Loading of Two Implants in the

The Journal of Implant & Advanced Clinical Dentistry
Volume 6, No. 3 June 2014
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The Journal of Implant & Advanced Clinical Dentistry • 3
The Journal of Implant & Advanced Clinical Dentistry
Volume 6, No. 3 • June 2014
Table of Contents
13 From Maxilla to Zygoma:
A Review on Zygomatic Implants
Dr. D.R. Prithviraj, Dr. Richa Vashisht,
Dr. Harleen Kaur Bhalla
21 Lateral Sinus Augmentation:
A Safer Technique
Dr. Gregori Kurtzman,
Dr. Douglas F. Dompkowski

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The Journal of Implant Advanced Clinical Dentistry • 5
The Journal of Implant Advanced Clinical Dentistry
Table of Contents
33 Loading of Two Implants in the
Mandible and Final Restoration
with a Locator: A Case Report
and Review
Dr. A. Abdulgani, Dr. M. Bajali,
Dr. M. Abu-Hussein
43 Smile Makeover with
all Ceramic Crowns
and Biologic Shaping
Dr. Arshad Hasan
53 Occurrence Regions and Sites of
Peri-implant Inflammation with
Bone Resorption in Japanese
Partially-Edentulous Patients
Motohiro Munakata, Noriko Tachikawa,
Katsuichiro Maruo, Aoi Sakuyama,
Yoko Yamaguchi, Shohei Kasugai

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Alan M. Atlas, DMD
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Peter Bertrand, DDS
Michael Block, DMD
Chris Bonacci, DDS, MD
Hugo Bonilla, DDS, MS
Gary F. Bouloux, MD, DDS
Ronald Brown, DDS, MS
Bobby Butler, DDS
Nicholas Caplanis, DMD, MS
Daniele Cardaropoli, DDS
Giuseppe Cardaropoli DDS, PhD
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Jennifer Cha, DMD, MS
Leon Chen, DMD, MS
Stepehn Chu, DMD, MSD
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Charles Cobb, DDS, PhD
Spyridon Condos, DDS
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Douglas Deporter, DDS, PhD
Alex Ehrlich, DDS, MS
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Paul Fugazzotto, DDS
David Garber, DMD
Arun K. Garg, DMD
Ronald Goldstein, DDS
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Istvan Hargitai, DDS, MS
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Robert Horowitz, DDS
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Richard Hughes, DDS
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Wilcko et al
Background: Patients with moderate to severe
atrophy challenge the surgeon to discover alter-
native ways to use existing bone or resort to
augmenting the patient with autogenous or
alloplastic bone materials. The objective was
to review the published literature to evalu-
ate treatment success with zygomatic implants
in patients with atrophic posterior maxilla.
Methods: MEDLINE/PubMed searches
were conducted using the terms atrophic
maxilla, zygomatic implant, zygomatic bone,
grafts, maxillary sinus, as well as combina-
tions of these and related terms. The few arti-
cles judged to be relevant were reviewed.
Results: Based on the current literature review,
zygomatic implants show excellent survival rates
( 90% ) and a low incidence of complications.
Conclusions: With proper case selection, cor-
rect indication, and knowledge of the surgi-
cal technique, the use of zygomatic implants
associated with standard implants offers
advantages in the rehabilitation of severely
resorbed maxillae, especially in areas with
inadequate bone quality and volume, with-
out needing an additional bone grafting
surgery, thereby shortening or avoiding hos-
pital stay and reducing surgical morbidity.
From Maxilla to Zygoma:
A Review on Zygomatic Implants
Dr. D.R. Prithviraj1
• Dr. Richa Vashisht2
• Dr. Harleen Kaur Bhalla3
1. Dean Cum Director, Dept. of Prosthodontics Govt. Dental College and Research Institute,
Bangalore Victoria Hospital Campus, Fort, Bangalore
2. Post Graduate Student, Dept. of Prosthodontics Govt. Dental College and Research Institute,
3. Post Graduate Student, Dept. of Prosthodontics Govt. Dental College and Research Institute,
Abstract
KEY WORDS: Zygomatic dental implants, maxilla, maxillary sinus

14 • Vol. 6, No. 3 • June 2014
Prithviraj et al
INTRODUCTION:
Dental implants are now commonly used for
replacing missing teeth in various clinical situ-
ations. Dental implants are surgically inserted
in the jawbones. Unfortunately, restrictions
have appeared in the use of oral implants.
One of them is the lack of sufficient bone vol-
ume, especially in the posterior maxilla.[1]
During the last 3 decades, several surgical
procedures have been developed to increase
local bone volume in deficient anatomical
regions, including total/segmental bone onlays,
Le Forte1 osteotomy with interpositional bone
grafts, and grafting of the maxillary sinus with
autogenous bone and/or bone substitute.[2]
These techniques pose a series of inconve-
niences, such as the need for multiple surgical
interventions, the use of extraoral bone donor
sites (e.g., iliac crest or skull) - with the morbid-
ity involved in surgery of these zones - and the
long duration during which patients remain with-
out rehabilitation during the graft consolidation
and healing interval. These factors complicate
patient acceptance of the restorative treatment
and limit the number of procedures carried out.
In order to overcome such limitations, dif-
ferent therapeutic alternatives have been pro-
posed, such as, implants placed in specific
anatomical areas like the pterygoid region,
the tuber or the zygoma. Any of these proce-
dures requires considerable surgical exper-
tise and has its own advantages, limits,
surgical risks and complications involving bio-
logical and financial costs. The placement of
implants in the zygomatic bone as an alterna-
tive to maxillary reconstruction with autoge-
nous bone grafts has been considered a viable
option in the rehabilitation of atrophic maxillae
(Fig. 1). Anatomical Buttresses of the
midface: 1) Frontomaxillary buttress; 2) Fronto-
zygomatic buttress; 3) Pterygomaxillary buttress.
ANATOMY OF
ZYGOMATIC BONE
The zygoma bone can be compared to a pyra-
mid, offering an interesting anatomy for the
insertion of implants. In 1993, Aparicio et
al. mentioned the possibility of inserting den-
tal implants in the zygomatic bone.[3]
In 1997,
Weischer et al. cited the use of the zygoma
as a support structure in the rehabilitation of
patients subjected to maxillectomies.[4]
Follow-
ing Branemark’s description, Uchida et al. in
2001, measured the maxilla and zygoma in 12
cadavers, observing that the apex of a 3.75
mm-diameter implant requires a zygoma of at
least 5.75 mm in thickness. With respect to
implant placement, they advised that an angu-
lation of 43.8º or less increases the risk of
perforating the infratemporal fossa or the lat-
eral area of the maxilla; if the angulation is
more vertical, 50.6º or more, this increases
the risk of perforating the orbital floor.[5]
Nkenke et al. used computed tomography
and histomorphometry to examine 30 human
zygoma, the study revealed that the zygomatic
bone consists of trabecular bone, an unfavor-
able parameter for implant placement; however,
the success of implants placed in the zygomatic
bone was achieved by the implant crossing four
portions of cortical bone.[6]
Kato et al. investi-
gated the internal structure of the edentulous
zygomatic bone in cadavers using micro-com-
puted tomography, finding that the presence
of wider and thicker trabeculae at the apical
end of the fixture promotes initial fixation.[7]

Prithviraj et al
DESCRIPTION OF THE
ZYGOMATIC IMPLANT
The zygomatic implants are self-tapping
screws in c.p. titanium with a well-defined
machined surface. They are available in eight
different lengths ranging from 30 to 52.5 mm.
They present a unique 450
angulated head
to compensate for the angulation between
the zygoma and the maxilla. The portion that
engages the zygoma has a diameter of 4.0
mm, and the portion that engages the resid-
ual maxillary alveolar process a diameter of
4.5 mm (Fig. 2).[8,9]
Radiologic aspect of a
patient restored with two zygomatic implants.
PRESURGICAL EVALUATION
Clinical examination is not sufficient for this
evaluation and radiologic assessment has to be
considered. Bedrossian et al. in their study on
zygomatic and premaxillary implants used pan-
oramic radiographs, which generally depict the
size and configuration of the maxillary sinuses,
the height of the residual ridge, and the posi-
tion of the nasal floor. The body of the zygoma
can usually be visualized.[9]
However, OPG
can give distorted information and therefore,
the examination of choice is the spiral or heli-
coid computed tomography (CT) scan, which
makes two- and three-dimensional imaging pos-
sible with axial cuts every 2 mm parallel to the
palatal arch and conventional tomography with
frontal tomograms perpendicular to the hard
palate every 3-4 mm. The CT scan also gives the
opportunity to visualize the health of the maxilla
and the sinus. Sinusitis, polyps or any sinusal
pathology can be excluded. The density, length
and volume of the zygoma can be evaluated
and special templates for inserting the zygo-
matic implants can be constructed on stereo-
lithographic models to facilitate the orientation
Figure 1: Anatomical Buttresses of the midface.
1) Frontomaxillary buttress; 2) Frontozygomatic buttress;
3) Pterygomaxillary buttress.
Figure 2: Radiologic aspect of a patient restored with two
zygomatic implants.

