Dental Management Coalition Annual Conference

Dental Management Coalition Annual Conference

July 21, 2008 Port St. Lucie, Florida
July 21, 2008 Port St. Lucie, Florida
Bone Grafting and
Bone Grafting and
Implant Dentistry Update
Implant Dentistry Update
Jeffrey L. Turchi, DDS Jeffrey L. Turchi, DDS
Director of Educational and Clinical Affairs Director of Educational and Clinical Affairs
Senior Product Manager Senior Product Manager
J . Morita USA J . Morita USA
Irvine, CA Irvine, CA
Objectives
Objectives

Understand the evolution of bone grafting
Understand the evolution of bone grafting
techniques and materials
techniques and materials

Identify the different types of bone grafts, their
Identify the different types of bone grafts, their
characteristics, and the benefits/risks of each
characteristics, and the benefits/risks of each

Overview of the latest trends in implant hardware
Overview of the latest trends in implant hardware
and the technology for diagnosis and planning
and the technology for diagnosis and planning
My Background
My Background


B.A. History
B.A. History
-
-
UCLA
UCLA


Teaching Credential Program
Teaching Credential Program
-
-
CSU Dominguez Hills
CSU Dominguez Hills


D.D.S.
D.D.S.
-
-
University of the Pacific, AAD SOD
University of the Pacific, AAD SOD


18 years private practice
18 years private practice


3 years with J. Morita USA
3 years with J. Morita USA


Member ADA, CDA, OCDS, AO, IADMFR
Member ADA, CDA, OCDS, AO, IADMFR

Family
Family

of dentists
of dentists
Motivation
Motivation

What is a Bone Graft?

What is a Bone Graft?
Historically, bone grafting has consisted of:
Historically, bone grafting has consisted of:

A surgical procedure to harvest the
A surgical procedure to harvest the
patients own bone from a secondary site
patients own bone from a secondary site

Utilization of an organic or artificial
Utilization of an organic or artificial
material to replace missing bone
material to replace missing bone
Bone Grafting
Bone Grafting
-
-
A Brief History
A Brief History
1668
1668
-
-
Dutch Surgeon, J ob J anszoon van Meekeren:
Dutch Surgeon, J ob J anszoon van Meekeren:


Described the use of canine bone to repair a cranial wound
Described the use of canine bone to repair a cranial wound


Who did it?
Who did it?


Did it work?
Did it work?


Russian church
Russian church


The
The

amazing
amazing

Dr. Van Meekeren???
Dr. Van Meekeren???
Thanks, destructive nature of warfare in the 20
Thanks, destructive nature of warfare in the 20
th th
century
century
Bone Grafting Today
Bone Grafting Today

Surpassed only by blood transfusions as the most
Surpassed only by blood transfusions as the most
transplanted human tissue
transplanted human tissue

7
7
-
-
10 days of antibiotic coverage is routine with
10 days of antibiotic coverage is routine with
all
all
bone grafting techniques
bone grafting techniques

Bone grafting has become a
Bone grafting has become a
very
very
hot dental topic
hot dental topic
Bone grafting applications
Bone grafting applications


Socket preservation Socket preservation


Periodontal defects Periodontal defects


Third molar extraction sites to support 2 Third molar extraction sites to support 2
nd nd

molars molars


Ridge augmentation Ridge augmentation


Defects following cyst removal / apicoectomies Defects following cyst removal / apicoectomies


Sinus lifts Sinus lifts


Distraction osteogenesis Distraction osteogenesis


Nerve repositioning Nerve repositioning


IMPLANT DENTISTRY!!! IMPLANT DENTISTRY!!!
Why Preserve the Alveolar Ridge?
Why Preserve the Alveolar Ridge?
Bone loss is continuous and inevitable
Bone loss is continuous and inevitable
Chewing pressure from roots or implants stimulate bone cells
Chewing pressure from roots or implants stimulate bone cells
Alveolar bone in edentulous areas resorbs 0.5 to 1 mm per year
Alveolar bone in edentulous areas resorbs 0.5 to 1 mm per year
Why Preserve the Alveolar Ridge?
Why Preserve the Alveolar Ridge?
Dr. J on Suzuki, Director Post
Dr. J on Suzuki, Director Post
-
-
Graduate
Graduate
Periodontics at Temple University:
Periodontics at Temple University:

placing some type of graft material in the

placing some type of graft material in the
socket following every extraction is rapidly
socket following every extraction is rapidly
approaching standard of care status.
approaching standard of care status.

Characteristics of Graft Materials

Characteristics of Graft Materials
Most bone graft materials fall into two main
Most bone graft materials fall into two main
categories:
categories:
Osteoconductive
Osteoconductive
:
:
A framework for new bone to grow into at its
A framework for new bone to grow into at its
normal healing rate.
normal healing rate.
Osteoinductive
Osteoinductive
:
:
Stimulate bone to grow at an advanced rate. Most
Stimulate bone to grow at an advanced rate. Most
have added ingredients, (Growth Factors or
have added ingredients, (Growth Factors or
Bone Morphogenetic Proteins).
Bone Morphogenetic Proteins).
Types of Bone Grafts
Types of Bone Grafts

Autografts
Autografts

Allografts
Allografts

Xenografts
Xenografts

Synthetics
Synthetics
Autografts
Autografts

Also referred to as
Also referred to as

autogenous
autogenous

or
or

autologous
autologous

grafts.
grafts.

