Tạp chí implant tháng 11-12/2013 Vol 6 No6

Post-extraction healing is characterized by osseous resorption and significant contour changes in buccal-lingual and apico-coronal width of the residual alveolar ridge.1 Research suggest

The most innovative 3D technology available today… Ask For It By NameSee the inside back cover to learn more about why the ProMax offers the ideal 3D imaging solution for your practice.

PLANMECA

11413_planmecaCOVERbanner_implantpractice:Layout 1 11/5/13 9:16 AM Page 2

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 (LODI) System 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.

2.5mm

2.4mm

4mm

2.9mm

included with each Implant

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 6 Implant practice 1

November/December 2013 - Volume 6 Number 6

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 MANAGER/CLIENT RELATIONS

Adrienne Good

Email: agood@medmarkaz.com Tel: (623) 340-4373

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.

Cone beam imaging is a relatively new technology, which has firmly established itself

in clinical dentistry since its introduction into the U.S dental marketplace in 2001

With cone beam imaging, the X-ray energy emitted from the device is divergent, forming

a cone-shaped beam During a cone beam scan, more than 500 images are obtained while the patient remains stationary, and the scanner rotates around the patient’s head The resulting images, which are interpreted by computer software, are three-dimensional, and it is the third dimension that allows for a world of difference in dental diagnosis and treatment planning The three-dimensional images generated by a cone beam scan can be manipulated by sophisticated computer software for a wide variety of applications, including implant diagnosis and treatment planning, orthodontic diagnosis, detailed evaluation of the temporomandibular joints, examination of the patient’s airway, endodontic diagnosis, evaluation of impactions, and assessment of maxillary and mandibular pathology, along with numerous other diagnostic purposes

For both general practitioners and specialists, cone beam technology deserves serious consideration for incorporation into everyday practice

Reason No 1: The standard in diagnosis and treatment planning has been raised

With the availability of the third dimension in diagnosis, it quickly becomes apparent that two-dimensional images present the clinician with severe limitations Because of its superior ability to view anatomical structures in their precise location with remarkable detail, the bar has been raised significantly when it comes to dental diagnosis For example, when evaluating an impacted third molar, a two-dimensional film superimposes all structures, and it is virtually impossible to distinguish exactly where any given tooth sits anatomically in relation to its surrounding structures The third dimension made available

by cone beam imaging allows the clinician to precisely plan a surgical approach that will avoid damage to surrounding structures and facilitate a safe surgical outcome

Reason No 2: Implant treatment planning is driven by the prosthetic needs of the patient.

Implant patients seek treatment because they are missing teeth, not because of a desire for implants In asking for implants, a patient’s true desire is to replace teeth that are missing Today in 2013, our patient expectations are high They expect teeth that will look good, feel good, allow them to eat comfortably, and which will be relatively free of maintenance This can only be accomplished when implant treatment is prosthetically driven The third dimension provided by cone beam imaging allows for a true

prosthetically driven implant placement

Reason number 3: Significant savings in terms of cost and radiation exposure.

Prior to the availability of cone beam imaging in dentistry, dentists often referred out their imaging needs to outpatient imaging centers or radiologists These required the patient to travel to a facility outside of the practice, with the financial cost of these images being far greater than that of in-office cone beam images The cost extends far beyond dollars – a CAT scan image delivers far greater radiation to the patient than a typical cone beam image Technology available to dentists today, such as Planmeca’s ProMax® 3D technologies, allows for adjusting the size of the volume to suit the specific area that is being studied

Huntington Bay Dental, was distinguished as “Dental Practice of the Month” by Dental Economics

in May 2003 and “Business of the Year” by the Huntington Chamber of Commerce for 2003

Dr Antenucci is a 1983 graduate of New York University College of Dentistry He was awarded his Fellowship in the Academy of General Dentistry in 1992, the American College of Dentists in

1999, and the International College of Dentists in 2005 Dr Antenucci is a certified CEREC Basic and Advanced Training Instructor, and has conducted training seminars throughout the United States He lectures internationally, conducting seminars in the clinical utilization of advanced technology in dentistry, as well as seminars in cosmetic dentistry, practice management, CEREC, and laser training Dr Antenucci serves on the Board of Benefactors of the Guide Dog Foundation and America’s Vet Dogs, and is also an active member of the National Italian American Foundation, serving as the New York Area Coordinator for the organization Dental equipment manufacturer Planmeca USA has retained Dr Antenucci as a spokesperson for its line of 3D imaging products and to advise the company on marketing, advertising, and continuing-education efforts.

Practice profile 6

Dr Yong-Han Koo: Honesty, integrity, and precision

Dr Koo strives to make a positive impact on his patients, colleagues, and staff.

Planmeca, a leader in dental imaging, stays in the forefront of technology as

Case study

Stem cell block grafts

Dr Paul Petrungaro delves into allogenic stem cell block grafts to facilitate reconstruction of localized/ severe ridge defects and reconstruct proper alveolar contours prior to dental implant placement 22

Ideal tissue management when immediate provisionalization is not appropriate

Drs Robert L Holt and Bernard E Keough illustrate a specific type of implant management 26

Reflections on the Straumann®

Tissue Level (TL) implant

Dr Robert Margeas discusses a predictable and easy-to-use implant option 28

ZEST Anchors

Overdenture product innovations changing the lives of edentulous patients

worldwide

4 Implant practice Volume 6 Number 6

Special section

Pride Institute “Best of Class”

special award tribute 32

Continuing

education

Hard tissues

Drs William C Martin, Emma Lewis,

and Dean Morton examine adjacent

implant restorations 42

The root of the matter

Drs Mike Lloyd Hughes and Graham

Stuart Roy look at the placement of

a first dental implant as part of an

in-house implant mentoring program

Practice management

Materials matter

Dr Paul A Fugazzotto offers advice

on avoiding therapeutic failure that can affect the implant practice 60

On the horizon

3D at 38,000 feet

Dr Justin Moody reflects on the benefits of cone beam 3D imaging 62

Materials &

Discover

Patient satisfaction meets clinical benefi ts

In addition to ATLANTIS™ patient-specifi c abutments,

the ATLANTIS™ ISUS solution includes a full range of implant

suprastructures for partial- and full-arch restorations The range

of standard and custom bars, bridges and hybrids allows for

fl exibility in supporting fi xed and removable dental prostheses

For more information, including a complete implant

compatibility list, visit www.dentsplyimplants.com.

79690-US-1307 ATLANTIS ISUS Implant Practice.indd 1 10/24/2013 4:58:52 PM

What can you tell us about your

background?

I was born and raised in Seoul, South

Korea, and moved to the U.S when I was

16 My father was an architect, and I had

always been fascinated with structures and

the engineering involved I was exposed

to dentistry during my years in college at

Washington University in St Louis and

decided that this was the field I wanted

to pursue Dentistry has the perfect

combination that satisfies my curiosity in

structural foundation and engineering, as

well as the ability to make a positive impact

on others’ lives

I proceeded to obtain my DDS from

Columbia University College of Dental

Medicine and my oral and maxillofacial

surgery residency training from Yale-New

Haven Hospital After several years in an

oral surgery group practice, I opened my

solo practice in Wayland, Massachusetts

Is your practice limited to

implants?

My practice is limited to oral and

maxillofacial surgery with emphasis on

3D-guided implantology

Why did you decide to focus on

implantology?

The dramatic impact that implants have on

dental reconstruction and the individual’s

quality of life is astounding We now have

options that we could not have imagined

years ago It is an exciting, ever-evolving

field, and the importance of continuing

education to stay abreast of current

technology is crucial I am passionate about

being innovative and seeking inspiration

from everyone I work with I believe that

continuing education should be utilized to

improve the quality of life of not only the

patients, but also the clinicians and all the

staff involved

To bring this vision into reality, I

launched my study club, the Academy

of 3D Connection in Osseo-Integration

We had a successful, 2-day inaugural

meeting this past May in Boston The main

purpose of the academy is for all of us to

appreciate the value of precision in dental

implantology utilizing 3D CBCT from the

diagnosis and treatment planning phase to the final surgical and prosthetic execution phase Through the academy, we also offer small-group, hands-on courses throughout the year Since I am also involved in clinical studies through Harvard School of Dental Medicine, my goal is to create a bridge between academics and the community clinicians, to bring in research results, and actively apply them to everyday practice that the clinicians can relate to

How long have you been practicing, and what systems do you use?

