At some

point, I recognized that many patients

who would like implant therapy were not

necessarily candidates due to anatomical

limitations This was an impetus to work

towards focusing on restorative-driven

implant solutions versus surgically-driven

Guided bone regeneration soon became

the focus of the practice, and is still a large

part

How long have you been

practicing, and what systems do

you use?

I began private practice in 1986 and placed

my first dental implants in November

of 1987 This patient still returns for periodontal maintenance, and I am proud

to say that the original prosthesis is still

in position I have used several systems through the years, including the original NobelPharma system for approximately 10 years I switched to Straumann® in 1998, which I have been using exclusively for the past 13 years This system provides me with all the surgical and restorative options that are necessary for state-of-the-art implant rehabilitations

What training have you undertaken?

I have taken many courses through the years, including the NobelPharma surgical certification course at Boston University

in 1987 Early on, there were very few comprehensive courses, and learning was more a function of groups of people getting together and discussing the various issues facing implant surgery and restoration

As implant dentistry evolved, certain individuals began to separate themselves

as the true leaders and innovators in the profession These included Drs Ron Nevins, Dennis Tarnow, Burt Langer, and Alan Meltzer These people were instrumental in my early training in surgical placement More recently, I have had the opportunity to take the Masters Level Bone Grafting course with Dr Danny Buser at the University of Bern, Switzerland There are many people who have been part of the evolution of implant dentistry, and I would

like to think that the next 27 years will be equally as exciting

Who has inspired you?

I have had many people inspire me through the years; however, as a resident, there are two people who come to mind Drs Steve Pollins and Simao Kon each had a hand in helping me to develop a practice philosophy and setting the bar high As a periodontal resident at Boston University, they would spend hours discussing cases and aspects of treatment for which they were passionate I learned from them the true joy of treatment success and a recipe

to deliver high quality care in a predictable fashion

What is the most satisfying aspect

of your practice?

I often say that my practice is primarily composed of my “friends” coming to “my house” to visit me Having been in practice for 27 years, I have many patients who have been part of the “family” for a number

of years It is extremely gratifying to have patients return to the office for periodontal maintenance who have had their implant rehabilitations functioning for over 20 years

Professionally, what are you most proud of?

I am most proud of becoming a Fellow of the ITI (International Team of Implantology) Attaining this goal was a culmination of a lot

of hard work and dedication Five years ago, with the urging of my close friend Dr Jeff

Dr Robert J Miller

Setting the bar high

PRACTICE PROFILE

Ganeles, I began to pursue the fellowship,

which requires a high level of activity in

education, research, or leadership It was

at that time I decided to take advantage

of publishing opportunities and went on

staff as a Courtesy Appointment with the

Community Based division program at the

University of Florida Hialeah Dental Clinic

Becoming a Fellow of the ITI has opened up

many doors and continues to be a source

of inspiration and resources for education

and leadership

What do you think is unique about

your practice?

One of the nicest parts of our practice is

the fact that we have four hygienists who

have each been working in our office no

less than 20 years Patients continually

remind me how comforting it is to see the

same familiar faces My surgical assistant

has been with me for 15 years, making her

truly my right hand

What has been your biggest

challenge?

My biggest challenge to date has been

incorporating the new technologies in

our office in a cost-effective and efficient

manner Dentistry changes every 6

months, particularly from a technological

perspective, but in the end, they may not

be adding value to our practices Weeding

through technology that is relevant and

appropriate for my practice has been an

ongoing challenge; however, this is never a

chore as I have always embraced change

and innovation

What would you have become if

you had not become a dentist?

More than likely I would have worked with

my father in the dress business However,

as I have been more involved in product

development, I have a lot of respect for

biomedical engineers As I learn more

about their importance in the medical

device industry, I find myself more intrigued

with this profession Perhaps this would

have been an option However, as they say, don’t give up your day job!

What is the future of implants and dentistry?

I am extremely excited about the future of implants and dentistry I see restorative dentistry moving more towards CAD/CAM restorations comprised of materials that are even more esthetic Ultimately, dentists who are not involved in digital dentistry are being left behind As far as the future

of dental implants per se, I feel that there will be a push towards robotic implant placement removing human involvement

In the short term, with the advent of zirconia dental implants, the concept of custom-milled dental implants may get some traction However, due to the fact that these are medical devices, FDA approval will be an uphill battle, making the concept very difficult to get off the ground

What are your top tips for taining a successful practice?

main-The best tip that I can give is to empathize with patients I firmly believe that one should keep the Golden Rule in mind, which is,

“One should treat others as one would like others to treat them.” If you use this as your mantra while treatment planning, you will always have the patient’s best interest in mind This translates to patient satisfaction that results in a successful practice

What advice would you give to budding implantologists?

My advice to budding implantologists would be to find a mentor who can help

you to choose your cases carefully, as there is no worse feeling than failure Often, less experienced clinicians will undertake procedures that may be too advanced for their experience level, resulting in an undesirable outcome This results in a black eye for both the clinician and the profession as a whole I also strongly suggest that less experienced clinicians should hitch their star to a surgical or restorative mentor and should also seek out top quality companies, as this is an area that one shouldn’t compromise If clinicians undertake procedures that are within their comfort zone using high quality materials, there is no reason that they should not enjoy success

What are your hobbies, and what

do you do in your spare time?

