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clinical articles • management advice • practice profiles • technology reviews

August/September 2013 – Vol 6 No 4

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 crestal

approach technique for

sinus elevation

Drs Ziv Mazor, Andreas Ioannou,

Narayan Venkataraman,

George Kotsakis, and Udatta Kher

Treatment planning of implants

in the esthetic zone: part three

Drs Sajid Jivraj, Mamaly Reshad,

and Winston Chee

Drs Robert J Miller and Randi J Korn

WHEN THE OSTEOTOMY MUST BE NARROW

-SO MUST YOUR IMPLANT CHOICE

Choose the LOCATOR® Overdenture Implant System It’s a fact – denture patients commonly have narrow ridges and will require bone grafting before standard implants can be placed Many

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

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

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

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

2.5mm

2.4mm

4mm

2.9mm

included with each Implant

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

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

Cuff Heights

Diameters

Volume 6 Number 4 Implant practice 1

August/September 2013 - Volume 6 Number 4

EDITORIAL ADVISORS

Steve Barter BDS, MSurgDent RCS

Anthony Bendkowski BDS, LDS RCS, MFGDP, DipDSed, DPDS,

MsurgDent

Philip Bennett BDS, LDS RCS, FICOI

Stephen Byfield BDS, MFGDP, FICD

Sanjay Chopra BDS

Andrew Dawood BDS, MSc, MRD RCS

Professor Nikolaos Donos DDS, MS, PhD

Abid Faqir BDS, MFDS RCS, MSc (MedSci)

Koray Feran BDS, MSC, LDS RCS, FDS RCS

Philip Freiburger BDS, MFGDP (UK)

Jeffrey Ganeles, DMD, FACD

Paul Tipton BDS, MSc, DGDP(UK)

Clive Waterman BDS, MDc, DGDP (UK)

Peter Young BDS, PhD

Brian T Young DDS, MS

CE QUALITY ASSURANCE ADVISORY BOARD

Dr Alexandra Day BDS, VT

Julian English BA (Hons), editorial director FMC

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

for Wales

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

Dentistry

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

Boots Dental, BUPA Dentalcover, Virgin

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

referral implant surgeon

PUBLISHER | Lisa Moler

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

MANAGING EDITOR | Mali Schantz-Feld

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

ASSISTANT EDITOR | Kay Harwell Fernández

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

EDITORIAL ASSISTANT | Mandi Gross

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

DIRECTOR OF SALES | Michelle Manning

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

NATIONAL SALES/MARKETING MANAGER

Drew Thornley

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

NATIONAL SALES REPRESENTATIVE

Sharon Conti

Email: sharon@medmarkaz.com Tel: (724) 496-6820

PRODUCTION/DIGITAL MARKETING MANAGER

Greg McGuire

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

PRODUCTION ASST./SUBSCRIPTION COORD

© FMC 2013 All rights reserved

FMC is part of the specialist publishing group Springer Science+Business Media The publisher’s written consent must be

obtained before any part of this publication may be reproduced in

any form whatsoever, including photocopies and information retrieval

systems While every care has been taken in the preparation of this

magazine, the publisher cannot be held responsible for the accuracy

of the information printed herein, or in any consequence arising from

it The views expressed herein are those of the author(s) and not

necessarily the opinion of either Implant Practice or the publisher.

The axiom “I placed the implant where the bone was” is a dated concept in implant dentistry today and no longer accepted as the “norm.” Osseous grafting has become

an integral part of implant treatment, allowing ideal implant placement without the compromises we accepted in the past related to where the residual bone remained

Practitioners who have been involved with implant treatment, both surgically and restoratively for 20 or more years have witnessed the evolution afforded by advances

in creating bone where is it needed so that the fixtures can be placed where restorative demands dictate It has been long preached that implant dentistry is a restorative treatment with a surgical component In the past due to resorptive patterns, restoratively

we had to compromise in some patients where the fixtures could be placed This often forced compromises in the esthetic results or created challenges to home hygiene care for the patient Advances in grafting materials and techniques permit a true restorative-driven treatment resulting in ideal placement of the fixtures regardless of where the bone lies prior to treatment

Predictability was not always the word associated with oral osseous grafting Early endeavors using rib, tibia, hip, and other areas distant from the oral cavity resulted

in mixed results, often demonstrating resorption of the host graft over time and postoperative issues (i.e., discomfort) at the donor site

Yet, what “goes around comes around.” Philip Boyne, one of the early pioneers (1970s) in the use of titanium mesh as a cage to contain graft materials at the host site, has seen his concepts generally embraced with the advances in grafting materials

Titanium mesh is available from multiple manufacturers, pre-shaped to the different regions of the arch that can be placed either with or without simultaneous fixture placement, allowing the graft to be undisturbed until integration has occurred to the underlaying bed The sinus augmentation techniques of Hilt Tatum, also from the 1970s, have seen new light with embracing of his pioneering approach of crestal-driven augmentation Simpler, easier, more predictable crestal sinus augmentation has opened the door to more practitioners being able to provide this service and allow implant placement in the deficient posterior maxilla, as well as providing the patient with a less traumatic approach to improving bone height in this region of the mouth

We have also witnessed remarkable improvements in the osseous graft materials themselves The demineralized bottled bone allograft materials that were the standard years ago have been replaced by materials that are better processed and engineered to direct bone growth (osseoconductive) and stimulate bone growth (osseoinductive), and provide improved handling

Bovine osseous products continue to be utilized, but synthetic osseous grafting materials have evolved to provide grafts that are completely replaced by native host bone leaving no remnants behind following healing of the site Bone morphogenic proteins (BMP) provided from select companies, along with factors derived from the patient’s own plasma, are helping us better engineer our grafts providing better quality results in less time Additionally, “putty” forms of osseous graft materials available, both alloplastic and synthetic, allow improved ease of placement without unwanted distribution of the graft material beyond the site, and shaping of the graft to the dimensions of the desired ridge at placement This circumvents the issues associated with granular graft materials that had been accepted yet undesired

CBCT has opened new frontiers permitting better evaluation of osseous structure and related anatomical features The CAD/CAM-derived surgical stents from the 3D planning allow the restorative team to determine where the coronal portion of the restoration needs to be placed and where bone may need to be created to accomplish those restorative goals

Today, implant dentistry is truly a restoratively-driven treatment modality allowing us

to replicate what Mother Nature had originally provided the patient

Gregori M KurtzmanDDS, MAGD, FACD, FPFA, FADI, DICOI, DADIA

This is no longer your father’s implant dentistry!

TABLE OF CONTENTS

Dr David Feinerman: Communication, attention to detail, and

hard work

This clinician strives to balance a full-scope oral and maxillofacial surgery practice

and family fun.

Henry Schein Dental Surgical Solutions

From cotton rolls to cone beams, this new division is a one-stop shop for the

Dr M Dean Wright uses MDIs to treat a challenging case 14

Adjunctive laser treatment in extraction/immediate implant placement

Dr Robert J Miller discusses technology that is changing the face

of implants at the speed of light 18

Clinical

Minimally invasive crestal approach technique for sinus elevation utilizing a cartridge delivery system

Drs Ziv Mazor, Andreas Ioannou, Narayan Venkataraman, George Kotsakis, and Udatta Kher delve into ways to overcome insufficient vertical bone height in the posterior maxilla in conjunction with maxillary sinus lift 20

An affordable overdenture option for an edentulous ridge

Dr Ara Nazarian discusses the benefits of a small diameter implant 26

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

TABLE OF CONTENTS

Best of class

Implant Practice US congratulates

the 18 winners of Pride Institute’s

“Best of Class” Technology

Awards .30

Continuing

education

Treatment planning of implants in

the esthetic zone: part 3

In the final part of the series, Drs Sajid

Jivraj, Mamaly Reshad, and Winston

Chee look at the considerations for

multiple implant placement 32

Monitoring, diagnosis, and

treatment of peri-implant diseases

Drs Cemal Ucer, David Speechley,

Simon Wright, and Eddie Scher look

at the clinical headlines from the

Association of Dental Implantology

UK’s consensus meeting 36

Drs Robert J Miller and Randi J

Korn discuss some history behind

new implant technology 44

Product profile

LAPIP protocol from Millennium Dental Technologies, Inc offers

a patient-friendly, predictable solution for ailing implants . 54

Southern Anesthesia & Surgical Inc adds synthetics to the Osteo-i® line of regenerative products . 56

Luster® kits by MEISINGER 58

Industry news

Straumann® introduces Emdogain™ 015 – designed to provide versatility in patient treatment

New smaller size syringes will help clinicians provide Emdogain regenerative therapy to more patients 50

Zimmer Dental Implant receives

2013 MDEA Silver Medal 52

www.dentsplyimplants.com

DENTSPLY Implants offers a comprehensive line of implants, including ASTRA TECH Implant System™, ANKYLOS® and XiVE®, digital technologies such as ATLANTIS™ patient-specific abutments, regenerative bone products and professional development programs

We are dedicated to continuing the tradition of DENTSPLY International, the world leader in dentistry with

110 years of industry experience,

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

DENTSPLY Implants is the union of two successful and innovative dental implant businesses:

DENTSPLY Friadent and Astra Tech Dental.

