Journal of Implant and Advanced Clinical Dentistry October 2013

Volume 5, No. 10 October 2013 The Journal of Implant & Advanced Clinical Dentistry Implant Stabilization of Dental Trauma Implant with Sinus Augmentation

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The Journal of Implant & Advanced Clinical Dentistry Volume 5, No. 10 • October 2013 Table of Contents11 Immediate Implant after Extraction of Lower Molar Tooth Sherman Lin19 P reventing Disfigurative Healing with Immediate Hard and Soft Tissue Treatment for Recent Dentoalveolar Trauma: A Case Report Dan Holtzclaw The Journal of Implant & Advanced Clinical Dentistry • 3

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The Journal of Implant & Advanced Clinical Dentistry Volume 5, No. 10 • October 2013 Table of Contents33 C omparison Between the Butt-Joint and Morse Taper Implant-Abutment Connection: A Literature Review Rola M. Shadid, Nasrin Sadaqah, Layla Abu-Naba’a, Wael M. Al-Omari42 S inus Augmentation with Immediate Implant Insertion: A Case Report Sherman Lin The Journal of Implant & Advanced Clinical Dentistry • 5

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The Journal of Implant & Advanced Clinical Dentistry Volume 5, No. 10 • October 2013Publisher Copyright © 2013 by LC Publications. All rightsLC Publications reserved under United States and International Copyright Conventions. No part of this journal may be reproducedDesign or transmitted in any form or by any means, electronic orJimmydog Design Group mechanical, including photocopying or any other informationwww.jimmydog.com retrieval system, without prior written permission from the publisher.Production ManagerStephanie Belcher Disclaimer: Reading an article in JIACD does not qualify336-201-7475 • [email protected] the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACDCopy Editor readers should exercise judgment according to theirJIACD staff educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, itsDigital Conversion staff, and parent company LC Publications (hereinafterNxtBook Media referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers.Internet ManagementInfoSwell Media Opinions expressed in JIACD articles and communications are those of the authors and not necessarily those of JIACD-Subscription Information: Annual rates as follows: SOM. JIACD-SOM disclaims any responsibility or liabilityNon-qualified individual: $99(USD) Institutional: $99(USD). for such material and does not guarantee, warrant, norFor more information regarding subscriptions, endorse any product, procedure, or technique discussed incontact [email protected] or 1-888-923-0002. JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claimsAdvertising Policy: All advertisements appearing in the made by manufact-urers of products advertised in JIACD, itsJournal of Implant and Advanced Clinical Dentistry (JIACD) affiliated websites, or affiliated communications.must be approved by the editorial staff which has the rightto reject or request changes to submitted advertisements. Conflicts of Interest: Authors submitting articles to JIACDThe publication of an advertisement in JIACD does not must declare, in writing, any potential conflicts of interest,constitute an endorsement by the publisher. Additionally, monetary or otherwise, that may exist with the article.the publisher does not guarantee or warrant any claims Failure to submit a conflict of interest declaration will resultmade by JIACD advertisers. in suspension of manuscript peer review.For advertising information, please contact: Erratum: Please notify JIACD of article discrepancies [email protected] or 1-888-923-0002 errors by contacting [email protected] Submission: JIACD publishing guidelines JIACD (ISSN 1947-5284) is published on a monthly basiscan be found at http://www.jiacd.com/author-guidelines by LC Publications, Las Vegas, Nevada, USA.or by calling 1-888-923-0002. The Journal of Implant & Advanced Clinical Dentistry • 7



The Journal of Implant & Advanced Clinical DentistryFounder, Co-Editor in Chief Founder, Co-Editor in Chief Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS Editorial Advisory BoardTara Aghaloo, DDS, MD Michael Herndon, DDS Michele Ravenel, DMD, MSFaizan Alawi, DDS Robert Horowitz, DDS Terry Rees, DDSMichael Apa, DDS Michael Huber, DDS Laurence Rifkin, DDSAlan M. Atlas, DMD Richard Hughes, DDS Georgios E. Romanos, DDS, PhDCharles Babbush, DMD, MS Miguel Angel Iglesia, DDS Paul Rosen, DMD, MSThomas Balshi, DDS Mian Iqbal, DMD, MS Joel Rosenlicht, DMDBarry Bartee, DDS, MD James Jacobs, DMD Larry Rosenthal, DDSLorin Berland, DDS Ziad N. Jalbout, DDS Steven Roser, DMD, MDPeter Bertrand, DDS John Johnson, DDS, MS Salvatore Ruggiero, DMD, MDMichael Block, DMD Sascha Jovanovic, DDS, MS Henry Salama, DMDChris Bonacci, DDS, MD John Kois, DMD, MSD Maurice Salama, DMDHugo Bonilla, DDS, MS Jack T Krauser, DMD Anthony Sclar, DMDGary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Frank Setzer, DDSRonald Brown, DDS, MS Burton Langer, DMD Maurizio Silvestri, DDS, MDBobby Butler, DDS Aldo Leopardi, DDS, MS Dennis Smiler, DDS, MScDNicholas Caplanis, DMD, MS Edward Lowe, DMD Dong-Seok Sohn, DDS, PhDDaniele Cardaropoli, DDS Miles Madison, DDS Muna Soltan, DDSGiuseppe Cardaropoli DDS, PhD Lanka Mahesh, BDS Michael Sonick, DMDJohn Cavallaro, DDS Carlo Maiorana, MD, DDS Ahmad Soolari, DMDJennifer Cha, DMD, MS Jay Malmquist, DMD Neil L. Starr, DDSLeon Chen, DMD, MS Louis Mandel, DDS Eric Stoopler, DMDStepehn Chu, DMD, MSD Michael Martin, DDS, PhD Scott Synnott, DMDDavid Clark, DDS Ziv Mazor, DMD Haim Tal, DMD, PhDCharles Cobb, DDS, PhD Dale Miles, DDS, MS Gregory Tarantola, DDSSpyridon Condos, DDS Robert Miller, DDS Dennis Tarnow, DDSSally Cram, DDS John Minichetti, DMD Geza Terezhalmy, DDS, MATomell DeBose, DDS Uwe Mohr, MDT Tiziano Testori, MD, DDSMassimo Del Fabbro, PhD Dwight Moss, DMD, MS Michael Tischler, DDSDouglas Deporter, DDS, PhD Peter K. Moy, DMD Tolga Tozum, DDS, PhDAlex Ehrlich, DDS, MS Mel Mupparapu, DMD Leonardo Trombelli, DDS, PhDNicolas Elian, DDS Ross Nash, DDS Ilser Turkyilmaz, DDS, PhDPaul Fugazzotto, DDS Gregory Naylor, DDS Dean Vafiadis, DDSDavid Garber, DMD Marcel Noujeim, DDS, MS Emil Verban, DDSArun K. Garg, DMD Sammy Noumbissi, DDS, MS Hom-Lay Wang, DDS, PhDRonald Goldstein, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDSDavid Guichet, DDS Adriano Piattelli, MD, DDS Alan Winter, DDSKenneth Hamlett, DDS Michael Pikos, DDS Glenn Wolfinger, DDSIstvan Hargitai, DDS, MS George Priest, DMD Richard K. Yoon, DDS Giulio Rasperini, DDS The Journal of Implant & Advanced Clinical Dentistry • 9

