International relief organisation, Bridge2Aid, which provides emergency dental treatment to some of the world’s poorest people, launched its Australian arm at a private event hosted by ADA NSW Centre for Professional Development at St Leonards on October 11.
“Incredible comprehensive, simply brilliant, truly inspirational”
Sverker Toreskog – Internationally renowned speaker
The one day ‘hands-on course’ has been designed to teach attendees how to use the Inman Aligner in order to be a certified user. All aspects of the treatment will be covered from case evaluation to filling and then retention, so that attendees will be able to handle simple to moderate cases immediately.
David Chan demonstrates a simple solution to the difficult problem of insufficient posterior maxillary bone
We are often presented with patients who meet the criteria for implant treatment, but have insufficient bone, in quantity and quality, in the posterior maxilla. Conventional sinus floor elevation (CSFE) may address the problem but it is often expensive, time-consuming and associated with high morbidity. The internal sinus lift, also known as Summer’s method, or osteotome sinus floor elevation (OSFE), uses a crestal or transalveolar approach to augment the sinus floor rather than the lateral window (Caldwell-Luc) approach used in CSFE (Summers, 1998). Various modifications to the original method have been described in the literature (Chen and Cha, 2005). It is used mainly to locally augment the height of the alveolar bone in the posterior maxilla, so that a single and longer implant can be placed simultaneously. An internal sinus lift is more technique sensitive but it produces less morbidity by avoiding the elevation of a muco-periosteal flap and the cutting of a lateral window. However, conventional and osteotome techniques are only possible without the presence of a vertical sinus septum. In CSFE, the presence of a vertical septum on the lateral wall will either complicate the opening of a lateral window, or make the process almost impossible. In OSFE, impact force from a mallet may break the fragile septum and tear the membrane. This case report intends to introduce a two-stage method of OSFE without the use of impact force or specialised tools, and make the OSFE technique simpler and more predictable, even in difficult anatomical situations.
Cone beam computed tomography (CBCT) imaging is essential for any planned sinus floor elevations. It is also better to take the CBCT volumetric image in a higher resolution. A CBCT image: • Provides a three-dimensional picture of the site • Provides greater appreciation of the local anatomy • Discloses any pathology in the sinus • Provides measurements of • Can be used to produce drilling guides. Although the OSFE technique has been successful in patients with residual alveolar bone height of less than 3mm, 3-6mm is considered to be more appropriate for providing better initial fixation (Emmerich et al, 2005). The presence of any sinus infection is a contra-indication to OSFE and should be treated before this procedure.
Surgical protocol – first stage
1. A crestal incision is made to raise a muco-periosteal flap to expose the crestal alveolar bone 2. The osteotomy site is prepared as normal with the final drill to 1mm short of the sinus floor 3. The final drill is then run at a very slow speed (30-40rpm) to the full thickness of the floor in order to intentionally perforate the floor (Figure 2) 4. The osteotomy is then covered with a resorbable membrane 5. The buccal flap is relieved to allow tension-free suturing and healing by first intention 6. The site is then left to heal over four weeks
1. The site is revisited. A partial mucoperiosteal flap is raised again and separated cleanly from the underlying immature bone 2. An osteotome similar in diameter to the last drill is used to push the healing content of the previous osteotomy apically, lifting the Schneiderian membrane from the sinus floor. The osteotome should never poke through the bone or come into contact with the membrane 3. Particulate graft Bio-Oss (Geistlich Biomaterials, 2012) is then introduced into the vacated osteotomy 4. The same osteotome is used again to push the Bio-Oss apically (Figure 3) 5. This process is repeated four or five times, depending on the amount of elevation desired 6. A periapical radiograph is taken after the first load of Bio-Oss to check for the patency of the membrane 7. No drilling is necessary and under-sized site forming with osteotomes is desirable 8. A selected implant is then placed in the osteotomy 9. Submerged healing for eight weeks is advisable before restoration.
A healthy 44-year-old woman presented, requiring implant placement at the posterior maxilla. Radiographs revealed the presence of a vertical sinus septum at the intended site of placement. Using the above two-stage OSFE technique, an implant was successfully placed at UL6 (Figures 2 and 4-6). No drilling was necessary in the second ‘push up’ stage. A Straumann bone level implant was placed at bone level rather than subcrestally, in case it was lost in the sinus (Figure 5). After three months, healing was complete (Figure 6) and an open tray impression was taken for the fabrication of a fixed prosthesis.
