Online Continuing Education / Course Details

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Maximizing Angled Screw Channels for Screw Retained Implant Restorations

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Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

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Educational Objectives

» Differentiate the options available to utilize an angled screw channel hybrid abutment

» Recognize the armamentarium needed for you and your lab to deliver an angled screw channel restoration

» Understand why angled screw channels are relative to you and your practice

Abstract

Clinicians today want to eliminate possible dental implant restorative complications and fabricate restorations with longevity and reparability built into the design. Ideally, all dental implant restorations would have the ability to be retrievable without compromising the integrity of the prosthetic. Traditionally, a screw-retained restoration required more accurate implant positioning and offered several advantages over a cemented restoration. Benefits included known retention, ease of removal or retightening, and assurance of no lingering cement.

The inability to angle all implants ideally for screw retention arises with the relationship of teeth to the relationship of bone or the lack of quality or quantity of bone. In some cases, the available bone to establish initial primary stability is located in areas that will not allow the long axis angulation of the implant to be in an ideal position to allow a screw-retained restoration. The need has existed for a screw-retained prosthetic solution when the long axis of the implant does not coincide with the lingual or occlusal aspect of the final restoration.

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Course 118 of 124

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CASE PRESENTATION: Implant Guided Surgical Guide and Immediate Provisionalization

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Date: 08-13-2020 09:26:40 am

    Guided surgical guides and premade provision­als are now considered a routine procedure because of their accuracy and predictability. This case details file merging of cone beam computed tomography (CBCT) DICOM data with iTero Element (Align Technology) STL file data to create a virtual plan­ning platform, design and 3D print the surgical guide, and place implants. 

Patient Presentation
The 21-year-old patient sustained facial, bone, and dental injuries (Figure 1) in an automobile accident while jogging, including the loss of teeth Nos. 7 and 8 (Figure 2). After discussing alternatives, benefits, and complications, the patient agreed to implant placement and immediate provisionalization of the missing anterior teeth.

Virtual Planning
We file-merged surface morphology STL data from an iTero Element digital scan (Figure 3) with the DICOM data of a NewTom VGi CBCT scan taken by Mobile Im­aging Solutions. Using SIMPLANT v16 software (Dentsply Sirona Implants), we created a virtual wax-up for optimal shape and contour of the missing teeth (Figure 4).

After crown down planning, we determined each implant location to allow precise placement of the lingual access cylinder for the retention screw of the screw-retained implant restoration, as well as to ensure it was optimally located in available bone (Figure 5). Us­ing 3Shape software, Glidewell Labs CAD designed and milled full-body polyetheretherketone (PEEK) provision­als with engaging titanium inserts (Figure 6). The tita­nium inserts, created to allow for screw retention, were secured with luting cement. Using the planning data, we designed a surgical guide that was 3D-printed using a Stratasys Objet 30 3D printer with FDA-approved MED 610 polymer (Figure 7).

Treatment
After administration of local anesthesia (4% Septo­caine, Septodont), we inspected the tooth-supported guided surgical guide and trial-fitted in the patient’s mouth. Designed inspection windows were viewed to ensure proper adaptation (Figure 8). As flapless surgery was planned, we used a tissue-removal drill followed by a sequential series of osteotomy drills (Figure 9). Care was taken to take each drill to full depth, with the drill shoulder contacting the metal guide insert (Figure 10).
We placed Glidewell 3.7 mm x 13 mm and 4.7 mm x 13 mm implants and torqued them to 35 Ncm with the surgical guide in place (Figure 11). We placed the flat of the fixture hex parallel to the flat of the surgical guide with the implant at full depth. PEEK provisionals were placed (Figure 12). No occlusal adjustment was neces­sary. We removed the composite restoration on tooth No. 9 and used Spectrum TPH3 (Dentsply Sirona Restor­ative) to develop an improved esthetic result (Figure 13).

Accuracy Leads to Success
Accurate scan data produces accurate file merg­ing, which leads to extremely accurate design and 3D printing of guided surgical guides. Accurate guided surgical guides then allow for such precise placement of implants that premade provisionals can be placed at the same time as the implants. With a 100% digital workflow, clinicians can produce predictably accurate premade provisionals in the anterior esthetic zone.



GO-TO PRODUCTS USED IN THIS CASE

SPECTRUM TPH3
Spectrum TPH3 is a visible light-activated, radiopaque microhybrid composite for anterior and posterior restorations. The composite is pre-dosed in compules tips or delivered in traditional syringes. It is available in a selection of precise VITA shades, enabling nature-like esthetics and desirable results.

