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SHORT DENTAL IMPLANT S IN REDUCED ALVEOLAR BONE HEIGHT

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clinical case studies and abstract of lectures

symposium.

technological and other developments at A.B. Dental Devices.

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Table of contents

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US ING AN IMPLANT MOUNT A S A TOOL FOR B ITE R EGI S TRATION R ECORD S

C HARACTERIZATION OF 5 DIFFERENT IM-PLANT SURFACE S AND T HEIR E FFECT ON OSS e OI n T egr ATIO n: A S T u DY In D Og S

Imp LA n T S upp Or T e D-TITA n Ium mILL e D BA r Over- Den T ure S

T HE EXPERT S RECOMMEND: " IMMEDIATE S cre W-re TAI ne D LOADI ng" On ImpLA n TS – F Or m Ax Imum c OmFO r T AND CONVENIENCE

ABST r Ac TS F r Om A.B. D en TAL'S FI r ST In T ern ATIO n AL SY mpOSI um

"IMMEDIATE LOADING MEAN S QUICK AND IMMEDIATE TREATMENT WITH ALL IT S ADVANTAGE S "

T He u S e OF T emp Or Ar Y ImpLA n TS FO r FI xe D pr Ov ISIO n AL re STO r ATIO n, In THE CA S E OF LATERAL AUGMENTATION OF THE UPPER JAW

A.B. Dental Academic Board:

Head: Prof. Eli Ravivmembers: Dr. Benjamin Retzkin

Dr. Gustavo YatzkaierDr. Yehuda Gill

Fig 1 (left) pretreatment radiograph, showing limited bone height.Fig 2 (center) c linical ridge mapping.Fig 3 (right) Schematic illustration of an A. B. short implant.

Fig 4 (left) postsurgical clinical presentation of the healing screw.Fig 5 (center) r adiograph obtained after the placement of an I5, 6 ! 6 mm implant with healing abutment.Fig 6 (right) c linical occlusal view of the implant restorative platform.

*SHO RT DE NTA L IM P L A NTS IN RED UC ED A LV E OL AR B ON E H E IG HT

e li r aviv, D mD1/Antony Turcotte, D mD2/mili Harel- r aviv, D mD3

r educed alveolar bone height is very common in the posterior jaws. The current treatment modality to replace the miss -

in the mandible. These procedures are invasive and require more time and cost. Short dental implants are used as an alternative treatment modality to bone grafting procedures. To enhance success rate, certain principles should apply. Short implants could provide comparable results to those of longer implants. The present article reviews the current literature on the use of short implants, discusses the biomechanical considerations when utilizing short implants, and presents a case.Key words:

c linicians often face challenges when placing implants in an area of reduced alveolar bone height. This is seen in both the maxilla and mandible due to alveolar bone resorption, pneumatization of maxillary sinuses, and the presence of anatomical structures (eg, inferior alveolar nerve). The accepted treatment for this condition has been conventionally to perform a sinus lift and bone grafting procedure. Despite good predictability and success rate of grafting procedures, patients are often reluctant to undergo the surgery because of the risks, morbidities, cost of the procedure, and the stress of undergoing an invasive procedure. Short implants (≥ 8 mm) have been introduced recently as a potential alternative treatment to bone grafting procedures in patients with limited alveolar bone height in the posterior maxilla and mandible.This article reviews the current literature on the use of short implants and presents a case treated with short implants.

C ASE REP ORT

A 47-year-old white female in good general health presented with porcelain fracture on a three-unit porcelain-fused-to-pF m-F p

pontic area with metal exposed. c linical examination revealed wear facets on the occlusal aspects of all teeth.The attrition of the teeth was compatible with bruxism. The parafunction could be the etiologic factor for the porcelain fracture. In addition to the clinical examination, periapical radiograph showed excellent marginal adaptation of the re -tainers (second premolar and second molar) (Fig 1). The patient was not aware of the parafunction and never had a nightguard prescribed.

1Associate professor, Faculty of Dentistry; Director of prosthodontics, Department of Dentistry, Sir mortimer B. Davis Jewish g eneral Hospital, mcg ill u niversity, montreal, c anada

2r esident in the mDr [Au: please expand.] program, Department of Dentistry, Sir mortimer B.Davis Jewish g eneral Hospital, montreal, c anada.

3Department of Dentistry, Sir mortimer B. Davis Jewish g eneral Hospital, montreal, c anada.

C orrespondence: Dr e li r aviv, Director of prosthodontics, Department of Dentistry, Sir mortimer B. Davis Jewish g eneralHospital, 3750 c ote des neiges, montreal, Qc. c anada H3S 1Y9.e mail: raviv.eli@gmail.com

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Three treatment options were presented to the patient: (1) replacement of the pF m-F pD with a new pF m-F pD; (2) to

molar with an endosseous implant-retained crown; and (3) removal of the remaining porcelain from the pontic and cast -ing of a pF m single onlay ( uBecause of lower sinus location and lack of alveolar bone height for placement of an implant of conventional length, sinus lift procedure was introduced to the patient as an adjunct to the implant surgery. Being a health care provider and working as a nurse in a hospital, she was reluctant to accept the sinus lift procedure, as for her it was an invasive procedure that she did not approve. The idea of keeping the two crowns intact was appealing to the patient. The option of placing a short-length implant was presented to the patient and discussed with her. The patient accepted the short implant option.Before implant placement, alveolar bone volume was measured using panoramic and periapical radiographs and clini -cal ridge mapping.Bone volume was found to be 7 mm in height and 8 mm in width (see Figs 1 and 2).A short, tapered, wide-diameter implant (A. B. Dental Devices, I5 (a tapered, groovy implant) 6 x 6 mm) was placed in the edentulous site (Fig 3). This self-tapping implant design consists of very sharp and deep threads, which increase the implant surface area, resulting in an improved primary stability . The implant was torqued to 32 n cm.According to a single-stage procedure (nonsubmerged), a healing screw was connected (Fig 4). periapical radiograph

healing process was within normal limits. n o adverse e�ects were reported.Six months postimplantation the healing screw was removed (Fig 6).

polyether, heavy-body impression material, Impregum and light-body material, permadyne (3 m e S pe pentamix) were used to pick up the impression coping (Fig 8). A straight hexlocked abutment was placed, using a resin jig for its ideal orientation ( gc pattern r esin LS, gc ) (Fig 9). A pF m crown was fabricated and temporarily cemented (Tempbond, Kerr) (Fig 10). A postinsertion radiograph was taken showing the platform switch concept used to better maintain the alveolar bone crest (Fig 11). To address the parafunc -tion, a light occlusal contact in centric occlusion and complete disclusion in lateral and protrusive excursions were per -formed. In addition, a Hawley bite appliance with anterior platform was prescribed as a nightguard.

Fig 7 (left) cFig 8 (right) Final impression obtained.

Fig 9a (left) Hex-locked abutment on model with a resin jig for proper placement.Fig 9b (center) Abutment positioned in the mouth with a resin jig.Fig 9c (right) Final abutment in place.

Fig 10 (left) pF m crown, temporarily cemented with Tempbond.Fig 11 (right) posttreatment radiograph of the implant, abutment, and crown.

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DIS CU SS ION

implants. most of the studies consider short implants as being less than 10 mm, 5–7 while few studies have included implants of 7 mm or less in length. 8,9 Implant length is generally selected according to the maximum amount of bone height present at the recipient site. This is based on the principle that longer implants provide better primary stability and a favorable distribution of occlusal forces due to an increased total surface area. 10,11 However, an important di�erence exists between total surface area and functional surface area. Total surface area represents the overall surface area of the implant, while a functional surface area represents the area that transfers the compressive and tensile loads to bone and does not include the passive portion of the implant.10 It was illustrated that unlike what occurs with the stresses applied to a natural tooth and the periodontal ligament, stresses around implants are greatest at the crest of the ridge and less in the apical portion. 10,12,13 Based on this principle, an increased length would simply improve primary stability of the implant during initial placement and enhance osseointegration. On the other hand, a wider diameter implant would increase not only primary stability but also the functional surface area at the crestal bone level, and thus lead to a better distribution of occlusal forces to the surrounding bone. Therefore, short wide diameter implants should bear functional stresses as e�ectively as longer implants. Several parameters need to be evaluated before the placement and restora -tion of short implants. The type of bone is an important variable when pla ing implants. Since bone quality is considered a major risk factor for implant failure because of the lack of primary st bility, the increased stability provided by the wide diameter would be a considerable advantage especially in the posterior maxilla where bone quality and quantity is often less than ideal. prosthetic loading of short implants also requires careful planning. most studies on short implants have reported that these implants can be restored with any type of prosthesis (ie, single crowns, F pDs, and removable pros -theses). 4 However, crown-to-implant ratio, excessive occlusal forces, and pre ence of cantilevers are some of the risk factors that may lead to an increased stress on the implants and may therefore compromise implant survival. 5 Other pa -rameters are the distance between the threads (thread pitch) and the depth of the threads. High number of threads anddeeper threads provide greater surface area that could compensate for the short length implant.

