Tạp chí cấy ghép Implant IPUS tháng 01+02/2014 Vol.7 No.1

FILL THE DEFECT. THE ENTIRE DEFECT!
Learn how to easily prevent
particle migration using expandable
NuOss
®
XC Socket and NuOss
®

XC Sinus.
For details
see page 49
White Box
covering the
left side bleed
should be
removed.
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clinical articles • management advice • practice proles • technology reviews
January/February 2014 – Vol 7 No 1
PROMOTING EXCELLENCE IN IMPLANTOLOGY
Verified osteoinductive
allograft putty for dental
implant regeneration
Dr. John Lupovici
Practice profile
Dr. Louis Kaufman
Corporate profile
DIO
Tackling a challenging

esthetic clinical
situation
Dr. Cary A. Shapoff
Multi-disciplinary
approach to the treatment
of traumatic root fracture
Drs. Peter Fairbairn and
Sharon Stern
A chemotherapy
patient’s experience
with dental implants
Dr. Bryan R. Krey and
Dr. Richard G. Dong
P
L
A
N
S
C
A
N
P
L
A
C
E
R
E
S
T

O
R
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WHEN THE OSTEOTOMY MUST BE NARROW -
SO MUST YOUR IMPLANT CHOICE
Choose the LOCATOR
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Overdenture Implant System
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Overdenture Implant (LODI) System may be the perfect fi t. Make LODI
your new go-to implant for overdenture patients with narrow ridges
or limited fi nances and stop turning away patients who decline
grafting. Your referrals will love that LODI features all the benefi ts of
the LOCATOR Attachment system that they prefer, and that all of the
restorative components are included.
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2.5mm
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4mm
2.9mm
included with each Implant

Discover the benefi ts that LODI can bring to your practice today
by visiting www.zestanchors.com/LODI/31 or calling
855.868.LODI (5634).
Cuff Heights
Diameters
Volume 7 Number 1 Implant
practice
1
January/February 2014 - Volume 7 Number 1
EDITORIAL ADVISORS
Steve Barter BDS, MSurgDent RCS
Anthony Bendkowski BDS, LDS RCS, MFGDP, DipDSed, DPDS,
MsurgDent
Philip Bennett BDS, LDS RCS, FICOI
Stephen Byfield BDS, MFGDP, FICD
Sanjay Chopra BDS
Andrew Dawood BDS, MSc, MRD RCS
Professor Nikolaos Donos DDS, MS, PhD
Abid Faqir BDS, MFDS RCS, MSc (MedSci)
Koray Feran BDS, MSC, LDS RCS, FDS RCS
Philip Freiburger BDS, MFGDP (UK)
Jeffrey Ganeles, DMD, FACD
Mark Hamburger BDS, BChD
Mark Haswell BDS, MSc
Gareth Jenkins BDS, FDS RCS, MScD
Stephen Jones BDS, MSc, MGDS RCS, MRD RCS
Gregori M. Kurtzman, DDS
Jonathan Lack DDS, CertPerio, FCDS
Samuel Lee, DDS
David Little DDS

Andrew Moore BDS, Dip Imp Dent RCS
Ara Nazarian DDS
Ken Nicholson BDS, MSc
Michael R. Norton BDS, FDS RCS(ed)
Rob Oretti BDS, MGDS RCS
Christopher Orr BDS, BSc
Fazeela Khan-Osborne BDS, LDS RCS, BSc, MSc
Jay B. Reznick DMD, MD
Nigel Saynor BDS
Malcolm Schaller BDS
Ashok Sethi BDS, DGDP, MGDS RCS, DUI
Harry Shiers BDS, MSc, MGDS, MFDS
Harris Sidelsky BDS, LDS RCS, MSc
Paul Tipton BDS, MSc, DGDP(UK)
Clive Waterman BDS, MDc, DGDP (UK)
Peter Young BDS, PhD
Brian T. Young DDS, MS
CE QUALITY ASSURANCE ADVISORY BOARD
Dr. Alexandra Day BDS, VT
Julian English BA (Hons), editorial director FMC
Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government
for Wales
Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private
Dentistry
Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of
Boots Dental, BUPA Dentalcover, Virgin
Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St
referral implant surgeon
PUBLISHER | Lisa Moler
Email: Tel: (480) 403-1505

MANAGING EDITOR | Mali Schantz-Feld
Email: Tel: (727) 515-5118
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necessarily the opinion of either Implant Practice or the publisher.
W
hen I think about advancements in implant dentistry that have most influenced
my practice, I think about three things: 3D imaging, sinus grafting techniques,
and guided bone regeneration (GBR) procedures. When I opened my practice 11 years
ago, I was trying to decide if I should implement digital imaging or continue with film.
Today, I have a three-dimensional image of my patient’s maxilla and mandible before
I’ve even introduced myself. It has provided us with the ability to accurately know the
position of nerves, sinuses, and that sneaky osseous defect that can be lingering buccal
to our osteotomy. Because of this information, flap designs have become minimally
invasive and far less painful for our patients. Case acceptance has increased, providing
patients a more thorough understanding of their treatment. 3D imaging has made the
next advancement, sinus grafting, so predictable that we now even can see the exact
thickness of the wall we need to drill through to access the sinus.
Sinus grafting itself hasn’t changed. It is still a surgical procedure aiming to increase
the amount of bone in the posterior maxilla by sacrificing the volume of the maxillary
sinus. Thus, increasing our ability to place dental implants using fixed restorations on
more patients. Although the outcome is the same, the methods have changed drastically.
The Piezosurgery
®
unit allows us to cut bone without harming soft tissue. We can now

predictably free up the Schneiderian membrane. There are drill kits akin to those used
in neurosurgery, developed to allow surgeons to cut through the skull without harming
the underlying dura mater. This same technology is now in place with the direct sinus
procedure. Similar drills are used in order to avoid perforating the membrane of the sinus.
When evaluating bone grafting techniques, the criteria must be predictability and ease of
use. I find it fascinating that cow bone, which has been popular for ages, is now mixed
within a collagen matrix to allow for precise placement, minimal migration, and enhanced
bone growth at the site. The same Piezo unit spoken about with sinus grafting can be
used for minimal heating of bone for a sagittal split with ridge-splitting techniques. This
technique, when used in the right situation, can result in some of the most predictable
gain in bone volume. The highly porous collagen structure allows for quicker turnover to
bone via a highly formulated matrix. You can actually put bone where you want it; it stays,
and it grows. There are now bone grafts used that have signals to form bone — bone
morphogenic protein (BMP) — calling in stem cells to allow for quicker, more predictable
bone formation.
My practice has always been focused on patient comfort, and these advancements
in 3D imaging have allowed for the most minimally invasive flap procedures, the most
predictable bone placement, and in turn, significantly decreased pain and down time for
my patients.
Ryan Taylor, DDS, MS
Dr. Taylor established his practice in Periodontics and Implant Dentistry in
Sarasota, Florida, in 2004. He is an active member in the American Academy
of Periodontology, American Academy of Implant Dentistry, the Academy
of Osseointegration, and the Academy of Oral Implantology. He is also a
member of the American Dental Association, Florida Dental Association, West Coast
District Dental Association, and Sarasota County Dental Association.
INTRODUCTION
New technologies in the
advancement of implant dentistry
TABLE OF CONTENTS

Practice profile 6
Dr. Louis Kaufman: Continuing a legacy
This clinician is driven by inspiration, a great team, and desire for knowledge.
2 Implant
practice
Volume 7 Number 1
Case study
Tackling a challenging esthetic
clinical situation
Dr. Cary A. Shapoff illustrates a case
replacing two adjacent maxillary
central incisors 14
Patient insight
A chemotherapy patient’s
experience with dental implants
Dr. Bryan R. Krey and retired
engineer Dr. Richard G. Dong join
forces to facilitate implant placement
during cancer treatment 18
Corporate profile 9
DIO Corporation
Promoting happiness and healthy lifestyles
ON THE COVER
Cover photo courtesy of Dr. John Lupovici.
Article begins on page 42.
TABLE OF CONTENTS
4 Implant
practice
Volume 7 Number 1

Continuing
education
Multi-disciplinary approach to
the treatment of traumatic root
fracture: a case study
Drs. Peter Fairbairn and Sharon Stern
present a multi-disciplinary approach
to tackling a tricky trauma case 25
Management of biological
and biomechanical implant
complications
Drs. Yung-Ting Hsu and Hom-
Lay Wang summarize and reveal
management protocols for implant
complications 32
Advanced
technologies
38
Technology
Advanced technologies and
materials to efficiently deliver full
mouth reconstructions
Dr. Ara Nazarian suggests a treatment
solution that results in more control
and fewer appointments 38
Verified osteoinductive allograft
putty for dental implant
regeneration: preliminary findings
of three clinical applications
Dr. John Lupovici illustrates clinical

cases using RegenerOss
®
Allograft
Putty to regenerate three distinct
osseous defects 42
Product profile
NuOss
®
XC bone grafting
composite 49
On the horizon
I want my teeth yesterday!
Dr. Justin Moody discusses a time-
saving technology in a fast-paced
world 50
Materials &
equipment 54
Diary 56
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What can you tell us about your
background?
I was born into a dental family. I graduated
from the University of Illinois College of
Dentistry, and in 1995, joined my father
Richard’s well-established 50-year-old
general dentistry practice treating third-
and fourth-generation patients.
Besides my clinical experience, I have
a diverse business background. I earned an
MBA from the Computer Science Executive
Management Program at DePaul University
and a BA in Marketing and Economics
from Kendall College in Evanston, Illinois.
Prior to attending dental school, I worked
in management at Pillsbury Corporation
as a specialist in point-of-service site
development and restaurant management

for 5 years. The skill set that I developed
in corporate management has helped
me grow my Hyde Park (Chicago) private
practice into a multimillion dollar business
focused on comprehensive oral healthcare
and cosmetic smile design.
I serve on the advisory board of
numerous dental manufacturers, consult
on product development, and am honored
to educate clinicians around the globe at
approximately 20 continuing education
programs annually. I also have published
numerous articles focused on restorative
and cosmetic dentistry.
Is your practice limited to
implants?
No.
Why did you decide to focus on
implantology?
I have been restoring implants since
graduating dental school.
How long have you been
practicing, and what systems do
you use?
Biomet 3i
™
, Noble Biocare
®
, BioHorizons
®

