Restorative Leadership

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Alan Rosenfeld, DDS, FACD & Gege Mandelaris, DDS, MS Restative Leadership Restative Leadership Collabative Accountability The Team Approach Optimal

Management of Periodontal Diseases CBCT Imaging www.chicagoperioimplants.

1 Alan Rosenfeld, DDS, FACD & Gege Mandelaris, DDS, MS Restative Leadership Restative Leadership Collabative Accountability The Team Approach Optimal Dental Implant Health PERIODONTAL Medicine Alan Rosenfeld DDS, FACD Dental Implant Surgery Esthetic and Regenerative Periodontics Oral Medicine Management of Periodontal Diseases CBCT Imaging Surgical SPECIALISTS Diplomates, American Board of Periodontology LTD Gege Mandelaris DDS, MS *This document may not be reprinted without express permission from its auths Restative Leadership.indd 1 1/13/12 2:22 PM

2 PERIODONTAL Medicine Surgical SPECIALISTS LTD PERSONALIZED PREVENTATIVE PREDICTABLE PROVEN Restative Leadership I Restative Leadership.indd 2 1/13/12 2:24 PM

Alan Rosenfeld, DDS, FACD & Gege Mandelaris, DDS, MS Diplomates, American Board of Periodontology The competition f patients continues to grow me heated, with new teeth in a box franchises and

This squeezes the restative practice that is committed to truly finding the best treatment f patients but can t offer these types of services.

that usually can t occur during a one-hour complimentary visit, as is often advertised.

Implant therapy carries significantly lower risk and better outcomes when approached in a team context, much like the treatment of any other medical condition.

3 Alan Rosenfeld, DDS, FACD & Gege Mandelaris, DDS, MS Diplomates, American Board of Periodontology The competition f patients continues to grow me heated, with new teeth in a box franchises and practices spending millions of dollars in advertising and making enticing promises that may not hold up over the long term. This squeezes the restative practice that is committed to truly finding the best treatment f patients but can t offer these types of services. Restative Leadership Team Approach Collabative Accountability The procedure f immediate-load prostheses can be complex, and the best results are achieved with though diagnostic planning something that usually can t occur during a one-hour complimentary visit, as is often advertised. Additionally, the necessary skills, judgment, and knowledge base are difficult to acquire through weekend courses continuums. Implant therapy carries significantly lower risk and better outcomes when approached in a team context, much like the treatment of any other medical condition. Our published process is a restative leadership program based on collabative accountability* to facilitate a true partnership f providing contempary dental implant therapy. By partnering with us, you set your practice apart by establishing a leadership position and offering your patients the highest quality treatment options. Our practice philosophy of CT-based treatment planning entitled Collabative Accountability is becoming the emerging standard of care f implant dentistry. The concept of collabative accountability draws upon three main principles: 1) You, the restative doct, set the surgical perfmance standards f those participating in interdisciplinary implant therapy. 2) Technology, including CAD/CAM surgical guides developed from computer software, improves the accuracy of implant placement and delivery of immediate teeth while fostering teamwk. 3) The use of appropriate scanning appliances can allow f prosthetically directed implant placement without bone exposure. We pioneered the use of CT scans f diagnosis and treatment planning beginning in We continue to use the most advanced CBCT imaging available today. Our leading-edge concepts and technology facilitate the collabative process between the restative doct, implant surgeon and labaty technologist, leading to improved outcomes f the patient. We remain fully committed to advancing the art and science of our profession f the patients benefit. Lastly, we would like to acknowledge and thank Dr. Richard Mecall f his contributions, and development of the case type pattern diagnostics.** Together, we look to create a medical center model experience through interdisciplinary dentistry in a team approach. Alan Rosenfeld, DDS, FACD Gege Mandelaris, DDS, MS *Rosenfeld AL, Mandelaris GA, Tardieu PB. Prosthetically directed implant placement using computer software to ensure precise placement and predictable prosthetic outcomes. Part I. Diagnostics, imaging and collabative accountability. Int J Perio Rest Dent 2006; 26(3): **Mecall, R.A. (2009) Computer-Guided Implant Treatment Pathway. Chapter 7. In: Tardieu, P.B. & Rosenfeld, A.L. The Art of Computer Guided Implantology. pp: Quintessence, Chicago. Restative Leadership I Restative Leadership.indd 3 1/13/12 2:24 PM

Case Type I Dental and surgical anatomy are within nmal limits.

