WWW.DENTALLEARNING.NET VOLUME 2 ISSUE 4 DENTAL LEARNING Knowledge for Clinical Practice A PEER-REVIEWED PUBLICATION Expanded Dental Implant Treatment David Feinerman, DMD, MD Page 3 INSIDE Earn 2 CE Credits Written for dentists, hygienists and assistants Foreword Fiona M. Collins, BDS, MBA, MA Page 2 Improving Patient Care Through Cutting-Edge Science and Technology Robert C. Vogel, DDS Page 18 Copyright 2013 by Dental Learning, LLC. No part of this publication may be reproduced or transmitted in any form without prewritten permission from the publisher. DENTAL LEARNING 500 Craig Road, Floor One, Manalapan, NJ 07726 CE Editor FIONA M. COLLINS Managing Editor JULIE CULLEN Creative Director MICHAEL HUBERT Art Director MICHAEL MOLFETTO
Expanded Dental Implant Treatment ABSTRACT Endosseous root-form dental implants were introduced approximately four decades ago. Since then, implant treatment has evolved into a predictable therapy with high implant survival and success rates as well as high success rates for implant-supported and implant-retained restorations and prostheses. However, clinicians face many challenges when treatment planning cases, including anatomical constraints, patient needs, expectations, and acceptance of implant treatment. Technological advances since the first standard diameter implants became available have included the development of wide-diameter, short and narrowdiameter implants as well as the availability of implants with sophisticated rough-surface coatings. These options help to address clinical challenges faced during treatment planning and therapy with implants, can reduce the invasiveness and length of treatment, and can increase case acceptance. ABOUT THE AUTHOR David Feinerman, DMD, MD Dr. David Feinerman is a Board-certified Oral Maxillofacial Surgeon in private practice. He is Co-Chair of the Oral Implantology Program at the Atlantic Coast Research Clinic, a current instructor in oral maxillofacial surgery at Nova University and a former instructor at the University of Connecticut. Dr. Feinerman is a reviewer for the Journal of Oral and Maxillofacial Surgery, the International Journal of Oral and Maxillofacial Surgery and for the Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology Journal. Dr. Feinerman earned his DMD from Harvard School of Dental Medicine, his MD from the University of Connecticut and completed a Fellowship in Maxillofacial Surgery at Saint Francis Hospital and Medical Center. Dr. Feinerman is the Director of the ITI Study Club of Boynton Beach and a speaker for Straumann. He can be reached at feinermanoralsurgery@yahoo.com. EDUCATIONAL OBJECTIVES The overall goal of this course is to provide the reader with information on considerations and challenges in implant treatment planning and on the role of technologies in increasing implant treatment options. On completion of this course, participants will be able to: 1. Review the development of dental implants 2. Describe the challenges clinicians face in treatment planning implant cases 3. List and describe technologies and options for overcoming treatment planning challenges 4. Describe the types of surface coatings used for implants and their impact on healing and osseointegration 5. Review the role of narrow-diameter implants, materials and treatment outcomes. Introduction Treatments with dental implants and the technologies behind them have developed considerably since the introduction of endosseous root-form standard diameter implants. These advancements include less invasive surgery and simpler treatment options for overdentures, single crowns and fixed prostheses. This has revolutionized the treatment options clinicians can provide to patients and the functionality that patients can obtain. In addition, while early dental implants had smooth surfaces, rough surfaces are now increasingly used on dental implants. These surface coatings have included calcium-like deposits, titanium plasma spray (TPS) surfaces, surfaces grit-blasted with aluminum oxide or titanium oxide, and, more recently, sandblasted and acid-etched surfaces. Treatment planning implant cases requires consideration of the patient s medical and dental history, habits, anatomy, SPONSOR/PROVIDER: This is a Dental Learning, LLC continuing education activity. COMMERCIAL SUPPORTER: This course has been made possible through an unrestricted educational grant from Straumann USA. DESIGNATION STATEMENTS: Dental Learning, LLC 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. Dental Learning, LLC designates this activity for 2 CE credits. Dental Learning, LLC is also 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 2/1/2012-1/31/2016. Provider ID: # 346890. Dental Learning, LLC is a Dental Board of California CE provider. The California Provider number is RP5062. This course meets the Dental Board of California s requirements for 2 units of continuing education. EDUCATIONAL METHODS: This course is a self-instructional journal and web activity. Information shared in this course is based on current information and evidence. REGISTRATION: The cost of this CE course is $29.00 for 2 CE credits. PUBLICATION DATE: July, 2013. EXPIRATION DATE: June, 2016. REQUIREMENTS FOR SUCCESSFUL COMPLETION: To obtain 2 CE credits for this educational activity, participants must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%. AUTHENTICITY STATEMENT: The images in this course have not been altered. SCIENTIFIC INTEGRITY STATEMENT: Information shared in this continuing education activity is developed from clinical research and represents the most current information available from evidence-based dentistry. KNOWN BENEFITS AND LIMITATIONS: Information in this continuing education activity is derived