,
Astra Tech Implant System™, and
Straumann
®
.
What training have you
undertaken?
I have taken numerous courses on
restoring and treatment planning implants,
and recently completed my training in the
surgical placement of implants.
What is the most satisfying aspect
of your practice?
The greatest satisfaction is giving patients
back the ability to function and re-create
their smile.
Professionally, what are you most
proud of?
I am proud of how as a profession we
stand together on so many fronts. We
have dentists who lobby and legislate for
those on the front lines providing care to
patients. There is a “we” mentality versus
an “I” mentality. I couldn’t imagine a better
career. Coming from corporate America
years ago, to being a true entrepreneur
with guidance and backing all around is
incredible.
What do you think is unique about
your practice?

Without a doubt, it’s location. If you have
never been to Hyde Park (a neighborhood
in Chicago), then it’s worth the trip. It
is a microcosm of the world. So many
nationalities and economic strata exist.
Another unique aspect is that we have
been a part of the community for 60-plus
years. We provide care to fifth-generation
patients.
What has been your biggest
challenge?
The biggest challenge right now is space.
I am in an old building, and our suites are
not designed for sit-down dentistry. I ask
myself how my dad did it for so long. At
the present time, I am 2½ years out for
my lease. I am getting quotes on gutting
the existing space or moving to a different
floor so we can continue to operate until
it’s time to move. Having stayed on top
of technology, I am finding we are running
out of space.
What would you have become if
you had not become a dentist?
Great question. I would have wanted to
become a thoracic surgeon but did not
Dr. Louis Kaufman
6 Implant
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Volume 7 Number 1

PRACTICE PROFILE
Continuing a legacy
Who has
inspired you?
I believe inspiration comes
from within or the desire to
learn and do more. I am lucky
my father was a practicing
dentist for more than 60
years. He always stayed up
to date on techniques and
procedures. I was fortunate
to have a strong role model.
The dental community has
many amazing specialists
and general dentists whom
I learn from by reading and
reviewing journals.
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8 Implant
practice
Volume 7 Number 1
PRACTICE PROFILE
want to be finishing up in my forties. I
already changed careers to go into either
medicine or dentistry. After my research of
both, I decided on the dental career path
because at age 27 I would not have finished
a medical-surgical path until around 40
years old.
What is the future of implants and
dentistry?
The future of implants in dentistry is
continually growing. We have so many
dentists who are not restoring or placing
implants. My goal this year was to take an
implant surgical course to place implants,
and I will only do the straightforward cases.

Everything else goes to the oral surgeon or
periodontist. I strongly believe that the use
of surgical guides will become the standard
of care in the placement of the implant.
What are your top tips for main-
taining a successful practice?
The key ingredient is to be engaged and
to surround myself with a great team of
people. We have to continually motivate,
educate, and appreciate our team
members. I am a big believer in educating
my team. I try to teach something new to
as many people as possible. I try to learn
something new from somebody every day.
The other key is to make sure you give your
patients the time they deserve. Become
interested in them as people. There are
so many pearls. The bottom line is that we
are in a “people business,” and we have
to have a team that works great with the
public. Also, don’t be afraid to fire a team
member that just won’t perform to the
levels that the business demands.
What advice would you give to
budding implantologists?
Take lots of continuing-education courses.
Get educated on the restorative side and
the surgical side of implants. Treatment
planning from the functional restorative
side is key for long-term success.

What are your hobbies, and what
do you do in your spare time?
I like to spend my spare time with my
teenage kids. It’s not a lot of time, but I
take what I can get. I like to read fiction
and enjoy going to the movies. I recently
rescued a dog, and we take a lot of walks.
I go to the gym regularly. Our profession
is physically and mentally demanding, so I
have become a big believer in eating right
and being on a fitness program. I also like
taking my bike out for rides. The rest of
my time is spent preparing for upcoming
lectures that I am presenting.
Dr. Kaufman’s team
Dr. Kaufman’s dog, Max
Dr. Kaufman with his children, Rachel and Jacob
Top Ten Favorites
1. Planmeca ProMax
®
3D — the
coolest piece of technology. I
am constantly learning with this
technology.
2. The technology called NuCalm
™
.
Everybody should have it.
3. Chocolate Chip Banana Blizzard
from Dairy Queen.

4. Must have music playing in the
office. I am old school rock-and-
roll with some of the new.
5. I like to try new restaurants.
6. Deep-fried Oreos with vanilla ice
cream. If I go to Las Vegas, I go
to Lava to have this. So much
for nutrition.
7. I like new clothes and should not
go into Nordstrom.
8. Taking my daughter clothes
shopping. I get time to talk to
her.
9. I love the game of basketball.
Going to see the Chicago Bulls
play is one of my greatest
sources of entertainment. I
understand the game but could
never play it well.
10. I like pretending I have a bad
cold/cough at the movie theater
so nobody will sit in front of me,
and I can put my feet up. :-)
IP
Volume 7 Number 1 Implant
practice
9
CORPORATE PROFILE
About the company
DIO Corporation

Volume 7 Number 1
CORPORATE PROFILE
Promoting happiness and healthy lifestyles

We at DIO Corporation (Kosdaq:039840) are
dedicated to promoting happiness and
healthy lifestyles in over 70 countries around
the world with investment in and develop-
ment of state-of-the-art dental implant
technologies and advanced digital dental
solutions.
To further enhance our efforts, the DIO
Implant Academy was established to provide
both practical and advanced dental educa-
tion to our partner clinicians globally. DIO
also organizes annual educational symposia
that serves as a way for our partner clinicians
to meet, exchange knowledge and collabo-
rate with renowned scholars and practitioners
in the dental implant field.
is in a strategic partnership with Dentsply
International (NASDAQ: XRAY) by virtue of
Dentsply being DIO’s largest shareholder.
Dentsply is one of the largest global dental
products companies in the world.
• So called “Premium” Implants →
“Affordable, Value-Added” Implants
• Traditional “Analog” Dentistry →
“Digital Dental Solutions”
DIO has long term staying power. DIO

DIO will lead the “Paradigm Shift in Dental
Implants”
10 Implant
practice
Volume 7 Number 1
CORPORATE PROFILE
Volume 7 Number 1 Implant
practice
X
DIO Symposium at Las Vegas
CORPORATE PROFILE
“Paradigm Shift in Implant Dentistry” will
be held on May 10 - 11th, 2014 at the
Mandalay Bay Resort and Casino.
DIO Symposium Las Vegas 2014 will be an
informative and educational event that will be a
landmark event for our Company; and one that
will not be forgotten.
We chose to organize our 2014 symposium in Las Vegas, which is an international destination for world-class entertainment, ultracool
nightlife, renowned restaurants and luxury shopping venues. Furthermore, stunning hotels have raised the bar for service and entertain-
ment. Amazing venues showcase world-class entertainers, whether they’re on the latest leg of a world tour or they’re must-see Las
Vegas staples. The city is also home to some of the world’s best magicians, singers, impressionists, comedians and tribute acts.
PRADIGM SHIFT IN IMPLANT DENTISTRY
“Premium” Implants to “Affordable, Value Added” Implants
Traditional “Analog” Dentistry to “Digital Dental Solutions”
PARADIGM SHIFT IN IMPLANT DENTISTRY
12 Implant
practice
Volume 7 Number 1

CORPORATE PROFILE
DIO Implant offers a full line up of implant designs
and options to perfect your implant procedure under
any situation with predictable and optimal results.
UF, SM, Protem, Extrawide, FSN/FTN
DIO holds best in class design, superior surfaces,
state-of-the-art manufacturing, highest quality tools,
drills and kits along with easy to learn protocols.
X Implant
practice
Volume 7 Number 1
CORPORATE PROFILE
DIO Implant
Renowned dental implants in over 70 countries

BEST IN CLASS MANUFACTURING
DIO Implant holds ISO 13485 certification
ISO 13485 is an International Organization for Standardiza-
tion (ISO) standard that represents the requirements for a
comprehensive quality management system for the design
and manufacture of medical devices.
UNIVERSAL FIXTURE
UF
SUBMERGED
SM
UNIVERSAL
FIXTURE
CORPORATE PROFILE
Volume 7 Number 1 Implant
practice

X
DIO Digital Solutions
This information was provided by DIO.
• DIO Digital Solutions “Trione” brand lineup is
composed of the “tried and true”
best products and technologies globally.
• Includes the most advanced intra-oral scanners,
CAD applications & software and precision milling
technologies.
• DIO has developed highly advanced implant-oriented
integrated digital applications and solutions designed
for leading dental clinics and laboratories.
• DIO is leading the “Paradigm Shift” from Analog to
Digital Dentistry
DIO Digital Solutions
Trios Scan
Milling (Trione G)
Milling (Trione Z)
DIO CNC Milling
3Shape Design
DIO Implant offers a full line up of implant designs
and options to perfect your implant procedure under
any situation with predictable and optimal results.
UF, SM, Protem, Extrawide, FSN/FTN
DIO holds best in class design, superior surfaces,
state-of-the-art manufacturing, highest quality tools,
drills and kits along with easy to learn protocols.
X Implant
practice
Volume 7 Number 1

