Other reported cases
1. Three case examples of one-piece type implant that showed bone regeneration with theirinstallations
Nakano Dental Clinic
Yoshiki Nakano
Introduction
Here, three success examples are presented where AQB one-piece type implants were installed to thearea of resorbed mandible due to marginal and apical peridontitis, and achieved new bone generation
with its excellent osteoconductive property.
Case 1
Patient: 60 years old
Chief complaint: Cannot chew on the molars strongly
Subject area: No. 30 and 31
Primary medical examination: June 2004
Medical history: None1-1. Before surgery

1-2. Implantation

1-3. One year later

1-4. 11/2 year later

Treatment process
June 2004

Removal of bridge that had been placed on No. 29, 30, 31 (No. 29 and 31 as anchors),
after which No. 31 was extracted as well as the infected granulation tissues.

October 2004

Orthopantomogram, parallel and transverse tomography were used to evaluate the No.
30 and 31 states for implantation. A wide area of transparency and downgrowth wasobserved at the No. 31 position. The distal section of No. 29 was shown to have verticalbone absorption.

November 2004 Implant types 5MS and 5SM of AQB one-piece implants were planted as was originallyplanned to the area corresponding to No. 30 and 31. Implantation was successful.
January 2005

All-ceramic crown was fitted onto the No. 30 and 31 implants

November 2005 No transparency in No. 30 and 29 were visible from the radiograph, confirming newbone generation to have occurred.

Case 2
Patient: 62 years old female (same patient as in Case 1)
Subject area: No. 20
First medical examination: February 2007

2-1. Before surgery

2-2. Implantation

2-3. 10 months later

Treatment process
March 2007

Removal of bridge on No. 13, 14, 15 (No. 13 and 14 were anchors), extraction of No. 13
tooth, and curettage to remove the infected granulation tissues before applying the
Teruplug for hemostasis.

June 2007

Orthopantomogram, parallel and transverse tomography were used to evaluate the No.
13 site for implantation.

July 2007

AQB one-piece implant, 5SM, was installed into the area corresponding to No. 29 tooth
undergoing the standard procedure. The implantation was successful. The radiographshowed transparency in the bone surrounding the implant.

May 2008

Evidence of newly generated bone surrounding the implant with X-ray radiography.

Case 3
Patient: 58 year old female
Chief complaint: Inflammation of the gum
Subject area: No. 30
First medical examination: May 2004
Medical history: None3-1. First medical examination

3-2. Before surgery

3-3. Implantation

3-4. 7 months later
July 2004

3-5. one and nine months later

3-6. 3 years later

Extract No. 30, and perform curettage to remove infected granulation tissues

December 2004 AQB one-piece implant was installed to the site that corresponded to No. 30 with thestandard procedure. The implantation was successful. Significant bone transparency
could be observed with the radiograph.
February 2005

No. 30 implant was fitted with a metal crown applied with hybrid ceramics on the front.

July 2005

Transparency of the bone surrounding the implant is still observed from the radiographbut is lessened from the state before.

January 2008

Transparency of the bone surrounding the implant had disappeared, confirming boneregeneration to have occurred.

Summary
The excellent osteoconductivity of AQB implant led to vast improvements in the regeneration of the bonewhen it was applied to areas that had been affected with bone resorption. This has also contributed to
improvements in the health of neighboring teeth.

2. Two case examples in which one-piece type implants were applied to multiple teeth loss
in the maxilla
Tome-Nakada-Sato Dental Clinic
Toshirou Sato
Introduction
We report here two cases in which one-piece type implants were installed to multiple teeth loss in the
maxilla, and their progresses after immediate loading were observed.
Case1
Patient: 53 year old male
Subject area: No. 2 to 13 and 15
Smoking history: 20 cigarettes/ day, for roughly 30 years
Others: None

Treatment progress
On March 23rd 2008, 9 implants (of which for sizes, refer to Table 1-8) were installed to the maxillary jaw
under anesthesia. Straight after which, the temporary crown (Fig. 1-4) were fitted with adhesives (EZcement). Since the request by the patient was ‘to be able to regain the original occlusion’, we attempted tomeet his needs. With no particular complaint made with regards to the implanted structure, importantcautionary points for after implantations were instructed such as eating only soft food, to observe theprogress made after immediate loading. With no apparent problems, and with the knocking soundturning to a more duller sound (Fig. 1-5), the impression was taken in early May, and was able to place athree-piece bridge, three months after the surgery (Fig. 1-6, 1-7). From the PVT (periotest) as shown in
Table 1-8, as well as the clinical evaluations showed that the degree of biointegration on May 23rd, wasthought to have been firmly established. The progress after the latest surgery on July 22nd, has been
proven to be favorable, along with good level of patient satisfaction.

Feb 23rd – before surgery

April 23rd – 2 months
after surgery

Feb 25th – After surgery

Prosthesis

Cast model andTemporary crown fabricatedold denturefrom the old denture

May 23rd – 3 months
after surgery

PVT 〵 Size
May 23 (3 months)
June 26 (4 months)
July 22 (5 months)

3LM 3LM T3MM T4MM T3MM T3MM T3MS T4SS T46S
1
1
0
-3
3
1
-1
-2
-3
1
0
0
-4
1
0
0
-1
-4
1
1
0
-3
2
0
1
-2
-3
1-8. Sizes used and the Periotest results

Case 2
Patient: 73 year-old male
Subject area: No. 2 to 15
Smoking history: 20 cigarettes/ day, for roughly 50 years
Medical history: 1992, Total gastrectomy due to stomach cancer
August 2007, Pharyngeal cancer excision under general anesthesia

