Implant Dentistry / Dentisterie implantaire Practice ......Implant dentistry continues to be...

Canadian Journal ofRestorative Dentistry & Prosthodontics

Publication officielle de l’Académie canadiennede dentisterie restauratrice et de prosthodontie

Journal canadien dedentisterie restauratrice et de prosthodontie

The official publication of the Canadian Academy ofRestorative Dentistry and Prosthodontics

PEER-REVIEWED - JOURNAL - REVUE DES PAIRS

VOLUME 3 - 2Spring/printemps, 2010PUBLICATIONS AGREEMENT # 40025049 • ISSN 1916-7520

www.andrewjohnpublishing.com

Implant Dentistry / Dentisterie implantaire

Practice Management/Gestion de cabinet

http://www.pacificimplantinstitute.com

VOL 3, NO.2 • SPRING/PRINTEMPS, 2010

Official Publication of the CanadianAcademy of Restorative Dentistry and Prosthodontics

Publication officielle de L’Académie canadienne de dentisterie restauratrice et de prosthodontie

EDITOR-IN-CHIEF/RÉDACTEUR EN CHEFHubert Gaucher

Québec City, Québec | [email protected]

ASSOCIATE EDITORS/RÉDACTEURS ASSOCIÉSEmmanuel J. Rajczak

Hamilton, Ontario | [email protected] Andrea

Chester, Nova Scotia | [email protected] Nimchuk

Vancouver, British Columbia | [email protected]

SECTION EDITORS/RÉDACTEURS DE SECTIONOcclusion and Temporo-Mandibular Dysfunctions/Occlusion et dysfonctions temporo-mandibulaires

Kim ParlettBracebridge, Ontario | [email protected]

Implant Dentistry/Dentister ie implantaireRon Zokol

Vancouver, British Columbia | [email protected] Fortin

Québec City, Québec | [email protected] Dentistry / Dentister ie esthétique

Paresh ShahWinnipeg, Manitoba | [email protected]

Dental Technology / Technologie dentairePaul Rotsaert

Hamilton, Ontario | [email protected]

MANAGING EDITOR/DIRECTEUR DE LA RÉDACTION

Scott [email protected]

CONTRIBUTORS/CONTRIBUTEURSYvan Fortin, Hubert Gaucher, Kenji Higuchi

Robert Miller, Dennis Nimchuk, Jo-Anne O'Connor-WebberAstley Smith, Richard Sullivan, Nicolas Tardif, Ron Zokol

ART DIRECTOR/DESIGN /DIRECTEUR ARTISTIQUE/DESIGN

Andrea [email protected]

SALES AND CIRCULATION COORDINATOR/COORDONATRICE DES VENTES ET DE LA DIFFUSION

Brenda [email protected]

TRANSLATION/TRADUCTION

Gladys St. LouisACCOUNTING / COMPTABILITÉ

Susan McClung

GROUP PUBLISHER / CHEF DE LA DIRECTIONJohn D. Birkby

[email protected]

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Susan Collins, MA, Certified Translator (ATIO),

MESSAGE FROM THE EDITOR-IN-CHIEF

Doctor, does your patient need dentalimplants or does your patient need

an implant-supported prosthesis? Thereinlies the answer.

Swedish prosthodontists placed the firstimplant-supported prosthesis in the mid-60s and they, along with theirinternational prosthodontist colleagues,remain instrumental to this day in theadvancement of contemporary implantdentistry. In the late 70s, Dr. George Zarb,now a retired professor of prosthodonticsfrom the University of Toronto and a wellpublished researcher and educator in thisfield, addressed the Association ofProsthodontists of Canada (APC) at aMontréal annual meeting on the topic ofosseointegrated dental implants and thetechnology arising from the BrånemarkInstitute based in Göteborg, Sweden.Canadian prosthodontists, well ahead oftheir American counterparts, wereencouraged by this enthusiastic keynotespeaker about integrating such predictabledental implant technology into their ownpractices and teaching environments.

Implant dentistry continues to beprosthodontically driven since patientsconsult for rehabilitations of theirdeficient oral functions and esthetics.However, the ADA and the CDA have notrecognized implant dentistry as a distinctdental specialty. Rather, they initiallyadvocated that implant dentistry ought tobe mainstreamed within the various

existing specialties or into a generaldentistry practice. Based on thisresolution, provincial professionalregulatory bodies, did not see fit to requireformal university implant dentistrytraining other than limited CE courses,mostly devoid of clinical evaluations. So,it fell upon a small number ofprosthodontist-educators, themselvesapostles of implant dentistry of the 80sand 90s, to make room in their regularundergraduate programs, then to initiateCE courses, with the aim of transferringto the profession at large, the scientific andclinical precepts of contemporary implantdentistry.

To begin with, prosthodontists had toaggressively convince surgeons to embarkon implant training in order toincorporate the surgical aspect of patients’treatment plans, often directly orindirectly sponsoring the emergence ofimplant surgical services nationwide.Dental implant manufacturers, looking toreach North American markets, rejoiced.Among some dental faculties, however,the well-meaning prosthodontic pioneerswere regarded as “implant pushers” whichcreated dissidence between the passionateinnovators and their indifferent fellowacademics and administrators.

Subsequently, once this specialty drivenphase had completed its mission, with amajority of oral surgery practices trained,equipped, and eager to advance,

ComprehensiveTreatment Planningin Implant Dentistry:Would a Workshop

be Beneficial?

Canadian Journal of Restorative Dentistry & Prosthodontics 3

4 Journal canadien de dentisterie restauratrice et de prosthodontie printemps 2010

MESSAGE FROM THE EDITOR-IN-CHIEF

unforeseen ramifications ensued; generalpractitioners started to be energeticallyrecruited by the industry for the purpose ofproviding extensive patient referral pools tokeep surgeons busy and interested in implantdentistry.

Merit was then bestowed by the industry onthe overall knowledge and capabilities ofsurgeons regarding implant dentistry, therebyleading to in-office study groups wheregeneral practitioners were invited to bring intheir patient cases so that surgeons wouldplan all aspects of treatment, including theprosthodontic. Every so often, a phone call tothe implant manufacturer might be deemednecessary in order to verify some prostheticcomponent or laboratory procedure and thatseemed to be enough for all concerned.

Consequently, at the start of the newmillennium, surgical and general dentistswere stealthily becoming best suited to planand execute extensive, comprehensive,rehabilitative implant treatments. Eventually,implant surgeons at large began involvingdenturists to feed their patient pools. Manyproclaimed that prosthodontics is a deadspecialty! Why did this happen? Were weprosthodontists asleep at the helm? Was itinevitable? Avoidable?

Is this the aftermath of what the ADA and theCDA had in mind when they deliberately

surrounded implant dentistry with a greyzone? Over the past three decades, as a clinicalprosthodontist, a good portion of mypractice has dealt with patient remakes,including implant dentistry cases. Howcome? Why do these implant-supportedprosthetic remakes, as well as non-implantremake cases, ultimately end up withprosthodontists? Is the last resort whatprosthodontists are destined to become? Forthe sake of the patient, and for no otherulterior motive, this is where comprehensivetreatment planning involving prosthodonticextensive rehabilitation cases should havestarted in the first place. Instead, I imagine,plenty more prosthodontists, have to dealwith maltreated, anxious, and at timesdepressed patients, necessitating the mostdelicate professional interventions, not tomention our professional expertise inlitigation issues that have become par for thecourse in our workload.

It is beyond me that a practitioner wouldpresume to be competent in the field ofimplant dentistry if he or she does not mastercomprehensive treatment planning and therelated clinical skills affecting the naturaldentition. Why not collaborate with aprosthodontist, to establish a treatmentsequence and mutually agree to implementthe proper treatment plan inclusive of thereferring dentist and participating surgeon?Not only would this interaction become

professionally enriching but would, first andforemost, benefit the patient. For instance,why replace three upper anteriors withimplant-supported restorations when thereis a diagnosed and untreated posterior bitecollapse affecting the overall dentition?Overtreatment or downright malpracticelawsuits can and should be avoided withproper comprehensive treatment planning.Not every edentulous case (full or partial)calls for implants. With all of the professionalresources available, there is no excuse for suchviolations.

Are prosthodontists becoming obsolescentwith regards to evaluating and masteringcontemporary implant prosthodontics? Areyou, in your own dental practice, comfortablewith the management of implantprosthodontic cases and proficient atexecuting the various stages of acomprehensive treatment plan? Would aworkshop on all of these matters be productive?Let me know your thoughts and suggestions.

Dr. Hubert GaucherEditor-in-Chief

Docteur, votre patient a t-il besoind’implants dentaires ou d’une prothèse

implanto-portée? La réponse réside dans laquestion elle-même.

Les prosthodontistes suédois ayant posé en

bouche la première prothèse sur implantsvers le milieu des années 60 continuent dejouer, avec leurs collègues internationaux, unrôle dans les progrès de l’implantologie. Versla fin des années 70, le Dr George Zarb, maintenant professeur retraité de

prosthodontie à l’Université de Toronto etchercheur publié, a fait une présentation à laréunion annuelle de l’Association desprosthodontistes du Canada (APC) àMontréal sur l’ostéointégration et latechnologie issue de l’Institut Brånemark

Plan de traitement compréhensifen implantologie dentaire :

un atelier serait-il bénéfique?

MESSAGE DU RÉDACTEUR EN CHEF

MESSAGE DU RÉDACTEUR EN CHEF

situé à Göteborg en Suède. Lesprosthodontistes canadiens, bien en avancesur leurs collègues américains, ont étéencouragés par ce conférencier de marqueenthousiaste, à intégrer cette technologiefiable dans leur pratique et dans leurenseignement.

L’implantologie continue d’être dictée par laprosthodontie puisque les patients consultenten raison d’une mauvaise fonction ou del’aspect esthétique de leurs dents. Toutefois,l’ADA et l’ADC n’ont pas reconnul’implantologie comme une spécialitédentaire distincte. Plutôt, ils ont décrété quel’implantologie ne doit pas être une classe àpart et devrait s’intégrer, ou bien aux diversesspécialités qui existent, ou à même unepratique générale. En vertu de cetterésolution, les organismes de règlementationdes professions à l’échelle provinciale n’ontpas cru nécessaire d’exiger une formationuniversitaire formelle en implantologie autreque les cours limités d’éducation continue,lesquels ne comportent pas, pour la plupart,d’évaluations cliniques. Ainsi, il incombe à un petit nombre de prosthodontistes-éducateurs, eux-mêmes apôtres del’implantologie des années 80 et 90,d’incorporer dans leurs programmesréguliers de premier cycle, puis de préparerdes cours d’éducation continue, les préceptesscientifiques et cliniques de l’implantologiecontemporaine.

Au début, ce sont les prosthodontistes quidevaient convaincre les chirurgiens de suivreune formation sur implants afin d’incorporerl’aspect chirurgical des plans de traitementdes patients, parrainant ainsi, directement ouindirectement, l’essor des services enimplantologie à l’échelle nationale. Lesfabricants d’implants dentaires, cherchant àrejoindre les marchés de l’Amérique du Nord,étaient comblés. Parmi certaines facultésdentaires, les pionniers en prosthodontieimplantaire étaient vus comme des«pousseux d’implants», ce qui a engendré unedissidence entre les innovateurs passionnés et leurs collègues universitaires etadministrateurs.

Ensuite, une fois cette phase de spécialitéaccomplie, avec une majorité de pratiques enchirurgie buccale formée, équipée et fière de

progresser, des ramifications inattendues sesont produites. Les omnipraticiens ontcommencé à être recrutés par l’Industrie dansle but de fournir un grand nombre depatients aux chirurgiens pour les occuper etles intéresser à l’implantologie.

Le mérite a donc été conféré par l’Industriesur les connaissances et les capacités deschirurgiens. Ceci a entraîné des groupesd’étude en cabinet où les généralistes étaientinvités à présenter leurs cas pour que leschirurgiens planifient tous les aspects dutraitement, y compris les traitementsprosthodontiques. À l’occasion, unecommunication téléphonique au fabricantd’implants pouvait être nécessaire afin devérifier certaines composantes prothétiquesou une procédure en laboratoire, et celasemblait suffire aux personnes concernées.Par conséquent, au début du nouveaumillénaire, les dentistes généralistes et leschirurgiens buccaux étaient bien placés pourplanifier et exécuter des traitementsimplantaires extensifs et complets deréadaptation. Les chirurgiens enimplantologie ont commencé à viser lesdenturologistes afin d’augmenter leursbanques de patients. Plusieurs ont proclaméque la prosthodontie était une spécialitémorte! Pourquoi cela s’est-il produit? Est-ceque les prosthodontistes dormaient à labarre? Était-ce inévitable? Était-ce évitable?Est-ce qu’il s’agit du regain que l’ADA etl’ADC avaient en tête lorsqu’ils ontdélibérément placé l’implantologie dans unezone grise? Au cours des trente dernièresannées, en tant que prosthodontiste clinicien,une bonne portion de ma pratique a étéconsacrée à des réfections de cas d’implants.Comment se fait-il? Pourquoi ces casd’implants échoués finissent-ils entre lesmains d’un prosthodontiste? Est-ce que lesprosthodontistes ne sont que des derniersrecours? Pour le patient, et pour aucune autreconsidération, c’est précisément là que laplanification du traitement de cas nécessitantun traitement prosthodontique élaboréaurait dû commencer. Plutôt, moi-même et,j’imagine, plusieurs autres prosthodontistes,devons composer avec des patients anxieux,parfois même sérieusement déprimés, ayantreçu des traitements médiocres. Ces patientsnécessitent nos interventions spécialisées desplus délicates, si ce n’est notre expertise

professionnelle en matière de litiges, devenuschose courante dans notre charge de travail.Je n’arrive pas à comprendre qu’un praticienpuisse présumer être compétent enimplantologie s’il ne maîtrise pas laplanification du traitement ni lescompétences cliniques correspondantesconcernant la dentition naturelle. Pourquoine pas collaborer avec un prosthodontistepour établir une séquence adéquate detraitements à laquelle le dentiste référant et lechirurgien participeraient? Non seulementcette interaction serait-elle enrichissante dupoint de vue professionnel, mais bénéficieraitavant tout le patient. Par exemple, pourquoiremplacer trois dents antérieures de l’arcadesupérieure par des restaurations implanto-portées lorsqu’il y a affaissement del’occlusion postérieure diagnostiqué et nontraité affectant toute la dentition? Unsurtraitement ou des poursuites pour fauteprofessionnelle sont évitables s’il y aplanification compréhensive du traitement.Les patients partiellement ou complètementédentés ne sont pas tous candidats pourimplants. Avec toutes les ressourcesprofessionnelles à notre disposition, il n’y aaucune raison pour de telles infractions.

Les prosthodontistes sont-ils désuets enmatière de l’évaluation et de la maîtrise de laprothèse dentaire en implantologie? Êtes-vous, dans votre propre pratique, à l’aise avecles traitements implantaires et suffisammentexpérimenté pour exécuter les différentesétapes d’un plan de traitement compréhensif?Un atelier sur ces sujets serait-il productif?J’aimerais connaître vos commentaires etsuggestions.

Dr Hubert GaucherRédacteur en chef

Spring 2010 Canadian Journal of Restorative Dentistry & Prosthodontics 5

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CJRDP Editorial Board/Le comité de rédaction JCDRP

Editor-in-Chief/Rédacteur en chefHUBERT GAUCHERQuébec City, Québec

Associate Editors/Rédacteurs associés

Section Editors/Section éditeurs

Occlusion andTemporo-MandibularDysfunctions/Occlusion et Dysfonctionstemporo-mandibulaireKIM PARLETTBracebridge, Ontario

Implant Dentistry/Dentisterie implantaireRON ZOKOLVancouver, British Columbia

Implant Dentistry/Dentisterie implantaireYVAN FORTINQuébec City, Québec

Esthetic Dentistry /Dentisterie esthétiquePARESH SHAHWinnipeg, Manitoba

Dental Technology /Technologie dentairePAUL ROTSAERTHamilton, Ontario

VOLUME 3 • I S SU E 2

Content/Sommaire

FEATUR ES/A RTICLES

3 Message from the Editor-in-ChiefMessage du Rédacteur en chefMessage from the Guest Co-EditorMessage du co-rédacteur invité

489

Spring / Printemps, 2010

Implant Dentistry / Dentisterie implantaire

16 Potential Comprehensive Rolefor Highly ConcentratedPlatelet Rich Plasma (hcPRP)in Bone Regeneration: Criteriafor Successful Bone Gra!ing andAdvantages of Gra!ing with hcPRPBy Astley E. Smith, MSc, DMD

20

26

30

INDICATES PEER REVIEWED/INDIQUE REVUE DES PAIRS

EMMANUELJ. RAJCZAKHamilton,Ontario

MAUREENANDREAChester,

Nova Scotia

DENNISNIMCHUKVancouver,

BritishColumbia

"e Fully Edentulous ResorbedMaxilla: Surgical and RestorativeTechniques to Avoid Bone Gra!ingBy Yvan Fortin, DMD, Kenji W. Higuchi, DDS, MS, Richard M. Sullivan, DDS

Nanotextured Implant Surfaces: Re-engineering the Bone ResponseBy Robert J. Miller, MA, DDS, FACD, DABOI

Practice Management / Gestion de cabinet49 E#ective Business Systems

Enhance the Delivery of Quality Dentistry and Will Impact Your Bottom Line!: Part IIBy Jo-Anne O’Connor-Webber

23 34 45

IAN TESTERSt. Catherines, Ontario

Cover image of the Alberta Rockies courtesy Tourism Calgary.

Photo couverture: Les Rocheuses, courtoisie de Tourisme Calgary

Occlusion andTemporo-MandibularDysfunctions/Occlusion et Dysfonctionstemporo-mandibulaire

Barres usinées pour prothèses implanto-portéesPar Nicolas Tardif TDC et Hubert Gaucher DDS, MScD

36 Milled Bars for Implant-Supported ProsthesesBy Nicolas Tardif CDT and Hubert Gaucher DDS, MScD

40 Achieving Initial Implant Stability – Observations on the E#ect of Implant Body Macro-Design and Osteotomy DesignBy Dennis P.A. Nimchuk, DDS, FRCD

MESSAGE FROM THE GUEST CO-EDITOR

As dental professionals, we are indeedprivileged to be in the midst of a growth

in the dental sciences such as we are presentlywitnessing. The exponential increase inscientific information and advances inclinical procedures are driven by the everincreasing desire for men and women toretain their youth and vitality while theystretch the limits of what we understand tobe a normal, healthy, and productive life. Oral implantology, or implant-supporteddentistry, has emerged as a standard of careand a fundamental resource for theconstruction dental solutions that are capableof providing the greatest potential for health,function, and longevity.

As you know, the field of oral implantologyis complex. While advances are being madeevery day, the propagation of newinformation and clinical techniques is miredin the fact that the majority of clinicians whorestore implants have a limited knowledge ofthe surgical phases, and those skilled in thesurgical phases have limited knowledge of therestorative phases. That is most unfortunateconsidering that the examination, diagnoses,and treatment planning phase, to be optimal,requires comprehensive knowledge of allphases of treatment. The number of dentalprofessionals considered to be expert in boththe surgical and prosthetic phases of oralimplantology is few indeed. Therefore, theneed for professional collaboration and amultidisciplinary approach to treatmentplanning is more essential than ever.

My goal is to provide you with authorsaddressing both science and techniques that

are in use today as well as those which areconsidered to be leading edge and relevant tothe benefit of your practice and benefit topublic which has entrusted us to their oralcare.

The theme for this issue is “OralImplantology: Today and Tomorrow.” Today,our reasonable expectation is that anytitanium-based implant can osseointegrate.In my opinion, there exists no perfectimplant and the key to success lays inunderstanding their individual advantagesand limitations. The science of bone graftingis well understood, but the management ofinterdental papillae and other soft tissuefactors have yet to be fully controlled. We areat the threshold of implementing the scienceand a variety of procedures which will makeeach and all of these factors moremanageable. Yet, in the face of poor patientcompliance, compromised systemic health,and one of the most hostile environments inthe human body, we are challenged to exactsolutions as they are conceived on treatmentplans.

We are privileged to provide articles by someof the leading researchers and clinicians whoare developing technology eminently usefulin developing clinical procedures which willbring higher levels of predictable success toour procedures in oral implantology.

One of our contributors is Dr. Robert Miller,not new to the CJRDP. A world-class lecturer,he is also a researcher in implant design andin implant surface technology which he willexpand upon in his article.

Another is Dr. Astley Smith who hasexpanded on the works of Drs. Robert Marxand Aron Gonshor in developing higherconcentrations of platelet rich plasma. He isthe very first person to predictably harvestautologous thrombin to be used to re-coagulate blood products for enhancing bonegrafting and soft tissue procedures.

Dr. Dennis Nimchuk’s article “AchievingInitial Implant Stability: Observations on theEffect of Implant Body Macro-Design andOsteotomy Design” addresses implantdesigns and their direct influence onpredictable successes in relation to thevarious encountered bone qualities. Theauthor suggests that the selection of animplant based on macro-design featuresmight have site specificity relevance.

Dr. Fortin’s article, along with co-authors,Drs. Kenji Higuchi and Richard Sullivandescribe their contribution in both surgeryand prosthodontics. Alternatives to bonegrafting procedures are illustrated with arelevant retrospective documentation.

Dr. Hubert Gaucher and Certified DentalTechnician Nicolas Tardif address theadvances made with milled titanium bars,replacing cast gold alloy bars with betteraccuracy and strength.

In addition to our oral implantology theme,we also have the second article in a series by Jo-Anne O’Connor-Webber, a practicemanagement consultant who providesguidance to effectively manage practices aswell as how to work with patients to give


Oral Implantology: Today and Tomorrow


MESSAGE DU CO-RÈDACTEUR INVITÈ

En tant que professionnels dentaires, noussommes en fait privilégiés de nous

trouver au cœur d’une croissance des sciencesdentaires qui prend forme et dont nous ensommes les témoins. L’augmentationexponentielle de l’information scientifique etles progrès réalisés dans les interventionscliniques sont dictés par un désir toujourscroissant pour les hommes et les femmes degarder la jeunesse et la vitalité tout endépassant les limites de ce que nouscomprenons comme étant une vie normale,saine et productive. L’implantologie dentaireou prothèse sur implants a fait surfacecomme une norme de traitement et uneressource fondamentale pour les solutions dereconstruction dentaire pouvant être les plus avantageuses pour la santé, lefonctionnement et la longévité.