CORPORATE PROFILE
DIO Implant
Renowned dental implants in over 70 countries

BEST IN CLASS MANUFACTURING
DIO Implant holds ISO 13485 certification
ISO 13485 is an International Organization for Standardiza-
tion (ISO) standard that represents the requirements for a
comprehensive quality management system for the design
and manufacture of medical devices.
UNIVERSAL FIXTURE
UF
SUBMERGED
SM
UNIVERSAL
FIXTURE
Volume 7 Number 1 Implant
practice
13
CORPORATE PROFILE
CORPORATE PROFILE
Volume 7 Number 1 Implant
practice
X
DIO Digital Solutions
This information was provided by DIO.
• DIO Digital Solutions “Trione” brand lineup is
composed of the “tried and true”
best products and technologies globally.
• Includes the most advanced intra-oral scanners,

CAD applications & software and precision milling
technologies.
• DIO has developed highly advanced implant-oriented
integrated digital applications and solutions designed
for leading dental clinics and laboratories.
• DIO is leading the “Paradigm Shift” from Analog to
Digital Dentistry
DIO Digital Solutions
Trios Scan
Milling (Trione G)
Milling (Trione Z)
DIO CNC Milling
3Shape Design
IP
R
eplacing two adjacent maxillary central
incisors is one of the most challenging
esthetic clinical situations we face in
providing dental implant therapeutics. The
maxillary anterior region provides numerous
esthetic, technical, and sequencing
challenges. This article describes a
surgical and restorative workflow for this
clinical problem from treatment planning
considerations to selection of a dental
implant system that provides surgical and
restorative advantages in order to enhance
the esthetic outcome.
Case 1
A 53-year-old female presented for

functional surgical crown-lengthening
procedure around her maxillary central
incisors (teeth Nos. 8 and 9) prior to
replacement of new crowns. The patient
reported mobility of the existing crowns
and an unpleasant odor in her mouth.
According to patient history, these crowns
were recent replacements of prior long-
standing unesthetic crowns. The patient
had an unremarkable medical history and
had previously sought dental and dental
hygiene care on a regular basis. Both teeth
Nos. 8-9 had prior endodontic therapy
(Figure 1).
At her initial examination, a complete
dental and periodontal evaluation, including
full-mouth radiographs, was completed with
photographic documentation. Significant
marginal inflammation was noted around
teeth Nos. 8-9 associated with poor fit
of the crown margins and with recurrent
decay. The patient demonstrated normal to
thick biotype with rolled, reddened margins
around the central incisors associated with
a high smile line and a dental history of
mouth breathing (Figure 2).
All other regions of her mouth demon-
strated marginal gingivitis associated with
retained interproximal plaque. The existing
shape of her central incisor crowns were

square and short and disproportionate in
shape and size to her other natural anterior
teeth.
The existing crowns were carefully
removed, and the underlying tooth
structure was inspected. It was noted
that there was inadequate core portion of
the crowns, with only the coronal aspect
of an endodontic post and composite
retaining the crowns. There had been no
ferrule portion of the tooth preparations
in the cervical region (Figure 3). The
likely contributing factor to the mobility
of the crowns was the excessive tooth
preparation resulting in crown flexure and
marginal leakage resulting in recurrent
caries.
At her request, she was referred to
a prosthodontist for further restorative
treatment. A composite-based diagnostic
wax-up was completed to assist in
determining optimum tooth height and
shape. Treatment plan options were
developed after discussing surgical and
restorative considerations with the patient.
These included functional surgical crown
lengthening and new crowns, orthodontic
extrusion of the two central incisors,
followed by functional crown lengthening
and new crowns, or extraction of the teeth

and replacement with two dental implants
and crowns. Based on the missing core
portion of her teeth and the extent of decay
around the post spaces, it was determined
that extraction of the teeth and replacement
with dental implants was the treatment
of choice. Based on the anatomy of the
tooth sockets and dimensions of palatal
bone, identified by three-dimensional
imaging CBCT, it was further determined
that immediate extraction and placement
of dental implants with intra-socket bone
grafting was possible.
The patient preferred interim fixed
provisionalization during the initial healing
phase, rather than any of the removable
provisional options discussed with her.
The surgical phase consisted of
Tackling a challenging esthetic clinical situation
14 Implant
practice
Volume 7 Number 1
CASE STUDY
Dr. Cary A. Shapoff illustrates a case replacing two adjacent maxillary central incisors
Figure 1
Cary A. Shapoff, DDS, has practiced in
Fairfield, Connecticut for over 36 years.
He is in private practice as a periodontist,
and is a Diplomate and past director of the
American Board of Periodontology. He lectures both

nationally and internationally on periodontal disease
and its treatment, bone grafting procedures, and dental
implant surgery. He has also written articles published
in the Journal of Periodontology, Compendium, the
International Journal of Periodontics and Restorative
Dentistry, and The Dental Guide (Canada). He has been
a consultant and lecturer for BioHorizons for 7 years.
Dr. Shapoff can be contacted at:
Figure 2
Figure 3 Figure 4
CASE STUDY
Volume 7 Number 1 Implant
practice
15
extraction of teeth with a flapless approach
followed by careful curettage of the intact
socket walls. Utilizing a surgical guide
based on the diagnostic wax-up, two
dental implants were placed, engaging the
palatal wall of the intact sockets (Figure 4).
The implants selected were the
BioHorizons
®
Tapered Internal with Laser-
Lok
®
microchannels on the coronal collar
portion (3.8 mm x 15 mm with 3.5 mm
prosthetic platforms). Precise three-
dimensional positioning was established