Treatment progress
April 4th 2008, conducted ten implants installation to the maxilla under anesthesia, (for size, refer to Fig.
2-8). Since sufficient alveolar bone width was available, the implantations to No. 3 and 4, as well as to No.
9 to 13 were conducted without formation of a flap (Fig. 2-4). With favorable primary stability achieved,
as with Case 1, the implants were immediately fitted with temporary crowns (Fig. 2-6), and the progress
was observed. There were nevertheless three instances whereby the temporary crown had to be re-fittedwith temporary packing and suturing including the two times due to the instability of the crown, in the
period till 20th April. On 23rd April, the temporary crown was removed due to the patient complaining ofpressure pain and discomfort in No. 7 to 10 region, especially on the No. 10 position. Upon uncovering thearea underneath, remnants of the temporary pack cement 4×2 mm was found in between No. 10 implant
and the gingiva, which was swiftly removed. The mobility of No. 7 implant was thought to have been due
to the natural loosening therefore the implants placed on the No. 7 to 10 positions were screwed tightly
before the placement with the temporary crown for the last time.
The impression for No. 4 to 8 was taken on the June 4th, followed by superstructure placement on June
21st. Having confirmed the absence of any discomfort, superstructure was also placed onto No. 9 to 13 onJune 24th (Fig 2-7). Currently, on July 22nd, no discomfort has been felt at the No. 10 position, favorable
clinical progress has been made and the patient has been pleased with the outcome.

Apr 1st – Before surgery

Apr 4th – After surgery

Apr 1st – Oral cavity

Apr 4th – After surgery

Apr 4th – Temporary

Apr 4th – After temporary

June 24th – After

crown

crown placement

superstructure placement

PVT〵Size

3LM

3LM

T3MM T4MM T3MM T3MM T3MS T4SS T46S

May 23 (3 months)

1

1

0

-3

3

1

-1

-2

-3

June 26 (4 months)

1

0

0

-4

1

0

0

-1

-4

July 22 (5 months)

1

1

0

-3

2

0

1

-2

-3

2-8. Sizes used and the Periotest results
Summary
There are many advantages to using AQB one-piece type implants to multiple tooth losses. The idea wasto reconstruct the original occlusal relationship accurately by immediately loading with the temporary
crown casted with the copy denture with the occlusal plane. This would subsequently lead to a condition
whereby the cleaning would be simple for both the patient and the practitioner to maintenance a
sufficient level of hygiene, and would enable superstructure to be placed in approximately 3 months, withadded indications from periotest results.
I would like to increase the number of clinical examples and consider their treatment progresses fromnow on.

3. Two examples in which early masticatory recovery could be achieved with the applicationof socket-lift technique, to a case with a presence of vertical bone deficiency in the molarsthat had reached the maxillary sinus floor
Sugisawa Dental Clinic
Mitsuru Sugisawa
Tokyo West Tokushukai Hospital
Tsuguo Sano
Hisatoshi Matsumoto
Introduction
We report here two examples where early masticatory recovery could be achieved with the application ofsocket-lift procedure to facilitate the implantation of one-piece T-type implant to a case where the verticalbone width from the alveolar ridge to the maxillary sinus floor had been 1 to 2 mm. The socket-lift
procedure is one that does not apply any bone graft, and limits the degree of surgical invasion by lifting
the sinus floor manually.
Case 1 – Heavily affected with periodontits.
This case was presented with bone resorption affecting the right and left maxillary molars, and the lengthof the bone from the alveolar to the maxillary sinus floor to be 2 mm.
Patient: 53 year-old female
First medical examination: June 2007
Chief complaint: Difficult to eat due to the lack of molar teeth
Medical history: None
Present medical history: Periodontitis affecting overall structures, resulting in looseness of teeth,with bleeding and tartar deposits.
■Image featuring the state of oral cavity and panoramic radiograph at the time of first medical
examination

Implantation to the right maxillary molars[Method]First, perforate with guide-drilland spiral-drill, followed by
end-mill reamer to elevate thesinus floor slowly with the hands
for AQB T-type implantation.

Implant T-5MM and T5Ms

Dental radiograph at implantation

The state of oral cavity when taking impression of the right maxillary molars (two months later)
In the dental radiograph taken 2
months after the implantation,
newly generated bone formation
can be seen in the implantsurroundings.
State of the oral cavity when placing the superstructures to the right maxillary molars
Dental radiograph
6 months after thesuperstructure
placement[Methods]

Pictures drawn by Leon Sakuma
Case 2 – A case of vertical bone deficiency where the length from the left maxillary sinus to the alveolarbone is merely 1 mm

Patient: 63 year-old female
First medical examination: December 1999
Chief complaint: Moving of the left maxillary molars
Medical history: None
Present medical history: Satisfactory level of oral hygiene

■Image featuring the state of oral cavity and panoramic radiograph at the time of first medical
examination



During implantation to the left maxillary molar region(Above) Images of the top left of the oral cavity.
Implant was inserted by perforating through the bone with sole use of spiral drill. The schneiderian
membrane can be seen from the implant cavity.

State of the oral

4MS, 4SS, T4SS

Temporarily stabilized

Dental X-ray taken

Impression taken

cavity at suture

type implants used

after surgery

at implantation

2 months laterState of the oral cavity during the superstructure placement to the left maxillary molars

Discussion and conclusion-

To cases where the width of the bone from the alveolar crest to the maxillary sinus floor weresignificantly deficient, with merely 1 to 2 mm in length, AQB one-piece T-types were placed
facilitated with socket-lift procedure. Here, two cases are presented where bone integration was able
to be achieved 2 months after the operation to such conditions, and quick masticatory recovery wasachieved after the superstructure placement.

-

It is vital to stabilize the T-type implants so that no external forces are applied during theirconsolidation stages. It is therefore recommended to temporarily connect the implant structures withadjacent implants or teeth that are already firmly stabilized.

-

The success of this treatment was thought to be due to the technique that was used to manually liftthe schneiderian membrane carefully that aided the rapid bone integration due to osteoinduction to
attract the osteoblast and bone augmentation in the space between the implant body and theschneiderian membrane as well as the periosteum.
-

In comparison to the sinus-lift, socket-lift technique has the advantages of shorter healing time andless invasion to the maxillary sinus, therefore it is thought to be an effective method for masticatory
recovery for the maxillary molars.

4. Implantation method using the ridge expansion osteotomy – application to the maxillaryanterior region
Kishimoto Dental Clinic
Yukiyasu Kishimoto
Matsumoto Dental Clinic
Yasugi Matsumoto
Introduction
The majority of the cases in which the teeth have been extracted from the maxillary anterior region due
to significant effects from periodontal diseases and apical periodontitis have the tendency to become
narrower. There are cases where implantations to these positions can become complex, and may require
GBR technique, veneer graft or distractions. These procedures are highly invasive therefore can become
highly stressful for the patients. To overcome these issues, we have been utilizing the ridge expansion
osteotomy (REO) that was published by Summers in 1994, to facilitate implantations to the narrowed
alveolar ridge of the maxillary anterior region in our clinic. With its relatively low degree of surgicalinvasion, this has so far been a success, thus the technique will be introduced here.
The past treatment plan for implantation to narrowed alveolar ridge of the maxillary anterior region

Selecting implants that are long and thin

But these frequently resulted in implant fractures

Implants with diameters ≽4 mm are required for solo implantation to the maxillary anterior region. REO
has been applied for this reason.
The surgical technique for REO used in our clinic
Form a primary guide hole with AQB guide drill↓
Expand the hole with osteotome↓
Implantation
Case 1Case where prosthesis was placed after the dental pulp treatment but fell out without any force.
Implantation was conducted to another area at the same time, and the bone graft was extracted from thecavity at the same time.

Alveolar bone

Labial alveolar ridge isApproximately

The contouring of the labial

resorption can belargely resorbed

2 months after

alveolar ridge can be seen

implantation

during the placement of theseen before surgery

superstructure.

The state 11/2 years after the superstructure placement.
This resulted in successful outcome with favorable estheticism.
Case 2
An example of failure after apicotomy. Implantation was conducted to another region simultaneously, andthe bone graft was extracted from this constructed cavity to facilitate the implantation.

At the primary medical

A month after the

The labial aspect of theexamination, the bone

extraction

alveolar ridge – a clear

resorption of the apicalindentation in thelateral wall and thealveolar ridge can be seen

traces from theapicotomy are evident

11/3 years since implantation

Case 3
A case example where immediate loading was applied

Preoperative

Perioperative expansion

Superstructure placement –of the implant cavity

2 months after the implantation

with osteotome

Case 4
An example in which REO and socket-lift procedures were utilized after the extraction of fractured toothwith apical lesion

Preoperative

16 days after the
extraction

Superstructure placement– 3 months after the implantation

Case 5
A case whereby REO and elevation of nasal cavity floor were applied concomitantly

Preoperative

13 days after

Implantation

21/2 months afterSuperstructure

Superstructure

the extraction– 11/2 months

the implantation

placement

placement

after theextraction

Pros of REO

Cons of REO

・Does not require specialized tools
・Simple operative procedures

・It is unreliable means to achieve estheticism,

・Limited degree of surgicalwhich must be explained to the patient preoperatively.

invasion
Summary-

REO is a technique that has minimal surgical intervention and relatively simple implant treatment.
However, the problem remains with the possibility of not achieving an esthetic outcome, andtherefore requires preoperative explanation.
-

The spectrum of the cases that it can be indicated for can be widened with the concomitant
application of bone graft, GBR, socket-lift, and nasal cavity floor elevations.

-

Can be applied to immediate loading cases-

Although the above examples have all been conducted with using one-stage method, the applicationof two-stage types could be the key to gaining esthetic outcome.

5. An example where one-piece type implant was placed into the right mandibular central
incisor after the extraction of residual cyst
Hamamatsu West Implant Laboratory
Yasuhito Suzuki
Yuko Suzuki
Akira Okamoto
Niwa KenIntroduction
The main issue often associated with implant treatment is resorption of alveolar bone. This isparticularly prevalent with the two-piece type implant with its design of the joint between the fixture andthe abutment to be placed under the gingival margin. The use of one-piece type could solve this problem,
but it was thought that its application with GBR technique to a case with significant bone resorption was
thought to be a difficult problem in itself.
Here we present a successful case whereby AQB one-piece type was installed into the anterior region
concurrently with the extraction of large cyst in the same area.
Case example:
Patient: 42 years-old maleTo the right mandibular central incisor position that had been extracted at the previous clinic, a residual
cyst, size of the head of a thumb had been left. At the same time as extracting the cyst, AQB one-piecetype implant was installed to remodel this position.
The treatment plan for implantation to an area with significant bone deficiency typically requires thebone to recover first, and then the implant placement to achieve a favorable outcome. However, it wasthought that by employing HA coated implant, and concomitantly using GBR, early bone integration
would be possible and would lead to improvements in patient’s QOL.

Fig. 1 Vacant area left after the extraction of cyst

Fig. 2 Indentation in the gum profile

Treatment plan
With the use of panoramic radiograph and study model, the treatment outline was explained to thepatient. The patient had requested placement of permanent prosthesis thus the pros and cons of implant
treatment were explained to gain patient consent.
In accordance with the treatment plan, the cyst was extracted on November 2006 after applying a
mucoperiosteal flap under local anesthesia (Fig. 3, 4).