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

For more information, visit www.dentsplyimplants.com.

What can you tell us about your

background?

I am Board Certified as an Oral and

Maxillofacial Surgeon and have been

practicing oral surgery since 1995

Originally from Queens, New York, I moved

to South Florida in 1997 and opened

Boynton Oral and Maxillofacial Surgery and

Implant Center, PA I graduated Summa

Cum Laude from the State University of

New York at Albany (SUNY), and received

my DMD (Cum Laude) from Harvard

School of Dental Medicine and my MD

degree from The University of Connecticut

Following completion of a 1-year General

Surgery and 4-year Oral and Maxillofacial

Surgery internship and residency at The

University of Connecticut, I went on to do a

1-year hospital-based maxillofacial surgery

fellowship at St Francis Hospital and

Medical Center During this time, I received

post-graduate training in advanced aspects

of oral and maxillofacial surgery, dental

implantology, head and neck oncologic

surgery, maxillofacial reconstruction, and

cosmetic facial surgery From 1995–1997,

I was an associate with Connecticut

Maxillofacial Surgeons, LLC in Hartford,

Connecticut, as well as a clinical instructor

in oral and maxillofacial surgery at The

University of Connecticut School of Dental

Medicine

In addition to private practice, I am

an Adjunct Clinical Professor at Nova

Southeastern University College of

Dental Medicine, co-chairman of the Oral

Implantology Course at the Atlantic Coast

Dental Research Clinic, and I lecture

nationally at oral and maxillofacial surgery

and oral implantology conferences I have

published several articles in peer reviewed

journals on various oral surgery topics and

currently serve as a reviewer for several

journals including the International Journal

of Oral and Maxillofacial Surgery, the

Journal of Oral and Maxillofacial Surgery

and the Oral Surgery, Oral Pathology, Oral

Medicine, Oral Radiology and Endodontics

Journal I have served on the South Palm

Beach County Dental Association Board

for the past 6 years and am currently on

staff at Delray Medical Center and Boca

Raton Outpatient Laser and Surgery Center I am a Diplomate of the American Board of Oral and Maxillofacial Surgery, fellow of the American Association of Oral and Maxillofacial Surgeons, a member of the Florida Society of Oral and Maxillofacial Surgeons, the American Dental Association, Florida Dental Association, American Medical Association, Florida Medical Association, Atlantic Coast Dental Association, South Palm Beach County Dental Association, the Academy of Osseointegration, the International Team of Implantology, and the American Academy

Why did you decide to focus on implantology?

When I practiced in Connecticut, I worked

in a hospital-based oral and maxillofacial surgery practice with a heavy emphasis

on orthognathic surgery, TMJ surgery, and cancer reconstruction When I moved

to Florida, the demographics of the surrounding population leant itself to a more office-based practice Many patients were being sent 15 miles north (to Palm Beach) and 15 miles south (to Boca Raton) for their implant surgery There seemed to

be a void in my area (Boynton Beach), and

I decided to focus my practice in the area

of implantology

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

I have been in private practice since 1995 The Straumann® Dental Implant System is the one I use most, but I occasionally place Zimmer®, Nobel Biocare®, Astra, Ankylos®

and Biomet 3i™ We have all the systems

in the office

What training have you undertaken?

As an oral and maxillofacial surgeon, I did

5 years of dental school (with one extra

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

year of research at Harvard) and a 5-year

oral and maxillofacial surgery residency

This included a 1-year internship in general

surgery that afforded me the time to

complete my medical degree When the

residency concluded, I completed a 1-year

hospital-based fellowship in advanced

maxillofacial reconstruction, which included

many aspects of dental implantology and

bone grafting

My training began at the Harvard

School of Dental Medicine Harvard had a

very strong pre-doctoral implant program

because of the pioneering work being

done there by Dr Paul Schnitman As an

oral and maxillofacial surgery resident at

the University of CT, I had the benefit of

additional instruction and clinical training

because of Dr Tom Taylor and Dr Leon

Assael (who were both heavily involved

early on with the ITI) At that time, only

oral surgeons were allowed to take

surgical implant training courses and, as a

resident, I took the ITI, Branemark, and IMZ

implant courses Today, I pursue as much

continuing education as my schedule will

allow for, and I am involved with the ITI

Who has inspired you?

When I was a first-year resident in oral

surgery at the University of CT, Drs Belzer

and Buser visited from Switzerland and

gave a lecture to the oral surgeons It was

a “private” lecture with only 20-30 of us in

the room, and they presented the most

unbelievable, cutting-edge, implant-related

treatment We were all amazed at what they were doing

Also, at the University of CT, I was fortunate to be taught by great surgeons and terrific people Many of them have been mentors and role models not only professionally, but personally as well

Lastly, having a loving wife and family

is extremely motivating; it pushes me to be the very best that I can be

What is the most satisfying aspect

of your practice?

Our goal in the practice is to deliver superior oral surgical care Providing great service to our patients is not only satisfying

to the patients, but to the entire practice

We become very close with some patients, and it is rewarding to help someone who is

in need of your expertise Equal to this are the professional and personal relationships

I have developed with the dentists who

refer patients to the practice Some of them have become very close personal friends, and it makes it easy and enjoyable

to discuss cases while working together daily to provide comprehensive patient care

Professionally, what are you most proud of?

Professionally, I am proud of a few things I

am proud that our practice has become one

of the largest implant practices in Florida as well as nationally I am proud that we have

an established reputation and that dentists from all over the country feel comfortable to call me if one of their patients is vacationing

in Florida and experiences an issue that requires attention I am proud that many of

my staff members have been with me since the day I started my practice in Florida My two surgical assistants have been with me for 15 and 16 years, my office manager for

I am proud that we have an established reputation and that dentists from all over the country feel comfortable to call me if one of their patients is vacationing in Florida and experiences

an issue that requires attention.

The staff at Boynton Oral and Maxillofacial Surgery and Implant Center Feinerman family in Beaver Creek, Colorado

PRACTICE PROFILE

2014 GLOBAL

BONE GRAFTING SYMPOSIUM

April 4-5, 2014 | Scottsdale, AZ

Hyatt Regency Scottsdale Resort

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Optional Hands-on Workshops

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Michael Pikos, DDS Thomas Wilson, Jr., DDS Brian Mealey, DDS Istvan Urban, DMD, MD, PhD Daniel Cullum, DDS

Gustavo Avila-Ortiz, DDS, MS, PhD Sascha Jovanovic, DDS, MS

Kirk Pasquinelli, DDS Hom-Lay Wang, DDS, MSD, PhD

To register, call Jeni Coy at 1.888.796.1923

or visit osteogenics.com/courses.

FOR MORE INFO

osteogenics.com/courses | 888.796.1923

10 Implant practice Volume 6 Number 4

PRACTICE PROFILE

14 years and other staff for about 10 years

now I am proud of the loyalty and bond I

have developed with them

What do you think is unique about

your practice?

Our practice was one of the first oral

and maxillofacial surgery practices in the

country to go digital We have been leaders

in developing a digital workflow that allows

computer-guided placement of dental

implants with immediate provisionalization

I have lectured around the country on

this topic, and we have received national

recognition for our work in this field We

have always tried to be “trendsetters” in the

field of dental implants We were one of the

first practices to start immediately loading

implants, and most recently, we were the

first practice in South Florida to become

totally Roxolid® for All Straumann

What has been your biggest

challenge?

My biggest challenge is probably not unique

to me, but it would be balance It is hard to

balance a busy practice, facial trauma call

at the hospital, coaching my sons’ baseball

and basketball teams, making it to all the

school events, and being a great dad and

a devoted husband

What would you have become if

you had not become a dentist?

In my dreams, a professional tennis player

(I played college tennis) In reality, probably

an ophthalmologist!

What is the future of implants and

dentistry?

The future is very bright for implant dentistry

The majority of dentists in the U.S are

still treatment planning three-unit bridges

over single implants As the education

for implants improves (especially at the

pre-doctoral level), implants will become

more mainstream and will become more

accepted and therefore, more popular

The U.S lags behind many European

countries as far as implants placed per

capita In addition, advancing technologies

and honing the digital workflow will make

implant surgery and restorations easier,

faster, and even more predictable

What are your top tips for

main-taining a successful practice?

