Tạp chí implant IPUS tháng 5& 6/2013 Vol 6 No3

Tạp chí implant IPUS tháng 5& 6/2013 Vol 6 No3

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dentistry

Dr Robert C Vogel

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

Minimally invasive

maxillary sinus lateral

approach (SLA): a series

of case reports

Millennium Dental Technologies, Inc.

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Dr Robert C Vogel

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maxillary sinus lateral

approach (SLA): a series

of case reports

Millennium Dental Technologies, Inc.

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clinical articles • management advice • practice profiles • technology reviews

May/June 2013 – Vol 6 No 3

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

Treatment planning of implants

in the esthetic zone: part 2

Drs Sajid Jivraj, Mamaly Reshad, and

Winston Chee

Practice profile

Dr Bao-Thy Grant

Incorporating state-of-the-art and science to provide stability and excellent esthetic results in

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dentistry

Dr Robert C Vogel

Minimally invasive

maxillary sinus lateral

approach (SLA): a series

of case reports

Millennium Dental Technologies, Inc.

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Volume 6 Number 3 Implant practice 1

May/June 2013 - Volume 6 Number 3

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.

It is a great time to practice implant dentistry due to all of the surgical and restorative technology available to us as clinicians

Surgically, we now have materials and growth factors that allow us to put the bone and soft tissue in an optimal position and in a predictable manner to help maximize positive restoration outcomes We are able to design the final prosthesis from the ideal incisal edge backwards, without being limited by the initial tissues present

Visually, the digital revolution affords us the ability to use CT scans, 3D images, and treatment planning software for precise placement When a complete and accurate picture of the individual patient is available, a lot of the guesswork is removed, and precision is possible With 3D imaging, dentists have the capability of virtual surgery and placement to bolster confidence and solidify the treatment plan before picking up the scalpel Radiation levels can also potentially be minimized by imaging equipment that allows adjustable settings for exposure time Additionally, treatment planning software uses the latest technology to help keep the process streamlined and organized while also offering state-of-the-art treatment options to patients

Technologically, the many applications of computer software in the dental office allow maximized patient comfort and minimized clinician aggravation I recently got a digital impression scanner (iTero®) It allows me to take a digital impression of the implant, replacing the goopy-mouth, old-style impressions Patients love it It is pretty slick, and clinicians enjoy that it saves them an impression appointment with the patient It creates

a digital file; then a treatment plan can be formulated; then the file is sent wirelessly to the lab The lab can now fabricate a restoration solely from that digital file without ever having

to pour up a stone model The digital file is much more precise as there is no margin of error from material shrinkage, etc It also allows for a faster turnaround time at the lab In

my practice, in less than a week the crown is back Similar treatment planning software as

is used by the CT scanner can now design abutments and crowns if desired

Globally, it is easier than ever to share ideas with implant dentists both nationally and internationally Breakthroughs are no longer locked to a geographic location or specific publication Information sharing is faster than ever, and questions can be posted

to peers and answered virtually instantly In the digital age, sharing files and radiographs with referring colleagues and specialists can be accomplished with the click of a mouse securely and quickly

Responsible use of technology is a must for patient safety and treatment success

Continuing education such as webinars, journals such as Implant Practice US,

congresses and seminars, as well as educational venues, such as the Rocky Mountain Dental Institute, where I lecture, are all valuable tools to learn about the technologies that are available and how to use them safely and effectively in this fast-paced, competitive dental world

Though some of the newer technologies are still in their infancies, I think that they too will become a great part of future progress When I lecture for continuing education classes, I stress the importance of integrating technology into implant dentistry because it

is exciting to be on the cutting edge (no pun intended) of implant dentistry today as these new methods grow in popularity, prevalence, and precision

Lewis C Cummings, DDS, MSKingwood Periodontics and Implant Dentistry, Kingwood, TexasCenter for Advanced Dental Education, Dallas, Texas

Rocky Mountain Dental Institute, Denver, Colorado

Strides in surgical and restorative technology

TABLE OF CONTENTS

Dr Bao-Thy Grant: Living life, loving family, and practicing with

passion

It takes dedication and motivation to maintain a balance between a growing

practice and a growing family

Millennium Dental Technologies, Inc.

Built by clinicians with products designed for clinicians, Millennium continues to

operate with the key tenets of research, training, and five-star service.

Case study

Incorporating state-of-the-art and science to provide stability and excellent esthetic results in implant dentistry

Dr Robert C Vogel illustrates how a patient with limited buccal bone and interadicular space benefitted

Late implantation in an anatomical medial diastema

Drs Nikolaos Papagiannoulis and Marius Steigmann present a case report that takes a minimally invasive

Connective tissue grafting

Dr Ken Akimoto presents a pictorial approach to improving a patient’s smile through soft-tissue

Case study: restoring form and function with implants and veneers

Dr Nilesh Parmar tackles a patient’s neglected dentition to restore his smile without resorting to the

EndoPracAD2_2013F_Layout 1 2/6/13 10:14 AM Page 1

TABLE OF CONTENTS

Continuing

education

Management of the black triangle

around dental implants in the

esthetic zone: part 2

Dr Scott Blyer explores management

and treatment of the black triangle

Treatment planning of implants in

the esthetic zone: part 2

In the second part of the series, Drs

Sajid Jivraj, Mamaly Reshad, and

Winston Chee explore how the facial

bony wall and the interproximal bone

Industry news

Nobel Biocare announces new

opportunities for education and

patient care 44

Technology

Minimally invasive maxillary sinus lateral approach (SLA): a series of case reports

Dr Suheil M Boutros opens the window to a new method of sinus

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What can you tell us about your

background?

I am 37 years old and was born in Santa

Monica, California to Vietnamese parents

My parents immigrated to the U.S the

night before the fall of Saigon My parents

are the core of my existence and taught me

how to love to the fullest I have a younger

sister I wanted to be a dentist since I was

in high school, but also wanted a business

degree, because I feel that it is a universal

degree and a very fundamental aspect of

any career I graduated from the University

of Southern California (USC) with a BS

in Business while fulfilling all my science

prerequisites to apply to dental school

While attending the USC School of

Dentistry, I became a work study student

in the orthodontic department, and was

introduced to oral maxillofacial surgery

(OMFS) and became absolutely fascinated

with the specialty — the rest is history! I

was determined to do what was required

to pursue a residency in OMFS I attended

Montefiore Medical Center/Albert Einstein

College of Medicine, Bronx, New York for

my OMFS residency

Is your practice limited to

implants?

No, I also specialize in OMFS with an

emphasis on multidisclipinary care

Why did you decide to focus on

implantology?