Comme vous le savez sans doute, le domainede l’implantologie dentaire est complexe.Bien que des progrès soient réalisés chaquejour, la diffusion de nouvelles informationset de techniques dentaires se perd dans le fait

que la majorité des cliniciens qui restaurentles implants ont des connaissances limitéesdes phases chirurgicales et que ceux qui ontdes compétences en chirurgie ont desconnaissances limitées dans les phases derestauration. Ce qui est très malheureux étantdonné que l’examen, le diagnostic et la phasede planification du traitement, pour être optimaux, exigent d’excellentesconnaissances de toutes les phases dutraitement. Le nombre de professionnelsdentaires considérés comme étant des expertsdans les phases chirurgicales etprosthodontiques de l’implantologie dentaireest limité. Par conséquent, la nécessité decollaborer et d’adopter une approchemultidisciplinaire à la planification dutraitement est plus essentielle que jamais.

Mon but est de trouver des auteurs quiaborderont les sujets scientifiques de mêmeque les techniques qui sont utilisées de nosjours ainsi que celles qui sont considéréescomme à la fois avant-gardistes, pertinentesà votre pratique et avantageuses pour les

patients qui nous ont confié leurs soinsdentaires.

Le thème de ce numéro est « Implantologiedentaire : aujourd’hui et demain ». De nosjours, on s’attend à ce que tout implant à base de titane puisse produire uneostéointégration. Selon moi, il n’existe pasd’implant parfait et la clé du succès se trouvedans la compréhension des avantages et deslimites individuelles. La science de la greffeosseuse est bien comprise, mais il reste encoreà maîtriser complètement la gestion despapilles interdentaires et des autres facteursdes tissus mous. Nous sommes au point demettre en application la science et une variétéd’interventions, ce qui permettra à tous cesfacteurs d’être plus gérables. En présenced’une observance médiocre de la part dupatient, d’une santé générale compromise, etl’un des milieux les plus hostiles du corpshumain, nous devons trouver les solutionsexactes au fur et à mesure qu’elles sontconçues sur les plans de traitement.Nous sommes privilégiés de pouvoir fournir

Implantologie dentaire :aujourd’hui et demain

them the best opportunity to approve yourtreatment plans.

I look forward to continuing the lineage ofexcellent researchers and clinicians with thehope that you receive value in the investmentof your time reading these articles. Yourcomments and feedback are greatlyappreciated.

Ronald J. Zokol, DMD, ABOI, FACDImplant Section

EditorGuest Co-editor

MESSAGE FROM THE GUEST CO-EDITOR


MESSAGE DU CO-RÉDACTEUR INVITÉ

des articles rédigés par des chercheurs etcliniciens renommés qui mettent au pointune technologie utile pour l’élaboration deprocédures cliniques qui permettront à nosinterventions en implantologie dentaired’atteindre des niveaux de réussite prévisibleplus élevés.

L’un de nos auteurs, Dr Robert Miller, est unconférencier de renommée internationale, unchercheur en conception et en technologie desurface des implants dentaires. Il abordera cessujets dans son article. Ce n’est pas lapremière fois que le Dr Miller offre sacontribution au JCDRP.

Le Dr Astley Smith a élargi l’application destravaux des docteurs Robert Marx et AronGonshor dans le but de développer desconcentrations plus élevées de plasma richeen plaquettes. Il est le premier à avoir récoltéde la thrombine autologue pouvant êtreutilisée pour coaguler à nouveau les produitssanguins dans le but d’améliorer la greffeosseuse et les interventions aux tissus mous.L’article du Dr Dennis Nimchuk « L’atteinted’une stabilité initiale de l’implant :observations sur l’effet du macro-design ducorps de l’implant et de l’ostéotomie » traitede la conception des implants et de leurinfluence directe sur le succès prévisible enrelation avec les diverses qualités des os.L’auteur suggère que la sélection d’unimplant basée sur les caractéristiques demacro-design peut avoir une pertinencespécifique au site.

L’article du Dr Fortin et des co-auteurs, lesdocteurs Kenji Higuhi et Richard Sullivandécrit la contribution de ces derniers dans lesdomaines de la chirurgie et de laprosthodontie. Les solutions de rechange à lagreffe osseuse sont illustrées et documentéesrétrospectivement.

Le Dr Hubert Gaucher et Nicolas Tardif,technicien dentaire agréé, traitent des progrèsréalisés avec les barres de titane usinées,remplaçant les barres d’alliage d’or coulé avecplus de précision et de force.En plus de notre thème sur l’implantologiedentaire, nous avons un deuxième articled’une série rédigé par Jo-Anne O’Connor-Webber, consultante en gestion de pratique,qui offre des conseils pour gérer efficacementvotre pratique et travailler avec les patientspour qu’ils puissent approuver vos plans detraitement.

Je souhaite pouvoir continuer à dénicherd’excellents chercheurs et cliniciens enespérant que vous retiriez quelque avantageà lire ces articles. Vos commentaires sontappréciés.

Ronald J. Zokol, DMB, ABOI, FACDRédacteur – section implantologie

Co-rédacteur invité

SUMMER ISSUE: Dental Research /PARUTION ÉTÉ: Recherche dentaireContact: Dr. Hubert Gaucher: [email protected] Date for Submissions: August 3rd, 2010 / Soumissions 3 août 2010

FALL ISSUE: Occlusion /PARUTION AUTOMNE: OcclusionContacts: Dr. Kim Parlett: [email protected];Dr Hubert Gaucher: [email protected] Date for Submissions: November 1st, 2010 / Soumissions 1 novembre2010

2010 Journal IssueAnnouncementAnnonces des parutionsdu Journal 2010

WINTER ISSUE: Esthetic Dentistry /PARUTION HIVER: Dentisterie esthétiqueContacts: Dr. Paresh Shah: [email protected]; Dr. Hubert Gaucher: hgaucher@sympaticoca

Due Date for Submissions: February 4, 2011 / Soumissions 4 fevrier, 2011

2011 Journal Issue Announcement

Annonces des parutions du journal 2011

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Meeting Theme: “Real World Dentistry 2010 and Beyond” Hands-On Course

DENTSCAPE: Dental Photography for Dentist-Laboratory Communication

Presented by Mr. Naoki Aiba, CDT, Oral Design

October 14th, 9:00 pm – 5:00 pm, Calgary Westin HotelCost: $ 300.00 Per Person – Space is Limited7 CE credits to be issuedBring your Own Camera and Flash to exercise photo

shooting. Breaks and a one hour lunch to be provided

Synopsis: “Dental photography” is not just taking photographs but also maximizing the use of them. An award-winning professional photographer and ceramist, Naoki Aiba, CDT will explain the fundamental of dental photography, and explore its use in daily practice by illustrating numbers of clinical cases fabricated solely with photo-graphic information without seeing the patients. In this seminar, the participants are welcomed to bring their own camera and flash to exercise photo shooting with him. Course Outline: • Lecture "Dentscape: Dental Photography for Functional Esthetic," which illustrates: • Basic science of photography • Photographic equipments and useful accessories • Basic technique of dental photography • Concept and use of the “Shade View” photographs • Photos and study cast for designing pleasing midline and incisal edge line • Photo protocol for dentist-laboratory esthetic communication by case design • Shooting profile and settings of major manufacturers’ camera and flash systems • Clinical case studies • Demonstration & Hands-on: • Set up of your camera system for the best exposure • Test shooting the Basic protocol (facial and intraoral photography) • Simple 4-step photo enhancement with Photoshop CS3 (for Mac users) and Photo-shop Elements 5.0 (for Windows users). Learning Objectives: • To learn how to communicate with esthetic elements through photography between dentists and laboratory for fabrication of restorations. • To understand how to overcome three most prominent esthetic challenges: Shade mismatch, canted mid-line, and unpleasing incisal edge line. • To understand the concept and the use of “Shade View” to read, map, and analyze the information into ceramic fabrication. • Learning the simple Photoshop workflow of the pictures into the dentist-laboratory communication. Attendees: Restorative dentists, laboratory technicians, dental assistants who takes photographs. Participants are welcomed to bring their own camera and flash to exercise photo shooting Mr. Naoki Aiba, CDT, Oral Design Born in Nagoya, Japan, Naoki Aiba graduated from the Dental Technology Program at the Dental School of Aichi Gakuin University in Nagoya in 1982 and completed the post-graduate ceramics course at the Tokai Dental Technicians School in 1986. He received the Young Speaker of the Year Award in 1989. In 1992, Mr. Willi Geller selected Naoki to be a member of Oral Design. He has lectured, conducted hands-on courses, published in more than thirty countries on ceramics, dental photography and dentist-laboratory communications. He has published and exhibited his photographs around the world. He currently serves as a member of the Editorial Board for the QDT and is a Technical Advisory Board Member of the Monterey-Bay Salinas Study Club. He maintains his laboratory, Science Art, Inc. in Monterey, California, and offers hands-on .

Social Activities Thursday, October 14th Horse Back Riding – Moose Mountain Adventures 8:00 am - 2:00 pm - Registrant and/or Partner/Guest Event Located in Bragg Creek, Alberta, between Calgary and Banff Na-tional Park, treat yourself with an extraordinary day and experience the Kananaskis Country on horseback. ----------------------------------------------------——————---- Fly Fishing on the Bow River 7:30 am - 5:00 pm - Registrant and/or Partner/Guest Event The Bow River, just downstream of Calgary, Alberta, Can-ada, is one of the top three trout streams in the world, har-bouring the most consistently large river run trout you will ever catch. ----------------------------——————---------------------------- Welcome Buffet at The Westin Calgary Hotel

6:00 – 10 pm - Registrant and Partner/Guest Event Kicking off this Year’s Scientific Meeting will be our Open-ing Reception hosted in the Calgary Westin Hotel, join your Meeting Sponsors, other registrants and guests to rekindle old acquaintances and make new.

Friday, October 15th Tour, Dine & Shop - Kananaskis & Canmore! 9:00 am - 2:30 pm - Partner/Guest Event Kananaskis Country and Canmore Be sure to bring your Camera so you don’t miss any of the breathtaking scenery. ---------------------------------------------------————------ Wild Western Night - Wainright Hotel, Heritage Park 6:00 pm - 10:00 pm - Registrant and/or Partner/Guest Event Discover “How the West was Once” at Canada’s largest living history museum, travelling back in time from the 1950s to the 1860s Saturday, October 16th President's Gala 6:30 pm - Partner/Guest Event Gala will offer a sumptuous menu featuring a variety of Calgary’s finest Cuisine. Don’t forget your dancing shoes as you’ll enjoy the sounds of Fun in the Front Seat, one of Alberta’s Hottest Dance Bands.

Join us in Calgary this October!

Table Clinics—Saturday, October 16 Topics

The ingenious stress free bar system on implant Simple steps on how to make bonding of indirect restorations predicatble and easy. Emergence profile development with tempoization in highly aesthetic zone using Astra temporary abutment DENTSCAPE: Dental Photography for Dentist-Laboratory Communication Diagnostics and Treatment of Obstructive Sleep Apnea Therapy Ulilizing Oral Appliances Cone Beam Imaging for Surgical and Prosthetic Planning Digital Age in Dentistry In Office Fabricated Appliances Treating Incisal Attrition, Fracture, and Augumentation with Composite Resin

Thème du congrès: La dentisterie pragmatique: aujourd’hui et au-delà Cours pratique

La photographie dentaire pour une communication dentiste-laboratoire

Présenté par M. Naoki Aiba, CDT, Design Oral

Le 14 octobre, 09h00 – 17h00, Calgary Westin Hotel Coût: 300$ pp – Places limitées 7 crédits de formation continue Apportez votre appareil photo avec flash pour les

pratiques. Collations et repas du midi seront fournis

Synopsis: La photographie dentaire n’implique pas seulement la prise de photos mais aussi leur mise en valeur. En tant que photographe et céramiste professionnel qui s’est mérité plusieurs prix d’excellence, Naoki Aiba expliquera les fondements de la photo-graphie dentaire et explorera son utilité dans la pratique quotidienne en illustrant des cas cliniques fabriqués uniquement avec l’information photographique, sans voir les patients. Les participants sont bienvenus d’apporter leur appareil photo et flash afin de pratiquer sur place.

Aperçu: Dentscape: La photographie dentaire qui soutient l’esthétique fonctionnelle La science de la photographie Équipement et accessoires photographiques Techniques de base de la photographie dentaire Le concept et l’utilisation de photographies Shade View Photos et modèles d’étude de bons designs de lignes médianes et rebords incisifs Protocole photographique pour communiquer au laboratoire un design esthétique Profils et réglages de certaines grandes marques d’appareils et de flash Cas d’études cliniques Démonstration et manipulation Réglages de votre caméra pour la meilleure exposition Protocole de base de photographie faciale et intra-orale Améliorations des photographies en 4 étapes: Avec Photoshop CS3 (pour Mac) et Photoshop Elements 5.0 (pour Windows)

Objectifs Communiquer les éléments esthétiques d’une restauration au laboratoire à l’aide de la photographie Surmonter trois défis esthétiques: Mauvaises teintes, lignes médianes inclinées et rebords incisifs inadéquats Lire, planifier et analyser les informations de Shade View pour la fabrication céramique Apprendre la simplicité de Photoshop pour communiquer entre dentiste et labora-toire

Participants: Dentistes en restaurations, techniciens de laboratoires, assistants den-taires qui prennent des photos. Les participants sont encouragés d’apporter leur propre appareil photo et leur flash. Mr Naoki Aiba, CDT, Oral Design Né à Nagoya au Japon, Naoki Aiba receva son diplôme du programme de technologie dentaire de l’école Aichi Gakuin à Nagoya en 1982 et compléta un cours en porce-laine de deuxième cycle à Tokai Dental Technicians School en 1986. En 1989 on lui présenta le prix Young Speaker of the Year et en 1992, il fut choisi par M. Willi Geller, pour devenir membre de Oral Design. M. Aiba a donné des conférences et des cours pratiques et est publié dans plus de trente pays sur la céramique, la photo-graphie dentaire et les communications entre dentistes et laboratoires. Ses photo-graphies sont publiées et affichées partout dans le monde. Il est sur le conseil d’ad-ministration du QDT et du Monterey-Bay Salinas Study Club. Il a son laboratoire, Science Art Inc., à Monterey en Californie et offre des cours pratiques à son installa-tion de formation, Oral Design Monterey.

Programme Social Jeudi le 14 octobre Équitation – Moose Mountain Adventures 08h00 – 14h00 - Pour membres inscrits ou conjoints/invités À Bragg Creek, entre Calgary et le parc national de Banff, faites l’expérience extraordinaire d’une journée d’équitation dans le pay-sage de Kananaskis. -------------------------------------------------------------------------- Pêche à la mouche sur le Bow River 07h30 – 17h00 - Pour membres inscrits ou conjoints/invités La rivière Bow, en aval de Calgary, est l’un des trois meil-leurs cours d’eau du monde pour la grosse truite de rivière. -------------------------------------------------------------------------- Buffet de bienvenue au Westin Calgary

18h00 – 22h00, Pour membres inscrits, conjoints/invités Pour ouvrir le congrès de cette année, nous vous offrons une réception à l’hôtel même, où vous pourrez rencontrer nos commanditaires ainsi que les autres membres et invités.

Vendredi le 15 octobre Excursion, repas, magasins – Kananaskis et Canmore 09h00 – 14h30 - Pour conjoints/invités N’oubliez surtout pas votre appareil photo pour saisir ces splendides paysages. ---------------------------------------------------—----------- Soirée Western – Hôtel Wainwright, Heritage Park 18h00 – 22h00 - Membre inscrit et conjoint/invité Découvrez l’ouest de jadis en reculant dans le temps, à compter de 1950 jusqu’à 1860.

Samedi le 16 octobre Gala du Président 18h30 - Avec conjoint/invité Venez festoyer avec un menu vous offrant un assorti-ment des meilleurs plats de Calgary et une soirée dansante animée par Fun in the Front Seat, l’un des meilleurs orchestres de danse de l’Alberta.

Soyez des-nôtres à Calgary en octobre prochain!

Démonstrations cliniques - Samedi le 16 octobre Thèmes

Le système ingénieux de la barre passive sur implants Des étapes simples pour l’adhésion de restaurations indirectes de façon facile et prévisible Dévelopement de profil d’émergence pour la temporisation dans les régions haute-ment esthétiques utilisant les piliers temporaires Astra DENTSCAPE: La photographie dentaire pour la communication dentiste-laboratoire Le diagnostic et le traitement de l’apnée du sommeil obstructive à l’aide d’appa-reils buccaux L’imagerie Cone Beam pour la planification chirurgicale et prothétique L'âge numérique en dentisterie Appareils intra-oraux fabriqués sur place Le traitement de l'attrition incisive et de la fracture, et l'augmentation de la dimen-sion verticale avec de la résine composite

Meeting Theme: “Real World Dentistry 2010 and Beyond” Friday Feature Speaker

Dr. David Gaber, DMD

Dr. David Garber is a member of the internationally recognized multidisciplinary group of educators known as “Team Atlanta.” He is the recipient of the 2005

Gordon J. Christensen Lecturer Recognition Award, the American College of Prosthodontics Distinguished Lecturer Award, the Northeastern Perio-dontal Society Isador Hirschfeld Award for Clinical Excellence, the Greater New York Academy of Prosthodontics Distinguished Lecturer Award, and the David Serson Medal of Research. He is a past President of the Ameri-can Academy of Esthetic Dentistry and has served on the boards of both the AAED and the American Academy of Fixed Prosthodontics. Dr. Garber is clinician and professor in the Department of Periodontics as well as in the Department of Oral Rehabilitation at the Medical College of Georgia. He is a Clinical Professor in the Department of Prosthodontics at Louisiana State University as well as in the Department of Restorative Den-tistry at the University of Texas in San Antonio. He is past Editor of the Journal of Esthetic Dentistry and co-author of Porcelain Laminate Veneers, Bleaching Teeth, Porcelain and Composite Inlays and Onlays, and Com-plete Dental Bleaching, and has published over 60 articles and textbook chapters. --------------------------------------------------------------------------------------------------------

Topic: "Real World Dentistry: 2010 and Beyond" Synopsis: Real World Dentistry 2010: Choices, Options and Alternatives

Today’s changing world in dentistry involves innovative clinical techniques coupled with an ever-evolving group of new products. A return to “needs-based dentistry” from the era of elective care or “wants-based dentistry” requires that today’s Dentist inte-grate innovative procedures with increased rapidity and predictability into their arma-mentarium. This program will address the following issues: Learning Objectives: Techniques

Accelerated crown preparationInnovative porcelain veneer techniquesPredictable bonding with today’s new productsRapid esthetic temporizationSimple esthetic soft tissue procedures for your generalist’s practiceIllusions of reality with “ovate pontics”Easy solving of esthetic dilemmasA simplified incisionless implant techniqueBleaching—Practice maintenance!

New Products and Systems New ceramic systems—Procera, Emax, Lava. Problems and solutionsPredictable bonding every timeCreative crown systems — CAD cam / ceramometal?One-stage implantsThe new diamond bursPorcelain veneers by the numbers Composite solutions in 2010

This program will introduce you to new products and techniques that have already proven to be most effective in practice and will show you just what to use, where to use it, and when. It will address our need to meet the ever evolving public demand for immediate dentistry by integrating innovative restorative systems with implants and simplified basic periodontal procedures. It will update the generalist and special-ist alike on state-of-the-art techniques and materials in restorative dentistry, esthetics, bonding, cosmetic and essential implants. This presentation includes a multi-media approach using computer simulation and video, which is designed for the whole den-tal team including Dental Technicians.

Saturday Speaker’s Dr. Kevin E. Lung, BSc, DDS, MSc Topic: "Implants: The Good, the Bad and the Ugly" Synopsis: Since the serendipitous discovery of Osseointegration, we as dental practitioners have been able to improve the quality of life for so many suffering and debilitated patients. The dental implant has been a vital and extremely successful treatment option in the recon-struction of these compromised masticatory systems. This modality has provided the dental profession with the technology to address

many difficult challenges in both edentulous spaces and deformities. The majority of the patient outcomes, utilizing this technology, have provided patients with impressive esthetic and functional dental prosthetic treatment. These satisfying outcomes can only occur if the practitioner maintains the highest levels of understanding of the applica-tions and the limitations of dental implants.

Dr. Glen H. Johnson, DDS, MS Topic: "New Dental Cements and Adhesives - What Can You Use and When?" Synopsis: New products for dental bonding involving fewer steps are available. What does the evidence show? The various bonding systems will be discussed and recommendations will be given. There are a host of new luting agents on the market. What does the evi-dence show for selection and use of these cements and how does their crown retention compare to established luting agents? What

cements can you use successfully with high-strength zirconium oxide crowns? How should one treat the internal surface of the zirconia crown for a most effective cementa-tion? These topics will be addressed based on evidence from recent studies.

Dr. Robert Miller, DDS Topic: "Laser Surgery: Re-Engineering the Biologic Response" Synopsis: Traditional resective surgical techniques may have unin-tended or undesirable effects on soft and hard tissue. As concepts move towards minimally invasive therapy, ablative laser techniques may have significant advantages over older resective procedures. Previous generations of dental lasers operate in vaporization mode. The high operating temperatures of these lasers results in charring

of tissue and may alter the surface of dental implants. Erbium based lasers, using a photoacoustic process, may be used to sculpt soft tissue, contour bone and teeth, and treat the surface of implants to enhance healing and provide a more ideal tissue enve-lope for implant aesthetics. This new generation of lasers holds the promise of replac-ing much of the hand and rotary instrumentation currently used in surgery.