CONCLU S IONThe aim of this report was to evaluate and discuss the clinical use of short wide-diameter implants in the posterior max -illa as an alternative treatment modality to sinus bone grafting procedures. In this case, an existing F pD was replacing

Therefore, the easiest treatment plan would probably have been fabrication of a new F pD. One of the disadvantages of an F p

In selected cases, short wide-diameter implants could be used e�ectively in an area of limited bone height, and ther fore represent an appropriate alternative treatment option to bone grafting.

functional surface area, further research on their long-term success in cases of reduced alveolar bone height is still necessary.

A C K NO WL EDG ME NTThe authors would like to thank A. B.Dental Devices for its support.

REFERE NC ES1. Kido H,Schulz ee ,Kumar A,Lozada J,Saha S. Implant diameter and bone density: e �ect on initial stability and pull-out resistance. J Oral Implantol 1997;23: 163–169.

2. maustsushita Y,Kitoh m,mizuta K, Ikeda H,Suetsugu T. Two-dimensional F em analysis of hydroxapatite implants: Diameter e�ects on stress distribution. J Oral Implantol 1990;16:6–11.

3. Bahat O, Handelsman m. u se of wide implants and double implants in the posterior jaw: A clinical report. Int J Oral maxillofac Implants 1996;11:379–386.

4. g entile mA, c huang SK, Dobson T. Survival estimates and risk factors for failure with 6 ! 5.7-mm implants. Int J Oral maxillofac Implants 2005;20:930–937.

5. Fugazzotto pA. Shorter implants in clinical practice: r ationale and treatment results. Int J Oral maxillofac Implants 2008;23:487–496.

6. Das n eves FD, Fones D, Bernardes S r , Do prado c J, Fernandes n eto AJ. Short implants: An analysis of longitudinal studies. Int J Oral maxillofac Implants 2006;21:86–93.

7. Feldman S, Boitel n ,Weng D, Kohles SS, Stach rm . Five-year survival distributions of short-length (10 mm) or less machined-surface and Osseotite implants. c lin Implant Dent r elat r es 2004;6:16–23.

8. Friberg B, g rondahl K, Lekholm u , Branemark pI. Long-term follow-up of severely atrophic edentulous mandibles reconstructed with short Branemark implants. c lin Implant Dent r elat r es 2000;2:184–189.

9. Ten Bruggenkate cm ,Asikainen p, Foitzik c ,Krekeler g , Sutter F. Short (6 mm) nonsubmerged dental implants: r esults of a multicenter clinical trial of 1 to 7 years. Int J Oral maxillofac Implants 1998;13:791–798.

10. misch ce , Steigenga J, Barboza e , misch-Dietsh F, c ianciola LJ, Kazor c . Short dental implants in posterior partial edentulism: A multicenter retrospective 6-year case series study. J periodontol 2006;77:1340–1347.

11. Lum LB.A biochemical rationale for the use of short implants. J Oral Implantol 1991;17:126–131.

12. Holgrem e T, Seckinger r J, Kilgren L m, mante F. e A 2-dimensionalcomparative study examining the e�ects of implant diameter, implant shape and load direction. J Oral Implantol 1998;24:80–88.

13. misch ce . Implant design considerations for the posterior regions of the mouth. Implant Dent 1999;8:376–386.

14. r oos J, Sennerby L, Lekholm u , Jemt T, g rondahl K, Albrektsson T. A qualitative and quantitative method for evaluating implant success: A 5-year retrospective analysis of the Branemark implant. Int J Oral maxillofac Implants 1997;12:504–514.

5*Quintessence International, July / August 2010

Figure 2

Figure 1

Figure 3

Figure 4

Figure 5

Figure 7

Figure 6

Figure 8

Figure 9

One of the critical steps in Prosthodontics is the impression.The precision of an impression determines the

record is taken in order to articulate the upper and lower models. In the Kennedy class one and two, partial edentulism, there is no posterior occlusal support. Therefore, bite registration can be performed accurately, utilizing a bite block.The bite block is fabricated in the dental laboratory

This procedure requires an additional appointment. When restoring a unilateral or bilateral free-end saddle with an implantretained Fixed partial Denture (F pD) (Figure 1), the implants can be used to provide posterior occlusal support. The objective is to use the most accurate technique that is the least time consuming.This article presents an alternative tool to the bite block, which is more accurate and less time consuming.

utilized to facilitate the bite registration procedure (Figure 2, 3). A disc is then used to cut the implant mount.The part of the implant mount with the c lip and Hex ( c lip and hex connection AB Implant System) is attached to the implant intra-orally (Figure 4). The components attached to the implants should be under the occlusal level to allow for the bite

5). g .c resin is mixed and placed over the components. In the case presented, two posterior AB implants were used as posterior support to the bite registration (Figure 6). The g .c . resin index is then removed from the mouth and sent to the lab along with the impression (Figure 7). c onsequently, the resin jig will be placed on the implant analogs, allowing accurate articulation of the working models (Figure 8). Abutments are

(Figures 9, 10, 11 and 12). e li r aviv is Associate professor, Faculty of Dentistry, mcg ill u niversity and Director of prosthodontics, Dept. of Dentistry, J g H, montreal, Quebec. www.ravivimplant.com Oral Health welcomes this original article.

When restoring a unilateral or bilateral free-end saddle with an implant-retained

Fixed partial Denture (F pD), the implants

can be used to provide posterior occlusal

support.

*US ING A N IMP L A NT MOUN T AS A TOOL F OR BI TE R EG ISTRAT ION R E CO RDS

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e li r aviv, D mD / mili Harel- r aviv, D mD

*Oral Health, August 2010

*C HARA C TER IZAT ION O F 5 DI FFERE NT IMP L A NT SU RFA C ES A ND TH E IR E FFE C T ON OSSE OIN TEGRAT ION: A S T UDY IN DO GS paulo g . c oelho phD*; e stevam A. Bonfante phD†; r oberto S. pessoa phD‡; c harles marin phD§; r odrigo g ranato phD§; g abriela g iro phD‡; Lukasz Witek mS*; marcelo Suzuki DDS�

* Department of Biomaterials and Biomimetics, n ew York u niversity, n ew York, n Y, u SA

† Department of prosthodontics, u niversity of São paulo – Bauru School of Dentistry, Bauru, S p, Brazil

‡ Department of Oral Diagnosis and Surgery, u niversidade e stadual paulista Júlio de mesquita Filho, Faculdade de Od -ontologia de Araraquara, Araraquara, S p, Brazil

§ Department of Dentistry, u niversidade Federal de Santa c atarina, Florianópolis, S c , Brazil

�Department of prosthodontics, Tufts u niversity School of Dental medicine, Boston, mA, u SA

a�ect early osseointegration. This study investigated the e�ects of controlled surface alterations in early osseointegration in an animal model.

methods: Five implant surfaces were evaluated: Alumina-Blasted, Biological Blasting, plasma, microblasted-resorbable blasting media (microblasted r B m), and Alumina-Blasted/Acid- e tched (AB/A e ). Surface topography was characterized by scanning electron microscopy, and optical interferometry, and chemical assessment by x-ray photoelectron spectros -copy ( xp S). The implants were placed in the radius of 6 dogs, remaining 2 and 4 weeks in vivo. Following euthanization,

-tact (BI c ), and bone area fraction occupied (BAFO) evaluation. Statistical evaluation was performed by one-way A n Ov A (p < 0.05), and post-hoc testing by the Tukey’s test.

r esults: The alumina-blasted surface presented the highest average surface roughness (Sa) and mean root square of the surface (Sq) values, the biological blasting the lowest, and AB/A e an intermediate value. The remaining presented inter -mediate values between the biological blasting and AB/A e . The xp S spectra revealed c a and p for the biological blasting and microblasted r B m surface, and the highest O levels for the plasma, microblasted r B m, and AB/A e -cantly higher torque was observed at 2 weeks for the microblasted r B m surface (p<0.04), but no di�erences existed be -tween surfaces at 4 weeks (p >0.74). n c and BAFO values were observed at 2 and 4 weeks.

c -

K e YWO r DS

implant surface; in vivo; torque; histology; osseointegration;Over the last four decades, clinical oral implantology have shown high survival rates over time (often exceeding 95% over 10 years1, 2 ), and has been regarded as one of the most successful treatment modalities in dentistry. Such high success rates have been attributed to the excellent biocompatibility of titanium that allow for intimate bone interaction at the optical microscopy resolution, regarded as osseointegration 3-5.