16 • Vol. 6, No. 3 • June 2014
of the zygomatic implants during the surgery
with minimal errors in angulation and position.
[10]
Vrielinck et al., presented a planning system
for zygomatic implant insertion based on pre-
operative CT imaging; they calculated the posi-
tion of the implants and fabricated a surgical
guide. Using this system they obtained a suc-
cess rate of 92% in 29 patients with zygomatic
implants (two implants did not reach the zygo-
matic arch when using this surgical guide).[11]
PROCEDURE
The original procedure, defined by Brane-
mark in 1998, consisted of the insertion of a
35-55 mm-long implant anchored in the zygo-
matic bone following an intra-sinusal trajec-
tory.[12]
Since this description, many authors
have varied the technique slightly. Stella and
Wagner described a variant of the technique
(Sinus Slot Technique) in which the implant is
positioned through the sinus via a narrow slot,
following the contour of the malar bone and
introducing the implant in the zygomatic pro-
cess. In this way, the need for fenestration of
the maxillary sinus is avoided, and the implant
is caused to emerge over the alveolar crest at
first molar level, with a more vertical angula-
tion.[13]
Penarrocha et al.[12]
published in 2007
a series of 21 cases with the “Slot technique”
with a 100% survival rate, but the Schneide-
rian membrane was perforated in all cases,
even though the incidence of sinus pathology
was low (two cases).[14]
(Fig 3.) Right - Trans-
zygomatic implantation following an intrasinusal
Figure 3: (Right): Trans-zygomatic implantation following an intrasinusal path. (Left): The extrasinus technique. Note the
implant emergence above the alveolar crest at first molar level, with a more vertical angulation.
Prithviraj et al

Table 1: Success Rate of Zygomatic Implants
No. of
Study/ No. of Zygomatic Follow- Success
Year Patients Implants up Rate Complication
Sinusitis, loosening of the
Aparicio 6- zygomatic implant gold screws
et al., 69 131 months 99% in nine patients, fracture of one
200617
5 years gold screw as well as the
prosthesis in one patient.
Bedrossian 14 28 12 100%
et al., 200618
months
Penarrocha 21 40 29 100% Ecchymosis
et al., 200714
months

Davo et al,. 42 81 12-42 100% Oroantral fistula and sinsusitis
200819
months
was found in one patient
Pi-Urgell 54 101 1-72 96% Sinusitis
et al. , 200820
months

Balshi et al., 56 110 9 months- 96%
200921
5 years
Aparicio et al., 25 47 2-5 years 100%
201022
Malevez et al., 20 80 6-40 96%
201023
months
Miglioranca 75 150 12 98.7% Two zygomatic implants
et al. , 201124
months (1.33%) failed and were removed
Davo et al., 42 81 5 years 98.5% One zygomatic impant was lost.
201325
path; Left - The extrasinus technique. Note the
implant emergence above the alveolar crest at
first molar level, with a more vertical angulation.
MULTIPLE ZYGOMATIC
IMPLANTS
The use of multiple zygomatic implants (i.e.
two to three in each side) was suggested by
Prithviraj et al

18 • Vol. 6, No. 3 • March 2014
Bothur et al.[15]
In a recent study, Duarte et al.
used four zygomatic implants and no premax-
illary conventional implants in the prosthetic
rehabilitation of 12 patients with edentulous
and severely resorbed maxillas. A fixed bridge
of a gold framework and acrylic teeth was fab-
ricated and delivered shortly after implant sur-
gery. The patients were evaluated after 6 and
30 months when the bridges were removed for
individual testing of implant stability. One zygo-
matic implant was found to be loose at the 6-
month follow-up and another one was found to
be loose at the 30-month check-up. Thus, the
overall survival rate was 95.8% after 30 months
of follow-up. No severe complications relating
to the sinus or the soft tissues were reported.[16]
COMPLICATIONS
The reported complications associated with
zygomatic implants include postoperative sinus-
itis, oroantral fistula formation, periorbital and
subconjunctival hematoma or edema, lip lacera-
tions, pain, facial edema, temporary paresthe-
sia, epistaxis, gingival inflammation, and orbital
penetration/injury. Postoperative concerns
regarding difficulty with speech articulation
and hygiene caused by the palatal emergence
of the zygomatic implant and its effect on the
prosthesis suprastructure have been reported.
CONCLUSION
The zygomatic implant is an alternative proce-
dure to bone augmentation, maxillary sinus lift
and to bone grafts in patients with posterior
atrophic maxillae. The zygomatic implant tech-
nique should be regarded as a major surgi-
cal procedure and proper training is of course
needed. However, in comparison with bone
grafting procedures, the technique is less
invasive and complicated and has a lower
risk of morbidity because of the fact that har-
vesting of bone graft is usually not needed.
Based on the current literature review, zygo-
matic implants show excellent survival rates
( 90 %) and a low incidence of complica-
tions, so this should be considered a valid
and safe treatment option when dealing with
patients with advanced maxillary atrophy. ●
Correspondence:
Dr. Richa Vashisht
Post Graduate Student
Dept. of Prosthodontics
Govt. Dental College and Research Institute
Bangalore
Victoria Hospital Campus
Fort Bangalore 560002
+918050606896
dr.richavashisht@gmail.com
Prithviraj et al

Disclosure
The authors report no conflicts of interest with any-
thing mentioned in this article.
References
1. Kuabara MR, Ferreira EJ, Gulinelli JL, Paz
LG. Rehabilitation with zygomatic implants: a
treatment option for the atrophic edentulous
maxilla--9-year follow-up.Quintessence Int. 2010
;41:9-12.
2. Raghoebar GM, Timmenga NM, Reintsema
H, Stegenga B, Vissink A. Maxillary bone
grafting for insertion of endosseous implants:
results after 12-124 months. Clin Oral Implants
Res. 2001;12:279-86.
3. Aparicio C, Branemark P-I, Keller EE, Olive J.
Reconstruction of the premaxila with autogenous
iliac bone in combination with osseointegrated. Int
J Oral maxillofac Implants 1993;8:61-7.
4. Weischer T, Schettler D, Mohr C. Titanium
implants in the zygoma as retaining elements after
hemimaxillectomy. Int J Oral Maxillofac Implants
1997;12:211-4.
5. Uchida Y, Goto M, Katsuki T, Akiyoshi T.
Measurement of the maxilla and zygoma as an aid
in installing zygomatic implants. J Oral Maxillofac
Surg 2001;59:1193-8.
6. Nkenke E, Hahn M, Lell M, Wiltfang J,
Schultze-Mosgau S, Stech B, et al. Anatomic
site evaluation of the zygomatic bone for
dental implant placement. Clin Oral Impl Res
2003;14:72-9.
7. Kato Y, Kizu Y, Tonogi M, Ide Y, Yamane G. Internal
structure of zygomatic bone related to zygomatic
fixture. J Oral Maxillofac Surg 2005;63:1325-9.
8. Malevez C, Daelemans P, Adriaenssens P,
Durdu F. Use of zygomatic implants to deal with
resorbed posterior maxillae. Periodontol 2000.
2003;33:82-89.
9. Bedrossian E, Stumpel L III, Beckely ML,
Indresano T. The zygomatic implant: preliminary
data on treatment of severely resorbed maxillae.
A clinical report. Int J Orai Maxiiiofac Implants.
2002;17:861-865.
10. Van Steenberghe D, Malevez C, Van
Cleynenbreugel J, Bou Serhal C, Dhoore E,
Schutyser F, Suetens P, Jacobs R. Accuracy
of drilling guides for the transfer from 3-D CT
based planning to placement of zygomatic
implants in human cadavers. Clin Oral Implants
Res 2003: 14: 131–136.
11. Vrielinck L, Politis C, Schepers S, Pauwels
M, Naert I. Image-based planning and clinical
validation of the zygoma and pterygoid implant
placement in patients with severe bone atrophy
using customized drill guides. Preliminary results
from a prospective clinical follow-up study. Int J
Oral Maxillofac Surg 2003;32:7-14.
12. Branemark P-I. Surgery and fixture installation.
Zygomaticus fixture clinical procedures (ed
1). Goteborg, Sweden: Nobel Biocare AB;
1998. p. 1.
13. Stella J, Warner M. Sinus slot technique for
simplification and improved orientation of
zygomaticus dental implants: a technical note.
Int J Oral Maxillofac Implants 2000;15:889-93.
14. Penarrocha M, Garcı´a B, Martı E, Boronat
A. Rehabilitation of severely atrophic maxillae
with fixed implant-supported prostheses using
zygomatic implants placed using the sinus
slot technique: clinical report on a series of 21
patients. Int J Oral Maxillofac Implants 2007: 22:
645–650.
15. Bothur S, Jonsson G, Sandahl L. Modified
technique using multiple zygomatic implants in
reconstruction of the atrophic maxilla: a technical
note. Int J Oral Maxillofac Implants 2003: 18:
902–904.
16. Duarte LR, Filho HN, Francischone CE, Peredo
LG, Branemark PI. The establishment of a
protocol for the total rehabilitation of atrophic
maxillae employing four zygomatic fixtures in an
immediate loading system – a 30- month clinical
and radiographic follow-up. Clin Implant Dent
Relat Res 2007: 9: 186–196
17. Aparicio C, Ouazzani W, Garcia R, Arevalo
X, Muela R, Fortes V. A prospective clinical
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months to 5 years. Clin Implant Dent Relat
Res. 2006;8:114-22.
18. Bedrossian E, Rangert B, Stumpel L, Indresano
T. Immediate function with the zygomatic implant:
a graftless solution for the patient with mild
to advanced atrophy of the maxilla. Int J Oral
Maxillofac Implants. 2006;21:937-42.
19. Davo R, Malevez C, Rojas J, Rodriguez J, Regolf
J. Clinical outcome of 42 patients treated with
81 immediately loaded zygomatic implants: a
12- to 42-month retrospective study. Eur J Oral
Implantol. 2008;1:141-50.
20. Pi Urgell J, Revilla Gutierrez V, Gay Escoda CG.
Rehabilitation of atrophic maxilla: a review of
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Bucal. 2008;13:363-70.
21. Balshi SF, Wolfinger GJ, Balshi TJ. A
retrospective analysis of 110 zygomatic implants
in a single-stage immediate loading protocol. Int
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V, Muela R, Pascual A, Codesal M, Barluenga
N, Franch M. Immediate/Early loading
of zygomatic implants: clinical experiences after
2 to 5 years of follow-up. Clin Implant Dent Relat
Res. 2010;12:77-82.
23. Stievenart M, Malevez C. Rehabilitation of
totally atrophied maxilla by means of four
zygomatic implants and fixed prosthesis: a
6-40-month follow-up. Int J Oral Maxillofac
Surg. 2010;39:358-63.
24. Miglioranca RM, Coppede A, Dias Rezende
RC, de Mayo T. Restoration of the edentulous
maxilla using extrasinus zygomatic implants
combined with anterior conventionalimplants:
a retrospective study. Int J Oral Maxillofac
Implants. 2011;26:665-72.
25. Davo R, Malevez C, Pons O. Immediately loaded
zygomatic implants:a 5-year prospective study.
Eur J Oral Implantol. 2013;6:39-47.
Prithviraj et al

Wilcko et al
T
he lateral sinus augmentation approach
can be challenging as tearing of the sinus
membrane often necessitates abandon-
ing the procedure and re-entry at a later date
after the membrane has healed. Previous tech-
niques involved use of diamonds or carbides
in a high speed hand piece or the use of peizo-
surgical units. These approaches had potential
for membrane damage (burs in a high speed)
or were very slow (peizo). A recently intro-
duced drilling kit allows for safe lateral access
to the sinus with reduced risk of perforation
of the Schneiderian membrane. This case
report demonstrates use of this new drilling kit.
Lateral Sinus Augmentation:
A Safer Technique
Dr. Gregori Kurtzman1
• Dr. Douglas F. Dompkowski2
1. Private practice, Silver Springs, Maryland, USA
2. Private practice, Bethesda, Maryland, USA
Abstract
KEY WORDS: Dental implants, sinus augmentation, Schneiderian membrane, bone graft

22 • Vol. 6, No. 3 • June 2014
Introduction
The posterior maxilla presents with a common
problem clinically following tooth extraction
or crestal bone loss resulting in loss of osse-
ous height sufficient to place implants. Resorp-
tive patterns in some patients along with sinus
enlargement result in minimal bone that can
accommodate implant placement. Maxillary sinus
augmentation over the past 18 years with various
bone graft materials has become routine treat-
ment. Numerous studies have reported highly
successful implant survival rates when placed
into the augmented sinus.1-3
Transalveolar sinus
floor elevation also referred to as subantrial aug-
mentation, was first described by Tatum4
and
later modified by Summers.5-7
This technique uti-
lized a series of osteotomes with a mallet to cre-
ate an osteotomy and subsequent in-fracturing of
the sinus floor while elevating the Schneiderian
membrane. Following manipulation, the space
created in the sinus is augmented with various
bone particulate graft materials increasing the
volume of bone available for implant placement.
Various studies have reported that when 5 mm
of residual alveolar bone is present, simultane-
ous implant placement can be preformed achiev-
ing adequate primary stability.6, 8, 9
But, when less
than 5 mm of residual alveolar bone height is
available, a delayed 2-stage approach has been
recommended.10, 11
The most common complica-
tion of the lateral sinus elevation approach is typi-
cally tearing of the Schneiderian membrane which
could allow for bacterial contamination or loose
particles to gain access to the sinus cavity. A safer
Figure 1: Lateral Approach Sinus Kit (LASK).
Kurtzman et al

lateral window approach sinus augmentation pro-
cedure will be discussed using specialized safe
cutting end drills with vertical stoppers for osse-
ous window formation and subsequent membrane
elevation (Lateral Approach Sinus Kit, HIOSSEN).
MATERIAL AND METHODS
The Lateral Approach Sinus Kit (LAS-Kit) (HIOS-
SEN) provides “Dome” drills, “Core” drills, metal
stoppers, side wall drill and a bone separator
tool (Figure 1). The Dome drill is a unique osse-
ous drill allowing removal of the lateral wall of
the maxillary sinus while collecting autogenous
bone to be added to the material to be placed
into the sinus. Macro and micro cutting blades
provide excellent cutting of the lateral wall with-
out tearing of the sinus membrane. These Dome
drills available in both 5.0 and 7.0mm diameter
are run at 1,200 to 1,500 RPM with irrigation in
an implant surgical handpiece. Metal depth con-
trol stoppers are provided that fit on the Dome
drills limiting depth of penetration (0.5, 1.0, 1.5,
2.0, 2.5 and 3.0 mm) and are used sequen-
tially to safely expose the sinus membrane.
The Core drill, also available in 5.0 and 7.0 mm
diameter differs from the Dome drill in that the cen-
ter does not cut, with bone removal resulting in a
core of bone being left over the sinus. This boney
lid may be elevated with the sinus membrane still
attached becoming the new “roof” to the sinus
with osseous augmentation being placed below it.
This particular drill follows the same design of the
CAS Kit (crestal augmentation sinus) drills and
is utilized at 1,200-1,500 RPM. The metal drill
stoppers also fit these drills allowing controlled
sequential depth preparation. The Bone Separator
tool is utilized to separate the osseous core cre-
ated with the Core drill if removal is desired and
is based on the practitioners preferred technique.
The Side Wall drill, may be used to enlarge
the osseous window created by the Dome
Figure 2a: CBCT radiograph pretreatment demonstrating
insufficient osseous height for implant placement without
sinus augmentation in the molar region.
Figure 2b: CBCT radiograph pretreatment demonstrating
insufficient osseous height for implant placement without
sinus augmentation in the molar region.
Kurtzman et al

24 • Vol. 6, No. 3 • June 2014
drill if desired. The tip of this drill is smooth and
designed to safely push the sinus membrane
away from the cutting portion of the drill, which
starts 1mm from the safe end. Osseous cut-
ting is performed at 1,500 RPM using the side
of the rotating drill to enlarge the osseous win-
dow. The CAS Kit metal drill stoppers may be
placed on this drill to limit accidental penetration
too far into the sinus and tearing of the mem-
brane during this drills use. As with the other
drills in this kit, irrigation is used during its use.
Case Report
A male aged 32, presented with the desire
for implant placement in the posterior maxil-
lary right quadrant which had been missing the
first molar for an extended period of time. The
result of long term loss of the tooth resulted
in drifting of the second molar into the space
which was corrected orthodontically prior to
Figure 3: Buccal concavity evident as a result of long
standing loss of the first molar compromising the width of
the site.
Figure 4: A trapezoidal shaped flap was created with a
scalpel with the crestal incision placed to the palatal aspect
of the ridge.
Figure 5: Lateral aspect of the maxillary posterior
following elevation of a full thickness flap.
Figure 6: Dome drill with 0.5mm stopper placed on the
surgical hand piece.
Kurtzman et al

implant surgery. Radiographically, enlargement
of the maxillary sinus was noted with insufficient
height in the molar region for implant placement
(Figure 2). Resorption was noted compromis-
ing the width of the ridge at the buccal leading
to a mild concavity (Figure 3). Sinus augmen-
tation was discussed to assist in achieving
the patients desired treatment goal of implant
placement and restoration with a fixed crown.
Following administration of local anesthetic,
a crestal lingual incision was made with verti-
cal releasing incisions at the mesial and distal
aspect of the site and a full thickness flap was
elevated, leaving the attached gingiva undis-
turbed on the adjacent teeth (Figure 4). Eleva-
tion of the flap extended superiorly to expose
the lateral wall of the maxillary sinus up to
the inferior aspect of the zygoma (Figure 5).
A 5mm wide Dome drill was placed onto
the surgical handpiece with a 0.5mm drill stop-
Figure 7: Lateral sinus approached initiated with the
Dome drill and a 0.5mm drill stopper.
Figure 8: The initial Dome drill created an outline into the
bony wall.
Figure 9: Lateral sinus approached continued with the
Figure 10: Bone is collected from the Dome drill to be
utilized to augment the graft to be placed.
Kurtzman et al

