Implant Practice US Summer 2020 Vol 13 No 2

clinical articles • management advice • practice profiles • technology reviews Summer 2020 – Vol 13 No 2 • implantpracticeus.com

PROMOTING EXCELLENCE IN IMPLANTOLOGY Practice profile Susan McMahon, DMD, AACD

A conversation with...

Dr. Louie Al-Faraje explains the Novadontics comprehensive software platform

Essential guidelines for using CBCT in implant dentistry: clinical considerations Dr. Johan Hartshorne

Clinician spotlight J. Stuart Williams, DDS

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EDITORIAL ADVISORS Steve Barter, BDS, MSurgDent RCS Anthony Bendkowski, BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent Philip Bennett, BDS, LDS RCS, FICOI Stephen Byfield, BDS, MFGDP, FICD Sanjay Chopra, BDS Andrew Dawood, BDS, MSc, MRD RCS Professor Nikolaos Donos, DDS, MS, PhD Abid Faqir, BDS, MFDS RCS, MSc (MedSci) Koray Feran, BDS, MSC, LDS RCS, FDS RCS Philip Freiburger, BDS, MFGDP (UK) Jeffrey Ganeles, DMD, FACD Mark Hamburger, BDS, BChD Mark Haswell, BDS, MSc Gareth Jenkins, BDS, FDS RCS, MScD Stephen Jones, BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack, DDS, CertPerio, FCDS Samuel Lee, DDS David Little, DDS Andrew Moore, BDS, Dip Imp Dent RCS Ara Nazarian, DDS Ken Nicholson, BDS, MSc Michael R. Norton, BDS, FDS RCS(ed) Rob Oretti, BDS, MGDS RCS Christopher Orr, BDS, BSc Fazeela Khan-Osborne, BDS, LDS RCS, BSc, MSc Jay B. Reznick, DMD, MD Nigel Saynor, BDS Malcolm Schaller, BDS Ashok Sethi, BDS, DGDP, MGDS RCS, DUI Harry Shiers, BDS, MSc, MGDS, MFDS Harris Sidelsky, BDS, LDS RCS, MSc Paul Tipton, BDS, MSc, DGDP(UK) Clive Waterman, BDS, MDc, DGDP (UK) Peter Young, BDS, PhD Brian T. Young, DDS, MS CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day, BDS, VT Julian English, BA (Hons), editorial director FMC Dr. Paul Langmaid, CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul, BDS, LDS, FFGDP (UK), FICD, editor-inchief Private Dentistry Dr. Chris Potts, BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers, BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

© FMC 2020. All rights reserved.

FMC is part of the specialist publishing group Springer Science+ Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproducedvw in any form whatsoever, including photocopies and information retrieval systems.

While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Implant Practice or the publisher.

What are you going to do now?

A

lthough it has seven letters, failure is a four-letter word in implant dentistry. Implant complications are often an overlooked component of introductory implant education. It is one thing to visualize a complication on a slide during a presentation and a completely different perspective to see it in your operatory.

I experienced my first failure on my 30th implant. The statistic “implants have success rates near 98%” had been drilled into my head since dental school. I had never stopped to consider the day that I would become a member of the remaining 2%.

I sheepishly explained my findings to the patient. He did not care that this only happens a small fraction of the time. For this patient and this implant, all that mattered was one thing — Steven Vorholt, DDS “What are you going to do now, Dr. Vorholt?”

After that first failure, I poured all of my energy into learning everything I could about dental implants. Along the way, I realized that I have learned the most from the complicated cases. You cannot learn implants by reading about them in textbooks or seeing them on Instagram or Facebook. You have to do the surgeries. And when you do the surgeries, the complications inevitably follow.

Failures affect every surgeon. A great friend and mentor told me, “Show me someone who has no failures, and I will show you someone who does not place very many implants.”

There are inherent risks when we try to influence biology. Conditions that may contribute to implant failure are hot topics in research articles. Some are widely written about, such as diabetes, smoking, bisphosphonate use, and active periodontal disease. Others are coming to the forefront more each day, such as vitamin D deficiencies and the use of certain antidepressant medications.

Not all failures can be attributed to the patient’s conditions or not “respecting the bite.”

We have to be able to look at our own processes and ensure we are doing everything possible to give the patient and the dental implant the best chance at success. This is where learning from failures comes into play. The adjunct skills that implant surgeons learn as they progress in their career are often spurred on by complication patterns they see over time in their practice. It is through failure that I refined my techniques for proper treatment planning and implant case selection, incision and flap design, hard- and soft-tissue grafting, guided versus non-guided protocols, and so much more. But this was not always the case.

When I was placing less than 50 implants a year in private practice, each failure felt like a direct insult to my surgical ego. Now I am slated to remove and replace around 200 implants a year. As Implant Director for Implant Pathway, I oversee everything from treatment planning to final restorations for over 5,000 implants a year. Working on such a large volume of surgeries and the inevitable complications that follow has taught me the true value of failure: the opportunity to learn and become even more successful.

Winston Churchill defined success as “walking from failure to failure with no loss of enthusiasm.” After my first implant failure, when I experienced a setback, I called some mentors with the patient still in the chair, and they helped me develop a game plan. That particular patient has been happy with his tooth for over 5 years now, and throughout that time, I have experienced additional implant case glitches. If anything, my enthusiasm for dental implant surgery has only multiplied, and one thing is abundantly clear — I have learned more from the failures than the successes many times over.

Dr. Steven Vorholt

Steven Vorholt, DDS, is a general dentist who focuses on dental implant surgery and restoration. He is currently the Clinic Director of the New Horizon Surgical Center in Tempe, Arizona. He is also the Implant Director for Implant Pathway and is faculty for NYU Langone’s AEGD program at the New Horizon Dental Center. Dr. Vorholt is actively working toward his associate fellowship in the AAID and plans to continue toward his Diplomate in the ABOI.

ISSN number 2372-9058

Volume 13 Number 2

Implant practice 1

INTRODUCTION

Summer 2020 - Volume 13 Number 2

TABLE OF CONTENTS

Women in dentistry/ practice profile

8

Susan McMahon, DMD, AACD

Publisher’s perspective “It’s what you learn after you know it all that counts” Lisa Moler, Founder/CEO, MedMark Media................................6

Dentist, practice owner, mother — finding a balance

Clinician spotlight J. Stuart Williams, DDS

A conversation with...

12

Changing lives through compassion, empathy, and implants.....................16

Dr. Louie Al-Faraje explains the Novadontics comprehensive software platform ON THE COVER Inset cover images courtesy of Dr. Susan McMahon. Article begins on page 8.

2 Implant practice

Volume 13 Number 2

WHY YOU NEED A

PROTECTION PLAN

DENTAL PROTECTION PLAN

TABLE OF CONTENTS Continuing education Implant placement using a newly designed single drill versus conventional sequential drills Drs. Amr Zahran, Ahmed Mortada, and Basma Mostafa present a randomized clinical study on the use of a single drill for implant placements compared to sequential drills......... 27

Service profile Silent partners provide unique benefits for implant focused practices Chip Fichtner discusses how to grow a practice bigger, better, and faster.... 34

Product profile

Continuing education Essential guidelines for using CBCT in implant dentistry: clinical considerations

20

Dr. Johan Hartshorne puts the clinical protocols for appropriate application of three-dimensional imaging in implant therapy in the spotlight

Boyd Industries Dependability, Respect, and Loyalty to our dental specialist community..... 36

Practice management Going viral

On the horizon

Medical billing for bone grafts, oral implants, and CBCT

The other biggest risk to your practice

Opportunity is on the horizon

Rose Nierman offers tips on beginning your medical-billing journey with the right tools.................................... 37

Thomas Terronez discusses the security of vital practice data

Dr. Justin D. Moody reflects on quarantine and a new outlook after the COVID-19 crisis

................................................. 38

................................................. 40

www.implantpracticeus.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your inbox by registering for our eNewsletter

CONNECT with us on social media Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

4 Implant practice

Volume 13 Number 2

PUBLISHER’S PERSPECTIVE

“It’s what you learn after you know it all that counts”

W

e never presume to know everything during any time period, but during this COVID-19 crisis, our learning curves have ramped up to high gear. Over the past few months, we have learned so many things — about business, medicine, dentistry’s evolving needs, resilience, hope, and caring — to name just a valuable few. Forward-looking leadership and a loyal team are attributes that MedMark Media has always cultivated, and all of us have turned our quarantines into positive action during these trying times. We are changing as our world changes, as needs evolve, and as dentists seek answers to difficult questions. We have also sought insight from mentors whose experience can be life-changing and game-changing.

“A mentor is someone who allows you to see the hope Lisa Moler inside yourself. A mentor is someone who allows you to know Founder/Publisher, MedMark Media that no matter how dark the night, in the morning joy will come.

A mentor is someone who allows you to see the higher part of yourself when sometimes it becomes hidden to your own view.”

These words by talk show host, media executive, actress and philanthropist Oprah Winfrey are meaningful to dentists as well as entrepreneurs. After being a part of the dental world for 20 years, I have had the opportunity to see firsthand the phenomenal benefits of having and being a mentor. Traveling on the journey to building a business can be frustrating and heartbreaking if you don’t have someone to offer advice on the right paths to take and the hazards to avoid.

I recently read an article from Inc. magazine that described why mentors are integral to success. John Rampton, entrepreneur and investor, pointed out these top 10 reasons: 1. Provide information and knowledge.

6. Are open to listening to our ideas.

2. Point out where we need to improve.

7. Are trusted advisors.

3. Stimulate our growth.

8. Help with networking.

4. Offer encouragement.

9. Have experience you can learn from.

5. Help us develop self-discipline.

10. Are free, but priceless.

With publications that are read by general dentists and specialists alike, MedMark Media brings the expertise of mentors and innovators in the dental community to your houses, offices, and computers. Authors write for us because they believe in sharing their knowledge for better patient care, more efficient workflow, and more lucrative business methods. Over the years, dental mentors have helped our company grow from print magazines to digital formats, webinars, videos, and podcasts. If there is a way to reach you, we will be there!

In this issue of Implant Practice US, we bring you a CE by Dr. Johan Hartshorne discussing clinical uses for CBCT in implant therapy — this imaging method increases accuracy in diagnostics and treatment, especially for patients with previously unknown anatomical and/ or pathological entities. In their CE, Dr. Zahran, et al., explore the pros and cons of using a newly designed single drill versus conventional sequential drills. Read about our conversation with Dr. Louie Al-Faraje, who discusses the Novadontics new management software platform focused on implant practices. Rose Nierman offers helpful pointers on medical billing for bone grafts, implants, and CBCT. Awareness of insurance codes and cross-coding techniques can expand your options and help patients get the treatment they need.

Mentors will help keep your protocols and knowledge fresh and exciting. So keep searching for those who can help you to achieve greatness. Of course, we want you to read our publications and listen to our digital offerings. But also at this time, you can take advantage of online speakers who can expand your horizons, no matter where you are on your career journey.

It’s never too late to have a mentor or to become one, since learning and sharing knowledge should happen in all stages of life. As President Harry S. Truman said, “It’s what you learn after you know it all that counts.”

To all of our readers, authors, and advertisers, we wish you all health, safety, and a speedy resolution to the COVID-19 crisis.

6 Implant practice

Published by

PUBLISHER Lisa Moler lmoler@medmarkmedia.com DIRECTOR OF OPERATIONS Don Gardner don@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com MANAGER CLIENT SERVICES/SALES SUPPORT Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING & DIGITAL STRATEGY Amzi Koury amzi@medmarkmedia.com EMEDIA COORDINATOR Michelle Britzius emedia@medmarkmedia.com SOCIAL MEDIA & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com

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WOMEN IN DENTISTRY/PRACTICE PROFILE

Susan McMahon, DMD, AACD Dentist, practice owner, mother — finding a balance

D

r. Susan McMahon, a graduate of the University of Pittsburgh, School of Dental Medicine, enjoys one of the largest cosmetic dental practices in Western Pennsylvania. She is accredited by the American Academy of Cosmetic Dentistry (AACD), a Fellow in the International Academy of Dental-Facial Esthetics, a Fellow in the American Society for Laser Medicine and Surgery, and an invited Fellow of the American Society for Dental Aesthetics (ASDA). She is a past clinical instructor in Prosthodontics and Operative Dentistry at the University of Pittsburgh and is the Director of New Product Evaluation and an Elite Speaker for Catapult Education.

She frequently lectures across the United States and occasionally in Europe on cosmetic dentistry and tooth whitening and is a 7-time award winner in the American Academy of Cosmetic Dentistry’s Annual Smile Gallery — twice being awarded gold medals. She had been honored as a Top Dentist 15 times and has also been voted by her peers as a Top Pittsburgh Dentist every year for more than a decade.

Attaining accreditation in the American Academy of Cosmetic Dentistry is Dr. McMahon’s proudest professional achievement. One of only 350 dentists worldwide to have AACD accreditation, Dr. McMahon

Dr. McMahon smile designing and planning implant placement utilizing photos, CBCT images, and digital intraoral scans

completed case submission and clinical peer review in 2005.

Excellent proficiency must be demonstrated across all areas of cosmetic dentistry, including porcelain veneers, implant restoration, full reconstruction, crowns, and cosmetic bonding.

8 Implant practice

What can you tell us about your background?

I had two of my three children while in dental school. Being a dentist, mother, and practice owner have brought unique challenges and benefits. Historically, women have been pretty underrepresented on the podium and in leadership roles in dentistry.

Volume 13 Number 2

When did you become a specialist and why?

Early on in my career, I decided to focus on cosmetic procedures. I became accredited with the American Academy of Cosmetic Dentistry in 2005. The accreditation journey made me a better dentist all around and also gave me the impetus to begin teaching.

When you photograph all of your cases and really start to evaluate them with a critical eye, you continue to refine your techniques and strive for excellence.

Is your practice limited solely to implants, or do you practice other types of dentistry?

In our practice, we have several doctors, and we all work together as a team. My focus is on comprehensive restorative. Dr. Eyad Aldara places our implants. Dr. Heba Alani does most of the general dental work.

An endodontist is joining our practice this summer. When a new patient comes to us for treatment, we perform a comprehensive exam including an intraoral digital scan and a CBCT scan. We treatment plan as a team and coordinate care.

Why did you decide to focus on implant dentistry?

Providing implants is necessary for every dental practice that wants to thrive in today’s competitive environment. Patients are

WOMEN IN DENTISTRY

It is so gratifying to see this becoming more balanced recently.

educated; they want the best treatment for themselves and their families, and many are willing to spend what is necessary for that treatment beyond typical dental insurance reimbursement. Technology has made implant placement easier and more predictable.

Do your patients come through referrals?

I find direct marketing to potential patients is essential. Currently, we have a digital campaign that focuses on driving implant patients to our website. We also cultivate referrals from medical offices by building relationships with our close colleagues. We also directly ask patients for reviews and referrals when we finish treatment.

How long have you been practicing implant dentistry, and what systems do you use?

I’ve been restoring implants for over 20 years. Before we started placing them in our office, I referred to a periodontist to have the implants placed. Now, after investing in the technology, we regularly place them here. It is definitely more convenient for the patients to have everything done in one place, and I believe we are getting better outcomes with having the whole team working together on evaluating, planning, placing, and restoring.

What types of implant systems do you use most often?

I use BioHorizons®, Nobel BioCare™, Straumann®, and Zimmer Biomet.

Same day restorations milled in-office offer reduced workflow time for the dentist and convenience for the patient Our Clinical team: Dr. Eyad Aldara; Dr. Susan McMahon; Dr. Heba Alani; Darcy Snyder, RDH; Delaney McCarron, Patient Care Coordinator; and Jim George, RDA Volume 13 Number 2

Implant practice 9

WOMEN IN DENTISTRY/PRACTICE PROFILE What training have you undertaken?

In addition to the AACD, I continually train on the latest restorative techniques — most recently in Italy with StyleItaliano™ and here in the U.S. with Dr. Jack Hahn.

Dr. Aldara trained and attained fellowship at the Misch Institute. He is also a Diplomate of the International Congress of Oral Implantologists (ICOI).

Who has inspired you?

I’ve been fortunate to have a few wonderful mentors. Dr. David Hoexter has led in periodontics; Dr. Lou Graham inspires the team approach; Dr. George Freedman shares his product knowledge all over the world; and my friend, Dr. Joyce Bassett, has and continues to be a groundbreaker in cosmetic dentistry. Stephenie Goddard, Guiding Leaders, is working tirelessly to help women rise up in dentistry, and Dr. Grace Yum leads in support of women dentists and mothers.

What is the most satisfying aspect of your practice?

I love insert day. It’s that moment when we finish a case, and there are hugs all around, and sometimes happy tears too. We do a lot of trauma cases; most often young people are getting injuries from sports, auto accidents, falls, and other causes. Being able to restore them back to full function and also beautiful natural-looking smiles makes all of us feel great!

Restoratively driven fully guided implant placement with integration of digital intraoral scans and CBCT scans for the best results

offer the most cutting-edge procedures in our office.

What do you think is unique about your practice?

We have the combination of very highly skilled and credentialed providers, a culture of excellence and nurturing for our patients; collaboration is our team’s mandate.

What has been your biggest challenge?

I’m like so many of us, so my challenge is finding, training, and retaining competent, caring, professional team members.

Professionally, what are you most proud of?

What would you have been if you had not become a dentist?

I am so proud of the work we do day in and day out on our patients. I am proud that I continue to learn new techniques and

If I had not become a dentist, I think I would have become a plastic surgeon. I love helping people feel their best.

What is the future of implants and dentistry?

Very bright. Implants are now the standard of care for missing teeth. It continues to get simpler to place implants with guided technology.

What are your top tips for maintaining a successful specialty practice?

It’s all about developing your brand from initial contact to first appointment to case presentation to treatment to support care to attracting patients who need what you do.

You must send a consistent message in all you do — the appearance of your office, the demeanor of your team, the skill of your providers, the feeling you give to your patients. For us, that means every contact with the patient says, “You have come to the 10 Implant practice

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PreXion CBCT Machine Itero Digital Scanner Gemini™ diode laser, Ultradent Weave® — The most effective way to communicate with current and prospective patients.

5. Z-PRIME™ Plus, Bisco 6. SideKick, Smile Line USA — Kit contains virtually every implant driver for those cases where you get presented with an implant you don’t recognize, and you need to unscrew or tighten the restoration.

It’s a lifesaver.

7. Riva Star, SDI (silver diamine fluoride) 8. Identium® impression material, KettenbachUSA 9. Variolink® Esthetic cement, Ivoclar Vivadent 10. TI Max Nano electric handpiece, NSK

right place; these doctors are the top at what they do, and we will all take very good care of you.” We all take great pride in our work, and we want our patients to know.

What advice would you give to a budding implant dentist?

Invest in the technology. It will pay off many times over, not just in income, but also give you the confidence you need to comprehensively diagnose and treat.

What are your hobbies, and what do you do in your spare time?

I love to travel. Most all of my lectures and articles are written in airports or on airplanes. IP Volume 13 Number 2

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Tooth #15, set to be extracted

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OsteoGen® is a low density bone graft and the will OsteoGen® Plugs show radiolucent on the day of placement

As the OsteoGen® crystals are resorbed and replaced by host bone, the site will become radiopaque

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Implant is placed. Note the histology showing mature osteocytes in lamellar bone formation.

Some of the larger OsteoGen® crystals and clusters are slowly resorbing. Bioactivity is 9 demonstrated by the high bone to crystal contact, absent of any fibrous tissue encapsulation

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A CONVERSATION WITH...

Dr. Louie Al-Faraje explains the Novadontics comprehensive software platform

F

ounder and CEO of Novadontics, Dr. Louie Al-Faraje, informs Implant Practice US about “the world’s first implant practice management software.” In this interview, he explains how implant dentists can benefit from this comprehensive software platform.

Dr. Al-Faraje, can you familiarize our readers with Novadontics software and its impact on implant practices?

Dr. Al-Faraje: As a Board-Certified oral implantologist, I have experienced the challenges and understand dentists’ needs.

None of the current practice management softwares are implant-oriented. All of them are either geared toward general dentistry or toward such specialties such as endodontic, orthodontics, OMS, etc. None is designed with implant dentistry in mind. The company has been founded and structured upon 12 Implant practice

knowing the important details of everyday life and workflow in the implant dental practice: although the software can run a general dentistry office as well. As a result, I am proud to say that Novadontics has grown to become the number one cloud-based dental implant practice management software in the industry. Novadontics’ popularity stems from its many improvements to the daily office workflow, including scheduling, charting, imaging, compliance, and billing.

There are many choices for treatment in the implant space right now. What applications does this software have to help dentists and staff navigate through it all?

We have created a technology-enabled, data-driven proprietary process called Digital Treatment Optimization to ensure that clinicians have all the necessary information at

Dr. Louie Al-Faraje, Founder and CEO of Novadontics Volume 13 Number 2

How does Novadontics help dentists closely monitor their patients?

Novadontics Nova Intellechart™ brings cloud-based electronic medical records technology to each clinician, enabling accurate and faster charting. Every detail about the patient and treatment is maintained in the software, facilitating a continuity of care among providers. The information, including patient history, is easily accessible and

“Novadontics has brought implant treatment to the palm of my hand. My staff and I take full advantage of the ease and huge discounts we receive ordering Implant and general dentistry supplies through the Novadontics app. The app also makes it easy to keep my skills up-to-date with in the app CE and consult request modules.” — Dr. Dawud Muhaimin, Fairfield, CA well-defined, and practitioners can share this information in their absence seamlessly and quickly. Providers can manage their practice from wherever they want, whenever they want, and sync changes to any device for real-time information. Of particular interest is the innovative iPad application that enables users to work from any location — with a swipe of a finger, dentists are able to quickly review patient charts and notes, and refill prescriptions. The iPad version of the software is 100% like the desktop version.

This means that, while you are on the go, if you have your iPad with you, then you have practically the entire office at your fingertips.

How do you achieve that sharing of information?

Nova Shared Care feature can import and share clinical information with other

dental care providers in the Novadontics Shared Care Community worldwide. This allows comparing multiple diagnostic images from various practices in a secure, HIPAAcompliant environment.

Nova Shared Care is a feature that Novadontics offers that no one else offers. For a variety of reasons, sometimes as a clinician, you would want to partially or fully share the patient files with other clinicians.

Reasons include: • Consulting with other clinicians on the patient’s case • Patient is moving from one area to another, and there is a need to transfer the file • Medico-legal reasons

What does the software do to promote connectivity with other services that are vital to the implant business?

Novadontics delivers online treatment planning services as well as in-office surgical, prosthodontic, and lab services. Also, we are proud to offer large capital equipment and product savings, up to 60% off, from world-leading manufacturers such as Nobel Biocare, Geistlich, Zimmer, Brasseler, PIEZOSURGERY®, Omnia, Osstell, W&H, Karl Schumacher, just to name a few.

Does the application offer support to dentists’ front office as well?

Yes, the administrative team can easily track performance metrics at a glance with the Novadontics practice growth dashboard. They can access everything from number of newly scheduled appointments to total collections and outstanding balances in real time. The innovative Volume 13 Number 2

Implant practice 13

A CONVERSATION WITH...

their fingertips to ensure a stress-free process and perfect outcome. This includes a specific data collection and data analysis method that is very useful for implant patients/cases. From this, providers can make quick, informed decisions about dental treatment options to fit specific patients’ needs. Whether on the desktop or app, the smart checklist streamlines and foolproofs the implant treatment process, and the software enables clinicians to tackle complicated dental implant procedures in a predictable fashion. It simplifies the amount of data, and the way that it can be organized in the software will help tremendously in minimizing the room in error for diagnosis and treatment planning.

The software includes the proprietary, technology-enabled, data-driven method called Digital Treatment Optimization™. This process provides the necessary information, which I explained earlier, at the dentists’ fingertips to ensure a stress-free and perfect outcome.

A CONVERSATION WITH...

Operational Dashboard helps answer critical questions related to collections and production with easy-to-read and understand charts and graphs. So that dentists can track and understand their progress, the well-organized and easy-to-understand dashboard summarizes key metrics related to all aspects of practice growth.

How do employees and dentists receive their training?

Realizing that improving convenience and saving time are two very important aspects of any staff training program, staff can be trained remotely. We do training both in-person and via a very well done video library saving unnecessary travel time and

“Novadontics has been a real boon to my implant practice.

The cloud-based interaction between the web interface and iPad app makes this software very easy to use. If you are interested in an implant-oriented patient software, impressively discounted fees, fantastic convenience, and the added benefit of support through ongoing CE and expert consulting services, then I would highly recommend joining the Novadontics family. Your patients will be the ultimate beneficiaries of this software. — Barry Hillam, DDS, MAGD, Provo, UT

money associated with getting the staff to a particular place and at a particular time. Also, we do not take away the attention of staff members for many hours or days at a time.

Training is delivered in “bite-sized” chunks.

We find that this keeps their attention effectively and helps the staff to assimilate the information more quickly. But that all said, Novadontics does offer in-office training.

How does the program assist practitioners in staying current in the latest implant techniques and innovations?

Novadontics offers online continuing education (CE) to its members to continue to grow their knowledge and skillset. With access from anytime, anywhere, the company’s CE platform provides access to more than 200 on-demand courses and lectures and 100-plus clinical videos for both general and implant practitioners. Besides helping these dentists to meet state licensure requirements, it also enhances their ability for treatment options. The platform also provides handouts, videos, and other multimedia materials for patient education. More than 1,000 dentists are using this comprehensive resource. Novadontics Platform is very unique because it offers: 1. Implant-oriented practice management solution 2. Tremendous savings 3. Comprehensive continuing education library 4. Online and in-office expert support 5. Mobility with its iPad version

Can you give us an idea of what each subscription includes?

Of course, each subscription includes: • 24/7/365 customer care • Regular updates that require nothing for the user to install • Analytics and reporting • Professionally managed data backups at a Tier 1 Amazon Web Services (AWS) data center • Best-in-class cybersecurity protection, including annual third-party intrusion analysis • Unlimited eClaims, eRemittances, and eligibility verification For more information, please visit www. novadontics.com. IP

14 Implant practice

Volume 13 Number 2

Improve Your Patient Care and Your Practice Profitability with Novadontics Novadontics is a totally new cloud-based practice management solution built from the ground up. A versatile, all-in-one product, Novadontics can be used on a PC, Mac, or iPad tablet. One monthly payment includes software, and all built-in modules.

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Intuitive user interface (TRUQJYJ UFUJWQJXX TK‫ܪ‬HJ

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No software or upgrade installations needed

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Unlimited users

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Cutting-edge knowledge in Novadontics implant module

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Access to full-line catalog with over 40,000 products for tremendous savings

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Continuing education library with over 200 courses and lectures

Find out how to take your practice to the cloud www.novadontics.com or call 888.838.NOVA

CLINICIAN SPOTLIGHT

J. Stuart Williams, DDS Changing lives through compassion, empathy, and implants

F

or children of doctors, so goes the story of following in your parents’ medical footsteps. Dr. J. Stuart Williams is no exception.

His father was the only cardiologist in the town of Laurel, Mississippi. As the youngest of five children, with none before him having traveled the medical road, Dr. Williams grew up thinking that was his course. Not that there was pressure to do so. In fact, he felt it was quite an honor.

As a child, Dr. Williams would accompany his father on Saturday mornings as he made his rounds at their town hospital. He’d visit his patients, many of whom were dying of congestive heart failure. The young Dr. Williams looked and listened and, more than anything, learned about true meaningful care.

“My dad would sit on the edge of their hospital bed, and he’d hold their hands because he knew they were terminal,” Dr. Williams remembers. “I’d see him hug the families; he was just the sweetest, kindest, most gentle doctor, and patients adored him.”

Other than witnessing compassion and care, Dr. Williams also noted his father’s sporadic and lengthy schedule — one that involved being “gone a lot, getting up in the middle of the night, missing church, and missing school plays.” He prepared himself for a life that revolved around a doctor’s schedule.

Dr. J. Stuart Williams is thrilled to be part of the new Monroe, North Carolina, ADI-affiliated practice

Dr. Williams attended William Carey University, graduating with a degree in biology.

Adhering to the plan, he began studying for the MCATs and applied to medical school, but his heart wasn’t in it. Upon a recommendation from his orthodontist, he instead turned his attention to dentistry and a path that, though requiring much hard work, allowed for life beyond the practice walls.

Dr. Williams thoughtfully greets each new patient by asking not, “Why are you here?” but instead, “What’s on your mind?”

16 Implant practice

Dr. Williams received his DDS from the University of Tennessee at Memphis and began his career in general dentistry.

“For the first little bit out of dental school when someone said ‘Dr. Williams,’ I’d turn around and look for my Dad,” Dr. Williams remembers, “That was him. That wasn’t me.”

Now he too could hold this prefix and “had big shoes to fill” as he embraced the values that his dad upheld with each and every patient he treated.

During Dr. Williams’ first 2 years in general dentistry, the bulk of his time was spent with denture and immediate denture patients; from this experience, he became extremely proficient in this aspect of dentistry.

Over the next 17 years, Dr. Williams opened two private practices — the first in the Charlotte, North Carolina area and the second in Asheville, North Carolina. Dr. Williams and his family returned to Charlotte in 2018; he had no plans to open another practice of his own.

At this point in his career, there were two things he knew: First, he didn’t want the responsibility and headaches that accompany the management of a private practice.

Second, he sought to treat a specific patient sector — those requiring not a repair but a transformation.

Volume 13 Number 2

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CLINICIAN SPOTLIGHT Those early mornings and late night hospital visits by his father’s side secured a deep sense of empathy and compassion in Dr. Williams, attributes that prove quite helpful when treating patients who are both vulnerable and in pain. Those were the patients Dr. Williams wanted to treat — those who allowed him to lean in to his strengths and make an impact.

After almost 2 decades in general dentistry, Dr. Williams, who had become highly versed in the surgical aspects of dentistry, joined Affordable Dentures & Implants (ADI) in August 2018. He was hired as an Associate Dentist, responsible for the surgical needs at the bustling Charlotte, North Carolina-affiliated practice.

“Here, I’m able to really interact with patients,” Dr. Williams recalls. “I wanted to go with a brand that is solid. You can’t miss that ADI is the brand that’s been out there for years.”

He was more than content as an Associate Dentist in Charlotte, yet realized through his experience there that the ADI model allowed for everything he was seeking. In the spring of 2019, opportunity knocked. ADI was seeking a practice owner for a new location in Monroe, North Carolina. Though Dr. Williams hadn’t planned on returning to this role, he says, “When the opportunity came up, I was like ‘YES!’” The ADI model is what sold him. First, he is able to practice his specialty, as ADI dentists focus strictly on dental extractions, implants, and dentures. Second, dentistry is all there is to it. The ADI Support Center handles all of Dr. Williams’s business operations from patient scheduling to marketing to payroll and beyond.

“I feel like I’m able to just truly focus on dentistry, and I have to because [patients] are counting on me to do it right,” Dr. Williams

Front Desk Assistant, Tina McKibben notes that Dr. Williams has a way with patients. “It’s his personality. His bedside manner...

I feel totally blessed to work with him”

says. That nonexistent list of business to-dos leaves more time and space to properly plan, to hone his skills, and to interact with his patients.

Dr. Williams opened the doors to his new ADI-affiliated practice in October 2019 and exhibits a bedside manner much like his father’s. Patients in dire need of extractions, dentures, and implants come to him brimming with embarrassment and pain. In return, he showers them with innate tenderness.

“I feel people’s pain. And that can be physical pain, but also an emotional pain. I just try to look them in the eye and say we’re not here to judge; we’re here to improve your life,” Dr. Williams says.

Though he is gentle, he is equally honest.

“I tell my patients, ‘You’re going to get frustrated. You’re going to struggle. You’re going to have to learn to eat again, to talk

“More than anything we are providing a very good service and treating the patients the way that they should be,” Dr. Williams says 18 Implant practice

again; but we’re going to be here with you.

We’re going to walk you through this journey, and we’re going to be here to lift you up when you need somebody to lift you up.’ ” The relationships Dr. Williams cultivates with his patients mirror what he has built with his practice staff. There is respect and consideration, whether intentional or innate.

Being called “Doctor” by them stirs him for another reason; it makes him feel elevated, something he finds unwarranted as he believes that “everybody is valuable. Everybody is an integral part of the team,” and the team is what makes the practice what it is.

“I don’t like when you have tiers or hierarchies. Sure, I’m the dentist, but I couldn’t do what I do without the help of everybody here.

I’m just another human here. I just happen to be the leader,” Dr. Williams says.

He supports a practice atmosphere that is comfortable, collaborative, and enjoyable.

And he says that the patients see it. “They see the fun, the warmth, and family-like atmosphere that we have,” Dr. Williams says.

After being open for business only 5 months, Dr. Williams and his practice have taken off. They are swamped, preparing to regularly take on 15 morning consultations, while afternoons of surgeries and deliveries promise transformation after transformation.

“This job has shown me that we can literally change people’s lives,” Dr. Williams continues, “I love what I do, and I owe it all to those along the way who inspired me. Most importantly, my Dad.” IP This information was provided by Affordable Dentures & Implants (ADI).

Volume 13 Number 2

AUTHOR GUIDELINES Implant Practice US is a peer-reviewed, quarterly publication containing articles by leading authors from around the world.

Implant Practice US is designed to be read by specialists in Periodontics, Oral Surgery, and Prosthodontics.

Submitting articles Implant Practice US requires original, unpublished article submissions on implant topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education.

Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Implant Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available.

Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses.

Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 13 Number 2

Pictures/images

Disclosure of financial interest

Illustrations should be clearly identified, numbered in sequential order, and accompanied by a caption. Digital images must be high resolution, 300 dpi minimum, and at least 90 mm wide. We can accept digital images in all image formats (preferring .tif or jpeg).

Authors must disclose any financial interest they (or family members) have in products mentioned in their articles. They must also disclose any developmental or research relationships with companies that manufacture products by signing a “Conflict of Interest Declaration” form after their article is accepted.

Any commercial or financial interest will be acknowledged in the article.

Tables Ensure that each table is cited in the text.

Number tables consecutively, and provide a brief title and caption (if appropriate) for each.

References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques.

Aesthetic & Implant Dentistry. 2000;1(1):92-96.

(Online) Author(s). Article title. Journal Name. Year; vol(issue#):inclusive pages. URL. Accessed [date].

Manuscript Review All clinical and continuing education manuscripts are peer reviewed and accepted, accepted with modification, or rejected at the discretion of the editorial review board. Authors are responsible for meeting review board requirements for final approval and publication of manuscripts.

Proofing Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity.

Articles should be submitted to: Mali Schantz-Feld, managing editor mali@medmarkmedia.com

Reprints/Extra issues If reprints or additional issues are desired, they must be ordered from the publisher when the page proofs are reviewed by the authors.

The publisher does not stock reprints; however, back issues can be purchased.

Or in the case of a Book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide.

London: Martin Dunitz; 2001.

Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011.

Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

Permissions Written permission must be obtained by the author for material that has been published in copyrighted material; this includes tables, figures, pictures, and quoted text that exceeds 150 words. Signed release forms are required for photographs of identifiable persons.

Checklist for article submissions: 3 A copy of the manuscript and figures, captions, including all pictures (low res) necessary for reviewers 3 Manuscript: double-spaced including separate references, figure legends, and tables 3 Abstract, educational objectives, expected outcomes paragraph 3 References: double-spaced, alphabetical, American Medical Association style 3 Tables: titled and cited in the text 3 Mandatory submission form, signed by all authors Please contact managing editor Mali SchantzFeld with any questions via email: Mali@medmarkmedia.com

Implant practice 19

CONTINUING EDUCATION

Essential guidelines for using CBCT in implant dentistry: clinical considerations, part 2 Dr. Johan Hartshorne puts the clinical protocols for appropriate application of three-dimensional imaging in implant therapy in the spotlight

T

his article is the second in a series that aims to provide clinicians with an overview of the scientific literature relating to the use of cone beam computed tomography (CBCT). It will suggest clinical guidelines for selecting an appropriate radiographic imaging modality, indications for using CBCT, and how to read and analyze CBCT data volume. The article will also address the clinical application and use of CBCT, and the advantages and limitations of CBCT in implant dentistry.

The knowledge gained and guidelines provided by this article aim to enhance clinicians’ understanding of when to use a CBCT, and how to systematically analyze and read the data volume to maximize the diagnostic and treatment planning benefits of this technology, while optimizing patient safety and minimizing radiation-related patient risk. Radiographic images used were obtained from a Carestream Kodak CS 9300 CBCT unit.

Introduction The role of 3D CBCT imaging as a new diagnostic tool in modern-day dentistry cannot be overemphasized.

It is increasingly being referred to as the “standard of care” for diagnostic maxillofacial imaging (Tipton and Metz, 2008; Curley and Hatcher, 2009; Zinman, et al., 2010).

It serves as an essential diagnostic tool for clinical assessment and treatment planning, and has revolutionized every aspect of how dental implant practices are performed (Sato, et al., 2004; Kobayashi, et al., 2004; Hatcher, et al., 2003).

Traditionally, preoperative information for dental implant diagnostics and treatment planning has been obtained from clinical examination, dental study model analysis, and 2D imaging such as intraoral periapical, Johan Hartshorne, BSc, BChD, MChD, MPA, PhD(Stell), FFPH. RCP(UK), is a general dental practitioner at Intercare Medical and Dental Centre, Tyger Valley, South Africa.

20 Implant practice

Educational aims and objectives

This clinical article aims to suggest some clinical protocols for effective use of CBCT imaging within implant dentistry treatment.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 26 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Recognize when it is appropriate to apply three-dimensional imaging along with a suggested protocol for analyzing CBCT data volumes.

•

Identify some procedures for which 3D-imaging serves as an essential diagnostic tool.

•

Identify some guidelines to identify the appropriate imaging modality to meet diagnostic and treatment goals.

•

Realize some recommendations from the AAE and AAOMR for diagnosis and treatment of the endodontic and implant patient.

•

Identify preoperative and postoperative reasons for using 3D imaging.

•

Recognize indications for CBCT in implant dentistry and protocols for reviewing CBCT data.

lateral cephalometric, and panoramic radiography. These radiographic procedures, used individually or in combination, suffer from the same inherent limitations common to all planar 2D projections — namely, magnification, distortion, and angulation discrepancies, superimposition, and misrepresentation of structures (Scarfe and Farman, 2008).

When an implant is to be placed in proximity to a vital structure — e.g., a nerve, artery, or sinus cavity — or where there are bone morphology discrepancies, radiographic information from traditional 2D radiographic imaging is limited. This is due to its inadequacy to properly assess the distance in proximity to vital neurovascular or anatomical structures, or when implant placement is potentially violating critical cortical bone margins.

The resulting errors from a reliance on traditional imaging led to potential complications, soft tissue insufficiency, implant failure, and paresthesia (Paquette, et al., 2006; Bagheri and Meyer, 2011). Complications may lead to an unsatisfactory patient outcome, referral to other specialists, and subsequent medicolegal claims (Curley and Hatcher, 2009; Grey, et al., 2013).

The introduction and widespread use of CBCT imaging over the past decade

Figure 1: Orthogonal planes (10x10 FOV) — axial or horizontal plane (top to bottom cross sections) (upper left), 3D rendering (upper right); coronal or frontal plane (front to back cross sections) (lower left); and sagittal plane (right to left or buccal to lingual cross sections) (lower right)

has enabled clinicians to diagnose and evaluate the jaws in three dimensions, thus replacing CT as the standard of care in implant dentistry (Bornstein, et al., 2014).

Furthermore, CBCT imaging has revolutionized dento-maxillofacial radiology by overcoming the major limitations of conventional 2D intraoral, cephalometric, and panoramic radiography (Mallya and Tetradis, 2015), thereby facilitating accurate preoperative treatment planning that is key to successful dental implant rehabilitation.

Published studies have reported improved clinical efficacy and diagnostic accuracy of Volume 13 Number 2

CBCT (Jacobs and Quirynen, 2014; Deeb, et al., 2017), compared with standard radiographic techniques for the evaluation of implant sites with challenging unknown anatomical boundaries and/or pathological entities and for ideal positioning of dental implants (Angelopoulos, 2014; Bornstein, et al., 2014). The value of CBCT imaging as a diagnostic tool has also been reported for various other fields of dentistry, such as oral maxillofacial surgery, dental traumatology, endodontics, temporomandibular joint, periodontology, orthodontics, airway analysis, and fabrication of implant surgical guides (Scarfe and Farman, 2008; Alamri, et al., 2012).

As with any new technology introduced to a profession, the education lags far behind the technological advance. This is especially true of cone beam imaging.

Dentists are quick to grasp the advantages and applications of using cone beam technology, but once adopted, often make the following statements: “These images are great, but what am I looking at,” and “Where can I get more information on interpreting the scan?” (Miles and Danforth, 2014).

An important basic requirement of using CBCT imaging as a diagnostic tool is that practitioners should have appropriate training to develop critical skills for operating CBCT equipment, managing imaging software, and acquiring a high level of competence and confidence in using and interpreting CBCT images.

Such training should include a thorough review of normal maxillofacial anatomy, common anatomic variants, and imaging signs of diseases and abnormalities. This is particularly important for CT and CBCT imaging because of the complexity of structures within the expanded field of view (FOV) (Carter, et al., 2008).

Guidelines for appropriate imaging The goal of radiographic selection criteria is to identify appropriate imaging modalities Volume 13 Number 2

Figure 3: Orientation of patient’s data volume on “curved slicing” (5x5 FOV) — axial plane (upper left), sagittal plane (upper right), 3D rendering (lower left), and coronal plane (lower right)

that complement diagnostic and treatment goals prior to and at each stage of dental implant therapy. The following consensusderived clinical guidelines and recommendations allow practitioners to select the appropriate imaging modality (with particular relevance to CBCT) at each phase of dental implant therapy (Tyndall, et al., 2012).

In 2011, the American Association of Endodontists (AAE) and the American Association of Oral and Maxillofacial Radiology (AAOMR) also jointly developed a position statement to guide clinicians on the use of CBCT in endodontics and support decisionmaking when to treat or extract. Additional guidelines have also been published by the European Society of Endodontology (Patel, et al., 2014).

Initial examination The purpose of the initial radiographic examination is to assess the overall status of the remaining dentition, identify and characterize the location and nature of the edentulous regions, and detect regional and site-specific anatomic structures and pathologies. Initial diagnostic imaging examination is best achieved with panoramic radiography and may be supplemented with periapical radiography (AAE, 2011). The use of CBCT is not recommended as an initial diagnostic imaging examination. However, CBCT may be an appropriate primary imaging modality in specific circumstances — for example, when multiple treatment needs are anticipated or when jawbone or sinus pathology is suspected (Bornstein, et al., 2014).

Endodontic assessment Radiographic imaging is an indispensable component of endodontic diagnosis

and treatment planning, such as the decision to do endodontic treatment or to extract, partial extraction therapies, and consideration of dental implant therapy. The AAE and AAOMR recommend that intraoral and panoramic radiography be used for the initial evaluation of the endodontic and dental implant patient.

Both of these position statements emphasize that CBCT imaging should be used only when the diagnostic information is inadequate by conventional intraoral (periapical X-rays) or extraoral (panoramic) radiography, and when the additional information from CBCT is likely to aid diagnosis and decision-making for endodontic treatment or extractions and planning for immediate or future dental implant therapy.

A CBCT with limited FOV is the preferred imaging protocol for most endodontic applications (Mallya, 2015).

CBCT imaging should thus be prescribed for patients who present with nonspecific or poorly localized clinical signs and symptoms of periapical pathology, but in whom conventional radiography fails to identify such pathology. CBCT is particularly useful in investigating the potential cause for endodontic treatment failures. However, the clinician must recognize the diagnostic accuracy is influenced by the presence of beam hardening artifacts from metal posts or gutta percha.

Preoperative site-specific imaging Preoperative site-specific imaging must provide information supportive of dental implant diagnostics and treatment planning goals.

Such information includes: • Quantitative bone volume availability (height and width) Implant practice 21

CONTINUING EDUCATION

Figure 2: Opening the patient’s data volume defaults on orthogonal slicing (5x5 FOV)

CONTINUING EDUCATION • Edentulous saddle length • Orientation of the residual alveolar ridge • Anatomical and pathological conditions that can restrict implant placement • To facilitate prosthetic treatment planning CBCT is recommended as the imaging modality of choice for preoperative diagnostics and treatment planning of potential dental implant sites (Tyndall, et al., 2012). CBCT imaging is also indicated if bone reconstruction and augmentation procedures (such as ridge preservation or bone grafting) are required to treat bone volume deficiencies before or with implant placement. The use of CBCT before bone grafting helps define both the donor and recipient sites, allows for improved planning for surgical procedures, and reduces patient morbidities.

Panoramic views of the posterior maxilla will underestimate the amount of bone available for implant placement and, if relied on, overestimate the number of clinical situations requiring a sinus augmentation. CBCT can overcome this problem as it provides more accurate measurements of the available bone volume and, in a proportion of borderline cases, will show that implants can be placed without recourse to sinus surgery (Fortin, et al., 2013; Temmerman, et al., 2011). Because cross-sectional imaging offers improved diagnostic efficacy, it is the preferred method for preoperative assessment for sinus augmentation surgery.

Postoperative imaging The purpose of postoperative imaging after dental implant placement is to confirm the location of the fixture and crestal bone levels at implant insertion. Intraoral periapical radiography is recommended for this purpose and is commonly referred to as the baseline image. Intraoral periapical radiography is also recommended for periodic postoperative assessment of the boneimplant interface and marginal peri-implant bone height implants (Tyndall, et al., 2012).

Panoramic radiographs may be indicated for screening of more extensive implant therapy cases. Titanium implant fixtures inherently produce artifacts, such as beamhardening and streak artifacts with CBCT, obscuring subtle changes in marginal and peri-implant bone. In addition, the resolution of CBCT images for the detection of these findings is inferior to intraoral radiography.

CBCT imaging, however, is indicated if the patient presents with implant mobility or 22 Implant practice

Figure 4: Activate “manually create arch” on the tools (5x5 FOV)

Figure 5: Setting the arch on the axial plane by clicking on center of the roots to draw an arch (red dots and line)

altered sensation —especially if the fixture is in the posterior mandible (Tyndall, et al., 2012; Mallya, 2015) — to facilitate assessment, to characterize the existing defect, and to plan for surgical removal and corrective procedures.

Indications for CBCT in implant dentistry Harris, et al. (2012), provide the following guidelines for clinical situations in which patients might potentially benefit from CBCT imaging for diagnosis and treatment planning.

• When the clinical examination and conventional radiography have failed to adequately demonstrate relevant anatomical boundaries and the absence of pathology • When reference to such images can provide additional information, which can help minimize the risk of damage to important anatomical structures and which is not obtainable when using conventional radiographic techniques • In clinical borderline situations in which there appears to be limited bone height and/or bone width available for successful implant treatment • Where implant positioning can be improved so that biomechanical, functional, and esthetic treatment results are optimized.

The diagnostic information can be enhanced by use of radiographic templates, computer-assisted planning, and surgical guides.