Source: patient
Source: patient

s own bone, usually harvested from

s own bone, usually harvested from
their palate, hip, chin, or pelvic crest.
their palate, hip, chin, or pelvic crest.

Gold Standard
Gold Standard

Autografts
Autografts
Pros
Pros
: contain living elements for bone
: contain living elements for bone
growth, no risk of rejection
growth, no risk of rejection
Cons
Cons
: requires a second surgery, not
: requires a second surgery, not
recommended for patients with low bone
recommended for patients with low bone
density
density
Allografts
Allografts


Human bone, usually harvested from cadavers.
Human bone, usually harvested from cadavers.


Risk of morbidity and mortality due to poorly screened sources
Risk of morbidity and mortality due to poorly screened sources


April, 2008: California DPH required a separate license if a
April, 2008: California DPH required a separate license if a
dental office stores an allograft for more than 24 hours.
dental office stores an allograft for more than 24 hours.


Commercially available
Commercially available
allografts
allografts
:
:
-
-
DFDB
DFDB
by Biomet
by Biomet
-
-
Puros
Puros
by Zimmer Dental
by Zimmer Dental
Allograft examples
Allograft examples
DFDB crystals (Biomet) Puros block (Zimmer)
DFDB crystals (Biomet) Puros block (Zimmer)
PBS
PBS
-
-
Masterpiece Theater
Masterpiece Theater
Alistair Cooke (1908
Alistair Cooke (1908
-
-
2004)
2004)
PBS
PBS
-
-
Monsterpiece Theater
Monsterpiece Theater
Cookie Monster (1969
Cookie Monster (1969
-
-
????)
????)
Alistair Cooke body snatch leader pleads guilty
Alistair Cooke body snatch leader pleads guilty
(March 19, 2008 London Telegraph) (March 19, 2008 London Telegraph)
The leader of a body The leader of a body- -snatching network which stole the bones of the snatching network which stole the bones of the
broadcaster Alistair Cooke and illegally plundered more than 1,4 broadcaster Alistair Cooke and illegally plundered more than 1,400 other 00 other
corpses between 2001 corpses between 2001- -2005 has pleaded guilty. 2005 has pleaded guilty.
Dr. Michael Mastromarino, the head of Biomedical Tissue Ser Dr. Michael Mastromarino, the head of Biomedical Tissue Services, made vices, made
more than $4.6 million by selling the body parts to about 20,000 more than $4.6 million by selling the body parts to about 20,000
transplant recipients throughout the US, Canada and Europe. transplant recipients throughout the US, Canada and Europe.
Funeral home owners in New York, Pennsylvania and New J erse Funeral home owners in New York, Pennsylvania and New J ersey were y were
paid $1,000 for each corpse to harvest bones, skin, arterial val paid $1,000 for each corpse to harvest bones, skin, arterial valves, ves,
ligaments and tendons ligaments and tendons - - some of them diseased. some of them diseased.
Mastromarino, a 44 Mastromarino, a 44- -year year- -old former oral surgeon, (whose license was old former oral surgeon, (whose license was
suspended prior to running BTS), was convicted and will spend 18 suspended prior to running BTS), was convicted and will spend 18- -54 54
years in prison. More than 900 civil law suits have been filed a years in prison. More than 900 civil law suits have been filed against him. gainst him.
Faux bone????
Faux bone????
Xenografts
Xenografts


Bone or other tissue from animals, usually bovine or porcine
Bone or other tissue from animals, usually bovine or porcine


Must be manufactured in a specific manner to ensure sterility
Must be manufactured in a specific manner to ensure sterility
and biocompatibility
and biocompatibility


Most materials act as a
Most materials act as a

scaffold
scaffold

for new bone to grow into at
for new bone to grow into at
its normal rate.
its normal rate.


Some examples include:
Some examples include:
BioOss
BioOss
by Osteohealth
by Osteohealth
PepGen15
PepGen15
by Dentsply
by Dentsply
Xenograft examples
Xenograft examples
Bio Oss (Geistlich)
Bio Oss (Geistlich)
Powder (minerals of bovine bone) and sterile saline
Xenograft examples
Xenograft examples
PepGen P15 (Dentsply) PepGen P15 (Dentsply)
Liquid (Sterile saline)
Powder (Collagen, Bovine minerals &
synthetic analog of a peptide chain)
Synthetic (Alloplast) Materials
Synthetic (Alloplast) Materials


Alternative materials to avoid the drawbacks of
Alternative materials to avoid the drawbacks of
autografts or
autografts or
allografts
allografts


Examples include coral and TCP
Examples include coral and TCP


Very little risk of morbidity or mortality
Very little risk of morbidity or mortality


Some are non
Some are non
-
-
resorbable and act as replacement bone
resorbable and act as replacement bone


Others are resorbable frameworks or scaffolds for bone
Others are resorbable frameworks or scaffolds for bone
to grow into at it
to grow into at it

s normal rate
s normal rate


Some commercially available products are:
Some commercially available products are:
Bioplant
Bioplant
by Kerr Dental
by Kerr Dental
Gem 21S
Gem 21S
by Osteohealth.
by Osteohealth.
Examples of Alloplasts
Examples of Alloplasts
Bioplant (Kerr) Gem 21S (Osteohealth
Bioplant (Kerr) Gem 21S (Osteohealth
)
)
B-TCP
granules
rh-PDGF solution
(Platelet Deri ved Growth Factor)
Polymethyl MA + Polyhydroxyethyl MA
BMP
BMP

s and Growth Factors

s and Growth Factors
Bone Morphogenetic Proteins: Bone Morphogenetic Proteins:


