Custom Emergence Profile

Volume 9, N o.
5 J uly 2017
The Journal of Implant & Advanced Clinical Dentistry
Custom
Emergence
Profile
Around
Implants
Partial Enucleation
of the Nasopalatine
Canal for Implant
Placement
International Inc.
The Journal of Implant and Advanced Clinical Dentistry has been providing high
quality, peer reviewed dental journals since 2007. We take pride in
knowing that tens of thousands of readers around the world continue to read
and contribute articles to JIACD. As you can imagine, there is a lot of expense
involved in managing a top quality dental journal and we sincerely appreciate
our advertisers purchasing ad space in both the journal and on the website
which allows our monthly journals to continue to be free to all of our readers.
In an effort to streamline our business practice and continue to provide no-fee,

open access journals, JIACD is now sponsored exclusively by Osseofuse
International Inc., a cutting edge dental implant company that provides
exceptional implants and prosthetics and believes in the free distribution of
information towards clinical advancements to dentists in the U.S. and around
the world.
This generous sponsorship, which provides funding towards our operating

expenses, allows JIACD to focus on the more important aspects of our journal;
monthly publishing of relevant clinical practices.
As a reader or author of JIACD, nothing will change. In fact, readers will see less
advertisements overall and authors can continue to submit articles relating to
any clinical topic.
We here at JIACD sincerely appreciate the continued financial support by

Osseofuse International Inc., and are excited about the opportunity it affords.
Thank you once again for your generous support.
Sincerely,
Leon Chen MD, MS, Co-Editor-in-Chief | Dave Beller, Director |The JIACD Team
Volume 9, No . 5 • J uly 2017
Table of Contents
6 An Innovative Approach for

the Selection, Generation and
Recording of a Custom Emergence
Profile Around Implants
Ioannis Vergoullis, Catherine Badell,
George Papadopoulos
20 P artial Enucleation of the

Nasopalatine Canal for Implant
Placement: A Novel Procedure
Dr. Samar M Jambi, Dr. Meisan A. Bukhari
2 • Vol. 9, No. 5 • July 2017

Volume 9, No . 5 • J uly 2017
Table of Contents
26 Clinical and Radiographic

Evaluation of Short Dental
Implants in Posterior Atrophic
Ridges with a Follow-up Period
of 1 Year after Loading:
A Controlled Clinical Trial
Amr Zahran, Fouad Al Tayib, Amr Ali,
Moemen Sheba
36 A New Standard Classification

System for Dental Implant
Drills and Role of Implant
Drills in Successful
Osseointegration
Dr. Bhushan Kumar, Dr. Sunny Bhatia,
Dr. Prabhdeep Kaur Sandhu,
Dr. Sachin Mittal
The Journal of Implant & Advanced Clinical Dentistry • 3

Volume 9, No. 5 • July 2017
Publisher Copyright © 2017 by LC Publications. All rights

LC Publications reserved under United States and International Copyright
Conventions. No part of this journal may be reproduced
Design or transmitted in any form or by any means, electronic or
Jimmydog Design Group mechanical, including photocopying or any other information
retrieval system, without prior written permission from the
www.jimmydog.com
publisher.
Production Manager
Disclaimer: Reading an article in JIACD does not qualify
Stephanie Belcher
the reader to incorporate new techniques or procedures
336-201-7475 • sbelcher@triad.rr.com discussed in JIACD into their scope of practice. JIACD
readers should exercise judgment according to their
Copy Editor
educational training, clinical experience, and professional
JIACD staff expertise when attempting new procedures. JIACD, its
staff, and parent company LC Publications (hereinafter
Digital Conversion referred to as JIACD-SOM) assume no responsibility or
JIACD staff liability for the actions of its readers.
Internet Management Opinions expressed in JIACD articles and communications

InfoSwell Media are those of the authors and not necessarily those of JIACD-
SOM. JIACD-SOM disclaims any responsibility or liability
Subscription Information: Annual rates as follows: for such material and does not guarantee, warrant, nor
Non-qualified individual: $99(USD) Institutional: $99(USD). endorse any product, procedure, or technique discussed in
For more information regarding subscriptions, JIACD, its affiliated websites, or affiliated communications.
contact info@jiacd.com or 1-888-923-0002. Additionally, JIACD-SOM does not guarantee any claims
made by manufact-urers of products advertised in JIACD, its
Advertising Policy: All advertisements appearing in the affiliated websites, or affiliated communications.
Journal of Implant and Advanced Clinical Dentistry (JIACD)
must be approved by the editorial staff which has the right Conflicts of Interest: Authors submitting articles to JIACD
to reject or request changes to submitted advertisements. must declare, in writing, any potential conflicts of interest,
The publication of an advertisement in JIACD does not monetary or otherwise, that may exist with the article.
constitute an endorsement by the publisher. Additionally, Failure to submit a conflict of interest declaration will result
the publisher does not guarantee or warrant any claims in suspension of manuscript peer review.
made by JIACD advertisers.
Erratum: Please notify JIACD of article discrepancies or
For advertising information, please contact: errors by contacting editors@JIACD.com
info@JIACD.com or 1-888-923-0002
JIACD (ISSN 1947-5284) is published on a monthly basis
Manuscript Submission: JIACD publishing guidelines by LC Publications, Las Vegas, Nevada, USA.
can be found at http://www.jiacd.com/author-guidelines
or by calling 1-888-923-0002.
4 • Vol. 9, No. 5 • July 2017

Founder, Co-Editor in Chief Co-Editor in Chief
Dan Holtzclaw, DDS, MS Leon Chen, DMD, MS, DICOI, DADIA
Tara Aghaloo, DDS, MD Michael Herndon, DDS Michele Ravenel, DMD, MS

Faizan Alawi, DDS Robert Horowitz, DDS Terry Rees, DDS
Michael Apa, DDS Michael Huber, DDS Laurence Rifkin, DDS
Alan M. Atlas, DMD Richard Hughes, DDS Georgios E. Romanos, DDS, PhD
Charles Babbush, DMD, MS Miguel Angel Iglesia, DDS Paul Rosen, DMD, MS
Thomas Balshi, DDS Mian Iqbal, DMD, MS Joel Rosenlicht, DMD
Barry Bartee, DDS, MD James Jacobs, DMD Larry Rosenthal, DDS
Lorin Berland, DDS Ziad N. Jalbout, DDS Steven Roser, DMD, MD
Peter Bertrand, DDS John Johnson, DDS, MS Salvatore Ruggiero, DMD, MD
Michael Block, DMD Sascha Jovanovic, DDS, MS Henry Salama, DMD
Chris Bonacci, DDS, MD John Kois, DMD, MSD Maurice Salama, DMD
Hugo Bonilla, DDS, MS Jack T Krauser, DMD Anthony Sclar, DMD
Gary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Frank Setzer, DDS
Ronald Brown, DDS, MS Burton Langer, DMD Maurizio Silvestri, DDS, MD
Bobby Butler, DDS Aldo Leopardi, DDS, MS Dennis Smiler, DDS, MScD
Nicholas Caplanis, DMD, MS Edward Lowe, DMD Dong-Seok Sohn, DDS, PhD
Daniele Cardaropoli, DDS Miles Madison, DDS Muna Soltan, DDS
Giuseppe Cardaropoli DDS, PhD Lanka Mahesh, BDS Michael Sonick, DMD
John Cavallaro, DDS Carlo Maiorana, MD, DDS Ahmad Soolari, DMD
Jennifer Cha, DMD, MS Jay Malmquist, DMD Neil L. Starr, DDS
Leon Chen, DMD, MS Louis Mandel, DDS Eric Stoopler, DMD
Stepehn Chu, DMD, MSD Michael Martin, DDS, PhD Scott Synnott, DMD
David Clark, DDS Ziv Mazor, DMD Haim Tal, DMD, PhD
Charles Cobb, DDS, PhD Dale Miles, DDS, MS Gregory Tarantola, DDS
Spyridon Condos, DDS Robert Miller, DDS Dennis Tarnow, DDS
Sally Cram, DDS John Minichetti, DMD Geza Terezhalmy, DDS, MA
Tomell DeBose, DDS Uwe Mohr, MDT Tiziano Testori, MD, DDS
Massimo Del Fabbro, PhD Dwight Moss, DMD, MS Michael Tischler, DDS
Douglas Deporter, DDS, PhD Peter K. Moy, DMD Tolga Tozum, DDS, PhD
Alex Ehrlich, DDS, MS Mel Mupparapu, DMD Leonardo Trombelli, DDS, PhD
Nicolas Elian, DDS Ross Nash, DDS Ilser Turkyilmaz, DDS, PhD
Paul Fugazzotto, DDS Gregory Naylor, DDS Dean Vafiadis, DDS
David Garber, DMD Marcel Noujeim, DDS, MS Emil Verban, DDS
Arun K. Garg, DMD Sammy Noumbissi, DDS, MS Hom-Lay Wang, DDS, PhD
Ronald Goldstein, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDS
David Guichet, DDS Adriano Piattelli, MD, DDS Alan Winter, DDS
Kenneth Hamlett, DDS Michael Pikos, DDS Glenn Wolfinger, DDS
Istvan Hargitai, DDS, MS George Priest, DMD Richard K. Yoon, DDS
Giulio Rasperini, DDS

Vergoullis et al
An Innovative Approach for the Selection,
Generation and Recording of a Custom Emergence
Profile Around Implants
Ioannis Vergoullis, DDS, MS1 • Catherine Badell, DDS1

George Papadopoulos, CDT2
Abstract
Background: Currently the clinical dexterity emergence profile to be generated and for
required along with the time and cost involved guiding the proper implant positioning in rela-
has been a constant obstacle for the evolve- tion to the aforementioned selected infor-
ment of the process of custom emergence mation. The mold tool of the system (EPM)
profile development to a standard of care. was utilized to fabricate the depicted by the
This is the first report on the protocol of use EPI proper shape and size custom healing
of a novel system (VPI EPMS) that can assist abutment and its duplicate impression post
the clinicians select, generate and record a to be used for the generation and record-
custom emergence profile in a predictable ing of the desired custom emergence profile.
way and a time and cost effective manner.
Results: 1 year post treatment evalua-
Methods: A 77 years old female patient pre- tion, the hard and soft tissues were clini-
sented with a hopeless upper first premo- cally and radiographically within normal limits.
lar seeking for implant replacement therapy.
The hopeless tooth was replaced with a den- Conclusions: The VPI EPMS and its proto-
tal implant utilizing the VPI EPMS system and col of use provide an easy and predictable way
its protocol of use. The guide tool of the sys- to properly select, generate and record a cus-
tem (EPI) was utilized to properly select the tom emergence profile around an implant and
shape, dimensions and orientation of the no adverse effects were noted with its use.
KEY WORDS: Emergence profile, dental implants, custom healing abutments, custom impression posts
1. Vergoullis Dental Clinic, Rhodes, Greece. Visiting Assistant Professor,

Periodontics, Louisiana State University, New Orleans, USA
2. Vergoullis Dental Clinic, Rhodes, Greece
6 • Vol. 9, No. 5 • July 2017

Vergoullis et al
Figure 1a: VPI EPMS, EPI. Figure 1B: VPI EPMS, EPM.
INTRODUCTION able a guide tool that can help them identify

One of the major existing problems in the daily intra-orally, the proper shape, dimensions and
practice of implant dentistry remains the routine orientation of the emergence profile that needs
generation and recording of a natural emergence to be generated in an edentulous space, in an
profile around an implant. The development of objective, fast and easy manner. This is a pro-
a natural emergence profile is a very important cess currently done mostly after the implant has
parameter as it relates not only to the esthetic but been placed and an impression has been taken.
also to the functional result of treatment.1,2 In par- The lab technician then depicts and generates
ticular a properly developed gingival emergence the emergence profile on the working cast before
profile is necessary in order for a final crown to fabricating one or a series of temporary pros-
be designed and fabricated, comprising a proper thesis to be utilized in order to gradually sculpt
contour and establishing adequate contact sur- the depicted emergence profile in the mouth.7
faces with the adjacent dentition.3, 4 However the This paper describes for the first time the pro-
process of custom emergence profile generation tocol of use of a novel system (VPI EPMS) (VP
and recording is a process that requires high clini- Innovato Holdings Ltd, Cyprus) that comprises an
cal dexterity, it involves extra cost and increases emergence profile indicator (EPI) and an emer-
working time.5, 6 All these factors prevent the gence profile mold (EPM) (Fig.1). The EPI is
process from becoming a standard practice. an intra-oral guide that can be used in order to
Finally, today the clinicians do not have avail- select the proper shape, dimensions and orienta-

Vergoullis et al
Figure 2a: Pre-op clinical view. Figure 2b: Pre-op x-ray.
Figure 2c: Pre-op evaluation with cylindrical tab of EPI. Figure 2d: Pre-op evaluation with anatomical tab of EPI.
tion of the suitable emergence profile to be gen- to the known shapes and sizes of the root trunk
erated and also to assist with implant position of different groups of teeth as this information is
and orientation in relation to the aforementioned available from the dental literature.8, 9, 10, 11, 12, 13
information. The EPM is used for the fabrica-
tion of a custom healing abutment and its dupli- CASE PRESENTATION
cate impression post, where their custom bodies A 77 year old female with a hopeless upper
are corresponded to the information depicted first premolar presented in our clinic for implant
by the EPI. The functional parts of the system replacement therapy. The patient was non smoker,
are coded in different groups (anterior, premo- with a medical history of controlled hypertension,
lars, molars) and their shapes and sizes relate no active dental disease and no contra-indica-
8 • Vol. 9, No. 5 • July 2017

Vergoullis et al
Figure 3a: Custom healing abutment. Figure 3b: Custom healing abutment.
Figure 3c: Custom impression post. Figure 3d: Custom impression post.
tions present for implant therapy.14 The radio- use of the cylindrical tabs of the premolar group
graphic and clinical evaluation revealed that there of the EPI. The selected tab was the small size
was adequate hard and soft tissue to proceed cylindrical (#4.0) as this fitted best in the eden-
with an immediate implant replacement therapy tulous space in the mesiodistal dimensions, being
(Fig. 2a, 2b). The requirements of the Helsinki in light contact with the proximal surfaces of the
Declaration were observed, and the patient gave adjacent teeth (Fig. 2c). The anatomical tabs from
informed consent for all surgical procedures. the premolar group were subsequently utilized for
At the day of consultation, the edentulous the selection of the proper size and shape of the
space was evaluated with the EPI of the system. emergence profile to be generated, along with
The edentulous site was first evaluated with the determination of the proper orientation of the lat-

Vergoullis et al
Figure 4: Custom healing abutment and impression post. Figure 5a: Osteotomy marking.
Figure 5b: Facial view post socket shield preparation. Figure 5c: Occlusal view post socket shield preparation.
ter. The medium size-premolar anatomical tab to be placed. In other words, the flat surface
(#5.1) was the one selected as most appropri- of the hex of the prosthetic connection of the
ate, as this resembled best the root trunk of the implant should be facing the same direction
tooth to be replaced by the implant, expanding as per the T line on the tab. In this case, the
1-2 mm within the borders of the future crown proper orientation was determined to be facially
(Fig. 2d). Moreover, the T line imprinted on the (Fig. 2d). The coding of the selected cylindri-
top surface of the anatomical tab, served as a cal and anatomical tab along with the orienta-
reference for the proper orientation of the emer- tion of the reference T-line and the implant type
gence profile and depicted the proper orienta- and platform size to be utilized were noted in
tion of the prosthetic connection of the implant the patient’s chart. The treatment plan of the
10 • Vol. 9, No. 5 • July 2017

Vergoullis et al
Figure 6a: Custom healing abutment. Figure 6b: Custom healing abutment.
Figure 6c: Custom impression post. Figure 6d: Custom impression post.
patient included the following information: a hex connection, 3.5mm platform and 2 mm pol-
3.5mm platform, internal hex implant will be ished shoulder was installed into the #5.1 well
placed and it will receive a medium size-pre- of the mold according to the manufacturer guide-
molar custom healing abutment (#5.1) with a lines (Fig. 3a). Composite nano-hybrid material
2mm titanium shoulder, facing facially. The #4.0 was then introduced into the open space avail-
cylindrical tab will be utilized as surgical guide. able in the well, until the space was completely
filled and it was subsequently light cured for
Custom Healing Abutment and Impression 40 seconds (Fig. 3b).15, 16, 17, 18, 19 The cus-
Post Fabrication Process tom healing abutment was then removed from
A temporary titanium abutment with an internal the well and it was light cured for an additional

Vergoullis et al
Figure 7a: Clinical evaluation post-surgery.
Figure 7c: Developed emergence profile post-surgery. Figure 7b: Radiographic evaluation post-surgery.
20 seconds. Minor height adjustments were healing abutment and duplicate impression post
done and the composite surface was highly pol- were fabricated and stored for later use (Fig. 4).
ished using polishing brushes and paste. The
#5.1 well of the mold was cleaned with a cotton Day of Surgery
tip soaked in alcohol and air dried. The described At the day of surgery the fabricated #5.1 cus-
process was performed again for the fabrication tom healing abutment was thoroughly cleaned
of the duplicate impression post by utilizing an with the use of steam, followed by an ultrasonic
impression post core with the same type pros- bath with 95% alcohol solution for 5 minutes. It
thetic connection and same size prosthetic plat- was then put in a sterile surgical cup filled with
form and shoulder (Fig. 3c, 3d). A custom shaped chlorhexidine solution 0.2% (Froiplak Plus, Froika,
12 • Vol. 9, No. 5 • July 2017

Vergoullis et al
Figure 8a: Custom impression post. Figure 8b: Custom impression post installed to the implant.
Figure 8c: Impression. Figure 8d: Custom impression post installed into the
impression.
Greece)for approximately 15 minutes.20, 21, 22, 23 bore of the tab (Fig. 5a). A full thickness flap was
Local anesthesia was administered (Ubistesin elevated. The palatal root was removed. The buc-
4%, 3M ESPE, Germany ) and the #4.0 cylindrical root was sectioned mesiodistally. The palatal
cal tab attached on the handle of the guide was portion of the buccal root was removed while a
placed on the edentulous site. The central refer- facial shield of 1.5 mm thickness was left intact in
ence line present on the top surface of the tab place24 (Fig. 5b, 5c). The socket was thoroughly
was aligned with the occlusal lines of the adjacent curetted and rinsed with a tetracycline solution
teeth. The initiation point of implant osteotomy (50mg/ml) and sterile saline solution. The osteot-
was performed with the use of a 1.3 mm pilot drill omy was then identified and enlarged with subse-
(Salvin Dental, VA, USA) through the central open quent drills of larger diameter as per the implant

Vergoullis et al
Figure 8e: Working cast. Figure 8f: Final screw-retained prosthesis, occlusal view.
Figure 8g: Final screw-retained prosthesis, facial view. Figure 8h: Final prosthesis in the mouth, occlusal view.
manufacturer recommended protocol for oste-

otomy preparation. After each drill was used, a
corresponding in size guide pin available in the
system was inserted into the osteotomy and the
selected #5.1 anatomical tab of the guide was
installed on the top pillar of the pin. This allowed
the consistent evaluation of the implant osteotomy
position and angulation in relation to the desired
emergence profile to be generated. After comple-
tion of the osteotomy, the implant was placed
Figure 8i: Final prosthesis in the mouth, facial view.
14 • Vol. 9, No. 5 • July 2017

Vergoullis et al
Figure 9a: Final prosthesis in the mouth, occlusal view Figure 9b: Final prosthesis in the mouth, facial view 1 year
1 year post surgery. post surgery.
Figure 9d: Bite-wing radiograph 1 year post surgery.
keeping the flat surface of the implant prosthetic

connection facing facially (Fig. 6a, 6b). The gap
between implant body and surrounding structures
was filled with allograft material (Oragraft, Freeze
dried bone allograft, Cortico-cancellous, Lifenet,
VA, USA) and the facial fenestration was treated
with the same allograft material and covered with
collagen membrane (T Barrier, B&B Dental, Italy).
Adequate primary stability of the implant was
achieved (Insertion torque 40N/cm and ISQ
Figure 9c: Peri-apical radiograph 1 year post surgery. 77). The #5.1 custom healing abutment was

Vergoullis et al
thoroughly rinsed with sterile saline and it was impression post was thoroughly cleaned with the
installed onto the implant with a 30 N/cm torque same protocol as per the custom healing abut-
as per the manufacturers recommendation for final ment previously described. The duplicate impres-
abutment torque. This technique has been shown sion post was installed onto the implant with the
to be beneficial for the hard tissue response in same orientation as the custom healing abutment
comparison to standard one piece healing abut- had (Fig. 8b). Proper installation onto the implant
ments. This response is due to the fact that it mini- was confirmed radiographically. An impres-
mizes micro-movement during the healing phase, sion was taken utilizing polyvislioxane material
but also because allows proper oral hygiene mea- (Image PVS, Dental Line, Greece), using a stan-
sures.25 A final evaluation was made and the flaps dard tray with the closed tray impression tech-
were repositioned and sutured utilizing resorb- nique26 (Fig. 8c). An impression of the opposing
able sutures (Chromic Gut 4.0 – Salvin Dental, arch was also taken along with bite registration.
VA, USA) (Fig. 6c). The occlusal screw access
bore was sealed with a bottom layer of sterile Tef- Laboratory
lon tape and a top layer of composite material as The lab technician coupled an appropriate
per standard practice of sealing the screw access implant analog with the duplicate impression
bore of a temporary or a final implant crown (Fig. post and installed the later into the impression
6d). Postoperative instructions were given. The (Fig. 8d). The notch present on the compos-
patient was given a prescription for Amoxicillin ite surface of the impression was replicated in
500mg (GlaxoSmithKline, UK) every 8 hours for 5 the impression and it provided a reference for
days; Ibuprofen 600mg (Actavis Group, Greece) proper installation in only one functional posi-
every 8 hours for 4 days and then as needed; tion (Fig. 8a, 8c, 8d). Silicone material (gingival
and Chlorexidine rinse 0.12% (Froiplak 0.12%, mask) was inserted around the exposed surface
Froika, Greece) twice a day for two weeks. of the custom impression post. The gypsum was
The healing process was evalu- then poured to fabricate the working casts. The
ated at 2, 4, 8, 12 and 16 weeks post two casts were articulated using a semi-adjust-
implant placement and it was uneventful. able articulator. The generated emergence pro-
file appeared to be accurately recorded and
Impression Stage provided the lab technician the foundation for
Five months post dental implant placement, clini- the fabrication of a screw retained, natural in
cal (ISQ 78 - Ostell) and radiographic evalua- shape and size implant prosthesis with proper
tion revealed successful osseointegration of the contour and contact surfaces 3 (Fig. 8e, 8f, 8g).
implant with healthy looking surrounding soft
tissue (Fig. 7). The area was rinsed with ster- Prosthesis Delivery
ile saline. A small notch was made on the top At the day of final prosthesis delivery, the cus-
surface of the composite area of the #5.1 dupli- tom healing abutment was replaced by the final
cate impression post using a high speed hand prosthesis. The proper fit of the prosthesis was
piece and a round diamond bur (Fig. 8a). The evaluated clinically and radiographically. Occlu-
16 • Vol. 9, No. 5 • July 2017

Vergoullis et al
sal adjustments were made. The contact surfaces abutments are used to support cemented res-
were evaluated with the use of dental floss. The torations, the process of controlling and remov-
screw-retained prosthesis was torqued at 30N/ ing the excess of cement during the cementation
cm as per the implant manufacturer recomman- process becomes a very difficult task that often
dation. The screw access bore was blocked with is ineffective. When left behind, the presence of
a layer of sterile Teflon tape and a second layer cement subgingivally leads to the development
of micro-hybrid composite material (Fig. 8h, of biological complications like cement sepsis
8i). Oral hygiene instructions were given to the around the implant.30, 31 Finally, there is evidence
patient. The patient was very happy and satis- arising from animal research that shows that in
fied with the esthetic outcome of the treatment. cases of immediate implants in extraction sockets,
The patient was re-evaluated at 12 months the standard healing abutments provide inferior
post implant placement. The hard and soft tis- outcomes compared to anatomical in shape and
sue was clinically stable and within normal lim- wider in dimensions custom healing abutments
its (Fig. 9). At this appointment the patient with regards to soft and hard tissue response.32
confirmed that she was totally satisfied with the Many clinicians have identified the aforemen-
esthetic and functional result of the treatment. tioned problems and try to prosthetically sculpt
the peri-implant tissue by using a series of tem-
DISCUSSION porary prostheses that they gradually adapt in
The development and recording of a natural, in shape and dimensions in order to change the
shape and size, custom emergence profile is existing cylindrical in shape emergence profile to
one of the fundamental elements for the estheti- one with a natural shape and dimensions.33,34,35,
cally and functionally successfull implant therapy. 36,37,38
Even when a natural emergence profile
Today the common practice is the develop- is achieved, another problem that the clinician
ment of a cylindrical in shape emergence profile might face is to accurately record the developed
as this is generated by the currently existing and custom emergence profile during the impression
widely used cylindrical in shape standard healing stage. In order to accurately record it, a custom-
abutments, available by the different implant com- ized impression post has to be developed with a
panies.27, 28 The cylindrical in shape emergence subgingival portion that will be the exact duplicate
profile leads to the design and fabrication of a of the subgingival portion of the final temporary
crown comprising a cylindrical sub-gingival por- prosthesis that was used to develop the custom
tion. This then results in a ridge lap contour of the emergence profile.39,40,41,42 This is a process that
crown, with areas of undercuts and inadequate requires high dexterity, is laborious, takes time and
contact surfaces with the adjacent dentition. The becomes even more difficult in cases involving the
contour of the prosthesis, with a mushroom like impression of several implants in the same arch.43
shape, creates several clinical problems, like food All those factors have played a role on inter-
impaction, large open triangles with the adjacent fering with the process of custom emergence
teeth on the cervical portion, among others.29 Also profile development and recording from becom-
in the aforementioned cases, when standard final ing a standard protocol of care for both anterior

Vergoullis et al
and posterior cases. The superior results that this

customization process withholds both estheti-
cally and biologically have been well proven. The
The Journal of Implant & Advanced Clinical Dentistry use of a system that could simplify the implemen-
tation of this process in the daily practice will
have a positive impact on the long term results of
ATTENTION implant therapy. The VPI EPMS is a system that

can facilitate the achievement of this goal since it
simplifies the process making it accessible to all
PROSPECTIVE dentists practicing implant dentistry. The innova-

tive tools in the VPI EPMS system, facilitate the
process of proper implant positioning as well as
AUTHORS the selection, establishment and recording of a

natural in shape and dimensions emergence pro-
file. We have been utilizing the system in our clinic
JIACD wants
for the last 3 years and no adverse effects asso-
ciated with the system have been noted in 120
cases treated with the assistance of the system.
to publish CONCLUSIONS
your article!
This is the first report of an innovative system
that appears to be effective in assisting clini-
cians to easily and predictably place a dental
implant in the proper restorative position; and to
select, develop and record the ideal custom emer-
For complete details gence profile during implant therapy. More stud-
regarding publication in ies involving a greater number of clinical cases
and different clinicians are needed to prove the
JIACD, please refer reproducibility of the results of the system. l
to our author guidelines
at the following link: Correspondence:
jiacd.com/ Ioannis Vergoullis, DDS, MS*
author-guidelines 31 Ammohostou street, 85100
Rhodes, Greece
or email us at: Tel: +30- 2241078843
editors@jicad.com Email: drvergoullis@gmail.com
18 • Vol. 9, No. 5 • July 2017

Vergoullis et al
Disclosure 17. J anus J, Fauxpoint G, Arntz Y, Pelletier H, 30. Piñeyro A, Ganeles J. Custom abutments
The authors report no conflicts of interest Etienne O. Surface roughness and morphol- alone will not eliminate the clinical effects
with anything mentioned in this article. ogy of three nanocomposites after two differ- of poor cementation techniques around
ent polishing treatments by a multitechnique dental implants. Compend Contin Educ
References approach. Dent Mater. 2010 May;26(5):416-25. Dent. 2014 Oct;35(9):678-80, 682-6.
1. Sadan A, Blatz MB, Salinas TJ, Block MS. Single- 18. Ozel E, Korkmaz Y, Attar N, Karabulut E. Effect 31. A lani A, Bishop K. Peri-implantitis. Part 2:
implant restorations: a contemporary approach for of one-step polishing systems on surface rough- Prevention and maintenance of peri-implant
achieving a predictable outcome. J Oral Maxillofac ness of different flowable restorative materi- health. Br Dent J. 2014 Sep;217(6):289-97.
Surg. 2004 Sep;62(9 Suppl 2):73-81. als. Dent Mater J. 2008 Nov;27(6):755-64. 32. L ópez-López PJ, Mareque-Bueno J, Boquete-
2. Norton MR. Single-tooth implant-supported res- 19. Andriani W Jr, Suzuki M, Bonfante EA, Castro A, Aguilar-Salvatierra Raya A, Martínez-
torations. Planning for an aesthetic and functional Carvalho RM, Silva NR, Coelho PG. González JM, Calvo-Guirado JL. The effects
solution. Dent Update. 2001 May;28(4):170-5. Mechanical testing of indirect composite of healing abutments of different size and
3. Su H, Gonzalez-Martin O, Weisgold A, Lee materials directly applied on implantabut- anatomic shape placed immediately in extrac-
E. Considerations of implant abutment and ments. J Adhes Dent. 2010 Aug;12(4):311-7. tion sockets on peri-implant hard and soft
crown contour: critical contour and sub- 20. Sennhenn-Kirchner S, Weustermann S, tissues. A pilot study in foxhound dogs. Clin
critical contour. Int J Periodontics Restor- Mergeryan H, Jacobs HG, Borg-von ZepelinM, Oral Implants Res. 2016 Jan;27(1):90-6.
ative Dent. 2010 Aug;30(4):335-43. Kirchner B. Preoperative sterilization and 33. W ittneben JG, Buser D, Belser UC, Bräg-
4. Kinsel RP, Pope BI, Capoferri D. A Review disinfection of drill guidetemplates. Clin ger U. Peri-implant soft tissue condition-
of the Positive Influence of Crown Contours Oral Investig. 2008 Jun;12(2):179-87. ing with provisional restorations in the
on Soft-Tissue Esthetics. Compend Contin 21. Canullo L, Micarelli C, Lembo-Fazio L, Iannello esthetic zone: the dynamic compression
Educ Dent. 2015 May;36(5):352-7. Review. G, Clementini M. Microscopical and microbio- technique. Int J Periodontics Restorative
5. Shah K, Yilmaz B. A Technique to Trans- logic characterization of customized titanium Dent. 2013 Jul-Aug;33(4):447-55.
fer the Emergence Profile Contours abutments after different cleaning procedures. 34. Al-Juboori MJ. Interdental Implant Papil-
of a Provisional Implant Crown to the Clin Oral Implants Res. 2014 Mar;25(3):328-36. lae Grow up with Temporary Abutment-
Definitive Impression. Int J Oral Maxillofac 22. Moeintaghavi A, Arab H, Khajekaramodini M, displaced at Monthly Intervals. J Contemp
Implants. 2016 Mar-Apr;31(2):e15-7. Hosseini R, Danesteh H, Niknami H. In vitro Dent Pract. 2015 May 1;16(5):422-6.
6. Papadopoulos I, Pozidi G, Goussias H, Kour- antimicrobial comparison of chlorhexidine, 35. S choenbaum TR. Abutment Emergence
tis S. Transferring the emergence profile from persica mouthwash and miswak extract. J Con- Profile and Its Effect on Peri-Implant Tis-
the provisional to the final restoration. J Esthet temp Dent Pract. 2012 Mar 1;13(2):147-52. sues. Compend Contin Educ Dent.
Restor Dent. 2014 May-Jun;26(3):154-61. 23. Haragushiku GA, Back ED, Tomazinho PH, 2015 Jul-Aug;36(7):474-9. Review.
7. A
l-Juboori MJ. Interdental Implant Papil- Baratto Filho F, Furuse AY. Influenceof antimi- 36. Macintosh DC, Sutherland M. Method for
lae Grow up with Temporary Abutment- crobial solutions in the decontamination and developing an optimal emergence profile using
displaced at Monthly Intervals. J Contemp adhesion of glass-fiber posts to root canals. J heat-polymerized provisional restorations for
Dent Pract. 2015 May 1;16(5):422-6. Appl Oral Sci. 2015 Jul-Aug;23(4):436-41. single-toothimplant-supported restorations.
8. Major, M; Ash and Stanley J. Nelson. Wheeler’s 24. Bäumer D, Zuhr O, Rebele S, Schneider D, J Prosthet Dent. 2004 Mar;91(3):289-92.
Dental Anatomy,Physiology and Oclussion. Schupbach P, Hürzeler M. The socket-shield 37. P
arpaiola A, Sbricoli L, Guazzo R, Bressan E,
8th Edition. ElSevier. 2003:158-321 technique: first histological, clinical, and volu- Lops D. Managing theperi-implant mucosa: a
9. Richardson ER, Malhotra SK. Mesiodistal crown metrical observations after separation of the clinically reliable method for optimizing soft tis-
dimension of the permanent dentition of American buccal tooth segment – a pilot study. Clin sue contours and emergence profile. J Esthet
Negroes. Am J Orthod. 1975 Aug;68(2):157-64. Implant Dent Relat Res. 2015 Feb;17(1):71-82. Restor Dent. 2013 Oct;25(5):317-23.
10. S antoro M, Ayoub ME, Pardi VA, Cangialosi 25. Nader N, Aboulhosn M, Berberi A, Manal C, 38. Hochwald DA. Surgical template impression
TJ. Mesiodistal crown dimensions and Younes R. Marginal Bone Remodeling around during stage I surgery forfabrication of a provi-
tooth size discrepancy of the permanent healing Abutment vs Final Abutment Place- sional restoration to be placed at stage II sur-
dentition of Dominican Americans. Angle ment at Second Stage ImplantSurgery: A gery. J Prosthet Dent. 1991 Dec;66(6):796-8.
Orthod. 2000 Aug;70(4):303-7. 12-month Randomized Clinical Trial. J Con- 39. Shah K, Yilmaz B. A Technique to Trans-
11. D ababneh R, Samara R, Abul-Ghanam M, temp Dent Pract. 2016 Jan 1;17(1):7-15. fer the Emergence Profile Contours
Obeidad L, Shudifat N. Root trunk: Types and 26. Gallucci GO, Papaspyridakos P, Ashy LM, of a Provisional Implant Crown to the
dimension and their influence on the diagnosis Kim GE, Brady NJ, Weber HP. Clinicalac- Definitive Impression. Int J Oral Maxillofac
and treatment of periodontally involved first curacy outcomes of closed-tray and open- Implants. 2016 Mar-Apr;31(2):e15-7.
molars. JRMS March 2011;18(1): 45-51 tray implant impression techniques for 40. Papadopoulos I, Pozidi G, Goussias H, Kourtis
12. A l-Shammari KF, Kazor CE, Wang HL. partially edentulous patients. Int J Prostho- S. Transferring the emergence profile from
Molar root anatomy and management dont. 2011 Sep-Oct;24(5):469-72. the provisional to the final restoration. J Esthet
of furcation defects. J Clin Periodontol. 27. B ernard JP, Belser UC, Martinet JP, Bor- Restor Dent. 2014 May-Jun;26(3):154-61.
2001 Aug;28(8):730-40. Review. gis SA. Osseointegration of Brånemark 41. E lian N, Tabourian G, Jalbout ZN, Classi A, Cho
13. Kerns DG, Greenwell H, Wittwer JW, Drisko C, fixtures using a single-step operating tech- SC, Froum S, Tarnow DP. Accurate transfer of
Williams JN, Kerns LL. Root trunk dimensions nique. A preliminary prospective one-year peri-implant soft tissue emergence profile from
of 5 different tooth types. Int J Periodontics study in the edentulous mandible. Clin Oral the provisional crown to the final prosthesis
Restorative Dent. 1999 Feb;19(1):82-91. Implants Res. 1995 Jun;6(2):122-9. using an emergence profile cast. J Esthet Restor
14. D e Jong KJ, Abraham-Inpijn L. A risk-related 28. Collins JR, Berg RW, Rodríguez M, Rodríguez Dent. 2007;19(6):306-14; discussion 315.
patient-administered medicalquestionnaire for I, Coelho PG, Tovar N. Evaluation of human 42. N eale D, Chee WW. Development of implant
dental practice. Int Dent J. 1994 periimplant soft tissues around nonsubmerged soft tissue emergence profile: a technique.
Oct;44(5):471-9. machined standard and platform-switched abut- J Prosthet Dent. 1994 Apr;71(4):364-8.
15. E ndo T, Finger WJ, Kanehira M, Utterodt A, ments. Implant Dent. 2015 Feb;24(1):57-61. 43. N tounis A, Pelekanos S. Custom cop-
Komatsu M. Surface texture and roughness of 29. Wang JH, Judge R, Bailey D. A 5-Year Ret- ings for accurate impressions of mul-
polished nanofill and nanohybrid resin compos- rospective Assay of Implant Treatments and tiple internal connection implants. Implant
ites. Dent Mater J. 2010 Mar;29(2):213-23. Complications in Private Practice: The Restor- Dent. 2010 Oct;19(5):365-9.
16. U çtali MB, Arisu HD, Omürlü H, Eligüzelolu E, ative Complications of Single and Short-Span
Ozcan S, Ergun G. The effect of different finish- Implant-Supported Fixed Prostheses. Int J
ing and polishing systems on the surface rough- Prosthodont. 2016 Sep-Oct;29(5):435-44.
ness ofdifferent composite restorative materials.
J Contemp Dent Pract. 2007 Feb1;8(2):89-96.

Jambi et al
Partial Enucleation of the Nasopalatine
Canal for Implant Placement:
A Novel Procedure
Dr. Samar M Jambi1 • Dr. Meisan A. Bukhari2
Abstract
O
ne of the anatomical obstacles for den- canal’s contents and placement of allograft bone
tal implants placement in the upper ante- is presented in this case report. Re-entry sur-
rior region of the oral cavity is the incisive gery after 6 months of the surgical site showed
canal or the nasopalatine canal. Presence of the an adequate bone. An implant was placed then
incisive canal jeopardizes the ideal position of the a prosthetic restoration was placed. After 1 year
implants placement. As a result, enucleation of of follow-up the implant was successful and no
the canal content and placement of bone graft or sensory disturbances were shown. This novel
substitute are necessary to improve the bone bed. surgical approach that shows partial removal of
In order to prevent any change in sensation neurovascular content of the incisive canal dur-
(even a temporarily one) and having bone aug- ing bone augmentation procedure is successful
mentation at the same time, partial removal of the for implant placement and function in the future.
KEY WORDS: Dental implants, nasopalatine canal, enucleation
1. The North Centre of Dental Specialities, Department of Dental Implantology and Periodontology, Jeddah, Saudi Arabia
2. The North Centre of Dental Specialities, Department of Prosthodontics, Jeddah , Saudi Arabia
20 • Vol. 9, No. 5 • July 2017

Jambi et al
Figure 1: Pre-surgical clinical appearance of missing right

central incisor.
Figure 2: Presurgical CBCT scan for the missing area.
INTRODUCTION to the canal range from 2.9 mm to 13.6 mm.3

A lot of patients face the embarrassment and Unfortunately, after extraction of the anterior
frustration of tooth loss either in the maxilla or maxillary teeth, high resorption rate happens on
in the mandible. In the maxilla, dentists are chal- the area. In addition, the presence of the incisive
lenging replacement of missing teeth in the canal jeopardizes the ideal position of the implant
maxilla in their daily practice. The incisive canal placement. Non-osseointegration of the implant
(the nasopalatine canal) is located between the and impairment of sensation are common implant
two central incisors, slightly palatal. Its volume complications when it is in a direct contact with
can prevent implant placement. The neurovas- nervous tissue.4 As a result, enucleation of the
cular content includes nasopalatine nerve and canal content and then replaced by bone graft or
terminal branch of nasopalatine artery and also substitute is necessary to improve the bone bed. It
anastomoses with the greater palatine nerve is crucial to evaluate the canal and its surrounding
and artery. This gives innervation and vascular- bone and anatomical landmarks precisely before
ization for the upper anterior region from the implants placement to avoid complications.5
right canine to the left canine. The incisive canal Neurological impairment of the soft tis-
ranges from 4 to 26 mm in length.1,2 Mraiwa sue such as paresthesia (abnormal sensa-
et al. published their 3-dimensional analysis of tion of the soft tissue such as tingling or
the incisive canal in 2004 and found that It’s pricking) or dysesthia (burning sensation)
diameter range from 1.5 mm to 9.2 mm and may exist after enucleation of the canal.2 The
The width of the bucco palatal bone anterior loss of sensation is the most concern when

Jambi et al
Figure 3: Canal enucleated.
dealing with the incisive canal enucleation.

In 2009, Spin-Neto et al. placed an implant
inside the canal after its enucleation without Figure 4: Allograft bone was placed.
using of any bone graft. No loss of sensation
was found.6 Artzi et al. displaced the content
posteriorly but not removed with using of cor-
tico-cancellous bone block graft. Then imme-
diate placement of an implant was placed.
There were no sensory disturbances in the
case he did and it was successful. The re-
entry was after 9 months of the procedure.7
There was slight loss of sensation ini-
tially then recovery happened in the patients
of Penarrocha et al.8,9 For Rosenquist et al
study, none of their cases had sensory distur-
bances.10 Slight numbness of the two cases Figure 5: Membrane covering the surgical area.
was reported by Verardi et al after one week
of the surgery and existed for 4 weeks.11
Variations of bone grafts were used after enu- approach for severely atrophic maxilla rehabilita-
cleation of the incisive canal. Autogenous can- tion. They .performed two studies and used the
cellous bone was used in 4 canals in a study by same type in addition to beta tricalcium phos-
Rosenquist et al. who used autogenous cancel- phate. He had successful reentry after 9 months
lous chips for chins. The results showed 100% in the earlier study of 7 implants placed into the
implant survival at 12-15 months.10 Penarrocha incisive canals after enc. The latter study had
et al concluded that placing implants in nasopala- follow up for 13 cases and 2 early failures of 2
tine canal may be considered a variable treatment cases were found and no failures for the rest
22 • Vol. 9, No. 5 • July 2017

Jambi et al
Figure 6: Postoperative CBCT. Figure 7: Clinical appearance of the surgical site.
Figure 8: Implant placement.
of the cases (mean follow up of 70 months). 8,9

Scher used DFDBA and Calcium sulphate after
removal of soft tissue content of 2 incisive canals
and he got 100% implant survival rate one of the
2 cases has follow up at 3 years.12 Verdi et al.
placed collagen plug in 2 cases apically and can-
cellous allograft particles in one case and bovine
xenograft and autograft in the other case placed
coronally.11 The most recent case was reported
by Wassdorp who used block allograft after
removal of the incisive canal contents. No sen- Figure 9: X-ray of installed implant.
sory disturbances was reported by the patient
after six months of the implant placement.13

Jambi et al
both the buccal and the lingual surfaces were

covered by BioMend®, a collagen membrane
(Zimmer, Warsaw, IN ) to get guided bone regen-
eration in the area (Figure 5). Multiple Simple
interrupted sutures using VICRYL® (ETHICON,
USA) were performed to close the flap after
obtaining periosteal releasing incisions. Dur-
ing healing time (6 months), patient was wearing
an interim partial denture which was relived to
be not in a direct contact with the surgical site.
Figure 10: Final restoration of missing right central incisor. After 6 months, CT scan and re-entry surgery
showed an adequate bone (Figure 6 & 7). An
implant was placed size 4.1*11.5 (Prima Con-
CASE REPORT nex, Keystone Dental Inc., Burlington, Massa-
A 20 years old Saudi male came to the Dental chusetts, USA) with cover screw (Figure 8).
Hospital of King Abdul-Aziz University in Jeddah The buccal bone covering the implant was thin
to replace missing tooth #11 which was extracted so Puros®(Zimmer, Warsaw, IN), demineralized
after its fracture due to trauma. His medical his- freeze-dried cortical bone allograft (DFDBA) was
tory was not significant. The patient has low lip placed over the buccal bone to gain thicker bone
line and has thick gingival biotype. He has a defi- (Zimmer, Warsaw, IN). Then a collagen membrane
cient bony ridge in the missing area (Figure 1). BioMend® (Zimmer, Warsaw, IN) was placed.
CBCT findings showed severe bone loss in the The surgical site was allowed to heal
missing area in close proximity to the incisive for another 6 months before starting mak-
canal (Figure 2). The surgical procedure was ing the final prosthetic part. An impression
discussed with the patient including the possi- was taken and a temporary crown was placed
bility of canal enucleation and its complications. for 1 month then a final impression was taken
After anesthetizing the area under local for the final restoration (Figure 10). After
anesthesia with buccal and nasopalatine infil- 1 year of follow-up the implant was success-
tration (Lignospan special, Lidocain hydrochlo- ful and no sensory disturbances were shown.
ride 2% & 1:80,000 epinephrine). Full thickness
flap was reflected with vertical releasing inci- CONCLUSION
sions. Enucleation of the coronal 2/3 of the inci- According to the previous findings regarding par-
sive canal was performed with copious irrigation tial removal of neurovascular during bone aug-
using debridement burs and curettes (Figure 3). mentation procedure in the upper anterior region
Puros® demineralized freeze-dried corti- is successful for implant placement and function
cal bone allograft (DFDBA) was placed into the in the future. This procedure can be performed
canal (Zimmer, Warsaw, IN) and on the buc- only in long nasopalatine and the canal should
cal surface of the surgical area (Figure 4) then be longer than the implant that would be placed.
24 • Vol. 9, No. 5 • July 2017

Jambi et al
This is to avoid placing the implant in a soft tis-

sue (the content of the canal). Otherwise implant
will be in a direct contact with neurovascular tis-
sue leading to loss of osseointegration and sen-
sory changes will happen Panjnoush et al.1 l
Correspondence:
Dr. Samar M. Jambi
ATTENTION
PROSPECTIVE
The North Centre of Dental Specialties
Al-Amal Street
Jeddah, Saudi Arabia
AUTHORS
Phone: +966595141616
Email: sjambi@moh.gov.sa
JIACD wants
Disclosure
The authors report no conflicts of interest with anything mentioned in this article.
References
to publish
1. Panjnoush M, Norouzi H, Kheirandish Y, Shamshiri AR, Mofidi N. Evaluation of
morphology and anatomical measurement of nasopalatine canal using cone
beam computed tomography. J Dent 2016; 13 (4):287-294.
2. Misch CE, Strong JT, Bidez MW. Contemporary Implant Dentistry, 3rd ed. St.
Louis, MO: Mosby; 2008: 200-229.
your article!
3. Mraiwa, N, Jacobs R, Van Cleynenbreugel J, Sanderink G, Schutyser F,
Suetens P, van Steenberghe D, Quirynen M. The nasopalatine canal revisited
using 2D and 3D CT imaging. Dentomaxil Radiol 2004; 33 (6): 396–402
4. Liang X, Jacobs R, Martens W, Hu Y, Adriaensens P, Quirynen M, Lambrichts
I. Macro- and micro-anatomical, histological and computed tomography
scan characterization of the nasopalatine canal. J Clin Periodontol 2009; 36
(7):598–603.
5. Loubele M, Guerrero ME, Jacobs R, Suetens P, van Steenberghe D.
A comparison of jaw dimensional and quality assessments of bone
characteristics with cone-beam CT, spiral tomography, and multi-slice spiral
CT Int J Oral Maxillofac Implants 2007; 22(3):446–54.
For complete details
regarding publication in
6. Spin-Neto R1, Bedran TB, de Paula WN, de Freitas RM, de Oliveira Ramalho
LT, Marcantonio E Jr. Incisive canal deflation for correct implant placement:
case report Implant Dent 2009; 18(6):473-9.
7. A
rtzi Z, Nemcovsky CE, Bitlitum I, Segal P. Displacement of the incisive
foramen in conjunction with implant placement in the anterior maxilla without JIACD, please refer
jeopardizing vitality of nasopalatine nerve and vessels: a novel surgical
approach. Clin Oral Implants Res 2000; 11(5):505–10.
8. Peñarrocha M, Carrillo C, Uribe R, García B. The nasopalatine canal as an
to our author guidelines
anatomic buttress for implant placement in the severely atrophic maxilla: a pilot
study. Int J Oral Maxillofac Implants 2009; 24(5):936–42. at the following link:
9. Peñarrocha D, Candel E, Guirado JL, Canullo L, Peñarrocha M. Implants
placed in the nasopalatine canal to rehabilitate severly atrophic maxillae:a
retrospective study with long follow up. J oral implant 2014; 40 (6): 699-706.
jiacd.com/
author-guidelines
10. R osenquist JB, Nyström E. Occlusion of the incisal canal with bone
chips. A procedure to facilitate insertion of implants in the anterior maxilla.
Int J Oral Maxillofac Surg 1992; 21(4):210–1.
11. S cher EL. Use of the incisive canal as a recipient site for root form implants:
preliminary clinical reports. Implant Dent 1994; 3(1):38–41. or email us at:
12. W aasdorp J Enucleation of the incisive canal for implant placement: a
comprehensive literature review and case report. J oral implant. 2016;
42 (2): 180-183.
editors@jicad.com

Zahran et al
Clinical and Radiographic Evaluation of Short Dental
Implants in Posterior Atrophic Ridges with a Follow-up
Period of 1 Year after Loading: A Controlled Clinical Trial
Amr Zahran, BDS, MDS, PhD1 • Fouad Al Tayib, BDS, MDS, PhD2
Amr Ali, BDS, MDS3 • Moemen Sheba,BDS4
Abstract
Objective: to evaluate clinically and radiographi- Results: 30 patients were evaluated at 1 year
cally the performance of short dental implants in the after loading. The PTMVs were -1.23 ± 0.31 in
posterior atrophic ridges (maxilla and mandible) with maxilla, and 2 ± 0.23 in mandible. Marginal bone
deficient vertical bone height as an alternative treat- loss in the maxilla recorded -1.55 ± 0.29 mm and
ment modality to other more invasive procedures. in the mandible -1.10 ± 0.12 mm after1 year of
loading. The difference between the two groups
Methods: 30 patients, with residual bone height showed no statistical significance (difference =
7-9 mm in the mandibular or the maxillary poste- -0.44 mm; 95% CI: -0.18 to 1.06; P = 0.1549).
rior regions, were selected to receive 6.5 mm 2 implants failed in the maxilla with a failure rate
short dental implants (Maxi Z Flat-End, Osteo- of 13.3% while there were no failures in the man-
Care™ Implant System, London, UK). Implants dible. Statistical analysis showed no significant dif-
were loaded 4 months (T2) after placement and ference between the studied groups (P=0.4828).
Patients were followed up 1 year after loading
(T3). 32 implants were inserted, 15 implants in Conclusion: Short dental implants seem to be an
the posterior maxilla and 17 implants in the pos- effective alternative treatment for atrophic ridges
terior mandible. Outcomes measured included: with a very high success rate in the mandible. They
Implant stability measured by Periotest®M minimize the need for bone grafting procedures
mean values (PTMVs), Implant failure rate, mar- and increase the patients` acceptance, as well as,
ginal bone loss (MBL) and other complications. maximizing dental implant placement possibilities.
KEY WORDS: Dental implants, short implants, dental implant survival, atrophic ridges
1. Professor, Department of Periodontology, Faculty of Dentistry, Cairo University, Cairo, Egypt.

2 .PhD Candidate, Department of Periodontology, Faculty of Dentistry, Cairo University, Cairo, Egypt.
3. Assistant Lecturer, Department of Fixed Prosthodontics, Faculty of Dentistry, Cairo University, Cairo, Egypt.
4. Resident, Department of Removable Prosthodontics, Faculty of Dentistry, Cairo University, Cairo, Egypt.
26 • Vol. 9, No. 5 • July 2017

Zahran et al
INTRODUCTION in terms of survival rate for short implants

Implant dentistry is becoming more popu- placed in posterior areas. Nevertheless, there
lar as a treatment modality especially with the are still controversies regarding the long-
emergence of newer and improved implan- term consequences of peri-implant bone loss
tation technologies. Much of these improve- around short implants and its impact on the
ments can be attributed to the relatively high long-term implant success rate. As a conse-
success rates of implants in both partially and quence, the borderline scenario with 5–8mm
completely edentulous patients.1 In patients of available bone still constitutes a challeng-
with long-standing edentulous arches, alveo- ing therapeutic dilemma for clinicians.13 How-
lar bone resorption (Both vertical and hori- ever the development of implant design,
zontal or combined defects) is frequently surface structure and improved surgical tech-
observed. The insertion of dental implants in niques have given a reason to re-evaluate pre-
patients with reduced alveolar bone height vious results, and recent randomized clinical
is challenging and may require additional studies with 3 to 5 years follow-up indicated
invasive bone augmentation procedures.2 that short implants survival and success rates
The use of short dental implants could ful- were similar to long implants and may support
fill various indications where there is insufficient most prosthetic restorations adequately.14,15,16
bone volume to avoid complicated bone aug- Most recently, a number of systematic
mentation or maxillary sinus floor elevation pro- reviews evaluated the survival rate of short den-
cedures. Owing to the need for rehabilitation tal implants, overall concluding that the survival
of such an increasing number of atrophic jaws, rates are similar to that of long implants.11,6,5,13,17
the 7mm standard implant was introduced in Nevertheless, limitations such as a slightly lower
1979. The survival rates of implants shorter than survival rate in soft bone or in the posterior max-
10mm seem to be comparable to that of longer illa were reported.5,18 Scientific evidence is scarce
implants. The success rate of short implants on short dental implants placed in the poste-
is proposed to be higher in the mandible than rior maxilla. In addition, in most clinical studies
the maxilla due to the nature of softer bone in short implants were splinted to longer ones.9,19
the maxilla.3,4,5,6 The possibility of restoring the Sinus floor elevation procedures with long
dentition without the need for significant surgi- implants or complicated bone augmentation
cal augmentation has widened the scope for procedures have been reported to suffer many
treatment options which, in turn, can lead to drawbacks in terms of complications faced and
simplified implant rehabilitation procedures. patients` acceptance, besides other consider-
These factors may increase patients` accep- ations including cost, treatment time and morbidity
tance, making the treatment option available associated with aforementioned procedures.18,19
to more people, further contributing towards The aim of the present study was
improved oral function and general health.7 to evaluate, clinically and radiographi-
A broad number of cases series,8,9,10 and cally short dental implants placed in
reviews,11,12 have reported favorable outcome the posterior maxilla and mandible.

Zahran et al
Figure 1: CBCT cross sectional view of immediate post Figure 2: CBCT cross sectional view after 1 year of loading
placement (T1) of short implant in the mandible. (T3) of short implant in the mandible.
SUBJECTS AND METHODS disorders; (5) radiotherapy; (6) chemotherapy; (7)

Patient Selection alcohol or drug abuse; (8) pregnancy or lactation;
Patients were selected, from the out-patient clinic (9) use of oral and/or intravenous amino-bisphos-
of the Faculty of Oral and Dental Medicine (Cairo phonates; (10) untreated active periodontal infec-
University), according to pre-set eligibility crite- tions; (11) active infection in the site of implant
ria. Any partially edentulous patient missing teeth placement (13) heavy smokers and (12) bruxism.
in the premolar and molar area requiring one to The study protocol was reviewed by the Ethi-
three dental implants, aged 18 years old or older, cal Committee for Human clinical trials at the Fac-
and able to sign an informed consent form, was ulty of Dentistry, Cairo University. The protocol of
considered eligible for inclusion in this trial. Ver- this study was also registered at the Pan African
tical bone heights at implant sites had to be at Clinical Trial Registry (PACTR) in 2015/07/11 and
least 8 - 9 mm above the mandibular canals and the registration no. is PACTR201610001197438.
7 - 8 mm below the maxillary sinuses, with bone
width of at least 6.0 mm as measured on cone Surgical Procedures
beam computed tomography (CBCT) scans. All procedures were done under completely
Exclusion criteria were as follows: (1) severe aseptic conditions. Patients were anesthetized
systemic diseases that might contraindicate surgi- at the surgical site by infiltration, using Artic-
cal intervention; (2) uncontrolled diabetes mellitus; aine Hydrochloride 4% (Septocaine® 1.8 ml.
(3) immune-compromised status; (4) coagulation Articaine Hydrochloride 4% and epinephrine
28 • Vol. 9, No. 5 • July 2017