There are a number of factors that are

necessary to maintain a successful practice

If I had to choose the top three, I would say communication, attention to detail, and hard work Good communication is paramount, whether it is with the referring dentists, the staff, or the patients We pride ourselves

on sending prompt, detailed letters to our referring dentists immediately after seeing their patients We also have monthly staff meetings as well as a separate monthly meeting with our office manager in order

to keep the lines of communication open

Patients are encouraged to call the office with any questions or concerns Patients also receive a detailed, written treatment plan for implant procedures

We stress the “attention to detail”

aspect of practice to our staff We frequently say that almost any practice can get things 90-95% correct, but it is that last 5% that will differentiate us from the other specialty practices in the area

Hard work is a given There are no

“silver platters,” and it takes work to be successful at anything Fortunately for me,

it is a “labor of love.” I arrive at the office by 6:30 a.m each day, and I usually get home around 7 p.m I have dinner meetings with referring dentists, study club meetings,

“lunch and learns,” and many other activities to help promote the practice

What advice would you give to budding implantologists?

I would suggest that you know both the surgical and restorative aspects of implantology, regardless of whether you are a surgeon or restorative dentist

Knowing both aspects makes treatment

planning and execution markedly easier Also, choose one or two implant systems, and become an expert on those systems Lastly, do not “cut corners.” Look at the big picture, and do not risk early failures just

to “get a case.” This is a sure way to give implants (and yourself) a bad reputation Take your time, do it right, and treat the patients as if they were family members

What are your hobbies, and what

do you do in your spare time?

Golf, ski, travel, fine wine, fine dining, coaching my kids’ sports teams, and spending time with family

Top 10 Favorites (in and out of the office)

1 Anytime my family is all together

2 Having a patient say “thank you” after treatment

3 Going to the Miami Heat, Miami Dolphins, Miami Marlins, or Florida Panthers games with my kids

4 Straumann® Guided Surgery

5 Watching each of my sons perform with their jazz band

6 The Roxolid® implant

7 Watching my sons’ varsity basketball or baseball games

8 The SLActive® surface technology

9 Playing golf with my sons

10 The Loxim™ transfer piece

IP

Drew Feinerman (with brother Jake in the background)

Kathy and Jake Feinerman

Surgical Solutions, a new division of Henry Schein Dental,

is focused exclusively on the evolving needs of surgical

specialists We redefine the customer experience by bringing

you a team of experts that combine a complete product offering

with exceptional service and proven practice-building solutions

specifically designed for the Surgical Specialist

To learn about exclusive promotions for surgical specialists,

YOU TAKE CARE OF PATIENTS

WE’LL TAKE CARE OF THE REST.

FullPage_9x11.7 8/1/13 11:01 AM Page 1

In an efficient and fast-paced specialty

office, choosing appropriate supplies and

equipment and finding quality products

and services in one place is essential

This year, Henry Schein Dental, the

largest worldwide distributor of dental

products, took a step towards its goal of

serving the very specialized needs of oral

surgeons and periodontists by creating a

new division, Henry Schein Dental Surgical

Solutions From cotton rolls to cone beam

scanners, specialists can rely on Surgical

Solutions as a one-stop shop for materials,

technology, and services for oral surgeons

and periodontists

Surgical Solutions is a result of

Henry Schein Dental’s increased focus

on bringing more comprehensive services

to oral and maxillofacial surgeons and

periodontists For nearly 80 years, Henry

Schein Inc has been North America’s

most reliable resource for dental supplies,

dental equipment, and dental financing

services Neil Park, DMD, general manager

of Surgical Solutions, says, “Henry Schein

Dental is already a proven partner for

general dentists, but specialists have

specific practice requirements As a result,

we created Surgical Solutions, with a whole

new team and a specialized focus, and

with a growing cadre of representatives

concentrated only on serving the entire

spectrum of specialists’ needs.” Dr Park

continues, “Besides the 15,000 SKUs

in our database, Henry Schein Dental

Surgical Solutions also provides our

specialist customers with pharmaceuticals,

equipment and technology, as well as

financing options for doctors and patients,

consulting services, office design, and

architectural services.” The American

College of Oral and Maxillofacial Surgeons

has already endorsed Henry Schein’s

exclusive purchasing program for oral

surgery products

As implant procedures evolve and

improve, specialists seek new implant

options for their armamentarium According

to a recent report by iData Research (www

idataresearch.net), a medical device,

den-tal, and pharmaceutical market research

firm, the U.S market for dental implants

is expected to regain double-digit growth

by 2013 and will help drive the dental prosthetic market to reach over 82 million prosthetic placements by 2016

Surgical Solutions offers its oral surgeon and periodontist customers the tools and materials for a successful and less stressful implant experience

Productive products

As an example, Surgical Solutions is the U.S distributor for the Camlog implant system As the market leader in Germany, Camlog systems are known for their extremely high precision, surgical simplicity, and excellent restorative flexibility Camlog®

Screw-Line implants are tapered, and suitable for immediate, late, and delayed implantation The self-tapping thread provides a continuous grip on the bone and high primary stability A new system, called Conelog®, has exactly the same outer geometry as Camlog, except for the height

of the Promote® surface that reaches up to the implant shoulder The conical internal configuration of the implant in conjunction with the Conelog® abutments allows integrated platform switching For more convenience, both systems use the same surgical instrument kit

In a separate category, where a smaller diameter implant is indicated, Surgical Solutions offers the miniMark™ Dental Implant System, precision engineered by ACE Surgical Supply, a company serving the dental specialty market for more than

40 years This implant features the popular Locator® Attachment by Zest Anchors— a trusted name in securing implant-retained dentures This small diameter implant can restore dental function with a standardized, minimally invasive procedure ACE Surgical also offers a high quality, value priced, full-line of bone and regenerative materials, membranes, allografts, xenografts, and other materials needed to prepare implant sites

With Surgical Solutions’ CAD/CAM options, specialists can explore the advantages of intraoral scanners from E4D (D4D Technologies), 3M™ ESPE,™ and 3Shape Digitally recording the position

of the implant during placement greatly simplifies the restorative procedure “We will be offering the scanning equipment, the scan bodies, and everything else needed to incorporate the technology into the surgeon’s implant practice,” says

Dr Park In the fall, Surgical Solutions will be launching a nationwide program

to introduce this technology to surgeons through a series of courses to help bring the equipment, concepts, and training into the practice

Surgical Solutions also offers a full line of imaging products, including the DEXIS digital X-ray system, with its state-of-the-art DEXIS® Platinum sensor and intuitive, easy-to-use imaging software The single-sensor system has remarkable image quality, is direct USB portable, and automatically saves, dates, and tooth numbers, and correctly orients the image when the sensor detects radiation For

a busy office, the One-Click-Full-Mouth series makes it possible to reduce a 25-minute FMX procedure to 5 minutes The DEXIS go, a companion app to the DEXIS Imaging Suite software, functions

as an imaging hub, displaying all images within the patient’s record, and allowing the clinician to communicate with patients using an iPad®

Henry Schein Dental Surgical Solutions

CORPORATE PROFILE

From cotton rolls to cone beams, this new division is a one-stop shop for the specialty practice

Neil Park, DMD

CORPORATE PROFILE

For those specialists who want to add

an additional dimension to their imaging and

obtain three-dimensional data and greater

precision for surgical procedures, Surgical

Solutions offers many brands of CBCT

units Henry Schein Dental is the exclusive

distributor in the U.S of the award-winning

i-CAT® (Imaging Sciences International)

brand of cone beam 3D imaging The

company recently debuted the i-CAT® FLX,

to help clinicians quickly diagnose complex

problems with less radiation* (i-CAT has

data on file) and develop treatment plans

more easily and accurately The i-CAT FLX

offers 3D planning and treatment tools for

implants, restorations, oral and maxillofacial

surgery, orthodontics, TMD, and airway

disorders The SmartScan STUDIO™

touchscreen interface promotes

ease-of-use and flexibility, and Visual iQuity™ image

technology provides i-CAT’s clearest 2D

and 3D images The most compelling part

of this system is that specialists can gain all

of the benefits of CBCT imaging, and with

the QuickScan+ feature can capture a

full-dentition 3D scan at a lower radiation dose

than a panoramic image Tx STUDIO™

optimized treatment planning software

provides immediate access to integrated

treatment tools for implant planning,

surgical guides, and other applications

All of these quality products

demonstrate that state-of-the-art

technology is a priority at Surgical

Solutions Dr Park describes, “The

firm sells more X-ray equipment, CBCT

scanners, and intraoral CAD/CAM units

than everyone else, so we understand how

they work for the specialty practice.” He

adds, “For instruments, we offer the full line

of Hu-Friedy and other quality instrument

makers, and we also have the Henry Schein brand of value-priced instruments

Our representatives are a veteran group who are committed to this industry.”

