John Kringel is chief operating officer at Cellerant Consulting Group, dentistry’s leading corporate incubator and accelerator. Prior to joining Cellerant, he served in various executive roles with leading medical device and dental industry manufacturers.

John Kringel

	How did you decide to team up and tackle emergence profile issues?

: I’ve been referring my surgical cases to Todd since he came out of residency. In 2012, we had a particular patient who I had referred for an implant on an upper cuspid. The implant was placed well, and the site had healed nicely. However, placing the crown was a very frustrating experience. I had to spend about an hour and a half cutting away nice healthy tissue to make it fit.

	Of course, the lab tech was forced to reconcile the emergence profile of a natural-looking crown with the site left by a conventional round healing cap. Cuspids aren’t round, so there’s no way a round healing cap creates an emergence profile that works well for a regular cuspid. I shared the story with Todd and that got us thinking about a better way to do this.

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	Is this a common scenario in restoring implants?

: Yes, very much so. First let’s be clear-you need good impressions and an experienced lab technician. But, even when that’s true, we still see these situations.

In the case Mark referenced, the lab tech did the right thing by providing an anatomic emergence profile. But, it didn’t fit the tissue shape created by standard round healing caps. So, labs typically under contour restorations-they don’t make them as anatomic as they can be-because they know the result may be lots of soft tissue manipulation during the restorative appointment for the dentist and pain for the patient. That happens enough and the dentist switches labs.

	There’s been a disconnect with the whole team as far as soft tissue management. We’re cutting tissue away at restoration time because the emergence profile of the crown is wrong. The crown is wrong almost by design because we don’t provide the lab with the correct soft tissue emergence profile to begin with. It’s a backward way of doing things.

	What are the patient implications of not managing an emergence profile?

: Patients expect form and function, although they don’t use those terms. When they invest thousands of dollars, they expect implants to look as natural as, or better than, their original teeth. They’re disappointed if they see black triangles or have molar pockets causing food impaction. And as their dentists, we’re just as disappointed when we see those problems.

A traditional round healing cuff and the resultant emergence profile. Non-anatomical shape and poor tissue condition set the stage for poor implant esthetics and function.

	When Mark approached me in 2012, I thought to myself, “I do a lot of implants, but it’s not always fun.” I get patients who come back from the restorative dentist saying, “I just spent $4,000 and look at this.” We could be batting .900 in what I call “Aesthetic Average.” At present, I’m not sure dentistry is batting over .400 when it comes to implant esthetics and related function. Proactive soft tissue management can close that gap.

	What is state-of-the-art in emergence profile management today?

: We’ve talked about the shortcomings of traditional round healing caps. They’ve been around since the early days of implant dentistry.

Establishing emergence profile with the Gingival Cuff Links healing cuff. The T-Handle provides a gripping surface and acts as a visual guide to confirm proper implant orientation.

	Provisionalization, where interim abutments are built out with esthetic materials, has also been around for some time. Clinically speaking, it’s a good solution for soft tissue management. In the last few years, provisionalization has enjoyed a bit of a resurgence as a hot topic on the lecture circuit.  Unfortunately, it’s tedious and time-consuming, so few dentists take this route.

	In the last several years, attempts to modernize and improve traditional healing caps have been introduced. One contoured healing cap system made from PEEK (Polyetheretherketone) offers a range of shapes and sizes for an incrementally more anatomical fit. Unfortunately, PEEK is hard to cut, so they can’t be adjusted; they either fit or they don’t. There’s also a system made of PMMA (Polymethyl methacrylate) that we tried in our research but found to break under loading.

	Todd and I have spent the last seven years developing our solution called Gingival Cuff Links, which will launch later this year at the AAOMS and AAID.

	Would you tell us a little about the Gingival Cuff Links technology?

: Our goal with Gingival Cuff Links (GCL) has been to achieve the advantages of provisionalization with the convenience, ease of use and chairside efficiency of conventional healing caps. We set “must-have” design objectives of adaptability, durability and reliability. Finally, we wanted a solution that would be practical for widespread use by our colleagues across specialties, so low cost and office visit efficiency have been priorities.

Gingival Cuff Links emergence profile. The ability to consistently create an anatomical emergence profile allows for implant restorations that fit well and look natural.

	As a maxillofacial surgeon/restorative dentist research team, you can imagine  development has consisted of years of chairside trials and refinement. As mentioned earlier, we tried a range of materials until we arrived at the current sculptable bis-acryl body cuff fused to specially modified interim abutments that are titanium-based. The patented T-handle feature, which maintains proper orientation relative to the implant, came from on-the-fly modifications that Todd made because initial molds made from stone were difficult to hold, drill and adjust.