While high survival rates have been reported for endosseous devices, current research has emphasized towards implant -

plant tissue response6. Such potential decrease in healing time may result in reduction in treatment time frames through prosthetic restorations that could be placed in occlusal function at early implantation times 6-8.

have been the most investigated 3-8

-tion with the device 9.

-sensus that both rough surfaces (over smooth turned surfaces) and surface chemistry (additions of c a-p based biocer -amics in various forms over non-coated surfaces) favor the early host-to-implant response 4-6. From a historical perspec -tive, dental implant surfaces evolved from the as-turned smooth surfaces towards textured rough surfaces, and recent

4-6, 10, 11 .

4-6, 10, 11 , as both have been showing promising results in vitro 12 and in vivo models 13-20 relative to their moderately rough predecessors. Im -provements have been achieved by alterations in surface wettability 21 , impregnation of c a and p onto the titanium oxide

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layer 18, deposition of discrete bioactive ceramics 19, 20, 22 , and through minor incorporation of other chemical elements such as 11, 23 . Since changes in surface chemistry typically result in surface texture during processing, controlling such variables

in order to determine their relative e�ects in healing is a challenging task, and the largest direct comparison between various surfaces in a suitable in vivo model is desirable. Thus, the present study biomechanically and histomorphometrically evaluated

MATERIAL S AND METHOD S

The implants used in this study were Ti-6Al-4 v screw type implants with 3.75 mm of diameter and 8 mm in length provided by

Biological Blasting, plasma, microblasted resorbable blasting media (microblasted r B m), and Alumina-Blasted/Acid- e tched (AB/A e ). Three implants from each group were used for surface characterization.

Surface c haracterization

The surface characterization was accomplished with three di�erent methods (n=3 implants per surface). First, scanning elec -tron microscopy * (S em v to observe the di�er -ent groups’ surfaces topography.The second step was to determine the roughness parameters by optical interferometry† (IF m). Three implants of each surface

absolute values of the surface height within the sampling area) and Sq (root mean square of the surface departures within the sampling area) parameters determined 24, 25. To separate roughness from waviness and shape for digital 3D measurements, on a micrometer scale, a high-pass g -

An Ov A.

xp S). The implants were inserted in a vacuum transfer chamber and degassed to 10-7 torr. The samples were then transferred un -der vacuum to the xp S spectrometer*. Survey spectra were obtained using a 165 mm mean radius concentric hemispherical analyzer operated at constant pass energy of 160 e v for survey and 80 e v for high resolution scans. The take o� angle was 90° and a spot size of 150 μm x 150 μm was used. The implant surfaces were evaluated at various locations (3 per implant).

Animal model and Surgical procedure

Following approval of e thics c ommittee for Animal r esearch at Federal u niversity of Santa c atarina, six mongrel dogs were

For surgery, three drugs were administered until general anesthesia achievement by intramuscular injection. The drugs were atropine sulfate (0.044 mg/kg), xilazine chlorate (8mg/kg) and Ketamine chlorate (15mg/kg). The implantation site was the ra -dius epiphysis, and the right limb of each animal provided implants that remained for 4 weeks in vivo, and the left limb provided implants that remained 2 weeks in vivo.For implant placement, the surgical site was shaved with a razor blade and was followed by application of antiseptic iodine solution. An incision of ≈5cm through the skin and periosteum was performed and the periosteum was elevated for bone ex -posure.Sequential drills were utilized following the manufacturer’s recommendation under abundant saline irrigation at 1.200rpm. The implants were placed in an interpolated distribution to minimize bias from di�erent implantation sites (sites 1 to 5 from proximal to distal) along the radial epiphysis for torque and histomorphometric evaluation.

After placement the healing caps were inserted and sutured in layers with vicryl 4-0* for periosteum and nylon 4-0† for skin was performed. The animals stayed in animal care facility and received antibiotic (Benzyl penicilin Benzatine 20.000 u I/Kg)

e uthanasia was performed after 4 weeks by anesthesia overdose and the limbs were retrieved by sharp dissection.For the torque testing, the radius was adapted to an electronic torque machine equipped with a 500 n cm torque load cell‡. c ustom machined tooling was adapted to each implant internal connection and the bone block was carefully positioned to avoid specimen misalignment during testing. The implants were torqued in counter clockwise direction at a rate of ~0.196 radians/min until a 10% decrease in maximum value was recorded, and a torque versus displacement curve was recorded for each specimen. The rationale for this procedure was to minimize interface damage prior to histological procedures 13, 14 .The implants in bone were then referred to histomorphometric analysis. The implants in bone were reduced to blocks and were then immersed in 10% bu�ered formalin solution for 24h. The blocks were then washed in running water for 24h, and gradually dehydrated in a series of alcohol solutions ranging from 70-100% ethanol. Following dehydration, the samples were embedded in a methacrylate-based resin* according to the manufacturer’s instructions. The blocks were then cut into slices (~300 μm thickness) aiming the center of the implant along its long axis with a precision diamond saw†, glued to acrylic plates with an acrylate-based cement, and a 24h setting time was allowed prior to grinding and polishing. The sections were reduced

c abrasive papers‡ (400, 600, 800, 1200 and 2400) in a grinding/polishing machine§ under water irrigation26. The sections were then toluidine blue stained and referred to optical microscopy for histomorphologic evaluation.The bone-to-implant contact (BI c ) was determined at 50 x -200 xof bone-to-implant contact along the implant perimeter were subtracted from the total implant perimeter, and calculations were

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performed to determine the BI c . The bone area fraction occupied (BAFO) between threads in trabecular bone regions was determined at 100 xfrom the total area between threads, and calculations were performed to determine the BAFO (reported in percentage values of bone area fraction occupied) 27.preliminary statistical analyses showed no e�ect of implant site (i.e., there were no consistent e�ects of positions 1 to 5 along the radius) on all measurements. Therefore, site was not considered further in the analysis. Statistical evalu -ation of torque to interface fracture, BI c , and BAFO were performed by one-way A n Ovindicated by p-levels less than 5%, and post-hoc testing employed the Fisher LSD test.

RE S ULT S

All implant surfaces’ electron micrographs are presented in Figures 1 and 2 and their representative 250μm x 250μm IF m three-dimensional reconstructions, in Figure 3. Their respective Sa and Sq values are presented in Figure 4 A.

m recon -struction (Figure 3) revealed morphologic di�erences between groups. While similar morphology was observed for the alumina-blasted, microblasted r B m, and AB/A e surfaces, scanning electron micrographs showed that the biological

grooves. The plasma group surface morphology presented a rough surface with rounded morphology compared to other groups (Figure 1 e and F). r esidual blasting media particles were observed on the alumina-blasting (Figure 1 A and B) and biological blasting surfaces only (Figure 1 c and D).The IF m -mina-blasted surface presented the highest, the biological blasting the lowest, and AB/A e intermediate value. The other surfaces presented intermediate values between the biological blasting and AB/A e(Figure 4 A and B).The xp S spectra evaluated the presence of Al, p, c a, n , Ti, c , v , O, and n a for the di�erent surfaces (Figure 4 A and c ). The highest aluminum concentration was observed for the alumina-blasting surface. The highest c a and p concentra -tion was observed for the biological blasting surface, followed by the microblasted r B m at much lower concentrations and all other surfaces without the presence of these chemical elements. n o Ti was detected for the plasma treated surface, and the second lowest Ti value was observed for the biological blasting surface. The highest c values were observed for the plasma and alumina blasting surfaces, and the highest O levels were observed for the plasma, micro -blasted r B m, and AB/A e surfaces (Figure 4 A and c ).The animal surgical procedures and follow-up demonstrated no complications regarding procedural conditions, post -operative infection, or other clinical concerns. n o implants were excluded from the study due to clinical instability im -mediately after the euthanization.