My favorite hobby is skiing However, for a South Florida resident, it becomes logistically difficult I try to ski on average

10 to 15 days a year, which is admirable for the geographically challenged Other hobbies include squash, photography, fly fishing, yoga, and working out

4 Single Malt Scotch

5 Good initial stabilization

6 A “white out” at Ajax Mountain

7 Quiet time with my family

8 Finishing a bike ride up Maroon Bells

9 New attachment!

10 Salmon roll with brown rice

11 Downshifting into third gear and accelerating in an open road!

With roots that can be traced back to

the 19th century, Carestream Dental

certainly has a long history of innovation

when it comes to dental specialties—

including implantology This legacy carries

on still, as the company continues to

develop imaging systems and software

and enter new markets It’s because of this

proud tradition that more than 800 million

images are captured each year on products

from the company’s imaging portfolio

Today, Carestream Dental is focused on

providing implantologists with the products

they need to facilitate treatment planning

and improve patient care

History of Carestream Dental

The Carestream Dental of today was

built on the shoulders of major industry

leaders of the past — starting in 1896

when Eastman Kodak introduced the first

photographic paper designed specifically

for dental X-rays As technology improved

and became more digitalized, Trophy

Radiologie filed a patent for the world’s

first digital intraoral sensor in 1983 Already

known for producing intraoral X-ray

generators, the digital intraoral sensor

earned Trophy a reputation as the world’s

leader in dental digital radiography

In 2000, PracticeWorks emerged as a

dominant dental software company when it

acquired several other software companies

PracticeWorks went on to acquire Trophy

Radiologie in 2002, and was purchased

the next year by Eastman Kodak to expand

its presence in the dental business With

the integration of PracticeWorks/Trophy,

Eastman Kodak built the industry’s leading

portfolio of film, digital imaging systems,

and practice management software Then,

in 2007, Onex Corporation purchased

Kodak’s Health Group, and Carestream

Dental was born

The Carestream Dental Factor

“We exist to make your practice better,”

said Marc Gordon, Carestream Dental’s

General Manager, U.S Equipment and

Software “Our number one goal is to make

user-friendly, yet sophisticated, technology

to put our customers’ practices at the

Workflow integration: Administrative

tasks cut into time that can be better spent communicating with and treating patients

For this reason, Carestream Dental designs systems and software to enhance treatment planning and fit seamlessly into busy implant practices Ensuring that every link in the chain fits and contributes to the workflow as a whole allows implantologists

to increase productivity and efficiency

Intuitive technology and software are the hallmarks of Carestream Dental By developing imaging systems that can be quickly utilized by practitioners — and are even compatible with third-party products

— implant specialists can eliminate time that would have been spent troubleshooting problems and instead focus on patients

Humanized technology: Patients

are an integral part of every implant

practice, so Carestream Dental is committed to providing solutions that facilitate communication between the implant specialist and patient When communication is optimized, patients are happier and healthier — allowing them

to make better, more informed decisions regarding their proposed treatment plan and, in turn, increasing case acceptance

Diagnostic excellence: When evaluating

sites for implant placement, details are everything To facilitate faster, more reliable implant planning, Carestream Dental has created a number of cutting-edge diagnostic tools that enable implant specialists to capture sharp, high-quality images quickly From industry-leading 3D imaging systems to high-resolution intraoral sensors, Carestream Dental offers

a range of solutions that allow practitioners

to identify areas of concern and determine the best course of action

Technology developed for clinicians, by clinicians

The Carestream Dental Factor isn’t the only thing driving user-focused and innovative products, and services — the clinicians at the heart of the company also play a large role Through meetings and forums with doctors in the field, Carestream Dental

A history of proven technology, a future dedicated to innovation

3D Symposium

• Optimize your image quality and dosimetry

• Make accurate assessments, diagnoses and treatments

• Experience seamless integration

• One system for superior 3D exams, 2D panoramic scans and

optional one-shot cephalometrics

To learn more about what a great image can do for your practice,

visit carestreamdental.com/3DIP or call 800.944.6365 today

© Carestream Health, Inc., 2013 9438 DE AD 0713

The CS 9000 3D and CS 9300 Select are

ready to work hard for your practice.

These technologically advanced systems will finally give you clarity, flexibility

and, most importantly, complete control of your image quality and dosimetry

It will also show your patients how dedicated you are to their dental health.

It’s amazing what a great image can

do for your practice.

is better able to understand the needs of

implant specialists in order to develop —

and modify — products In fact, the voice

of the customer (VOC) is critical throughout

the development process

To ensure quality, Carestream Dental

also keeps tight control over the products

they develop “We are the only company that

is designing its own practice management

software and imaging equipment,” said

Mr Gordon “By controlling every step in

the process — from development and

manufacturing all the way to support — we

make it easier for implantologists to deliver

better patient outcomes.”

Innovative products to facilitate

implant planning

Implant specialists require high-resolution

images to evaluate the implant site, and

Carestream Dental certainly delivers The

following is just a sample of the imaging

products Carestream Dental has designed

to meet the specific needs of implant

practices:

CS 9300: As a two-in-one unit (or

three-in-one, for doctors who choose the

cephalometric option), the CS 9300

allows users to select from panoramic

and cone beam computed tomography

(CBCT) imaging Users can also choose

from seven selectable fields of view for the

Premium model (ranging from 5 cm x 5 cm

to 17 cm x 13.5 cm) and four selectable

fields of view for the Select model (5 x 5

cm to 10 x 10 cm) to tailor their image

based on the specific clinical application

And, the system features Intelligent Dose Management for greater control over patient exposure

CS 3D Imaging Software: Included

with Carestream Dental’s CBCT imaging units, CS 3D Imaging Software allows practitioners to view images slice by slice

in axial, coronal, sagittal, cross-sectional and oblique views to enhance diagnostic interpretation In addition, the software includes two sophisticated implant planning modules so users can select from a comprehensive library of implant manufacturers or create their own custom implant sizes

RVG 6100: With greater than 20 lp/

mm resolution per image, Carestream Dental’s RVG 6100 sensors deliver the highest image resolution in the industry

Each sensor undergoes rigorous testing to provide maximum durability and flexibility, and the RVG 6100 features a rear-entry cable, three different sizes, and rounded corners to improve comfort for patients and make positioning easier for users

Comprehensive education

When implant specialists understand how

to fully maximize their imaging capabilities, they are better able to get the most of out of their equipment For this reason, Carestream Dental is committed to providing thorough training and education

to ensure their customers have the skill and

knowledge necessary to use their imaging products and software

In addition to providing web-based and in-person training, Carestream Dental holds 3D Symposiums, where dental practitioners can learn how to use 3D imaging equipment in their daily practice This event features leaders in the industry who share advice and insights, as well as information on the latest industry trends in 3D, to make participants’ practices more efficient and successful