from data and information obtained from the reference section. EDUCATIONAL DISCLAIMER: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. PROVIDER DISCLOSURE: Dental Learning does not have a leadership position or a commercial interest in any products that are mentioned in this article. No manufacturer or third party has had any input into the development of course content. CE PLANNER DISCLOSURE: The planner of this course, Tricia Branch, does not have a leadership or commercial interest in any products or services discussed in this educational activity. She can be reached at tbranch@dentallearning.net. TARGET AUDIENCE: This course was written for dentists, dental hygienists, and assistants, from novice to skilled. CANCELLATION/REFUND POLICY: Any participant who is not 100% satisfied with this course can request a full refund by contacting Dental Learning, LLC, in writing. Go Green, Go Online to www.dentallearning.net take your course. Please direct all questions pertaining to Dental Learning, LLC or the administration of this course to tbranch@dentallearning.net. JULY 2013 Integrated Media Solutions/Dental Learning LLC 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. Integrated Media Solutions/Dental Learning LLC designates this activity for 2 continuing education credits. Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. 2/1/2012-1/31/2016 Provider ID: # 346890 AGD Subject Codes: 690, 691 3
DENTAL LEARNING www.dentallearning.net needs, expectations, and cost. If, based on these factors, implant treatment is indicated, planning should involve first considering the desired restorative outcome and then planning the surgical and restorative treatment from this standpoint. 1 Challenges faced by clinicians include anatomical constraints and patient acceptance. Treatment Planning Challenges Anatomical structures Key factors in the maxilla include the proximity of the maxillary sinus 2 as well as the position of the nasopalatine canal and nasal floor. In the mandible, anatomical structures of importance include the mental nerve, the inferior alveolar canal (Fig. 1), the lingual artery and the sublingual artery. 3 These structures create significant challenges in patients with edentulous atrophic ridges and partially dentate patients with missing posterior teeth. The proximity of the roots of adjacent teeth to the proposed osteotomy site also cannot be overlooked (Fig. 2) a poorly planned/executed implant can result in damage to an adjacent root/roots. Bone volume, height and width Sufficient bone must be present bucco-lingually, mesiodistally and apico-coronally for implant placement. If insufficient bone is present, ideal implant placement may be impossible without impinging on anatomical structures. In partially dentate patients, inadequate mesiodistal width can result in damage to adjacent roots, an inadequate width for placement of the fixed, implant-supported restoration, and/or poor esthetics. Narrow width can preclude standard diameter implant treatment. 4 If the implant is placed such that the biologic width cannot be achieved, and if the contact point distance from the crestal bone is too great, soft tissue esthetics and development of the papillae/gingival architecture that appears normal are not possible. 5,6 Papillae also cannot develop between 2 implants without adequate mesio-distal space between the 2 (or more) implants. 7 A narrow bucco-lingual width of bone and/or the presence of undercuts can lead to nonideal placement of an implant, particularly a standard diameter implant, with implications for esthetics and function. It can also lead to potentially disastrous perforation of the lingual (or buccal) bone plate. In addition, even if the plate is not perforated at the time of implant placement, if inadequate width of bone is present, the implant site can become fenestrated with loss of the thin plate existing at the time of implant placement. Adjunctive treatments that can resolve anatomical challenges include an invasive sinus lift or bone grafting to achieve sufficient bone height for posterior maxillary implant placement. 8 Bone grafting/guided tissue regeneration may be performed to achieve adequate bone height/ Figure 1. Proximity of inferior alveolar canal Figure 2. Proximity to adjacent roots and narrow mesio-distal width 4 VOLUME 2 ISSUE 4
Expanded Dental Implant Treatment width/volume for implant placement. Ridge splitting to widen a narrow alveolar ridge has also been advocated. 9,10 Patient satisfaction and treatment acceptance Patient satisfaction is generally high with implant-supported/implant-retained restorations. 11,12 In a multicountry prospective study, there was significantly greater patient satisfaction with implant-supported overdentures than with conventional removable dentures, including greater satisfaction with chewing ability, speech, comfort and denture stability. 13 Other studies variously reported improved chewing ability, taste, function, psychological well-being, comfort and quality of life in patients following treatment with implants of various diameters. 14,15,16,17,18 Subjective satisfaction (patient perception) and objective results following treatment with implant-supported overdentures is also correlated. 19 Subjective improvements in oral health were reported by patients receiving implants and single crowns; in a study by van Lierde, 100% patient satisfaction was reported with implant-supported single crowns. 20,21 Patient satisfaction with full-arch implantsupported fixed prostheses is also high in one study of 250 patients, 95% were either extremely satisfied or very satisfied with treatment outcomes and 98% stated they would recommend such treatment to others (Table 1). 