I have been in practice since I finished my residency in 2007 I have used multiple systems over the years, and presently

my preferences are Nobel Biocare® and Straumann® I personally believe they have the best 3D-guided systems currently on the market

What training have you undertaken?

I am board certified through the American Board of Oral and Maxillofacial Surgery I regularly attend meetings with AAOMS,

AO, and ITI, as well as numerous advanced courses both domestically and internationally

I also teach through my academy, and I am also clinical faculty for the implant

CE courses at Harvard School of Dental Medicine Teaching and lecturing opens up avenues that I may not have been aware of, and I always feel that I gain so much more knowledge

Who has inspired you?

By far, my late father and father-in-law

My father owned his architectural/civil engineering firm, and my father-in-law was the head of a global Fortune 500 company Although neither one was in the healthcare industry, I learned the importance of honesty, integrity, precision, and the fact that “people” are the biggest assets in

a business They both put tremendous emphasis on developing and supporting staff members, which I also aspire to do always Patients come first, but our staff members must be happy and fulfilled in order to provide a great environment for the patients

I was also very fortunate to undergo

my oral and maxillofacial surgery training under the tutelage of the incomparable Dr John P Kelly

I cannot forget my imaginary best friend, Steve Jobs, who reminded us that death renews the old, and our time on earth is truly limited It is our job to find the

Dr Yong-Han Koo

Honesty, integrity, and precision

O.R suite at Wayland Oral Surgery

PRACTICE PROFILE

unique talent that God has instilled in each

and every one of us and to utilize it for the

greater good

What is the most satisfying aspect

of your practice?

The feedback we receive from our patients

For instance, we received a letter from the

mother of a 4-year-old-boy who told his

classmates that he wants “to be like Dr

Koo” so he can help people; we were also

told by a Stage IV cancer patient’s wife that

we provided “much more than oral surgery”

for her husband and her family These

are reminders that we are all part of each

others’ lives and that we have a chance to

inspire people through our profession

Professionally, what are you most

proud of?

Connections and relationships we have

built over the years with clinicians, staff,

corporate partners, and patients With

synergy and collaboration, we can make a

significant difference

What do you think is unique about

your practice?

We make a point to fully engage our

patients, educate them on the technology

available, and allow them to become active

participants in their treatment planning

process This enables them to grasp

realistic expectations of their treatment,

whether good or bad, prior to committing

to any procedures

Our practice was recently chosen as

one of the five beta centers for the new

Sirona Galileos® Cone Beam CT scan with face scanner Sirona/SiCAT has a great 3D-guided system and technical support team, which have allowed us to incorporate unparalleled precision into not only implant placement, but to the pre-prosthetic surgical stage as well We also have the beta version of the NobelClinician™ I am also one of the key opinion leaders for Sirona, Nobel Biocare®, and Straumann® These opportunities allow us to be on the cutting edge of new technology and to be constantly involved in its development

What has been your biggest challenge?

What is the future of implants and dentistry?

True digital integration from start to finish

What are your top tips for taining a successful practice?

main-Honesty, integrity, and professionalism,

in that order I believe everything else will follow as long as we do not lose sight of these qualities Also, to continue to inspire

my staff to make a difference together as

a team

What advice would you give to budding implantologists?

“You can’t treat what you can’t see.”

Therefore, having the best diagnostic tools, as well as the ability to execute your plan accordingly with precision, is paramount Always listen to your patients, and do not initiate treatment until they have a good understanding of the process involved Assemble an outstanding team

of professionals who are truly committed

to excellence in patient care Last but not least, as cliché as this sounds, treat all your patients as though they are your family members and present the most optimal plan

What are your hobbies, and what

do you do in your spare time?

I love to travel with my family I am an avid golfer and also enjoy skiing during the long winters in the Northeast

The staff at Wayland Oral Surgery Reception Area (above)

Dr Koo at the Academy of 3D Connection in Integration meeting (below)

Osseo-Top Ten Favorites

1 God

2 Family and friends

3 Patients and staff

9 Galileos with face scanner

10 Kimchi and sushi

IP

Company history

Planmeca is the world’s largest privately

held dental imaging company and one of

the industry’s leading manufacturers of

panoramic and cephalometric X-rays Over

the past four decades, it has expanded its

sales network in more than 100 countries

worldwide Planmeca’s imaging units

offer superior image quality, reduced

radiation during routine procedures, easy

upgradeabililty, and advanced,

user-friendly imaging software Planmeca

has been a leader in digital imaging and

advanced computer-integrated dental

care concepts for years and remains in

the forefront of technology as the field of

dentistry evolves

Since the company’s establishment,

Planmeca’s developers have worked

closely with dentists and leading universities

to anticipate future trends, using the data

to design an advanced line of high-tech

products From the introduction of the

first microprocessor-controlled chair, to

the development of the ProMax™ line of

imaging units with SCARA (Selectively

Compliant Articulated Robotic Arm)

technology, Planmeca has always led the

way with new technology The company’s

goal is to supply dental professionals with

the highest quality dental equipment that

is uniquely designed for today’s modern,

technologically advanced practice

Patented SCARA technology

What truly sets Planmeca apart from the

competition is the company’s patented,

exclusive SCARA technology This robotic

arm, which comes standard on all ProMax

units, enables free geometry based on

image formation and can produce any

movement pattern required The precise,

free-flowing arm movements allow for

a wide variety of imaging programs not

possible with any other X-ray unit on the

market; this allows the dental professional

to take images based on diagnostic needs,

not machine limitations

Anatomically accurate extraoral

bitewing program

Planmeca’s ProMax S3, 3D, and 3D

Mid imaging units offer an exclusive

extraoral bitewing program, possible

only with SCARA technology This

innovative program consistently opens

interproximal contacts, eliminates patient positioning errors, and is more diagnostic than other intraoral modalities ProMax extraoral bitewings are ideal for a number

of patients, from the elderly and those requiring periodontal work to those with claustrophobia, sensitive gag reflexes, or those in pain All of this comes in a true bitewing program that enhances clinical efficiency and takes less time and effort than a conventional intraoral bitewing

Upgradeable innovation

One of Planmeca’s greatest contributions

to dental imaging is its innovative, upgradeable product platform — all based

on exclusive, patented SCARA technology

Since it’s software-driven, SCARA technology enables limitless possibilities

to upgrade existing equipment, allowing the new dentist on a smaller budget to grow while making only appropriate and necessary equipment investments For example, Planmeca products can be upgraded from a 2D panoramic X-ray to a combination of pan/ceph capabilities, which can be further upgraded to accommodate 3D imaging needs Whether it is the transformation of a film to a 3D unit, or the addition of a cephalometric arm, Planmeca offers solutions for every upgrade need

This single piece of technology makes the ProMax the most versatile all-in-one X-ray unit available on the market

Reduced radiation for safer procedures

All Planmeca products are designed around the ALARA radiation principle (As Low As Reasonably Achievable) Through specially designed programs, such as horizontal and vertical segmenting, autofocus, and pediatric pans, dental professionals are able to provide their patients with excellent care without compromising their safety

Horizontal and vertical segmenting options limit the exposure to diagnostic areas of interest By selecting these options, patient dosage can be reduced by

up to 93%, which is highly advantageous when follow-up images are needed

Autofocus automatically positions the focal layer using a low-dose scout image

of the patient’s central incisors, and uses landmarks within the patient’s anatomy

to calculate placement The result is a

fast, diagnostic pan every time, which drastically reduces retakes caused by false positioning

Pediatric programs further lower the dose by automatically selecting the narrow focal layer of young patients, adjusting the collimator, and reducing the area of exposure from the top and the sides This reduces the dosage area while still providing full diagnostic information

Digital Perfection™: the new standard

Building on the well-established all-in-one idea of integration, Planmeca introduced the Digital Perfection concept in 2011 Seamless integration of dental equipment and software creates efficient diagnostic tools, optimized workflow, and advanced infection control methods that result in a treatment environment where all equipment shares an open interface

The company works worldwide with all aspects of the dental industry, including dental schools, dentists, and dental team members, as well as dealers, and uses the latest technologies to create the best products for dental offices and patients alike As a forerunner in digital imaging technology, Planmeca delivers complete dental solutions based on integrated high-tech device and software options with exquisite design

For more information, visit www.planmecausa.com

This information was provided by Planmeca.