Fig. 3 Vacant area containing residual cyst

Fig. 4 Cyst extracted

The layer of surrounding bone that was suspected of being infected was milled (Fig. 5) before placing theimplant, 4LM for trial placement (Fig. 6). The titanium mesh, 0.1 mm in thickness, was trimmed tomatch the deficient area. The vacant space that was created upon cyst removal was filled with
amalgamate paste consisting of 1 ml of DFDBA (LifeNet Health, use of which had been given consent toby the patient) and 0.4 g of HA (Zimmer Dental, Inc.) added with patient’s blood. The treated area was
finally covered with the prepared titanium mesh and with non-absorbable membrane – Cytoplast®
(Osteogenics Biomedical) that corresponded to the size of the titanium mesh, to be fixed onto the bone
surface with Bone Tack (ACE Surgical Supply, Inc.).

Fig. 5 Area of vacancy

Fig. 6 Trial implantFig. 7 suitably fitted

where a layer of boneplacement

implant

has been removed

The detached mucoperiosteal flap was sutured closed after it was restored to its original position (Fig. 8).
The condition was examined by taking postoperative dental radiograph (Fig. 9), and then the procedure
was completed with administration of antibiotics and analgesics to the patient.

Fig. 8 Wound closure with mattress suture

Fig. 9 Postoperative radiograph

The treatment area was washed the next day, and the suture was removed two weeks later. The wound
was found to have healed four weeks after the operation (Fig. 10). After 12 weeks, the GBR subjected area
was considered to have stabilized, therefore the titanium mesh and non-absorbable membrane wasremoved (Fig 11, 12), completing the secondary procedure by preparing the gum that surrounded the
portion of the implant that was left exposed.

Fig. 10 State of the gum 4

Fig. 11 Membrane before

Fig. 12 The bone that has

weeks after the operation

its removal

been fully filled out can beobserved

The state of the gum had been shown to have stabilized three weeks after the secondary surgery (Fig. 13)
therefore surgical crown elongation was conducted to the top of the implant in preparation for theprosthesis (Fig. 14). The provisional crown was fitted onto the implant to wait for the healing of thetreated area to be completed.

Fig. 13 The top of the implantFig. 14 Surgical crown elongationthat is slightly exposed

The epithelial tissues of the gum was shown to be in favorable condition two weeks later therefore theimpression was taken using personalized tray and silicon impression agent. A working model was
fabricated with ultra-hard plaster, which was then set up on the average value articulator (Dental
Hoby, Shofu Dental Co.) to be trialed.
Since the patient’s occlusal form had been edge-to-edge bite, the prosthesis was fabricated by applying
Rocatec treatment (3M) to the platinum-gold alloy frame (Fig. 15), to which sinfony composite wasapplied for esthetics (Fig. 16) instead of metal bonding resin, to avoid attrition of the antagonistic teeth.
The fabricated superstructure was fixed with glass iononomers, and the residual cement on the gingival
margin was removed as much as possible under infiltration anesthesia.
The patient was satisfied with the outcome as the attached superstructure showed no significant
differences with the natural teeth in terms of the structural appearance and color tone, and the indented
cervical region restored (Fig. 17).

Fig. 15 Metal frame that

Fig. 16 Synfony applied

Fig. 17 Superstructure thathas undergone Rocatec

on the working model

merges in with the overall

treatment

structural appearance

Conclusion
Implantation is usually difficult to be applied to cases with large bone deficiency such as the example
presented here. However, by using tools such as titanium mesh and with simultaneous implantations,shortening of the implant treatment is possible. The downside to this in the long-run is the risk of
exposure of the fixture due to constriction of the augmented bone, leading to loss of osseointegration andindentation of the gum as a result. We considered that the risk would be amplified with the use of
two-piece type implant with the microgap, therefore one-piece type was chosen for this case instead.
Healthy bones resided in the surroundings of the indented area and therefore was thought that the bonewould heal relatively well in comparison to other techniques such as veneer grafts. The edge-to-edge biteof the patient indicates that the occlusal adjustment must be conducted with extreme caution therefore
the follow-up has been conducted regularly every 12 weeks.
The elevated mucoperiosteal flap was restored to its original position for it to be closed with mattresssuture (Fig. 8). The postoperative panoramic radiograph was taken (Fig. 9) and the implant treatment
was completed by prescribing the patient with antimicrobial agent and anti-inflammatory agent toprevent complications such as infection and pain.

6. A case of thinning maxillary molar alveolar bone which has been subjected withconcomitant application of Piezosurgery and bone compression with socket-lift procedure
Ajimu Watanabe Dental Office
Naoshi Watanabe
Introduction
The implantation to thinning alveolar bone of the maxillary molars often requires maxillary sinus floor
elevation. Sinus-lift or socket-lift procedures are indicated for this type of case, often choosing socket-liftconsidering the degree of surgical invasion on the patient. However, the major drawback of this procedureis that the most important step, the elevation of the floor is done blinded, thus lacking the accuracy factor.
The widely applied socket-lift with osteotome is often caused problems such as sense of pain anddiscomfort from the hammering; and resulting in postoperative swelling and pain. Additionally, for thoseless experienced practitioners, the risk of perforation of the sinus membrane cannot be overlooked.
In an attempt to reduce the aforementioned risks, Piezosurgery (will be referred to as Pierzo)was
conducted to the right hand side, and socket-lift procedure was conducted with bone compression kit to
the left hand side to a patient with thinning alveolar bone of the maxillary molars. The two procedures
are compared and discussed in the following sections.
Case 1
Patient: 51 year-old male
Chief complaint: Spontaneous pain to No. 19, 20. Wanted to be able to chew again.
First medical examination: March 2008
Medical history: None
Family medical history: None

