Crown-to-Implant Ratio The length of the crown is

defined as the distance from the implant shoulder to the most coronal aspect of the restoration. The implant, therefore, is defined as the distance from the implant platform to the apex. Similar concept applies to teeth - distance above the bone crest is considered the crown, below is root.

FLOSSOPHYN e w s l e t t e r

Soft Tissue Management Amongst all the available options for soft tissue grafting around teeth and implants, what’s best? Page 2

Implants in the Esthetic Zone The importance about implant placement in the esthetic zone Page 3

Office & CE Updates New technology, anticipated move-in date, and free CE dates. Page 4

CROWN-TO-IMPLANT RATIO: WHAT IS THE LATEST?

Over the past decade, implant companies have been pushing the limits with implant length in an attempt to make available implants as a restorative option in anatomically limiting situations. Currently, implant companies consider any length shorter than 10mm to be a “short implant”. Crown-to-root ratio (C/I) is a key factor in determining the periodontal and restorative prognoses of teeth and thus as implant lengths vary, so clinicians have questioned if the same “rules” apply with crown-to-implant ratios.

Reviewing three systemic reviews and two long-term (3-10 years) retrospective studies, the majority of the studies suggested C/I ratio does not impact implant survival or peri-implant bone loss. However prosthetic failure (fracture) and complications (screw loosening) were shown to be more prevalent issues with shorter implants.

OUR SUGGESTION: It is paramount to remember that implants do not have periodontal ligaments (hence the term osseointegration), which gives the patient proprioception (the brains’ ability perceive & quantity force when chewing). Several studies have confirmed patients can chew with 3 times more force on an implant crown than a natural/restored tooth (1300N vs. 340N).

Therefore, it is not hard to imagine abutment failure or complications can arise if the C/I is not adequate. Therefore, we don’t regularly use or advocate implants shorter than 8mm unless there are significant health or anatomical issues that preclude grating to allow for 8mm implants or longer. And, if we do use short implants, it would predominately be in the mandibular posterior where bone quality is exceptionally better and bone-to-implant contact is greater rather than the maxilla where you may have up to 50% less bone contact the implant surface.

FORSYTH

Dr. Mark Suttle has been practicing periodontics & implant dentistry for over 13 years after completing his dental & specialty training at UNC, and is board certified by the Board of Periodontology. Mark & his wife, Wesley, have recently celebrated the birth of their 4th child, Graham.

Dr. Trent Pierce has been practicing periodontics & implant dentistry for over 2 years after completing his dental & specialty training at MUSC, and is board certified by the Board of Periodontology. Trent & his wife Amy, a general dentist in King, NC, enjoy spending time with their dogs & love the outdoors.

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F o r s y t h F l o s s o p h y • F o r s y t h P e r i o d o n t a l A s s o c i a t e s • 3 3 6 . 7 6 5 . 9 2 2 4 - P a g e ! -2

Attached & Keratinized: Simplified We feel one of the most commonly confused concepts of gingiva involves attached tissue (AT) and keratinized tissue (KT). Simply put, both are properties. Keratine is a substance in the epithelial layer that provides protection and resistance. And, it just so happens that keratine is found only in AT, not in lining tissues (mucosa). Consequently, journals and speakers will throw around AT and KT synonymously. Thus, for simplicity sake just consider AT~KT in clinical exams. When we are determining if a graft is needed, we assess more than the pretense of recession. The lack of AT alone could necessitate treatment. An easy way to determine if there is any AT left: take a probe, lay it in the mucosa and push coronal carefully. Assess where the tissue stops moving and the distance to the top of the tissue is how much AT remains.

FORSYTH FLOSSOPHYEsthetic Soft Tissue Management for Teeth and

Implants A recent high quality study (Jia-Hui, 2012) analyzed several studies to

assess which available soft tissue graft material the best in augmentation around teeth and dental implants. Today, the available options are - Autogenous (connective tissue/free gingival), Allografts (acellular dermis), Guided tissue regeneration (membrane), Xenografts, and Biologic agents (growth factors).

To determine which is better, studies analyze root coverage (RC) and attached tissue gained (AT) (see column to right for more information on attached and keratinized tissue). Regarding existing AT on a tooth or implant, the most recent studies have found that implants with less surrounding AT exhibited more recession. Other studies have found similar results with teeth as well. Not to mention, inflammation and sensitivity/pain seems to be more prevalent in sites with no AT existing.

This study concluded of the available grafting options, the gold standard for results and predictability is still autogenous grafting and allografts showed the next best results in gain of AT and RC.

OUR INTERPRETATION: Our practice works largely with autogenous grafts as well as Perioderm (allograft). We prefer to use autogenous grafts when/if possible however in certain circumstances we will use Perioderm. Perioderm, in our hands has a few more favorable properties than Alloderm, however both have been shown to generate results. Our preference of autogenous over allografts is summarized in Harris’ 2004 study: compared autogenous to allografts and found root coverage was better for autogenous (97%) than allografts (67%) at 10 years. Moreover, gain in attached gingiva was more prevalent as well 10 years out.