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Immediate Implant after Extraction Wilcko et al of Lower Molar ToothSherman Lin, DDS1 AbstractImmediate implant placement at the man- a difficult process. The following dibular molar site is one of the most challenging procedures in implant case report demonstrates immediatedentistry. Anatomical features such asthe inferior alveolar nerve make this implant placement in the mandibular molar location following extraction of the tooth.KEY WORDS: Dental implants, mandible, bone grafting, prosthetics 1. Private practice San Diego, California, USA The Journal of Implant & Advanced Clinical Dentistry • 11

Lin CASE REPORT done with Chlorohexidine solution and a surgical spoon instrument. A trephine bur of 4mm in diam-A 67 year old female of no known significant med- eter was used to prepare the implant osteotomyical conditions was admitted to the clinic for eval- (Fig.2) to the depth of 11 mm apicaly measur-uation of lower right first molar (#30). Her chief ing from the crest of the intact lingual wall. Thecomplaint was chronic suppuration extruding from osteotomy was made through the center of thebuccal gingiva of tooth #30, and pain upon bit- furcation of the socket (Fig.3). A bone core wasing. Clinical evaluation revealed 9+ mm of peri- harvested from the osteotomy and left in a salineodontal pocket depth around the distal root and dish (Fig.4). An implant fixture of 4.8mm bodythe tooth was mobile. The clinical crown was also size, 6.0mm platform size, and 10mm in lengthfractured on the distal side involving the buccal was taped into the osteotomy site with the implantcusp. The patient also showed history of brux- motor at 30Nm torque and final torqueing to fullism by the severely worn dentition in her mouth. depth with the torque wrench. Using a smallA periapical radiograph was taken which revealed hand held bone mill, the harvested bony core wasradiolucency surrounding the distal root (Fig.1), a crushed into particulates (Fig.5). The surround-possible suggestion of perio-endo lesion. Treat- ing space of the implant fixture and bony defectsment options consisted of 1) Extraction, followed were filled with these autogenous particulates asby a fixed 3 unit bridge; 2) Root Canal therapy the graft material (Fig.6). A nonresorbable mem-and perio surgery with bone graft for tissue regen- brane (PTFE) was tucked under the gingiva anderation and crown and; 3) Extraction and implant sutured in place to cover the implant site (Fig.7).were given to the patient. The pros and cons A post-operative radiograph was taken follow-of each treatment options were explained to the ing implant placement (Fig.8). The patient waspatient. The patient decided to go with extrac- dismissed with post- op care instruction and thetion and implant on the basis of long term suc- follow up antibiotic regiment and pain medica-cess rate, and preservation of adjacent teeth. tions (Amoxicillin 500mg and Vicodin as needed). The patient was prepped for implant surgery Following surgery, the patient was recalledand 2 grams of Amoxicillin 500 was given for pre- in one week for evaluation and the followingoperative prophylaxis. The patient was anesthe- week to remove the sutures. One month latertized with Inferior alveolar nerve block and local patient returned for membrane removal. Fourinfiltration around the tooth (2 carpules of 2% months after surgery, the implant was uncov-lidocaine, 1:100,000 epinephrine). A sulcular ered with a minimal crestal incision and flap.incision was made around the entire circumfer- The implant site was evaluated (Figs. 9, 10) andence of tooth #30. The tooth was sectioned in a healing screw of 5.0mm diameter and 2.5 gin-half separating the mesial and buccal roots com- gival height was screwed on to the fixture. Twopletely with a surgical carbide bur. The sepa- weeks later, the final impression was taken atrated roots were carefully luxated and elevated fixture level using the transfer post (Dentiumout of the sockets with minimal trauma using company) and the case was sent to the lab forperiosteal and elevator instruments. Thorough fabrication of the final crown. Ten days later,debridement and degranulation of the socket was12 • Vol. 5, No. 10 • October 2013

LinFigure 1: Pre-surgical radiograph of hopeless tooth #30. Figure 2 Trephine osteotomy preparation of site #30 following extraction.the patient returned for delivery of the final pros-thesis. The selected abutment of 2.5 mm in Figure 3: Site #30 following trephine preparation.gingival height and 5.5mm in diameter (Dual abut-ment by Dentium) was screwed in place at 25Ncm and the final PFM crown was cemented onto the abutment (Fig. 11). A peri-apical radio-graph was taken for evaluation before the finalcementation (Fig. 12). A night guard was fabri-cated for the patient as part of post–operativecare. The patient was scheduled for follow upappointments at 6month intervals forthe hygieneappointments. A two year post-prostheticradiograph was taken on record (Fig.13). ● The Journal of Implant & Advanced Clinical Dentistry • 13

LinFigure 4: Bone core from trephine osteotomy of site #30. Figure 5: Autogenous particulated bone created from trephine core.Figure 6: Peri-implant defect space filled with particulated Figure 7: Membrane sutured in place at surgical site.bone.14 • Vol. 5, No. 10 • October 2013