22 Implant-supported single crowns are also cost-effective compared to a traditional three-unit bridge and do not require involvement of adjacent teeth; longer-term, implant-retained overdentures are also cost-effective although initially more costly than traditional removable full dentures. 23 Thus, patient acceptance of implant treatment results in high levels of patient satisfaction and good esthetic and functional outcomes. Nonetheless, patient nonacceptance of implant treatment is not uncommon. Reasons given include the idea that their jaw is being drilled ; a perception that there would be considerable pain and possibly infection; and dental anxiety or outright fear. 4,24,25 The relatively high cost of implant treatment also results in treatment declination. 26 Patient expectations include the desire for implant treatment that is relatively noninvasive, painless, low-cost (or at least, less costly), quick overall and with fewer treatment phases, as well as for immediate restorative care. (On the other hand, unrealistic patient expectations render treatment difficult and cause patient dissatisfaction.) Meeting these high expectations can aid case acceptance. Addressing Treatment Challenges Meeting expectations and overcoming treatment challenges with modern implant technology can result in greater case acceptance. Techniques that reduce the anxiety, cost, and invasiveness and length of treatment are available. In many cases, the use of short implants or narrow-diameter implants avoids the need for invasive adjunctive treatments such as bone grafts, simplifies treatment and makes the process less daunting for patients. The use of contemporary rough-surface coatings speeds up osseointegration and shortens length of treatment. The use of digital technology and guided surgery allows for flapless procedures and ideal implant placement. Digital technology has provided the ability to more accurately assess the volume, height and width of bone at proposed osteotomy sites as well as the location of key anatomical structures. This improves treatment planning and aids in the selection of an implant with an appropriate length and diameter. TABLE 1. Patient satisfiers following implant treatment Improved chewing ability Improved speech Improved denture stability Greater comfort Improved taste Improved function Psychological well-being Improved quality of life JULY 2013 5
DENTAL LEARNING www.dentallearning.net The use of narrow-diameter implants Narrow-diameter implants are useful where insufficient mesio-distal width is available for standard diameter implants (~4 mm) such as in the case of missing lateral incisors or where insufficient bucco-lingual bone width is available. 27 Inadequate bone width may also occur only at specific depths of the proposed osteotomy site (e.g., due to converging root apices of adjacent teeth or due to undercuts). Narrowdiameter implants may also be useful in situations where the existing bone and angulation would otherwise preclude use of a screw-retained restoration (Fig. 3). Narrow-diameter implants are available in diameters from 1.8 mm ( mini-implants ) to around 3.5 mm. Using a narrow-diameter implant in areas with a narrow mesiodistal space 28 can allow sufficient space for adequate soft tissue development (a space of 3 mm between implants has been found to be suitable). 29 Narrow- and standard diameter implants have similar survival and success rates. In a 5-year prospective trial involving more than 600 implants placed in 200 patients, the 5-year survival rate for TPS screw and cylinder implants was 99.4% and the success rate was 92.5%. 30 In a study of 3.0 mm and 3.5 mm diameter implants (n=510 in total), of which 50% were restored immediately but not loaded, the combined implant survival rate was 99.4%. 31 In a 10-year retrospective study, implants with a sandblasted, acid-etched (SLA) surface (n=511) were placed in 303 partially edentulous patients. Most of the implants placed were 4.1 mm standard diameter implants. The 10-year implant survival rate was 98.8% and the 10-year implant success rate was 97%. 32 Yaltirik et al found a cumulative 5-year implant survival rate of 93.75% (5 years in function) with 3.3 mm narrow-diameter implants (n=48) in 28 partially dentate patients. 33 Zinsli et al placed narrow-diameter (3.3 mm) implants (n=298) in 149 patients receiving restorations (overdentures/fixed partial dentures/single crowns), demonstrating a cumulative 5-year survival rate of 98.7%. 27 Lastly, a literature review of 41 studies on narrow small-diameter implants (n=10,093), with diameters ranging from 1.8 mm to 3.5 mm, and with a follow-up of 5 months to 9 years, found an implant survival rate that was consistently >90% ( 95% in 22 of the studies). Both flap and flapless protocols had been used 26 (Table 2). Rough implant surfaces and osseointegration An osteotomy site that closely matches the dimensions of the implant is important to achieve primary stability. Longterm implant stability is achieved through osseointegration, whereby bone grows onto and into the implant surface. Rough implant surfaces increase the amount of surface area available, thereby increasing bone-to-implant contact (BIC) and the area available for osseointegration. 34 It has also been Figure 3a. CBCT scan and CBCT slice postoperatively Figure 3b. Screw-retained restoration supported by a 3.3 mm diameter implant 6 VOLUME 2 ISSUE 4
