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clinical articles • management advice • practice profiles • technology reviews REACH FOR THE BETTER GRADE

June/July 2017 – Vol 10 No 3

High-performance polymers Drs. Paul Tipton and Bernd Siewert

Using OsteoGen® Strips to graft the gap around an implant: a case study Dr. Charles D. Schlesinger

Implant surgery in the mandible — a summary of recent research findings Drs. Cemal Ucer and Eddie Scher

The Proximator The instrument you wish you always had.

PROMOTING EXCELLENCE IN IMPLANTOLOGY

Company spotlight Karl Schumacher Dental, LLC

Corporate profile Boyd Industries, Inc.

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION CREDITS PER YEAR!

Category: Oral Surgery & Implant Hand Instruments

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Fixed for the patient. Easily removed by the clinician. LOCATOR F-Tx® is a simplified, time-saving solution for full-arch restorations with no compromise to prosthesis strength or esthetics. Optimized for efficiency and chair time savings compared to conventional screw-retained systems, LOCATOR F-Tx features a novel, “snap-in” attachment that eliminates the need for sub-gingival cement or screw access channels. LOCATOR F-Tx is the latest innovation from Zest Dental Solutions expanding treatment options for the edentulous patient— with less chair time and higher patient satisfaction. To learn more, please visit our website at www.zestdent.com/FTx or call 800.262.2310. ©2017 ZEST Anchors LLC. All rights reserved. ZEST and LOCATOR F-Tx are registered trademarks and Zest Dental Solutions is trademark of ZEST IP Holdings, LLC.

June/July 2017 - Volume 10 Number 3

EDITORIAL ADVISORS Steve Barter, BDS, MSurgDent RCS Anthony Bendkowsk,i 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 Mark Hamburger, BDS, BChD Mark Haswell, BDS, MSc Gareth Jenkins, BDS, FDS RCS, MScD Stephen Jones, BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack, DDS, CertPerio, FCDS Samuel Lee, DDS David Little, DDS Andrew Moore, BDS, Dip Imp Dent RCS Ara Nazarian, DDS Ken Nicholson, BDS, MSc Michael R. Norton, BDS, FDS RCS(ed) Rob Oretti, BDS, MGDS RCS Christopher Orr, BDS, BSc Fazeela Khan-Osborne, BDS, LDS RCS, BSc, MSc Jay B. Reznick, DMD, MD Nigel Saynor, BDS Malcolm Schaller, BDS Ashok Sethi, BDS, DGDP, MGDS RCS, DUI Harry Shiers, BDS, MSc, MGDS, MFDS Harris Sidelsky, BDS, LDS RCS, MSc 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-inchief 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

© FMC 2017. 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 reproducedvw 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.

Volume 10 Number 3

ducation is evolving. The fast-paced development in technology and medical sciences has created an environment of exponential information. No longer are the days where a clinician’s educational degree is enough preparation for a lifelong career. Continuing education is growing at an ever-increasing speed and is not limited to dentistry. Today’s clinician seeking dental implant education has a plethora of choices. Many of the implant courses offered are 1- or 2-day programs on a particular topic, often taking place over a weekend. While many see these courses as a convenient way to fit education into their busy schedule, there’s a downside to this arrangement. Getting all this informational overload can often become confusing and hard to assimilate into a clinician’s practice. When I was first introduced to implantology in 1982, I was fortunate enough to have practiced under a mentorship with an experienced implantologist for 3 years. Unfortunately, there were no formal courses or programs back then, so I had to take as many courses as I could. There were no continuums courses back then, only technical training courses offered by implant companies. Today’s young clinician has many more educational opportunities to get involved in implant dentistry. When considering implant continuing education, it’s important for a clinician to realize that choosing a continuum educational program will set his/her implant foundation. Comprehensive programs such as the American Academy of Implant Dentistry’s (AAID) MaxiCourses® are excellent examples of a continuum course, which offer a solid foundation for successful integration of implant dentistry into a clinician’s practice. MaxiCourses® programs are 300-plus hour programs, designed to position the participants to become proficient in all aspects of implant dentistry. Credentialed members who are board certified by the American Board of Oral Implantology give these courses throughout the world. As Director of both the New York and Las Vegas AAID MaxiCourses®, I have personally witnessed the growth that these programs have provided to hundreds of participants. Programs such as the MaxiCourse®, focusing on the basic sciences, academic materials, clinical case reporting, hands-on exercises, and live surgical experiences, are the highest level of implant education. Repetitive learning over a 1-year curriculum really helps. Students who have taken many weekend courses come to our program and say, “Wow, now I’m starting to understand it!” These programs encourage participants to go to their practices and look at real-life situations. The intent is for the doctors to be able to perform implants in their own practices in a predictable manner. The AAID MaxiCourse® provides the CE hours necessary to fulfill the CE requirement of the Fellow Membership process of the AAID. The AAID credentials both specialists and general dentists. Today, everyone claims to be performing implant dentistry. The Diplomate credential of the American Board of Implant Dentistry is the highest recognition of implant credentialing. Credentialing is a way for dentists to separate themselves from the pack. Technological advancements will continue to make the placement and restoration of dental implants easier and more precise. Within the next decade or two, the placement of implants will be as much a part of the average general dentist’s menu of services as fillings, extractions, and cleanings. CT scanning and surgical guides are making things a little less complicated, and as more doctors get trained and the technology continues to evolve, they’ll be able to provide these services. The dental profession in general needs more comprehensive continuing education courses, such as the AAID MaxiCourses®, so that everyone has a better understanding of all the diagnostics, intricacies, and surgical techniques in the field of implantology. We still need to work together in multi-specialty settings. Doctors need to be able to identify which cases are more straightforward and which should be in the hands of more experienced implant dentists. Implant dentistry is evolving, and many dentists are going to be performing implant procedures in the future. Those who have the proper training will be much more successful, providing safer treatment to the public. I look forward to seeing even more dentists properly trained and tested so that both the profession and the public know who’s qualified to perform these procedures. John C. Minichetti, DMD John C. Minichetti, DMD, is a Fellow of the Academy of General Dentistry and the American Academy of Implant Dentistry, and a Diplomate of the American Board of Oral Implantology/Implant Dentistry. He is an Attending at Englewood Hospital, Jersey City Medical Center, and St. Barnabas Medical Center. Dr. Minichetti is Past President of the American Academy of Implant Dentistry, President of the Bergen County Dental Implant Study Group, and Board Member of the American Board of Oral Implantology, as well as Director of the New York AAID MaxiCourse® at St. Barnabas Medical Center, and Director of the Las Vegas AAID Maxicourse® at UNLV, School of Dental Medicine.

Implant practice 1

INTRODUCTION

The new era of implant education: separating yourself from the pack

TABLE OF CONTENTS

Corporate profile Boyd Industries, Inc.

Built to Last. Built for You. Built by Boyd!

Technique Using OsteoGenÂŽ Strips to graft the gap around an implant: a case study Dr. Charles D. Schlesinger discusses a method for addressing the gap between an implant body and the residual socket................................ 14

Company spotlight

Karl Schumacher Dental, LLC Making a difference in dental instruments for 70 years ON THE COVER Cover photo courtesy of Dr. Charles D. Schlesinger. Article begins on page 14.

2 Implant practice

Volume 10 Number 3

Neither is the anatomy of your implant patients

Astra Tech Implant System® OsseoSpeed® Profile EV – for sloped ridge situations Your world is already full of clinical challenges so why work harder because of conventional thinking? Instead of augmenting sloped ridges to accommodate flat-top implants, it’s time to discover a simpler solution by using an implant that follows the bone. Because sloped-ridge situations call for anatomically designed sloped implants.

It’s time to challenge conventional thinking

www.profiledentalimplants.com

Conventional vs innovative approach

OUR WORLD IS NOT FLAT

TABLE OF CONTENTS

Continuing education Continuing education High-performance polymers Drs. Paul Tipton and Bernd Siewert look at a new material for framework fabrication and consider processing methods, pressing versus milling, and the long-term findings...................32

Implant surgery in the mandible â€” a summary of recent research findings and a protocol of risk management

Drs. Cemal Ucer and Eddie Scher summarize a recent series of papers to provide an evidence-based protocol for implant placement in the mandible

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com

Industry news.............37

MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com | Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com NATIONAL SALES DIRECTOR | Kristin Sammarco Email: kristin@medmarkaz.com NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez Email: celeste@medmarkaz.com CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: agood@medmarkaz.com

Practice development On the horizon The importance of website lead conversion

Esthetic failures start as soon as we fail to plan

Ian McNickle, MBA, discusses how your website can lead patients to your practice...............................38

Dr. Justin Moody discusses how to save time and money and reduce stress.........................................40

CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkaz.com WEBSITE MANAGER | Anne Watson-Barber Email: anne@medmarkaz.com E-MEDIA PROJECT COORDINATOR | Michelle Kang Email: michellekang@medmarkaz.com FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.implantpracticeus.com | www.medmarkaz.com SUBSCRIPTION RATES 1 year (6 issues) $149 | 3 years (18 issues) $399

4 Implant practice

Volume 10 Number 3

IMPLANTING CONFIDENCE

WORKFLOW INTEGRATION I HUMANIZED TECHNOLOGY I DIAGNOSTIC EXCELLENCE

With open-format image files, implant planning has never been easier. Carestream Dental’s digital imaging and implant planning software simplifies your workflow, allowing you to easily scan your patients and plan the implant placement. Plus, integration with third-party surgical guide software makes placing implants easier than ever.

For more information, call 800.944.6365 or visit carestreamdental.com

CORPORATE PROFILE

Boyd Industries, Inc. Built to Last. Built for You. Built by Boyd!

oydâ€™s tag line is more than an attentiongetting catchphrase: It signifies the commitment that everyone at Boyd makes to each and every one of its customers. From its team on the factory floor to its sales professionals in the field, the company is united in its passion for quality and customer service. It starts by listening to customers about ways to continually improve Boyd products to the consultative doctor-direct sales approach. By keeping the doctors and their staffs at the forefront of its actions, the entire Boyd team works in unison. Founded in 1957 in Pinellas County, Florida, Boyd has been best known for the durability and reliability of its awardwinning dental equipment products. Boyd has accomplished this by combining 60 years of design and manufacturing expertise to create personalized products that match the dreams of the doctors they serve. Over the years, Boyd has been known as a thought leader in the design and

manufacture of exam and treatment chairs, delivery systems, and custom cabinetry for dental specialists. The company has excelled at creating highly efficient yet esthetically pleasing office environments. The coupling of these two characteristics with a powerful reputation for producing high-quality and durable products has been the legacy of the company. Boyd has helped thousands of customers to work with confidence due to the reliability of their Boyd operatory equipment. The design concepts of its cabinetry, durability of its chairs and side units, and variety of office accessories help Boyd customers to be more competitive in the growing landscape of dentistry.

Leadership transition Boyd entered a new phase of its business development in 2012 when it was acquired by Adrian LaTrace, its current Chief Executive Officer. Upon joining the company, Adrian LaTrace, CEO

Boyd factory 6 Implant practice

Volume 10 Number 3

CORPORATE PROFILE

LaTrace set out on a plan to leverage his more than 20 years of manufacturing and construction experience to position Boyd for the future. Having held senior management and executive positions at companies such as Gulfstream Aerospace, Knowles Electronics, and Acciona Windpower, he learned the business requirements to produce highly reliable and technically complex products while keeping an eye on style and design. Since 2012, the company has assembled an entrepreneurial leadership team, invested in upgraded business and manufacturing computer systems, expanded its sales force, and achieved the ISO13485:2016 international quality certification. Each of these initiatives better positions Boyd for the future and continued growth. Besides LaTrace, the company’s leaders bring a wide range of skills and talents to the company to provide the professionalism needed to move the business forward. Although the diversified leadership team provides contrasting perspectives to meeting current and future challenges, it does share a common set of values — Integrity, Dependability, Innovation, Loyalty, and Respect — with which they lead their respective teams. By embodying a shared set of values, the team works together toward a singular mission to build highly reliable products that assist dental professionals provide high quality patient care.