Discovered 1965 Discovered 1965 Dr. Marshall Dr. Marshall Urist Urist UCLA UCLA


Found in human blood and bones Found in human blood and bones that stimulate that stimulate osteoinduction osteoinduction


20 have been identified, 2 have FDA approval for use in bone gra 20 have been identified, 2 have FDA approval for use in bone grafting (2 & 7) fting (2 & 7)


Extracted from human tissue or fabricated in the lab Extracted from human tissue or fabricated in the lab


Interact with receptors on surface of bone cells Interact with receptors on surface of bone cells


Expensive, but stimulate bone to grow faster Expensive, but stimulate bone to grow faster


Suspicion of carcinogenicity? (J une 2008 J ournal of American Aca Suspicion of carcinogenicity? (J une 2008 J ournal of American Academy of demy of
Orthopaedic Surgeons) Orthopaedic Surgeons)
BMP
BMP

s and Growth Factors

s and Growth Factors
Products containing BMPs:
Products containing BMPs:

Infuse
Infuse
:
:
(
(
Medtronics
Medtronics
Corporation)
Corporation)

OP
OP
-
-
1
1
:
:
(Stryker Biotech)
(Stryker Biotech)

Accel
Accel
Connexus
Connexus
:
:
(
(
IsoTis
IsoTis
Orthobiologics
Orthobiologics
)
)

Accel
Accel
DBM 100
DBM 100
:
:
(
(
IsoTis
IsoTis
Orthobiologics
Orthobiologics
)
)

Grafton DBM
Grafton DBM
:
:
(
(
BioHorizons
BioHorizons
)
)

Regenafil
Regenafil
:
:
(
(
Exactech
Exactech
)
)
BMP
BMP

s and Growth Factors

s and Growth Factors
Platelet
Platelet
-
-
derived growth factor (PDGF):
derived growth factor (PDGF):


One of numerous
One of numerous
proteins
proteins
regulating
regulating
cell
cell
growth and
growth and
division
division


Role in
Role in
embryonic
embryonic
development, cell proliferation, cell
development, cell proliferation, cell
migration
migration


Stimulates bone to grow faster
Stimulates bone to grow faster
PRP
PRP
Platelet Rich Plasma Centrifuge Technique
Platelet Rich Plasma Centrifuge Technique
Platelet functions: Platelet functions:


Hemostasis Hemostasis


Scaffold for tissue Scaffold for tissue
regeneration regeneration


Increase level of Increase level of GF GF s s


Attract stem cells Attract stem cells
PPP
PRP
Barrier Membranes
Barrier Membranes
Are there other grafting options?
Are there other grafting options?
YES!!!
YES!!!
Collagen
Collagen
-
-
based products are also now available.
based products are also now available.
FOUNDATI ON
TM
Collagen-Based Bone Filling Augmentation Material
for Use in the Filling of Extraction Sockets
What is Collagen?
What is Collagen?

Insoluble, extra
Insoluble, extra
-
-
cellular protein found in all animals
cellular protein found in all animals

Most abundant protein in the human body
Most abundant protein in the human body

Essential component of all connective tissues such
Essential component of all connective tissues such
as cartilage, bone, tendons, ligaments, and skin
as cartilage, bone, tendons, ligaments, and skin
The History of Foundation
The History of Foundation
Terudermis
Terudermis
Teruplug
Teruplug
(approved in J apan 1993 (approved in J apan 1993- -skin grafting) (approved in J apan 1997 skin grafting) (approved in J apan 1997- - dental) dental)
Terumo Medical Corporation, Tokyo, J apan
Terumo Medical Corporation, Tokyo, J apan
FDA 510(K) Clearance #K040783
FDA 510(K) Clearance #K040783
FOUNDATION is a collagen FOUNDATION is a collagen- -based bone filling augmentation material based bone filling augmentation material
for use in the filling of extraction sockets for use in the filling of extraction sockets (2004) (2004)
Manufactured Manufactured- - Terumo Corp. Terumo Corp.- - J apan, (now Olympus J apan, (now Olympus- -Terumo Biomaterials) Terumo Biomaterials)
Approved Approved- - J apanese Ministry of Health as J apanese Ministry of Health as Teruplug Teruplug - - J uly 1997 J uly 1997
FDA as FDA as Foundation Foundation - - October 2004 October 2004
Launched Launched- - Foundation Foundation in U.S. Market by J . Morita USA in U.S. Market by J . Morita USA- - February 2006 February 2006
Foundation Research
Foundation Research
There are There are five published studies five published studies done in J apan by the following institutions: done in J apan by the following institutions:


Nihon University School of Dentistry at Matsudo Nihon University School of Dentistry at Matsudo


Kanagawa Dental College, Department of Periodontology Kanagawa Dental College, Department of Periodontology


School of Medicine, Yokohama City University, Dept. of OMFS School of Medicine, Yokohama City University, Dept. of OMFS


Osaka Dental University Osaka Dental University


Terumo Corporation Terumo Corporation
There is another study currently in progress at the University There is another study currently in progress at the University of Rochester of Rochester
Bovine collagen Bovine collagen- - Type III Type III
(skin only) (skin only)
Telopeptide
(this protein acts as an antigen in
a different species)
Protease (pepsin) treatment
to remove telopeptides (pH 3)
Atelo Atelo- -collagen collagen
Neutralized (pH 7)
Heat-denatured atelo-collagen Fibrillar atelo-collagen
Telopeptide
Stimulates infiltration of cells into the scaffold Scaffold for surrounding cells
Heated over 37/100

F
Foundation
Foundation

s Manufacturing Process
s Manufacturing Process
Fibrillar atelo-collagen
(scaffold)
Heat-denatured atelo-collagen
FOUNDATIONTM
Collagen-Based Bone Filling Augmentation Material
Cross-linked by heat and
formed into a bullet shape
S size M size
25 mm
8 mm 15 mm
How Does
How Does

Heat Denatured
Heat Denatured

Atelocollagen stimulate bone to grow?
Atelocollagen stimulate bone to grow?