Zahran et al
Figure 3: CBCT cross sectional view of immediate post Figure 4: CBCT cross sectional view after 1 year of loading
placement (T1) of short implant in the maxilla. (T3) of short implant in the maxilla.
1:100000. Septodont, USA). Bone width was mate the initial bone level around the implant.
assessed using a bone caliper. Using a Bard The recipient site area was then sutured
Parker blade no.15, a palatal or lingual sub- with 4-0 silk (Hu-Friedy, USA) interrupted
crestal incision was created in the surgical site, sutures which were removed after 2 weeks.
extending the entire length of the edentulous Post-operative care: post-surgically patients
area. Two oblique releasing incisions were then were prescribed 875mg of Amoxicillin and
created on the buccal aspect. A full thickness 125mg of Clavulanic acid tablet (1gm Augmen-
flap was then elevated to expose the under- tin, Glaxosmith Kline, England) twice daily for 7
neath buccal alveolar bone. Under copious days, anti-inflammatory tablets (Brufen 200 mg,
saline irrigation, the osteotomy was prepared by Abbott, India ltd.) twice per day for three days. A
sequential drilling. The Maxi Z Flat-End implant CBVT (Scanora 3D Soredex, Helsinki, Finland)
4.5 x 6.5mm (OsteoCare™ Implant System, Lon- scan was done within 24 hours post-surgically
don, UK) was inserted into the osteotomy using (T1) to assess marginal bone level (Fig.1, Fig.3)
its peek carrier. Then the full seating of the Four months after implant placement (T2),
implant was done using the 2.2mm hex-driver re-entry using a tissue punch was done to fit
until implant platform was flush with the bone a healing collar. A periapical radiograph was
level and torqued to 30NCm to check the ini- taken to check the proper fixation of the heal-
tial stability. A periapical radiograph was taken ing collar. Seven to 10 days later, impressions
to check the final implant position and to esti- were made using impression transfers and

Zahran et al
implant replicas and the final ceramo-metallic ues and results of the Students’ T-test for
restorations were delivered and cemented after the changes by time in marginal bone level
being checked for shade matching, marginal around implants of each group were used.
fitness and occlusion. Stability of implants in
the two groups was tested using Periotest® M RESULTS
(Medizintechnik Gulden, Bensheim, Germany). During the 1 year follow-up period no drop-
outs occurred. The main baseline patient and
Outcome Measures intervention characteristics are presented in
lS tability was tested using Periotest® M at the (Table 1). There were no failures in the man-
loading stage (T2) and 1 year after loading dible while there were two failures in max-
(T3). Periotest® M values of (-8 to 0) were con- illary implants (Table 2). The failure in the
sidered the ideal values that denote successful maxilla occurred in two patients, one fail-
osseointegration. ure occurred in the preloading stage and
lT he marginal bone loss (MBL) around the the other occurred four months after load-
short implants was assessed using CBVT ing (PTMV > 0). Post-operative swelling
within the first 24 hours post-surgically (T1) occurred in five cases, three in the maxilla and
and also after 1 year (T3) (Fig.2, Fig.4). two in the mandible. The data of all patients
The CBVT raw DICOM data set images was evaluated in the statistical analyses.
CT was imported to the third party soft- Implant stability was measured by Periotest
ware for secondary reconstruction. M at preloading stage (T2) and 1 year after load-
lA ny biological or prosthetic complications ing (T3). At the pre-loading stage the mean
were recorded. Periotest values were -1.99 ± 0.3 in the max-
l Implant failure: implant mobility and removal of illa and -2.42 ± 0.26 in the mandible. At 1 year
stable implants dictated by progressive after loading the mean Periotest values were
marginal bone loss or infection. -1.23 ± 0.31 in the maxilla and -2 ± 0.23 in the
mandible. Statistical analysis showed no sig-
Statistical Analysis nificant differences (P ≥ 0.05) between the
The statistical software used was IBM SPSS mandible and maxilla at T2 and T3 (Table 3).
(IBM Corp., Armonk, NY, USA), and Excel The marginal bone loss around implants was
(Microsoft, Redmond, WA, USA).The patient measured at the mesial, distal, buccal and lin-
was the statistical unit of the analyses. A para- gual aspects of all implants. The mean marginal
metric statistical approach was applied. Dif- bone loss 1 year after loading in the maxilla was
ferences in the proportion of patients with -1.55 ± 0.29 mm while in the mandible it was
implant failures and complications (dichoto- -1.10 ± 0.12 mm, statistical analysis showed
mous outcomes) between maxilla and man- no significant difference (P ≥ 0.05) between
dible were compared using the Fisher‘s the two groups. The results of Students’ T-test
exact test. The mean differences, standard for the marginal bone loss around implants
deviation (SD), confidence intervals, val- of each group were presented in (Table 4).
30 • Vol. 9, No. 5 • July 2017

Zahran et al
Table 1: Summary of the Main Results

Maxilla Mandible
Female 8 (53.34%) 10 (66.67%)
Mean age at recruitment 32.7 ± 0.97 33.67 ± 1.28
No. of patient 15 15
Total of implant inserted 15 17
Implant length and diameter 6.5 (4.5) 6.5 (4.5)
No. of implants placed with less 6 1
than 25 N/cm torque
No. of patients 15 13
receiving 1 implant
No. of patients 0 2
receiving 2 implants
Drop outs 0 0
Implant failure 2 0
Complication 3 2
DISCUSSION ate to extensive bone resorption which results in

Restoration of the atrophic ridges presented increased crown height space and unfavorable
a challenge in the past due to the limitation of crown-to-implant ratio. However, recently, the
implant placement especially in the posterior development of modified implant designs and sur-
mandible and maxilla and the risk of approximat- face treatments contributed for to the increased
ing vital structures. In the past, the only solution survival rates of short implants. Clinical literature
was performing bone augmentation procedures, has demonstrated no significant differences in the
which required extended treatment periods, extra survival rate of short and standard implants.21,22
expenses and surgical complications. An alterna- Care was taken to standardize the study con-
tive for restoration of such atrophic ridges is the ditions for all patients and to exclude conditions
use of short implants. Short implants were com- that might affect the success of short implants,
monly associated with lower survival rates due to such as smokers and medically compromised
the reduced bone-to implant contact. Moreover, patients and patients exhibiting parafunctional
the posterior region commonly shows moder- habits - such exclusion was executed in line with

Zahran et al
Table 2: Results of Fisher’s Exact Test. *:Significant at P ≤ 0.05.
Test Group Percentage Control Percentage P value
Implant failure 2 (15) 13.33% 0 (15) 0% 0.4828
Complications 3 (15) 20% 2 (15) 13.33% > 0.9999
the recommendations of previous studies.23,24,5 loading. Al-ghamdi et al.30 also reported that from
These criteria limited the number of patients the observed primary stability it can be concluded
recruited in the current study. The primary stability that short implants are able to achieve desired
of the implant, which results from the initial inter- primary stability in areas with good bone quality.
locking between alveolar bone and the body of The percentage of implant failure in maxilla
the implant, affects the secondary stability of the was 13.3% while in mandible it was 0%. Many
implant because the latter results from subsequent researchers,3132 considered bone quality as a sig-
contact osteogenesis and bone remodeling.25,26 nificant risk factor for failures. Goodacre et al.33
Implant stability is a prerequisite for the long-term reported that implants placed in poor bone qual-
clinical success of osseointegrated implants.27 ity areas showed failures rates 16% higher than
In this study, implant stability was assessed by those placed into greater bone density areas.
means of Periotest®M, which is considered as a Another 5-year report of a prospective single-
fast, safe and non-invasive method of measure- cohort study reported by Perelli and co-workers
ment that is useful for long-term implant follow- in 2012,34 reported that implant failure in 110
up. This was in accordance with Wijaya et al.28 short implants placed in posterior atrophic maxilla
who concluded that the implant mobility checker after 5 years was 10% and at the end of the fol-
(Periotest®) was reliable and a reproducible low-up period the implant survival rate was 90%,
method for dental implant mobility assessment. and 93.1% with regard to prosthetic reconstruc-
At the pre-loading stage (T2) and at 1 year tion. On the other hand another study by Weng
after loading (T3), there was no statistical signifi- et al.35 reported a 25% failure rate when short
cance difference in mean Periotest®M values in implants were placed in the posterior maxilla,
both mandible and maxilla. The Periotest®M value especially during the first 18 months of loading.
of one short maxillary implant was (+3) after 1 year Crestal bone loss is another important
of loading (T3) and was considered as a failed parameter to guarantee long-term clinical ser-
implant while the other implant was lost at the vice. The maintenance of a stable marginal bone
pre-loading stage (T2). This was in accordance level becomes more critical when short implants
with Al Hashedi et al.29 where they considered the are used.36,37 In the present study the crestal
positive implants periotest values as questionable bone loss around implants was measured at the
and requiring further clinical examination before mesial, distal, buccal and lingual aspects of all
32 • Vol. 9, No. 5 • July 2017

Zahran et al
Table 3: Mean Periotest Values at T2 (Pre-loading) and T3 (1 Year After Loading).
Maxilla Mandible Mean

Time Mean ± SD 95% CI Mean ± SD 95% CI Difference 95% CI P value
Pre-loading -1.99 ± 0.3 -2.14 to -2.42 ± 0.26 -2.56 to -0.44 ± 0.4 -1.26 to 0.2795
Stage (T2) -1.84 -2.29 0.38
1 Year After -1.23 ± 0.31 -1.39 to -2 ± 0.23 -2.12 to -0.77 ± 0.39 -1.56 to 0.0585
Loading (T3) -1.07 -1.88 0.03
Table 4: Marginal Bone Loss Around Implants 1 Year After Loading. *:Significant at P ≤ 0.05
Data Maxilla Mandible Mean
Time Mean ± SD 95% CI Mean ± SD 95% CI Difference 95% CI P value
Insertion (T1) -1.55 ± 0.29 -1.7 to -1.10 ± 0.12 -1.16 to -0.44 ± 0.3 -0.18 to 0.1549
1 Year After -1.4 -1.04 1.06
Loading
Insertion (T1) -1.55 ± 0.29 -1.7 to -1.10 ± 0.12 -1.16 to -0.44 ± 0.3 -0.18 to 0.1549
1 Year After -1.4 -1.04 1.06
Loading (T3)
implants by using CBVT which was taken at up, he reported 1 mm marginal bone loss around
baseline (T1: immediately after insertion) and 1 5 mm implants and 2 mm bone loss around
year after loading (T3). There was no statistical 7 mm implants. In contrast with our study Ren-
significant difference between the two groups ouard and Nisand9 placed 96 short implants in
for the marginal bone level changes around short the posterior atrophic maxilla. The mean marginal
implants from the baseline (T1) till after 1 year bone resorption after 2 years in function was
of loading (T3). After 1 year of loading the short 0.44 ± 0.52 mm. Recently Felice et al.38 evalu-
implants placed in the maxilla showed a mean ate the efficacy of short (5 or 6 mm-long) dental
marginal bone loss of -1.55 ± 0.29 mm while the implants versus 10 mm or longer implants placed
short implants placed in the mandible showed a in crestally-lifted sinuses. They placed 16 short
mean marginal bone loss of -1.10 ± 0.12 mm. implants and 18 longer implants and they found
Perelli el al.34 reported a minimal crestal bone that there was no significance difference in the
resorption around short implants placed in the mean crestal bone loss after 1 year follow up.
posterior atrophic mandible after 5 years follow- The use of short dental implants could be con-

Zahran et al
sidered as an alternative to avoid complicated cessful treatment option for restoration of

bone augmentation procedures. The possibil- atrophic ridges with deficient vertical bone
ity of restoring the dentition without the need for height in both the maxilla and the mandible.
complicated surgical procedures has widened 2. Short implants placed in the atro-
the scope for treatment options and increased phic mandible showed higher success
patients` acceptance which contributes towards rate and less crestal bone resorption than
improved oral function and general health those placed in the atrophic maxilla. l
CONCLUSIONS Correspondence:
Within the limitations of the cur- Dr. Amr Ali
rent study it was concluded that: a.youssef88@gmail.com
1. Short implants are considered a suc-
ATTENTION
PROSPECTIVE AUTHORS
JIACD wants to publish
your article!
For complete details regarding publication in JIACD,
please refer to our author guidelines at
the following link:
jiacd.com/author-guidelines
or email us at: editors@jicad.com
34 • Vol. 9, No. 5 • July 2017