-lasted r B m surface relative to others at 2 weeks (p<0.04), but that at 4 weeks no di�erences were observed between surfaces (p >0.74) (Figure 5 A and B).

to mechanical testing bone disruption (Figure 6).Qualitative evaluation of the toluidine blue stained thin sections revealed no morphologic di�erences between surfaces at 2 weeks (Figure 6 A, B, and c ) and 4 weeks (Figure 6 D, e , and F) in vivo, where intimate contact between cortical (Figure 6 A, B, D, and e ) and trabecular (Figure 6 c and 6 F) bone were observed. In addition, di�erent healing patterns were observed at di�erent regions along the implant bulk, depending on the interplay between implant geometry and surgical instrumentation dimensions.

-lowing intimate contact between implant surface and cortical bone occurred immediately after implantation, substantial bone remodeling in proximity with the implant surface occurred between 2 (Figure 6A) and 4 (Figure 6D) weeks in vivo for all groups. While at 2 weeks in vivo old bone remodeling was observed along with regions of newly formed woven bone (Figure 6A), at 4 weeks substantial woven bone was observed in proximity with the implant surface (Figure 6D).At regions where a healing chamber was formed due to the formation of a space between the outer diameter of the surgical instrumentation and the inner diameter of the implant thread, woven bone formation was observed throughout the space of the chamber and directly onto the implant surface at 2 weeks in vivo (Figure 6B). At 4 weeks, initial woven bone replacement by lamellar bone was observed throughout the healing chamber (Figure 6 e ).At trabecular bone regions, newly formed woven bone was observed at 2 weeks (Figure 6 c ), and initial woven bone replacement by lamellar bone was observed at 4 weeks (Figure 6F) at regions in proximity with all implant surfaces.

c and BAFO at 2 and 4 weeks in vivo (BI c p>0.26 and p>0.09, respectively; BAFO p>0.94 and p>0.09, respectively- Figures 5 c ,D, e , and F).

DIS CU SS ION

Implant surfaces have evolved from the smooth as-machined (as-turned) surfaces towards the now considered stand -ard rough surfaces that are fabricated by a variety of methods, which include all those employed to fabricate the dif -

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ferent surfaces evaluated in the present study6. c ompared to published data, the obtained surface roughness values m

obtained28). n onetheless, the relative di�erences between groups are in agreement with previously published work 4, 5. While the alumina blasting group presented a textured surface along with blasting media particles embedded on the surface, the AB/A e surface presented a reduced surface roughness, however without evidence of particle embedding in the surface, demonstrating the e�ectiveness of acid-etching on further cleaning the surface after blasting procedures.

c a- and p-based bioactive ceramics, although both the biological blasting and micro -blasted r B m surfaces were blasted with resorbable blasting media, the blasting machinery and subsequent surface cleaning di�erences resulted in di�erent textures and chemistries. First, due to the lower hardness of r B m compared to alumina, lower degrees of roughness were observed compared to both alumina blasting and AB/A e samples. Second, observation of the electron micrographs for the biological blasting and microsblasted r B m revealed more consistent spatial distribution of texture for the microblasted r B m surface, which unlike the biological blasting group did not show regions where machining grooves were apparent between textured regions. Third, di�erent post-blasting procedures resulted in c a-p particles throughout the biological blasting surface and high degrees of c a and p on its surface chem -istry spectrum, and chemical impregnation10 of c a and p elements on the microblasted r B m surface.

Although no detail was provided regarding the plasma source composition and temperature for the plasma group, it is apparent from the electron micrographs that the surface was previously blasted and that the texture was a�ected by the plasma processing. Such statements can be rationalized since rounded structures were observed compared to sharp

method, where Ti was not detected along with increased c and O in the surface composition. This chemical shift may have originated from a substantial increase in the surface oxide layer, or possibly by a high surface energy characteristic that may have readily adsorbed carbon-based species from the atmosphere during sample preparation.

r B m compared to other surfaces), and a general increase for all groups at 4 r B m surface

roughness and chemistry combination favored the early host-to-implant response, and that shortly after this observation period, no di�erence was evident due to the osseoconductive and biocompatible properties of other surfaces. The low degree of mechanical disruption between bone and implant observed in the histology slides following mechanical test -ing was likely due to the proper specimen alignment and the slow controlled torque rate. Thus, mechanical disruption was observed only in a few histologic sections and did not compromise the histomorphologic and histomorphometric evaluations 13, 14, 17 .In general, results from the histologic sections showed that all of the surfaces investigated were biocompatible and os -seconductive, presenting bone in close contact with the implant surface at regions of cortical and trabecular bone. From a morphologic standpoint no di�erences were observed between all surface investigated. Woven bone was observed around all surfaces at 2 weeks, and at 4 weeks, initial replacement of woven bone by lamellar bone was observed for all surfaces. n o detrimental e�ect due to blasting media particle presence on the surface was observed for the alumina blasting and microblasted r B m groups at both implantation times.

patterns were observed throughout the implant length. At regions where intimate contact between cortical bone and implant surface existed immediately after placement, an appositional bone healing was observed16, 27, 29. Such heal -ing pattern comprises in interfacial remodeling with subsequent woven bone apposition in close contact with the implant

in high degrees of implant primary stability 27.On the other hand, when the interplay between implant geometry and surgical drilling dimensions resulted in healing chamber formation, an intramembranous-like healing pattern was observed 16, 27, 29 . Healing chambers have been previ -

placement for osseointegration achievement 16, 17, 27, 29, 30 . In agreement with previous studies, the present results showed

before or at 2 weeks, and initial remodeling comprising initial woven bone replacement by lamellar bone was observed by 4 weeks implatation time. The same morphologic evolution trend was observed at regions of trabecular bone 31.

c and BAFO, a general increase was observed from 2 to 4 weeks in vivo, revealing that the time frames investigated in the present study was within the dynamic healing phases that occur at early implantation times. Within groups, the highest increase in BI c and BAFO values over time was ob -served for the biological blasting group, which at 4 weeks presented the highest mean values for BI c and BAFO among all surfaces evaluated. Such observation was likely due to the e�ect of higher amounts of c a and p elements on the surface relative to other groups, suggesting that their presence resulted in alteration in bone healing dynamics after implantation17-20, 32 .

CONCLU S ION

the di�erences in biomechanical and histomorphometric results is not possible, experimental studies controlling these variables are warranted.

10

ACKNOWLEDGEMENT S AND CONFLICT OF INTERE S T

REFERENCE S

1. c huang SK, Tian L, Wei LJ, Dodson TB. predicting dental implant survival by use of the marginal approach of the semi-parametric survival methods for clustered observations. J Dent r es 2002;81:851-855.

2. c huang SK, Wei LJ, Douglass c W, Dodson TB. r isk factors for dental implant failure: a strategy for the analysis of clustered failure-time observations. J Dent r es 2002;81:572-577.

3. Albrektsson T, g ottlow J, meirelles L, Ostman pO, r occi A, Sennerby L. Survival of n obelDirect implants: an analysis of 550 consecutively placed implants at 18 di�erent clinical centers. c lin Implant Dent r elat r es 2007;9:65-70.

4. Albrektsson T, Wennerberg A. Oral implant surfaces: part 1--review focusing on topographic and chemical properties of di�erent surfaces and in vivo responses to them. Int J prosthodont 2004;17:536-543.

5. Albrektsson T, Wennerberg A. Oral implant surfaces: part 2--review focusing on clinical knowledge of di�erent sur -faces. Int J prosthodont 2004;17:544-564.

6. c oelho pg , g ranjeiro J m, r omanos ge , et al. Basic research methods and current trends of dental implant surfaces. J Biomed mater r es B Appl Biomater 2009;88:579-596.

7. Jimbo r , Ono D, Hirakawa Y, Odatsu T, Tanaka T, Sawase T. Accelerated photo-Induced Hydrophilicity promotes Osseointegration: An Animal Study. c lin Implant Dent r elat r es 2009 in press.

8. Jimbo r , Sawase T, Baba K, Kurogi T, Shibata Y, Atsuta m. eanodized titanium. c lin Implant Dent r elat r es 2008;10:55-61.

9. Jimbo r , Sawase T, Shibata Y, et al. e

10. Dohan e hrenfest D m, c oelho pg , Kang BS, Sul YT, Albrektsson T. c -faces: materials, chemistry and topography. Trends Biotechnol 2010;28:198-206.

11. Kang BS, Sul YT, Oh SJ, Lee HJ, Albrektsson T. xp S, A e S and S em analysis of recent dental implants. Acta Bio -mater 2009;5:2222-2229.

12. moura cc , Souza mA, Dechichi p, Zanetta-Barbosa D, Teixeira cc , c oelho pg . The e�ect of a nanothickness coat -ing on rough titanium substrate in the osteogenic properties of human bone cells. J Biomed mater r es A 2010;94:103-111.