with the surgical guide. Following implant
placement, the voids within the socket were
bone grafted with a combination cortical
and cancellous allograft (MinerOss
®
), and
flared healing abutments were placed to
support the soft tissues (Figure 5).
The composite-based diagnostic wax-
Figure 5
Figure 6
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10232 OM DI AD 0114
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Figure 7A Figure 7B
16 Implant
practice
Volume 7 Number 1
CASE STUDY
up was then bonded to adjacent laterals as
a fixed provisional.
Three months after surgical placement
of the implants, screw-retained provisional
crowns were fabricated onto PEEK
abutments and were modified to achieve
ideal tooth shape and gingival architectural
framework (Figure 6). Maintenance of the
interproximal bone between the implants
was achieved with use of the BioHorizons
implants with Laser-Lok microchannels.
Minor modifications to the interproximal
and facial dimensions of the composite
crowns were made over a period of 12
weeks (Figures 7A and 7B).

Once ideal tooth and gingival size and
shape were established, custom, open-
tray impressions were taken to capture
the precise ideal subgingival form for
final crown fabrication (Figures 8-9). Final
crowns were then provisionally cemented
and monitored for potential additional
minor modifications (Figures 10A and 10B).
The radiograph of the final crowns at 12
months demonstrates the maintenance
of the crestal bone around each dental
implant as well as maintenance of the
interproximal bone between the implants
(Figure 11).
Discussion
Numerous lessons can be learned from a
critical review of this case.
1. Evaluation of the failed crowns
identified excessive tooth preparation and
inadequate coronal portion of the tooth to
provide predictable restoration with basic
fixed partial dentures (crowns). In addition,
the design of the failed crowns did not
mimic the tapered shape of her adjacent
natural teeth. Critical documentation of
tooth shape and size and smile analysis is
an essential element of proper treatment
planning. Lack of adequate ferrule and
lack of coronal tooth portion should
have precluded placement of the failed

permanent crowns.
2. Dental implant treatment planning should
include photographic documentation,
diagnostic wax-up, evaluation of the
gingival tissue biotype, position of the
maxillary lip position relative to the gingival
margin of the teeth, and shape and form of
the intended implant restoration.
3. Surgical treatment planning should
include three-dimensional imaging
especially if a flapless approach is
considered. Because of the thick gingival
biotype and intact sockets of both teeth,
immediate placement was considered. In
other cases of high smile line, and thinner
biotype, a delayed two-phased approach
of grafting followed by implant placement
would have been the treatment choice. A
delayed two-phased approach would also
be required if the remaining alveolar bone
prevented adequate initial biomechanical
stability at implant insertion.
4. Selection of the BioHorizons Tapered
Internal implant was a key element of the
success of maintaining interproximal bone
between two implants. Use of the tapered
3.8 implant body allowed ideal positioning
in the palatal bone without encroachment
on the facial bone dimension or elimination
of the mesiodistal bone within the socket

reducing initial stability. Intra-socket bone
grafting with a calcified allograft minimized
the horizontal dimension bone resorption
often seen even with immediate implant
placement. The use of the BioHorizons
implants with the Laser-Lok microchannels
was another key element in maintaining
the ideal intra-implant bone level, which
in turn supported the ideal height of the
interproximal papilla. Numerous published
articles have supported the concept of
enhanced bone maintenance with the
non-random Laser-Lok microchannels
(Figures 12A and 12B). Additional animal
and human clinical and histologic studies
have demonstrated “functionally oriented”
connective tissue attachment to the Laser-
Lok surface along with inhibition of the
epithelial downgrowth against the implant
surface and Laser-Lok abutment surface
(Figure 13).
Figure 12A Figure 12B
Figure 13: Polarized light micrograph
Figure 14
Figure 8 Figure 9 Figure 10A
Figure 10B Figure 11
Figure 15
CASE STUDY
Volume 7 Number 1 Implant
practice

17
5. Maintaining support of the facial and
interproximal tissue contours with use of
the flared healing abutments assisted in
recapturing the proper gingival contour
around the provisional crowns. This could
have been further improved by fabrication
of “custom” healing abutments utilizing
the BioHorizons 3inOne abutment and
composite. This customized technique
is used often in this practice but was not
utilized in this case.
6. Fabrication and modification of the well-
contoured, screw-retained provisionals by
the prosthodontist, Dr. Jeffrey O’Connell,
(Bridgeport, Connecticut) was also another
key element in achieving ideal tooth shape
and gingival framework. In addition, the
established subgingival contours were
captured in the final impression technique
utilizing the BioHorizons open-tray copings
modified with resin. The excellent working
relationship of the prosthodontist and his
dental laboratory technician also needs
to be mentioned in achieving natural-
looking, all-ceramic crowns. This case was
completed before the company release
of CAD-CAM custom abutments with
Laser-Lok microchannels (Figure 14). Use
of these abutments would have further

