Tạp chí implant tháng 1-2 /2013 Vol 6 No1

Tạp chí implant tháng 1-2 /2013 Vol 6 No1

The Most Efficient Clinical Workflow in Dentistry

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CONTINUING EDUCATION CREDITS

PER YEAR!

Volume 6 Number 1 Implant practice 1

January/February 2013 - Volume 6 Number 1

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)

Mali Schantz-Feld Email: mali@medmarkaz.com

Tel: (727) 515-5118 ASSISTANT EDITOR

Kay Harwell Fernández Email: kay@medmarkaz.com

PRODUCTION MANAGER/CLIENT RELATIONS

Kim Murphy Email: kmurphy@medmarkaz.com

NATIONAL SALES/MARKETING MANAGER

Drew Thornley Email: drew@medmarkaz.com

Tel: (619) 459-9595 NATIONAL SALES REPRESENTATIVE

Sharon Conti Email: sharon@medmarkaz.com

Tel: (724) 496-6820 E-MEDIA MANAGER/GRAPHIC DESIGN

Greg McGuire Email: greg@medmarkaz.com

PRODUCTION ASST./SUBSCRIPTION COORDINATOR

Lauren Peyton Email: lauren@medmarkaz.com

consent must be obtained before any part of this publication may

be reproduced in any form whatsoever, including photocopies

and information retrieval systems While every care has been

taken in the preparation of this magazine, the publisher cannot

be held responsible for the accuracy of the information printed

herein, or in any consequence arising from it The views

expressed herein are those of the author(s) and not necessarily

the opinion of either Implant Practice or the publisher.

Dear Readers:

Happy 2013! It seems like only yesterday that we were busily preparing to welcome 2012, but in fact, so much has happened in the dental profession and in our publications, that the time has just flown by The positive momentum of the past year continues to propel

us forward We are happy to note that this year brings a fresh, contemporary look for the magazines New design elements, an easy-to-read print style, and expanded page size are just a few of the exciting changes that you will find in this, and future issues

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

Besides our magazine, Implant Practice US also features a vital and continually changing

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

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

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

All the best,

Lisa MolerPublisher

ITI Congress North America

Chicago, USA April 4 – 6

2013

5 Great Reasons to CONNECT

with the ITI in Chicago.

What puzzle pieces are you missing in your practice?

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

Do not wait, take advantage of the early bird

rate which expires January 31st and save $100.

Connectivity in Implant Dentistry: Putting the Pieces Together.

ITI Congress North America

Chicago, USA April 4 – 6

2013

5 Great Reasons to CONNECT

with the ITI in Chicago.

What puzzle pieces are you missing in your practice?

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

Do not wait, take advantage of the early bird

rate which expires January 31st and save $100.

Connectivity in Implant Dentistry: Putting the Pieces Together.

Perhaps the best gift I have ever given myself was the pursuit of education I remember the day I received my dental degree, knowing

that a long journey was ahead I had a plan, and my goal was simple: I would take continuing education courses that interested

me and lay the foundation for my future success It began with restorative treatment and included esthetics At the same time, my self-confidence in endodontics was lacking, and I committed years to that discipline Confident with the ability to heal and restore ailing teeth, I set my sights on surgery Unfortunately, dental school and residency could only prepare me so far I yearned to understand the finer points of saving teeth with periodontal surgery, and when unable, then to extract those teeth After 14 years of more education and honing my craft, I was awarded a Mastership in the Academy of General Dentistry

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

For me, the holy grail of dentistry was learning, understanding, and acquiring the wisdom to surgically place the implant in vivo I had always felt that all other fundamentals had to be acquired, and at that time, I believed those elements were in my repertoire With the groundwork laid out, and the foundation solid, I stood at the precipice, wanting to dive into the implant surgical arena What held me back was fear Fear

of the unknown Fear of those anatomical structures that haunted me, leading me to believe that with one wrong move, I would violate the maxillary sinus, the mental foramen, or the inferior alveolar nerve

I knew those areas well enough, and frankly, they scared me So, one day, I decided that it was time to overcome my anxiety and discover

if those bugaboos were really a threat or just the primal fear they inject you with at the undergraduate level I needed big time education

I sought something that was a commitment of time and funds, the two ingredients integral to any worthwhile venture For me personally,

I discovered and developed this talent (and continue to do so) in a “mini-residency.” Akin to the famed maxi-course, the location was Englewood, New Jersey, a 3-hour drive from my Baltimore home It was a 6-month commitment of bimonthly lectures, participation, and over-the-shoulder live placement And yes, there were lots of homework and tests My teacher and mentor, Dr John Minichetti, assembled

an all-star cast of educators, and between his excellent teaching skills, guidance, and care, I began my journey

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

I look forward to continued discovery and collaboration in 2013!