Mr. Naoki Aiba, CDT, Oral Design Topic: "DENTSCAPE: Dental Photography for Dentist-Laboratory Communications" Synopsis: Dental photography provides a means for bridging the gap between the patient and the technician. This lecture will dis-cuss the method of overcoming three major esthetic challenges faced by the dental technician: shade matching, midline orientation and incisal edge position. An award-winning professional photog-

rapher and ceramist, Naoki Aiba will explain how he overcomes those challenges util-izing digital photography. He presents the fundamentals of dental photography, then addresses its practical uses in dentist-laboratory communication. In the latter half of the lecture, he will illustrate those applications in daily practice using clinical cases fabri-cated solely with photographic information, without seeing the patients. He will also discuss porcelain build-up and comment on the concepts of Transition Powder Tech-nique™, Translucent Dentine Powder Technique™, Internal Staining Technique, as well as Pre-margin Correction Technique™ to improve marginal fit.

14 CE credits to be issued for Friday & Saturday

Join us in Calgary this October!

Thème du congrès: La dentisterie pragmatique: aujourd’hui et au-delà Conférencier notoire du vendredi

Dr. David Gaber, DMD Dr. David Garber est membre d’un groupe d’éducateurs multidisciplinaires reconnus internationalement sous l’appellation Team Atlanta. Il est récipiendaire de: 2005 Gordon J. Christensen Lecturer Recognition Award,

American College of Prosthodontics Distinguished Lecturer Award, North-eastern Periodontal Society Isador Hirschfeld Award for Clinical Excel-lence, Greater New York Academy of Prosthodontics Distinguished Lec-turer Award, et David Serson Medal of Research. Il fut Président du Ameri-can Academy of Esthetic Dentistry et siégea au Conseil d’administration de celui-ci ainsi que American Academy of Fixed Prosthodontics. Dr. Garber oeuvre comme clinicien et professeur dans les départements de Parodontie et de Réhabilitation buccale au Medical College of Georgia, dans le département de Prosthodontie à Louisiana State University et dans le département de Dentisterie restauratrice de University of Texas à San Anto-nio. Il fut rédacteur du Journal of Esthetic Dentistry et co-auteur de Porce-lain Laminate Veneers, Bleaching Teeth, Porcelain and Composite Inlays and Onlays, et Complete Dental Bleaching, et a publié plus de 60 articles et chapitres de manuels. ------------------------------------------------------------------------------------------------------

La dentisterie réalisable: 2010 et au-delà Synopsis: La dentisterie réalisable 2010: Choix, options et alternatives

Le monde dentaire évolue et se manifeste par des techniques cliniques novatrices jumelées à des nouvelles gammes de produits qui exigent que le praticien s’arme de procédures rapides et prévisibles. Ce programme touchera les sujets suivants: Objectifs Les techniques

Préparation accélérée des couronnesTechniques novatrices pour facettes de procelaineAdhésion prévisible utilisant les produits actuelsTemporisation esthétique rapideExécution esthétique simple pour les tissus mous en pratique généraleRéalisme des pontics ovoïdesSolutions faciles aux dilemmes esthétiquesUn implant «sans incision» simplifié pour l’omnipraticien Blanchiment – maintien de la pratique

Les nouveaux produits et systèmes Nouveaux systèmes de céramique: Procera, Emax, Lava - problèmes et solutionsAdhésion prévisible à chaque foisSystèmes créatifs de couronnes: CAO/FAO/céramométalliquesImplants en un seul stadeLes nouvelles fraises diamantFacettes de porcelainéSolutions avec composites en 2010

Ce programme vous introduira aux nouveaux produits et techniques déjà éprouvés et fera la démonstration de quoi, où et quand les employer. Il discutera du besoin du public pour la dentisterie immédiate et intègrera les nouveaux systèmes de restau-ration avec les implants et des procédures parodontales simplifiées. Il fera une mise-à-jour des techniques et matériaux de fine pointe en dentisterie restauratrice, esthé-tique, adhésive, implantaire cosmétique et essentielle. Une approche multi-média faisant usage de simulation informatisée et de vidéo s’adressera à l’équipe dentaire intégrale incluant hygiénistes, assistants et personnel de laboratoire.

Conférenciers du samedi

Dr Kevin E. Lung, BSc, DDS, MSc Les implants: Le Bon, La Brute, Le Truand Synopsis: Depuis la chanceuse découverte de l’Osséointégration, nous avons, en tant que praticiens dentaires, été capables d’améliorer la qualité de vie de tellement de patients. L’implant dentaire a con-tribué de façon vitale à la réhabilitation buccale de ces systèmes masticatoires, compromis soit par les espaces édentés ou les diformi-tés. La majorité des résultats de cette technologie se sont avérés des

réussites éloquentes en rétablissant fonction et esthétique suite aux traitments prothé-tiques. Or, la compréhension profonde des applications et limites de l’implant dentaire est le seul gage de succès du praticien.

Dr. Glen H. Johnson, DDS, MS Les nouveaux ciments et adhésifs: Lesquels utiliser et quand? Synopsis: Des nouveaux produits adhésifs impliquant moins d’étapes sont maintenant disponibles. Divers systèmes d’adhésion seront discutés et certains recommandés. Il y a une multitude d’agents liants sur le marché. Que nous démontre les données pour le choix et l’utilisation de ces ciments et comment se comparent-ils

aux produits conventionnels du point de vue rétention de la couronne? Quels ciments sont les plus compatibles avec les couronnes d’oxyde de zircon? Comment doit-on traiter la surface interne de la couronne en zircon afin d’obtenir la cimentation la plus efficace? Ces sujets seront présentés basés sur les données d’études récentes.

Dr. Robert Miller, DDS La chirurgie au laser: Ré-ingénirie de la réaction biologique Synopsis: Les techniques traditionnelles de chirurgie résective peu-vent causer des effets indésirables sur les tissus mous ou durs. Étant donné la tendance vers des thérapies moins envahissantes, l’ablation par laser pourrait avoir des avantages significatifs par rapport aux interventions usuelles. Les générations précédentes de lasers den-taires fonctionnent en mode vaporisation. Leur température élevée

carbonise les tissus et peut modifier la surface des implants dentaires. Les lasers à l’er-bium, utilisant un procédé photoacoustique, peuvent être employés pour sculpter les tissus mous, recontourner l’os et les dents, et traiter la surface des implants dans le but d’améliorer la guérison et de procurer une meilleure esthétique de l’enveloppe tissu-laire. Cette nouvelle génération de lasers remplacera sans doute la plupart des instru-ments rotatifs présentement sur le marché.

Mr. Naoki Aiba, CDT, Design Oral La photographie dentaire pour les communications dentistes-laboratoires Synopsis: La photographie dentaire accorde un moyen de rap-procher le patient et le technicien. Cette présentation discutera des moyens de surmonter trois défis esthétiques importants auxquels fait face le technicien dentaire, à savoir: La sélection des teintes, l’orientation de la ligne médiane et le positionnement des rebords incisifs. Céramiste et photographe professionnel qui s’est mérité

plusieurs prix, Naoki Aiba expliquera comment il maîtrise ces problèmes avec la photo-graphie digitale. Il introduira les fondements de la photographie dentaire pour ensuite discuter de son utilisation dans la communication dentiste-laboratoire. Dans la seconde partie de son discours il fera la démonstation de ces applications dans la pratique cou-rante pour les cas cliniques fabriqués uniquement de l’information photographique, sans voir les patients. Il parlera aussi des ajouts de porcelaine et commentera les con-cepts de Transition Powder Technique™, Translucent Dentine Powder Technique™, la technique de coloration interne, ainsi que Pre-margin Correction Technique™ pour améliorer l’adaptation marginale.

14 crédits de formation continue, vendredi & samedi

Soyez des-nôtres à Calgary en octobre prochain!

IMPLANT DENTISTRY / DENTISTERIE IMPLANTAIRE


Potential Comprehensive Role for HighlyConcentrated Platelet Rich Plasma

(hcPRP) in Bone Regeneration: Criteriafor Successful Bone Grafting and

Advantages of Grafting with hcPRP

About the Author

Dr. Astley E. Smith is with the Global Autografting Institute, BelmontDental Centre in New Westminster, Metro Vancouver, British Columbia.He can be contacted at: [email protected].

ABSTRACTHighly concentrated platelet rich plasma (hcPRP) is a new terminology, defined as plateletconcentrate greater than eight times the baseline of platelets in whole blood. The positivethat comes from hcPRP is that transforming growth factor beta (TGF-β) hasimmunosuppressive, anti-rejection, anti-inflammatory, pro-tolerant, and pro-healingproperties. Therefore, this molecule is probably responsible for controlling negativeimmune responses when xenografts and allografts are used for oral grafting. This articlediscusses the idea that it might be prudent to mix allografts and xenografts with hcPRP.The article also presents criteria for successful bone grafting with hcPRP and advantagesof grafting with hcPRP.

RÉSUMÉLe plasma riche en plaquettes hautement concentré est une nouvelle terminologie et sedéfinit comme étant huit fois plus concentré que les plaquettes du sang entier. De ceconcentré plaquettaire, on obtient le facteur de croissance transformant bêta (TGF-β) quia des propriétés immunosuppressives, anti-rejet, anti-inflammatoires, pro-tolérantes etpro-cicatrisantes. Par conséquent, cette molécule est probablement responsable decontrôler les réponses immunitaires négatives lorsque les xénogreffes et les allogreffessont utilisées. Cet article traite de l’idée qu’il peut être prudent de mélanger les allogreffeset les xénogreffes avec le plasma riche en plaquettes. Il aborde également les critèresnécessaires à la réussite d’une greffe osseuse avec le plasma riche en plaquettes et sesavantages.

Astley E. Smith, MSc, DMD

SMITH

Highly concentrated platelet rich plasma(hcPRP) is a new terminology, defined

as platelet concentrate greater than eighttimes the baseline of platelets in whole blood.PRP23× represents platelet concentrate at 23times baseline. During the past 16 years someresearchers defined platelet rich plasma as platelet concentrate with at least1,000,000/µL.1 Normal platelet concentrationbaseline, which varies with individuals, iswithin the range of 150,000/µL to450,000/µL.2 Since patients may respondphysiologically according to his or her ownplatelet baseline, we are now provided withanother method to define and compareplatelet concentration.

Accurate counting of platelets has presentedsome difficulty in the past,3 but at the Centrefor Blood Research at the University ofBritish Columbia, the Bayer ADVIA 120Hematology Analyzer4 counted plateletsaccurately up to 5 million/µL with or withoutdilution.5

Since the early 1990s platelet rich plasma(PRP) at 2–8× baseline has been used inimplant dentistry for the enhancement andacceleration of bone regeneration whenmixed with xenografts, allografts, autogenousbone, and alloplasts.6–10

In my research during the past five years Ihave been able to produce plateletconcentrates from 9–90× baseline (Figure 1).In these procedures, the platelets are exposed

to a range of 10,200 to 14,200 g-minutes ofcentrifugation (Figure 2). The threshold forlysis of platelet membrane is 30,000 g-minutes.1 These concentrates are activatedwith autologous thrombin in the serumextracted from the patient’s own blood.Clinical applications have revealed that allconcentrates ≥15× baseline will rapidlyregenerate 100% vital new bone without theaddition of bone or bone substitute while stillproviding the usual positive working andphysiological characteristics of regular PRPat 2–8× baseline. The grafted bone usingPRP23× and collagen sponge as ascaffold/carrier induced D3 bone in themaxillary sinus floor within 5 months andaccommodated the placement of twoendosseous implants which have beenrestored and are in function. At these veryhigh concentrations of platelets all growthfactors are concentrated, giving greaterenhancement to the regeneration of vital newbone in an oral surgical site. In 3 months,different concentrations of platelets produceddifferent densities in the bone regeneratedwhen compared in sockets on both sides ofthe same patient’s mandible. This revealedthat the development of bone density wasdose dependent on hcPRP (Figure 3). Thevarying concentrations of hcPRP mayprobably have varying regenerative potentialin different anatomical sites of the humanskeleton.

The procedure for developing hcPRP requiresa centrifuge with variable speed and a fixed

angled internal attachment which canaccommodate 10 mL vacutainer tubes. Acustom-ordered blood collection kit is alsonecessary along with a tray and kit forpresentation of the processed hcPRP to thesurgeon in the surgical operatory. Propertraining for the production, activation, andclinical applications of the variousconcentrations of hcPRP is mandatory toachieve the best result.

Morcelized resorbable collagen sponge(MRCS), fibrin, bone, and bone substitutesare used as carriers of PRP23× into the varioussurgical sites. When one carrier MRCS wasused with allograft and PRP23×, theregeneration of vital new bone wasapproximately 16% higher compared with nocarrier with the same allograft over the sameperiod of time. So far clinical results revealthat when two carriers (collagen + alloplast)were used the regeneration of vital new bonewas approximately 25% higher than whenone carrier (collagen) was used. When fivecases of allograft mixed with PRP23× werecompared with five cases of PRP23× alone withno added bone or bone substitutes the PRP23×

cases regenerated 16% more vital new boneover the allograft cases during an averageperiod of 6 months. The allograft had to beresorbed while no resorption was requiredwith PRP23× alone.

The study of immunology reveals thatallografts and xenografts can sometimes berejected by the human body under the


Figure 1. Production of highly concentratedplatelet-rich plasma (hcPRP). hcPRP = plateletconcentrate > 8× baseline.

Figure 2. Six-tube model with strategic poolingand triple spin.

Figure 3: Comparison of corticocancellous bonedensity in right and left mandibular molar socketsat 3 months using two different hcPRPconcentrations


POTENTIAL COMPREHENSIVE ROLE FOR HCPRP IN BONE REGENERATION

heading of delayed type hypersensitivity(type IV), a cell-mediated acquired immuneresponse accompanied by not onlydestruction of the grafted bone material butalso of the host bone suffering collateraldamage. This phenomenon occurs when theimmune response controls the antigen butdoes not destroy it and a granuloma developsto wall off the invading antigen embedded inthe phagosomes of macrophages.11–14 Mostcases are self-limiting and the body gainscontrol, but it can be life threatening if the patient is immunodeficient.15 Oralcandidiasis is a marker of mildimmunodeficiency, and it is often the firstopportunistic infection in patients with HIV and in other mild secondaryimmunodeficiencies such as those caused byextreme age and immunosuppressive drugs.

This type of negative immune response maygo unnoticed by the surgeon but is probablyresponsible for some bone grafting andimplant failures since symptoms appear atthe end of the time taken for antigens to betransported to the lymph nodes, T-lymphocytes cloned and activated, andthen returned to the site of antigen invasion.For the formation of a granuloma, the peakdelayed response time is 21 to 28 days,16

which is after the sutures have been removedand the post-surgical check has been done.Bone graft and host bone destruction are best

shown by a computed tomography (CT) scantaken 3 months post-surgery. If bonedestruction is taking place, implants shouldnot be inserted.

The positive that comes from hcPRP is thattransforming growth factor beta (TGF-β),which is exocytosed from activated platelets,is listed in the literature as a cytokine that is immunosuppressive, anti-rejection, anti-inflammatory, pro-tolerant, and pro-healing.17–22 Therefore, this molecule isprobably responsible for controlling negativeimmune responses when xenografts andallografts are used for oral grafting. Myexperience over 15 years of grafting hasrevealed 100% success rate when hcPRP ismixed with different grafting materials, but Ihave had two failures with a xenograft and anallograft when hcPRP was not involved. Thedelayed times for the symptoms of theimmune reactions were 27 days for the xenograftand 30 days for the allograft (Figure 4).

The sample of two failures is too small todraw a statistical conclusion, but it is hopedthat this will alert surgeons to the possibilityand probability of negative immune reactionswhen using xenografts and allografts withouthcPRP. Both cases with the negative immuneresponses were treated with antibiotics andcorticosteroid, and the body gained completecontrol of the symptoms and tissue

destruction. In order to gain patient benefitsfrom the natural immunosuppressive, anti-inflammatory, and pro-healingcharacteristics of TGF-β, it might be prudentto mix allografts and xenografts with hcPRP.Viable vital new bone can now be regeneratedin any surgical site of the skeleton by usinghcPRP with a scaffold/carrier. Based upon myresearch and clinical experience, I wish tosubmit some criteria for successful bonegrafting with varying concentrations ofhcPRP, as well as the advantages of graftingwith hcPRP.

Criteria for Successful Bone Graftingwith Various Concentrations of hcPRP

1. The trabecular bone struts should have connectivity.

2. The grafted bone should have a distribution of bone metabolic units.

3. The grafted bone should turnover and show signs of maturity (lamelar architecture) as it remodels.

4. The grafted bone should have normal bone density after three months with variations for different anatomic sites.

5. The grafted bone should not precipitateany negative immunological reactions.

6. The grafted bone should attach to the host bone by osteocoalescence.

7. The grafted bone should be denser thanthe host bone.

8. The grafted bone should display the absence of giant multinucleated inflammatory cells when analyzed histologically and histomorphometrically.

9. The bone grafting experience should demonstrate the absence of allergic reactions.

Advantages of Grafting with hcPRP

• The procedure is completely autologous• It’s free of disease transmission• It’s free of negative immune reactions• It minimizes swelling and discomfort• It is the only procedure in which hcPRP

and autologous thrombin/platelet activating factor 4 (PAF4) are producedsimultaneously from the patient’s own blood

• It is the only procedure in which 6 mL ofhcPRP can be produced at 15 times baseline

Figure 4. Osteolysis of allograft in the right sinus (hcPRP graft in left sinus was unaffected).

SMITH

• hcPRP alone can produce D2 bone in 3 months in five-wall bony defects

• hcPRP alone will regenerate all mesengenic tissues in human skeletal joints

• Platelet activation is done by using autologous biomaterials

• This method of grafting has applicationsin dentistry, sports medicine, orthopedics, and other medical professions

• hcPRP may reduce recovery time for injured athletes

ConflictsNone declared.

References 1. Marx RE, Garg AK. Dental and

craniofacial applications of platelet-richplasma. Hanover Park, IL: QuintessencePublishing Co; 2005: 31–47, 53–75.

2. Anitua E, Andia I, Ardanza B, et al. Autologous platelets as a source of proteins for healing and tissue regeneration. J Thrombo Haemosta 2004;91:4–15.

3. Gonshor A. Technique for producing platelet-rich plasma and platelet concentrate: Background and process. Int J Periodont Rest Dent 2002;6:547–57.

4. Stanworth SJ, Denton K, Monteath J, Patton WN. Automated counting of platelets on the Bayer ADVIA 120 analyser. Clin Lab Haem 1999;21:113–17.

5. Smith AE, Prasad HS, Rohrer MD. Boneregeneration with autologous biomaterial; rapid induction of vital newbone in maxillary sinus floor by plateletconcentrate alone at 23x baseline (PRP23x): A case report. Implant Dent 2009;18(3):210–19.

6. Marx RE, Carlson ER, Eichstaedt RM, etal. Platelet-rich plsma. Growth factor enhancement for bone grafts. Oral SurgOral Med Oral Pathol Oral Radiol Endod. 1998;85:638–46.

7. Whitman DH, Berry Rl, Green DM. Platelet gel: an autologous alternative tofibrin glue with applications in oral andmaxillofacial surgery. J Maxillofac Surg 1997;55:1294–9.

8. Marx RE. Platelet-rich plasma: A sourceof multiple autologous growth factors for bone grafts. In: Lynch Se, Genco RJ, Marx RE (eds). Tissue Engineering: Applications in Maxillofacial Surgery and Periodontics. Chicago: Quintessence; 1999, 71–82.

9. Sänchez AR, Sheridan PJ, Kupp LI. Is platelet-rich plasma the perfect enhancement factor? A current review. Int J Oral Maxillofac Implants 2003;18:93–103.

10. Tischler M. Platelet rich plasma. The useof autologous growth factors to enhancebone and soft tissue grafts. NY State Dent J 2002;68:22–4.

11. Delves PJ, Martin SJ, Burton DR, and Roitt IM. Essential Immunology, 11th Edition. Ames, IA: Blackwell Publishing;2006, 356–59.

12. Nairn R, Helbert M. Immunology for Medical Students, Second Edition. Philadelphia: Mosby Elsevier; 2007, 244–48.

13. Edgar JDM. Immunology, A Core Text With Self-Assessment. Philadelphia: Elsevier, Churchill Livingstone; 2006, 28–30.

14. Sears BW, Spear L, Saenz R. Microbiology and Immunology. Lippincott Williams & Wilkins; 2007, 131–32.

15. Ganong WF. Review of Medical Physiology, 22nd Edition. Lange MedicalBooks/McGraw-Hill; 2007, 522–23.

16. Edgar JDM. Immunology, A Core Text With Self-Assessment Philadelphia: Elsevier, Churchill Livingstone; 2006, 28.

17. Ganong WF. Review of Medical Physiology, 22nd Edition. Lange MedicalBooks/McGraw-Hill: 2007, 522–23.

18. Vaman Rao C. Immunology, Second Edition. Oxford, UK: Alpha Science International Ltd; 2006, 347–48.

19. McCartney-Francis NL, Wahl SM Transforming growth factor-beta: a matter of life and death. J Leukocyte Biol1994;55:401–9.

20. Palladino MA, Morris RE, Starnes HF, Levison AD. The transforming growth factor-beta. A new family of immunoregulatory molecules. Ann NewYork Acad Sci 1990;593:181–87.

21. Wahl SM, McCartney-Francis N, Mergenhagen SE. Inflammatory and immunomodulatory roles of TGF-beta.Immunol Today 1989;10:258–61.

22. Weiner HL. Induction and mechanism of action of transforming growth factor-�secreting TH3 regulatory cells. Immunol Rev 2001;182:207–14.




The Fully EdentulousResorbed Maxilla: Surgicaland Restorative Techniques

to Avoid Bone Grafting

About the Authors

Yvan Fortin’s practice is limited to dental implantology for the past 18years. The fully edentulous maxilla represents a large part of histreatments. He is well known for his non bone grafting approach inthe moderately to the severely resorbed maxilla. He shares his timebetween the city of Montreal and Quebec clinics. Dr Fortin is a fellowof the Academy of Osseointegration and a diplomate of AmericanBoard of Oral Implantology.

Yvan Fortin, DMD, Kenji W. Higuchi, DDS, MS, Richard M. Sullivan, DDS

Dr. Higuchi is a diplomate of the American Board of Oral andMaxillofacial Surgery in private practice in Spokane, WA. He has closelycollaborated with Professor P-I Brånemark since 1982 and his practiceemphasizes reconstructive implant surgery. He has contributedextensively to the literature and serves on the review board for theInternational Journal of Oral and Maxillofacial Implants and ClinicalImplant Dentistry and Related Research.

Richard M. Sullivan, is vice president of clinical technologies for NobelBiocare and maintains a private practice with special emphasis of thefully edentulous patient in Yorba Linda, California. Dr. Sullivan is afellow of the Academy of Osseointegration and completed the two-year Harvard University Seminars in Implant Dentistry program in1988.

FORTIN ET AL.

Demographic information shows that thenumber of people missing all of their

teeth in one or both arches will continue toincrease for the next 10 years.1 Increasingnumbers of fully edentulous patients will beturning to dental implantology during thistime to treat their condition. However, thetrend in recent years by dental surgeons topropose bone grafts has considerablydiminished the enthusiasm of patients forthis type of treatment.

Already in 1985, Professor P-I Brånemark,with hundreds of fully edentulous patientstreated, had stated that bone grafts in the fullyedentulous maxilla would only be necessaryin about 5–10% of patients.2 Personalobservation since 1992 has confirmed thatimplant restoration of the maxilla is possibleand predictable without compromise withalternatives to bone grafts in the vast majorityof patients, even with advanced resorption.The future appears very promising in termsof interesting new patients who would like toonce again have teeth in their maxilla withoutthe necessity of bone grafts.

This article is a brief summary of surgical andprosthetic options that help to avoid the use

of bone-grafting procedures. Recognizingthat each approach has been documented byitself, it is the combination of approaches thathave served as a foundation for treatmentplanning to evaluate patient treatment withnon-grafting methods. This article willdescribe the following four treatment optionsthat have been utilized: short implants, tiltedimplants, molar-to-malar process trans-sinusimplants, and the Marius CAD/CAM bridge,a fixed/detachable prosthesis design.

Short ImplantsA literature review by Renouard and Nissandhas shown conflicting results with shortimplants (7 to 9 mm length), with somestudies showing increased loss, and others,using an adapted surgical technique andtextured implant surfaces reporting the sameresults as longer implants.3 A notableretrospective study by Brånemark andcolleagues compared the outcomes of fullyedentulous jaws over a 10 year period. In thisanalysis, the intention was to place siximplants in all patients. However, due toanatomic limitations including decreasedbone volume, sometimes only four implantscould be placed; during this time period, only7- and 10-mm long implants were available.


ABSTRACTIncreasing numbers of fully edentulous patients are turning to dental implantology totreat their condition. However, the trend in recent years by dental surgeons to proposebone grafts has considerably diminished the enthusiasm of patients for this type oftreatment. Personal observation since 1992 has confirmed that implant restoration of themaxilla is possible and predictable without compromise with alternatives to bone graftsin the vast majority of patients, even with advanced resorption. This article is a briefsummary of surgical and prosthetic options that help to avoid the use of bone-graftingprocedures.

RÉSUMÉDe plus en plus de patients complètement édentés se tournent vers les implants pourrésoudre ce problème. Toutefois, au cours des dernières années, les chirurgiens dentairesavaient tendance à proposer des greffes osseuses, ce qui a diminué considérablementl’enthousiasme des patients pour ce type de traitement. Une observation personnelledepuis 1992 a confirmé que la restauration du maxillaire par la pose d’implants est possibleet prévisible sans compromis avec des solutions de rechange aux greffes osseuses pour lagrande majorité des patients, même s’il y a résorption avancée. Cet article est un brefrésumé des options chirurgicales et prosthétiques permettant d’éviter les greffes osseuses.

Figure 1. Seven millimetre implants in highlyresorbed residual ridge crest in anterior maxilla.Note posterior support provided by tiltedimplants anterior to maxillary sinus wall.


THE FULLY EDENTULOUS RESORBED MAXILLA

Their finding for both jaws was thatprosthesis survival and implant survival wasthe same for full arch fixed implantrestorations.4 Personal experience over aperiod of 18 years with the high quality boneobserved in the anterior portion of themaxilla of most patients with moderate tosevere resorption has confirmed these results.(Figure 1).

Tilted ImplantsTilted implants began being evaluated as asinus graft alternative by the author in 1992,with 5 year results of the first 45 patientstreated published in 2002. The data presentedshowed no difference in implant survivalwith tilted implants in the posterior maxillacompared to straight implants within thesame patient.5 These findings have beenconfirmed by other authors.6–9 Tiltedimplants are indicated in the posteriormaxilla when there is insufficient bone in themolar area, but implants are able to beinclined following the anterior wall of themaxillary sinus in the premolar area. Thereare many patient benefits associated with theuse of tilted implants.

The first advantage is that the anatomy of themaxilla of most patients makes it possible toinstall implants that engage the three cortices– palate, buccal plate, and anterior wall of thesinus – in a three-dimensional pyramidalzone along the anterior wall of the sinus.(Figures 2 and 3) This permits placement ofa longer implant with greater initial stability.While not appropriate for single toothrestoration, there have been no biochemicalcomplications associated with tilted implantswhen joined with a rigid framework to otherimplants in a full arch distribution.

The second advantage is that there is a betterarch form distribution of anchorage resultingin a better anterior/posterior spread withoutsinus grafts. This minimizes cantileverextension while providing posteriorstructural support of masticatory forces.(Figure 4 A–D).

Molar-to-Malar Process Trans-sinusImplantsZygomatic implants were originallydeveloped by Per-Ingvar Brånemark as amethod of fixation for the severely resorbed

maxilla.10 Zygomatic implants have been usedfor over 15 years, and are indicated whenthere is no bone in either posterior molar orpremolar positions.11 The implant survivalrates supported by Brånemark and others aresimilar to other implants and have fewcomplications.12–14 Despite this history anddocumentation, zygomatic implants havenever been very popular in the field ofimplantology, mainly because of thecompromises in terms of phonetics, hygiene,and comfort where these implants protrudein the palate and because of the relativelyextensive surgery required (Figure 5).

To be able to utilize the potential of thezygomatic implant without the phonetic andesthetic compromises, a new approach hasbeen developed which we refer to as the“molar/malar implant.” Malar process is anolder term for the zygomatic process, usedhere as a play on words to describe adifferentiated insertion path used withzygomatic implants to achieve favourableprosthetic results for alignment at or near theresidual ridge crest. This technique utilizes azygomatic implant inserted just palatal to the

Figure 2. A, even with a thin maxillary ridge, the area anterior to the sinus is broad creating a three-dimensional pyramid of bone; B, traditional approach ofstraight implants. C, illustration of tilted implant showing additional length of posterior support with one additional tooth and reduced cantilever length.

Figure 3. A, radiograph of restored patient fromfigure. B, three-dimensional screen capture fromplanning software, superior view, showing implantapex located between three cortices.

A B C

A B

A

B

FORTIN ET AL.

residual alveolar ridge in the first molar areawith apical fixation in the malar process(zygomatic process). This is a development ofthe original technique which anchored thezygomatic implant apex in the main body ofthe zygoma. The results of approximately 300zygomatic implants placed with thistechnique over the past 8 years havedemonstrated the possibility to haverestorative alignment comparable to atraditional implant relative to the ridge crest.Besides the improvement of implantalignment for a restoration without

compromise, the technique is also moreminimally invasive than the original protocol.This is due not only to less manipulation ofthe sinus membrane to reduce the incidenceof perforation, but also being able to safelyplace the apical aspect of the implant withoutdirect visualization utilizing a variation of thesinus slot technique15,16 (Figures 6 and 7).

The Marius CAD-CAM Bridge: A Fixed-Detachable Prosthesis DesignThe possibility of performing rehabilitations

that meet the expectations of our moderatelyto severely edentulous patients, i.e., a fixedrehabilitation that has no compromises interms of phonetics, hygiene, comfort,esthetics, and lip support, is a major plus forimplant treatment of the fully edentulousmaxilla.

A removable, fixed bridge is the only tool thatallows us to deal with all these factors inpatients with moderate to severe resorptiondue to deficiencies of bone structure and theeffects on patient facial and lip support.

The Marius Bridge is a double structure,removable fixed bridge that provides all thebenefits listed above.5 The CAD-CAMstructure provides a highly preciseconnection between the bridge, which thepatient can remove, and the structure that isscrewed into his or her mouth. It eliminatesthe useless palatal extension commonlyassociated with maxillary overdentures, andmakes it possible to reproduce the patient’slip support with no compromises in terms ofhygiene and phonetics. It is held in place bycombination of an undercut angle in the bardesign and a secure posterior lock17 (Figure8).

ConclusionBased on over 1,000 patients with acompletely edentulous maxilla treated overan 18-year period, we can affirm that we cantreat most patients using the method that wedeem is the best suited for the needs of eachpatient, i.e., a zirconia-to-porcelain fixedbridge, a profile titanium-acrylic bridge,18,19

or a Marius CAD-CAM removable fixedbridge.


Figure 4 A–D. Patient restored in 1994 with tilted implants and full arch splinted ceramo-metalrestoration. Note appropriate contours of restoration and limited cantilever length with pneumatizedsinus achieved without bone grafts.

Figure 5 A–C. Representative results of early zygomatic implant protocol with palatal extensions of prosthesis.

A B

C D

A B C


THE FULLY EDENTULOUS RESORBED MAXILLA

Figure 6 A–C. Molar-malar implant. A, insertion point in area of maxillary first molar with minimaltrans-sinus penetration using sinus slot to push membrane away during site preparation. B, alignmentof same implant on ridge crest allowing routine restoration with no unnatural prosthesis contours. C,apical extension of implant is in malar process (zygomatic process) short of main body of zygoma boneas used in the initial protocol.

Figures 7A–H. Representative examples ofalignment and posterior support achieved withcombinations of short, tilted and molar-malarimplants without the use of bone grafts. Notethat ideal prosthetic restoration is possible withimplant emergence exiting at ridge crest withsurrounding attached gingiva.

A B

A B

C

D E

C

F

G H

We can also assert that we can treat 98% ofpatients using tilted implants, short implantspositioned in good quality bone in theanterior portion of the upper maxilla, orzygomatic implants (molars-malar) withoutresorting to bone grafts. The exit points of allthese implants are on the top of the crest andare surrounded by attached gingival tissue.The choice of the most appropriate prostheticsolution for each patient, among thosementioned above, should provide a resultwith no compromises in terms of phonetics,comfort, esthetics, or hygiene.


References1. Douglass CW, DMD, Shih A, Ostry L.

Will there be a need for complete dentures in the United States in 2020? JProsthet Dent 2002;87:5–8.

2. Brånemark P-I, Zarb G, Albrektsson T, eds: Tissue-Integrated Prostheses. Chicago, IL: Quintessence; 1985, 211.

3. Renouard F, Nisand D. Impact of implant length and diameter on survivalrates. Clin Oral Implants Res 2006;17(Suppl 2):35–51.

4. Brånemark P-I, Svensson B, van Steenberghe D. Ten-year survival rates

of fxed prostheses on four or six implants ad modum Brinemark in full edentulism. Clin Oral Implants Res 1995;6:227–231.

5. Fortin Y, Sullivan RM, Rangert B. The Marius implant bridge: Surgical and prosthetic rehabilitation for the completely edentulous upper jaw with moderate to severe resorption: A 5-yearretrospective clinical study. Clin ImplantDent Relat Res 2002;4:69–77.

6. Mattsson T, Kondell P, Gynther GW, Fredholm U, Bolin A. Implant treatmentwithout bone grafting in severely resorbed edentulous maxillae. J Oral Maxillofac Surg 1999;57:281.

7. Krekmanov L. Placement of posterior mandibular and maxillary implants in patients with severe bone deficiency: A clinical report of procedure. Int J Oral Maxillofac Implants 2000;15:722.

8. Aparicio C, Perales P, Rangert B: Tilted implants as an alternative to maxillary sinus grafting: A clinical, radiologic, andperiotest study. Clin Implant Dent RelatRes 2001;1:39.

9. Maló P, Rangert B, Nobre M. All-on-4 immediate-function concept with Brånemark system implants for completely edentulous maxillae: A 1-year retrospective clinical study. Clin Implant Dent Relat Res 2005;7(Suppl 1):S88.

10. Brånemark PI, Gröndahl K, Ohrnell LO,et al. Zygoma fixture in the managementof advanced atrophy of the maxilla: technique and long-term results. ScandJ Plast Reconstr Surg Hand Surg 2004;38(2):70–85.

11. Bedrossian E, Sullivan R, Fortin Y, et al.Fixed-prosthetic restoration of the edentulous maxilla: A systematic pre-treatment evaluation method. J Oral Maxillofac Surg 2008;66(1):112–22.

12. Aparicio C, Ouazzani W, Garcia R, et al.A prospective clinical study on titaniumimplants in the zygomatic arch for prosthetic rehabilitation of the atrophicedentulous maxilla with a follow-up of6 months to 5 years. Clin Implant DentRelat Res 2006;8(3):114–22.

13. Kahnberg KE, Henry PJ, Hirsch JM, et al. Clinical evaluation of the zygoma implant: 3-year follow-up at 16 clinics. J Oral Maxillofac Surg 2007 Oct;65(10):2033–8.

14. Balshi SF, Wolfinger GJ, Balshi TJ. A retrospective analysis of 110 zygomaticimplants in a single-stage immediate loading protocol. Int J Oral Maxillofac Implants 2009;24(2):335–41.

15. Stella JP, Warner MR. Sinus slot technique for simplification and improved orientation of zygomaticus dental implants: a technical note. Int J Oral Maxillofac Implants 2000;15(6):889–93.

16. Peñarrocha M, García B, Martí E, Boronat A. Rehabilitation of severely atrophic maxillae with fixed implant-supported prostheses using zygomatic implants placed using the sinus slot technique: clinical report on a series of 21 patients. Int J Oral Maxillofac Implants 2007;22(4):645–50.

17. Fortin Y, Sullivan R. A New Prefabricated Mesostructure Bar Systemfor Patient-Removable Fixed Restoration of the Fully Edentulous Maxilla. Acad Osseointegrat Clin Innovat 2006 (published abstract).

18. Schnitman P. The profile prosthesis: Anaesthetic fixed implant supported restoration for the resorbed maxilla. Pract Periodont Aesthet Dent 1999;11:143.

19. Schnitman P, Vasilic M, Sullivan R. A new milled titanium frame design simplifying the profile prosthesis: A solution for the resorbed edentulous maxilla. Acad Osseointegrat Clin Innovat 2006 (published abstract).

FORTIN ET AL.


Figure 8. Marius CAD/CAM bridge with patient removable suprastructure offering hygiene access withstable non-resilient flanged restoration. Note open palate without extensions as typical onoverdenture restorations.



Nanotextured ImplantSurfaces: Re-engineering the

Bone ResponseRobert J. Miller, MA, DDS, FACD, DABOI

About the Author

Dr. Miller received his BA from New York University and M.A. from HofstraUniversity, both in biology. He graduated with honours from New York UniversityCollege of Dentistry where he received the International College of Dentists Awardfor clinical excellence. Following graduation, he completed a residency program atFlushing Hospital and Medical Center where he was involved in all phases ofdentistry including facial trauma. Dr. Miller is a board certified diplomate of theAmerican Board of Oral Implantology/Implant Dentistry and a fellow of theAmerican College of Dentists.

Dr. Miller is chairman of the Department of Oral Implantology at the Atlantic CoastDental Research Clinic in Palm Beach, Florida. He has lectured internationally onall phases of oral implantology and laser surgery and is director of The Center forAdvanced Aesthetic and Implant Dentistry in Delray Beach, Florida.

ABSTRACTChanges in the microtopography of implant surfaces to increase roughness has beenshown to increase to speed of osseointegration and percentage of bone-to-implantcontact. Bone cell adhesion and metabolism can be further enhanced through the use ofnanotextured surface and calcium phosphate impregnation. Reduction of the catabolicphase of bone leads to earlier bone bonding. Our ability to re-engineer the bone responsemay lead to earlier loading and more predictable outcomes in implant dentistry.

RÉSUMÉIl a été démontré que les changements dans la microtopographie des surfaces implantairespour augmenter la rugosité augmentaient la vitesse d’ostéointégration et le pourcentagedu contact du matériau implanté et de l’os. L’adhésion de cellules osseuses et lemétabolisme peuvent être améliorés par l’utilisation d’une surface nanostructurée et parimprégnation au phosphate de calcium. La réduction de la phase catabolique de l’osentraîne une liaison osseuse précoce. Notre capacité à redéfinir la réponse osseuse peutmener à la mise en charge précoce et à des résultats plus prévisibles en implantologie.

MILLER

Interaction between an artificial device andliving tissue is a fascinating field ofexploration and science. In the last 30 years,we have observed an ever-increasingconvergence of diverse branches of science.Today, specialists can no longer rest on whatwas learned from the pioneers of theirdiscipline. Cross-disciplinary education andperusal of the scientific literature is a “must”for the contemporary practitioner. Thus, aperiodontist must have a basic understandingof advanced immunology, the immunologistmust understand advanced biochemistry, andthe biochemist needs to remain updated inadvanced physics and mathematics. Inaddition, all can benefit from a good dose ofphilosophy, which is indispensible for gaininga perspective in a time of rapidly changingtechnology and for the conceptualization ofcomplex theories.

With respect to the interactions between animplant and its surrounding tissues, the workof Professor Per Ingvar Branemark clearlyestablished the basics of “osseointegration”and demonstrated that bone may healuneventfully when placed in contact withtitanium. But that was only a beginning. Toomany questions were left unanswered; whydo we continue to experience implantfailures, usually at early stage of bone repair?Do all the implant designs trigger the sameresponse from bone? Is bone healing alwaysthe same, regardless of thread design, surfacecharacteristics, load or no-load, or degree ofapproximation to the implant?

If we consider the multitude of endosseousimplant designs on the market, with differentsurface finishes, we are faced with the paucityof studies to validate the merits of thoserefinements. Instead, we are bombarded byadvertising claims, numerous anecdotal andclinical case reports, literature published byuniversities that rely on multi-million dollarresearch grants, and, only recently, somebiologically driven implant designs.

An example of addressing the biologicimperative can be seen in the work ofBerglundh, et al. This report demonstratesthat changing thread design and drillingsequence could significantly alter the kineticsof bone healing.1 Coelho, et al, also providedevidence that a thread design change,

combined with a change in drilling sequencewould speed up bone formation by a factoras great as 10 times.2 The data are impressive,and even more impressive when you considerthe fact that these experiments were stilllooking at a macro scale where we canvisualize the changes that were made to theimplant architecture by the naked eye.

The history of surface modifications has alsoundergone its share of trial and error,progressing from machined surfaces, totitanium plasma spray (TPS), acid etched,and plasma spray hydroxyapatite. Thankfully,a consensus has emerged from the scientificcommunity with respect to thischaracteristic, and the verdict has come in:micro-rough surfaces are superior when directbone apposition is desired. Despite the factthat the technologies employed to generatethese surfaces may vary from onemanufacturer to another, the same profileand surface chemistry will provide the samebiological response. An important differenceto note in this advance is that whereas thechanges in thread design and drillingsequences are discernible by the human eye,the perception of significant surface changescan only be determined via microscopicexamination. Kikuchi, et al, have shown thatthe surface characteristics that exist at thislevel are essential for platelet activation.3 Theyhave concluded that the surface characteristicpresent at the level where measurement bysurface profilometry is required is moreimportant than gross surface chemistry. Atthis level of technology, the changes are onthe micro scale.

Most implant manufacturers have remainedfocused on the micro level even though manyuse the “buzz-word” of nanotechnology.Nanotechnology is a relatively new science(less than 30 years old) and its developmentincreased exponentially in the nineties withthe introduction of the scanning tunnelingmicroscope and the atomic force microscope.The discipline encompasses various areas:nanomaterials and molecular nanotechnology.Molecular nanotechnology consists ofcreating complex structures, using the atoms as elemental building blocks.Nanoprofilometry is often confused with theterm nanotechnology, but they are notsynonymous. They are as different as

“looking” versus “doing.”

OSSEAN Surface TreatmentSurgical principles in oral implantology arereturning to a paradigm of early orimmediate loading of dental implants.Therefore, respect for both prosthetic andbiologic principles is imperative. When adental implant is placed, the bone to implantinterface is weaker at two weeks immediatelyafter implant insertion because of aninflammatory cascade and catabolic eventswhich result in bone breakdown andremodeling.4 This places the implant at riskif it is placed in immediate function or in anextraction site with a significant defect.Previous implant coatings, such as plasma-sprayed hydroxyapatite (HA), have attemptedto address this breakdown phase withdemonstrable success.5 Earlier amorphousHA coatings were highly osteoinductivebecause of the bioavailability of free calciumions and the effect on osteogenic cells.6

Studies of HA coated implants in the 1980sclearly demonstrated earlier osseointegrationand a higher bone-to-implant contact.7

However, the low crystallinity of HA led tofractures of these coatings and severe peri-implant infections after cyclical loading.8 Forover a decade, many clinicians have avoidedHA coatings as a result of thesecomplications. In an attempt to eliminatethese clinical problems, manufacturerssubsequently changed the HA formulation toapproximately 97% crystallinity. This solvedthe fracture problem but had the oppositeeffect on osteoinductivity. Highly dense HAdoes not resorb to any significant degree. Thisdramatically reduces the bioavailability offree calcium from the implant surface.Therefore, current HA surfaces have limitedbiologic interaction when compared to neweracid-etched titanium surfaces and no longeroffer any significant clinical advantage.9

In 1991, the concept of “bone-bonding” wasfirst described.10 Different from the type ofinterface originally described by Branemarkand known as osseointegration, bone-bonding is characterized as an interfacialbond between the bone and implant surfacethat exceeds the cohesive strength of eitherbone or implant.11 A chemical interactionoccurs between bone and implant thatenhances both bone crystallinity and



NANOTEXTURED IMPLANT SURFACES: RE-ENGINEERING THE BONE RESPONSE

adhesion, and can be demonstrated whencalcium phosphate materials are present in the correct concentrations.12 Theintroduction of a nanotextured surface,further enhanced by molecular impregnationwith calcium phosphate (Figure 1), has beenshown to significantly enhance osteoblasticactivity and dramatically reduce the catabolicphase of bone remodeling.13

Vetrone, et al, recently showed in 2008 thatnanostructured surfaces influence thebehaviour of various cell types and even alterthe potential for the differentiation of stemcells.14 The Ossean research project wasinitiated in 2005 (Intra-Lock International),and the surface was launched in 2007. It ischaracterized by a fractal structure with thesame pattern repeating itself from themacroscale to the microscale, then to thenanoscale and beyond. There is no additionof particulate material of any kind on thesurface. Instead, there is an elementalmodification of the surface chemistry withinthe titanium oxide layer via the incorporationof calcium phosphate. High resolution SEM

shows that, at 200,000× magnification, thenanotexture of the surface is pristine anddevoid of any discrete particles orcontaminants. In addition, the Osseansurface dramatically increases the rate ofosteoblastic synthesis of type I collagen, thuspromoting osseointegration and reducing thechances of early failure of immediatelyloaded implant.15 Even distribution of thecalcium phosphate surface is critical tocontrol the physiology of osteoblasts.Calcium phosphate is evident under XPS-ESCA or Auger spectroscopy (Figure 2).

This increase in bone-bonding strength isclearly demonstrated in a study conducted byMarin, et al, where Intra-Lock implants withand without the Ossean surface were testedin a reverse torque removal study (Figure 3).The Ossean surface implants at two weeksafter placement exhibited a 100% greaterbone adhesion than the implants without thesurface modification.16

The Ossean surface is clearly biologicallyactive in the sense that bone goes directly to

the anabolic phase without intervening bonebreakdown. It is postulated that the Osseansurface changes the genetic “fate” or thecoding of the surrounding osteogenic cells.17

This is extremely important in immediateload cases and for extraction site defectswhere the percentage of initial bone-to-implant contact is compromised.18

Similar conclusions can be drawn fromanother study published by Piatelli, et al. Inthis human study, Ossean surface implantshave been compared to an identical implantwith a conventional blasted/acid etchedsurface. An osteocyte count was performedadjacent to the implant surface and atdistance. The results show a 50% increase ofthose cells compared to the control.19 Thesestudies and other data confirm the fact thatwe are not only working at the nanoscale, butalso within the true realm of nanotechnology,at the molecular level.

These recent findings are changing theparadigm of tissue healing around implants,and will enable us to redefine the concept of

Figure 1. SEM of Ossean surface at 50,000×�magnification

Figure 2. Auger spectroscopy demonstrating even distribution of calcium phosphate.

Figure 3. Reverse torque values comparing Osseanversus Non-Ossean surface implants.

MILLER

osseointegration with greater precision anddepth of understanding. Our capacity to re-engineer the biologic response aroundimplanted devices will lead to morepredictable outcomes in dental implanttreatment.

ConflictsThe author has received honorariums andproduct for research from several companies,including Intra-Lock International.

References1. Berglundh T, Abrahamsson I, Lang NP,

Lindhe J. De novo alveolar bone formation adjacent to endosseous implants. A model study in the dog. ClinOral Implants Res 2003;14:251–62.

2. Coelho P, Suzuki M, Guimaraes M, et al.Early bone healing around different implant bulk designs and surgical techniques; A study in dogs. Clin Impl Dent and Relat Res 2009; In Press.

3. Kikuchi L, Park JY, Victor C, Davies JE. Platelet interactions with calcium-phosphate-coated surface. Biomaterials 2005;26(26):5267–426.

4. Albrektsson T, Johansson C. Quantified bone tissue reactions to various metallicmaterials with reference to the so-calledosseointegration concept. In: Davies JE, ed. The Bone-Biomaterial Interface. Toronto: University of Toronto Press; 1991, 357–63.

5. Block MS. Advantages and disadvantagesof hydroxyapatite-coated implants. OralMaxillofac Surg Clin of North Amer 1991;3:835–51.

6. MacDonald DE, Betts F, Stranick M, et al. Physicochemical study of plasma-sprayed hydroxyapatite-coated implantsin humans. J Biomed Mat Res 2000;54(4):480–90.

7. Engquist B, Bergendal T, Kallus T, LindenU. A retrospective multicenter evaluationof osseointegrated implants supporting overdentures. Intl J Oral Maxillofac Implants 1988;(3):129–34.

8. Dalton JE, Cook SD. In vivo mechanicaland histological characteristics of HA-coated implants vary with coating vendor. J Biomed Mat Res 2004;29(2):239–45.

9. Lee SC, Song WS. Histomorphometric and removal torque values comparison of rough surface titanium implants. J Korean Assoc Maxillofac Plast Reconstr Surg 2001;23(5):396–405.

10. Anselme K. Osteoblast adhesion on biomaterials. Biomaterials 2000;21:667–81.

11. Mendes VC, Moineddin R, Davies JE. The effect of discrete calcium phosphatenanocrystals on bone bonding. Biomaterials 2007;28(207)4748–55.

12. Coelho P, Freire J, Coelho A, et al. Nanothickness bioceramic coatings: Improving the host response to surgicalimplants. In: Leipsch D, ed. World Congress of Biomechanis Conference Proceedings. Munich: Medimont; 2006, 253–58.

13. Gerner BT, Albrektson T, Ronningen H,Solheim LF, Wie H. Comparison of bonereactions to coated calcium phosphate and pure titanium implant in the canineiliac creast. Scan J Dent Res 1988;96:142–48.

14. Vetrone F, Variola F, Tambasco de Oliviera P, et al. Nanoscale oxidative patterning of metallic surfaces to modulate cell activity and fate. Nano Lett2009;9:659–65.

15. Susarla SM, Chuang SK, Dodson TB. Delayed versus immediate loading of implants: survival analysis and risk factors for dental implant failure. J OralMaxillofac Surg 2008;66:251.

16. Marin C, Granato R, Suzuki M, et al. Removal torque and histomorphometricevaluation of bioceramic grit-blasted/acid-etched and dual acid-etchedimplant surfaces: an experimental studyin dogs. J Perio 2008;79:10(1942-1949). doi: 10.1902/jop.2008.080106.

17. Bucci V, Cassinelli C, Coelho P, et al. Effect of titanium implant surface roughness and calcium phosphate low impregnation on bone cell activity in vitro. Oral Surg Oral Med OralPathol Oral Radiol Endod 2010;109:217–24.

18. Castellon P, Blatz MB, Block MS, et al. Immediate loading of dental implants inthe edentulous mandible. J Am Dent Assoc 2004;135(11)1543–49.

19. Shibli JA, Grassi S, Piattelli A, et al. Histomorphometric evaluation of bioceramic molecular impregnated anddual acid etched implant surfaces in thehuman posterior maxilla. Clin Implant Dent Relat Res. DOI:10.1111/j,1708-8208.2010.00174.


DENTISTERIE IMPLANTAIRE


Barres usinées pourprothèses implanto-portées

Nicolas Tardif TDC et Hubert Gaucher DDS, MScD

Au sujet des auteurs

Technicien dentaire diplômé du Collège Édouard-Monpetit et membre de l'Ordredes techniciens et techniciennes dentaires du Québec, M. Tardif a reçu uneformation Nobel Procera (NobelBiocare) à Mahwah, N.J.. Il est le Directeur dudépartement d'implantologie au Laboratoire Dentec à Québec. Il peut être joint aucourriel: [email protected].

Prosthodontiste, membre de l’Ordre des dentistes du Québec, en pratique privéeà Québec et Prosthodontiste résident pour la 1e Unité dentaire à BFC Valcartier,Fellow de l’Académie canadienne de dentisterie restauratrice et de prosthodon-tie et Fellow de l’Académie dentaire internationale, il est le Directeur scien-tifique de l’Institut canadien de recherche dentaire (ICRD). Il peut être joint aucourriel: [email protected].

RÉSUMÉLa CAO/FAO dentaire a évolué sur une période de décennies et offre aux laboratoiresdentaires de nouvelles applications numériques pour la fabrication de prothèses implanto-portées utilisant les barres usinées. Un rapport de cas patient illustre les étapes cliniquesnécessaires à l’incorporation d’un nouveau logiciel 3D Procera (Nobel Biocare, Centre deproduction de Québec) utilisé pour le design et l’usinage de barres, permettant ainsid’excéder les résultats cliniques prévisibles.

TARDIF ET GAUCHER

Déjà en 1965, un premier patient fut traitéselon les principes de l’ostéo-

intégration. Le Prof Dr Per-Ingvar Brånemarket son équipe avaient mis au point lesprincipes biologiques de l’implantologiecontemporaine, définie comme étant unejonction anatomique et fonctionnelle directeentre l’os vivant remanié et la surface del’implant mis en charge.1 Ce type d’interfacepermet le maintien à long terme des implantsendo-osseux. De nombreux systèmesd’implants dentaires ont vu le jour depuisavec des taux de succès de 95% à 100%documentés.2

C’est en 1985 que sont apparus les deuxsystèmes de CAO/FAO très répandusaujourd’hui : le système Cerec (Sirona)développé à Zürich par le Prof W. Moermanet M. Brandestini, ing, et le système Procera(NobelBiocare) développé par MattAnderson en Suède. La CAO/FAO(conception assistée par ordinateur etfabrication assistée par ordinateur) estmaintenant possible grâce aux connaissancesaccrues de l’usinage des matériaux durs etmous. La modélisation de couronnes et ponts

est réalisée au moyen de prise d’empreintepar micropalpage ou par laser grâce àl’informatique qui permet de calculer cesacquisitions et qui par la suite permet de fairel’usinage d’un matériau connu.3,4

Cas CliniqueUne patiente âgée de 50 ans, en bonne santé,est référée par un dentiste généraliste quiavait débuté des traitements de prosthodontiechez elle. Au moment de l’examen cliniqueinitial, celle-ci avait sept implantsostéointégrés avec piliers de guérison en placeet une prothèse complète conventionnelle detransition regarnie avec un matériautemporaire (Tru-Soft, Bosworth) aumaxillaire. Cinq implants ostéointégrés avecpiliers de guérison et une prothèse complètede transition regarnie avec le même matériautemporaire étaient aussi en place à lamandibule. Ces prothèses de transitionprésentaient une béance antérieureprononcée et occasionnaient des problèmesde phonétique pour la patiente. Les tissusétaient normaux et la gencive attachéeadéquate en périphérie des implants. Lapatiente présentait une relation de Classe I

des bases osseuses squelettiques étant donnéson histoire d’édentation complète récente.

Celle-ci avait subi les extractions complètesdes dents haut et bas et le placement de 12implants (Nobel Biocare Mark III - TIUnite) avec greffes osseuses autogènesconcomitantes sur 5 de ces implants, le touteffectué par un parodontiste, compte tenu dupronostic parodontal défavorable pour lemaintien des dents restantes. Un rapport duparodontiste confirmant l’ostéointégrationde l’ensemble des implants accompagnait laréférence du dentiste généraliste. L’implantNo 22 visible sur le panogramme initial a étéretiré un mois suivant la pose, pour êtreremplacé par des implants aux sites No 21 et23. (Figure 1 et Figure 2).

Les modèles d’étude (Figures 3A–C)représentant la dentition en place ont étéobtenus du dentiste référant afin d’évaluerl’occlusion et la dimension verticale présenteen début de traitement. La patiente rapporteavoir une habitude de serrement, mais aucunsigne de problèmes articulaires oumusculaires à l’examen n’est noté. La patientedemande des prothèses fixes implanto-portées haut et bas et souhaite compléter cestraitements de prosthodontie dans un tempsrapproché pour raison de disponibilité. Unplan de traitement est élaboré afin defabriquer les prothèses fixes implanto-portées(barres usinées) avec une séquence des étapesde traitements permettant les vérifications del’occlusion, de l’esthétique, de la phonétique,d’une dimension verticale acceptable ainsique la vérification de l’assise passive desbarres usinées. Figure 3. A, maxillaire. B, mandibule, C.occlusion antérieure.


Figure 1 : Panogramme pré-opératoire. Figure 2 : Panogramme initial post-opératoire.

Figure 3. A, maxillaire. B, mandibule, C. occlusion antérieure.

A B C

Des empreintes au niveau des têtes desimplants utilisant des transferts carrés et desradiographies périapicales confirmant leursplacements adéquats sont prises au moyen deporte-empreintes individuels avec matériauà empreinte du type polyéther (Impregum,3M-ESPE). Des modèles de travail haut et bas(Figures 4A et B), avec gencives amovibles,sont articulés au moyen de plaques bases(Figures 5A et B) en utilisant l’arc facialHanau. Le choix des moules des dents deprothèse en acrylique5 ainsi que la

détermination des surplombs verticaux ethorizontaux sont en grande partiedéterminés par les modèles d’étude pré-opératoires (Figures 3A–C). L’essayage desplaques bases et dents montées dans la cirepermettent d’évaluer la dimension verticalede l’occlusion, l’esthétique, ainsi que laphonétique, dans le but d’apporter lescorrections nécessaires. Des clefs derepositionnement en silicone pour les dentsdes prothèses haut et bas ainsi qu’un articuléde vérification sont alors fabriqués à partir

des modèles de travail montés surarticulateurs. Ces éléments serviront àreplacer précisément les dents sur les barresusinées une fois celles-ci disponibles.

Il existe plusieurs façons de valider le modèlede travail en dentisterie implantaire.L’utilisation d’une gigue de vérification esttoutefois avantageuse pour le praticien,puisque cette validation a lieu en bouche. Laméthode consiste a placer des transfertsmétalliques sur le modèle de travail et de lesjumeler avec une résine auto-polymérisantede type Duralay ou GC. Il faut s’assurer quela gigue de vérification soit passive sur lemodèle de travail. Lorsque le praticien faitl’essaie de la gigue en bouche et qu’il y noteune différence dans l’assise, il peut alorssectionner l’acrylique et indexer avec de larésine afin de corriger la gigue en bouche. Enretournant cette gigue modifiée aulaboratoire, le modèle de travail originalpourra être altéré en tenant compte dunouveau positionnement des transferts.6 Il esttrès important que le modèle soitparfaitement identique à ce que nous avonsen bouche, afin d’éviter des reprisesprolongeant indûment le temps defabrication.

Dans le cas qui nous intéresse, les barresimplantaires ont été conçues par CAO/FAO.Leur conception a été réalisée en utilisant lesystème Nobel Procera et un tout nouveaulogiciel disponible depuis 2009. Ce logiciel futdéveloppé par la compagnie Biocad (Québec,Qc) et conçu pour faciliter le travail dutechnicien lors de la fabrication de barresimplanto-portées, de la conception de


BARRES USINÉES POUR PROTHÈSES IMPLANTO-PORTÉES

Figure 4A. Modèle de travail maxillaire. Figure 4B. Modèle de travail mandibule.

Figure 5A. Plaque base maxillaire.

Figure 6A. Barre de Montréal usinée à lamandibule.

Figure 6B. Vue occlusale de la barre. Figure 6C. Vue gingivale de la barre.

Figure 5B. Plaque base mandibule.

couronnes et ponts et de piliers sur implants.

Choix de BarresPour la mandibule, nous avons fabriqué unebarre de Montréal (Figures 6A–C): une barredont la partie gingivale de la prothèse sera entitane et à environ 1,5 mm de la gencive. Aumaxillaire, une barre Wrap-Around deMontréal a été choisie (Figures 7A–C). Uneprescription de fabrication NobelProcera™est utilisée indiquant notre préférence parmide multiples types de barre. Les barrespeuvent être fraisées selon différentesspécifications, soit : 0, 2, 4, ou 6 degrés avecla possibilité d’incorporer plusieursattachements : Dalbo, TSB, Ceka, Locator,OSO, Bredent. Des extensions Dolder, dedifférents volumes, peuvent être usinées ainsique la barre Hader. Des barres Wrap-Aroundde Montréal (acrylique en contact avec lacrête), de Montréal avec lingual en métal et labarre de Paris, laquelle est amovo-inamovible(structure métallique vissée avecattachements recevant une composanteamovible en acrylique) peuvent aussi êtreprescrites. Une fois le choix de barrecomplété, nous effectuons l’ordonnance pourla conception de la barre.

Le système Procera pour les barres usinéesconsiste initialement à reproduirevirtuellement le modèle de travail afin depermettre la réalisation des étapes deCAO/FAO ultérieures. Pour ce faire, nousavons besoin d’un modèle de travail en plâtreavec gencive amovible, afin de permettre lalecture des répliques métalliques sur lemodèle au moyen d’un scanneur laserspécifique. Celui-ci est disponibleuniquement au Nobel Procera InnovationCentre situé dans le Parc technologique de la

Ville de Québec. Une fois la gencive enlevéedu modèle nous devons avoir au moins 1,5mm libre de plâtre en périphérie des têtes desrépliques non-altérées. Vient ensuitel’acquisition numérique de l’articulé del’occlusion obtenue en bouche. Une fois lesacquisitions numériques terminées (dumodèle de travail et de l’articulé), ces fichiersinformatiques sont retournés au laboratoiredentaire accompagnés d’une proposition dedessin de barre lequel doit être modifié parl’utilisateur (Figs 8A–D). Ce logiciel novateurde CAO pour barres offre plusieurs outils de

conception, tels :

• l’étendue des extensions distales selon larègle de Misch7

• outils pour mesurer l’espace sous la barre• outils pour modifier l’angle de

conception de la barre• fenêtre de coupe axiale en mm carrés

permettant de visualiser la gencive, la barre et l’articulé d’occlusion et de valider l’espace disponible pour l’acrylique ainsi que pour les dents prothétiques

TARDIF ET GAUCHER


Figure 7A. Barre de Montréal usinée Wrap-Around au maxillaire.

Figure 7B. Vue occlusale de la barre complétée. Figure 7C. Vue gingivale de la barre complétée.

Figure 8A. Modélisation barre supérieure. Figure 8B. Superposition des dents sur la barresupérieure.

Figure 8C. Modélisation barre inférieureprothèse.

Figure 8D. Superposition des dents de sur la barreinférieure.


BARRES USINÉES POUR PROTHÈSES IMPLANTO-PORTÉES

Une fois l’étape de la CAO complétée par lelaboratoire dentaire, le fichier numérique dela barre est retourné au centre de productionafin d’amorcer l’usinage d’un monoblocd’alliage de titane (Ti6A14VL). Une machine-outils Nobel Procera™ à 5 axes fonctionnesur trois axes de translation : gauche/droite,avant/arrière, haut/bas, plus deux axes derotation : A et B (Figure 9) résulte en unusinage très précis.8 Une fois la pièceterminée, elle est polie de façon manuellesous microscope pour produire une surfaceidéale (Figure 6C). Pour les besoin du casprésent il y avait peu d’espace au maxillaireet il a fallu modifier la barre supérieure pouranguler la cheminée des cylindres, ainsi quelibérer l’espace sous la papille incisive, dansle but d’enrober d’acrylique la barre Wrap-Around. (Figure 7B).

Les avantages des barres CAO/FAOcomparativement aux barres conven-tionnelles

Elles utilisent le même matériau que les

implants (titane), évitant ainsi tout chocgalvanique possible. La barre étant unmonobloc, il n’y a donc pas de faiblesse demétal pouvant provenir de porosités dues auxsoudures. Il est démontré que l’adaptationdes armatures CAO/FAO en titane est valablepour les couronnes et ponts, conférant cettemême précision aux barres usinées.9–12

La coulée d’une barre implanto-portéeconventionnelle présente beaucoup derisques de porosités causées par unetechnique incorrecte de coulée. Lors dessoudures ces porosités sont souvent fonctionde la distance ou de l’espace vide séparant lesdeux pièces à souder.

La barre conventionnelle coulée en titane degrade 1 n’a pas les mêmes résistancesphysiques qu’une barre usinée. La limiteélastique du titane usiné Ti6A14VL estsupérieure à 800 MPa, soit plus de trois foissupérieure à celle du titane coulé de grade 1.

En matière de résistance à la fatigue, leTi6A14VL est l’alliage de titane le plus

Figure 9. Schéma machine–outils cinq axes.

Figure 10E. Vue miroir prothèse mandibulaire. Figure 10F. Position de repos. Figure 10G. Dégagement au sourire.

Figure 10B. Cuisson mandibulaire. Figure 10C. Prothèse fixes implanto-portées hautet bas.

Figure 10D. Vue miroir prothèse maxillaire.

Figure 10A. Cuisson au maxillaire.

TARDIF ET GAUCHER

performant et est quatre fois plus léger quel’or. Le Titane usiné est donc un matériau dechoix pour les prothèses implanto-portées.10,11

Continuation des Étapes CliniquesLes barres usinées (Figures 6A et 7A)recevront les dents de prothèses etsupporteront les rebords des prothèses enutilisant les clefs de positionnement etl’articulé fabriqués à compter des montagespréalablement vérifiés en bouche à l’aide desplaques bases vissées (Figures 5A et B).

Le cas est remis en bouche afin d’évaluer lesassises passives des barres au moyen deradiographies périapicales et d’une séquencede serrement des vis visant à déceler toutmouvement des barres. Encore une fois, leséléments critiques, tels l’occlusion,l’esthétique et la phonétique sont évalués etdoivent être confirmés acceptables par lapatiente avant les cuissons finales. Une prised’articulé en bouche valide la relation surarticulateur avant l’ordonnance pour lescuissons. Un balancement de l’occlusionpost-cuisson en laboratoire est recommandéafin de finaliser les contacts occlusaux.

La mise en bouche des prothèses (Figures10A–G) vérifie l’occlusion centrique stable etl’occlusion bilatérale balancée. Ledégagement adéquat de l’acrylique aumaxillaire pour le passage de la soie dentaireest modifié au besoin. C’est alors que lesinstructions d’hygiène spécifiques sontexpliquées à la patiente. Le serrement des visprothétiques au niveau des implants suit lesrecommandations du manufacturier et lestrous de vis sont obturés au moyen dematériau temporaire.

L’examen de contrôle dans les semaines quisuivent vérifie la stabilité des contactsocclusaux des prothèses ainsi que leserrement non altéré des vis prothétiques.L’adaptation pour la patiente est notée avantde finaliser les obturations des trous de vis aumoyen de composites. Dans ce cas précis, dûà ses habitudes de serrement, des empreintesprimaires des prothèses sont utilisées pour laconfection d’une plaque occlusale pour portnocturne au maxillaire puisque ceci avait étédéterminé au plan de traitement initial. Descontrôles d’hygiène bi-annuels sont

recommandés à la patiente.

DiscussionLa CAO/FAO dentaire s’étend rapidement audomaine de la prothèse implanto-portée.Toutefois, à ce stade, le praticien restaurateurdoit toujours suivre l’ensemble des protocolescliniques prosthodontiques conventionnels.L’optique intra-orale n’a pas encoresuffisamment évolué pour produire desempreintes virtuelles visant la CAO/FAO desprothèses complètes implanto-portées. Cedéfi est de taille car les praticiens soucieux deprogresser vers la technologie CAO/FAOl’attendent ardemment. Pour le momentdonc, cette technologie intéresseprincipalement les laboratoires dentaires etles manufacturiers d’implants dentaires. Lesfrais de laboratoire pour le praticien utilisantla technologie de barres usinées sontcomparables aux frais associés aux barrescoulées conventionnelles. Reste à établir, demanière non équivoque, la supériorité desbarres usinées au moyen d’études cliniquesaléatoires. À notre connaissance de tellesétudes n’existent pas et devraient êtreentreprises afin de favoriser la mise enmarché des barres usinées par les diversmanufacturiers de systèmes CAO/FAO.

Il est à noter que le présent cas clinique offrepeu d’espace inter-arches pour les prothèsesimplanto-portées et ne permet pas lapossibilité de placer des piliers intermédiairesservant d’assises pour les barres. Ces barresusinées offrent-elles des tolérances demachinage supérieures aux différentescomposantes (piliers et cylindres) déjàdisponibles sur le marché?

À ce stade, l’essor de la CAO/FAO impose unecourbe d’apprentissage nettement plusexigeante pour les laboratoires dentaires quepour les praticiens utilisateurs de barresusinées.

Bibliographie1. Duret F. Technologie dentaire;

juillet/août 2003:200(201):5–11 2 Gaucher H, et al. Multi-center study of

osseotite implants supporting mandibular restorations: A 3-year report. J Can Dent Assoc 2001;67(9):528–33.

3. Duret F, Duret B, Pellesier B. Le temps

des pionniers – Le temps des démonstrations. L’information dentaire2007;29:1660–88.

4. Gaucher H, Prévost A, Stangel I. Computer assisted creation and fabrication of ceramic inlays and crowns.J Dent du Québec 1991;28:145–9.

5. Ciftçi Y. Canay S. The effect of veneeringmaterials on stress distribution in implant-supported fixed prosthetic restorations. Int J Oral Maxillofac Implants 2000;15(4):571–82.

6. Chang BMW, Wright RF. A solid bar splint for open-tray implant impressiontechnique. J Pros Dent August 2006;96(2):143–44.

7. Misch CE. Treatment options for mandibular implant overdentures an organized approach. In: Dental ImplantProsthetics Elsevier Mosby:2005, 221–22.

8. Wöhrle PS, Cornell DF. Contemporary maxillary implant-supported full-arch restorations combining esthetics and passive fit. Quint Dent Tech 2008;31–47.

9. Witkowski S, Komine F, Gerds T. Marginal accuracy of titanium copings fabricated by casting and CAD/CAM technology. J Pros Dent 2006;96(1):47–52.

10. Shokry TE, et al. Effect of metal selectionand porcelain firing on the marginal accuracy of titanium-based metal ceramic restorations. J Prosthet Dent 2010;103(1):45–52.

11. Ortorp A, Jemt T, Jalevik T. Comparisonof precision of fit between cast and CNC-milled titanium implant frameworks for the edentulous mandible. Int J Prosthodont 2003;2:194–200.

12. Ortorp A. Jemt T. Clinical experiences ofcomputer numeric control-milled titanium frameworks supported by implants in the edentulous jaw: A 5 yearprospective study. Clin Implant Dental Relat Res 2004;6(4):199–209.



IMPLANT DENTISTRY

Milled Bars for Implant-Supported Prostheses

Nicolas Tardif TDC and Hubert Gaucher DDS, MScD

About the Authors

Dental technician and graduate of Collège Édouard-Monpetit as well as a Memberof the Order of Dental Technicians of Québec, Mr. Tardif received his Nobel Procera(NobelBiocare) training in Mahwah, NJ. He is director of the Department ofImplants at the Dentec Dental Laboratory in Québec City. He can be contacted byemail at: [email protected]

Dr. Gaucher is a prosthodontist, a member of the Order of Dentists of Québec,is in private practice in Québec City and is resident prosthodontist for the 1stDental Unit at CFB Valcartier, fellow of the Canadian Academy of RestorativeDentistry and Prosthodontics and fellow of the Academy of Dentistry Interna-tional, Dr. Gaucher is scientific director of the Canadian Dental Research Insti-tute (CDRI). He can be contacted at: [email protected].

ABSTRACTDental CAD/CAM technology has been evolving over many decades and offers dentallaboratories new computerized applications for the fabrication of implant supportedprostheses using machined bars. A patient case report illustrates the clinical proceduresnecessary for the successful incorporation of a new Procera 3D software (Nobel Biocare,Quebec City Production Centre) used in the design and the machining of bars, thusensuring better predictable clinical outcomes.

TARDIF AND GAUCHER

As early as 1965, the first patient was treated using osseointegration

principles. Professor Per-Ingvar Brånemarkand his team had developed the biologicalprinciples of contemporary implantology,defined as being a direct structural andfunctional connection between the adaptedliving bone and the surface of a load-bearingimplant.1 This type of interface allowsendosseous implants to be maintained in thelong term. Many dental implant systems haveemerged since then, with documentedsuccess rates of 95–100%.2

The two CAD/CAM systems that are mostwidespread today appeared in 1985: the Cerecsystem (Sirona), developed in Zurich by Prof.W. Moerman and engineer Dr. M.Brandestini, and the Procera system(NobelBiocare), developed by Matt Andersonin Sweden. CAD/CAM (computer-aideddesign/computer-aided manufacturing) is nowpossible due to improved knowledge aboutmilling hard and soft materials. Crowns andbridges are modelled by making animpression with profilometry or laser usingcomputers in order to calculate acquisitionsand subsequently mill a known material.3,4

Clinical CaseA female patient aged 50, in good health, wasreferred by a general dentist who had startedprosthodontic treatments with her. At thetime of the initial clinical examination, shehad seven osteointegrated implants withhealing abutments in place and a completeconventional transition prosthesis relinedwith temporary material (Trusoft, Bosworth,Skokie, IL) in the maxilla. Five osteointegratedimplants with healing abutments and acomplete transition prosthesis relined withthe same temporary material were also inplace in the mandible. The transitionprostheses had a pronounced anterior openbite and were causing phonetic problems forthe patient. Tissue was normal and theattached gingiva adequate around theimplants. The patient had a class Irelationship in terms of skeletal bone bases,given her history of recent full-mouth toothextraction.

She had undergone full-mouth extraction ofupper and lower teeth and the placement of

12 implants (Nobel Biocare Mark III –TIUnite, Richmond Hill, ON) withconcomitant autogenous bone grafts on fiveof the implants, with all the work beingperformed by a periodontist, given theunfavourable periodontal prognosis formaintaining the remaining teeth. A reportfrom the periodontist confirmingosseointegration of all the implantsaccompanied the referral from the generaldentist. Implant number 22, visible on theinitial panogram, was removed one monthafter its insertion, to be replaced by implantsat sites number 21 and 23 (see page 31, Figure1 and Figure 2).

The study models (see page 31, Figures 3A toC), representing existing dentition, wereobtained from the referring dentist in orderto assess occlusion and the vertical dimensionexisting at the start of treatment. The patientreported a habit of teeth clenching, but nosign of joint or muscle problems were notedon examination. The patient asked for upperand lower implant-supported fixedprostheses and wanted to complete theprosthodontal treatments in short orderbecause of availability. A treatment plan wasdeveloped for manufacturing the implant-supported fixed prostheses (milled bars) witha sequence of treatment steps for checkingocclusion, esthetics, phonetics, an acceptablevertical dimension and checking the passiveseating of the milled bars.

Impressions of the implant heads usingsquare transfers and periapical radiographsto confirm their appropriate placements weretaken using individual impression trays withpolyether impression material (Impregum,3M-ESPE, London, ON). Upper and lowerworking models (see page 32, Figures 4A and4B) with removable gums were articulated bymeans of denture bases (see page 32, Figures5A and 5B) using the Hanau facebow. Thechoice of acrylic prosthetic tooth moulds5

and determination of overbites and overjetswere to a large extent determined by the pre-operative study models (see Figures 3A to C).Denture bases and a waxed teeth assemblywere tried out in order to assess the verticaldimension of occlusion, esthetics andphonetics, so that the necessary correctionscould be made. Silicone positioning keys forthe upper and lower prosthetic teeth and a

check bite were then manufactured based onthe working models mounted on articulators.Those components would be used to positionthe teeth precisely on the milled bars onceavailable.

There are several ways of validating theworking model in implant dentistry.However, the use of a verification jig isbeneficial for the practitioner, since thevalidation is intra-oral. The method consistsof placing metal transfers on the workingmodel and matching them with a Duralay orGC autopolymerizing resin. It is important toensure that the verification jig is passive onthe working model. When a practitioner triesthe jig intraorally and notes a difference inseating, he can then section the acrylic andindex with resin in order to correct the jigintraorally. By returning the modified jig tothe laboratory, the original working modelcan be altered to take into account the newpositions of the transfers.6 It is veryimportant that the model is completelyidentical to what we have in the mouth, to avoid reworks which can extendmanufacturing time unduly.

In our case, the implant bars were designedwith CAD/CAM. They were designed usingthe Nobel Procera system (Nobel Biocare)and a brand new software package availablesince 2009. The software was developed byBiocad (Quebec City, QC) and designed tofacilitate the technician's job whenmanufacturing implant-supported bars,designing crowns and bridges and implantabutments.

Choice of BarsFor the mandible, we manufactured aMontreal bar (Figures 6A to C): a bar withthe gingival part of the prosthesis made oftitanium and about 1.5 mm from the gum.For the maxilla, a wrap-around Montreal barwas chosen (see page 33, Figures 7A to C). A NobelProcera (Nobel Biocare) manufacturingprescription was used, indicating ourpreference among multiple types of bar. Barscan also be milled to different specifications,namely: 0, 2, 4, or 6 degrees, with thepossibility of incorporating severalattachments: Dalbo, TSB, Ceka, Locator,OSO, or Bredent. Dolder extensions, with



MILLED BARS FOR IMPLANT-SUPPORTED PROSTHESES

different volumes, can also be milled, as canthe Hader bar. Montreal wrap-around bars(acrylic in contact with the ridge), Montrealbars with metallic lingual and the Paris bar,which is permanent-removable (a metalstructure screwed in with attachments whichreceive a removable acrylic component) canalso be prescribed. Once the choice of bar wasmade, we prepared the prescription fordesigning the bar.

The Procera system for milled bars consistsinitially of virtually reproducing the workingmodel so that subsequent CAD/CAM stagescan be carried out. To achieve this, we neededa plaster working model with a detachablegingiva, so that a specific laser scanner couldbe used to read metal dies on the model. Thisis available only at the Nobel ProceraInnovation Centre located in the QuébecMetro High Tech Park. Once the gingiva wasremoved from the model, we needed to haveat least 1.5 mm free of plaster around theheads of the unaltered dies. Then came theintra-oral digital acquisition of the occlusalbite. Once the digital acquisitions werecompleted (of the working model and thebite), the computer files were returned to thedental laboratory together with a bar designproposal to be modified by the user (see page33, Figures 8A to D). This innovative CADsoftware for bars offers several design tools,such as:

• span of distal extensions using Misch's rule7

• tools for measuring the space below thebar

• tools for modifying the bar design angle• axial section window in square mm so

that the gingiva, bar and occlusal bite can be visualized and the space availablefor acrylic and for prosthetic teeth can bevalidated

Once the CAD stage was completed by thedental laboratory, the digital file for the barwas returned to the production centre inorder to start milling the titanium alloymonoblock (Ti6A14VL). A five-axis NobelProcera machine-tool works on threetranslation axes: left/right, in front/behind,high/low, plus two rotation axes: A and B (seepage 34, Figure 9), resulting in very precisemilling.8 Once the part was completed, it was

polished by hand under a microscope toproduce an ideal surface (see Figure 6C). Forthe needs of this case, there was little space inthe maxilla and the upper bar had to bemodified to angle the cylinders' chimneysand to free up space under the incisivepapilla, in order to coat the wrap-around barwith acrylic. (see Figure 7B)

The Advantages of CAD/CAM BarsCompared with Conventional BarsThey use the same material as implants(titanium), thus avoiding any possiblegalvanic shock. Since the bar is a monoblock,there is no metal weakness which can resultfrom porosity due to welding. It has beendemonstrated that adapting titaniumCAD/CAM assemblies is valuable for crownsand bridges, conferring the same precision onmilled bars.9–12

Casting a conventional implant-supportedbar poses many risks of porosity caused byincorrect casting technique. When welding,porosity is often based on the distance orempty space separating the two pieces to bewelded.

A cast grade 1 titanium conventional bar doesnot have the same physical resistance as amilled bar. The elastic limit of milledTi6A14VL titanium is over 800 MPa, morethan three times greater than grade 1 casttitanium.

With respect to fatigue resistance, Ti6A14VLis the best performing titanium alloy and isfour times lighter than gold. Milled titaniumis therefore an excellent material for implant-supported prostheses.10,11

Continuation of Clinical StepsThe milled bars (see Figures 6a and 7a) wouldreceive the prosthetic teeth and support theprosthetic rims using the positioning keysand bite manufactured based on assemblieschecked intra-orally in advance usingscrewed-in denture bases (see Figures 5A and B).

The bar was again placed intra-orally toassess the bars' passive seating usingperiapical radiography and a sequence ofscrew tightening to detect any bar movement.Once again, the critical elements, such asocclusion, esthetics, and phonetics, were

assessed and had to be confirmed acceptableby the patient before final curing. An intra-oral check bite was used to validate thearticulator cast mountings before theprescription for curing. A post-curingbalancing of occlusion in the laboratory isrecommended for finalizing occlusalcontacts.

Intra-oral placement of the prostheses (seepage 34, Figures 10A to G) was used to checkstable centric occlusion and balanced bilateralocclusion. Adequate clearance between theacrylic and maxilla for dental floss wasmodified as needed. At this time, the specifichygiene instructions were explained to thepatient. Tightening the prosthetic screws inthe implants followed the manufacturer'srecommendations and the screw holes werecapped with temporary material.

The follow-up examination in the followingweeks checked the stability of the prostheticocclusal contacts and that the tightening ofthe prosthetic screws was unchanged. Thepatient's adaptations were noted beforefinalizing the screw-hole caps usingcomposites. In this specific case, because ofher clenching habit, primary imprints of theprostheses were used to produce a bite plateto be worn on the maxilla at night, since thathad been determined in the initial treatmentplan. The patient was recommended to havebi-annual hygiene check-ups.

Discussion Dental CAD/CAM is rapidly spreading to therealm of the implant-supported prosthesis.However, at this stage, the restorativepractitioner must always follow all theconventional prosthodontic clinicalprotocols. The intra-oral optic has notdeveloped sufficiently to produce virtualimpressions for complete CAD/CAMimplant-supported prostheses. This is asizable challenge because practitionerswishing to progress towards CAD/CAMtechnology are awaiting it passionately.Therefore, for the time being, this technologyis of interest mainly for dental laboratoriesand dental implant manufacturers. Thelaboratory costs for practitioners using milledbar technology are comparable to the costsassociated with conventional cast bars. Itneeds to be unequivocally established

TARDIF AND GAUCHER

whether milled bars are superior, usingrandomized clinical trials. To our knowledge,studies of this kind do not exist and shouldbe undertaken in order to promote themarketing of milled bars by the variousCAD/CAM system manufacturers.

It is important to note that this clinical caseoffered little inter-arch space for the implant-supported prostheses and did not allow thepossibility of placing intermediate abutmentsas foundations for the bars. Do these milledbars offer milling tolerances which aresuperior to the various components(abutments and cylinders) already availableon the market?

At this stage, the expansion of CAD/CAM isplacing a much more demanding learningcurve on dental laboratories than onpractitioners who make use of milled bars.


References1. Duret F. Technologie dentaire;

juillet/août 2003:200(201):5–11

2 Gaucher H, et al. Multi-center study of osseotite implants supporting mandibular restorations: A 3-year report. J Can Dent Assoc 2001;67(9):528–33.

3. Duret F, Duret B, Pellesier B. Le temps des pionniers – Le temps des démonstrations. L’information dentaire2007;29:1660–88.

4. Gaucher H, Prévost A, Stangel I. Computer assisted creation and fabrication of ceramic inlays and crowns.J Dent du Québec 1991;28:145–9.

5. Ciftçi Y. Canay S. The effect of veneeringmaterials on stress distribution in implant-supported fixed prosthetic restorations. Int J Oral Maxillofac Implants 2000;15(4):571–82.

6. Chang BMW, Wright RF. A solid bar splint for open-tray implant impressiontechnique. J Pros Dent August 2006;96(2):143–44.

7. Misch CE. Treatment options for mandibular implant overdentures an organized approach. In: Dental ImplantProsthetics Elsevier Mosby:2005, 221–22.

8. Wöhrle PS, Cornell DF. Contemporary maxillary implant-supported full-arch restorations combining esthetics and passive fit. Quint Dent Tech 2008;31–47.

9. Witkowski S, Komine F, Gerds T. Marginal accuracy of titanium copings fabricated by casting and CAD/CAM technology. J Pros Dent 2006;96(1):47–52.

10. Shokry TE, et al. Effect of metal selectionand porcelain firing on the marginal accuracy of titanium-based metal ceramic restorations. J Prosthet Dent 2010;103(1):45–52.

11. Ortorp A, Jemt T, Jalevik T. Comparisonof precision of fit between cast and CNC-milled titanium implant frameworks for the edentulous mandible. Int J Prosthodont 2003;2:194–200.

12. Ortorp A. Jemt T. Clinical experiences ofcomputer numeric control-milled titanium frameworks supported by implants in the edentulous jaw: A 5 yearprospective study. Clin Implant Dental Relat Res 2004;6(4):199–209.


Inc.

http://www.thesurgicalroom.ca



Achieving Initial ImplantStability – Observations on theEffect of Implant Body Macro-Design and Osteotomy DesignDennis P.A. Nimchuk, DDS, FRCD

About the Author

Dr. Dennis Nimchuck is a certified specialist in prosthodontics and isin private practice in Vancouver, BC.

ABSTRACTMany factors influence obtaining initial implant stability. One of the most relevantfactors is the macro-design of the implant. Tapering implants with aggressive threadpatterns allow an implant to be placed under higher insertion torque values that willpermit compression of the body of the implant against the bony wall of theosteotomy. Some implants are designed to maximize bone compression at the apex,while others provide even bone compression along the implant length; still othersconcentrate the compressive forces in the crestal area. Depending on thecircumstances of the proposed implant site, utilizing a single implant design may notalways be the most suitable when it comes to obtaining satisfactory initial implantstability. This is particularly relevant when implants are inserted as an immediateimplantation protocol. Because of the variability of conditions of surgical sites, theselection of an implant based on macro-design features may have site specificityrelevance.

NIMCHUK

Dental implants are now a widelyestablished modality for tooth

replacement. Four decades studying theutilization of dental implants has producedwidespread corroboration validating theireffectiveness as a viable treatment protocol.1–3

Until recently these studies have been basedon a two-stage submerged surgical protocol,having an initial healing phase of 4 to 5months for sufficient bone development,1

followed by another interval delay forsecond-stage soft tissue surgical healing,followed further by appointments forimpressioning of the implant location andfinally followed by a term of laboratoryfabrication and installation into the patient.The total treatment time for an implantsupported prosthesis with this protocol oftentakes 7 to 8 months. From a patientperspective this process may be viewed asunsatisfactory because of the morbidity ofexperiencing two surgeries plus the longtreatment interval before obtaining the finaldelivery of a restoration.