Next steps

With the launch of CS Solutions, a appointment CAD/CAM restoration system, Carestream Dental will once again enter an entirely new market—and it certainly will not be the last As an integrated, open-architecture system, practitioners can scan

one-an impression with a CBCT unit or scone-an the patient’s mouth directly with the CS 3500 intraoral scanner, design the crown, inlay,

or onlay using the CS Restore software, and mill the crown in-office with the CS

3000 milling machine For doctors who would rather send the design or milling off to the lab, they can easily submit the information electronically to their dental lab

Mr Gordon

To learn more about Carestream Dental’s portfolio of imaging products and software for implant practices, please call 800-944-6365 or visit carestreamdental.com today

This information was provided by Carestream Dental.

Implant planning with software

Implant planning

For more information, please contact your local

BIOMET 3i Sales Representative today!

In the USA: 1-888-800-8045

Outside the USA: +1-561-776-6700

Or visit us online at www.biomet3i.com

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 n = 102.

† Dr Östman has a financial relationship with BIOMET 3i LLC resulting from speaking engagements,

consulting engagements and other retained services.

Reference 1 discusses BIOMET 3i PREVAIL Implants with an integrated platform switching design,

which is also incorporated into the 3i T3® Implant.

* 0.37mm bone recession not typical of all cases.

For additional product information, including indications, contraindications, warnings, tions, and potential adverse effects, see the product package insert and the BIOMET 3i Website 3i T3, Preservation By Design and PREVAIL are registered trademarks and 3i T3 Implant

precau-design, NanoTite and Providing Solutions - One Patient At A Time are trademarks of BIOMET

3i LLC ©2013 BIOMET 3i LLC

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

material is intended for clinicians only and is NOT intended for patient distribution This rial is not to be redistributed, duplicated, or disclosed without the express written consent of BIOMET 3i

mate-Introducing the

Digital design software programs for teeth

and implant restorations have evolved

over the past 5 years.1-3 Using CBCT

scans and digital preoperative scans, the

clinician can properly plan the placement

of implant fixtures.4 Various software

programs and intraoral scanners offer

analysis of proper implant position, angle

of implant placement, and depth of tissue

and occlusal clearance.5,6 The utilization

of coded healing abutments (BellaTek®,

Encode®, Biomet 3i) may also add to the

precision of design and calibration of all tissue contacting points of the emerging abutment.7-10

The proper design of a healing abutment circumferentially can support the tissues when necessary or can relieve the areas of thin tissue or underlying bone

Each area of the healing abutment contact surface plays an integral role for the final tissue position Although prefabricated abutments are widely used, CAD/CAM customized healing abutments can be designed to support tissue Instead of using fixture level impression technique, a coded healing abutment was used The intraoral scanner captured the codes on this healing abutment The use of intraoral scanners

to capture the Encode healing abutment rather than a conventional impression material provide benefits in accuracy of models in maximum intercuspation position (MIP) and model fabrication.11 Unlike stone casts that may have expansion and water-sorption properties, digitally printed models can avoid these potential sources

of error, especially in mounting, indexing, margination, casting, and most importantly, occlusion This article will introduce and describe a current model for fabrication of ideal abutments, and fabrication of CAD/

CAM restorations for the anterior esthetic zone

Case presentation anterior central incisor No.8

Materials used and steps to final restoration

• CBCT scan of planned surgery, GALILEOS® 3D CT Scanner (Sirona)

• NanoTite Certain®( Biomet 3i) internal

connection 4.0 mm implant fixture

• Coded abutments (BellaTek Encode,

Biomet 3i)

• Final impression with intraoral digital acquisition; Lava™ Chairside Oral Scanner (C.O.S.) [3M ESPE]

• SLR models created

• CAD/CAM Abutment Design (3-Shape

Abutment Designer/BellaTek, Biomet 3i)

• Final abutment; Zirconia, internal

connection (Certain, Biomet 3i)

• Final impression of abutment and teeth with Cerec® Blue Cam (Sirona)

• Restorative material: monolithic reinforced ceramic (Empress® CAD-HT, Ivoclar )

leucite-• Laboratory: NY Smile Labs

• Cement Utilized = RelyX™, (permanent) [3M ESPE]

• Restoration time = five visits - 3 monthsPatient presented with a traumatic fracture of the upper left central incisor (Figure 1) The tooth was extracted atraumatically without incisions to preserve interproximal tissue Software was utilized in conjunction with a CBCT scan to fabricate

CAD/CAM anterior esthetic implant restorations:

the BellaTek Encode healing abutment and

CAD-Block ceramics

Dr Dean Vafiadis delves into the use of a coded healing abutment

Dean Vafiadis, DDS, prosthodontist,

is Program Director of the Full Mouth

Rehabilitation CE Course at NYUCD, Clinical

Associate Professor of Prosthodontics and

Implant Dentistry, New York University College

of Dentistry; former Coordinator of Prosthodontics and

Implant Dentistry, St Barnabas Hospital in New York

City, and Founder of New York Smile Institute He

has published many articles on CAD/CAM, esthetics,

and implant dentistry and is currently on the Clinical

Advisor Board of Journal of Clinical Advanced Implant

Dentistry, World Journal of Dentistry, Dental XP, and

Stemsave.com He is radio show host of Talk N’ Teeth,

on COSMOS 91.5 FM and has given 500 programs and

educated over 8,000 dentists over the past 18 years in

the U.S and abroad He is a member of ACP, ADA, AO,

ICOI, and AACD and in in private practice in New York

City He can be reached at:

New York Smile Institute

693 Fifth Avenue

New York, NY 10022

212-319-6363

www.NYSI.org

a surgical guide The precise measurement

of this particular central incisor width at

the root section, 3 mm above the CEJ

restoration, was measured at 5.73 mm

Because the natural tooth was available for

measurement, the root was also measured

after extraction and was measured at

5.97 mm (Note: The average of these

two measurements would be used as the

final abutment width later in the design

phase.) Considering that the natural tooth

is not always available, the measurement

from the CBCT scan could be used as a

guide in other instances A 4.0 mm wide

endosseos implant was placed (NanoTite™

Certain, Biomet 3i) [Figure 2] The site was

sutured and healed with primary closure

It was determined that the adjacent teeth

would also need restorations in the future

A bonded provisional was fabricated from

a composite, autopolymerizing provisional

material (Luxatemp®, DMG) and placed for

a 6-month healing period The provisional

was removed after implant healing,

and the implant fixture was exposed

without flapping the gingival tissues A

prefabricated abutment was used to

develop and scallop the tissue to conform

to the ideal central incisors cervical shape

(Performance® Post, Biomet 3i) This

was made using highly polished flowable

composite material (LuxaFlow, DMG) with

a screw-retained method for a period of 6

weeks After the tissue had matured, the provisional abutment was removed, and

a coded healing abutment was placed (BellaTek, Encode impression abutment,

Biomet 3i) [Figures 3 and 4] At this time,

a digital impression of the coded healing abutment was made with an intraoral scanner (Lava C.O.S., 3M ESPE) [Figures 5-7]

Intraoral scanning and design

Fabrication and design of implant abutments has been previously published.7-10 Using CAD/CAM software to design the final abutments has increased the precision of designs and decreased laboratory fabrication times The specific design programs require information from the clinician to better understand each specific tooth emergence for each site Using radiographs, tissue biotypes, and algorithmic equations, the design technician, in conjunction with the clinician, can better design the final contours and emergence that are necessary for ideal tissue support and long-term tissue stability The use of intraoral digital acquisition units (Table 1) can also help the fabrication of CAD/CAM restorations that follow the emergence from the abutment to the final restoration Using a coded healing abutment such as Encode can facilitate

the transfer of digital information from the clinical environment to the laboratory in a matter of minutes

The digital scan begins with isolation

of the coded abutment, ensuring that it

is more than 2 mm above the gingival tissues The tissues must be dry and clean

A series of scans from the occlusal view

of the abutment are captured After this

is completed (approximately 2 minutes),

an additional scan of the lower opposing arch is made (approximately 1 minute) A third scan of the teeth in MIP is also made (approximately 1 minute) The software program merges these three scans onto

a virtual model on the computer screen

The clinician chooses the tooth area

to be restored, confirms the accuracy and capture of all the data points, and approves the scan The clinician completes the laboratory prescription form and sends the file via email to the corresponding laboratory for model fabrication and final abutment fabrication

Many variables such as implant width and connection, depth of tissue, abutment material, margin placement, surface texture, shade, and final restorative material are all chosen by the clinician

This ensures that the clinician will achieve the exact result that was planned for each patient The digital scan of the occlusal

Figure 7

Digital Impression Digital Impression +In-Office Milling CAD/CAM Abutments

Lava/3M ESPEiTero/CadentTrios/3-Shape

E4D/D4D Technologies

Cerec AC 4.0/Sirona

Encode/Biomet 3iProcera/Nobel BiocareAtlantis/Astra TechAkton System/StraumannTable 1: Various digital acquisition software

relationships in MIP position is more precise

and accurate than stone casts because

they are captured digitally in a static mode,

as opposed to models being mounted with

a bite registration The files are emailed

to the digital facility (BellaTek Production

center, Biomet 3i) and are then transferred

to 3-D shape software for design

Design of final abutments

There are four areas of clinical importance

for designing the abutment Their relative

importance is as follows:

1- Gingival margin position as it relates to

thick or thin biotype of tissue

2- Depth of tissue around abutment

circumferentially as it relates to the

radiograph of the bone

3- Angle of the emergence as it relates to

algorithmic equation to determine tissue

displacement, especially on the facial

aspect of this patient treatment (Figure 8)

4- Width of the gingival floor as it relates to

the support of all ceramic materials as they

seat on the abutment.12 In this patient, it

was measured at 1.7 mm Note: The width

of the final abutment will be designated at

5.8 mm based on the original width of the

natural tooth that was extracted (Figures

9-13)

Once the design is approved by

the clinician or the laboratory, the final

abutment is milled from either a titanium or

zirconia material The abutment is polished

and finished, and returned with the digital

model to the laboratory The laboratory

delivers the final abutment to the clinician

The provisional restoration is removed,

and the ideal final abutment is placed into

position The final abutment is placed and

torqued to proper position based on the

manufacturer’s recommendation (30Ncm)

[Figures 14-16] The adjacent teeth were

prepared for ceramic crowns due to decay

at the root surfaces A highly polished

provisional is placed to secure the tissue

position and to allow the interproximal

tissue to grow as much as possible The

provisional was fabricated with

auto-polymerizing composite provisional

material (LuxaTemp, DMG) [Figures

17-19] The tissues were allowed to heal for

3 weeks The preparations and abutment

were now ready for the final impression

Digital scanning of the abutments

and teeth

Intraoral scanning

The provisional is removed, and the teeth

and the implant abutment are cleaned

Figure 14

Light powder is applied to the abutments,

and the access hole is temporarily sealed

with Teflon tape and flowable

light-cured composite resin Using a CAD/

CAM intraoral scanner (Cerec 3D blue/

cam, Sirona), the abutment and teeth

are scanned in the mouth (Figure 20)

Also needed are an occlusal scan of the

sextant, a frontal scan in MIP position,

and the scan of the opposing arch The

software merges the three scans onto

one design virtual model on the computer

screen In the preparation window of the

design software, digital scans are captured

of the abutment and teeth The amount of

digital scans depends on the size of the

restoration and how many adjacent teeth

are involved The average is seven to eight

scans

Computer Assisted Design - CAD

Once the digital images have been

approved, the abutment margin and teeth

margins are highlighted and verified for

exact position This is called margination,

the exact margin that the restoration will

be milled to In the settings mode, the

parameters for each type of restoration can

Figure 19

be adjusted for each clinician’s preference

Some of these parameters include occlusal offset, margin thickness, cement spacer, and restoration thickness A scan of the perfectly contoured provisional restorations

is used in “correlation” mode to best mimic what has been created, in terms of contour, contacts, and shape