Expanded Dental Implant Treatment hypothesized, based on in vitro cell studies, that a rough surface changes the host response at the cellular level and results in greater differentiation of osteoblasts as well as increased prostaglandin and TGF production. 35 Rough surfaces can result in improved results in potentially compromised cases. One study compared the outcomes for smooth-surface implants (n=2,182) placed in 593 patients from 1991 to 1996 and rough-surface implants (n=2,425) in 905 patients between 2001 and 2005. While both rough and smooth surfaces had a survival rate in excess of 94%, a length of less than 10 mm was a risk factor for failure of smooth-surface implants but not for rough-surface implants. 36 Several studies have demonstrated an increased rate of healing and greater BIC and osseointegration with roughsurface implants. Higher removal torque values (in Ncm) have also been observed. TPS surface-coated implants were conceived in the 1980s. Later developments led to the introduction of sandblasted and etched surfaces that were shown in research to further enhance the rate of healing, BIC and osseointegration. 37,38 In a retrospective analysis with an observation period of up to 5 years, implant-supported single crowns, fixed partial dentures, removable dentures and fixed dentures were provided. All implants placed had SLA surfaces and were restored using an early loading protocol of 6 weeks for the mandible and 12 weeks for the maxilla, with an implant success rate of 99.4%. 39 In a prospective 3-year multicenter study, immediate and early loading of SLActive surfacetreated implants (n=383) on 266 patients was conducted. At five months, during interim assessment, the implant survival rate was 98% in the immediate and 97% in the early loading group, demonstrating the ability to immediately load these implants. The mean bone level change was slightly higher for the immediate loading group. 40 Shorter healing times can result in the ability to restore and load implants earlier. There is an increasing trend to load implants either immediately or to perform early loading. Provided that treatment is well-executed and a high level of primary stability exists, one meta-analysis found no differences in failure rates and outcomes among immediate, early or conventional loading. 41 However, a review concluded that in the case of mandibular overdentures supported by 2 implants, conventional loading continues to be standard treatment. 42 An early loading protocol at 6 to 8 weeks post-placement for implants with rough surfaces that supported single crowns and fixed prostheses in the posterior mandible, as well as immediate loading, was also supported in a review of 19 papers by Cordaro et al, including 8 on early loading. 43 Most recently, an SLActive surface coating has been used on a zirconium-titanium implant. Titanium-zirconium offers greater tensile and fatigue strength than titanium, which may be useful in some challenging situations requiring greater implant strength, including for narrow-diameter implants. 44 In addition, in such challenging situations, this TABLE 2. Survival rates for narrow-diameter implants Lead author Study/trial # implants Survival rate Cochran et al (2011) 5-year prospective 626 99.40% Degidi et al (2008) 7-year prospective 510 99.40% Buser et al (2012) 10-year retrospective 511 98.80% Yaltirik et al (2011) 5-year retrospective 48 93.75% Zinsli et al (2004) 10-year prospective 298 98.70% Sohrabi et al (2012) Review of 41 studies >10,000 All >90% JULY 2013 7
DENTAL LEARNING www.dentallearning.net increased strength might enable the use of 4.1 mm diameter instead of 4.8 mm diameter implants, or 3.3 mm diameter implants instead of 4.1 mm diameter implants to accommodate the available bone and remove less bone during creation of the osteotomy. Zirconium and titanium have also been shown to have similar properties with respect to microbiological findings. 45 In a double-blind randomized controlled trial comparing zirconium-titanium and titanium implants in a split-mouth model with mandibular overdentures retained by 2 implants, both the survival and success rates were similar and slightly higher for the titanium-zirconium implants with an SLActive coating compared to SLA titanium implants (98.9% vs 97.8% for survival rates and 96.6% vs 94.4% for success rates). There was no significant difference in the peri-implant bone levels at 1 year. 46 Titanium-zirconium implants with SLActive surface coatings have also been shown in animal studies to offer greater osseointegration than SLA titanium implants 47 and a faster healing time. 48 A pilot study also demonstrated excellent osseointegration, good survival and success rates at 24 months postplacement, as well as good crestal bone levels. 49 Given the improved osseointegration observed with these implants, it can be hypothesized that these may prove useful in the future by allowing the use of longer posterior cantilevers or cantilevers from a single tooth. They may also prove to be useful in some clinical situations where bone physiology is compromised by the use of medications (bisphosphonates, steroids or disease-modifying anti-rheumatic drugs), previous head and neck radiation, diabetes, or osteoporosis. The cases below show the use of 3.3 mm narrow-diameter zirconium-titanium implants. Case Studies Case 1. Lower anterior implant-supported fixed partial denture (bridge) The patient was referred from her general dentist for implant placement. The patient s lower anterior teeth had been restored many years earlier with crowns, and recurrent caries had resulted in the crowns no longer fitting and loss of tooth structure (Fig. 4). In consultation between Figure 4. Preoperative clinical view Figure 5a. Preoperative CBCT 5b. Preoperative CBCT slices showing narrow bone 8 VOLUME 2 ISSUE 4
Expanded Dental Implant Treatment Figure 6a, b. CAD simulation of proposed implant placement Figure 9. Drilling the osteotomy sites for 3.3 mm narrowdiameter zirconium-titanium SLActive implants Figure 7. Laboratory-fabricated provisional prosthesis Figure 10. Abutments placed Figure 8. Atraumatic extraction of roots and surgical guide in position Figure 11. Provisional restoration seated JULY 2013 9