“The company’s goal is to supply dental professionals with the highest quality dental equipment that is uniquely designed for today’s modern, technologically advanced practice.”

IP

Located in Southern California, ZEST

Anchors is a global leader in the

manufacturing and distribution of innovative

technologies developed specifically for

overdenture treatment Its impressive

41-year history of producing innovative

products for overdenture patients has been

driven by the philosophy of placing patient

satisfaction above all else This philosophy

led to the creation of the original ZEST

Anchor Attachment developed in 1972 by

Max Zuest at his dental laboratory in San

Diego, California Following in his footsteps

was Max’s son Paul Zuest who had the

same vision and passion for bettering the

lives of patients worldwide This vision

led to the development of the industry’s

first self-aligning attachment, combating

the improper seating of overdentures In

2001, Paul Zuest and Scott Mullaly, then

Chief Operating Officer for ZEST Anchors,

Attachment A third generation attachment,

LOCATOR, has achieved worldwide

acceptance as the premier overdenture

attachment in the dental industry and is

currently interface compatible with more

than 350 implant products, making it

compatible with nearly all implant designs

ZEST Anchors is the only manufacturer

of LOCATOR ZEST sells the LOCATOR

Attachment directly in the U.S., and

it is distributed through OEM implant

companies and distributor networks

worldwide in more than 45 countries

These genuine LOCATOR Attachments are

designed with the primary benefits of ease

of insertion and removal, customizable

levels of retention, low vertical profile,

and exceptional durability Its most critical

design feature is its innovative ability to

pivot, which cannot be replicated due

to its patented technology The pivoting

technology increases LOCATOR’s

resiliency and tolerance for the high

mastication forces an attachment must

withstand and allows it to compensate for

the path of insertion even with up to 40

degrees of divergence between implants

During seating, while the LOCATOR

male pivots inside the denture cap, the

system’s self-aligning design centers

the male on the attachment before

engagement These two actions in concert allow the LOCATOR to self-align into place, enabling patients to easily seat their overdenture without the need for accurate alignment and without causing damage

to the attachment components This aligning feature also increases the durability

self-of the LOCATOR Attachment Once seated, the male remains in static contact with the attachment while the denture cap, which

is processed into the overdenture, has a full range of rotational movement over the male for a genuine resilient connection of the prosthesis without any loss of retention

The introduction and ultimately the success of LOCATOR have allowed millions of patients to realize the benefits

of implant-retained overdentures ZEST Anchors continually receives feedback ZEST Anchors

Overdenture product innovations changing the lives of edentulous patients worldwide

from clinicians about what a great product LOCATOR is, and how it has changed their patients’ lives Being a leader in this product category, clinicians contact ZEST to provide input about new solutions needed for this niche group of patients Collaborating with these clinicians allows the company to identify new key market opportunities within the overdenture category Recent market research demonstrated that the implant-retained overdenture demographic is projected to grow substantially throughout the next 20 years and indicated that narrow (less than 3 mm) diameter implants will play

an increased role in retaining overdentures Even today, this type of technology is being used to retain about a third of all implant-retained overdentures The LOCATOR Attachment, while made for nearly all

“We are now celebrating

a year since the system commercially launched

It is clear that the LODI System surpasses what was available on the market previously, as well as our own sales projections… this

is no temporary implant.”

— Steve Schiess, ZEST Anchors CEO

• Optimize your image quality and dosimetry

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.

implant systems, at the time, was not

available for the narrow diameter implant

segment Recognizing this and the desire

to continue developing innovative products

specifically for overdenture patients led to

ZEST Anchors’ latest product innovation,

a next generation narrow diameter implant

system — The LOCATOR Overdenture

Implant (LODI) System Utilizing years of

collective knowledge in the dental implant

market while focusing on all of the features

that were lacking in current designs, such

as o-ball mini implants, allowed for the

creation of an enhanced narrow diameter

implant system designed exclusively for

overdenture patients “With LODI, we

were able to listen to, and benefit from,

the valuable information of Key Opinion

Leaders about other mini implant systems

on the market,” says Steve Schiess, ZEST

Anchors CEO “What we found was that

the mini implants on the market had little to

no innovation throughout the last decade

This allowed us to design LODI, addressing

the most sought after improvements

We are now celebrating a year since the

system commercially launched It is clear

that the LODI System surpasses what was

available on the market previously, as well

as our own sales projections…this is no

temporary implant.”

The implant

The implant is manufactured using the

strongest titanium available and has a

proven RBM surface The implant body is

tapered and includes self-tapping, cutting

edges for easy insertion The thread design

on LODI is unique in the narrow diameter

implant market; the threads are aggressive

in pitch and gradually widen to the coronal

thread terminus to provide increased

primary stability

The LOCATOR Attachment

The LOCATOR Attachment is detachable

for simple replacement if tissue height

changes or if wear occurs throughout

time It is also the same familiar design

that clinicians have used for years, offering

dramatically lower attachment height

necessary for denture strength and patient

comfort when the denture is removed

Since the LOCATOR Attachment for LODI

is identical to that of a LOCATOR used for

standard-sized implants, the LOCATOR

Overdenture Implant can also be used

alongside standard-sized implants on the

same case

The surgical instrumentation

The surgical instrumentation includes easily identifiable laser-etched depth markings and drill stops, as well as a simple procedure making osteotomy preparation intuitive and safe while offering the less invasive option of a flapless surgery or the option to create a flap

Answering the needs of patients

All of these features combine to answer the market need for an implant system designed specifically for patients requiring

a cost-effective, predictable, and long-term implant-retained overdenture option.The success of LOCATOR and now LODI has propelled a small business into a leading manufacturer and global distributor of dental solutions for the treatment of edentulous patients In 2010, Paul Zuest retired from ZEST, passing the leadership role to Steve Schiess who maintains the position of CEO of ZEST Anchors The company now has more than 120 employees with more than 70 years of experience on its leadership team, consisting of Steve Schiess CEO, Tait Robb replacing Scott Mullaly as COO, Matt Powell who is directing all marketing activities and Chris Gervais who directs engineering The company was recently acquired by Avista Capital Partners,

a leading private equity firm with vast expertise and an impressive track record

in the healthcare space Partnering with Avista Capital allows ZEST Anchors to continue to improve the lives of edentulous patients with the company’s existing product portfolio as well as expanding into exciting new products focused on overdenture treatment options

With this laser-sharp focus, clinicians can be assured that ZEST Anchors will continue to define the overdenture market

by introducing new products designed to provide clinicians with new opportunities

to increase practice revenues and fill the gaps in overdenture treatment available to patients today

For more information, please call 1-800-262-2310 or visit www.zestanchors.com

This information was provided by Zest Anchors.

IP

The LOCATOR Overdenture Implant (LODI) System incorporates key features not found with other small diameter implant systems.

2014 Meisinger’s HigH Altitude

Bone MAnAgeMent

Winter CAMp

February 5 th – February 8 th 2014 Beaver Creek, Colorado, uSA

Maxillary Arch reconstruction:

Single tooth to Full Arch

Autologous growth Factors for

7 days plus a Bioactive implant System for Better esthetics

Horizontal ridge Augmentation

of the Anterior Maxilla and posterior Mandible

understanding and Application

of Amnion Chorion Allograft,

A protein enriched Barrier,

to reduce Surgery time, Minimize patient trauma, and enhance esthetic outcomes and predictability in regenerative procedures

Dr Sascha Jovanovic

gBr-From optimal esthetic implant therapy to peri- implantitis: Facts, Myths and limitations

Post-extraction healing is characterized

by osseous resorption and significant

contour changes in buccal-lingual and

apico-coronal width of the residual

alveolar ridge.1 Research suggests that

an extraction socket augmentation carried

out at the time of tooth removal is a

reliable and predictable method to reduce

significantly crestal bone resorption and

atrophy, aid socket fill, and minimize loss

of horizontal ridge height Ultimately, it

helps patient and practitioner to reduce

or eliminate the need for further costly and

traumatic ridge defect augmentation at the

time of esthetic rehabilitation or implant

placement.1 Clinicians today are aware

that sufficient alveolar bone volume and

favorable architecture of the alveolar ridge

are essential to achieve ideal functional and

esthetic prosthetic reconstruction

Ridge preservation procedures

that are carried out immediately after

extractions significantly reduce the

three-dimensional alveolar bone loss that

inevitably follows tooth extraction alone..2

Patients undergoing this procedure benefit

from a ridge form that allows for better

esthetics, contour of fixed or removable

prosthesis, and implant placement.1

This article will discuss the efficacy of

a collagen plug-in, preserving alveolar ridge

dimensions in immediate extraction sites

and present the data from the literature

that involves flapless ridge preservation

procedures with the use of specially

heat-treated collagen plugs for occlusion of the

extraction socket.3

Traditional methods of tooth

extraction often result, at the least, in loss

of the labial plate of the alveolar bone

Atraumatic extraction focuses on gently severing the periodontal ligament using micro instrumentation, e.g., periotomes, intending to preserve alveolar crestal height

in all three dimensions.1 Already before

1970, the first attempt for the reasonable studying and the prevention of the ridge resorption phenomenon had started.4 The submerged root concept was introduced

as a ridge preservation technique.7,13

The trauma of the extraction brings

a cascade of cellular events to fill the socket with bone Grafting at the same time takes advantage of this phenomenon

Contemporary socket preservation techniques involve the placement of different biomaterials into the socket.5,8

Dr B.K Bartee proposed a classification

of application techniques depending on the purpose of the ridge preservation This classification is based on the resorbability pattern of the bone graft, and three categories were identified as follows.37

As far as primary wound closure is concerned, soft tissue coverage of the graft with or without membrane, sealing

of the socket with a free gingival graft, or

a connective tissue graft, and placement

of a collagen plug for socket occlusion have all been proposed.14,15,36,38 Barrier membranes as used for GBR have been employed, showing good results

in ridge preservation.17,18,19 The need for primary soft tissue closure presents the main drawback associated with this technique.3 It requires significant coronal flap advancement causing coronal displacement of the mucogingival junction and of the keratinized gingiva toward the crest, and increases postoperative swelling and discomfort due to periosteal scoring and/or relieve incisions.20 Furthermore,

if membrane exposure occurs, risk for infection of the graft increases, and the outcome of the preservation procedure becomes less predictable,21 even though one study by Nam and Park in 200911

showed that membrane exposure during the healing period did not affect the efficacy

of ridge preservation procedures

In full-thickness buccal and palatal/lingual mucoperiosteal flaps, which are raised to facilitate barrier membrane placement over sound alveolar bone, Collagen plug application in extraction sockets

Drs Jon B Suzuki and Diana Bronstein explore the efficacy of a collagen plug-in

Jon B Suzuki DDS, PhD, MBA, is a Professor at Temple

University, Kornberg School of Dentistry, Graduate

Periodontology and Oral Implantology Department,

Philadelphia, Pennsylvania.

Diana Bronstein DDS, MS, is a Professor at Nova

Southeastern University, College of Dental Medicine,

Department of Periodontology, Ft Lauderdale, Florida.

Technique Rationale

Long-term ridge preservation

• pontic site development or to improve the stability of removable appliances

• non-resorbable materials are used for this indication and

• not favorable for implant placement

Medium-term or transitional ridge preservation

• slowly resorbable bone grafts used in ridge preservation allow for the preservation

of the alveolar ridge for an extended period of time, enabling the placement of

an osseointegrated implant in the site after the initial healing period, even in the presence of some unresorbed graft particles

• indicated in cases where it is still undetermined whether the patient is going to restore the edentulism with an implant, or in cases where the patient has chosen

to have an implant placed, but will be unable to return and place the implant for a substantial amount of time3

Short-term ridge preservation

• objective is to maintain the post-extraction alveolar dimensions during the initial healing phase in order to allow for the placement of an implant in the shortest possible time period3

Modified from B.K Bartee37

the vascular innervation via the

bone-periosteum continuity is disrupted, and a

marginal bone resorption of approximately

1 mm should be anticipated.6

Based on this, for predictable

post-extraction ridge preservation, flapless

techniques should be favored Reflecting

a flap may initiate further bone resorption

due to disruption in the blood supply to the

cortical bone under the periosteum Further

ridge atrophy would occur additional to

the natural bundle bone resorption of the

alveolar post-extraction healing socket.1

The “socket seal surgery” technique, a

ridge preservation technique that does not

require flap advancement, was introduced

to counter these procedure-inherent

drawbacks.22 This minimally invasive ridge

preservation procedure involves bone

and soft tissue grafting The extraction

socket is filled with bone graft, and then an

autogenous soft tissue graft of adequate

size is harvested from the palate and is

placed over the bone graft in order to seal

the socket.23 Even though the “socket

seal surgery” technique was innovative in

introducing a ridge preservation procedure

that would not require advancement of

mucoperiosteal flaps for primary wound

closure, it still did not minimize the

postoperative discomfort due to the graft

harvesting at the donor site.3 Recent work

by Araujo and Lindhe37 in a dog model

showed using a subepithelial connective

tissue graft taken by a window or envelope

procedure from the palate may increase

soft tissue coverage, but this did not result

in increased bone fill.3

Then, the Bio-Col technique was introduced shortly afterwards, using the same principles as the “socket seal surgery,” but specifically using anorganic slow-resorbing bovine bone particulates as

a socket graft and replacing the soft tissue graft with the use of a collagen plug to occlude the wound.24 This new technique reduced postoperative morbidity, as there was no need for flap elevation or graft harvesting.3 After the introduction

of this concept, many modifications were proposed in the literature, differing either in the graft that was used (Alloplug technique, Nu-mem technique) or in the placement

of the collagen plug (modified Bio-Col technique ).25-27

Because of the configuration of the extraction socket, the majority of bone graft may be lost if no protection is provided.1

Therefore, the use of collagen dressing material was suggested, not only

wound-to protect the graft material, but also wound-to induce blood clot formation and stabilize the wound.8 A collagen dressing material

is preferable due to its high biocompatibility and hemostatic ability that can enhance platelet aggregation, and thus, facilitate clot formation and wound stabilization.9

Collagen also has a high chemotactic function for fibroblasts This might promote cell migration and accelerate primary wound coverage.10

Variations of the “socket-plug”

technique have been also used for more than a decade to help minimize the amount

of bone loss and ensure the esthetics of the future restoration.24 One contraindication to

the application of this technique is severe buccal plate dehiscence.3 In such cases,

a barrier membrane should be employed

in order to contain the graft and exclude the soft tissue from invading the buccal space.39

The cases presented will illustrate the basic steps used in this technique:3

Dr Yueh Hsiao, Temple University

Fractured No 19 was extracted atraumatically, and ridge preservation with Foundation® Bone Filling Augmentation Material was performed for future implant placement

Figure 1 depicts preserved socket after careful extraction of tooth No.19 with intact buccal plate and interdental septum

Figures 2 and 3 depict J Morita’s Foundation®.31 It is a bone-filling augmentation material indicated for use after extractions, providing support for implants, bridges, and dentures

According to the manufacturer, the collagen-based material is formulated to stimulate growth of the patient’s own bone

bovine-at an accelerbovine-ated rbovine-ate while minimizing antigenicity Foundation® comes in two sizes of solid bullet-shaped plugs, designed for easy handling and placement in the extraction socket If desired, the plugs can