Single Tooth Case Type I Multiple Teeth Case Type Pattern Clinical Features Acceptable tooth position

Wax-Up Tooth-fm Scanning Appliance Design (see page 9) Tooth-fm Provisional restation Solid

040 vacufm wafer Inspection windows Interocclusal radiolucent bite registration Cone Beam CT Scan

Initial exam and residual architecture of single edentulism #9. Diagnostic wax-up perfmed.

Inspection Windows Negative Image Center Solid tooth with negative image center.

Initial exam and residual architecture of partial edentulism #7-10.

Gingival architecture/position is intact. Note space appropriation is given high priity.

040 vacufm wafer which has inspection windows on the occlusal aspect to ensure seating of the

4 Case Type I Dental and surgical anatomy are within nmal limits. Dental anatomy only requires wk up/modification. Single Tooth Case Type I Multiple Teeth Case Type Pattern Clinical Features Acceptable tooth position Favable gingival symmetry, volume and col Nmal bone height and width Occlusal stability Diagnostic Wax-Up Tooth-fm Scanning Appliance Design (see page 9) Tooth-fm Provisional restation Solid barium/acrylic tooth with negative image center demonstrating the desired implant emergence vacufm wafer Inspection windows Interocclusal radiolucent bite registration Cone Beam CT Scan (CBCT) CBCT imaging and surgical referral to Periodontal Medicine and Surgical Specialists, LTD Initial exam and residual architecture of single edentulism #9. Diagnostic wax-up perfmed. Conal fm of tooth only. Gingival architecture is intact. Inspection Windows Negative Image Center Solid tooth with negative image center. Inspection windows included to verify complete seating of scanning appliance. Initial exam and residual architecture of partial edentulism #7-10. Diagnostic wax-up perfmed f teeth #7-10. Conal fm of teeth only. Gingival architecture/position is intact. Note space appropriation is given high priity. Scanning appliance created. Solid barium acrylic teeth within a vacufm wafer which has inspection windows on the occlusal aspect to ensure seating of the appliance. A radiolucent bite registration is also used to ensure complete seating. 3D imaging and prosthetically directed CT-based planning. 4 I Restative Leadership Clinical note: In many instances, the vertical dimension/proption of planned tooth p first to avoid a ridge lap in the scanning appliance. In these cases where the vertical p should be perfmed to agree on what action will be taken to compensate pri to m Restative Leadership.indd 4 1/13/12 2:24 PM

Single Tooth Case Type II Multiple Teeth Case Type II Dental anatomy within nmal limits.

Initial exam showing gingival asymmetry and facial bone loss. diagnostic wax-up perfmed.

Scanning appliance representing optimal prosthetic tooth position, 30% barium is used f tooth, 10%

Initial examination where multiple teeth will be replaced and occlusal instability requires

Scanning appliance is fitted with radiolucent bite registration to ensure complete seating during

Case Type Pattern Clinical Features Gingival asymmetry col alteration Evidence of early facial

demonstrating the desired implant emergence 0.

5 Single Tooth Case Type II Multiple Teeth Case Type II Dental anatomy within nmal limits. Surgical anatomy requires augmentation, volume and/ position of tissue must be determined. Initial exam showing gingival asymmetry and facial bone loss. diagnostic wax-up perfmed. Optimal final tooth position and soft tissue fm/volume established in wax-up. Scanning appliance representing optimal prosthetic tooth position, 30% barium is used f tooth, 10% f soft tissue. Initial examination where multiple teeth will be replaced and occlusal instability requires further investigation. Tooth-fm diagnostic wax-up. Scanning appliance is fitted with radiolucent bite registration to ensure complete seating during imaging. Case Type Pattern Clinical Features Gingival asymmetry col alteration Evidence of early facial bone loss Possible mucogingival abnmalities thin biotype Possible occlusal instability Diagnostic Wax-Up Tooth-fm. Scanning Appliance (see page 9) Tooth-fm Solid barium/acrylic tooth with negative image center demonstrating the desired implant emergence vacufm wafer Inspection windows Interocclusal radiolucent bite registration Cone Beam CT Scan (CBCT) CBCT imaging and surgical referral to Periodontal Medicine and Surgical Specialists, LTD 3D imaging and prosthetically directed CT-based planning. th position may not be possible without significant pontic/recept site development l proption of teeth is not acceptable (too sht), an interdisciplinary discussion to making the scan appliance. Restative Leadership I Restative Leadership.indd 5 1/13/12 2:24 PM

Case Type III Case Type III Dental anatomy mostly within nmal limits.