WITH THE ADDITION OF DR. PIERCE, BOTH OF OUR DOCTORS PROVIDE THE FOLLOWING SERVICES:

Dental Implants Dental Implants Periodontics Other

Extractions & Socket Preservation Immediate & Delayed Implant Placement Non-Surgical Therapy IV & Oral Sedation

Sinus Elevations & Alveolar Ridge Augmentations

Immediate & Delayed Temporary Crowns for Anterior Implants

Pocket Reduction SurgeryImpacted Canine

Exposures

Pre-Treatment Consultation with You & Your Lab

Implants for Hybrid/Fixed-detachable Full Arch Restorations

Soft tissue Grafting - from Patient & Tissue Bank

3D/Cone Beam Scans (Coming May 2015)

Implants for Fixed Single and Multi-unit Fixed Prosthesis

We Provide Stock/Custom/Locator Abutments + Impression Components

Guided Tissue Regeneration for Periodontal Defects - Gem 21, Emdogain

Frenectomies

Treatment of Peri-Implantitis Implant for Full & Partial Dentures Esthetic & Functional Crown Lengthening Biopsies

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FORSYTH FLOSSOPHY

Before/After Regeneration Above is one of our cases: the initial (top) and post (bottom) treatment radiographs after using GEM 21S.

Regenerating Bone Adjacent to Teeth - Predictable? As Patient demands must always be taken into consideration prior to surgery, and

presurgical mockups may be necessary to convey the information to the patient. Prosthetic treatment planning helps the clinician with a restorative-driven implant placement rather than a bone-driven approach, with the latter leading to poor abutment angulations and drastically reduced restorative options. Bone augmentation is often necessary in order to achieve optimal residual ridge dimensions prior to implant placement.

In combination with the use of a surgical or guided stent, proper 3-D positioning of a dental implant has become an attainable goa l , l ead ing to increased confidence for the clinician and accurate c l in i ca l r e s u l t s . T h e importance of the implant position can be manifested in the four dimensionally sensitive positioning criteria: mesiodistal, buccolingual, and apico- coronal location, as well as implant angulation.

Mesdiodistally … Maintaining adequate distance from adjacent teeth also helps preserve crestal bone and interproximal papillary height. When placing an implant adjacent to a tooth, it has been shown that crestal bone peak is based on and maintained by the bone level of the teeth adjacent to the missing space. A minimum distance of 1.5 mm between implant and existing dentition has been determined to prevent damage to the adjacent teeth and to provide proper osseointegration and gingival contours (Fig. 1a). 4-6 Implants placed too closely together can reduce the height of the inter-implant bone crest, and a distance of below 3 mm between two adjacent implants leads to increased bone loss. If the space between implants is 3 mm or less, the average resorption of the interproximal bone peak increases to 1.04 mm, compromising support for the interdental papilla.

Labiolingual implant position is often determined by the gingival biotype, occlusal considerations of opposing teeth, and desired emergence profile. An implant placed too far labially can cause bone dehiscence and gingival recession leading to exposure or show-through of the implant collar. An implant placed too far lingually can cause prosthetic difficulties with ridge-lap restorations that can be unhygienic and unesthetic.outcome.

1.8 mm of labial bone has been determined to be critical in maintaining an implant soft tissue profile and increasing the likelihood of an esthetic outcome8 (Fig 2). Labially oriented implants compromise the subgingival emergence profile development, creating long crowns and misalignment of the collar with respect to the adjacent teeth.

Several factors are cause for concern in the apico-coronal placement of implants. Implants placed too shallow may reveal the metal collar of the implant through the gingiva. Countersinking implants below the level of the crestal bone may give prosthetic advantages with more running room for prosthetic components and tissue contouring, but can lead to crestal bone loss due to the location of a microgap at the implant-abutment interface. The ideal solution to exposure of the implant collar would be the placement of an implant equicrestal or subcrestal to the ridge. However, the existing microgap at the implant-abutment junction leads to bone resorption due to peri-implant inflammation.12 It is suggested that an implant collar be located 2 mm apical to the CEJ of an adjacent tooth if no gingival recession is present13 (Fig. 3). Implant diameter also plays a role in apico-coronal position, with smaller diameter implants needing more space for soft-tissue development and tissue contouring.

OUR INTERPRETATION: Regenerating adjacent to teeth is one of periodontics

This study is a nice comparison of implant bridges (FDPs) (aka app les ) t o fu l l a rch fixed -de t a c hab le so l u t i on s ( aka oranges) and showed the survival rate is very comparable between the two at 10 years.

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New Building Update We are looking forward to our move to our new facility in May!

We will provide your office with all our our new contact information and maps for your patients as the time approaches. Our current office has been in place for over 30 years and can no longer support our mission to maintain high quality care for your patients while remaining cutting-edge with today’s fast-growing technology. Mark

and Trent have been investigating the latest surgical technology available and will be adding the following technology to the new office to provide you and your patients with the latest available techniques/diagnostics:

- iCAT 3D Cone Beam Volumetric Tomography (CBVT) - A second Piezoelectric Surgery Unit - Piezoscalers - Nomad Pro 2

FORSYTH FLOSSOPHY

Upcoming CE for You and Your Staff Further information to be mailed to your office in the coming months

Friday, May 8 --- 4th Annual Hygiene Symposium with Stacey McCauley (back by popular demand) - Doctors & Hygienists Friday, September 18 --- Implant Continuing Education Course for Doctors with Dr. Matthew Palermo --- Implant Course for Hygienists including our always popular Hands-on session with Kathi Carlson Thursday, October 15 --- Evening Implant Course for Doctors with Dr. Bob Vogel (back by popular demand)

As always, our Continuing Education Courses are provided at no charge to you and your staff, and Continuing Education Credits are given.

You can now expect your patients to be seen within 3 weeks for an evaluation. If they need to be seen ASAP please personally speak with Mark or Trent.

View: Side & back of the office that can be seen from our existing office (faces S. Hawthorne Road).

Our anticipated grand opening is June 1, 2015

ORGANIZATIONS/CERTIFICATIONS WE ARE ASSOCIATED WITH: