Tạp chí implant tháng 1-2 /2013 Vol 6 No1

clinical articles • management advice • practice profiles • technology reviews
January/February 2013 – Vol 6 No 1

PROMOTING EXCELLENCE IN IMPLANTOLOGY
Every picture tells a story:
chlorhexidine conundrum
Dr. Eddie Scher

SonicWeld Rx™ — A novel
replacement for traditional
titanium mesh in particulate
bone grafting
Dr. Lewis Cummings

Straumann’s 2013 Dental
Implant Complications
Symposium

Clinical Case: All-on-4™
and NobelGuide™ in an
atrophic mandible

The Most
Efficient
Clinical
Workflow
in
Dentistry

SCAN

Drs. Paulo Malo, Armando Lopes,
Mariana Nunes, André Rodrigues, Ana
Ferro, and Miguel De Araújo Nobre

Corporate profile

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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

PUBLISHER
Lisa Moler


Email:
Tel: (480) 403-1505

MANAGING EDITOR
Mali Schantz-Feld


Email:
Tel: (727) 515-5118

ASSISTANT EDITOR
Kay Harwell Fernández

Dear Readers:
Happy 2013! It seems like only yesterday that we were busily preparing to welcome 2012,
but in fact, so much has happened in the dental profession and in our publications, that
the time has just flown by. The positive momentum of the past year continues to propel
us forward. We are happy to note that this year brings a fresh, contemporary look for the
magazines. New design elements, an easy-to-read print style, and expanded page size
are just a few of the exciting changes that you will find in this, and future issues.

Implant Practice US is growing and evolving to help you grow and evolve. We strive to
keep up with current implant trends and to keep our readers up-to-date on the latest
techniques and technology in the specialty. Our dentist-authors give of their time and
expertise to share the methods that result in better dental care for patients. We are
always seeking out new ideas and innovation in our clinical, technology and continuing
education articles, and case studies. Our corporate profiles tell the stories of companies
that facilitate innovation, and practice profiles share the insights and concepts that inspire
practice excellence. And, practice management columns spotlight ways to improve the
business aspects of the dental office that can make lives easier for the staff and the boss!
Besides our magazine, Implant Practice US also features a vital and continually changing
website (www.medmarkaz.com/web) and e-newsletter with the latest industry news,
articles, and information. Our social media mavens keep the action going on Facebook,
Twitter, and LinkedIn. So whether you like to turn the pages or click the mouse,
information can be in your lap or on your laptop!
Publishing a thought-provoking, diverse magazine with such high standards is a difficult
task, but our authors, peer reviewers, editorial advisory board, advertisers, and columnists
make it a smooth and enjoyable process. Our editors, sales and production staff, and I
appreciate all of our authors and readers and value feedback as we continue to strive for
excellence. Please feel free to call or email – we’d love to hear from you.

Email:

PRODUCTION MANAGER/CLIENT RELATIONS
Kim Murphy
Email:

January is a time for resolutions. We strive to keep up the momentum so that we all can
grow together in 2013.
All the best,

NATIONAL SALES/MARKETING MANAGER
Drew Thornley
Email:

Tel: (619) 459-9595
NATIONAL SALES REPRESENTATIVE
Sharon Conti
Email:

Tel: (724) 496-6820
E-MEDIA MANAGER/GRAPHIC DESIGN
Email:
Greg McGuire
PRODUCTION ASST./SUBSCRIPTION COORDINATOR
Email:
Lauren Peyton
MedMark, LLC
15720 N. Greenway-Hayden Loop #9
Scottsdale, AZ 85260
Fax: (480) 629-4002
Tel: (480) 621-8955
Toll-free: (866) 579-9496 Web: www.endopracticeus.com
SUBSCRIPTION RATES
Individual subscription
1 year
(6 issues)
3 years
(18 issues)

Lisa Moler

Publisher

$99
$239

© 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.

Volume 6 Number 1

Implant practice 1

MEMO FROM THE PUBLISHER

January/February 2013 - Volume 6 Number 1


5 Great Reasons to CONNECT
with the ITI in Chicago.
What puzzle pieces are you missing in your practice?

Attend the ITI Congress and complete your puzzle for a successful future.
1. rowyourpracticerevenuebyattendingThursday’sPre-CongressPracticeManagement
G
Forumandlearnabout:Money,HowtoMakeit,HowtoGrowit&CaseAcceptance.
2.







Learnfromtopinternationalexpertsandeducators:
•UrsBelser:UniversityofGeneva,Switzerland
•DanielBuser:UniversityofBern,Switzerland
•DavidCochran:UniversityofTexasSanAntonio,USA
•JocelyneFeine:McGillUniversity,Canada
•Hans-PeterWeber:TuftsUniversity,USA
•andmanymore

3. ConnectandbeapartofthelargestdentalNetwork;sharebestpracticesattheITICongress
PartyonFridaytobenefittheNFED(NationalFoundationforEctodermalDysplasia)
4.




ElevateyourskillintheTechnologyPodswithdemonstrationstaughtbyKeyOpinion
LeadersintheTechnologyHall.(DigitalDentalPhotography,LOCATOR®Techniques,
CementingonDentalImplants,ProvisionalFabrication,Augmentationtechniques

andmore...)