LinFigure 8: Immediate post-surgical radiograph. Figure 9: Clinical presentation at 4 months after surgery.Figure 10: Subgingival exposure of dental implant at 4 Figure 11: Clinical presentation following delivery ofmonths after surgery. dental implant crown. The Journal of Implant & Advanced Clinical Dentistry • 15

LinFigure 12: Radiograph following delivery of dental Figure 13: Radiograph 2 years following delivery of dentalimplant crown. implant crown.DisclosureThe author reports no conflicts of interest with anything mentioned in this article.CorrespondenceDr. Sherman Lin12925 El Camino Real J-28San Diego, California, USA 92130Tel: 818-995-797116 • Vol. 5, No. 10 • October 2013

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Preventing Disfigurative Healing with Wilcko et alImmediate Hard and Soft Tissue Treatment forRecent Dentoalveolar Trauma: A Case Report Dan Holtzclaw, DDS, MS1 AbstractWhile there are many articles that tial treatment in hospital emergency rooms with describe treatment of dentoalveo- initial and follow up care by oral and maxillofa- lar trauma1-7 for instances such as cial surgeons. Less severe cases of oral trauma,tooth avulsion or subluxation, very few address although not life threatening, are still importantthe immediate treatment of the supporting peri- to treat quickly as they may result in disfigura-odontium, especially for esthetic concerns, tive healing if not treated properly. The aim ofand subsequent restoration of the case in the this case report is to describe the periodon-future. The fact is that the typical dental profes- tal treatment of a single case in which a patientsional will not see cases of advanced dental suffered significant non-life threatening dento-trauma in his or her scope of practice. Severe alveolar trauma that would have resulted in dis-maxillofacial trauma cases typically receive ini- figurative healing without immediate intervention.KEY WORDS: Dental implants, trauma, guide bone regeneration, mucogingival grafting, provisionalization 1. Private practice limited to periodontics and dental implants, Austin, Texas, USA The Journal of Implant & Advanced Clinical Dentistry • 19

HoltzclawFigure 1: Initial presentation of patient (facial view). Figure 2: Initial presentation of patient (incisal view).Replantation of avulsed tooth #8 and attempted Replantation of avulsed tooth #8 and attemptedstabilization performed by local hospital emergency room stabilization performed by local hospital emergency roompersonnel. personnel.Figure 3: Mucogingival and hard tissue damage to Figure 4: Significant full thickness laceration of gingivalmaxillary anterior region. tissue over maxillary canine. Case ReportA 26 year old African American female presentedto my clinic on an emergency basis for evaluationof facial trauma sustained the previous night. Thepatient indicated that she had fainted at her homeand fell face first onto her desk. Upon beingawakened by her boyfriend, the patient was trans-20 • Vol. 5, No. 10 • October 2013

HoltzclawFigure 5: Periapical radiograph showing condition of teeth Figure 6: Periapical radiograph (alternative view) showingand bone at initial patient presentation. Note incomplete condition of teeth and bone at initial patient presentation.replantation of tooth #8 and significantly widened Note incomplete replantation of tooth #8 and significantlyperiodontal ligament of tooth #7. widened periodontal ligament of tooth #7.ported to a local hospital emergency room where The patient had an avulsed tooth #8 which wasshe was examined and treated. Clinical and radio- stored in a cup of water and subluxated teeth 7graphic examination at the hospital revealed no life and 9. The hospital staff replanted tooth #8 andthreatening injuries or significant damage such as attempted stabilization with an unknown com-spinal fracture, cranial bleeding, etc. The patient’s posite material (Figures 1, 2). The patient wassyncope episode was attributed to fatigue and then discharged to her own accord and informeddehydration. Upon stabilization in the emergency to seek dental treatment the following day.room, the patient was treated for dental injuries bythe medical staff at the hospital. No dentist was On the following day, the patient called mypresent or called to treat the patient at that time. clinic and described her injuries. Due to the nature of her injuries, I made arrangements The Journal of Implant & Advanced Clinical Dentistry • 21

HoltzclawFigure 7: Extracted tooth #8 with stabilization material. Figure 8: Trauma site in anterior maxilla following debridement. Note significant damage to the bone causing loss of the facial plate.Figure 9: Anterior maxillary trauma site grafted with Acell Figure 10: Overlapping DynaMatrix membranes (Keystonebone putty (Keystone Dental, Burlington, Massachusetts, Dental, Burlington, Massachusetts, USA) used for guidedUSA). bone regeneration.to see her immediately. After gathering back- did not achieve and adequate bond to tooth #7.ground on the patient, her injury, and pertinent Tooth #7 exhibited Miller Class 2 mobility andhealth history, an initial clinical examination was was sensitive to percussion. Tooth #9 exhibitedperformed. Tooth #8 was Miller Class 3 mobile Miller Class 1 mobility and was also sensitiveas the material which was utilized by the hospi- to percussion. A severe full thickness gingi-tal emergency room staff to stabilize the tooth val laceration was noted on the facial surface of22 • Vol. 5, No. 10 • October 2013

HoltzclawFigure 11: Closure of surgical site with 6-0 nylon sutures. Figure 12: Lateral pedicle flap rotated from tooth #5 to cover the significant gingival laceration on tooth #6.Figure 13: Edentulous site #8 socket left exposed to Figure 14: Ovate pontic created from avulsed tooth #8the oral environment. Note the exposed DynaMatrix secured to place with arch wire.membrane (Keystone Dental, Burlington, Massachusetts,USA) at this location.tooth #6 which extended approximately 20mmand a smaller laceration was noted at the mesialaspect of tooth #8 next to the maxillary labial fre-num (Figures 3, 4). Radiographic evaluation ofthe traumatized area suggested avulsion andattempted replantation of tooth #8 with some sort The Journal of Implant & Advanced Clinical Dentistry • 23