DENTAL LEARNING www.dentallearning.net Figure 12. Postplacement CBCT Figure 13. Postplacement CBCT slices the patient and her regular dentist, it was decided to place a fixed partial denture supported by 2 implants. During treatment planning, the position of the mental foramena and nerves was ascertained, as well as the volume, height and width of bone available for implant placement. Given the narrow anterior ridge, 3.3 mm narrow-diameter implants were indicated, and zirconium-titanium SLActive coated implants were chosen. CAD/CAM was used to scan and create models, with the lower model used to create a surgical guide and a provisional restoration. During treatment planning, CAD simulation had been used to determine the most optimal implant placement that would ensure placement in adequate bone and in appropriate positions for the envisioned final restoration. At the time of surgery, the roots were extracted atraumatically, and after placement of the surgical guide in position, the osteotomy sites were created and the implants placed. After seating the abutments, the temporary restoration was cemented and all excess cement removed, taking care to ensure the restoration was out of occlusion (i.e., not loaded). A CBCT scan and slices were taken to ensure the position of the implants was correct. At two weeks postoperatively, the tissues were healing well and the patient was satisfied with the provisional result (Figs. 5-14). She was referred back to her dentist for the definitive fixed partial denture, which would be fabricated a few weeks later. Figure 14. Two weeks postoperative view Case 2. Upper lateral incisor The patient in this case was a regular dental attender and was referred with a horizontal fracture in tooth #10 for extraction and implant placement. In this case, during treatment planning it was determined that the narrow mesiodistal and bucco-palatal ridge width would preclude use of a standard diameter implant. Computer-aided design was again used to simulate implant positioning and determine the best angulation and position that would allow for the biologic width, the development of a normal gingival architecture and thus for an optimized esthetic restorative result. Due to the narrow mesio-distal width available between teeth #9 and #11, as well as bucco-palatal width and the 10 VOLUME 2 ISSUE 4
Expanded Dental Implant Treatment need for sufficient space for optimal soft tissue development, a 3.3 mm narrow-diameter implant was again selected. A surgical guide was fabricated and used for accurate immediate implant placement after the root had been extracted. The laboratory-fabricated crown was then screw-retained to the implant. The postoperative image shows good contouring and dimensions for the provisional restoration and adequate width for papillae. The patient was satisfied with the ease of surgery, esthetic provisional crown and rapid treatment (Figs. 15-20). She was referred back to her dentist for the final restoration. Figure 16b. CAD simulation of implant positioning Figure 15. Preoperative clinical view Figure 17. Surgical guide Figure 16a. CAD simulation of implant positioning showing mesio-distal and bucco-palatal slices Figure 18. Prefabricated provisional restoration JULY 2013 11
DENTAL LEARNING www.dentallearning.net Figure 19a, b. Postoperative images of placement of 3.3 mm narrow-diameter zirconium-titanium SLActive implants Figure 20a. Seated provisional screw-retained crown immediately post-op Figure 20b. Seated provisional screw-retained crown immediately post-op Summary Clinicians face many challenges when treatment planning cases for implants. These include anatomical constraints, patient declination and high expectations. Patient expectations include a desire for less aggressive procedures with faster healing times and minimal discomfort. The treatment options available today allow clinicians to offer implant therapy to patients who were not previously candidates for implant therapy without adjunctive treatment due to narrow mesio-distal spaces/interdental spaces, limited bone or treatment complexity. This includes the development of combinations of surface technology and implant material designed to give clinicians more confidence when placing small-diameter implants and to give the restoring doctor expanded prosthetic options when taking implant-level impressions. As advances in dentistry and implant dentistry continue to evolve, technologies continue to develop that offer flexibility and solutions to treatment challenges. References 1. Patel N. Integrating three-dimensional digital technologies for comprehensive implant dentistry. J Am Dent Assoc. 2010;141:20S-24S. 2. Nunes LS, Bornstein MM, Sendi P, Buser D. Anatomical characteristics and dimensions of edentulous sites in the posterior maxillae of patients referred for implant therapy. Int J Periodontics Restorative Dent. 2013 May-Jun;33(3):337-45. 3. Froum S, Casanova L, Byrne S, Cho SC. Risk assessment before extraction for immediate implant placement in the posterior mandible: a computerized tomographic scan study. J Periodontol. 2011 Mar;82(3):395-402. 4. Meijer HJ, Cune MS. Treatment of a single-tooth space in the occlusal system. Ned Tijdschr Tandheelkd. 2012;119(12):621-4. 5. Hermann JS, Buser D, Schenk RK, Schoolfield JD, Cochran DL. Biologic Width around one- and two-piece titanium implants. Clin Oral Implants Res. 2001 Dec;12(6):559-71. 6.Degidi M, Novaes AB Jr, Nardi D, Piattelli A. Outcome analysis of immediately placed, immediately restored implants in the esthetic area: the clinical relevance of different interimplant distances. J Periodontol. 2008 Jun;79(6):1056-61. 7. Elian N, Jalbout ZN, Cho S-C, Froum S, Tarnow DP. Realities and limitations in the management of the interdental papilla be- 12 VOLUME 2 ISSUE 4