Members of the Boyd sales team

Dedicated sales force Boyd’s sales philosophy is to supply products and services that add value for its thousands of customers. To accomplish this, the company uses a doctor-direct sales approach to support its customers through a team of sales professionals across the country. This is unique and differentiates Boyd from many other office equipment manufacturers in the industry. By using this sales approach, as an original equipment manufacturer (OEM), the company can connect directly with its customers to build trust and confidence between them, the sales team, and the company products. The trust forged between Boyd and its customers in many cases has lasted for over 25 years. Its network of Boyd sales representatives around the United States works directly with doctors and their staffs to design and specify Boyd products. This collaboration helps the customers to create unique office environments that bring their vision of the office to life. “My sales team and I find a great deal of personal satisfaction when we see a doctor’s Volume 10 Number 3

Members of the Boyd manufacturing team

dream office turn into a reality with Boyd’s help,” says Kurt Schwarz, Boyd’s Vice President of Sales. In addition to the in-field territory sales representatives, the company’s Clearwater-based Account Management team supports practices outside of its sales representative’s territories, international customers, universities, and government accounts. Each sales team member completes product, quality, and systems training at the Boyd factory in Clearwater upon joining the company. This way, the sales team member fully understands the methods used and reasons for the ways the products are manufactured and configured. Training continues after completing the factory training. This is accomplished by using a mentor system where a new salesperson is assigned an experienced sales mentor to help with questions and serve as an advisor once the new sales team member is working in the field. This way the customer gets the benefit of

dedicated salesperson with support from a sales mentor and the Clearwater team.

Manufacturing process The company can supply a complete suite of operatory equipment comprised of chairs, delivery systems, stools, exam lights, as well as office cabinetry for sterilization, labs, records, and other cabinetry for a busy dental office. All equipment and cabinetry is manufactured at its Clearwater, Florida, factory by a skilled team of technicians and craftsmen. What distinguishes Boyd from other manufacturers is the company’s capability to customize or “personalize” its products to meet the customer’s functional and styling characteristics. This is accomplished by using a build to order/configure to order manufacturing system. This means Boyd does not prebuild products to stock, but instead using the MS Dynamics ERP Implant practice 7

CORPORATE PROFILE business system processes the customer order in accordance with the details provided by the customer to the sales team member. As mentioned previously, Boyd’s sales members are trained to assist doctors in deciding on the right product configurations for their practice. Once the doctor decides on the details, the information is entered as a quote that is presented to the customer for final approval. Using MS Dynamics, the approved quote is converted into a sales/ manufacturing order that is submitted electronically to the factory floor. By employing a fully integrated cloud and premise-based business system, it reduces the chance of an order error and shortens lead times for the manufacturing process. If the product requested is completely customized as in office cabinetry, Boyd has in-house designers to assist from concept to finished product. The company’s designers use a 3D computer-aided design (CAD) system to provide the customers with drawings reflecting the look and dimensions specific to their office. The company offers a broad selection of cabinet laminate choices from Wilsonart®, Nevamar®, Formica®, and others that will meet the customer’s styling

and/or branding requirements. In addition, the company provides countertop solidsurface products from Corian and Silestone to complement the laminate selection. Boyd’s factory is organized as a vertically integrated facility. This means Boyd manufactures almost all components used in the finished product at the Clearwater factory. The production team cuts, sews, and attaches all upholstered items; has a high-capacity metal machining department to cut, mill, or turn the many steel components used in the chair products; welds and powder-coat paints steel chair frames and other metal subassemblies, thermoforms Kydex plastic used for covers and parts; and has a fully equipped cabinetry department with computerized wood-cutting equipment. The company believes by maintaining these important manufacturing processes in-house, it can better control the quality and availability of the many thousands of items it needs to produce its products.

Wide range of dental equipment products Boyd has a wide choice of products for dental specialists. Boyd’s products are

specially designed for the dental specialist — orthodontics, oral and implant surgery, pediatric dentistry, endodontics, and others. The company still makes procedure chairs for legacy product lines such as dermatology and hair transplant markets but considers dentistry as its core market. All Boyd medical device products — dental exam and treatment chairs, surgical tables and chairs, delivery systems, and exam lights — are listed with the FDA and have passed either ETL or UL electrical and safety standards certification. This is an important distinction when investing in equipment for dental office or clinic. The Orthodontic products line features an array of exam and treatment chairs, side delivery units, exam lights, stools, and other accessories. The flagship products in the orthodontic line are the M3000LC Treatment Chair, M3010LC Exam Chair, CSU356FLM side delivery unit, and C300 Exam Light. These products have become the mainstay of hundreds of orthodontic offices across the country. The Oral and Implant Surgery product line is comprised of surgery chairs and tables, operatory carts, and surgery light.

NOVA Pediatric Dentistry & Orthodontics in Ashburn, Virginia 8 Implant practice

Volume 10 Number 3

It’s More Than Our Chair. It’s Our Promise To You. We know that the future of oral surgery rests solidly in the skilled,

talented hands of professionals like you, oral surgeons providing the compassionate, trusted, advanced care their patients deserve.

That’s why our promise is to

craft every Boyd chair to be worthy of all that you stand for. And we honor our promise by using the finest materials, making our chairs affordable, building each one in our own factory in the US, further ensuring its durability with the most rigorous quality control, while giving you the highest level of customization.

And all this is accomplished

by Boyd craftsmen who are as committed to excellence — and to the future of oral surgery — as you are.

Exam and Surgery Chairs, Surgical Tables, Cabinetry and Other Operatory Equipment

Built to last. Built for you. Built by Boyd.

800-255-2693 727-561-9292 Fax: 727-561-9393

www.boydindustries.com

Boyd Industries 12900 44th Street N, Clearwater, FL 33762 © BOYD INDUSTRIES 2017

1957 – 2017

CORPORATE PROFILE

Over the years, Boyd has been known as a thought leader in the design and manufacture of exam and treatment chairs, delivery systems, and custom cabinetry for dental specialists.

S2615 Oral Surgery procedures chair

Among these products, the S2614 and S2615 procedures chairs are the most popular with oral surgeons. These chairs are similar in configuration with the S2614 being a drop-toe version of the S2615 fixedtoe model. The Pediatric Dentistry product line includes the M3000CB Treatment Chair, PB4001 Pedo Bench, standard and custom rear delivery units, and recently introduced Concealed Delivery Unit. Boyd’s products offer options for doctors who may see a wide range of age groups. Introduced at last year’s AAPD show, the Concealed Delivery Unit is unique because the delivery system can be hidden within the cart prior to and after procedures. Since the CDU’s launch, the company has seen demand for the system increase particularly with pediatric dentists. According to Adrian LaTrace, “The CDU was created out of our intimate understanding of the needs of pediatric dentists. This started by listening to their needs and designing a product to meet them. The CDU is a perfect example of this collaboration.”

What’s next at Boyd? LaTrace and his team are proud of their recent accomplishments but remain focused on Boyd’s future. He sees the dental specialist market continuing to expand particularly in implant surgery and pediatric dentistry. The demographic shift underway with the population of baby boomer retirees increasing 10 Implant practice

M3100LC Endodontic Treatment chair

bodes well for the dental implant market. With innovative technologies to make implant surgery more efficient and convenient, this segment of the dental industry should see many more years of growth. The pediatric dentistry market will grow due the heightened focus on good dental hygiene at a younger age. As millennials and other recent generations become parents, they want to assure their children receive the benefits of good dental care. LaTrace sees Boyd well positioned to meet the needs of these growing markets. In 2017, the company entered the endodontic market launching its first treatment chair product, M3100LC, specifically designed for endodontists. Like all the company’s other exam and treatment chairs, the M3100LC was designed using proven technology for reliability and ergonomics. The Boyd team sees the endodontic market as a natural extension of the company’s support of dental specialists.

The company will attend AAE 2017 to introduce the new product. Beyond the domestic market, Boyd plans to grow its international customer base. The company currently exports to Canada and several European Union countries and sees an opportunity grow its international business in the coming years. Achieving ISO 13485:2016 certification was an important first step toward this goal. The ISO certification helps the company to meet the regulatory requirements of many of the countries in which it intends to market its products. In short, Boyd looks to strengthen its market leadership in the specialty dental market both in the U.S. and abroad. There is excitement at Boyd about the future of the company. The team looks to hold true to its legacy for producing durable, innovative, and customized equipment for the next 60 years. Built to last. Built for you. Built by Boyd! IP This information was provided by Boyd Industries, Inc.

Volume 10 Number 3

COMPANY SPOTLIGHT

Karl Schumacher Dental, LLC Making a difference in dental instruments for 70 years

t takes a solid foundation, continuous innovation, and a tremendous understanding of the customer’s needs for a company to go strong 70 years after it was started. In 1947, Karl Schumacher established Karl Schumacher Dental, LLC, and said, “I am only interested in two things — quality and consistency.” Those principals continue to be the focus at Karl Schumacher Dental, from the engineering of a high-quality dental instrument to personal, one-on-one relationships with dentists.

The legacy From the early days of his career, Karl Schumacher was an innovator. He worked as a representative for German steel manufacturer, Krupp. During Mr. Schumacher’s time with the company, he gained extensive knowledge of specialty steels. This led to an opportunity to work with an oral surgeon to create one of the earliest steel bone-plating systems. Mr. Schumacher believed it was important to not just talk to dentists about the product, but to personally travel the country

Proximator, exclusively from Karl Schumacher Dental Volume 10 Number 3

and call on dentists to understand their needs. He combined the knowledge he gained from dentists with his remarkable attention to detail for assurance of customer satisfaction.

Feel the difference The legacy Mr. Schumacher left behind carries forward today with a rich tradition of experience. Seven decades after he formed the company, Karl Schumacher Dental provides dental surgical instruments and products that are used by leading dentists nationwide. At Karl Schumacher Dental, the goal has been and continues to be for every dental practitioner to achieve greater procedural efficiency and optimum patient outcomes using the instruments. The company adheres to the strictest specifications when developing instruments. The difference in Karl Schumacher Dental instruments is shown through the specialized engineering, research, and detailed craftsmanship applied to every instrument, from the award-wining Proximator™ to the RoBa™ Forceps. It is that attention to the

Karl Schumacher, founder of Karl Schumacher Dental

craftsmanship that earned a Townie Choice Award 8 years in a row for the Proximator™ in the Oral Surgery and Implant Hand Instruments category. Since the beginning, the company has created instruments by hand to provide precise detail. This method allows products like the forceps to have a more aggressive serration pattern, a more tapered profile to fit in tight spaces, and serrations that assist when applying rotational and axial forces. Using the finest materials and devoting the time for a handcrafted design allow for

Aetranox Upper Universal RoBa Forceps and Diamond RoBa Upper Universal Forceps Implant practice 11

COMPANY SPOTLIGHT the creation of finer tips, a better size, and unmatched strength. Quality materials led to the development of the RoBa™ Diamond edition forceps, which have a superior grip in all applications, including wet conditions. At Karl Schumacher Dental, the focus on engineering always ties back to customer needs. As dental surgeons use the instruments, there is a responsive feel in the grip that enables a previously unreachable level of accuracy and less hand fatigue. Designed to optimize office and procedural efficiency, Karl Schumacher Dental kits and sterilization cassettes provide everything necessary for specific diagnostic, restorative, and dental surgery procedures.

Dentists want their instruments to offer quality performance and productivity during each procedure. Karl Schumacher Dental works closely with esteemed dentists who share industry expertise for continuous improvement of instruments. “You can only do the best work if you have the best,” Dr. Jay Reznick, DMD, MD, said. “The best analogy is in the kitchen. If you’re trying to cut a piece of steak with a cheap knife, versus a good knife, you can absolutely feel the difference. And the same when it comes to surgery. I think it’s important to invest more upfront, because the return will come back multiple times over when you are more efficient with good instruments.”

Instruments of a better grade Karl Schumacher Dental collaborates with a prominent group of leaders in the dental industry for their valuable insight to develop innovative products that are responsive to the needs of dentists. These distinguished professionals are renowned for their work, and they generously consult with the Karl Schumacher Dental team on the development of new and custom-designed products. The guidance and feedback from these key opinion leaders, combined with decades of high-quality engineering and craftsmanship, ensure Karl Schumacher Dental instruments are of a better grade.