Each restoration must be designed separately and then merged together in the final master digital mode Additional design features such as “add” and “smooth” tool can be used to finalize the shape each restoration

Occlusion

The ideal occlusion contact position is carefully designed with freedom in the anterior from MIP This position is critical in the anterior implant restoration because the adjacent teeth have an adaptive PDL that is different than a fixed dental implant Careful occlusion analysis needs to be performed

so that initial contact is on natural teeth first

Using articulating paper with a 20-micron thickness (AccuFilm® red/black, Parkell) can show the clinician the variable contact points of natural teeth compared to the

Figure 20

implant restoration It seems logical that the 20-micron articulating paper should be free of contact on the implant restoration when the adjacent teeth are in contact and marking the paper Other thickness of articulating paper may be used to further examine the movement of the anterior adjacent teeth, in protrusive movement, before the implant restoration comes into contact Interproximal contacts are also adjusted to desired position, one at a time

Computer Assisted Milling - CAM

Various CAD block materials have reportedly been used as final crowns and veneers.13-14 The restoration is designed for each tooth position After the final design is approved, it is sent to the milling center for final mill The designated blocks chosen for this patient treatment were Empress CAD blocks LT (Ivoclar/Vivadent)

In the pre-glazed phase after milling, they are tried intraorally for final occlusion and interproximal contact points Selective grinding with a high speed handpiece

is necessary to get the proper contour and transmission of light on each tooth Shaping, incisal thinning, and polishing

1 Binon PP Evaluation of machining accuracy

and consistency of selected implants, standard

abutments and laboratory analogs Int J Prosthodont

1995;8(2):162-178.

2 Finger IM, Castellon P, Block M, Elian N

The evolution of external and internal implant/

abutment connections Pract Proced Aesthet Dent

2003;15(8):625-632, 634.

3 Priest G Virtual-designed and computer-milled

implant abutments J Oral Maxillofac Surg 2005;63(9)

(suppl 2):22-32.

4 Patel N Integrating three-dimensional digital

technologies for comprehensive implant dentistry J Am

Dent Assoc 2010;141(suppl 2):20S-24S

5 Birnbaum NS, Aaronson HB Dental impressions

using 3D digital scanners: virtual becomes reality

Compend Contin Educ Dent 2008;29(8):494, 496,

498-505.

6 Christensen GJ Will digital impressions eliminate the

current problems with conventional impressions? J Am

Dent Assoc 2008;139(6):761-763.

7 Drago CJ Two new clinical/laboratory protocols

for CAD/CAM implant restorations J Am Dent Assoc

2006;137(6):794-800.

8 Grossman Y, Pasciuta M, Finger IM A novel technique using a coded healing abutment for the fabrication of a CAD/CAM titanium abutment for

an implant-supported restoration J Prosthet Dent

2006;95(3):258-261.

9 Vafiadis DC Computer-generated abutments using a coded healing abutment: a two-year preliminary report

Pract Proced Aesthet Dent 2007;19(7):443-448.

10 Vafiadis DC Full arch restorations using

computerized abutments Implant Dent Today

12 Akbar JH, Petrie CS, Walker MP, Williams K, Eick

JD Marginal adaptation of Cerec 3 CAD/CAM crowns

using two different finish line preparation designs J

Prosthodont 2006;15(3):155-163.

13 Guess PC, Zavanelli RA, Silva NR, Bonfante EA, Coelho PG, Thompson VP Monolithic CAD/CAM lithium disilicate versus veneered Y-TZP crowns: comparison

of failure modes and reliability after fatigue Int J

are critical to the natural appearance

of the restorations After approval of fit

and position, they are placed in the firing

oven for final crystallization and glaze with

the appropriate shade and stain match

for the adjacent teeth Final radiographs

are taken, and then the restoration is

cemented with final cement A dual-cured

resin cement (RelyX™ 3M ESPE) was

used for cementation Final occlusion was

confirmed with digital occlusion analysis

(Tekscan®)

The patient returned for follow-up in 3

and 6 weeks, respectively The restorations

were checked for gingival health, occlusion

verified, and final photos taken (Figures

21-23)

Advantages of CAD/CAM

impressions and restorations

• Avoiding conventional steps such as

impression material, strong gag reflex,

pouring, mounting, alginate, bagging,

delivery, pindex, ditching, etc

• Reduces laboratory costs and lab time

• Saves time for clinician, laboratory, and

patient

• Most accurate interocclusal records

• Margin capture and review more easily

seen than cast ditching

• Fewer remakes

• Saves office costs due to materials,

trays, dental assistant

• Impressive technology for patients

• Promotes better preparations

• Digital files can be transferred with

back-up and no loss of cases

• Digitally trained designers

Disadvantages

• Cost of scanners

• Learning curve of 2 to 3 months

• Complete isolation, which means no tissues and no fluids in the scanning field

• Bulky equipment in the operatory

• Continuing education

Conclusions

The use of in-office CAD/CAM techniques has been highlighted to fabricate anterior implant crowns Utilizing the coded healing abutments can save time and increase efficiency with the digital designs

of final abutments The clinician can use clinical knowledge to help designers make ideal final abutments Monolithic leucite-reinforced and feldspathic ceramic blocks can be utilized to fabricate life-like color and

translucency in addition to fit and marginal integrity Computerized and CAD/CAM prosthodontic care of our patients can be more efficient, more predictable, and save chair time for our patients

Acknowledgements

The author would like to thank NY Smile labs and Carlos Carranza, MDT, New York City, and Roe Dental Laboratory, Cleveland, Ohio for their dedication to digital technologies, the Bellatek production

team at Biomet 3i for their digital designs

and endless work ethic, Dr Jim Jacobs, Periodontist, New York City, and John Kim, dental digital officer for their efforts on this patient’s successful treatment IP

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Case study

This case demonstrates the successful

use of Straumann Locator ® abutments in

the atrophic anterior maxilla.