Figure 6: Scouting the data volume and reviewing the area of interest

Reviewing CBCT data volume All CBCT volumes, regardless of clinical application, should be evaluated in a structured fashion for signs of abnormalities and to ensure that no available diagnostic and treatment planning information is missed.

Dental practitioners must not be caught in the trap of looking only at the data they are interested in such as an impacted tooth or implant site evaluation, or characterization of some pathologic entity that they found in another radiograph. Practitioners must examine all the data in the scan and must do so in a systematic and somewhat structured fashion (Miles and Danforth, 2014).

Reviewing CBCT scans can be performed by an adequately trained dentist or specialist treating the patient or, alternatively, a specialist maxillofacial radiologist (Tyndall, et al., 2012).

Critical skills that dentists need for reviewing CBCT scans follow: • Knowing what they are looking at Volume 13 Number 2

• Mastering the CBCT imaging software and speaking the CBCT language • Knowing how to manipulate and work through the data volume • Reading the CBCT • Analyzing and interpreting the data • Understanding the different anatomical structures that can cause problems in implant placement surgery • Applying the imaging software to do virtual implant treatment planning A wide range of video tutorials are available on YouTube and the Internet on how to use CBCT 3D-imaging software.

To meet these CBCT reviewing objectives, clinicians need to acquire the necessary skills. Images should have appropriate diagnostic quality and not contain artifacts that could compromise anatomic structure assessments. Images should also extend beyond the immediate area of interest to include areas that could be affected by implant placement or vice versa.

The CBCT scan (data volume) provides cross sections through various planes, allowing 3D evaluation of hard and soft tissues. There are three orthogonal planes (Figure 1): • Axial or horizontal plane provides cross sections of the data volume from top to bottom of the FOV • Coronal or frontal or side view provides cross sectional views from front to back of the FOV • Sagittal view provides cross sections from buccal to lingual, or left to right of the FOV. Besides the three planes, there is also a 3D rendering (Figure 1, upper right).

A structured or systematic approach for reading a CBCT scan is recommended because there is a huge amount of anatomy Volume 13 Number 2

CBCT is recommended as the imaging modality of choice for preoperative diagnostics and treatment planning of potential dental implant sites.

contained within the scanned volume, and unless a structured approach is used, it is likely you will miss some information that could impact your diagnosis and treatment planning.

CBCT data volume: review protocol Each section of the data volume (FOV) must be reviewed and analyzed for possible clinically significant findings. This requires discipline, and it may take some time and practice to establish a pattern so as to make it almost second nature to follow this process.

In reviewing each of the anatomical structures in the FOV, special attention is paid to the “main complaint,” or the reason for the scan acquisition. The purpose of a structured reviewing process is to prevent overlooking significant diagnostic findings that may have an impact on the success or predictability of outcome of implant treatment and any other abnormalities that may lead to medicolegal actions.

The following reviewing protocol is based on the Carestream Kodak CS 9300 3D unit.

Clinical history Start by reviewing the clinical history.

What is the purpose of the data acquisition?

Which teeth have been removed (and when?) that explain areas of bone loss with healing and/or residual alveolar bone defects?

Establish whether previous bone grafts or socket augmentations were done previously.

Orientation Open the patient’s data volume. The default scan is usually on “orthogonal slicing” (Figure 2). Select “curved slicing” on the upper menu bar (Figure 3). Identify the three cross-sectional planes: Axial is upper left, sagittal is upper right, 3D rendering is lower left, and coronal is lower right (Figure 3).

Identify where left and right, and buccal and lingual are as well as the horizontal (yellow) and vertical (blue and red) lines, and cursor buttons used for scouting and orientation vertically and horizontally along the planes.

Scout the axial (top to bottom) (yellow cursor line), coronal (front to back) (red cursor line), and sagittal (right to left) (blue cursor line) planes by moving the horizontal and vertical lines to orient yourself where you are and what you are looking at.

Set arch on the axial plane Select the “manually create arch” icon on the tool menu on the left side of the image (Figure 4). A text box will pop up with prompt: “Delete previous arch.” Select OK. Move the blue cursor button on the horizontal bar below the axial cross section to get a good crosssectional view of the roots on the arch (Figure 4). Click and draw an arch through the center of the root from left to right side (Figure 5).

Implant practice 23

CONTINUING EDUCATION

Figures 7 and 8: 7. Activating “nerve canal tool” icon to plot the inferior alveolar nerve and “measurement mode” icon for measuring the implant osteotomy site. Typical implant treatment planning measurements —saddle length (mesio-distal) (upper right); residual alveolar bone width (bucco-lingual); and vertical length (occlusal-apical) (lower right). 8. Activate the “implant placement tool” icon to select the type of implant, implant diameter, and length

CONTINUING EDUCATION

Figure 9: Virtual implant placement in the correct 3D position

Scouting the coronal cross section Go to the sagittal plane (upper right cross section) (Figure 6). Move the vertical cursor (blue) from left to right on the FOV to review the coronal cross section (lower right) to identify clinically significant pathosis and neurovascular structures (Figure 6). Return again to the center of the area of interest with the vertical line in the sagittal crosssectional plane.

Scouting the sagittal cross section Go to the coronal cross section (lower right) (Figure 6). Move the red cursor of the vertical line from buccal to lingual (left to right) to review the upper sagittal cross section to identify any clinically significant pathosis and neurovascular structures. Return again to the center of the area of interest with the red vertical line in the coronal cross-sectional plane (Figure 6). At this stage, the “nerve canal tool” icon can be activated to plot the inferior alveolar nerve (Figure 7).

Review area of interest (implant site) Lastly, scout and assess the region of interest (implant site) and adjacent teeth.

Note any morphological abnormalities, neurovascular structures, anatomical structures (sinus, nasal), and residual alveolar ridge morphology or other clinically significant findings that may have an impact on implant treatment planning.

Move the horizontal line of the sagittal cross section (upper right) to 1 mm below the crestal level (Figure 6).

Implant treatment planning Software tools can be applied to facilitate implant treatment planning. Activate the “measurement mode” icon in the “tools menu” 24 Implant practice

Figure 10: Using a radiographic stent for virtual implant placement

(Figure 7). Go to the axial cross section (upper left), and click buccal and then palatal to measure the bucco-palatal width. Move to the sagittal cross section (upper right), and click mesial to distal of the implant site to measure the saddle length of the residual alveolar ridge (Figure 7). Select the coronal cross section (lower right), and measure the width and length of the residual alveolar bone (Figure 7). If the implant site is in the lower posterior mandible, then measure from the crestal level to 2 mm above the inferior alveolar nerve. The correct implant diameter and length can now be selected for this implant site.

Virtual implant selection and placement Position the vertical line in the correct position of the osteotomy site in the coronal cross section (lower right). Activate the “implant placement tool” icon in the “tool menu” (Figure 8). Select the desired implant type, diameter, and length according to the abovementioned measurements. Adjust fine tuning of the implant in its correct 3D position by checking all three planes (axial, sagittal, and coronal (Figure 9).

A stent can also be used to position the vertical line in the correct position where the implant must be placed (Figure 10).

Check placement of the implant in all three planes to assess that the cortical plate, anatomical structures — such as the sinus and nasal cavity, neurovascular structures, and neighboring teeth — are not violated, and that the implant is placed in the correct 3D position in the residual alveolar bone for optimal implant stability and a successful prosthetic restoration.

Go to the menu bar above the sagittal cross section (upper right), select “set

Figure 11: Using the magnification tool to assess views in close-up to check that the implant is placed in the correct 3D position

integration,” and select 15 mm on the scroll-down menu to activate ray sum for the sagittal cross section to simulate a typical panoramic X-ray. The magnification tool can be used to better assess the area of interest (Figure 11). The virtual implant planning and placement can now be communicated visually and discussed with the patient.

Conclusion CBCT imaging technology computer software has significantly increased the accuracy and efficiency of diagnostic and treatment capabilities, thereby offering an unparalleled diagnostic approach when dealing with previously challenging unknown anatomical and/or pathological entities in implant dentistry.

This article proposes a protocol for performing a structured review and reading CBCT data volume to ensure that pathology or critical anatomical structures are not missed that may impact on or enhance Volume 13 Number 2

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17. Danesh-Sani SA, Movahed A, ElChaar E, Chan KC, Amintavaloti N. Radiographic evaluation of maxillary sinus lateral wall and posterior superior alveolar artery anatomy: a conebeam computed tomographic study. Clin Implant Dent Relat Res. 2017;19(1):151-160.

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Volume 13 Number 2

20. Farman AG. Self-referral—an ethical concern with respect to multidimensional imaging in dentistry? J Appl Oral Sci. 2009;17(5).

21. Fortin T, Camby E, Alik M, Isidori M, Bouchet H. Panoramic images versus three-dimensional planning software for oral implant planning in atrophied posterior maxillary: a clinical radiological study. Clin Implant Dent Relat Res. 2013;15(2):198-204.

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24. Greenstein G, Carpentieri JR, Cavallaro J. Dental ConeBeam Scans: Important Anatomic Views for the Contemporary Implant Surgeon. Compendium Cont Educ Dent.

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25. Greenstein G, Tarnow D. The mental foramen and nerve: clinical and anatomical factors related to dental implant placement: a literature review. J Periodontol.

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26. Greenstein G, Cavallaro J, Romanos G, Tarnow D. Clinical recommendations for avoiding and managing surgical complications associated with implant dentistry: a review.

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27. Grey EB, Harcourt D, O’Sullivan D, Buchanan H, Kilpatrick NM. A qualitative study of patients’ motivations and expectations for dental implants. Br Dent J. 2013;214(1): E1.