Protecting a long-lasting dental instrument Even with the finest instruments, proper care ensures it will be a long-lasting instrument. Karl Schumacher Dental recommends using the Instrument Reprocessing Cycle. Once a new instrument is received, there should be an initial cleaning to remove any oils and compounds from manufacturing. With any stainless steel dental instruments, never use corrosive cleaning agents or abrasive cleaners. Within 15 minutes of using the instrument on a patient, rinse the instrument. Then, remove any debris with a recommended, light detergent, and follow with cleaning using an enzymatic solution. Inspect the instrument for thorough cleanliness. If further cleaning is necessary, manually scrub the instrument with a nylon brush, and return to the cleaning process again. This process will maintain the high quality of Karl Schumacher Dental instruments.

A commitment to quality and consistency It was Mr. Schumacher who said he’s interested in two things: “quality and consistency.” Seventy years later, the company he started continues to guarantee that quality with a warranty on all instruments, a sharpening and repair program, and a lifetime warranty on all dental extraction forceps. When Mr. Schumacher visited dentists, he formed a commitment by signing his name to demonstrate he personally promises an instrument of the finest quality that is made to last. His signature remains the Karl Schumacher Dental logo to this day, as a continued commitment that the company stands behind every high-quality instrument and product. IP Joe Mehranfar, DDS, MS, using Karl Schumacher Dental instruments 12 Implant practice

This information was provided by Karl Schumacher Dental, LLC.

Volume 10 Number 3

REACH FOR THE BETTER GRADE

Celebrating 70 Years

MINIMIZE SURGICAL TRAUMA PrecísPOINT™ Suture Needles are engineered and manufactured with the same precision that makes Karl Schumacher a leader in the dental industry for 70 years.

Less Tissue Drag

PrecísPOINT SUTURES TM

Premium Surgical Wound Closure

Exceptional Strength

Finer Point Geometry

Reach for the better grade. Karl Schumacher PrecísPOINT ™ Suture Needles are made from 300 series stainless steel, the gold standard material for suture needles. They minimize the degree of trauma caused by dental surgery by using noticeably sharper needles.

(800) 523-2427

w w w.karlschumacher.com

TECHNIQUE

Using OsteoGen® Strips to graft the gap around an implant: a case study Dr. Charles D. Schlesinger discusses a method for addressing the gap between an implant body and the residual socket

oday’s implant patient wishes to decrease overall treatment time as much as practitioners. Due to this fact, we are more frequently placing implants at the same time as an extraction is being done. By placing the implant at the same time as the extraction and not grafting first, there is a 4-6 month decrease in overall treatment time when compared to the later. Most roots differ in both length and three-dimensional form when compared to the typical cylindrical root-formed implant.

without any intervention by the practitioner. In fact, it has been shown that it is possible to have complete fill-in with a gap up to 4.2 mm, but this is not predictable.5 There are many materials on the market that are used to successfully fill this gap. Allograft, xenograft, and alloplastic materials all work, so it will come down to the clinical advantages and disadvantages of these materials along with their corresponding handling characteristics.

Grafting the gap

The OsteoGen® Strips (Impladent Ltd.) are a combination of OsteoGen® non-ceramic bone graft crystals with bovine Achilles tendon collagen. The graft material is homogenously mixed with the collagen to create pliable sheets, which simplify placement and delivery of the graft while virtually eliminating the chance of particulate wash out. OsteoGen® Strips (Figure 1) were developed specifically to address clinical issues surrounding extraction/immediate placement of implants. The graft inside these Plugs and Strips is OsteoGen®, a bioactive, non-ceramic (un-sintered) calcium-phosphate based

Much has been written regarding how to manage the “gap” that results when an implant is placed in an extraction socket. When a dental implant is placed into a fresh extraction socket, the space between the implant periphery and surrounding bone is called the gap or jumping distance.1 Bone fill in the gap between the implant and the peripheral bone is important. The buccal aspect of an implant is of great concern, especially in the esthetic zone because the buccal bony plate is usually thin, and its resorption can result in soft tissue recession.2,3,4 The horizontal gap, if less than 2 mm, will likely fill in

OsteoGen® Strips

graft with physicochemical properties similar to human bone mineral. The unique low temperature production process generates osteoconductive and resorbable low density crystals and crystal clusters with a unique calcium-tophosphate ratio that is neither a beta-tricalcium phosphate nor a dense non-resorbable ceramic hydroxyapatite.6,7,8 OsteoGen® is highly hydrophilic, has been used as a particulate graft material since 1984, and has documented clinical success for use with implants in periodontal procedures,9,10 general osseous repair,11 and sinus lifts, including a decadelong longitudinal study of implant survival and success rates.12,13,14,15 The OsteoGen® Strips are radiolucent on the day of placement given their low-density properties; therefore, it is easy to follow the healing process radiographically as the site changes from radiolucent to radiopaque as the material is replaced by native bone over the course of 3-6 months.

Case study A 63-year-old male with a non-contributory medical history presented with an endodontically treated upper right first bicuspid with recurrent decay (Figures 2 and 3). The tooth was evaluated clinically, and the pros and cons of trying to restore the tooth

Figure 1: OsteoGen® Strip

Charles Schlesinger, DDS, FICOI, is a dental implant educator and clinician who has been lecturing internationally for the past 10 years. He graduated with honors from The Ohio State College of Dentistry in 1996. After graduation, he completed a General Practice residency at the VAMC San Diego and then went on to become the Chief Resident at the VAMC West Los Angeles. During his time in Los Angeles, he completed extensive training in oral surgery, implantology, and advanced restorative treatment. Once he completed his residency, Dr. Schlesinger maintained a thriving restorative and implant practice in San Diego, California for 14 years. In 2012, he relocated to Albuquerque, New Mexico to become the Director of Education and Clinical Affairs for OCO Biomedical. In 2013, he took over as Chief Operating Officer of OCO Biomedical along with his clinical responsibilities. In 2016, Dr. Schlesinger left OCO Biomedical and founded The CD Schlesinger Group, LLC, to help practitioners gain knowledge and experience with implants and became a Key Opinion Leader for The Hahn Implant System. Additionally, he continues to provide comprehensive implant care to patients in a private practice setting in Albuquerque, New Mexico. Disclosure: Dr. Schlesinger does not receive any compensation from Impladent.

Figure 2: Pre-op non-restorable tooth No. 5 14 Implant practice

Volume 10 Number 3

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RESORBABLE MINERALIZED COLLAGEN BONE GRAFTING STRIP

OSTEOGEN® BIOACTIVE RESORBABLE CALCIUM APATITE CRYSTALS & TYPE I BOVINE ACHILLES TENDON COLLAGEN

The OsteoGen® Bone Grafting Strip from Impladent Ltd infuses OsteoGen® bone graft crystals into a collagen sheet eliminating issues associated with particulate migration. The bioactive OsteoGen® assists to control the migration of connective tissue.1-4 The OsteoGen® Strip is a predictable and simple solution for sinus lifts as well as for grafting gaps between the implant and extraction socket wall.

Clinical Case Example 1

Implant is placed lingually following extraction. OsteoGen® Strip will be used to fill gaps and to reinforce the buccal wall

The OsteoGen® Strip is a hydrophilic material that can be hydrated with patients blood and substantially compressed to fill a variety of defects

OsteoGen® Strip is hydrated with patients blood from the surgical site and, if desired, autologous serum or other growth factors prior to delivery

OsteoGen® Strip can be folded after hydration and prior to or during placement with a blunt instrument for additional bone width and stability

Buccal plate is reinforced by feeding the OsteoGen® Strip downwards in between the implant and the buccal wall

OsteoGen® Strip is in place which reinforces the buccal wall while grafting the gaps between the buccal plate and the implant

1. Valen (2002), 2. Artzi (2003) 3. Spivak (1990) 4. Ricci (1992)

Clinical images courtesy of Robert Miller, MA, DDS, FACD, DABOI

Contact 800-526-9343 or Shop Online at www.impladentltd.com

TECHNIQUE

Figure 3: Previously endodontically treated tooth No. 5

Figure 6: Pilot drill into furcal bone

Figure 4: Tooth is atraumatically extracted

Figure 7: Verification of trajectory

Figure 5: 4.3 x 15 Final drill

Figure 8: Final drill used to approximately 1mm below the facial crestal bone

The consistency of the product lends itself perfectly to the task by being stable, possibly enhancing initial stability, and providing a scaffold for new bone growth.

Figures 9-10: 9. OsteoGen® Strip soaked with patient’s blood. 10. Placement of strip buccally 16 Implant practice

were discussed with the patient. Ultimately, the decision to extract the tooth and place an immediate implant was decided upon. After profound anesthesia was achieved with Septocaine® (Septodont USA), the tooth was atraumatically extracted (Figure 4) making sure not to fracture the bifurcated root. By making sure to not fracture the root, there were no potential issues that could have arisen if a more aggressive surgery was necessitated to remove a fractured root tip. The root dimensions were used to decide upon the final implant length and diameter (Figure 5). A purchase point was created with a high-speed bur to allow the pilot drill to be centered on the interseptal bone (Figure 6). A paralleling pin was placed to verify the position (Figure 7). The osteotomy was finalized utilizing a sequential osteotomy preparation (Figure 8). A 557 LS surgical carbide was used to perforate the lamina dura and produce adequate bleeding to establish a sufficient blood supply. OsteoGen® Strips were first saturated with the patient’s blood (Figure 9) Volume 10 Number 3

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TECHNIQUE

Figure 11: Strips placed both against the buccal and lingual wall

Figure 13: Final position of implant

before being placed in both buccally and lingually (Figures 10 and 11). A 4.3 x 10 Hahnâ„˘ Tapered Implant (Glidewell Direct) was placed between the strips and into the prepared osteotomy (Figure 12). Excellent primary stability was attained with a seating torque value of 50N/ cm and an ISQ of 68 utilizing an Osstell IDx, and the optimal position for restoration was achieved (Figure 13). According to the most recent literature published, an Osstell reading of 70 is desired for loading of an implant.16 The consistency of the strip no doubt contributed to the increased stability. Normally, this would be a good situation to immediately load this implant,17 but the decision to allow the graft material to mature first before loading in order to achieve the highest resistance to micro-motion was taken. 18 Implant practice

Figure 12: Implant insertion

Figure 14: Placement X-ray

Figure 15: Closed site with sling suture and 3 mm healing abutment

Figure 16: Final radiograph Volume 10 Number 3

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To see how straightforward patient financing can be: Call (844) 936-6673 Visit lendingclub.com/providers * No interest for 6, 12, 18 or 24 months, after that 23.73% variable APR. Interest will be charged to your account at the standard variable APR of 23.73% (based on the Prime Rate) from the end of the promotional period on the remaining balance if the purchase balance is not paid in full within the promotional period. Minimum monthly payments for this plan during the promotional period will be the greater of: the amount of the purchase divided by the number of months in the promotional period (rounded up to the nearest $1.00); or $5. Required minimum purchase of $499 for the 6-month plan; $999 for the 12-month plan; $1,499 for the 18-month plan; $2,499 for the 24-month plan. Lending Club Patient Solutions credit accounts are offered by Comenity Capital Bank who determines qualifications for credit and promotion eligibility. Minimum interest charge is $1.00 per credit plan. Standard variable APR of 23.73%. © 2017 Lending Club Patient Solutions products and services provided through Springstone Financial, LLC, a subsidiary of LendingClub Corporation. Payment plans made by issuing bank partners.