Ian E Shuman, DDS, MAGD

The best gift – education

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

TABLE OF CONTENTS

Through the keyhole

Dr Scott Marshall Blyer: An affinity for accessibility and approachability

A strong medical and surgical background, dedication to customer service, and a penchant for “pushing the envelope” keeps this clinician’s practice immersed in innovation

mouthwash 20

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

Dr David Furze and Mr Ashley Byrne describe a method in which all four maxillary incisors are replaced with an implant-supported fixed partial denture 22

Continuing education

replacement for traditional titanium mesh in particulate bone grafting

Dr Lewis Cummings discusses an improved method for particulate bone grafting 32

Secure bonding: implants and overdentures

Dr Ludwig Hermeler demonstrates how to modify an existing

overdenture for use with implants and secure it with direct intraoral adhesion 36

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

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TABLE OF CONTENTS

Research

Early loading versus immediate

loading: case examples

Drs Alberto Maltagliati, Andrea

Ottonello, Giulio Raffaghello, and

Andrea Mascolo explore esthetics

and function of early and immediate

Abstracts

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

Dr Maria Retzepi rounds up the current thinking on an increasingly important aspect of implant dentistry 52

Practice management

Know your liability as a business owner

Dr Robert M Fleisher discusses how to mitigate general liability risks besides malpractice claims 54

Materials &

equipment 56

Socket grafting

What can you tell us about your

background?

I grew up in the streets and went to the

school of hard knocks My first experience

with dental implants was getting my teeth

knocked out after a mix-up of mistaken

identity with the local crack dealer Ok,

none of that is true, but what is more

boring than a being a dentist from Long

Island? The genesis of my interest was

after volunteering for an oral surgeon in

college

Is your practice limited to

implants?

In my practice, I perform the full scope of

oral and maxillofacial surgery, although

a large portion is dedicated to dental

implants

Why did you decide to focus on

implantology?

We actually chose each other I was well

trained in my residency in dental implants

and continued my learning thereafter

Many of the dentists in my community have

a high dental IQ and perform many simple

cases themselves The cases I was getting

were cases that were complex, “hopeless,”

and failing It allowed me to push the

envelope of science, and in many cases,

be the hero doing what others deemed

impossible This excited me as a surgeon

and a scientist

How long have you been

practicing, and what systems do

you use?

I graduated dental school in 2000 and

residency in 2006 I have been in private

practice for over 6 years I have worked with

many different systems Straumann® is my

personal preference, but Nobel is the most

popular in my community, and therefore,

my most commonly placed implant

What training have you

undertak-en?

I graduated from the Pennsylvania

trusted me to care for them I have visited

my out-of-town patients after treatment in their hotels and even walked their dogs for them, and drove out of state to see a patient because she couldn’t come in It

is a tremendous responsibility to operate

on someone, and it is a responsibility I

do not take lightly My accessibility and approachability to my family of patients is what I am most proud of I have instilled this work ethic into my entire team

What do you think is unique about your practice?

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

PRACTICE PROFILE

Dr Scott Marshall Blyer

An affinity for accessibility and approachability

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

in Plano, Texas

Who has inspired you?

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

What is the most satisfying aspect

of your practice?

Like Frank Sinatra said, “I did it my way.” It

is not the typical office in terms of patient care, ambiance, or services rendered We don’t stand on ceremony and are very

“down to earth.” I love offering different options to patients, and together make their expectations a reality

Professionally, what are you most proud of?

I have done pro bono work, taught, held fundraisers for breast cancer and MS in my community, but my biggest pride comes from my daily dedication to those who

©2012 Zimmer Dental Inc All rights reserved * Data on file with Zimmer Dental

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Visit TrabecularMetal.zimmerdental.com

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12 Implant practice Volume 6 Number 1

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

What has been your biggest challenge?

Trying to find the balance between family and professional life I work essentially

7 days a week, and even when I am at home, it is difficult to get our profession off

my mind Different ideas are always racing through my mind

What would you have become if you had not become a dentist?

My father wanted me to be a chiropractor,

my uncle a caterer, and my mother, the president I love being creative and thinking

of new ideas I think I would have enjoyed a career in television marketing

What is the future of implants and dentistry?

In the titanium arena, immediate placement

of CAD/CAM customized one-piece implants and crowns are the future

Zirconium implants are getting some buzz

in the U.S., as we await long-term data I

am currently involved with research using stromal vascular fractions for implant site development, with promising early results

At some point, stem cells will probably replace implants entirely

What are your top tips for taining a successful practice?

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

What advice would you give to budding implantologists?

Find yourself a mentor or someone you can turn to with a problem or question

It is unfortunate more people can’t work like colleagues rather than competitors Don’t be a robot Think before you act The specialty must continue to evolve, so don’t listen to naysayers If it makes sense biologically, give it a shot

What are your hobbies, and what

do you do in your spare time?

