| technique | case report | industry news

| technique3-D Virtual Planning Concepts: Maxillary Implant Supported Removable or Fixed Prostheses

| case reportDiagnosis and management of a rare case of a maxillary second molar with two palatal roots

| industry newsA winning combination: CAD/CAM and CBCT in one

22015

issn 2198-6762 Vol. 2 • Issue 2/2015

cone beaminternational magazine of cone beam dentistry

I 03

editorial _ cone beam I

cone beam 2_2015

_Without questions, Cone Beam Computed Tomography has provided clinicians with an amazing imaging modality to assess our patient’s individual anatomy. In fact today, manyclinicians will not place a dental implant without a CBCT scan prior to any surgical interven-tion. While this alone is a powerful statement, there are still questions that need to be askedwith regard to how the technology is utilized. Are we seeing what we need to see? Having a CBCT scan does not in itself mean that clinicians are able to clearly visualize all aspects ofthe bone, soft tissue, teeth, and adjacent vital structures. The implication is that if clinicianscan not see everything that we need to see, are we able to diagnose properly? In my opinion,diagnosis is a key..

The data that is derived from a CBCT is invaluable for certain, but it does require softwareintervention to convert that data into information that can be used for diagnosis and treat-ment planning for a variety of different purposes. Managing the DICOM data from the CBCTdevice perhaps the most important consideration that can define the clinicians’ ability to vi-sualize everything necessary for proper diagnosis. One example of the impact of the softwarecapabilities is how the data is revealed on our computer screen. The software should easily allow for each cross-sectional, axial, coronal, and 3-D reconstructed volume to be enlargedwithout distortion for careful inspection at highlevels of magnification. The ability to changethe opacity of various anatomical structures, as I have previously termed, “selective trans-parency” is essential to provide clinicians with very powerful tools to visualize relationshipsbetween these structures.

When the software attempts to create beautiful and visually pleasing three-dimensionalreconstructed volumes, problems often occur when there are existing crowns, or metal withinthe field of view resulting in scatter artifact. This scatter can mask underlying anatomy in crit-ical regions that clinicians need to analyze, making the scan useless for diagnosis. Therefore,the software must have an ability to help remove or diminish scatter artifact, and this may require ancillary superimposition of intra-oral scans or optical scans of stone casts to improvesurface accuracy, as an aid for planning and the eventual fabrication of surgical templates viastereolithography, 3-D printing, or CAD/CAM processes.

In the pages of CBCT International Magazine, we continue to strive to provide our read-ership with information that will help inform and educate about state-of-the-art tools asutilized by world-class authors who have taken the time to document their cases and con-cepts. The information will illustrate that there are vast differences in how data is used fromvarious CBCT devices and software applications. The underlying and most important goalfor our publication is to deliver the “clarity of vision” to help clinicians make the best deci-sions for our patients.

Please enjoy our latest issue!

Dr Scott D. GanzEditor-in-Chief

Clarity of Vision

Dr Scott D. Ganz

cone beam2_201504 I

I content _ cone beam

page 38

I editorial

03 Clarity of Vision| Dr Scott D. Ganz

I technique

06 3-D Virtual Planning Concepts: Maxillary ImplantSupported Removable or Fixed Prostheses| Dr Scott D. Ganz

12 Lateral maxillary incisor implant – Key issues for aesthetic success | Drs Philippe Russe & Patrick Limbour

I case report

20 Small-diameter implants for single anterior restorations| Dr Richard Marcelat

26 Diagnosis and management of a rare case of a maxillary second molar with two palatal rootsSupported by conventional radiography and CBCT| Ass. Prof. Katarina Beljic-Ivanovic

I research

30 Interdisciplinary approach to treatment of maxillary radicular cysts: Minimization of surgicalinvasiveness and medication load| Prof. Galyna Biloklytska, Dr Vasyl Rybak, Dr Iuliia Braun &

Dr Ievgen Fesenko

I industry news

38 A winning combination: CAD/CAM and CBCT in one| Planmeca

40 X-Mind trium: 3 in 1 extra-oral imaging forall your 3-D requirements| ACTEON IMAGING

41 3DISC Imaging reveals new FireCam HD intra-oral camera at IDS 2015| 3DISC Europe

42 RAY introduces new imaging system at IDS| RAY Co., Ltd.

I meetings

44 Biggest IDS of all time in Cologne

48 International Events

I about the publisher

49 | submission guidelines50 | imprint

Cover image courtesy ofDr Scott D. Ganz

I technique _ virtual planning

_“Pre-surgical prosthetic planning” can bedefined as the process of accumulating diagnosticinformation to determine which course of treatmentshould be considered for the fully edentate patient.The first step in patient evaluation should includeconventional periapical radiographs, panoramic

radiographs, oral examination, and mounted, artic-ulated study casts. In the completely edentulouspatient it is essential for the clinician to assess sev-eral important aspects of the individual anatomicalpresentation including vertical dimension of oc-clusion, lip support, phonetics, smile line, over-jet,overbite, ridge contours, and a basic understandingof the underlying bone structures. The accumula-tion of preliminary data afforded by conventionaldiagnostics provides a foundation to prepare acourse of treatment for the patient. However, if the

review of findings is based upon a two-dimensionalpanoramic radiograph, it may not be accurate inappreciating the true spatial positioning of vitalstructures such as the incisal canal, the floor of thenose, or the maxillary sinus. To fully understandeach individual patient’s actual bone anatomy, it is

essential that clinicians adopt aninnovative set of virtual, three-dimensional tools. Through theuse of advanced imaging modal-ities new paradigms have beenestablished that in the author’sopinion will continue to redefinethe process of diagnosis andtreatment planning dental im-plant procedures for years tocome. Without the applicationof computed tomography (CT)or lower radiation dosage conebeam computed tomography(CBCT), an understanding of thethree-dimensional anatomic re-ality cannot be accurately de-termined, potentially increasingsurgical and restorative com -plications.

The utilization of 3-D imagingmodalities as part of pre-surgi-cal prosthetic planning can takeseveral paths. The first involvesacquiring a three- dimensionalscan directly, without any prior

planning or ancillary appliances. The scan processcan be accomplished at a local radiology centre,mobile imaging company, or via an in-office CBCTdevice. The scan itself can be completed within sev-eral minutes. Once the data is processed, it can beviewed on the native software of the CBCT machineitself, evaluated for potential implant receptorsites, followed by the surgical intervention, or witha third party interactive treatment planning soft-ware. A second path requires the fabrication of a radiopaque “scannographic” appliance that incor-

Fig. 1_The axial view provides insight into the global

topography of the maxilla.

Fig. 2_The volumetric rendering aidsin the inspection of the bone but does

not the desired restorative position. Figs. 3a & b_A radiopaque scanningappliance fabricated from a duplicate

of a patient’s existing well-fittingdenture (a) allows inspection of toothposition in relation to the underlying

bone (b).

3-D Virtual Planning Concepts:Maxillary Implant Supported Removable or Fixed Prostheses Author_ Dr Scott D. Ganz, USA

06 I cone beam2_2015

Fig. 1 Fig. 2

Fig. 3a Fig. 3b

technique _ virtual planning I

porates vital restorative information that will beworn by the patient during the acquisition of thescan. In this manner, the desired tooth position canbe evaluated in relation to the underlying bone andother important anatomic structures such as themaxillary sinus or the inferior alveolar nerve. Certainproprietary methods incorporate the use of fiducialmarkers to help with the registration process forplanning based directly upon the restorative needsfor the patient.

The use of interactive treatment planning hasexpanded dramatically in the past ten years as com-

puting power has increased exponentially. As de-fined by the author, guided surgery can be dividedinto three distinct categories once a “virtual” planhas been established based on 3-D scan diagnosis(Ganz-Rinaldi Classification of Guided ImplantSurgery Protocols). The first allows the informationto be assessed, providing important information tothe clinician who will perform the surgical inter-vention free-hand based upon the software plan,termed “Diagnostic-Freehand”. The second cate-gory involves the fabrication of a surgical guide ortemplate that is remotely constructed from the digital plan usually through rapid prototyping or

Figs. 4a–c_Cross-sectional slice reveals tooth position in relationshipto the bone (a) and the extension ofthe labial vestibule (red arrow) (b).The relationship to the maxillary sinusis essential for planning in the posteriorregion, where thin cortical plate canbe clearly visualized (arrow) (c). Figs. 5a & b_Evaluating a potentialreceptor site within the cross-sec-tional view (Slice 63) (a). The posi-tioning of the implant(s) need to fallwithin the envelope of the teeth (b).

I 07cone beam2_2015

Fig. 4a Fig. 4b Fig. 4c Fig. 5a

Fig. 5b Fig. 6a Fig. 6b Fig. 6c

Fig. 7a Fig. 7b Fig. 8a

Fig. 8b Fig. 9a Fig. 9b


stereolithography, CAD/CAM, or laboratory fabri-cated, termed CT-derived “Template-Assisted”. Thedrilling process is started and can be completedwithin the template helping to control trajectoryand depth with the proper instrumentation. The thirdcategory requires a specific template design thatallows for accurate drilling and osteotomy prepa-ration, and with the proper manufacturer-specificcarriers the implants can then be accurately deliv-ered through the template, termed, "Full TemplateGuidance." The use of advanced imaging modalitiesfor pre-surgical prosthetic planning is essential forany type of implant surgical and restorative inter-vention, from the single tooth, multiple toothrestoration, full arch fixed and removable over-denture reconstruction. However, it is the correctuse of three-dimensional tools that provides clini-cians with the power to diagnose and treatment planwith the highest degree of acuity and ac curacy.

_3-D Planning Concepts: Full Arch Maxillary Overdenture

Due to anatomical variations related to the max-illary sinus, the floor of the nose, the incisal canal,the facial trajectory of the anterior segment, thincortical plates, and diminished overall bone densitywhen compared to the mandible, the completelyedentate maxilla offers additional diagnostic chal-lenges for clinicians. The axial view provides insightinto the global topography of the maxilla (Fig. 1).The position of the incisal canal can be visualized,along with thin facial and palatal cortical plates.The volumetric rendering aids in the inspection ofthe bone, but does not offer any information regarding tooth or ultimate restorative position(Fig. 2). In order to achieve the concept of “truerestoratively driven implant dentistry” pre-surgicalprosthetic planning should start prior to any scan

being taken. A scanning appliance can befabricated from a duplicate of a patient’s existing well-fitting denture, or a new diag-nostic set-up which positions the teeth atthe ideal vertical dimension of occlusion,centric relation, and functional/aestheticcomponents (Fig. 3a). The patient wears thescannographic appliance during the scan,ideally held in place with a pre-determinedbite registration to minimize movement.The scan reconstruction will then containboth the tooth position and the underlyingbone (Fig. 3b).

The combination of the anatomical scandata with the radiopaque template allowsunprecedented diagnostic potential. Thetemplate reveals the tooth position (red arrows) in relationship to the underlying

Figs. 6a–c_The cross-sectional image reveals a potential receptor

site (a); the realistic implant andabutment simulation (b); the author’spreference places the implant within

a defined zone of available bone defined as the “Triangle of Bone”

(TOB) that also acts to relate implantposition to the restorative outcome (c).

Figs. 7a & b_The occlusal view ofthe volumetric rendering aids in the

implant-to-implant positioning withinthe bone (a). Superimposing a

translucent scannographic templateover the maxilla provides the

information to position implantswithin the restorative envelope (b).