13. c oelho pg , c ardaropoli g , Suzuki m, Lemons J e . e arly healing of nanothickness bioceramic coatings on dental implants. An experimental study in dogs. J Biomed mater r es B Appl Biomater 2009;88:387-393.

14. c oelho pg , Lemons J e . physico/chemical characterization and in vivo evaluation of nanothickness bioceramic depositions on alumina-blasted/acid-etched Ti-6Al-4 v implant surfaces. J Biomed mater r es A 2009;90:351-361.

15. c oelho pg , marin c , g ranato r , Suzuki m. Histomorphologic analysis of 30 plateau root form implants retrieved after 8 to 13 years in function. A human retrieval study. J Biomed mater r es B Appl Biomater 2009;91:975-979.

16. c oelho pg , Suzuki m, g uimaraes mv, et al. e arly bone healing around di�erent implant bulk designs and surgical techniques: A study in dogs. c lin Implant Dent r elat r es 2010;12:202-208.

17. g ranato r , marin c , Suzuki m, g il J n , Janal mn , c oelho pg . Biomechanical and histomorphometric evaluation of a thin ion beam bioceramic deposition on plateau root form implants: an experimental study in dogs. J Biomed mater r es B Appl Biomater 2009;90:396-403.

18. marin c , g ranato r , Suzuki m, g il J n , p iattelli A, c oelho pg . r emoval Torque and Histomorphometric e valuation of Bioceramic g rit-Blasted/Acid- e tched and Dual Acid- e tched Implant Surfaces: An e xperimental Study in Dogs. J peri-odontol 2008;79:1942-1949.

19. mendes vc , moineddin r , Davies J e . The e�ect of discrete calcium phosphate nanocrystals on bone-bonding to titanium surfaces. Biomaterials 2007;28:4748-4755.

11

20. mendes vc , moineddin r , Davies J e . Discrete calcium phosphate nanocrystalline deposition enhances osteocon -duction on titanium-based implant surfaces. J Biomed mater r es A 2009;90:577-585.

21. Buser D, Broggini n , Wieland m, et al. eDent r es 2004;83:529-533.

22. Orsini g , p iattelli m, Scarano A, et al. r andomized, controlled histologic and histomorphometric evaluation of im -plants with nanometer-scale calcium phosphate added to the dual acid-etched surface in the human posterior maxilla. J periodontol 2007;78:209-218.

23. mendonca g , mendonca DB, Aragao FJ, c ooper LF. Advancing dental implant surface technology--from micron- to nanotopography. Biomaterials 2008;29:3822-3835.

24. Leach r . Surface Topography c haracterisation. In: Fundamental principles of engineering nanometrology: William Andrew pub, 2009:211-258.

25. Stout K, Sullivan p, Dong W, et al. Development of methods for the characterisation of roughness in three dimen -sions: penton pr.; 2000.

26. Donath K, Breuner gSchli� (sawing and grinding) technique. J Oral pathol 1982;11:318-326.

27. Leonard g , c oelho p, polyzois I, Stassen L, c la�ey n . A study of the bone healing kinetics of plateau versus screw root design titanium dental implants. c lin Oral Implants r es 2009;20:232-239.

28. Wennerberg A, Albrektsson T. Suggested guidelines for the topographic evaluation of implant surfaces. Int J Oral maxillofac Implants 2000;15:331-344.

29. Berglundh T, Abrahamsson I, Lang np , Lindhe J. De novo alveolar bone formation adjacent to endosseous implants. c lin Oral Implants r es 2003;14:251-262.

30. c oelho pg , g ranato r , marin c , Bonfante e A, Janal mn , Suzuki m. Biomechanical and bone histomorphologic evaluation of four surfaces on plateau root form implants: an experimental study in dogs. Oral Surg Oral med Oral pathol Oral r adiol e ndod 2010;109:e39-45.

31. Quaranta A, Iezzi g , Scarano A, et al. A histomorphometric study of nanothickness and plasma-sprayed calcium-phosphorous-coated implant surfaces in rabbit bone. J periodontol 2010;81:556-561.

32. meirelles L, melin L, peltola T, et al. e �ect of hydroxyapatite and titania nanostructures on early in vivo bone re -sponse. c lin Implant Dent r elat r es 2008;10:245-254.

c orresponding Author: e stevam A. Bonfante, Al. Octávio pinheiro Brisola, 9-75 - Bauru - S p - Brasil - 17012-901, phone: 55 – 14 – 8153-0860 / Fax: 55-14-32342566 / estevamab@gmail.com (e-mail can be published)

Submitted August 21, 2010; accepted for publication September 29, 2010.

Figure 1: Scanning electron micrographs of the (A and B) alumina-blasting, ( c and D) biological blasting, and ( e and F) plasma.

Figure 2: Scanning electron micrographs of the (A and B) microblasted r B m, and ( c and D) AB/A e .

Figure 3: IF m 3D reconstructions of the (A) alumina-blasting, (B) biological blasting, ( c ) plasma, (D) microblasted r B m, and ( e ) AB/A e .

Figure 4: (A) Average chemical composition for the di�erent surfaces as observed in the xp S spectra and the statistics summary for the Sa and Sq values (mean ± standard deviation). (B) r oughness parameters Sa and Sq (mean ± stand -ard deviation) for the di�erent surfaces. The number of asterisks denotes statistically homogeneous groups. ( c ) Surface atomic compositions for the di�erent implant surfaces (mean ± standard deviation).

Figure 5: Torque to interface fracture statistics summary (mean ± 95% c I) for the di�erent surfaces at (A) 2 weeks and (B) 4 weeks in vivo. BI c statistics summary (mean ± 95% c I) for the di�erent surfaces at ( c ) 2 weeks and (D) 4 weeks in vivo. BAFO statistics summary (mean ± 95% c I) for the di�erent surfaces at ( e ) 2 weeks and (F) 4 weeks in vivo. The number of asterisks denotes statistically homogeneous groups.

Figure 6: r epresentative histologic section for all groups at 2 and 4 weeks in vivo: (A and D respectively) at a region where intimate contact between implant surface and cortical bone occurred immediately after placement, (B and e re -spectively) region where healing chamber formation occurred between implant thread and cortical bone, and ( c and F,

12

respectively) trabecular bone region.

* (AB-Dental, n ir-galim, Israel)* philips x L 30, e indhoven, The n etherlands† phase v iew 2.5, palaiseau, France* Kratos Axis 165 multi-technique, Kratos Analytical Inc., c hestnut r idge, n Y, u SA)* e thicon Johnson, miami, FL, u SA† e thicon Johnson, miami, FL, u SA‡ Test r esources, minneapolis, mn , u SA* Technovit 9100, Heraeus Kulzer g mbH, Wehrheim, g ermany† Isomet 2000, Buehler Ltd., Lake Blu�, IL, u SA‡ Buehler Ltd., Lake Blu�, IL, u SA§ metaserv 3000, Buehler Ltd., Lake Blu�, IL u SA� Leica D m2500 m, Leica microsystems g mbH, Wetzlar, g ermany¶ Leica Application Suite, Leica microsystems g mbH, Wetzlar, g ermany

Figure 1

Figure 2

13

Figure 3

Figure 5 Figure 6

Figure 4

*Journal of periodontology n ovember 201014

IMP L A NT S UPP ORTED -T ITA NIUM MILL ED BAR OV ER -DE NT URES

e li r aviv, D mD / mili Harel- r aviv, D mD

Over-dentures are one of the traditional treatment modalities for completely edentulous patients. u ntil recently, one of the most challenging areas in implant dentistry was to achieve passive insertion of a cast screw-retained metal

There are several ways to fabricate an implant supported over-denture: The conventional standard of care treatment includes two implants in the anterior mandible and two ball or Locator* attachments. In the case where three or more implants are placed, a cast, gold Dolder bar connecting the implants is used. (Fig. 1)

After receiving the framework from the lab, occasionally we had to section it, connecting the segments with acrylic resin and picking up the united framework in an impression to return to the lab for soldering or welding. Due to the limitations of casting process, complications such as cracks and fracture of the bar occur. (Fig. 2,3)c AD/c Am technology eliminates this situation.Today, a recent mode of treatment, using a milled bar- implant supported over-denture is applied. Implant bars milled from solid blocks of medical gresult. (Fig. 4)The lab mills a mono-block that requires no welding or soldering, thus, creating a strong infrastructure.This types of over-dentures are easy to maintain and do not cause harm to the surrounded soft tissue.The bars are milled with an accuracy of 8 microns between interfaces and available in many platforms for dif ferent implant systems.They are screwed directly to the implant restorative platform or to the abutments restorative platform.

