The past 3 years of experience in our practice have made it clear that 3D printing provides numerous benefits for patients and practices alike. The digital impression-taking process is far more comfortable for the patient than the conventional process of using an alginate and pouring it up in stone. The 3D printing process eliminates the bubbles and imperfections often resulting from the conventional fabrication approach while delivering far better precision and durability. The ability to 3D print in the office also reduces the number of visits to the practice—which is particularly important to patients who live far from the practice. If a printed appliance is ever lost or damaged, a replacement can quickly be printed using the existing model. In addition, utilizing a digital workflow makes it easier for patients to visualize how their teeth will look at the temporary stage, reducing the number of adjustments and lab remakes at the final stage. Finally, patients benefit from the same-day 3D printing of retainers, which avoids the risk of relapse that could occur if the patient fails to appear for the follow-up appointment to pick up a lab-made retainer.  

Our practice also enjoys several benefits from 3D printing, including streamlining workflow, significantly reducing lab work and rework expenses, reducing shipping expenses, and providing a more predictable result with greater control.

The benefits of 3D printing are especially significant when patients require orthodontic treatment followed by restorative treatment, as illustrated in the following 2 cases.

CASE REPORTS

Case 1

A 46-year-old male patient presented with a medical history including cleft lip and palate repair and also had a missing upper left lateral incisor (Figure 1). His upper midline had shifted to the left of his facial midline due to the asymmetry (Figure 2). Only 3 mm of space was available between the upper left canine and central incisor for a replacement for tooth No. 10. There was an anterior crossbite of No. 9 and No. 11 with Nos. 22 to 24 (Figure 3), causing fremitus and a horizontal fracture line on No. 9. In addition, No. 8 was in edge-to-edge occlusion with Nos. 25 and 26, leading to excessive incisal wear on No. 8 as well as No. 7 (Figure 4). The patient desired not only to improve the aesthetics of his smile but also to address the trauma caused by the malocclusion. 

Figure 1. Initial upper arch image showing missing tooth No. 10.

Figure 2. Initial low smile view showing the upper midline to the left of the facial midline.

Figure 3. Initial intraoral image showing missing No. 10 and the crossbite of Nos. 9 and 11 with Nos. 22 to 24.

Figure 4. Initial intraoral edge-to-edge view between No. 8 and Nos. 25 and 26.

Figure 5. Post-ortho intraoral view showing space created for Nos. 7, 8, and 10 and the corrected crossbite.

In order to restore the patient’s dentition, orthodontics was necessary, and the patient preferred clear aligner therapy. Invisalign aligners were used to create 7 mm of space to replace No. 10 (Figure 5), to intrude Nos. 7 and 8 for adequate clearance for the future crowns, to close the spacing on the lower, and to correct the crossbite. An implant was not an option due to an inadequate amount of available bone. Instead, we decided to place crowns on Nos. 7 and 8 and a bridge for Nos. 9 through 11. The orthodontic treatment took 17 months and included 2 refinements. During the Invisalign treatment (Align Technology), A1 shade pontic paint was placed in the No. 10 pontic on the aligner, so it was not obvious the patient was missing a tooth. This is a major advantage of using clear aligners when a patient is missing an anterior tooth and why Invisalign is preferred in these situations (Figure 6).

Figure 6. Post-ortho maxillary arch.

Once orthodontic treatment was complete, the attachments were removed, and using a digital scanner (iTero Element 5D [Align Technology]), STL files of the final occlusion were created and temporary retainers were printed in the office on the 3D printer (3Demax [DMG]) using a 3D printing resin (LuxaPrint Model [DMG]). The STL files were uploaded to the design software (3D A.I. Mockup Design [SmileFy]), which was used to design teeth Nos. 7 through 11 (Figures 7 and 8). The STL files were then imported to the nesting and slicing software (Netfabb [Autodesk]) and a model of the patient’s upper arch with the 3D designed anterior teeth was printed using LuxaPrint Model. A positive pressure machine was used to fabricate the stent for temporary crowns on Nos. 7 and 8 as well as a temporary bridge for Nos. 9 through 11 (Figures 9 and 10). The model was run through the curing unit (3Decure [DMG]) and washing unit (3Dewash [DMG]). 

Figures 7 and 8. Crown and bridge designed using SmileFy software.

Figure 9. Stent.

Figure 10. Stent.

Figure 11. Teeth prepped for restorative treatment.

For the temporary crowns and bridge, a high-performance crown and bridge material (LuxaCrown [DMG]) was used. After prepping the teeth (Figure 11), temporaries were placed (Figure 12) using an aesthetically oriented temporary cement (TempoCem ID [DMG]). I use this for all of my temporaries due to its uncanny ability to allow the temporary to stay on yet leave no residue on the tooth when it is removed. From the design model, which had been printed earlier, a retainer was printed to protect the temporaries and prevent the teeth from shifting prior to the final restoration.

Figure 12. Patient with temporaries fabricated with LuxaCrown (DMG) and cemented with TempoCem ID (DMG).

Figure 13. Final intraoral image.

Figure 14. Patient with final restoration.

The final design of the temporary was sent to the outside lab to give the lab a clear idea of what the permanent restoration should look like. The permanent restorations were fabricated using multilayered KATANA Zirconia [Kuraray Noritake]). Once the final restoration was cemented (Figure 13), we took a scan immediately afterward and printed a model for a permanent retainer the same day. The patient was extremely happy with the outcome (Figure 14).

Case 2

A 50-year-old female presented who was unhappy with the aesthetics of her veneers that had been placed more than 20 years ago (Figure 15). She exhibited significant recession around the veneers and significant staining on the margins of the veneers and on the composite that had been placed over the roots of the teeth (Figure 16). In order to achieve the broad smile she desired, orthodontic treatment was necessary. This was to correct her unilateral functional posterior crossbite caused by her narrow palate and a shift of the mandible to the right when she closed her mouth. We also needed to correct the upper midline, which had a significant cant to her left (Figure 17). 

Figure 15. Patient with 20-plus-year-old veneers.

Figure 16. Staining visible on margins and composite buildups and the posterior crossbite.

Figure 17. The upper midline’s slant to patient’s left is apparent.

For this case, the patient preferred fixed appliances rather than removable ones. Brackets (Damon System [Ormco]) were designed using orthodontic design software (Insignia Advantage [Ormco]). Her maxillary arch width was increased by uprighting the lingually inclined posterior teeth, and the crossbite was corrected with crossbite elastic on her right side. The orthodontic treatment took 14 months (Figures 18 to 22).

Figure 18. Pre-ortho view of the mandible.

Figure 19. Pre-ortho view of the maxilla.

Figure 20. Post-ortho view of the mandible.

Figure 21. Post-ortho view of the maxilla.

Figure 22. Post-ortho view of the patient’s smile.

When her orthodontic treatment was complete, her teeth were scanned using the iTero Element 5D, the brackets were digitally removed from the STL file using triangle mesh software (Meshmixer [Autodesk]), and the 3Demax printer was used to create upper and lower retainers. Creating retainers ahead of time was advantageous since, at the bracket removal appointment, her retainers were able to be delivered immediately.

To plan her restorations, the same STL file  was imported into the SmifeFy design software, which was used to design 8 temporary veneers from the first premolar to the first premolar. The model was printed (Figure 23) using LuxaPrint Model 3D printing resin, and a positive pressure machine was used to create a stent and retainer (Figure 24). After removing the old veneers and prepping the teeth for new restorations, the stent was used to fabricate the temporary veneers (Figure 25) with a temporary crown and bridge material (Luxatemp [DMG]). These were cemented using an invisible temporary cement (TempoCem ID [DMG]). 

Figure 23. The 3D printed model with blockout for fabricating retainers.

Figure 24. The 3D printed stent from the designed STL file.

Figure 25. The patient with temporary veneers cemented.

Figure 26. The patient with permanent veneers cemented.

While I was very pleased with the look and fit of the temporaries, the patient was accustomed to her teeth being shorter and asked that her upper anterior teeth be shortened slightly. Her request was easy to accommodate, as the design file was simply sent to the outside lab, and they were instructed to shorten the upper anterior teeth by 1 mm. The final veneers were fabricated using a lithium disilicate glass-ceramic (IPS e.max [Ivoclar]). They were cemented using PANAVIA Veneer LC (Kuraray Noritake). The patient was very happy with the final result (Figure 26).

CONCLUSION

Our 16-operatory practice does a great deal of orthodontic work, often followed by restorative work, as in the 2 cases above, and the use of 3D printing in this work has been a real game-changer for our patients and us.

ABOUT THE AUTHOR

Dr. Latham received a BS degree from Boston University, where she was her class valedictorian, and a DDS degree from the University of Michigan School of Dentistry. She is currently a general dentist in a 4-doctor, 16-operatory practice in Stratford, Conn. She previously served in a military dental clinic in Rota, Spain, and in a private practice in Virginia Beach, Va. She has completed numerous postdoctoral courses in orthodontics and Invisalign. Dr. Latham is a recipient of the William S. Kramer Award of Excellence from Omicron Kappa Upsilon, a member of the International Association of Orthodontics, and an Invisalign Platinum Provider. She grew up in New Zealand and moved across the Pacific in 2001 to attend Boston University and compete as a track and field athlete. She can be reached at julialathamdds@gmail.com. 

Disclosure: Dr. Latham reports no disclosures.

This case report describes using Pac-Dent’s Rodin Sculpture, a ceramic nanohybrid resin, to make successive temporary bridges for a patient with 3 old maxillary bridges, 2 of which had fractured due to a history of bruxism. The second temporary was a long-span bridge that opened the bite 2 mm to reduce maximum intercuspation load on the anterior teeth before delivery of the definitive prosthesis. This case demonstrates using the 3D printing protocol for same-appointment treatment.

CASE REPORT

A 90-year-old patient presented for an emergency exam. She was an existing patient who, until then, was basically on routine hygiene recall. The previous dentist had provided her with 3 maxillary bridges spanning from teeth Nos. 3 to 6 with pontics at teeth Nos. 4 and 5 and abutments at Nos. 3 and 6, from teeth Nos. 7 to 9 with a pontic at No. 7 and abutments at Nos. 8 and 9, and from teeth Nos. 10 through 14 with pontics at teeth Nos. 11 to 13 and abutments at Nos. 10 and 14.

The anterior right bridge had fractured off, and she was complaining of pain in the area. Clinical examination and an x-ray indicated that the root of tooth No. 6 had partially fractured (Figure 1). The mobility of the fractured portion of the root was causing the pain. Tooth No. 6 had previously received root canal treatment. It was also noted that the bridge from teeth Nos. 10 to 14 had fractured at tooth No. 11. 

Figure 1. Digital x-ray of the fractured portion of the tooth No. 6 root.

The patient’s mandibular teeth exhibited a cant with occlusal surfaces rising toward the left side. She did not want any treatment done on her lower teeth and declined to have any implants placed. The topography of the bone was such that using implants in conjunction with natural teeth abutments was not feasible. It would have been necessary to extract the remaining teeth and use an All-on-X, full-arch implant prosthesis to use implants.

Treatment Plan

The treatment plan included a full-arch roundhouse porcelain-fused-to-metal (PFM) bridge with metal occlusal because the patient had a history of fracturing porcelain restorations due to her grinding habit. The vertical dimension would be increased to reduce the maximum intercuspation load on the anterior teeth. The fractured portion of tooth No. 6 would be extracted, and a post-and-core buildup would be done on the remaining portion of tooth No. 6 to help support the new bridge. The bridge on the left side would be left intact for the time being, and the 2 bridges on the right side would be combined temporarily for same-day treatment. At a later appointment, a new temporary full-arch bridge would be created.

The abutment teeth for the roundhouse bridge would be teeth Nos. 3, 6, 8 to 10, and 14. The pontics would be teeth Nos. 4, 5, 7, and 11 to 13.

Immediate Treatment Using 3D Printing

At the same appointment, the bridge from teeth Nos. 3 to 6 was removed, and the fractured portion of tooth No. 6 was extracted. After cleaning up the root that was still evident within the remaining part of tooth No. 6, a post-and-core buildup was placed to enable retaining tooth No. 6 as an abutment tooth. 

Next, an intraoral scan was taken to design a temporary bridge spanning from tooth No. 3 to tooth No. 11 at the current bite. The prosthesis was designed in exocad (Figures 2 to 4). The 2 existing maxillary right bridges were replaced with one as a temporary measure.

Figures 2 and 3. Occlusal and frontal views of the intraoral scan after the broken bridge and fractured root tip were removed.

Figure 4. Temporary bridge design at current occlusion using exocad.

The prosthesis was printed using Rodin Sculpture resin in the SOL 3D printer (Ackuretta). The print time was approximately 30 minutes, followed by a 7-minute cure in the Otoflash (NK-Optik) light-curing unit. No adjustments were needed when the temporary bridge was seated.

A ceramic-reinforced nanohybrid material such as Rodin Sculpture is an excellent material to use for long-span temporary and permanent bridges. It was one of the first printable ceramic resins approved for definitive single full-contour crowns, inlays/onlays, and veneers. It can also be used to fabricate All-on-X immediate prostheses, monolithic dentures, and split-file denture tooth arches. It is biocompatible and light-curable, and its high concentration of true nano-ceramic fillers provides excellent radiopacity. Sculpture has demonstrated superior mechanical characteristics and can be customized to produce natural-looking aesthetic restorations that will last. It also contains enough ceramic filler to be coded as a ceramic crown according to the new CDT 2023 coding. 

One of its most attractive features for same-day treatment is time savings. On average, a temporary bridge milled from polymethyl methacrylate is estimated to take about 2 hours. Milling is a subtractive process requiring a bur to grind one portion of the bridge at a time. It is more feasible for same-appointment treatment to use 3D printing because it is an additive process that builds the prosthesis in layers. Whether the case calls for one crown or 10 crowns, they print in the same amount of time if they are all on the same plane. Three-dimensional printing is limited only by the size of the printer build plate, ie, if multiple arches are planned. 

In this case, the advantage of 3D printing was the reduced amount of time spent printing large-span temporary bridges, which were delivered to the patient in less than an hour at each visit. The fit and occlusion of the first temporary bridge were checked, and it was cemented with temporary cement (Figures 5 and 6).

Figures 5 and 6. The first temporary bridge was printed with Rodin Sculpture Resin and cemented in the mouth.

Printing also has advantages for patients who may not be able to afford zirconia crowns and bridges. As a temporary and permanent measure for patients diagnosed with bruxism who potentially fracture restorations more frequently, printing will allow the capability to duplicate identical temporary prostheses in a short amount of time.

In addition to time savings, accessibility to 3D printing vs a milling machine should be taken into consideration. More offices are purchasing 3D printers because the prices are lower than milling machines. 

Implant Cases

Rodin Sculpture has also been used for implant-supported bridges in the initial temporary phase. The process is similar: The implants are placed, intraoral scans are taken, the prosthesis is designed in exocad, and the temporary bridge is printed and screwed onto the implants. Final implant crowns were also placed by the author with this material. The initial research shows that the material is beneficial for implant crowns because it disperses the stress away from the implant itself and more onto the crown compared to zirconia, which is very rigid and causes more stress on the implant.^1-3 As a result, failure of the prosthesis is more likely to occur than implant failure, and the 3D printed crown helps dissipate the stress through the bone.^4,5 In the case of prosthetic failure, a new prosthesis can be printed. This is initial research, so we must wait for long-term results to be reported.

Fabricating the Second Temporary Bridge

About a week later, the second appointment focused on opening the bite and creating a temporary roundhouse bridge. A wax-up was prepared ahead of time using the intraoral scans from the first appointment with exocad. This extended the prosthesis to the other side of the mouth, where the left-side bridge was broken (Figure 7). The wax-up opened the bite 2 mm.

Figure 7. Wax-up of the roundhouse bridge opening the bite 2 mm.