SIMPLANT
SIMPLANT dental planning software offers clinicians a comprehensive 3D system for accurate and predictable implant planning and treatment. Clinicians can access a patient’s anatomy and see exactly how it relates to the proposed restoration. SIMPLANT is compatible with more than 10,000 implants from more than 100 brands.

ITERO ELEMENT
The iTero Element scanner has a compact footprint so you can fit high-precision scanning power almost anywhere. Its wand operation features built-in controls like side buttons and a touchpad for user interface control. 3D scan images appear instantly with crisp definition on a 19-inch touchscreen display.
 
Article 32 of 39

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CASE PRESENTATION: Overdenture Implant Placement Using a 3D-Printed Surgical Guide

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Date: 07-15-2020 08:58:55 am



A healthy, 70-year-old woman presented with a loose mandibular complete denture, complaining that she was unable to chew hard and crunchy foods. She requested minimally invasive narrow diameter implants to stabilize her denture. Her mandible edentulous ridge had
adequate bone volume to allow for flapless implant placement (Figures 1 and 2).

A radiopaque PVS (Green-Mousse, Parkell) was applied to the intaglio of the mandibular complete denture, and the patient and denture were CBCT scanned using the PreXion3D Eclipse (PreXion). Cotton rolls were used to aid in occlusal and soft- tissue separation.

Using Blue Sky Plan (Blue Sky Bio) dental implant planning software, I opened the DICOM files to be- gin digitally planning the patient’s treatment. Her treatment included four 2.9 mm x 12 mm LOCA-  TOR Overdenture Implants (Zest Dental Solutions) (Figure 3). A surgical guide incorporating these im- plants was designed and exported into a 3D print- able file. I printed the guide design file on Dental   SG biocompatible surgical guide material using the Form 2 3D printer, both from Formlabs (Figure 4).

The osteotomy was prepared through the 3D printed surgical guide using the drill stop as an indicator. After the guide was removed, the remaining osteotomies were prepared freehand. Four implants were placed using a minimally inva- sive technique, and fully inserted using a torque wrench (Figures 5–8). The LOCATOR abutments were placed onto each implant and torqued to 30 Ncm (Figure 9). The patient’s bone density was ideal, which resulted in a high insertion torque (Figure 10). Recesses in the denture were prepared using acrylic burs from the Denture Prep & Polish Kit (Zest Dental Solutions) (Figure 11).

Because the patient preferred not to immediately attach the implants, CHAIRISIDE Soft Reline Material (Zest Dental Solutions) was injected into the intaglio of the denture and placed onto the edentulous ridge. After complete polymerization, the denture was removed, trimmed, and inserted back onto the ridge (Figure 12). The patient returned 3 months after treatment to receive final prosthetic procedures.

 
 
 
Article 28 of 39

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CASE PRESENTATION: Guided Implant Placement & Restoration in a Narrow Ridge

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Date: 07-15-2020 08:33:47 am




Today, we’re finding that more and more patients are presenting to the dental practice seeking tooth replacement with dental implant treatment. The need for implant therapy usually results from teeth that are severely decayed, vertically fractured, or periodontally involved.

A patient presented to my practice wanting to replace missing teeth with dental implants in the areas of teeth Nos. 28, 29, and 30 (Figure 1). According to the patient, these teeth were extracted a few years prior without any form of socket preservation, resulting in a deficient edentulous ridge. To accurately assess the area for bone height and width, as well as identify any crucial anatomical landmarks, a CBCT was used. Using the CS 8100 (Carestream Dental) (Figure 2), the narrow ridge was scanned to see if there was adequate bone.

When the CBCT scan was achieved, a treatment plan (Figure 3) was created using 3DDX (3D Diagnostix) where the edentulous ridge would be restored with 3 dental implants in addition to the placement of grafting material. A blend of cortical mineralized and demineralized bone-grafting material would be used in any residual areas around the dental implants.

When the treatment plan was presented to the patient and accepted, the fabrication of a tooth-borne pilot drill surgical guide was initiated and completed using 3DDX within a short amount of time. The surgical guide was tried in to confirm it was completely seated onto the supporting teeth, and to ensure there was no movement upon any pressure.

With a simplified drilling protocol using a guided surgical kit (OCO Biomedical) (Figure 4), the osteotomies were prepared using the AEU7000 Surgical Motor (Aseptico) and handpiece with copious amounts of sterile irrigation. Once the osteotomies were complete, an implant driver was used to place 3 Engage (OCO Biomedical) dental implants (Figure 5) precisely into the ridge until increased torque was necessary. The ratchet wrench was then connected to the adapter and the implants torqued to final depths, reaching a torque level of about 40 to 50 Ncm.