Figure 1 Figure 2 Figure 3

Figure 4 Figure 5 Figure 6

16 Implant practice Volume 6 Number 6

be trimmed or shaped for a better fit It is

radiolucent and resorbable

31The Foundation bullet-shaped plugs

come in two sizes — small (8 mm x 25 mm)

and medium (15 mm x 25 mm) — and are

individually packaged in sterile containers

Figure 4 depicts the Foundation

collagen plug placed in extraction socket

and held by non-resorbable sutures

Immediately after extraction and socket

curettage, forceps are used to place the

Foundation plug on a 2 x 2 gauze pad

before insertion into the extraction socket

There is no need to remove the product

once it’s placed, and no membrane is

required The plugs can be shaped to

mimic the root tip when needed After

placement, the Foundation plug is gently

condensed into the socket

Figure 5 depicts 1 week post-op

healing after suture removal with ridge

maintaining width and height.31 According

to the manufacturer, implants may be

placed as soon as 8 to 12 weeks after

Foundation is placed in the extraction

Alveolar ridge height and width appear adequate for prosthetic restoration

implants were placed 6 weeks after the extractions on the left side Ten weeks after the extraction, the lower left side filled with Foundation was restored with implants, which were immediately loaded by a provisional prosthesis Four months later, the final prosthesis was inserted

Figure 8 depicts patient panoramic radiograph 2 weeks after the extractions and the placement of Foundation into the extraction sockets of the posterior lower left teeth

Figures 9 and 10 depict patient panoramic radiograph 6 and 10 weeks after the post-extraction ridge preservation procedure in the posterior lower left Implants were also placed lower right.Figure 11 depicts patient panoramic radiograph 4 months after implant placement with definitive restoration in place

Figure 12 depicts patient 4 months after implant placement, and Figure 13 shows definitive restoration in place

Figure 7 Figure 8 Figure 9

Figure 10 Figure 11 Figure 12

Figure 13 Figure 14 Figure 15

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Case 4

Dr Arthur Greenspoon, Montreal,

Quebec, Canada

Figure 14 depicts pre-extraction PA of

tooth No 13 after failed endodontic

treatment and apicoectomy, post and core

in place with defective restoration

Figure 15 depicts immediate

post-extraction PA of tooth No 13

Figure 16 depicts placement of

Foundation after the extraction of No 13

and future implant planning

Figures 16 and 17 depict grafted

extraction socket at 4 weeks and 8 weeks

Figure 18 depicts implant in place

at about 3 months after extraction and

grafting with slight mesial angulation of the

coronal part to improve prosthetic access

and engage more of the native bone

apically

Case 5

Dr Arthur Greenspoon, Montreal,

Quebec, Canada

Figure 19 depicts tooth No 19 with sinus

tract and radiolucent J-form lesion apically

with inflammatory resorption, possibly

mesial root fracture

Figure 20 depicts tooth No.19

after root amputation and placement of

Foundation into the mesial root socket

Figure 21 depicts tooth No 19

post-op radiograph after definitive restoration

and splint to adjacent premolar with PFM

Not many studies have documented the histology of extraction-socket healing

in human subjects, and most research involving extraction-socket healing has been performed on animals, which regenerate oral tissues much faster

Accordingly, studies of extraction-socket healing in animals cannot be equated to human extraction-socket healing

Amler, et al.41 found that the blood clot filling the socket after extraction was replaced with granulation tissue after 7 days After 20 days, the granulation tissue was replaced by collagen, and bone began forming at the base and the periphery of the extraction socket and at 5 weeks, two-thirds of the extraction socket had filled with bone.38 Epithelium was found to require a minimum of 24 days to completely cover the extraction socket, with some extraction sites requiring up to 35 days to completely cover the socket.41 The epithelium was found to grow progressively, enveloping islands of granulation tissue, debris, and bone splinters 38Amler noted that all stages

of bone regeneration progressed from the apex and periphery, and proceeded finally

to the center and crest of the extraction socket

Boyne found new bone formation after extraction only after 8 days under the socket wall but not on the surface of the bone lining the extraction socket.42 After

10 days, bone formation was occurred on the surface of the socket wall, and after

12 days, new bone formation continued along the socket wall and in the trabecular spaces surrounding the extraction site.42

In their histological samples, Devon and Sloan noted woven bone trabecula

at the periphery of the socket 2 weeks after extraction Osteoprogenitor cells, preosteoblasts, and osteoblasts surrounded the trabecula The periodontal ligament was displaced to the center of the extraction socket and not attached to the socket wall.40

These findings indicate that, in humans, the first phase of extraction-socket healing is most likely osteoclastic undermining and rejection of the original socket wall into the healing socket.38

While it is generally assumed that after extraction bone lining the socket wall

is stimulated into new bone growth, this contention is at odds with what is known about how bone responds to trauma and surgical exposure.38 During gingival flap surgery, raising the soft tissue off the bone will result in resorption of bone from the bone surface.6,43 Usualy after extraction the buccal plate is significantly resorbed, and the bony socket wall is exposed to bacterial colonization, while the body attempts to form a fibrin clot.41,44-46

Inflammatory cells trying to prevent infection infiltrate the fibrin clot As seen in

Figure 16 Figure 17 Figure 18

Figure 19 Figure 20 Figure 21

20 Implant practice Volume 6 Number 6

RefeRences

1 Gupta D, Gundannavar G, Chinni DD, Alampalli RV Ridge

preservation done immediately following extraction using bovine

bone graft, collagen plug and collagen membrane Int J Oral

Implantol Clin Res 2012;3(1):8-16

2 Luczyszyn SM, Papalexiou V, Novaes AB Jr, Grisi MF, Souza

SL, Taba M Jr Acellular dermal matrix and hydroxyapatite in

prevention of ridge deformities after tooth extraction Implant

Dent 2005;14(2):176-184.

3 Kotsakis G, Markou N, Chrepa V, Krompa V, Kotsakis A

Alveolar ridge preservation utilizing the ‘socket-plug’ technique

Int J Oral Implantol Clin Res 2012;3(1):24-30.

4 Atwood DA Postextraction changes in the adult mandible as

illustrated by microradiographs of midsagittal sections and serial

cephalometric roentgenograms J Prosthet Dent

1963;13(5):810-824.

5 Ten Heggeler JM, Slot DE, Van der Weijden GA Effect of

socket preservation therapies following tooth extraction in

non-molar regions in humans: a systematic review Clin Oral

Implants Res 2011;22(8):779-788.

6 Moghaddas H, Stahl SS Alveolar bone remodeling following

osseous surgery A clinical study J Periodontol

1980;51(7):376-381.

7 Casey DM, Lauciello FR A review of the submerged-root

concept J Prosthet Dent 1980;43(2):128-132.

8 Wang HL, Kiyonobu K, Neiva RF Socket augmentation:

Rationale and technique Implant Dent 2004;13(4):286-296.

9 Sableman E Biology, biotechnology and biocompatibility of

collagen In: Williams DF, ed Biocompatibility of Tissue Analogs

Boca Raton, Florida: CRC Press; 1985:27.

10 Postlethwaite AE, Seyer JM, Kang AH Chemotactic attraction

of human fibroblasts to type I, II, and III collagens and

collagen-derived peptides Proc Natl Acad Sci U S A 1978;75(2):871-875.

11 Nam HW, Park YJ, Koo KT, Kim TI, Seol YJ, Lee YM, Gu Y,

Rhyu IC, Chung CP The influence of membrane exposure on

post-extraction dimensional change following ridge preservation

technique J Korean Acad Periodontol 2009;39(3):367-374.

12 Atwood DA, Coy WA Clinical, cephalometric, and

densitometric study of reduction of residual ridges J Prosthet

Dent 1971;26(3):280-295.

13 von Wowern N, Winther S Submergence of roots for alveolar

ridge preservation A failure (4-year follow-up study) Int J Oral

Surg 1981;10(4):247-250.

14 Landsberg CJ Socket seal surgery combined with

immediate implant placement: a novel approach for single-tooth

replacement Int J Periodontics Restorative Dent

1997;17(2):140-149.

15 Tal H Autogenous masticatory mucosal grafts in extraction

socket seal procedures: a comparison between sockets grafted

with demineralized freeze-dried bone and deproteinized bovine

bone mineral Clin Oral Implants Res 1999;10(4):289-296.

16 Juodzbalys G, Sakavicius D, Wang HL Classification of

extraction sockets based upon soft and hard tissue components

18 Mardas N, D’Aiuto F, Mezzomo L, Arzoumanidi M, Donos N

Radiographic alveolar bone changes following ridge preservation

with two different biomaterials Clin Oral Implants Res

2011;22(4):416-423.