The temporary bridge and the remaining fractured bridge spanning from teeth Nos. 12 to 14 were removed, and a new digital intraoral scan was completed. Next, the wax-up created in exocad was used to design a second temporary roundhouse bridge that would open the bite 2 mm. Using this digital technology instead of a wax-up decreased the time from more than 30 minutes to less than 10. The new temporary bridge was again printed with Rodin Sculpture (Figure 8) within 30 minutes, cleaned, and cured in the Otoflash for 7 minutes. 

Figure 8. The second temporary bridge was printed in Rodin Sculpture on the SOL 3D printer (Ackuretta).

After try-in, the occlusion was adjusted, and the second temporary bridge was cemented with temporary cement (Figures 9 and 10). The new impression was sent to the dental lab, along with the scan of the new temporary that included the opened bite, to fabricate the final bridge. This process ensured that the final bridge would require minimal adjustments and allowed the lab to compare the aesthetics of the temporary to a smile picture to adjust the final prosthesis design aesthetically.

Figures 9 and 10. The temporary roundhouse bridge was cemented in the patient’s mouth.

Note that if necessary for aesthetics or if the patient requests it, Rodin Sculpture can be stained to customize the color of temporary restorations to blend in with surrounding natural teeth.

It is important to follow the manufacturer’s guidelines, especially for long-span bridges. This requires ensuring connectors for the bridge are large enough to prevent fractures. In the posterior, the manufacturer advises that the connectors be at least 27 mm to reduce or eliminate fracture of the material. The material is not recommended for bridges spanning longer than 3 units or for patients diagnosed with bruxism. This case pushed the limits of those parameters and, with proper occlusion and maintenance, allowed the patient to have teeth while waiting for the final prosthesis.

Framework Try-in

About 2 weeks later, the lab delivered the metal framework for try-in to check the fit (Figure 11). This timing also left the patient in the open bite to make sure she could tolerate it and that there were no further fractures or adjustments needed.

Figure 11. The patient returned for a third appointment to try in the metal framework before adding porcelain to the final bridge.

The fit of the metal framework should be checked before the porcelain is added to ensure that it fits properly on the teeth, and it did. It was then returned to the lab with an additional bite to confirm the previous digital bite matched well on the articulator. 

Final Bridge Insertion

The patient returned for the final full-arch PFM bridge insertion after another 2 weeks (Figure 12). This period allowed even more time for her to become used to the open bite and verify that she would continue to tolerate it. Because the printed prototype had captured the bite, it translated to the final bridge needing no adjustments. The final bridge was cemented with GC FujiCEM cement (GC America) (Figure 13).

Figure 12. The final PFM bridge.

Figure 13. Because the printed prototype captured the bite, it translated to the final bridge without needing adjustments.

CONCLUSION

Innovations in 3D printing and resins like Rodin Sculpture have allowed a quick and accurate turnaround for temporary and permanent solutions in emergency situations. This patient presented with an emergency, and a solution was provided in the same appointment, solving multiple issues with 3 bridges by gradually converting the case to one full-arch prosthetic with a more open bite. This process eliminated taking impressions, sending her home, and having her return in a week to receive a lab-fabricated prosthetic. This approach provided her with an immediate, functioning, and aesthetic temporary prosthesis, allowed time for her to adjust to a more open bite, and enabled her to eat normally throughout treatment. It also allowed the lab to make a final prosthesis accurately based on the design and bite of the temporary.

REFERENCES

1. Corbani K, Hardan L, Skienhe H, et al. Effect of material thickness on the fracture resistance and failure pattern of 3D-printed composite crowns. Int J Comput Dent. 2020;23(3):225–33. 

2. Gad MM, Alalawi H, Akhtar S, et al. Strength and wear behavior of three-dimensional printed and prefabricated denture teeth: an in vitro comparative analysis. Eur J Dent. 2023. doi:10.1055/s-0042-1759885

3. Rosentritt M, Schneider-Feyrer S, Behr M, et al. In vitro shock absorption tests on implant-supported crowns: influence of crown materials and luting agents. Int J Oral Maxillofac Implants. 2018;33(1):116–22. doi:10.11607/jomi.5463  

4. Bonfante EA, Suzuki M, Lubelski W, et al. Abutment design for implant-supported indirect composite molar crowns: reliability and fractography. J Prosthodont. 2012;21(8):596-603. doi:10.1111/j.1532-849X.2012.00872.x 

5. Bijjargi S, Chowdhary R. Stress dissipation in the bone through various crown materials of dental implant restoration: a 2-D finite element analysis. J Investig Clin Dent. 2013;4(3):172–7. doi:10.1111/j.2041-1626.2012.00149.x 

ABOUT THE AUTHOR

Dr. Siddiqui received his DDS degree from the University of Maryland School of Dentistry and went on to complete his AEGD program at Virginia Commonwealth University, in which he focused on complex restorative and implant procedures. He maintains a full-time practice in Chevy Chase, Md, incorporating digital design, 3D printing, and in-office milling. He can be reached via email at jay@radiant-dental.com. 

Disclosure: Dr. Siddiqui reports no disclosures. 

Although scientific and technological advancements have enhanced the predictability of many dental procedures, the clinical techniques and products used for gingival retraction and hemostasis remain critical to the success of crown, bridge, and other restorative treatments. In particular, the retraction, hemostatic, and moisture control protocol undertaken when creating a clearly visible and unincumbered path to gingival margins and finish lines significantly affect efficiency, accuracy, and comfort during preparation and impression-taking procedures—whether they be conventional or digital.

Fortunately, retraction paste can be used to effectively displace the soft tissue and produce a localized hemostatic effect.¹ A study comparing conventional corded to cordless paste retraction techniques found that nonimpregnated displacement cord was least effective for hemostasis and impression quality.² Conversely, the same study found that using aluminum chloride-impregnated cord and using displacement paste were comparable for dilatation and impression quality, but retraction paste demonstrated better ease of use and hemostasis.² Additionally, a more recent study analyzing the clinical effectiveness of different gingival retraction systems found that an aluminum chloride-containing paste produced the highest mean gingival retraction when compared to knitted retraction cord and expanding polyvinyl siloxane, and it also was effective in almost all analysis areas.³

Among available retraction pastes is an aluminum chloride-based paste that effectively widens and dries the gingival sulcus to establish the ideal conditions for accurate and successful digital or conventional impressions (Retraction Paste [VOCO]). Provided in 0.3-g unit dose capsules (sufficient, for example, for displacing up to 3 sulci) with an extra-long, thin, and flexible plastic tip, the astringent paste promotes simple and precise application directly into the sulcus (ie, up to 50% faster than conventional retraction cord), without the potential for tissue injury or discomfort. 

CASE REPORT

A 68-year-old man presented with a fractured maxillary right molar (tooth No. 3) (Figure 1). Clinical and radiographic examination confirmed a fractured mesial/lingual cusp and recurring decay at the mesial, buccal, and lingual gingival margins.

Figure 1. Preoperative view of tooth No. 3 that would be prepared and digitally scanned for impressions for a full-coverage zirconia crown.

The tooth had been directly restored many times and was crucial for posterior stabilization of his maxillary partial denture. The patient was informed and understood that additional direct restoration of tooth No. 3 would not provide predictable long-term function for either the tooth itself or his partial denture. After reviewing treatment options, the patient decided to proceed with a full-coverage zirconia crown restoration.

Figure 2. Following initial preparation and decay removal, the biologic width was checked.

During tooth preparation, it became apparent that the mesial decay extended subgingivally. Therefore, periodontal probings were recorded (Figure 2) to determine biologic width and proper margin depth.⁴ The biologic width measured between 2.0 to 2.5 mm, making it imperative that the preparations would not extend beyond 0.5 to 1.0 mm subgingival. To mitigate inflammation, bone resorption, and periodontitis, a 2.0-mm dimension from the bottom of the epithelium junctional to the tip of the alveolar bone was essential.⁴

Figure 3. View of bleeding in the sulcus and gingival tissues after tooth preparation.

Following tooth preparation, bleeding around the sulcus was evident (Figure 3). Given the depth of the preparation and the need to avoid further removal of sulcular gingival tissue and violation of the biologic width, chemical retraction/hemostasis was necessary. An aluminum chloride-based paste (Retraction Paste) was the ideal solution to address this clinical situation (Figure 4).

Figure 4. An aluminum chloride-based paste (Retraction Paste [VOCO]) was selected to establish hemostasis and gently manage the gingival tissues.

Figure 5. The extra-long, thin, plastic tip was inserted into the sulcus, and the paste was extruded.

Figure 6. The tip was moved around the preparation sulcus subgingivally while extruding the retraction paste.

Figure 7. View of the extruded retraction paste after setting for 2 to 3 minutes.

Figure 8. Pressure was administered into the marginal sulcus using a 2- × 2-in sponge gauze.

Pressure into the marginal sulcus was administered using a 2- × 2-in cotton sponge gauze (Figure 8), after which bleeding persisted from the mesial margin (Figure 9). Therefore, Teflon tape was rolled and pushed through the retraction paste into the sulcus (Figures 10 and 11). This further carried the paste into the sulcus, placing pressure on the sulcular tissue, mitigating the bleeding, and widening the distance between the tissue and the margin. The Teflon tape remained in place for 2 to 3 minutes (Figure 12).

Figure 9. Bleeding persisted from the mesial margin.

Figure 10. View of the rolled Teflon tape.

Figure 11. The Teflon tape was pushed through the retraction paste and into the sulcus.

Figure 12. The Teflon tape remained in place for 2 to 3 minutes

Figure 13. The high- contrast retraction paste’s consistency made it easy to wash off for quick cleanup.

Figure 14. After the Teflon tape was removed, the finished preparation and surrounding gingival tissues demonstrated clear and clean margins.

Figure 15. A precise and accurate digital impression scan was obtained due to the readily visible and clear path established by using the aluminum chloride-based VOCO Retraction Paste.

Due to the material consistency of the high-contrast retraction paste, it was easily washed off for quick cleanup (Figure 13). Once the Teflon tape was removed, the finished preparation and surrounding gingival tissues demonstrated clear and clean margins (Figure 14), providing a readily visible and clear path for easy and accurate intraoral digital impression scans (Figure 15).

CONCLUSION

When temporary retraction of the gingival tissues surrounding preparation margins is required, VOCO Retraction Paste represents an alternative method for establishing the moisture control and gentle soft-tissue management essential for exact crown margins; ideal adaptation; and long-lasting, aesthetic restorations. Akin to a cord in a capsule, VOCO Retraction Paste can be used to provide a dry gingival sulcus prior to taking conventional or digital impressions, for undertaking cementation of temporary or permanent restorations, and for preparing Class II and V restorations. As illustrated in this case, it can be an essential element for ensuring a visible and unincumbered path to gingival areas during preparation and digital impression-taking procedures.

REFERENCES

1. Radz G. The key to the perfect impression. Compend Contin Educ Dent. 2010;31(6):464-465.

2. Acar O, Erkut S, Özçelik TB, et al. A clinical comparison of cordless and conventional displacement systems regarding clinical performance and impression quality. J Prosthet Dent. 2014 May;111(5):388-94.

3. Kumari S, Singh P, Parmar UG, et al. Evaluation of effectiveness of three new gingival retraction systems: a comparative study. J Contemp Dent Pract. 2021 Aug 1;22(8):922-927.

4. Stafee AA, Zinov’ev GI. Dental preparation features by subgingival location of circular ledge. Stomatologiia (Mosk). 2012;91(2):49-50.

ABOUT THE AUTHOR

Dr. Simos received his DDS degree from Loyola University in Chicago and maintains a private practice, Allstar Smiles, in Bolingbrook and Ottawa, Ill. The founder and president of the Allstar Smiles Learning Center, Dr. Simos teaches postgraduate courses in comprehensive restorative dentistry and is a recognized leader in cosmetic and restorative dentistry. In addition, he lectures throughout the country and is an internationally published author on the use of today’s innovative techniques and materials in dentistry. He can be reached at sam.s@allstarsmiles.com.

Disclosure: Dr. Simos reports no disclosures. 

It has been well-substantiated that extractions (without supplemental guided bone regeneration [GBR], or “unassisted”) can lead to loss of horizontal and vertical ridge dimensions. Numerous studies have concluded that the use of GBR techniques with barrier membranes minimizes the loss of alveolar bone height and width. This is of special concern in the aesthetic zone, in areas of unfavorable pontic anatomy, and in future implant sites. It is imperative to evaluate socket anatomy and compromised bony housing before treating socket defects. The benefits of laser-assisted socket management in the treatment of these defects will be addressed, as will a step-by-step protocol. These case reports present a novel technique for laser-assisted socket grafting (LASG) without the use of barrier membranes.

Tooth eruption studies have shown that the alveolar process is dependent on the presence of a tooth. Surrounding bone volume is related to the shape, size, inclination, and eruption of the tooth, along with genetic and developmental factors. The tooth is housed by bundle bone, which is penetrated by the periodontal ligament fibers.¹ 

In a systematic review, Van der Weijden et al² found a mean clinical loss of 3.87 mm in width and 1.53 mm in height (radiographically) with unassisted socket healing. Similarly, in a more recent review, Tan et al³ found a mean horizontal loss of 3.79 mm and a vertical loss of 1.24 mm with unassisted socket healing. When socket preservation therapies were used, a gain in width of 1.83 mm and a gain in height of 1.47 mm were found in test vs control groups.⁴ It was concluded that horizontal resorption is more pronounced than vertical loss and dimensional changes of the alveolar ridge can be limited by GBR techniques.⁵ 

Nowadays, the most important reason for socket grafting is to preserve the form of the ridge for a restoratively driven implant.⁶ The survival rate of fixtures placed in grafted sites is similar to those placed into native bone.⁷ The principles of GBR, which include maintenance of space, angiogenesis within the grafted material, prevention of epithelial down-growth, and stabilization of the blood clot during healing, are crucial to the success of socket grafting. This is especially important in deficient sockets, such as Funato’s Class III and IV or Elian’s Type III sockets.^8,9 

The Nd:YAG laser is a useful instrument for assisting with multiple aspects of extraction socket management. When the Nd:YAG laser tip is applied to the sulcular collar around periodontally unhealthy teeth, it ablates the ulcerated epithelium, leaving healthy connective tissue intact.¹⁰ The laser energy can function similarly when applied to residual unhealthy tissue in an extraction socket. This specific laser wavelength eliminates periodontal pathogens in the periodontal pockets of the tooth slated for extraction.^11,12 Additionally, Nd:YAG lasers can potentially convert granulomatous tissue (tissues that have inflammatory components and pathogens) into granulation tissue. Granulation tissue has cellular components, possibly stem cells,¹³ and vascularity important for the regeneration process. The Nd:YAG can transform blood into a “thermogenic clot.” This acts as a membrane protecting the site from epithelial down-growth. Lasers have been shown to help in repair^14-16 and regeneration^17-19 of bony defects as well as in providing biostimulation and pain reduction.²⁰

This article will present clinical case reports utilizing an LASG technique, dependent on the anatomy of the socket, in preparation for implant placement. 

MATERIALS AND METHODS

1. After confirming that the tooth was required to be extracted (Figure 1), an “atraumatic” extraction protocol was followed to minimize trauma to the adjacent tissue and bone. Following administration of local anesthetic, a 360° intrasulcular incision was made. Periotomes and appropriate forceps were then used to deliver the tooth. 

2. The sulcular ulcerated tissue was ablated with an Nd:YAG laser (Millennium Dental Technologies) placed alongside the socket wall to the accessible depth of the base of the pocket (Figure 2).

3. The socket was gently debrided. The laser was then used to remove bacterial pathogens from the granulomatous tissue. Laser ablation alters this pathological tissue (Figure 3). The residual remaining granulation tissue has cellular components, vascularity, and possible growth factors to aid with socket regeneration. 

Figure 1. Diagnosis of non-restorable tooth.

Figure 2. Laser ablation to remove ulcerated epithelium at the internal coronal marginal area.

Figure 3. Laser detoxification, leaving cellular components, vascularity, and potential growth factors for regeneration.