When restoring the edentulous maxilla,

there are many different methods

dictated by various implant systems Each

differs in cost and the number of implants

required to support the restoration – and

more importantly, in how well-supported

they are by sufficient levels of clinical

research that demonstrate long-term

success rates Therefore, it can be difficult

selecting the most suitable system and

methods for your patients

The Straumann Locator abutment

was launched in its current form in

2009, following years of research and

development, and many clinicians haven’t

looked back since

The ease of use – both in the practice

and in the laboratory – make for a very

simple yet successful and safe method

for fixating an upper overdenture with a

cement-retained restoration (Figure 1)

Patient’s perspective

When deciding upon the design of a full arch

maxillary prosthesis, there are often various

options available However, any prosthesis

must be comfortable, retentive, functional,

and esthetic with good appearance of both

hard and soft tissues The patient’s speech

and taste must not be impaired and, at all

times, we must consider how all of these

factors can influence his/her self-esteem

From the patient’s perspective, a

fixed restoration is sometimes preferred, especially for those who are used to a

loose, removable prosthesis, or who have

a severe gag reflex These types of patients will often want to avoid a removable denture-type restoration

Loose dentures are often caused, or

a result of bony resorption of the bearing area

denture-Most bone resorption occurs 1 to 3 years post-extraction, but it never really stops – it merely decreases in rate It

is this lack of bone structure that often means fixed prostheses are unavailable to the patient without the need for extensive bone-grafting procedures

Patients with a hopeless residual dentition are also more likely to favor a fixed prosthesis for rehabilitation (Figures 2 and 3)

However, it is important that we have

an open and honest discussion with our patients regarding the limitations of a fixed prosthesis As these restorations are far more demanding in terms of maintenance, patients with a failed natural dentition are often not appropriate, because if fixed prostheses are not properly maintained and cared for, this can lead to problems 5

to 10 years post-rehabilitation

Restoring the edentulous maxilla

Dr Ross Cutts discusses a cost effective way to restore the edentulous upper arch

Figure 1: Locator abutment Figure 2: Failing natural dentition

Figure 3: Restored natural dentition

Dr Ross Cutts is the principal dentist at Cirencester

Dental Practice, Gloucestershire, England Having

graduated from Guy’s Hospital, Dr Cutts is a general

dentist with special interests in advanced restorative

procedures and dental implants He has been awarded

the highly regarded Diploma in Implant Dentistry

from the Royal College of Surgeons, London, and

is a committed member of the International Team for

Implantology (ITI), where he is a study club director and

clinical mentor He regularly holds implant courses at

his Cirencester practice, and lectures nationwide on a

variety of topics at different levels He is also a member

of the Association of Dental Implantology, the British

Academy of Cosmetic Dentistry, and the Royal College

of Surgeons.

Figure 4: Lack of soft tissue support

Figure 5: Soft tissue replaced with pink acrylic Figure 6: Previously extracted full arch, showing

emphasized bone loss with a thin flabby ridge

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Careful planning

Often in cases of moderate maxillary

atrophy, there is a large deficiency in hard

and soft tissue volume This means that a

fixed prosthesis can have long proclined

teeth, which is not necessarily esthetically

or phonetically successful Careful planning

of the final appearance of the prosthesis is

therefore crucial

Figure 7: Recently extracted teeth next to overdenture

locators Figure 8: Edentulous maxilla showing marked resorption and knife-edge nature due to long-term tooth loss Figure 9: Edentulous maxilla with opposing teeth following recent extraction

Figures 10 and 11: The atrophic maxilla with evidence of pronounced incisive papilla, showing extensive maxillary atrophy and opposing lower arch model

Figures 12 and 13: Surgical implant placement in the narrow ridge with simultaneous-guided bone regeneration to increase ridge width

Often this discrepancy can be rectified with an overdenture-type restoration, allowing the appropriate choice of tooth size In addition, the use of pink acrylic to replicate the support for lips and missing keratinized tissue will create highly esthetic results (Figures 4 and 5)

It’s worth noting that if teeth have been recently extracted to become a full

arch, the fixed solution is likely to create more esthetic results Similarly, the longer the teeth have been missing, the greater the chance of substantial hard and soft tissue loss (Figures 6 and 7)

Successful full arch rehabilitation

As it has been well documented that

an edentulous maxilla opposed by a

complete natural lower dentition causes

severe maxillary atrophy, it’s important

that we evaluate interarch relationships in

the planning stage, and discuss this with

patients, stressing that early intervention of

treatment will greatly reduce the need for

complicated grafting procedures (Figures

8 and 9)

However, we do know that there is

scientific evidence, which clearly shows

that either removable or fixed

implant-supported rehabilitation of an edentulous

jaw can significantly improve a patient’s

quality of life (Wismeijer, et al., 1992; 1995;

1997) We understand that in the maxilla

we have less favorable bone quality and

quantity than in the mandible, so our

options are reduced Weng, et al., (2007),

clearly showed that placing only two

implants in the anterior maxilla is a risky

procedure with poor long-term survival and

success rates

In light of this research, we now

know that placing four maxillary implants

is the minimum for a successful full arch

rehabilitation If we use locator abutments

such as Straumann Locator abutments

– a relatively more cost-effective and

straightforward method for retaining an

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Figure 14: Exposure of the implant fixtures and placement

of Straumann Locator abutments

Figure 15: The pick-up impression copings attached to

the Straumann Locator abutments

Figures 20 and 21: The final postoperative photographs, demonstrating good hard and soft tissue support

implant overdenture – it can offer changing results for patients

life-Conclusion

The benefits of locator abutment-retained overdentures are vast As well as providing

a very cost-effective method for restoring

a full arch prosthesis, they offer ease of maintenance and repair in the future due

to removable nature, and can replicate both hard and soft tissue loss, producing highly esthetic results However, as with all treatments, they are not suitable for all patients Some patients may not psychologically want this treatment modality and instead will request a fixed solution