TECHNIQUE

Figure 17: Intraorally after healing phase

Figure 19: Another view of coping showing ideal restorative position

Figure 21: Stock titanium abutment in place 20 Implant practice

Figure 18: Closed-tray impression coping

Figure 20: Impression coping and analog placed in impression

A 3 mm tall concave healing abutment was hand tightened (Figure 14), and the site was sutured with 4.0 pTfE sling suture (Figure 15). At 3 months, the implant was radiographed and demonstrated bone regeneration around the implant and crestal bone growth over the platform (Figure 16). The growth over the machined platform was made possible by the concave healing abutment and the initial sub-crestal platform position. The soft tissue was also fully healed, and sufficient keratinized tissue had matured around the healing abutment (Figure 17). A closed tray impression coping was inserted (Figures 18 and 19), and a PVS impression was taken. An analog was placed on the impression coping after removal from the implant and inserted back into the impression (Figure 20). A shade was taken along with an opposing impression and bite registration before sending the case to the lab. One week later, the case returned from the lab, and the restorative dentist placed the Volume 10 Number 3

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Our hands-free hot/cold therapy system helps promote patient compliance and reduce post-op complications. Cool Jaw provides mutliple options of facial wraps and gel packs which assist in recovery following dental implants and other oral surgeries. Our Clear Cold Gel Packs freeze solid and remain cold up to an hour. Our Blue Hot/Cold Gel Packs, as well as our Green Peas Hot/Cold Gel Packs, remain pliable when frozen, contour to the face and provide patients with more post-op therapy options. All of our products can be customized with your practice logo and information for long lasting promotion. Cool Jaw’s reusable hands-free system arrives with preprinted, patient-friendly instructions for added convenience.

TECHNIQUE abutment (Figure 21) and torqued it to 30 N/cm. Note the healthy keratinized tissue and gingival contour. The final full contour Zr crown was tried in and adjusted and finally cemented with resin-modified glass ionomer cement (Figures 22 and 23). The excess cement was removed, and the patient was dismissed.

Conclusion The immediate placement of a dental implant can be technically challenging. Attaining primary stability and preventing unwanted sequelae are priorities with this type of treatment. It is imperative to have a regenerative material that will not only fill the void between an implant and native bone, but also will not migrate from the site during healing. There are many ways to address the gap between an implant body and the residual socket; OsteoGenÂŽ Strips are an easy and cost-effective way to address these issues with outstanding results. The consistency of the product lends itself perfectly to the task by being stable, possibly enhancing initial stability, and providing a scaffold for new bone growth. If immediately placing dental implants in extraction sites is part of your practice, do yourself a favor and take a look at this product. IP

Figure 22: Occlusal view of final restoration

REFERENCES 1. Botticelli D, Berglundh T, Buser D, et al. The jumping distance revisited: an experimental study in the dog. Clin Oral Implants Res. 2003;14(1):35-42. 2. JanuaĚ rio AL, Duarte WR, Barriviera M, et al. Dimension of the facial bone wall in the anterior maxilla: a cone- beam computed tomography study. Clin Oral Implants Res. 2011;22(10):1168-1171. 3. Katranji A, Misch K, Wang HL. Cortical bone thickness in dentate and edentulous human cadavers. J Periodontol. 2007;78(5):874-878. 4. Chen ST, Darby IB, Reynolds EC. A prospective clinical study of non-submerged immediate implants: clinical outcomes and esthetic results. Clin Oral Implants Res. 2007;18(5):552-562. 5. Rosenbach, DR. GAP management around immediate implants: a review of the literature and its application in clinical practice. Dentaltown. September 2014:44-49. 6. Valen M, Ganz SD. A synthetic bioactive resorbable graft for predictable implant reconstruction: part one. J Oral Implantol. 2002;28(4):167-177. 7. Artzi Z, Nemcovsky CE, Dayan D. Nonceramic hydroxyapatite bone derivative in sinus augmentation procedures: clinical and histomorphometric observations in 10 consecutive cases. Int J Periodontics Restorative Dent. 2003;23(4):381-389. 8. Ricci JL, Blumenthal NC, Spivak JM, et al. Evaluation of a low temperature calcium phosphate particulate implant material: physicochemical properties and in vivo bone response. J Oral Maxillofac Surg. 1992;50(9):969-978. 9. Epstein SR, Valen M. An alternative treatment for the periodontal infrabony defect: a synthetic bioactive resorbable composite graft. Dent Today. 2006;25(2):92-97.

Figure 23: Lateral view (Dentistry by George Harper, DDS)

12. Fugazzotto PA, Vlassis JM. Long-term success of sinus augmentation using various surgical approaches and grafting materials. Int J Oral Maxillofac Implants. 1998;13(1):52-58.

10. Corsair A. A clinical evaluation of resorbable hydroxylapatite for the repair of human intra-osseous defects. J Oral Implantol. 1990;16(2):125-128.

13. Vlassis JM, Hurzeler MB, Quinones CR. Sinus lift augmentation to facilitate placement of nonsubmerged implants: a clinical and histological report. Pract Periodontics Aesthet Dent. 1993;5(2):15-24.

11. Wagner JR. Clinical and histological case study using resorbable hydroxylapatite for the repair of osseous defects prior to endosseous implant surgery. J Oral Implantol. 1989;15:186-192.

14. Whittaker JM, James RA, Lozada J, Cordova C, GaRey DJ. Histological response and clinical evaluation of heterograft and allograft materials in the elevation of the maxillary sinus for the preparation of endosteal dental implant

22 Implant practice

sites. Simultaneous sinus elevation and root form implantation: an eight-month autopsy report. J Oral Implantol. 1989;15(2):141-144. 15. Manso M, Wassal, T. A 10-year longitudinal study of 160 implants simultaneously installed in severely atrophic posterior maxillas grafted with autogenous bone and a synthetic bioactive resorbable graft. Implant Dent. 2010;19(4):351-360. 16. Schlesinger C. Torque versus RFA at implant placement: a case study. Implant Practice US. 2016;9(4):14-20. 17. Schlesinger C. Immediate placement of dental implants: a safe, a predictable treatment option. J Dent Sci. 2016;4(3).

Volume 10 Number 3

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CONTINUING EDUCATION

Implant surgery in the mandible — a summary of recent research findings and a protocol of risk management Drs. Cemal Ucer and Eddie Scher summarize a recent series of papers to provide an evidence-based protocol for implant placement in the mandible

he trigeminal nerve (TGN) and its branches as well as the lingual artery are at risk during implant surgery in the mandible. Complications in this area are serious — even life threatening — and often result in medico-legal complaints. This article aims to summarize the findings of a recent series of papers published by Yilmaz, Ucer, Scher, Suzuki, and Renton (2016; 2017), and Renton and Yilmaz (2011) and to outline a risk management protocol for implant placement surgery in the mandible, based on these results and previous protocols published by Scher (2002) and Renton (2013). Nerve damage can be caused by direct or indirect mechanical, thermal, ischemic, chemical injury, or infectious means and can also occur following local anesthetic (LA) injections. There are concerns that the incidence of iatrogenic trigeminal nerve injuries (TGI) may be on the rise with the increasing popularity of implant treatment and the surgery being undertaken by clinicians of varying levels of experience and training. The resulting neurosensory disturbances (NSDs) are characterized by altered sensation or numbness affecting the area that is innervated by the branches of the TGN. More significantly, iatrogenic TNIs commonly cause chronic neuropathic pain resulting in constant interference with speaking, eating, kissing, shaving, applying makeup, tooth brushing, and drinking. These injuries have a significant negative effect on the patient’s self-image and quality of life with profound

Professor Cemal Ucer, BDS, MSc, PhD, is a specialist oral surgeon and professor of dental implantology at Edge Hill University in Lancashire. He is also clinical director of the ICE postgraduate dental institute in Manchester. Eddie Scher, BDS, LDS, RCS, MFGDP, is a specialist in oral surgery and prosthodontics. He is a visiting professor of implantology at Temple University, Philadelphia, and is editor-in-chief of Implant Dentistry Today.

Educational aims and objectives

This article aims to highlight the risk factors for nerve and blood vessel injury related to dental implants and to present an evidence-based protocol of risk management for placement of implants in the mandible.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 31 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Realize an evidence-based understanding of the cause of collateral damage to vital tissues related to implant surgery and an ability to apply risk management strategies when placing implants in the mandible.

•

Identify a protocol of risk management strategies in mandibular implant surgery.

•

Recognize the benefits of surgical guides.

•

Recognize the importance of flap design.

•

Identify some postoperative risk management strategies.

psychological effects (Renton and Yilmaz, 2011; Yilmaz, et al., 2016) (Table 1). Our research showed that specific training in the prevention and management of iatrogenic nerve damage related to dental implants might be lacking or inadequate during implant training. This deficiency should be addressed by course providers urgently given the devastating nature of this type of complication. Implant surgeons do not seem to be aware that iatrogenic nerve damage is a serious surgical complication that is reportable to the Care Quality Commission (CQC) in the UK (Yilmaz, et al., 2016; 2017) Furthermore, there is evidence to suggest that risk assessment, treatment planning, and the consent processes performed by implant dentists may be inadequate or short of the

best-practice guidelines in implant dentistry. Implant organizations, including the International Team for Implantology (ITI), Academy of Osseointegration (AO), European Association for Osseointegration (EAO), International Congress of Oral Implantologists (ICOI), and so on have evidence-based guidelines and good-practice recommendations, but clinicians may not be using these recommendations fully — particularly when placing implants in the mandible. The evidence shows that inaccurate radiological identification of the inferior alveolar nerve (IAN) or mental nerve (MN) and their anatomical variations are the most frequent cause of TGIs. Interestingly, disclosure of the relative risk of surgery and benefits of alternative implant treatment strategies

Table 1: Outcome of trigeminal nerve pain • Constant, spontaneous, or evoked neuropathic pain • Functional problems such as interference with speaking, eating, kissing, shaving, applying makeup, tooth brushing, and drinking • Psychological problems and depression • Numbness/altered sensation due to anesthesia, hypoesthesia, dysesthesia, or allodynia • Chronic neuropathic pain

24 Implant practice

Volume 10 Number 3

INTRAOPERATIVE Risk Management Strategies

POSTOPERATIVE Risk Management Strategies

• • • •

• • • • • • • • • •

• Home checks • Post-op medication • Post-op instructions and review

• • • • •

Assessment (dental, anatomical, functional) Occlusal analysis Treatment needs assessment Diagnostic imaging: bone quality and density and vital structures Treatment plan/alternatives Risk assessment Case complexity and clinical skills assessment Individualized disclosure and consent Surgical planning, surgical guides, preop medication

was not deemed to be essential to an individualized consent process by a quarter of the participants (Yilmaz, et al., 2016). Nevertheless, the results showed that the incidence of TGI is reduced when implant surgery is carried out by experienced and well-trained surgeons using a standardized technique and certain preventive measures (Yilmaz, et al., 2016; Devine, et al., 2014). The authors therefore recommended that surgeons should acquire evidence-based specific skills in assessment and planning of implant surgery, use appropriate diagnostic imaging, and employ evidencebased strategies to minimize the collateral surgical damage when placing implants in the mandible. The literature shows that cone beam computer tomography (CBCT) could play an important role in reducing the risk of TG damage and any associated morbidity. It is important to note that the American Academy of Oral and Maxillofacial Radiology (AAOMR), in its revised evidence-based position statement on the selection criteria for radiology in implant dentistry, recommends that CBCT should be used for the assessment of all dental implant sites (Tyndall, et al., 2012). In this respect, the use of small field of view (sFOV) CBCT scanning could be regarded as essential as a choice of diagnostic imaging in the mandible subject to fulfilling national justification criteria such as those published by the FGDP. This new protocol comprises a structured preoperative assessment, diagnosis, planning, and perioperative risk management strategies. Volume 10 Number 3

Surgical technique Incision Identify and protect vital structures LA technique and choice of drugs CBCT-guided surgery Use of intraoperative PA check X-ray Sharp drills Drill stops Zone of safety (2 mm-4 mm) Medication (e.g., antibiotics, steroids)

Figure 1: The preoperative, intraoperative, and postoperative risk management strategies and protocols for implant placement in the mandible

A protocol of risk management strategies in mandibular implant surgery Iatrogenic nerve damage can occur if adequate clearance is not allowed when placing an implant near the mandibular branches of the TG nerve. It can also occur when the surgeon diverges from the planned implant position, either inadvertently or deliberately — for example, if unexpected anatomical variations are encountered during surgery (Table 2). A higher standard of care with meticulous planning and surgical precision is therefore essential. TGI should be fully avoidable due to the elective nature of implant surgery. Nerve damage can also occur when adjunctive high-risk procedures, such as bone harvesting and grafting, or nerve lateralization, are carried out to avoid implant-related nerve injury by increasing the clearance from the underlying vital structure (Yilmaz, et al., 2016). Systematic perioperative risk management strategies are needed in order to minimize collateral damage to the vital structures that may be located in close proximity of the implant sites when operating in the mandible. The risk management strategies presented in this article apply to all three distinct phases of implant treatment: preoperative, intraoperative, and postoperative (Figure 1).

