Tạp chí implant tháng 11-12/2013 Vol 6 No6

The most
innovative
3D technology
available today…
Ask For It By Name
See the inside back cover to
learn more about why the
ProMax offers the ideal 3D
imaging solution for your practice.
PLANMECA
ProMax
®
3D
11413_planmecaCOVERbanner_implantpractice:Layout 1 11/5/13 9:16 AM Page 2
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clinical articles • management advice • practice proles • technology reviews
November/December 2013 – Vol 6 No 6
PROMOTING EXCELLENCE IN IMPLANTOLOGY
Hard tissues
Drs. William C. Martin,
Emma Lewis, and
Dean Morton
Practice profile
Dr. Yong-Han Koo
Corporate profile
Planmeca
Collagen plug
application in
extraction sockets

Drs. Jon B. Suzuki and
Diana Bronstein
Corporate insight
ZEST Anchors
Pride Institute
“Best of Class”
special awards tribute
WHEN THE OSTEOTOMY MUST BE NARROW -
SO MUST YOUR IMPLANT CHOICE
Choose the LOCATOR
®
Overdenture Implant System
It’s a fact – denture patients commonly have narrow ridges and will
require bone grafting before standard implants can be placed. Many
of these patients will decline grafting due to the additional treatment
time or cost. For these patients, the new narrow diameter LOCATOR
Overdenture Implant (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.
©2013 ZEST Anchors LLC. All rights reserved. ZEST

and LOCATOR

are registered
trademarks of ZEST IP Holdings, LLC.
2.5mm
2.4mm

4mm
2.9mm
included with each Implant
Discover the benefi ts that LODI can bring to your practice today
by visiting www.zestanchors.com/LODI/31 or calling
855.868.LODI (5634).
Cuff Heights
Diameters
Volume 6 Number 6 Implant
practice
1
November/December 2013 - Volume 6 Number 6
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
ASSISTANT EDITOR | Kay Harwell Fernández
Email: Tel: (386) 212-0413

EDITORIAL ASSISTANT | Mandi Gross
Email: Tel: (727) 393-3394

DIRECTOR OF SALES | Michelle Manning
Email: Tel: (480) 621-8955
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Drew Thornley
Email: Tel: (619) 459-9595
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Email: Tel: (623) 340-4373

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Tel: (480) 621-8955 Fax: (480) 629-4002
Toll-free: (866) 579-9496 Web: www.implantpracticeus.com
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© FMC 2013. All rights reserved.
FMC is part of the specialist
publishing group Springer
Science+Business Media.
The publisher’s written consent must be
obtained before any part of this publication may be reproduced in
any form whatsoever, including photocopies and information retrieval
systems. While every care has been taken in the preparation of this
magazine, the publisher cannot be held responsible for the accuracy
of the information printed herein, or in any consequence arising from
it. The views expressed herein are those of the author(s) and not
necessarily the opinion of either Implant Practice or the publisher.
C
one beam imaging is a relatively new technology, which has firmly established itself
in clinical dentistry since its introduction into the U.S. dental marketplace in 2001.
With cone beam imaging, the X-ray energy emitted from the device is divergent, forming
a cone-shaped beam. During a cone beam scan, more than 500 images are obtained
while the patient remains stationary, and the scanner rotates around the patient’s
head. The resulting images, which are interpreted by computer software, are three-
dimensional, and it is the third dimension that allows for a world of difference in dental
diagnosis and treatment planning. The three-dimensional images generated by a cone
beam scan can be manipulated by sophisticated computer software for a wide variety of
applications, including implant diagnosis and treatment planning, orthodontic diagnosis,
detailed evaluation of the temporomandibular joints, examination of the patient’s airway,
endodontic diagnosis, evaluation of impactions, and assessment of maxillary and
mandibular pathology, along with numerous other diagnostic purposes.
For both general practitioners and specialists, cone beam technology deserves serious
consideration for incorporation into everyday practice.
Reason No. 1: The standard in diagnosis and treatment planning has been raised.

With the availability of the third dimension in diagnosis, it quickly becomes apparent
that two-dimensional images present the clinician with severe limitations. Because of its
superior ability to view anatomical structures in their precise location with remarkable
detail, the bar has been raised significantly when it comes to dental diagnosis. For
example, when evaluating an impacted third molar, a two-dimensional film superimposes
all structures, and it is virtually impossible to distinguish exactly where any given tooth sits
anatomically in relation to its surrounding structures. The third dimension made available
by cone beam imaging allows the clinician to precisely plan a surgical approach that will
avoid damage to surrounding structures and facilitate a safe surgical outcome.
Reason No. 2: Implant treatment planning is driven by the prosthetic needs of the
patient.
Implant patients seek treatment because they are missing teeth, not because of a desire
for implants. In asking for implants, a patient’s true desire is to replace teeth that are
missing. Today in 2013, our patient expectations are high. They expect teeth that will
look good, feel good, allow them to eat comfortably, and which will be relatively free of
maintenance. This can only be accomplished when implant treatment is prosthetically
driven. The third dimension provided by cone beam imaging allows for a true
prosthetically driven implant placement.
Reason number 3: Significant savings in terms of cost and radiation exposure.
Prior to the availability of cone beam imaging in dentistry, dentists often referred out
their imaging needs to outpatient imaging centers or radiologists. These required the
patient to travel to a facility outside of the practice, with the financial cost of these images
being far greater than that of in-office cone beam images. The cost extends far beyond
dollars – a CAT scan image delivers far greater radiation to the patient than a typical cone
beam image. Technology available to dentists today, such as Planmeca’s ProMax
®
3D
technologies, allows for adjusting the size of the volume to suit the specific area that is
being studied.
INTRODUCTION

Three reasons why cone beam
imaging is good for your practice
Eugene Antenucci, DDS, is a general dentist who maintains a full-time private practice in
Huntington, New York. His state-of-the-art dental facility is also home to a continuing dental
education training center for dentists, as well as a commercial dental laboratory. His practice,
Huntington Bay Dental, was distinguished as “Dental Practice of the Month” by Dental Economics
in May 2003 and “Business of the Year” by the Huntington Chamber of Commerce for 2003.
Dr. Antenucci is a 1983 graduate of New York University College of Dentistry. He was awarded
his Fellowship in the Academy of General Dentistry in 1992, the American College of Dentists in
1999, and the International College of Dentists in 2005. Dr. Antenucci is a certified CEREC Basic and Advanced
Training Instructor, and has conducted training seminars throughout the United States. He lectures internationally,
conducting seminars in the clinical utilization of advanced technology in dentistry, as well as seminars in cosmetic
dentistry, practice management, CEREC, and laser training. Dr. Antenucci serves on the Board of Benefactors of
the Guide Dog Foundation and America’s Vet Dogs, and is also an active member of the National Italian American
Foundation, serving as the New York Area Coordinator for the organization. Dental equipment manufacturer
Planmeca USA has retained Dr. Antenucci as a spokesperson for its line of 3D imaging products and to advise the
company on marketing, advertising, and continuing-education efforts.
TABLE OF CONTENTS
Practice profile 6
Dr. Yong-Han Koo: Honesty, integrity, and precision
Dr. Koo strives to make a positive impact on his patients, colleagues, and staff.
Corporate profile 8
Planmeca
®
: innovative, upgradeable imaging technology
Planmeca, a leader in dental imaging, stays in the forefront of technology as
dentistry evolves.
2 Implant
practice
Volume 6 Number 6