5. ackleComplications–attendSaturday’s“ManagingPuzzleProblems”Sessionand
T
approachcomplicationswithconfidence.Theprogramwillstartwithcomplicationsfromthe
restorativeandsurgicalaspectsintheestheticzone.
TheInternationalTeamforImplantology(ITI)isauniquenetworkthatunitesprofessionalsaround
theworldfromeveryfieldofimplantdentistryandrelatedtissueregeneration.Notamember?
Signuptodaytotakeadvantageofthehighestqualityeducationalsupportandawealthof
benefitstoenhanceprofessionalactivities.Findouthowyoucangeta$200discountonthe
ITINorthAmericaCongressfee.

www.iti.org/congressnorthamerica

Do not wait, take advantage of the early bird
rate which expires January 31st and save $100.


ITI
Congress North America
Chicago, USA
April 4 – 6
2013

Connectivity in Implant Dentistry:
Putting the Pieces Together.


INTRODUCTION

The best gift – education

P

erhaps the best gift I have ever given myself was the pursuit of education. I remember the day I received my dental degree, knowing
that a long journey was ahead. I had a plan, and my goal was simple: I would take continuing education courses that interested
me and lay the foundation for my future success. It began with restorative treatment and included esthetics. At the same time, my
self-confidence in endodontics was lacking, and I committed years to that discipline. Confident with the ability to heal and restore
ailing teeth, I set my sights on surgery. Unfortunately, dental school and residency could only prepare me so far. I yearned to understand
the finer points of saving teeth with periodontal surgery, and when unable, then to extract those teeth. After 14 years of more education and
honing my craft, I was awarded a Mastership in the Academy of General Dentistry.
Yet, even with that, I always knew there was one discipline in which I was lacking, and it was dental implants. I wasn’t simply interested in
learning the science of restoring dental implants. I wanted much more. I sat through many weekend-warrior implant courses, often with a
hands-on component using dentoform style models. But rubber and plastic models are a poor substitute for the real thing.
For me, the holy grail of dentistry was learning, understanding, and acquiring the wisdom to surgically place the implant in vivo. I had always
felt that all other fundamentals had to be acquired, and at that time, I believed those elements were in my repertoire. With the groundwork
laid out, and the foundation solid, I stood at the precipice, wanting to dive into the implant surgical arena. What held me back was fear. Fear
of the unknown. Fear of those anatomical structures that haunted me, leading me to believe that with one wrong move, I would violate the
maxillary sinus, the mental foramen, or the inferior alveolar nerve.
I knew those areas well enough, and frankly, they scared me. So, one day, I decided that it was time to overcome my anxiety and discover
if those bugaboos were really a threat or just the primal fear they inject you with at the undergraduate level. I needed big time education.
I sought something that was a commitment of time and funds, the two ingredients integral to any worthwhile venture. For me personally,
I discovered and developed this talent (and continue to do so) in a “mini-residency.” Akin to the famed maxi-course, the location was
Englewood, New Jersey, a 3-hour drive from my Baltimore home. It was a 6-month commitment of bimonthly lectures, participation, and
over-the-shoulder live placement. And yes, there were lots of homework and tests. My teacher and mentor, Dr. John Minichetti, assembled
an all-star cast of educators, and between his excellent teaching skills, guidance, and care, I began my journey.
I was thrilled when I learned not only the mechanics of implantology, but also all of the supporting pieces needed for success. I relearned
how to extract a tooth, this time ensuring that the event was as atraumatic as possible. I discovered the art of bone grafting extraction
sockets, and when they weren’t intact, then how to grow bone. I even deprogrammed my fear of those once dreaded anatomical sites,
learning how to correct them (the sinus lift) or avoid them (the mandibular nerves). Once the course was complete, I was sent back into my

world to begin this wonderful and exciting journey. Initially, I began cherry-picking my cases, staying within my comfort zone, and as my
self-confidence grew, so did my treatment. Today, I am a proud recipient of the Associate Fellowship in the American Academy of Implant
Dentistry. Yet, I am even more proud to be considered a kindred spirit with all of you, my fellow implantologists.
I look forward to continued discovery and collaboration in 2013!

Ian E. Shuman, DDS, MAGD

4 Implant practice

Volume 6 Number 1


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TABLE OF CONTENTS

Through the keyhole
Dr. Scott Marshall Blyer: An affinity for
accessibility and approachability
A strong medical and surgical background,
dedication to customer service, and a
penchant for “pushing the envelope” keeps
this clinician’s practice immersed in innovation

10
Corporate profile
Biomet 3i
Sustainable esthetic treatment, comprehensive
tissue management, accelerated therapy,
and digitally-driven patient and practice
management solutions

14

Clinical

Every picture tells a story:
chlorhexidine conundrum
Dr. Eddie Scher raises the alarm on
the potentially dangerous effects of
chlorhexidine digluconate
mouthwash................................. 20
Customized impression of an
implant-supported fixed partial
denture in the esthetic zone
Dr. David Furze and Mr. Ashley
Byrne describe a method in which all
four maxillary incisors are replaced
with an implant-supported fixed
partial denture............................. 22

Continuing
education

Case study
Clinical Case: All-on-4™ and
NobelGuide™ in an atrophic mandible
Drs. Paulo Malo, Armando Lopes, Mariana
Nunes, André Rodrigues, Ana Ferro, and
Miguel De Araújo Nobre explore an implant
solution for extreme cases

28

SonicWeld Rx™ — A novel
replacement for traditional

titanium mesh in particulate
bone grafting
Dr. Lewis Cummings discusses an
improved method for particulate
bone grafting............................... 32
Secure bonding: implants and
overdentures
Dr. Ludwig Hermeler demonstrates
how to modify an existing
overdenture for use with implants
and secure it with direct intraoral
adhesion..................................... 36

6 Implant practice

Volume 6 Number 1



79459-US-1208 © 2012 DENTSPLY International, Inc.