28. Gupta A, Rathee S, Agarwal J, Pachar RB. Measurement of Crestal Cortical Bone Thickness at Implant Site: A Cone Beam Computed Tomography Study. J Contemp Dent Pract.

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30. Harris D, Horner K, Gröndahl K, et al. E.A.O. guidelines for the use of diagnostic imaging in implant dentistry 2011. A consensus workshop organized by the European Association for Osseointegration at the Medical University of Warsaw. Clin Oral Implants Res. 2012;23(11):1243-1253.

31. Jacobs R, Quirynen M. Dental cone beam computed tomography: justification for use in planning oral implant placement. Periodontol 2000. 2014;66(1):203-213.

32. Janner SF, Caversaccio MD, Dubach P, et al. Characteristics and dimensions of the Schneiderian membrane: a radiographic analysis using cone beam computed tomography in patients referred for dental implant surgery in the posterior maxilla. Clin Oral Implants Res. 2011;22(12):1446-1453.

33. Juodzbalys G, Wang HL, Sabalys G, Sidlauskas A, GalindoMoreno P. Inferior alveolar nerve injury associated with implant surgery. Clin Oral Implants Res. 2013;24(2):183-190.

MO: Mosby Elsevier; 2008.

44. Mraiwa N, Jacobs R, Van Cleynenbreugel J, et al. The nasopalatine canal revisited using 2D and 3D CT imaging.

Dentomaxillofac Radiol. 2004;33(6):396-402.

45. Oliveira ML, Tosoni GM, Lindsey DH, et al. Influence of anatomical location on CT numbers in cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol.

2013;115(4):558-564.

46. Oliveira ML, Tosoni GM, Lindsey DH, et al. Assessment of CT numbers in limited and medium field-of-view scans taken using Accuitomo 170 and Veraviewepocs 3De conebeam computed tomography scanners. Imaging Sci Dent.

2014;44(4):279-285.

47. Paquette DW, Brodala N, Williams RC. Risk factors for endosseous dental implant failure. Dent Clin North Amer.

2006;50(3):361-374.

48. Park YB, Jeon HS, Shim JS, Lee KW, Moon HS. Analysis of the anatomy of the maxillary sinus septum using 3-dimensional computed tomography. J Oral Maxillofac Surg. 2011; 69(4):1070-1078.

49. Parks ET. Cone beam computed tomography for the nasal cavity and paranasal sinuses. Dent Clin North Amer.

2014;58(3):627-651.

50. Parsa A, Ibrahim N, Hassan B, et al. Influence of cone beam CT scanning parameters on grey value measurements at an implant site. Dentomaxillofac Radiol. 2013;42(3).

51. Patel S, Durack C, Abella F, et al.; European Society of Endodontology position statement: the use of CBCT in endodontics. Int Endod J. 2014;47(6):502-504.

52. Pauwels R, Nackaerts O, Bellaiche N, et al; SEDENTEXCT Project Consortium. Variability of dental cone beam CT grey values for density estimations. Br J Radiol. 2013;86(1021).

53. Pauwels R, Jacobs R, Singer SR, Mupparapu M. CBCTbased bone quality assessment: are Hounsfield U units applicable? Dentomaxillofac Radiol. 2015;44(1).

54. Ribeiro-Rotta RF, Lindh C, Pereira AC, Rohlin M. Ambiguity in bone tissue characteristics as presented in studies on dental implant planning and placement: a systematic review.

Clin Oral Implants Res. 2011;22(8):789-801.

55. Romanos GE, Greenstein G. The incisive canal. Considerations during implant placement: case report and literature review. Int J Oral Maxillofac Implants. 2009;24(4):740-745.

56. Sakhdari S, Panjnoush M, Eyvazlou A, Niktash A. Determination of the Prevalence, Height, and Location of the Maxillary Sinus Septa Using Cone Beam Computed Tomography.

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57. Sato S, Arai Y, Shinoda K, Ito K. Clinical application of a new cone-beam computerized tomography system to assess multiple two-dimensional images for the preoperative treatment planning of maxillary implants: case reports. Quintessence Int. 2004;35(7):525-528.

58. Scarfe WC, Farman AG. What is cone-beam CT and how does it work? Dent Clin North Amer. 2008;52(4):707-730.

34. Kalpidis CD, Setayesh RM. Hemorrhaging associated with endosseous implant placement in the anterior mandible: a review of the literature. J Periodontol. 2004;75(5):631-645.

59. Scherer MD. Presurgical implant-site assessment and restoratively driven digital planning. Dent Clin North Amer.

2014;58(3):561-595.

35. Klokkevold PR. Cone beam computed tomography for the dental implant patient. J Calif Dent Assoc. 2015;43(9): 521-530.

60. Shanbhag S, Karnik P, Shirke P, Shanbhag V. Cone-beam computed tomographic analysis of sinus membrane thickness, ostium patency, and residual ridge heights in the posterior maxilla: implications for sinus floor elevation. Clin Oral Implant Res. 2014;25(6):755-760.

36. Kobayashi K, Shimoda S, Nakagawa Y, Yamamoto A. Accuracy in measurement of distance using limited cone-beam computerized tomography. Int J Oral Maxillofac Implants.

2004;19(2):228-231.

37. Lekholm U, Zarb GA. Patient selection and preparation. In: Brånemark PI, Zarb GA, Albrektsson T, eds. Tissue-Integrated Prostheses: Osseointegration in Clinical Dentistry.

Chicago, IL: Quintessence Publishing; 1985.

38. Mah P, Reeves TE, McDavid WD. Deriving Hounsfield units using grey levels in cone beam computed tomography.

Dentomaxillofac Radiol. 2010;39(6):323-335.

39. Makins SR. Artifacts interfering with interpretation of cone beam computed tomography images. Dent Clin North Amer.

2014;58(3):485-495.

40. Mallya SM, Tetradis S. Trends in dentomaxillofacial imaging.

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41. Mallya SM. Evidence and Professional Guidelines for Appropriate Use of Cone Beam Computed Tomography. J Calif Dent Assoc. 2015;43(9):512-520.

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64. Valiyaparambil JV, Yamany I, Ortiz D, et al. Bone quality evaluation: comparison of cone beam computed tomography and subjective surgical assessment. Int J Oral Maxillofac Implants. 2012;27(5):1271-1277.

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Implant practice 25

CONTINUING EDUCATION

diagnosis, treatment planning, and treatment outcomes.

The next article in this series will look more closely at the specific application of CBCT imaging in implant dentistry. IP

REF: IP V13.2 HARTSHORNE

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Essential guidelines for using CBCT in implant dentistry: clinical considerations HARTSHORNE

1. When an implant is to be placed in proximity to a vital structure — e.g., ________ — or where there are bone morphology discrepancies, radiographic information from traditional 2D radiographic imaging is limited. a. a nerve b. an artery c. a sinus cavity d. all of the above 2. In 2011, the ________ also jointly developed a position statement to guide clinicians on the use of CBCT in endodontics and support decision-making when to treat or extract. a. American Association of Endodontists (AAE) and the American Association of Oral and Maxillofacial Radiology (AAOMR) b. American Association of Endodontists (AAE) and the American Dental Association c. American Academy of Periodontology (AAP) and American Association of Oral and Maxillofacial Radiology (AAOMR) d. American Association of Endodontists (AAE) and American Association of Oral and Maxillofacial Surgeons (AAOMS) 3. The purpose of the initial radiographic examination is to __________. a. assess the overall status of the remaining dentition

26 Implant practice

b. identify and characterize the location and nature of the edentulous regions c. detect regional and site-specific anatomic structures and pathologies d. all of the above

a. helps define both the donor and recipient sites b. allows for improved planning for surgical procedures c. reduces patient morbidities d. all of the above

4. Initial diagnostic imaging examination is best achieved with _______ and may be supplemented with periapical radiography. a. visual inspection b. panoramic radiography c. transillumination d. CBCT

8. The purpose of postoperative imaging after dental implant placement is to confirm the location of the fixture and crestal bone levels at implant insertion. _______ is/are recommended for this purpose and is commonly referred to as the baseline image. a. CBCT b. Intraoral periapical radiography c. Panoramic radiographs d. Cephalometric radiographs

5. A ______ is the preferred imaging protocol for most endodontic applications. a. CBCT with full FOV b. CBCT with limited FOV c. periapical radiograph d. 2D FMX 6. _____ is/are recommended as the imaging modality of choice for preoperative diagnostics and treatment planning of potential dental implant sites. a. Periapical radiographs b. Panoramic radiographs c. CBCT d. Cephalometric radiographs 7. The use of CBCT before bone grafting ______.

9. ______ inherently produce artifacts, such as beam hardening and streak artifacts with CBCT, obscuring subtle changes in marginal and peri-implant bone. a. Zirconia implants b. Bone grafts c. Titanium implant fixtures d. Adjacent amalgams 10. Reviewing CBCT scans can be performed by _____. a. any dentist, regardless of training b. an adequately trained dentist or specialist treating the patient c. a specialist maxillofacial radiologist d. both b and c

Volume 13 Number 2

CE CREDITS

IMPLANT PRACTICE CE

Drs. Amr Zahran, Ahmed Mortada, and Basma Mostafa present a randomized clinical study on the use of a single drill for implant placements compared to sequential drills

D

ental implant success is evident nowadays with the predictable functional and esthetic results obtained (Karaca and Aksakal, 2013). Simplified techniques and approaches are preferred for the convenience of both the patients and operators (Eriksson, et al., 1982).