Figs. 8a & b_Use of “selective transparency” with abutment


Fig. 10a Fig. 10b Fig. 11


Fig. 14a Fig. 14b



bone in the cross-sectional slice (Fig. 4a). The thincortical plates can be clearly visualized, along withthe extension of the labial vestibule (red arrow, Fig. 4b). The relationship to the maxillary sinus isimportant when deciding if implants might be anoption in the posterior region (Fig. 4c). In this ex-ample the pneumatisation of the sinus has resultedin extremely thin lateral cortical plate (see red ar-rows). The radiopaque template is helpful whenevaluating other receptor sites, and positioning asimulated implant within the cross-sectional view(Slice 63, Fig. 5a). For an over-denture applicationthe positioning of implants need to fall within theenvelope of the teeth, and it is even more practicalto visualize the abutments that might be utilized(Fig. 5b). For this example a realistic stock “ball type”abutment was utilized on the virtual realistic im-plant. In order to provide some guidance, it is theauthor’s preference to place the implant within a defined zone of available bone (Figs. 6a & b). This zone has been previously defined as the “Triangle of Bone” (TOB) that also acts as a decisiontree to connect the implant placement to therestorative outcome (Fig. 6c). Positioning the im-

plant within the zone of the TOB, or actually bisect-ing the triangle, allows for the most bone volume to surround the implant. Following this formula,the implant and abutment will be positioned in afavourable restorative position.

Further inspection through the utilization of additional views can be extremely enlighteningwith regard to the final positioning of the implants.The occlusal view of the volumetric reconstructionaids in the implant-to-implant positioning withinthe bone (Fig 7a). However, without a complete

understanding of the tooth position, the implantsmay not be ideally located based upon the pros-thetic plan.

Superimposing a translucent scannographictemplate over the maxilla provides the importantinformation to position the implants within therestorative envelope (Fig. 7b). The prosthesis designcan be evaluated to determine whether to fabricatea complete denture that would extend to incorpo-rate a conventional post-palatal seal, or an open-palate horseshoe type prosthesis. To aid in the finalpositioning, it is helpful to visualize the outline ofthe occlusion using the author’s concept of “selec-tive transparency”, and extend the abutmentsabove the occlusal plane (Fig. 8a). “Selective trans-parency” is a software tool which can help separateone anatomical structure from another by adjust-ing the opacity of the various objects. Once the im-plants are placed, the ball abutments can then bepositioned at the proper tissue cuff height (Fig. 8b).Rotating the views can substantiate the plan toplace the implants where they will be support theremovable prosthesis (Figs. 9a & b).

It is important to assess the clearance within the denture to allow for sufficient thickness ofacrylic within the over-denture abutment housingavoiding potential fracture of the prosthesis. This“prosthetic space” requirement may be differentdepending upon the type of attachment used. Using the power of digital technology and selectivetransparency, the realistic implant and ball abut-ment can be seen through the prosthesis and theunderling bone (Figs. 10a & b). These illustrationsreveal that the two right implants are parallel, whilethe left implants are seen to follow the natural

extensions above the occlusal plane (a). Ball abutments positionedat the proper tissue cuff height (b). Figs. 9a & b_Rotating the views help position implants where theywill best support the removable prosthesis. Figs. 10a & b_Selective transparency allows the realistic implants and ball abutments to be seen through the prosthesis and the maxillary bone. Fig. 11_The distance between the two anterior implants and themaxillary incisor teeth (red arrows)represents a cantilever that could result in tipping of the denture. Figs. 12a & b_The use of realistic attachments allows for implant-to-implant positioning around thearch necessary to gain maximum retention and resistance of the prosthesis to dislodgement duringmastication.

Fig. 13_Utilization of virtual abutments aids in determining thecorrect tissue cuff heights of theabutments above the bone, and through the soft tissue. Figs. 14a & b_The vertical distance can be evaluated within the prosthetic design (a), crown-to-root ratios, and the trajectory of the implant-abutment complexcan be visualized within the virtualplan.

I 09cone beam2_2015

Fig. 17a Fig. 17b Fig. 17c



trajectory of the maxillary alveolus (a), and the re-verse is true after rotating the maxillary volumetricreconstruction to view the left side (b). Finally, whenconsidering the mechanical forces of masticationand movement of the prosthesis, a line can bedrawn between the two most anterior implantsthat establishes the potential for rotation in the occlusal plane (Fig. 11). A second line can be drawnat the most anterior aspect of the maxillary teeth.The distance between the two anterior implantsand the maxillary incisor teeth (red arrows) repre-sents a cantilever that could result in tipping of thedenture when the patient bites into an apple.

The ball-abutment is only one potential stockabutment choice for an over-denture application.Another widely used abutment is the Locator attachment (Zest Anchors). The use of realistic Lo-cator attachments allows for a precise understand-ing of the implant-to-implant relationship, andspacing around the arch which is necessary to gain maximum retention of the prosthesis to resist dislodgment during mastication (Figs. 12a & b). In addition, the utilization of virtual abutments aidsin determining the correct tissue cuff heights of the abutments above the bone, and through thesoft tissue (Fig. 13). The vertical distance can beevaluated within the framework of the prostheticdesign (Fig. 14a). The new digital tools allow for newparadigms to be established assessing the relation-ship of the implant position, abutment position,and prosthesis prior to the scalpel ever touching thepatient. Crown-to-root ratios and the trajectory ofthe implant-abutment complex can be visualizedwithin the virtual plan, providing valuable surgicaland restorative information during the planningphase (Fig. 14b).

In addition to the axial, panoramic, and three-dimensional reconstructed volume, the impor-tance of the cross-sectional image is critical to fullyappreciate the relationship between the implantposition within the bone, and the emergencethrough the tooth. One area that has not been emphasized however, is the ability to determine theprosthetic space required for the abutment as it relates to the thickness of soft tissue supporting

the overdenture (Fig. 15a). The realistic ball abut-ment can be clearly visualized sitting on the coro-nal aspect of the implant (red line), and the tissuecuff height of the abutment (green line). One com-ponent that is not easy to determine is the metalhousing that will be processed within the denture.This component part is not yet available within thesoftware libraries to the author’s present knowl-edge. Therefore an approximation was digitallyrepresented (gold), so that the extra height can bevisualized (yellow line), revealing the thin palatalaspect of the overdenture (Fig. 15b). Once the vir-tual plan has been established a surgical templatecan be designed by the software and then fabri-cated through 3-D printing, stereolithography, or aCAD/CAM process to assist in the placement of theimplants within the anticipated restorative needsof the patient (Fig. 16).

_3-D Planning Concepts: Full Arch Maxillary Fixed Prosthesis

There are few differences between 3-D planningconcepts for an overdenture prosthetic design, or a fixed prosthetic rehabilitation supported by implants. All aspects of the patient’s bone and softtissue anatomy must be carefully evaluated. After a proper assessment of the available bone, key im-plant positions are identified, and simulated withinthe 3-D reconstructed volume as seen in Figure 17a.However, it is important to once again evaluate thepotential implant receptor sites based upon the en-velope of the occlusion (Fig. 17b). Using “selectivetransparency” helps to provide an enhanced per-spective of how the implant abutment projections(yellow) are spaced within the desired restoration(Fig. 17c). The frontal view clearly illustrates the importance of the implant abutment projections,revealing for this example a nearly parallel place-ment of the implants (Figs. 18a & b). “SelectiveTransparency” can be applied to multiple struc-tures, to help visualize the entire complex of the im-plant, abutment projection, radiopaque template,and the underlying bone (Fig. 18c). By rotating the3-D reconstructed volumes, it is apparent howpowerful these interactive software tools can be(Figs. 19a & b). Once the final positions of the im-

Figs. 15a & b_The top of the implant(red line) serves as the foundation forthe abutment at a specific tissue cuff

height (green line) (a); the metalhousing represented in gold also hasa vertical component (yellow line) (b).

Fig. 16_Once the implant positionhas been confirmed, the software

will generate the virtual design of the template.

Figs. 17a–c_Eight implants positioned to support a fixed

restoration (a) to fit within the framework of the desired tooth

position (b); using “selective transparency” the underlying

bone can be visualized (c). Figs. 18a–c_Frontal view of the

scanning template with yellow abutment projections seen above theocclusal plane (a); semi-transparentscanning template (b); and all three

objects translucent to visualize the position of the implants within

the bone (c). Fig. 19a & b_Another 3-D view

showing the emergence of the abutment projections

through the scanning template.


Fig. 19a Fig. 19b


plants are confirmed for the edentulous presen -tation, a mucosal-supported template can be designed and fabricated through 3-D printing,stereolithography, or a CAD/CAM process. The mucosal-supported template should be fixated tothe bone, to insure accuracy of the drilling se-quence. The template with the blue screws can bevisualized in Figures 20a–c.

_Conclusion

The advent of complete denture fabricationevolved into the adoption of over-denture con-cepts for both natural and implant supportedrestorations. Conventional prosthodontic proto-cols were developed to aid in the diagnosis, treat-ment planning, and laboratory phase of the recon-struction. These included conventional periapicalradiographs, panoramic radiographs, oral exam -ination, and mounted, articulated study casts. The clinician was then expected to assess severalimportant aspects of the patient’s anatomical pres-entation including vertical dimension of occlusion,lip support, phonetics, smile line, overjet, overbite,ridge contours, and a basic understanding of theunderlying bone structures. The accumulation ofpreliminary data afforded by conventional diag-nostics provided a foundation to prepare a courseof treatment for the patient. However, the conven-tional review of findings was based upon a two- dimensional assessment of the actual patient’sbone anatomy. To fully understand each individualpatient’s presentation, this article provided clini-cians with an appreciation of various innovativevirtual, three-dimensional tools based upon the useof advanced three dimensional imaging modalitiesfor both removable and fixed prosthetic treatmentalternatives.

The application of CBCT and interactive treat-ment planning software, empowers clinicians withan accurate understanding of the three-dimen-sional anatomic reality for our patients as an aid in providing state-of-the-art treatment. Implantswill be better positioned, with fewer surgical andrestorative complications, and reduced laboratoryremakes based upon these improved diagnostic

tools. The benefits will enable clinicians to betterunderstand the relationship between patientanatomy and the desired restorative outcomes, in the process of achieving true restorative drivenimplant reconstruction. The ability to utilize digitalimaging and treatment planning technology is nowwithin the reach of most clinicians through the various software products that are on the market.In addition there are many third party outletsthrough internet portals that enable clinicians toupload their DICOM data for evaluation, process-ing, treatment planning, and even surgical tem-plate fabrication without actually owning the planning software. New paradigms have been es-tablished that in the author’s opinion will continueto redefine the process of diagnosis and treatmentplanning dental implant procedures, both remov-able and fixed alternatives for years to come. Pleaseremember though that the “template is only asgood as the plan”._

Figs. 20a–c_The template designrevealing the guide tubes (a); three blue fixation pins (b); and the entire complex on the 3-D reconstructed volume (c).

I 11cone beam2_2015


Dr Scott D. Ganzmaintains a private practice for prosthodontics,maxillofacial prosthetics, and implant dentistry in Fort Lee, New Jersey, USA. He has served asPresident of the NJ Section of the American Collegeof Prosthodontists and the Computer Aided Implan-tology Academy (CAI). He has served as Presidentof the New Jersey Section of the American Collegeof Prosthodontists and of the Computer Aided Implantology Academy.

Dr Ganz delivers presentations worldwide on both the surgical and restorative phases of implantdentistry, and has published extensively on thesetopics. He is considered one of America’s leadingexperts in the evolution of computer utilisation andinteractive software for diagnostic and treatmentplanning applications using CT and newer-generation CBCT imaging modalities.

cone beam_about the author

I technique _ first part of an implant treatment

_Introduction

Faced by a missing lateral incisor, practitioners often consider a wide range of issues and are alsofaced by numerous treatment options:

_in a young patient, faced with a unilateral or bilat-eral agenesis, he has to choose between an ortho-dontic treatment that either opens up the spaces orcloses them. This decision, when taken early in theoverall treatment, will affect both the patient andtheir caregiver for a long time (Fig. 1);

_in an adult patient, this is a consequence of bone,physiological, traumatic or infectious resorption,which will result in a decision whether or not to rec-ommend a bone reconstruction or a gingival aug-mentation.

In every situation, the results will be judged by thepatient and those around him. Since the lateral max-illary incisor is an integral part of the smile, aestheticexpectations are generally very high and, if the resultsdo not meet the expectations, disappointment can bepowerfully felt.

When describing the different treatment stages, a number of pitfalls and difficulties will be highlightedand advice and clinical protocols will be given, in or-der to ensure that the results of this implant/pros-thetic treatment are predictable and as aestheticallyattractive as possible. This first article is concernedwith these issues as regards the preprosthetic stages;the second will consider the most important aspectsof the prosthetic stages as well as aesthetic outcomesand their evolution over the long term.

Fig. 1_Agenesis of 22, opening of orthodontic space.

Fig. 2_Line of intermediate smile.The smile uncovers the papillae and

reaches the collar of the incisors (12 and 22 are supported by implants).

Fig. 3a_Average forms, types and dimensions of the lateral incisor according to Papathanassiou.6

Overall height: 21mm, coronalheight: 9 mm, radical height: 12 mm,

mesio-distal cervical diameter: 5 mm, mesio-distal coronal diameter:

6.5 mm, vestibular-lingual cervicaldiameter: 5 mm, vestibular-lingual

coronal diameter: 6.5 mm.Fig. 3b_Proximal view photographs

showing 10 anatomical variants oflateral maxillary incisors described

by the author.6

Lateral maxillary incisor implant –Key issues for aesthetic successAuthors_ Drs Philippe Russe & Patrick Limbour, France


Fig. 1 Fig. 2

Fig. 3a Fig. 3b

technique _ first part of an implant treatment I

Anamnesis

Once the usual contraindications for oral and implant surgery have been eliminated, particular at-tention should be given to the patient’s answers con-cerning their smoking habits. Indeed, meta-analysisgive an accurate picture of the consequences ofsmoking, with increases of:

_peri-implantitis1, 2 and bone loss2; _failure rates.3

The conclusions of Snider et al.4 can provide recom-mendations for the practitioner faced with a patientwho is a smoker:

_the best is to ask the patient to stop smoking...;_if this approach is not acted on, then the patient

must be warned of the increased risk of failure andof postoperative complications.

This last issue is important, as smoking can be con-sidered a lost opportunity as far as implant treatmentis concerned.

“It is preferable to avoid patients thatare smokers.”

_Clinical examination

The smile line

When replacing a tooth in an aesthetic region,understanding the location of the smile line is oneof the determining issues during the clinical ex-amination. There are two factors to consider: theexposure of papillae and visibility of the collar ofthe lateral incisor, and there is one significantproblem: any aesthetic deficit experienced by thepatient tends to make them change their smileline, which can happen more or less as a consciousprocess and this can be a source of significant errors. Analysis of gingival composition is also adetermining issue in positioning the collar of thelateral incisors in a location that is aestheticallyoptimal. The gull-wing profile, where the collar ofthe lateral incisors is slightly more coronal thanthat of the front teeth or the canine teeth, is con-sidered to be more attractive according to Chiche5

(Fig. 2).

Dental aesthetics

As regards dental aesthetics, the proportions ofthe proposed implant supported tooth can reflect twodifferent scenarios:

Fig. 4_According to Levin, following the golden ratio, the widthof the lateral incisor y = 0.62 x and,for Preston, it is 0.66 x (images fromPapathanassiou).6

Fig. 5_Evidence of bone deficit at 22(case shown in Fig.1).6

I 13cone beam2_2015

Fig. 6_Simulation of location of3mm6 implant in cross section (case shown in Fig.1).6

Fig. 7_Evidence of radicular convergence.Fig. 8_Orthodontic layout of implant corridor.

Fig. 4 Fig. 5

Fig. 6 Fig. 7 Fig. 8


_there is a unilateral missing tooth and the contro-lateral incisor has normal and aesthetically pleasingproportions. The objective will be to create a lateralincisor implant that is a mirror image;

_with the same situation but where the controlateralincisor is small; this is a situation that occurs fre-quently in unilateral agenesis where the incisor thatis present is riziform or, if there is agenesis of bothlateral incisors, the clinical examination shouldgather the information required to decide on the dimensions and coronal axes of the proposed lateralincisors. An analysis of the occlusion and the dimen-sions of the central incisors are the clinical parame-ters that make it possible to establish the character-istics of the planned prosthetic teeth.

The anatomy of the lateral incisor has been the sub-ject of various publications, including, notably, by Pa -pathanassiou6 who defined average dimensions and a typical form (Fig. 3a) and also presented numerousmorphological variants affecting these dimensionsand also other characteristics such as the crown/rootratio and the coronal and root axes (Fig. 3b). These mor-phological criteria, which can now be found using 3-Dimaging, have had a significant influence on the loca-tion of implants in all spatial planes in order to achievethe goal of harmony of form and dimension. Otherpublications, such as those by Levin7 and Preston8

make it possible to estimate the width of absent lateralincisors on the basis of the central incisors (Fig. 4).

“Establish the ideal width and orientation of the planned

prosthetic crown.”

Implant location

A clinically significant deficit signals the needfor reconstruction of hard tissue but, conversely, a site without a tooth with no loss of volume shouldbe subjected to a three-dimensional X-ray, as thicksoft tissue can hide a lack of hard tissue (Fig. 5). A thin tissue biotype or a lack of attached gingivacan be a sign that gingival augmentation surgerywill be required, particularly if a bone graft needs tobe performed.

Occlusion

For orthodontic treatments, the anterior guid-ance should be analyzed carefully. It can be tempt-ing to increase the perimeter of the maxillary arcade in order to obtain, at the least, implant cor-ridors that are sufficiently wide at the level of 12or 22. However, an overjet will make it very likelythat the natural teeth will move in relation to theimplant prosthesis with highly negative conse-quences for the sustainability of the cosmetic out-come.

Documentation

Taking photographs at the start of the treat-ment will make it possible to maintain a record ofthe initial condition, which is always useful if thereare medical/legal problems at the end of the treat-ment. In addition, the images often make it possi-ble to see problems relating to width, axis or asym-metry that sometimes go unnoticed during a clin-ical examination.

“Check anterior guidance and absenceof overjet.”

Fig. 9_Diastemas created around a riziform tooth to obtain a space

of 6mm.

Figs. 10a & b_Centered location of zenith of 22 (a) (arrow)

to be taken into account when making the crown 12 (b).


Fig. 9

Fig. 10a Fig. 10b


_Complementary tests

2-D imaging

Panoramic X-rays or retroalveolar radiographymake it possible to check the depth of implantablebone in relation to the floor of the nasal cavity, thebone level in relation to that of adjacent teeth andthe parallelism of the central incisor and canine.

3-D imaging

3-D imaging is required to check the vestibularpalatal dimensions of the bone crest. There are threepossibilities:

_the crest is sufficiently wide to take an implant with-out any bone augmentation;

_the crest is narrow, bone augmentation is requiredprior to siting the implant (Fig. 6);

_intermediate situations where the siting of the im-plant will be accompanied either by bone splitting orby guided bone regeneration.

_Orthodontic preparation

When the adjacent teeth present apical conver-gence, the orthodontic preparation should create a mesio-distal dimension at the level of the root thatallows the implant to pass with a margin of at least1mm of bone (Figs. 7 & 8). Where there is a controlat-eral incisor of a normal size, the rule for the ortho-dontist is to measure the width of that tooth carefullyand to recreate the same width in the crown of theplanned implant. Where the controlateral incisor isriziform, the orthodontist should plan the future faceof the tooth in order to achieve two laterals with thesame shape.

Diastemas around the riziform tooth make it pos-sible to achieve a smile that, in the end, is almost sym-metrical (Fig. 9). The riziform incisor does not have tobe in the centre of the space but should be positionedin such a way that the papillae and the future zenithof the tooth are optimized. The zenith should be lo-cated 0.4mm distal from the centre of the tooth for alateral incisor, according to Chu et al.9 (Figs. 10a & b).

Fig. 11_Cortical graft in place,shaped to support future papillae(case as shown in Fig. 1).Fig. 12_X-ray result, compare withFig. 6.Fig. 13_Clinical outcome 5 monthsafter the graft. Compare with Fig. 11.Fig. 14_3 mm diameter Nobel Activeimplant.

Figs. 15a & b_Papillary view (b) X-ray view (a), 2 years after the insertion of the implant.

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Fig. 15a Fig. 15b

Fig. 11 Fig. 12 Fig. 13 Fig. 14


Sometimes, a zenith situated more than 1mm from a line between the collars of the central incisor and the canine should be surgically altered by coronallengthening as a lateral incisor that is too short canalso be aesthetically unacceptable.

“The orthodontist should anticipate the future prosthetic morphology of

the riziform incisor.”

_Hard tissue augmentation

Where a bone reconstruction is indicated, thisshould take into account one of the key factors for theoverall cosmetic outcome: restoration of papillarysupport in order to avoid any unsightly black trianglesbetween the lateral incisor and the adjacent teeth orany concave area above the implant crown that wouldcreate an ugly shadow.

The cortical graft, taken from the chin or the ex-ternal oblique, should be formed in such a way as toprovide support for the gingival papillae (Fig. 11). Gapsunder and around the graft should be filled with cortical bone particles, crushed from the chin block orlateral mandibular area using a bone mill.

The attachment must be reliable. This is done using two 1.6mm diameter osteosynthesis screws(Fig. 12). Autografts take about 5 months to heal. Ide-ally, the implant should be inserted between 4.5 and5.5 months after the graft (Fig. 13).

“Fully reconstruct papillary support.”

_Insertion of implant

Choice of implant

The mesio-distal dimension of the gap will deter-mine the choice of the implant. When this is close to or less than the average size of 6.5mm, the bone andpapillary volume around standard size implants will be limited. According to Hasan et al.10 and Bourauel et al.,11 the disadvantage of small diameter implants isthat they transmit higher stresses to the crestal bonethan do standard implants. When replacing a lateralmaxillary incisor, it is possible to arrange both the an-terior guidance and the deduction in such a way as tomake them largely affect the natural teeth, in the ab-sence of any significant malpositioning, and in thisway reduce the stresses applied to the implants. Underthese conditions, small diameter implants have theadvantage of increasing surrounding residual bonevolume as well as space available for papillary healing.

In a forthcoming study of 120 Nobel Active 3mmdiameter implants, one of the conclusions confirmedthe importance of these small diameter implants asregards the additional height of the papillae, result-ing in an improvement in the Fürhauser pink aestheticscore12 (Figs. 14, 15a & b).

“Favor small diameter implants.”

Fig. 16_Mobile Anyray 2 (Vatech) X-ray generator.

Fig. 17_Intraoperative X-ray, Precision Drill inlay (left on picture)

and in situ (right on picture).Fig. 18_Clinical outcome 5 monthsafter the graft. Postoperative X-ray

Nobel Active 3/0 implant and 15° abutment in place.

Fig. 19_Initial situation.Fig. 20_De-epithelialisation of

a palatal flap into a diamond shape.Fig. 21_Unfoldment of palatal flap,

vestibular edge.


Fig. 16 Fig. 17 Fig. 18

Fig. 19 Fig. 20 Fig. 21


3-D positioning

As regards replacement of a lateral maxillary inci-sor, the tolerances for the location of the implant arevery small because of the narrow width of the implantcorridor. Two recent meta-analysis13,14 concerningthe precision of surgical guides resulting from 3-Dimagery, even if these do not apply specifically to thelateral incisor replacement, has found a deviation inthe order of a millimetre at the point the implantemerges and 4 to 5 degrees as regards the drilling axis.For Van Assche et al.,14 the average imprecision at theapex of the implant is 1.24mm.

Since these measurements are incompatible witha 12 or 22 implant corridor, it is important to check thefirst drill hole(s) during the operation, whether the

surgery is guided or being carried out freehand. If the implant clinic does not have retroalveolar X-rayequipment, portable generators such as the Anyray 2(Vatech) are available on the market, which allow youto produce intraoperative images (Fig. 16).

In this context the Precision Drill from the NobelBiocare kits is particularly helpful. Its sharp point pro-vides considerable precision at the point of entry andits small dimensions make it possible to correct anydeviations from the ideal axis occurring during thefirst drilling (Fig. 17).

In the vestibular palatal plane, it is essential toprepare a prosthetic treatment plan before insertingthe implant because the positioning requirementsdiffer:

Fig. 22_Creation of flap envelope,Swann-Morton blade through the envelope. SM 63, inlaid with transparency.Fig. 23_Passage of suture throughthe envelope.Fig. 24_The palatal flap is folded into the vestibular envelope using a suture thread.Fig. 25_Tissue integration with ceramic crown.Fig. 26_Vestibular bulge obtainedwith modified flap.

Figs. 27a-c_Clinical and X-rayviews, vitroceramic in place.

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Fig. 22 Fig. 23 Fig. 24

Fig. 25 Fig. 26



_for a screwed prosthesis, the axis of the implant isvery strictly determined by the point in the cingulumwhere the screw emerges;

_with a cemented prosthesis, the tolerance is slightlygreater as it is possible to make a correction to theaxis by an abutment angled up to 15 degrees or by a Procera type individualized abutment (Fig. 18).

“Position the implant underX-ray monitoring.”

_Soft tissue management

Whether the soft tissue management is carried out at the time the implant is put in place or when it is exposed, the choice of surgical technique dependson an examination of the initial situation:

_horizontal deficit of soft tissue that could result inthe underlying titanium being visible;

_vertical deficit in the papillae that could result in unsightly black triangles.

Different surgical techniques can be used, de-pending on these deficits, which are taken from threepublications: the roll flap developed by Abrams,15

the envelope technique of Peter Raetzke16 and CarlMisch’s split-finger:17

_if there is just a horizontal deficit, a modified rolledflap6 can be carried out, without separation of papil-lae and without vestibular incisions, the palatal flapbeing folded into an envelope flap (Figs. 19 to 25).The attraction of this technique for the patient isthat a second operation site to take a graft is not required. In addition, it makes it possible to recreatea root eminence, considered already 20 years ago by Silverstein and Lefkove18 to be an important fac-tor for the aesthetic outcome (Figs. 26 & 27a to c);

_where there is a vertical deficit, a crestal W-shapedincision as described by Carl Misch17 is indicated. This makes it possible to recreate an anatomical gin-gival architecture while, as a first step, creating twovestibular neo-papillae (Fig. 28). After separatingthe sections, the palatal tissue (finger) is divided intotwo to make two palatal half-papillae, joined one onone with their vestibular counterparts (Fig. 29);

_where there is a combined deficit, the same incisionsare combined with a buried connective vestibulargraft. Provided that there is sufficient volume, thegraft is taken from the maxillary tuberosity, sincethis area has the advantage of providing graft tissuethat is more dense, opaque and less adipose than thepalate and, in addition, results in less postoperativepain. If the graft is transferred in a V- or Y-shape, it can support the newly formed papillae. The shapeof the palatal incision can be modified to a Y-shapeto assist rotation of the palatal half papilla (Fig. 31).

If the thickness of the buccal gingival tissues hasnot been augmented or if collagen substitutes areused that do not have the opacity characteristics oftuberosity connective tissue, the aesthetic outcomecan be compromised. If there is recession of the exter-nal table or the titanium abutment under thin con-

Fig. 28_Initial incision creating two vestibular half papillae.

Fig. 29_Suture of half papillae (situation in Fig. 1).

Fig. 30_De-epithelialisation tuberosity graft.


Fig. 28 Fig. 29

Fig. 30


nective tissue, the grey titanium colour can be seenthrough the gum as a grey halo above the crown col-lar, which is detrimental to the aesthetic appearance(Figs. 32 & 33).

“Systematically augment the thickness of buccal connective tissue.”

_Conclusion

The aesthetic fundamentals for an implant are inthe preprosthetic surgical stages of the treatment.Any approximation in the location of the implant insuch a narrow implant corridor, any lack of support for papillae or any deficiency in the thickness of hardor soft tissues, will result in aesthetic problems. Theprosthetic stages allow optimisation of the result asregards the gingival context but any error in the sur-gical stage will often be impossible to correct duringthe prosthetic stages. For this reason it is vital to ap-proach this first part of the implant treatment for alateral incisor with thoroughness and precision._

Editorial note: A complete list of references is availablefrom the publisher.

This article was originally published in the Éditions CdPprosthetic journal, No 167, September 2014 and the ClinicalMasters Magazine No 1/2015.

Fig. 31_Insertion of connective graft buried under the papillae.Fig. 32_Clinical outcome in a case of gummy smile.

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Dr Philippe Russe, former assistant at the Reims University and Hospital.He runs his private practice inReims, France.

Dr Patrick Limbour, MCU-PH, Head of departmentof oral surgery, Pontchaillou University Hospital,Rennes, France.

cone beam_about the authors

Fig. 33_Insufficient soft tissue thick-ness alters the chromatic outcome.

Fig. 31 Fig. 32

Fig. 33

I case report _ CBCT in diagnosis

_The limited bone volumeoften present in anteriorzones means that the use of standard-diameter im-plants is not always possible. In order to avoid bonegrafts, we use narrow implants with satisfactory results.

By reviewing four clinical cases, the author demon-strates how the replacement of maxillary lateral inci-sors and mandibular incisors can be considerably simplified through the use of small-diameter implants,while providing results that are entirely satisfactory to the patient both aesthetically and functionally.

_Case 1: Small vestibulo-palatal bone volume

A 42-year-old patient presented with bilateralagenesis of the maxillary lateral incisors (Fig. 1). Thesmile line analysis indicated a low smile line associ-ated with toned lips. The oral examination showedsmall mesiodistal spaces in regions #12 and 22, aswell as a rather thick gingival biotype.

The patient’s reason for consultation was aes-thetic. After discussing alternative solutions withthe patient—orthodontic space closure, replace-ment with fixed prostheses (bridge or crowns)—thepatient ultimately chose implant-supported pros-theses. We worked in close collaboration with an or-thodontist colleague, Dr Frédéric Chalas, who tookresponsibility for adapting the mesiodistal spaces,which were required for the placement of the en-dosteal implants in regions #12 and 22. We saw thepatient again after 14 months of orthodontic treat-ment (Figs. 2a & b), which consisted of wearing a multi-bracket appliance to open up the spaces at

Fig. 1_Baseline panoramic radiograph.

Figs. 2a & b_The clinical situation atthe end of orthodontic treatment.

Figs. 3a–d_CT scan cross-sectionsshowing the small exploitable volume

on the vestibulo-palatal plane.

Small-diameter implants forsingle anterior restorationsAuthor_ Dr Richard Marcelat, France


Fig. 1

Fig. 2a Fig. 2b

Fig. 3a Fig. 3b Fig. 3c Fig. 3d

case report _ CBCT in diagnosis I

regions #12 and 22, while aligning the apices of theadjacent teeth.

CT scan analysis and choice of implants

The CT scan cross-sections of regions #12 and 22showed a limited bone volume on the vestibulo-palatal plane, which would not have allowed forstandard-diameter implants to be placed withoutthe use of a bone augmentation technique. The cortical bone, however, was preserved (Figs. 3a–4).

Narrow implants (Axiom 2.8, Anthogyr) wereused for this restoration. Axiom 2.8 has been de-signed exclusively to replace mandibular incisorsand maxillary lateral incisors. It is equipped with athree-degree Morse taper connection system withan integrated switching platform. The special fea-ture of the system is that the abutment is impactedwithout a transfixation screw. Abutments are avail-able in several gingival heights and angulations,making Axiom 2.8 adaptable for any prosthetic situation.

Placing the implants and fabricating the prostheses

Placement of the implants in regions #12 and 22was done during the same procedure. Under localanaesthesia, two 2.8 mm x 10 mm implants wereplaced 0.5 mm sub-crestally (Figs. 5a–d). Very lightdrilling enabled bone condensation of the specificsites. The correct 3-D positioning of the implant wasvital for the final aesthetic result. Temporary crownswere attached to the orthodontic arch wire and leftin place for the three months of osseointegration inorder to ensure post-orthodontic fixation of theteeth.

Three months postoperatively, the patient’s brack-ets were removed by the orthodontist and the tem-porary crowns fabricated directly on the PEEK healingplugs (Fig. 6). The basal surface of the temporarycrowns was carefully polished.

After a period of two months of gingival matu-ration, which was put to good use by performingdental whitening in an outpatient setting, theprosthetic phase could begin. The implant impres-sions were taken with the pop-in technique (Fig. 7)using an individual impression tray fabricated inthe laboratory. The choice of the most suitableabutment by means of the planning kit by the laboratory was a vital step. In fact, the abutmentsrequired only very slight adjustments or none atall. Having the option of four gingival heights andfour angulations enabled us to adapt to any clini-cal situation.

The laboratory prepared the metal–ceramiccrowns (Figs. 8a–9). The prostheses were verified inthe mouth and then the crowns were fixed to theabutment with Fuji PLUS cement (GC) outside ofthe mouth (Figs. 10–13b). This allowed for perfectcontrol of excess cement and guarded against anyrisk of gingival inflammation.

The abutment together with the crown was im-pacted with the Safe Lock system, mounted on thechair unit. The Safe Lock system made it possible to control the impaction. The recommended fiveimpactions were applied to seat the prosthesespermanently (Figs. 10–13b). The good aesthetic re-sults were related to the symmetry of the emer-gence profiles. The narrow diameter of the implantwas perfectly adapted to this clinical situation.

Fig. 4_3-D reconstruction of the CT scan cross-sections of the premaxillary zone. The high concavity of the vestibularcortical plates can be observed in regions #12 and 22.

Figs. 5a–d_Pre- and post-op radiographs of regions #12 and 22.Fig. 6_The temporary crowns werefabricated on PEEK healing plugs.

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Fig. 4

Fig. 5a Fig. 5b Fig. 5c Fig. 5d Fig. 6

_Case 2: Limited mesiodistal space and proximityto the apices of the adjacent teeth

A 20-year-old male patient presented with uni -lateral agenesis at region #12. This patient had justfinished his orthodontic treatment. His brackets hadbeen removed several months before. He was wear-ing a removable partial denture while waiting for theplacement of an implant. The periapical radiographicexaminations and CT scan cross-sections showed anextremely small mesiodistal space, especially at thelevel of the apices of the adjacent teeth (Figs. 14–16).

The treatment of this small space required greatprecision during the surgical phase. The insertion axis

was visualized on the 3-D reconstruction of the CT scancross-sections using SIMPLANT software (DENTS PLY).Preoperative periapical radiographs were performedat each drilling sequence.

The treatment of this very small mesiodistal spacewas only made possible by the use of an implant of 2.8 mm in diameter (Axiom 2.8), without which it wouldhave been necessary to resume orthodontic treatmentin order to align the apices of the adjacent teeth. Thatwas not what the young patient desired (Figs. 17 & 18).

_Cases 3 and 4: Small antero-posterior volume

Case 3

A 25-year-old female patient at the end of ortho-dontic treatment presented with unilateral agenesisat region #22. The smile line was moderately high, as-sociated with right–left asymmetry of the positioningof the anterior teeth in relation to the midsagittalplane. The analysis of the CT scan cross-sectionsshowed a small bone volume on the vestibulo-palatalplane (Figs. 19 & 20).

A narrow 2.8 mm × 12 mm implant was placed (Fig. 21a). The orthodontic arch wire served as fixationduring the osseointegration phase and was removedthree months postoperatively. A temporary crown wasfabricated on a PEEK healing plug in order to shape theperi-implant soft tissue. The permanent crown was to be fabricated four months after surgery (Fig. 21b).

Case 4

A 59-year-old patient came to our clinic withtooth #31 missing, which had been managed for

Fig. 7_The impressions were takenwith the pop-in technique.

Figs. 8a & b_Master model with abutments.

Fig. 9_Metal–ceramic crowns on the master model.

Fig. 10_The crowns were seated outside the mouth and

the unit was impacted with the Safe Lock instrument.

Fig. 11_Safe Lock instrument andthe different abutments.

Fig. 12_Diagram showing thenumber of impactions required for

permanent seating of the prostheses.



Fig. 7 Fig. 8a Fig. 8b

Fig. 11Fig. 10Fig. 9

Fig. 12


years with a glued metal brace. Owing to frequent detachment of this prosthesis, the patient desired a fixed prosthetic solution. The periodontal conditionof the surrounding teeth was stable, but the availablebone volume around region #31 on the vestibulo-lin-gual plane was small. There were two surgical options:(a) augment the bone and place a standard implant,or (b) use a narrow implant. A 2.8 mm × 10 mm im-plant was placed. After a healing period of three

months, a standard metal–ceramic prosthesis wasfabricated (Figs. 22–24).

_Discussion

The Axiom 2.8 implant makes it possible to restoresingle teeth in the incisal area using implant-sup-ported prostheses in cases in which there is a smallmesiodistal space. Having narrow implants available

Figs. 13a & b_Standard crowns on implants #12 and 22 in the mouth.Figs. 14–16_The periapical radiographs and 3-D reconstructionsshowed the proximity of the apices of the adjacent teeth to the agenesisin region #12.Figs. 17 & 18_The Axiom 2.8 implantand a suitable abutment.

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Fig. 15 Fig. 16

Fig. 17 Fig. 18


allowed us to avoid bone augmentation by guidedbone regeneration or an onlay graft—techniques thatcan be restrictive for patients and are not always accepted.

Small space, proximity to the apices of the adja-cent teeth and small bone volume present surgicaldifficulties in the ideal positioning of implants. We believe it is important to use abutment teeth that in-tegrate platform shifting, including on implants witha small diameter. The large choice of abutments, interms of gingival height and angulation, makes it possible to adapt to any clinical situation.

_Conclusion

Although we do not have the clinical retrospectionto offer our opinion on the strength and long-termdurability of implants with small diameters at thispoint, the average success rate of these narrow im-plants is comparable to that of standard implants. Theuse of narrow implants for the management of singleanterior restorations, especially for the replacementof mandibular incisors and maxillary lateral incisors,constitutes an important option that makes it possi-ble to simplify the surgical approach, sparing patientsfrom more invasive techniques and securing the sur-gical procedure in relation to the roots of adjacentteeth._

Acknowledgements: Many thanks to Laurent Bougette fromLaboratoire Créadent in Grabels and Dr Frédéric Chalas inMontélimar in France for the orthodontic treatment of Case 1.

Figs. 19 & 20_Implant planning at the end of orthodontic treatment.

Fig. 21a_The 2.8 mm x 12 mm implant.

Fig. 21b_Appearance 18 months after placement of the prosthesis andafter gingival maturation. Reforming

of the papillae can be observed.

Figs. 22 & 23_Implant planning for a 2.8 mm x 10 mm implant.Fig. 24_The metal–ceramic

prosthesis on the day of seating.


Fig. 23 Fig. 24Fig. 22

Fig. 21bFig. 21a

Dr Richard Marcelathas a DDS in Oral Implantology from the University of Liège and inBasal Implantology from the University of Nice Sophia Antipolis, aswell as a Postgraduate Certificate in Implantology from CURAIO inLyon in France.

He can be contacted at [email protected]

cone beam_about the author

Fig. 19 Fig. 20


_Introduction

Besides adequate knowledge of root canal morphol-ogy in general, it is of utmost importance to evaluateeach individual case for aberrant anatomy and to iden-tify any morphological variation before performing andduring an endodontic procedure on such teeth. In clin-ical practice, conventional radiography with the assis-tance of an operating microscope is the most commonmethod for evaluating root canal anatomy. However, ithas been shown that their use does not reveal allanatomical details. Recently introduced and developedcone beam computed tomography (CBCT) for dental usehas proved to be more accurate in detecting root canalmorphology, especially in maxillary posterior teeth. Oneof the most unusual and rare aberrations of toothanatomy is a maxillary second molar with two separatedpalatal roots. This article presents the case of such a pa-tient, who presented ten years after another such pa-tient had been recorded.

_Case report

A 26-year-old male patient sought treatment at the Department of Restorative Odontology and Endodontics at the University of Belgrade with thefollowing chief symptoms, which had persisted forseveral weeks already:

_spontaneous dull, mild and intermittent pain in theregion of the left maxillary molar;

_moderate sensation of pain when biting hard food.

Additional information was acquired from furtheranamnesis:

_There were no other symptoms, and no irradiation ofexisting pain.

_The patient recalled that a root canal therapy had beenperformed on the same tooth several years before.

_He also recalled that two teeth on the same side ofthe upper jaw had been extracted at least ten yearsbefore.

Furthermore, clinical examination confirmed thefollowing:

_only the second molar, #27, with an extensive amal-gam restoration, was present in the left maxilla;

_moderate sensitivity on vertical percussion of thebuccal cusps, and painful response to percussion ofthe mesiopalatal cusp;

_no sensitivity on digital palpation on the vestibularor palatal side;

_both hot–cold and electric vitality tests were nega-tive;

_no pathological mobility of the tooth.

The diagnostic periapical radiograph (bisectingangle technique) showed

Diagnosis and management of a rare case of a maxillary secondmolar with two palatal roots Supported by conventional radiography and CBCTAuthor_ Ass. Prof. Katarina Beljic-Ivanovic, Serbia


Fig. 1_Straight-line access to all four root canals of tooth #27.Fig. 2_Intra-oral radiograph

indicating all four root canals of tooth #27.

Fig. 3_Obturated root canal orifices of tooth #27.

Fig. 4_Intra-oral radiograph of tooth#27 lacking periapical information.

Fig. 1 Fig. 2

Fig. 3 Fig. 4


_partly obturated palatal and mesiobuccal (MB) rootcanals and an unfilled distobuccal (DB) root canal;

_slight radiolucency around the palatal root apex; nodistinctive border towards the surrounding maxil-lary bone structure.

The necessity of an endodontic retreatment of thetooth was explained in detail to the patient, who ac-cepted the suggested therapeutic procedure and thegeneral schedule for further appointments.

Treatment procedure

The old amalgam restoration and the phosphatecement base were completely removed, and the cavity walls were additionally prepared to enableclear visibility and straight-line access to all root canalorifices. The orifices of the palatal and MB root canalshad been blocked with obturation material, presum-ably iodine phosphate cement and a gutta-perchacone. Approximately 3 mm distal from the orifice ofthe obturated palatal root canal, another oval, crack-like orifice could be seen, with the appearance of aperforation. Further assessment of the pulp chamberfloor was performed with 4.5 x magnifying loupes andthe Endodontic Probe Orifice Opener (DENTSPLYMaillefer). Using the probe and a #10 K-file to nego-tiate the flat oval orifice, the presence of a secondpalatal (distopalatal, DP) root canal was detected.

The orifice of the DB root canal was hidden underbrownish deposits of tertiary dentine, located about2 mm distal from the obturated MB canal orifice andapproximately 2 mm buccal from the DP canal orifice.The DB canal orifice was negotiated and slightlywidened with the Orifice Opener, ensuring that itcould be easily detected in a further procedure. Thesecond MB root canal could not be found with metic-ulous searching under loupes and the application ofa decalcifying solution (17 % EDTA).

After consultation and receiving the approval ofthe patient, it was decided to conduct the entire pro-

cedure in at least two sessions. First, the root fillingmaterial in the MB and mesiopalatal (MP) root canalswas removed using rotating NiTi files, ProTaper D1,D2 and D3 files (DENTSPLY Maillefer), and manual H-files (DENTSPLY Maillefer). Further instrumenta-tion of those canals was performed using WaveOnefiles (DENTSPLY Maillefer) with reciprocating motion:the MP canal with black (#40) and the MB canal withred (#25). The working length was determined andchecked throughout the entire procedure using anelectronic apex locator (RomiApex A-15, Romidan).

The DP root canal was then negotiated and a glide path was created approximately 1–1.5 mm shy of the apical foramen using #10 and 15 K-files. Thecoronal portion was flared successively with #3 and 2Gates–Glidden drills. The same procedure was per-formed at the DB root canal. Clear visibility and straight-line access were established for all four canals (Fig. 1).

Two intra-oral radiographs were captured fromtwo different horizontal angles with an inserted K-filein each root canal, but only one revealed all four rootcanals (Fig. 2), showing vague contours of the apicalportion of the roots.

A calcium hydroxide dressing was applied at theMP root canal and a paper point, soaked with a 2 %solution of chlorhexidine (R4, Septodont), was left inthe MB root canal. A cotton pellet with chlorhexidine

Figs. 5–7_Axial view of the middlelevel, axial view of the apical level,and sagittal detailed view of tooth#27.

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Fig. 5 Fig. 6

Fig. 7


was left in the pulp chamber and the cavity was thensealed with a temporary filling material.

In the second session, two weeks later, the DP andDB root canals were carefully prepared, applying thesame WaveOne technique as used for the MP and MBroot canals: the DP canal with WaveOne black (#40)and the DB canal with WaveOne red (#25). The work-ing length was determined and checked using thesame electronic apex locator.

Throughout the entire endodontic procedure,2.2 % sodium hypochlorite and 10 % citric acid so-lutions were used as irrigants, successively, in all fourroot canals. Each of the four canals was finally irri-gated with 40 ml of a 2.2 % NaOCl solution, dried andobturated using Acroseal (Septodont) and a singlegutta-percha cone with an adequate taper (DENTS -PLY Maillefer; Fig. 3).

The intra-oral, retro-alveolar radiograph capturedpost-treatment was of relatively poor quality owingto superimposition and interference of the infra-zygomatic arch and adjacent bone structures, andfailed to show the most important apical portions ofthe roots with the correct root canal fillings (Fig. 4).

In agreement with the patient, a CBCT scan was ob-tained, primarily to check the treatment outcome, butalso to document this extremely rare case with much

more accurate and reliable images. The small field ofview (50 x 50 mm) was recommended, and the datawas acquired by SCANORA 3Dx (SOREDEX) immedi-ately after the treatment and at the six-month recall.

The edited images (OnDemand3D, Cybermed)clearly visualized two distinctive palatal roots, their re-lation to the two buccal roots, the adjacent anatomicstructures and, most importantly, the quality of theobturation of all four root canals (Figs. 5–9, arrows).

_Conclusion and key learning points

A careful assessment of the internal anatomy of thepulp chamber is essential for detecting all root canals.

A maxillary second molar with two separate palatalroots is a rare anatomical variation and, according toour records, is detected only once in a decade.

CBCT images provide more accurate and reliableinformation regarding roots and the root canal mor-phology than conventional radiographs are able toprovide. Furthermore, concerning the treatment out-come, CBCT images enable a much more predictableand successful endodontic treatment procedure._

Editorial note: This article is based on the work presented atthe 16th congress of the European Society of Endodontologyin Lisbon in Portugal in 2013.