4. Following socket laser ablation and detoxification, the piezo tip was used to penetrate the surrounding bone. This decortication was intended to further release potential healing growth factors and stem cells into the socket (Figure 4). 

5. After allowing an initial clot to form, the Nd:YAG laser was set on a hemostasis mode. The socket was lased for hemostasis (Figure 5), and afterward, a firm gelatinous clot was formed. 

6. This clot would act as a barrier membrane to contain graft materials (such as particulate allograft, xenograft, or a calcium phosphate plug and/or block) that conforms to the residual anatomy of the socket and prevent epithelial migration into the socket (Figure 5).

7. If socket walls are missing, a semi-solid collagen plug incorporated with graft material (eg, an OsteoGen Bone Grafting Plug [IMPLADENT LTD]) or an allogenic block can be shaped to conform to the socket. The extracted root can be used as a template to shape the block. The material is placed into the clot approaching the accessible base of the socket (Figure 6).

Figure 4. Decortication/bone modification to potentially release growth factors and stem cells.

Figure 5. Laser hemostasis to form a thermogenic clot that acts as a barrier to epithelial penetration.

Figure 6. Depending on space maintenance requirements, either a particulate graft, plug, or block is placed into the clot.

8. If the clot has been disrupted after graft material placement, the site is lased again with the Nd:YAG in hemostasis mode using 450 to 650 pulse duration, depending on the amount of bleeding (Figure 7). Postoperative instructions are similar to those for routine extractions and GBR protocols. The patient was advised not to disrupt the clot. Gauze placement and biting are not recommended. The patient was asked to refrain from hot liquids, rinsing, exercise, and disruption of the clot for 48 hours. 

9. The site was monitored clinically and radiographically for complete soft-tissue and hard-tissue maturation (Figure 8).

Figure 7. Determination of laser hemostasis and additional laser hemostasis, if required.

Figure 8. Adequate osseous fill following laser-assisted socket grafting.

CASE REPORTS

Case 1

A 17-year-old male was referred to the Department of Periodontology at the Rutgers School of Dental Medicine (RSDM). The patient’s medical history revealed no systemic contraindications for dental treatment. Clinical and radiographic examination revealed external root resorption with a history of trauma on the maxillary right central incisor (Figures 9 and 10). Using a PerioLase MVP-7 Laser (Millennium Dental Technologies), a sulcular incision was made in 360° in ablation mode. The tooth was extracted using periotomes and luxators (PDL-Evator Precise Tip Luxating Elevators [Salvin Dental Specialties]) without elevating a flap. Upon examination, a 6-mm buccal plate dehiscence was noted, and the decision was made to use a block allograft. The Nd:YAG laser (PerioLase MVP-7) was used on the hemostasis setting, 550 pulse duration, to administer 146 J to create a stable blood clot (Figure 11). A bone block (Puros Block Allograft [Zimmer Biomet]) was carved using the root as a template to mimic the shape of the extracted tooth (Figure 11). An additional 100 J were administered to complete hemostasis over the bone block. Post-op ibuprofen 400 mg, 20 tabs q6h prn pain, was prescribed. An Essix retainer with a pontic was fabricated as an interim prosthesis. The patient was instructed not to function on the temporary prosthesis during the healing phase. The patient was seen for a 2-week followup, and then every 4 weeks after that, for supragingival debridement and oral hygiene reinforcement. Dimensional stability and adequate clinical healing were noted at 3 months. A 3.3- × 12-mm implant (Bone Level Straight implant [Straumann]) was placed in good-quality bone with good stability and no complications (Figure 12). The final prosthesis was delivered 4 months following implant placement (Figure 13). 

Figure 9. Preoperative view of the maxillary right central incisor.

Figure 10. Pre-op radiograph.

Figure 11. Placement of the carved allograft bone block into the socket following extraction and laser hemostasis.

Figure 12. Radiograph of the implant 4 months after placement.

Figure 13. Final screw-retained crown.

Case 2

A 65-year-old male presented with remaining root tips of the mandibular right first molar (Figure 14). After an explanation of treatment options, the patient elected to have the tooth extracted and replaced with an implant-retained prosthesis. The remaining roots were extracted using elevators (Salvin Dental Specialties) without elevating a flap. The PerioLase MVP-7 Nd:YAG laser was used to ablate the remaining sulcular epithelium. Hemostasis was achieved using 158 J. Immediately after, particulate allograft (Puros Block Allograft) was placed into the socket. An additional 102 J were administered over the bone allograft because hemostasis was disrupted. No sutures or membrane was placed. Post-op medications of ibuprofen 400 mg, 20 tabs q6h prn pain, and Azithromycin 500 mg, 10 tabs QD, were prescribed. The healing phase was closely monitored and had no adverse events. After 3 months of healing, a trephine core biopsy was obtained. Histological analysis confirmed vital bone formation (Figure 15). A Full OSSEOTITE Tapered Certain Prevail 5/4- × 10-mm platform-switched implant was placed (3i [Zimmer Biomet]) (Figure 16). A screw-retained final restoration was placed after 4 months of healing (Figures 17 and 18).

Figure 14. Pre-op radiograph of the remaining tooth structure.

Figure 15. Histology showing vital new bone.

Figure 16. Radiograph of implant placement.

Figure 17. Radiograph of final crown placement.

Figure 18. Buccal photograph of the screw-retained crown.

Case 3

A 73-year-old female presented with an apical lesion labial to her maxillary left central and lateral incisors. Suppuration and pain upon percussion were noted (Figure 19). Radiographic and CBCT exams revealed a through-and-through defect from the labial to palatal bone (Figure 20). The patient’s health history included total hip replacement and hyperparathyroidism. The patient was taking a bisphosphonate for osteoporosis. These factors contributed to the decision to not pursue an implant and to prepare the site for a pontic in a fixed bridge. An LASG technique (PerioLase MVP-7 Nd:YAG laser) provided a conservative approach, eliminating the need to elevate a flap and still meet the objective of bone repair and an aesthetic result. Two medium-sized absorbable collagen bullet-shaped plugs were used to ensure space maintenance of the defect. The plug was slightly larger than the roots to help maintain contact with the apical and interproximal bone. 

The hemostatic clot that was formed after laser application provided a scaffold to secure the position of the plug and prevent its dislodgement from the socket. No sutures were needed (Figure 21). An 8-month periapical radiograph showed new bone fill at the site (Figure 22). The patient was restored with a new fixed prosthesis from Nos. 6 to 11 (Figure 23). An appropriate emergence profile was developed during the transitional healing phase, and no significant defect was noted.

Figure 19. Pre-op photograph of the failing teeth with a large buccal swelling.

Figure 20. Pre-op CBCT radiograph of the infection around the maxillary left central incisor.

Figure 21. Immediate post-extraction photograph with provisional FPD in place. Post-extraction sockets had collagen sponges added following laser socket hemostasis.

Figure 22. CBCT showing bone fill in previous area of severe bone resorption.

Figure 23. Seven months after crown insertion.

DISCUSSION

The laser socket grafting technique described was developed based on proven techniques and available literature. The initial step uses the laser to make an intrasulcular incision, which selectively ablates diseased epithelium but maintains healthy connective tissue. Gold and Vilardi¹⁰ evaluated human gingival tissue following the removal of pocket-lining epithelium with a pulsed Nd:YAG laser. Sections showed complete removal of epithelium (83%), with 17% having trace amounts of viable basal cell remnants at the coronal margin. The connective tissue showed no evidence of carbonization or necrosis.¹⁰ Ting et al²¹ performed a human histologic study using the Nd:YAG laser, demonstrating complete removal of the ulcerated epithelium without harming the underlying connective tissue. In patients with a thin phenotype, this is particularly important, especially compared to traditional incisions. 

Following extraction, laser energy is used to reduce bacteria in the sockets. An in vitro study demonstrated that the pulsed Nd:YAG laser selectively destroyed pigmented pathogens.¹¹ In 2014, a human study compared the antibacterial effects of laser periodontal therapy using an Nd:YAG laser vs ultrasonic root debridement. Eighty-five percent of patients treated with the laser-assisted new attachment procedure were culture-negative for all evaluated periodontal pathogens in immediate post-treatment samples. Patients treated within the ultrasonic group had 100% of culture samples remain positive for most subgingival bacterial pathogens recorded at baseline.¹²

If granulomatous tissue is present, the laser can detoxify the tissue. The remaining granulation tissue may provide vasculature and cellular components to aid in regeneration. Recently, Ronay et al¹³ removed granulation tissue from furcation and infrabony defects. Cells expressing embryonic stem cell markers and the tissue exhibiting osteogenic capacities were found when cultured in vitro.¹³ An in vivo animal model showed that periodontium-derived stem cells can be cultured and are capable of regenerating bone and collagen elements.²²

The bone modification and decortication of the socket may release growth factor components. An in vitro study demonstrated that the Nd:YAG laser increased osteoblast activity and additionally accelerated mineral deposition. The authors speculated that the laser might activate BMP-2.²³ In another in vitro study, the Nd:YAG laser induced gingival fibroblasts to proliferate and up-regulated the secretion of epidermal growth factor.²⁴ 

A study comparing treatment of intrabony defects with and without intramarrow penetration (IP) demonstrated clinical and radiographic outcomes that were significantly improved with IP.²⁵ Verdugo et al²⁶ found that when performing GBR, cortical perforations may improve clinical and histological outcomes. The thick thermogenic clot formed with the Nd:YAG laser acts as a barrier membrane to exclude the epithelium and allow the necessary cellular components to form osteoid and, eventually, bone. 

The determination to use a particulate graft, a semi-solid collagen plug, or an allogeneic block is based on principles of GBR. If additional space maintenance is needed, a plug or block is used. Reddy et al²⁷ emphasized the importance of space maintenance in treating the atrophic socket. A benefit of the laser is that less post-op discomfort should be anticipated due to the photostimulation from the laser energy. Lasers have been shown to provide pain relief, improve wound healing, and stimulate collagen growth.²⁸ 

CONCLUSION

These case reports present a novel socket grafting procedure based on GBR principles. Critical for success is the evaluation of the socket defect and whether particulate material, a plug, or a block graft is necessary for space maintenance. A sound thermogenic clot is an absolute requirement to act as a barrier membrane. With the improvement of CAD/CAM technology and grafting materials, the potential to create a plug or bone block based on root morphology will have the potential to aid in space maintenance for optimum bone regeneration. Additional research with LASG is recommended to improve and advance the technique of using the inherent blood clot and grafting material to enhance the patient outcome.

ACKNOWLEDGMENTS

We would like to thank Alireza Oryan for editing and formatting the manuscript prior to its submission.

REFERENCES

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6. Tarnow DP, Eskow RN. Preservation of implant esthetics: soft tissue and restorative considerations. J Esthet Dent. 1996;8(1):12-9. doi:10.1111/j.1708-8240.1996.tb00904.x

7. Fiorellini JP, Nevins ML. Localized ridge augmentation/preservation. A systematic review. Ann Periodontol. 2003;8(1):321–7. doi:10.1902/annals.2003.8.1.321

8. Funato A, Salama MA, Ishikawa T, et al. Timing, positioning, and sequential staging in esthetic implant therapy: a four-dimensional perspective. Int J Periodontics Restorative Dent. 2007;27(4):313–23. 

9. Elian N, Cho SC, Froum S, et al. A simplified socket classification and repair technique. Pract Proced Aesthet Dent. 2007;19(2):99-104. 

10. Gold SI, Vilardi MA. Pulsed laser beam effects on gingiva. J Clin Periodontol. 1994;21(6):391-6. doi:10.1111/j.1600-051x.1994.tb00735.x

11. Harris DM, Yessik M. Therapeutic ratio quantifies laser antisepsis: ablation of Porphyromonas gingivalis with dental lasers. Lasers Surg Med. 2004;35(3):206–13. doi:10.1002/lsm.20086 

12. McCawley TK, McCawley MN, Rams TE. LANAP Immediate Effects In Vivo on Human Chronic Periodontitis Microbiota. In J Dent Res; March 20, 2014. American Association for Dental Research 43rd Annual Meeting, Charlotte, NJ. 93 (Spec Issue A); Abstract 428.

13. Ronay V, Belibasakis GN, Attin T, et al. Expression of embryonic stem cell markers and osteogenic differentiation potential in cells derived from periodontal granulation tissue. Cell Biol Int. 2014;38(2):179–86. doi:10.1002/cbin.10190 

14. Pinheiro AL, Limeira Júnior Fde A, Gerbi ME, et al. Effect of low level laser therapy on the repair of bone defects grafted with inorganic bovine bone. Braz Dent J. 2003;14(3):177-81. doi:10.1590/s0103-64402003000300007

15. Soares LG, Marques AM, Guarda MG, et al. Raman spectroscopic study of the repair of surgical bone defects grafted or not with biphasic synthetic micro-granular HA + β-calcium triphosphate irradiated or not with λ850 nm LED light. Lasers Med Sci. 2014;29(6):1927–36. doi:10.1007/s10103-014-1601-9 

16. Monea A, Beresescu G, Boeriu S, et al. Bone healing after low-level laser application in extraction sockets grafted with allograft material and covered with a resorbable collagen dressing: a pilot histological evaluation. BMC Oral Health. 2015;15:134. doi:10.1186/s12903-015-0122-7

17. Nevins ML, Camelo M, Schupbach P, et al. Human clinical and histologic evaluation of laser-assisted new attachment procedure. Int J Periodontics Restorative Dent. 2012;32(5):497-507. 

18. Nevins M, Kim SW, Camelo M, et al. A prospective 9-month human clinical evaluation of Laser-Assisted New Attachment Procedure (LANAP) therapy. Int J Periodontics Restorative Dent. 2014;34(1):21–7. doi:10.11607/prd.1848 

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20. Ozen T, Orhan K, Gorur I, et al. Efficacy of low-level laser therapy on neurosensory recovery after injury to the inferior alveolar nerve. Head Face Med. 2006;2:3. doi:10.1186/1746-160X-2-3

21. Ting CC, Fukuda M, Watanabe T, et al. Morphological alterations of periodontal pocket epithelium following Nd:YAG laser irradiation. Photomed Laser Surg. 2014;32(12):649–57. doi:10.1089/pho.2014.3793 

22. Grimm WD, Dannan A, Becher S, et al. The ability of human periodontium-derived stem cells to regenerate periodontal tissues: a preliminary in vivo investigation. Int J Periodontics Restorative Dent. 2011;31(6):e94-e101. https://pubmed.ncbi.nlm.nih.gov/22140674/

23. Kim IS, Cho TH, Kim K, et al. High power-pulsed Nd:YAG laser as a new stimulus to induce BMP-2 expression in MC3T3-E1 osteoblasts. Lasers Surg Med. 2010;42(6):510–8. doi:10.1002/lsm.20870 

24. Gkogkos AS, Karoussis IK, Prevezanos ID, et al. Effect of Nd:YAG Low Level Laser Therapy on Human Gingival Fibroblasts. Int J Dent. 2015;2015:258941. doi:10.1155/2015/258941

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26. Verdugo F, D’Addona A, Pontón J. Clinical, tomographic, and histological assessment of periosteal guided bone regeneration with cortical perforations in advanced human critical size defects. Clin Implant Dent Relat Res. 2012;14(1):112–20. doi:10.1111/j.1708-8208.2009.00235.x 

27. Reddy TS, Shah NR, Roca AL, et al. Space maintenance using tenting screws in atrophic extraction sockets. J Oral Implantol. 2016;42(4):353–7. doi:10.1563/aaid-joi-D-15-00048

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ABOUT THE AUTHORS

Dr. Lehrman is a periodontist with practices both in New York City and Southampton, NY. Upon completion of his postgraduate training and his exposure to laser-assisted regenerative surgery in 2006, Dr. Lehrman has dedicated his clinical practice to the treatment of periodontal, peri-implant, and cosmetic periodontic cases with a laser-assisted approach. He is engaged in both clinical and laboratory research with an eye toward creating “wound healing” with the advent of the Nd:YAG wavelength. He can be reached at nl@nldds.com.