An accurate impression is taken, the model is scanned and an over-denture bar is designed using specialized software and equipment. (Implant/c ad software).

C ase presentation:

c aucasian male presented to our clinic with a main concern: “ my teeth are loose, I can not eat”. medical history: controlled diabetes type II.Intra-oral and radiographic examination revealed a partially edentulous patient with Sever, g eneralized Adult Type periodontitis. (Fig. 5-9)Treatment rendered:Full mouth extractions.Immediate complete upper and lower dentures.Four months post extractions: r e-evaluation and assessment of bone volume and quality for implants placement. (Fig. 10-12)Ten endosseous implants (AB Dental Devices) were placed in a single stage protocol. (Six in the maxilla and four in the anterior mandible). (Fig. 13,14)

u pper and lower titanium alloy milled bars (Bio- c ad, n obel Bio-care*) where fabricated.pick-up, open tray impressions were taken. (Fig. 15.16)u pper and lower milled bars were fabricated. (Fig. 17-19)Implant supported over-dentures were constructed and delivered. (Fig. 20).One year follow-up revealed an extremely happy patient, no deterioration of the bars or prostheses. (Fig. 21)

Summary:

c AD/c Am restorations are the future of restorative dentistry. A c ustom milled Bar is a one piece milled titanium alloy structure with

is more durable, superior in strength, weight and cost less than the conventional cast gold bar .

This mode of treatment increases the denture retention and stability and improves the patient's quality of life.

References;

1. milled Bar-Supported Implant Overdenture After mandibular r esection: A c ase r eportr enata v ecchiatini, n icola mobilio, Demis Barbin, Santo c atapano, g iorgio c alura. Journal of Oral Implantology October 2009, v ol. 35, n o. 5, pp. 216-220 2. The implant-supported milled bar overdenture:A literature review.Antonio Bueno-Samper, manuel Hernandez-Aliaga, Jose-Luis c alvo- g uirado.med. Oral patol. c ir Buccal. march 1, 2010; 15 (2): e375-8.

15

Figure legend:

Fig 1 - c ast gold Dolder bar Fig 2 - c ast bar fracture Fig 3 - c ast bar fracture

Fig 19 - u pper Bio-cad titanium bar (Intraoral)

Fig 20 - Intaglio surface of upper implant supported overdenture

Fig 21 - post treatment patient front view

Fig 13 - panoramic radiograph illustrating ten implants placed

Fig 14 - Healing abutments of lower implants

Fig 15 - Impression taking in the lower jaw

Fig 16 - Final, pick up impression- upper jaw

Fig 17 - Lower Bio-cad titanium bar (Intraoral)

Fig 18 - n on engaging connection of Bio cad bar

Fig 7 - u pper occlusal view Fig 8 - Lower occlusal view

Fig 10 - u pper ridge four months post extractions

Fig 11 - Lower ridge four months post extractions

Fig 12 - panoramic radiograph four months post extractions

Fig 9 - pre-treatment panoramic radiograph

Fig 4 - milled titanium bar Fig 5 - patient front and lateral view Fig 6 - Intra-oral front view

16

Dr. Benjamin Retzkin - Periodontist

moreover, c linical and x -ray examination revealed that the teeth from the upper jaw and

the implants at the lower jaw are irreparable. The jaws are too narrow to insert and load 3.75 mm diameter implants. Thus, the treatment plan included extraction, bone-block-graft and the use of temporary implants. The temporary implants provide support to the transitional restoration without creating pressure on the bone-graft and, therefore, preventing resorption of the graft.

After waiting six months, permanent implants are inserted.

This case is showing a solution for the upper jaw. Later on, the patient will have her lower jaw treated as well by augmentation which is followed by implants' insertion.

TH E U SE O F TE MP ORARY IM P L A NTS F OR F IX ED PR OVI S ION A L REST ORAT ION, IN T HE C ASE O F L ATERA L A UG ME NTAT ION O F T HE U PPER J AW .

17

Fig 7 - Installation of temporary implants (A.B. Dental implants type I6, diameter of 2.4 mm, length of 13 mm). Fig 8 - Suturing.

Fig 9 - Fixation of temporary implants with the aid of a titanium rod welding.

Fig 10 - panoramic picture immediately after surgery. Fig 11 - provisional bridge (Dr. g ad Joseph).

Fig 13 - panoramic x -r ay showing the permanent implants .)mm 31 fo htgnel ,mm 57.3 fo retemaid 5I epyt latneD .B.A(

The provisional bridge is supported by temporary implants until the permanent implants are exposed and ready to be rehabilitated.

Fig 1 - The patient's upper bridge.

Fig 4 - Teeth after extraction.

Fig 2 - c T of the upper jaw.

Fig 5 - Thorough debridement.

Fig 3 - The bridge after its removal.

Fig 6 - u sing allogenic bone block graft.

Fig 12 - After six months, removal

temporary implants is done for the purpose of inserting six permanent implants.

Says Dr. Yehuda Gill in a professional interview in which he explains his philosophy of dentistry.Dr. Yehuda Gill's multidisciplinary clinic already has a tradition of impressive dental achievements. With 30 years of experience in advanced dentistry and oral rehabilitation, Dr. Gill, together with an experienced team of doctors, provides solutions to all the challenges of dental implants and oral rehabilitation.I visited Dr. g ill's clinic in Haifa, Israel, and was amazed to discover a new and advanced world of dentistry, which frees people of all ages from years of nightmares.

So we can say that science has been enlisted for the purpose of oral health and aesthetics?"Implants have brought about a revolution in dentistry and have become an important solution to aesthetics," explains Dr. g ill. " most people come for implantations for aesthetic reasons, a minority for health reasons. If in the 1990's we were happy when the implantation was successful, today the emphasis is on aesthetic success."How much do you think about prosthetics when you do an implantation, asks Yael, a company's client manager. "That's on my mind most of the time," says Dr. g

People are used to thinking about dentistry and pain in the same breath. What news can you give us regarding current implantation treatments?"Implants provide quality of life, with all that implies. Today, technology is advanced and patient- friendly: faster, better and shorter. In 1985," he says, "Dr. Leonard Berry, a marketing expert, developed the model of service and client expectations. According to this model, the smaller the gap between client expectations and those of the professional, the greater the client's satisfaction. I always see myself as a client who wants good, professional and non-painful work."

You deal a lot, both on the theoretical and professional level, with the subject of " Immediate L oading." When do you prefer to use it and in which cases do you avoid it?"prof. c arl misch (an expert on dental implants from the u nited States) once said regarding "Immediate Loading" that

the doctor, and the loss means destruction of the client's bone, cost, chair time and the cost of the repairs, which is absorbed by the doctor. On the other hand," says Dr. g ill, correcting the impression, "Immediate Loading means fast, convenient treatment, less pain and su�ering, and it has a great psychological advantage, because the patient leaves the clinic with real teeth rather than a prosthesis. However, as in any medical treatment, the treatment must be suited to the patient's clinical condition and his desires, just as we adapt the implant to the type of treatment."

You mentioned implants Ð what are your considerations in choosing an implant for a patient?"First, I work only with spirals and always prefer the largest implants possible in a given site in order to provide a good grip and stability. I prefer as much surface area as possible. The rule as far as I'm concerned: to what degree an implant can stand next to a tooth and next to another implant. I recommend choosing an implant according to the existing condition of the bone or bringing the bone to optimal condition. personally, I like to work with the I5 because it's spiral, the screw shelves/blades are longer and wider, so that the implant cuts itself into the bone and doesn't crush itself into it, so that the implant cuts the bone rather than crushing it. In addition, the initial manual insertion is easier. This is an implant that has proved itself in recent years with very high percentages of success for me."

dentistry look in the future? .scitehtsea fo ecnatropmi namuh eht fo esuaceb stnalpmi fo esu erom dna erom eb lliw ereht erutuf eht ni taht eveileb I"

my son is now studying dentistry. I will recommend that he specialize in dental implants. That's the future."

" IMMED IATE LO AD ING MEA NS QUIC K A ND IMM ED IATE TREAT ME NT WIT H A LL I TS AD VA NTAGES "

18

TOO T H E XTRA C T ION IN T HE LO WER J AW IN T HE U PPER J AW

A - 58-year-old man who works in high-tech and frequently travels abroad on business trips. The man needed general extractions and permanent restoration for the implants. The entire treatment was done in one sitting.