Figs. 8 & 9_PAN detail, volume-rendered view and

Multi-Planar Reformat view of treatment check-up of tooth #27.


Ass. Prof. Katarina Beljic-Ivanovic is an assistant professor at the Department ofRestorative Odontology andEndodontics at the Facultyof Dental Medicine of theUniversity of Belgrade inSerbia.

cone beam_author

Fig. 8

Fig. 9

I research _ treatment of maxillary radicular cysts

_Introduction

Taking into consideration the active lifestyle ofmost of our working patients with maxillary odon-togenic radicular cysts, such patients require moreminimally invasive interventions that will not disturbtheir usual activities, can be provided in outpatientdepartments (do not require hospitalization), do notlead to typical post-operative complications, do notrequire additional antibacterial load, and do not disturb the natural contour of the soft periodontaltissue in operated area, leading to postoperative aesthetic complications. With new treatment ap-proaches, such as using autologous plasma rich ingrowth factors (PRGF-Endoret, BTI BiotechnologyInstitute), and the development of the Minimally Invasive Surgical Technique,1 there is opportunity for modification of the standard approaches to thetreatment of odontogenic radicular cysts, retainingthe basic principles, but minimizing the invasiveness

of such an operation. Using modern approaches, in-cluding different types of surgical incisions for pre-dictable preservation of periodontal soft tissue post-operatively, cyst cavity preparation with modern devices and choice of suturing technique, it is possi-ble to minimize the typical post-operative complica-tions, the medication load and post-operative gingi-val recession. The use of autologous plasma has beenexplored in periodontology and maxillofacial sur-gery. Since it has a high concentration of biologicallyactive factors and can be used in different forms (liquid, membrane, clot), it can be used in surgeries,including on bone tissue. Based on data on the effectof autologous plasma on inflammatory response,stimulation of osteogenesis and tissue regenerationaccording to the biological pathway, studies todaycontinue to make supporting findings for the use ofautologous plasma. In addition, the use of ultrasonicdevices in dentistry is widespread and ultrasonica-tion can be used during surgery on bone tissue.

Table 1_Patient division into groupsaccording to type of preoperative

preparation.

Interdisciplinary approachto treatment of maxillaryradicular cysts: Minimization of surgical invasiveness and medication loadAuthors_ Prof. Galyna Biloklytska, Dr Vasyl Rybak, Dr Iuliia Braun & Dr Ievgen Fesenko, Ukraine


GROUP Age (years) Sex (F/M) Place of operation Preoperative preparation

Endodontic treatment Anti-inflammatory, anti-oedematous therapy

Main 24–55 2 F, 1 M DSPMC, Kyiv Regional Endodontic root canal treatment with 3 days before: (3 patients) Clinical Hospital _ProTaper _Nimesulid powder 100 mg (o.d.)

_AH Plus _Loratadinum 0.01 mg (o.d.)

Control 1 24–55 3 F, 2 M DSPMC, Kyiv Regional Endodontic root canal treatment with 3 days before:(5 patients) Clinical Hospital _Foredent (SpofaDental) _Nimesulid powder 100 mg (o.d.)

_Endomethasone N (Septodont) _Loratadinum 0.01 mg (o.d.)_phosphate cement

Control 2 24–55 2 F, 2 M Other city policlinics Endodontic root canal treatment with None(4 patients) _Foredent

_Endomethasone_phosphate cement

Control 3 24–55 2 F, 2 M Other city policlinics Endodontic root canal treatment with None(4 patients) _Foredent

_Endomethasone_phosphate cement Table 1

research _ treatment of maxillary radicular cysts I

_Material and methods

Sixteen patients aged 24–55 who had been diag-nosed with maxillary odontogenic radicular cystswere selected for the study and had undergoneetiotropic treatment. The patients were divided intofour groups depending on the treatment providedand the criteria given in Tables 1–3. All patients in the main and Control 1 groups underwent completeclinical and radiographic examination. Data on pa-tients in the Control 2 and 3 groups was collectedfrom a database of city policlinics in Kiev. All of thepatients were divided according to preoperativepreparation and surgical method during cystec-tomy. In the main and Control 1 groups, preoperative endodontic treatment of the involved teeth was performed and temporary splinting was done usingorthodontic buttons attached with a light-curingcomposite (Spectrum TPH, DENTSPLY) and fixed withan elastic ligature without tension. In patients in themain group, venous blood was drawn preoperatively

and autologous plasma was prepared using BTI tech-nology. The prepared material was stored in sterileglass vials until needed.

For surgical access, under local anaesthetic, an intrasulcus incision was performed, as well as a hori-zontal incision, in the area of the interdental papillabase according to the Minimally Invasive Surgical

Figs. 1a–f_A series of CT scans of a 23-year-old patient showing the diagnosed maxillary radicular cyst inthe area of the maxillary right incisorsand canine (teeth #11–13).

Fig. 2_Primary tissue condition and marginal periodontal tissue condition, showing a Class II recession (according to Miller’s classification) on the maxillary rightcanine (tooth #13).

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Fig. 2

Fig. 1a Fig. 1b

Fig. 1c Fig. 1d

Fig. 1e Fig. 1f


Technique and the Modified Papilla PreservationTechnique,2 and vertical incisions were made in the area of the adjacent healthy teeth. The mucope-riosteal flap was formed and raised, and a bone win-dow over the cyst was made using a surgical drilling

bur. The curettage of the cyst cavity and the roots of the involved teeth was performed using a combi-nation of manual and ultrasonic methods (CavitronSelect SPS, DENTSPLY) until complete cavity de-granulation.

Table 2_Patient division into groupsaccording to type of surgical method. Table 3_Patient division into groupsaccording to suturing technique and

post-operative management.

Figs. 3a & b_A series of radiographstaken during the endodontic stage

of treatment. The teeth involved(teeth #11–13) were treated with

ProTaper files (DENTSPLY) and AH Plus (DENTSPLY).

Fig. 4_Fixation of orthodontic buttons on the teeth in the

future surgical area.Fig. 5_The mucoperiosteal flap was

formed and raised. The bone windowover the cystic cavity was made.

The apices of the involved teeth werelocated in the cystic cavity.

Figs. 6a & b_Ultrasonication of thecystic cavity (a) and root surfaces (b).


GROUP Surgical stage

Incision, shape of Treatment of cystic cavity Cystectomy with apicectomy and Filling of cystic cavitymucoperiosteal flap Curettage (method) retrograde filling of root canals

Main Trapezoidal with preservation Standard Standard + Resection + filling with ProRoot MTA PRGF-Endoret (clot, membrane)of interdental papilla and ultrasonicationgingival contour

Control 1 Trapezoidal, semilunar Standard Standard + Resection + filling with ProRoot MTA Bio-Ossultrasonication

Control 2 Trapezoidal, semilunar Standard None Resection + filling with Phosphadent (VladMiVa) Other bone fillers

Control 3 Trapezoidal, semilunar Standard None Resection + retrograde root filling None Table 2

GROUP Suturing method Post-operative managementand material

Standard Proposed method Antibiotics Anti-inflammatory Time of (interrupted sutures) and analgesic therapy suture removal

Main None Polyamide 5.0 None _Nimesulid powder 100 mg (b.i.d. for 5 days) Day 14 _Loratadinum 0.01 mg (o.d. for 5 days)

Control 1 None Polyamide 5.0 Azithromycin 500 mg _Nimesulid powder 100 mg (b.i.d. for 5 days) Day 14 (1 tablet per day for 3 days) _Loratadinum 0.01 mg (o.d. for 5 days)

Control 2 _Polyamide 3.0–4.0 None Ceftriaxone 500 mg _Nimesulid powder 100 mg (b.i.d. for 5 days) Day 7–10 _Polyester 3.0–4.0 (1 tablet b.i.d. for 7 days) _Loratadinum 0.01 mg (o.d. for 5 days)

Control 3 _Polyamide 3.0–4.0 None Ceftriaxone 500 mg _Nimesulid powder 100 mg (b.i.d. for 5 days) Day 7–10 _Polyester 3.0–4.0 (1 tablet b.i.d. for 7 days) _Loratadinum 0.01 mg (o.d. for 5 days) Table 3

Fig. 3a Fig. 3b

Fig. 4 Fig. 5

Fig. 6a Fig. 6b


In the main and Control 1 groups, apicectomy ofthe involved teeth was performed. Before retrograderoot canal filling (ProRoot MTA, DENTSPLY), the re-sectioned root canal cavities were prepared by ultra-sonication (Cavitron Select SPS). In the main group,after antiseptic irrigation of the cyst cavity (Decasan,Yuria-Pharm), an intrafocus, grid-like osteotomywas performed using a small round bur (2mm) andstaggered small perforations were made, achieving

removal of 50 % of the cortical bone layer surround-ing the cyst. The prepared cavity was completely filledwith PRGF autologous plasma in the form of a gel-likeclot (mixed with blood clots collected during surgery)and a PRGF membrane, which completely covered thevestibular aspect of the defect. In the Control 1 group,the cyst cavity was filled using a xenogeneic bonesubstitute material (Bio-Oss, Geistlich) mixed withblood.

Figs. 7a & b_The prepared bone cavity after degranulation usingcurettes and ultrasonication, showing the bone cavity contours (a).Apicoectomy of teeth #11–13 (b). Figs. 8a–d_Ultrasonication of theroot cement (a & b). Ultrasonicationof the resected roots before retrograde filling (c). Cavitron Select SPS (d).

Figs. 9a & b_The osteotomy (a) andcorticotomy (b).Fig. 10_Prepared PRGF-Endoret clot.Fig. 11_Filling of the bone cavity withthe PRGF-Endoret clot.

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Fig. 7a Fig. 7b

Fig. 8a Fig. 8b

Fig. 8c Fig. 8d

Fig. 9a Fig. 9b

Fig. 10 Fig. 11


The flap was then adapted and repositioned coro-nally with the marginal flap edge advanced 0.2–0.5 mmcoronally to cement-enamel junction (CEJ). The sutur-ing technique used in both groups was the same. Thewound was sutured using a modified internal mat-tress suture.1,3,4 The proximal ends of the sutures wereknotted on to the orthodontic buttons, the suture inthe interdental space was attached to two buttons on the adjacent teeth, which provided additionalcoronal flap repositioning and complete closure of thepreviously opened periodontium, as well as long-term

blood clot stability. Interrupted sutures were used inthe area of the vertical incisions until complete woundclosure. The elastic ligature was attached to the ortho-dontic buttons without tension, providing additionalimmobilization of the teeth.

The surgical site was then covered with a cellulosedressing (Reso-Pac, Hager & Werken). The pressurebandage was prescribed for patients for a period ofthree nights. The post-operative medications pre-scribed are shown in Table 3 for each group. In the

Figs. 12a & b_Sutured wound according to the proposed method.

Figs. 13a & b_Post-op condition after one week. The suture tension is reduced and the gingival surface

is covered with a thin fibrinous matrix(a). The interdental papilla has been

replaced completely (b).Fig. 14_Post-op condition after one

month. There is complete healing of the marginal periodontal tissue.

The tissue in the surgical area is a more saturated colour due to

revascularization and visible superficial vessels. Signs of soft

tissue maturation and volume reconstruction.

Figs. 15a & b_Tissue condition aftertwo months. Complete soft-tissue

healing and maturation. The contourof the marginal periodontal tissue

is undergoing final maturation. Tissue regeneration continues

owing to primary fixed position after suturing. The marginal periodontal

contour has been restored accordingto the initial tissue position (a).