Panoramic radiograph at the time of first medical examination

Current medical history and current state
On 2nd March 2008, the patient came to visit the clinic due to spontaneous pain arising in No 19 and 20
positions from acute case of periodontal disease. The partial floor denture for the maxilla (No. 13 to 15,
and 2 to 7 free-end removable dentures), fabricated by the previous clinic, had not been used, for he had
been dissatisfied with the esthetics and functionality of it. Additionally, the previous clinic had explainedthat implantation to these positions would be difficult due to the extreme thinness of the maxilla, and ad
caused the patient to give up.
In explaining that with the use of HA coated AQB implants, the implantation could be possible, herequested implant treatment therefore the treatment was initiated once the preprosthetic surgery hadbeen completed.
Preoperative plan
Implant will be inserted to No. 13, 14 and No. 3, 4, 5.
The distance from the alveolar ride to the maxillary sinus floor from the CT scan and panoramic
radiograph were:
1. 2.2 – 4.5 mm for No. 13, 14→ Socket-lift procedure with Piezosurgery

2. ≽ 12 mm for No. 4, 5

→ Implantation with the standard procedure

3. Approx. 5 mm for No. 3→ Socket-lift procedure with Bone compression kit(Microtec Medical Holdings, Inc.)

Fixture used: AQB Implant 4102×5
Bone graft agent: β-TCP (OSferion, Olympus Corporation) &Minopen (minocycline hydrochloride powder)
Details of the technique
June 9th 2008 Socket-lift procedure with Piezosurgery to No. 13, 14 (Fig. 2)
1. To No. 14 (roughly 2.2 mm from the maxillary sinus floor to the alveolar ridge) Pierzosurgery was
conducted to break through the cortical bone of the sinus floor immediately after marking with theround bar (Fig. 3).
2. To No. 13 (roughly 4.5 mm from the maxillary sinus floor to the alveolar ridge) Pierzosurgery was
attempted, but due to the thickness of the bone, it was difficult to breakthrough so guide-drill wasused primarily till reaching 4 mm, then applied Pierzo for a second attempt.
3. Bone graft agent [β-TCP (OSferin) and minopen] was applied with AQB osteotome (Fig. 4). Width ofthe cavity was gradually increased from 2.5 to 3.5 mm, and the structure was smoothed with theend-mill reamer (diameter 3.75 mm).
4. The No. 13 appeared to have achieved primary stability therefore was implanted using the standard
protocol.
5. The primary stability in No. 14 position appeared difficult to be achieved along with the risk ofsubsidence into the maxillary sinus, therefore the 4102 fixture was implanted placed with a 5 mmcover cap (Fig. 5).

Fig. 2

Fig. 3Fig. 4The postoperative state
Presented with a light nose bleed, but had stopped by the next day.
Pain or swelling was not observed (Fig. 6)

Fig. 5

Fig. 6

Bone compression kit (Microtec Medical Holdings, Inc.) (Fig. 7)
1. Form a cavity till reaching 1 mm from the cortical bone of the maxillary sinus floor with Compress
screw that has a drill as its tip (Fig 8).
2. Break the cortical bone of the maxillary sinus by using sinus screw with its tip shaped as an
osteotome (Fig. 9).
3. Elevate the maxillary sinus floor by filling bone graft with sinus screw.
4. Increase the diameter of the sinus screw accordingly with the diameter of the fixture used.

Fig. 7

Fig. 8Fig. 9July 6th 2008, Socket-lift procedure with bone compression kit to No. 3, 4, 5
1. Implant cavity was constructed for positions No. 4 and 5.
2. Bone compression was applied to No. 3 (approx. 6 mm from the alveolar ridge to the maxillary sinus
floor) with the following steps.
① Implant cavity was formed till reaching the cortical bone of the maxillary sinus with AQB
guide-drill (Fig. 10)② The cavity diameter was expanded with the compress screw #2 (2.0 mm diameter tip), #3(2.4 mm diameter tip) from the Bone compression kit.
The distance from the base of the cavity and the cortical bone of the maxillary sinus
was 1 mm.

③ The cortical bone of the sinus floor was broken though with 3 mm diameter sinus screw (Fig.
11).
④ Bone graft agent [β-TCP (OSferin) and minopen] were gradually filled in three batches
using the 3 mm diameter sinus screw, (Fig. 12).
⑤ Conducted step④ three times with 3.5 mm sinus screw, and smoothed out the cavity wallwith 3.5 mm diameter end-mill reamer.
⑥ Implantation was conducted undergoing the standard protocol confirming that 10 mm of
AQB alarm gauge would fit into the cavity (Fig. 13)