Osteotome sinus floor elevation (OSFE) is well documented in literature for increasing the alveolar bone height in the posterior atrophic maxilla. Ideally, the height of the residual ridge should be about 3-6 mm to provide proper fixation for the implant (Greenstein and Cavallaro, 2011, Emmerich et al, 2005). The sinus floor should preferably be flat in the mesio-distal and bucco-lingual directions without an intervening septum. Impact from a mallet on a particulate graft introduced into the osteotomy causes infracture of the sinus floor and lifts the overlying Schneiderian membrane (Buser et al, 2007). The osteotome should never extend beyond the bone or come into contact with the Schneiderian membrane to avoid tearing it. In contrast with the lateral window approach, where more time (four to five months) is required for the osseointegration, the implant inserted by OSFE technique is ready for restoration after eight weeks. This can be explained by the fact that the presence of thicker natural bone is a prerequisite for the osteotome technique, which provides better fixation. Although a greater gain in height is reported in the literature using the OSFE technique, a height of 5-7mm is more practical and can be safely achievable. The success rate of implants placed in the OSFE augmented ridge is comparable to those placed in other part of the mouth. The success rate has been put at 95-96% in a systematic review and meta-analysis by Emmerich et al (2005) and 92.8% by Tan et al (2008). However, statistical analysis is not possible due to the multivariate nature of the techniques, grafting materials and type of implants used. Over the years many modifications to the original OSFE technique such as the hydropneumatic balloon elevation technique, or Dask technique have been proposed. The purchase of additional expensive tools is required and the dentist has to develop new skills for their use. The method described in this case report offers a simple solution to a difficult problem using existing tools available in an average implant practice. The ‘push up’ technique described in this case report makes use of the fact that bone healing always lags behind the healing of the Schneiderian membrane, and that early osteoid tissue is soft and can be manipulated with an osteotome using gentle pushing pressure only. A gentle and apical pressure on this osteoid tissue lifts the overlying membrane easily (Figure 3). Timing is crucial in this technique. In the absent of infection, the Schneiderian membrane heals two weeks after the osteotomy and hard bone is present in the same site after eight weeks. The ideal time for the second ‘push up’ stage is in the fifth week. The immature woven bone eventually calcifies with the rest of the particulate graft (Figure 6). This technique is not affected by the difficult anatomy at the intended site such as sloping sinus floor and the presence of a septum (Ulm et al, 1995; Krennmair et al, 1997, Maestre-Ferrín et al, 2010). Benign paroxysmal positional vertigo (BPPV) has been noted as one of the side effects of the osteotome technique, in addition to other complications such as membrane perforation, or loss of the particulate graft or implant into the sinus (Kim et al, 2010; Di Girolamo et al, 2005). The use of impact force is not necessary with this technique and the incidence of BPPV can be avoided. However, the sinus must be free from infection before using this technique. The deliberate creation of an oro-antral communication (OAC) must be done using aseptic procedures. An extra visit is necessary for this twostage technique and the patient must be able to attend in the specified time period. Membrane binding and tearing is possible during the internal membrane elevation and this should be checked with a postoperative periapical radiograph.
The technique described in this case report offers a new way of elevating the sinus membrane with osteotomes, in difficult anatomical situations such as a sloping sinus floor and the present of a sinus septum. With proper planning, the technique can be incorporated during the extraction stage of the treatment. The use of impact forces is avoided and this modified OSFE technique may be more acceptable to the patients.
Dentistry – the economics of time
The economic and clinical benefits of dental prescribing and dispensing in your practice.
Real cost of an interaction or purchase includes all the activities leading up to the point of the exchange and the activities directly related to that moment as a consequence of the exchange. The real cost of dentistry is not just the price of the dental visit or the product you provide. So improving the dental experience includes improving what happens up to sitting in the chair, the actual clinical care and what happens after the visit. A simple example of improving the value you offer is just adding prescribing and dispensing in the dental practice. Improving the patient experience by ensuring the correct medication is taken at the correct time and is easy to do for your patient and the practice improves care outcomes – it is that simple. Value is remembered long after the price is forgotten. Patients come to you to avoid or relieve pain and fix their dental concerns, use all the tools available to you. Start prescribing and dispensing today. You are rewarded for the value you bring, not the time you spend Adding value often increase your average hourly rate the income of a practice is merely the time you have multiplied by your average hourly rate. So improving the experience for the patient also can improve your bottom line. As an example a dentist that provides say just two scripts a day, say one analgesic like Maxigesic and an amoxicillin over say the 15 patients they see for just 45 weeks per year could add up to $10,000 additional profit to their practice per dentist using the basic 927 item number and feeing a set $29.95 for the advice, prescription and dispensing services. Basically you can benefit commercially while improving the care of your patients. Saving time An appointment missed is one never recouped – every minute of your clinical time is valuable… Your time is too important to have a patient not take their antibiotics, not have their correct pain relief pre and post clinical activity. Staff’s time is too important to fix problems that arise from an emergency patient that could be managed on the spot with the right solutions. The patient’s time is better spent getting the right advice and medication from you than having to make a separate visit to a pharmacy that they may not do or not get exactly what your want them to have. Adding this simple program of prescribing and dispensing in your practice puts you in control and saves you time. Prescribing and dispensing in your practice improves treatment control and productivity, improves patient care and improve patient convenience and medication compliance. Adding these services reduces cost to practice and patient and adds significant value. Ingenuity Dental provides a complete Prescribing and Dispensing Guide with your first order. Start prescribing and dispensing today! It is a new service you can do today, use the item number 927 and have a go, it’s really simple. We have developed a simple Web page www.ingenuitydental.com to assist you with this new service in your practice. We provide downloadable order forms and we will give you a comprehensive How to Guide FREE with your first order. Follow the steps to ensure you implement it in a no-fuss way We have provided all the tips and guidelines in plain English There is no need to keep the forms as the site is set up to easily download your requirements – so keep in your favourites. We love to share in our practice and help other practices. If you have any questions go to the site and drop us a line.