Abutments as individual
as your patients
Available for all major implant systems and in your
choice of titanium, gold-shaded titanium and four
shades of zirconia, ATLANTIS™ patient-specific

ATLANTIS BioDesign Matrix™
The four features of the ATLANTIS BioDesign Matrix™
work together to support soft tissue management

for ideal functional and esthetic result. This is the
true value of ATLANTIS™ for you and
your patients.

CAD/CAM abutments help to eliminate the need
for inventory management of stock components and
simplify the restorative procedure.

ATLANTIS VAD™
Designed from the
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Shape and
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patient anatomy.

Soft-tissue Adapt™
Optimal support for
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Find out how ATLANTIS™ can
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TABLE OF CONTENTS

44

Socket grafting
made simple

Research

Event preview

Early loading versus immediate

Straumann’s 2013 Dental Implant

loading: case examples
Drs. Alberto Maltagliati, Andrea
Ottonello, Giulio Raffaghello, and
Andrea Mascolo explore esthetics
and function of early and immediate
loading implants............................40

Complications Symposium
Providing Solutions for Your Practice.
.....................................................48

Industry news

Practice
management
Know your liability as a business
owner
Dr. Robert M. Fleisher discusses
how to mitigate general liability risks
besides malpractice claims............54

Aribex acquired by the KaVo

Step-By-Step
BondBone®
Socket grafting made simple.........44

Product profile
Aseptico
Aseptico’s AEU-7000L-70V fiber optic
motor system................................46

8 Implant practice

Group
Aribex, the leader in portable X-ray
technology, joins the KaVo Group’s

portfolio of dental brands...............50

Abstracts
Treatment of peri-implant
diseases: a compilation of
systematic reviews
Dr. Maria Retzepi rounds up the
current thinking on an increasingly
important aspect of implant dentistry
.....................................................52

Materials &
equipment......................56

Volume 6 Number 1


PRACTICE PROFILE

Dr. Scott Marshall Blyer
An affinity for accessibility and approachability
What can you tell us about your
background?
I grew up in the streets and went to the
school of hard knocks. My first experience
with dental implants was getting my teeth
knocked out after a mix-up of mistaken
identity with the local crack dealer. Ok,
none of that is true, but what is more
boring than a being a dentist from Long

Island? The genesis of my interest was
after volunteering for an oral surgeon in
college.

Is your practice
implants?

limited

to

In my practice, I perform the full scope of
oral and maxillofacial surgery, although
a large portion is dedicated to dental
implants.

Why did you decide to focus on
implantology?
We actually chose each other. I was well
trained in my residency in dental implants
and continued my learning thereafter.
Many of the dentists in my community have
a high dental IQ and perform many simple
cases themselves. The cases I was getting
were cases that were complex, “hopeless,”
and failing. It allowed me to push the
envelope of science, and in many cases,
be the hero doing what others deemed
impossible. This excited me as a surgeon
and a scientist.

How long have you been
practicing, and what systems do
you use?
I graduated dental school in 2000 and
residency in 2006. I have been in private
practice for over 6 years. I have worked with
many different systems. Straumann® is my
personal preference, but Nobel is the most
popular in my community, and therefore,
my most commonly placed implant.

What training have you undertaken?
I

graduated

from

10 Implant practice

the

Pennsylvania

State University with a BS in nutritional
biochemistry. I then went to Stony
Brook dental school. I completed my
6-year oral and maxillofacial surgery
training at Long Island Jewish

Hospital. In the program, I earned a
medical degree (MD) from Stony
Brook, and completed a year of
general surgery at North Shore
University Hospital. I then
did a fellowship in cosmetic
surgery at Willow Bend
Cosmetic Surgery Center
in Plano, Texas.

Who has inspired
you?
On a personal level, my
parents are responsible
for who I am. My
practice’s logo is a
portrait of my deceased
mother and is a constant
reminder of the values
she taught me. Professionally, Dr. Uday
Reebye is a great friend and an amazing
young surgeon who will change dental
implantology as we know it. My list of people
inspiring me is quite long. These are people
who were not afraid to take chances, do
the right thing by people, work hard, and
who earned everything they have.

What is the most satisfying aspect
of your practice?

Like Frank Sinatra said, “I did it my way.” It
is not the typical office in terms of patient
care, ambiance, or services rendered. We
don’t stand on ceremony and are very
“down to earth.” I love offering different
options to patients, and together make
their expectations a reality.

Professionally, what are you most
proud of?
I have done pro bono work, taught, held
fundraisers for breast cancer and MS in my
community, but my biggest pride comes
from my daily dedication to those who

trusted me to care for them. I have visited
my out-of-town patients after treatment in
their hotels and even walked their dogs
for them, and drove out of state to see a
patient because she couldn’t come in. It
is a tremendous responsibility to operate
on someone, and it is a responsibility I
do not take lightly. My accessibility and
approachability to my family of patients is
what I am most proud of. I have instilled
this work ethic into my entire team.