I am not particularly fond of the terms

“implantologist” or “implantology,” because

my practice is not just about placing

implants in edentulous areas I am an oral

healthcare provider who educates patients

on the option of having dental implants as

a part their treatment plan, depending on

each individual case I instill information

in my patients to understand the inherent

value of dental implants as they relate to

improving the quality of life and long-term

oral function, but also to give them realistic

expectations of treatment outcomes and

risk factors as well

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

I have been practicing since 2008, and predominately use Straumann®, followed

by Astra Tech, and NobelActive™, but I base my decision on each particular case

What training have you undertaken?

While at Montefiore Medical Center/Albert Einstein College of Medicine, I served as the Chief Resident at Beth Israel Hospital, Bronx Lebanon Hospital, Jersey City Medical Center, Montefiore Hospital, and Weiler Hospital I was inducted as a member of the Leo M Davidoff Society for outstanding achievement in the teaching

of medical students I am the co-founder and instructor of the Orange County CPR Angels, teaching basic life support

to healthcare providers and the public

I am also on staff at St Joseph Hospital

of Orange and Children’s Hospital of Orange County, an active delegate and chair on the state and local organizations for the California Dental Association, a Diplomate of the American Board of Oral and Maxillofacial Surgery, and a fellow

of the American Association of Oral and

Maxillofacial Surgeons Currently, I serve

as the team oral surgeon to the Anaheim Ducks NHL team I have published articles and CEs, and lectured on dental implants and patients taking oral bisphosphonates

Who has inspired you?

My parents My dad taught me to have

a good work ethic, while my mom taught

me how to be respectful and kind to others Together, they taught me to have compassion and humility

Several oral and maxillofacial surgeons have inspired me during different phases in

my life:

Dr Alan Felsenfeld (a great mentor I have known since I was in college) taught

me to have a voice in our dental profession,

to be active in organized dentistry, and to always lead by example He truly was an integral part in my educational ambitions.Drs John Given, Ralph Buoncristiani and Howard Park (I was an oral surgery assistant in their office in college) taught me all the fundamentals of caring for patients in

a private practice setting with compassion, and how to run a practice efficiently and treat your staff well They gave me my first exposure to a team approach

Dr Richard Kraut (my chairman/

director in my OMFS residency) taught

me great work ethics and to practice with

integrity No excuses; just get the job

done, and do it well!

Dr Jeffery Pulver (my business partner

who sadly passed away in 2010) embodied

all of the attributes above; most of all taught

me to live life, love family, and practice oral

surgery daily with great passion

What is the most satisfying aspect

of your practice?

The most satisfying aspects of my practice

are: first, the confidence that my staff

and I have to care for our patients with

compassion It is incredible to meet and

get to know our patients first, and then to

educate them on their surgical needs so

that they are comfortable and certain of

the care that will be rendered Also I enjoy receiving the heartfelt handwritten notes from our patients and referrals

My staff and I cherish the moments that we share with our patients who are

so grateful and appreciative of the care that was rendered, as that is such an emotionally rewarding part of this journey

Professionally, what are you most proud of?

I am proud to be a part of such a great specialty, doing what I love with passion and grace I was always motivated by a desire to pay my own bills and to be an independent woman who could stand on

my own two feet no matter what I knew the kind of woman I wanted to be — an independent woman with my own career

while at the same time enjoying a marriage and raising my children with the help of

my amazing husband This dream has become a reality as I am experiencing a life where I am a wife, mother, and an oral and maxillofacial surgeon

What do you think is unique about your practice?

We work hard each day to provide excellent care without any compromise We provide

an environment where our patients feel confident of their care, know that we are honest, and we also have a great sense of humor, as laughter connects us as people Each patient is unique and has a different story, so it is our objective to honor that and make his/her experience unparalleled Many times when we connect with our patients in such a profound way, we actually learn from them They share their stories, and we create a bond that is meaningful It

is not always about the surgery It is about connecting with people

What has been your biggest challenge?

Balancing family and professional life is a heartfelt journey

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10 Implant practice Volume 6 Number 3

4 Ski trip to Deer Valley in February and Hawaii

in August with my family

5 New Straumann ® mount

6 INFUSE ® rhBMP-2 bone graft

7 Cooking recipes from Thomas Keller’s Ad

Hoc at Home cookbook

8 Lounging under the sun while reading a book or journal as the kids run around in the backyard

9 A great periotome

10 Hearing and learning about someone’s life stories and lessons It makes me a better person.

What would you have become if

you had not become a dentist?

I would have been a chief executive officer

for a major corporation in the fashion

industry or a talk show host to empower

young boys and girls

What is the future of implants and

dentistry?

Preventing the need for implants in the

first place As an oral healthcare provider,

preventative dentistry is essential Implants

have been extremely valuable; however,

more emphasis is needed regarding the

challenges of peri-implantitis

We also should strive towards a

paradigm shift to do what truly is right

for patients among all oral healthcare

providers In a society, our professional

name has been tarnished from practitioners

who have substituted doing what is

right for patients for the “almighty dollar”

(i.e., coupon dentistry, bait-and-switch

dentistry, etc.) This truly disheartens me

What are your top tips for

maintaining a successful

practice?

• Accountability

• Stay ahead of new advances in the field

• Empower, educate, and take care of

your staff, as they are the gatekeepers

What advice would you give to budding implantologists?

I am not fond of the term “implantologist.”

Every practitioner has a responsibility to diagnose, educate, and treatment plan a case in the best interests of their patients, whether implants are involved or not

What are your hobbies, and what

do you do in your spare time?

Family time with my husband and kids I love the experience of being a wife and mom! I love eating! I enjoy cooking and going out to great restaurants for a culinary experience I drink hot green tea at least four times a day I am also trying to learn how to knit and play bridge I admit, I am

an old soul trapped in a young body!IP

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Headquartered in Cerritos, California, Millennium Dental Technologies Inc

is the developer of the LANAP® protocol for the treatment of gum disease and the manufacturer of the PerioLase® MVP-7™

digital dental laser Built by clinicians with products designed for clinicians, Millennium continues to operate with the key tenets of research, training, and five-star service

A foundation of research

Groundbreaking research in the early 1990s on Nd:YAG lasers caught the attention of the founders of Millennium Dental Technologies, Inc., Drs Gregg and McCarthy Studies by TD Myers in 19891, Midda, 19902; Tseng, 19913; Lin & Horton,

19924; Cobb, 19925; and Gold SI & Vilardi

in 19926 formed the foundation for spirited clinical discussions as to the applications

of lasers in dentistry

Drs McCarthy and Gregg continued research to test tissue interactions with different lasers and operating parameters

— from surgical argons (515 nm), free running Nd:YAG “neodymium YAG” (1064 nm), Ho:YAG “Holmium YAG” (2100 nm), Er:YAG “Erbium YAG” (2940 nm) to Continuous Wave (CW) carbon dioxide A curious thing happened The researchers noticed certain laser wavelengths — with modified operating parameters not seen

in dental lasers at the time — interacted with tissues in profoundly different ways and produced profoundly different results than what mere wavelength-specific tissue interactions would predict

These observations evolved into the critical operating parameters of the LANAP protocol – a surgical treatment for periodontitis, using the free running pulsed Nd:YAG laser – the PerioLase MVP-7

Millennium Dental Technologies, Inc.