Dr. Drew is a professor, a director of implantology, and the vice chairman in the Department of Periodontics at the Rutgers School of Dental Medicine (RSDM). He received his doctorate and degree in periodontics from RSDM. He has been awarded the RSDM Excellence in Teaching Award, the Stuart D. Cook Master Educators Guild Award, and the prestigious AAP Educator Award. Dr. Drew was inducted into the American College of Dentists, and he was awarded the RSDM Alumni Association Decade (1980s) Award. He has written more than 25 articles for publications and has lectured throughout the country. He was in full-time clinical practice for more than 25 years. He can be reached at drhjdrew@aol.com.

Dr. Strauss is a board-certified periodontist with a private practice in Englewood, NJ, limited to periodontics and implantology. He received his doctorate in dental medicine from the University of Pennsylvania where he graduated with clinical honors and completed his postgraduate training in periodontics at Rutgers University, where he received multiple honors and awards, including the Balbo clinical poster award. He has presented and published articles on surgical canine exposures, periosteal pouch bone grafting, implant osteotomy preparation, and the treatment of peri-implantitis. At the 2018 Greater New York Dental Meeting, Dr. Strauss received the prestigious Carl Misch award for his excellence in presenting on the topic of alternative bone grafting techniques. He can be reached at gabriel.m.strauss@gmail.com.

Dr. Rynar is a graduate of Brown University and received his DMD degree and Certificate of Advanced Graduate Study in Periodontology at Boston University. He is a clinical professor of periodontics at RSDM. He is a certified Institute for Advanced Laser Dentistry Instructor. He has lectured throughout North America and Europe on periodontic and implantology topics, including immediate loading, implant concerns in soft bone, and periodontal/implant aesthetics. He has been published in various periodontal journals. Dr. Rynar practices in Florham Park, NJ. He can be reached at jamesrynar@gmail.com.

Dr. Kashikar is a board-certified oral pathologist with a doctorate in dentistry from the New York University College of Dentistry. She completed her residency at the NewYork-Presbyterian Queens Hospital in Queens, NY. Dr. Kashikar completed a one-year fellowship in dental oncology at Memorial Sloan Kettering Cancer Center in New York City. She has taught as a professor at RSDM for the last 3 years and was interim director of the biopsy service at the school. She is currently pursuing other interests and maintains her board status in oral pathology. She can be reached at skashikar86@gmail.com. 

Disclosures: Dr. Lehrman has served as an instructor at the Institute for Advanced Laser Dentistry (IALD), but currently does not receive compensation from Millennium Dental Technologies, Inc. Drs. Lehrman and Strauss have received honoraria for lectures for the IALD. All other authors report no disclosures.

As I contemplate my 42-year career, I am struck by how much progress has been made in the field of dentistry in general and in dental impressions in particular. Two other observations also strike me: First, it is virtually impossible for younger dentists to fully appreciate just how far the practice of dental impressions has come in the past 70 years. Second, many dentists of all ages are uncertain about the role—and even the very existence—of conventional dental impressions in the era of digital dentistry.

This article is intended to shed what I hope will be some helpful light on the past, present, and future of dental impressions.

BALANCING THE ART, SCIENCE, AND BUSINESS OF DENTAL IMPRESSIONS

Suppose you have read any of my other articles or attended any of my lectures. In that case, you are probably aware of my deep conviction that true success in private practice comes only when the dentist consistently finds the balance between the art, science, and business of dentistry. Metaphorically speaking, I believe that dental success rests on the following “3-legged stool”:

• Art—creating something beautiful
• Science—using an evidence-based approach incorporating the latest research
• Business—being able to affordably reproduce procedures in a timely manner

You can create a beautiful restoration out of different shades of soap, but it won’t last because it’s built on bad science, and it won’t be good business because it will not last. Conversely, you could make a front crown out of solid titanium that will last forever, but it won’t be beautiful, and the patient will not accept it. Or you could do a very quick procedure that will earn you a lot on a per-hour basis, but it wouldn’t be based on sound science or look beautiful and ultimately wouldn’t be acceptable to patients. Only when you can check all 3 boxes—great art, great science, and great business—will you be able to achieve sustained success in your practice. And that maxim is particularly true with dental impressions.

IMPRESSION-TAKING MATERIALS: HOW FAR WE’VE COME

Here’s a brief history of the impression materials our profession has relied on over the last century-and-a-half:

• 1800s—wax or plaster of Paris dominated
• 1940s—alginate materials were introduced
• 1950s—elastomeric impression materials were introduced, featuring silicon-based materials, polyethers, and polysulfides
• 1960s—reversible hydrocolloid impression materials gained popularity due to the major advancement these hydrophilic materials brought in terms of capturing accurate impressions despite the presence of saliva and blood.
• 1970s—a new generation of elastomeric impression materials was introduced, offering more viscosity and elasticity, similar to rubber-based materials, and enabling surface materials to be captured even more accurately.

And, of course, now we have the option of taking digital impressions. Figures 1 and 2 dramatically illustrate just how far we’ve come with dental impression technology.

Figure 1. Copper bands for impression taking.

Figure 2. Digital impressions.

 The key, as I will discuss below, is to create these analog impressions by: 

• Selecting the proper techniques
• Using those techniques precisely the way they are designed to be used, and
• Using the right materials with those techniques.

The fact is that, with the proper technique, it is still possible to use a simple copper band to create a wonderful impression. However, it’s very difficult for the practitioner and very uncomfortable for the patient. In contrast, digital impressions are much easier for both practitioner and patient. But for all the benefits of digital impressions, there are many situations for which analog impressions are not only highly relevant but clearly preferable.

The 3 points above apply not just to impression-taking but to virtually every dental procedure. Unfortunately, they too often aren’t taken to heart by our profession. As dentists, we have no right to criticize the efficacy of a technique when we don’t use it properly.

IMPRESSION TAKING HAS NEVER BEEN EASIER

Remember how difficult your first impression was in dental school? I remember getting materials all over myself and my procedure partner and thinking that I’d never master this skill. Fortunately, dramatic improvements have been made in all the physical aspects of impression materials: wettability, hydrophobic properties, hydrophilic properties, working time, accuracy, maintaining dimensional stability, tear strength, and even the taste of the materials. Moreover, the ability to automatically mix impression materials in guns and cartridges has made them so much easier to handle than mixing them up manually on a pad, which introduces air and other problems to the materials.

 When using the right techniques, the right bonding material, and the right composite with the right hue value and chroma and keeping in mind what the occlusion and the anterior guidance should be and doing it in a timely manner, you’ll achieve balance of the art, science, and business of dentistry. Now let’s talk about impression taking for composite restorations.

CROWN AND BRIDGE IMPRESSIONS: 3 TECHNIQUES

The following 3 techniques are frequently in use today. The first 2 are conventional techniques, while the third is unconventional.

1. All-in-one technique:

• A full- or dual-arch impression tray is simultaneously filled with impression material while a light-body flowable wash is squirted around the teeth with a syringe.
• A conventional vinyl polysiloxane (VPS) impression material is typically used.

2. One-step putty wash technique:

• A putty impression is made, and the tray is taken out of the mouth. The light body is squirted into it with a syringe, and the tray is reseated in the mouth.
• Putties from 2 tubs are mixed and used as the impression material.

3. Hydraulic and hydrophobic (H&H) technique:

• The underlying concept is to use hydraulics to push a hydrophobic impression material capable of displacing blood and saliva. A preliminary impression is taken; it’s not relieved and doesn’t use a spacer. It’s then lined with the hydrophobic impression material. The patient is instructed to bite back into the impression, causing the material to be extruded from the impression. The resulting hydraulic pressure forces it into the sulcus laterally and occlusally throughout the entire impression. The tray is never removed from the mouth.
• A high-durometer VPS impression material is required for the initial impression. A light-body impression is used within the initial impression.

Crown and Bridge Impressions: The H&H Technique

Let’s go into more detail about the H&H technique for 3 reasons. First, it’s less well understood than the 2 conventional techniques. Second, in my experience, it’s the most effective technique. And third (full disclosure time), I invented and patented the technique.

I introduced the H&H technique in 1998 to address one of the most frustrating aspects of making final impressions for crowns and bridges: managing finish lines that extend subgingivally. Dentists were having to contend with problems like relapsing gingival tissue that can obstruct the flow of impression material into the sulcus. This was most often managed by packing a retraction cord, which was time-consuming, difficult, and often uncomfortable for the patient.

Dentists were also having to contend with gingival hemorrhaging that could fill the sulcus with blood and interfere with the flow of impression material. This was most often managed with hemostatic agents that could require multiple applications and taste bad. Moreover, hemorrhaging could recur spontaneously or when the cord was removed. And the hemostatic agents used to address the hemorrhaging contained sulfur that could inhibit the setting of VPS impression materials.

Yet another problem was that saliva could flood the field if the assistant was unable to maintain adequate suction and isolation, which was not uncommon for some patients.

Making final impressions of subgingival finish lines can still be a challenge, even under the best of circumstances. Fortunately, the H&H impression technique eliminates the need for retraction of the gingival tissue, the need to apply hemostatic agents, the need for syringe-able retraction clay, and the need for maintaining a dry field. Here’s a quick summary of how to use this technique:

1. Inject a high-durometer VPS (Honigum Pro Putty [DMG America]) onto a plastic or metal triple tray.

2. The patient closes into the high-durometer VPS, which forms a “peripherally sealed custom tray” around the prep area (Figure 3).

Figure 3. Initial impression with high-durometer VPS (Honigum [DMG America]).

Figure 4. Honigum Pro light body (DMG America) syringed onto VPS while still seated in the mouth (blue).

3. After the high-durometer VPS sets, the patient opens while your fingers retain the impression on the opposing arch. Note that it’s important that the tray remain in the mouth at this point. Do not remove and reseat as this is unnecessary and can lead to reseating errors. The patient must be able to bite back into the impression, and if there are broken pieces or interproximal tags, they must be removed.

4. Spray, wash, and dry the impression surface while in the mouth.

5. Using an auto-mix tip, syringe light-body impression material (Honigum Pro light body [DMG America]) onto the high-durometer VPS in the prep areas and adjacent areas (Figure 4). There’s no need to syringe light-body material directly onto the teeth as that tends to trap bubbles. You only need to syringe the light-body material into the prep area (Figure 5). 

Figure 5. The amount of light body necessary.

6. Instruct the patient to close fully and forcefully, thereby exerting hydraulic force on the light-body impression material, and wait until the material sets on the tip of the gun to remove it. The light body flows and follows the path of least resistance, first flowing subgingivally since the periphery is sealed by the high-durometer VPS. Typically, the light body flows past the margins. The excess then flows out the periphery. Note that it’s ideal to hold your hand on the patient’s chin and masseter muscle while the light body polymerizes to avoid patient movement (Figure 6). 

Figure 6. Patient closed (with help).

7. After the initial forceful closure, the patient should remain closed and maintain steady pressure. When the material is set on the tip of the gun, you then can remove and inspect your impression (Figure 7).

Figure 7. Final impression (blue and yellow).

As you can see, the H&H technique doesn’t call for the initial impression tray to be removed from the mouth after the high-durometer VPS has been used, which means the impression never needs to be reseated.

Over the past 24 years, the H&H technique has been used successfully by thousands of dentists and written about in dozens of articles. While most of those articles have been favorable, a few have levied some criticisms. One criticism is that reseating the impression in the mouth often results in a step in the impression. What this criticism fails to understand is that the H&H technique doesn’t call for the impression tray to be removed from the mouth, which means the impression shouldn’t be reseated.

A related criticism from some is that the technique often results in occlusal interferences. The truth is that this will not happen if you check to make sure the tray seats properly when you have the patient re-bite into the tray. Occlusal interferences will be avoided by having the patient (1) bite into the tray; (2) open his or her mouth, leaving the tray resting on the opposite arch; and (3) practice biting back into the tray to make sure he or she does it properly. By the way, if you have any material that breaks off from the interproximals, just carefully move it and/or rinse it away from the underside of the tray.

Another occasional criticism has been that there is an increased risk of the wash not completely bonding to the set putty material due to salivary contamination. The problem is easily avoided if you simply rinse and dry it—as the technique calls for—so there can be no salivary contamination. Some have also complained that hydrostatic pressure can cause a rebound effect. The fact is that if you use a high-durometer preliminary impression material—which, like a typical bite registration material, will be stiff after setting—there will be no rebound effect. Most high-durometer VPS materials, such as DMG’s Honigum Pro line, exhibit the proper stiffness.

FULL DENTURE IMPRESSIONS

The denture impressions technique used by most dentists involves doing a first impression with a stock tray using an alginate impression material. The patient leaves the practice wearing his or her old denture, after which a custom tray is made from the initial impression (Figure 8). The patient then returns a week or so later for the second and final impression using the custom tray.

Figure 8. Custom tray mimicking the patient’s old denture.

There is a system called AccuDent System (Ivoclar Vivadent) that allows you to use a specific proprietary stock tray with 2 types of alginates to create a final impression. While some might prefer this option, I would rather not have to create a model in my office before sending it to the dental lab.

My preferred technique for denture impressions involves using a stock edentulous tray with a high-durometer VPS (Honigum Pro), making that stock tray into a custom tray, and then relining it with light-body VPS. This means you can take your final impressions on the patient’s first visit and save him or her a trip to your office. Figure 9 shows a final denture impression created using this technique. Note its ability to reproduce tissue landmarks in great detail.

Figure 9. The final denture impression reproduced tissue landmarks in great detail in a single visit.

The patient’s time is valuable, and he or she will greatly appreciate being able to avoid a second visit. What’s more, being able to produce the final impression in a single visit greatly reduces your costs and increases your profit. It’s the classic win-win scenario for patient and practice, and it’s hard to imagine why any practice wouldn’t embrace this single-visit impression technique.

Accurate full denture impressions like the one depicted in Figure 9 allow you to achieve 3 important factors:

1. Stability and retention

2. Soft-tissue and alveolar ridge preservation

3. Patient comfort

PARTIAL DENTURE IMPRESSIONS

In my experience working with complex partial dentures, it’s very difficult to create an accurate major connector and minor connectors and to capture the soft tissue using digital impressions. When using digital denture methods, the try-in is often modified using impression materials and by scanning the impression and sending it over the Internet to the lab for final modifications.

A complex partial denture was clearly required for a patient who kept breaking his partial dentures (Figures 10 to 15). He was very frustrated by teeth breaking off and having to pay for repairs. He succinctly posed his only requirement for his partial denture: “I want to be able to chew bones without my partial breaking.”    

Figure 10. Preoperative retracted view.

Figure 11. Final impression of a complex partial denture.

Figure 12. Underside of the complex partial denture model.

Figure 13. Underside of the model with a major connector.

Figure 14. The model with denture teeth in place.

Figure 15. Postoperative view.

This made it necessary to have the partial be metal-supported. The fact that such a partial couldn’t be modified with acrylic meant we would need a degree of accuracy of the soft-tissue pickup that would be very difficult to achieve with digital impressions. 

THE BENEFITS OF DIGITAL IMPRESSIONS

There is no question that digital impressions can capture great detail, as is demonstrated in the printed model in Figure 16. 

Figure 16. Printed models made from digital impressions.

Another advantage of digital technology as it applies to impression taking is illustrated in Figure 17. The image shows how a bite taken using a digital impression revealed insufficient clearance with the restoration. This enabled a modification to be made before sending the digital file to the laboratory for fabrication of the crown or 3D printing.

Figure 17. A digital impression reveals insufficient clearance.

While digital technology can offer many advantages in many areas of dentistry, not every dental practice can afford to incorporate all of the digital technology that’s available. Fortunately, the dental laboratories will be able to digitize the impressions the practice makes using conventional impression materials.

THE RELEVANCE OF ANALOG IMPRESSIONS

Whether you own your own digital 3D printer and related digital equipment or you rely on your lab to supply the digital capability, the fact is that any practice dealing with very sophisticated dentistry or treating edentulous patients will still need to rely on analog impression taking.