I love the New York Knicks, Giants, and Penn State Football In my spare time, I

am always reading and writing scientific articles (yes, I am a nerd) I enjoy going

to the gym, playing golf, and spending time with my family, fiancé, and my Daisy (my Chihuahua-Rat Terrier rescue; she’s delicious) With only 24 hours in a day, sleep is not overrated

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

TOP FAVORITES

1 CVS gummy bears

2 Piezosurgery ® unit — I love that little sucker

3 Daydreaming and getting a deep tissue massage

4 Making people happy

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

6 When things work out

10 Hand torquing to 40 Ncm ahhhhhh heaven!

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

of the American Dental Association to assist dental professionals in identifying quality

providers of continuing dental education ADA CERP does not approve or endorse individual

courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry

Concerns or complaints about CE provider may be directed to the provider or to ADA CERP

at www.ada.org/cerp

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

Founded in 1987 by a periodontist and

an engineer who wanted to be more

responsive to dental needs, BIOMET 3i

is now one of the largest dental implant

companies in the world Headquartered in

Palm Beach Gardens, Florida, the company

spans the globe with nearly 1,000 team

members, 18 subsidiaries, and operations

in more than 40 countries

treatment, comprehensive tissue

manage-ment, accelerated therapy and

digitally-driven patient and practice management

solutions, BIOMET 3i strives to enhance

the lives of patients – one at a time

Sustainable aesthetic treatment

solutions

The PREVAIL® Implant System with

integrated platform-switching uses “The

Science of Aesthetics” to deliver outcomes

through tissue protection1, enhanced

osseointegration,2-9 and crestal bone

preservation2-6

Comprehensive tissue ment solutions

manage-Successful patient outcomes begin with

effective tissue management BIOMET 3i

provides a portfolio of site-specific options that are designed to achieve better results

at crucial steps in the process – laying the foundation for successful Guided Bone Regeneration procedures

Accelerated therapy solutions

BIOMET 3i provides patients with the

option of immediate full arch rehabilitation

in as little as one day* with DIEM®2 This innovative solution is designed to allow clinicians to differentiate their practices while increasing productivity and patient satisfaction

prac-BIOMET 3i delivers a digital solution with a

streamlined workflow from start to finish – the BellaTek® Encode® Impression System The patented BellaTek Encode Impression System with intraoral scanning eliminates the need for impression copings, streamlining the process while improving the patient experience

The PREVAIL ® Implant System

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

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

The key to achieving long-term sustainable aesthetic outcomes

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Implants designed for primary stability with

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Optimized aesthetics with as little as

Higher seal strength as compared

Seal integrity test was performed by BIOMET 3i on December

2011 Testing was done under testing standard ISO 14801

Five (5) BIOMET 3i PREVAIL Implant Systems and five (5) of

three (3) competitors’ implant systems were tested Bench test

results are not necessarily indicative of clinical performance.

1 Östman PO †, Wennerberg A, Albrektsson T Immediate occlusal loading of NanoTite Prevail Implants: A prospective 1-year clinical and radiographic study Clin Implant

Dent Relat Res 2010 Mar;12(1):39–47

2 Baumgarten H † , Meltzer A † Improving outcomes while employing accelerated treatment protocols within the aesthetic zone: From single tooth to full arch restorations

Presented at the Academy of Osseointegration, 27th Annual Meeting; March 2012; Phoenix, AZ

3 Suttin Z † , Towse R † , Cruz J † A novel method for assessing implant-abutment connection seal robustness Poster Presentation 188: Academy Of Osseointegration, 27th

Annual Meeting: 2012 March 1–3; Phoenix, Arizona http://biomet3i.com/Pdf/Posters/Poster_Seal%20Study_ZS_AO2012_no%20logo.pdf Testing done by BIOMET 3i,

Palm Beach Gardens, FL; n = 20.

4 Byrne D, Jacobs S, O’Connell B, Houston F, Claffey N Preloads generated with repeated tightening in three types of screws used in dental implant assemblies

J Prosthodont 2006 May–Jun;15(3):164-71

5 Boitel N, Andreoni C, Grunder U † , Naef R, Meyenberg, K † A three year prospective, multicenter, randomized-controlled study evaluating platform-switching for the

preservation of peri-implant bone levels Poster presentation P83: Academy of Osseointegration, 26th Annual Meeting: 2011 March 3–5; Washington DC.

6 Lin A, Wang CJ, Kelly J, Gubbi P, Nishimura I The role of titanium implant surface modification with hydroxyapatite nanoparticles in progressive early bone-implant

fixation in vivo Int J Oral Maxillofac Implants 2009 Sep–Oct;24(5):808–816.

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

April, 2010.