Any residual areas around the implants were grafted with a cortical mineralized and demineralized bone-grafting material (Goldendent) to optimize the area (Figure 6).

Upon examination 4 months later, the soft tissue and bone surrounding the dental implants were very healthy (Figures 7 and 8), so the implants’ Implant Stability Quotient values were tested with an Osstell unit. Since the dental implants had a high reading—indicating osseointegration—impression posts were inserted (Figure 9) and a full-arch im­pression was taken using a vinylpolysiloxane light/tray material (Panasil, Kettenbach) (Figure 10). From these impressions, final abutment and Zenostar (Ivo­clar Vivadent) crown restorations were fabricated.

After delivery from the dental lab (Arrowhead Dental Lab), the definitive abutment and crown restorations were tried in and radiographs taken to ensure complete seating. Once confirmed, the abutments were torqued into place (Figure 11) and the splinted crown restorations were seated with Premier Implant Cement (Premier) (Figure 12).

With proper planning, placement, and restoration, a dental provider may predictably restore a patient’s smile to proper form and function. In today’s practice, it is essential to have the appropriate skills, technology, and dental materials to accurately deliver implant treatment in a systematic, effective approach.
 
Article 27 of 39

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CASE PRESENTATION: Immediate Premade Provisional Bridge on Implants Placed With Guide

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Date: 05-18-2020 06:36:11 am

The accuracy of implant placement has increased dramatically with the advent of guided surgical guides. The digital workflow offers the possibility of premade provisionals that can be delivered at the time of implant placement. Considering that precise data is the key to excellent outcomes, CBCT-based DICOM data can be file-merged with STL intraoral scan data to create a virtual planning platform. Planning software allows crown-down planning, with virtual representation of missing teeth and virtual placement of implants. This case will present the workflow used to plan and precisely place 3 implants to support an immediate placed 4-unit anterior provisional bridge. Following a bicycle accident in which he collided with a truck, this 28-year-old patient lost his 4 maxillary incisors. The patient presented with no contraindications to implant placement. After a discussion of alternatives, benefits, and complications, the patient consented to have 3 implants and a premade provisional placed.

Virtual Planning

Using implant planning software, CBCT-based DICOM data (PreXion) was file-merged with STL scan data (iTero Element scanner, Align Technology) to create a virtual planning platform. The 4 missing incisors were virtually created and placed in an optimal position to allow screw retention with the access hole lingual to the incisal edge. The implant locations were planned in relation both to available bone and the position of the wax-up maxillary incisors. As there was insufficient room for implant placement of tooth No. 10, three implants were planned with a cantilever 4-unit bridge resting on the implants. The access cylinders for the retention screws were precisely designed to be lingual to the incisal edges.

Using the planned bridge design, Glidewell Labs milled a PMMA Implant Provisional and cemented 3 titanium insert cylinders using Shofu luting cement. The planned surgical guide was created using an Objet30 3D printer (Stratysis) with FDA-approved MED610 translucent polymer.

Treatment

After administering 4% Septocaine (Septodont) local anesthesia, an anterior ridge incision with bilateral vertical releasing incisions was performed to allow observation of the implant to titanium insert fit for the premade provisional bridge. Using the 3D-printed surgical guide, sequential osteotomy drills implants were placed to shoulder stop depth. To ensure precision fit of the premade provisional, the Glidewell Direct Inclusive Tapered implants were placed with surgical guide in place and torqued to 35 Ncm. Close inspection of the PMMA provisional to the implant surface revealed a precise fit. No adjustment of implant depth or occlusal adjustment was necessary.

Outcome Summary

The patient was extremely happy with the immediate esthetic result, and the healing after 6 months was excellent. Superior outcomes can result from the use of accurate scan data for file merge and virtual planning. In this case, precise accuracy was achieved using a guided surgical guide sufficient to place 3 implants and immediately seat a premade provisional with no adjustment necessary.

Article 19 of 39

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CASE PRESENTATION: Designing an Implant Surgical Guide Using 3D Technology

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Date: 05-10-2020 08:17:28 am

Prosthetically driven digital implant planning is revolutionizing implant dentistry, resulting in improved surgical and prosthetic outcomes. Likewise, utilizing a full digital workflow with in-house 3D printing and milling improves the efficiency of implant cases, resulting in better patient experiences. One of my passions is to teach digital implant dentistry to other clinicians, especially to expe­rienced implant surgeons. This case provided a unique opportunity for me to help one of my men­tors, Dr. Robert Gellin, with his first digital implant planning case. A combination of challenging esthet­ics, emergence, intraosseous residual endodontic material, and malocclusion motivated Dr. Gellin to digitally plan this single-unit anterior case as a guided surgery from start to finish.

The patient presented with an intact edentulous ridge at site No. 10 with a possible retained root fragment and residual endodontic material in that position, but with adequate ridge dimensions for implant placement.

Digital Implant Planning and Treatment

A CBCT image was captured using the Planmeca ProMax 3D Max, and a scan of the intraoral tissues was merged in the Planmeca Romexis implant planning software. A digital waxup was created in the Romexis CAD/CAM module with considerations of occlusion, gingival margin, incisal edge position, emergence profile, and prosthetic connection. This data was observed in tandem when virtually positioning the implant, with careful attention to place the implant in an ideal relationship to the labial plate of bone, adjacent anatomy, and to allow proper positioning of the implant platform for prosthetic success and future health. A virtual temporary abutment was placed and all of the planned elements were exported from Romexis to Meshmixer (Autodesk) to create the screw access hole through the planned restoration. The prosthesis was milled from CERASMART (GC America) on a Planmeca PlanMill 30 S, then cemented to the abutment to create an immediate temporary restoration. A surgical guide was designed with the Romexis guide design module, and the guide was 3D printed. A metal Steco guide sleeve was luted into the guide’s sleeve holder, and the guide was processed in preparation for clinical use. On the day of surgery, fully guided Astra twist drills (Dentsply Sirona) were used to prepare the osteotomy via flapless approach and an Astra Tech OsseoSpeed EV 3.6 x 9-mm implant (Dentsply Sirona) was inserted with torque exceeding 45 Ncm. The temporary was seated with minimal adjustment, confirming lack of occlusion. Postoperative healing was uneventful and the implant is now fully integrated.

Conclusion

The treatment plan is evolving for this patient. She is now interested in restoration of the maxillary anterior teeth to improve function and esthetics. We can be confident that because of the careful planning and accurate implant position, the potential restorative outcome will be successful. Dr. Gellin felt that this case was an enlightening experience compared to how he’d been handling implants previously. Digital implant planning, he said, is a method that allows the clinician to come as close as possible to a perfect result.Fig 1 - 6

 

Article 21 of 39

Online Continuing Education / Course Details

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

To Treat or Extract? Factors to Consider for Tooth Retention with Root Canal Therapy

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Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

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Educational Objectives

Learning Objectives
After completing this webinar, participants will:
»      Identify the determining factors that would improve the outcome for a tooth to be saved
»      Determine if a tooth should be saved using endodontic procedures or extracted and replaced with an implant
»      Assess and implement ways that would increase the likelihood of long term tooth retention when performing root canal treatment

Abstract

Implants have changed the way patients deal with edentulism, missing teeth, and teeth that have poor to hopeless prognosis. Unfortunately, implants have more recently been seen as a substitute for teeth that are salvageable with the right treatment approach. This has specially come to light as more and more implant failures have been observed in the past 5-10 years. Implants have also forced endodontists to more critically self evaluate and determine what can be improved in performing root canal treatment in order for endodontic teeth to have an overall better long term outcome.

This presentation reviews factors that would determine whether a tooth should have endodontic treatment/retreatment or be extracted and replaced with an implant. Dr. Odabashian will discuss patient, tooth and other appropriate questions that should be asked and answered in determining whether a tooth should be kept or extracted. Finally, Dr. Odabashian will go over the lessons learned from 30 years of practice which include 10 years of general and restorative dentistry and 20 years of endodontic practice

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Course 86 of 124

Online Continuing Education / Course Details

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

INTRAORAL SCANNING: Improving Efficiency and Advanced Workflow

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Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

Educational Objectives

After completing this course, participants will be able to identify the potential advantages of digital impression systems over conventional impressions, as well as be able to:
  1. Comprehend how digital impressions are being used to fabricate dental restorations
  2. Understand how digital impressions are impacting orthodontics
  3. Learn how digital impressions are being used in implantology
  4. Recognize the potential benefits of CAD/CAM technologies
  5. See the potential in diagnostics and communication with patients.

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______________________________

Abstract

Digital impressions are reshaping the way modern dentistry is being practiced. They are able to eliminate some of the issues found with conventional workflow and provide clinicians with unique advantages compared to traditional impression techniques. With various implications in the field, digital scanners are making their mark on the profession. This article will review some of the advantages of digital impression systems over their conventional counterparts, as well as review how they are currently being used in practice today.

COMMERCIAL SUPPORTER: This educational activity is made possible through an unrestricted educational grant from Align Technologies.