HoltzclawFigure 15: Patient upon completion of initial surgery. Figure 16: One month healing facial view. Note the mucogingival coverage of the maxillary right canine tooth compared to the initial severe laceration.Figure 17: One month healing incisal view. Note the Figure 18: Intrasurgical view of regenerated bone at sitesfull contours at the site of the initial hard and soft tissue 7 and 8 four months after initial surgery.trauma. #8 and its ineffective stabilization material wereof attempted composite stabilization and a sub- removed (Figure 7). Debridement of the surgi-luxated tooth #7 (Figures 5, 6). No radiographic cal site revealed a significant bone deficit at siteevidence of alveolar or dental fracture was noted. #8 and a bony dehiscence on the facial aspect of tooth #7 due to damaged bone (Figure 8). Following administration of local anesthe- After irrigation with sterile saline, the defect atsia, treatment was initiated with a full thickness site 8 and the dehiscence on tooth #7 wereflap extending from the mesial aspect of tooth#9 to the gingival laceration at tooth #6. Tooth24 • Vol. 5, No. 10 • October 2013

HoltzclawFigure 19: Dental implant prior to placement (Keystone Figure 20: Dental implant placed at site #8 with additionalGenesis 4.5 x 13mm, Keystone Dental, Burlington, Accell bone graft putty (Keystone Dental, Burlington,Massachusetts, USA). Massachusetts, USA).Figure 21: Radiograph of dental implant #8 at time of Figure 22: Radiograph of dental implant #8 at 2 monthsplacement. healing. The Journal of Implant & Advanced Clinical Dentistry • 25

Holtzclaw Figure 24: Arch wire removal and initial laser gingivectomy of gingival tissue.Figure 23: Radiograph of dental implant #8 at 4 monthshealing.Figure 25: Finished gingivectomy of maxillary gingival Figure 26: Dental implant exposure prior to open traytissues. impression for fabrication of custom provisional implant restoration. Note the full facial contours of the supporting26 • Vol. 5, No. 10 • October 2013 periodontium. grafted with Accell bone graft (Keystone Dental, Burlington, Massachusetts, USA) and covered with perpendicular overlapping pieces of Dyna- Matrix membranes (Keystone Dental, Burling- ton, Massachusetts, USA) for guided bone and guided tissue regeneration (Figures 9, 10). In order to achieve improved closure over the bone

HoltzclawFigure 27: Incisal view of open tray impression coping in Figure 28: Facial view of open tray impression coping inplace for indexing. place for indexing.Figure 29: Provisional restoration on dental implant Figure 30: Radiograph of dental implant #8 with its#8 four months after delivery. Note the natural and full custom provisional restoration 4 months after placement.appearance of the supporting periodontium around the Note the outstanding peri-implant bone preservation.dental implant.graft and address the mucogingival damage totooth #6, a lateral pedicle flap was rotated fromtooth #5 to cover the defect on tooth #6 (Fig-ures 11, 12). The extraction socket of tooth #8was allowed to remain open with the DynaMatrixmembrane exposed to the oral cavity (Figure 13). Once the supporting periodontium had The Journal of Implant & Advanced Clinical Dentistry • 27

Holtzclawbeen addressed, tooth #8 was sectioned with tom made provisional implant restoration. Thea high speed rotary bur to separate the clini- acrylic provisional implant restoration was deliv-cal crown from the root. The pulp was removed ered and torqued to 15 Ncm (Figures 29, 30).from the clinical crown and following acid etch-ing and bonding, composite material was used Following delivery of the provisional dentalto seal the apical aspect of the tooth in the implant restoration, the patient was appointedfashion of an ovate pontic. The pontic was to have the fixture restored with a local prosth-then placed at site #8 and secured with a odontist. Unfortunately, the patient never wentlight arch wire that stabilized teeth 5-11 (Fig- to the prosthodontist and disappeared for 4ure 14). The patient left the initial appointment months. Due to financial constraints on thewith much improved esthetics and stabilization part of the patient, this case was performed onof the traumatized anterior maxilla (Figure 15). a pro-bono basis. This may have had some- thing to do with the patient disappearing and Healing was uneventful for the patient not getting the final restoration. After multipledespite the fact that she missed multiple follow attempts, we were finally able to get the patientup appointments. After one month, the gingival to return to our clinic for a follow up examina-tissues demonstrated significant improvement tion. At this visit, the temporized dental implantwith complete coverage of the lacerated canine exhibited excellent esthetics and the overalland excellent tissue stability at the site of the surgical site of the traumatized anterior maxillaavulsed central incisor (Figures 16, 17). After demonstrated significant improvement over its4 months of healing, surgery was performed to initial presentation. The patient was reassuredplace a dental implant at site #8. A full thick- that her final restoration would be performedness flap revealed significant bone formation at at no charge and she made an appointmentthe site of the initial trauma (Figure 18). A 4.5 to see the prosthodontist for restoration ofx 13mm dental implant (Figure 19) (Keystone the dental implant. Once again, however, theGenesis, Keystone Dental, Burlington, Mas- patient disappeared. We later received a let-sachusetts, USA) was placed at site #8 and ter from the patient informing us that she andadditional Accell bone graft (Keystone Dental, her boyfriend had moved to a different state andBurlington, Massachusetts, USA) was added would not be able to finish her treatment. That(Figure 20). Following closure of the surgical was our last communication from the patient.site, the ovate pontic was rebounded into place. This Case Report demonstrates that quick After 4 uneventful additional months of heal- intervention following dental trauma can miti-ing (Figures 21-23), the arch ovate pontic and gate disfigurative healing. In addition toarch wire were removed for implant uncov- treatment of the damaged teeth, immediateering. At the time of this surgery, gingivec- treatment of the damaged bone and gingival tis-tomy was performed on the maxillary anterior sues preserved the possibility for placement ofteeth to achieve improved esthetics (Figures a future dental implant. Without quick interven-24, 25). A closed tray impression coping was tion, this may not have been possible or the finalindexed (Figures 26-28) to fabricate a cus- outcome may have been poorly aesthetic. ●28 • Vol. 5, No. 10 • October 2013