26 • Vol. 6, No. 3 • June 2014
Figure 11: Following each Dome drill the site is examined
for identification of the underlaying membrane which will
appear darker as bone is removed over it.
Figure 14: Lateral wall of the maxillary sinus following
sequential use of the Dome drill with increasing stopper
depth demonstrating no damage to the sinus membrane
after bone removal.
per (Figure 6). This would allow initiation of the
window without the possibility of excessive pen-
etration and subsequent damage to the sinus
membrane. The initial Dome drill is placed onto
the surgical handpiece with the selected drill stop.
The Dome drill with stopper was placed on the lat-
eral sinus wall at a height more superior then the
current height of the available bone as measured
radiographically (Figure 7). This is done to ensure
that the window created has elevated the mem-
brane circumferentially. When maximum depth
has been achieved with the 0.5mm drill stopper
present, the drill stopper is changed to a 1.0mm
stopper and drilling is continued (Figure 8). The
drill stopper is sequentially increased checking
for membrane exposure. Lateral drilling continues
Kurtzman et al

Figure 15: A curette is utilized to separate the sinus
membrane from the bone of the maxillary sinus, elevating
it superiorly from the inferior floor to the medial wall.
Figure 16: Lateral window completed demonstrating the
intact sinus membrane following use of the Dome drills
and stoppers.
Figure 17: A collagen membrane is placed into the sinus
over the elevated membrane to help confine the graft to be
placed should a micro tear be present in the elevated sinus
membrane.
Figure 18: Osseous graft material was mixed with the
patients donor bone collected from the Dome drills and is
gently packed into the sinus.
stepping up to the next drill stop (Figure 9). Bone
collected on the Dome drills is removed from the
drill and placed into a sterile dish to be added to
the graft to be placed, adding the host’s osteo-
potential cells to the graft (Figure 10). As bone
is removed over the sinus membrane, the area
changes in color from the light color of the bone
(ivory) to darker gray as the dark sinus begins
to show clinically at the window (Figure 11).
Final window creation is made with the
Dome drill, in this particular case with a 2.5mm
drill stopper (Figure 13). Some patients may
require deeper drilling which is dependant on
thickness of the lateral maxillary sinus wall. The
intact sinus membrane is noted with no bone
over the membrane at the window that has been
Kurtzman et al

28 • Vol. 6, No. 3 • June 2014
Figure 19: The elevated sinus area has been completely
packed with osseous graft material.
Figure 20: Implant placement following osseous graft
healing demonstrating the new sinus height achieved.
Figure 21: A resorbable membrane was placed over the
boney sinus window to limit soft tissue ingrowth into the
graft during the healing phase.
created on the lateral wall (Figure 14). Addi-
tional, host bone is collected from the Dome drill.
Sinus curettes are utilized to start the sinus
membrane elevation at the inferior aspect, teasing
the membrane from the osseous wall of the sinus
interiorly (Figure 15). Following elevation of the
membrane, the membrane should be intact and
free of visible tears that may prevent graft distribu-
tion within the sinus during initial healing (Figure
16). It is important that the elevation also include
the medial wall of the sinus so that fills a volume
great enough that the implant when placed will be
surrounded by bone. Failure to elevate the medial
aspect may result in the implant when placed
having no osseous contact which may decrease
clinical success following loading. Additionally,
the authors advise elevation to a greater height
then the implant length to be placed when a
delayed fixture placement is to be performed. This
will allow for possible graft settling during heal-
ing that may yield less height then was planned.
An absorbable extracellular membrane
(Dynamatrix, Keystone Dental, Burlington, MA)
is inserted into the sinus to act as protec-
tion containing the graft material and thicken
the sinus membrane sealing any micro tears
that might be present (Figure 17). The resor-
able membrane is cut to size and placed into
the sinus dry using the patients blood in the
site to wet it as its placed. Once wetted with
blood the resorable membrane becomes
sticky gluing itself to the sinus membrane.
Kurtzman et al

Figure 22: The flap was repositioned and closed with a
horizontal mattress and interrupted sutures.
Figure 23: I mplant following 8 months healing and
exposure to place a healing abutment demonstrating
blending of the grafted sinus with the surrounding native
bone.
Figure 24a: CBCT demonstrating new volume of bone
achieved following sinus augmentation and implant
placement which is ready for restoration of the implant.
Figure 24b: CBCT demonstrating new volume of bone
achieved following sinus augmentation and implant
placement which is ready for restoration of the implant.
Regenform Cortical Cancellous Bone Chips
(Exatech, Gainsville, FL) and Sureoss, a freeze-
dried cortical allograft (Hiossen, Philadelphia,
PA) in a 50:50 ratio in a sterile dappen dish
and mixed with the autogenous bone collected
from the Dome drill. The osseous graft mixture
was carried to the oral cavity and introduced
into the elevated sinus and gently condensed
with a large plugger, pushing the mixture to the
medial wall and filling in a lateral direction until
Kurtzman et al

30 • Vol. 6, No. 3 • June 2014
the entire cavity was filled (Figure 18). The pro-
cess was repeated in the cavity anterior to the
septa. Sufficient osseous graft was placed till
the sinus was augmented to be flush with the
outer aspect of the lateral sinus wall at the
window that had been created (Figure 19).
Following sinus grafting the site was pre-
pared and an implant (4.5 x 10mm, ETIII, Hios-
sen, Philadelphia, PA) was placed and the site.
A low profile cover screw was used to allow pri-
mary closure of the flap. The radiograph shows
initial graft placement and the elevation achiev-
ing a site that can accommodate implant place-
ment at this surgical appointment (Figure 20).
A long term resorbable membrane (Dyna-
matrix) was cut to extend beyond the outline of
the lateral window and placed over the osseous
graft that had been placed into the sinus (Fig-
ure 21). The flap was repositioned and initially
closed with a horizontal mattress suture using
a 5-0 Cytoplast suture material, (Osteogenics
Biomedical, Inc., Lubbock, TX) to achieve pri-
mary closure of the flap without tension then
the crest was closed with interrupted sutures
(Figure 22). This suture serves to resist soft
tissue tension that may result due to inflamma-
tion and the resulting swelling following surgery.
Additional sutures are placed to close the inci-
sion line using a simple interrupted technique.
The patient returned 8 months following
implant placement. Soft tissue in the site on
the lateral aspect demonstrated no inflam-
mation and incision lines were not discern-
able on the gingiva. The implant was exposed
using a disposable tissue punch and the cover
screw was replaced by a healing abutment.
A radiograph was taken to check and verify
the organization of the osseous graft that had
been placed into the sinus, integration of the
implant and seating of the healing abutment
on the fixture (Figure 23). A CBCT was taken
to check the graft and implant integration and
the implant is ready to be restored (Figure 24).
Conclusion
Emphasis has moved to the use of a crestal
approach to sinus elevation when additional
osseous height is required for implant place-
ment. This approach works well when at
least 5mm of osseous height is present for
immediate implant placement. Yet, when
less bone height is present, a lateral window
approach may be the preferred technique to
increase crestal height and geometric vol-
ume so that implant fixtures may be placed.
The lateral sinus augmentation approach
can be challenging as tearing of the sinus
membrane often necessitates abandoning the
procedure and re-entry at a later date after
the membrane has healed. Previous tech-
niques involved use of diamonds or carbides
in a highspeed handpiece or the use of peizo
surgical units. These approaches had poten-
tial for membrane damage (burs in a high-
speed) or were very slow (peizo). The LAS Kit,
from Hiossen utilizes special designed drills
that greatly minimize tearing of the membrane
and improve the safety of the procedure. ●
Correspondence:
Dr. Gregori Kurtzman
3801 International Drive, Suite 102
Silver Spring, MD 20906
301-598-3500
Kurtzman et al

Disclosure
The authors report no conflicts of interest with anything mentioned in this article.
References
1. Blomqvist JE, Alberius P, Isaksson S. Two maxillary sinus reconstruction with
endosseous implants: A prospective study. Int J Oral Maxillofac implants 1998;
13:758-766.
2. Valentini P, Abensur DJ. Maxillary sinus grafting with anor-ganic bovine bone: A
clinical report of long-term results. Int J Oral Maxillofac Implants 2003; 18:556-
560.
3. Tong DC, Drangsholt M, Beirne OR. A review of survival rates for implants
placed in grafted maxillary sinuses using meta-analysis. Int J Oral Maxillofac
Implants 1998; 13:175-182
4. Tatum OH Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am
1986; 30:207-229
5. Rosen PS, Summers R, Mellado Jr, et al. The bone-added osteotome sinus
floor elevation technique: multicenter retrospective report of consecutively
treated patients. Int J Oral Maxillofac implants 1999; 14:853-858
6. Summers RB. A new concept in maxillary implant surgery: the osteotome
technique. Compend Contin Educ Dent 1994; 15:152-162
7. Summers RB. The osteotome technique: part 3- less invasive methods of
elevating the sinus floor. Compend Contin Educ Dent 1994: 15:698-710
8. Emmerich D, Att W, Stappert C. Sinus floor elevation using osteotomes: a
systemic review and meta-analysis. J periodontal 2005; 76:1237-1251
9. Toffler M. Osteotome- mediated sinus floor elevation: a clinical report. Int J Oral
Maxillofac implants 2004; 19:266-73
10. Peleg M, Mazor Z, Chaushu G, Garg AK. Sinus floor augmentation with
simultaneous implant placement in the severely atrophic maxilla. J Periodontal
1998; 69:1397-1403
11. Peleg M, Mazor Z, Garg AK. Augmentation grafting of the maxillary sinus
and simultaneous implant placement in patients with 3 to 5 mm of residual
alveolar bone height. Int J Oral Maxillofac implants 1999; 14:549-556
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Wilcko et al
S
uccessful treatment with the two-implant
overdenture has been documented with
multiple implant designs (ie. hexago-
nal, Morse taper, internal connection) and many
implant systems. Clinicians may select implants
for retention of the two-implant overdenture
according to personal experience and prefer-
ence with confidence that treatment success
will not be determined by the selection made.
This is due primarily to the anatomy and den-
sity of the bone in the anterior mandible. The
aim of this case report is to demonstrate the
concept of immediate functional loading in the
mandible using unsplinted implants to support
a locator attachment supported overdenture.
Loading of Two Implants in the
Mandible and Final Restoration with a Locator:
A Case Report and Review
Dr. A. Abdulgani1
• Dr. M. Bajali2
• Dr. M. Abu-Hussein3
1. Assist.Professor, Al Quds University, Jerusalem, Palestine
2. Assistant Professor, Al Quds University, Jerusalem, Palestine
3. Visiting Professor, Napoli university, Italy and University of Athens, Greece
Abstract
KEY WORDS: Dental implants, denture, locator attachments, overdenture

34 • Vol. 6, No. 3 • June 2014
Abdulgani et al
Introduction
Dental implants are prosthetic devices, made
of alloplastic materials that are inserted into the
oral cavity to provide retention and support to
removable and fixed dental prostheses.1,2
The
concept of using implants to replace teeth is
age old. In fact, in ancient history thousands of
years ago, ivory teeth were used as implants in
Egyptian mummies. However, the era of mod-
ern dental implantology began much later, in
the 1940’s, with the discovery of screw type
implants by Formiggini et al.3,4
The introduc-
tion of the concept and the biology of osseoin-
tegration, by Branemark et al.5
added another
milestone in the history of dental implantol-
ogy. Over the years, this field has signifi-
cantly evolved and emerged as an extensively
used treatment modality for oral rehabilitation.
The first clinical outcome of surgical pro-
cedure is the primary stability of the implant.
Primary stability is rigid fixation and lack of
micro motion of the implant into the bone cav-
ity.1,6,7
Absence of stability can lead to exces-
sive mobility and cause fibrous tissue formation
around the implants inhibiting osseointegra-
tion.7,9
Primary stability depends on the surgi-
cal technique, implant design and the implant
site.9,10
Bone tissue is arranged in two macro
architectural forms, trabecular or cancellous
and cortical or compact. Leckholm and Zarb
(1985) have classified bone types in the oral
cavity, depending on the relative proportions
of cancellous and cortical bone: A) Class I:
predominantly cortical; B) Class II: thick layer
of compact bone surrounding a dense cancel-
lous core; C) Class III: thin layer of compact
bone surrounding a cancellous core; D) Class
IV: very thin compact layer around a low den-
sity trabecular bone. Sennerby et al.11
com-
pared implants placed in rabbit cortical versus
cancellous bone and established that corti-
cal bone has a higher modulus of elasticity, is
harder to deform and provides greater resis-
tance to motion. Hence, Class I and Class II
bone would facilitate higher primary stability
The original protocol for loading, as
described by Branemark, involved waiting for
three months (for mandible) to six months (for
maxilla) after implant placement. Such a delayed
loading protocol was aimed at allowing undis-
turbed healing and complete osseointegra-
tion before implants could be loaded. For a
long time it was assumed that premature load-
ing would limit peri-implant osteogenesis and
induce fibrous tissue formation.7,12
Schnitman
et al. introduced the concept of immediate
loading, which has been described as attach-
ment of the prostheses within twenty-four
hours to one week after implant placement.13,14
Some of the advantages of immediate load-
ing are shortened treatment time and early
functional, physiological and psychological
rehabilitation of the patient. In addition, there
have been some claims made about a biologic
advantage in the form of enhanced osteoblas-
togenesis with immediate loading. An in-vivo
study by Qi et al. evaluated the response of
mesenchymal stem cells to mechanical strain
and their consequent gene expression pat-
terns.15
Their results suggested that mechani-
cal strain might act as a stimulator to induce
differentiation of stem cells into osteoblasts.15
Indeed, cyclic tensile strain has been shown
to increase osteoprotegrin synthesis and
decrease soluble receptor activator of nuclear
factor kappa-B ligand (RANKL), thus favoring
Abdulgani et al

bone formation.16
This theory was tested in an
rabbit model by Duyck et al. who concluded
that mechanical loading stimulated bone for-
mation and led to a higher bone fraction.17,18
Treatment of Complete Edentulism with
Implant Overdentures
An overdenture is defined as any dental pros-
thesis that covers and rests on one or more
remaining natural teeth, the roots of natural
teeth, and /or dental implants.2
The concept
of overdentures is age old. Ledger as early as
1856, suggested utilizing natural teeth to sta-
bilize removable prostheses and after a whole
century Miller introduced the concept of tooth
retained overdentures.19
The downside of
these prostheses was frequent failure of abut-
ments caused by periodontal disease, peri-
apical lesions, caries and fracture of teeth.20
The introduction of osseointegrated implants
and implant-retained prostheses led to a para-
digm shift for the management of edentulism.
This is true especially for mandibular edentu-
lism, where the problem of advanced alveo-
lar resorption and difficulty in providing stable,
retentive and functionally comfortable prosthe-
ses seemed to represent a major challenge.21
A number of randomized controlled tri-
als have demonstrated increased patient
satisfaction and reduced negative impact
on quality of life with implant retained over-
dentures as opposed to conventional den-
tures in the mandible.22
Other studies have
reported an improvement in chewing abil-
ity, bite force and in serum nutritional and
anthropometric parameters (such as skin
fold thickness, waist hip ratio and body mass
index).23,24
The long-term efficacy of implant-
supported overdentures has been established
in many retrospective and longitudinal trials.25-27
Implant overdentures are used in conjunc-
tion with attachments and there are many
different attachments provided by a large
number of manufacturers around the world.
The attachments currently available can be
broadly divided into two major categories: A)
Splinted / Bar Attachments (Dolder bar and
Hader bar are examples of splinted attach-
ments); B) Non-splinted / Solitary / Stud
Attachments (Ball attachments, magnets
and locators exemplify solitary attachments).
Loading of Implant Overdentures
A fairly recent systematic review by Gallucci
et al (2009), presented the strength of evi-
dence available for different loading protocols
(conventional, early and immediate loading) in
completely edentulous patients. Their search
led to a conclusion that the highest level of
scientific and clinical validation was avail-
able for conventional loading with mandibu-
lar overdentures. However, immediate loading
of mandibular dentures was clinically well
documented but not scientifically validated.28
Clinical documentation of immediate load-
ing can be exemplified by various prospective
trials that have been conducted using this pro-
tocol for mandibular dentures. For example, a
longitudinal study with 3-8 years of follow up by
Chiapasco et al.33
looked at success and sur-
vival of immediately loaded implants supporting
a mandibular overdenture. Four implants were
placed per patient, connected by a splinted
bar attachment. A cumulative success rate of
Abdulgani et al

36 • Vol. 6, No. 3 • June 2014
88.2% and survival rate of 96.1% was seen
after a mean follow up period of 62 months.
The authors concluded that, for about 3 years
after immediately loading the implants, the suc-
cess and survival were the same as that docu-
mented for delayed loading. However, with a
longer follow up it became evident that immedi-
ately loaded implants had a moderate decrease
in success rate.29
Similar results were reported
by Kronstrom et al.30
wherein he advised cau-
tion in using immediate loading due to a low
survival rate of 81.8% at 1 year follow up.
Other investigators have, however, reported
higher rates of success and survival using
an immediate loading protocol. A cohort
study by Gatti et al.31
has shown a cumula-
tive survival rate of 100% and minimal bone
level changes (0.5–0.9 mm) around immedi-
ately loaded implants. Alfadda et al.32
used
historical controls with delayed loading in a
prospective cohort study and compared it to
immediate loading. At 5 years, they found iden-
tical success, survival, satisfaction and impact
on quality of life between the two groups.
Randomized clinical controlled trials (RCT)
are considered as the most reliable (Level I)
form of validation in the hierarchy of scien-
tific evidence, essentially because they reduce
spurious causality and bias. In order to prove
the efficacy and safety of an immediate load-
ing protocol Chiapasco et al.33
performed a
RCT comparing an immediate and a delayed
protocol for four splinted implants supporting
a mandibular overdenture. They found no dif-
ference in cumulative survival rate, bone loss,
clinical and radiographic parameters at 2 years
between the two groups. A review paper by
Gallucci et al (2009) and a 10 years clinical
trial by Meijer et al (2009), among many oth-
ers, have shown that there is no difference in
the clinical and radiographic performance of
two or four implants supporting a mandibular
overdenture.27,28
Hence, having established
that immediately loaded four implants support-
ing a mandibular overdentures are comparable
to delayed loaded implants, it would be inter-
esting to see if these results can be replicated
when two implants were used in conjunction
with unsplinted attachments such as locators.
Case Report
A 58-year-old female patient without any medical
contra-indications for implant therapy presented
with an ill-fitting, lower complete denture that
she had been wearing for four years. The clini-
cal and radiographic findings revealed slight to
moderate mandibular ridge resorption with an
ill-fitting lower denture (Figs. 1, 2). The patient
was given the option of placing two implants
to support her existing lower denture. The
treatment plan was accepted and included an
immediate functional loading by using a locator
attachment-supported mandibular overdenture.
At the surgical appointment, following the
administration of local anesthetic, a mid-crestal
incision was performed and a full-thickness
flap was reflected. In addition, osteotomies
were prepared in type II bone. Bone taps were
used to countersink the sites, after which two
ITI Tapered implants (ITI 3.3X14-mm) were
placed with the hand piece and hand ratchet.
The implants were torqued to 35 N (Figs. 3, 4).
Immediately after implant surgery (Fig. 5), the
mandibular denture was seated in the patient’s
mouth and adjusted to provide clearance in
the area of the locators (Fig. 6). Two locators
Abdulgani et al

(4 mm in length) were torqued to 30 N (Figs.
7, 8). Following the suture of the flap with4-0
vicryl, the processing rings were placed over
the locators and were picked up directly in the
mouth using hard self-curing acrylic (Rebase II,
Tokuyama; Fig. 7). The patient was given post-
operative instructions, including the use of 0.12
% chlorhexidine gluconate three times a day.
She was furthermore prescribed 500 mg of
amoxicillin (to be taken every six hours for seven
days). The patient was then informed that the
implant-supported overdenture was to be left
in place for 48 hours. Two days later, she was
seen for a follow-up visit and the healing pro-
cess was uneventful. The black processing
rings were switched to blue rings ten weeks
after placement. After six months, the patient
returned for another follow-up visit and both
locators were torqued to 30 N again. It was
determined that both implants had achieved full
integration. Currently, the patient is on a six-
month recall to ensure the proper maintenance
Figure 1: Mandible at the time of implant placement with
moderate bone resorption.
Figure. 2: Pre-op panoramic radiograph.
Figure 3: Guiding pins at the time of implant placement. Figure 4: Two tapered implants at placement.
Abdulgani et al

38 • Vol. 6, No. 3 • June 2014
Figure 9: Buccal view of the overdenture in place. Figure 10: Final smile.
Figure 5: Panoramic radiograph immediately after implant
placement.
Figure 6: The processing rings were picked up directly in
the mouth.
Figure 7: Occlusal view of the locators two weeks post-
implant placement.
Figure 8: Buccal view of the locators two weeks post-
implant placement.
Abdulgani et al

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of the implants and the prosthesis (Figs. 9, 10).
The last maintenance visit was 24 months post-
placement and all implants have maintained
healthy soft tissue and a stable bone level.
Conclusion
Within the limits of this interim report, immedi-
ate loading of two implants supporting a loca-
tor retained mandibular overdenture seems
to be a suitable treatment option. The mar-
ginal bone level changes around immediately
loaded implants are comparable to those seen
around implants loaded with a torque do not
effect peri-implant bone loss. Implant sur-
vival of immediately loaded implants maybe
lower than those loaded with a delayed pro-
tocol, but this needs to be confirmed in future
investigations with a larger sample size. ●
Correspondence:
Dr. Abu-Hussein Muhamad
123 Argus Street
10441 Athens
Greece
abuhusseinmuhamad@gmail.com
Abdulgani et al

40 • Vol. 6, No. 2 • June 2014
Disclosure
The authors report no conflicts of interest with anything mentioned in this article.
References
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14. Schnitman PA, Wohrle PS, Rubenstein JE: Immediate fixed interim prostheses
supported by two-stage threaded implants: methodology and results. J Oral
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15. Qi MC, Zou SJ, Han LC, Zhou HX, Hu J: Expression of bone-related genes in
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17. Duyck J, Slaets E, Sasaguri K, Vandamme K, Naert I: Effect of intermittent
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chamber model. J Clin Periodontol 2007, 34(11):998-1006.
18. Vandamme K, Naert I, Vander Sloten J, Puers R, Duyck J: Effect of implant
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20. Fenlon MR: Periodontal disease, periapical lesions and caries were, in that
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Lund JP, MacEntee M, Mericske-Stern R et al: The McGill consensus statement
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22. Thomason JM, Lund JP, Chehade A, Feine JS: Patient satisfaction with
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26. Attard NJ, Zarb GA: Long-term treatment outcomes in edentulous patients
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27. Meijer HJ, Raghoebar GM, Batenburg RH, Visser A, Vissink A: Mandibular
overdentures supported by two or four endosseousimplants: a 10-year clinical
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supporting a ball attachment-retained mandibular overdenture: a prospective
clinical study. Clin Implant Dent Relat Res2007, 9(3):136-143.
29. Chiapasco M, Gatti C: Implant-retained mandibular overdentures with
immediate loading: a 3- to 8-year prospective study on 328 implants. Clin
Implant Dent Relat Res 2003, 5(1):29-38.
30. Kronstrom M, Davis B, Loney R, Gerrow J, Hollender L: A prospective
randomized study on the immediate loading of mandibular overdentures
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31. Gatti C, Chiapasco M: Immediate loading of Branemark implants: a 24-month
follow-up of a comparative prospective pilot study between mandibular
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32. Alfadda SA, Attard NJ, David LA: Five-year clinical results of immediately
loaded dental implants using mandibular overdentures. Int J Prosthodont 2009,
22(4):368-373.
33. Chiapasco M, Abati S, Romeo E, Vogel G: Implant-retained mandibular
overdentures with Branemark System MKII implants: a prospective comparative
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2001, 16(4):537-546.
Abdulgani et al

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Background: Smile makeover with the use of
All Ceramic restorations is a proven and well
accepted modality. When there is a violation of
biological width in such cases, soft and hard
tissues might be trimmed to achieve a healthy
foundation and ideal proportions. Recent publi-
cations suggest a more conservative approach
to address this situation, namely the Biologic
Shaping. A case of biologic width impingement
is presented here in which the need for crown
lengthening was substantially reduced due to
application of principals of biologic shaping.
Methods: A female patient, 24 years old pre-
sented with unsightly crowns on teeth no. 13 to
33(FDI). Clinically, the porcelain fused to metal
crowns had overhanging and impinging margins,
improper proportions and a very monochromatic
artificial appearance. The teeth were also end-
odontically treated which was also unsatisfac-
tory. All endodontics treatment was repeated
and crowns were removed. After reshaping
the abutments, temporary restorations were
provided and incrementally adjusted which
allowed the soft tissues to heal and regain
their shape. Minimal gingivoplasty was required
on teeth no 11 and 21. A healing period was
followed by the final preparations and place-
ment of 6 all ceramic (Empress 2) crowns.
Results: The concept of biologic shap-
ing allowed to complete the case with mini-
mal surgical intervention and resulted in
an extremely happy and satisfied patient.
Conclusions: Biologic shaping is a con-
servative option to treat cases with bio-
logic width impingement and can be
successfully used in the aesthetic zone.
Smile Makeover with all
Ceramic Crowns and Biologic Shaping
Dr. Arshad Hasan1
1. Associate Professor and Head of Operative Dentistry, Dow Dental College, Dow University of Health Sciences,
Baba-e-Urdu Road, Karachi Pakistan
Abstract
KEY WORDS: Biological width, Biologic shaping, All ceramic restorations, IPS Empress 2, Bleaching,
Smile makeover, Golden proportions, Endodontic retreatment

44 • Vol. 6, No. 3 • June 2014
Hasan
Introduction
Biologic width violation is treated convention-
ally by either surgical crown lengthening or orth-
odontic extrusion.1
Former procedure requires
the operator to remove significant hard and
soft tissues, so that a 3mm zone is established
from the margin of restoration to the crestal
bone as described by Gargiulo.2
This results
in significant and often un-necessary removal
of soft and hard tissues to achieve the objec-
tive. It also doesn’t allow for individual varia-
tion of biologic width to exist as it forces a
3mm rule to every tooth.3
Biologic shaping
was recently introduced by Melker which allows
individual variation in biologic width to exist
and significantly reduces the need for soft and
hard tissue removal.4
In the first appointment
a buccal partial thickness and palatal full thick-
ness flap is raised, root surfaces are rendered
clean of irregularities, existing restorative mar-
gins and calculus. A series of diamonds from
coarse to extra-fine are used to give a smooth
root surface. This is followed by apically repo-
sitioned flap closure and healing by second-
ary intention is encouraged. A provisional
restoration with 1mm clearance from gingival
margin is placed over the teeth and left there
for 3 months. Once the gingival apparatus has
healed, permanent restorations are provided
with margins just coronal to this newly estab-
lished gingiva.3
The case presented here was
treated by the author without the knowledge of
these principals at the time of treatment. How-
ever, the ideology was similar i.e. to allow gin-
gival tissues to heal and regain their original
dimensions before provision of permanent resto-
rations rather than surgical crown lengthening.
Figure 1: Pre-operative view.
Figure 2: Pre-operative view.