Case Type Pattern Clinical Features Predominantly hizontal with some vertical bone loss Initial exam

Post extraction disuse atrophy/residual ridge resption noted (predominantly hizontal).

Wax-Up diagnostic wax-up perfmed to compensate f lost anatomical structures.

Scanning Appliance (see page 9) Solid barium/acrylic tooth with negative image center demonstrating the

040 vacufm wafer Inspection windows Interocclusal radiolucent bite registration Scanning appliance

6 Case Type III Case Type III Dental anatomy mostly within nmal limits. Surgical anatomy requires augmentation and volume/position of tissue must be determined. Case Type Pattern Clinical Features Predominantly hizontal with some vertical bone loss Initial exam showing partial edentulism in the anteri maxilla. Post extraction disuse atrophy/residual ridge resption noted (predominantly hizontal). Altered occlusal vertical dimension Reduced mesiodistal space Possible occlusal instability Diagnostic Wax-Up diagnostic wax-up perfmed to compensate f lost anatomical structures. Optimal final soft tissue fm/volume, gingival margin position and tooth proptions established in wax-up. Scanning Appliance (see page 9) Solid barium/acrylic tooth with negative image center demonstrating the desired implant emergence vacufm wafer Inspection windows Interocclusal radiolucent bite registration Scanning appliance representing optimal prosthetic tooth position is 30% barium, soft tissue position is 10% barium. Solid barium/acrylic teeth within a vacufm wafer which have inspection windows on the occlusal aspect to ensure full seating of the appliance to the teeth. A radiolucent bite registration is also used to further ensure complete seating. Cone Beam CT Scan (CBCT) CBCT imaging and surgical referral to Periodontal Medicine and Surgical Specialists, LTD 3D imaging and prosthetically directed CT-based planning. 6 I Restative Leadership Restative Leadership.indd 6 1/13/12 2:24 PM

Case Type IV Case Type IV Dental and surgical anatomy require modification. Initial exam showing partial edentulism in the posteri maxilla.

Barium differential gradient scanning appliance is created from the full-contour wax-up whereby the denture flange is 10% barium and the prosthetic teeth

Case Type Pattern Clinical Features Predominantly vertical with some hizontal bone loss Altered occlusal vertical dimension Reduced mesiodistal space

negative image center demonstrating the desired implant emergence Interocclusal radiolucent bite registration If not using a processed denture scannoguide,

7 Case Type IV Case Type IV Dental and surgical anatomy require modification. Initial exam showing partial edentulism in the posteri maxilla. Posteri edentulism area has predominantly vertical and some hizontal bone loss. diagnostic wax-up. Barium differential gradient scanning appliance is created from the full-contour wax-up whereby the denture flange is 10% barium and the prosthetic teeth are 30% barium. A radiolucent bite registration should be used to further ensure complete seating. Case Type Pattern Clinical Features Predominantly vertical with some hizontal bone loss Altered occlusal vertical dimension Reduced mesiodistal space Possible occlusal instability Diagnostic Wax-Up Trial tooth set-up Scanning Appliance (see page 9) Denture scannoguide Solid barium/acrylic tooth with negative image center demonstrating the desired implant emergence Interocclusal radiolucent bite registration If not using a processed denture scannoguide, a vacufm wafer with inspection windows must be used 3D imaging and prosthetically directed CT-based planning. Cone Beam CT Scan (CBCT) CBCT imaging and surgical referral to Periodontal Medicine and Surgical Specialists, LTD Restative Leadership I Restative Leadership.indd 7 1/13/12 2:25 PM

Case Type V Case Type V Dental and surgical anatomy require modification.

Diagnostic Wax-Up Trial tooth set-up Scanning Appliance (see page 9) Denture scannoguide Patient s existing appliance (if prosthetically acceptable)

Trial tooth set-up is perfmed using anatomically crect denture teeth to re-establish esthetics, vertical dimension of occlusion, lip suppt, phonetics,

Scanning appliance is 30% barium f teeth, 10% barium f denture flange soft tissue identification Utilize existing removable prosthesis via dual scan

of scan appliance flange is needed to investigate screw fixation possibilities In the case where a patient s existing partial complete denture meets all

under the dual scan protocol. Fiduciary markers are required.