8 Östman PO † , Wennerberg A, Ekestubbe A, et al Immediate occlusal loading of NanoTite™ Tapered Implants: A prospective 1-year clinical and radiographic study

Clin Implant Dent Relat Res 2012 Jan 17 [Epub ahead of print]

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

16 Implant practice Volume 6 Number 1

CORPORATE PROFILE

References

1 Zetterqvist L, et al A prospective, multicenter, randomized controlled 5-year study of hybrid and fully etched implants for

the incidence of peri-implantitis J Periodontol

April, 2010.

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

AZ

3 Suttin Z †† , Towse R †† , Cruz J †† A novel method for assessing implant- abutment connection seal robustness Poster Presentation 188: Academy Of Osseointegration, 27th Annual Meeting: 2012

March 1–3; Phoenix, Arizona http://biomet3i.

com/Pdf/Posters/Poster_Seal%20Study_ZS_ AO2012_no%20logo.pdf Testing done by

BIOMET 3i, Palm Beach Gardens, FL; n = 20.

4 Byrne D, Jacobs S, O’Connell B, Houston

F, Claffey N Preloads generated with repeated tightening in three types of screws used in

dental implant assemblies J Prosthodont

2006 May–Jun;15(3):164-71.

5 Östman PO † , Wennerberg A, Albrektsson

T Immediate occlusal loading of NanoTite Prevail Implants: A prospective 1-year clinical

and radiographic study Clin Implant Dent

Relat Res 2010 Mar;12(1):39–47.

6 Boitel N, Andreoni C, Grunder U † , Naef

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

7 Lin A, Wang CJ, Kelly J, Gubbi P †† , Nishimura I The role of titanium implant surface modification with hydroxyapatite nanoparticles in progressive early bone-

implant fixation in vivo Int J Oral Maxillofac

Implants 2009 Sep–Oct;24(5):808–816.

8 Östman PO † , Wennerberg A, Ekestubbe A,

et al Immediate occlusal loading of NanoTite ™

Tapered Implants: A prospective 1-year

clinical and radiographic study Clin Implant

Dent Relat Res 2012 Jan 17 [Epub ahead of

print]

9 Block MS † Placement of implants into

fresh molar sites: Results of 35 cases J Oral

Maxillofac Surg 2011 Jan;69(1):170-4.

† Dr Baumgarten, Dr Block, Dr Grunder,

Dr Meltzer, Dr Meyenberg and Dr Östman

have financial relationships with BIOMET 3i

LLC resulting from speaking engagements, consulting engagements and other retained services.

†† Dr Gubbi, Mr Cruz, Mr Suttin and Mr Towse contributed to the above research while

employed by BIOMET 3i.

World-class learning for dental

clinicians

Located in Palm Beach Gardens, Florida,

the Institute for Implant & Reconstructive

Dentistry (IIRD®) is a BIOMET 3i initiative

for continuous learning and training for

dental professionals This state-of-the-art

facility provides clinicians with the latest

techniques and courses, empowering

clinicians to provide outstanding patient

care

The IIRD® was founded by Richard

Lazzara, DMD, MScD, who passionately

believes that education, evidence-based

research and advanced techniques are

essential in providing the best solutions to

clinicians and patients

IIRD® lecture hall

IIRD® operatory

*Not all patients are candidates for immediate load procedures

All trademarks herein are the property of

BIOMET 3i LLC unless otherwise indicated.

For additional product information, including indications, contraindications, warnings, precautions, and potential adverse effects, see the product package

insert and the BIOMET 3i website.

Want more information regarding BIOMET

3i? Please visit the company’s website

California Implant Institute offers a comprehensive fellowship program in oral implantology This training program

includes 4 sessions (five days each) designed to provide dentists with practical information that will be immediately

useful to them The fellowship program offers more than 300 combined hours of lectures, laboratory sessions, online

webinars, and LIVE surgical demonstrations performed at the California Implant Institute facility

The curriculum of the fellowship program is divided between the biomedical sciences related to implant dentistry and

clinical implant education and it exceeds the guidelines set by the AAID for a 300 hours of instruction program

Whether you're just starting out or looking to enhance your existing surgical or prosthetic skills, our dental implant

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California Implant Institute pursues excellence above all else

Please visit our website or call for more information on the fellowship and other programs offered by CII

California Implant Institute is the world’s premier dental implant educator

The fellowship program is very comprehensive It will get you the clinical confidence to know how to plan and what to

expect when doing the surgery Live surgeries were excellent and the review of the related anatomy and pharmacology

was invaluable It was money and time well spent

Dr Michael Shashaty, Los Angeles, CA

I feel I have made the right choice by taking the fellowship program at CII I found answers to many questions left

unanswered from other implant dentistry classes I have taken in the past I highly recommend this program

Dr Mary Spencer, San Diego, CA

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I would like to express my overwhelming satisfaction with the Inclusive® Tooth Replacement Solution, which made this one of the easiest implant cases I have ever done Because I achieved primary stability and used the included custom temporary abutment and BioTemps® crown, I was able to achieve optimum esthetic results and cut down my chairtime Now I can offer my patients a more esthetic and biologically superior result using the Inclusive Tooth Replacement Solution instead of the stock components normally used It is, for me, a very cost-effective way to deliver superior treatment with custom components for each case I used to spend more time and money with other systems, but now I have a great alternative!