Meet the team

Surgical Solutions was created by a team

of dedicated, experienced professionals who bring their individual expertise to the new division Dr Park is a dentist with 19 years of experience with Nobel Biocare,

a global leader and pioneer in implant systems Dr Park notes, “The importance

of offering focused services to oral and maxillofacial surgeons and periodontists is

a strategy that has received tremendous support from the very top of Henry Schein’s executive team George Guttroff, president

of the Dental Specialties Group, and I have worked together very closely to bring this new division to fruition.”

Kerri Leslie, the new head of marketing, brings her 8 years of experience in the medical field to spread the news of the expanding endeavor The knowledgeable and enthusiastic sales team, which has already grown to 34 reps and managers with more expected, brings expertise across a gamut of categories National Director of Sales, Maritza Alford brings her extensive management experience from within the Henry Schein group Todd Colvin, who directs sales in the Northeast region, spent many years with the implant giant, Zimmer, before joining Camlog/

Henry Schein 6 years ago Donald Boyd, regional manager for the Southeast, spent

16 years with Nobel Biocare Robert Riley, CDT, will serve as Director of Training and Technical services, from a new technical resource center in San Antonio, Texas that answers technical questions related to any product offered by the group Riley has extensive experience that includes several key positions in the implant and orthodontic industries

The entire Surgical Solutions’ team is dedicated to bringing quality technology and products to the specialty office in a convenient and efficient way Dr Park sums up, “We will prove that we can meet the needs of oral and maxillofacial surgeons and periodontists These professionals typically purchase their products from

a variety of vendors — drugs from one company, implants from another, bone-related products from yet another We can streamline that process while providing additional value to the practice Our surgical sales consultants will become a part of the practice family in that targeted field and help to bring our customers’

practices to higher levels of clinical and business success.” Customers are already sharing positive feedback on how Surgical Solutions brings targeted and professional service to surgical specialists

professionals who bring

their individual expertise to

the new division.

Abstract: A previously published article

by the author reviewed the current data

on mini dental implants and their use in

denture stabilization The case showed the

insertion of 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 Such a case may be categorized

as a “classic” and straightforward MDI

denture stabilization treatment In contrast,

the case illustrated in this article — a

medical first — demonstrates the more

advanced treatments made possible

by MDIs The patient in this case was a

quadriplegic who underwent extraction of

25 teeth, followed by placement of eight

MDIs in the maxilla and seven MDIs in the

mandible The procedure was performed in

less than 9 hours under general anesthesia

in a hospital

In an article previously published in the

May/June issue of this magazine, I

outlined my decades of experience with

dental implants, along with my belief in

the practicality and utility of mini dental

implants (MDIs) as a more affordable and

accessible alternative to traditional implants

for many patients As stated in that article,

MDIs require less bone to place, are less

invasive, and treatment can be completed

much faster than with traditional implants

MDIs have been used for more than 10

years, and a recent prospective clinical

study showed a 98.3% success rate after a

1-year observation period.1 A 5-year study

following 2,500 mini dental implants found

a success rate of 94.2%.2

I estimate that I place approximately

100 MDIs each month, and have

seen many times over the enthusiastic

responses of patients for whom they make

a life-changing difference While these implants can be used to support crowns and bridges, they are primarily utilized for the stabilization of dentures Patients experience an immediate and dramatic boost in retention with these implants, making it a very rewarding treatment to offer

The simplicity of the basic MDI denture stabilization treatment makes it an attractive procedure for many dentists, but MDIs can also be utilized in complex cases such as the one shown in this article While the individual techniques used in the case illustrated here were not new to the team involved in the procedure, I believe that the case itself may be a medical first

of the patient’s teeth The patient’s benefits from the state of Kansas entitled him to a single hospital treatment for the condition

He had seen a number of local specialists prior to visiting my office, none of whom could come up with a satisfactory solution given the constraints of the case

When I met with the patient, however, I was able to propose a realistic — although ambitious — treatment plan My experience

placing MDIs, combined with the fact that I have hospital privileges at the facility where

he would be treated, presented a strong opportunity

An initial panoramic X-ray was taken, which showed 25 severely abscessed and decayed teeth (Figure 1) (A CT scanner could not be used during treatment planning due to the patient’s condition and mobility restrictions.) A treatment plan

to extract the decayed teeth and place eight MDIs in the maxilla and seven in the mandible was presented to the patient and accepted

The panoramic image was used to determine initial implant locations and sizes On the day prior to the surgery, slots were cut into the immediate denture

to accommodate the future sites of the implants, and a bite registration was taken outside of the mouth

On the day of the procedure, after nasal intubation and general anesthesia,

a 4 x 4 throat pack was placed, and the

25 teeth were extracted Any bone loss due to breakage or tooth attachment was harvested and used for autogenous grafting where needed later

Alveoplasty was then performed as needed, and the 15 3M™ ESPE™ MDI Mini Dental Implants were placed The MDIs ranged from 10 mm to 18 mm in length and 1.8 mm to 2.4 mm in diameter Space limitations prohibit the inclusion of details

on the advanced technique of threading an implant between two opposing extraction sites, but it should be noted that varying

An advanced mini dental implant case: 25 extractions and insertion of 15 MDIs for a quadriplegic patient

CASE STUDY

Dr M Dean Wright uses MDIs to treat a challenging case

Figure 1: Panoramic X-ray showing 25 severely abscessed and decayed teeth Initial measurements for implant locations and sizes were drawn on during the consultation

Figure 2: X-ray following placement of eight maxillary and seven mandibular MDIs Divergence of the implants is of

no consequence

M Dean Wright, DDS, 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 12,000 implants – both traditional and

small-diameter Dr Wright is the owner and director of

Cambridge Family Dentistry, a 20-operatory general

practice and implant center located in Wichita, Kansas.

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16 Implant practice Volume 6 Number 4

CASE STUDY

densities, widths, and depths of bone

were encountered Multiples of every size

and diameter of MDI were on hand for the

procedure in order to be prepared for any

necessary adjustments

Experienced readers reviewing the

radiographs may note that one more

implant could have been placed in the No

31 area above the inferior alveolar nerve;

however, without having the 3D scan and

not knowing the precise length of bone, I

did not want to risk any chance of a nerve

parasthesia, especially with this patient

The radiographs also show how some

of the lower implants are slanted away

from the nerve areas (Figure 2) 3M ESPE

MDIs can withstand up to 30 degrees of

divergence, and this slight angle actually

adds to the final denture retention This is

done regularly, and the visual slanting of the

MDIs on the X-rays is of no consequence

Following placement of the implants,

the autogenous grafts were placed where

necessary and into extraction sites along

with collagen plugs, and the sites were

closed with 4-0 Vicryl™ suture (Figure

3) These steps help to preserve bone

and minimize bleeding Practitioners are

encouraged to do a thorough job of this, as

it greatly helps in the final product

Metal housings were snapped onto

the O-ball heads of the implants, and

rubber base reline impressions were taken

using the bite registration as a guide

Analogs were placed in the impressions,

and the case was sent to Kaylor Dental

Lab in Wichita, Kansas, which processed

the snaps and relined the denture within

a few hours The laboratory’s assistance

was greatly appreciated, as insertion of

the dentures on the same day helps to

minimize swelling and bleeding, and to

lessen the patient’s discomfort

Before the conclusion of surgery, the

patient was given 10 carpules of Marcaine

so that he would be numb all day and when

the dentures were placed Antibiotics were

given before and after surgery, as well

as an anti-inflammatory and a narcotic painkiller By 5 p.m., the patient returned

to the dental office, and the new dentures were seated

At a post-op visit 3 days later, the patient stated that the procedure wasn’t

as bad as he had anticipated Examination revealed the implants held the dentures tightly and kept them from compressing the ridge Our observation was that the patient had less pain than if he had no implants and just the immediate dentures

A visit 1 month later showed satisfactory healing of the tissue and a very satisfied patient (Figures 4-6)

Conclusion

The two articles presented in this series represent both the basic and advanced capabilities of MDI treatment As both cases illustrate, MDIs provide dentists with

a valuable tool for denture stabilization, proving versatile enough to be used in everyday cases or in very challenging treatments such as the one shown here

Their affordability, small size, and minimally invasive nature give them capabilities that traditional implants simply can’t match Eleven years ago, skeptics of MDI treatments were numerous and vocal

I continue to know doctors who do not believe in MDIs, and that is, of course, their choice However, I believe that in the not-too-distant future, MDIs will be as common

as amalgams and offered routinely by most dentists The benefits for patients are too great to overlook, and I believe that MDIs are one of the finest solutions you can offer

to patients who have lost or are losing their natural teeth

Figure 3: Immediate state following placement of implants

and suturing of extraction sites

Figure 4: The implants at 1 month post-op Figure 5: Final result with dentures

Figure 6: The author and patient

RefeRences

1 Todorovic A, Markovic A, Šcepanovic M

Stability and peri-implant bone resorption of the mini implants as complete lower denture retainers [Espertise Scientific Facts brochure] St Paul, MN: 3M ESPE; 2012.