Clinical
Collagen plug application in
extraction sockets
Drs. Jon B. Suzuki and Diana
Bronstein explore the efficacy of a
collagen plug-in ..........................14
Case study
Stem cell block grafts
Dr. Paul Petrungaro delves into
allogenic stem cell block grafts to
facilitate reconstruction of localized/
severe ridge defects and reconstruct
proper alveolar contours prior to
dental implant placement ...........22
Ideal tissue management when
immediate provisionalization is
not appropriate
Drs. Robert L. Holt and Bernard E.
Keough illustrate a specific type of
implant management .................26
Reflections on the Straumann
®

Tissue Level (TL) implant
Dr. Robert Margeas discusses a
predictable and easy-to-use implant
option ........................................28
Corporate insight 10
ZEST Anchors
Overdenture product innovations changing the lives of edentulous patients

worldwide

TABLE OF CONTENTS
4 Implant
practice
Volume 6 Number 6
Special section
Pride Institute “Best of Class”
special award tribute ................32
Continuing
education
Hard tissues
Drs. William C. Martin, Emma Lewis,
and Dean Morton examine adjacent
implant restorations ......................42
The root of the matter
Drs. Mike Lloyd Hughes and Graham
Stuart Roy look at the placement of
a first dental implant as part of an in-
house implant mentoring program
.....................................................46
Avoiding therapeutic failure
60
Step-by-step
Integrated implant technology
– GALILEOS CEREC Integration
(GCI) by Sirona

..........................50
Product insight

VELscope
®
.................................52
Product profile
Osstell ISQ .................................54
ACE Surgical – infinity Dental
Implant Systems ........................56
Dental technology gets a new look
with Henry Schein’s augmented
reality app ...................................58
Practice
management
Materials matter
Dr. Paul A. Fugazzotto offers advice
on avoiding therapeutic failure that
can affect the implant practice ......60
On the horizon
3D at 38,000 feet
Dr. Justin Moody reflects on the
benefits of cone beam 3D imaging
.....................................................62
Materials &
equipment
....................64
Discover
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In addition to ATLANTIS

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the ATLANTIS
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of standard and custom bars, bridges and hybrids allows for
fl exibility in supporting fi xed and removable dental prostheses.
For more information, including a complete implant
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What can you tell us about your
background?
I was born and raised in Seoul, South
Korea, and moved to the U.S. when I was
16. My father was an architect, and I had
always been fascinated with structures and
the engineering involved. I was exposed
to dentistry during my years in college at
Washington University in St. Louis and
decided that this was the field I wanted
to pursue. Dentistry has the perfect
combination that satisfies my curiosity in

structural foundation and engineering, as
well as the ability to make a positive impact
on others’ lives.
I proceeded to obtain my DDS from
Columbia University College of Dental
Medicine and my oral and maxillofacial
surgery residency training from Yale-New
Haven Hospital. After several years in an
oral surgery group practice, I opened my
solo practice in Wayland, Massachusetts.
Is your practice limited to
implants?
My practice is limited to oral and
maxillofacial surgery with emphasis on
3D-guided implantology.
Why did you decide to focus on
implantology?
The dramatic impact that implants have on
dental reconstruction and the individual’s
quality of life is astounding. We now have
options that we could not have imagined
years ago. It is an exciting, ever-evolving
field, and the importance of continuing
education to stay abreast of current
technology is crucial. I am passionate about
being innovative and seeking inspiration
from everyone I work with. I believe that
continuing education should be utilized to
improve the quality of life of not only the
patients, but also the clinicians and all the

staff involved.
To bring this vision into reality, I
launched my study club, the Academy
of 3D Connection in Osseo-Integration.
We had a successful, 2-day inaugural
meeting this past May in Boston. The main
purpose of the academy is for all of us to
appreciate the value of precision in dental
implantology utilizing 3D CBCT from the
diagnosis and treatment planning phase to
the final surgical and prosthetic execution
phase. Through the academy, we also offer
small-group, hands-on courses throughout
the year. Since I am also involved in clinical
studies through Harvard School of Dental
Medicine, my goal is to create a bridge
between academics and the community
clinicians, to bring in research results, and
actively apply them to everyday practice
that the clinicians can relate to.

How long have you been
practicing, and what systems do
you use?
I have been in practice since I finished my
residency in 2007. I have used multiple
systems over the years, and presently
my preferences are Nobel Biocare
®
and

Straumann
®
. I personally believe they have
the best 3D-guided systems currently on
the market.
What training have you
undertaken?
I am board certified through the American
Board of Oral and Maxillofacial Surgery. I
regularly attend meetings with AAOMS,
AO, and ITI, as well as numerous
advanced courses both domestically and
internationally.
I also teach through my academy,
and I am also clinical faculty for the implant
CE courses at Harvard School of Dental
Medicine. Teaching and lecturing opens up
avenues that I may not have been aware of,
and I always feel that I gain so much more
knowledge.
Who has inspired you?
By far, my late father and father-in-law.
My father owned his architectural/civil
engineering firm, and my father-in-law was
the head of a global Fortune 500 company.
Although neither one was in the healthcare
industry, I learned the importance of
honesty, integrity, precision, and the fact
that “people” are the biggest assets in
a business. They both put tremendous

emphasis on developing and supporting
staff members, which I also aspire to do
always. Patients come first, but our staff
members must be happy and fulfilled in
order to provide a great environment for
the patients.
I was also very fortunate to undergo
my oral and maxillofacial surgery training
under the tutelage of the incomparable Dr.
John P. Kelly.
I cannot forget my imaginary best
friend, Steve Jobs, who reminded us that
death renews the old, and our time on
earth is truly limited. It is our job to find the
Dr. Yong-Han Koo
6 Implant
practice
Volume 6 Number 6
PRACTICE PROFILE
Honesty, integrity, and precision
O.R. suite at Wayland Oral Surgery
PRACTICE PROFILE
Volume 6 Number 6 Implant
practice
7
unique talent that God has instilled in each
and every one of us and to utilize it for the
greater good.
What is the most satisfying aspect
of your practice?

The feedback we receive from our patients.
For instance, we received a letter from the
mother of a 4-year-old-boy who told his
classmates that he wants “to be like Dr.
Koo” so he can help people; we were also
told by a Stage IV cancer patient’s wife that
we provided “much more than oral surgery”
for her husband and her family. These
are reminders that we are all part of each
others’ lives and that we have a chance to
inspire people through our profession.
Professionally, what are you most
proud of?
Connections and relationships we have
built over the years with clinicians, staff,
corporate partners, and patients. With
synergy and collaboration, we can make a
significant difference.
What do you think is unique about
your practice?
We make a point to fully engage our
patients, educate them on the technology
available, and allow them to become active
participants in their treatment planning
process. This enables them to grasp
realistic expectations of their treatment,
whether good or bad, prior to committing
to any procedures.
Our practice was recently chosen as
one of the five beta centers for the new

Sirona Galileos
®
Cone Beam CT scan with
face scanner. Sirona/SiCAT has a great
3D-guided system and technical support
team, which have allowed us to incorporate
unparalleled precision into not only implant
placement, but to the pre-prosthetic
surgical stage as well. We also have the
beta version of the NobelClinician
™
. I am
also one of the key opinion leaders for
Sirona, Nobel Biocare
®
, and Straumann
®
.
These opportunities allow us to be on the
cutting edge of new technology and to be
constantly involved in its development.
What has been your biggest
challenge?
Time management!!
What would you have become if
you had not become a dentist?
Professional golfer. Not that I am saying
that I would have definitely made it, but I
certainly would have tried my very best to
become one!