Preoperative risk management strategies In addition to a routine case assessment, a full periodontal examination should be carried out as well as adequate restorative and occlusal analysis, including the determination of the inter-arch clearance with articulated models. The aim is to document that restorative implant treatment is feasible, that tooth replacement is indicated for good functional reasons (a low, moderate, or strong indication, for example), that dental implants are the choice of treatment with respect to specific individual functional and anatomical conditions, and that the benefits outweigh the risks (such as TGI occurring, for example) of the case. At this stage, individual treatment needs (TN) should be established as well as performing a complexity of treatment analyses, using an established index such as the ITI’s straightforward, advanced, and complex (SAC) classification, or the Cologne ABC risk assessment scores should be performed. Case-specific factors affecting the longterm prognosis and the related risk:benefit analysis should be performed and discussed with patients in view of their autonomy, preferences, and concerns. The choice of the radiograph should allow the determination of the bone quality and density at each implant site, the location of the vital structures, and

Table 2: Predisposing factors for iatrogenic trigeminal nerve injury • Inadequate assessment and treatment plan • Inadequate or poor surgical technique or divergence from planned surgery • Inadequate or inappropriate post-op management Implant practice 25

CONTINUING EDUCATION

PREOPERATIVE Risk Management Strategies

CONTINUING EDUCATION their potential proximity to the planned implant sites. Although the panoramic radiograph is a safe and reliable technique for assessing bone height and space when there is sufficient bone, a CBCT study has shown that it may be unsafe to use an arbitrary safety margin (of 2 mm-4 mm) and recommends that individual determination of a zone of safety should be made on a case-by-case basis (Parnia, et al., 2012) optimally by using a CBCT (Yilmaz, et al., 2016; 2017). Given that there is evidence to suggest that the most common cause of TGI may be inadequate radiological assessment of the implant site, the use of small field-of-view (sFOV) CBCT may be justifiable for optimal preoperative surgical planning when placing implants in close proximity of vital structures particularly in presence of limited bone density or quantity. Carrying out a panoramic radiograph routinely at first, only to realize that a 3D cross-sectional image would be required for implant placement, would simply add to the radiological burden. It should however be noted that CBCT scanning is an invasive technique and is still considered as a supplementary method of imaging in implant dentistry by most dental organizations. Nevertheless the radiological risk benefit analysis could be further improved if all of the objectives outlined in Figure 2 are also considered as part of the justification criteria when selecting the most optimum imaging technique in the mandible (Table 3). During this stage, special considerations should be given to the strength of the need for tooth replacement using dental implants, the material risk of TGI occurring with reference to the patient’s individual anatomical condition and the proximity of the vital structures, the prognosis of the proposed treatment, and the likelihood of satisfactory treatment outcome if traditional prosthodontic alternatives were offered. This will form the basis of the patient information and consent process in which the patient is entitled to receive a full disclosure of the material risks, including the likelihood of TGI with reference to their specific individual anatomical condition. In this respect, for the consent process to be valid (Montgomery, 2015), all material risks related to implant surgery in the mandible as outlined in Table 1 should be disclosed even if the risk has been quantified to be low (Figure 2).

Intraoperative risk management strategies The aim of surgical planning is to facilitate the placement of dental implants with 26 Implant practice

Assessment, diagnostic imaging and consent

Figure 2: Preoperative risk management strategies for implant surgery in the mandible

PREOPERATIVE PLANNING

Determine: Treatment needs Complexity of treatment 3D restorative design DIAGNOSTIC SETUP

Prosthodontic alternatives and implant options ALTERNATIVES

Location of IAN, MN, Bone quality and density 3D-guided surgery Avoid perforations to lingual plate DIAGNOSTIC IMAGING

Proximity of vital structures Zone of safety (2-4 mm) 3D implant positioning RISK ASSESSMENT

Zone of safety > 4 mm Good bone quality and density

Zone of safety 2-4 mm Good bone density Reduced bone volume

Zone of safety 2 mm Reduced bone quality and density

LOW RISK

MODERATE RISK

HIGH RISK

Table 3: Objectives of CBCT diagnostic imaging • Determine bone density and quantity at each implant site • Identify vital structures such as IAN • Determine ideal implant location • Identify variations in anatomical structures (i.e., multiple IAN or bifid MN) • Determine an adequate safety zone (ZOS) • Select optimum implant length and diameter • CBCT-guided surgical stent design for restoratively driven implant placement

Table 4: Objectives of CBCT diagnostic imaging • Location, severity, and mechanism of injury • Proximity of the injury to the cell body • Time elapsed since injury • Early medical and surgical management of injury

precision at the planned three-dimensional position with correct angulation, depth, and crestal location. Freehand placement technique or use of a limited guidance laboratory fabricated surgical guide, although cheaper, could result in significantly more errors compared with CBCT-guided surgical stents (Block and Emery, 2016). An intraoperative protocol of risk management strategies is outlined in Figure

3. Research evidence reported by Yilmaz, et al., (2016; 2017) and previous protocols used by Scher (2002) and Devine, Ucer, et al., 2014, have highlighted the importance of the following risk management strategies when placing implants in the mandible. Surgical guides CBCT-guided static stents have been shown to improve the surgical precision of implant placement if used with a coordinated Volume 10 Number 3

Zone of safety In the UK survey, the majority of participants (76% of 134 responses) reported that they allowed a 2 mm-4 mm safety zone radiologically above the IAN when placing implants. Safety zones of more than 4 mm and less than 2 mm were allowed by 9% and 15% responders, respectively (Yilmaz, et al., 2016; 2017). The authors recommend that a zone of safety should be determined individually (2 mm-4 mm) as a function of the available bone height above the nerve and minimum implant length that can be used predictably, using a CBCT scan (Figure 2).

• Surgical technique • Flap design • Identify and protect vital structures • LA technique • CBCT-guided surgery • Sharp drills • Drill stops • Unilateral surgery • Periapical check X-ray • Avoid perforations of lingual plate • Zone of safety • Bone quality and density • Anatomical variations

• Medication (e.g., antibiotics, steroids)

Figure 3: Intraoperative risk management strategies

Intraoperative X-rays The authors recommend the use of intraoperative periodical check X-rays during implant placement surgery in order to reduce the risk of collateral damage to surrounding tissues. Local anesthetic (LA) Articaine was the most frequently cited LA used in the posterior mandible, followed by lignocaine. Nevertheless, a total of 73% of the responders reported that they did not use articaine in inferior dental blocks (IDB). Of those who encountered LA-related IAN injury (n = 62), pain on injection (17%), infection in proximity of the mental nerve (11%), use of articaine (8%), and multiple ID blocks (IDBs; 5%) were the main predictors of nerve damage related to LA during dental implant surgery. It is clinically important to document any intraoperative findings such as pain on injection as these can help in postoperative diagnosis of the nature of the cause of NSD and how best to manage this complication (Yilmaz, et al., 2016; 2017). In this study, 59% (n = 70) used infiltration anesthesia only for implant placement Volume 10 Number 3

Figure 4A: CBCT-guided CAD/CAM surgical stent on 3D model of the mandible

in the posterior mandible to avoid giving IDBs — presumably to reduce the risk of LA-related neurosensory disturbances as well as to prevent IAN injury during implant placement. Interestingly, LA infiltration technique was reported to be always effective by 71% (n = 84). There is no agreement in the literature on using IDB or LA infiltration anesthesia during dental implant surgery in the posterior mandibular region. It has been argued that permanent IAN injury can be avoided if IDB is not administered to allow the patient to retain some sensory sensation during implant placement. Etoz, et al., 2011, showed that an LA infiltration was an effective method of anesthesia for implant surgery in the posterior mandible but recommended that the

Figure 4B: The Navident-guided navigation system

length of the implant should still be determined carefully to avoid possible damage to the IAN during implant placement. The authors, based on their audited long-term experience, routinely use and Implant practice 27

CONTINUING EDUCATION

drilling system (typically less than 2 mm apical and crestal deviation and less than 5º angulation error) and might reduce the risk of TGI (Block and Emery, 2016). CBCT-based surgical planning (Figure 4) can also eliminate the chance of unforeseen anatomical anomalies or variations becoming apparent during the operation and forcing unplanned surgical deviations (Juodzbalys, et al., 2010; 2010). If preoperative planning can be completed with three-dimensional accuracy, the surgeon will not be forced to deviate from the planned surgery intraoperatively or violate the zone of safety that has been planned around the vital structure(s). Further studies, however, are needed in this area.

CONTINUING EDUCATION

Figure 5: A short implant (shown here with a bone ring) used to avoid staged block grafting

Figure 6: Block bone grafting in the mandible to increase bone height above IAN

recommend an LA infiltration technique instead of IDBs when placing implants in the posterior mandible. However, the safety and effectiveness of this technique as a risk management strategy in reducing IAN or LN nerve damage is largely unknown but warrants further study. Flap design Identification and protection of a vital anatomical structure is a sound surgical practice, and clinicians should consider doing so when operating in close proximity of the IAN (Yilmaz, et al., 2016). Clinicians should be familiar with the surgical anatomy of the mandible. In moderate to severely atrophic mandibles, lingual and mental branches of the TG become more superficially located. Incision design should avoid damage to the mental and lingual nerves in particular. Short implants The use of short implants (Figure 5) provides an alternative to bone grafting (Figure 6) in situations of limited bone volume and is becoming a viable alternative to longer implants that often require additional augmentation procedures — thus risking further NSD in the posterior mandible. The current literature supports the use of short implants (6 mm-8 mm), which have been shown to have high survival rates after 5-10 years without marginal bone loss or complications and, therefore, can be employed for simplification of implant therapy in situations of reduced alveolar heights in the posterior jaw (Atieh, et al., 2012; Srinivasan, et al., 2012). Caution is however required when using short implants. The UK survey revealed that the most frequent standard length of implants used 28 Implant practice

Figure 7: Drill stops

within the posterior mandible by (56%) was 10 mm. The most frequent, shortest implant length they would be happy to use in the molar region in the mandible were 6 mm and 8 mm, at 51 (39%) and 50 (38%), respectively (Yilmaz, et al., 2016; 2017). However, long-term randomized controlled trials are needed to show their long-term efficiency compared with longer implants. Implant drills Manufacturers recommend their implant drills should ideally be one-use only or replaced frequently (after 10-15 cases). Most of the responding dentists questioned

in a UK survey indicated that they replaced their surgical drills after 10 uses (35.9%). The second most popular choice indicated by the dentists (at 17.2%) was single-use only. This was then followed by “after 20 uses” or “more than 20 uses,” at 16.4% and 12.5%, respectively. Nineteen responders (14.8%) did not have a policy for replacing implant drills, and a further 11 (8.6%) indicated that they had other policies regarding the replacement of implant drills. The authors recommend that implant drills should be replaced according to the manufacturers’ recommendations so that they are sharp and efficient cutting Volume 10 Number 3

Drill stops Drill stops (Figure 7) appear to be used by only a small number of dentists in the United Kiingdom. Although the efficacy of using drill stops in this respect has not been demonstrated, they are seen as a good safety measure in preventing inadvertent extension of the osteotomy site or avoiding sudden sink of the drills when drilling in less dense bone (such as types D3 or D4). This should be investigated in future studies. Steroids In this study, steroids were used perioperatively always by 18%, while 18% used them when operating in borderline cases of limited bone volume. Antibiotics were also used prophylactically to reduce infection and the associated perineural edema. Efficacy of such medication is unknown, although Al-Bishri, et al., 2008, demonstrated a beneficial effect of a moderate perioperative dose of steroids on recovery of NSD that was mediated by recruitment of macrophages. The authors recommend the use of steroids (such as dexamethasone) when operating in close proximity of vital structures in the mandible unless there are systemic contraindications. Dexamethasone can be administered intravenously, subcutaneously, or intramuscularly. Oral formulations of steroids can also be considered pre- and postoperatively.