2 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):92-101.

IP

Throughout the history of oral

implantology, strategies have been

based on the paradigm of placing

endosseous dental implants in healed sites

With diminishing numbers of completely

edentulous patients being treated, there

is an increasing need to place implants

at the time of tooth removal Additionally,

over the past decade, our discipline has

seen a dramatic change with either earlier

loading times or immediate loading Unlike

the healed site with balanced bone density

and soft tissue coverage, extraction sites

present additional challenges with respect

to implant stability and potential presence of

infection Therefore, if our paradigm is going

to change from placement of implants in

healed sites to one of immediate placement

in extraction sites, new modalities must

be developed These changes, known as

“biologically-driven” surgical strategies,

reflect our understanding of the interaction

of implanted materials and living tissue

However, they also reflect our new respect

for the consequences of placing implants

in compromised osteotomies

Extraction site defects bring increasing

complexity with respect to initial healing

of implants In most cases, periodontally

involved teeth or failed endodontically

treated teeth are removed, and the site is

prepared to accept an implant Unlike the

healed site in which pathology has been

resolved, extraction sites may contain

pathogenic bacteria or granulomatous

lesions that can cause infection or implant failure The key components of a strategy

to reduce potential complications following implant placement in this type of site is complete debridement of the hard tissue and removal of epithelium in the gingival sulcus Sulcular epithelium harbors periodontal pathogens that may cause inflammation following implant placement

These pathogens can migrate to the walls

of the portion of the implant not covered

by bone They can delay or even prevent integration of these exposed portions of the implant, predisposing the implant body

to future infection and bone loss Apical granulomas have a different type of biologic response Granulomas that have formed

as a result of incomplete endodontic debridement may harbor vegetative forms

of pathogenic bacteria However, they may also result in an untoward immunologic response different from that of bacterial origin This may result in a cyclical biologic process that perpetuates production

of inflammatory tissue that results in a retrograde peri-implantitis, starting at the implant apex and moving coronally

The following case illustrates how

an Erbium, Chromium;YSGG laser

(Biolase Technologies) can be used as

an effective means of debridement and de-epithelialization prior to immediate implant placement.This patient presented with fracture of an endodontically treated maxillary left cuspid as a result of recurrent decay (Figure 1) The decay reached the osseous crest making the tooth unrestorable without a crown extension However, with a high smile line, the patient opted for tooth removal and immediate implant placement to maintain the position

of tissue architecture Following destructive tooth removal and maintenance

non-of the facial plate, the retained root was evaluated for depth and length Remnants

Adjunctive laser treatment in extraction/immediate

implant placement

CASE STUDY

Dr Robert J Miller discusses technology that is changing the face of implants at the speed of light

Figure 1: Fracture of an endodontically treated maxillary cuspid with recurrent decay Figure 2: Remnants of an apical granuloma still attached to the root apex

Robert J Miller, MA, DDS, FACD, received

both a Bachelor of Arts and Master of Arts

in Biology and then continued his education

at New York University College of Dentistry

where he received his Doctor of Dental

Surgery degree (DDS) in 1981 Upon graduation,

Dr Miller was honored to be chosen as one of 200

applicants to complete a residency program at Flushing

Hospital and Medical Center He is one of the few

Dentists in the United States to be Board Certified by

the American Board of Oral Implantology (ABOI) Dr

Miller is also a Diplomate of the International Congress

of Oral Implantologists (DICOI) and holds current

memberships in the The American College of Dentists,

The American Dental Association (ADA), The Florida

Dental Association (FDA), and the South Palm Beach

County Dental Association (SPBCDA) He has been

practicing dentistry in Delray Beach, Florida for 30

CASE STUDY

of a portion of the apical granuloma can be seen still attached to

the root apex (Figure 2)

Following extraction, an erbium laser with a 14-mm zirconium

tip is introduced into the osteotomy (Figure 3) Careful debridement

of the entire extraction site is carried out until all remnants of

granulomatous tissue is removed Additionally, the inner lining of

the sulcus up to the free gingival margin is ablated to reduce the

bacterial load and to create a bleeding interface to accelerate soft

tissue attachment to the healing abutment (Figure 4)

Following implant placement, a healing abutment is placed

and the facial defect grafted (Figure 5) In some cases, if there

is adequate initial stability, a temporary abutment and provisional

may be placed The implant is allowed to heal for at least 2 months

When the healing abutment is removed, we can demonstrate the

formation of a new gingival sulcus coronal to the top of the implant

and a bleeding interface apical to that zone which indicates

the presence of a hemidesmosomal attachment to the healing

abutment (Figure 6) This represents regeneration of biologic width

at the coronal aspect of the implant

The prosthetic phase is completed, and final crown placed

on a milled titanium abutment The final photograph (Figure 7) was

taken at 1-year post-op This demonstrates a stable and healthy

dentogingival complex, even in a tooth position with highly parabolic

architecture and long papillae The use of an ablative erbium laser

is ideal in implant cases when dealing with potentially infected sites

and to enhance initial healing of soft tissue architecture

Erbium, Chromium;YSGG lasers can also be used for many

other procedures in oral implantology These include gingival

recontouring, removal of hyperplastic tissue, flap incisions,

osseous recontouring, bone harvesting, lateral wall sinus grafts,

ridge splitting, preparation of the implant osteotomy, implant

debridement, treatment of peri-implantitis, and removal of failed

implants

Figure 6: Removal of the healing abutment at 2 months

demonstrating regeneration of the dentogingival complex

Figure 7: One-year post-op photograph reflecting stable

gingival architecture and a healthy tissue response

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IP

Dental implants are successfully used to

replace both the form and the function of

missing teeth The main prerequisite for

implant placement is sufficient volume of

bone in the edentulous ridge to support

the body of the implant In the maxilla,

when severe atrophy of the edentulous

ridge exists in combination with maxillary

sinus pneumatization, maxillary sinus

augmentation surgery is frequently

employed to provide adequate vertical

bony dimensions for the placement of an

implant

A variety of surgical techniques and

materials have been used to overcome the

problem of insufficient vertical bone height

in the posterior maxilla in conjunction with

maxillary sinus lift This procedure aims to

increase the dimensions of the available

bone in the area by placement of bone-graft

material in the space created following the

elevation of the maxillary sinus, performed

in two distinct ways: the direct sinus lift procedure using a lateral approach and the indirect sinus lift procedure through a crestal approach which was introduced by Summers in 1994.1

When the treatment of choice is the direct sinus elevation technique, complications can occur, including a possibility of sinus membrane perforation

The indirect sinus elevation technique is less invasive, less time-consuming, and reduces the postoperative discomfort for the patient The lack of direct visualization

of the membrane and the use for the osteotomes for the fracture of the sinus floor may lead to a risk of Schneiderian membrane perforation as high as 26%.2

The limit of bone volume gained with the Summers technique is approximately up to

5 mm.3

Technique-related risks such as reports of benign paroxysmal positional vertigo following sinus elevation utilizing the osteotomes technique have led to the innovation of more atraumatic modifications

of the original technique Such one is the minimally invasive antral membrane balloon elevation (MIAMBE).4 In this technique, a transalveolar approach is utilized, and the endosteal implant osteotomy is prepared 1-2 mm below the floor of the antrum

This surgical approach includes causing a small fracture in the antral floor and slowly elevating the sinus membrane with the aid

of hydraulic pressure utilizing a balloon that inflates and ‘‘pushes’’ the Schneiderian membrane The gap present between the initial position of the sinus floor and

the elevated membrane is filled with graft materials, and an implant is placed

In another technique, novel atraumatic drills and reamers that can rotate in proximity to the sinus membrane and without perforating the Schneiderian membrane have been utilized to make the use of osteotomes redundant In this technique, an atraumatic drill is advanced

to the floor of the sinus, and then a reamer

is employed to drill any bone left at the floor

of the sinus and elevate the membrane Following slight elevation of the membrane with the reamer, a carrier is used to deliver bone graft through the osteotomy and further advance the membrane.5

Various bone grafting materials are frequently used in sinus lift procedures, such as autogenous bone, freeze-dried bone, demineralized freeze-dried bone, xenogeneic bone, and alloplastic bone substitutes.6-7 Recent data have shown that bone substitutes displaying a putty consistency can present a valuable alternative in bone-grafting procedures.8-9

The handling characteristics of putty bone substitutes have expanded the available

Minimally invasive crestal approach technique for

sinus elevation utilizing a cartridge delivery system

CLINICAL

Drs Ziv Mazor, Andreas Ioannou, Narayan Venkataraman, George Kotsakis, and Udatta Kher delve into ways

to overcome insufficient vertical bone height in the posterior maxilla in conjunction with maxillary sinus lift

Figure 1: In contrast to the original osteotome technique, before the in-fracture of the sinus floor with the osteotome, a small quantity of CPS is inserted in the osteotomy to function as a protective “cushion’’ during percussion

Ziv Mazor, DMD, is a leading Israeli periodontist He

graduated the periodontal department of Hadassah

School for Dental Medicine-Jerusalem, Israel, where

he served as clinical instructor and lecturer for

undergraduate and postgraduate dental students Dr

Mazor maintains private practice limited to periodontal

and implant dentistry in Raanana, Israel Since 1993,

Dr Mazor has been engaged in clinical research in the

field of bone augmentation and sinus floor elevation

Dr Mazor is the past president of the Israeli Periodontal

Society and is currently the president elect of the Israeli

Association of Oral Implants.