What is the future of implants and
dentistry?
True digital integration from start to finish.
What are your top tips for main-
taining a successful practice?
Honesty, integrity, and professionalism,
in that order. I believe everything else will
follow as long as we do not lose sight of
these qualities. Also, to continue to inspire
my staff to make a difference together as
a team.
What advice would you give to
budding implantologists?
“You can’t treat what you can’t see.”
Therefore, having the best diagnostic
tools, as well as the ability to execute
your plan accordingly with precision, is
paramount. Always listen to your patients,
and do not initiate treatment until they
have a good understanding of the process
involved. Assemble an outstanding team
of professionals who are truly committed
to excellence in patient care. Last but not
least, as cliché as this sounds, treat all your
patients as though they are your family
members and present the most optimal
plan.
What are your hobbies, and what
do you do in your spare time?
I love to travel with my family. I am an avid

golfer and also enjoy skiing during the long
winters in the Northeast.
The staff at Wayland Oral Surgery Reception Area (above)
Dr. Koo at the Academy of 3D Connection in Osseo-
Integration meeting (below)
Top Ten Favorites
1. God
2. Family and friends
3. Patients and staff
4. Golf
5. Starbucks
6. Traveling
7. Reviewing and learning from
past complications
8. Ketorolac
9. Galileos with face scanner
10. Kimchi and sushi
IP
Company history
Planmeca is the world’s largest privately
held dental imaging company and one of
the industry’s leading manufacturers of
panoramic and cephalometric X-rays. Over
the past four decades, it has expanded its
sales network in more than 100 countries
worldwide. Planmeca’s imaging units
offer superior image quality, reduced
radiation during routine procedures, easy
upgradeabililty, and advanced, user-
friendly imaging software. Planmeca

has been a leader in digital imaging and
advanced computer-integrated dental
care concepts for years and remains in
the forefront of technology as the field of
dentistry evolves.
Since the company’s establishment,
Planmeca’s developers have worked
closely with dentists and leading universities
to anticipate future trends, using the data
to design an advanced line of high-tech
products. From the introduction of the
first microprocessor-controlled chair, to
the development of the ProMax
™
line of
imaging units with SCARA (Selectively
Compliant Articulated Robotic Arm)
technology, Planmeca has always led the
way with new technology. The company’s
goal is to supply dental professionals with
the highest quality dental equipment that
is uniquely designed for today’s modern,
technologically advanced practice.
Patented SCARA technology
What truly sets Planmeca apart from the
competition is the company’s patented,
exclusive SCARA technology. This robotic
arm, which comes standard on all ProMax
units, enables free geometry based on
image formation and can produce any

movement pattern required. The precise,
free-flowing arm movements allow for
a wide variety of imaging programs not
possible with any other X-ray unit on the
market; this allows the dental professional
to take images based on diagnostic needs,
not machine limitations.
Anatomically accurate extraoral
bitewing program
Planmeca’s ProMax S3, 3D, and 3D
Mid imaging units offer an exclusive
extraoral bitewing program, possible
only with SCARA technology. This
innovative program consistently opens
interproximal contacts, eliminates patient
positioning errors, and is more diagnostic
than other intraoral modalities. ProMax
extraoral bitewings are ideal for a number
of patients, from the elderly and those
requiring periodontal work to those with
claustrophobia, sensitive gag reflexes, or
those in pain. All of this comes in a true
bitewing program that enhances clinical
efficiency and takes less time and effort
than a conventional intraoral bitewing.
Upgradeable innovation
One of Planmeca’s greatest contributions
to dental imaging is its innovative,
upgradeable product platform — all based
on exclusive, patented SCARA technology.

Since it’s software-driven, SCARA
technology enables limitless possibilities
to upgrade existing equipment, allowing
the new dentist on a smaller budget to
grow while making only appropriate and
necessary equipment investments. For
example, Planmeca products can be
upgraded from a 2D panoramic X-ray to a
combination of pan/ceph capabilities, which
can be further upgraded to accommodate
3D imaging needs. Whether it is the
transformation of a film to a 3D unit, or the
addition of a cephalometric arm, Planmeca
offers solutions for every upgrade need.
This single piece of technology makes the
ProMax the most versatile all-in-one X-ray
unit available on the market.
Reduced radiation for safer
procedures
All Planmeca products are designed around
the ALARA radiation principle (As Low As
Reasonably Achievable). Through specially
designed programs, such as horizontal
and vertical segmenting, autofocus, and
pediatric pans, dental professionals are
able to provide their patients with excellent
care without compromising their safety.
Horizontal and vertical segmenting
options limit the exposure to diagnostic
areas of interest. By selecting these

options, patient dosage can be reduced by
up to 93%, which is highly advantageous
when follow-up images are needed.
Autofocus automatically positions the
focal layer using a low-dose scout image
of the patient’s central incisors, and uses
landmarks within the patient’s anatomy
to calculate placement. The result is a
fast, diagnostic pan every time, which
drastically reduces retakes caused by false
positioning.
Pediatric programs further lower the
dose by automatically selecting the narrow
focal layer of young patients, adjusting
the collimator, and reducing the area of
exposure from the top and the sides.
This reduces the dosage area while still
providing full diagnostic information.
Digital Perfection™: the new
standard
Building on the well-established all-in-one
idea of integration, Planmeca introduced
the Digital Perfection concept in 2011.
Seamless integration of dental equipment
and software creates efficient diagnostic
tools, optimized workflow, and advanced
infection control methods that result in a
treatment environment where all equipment
shares an open interface.
The company works worldwide with

all aspects of the dental industry, including
dental schools, dentists, and dental team
members, as well as dealers, and uses
the latest technologies to create the best
products for dental offices and patients
alike. As a forerunner in digital imaging
technology, Planmeca delivers complete
dental solutions based on integrated high-
tech device and software options with
exquisite design.
For more information, visit
www.planmecausa.com
This information was provided by
Planmeca.
Planmeca
®
: innovative, upgradeable imaging technology
8 Implant
practice
Volume 6 Number 6
CORPORATE PROFILE
“The company’s goal is to
supply dental professionals
with the highest quality
dental equipment that is
uniquely designed for today’s
modern, technologically
advanced practice.”
IP

L
ocated in Southern California, ZEST
Anchors is a global leader in the
manufacturing and distribution of innovative
technologies developed specifically for
overdenture treatment. Its impressive
41-year history of producing innovative
products for overdenture patients has been
driven by the philosophy of placing patient
satisfaction above all else. This philosophy
led to the creation of the original ZEST
Anchor Attachment developed in 1972 by
Max Zuest at his dental laboratory in San
Diego, California. Following in his footsteps
was Max’s son Paul Zuest who had the
same vision and passion for bettering the
lives of patients worldwide. This vision
led to the development of the industry’s
first self-aligning attachment, combating
the improper seating of overdentures. In
2001, Paul Zuest and Scott Mullaly, then
Chief Operating Officer for ZEST Anchors,
developed the patented LOCATOR
®

