Implants Today | Dentistry Today

The Hidden Complication of Full-Arch Implant Prostheses

Dentistry Today — Mon, 16 Aug 2021 18:37:05 +0000

INTRODUCTION

Full-arch fixed prostheses (eg, All-on-X) have become very popular in implant dentistry today. There is an abundance of literature discussing complications with this type of prosthesis, such as fractures, hygiene and aesthetic issues. A significant complication that may be devastating, yet often overlooked, is speech or phonetic issues. Various clinical studies have reported a high prevalence of speech issues with fixed implant prostheses; Collaert et al¹ reported that 84% of patients with full-arch fixed implant prostheses exhibited one or more pronunciation errors after 6 years, Bothur and Garsten² concluded 83% of patients receiving implant prostheses had generalized speech problems, and Van Lierde et al³ reported that more than 87% had at least one consonant phonetic deficit. Therefore, to minimize the possibility of postoperative speech and phonetic problems, clinicians must have a strong understanding of the physiologic effects that full-arch implant prostheses may have on speech.

In the re-establishment of dental health for edentulous patients, mechanics, aesthetics, and speech maintenance are important principles that must be evaluated. Unfortunately, many clinicians do not place emphasis on the design and type of prosthesis with respect to its impact on the speech process. The ability to pronounce various phonetic sounds is dictated by the position and musculature of the tongue.⁴If the tongue is impeded by the design of the prosthesis in any way, patients may have difficulty pronouncing certain phonetic sounds.

There exist many reasons why patients exhibit speech problems after full-arch implant treatment:

1. Overbulked prostheses. After teeth are lost, the natural bone resorption process usually will result in the loss of existing hard and soft tissue. This most commonly will lead to a final implant prosthesis that is larger (overbulked) in the vertical and horizontal planes. Initially, because the prosthesis is foreign to the patient, the alteration of speech sounds often results. This is directly related to the inability of the tongue to freely move because of the impingement of the prosthesis (Figure 1).


Figure 1. (a) A maxillary prosthesis depicting overcontoured lingual contours. (b) A mandibular prosthesis showing lingually positioned implant positions, resulting in a lingually overcontoured prosthesis. Both of these prostheses will prevent free movement of the tongue for ideal articulation.	Figure 2. Macroglossia resulting from mandibular edentulism and the lack of an interim prosthesis.

Figure 3. Multiple air spaces resulting from tissue recession.

2. Macroglossia (enlarged tongue). The tongue is the most important articulator of speech sounds and is controlled by 8 different muscles classified as intrinsic and extrinsic. The intrinsic muscles allow the tongue to change shape, and the extrinsic muscles act to modify the position of the tongue.⁴ When teeth are lost, these muscles are directly affected, which results in alteration of speech. In addition, the tongue may increase in size (macroglossia), especially if an interim prosthesis is not worn. The enlarged tongue is problematic for patients when adapting to an implant prosthesis as patients often complain inadequate room exists for proper articulation (Figure 2).

3. Prosthesis adaptation. The most common dental materials used today for full-arch implant prostheses include zirconia, porcelain-fused-to-metal, and acrylic. Because these materials are “foreign” to the patient, patients will often have difficulty adapting to the prosthesis, which may result in speech difficulties. In addition, these prostheses are often heavier than conventional prostheses, which further complicates the prosthesis adaptation process.

4. Loss of proprioception. When teeth and their associated soft tissues are lost, the proprioceptive feedback system is often altered. The fine motor movements in the oral cavity are dictated by the teeth and their associated structures. Therefore, because speech is an unconscious act, the loss of the proprioceptive mechanism may result in the patient having difficulty in tongue control and producing various speech sounds.

5. Prosthesis air spaces. The design of the prosthesis, especially in relation to the intaglio surface, may lead to speech difficulties. Embrasure spaces are an integral part of allowing for proper post-op hygiene maintenance. Most commonly found in the maxillary arch, space present between the tissue and the prosthesis may allow air and saliva to flow through the openings, causing speech issues (Figure 3).


Figure 4a. Speech sounds: (a) “F” and “V”;	Figure 4b. (b) “S”;

Figure 4c. (c) “TH” and “L”;	Figure 4d. (d) “B,” “M,” and “P”;

Figure 4e. (e) “D,” “N,” and “T.”

PHONETIC COMPLICATIONS

In the process of recording maxillomandibular records for patients, it is imperative that the clinician understands the relationship between the prosthesis and the tongue, teeth, and lips. Initially, many full-arch fixed implant patients have difficulty pronouncing consonant sounds. The following are examples of specific consonant sounds that are affected by a final implant prosthesis.

1. “F” and “V” (labiodental sounds). The sound generation of the labiodental sounds (“F” and “V”) occurs directly from forced air between the maxillary incisal edges (anterior) and the lower lip. These specific sounds are important in determining the occlusal plane and the anterior-posterior positioning of the maxillary incisors. Ideally, the maxillary incisal edges should slightly contact the vermillion border of the lower lip in the pronunciation of these sounds. When the maxillary anterior incisal edges are positioned too “long,” “F” sounds will often be pronounced as “V” sounds. If the maxillary anterior incisal edges are too “short,” “V” sounds may be articulated as “F” sounds. These sounds are also directly affected by the occlusal plane. If the occlusal plane is positioned too high, relaxation of the lips will be impaired. If the occlusal plane is positioned too low, the lower lip will overlap the maxillary incisal edges, which will result in strained speech sounds⁵ (Figure 4a).

2. “S,” “Z,” “SH,” and “ZH” (sibilant sounds). The “S” sounds (and also “Z,” “SH,” and “ZH” sounds) are generated when the tongue is moved anteriorly toward the roof of the mouth, coming very close to the anterior teeth without making contact. A “hissing” sound is formed by air being pushed past the tongue. Often, because of non-ideal implant positioning in the premaxilla, these sounds are directly affected due to an overbulked anterior region. In addition, the premolar area may be bulky, which may obstruct the tongue, preventing air from escaping and resulting in a whistling sound. In the pronunciation of “S” sounds, lisping may occur if the palatal part of the implant prosthesis is too thick or if a lack of freeway space is present (Figure 4b).

3. “TH” and “L” (linguo-dental sounds). The linguo-dental sounds are produced when the tip of the tongue passes between the anterior incisal edges in very slight contact with the maxillary teeth (lingual). In the establishment of the labiolingual position of the anterior teeth, these sounds are often used. In ideal positioning, approximately 3 mm of the tip of the tongue should be seen when pronouncing the linguodental sounds. If less than 3 mm of the tongue tip is seen, the position of the teeth is too far forward (excessive vertical overlap). When more than 6 mm is seen, the maxillary teeth are positioned too far lingually⁶ (Figure 4c).

4. “B,” “M,” and “P” (bilabial sounds). The “B,” “M,” and “P” sounds are produced when the upper and lower lips come into contact. The “P” and “B” sounds are pronounced with an explosive effect. “M” sounds are produced with a more passive effect. These sounds are commonly used in establishing the ideal vertical dimension. When the vertical dimension is too open, inadequate freeway space will be present, and the lips will have difficulty contacting each other. When lip strain is present, the bilabial sounds will be distorted (Figure 4d).

5. “D,” “N,” and “T” (tongue to anterior lingual teeth sounds). The “D,” “N,” and “T” sounds are generated when the tip of the tongue contacts the maxillary lingual tooth surfaces and the anterior palate (incisive papilla). An explosive sound is formed when the tongue is drawn downward after contacting the lingual area. D, N, and T are termed “plosive” consonants. These sounds are often difficult to articulate because of an overcontoured lingual prosthesis, which results from a lingual-oriented implant position in the premaxilla (Figure 4e).

PREVENTION

To minimize the possibility of post-op phonetic complications, the following may be implemented:

1. Detailed informed consent. The patient should be educated, both verbally and in writing, on exactly what type (eg, design, shape, and size) of prosthesis he or she will be receiving. The use of prosthesis patient models made from the type of prosthesis material to be used (eg, zirco- nia, porcelain/metal, or acrylic) is an ideal way to convey the final prosthesis type.

In addition, the patient should be instructed on expectations and an adaptation period, which will reduce any possible misconceptions.

2. An interim prosthesis. After tooth removal, it is crucial that patients wear an interim prosthesis, even for a short period of time during the day. Because of the loss of proprioception and muscle control after tooth loss, speech may be affected. In addition, the vertical dimension of occlusion, centric occlusion, increased muscle atrophy, and tongue enlargement (macroglossia) may be altered or lost if no interim prosthesis is worn.

3. Post-op exercises. The tongue must have sufficient time to adapt to the new implant prosthesis. The easiest technique to allow for patient adaptation is to instruct patients on the use of musculature and phonetic exercises. An ideal exercise plan includes instructing patients to speak or read out loud, usually with a book or magazine, for 30 minutes twice a day. It is highly variable how long it can take a patient to adapt to a prosthesis.

IN SUMMARY

Since the early days of the Brånemark fixed hybrid prosthesis, many advances in implant technology have developed. However, patient education is very important as patients have far greater expectations today than in the past. Therefore, it is imperative that the implant clinician educates the patient on the adaptation phase of full-arch implant prostheses and the importance of proper speech articulation. Speech articulation is a complex component and an often-misunderstood part of the implant process. When a full-arch implant prosthesis is inserted, the goal is not only to restore function and aesthetics but also to maintain proper patient phonetics. Ideally, this may be accomplished by having the patient wear an interim prosthesis that closely parallels the patient’s original maxillomandibular measurements and through the use of post-op phonetic exercises.

REFERENCES

1. Collaert B, Van Dessel J, Konings M, et al. On speech problems with fixed restorations on implants in the edentulous maxilla: introduction of a novel management concept. Clin Implant Dent Relat Res. 2015;17 Suppl 2:e745–50. doi:10.1111/cid.12309

2. Bothur S, Garsten M. Initial speech problems in patients treated with multiple zygomatic implants. Int J Oral Maxillofac Implants. 2010;25(2):379–84.

3. Van Lierde K, Browaeys H, Corthals P, Muss- che P, Van Kerkhoven E, De Bruyn H. Comparison of speech intelligibility, articulation and oromyofunctional behaviour in subjects with single-tooth implants, fixed implant prosthetics or conventional removable prostheses. J Oral Rehabil. 2012;39(4):285–93. doi:10.1111/j.1365-2842.2011.02282.x

4. Liddelow FG. Clinical dental prosthodontics: Phonetics. Butterworth and Co. Ltd.;1989:136-139.

5. Pound E. Utilizing speech to simplify a personalized denture service. 1970. J Prosthet Dent. 2006;95(1):1-9. doi:10.1016/j. prosdent.2005.10.004

6. Chaturvedi S, Gupta N, Tandon A. Speech considerations. J Dental Med Sciences.2015;14(17):34-36.

ABOUT THE AUTHOR

Dr. Resnik is a leading clinician, educator, researcher, and author in the field of prosthodontics and oral implantology. Dr. Resnik received a specialty degree in prosthodontics and oral implantology from the University of Pittsburgh, along with a master’s degree in oral implantology/radiology. He is currently the chief of staff and surgical director of the Misch Implant Institute. He also holds faculty positions at the University of Pittsburgh (graduate prosthodontics), Temple University (graduate periodontics), and Allegheny General Hospital in Pittsburgh (oral and maxil- lofacial surgery). Along with his passion for lecturing and education, Dr. Resnik is also an accomplished author, having published numerous research articles and textbooks across his career. His 2 most recent books, Misch’s Avoiding Complications in Oral Implantology and Misch’s Contemporary Implant Dentistry, 4th Edition are best sellers in the field of oral implantology. He can be reached via email at resnikdmd@gmail.com.

Disclosure: Dr. Resnik reports no disclosures.

The Screw-Retained, Full-Arch Implant Prosthesis

Dentistry Today — Mon, 16 Aug 2021 17:13:41 +0000

Certainly, there are many options for the restoration of our edentulous patients. Conventional dentures still have a place for some people. Removable implant-retained overdentures are often a positive treatment option improving both form and function and eliminating the prohibitive palate in the maxillary arch. Those patients who request a fixed appliance can benefit from the CAD/CAM technology available to the profession today. Understanding anatomy and implant position—but, most importantly, realizing the emergence profile that is needed to maintain a screw-retained, fixed implant prosthesis will provide for an outstanding final result, a satisfied patient, and a positive long-term prognosis.

Edentulous patients continue to lose bone height and width over time. Facial and lip support are compromised, and vertical dimension of occlusion may decrease. Dental implant reconstruction has become a viable alternative to more conventional techniques and is certainly within the realm of the general practitioner. The essential aspects of implant dentistry today are proper implant position; soft tissue management and health; and knowledgeable dental laboratory technicians who understand the principles of design, form, and function.¹

Most of the public today has a fairly sophisticated understanding of the benefits that implant dentistry provides. Marketing and internet searches provide some positive information that directs patients to our practices. In the past, dental implants could be placed to support a removable appliance that had much more stability and function than conventional complete dentures.

However, permanent fixed prostheses are more mainstream than ever before. These appliances have become popular where the anatomy is acceptable and there is enough spacing of the implants to provide for a properly engineered design. Modern technology and materials provide for CAD/CAM design and precise milling of a prosthetic appliance from solid zirconia (BruxZir [Glidewell]).^2,3 These full-arch, implant-restored options provide excellent function, easy maintenance, aesthetics, and a long-term resistance to wear. The material is also wear-compatible with the enamel of the opposing dentition.

This bridge is attached to the underlying implants integrated into the bone via custom abutments, which allow the prosthesis to be cemented to place, or with multi-unit abutments, which allow the appliance to be threaded to position.^2,4


Figure 1. A preoperative panoramic radiograph indicated potential available bone in the anterior maxilla.	Figure 2. Pre-op CBCT analysis indicated available vertical height of bone but compromised horizontal width.

Figure 3. Occlusal view of the edentulous ridge prior to surgical intervention.	Figure 4. The patient’s conventional maxillary complete denture, which she had worn for many years

Diagnosing and treatment planning are critical to the long-term prognosis of the implant-retained prosthesis. Vital anatomy is reviewed using conventional radiographs, and CBCT analysis allows for visualization of the available bone in the sagittal view. Advances in technology also allow for virtual placement of our implants prior to any surgical intervention. Often, surgical guides can be created to help the practitioner strategically place implants in the best positions.⁵ Understanding arch form is important to final stability. Misch⁶ stated that we could predictably cantilever 1.5 times the distance from a line drawn between the 2 most anterior contralateral implants and the most posterior implants in the arch.

Following the strategic surgical placement of dental implants to support a screw-retained, full-arch prosthesis, there are some critical prosthetic applications that the dentist must clearly understand. Depending on the subsequent angulation of the implants in the available hard tissue, the prosthesis can attach directly to the implants themselves or connect to multi-unit abutments when the access holes for the abutment screws are in an unacceptable position. These multi-unit abutments serve to re-angle the abutment screws to a better access on the palatal aspect of the restoration. The connection, strength, long-term periodontal health, and final aesthetics of the prosthesis can be affected by the choice of abutments, so choosing wisely is important.^7-9


Figure 5. A reflection was made to visual- ize the available hard tissue.	Figure 6. Without the use of a surgical guide, implants were paralleled using the 2.4-mm-diameter pilot bur from the Hahn Tapered Implant Surgical Kit (Glidewell).

Figure 7. Following torquing of the implants to approximately 35 Ncm, cover screws were placed into each implant to allow for uninterrupted integration of the newly placed implants.	Figure 8. Postoperative saggital view from the CBCT analysis indicated proper positioning of the 4 strategically placed dental implants.

BruxZir zirconia provides outstanding strength, wear-resistance, and aesthetics. The appliance is CAD/CAM-designed and milled to the desires of the patient and under the direction of the dentist.¹⁰

CASE REPORT

Our patient was a 67-year-old white female with no significant medical or healing findings. Her maxillary conventional denture was barely tolerated for many years. With a better understanding of the benefits that dental implants could provide, she investigated alternatives to improve her quality of life and function without sacrificing the aesthetics she was accustomed to. Implant position was determined prior to any surgical intervention considering the available residual bone and undercuts. It was determined that 4 strategically placed dental implants could support an implant-retained overdenture or a fixed, implant-retained prosthesis.

There are protocols that must be followed to ensure a quality and well-fitting prosthesis that does not stress the underlying implants. The clinical procedures for restoring this maxillary edentulous ridge with a Bruxzir full-arch, implant-retained prosthesis are described in detail. It is essential to follow the steps precisely to ensure an accurate final result.

Our patient presented edentulous in her maxilla for many years. CBCT analysis assessed the patient’s bone volume and position of vital anatomy. The scan allowed me to determine the number of dental implants and the positions in which I would ideally like to place them. Certainly, the information obtained with the CBCT scans could be used to virtually design the implant positions and even the final prosthetic design. However, I decided to surgically place the implants without the use of a prefabricated surgical guide. The literature clearly indicates that the surgical placement of 4 properly spaced implants has an outstanding prognosis for this fixed, implant-retained prosthesis.^9,11,12The patient’s residual ridge exhibited adequate quality and quantity of bone for the placement of implants.

Figures 1 and 2 illustrate the preoperative panoramic radiograph and the sagittal view of the CBCT analysis (Vatech Green CT) (Vatech America). These radiographs indicated the potentially available bone in the anterior maxilla. The occlusal view of the edentulous maxillary ridge prior to any surgical intervention (Figure 3) showed that it would allow for enough interocclusal space to accept a fixed maxillary implant-supported bridge. The patient’s existing denture was evaluated for aesthetics, tooth shape, and position (Figure 4). The patient had no complaints about the aesthetics here. A minimum of 16 mm of interocclusal space is always required per arch for this particular type of fixed prosthesis.


Figure 9. The tissue reflection was sutured closed using a continuous Vicryl technique.	Figure 10. Following 4 months of inte- gration, the implants were uncovered, and open tray impression copings were engaged into each implant.

Figure 11. The dental laboratory (Glidewell) created the preliminary cast and determined the proper multi-unit abut- ments to be used for this screw-retained implant prosthesis.	Figure 12. The laboratory created impres- sion jigs for each implant, which were luted together with flowable composite material chairside to create the final accu- rate master cast that was used to create the final prosthesis. The connection of the final impression coping was checked radiographically.

With my treatment plan finalized, surgical placement of the implants was started. A reflection was made facially and palatally to expose the available hard tissue (Figure 5). The Hahn Tapered Implant Surgical Kit (Glidewell) was used. A 2.4-mm- diameter pilot bur created the initial osteotomy, allowing for proper mesial-distal and facial-palatal direction. Depth was determined radiographically. Once the first implant was ideally positioned, the subsequent osteotomies were easily completed, paralleling the strategically placed first implant (Figure 6). Since the patient would wear her existing denture during the 4-month integration period, cover screws were threaded into each implant to allow for stress-free healing (Figure 7). Figure 8 demonstrates a postoperative sagittal view of one of the implants in the available bone. A mattress Vicryl suture (Glidewell) was completed, approximating the reflected tissue and maintaining attached gingiva on the facial aspect of the implants (Figure 9). With proper suturing techniques, tissue approximation is excellent after one week. Sutures are removed in 7 to 10 days.


Figure 13. The laboratory then fabricated a screw-retained occlusal rim that engaged the angled multi-unit abutments, and a conventional denture setup was done to evaluate occlusion and aesthetics.	Figure 14. In a subsequent visit, the screw-retained wax try-in was evaluated.

Figure 15. From the wax set-up guide, the lab created a PMMA in composite, which the patient was able to wear for a short time to determine comfort, aesthetics, and function. Any changes to occlusion were easily made chairside.	Figure 16. The transitional appliance was verified with the patient. Access holes were covered with a small cotton pellet and cavit material. This allowed for easy removal and access to the abutment screws for removal.

Following 4 months of integration, the implants were uncovered, and open tray impression copings were engaged into each implant (Figure 10). The open tray technique is preferred when multiple implants are placed across the arch and are not in precise parallel position. Glidewell dental lab created the preliminary cast and determined the proper multi-unit abutment height and angulation to be used for this screw-retained implant prosthesis (Figure 11). The lab also created the final impression jigs for each individual implant. These were luted together with a flowable composite material chairside (Primopattern LC Gel [Pri- motec]) to create the final accurate master cast that would be used to create the final, passively fitting prosthesis (Figure 12). The connection of the final impression copings were checked radiographically for a complete seat. The lab then fabricated a screw-retained occlusal rim that engaged the angled multi-unit abutments (Figure 13), and a conventional denture setup was done to evaluate occlusion and aesthetics. Figure 14 illustrates the stable, screw-retained wax setup. From this approved wax setup, the lab then created a poly-methyl methacrylate (PMMA) transitional appliance, which the patient wore for a couple of weeks to evaluate comfort, aesthetics, and function (Figure 15). Any changes to occlusion or design were easily made. The transitional appliance was verified with the patient. Access holes were covered with a small cotton pellet and light-body polyvinylsiloxane impression material (Panasil initial contact regular [Kettenbach LP]). This allowed for easy removal and access to the abutment screws upon removal (Figure 16). Once the patient and the dentist make final approval, the transitional PMMA is returned to the lab for fabrication of the final BruxZir implant-retained prosthesis (Figure 17). Our patient was returned to function and aesthetics with the final screw-retained bridge over the strategically placed implants (Figure 18). Figure 19 shows the final positioning and seat of the prosthesis.


Figure 17. Once approved by the patient, the transitional PMMA was returned to the lab for fabrication of the final BruxZir implant screw-retained prosthesis. Very little to no adjustments were necessary.	Figure 18. The patient was pleased with the final functional and aesthetic BruxZir implant-retained prosthesis.

Figure 19. The final CBCT analysis indicated well-positioned and integrated Hahn dental implants supporting this fixed BruxZir zirconia screw-retained prosthesis.

REFERENCES

1. Tischler M. A maxillary fixed bridge supported by dental implants: treatment sequence and soft tissue considerations. Compend Contin Educ Dent. 2012;33(5):340–4. https://pubmed. ncbi.nlm.nih.gov/22616216/

2. Carames J, Tovar Suinaga L, Yu YC, et al. Clinical advantages and limitations of monolithic zirconia restorations full arch implant supported reconstruction: case series. Int J Dent. 2015;2015:392496. doi:10.1155/2015/392496

3. Wadhwani C. Prosthetic retention options for dental implants. Decisions in Dentistry. 2016;24-26.

4. Egilmez F, Ergun G, Cekic-Nagas I, et al. Implant-supported hybrid prosthesis: con- ventional treatment method for borderline cases. Eur J Dent. 2015;9(3):442-448. doi:10.4103/1305-7456.163324

5. Javed F, Ahmed HB, Crespi R, et al. Role of pri- mary stability for successful osseointegration of dental implants: Factors of influence and evalu- ation. Interv Med Appl Sci. 2013;5(4):162–7. doi:10.1556/IMAS.5.2013.4.3

6. Misch CE. Contemporary Implant Dentistry. 3rd ed. Mosby Elsevier; 2008.

7. Limmer B, Sanders AE, Reside G, et al. Com- plications and patient-centered outcomes with an implant-supported monolithic zirconia fixed dental prosthesis: 1 year results. J Prosthodont. 2014;23(4):267–75. doi:10.1111/jopr.12110

8. Oh SH, Kim Y, Park JY, et al. Comparison of fixed implant-supported prostheses, removable implant-supported prostheses, and complete dentures: patient satisfaction and oral health- related quality of life. Clin Oral Implants Res. 2016;27(2):e31-7. doi:10.1111/clr.12514

9. Preciado A, Del Río J, Lynch CD, et al. Impact of various screwed implant prostheses on oral health-related quality of life as measured with the QoLIP-10 and OHIP-14 scales: a cross-sec- tional study. J Dent. 2013;41(12):1196–207. doi:10.1016/j.jdent.2013.08.026

10.Agustín-Panadero R, Román-Rodríguez JL, Fer- reiroa A, et al. Zirconia in fixed prosthesis. A liter- ature review. J Clin Exp Dent. 2014;6(1):e66-73. doi:10.4317/jced.51304

11. Wilson TG Jr. The positive relationship between excess cement and peri-implant disease: a prospective clinical endoscopic study. J Peri- odontol. 2009;80(9):1388–92. doi:10.1902/ jop.2009.090115

12. Balshi TJ, Wolfinger GJ, Slauch RW, et al. A ret- rospective analysis of 800 Brånemark System implants following the All-on-Four protocol. J Prosthodont. 2014;23(2):83–8. doi:10.1111/
jopr.12089

ABOUT THE AUTHOR

Dr. Tilley is a graduate of the University of Alabama School of Dentistry. She is a native of Pensacola, Fla, and has been practic- ing dentistry in her hometown since 1998. She keeps up with the latest in dentistry by attending continuing education seminars on topics such as oral surgery, implants, veneers, periodontal disease, cosmetic pro- cedures, and much more. Dr. Tilley has also done extensive training at the Las Vegas Institute for Advanced Dental Studies and the Engel Institute with Drs. Timothy Kosinski and Todd Engel. She is a Fellow of the International College of Dentists (ICD) and is member of the AGD, the ADA, the Florida Dental Association, the Alabama Dental Association, the Academy of Laser Dentistry, and the Academy of American Facial Esthetics. Dr. Tilley has received a fellowship with the International College of Oral Implantologists and the ICD and has published extensively on implant dentistry techniques, lasers, and Botox/fillers.

She can be reached via email at stephflynntilley@cox.net.

Reviewing Implant Technology and Material Innovations

Kirtan — Wed, 16 Jun 2021 20:22:43 +0000

Presented here are 3 outstanding teaching articles that will help our readers understand the most innovative treatment modalities available to all dentists.

Early in my career, my mentor always promoted, “visualizing the case finished before you ever start.” This is a wonderful concept but took years of experience to become proficient. Taking a “tooth up or down” approach to implant dentistry is most critical. The days of placing implants in available bone and having the patient accept whatever final prosthetic result that could be achieved are no longer acceptable to many paying customers. Our patients expect to be educated on the process. Communication is the key to clinical success, as the more the individual understands about the procedure and the final result, the more positive that result will be. Understanding the anatomic pitfalls and aesthetic complications with implant dentistry cannot be trivialized. Digital diagnosing, treatment planning, and clinical applications are now achievable with our modern technology.

In his article, “Digital Clinical Laboratory Workflow for Full-Arch Implantolgy,” Dr. Michael Scherer precisely describes the techniques used to achieve a high level of prosthetic design, all done prior to any surgical intervention. From 3D printing to surgical guides to digital impressions, the protocols are concisely followed.

Dr. Angel-Orion Salgado-Peralvo and team present their article, “Metal-Free, Implant-Supported Full-Arch Rehabilitation.” This case report discusses the fabrication of a prosthesis with an innovative biopolymer material reinforced with glass fibers. Again, demonstration of ideal form and function precedes the surgical placement of implants.

Finally, our third submission from Drs. Sean Meitner and Gregori Kurtzman, “Simplifying Implant Placement in the Maxilla Anterior,” details ideal placement of dental implants using an in-office guide worn during the CBCT scan. The authors’ use of this cost-saving surgical guide is another tool that could be considered by the practitioner to better surgically place dental implants, reducing clinical error.

All 3 articles are interesting reads which should help us understand the importance of predictable and concise implant placement using technology and the fabrication of prostheses that provide a long-term solution for our dental patients.

Grafting and Attached Gingiva to Maximize Implant Prostheses

Dentistry Today — Thu, 01 Apr 2021 15:59:21 +0000

Dental implants have obviously become an integral part of many dental practices today. General dentists, often being the first oral professionals to discuss the possibility of dental implants to inquisitive patients, must understand basic concepts for proper diagnosis and treatment planning, predictable surgical placement, ideal emergence profile and smile design, and postoperative patient management.

Patients often present to our practices with a basic understanding of dental implants that they have gathered from family or friends or, most probably, from the internet. Some of the information designed for patient education is actually pretty good, but there are many clinical holes left for us to educate and instruct these candidates on.

One of the most critical situations that may be missed by the generalist is the importance of attached gingiva on the facial aspect of every implant. The literature states that there must be a band of at least 2 mm of attached gingiva present to provide periodontal health around any implant.

Have you ever had a patient present to your practice with a dental implant, that you may have placed or had come from another office, that has vague symptoms of soreness? Our first response is to look intraorally and make a digital radiograph. If there is no significant hard-tissue loss and the abutment and crowns look proper and precise, we may scratch our heads on why the patient has discomfort.

What we must look for is the lack of attached gingiva. When teeth are lost, bone will shrink, and the mucosal tissue will often follow this recontouring. Mucosa on the facial aspect of our implants is just asking for problems. Techniques have been developed to replace or grow bone in deficient areas.

Our related topics in this issue discuss both achieving attached gingiva around implants and a unique approach to creating bone in sites using the maxillary tuberosity.

Drs. Daniel Domingue and N. Cory Glenn present “Guided Ridge Healing With Full-Arch Custom Prosthetics” and do an excellent job explaining some relevant information on gaining attached gingiva around implants and how to maximize the long-term health and stability of the prosthesis in question. This is critical information for the general dentist to understand.

Our second implant-related presentation is from Dr. Steven Rasner, titled “Maxillary Tuberosity: An Overlooked Site for Block Grafts Rich in Cortical-Cancellous Bone.” This article will allow the reader to consider a donor site that may not have been in our clinical wheelhouse.

Dentistry Today is motivated to present practical clinical procedures to help stimulate our thought processes and provide outstanding surgical and prosthetic results for our patients. If you have any questions or comments about this topic, or any other subject presented in Implants Today, feel free to contact Dr. Kosinski at drkosin@aol.com.

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Virtual Design Improves Implant Prognosis

Dentistry Today — Tue, 01 Dec 2020 12:00:00 +0000

What makes for a successful dental restoration? Some may say that success occurs when the margins of our crowns look complete on a digital radiograph, or that occlusion has perfect tri-podial contacts, or when the shade and shape of the tooth look ideal. Emergence profile and smile design are important considerations in all our dental therapies, but especially when considering dental implants.

In this issue, Dr. Randy Resnik, a true leader and educator in all facets of implant dentistry, discusses in great detail the complications that can occur when practicing implant dentistry. Many of these complications are the result of improper treatment planning and the execution of surgical placement, as well as prosthetic design flaws. Again, visualizing the case finished before ever starting is certainly a major part of the art of dentistry. However, how is this achieved? Understanding the benefits and limits of the dental implant is critical to achieving a positive long-term prognosis. To optimize the end result, the clinician must address knowing which cases are appropriate to do and to evaluate which cases may need more invasive procedures. It is not simply about collecting a fee by threading a screw into the jaw! Complications may result in an unhappy patient who assumed that this reasonably expensive treatment would improve his or her form and function and quality of life. Retreatments are expensive and eliminate any profit margin the dentist may receive.

In another excellent article, Dr. Elaine Blylis discusses the newest diagnostic tools that can help the less experienced dentist diagnose, treatment plan, and surgically place implants at an exceptionally high level. Being able to virtually design the final prosthesis prior to any surgical intervention allows the practitioner to determine which cases are appropriate for any given practitioner (based on his or her experience and comfort level) to tackle. Technology allows us to educate and instruct our patients about our treatments and helps us provide the best possible product. Chair time and cost to the patient are reduced, thus providing the profession a dynamic means of providing care.

Continual postgraduate education is a big factor for success in our practices, and I hope that our 2 quality submissions on implant dentistry inspire and motivate you to get involved and to better realize the possible benefits and risks.

If you have any questions or comments about this topic, or any other subject presented in Implants Today, feel free to contact Dr. Kosinski at drkosin@aol.com.

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Dentistry Today — Thu, 01 Oct 2020 12:00:00 +0000

Techniques, materials, and technologies used by our profession have become so innovative. Digital impressions, CBCT, virtual design software, and CAD/CAM milling have allowed clinicians to be very efficient in accomplishing the work while providing accurate and predictable treatment results for patients. At the same time, costs to produce this clinical work are being reduced, making our procedures more profitable to the dentist yet maintaining the ability to deliver high-quality results. Investing in this technology helps to professionally stimulate the practitioner, and the associated, much needed, continuing education elevates the entire dental team.

In this issue, we present 3 outstanding articles. First, Dr. Todd Schoenbaum, Dr. Peter Moy, and Mr. Sam Alawie share an interesting and relevant article on the treatment of compromised implants. Next, Dr. Todd Engel, from the Engel Institute Dental Implant Training program, presents an article involving the emergency implant treatment concept. Then, in another implant-related article, Drs. Naheed Mohamed, Mark Bishara, and Richard Miron discuss custom 3-D allograft block fabrication. Being able to create ideal grafting design within our practices seemed unimaginable only a short while ago.

General practitioners are embracing both surgical and prosthetic applications. However, as more dentists are providing this service and more implants are being placed and restored, we certainly see the challenges that these procedures present. The ideal placement of implants is only achieved with adequate health and available bone. What happens when there is not enough vertical or horizontal width of hard tissue to maximize the result? Being able to visualize the final aesthetic and emergence outcome is critical to a successful implant case. This can be done using digital technology. Once the prosthetic design is selected, it is our duty to then surgically place the implant in a position that optimizes the final outcome. This is especially important in the aesthetic zone of the pre-maxilla. The smallest error in judgment can create a less-than-desirable final restoration. Remember, the patient never sees the implant embedded into the hard tissue, rather he or she is judging the clinical outcome on the white structure that protrudes through the gum and shows when he or she smiles. So, as dentists, smiles are a major component of what we are all about; therefore, let’s make them as aesthetic as humanly possible.

If you have any questions or comments about this topic, or any other subject presented in Implants Today, feel free to contact Dr. Kosinski at drkosin@aol.com.

Implant Complications

Dentistry Today — Mon, 14 Sep 2020 17:36:51 +0000

Implant dentistry keeps evolving to highly innovative yet practical levels. Techniques that are used, from single-tooth implant restorations to the popular immediately loaded full-arch prostheses, have improved to such a high level that they have become rather routine for the experienced dental surgeon. Materials, high-quality and engineered surgical instrumentation, and implant designs have allowed for proficiency and predictability in the delivery of our cases. CBCT technology has made it much easier and more accurate for practitioners to visually diagnosis and treatment plan their cases prior to any surgical intervention.

Although surgical and prosthetic applications are readily presented in the dental literature, the treatment of failing implants and complex clinical situations in the aesthetic zone are certainly interesting topics deserving more attention. As more dental implants are placed and restored, we are going to see some complications. Being able to address these problem situations is an art unto itself. Placing and restoring implants is just one phase of the profession. Preventing and fixing problems that may occur over time is an entirely different concept.

Bone loss is a common problem associated with dental implant therapy. As teeth are lost, the available facial bone resorbs, resulting in horizontal bone loss, and the vertical available bone may shrink. This results in complications in the posterior mandible where the mandibular nerve rests and the posterior maxilla where the sinus often collapses. Increasing available bone is a technique that is done with grafting procedures. Different materials are used in the process of creating new bone to make a site acceptable for surgical placement of the implants.

In this issue, Dr. Stephanie Tilley describes a technique to remove a damaged implant and graft with calcium apatite material to re-establish a suitable site for a new implant placement and restoration. Also, Drs. Scott Ganz and Isaac Tawil describe an innovative technique to maintain the facial plate of bone using the patient’s existing root structure. These 2 articles are useful clinical case report demonstrations of how to maintain hard tissue in the aesthetic zone and, in addition, examples that show how to predictably grow bone to idealize edentulous sites.

If you have any questions or comments about this topic, or any other subject presented in Implants Today, feel free to contact Dr. Kosinski at drkosin@aol.com.

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Dentistry Today — Thu, 06 Aug 2020 15:08:48 +0000

Dental implants have certainly become a viable alternative to conventional dental techniques.
I started my implant training in 1984, when our modern dental implants were relatively new to the profession. At that time, the prominent implant system was not available to the general dentist. Slowly, over time, our materials and techniques have vastly improved, but there certainly were many bumps in this road over the years. Some materials and designs worked reasonably well, while others did not. We learned together through study clubs and continuing education sponsored by a variety of national and international dental organizations.
High-quality clinical education has elevated our profession to a very high level. Digital dental radiographs, and now CBCT analysis, along with CAD/CAM design and milling, have made implant dentistry fairly mainstream as more and more general dentists are embracing both the surgical and prosthetic aspects. Also, the Internet allows our potential patients to get some education as to what is possible to replace missing teeth or ill-fitting dental prostheses.
Increasing numbers of patients are now coming to the offices of general practitioners (GPs) with specific requests for dental implant therapy. It is the GP’s duty to educate and instruct these patients on the benefits and risks of treatment.
In this issue, we have a wonderful interview with the very talented Dr. Charles Schlesinger. It is an informative read for those practitioners just getting started in implant dentistry. Learning from his vast experience and opinions in this realm of dentistry will be very helpful. The article proves interesting for those who have more experience with the therapy as well. We also have a second article by Drs. JaeSeok Kang and Meekyung Son who present a clinical case involving a full-arch, multi-unit implant-supported reconstruction. This technique has become very popular around the country as we are able to predictably restore our full-arch edentulous patients with permanent fixed prostheses. This mode of treatment has specific guidelines that must be followed precisely to achieve the maximum functional and aesthetic outcomes. This article is an excellent read if you want to incorporate this treatment option into your practice. Likely, your patients have been, and will be, asking about it.
Presenting outcomes to patients who present to our offices requesting changes in their dental and facial aesthetics can be challenging. Clinical expertise and experience allows the dentist to visualize the end result prior to any surgical intervention. Proper, high-quality continuing dental education is the key to success. I challenge our readers to take the information presented in this issue and use it to help elevate diagnoses, treatment planning, and clinical thought processes to the highest level possible.

If you have any questions or comments about this topic, or any other subject presented in Implants Today, feel free to contact Dr. Kosinski at drkosin@aol.com.

Dental Implant Treatment Options

Dentistry Today — Wed, 01 Apr 2020 12:00:00 +0000

As technology improves, there are often questions on to how to best treat our patients who present with significant decay in their teeth. This issue of Dentistry Today focuses on endodontics as a reliable method to help our patients retain their natural dentition.

Often, the cost of treatment to our patients for root canal treatment of an infected tooth and the subsequent restoration is equal to or less than our dental implant therapy. However, when indicated, dental implant therapy is becoming an extremely popular option of restoring form and function.

In this issue, Dr. Stephanie Tilley describes how to do simple maxillary sinus tenting with dental implant placement. Losing teeth can result in some serious dental concerns, especially in the posterior maxilla. Teeth roots act like tent poles holding up a circus tent, but when the poles are removed, the circus tent collapses. This common result often inhibits dental implant placement without more invasive surgical procedures, which are expensive and time consuming. So, when possible, is it better to retain teeth via endodontic therapy or to simply remove the damaged teeth and place dental implants? That is a question that the dental professional needs to consider carefully.

Also in this issue, Drs. Richard Miron, Michael Pikos, and Mark Bishara write about how vitamin D and antioxidant deficiencies in our patients can result in poor prognoses. Restoring edentulous spaces to function and aesthetics is much more than anesthetizing, reflecting, drilling into hard tissue, and placing titanium screws into jawbones. Proper diagnosing and a thorough evaluation of the patient’s general health is just as important as our clinical skills in surgical placement. Conventional root canal therapy is a viable alternative to extraction and implant placement. However, there are times when dental implant therapy may be a better solution. Educating and instructing our patients as to the benefits and risks of treatment should be above “selling” a procedure.

If you have any questions or comments about this topic, or any other subject presented in Implants Today, feel free to contact Dr. Kosinski at drkosin@aol.com.

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Dentistry Today — Sun, 01 Mar 2020 12:00:00 +0000

Over the years, Dentistry Today has been an awesome source of information to stimulate dentists to investigate the newest protocols and their possible implementations in the practice. Of course, these decisions should be made after undertaking further research and additional education.

Dentists of all experience levels need to know that some of the procedures presented are complicated and require a full understanding of the techniques involved.

For example, Dr. Todd Engel’s article in this issue provides a step-by-step discussion of one of the most publically advertised dental implant treatments: edentulous arches. This type of therapy seems simple enough, but there is a lot of thought and preparation that goes into the process prior to any surgical intervention. CBCT analysis allows us to virtually determine the position of dental implants to support a fixed or fixed/detachable prosthesis. It is imperative that doctors understand the specific rules to follow to create such an appliance before any placement of implants. There needs to be a certain amount of inter-occlusal space per arch provided, and this can mean removing valuable bone to accommodate the implant-retained bridgework. Precise surgical guides must be fabricated.

In his article, Dr. Engel describes a reduction guide to level the available hard tissue, then an implant placement guide allowing for specific positioning of the supporting dental implants. Once the implants were initially stabilized, a prefabricated screw-retained transitional appliance was delivered. Please be aware that this step is critical to the long-term success of the case. When immediate loading of implants is required, the prosthetic architectural design is important for initial stabilization and integration. Any discrepancy in the evaluation, virtual design of the surgical guides, surgical placement, and/or immediate positioning of the transitional appliance can result in retreatment. It is crucial that clinicians who want to provide this often-requested therapy be well educated and skilled.

If you have any questions or comments about this topic, or any other subject presented in Implants Today, feel free to contact Dr. Kosinski at drkosin@aol.com.

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