What do you think is unique about
your practice?
Certainly my training. With a strong medical

and surgical background, it allows me to
undertake cases where others may not. I
also find myself thinking differently than
most other implant surgeons, placing more
importance on how the teeth fit to the face
and the perioral structures. We also hold
customer service as a top priority. Upon
entering through our glass doors, our
waterfall, marble and teak floors set up a
serene environment. Our warm, welcoming
Volume 6 Number 1


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*

Artistic Rendering

I am the Zimmer® Trabecular Metal™ Dental Implant, the first dental implant
to offer a mid-section with up to 80% porosity—designed to enable bone INGROWTH as well as bone
ONGROWTH. Through osseoincorporation, I harness the tried-and-true technology of Trabecular Metal
Material, used by Zimmer for over fifteen years in orthopedics. My material adds a high volume of
ingrowth designed to enhance secondary stability.... and I am Zimmer.

Visit TrabecularMetal.zimmerdental.com
to view a special bone ingrowth animation and
request a Trabecular Metal Technology demo.
www.zimmerdental.com
©2012 Zimmer Dental Inc. All rights reserved. * Data on file with Zimmer Dental.
Please check with a Zimmer Dental representative for availability and additional information.

e


PRACTICE PROFILE

Dr. Blyer and his mother

Dr. Blyer in action during a consultation

Dr. Blyer sponsoring the Carol Baldwin breast cancer
fundraiser, 2011

team will offer you a warm cup of coffee
and a seat on our leather lounge chairs. We
often send flowers after surgery, and even
have a top-of-the-line full-service spa in the
office.

What advice would you give to
budding implantologists?

What has been your biggest
challenge?
Treatment room

Trying to find the balance between family
and professional life. I work essentially
7 days a week, and even when I am at
home, it is difficult to get our profession off
my mind. Different ideas are always racing
through my mind.

What would you have become if
you had not become a dentist?

Front desk

My father wanted me to be a chiropractor,

my uncle a caterer, and my mother, the
president. I love being creative and thinking
of new ideas. I think I would have enjoyed a
career in television marketing.

Find yourself a mentor or someone you
can turn to with a problem or question.
It is unfortunate more people can’t work
like colleagues rather than competitors.
Don’t be a robot. Think before you act.
The specialty must continue to evolve, so
don’t listen to naysayers. If it makes sense
biologically, give it a shot.

What are your hobbies, and what
do you do in your spare time?
I love the New York Knicks, Giants, and
Penn State Football. In my spare time, I
am always reading and writing scientific
articles (yes, I am a nerd). I enjoy going
to the gym, playing golf, and spending
time with my family, fiancé, and my Daisy
(my Chihuahua-Rat Terrier rescue; she’s
delicious). With only 24 hours in a day,
sleep is not overrated. IP

What is the future of implants and
dentistry?
In the titanium arena, immediate placement
of CAD/CAM customized one-piece

implants and crowns are the future.
Zirconium implants are getting some buzz
in the U.S., as we await long-term data. I
am currently involved with research using
stromal vascular fractions for implant site
development, with promising early results.
At some point, stem cells will probably
replace implants entirely.
Main waiting room

TOP FAVORITES
1. CVS gummy bears
2.Piezosurgery® unit — I love that little sucker
3. Daydreaming and getting a deep tissue
massage
4. Making people happy
5. Waking up in the middle of the night and
realizing I have another 2 hours of sleep left
6. When things work out

What are your top tips for maintaining a successful practice?
Always be available. Maintain great
communication with your referrals. Treat
your patients like one of the family. Every
patient gets my cell phone number and a
call after surgery. With texting, it allows my
patients to reach me at any time and is a
welcoming security blanket for them.

7.Lecturing/teaching

8. Sitting back with an interesting article and
keeping up with current literature
9.




Foundation bone graft material for
socket preservation grafts: easy placement,
compressible, no membrane needed, and
converts to rock solid bone

10.Hand torquing to 40 Ncm..... ahhhhhh
heaven!

Dr. Blyer’s office team
12 Implant practice

Volume 6 Number 1


www.icoivegas2013.org

ICOI is an ADA CERP Recognized
Provider. ADA CERP is a service
of the American Dental Association to assist dental professionals in identifying quality
providers of continuing dental education. ADA CERP does not approve or endorse individual
courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.
Concerns or complaints about CE provider may be directed to the provider or to ADA CERP
at www.ada.org/cerp.

ICOI is designated as an Approved PACE Program Provider by the Academy of
General Dentistry. The formal continuing education programs of this program
provider are accepted by AGD for Fellowship, Mastership and membership
maintenance credit. Approval does not imply acceptance by a state or
provincial board of dentistry or AGD endorsement. The current term of
approval extends from April 1, 2010 to March 31, 2014. Provider ID# 217378.


CORPORATE PROFILE

BIOMET 3i

F

ounded in 1987 by a periodontist and
an engineer who wanted to be more
responsive to dental needs, BIOMET 3i
is now one of the largest dental implant
companies in the world. Headquartered in
Palm Beach Gardens, Florida, the company
spans the globe with nearly 1,000 team
members, 18 subsidiaries, and operations
in more than 40 countries.
sustainable
aesthetic

Through
treatment, comprehensive tissue management, accelerated therapy and digitallydriven patient and practice management
solutions, BIOMET 3i strives to enhance

the lives of patients – one at a time.