CORPORATE PROFILE

Established in 1990 by clinicians, Robert H Gregg II, DDS, and Delwin K McCarthy, DDS, Millennium Dental Technologies, Inc is the longest lasting dental laser company The founders continue to operate the company with a shared vision and purpose: To create better clinical outcomes in periodontal disease patients and to remain true to the guiding principle: “It’s all about the patient.”

(IALD) are mandatory inclusions into the PerioLase® Periodontal Package®

Over 30 clinical instructors oversee live-patient training, with a 3:1 student-to-instructor ratio Clinicians treat three different patients with varying degrees

of periodontitis during their training All patients are provided by the IALD as part

of our comprehensive support and receive

1 year of complimentary follow-up care

To date, Millennium and the IALD have partnered to provide over $6.5 million in free periodontal surgery for infection control and follow-up care

Clinical results guarantee

How can a company guarantee clinical results? Clinical real-world experience! The LANAP protocol was developed during

a decade-long process in a real-world practice setting by clinicians for clinicians

No other manufacturer, in any medical

or dental field, has ever guaranteed a clinical outcome Millennium guarantees that the LANAP protocol will result in 50% pocket reduction by regeneration versus subtraction

Figure 1: Simulated canal injected with ink

It’s All About the Patient™

The LANAP protocol was developed to meet the needs of periodontally challenged patients who would not accept traditional osseous surgery An original icon, the “No Cut, No Sew, No Fear” logo, provided patients a reassuring message by alleviating fear

The procedure combines the best aspects of laser soft tissue surgery with well-established principles of periodontal disease management The result is a tissue-sparing, non-destructive surgery with consistent, reproducible, positive results Other advantages include improved hemostasis intraoperatively, and improved patient comfort and acceptance

Elite training – better for the clinician, better for the patient

Critical to the success of any procedure is the clinician’s ability to replicate results in their own patients Founders Drs Gregg and McCarthy passionately believe proper training is vital to the clinician’s success and the patient’s health Five days of exceptional training received through the Institute of Advanced Laser Dentistry

CORPORATE PROFILE

Best-in-class technology

The PerioLase MVP-7 was honored with the

Pride Institute “Best-of-Class” technology

award for the world’s first integration of

the Android™ based Samsung® tablet

display into a medical device, combining

advanced laser components with the latest

LCD display technology for an optimum

operating experience This enables

clinicians’ immediate access to patient

treatment records at their fingertips, factory

pre-sets for common procedures as well

as continual product upgrades without the

purchase of new equipment — breaking

the paradigm of planned obsolescence

built into the manufacturing of capital

equipment within the dental industry and

making obsolescence obsolete

As part of the clinician-centric

environment, it was important to ensure

the Android system is fully retro-compatible

with all existing units so current clinicians

are not forced into unnecessary product

The LAPiP protocol eliminates local inflammatory response with consistent, positive results in the regeneration of alveolar bone The protocol is part of the training curriculum taught by the IALD

Supporting the fight against gum disease

Millennium is a proud supporter of the Fight Gum Disease campaign – a literacy campaign aimed at increasing public awareness of the prevalence and dangers

of gum disease Twenty-three U.S state governors and two Canadian provinces have signed proclamations supporting Gum Disease Awareness month Helping patients understand the systemic impact

of periodontitis truly supports Millennium’s key principle of “It’s all about the patient.”

We encourage you to show your support

at www.fightgumdisease.com, or on Facebook and Twitter at #fightgumdisease

Ongoing research

In the last 14 years, 268 positive patient outcomes have been published in peer-reviewed journals In 2012, the results of

a long-term tooth survival study by Lloyd Tilt, DDS, MS,7 were published as was a second human histology study by Marc Nevins, DMD, MMSc.8

Although the LANAP protocol has been proven in multiple studies, Millennium is still committed to acceptance through research, willing to financially support further research despite lack

14 Implant practice Volume 6 Number 3

CORPORATE PROFILE

RefeRences

1 Myers TD, Myers WD, Stone RM First soft tissue study utilizing a pulsed Nd:YAG dental

laser Northwest Dent 1989;68(2):14-17.

2 Midda M Nd:YAG Subgingival Curettage Innovation et technologie en biologie et medicine Actes du deuxienne congre modial L, impact des lasers en sciences odontologiques Presentation; 1990; Paris, France.

3 Tseng P, Gilkeson CF, Pearlman B, Liew V The effect of Nd:YAG laser treatment on subgingival

calculus in vitro [abstract 62] J Dent Res

1991;70(4):657.

4 Lin PP, Rosen S, Beck FM, Matsue M, Horton

JE The effect of a pulsed ND:YAG laser on periodontal pockets following subgingival application [abstract 1548]; The effect of a pulsed Nd:YAG laser on periodontal diseased root surfaces: a SEM study [abstract 1546];

A comparative effect of the Nd:YAG laser with root planing on subgingival anaerobes in

periodontal pockets [abstract 1547] J Dent Res

1992;71:299.

5 Cobb CM, McCawley TK, Killoy WJ A preliminary study on the effects of the Nd:YAG laser on root surfaces and subgingival microflora

in vivo J Periodontal 1992;63(8):701-707.

6 Gold SJ, Vilardi MA Effect of Nd:YAG laser curettage on gingival crevicular tissues [abstract

1549] J Dent Res 1992;71:299.

7 Tilt LV Effectiveness of LANAP over

time as measured by tooth loss Gen Dent

2012;60(2):143-146.