The effective creation of dental impressions for complex implant restorations requires understanding how impressions are to be taken when doing multiple units. In many cases, analog impressions will be the preferred—or only—option. For example, in implant cases, digital scanning is unable to pick up metal abutments (Figure 18). This requires the use of scan bodies to pick up the relationship of the implants so that a final prosthesis can be manufactured (Figure 19).

Figure 18. Implant abutments make digital scanning impractical.

Figure 19. Final implant prosthesis.

A combination case of a partial and a crown would also be very difficult to achieve using digital scanning, making an analog restoration like the one shown in Figure 20 advisable. Figure 21 shows a closeup of the single crown where the margins are critical. A single impression was made for the crown and then “pulled” in the master impression. The relationship of the single crown to the partial requires a good working knowledge of the digital software. Until this process becomes simpler, the traditional analog workflow makes sense for most practitioners. 

Figure 20. Master impression for a combination case.

Figure 21. Single-crown impression “pulled” in a master impression.

A single impression was taken for the crown, similar to how a copper band impression is taken, and then a master impression was taken using a high-durometer VPS impression and a light-body impression material to pick up all of the details. Note the detail of the crown preparation first and then the master impression for the major connector framework.

 You might want to take a hybrid approach that involves conventional impressions, scanning them, and having your lab use its digital technology to fabricate the prosthesis using printed materials. We’re combining the best of both worlds: analog and digital dentistry.

THE HYBRID APPROACH TO IMPRESSION TAKING

A good example of how analog and digital impression taking can and should coexist was demonstrated with a patient who decided to redo her upper teeth (Figure 22). As can be seen in Figure 23, digital technology made it easy to accurately capture the correct bite.

Figure 22. Pre-op view.

Figure 23. Digital image enabling capture of the correct bite.

I then took both digital (Figure 24) and analog (Figure 25) impressions and took a postoperative photo (Figure 26). I’ll leave it to you to guess whether it was the digital or analog impression that was used to help produce this outcome.

Figure 24. Digital impression.

Figure 25. Analog impression.

Figure 26. Post-op view.

WE’RE ONLY TRYING TO GET TO PERFECTION

With the right mindset, materials, and technique, achieving the perfect margins, the perfect contours, the perfect occlusion, and the perfect shade is easy to do.

 Its essential that we be able to count on manufacturers to provide us with the highest quality materials and instruments so we can pursue the perfection that always seems to elude us.

 To be able to try new, potentially better ways of doing things, you have to be willing to stick your neck out. As president and sole member of the Giraffe Society, I practice this every day, inspired by quotes like these from my hero, Albert Einstein:

• “If you can’t explain it simply, you don’t understand it well enough.”
• “Anyone who has never made a mistake has never tried anything new.”
• “The measure of intelligence is the ability to change.”
• “Everything must be made as simple as possible. But not simpler.”
• “Creativity is intelligence having fun.”

If you’re reading this, you’ve nearly finished the article. Because that tells me you are clearly willing to consider new ideas, I hereby dub thee an honorary member of the Giraffe Society.

CONCLUSION

So can we achieve the balance of art, science, and business of dentistry?

If we use the best materials and methods to create beautiful dentistry based on the most current science related to impression materials, and if we do it in a timely manner so we can earn the highest return on investment for ourselves and our staff, we will absolutely achieve the balance of art, science, and business of dentistry in general, and dental impressions in particular, and approach the ever-elusive goal of perfection.

ACKNOWLEDGMENTS

I must acknowledge the support of my partners and staff for “allowing me to do what I do,” including Murray Kaiser Dental Lab and North Star Dental Lab, but I would not or could not have done any of it without Betsy Smirnoff Hoos, who has been by my side for 50 years. She has been to so many lectures and edited so many articles that “she could do it herself.”  

ABOUT THE AUTHOR

Dr. Hoos received his MS degree in biology from the University of Bridgeport, his BA in zoology from Drew University, and his DMD degree from Tufts University School of Dental Medicine. He lectures nationally and internationally on advanced techniques as well as innovative procedures that he’s developed. He maintains a practice, Brush & Floss Dental Center, in Stratford, Conn. He can be reached at jchdmd@gmail.com.

Disclosure: Dr. Hoos reports no disclosures.

With the significant number of endosseous root form implants placed each year (approximately 3 million in the United States), there continues to be a direct proportional increase in peri-implantitis cases. The number varies per study, with reports of 26% in patients.¹ Likewise, there are multiple opinions on the etiology of implant disease that vary from the always mentioned biofilm-induced to restorative-related issues to today’s theories, including the theory of titanium implant corrosion.

The American Academy of Periodontology now includes a classification of implant disease. It suggests that the definition is a plaque-associated pathologic condition with progressive loss of supporting bone as defined by radiographic data. The progress is not linear and is considered an acceleration beyond what is noted with periodontitis progression.²

The etiology is critical, and the reversal of peri-implantitis can be related somewhat to that which was responsible for the initial inflammation. There exist many prescribed techniques for managing peri-implantitis that range from monitoring (watch and wait) to options of explanation and replacement with a new implant fixture. Decisions on therapy directions can be based on the severity of the peri-implantitis. 

Most surgical procedures utilized in managing peri-implantitis focus on 3 major objectives:

1. Degranulation. It is essential that granulation tissue resulting from inflammation be removed from the surgical site. The removal of granulation helps reduce LPS and pro-inflammatory cytokines. The process also allows for better visualization of any local factors, such as resin cement, or prosthetic issues, such as implant fractures. It also allows for the determination of the extent of osseous resorption and the characteristics of the boney topography. Two-dimensional radiographs are generally not accurate, especially in a facial/buccal to lingual/palatal view, to characterize boney walls. Degranulation can be a challenge in peri-implant  sites due to irregular bony topography and limited visualization, resulting in compromised access with conventional instrumentation. Moreover, the instrumentation utilized can have adverse effects on the implant surface when devices such as power-driven ultrasonic instruments come in contact with titanium surfaces.

2. Decontamination of implant surfaces. References to enhancing the bone-implant contact suggest that the exposed implant surface requires detoxification.³ This can consist of the removal of cement and/or biofilm associated with peri-implant disease. Currently, mechanical and chemical decontamination methods are most popular. However, studies have shown that mechanical instrumentation can scratch and pit the implant surface. Chemical decontamination, such as use of citric acid, EDTA, tetracycline, and phosphoric acid, has been recommended, in addition to mechanical methods, to increase effectiveness. Some chemical interventions can create collateral damage to healthy tissue, resulting in delayed wound healing. There is increasing concern about the implant surface itself in long-standing peri-implant surfaces exposed to biofilm. Metallosis can result from corrosive damage to the titanium dioxide (TiO₂) layer. When this layer is removed, it can expose the non-oxidized portion of the implant surface, resulting in a release of titanium particles and ions. This corrosive process has been found on diseased dental implants.⁴  

3. Decortication. Studies demonstrate that limited removal of the cortical plate allows for exposure of the cancellous bone in both periodontal and peri-implant lesions, releasing bone morphogenic proteins necessary for regenerative wound healing.⁵ Decortication can be implemented with a variety of devices, including handpiece drills. On occasion, traditional dental handpieces cannot perform decortication properly due to an inability to access the tortuous defects. Laser tips (with diameters of 0.5 to 0.6 mm) can gain access to deep bony defects where no other instruments can and not damage implant surfaces.  

The utilization of dental lasers to manage peri-implantitis is not new. Appreciating the physics of laser light energy and how different wavelengths have an affinity for different targets (chromophores) is critical to having an effective dental laser action. When lasers interact with a target, the beam is either reflected; scattered; transmitted through; or, preferably, absorbed. 

Incorporating dental lasers as monotherapy has demonstrated limited value in managing peri-implantitis over conventional flap and resection or augmentation methodologies. However, utilizing lasers to assist/augment peri-implantitis management has rendered favorable results.^6-8 Studies have utilized erbium lasers such as Er,Cr:YSGG or Er:YAG for decontamination, degranulation, and decortication. The erbium wavelength demonstrates an enhanced ability to decontaminate titanium surfaces and have increased success when respective settings and techniques are in defined protocols. 

CASE REPORTS

Case 1: Managing Early Peri-implantitis

A 38-year-old female patient presented with a chief concern of “receding gum around my implant.” The medical history was uneventful, and she did not have a history of nicotine use. Six years prior, the maxillary left central had fractured after endodontic therapy. The tooth was extracted using a minimally invasive technique, and an immediate implant was placed with freeze-dried mineralized cortical bone and completed with a final restoration.

At the current examination, the patient presented with bleeding on probing, generalized suppuration, and recession (Figure 1).

Figure 1. The patient presents on examination with significant recession, bleeding, and suppuration on probing around an implant in the maxillary left central area.

The radiograph analysis demonstrated crestal bone loss (Figure 2).

Figure 2. A radiograph demonstrates bony resorption around the crestal bone with the appearance of angular defects.

The diagnosis was early peri-implantitis with submarginal cement and minimal attached gingivae as possible contributing factors. 

The patient agreed to an implant repair procedure utilizing an Er,Cr:YSGG all-tissue laser (Waterlase Express [BIOLASE]). The implant crown and abutment were removed to allow better access to the implant defect. The laser was used to de-epithelialize the marginal gingival collar to slow future epithelial migration into the wound. 

Vertical incisions were created to expose the surgical site, and a full-thickness flap was reflected. Granulation tissue was effectively removed with the Er,Cr:YSGG laser using a combination of end- and radial-firing laser tips (Figure 3).

Figure 3. Vertical incisions were made for access, sparing interdental papillae, and the removal of granulation was performed with an Er,CR:YSGG all-tissue laser (Waterlase Express [BIOLASE]) utilizing a radial-firing tip.

The exposed titanium implant surface was decontaminated with the erbium laser using a unique sapphire side-firing tip (Figure 4).

Figure 4. To detoxify/decontaminate the titanium surface, a unique sapphire right angle tip was aimed into the pitch of the threads and cleaned the surface for future re-osteointegration.

The tip allowed energy to leave it in a perpendicular manner to achieve decontamination into the inner aspects of the pitch of the threads. This is especially critical for implants that have angular defects, which make access difficult. Adjacent alveolar bone, including angular defects, was decorticated using an end-firing, zirconium, 0.6-mm laser tip (Figure 5).

Figure 5. An end-firing tip with the Er,CR:YSGG laser photo acoustics decorticated the bone with the potential to release bone morphogenic protein to enhance osseous regeneration.

A biologic of enamel matrix protein was applied to the site, and freeze-dried mineralized bone was placed with a membrane (Figure 6). A connective tissue graft was harvested from the palate and placed on the site, and the flap was coronally advanced over the entire surgical site (Figures 7 and 8). The existing abutment and crown were reattached to the implant immediately. Photo biomodulation (PBM) for wound healing was directed toward the surgical site with a 940-μm diode laser (Epic X [BIOLASE]). 

Figure 6. Due to angular bony walls, the defects were augmented with freeze-dried bone allograft and a subsequent membrane.

Figure 7. The area was deficient in both the vertical and horizontal bulk of keratinized tissue, and a connective tissue graft harvested from the palate was placed over the bony matrix.

Figure 8. Closure was accomplished with sutures and the established placement of the flap coronally to the wound area.

For postoperative care, an oral microbial rinse (PerioSciences) was utilized by the patient along with a systemic antibiotic of amoxicillin 500 mg for 10 days. The patient was instructed not to brush the affected area for 2 weeks. Sutures were removed at the 6-week post-op appointment. The patient was seen on a periodic basis for over one year. 

At the one-year followup, the abutment was covered with a healthy gingival biotype of thick keratinization (Figure 9). One-year radiographs demonstrated possible osseous regeneration around the implant platform with an excellent long-term prognosis (Figure 10).

Figure 9. At one year, the healing was excellent with minimal pocket depth, no suppuration, and an adequate zone of keratinized gingiva.

Figure 10. A radiograph at one year demonstrated minimal resorption around the implant threads and stabilization of implant health.

Case 2: Managing Moderate to Severe Peri-implantitis 

A 66-year-old male patient had a chief concern of “gum swelling around my implant.” The implant for the maxillary left canine had been placed 12 years previously. There was a diagnosis of early peri-implantitis (2 years after the implant was restored) with bleeding around the implant and significant pocket depth. The patient elected not to have treatment at that time. Presently, upon observation, there was a severe gingival abscess on the facial aspect with suppuration upon palpitation (Figure 11).

Figure 11. The patient presented with a gingival abscess around a maxillary left canine with bleeding on gentle probing and substantial suppuration on palpation. The pocket depths were in excess of 10 mm.

The radiograph demonstrated severe osseous resorption and pocket depths of more than 10 mm at the mesial and distal sites of the canine implant with involvement of the adjacent natural dentition (Figure 12). Clinically, Class III mobility was found on the maxillary left lateral tooth.

Figure 12. The radiograph demonstrated major osseous resorption circumferentially around the implant with a large 3-wall defect on the mesial site.

No mobility was observed on the maxillary left canine implant nor the maxillary left first premolar tooth. 

The patient was adamant about not extracting the implant and desiring as minimal a loss of teeth as possible. Therefore, the clinician/author elected to extract the left maxillary lateral and repair the implant and the maxillary first premolar with biologic regeneration and a laser. If the procedure achieved the desired results, then a cantilever prosthesis would be considered. 

The surgical repair implant procedure included external de-epithelization with the Er,Cr:YSGG laser to exclude epithelial migration into the subsequent wound. Prior to the incision, the sulcular epithelium was removed with the laser. After an inverse bevel sulcular incision and a vertical incision at the distal of the premolar, a full-thickness flap was reflected.

The lateral tooth was removed without complications (Figure 13).

Figure 13. Vertical incisions were performed to provide access to the implant site. Significant granulation tissues were associated with the bony defect.

All granulation tissue was removed with the radial-firing laser tip revealing significant osseous resorption around the implant surfaces (Figure 14). The implant surfaces were decontaminated with the sapphire side-firing laser tip. The maxillary first premolar root was also managed with a repair laser procedure including ultrasonic and manual instrumentation, followed by smear layer removal with the laser using a radial-firing tip.

Figure 14. The Er,Cr:YSGG laser with a radial-firing tip was utilized to remove the granulation tissue. The side-firing tip directed energy at right angles into the pitch of the threads for decontamination.

The entire defect area was de-corticated using an end-firing tip to promote osteogenesis.

For augmentation, mineralized freeze-dried bone allograft was mixed with platelet-rich fibrin (PRF) and secured with an amnion/chorion membrane with a PRF membrane on top (Figure 15). The flap was then replaced with a non-resorbable, monofilament suture (Figures 16 and 17). PBM was achieved with the 940-μm diode laser.

Figure 15. Due to the angular osseous architecture, a mineralized, freeze-dried bone allograft was mixed with platelet-rich fibrin (PRF) and secured with a PRF membrane, then placed in the defect after decortication with an end-firing tip and Er,Cr:YSGG laser.

Figure 16. The area was closed with a non-resorbable monofilament suture, and photo biomodulation was achieved with a 940-μm diode laser (Epic X [BIOLASE]).

Figure 17. An immediate postoperative radiograph was taken demonstrating correct positioning of the bone graft.

An antimicrobial rinse and amoxicillin were administered post-op. The patient returned for periodic debridement utilizing the guided biofilm therapy protocol with an erythritol air delivery device (AIRFLOW Prophylaxis Master [EMS]). At 6 months, the radiograph and clinical evaluation appeared to demonstrate osseous regeneration, and the patient was scheduled for a provisional implant cantilever prosthesis (Figures 18 and 19).

Figure 18. At the 6-month post-op appointment, the wound healing was acceptable, with no suppuration and minimal inflammation.

Figure 19. The 6-month radiograph shows stabilization of the osseous augmentation.

At one year, a final restoration will be completed with the 1-year post, demonstrating osseous regeneration around the implant (Figures 20 and 21). 

Figure 20. A provisional restoration was fabricated with a cantilever from the maxillary left canine replacing the maxillary left lateral.

Figure 21. The final radiograph demonstrated continued osseous fill around the maxillary left canine implant.

CONCLUSION

These case studies demonstrate that the Er,Cr:YSGG laser can create a receptive environment for both biologic and osseous grafting material to enhance the regeneration of osseous structure and allow for a quality bone implant contact. The Er,Cr:YSGG laser can effectively degranulate inflammatory tissue, decorticate osseous structures, and decontaminate titanium implant surfaces with no adverse events and, thus, enhance a wound-healing regenerative environment. 

While in the past with peri-implant disease, the clinician had minimal options to manage diseased implants, we now can enhance the prognosis by utilizing laser technology in combination with regenerative materials to save dental implants.

REFERENCES

1. Daubert DM, Weinstein BF, Bordin S, et al. Prevalence and predictive factors for peri-implant disease and implant failure: a cross-sectional analysis. J Periodontol. 2015;86(3):337–47. doi:10.1902/jop.2014.140438

2. Schwarz F, Derks J, Monje A, et al. Peri-implantitis. J Clin Periodontol. 2018;45 Suppl 20:S246-S266. doi:10.1111/jcpe.12954 

3. Yamamoto A, Tanabe T. Treatment of peri-implantitis around TiUnite-surface implants using Er:YAG laser microexplosions. Int J Periodontics Restorative Dent. 2013;33(1):21-30. doi:10.11607/prd.1593 

4. Wilson TG Jr, Valderrama P, Burbano M, et al. Foreign bodies associated with peri-implantitis human biopsies. J Periodontol. 2015;86(1):9-15. doi:10.1902/jop.2014.140363 

5. Danesh-Sani SA, Tarnow D, Yip JK, et al. The influence of cortical bone perforation on guided bone regeneration in humans. Int J Oral Maxillofac Surg. 2017;46(2):261–6. doi:10.1016/j.ijom.2016.10.017

6. Clem D, Gunsolley JC. Peri-implantitis treatment using Er:YAG laser and bone grafting. A prospective consecutive case series evaluation: 1 year posttherapy. Int J Periodontics Restorative Dent. 2019;39(4):479–89. doi:10.11607/prd.4158

7. Nevins M, Nevins ML, Yamamoto A, et al. Use of Er:YAG laser to decontaminate infected dental implant surface in preparation for reestablishment of bone-to-implant contact. Int J Periodontics Restorative Dent. 2014;34(4):461–6. doi:10.11607/prd.2192 

8. Nevins M, Benfenati SP, Galletti P, et al. Human histologic evaluations of the use of Er,Cr:YSGG laser to decontaminate an infected dental implant surface in preparation for implant reosseointegration. Int J Periodontics Restorative Dent. 2020;40(6):805–12. doi:10.11607/prd.5139 

ABOUT THE AUTHORS

Dr. Low received his DDS and MS degrees from the University of Texas at Houston. He also completed his residency in periodontics at the University of Texas at Houston and received an MEd degree from the University of Florida. He was named vice president, dental and clinical affairs, and chief dental officer of BIOLASE in October 2016.

He is professor emeritus at the University of Florida College of Dentistry and associate faculty member of the Pankey Institute and has 30 years of private practice experience in periodontics, lasers, and implant placement. He is a Diplomate of the American Board of Periodontology and past president of the American Academy of Periodontology. Dr. Low is also a past president of the Florida Dental Association and a past ADA trustee. He can be reached at slow@dental.ufl.edu. 

Disclosure: Dr. Low is chief dental officer, BIOLASE, Inc, and a consultant for PerioScience and EMS.

Dr. Chang is a graduate of the University of Maryland Dental School and practices in McKinney, Texas. He obtained his certificate in periodontics and prosthodontics through a 5-year residency program at the University of Texas Health Science Center, San Antonio. Dr. Chang is a diplomate of the American Board of Prosthodontics and the American Board of Periodontology. He can be reached at pchangdds@gmail.com. 

Disclosure: Dr. Chang receives honoraria from BIOLASE, Inc, and is a speaker and trainer for the company.

Since the COVID-19 pandemic began, turnaround and shipping times for many laboratories have increased. Relying on dental laboratories means scheduling patients further out and occasionally having to reschedule when the appliance is not back in time—an inconvenience for both the practice and the patient. Three-dimensional printing has eliminated the time wasted in shipping and has given us control over when a case is ready to be delivered. For this reason, the ability to 3D print is essential to our office. If a patient loses a retainer or nightguard, we are able to fabricate a new one the same day and reduce the risk of orthodontic relapse or patient symptoms returning.

INTRODUCING 3D TO YOUR PRACTICE 

The biggest challenge in introducing 3D printing to your practice is learning the digital workflow. However, once the team learns the software and the process for converting the STL file into a printable file, the rest of the process is straightforward.

In our office, the software training was very comprehensive, and our team was able to quickly learn and begin 3D printing the same day. 

Several components are required to 3D print dental workpieces in the office: an intraoral scanner, appliance design software, integration software for the printer, a wash unit, and a curing unit. When choosing the right 3D printing solution our office, I quickly learned that it is important to fully understand the process and workflow that needed to be implemented. After understanding this process, we chose to begin our printing journey with DMG’s Digital 3D printing solution.

We did this for several reasons, which I will cover below. Overall, we found that DMG integrates a complete workflow system with cloud-based software. Radio-frequency identification (RFID) technology, and a validated process to create quality print results, is incorporated into an efficient, compact, easy, and user-friendly design. 

UNDERSTANDING THE PROCESS

1. The process begins with an intraoral scan to generate an STL file of the patient’s oral environment. Getting a high-resolution, quality scan is important. There are many great scanners on the market. For our office, we incorporated the iTero scanner (Align Technology) and Medit i700 scanner.

2. Next is the design of the workpieces. For most 3D printers to custom design workpieces such as sleep appliances, occlusal guards, or aligners, third-party software is used to create the design before sending it to the printer. Software such as Meshmixer or Blue Sky Bio may be used for design. We are currently using Blue Sky Bio to create each step in the clear aligner treatment. 

3. The designed STL files are then imported to a nesting and slicing software, Netfabb, where the workpieces are positioned on the printer’s build area in preparation for printing.    

4. The 3D printer is then used to print the workpieces. We produce a high number of models for aligner orthodontic treatment. With 3Demax (DMG), the build area is a generous size, allowing multiple models to be printed simultaneously. Tags may be added to these models utilizing Netfabb software within the printer to identify the patient. The patented Force Feedback technology accelerates the printing process by up to 50% and minimizes the risk of misprints.  

5. After printing, the pieces go through the additional processing steps of washing off residual resin and curing to the lock the mechanical properties. Many printing systems do not provide solutions for the final fabrication processes of the workpiece, instead giving only general instructions for using your choice of wash and cure systems. DMG has a validated, easy workflow for printing, washing, and curing, which ensures a quality printed workpiece every time. The appropriate material is chosen for the printed piece and loaded into the printing tray. DMG’s Luxaprint materials have a unique RFID, which is communicated to the printer using an RFID sensor. The display then shows the amount of time required for the build and the progress while communicating the correct wash and cure time for each process, validating the final print piece.  

Although there are many choices, we chose a DMG printer that is evolving via software integration, which is one of our requirements. Later this year, DMG will launch cloud-based software called DentaMile connect that takes the above process and simplifies it further. We are in the process of testing this software, and, currently, a splint or nightguard can be designed and positioned using this one software platform. DMG is continuing to improve this software for ease of printing all applications with a comprehensive line of resins.

The number of applications for 3D printing will continue to increase throughout the year. Coming soon, Luxaprint Crown will allow the printing of semi-permanent crowns and bridges, and Luxaprint Orthoflex will be used for the printing of flexible dental splints, such as sports guards. DMG DentaMile connect will also offer easy steps to incorporate the correct amount of undercut on the appliance, the vertical opening, and the occlusion for a precisely planned and accurately fitting appliance, resulting in fewer chairside adjustments.

Once the team members are familiar with the software, this process is completed in just a couple of minutes. 

BENEFITS TO PATIENT AND PRACTICE

The benefits of in-office 3D printing are numerous, including reducing laboratory costs and improving the patient experience. Eliminating the laboratory turnaround time and providing your patients with same-day service is a benefit for both the patient and the dental office. The ability to 3D print workpieces can reduce the need to reschedule patients because the appliance wasn’t back in time due to shipping or laboratory delays.

Taking an intraoral scan, rather than a traditional impression, is much more comfortable for the patient and allows the patient to visualize his or her oral environment and better understand and accept the treatment required. The digital file is much more convenient to store, and 3D printed models can be saved and used numerous times without breaking due to their increased strength. The large build area on the 3Demax allows many workpieces to be printed simultaneously and at a fast pace with the Force Feedback technology.

The simple, user-friendly design allows the staff to learn the process quickly and incorporate it into the office workflow.

Reducing office overhead is also a major benefit. The ability to design and print your own clear aligners can cut down on outside laboratory costs. 

CASE REPORT

In our practice, 3D printing has numerous applications. The ability to print models for retainers, nightguards, diagnostic casts, and aligners is invaluable. In instances where retainers need to be delivered to the patient as soon as possible after the orthodontics or restorative procedure is completed, we can now take a highly accurate 3D scan. With the fast speed of the 3Demax, the staff can scan, print, and fabricate the retainers for the patient to pick up a few hours later and reduce the risk of orthodontic relapse. 

Figures 1 to 20 provide a case example of how we fabricate retainers ahead of time for patients with orthodontic brackets. It is simple to scan the patient, digitally remove the brackets, and fabricate the retainer so that it is ready to be inserted at the debonding appointment.

ABOUT THE AUTHOR

Dr. Latham received her undergraduate degree from Boston University and her DDS degree from the University of Michigan (U-M) School of Dentistry in 2011.

While attending the U-M School of Dentistry, Dr. Latham was the recipient of the William S. Kramer Award of Excellence, inducted into the Omicron Kappa Upsilon Dental Honor Society, and served as co-chair for the Scholars Program in Dental Leadership where she led a capstone project collaborating with students, faculty, and community dentists to increase the efficiency and efficacy of a local children’s clinic to help improve access to care.

Dr. Latham began her dental career as a general dentist for the US Navy serving in a military dental clinic in Rota, Spain, and returned to the United States to practice general dentistry with Tidewater Dental Group in Virginia Beach, Va. In 2014, she partnered with a successful multidisciplined practice, Brush and Floss Dental Center in Stratford, Conn, where she now maintains a private practice focused on orthodontic and restorative care. She can be reached at julialathamdds@gmail.com.

Disclosure: Dr. Latham reports no disclosures

INTRODUCTION

The expected high ranking of lasers, unique in class technology, merits attention to understand why they lack clinical market penetration in dentistry. Their validated potential and similar target market position have already been captured for decades in other healthcare sectors. I will discuss in broad strokes the top 3 currently relevant self-imposed limitations in utilizing lasers in dentistry. These are (1) incomplete and incorrect optical physics education (excellent clinicians practice science), (2) magnification (laser parameters demand magnification), and (3) inadequate device packaging of wavelength and parameter selection as well as coordination (medical device technology packaging). Three solutions will be presented to these historical reflections. Modification of these 3 variables in function of not only the present, but future considerations for integration, is essential in transforming pathology to healthy tissue. No other technology does it like lasers.

Optical physics technology has been readily available in the medical sector, successfully applied, and integrated into cutting-edge clinical outcome techniques, with more temperamental pathologic characterization as compared to simple pathology. Although it contributed to the first springboard of laser applications to tissue, the dental sector had the opportune time to bring this technology to the forefront and seemingly did not. We have seen a great concern for its minimal utilization compared to its proven potential, even in difficult clinical scenarios. It has lagged in market penetration, and the question is why?

EDUCATION

It is unfortunate that with increased resources, more data, and magnified research efforts, the field of lasers in dentistry has suffered from little penetration of accurate laser physics in its educational and training spaces. A precise understanding of physics, light-transfer biomaterials, and interaction with tissue are determinants of clinical application modification and application in reproducible, optimal outcomes. It is not a mere race from point A to point B. The terrain that stands between the points requires the technology selection and renders its superlative clinical outcome. In this sense, it is not like any other technology in medical devices. Optical and quantum physics-based medical devices generally fall into 2 categories: diagnostic and intervention. Both require real-time modification in function of subject tissue profiles, with the latter often requiring the most customization in the dental and oral science sector. Homogeneity, by virtue of generalizations of historical grouping of clinical phenotypes, is a luxury of the past. The best clinicians practice science in real time. Clinicians are scientists. Case in point, the “do no harm and do all to heal” clause of the Hippocratic Oath requires that very protocol customization and optimization rendered by credentials, experience, and knowledge.

The solution: Accurate and comprehensive optical physics education is the dependent variable for device scrutiny and selection.

MAGNIFICATION

Laser capability and function, by definition, rests within such small parameters as only magnification can appropriately idealize during reading and execution. Few diagnostic technology packages have made it to the dental market, although the demand is great and the medical market already enjoys a wide historical range of applications of that caliber. For the intervention aspect of laser technology, magnification is the most appropriate match of delivery to really enhance access to the applications of laser technology. Tissue differentiation claims different laser setting potential and can and will result in a high precision of clinical outcome vs a typical conventional outcome. A great example of this is depicted in the optimization of tissue treatment without loss of tissue volume, as one clinical case below will showcase. Without magnification and specified tissue geo-position, the laser technology can be easily underutilized.

The solution: The incorporation of segmental range of visualization selection in function of pathology characterization is key to laser settings and modality of application. Stop points and laser settings become crucial for optimal results, while magnification guides and ensures this.

TECHNOLOGY PACKAGING

The expanded medical sector has enjoyed continuous application of optical physics from neurology to dermatology, ophthalmology, and cardiovascular disciplines, to name a few. Dentistry, though it encases a smaller volume extension per body size, corresponds to extremely high-differentiated tissue subtypes in extremely close proximity. And yet, the laser technology packaging has remained poor and undifferentiated compared to that of other disciplines. Medical device packaging includes the package insert, which stipulates various elements that comprise medical device developments, claims, parameters, and technical features. The existing available collection of laser equipment in dentistry could easily improve in quality, quantity, and variation of referenced technology with very little cost efforts from manufacturing to market launch, while the cost-benefit analysis is favorable for all parties involved. The resulting outcome translates in generating excellent clinical results with minimal invasion; less instrumentation requirements, including anesthesia; and improved healing potential, which supersedes the conventional sequence manifestation and inadvertently should translate into lower cost. However, incomplete or expensive technology packaging choices can hurt access to superior treatment options in certain pathologies in the long run, which can even eliminate the product’s availability and participation in the marketplace. Logic in medical device development can make or break a clinical protocol even if demand is high, resulting in generating clinical phenotypes, which can perpetuate higher prevalence and incidence rates with increased proliferation of additional clinical demands. For example, choice in wavelength utilization in oral viral lesions can and will result in different profiles of clinical outcomes and recurrence. Laser profiles are largely defined by type of wavelength and other parameters, which make lasers devices that are sensitive in selection to precision, and hence, industry participation needs to parallel research and development support.

The solution: The incorporation of segmental range of visualization in function of pathology characterization. This is the key to laser choice, settings, and modality of application—ie, hot tip technology does not have the same impact as laser optical technology and its associated parameters.

CLINICAL ANGLE

Examples of clinical cases outlined may separately exemplify similar limited portions of a larger and complete full protocol, pending publication. The following cases and illustrations will demonstrate the various adaptations of the above discussion and premise. The dimension and characterization of lesions at the baseline are illustrated by photo and video stills and dynamic images with a Canon 7D Camera (Figure 1), A Series Microscope (Global Surgical) (Figure 2), 3D Scanner (3Shape) (Figure 3), and with surplus adjuvants like the Toluidine Blue Staining Silverman Protocol (Figure 4)¹ and other methods.