19 Carmagnola D, Adriaens P, Berglundh T Healing of human

extraction sockets filled with Bio-Oss Clin Oral Implants Res

2003;14(2):137-143.

20 Engler-Hamm D, Cheung WS, Yen A, Stark PC, Griffin

T Ridge preservation using a composite bone graft and

a bioabsorbable membrane with and without primary

wound closure: A comparative clinical trial J Periodontol

2011;82(3):377-387.

21 Verardi S, Simion M Management of the exposure of e-PTFE

membranes in guided bone regeneration Pract Proced Aesthet

25 Sclar AG Strategies for management of single-tooth

extraction sites in aesthetic implant therapy J Oral Maxillofac

Surg 2004;62(9 Suppl 2):90-105.

26 Fowler EB, Whicker R Modified approach to the Bio-Col ridge

preservation technique: a case report J Contemp Dent Pract

2004;5(3):82-96.

27 Wang HL, Tsao YP Mineralized bone allograft-plug

socket augmentation: rationale and technique Implant Dent

2007;16(1):33-41.

28 Iasella JM, Greenwell H, Miller RL, Hill M, Drisko C, Bohra

AA, Scheetz JP Ridge preservation with freeze-dried bone allograft and a collagen membrane compared to extraction alone for implant site development: a clinical and histologic study in

humans J Periodontol 2003;74(7):990-999.

29 Garg AK, Reddi SN, Chacon GE The importance of asepsis in

dental implantology Implant Soc 1994;5(3):8-11.

30 Zitzmann NU, Scharer P Oral rehabilitation with dental

implants Aegis Communications 2009;2(2).

31 J Morita USA Foundation http://www.morita.com/usa/

cms/website.php?id=/en/products/dental/partner/auxiliaries/

foundation.htm Accessed October 10, 2013.

32 Becker W, Clokie C, Sennerby L, Urist MR, Becker BE

Histologic findings after implantation and evaluation of different grafting materials and titanium micro screws into extraction

sockets: case reports J Periodontol 1998;69(4):414-421.

33 Vance GS, Greenwell H, Miller RL, Hill M, Johnston H, Scheetz JP Comparison of an allograft in an experimental putty carrier and a bovine-derived xenograft used in ridge preservation:

a clinical and histologic study in humans Int J Oral Maxillofac

Implants 2004;19(4):491-497.

34 Postlethwaite AE, Seyer JM, Kang AH Chemotactic attraction

of human fibroblasts to type I, II, and III collagens and

collagen-derived peptides Proc Natl Acad Sci USA 1978;75(2):871-875.

35 Damien C, Parsons JR Bone graft and bone graft substitutes:

a review of current technology and applications J Appl Biomater

1991;2(3):187-208.

36 Bitter RN A rotated palatal flap ridge preservation technique

to enhance restorative and hard and soft tissue esthetics for tooth

replacement in the anterior maxilla Int J Periodontics Restorative

Dent 2010;30(2):195-201.

37 Bartee BK Extraction site reconstruction for alveolar ridge

preservation Part 1: rationale and materials selection J Oral

Implantol 2001;27(4):187-193.

38 Steiner GG, Francis W, Burrell R, Kallet MP, Steiner DM,

Macias R The healing socket and socket regeneration Compend

Contin Educ Dent 2008 Mar;29(2):114-6,118,120-4 passim.

39 Misch CE Contemporary implant dentistry (3rd ed) St Louis: Mosby Inc 2007.

40 Devlin H, Sloan P Early bone healing events in the human

extraction socket Int J Oral Maxillofac Surg 2002;31(6):641-645

41 Amler MH, Johnson PL, Salman I Histological and histochemical investigation of human alveolar socket healing in

undisturbed extraction wounds J Am Dent Assoc

1960;61(7):32-44

42 Boyne PJ Osseous repair of the postextraction alveolus in

man Oral Surg Oral Med Oral Pathol 1966;21(6):805-813

43 Pfeifer JS The reaction of alveolar bone to flap procedures in

man Periodontics 1965;20:135-140

44 Araújo MG, Sukekava F, Wennström JL, et al Tissue modeling

following implant placement in fresh extraction sockets Clin Oral

Implants Res 2006;17(6):615-624

45 Covani U, Bortolaia C, Barone A, et al Bucco-lingual crestal

bone changes after immediate and delayed implant placement J

47 Coon D, Gulati A, Cowan C, et al The role of

cyclooxygenase-2 (COX-2) in inflammatory bone resorption J

Endod 2007;33(4):432-436

48 Taubman MA, Kawai T, Han X The new concept of periodontal disease pathogenesis requires new and novel

therapeutic strategies J Clin Periodontol 2007;34(5):367-369

periodontal and endodontic diseases, bone

is resorbed in the presence of inflammatory

cells.47,48

It is more plausible that the socket wall

will proceed through a phase of resorption

before regeneration.38

The possible origins of osteoblasts

in the human tooth extraction socket are

Pericytes, Adipocytes, the periodontal

ligament fibroblasts, the marrow stem

cells, and the periosteum

We know that the periodontal

ligament can regenerate alveolar bone,

although guided tissue regeneration

techniques, which allow further

osteogenic differentiation of these cells,

produce unpredictable clinical results

Osteoprogenitor cells in the periodontal

ligament and bone marrow may contribute

to bone regeneration following tooth

extraction.40

Conclusion

The resorption of alveolar bone following extractions results in a narrowing and shortening of the residual ridge.2 According

to the literature, alveolar ridge resorption can be limited but not avoided Complete preservation of the pre-extraction ridge dimensions should not be anticipated, even when alveolar ridge preservation techniques involving post-extraction socket grafting are applied Ridge preservation requires thorough comprehension of tissue-healing procedures after the extraction of one or more teeth, as well as deep knowledge of bone substitute properties The “socket-plug” technique can help the clinician to provide the best possible outcome with the least patient discomfort The results not only depend on the delicate handling of the tissues, but also on the resorption rate

of the graft material and its replacement

by mature bone capable of withstanding functional loading.3 Obviously, the different anatomical and dimensional characteristics

of hard tissue and soft tissue quantities, qualities, and gingival tissue biotypes, together with several other factors (e.g., reason for extraction, tooth location, etc.), may influence the final outcome of any socket preservation procedure and may be important in making the decision of whether

or not a ridge preservation technique is indicated Ultimately, the ridge preservation approach significantly limits the osseous resorption of the alveolar post-extraction ridge compared to extraction alone.1 IP

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One of the most challenging clinical

situations to present to the implant

team is advanced bone loss that leads

to insufficient bone volume for proper

implant placement Rebuilding bone height

and width has been a difficult technique

and sensitive procedure, which usually

requires the patient to undergo painful and

aggressive surgeries to harvest autogenous

bone from the ramus, symphisis, iliac

crest, or tibia Commonly, the site where

the bone was harvested from caused

more postoperative pain and sequella than

the actual surgical site itself Additionally,

from the literature, a 16-20% loss in bone

volume of the healed graft can be noticed

at re-entry for implant placement This can

be a problem for the reconstruction of

normal soft tissue architecture for implant

esthetics and long-term maintenance

The following case report presents

a new technique and allogenic grafting procedure to increase both bone volume

in the height and width dimensions Dr

Petrungaro is one of the only surgeons

in the country using this art material for the reconstruction of small to large intraoral osseous defects

state-of-the-A 42- year-old, non-smoking female presented for reconstruction of her lower arch with dental implants (Figures 1 and 2) The patient had a congenitally missing dentition, which contributed to large defects in her mandibular arch in the buccal-lingual dimension (Figure 3)

The defects made conventional implant placement impossible without a prior bone reconstruction procedure The patient had also obtained other opinions regarding treatment, which consisted of removal of over 20+ millimeters of bone and an All-on-4 type option, advanced bone harvesting procedures from the iliac crest region, and the option she chose in

Dr Petrungaro’s practice, localized ridge augmentation using a stem-cell infused allogenic block graft procedure This technique negates the patient undergoing a painful bone harvesting surgical procedure, and provides a bone reconstruction and remodeling process in which her own osseous structures are stimulated and reconstructed prior to implant placement