Currently there is a developing trend towardsestablishing a single-stage, non-submergedsurgical procedure along with early or evenimmediate loading protocols. This trend is asignificant deviation from the criteria ofdelayed loading established by Brånemark etal. The Brånemark protocol advocated a 20-week interval healing period after implantplacement to allow for bone developmentaround the dental implant.1 It was proposedthat early loading soon after the first-stagesurgery would lead to a fibrous tissue

formation around the implant because of“micro-motion” and that implants placedunder such a shortened time protocol wouldfail to integrate.4–6

A number of studies have implicated micro-motion as a factor in fibrous tissue formationat the expense of osseointegration.7–10 Othermore recent studies have indicated that low-intensity micro-motion, during the healingphase, may actually stimulate bone healingand bone development around an implantand it may be that excessive micro-motion onimplants having weak initial stability is whatis responsible for the failure of integration.13–15 Micro-motion in the order of 50–150microns therefore may be tolerable and may even be a desirable stimuli forosseointegration,15,16 depending on theimplant macro-design and micro surfacetopography.16

Primary or initial implant stability is viewedas a prerequisite to establish adequatemechanical fixation to provide forundisturbed bone healing and to overcomethe effect of any direct or indirect stresseswhich may result in a mechanical overloadduring the critical time of early osseousrebuild.17–20 Primary stability is considered tobe a highly critical factor in influencing thesuccessful osseointegration of single stagesurgeries where the implant is exposed intothe intra-oral environment.21 Several factors,such as implant design, preparationtechnique,22 and the quality and quantity oflocal bone influence the achievement of

initial stability.23 Several non-invasive clinicaltest systems have been devised to evaluate thedegree of initial implant stability; i.e.,insertion torque, periotest, resonancefrequency analysis. Any of these systemsindividually or in combination can be readilyutilized in the clinical setting for a relativeverification of initial implant stability. Basedon resonance frequency analysis, studies havedemonstrated that primary implant stabilityis improved where the density of the bone isgreater,23–27 such as in the lower jaw, by theproximity and thickness of the corticalplates24 and by the degree of bonecompression induced from creating anundersized osteotomy and inserting a slightlyoversized implant.23,25,28

Based on the criteria of bone compression,there may be a correlation between thelocation and design of the osteotomy and themacro-geometry of the implant, sincedifferent implants are designed to compressbone in differing ways.27,29–32 When it comesto placing an immediate implant in a anasymmetrical or funnel shaped osteotomyresidual to an exodontia, the requirements forprimary stability and elimination of excessivemicro-movement becomes more challengingto accomplish. Development of optimumsecurity and stabilization in the extractionsite will become more dependent on theosteotomy technique and on the behaviourof the bone compression qualities of theimplant than would be in a delayed implantplacement procedure. Clinician feel, ortorque insertion controllers built into the


RÉSUMÉPlusieurs facteurs influencent la stabilité initiale de l’implant. L’un de ces facteurs les pluspertinents est le macro-design de l’implant. Le profilage et le filetage des implantspermettent à l’implant d’être placé sous des couples de serrage d’insertion plus élevés quifaciliteront la compression du corps de l’implant sur la paroi osseuse de l’ostéotomie.Certains implants sont conçus pour maximiser la compression osseuse à l’apex, d’autresprocurent une compression osseuse uniforme le long de l’implant, alors que d’autresconcentrent les forces compressives dans la zone apicale. Selon les circonstances del’implant proposé, l’utilisation d’un seul design peut ne pas toujours convenir lorsqu’ils’agit d’obtenir une stabilité initiale de l’implant satisfaisante. Ceci est particulièrementpertinent lorsque les implants sont insérés selon un protocole d’implants immédiats. Enraison de la variabilité des champs opératoires, le choix d’un implant selon lescaractéristiques de macro-design peut avoir une pertinence spécifique au site.

implant motors or torque wrenches will givea reasonable indication as to the degree ofstability obtained. Recently, resonancefrequency analysis (RAF) instruments havebeen introduced which will give an additionalquantitative measurement as to the degree ofprimary stability.33–39

Implant Designs FeaturesImplant Body DesignsThere are three basic types of implant shapes,(1) cylindrical non-threaded, (2) parallel-walled with threads, and (3) tapered withthreads. Each of these designs can be used asa compression implant if the osteotomy isundersized relative to the implant bodydiameter.26 However, certain features such asself-tapping threads,32 dramatically increasethe ability to insert implants more easily andwith more compression.

Thread DesignsThere are three basic designs which are usedwith dental implants; “V-shaped” threads(Figure 1A), reverse-buttress threads (Figure1B), and square threads (Figure 1C). Thethreads are designed to provide for the self-tapping feature and all of them will workreasonably effectively for this purpose,excepting the square threads, which usuallywill need a separate bone tap for insertioninto denser bone. The differing threaddesigns, depending on the pitch andextension of the treads will enable more orless elemental degrees of fixation atplacement time. Differences in stabilizationwill also occur after bone healing due toestablishment of different values in resistingfunctional shear forces.40,41 Generally, themore aggressive the threads are, the greaterwill be the potential for achieving higherprimary fixation values because of the moreeffective tapping action. On the other hand,if threads become too aggressive they will bemore difficult to install in denser zones ofbone. In porous bone, very aggressivelythreaded implants will not always act as truecompression implants because as the

extension of the threads cut into the bone,they induce little compression against thebody wall of the implant (Figure 2). The bonebetween the extended threads merely fills inthe reservoir of space between the threads.High compression fixation comes from thesurface area of the body of the implant itself,firmly wedging against a wall of resistantbone.

Surface DesignsOriginal implants aka. Brånemark, wererelatively smooth, having a rudimentarysurface texture derived only from themachining process. Later, implants weredesigned to have varying degrees of surfaceroughness or texture that proved to increasethe surface area and that would attract ahigher percentage of bone appositionallowing for an accelerated time-intervalrestorative phase. Introducing mediumvalues of surface roughness of approximately.5 to 1.8 microns has been shown tosignificantly enhance ongoing osseo-integration as well as producing greaterreverse-torque values.42,43 The practicalapplication of dependable, early,osseointegration means shorter delays forrestoration and that clinicians, whenunscrewing healing abutments at shorterhealing time intervals, will not find theimplants also unscrewing.

Implant Compression PerformanceAn implant’s ability to compress bone, for themost part, will be based on how the implantbody form and diameter is matched to theosteotomy form and diameter. Three generalcombinations are available.

A. A parallel walled implant placed into a parallel walled osteotomy that is slightlyundersized.

B. A tapering walled implant placed into aparallel walled osteotomy that is slightlyundersized.

C. A tapering walled implant placed into atapering walled osteotomy that is slightly undersized.

Generally, combination A will produce gentleand even compression throughout the entireinterface of the implant body (Figures 3 and4). Combination B will produce a greater


ACHIEVING INITIAL IMPLANT STABILITY

Figure 1. The three basic designs that are used with dental implants: A,“V-shaped” threads; B, reverse-buttress threads; and C, square threads.

Figure 2. A tapering body implant placed into astraight osteotomy and having aggressiveparallel external threads will displace bone withthe threads but will minimally compress boneunless the osteotomy is undersized considerablyto engage the implant body itself. Red = areas ofhigh compression; orange = areas of moderate tohigh compression; green = areas of moderatecompression; yellow = areas of light compression.

A. B. C.

NIMCHUK

concentration of compression thancombination A, and the compression will bemore localized at the crestal zone of theinterface of the implant body (Figure 5).Combination C will produce a higherconcentration of compression than eithercombination A or B, and this compressionwill be most concentrated at the apical zoneof the implant interface (Figures 6 and 7).

A wide range of variability as to compressionmay occur with any of these combinations,based on the relative degree of the undersize,the density of the bone, the length of theimplant, the width of the implant, theproximity of the cortical plates, surfacetexture of the implant and the thread patternof the implant.

Bone Compression and Compression-Induced OsteonecrosisWhen the Nobel “Replace” implant was firstintroduced some clinicians observed a lack ofosseointegration and extended bone

resorbtion arising with the use of thisimplant. The “new” Replace behaved vastlydifferent from traditional straight walledimplants in its insertion handling. TheReplace, being a tapering implant, wasdesigned to be inserted into a taperingosteotomy and became capable of developingextremely high levels of resistance toinsertion, particularly into dense bone sites.It was suggested that a phenomenon couldexist whereby bone would necrose ifsubjected to very high compression forces.The theory is that compression of bonebeyond its physiologic limits may result inischemia leading to osseous necrosis.44–46 Inresponse to this, Nobel advocated anarbitrary value of 35 Ncm, based on ameasured insertion torque that would beconsidered adequate for primary stability andwould not be likely to create any bonecompression damage. This theory has neverbeen validated not has the concept of bonenecrosis from high values of dental implantbone compression been validated. On the

contrary, there is accumulating evidence thatvery high insertion torque values are notdestructive but within reason, may bedesirable to evolve the clinical application ofsingle stage implants to be early orimmediately loaded. Khayat et al.47 havepresented results utilizing Zimmer taperedimplants inserted with torques of up to 176Ncm, and followed up to 1 year, showing nosign of pressure necrosis. Current histologicresearch by Trisi48 evaluating the effect ofhigh insertion torques of 110 Ncm failed todemonstrate adverse outcomes. Meltzer etal.49 followed a series of Biomet 3I implantsplaced with torque values averaging 90 Ncmwith no unusual radiographic or crestal bonechanges. There is a practical limit to highinsertion torque which may deform or causedamage to the macrogeometric features ofthe implant itself or the driver tips. Somemanufacturers caution that the implantstructure itself may not sustain insertiontorques beyond a certain value. Also is theproblem of fully seating certain implant


Figure 3. A and B, Two examples of straight walled implants placedinto straight osteotomies provide for mild and uniformconcentration of bone compression. Red = areas of highcompression; orange = areas of moderate to high compression;green = areas of moderate compression; yellow = areas of lightcompression.

Figure 4. A straight implant with a crestalflare placed into a non-engagingcountersink provides for mild and evenbone compression but not at the crest.Red = areas of high compression; orange= areas of moderate to high compression;green = areas of moderate compression;yellow = areas of light compression.

Figure 5. A tapering implant placedinto a straight walled osteotomyconcentrates compression in thecrestal region. Red = areas of highcompression; orange = areas ofmoderate to high compression;green = areas of moderatecompression; yellow = areas of lightcompression.

A B



geometries. These are clinically dependentsituations and may require the use of separatebone taps or dense bone drills.

General Applications for Implant Selection

1. D2 or D3 Bone – two stage procedure. Almost any implant can be placed effectively and will have adequate primary stability.

2. D2 or D3 Bone – single stage procedure – delayed loading. Recommended is a tapering implant with moderate to aggressive thread design in an undersized osteotomy.

3. D2 or D3 Bone – single stage procedure

and with immediate or early loading. Recommended is a tapering implant with moderate to aggressive thread design in an undersized osteotomy. An implant with even body compression orapical concentration or crestal concentration will all work well.

4. D1 Bone – single or two-stage procedure. Use parallel walled implants with moderate threads or with taperingimplants, use dense bone drill so that theimplant will go to place.

5. D4 Bone – two stage procedure. Almost any implant can be placed with adequateprimary stability if the osteotomy is undersized enough. These sites may benefit from special micro-texturing

and surface treatments or by having a high crystallinity HA coating.

6. D4 Bone – single stage procedure. These circumstances are indicated for a high compression tapering implant with aggressive thread design preferably withone which produces crestal compressionin order to engage the cortical plates (seeFigure 4).

Specific Applications for Implant SelectionImmediate Implants: Because of the funnelshape, a high compression, highly taperedimplant that focuses compression in theapical zone is recommended (see Figures 6and 7 and Figures 8 to 11).

Figure 6. A tapering implant placed into a tapering osteotomy will continue to develop apicalcompression as it progressively is turned in to complete depth.

Figure 7. Tapering implant into atapering osteotomy concentratescompressive forces in the apical zone.Red = areas of high compression;orange = areas of moderate to highcompression; green = areas ofmoderate compression; yellow =areas of light compression.

Figure 8. A series of different tapered implants placed into arbitrarily flared maxillary socketsshowing non-engagement at the crest but only below the yellow lines.

One-Piece Implants: These implants areexposed at insertion time and will need to betemporized and to some extent, will beimmediately loaded. Also, the abutmentportion of the implant often will have to beprepared at insertion time with handpiece.This protocol will require an implantdesigned for high initial stability in anundersized osteotomy and utilizingmaximum length into supportive bone (seeFigures 12 and 13).

Sinus Elevations Performed Crestally: Thisis also known as the Summers method withsimultaneous insertion of single stageimplants. Recommended is a taperingimplant that has compression concentrationsat the crestal area and which will enable rigidfixation against the crestal cortical plates andthereby also assist preventing the implantfrom popping through the osteotomy and

NIMCHUK


Figure 9. Tapered implant/tapered osteotomy. Figure 10. Implant inserted right central.

Figure 11. A, Immediate post and temporary. B, Radiograph at 24 weeks.

Figure 12. A, One-piece implant, temporary crown removed; B, radiograph.

Figure 13. A, One piece implant with crown; B, completed radiograph

Figure 14. A tapering implant with apronounced crestal flare placed into atapering osteotomy will concentratecompression along the entire length andaggressively at the crest. Red = areas of highcompression; orange = areas of moderate tohigh compression; green = areas of moderatecompression; yellow = areas of lightcompression.

A

B

A

B

A

B



into the antrum (see Figure 5 and Figures 14to 17).ConclusionsInitial implant stability to fixate againstexcessive micro-movements is a primaryconsideration where immediate implantationis undertaken and particularly if immediateor early loading is contemplated.

Implants with sharp threads and a taperingbody when placed into an undersizedosteotomy will effectively engage bone bycompression of the threads as well as bycompression of the implant body wall againstthe osseous preparation.

Different implant macro-designs willproduce different effects on the way bonecompression fixation is developed. It isrecommended that implant selection shouldbe based according to surgical site specificityrequirements.


References1. Brånemark PI, Hansson BO, Adell R, et

al. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10 year period. ScandJ Plast Reconstr Surg Suppl 1977;16:1–132.

2. Adell R, Lekholm U, Rockler B, Brånemark PI. A 15 year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10(6):387–416.

3. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long term efficacy of currently used dental implants. A review

and proposed criteria of success. Int J Oral Maxillofac Implants 1986;1(1):11–25.

4. Brånemark PI, Adell R ,Breine U, Hansson BO, Lindstrom J, Ohlsson A. Intra osseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg 1969; 3(2): 81–100.

5. Cameron HU, Pilliar RM, Mac Nab I. The effect of movement on the bondingof porous metal to bone. J Biomed Mater Res 1973; 7(4):301–11.

6. Schatzker J, Horne JG, Sumner-Smith G.The effect of movement on the holdingpower of screws in bone. Clin Orthop 1975;(111):257–62.

7. Brunski JB, Moccia AFJ, Pollack SR, Korostoff E, Trachtenberg DI. The influence of functional use of endosseous dental implants on the tissue-implant interface. I. Histological aspects. J Dent Res 1979;58(10):1953–69.

8. Brunski JB. Influence of biomechanicalfactors at the bone-biomaterial interface. In Davies JE, editor. The bone-biomaterial interface. Toronto: University of Toronto Press; 1991, 391–405.

9. Aspenberg P, Goodman S, Toksvig-Larsen S, Ryd L, Albrektsson T. Intermittent micromotion inhibits boneingrowth. Titanium implants in rabbits.Acta Orthop Scand 1992;63(2):141–5.

10. Soballe K, Hansen ES, B-Rasmussen H,Jorgensen PH, Bunger C. Tissue ingrowth into titanium and hydroxyapati1te coated implants duringstable and unstable mechanical conditions. J Orthop Res 1992; 10(2):285–99.

11. Goodman S, Wang JS, Doshi A, Aspenberg P. Difference in bone

ingrowth after one versus two daily episodes of micromotion. Experimentswith titanium chambers in rabbits. J Biomed Mater Res 1993;27:1419–24.

12. Goodman SB. The effects of micromotion and particulate materials on tissue differentiation. Bone chamberstudies in rabbits. Acta Orthop Scand Suppl 1994;258:1–43.

13. Brunski JB. Biomechanical factors affecting the bone- dental implant interface. Clin Mater 1992;10(3):153–201.

14. Pilliar RM. Quantative evaluation of theeffect of movement at a porous coated implant–bone interface. In: Davies EJ, editor. The bone–biomaterial Interface.Toronto: University of Toronto Press; 1991, 380–7.

15. Szmukler-Moncler S, Salama S, Reingewirtz Y, Dubruille JH. Timing ofloading and effect of micromotion on bone-dental implant interface. A reviewof experimental literature. J Biomed. Mater Res 1998;43(2):192–203.

16. Willie BM, Yang X, Kelly NH, et al. Cancellous bone osseointegration is enhanced by in vivo loading. Tissue EngPart C Methods 2010 Apr 2.

17. Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factors contributing to failures of osseointegrated oral implants. (II). Etiopathogenesis. Eur J Oral Sci 1998b;106(3):721–64.

18. Albektsson T, Brånemark PI, Hansson HA, Lindström J. Oseointegrated titanium implants: Requirements for ensuring a long-lasting, direct bone to implant anchorage in man. Acta OrthopScand 1981;52(2):155–70.

Figure 15. Low antrum, 5 mm vertical boneheight.

Figure 16. 10 mm implant with crestalaugmentation.

Figure 17. Implant crown at 1 year.

NIMCHUK

19. Friberg B, Jemt T, Lekholm U. Early failures in 4,641 consecutively placed Branemark dental implants: a study from stage 1 surgery to the connection of completed prostheses. Int J Oral Maxillofac Implants 1991;6(2):142–6.

20. Meredith N. Assessment of implant stability as a prognostic determinant. IntJ Prosthodont 1998;11;491–501

21. Trisi P, Perfetti G, Baldoni E, Berardi D,Colagiovanni M, Scogna G. Implant micromotion is related to peak insertiontorque and bone density. Clin Oral Implants Res 2009 May;20(5):467–71.

22. Degidi M, Perrotti V, Strocchi R, PiattelliA, Iezzi G. Is insertion torque correlatedto bone-implant contact percentage in the early healing period? A histological and histomorphometrical evaluation of17 human-retrieved dental implants. Clin Oral Implants Res 2009;20(8):778–81.

23. Turkyilmaz I, McGlumphy EA. Influence of bone density on implant stability parameters and implant success: a retrospective clinical study. BMC Oral Health 2008;8:32.

24. Rozé J, Babu S, Saffarzadeh A, et al. Correlating implant stability to bone structure. Clin Oral Implants Res 2009 Oct;20(10):1140–5. Epub 2009 Jun 10.

25. Molly L Bone density and primary stability in implant therapy. Clin Oral Implants Res 2006;17 Suppl 2:124–35.

26. Cavallaro J Jr, Greenstein B, GreensteinG. Clinical methodologies for achievingprimary dental implant stability: the effects of alveolar bone density. J Am Dent Assoc 2009;140(11):1366–72.

27. Tricio J, van Steenberghe D, Rosenberg D, Duchateau L. Implant stability relatedto insertion torque force and bone density: An in vitro study. J Prosthet Dent 1995;74(6):608–12.

28. Tabassum A, Walboomers XF, Wolke JG,Meijer GJ, Jansen JA. Bone particles andthe undersized surgical technique. J Dent Res. 2010 Mar 8.

29. Chong L, Khocht A, Suzuki JB, GaughanJ.Effect of implant design on initial stability of tapered implants. J Oral Implantol. 2009;35(3):130–5.

30. Alves CC, Neves M. Tapered implants: from indications to advantages. Int J Periodontics Restorative Dent. 2009;29(2):161–7.29.

31. Turkyilmaz I, Aksoy U, McGlumphy EA.Two alternative surgical techniques for enhancing primary implant stability in the posterior maxilla: a clinical study including bone density, insertion torque,and resonance frequency analysis data. Clin Implant Dent Relat Res 2008;10(4):231–7. Epub 2008 Apr 1.

32. Alves CC, Neves M. Tapered implants: from indications to advantages. Int J Periodontics Restorative Dent 2009;29(2):161–7.

33. Heo SJ, Sennerby L, Odersjö M, et al. Stability measurements of craniofacial implants by means of resonance frequency analysis. A clinical pilot study.J Laryngol Otol 1998;112(6):537–42.

34. Renouard F, Nisand D. Impact of implant length and diameter on survivalrates. Clin Oral Implants Res 2006;17 Suppl 2:35–51.

35. Shiigai T. Pilot study in the identification of stability values for determining immediate and early loading of implants. Oral Implantol. 2007;33(1):13–22.

36. O’Sullivan D, Sennerby L, Meredith N. Measurements comparing the initial stability of five designs of dental implants: a human cadaver study. Clin Implant Dent Relat Res 2000;2(2):85–92.

37. Sennerby L, Meredith N. Implant stability measurements using resonancefrequency analysis: biological and biomechanical aspects and clinical implications. Periodontology 2000 2008;47:51–66.

38. Nedir R, Bischof M, Szmukler-MonclerS, Bernard JP, Samson J. Predicting osseointegration by means of implant primary stability. Clin Oral Implants Res2004;15:520–8.

39. Degidi M, Daprile G, Piattelli A, Primarystability determination: operating surgeon’s perception and objective measurement. Int J Oral Maxillofac Surg2009. In press.

40. Strong JT, Misch CE, Bidez MW, and Nalluri P. Functional surface area: thread-form parameter optimization forimplant body design. Compend ContinEduc Dent 1998;19:4–9.

41. Liang K, Yunzhuan Z, Kaijin H, et al. Selection of the implant thread pitch foroptimal biomechanical properties: A three-dimensional finite element

analysis; Compendium Cont Ed Dent. 2009.

42. Fernandes Ede L, Unikowski IL, TeixeiraER, da Costa NP, Shinkai RS Primary stability of turned and acid-etched screw-type implants: a removal torque and histomorphometric study in rabbits. Int J Oral Maxillofac Implants 2007 Nov-Dec;22(6):886–92.

43. Wennerberg A, Albrektsson T. On implant surfaces: a review of current knowledge and opinions, Int J Oral Maxillofac Implants 2010;25(1):63–74.

44. Sennerby L, Roos J. Surgical determinants of clinical success of osseointegrated oral implants: a review of the literature. Int J Prosthodont 1998;11(5):408–20.

45. Nimchuk, DPA., Personal communication with Nobel Biocare chief scientist: May, 2009.

46. Bashutski JD, et al. Implant pressure necrosis: Current understanding and case report. J Periodontal 2009;80:700–704.

47. Khayat P, et al. Clinical outcome of tapered implants placed with high insertion torques (up to 176 ncm): Shortoral communication (oral presentation–Abstract 59) Clin Oral Implants Res 2008;19(9):855.

48. Trisi P. Immediate or late reconstructions in partially edentulous patients: Effect regarding hard tissue aspects. 15TH Annual Scientific Meetingof the European Association of Osseointegration, Kongresshaus Zurich,Zurich Switzerland; October 6, 2006.

49. Meltzer A, Baumgarten H, Testori T, Trisi P. Pressure necrosis and osseointegration: An editorial white paper; Pub. By Biomet 3i, 2010.