Fig. 10

Fig.11

Fig. 12Fig. 13

Fig. 14

Postoperative state
No nose bleeds or the pain had receded by the next morning.
The postoperative panoramic radiograph confirmed that the maxillary sinus floor to have been elevated(Fig. 14).
The plan from present is to go onto prosthesis placement after an observation period of 3 to 4 months.
Discussion comparing the two surgical techniques
1. Degree of surgical invasion
Pierzosurgery is a method to hammer through the sinus floor with an osteotome, but for this example,
since it had been a greenstick fracture, and the thickness of the bone was merely 2 to3 mm, the patient
did not feel any discomfort or pain from the hammering.
On the other hand, the degree of surgical invasion from using bone compression kit is relatively small as
the elevation is conducted with wrench and screw. However, it was found to be more time consuming than
the former technique.
2. Sense of breaking through the cortical bones of the maxillary sinus floor
It is hard to say either of them have distinct signs.
With Pierzo, it has been described as having a sense of fall through, but this has not always been
apparent. While milling the bone, the pitch of the ultrasound shifts to a higher note as it is transferredfrom the palatal side to the cortical bones of the sinus floor, thus this change might also be an effective fordetermining the point of breakthrough.
On the contrary, point of breakthrough using the Bone compression kit is not at all audible whileelevating with the wrench and screw. Therefore the breaking point was confirmed with the use of dental
radiograph when the screw was inserted to 6 to 7 mm meniscus markings. In other cases, however, there
have been instances where a sudden loss of resistance is felt. This could also be said to be the sense of
breaking through the cortical bone. The risk of perforation of the maxillary sinus membrane is considered
to be relatively low since the elevation is conducted via the hand held ratchet wrench instead of ahammer.
3. Comparison of the two techniques
The time that it takes to breakthrough the cortical bone is shorter with Pierzo, but due to theindistinctive nature of breakage signs, it is necessary to be aware of the changes in the milling sounds.
The milling with Pierzo is by ultrasounds which is said to only affect the hard tissues, therefore wasthought no to be damaging to the sinus membrane. However, there have been reports in other examples
using ultrasounds that have resulted in postoperative nose bleeds therefore it must have had sequential
effect in some way. In addition to the fact that the meniscus markings on the tip of the drills are difficult
to see, milling should be conducted with upmost care to avoid perforating the membrane.
Since the elevation with bone compression kit is conducted manually with a wrench, the risk ofmembrane perforation is thought to be relatively low. However, as with the Pierzo method, the sense of
breakthrough is not extremely noticeable, it is vital to confirm with dental radiograph during theprocedure (multiple checks may be necessary for some cases) therefore inevitably lengthening thetreatment time.
There have been instances in the past whereby the bone was so weak and thin (Class III to IV under the
Lekholm & Zahb classification) that the torque force could not be gained to break through the sinus
cortical bone resulting in idling of the screw. Fortunately, the bone was able to be broken though on thesecond hammering with the osteotome therefore the degree of invasion could be minimized.
Conclusion
Socket-lift method is an indispensible tool for clinical practice with implants, but there are many aspects
that are largely dependent on the experiences of the practitioner, therefore cannot be said to be a highly
reliable method.
To minimize the risks and to increase the reliability of the procedures, it is thought extremely effective tomaster a number of procedures, and understand the pros and cons of each to be able to differentiate
accordingly to their indications.

7. Application of one-piece implant to a case after the extraction of keratocystic odontogenic tumor that
had arisen in the wisdom tooth of the left mandible
Oral and Maxillofacial Surgery, Nasu Chuo Hospital
Yasuo Watanabe
Background
Under 1992 WHO classification, keratocystic odontogenic tumor had been classified as a type of cyst with
the name odontogenic keratocyst. However in 2005, the WHO histological classification for odontogenic
cyst was revised and the odontogenic keratocyst from the past classification that had the keratinizedepithelial lining on the cyst became known as keratocystic odontogenic tumor to be managed as one of thebenign tumors.
The present case example is one where keratocystic odontogenic tumor that had developed close to thewisdom tooth on the left mandibular was extracted, and the wound was left open.
The bone augmentation and repair of the treated area was confirmed a year and two months later, in
preparation for AQB one-piece type implant placement to reconstruct the occlusal form. This resulted in
improved QOL of the patients.
Case 1
Patient: 42 year-old maleFirst medical examination: March 2005
Chief complaint: Swelling in the gingiva, surrounding the left mandibular molars
Medical history: Allergic rhinitis
Present medical history: On March 2005, the patient became conscious of the swelling of the gum inthe left mandible and bad breath, and went to visit the nearby dental clinic for a consultation. A
shadow the size of a chicken egg became evident with analysis of the X-ray radiograph, from theapical region of the mandibular second molar to the mandibular ramus on the left, and was referredto our clinic for further inspection.

Panoramic radiographs at the time of first medical examination

CT scanned images at the time of first medical examination
Facial features: Swelling in the left corner of the mandible
State of the oral cavity: Swelling in the left mandibular molar region
Image analysis: A shadow the size of a chicken egg was found from the left mandibular second molar to
the mandibular ramus that included the wisdom tooth. A portion of bone on the labial side was found tohave been resorbed due to the pressure exerted.
Treatment procedure
March 2005

First medical examination at our clinic
Panoramic radiograph: A shadow the size of a chicken egg was found from the left
mandibular second molar to the mandibular ramus that included the wisdom tooth.
CT scanned image: confirmed a portion of the bone on the labial side to have beenresorbed with pressure.
Clinical evaluation: odontogenic keratocyst

March 2005

Operation
The lesion that was present on the left mandibular second molar to themandibular ramus was extracted, and the wound was left open.
Histopathological finding: Keratocystic odontogenic tumor

March 2006

Panoramic radiography:
Pathological condition – relapse was absent, and confirmed bone recovery withaugmentation.

June 2006

Implantation

August 2008

Superstructure placement

July 2009

Treatment outcome is still under observation.

Panoramic radiograph

Panoramic radiograph of the

Panorama radiograph at

Panoramic radiograph 2

take at the firststate a year and 2 months

the time of implantation

years after superstructure

examination

after the cyst extraction

placement

Discussion
Keratocystic odontogenic tumor was extracted. dd
The bone repaired with augmentation in the area of treatment was confirmed a year and two months
later ready to install AQB one-piece type implant to reconstruct the occlusal form. Strict monitoring will
be conducted by taking into account the possibility of relapse and migration of the keratocystic
odontogenic tumor, alongside the state of implant.
The classification of keratinized cysts under WHO
1992 – Histological classification of epithelial cyst
Odontogenic Keratocyst: Orthokeratinized, parakeratinizedPrimodial cyst
: Non-keratinized, slightly parakeratinized, orthokeratinized
Dentigerous cyst
: Non-keratinized, slightly parakeratinized, orthokeratinized2005 – Odontogenic Tumour
Benign tumor
Keratocystic odontogenic tumor* The epithelial cells must be parakeratinized.
A partial modification of WHO histological classification of epithelial cyst
Odontogenic orthokeratocyst:

OrthokeratinizedPrimodial cyst (excludes embedded teeth) :Non-keratinized, slightly parakeratinized, orthokeratinized
Dentigerous cyst (includes embedded teeth) :Non-keratinized, slightly parakeratinized, orthokeratinized
Conclusion
Keratocystic odontogenic tumor, present from the region of left mandibular wisdom tooth to themandibular ramus, was extracted. AQB one-piece type implant was installed a year and two months later,
once confirming bone augmentation to have been achieved. This was able to improve patient’s QOL.