Zahran et al
Disclosure 14. Esposito, M., Pistilli, R., Barausse, C. & Felice, P. 26. E
sposito, M., Grusovin, M. G., Maghaireh, H.
The authors report no conflicts of inter- Three-year results from a randomised controlled & Worthington, H. V. in Cochrane Database
est with anything in this article. trial comparing prostheses supported by 5-mm of Systematic Reviews (ed. Esposito, M.)
long implants or by longer implants in aug- CD003878 (John Wiley & Sons, Ltd, 2013).
References mented bone in posterior atrophic edentulous doi:10.1002/14651858.CD003878.pub5
1. Menchero-Cantalejo, E., Barona-Dorado, jaws. Eur. J. Oral Implantol. 7, 383–95 (2014). 27. D
ilek, O., Tezulas, E. & Dincel, M. Required
C., Cantero-Álvarez, M., Fernández-Cáliz, 15. Felice, P., Cannizzaro, G., Barausse, C., Pis- minimum primary stability and torque values for
F. & Martínez-González, J. M. Meta-analysis tilli, R. & Esposito, M. Short implants versus immediate loading of mini dental implants: an
on the survival of short implants. Med. longer implants in vertically augmented pos- experimental study in nonviable bovine femoral
Oral Patol. Oral Cir. Bucal 16, (2011). terior mandibles: a randomised controlled bone. Oral Surgery, Oral Med. Oral Pathol. Oral
2. Anitua, E., Piñas, L., Begoña, L. & Orive, G. Long- trial with 5-year after loading follow-up. Eur. Radiol. Endodontology 105, e20–e27 (2008).
term retrospective evaluation of short implants in J. Oral Implantol. 7, 359–69 (2014). 28. W
ijaya, S. K., Oka, H., Saratani, K., Sumikawa,
the posterior areas: clinical results after 10-12 16. Romeo, E., Storelli, S., Casano, G., Scan- T. & Kawazoe, T. Development of implant move-
years. J. Clin. Periodontol. 41, 404–411 (2014). ferla, M. & Botticelli, D. Six-mm versus ment checker for determining dental implant
3. Anitua, E. & Orive, G. Short Implants in 10-mm long implants in the rehabilita- stability. Med. Eng. Phys. 26, 513–522 (2004).
Maxillae and Mandibles: A Retrospec- tion of posterior edentulous jaws: a 5-year 29. A
l-Hashedi, A., Taiyeb-Ali, T. & Yunus, N. Out-
tive Study With 1 to 8 Years of Follow-Up. follow-up of a randomised controlled trial. comes of placing short implants in the posterior
J. Periodontol. 81, 819–826 (2010). Eur. J. Oral Implantol. 7, 371–81 (2014). mandible: a preliminary randomized controlled
4. Pommer, B. et al. Impact of dental implant 17. F
an, T., Li, Y., Deng, W.-W., Wu, T. & trial. Aust. Dent. J. 61, 208–218 (2016).
length on early failure rates: a meta- Zhang, W. Short Implants (5 to 8 mm) 30. A
lghamdi, A. Influence of Dimensions on the
analysis of observational studies. J. Clin. Versus Longer Implants (>8 mm) with Primary Stability and Removal Torque of Short
Periodontol. 38, 856–863 (2011). Sinus Lifting in Atrophic Posterior Maxilla: Dental Implants Influence of Dimensions on
5. Telleman, G. et al. A systematic review of the A Meta-Analysis of RCTs. Clin. Implant the Primary Stability and Removal Torque of
prognosis of short (<10 mm) dental implants Dent. Relat. Res. 19, 207–215 (2017). Short Dental Implants. 1, 2005 (2015).
placed in the partially edentulous patient. J. 18. Thoma, D. S., Zeltner, M., Hüsler, J., Hämmerle, 31. G
entile, M. A., Chuang, S.-K. & Dodson,
Clin. Periodontol. 38, 667–676 (2011). C. H. F. & Jung, R. E. EAO Supplement Working T. B. Survival estimates and risk factors
6. Annibali, S. et al. Short Dental Implants: A Sys- Group 4 - EAO CC 2015 Short implants versus for failure with 6 x 5.7-mm implants. Int. J.
tematic Review. J. Dent. Res. 91, 25–32 (2012). sinus lifting with longer implants to restore the Oral Maxillofac. Implants 20, 930–7
posterior maxilla: a systematic review. Clin.
7. G
erritsen, A. E., Allen, P. F., Witter, D. J., Oral Implants Res. 26, 154–169 (2015). 32. M
orand, M. & Irinakis, T. The Challenge of
Bronkhorst, E. M. & Creugers, N. H. Tooth Implant Therapy in the Posterior Maxilla: Provid-
loss and oral health-related quality of life: a 19. Sahrmann, P. et al. Success of 6-mm ing a Rationale for the Use of Short Implants.
systematic review and meta-analysis. Health Implants with Single-Tooth Restorations. J. Oral Implantol. 33, 257–266 (2007).
Qual. Life Outcomes 8, 126 (2010). J. Dent. Res. 95, 623–628 (2016).
33. G
oodacre, C. J., Bernal, G., Rungcharas-
8. Fugazzotto, P. A. et al. Success and Failure Rates 20. Sahrmann, P. et al. Success of 6-mm Implants saeng, K. & Kan, J. Y. . Clinical complica-
of 9 mm or Shorter Implants in the Replacement with Single-Tooth Restorations: A 3-year Ran- tions with implants and implant prostheses.
of Missing Maxillary Molars When Restored domized Controlled Clinical Trial. J. Dent. Res. J. Prosthet. Dent. 90, 121–132 (2003).
with Individual Crowns: Preliminary Results (2016). doi:10.1177/0022034516633432
34. P
erelli, M., Abundo, R., Corrente, G. & Sac-
0 to 84 Months in Function. A Retrospective 21. Gonalves, T. M. S. V. et al. Long-term short cone, C. Short (5 and 7 mm long) porous
Study. J. Periodontol. 75, 327–332 (2004). implants performance: Systematic review and implants in the posterior atrophic maxilla: a
9. Renouard, F. & Nisand, D. Short implants in meta - Analysisofthe essential assessment 5-year report of a prospective single-cohort
the severely resorbed maxilla: a 2-year ret- parameters. Braz. Dent. J. 26, 325–336 (2015). study. Eur. J. Oral Implantol. 5, 265–72 (2012).
rospective clinical study. Clin. Implant Dent. 22. das Neves, F. D., Fones, D., Bernardes, 35. W
eng, D. et al. A prospective multicenter
Relat. Res. 7 Suppl 1, S104-10 (2005). S. R., do Prado, C. J. & Fernandes Neto, clinical trial of 3i machined-surface implants:
10. Grant, B.-T. N., Pancko, F. X. & Kraut, R. A. J. Short Implants - An Analysis of results after 6 years of follow-up. Int. J.
A. Outcomes of Placing Short Dental Longitudinal Studies. Int. J. Oral Maxil- Oral Maxillofac. Implants 18, 417–23
Implants in the Posterior Mandible: A Ret- lofac. Implants 21, 86–93 (2006).
36. S
alvi, G. E., Gallini, G. & Lang, N. P. Early
rospective Study of 124 Cases. J. Oral 23. Misch, C. E. Short dental implants: a literature loading (2 or 6 weeks) of sandblasted
Maxillofac. Surg. 67, 713–717 (2009). review and rationale for use. Dent. Today 24, and acid-etched (SLA) ITI implants in the
11. Srinivasan, M. et al. Efficacy and predict- 64–6, 68 (2005). posterior mandible. A 1-year random-
ability of short dental implants (. Int. J. 24. Romeo, E., Ghisolfi, M., Rozza, R., Chiapasco, ized controlled clinical trial. Clin. Oral
Oral Maxillofac. Implants 27, 1429–37 M. & Lops, D. Short (8-mm) dental implants Implants Res. 15, 142–9 (2004).
12. Mohammed, S. short dental implants Short in the rehabilitation of partial and complete 37. M
onje, A. et al. Are Short Dental Implants
Dental Implants : Its Rationale for Use. 50–54 edentulism: a 3- to 14-year longitudinal study. (<10 mm) Effective? A Meta-Analysis
(2015). doi:10.13140/RG.2.1.5170.4163 Int. J. Prosthodont. 19, 586–92 (2005). on Prospective Clinical Trials. J. Peri-
13. Nisand, D., Picard, N. & Rocchietta, I. Short 25. Berglundh, T., Abrahamsson, I., Lang, N. P. odontol. 84, 895–904 (2013).
implants compared to implants in vertically & Lindhe, J. De novo alveolar bone forma- 38. F
elice, P. et al. Short implants as an alter-
augmented bone: a systematic review. Clin. tion adjacent to endosseous implants. Clin. native to crestal sinus lift: A 1-year mul-
Oral Implants Res. 26, 170–179 (2015). Oral Implants Res. 14, 251–62 (2003). ticentre randomised controlled trial. Eur.
J. Oral Implantol. 8, 375–84 (2015).

Kumar et al
A New Standard Classification System for
Dental Implant Drills and Role of Implant
Drills in Successful Osseointegration
Dr. Bhushan Kumar1 • Dr. Sunny Bhatia2

Dr. Prabhdeep Kaur Sandhu3 • Dr. Sachin Mittal4
Abstract
Background: Implant drill use is common and integration process (Implant Success rate).
clinicians are acutely aware of the implant drills Results: Reviewed literature revealed that there
for the system which they are using. It is demand are four different criteria based on which implant
of the time that we should formulate a clas- drills are classified in this review. Even the drilling
sification system to categories these drills for process seems very easy but little more aware-
ease to remember and identification. Attempts ness about small looking steps can drastically
have been made through this article to shed improve Implant success rate. This procedural
some light on various types of implant drills information is concluded as “guidelines of drilling
along with a simplified system of their classifica- process” for the betterment of clinical practice.
tion. Another aspect included in this article is
various factors influencing the drilling process Conclusions: Every clinician should be well
and causing overheating in osteotomy site. aware about the instruments which they use in
daily routine and a classification system helps in
Methods: Searches performed in MEDLINE categorization and easy remembrance of these
related to Dental Implant Drills and a system- similar looking mechanical tools. This review arti-
atic review was carried out regarding various cle is presenting a classification system for the
types of drills available and various variables dental implant drills and also discussing the points
during drilling process which affect the osseo- where operator’s negligence is very common.
KEY WORDS: Dental implants, dental implant drills, review
1. Prosthodontics, Graded Specialist, Army Dental Corps, India.

2. Dental Officer, Army Dental Corps, India.
3. Orthodontics, Private Practitioner, Hisar (Haryana), India.
4. Oral and Maxillofacial Surgery, Private Practitioner, Hisar (Haryana), India.
36 • Vol. 9, No. 5 • July 2017

Kumar et al
INTRODUCTION: CLASSIFICATION SYSTEM FOR

Dental implants have been used since mid- IMPLANT DRILLS:
1960s, but in recent years their use has been Presently available implant drills can
increased drastically as evidence from studies be classified on the following basis:
and clinical experience have shown that they
are safe, most conservative approach for resto- BASED UPON THE DRILL DESIGN [2,3]
ration, convenient to place and their results not l Twisted Implant drills (further categorized into)
only restoring function but aesthetics too. This l Triple twist drill with a relief angle
success rate is determined by various factors l Triple twist drill without a relief angle
like operator knowledge & skill, case selection, l Double twist drills with a relief angle
surgical technique, bone graft/augmentation l Double Twist drill without a relief angle
procedure, implant type/design/number/angu- l Fluted drills
lations, loading protocol and type of overly-
ing prosthesis.1 However the focus of most of BASED UPON METHOD OF COOLING [4-10]
the studies/ research in literature is on design, l Drills with internal irrigation
surface modification, and loading conditions. l Drills with External irrigation
It is unfortunate that the effect of surgical pro-
cedures such as the drilling protocol has been BASED UPON DRILL USE [11,12]
sparsely explored, and clinicians basically fol- l Single use/disposable drills
low the instructions given by the manufacturers. l Multiple use drills
This article is bound to discuss role of Implant
Drills in healing process (osseointegration) and BASED UPON THE USAGE DURING
a system of classifying dental implant drills is OSTEOTOMY [13]
also incorporated for a better understanding. l Mucosal punch drill [14]
A dental implant drill is a small-high l Locator drill
speed drill used during dental implant proce- l Pilot drill
dure to create a hole and to prepare implant l Conical or cylindrical drill
bed for the best fit at recipient site. These drills l Countersink drill/profile drill
are run by a powered hand-piece/ dental engine l Tap drill
designed with special controlling features l Trephine drill [5]
meant for implant placement. They can be of
different shapes and designs as per their func-
tional requirement. Unfortunately, no standard
classification system is available for them. A very
simplified way to categorize them is as follows:

Kumar et al
ROLE OF DRILLS AND DRILL SHARPNESS

DRILLING PROCESS IN The condition of drill plays a major role in regu-
OSSEOINTEGRATION lating the temperature of bone during drilling.30
Dental implant surgery involves drilling a hole A worn drill will thus have more heat produc-
in the bone, which is a friction process between tion than a sharper drill.23 There are many fac-
the drill and bone resulting in heat generation.15,16 tors that reduce the sharpness of a drill like
Majority of generated heat is absorbed by drill but density of bone, multiple reuse of the drill, the
bone also absorbs a significant amount of heat. In debris released during the process, material con-
the absence of irrigation, bone temperatures may struction & surface treatment of drill.10 Indica-
exceed 1000 C. It has been documented that bone tion for drill change are loss of shine at cutting
cell changes may occur when bone is heated over edge and wear off along cutting blade (visual
the critical temperature i.e. 470 C16,17,18,19 (thresh- examination), clinical observation of when the
old temperature is 30.3o C for 5 seconds20 or drill fails to progress rapidly and after number of
44-47o C for 1 min).7,15,18,20 The negative effect sites prepared as suggested by manufacturers.
of heat on bone results in the denaturation of
the enzymatic & membrane proteins, hyperemia, DRILLING SPEED AND
dehydration, desiccation, fibrosis, decreased PRESSURE
osteoclastic & osteoblastic activity and necrosis, There are variable results from different studies
which may all contribute to cell death (osteone- about the optimal speed for dental implant sur-
crosis).21-26 This may result in a failure of bone to gery. Earlier reports have supported the slow-
bond to the implant, leading to early failure.27, 28 speed as heat generation was assumed to be less
compared with high-speed31-33 (recommended
FACTORS AFFECTING HEAT speeds were 600 rpm,34125-2000 rpm2) and this
GENERATION3,29 rise in temperature was noticed up to an approxi-
After a detailed literature survey, the fac- mate speed of 10,000 rpm.34 At very high speeds
tors that can affect a temperature rise during (27,000 rpm to 97,000 rpm) temperature rise was
the drilling process can be listed as follows: very less and healing was faster compared to
l Drill sharpness lower speeds.31,35.36 At this point of discussion,
l Drilling speed and pressure it is very important to understand that osteotomy
l Drilling time procedures for implant bed preparation require a
l Drilling status precise cutting because it should match exactly
l Drill design/ drill geometry the specifications like implant diameter/length,
l Drill material and wearing/coating thread shape/design for its primary stability which
l Drill diameter can’t be achieved with high speed beyond 2500
l Drilling depth rpm. Slower rotational speeds require more drill-
l Irrigation (coolant delivery) systems ing time, which produces more frictional heat so
l Miscellaneous factors (type of the rpm (drilling speed) is not the only factor for rise
recipient bone, age of the patient and of temperature, however duration/time of drilling
experience & skill of clinician)
38 • Vol. 9, No. 5 • July 2017

Kumar et al
is more important and is major determinant than the temperature of bone to return to baseline and
speed. This duration of drilling can be reduced use of copious irrigation (Intermittent Drilling).
by incorporating factors like torque and pres-
sure10,23,37-39 along with optimum speed. Eriksson DRILLING STATUS
has shown that using high torque and low rpm Incremental Vs Single step drilling: In one step
(1500-2000) are ideal to avoid temperature rise drilling, the hole is being drilled in a single step
and to increase drilling accuracy.19 Role of pres- using a single drilling tool whereas in incremen-
sure was studied by Brisman40 who compared tal or multi-step drilling the diameter is increased
the drilling at 1,200 rpm and 2,400 rpm under gradually starting from the minimum to the final
loads of 1.2 kg and 2.4 kg in dry bovine femo- diameter using a series of drilling tools. Eriks-
ral bone and found that less heat was generated son44 has described a single step technique
with 2,400 rpm (or 2500 rpm41) under 2.4 kg of while Branemark46 and others15,18-20,47,48 have rec-
force.40 However the pressure is a variable factor ommended an incremental enlargement of the
which differs from operator to operator42 and there osteotomy site. Branemark’s46 hypothesis on the
is no standard way to optimize it but it is interest- incremental drilling sequence was that each drill
ing to know that generally clinicians use a force bit gradually enlarges the osteotomy site, which
of approximately 2 kg during implant drilling pro- would dissipate heat better than a one-stage drill
cedure under normal clinical conditions.3,38,42 So sequence. In a later study, Eriksson also found
this factor can be assumed optimal for all opera- that the incremental drilling is better at reduc-
tors; with its least effects on heat generation. ing heat production compared to single drilling.18
Intermittent Vs Continuous drilling: Drill-
DRILLING TIME ing into bone involves the use of irrigation, either
This factor can be discussed under two crite- internal or external, to reduce the heat gener-
ria, i.e. drilling time and the time required for the ated. Because of the intimate contact present at
heated part to return to its normal temperature. the bone-drill interface, the irrigation solution has
This can be simplified as more drilling time will to reduce the temperature throughout the whole
cause more rise in the bone temperature which length of the bony walls. This mechanism could
will require more time for the heated part to return not be achieved unless the bur or drill was inter-
to its normal temperature hence more damage can mittently removed to allow the escape of bone
be noticed in situ. Eriksson and Albrektsson dem- chips and access for the irrigation fluid.37 When-
onstrated that the long-term effect of heating bone ever continuous drilling is performed, temperature
up to 47°C for 5 minutes resulted in dominant will rise not only because of the inaccessibil-
bone resorption (about 20%) after a period of ity of coolant, but also because of the clogging
30 days.20 This was accompanied by an invasion effect of the bone debris on the cutting edge of
of fat cells and little osteogenic activity, so less the drill, which will decrease its cutting efficiency
osseointegration at site.44,45 Best way to control and consequently increase the time required
this variable is to remove drill gradually in between for the bone bed preparation.10,18,47,49 In addi-
every 5 seconds for at least 10 seconds to allow tion, it is suggested the clinicians should inter-