Figure 8: Insertion of vessels in to the midline mandible from the lingual artery Volume 10 Number 3

Staging bilateral surgical procedure It is recommended that bilateral implant placement in the mandible is staged in order to eliminate the possibility of bilateral nerve damage occurring. In the survey, 57% of the responders always staged bilateral implant placement although 19% did so only when bone volume was very limited. Antibiotics Routine use of preoperative antibiotics is recommended when placing implants in the mandible with or without adjunctive bone grafting procedures in order to reduce the risk of postoperative infection and possible nerve damage. Lingual artery When placing implants in the anterior mandible, perforation of the lingual plate should be avoided to prevent laceration injuries to the lingual artery branches (Figure 8). The precision of surgery can be improved significantly if a CBCT-guided surgical stent is used to ensure that implants are placed within the planned position, depth, and angulation (Figure 9). Anatomical variations in nerve morphology Morphological anatomical variations in the IAN or mental nerve are often noted intraoperatively and may force the surgeon to deviate from the intended course of action when placing implants. This could violate the planned safety zone and might result in inadvertent nerve damage.

In the UK survey, 86 of 122 responders (70%) noticed a large anterior loop, 16 (13%) encountered multiple canals, 13 (11%) noticed bifid mental nerve, and 21 (17%) noticed multiple mental foramina. CBCT planning would be highly indicated in order to identify anatomical variations in nerve morphology and should be considered (Yilmaz, et al., 2016; 2017).

Postoperative risk management strategies Successful management of trigeminal nerve injury (TGI) depends on timely diagnosis of the mechanism of nerve injury. In case of IAN injury, the timing and duration of the injury is of particular relevance as the IAN is highly prone to irreversible ischemic changes if the nerve becomes compressed within its bony canal. This could occur due to infection, edema, hematoma formation, or pressure from bone debris (Renton, 2002; Yilmaz, et al., 2016; 2017). Neurosensory disturbances once the LA has worn off should be investigated urgently after surgery in order to make a diagnosis and commence treatment without delay. Home check A home check within 6-12 hours after implant surgery is recommended to detect nerve injury as early as possible. The patient should be instructed both verbally and in writing to report back any neurosensory disturbance such as numbness, altered sensation, or intense pain that does not respond to usual postoperative analgesics

Figure 9: CBCT-guided surgical stent being used to avoid perforation of the lingual plate Implant practice 29

CONTINUING EDUCATION

instruments when placing implants in the mandible.

CONTINUING EDUCATION once the LA has worn off. As the onset of nerve damage can be delayed, the patient should be followed closely, and any persistent infection should be treated adequately (Yilmaz, et al., 2016; 2017). Diagnosis of trigeminal nerve injury There are no clinical tests that can distinguish a bruised nerve from a sectioned nerve in the early postoperative phase. CBCT is not reliable in evaluating the outcome of IAN injury. Trigeminal sensory disturbances related to dental implants (Figure 10) must therefore be diagnosed subjectively according to patients’ complaints and symptoms. It is also important to differentiate between TGI caused by LA administration or dental implant placement as this has a bearing on the management of the nerve damage (such as removal of the implant or not). It is essential that clinicians make accurate intraoperative notes describing the key stages of the surgical procedure undertaken. This should include any unusual response such as a sudden give when drilling in close proximity of the nerve, or an “electric shock” that may be experienced by the patient when the LA is being administered. In order to effectively diagnose trigeminal nerve injury (TGI), a full clinical examination would be required. The aim is to map out the area (and the dermatome) affected (the mucosa, skin, the lower lip, teeth, or the tongue, for example). The size of the area and the percentage of the dermatome affected will give an idea

about the extent of the injury. Mechanosensory tests such as light touch, sharp/ blunt discrimination, pressure point pain, moving point allodynia, two-point discrimination, and thermal stimuli testing should be carried out and mapped. Early referral Clinicians who have not had specific training or experience in diagnosis and management of TGI should consider referring their patients to a specialist for prompt treatment of nerve injury as early as possible. The prognosis is affected by the mechanism as well as the timing and the duration of the injury. Prompt treatment could minimize the severity of the permanency of nerve damage. The management of TGI depends on the mechanism of the injury and often on the severity of the patient’s symptoms. If the neuropathy affects most of the dermatome and is associated with severe neuropathic pain, medical management and early removal of the implant might be strongly indicated (Renton, 2013).

Conclusion TGI is a devastating complication of dental implant surgery in the mandible. Given the fact that implant treatment is an elective surgery, this complication should be fully avoidable. The evidence suggests that TGI related to dental implants can be minimized with meticulous attention to accurate assessment, diagnosis, and treatment planning as well as carrying out the surgery with a high degree of precision.

In this article, the authors presented an outline of a protocol that comprises preoperative, intraoperative, and postoperative risk management strategies for dental implant surgical procedures in the mandible, based on a recent series of papers by Yilmaz, Ucer, Scher, Suzuki, and Renton (2016; 2017); Scher (2002), Devine, Ucer and Renton (2014), and Renton (2013). IP

REFERENCES 1. Al-Bishri A, Forsgren S, Al-Thobaiti Y, Sunzel B, Rosenquist J. Effect of betamethasone on the degree of macrophage recruitment and nerve growth factor receptor p75 immunoreaction during recovery of the sciatic nerve after injury: an experimental study in rats. Br J Oral Maxillofac Surg. 2008;46(6): 455-459. 2. Atieh MA, Zadeh H, Stanford CM, Cooper LF. Survival of short dental implants for treatment of posterior partial edentulism: a systematic review. Int J Oral Maxillofac Implants. 2012;27(6):1323-1331. 3. Block MS, Emery RW. Static or dynamic navigation for implant placement — choosing the method of guidance. J Oral Maxillofac Surg. 2016; 74(2):269-277. 4. Devine M, Ucer C, Renton T. Incidence of Inferior Alveolar Nerve Injury with Mandibular Dental Implants. Paper presented at 43rd Annual Meeting & Exhibition of the American Association of Dental Research; March 19-24, 2014; Charlotte, NC. 5. Etoz OA, Er N, Demirbas AE. Is supraperiosteal infiltration anesthesia safe enough to prevent inferior alveolar nerve during posterior mandibular implant surgery? Med Oral Patol Oral Cir Bucal. 2011;16(3):e386-e389. 6. Juodzbalys G, Wang HL, Sabalys G. Anatomy of mandibular vital structures. Part I: mandibular canal and inferior alveolar neurovascular bundle in relation with dental implantology. J Oral Maxillofac Res. 2010; 1(1): e2. 7. Juodzbalys G, Wang HL, Sabalys G. Anatomy of mandibular vital structures. Part II: Mandibular incisive canal, mental foramen and associated neurovascular bundles in relation with dental implantology. J Oral Maxillofac Res. 2010; 1(1):e3. 8. Montgomery v Lanarkshire Health Board (2015) UKSC 11. On appeal from: (2013) CSIH 3; (2010) CSIH 104 9. Parnia F, Moslehifard E, Hafezeqoran A, Mahboub F, Mojaver-Kahnamoui H. Characteristics of anatomical landmarks in the mandibular interforaminal region: a cone-beam computed tomography study. Med Oral Patol Oral Cir Bucal. 2012; 17(3):e420-e425. 10. Renton T, Yilmaz Z. Profiling of patients presenting with posttraumatic neuropathy of the trigeminal nerve. J Orofac Pain. 2011;25(4): 333-344. 11. Renton T (2013). Oral surgery: part 4. Minimising and managing nerve injuries and other complications. Br Dent J. 2011; 215(8):393-399. 12. Renton T. Association of Dental Implantology (ADI) Guidelines. 2013. https://www.adi.org.uk/resources/guidelines_ and_papers/guidance_on_inferior_alveolar_nerve_injury/ index.html. Accessed January 2017. 13. Scher EL. Risk management when operating in the posterior mandible. Implant Dent. 2002;11(1):67-72. 14. Srinivasan M, Vazquez L, Rieder P, Moraguez O, Bernard JP, Belser UC. Efficacy and predictability of short dental implants (<8 mm): a critical appraisal of the recent literature. Int J Oral Maxillofac Implants. 2012;27(6):1429-1437. 15. Tyndall DA, Price JB, Tetradis S, Ganz SD, Hildebolt C, Scarfe WC: American Academy of Oral and Maxillofacial Radiology. Position statement of the American Academy of Oral and Maxillofacial Radiology on selection criteria for the use of radiology in dental implantology with emphasis on cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;113(6):817-826. 16. Yilmaz Z, Ucer C, Scher E, Suzuki J, Renton T. A survey of the opinion and experience of uk dentists: Part 1: The incidence and cause of iatrogenic trigeminal nerve injuries related to dental implant surgery. Implant Dent. 2016;25(5):638-645.

Figure 10: Perforation of the mental canal by an inappropriately long implant 30 Implant practice

17. Yilmaz Z, Ucer C, Scher E, Suzuki J, Renton T. A survey of the opinion and experience of UK dentists: Part 2: Risk assessment strategies and the management of iatrogenic trigeminal nerve injuries related to dental implant surgery. Implant Dent. 2017;26(2):256-262.

Volume 10 Number 3

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Implant surgery in the mandible — a summary of recent research findings and a protocol of risk management UCER/SCHER

1. The ________ is/are at risk during implant surgery in the mandible. a. trigeminal nerve (TGN) and its branches b. lingual artery c. zygomatic nerve d. both a and b

recommends that ____ should be used for the assessment of all dental implant sites. a. 2D panoramic images b. CBCT c. intraoral photographs d. 2D digital radiographs

2. The evidence shows that _______ of the inferior alveolar nerve (IAN) or mental nerve (MN) and their anatomical variations are the most frequent cause of trigeminal nerve injuries (TGIs). a. poor extraction techniques b. infection c. inaccurate radiological identification d. general anesthetic

5. The aim of surgical planning is to facilitate the placement of dental implants with precision at the planned three-dimensional position with correct _______. a. angulation b. depth c. crestal location d. all of the above

3. The authors therefore recommended that surgeons should ________ to minimize the collateral surgical damage when placing implants in the mandible. a. acquire evidence-based specific skills in assessment and planning of implant surgery b. use appropriate diagnostic imaging c. employ evidence-based strategies d. all of the above

6. ____ have been shown to improve the surgical precision of implant placement if used with a coordinated drilling system (typically less than 2 mm apical and crestal deviation and less than 5º angulation error) and might reduce the risk of TGI. a. CBCT-guided static stents b. Freehand placement techniques c. Limited guidance laboratory fabricated surgical guided d. An arbitrary safety margin

4. It is important to note that the American Academy of Oral and Maxillofacial Radiology (AAOMR), in its revised evidence-based position statement on the selection criteria for radiology in implant dentistry,

Volume 10 Number 3

7. The UK survey revealed that the most frequent standard length of implants used within the

posterior mandible by (56%) was ____. a. 4 mm b. 6 mm c. 8 mm d. 10 mm 8. The authors recommend the use of _____ when operating in close proximity of vital structures in the mandible unless there are systemic contraindications. a. vasopressors (such as norepinephrine) b. steroids (such as dexamethasone) c. NSAIDS (such as Advil®) d. coagulation modifiers (such as heparin) 9. A home check within ________ after implant surgery is recommended to detect nerve injury as early as possible. a. 6-12 hours b. 14-18 hours c. 24 hours d. 36 hours 10. If the neuropathy affects most of the dermatome and is associated with severe neuropathic pain, ____ might be strongly indicated. a. an additional course of steroids b. medical management c. early removal of the implant d. both b and c

Implant practice 31

CE CREDITS

IMPLANT PRACTICE CE

CONTINUING EDUCATION

High-performance polymers Drs. Paul Tipton and Bernd Siewert look at a new material for framework fabrication and consider processing methods, pressing versus milling, and the long-term findings

olyetheretherketone (PEEK), the highperformance polymer, has proven successful in many areas of medicine for a number of years and is also gaining an everincreasing number of advocates in dentistry thanks to its good physical properties and chemical resistance. CAD/CAM processing of PEEK also opens new options. In the following article, the authors demonstrate the possibility of milling PEEK in the CAD/CAM procedure from industrially manufactured material blocks (Juvora™ Dental Disc, Juvora) rather than injection molding and present long-term documentation of a case involving treatment of bruxism by means of a prosthetic restoration.