Attachment. A third generation attachment,
LOCATOR, has achieved worldwide
acceptance as the premier overdenture
attachment in the dental industry and is
currently interface compatible with more

than 350 implant products, making it
compatible with nearly all implant designs.
ZEST Anchors is the only manufacturer
of LOCATOR. ZEST sells the LOCATOR
Attachment directly in the U.S., and
it is distributed through OEM implant
companies and distributor networks
worldwide in more than 45 countries.
These genuine LOCATOR Attachments are
designed with the primary benefits of ease
of insertion and removal, customizable
levels of retention, low vertical profile,
and exceptional durability. Its most critical
design feature is its innovative ability to
pivot, which cannot be replicated due
to its patented technology. The pivoting
technology increases LOCATOR’s
resiliency and tolerance for the high
mastication forces an attachment must
withstand and allows it to compensate for
the path of insertion even with up to 40
degrees of divergence between implants.
During seating, while the LOCATOR
male pivots inside the denture cap, the
system’s self-aligning design centers
the male on the attachment before
engagement. These two actions in concert
allow the LOCATOR to self-align into
place, enabling patients to easily seat their
overdenture without the need for accurate

alignment and without causing damage
to the attachment components. This self-
aligning feature also increases the durability
of the LOCATOR Attachment. Once seated,
the male remains in static contact with the
attachment while the denture cap, which
is processed into the overdenture, has a
full range of rotational movement over the
male for a genuine resilient connection of
the prosthesis without any loss of retention.
The introduction and ultimately the
success of LOCATOR have allowed
millions of patients to realize the benefits
of implant-retained overdentures. ZEST
Anchors continually receives feedback
ZEST Anchors
10 Implant
practice
Volume 6 Number 6
CORPORATE INSIGHT
Overdenture product innovations changing the lives of edentulous patients worldwide
from clinicians about what a great product
LOCATOR is, and how it has changed their
patients’ lives. Being a leader in this product
category, clinicians contact ZEST to provide
input about new solutions needed for this
niche group of patients. Collaborating with
these clinicians allows the company to
identify new key market opportunities within
the overdenture category. Recent market

research demonstrated that the implant-
retained overdenture demographic is
projected to grow substantially throughout
the next 20 years and indicated that narrow
(less than 3 mm) diameter implants will play
an increased role in retaining overdentures.
Even today, this type of technology is being
used to retain about a third of all implant-
retained overdentures. The LOCATOR
Attachment, while made for nearly all
“We are now celebrating
a year since the system
commercially launched.
It is clear that the LODI
System surpasses what
was available on the market
previously, as well as our
own sales projections… this
is no temporary implant.”
— Steve Schiess,
ZEST Anchors CEO
• Optimize your image quality and dosimetry
• Make accurate assessments, diagnoses and treatments
• Experience seamless integration
• One system for superior 3D exams, 2D panoramic scans and
optional one-shot cephalometrics

To learn more about what a great image can do for your practice,
visit carestreamdental.com/3DIP or call 800.944.6365 today.
© Carestream Health, Inc., 2013 9438 DE AD 0713

The CS 9000 3D and CS 9300 Select are
ready to work hard for your practice.

These technologically advanced systems will finally give you clarity, flexibility
and, most importantly, complete control of your image quality and dosimetry.
It will also show your patients how dedicated you are to their dental health.
It’s amazing what a great image can
do for your practice.
8682_General_3D_Ad_Chosen.indd 1 7/16/13 3:24 PM
implant systems, at the time, was not
available for the narrow diameter implant
segment. Recognizing this and the desire
to continue developing innovative products
specifically for overdenture patients led to
ZEST Anchors’ latest product innovation,
a next generation narrow diameter implant
system — The LOCATOR Overdenture
Implant (LODI) System. Utilizing years of
collective knowledge in the dental implant
market while focusing on all of the features
that were lacking in current designs, such
as o-ball mini implants, allowed for the
creation of an enhanced narrow diameter
implant system designed exclusively for
overdenture patients. “With LODI, we
were able to listen to, and benefit from,
the valuable information of Key Opinion
Leaders about other mini implant systems
on the market,” says Steve Schiess, ZEST
Anchors CEO. “What we found was that

the mini implants on the market had little to
no innovation throughout the last decade.
This allowed us to design LODI, addressing
the most sought after improvements.
We are now celebrating a year since the
system commercially launched. It is clear
that the LODI System surpasses what was
available on the market previously, as well
as our own sales projections…this is no
temporary implant.”
The implant
The implant is manufactured using the
strongest titanium available and has a
proven RBM surface. The implant body is
tapered and includes self-tapping, cutting
edges for easy insertion. The thread design
on LODI is unique in the narrow diameter
implant market; the threads are aggressive
in pitch and gradually widen to the coronal
thread terminus to provide increased
primary stability.
The LOCATOR Attachment
The LOCATOR Attachment is detachable
for simple replacement if tissue height
changes or if wear occurs throughout
time. It is also the same familiar design
that clinicians have used for years, offering
dramatically lower attachment height
necessary for denture strength and patient
comfort when the denture is removed.

Since the LOCATOR Attachment for LODI
is identical to that of a LOCATOR used for
standard-sized implants, the LOCATOR
Overdenture Implant can also be used
alongside standard-sized implants on the
same case.
The surgical instrumentation
The surgical instrumentation includes easily
identifiable laser-etched depth markings
and drill stops, as well as a simple
procedure making osteotomy preparation
intuitive and safe while offering the less
invasive option of a flapless surgery or the
option to create a flap.

Answering the needs of patients
All of these features combine to answer
the market need for an implant system
designed specifically for patients requiring
a cost-effective, predictable, and long-term
implant-retained overdenture option.
The success of LOCATOR and now
LODI has propelled a small business
into a leading manufacturer and global
distributor of dental solutions for the
treatment of edentulous patients. In 2010,
Paul Zuest retired from ZEST, passing
the leadership role to Steve Schiess who
maintains the position of CEO of ZEST
Anchors. The company now has more

than 120 employees with more than 70
years of experience on its leadership
team, consisting of Steve Schiess CEO,
Tait Robb replacing Scott Mullaly as COO,
Matt Powell who is directing all marketing
activities and Chris Gervais who directs
engineering. The company was recently
acquired by Avista Capital Partners,
a leading private equity firm with vast
expertise and an impressive track record
in the healthcare space. Partnering with
Avista Capital allows ZEST Anchors to
continue to improve the lives of edentulous
patients with the company’s existing
product portfolio as well as expanding
into exciting new products focused on
overdenture treatment options.
With this laser-sharp focus, clinicians
can be assured that ZEST Anchors will
continue to define the overdenture market
by introducing new products designed to
provide clinicians with new opportunities
to increase practice revenues and fill the
gaps in overdenture treatment available to
patients today.
For more information, please call
1-800-262-2310 or visit www.zestanchors.
com.
This information was provided by Zest
Anchors.

IP
12 Implant
practice
Volume 6 Number 6
CORPORATE INSIGHT
The LOCATOR
Overdenture Implant
(LODI) System
incorporates key features
not found with other small
diameter implant systems.