Kumar et al
rupt the drilling procedure, while saline is applied mina oxide) have also been studied and found that
to the bone. The interruption will dramatically they show more hardness with less wear com-
decrease the bone temperature. Even while pro- pared to stainless steel so have better cutting
ceeding to next size drill in the osteotomy before efficiency and induce less heat but further studies
allowing the bone to return to baseline tempera- under different conditions are still needed.40,54-56
ture may eventually heat up the bone more than
10°C (47°C when baseline is body temperature). DRILL DIAMETER
This is most important in the dense bone types. Larger diameter drills produce less heat than
smaller diameter, even the time required for
DRILL DESIGN the temperature to return to baseline is also
The drills usually follow the morphological and the less.2,10,51 Amount of bone removed by smaller
topographic skeleton of the implant. In general, diameter is less so needs more time for same
twist drills and taps are used to prepare sites for osteotomy when compared with larger diameter.
screw-shaped implants, whereas fluted drills are Therefore, time of drilling is more critical than
used to prepare sites for cylindrical implants.50 the diameter of the drill. Correct orientation and
Cordioli and Majzoub compared twisted and depth of pilot drill is key to minimize temperature
fluted drills for heat generation and found fluted rise during complete osteotomy procedure.10
drills increase less temperature than twisted
drills.18,51 But screw implants are used more than DRILLING DEPTH
cylindrical and fluted drills can’t be used for screw More deep drilling increases temperature rises
implants as it will decrease primary stability so due to increase in cutting surface area along
twisted drills are more in use. Twisted drills with with less irrigation at the inaccessible apical
relief angle at cutting sides52 and point angle at extent of the drill and also because of the clog-
apex53 are more efficient and produce less heat ging effect of the bone cuttings.2,8,50 Such cases
than twisted drill without relief angle. Among flute are highly indicated for intermittent drilling
geometry, the four flute drill has been considered with adequate intervals and copious irrigation.
to reduce frictional heat, although Kay et al rec-
ommended that 3 is the maximum no of flutes that IRRIGATION SYSTEMS
could withstand use without technical problems.50 Implant systems have begun to use irrigation
systems with coolants for heat dissipation dur-
DRILL MATERIAL AND ing osteotomy for implant placement. There are
ITS COATING two types of cooling system: internal and exter-
Most of available drills are made in stainless steel nal. If one does not use any coolant, then the
alloys however they are available with coatings critical bone temperature is always exceeded so
also to increase cutting efficiency and to reduce irrigation is a key factor in implant osteotomy.10
wear rate (e.g. Stainless steel coated with tita- Kirschner and Meyer9 introduced internally
nium nitride). Recently oxide Zirconia based cooled drills to dentistry, later Huhule57 con-
ceramic drills (80% Zirconia oxide and 20% alu- cluded several advantages of internal irrigation
40 • Vol. 9, No. 5 • July 2017

Kumar et al
over external like; it prevents clogging of the ALTERNATIVE METHODS

drill twists/flutes by bone chips thus increas- TO DRILLING
ing its efficacy regardless of the depth of the Ridge split technique (Pneumatic chisel
cavity and causes more heat dissipation.9,58-60 and osteotome),73-75 bone-condensing tech-
Haider et al. found external cooling better in nique,76 Er:YAG laser,77 piezoelectric surgery,77
superficial cutting whereas internal more effi- peizotome;78 however ultrasonic implant site
cient in deep drilling so he recommended that preparation is more time consuming and gen-
additional of external cooling alongwith internal erates higher bone temperatures than con-
system, particularly in compact bone, seemed ventional drilling.79 These techniques are not
most beneficial.8 The low temperature (4oC) common among clinicians due to lack of long
irrigation solution is better than room tempera- term studies to support their reliability and
ture solution.61,62 Normal saline or distilled water superiority over conventional drill osteotomy.
can be used as irrigation solution;51 however
air-water coolant mixture should not be used as CONCLUSION
chances of air embolism formation are there.63,64 Even after following all guidelines we can’t totally
avoid rise in temperature in osteotomy site, we
MISCELLANEOUS FACTORS can only minimize it to below critical level. Accord-
The temperature produced also depends on ing to a theory, a smaller devitalized zone next to
many factors like density and the texture of implant surface would be beneficial in immedi-
the bone, age of the patient etc. Bone usu- ate loading as implants are loaded before bone
ally varies in density from person to person, remodeling is complete and this devital zone will
bone to bone in the skeleton, and from site to be replaced by healthy bone during remodel-
site in the same bone. Compact or dense bone ing process.84 If future implants have the ability
has less body fluid (blood, lymph, tissue fluid) of bone regeneration around their surface then
for heat absorption and requires more drill- there will be no or very less failures; till then suc-
ing time as it poses more friction for cutting cess rate is relying on repair/healing process
so all these factors result in more raise in local which is dictated by various guidelines for all
temperature.5,10,65 Similarly, drilling in heal- determinant procedures used during implant
ing socket or extraction socket during imme- placement, restoration and maintenance. l
diate implant placement requires less cutting
and less time so resulting in less heat produc-
tion compared to healed socket.66-69 Even bony Correspondence:
structures in older patients tend to become Dr. Bhushan Kumar
denser and more fragile; the medullary cav- E-mail: drbhushansheoranmds@gmail.com
ity space enlarges faster thus resulting in a net
decrease of cortical thickness and mass and
also healing capability is usually impaired.70-72

Kumar et al
Disclosure 15. Eriksson A, Albrektsson T, Grane B, 30. P

eterson LT. Principles of internal fixa-
The authors report no conflicts of inter- McQueen D. Thermal injury to bone. A vital tion with plate and screws. AMA Arch
est with anything in this article. microscopic description of heat effects. Int Surg. 1952 Mar;64(3):345–354.
J Oral Surg 1982 Apr;11(2):115–121.
31. B
oyne PJ. Histologic response of bone to
References
16. Oh HJ, Wikesjo UM, Kang HS, Ku Y, sectioning by high-speed rotary instruments.
1. Albrektsson T, Brånemark PI, Hansson HA,
Eom TG, Koo KT. Effect of implant drill J Dent Res. 1966 Mar-Apr;45(2): 270–276.
Lindström J. Osseointegrated titanium implants.
characteristics on heat generation in oste-
Requirements for ensuring a long-lasting, 32. T
hompson HC. Effect of drilling into bone. J
otomy sites: a pilot study. Clinical Oral
direct bone-to-implant anchorage in man. Acta Oral Surg (Chic) 1958 Jan;16(1):22–30.
Implants Res. 2011 Jul;22(7):722-726.
Orthop Scand. 1981;52(2):155-70. 33. L
entrodt J, Bull HG. Animal experimental studies
17. W
einlaender M. Bone growth around
2. Cordioli G, Majzoub Z. Heat generation during on bone regeration following drilling of the bone.
dental implants. Dent Clin North
implant site preparation: an in vitro study. Int J Oral Dtsch Zahnärztl Z. 1976 Feb;31(2):115–124.
Am. 1991 Jul;35(3):585–601.
Maxillofac Implants. 1997 Mar-Apr;12(2):186-93. 34. R
eingewirtz Y, Szmukler-Moncler S, Senger
18. Eriksson RA, Albrektsson T. The effect of heat
3. Tehemar SH. Factors affecting heat gen- B: Influence of different parameters on bone
on bone regeneration: An experimental study in
eration during implant site preparation: heating and drilling in implantology. Clin
rabbit using the bone growth chamber. J Oral
a review of biologic observations and Oral Implant Res. 1997 Jun;8(3):189-97.
Maxillofac Surg. 1984 Nov;42(11):705–711.
future considerations. Int J Oral Maxillofac 35. K
ilpatrick HC. Removal of impaired third
Implants. 1999 Jan-Feb;14(1):127-36. 19. Eriksson RA, Adell R. Temperatures dur-
molars utilizing speeds up to 200,000
ing drilling for the placement of implants
4. Lavelle C, Wedgwood D. Effect of internal irri- rpm. J Oral Surg Oral Med Oral Pathol.
using the osseointegration technique. J Oral
gation on frictional heat generated from bone 1958 Apr;11(4):364–369.
Maxillofac Surg. 1986 Jan;44(1):4–7.
drilling. J Oral Surg 1980 Jul;38(7):499–503. 36. C
alderwood RG, Hera SS, Davis JR,
20. Eriksson RA, Albrektsson T. Temperature
5. Sutter F, Krekeler G, Schwammerger AE, Waite DE. A comparison of the heal-
threshold levels for heat-induced bone tis-
Sutter FJ. Atraumatic surgical technique ing rate of bone after the production of
sue injury. A vital microscopic study in rabbit.
and implant bed preparation. Quintes- defects by various rotary instruments. J
J Prosthet Dent. 1983 Jul;50(1):101–107.
sence Int 1992 Dec;23(12):811–816. Dent Res 1964 Mar-Apr;43:207–216.
21. Collins DH. Surgical changes around
6. Costich ER, Youngblood PJ, Walden JM. A study 37. A
bouzgia MB, James DF. Measurements of shaft
nails and screws in bone. J Pathol Bac-
of the effects of high-speed rotatory instru- speed while drilling through bone. J Oral Maxil-
teriol.1953 Jan;65(1):109–121.
ments on bone repair in dogs. Oral Surg Oral lofac Surg 1995 Nov;53(11):1308–1315.
Med Oral Pathol. 1964 May;17:563–571. 22. Moss RW. Histopathologic reaction of bone
38. A
bouzgia MB, Symington JM. Effect of drill
to surgical cutting. Oral Surg Oral Med
7. E
riksson RA, Albrektsson T, Magnusson B. speed on bone temperature. Int J Oral Maxil-
Oral Pathol. 1964 Mar;17:405–414.
Assessment of bone viability after heat trauma. lofac Surg 1996 Oct;25(5):394–399.
A histological, histochemical and vital micro- 23. Matthews LS, Hirsch C. Temperatures measured
39. A
bouzgia MB, James DF. Temperature rise
scopic study in the rabbit. Scand J Plast in human cortical bone when drilling. J Bone
during drilling through bone. Int J Oral Maxil-
Reconstr Surg 1984;18(3):261–268. Joint Surg Am. 1972 Mar;54(2):297–308.
lofac Implants 1997May-Jun;12(3):342–353.
8. Haider R, Watzek G, Plenk H Jr. Effects 24. Esposito M, Hirsch JM, Lekholm U, Thomsen
40. B
risman DL. The effect of speed, pressure,
of drill cooling and bone structure on P. Biological factors contributing to failures of
and time on bone temperature during the
IMZ implant fixation. Int J Oral Maxil- osseointegrated oral implants: (II). Etiopathogen-
drilling of implant sites. Int J Oral Maxillofac
lofac Implants 1993;8(1):83–91. esis. Eur J Oral Sci, 1998 Jun;106(3):721–764.
Implants 1996 Jan-Feb;11(1):35–37.
9. Kirschner H, Meyer W. [Development of an 25. Rhinelander F, Nelson CL, Stewart RD,
41. S
harawy M, Misch CE, Weller N, Tehemar
internal cooling mechanism for surgical drills]. Stewart CL. Experimental reaming of the
S. Heat generation during implant drilling:
Dtsch Zahnarzt Z. 1975 Jul;30(7):436-438. proximal femur and acrylic cement implanta-
the significance of motor speed. Journal of
tion. Vascular and histologic effects. Clin
10. Y
acker M, Klein M. The effect of irri- oral and maxillofacial surgery : J Oral Maxil-
Orthop Relat Res. 1979 Jun;(141):74–89.
gation on osteotomy depth and bur lofac Surg. 2002 Oct;60(10):1160-1169.
diameter. Int J Oral Maxillofac Implants 26. Berman AT, Reid JS, Yaniko DR Jr, Sih GC, Zim-
42. H
obkirk JA, Rusiniak K. Investigation of
1996 Sep-Oct;11(5):634–638. merman MR. Thermally induced bone necrosis in
variable factors in drilling bone. J Oral
rabbits. Relationship to implant failure in humans.
11. K
rause WR, Bradbury DW, Kelly JE, Lunceford Surg 1977 Dec;35(12):968–973.
Clin Orthop Relat Res. 1984 Jun;(186):284–92.
EM. Temperature elevation in orthopedic cutting 43. K
ondo S, Okada Y, Iseki H, Hori T, Takakura
operations. J Biomech. 1982;15(4):267–275. 27. A
lbrektsson T, Brunski J, and Wennerberg A, “‘A
K, Kobayashi A, et al. Thermological study of
requiem for the periodontal ligament’ revisited,”
12. https://aaoms.confex.com/aaoms/ drilling bone tissue with a high-speed drill.
Int J Prosthodont. 2009 Mar-Apr;22(2):120–2.
am1310/webprogram/Paper3399.html Neurosurgery 2000 May;46(5):1162-1168.
(search made on 24 April 2014). 28. Esposito M, Hirsch J. M, Lekholm U, and
44. R
afel SS. Temperature changes during high-
Thomsen P, “Biological factors contribut-
13. http://drills-burs.salvin.com/Implant- speed drilling on bone. J Oral Surg Anesth
ing to failures of osseointegrated oral
Drills.html?parentId=237(search Hos Dent Serv. 1962 Nov;20:475–477.
implants: (II). Etiopathogenesis,” Eur J
made on 24 April 2014). 45. E
riksson AR, Albrektsson T, Albrektsson B. Heat
Oral Sci. 1998 Jun;106(3):721–764.
14. W
ittwer G, Adeyemo WL, Schicho K, Gigovic caused by drilling cortical bone. Temperature
29. Augustin G, Zigman T, Davila S, Udilljak T,
N, Turhani D, Enislidis G. Computer-guided measured in vivo in patients and animals. Acta
Staroveski T, Brezak D, Babic S.Cortical bone
flapless transmucosal implant placement in the Orthop Scand 1984 Dec;55(6):629–631.
drilling and thermal osteonecrosis. Clin Biomech
mandible: a new combination of two innovative 46. B
rånemark P-I. Osseointegration and
(Bristol, Avon). 2012 May;27(4):313-25.
techniques. Oral Surg Oral Med Oral Pathol its experimental background. J Prosthet
Oral Radiol Endod. 2006 Jun;101(6):718-23. Dent 1983 Sep;50(3):399–410.
42 • Vol. 9, No. 5 • July 2017