enhanced the attachment of soft tissue to
the abutment surface resulting in protection
of the underlying crestal bone.
In summary, the patient was
successfully restored with two single-
crown dental implant restorations following
an interdisciplinary workflow from treatment
planning through final restorations. The use
of the BioHorizons Tapered Internal dental
implant with Laser-Lok microchannels
was an integral part of the success of this
case. In similar cases where the gingival
biotype is thinner, I would have considered
using the platform switched BioHorizons
Tapered Internal Plus implant in order to
create a thicker dimension of marginal
tissue around the abutments (Figure 15).
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Background
Dental problems of cancer patients
are often worsened when the patient
undergoes chemotherapy. Dentists and
other dental care professionals have seen
this. Dental problems definitely worsened
for Dr. Richard G. Dong, a retired engineer,
during his 3½ years of treatment with the
chemo-therapeutic drug Bacillus Calmette-
Guerin (BCG), a live bacteria injection used
to treat bladder cancer. The problems
included persistent infections developing in
two existing molar dental implants on teeth
Nos. 19 and 30. Dr. Bryan R. Krey is the
oral surgeon performing the dental implant
procedures and has followed Dr. Dong’s
problems and his inventive ways of handling
them. This article describes the simple
instruments and techniques Dr. Dong

developed that saved one of the existing
implants and, together with Dr. Krey’s
help, extended the life of the other by an
estimated 2 years. Conclusions reached by
Dr. Dong and Dr. Krey are summarized at
the end of the article regarding the handling
and designing of implants for individuals on
chemotherapy or who had chemotherapy,
and who had experienced worsened
dental problems while on chemotherapy.
Dr. Dong is a nonsmoker, with no diabetes
or other systemic disorders. He exercises
regularly and eats a healthy diet.
Effects of an altered immune
system
The chemotherapy was to train Dr. Dong’s
immune system to fight the cancer. The
following might or might not be medically
established, but from an engineer’s point
of view, this means the immune system will
be altered; and therefore, various changes
in immunity reactions will progressively
show up as the alteration increases. This
was confirmed by the fact that various
forms of immunity reaction came forth one
after the other over Dr. Dong’s 3½ years
of treatment. This included arthritic auto-
immunity reactions, weakened ability to
fight off certain bacteria, such as those
causing dental problems and those caus-

ing cellulitis. Dr. Dong’s last treatment
resulted in a severe rash all over his body,
as his immune system became sensitized
to the drug. Thank goodness it was the
last treatment; who knows what else
might have arisen next. General tiredness,
headache-nausea reactions to weather
changes, and allergic reactions to certain
foods also developed. The bladder became
hyper from three rounds of surgeries
and from the prolonged exposure to the
chemotherapy drug. Hyper is defined here
as constant urgency and frequency to
urinate on an hourly basis. Therefore, this
is also at least partly an immunity reaction.
Besides the immune system becoming
more able to fight the cancer, a secondary
positive change was that his seasonal hay
fever became much milder.
Not everyone would react the same
way to this particular chemotherapy, and
therefore, not everyone is necessarily
going to have the reactions mentioned.
Everyone’s immune system is different.
This is becoming increasingly clear in
general cancer research. Immune systems
in individuals could vary widely as revealed
in current research using humanized
mice. The immune systems of numerous
individuals are grown in mice to study their

reactions to various cancer-fighting drugs
and various cocktails of the drugs. The
reactions were found to vary widely among
the immune systems.
Ideally, the longer the chemotherapy
Dr. Dong received could continue, the
more his immune system would be altered
to fight the cancer. However, it became
apparent to him that the likely reason the
standard duration is set at 3½ years is
because that is probably what a typical
patient could tolerate before the immunity
reactions become more intolerable than
the cancer. However, at the current level
of alteration, Dr. Dong prefers to put up
with current reactions than to have his
immune system return to how it was, thus
allowing the cancer an increased chance of
recurring.
Implant failure increases when the
implant procedure is timed near
or during chemotherapy
Bone formation takes place slowly to fill in
A chemotherapy patient’s experience with dental
implants
18 Implant
practice
Volume 7 Number 1
PATIENT INSIGHT
Dr. Bryan R. Krey and retired engineer Dr. Richard G. Dong join forces to facilitate implant placement during