HoltzclawCorrespondence: AADDVVERETIRSETWISITHEDr. Dan Holtzclaw711 W. 38th Street TODAY!Suite G5Austin, TX 78705 Reach more customersUSA with the dental512-453-1600 profession’s [email protected] truly interactiveDisclosure paperless journal!Upon notification of this patient’s dire financial situation, Keystone Dentalgenerously donated many of the products used for this case. Using recolutionary online technology, JIACD provides its readers with anReferences1. A ntunes AA, Santos TS, Carvalho de Melo AU, Ribiero CF, Goncalves SR, de experience that is simply not available with traditional hard copy paper journals. Mello Rode S. Tooth embedded in lower lip following dentoalveolar trauma: case report and literature review.Gen Dent 2012; 60(6):544-547.2. M arão HF, Panzarini SR, Manrrique GR, Luvizuto ER, Evangelista Melo M. Importance of clinical examination in dentoalveolar trauma. J Craniofac Surg 2012; 23(5):404-405.3. M acLeod SP, Rudd TC.Update on the management of dentoalveolar trauma. Curr Opin Otolaryngol Head Neck Surg 2012; 20(4):318-324.4. R obinson FG, Cunningham LL Oral rehabilitation of severe dentoalveolar trau- ma: a clinical report. J Oral Implantol 2012; 38(6):757-761.5. D e Rossi M, De Rossi A, Queiroz AM, Nelson Filho P. Management of a com- plex dentoalveolar trauma: a case report. Braz Dent J 2009; 20(3): 259-262.6. S aito C, Gulinelli J, Cardoso L, Garcia IR Jr, Panzarini S, Poi W, Sonoda C.Severe fracture of the maxillary alveolar process associated with extrusive luxation and tooth avulsion: a case report. J Contemp Dent Pract 2009; 10(1):91-97.7. S ahin S, Saygun NI, Kaya Y, Ozdemir A. Treatment of complex dentoalveolar injury--avulsion and loss of periodontal tissue: a case report. Dent Traumatol 2008; 24(5):581-584. WWW.JIACD.COM The Journal of Implant & Advanced Clinical Dentistry • 29

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Comparison Between the Butt-Joint and Wilcko et alMorse Taper Implant-Abutment Connection: A Literature ReviewRola M. Shadid, BDS, MSc1 • Nasrin Sadaqah, BDS, MSc2 • Layla Abu-Naba’a, BDS, PhD, MFDRCS3 Wael M. Al-Omari, BDS, MDentSci, PhD4 AbstractBackground: The aim of this review was to Material and Methods: A net-baseddiscuss different designs of implant-abutment search in PubMed was performed and com-interface and to compare between the con- bined with a manual search. The searchventional butt-joint connection and the Morse was limited to articles written in English.taper one from different mechanical, bio-logical and clinical aspects. Also this review Results: The published literature revealedarticle aimed to summarize some clinical situ- that the Morse taper connection when com-ations where it is more appropriate to use pared with the external hex or butt-joint one,one design of connection instead of the other. offers higher mechanical and biological sta- bility, better force distribution, more seal- ing capability, adequate soft tissue and bone crest stability, increased prosthetic versatility, and better esthetic outcome.KEY WORDS: Dental implant, butt-joint, Morse taper, Implant-abutment interface microgap1. Lecturer, Department of Prosthodontics, Faculty of Dentistry, Arab American University, Jenin, Palestinian Territory; Private Practice, Tulkarm City, Palestinian Territory 2. Assistant Professor, Department of Prosthodontics, Faculty of Dentistry, Arab American University, Jenin, Palestinian Territory; Private Practice, Jenin City, Palestinian Territory 3. Assistant Professor of Prosthodontics, Department of Substitutive Dental Sciences, Faculty of Dentistry,TAIBAH UNIVERSITY, Madinah Munawarah. KSA- FORMERLY Jordan University of Science and Technology, Jordan 4. Associate Professor, Department of Prosthodontics, Faculty of Dentistry, Jordan University of Science and Technology, Jordan The Journal of Implant & Advanced Clinical Dentistry • 33

Shadid et al Introduction tooth abutments and with angled abutments in order to reduce the incidence of abutmentThe implant-abutment interface is the level at screw loosening.3 Also, it is recommended thatwhich the abutment connects to the implant the non-rotational configuration should be usedbody; also called the implant-abutment con- whenever a custom re-angulation is required,nection or the implant-abutment junction. The even with multiple implants.3 The non-rotationalimplant-abutment interface is important because feature provides a built-in redundancy for trou-it plays a primary role in joint strength, joint sta- bleshooting in the event of implant loss, and canbility, and rotational and locational stability.1 The decrease the torque on the retaining screws.3aim of this review article was discuss differentdesigns of implant-abutment connection and to The external hexagonal was originally usedcompare between the conventional butt-joint con- to restore a completely edentulous arch. Allnection and the Morse taper one from different the implants were joined together with a rigidmechanical, biological and clinical aspects. Also metal superstructure and the external hexago-this review article aimed to summarize some clini- nal and simple butt joints performed quite well.4cal situations where it is more appropriate to use However, in more complex partially edentulousone design of connection instead of the other. and single-tooth applications, the interface and its retaining screw are exposed to more rigor-Implant-Abutment Interface ous forces.5 Such forces could cause screwThe implant-abutment interface connection is gen- loosening and joint opening because the con-erally described as an internal or external con- necting screw is no longer shielded from lat-nection based on the presence or absence of a eral bending loads, tipping or elongation.6geometric feature that extends above the coronalsurface of the implant.1 Furthermore, the con- Since short, narrow external geometry is par-nection can be described as a slip-fit joint when ticularly susceptible to tipping forces becausethe connection is passive and a minimal space of the limited engagement of its external com-exists between the mating components or as ponent and the presence of a short fulcruma friction-fit joint when the mating parts are lit- point,7,8 Brånemark, (the first who noted thiserally forced together with no space existing problem), recommended that the height ofbetween them.1 The mating surfaces are also the external hex connection should be a mini-characterized as being a butt joint, consisting mum of 1.2 mm to provide both lateral and rota-of two right-angle flat surfaces making contact tional stability, particularly in single-tooth cases.9with each other; or a bevel joint, when the sur-faces are angled either internally or externally.1 In spite of the modifications of the exter- nal hex height, width and design, several other The joined surfaces may have a non-rotational factors still remain unresolved.1 Therefore, afeature that is further described as hexagonal, variety of alternative connections have beenoctagonal, cone hex, cone screw, cylinder hex, developed. The most notable are the externalspline, cam, cam tube or slot.2 This non-rota- octagon, the spline, the internal hexagonal, thetional configuration should be used with single- internal- cylinder hex, the internal cam tube, the internal cam cylinder, the internal spline, and the34 • Vol. 5, No. 10 • October 2013