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Dr. George Duello
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Dr. Avi Schetritt
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Dr. Robert J. Miller
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
Dr. Mitra Sadrameli


Dr. Bach Le

Dr. Giles Horrocks
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
Dr. Michael S. Block

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Dr. Sascha Jovanovic
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MEISINGER USA, L.L.C.
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

Introduction

Post-extraction healing is characterized
by osseous resorption and significant
contour changes in buccal-lingual and
apico-coronal width of the residual
alveolar ridge.
1
Research suggests that
an extraction socket augmentation carried
out at the time of tooth removal is a
reliable and predictable method to reduce
significantly crestal bone resorption and
atrophy, aid socket fill, and minimize loss
of horizontal ridge height. Ultimately, it
helps patient and practitioner to reduce
or eliminate the need for further costly and
traumatic ridge defect augmentation at the
time of esthetic rehabilitation or implant
placement.
1
Clinicians today are aware
that sufficient alveolar bone volume and
favorable architecture of the alveolar ridge
are essential to achieve ideal functional and
esthetic prosthetic reconstruction.
Ridge preservation procedures
that are carried out immediately after
extractions significantly reduce the three-
dimensional alveolar bone loss that
inevitably follows tooth extraction alone.
.2

Patients undergoing this procedure benefit
from a ridge form that allows for better
esthetics, contour of fixed or removable
prosthesis, and implant placement.
1

This article will discuss the efficacy of
a collagen plug-in, preserving alveolar ridge
dimensions in immediate extraction sites
and present the data from the literature
that involves flapless ridge preservation
procedures with the use of specially heat-
treated collagen plugs for occlusion of the
extraction socket.
3
Traditional methods of tooth
extraction often result, at the least, in loss
of the labial plate of the alveolar bone.
Atraumatic extraction focuses on gently
severing the periodontal ligament using
micro instrumentation, e.g., periotomes,
intending to preserve alveolar crestal height
in all three dimensions.
1
Already before
1970, the first attempt for the reasonable
studying and the prevention of the ridge
resorption phenomenon had started.
4

The
submerged root concept was introduced
as a ridge preservation technique.
7,13

The trauma of the extraction brings
a cascade of cellular events to fill the
socket with bone. Grafting at the same
time takes advantage of this phenomenon.
Contemporary socket preservation
techniques involve the placement of
different biomaterials into the socket.
5,8

Dr. B.K. Bartee proposed a classification
of application techniques depending on
the purpose of the ridge preservation. This
classification is based on the resorbability
pattern of the bone graft, and three
categories were identified as follows.
37
As far as primary wound closure is
concerned, soft tissue coverage of the
graft with or without membrane, sealing
of the socket with a free gingival graft, or
a connective tissue graft, and placement
of a collagen plug for socket occlusion
have all been proposed.
14,15,36,38
Barrier

membranes as used for GBR have
been employed, showing good results
in ridge preservation.
17,18,19
The need
for primary soft tissue closure presents
the main drawback associated with this
technique.
3
It requires significant coronal
flap advancement causing coronal
displacement of the mucogingival junction
and of the keratinized gingiva toward the
crest, and increases postoperative swelling
and discomfort due to periosteal scoring
and/or relieve incisions.
20
Furthermore,
if membrane exposure occurs, risk for
infection of the graft increases, and the
outcome of the preservation procedure
becomes less predictable,
21
even though
one study by Nam and Park in 2009
11
showed that membrane exposure during
the healing period did not affect the efficacy
of ridge preservation procedures.
In full-thickness buccal and palatal/

lingual mucoperiosteal flaps, which are
raised to facilitate barrier membrane
placement over sound alveolar bone,
Collagen plug application in extraction sockets
14 Implant
practice
Volume 6 Number 6
CLINICAL
Drs. Jon B. Suzuki and Diana Bronstein explore the efficacy of a collagen plug-in
Jon B. Suzuki DDS, PhD, MBA, is a Professor at Temple
University, Kornberg School of Dentistry, Graduate
Periodontology and Oral Implantology Department,
Philadelphia, Pennsylvania.
Diana Bronstein DDS, MS, is a Professor at Nova
Southeastern University, College of Dental Medicine,
Department of Periodontology, Ft. Lauderdale, Florida.
Technique Rationale
Long-term ridge
preservation
• pontic site development or to improve the stability of removable appliances
• non-resorbable materials are used for this indication and
• not favorable for implant placement
Medium-term or
transitional ridge
preservation
• slowly resorbable bone grafts used in ridge preservation allow for the preservation
of the alveolar ridge for an extended period of time, enabling the placement of
an osseointegrated implant in the site after the initial healing period, even in the
presence of some unresorbed graft particles
• indicated in cases where it is still undetermined whether the patient is going to

restore the edentulism with an implant, or in cases where the patient has chosen
to have an implant placed, but will be unable to return and place the implant for a
substantial amount of time
3
Short-term ridge
preservation
• objective is to maintain the post-extraction alveolar dimensions during the initial
healing phase in order to allow for the placement of an implant in the shortest
possible time period
3
Modified from B.K. Bartee
37
CLINICAL
Volume 6 Number 6 Implant
practice
15
the vascular innervation via the bone-
periosteum continuity is disrupted, and a
marginal bone resorption of approximately
1 mm should be anticipated.
6
Based on this, for predictable post-
extraction ridge preservation, flapless
techniques should be favored. Reflecting
a flap may initiate further bone resorption
due to disruption in the blood supply to the
cortical bone under the periosteum. Further
ridge atrophy would occur additional to
the natural bundle bone resorption of the
alveolar post-extraction healing socket.

1
The “socket seal surgery” technique, a
ridge preservation technique that does not
require flap advancement, was introduced
to counter these procedure-inherent
drawbacks.
22
This minimally invasive ridge
preservation procedure involves bone
and soft tissue grafting. The extraction
socket is filled with bone graft, and then an
autogenous soft tissue graft of adequate
size is harvested from the palate and is
placed over the bone graft in order to seal
the socket.
23
Even though the “socket
seal surgery” technique was innovative in
introducing a ridge preservation procedure
that would not require advancement of
mucoperiosteal flaps for primary wound
closure, it still did not minimize the
postoperative discomfort due to the graft
harvesting at the donor site.
3
Recent work
by Araujo and Lindhe
37
in a dog model
showed using a subepithelial connective

tissue graft taken by a window or envelope
procedure from the palate may increase
soft tissue coverage, but this did not result
in increased bone fill.
3
Then, the Bio-Col technique was
introduced shortly afterwards, using
the same principles as the “socket seal
surgery,” but specifically using anorganic
slow-resorbing bovine bone particulates as
a socket graft and replacing the soft tissue
graft with the use of a collagen plug to
occlude the wound.
24
This new technique
reduced postoperative morbidity, as
there was no need for flap elevation or
graft harvesting.
3
After the introduction
of this concept, many modifications were
proposed in the literature, differing either in
the graft that was used (Alloplug technique,
Nu-mem technique) or in the placement
of the collagen plug (modified Bio-Col
technique ).
25-27
Because of the configuration of the
extraction socket, the majority of bone graft
may be lost if no protection is provided.

1

Therefore, the use of collagen wound-
dressing material was suggested, not only
to protect the graft material, but also to
induce blood clot formation and stabilize
the wound.
8
A collagen dressing material
is preferable due to its high biocompatibility
and hemostatic ability that can enhance
platelet aggregation, and thus, facilitate
clot formation and wound stabilization.
9

Collagen also has a high chemotactic
function for fibroblasts. This might promote
cell migration and accelerate primary
wound coverage.
10
Variations of the “socket-plug”
technique have been also used for more
than a decade to help minimize the amount
of bone loss and ensure the esthetics of the
future restoration.
24
One contraindication to
the application of this technique is severe
buccal plate dehiscence.
3

In such cases,
a barrier membrane should be employed
in order to contain the graft and exclude
the soft tissue from invading the buccal
space.
39
The cases presented will illustrate the
basic steps used in this technique:
3
•Atraumatictoothextraction
•Preservation of soft tissue architecture
with the flapless technique
•Placementoftheappropriatebiomaterials
in the extraction site
•Collagenplugstabilization
Case 1
Dr. Yueh Hsiao, Temple University
Fractured No. 19 was extracted
atraumatically, and ridge preservation with
Foundation
®
Bone Filling Augmentation
Material was performed for future implant
placement.
Figure 1 depicts preserved socket
after careful extraction of tooth No.19 with
intact buccal plate and interdental septum.
Figures 2 and 3 depict J. Morita’s
Foundation
®

.
31
It is a bone-filling
augmentation material indicated for
use after extractions, providing support
for implants, bridges, and dentures.
According to the manufacturer, the bovine-
collagen-based material is formulated to
stimulate growth of the patient’s own bone
at an accelerated rate while minimizing
antigenicity. Foundation
®
comes in two
sizes of solid bullet-shaped plugs, designed
for easy handling and placement in the
extraction socket. If desired, the plugs can
Figure 1 Figure 2 Figure 3
Figure 4
Figure 5
Figure 6
16 Implant
practice
Volume 6 Number 6
CLINICAL
be trimmed or shaped for a better fit. It is
radiolucent and resorbable.