— James Nicholson, DDS; Muskogee, Okla.

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I absolutely believe that the Inclusive® Tapered Implant System is the simplest, most predictable and most affordable implant system that I have ever used It will continue to

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I would like to express my overwhelming satisfaction with the Inclusive® Tooth Replacement Solution, which made this one of the easiest implant cases I have ever done Because I achieved primary stability and used the included custom temporary abutment and BioTemps® crown, I was able to achieve optimum esthetic results and cut down my chairtime Now I can offer my patients a more esthetic and biologically superior result using the Inclusive Tooth Replacement Solution instead of the stock components normally used It is, for me, a very cost-effective way to deliver superior treatment with custom components for each case I used to spend more time and money with other systems, but now I have a great alternative!

— James Nicholson, DDS; Muskogee, Okla.

Irvine, Calif., facility.

Back in 2005, I wrote an article warning

colleagues about the possibility

of an allergic reaction to chlorhexidine

digluconate (Figure 1) This is a compound

used in many medical procedures, and of

course, is also used as a mouthwash in

dentistry In the U.S., its use is controlled,

but in the UK, we can still buy the

mouthwash over the counter

The right mouthwash

There is no question that this drug is very

useful when performing surgery, as a pre-

surgical rinse, and a follow-up mouthwash

(Lambert, et al., 1997; Young, et al., 2002)

It also has a major place in the treatment of

different types of periodontal disease

In my 2005 article, I included Figure

2 to demonstrate the effect of changing

from a chlorhexidine mouthwash to a hot

saltwater mouthwash only Figure 3 shows

almost complete healing after 7 days

In that article, I warned colleagues that

they must look out for any signs of allergic

response when using this compound

However, at that time, there were very few

cases reported in the literature

Fatalities

Since then, there have been at least

two cases reported in the press, where chlorhexidine has been linked to a fatal

anaphylactic reaction The Daily Mail

reported one such case on March 22, 2011 with the headline “Patient, 30, collapses and dies at dentist after suffering allergic reaction to mouthwash.” Another such case was reported on February 16, 2011,

in the Whitehaven News, this time with the

headline “Mouthwash linked to death of patient, 63.”

Plan of actionSince then, the Medicines and Healthcare products Regulatory Agency (MHRA) has issued a Medical Device Alert dated October 25, 2012 (MDA/2012/075) It warns of the risk of anaphylactic reaction due to a chlorhexidine allergy It gives the following action points, which I am quoting:

• Be aware of the potential for an anaphylactic reaction to chlorhexidine

• Ensure that known allergies are recorded

in patient notes

• Check the labels and instructions for use to establish if products contain chlorhexidine prior to use on patients with

a known allergy

• If a patient experiences an unexplained reaction, check whether chlorhexidine was used or was impregnated in a medical device that was used

• Report allergic reactions to products containing chlorhexidine to the MHRA

• Further guidance on anaphylaxis is available from National Institute for Health and Clinical Excellence, the Resuscitation

Anaesthetists of Great Britain and Ireland.First aid training

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

of anaphylaxis, and be well-versed in how

to treat it

The patient backgroundFinally, prevention is better than treatment, and if the patient has a history of allergies, this must alert us immediately to potential problems The Care Quality Commission suggests that medical histories are updated each time we see our patients: I believe that this is an excellent suggestion,

as we can also check their allergy status at this time

Every picture tells a story: chlorhexidine conundrum

specialist in oral surgery and prosthodontics

He is a visiting professor of implantology at

Temple University, Philadelphia, and is

editor-in-chief of Implant Dentistry Today.

Figure 2: Changing the mouthwash to hot saltwater:

improvement after 3 days Figure 3: Improvement after 7 days of hot saltwater

RefeRences

Lambert PM, Morris HF, Ochi S The influence

of 0.12% chlorhexidine digluconate rinses

on the incidence of infectious complications

and implant success J Oral Maxillofac Surg

1997;55:25-30,Suppl 5.

Young MPJ, Korachi M, Carter DH, Worthington

HV, McCord JF, Drucker DB The effects of an immediately pre-surgical chlorhexidine oral rinse

on the bacterial contaminants of bone debris

collected during dental implant surgery Clin Oral

Impl Res 2002;13:20-29.