Comprehensive tissue management solutions
Successful patient outcomes begin with
effective tissue management. BIOMET 3i
provides a portfolio of site-specific options
that are designed to achieve better results
at crucial steps in the process – laying the
foundation for successful Guided Bone
Regeneration procedures.

Accelerated therapy solutions
BIOMET 3i provides patients with the
option of immediate full arch rehabilitation
in as little as one day* with DIEM®2. This
innovative solution is designed to allow
clinicians to differentiate their practices
while increasing productivity and patient
satisfaction.

Sustainable aesthetic treatment
solutions
The PREVAIL® Implant System with
integrated platform-switching uses “The
Science of Aesthetics” to deliver outcomes
through tissue protection1, enhanced
osseointegration,2-9 and crestal bone
preservation2-6.

RegenerOss® Allograft

DIEM® 2

Digitally-driven patient and practice management solutions
OsseoGuard Flex™ Membrane

BIOMET 3i NanoTite™
Tapered Certain®
PREVAIL® Implant

BIOMET 3i NanoTite™
Certain® PREVAIL®
Implant

For patients, too many dental visits over too
long a period of time are barriers to implant
dentistry being the treatment of choice.
BIOMET 3i delivers a digital solution with a
streamlined workflow from start to finish –
the BellaTek® Encode® Impression System.

The patented BellaTek Encode
Impression System with intraoral scanning
eliminates the need for impression copings,
streamlining the process while improving
the patient experience.

Endobon® Xenograft Granules

BellaTek® Encode® Impression System

OsseoGuard® Membrane
14 Implant practice

Volume 6 Number 1


The PREVAIL® Implant System
The key to achieving long-term sustainable aesthetic outcomes
is preservation of hard and soft tissues. The PREVAIL Implant
System’s unique features are designed for preservation.

enHAnceD
o s s e o i n T e g r AT i o n 1-6,8,9

c r e s TA l b o n e
P r e s e r VAT i o n 1 - 5

preservation
BY DESIGN™
Optimized aesthetics with as little as
0.37mm of bone recession1

Tissue
ProTecTion7

Higher seal strength as compared
to the competitive average 2,3
Seal integrity test was performed by BIOMET 3i on December
2011. Testing was done under testing standard ISO 14801.

Five (5) BIOMET 3i PREVAIL Implant Systems and five (5) of
three (3) competitors’ implant systems were tested. Bench test
results are not necessarily indicative of clinical performance.

Implants designed for primary stability with
two well-researched surface options for
bone apposition

Please contact us at 561.776.6700 or visit us online at www.biomet3i.com to learn more.
1. Östman PO†, Wennerberg A, Albrektsson T. Immediate occlusal loading of NanoTite Prevail Implants: A prospective 1-year clinical and radiographic study. Clin Implant
Dent Relat Res. 2010 Mar;12(1):39–47.
2. Baumgarten H†, Meltzer A†. Improving outcomes while employing accelerated treatment protocols within the aesthetic zone: From single tooth to full arch restorations.
Presented at the Academy of Osseointegration, 27th Annual Meeting; March 2012; Phoenix, AZ.
3. Suttin Z†, Towse R†, Cruz J†. A novel method for assessing implant-abutment connection seal robustness. Poster Presentation 188: Academy Of Osseointegration, 27th
Annual Meeting: 2012 March 1–3; Phoenix, Arizona. Testing done by BIOMET 3i,
Palm Beach Gardens, FL; n = 20.
4. Byrne D, Jacobs S, O’Connell B, Houston F, Claffey N. Preloads generated with repeated tightening in three types of screws used in dental implant assemblies.
J. Prosthodont. 2006 May–Jun;15(3):164-71.
5. Boitel N, Andreoni C, Grunder U†, Naef R, Meyenberg, K†. A three year prospective, multicenter, randomized-controlled study evaluating platform-switching for the
preservation of peri-implant bone levels. Poster presentation P83: Academy of Osseointegration, 26th Annual Meeting: 2011 March 3–5; Washington DC.
6. Lin A, Wang CJ, Kelly J, Gubbi P, Nishimura I. The role of titanium implant surface modification with hydroxyapatite nanoparticles in progressive early bone-implant
fixation in vivo. Int J Oral Maxillofac Implants. 2009 Sep–Oct;24(5):808–816.
7. Zetterqvist et al. A prospective, multicenter, randomized controlled 5-year study of hybrid and fully etched implants for the incidence of peri-implantitis. J Periodontol.
April, 2010.
8. Östman PO†, Wennerberg A, Ekestubbe A, et al. Immediate occlusal loading of NanoTite™ Tapered Implants: A prospective 1-year clinical and radiographic study.
Clin Implant Dent Relat Res. 2012 Jan 17. [Epub ahead of print]
9. Block MS†. Placement of implants into fresh molar sites: Results of 35 cases. J Oral Maxillofac Surg. 2011 Jan;69(1):170-4.
†

Aforementioned have financial relationships with BIOMET 3i LLC resulting from speaking engagements, consulting engagements and other retained services.

PREVAIL is a registered trademark of BIOMET 3i LLC. Preservation By Design and Providing Solutions - One Patient At A Time are trademarks of BIOMET 3i LLC. ©2013 BIOMET 3i LLC.