By Peter Watt
When discussing dental implants, companies like Straumann and Nobel Biocare often come up as providing the benchmark for quality and innovation. But these great European companies are now looking over their shoulders at Osstem, the dynamic, fast-growing Korean implant maker.
Established in the late 1990s and present in the Australian market since 2008, Osstem is now the No. 1 implant company in the Asia-Pacific region and will soon be the fifth-ranked implant company worldwide. Openly ambitious, Osstem has targeted 2023 as the year it will become the world’s largest manufacturer of implants. In pursuit of global domination, the company is a leading innovator in the field, investing heavily in R&D and training.
It will come as no surprise that many dentists are seeing Osstem implants as considerably better value than their top international equivalents. What may surprise is that in this case quality is not the first casualty of a lower price.
One of the earliest users of Osstem implants in Australia was Lane Cove, Sydney, dentist Michael Ho. Like many dentists, Michael started his implant training using Brånemark, Nobel Biocare’s flagship product. He also used Endopore, PittEasy, Sybron and Straumann implants. When initially approached by Osstem, Michael was a little apprehensive. “I was thinking, why would I go from a BMW to a Hyundai? But a close Korean colleague of mine pointed out that Osstem is the top-selling implant in Korea and that gave me the confidence to try it.”
Michael’s colleague also explained that Korea’s equivalent of the TGA is not as strict, and the resulting environment has given rise to the development of many implant companies and implant designs. Moreover, it has created fierce competition and implant companies therefore have to be highly competitive to survive. “If an implant company survives in Korea it has to be good,” Michael says, “and Osstem is more than just surviving.”
Cost and quality were initial reasons for Michael to look at Osstem. “The Osstem implant cost less than half what I was used to, and when I looked at it, it was very similar to the Straumann implant design I was most familiar with and it worked just the same.”
Three other factors have played a big part in Michael’s commitment to Osstem: simplicity, product range and customer service.
“With previous implants I was used to taking about 14 steps before I even screwed in the implant, but with Osstem it was only two or three. Wow, that was new. I don’t want to exaggerate the simplicity but it really was significantly simpler.
“And Osstem is a one-stop shop; it has every type of implant I need, which has saved me a lot of time over the years. It’s especially useful to me with their range of mini implants and their orthodontic temporary anchorage implants. I also do a lot of orthodontics and the two disciplines do merge; temporary anchorage implants have changed orthodontics greatly in recent years.”
Michael’s satisfaction with Osstem’s service hinges mostly on its speedy response. “I can’t carry a large inventory, so I’m often calling them and saying ‘I need this and I need it now’. Their delivery times are very quick and I can hardly fault them in all the years I’ve been using them.”
Michael’s interest in technology and innovation first bore fruit with a degree in Computer Science in the 1980s, before he took up dentistry. In general practice since 1991, he has gained particular expertise in orthodontics, implantology and CAD-CAM chairside delivery of ceramic restorations. This in turn has led to a desire to share his learnings with other dentists, in particular training dentists in the use of CAD-CAM chairside systems and the Cfast orthodontic system. He emphasises that he received no inducement for this article; the motivation was purely to share his positive experiences with the Osstem product. Osstem. Remember the name.
Tooth extraction is one of the most effective ways to help a patient with acute toothache. In many cases teeth roots without acute symptoms are extracted to prevent complications such as the spread of infection. In rare cases the extraction of healthy teeth is recommended as in carefully selected orthodontic cases.
A certain degree of damage to the alveolar bone, gingival and mucous tissue is unfortunately always part of an extraction. The aim of every clinician should be to carry out the operation with little to no damage to the surrounding tissue and adjacent teeth.
Alveolar bone preservation is vital for both successful implant placement and to achieve the optimum aesthetic appearance. The amount of alveolar bone left intact after the extraction will also play a significant role in the long term prognosis of the implant.
Fracturing of the maxillary tuburositas is a relatively frequent complication of upper wisdom tooth removals. This can result in severe pain, prolonged healing phase and long term problems for the patient which should be avoided at all costs.
The correct use of the extraction instruments is crucial and the improper handling of these instruments will focus forces in the wrong areas, resulting in unnecessary tissue damage.
The Luxator® LX was designed to avoid this unnecessary tissue damage and also improves the accessibility in difficult to reach areas. The titanium nitride coated periotome tips, available in 4 different types, can be inserted into a specially designed contra angled hand piece. Driven by this hand piece, these tips will move in a vertical reciprocation fashion to become a mechanical peritome.
By using the Luxator® LX in combination with the manual Luxator ®instruments a safer and less traumatic extraction can be possible.