8 Nevins ML, Camelo M, Schupbach P, Kim SW, Kim DM, Nevins M Human clinical and histologic evaluation of laser-assisted new attachment

procedure Int J Periodontics Restorative Dent

2012;32(5):497-507.

of government or industry funding In

August of 2011, Millennium and the IALD

launched a university-based, five center,

six PI, prospective, longitudinal, calibrated,

multicenter clinical study comparing

LANAP to Modified-Widman to Scaling and

Root Planing, to coronal debridement For

study details, visit www.clinicaltrials.gov

and search for “LANAP”

Principles that withstand the test

of time

Millennium Dental Technologies stands

as the longest lasting laser company that

manufactures its own laser in the U.S., with

the same name, same management team,

the same laser, and the same product

The focus of the founders, Drs Gregg and McCarthy, has never changed – to

do what’s right for the patient in making

a treatment available that achieves results not routinely and widely available when compared to existing treatments

Doing the “right” thing — putting patients before profits — has been the key

to success and longevity in the dental laser and manufacturing industry

For more information about Millennium Dental Technologies, visit www.LANAP

com or call 877-526-2759

This information was provided by Millennium Dental Technologies.

IP

ROXOLID ® FOR ALL

THREE INNOVATIONS ■ ALL DIAMETERS ■ AWARD WINNING TECHNOLOGIES

Designed to increase your treatment options and help

to increase patient acceptance of implant therapy.

www.straumann.us 800/448 8168

Incorporating the latest developments in

implant dentistry into practice may result

in increased security and less aggressive

surgical techniques with long-term stability

and excellent esthetics The case below

illustrates the use of a Straumann®

Roxolid® narrow diameter implant with

improved strength* and osseointegration

with prosthetic flexibility through the use of

a CAD/CAM zirconia abutment

Limited buccal bone and interradicular

space necessitated the use of a narrow

diameter implant such as the Straumann

Bone Level Ø3.3mm Roxolid Implant

The biologic advantage of a platform

shift allows for maintenance of crestal

bone levels and maintenance of the

soft tissue The strength of this implant

(titanium alloyed with zirconium) allows for

increased thickness of the abutment at the

level of connection resulting in the ability

to use a CAD/CAM all zirconia abutment

not previously feasible with other small

diameter implants

The use of a zirconia abutment in

the case presented here addresses the

high esthetic demands of a patient with a

high smile line, thin tissue type, and high

scalloped architecture Combining the

SLActive® surface for reduced healing times with a narrow diameter for decreased grafting needs, along with a platform shift design, all allow for more conservative treatment in the difficult esthetic situation

The ability to incorporate these biologic and mechanical advantages with an all

zirconia CAD/CAM abutment allows for precise angulation, emergence, and margin placement with an esthetic advantage over titanium or gold abutments

*Norm ASTM F67 (states minimum tensile strength of annealed titanium); data on file.

Incorporating state-of-the-art and science to provide stability and excellent esthetic results in implant

Robert Vogel, DDS, graduated from the

Columbia University School of Dental and

Oral Surgery in New York City, New York;

upon graduation, he completed a combined

residency program in Miami, Florida at

Jackson Memorial Hospital, Mount Sinai Medical

Center, and Miami Children’s Hospital He maintains

a full-time private practice in implant prosthetics and

reconstructive dentistry in Palm Beach Gardens,

Florida He works closely as a team member with several

specialists providing implant-based comprehensive

treatment, as well as conducting clinical trials and

providing clinical advice to the dental attachment and

implant fields Dr Vogel has developed and collaborated

on the development of several prosthetic components

and techniques currently in use in implant dentistry He

lectures internationally on implant dentistry, focusing on

simplification, confidence, and predictability of implant

prosthetics through ideal treatment planning and team

interaction Dr Vogel continues to publish scientific

articles on implant dentistry, and is a Fellow of the

International Team for Implantology (ITI).

Figure 2: Temporary abutment and provisional restoration

in place 6 weeks after implant placement for “provisional guided tissue conditioning”

Figure 3: Esthetic evaluation of provisional restoration 3 weeks after insertion

Figures 4A and 4B: Straumann® CAD/CAD zirconia ment for Bone Level Ø3.3mm Roxolid® Implant

abut-Figure 5: Abutment and lithium disilacate (IPS e.max®) crown ready for delivery shown on Bone Level NC (Narrow CrossFit®) analog

Figure 6: Delivery of final abutment to 35Ncm

Figure 7: Final restoration in place

Figure 8: Twenty-six-month post-op radiograph noting

no change in bone levels and stable implant/abutment connection

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During the last decades, implantology

and guided bone and tissue

regeneration have made major steps in

improving osseointegration and soft tissue

esthetics The conclusions reached by a

number of experienced clinicians now form

part of almost every surgical protocol

Studies by Tarnow, et al., (2000) and

many specialized clinicians have shown

the optimal interimplant or implant-tooth

distance They have also determined

the right distance between the proximal

contact and the bone lever as well as

the right geometry of the restorations in

order to achieve the best possible esthetic

outcome

Many of these studies are more than

10 or 15 years old During this time, implant

designs and surfaces have changed

considerably Since modern biology

revealed the principles of osseointegration,

this topic no longer presents a problem

Knowing how osseointegration works and

being able to predict the outcome – even

in cases of lateral augmentation, ridge

preservation, and severe defect treatment

– has moved the focus of modern

implantology to soft tissue esthetics

The prime challenge today is the

long-term esthetic result These results depend

not only on osseointegration, but also on

the quality and amount of bone tissue

around the implant, and the amount and

treatment procedure of the soft tissue

Factors such as the implant neck, proximal

contact to crestal bone, and the

implant-to-tooth distance have a major influence

on the esthetic outcome of a single tooth

restoration

Taking into account that new materials and designs offer more possibilities, surgeons today have to vary their protocols and rethink some of the standards established when there were only a few implant designs and surfaces

Such an occasion will be described

in this case report Clinical and anatomical findings lead us to an alternative protocol and the choice of a specific implant design surface

Case report

A 35-year-old patient presented with an old and esthetically insufficient bridge in the anterior maxilla The clinical situation showed a 15-year-old bridge from UR2

to UL1, while the right middle incisor was missing after endodontic and surgical root treatment (Figures 1 and 2) The bridge was only vestibularly veneered, the teeth too small, and the soft tissue was inflamed

The soft tissue in the region of the missing tooth was scarred, and the lip band was transpositioned The lateral bone loss was massive but a logical result of the missing tooth

The control radiograph showed a vertical bone loss of 2-4 mm The bone proximal to UL1 was intact, while the bone proximal to UR2 had resorbed by almost 2

mm (Figure 3) Teeth UL1 and UR2 were endodontically treated and sufficiently filled

We set the following goals for treatment:

1 Removal of the bridge UR2-UL1

2 Conservative treatment of UR2 and UL1 with composite reconstruction

3 Temporary bridge insertion

4 Implantation and guided bone eration (GBR)

regen-5 Implant exposure and soft tissue plastic

6 Crown on UR2 and UL1

7 Forming of the papilla

8 Crown at UR1

Late implantation in an anatomical medial diastema

CASE STUDY

Drs Nikolaos Papagiannoulis and Marius Steigmann present a case report that takes a minimally invasive approach to soft tissue surgery

Figures 1 and 2: Situation before implantation, with a bridge from UR2 to UL1 and tooth UR1 missing

Dr Nikolaos Papagiannoulis is in private practice in

Germany He graduated from the Dentistry School

in Eberhard-Karls University of Tubingen He is

experienced with various implant systems, and in bone

regeneration and in sinus lifts, bone splitting, block

augmentation, prosthetic, and periodontal surgery.