George Kotsakis, DDS, is a Resident in the Advanced

Education Program in Periodontology at the University

of Minnesota Dr Kotsakis graduated from the University

of Athens, Greece and spent 3 years in private practice

where he focused in implant treatment and complex

restorative cases During that time he got involved in

practice-based clinical research that led him to pursue

specialty training Dr Kotsakis has published numerous

scientific publications in peer-reviewed journals with a

main interest in clinical and histological outcomes of

bone augmentation with different types of grafts.

Andreas Ioannou, DDS, is a Resident, Advanced

Education in Periodontology at the University of

Minnesota.

Narayan Venkataraman, MDS, is an Implantologist in

Bangalore, India.

Udatta Kher, MDS, is an Oral Surgeon in Mumbai, India.

Figure 2: The putty absorbs part of the forces that are applied to the bone and evenly distributes the remaining force while minimizing the risk of membrane perforation

22 Implant practice Volume 6 Number 4

CLINICAL

treatment options for bone grafting

in narrow spaces, and their physical

properties can be exploited to increase

the safety and predictability of sinus lift

procedures

In this improvisation, viscoelastic

calcium phosphosilicate alloplastic putty

(CPS), available in a unique cartridge

delivery system, is utilized CPS is a

completely synthetic graft substitute that is

approved for bone repair and regeneration

in dental and orthopedic osseous defects

It is a premixed composite of 70% calcium

phosphosilicate particulate and 30%

synthetic absorbable binder Bioactivity

of CPS results from the chemical release

of ionic dissolution products: silicon,

sodium, calcium, and phosphate, and has

shown to stimulate multiple generations

of undifferentiated cells into osteoblasts.10

CPS has been successfully used in various

osseous defects with no reported adverse

events.11,12

CPS not only acts as a “protective

cushion” but also provides hydraulic

pressure to lift the Schneiderian membrane

This approach minimizes risks of benign

paroxysmal positional vertigo or mechanical

perforations of the Schneiderian membrane

associated with the traditional osteotome

technique In the first case example, a

modification of the MIAMBE technique

with the use of CPS instead of an inflatable

balloon will be presented In the second

case example, a series of atraumatic drills

will be utilized in conjunction with CPS to

perform an indirect sinus lift without the use

of osteotomes

Illustration of the minimally

inva-sive technique using hydraulic

pressure

The technique illustrated aims to describe

a modification of MIAMBE technique that

employs hydraulic pressure for sinus

membrane elevation This improvisation is

made possible by the unique consistency

and delivery mechanism of the CPS graft

The technique also helps to minimize

complications associated with the use of

osteotomes

A Transalveolar Sinus Floor Elevation

(TSFE) technique is utilized, and the

osteotomy site is prepared to the size of

the final implant diameter and stopped

0.5-1 mm short of the sinus floor (Figures 0.5-1A

and 1B)

A small quantity (~0.25 cc) of the

putty graft is inserted in the implant bed to

function as a “cushion,’’ thus preventing

perforation of the membrane before the osteotome is used to tap firmly and produce a green-stick fracture (Figure 2)

A putty cartridge is snapped into the dispensing gun, and the bent cannula of the cartridge is placed in the osteotomy site The width of the cannula is narrow enough to allow it to be inserted into the osteotomy following the use of a 2.0 mm pilot drill While applying pressure against the bone, CPS is injected into the site

The hydraulic pressure from delivery of the graft material elevates the sinus membrane (Figures 3A and 3B) For every 0.5cc injected into the sinus, the floor is elevated approximately by 2 mm

Following adequate elevation of the sinus floor, an implant is placed in the socket (Figures 4A and 4B) Approximately 85% of the graft gets remodeled into vital bone in 5-7 months with approximately 15% residual graft after 6 months in the site.13

Representative case of the fied reamer technique

modi-A 50-year-old, healthy female smoker) presented for implant placement

(non-in the edentulous upper left premolar area

The subantral bone height was measured

at 9.3 mm in the 24 area and 5.3 mm

in the 25 area (Figure 5A) The patient was premedicated with 2g amoxicillin 1 hour before the surgery Following local anesthesia, initial drilling with a 2 mm twist drill, followed by a 2.9 mm drill to widen

the osteotome to approximately 1.0 mm short of the sinus floor was performed utilizing a crestal approach (Neobiotech SCA™ kit) Subsequently, an appropriately sized (2.8 mm in 24 area and 3.2 mm in

25 area) S-reamer was utilized until the sinus floor was breached, while leaving the membrane intact owing to the design

of the reamer Separation of the sinus floor was performed using a round-ended depth gauge Approximately 0.5 cc CPS was injected into the No 24 area and 1.5

cc into the No 25 area (Figures 5B and 5C) using the cartridge delivery system and continued until the hydraulic pressure caused elevation of the sinus membrane Once the membrane was adequately elevated as evidenced by the tactile sensation of resistance to additional bone grafting, the grafted material was laterally spread using a paddle-shaped bone spreader with a stopper running at 70 rpm

4 mm x 10 mm and 5 mm x 8.5 mm CMI

IS II implants were placed in No 24/25 areas, respectively Implants were inserted with a primary stability greater than 35N/cm2 in both sites, and a healing abutment was placed for non-submerged healing

A 7-month postoperative radiograph demonstrated trabecular pattern in the grafted area indicative of the graft turnover and bone regeneration

Discussion

In cases where adequate amount of bone is not available for the placement of implants

Figure 3:The narrow tip of the delivery system allows it to enter the narrow osteotomy and reach the floor of the sinus

Figure 4: The viscosity of the CPS that surrounds the apex of the implant aids in achieving increased primary stability

24 Implant practice Volume 6 Number 4

CLINICAL

in the posterior maxilla area, maxillary

sinus lift is indicated The approach using

the Summers’ osteotomy was developed

to simplify the sinus-lift procedure using

simultaneous sinus floor elevation and

implantation in one stage through the

socket However, the lateral approach

offers a better control of the surgical site,

particularly in a severely resorbed maxilla

or when extensive implantation is needed

Both approaches seem to yield similar

success rates.14-17

By exploiting the superior handling

characteristics and unique delivery

system of CPS, a less invasive, with

minimal osteotomy preparation, and

more predictable trans-alveolar sinus

floor elevation technique, was conceived

Due to the consistency of CPS material,

this technique also helps in minimizing

membrane perforations and associated

adverse events The technique is also an

attempt to reduce the grafting volume to

the minimum while generating adequate

bone volume required for optimal

osseointegration and anchorage of the

implants CPS in unidose cartridges

facilitates precise delivery of the graft

material and controlled elevation of the

sinus membrane Additional advantages of

this technique are reduced chair-side times

and minimal graft wastage

CPS in the cartridge system for sinus

floor elevation offers a more conservative

procedure, localized augmentation of

sinus, and less postoperative morbidity

This technique can be successfully used

for sinus augmentation with immediate

implant placement, as it offers key primary

stability to the implant All these advantages

make TSFE along with the use of calcium

phosphosilicate alloplastic putty (CPS) a

RefeRences

1 Summers RB A new concept in maxillary implant surgery:

the osteotome technique Compendium 1994;15(2):152,

154-156, 158, 162

2 Hernández-Alfaro F, Torradeflot MM, Marti C Prevalence

and management of Schneiderian membrane perforations

during sinus-lift procedures Clin Oral Implants Res

2008;19(1):91-98

3 Engelke W, Deckwer I Endoscopically controlled sinus

floor augmentation A preliminary report Clin Oral Implants

Res 1997;8(6):527–531.

4 Kfir E, Goldstein M, Yerushalmi I, Rafaelov R, Mazor Z,

Kfir V, Kaluski E Minimally invasive antral membrane balloon

Relat Res 2009;11(suppl 1):e83–91.

5 Ahn SH, Park EJ, Kim ES Reamer-mediated transalveolar

sinus floor elevation without osteotome and simultaneous

implant placement in the maxillary molar area: clinical

outcomes of 391 implants in 380 patients Clin Oral Implants

Res 2012;23(7):866–872.