After removal of tooth Nos 24 and 25 (Figure 4), the large buccal-lingual defect can be seen clearly from this clinical view

Figures 5 and 6 show the undercut in the crest of the ridge from the buccal and occlusal views, respectively This thin knife-edged ridge, and significant undercut, would make proper implant placement very difficult, if at all possible to achieve

Coronal flattening of the crest of the ridge (Figure 7) is necessary for closure

of the wound and stimulation of the marrow spaces at the crest of the ridge by removing the cortical plate Figure 8 shows the allogenic stem cell block grafts placed

at the buccal aspect of the ridge from the tooth No 19 area to the tooth No 27 area

Over 140,000 stem cells are at the facial aspect of the crest of the ridge to stimulate the patient’s own osseous structures to help rebuild the insufficient buccal aspect

Stem cell block grafts

Dr Paul Petrungaro delves into allogenic stem cell block grafts to facilitate reconstruction of localized/ severe ridge defects and reconstruct proper alveolar contours prior to dental implant placement

Preoperative serial views

Paul Petrungaro, DDS, MS, graduated from

Loyola University Dental School in 1986

and completed an independent study of

Periodontics at the Welsh National Dental

School in the United Kingdom He completed

a residency, specialty certificate, and Master of

Science Degree in Periodontics from Northwestern

University Dental School, and formerly served as

the Coordinator of Implantology for the university’s

Graduate Department of Periodontics Dr Petrungaro

has maintained a private practice in Periodontics and

Implantology since 1988, and holds licenses in Illinois,

Minnesota, and Washington As a world-renowned and

pre-eminent educator, he has presented numerous

seminars and lectures worldwide on topics of advanced

periodontal, prosthetic, and implant interrelationships,

bone regeneration, esthetic tissue formation, transitional

implants, immediate restoration of dental implants,

and the use of platelet rich plasma in bone grafting

In addition, he has authored over 75 articles on these

topics including cosmetic bone grafting and esthetic

implant procedures in such prestigious publications

as Compendium, Inside Dentistry, and the American

Academy of Cosmetic Dentistry’s Journal of Cosmetic

Dentistry Dr Petrungaro’s consultant role to several

biomedical companies and laboratories has resulted

in many new innovations in surgical dentistry He is

a fellow of the International and American College of

Dentists and a Diplomate of the International Congress

of Oral Implantologists and holds memberships in

several professional associations.

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Additional allogenic cortical and cancellous

particulate grafting is accomplished (Figure

9) prior to isolation and stabilization of

the stem cell graft by a nonresorbable

expanded polytetrafluoroethylene (e-PTFE)

titanium-reinforced membrane (Figure 10)

Figure 6 Figure 7 Figure 8

Figure 9 Figure 10 Figure 11

of the desired crestal bone dimension being regenerated An additional membrane, BioXclude™ (Snoasis Medical),

comprised of amniotic tissue (Figure 11) is then placed over the e-PTFE membrane prior to wound closure (Figure 12) This amniotic membrane contains stem cells also, and aids in the rapid soft tissue healing necessary to obtain optimal wound closure, and provides a stable wound throughout the healing phase Figure

13 demonstrates optimal closure, while Figure 14 demonstrates the immediate fixed provisional restoration supported

by a provisional implant in the tooth No

18 position Figure 15 shows 4-month postoperative serial views Please note the significant increase in the buccal-lingual dimension of the ridge obtained Figure

16 shows the 4-month clinical re-entry view, and Figure 17 shows the implant placement clinical view

The radiographic confirmation of the increase in buccal-lingual ridge dimension can be readily seen, and comparing

to Figure 2, it is readily apparent The introduction of stem cells to this allogenic material creates an ideal situation for rapid bone replacement in difficult osseous defect sites, eliminating the need for painful harvesting of bone from other parts of a patient’s oral cavity or body This is a much less invasive option for patients to consider

IP

Figures 1A and 1B

Patient presented with a recent fracture

of the crown and coronal aspect of the

maxillary left central incisor tooth No

9 (21) This was a second fracture of

this tooth as it was repaired by clinical

lengthening surgery, post and core, and

a crown 5 years prior The patient had a

bite protective occlusal appliance, which

she chose to not use The current fracture

included the facial cervical tooth structure

to the osseous crest The prosthodontist

placed a provisional post-supported acrylic

resin crown and made the decision that

this tooth would be better replaced by an

implant-supported crown, since this would

offer the best opportunity to preserve the

integrity of the alveolar bone and gingival

framework The radiographic image

suggested that there may be no damage to

the alveolar bone as a result of the fracture

Figures 2A and 2B

Following anesthesia by the infiltration

of Articaine, the remainder of tooth No

9 (21) was extracted without a gingival flap access The acrylic crown with the provisional post was removed using crown

and bridge forceps, and the remaining root was atraumatically extracted using the Easy X-Trac (A-Titan) screwed into the endodontic canal post space All bone walls of the socket were retained, and the gingival tissues were not traumatized or incised The bone on the facial aspect of the socket was determined to be relatively thick (2 mm) and intact, and the socket anatomy was well suited for immediate implantation An osteotomy was carefully prepared for a Straumann® implant, with intentional over-extension in depth at the apex The 4.8 X 10 mm RC Straumann®

Bone Level SLActive® implant was placed, following recommended protocol, until the implant shoulder was about 2+ mm below the facial gingival margin A radiograph was taken, since the facial bone could

no longer be visualized, with the implant and insertion device filling the space The radiograph shows the relationship of the implant to the crestal bone and the available area of added osteotomy depth at the apex, which can be measured with the digital radiographic software Based on the appearance of the radiograph, the implant was rotated into the osteotomy to achieve

a final desired position relative to depth and the crestal bone and gingival tissues

Figures 3A and 3B

A customizable healing abutment (Straumann, 024.4270) was modified at

Ideal tissue management when immediate

provisionalization is not appropriate

Drs Robert L Holt and Bernard E Keough illustrate a specific type of implant management

Figure 1A Figure 1B

West Palm Beach, Florida-based Periodontist Robert L Holt, DMD, earned a BA from Washington

and Lee University in Lexington, Virginia, followed by his DMD from the University of Alabama in

Birmingham in 1971 He was awarded a National Institutes of Health fellowship and earned a PhD in

Microbiology and a Specialty in Periodontics He served in the U S Navy as Chief of Periodontics

for the 2nd Marine Division at Camp Lejeune, North Carolina Dr Holt has been President of the Atlantic Coast

Dental Research Clinic and Co-Chairman of the Periodontal-Prosthetics Section and the Implantology Section

He is a former visiting Assistant Professor at Nova Southeastern University’s College of Dental Medicine and a

Fellow of the American College of Dentists Dr Holt continues to serve as a consultant to multiple dental implant

and pharmaceutical companies Dr Holt co-authored the textbook Periodontal and Prosthetic Management

of the Advanced Case He has lectured extensively in the U.S and in Europe He has vast experience and

expertise in periodontal-implant-prosthetic management of patients with complex problems His special areas

of interest and treatment activity include bone and tissue regeneration, periodontal-prosthetics, esthetics, and

dental implantology Dr Holt is a native of Florida.

West Palm Beach, Florida-based Prosthodontist Bernard E Keough, DMD, graduated Cum Laude

from the University of Kentucky and received his DMD from the University Of Kentucky College Of

Dentistry in 1972 There he was honored with the Academy of General Dentistry Award and the

American Academy of Gold Foil Operators Achievement Award for excellence in restorative dentistry

Following active duty in the United States Air Force, Dr Keough graduated from Boston University School

of Graduate Dentistry receiving his Certificate of Advanced Graduate Study in Prosthetic Dentistry He is a

specialist in full-mouth reconstruction and dental esthetics, having extensive experience in complex dental

and implant restorations, and the current use of CAD/CAM technology Dr Keough has presented his clinical

findings at international symposiums in Germany, Italy, and Spain, and at meetings and study clubs throughout

the United States He has authored articles for publications including The International Journal of Periodontics

& Restorative Dentistry, Practical Procedures and Aesthetic Dentistry and the Compendium of Continuing

Education in Dentistry In addition, he co-authored a chapter on periodontal-prosthetic dentistry in Clinical

Dentistry (JW Clark, Ed.), as well as co-authoring the textbook Periodontal and Prosthetic Management for

Advanced Cases (Quintessence) In 2001, as an Adjunct Assistant Clinical Professor at Nova Southeastern

University School of Dentistry, Dr Keough helped establish the curriculum for the school’s first

Periodontal-Prosthetic program Dr Keough is a member of the Omicron Kappa Upsilon Honorary Dental Society, the

American College of Prosthodontics, the American Dental Association, as well as several state and local dental

societies.