Injection molding technique If industrially manufactured elements are used for an implant-borne prosthetic restoration, they can be overmolded (thermopress system) with PEEK. This eliminates the need for additional adhesive retention, which can be of particular advantage where

Educational aims and objectives

This article aims to demonstrate the possibility of milling polyetheretherketone (PEEK) in the CAD/CAM procedure from industrially manufactured material blocks and present long-term findings of a case involving treatment of bruxism.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 36 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Garner more information about PEEK high-performance polymer.

•

Identify some positive aspects of the injection molding technique.

•

Recognize some advantages of CAD/CAM bridge frameworks

little space is available, for example, in the anterior region. Furthermore, the injection molding technique requires lower financial investment than CAD/CAM fabrication of PEEK frameworks. The entire fabrication process of wax-up, investing, and finishing is time-consuming. The procedure with the thermopress system was not fully developed technically. In some cases, visible voids and cracks

were produced in the framework due to the familiar problems of injection molding. In these cases, the complete fabrication process had to be repeated. It was not always possible to maintain the surface contours of the wax-up exactly due to adjustments to the surface that were occasionally necessary. This is counterproductive, in particular with fully anatomically designed bridge frameworks. The transition to the plastic phase (heating and subsequent cooling) impairs the material-technical properties, especially with high-performance polymers such as PEEK. There is the risk of changes in the crystal lattice structure. Despite these factors, which may result in a reduction in quality, no problems with regard to crack formation, material fatigue, or even fracture have occurred.

CAD/CAM bridge frameworks Industrially manufactured blanks with approval for permanent restorations have recently become available (Juvora Dental

Professor Paul Tipton, BDS, MSc, DGDP, RCS, is a specialist in prosthodontics with more than 30 years’ experience in private practice. He is the founder of Tipton Training and a widely published author. He gained his master’s degree in 1989 from the Eastman Dental Hospital and London University and started teaching on the University of Manchester’s MSc in restorative dentistry. He is now professor of restorative and cosmetic dentistry at the City of London Dental School. He practices at his clinics in Manchester, Watford and Harley Street, London. For more information, visit www. drpaultipton.co.uk. Dr. Bernd Siewert graduated from the Christian Albrecht University, Kiel, Germany, in 1986, and gained his Dr.med. dent doctorate in 1989. Since 1996, Dr. Siewert has had his own private practice in Madrid and specializes in implant treatment. Since 2007, he has worked as an instructor at the International Training Center for Dental Implantology (IFZI), Nuremberg, Germany. He lectures internationally and is the author of numerous publications.

32 Implant practice

Figures 1 and 2: Framework (left: basal, right: occlusal), Juvora Dental Disc fabricated in the CAD/CAM-supported process Volume 10 Number 3

Figure 3: The veneered bridge on the master model (palatal view)

The reworking required is limited to highluster polishing, provided a correct CAD/ CAM chain is employed. This guarantees that the shape contoured during softwaresupported fabrication is retained exactly.

Metal or all-ceramic restorations are at risk of fracture and do not provide any shockabsorbing effect to prevent overloading of the patient’s natural teeth and the implants.

Bruxism in patients

A 55-year-old female patient was referred to the practice for implant treatment and prosthetic restoration (Figure 5). She had previously been treated via a barsupported denture placed on four implants (Figures 6-9).

In the authors’ opinion, the ideal method and materials have yet to be found in the search for an optimal prosthetic solution for bruxism patients. Acrylic teeth have a damping effect but are subject to abrasion.

Prosthetic restoration

Figure 4: The bridge in the patient’s mouth after 10 months in situ. The secondary telescope UL6 and bridge pontic UL5 have been designed fully anatomically. The shade of the non-veneered PEEK (Juvora Dental Disc) is acceptable for the occlusal surface in the posterior region. The gingival conditions are excellent

Figure 5: Initial situation, partially edentulous upper jaw with retained and displaced canines

Figure 6: After removal of the canines and placement of four implants

Figures 7-9: At the time (1996), the patient was prosthetically treated with a bar-supported denture Volume 10 Number 3

Implant practice 33

CONTINUING EDUCATION

Disc, Juvora). This material has no additives — it is therefore pure and has been used in medicine for many years (PEEK-Optima, Invibio™). The advantage of CAD/CAM-fabricated bridge frameworks is that the material is not adversely affected during the fabrication process, provided it is used correctly. Bridge frameworks, milled from a high-grade, industrially manufactured block (Figures 1 and 2), undergo no physical changes during the fabrication process and exhibit the same or possibly better material/technical properties (Figures 3 and 4). Advantages of CAD/CAM: • High-quality bridge frameworks with no material faults • Precise manufacture • Reduced manufacturing time • Easily reproducible fabrication process.

CONTINUING EDUCATION

Figures 10-12: After 13 years, the damaged denture was replaced by a fixed, operator-removable, horizontally screw-retained bridge

Figures 13 and 14: After 3 years in situ, the veneers split off again (bruxism); the PEEK frameworks, however, show no signs of impairment

Figure 15: Neither the implants nor the molars (primary crowns) show any clinical anomalies

Figures 16 and 17: The implant-supported bridge was remade with CAD/CAM

After 13 years of use, the overdenture was damaged due to severe bruxism and was no longer sufficient. It was replaced by a fixed, operator-removable, horizontally screw-retained bridge (Figures 10-12). The chrome-cobalt-molybdenum alloy telescope crowns on four implants and two molars were adhesively retained in a bridge framework fabricated using PEEK (BioXS, Bredent). After 3 years in situ, the occlusal surfaces (veneers) had been abraded completely in the posterior region, and later, the veneers split off tooth UL2 due to the bruxism (Figures 13 and 14). A remake of the prosthetic restoration was unavoidable. The BioXS PEEK framework material was completely intact. Following abrasion of the acrylic teeth, the framework surface was in direct occlusal contact, and there were only minimal signs 34 Implant practice

of wear. No cracks or decementation were observed basally. Neither the implants nor the molars with the cemented primary crowns showed any clinical anomalies (Figure 15). What appeared to be clear was that the composite bridge design of the PEEK bridge framework is also sufficiently resistant to withstand enormous masticatory forces, but that the acrylic teeth in the posterior region are the weak point in patients with bruxism.

Second prosthetic restoration It was then decided on CAD/CAMsupported fabrication of a fully anatomical bridge framework for the remake of the prosthetic restoration. The material used was unfilled PEEK (Juvora Dental Disc), which can be used for fabricating highly precise restorations.

The basal region was designed fully anatomically in a convex shape (Figures 16-19). The buccal aspects in the visible areas from premolar to premolar were veneered. As both the protrusive and lateral excursions were to be on the PEEK framework, no prefabricated laminate veneers were placed in this area but rather custommilled composite veneers (Figures 18 and 19). The occlusal surfaces and guidance pathways were not veneered. An occlusal screw-retained restoration was fabricated, as horizontal screw retention in combination with the telescope principle can be problematic from a hygiene point of view. To ensure that the bridge fitted passively, the four implant copings in the mouth were adhesively retained and then the new restoration fitted. Volume 10 Number 3

Figures 18 and 19: The finished bridge. The Juvora Dental Disc framework was designed fully anatomically in the functionally critical areas

Discussion PEEK-Optima (Invibio) has been tried and tested as a material for implants in the medical field for more than 10 years. Its high biocompatibility has been proven in several clinical studies (Siewert, 2013). The low specific weight, bone-like elasticity, metalfree character, and toughness, combined with virtually nonexistent material fatigue, make it an ideal material for use in prosthetic dentistry. The CAD/CAM-supported processing of PEEK opens up new possibilities. The physical properties of the material described allow approximately the same design dimensions as those of metallic materials. To date, approval of the Juvora Dental Disc covers removable restorations, implant-borne prosthetics, and crowns and bridges. This means that cast-metal denture bases, secondary units, superstructures with fixed/removable restorations, implant-supported, posterior full crowns, and (as demonstrated here) operator removable, screw-retained bridges can be fabricated using the material described. In the past, long-term clinical results were achieved in patients with bruxism and heavy pressing using a gold alloy on the occlusal surface. A material is now available for these indications, which has the effect of damping masticatory forces and, due to its grayish shade, can also be used for occlusal contours — metal-free and biocompatible.

Conclusion The positive clinical experiences, using fully anatomical PEEK bridge frameworks fabricated using the injection molding technique, can be transferred to CAD/CAM processing. This enables frameworks to be fabricated in a reliable, reproducible Volume 10 Number 3

Figures 20 and 21: Finished bridge in situ

Figure 22: The Juvora Dental Disc is highly pure and free of additives and is therefore not visible on the X-ray

production procedure. Consistent, optimum material quality is also guaranteed. The chemical properties of PEEK do exclude any transparent versions. However, it may be possible in the future to add inorganic dyes to reproduce the shades on the Vita shade guide. Full crowns made from this material could then be used with confidence, including with regard to esthetic parameters.

A material has therefore been found that builds on the clinical experience of gold. IP

REFERENCE 1. Siewert B, Parra M (2013) Eine neue Werkstoffklasse in der Zahn,edizin. PEEK als Gerüstmaterial bei 12-gliedrigen implantatgetragenen Brücken (A new material class in dentistry. PEEK as a framework material with 12-unit, implant-supported bridges). Z Zahnärztl Implantol. 2013; 29:148-159.

Implant practice 35

CONTINUING EDUCATION

The non-veneered Juvora Dental Disc is barely noticeable as an occlusal surface material. The gray-brown shade of the occlusal and oral sections was accepted by the patient without any problem (Figures 20 and 21). In such cases where bruxism is a problem, the focus is on producing a durable, functioning restoration. The shock-absorbing properties of the new design should protect the implants and the patient’s natural teeth against the destructive forces of bruxism. Juvora Dental Disc PEEK material is completely free of additives (such as barium sulphate, for example) and is therefore not visible on an orthopantomogram; a detail that one has to become accustomed to (Figure 22).

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High-performance polymers: part 2 TIPTON/SIEWERT

1. (Regarding overmolding with PEEK) This eliminates the need for additional adhesive retention, which can be of particular advantage where _________, for example, in the anterior region. a. little space is available b. a lot of space is available c. implants are not recommended d. problems have been identified 2. Furthermore, the injection molding technique requires ________ than CAD/CAM fabrication of PEEK frameworks. a. higher financial investment b. lower financial investment c. less precision d. less clinical expertise 3. Bridge frameworks, milled from a high-grade, industrially manufactured block, undergo _____ physical changes during the fabrication process and exhibit the same or possibly better material/ technical properties. a. no b. some c. complicated d. abrasive 4. The reworking required is limited to _______, provided a correct CAD/CAM chain is employed.