Dr Marius Steigmann is an adjunct associate professor

of oral and maxillofacial surgery at Boston University,

and honorary professor of the Carol Davila University

Bucharest He is the continuing education assessor

for the International Academy of Oral Implantology

Dr Steigmann maintains a private practice in Germany

limited to esthetic and implant surgery.

Figure 5: Teeth UR2 and UL1 treated with composite

CASE STUDY

Treatment

After professional tooth cleaning, the

old bridge was removed, and teeth UR2

and UL1 were treated with composite to

reconstruct the crown and gain stability for

the denture (Figures 4 and 5)

A temporary bridge was inserted while

the soft tissue around UR2 and UL1 healed

The implant was placed after 2 weeks

Implant placement

Because of where the implant was to be

placed, we decided to use a tapered

implant with micro laser threads at the

implant neck This design was chosen to

achieve maximum bone and soft tissue

integration with the implant surface, so that

the esthetic result satisfied both our own

and the patient’s expectations

The SST medial to UL1 and UR2 was

less than 2 mm and allowed us to lift the

papilla on both sides A split thickness

flap was performed The exposed bone

showed a lateral defect and the need for

GBR to increase the bone level to at least

2.5 mm

The form of the old bridge as well as

the clinically and radiologically-determined

anatomical bone geometry, and the

patient’s statement confirmed that the

patient had a diastema in her childhood

This diastema was closed after losing

the tooth at UR1 Although the literature

recommends a distance of at least 1.5

mm from the neighboring tooth as optimal

for esthetic result, we decided to position

our implant 1.5 mm from tooth UR2 and

1.5 mm from the middle line, resulting in

a distance of 3 mm to UL1 Therefore,

we inserted a 3.8 mm diameter tapered

implant with internal hexagon A length of

12 mm was chosen (Figures 6 and 7)

Figure 6: Exposing the bone 2 weeks later showed the

lateral defect

Figure 7: Insertion of tapered implant

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CASE STUDY

The lateral defect was treated with

autologous bone won with a bone trap,

human cancellous cortico-spongious bone

chips (Maxgraft®, Botiss), and bovine chips

of 0.5-1 mm diameter (Cerabone®, Botiss),

resulting in a double layer GBR material of

2.5 mm on the higher third of the implant

The augmentation site was covered with

a porcine pericardium membrane (Jason®

membrane, Botiss) as a barrier to faster

growing soft tissue The flap was closed

with only three 5-0 polyester sutures

(Figures 8-10)

We prescribed antibiotics for 4 days

and a 0.05% chlorhexidine solution for 1

week The patient was recalled at 1, 2, 4,

10, and 16 weeks postoperatively

The whole healing period passed

without any complications, membrane

exposures, or complaints from the patient

Exposure

The implants were exposed 4 months

after placement A simple mucoperiosteal

flap was raised, and a standard gingival

former inserted The clinical situation

showed a fault position of the distal papilla

The papilla was raised again The gingival former was removed, and a standard abutment inserted Without individualizing the abutment, we changed the position

of the papilla, sutured it again, and fixed it with a single suture to the keratinized gum tissue After fabricating a new temporary bridge, a new appointment was scheduled for 2 weeks later (Figures 11-13)

At this appointment, we fitted the crowns

at UR2 and UL1, and started with the manipulation of the mesial papilla

Having the crown on tooth UL1 and enough soft tissue, we decided

on a conservative procedure using an individualized abutment to form the mesial papilla The new temporary crown on UR1 was left for another 2 weeks (Figure 14)

Prosthetic period

The outcome was impressive The mesial papilla led to the crown of tooth UL1, we observed no retraction of the soft tissue, and the distal papilla was stable The impression followed as usual with a direct transfer The crown at UR1 was fabricated and loaded after 2 weeks and a wax-up

The patient was very satisfied with the

result (Figures 15-17)

Results

Through minimally invasive procedures, appropriate planning and detailed discussion with the patient, the following results, important for the clinicians, were achieved:

• Correction of the frenulum position

• Natural form of the mesial papilla

• Correction and natural form of the distal papilla

• Correction of the quality and quantity of bone and soft tissue

• Optimal hygiene situation

• Elimination of old scars at the operation site

• Depression of new scar at the operation site

Conclusion

Our primary aim in this case was a highly esthetic result in a difficult and sensitive region, while solving the patient’s problems

in as minimally invasive a way as possible The outcome was more than satisfactory, resulting from good planning and the knowledge of anatomy and biology of implant surgery and GBR⁄GTR

The way our bodies function has not changed What has changed is our understanding of the biology We know how osseointegration works, and we can treat with predictable results The procedure of the treatment is also the result of our new understanding over the last decades This understanding can now

be used to manipulate and guide biology to the direction we want

Figure 8: Augmentation of lateral defect with Cerabone

Figure 10: Postoperative control radiographFigure 11: Situation at 4 months postoperative with poor

Figure 13: Insertion of standard abutment and altering the

position of the papilla

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Botos S, Yousef H, Zweig B, Flinton R, Weiner S The

effects of laser microtexturing of the dental implant

collar on crestal bone levels and peri-implant health Int

J Oral Maxillofac Implants 2011;26(3):492-498.

den Hartog L, Meijer HJ, Stegenga B, Tymstra N,

Vissink A, Raghoebar GM Single implants with different

neck designs in the aesthetic zone: a randomized

clinical trial Clin Oral Implants Res

2011;22(11):1289-1297

den Hartog L, Raghoebar GM, Slater JJ, Stellingsma

K, Vissink A, Meijer HJ Single-tooth implants with

different neck designs: a randomized clinical trial

evaluating the aesthetic outcome [published online

ahead of print August 4, 2011] Clin Implant Dent Relat

Res

Elian N, Bloom M, Dard M, Cho SC, Trushkowsky

RD, Tarnow D Effect of Interimplant distance (2

and 3 mm) on the height of interimplant bone crest:

a histomorphometric evaluation J Periodontol

2011;82(12):1749-1756.