There are many different ways to restore the edentulous maxilla each with varying degrees of long-term clinical research behind them Further evidence-based options can be found in the book from the International Team for

Implantology (ITI) Treatment Guide 4. IP

Figure 19: The healed soft tissue around the locator abutments

Figures 17 and 18: The overdenture and lower acrylic denture fabricated in a traditional mannerFigure 16: The laboratory-made model

A 67-year-old patient presented in the

dental practice for implant

consulta-tion The medical history revealed some

specific conditions, in particular an allergy

to dental metals At this time, prosthetic

restoration in the area to be reviewed

con-sisted of an insufficient crown block in the

anterior tooth area corresponding with an

attachment-monoreducer-combination

denture Significant loosening of the

abut-ment teeth in the anterior tooth area was

found, and posts and cores that had

al-ready loosened several times were found in

the insufficiently filled root canals, probably

due to monoreducer leverage (Figure 1)

The prognosis for conservative

restoration was thought to be extremely

poor During the consultation, the patient

expressed a preference for an implant

solution The patient also specified a cost

limit

Procedure

Treatment planning

For optimum assessment of the initial

situation and subsequent treatment

planning, after assessing the clinical

situation, a panoramic radiograph with

intraoperative assessment of the implant

site was favored as method of choice

(Figure 2) This would take into account a

minimally invasive therapeutic concept of

surgical augmentation

Surgical planning involved the

extraction of non-restorable teeth and

immediate placement of a Straumann® bone

level implant in the region Two implants

were to be inserted in the premolar region

We planned to expand the bone with a

bone-spreading procedure and to use two

Straumann Standard Plus Narrow Neck

Crossfit® implants (NNC) made from the implant material Roxolid® if the transversal bone at the site was compromised

The prosthetic restoration needed

to fulfill the requirements of an free dental prosthesis The prosthetic construction was to be manufactured with the Straumann® Cares® system in the in-house dental master laboratory

allergy-Surgical procedure

Due to the impaired vasoconstriction, anesthetization was adrenaline-free with local anesthetic and one subsequent injection during the operation Extraction

of the middle and left lateral incisors was carried out without complication A central crestal incision was made with little crestal bone denudation and no relief incision

The anticipated reduction of the transverse bone then became clearly visible, and as the method of choice, the bone-spreading procedure was performed, and two NNC implants were placed (Figure 3)

The insertion site in the region of both left premolars was prepared by manually shaving the bone until an even bone plateau had been created The autologous bone chips gained here were later used

for implant augmentation in the central left incisor area

Once the implant site had been carefully prepared by means of bone spreading (Figure 4) and the final implant cavities drilled, the prepared bone was meticulously examined with a bulbous probe and gauges from the Straumann surgery set Two NNC implants were then inserted in the controlled, intact bony structures (Figure 5) The NNC SLActive®implant (3.3 mm x 14 mm) was inserted in the region of the first premolars The 3 mm reduced height NNC healing cap was used for both the implant seal as well as primary soft tissue conditioning We decided to use NNC SLActive implant (3.3 mm x 12 mm) and the identical 3 mm closure screw for the region of the second premolars Once this stage of the operation was complete, alveolar implant restoration in the central anterior tooth area was performed The immediate implantation of a Straumann bone level implant (4.1 mm x 10 mm), fitted with a 0.5 mm regular Crossfit (RC) closure screw, was then performed The alveolar walls were undamaged, and primary implant stability was good

As a sufficient amount of autologous bone chips had been gained from maxillary

Bridge construction in the anterior tooth area of the maxilla

Dr Steffen Wolf juggles esthetic requirements to produce pocket-friendly results for a patient with very particular needs

Figure 3

Steffen A Wolf, Dr med Dent., MSc (DGI) is in private

practice in Halberstadt, Germany He graduated from

the Clinic for Oral and Maxillofacial Surgery at the

Free University of Berlin He received his MSc in oral

implantology in 2010

Figure 4

crest levelling in the premolar area, this

was used as volume filler for the alveolar

augmentation The distance between the

body of the implant and the alveolar wall

that required augmentation was 1–2 mm

Augmentation was vertical with slight

overlap by means of a platform switch at

the implant shoulder Alveolar restoration

of the lateral incisor was performed using a

collagen matrix

Suture closure in the area of the

anterior tooth implant resulted in complete

coverage of the augmentation area:

the closure screw lay only minimally

exposed approximately 3 mm below the

mucogingival soft tissue Soft tissue closure

at the NNC closure screw supported

transgingival healing of the implant (Figure

6)

Intraoperative haptic assessment of

the various fixations of the implant insertion aids was easily possible (Figure 7) To assess postoperative treatment success –

in particular with regard to adequate implant bone coverage – a control DTV was made on which the correct implant-bone relation could be verified This meant additional augmentation measures could be safely dispensed with (Figure 8) Perioperative medication included antibiotic endocarditis prophylaxis; the patient was also given postoperative pain medication for 1 day

peri-Prosthetic restoration

Following integration of a provisional denture and complication-free healing time, individual gingival recontouring then was performed in the anterior tooth area

To facilitate continued wearing of the

provisional denture during the gradual process of soft tissue conditioning, our dental laboratory prepared and shortened

an RC temporary abutment with hard polymer plastic, individualized to the area

of the soft tissue profile (Figures 9-11)

The impression for the individual incisor abutment was made with a gingival former on the basis of an RC impression post to match the individual impression post The NNC implants were incorporated into the impression (Figure 12) with the ready-made NNC impression posts

On account of the patient’s allergy and

in consideration of the esthetic aspect, we decided to use titanium abutments (Figure 13) as well as a zirconium-based bridge framework with ceramic veneering (Figures