HAC has an inherent quality called
HAC has an inherent quality called

chemotaxis
chemotaxis

A
A
response
response
of
of
motile
motile
cells
cells
where the direction of
where the direction of
movement
movement
is
is
affected
affected
by the
by the
gradient
gradient
of a
of a
diffusible
diffusible
substance
substance

The HAC creates a chemical stimulus that causes bone
The HAC creates a chemical stimulus that causes bone
growth cells to be drawn into the plug at a rapid pace
growth cells to be drawn into the plug at a rapid pace


Only product on the market that speeds up the healing
Only product on the market that speeds up the healing
process without BMPs or PDGFs
process without BMPs or PDGFs
Why Bovine Collagen?
Why Bovine Collagen?

Abundant supply
Abundant supply

Highly compatible with alveolar bone
Highly compatible with alveolar bone

Attracts fibroblasts and osteoblasts which
Attracts fibroblasts and osteoblasts which
accelerate new bone formation
accelerate new bone formation
Hypersensitivity to Bovine Collagen
Hypersensitivity to Bovine Collagen
Japan
Japan
:
:
October 1998
October 1998
-
-
March 2005, over 450,000 units sold
March 2005, over 450,000 units sold
Three cases of
Three cases of

rash
rash

have been reported from users.
have been reported from users.
U.S.A./Canada
U.S.A./Canada
:
:
February 2006
February 2006
-
-
present
present
No cases reported
No cases reported
Safety Precautions for Prevention of BSE Exposure
Safety Precautions for Prevention of BSE Exposure
(Bovine Spongiform Encephalopathy), or
(Bovine Spongiform Encephalopathy), or
Mad Cow Disease
Mad Cow Disease


All documented cases of BSE have been in animals older than
All documented cases of BSE have been in animals older than
12 months. All bovines used for FOUNDATION are less than 6
12 months. All bovines used for FOUNDATION are less than 6
months old.
months old.


Only
Only
skin
skin
is extracted from the bovine.
is extracted from the bovine.


99% of cases have been in Europe.
99% of cases have been in Europe.


European Medical Examination Agency (EMEA) classifies each
European Medical Examination Agency (EMEA) classifies each
organ into 4 risk categories for potential BSE infection,
organ into 4 risk categories for potential BSE infection,

High
High

,
,

Middle
Middle

,
,

Low
Low

, and
, and

No risk
No risk

. Skin is defined as
. Skin is defined as

No risk
No risk

.
.


The FDA and the U.S. Dept. of Agriculture (USDA) also state
The FDA and the U.S. Dept. of Agriculture (USDA) also state
that skin
that skin
-
-
derived bovine products present
derived bovine products present

No risk
No risk

for BSE.
for BSE.
Foundation Safety
Foundation Safety
During Manufacturing
During Manufacturing
Sterility Assurance Level
Sterility Assurance Level
(SAL):
(SAL):


Estimates the
Estimates the
probabili
probabili
ty of any medical device being
ty of any medical device being
non
non
-
-
sterile after
sterile after
sterilization
sterilization
.
.


Foundation is dry
Foundation is dry
-
-
heat sterilized (3X) to a SAL of 10(
heat sterilized (3X) to a SAL of 10(
-
-
6),
6),
or a 1 in 1 million chance on non
or a 1 in 1 million chance on non
-
-
sterility prior to
sterility prior to
packaging.
packaging.


Same SAL as sterile surgical gloves.
Same SAL as sterile surgical gloves.
Foundation vs. Collaplug
Foundation vs. Collaplug
Confusion, but no comparison
Confusion, but no comparison
Collaplug
Collaplug (Zimmer Dental) (Zimmer Dental)


Bovine collagen Bovine collagen


Bullet shaped plug Bullet shaped plug


Wound healer Wound healer only only


Used in combination with Used in combination with
other products other products
Foundation
Foundation


Bovine collagen Bovine collagen


Bullet shaped plug Bullet shaped plug


No membrane No membrane


Accelerates bone growth Accelerates bone growth


Maintains alveolar ridge Maintains alveolar ridge


Implants placed as sooner Implants placed as sooner
Tooth
Extraction
Insertion of
FOUNDATION
Surrounding cells and
capillaries infiltrate into
FOUNDATION.
Peripheral gingiva extends
onto it.
The extraction socket
closes and is filled
with augmented bone.
The socket is filled
with FOUNDATION
and it also covers the
extraction surface.
Extraction socket is
created and bone is
exposed.
The Basics for using
The Basics for using
Foundation
Foundation
Photos Courtesy of Dr. Edward Marcus
Photos Courtesy of Dr. Edward Marcus
Yardley, PA
Yardley, PA