Expanded Dental Implant Treatment tween implants: Three case reports. Pract Proced Aesthet Dent. 2003;15(10):737-44. 8. Krennmair G, Krainhöfner M, Schmid-Schwap M, Piehslinger E. Maxillary sinus lift for single implant-supported restorations: A clinical study. Int J Oral Maxillofac Impl. 2007;22(3):351-8. 9. Tasoulis G, Yao SG, Fine JB. The maxillary sinus: Challenges and treatments for implant placement. Comp Cont Educ Dent. 2011;32(1):10-9. 10. Koo S, Dibart S, Weber H-P. Ridge-splitting technique with simultaneous implant placement. Comp Cont Educ Dent. 2008;29(2):106-10. 11. Johannsen A, Wikesjö U, Tellefsen G, Johannsen G. Patient attitudes and expectations of dental implant treatment: A questionnaire study. Swed Dent J. 2012;36(1):7-14. 12. Borges Tde F, Mendes FA, de Oliveira TR, Gomes VL, do Prado CJ, das Neves FD. Mandibular overdentures with immediate loading: Satisfaction and quality of life. Int J Prosthodont. 2011;24(6):534-9. 13. Rashid F, Awad MA, Thomason JM, et al. The effectiveness of 2-implant overdentures: A pragmatic international multicentre study. J Oral Rehabil. 2011;38(3):176-84. 14. Turkyilmaz I, Company AM, McGlumphy EA. Should edentulous patients be constrained to removable complete dentures? The use of dental implants to improve the quality of life for edentulous patients. Gerodontol. 2010;27(1):3-10. 15. Geckili O, Bilhan H, Mumcu E, Dayan C, Yabul A, Tuncer N. Comparison of patient satisfaction, quality of life, and bite force between elderly edentulous patients wearing mandibular two implant-supported overdentures and conventional complete dentures after 4 years. Spec Care Dentist. 2012;32(4):136-41. 16. Zembic A, Wismeijer D. Patient-reported outcomes of maxillary implant-supported overdentures compared with conventional dentures. Clin Oral Implants Res. 2013 Apr 15. [Epub ahead of print] 17. Shatkin TE, Petrotto CA. Mini dental implants: A retrospective analysis of 5640 implants placed over a 12-year period. Compend Contin Educ Dent. 2012;33(Spec Iss 3):1-7. 18. Cochran DL, Jackson JM, Jones AA, Jones JD, Kaiser DA, Taylor TD, Weber HP, Higginbottom FL, Richardson JR, Oates T. A 5-year prospective multicenter clinical trial of non-submerged dental implants with a titanium plasma-sprayed surface in 200 patients. J Periodontol. 2011;82(7):990-9. 19. Vieira RA, Melo AM, Sartori IA, Budel L, Gama JC, Thomé G. Benefits of rehabilitation with implants in masticatory function: Is patient perception of change in accordance to the real improvement? J Oral Implantol. 2012 Feb 29. [Epub ahead of print] 20. Ponsi J, Lahti S, Rissanen H, Oikarinen K. Change in subjective oral health after single dental implant treatment. Int J Oral Maxillofac Implants. 2011;26(3):571-7. 22. Van Lierde K, Browaeys H, Corthals P, Mussche P, Van Kerkhoven E, De Bruyn H. Comparison of speech intelligibility, articulation and oromyofunctional behaviour in subjects with single-tooth implants, fixed implant prosthetics or conventional removable prostheses. J Oral Rehabil. 2012;39(4):285-93. 22. Babbush CA. Posttreatment quantification of patient experiences with full-arch implant treatment using a modification of the OHIP-14 questionnaire. J Oral Implantol. 2012 Jun;38(3):251-60. 23. Vogel R, Smith-Palmer J, Valentine W. Evaluating the health, economic implications and cost-effectiveness of dental implants: A literature review. Int J Oral Maxillofac Implants. 2013;28(2):343-56. 24. Ellis JS, Levine A, Bedos C, Mojon P, Rosberger Z, Feine J, Thomason JM. Refusal of implant supported mandibular overdentures by elderly patients. Gerodontol. 2010;28(1):62-8. 25. Narby B, Hallberg U, Bagewitz IC, Soderfeldt B. Grounded theory on factors involved in the decision-making processes of patients treated with implant therapy. Int J Prosthodont. 2012 May-Jun;25(3):270-8. 26. Sohrabi K, Mushantat A, Esfandiari S, Feine J. How successful are small-diameter implants? A literature review. Clin Oral Implants Res. 2012 May;23(5):515-25. 27. Zinsli B, Sägesser T, Mericske E, Mericske-Stern R. Clinical evaluation of small-diameter ITI implants: A prospective study. Int J Oral Maxillofac Implants. 2004;19(1):92-9. 28. Froum SJ, Cho SC, Cho YS, Elian N, Tarnow D. Narrow-diameter implants: A restorative option for limited interdental space. Int J Periodont Restor Dent. 2007; 27: 449-55. 29. Teughels W, Merheb J, Quirynen M. Critical horizontal dimensions of interproximal and buccal bone around implants for optimal esthetic outcomes: A systematic review. Clin Oral Implants Res. 2009; 20 (Suppl 4): 134-45. 30. Cochran DL, Jackson JM, Jones AA, Jones JD, Kaiser DA, Taylor TD, Weber HP, Higginbottom FL, Richardson JR, Oates T. A 5-year prospective multicenter clinical trial of non-submerged dental implants with a titanium plasma-sprayed surface in 200 patients. J Periodontol. 2011;82(7):990-9. 31. Degidi M, Piattelli A, Carinci F. Clinical outcome of narrow- JULY 2013 13