8 Case Type V Case Type V Dental and surgical anatomy require modification. Case Type Pattern Clinical Features Significant vertical and hizontal bone loss Loss of perial musculature suppt Possible occlusal instability Diagnostic Wax-Up Trial tooth set-up Scanning Appliance (see page 9) Denture scannoguide Patient s existing appliance (if prosthetically acceptable) Initial examination with significant hizontal and vertical bone loss. Loss of perial musculature suppt also present. Trial tooth set-up is perfmed using anatomically crect denture teeth to re-establish esthetics, vertical dimension of occlusion, lip suppt, phonetics, and occlusal/denture stability, as needed. Scanning appliance is 30% barium f teeth, 10% barium f denture flange soft tissue identification Utilize existing removable prosthesis via dual scan technique (fiduciary markers required) Radiolucent interocclusal recd to ensure repeatability of the positioning of the scan template Proper extension of scan appliance flange is needed to investigate screw fixation possibilities In the case where a patient s existing partial complete denture meets all the fundamental prosthodontic criteria of success and requires no further change set-up, the prosthesis itself can be used as the scanning appliance under the dual scan protocol. Fiduciary markers are required. Barium differential gradient scanning appliance is created from trial tooth set-up whereby the denture flange is 10% barium and the prosthetic teeth are 30% barium. A radiolucent bite registration is also used to further ensure complete seating. Cone Beam CT Scan (CBCT) CBCT imaging and surgical referral to Periodontal Medicine and Surgical Specialists, LTD 3D imaging and prosthetically directed CT-based planning. 8 I Restative Leadership Restative Leadership.indd 8 1/13/12 2:25 PM

9 Scanning Appliance Considerations 1. Type of scanning appliance: See chart below. 2. Contrast medium soft tissue representation: In all scanning appliances, 30% barium is used to enable dental anatomy identification and 10% is used to identify soft tissue. These mediums are commercially available through Great Lakes Orthodontics with the trade names Biocryl X radio-opaque acrylic resin (30%) and Biocryl XR reduced acrylic resin (10%). 3. Inspection windows and negative image centers: All vacufm-based scanning appliances f partially edentulous patients should be made with inspection windows at three different cusp tips to produce a triangulated plane. This allows verification of complete seating of the appliance between the stone model (lab) and the patient (clinic). Negative image centers should also be made in the position of the planned prosthesis where the emergence access is desired. This is accomplished by creating a 2mm hole within the tooth. 4. Radiolucent interocclusal bite registration: This is desired f all scanning appliances with the exception of the provisional restation natural tooth serving as the scan prosthesis. An interocclusal bite registration should be created so that complete seating of mandible and scanning appliance can be ensured and positioning verified. The bite registration is critical in cases where immediate loading is planned, as it allows f accurate cross mounting of the scanning appliance, virtual denture and CAD/CAM surgical guide which are generated from the CBCT data set and stereolithographic process. Radiolucent bite registration material is commercially available and has a Hounsfield unit density of about 180. This low density allows it to be masked in the 3D SimPlant Master Conversion process that our CBCT Imaging Center perfms. 5. Surgical guide fixation: A decision should be made as to whether the surgical guide will be fixated. The scanning appliance must include sufficient regional anatomy to allow f the possibility of screw fixation. Types of scanning appliances with associated wax-ups and indications* Type of scanning appliance Type of wax-up Indications Tooth-fm Tooth-fm Dental and surgical anatomy within nmal limits Dental anatomy may may not be within nmal limits; surgical anatomy requires augmentation, volume and/ position of tissue needs to be determined Partial complete Trial tooth set-up Complete edentulism; dental and possibly surgical denture scannoguide anatomy require modification Provisional restation Tooth-fm Dental anatomy only requires modification Patient s existing removable prosthesis None, but the existing prosthesis must meet all acceptable prosthodontic criteria Prosthesis itself can be used as the scanning appliance using fiduciary markers that our CBCT Imaging Center provides *Mecall, R.A. (2009) Computer-Guided Implant Treatment Pathway. Chapter 7. In: Tardieu, P.B. & Rosenfeld, A.L. The Art of Computer Guided Implantology. pp: Quintessence, Chicago. Restative Leadership I Restative Leadership.indd 9 1/13/12 2:25 PM