31
The Foundation bullet-shaped plugs
come in two sizes — small (8 mm x 25 mm)

and medium (15 mm x 25 mm) — and are
individually packaged in sterile containers.
Figure 4 depicts the Foundation
collagen plug placed in extraction socket
and held by non-resorbable sutures.
Immediately after extraction and socket
curettage, forceps are used to place the
Foundation plug on a 2 x 2 gauze pad
before insertion into the extraction socket.
There is no need to remove the product
once it’s placed, and no membrane is
required. The plugs can be shaped to
mimic the root tip when needed. After
placement, the Foundation plug is gently
condensed into the socket.
Figure 5 depicts 1 week post-op
healing after suture removal with ridge
maintaining width and height.
31
According
to the manufacturer, implants may be
placed as soon as 8 to 12 weeks after
Foundation is placed in the extraction
socket.
Case 2
Dr. Masa Suzuki, Suzuki Dental Clinic,
Japan
Figure 6 depicts ridge preservation
with Foundation
®

immediately following
extraction of tooth No. 8 and socket
debridement. Figure 7 depicts excellent
healing after several weeks with keratinized
tissue buccal and no loss of vestibulum.
Alveolar ridge height and width appear
adequate for prosthetic restoration.
Case 3
Dr. Masa Suzuki, Suzuki Dental Clinic,
Japan
Case 3 pertains to teeth Nos. 17, 18, 20,
and 21 due to secondary occlusal trauma
in a bruxing patient with past periodontal
disease. After the atraumatic extraction,
granulomatous tissue was curetted out,
and bone surface was exposed. Two
pieces of S size and two pieces of SS size
Foundation were placed in the sockets
and sutured. In the lower right, GBR was
performed to increase ridge width, and
implants were placed 6 weeks after the
extractions on the left side. Ten weeks after
the extraction, the lower left side filled with
Foundation was restored with implants,
which were immediately loaded by a
provisional prosthesis. Four months later,
the final prosthesis was inserted.
Figure 8 depicts patient panoramic
radiograph 2 weeks after the extractions
and the placement of Foundation into the

extraction sockets of the posterior lower
left teeth.
Figures 9 and 10 depict patient
panoramic radiograph 6 and 10 weeks
after the post-extraction ridge preservation
procedure in the posterior lower left.
Implants were also placed lower right.
Figure 11 depicts patient panoramic
radiograph 4 months after implant
placement with definitive restoration in
place.
Figure 12 depicts patient 4 months
after implant placement, and Figure 13
shows definitive restoration in place.
Figure 7 Figure 8 Figure 9
Figure 10 Figure 11 Figure 12
Figure 13 Figure 14 Figure 15
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Case 4
Dr. Arthur Greenspoon, Montreal,
Quebec, Canada
Figure 14 depicts pre-extraction PA of
tooth No. 13 after failed endodontic
treatment and apicoectomy, post and core
in place with defective restoration.
Figure 15 depicts immediate post-
extraction PA of tooth No. 13
Figure 16 depicts placement of
Foundation after the extraction of No. 13
and future implant planning.
Figures 16 and 17 depict grafted
extraction socket at 4 weeks and 8 weeks
Figure 18 depicts implant in place
at about 3 months after extraction and
grafting with slight mesial angulation of the

coronal part to improve prosthetic access
and engage more of the native bone
apically.
Case 5
Dr. Arthur Greenspoon, Montreal,
Quebec, Canada
Figure 19 depicts tooth No. 19 with sinus
tract and radiolucent J-form lesion apically
with inflammatory resorption, possibly
mesial root fracture
Figure 20 depicts tooth No.19
after root amputation and placement of
Foundation into the mesial root socket
Figure 21 depicts tooth No. 19 post-
op radiograph after definitive restoration
and splint to adjacent premolar with PFM
Not many studies have documented
the histology of extraction-socket healing
in human subjects, and most research
involving extraction-socket healing has
been performed on animals, which
regenerate oral tissues much faster
and more completely than humans.
38

Accordingly, studies of extraction-socket
healing in animals cannot be equated to
human extraction-socket healing.
Amler, et al.
41

found that the blood
clot filling the socket after extraction was
replaced with granulation tissue after 7
days. After 20 days, the granulation tissue
was replaced by collagen, and bone began
forming at the base and the periphery of
the extraction socket and at 5 weeks, two-
thirds of the extraction socket had filled with
bone.
38
Epithelium was found to require a
minimum of 24 days to completely cover
the extraction socket, with some extraction
sites requiring up to 35 days to completely
cover the socket.
41
The epithelium was
found to grow progressively, enveloping
islands of granulation tissue, debris, and
bone splinters.
38
Amler noted that all stages
of bone regeneration progressed from the
apex and periphery, and proceeded finally
to the center and crest of the extraction
socket.
Boyne found new bone formation
after extraction only after 8 days under the
socket wall but not on the surface of the
bone lining the extraction socket.

42
After
10 days, bone formation was occurred on
the surface of the socket wall, and after
12 days, new bone formation continued
along the socket wall and in the trabecular
spaces surrounding the extraction site.
42

In their histological samples, Devon
and Sloan noted woven bone trabecula
at the periphery of the socket 2 weeks
after extraction. Osteoprogenitor
cells, preosteoblasts, and osteoblasts
surrounded the trabecula. The periodontal
ligament was displaced to the center of the
extraction socket and not attached to the
socket wall.
40
These findings indicate that, in
humans, the first phase of extraction-
socket healing is most likely osteoclastic
undermining and rejection of the original
socket wall into the healing socket.
38

While it is generally assumed that
after extraction bone lining the socket wall
is stimulated into new bone growth, this
contention is at odds with what is known

about how bone responds to trauma and
surgical exposure.
38
During gingival flap
surgery, raising the soft tissue off the bone
will result in resorption of bone from the
bone surface.
6,43
Usualy after extraction the
buccal plate is significantly resorbed, and
the bony socket wall is exposed to bacterial
colonization, while the body attempts to
form a fibrin clot.
41,44-46
Inflammatory cells trying to prevent
infection infiltrate the fibrin clot. As seen in
Figure 16 Figure 17 Figure 18
Figure 19 Figure 20 Figure 21
18 Implant
practice
Volume 6 Number 6
CLINICAL