Kumar et al
47. A
lbrektsson T, Eriksson A. Thermally 62. Sener BC, Dergin G, Gursoy B, Kelesoglu E, 76. M
arkovic A, Calasan D, Colic S, Stojcev-Stajcic
induced bone necrosis in rabbits: Relation Slih I. Effects of irrigation temperature on heat L, Janjic B, Misic T. Implant stability in posterior
to implant failure in humans. Clin Orthop control in vitro at different drilling depths. Clin maxilla: bone-condensing versus bone-drilling:
Relat Res. 1985 May;(195):311–312. Oral Implants Res. 2009 Mar;20(3):294-8. a clinical study. Oral Surg Oral Med Oral Pathol
48. Albrektsson T. The healing of autologous bone Oral Radiol Endod 2011;112(5):557-563.
63. Girdler NM. Fatal sequel to dental implant sur-
grafts after varying degrees of surgical trauma. gery. J Oral Rehabil. 1994 Nov;21(6):721-722. 77. S
tubinger S, Biermeier K, Bachi B, Ferguson
J Bone Joint Surg Br. 1980 Aug;62(3):403-10. SJ, Sader R, von Rechenberg B. Comparison of
64. Davies JM, Campell LA. Fatal air embolism dur-
49. Watcher R, Stoll P. Increase of tem- Er:YAG laser, piezoelectric, and drill osteotomy
ing dental implant surgery: A report of three
perature during osteotomy. In vitro and for dental implant site preparation: a biome-
cases. Can J Anaesth. 1990 Jan;37(1):112-121.
in vivo investigations. Int J Oral Maxil- chanical and histological analysis in sheep.
65. Spatz S. Early reaction in bone following the Lasers Surg Med 2010;42(7):652-661.
lofac Surg 1991Aug;20(4):245–249.
use of burs rotating at conventional and ultra-
50. Kay JF, Gilman L, May Y. The tri-spade drill 78. H
arder S, Wolfart S, Mehl C, Kern M. Per-
speeds. A comparison study. Oral Surg Oral
for endosseous dental implant installation. formance of ultrasonic devices for bone
Med Oral Pathol. 1965 Jun;19:808–816.
J Oral Implantol 1991;17(4):424–428. surgery and associated intraosseous
66. Lazzara R. Immediate implant place- temperature development. Int J Oral Maxil-
51. W
atanabe F, Tawada Y, Komatsu S, Hata ment into extraction sites: Surgical and lofac Implants 2009;24(3):484-490.
Y. Heat distribution in bone during prepa- restorative advantages. Int J Periodontics
ration of implant sites: Heat analysis by 79. R
ashad A, Kaiser A, Prochnow N, Schmitz I,
Restorative Dent. 1989;9(5):333–343.
real-time thermography. Int J Oral Maxil- Hoffmann E, Maurer P. Heat production during
67. B
ecker W, Becker BE. Guided tissue regen- different ultrasonic and conventional osteotomy
lofac Implants 1992(2);7:212–219.
eration for implants placed into extraction preparations for dental implants. Clin Oral
52. C
hacon GE, Bower DL, Larsen PE, McGlumphy sockets and for implant dehiscences: Surgical Implants Res 2011;22(12):1361-1365.
EA, Beck FM. Heat production by 3 implant drill technique and case reports. Int J Periodontics
systems after repeated drilling and sterilization. 80. K
erawala CJ, Martin IC, Allan W, Williams
Restorative Dent 1990;10(5):376–391.
J Oral Maxillofac Surg. 2006 Feb;64(2):265-9. ED. The effects of operator technique and
68. Gher ME, Quintero G, Assad D, Monaco bur design on temperature during osseous
53. S
. Saha, S. Pal, and J.A. Albright, E, Richardson AC. Bone grafting and preparation for osteosynthesis self-tapping
“Surgical drilling: Design and perfor- guided bone regeneration for immedi- screws. Oral Surg Oral Med Oral Pathol
mance of an improved Drill,” J Biomech ate dental implants in humans. J Peri- Oral Radiol Endod 1999;88(2):145-150.
Eng. 1982 Aug;104(3):245-252 odontol. 1994 Sep;65(9): 881–891.
81. V
enturelli A. A modified surgical protocol for
54. Oliveira N, Alaejos-Algarra F, Mareque-Bueno 69. Meffert RM. Issues related to single- placing implants in tbe maxillary tuberosity:
J, Ferrés-Padró E, Hernández-Alfaro F. Thermal tooth implant. J Am Dent Assoc. Clinical results at 36 months after loading
Changes and drill wear in bovine bone during 1997 Oct;128(10):1383–1390. with fixed partial dentures. Int J Oral Maxil-
implant site preparation. A comparative in vitro lofac Implants 1996;11(6):743-749.
70. L
egros R, Balmain N, Bonel G. Age-
study: twisted stainless steel and ceramic drills.
related changes in mineral of rats 82. D
ent CD, Olson JW, Farish SE, Bellome J,
Clin Oral Implants Res. 2012 Aug;23(8):963-9.
and bovine cortical bone. Calcif Tis- Casino AJ, Morris HF, Ochi S. The influence of
55. B
ayerlein T, Proff P, Richter G, Dietze S, Fang- sue Int. 1987 Sep;41(3):137–144. preoperative antibiotics on success of endos-
hanel J, Gedrange T. The use of ceramic drills seous implants up to and including stage II
71. Menzel J, Posner AS, Harper RA. Age
on a zirconium oxide basis in bone prepara- surgery: a study of 2,641 implants. J Oral Maxil-
changes in the crystallinity of rats bone apa-
tion. Folia morphol. 2006 Feb;65(1):72-74. lofac Surg. 1997 Dec;55(12 Suppl 5):19-24.
tite. Isr J Med Sci 1965 Mar;1:251–252.
56. Sumer M, Misir AF, Telcioglu NT, Guler 83. L
ambert PM, Morris HF, Ochi S. The influence
72. H
olden JL, Clement JG, Phakey PP. Age and
AU, Yenisey M. Comparison of heat gen- of 0.12% chlorhexidine digluconate rinses
temperature related changes to the ultrastruc-
eration during implant drilling using stainless on the incidence of infectious complica-
ture and composition of human bone mineral. J
steel and ceramic drills. J Oral Maxillofac tions and implant success. J Oral Maxillofac
Bone Joint Surg 1995 Sep;10(9):1400–1409.
Surg. 2011 May;69(5):1350-4. Surg. 1997 Dec;55(12 Suppl 5):25-30.
73. S
trietzel FP, Nowak M, Kuchler I, Fried-
57. H
ohnle T. A new device for automatic irri- 84. M
ohamed Sharawy, Carl E. Misch, Norman
mann A. Peri-implant alveolar bone loss
gation of the operating field in osteotomy. Weller, Sherif Tehemar. Heat generation during
with respect to bone quality after use of
Dtsch Zahnärztl Z. 1974 Jan;29(1):63. implant drilling: the significance of motor speed.
the osteotome technique: results of a ret-
58. Lavelle C, Wedgwood D. Effect of internal irri- rospective study. Clinical oral implants J Oral Maxillofac Surg 60:1160-1169, 2002.
gation on frictional heat generated from bone research 2002 Oct;13(5):508-513.
drilling. J Oral Surg 1980 Jul;38(7):499-503.
74. N
kenke E, Kloss F, Wiltfang J, Schultze-
59. Kirschner H, Bolz U, Michel G. Thermo- Mosgau S, Radespiel-Troger M, Loos K,
metric studies using internally cooled and Neukam FW. Histomorphometric and
uncooled burs on the jaws and teeth. Dtsch fluorescence microscopic analysis of bone
Zahnärztl Z 1984 Jan;39(1):30–32. remodelling after installation of implants
using an osteotome technique. Clin Oral
60. Schmitt W, Weber HJ, Jahn D. Thermic
Implants Res. 2002 Dec;13(6):595-602.
studies during drilling in compact bone
with different cooling systems. Dtsch 75. Summers RB. A new concept in maxil-
Zahnärztl Z 1988 Jul;43(7):802–805. lary implant surgery: the osteotome tech-
nique. Compendium 1994;15(2):152,
61. Isler SC, Cansiz E, Tanyel C, Soluk M, Selvi F,
154-156, 158 passim; quiz 162.
Cebi Z. The effect of irrigation temperature on
bone healing. Int J Med Sci. 2011;8(8):704-708.

The Best Things in Life Are FREE!
Volume 8, N o . 8 December 2016 Volume 8, N o. 1 m arch 2016
The Journal of Implant & Advanced Clinical Dentistry The Journal of Implant & Advanced Clinical Dentistry
Modified
Mandibular
Implant Bar
Implant-Supported
Overdenture
Milled Bar
Overdenture
Full Mouth Rehabilitation

Treatment of the Atrophic
of Periodontitis Patient Maxilla with Autogenous Blocks
Volume 8, N o. 3 may /JuNe 2016 Volume 8, N o . 4 July /August 2016
The Journal of Implant & Advanced Clinical Dentistry The Journal of Implant & Advanced Clinical Dentistry
Titanium Mesh Ridge Augmentation of Severe

Augmentation for Dental Ridge Defect with rhBMP-2
Implant Placement and Titanium Mesh
Mandibular Overdentures
Treatment of Mandibular with Mini-Implants
Central Giant Cell Granuloma
Subscribe now to enjoy articles free of charge that will benefit you, the actively practicing
dental provider. With each JIACD issue, readers are afforded the opportunity to
assess clinical techniques, cases, literature reviews, and expert commentary
that can immediately impact their daily dental practice.
Email notification when new issues are available online.
Start your FREE subscription today at www.jiacd.com

Custom Emergence Profile

Загружено:

Сведения о документе

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Custom Emergence Profile

Загружено:

Авторское право:

Доступные форматы

Volume 9, N o.

The Journal of Implant & Advanced Clinical Dentistry

In an effort to streamline our business practice and continue to provide no-fee,

This generous sponsorship, which provides funding towards our operating

We here at JIACD sincerely appreciate the continued financial support by

6 An Innovative Approach for

20 P artial Enucleation of the

2 • Vol. 9, No. 5 • July 2017

26 Clinical and Radiographic

36 A New Standard Classification

The Journal of Implant & Advanced Clinical Dentistry • 3

Publisher Copyright © 2017 by LC Publications. All rights

Internet Management Opinions expressed in JIACD articles and communications

4 • Vol. 9, No. 5 • July 2017

Tara Aghaloo, DDS, MD Michael Herndon, DDS Michele Ravenel, DMD, MS

The Journal of Implant & Advanced Clinical Dentistry • 5

Ioannis Vergoullis, DDS, MS1 • Catherine Badell, DDS1

1. Vergoullis Dental Clinic, Rhodes, Greece. Visiting Assistant Professor,

6 • Vol. 9, No. 5 • July 2017

INTRODUCTION able a guide tool that can help them identify

The Journal of Implant & Advanced Clinical Dentistry • 7

Figure 2a: Pre-op clinical view. Figure 2b: Pre-op x-ray.

8 • Vol. 9, No. 5 • July 2017

The Journal of Implant & Advanced Clinical Dentistry • 9

10 • Vol. 9, No. 5 • July 2017

The Journal of Implant & Advanced Clinical Dentistry • 11

Figure 7a: Clinical evaluation post-surgery.

12 • Vol. 9, No. 5 • July 2017

The Journal of Implant & Advanced Clinical Dentistry • 13

manufacturer recommended protocol for oste-

14 • Vol. 9, No. 5 • July 2017

Figure 9d: Bite-wing radiograph 1 year post surgery.

keeping the flat surface of the implant prosthetic

The Journal of Implant & Advanced Clinical Dentistry • 15

16 • Vol. 9, No. 5 • July 2017

The Journal of Implant & Advanced Clinical Dentistry • 17

and posterior cases. The superior results that this

ATTENTION implant therapy. The VPI EPMS is a system that

PROSPECTIVE dentists practicing implant dentistry. The innova-

AUTHORS the selection, establishment and recording of a

18 • Vol. 9, No. 5 • July 2017

The Journal of Implant & Advanced Clinical Dentistry • 19

Dr. Samar M Jambi1 • Dr. Meisan A. Bukhari2

KEY WORDS: Dental implants, nasopalatine canal, enucleation

20 • Vol. 9, No. 5 • July 2017

Figure 1: Pre-surgical clinical appearance of missing right

Figure 2: Presurgical CBCT scan for the missing area.

INTRODUCTION to the canal range from 2.9 mm to 13.6 mm.3

The Journal of Implant & Advanced Clinical Dentistry • 21

Figure 3: Canal enucleated.

dealing with the incisive canal enucleation.

22 • Vol. 9, No. 5 • July 2017

Figure 6: Postoperative CBCT. Figure 7: Clinical appearance of the surgical site.

Figure 8: Implant placement.

of the cases (mean follow up of 70 months). 8,9

The Journal of Implant & Advanced Clinical Dentistry • 23

both the buccal and the lingual surfaces were

24 • Vol. 9, No. 5 • July 2017

This is to avoid placing the implant in a soft tis-

The Journal of Implant & Advanced Clinical Dentistry • 25

1. Professor, Department of Periodontology, Faculty of Dentistry, Cairo University, Cairo, Egypt.

26 • Vol. 9, No. 5 • July 2017

INTRODUCTION in terms of survival rate for short implants

The Journal of Implant & Advanced Clinical Dentistry • 27

6 An Innovative Approach for

20 P artial Enucleation of the

26 Clinical and Radiographic

36 A New Standard Classification

Disclosure 15. Eriksson A, Albrektsson T, Grane B, 30. P