Shadid et alinternal conical connection or morse taper con- crowns. Also, it has been confirmed that when thenection.1 Sutter et al.10 proposed an 8-degree Morse taper connections are used, the abutmentinternal taper connection between the implant loosening is a lesser problem.18,19 As a result, theand the abutment, which is known in the litera- Morse taper lock ensures a superior mechanicalture as the “Morse taper.” A similar cone screw stability, when compared with the external hex, orconnection with an 11-degree taper is avail- butt-joint designs20 and therefore achieves betterable from Astra Tech.1 Also, a 4-degree cone short-term and long-term clinical performance.20,21screw connection was developed by Nentwigand Moser for the Ankylos implant system.11 Regarding the torque recommended to tighten the abutment screw, it ranges between 15 and However, a true Morse taper without 45 N/cm depending on the implant system usedany threaded component has been devel- (Table 1). For an external hex connection, Grattonoped by the Bicon system. The abutment et al.22 found that lower abutment screw preloadshas a 1-2- degree tapered post that fits resulted in greater micro motion at the abutment–into a smooth mirror-image shaft within the implant interface. However, the Morse taper con-implant. Such a connection depends solely nection requires less screwing torque to preventon frictional fit to provide optimal stability.1 micro movement under given loading conditions.23Comparison Between the Butt-Joint and the With regard to the strength characteristics ofInternal Taper (Morse Taper) Connections the two types, the Morse taper connection wasIn the external hex, butt-joint connection, the abut- found to be approximately 60% stronger.24 Nor-ment screw alone is the primary element respon- ton24 also demonstrated that the internal conicalsible for keeping the implant and the abutment joint was significantly more stable than the exter-assembled; hence, the maintenance of the pre- nal hexagonal one in resisting extreme bendingload is crucial.12 However, in the internal taper moments in a 3-point bending test. Khraisat etconnection, form lock and friction, (referred to as al.25 reported that the tapered joint system hadpositive or geometric locking), are the basic princi- far better resistance than the external hex sys-ples for maintaining the connection and protecting tem in terms of fatigue resistance when testedthe abutment threads from excessive functional under cyclic loading. Concerning the effect ofload.13 Many studies14-38 have been undertaken to the design of the implant-abutment joint on thecompare the external hex, or butt-joint connection distribution of stresses in the supporting bone,with the morse taper connection. With respect to Maeda et al.26 found that fixtures with internal hexthe incidence of screw loosening, Jemt et al.,14 showed widely spread force distribution downand Becker and Becker15 reported a high rate of to the fixture tip compared with the external hexscrew loosening of up to 40% with an external hex ones. Also, Hanson27 confirmed in a finite ele-connection. However, Levine et al.16,17 found a far ment study that a conical implant–abutment inter-lower rate of abutment loosening (3.6% to 5.3%) face at the level of the marginal bone had a morewith the Morse taper connection when restoring apical location of the peak shear stress comparedsingle-tooth replacements with cement-retained with a “flat to flat” (butt-joint) one; this improves the distribution of stresses in the supporting bone. The Journal of Implant & Advanced Clinical Dentistry • 35

Shadid et al Table 1 Design of Recommended Implant- abutment Abutment Type Screwing Implant System Connection Torque (N/cm) Biohorizons Internal hex connection- Two-piece abutments 30 N/cm External Hex Connection One-piece and 35 N/cm 8-degree conical synOcta two-piece Straumann (ITI) connection (morse taper) 35 N/cm with four internal grooves abutments 45 N/cm Internal conical One-piece and 35 N/cm connection (Nobel active) two-piece 30 N/cm abutments 15N/cm Cam tube connection Nobel Biocare (internal cylindrical connection Two-piece 20 N/cm abutments with three cams that fit into One-piece abutments 25 N/cm slots in the inner implant wall) Two-piece abutments 15 N/cm Two-piece angled 25 N/cm (Replace-select system) transmucosal 30 N/cm component 3.0 (x-smal) 30 N/cm Branemark External hex/cylindric Two-piece angled 28.2-30 N/cm connection transmucosal 25 N/cm component 3.5/4.0 (small) 25 N/cm Intra-lock system Internal modified Two-piece angled 15 N/cm Hexagonal connection transmucosal 15N/cm component 4.5/5.0 (large) 20 N/cm One-piece titanium abutments Zirconia abutments One-piece abutments 11-degree internal conical One-piece abutments Astra tech system connection (morse taper) One-piece abutments One-piece base abutments Internal connection with One-piece straight abutments internal double hexagon One-piece angled abutments SynCone two-piece abutments One-piece abutments SwissPlus (Zimmer) Internal octagon or hex connection Screw-Vent (Zimmer) Friction-fit tapered internal hex connection Spline (Zimmer) External spline connection Ankylos system Internal anti-rotational tapered connection (morse taper) Cam cylinder connection Camlog system (internal cylindircal connection with 3 cams that fit into cylindrical slots in the inner implant wall)36 • Vol. 5, No. 10 • October 2013