Figure 5 shows a baseline lip diagnosis of a 56-year-old male ASA I illustrating actinic cheilitis by histopathology biopsy (IMMCO Diagnostics) in various portions of the lip extending from the vermilion border. Lesion dimension, measurements, and real-time characterization of tissue can be obtained with the utilization of a probe instrument (Hu-Friedy Instruments) and other methods, including using the Sapphire Plus (DenMat), as shown in Figure 6. To optimize comprehensive treatment with a low risk of recurrence and minimal or no volumetric loss, a selection of wavelength and parameters finalized the choice to the CO2 wavelength (LightScalpel) and set parameters with and without the utilization of topical anesthetic (4% Oroquix), depending on patient request, lesion position, and tissue depth. The CO2 choice of wavelength in treating actinic cheilitis has been reported as a leading choice with optimal results and a low risk of recurrence.² Further customization to eliminate the risk of volumetric loss of tissue is especially relevant in moderate to large lesions, and early intervention opportunities are necessary. The full protocol is pending publication (Washington Institute for Dentistry & Laser Surgery).

Figure 7, a different case, shows tissue under magnification (Leica Microscope) during the intervention phase of a frenectomy, which precisely determined the optimization of speed and stop points utilizing the CO2 laser wavelength (LightScalpel) vs other lasers or packages, such as hot tip light transfer technologies. Figures 3, 8, 9, 10 and 11 also illustrate various views of baseline to clinical intervention tissue stops with still and dynamic tissue captures using an A Series Microscope, a Toluidine Blue (Sigma-Aldrich) Testing Protocol Silverman guided Punch Biopsy (C3 Think Tank, Washington Institute for Dentistry & Laser Surgery), and an Apple iPhone capture of a 3Shape scan. These varied references have clearly made the case for supporting the points presented in the scope of this article.

CONCLUSION

In summary, self-limiting factors have brought dentistry considerable consequences and setbacks in laser-technology adoption. The scope of translational research should make it easier to adapt cross-discipline discoveries and allow for quick cross-market launch. However, the core of laser technology cannot be ignored nor forgotten as adaption occurs, while prototypical product development strategies cannot override and ultimately sacrifice its original technological core potential. Optical physics education is crucial in tissue matching and recognition of pathological progression and when making the choice of a laser and its inherent required parameters and settings, which more often than not should always be customized. Visualization to match laser-technology potential is a necessary consideration to enjoy a full range of capabilities in clinical outcome optimization in interdisciplinary dentistry.

ACKNOWLEDGEMENT

All images and content/concepts in this article are proprietary of C3 Think Tank, Washington Institute for Dentistry & Laser Surgery.

REFERENCES

1. Silverman S Jr, Migliorati C, Barbosa J. Toluidine blue staining in the detection of oral precancerous and malignant lesions. Oral Surg Oral Med Oral Pathol. 1984;57(4):379–82. doi:10.1016/0030-4220(84)90154-3

2. Shah AY, Doherty SD, Rosen T. Actinic cheilitis: a treatment review. Int J Dermatol. 2010;49(11):1225–34. doi:10.1111/j.1365-4632.2010.04580.x

ABOUT THE AUTHOR

Dr. Cotca received a Bachelor of Science degree in Chemistry and Cellular Molecular Biology, a Master’s degree in Public Health and Toxicology, and a DDS degree from University of Michigan. She is an international lecturer and aesthetic restorative dentist and founded the Washington Institute for Dentistry & Laser Surgery in the Washington, DC, area—a private practice institute, a C3 Think Tank, and an innovative, real-time protocol incubator where she develops advanced oral systemic aesthetic clinical protocols. Dr. Cotca consults in medical device and clinical protocol development and serves on the ADA Standards Committee on Dental Products and as the US Delegate to the International Organizations of Standardization, among many others.

She serves as an editor and reviewer of various peer-reviewed oral sciences journals and is a Fellow of the American Academy of Oral Medicine, the Pierre Fauchard Academy, and the International College of Dentists. Dr. Cotca is also a member of the International College of Prosthodontists. She has been an active expert on Capitol Hill, testifying before the United States Congress and the White House, and she is a dental expert and contributor for ABC and NBC and in the healthcare industry sectors. She can be reached at claudiaccotca.com.

Disclosure: Dr. Cotca reports no disclosures.

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As microscope use became more common among endodontic training programs, it was absolutely startling that its use did not translate to other specialties in dentistry. Everyone seemed to be continuing with their use of magnifying loupes, generally in the range of 2.5x or a tad higher in magnification. Looking back, there were a few reasons for this. The use of an SOM does require training as the learning curve associated with such scopes is quite steep. At that time, there were few premier training centers other than Penn. There were also the costs associated with purchasing an SOM. These were significant. It is also noteworthy that an SOM is ideally attached with a ceiling mount or a wall mount. Portable scopes on wheels could present a challenge when people walked into the treatment room due to the movement of the supporting arm. This movement was generated by the significant weight associated with the optic center of an SOM. Subsequently, there was an unpleasant tendency for the supporting arm to move up and down. Even a slight movement was disconcerting to the clinician because, after all, we were working under magnification.

This trend of principally only endodontists utilizing a scope to practice continued into the 21st century. Even as of late 2018, some studies listed microscope usage among general dentists as less than 4%!³ Why was there not greater adaptation to a protocol that could deliver enhanced magnification and light? This is a good question.

Cost and physical size were both seen by some practitioners as reasons not to employ a microscope. But clearly, the biggest challenge was the lack of ease of use. Microscopes do require training in their use, and too often, older clinicians, when giving scopes a “test drive,” discovered that they were not seeing what they thought they would be seeing. Furthermore, the need to par focus continued to be an issue. Also, as previously mentioned, proper patient positioning presented its own problems. Patient positioning with a traditional SOM can be a challenge because of the strict limitation of the optic head. The arc of movement is less than 40°, and some clinicians have reported a microscope’s range of angulation to be about 15°.⁴ One of the workarounds to solve this problem has been to have patients lie on their sides during a procedure. However, having patients lie on their sides is not ideal for many people. If the patient is overweight, the distribution of weight on various organs can be a concern, and for some patients, depending upon how they are attired, there may even be some modesty issues.

As we entered 2020, a few salient changes have been noted. In addition to the previously mentioned challenges associated with SOMs, digital technology has advanced to unprecedented levels. Years ago in dentistry, when we mentioned digital imaging, we were thinking of digital radiography. Furthermore, the concept of producing a digital image was criticized by the microscope companies as being merely 2D and, therefore, representing an inferior image. However, the upgrade in digital technology has changed the game. Think of your cell phone. What is the quality of your cell phone pictures? How easy is it to use? Can you zoom easily with your phone? This is digital technology circa 2021! When a clinician today views a digital image under relatively high magnification, it appears 3D (Figure 1).

If you are a dentist currently using an SOM, and it is working well for you, what is our recommendation? Keep using it! Binocular SOMs changed the way we practice endodontics, and if you are able to use them comfortably and work at a reasonable speed, keep at it. But if you are one of the many dentists who could never get the hang of an SOM, or if for some other reason you were not able to employ their use in your office, it is recommended that you investigate EZscope (KGG Inc) (Figure 2).

A NEW PARADIGM
EZscope is a digital imaging system that is digitally based and ergonomically designed. The first things that EZscope eliminated were the binocular eyepieces and the video ports usually associated with SOMs. In lieu of the binocular eyepieces, we have substituted a high-grade Microsoft tablet that acts as a monitor. Software associated with the tablet (acting as a monitor), along with our own proprietary software, allows the programming of many functions (Figure 3). Furthermore, a lightweight optic center has been designed that consists of a digital sensor (camera), a high-grade lens, and a diffused light source.

Figure 1. Digital image of a finger at moderate magnification, demonstrating fine detail.

Figure 2. EZscope (KGG Inc) is a next-generation digital imaging system with simple and intuitive ergonomic design.	Figure 3. The optic center and its monitor, which is a high-grade Microsoft tablet.
Figure 4. The weighted distal end of the balancing arm prevents swaying of the optic center.	Figure 5. Vertical positioning of the EZscope allows for easy storage.
Figure 6. The one-button optic head quick release allows for complete disengagement of the optic center. When placed in its custom carrying case, EZscope becomes totally portable.	Figure 7. Elastomeric textures on high-frequency touch points provide precise zoom and focus control.

Additionally, we have placed the optic center on a balancing arm that connects to a mobile stand. Sufficient weight has been added to the distal end of the balancing arm that prevents any up-and-down movement of the arm (Figure 4). The entire optic center has been designed to be fully detachable by a push-button release, thereby making the optic center completely portable. In addition to being fully portable, the optic center has been designed to be fully maneuverable, thereby making patient positioning much easier and more comfortable for the patient. The ergonomic design features of the EZscope were principally generated by our own experiences and needs as clinicians in concert with Metaphase Design Group (St. Louis), the design firm that collaborated with intuitive surgical in creating their next generation surgical robot.

OVERVIEW OF THE CONCEPT
The EZscope is a digital imaging system that allows the user to orient a digital camera and display an image on a tablet (monitor) for optimum viewing of a dentition or surgical field. The camera is guided by hand to the desired position of viewing. The counterbalanced arm “follows” and holds its position via friction and counterweighting located at the end of the balancing arm. The arm has a 90° range of motion from horizontal to vertical. The vertical post is also free to rotate on the base, thereby creating a point of rotation, which allows for additional fine positioning. Additionally, there is an offset on the vertical post that allows clearance for the arm in a vertical position.

However, the best way to understand the functionality and performance of a digital imaging system is to start at the top with the optic center and work down to the base.

OVERVIEW OF THE DIGITAL IMAGING SYSTEM
The EZscope consists of 4 main modules: the imaging module, the balancing arm module, the camera overview, and the camera enclosure. The imaging module, which is also known as the optic center, can be completely removed from the counterbalanced arm, which makes the unit portable. A vertical post attaches to the balancing arm, and the vertical post also attaches to a base and wheel assembly, which adds to the mobility of the unit. The weight located in the rear of the balancing arm is sufficient to prevent movement of the arm when someone enters a room. The base itself is very solid, and the oversized wheels have a locking system to prevent rolling. The width of the base is such that the wheels will hit a wall before any of the optic components do. This is a safety factor built into the design (Figure 5).

Imaging Module Overview
The imaging module consists of a camera-digital sensor and the display module, which is a computer tablet. The display module includes a front and rear bezel and has an adjustable arm. A button lock is used to separate the balancing arm from the optic center (Figure 6). Upon separation from the balancing arm, the optic center (imaging module) will fit into a specially designed travel case for safe transportation.

Module Arm Overview
The module arm clips into the counterbalance arm and is detachable via a button lock similar to what is seen on a vacuum cleaner tube. There is a display module pocket, which allows for coupling to the imaging module (tablet). There is also a built-in space within the arm to allow the passage of cables or wires. Precision-made Delrin components are employed to capture and secure the camera ball mount position. The button lock release operates so that it allows for the passage of wires or cables through a machined space.

Camera Overview
The camera is built around an existing digital sensor and lens component. The camera is attached to the module arm via a ball mount, allowing for an unprecedented degree of movement from the center in any direction. There are adjustment rings on the camera for focus and aperture. Both rings are able to fully rotate and are easy to grasp. Additionally, a ring light and diffuser are enclosed in a housing located at the end of the lens. Overmolded touch points enable a secure grip for users to position the camera easily with one hand. In fact, as a result of its minimal weight, the optic center has been designed for movement with 3 fingers.

Camera Enclosure Overview
The camera components are inserted through the top of the camera enclosure and captured in place with the top cap. The top cap is intended to be held in place by 4 head screws. A flange on the top cap also conceals a threaded rod. The easy-to-grip focus and aperture rings have rubber overmolds (to facilitate turning capability). Specific screws have been designed that hold the focus and aperture rings in place. Particularly noteworthy is that the screws must be short enough so that they do not lock the lens components from turning when tightened (Figure 7).

SUMMARY OF THE EZSCOPE
EZscope is actually a complete digital imaging system. Instead of looking through binoculars, as is common with an SOM, the clinician looks at a monitor that is, in reality, a sophisticated computer tablet. The software with the tablet is also its latest version (Windows Pro 10.0), accompanied by our own proprietary software. This combination allows the system to program many functions. The optic center combines a digital sensor with a very sophisticated lens and also contains the obligatory light source and diffuser. ‘

Because of a special ball-swivel adaptor (the Gatti adaptor), the optic center has incredible maneuverability, which makes patient positioning quite easy. In fact, the optic center can be positioned below the occlusal plane, shining directly up into the maxillary arch. This is a significant improvement because, as is very often the case with SOMs, the patient has to lie on his or her side. In the case of a digital imaging system, the optic center is being maneuvered, not the patient. Furthermore, since it is entirely digital, there is no need to par focus anything with the EZscope. For many clinicians, the need to par focus is the biggest frustration associated with an SOM.

When using the digital EZscope, one can zoom up in magnification to approximately 20x and still remain in focus. A Bluetooth-enabled foot pedal may also be employed to zoom in or zoom out as well as pan left or pan right. These features allow the operator to view the entire ROI (region of interest) or field. Additionally, the foot pedal has the ability to fine focus. In Version 2.0 of the digital system, we are already programming in voice recognition to zoom in, zoom out, pan left, pan right, etc.

As a result of the sophisticated software associated with the tablet, along with our proprietary software that we have built into the system, we anticipate having digital overlay surgical stents for implant placement and other complicated procedures. After activating the system, there is a red dot function that allows you to place a red dot over a target area. Once satisfied with the ROI, the operator simply zooms up to whatever magnification he or she needs. The surgical stent will, in fact, be a digital overlay.

This digital imaging system has been designed to be completely portable. As more dentists (especially dental specialists) and other healthcare providers work in multiple offices, we have made the optic center of the EZscope fully portable. At the end of the day, the doctor simply removes the optic center (one connection) and places it into our custom-designed Pelican case for easy transportation. He or she then goes to a different office and simply connects the digital optic center to the stand assembly that office has purchased.

CLINICAL APPLICATIONS
Clearly, the use of enhanced magnification and light can be utilized in all aspects of dentistry.⁵ But for this article’s sake, let’s briefly discuss 2: endodontics and prosthodontics.
The use of the surgical operating microscope in both surgical and non-surgical endodontics is what really puts microscopy on the map in dentistry. Along with NiTi rotary files and CBCT technology, the SOM is one of the technologies that has seriously raised the bar in endodontics.

Initially, endodontists were using the scope principally for surgical procedures, but as more residents became trained in their use, microscopes started being used in both non-surgical treatments as well as in diagnostic workups. A good example is the sudden explosion we have seen in cracked or fractured teeth as a result of the pandemic. Historically, dentists have used a periodontal probe and a tooth slooth to help differentiate a cracked tooth from one that is fractured. Transillumination, which can be very helpful in diagnosis, was not used nearly enough, but the use of such a technique is very easy with a microscope or a digital imaging system.

In terms of clinical use, obviously, the more one can see, the easier it is to locate hidden orifices and accessory canals. The reluctance to microscope use by general dentists has not been due to the lack of recognition of their benefits. It has been more related to cost and the challenge with par focusing a scope. Endodontists usually don’t buy microscopes; endodontic practices buy microscopes. That’s a big difference.

It has always seemed obvious that the use of magnification in dentistry would increase significantly if we could find a less expensive, easier-to-use technology. The average dentist is not performing brain surgery (nor complicated endodontic procedures), so the car analogy does apply. Not everyone needs a Ferrari; a Lexus that performs beautifully will do fine! The vast majority of dentists do not need magnification in excess of 10x. In fact, 8x to 10x is a lot of magnification, and it is magnification under which clinicians can work comfortably for extended periods of time. When using a digital imaging system, magnification is not necessarily read as 4x, 10x, or 20x. More commonly, the increase in magnification is seen as intervals rather than being read as ordinals. There are some complicated formulas that exist to make the conversion over to a magnification number, but these are very complicated and involve things such as focal length, etc. It is so easy to “zoom up” with a digital system that we just simply slide to whatever level we desire for the procedure.