CORPORATE PROFILE
References
1. Zetterqvist L, et al. A prospective,
multicenter, randomized controlled 5-year
study of hybrid and fully etched implants for
the incidence of peri-implantitis. J Periodontol.
April, 2010.
2. Baumgarten H†, Meltzer A†. Improving
outcomes while employing accelerated
treatment protocols within the aesthetic zone:
From single tooth to full arch restorations.
Presented at the Academy of Osseointegration,
27th Annual Meeting; March 2012; Phoenix,
AZ.
3. Suttin Z††, Towse R††, Cruz J††. A
novel method for assessing implantabutment connection seal robustness.
Poster Presentation 188: Academy Of
Osseointegration, 27th Annual Meeting: 2012
March 1–3; Phoenix, Arizona. http://biomet3i.
com/Pdf/Posters/Poster_Seal%20Study_ZS_
AO2012_no%20logo.pdf. Testing done by
BIOMET 3i, Palm Beach Gardens, FL; n = 20.

IIRD® lecture hall

4. Byrne D, Jacobs S, O’Connell B, Houston

F, Claffey N. Preloads generated with repeated
tightening in three types of screws used in
dental implant assemblies. J. Prosthodont.
2006 May–Jun;15(3):164-71.
5. Östman PO†, Wennerberg A, Albrektsson
T. Immediate occlusal loading of NanoTite
Prevail Implants: A prospective 1-year clinical
and radiographic study. Clin Implant Dent
Relat Res. 2010 Mar;12(1):39–47.
6. Boitel N, Andreoni C, Grunder U†, Naef
R, Meyenberg, K†. A three year prospective,
multicenter, randomized-controlled study
evaluating
platform-switching
for
the
preservation of peri-implant bone levels.
Poster presentation P83: Academy of
Osseointegration, 26th Annual Meeting: 2011
March 3–5; Washington DC.

IIRD® operatory

World-class learning for dental
clinicians
Located in Palm Beach Gardens, Florida,
the Institute for Implant & Reconstructive
Dentistry (IIRD®) is a BIOMET 3i initiative
for continuous learning and training for
dental professionals. This state-of-the-art

facility provides clinicians with the latest
techniques and courses, empowering
clinicians to provide outstanding patient
care.

The IIRD® was founded by Richard
Lazzara, DMD, MScD, who passionately
believes that education, evidence-based
research and advanced techniques are
essential in providing the best solutions to
clinicians and patients.

*Not all patients are candidates for
immediate load procedures.
All trademarks herein are the property of
BIOMET 3i LLC unless otherwise indicated.
For additional product information,
including indications, contraindications,
warnings, precautions, and potential
adverse effects, see the product package
insert and the BIOMET 3i website.
Want more information regarding BIOMET
3i? Please visit the company’s website
at www.biomet3i.com or call 1-800-3425454. Outside the US, please dial +561776-6700.

7. Lin A, Wang CJ, Kelly J, Gubbi P††,
Nishimura I. The role of titanium implant
surface modification with hydroxyapatite
nanoparticles in progressive early boneimplant fixation in vivo. Int J Oral Maxillofac
Implants 2009 Sep–Oct;24(5):808–816.

8. Östman PO†, Wennerberg A, Ekestubbe A,
et al. Immediate occlusal loading of NanoTite™
Tapered Implants: A prospective 1-year
clinical and radiographic study. Clin Implant
Dent Relat Res 2012 Jan 17. [Epub ahead of
print]
9. Block MS†. Placement of implants into
fresh molar sites: Results of 35 cases. J Oral
Maxillofac Surg. 2011 Jan;69(1):170-4.
Dr. Baumgarten, Dr. Block, Dr. Grunder,
Dr. Meltzer, Dr. Meyenberg and Dr. Östman
have financial relationships with BIOMET 3i
LLC resulting from speaking engagements,
consulting engagements and other retained
services.

†

Dr. Gubbi, Mr. Cruz, Mr. Suttin and Mr. Towse
contributed to the above research while
employed by BIOMET 3i.

††

This information was provided by BIOMET
3i.

16 Implant practice

Volume 6 Number 1

California Implant Institute is the world’s premier dental implant educator
California Implant Institute offers a comprehensive fellowship program in oral implantology. This training program
includes 4 sessions (five days each) designed to provide dentists with practical information that will be immediately
useful to them. The fellowship program offers more than 300 combined hours of lectures, laboratory sessions, online
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The curriculum of the fellowship program is divided between the biomedical sciences related to implant dentistry and
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California Implant Institute pursues excellence above all else.
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CLINICAL

Every picture tells a story: chlorhexidine conundrum
Dr. Eddie Scher raises the alarm on the potentially dangerous effects of chlorhexidine digluconate
mouthwash

Figure 1: Acute allergic reaction due to chlorhexidine
mouthwash

B

ack in 2005, I wrote an article warning

colleagues about the possibility
of an allergic reaction to chlorhexidine
digluconate (Figure 1). This is a compound
used in many medical procedures, and of
course, is also used as a mouthwash in
dentistry. In the U.S., its use is controlled,
but in the UK, we can still buy the
mouthwash over the counter.

The right mouthwash
There is no question that this drug is very
useful when performing surgery, as a presurgical rinse, and a follow-up mouthwash
(Lambert, et al., 1997; Young, et al., 2002).
It also has a major place in the treatment of
different types of periodontal disease.

In my 2005 article, I included Figure
2 to demonstrate the effect of changing
from a chlorhexidine mouthwash to a hot
saltwater mouthwash only. Figure 3 shows
almost complete healing after 7 days.