8. Application of PRGF (plasma rich growth factor) as a technique for alveolar boneregeneration for implant treatment
Sato Dental Clinic
Dr. Fumiaki Sato
Introduction
The PRGF method that has been developed by Dr Eduardo Anituan (Biotechnology institute, Spain) is a
viable means for implant treatment and is distinct from PRP method as this method can be applied toperiodontal bone regeneration without damaging the signaling growth factor is transferred around the
body residing in the blood platelets.

Extracted patient’s venal blood preoperatively. Separate with the specialized centrifuge for 8 minutes,
460×g 1800 rpm into Fractions 1, 2 and 3 to be extracted individually with transfer pipette.

A case where maxillary sinus floor elevation was no longer required with the application of PRGF system

Patient: 54 year-old male
Implant treatment was planned to the maxillary right first molar and the second molar after extracting
the second molar tooth since it had been severely affected with periodontal disease and periodontal
inflammation and had fractured root.
Fibrin clot pre-prepared with the PRGF system was filled into the extraction cavity (bone graft agent was
not used) at the same time as the extraction of the first molar.
Sufficient amount of bone regeneration was confirmed three months later, and AQB implant treatment
was conducted under the standard protocol without the elevation of maxillary sinus floor.

1. 20 ml of patient’s venal blood had been collected – after fractionation with the centrifuge
2. Right maxillary molar – decided to be extracted as it had been severely affected with bone resorption
and with a fractured root.

3. The alveolar bone resorption profile can be confirmed – extracted on April 14th 2008.

4. Consists of growth factor that has been prepared with the PGRF system. Extracted and prepared thefibrin membrane from the blood plasma collected from the patient right before tooth extraction.
5. Fibrin clot in its gel-form prepared with extracts from Fraction 3.
6. Fibrin clot in its gel-form prepared with extracts from Fraction 2.

7. Fibrin membrane in its gel-form prepared with extracts from Fraction 1 was used to fill the treatmentarea. Bone grafting agents were not used.
8. The distance from the alveolar ridge to the maxillary sinus floor was calculated to be 3.8 mm from theCT scan taken before the extraction.
9. Alveolar bone regeneration can be confirmed from the CT scan taken on June 27th 2007.
10. Alveolar bone regeneration can be seen with incision and detachment of the mucoperiosteal flap.

11. The presence of alveolar bone can be seen after the formation of implant cavity for AQB 5102 type.
12. Fixture type 5102 implanted, type 5082 also implanted to the second molar region – July 15th 2008.
13. CT scan was taken immediately after the operation on the same day. Fixture was inserted without
elevating the maxillary sinus floor (used AQB 5102).

Advantages of PRGF system
There are two means in which to apply the growth factors derived from plateletαgranule containedin the blood taken from patient’s own vein, for tissue regeneration – PRGF and PRP techniques.
1. With the PRGF method the centrifugation only requires a single spin at low rotational speed,
therefore does not damage the platelets that are sensitive to heat.
2. The white blood cells that act to inhibit the platelets are removed with the PRGF method.
3. The reaction mixture of PRGF consists of and activates viscous proteins, similar to fibrins,
required as the scaffold for regeneration.
The bone regeneration (augmentation) is achieved with these properties of PRGF.

Conclusion
The tissue regeneration is accelerated by insertion of growth factor and fibrin membrane, extracted with
PRGF method from own peripheral blood, and conducting this simultaneously with tooth extraction.
With the application of this method, the alveolar bone quantity (height, width) can be maintained, andthe fixture can be inserted to cases that would normally require elevation of the maxillary sinus floor.
In addition, it can also be applied to those cases in which the distance to the mandibular canal isshortened with the extraction of mandibular tooth. This would allow safe insertion of the fixture.

9. Clinical co-development in the application of β-TCP beads to jaw bone regeneration
Oral and Maxillofacial Surgery,
National Hospital Organization Chiba Medical Center
Makoto Nakatsuru
Masako Takei
Oral and Maxillofacial Surgery, Chiba University Hospital
Dai Nakajima
ADVANCE Co., Ltd
Yoshikazu Umetsu
Yasuyuki Ozeki
Outline
The use of β-TCP has currently been approved in the field of orthopedics but unfortunately not in thefield of craniocervial. We report here of the clinical co-development that was conducted with ADVANCE
Co., Ltd., for β-TCP beads to be applicable to jaw bone regeneration.
The use of β-TCP beads was approved by the ethics committee of Chiba medical center, restricted to be
applied to cases treated with AQB implants with the aim of jaw bone augmentation. The clinicalco-development is still being continued.
Material
β-TCP beads (manufactured by ADVANCE Co., Ltd.)
Generic name: β-Tricalcium phosphate
Molecular formula: Ca3(PO4)2
Molecular weight: 310.18
External appearance, molecular diameter: white granular, 500 to 700 μm
Porosity: approx. 30%

β-TCP analysis① Powdered X-ray diffraction apparatus (XRD)
Top: β-TCP beads
Bottom: OSferin (Olympus Corporation)
The three distinctive peaks that are a characteristic ofβ-TCP were shown. Both samples showed thesame diffraction peaks thus confirming that the crystal structures to be the same.