10 Alan Rosenfeld, DDS, FACD & Gege Mandelaris, DDS, MS Diplomates, American Board of Periodontology CBCT Imaging Protocols Single Scan vs. Dual Scan There are two imaging protocols that can be used to transfer prosthetically relevant infmation to the CBCT dataset. They are described below: 1. Single Scan Protocol This protocol implies that the patient is imaged with a fully seated scanning appliance. It is the traditional method f impting prosthetically meaningful infmation to the CT data set. 2. Dual Scan Protocol This protocol is used when a specific differential barium gradient scanning appliance is not created needed. In this circumstance, the patient s existing prosthesis meets the prosthetic criteria and multiple fiduciary markers are attached to the appliance at strategic positions. The patient is imaged with the appliance fully seated, and then the appliance itself is imaged using a specific protocol which is CBCT manufacturer dependent. Because the appliance is not radio-opaque, but the fiduciary markers are, the two scans can be spatially united through a double scan registration wizard in SimPlant. The benefit of the dual scan protocol is that a separate scanning appliance is not needed, reducing the cost of diagnostics. However, it does not marginalize the need to ensure that the scanning appliance itself is indeed an accurate prosthodontic prosthesis. Imaging should be perfmed with a radiolucent interocclusal bite registration which allows the appliance to be fully seated and in a reproducible position. If sht cuts are used at this point in the diagnostic process, the accuracy of the case may be compromised. Dimensions of Anatomically Crect Teeth Mesiodistal (mm) MAXILLARY Buccolingual (mm) Mesiodistal (mm) MANDIBULAR Buccolingual (mm) Central incis Lateral incis Cuspid First premolar Second premolar First molar Second molar F the M-D dimensions of maxillary anteri teeth: Sterret JD, Oliver T, Robinson F, et al. Width/length ratios of nmal clinical crowns of the maxillary anteri dentition in man. J Clin Periodontol 1999; 26(3): F the B-L dimensions of teeth: Kraus BS, Jdan RE, Abrahams L. Anatomy of the individual teeth. In: Dental Anatomy and Occlusion. Williams and Wilkins 1969; Baltime. Section 2-6. p I Restative Leadership Restative Leadership.indd 10 1/13/12 2:25 PM

11 Restative Leadership in Action Periodontal Medicine and Surgical Specialists, LTD is the periodontal and implant surgical partner of choice f leading dental practices throughout the Chicagoland area. Wking together under the context of collabative accountability, we can provide the highest standard of care f your patients in an atmosphere of co-discovery and enhanced disclosure. To facilitate wking in tandem to improve the quality of care f patients, we have created a step-by-step algithm that outlines the implant diagnostic process. In addition to maximizing appointment effectiveness between the restative and surgical practices, this process facilitates highly predictable prosthetic outcomes. Restative leadership is designed to streamline the implant process through proper diagnostics and allows the surgical consultation process to occur in a me infmed way through the use of CBCT scan technology. Our CBCT Imaging Center sets the standard f 3D image quality, patient safety, radiology analysis, SimPlant conversion plus masking, and customer service. The Center s staff includes a licensed radiology technologist as its co-direct. The algithm helps ensure successful CT-based implant therapy and can be used f single tooth replacement advanced immediate loading cases with CT surgical guidance. The case type patterns are based on establishing a diagnosis at the initial examination which in turn leads to the selection of the appropriate diagnostic wax-up trial tooth set-up and scanning appliance design f three-dimensional CBCT imaging. Together, we look to create a medical center model experience through interdisciplinary dentistry in a team approach. PERIODONTAL Medicine Surgical SPECIALISTS LTD Restative Leadership.indd 11 1/13/12 2:25 PM

Preventative PERIODONTAL Medicine Park Ridge Advocate Lutheran General Hospital

1180 Fax: 847.698.1185 Oakbrook Terrace Oakbrook Terrace Medical Center Suite 205 1 S.

Periodontics Oral Medicine Management of Periodontal Diseases CBCT Imaging www.

12 Preventative PERIODONTAL Medicine Park Ridge Advocate Lutheran General Hospital Parkside Center Suite Dempster Street Park Ridge, IL Fax: Oakbrook Terrace Oakbrook Terrace Medical Center Suite S. 224 Summit Avenue Oakbrook Terrace, IL Fax: Surgical SPECIALISTS Dental Implant Surgery Esthetic and Regenerative Periodontics Oral Medicine Management of Periodontal Diseases CBCT Imaging Personalized Proven Predictable LTD Alan Rosenfeld, DDS, FACD & Gege Mandelaris, DDS, MS Diplomates, American Board of Periodontology Restative Leadership.indd 12 1/13/12 2:25 PM

UNDERSTANDING DIGITAL DENTISTRY: CBCT AND INTRA-ORAL 30 SCANNING

UNDERSTANDING DIGITAL DENTISTRY: CBCT AND INTRA-ORAL 30 SCANNING -=- & UNDERSTANDING DIGITAL DENTISTRY: CBCT AND INTRA-ORAL 30 SCANNING ----CBCTi-------iTERO------ NewTom VGi *Vertical Patient Positioning