cancer treatment
Figure 1: Radiograph prior to placement of tooth No. 19
implant
Richard G. Dong, PhD, was born and raised in
Sacramento, California. He earned his BS and MS
degrees in Mechanical Engineering at the University of
California in Berkeley, California. He worked for 2 years
at the Aerojet-General Corporation in Sacramento,
California. He returned to the Berkeley campus and
earned his PhD in Structural Mechanics. He then
worked at the Lawrence Livermore National Laboratory
in Livermore, California, as a research engineer and
as one of the technical reviewers for the laboratory’s
Nuclear Test Program. He retired in 1993. He lives in
Danville, California, where he and his wife raised two
children.
Bryan R. Krey, DMD, was born and raised in Brentwood,
California. He earned his dental degree at Oregon
Health and Science University in Portland, Oregon,
in 1993. He completed his Oral Surgery residency at
Highland Hospital in Oakland, California, and later
completed his board exams and is a Diplomate of the
American Board of Oral and Maxillofacial Surgery. He is
in private practice with offices in Berkeley and Orinda,
California. He lives in Lafayette, California, with his wife
and four children.
Figure 2: Radiograph with tooth No. 19 and tooth No. 30
implants in place. Prior to restoration. Ideal bone levels
20 Implant

practice
Volume 7 Number 1
PATIENT INSIGHT
the hole left from a tooth extraction. After 4
months, enough bone has usually formed
to enable the implant post to be installed.
But an X-ray would clearly indicate the
bone has not yet reached normal density.
Four months after that, the crown is usually
installed. An X-ray would indicate the bone
density is better but still not at normal
level. From an engineer’s perspective, the
bacteria could now begin accumulating at
the crown-implant junction. The surface
transitioning from the crown to the post
would not be perfectly smooth, as could
be seen on the implant removed from Dr.
Dong’s molar tooth No. 30 site. The crown
and post are minutely different in diameter
and roundness such that a tiny ridge and a
tiny shelf are formed there. Tiny gaps likely
also exist at various locations where the
crown mates with post. Such imperfections
are deeply located and somewhat hidden
since they are not easily reached during
brushing and flossing. Bacteria could
accumulate at these imperfections and
then migrate to where the post meets the
bone to initiate bone loss. Also, as pointed
out by Dr. Dong’s regular dentist, the

migration is intensified by the “pumping”
action during food chewing. There must
be reasons why bone loss occurs after
the crown is installed, and the factors
mentioned seemed logically to be why.
If bone density were less than normal,
the initiation of bone loss would be easier,
and continued bone loss would be
faster. In addition, if the patient’s immune
system’s ability to fight the bacteria were
weakened by chemotherapy, the entire
bone loss process would progress even
faster. Under this condition, the pocket
formed by bone loss could quickly grow
to where the bacteria would have many
corners and crevices in which to hide and
colonize. Once colonization occurs, the
bacteria would be more difficult to dislodge
and eliminate, bone loss might be slowed
with extraordinary care but not stopped,
and the implant would eventually fail.
Under normal circumstances, with the
patient’s immune system well able to fight
off the bacteria, bone loss could initiate but
would stabilize and essentially stop. The
implant would then be successful. An X-ray
could show a small amount of bone loss,
but that would be considered normal.
Dr. Dong’s experience with implants
appears to match the descriptions in the

preceding paragraphs. Four of his molars
at different times needed to be replaced
with implants, and chemotherapy affected
all four. The following are the timelines
relative to the beginning or ending of
chemotherapy.
Molar 19
• Implant post was installed 1.25 years
before chemotherapy began.
• Crown was installed 0.88 years before
chemotherapy began.
• While chemotherapy affected this
implant, the implant was saved by the
procedure developed by Dr. Dong.
Molar 30
• Implant post was installed 1.0 year
before chemotherapy began. Crown
was installed 0.63 years before
chemotherapy began.
• The implant failed due to effects of
chemotherapy, in spite of Dr. Dong and
Dr. Krey’s best efforts, and was removed
1.4 years after chemotherapy ended.
Thus, the implant lasted 5.53 years after
the crown was installed.
• The implant procedure is currently
being repeated. Implant post is not yet
installed.
Molar 18
• Molar 18 was extracted 1.06 years

after chemotherapy ended and about
0.06 years after the chemotherapy drug
completely left the body.
• Implant post was installed 1.4 years
after chemotherapy ended and about
0.4 years after the chemotherapy drug
completely left the body. Crown is not
yet installed.
Molar 31
• Molar 31 was extracted 1.7 years after
chemotherapy ended and about 0.7
years after the chemotherapy drug
completely left the body.
• Implant post is not yet installed.
• The fact that molar 31 went bad quickly
could indicate that Dr. Dong’s immune
system remains altered and was thus
unable to fight the bacteria adequately.
His urologist treating the cancer and
his primary care doctor indicated his
immune system is likely to remain
altered for the rest of this life, especially
since chemotherapy was done at his
somewhat advanced age of 70 years.
Dr. Dong had quite a few dental
problems even before he had cancer.
According to his dentist, he keeps his
teeth so clean; he should not have so
many problems. Consequently, it must be
in his genes. The need to replace molars

Figure 5: Radiograph showing loss of tooth No. 30 im-
plant, restored tooth No. 19 implant, and recently placed
tooth No. 18 implant. Tooth No. 18 implant features
internal abutment connection and platform switching
Figure 3A: Restored tooth No. 30 implant with
vertical bone loss
Figure 3B: Prior to tooth No. 19 implant being
restored.
Figure 4: Restored tooth No. 30 implant. 2011. Severe
bone loss.
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