A - 70-year-old man who su�ers from ischemic heart disease, who wanted quality of life by means of a permanent restoration. An implantation could not be done in the right posterior segment.

degrees, and immediate restoration with an acrylic bridge, in one sitting. 1 2

3 4

6 7

10 11

5

8 9

preparing a model for a temporary bridge (Omnivac)

The abutments are placed on top of the angular implants.

A panoramic structural x-ray taken

later.

Final abutments from the regular restoration frame.

The permanent restoration is of the F p-3 type.

The temporary

goes home immediately with the bridge).

n ine implants performed by"Immediate Loading" immediately after the extractions. A panoramic x-ray.

A panoramic x-ray beforethe start of treatment.

A clinical picture before treatment.

Tooth extraction – identifying the location of the mental nerve.

The temporary bridge prepared with "Immediate Loading".

17:20 – construction of an acrylic bridge.

Spraying the I5 implant. n otice the horizontal marking on the conduit that enables optimal placement of the implant.

1 2

3 4

5 6

7 8

9

Initial drilling at a 45-degree angle above the point of mental foramen, which enables placing the future abutment as as possible.

attention to the parallels during the use of a 45-degree abutment

17:45 – conclusion of the preparation

in the mouth.

panoramic x-ray before the treatment. The cin the vertical dimension in the posterior segments. This is a 3-dimensional c AT scan in the lower jaw.

19

TH E E XPERTS RE COMM E ND: " IMMED IATE S C REW -RETA INED LO AD ING " ON IM P L A NTS Ð FO R MA XIMUM COM F ORT A ND CONV E NIE NC E

Dr. Gil Rafalovitz, an oral surgeon and prosthodontic, explains how the latest

dental patients.

In the past, people all over the world, young and old, who had lost some or all of their teeth, were forced to use removable prostheses. Today, as a result of new methods that have been developed, the patients can replace removable prostheses with a permanent prosthesis that adheres to the jaw, immediately after extraction.

The method, which is called "All On Four," was developed in order to provide a solution for people who do not have

bone augmentation.

Dr. g il r afalovitz, a leader in dental surgery and restoration, met with us to talk about "Immediate Loading," implantations at extreme angles, etc.

"In the past I traveled to portugal to study the 'All On Four' method," says r afalovitz. "The system is based on implantations P12 and P14 , which provide a more comfortable,

reliable, accessible and less expensive system.

What are your considerations in choosing an implant for the patient?

"In the Inbal c linics I work (located in Israel) we have developed a method for 'screw-retained immediate loading' on implants placed in extreme angles."

What are the advantages of this method?

"There are a number of clear advantages to the method:1. It enables the patient to avoid sinus and bone augmentations .2. It enables the patient to leave the clinic with teeth with which he can eat immediately, and without a temporary prosthesis.3. It reduces the number of operations."

And the risks?

"I do a great many of these procedures. The statistics don't lie, and until now I have not had a single failure. However, this is a method that requires a great deal of experience and knowle dge of surgery and prosthodontics."

You spoke of the use of P12 and P14 abutments when you do the "All On Four" procedure. Why use those in particular?

"T he P14 provides a real practical solution for screw-retained restoration on an implant placed in angles. The abutment is user-friendly, and makes it possible to direct the angle as desired, in other words, to determine from where the prosthetic screw will emerge. In most cases when I perform a screw-retained restoration on implants, the implants in the upper jaw require a change in angle to prevent the restoration screw from emerging from the buccal side of the teeth.

"T he P12 is perfectly suited to places where no adjustment of the angle is necessary. As far as I'm concerned, as a surgeon and a specialist in restoration, this abutment spares the need for an adaptor (a saving of time and money) by enabling me a direct connection to the top of the implant, even when the implant is angled. For the most part, in the anterior implants in the lower jaw there is no need for a change in angle, and these are precisely the cases in which I use the P12 ."

ce recognition of the company's

processes are reliable, and spare me and the patient from clinical surprises. most of the implants made by all the various manufacturers look the same, and therefore I prefer to rely on the monitoring processes that precede the manufacture."The second consideration is practical: I choose the implant based on the accessibility of the bone – if the bone is thinner, I'll choose a narrower implant, such as the I6 or the I6B . When the space is not narrow, I'll use the I5, which is a convenient implant and does the work for me and the patient in the best possible way. personally and professionally, I have found the unique A.B. Dental invention, the Double Platform , a consideration in choosing the therapeutic products in my clinic. The Double platform, which enables full adaptation for all the abutments, saves me from keeping a double inventory, as is the case with various implant platforms.

P12 Upper jaw lacks teeth. In the lower jaw the last teeth were lost recently.

Due to limitations in the accessibility of the bone, tilted implants were inserted in both jaws, with immediate loading. In that way, maximum comfort was obtained immediately.

We used the I5 implants and the P12 and P14 adaptors.

C ase study, Dr. Gil Rafalovitz - 50-year-old woman, generally in good health.

20

The use of short dental implants In reduced alveolar bone height

DentistsÊ oftenÊ faceÊ challengesÊ whenÊ placingÊ implantsÊ inÊ anÊ areaÊofÊreducedÊalveolarÊboneÊheight.ÊThisÊsituationÊisÊseenÊinÊbothÊtheÊposteriorÊ maxillaÊ andÊ mandibleÊ dueÊ toÊ alveolarÊ boneÊ resorption,ÊpneumatizationÊofÊmaxillaryÊsinusesÊandÊtheÊpresenceÊofÊanatomicÊstructuresÊ(e.g.ÊinferiorÊalveolarÊnerve).ÊTheÊacceptedÊsolutionÊforÊthisÊproblemÊhasÊbeenÊconventionallyÊtoÊperformÊaÊboneÊgraftingÊprocedure.ÊDespiteÊgoodÊpredictabilityÊandÊsuccessÊrateÊofÊgraftingÊprocedures,ÊpatientsÊareÊoftenÊreluctantÊtoÊundergoÊtheÊsurgeryÊdueÊtoÊtheÊrisks,Êmorbidities,ÊandÊcostsÊofÊtheÊprocedureÊandÊtheÊstressÊofÊundergoingÊanÊinvasiveÊprocedure.Ê

Short implants (≤ 8mm) have been introduced recently as a potentialÊ treatmentÊ alternativeÊ toÊ boneÊ graftingÊ proceduresÊ inÊpatientsÊwithÊlimitedÊalveolarÊboneÊheightÊinÊtheÊposteriorÊmaxillaÊandÊinÊtheÊseverelyÊatrophicÊmandible.Ê

InÊ thisÊ presentationÊ weÊ willÊ discussÊ theÊ criteriaÊ forÊ successfulÊclinicalÊapplicationÊofÊshortÊwideÊdiameterÊimplantsÊandÊshareÊwithÊtheÊaudienceÊourÊclinicalÊexperience.

ABSTRACTS TAKEN FROM A.B. DENTAL DEVICES FIRST INTERNATIONAL SYMPOSIUM HELD ON DECEMBER 2 nd, 2010

Prof.ÊEliÊRavivÊ

Current Trends on Endosseous Implant Bulk and Surface Design

ÊSubstantialÊ disagreementÊ withÊ respectÊ toÊ whichÊ implantÊ designÊfeaturesÊ mayÊ resultÊ inÊ theÊ bestÊ short-Ê andÊ long-termÊ biologicalÊresponse.ThisÊ in-vivo,Ê ex-vivo,Ê andÊ computationalÊ researchÊ basedÊpresentationÊ discussesÊ severalÊ aspectsÊ ofÊ short-Ê andÊ long-termÊosseointegrationÊandÊitsÊrelationshipÊwithÊimplantÊtherapyÊsuccess,ÊwhichÊ includeÊ surgicalÊ techniqueÊ design,Ê boneÊ healingÊ aroundÊdi�erentÊ implantÊ designs,Ê theÊ e�ectÊ ofÊ surfaceÊ treatmentÊ currentÊtrendsÊ likeÊ nanotechnology,Ê biomechanicalÊ stimulationÊ andÊ theÊresultingÊboneÊmorphologyÊandÊmechanicalÊpropertyÊevolution.Ê

Dr.ÊPauloÊCoelho

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"All - on - Four" made simple.

ÊandÊrequiresÊmeticulousÊplanningÊbecauseÊofÊanatomicÊvariationsÊandÊtheÊimportanceÊofÊfacialÊandÊdentalÊesthetics.