A radiograph of the healing bone,showing the reduction of the bone

cavity owing to peripheral ossificationprocesses in the bone (b).


Fig. 12a Fig. 12b

Fig. 13a Fig. 13b

Fig. 14 Fig. 15a Fig. 15b

Fig. 16 Fig. 17


main and Control 1 groups, 0.12 % chlorhexidine wasprescribed (rising three times per day) for three weekspost-operatively for oral hygiene. The treatment ofthe Control 2 and 3 groups was provided in other clin-ics, and the data collection and details regarding thetreatment process were obtained from the archives of the respective city clinics. The anamnesis and post-operative description of the soft-tissue conditionwere done at the Dental Training Centre (DSPMC) atP.L. Shupyk National Medical Academy of Postgrad-uate Education in Kiev.

_Results

Our preliminary results during observation showedthat the healing process in the main group was notaccompanied by pain, owing to wound stability dueto the suturing technique used. Only 33 % of pa-tients in the main group experienced pain on Day 1and 2 post-operatively, compared with 50–60 % ofpatients in all three control groups who experiencedpain for 1–7 days. Also post-operative facial oedemawas observed in all patients, but its duration was theshortest in all three patients in the main group, last-ing 1–2 days, with a significant decrease on the third

day. In patients in all three control groups, generalantibiotic therapy was prescribed; in spite of this, in25–50 % of patients, a slight temperature increasewas observed (from 37.0 °C to 37.5 °C) 1–2 dayspost-operatively. In the main group, general an-tibiotic therapy was not prescribed and the tem-perature increase was absent in all patients. Pa-tients in all three control groups reported slight dis-comfort during eating 1–7 days post-operatively,but this was completely absent in patients in themain group.

During examination of post-operative ossifica-tion, the preliminary observation three weeks post-operatively was a decrease in the cystic cavity bonedefect due to peripheral defect ossification corre-sponding to physiological mechanisms. Post-oper-ative recession occurred in 40 % of patients in theControl 1 group and in 87.5 % of patients in the Control 2 and 3 groups after one month. The ratewas 20 % and 87.5 %, respectively, after two monthsand 20 % and 75 %, respectively, after three months.In patients in the main group, marginal contour sta-bility was observed and absence of recession afterthree months post-operatively.

Fig. 16_A panoramic radiograph six months post-op. In the area of the defect, new bone formation canbe observed. The apical filling withProRoot MTA can be seen in teeth #11and 12, and no signs of inflammationcan be seen in the surgical area.Fig. 17_A radiograph of teeth#11–13, showing new bone formation and a reduction of the defect contour.Figs. 18a–c_A CT scan of tooth #11six months post-op in the area of theprevious defect (a). The bone densityis 135.685 HU (b). In comparison, the cortical bone density in the areaof tooth #21 is 716 HU (c).

Table 4_Details of post-operativeclinical manifestations.

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GROUP Post-operative manifestations

Pain (%) Facial oedema (%) Temperature Discomfort during Tooth mobility (days) Gingival recessionincrease (%) eating (days) Month 1 Month 2 Month 3

Main 33 % on 100 % on Day 1–3 None Day 1–3 None None None NoneDay 1–2 and decrease of

symptoms on Day 4–7

Control 1 60 % on 100 % on Day 5–7 40 % on Day 1–3 Day 1–3 None 40 % 20 % 20 %Day 1–5

Control 2 50 % on 100 % on Day 5–7 50 % on Day 1–3 Day 5–7 25% on Day 1–3 87.5 % 87.5 % 75 %Day 1–7

Control 3 50 % on 100 % on Day 5–7 25 % on Day 1–3 Day 5–7 25% on Day 1–3 87.5 % 87.5 % 75 %Day 1–5


Table 4


_Conclusion

The preliminary results showed that using PRGFautologous plasma prepared using BTI technologywith its various consistencies (clot, membrane) forfilling cystic bone cavities after their ultrasonicationduring cystectomy can be a useful method to mini-mize surgery time with quick antiseptic debridementand preparation and to avoid the usual antibiotictherapy if cysts are smaller than 3 cm. In addition, thesuturing technique used provides complete woundclosure in the interdental space and long-term coro-

nal flap repositioning, minimizing the risk of post-operative recession and other complications. Thepreliminary data indicates a positive therapeutic effect of PRGF autologous plasma on the maturationand revascularization of the soft periodontal tissueand support of physiological bone tissue regenera-tion. Further studies are, however, required. Further-more, this approach minimizes the medication loadand maximally decreases patients’ discomfort duringhealing, which is the very aim of modern dental treat-ment approaches, being minimally invasive and sup-porting physiological response._


Prof. Galyna Biloklytska,DDSc, Honoured Master of Science of Ukraine, is head ofthe Dental Training Centre atP.L. Shupyk National MedicalAcademy of Postgraduate Education in Kiev in Ukraine

and head of the Department of Therapeutic Dentistry at the same institution.

Dr Vasyl Rybak is head of the Centre of Maxillofacial Surgery at Kyiv Regional Clinical Hospital in Kiev.

Dr Iuliia Braun conductedher PhD research on the com-bined use of diode laser andEmdogain during the surgicalstage of treatment in patientswith moderate and severe periodontal disease. She is

currently a maxillofacial surgeon at the DentalPractical-Scientific Centre at P.L. Shupyk NationalMedical Academy of Postgraduate Education.

Dr Ievgen Fesenko is a maxillofacial surgeon at the Department of Maxillofacial Surgery at KyivRegional Clinical Hospital.

_contactDr Iuliia [email protected]

cone beam_about the authors

Figs. 19a–d_Condition of soft tissuesix months post-op. The marginal

periodontal tissue has healed completely and matured and the

interdental papilla fills the interdentalspace. The recession of tooth #13

has not increased and the amount ofsurrounding gingival tissue is suchthat it can be used for covering the

recession in the future.

Fig. 19a Fig. 19b

Fig. 19c Fig. 19d

I industry news _ Planmeca


_The field of digital dentistry is rapidly evolv-ing, with new dental technologies emerging as partof a more efficient and comprehensive workflow. By pairing Planmeca CAD/CAM solutions with radi-ographic units in the Planmeca ProMax 3D family,dental professionals can bring together a widerange of detailed information for treatment plan-ning and diagnostic purposes. This seamlesscombination of CAD/CAM and CBCT tech-nology presents new possibilities in creat-ing a new standard of care for patients, of-fering high-quality features for differentspecialities, all available through one soft-ware interface.

Planmeca Romexis is the only dental soft-ware platform in the world to combine all

imaging and the complete CAD/CAMworkflow. This powerful solution is at

the heart of the Planmeca eco -system, as it provides dental pro-fessionals with the ability to ac-quire datasets that are more de-tailed than ever before. PlanmecaRomexis includes advanced toolsfor all specialities, such as im-plant planning and other restora-

tive treatments. The software pres-ents dental clinics with a superior way to in-

crease their patient flow and improve the levelof care offered.

_Seeing more than ever before

Bringing together CBCT data and CAD/CAM workprovides a comprehensive level of clarity. PlanmecaProMax 3D imaging units reveal intricate informationon soft- and hard-tissue structures, including themandibular nerve canal, while the Planmeca PlanScanintra-oral scanner captures precise data above the

gingival margin. This combination of dataensures a complete understanding of anycase and makes 3-D prosthetic design quick,accurate and easy. Clinics are able to operatemore flexibly, as restorations can either bemilled in-house with the Planmeca PlanMill40 milling unit or easily sent to a dental lab-oratory in an open STL data format.

_The rise of same-day dentistry

A more active role in the manufacture of restora-tions opens up avenues for dental clinics to signifi-cantly increase their patient volume and grow theirbusiness. A streamlined digital workflow ensures the

full utilization of resources, leading to a more efficienttreatment environment. Same-day dentistry is asbeneficial for patients as it is for clinics: instead of twovisits, patients can be treated in 1 hour—with no tem-porary crowns or physical dental models required.

_Open architecture for maximized efficiency

Standardized data is the driving force behind manyof the latest developments in digital dentistry, as itguarantees the interoperability of images and dentaldata across different hardware platforms—reducingcosts, increasing predictability and enhancing pa-tient safety. Bringing Planmeca’s CBCT and CAD/CAMsystems together through Planmeca Romexis makeseffective chairside dentistry a reality and presentsdentists with a streamlined opportunity to grow theirpractice substantially._

A winning combination:CAD/CAM and CBCT in one

Planmeca OyAsentajankatu 600880 HelsinkiFinland

www.planmeca.com

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I industry news _ ACTEON IMAGING


_X-Mind trium: I need 3 solutions in 1

ACTEON presents its new X-Mind trium panoramicdental unit, which can be upgraded to 3-D (CBCT)and/or cephalometry. It has a full range of mediumFOV sizes to facilitate 2-D and 3-D examinations.

_I am demanding

X-Mind trium is the only device that combines allthe best image qualities in one package. The smallest

voxel size available on the market (75µm), combinedwith in-house innovative metal artefact filter STAR,enable easier and more reliable diagnoses. X-Mindtrium has 4 FOV sizes ranging from Ø40x40mm toØ110x80mm to minimise exposure in the relevantarea. The FOVs do not come from a stitching tech-nique.

_I demand cephalometry

Due to its patented mechanism, the secondarycollimation does not need to be on the cephalometricarm. Furthermore, this means that the arm can beshorter, making the X-Mind trium one of the smallestfootprints for a cephalometric device.

_I want minimum exposure for my patients

X-Mind trium uses 1.5 to 12 times less radiationthan a medical scanner, and reduces the necessarydose by 30% compared to other cone beams. Thismakes it one of the most suitable for ALARA principledevices.

_I want no limitations

Developed to provide the optimum level of imagequality for superior diagnosis at a minimal dose, X-Mind trium is your ideal work companion. ACTEONImaging Suite (AIS) is simple to use and is compatiblewith Windows and Mac OS X._

X-Mind trium:3 in 1 extra-oral imaging forall your 3-D requirements

ACTEON IMAGING 17, avenue Gustave EiffelBP 3021633708 MERIGNAC CedexFRANCE

www.acteongroup.com

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industry news _ 3DISC I

I 41cone beam2_2015

_The new FireCam HD by 3DISC Imaging, amanufacturer of digital imaging solutions, is an intra-oral camera that rapidly delivers high-defini-tion images during consultations, enhancing chair-side time with patients.

“Advancements in camera technology have al-lowed us to fit an incredibly high number of pixelsinto the FireCam HD. With 5M pixels, it is the intra-oral camera with the highest definition image onthe market. It enables you to see every little detailwhile examining patients’ teeth,” said Sigrid Smitt-Jeppesen, CEO of 3DISC Americas.

Dentists can use the FireCam HD during con-sultations to show patients a clear image of theirdental problems, document patients’ issues beforestarting treatments and record progress during ongoing treatments. It can be used to motivate pa-tients to initiate further treatment and encouragepatients to change their oral hygiene habits, as itenables them to see the problem with their own eyes.

The FireCam HD adjusts images automatically.With auto-focus and auto-brightness, it yields thebest image possible. This allows dentists to focuson their patients instead of dealing with hardwaresettings.

A specially designed heating mechanism pre-vents the patient’s breath fogging the lens and thuscausing images to become unclear. The seamlessexterior of the FireCam HD leaves nowhere for bac-teria to hide and is easily cleaned with disinfectantliquid. These two features eliminate the need forplastic sheaths, which blur and lower the imagequality and detail.

As 3DISC has designed the FireCam HD to be thesize of common dental instruments, the compactdesign fits naturally into the hand of the dentist.The slim design also makes it a more pleasant ex -perience for the patient.