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With the advances in implant surfaces and

regenerative techniques, the survival rates

of dental implants are quoted between

96% and 99% As such, there has been a

change in ethos of implant placement that

should now be placed in a restoratively

driven manner The success of implant

treatment is no longer merely based on

the survival of the implant, but a greater

influence is being placed on the esthetic

result achieved The most challenging of

aspects of esthetic implant treatment lies

within the soft tissue management

Treatment planning the replacement of

multiple teeth in the esthetic zone may be

considered to be complicated The number

and position of the implants to be placed

should carefully consider the soft tissues

and, in particular, obtaining the correct

papillary heights, an equivalent gingival height, and buccal soft tissue contour

This clinical report aims to document

a technique of provisional restorations

to condition the soft tissue, followed by

a customized fixed partial denture (FPD) impression designed to give the technical team the correct emergence profiles of both the implant and pontic sites

Clinical report

A 55-year-old female was referred for

an implant consultation (Strand on the Green Dental Surgery, London, England)

Her main complaints were continued loss

of post crowns, poor esthetics of her resin-bonded FPD, and the loss of bone following the extraction of her upper right lateral incisor The patient was a non-smoker and revealed no systemic medical

problems that would contraindicate implant therapy On examination, she had failing restorations of her upper central incisors and her upper left lateral incisor Bone resorption was clearly noted in the upper right lateral position Occlusally, she was an incisal class 1 relationship and group function in lateral excursions The unrestorable incisor teeth were removed without raising a mucoperiosteal flap, consistent with an early implant placement protocol An immediate composite resin-bonded FPD with metal wings on both canines was modeled to support the interdental papilla and cemented using

a glass ionomer cement (Fuji IX, GC) A 6-week healing period was followed by implant placement (Straumann® bone level 4.1 mm diameter, 12 mm length SLActive®, Straumann®) in the central incisor positions according to early implant protocol utilizing

a surgical stent The lateral incisor positions were not used for the implants due to the requirement of a block bone graft The ridge was contoured using Straumann bone ceramic at both the implant and pontic sites, and a bilayered cross-linked collagen membrane (Bio-Gide®, Geistlich)

in a two-layered technique A further healing period of 3 months was observed prior to a second-stage surgical uncovering

Direct, GC America, Inc.) was added to the palatal surfaces of both canines to return the patient to canine guidance A closed-tray impression technique was taken in polyether (Impregum™ Penta™;

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

CLINICAL

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

Figure 1: Pre-op

David Furze, BDS, MFDS RCS, qualified from Cardiff in 2000 and joined the Royal Army Dental Corp where he

achieved the rank of Major He has served in Germany, Brunei, Bosnia, and all over the U.K He left the army

in 2006 and has since been based in private practice Dr Furze has quickly increased his implant exposure by

working in Ilkley, London, and Cornwall in implant referral practices He is currently completing his MClinDent

with Kings College London in Fixed and Removable Prosthodontics He holds an honorary research contract at

the Eastman Dental Institute and is currently awaiting several papers for publication He has recently completed

a month fellowship at the University of Bern, Switzerland, working alongside world-renowned implant surgeons

He has lectured nationally and internationally on both the surgical and restorative aspects of implant dentistry,

including at the Royal College of Surgeons where he is involved in the teaching and examination of the IQE

and MJDF examinations Dr Furze is a member of the ITI, the BDA, and SAAD (Society for the Advancement of

Anaesthesia in Dentistry) His main area of interest is in implants in the esthetic zone, temporization of implants,

customizing impressions, and bone regeneration techniques.

Ashley Byrne, RDT, BSc (Hons), graduated from Manchester Metropolitan University in 2001 and is co-founder

and director of Byrnes Dental Laboratory in Oxfordshire, England He has lectured across the U.K and Europe

on CAD/CAM technology and has been involved in the research and development of the Etkon CAD/CAM

system from Straumann.

Figure 2: Surgical stent and implants in place with delivery system still attached Figure 3: Bone ceramic with lots of blood covering implant and pontic site

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

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

CLINICAL

3M™ ESPE™), and a composite provisional

bridge was manufactured

Following 6 months of tissue

conditioning, a customized FPD impression

was taken The procedure is summarized

in Table 1

An irreversible hydrocolloid impression

was taken of the provisional FPD in situ,

and a full series of clinical photographs

was emailed to the laboratory From the

customized implant FPD, impression two

casts were constructed The first was a

soft tissue and the second a solid stone

An additional cast of the provisional FPD

was used as a guide for the definitive

case The casts were mounted on a

semi-adjustable articulator, using the previous

lower to ensure the face bow recorded

maintained constant A customized

an-terior guidance table was constructed

using light-cured acrylic resin A silicone

index of the current provisional was taken

to aid in the design of the metal work ensuring correct support of the porcelain

Two gold cylinders (Straumann bone level regular crossfit) were screwed to the cast and cut down to fit within the index The metal work was then waxed up allowing 1.5 mm of clearance for the porcelain

The wax was sprued and invested with a phosphate investment (Fujivest® premium,

GC America, Inc.) using a 25% liquid to distilled water mix The FPD was cast in Implant 58 alloy (Cendres Metaux, Biel/

Bienne, Switzerland) and allowed to bench cool The investment was removed, and the metal heat treated in accordance

to the Cendres Metaux guidelines The metal framework was then veneered with porcelain (GC Initial™, GC America, Inc.)