In terms of prosthodontics and cosmetic dentistry, the indication of use for enhanced magnification and visibility is very high. With greater magnification, we suddenly can see how smooth our crown preps are. Years ago, when performing prosthodontics, I used to prepare many butt joint porcelain crowns. I would put the shoulder on using an end-cutting diamond. When I finally started using enhanced magnification, I was stunned to see all the swirls and striations from the diamond bur on the shoulder. Soon after, I started preparing my butt joint shoulders with a hand instrument. I also used to ditch my own dies—under a benchtop microscope! Simply said, the use of magnification is the best way to follow a finish line.

Another note is that the most effective microscope operators and those with the best ergonomic postures are those clinicians who, once they get comfortable in the eyecups, don’t come out (or, at least, not too often) until the procedure is complete. If you are constantly going back and forth and having to refocus every time, it gets both very frustrating and fatiguing. However, with a digital imaging system, you can go back and forth at will and not suffer any ill effects. Instead of getting hunched over like many practitioners looking into eyecups, you simply sit back and look at the monitor: “EZ!”

IN SUMMARY
In this article, we have introduced a digital imaging system that is both multifunctional and easy to use. Everyone in dentistry benefits from enhanced magnification and increased visibility. The key is having new technology that works for you, the practitioner. Think of your cell phone and the quality of the pictures made possible by digital technology. The time for inexpensive, quality digital imaging in dentistry has come. The time for EZscope is now!

References

1. Carr GB. Microscopes in endodontics. J Calif Dent Assoc. 1992;20(11):55-61.
2. Koch K. The microscope. Its effect on your practice. Dent Clin North Am. 1997;41(3):619-26.
3. Dental Microsurgery Market Size, Share & Trends Analysis Report By Procedure, By Product (Optical/Viewing Instruments, Microsurgical Instrumentation), By Region, And Segment Forecasts, 2019 – 2026. https://www.grandviewresearch.com/industry-analysis/dental-microsurgery-market
4. Buchanan SL. MoraVision 3D: A paradigm shift in the ergonomics of dental imaging. Endodontic Practice. 2016;19(2):52-54.
5. van As GA. Magnification alternatives: seeing is believing, part 2. Dent Today. 2013;32(8):80–4.

Dr. Koch received both her DMD degree and certificate in endodontics from the University of Pennsylvania School of Dental Medicine (Penn Dental). She is also the founder and past director of the Postdoctoral Program in Endodontics and Microsurgery at the Harvard School of Dental Medicine. Following her clinical and academic career, she formed her own successful technology and development company, Real World Endo, where she was CEO and president. Dr. Koch is the holder of multiple patents, maintains a faculty position in the Department of Endodontics at Penn Dental, and serves as a Senior Fellow with Penn Medicine. She is also a member of the Board of Overseers for Penn Dental and maintains an adjunct faculty position at the Harvard School of Dental Medicine. She can be reached at annelaurenkoch@gmail.com.

Disclosure: Dr. Koch is an equity owner and partner in KGG Inc.

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Numerous advancements have been made to enhance our patients’ oral health, including the prevention and treatment of periodontal disease as well as risk assessment and the management of caries disease. Unfortunately, many individuals still remain for whom the extraction of all teeth in one or both arches will be necessary and the replacement of lost teeth with an immediate full-arch removable prosthesis will be the most affordable and prudent treatment.¹ However, even when undertaken in the most atraumatic manner possible, tooth extraction results in alterations to the hard and soft tissues that can compromise the fit and function of the prosthesis and contribute to aesthetic deficits and further bone resorption and soft-tissue collapse.² For this reason, bone preservation has become of paramount importance when tooth extractions are performed and, in particular, when immediate full-arch dentures are indicated.³

Over the years, a variety of bone grafting materials has been utilized in combination with different ridge preservation and augmentation techniques. These have included allografts (ie, derived from human cadaver bone), xenografts (ie, derived from different species, such as bovine, porcine, equine, etc), autologous material (ie, derived from an individual’s own bone), and autogenous dentin (ie, derived from a patient’s extracted teeth).

Figure 1. Preoperative radiograph of a woman who presented with severely mobile maxillary dentition that was poorly supported by deficient alveolar bone. The extraction of these teeth and their replacement with a full-arch removable prosthesis was planned.

Most recently in the literature, the physical and chemical composition of tooth-derived bone grafting materials has been studied. Reports indicate that the osteoconductive properties of these materials make them efficacious as an alternative bone grafting material.^4,5 Additionally, because the materials can be produced from freshly extracted teeth and processed chairside using a dentin grinder (eg, the Smart Dentin Grinder), researchers have also cited this alternative’s availability and low cost as compared to other commercially available bone grafting materials.⁵

Contributing to dentin’s favorable use as a bone grafting material is its natural, bioactive, and autologous structure, which is virtually identical in composition to bone. When placed into an extraction socket, the tooth-derived dentin bone graft material does not resorb quickly but instead attracts osteoprogenitors from the site, essentially undergoing ankylosis (ie, fusion) with the bone.5 The fused bone/dentin matrix then remodels slowly, which in turn helps to maintain aesthetics. Still, more importantly, the matrix promotes new bone formation at the site due to the autologous nature of the graft.^6,7 In fact, after 15 to 18 months of remodeling, the dentin particulate is usually no longer visible in the bone, and healing occurs without signs of inflammatory response.^5-7

A Chairside Approach
The Smart Dentin Grinder is a chairside device that converts a patient’s own tooth or teeth into autologous grafting material for placement back into the same patient. The device features a single-use grinding chamber that pulverizes the tooth into granules, then subsequently sorts them into 2 size ranges (eg, between 300 and 1,200 µm and smaller than 300 µm). Once the grinding procedure is finished, the granules are sterilized using chemical sterilization, although autoclave sterilization is also possible.

According to the manufacturer, testing has demonstrated that more than 98% of an original tooth processed by the Smart Dentin Grinder is ground, sorted, and recovered in the unit’s compartments. The dentist can use all granules that are produced or choose one size range if preferred. Additionally, the device has demonstrated effectiveness at grinding teeth consistently, regardless of variations in tooth morphology, as well as achieving consistent particulate sizing based on the sieves that sort the graft material.

The Smart Dentin Grinder offers 2 protocols: one for mineralized dentin grafts and a separate protocol for demineralized dentin grafts. The demineralized dentin graft protocol produces a combination of mineralized and demineralized particulate, which helps to expose the organic portion earlier while still maintaining an excellent, slow-resorbing mineral scaffold.

Interestingly, the Smart Dentin Grinder does not produce heat during the standard 3-second protocol (ie, the pulverization of the tooth structure, as opposed to grinding, cutting, or drilling). Therefore, there is no heat impact on the organic portion of the material, which is protected by the tooth’s mineralization.

The following case demonstrates the chairside use of the Smart Dentin Grinder when treating a patient who required extraction of her remaining maxillary dentition, im-mediate bone grafting, and delivery of an interim healing full-arch removable denture.

CASE REPORT
Diagnosis and Treatment Planning
A 57-year-old woman presented with severely mobile maxillary dentition (ie, teeth Nos. 3 to 9 and 11 to 13) that were poorly supported by deficient alveolar bone (Figure 1). Her other maxillary dentition was already missing, and a thorough intraoral and radiographic examination revealed significant periodontal disease.

Following a comprehensive discussion with the patient about her dentition’s hopelessness, it was determined that the extraction of all remaining maxillary teeth was prudent, and her teeth would be replaced with a full-arch, removable prosthesis. Although an implant-retained/supported overdenture was discussed with the patient as a more stable prosthetic solution, the patient declined this option due to health concerns (ie, she recently received a cancer diagnosis).

Figure 2. The extracted teeth were prepared for grinding by using a high-speed handpiece to remove any cavities or foreign material, ensuring that only pristine tooth structure remained.	Figure 3. Four of the prepared teeth were placed inside the Smart Dentin Grinder (KometaBio) chamber and adjacent to the blades.
Figure 4. After closing the chamber cap and twisting and clicking it into place, the grinding time was set to the recommended 3 seconds.	Figure 5. Once grinding was finished, the particles were sorted for 10 seconds, and no large particles were left in the grinding chamber.
Figure 6. The ground tooth particles were sorted into 2 different chambers. Here, the top-drawer compartment shows particles of between 300 to 1,200 µm.	Figure 7. The remaining extracted teeth were then also ground according to the previously described protocol.
Figure 8. View of the particles generated by grinding the remaining extracted teeth.	Figure 9. The sterile container was filled with a dentin cleanser, which was poured over and completely covered the dentin particles.
Figure 10. A sterile gauze was used to dehydrate the dentin cleanser solution.	Figure 11. The EDTA and dentin particles were dehydrated using sterile gauze.

Additionally, due to the extent of bone loss and lack of periodontal support, the patient was advised that bone grafting of the extraction sockets would be necessary to ensure the comfortable fit and proper function of her prosthesis. In fact, the literature cites numerous physical effects of tooth loss that ultimately contribute to the instability of removable denture prostheses, including the loss of hard and soft tissue due to bone resorption. This can lead patients to experience difficulty when speaking and eating, as well as force them to use their cheek muscles, tongues, and lips to keep their dentures in place.^8-10 However, the patient was advised that autogenous bone grafting material produced by grinding her extracted teeth (eg, with the Smart Dentin Grinder) would be placed immediately into the extraction sockets to preserve aesthetics, prevent bone resorption, and avoid the need for future grafting procedures that could be more complicated and costly.

Extraction
Local anesthesia was administered to infiltrate both the buccal and palatal areas. Care was taken to atraumatically extract teeth Nos. 3 to 9 and 11 to 13 with forceps. A simple extraction technique was performed with care taken to ensure that 3 or more bony walls (ie, lingual, mesial, distal, apical) remained intact. This would facilitate augmentation and preservation of the edentulous sites and the bony ridge overall.

Figure 12. A phosphate-buffered saline wash was then placed into the sterile mixing container to completely cover the particulate.

Dentin Autologous Bone Graft Material
Following the extraction of teeth Nos. 3 to 9 and 11 to 13, the teeth were prepared for grinding. Using a high-speed handpiece, any cavities or foreign material was removed, ensuring that only pristine tooth structure remained (Figure 2); it was not necessary to decoronate or remove the enamel. The teeth were then thoroughly dried using an air syringe.

Four of the prepared teeth were then placed inside the grinding chamber of a chairside dentin grinder (eg, Smart Dentin Grinder) and adjacent to the blades (Figure 3), as only 4 teeth can be ground at a time. The chamber cap was then closed, twisted, and clicked into place, and the grinding time was set to the recommended 3 seconds (Figure 4). Once grinding was done, the particles were sorted for 10 seconds, with no large particles left in the grinding chamber (Figure 5). Note that particles were sorted into 2 different chambers: a top-drawer compartment contained particles of between 300 and 1,200 µm (Figure 6); a bottom-drawer compartment contained particles smaller than 300 µm.

The ground tooth particles were transferred to a sterile container/mixing dish for cleaning and preparation prior to placement in the extraction sockets. The remaining extracted teeth were then also ground according to the previously described protocol (Figures 7 and 8), and the particles were added to the sterile container/mixing dish. When combined, the grinding of all the extracted teeth produced a significant volume of tooth particle material for use in bone grafting the extraction sockets. In fact, depending upon the tooth, the Smart Dentin Grinder typically generates between 2.5 and 3 times the volume of a tooth, which equates to between 0.8 cc and 3 cc of dentin graft.

To clean the dentin graft particles, the sterile container was filled with a dentin cleanser, which was poured over the dentin particles to completely cover them (Figure 9). After resting for 5 minutes at room temperature, a sterile gauze was used to dehydrate the dentin cleanser solution (Figure 10).

Next, EDTA was added to the dentin graft particles, allowed to sit for 2 minutes, and then dehydrated using a sterile gauze (Figure 11). To complete the preparation process, a phosphate-buffered saline wash (Figure 12) was then placed into the sterile mixing container to completely cover the particulate, a sterile instrument was used to mix the material, and a new sterile gauze was used for dehydrating the graft material.

Bone Graft Placement/Healing
The dentin-derived bone graft material was immediately placed into the extraction sockets using hand instrumentation, and the material was stabilized and secured with a resorbable collagen membrane (Salvin Dental). Primary closure was achieved using gut sutures. A full interim healing denture was then placed.

CONCLUSION
Autologous-sourced bone graft materials, such as the tooth-derived material available using the Smart Dentin Grinder, help promote non-disruptive healing when tooth extractions and immediate bone grafting are required. In addition to being one of the few graft types that induces bone regeneration, dentin bone graft material contributes to a durable scaffold that resorbs slowly, so woven bone material can sufficiently mature.¹¹ For this case, it was a cost-effective and conservative means to provide the bone grafting treatment that the patient required in the most biocompatible manner possible.

References

1. Yeung C, Leung KCM, Yu OY, et al. Prosthodontic rehabilitation and follow-up using maxillary complete conventional immediate denture. Clin Cosmet Investig Dent. 2020;12:437-445. doi:10.2147/CCIDE.S271304
2. Caplanis N, Lozada JL, Kan JY. Extraction defect assessment, classification, and management. J Calif Dent Assoc. 2005;33(11):853–63. https://pubmed.ncbi.nlm.nih.gov/16463907/.
3. Rignon-Bret C, Hadida A, Aidan A, et al. Efficacy of bone substitute material in preserving volume when placing a maxillary immediate complete denture: study protocol for the PANORAMIX randomized controlled trial. Trials. 2016;17(1):255. doi:10.1186/s13063-016-1380-7
4. Khanijou M, Zhang R, Boonsiriseth K, et al. Physicochemical and osteogenic properties of chairside processed tooth derived bone substitute and bone graft materials. Dent Mater J. 2021;40(1):173-183. doi: 10.4012/dmj.2019-341
5. Mazor Z, Horowitz RA, Prasad H, et al. Healing dynamics following alveolar ridge preservation with autologous tooth structure. Int J Perio Restor Dent. 2019;39(5):697-702. doi:10.11607/prd.4138
6. Fernandez de Grado G, Keller L, Idoux-Gillet Y, et al. Bone substitutes: a review of their characteristics, clinical use, and perspectives for large bone defects management. J Tissue Eng. 2018;9:2041731418776819. doi:10.1177/2041731418776819
7. Andrade C, Camino J, Nally M, et al. Combining autologous particulate dentin, L-PRF, and fibrinogen to create a matrix for predictable ridge preservation: A pilot clinical study. Clin Oral Investig. 2020;24(3):1151–60. doi:10.1007/s00784-019-02922-z
8. Vogel RC. Implant overdentures: a new standard of care for edentulous patients current concepts and techniques. Compend Contin Educ Dent. 2008;29(5):270-6; quiz 277-8. PMID: 18795644. https://pubmed.ncbi.nlm.nih.gov/18795644/.
9. Henry K. Q&A on the future of implants. Dental Equipment and Materials. September/October 2006.
10. Rossein KD. Alternative treatment plans: implant supported mandibular dentures. Inside Dentistry. 2006;2:42-43. https://www.aegisdentalnetwork.com/id/2006/08/clinical-treatment-options-alternative-treatment-plans-implant-supported-mandibular-dentures.
11. Sánchez-Labrador L, Martín-Ares M, Ortega-Aranegui R, et al. Autogenous dentin graft in bone defects after lower third molar extraction: a split-mouth clinical trial. Materials. 2020;13(14):3090. doi:10.3390/ma13143090

Dr. Simos received his DDS degree from Loyola University in Chicago and maintains a private practice, Allstar Smiles, in Bolingbrook and Ottawa, Ill. He is the founder and president of the Allstar Smiles Learning Center, teaches postgraduate courses in comprehensive restorative dentistry, and is a recognized leader in cosmetic and restorative dentistry. In addition, he lectures throughout the country and is an internationally published author on the use of today’s innovative techniques and materials in dentistry. He can be reached at sam.s@allstarsmiles.com.

Disclosure: Dr. Simos reports no disclosures.

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