Tooth
Tooth

#12
#12
Beginning the extraction
Beginning the extraction
Atraumatic root tip removal
Atraumatic root tip removal
Proper handling of Foundation
Proper handling of Foundation
Small size Foundation
Small size Foundation
Shaping the plug
Shaping the plug
Plug now mimics shape of root tip
Plug now mimics shape of root tip
Extraction of intact root tip
Extraction of intact root tip
Curetting the socket
Curetting the socket
Inserting the plug
Inserting the plug
Further
Further

..
..
Further
Further

Foundation in place
Foundation in place
Gentle condensation of the plug
Gentle condensation of the plug
Compression of buccal and lingual plates
Compression of buccal and lingual plates
Done, ready for passive suture
Done, ready for passive suture
2 weeks post
2 weeks post
-
-
op healing
op healing
4 weeks post
4 weeks post
-
-
op healing
op healing
12 weeks post
12 weeks post
-
-
op healing
op healing
Implant placement
Implant placement
-
-
12 weeks post
12 weeks post
-
-
op
op
Implant in place
Implant in place
-
-
12 weeks post
12 weeks post
-
-
op
op
Digital panoramic survey
Digital panoramic survey
-
-
12weeks
12weeks
post
post
-
-
op
op
Indications for Use
Indications for Use
The following cases
The following cases
demonstrate the use of
demonstrate the use of
Foundation in strict adherence
Foundation in strict adherence
to the FDA
to the FDA
-
-
approved
approved

Indications for Use

Indications for Use

guidelines.
guidelines.
Extraction of #8 due to advanced perio disease in a 65 year old female
Before extraction
Application of FOUNDATION
Immediately after extraction
Sutured
1 week later
18 weeks later (from low angle)
2 weeks later
18 weeks later (front)
Pre
Pre
-
-
op / Post
op / Post
-
-
op
op
Oro-antral fistula (58 year-old male)
1 week later
Application of FOUNDATION
Tooth extraction
2 weeks later
Routine extraction in a diabetic patient
Tooth extraction Application of FOUNDATION
3 days later 1 week later 2 weeks later
FAILURE CASE
Extraction Sockets by Marginal Periodontitis
(78 year-old male)
Four days post-op Immediate post-op, socket not
well curetted
Health Canada License
Health Canada License
Health Canada issued license #71546 on J une 7,
Health Canada issued license #71546 on J une 7,
2006 for Foundation as follows:
2006 for Foundation as follows:

A collagen based bone filling material

A collagen based bone filling material

Missing teeth
Decorticating the bone
Full-thickness flap Pre-Op
Application of FOUNDATION
Pre-Op
Suture placed Membrane placed
3 months Post-Op
Pre-Op
(3mm wide)
3 months Post-Op
(6mm wide)
Foundation viewed by J. Morita Accuitomo
Foundation viewed by J. Morita Accuitomo
3D Imaging demonstrating bone growth
3D Imaging demonstrating bone growth
Day of extraction 12 weeks post Day of extraction 12 weeks post - -op op
Keys to Success
Keys to Success
1. Curette the socket and remove any unhealthy tissue to expos 1. Curette the socket and remove any unhealthy tissue to expose bone. e bone.
2. Place FOUNDATION in the socket using forceps or clean glove 2. Place FOUNDATION in the socket using forceps or clean gloves. s.
3. FOUNDATION 3. FOUNDATION must be saturated with blood must be saturated with blood. .
4. Select a slightly larger size of FOUNDATION than the socket 4. Select a slightly larger size of FOUNDATION than the socket to be to be
filled. filled. FOUNDATION must be in contact with bone to stimulate new FOUNDATION must be in contact with bone to stimulate new
growth growth.
5. If a bony wall is missing make sure FOUNDATION is firmly 5. If a bony wall is missing make sure FOUNDATION is firmly
supporting the soft tissue in that area. supporting the soft tissue in that area.
6. Secure FOUNDATION by suturing to prevent its dislodgement f 6. Secure FOUNDATION by suturing to prevent its dislodgement f rom rom
the extraction socket. Primary closure is the extraction socket. Primary closure is not not required. required.
What others are saying:
What others are saying:


Gordon Christiansen, (Clinical Research Associates)
Gordon Christiansen, (Clinical Research Associates)
reported a
reported a

96% Clinical Success Rate

96% Clinical Success Rate

in their September
in their September
2007 CRA Newsletter
2007 CRA Newsletter


Dr. J oe Blaes, Editor of
Dr. J oe Blaes, Editor of
Dental Economics
Dental Economics
wrote an article in
wrote an article in
the J uly 2007 issue called
the J uly 2007 issue called

From Footings to
From Footings to
Finishes
Finishes

in his
in his

Pearls for your Practice

Pearls for your Practice

column
column


Foundation was named as a
Foundation was named as a
"Top 100 Product
"Top 100 Product

by
by
Dentistry
Dentistry
Today
Today
in 2007
in 2007
and
and
2008
2008
ROI
ROI
-
-
A Win / Win for you and your patient
A Win / Win for you and your patient

Preserves ridge/socket after any
Preserves ridge/socket after any
permanent tooth extraction
permanent tooth extraction

3
3
rd rd
molars
molars

Higher level of patient care
Higher level of patient care

Increase production
Increase production
Insurance Code
Insurance Code
-
-
U.S.
U.S.
ADA
ADA

CDT Code #7953:

CDT Code #7953:

Ridge Preservation Bone Graft

Ridge Preservation Bone Graft

Insurance Code
Insurance Code
-
-
Canada
Canada
72431
72431
-
-
Alveolar Bone Preservation
Alveolar Bone Preservation
-
-
Xenograft
Xenograft
(first socket)
(first socket)
72439
72439
-
-
Alveolar Bone Preservation
Alveolar Bone Preservation
-
-
Xenograft
Xenograft
(each additional socket)
(each additional socket)
* * As per Dr. J im Gray, Director Member Services As per Dr. J im Gray, Director Member Services- - BC Dental Association BC Dental Association
Summary
Summary


Bone grafting for socket/ridge preservation has become a key
Bone grafting for socket/ridge preservation has become a key
part of the exploding practice of implant dentistry
part of the exploding practice of implant dentistry


Older grafting techniques and materials are no less successful
Older grafting techniques and materials are no less successful


New materials are making the process more efficient without
New materials are making the process more efficient without
sacrificing any of the predictability of the past
sacrificing any of the predictability of the past


Socket/ridge preservation will soon become a routine procedure
Socket/ridge preservation will soon become a routine procedure
not only for the specialist, but also for the general practition
not only for the specialist, but also for the general practition
er
er
Osseointegration
Osseointegration
Osteoblast
Titanium
SEM
Implant Dentistry
Implant Dentistry
Edentulism
Edentulism

Primary
Primary
Etiology?
Etiology?

U.S. stats:
U.S. stats:
20M totally edentulous
20M totally edentulous
15M edentulous in one arch
15M edentulous in one arch
100M partially edentulous
100M partially edentulous
Kalorama Information, 2005 Kalorama Information, 2005
Implant Dentistry
Implant Dentistry
2004 BRFSS
2004 BRFSS
*
*
study on Edentulous Seniors (65+), Rhode Island
study on Edentulous Seniors (65+), Rhode Island


Female
Female


Minority
Minority


High school diploma or less
High school diploma or less


Low income
Low income


Single
Single


Renter
Renter


Urban dweller
Urban dweller
*Behavioral Risk Factor Surveillance System- A component of the CDC
Implant Dentistry
Implant Dentistry
Other characteristics (Edentulous 65+):
Other characteristics (Edentulous 65+):


Don
Don

t exercise
t exercise


Overweight
Overweight


Smoker
Smoker


Regular alcohol use
Regular alcohol use


No regular dental or medical visits
No regular dental or medical visits


Physically or mentally unhealthy
Physically or mentally unhealthy


Depressed or anxious
Depressed or anxious


Poor sleep
Poor sleep


No energy
No energy
Implant Dentistry
Implant Dentistry
Patients with no dental insurance:
Patients with no dental insurance:

Elderly
Elderly

Minority
Minority

High school diploma or less
High school diploma or less

Low income
Low income

Unemployed or retired
Unemployed or retired

Also has no health insurance
Also has no health insurance
Implant Dentistry
Implant Dentistry
Yet
Yet

.
.
People are living longer and developments
People are living longer and developments
in bone grafting and implant techniques
in bone grafting and implant techniques
are providing better options for the
are providing better options for the
edentulous and the partially edentulous
edentulous and the partially edentulous
Implant Dentistry
Implant Dentistry

Big Four
Big Four

Nobel Biocare, Straumann, Biomet 3i, Zimmer

Nobel Biocare, Straumann, Biomet 3i, Zimmer

2006= 73.7%
2006= 73.7%

2007= 70.1%
2007= 70.1%

100+ implant companies worldwide
100+ implant companies worldwide
Why???
Why???
Per Ingvar Branemark
Per Ingvar Branemark


1952 1952- - Titanium implants in rabbits Titanium implants in rabbits


Swedish Swedish o orthopaedic surgeon rthopaedic surgeon- - initially focused on knee and hip applications initially focused on knee and hip applications


High rate of edentulism changed his focus High rate of edentulism changed his focus


1965 1965- - Gosta Larrson Gosta Larrson


Partnership with Partnership with Bofors AB Bofors AB Nobelpharma Nobelpharma Nobel Biocare Nobel Biocare


Osseointegration Osseointegration
Dr. Leonard Linkow
Dr. Leonard Linkow
Blade implants,
Blade implants,
implantologist
implantologist
to the
to the

stars
stars

???
???
Dr. Gerald Niznick
Dr. Gerald Niznick


Paragon/Core Paragon/Core- -Vent from 1982 Vent from 1982- -2001 2001


Sold to Sulzer 2001 (later acquired by Zimmer) for $102M Sold to Sulzer 2001 (later acquired by Zimmer) for $102M


Agreed to a 5 year Agreed to a 5 year Non Non- -compete compete clause clause


Started Implant Direct LLC with 7 new patents Started Implant Direct LLC with 7 new patents
Osseoperception
Osseoperception as per P.I. Branemark as per P.I. Branemark

Osseointegration: A living process
Osseointegration: A living process

Fixtures are connected to a prosthesis and forces
Fixtures are connected to a prosthesis and forces
are transmitted to surrounding bone
are transmitted to surrounding bone

The fixture becomes part of the body
The fixture becomes part of the body
and
and
the mind
the mind

Prosthetics somehow communicate with the brain
Prosthetics somehow communicate with the brain
to restore function
to restore function
Osseoperception
Osseoperception
Original Branemark System
Original Branemark System
Implant Dentistry
Implant Dentistry

Traditional implant systems
Traditional implant systems
Crown
Crown
Abutment
Abutment
Fixture
Fixture
Implant Dentistry
Implant Dentistry
SLActive
BICON
Straumann
Zimmer One piece
3i
Nobel Active
NanoTite Ca Ph coated
3i
Implant Dentistry
Implant Dentistry


Straumann SLActive
Straumann SLActive
:
:
S
S
andblasted with
andblasted with
L
L
arge grit followed by
arge grit followed by
A
A
cid etching,
cid etching,
then conditioned in
then conditioned in
nitrogen
nitrogen
and preserved in saline.
and preserved in saline.
Surface becomes hydrophilic, attracting blood and
Surface becomes hydrophilic, attracting blood and
proteins, potentially promoting faster osseointegration.
proteins, potentially promoting faster osseointegration.


3i NanoTite
3i NanoTite
:
:
High energy beams bombard HA coated target, creating
High energy beams bombard HA coated target, creating
a molecular cloud which bonds to implant. The implant is
a molecular cloud which bonds to implant. The implant is
then coated with Ca Ph for enhanced integration.
then coated with Ca Ph for enhanced integration.


The
The

first
first

implant?
implant?
Implant Dentistry
Implant Dentistry
Zirconium
Titanium
BICON
SYBRON Endopore
Coated Implants
Coated Implants
HA coated
HA + Plasma coated
Simpler Implants
Bone Screws Milled from Cow Metatarsals
Overdentures
Overdentures
Overdentures
Overdentures
Overdentures
Overdentures
Implant Trends
Implant Trends


Market shift? (cost vs. big name) Market shift? (cost vs. big name)


Traditional C&B vs. single tooth implant Traditional C&B vs. single tooth implant


Dx Dx and Tx Planning Standard of Care and Tx Planning Standard of Care


Endodontists (2008 AAE meeting) Endodontists (2008 AAE meeting)


GP GP s vs. specialists s vs. specialists


Delayed placement vs. Immediate placement vs. Immediate load Delayed placement vs. Immediate placement vs. Immediate load


Roughened surface preferred over coating Roughened surface preferred over coating


Dental Tourism Dental Tourism
( (272,000 medical & dental 272,000 medical & dental tourists tourists spent $656 million in India in 2007. This total is expected spent $656 million in India in 2007. This total is expected
to hit $2.5 billion by 2012. to hit $2.5 billion by 2012.
Imaging
Imaging

OMFR is a specialty
OMFR is a specialty

Only about 80 OMFRs in the U.S.
Only about 80 OMFRs in the U.S.

Only 5 programs (Iowa, Conn, UMKC, SA, UNC)
Only 5 programs (Iowa, Conn, UMKC, SA, UNC)

Opportunities???
Opportunities???
Digital Imaging
Digital Imaging
According to Dentalcompare.com:
According to Dentalcompare.com:


20 percent to 35 percent of dentists have incorporated
20 percent to 35 percent of dentists have incorporated
digital x
digital x
-
-
ray systems
ray systems


Majority are general dentists
Majority are general dentists


Digital radiography is fast becoming the standard of care
Digital radiography is fast becoming the standard of care
for diagnostic imaging in dentistry
for diagnostic imaging in dentistry
Digital Imaging
Digital Imaging


DICOM
DICOM
(
(
D
D
igital
igital
I
I
maging and
maging and
Co
Co
mmunications in
mmunications in
M
M
edicine) is a standardized format for handling, storing,
edicine) is a standardized format for handling, storing,
printing, and transmitting information in
printing, and transmitting information in
medical imaging
medical imaging
.
.


DICOM
DICOM
standards are developed by
standards are developed by
American College of
American College of
Radiology
Radiology
(ACR) and
(ACR) and
National Electrical Manufacturers
National Electrical Manufacturers
Association
Association
(NEMA).
(NEMA).


DICOM
DICOM
enables the integration of scanners, servers,
enables the integration of scanners, servers,
workstations, printers, and network hardware from
workstations, printers, and network hardware from
multiple manufacturers into an
multiple manufacturers into an
archiving and
archiving and
communication system
communication system
.
.
Digital Imaging
Digital Imaging
Digital panoramic x
Digital panoramic x
-
-
ray units are the fastest growing
ray units are the fastest growing
capital equipment market in the world
capital equipment market in the world
2006 compared to 2007
2006 compared to 2007
:
:

Digital pan sales grew by 27%
Digital pan sales grew by 27%

Film based pan sales dropped by 49%
Film based pan sales dropped by 49%

Digital
Digital
-
-
Film based sales ratio went from 6
Film based sales ratio went from 6
-
-
1 to 14
1 to 14
-
-
1
1
WHY???
WHY???
Digital Imaging
Digital Imaging


Higher resolution
Higher resolution


Lower dosage
Lower dosage (as much as 80 (as much as 80- -90%) 90%)


A
As s
L
Low ow
A
As s
R
Reasonably easonably
A
Achievable chievable


Electronic claims
Electronic claims


Better patient communication, case acceptance
Better patient communication, case acceptance


Elimination of poor images
Elimination of poor images


Environmentally responsible
Environmentally responsible (No chemical disposal) (No chemical disposal)
Digital Imaging
Digital Imaging
Causes of poor images with Film
Causes of poor images with Film
-
-
based systems:
based systems:

Patient movement
Patient movement

Improper
Improper
Kv
Kv
or
or
mA
mA
settings
settings

Poor patient positioning
Poor patient positioning

DARKROOM ISSUES
DARKROOM ISSUES
(80% of problems)
(80% of problems)
3D Cone Beam CT Imaging
3D Cone Beam CT Imaging
Axial
Coronal
Sagittal
3D Cone Beam CT Imaging
3D Cone Beam CT Imaging

A radiograph is a 2D representation of a 3D object

That 3
rd
dimension is what radiologists/clinicians have been searching for
The Changing World of 3D Imaging
The Changing World of 3D Imaging

Linear
Linear
tomography
tomography
-
-
mid 1930s
mid 1930s

Computed Tomography (CT)
Computed Tomography (CT)
-
-
1970
1970

s
s

Cone Beam CT (CBCT)
Cone Beam CT (CBCT)
-
-
late 20
late 20
th th
Century
Century
The Changing World of 3D Imaging
The Changing World of 3D Imaging
Linear Tomography Computed Tomography Cone Beam CT
Cone Beam CT vs. Medical CT
Cone Beam CT vs. Medical CT


Cost of CBCT scan is much less than medical CT
Cost of CBCT scan is much less than medical CT


The equipment is substantially lighter and smaller.
The equipment is substantially lighter and smaller.


CBCTs have better image resolution (
CBCTs have better image resolution (
smaller pixels
smaller pixels
)
)


Very easy to operate and to maintain; little
Very easy to operate and to maintain; little
technician training is required
technician training is required


Some cone beam manufacturers are dedicated to the
Some cone beam manufacturers are dedicated to the
dental market
dental market
Cone Beam CT vs. Medical CT
Cone Beam CT vs. Medical CT


In CBCT patient is seated, as compared with lying down
In CBCT patient is seated, as compared with lying down
in a medical CT unit
in a medical CT unit


Open design of the cone beam CT units virtually
Open design of the cone beam CT units virtually
eliminates claustrophobia
eliminates claustrophobia


The upright position is also thought to provide a more
The upright position is also thought to provide a more
realistic picture of condylar positions during a TMJ exam
realistic picture of condylar positions during a TMJ exam


Radiation dose is considerably less than a medical CT
Radiation dose is considerably less than a medical CT
Computed Tomography (CT)- 1970s
Cone Beam CT (CBCT)- late 20th century
2D reconstruction
X-ray
Source
2D (pixel)
Reconstruction
Row of X-ray
Detectors
Flat panel
X-ray
Detector
Cone Beam reconstruction
3D (Voxel)
Reconstruction
X-ray
Source
Medical CT
Medical CT
v
v
s CBCT
s CBCT
Voxel?
Voxel?

volume
volume

and
and

pixel
pixel

3D Cone Beam CT Imaging

3D Cone Beam CT Imaging
Applications:
Applications:


Implant planning (Now the S.O.C.???)
Implant planning (Now the S.O.C.???)


Endo
Endo
-
-
as per Steve Buchanan
as per Steve Buchanan


Identifying pathology
Identifying pathology


TMJ
TMJ


ENT
ENT


Ortho evaluation
Ortho evaluation


Pre/Intra/Post
Pre/Intra/Post
-
-
Op assessment of trauma
Op assessment of trauma


Locating foreign bodies
Locating foreign bodies


Cleft lip/palate
Cleft lip/palate


Caries detection
Caries detection
D Accuitomo
Imaging Areas
40mm

x 40mm H
60mm

x 60mm H
80mm

x 80mm H
Voxel Sizes

40H40mm
Small Area
40H80mm
Full view of
Antagonistic Teeth
80H80mm
Full Mouth
Field of View
FOV
FOV

Field Of View
Field Of View

How big is too big?
How big is too big?

Liability
Liability
Implant Tx Planning Systems
Implant Tx Planning Systems
Materialise (Simplant)
Materialise (Simplant)


world's first interactive 3D Implant Planning System 1998 world's first interactive 3D Implant Planning System 1998


precise preoperative planning software precise preoperative planning software


allows clinician to find the ideal position of the implants allows clinician to find the ideal position of the implants


compatible with every implant brand compatible with every implant brand
After vital structures are located, the After vital structures are located, the
SurgiGuide SurgiGuide is fabricated to drill exactly to is fabricated to drill exactly to
the planned implant location the planned implant location
Implant Tx Planning Systems
Implant Tx Planning Systems
NobelGuide
NobelGuide


Introduced 2005
Introduced 2005


Only works with NB
Only works with NB
implants
implants


Uses
Uses

Procera
Procera

software
software
Materialise vs. Nobel Biocare
Materialise vs. Nobel Biocare

June 1998 Materialise is awarded a U.S. Patent

August 1998 Materialise is awarded a European Patent

June 2005 Nobel Biocare launches its NobelGuide product in Germany.

November 2006 Materialise files a patent infringement action in Germany

June 25 2005 - Nobel Biocare files a nullify action in Germany

August 2007 Nobel Biocare files civil action in California seeking a declaration of
patent non-infringement

August 2007 German court rules that Nobel Biocare is indeed infringing on
Materialises European patent

September 2007 Nobel Biocare files an appeal against the decision of the District
Court of Dsseldorf with the Dsseldorf Court of Appeals (pending)

October 2007 Materialise files a counterclaim for U.S. patent infringement in
California
The Main Event
NB
MATERIALISE
Thank You For Your Attention!
Thank You For Your Attention!
Contact Information:
Contact Information:
jturchi@jmoritausa.com
jturchi@jmoritausa.com
(800) 818
(800) 818
-
-
7788
7788
9 Mason
9 Mason
Irvine, CA 92688
Irvine, CA 92688