36 Implant practice

a. b. c. d.

changes in the crystal lattice structure filling voids high-luster polishing adhesive retention

5. (In the case of the 55-year-old female patient) What appeared to be clear was that the composite bridge design of the PEEK bridge framework is also sufficiently resistant to withstand enormous masticatory forces, but that the acrylic teeth in the posterior region are the _______ in patients with bruxism. a. least important b. most abrasive c. strongest point d. weak point 6. In such cases where bruxism is a problem, the focus is on producing a _______ restoration. a. durable b. functioning c. removable d. both a and b 7. (Regarding PEEK-Optima) The low specific weight, ________, combined with virtually nonexistent material fatigue, make it an ideal material for use in prosthetic dentistry.

a. bone-like elasticity b. metal-free character c. toughness d. all of the above 8. The CAD/CAM-supported processing of PEEK opens up new possibilities. The physical properties of the material described allow _______ design dimensions as those of metallic materials. a. approximately the same b. for completely different c. for more creative d. none of the above 9. In the past, long-term clinical results were achieved in patients with bruxism and heavy pressing using a gold alloy on the ______ surface. a. lingual b. occlusal c. buccal d. facial 10. The chemical properties of PEEK do exclude any ______ versions. a. gray b. gold c. transparent d. white

Volume 10 Number 3

CE CREDITS

IMPLANT PRACTICE CE

The Board of Trustees of the American Academy of Implant Dentistry unanimously selected Cheryl Parker, CAE, to be the new Executive Director of the Academy. Ms. Parker has a very strong background in the dental world, having most recently served for over 10 years as Director, Academics, Regulatory Affairs, and Advocacy for the American Academy Cheryl Parker, CAE of Periodontology. She previously worked for nearly 7 years for the American Dental Association. She was Manager, Tripartite Grassroots Membership Initiative and Manager, Allied Dental Program Reviews/Dental Laboratory Technology Education (CODA). She has also earned the Certified Association Executive designation from the American Society of Association Executives. A graduate of the University of Illinois at Chicago, Ms. Parker is currently pursuing a Master of Science in Public Services at DePaul University. For more information, visit www.aaid.com, or call 312-335-1550.

INDUSTRY NEWS

American Academy of Implant Dentistry selects new Executive Director

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CLASSIC alloplastic bone grafting system

Designed for Easy Placement

Once the coated granules of GUIDOR® easy-graft® are syringed into the bone defect and come in contact with blood, they change in approximately one minute from a moldable material to a rigid, porous scaffold. Fully resorbable AO announces recipients of 2017-2018 Osseointegration Foundation Research Grants Recipients of the 2017-2018 Osseointegration Foundation (OF) Research Grants were announced at the Academy of Osseointegration’s (AO) 2017 Annual Meeting in Orlando, Florida. First-place grants of up to $30,000 each will be awarded to research teams in the several categories, and the grant recipients will present their results at the 2018 AO Annual Meeting to be held March 1-3, 2018, in Los Angeles, California. A call for applications for the 2017-2018 OF Research Grants will be announced this fall. To qualify, research grant proposals must be submitted by an AO member, faculty member, or student who conducts research in any academic dental institution (at least one person on the research team must be an AO member). For more information, visit www.osseo.org.

No human or animal-derived materials Ideal for ridge preservation and filling voids around immediate implant placements This product should not be used in pregnant or nursing women.

Watch video @ http://us.guidor.com/InAction

Try it! Buy 2 (any size), Get 1 Small (C11-018) at no charge! Promo Code: GDRSML. Expires 6/30/2017. Promo is valid while supplies last.

To purchase or learn more, visit http://us.GUIDOR.com/easy-graft/ or call 1-877-484-3671. Instructions for Use (IFU), including indications, contraindications, precautions and potential adverse effects, are available at http://us.GUIDOR.com/IFU/. © 2017 Sunstar Americas, Inc.All rights reserved. GDR17032 05032017v1 The trademarks GUIDOR, easy-graft and BioLinker are owned by Sunstar Suisse, SA.

Volume 10 Number 3

Implant practice 37

PRACTICE DEVELOPMENT

The importance of website lead conversion Ian McNickle, MBA, discusses how your website can lead patients to your practice

hat would you say if I told you that by making some changes to your website design, content, and layout, you could generate over $100,000 in additional revenue in 12 months? You might think I’m crazy, but I encourage you to take 5 minutes to read this article. You might be very glad you did. To learn how, we need to first take a step back and discuss online marketing. When it comes to online marketing, there are two primary objectives: 1. Generate as much “relevant” traffic as possible. 2. Convert that traffic into as many new patient leads and appointments as possible. I frequently lecture at dental conferences and study clubs all over North America, and almost without exception, the clinicians and staff in attendance are not familiar with the performance metric of website lead conversion.

Website traffic To better understand this metric, let’s start with generating traffic. There are many ways to generate traffic to a website such as high search rankings on Google, Bing, Yahoo, etc., which is achieved through effective Search Engine Optimization (SEO). Driving lots of patient reviews to review sites such as Google, Facebook, Healthgrades, and Yelp also have a very positive impact on your search rankings and traffic. Social media activity, engagement, boosted posts, and paid ads can all drive traffic to a website as well. Online directories can drive traffic, and the list goes on and on.

Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a Co-Founder and Partner at WEO Media, winner of the 2016 Cellerant Best of Class Award for Dental Marketing and Dental Websites. If you have questions about any marketing-related topic, please contact Ian McNickle directly at ian@ weomedia.com, or call 888-246-6906. For more information, you can visit online at www.weodental.com.

38 Implant practice

Lead conversion Once you’ve implemented a robust program to generate traffic, it is equally important to understand how to convert all this traffic into new patient leads. As with traffic, there are many items that affect website lead conversion such as: • having a modern website design with proper layout • the location of the phone number • appointment request buttons or forms • clear calls to action • effective use of videos • compelling offers • online scheduling links • the use of actual photos instead of stock photos • great doctor bio and team pages • patient testimonials (video and written) • helpful and accurate content An experienced online marketing agency with expertise in the dental industry like WEO Media should be consulted for best practices in this area.

How is the lead conversion rate calculated? The lead conversion rate is calculated by dividing the amount of conversion activities (phone calls, appointment requests, etc.) by your website traffic each month. By doing this, you’ll be able to develop a baseline range for how your website typically converts traffic. Consider this example: Let’s suppose your website generates 400 visits (traffic) in a month. You received 30 phone calls from the website and 10 appointment requests through the website. Your conversion rate

would be 40 conversion activities divided into 400 visits for a conversion rate of 10%. If you monitor this rate over time, you’ll be able to understand how your website is actually performing as a marketing tool.

Maximize your Return on Investment (ROI) Where this gets really interesting is when you can improve items on your website that improve your website conversion rate. Even a small improvement can result in tens of thousands or even hundreds of thousands of dollars per year in extra revenue. An average website may generate 500 visits per month with an average conversion rate of around 10%. If you can implement strategies to improve your conversion rate, and it improves to 12%, consider the impact. This slight 2% improvement equates to 10 additional new patients leads per month or 120 per year. If you can convert even 25% of these new patient leads, you’ve now generated an extra 30 patients per year. How much is that worth? The good news is most of the items that improve the website conversion rate do not involve ongoing costs, but rather specific expertise and industry experience to properly design and construct the website.

Marketing consultation If you have questions about your website, social media, or online marketing, you may contact WEO Media for a consultation to learn more about the latest industry trends and strategies. The consultation is free if you identify yourself as a reader of this publication. IP

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com Volume 10 Number 3

HANDS-ON DENTAL IMPLANT TRAINING FROM DR. JUSTIN MOODY AND HIS FACULTY, ONE OF THE MOST CREDENTIALED TEAMS OF IMPLANTOLOGISTS IN THE COUNTRY.

UPCOMING SESSIONS DENVER, COLORADO JULY 21 AND 22, 2017 SAN FRANCISCO, CALIFORNIA SEPTEMBER 22 AND 23, 2017

ON THE HORIZON

Esthetic failures start as soon as we fail to plan Dr. Justin Moody discusses how to save time and money and reduce stress

hen we think of esthetic failures in dento ensure an ideal outcome. With the removal stage that the case entered my world; the fork tistry we think of color, size, shape, of tooth No. 9, an immediate implant was not in the road was either to remove and try to position, gingival height, symmetry, etc. Imconsidered and was taken straight to a bone rebuild for a possible better outcome or leave the integrated implant and see what could be plant dentistry takes this one step further. In graft and a temporary bridge. This decision done with what we got. Ultimately, after long addition to all the above, we need to take into led to the flattening of the papilla, decreased height of buccal bone, and overall loss of discussions with the patient as to the difficulty consideration such aspects as bone height, quality, quantity, keratinized tissue, gingival bone quantity and quality. of rebuilding the site and with restoring what scallop, temporary restorations, and materiThe placement of the implant ended up she had, we agreed upon the decision to fix als. Having recently treated a case where this in a supra-crestal position, limiting the emerwhat we had. A custom IPS e.max® screwretained crown was made with an authentic is was so true, I wanted to share how starting gence profile and handicapping the restoration from having an ideal outcome. It is at this BioHorizons® titanium base followed with with a plan can save everyone time, money, IPS e.max crowns from ProSmiles dental and hard feelings down the road. Prior to walking into my clinic, the studio on teeth Nos. 7, 8, and 10. patient had been given a cosmetic treatThe outcome was esthetically pleasing to the patient and clinically ment plan for some veneers so that she acceptable to me, but it always reminds could show more incisal edge when she smiles. The previous doctor prepared the me of how important proper planning is teeth for veneers, things got away from to the final outcome. Try to remember them, and they ended up in full coverage, that old carpenter adage, “Measure and ultimately tooth No. 9 was going to twice and cut once,” as it is so true. In my 20 years of placing implants, I too require extraction. It is at this point that decisions need to be made that will affect have many cases that are far from perfect the long term survivability and esthetic from lack of planning, mostly because I outcome of the implant and ultimately the didn’t know what I didn’t know. As long Figure 1: Acquired preoperative Figure 2: PA of case at the time of entire case.” Knowing this is an esthetic as we learn from our mistakes, then it is PA of tooth Nos. 8 and 9 consultation, healing abutment on case, one must determine the best way worth the effort! IP implant under temporary bridge

Figure 3: Clinical photo of temporary bridge at time of consultation

Figure 5: IPS e.max® crowns fabricated by ProSmiles Dental Studio

Figure 6: PA of seated crowns and screw-retained implant crown

Figure 4: Clinical photo of preps and healing abutment upon removal of temporary bridge

Justin Moody, DDS, DICOI, DABOI, is a Diplomate of the American Board of Oral Implantology and of the International Congress of Oral Implantologists, Fellow and Associate Fellow of the American Academy of Implant Dentistry, and Adjunct Professor at the University of Nebraska Medical College. He is an international speaker and is in private practice at The Dental Implant Center in Rapid City, South Dakota. He can be reached at justin@justinmoodydds.com or at www.justinmoodydds.com. Disclosure: Dr. Moody is a paid speaker for BioHorizons®.

Figure 7: Clinical photo the day of seating the crowns 40 Implant practice

Volume 10 Number 3

multi-unit abutments simple. flexible. smart.

full arch solutions for every scenario Your patients are unique, shouldn’t your treatment plans be as well? The BioHorizons Multi-unit abutment system provides the tools to restore even compromised edentulous cases. With a wide variety of abutment angles, collar heights and platform diameters, no system better equips you to plan for your patients’ individual needs. The abutment’s intelligent design and restorative flexibility is matched only by its ease of use and surgical efficiency. The Multi-unit abutment system will provide your patients with secure, beautiful smiles.

For more information, contact BioHorizons Customer Care: 888.246.8338 or shop online at www.biohorizons.com

Made in the USA

SPMP14072 REV C JUN 2015

The BellaTek® Encode® Impression System

The BellaTek Encode Impression System is the gateway to creating a customized solution for you and your patients. • A more efficient workflow and less inventory to stock provide a vehicle for practice growth. • Create and select aesthetic BellaTek Patient Specific Abutments available in titanium or with titanium nitride coating. • No need to remove the healing abutment, preserving tissue and resulting in aesthetic outcomes.

It’s not just what we make… it’s what we make possible.

For more information please contact your local Zimmer Biomet Sales Representative or visit our online store at zimmerbiometdental.com

All trademarks are the property of Zimmer Biomet or its affiliates, unless otherwise indicated. Due to regulatory requirements, Zimmer Biomet’s dental division will continue to manufacture products under Zimmer Dental Inc. Biomet 3i, LLC respectively until further notice. BellaTek Encode is manufactured and distributed by Biomet 3i. Please note that not all products are registered or available in every country/region. Please contact your Zimmer Biomet Dental representative for product availability and additional information. AD060 REV B 09/16 ©2016 Zimmer Biomet. All rights reserved.