	Todd and I set the bar at 500 successful cases before we would even show a design to colleagues. Now, six years later, we have thousands of successful cases. And we’ve seen our own Aesthetic Average climb to well over .900.

Articles

How a new solution achieves the advantages of provisionalization with the convenience and efficiency of conventional healing caps. 

Tackling a common issue with restoring implants

	You remember the procedure and know it went perfectly. Proximal margins clean and clear? Check. Proven high-quality composite and bonding materials? Check. Occlusion adjusted? Check. And yet a long-time patient sits in front of you with a prematurely failed restoration leaving you both asking “What went wrong?”

	The truth is your seemingly trusty curing light may be letting you down far more often than you know. The familiar blue light may pop on when you press the button, but is sufficient energy actually being delivered to the composite?

	Chris Felix is a materials scientist and noted author who has spent the last 16 years conducting research in the field of light-cured dental materials between Dalhousie University and 

. Chris and I recently spoke in-depth about new technologies that address curing light performance issues.

	As a researcher, you once supported manufacturers in developing better light-cured materials; however, the focus ultimately shifted. Talk about how your early research uncovered the significance of problems associated with curing lights and curing technique.

	At the university, we provided highly accurate data on the interactions between lights and light-cured materials for some of the top companies in the world. It was relatively easy to show these manufacturers what light was better or what material had better properties under strictly controlled laboratory conditions.

	But the oral environment is far from ideal laboratory conditions. To make our data more clinically relevant, we designed tests to simulate how light curing was done on a patient in a dental office. The first “aha moment” came from testing dental students and practicing clinicians under these clinical simulations to see how good they were at getting that light where it needed to go in the oral cavity. Some of them did really well, some did really poorly, but it was all left to chance. We uncovered a real gap in the dental training that existed because light curing was considered such a simple skill.

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	So, how frequently is poor curing light performance a potential culprit in restoration failure?

	In the process of studying the interaction between various models of curing lights and light-cured dental materials, we amassed a huge database of more than 80,000 unique curing light tests. We were pretty astonished to find that at least one in five curing lights was significantly outside of the manufacturer’s specification. We define “significantly outside” as plus or minus 20 percent deviation from the stated irradiance, at which point there’s not much question as to whether the performance variation will have an impact on proper curing.

	What determines whether a curing light is going to deliver the appropriate amount of energy to the materials?

	Let’s presume the dentist is aware of and follows the manufacturer’s recommended settings and optimal curing times for each of the resins used in the practice. These recommended curing times assume the light is working to a specified output, or irradiance. Our data shows about 75 percent of the time that assumption is wrong.

	One reason for this can be attributed to low-quality lights that are showing up in increasing numbers on the internet. We recently devised an automated test that cycles fully charged lights on and off until the batteries die and measures how the output varies over the charge cycle. While quality lights maintain nearly consistent output, we found some of these low-end lights were losing 50 to 60 percent over a single cycle - the worst one we tested lost 96 percent of its output. Based on this testing, I would advise dentists that reducing practice costs by purchasing cheap curing lights can be the single most expensive decision you make.

	Even quality lights do degrade with normal wear and tear. Let’s say a light that had an original output of over 1,000 mW/cm

 over two years of normal use. For some materials, a change of that magnitude might require doubling the curing time to achieve full polymerization.

	Maintenance issues also can compromise curing light performance. Autoclaving tips have been shown to reduce throughput. If lights aren’t cleaned thoroughly, cured material can adhere to the tips, reducing the light delivered to restorations. Of course, the fiber optic tips can fracture or crack, so lights that are dropped should be tested before being returned to service.

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	Please talk about new technology on the horizon that will help dentists detect these curing light problems before they impact patients

	The simple dental radiometers available today are affordable but have reliability issues and limitations. Many radiometers only provide a simple pass/fail readout and don’t assist dentists with the interaction between their specific light with their specific materials. In our lab testing, we use highly accurate spectrometers. While spectrometers don’t have these limitations, they’re too fragile and expensive to be practical for dental practice.

	As a solution, BlueLight Analytics has incorporated a cost-effective sensor technology driven by an advanced machine learning algorithm and a large database of spectral measurements to train this sensor to work as a virtual spectrometer. The database includes test results from a wide array of curing light makes and models as well as the recommended curing times from composite manufacturers.

	Via a smartphone app, the user gets the irradiance output of his or her light, recommendations in the case of malfunction and adjusted curing times for the specific materials used in that practice. The system, called checkUP, is currently in beta testing and should be commercially available in late spring.

Why your curing light could lead to restoration failure.