② Energy Dispersive X-ray Fluorescence Spectrometer

Analysis Device:

JED2140

Accelerating voltage

30.0KV

Take-off angle

35.0 degree

Effective time

100 seconds

Elements

Weight (%)

Atomic weight (%)

O

38.8

59.60

P

16.1

12.79

Ca

45.1

27.61

100

100.00The samples were analyzed with the X-ray fluorescence spectrometer attached to the scanningelectron microscope to detect the characteristic X-ray that emerged from the sample irradiated withelectron beam. The resulting element distribution confirmed β-TCP to be a highly pure form.
Case 1 -β-TCP beads were applied on the surface to increase the alveolar bone width
Patient: 53 year-old female
Subject area: The right mandibular molars (corresponding to No. 18, 19)

Preoperative

The state before

The state after

image

application of

application of beads after application

beads

Three monthsof beads

Five months after
application of beads.
Three months after
implantation-

Seven months after application of beads
Five months and one month after the
implantations-

Fourteen months after application of beads
Twelve months and eight month after the
implantations

Three more similar cases were conducted to the patients listed below:
Case 2: 32 year-old female, to the left mandibular molars, No. 30, 31.
Case 3: 63 year-old male, right mandibular molar, No. 19.
Case 4: 39 year-old female, right maxillary anterior tooth, No. 9.
Case 2 – A case in whichβ-TCP beads were subjected to the extraction cavity which had not healed
Patient: 67 year-old male
Subject area: Right mandibular molars (corresponding to No. 19)

Preoperative

State before beads

State after beads

Three months

Five months after

image

application

application

after application

application of beads

of beads

A month after
implantation

Nine months after

Five months afterTwelve months after

application of

application of

application of beads,

beads

beads

and 8 months after
implantation

A similar case:
Case 6: 67 year-old male, right maxillary molar, No. 14.
Result①

Cases where the alveolar cortical bones were augmented
Theβ-TCP beads applied to the area where the bone surface was not surgically pre-treated, became
tangled with the periosteal fibers, and were not absorbed even when a period of 14 months had
passed in some case examples. However, there were no evidence of postoperative infections, and its
tissue biocompatibility was thought to be relatively low.

②

Cases where the beads were applied to the extraction cavity that were not healing well
The bonding with the bone was confirmed 4 months after the application ofβ-TCP beads. At 9
months, the beads had been absorbed gradually becoming replaced by bone, and by 12 months, thebone structure had been developed to the extent that it could be thought of as a portion of the boneridge.

Discussion
Theβ-TCP beads (approx. 30% porosity) was confirmed to be an effective artificial bone graft material

that could be safely applied to the oral cavity from the absence of postoperative infection. However there
were still unknown factors that were needed to be clarified due to the inexperience, such as theabsorption time of the beads (some cases took 12 months) or for the replacement with bone.
To provide answers to these queries, more absorbable beads with increased porosity (up to 50%) predicted
to have sufficient strength was newly developed. By increasing the number of cases with this technique,
we are planning to elucidate the characteristics of theβ-TCP in terms of the operating strength,
absorption time and replacement of bone and in comparison to the beads that was used in thisinvestigation.
The efficacy ofβ-TCP beads in the implant treatment was affirmed from the current clinicalco-development, and has acted as a driving force in accelerating the rate of the development in
preparation for the clinical trials in order to gain approval to be readily available for general implant
treatment.

10. Fabrication of superstructure with Cadim 105 (CAD/CAM)
Hoshi Dental Clinic
Haruo Hoshi
Introduction
The prosthesis treatments with CAD/CAM and implant treatment are the most advanced technology atpresent.
The summary of the methods to apply Cadim 105 system CAD/CAM (ADVANCE Co., Ltd.) to fabricate
the superstructure of the AQB one-piece implant are presented in the subsequent sections.
Materials and methods
1) Cadim system
The CAD 025 system consists of part for taking measurements, CAD that can operate and modify themeasured form, and CAM that mechanically process the material.
There are various sizes of ceramic blocks that can be used are provided to be applicable to different teeth,
anterior, canines or molar teeth. The blocks that are in use are chosen to have properties that are as close
to the natural teeth as possible.
Material

Flexural strength (MPa)

Pressure (yield) strength (MPa)Vickers Hardness

Enamel ofnatural teeth
Cadim
Bioceramics

80-90

200-442270-366

90-100400-500

280-380

Table 1 – properties of the blocks
2) Measuring the model
Construct the pattern with resin. Measure the pattern with Cadim 105. First, measure the highest
expanded region in 2D mode then measure the three-dimensional form in its 3D mode, before analyzing
the occlusal plane and the abutment plane.

3) Mechanical milling
From the measured occlusal plane and abutment plane data, construct a target model on computer,attaching a collar where necessary, to enable it to calculate the cutting path with respect to this model.
This information is transferred to the controller to operate the cutting machine.

Case examples
Patient: 53 year-old male
Medical history: No systemic conditions needed to note
The patient came to the clinic having recognized his masticatory dysfunction with the fracturing of thepartial denture to the right mandibular teeth, No. 18, 19. He complained of the difficulty in placement/
displacement of the denture and chewing with the denture. No. 18, 19 teeth, on the right side of themandible, had been lost. In accordance with the patient’s request, the implant was inserted into thevacant positions to improve the masticatory functions.

The all-ceramic crown as the superstructure was fabricated using the standard impression imaging
procedure, and using the Cadim 105 (ADVANCE Co., Ltd) with the aforementioned procedure.

Conclusion
The spectrum of dental treatments required by the patients has widened. The need for estheticism andbiocompatibility are needless to say, but also the shorter treatment periods, and their cost effectivenesshave increasingly become the norm. There are several advantages of using CAD/CAM systems such as all
ceramics restorations are possible at a much lower cost than it had been in the past, or the fact that thetreatments are possible to be conducted the next day in some cases, due to the rapid fabrication process.
Further transformations in the system, as well as the materials can be expected. In addition, along withthe strong demand for estheticism in the current practice, the popularity of all-ceramic crown can be
expected to increase in the future.