CASE STUDY

chairside by the surgeon and placed on

the implant The radiograph confirms full

seating of the healing abutment and the

proper level of the Bone Level implant

in relationship to the alveolar bone The

customized healing abutment was shaped

to have the appropriate trigonal shape

and the sufficient size to maintain and

preserve the three-dimensional contours

of the scalloped gingival complex as if

the tooth was still present Immediate

prosthetic provisionalization was not an

option for this case given a positive history

of parafunction and the two fractures of the

No 9 (21) tooth from occlusal loading The

patient wore a removable provisional that

was adjusted to have no contact with the

customized healing abutment

Figures 4A and 4B

Two-month healing reveals excellent

preservation and maintenance of the

gingival tissue contours, supported

and maintained by the custom healing

abutment The implant did not yield to

torque testing

Figures 5A and 5B

Following implant integration and soft

tissue maturation, the patient presented to the prosthodontist for final impression and substitution of the removable appliance with a provisional abutment-supported temporary crown A customized impression post (Straumann, 025.4201), modified

to capture the anatomy of the formed soft tissue, was used so as to replicate those contours in the final master cast A standard RC PEEK provisional abutment (Straumann 024.4370) was then modified and shaped by the prosthodontist to mimic the approximate subgingival, interproximal, and crestal gingival contours of the root of the tooth that the abutment was replacing The supragingival contours of the abutment were shaped in classic tooth preparation form to support a cement-on provisional crown Margin location on the abutment was established approximately

½ to 1 mm subgingivally circumferentially around the abutment This resulted in

a scalloped-shaped form as the margin followed the rise and fall of the gingival tissues around the abutment At this time, the implant No 9 (21) was then “loaded”

with a provisional restorative acrylic crown

Without the efforts of the prosthodontist

to refine and appropriately reshape the

Figure 2A Figure 2B Figure 3A Figure 3B

Figure 4A Figure 4B Figure 5A Figure 5B

Figure 6A Figure 6B Figure 7

provisional restorative abutment to create the emergence profile and tooth shape, the contours that were retained by the custom healing abutment could have been lost at this stage

Figure 7

The final crown is in place, and the gingival tissue complex is intact and stable, supported by bone, formed by an appropriate abutment with appropriate emergence profile, and a porcelain-fused-to-metal crown cemented with shallow, scalloped margins.IP

Introduction

When patients present with missing

teeth, there are several treatment options

that can be considered The tooth – or

teeth – can be replaced with a removable

appliance, a fixed partial denture, or implant

restorations Sometimes the decision is

based on what the insurance is going to

pay, or if the patient has adequate bone to

support the implant and restoration Also,

the clinical skill of the dentist can often

dictate the treatment

In the early 80s when root form

implants became popular, there was a

lot of extra equipment the dentist needed

to have in order to provide an implant

restoration There were many parts

and pieces, torque drivers, and some

companies that only focused on surgeons

and specialists providing these services

Today, implant restorations are

the most profitable service I offer in my

practice One reason is the ease of use

The Straumann® Tissue Level (TL) implant

offers simplicity at a reasonable cost with

minimal equipment needed, and I find it to

be the most predictable implant system

in my office today With supragingival or

slightly subgingival margins, I am currently

restoring most posterior cases with TL

implants because of their simplicity, ease of

impression taking, and delivery of the final

restoration

There is no typical day in my practice,

so predicting which procedures I will be performing from day to day in my office

is nearly impossible Because of this, inventory management is critical to our success and ensures a readily available supply of impression copings, solid abutments of all sizes, implant analogs, and protection or temporary pieces If the surgeon calls to say the patient is ready

to have the implant restored, we can then have the patient come in that same day for final impressions This usually takes

less than 10 minutes and can dramatically impact the bottom line Without an adequate supply of restorative parts, this would not be possible, and I would lose the opportunity to get the patient in that day The Straumann Dental Implant System TL has an array of implant and abutment sizes to accommodate different thicknesses of bone and the interocclusal height of the opposing teeth The standard abutment heights for the Regular Neck (RN) implants are 4.0, 5.5, and 7.0 mm Also available are Wide Neck (WN) implants with

Reflections on the Straumann ® Tissue Level (TL) implant

Dr Robert Margeas discusses a predictable and easy-to-use implant option

Figure 1

Robert Margeas, DDS, graduated from the

University of Iowa College of Dentistry in

1986 and completed his AEGD residency

the following year He is currently an adjunct

professor in the Department of Operative Dentistry

at the University of Iowa He is Board Certified by

the American Board of Operative Dentistry He is a

Diplomate of the American Board of Aesthetic Dentistry,

a Fellow of the Academy of General Dentistry, and

International Team of Oral implantologists (ITI) He

has written numerous articles on esthetic and implant

dentistry, and lectures and presents hands-on courses

nationally and internationally on those subjects

He serves on the Editorial Advisory board of Inside

Dentistry, Compendium, and is a contributing editor to

Dentistry Today and Oral Health in Canada Dr Margeas

maintains a full-time private practice focusing on

comprehensive restorative and implant dentistry in Des

Moines, Iowa.

Figure 2

Figure 3 Figure 4

Figure 5 Figure 6

ROXOLID ® FOR ALL

Designed to increase your treatment options and help

to increase patient acceptance of implant therapy.

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two different abutment heights, as well as

Tapered Effect (TE) implants for immediate

placement What I find to be the beauty of

the Straumann TL implant system is that

the abutments are made of solid titanium

and are standard, which does not require a

custom abutment Because the margins of

the restoration are on the implant, surgeons

can place them at the tissue level, and with

the Morse taper of the solid abutments,

screw loosening is rarely an issue

Case presentation

A 55-year-old patient presented with

missing posterior teeth in the lower right

quadrant The patient wished to have

implants placed Because of the tipped

lower molar and the space not being wide

enough for three implants and too wide for

two, the decision was made to place two

implants and cantilever a tooth off

Two Regular Neck (RN) 4.1 mm wide

implants were placed with the healing

abutments protruding through the tissue

for a single stage surgery (Figure 1) – an

advantage for the patient as it does not

require a second stage surgery The

implants were not submerged

The healing abutments were removed

(Figure 2), revealing excellent tissue health

with no bleeding Impression-taking is

easier than traditional crown and bridge

Solid abutments (5.5 mm and 7.0 mm)

were selected for the clearance necessary

to restore the teeth and were placed using

an abutment carrier, and hand tightened

(Figure 3) Next, the abutments were

torqued to 35 Ncm using a torque wrench

(Figures 4 and 5) Then impression cylinders

were placed (Figure 6) A color-coordinated

positioning cylinder was placed over the

corresponding abutment and seated to be

flush with the impression cap (Figure 7) A

final impression was made, and the plastic

pieces became incorporated into the

impression (Figure 8) Laboratory analogs

were then snapped into the impression

and sent to the laboratory to be poured

up (Figure 9) Protection caps (Figure 10)

were then placed, and the patient was sent

home This impression procedure usually

takes less than 10 minutes

The laboratory then fabricated a soft

tissue model (Figure 11), and restorations

for cementation (Figure 12) Figure 12

shows the final restorations on the day of insertion The slight tissue blanching you will notice typically subsides within 4-5 minutes The restorations were placed with resin-modified glass ionomer cement

The final occlusion was checked to confirm slight contact on the restorations (Figure 13*)

The Straumann Tissue Level implant has been used in my practice for over 18 years with great success The ease of use makes it my go-to implant system for most posterior restorations, and the addition

of the bone level implant rounds out my armamentarium to meet the needs of my patients

*The abutment carrier, screwdriver, and torque wrench were the only pieces of equipment required to restore this case

from MedMark, llc