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Course 79 of 124

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Implant Placement Using a Guided Socket Shield

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Date: 01-14-2020 11:52:16 am

Case Presentation:
The pursuit of function, form, and esthetics is a driving force for clinicians. Our current dental landscape has advanced to the point where we can predictably design the tooth replacement process prior to even lifting a scalpel. Now, we start with a prosthetic vision and work backwards so that our final solution does not look like a crown or an implant, it looks like what we aim to replace—a tooth.

Digital Planning and Placement

A patient presents with a nonrestorable central incisor. An implant is indicated, but because the preop periapical x-ray (Schick 33, Dentsply Sirona) reveals a very thin buccal plate, we determine that a socket shield is needed to predictably maintain the soft- and hard tissue profiles. We section the tooth using a surgical guide, a surgical trephine bur (Salvin Dental), and a Lindemann bur. The CEREC chairside system (Dentsply Sirona) is used to design and fabricate the 2 surgical guides: one for guiding the trephine bur and another to create the osteotomy for the tapered implant.

Periapical Xray using Schick 33The trephine plan follows the long axis of the failing tooth, leaving a uniform thickness for the residual root fragment. The implant plan does not need to follow the same path—in fact, the cingulum is the desired location, affording the most flexibility when restoring.

The trephine guide is placed and the 4.5-mm trephine bur is guided, following the plan without deviation. The trephine is able to produce a thin uniform thickness, which is difficult to accomplish without a guide. When brought to length, the Lindemann bur is used to complete the sectioning. The fragments are removed without disturbing the desired buccal fragment.

The 4.1-mm implant is placed, followed by placement of a cancellous allograft material (OraGRAFT, LifeNet Health) in the gap between the bone and implant. Immediate loading is not attempted in this case, so a Maryland bridge is fabricated with CEREC out of Tetric CAD (Ivoclar Vivadent) and bonded into place. The Isolite system (Zyris) helped to control moisture and create visibility.

Uncover Visit

After 12 weeks, the implant is uncovered. A scan post is placed and the implant site is imaged. This is used to fabricate a screw-retained provisional with a meso bloc (Telio CAD, Ivoclar Vivadent). After the soft-tissue has matured, it is imaged and then the final prosthesis fabricated. A custom abutment is made with a Straumann Variobase for CEREC – TAN and a meso bloc (inCoris ZI, Dentsply Sirona). The zirconia is infiltrated to mimic a true dentin shade. The veneer crown is then fabricated with an MT block (IPS e.max, Ivoclar Vivadent) so that the warmth of the dentinal shade abutment shows through and creates a lifelike result.

Go-To Product Used in this Case

Schick 33 by Dentsply Sirona

Schick 33 provides industry-leading image quality that can make substantial improvements to diagnosis and patient acceptance, offering an unprecedented resolution for consistently detailed images and advanced diagnostic capabilities. Kevlar-reinforced, silicon-coated cables help keep your sensor up and running. With 3 sensor sizes, multiple cables lengths, and limitless enhancement capabilities, Schick 33 is designed to suit your patient's needs, as well as your practice and personal preferences. 

 

About the Doctor

Dr. Gardell graduated from NYU College of Dentistry and has a technology-based practice with an emphasis on cosmetic dentistry in Stamford, CT. He has been using CEREC in his practice since 2005 and he successfully completed the CON process in the state of Connecticut and, in 2010, installed the first GALILEOS in the state. Through his work, the laws requiring a CON have been changed, so that it is not required any longer. He has been a beta tester for the CEREC chairside system since 2009 and has been involved in the beta testing of the Digital Encode workflow for implant systems from Zimmer Biomet. Dr. Gardell has lectured nationally on topics ranging from CEREC and GALILEOS to implants, and practice integration.

Article 11 of 39

Online Continuing Education / Course Details

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

A Guide to Sutures

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Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

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Educational Objectives

After completing this article, the reader should be able to:

  1. Gain a fundamental understanding of tissue repair and the role of suturing.
  2. Recognize the various types of suture materials and needles.
  3. Learn fundamental suture techniques and ergonomics.
  4. Determine alternative suture techniques and their indications.

Abstract

“Suturing” is a fundamental skill in dentistry but can be a very daunting and confusing topic for many dental providers. Gut suture or polytetra°uoroethylene (PTFE)? Square knot or surgeon’s knot? Simple interrupted or mattress suture? The abundance of available techniques, materials, and clinical applications can be overwhelming. Fortunately, the vast majority of clinical scenarios can be addressed by understanding the basic technique and fundamental concepts. This guide will review wound healing, suture types and materials, and basic and advanced techniques to equip the dental provider with a foundation in wound closure and management.

COMMERCIAL SUPPORTER: This course has been made possible through an unrestricted educational grant from Karl Schumacher.

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Course 78 of 124