DENTAL LEARNING www.dentallearning.net diameter implants: A retrospective study of 510 implants. J Periodontol. 2008 Jan;79(1):49-54. 32. Buser D, Janner SF, Wittneben JG, Brägger U, Ramseier CA, Salvi GE. 10-year survival and success rates of 511 titanium implants with a sandblasted and acid-etched surface: a retrospective study in 303 partially edentulous patients. Clin Implant Dent Relat Res. 2012;14(6):839-51. 33. Yaltirik M, Gökçen-Röhlig B, Ozer S, Evlioglu F. Clinical evaluation of small diameter Straumann implants in partially edentulous patients: A 5-year retrospective study. J Dent, Tehran U Med Sci. 2011;8(2):75-80. 34. Cochran DL. A comparison of endosseous dental implant surfaces. J Periodontol. 1999 Dec;70(12):1523-39. 35. Nasatzky E, Gultchin J, Schwartz Z. The role of surface roughness in promoting osteointegration. Refuat Hapeh Vehashinayim. 2003;20(3):8-19, 98. 36. Balshe AA, Assad DA, Eckert SE, Koka S, Weaver AL. A retrospective study of the survival of smooth- and rough-surface dental implants. Int J Oral Maxillofac Implants. 2009 Nov- Dec;24(6):1113-8. 37. Koh J-W, Yang J-H, Han J-S, Lee J-B, Kim S-H. Biomechanical evaluation of dental implants with different surfaces: Removal torque and resonance frequency analysis in rabbits. J Adv Prosthodont. 2009;1:107-12. 38. Ivanoff CJ, Hallgren C, Widmark G, Sennerby L, Wennerberg A. Histologic evaluation of the bone integration of TiO(2) blasted and turned titanium microimplants in humans. Clin Oral Implants Res. 2001 Apr;12(2):128-34. 39. Nelson K, Semper W, Hildebrand D, Özyuvaci H. A retrospective analysis of sandblasted, acid-etched implants with reduced healing times with an observation period of up to 5 years. Int J Oral Maxillofac Impl. 2008;23(4):726-32. 40. Zöllner A, Ganeles J, Korostoff J, Guerra F, Krafft T, Brägger U. Immediate and early non-occlusal loading of Straumann implants with a chemically modified surface (SLActive) in the posterior mandible and maxilla: Interim results from a prospective multicenter randomized-controlled study. Clin Oral Implants Res. 2008;19(5):442-50. 41. Esposito M, Grusovin MG, Willings M, Coulthard P, Worthington HV. Interventions for replacing missing teeth: Different times for loading dental implants. Cochrane Database Syst Rev. 2007(2). 42. Hunter P. Limited evidence for evaluating differences in marginal bone loss between conventional, early and immediate loading protocols for mandibular two-implant overdentures. J Am Dent Assoc. 2011 April;142:427-8. 43. Cordaro L, Torsello F, Roccuzzo M. Implant loading protocols for the partially edentulous posterior mandible. Int J Oral Maxillofac Implants. 2009;24 Suppl:158-68. 44. Norm ASTM F67. 45. de Oliveira GR, Pozzer L, Cavalieri-Pereira L, de Moraes PH, Olate S, de Albergaría Barbosa JR. Bacterial adhesion and colonization differences between zirconia and titanium implant abutments: An in vivo human study. J Periodontal Implant Sci. 2012;42:217-23. 46. Al-Nawas B, Brägger U, Meijer HJA, Naert I, Persson, et al. A double-blind randomized controlled trial (RCT) of titanium- 13zirconium versus titanium grade IV small-diameter bone level implants in edentulous mandibles: Results from a 1-year observation period. Clin Implant Dent Relat Res. 2011;1-9. 47. Thoma DS, Jones AA, Dard M, Grize L, Obrecht M, Cochran DL. Tissue Integration of a New Titanium-Zirconium Dental implant: A Comparative Histologic and Radiographic Study in the Canine. J Periodontol. 2011 Oct;82(10):1453-61. 48. Gottlow J, Dard M, Kjellson F, Obrecht M, Sennerby L. Evaluation of a new titanium-zirconium dental implant: A biomechanical and histological comparative study in the mini pig. Clin Implant Dent Relat Res. 2012 Aug;14(4):538-45. 49. Barter S, Stone P, Brägger U. A pilot study to evaluate the success and survival rate of titanium-zirconium implants in partially edentulous patients: Results after 24 months of follow-up. Clin Oral Impl Res. 2011;(10):1-9. Webliography Alsabeeha N, Atieh M, Payne AG. Loading protocols for mandibular implant overdentures: a systematic review with meta-analysis. Clin Implant Dent Relat Res. 2010 May;12 Suppl 1:e28-38. Abstract available at: http://www.ncbi.nlm.nih.gov/ pubmed/19438962. Esposito M, Grusovin MG, Polyzos IP, Felice P, Worthington HV. Timing of implant placement after tooth extraction: immediate, immediate-delayed or delayed implants? A Cochrane systematic review. Eur J Oral Implantol. 2010 Autumn;3(3):189-205. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/20847990. Strub JR, Jurdzik BA, Tuna T. Prognosis of immediately loaded implants and their restorations: a systematic literature review. J Oral Rehabil. 2012 Sep;39(9):704-17. Abstract available at: http:// www.ncbi.nlm.nih.gov/pubmed/22607161. 14 VOLUME 2 ISSUE 4
Expanded Dental Implant Treatment CEQuiz To complete this quiz online and immediately download your CE verification document, visit www.dentallearning.net/eit-ce, then log into your account (or register to create an account). Upon completion and passing of the exam, you can immediately download your CE verification document. We accept Visa, MasterCard, and American Express. 1. are now increasingly used on dental implants. a. Plastic resins b. Smooth surfaces c. Rough surfaces d. a and b 2. is a rough surface coating that has been used for root-form endosseous implants. a. Titanium plasma spray b. Calcium-like deposits c. Titanium oxide 3. Key factors to consider during implant treatment in the maxilla include the. a. proximity of the maxillary sinus b. position of the nasopalatine canal c. position of the nasal floor 4. Sufficient bone must be present for implant placement. a. bucco-lingually b. mesio-distally c. apico-coronally 5. Development of a papilla/gingival architecture that appears normal is not possible if. a. the contact point distance from the crestal bone is too great b. a rough surface implant is used c. biologic width cannot be achieved d. a and c 6. The presence of undercuts can lead to. a. nonideal placement of an implant b. difficulty seating an abutment c. difficulty using zirconia abutments 7. If inadequate width of bone is present, the implant site can become. a. wider b. fenestrated c. negligent 8. Ridge splitting has been advocated to. a. lengthen a deficient ridge b. widen a narrow ridge