6 Aloy-Prósper A, Maestre-Ferrin L, Peñarrocha-Oltra

D, Peñarrocha-Diago M Bone regeneration using

particulate grafts: an update Med Oral Patol Oral Cir Bucal

2011;16(2):e210-214.

7 Rickert D, Slater JJ, Meijer HJ, Vissink A, Raghoebar GM

Maxillary sinus lift with solely autogenous bone compared

to a combination of autogenous bone and growth factors

or (solely) bone substitutes A systematic review Int J Oral

Maxillofac Surg 2012;41(2):160-167.

8 Kotsakis G, Chrepa V, Marcou N, Prasad H, Hinrichs J

Flapless alveolar ridge preservation utilizing the plug’’ technique: clinical technique and review of the

‘’socket-literature J Oral Implantol November 12, 2012 epub ahead

10 Xynos ID, Edgar AJ, Buttery LD, Hench LL, Polak JM

Gene-expression profiling of human osteoblasts following treatment with the ionic products of Bioglass 45S5

dissolution J Biomed Mater Res 2001;55(2):151-157.

11 Kotsakis G, Chrepa V, Katta S Practical application

of the newly introduced natural bone regeneration (NBR)

concept utilizing alloplastic putty Int J Oral Implantol Clin

Res 2011;2(3):145-149.

12 Mahesh L, Salama MA, Kurtzman GM, Joachim FP

Socket grafting with calcium phosphosilicate alloplast putty:

a histomorphometric evaluation Compend Contin Educ

Dent 2012;33(8):e109-115.

13 Mahesh L, Kotsakis G, Venkataraman N, Shukla

S, Prasad H Ridge preservation with the socket-plug technique utilizing an alloplastic putty bone substitute or

a particulate xenograft: a histological pilot study J Oral

Implantol June 17, 2013 June epub ahead of print.

14 Peleg M, Garg AK, Mazor Z Predictability of simultaneous implant placement in the severely atrophic posterior maxilla: A 9-year longitudinal experience study of

2132 implants placed into 731 human sinus grafts Int J Oral

patients with 3 to 5 mm of residual alveolar bone height Int

J Oral Maxillofac Implants 1999;14(4):549-556.

17 Fermergard R, Astrand P Osteotome sinus floor elevation and simultaneous placement of implants a

1-year retrospective study with Astra Tech implants Clin

Implant Dent Relat Res 2008;10(1):62-69.

viable option for implant placement in the posterior maxilla

Conclusions

The objective of an indirect sinus lift procedure is to increase the height of the vertical bone in the posterior maxilla and provide the opportunity for implant restoration in that area with adequate primary stability of the implant This article

introduces a technique for indirect sinus elevation with the placement of a calcium phosphosilicate putty bone substitute

as a graft material The use of CPS for indirect sinus lift provides a clinically safe and effective option for simultaneous placement of implants that allows for a less invasive approach, less complications, and minimum discomfort for the patient

Figure 5A:The cross-sections reveal the concave anatomy

of the floor of the sinus Also note thickening of the sinus mucosa Significant elevation of the floor of the sinus has

to be performed in the area of the second premolar to allow for implant placement

Figure 5B: The reamer is specially designed to allow for removal of the bony floor of the sinus without perforating the Schneiderian membrane Note the loss of continuity

of bone at the end of the reamer consistent with direct clinical contact of the reamer with the membrane

Figure 5C: Immediate postoperative radiograph shows the sinus elevation achieved was adequate, and both implants were successfully placed using this atraumatic technique

Figure 5D: Seven-month postoperative radiograph demonstrates the trabecularization of the hard tissue at the apex of the implants, in the area of the sinus lift, is almost identical to the trabecularization of the native bone

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As the Baby Boomer population

increases in number and size, so does

the number of edentulous patients, since

tooth loss and age are totally related

Whether it is due to neglect, caries,

medications, or other systemic reasons,

patients are presenting to practices all over

America with their teeth already extracted

However, patients who have been

wearing removable prosthetics for several

years may discover the common denture

problems of instability, sores, and pain

Their dentures no longer fit very well, unless

they incorporate some type of implants

into the plan Implants, whether small or

traditional, allow patients with dentures to

eat and function like they once did when

they had teeth

Endosseous implants have been

successfully used to restore edentulous

ridges with implant-supported fixed

bridges, hybrid prosthetic dentures, and

removable overdenture prostheses for

many years However, due to deficiencies

in the remaining bone, complicated medical

history, or financial reasons, not everyone

is a candidate for traditional-sized implants

Small diameter implants placed with

flapless surgery to support dentures present

an alternative method of restoring patients

with atrophic jaws They dramatically

broaden the spectrum of overdenture

patients who can be successfully treated

These small diameter implants (1.8 mm-3.0

mm) differ from their full-sized counterparts

in a number of significant ways The

configuration of the implant permits a

more conservative placement protocol

No tissue flaps or tapping procedures are

required, which results in fewer traumas

to both gingival tissue and bone Their smaller size also permits placement in ridges that might not otherwise be suitable for full-sized implants

Case history

A woman in her early 60s presented to our office frustrated with her upper complete denture that opposed a lower complete overdenture supported by five dental implants with corresponding Locator®

(Zest) attachments She complained that her upper denture was currently non-retentive, always moving around during eating She was pleased with her lower overdenture, so she requested a similar type of restoration for the upper arch

Palpation and radiographic tion revealed a moderately narrowed maxillary ridge that would not allow adequate width for traditional-sized dental

examina-implants (Figure 1) Because of this, it was decided to get a CT scan to accurately detect the amount and quality of bone remaining in the maxilla

Using a dual scan technique, the patient’s denture was scanned individually

as well as in the patient’s mouth It

is important to note the denture had radiographic markers (gutta-percha points) placed on the facial and palatal aspects

of her existing denture held by sticky wax (Figure 2)

The DICOM file was then seamlessly uploaded to 3DDX.com (3D Diagnostics) for conversion and a treatment planning session using SimPlant (Materialise) With the assistance of the doctor on staff, we identified the most ideal areas for placement

of the implants within the boundaries of the prosthesis (Figure 3) In order to stabilize her maxillary denture, four dental implants would be placed in the premaxilla area to

An affordable overdenture option for an

edentulous ridge

CLINICAL

Dr Ara Nazarian discusses the benefits of a small diameter implant

Figure 1: Preoperative retracted view of maxillary arch Figure 2: Denture with radiopaque markers

Ara Nazarian, DDS, DICOI, maintains a

private practice in Troy, Michigan with an

emphasis on comprehensive and restorative

care He is a Diplomate in the International

Congress of Oral Implantologists (ICOI) His

articles have been published in many of today’s popular

dental publications Dr Nazarian is the director of the

Reconstructive Dentistry Institute He has conducted

lectures and hands-on workshops on esthetic materials

and dental implants throughout the United States,

Europe, New Zealand, and Australia Dr Nazarian is also

the creator of the DemoDent patient education model

system He can be reached at 248-457-0500 or at the

Web site www.aranazariandds.com.

Figure 3: Virtual treatment plan from 3DDX

Figure 5: 1.6 mm pilot drill Figure 6: Paralleling pins

Figure 4: Pilot surgical guide

aid in the retention of this prosthesis Our

selection consisted of four 2.9 mm x 10

mm Zest LODI (Locator Overdenture Dental

Implants) dental implants Once implant

size and location were agreed upon, a

surgical pilot guide was ordered by 3DDX

and fabricated by SimPlant® (Materialise)

(Figure 4)

Freestanding small diameter implants

with attachments like the Locator

Overdenture System (Zest) used to

retain overdentures provide numerous

advantages, including enhanced esthetics,

phonetics, ease of maintenance, low

cost, and simplified hygiene for patients

who don’t have the bone for

traditional-sized dental implants It is important to

remember that this type of prosthesis is

primarily tissue-borne with the implants

providing retention and stability According

to Misch’s classification, this would be a

RP5 restoration

Utilizing the pilot surgical guide for

alignment, a 1.6 mm pilot drill was placed

into the sites and advanced to the full

depth using a surgical motor (AEU-7000E, Aseptico) with generous amounts of cooled sterile water at a set speed of 1200rpm

Once the initial osteotomies were created, the surgical guide was removed The pilot drill was then reintroduced into the sites with a surgical stop ensuring adequate length was achieved (Figure 5)

Paralleling pins (Zest) were placed in the sites of the osteotomies (Figure 6), and

an X-ray taken to check the angulations

to ensure proper orientation among the implant sites Once the osteotomies were completed, four (2.9 mm x 10 mm) LODI dental implants (Figure 7) were placed in the osteotomies using the implant latch driver (Figure 8) set at a speed of 50rpm with a placement torque at 35Ncm until increased torque was necessary The ratchet wrench was then connected to the adapter, and the implants torqued to final depth reaching a torque level of 55Ncm (Figure 9) Since the final seating torque measured over 30Ncm, the implants were immediately loaded