Jaiswal P, Bhongade M, Tiwari I, Chavan R, Banode

P Surgical reconstruction of interdental papilla using

subepithelial connective tissue graft (SCTG) with a

coronally advanced flap: a clinical evaluation of five

cases J Contemp Dent Pract 2010;11(6):E049-57.

Nevins M, Nevins ML, Camelo M, Boyesen JL, Kim

DM Human histologic evidence of a connective tissue

attachment to a dental implant Int J Periodontics

Restorative Dent 2008;28(2):111-121.

Novaes AB Jr, Barros RR, Muglia VA, Borges GJ

Influence of interimplant distances and placement

depth on papilla formation and crestal resorption:

a clinical and radiographic study in dogs J Oral

Implantol 2009;35(1):18-27.

Pecora GE, Ceccarelli R, Bonelli M, Alexander H, Ricci

JL Clinical evaluation of laser microtexturing for soft

tissue and bone attachment to dental implants Implant

Dent 2009;18(1):57-66.

Raes F, Cosyn J, Crommelinck E, Coessens P, De Bruyn H Immediate and conventional single implant treatment in the anterior maxilla: 1-year results of a case series on hard and soft tissue response and

aesthetics J Clin Periodontol 2011;38(4):385-394.

Rodríguez-Ciurana X, Vela-Nebot X, Segalà-Torres

M, Calvo-Guirado JL, Cambra J, Méndez-Blanco

V, Tarnow DP The effect of interimplant distance

on the height of the interimplant bone crest when

using platform-switched implants Int J Periodontics

Restorative Dent 2009;29(2):141-151.

Romeo E, Lops D, Rossi A, Storelli S, Rozza R, Chiapasco M Surgical and prosthetic management

of interproximal region with single-implant

restorations: 1-year prospective study J Periodontol

2008;79(6):1048-1055.

Rothamel D, Schwarz F, Sager M, Herten M, Sculean

A, Becker J Biodegradation of differently cross-linked collagen membranes: an experimental study in the rat

Clin Oral Implants Res 2005;16(3):369-378.

Schwarz F, Sager M, Rothamel D, Herten M, Sculean

A, Becker J Use of native and cross-linked collagen membranes for guided tissue and bone regeneration

[in German] Schweiz Monatsschr Zahnmed

2006;116(11):1112-1123.

Seebach C, Schultheiss J, Wilhelm K, Frank J, Henrich

D Comparison of six bone-graft substitutes regarding

to cell seeding efficiency, metabolism and growth behaviour of human mesenchymal stem cells (MSC) in

vitro Injury 2010;41(7):731-738

Shapoff CA, Lahey B, Wasserlauf PA, Kim DM

Radiographic analysis of crestal bone levels around

Laser-Lok collar dental implants Int J Periodontics

Restorative Dent 2010;30(2):129-137.

Steigenga J, Al-Shammari K, Misch C, Nociti FH

Jr, Wang HL Effects of implant thread geometry on percentage of osseointegration and resistance to

reverse torque in the tibia of rabbits J Periodontol

surfaced implants: a histologic analysis in dogs J

Periodontol 2011;82(7):1025-1034

Weiner S, Simon J, Ehrenberg DS, Zweig B, Ricci

JL The effects of laser microtextured collars upon

crestal bone levels of dental implants Implant Dent

2008;17(2):217-228.

Figure 14: Situation after forming the mesial papilla with

individualized abutment and new crowns on UR2 and UL1 Figures 15 and 16: Situation after 2 weeks further healing

Figure 17: Final prosthetic restoration

Dental implants have evolved greatly,

from the first implants with polished necks

up to 3 mm high, to implants with threaded

necks, implants designed with special

thread morphology, or surfaces that allow

better bone adaptation Together with the

advancement of biomaterials and surgical

techniques, we now have a wide variety of

choices

This variety allows us to choose the best material, design, or procedure for each patient That is why, in this case, we proceeded differently from the evidence base We do not always have

to place the implant at least 1.5 mm from the neighboring tooth or 3 mm from the next implant The interimplant distance

is important, but so too is the diameter

of the implants, their prosthetic position, which teeth they replace, and so on In this case report, we placed our implant in the correct prosthetic position, respecting the anatomical findings

A wide knowledge of the variety of surgical techniques that has evolved in this growing field of dentistry is also very important

Various techniques from ogy, oral surgery, or maxillofacial surgery can be useful and often help with solving complications But in this case, lavish soft tissue plastic techniques would not have led to better results Moreover, they would have been expensive and more invasive for the patient IP

CASE STUDY

A 39-year-old, non-smoking female with

no systemic disease presented with a

chief complaint of wanting to improve her

smile

Upon clinical examination, probing

depths ranged from 2 to 3 mm with minimal

bleeding found upon probing Gingival

recessions of 2-5 mm were found on most

of her maxillary and mandibular teeth The

patient admitted past aggressive brushing

and reported that the recessions had been

present for more than 10 years She was

using desensitizing toothpaste, and only

minor cold sensitivity was reported She

learned to control her smile to hide the

gingival recessions and exposed roots

Diagnosis was made as Miller type

I-II gingival recessions with a lack of

keratinized tissue Their etiologies included

thin periodontal biotype as well as trauma

from aggressive brushing Oral hygiene

instructions were given, and she was

instructed to refrain from using hard bristle

toothbrushes and avoid excessive brushing

pressure

The treatment plan included

performing a connective tissue graft with

the use of Straumann® Emdogain™ Due to

the limitation of the donor tissue, surgery

was planned separately for the maxilla and

mandible

The tunnelling technique was used

in the maxilla, whereas a combination

of tunnelling and flap was used for the

mandible to minimize trauma to the thin

tissue The patient was instructed to use an

Connective tissue grafting

CASE STUDY

Dr Ken Akimoto presents a pictorial approach to improving a patient’s smile through soft-tissue

regeneration

Ken Akimoto, DDS, MSD, graduated from Tokyo

Medical and Dental University in 1989 and went into

private practice in Tokyo Since 2003 he has been in

private practice limited to periodontics and implants in

the United States He is an affiliate assistant professor

at the University of Washington and a fellow of the

International Team for Implantology (ITI).