The pontic and implant emergence were matched in the ceramic and consistent

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

Discussion This use of provisional restorations to condition the tissue is now considered routine if the optimum esthetics are to

be achieved It would seem sensible to provide the technical team with every piece of information required The use of customized impressions in single tooth replacement has been well documented, but extending the customized impression into the pontic site can further provide the technical team with accurate soft tissue information The soft tissues collapse almost immediately following the removal

of the provisional bridge In customizing

Table 1

1 The provisional FPD is removed from the patient and replaced onto the initial cast Care is taken to ensure that there is no contact of the pontics with the cast

2 A light-bodied, fast-setting addition silicone (Provil® Novo CD 2, Heraeus Kulzer) impression is then taken of the apical half of the provisional FPD

3 The provisional FPD is then removed and replaced in the patient

4 Open-tray impression copings are then inserted into the cast

5 Bis-acrylic temporary crown and bridge material, (Integrity®, Dentsply) is used to customize the impression copings to provide an exact replica of the provisional FPD

6 The FPD is removed from the patient, and the customized impression coping is immediately screwed into position supporting the soft tissue contour

7 An open-tray polyether impression is taken (Impregum Penta; 3M ESPE)

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

26 Implant practice Volume 6 Number 1

CLINICAL

Figure 13: Final restoration with black diffuser

Figure 14: Final restoration with black diffuser

Figure 10: Impression Figure 11: Hard tissue cast

Figure 12: Soft tissue cast

the impression copings, the soft tissues are

adequately supported while the impression

material sets This information is replicated

on the master casts The accuracy of the

impression technique is shown by the

immediate support of the soft tissues with

no blanching of the tissues at any point

The extent of soft tissue management

that may be achieved during this restorative

phase is limited It is regarded that the most

important factor in achieving an esthetic

result is the correct three-dimensional

positioning of the implants A correct

wax-up and surgical stent are therefore required

in all esthetic cases

The choice of positioning the implants

in these cases of replacing all the maxillary incisors is critical The treatment outcome may have been greater if the implants had been placed in the lateral incisor positions

This configuration would remove the potentially hazardous position of placing two adjacent implants In this case report, this would have required a lateral ridge augmentation procedure, and as such the central incisors sites were chosen

This esthetic risk is minimized as there will only be one midline papilla, and therefore, symmetry will not be altered in this case of placing two adjacent implants In order to

give the best potential to create a midline papilla, the implants were placed more than 3 mm apart and were of a platform-switched design This design appears

to protect the crestal bone and the subsequent overlying tissue

This clinical report describes a simple, fast, and effective impression technique that accurately replicates the soft tissue emergence from the implant as well as the soft tissue sculpturing of the pontic site

References available upon request.

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Edentulous patients with extremely

resorbed jaws have serious limitations

when using a removable prosthesis: lack of

retention, pain, masticatory and phonetic

difficulties, lack of lip support, and loss of

vertical dimension The All-on-4™ concept

(Nobel Biocare AB, Gothenburg, Sweden)

enables the rehabilitation of extremely

resorbed edentulous maxillae or mandibles,

placing only four implants, avoiding

complex surgical techniques such as

bone graft procedures The NobelGuide™

system (Nobel Biocare AB) allows not only

a minimally invasive and simplified surgery,

but also the previous planning of the exact

position and direction of the implants in

the 3D software This results in a great

advantage in “extreme cases.”

Case presentation

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

DiagnosisRadiological and clinical evaluations determined that all the inclusion criteria were fulfilled to perform an All-on-4™ surgery following the NobelGuide procedure

– orthopantomography and CBCT – demonstrated bone availability of 8 mm

in height and 5 mm in width between the mental foramina The clinical evaluation determined an adequate keratinized gingival thickness, low smile line, and mouth opening capability over 40 mm Because the jaw was completely edentulous, there were no teeth interfering with the surgical planning

Planning

manufactured, taking into account the esthetic and functional requirements of the patient, which was used as a radiographic guide The DICOM files were converted

to 3D images by the NobelClinician™

Software (Nobel Biocare AB), and the implants’ virtual planning followed the All-on-4™ concept