In March 2015, the company exhibited the FireCam HD at the International Dental Show (IDS)in Cologne in Germany._

3DISC Imaging reveals new FireCam HD intra-oralcamera at IDS 2015

3DISC EuropeGydevang 39–413450 LillerødDenmark

www.3discimaging.com

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I industry news _ RAY

_RAY, a specialist in digital radiation technol-ogy, introduced its latest extra-oral imaging system,the RAYSCAN !+, at the 2015 International DentalShow (IDS). In addition, the company, formerly asubsidiary of Samsung Electronics, has announced a new initiative to become an independent manu-facturer. RAY’s strategic decision to leave the Sam-sung Electronics venture fund provides the companythe freedom to create innovative dental imagingtechnologies, the company stated.

Recently, Dr Sangchul Lee, the founder of RAY,purchased the main stocks from Samsung to ownthe company. This founder-owned system allowsRAY to make faster decisions and progress towardthe global market, the company stated. RAY’s sin-gular focus on the dental market and a significant investment by a investment by BRV Lotus, part ofventure capital firm BlueRun Ventures will lead to

substantial growth, particularly in thecrucial US and European markets,which comprise 70 per cent of all ofits dental imaging sales.

According to RAY, Samsung se-lected the manufacturer as the first

subsidiary to start up in the healthcare business owing to its expertisein the field. During the project withSamsung, RAY built an effectivequality control system and intro-duced the first radiographic unit inthe medical field. In 2012, RAY intro-duced RAYSCAN !, and its revenuehas almost doubled every year over

the last two years.

IDS attendees could visit RAY booth for a demon-stration of the new RAYSCAN !+. The state-of-the-art technology allows for faster scanning (4.9 sec-onds) and real-time CT (reconstruction, 1.5 sec-onds). Also on display was the new RIOSensor dig-ital radiography system, an intra-oral sensor withdedicated radiographic imaging software._

RAY introduces newimaging system at IDS


RAY Co., Ltd.218, Maeyeong Rd., Yeongtong-Gu, Suwon-SiGyeonggi-Do443-823Korea

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meetings _ IDS I

I 45cone beam2_2015

68 per cent) and a 17 per cent increase in the num-ber of trade visitors from abroad the level of interna-tionality of the event was once again significantlyincreased. At the same time, the number of trade visitors from Germany also increased markedly incomparison to 2013 (+4.3 per cent).

"We succeeded in making the International Den-tal Show in Cologne even more attractive, on both anational and international basis. It is thus the mostsuccessful IDS of all time," summed up Dr MartinRickert, Chairman of the Association of GermanDental Manufacturers (VDDI). "The quality of thebusiness contacts between the industry and the tradeas well as between the indus-try, dentists and dental tech-nicians was extremely high.The number of orders placedat IDS rose once again and weare reckoning with sustain-able impulses for the post-fairfollow-up business," addedKatharina C. Hamma, ChiefOperating Officer of Koeln-messe GmbH.

Furthermore she said: "Inaddition to the growth in thenumber of German trade vis-itors, the high internationalresponse once again under-lines the character of IDS asthe world's leading trade fair of the dental industry.The International Dental Show particularly recordedstrong growth in the number of visitors from theNear and Middle East, the United States and Canada,Brazil as well as from China, Japan and Korea. Thebusiness in the South East European market, espe-cially Italy and Spain, has also increased noticeably."

_Strong interest in innovations

The trade and the users were extremely interestedin innovative products and technologies. "In this respect, staged every two years, IDS fits in perfectlywith the innovation cycles of the industry regardingthe development and further development of prod-ucts, materials and services," emphasised Dr MarkusHeibach, Executive Director of VDDI. "This applies forboth breakthrough innovations and further devel-opments of existing products, but also for develop-ment progress in smaller phases that are howeversignificant in terms of quality."

IDS 2015 focused on the intelligent networking of components for computer-controlled dentistry.Today, the world of digital systems in diagnostics and production encompasses the entire workflow

from the practise through to thelaboratory. The computer-con-trolled process chains are in themeantime complete and are put-ting their enormous flexibility touse.

_Fantastic outcome of the trade fair and excellent mood

The hustle and bustle in thehalls made the high attendance at

IDS very apparent. By all accounts, representativesfrom all relevant professional groups—from dentists'surgeries, dental laboratories, from the dental trade,but also from the higher education sector—from allover the world had visited the exhibition stands. Theexhibitors were especially pleased about the highlevel of internationality of the trade visitors. In termsof business, IDS was very successful for many com-panies, because orders were placed—by both na-tional and international customers.

Numerous companies were pleased to an-nounce full order books. Aspects such as groomingcontacts, customer bonding, winning over new cus-tomers or penetrating new foreign markets were at least equally important for the exhibitors. Thesegoals were also achieved to complete satisfaction atthe 36th International Dental Show. The exhibitorsevaluated the quality of the visitors very positively.This finding is confirmed by the initial results of anindependent visitor survey: 83 per cent of all of thevisitors are involved in purchasing decisions at theircompany.

"The world meets up at IDS in Cologne," summedup Sebastian Voss, managing partner of Hager &

I meetings _ IDS

Meisinger GmbH. "More international customercontacts visited our stand this year than in 2013.Visitors from Latin America were particularly wellrepresented, but also from Asia. "We were able to es-tablish countless new contacts at IDS and also metup with our existing customers." Martin Dürrstein,Chairman of Dürr Dental AG, was also extremelysatisfied: "The trade fair went very well for us, it wasfantastic. We received a high number of particularlyqualified trade visitors. We are totally satisfied withthe fair, because we were able to welcome many newcustomers from Asia, Arabia, Latin America andSouth Africa."

Christian Scheu, Executive Director of Scheu-Dental GmbH also praised the further increased in-ternationality of IDS: "In comparison to 2013, wewere able to further increase the number of visitorsat our stand, in particular visitors from abroad. TheAsiatic region, for instance China and Korea, were

especially well represented, but we also registeredan increase in the number of customers fromSouthern Europe." As well as the high frequency ofvisitors at his stand, Axel Klarmeyer, Executive Di-rector of BEGO, also reported, "that the customerswere well informed and that they showed great in-terest in new technologies."

Walter Petersohn, Vice President Sales of SironaDental Systems, was also pleased "about the vastnumbers of international visitors, the buying inter-est and as always about the large number of at-tending German dentists and dental technicians."Michael Tuber, Executive Director of A. Titan alsoawarded IDS 2015 top marks. "This is the seventhtime we have exhibited at IDS and we have optimallyachieved the goal we set ourselves, namely furtherexpanding our international sales network. Thetrade fair offers us the perfect platform for meetingup with our existing customers from all over theworld, but at the same time, we were able to estab-lish many new customer contacts. This is why the International Dental Show is an absolute must forevery American manufacturer from the dental in-dustry."

IDS 2015 was also a success for Andrew Parker,CEO of Mydent International: "We met up with ourinternational customers here in Cologne and wereadditionally able to make over 100 interesting newcontacts to dental dealers. No other event in theworld has such international appeal."

_Satisfied visitors all round

The visitor survey revealed that over 75 per centof the respondents were (very) satisfied with IDS.The fair's comprehensive spectrum of products andnew products ensured that 81 per cent of visitorsrated the product range as being (very) good. 74 percent of the exhibitors were (very) satisfied in termsof reaching the goals they had set themselves for thefair. Overall, 95 per cent of the visitors questionedwould recommend visiting IDS to business partnersand 77 per cent also intend to visit IDS 2017.

The International Dental Show (IDS) takes placein Cologne every two years and is organised by theGFDI Gesellschaft zur Förderung der Dental-Indus-trie mbH, the commercial enterprise of the Associa-tion of German Dental Manufacturers (VDDI) and isstaged by Koelnmesse GmbH, Cologne.

The next IDS—the 37th International Dental Show—is scheduled to take place from 21 to 25 March2017._

www.ids-cologne.de


I 49

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Image requirementsPlease number images consecutively throughout the article by using a new number for each image. If it is imperative that certain images are grouped together, then use lowercase lettersto designate these in a group (for example, 2a, 2b, 2c).

Please place image references in your article wherever they are appropriate, whether in the middle or at the end of a sentence.If you do not directly refer to the image, place the reference at the end of the sentence to which it relates enclosed withinbrackets and before the period.

In addition, please note:

_We require images in TIF or JPEG format._These images must be no smaller than 6 x 6 cm in size at 300 DPI._These image files must be no smaller than 80 KB in size (or theywill print the size of a postage stamp!).

Larger image files are always better, and those approximately the size of 1 MB are best. Thus, do not size large image files downto meet our requirements but send us the largest files available.(The larger the starting image is in terms of bytes, the more lee-way the designer has for resizing the image in order to fill up morespace should there be room available.)

Also, please remember that images must not be embedded intothe body of the article submitted. Images must be submitted separately to the textual submission.

You may submit images via e-mail, via our FTP server or post a CD containing your images directly to us (please contact us for the mailing address, as this will depend upon the country fromwhich you will be mailing).

Please also send us a head shot of yourself that is in accordancewith the requirements stated above so that it can be printed withyour article.

AbstractsAn abstract of your article is not required.

Author or contact informationThe author’s contact information and a head shot of the authorare included at the end of every article. Please note the exact information you would like to appear in this section and for-mat it according to the requirements stated above. A short biographical sketch may precede the contact information if you provide us with the necessary information (60 words or less).

Questions?Magda Wojtkiewicz (Managing Editor)[email protected]


I about the publisher _ imprint

cone beam2_201550 I

Copyright Regulations _cone beam international magazine of cone beam dentistry is published by Dental Tribune International (DTI) and appears with four issues in 2015. The

magazine and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is in admissibleand liable to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.

Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to theeditorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right tocheck all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicitedbooks and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, representthe opinion of the afore-mentioned, and do not have to comply with the views of DTI. Responsibility for such articles shall be borne by the author.

Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate orfaulty representation are excluded. General terms and conditions apply. Legal venue is Leipzig, Germany.

PublisherTorsten R. Oemus [email protected]

Editor-in-ChiefDr Scott D. [email protected]

Managing EditorMagda [email protected]

Designer Josephine Ritter

Copy EditorsSabrina RaaffHans Motschmann

International Administration

Chief Financial OfficerDan Wunderlich

Business Development ManagerClaudia Salwiczek

Event ManagerLars Hoffmann

Event ServicesEsther Wodarski

Marketing ServicesNadine Dehmel

Sales ServicesNicole Andrä

Executive ProducerGernot Meyer

International Media Sales

Matthias Diessner (Key Accounts)[email protected]

Melissa Brown (International)[email protected]

Peter Witteczek (Asia Pacific)[email protected]

Weridiana Mageswki (Latin America)[email protected]

Hélène Carpentier (Europe)[email protected]

Barbora Solarova (Eastern Europe)[email protected]

International Offices

Dental Tribune InternationalHolbeinstr. 29, 04229 Leipzig, GermanyTel.: +49 341 48474-302Fax: +49 341 [email protected]

Dental Tribune Asia Pacific Ltd.Room A, 20/F, Harvard Commercial Building,105–111 Thomson Road, Wanchai, Hong KongTel.: +852 3113 6177Fax: +852 3113 6199

Tribune America, LLC116 West 23rd Street, Ste. 500, New York, N.Y. 10011, USATel.: +1 212 244 7181Fax: +1 212 244 7185

Editorial BoardDr David Hatcher, USADr Jack Krauser, USAUli Hauschild, ItalyDr Henriette Lerner, GermanyDr Roberto Marra, ItalyDr Ziv Mazor, IsraelSabine Nahme, USADr Alvaro Ordonez, USADr Marco Rinaldi, ItalyDr Mitra Sadramelli, CanadaDr Tiziano Testori, ItalyDr Gerlig Widmann, Austria

www.conebeamcampus.com

[email protected]

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