50. Davarpanah M, Martinez H, TecucianuJF, et al. The modified osteotome technique. Int J Periodontics RestorativeDent 2001;21(6):599–607.


http://www.protecdental.com

PRACTICE MANAGEMENT / GESTION DE CABINET

Effective Business SystemsEnhance the Delivery of QualityDentistry and Will Impact Your

Bottom Line! Part I I


My last article in the 2010 winter issueof CJRDP left you with three

assignments!

No.1 – Creating Your Practice VisionIf you had an opportunity to accomplish thismake sure it is within your easy reach.

No. 2 – Leadership and Your TeamIt is my hope that you (a) were able to usethe criteria provided to complete an initialpositive evaluation of your team. This willput you in a solid starting place withincorporating improvements into yourpractice. And (b) have asked yourself on a

regular basis how something in your dailyroutine could be done better, andencouraged your team to do the same.

No 3 - Assessing Your Systems is illustratedin the box on page 50.

The interconnectedness of these areas can beseen in the following example: In advance ofscheduling a new patient we have to developour practice’s scheduling guidelines,determine the estimated fee for their initialappointment to allow us to properly informthe patient in advance, put protocols in placeto educate the patient on their oral health

state and recommended treatment, andidentify the practice’s specialty leadershipteam to be collaborated with as necessary.

Although many of the business systems inthe dental office are universal, these internalassessments are critical and should beadapted to the individual type and size ofpractice. I have over the years observed thatsome personality temperaments view thisdegree of administrative detail as beingoptional or just plain uninteresting. Be thatas it may, in my experience if theseassessments are not properly completed theimpact will be pronounced.

By Ms. Jo-Anne O’Connor-Webber

About the Author

Jo-Anne O’Connor-Webber is the president of IPCA, the developer of “Dental CATALYSTSolutions,” – which is committed to making business consulting for the dental industrymore authentic, more efficient, more cost effective, more dynamic, and less complex. She isalso a certified DISC behavioural studies trainer. Over the past 25 years, Jo-Anne hasmastered the roles of: business manager, treatment coordinator, software trainer, practicemanagement consultant, and mentor in the specialty and general dental practice.

Since 1984, Jo-Anne has been “hands on” in the prosthodontic, pedodontic, periodontic,orthodontic, and general dentistry practices, She has held integral business roles in practicesthat provide full mouth rehabilitation, implant placement and restoration as well aslaboratory services. Jo-Anne continues to train dental teams on how to effectively educatepatients on the benefits of comprehensive dentistry utilizing the case presentations skillstaught in her consulting. She can be reached at: Phone: 519-886-6872; Email: [email protected]; www.dentalcatalystsolutions.com.

Efficient Systems and Effective SystemsAuthor, Kevin W. McCarthy in his book, TheOn-Purpose Person suggests that efficientmeans doing things right while effective isdoing the right things! In our practices weneed to have systems in place which allow usto efficiently and effectively execute ourresponsibilities on a daily basis.

Practice administrative forms are atremendous tool in prompting us throughour daily tasks. In your dental practice we candivide these forms into two categories (1) patient forms and (2) system forms.

Patient forms, such as those used to obtainpersonal information and clinical chartingforms, assure that we are collecting therequired information to properly look afterour patient’s individual needs.

Intelligently designed system forms such as anew patient checklist and case planningworksheet, walk us through completing ourdaily tasks and make what we do becomeroutine. The nature of the task becomes lessstressful and less time consuming. In essence,with time and practise an individual will beon autopilot with some of the moremundane administrative tasks. These tasksare now accomplished with ease regardless ofthe individual performing the function. Inyour dental office this will allow for moretime to be spent being attentive to patients

and better prepared to handle obstacleswhich may present themselves during theday.

In his book The E Myth Revisited, Michael E.Gerber, says “the system becomes the toolsyour people use to increase their productivity,to get the job done in the way it needs to bedone in order for your business tosuccessfully differentiate itself.”

DO YOUR PRACTICE FORMS NEED ANINTELLIGENT MAKEOVER?

Possible Unidentified Inefficiencies inYour PracticeThe Patient ChartI am aware a percentage of offices havecomputerized patient charts but the majoritydo not. I have to confess that as much as I aman advocate of technology I remain moreconfident with relying on a manual patientchart.

I continue to be surprised at the number ofoffices where I observe individuals wastingtime “searching” through the chart and I amsure we have all witnessed a chart beingdropped resulting in radiographs and papersflying in all directions. My frustration withthese scenarios led me some time ago tocollaborate with a manufacturer to design achart which secures the documents and easesretrieval of necessary information. The oldaxiom “a filing system is only as good as its

ease of retrieval” is as true as ever.

Computer TechnologyIs your IT department up to date or at leastfunctioning in the current millennium? Doyou have a server separate from theworkstations? Does your practice have anadequate number of work stations? Are youusing current business software? Does thepractice have a daily, offsite back-up? Are thecomputer work stations designed to beergonomically friendly? Is at least one persontrained in running all reports available inboth your dental management andaccounting software?

Whether you are running your dailyoperations with one or 10 computers makesure the above questions have beenaddressed. In addition I would makeabsolutely certain that a back-up is beingcreated daily. One practice I was recentlyworking with assured me that a back-up wasbeing performed daily only to discover that ithad not been properly backed up in sixmonths. Computer technicians I work withrecommend you contract an online service toback up your data off-site because they donot trust the reliability of a tape back-up. Youmay not be aware there is a problem withyour back-up tape until you need to accessthe data on it only to realize that it isdefective. I do not think I need to describe thefrustration and the negative impact this mayhave on your practice. A computer technicianrecently advised me as to the importance ofensuring that the company providing youroff-site back-up service not only confirmsthat the back-up has been successfullyaccomplished each day, but has beenexamined by someone within their companyto identify any errors that should beaddressed in their infancy. For offices withcomputerized charting this is process isimperative.

The InternetYes, you need to be connected! For manyyears my message to practices has been tobegin collecting patient email addresses andif the practice didn’t have Internet access intheir facility to consider acquiring it in thenear future. Today we know the Internet is anabsolute necessity in the majority ofbusinesses. The Internet is a very useful toolwhether to order supplies, complete youronline back-up as mentioned, orcommunicate with your patients, team,

No.3 – Assessing Your Systems

Administrative Systems Active Patient ManagementNew Patient Protocols Patient Finance ManagementCase Presentation Referral ManagementPatient Case Acceptance Lab Case ManagementScheduling Practice Success Monitors

As you were assessing the above areas did you notice their interconnectedness?

When assessing: We have to include a thorough review of:New Patient Protocols Practice scheduling, case presentation, case

acceptance, patient financial, and referral protocolsActive Patient Management Practice scheduling, case presentation, case

acceptance, patient financial, referral, and lab case management protocols.

Patient Case Acceptance New patient, case presentation, scheduling, patient finance, active patient management, referral and labcase management protocols


EFFECTIVE BUSINESS SYSTEMS ENHANCE THE DELIVERY OF QUALITY DENTISTRY

http://www.biomet3i.com

O’CONNOR-WEBBER

colleagues, and other members of theprofession.

Telephone SystemThis seems like a very basic question, but doesyour phone system have enough lines? If youhave a boutique practice with one clinician,two hygienists, and two administrativepersonnel, I would recommend a minimumof three lines on the main number and aseparate private line for doctors and labs tocontact you easily. If your fax is phone-linebased, I would designate it to the private line.

Do your administrative team have wirelesshead sets to allow them to write while on thephone and avoid neck strain?

It has been a controversial subject, but someoffices are still enforcing the rule ofanswering the phone by the third ring. Unlessyou have a person whose sole responsibilityis to answer the phone in your practice thisrule needs to be modified.

Offices should consider using their answeringmachine as additional administrative teammember. More important than multitaskingin our business office today is prioritizing. Ifyou are attending to a patient and there is noone else available to answer the phone, let itgo to your voice message. The patient in frontof you is the most important person at thatmoment. Not only is it rude to answer thephone in the middle of assisting anotherpatient, it is also inconsiderate to then put thecaller on hold for an indefinite amount oftime before you can attend to them. I wouldrecommend that you leave a detailed messageinforming the caller of the administrativeoffice hours, and that you are currentlyassisting another patient and request theyleave a detailed message providing the reasonfor their call and an assurance that you willreturn their call promptly. The key is then toreturn the call promptly! This format canimprove efficiencies by providing the teammember an opportunity to gather keyinformation from the caller’s message, reviewtheir chart and acquire other intelligencebefore making the return call.

The Comprehensive Examination & Di-agnosis: The Prerequisite to EducatingOur PatientGiven that this issue of CJRDP is a specialimplant dentistry issue, and my experiencesince 1989 has included developing,

executing, and training on the businesssystems required to incorporate dentalimplants into the speciality and generaldental practices, I feel it is appropriate tocomment on the topic of incorporatingimplants into your practice.

Throughout my career I have approached thetopic of including implants in the dentalpractice as an excellent opportunity toencourage the practitioner to address themore expansive topic of providing theirpatients with comprehensive diagnosis andtreatment planning. This, followed byeducating the patient regarding their currentstate of their oral health, combined witheducating them as to the applicable treatmentrecommendations, options and the possibleoutcome of not proceeding with anytreatment.

These protocols will assist us in meeting therequirements for patient informed consent.Patient acceptance of comprehensivetreatment will allow us to effectively andprofitably sequence our appointments tooptimize hourly production. Although apatient may not immediately accept thecomprehensive treatment plan in its entiretythey may chose to either phase theirtreatment or make the decision to proceed inthe future. I think you will agree with me thatwhen our patient does decide to invest intheir oral health that you would prefer it is inyour office. The fact is if we don’t present thetreatment option they can’t accept it!

Dental implants are an excellent modality oftreatment when offered as part of overallpatient care. As we more consistently informthe patient as to their available treatmentrecommendations and options, the deliveryof implant-related treatments will naturallyincrease.

To ensure the patient and the practice realizesthe greatest possible benefit from theexecution of these protocols these systemsmust be continually monitored andimproved.

Throughout my career as a non-clinical teammember I have had the opportunity tocollaborate with both restorative specialistsand general practitioners in the delivery ofinformation to literally thousands of patientsas to their current oral health state as well astreatment recommendations and options.

With each patient it was necessary to take theappropriate amount of time to ensure theyunderstood the information provided andanswer the questions that routinely surfacedonce the clinician left the room. At this stageof the meeting, I would also discusstreatment fees along with financial paymentoptions and proceed with the coordinationof their appointments and referrals asnecessary.

From these experiences, I feel it is importantto share with you the following commonremarks, concerns, and questions of patientswho have been referred to these offices. Oftena patient would not be confident enough orhave the opportunity to deliver this messageto the clinicians themselves. Our patient’ssincerely expressed concerns allow us theopportunity to re-evaluate and clarify ourvision as an industry as to whereimprovement needs to take place.

Example # 1: The patient was referred forconsideration of replacement of a molar.Following the treatment discussion, thepatient indicated the referring dentist hadreplaced another missing molar with aconventional bridge a few months earlier andat that time she had not been informed of animplant option. The patient also questionedwhy they had not been referred to theprosthodontist sooner.

Example # 2: The patient had been referredfor assessment and possible treatment of atooth with a large restoration that hadfractured. He was subsequently providedwith restorative options including animplant-retained prosthesis and otherrestorative treatments as part of acomprehensive treatment plan. After thetreatment discussion, the patient indicatedthat he had been seeing his dentist for 20years and had never been informed as to theextent of treatment necessary or been offeredthis type of treatment option.

It is clear that today’s patient is expecting tobe advised of their treatment options and tobe referred to a specialist when thecomplexity of the treatment warrants it. Theaverage patient may not be sufficientlyeducated in this area to request these choicesdirectly of you. We risk having our patientbecoming disgruntled with us if they learnwhat is available to them from otherpractitioners.


To register or request more information for this course, please contact Stephanie Lewis:Phone: 519-432-1153Email [email protected]

For a detailed course description,please visit www.knowledgefactoryco.com.

Dental Implant Restorative Residency Program

Co-sponsored by

Jason Bortolussi DDS, MS Prosthodontist

A comprehensive approach to Dental Implant Continuing Education utilizing the Team Approach to empower participating doctors and their team in building their implant practices.

Aldo LeopardiBDS, DDS, MS Prosthodontist

Presented by

Location: Ivey Spencer Leadership Center 551 Windermere Road London, ON N5X 2T1, Canada

Tuition: $2,495

CE Credits: 16 hours

September 17-19, 2010

When compared to conventional fixed or removable prosthetic options for tooth replacement, implant therapy is a biologically conservative treatment approach with the potential for achieving rewarding treatment outcomes for both the patient and dentist.

Topics will include:

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O’CONNOR-WEBBER

There seems to be an increased desire ofindividuals to seek options which improvetheir overall health and/or prevent futurehealth problems. Undoubtedly this growingawareness will continue to spill over into thedental industry as our patients are madeaware of the connections between their oralhealth and overall well-being.

One consistent comment I have heard fromclinicians and teams in our industry whilediscussing ways to increase the acceptance ofimplant retained prostheses in their practiceis that they do not want to “sell” dentistry!My objective in working with a clinician whofeels this way is to change their perceptionthat they are selling dentistry to anunderstanding that it is their professionalresponsibility to educate the patient as to theirneeds and treatment options; there is noselling involved! When a team memberexpresses this concern it tells us that we needto focus our team training so everyoneunderstands and is confident with thetreatment services offered within our practiceand the benefits of these treatments to thepatient who received them.

Incorporating Implant or Other NewModalities of TreatmentWhen the appropriate provincial fee guide isreviewed we see that the services provided aredivided into categories. The ODA Fee Guidelists these services as follows: diagnosticservices, preventive services, restorativeservices, endodontic services, periodontalservices, prosthetics-removable, prostho-dontic services-fixed, oral and maxillofacialsurgery, and orthodontic services. Obviouslyas professionals we know we do not have theprerogative to ignore sections of the guidebecause we have chosen not to include thoseservices in our practice.

In a general practice clinicians have a verylarge menu to serve! Without doubt part ofyour practice vision includes providing thehighest standard of care as well as developinga profitable practice. I’m sure after assessingyour own strengths, likes and dislikes youhave decided which treatments you willprovide in your office and determine thetreatments you will refer as appropriate. Before you make a final decision toincorporate any new modality of treatmentinto your practice, such as the surgical aspectof implants, I would recommend that you

have considered the following:

1. Are all aspects of effective business systems incorporated into your practiceand being executed efficiently? Are you business system ready?

2. Do you have a trained team member aspart of your synergistic business team toassist you with communicating with your patients?

3. Have you identified and written down the objectives you hope to achieve for the patient and the practice through incorporating this additional modality of treatment? Have you shared this withyour team?

4. Has a thorough analysis of your practicefinancials been completed and are you aware of your current average hourly clinical production?

5. Has the professional fee you will chargethe patient been determined and a cost/benefit analysis to the practice beencompleted?

6. Have your practice’s current schedulingprotocols been reviewed and a new scheduling template created along witha strategy to incorporate these treatments into your schedule?

7. Are there treatments you may need to refer to another practitioner allowing room in your schedule if your scheduleis relatively full?

8. Does your practice have the team capacity or will the projected increased profit from the treatment allow you to hire an additional team member who, inthe implant scenario, will handle the ordering and tracking of implants as well as setting up and tearing down of the surgical operatory and assist with thesurgery?

9. Do you have the appropriate number of operatories to accommodate the treatmentset up and tear down procedures to avoid interrupting delivery of other treatments during this process?

10. Have you itemized and determine the estimated financial investment the practice will need to make to address anyof the necessary above points, training costs for you and your clinical assistant,the required clinical equipment set up, etc.?

Once you have accomplished the abovepoints you are now ready to research andcomplete the clinical training you will

require. I recommend following your trainingyou review this list again and have a teammeeting to outline the details ofimplementation.

My caution to you is to not start the decisionmaking process with completing the trainingand purchasing the clinical equipment!Points 1 through 10 must be completed first!

Case ScenarioA general practitioner was consideringincorporating the surgical aspect of implantsinto his practice. The practice alreadyprovided the restorative aspect of implantretained crowns and bridges. In addition toproviding conventional major restorativetreatments, he also offered the treatment oforthodontics in his practice. Following anassessment of the practice the clinician cameto realize that he would have to limit thenumber of orthodontic patients in hispractice to incorporate the surgical aspect ofimplants. The decision was made to notincorporate implant surgery into his practice.We developed a strategy to increase theoverall acceptance of treatment in his practicewhich included a concentrated focus onimplant retained prostheses.

Case AcceptanceWhere does case acceptance start? Before thenew patient exam!

Before our next meeting, consider havingeach team member provide you with theiropinion of the areas in the practice whichshould be addressed. Ask them toconfidentially provide you with their likes,concerns and suggestions.

If you are prepared to grow in your leadershipability and hear your team members “truthstatements” ask them to share with you theirlikes, concerns, and suggestions of you aspractice leader. Let them know that you wantto grow in your leadership role and that youneed to hear their honest feedback!

References1. McCarthy KW. The On-Purpose Person,

Colorado Springs, CO: Piñon Press, 1992.2. Gerber, ME. The E Myth Revisited, New

York NY: HarperCollins, 1995.


For more information about Southern Implants, contact us today at 866 700 2100 or visit www.southernimplants.us.

© 2010 Southern Implants, Inc. All rights reserved. SIM-10-005C

The Co-Axis Dental Implant System

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Sumita joined 3M's corporate researchlaboratory in 1978. In 1983 she became

a research specialist with 3M Dental.During the next 27 years, Sumita, and theteams she led, were responsible formultiple new technologies and subsequentsuccessful product introductions withinthe dental industry. She has become aworld renowned scientist, lecturer andauthor. In 1998 Sumita was inducted intoThe 3M Carlton Society and promoted tocorporate scientist – the highestrecognition within 3M Company for atechnical employee. Sumita has received inexcess of 37 patents. Most recently, in2009, she received the prestigious "Hero ofChemistry" award from the AmericanChemical Society. Sumita was responsiblefor inventing the Vitrebond Co-polymerwhich enabled the creation of the resinmodified glass ionomer category. 3MtESPEt RelyXt Luting Cement and RelyXtLuting Plus are the leading products in thecategory. Sumita was also responsible fordeveloping the first composite restorativematerial with nanotechnology. 3M ESPEFiltek Supreme Ultra is the latest iterationof the technology. Launched on March 1stof this year, it is receiving outstandingsupport and commercial success.

Dr. Sumita MitraAnnounces HerRetirement from3M Effective

Winter 2010 Canadian Journal of Restorative Dentistry and Prosthodontics 57

Periodontal Laser EducationProves To Be Popular WithQuebec City Audience

INDUSTRY NEWS / NOUVELLES DE L’INDUSTRIE

Pulpdent Pioneers New Provisional Chemistry

Ivoclar Vivadent and Patterson Dental areexcited to be teaming up to spread the word

about the benefits of using lasers forperiodontal treatments. Patterson’s Quebecbranch hosted an enthusiastic group of 25area dentists and hygienists in Quebec Citythis April for a full-day seminar, followed bya live patient hands-on training with theIvoclar Vivadent Odyssey Navigator diodelaser system for soft tissue treatment.

“The theme of the event was Dental Hygienefor the 21st Century,” said National SalesManager Dan Carrington. “Participantslearned about periodontal and soft tissuetreatments which fall within the dentalhygienist scope of practice using the soft tissuediode laser. Janet Press, RDH reviewed theselaser applications and how to themincorporate into a more patient-centeredpractice.”

The lecture was presented by Janet Press,

RDH from Las Vegas, who made aninformative, interactive presentation, whichwas simultaneously translated into French forthe French speaking audience. Press is a dentalhygienist with over 31 years of experience,with 12 years clinical experience using softtissue lasers. She conducts nationalworkshops, private dental office consultationand training programs with emphasis on softtissue laser dentistry.

“The program was a big hit with ourclinicians,” said Carrington. “I anticipate asurge in Odyssey Laser periodontal treatmentswill be implemented in the Quebec City areavery soon.”

Patterson Dental is a provider of high-technology dental products, operatoryequipment, supplies, technical services andoffice design. Ivoclar Vivadent is a leadingproducer of laser technology for periodontaltreatments and other dental applications.

Pulpdent Corporation has introduced Rubberized-UrethaneT, a new category of provisional materials. The breakthrough is the first advancein provisional chemistry in 18 years.

During the past two decades, many practitioners have favoured bis-acrylic provisional materials from Germany over traditional powder andliquid acrylic. Now, Pulpdent has introduced a new provisional chemistry. By inserting a synthetic rubber molecule into a diurethanedimethacrylate molecule, Pulpdent has developed Tuff-TempT, a proprietary rubberized-urethane provisional material with clear advantagesover the older technologies.

www.pulpdent.com

58 Journal canadien de dentisterie restauratrice et de prosthodontie Hiver 2010

INDUSTRY NEWS / NOUVELLES DE L’INDUSTRIE

New Eclipse-Ti frames bridge the gapbetween style and functionality

Dental loupes have become an indispensabletool for most dentists in their daily practice, asthey depend on the improved vision toperform at a higher level, as well as to preventstrain injuries resulting from poor posture.

Until now, dentists have been forced tocompromise by having to choose betweenfunctionality such as prescription

accommodation and durability, and stylefactors such as fashion and comfort.

The launch of the Eclipse-Ti titanium sportsframes is the culmination of a 2-yeardevelopment effort that utilized feedbackfrom dentists to build a loup that combines allthe positive features identified duringresearch: It is a lightweight, comfortable, andstylish wrap-around titanium frame that ispurpose designed for dentistry. The Eclipse-Ti incorporates an exclusive quick release

mechanism for any strength prescription, andoffers a limited lifetime warranty on the frameand optics.

Q-Optics is based in Dallas, TX, and is awholly owned subsidiary of QualityAspirators. The Surgical Room is the exclusiveCanadian distributor for Q-Optics.

www.q-optics.ca

Q-OPTICS LAUNCHES FIRST ALL-TITANIUM SPORTS FRAMESFOR DENTAL LOUPES

http://www.q-optics.com/

Meeting Theme: “Real World Dentistry 2010 and Beyond”

Thème du congrès: La dentisterie pragmatique: aujourd’hui et au-delà

http://www.cardp.ca

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