ÊImmediateÊimplantÊfunctionÊhasÊbecomeÊanÊacceptedÊtreatmentÊmodalityÊ

ÊTheÊ"All-on-Four"ÊconceptÊÊÊi.eÊÊimmediateÊloadingÊassociatedÊwithÊtiltedÊimplantsÊusingÊÊBrånemarkÊSystemÊimplantsÊ(NobelÊBiocare,ÊGothenburg,ÊSweden)ÊhasÊbecomeÊÊinÊrecentÊyearsÊpopularÊÊandÊanÊacceptedÊalternativeÊ

ÊTheÊ "All-on-Four"Ê immediate-functionÊ conceptÊ involvesÊ Screw-retainedÊprovisionalÊimplant-supportedÊprosthesesÊ.ÊÊÊTheÊfabricationÊproceduresÊofÊthisÊlaboratory-processed,Êprovisional,Êscrew-retained,Êimplant-supportedÊ

andÊdependedÊonÊheightÊlevelÊofÊlaboratoryÊexpertise.Ê

ÊloadingÊprotocolÊtoÊrehabilitateÊfullÊarchÊusingÊextremeÊangulatedÊimplants.Ê

prostheticÊprotocolÊÊforÊimmediateÊfunctionÊ,usingÊA.B.ÊDental'sÊ450ÊandÊ35 0ÊabutmentsÊinÊtheÊfabricationÊofÊaÊcement-retainedÊimplant-supportedÊrestorationsÊasÊanÊimmediateÊprovisionalÊprostheses.ÊÊ

Dr.ÊYehudaÊGill

IMPLANT TOOTH REPLACEMENT: The Esthetic Challenge

ÊTheÊchallengeÊofÊtheÊmissingÊmaxillaryÊanteriorÊtoothÊisÊrecreatingÊtheÊharmonyÊandÊbalanceÊofÊtheÊwhiteÊandÊpinkÊsurroundingsÊofÊtheÊremainingÊnaturalÊdentition.ÊÊOsseointegrationÊhappens,ÊestheticsÊneedsÊtoÊbeÊcreated.ÊÊSmileÊdesignÊprinciplesÊwillÊbeÊbrokenÊdownÊtoÊ bringÊ clarityÊ toÊ ourÊ everyÊ dayÊ clinicalÊ procedures.ÊÊ MacroÊ andÊMicroÊ EstheticÊ principlesÊ willÊ beÊ discussedÊ inÊ detail,Ê toÊ aidÊ theÊclinicianÊinÊtreatmentÊplanningÊdialogueÊwithÊtheÊsurgeonÊandÊtheÊtechnician.

1. ÊÊ EvaluateÊ eachÊ patient'sÊ smileÊ usingÊ whiteÊ andÊ pinkÊ estheticÊcriteriaÊtoÊgainÊclarityÊandÊaÊpredictableÊestheticÊoutcome.

2. ÊÊ EmphasisÊ willÊ beÊ inÊ understandingÊ pinkÊ estheticÊ parametersÊandÊhowÊtheseÊwillÊguideÊtheÊimplantÊteamÊinÊtreatmentÊplanning,ÊplacementÊandÊprototypeÊfabrication.

3. ÊÊ DiscussionÊ willÊ includeÊ "prostheticallyÊ generated"Ê papillae-Ê isÊthisÊaÊreality?

Dr.ÊBrianÊLesage

Predictable and Innovative Bone Grafting Techniques

ÊAutogenousÊboneÊcanÊoftenÊnotÊbeÊfoundÊinÊadequateÊsupply.ÊNewÊsurgicalÊtechniquesÊcanÊincreaseÊoverallÊalveolarÊboneÊdimensions,ÊusingÊ theÊ latestÊ inÊ boneÊ allografts,Ê xenografts,Ê andÊ membranes,ÊthatÊ initiateÊ andÊ maintainÊ osteogenesis,Ê osteoinduction,Ê andÊosteoconduction.EmphasisÊwillÊbeÊplacedÊonÊrecentÊcellularÊandÊmolecularÊadvancesÊutilizingÊ stemÊ cells,Ê growthÊ andÊ di�erentiationÊ factors.Ê HowÊ andÊwhenÊ theseÊ technologiesÊ mayÊ beÊ usedÊ willÊ beÊ discussedÊ andÊcomparedÊwithÊconventionalÊtechniques.Dr.ÊAronÊGonshor

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Bone augmentation in complex implant cases

ÊFollowingÊtheÊlossÊofÊhardÊandÊsoftÊtissuesÊasÊaÊresultÊofÊtoothÊextractions,ÊperiodontalÊdisease,ÊtraumaÊorÊinÊcasesÊofÊanodontiaÊwereÊtheÊtoothÊandÊtheÊpertinentÊboneÊdidÊnotÊdevelop,ÊaÊrestorationÊofÊfunctionÊandÊaestheticsÊutilizingÊdentalÊimplantsÊisÊtheÊtreatmentÊofÊchoice.ÊTheÊqualityÊandÊquantityÊofÊtheÊbone,ÊwhichÊisÊtheÊfoundationÊforÊsuccess,ÊshouldÊbeÊconsidered.InÊ theÊ lastÊ fewÊ yearsÊ theÊ useÊ ofÊ boneÊ augmentationÊ proceduresÊ fromÊintraoralÊandÊextraÊoralÊoriginÊhaveÊspreadÊgreatly.ThereÊ areÊ severalÊ waysÊ toÊ enhanceÊ boneÊ quantity.Ê One,Ê isÊ distractionÊosteogenesisÊ,ÊtheÊsecond,ÊisÊonlayÊgraftÊ(autogenousÊ/Ênonautogenous)ÊandÊtheÊthird,ÊisÊguidedÊboneÊregeneration.TheÊ useÊ ofÊ membranesÊ inÊ guidedÊ boneÊ augmentationÊ andÊ regenerationÊhasÊprogressedÊandÊbecameÊmoreÊpopular.ImmediateÊ loadingÊ andÊ provisionalizationÊ asÊ aÊ treatmentÊ modalityÊ toÊmaintainÊ theÊ newlyÊ formedÊ boneÊ willÊ beÊ presentedÊ withÊ someÊ clinicalÊexamplesÊandÊreviewÊofÊtheÊcurrentÊliterature.

Dr.ÊBenjaminÊRetzkin

Implant supported FPD for the completely edentulous patient- Surgical, functional and aesthetics.

ÊTheÊsurgicalÊandÊrehabilitationÊofÊtheÊcompleteÊedentulousÊpatientÊ

practitioner.ÊTheÊ purposeÊ ofÊ thisÊ presentationÊ isÊ toÊ followÊ theÊ diagnosis,ÊtreatmentÊplanning,ÊsurgicalÊandÊprostheticÊconsiderationsÊinÊorderÊtoÊachieveÊfunctional,ÊaestheticÊandÊqualityÊofÊlifeÊtoÊourÊpatient.

Implant Retained, All zirconia, Oral Rehabilitation: A Novel Concept

TheÊlongÊtimeÊstandardÊofÊcareÊforÊextraÊcoronalÊrestorationsÊhasÊbeenÊtheÊporcelainÊfusedÊtoÊmetalÊ(PFM)Êcrown.ÊÊTheÊmetalÊsubstructureÊandÊestheticÊporcelainÊhaveÊbeenÊappliedÊtoÊsingleÊunits,ÊanteriorÊandÊposteriorÊbridgesÊandÊmostÊrecentlyÊimplantÊsupportedÊpartialÊandÊcompleteÊprostheses.ÊÊWithÊincreasingÊpatientsÊdemands,ÊnewÊmaterialsÊ andÊ technology,Ê andÊ theÊ ideaÊ ofÊ “ metal-freeÊ dentistry” ,ÊtheÊcurrentÊporcelainÊfusedÊtoÊmetalÊrestorationÊisÊbeingÊchallengedÊbyÊaÊvarietyÊofÊceramicsÊincludingÊlithiumÊdisilicate,ÊaluminaÊand,ÊmostÊrecently,ÊzirconiaÊ.ÊTheÊceramicÊwhichÊstandsÊoutÊforÊitsÊbestÊmechanicalÊ propertiesÊ isÊ yttriumÊ tetragonalÊ zirconiaÊ polycrystalsÊ(Y-TZP).ÊÊTheÊ focusÊ ofÊ thisÊ presentationÊ isÊ toÊ presentÊ aÊ NovelÊ concept:ÊImplantÊRetained,ÊAllÊzirconia,ÊOralÊRehabilitation.ÊTheÊtechniqueÊofÊfabrication,ÊasÊwellÊasÊbiocompatibility,ÊstrengthÊandÊestheticsÊofÊallÊzirconiaÊrestorationsÊwillÊbeÊpresented.

Prof.ÊEliÊRavivÊ

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