Hasan
Case Report
A 24 year old medically healthy female presented
to the Department of Operative Dentistry, Ham-
dard University Dental Hospital in April 2009.
Her chief complaint was poor aesthetics of front
six maxillary teeth. Clinically there were six indi-
vidual porcelain fused to metal crowns pres-
ent on teeth no 6, 7, 8, 9, 10, and 11 (FDI tooth
numbering system). The crowns were mono-
chromatic and had overhanging and impinging
margins. The soft tissues adjacent to these res-
torations were edematous and bled on prob-
ing (Figure 1). There was an asymmetry of
papilla between teeth 7-10. An adequate band
of attached gingiva was present. Radiographic
evaluation revealed inadequate endodontic treat-
ment of all restored teeth (Figure 2). A diagnosis
of biologic width impingement was made based
Figure 3: Assessment of teeth proportions.
Figure 4: Endodontic retreatments. Figure 5: Putty stent for temporization.

46 • Vol. 6, No. 3 • June 2014
Hasan
on clinical findings and probing depths. Further
digital smile analysis revealed that teeth 8 and
9 had improper width to length ratio and were
shorter than the smile arc (Figure 3). The treat-
ment plan included retreatment of inadequate
endodontics, tooth reshaping, long term provision-
alization, reassessment of aesthetic proportions
and delivery of final all ceramic (IPS EMPRESS
2, Ivoclar Vivadent, Liechtenstein) restorations.
The endodontic retreatments were performed
through the existing crowns to facilitate place-
ment of rubber dam (Figure 4). Once endodon-
tics was complete, a putty stent (Express STD,
3M ESPE, Seefeld Germany) of existing restora-
tions was made (Figure 5). The existing crowns
were removed by cutting a groove through the
facial surface and twisting with a plastic instru-
ment. Once removed the damage to the soft tis-
sues was evident (Figure 6). A soft tissue flap
was not raised as the author was not aware of
the principals of biologic shaping at that time.
However, a plan was made to allow the soft tis-
sues to heal, recoil and regain its natural dimen-
sions without dictating any dimensions. The
teeth were lightly prepared with a chamfer bur
to remove the debris (Figure 7). The putty stent
Figure 6: Extensive damage to soft tissues revealed. Figure 7: Initial preps and cleaning of debris.
Figure 8: Fabrication of temporary restoration using the
putty stent.
Figure 9: Adjustment of contours of temporary
restoration.

Hasan
Figure 10: 1 week healing after temporization.
Figure 11: Biologic shaping, gradual relief of temporary
restoration to allow the soft tissues to regain health.
Figure 12: Non-vital bleaching to lighten discolored teeth
no. 9 and 10.
was used to fabricate a provisional using an auto
polymerizing resin (Protemp, 3M ESPE, Seefeld
Germany) (Figure 8). The margins of the provi-
sional restoration were kept short of the gingi-
val margins to facilitate healing (Figure 9). The
results were immediately evident at 1 week recall
as there was excellent tissue healing (Figure 10).
The margins of provisional were further modi-
fied over a period of 3 appointments and papilla
between teeth 8 and 9 was allowed to become
symmetrical with its counterpart (Figure 11). Dur-
ing these appointments teeth 9 and 10 were
also bleached since they exhibited discoloration
(Figure 12). A classic walking bleach technique
was used here with a mixture of sodium perborate
(Nanchang Dental Bright Technology, China) and
hydrogen peroxide (Hydrogen Peroxide Solution,
Karachi Pharmaceutical Laboratories, Karachi).
After the completion of bleaching and soft
tissue healing, the dimensions were once again
assessed. Teeth 8 and 9 were found to have
improper width to length ratio (Figure 13). This
evaluation showed that both central incisors could
be lengthened incisally and cervically. The teeth
were probed to reveal an adequate sulcus depth,
a gingivectomy was performed to bring the gingi-
val margins to correct a level, as determined by the
post provisionalization aesthetic evaluation (Fig-
ure 14). Once this surgical site healed, the cor-
onal structure of teeth 9 and 10 were reinforced
with fiber posts (Rebuilda Post, Voco Germany).
The posts were luted with a self-adhesive resin
(Breeze, Pentron Clinical Technologies, Walling-

48 • Vol. 6, No. 3 • June 2014
Hasan
Figure 13: Final assessment of proportions after biologic
shaping.
Figure 14: Aesthetic crown lengthening, 1 week post-
operative healing.
Figure 15: Fiber posts placed in teeth no 9 and 10.
ford, Connecticut, USA)(Figure 15). Core build-
ups were performed with a fiber reinforced dual
cure core buildup resin (Buildit FR, Pentron Clini-
cal Technologies, Wallingford, Connecticut, USA).
The teeth were now ready for final prepara-
tions. The finish line was at the level of gingival
margin in teeth 8 and 9, however it was subgin-
gival in rest of teeth (Figure 16). An impression
was recorded with an addition silicon material in
a stock tray. The impression of opposing arch
was recorded with alginate in a stock tray. Bite
registration paste was used to register the centric
occlusion. Shade A1 was selected for body of
crowns and A2 for the gingival third. Slight inci-
sal translucency was requested since patient was
still young. The case was then sent to lab for fab-
rication of All Ceramic crowns (IPS EMPRESS
2, Ivoclar Vivadent, Liechtenstein). The case was
received from the lab 2 weeks later (Figure 17).
It was first tried in and was found to be adequate
with respect to occlusion, margins, contact,
emergence profile and aesthetics. The restora-
tions were luted with dual cure luting resin of A1
shade (RelyX Unicem, 3M ESPE, Seefeld, Ger-
many) (Figure 18). The cement was cured with
a light curing unit (Elipar Freelight, 3M ESPE,
Seefeld Germany), excess removed and patient
was dismissed with home care instructions.
The patient returned on a follow up visit
2 months later (Figure 19). The gingival tis-

Hasan
Figure 16: Final teeth preparations for All ceramic crowns.
Figure 17: All ceramic IPS Empress 2 crowns on cast,
(Ceramist, Mohammad Ali Khan, Khan Dental Laboratories,
Karahi).
Figure 18: Front and side profile after final cementation.
sues exhibited excellent health. There was
complete papilla fill in all embrasures. How-
ever a slight swelling in interdental papilla was
noticed between teeth 7 and 8. Since there was
no bleeding on probing and probing depths
were within normal limits, no further action was
taken. Also the gingiva on tooth 9 had grown
over the crown margin and altered the width
to length ratio. The patient returned on a sec-
ond follow-up a year later and presented a simi-
lar healthy gingival tissue except between teeth
7 and 8 (Figure 19). The patient was extremely
satisfied with the results, while operator was
concerned about the slight gingival swelling.
Discussion
Health, function and aesthetics are the three most
important aspects of Aesthetics Dentistry which
must be addressed to obtain exceptional results.

50 • Vol. 6, No. 3 • June 2014
Hasan
Figure 19: 2 month and 1 year recall. Figure 20: Before and after.
While health and function can exist indepen-
dently, aesthetics cannot be achieved unless the
former two are obtained.5
Aesthetic cases with
biologic width violation are most challenging to
treat, since there is not only an unhealthy soft tis-
sue response, tooth to tooth proportions are also
usually incorrect. Traditionally, these cases have
been treated with surgical crown lengthening
alone. Major disadvantage of crown lengthening
procedure is the need to remove bone and gin-
giva, sometimes unnecessarily to fulfill biological
objectives. Another shortcoming is that it brings
the narrower part of root more coronally and this
results in compromised emergence profile, tri-
angular gingivae and possible black triangles.1
Biologic shaping was introduced by Melker
to address the shortcomings of surgical crown
lengthening. The benefits of this procedure have
been explained by Melker.4
The author was
not aware of this technique since the case was
treated in 2009 and hence could not apply all
the principals of this novel concept. We cleaned
the tooth surface and provided a long term provi-
sional with margins short of gingiva as proposed
by Melker.3
Definitive restorations were placed
(IPS EMPRESS 2, Ivoclar Vivadent, Liechten-
stein) after ensuring adequate healing of soft tis-
sues. However two undesirable events occurred
on follow up. The interdental papilla between
teeth number 7 and 8 exhibited slight swelling but
did not bled on probing. Also the gingiva on tooth
9 had grown over the crown margin and altered
the width to length ratio. Both the events were
not expected. However, the patient was not both-
ered about either and no further action was taken.
Conclusion
Biologic shaping is a conservative option to treat
cases with biologic width impingement and can
be successfully used in the aesthetic zone. ●
Correspondence:
Dr. Arshad Hasan
Dow Dental College, Dow University of Health
Sciences
Baba-e-Urdu Road, Karachi Pakistan
Phone Office: 009221-99215754 ext 324
Cell No. 0092321-2437304
Email: arshadhasan@gmail.com