In that article, I warned colleagues that
they must look out for any signs of allergic
response when using this compound.
However, at that time, there were very few
cases reported in the literature.

Fatalities
Since then, there have been at least

Eddie Scher, BDS, LDS, RCS, MFGDP, is a
specialist in oral surgery and prosthodontics.
He is a visiting professor of implantology at
Temple University, Philadelphia, and is editorin-chief of Implant Dentistry Today.

20 Implant practice

Figure 2: Changing the mouthwash to hot saltwater:
improvement after 3 days

Figure 3: Improvement after 7 days of hot saltwater

two cases reported in the press, where
chlorhexidine has been linked to a fatal
anaphylactic reaction. The Daily Mail
reported one such case on March 22, 2011
with the headline “Patient, 30, collapses
and dies at dentist after suffering allergic
reaction to mouthwash.” Another such
case was reported on February 16, 2011,
in the Whitehaven News, this time with the
headline “Mouthwash linked to death of
patient, 63.”

Council,
and
the
Association
of

Anaesthetists of Great Britain and Ireland.

Plan of action
Since then, the Medicines and Healthcare
products Regulatory Agency (MHRA)
has issued a Medical Device Alert dated
October 25, 2012 (MDA/2012/075). It
warns of the risk of anaphylactic reaction
due to a chlorhexidine allergy. It gives the
following action points, which I am quoting:
• Be aware of the potential for an
anaphylactic reaction to chlorhexidine
• Ensure that known allergies are recorded
in patient notes
• Check the labels and instructions
for use to establish if products contain
chlorhexidine prior to use on patients with
a known allergy
• If a patient experiences an unexplained
reaction, check whether chlorhexidine was
used or was impregnated in a medical
device that was used
• Report allergic reactions to products
containing chlorhexidine to the MHRA
• Further guidance on anaphylaxis is
available from National Institute for Health
and Clinical Excellence, the Resuscitation

First aid training
As well as the above guidance, I would

add that, in my view, it is essential for
practices to keep all staff members fully
trained in emergency procedures and first
aid, including the treatment of anaphylactic
shock. Adrenaline should be available in
your emergency kit, and all practitioners
should be able to recognize the symptoms
of anaphylaxis, and be well-versed in how
to treat it.

The patient background
Finally, prevention is better than treatment,
and if the patient has a history of allergies,
this must alert us immediately to potential
problems. The Care Quality Commission
suggests that medical histories are
updated each time we see our patients: I
believe that this is an excellent suggestion,
as we can also check their allergy status at
this time. IP

References
Lambert PM, Morris HF, Ochi S. The influence
of 0.12% chlorhexidine digluconate rinses
on the incidence of infectious complications
and implant success. J Oral Maxillofac Surg.
1997;55:25-30,Suppl 5.
Young MPJ, Korachi M, Carter DH, Worthington
HV, McCord JF, Drucker DB. The effects of an
immediately pre-surgical chlorhexidine oral rinse

on the bacterial contaminants of bone debris
collected during dental implant surgery. Clin Oral
Impl Res. 2002;13:20-29.

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CLINICAL

Customized impression of an implant-supported fixed
partial denture in the esthetic zone
Dr. David Furze and Mr. Ashley Byrne describe a method in which all four maxillary incisors are replaced
with an implant-supported fixed partial denture

Figure 1: Pre-op

Figure 2: Surgical stent and implants in place with delivery
system still attached

Figure 3: Bone ceramic with lots of blood covering implant
and pontic site

Introduction

papillary heights, an equivalent gingival
height, and buccal soft tissue contour.

This clinical report aims to document
a technique of provisional restorations
to condition the soft tissue, followed by
a customized fixed partial denture (FPD)

impression designed to give the technical
team the correct emergence profiles of
both the implant and pontic sites.

problems that would contraindicate
implant therapy. On examination, she had
failing restorations of her upper central
incisors and her upper left lateral incisor.
Bone resorption was clearly noted in the
upper right lateral position. Occlusally,
she was an incisal class 1 relationship and
group function in lateral excursions. The
unrestorable incisor teeth were removed
without raising a mucoperiosteal flap,
consistent with an early implant placement
protocol. An immediate composite resinbonded FPD with metal wings on both
canines was modeled to support the
interdental papilla and cemented using
a glass ionomer cement (Fuji IX, GC). A
6-week healing period was followed by
implant placement (Straumann® bone level
4.1 mm diameter, 12 mm length SLActive®,
Straumann®) in the central incisor positions
according to early implant protocol utilizing
a surgical stent. The lateral incisor positions
were not used for the implants due to the
requirement of a block bone graft. The
ridge was contoured using Straumann
bone ceramic at both the implant and
pontic sites, and a bilayered cross-linked

collagen membrane (Bio-Gide®, Geistlich)
in a two-layered technique. A further
healing period of 3 months was observed
prior to a second-stage surgical uncovering
of the implants. Composite (Gradia®
Direct, GC America, Inc.) was added to
the palatal surfaces of both canines to
return the patient to canine guidance. A
closed-tray impression technique was
taken in polyether (Impregum™ Penta™;

With the advances in implant surfaces and
regenerative techniques, the survival rates
of dental implants are quoted between
96% and 99%. As such, there has been a
change in ethos of implant placement that
should now be placed in a restoratively
driven manner. The success of implant
treatment is no longer merely based on
the survival of the implant, but a greater
influence is being placed on the esthetic
result achieved. The most challenging of
aspects of esthetic implant treatment lies
within the soft tissue management.