Figure 3: Initial presentation (upper right)

Figure 5: Initial presentation (lower right)

Figure 6: Situation immediately after maxillary surgery, in which tunnelling was used and part of graft was left exposed to increase keratinized tissue

Figure 8: Situation immediately after maxillary surgery (upper right)

Figure 9: Eight weeks after maxillary

Figure 7: Situation immediately after maxillary surgery (upper left)

Figure 10: Mandibular surgery A combination of tunnelling and flap approach was used due to thin periodontal tissue

Figure 12: Six months postoperative

in maxilla (upper left) Figure 13: Six months postoperative in maxilla (upper right) Figure 14: Six months postoperative in maxilla (anterior)

Figure 16: Final documentation Eighteen months postoperative in maxilla, 15 months postoperative in mandible

Figure 15: Six months postoperative

This patient presented with a view to

improving his entire smile He was

aware that he had neglected his teeth over

the years and wanted treatment on his

entire mouth (Figure 1)

Medically, he was fit and well He

had given up smoking 3 years previously

Extraoral findings were normal, with

adequate oral hygiene in all quadrants

The patient’s BPE scores were 112 and

211 The patient admitted to not always

brushing before he went to bed He did not

floss and occasionally used mouthwash

Intraorally, he had a large edentulous

area in the lower right and upper left areas

of his mouth This made eating difficult

as he had very few posterior contacts to

masticate with He had a crown with poor

margins on the UL2, and various amalgam

fillings that required replacing The UR2

was heavily compromised, with little actual

tooth tissue remaining

The patient’s specific demands were

to have a nicer, whiter smile, with some

back teeth to eat with

Various treatment options were

discussed, and a combined restorative/

perio/implant/cosmetic treatment plan was

restora-• Fitting of a three-unit screw-retained implant bridge in the lower right edentulous area

• Fitting of IPS e.max® (Ivoclar Vivadent®) veneers and crowns on the upper incisors

As with all smile makeover cases, the

prototypes proved invaluable in reaffirming the proposed wax-ups The teeth were prepared, and Luxatemp® B1 prototypes (DMG) were fabricated using the putty mask provided by the lab The patient requested some minor contour changes, and this information was used when the final E.max restorations were made The final restorations were made at the same time as the implant bridge in order to successfully manage the patient’s occlusion The E.max restorations were bonded on with Variolink® II (Ivoclar Vivadent)

Figures 2 to 5 show the veneer process

Implant treatment

During the consultation process, the patient was not keen on having any form

of internal or external sinus lift in order to

Case study: restoring form and function with implants and veneers

CASE STUDY

Dr Nilesh Parmar tackles a patient’s neglected dentition to restore his smile without resorting to the

“Hollywood” look

Figure 1: The patient at presentation

Nilesh R Parmar, BDS (Lond), MSc (ProsthDent), MSc

(ImpDent) Cert.Ortho, runs a five-surgery practice close

to London and is a visiting implant dentist to a central

London practice He is one of the few dentists in the UK

to have a degree from all three London dental schools

and has recently obtained his certificate in orthodontics

from Warwick University His main area of interest is in

dental implants and Cerec CAD/CAM technology He

offers training and mentoring to dentists starting out in

implant dentistry More information can be found on his

website www.drnileshparmar.com.

preparations for veneers and crowns

place implants in the upper left edentulous

area Due to the limited height of alveolar

bone, implant placement could not be

carried out without some form of sinus

floor manipulation Due to this, it was

decided to place implants in the lower

right area, thereby restoring occlusion and

masticatory function to one side of the

patient’s mouth at this time A CBCT scan

(Figure 6) showed adequate bone height

for the placement of two Astra Tech TX OsseoSpeed™ implants (Dentsply)

The implants were placed under local anesthetic (Figure 7) using the Bien Air iChiropro surgical unit This unit has the advantage of recording the entire implant procedure, and creating a graphical representation of the insertion torques of each implant placed

The implants achieved good primary

stability, and healing abutments were placed at the time of surgery (Figure 8)

Care was taken to maintain the limited keratinized mucosa around each healing abutment

The patient healed without incident, with fixture level impressions taken 3 months after implant insertion (Figure 9)

The implants were restored using a unit fixed, screw-retained bridge

three-The patient was delighted with the final result (Figures 10-12) and has been maintaining excellent oral hygiene since the work was begun

He is due to return within 3 months

to begin work on restoring the upper left edentulous area, as he has now consented

to sinus floor manipulation This patient

is a very well-motivated individual, and I believe his work has an excellent long-term prognosis

showing parallel implant placement with guide pins

Figure 8: Closure of surgical site with 5.0 PGA sutures and 4 mm Astra Tech healing abutment

Figure 9: Image showing healthy keratinized mucosa

around the implants after 3 months healing

Figure 12: Postoperative long cone periapical radiograph showing baseline bone levels

IP

Abstract: M Dean Wright, DDS, has been

placing various types of implants for more

than 30 years, and describes the popularity

of mini dental implants in his practice The

case illustrated demonstrates a denture

stabilization treatment with six mini implants

in the maxilla to stabilize a full upper denture,

as well as four mini implants in the mandible

to support a partial The implants were

placed in 1 day and immediately loaded

This case represents a classic example of

denture stabilization with mini implants; a

future article will highlight a more advanced

case in which 25 teeth were extracted, and

15 implants placed in a 1-day treatment

The “law of the instrument” holds that if

the only tool you have is a hammer, it is

tempting to treat everything as though it

were a nail As implant practitioners, it is

important that we keep this in mind In

today’s dental market, we need more than

just one tool or method of treatment to offer

patients solutions that will meet their needs

in terms of convenience and affordability

I began placing traditional implants

in 1977 and to date have placed over

13,000 implants of various types and sizes,

developing my toolbox far beyond just a

hammer In 2001, I began investigating

what was then the IMTEC Sendax MDI

System (now 3M™ ESPE™ MDI Mini Dental

Implants) After my first case attaching a

maxillary denture to six mini dental implants,

it was clear that MDIs offered a new and

revolutionary technique that patients could

afford, quickly accept, and appreciate

Implant practitioners are likely familiar

with the chief benefits of mini dental

implants A primary advantage of these

implants is that because of their small size,

they provide a treatment option for many patients who are not ideal candidates for traditional implants, whether due to lack

of bone or other health conditions Mini dental implants are also significantly more affordable than traditional implants, as a typical case can be treated with a flapless, 1-day procedure at one-fourth to one-third the cost of traditional implant treatment

The potential to complete treatment in just

1 day is very appealing to patients who are faced with a choice of investing months of healing time in a traditional implant process, versus having mini implants placed and being able to immediately load the denture and enjoy their normal lifestyle

A decade of data

After more than a decade in use, the clinical data in support of mini dental implants continues to grow more significant