Hasan
Disclosure
The author reports no conflicts of interest with anything mentioned in this article.
References
1. Sadan A, Adar P. Esthetic proportions versus biologic width considerations: a
clinical dilemma. J Esthet Dent. 1998;10(4):175-81.
2. Gargiulo A, Wentz F. Dimensions of the dentogingival junction in humans. J
Periodontol. 1953;32:261-7.
3. Melker DJ, Richardson CR. Root reshaping: an integral component of periodontal
surgery. Int J Periodontics Restorative Dent. 2001 Jun;21(3):296-304.
4. Melker DJ. Biologic shaping from a restorative prospective. J Implant Adv Clin
Den. 2013;5(8):27-32.
5. Ahmad I. The Health, Function and Aesthetic Triad. Protocols for Predictable
Aesthetic Dental Restorations: Blackwell Munksgaard; 2008. p. 21-54.
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Munakata et al
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Munakata et al
Background: The aim of this study was to
clarify the occurrence regions and sites of
peri-implant bone resorption and inflamma-
tion in Japanese partially-edentulous patients.
Methods: Five hundred one partially-edentu-
lous patients with 738 implants in function for
more than 5 years, were included in this study
for the evaluation of the bone resorption by
using dental radiograph and probing. Con-
sidering physiological bone remodeling, the
mean mesio-distal bone resorption around the
implant was measured on dental radiograph.
Results: In 65 patients (13.0% of the total
patients) with 76 implants (10.3% of the
total implants), peri-implant bone resorption
was identified. The mean functional loading
time of these implants was 8.4 years. Occur-
rence regions were frequently found in the
molar regions in maxilla (15.4%) and the molar
region in mandible (10.0%). In these lesions
detected radiologically, the bleeding on prob-
ing was seen in 95.2% of the buccal sites
in mandibular molar regions, 70.0% of the
palatal sites in maxillary molar regions and
56.7% of the buccal sites in maxillary molar
regions with statistically significant differences.
Conclusions: From the limitation of the infor-
mation in this study, it was concluded that the
sites that tend to be vulnerable to peri-implant
inflammation were the buccal site in mandi-
ble, and the buccal and palatal sites in maxilla.
Occurrence Regions and Sites of Peri-implant
Inflammation with Bone Resorption in
Japanese Partially-Edentulous Patients
Motohiro Munakata1
• Noriko Tachikawa1
• Katsuichiro Maruo2
,
Aoi Sakuyama1
• Yoko Yamaguchi1
• Shohei Kasugai1
1. Oral Implantology and Regenerative Dental Medicine, Tokyo Medical and Dental University, Tokyo, Japan,
1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8549, Japan.
2. Department of Prosthodontic Dentistry for Function of TMJ and Occlusion, Kanagawa Dental University
Abstract
KEY WORDS: Dental implants, peri-implantitis, bone loss

54 • Vol. 6, No. 3 • June 2014
Munakata et al
Introduction
Dental implants have been successfully used in
the treatment of complete and partial edentulous
patient subjects.1
Nevertheless, dental implant
failures have also been reported.2,3
These fail-
ures are classified on the basis of chronology, i.e.
early or late failure. Early dental implant failures
are attributed to surgical trauma, inadequate
bone volume, lack of primary stability, intra-osse-
ous infection, and bacterial contamination of the
recipient site.3,4
Late dental implant failures are
associated with peri-implantitis and/or biome-
chanical overload.2,3,5
In the Sixth European Work-
shop on Periodontology, peri-implant disease
was a collective term for inflammatory reactions
in the tissues surrounding an implant.6,7
“Peri-
implant mucositis” is defined as inflammation of
the mucosa around an implant without loss of
supporting bone, while “peri-implantitis” is char-
acterized by loss of supporting bone together
with mucosa inflammation. It has been reported
that peri-implant mucositis occurs in 80% of the
subjects and in 50% of the implant sites and that
peri-implantitis is identified in 28% and 56% of
subjects and in 12% and 43% of implant sites,
respectively.7
As potential risk factors for peri-
implantitis, Heitz-Mayfield8
listed the history of
periodontal disease, diabetes mellitus, smoking,
oral hygiene condition, alcohol intake, genotype,
presence of cornified mucosa, and the implant
surface property. Oral hygiene condition, history
of periodontal disease, smoking, and diabetes
mellitus, etc., have been reported as related risk
factors. Thus, the disease will be obviously more
frequent in the future, as long as a specific ther-
apy or prevention will not established. Clinically,
bleeding and/or suppuration following probing
has been proposed as a valuable clinical sign for
the diagnosis of both peri-implant mucositis and
peri-implantitis, while the concomitant detection
of marginal peri-implant bone loss in radiographs
will distinguish peri-implantitis from mucositis.7
Radiographic techniques including panoramic
tomography and intra-oral radiography with long
cone paralleling techniques have been widely
used to monitor marginal bone levels around
implants and diagnose interproximal bone
loss.9
However, conventional radiography does
not enable to monitor facial and lingual/palatal
bone levels (Photo 1) around the implants being
insensitive in detecting early bone changes and
underestimating bone loss.10,11
In clinical situa-
tions, cases where suppuration is found only on
the buccal side or lingual/palatal sites, cases
with BOP, or cases with advanced bone resorp-
tion on the buccal and lingual/palatal sites are
often experienced (Fig. 1). The aim of this study
was to clarify the occurrence regions and sites
of peri-implant bone resorption and inflamma-
tion in Japanese partially-edentulous patients.
Photo 1: Dental implant with significant facial bone loss.

Munakata et al
Material and Methods
The present clinical study was approved by the
Ethical Committee, Faculty of Dentistry, Tokyo
Medical and Dental University, and the writ-
ten informed consents were obtained from all
the patients. Subjects were 501 partial eden-
tulous Japanese patients (738 implants) who
received superstructure more than 5 years
ago. All the patients who had implants inserted
and superstructures made at Dental Hospital,
Tokyo Medical and Dental University, between
1999 and 2006, were examined. Severe illness,
uncontrolled diabetes, untreated periodontal
disease and a history of head and neck radia-
tion were excluded from the analysis. Probing
pocket depth (PPD) and bleeding on probing
(BOP) in the peri-implant sulcus where bone
resorption was observed on the dental radio-
graph were explored with the 4-point method.
In addition, the mean height of vertical bone
defects at the both sites of the mesial and distal
areas of implants was measured from the den-
tal radiographic evaluation at least 1 year after
the placement of the superstructures, since the
reference time point should be considered of
the bone remodeling within one year after load-
ing. In the radiographs the distance between
the reference point and the most coronal posi-
Figure 1: Frequent implant regions. Figure 2: Frequent implant sites of inflammation in
maxillary molar region.
Figure 3: Frequent implant sites of inflammation in
mandible molar region.

56 • Vol. 6, No. 3 • June 2014
tion of bone to implant contact was assessed at
the both of mesial and distal aspects of the 76
implants using a magnifying lens (×10) with a
0.1mm graded scale. Peri-implantitis was diag-
nosed when the bone resorption was pictured as
2 mm or larger on dental radiograph and further
BOP was observed in the peri-implant sulcus.
Data Analyses
● Reference of peri-implantitis in different
four regions
● Examination of BOP in implant sites
● Man-Whitney U-test was conducted for
comparisons between different regions
and sites. A p-value less than 0.05 was
considered statistically significant. All
statistical analyses were performed
using the IBM SPSS Statistics.21

Results
Peri-implantitis was diagnosed in 65 patients (76
implants) of the 501 patients (738 implants). The
patientrelatedprevalencerateofperi-implantitiswas
13.0% (smokers history: 25%). The implant related
prevalence rate of peri-implantitis was 10.3%.
Forty-two women and 23 men of 65 peri-implan-
titis were included in this study with the mean age
of 62.5 years. The mean time period after the place-
ment of the superstructure was 8.4 years. The mean
bone resorption in peri-implantitis was 3.8 ± 1.5
mm. The mean PPD was 5.6 ± 1.5 mm (Table 1).
Occurrence regions were frequently found
in the molar regions in maxilla (15.4%, p 0.01)
and the molar region in mandible (10.0%) (Fig. 2).
BOP around implant sites was observed in
the buccal sites of the molar regions in man-
dible with 95.2% of the rate (p 0.01), and
in the palatal and buccal sites of the molar
Figure 4: Morphological change of the bone due to peri-
implantitis in a case with sufficient width. Saucer-shaped
bone resorption occurs evenly toward the mesio-distal and
bucco-lingual directions.
Figure 5: Morphological change of the bone due to peri-
implantitis in a case with insufficient width. Defect of the
bucco-lingual bone wall and thread exposure are induced
during the process of developing saucer-shaped bone
resorption.
Munakata et al

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