Shadid et al Because conical connection implants have another factor for the optimal protection of thehigh mechanical stability, they can be used in peri-implant soft tissue and allows the estab-compromised clinical situations. For instance, lishment of a tissue collar overlapping thethey can be used when a patient has bruxism bone-implant interface.34 However, this fea-or malocclusion; as the implants have withstood ture cannot be found with conventional exter-extra-axial loads for years.28 Additionally, it has nal or internal butt-joint connections becausebeen found that conical connection implants diameters of both the implant body and the(Ankylos implant system) proved to be suc- abutment are identical.35 Also, the conicalcessful when splinted and immediately loaded implant-abutment joint contributes to the for-in posterior mandible of Macaca Fascicularis mation of healthy biological width because themonkeys.29 Also, Romanos et al. 21 found in a area between implant shoulder and abutmentretrospective study that it is possible to replace is not exposed on the peripheral contour nexta molar with only one implant as no implant to the bone; this might minimize bone loss.28failures were reported when using the coni-cal connection implants (Ankylos system). On Supporting the superior mechanical andthe other hand, another clinical investigation biological stability encountered with Morseshowed failures of the 14% examined implants taper connection compared with the butt-replacing single molars when using external joint ones, animal experiments have shownhex connection implants (Branemark system).30 that with the conventional butt-joint implants, the crestal bone loss is between 1.5 and 2.0 The design of the implant-abutment con- mm.36,37 On the other hand, Chou et al.38 havenection not only has an effect on its mechani- documented no major crestal bone loss (0.2cal stability, but also has biological effects. mm/y from the time of implant placement to 36For instance, the Morse taper connection sig- months) for a conical taper connection (Anky-nificantly reduces microgap dimensions at the los system). Other advantages of the Morseimplant–abutment interface, providing an ade- taper connection over the butt-joint one havequate biological seal and avoiding any kind of also been demonstrated in clinical use. In thebacterial leakage.31 This contributes to mini- conical connection, the dimensions of the con-mal level of peri-implant soft tissues inflam- nection are always the same, so that any endos-mation, and can guarantee adequate bone seous component can be combined with anycrest stability.32 On the other hand, soft tissue abutment as required.34 Additionally, the coni-inflammatory reaction around implants with cal abutment can be freely rotated to achieve aexternal hex connection has been reported.33 harmonic integration in the dental arch; in con- trast to implant-abutment joints rotary-secured Moreover, the Morse taper connection by a hexagon or an octagon, the rotary positionprovides “platform switching” between the of the abutments is limited to 6 or 8 degreesendosseous implant and the abutment com- defined positions.28 Also, the second-stageponents, i.e., the dimension of the abutment is surgery is minimally invasive because it is notsmaller than the diameter of the implant body necessary to expose the periphery of the sub-at the level of the connection. This provides The Journal of Implant & Advanced Clinical Dentistry • 37

Shadid et al Table 2 Area of Comparison External Hex, Butt-joint Connection The abutment screw alone is the primary element Method of implant-abutment connection responsible for keeping the implant and the abutment assembled. Incidence of abutment screw loosening HIgh rate of screw loosening. Screwing torque More screwing torque to prevent micromovement under given loading conditions. Less stable in resisting extreme bending moments Stability under fatigue loading in a 3-point bending test and less resistance to fatigue when tested under cyclic loading. Distribution of stresses in the supporting bone Does not improve the distribution of stresses in the supporting bone. Replacing single missing molar Implant faiures were reported when replacement of a molar with a single implant. Platform switching No Increases microgap dimensions Size of implant-abutment microgap at the implant abutment interface. Soft tissue stability Soft tissue inflammatory reaction around implants has been reported. Bone crest stability More crestal bone loss has been reported. More invasive second-stage surgery because it is Second-stage surgery necessary to expose the periphery of the submerged endosseous implant. Incidence of trapping of soft tissue between Trapping of soft tissue between the abutment and the the abutment and implant body and the need for and the implant body is a problem therefore an an X-ray after abutment connection X-ray after abutment connection is neccessary. Esthetics Does not enhance the esthetics unless a ceramic abutment is used. Not preferred to be used when a patient has a Clinical applications patient has a bruxism or malocclusion or for immediate loading in weak bone qualities. It is suitable for the two-stage submerged procedure. Each implant si e requires a corresponding si e Prosthetic versatility of implant abutment. And the rotary position of the abutments is limited to 6- or 8- degree defined positions. It is compatible with different systems. It incorporates an anti-rotational mechanism and is retrievable. Advantages The weak connection between the implant and the abutment is often considered to be a fail-self mechanism for Over-loading conditions. Disadvantages As mentioned above. 38 • Vol. 5, No. 10 • October 2013

Shadid et al Internal Taper Connection (Morse Taper) merged endosseous implant as the tapered Form lock and friction are the connection can always be assembled pre- basic principles for cisely.34 Furthermore, the trapping of soft tis- maintaining the connection. sue between the abutment and the implant body that may occur with other conventional Far lower rate of abutment lossening. butt joints is not a problem with the conical Less screwing torque to prevent micromovement joint; therefore an X-ray after abutment connec- tion is not necessary.28,34 Finally, the design of under given loading conditions. implant-abutment connection has an effect on esthetics. It is found that the tapered abutment connection could produce an enhanced vol- More stable and better resistance to fatique. ume of connective tissue around the submuco- sal neck of an abutment, covering the dark grayImproves the distribution of stresses in the titanium of the neck of the abutment. However, supporting bone. the esthetic outcome of external hex connection implants is sometimes less than satisfactory asIt is possible to replace a molar with only one a result of the thin layer of soft tissue cover- implant as no implant failure reported. ing the apical part of the implant-abutment; or an expensive all-ceramic abutment is used.28 Yes The advantages, disadvantages, andSignificantly reduces microgap dimensions at the implant clinical applications of the external hex, adutment interface, providing an adequate biological butt-joint connection and the Morse taper seal, avoiding any kind of bacterial leakage. connection are summarized in Table 2.Minimal level of peri-implant with soft tissues inflammation, CONCLUSION and can guarantee adequate bone crest stability. The published literature revealed that theLess crestal bone loss has been reported. Morse taper connection when compared with the external hex or butt-joint one, offers higher Minimally invasive second-stage surgery because it is mechanical and biological stability, better forcenot necessary to expose the periphery of the submerged distribution, more sealing capability, adequate soft tissue and bone crest stability, increased endosseous implant. prosthetic versatility, and better esthetic out- come. Therefore, the Morse taper connectionsTrapping of soft tissue between the abutment and the from different implant systems are promising implant body is not a problem therefore an especially for compromised clinical indications like immediate loading in weak bone qualities, X-ray after abutment connection is not neccessary. when patient has bruxism or malocclusion, or when replacing a molar with single implant. ●Enhances the esthetics because it could produce an enhanced volume of connective tissue around The Journal of Implant & Advanced Clinical Dentistry • 39 the submucusal neck if an abutment, coveringthe dark gray titanium of the neck of the abutment. Because of high mechanical stability, they can be used when a patient has a bruxism or malocclusion. And for immediate loading in weak bone qualities.It is suitable for one-stage submerged implant installation. The dimensions of the connection are always the same, so that any endosseous component can be combined with any abutment as required. Also,the conical abutment can be freely rotated to achieve a harmonic integration in the dental arch. As mentioned above.It has a thinner lateral implant wall at the connecting part which is susceptible for fracture.