Published success rates have ranged from 91% to 98.3%.1,2,3,4,5 The 98.3% figure comes from a recent prospective clinical study that followed implants for a 1-year observation period, while a 5-year study

of 2,500 implants found a 94.2% success rate.6

In my practice, we have now placed over 10,000 MDIs, and continue

to treat new cases every day, placing approximately 100 MDIs each month The dramatic success that my practice has realized by offering this solution highlights the niche in the market that these implants fill Many denture patients are unhappy with the stability of their dentures, and feel self-conscious during everyday activities like eating and socializing However, traditional implant options, which tend to be better

known by patients than minis, can be prohibitively expensive There is a huge need in the patient population for an implant treatment that is more affordable and also more accessible for patients with resorbed ridges and other health conditions, which inevitably rule them out for traditional implants Although my practice offers a full range of implant options, we estimate that 70% of our implant volume is in MDIs—a testament to their popularity and enthusiastic reception by patients

While they are primarily marketed for denture stabilization, MDIs can also

be used for crowns and bridges Their versatility makes them helpful in challenging cases like treatment of cancer sufferers and accident victims (An upcoming article will demonstrate the use of 15 MDIs to stabilize dentures for a quadriplegic patient.) I have even used them to fix a lower denture onto

a 3 mm tall mandible with no grafting The case shown here presents what

is, for me, a typical denture stabilization procedure While cases are often shown with four implants supporting dentures in the mandible or maxilla, I typically prefer

to place more, often six to eight This case shows treatment with six MDIs in the upper arch to support a full denture, and four MDIs in the lower to stabilize a partial denture

Case presentation

The patient presented to the office with

an existing upper denture Numbers

21-27 were intact in the mandible, but the patient was seeking a solution that would provide her with a fuller and brighter smile She was also unhappy with the stability

The basics and beyond with mini dental implants

CASE STUDY

Dr M Dean Wright illustrates the advantages of mini implants as a denture stabilization option

Figure 1: The locations of the implants were marked on the tissue

Dr M Dean Wright is a 1972 graduate of

Wichita State University in Wichita, Kansas,

with a BS in Chemistry and a 1976 graduate

of the Kansas City School of Dentistry Dr

Wright has been placing implants since 1977, and has

to date personally placed and restored over 13,000

implants – both traditional and small-diameter Dr

Wright is the proud owner and director of Cambridge

Family Dentistry, a 20-operatory general practice and

implant center located in Wichita, Kansas.

Figure 2: The four lower implants immediately following placement

CASE STUDY

of her existing maxillary denture After

consultation, it was confirmed that the

patient was an appropriate candidate for

treatment with MDIs She consented to

the fabrication of a new maxillary denture

as well as a lower partial denture, both to

be stabilized with MDIs The existing lower

teeth would also be bleached during this process

Impressions were captured for the new dentures, and a jaw relation was taken The patient completed bleaching treatment, and a wax try-in was done to confirm the fit of the new dentures Once

the new dentures were completed, the patient returned to the office for implant placement It was determined that six upper implants and four lower implants would provide the best stability The locations of the implants were marked on the patient’s tissue with a marker, and each implant was

captured to integrate them into the denture

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30 Implant practice Volume 6 Number 3

CASE STUDY

RefeRences

1 Bulard RA, Vance JB Multi-clinic evaluation using mini-dental implants for long-term denture stabilization: a preliminary biometric evaluation

Compend Contin Educ Dent

2005;26(12):892-897.

2 Griffitts TM, Collins CP, Collins PC Mini dental implants: an adjunct for retention, stability,

and comfort for the edentulous patient Oral

Surg Oral Med Oral Pathol Oral Radiol Endod

2005;100(5):E81-84

3 Shatkin TE, Shatkin S, Oppenheimer BD, Oppenheimer AJ Mini dental implants for long-term fixed and removable prosthetics: a retrospective analysis of 2514 implants placed

over a five-year period Compend Contin Educ

Dent 2007;28(2):92-99.

4 Christensen GJ Critical appraisal Mini

implants: good or bad for long-term service? J

Esthet Restor Dent 2008;20(5):343-348.

5 Todorovic A, Markovic A, Scepanovic M Stability and peri-implant bone resorption

of mini-implants as complete lower denture retainers Poster contribution to the conference: Implantology for the compromised patient; February 1st-4th 2012; University Medical Center Groningen, The Netherlands.

6 Shatkin TE, Shatkin S, Oppenheimer BD, Oppenheimer AJ Mini dental implants for long-term fixed and removable prosthetics: a retrospective analysis of 2514 implants placed

over a five-year period Compend Contin Educ

Dent 2007;28(2):92-99

7 Douglass CW, Shih A, Ostry L Will there be a need for complete dentures in the United States

in 2020? J Prosthet Dent 2002;87(1):5-8.

8 Dental, Oral and Craniofacial Data Resource

Center Oral Health U.S., 2002 Section 4: Tooth

Loss Bethesda, Maryland: 2002, 35 Accessed

online: http://drc.hhs.gov/report.htm.

Figure 5: The final maxillary denture with housings in place

Figure 6: The final mandibular partial

Figure 7: Final result

placed in turn (Figure 1)

To place each implant, a 1.1 mm pilot

drill was placed over the entry point and

lightly pumped up and down to penetrate

the cortical plate The pilot hole was drilled

to a depth of approximately one-third

the threaded length of the implant The

implant was inserted into the pilot opening

and rotated under pressure, allowing the

self-tapping implant to advance further

The implant was advanced until there

was noticeable resistance, after which a

winged thumb wrench was used to further

thread the implant into place The insertion

process was finalized with the 3M™ ESPE™

Graduated Torque Wrench with Adaptor

The implants were inserted until the heads

protruded from the tissue with no thread

portions visible (Figures 2 and 3)

The dentures were relieved to fit over

the implants, and implant housings were fit

on the o-ball heads of each implant (Figure

4) Reline impressions were then captured,

and the case was sent to the lab to have

the housings processed in the denture and

partial Both were returned from the lab

the same day, and the dentures were then

seated in the patient’s mouth (Figures 5-7)

The patient was very happy with

the outcome of the procedure and felt

comfortable enough to go out to dinner

that night She returned to the office for a

minor adjustment 1 week following, and has been satisfied with the dentures since

Discussion

By the year 2020, statisticians estimate that 37.9 million people will be in need of one or two complete dentures This is an increase

of 4.3 million from the early 1990s.7

Currently, 25 percent of people aged 65 to

74 are edentulous in both arches.8 These statistics are included here to emphasize the current need for denture stabilization solutions, as well as the fact that this need will only continue to grow in the future

We have all likely read stories about the demands of Baby Boomers and the fact that this generation is intent on aging well and living comfortably For many patients

of this generation, living with a loose-fitting denture is not an acceptable option

In light of these trends, dentists would

be well served to familiarize themselves with the available denture stabilization options and be prepared to counsel patients on what treatments might be most appropriate for them After more than 10 years of placing MDIs, I have seen time and again the difference they make in patients’

lives, and I have never seen a procedure where patients are consistently so happy with the result IP