Figure 7: Zest’s LODI implants

BONE GRAFT PERFORMANCE

1 Data on file at Exactech 2 Keller T, et al Carriers may change osteoinductivity of human demineralized bone in

the athymic mouse The 32nd annual Meeting and Exhibition of the American Academy of Dental Research 2003 Mar

Figure 8: LODI implant ready for insertion

Figure 9: Placement of LODI implants

28 Implant practice Volume 6 Number 4

CLINICAL

A 2.5 mm height Locator attachment

was placed onto the implants (Figures

10 and 11) with a white block out spacer

ring and Locator denture cap (Figure 12)

Utilizing a marking stick (Dr Thompson’s

Marking Sticks), we identified the areas

in the denture that would require removal

for the overdenture housings Once

relieved, Quick Up Test C&B silicone

(VOCO America) was injected into the

overdenture recesses The overdenture

was seated over the attachment caps and

the Quick Up Test C&B (VOCO America)

was allowed to set before the overdenture

was removed Any interference that was

detected between the denture base and

attachments was checked and eliminated

(Figure 13)

Adhesive was added to the cleaned

and dried recesses (Figure 14) that we

created in the denture and filled with cold

cure acrylic (Quick Up, VOCO America)

[Figure 15] Additionally, Quick Up material

was also placed onto the Locator caps

(Figure 16) The denture was then

seated onto the implants and allowed to

polymerize Upon setting, the denture

was relieved of any excess flash (Figure

17) The patient was very pleased with the

fit, function and esthetics of the modified

denture prosthesis The Panorex X-ray of

the implants depicted an ideal placement

(Figure 18)

With the addition of small diameter implants such as the Locator Overdenture Implants, thin ridges can now benefit from denture stabilization with the huge benefit of the Locator (Zest) overdenture attachment system Some of the advantages of the Locator (Zest) attachment system include

a self-aligning feature, dual-retention, and

Figure 14: Placement of adhesive for pick-up material Figure 15: Placement of Quick Up into denture

Figure 16: Placement of Quick Up onto Locator caps Figure 17: Denture with picked up housingsFigure 13: VOCO’s fit test check

Figure 11: Locator attachments tightened onto implants Figure 12: Locator caps with block out ringsFigure 10: 2.5 mm gingival height Locator attachment

one of the lowest implant attachment profiles available Most importantly, these small diameter implants give dentists and their patients an easy, less expensive, and rapid way of solving many of the difficult problems that arise with complete dentures IP

Figure 18: Final panorex

©2013 Zimmer Dental Inc All rights reserved * Data on file with Zimmer Dental

Please check with a Zimmer Dental representative for availability and additional information.

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For 5 years, these prestigious awards have become renowned for

recognition of products and services that impact clinicians and

demonstrate excellence Pride Institute’s “Best of Class” Technology

Awards, created by Dr Lou Shuman, President of Pride Institute,

are determined through thoughtful, unbiased discussion by a panel of

dental professionals The distinguished panel of experts works all year

assessing products, culminating in a spirited and honest debate and final

decision process that occurs annually at the Chicago Midwinter Meeting

The winning technologies can have a profound impact on purchasing

decisions by the dental community, leading to better patient care and

more effective practice management The Awards allow a variety of

products — obscure, well-known, basic, and aspirational — the chance

to be honored “I am very proud of the integrity and unbiased selection

process provided by our panel,” said Dr Shuman “Not every category

has a winner – only those products that are truly differentiated from

the competition The purpose of these awards is to provide the dental

community with products of excellence that will have the greatest impact.”

Implant Practice US congratulates the 18

winners of Pride Institute’s “Best of Class”

• Align Technology Smart Track

• DEXIS Imaging Suite and DEXIS go

• Doxa Ceramir

• Gendex SRT Technology

• Glidewell Laboratories BruxZir Shaded

• HealthFirst Tru-Align

• Imaging Sciences Int’l i-CAT® FLX

• Isolite IsoDry

• Kerr Dental SonicFill

• Lexicomp® Online™ for Dentistry featuring VisualDx Oral

• Liptak Dental DDS Rescue

• Orascoptic XV1

• SciCan STATIMG4

• Sesame Communications Sesame 24-7

• Ultradent VALO

• Lou Shuman, DMD, CAG — President

of Pride Institute, Best of Class founder

• John Flucke, DDS — Writer, speaker, and

Technology Editor for Dental Products Report

• Paul Feuerstein, DMD — Writer,

speaker, and Technology Editor for Dental

Economics

• Parag Kachalia, DDS — Vice-Chair of

Preclinical Education, Research and Technology,

University of Pacific School of Dentistry

• Marty Jablow, DMD — Writer and speaker

• Larry Emmott, DDS — Writer, speaker, and Technology Editor for dentalcompare.com

• Titus Schleyer, DMD, PhD — Associate Professor and Director, Center for Dental Informatics at the University of Pittsburgh, School of Dental Medicine

2 0 1 3

THE DISTINGUISHED PANEL

2013-2014 HONOREES

IP

Previously, this series has looked at some

of the factors that the predictability

of the esthetic outcome of an implant

restoration is dependent on, including:

This article will look at the considerations

for multiple implants

Considerations for multiple

implants

Patients with extended edentulous spaces

present greater anatomic and esthetic

challenges, making it even more difficult to

obtain an esthetic result with certainty

Following extraction and wound

healing of two adjacent teeth, the ensuing

apical and faciolingual resorption results in

an edentulous segment that is flattened

The same diagnostic considerations need

to be addressed as when looking at single-tooth edentulous sites

The aim prior to implant placement is

to have a three-dimensional configuration

of hard and soft tissue, which will allow

placement of implants in an ideal position

The placement of two missing central

incisors poses an additional challenge

Following surgical placement, additional

peri-implant bone remodelling takes place

In the frontal plane, two processes occur –

one between the implant and the adjacent natural tooth and one between the two adjacent implants

On the tooth-implant side, the predictability of the interdental papilla is governed by the height of the interproximal bone crest of the tooth If this height is favorable, there is a good certainty that the interdental papilla will be maintained following implant placement The bone crest between the two implants is likely

to undergo further resorption in an apical direction This is accompanied by a loss

of inter-implant soft tissue that, in the case

of multiple edentulous sites, will result

in black triangles between the adjacent restorations

Tackling adjacency

Many clinicians have sought after the ideal implant distance required to maintain the interdental papilla Tarnow, et al., (2000), performed a radiographic study to address this clinical problem Radiographic measurements were taken at a minimum

of 1 and 3 years after implant exposure All radiographs were taken with a paralleling technique

Radiographs were computer scanned, imaged, and magnified for measurement

Treatment planning of implants in the esthetic zone: part three

CONTINUING EDUCATION

In the final part of the series, Drs Sajid Jivraj, Mamaly Reshad, and Winston Chee look at the

considerations for multiple implant placement

Figure 1: When implants are placed 3 mm and greater apart, the bone loss from the adjacent implants does not overlap, resulting in minimal crestal bone loss (modified from Tarnow, et al., 2000)

Sajid Jivraj, DDS, MSEd, is clinical associate professor

at Herman Ostrow USC School of Dentistry in Los

Angeles, California He is a board member of the British

Academy of Restorative Dentistry and honorary clinical

teacher at Eastman Dental Institute London, England

He owns a private practice in Ventura, California.

Mamaly Reshad, BDS, MSc, is honorary clinical teacher

at Eastman Dental Institute London, England He works

in private practice at 30a Wimpole Street, London.

Winston W.L Chee, DDS, FACP, is the Ralph and Jean

Bleak Professor of restorative dentistry, director of

implant dentistry, and the co-director of the advanced

prosthodontics program at the Ostrow School of

Dentistry of the University of Southern California.

Educational aims and objectives

This article aims to highlight the specific considerations that must be kept in mind when placing multiple implants.

Expected outcomes

Correctly answering the questions on page 41, worth 2 hours of CE, will demonstrate the reader can:

• Understand the mechanism of bone loss.

• Learn the best way to plan soft tissue management.

• See how to approach cases for a predictably esthetic result.

Figure 2: When implants are placed too close together, bone loss from adjacent implants overlaps, resulting in additional loss of the crestal bone (modified from Tarnow,

et al., 2000)

Figure 3: Bone loss is circumferential around the implants

When implants are placed too close together, the vertical and horizontal components of bone loss compromise the peak of the interproximal bone and thus the resulting soft tissues

Figure 4: Ideal implant theoretically will maintain the interproximal peak of bone; however, there are no long-term studies to support this