Shadid et alCorrespondence:Dr. Rola M. Shadid • Department of Prosthodontics, Faculty of Dentistry, Arab American University,Jenin, Palestinian Territory • P.O Box: 240 Jenin • E-mail: [email protected] 14. J emt T, Laney WR, Harris D, Henry PJ, Krogh 26. Maeda Y, Satoh T, Sogo M. In vitro differencesThe author reports no conflicts of interest with PH Jr, Polizzi G, et al. Osseointegrated implants of stress concentrations for internal and externalanything mentioned in this article. for single tooth replacement: a 1-year report hex implant–abutment connections: a short from a multicenter prospective study. Int J Oral communication. J Oral Rehabil 2006; 33: 75–8.References Maxillofac Implants 1991; 6: 29–36.1. B inon PP. Implants and components: entering 28. H ansson S. Implant–abutment interface: 15. B ecker W, Becker BE. Replacement of maxillary biomechanical study of flat top versus conical. the new millennium. 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Sinus Augmentation with Immediate Wilcko et al Implant Insertion: A Case Report Sherman Lin, DDS1 AbstractIn many cases following removal of a maxil- lary sinus lift is often required. The following lary molar, pneumatization of the maxillary case report demonstrates simultaneous place- sinus results in inadequate bone height ment of a dental implant in conjunction with afor the placement of dental implants. In order maxillary sinus lift along with 7 year follow up.to place dental implants in such sites, a maxil-KEY WORDS: Dental implants, maxillary sinus, bone grafting, prosthetics 1. Private practice San Diego, California, USA42 • Vol. 5, No. 10 • October 2013

Lin Case Report condense the graft material to ensure space for angiogenesis and cellular apposition. An implantA 59 year old man in good physical condition fixture of 4.8mm body diameter, 10mm height, andand medical health was admitted to the clinic 5.0mm diameter platform by Implantium (Dentium)for implant consultation regarding missing maxil- company was inserted simultaneously at the implantlary molar tooth #3. The patient gave a history site. Excellent primary stability was achieved. Theof prior extraction and socket graft of a fractured sinus window was covered with resorbable colla-tooth. Clinical evaluation gave a well healed post gen membrane and primary closure of the surgi-extraction site covered with healthy attached gin- cal site was achieved with 4-0 PTFE sutures. Angiva. The buccolingual width appeared adequate immediate post-surgical radiograph was taken forfor wide diameter implants (4.5+mm) upon mea- evaluation (Fig.2). The patient was dismissed aftersurement with bone caliber. Panoramic and peri- post- op instructions and follow up antibiotic regi-apical radiographs were taken for evaluation of ment and pain medication (Vicodin) were given.bone quality and height. The radiographs showedinadequate bone height for desired length of den- The patient was seen ten days after surgerytal implant (Fig.1). A sinus lift augmentation was for a surgical check. Healing was uneventful andneeded to achieve optimal osseointegration of the the patient claimed to have minimal swelling andimplant for function. The sinus lift and augmenta- almost no pain. The surgical site was left undis-tion procedure was explained to the patient and turbed for 4 months. A restorative procedurepatient concurred. Patient was also informed that was performed 4 months after the initial surgery.if primary stability of implant insertion was achiev- The dental Implant was uncovered with a 5 mmable during surgery, implant were to be inserted in diameter tissue punch and transfer impressionat the same time. This will save the patient time technique was made at the fixture level with theand subsequent second surgery for implanta- compatible impression transfer post. A healingtion. Patient agreed and liked the treatment plan. abutment of 5mm diameter and 1.5 mm in gin- gival height was placed on top of the fixture in The patient was instructed to take 2 grams of place of the cover screw. An abutment of 5mm inAmoxicillin 500 one hour before surgery for pro- diameter and 1.5mm height was selected (Dualphylaxis. The patient was surgically prepped and abutment, Dentium), and the case was sent toanesthetized. A full thickness flap was made from a laboratory for final fabrication of a porcelaindistal of tooth #2 to distal of tooth #5 by combina- fused to metal (PFM) crown. After two weeks,tion of sulcular, crestal, and vertical incision to gain the patient was readmitted for delivery of theaccess for lateral window sinus augmentation tech- crown. The crown was adjusted for interproximalnique. A piezoelectric surgical unit was used for contacts and occlusion and radiographs werethe osteotomy of sinus window. Using a specially taken for evaluation (Fig.3). Next, the crowndesigned sinus lifting elevator, the sinus membrane was cemented permanently. The patient waswas fully lifted without any perforation nor tears in followed 7 years clinically and with radiographsall dimensions of the sinus space. Sixcc of pure (Figs. 4-7). No complications were noted and thephase Beta-Tricalcium phosphate (B-TCP) particu- prosthesis remained stable and fully functionallate of 500-1000 um in size were syringed into the with excellent preservation of bone levels. ●prepared sinus cavity. Care was taken not to over The Journal of Implant & Advanced Clinical Dentistry • 43

LinFigure 1: Pre-surgical radiograph demonstrating Figure 2: Post-surgical panoramic radiograph followingpneumatized maxillary sinus. implant placement and sinus lift.Figure 3: Post-surgical peri-apical radiograph following Figure 4: Radiograph at 1 year.implant placement and sinus lift.44 • Vol. 5, No. 10 • October 2013

LinFigure 5: Radiograph at 6 years. Figure 6: Radiograph at 7 years. Note excellentFigure 7: Clinical presentation at 7 years. preservation of peri-implant bone levels. Disclosure The author reports no conflicts of interest with anything mentioned in this article. Correspondence: Dr. Sherman Lin 12925 El Camino Real J-28 San Diego, California, USA 92130 Tel: 818-995-7971 The Journal of Implant & Advanced Clinical Dentistry • 45

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