A surgical guide was manufactured

by Nobel Biocare according to the plan The surgical template was used as a guide

to obtain a stone cast and to make all the laboratory work A surgical index was made with silicone (Silagum® Putty; DMG, Hamburg, Germany), and all prosthetic procedures were performed before surgery

Surgical procedureFollowing the NobelGuide protocol, the surgical guide was stabilized with anchor pins using a surgical index The surgery was performed following a similar protocol

of the All-on-4™ conventional technique NobelSpeedy™ Groovy RP 13 mm implants (Nobel Biocare AB) were placed in the posterior area, and NobelSpeedy™ Groovy

RP 11.5 mm implants (Nobel Biocare AB) were placed in the anterior area according

to a flapless approach All implants were placed with an insertion torque over 50N/

cm, and after the implant placement, the surgical guide was removed and the multi-unit abutments (Nobel Biocare AB) were connected using custom positioning guides The full-arch acrylic resin (Heraeus Kulzer GmbH, Hanau, Germany) prosthesis was screwed on immediately, and occlusal adjustments were performed

The patient was enrolled in an implant maintenance program and instructed to eat a soft diet for 2 months

Oral hygiene appointments were performed postoperatively on day 10, on months 2, 4 and 6, and every 6 months

Paulo Malo, DDS, PhD, is the president of the Malo

Clinic in Lisbon, Portugal

Armando Lopes, DDS, is the director of implantology

at the Malo Clinic.

Mariana Nunes, DDS, works in the department of

implantology at the Malo Clinic.

André Rodrigues, DDS, works in the prosthodontic

department at the Malo Clinic

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

the Malo Clinic.

Miguel De Araújo Nobre, RDH, MSc, is the director of

oral hygiene at the Malo Clinic.

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

Volume 6 Number 1 Implant practice 29

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

Figure 7: Computer planning NobelClinician Software™ Figure 8: Intraoral photograph with the radiographic guide

and the radiographic index bite registration (Occlufast®, Zhermack SpA, Badia Polisione, Rovigo, Italy) in position before the CBCT according to the double scan technique

Figure 9: Surgical template - mandible

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30 Implant practice Volume 6 Number 1

CASE STUDY

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

Figure 15: Occlusal photograph of Malo Clinic acrylic

bridge Figure 16: Frontal intraoral photograph of Malo Clinic acrylic bridges

RefeRences

van Steenberghe D, Ericsson I, Van Cleynenbreugel J, Schutyser F, Brajnovic I, Andersson M High precision planning for oral implants based on 3D CT scanning A new surgical technique for immediate and delayed

loading Appl Osseoint Res 2004;4:27-31.

Maló P, Rangert B, Nobre M All-on-Four immediate-function concept with Branemark System implants for completely edentulous

mandibles: a retrospective clinical study Clin

Implant Dent Relat Res 2003;5(Suppl 1):2-9.

Maló P, Nobre M, Lopes A The use of guided flapless implant surgery and 4 implants placed in immediate function to support a fixed denture: preliminary results after a mean

computer-follow-up period of 13 months J Prosthet Dent

2007;97:S26-S34.

between 1 and 5 years of follow-up,

without registering any signs or symptoms

of peri-implant pathology, or presence

of significant marginal bone resorption

(radiographically confirmed)

Final prosthetic protocol

Six months after surgery, a Malo Clinic

acrylic bridge was manufactured, finalizing

the rehabilitation, and fulfilling functional,

phonetic, and esthetic requirements

A titanium-acrylic resin

implant-supported fixed prosthesis (NobelProcera

titanium framework; Nobel Biocare AB)

Figure 10: 30° non-engaging multi-unit abutment guides Figure 11: Surgical index Figure 12: Pre-made removable denture converted into

screw-retained fixed acrylic resin complete prosthesis

with acrylic resin prosthetic teeth (Heraeus Kulzer GmbH) was connected In this final bridge, the occlusion was adjusted according to the patient’s natural dentition:

bilateral anteroposterior harmonious contacts more pronounced in the posterior teeth, anterior group incisor protrusive guide, and lateral canine excursive guide

A final orthopantomography was made after fitting of the final rehabilitation

The clinical and radiographic parameters remained stable during the 5-year follow-up

ConclusionWhen there is a suitable patient selection and a good surgical planning, the use of the All-on-4™ and NobelGuide presents advantages The time required to perform the surgery is reduced when compared with other methods, making it more convenient to the patient

As this is a flapless procedure, the patient’s well-being is maximized

by ensuring greater comfort and minor edema in the oral region For the surgeon, this technique presents as a precise and predictable approach This case shows that the rehabilitation of atrophic mandibles with immediate fixed bridges is possible using the All-on-4™ concept The NobelGuide planning decreases the surgical risks, adding to the known advantages the possibility of using it on extreme cases