20 Implant
practice
Volume 6 Number 6
CLINICAL
REFERENCES
1. Gupta D, Gundannavar G, Chinni DD, Alampalli RV. Ridge
preservation done immediately following extraction using bovine

bone graft, collagen plug and collagen membrane. Int J Oral
Implantol Clin Res. 2012;3(1):8-16.
2. Luczyszyn SM, Papalexiou V, Novaes AB Jr, Grisi MF, Souza
SL, Taba M Jr. Acellular dermal matrix and hydroxyapatite in
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Dent. 2005;14(2):176-184.
3. Kotsakis G, Markou N, Chrepa V, Krompa V, Kotsakis A.
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4. Atwood DA. Postextraction changes in the adult mandible as
illustrated by microradiographs of midsagittal sections and serial
cephalometric roentgenograms. J Prosthet Dent. 1963;13(5):810-
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5. Ten Heggeler JM, Slot DE, Van der Weijden GA. Effect of
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molar regions in humans: a systematic review. Clin Oral
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6. Moghaddas H, Stahl SS. Alveolar bone remodeling following
osseous surgery. A clinical study. J Periodontol. 1980;51(7):376-
381.
7. Casey DM, Lauciello FR. A review of the submerged-root
concept. J Prosthet Dent. 1980;43(2):128-132.
8. Wang HL, Kiyonobu K, Neiva RF. Socket augmentation:
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Boca Raton, Florida: CRC Press; 1985:27.
10. Postlethwaite AE, Seyer JM, Kang AH. Chemotactic attraction
of human fibroblasts to type I, II, and III collagens and collagen-
derived peptides. Proc Natl Acad Sci U S A. 1978;75(2):871-875.

11. Nam HW, Park YJ, Koo KT, Kim TI, Seol YJ, Lee YM, Gu Y,
Rhyu IC, Chung CP. The influence of membrane exposure on
post-extraction dimensional change following ridge preservation
technique. J Korean Acad Periodontol. 2009;39(3):367-374.
12. Atwood DA, Coy WA. Clinical, cephalometric, and
densitometric study of reduction of residual ridges. J Prosthet
Dent. 1971;26(3):280-295.
13. von Wowern N, Winther S. Submergence of roots for alveolar
ridge preservation. A failure (4-year follow-up study). Int J Oral
Surg. 1981;10(4):247-250.
14. Landsberg CJ. Socket seal surgery combined with
immediate implant placement: a novel approach for single-tooth
replacement. Int J Periodontics Restorative Dent. 1997;17(2):140-
149.
15. Tal H. Autogenous masticatory mucosal grafts in extraction
socket seal procedures: a comparison between sockets grafted
with demineralized freeze-dried bone and deproteinized bovine
bone mineral. Clin Oral Implants Res. 1999;10(4):289-296.
16. Juodzbalys G, Sakavicius D, Wang HL. Classification of
extraction sockets based upon soft and hard tissue components.
J Periodontol. 2008;79(3):413-424.
17. Lekovic V, Camargo PM, Klokkevold PR, Weinlaender M,
Kenney EB, Dimitrijevic B, Nedic M. Preservation of alveolar bone
in extraction sockets using bioabsorbable membranes. J
Periodontol. 1998;69(9):1044-1049.
18. Mardas N, D’Aiuto F, Mezzomo L, Arzoumanidi M, Donos N.
Radiographic alveolar bone changes following ridge preservation
with two different biomaterials. Clin Oral Implants Res.
2011;22(4):416-423.
19. Carmagnola D, Adriaens P, Berglundh T. Healing of human

extraction sockets filled with Bio-Oss. Clin Oral Implants Res.
2003;14(2):137-143.
20. Engler-Hamm D, Cheung WS, Yen A, Stark PC, Griffin
T. Ridge preservation using a composite bone graft and
a bioabsorbable membrane with and without primary
wound closure: A comparative clinical trial. J Periodontol.
2011;82(3):377-387.
21. Verardi S, Simion M. Management of the exposure of e-PTFE
membranes in guided bone regeneration. Pract Proced Aesthet
Dent. 2007;19(2):111-117.
22. Landsberg CJ, Bichacho N. A modified surgical/prosthetic
approach for optimal single implant supported crown. Part I-- The
socket seal surgery. Pract Periodontics Aesthet Dent.
1994;6(2):11-17, 19.
23. Landsberg CJ. Implementing socket seal surgery as a socket
preservation technique for pontic site development: surgical steps
revisited—a report of two cases. J Periodontol.
2008;79(5):945-954.
24. Sclar AG. Preserving alveolar ridge anatomy following tooth
removal in conjunction with immediate implant placement. The
Bio-Col technique. Atlas Oral Maxillofac Surg Clin North Am.
1999;7(2):39-59.
25. Sclar AG. Strategies for management of single-tooth
extraction sites in aesthetic implant therapy. J Oral Maxillofac
Surg. 2004;62(9 Suppl 2):90-105.
26. Fowler EB, Whicker R. Modified approach to the Bio-Col ridge
preservation technique: a case report. J Contemp Dent Pract.
2004;5(3):82-96.
27. Wang HL, Tsao YP. Mineralized bone allograft-plug
socket augmentation: rationale and technique. Implant Dent.

2007;16(1):33-41.
28. Iasella JM, Greenwell H, Miller RL, Hill M, Drisko C, Bohra
AA, Scheetz JP. Ridge preservation with freeze-dried bone
allograft and a collagen membrane compared to extraction alone
for implant site development: a clinical and histologic study in
humans. J Periodontol. 2003;74(7):990-999.
29. Garg AK, Reddi SN, Chacon GE. The importance of asepsis in
dental implantology. Implant Soc. 1994;5(3):8-11.
30. Zitzmann NU, Scharer P. Oral rehabilitation with dental
implants. Aegis Communications. 2009;2(2).
31. J Morita USA. Foundation. />cms/website.php?id=/en/products/dental/partner/auxiliaries/
foundation.htm. Accessed October 10, 2013.
32. Becker W, Clokie C, Sennerby L, Urist MR, Becker BE.
Histologic findings after implantation and evaluation of different
grafting materials and titanium micro screws into extraction
sockets: case reports. J Periodontol. 1998;69(4):414-421.
33. Vance GS, Greenwell H, Miller RL, Hill M, Johnston H,
Scheetz JP. Comparison of an allograft in an experimental putty
carrier and a bovine-derived xenograft used in ridge preservation:
a clinical and histologic study in humans. Int J Oral Maxillofac
Implants. 2004;19(4):491-497.
34. Postlethwaite AE, Seyer JM, Kang AH. Chemotactic attraction
of human fibroblasts to type I, II, and III collagens and collagen-
derived peptides. Proc Natl Acad Sci USA. 1978;75(2):871-875.
35. Damien C, Parsons JR. Bone graft and bone graft substitutes:
a review of current technology and applications. J Appl Biomater.
1991;2(3):187-208.
36. Bitter RN. A rotated palatal flap ridge preservation technique
to enhance restorative and hard and soft tissue esthetics for tooth
replacement in the anterior maxilla. Int J Periodontics Restorative