14 and 15) The titanium abutments and zirconium bridge were constructed

Figure 8

Figure 9

Figure 10

virtually in CAD/CAM procedure with the

Straumann CS2 scanner in our own dental

laboratory, and the framework was made

at the Straumann Milling Centre in Leipzig,

Germany

Because of the interocclusal distance,

the decision was to use an

anatomically-formed zirconium morsal surface, which

could be optimally prepared with the

Straumann Cares system processing

software during the construction phase

In consideration of the esthetic aspect,

the individual veneer was mostly in the vestibular region (Figures 16 and 17) A postoperative control X-ray confirmed the correct positioning of the prosthetic components (Figure 18)

Figure 17

requirements of the visible areas In the event of later loss of the second molars, the patient wishes to undertake prosthetic restoration of the ensuing end gap situation

As shown here, the use of NNC implants can lead to very positive results in cases where the bone is compromised and when esthetics or the use of different CAD/CAM materials need to be considered

Figure 18

Figure 13Figure 12

Figure 11

IP

According to the American Association

of Oral and Maxillofacial Surgeons,

“69% of adults ages 35 to 44 have lost

at least one permanent tooth…[and] by

age 74, 26% of adults have lost all of their

permanent teeth.”1 Every patient’s dentition

is different, and each patient requires

an individualized treatment plan Hybrid

dentures, also called fixed-detachable

dentures, present a solution that combines

both function and esthetics This method

is generally used when there is bone

loss, possibly due to long-term denture

wear The bridge is attached to implants

providing teeth and artificial gums

The following case study illustrates

where this type of implant solution resulted

in a happy patient and an effective

treatment

A female patient came to our office for

a new patient exam She had a denture for

25 years and was unhappy with her limited

chewing ability, phonetics, and the large

range of denture mobility A panoramic X-ray

showed adequate height of bone (Figure

1), but clinical finding supported a narrow

ridge (Figure 2) A CBCT scan (GXCB-500

HD, Gendex) was taken of this patient The

scan verified atrophic anterior mandible

width, Class III bite, and insufficient height

of alveolar ridge in posterior segments

(Figures 3-6) The decision was made

to remove the top 10 mm of bone in the anterior region revealing healthy dense bone and graft the posterior region with OraGRAFT® (Salvin® Dental Specialties/

LifeNet Health®) mineralized freeze-dried bone allograft with calcium sulfate and gentamycin Under local anesthetic, a full thickness incision was placed releasing buccal and lingual tissues (Figure 7)

Then, 10 mm of bone was removed from the anterior segment with a surgical high speed drill and copious irrigation (Figures 8 and 9) Also, six osteotomies were made:

four anterior to mental foreman and two posterior (Figure 10) All BioHorizons® tapered internal implants were inserted at 50Ncm in the following locations (Figures 11-16)

sutures After tissues were approximated around implants properly, the abutments were removed, and cover screws were placed to idealized soft tissue for prosthetics (Figure 17) Careful manipulation for her peri-implant tissue to promote proper healing was the most important step in this surgical procedure The patient did not wear her denture during the entire healing period After 12 weeks (Figure 18), the tissues looked great, so the implants were uncovered, and healing abutments were placed (Figure 19) Impressions were taken

of the tissues and implants (Figure 21) A verification jig was fabricated to ensure implant position in the prosthetic work up The lab fabricated a custom framework for

a hybrid denture taking into account her skeletal Class III profile (Figure 20) The hybrid denture was delivered, torqued, and access holes were covered Then the patient’s bite was verified and adjusted (Figures 22 and 23)

One-year post prosthetics, the patient has chewed a piece of gum every day since we delivered Chewing ability has dramatically increased; denture mobility

Hybrid dentures provide a practical solution

Dr Daniel Domingue illustrates a case treated with fixed-detachable dentures

Figure 3

Daniel Domingue, DDS, FICOI, MICOI, DICOI,

AFAAID, DABOI/ID, graduated from Louisiana

State University in Baton Rouge in 2003 and

obtained his DDS degree from the LSU School

of Dentistry in New Orleans in 2007 After dental

school, he completed 3 years in advanced

training at Brookdale University Hospital and Medical

Center in New York City, and he served as Chief Resident

of the Dental and Oral Surgery Department His training

included 1 year in General Practice Residency and 2 years in

Dental Implantology Fellowship During these years, he was

awarded the Certificate of Achievement from the American

Academy of Implant Dentistry for outstanding leadership

in Implant Dentistry, a Fellowship from the International

Congress of Oral Implantologists, and an Associate

Fellowship of the American Academy of Implant Dentistry in

New York City After residency and during his first years in

private practice, Dr Domingue was awarded the Diplomate

from the American Board of Oral Implantology in Las Vegas,

Nevada He was also recognized as the youngest recipient

of this award in the world Dr Domingue was later given

a Mastership and Diplomate award from the International

Congress of Oral Implantology in New York City for his

outstanding work in Implant Dentistry and a Fellowship

award from The American Academy of Implant Dentistry in

Phoeniz, Arizona Dr Domingue is a member of the American

Dental Association as well as the Acadiana District Dental

Association, and American Academy of General Dentistry,

where he is the current president.

Figure 4

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and phonetics are no longer problems, and

for the first time, the patient is in a Class 1

occlusion, thanks to the alveolarplasty and

the hybrid denture combination (Figure 24)

The patient has lost weight, primarily due

to a healthier diet and happier overall

self-image

While traditional dentures work

for some, hybrid dentures are often a good option when the patient needs both hard and soft tissue replacement

Additionally, hybrid dentures also solve the patient’s problems of inconvenience

or embarrassment when having to remove his/her own dentures This patient’s hybrid dentures promoted a more functional

solution to traditional dentures while also providing a more natural look

IP

RefeRence

American Association of Oral and Maxillofacial Surgeons Dental Implants http://www.aaoms org/conditions-and-treatments/dental-implants/ Accessed September 10, 2013.