Treatment planning the replacement of
multiple teeth in the esthetic zone may be
considered to be complicated. The number
and position of the implants to be placed
should carefully consider the soft tissues

and, in particular, obtaining the correct

Clinical report
A 55-year-old female was referred for
an implant consultation (Strand on the
Green Dental Surgery, London, England).
Her main complaints were continued loss
of post crowns, poor esthetics of her
resin-bonded FPD, and the loss of bone
following the extraction of her upper right
lateral incisor. The patient was a nonsmoker and revealed no systemic medical

David Furze, BDS, MFDS RCS, qualified from Cardiff in 2000 and joined the Royal Army Dental Corp where he
achieved the rank of Major. He has served in Germany, Brunei, Bosnia, and all over the U.K. He left the army
in 2006 and has since been based in private practice. Dr. Furze has quickly increased his implant exposure by
working in Ilkley, London, and Cornwall in implant referral practices. He is currently completing his MClinDent
with Kings College London in Fixed and Removable Prosthodontics. He holds an honorary research contract at
the Eastman Dental Institute and is currently awaiting several papers for publication. He has recently completed
a month fellowship at the University of Bern, Switzerland, working alongside world-renowned implant surgeons.
He has lectured nationally and internationally on both the surgical and restorative aspects of implant dentistry,
including at the Royal College of Surgeons where he is involved in the teaching and examination of the IQE
and MJDF examinations. Dr. Furze is a member of the ITI, the BDA, and SAAD (Society for the Advancement of
Anaesthesia in Dentistry). His main area of interest is in implants in the esthetic zone, temporization of implants,
customizing impressions, and bone regeneration techniques.
Ashley Byrne, RDT, BSc (Hons), graduated from Manchester Metropolitan University in 2001 and is co-founder
and director of Byrnes Dental Laboratory in Oxfordshire, England. He has lectured across the U.K. and Europe
on CAD/CAM technology and has been involved in the research and development of the Etkon CAD/CAM
system from Straumann.

22 Implant practice

Volume 6 Number 1


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CLINICAL

Figure 4: Membrane covering

Figure 5: Provisional in situ

Figure 6: Gingival contour with provisional removed

Figure 7: Provisional attached to primary cast

Figure 8: Silicone impression of provisional

Figure 9: Impression copings in situ

Table 1

1. The provisional FPD is removed from the patient and replaced onto the initial cast. Care is taken to ensure that there is no contact of the pontics with the cast.
2. A light-bodied, fast-setting addition silicone (Provil® Novo CD 2, Heraeus Kulzer) impression is then taken of the apical half of the provisional FPD.
3. The provisional FPD is then removed and replaced in the patient.
4. Open-tray impression copings are then inserted into the cast.
5. Bis-acrylic temporary crown and bridge material, (Integrity®, Dentsply) is used to customize the impression copings to provide an exact replica of the
provisional FPD.
6. The FPD is removed from the patient, and the customized impression coping is immediately screwed into position supporting the soft tissue contour.
7. An open-tray polyether impression is taken (Impregum Penta; 3M ESPE).
A video of the technique may be accessed via www.brynesdental.com.

3M™ ESPE™), and a composite provisional
bridge was manufactured.
Following 6 months of tissue
conditioning, a customized FPD impression
was taken. The procedure is summarized
in Table 1.

An irreversible hydrocolloid impression
was taken of the provisional FPD in situ,
and a full series of clinical photographs
was emailed to the laboratory. From the
customized implant FPD, impression two
casts were constructed. The first was a
soft tissue and the second a solid stone.
An additional cast of the provisional FPD
was used as a guide for the definitive
case. The casts were mounted on a semiadjustable articulator, using the previous
lower to ensure the face bow recorded
maintained constant. A customized anterior guidance table was constructed
using light-cured acrylic resin. A silicone

24 Implant practice

index of the current provisional was taken
to aid in the design of the metal work
ensuring correct support of the porcelain.
Two gold cylinders (Straumann bone level
regular crossfit) were screwed to the cast
and cut down to fit within the index. The
metal work was then waxed up allowing
1.5 mm of clearance for the porcelain.
The wax was sprued and invested with a
phosphate investment (Fujivest® premium,
GC America, Inc.) using a 25% liquid to
distilled water mix. The FPD was cast in
Implant 58 alloy (Cendres Metaux, Biel/
Bienne, Switzerland) and allowed to bench
cool. The investment was removed, and
the metal heat treated in accordance
to the Cendres Metaux guidelines. The
metal framework was then veneered with
porcelain (GC Initial™, GC America, Inc.).
The pontic and implant emergence
were matched in the ceramic and consistent

on both the soft tissue and stone casts.
The definitive FPD is tried in at a bisque
bake stage and modifications made. The
definitive FPD is then torqued to 35N and
access holes filled with composite.

Discussion
This use of provisional restorations to
condition the tissue is now considered
routine if the optimum esthetics are to
be achieved. It would seem sensible to
provide the technical team with every
piece of information required. The use of
customized impressions in single tooth
replacement has been well documented,
but extending the customized impression
into the pontic site can further provide the
technical team with accurate soft tissue
information. The soft tissues collapse
almost immediately following the removal
of the provisional bridge. In customizing
Volume 6 Number 1