Dent. 2010;30(2):195-201.
37. Bartee BK. Extraction site reconstruction for alveolar ridge
preservation. Part 1: rationale and materials selection. J Oral
Implantol. 2001;27(4):187-193.
38. Steiner GG, Francis W, Burrell R, Kallet MP, Steiner DM,
Macias R. The healing socket and socket regeneration. Compend
Contin Educ Dent. 2008 Mar;29(2):114-6,118,120-4 passim.
39. Misch CE. Contemporary implant dentistry (3rd ed). St Louis:
Mosby Inc. 2007.
40. Devlin H, Sloan P. Early bone healing events in the human
extraction socket. Int J Oral Maxillofac Surg. 2002;31(6):641-645.
41. Amler MH, Johnson PL, Salman I. Histological and
histochemical investigation of human alveolar socket healing in
undisturbed extraction wounds. J Am Dent Assoc. 1960;61(7):32-
44.
42. Boyne PJ. Osseous repair of the postextraction alveolus in
man. Oral Surg Oral Med Oral Pathol. 1966;21(6):805-813.
43. Pfeifer JS. The reaction of alveolar bone to flap procedures in
man. Periodontics. 1965;20:135-140.
44. Araújo MG, Sukekava F, Wennström JL, et al. Tissue modeling
following implant placement in fresh extraction sockets. Clin Oral
Implants Res. 2006;17(6):615-624.
45. Covani U, Bortolaia C, Barone A, et al. Bucco-lingual crestal
bone changes after immediate and delayed implant placement. J
Periodontol. 2004;75(12):1605-1612.
46. Stiebe B, Poethe I, Bernhardt H. The bacteriology of normal
wound healing following tooth extraction with special reference
to anaerobic microorganism diagnosis. Zahn Mund Kieferheilkd
Zentralbl. 1990;78(3):247-251.
47. Coon D, Gulati A, Cowan C, et al. The role of

cyclooxygenase-2 (COX-2) in inflammatory bone resorption. J
Endod. 2007;33(4):432-436.
48. Taubman MA, Kawai T, Han X. The new concept of
periodontal disease pathogenesis requires new and novel
therapeutic strategies. J Clin Periodontol. 2007;34(5):367-369.
periodontal and endodontic diseases, bone
is resorbed in the presence of inflammatory
cells.
47,48
It is more plausible that the socket wall
will proceed through a phase of resorption
before regeneration.
38
The possible origins of osteoblasts
in the human tooth extraction socket are
Pericytes, Adipocytes, the periodontal
ligament fibroblasts, the marrow stem
cells, and the periosteum.
We know that the periodontal
ligament can regenerate alveolar bone,
although guided tissue regeneration
techniques, which allow further
osteogenic differentiation of these cells,
produce unpredictable clinical results.
Osteoprogenitor cells in the periodontal
ligament and bone marrow may contribute
to bone regeneration following tooth
extraction.
40
Conclusion

The resorption of alveolar bone following
extractions results in a narrowing and
shortening of the residual ridge.
2
According
to the literature, alveolar ridge resorption
can be limited but not avoided. Complete
preservation of the pre-extraction ridge
dimensions should not be anticipated, even
when alveolar ridge preservation techniques
involving post-extraction socket grafting
are applied. Ridge preservation requires
thorough comprehension of tissue-healing
procedures after the extraction of one or
more teeth, as well as deep knowledge of
bone substitute properties. The “socket-
plug” technique can help the clinician to
provide the best possible outcome with
the least patient discomfort. The results
not only depend on the delicate handling of
the tissues, but also on the resorption rate
of the graft material and its replacement
by mature bone capable of withstanding
functional loading.
3
Obviously, the different
anatomical and dimensional characteristics
of hard tissue and soft tissue quantities,
qualities, and gingival tissue biotypes,
together with several other factors (e.g.,

reason for extraction, tooth location, etc.),
may influence the final outcome of any
socket preservation procedure and may be
important in making the decision of whether
or not a ridge preservation technique is
indicated. Ultimately, the ridge preservation
approach significantly limits the osseous
resorption of the alveolar post-extraction
ridge compared to extraction alone.
1
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ne of the most challenging clinical
situations to present to the implant
team is advanced bone loss that leads
to insufficient bone volume for proper
implant placement. Rebuilding bone height
and width has been a difficult technique
and sensitive procedure, which usually
requires the patient to undergo painful and
aggressive surgeries to harvest autogenous
bone from the ramus, symphisis, iliac
crest, or tibia. Commonly, the site where
the bone was harvested from caused
more postoperative pain and sequella than
the actual surgical site itself. Additionally,
from the literature, a 16-20% loss in bone
volume of the healed graft can be noticed
at re-entry for implant placement. This can
be a problem for the reconstruction of
normal soft tissue architecture for implant
esthetics and long-term maintenance.
The following case report presents
a new technique and allogenic grafting
procedure to increase both bone volume
in the height and width dimensions. Dr.
Petrungaro is one of the only surgeons
in the country using this state-of-the-
art material for the reconstruction of
small to large intraoral osseous defects.
A 42- year-old, non-smoking female
presented for reconstruction of her lower

arch with dental implants (Figures 1
and 2). The patient had a congenitally
missing dentition, which contributed to
large defects in her mandibular arch in
the buccal-lingual dimension (Figure 3).
The defects made conventional implant
placement impossible without a prior
bone reconstruction procedure. The
patient had also obtained other opinions
regarding treatment, which consisted of
removal of over 20+ millimeters of bone
and an All-on-4 type option, advanced
bone harvesting procedures from the iliac
crest region, and the option she chose in
Dr. Petrungaro’s practice, localized ridge
augmentation using a stem-cell infused
allogenic block graft procedure. This
technique negates the patient undergoing a
painful bone harvesting surgical procedure,
and provides a bone reconstruction and
remodeling process in which her own
osseous structures are stimulated and
reconstructed prior to implant placement.
After removal of tooth Nos. 24 and 25
(Figure 4), the large buccal-lingual defect
can be seen clearly from this clinical view.
Figures 5 and 6 show the undercut in the
crest of the ridge from the buccal and
occlusal views, respectively. This thin knife-
edged ridge, and significant undercut,

would make proper implant placement very
difficult, if at all possible to achieve.
Coronal flattening of the crest of the
ridge (Figure 7) is necessary for closure
of the wound and stimulation of the
marrow spaces at the crest of the ridge by
removing the cortical plate. Figure 8 shows
the allogenic stem cell block grafts placed
at the buccal aspect of the ridge from the
tooth No. 19 area to the tooth No. 27 area.
Over 140,000 stem cells are at the facial
aspect of the crest of the ridge to stimulate
the patient’s own osseous structures to
help rebuild the insufficient buccal aspect.
Stem cell block grafts
22 Implant
practice
Volume 6 Number 6
CASE STUDY
Dr. Paul Petrungaro delves into allogenic stem cell block grafts to facilitate reconstruction of localized/
severe ridge defects and reconstruct proper alveolar contours prior to dental implant placement
Preoperative serial views
Paul Petrungaro, DDS, MS, graduated from
Loyola University Dental School in 1986
and completed an independent study of
Periodontics at the Welsh National Dental
School in the United Kingdom. He completed
a residency, specialty certificate, and Master of
Science Degree in Periodontics from Northwestern
University Dental School, and formerly served as

the Coordinator of Implantology for the university’s
Graduate Department of Periodontics. Dr. Petrungaro
has maintained a private practice in Periodontics and
Implantology since 1988, and holds licenses in Illinois,
Minnesota, and Washington. As a world-renowned and
pre-eminent educator, he has presented numerous
seminars and lectures worldwide on topics of advanced
periodontal, prosthetic, and implant interrelationships,
bone regeneration, esthetic tissue formation, transitional
implants, immediate restoration of dental implants,
and the use of platelet rich plasma in bone grafting.
In addition, he has authored over 75 articles on these
topics including cosmetic bone grafting and esthetic
implant procedures in such prestigious publications
as Compendium, Inside Dentistry, and the American
Academy of Cosmetic Dentistry’s Journal of Cosmetic
Dentistry. Dr. Petrungaro’s consultant role to several
biomedical companies and laboratories has resulted
in many new innovations in surgical dentistry. He is
a fellow of the International and American College of
Dentists and a Diplomate of the International Congress
of Oral Implantologists and holds memberships in
several professional associations.
Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
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