c. remove undercuts 9. In a multicountry prospective study, there was significantly greater patient satisfaction with than with. a. conventional dentures; fixed restorations b. conventional dentures; implant-supported overdentures c. implant-supported overdentures; fixed restorations d. implant-supported overdentures; conventional dentures 10. Subjective satisfaction and objective results after treatment with implant-supported overdentures is. a. correlated b. uncorrelated c. difficult to measure d. none of the above 11. In a study by van Lierde, patient satisfaction was reported with implant-supported single crowns. a. 85% b. 90% c. 95% d. 100% 12. is a patient satisfier after implant treatment. a. Improved chewing ability b. Improved function c. Psychological well-being 13. Patient expectations with respect to implant treatment include the desire for. a. relatively noninvasive treatment b. quicker treatment and fewer treatment phases c. immediate restorative care 14. In many cases, the use of short implants or narrow-diameter implants. a. avoids the need for invasive adjunctive treatments b. makes the process less daunting for patients c. simplifies treatment JULY 2013 15
DENTAL LEARNING www.dentallearning.net CE QUIZ 15. Narrow-diameter implants are useful where insufficient is available. a. apico-coronal length b. mesio-distal width c. space for a platform 16. In some situations, bone angulation could preclude use of if a standard diameter implant is used. a. a screw-retained restoration b. a bilateral prosthesis c. an impression d. none of the above 17. A space of 3 mm between implants has been found to be suitable for. a. wide diastemas b. adequate soft tissue development c. short, wide implants d. none of the above 18. Narrow- and standard diameter implants have. a. disparate survival and success rates b. similar survival and success rates c. similar survival rates but disparate success rates d. none of the above 19. An osteotomy site that closely matches the dimensions of the implant is important to achieve. a. primary stability b. secondary stability c. tertiary stability d. a and b 20. Rough implant surfaces increase the amount of. a. bone-to-implant contact b. osteotomy activity c. the area available for osseointegration d. a and c 21. It has been hypothesized that a rough surface changes the. a. implant surface response b. host response c. periodontal parameters 22. Based on in vitro studies, it is believed that greater differentiation of osteoblasts is found using implants with. a. rough surfaces b. smooth surfaces c. calcific surfaces 23. has/have been observed with rough surface implants. a. An increased rate of healing b. Higher removal torque values c. Less biodiversity d. a and b 24. There is an increasing trend to load implants. a. immediately b. earlier c. later d. a and b 25. A review concluded that in the case of mandibular overdentures supported by 2 implants that loading continues to be standard treatment. a. conventional b. delayed c. early d. immediate 26. offers greater tensile and fatigue strength than titanium. a. Titanium-disilicate b. Titanium-zirconium c. Titanium-lanthanite 27. and titanium have been shown to have similar properties with respect to microbiological findings. a. Zirconium b. Disilicate c. Lanthanite 28. can compromise bone physiology. a. Bisphosphonates b. Previous head and neck radiation c. Anti-rheumatic drugs 29. During treatment planning, CAD simulation can be used to determine the. a. most optimal implant placement b. most optimal implant surface c. least strength required d. a and b 30. The treatment options available today allow clinicians to offer implant therapy to patients who were not previously candidates for implant therapy. a. without adjunctive treatments b. under any circumstances c. due to geographic location 16 VOLUME 2 ISSUE 4
CE ANSWER FORM (E-mail address required for processing) Expanded Dental Implant Treatment *Name: Title: Specialty: *Address: *E-mail: *City: *State: *Zip: *Telephone: License renewal date: AGD Identification No. Practice Name EDUCATIONAL OBJECTIVES Review the development of dental implants Describe the challenges clinicians face in treatment planning implant cases List and describe technologies and options for overcoming treatment planning challenges Describe the types of surface coatings used for implants and their impact on healing and osseointegration Review the role of narrow-diameter implants, materials and treatment outcomes If you have any questions, please email questions@dentallearning.net or call Dental Learning at 888-724-5230. COURSE EVALUATION Please evaluate this course using a scale of 5 to 1, where 5 is excellent and 1 is poor 1. To what extent were the course objectives accomplished overall? 5 4 3 2 1 2. Please rate your overall mastery of the educations objectives? 5 4 3 2 1 3. How would you rate the educational methods? 5 4 3 2 1 4. How do you rate the author s mastery of the topic? 5 4 3 2 1 5. Please rate the instructor s effectiveness. 5 4 3 2 1 6. Do you feel the references were adequate? 5 4 3 2 1 7. Would you participate in a similar course? 5 4 3 2 1 8. Was any subject matter confusing please describe. 5 4 3 2 1 Price: $29 CE Credits: 2 Save time and the environment by taking this course online. To obtain credits: 1. Read the entire course. 2. Complete this entire answer sheet in either pen or pencil. 3. Mark only one answer for each question. 4. A score of 70% will earn your credits. OR For Immediate results: 1. Read the entire course 2. Go to www.dentallearning.net/eit-ce 3. Choose this course from the course listing 4. Log in to your account or register to create an account 5. 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