Current research is focusing on decreasing the number of instruments used, shortening of the operation time, and performing flapless approaches for implant placement whenever possible. This is done to reduce the postoperative complaints such as pain, swelling, and bleeding, thus decreasing the need for analgesics and minimizing the occurrence of morbidity (Eriksson and Albrektsson, 1984).

Using surgical drills under specific rotational speed and torque with copious amounts of irrigation, the implant fixture is placed into bone through preparation of the alveolar bone bed. The osteotomy preparation is usually performed by a sequential set of drills increasing in diameter size or by a simplified osteotomy protocol using a reduced number of drills (only pilot and final drill). The latter technique has the benefit of reduced operative time as compared to the conventional sequential drilling technique (Jimbo, et al., 2013).

Guazzi, et al. (2013), examined the use of single bur compared to sequential drilling for the preparation of the implant bed. They found both techniques resulted in implant osseointegration, but the single-bur technique required less surgical time and revealed less postoperative morbidity.

Amr Zahran, BDS, MDS, PhD, is professor at the department of periodontology, faculty of oral and dental medicine, Cairo University, Cairo, Egypt.

Ahmed Mortada, MD, MSc, BSc., is lecturer at the department of periodontology, faculty of oral and dental medicine, Assiut University, Assiut, Egypt.

Basma Mostafa is associate professor at the surgery and oral medicine department, oral and dental research division, National Research Centre, Cairo, Egypt.

Volume 13 Number 2

Educational aims and objectives

This clinical article aims to present a study to assess the clinical success of implant placement by a single specially designed drill compared with the conventional placement using the sequential drills.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 33 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Realize how the use of single drill is compared to the use of sequential drills

•

Recognize what the benefits of shortening the operative time and simplicity can mean for surgeons and patients.

•

Identify what drill geometry in general should be used to prepare sites for screw-shaped implants and cylindrical implants.

•

Observe some results of several studies that examined the osteotomy preparation temperature produced by drilling with a single drill versus sequential drills.

Figure 1: OsteoCare Ultra 3.25 mm drill used for group 1

Figure 2: OsteoCare conventional drills were used for osteotomy preparations of group 2

When considering drill geometry in general, twist drills and taps are used to prepare sites for screw-shaped implants, and triflute drills are used to prepare sites for cylindrical implants (Cordioli and Majzoub, 1997). The OsteoCare™ Ultra 3.25 mm profile drill design is based on the concept of double triflute geometric form. To enable the preparation of a tapered osteotomy, the drill is designed with two cutting planes.

The first trifaceted cutting plane at the point of the drill is at an acute angle to the osteotomy site, is self-stabilizing, and enables accurate initial positioning. The second trifaceted cutting plane, extended along the entire outer edge of the drill, enables cutting along the length of the osteotomy site and produces the tapered form.

The drill may be used for single drilling technique; this shortens the procedure time

and reduces the friction between the drill and the bony surface inside the osteotomy during preparation, which reduces the temperature of bone drilling induced by the procedure (Garber, et al., 2001).

Several studies have examined the osteotomy preparation temperature (Sharawy, et al., 2002). Gehrke, et al. (2015), compared the heat produced by drilling with a single drill versus the use of sequential drills. They concluded that the single drill technique did not generate more heat than sequential drilling.

Bulloch, et al. (2012), also reported no significant difference in temperature rise between the use of single drills and sequential drills in 3.5 mm and 4.2 mm diameter implants. The aim of the present study was to assess the clinical success of implant placement by a single, specially designed drill compared to conventional placement using sequential drills.

Implant practice 27

CONTINUING EDUCATION

Implant placement using a newly designed single drill versus conventional sequential drills

CONTINUING EDUCATION

Figure 3: Flapless osteotomy preparation using the Ultra 3.25 mm drill

Figure 4: Osteotomy preparation under copious saline irrigation

Figure 5: Placement of OsteoCare Maxi Z implant

Figure 7: Six-month postoperative CBCT after implant placement

Figure 6: Immediate postoperative periapical X-ray after fixation of the ball abutments

Materials and methods A total of 161 implants were placed: 31 patients received 82 implants placed by a single drill as the test group, and 30 patients received 79 implants placed by the conventional way using sequential drills as a comparative group. Randomization of the patients and concealment of the assessors were performed to avoid any bias.

Patient selection This study was carried out on 61 patients (34 male and 27 female). Ages ranged from 21 years old to 73 years old with upper or lower edentulous areas requiring restoration by dental implants. The inclusion criteria included implant recipient sites free from any pathological conditions. Patients who were cooperative, motivated, and hygiene-conscious were selected. Patients unable to undergo minor oral surgical procedures and patients with a history of drug abuse or catabolic drugs 28 Implant practice

Figure 8: Flapless osteotomy preparation using single drill

Figure 9: Flapless implant placement

were not included. Patients with a history of psychiatric disorder and those with unrealistic expectations about the esthetic outcome of implant therapy were also excluded. Patients with insufficient vertical interarch space on centric occlusion to accommodate the available restorative components and those who had any systemic condition that may contraindicate implant therapy were excluded from the study.

Exclusion criteria also included patients who had any habits, such as heavy smoking and alcoholism, that might jeopardize the osseointegration process. Patients with para-functional habits that produce overload on the implant, such as bruxism and

clenching, were excluded. The medical condition of the subjects was evaluated according to the modified Cornell Medical Index (Brightman, 1994).

Implant selection OsteoCare™ Maxi Z two-piece, Maxi Z plus, and Maxi-Z flat-end dental implants were used in this study. They are tapered, two-piece implants with either a pointed or flat end, and available in variable lengths and diameters.

Implant fixture Tapered screw fixtures with flared collar and internal hex connection were used. The Volume 13 Number 2

Implant armamentarium For the test group (group 1), a 3.25 mm diameter stainless steel drill was used. For the control group, four drills (2.2 mm, 2.75 mm, 3.25 mm, and 4 mm diameter), made from either titanium or stainless steel, were used and were mounted on a reductionspeed high-torque, low-speed handpiece. A hex driver (2.2 mm) with different lengths and a ratchet wrench was used for seating the implants. The torque wrench was adjusted at 30 Ncm. A 1.5 mm screwdriver was used to fix the cover screw, as well as to fix the healing collars and abutments postoperatively.

Radiographic assessment Periapical radiographs were taken for all patients preoperatively, immediately postoperative, and 6 months after implant placement. Cone beam computed tomography was also performed preoperatively for all patients.

Preoperative Alginate impressions were taken for each patient to obtain study casts for evaluation of the interarch space adequacy and to detect if there was any occlusal discrepancy.

As part of the presurgical preparation, all patients received initial therapy. This included caries removal, restoration, and periodontal debridement. Photographs were also obtained for documentation and comparison.

Surgical protocol Local anesthesia was induced using articaine with adrenaline 1:100,000. The

Figure 10: Immediate periapical radiograph after implant placement

Figure 11: Six-month postoperative radiograph after delivery of the crown

surgical procedures were flapless in cases where the ridge width was more than 5 mm and free of any bony defects or concavities.

In other cases, a full thickness flap elevation was performed, with para-crestal (palatal or lingual) incisions extended by one tooth mesially and distally to the implant site, with two vertical-releasing incisions.

In cases where implants had been immediately inserted in fresh post-extraction sites after atraumatic tooth extraction, the socket was debrided, and the implant was carefully placed in the correct prosthetically driven position, with the implant platform leveled 2 mm below the marginal level of the buccal wall. Implant site preparation was performed using a specially designed tapered triflute drill for group 1 and sequential drills for group 2. The recommended rotation speed is 2000 rpm, and the cooling is obtained by copious irrigation with normal saline. Primary stability was established and checked with the torque wrench to be more than 30 Ncm. After implant placement, the surgical flaps (if performed) were sutured, achieving a soft tissue primary closure.

mg (Pfizer) twice a day for penicillin-allergic patients. Paracetamol 500mg was also taken as pain control. Patients were not allowed to use any removable prosthesis. Sutures (where performed) were removed after 10 days.

Postoperative care Medications were prescribed, including 1,000 mg Augmentin® (GlaxoSmithKline) twice a day for 7 days or Dalacin® C 300

Figure 12: Column chart representing age distributions in the two groups Volume 13 Number 2

Follow-up Clinical evaluation Each patient was evaluated 6 months postoperatively and examined for the following: • Discomfort, pain, and tenderness: These were evaluated according symptoms of the patients.

• Condition of the peri-implant tissues: Presence of any abnormalities, including redness and swelling, was checked.

Probing depth was measured on axial surfaces of all implants, according to a standard procedure described by Glavind and Loe (1967) to measure pocket depth that refers to the distance from the peri-implant mucosal margin to the base of the clinical probing depth. The measurements were carried out using a 0.5 mm-thick periodontal probe with Williams calibrations marked from 1 mm to 10 mm. Measurements were taken mesially, buccally, distally, and lingually around the implant. The probing

Figure 13: Cylinder chart representing gender distributions in the two groups Implant practice 29

CONTINUING EDUCATION

implant is made of titanium alloy (6AL-4V ELI).

The implant body is threaded with buttress threads, and the surface is grit-blasted and acid-etched. Variable fixture lengths (10 mm, 12 mm, and 13 mm) were used. Variable fixture diameters (3.75 mm and 4.5 mm) were used.

CONTINUING EDUCATION

Figure 14: Cylinder chart representing implant success in the two groups

depths were obtained by totaling the four probing depth scores per implant. The sum of these readings was divided by four, and the probing depth score for the implant was obtained.

• Mobility was tested using the Periotest M (Medizintechnik Gulden) to evaluate the clinical stability of the implant. Periotest values -8 to 0 were considered the ideal values to denote successful osseointegration.

• Occurrence of various complications, including: ° biological complications — e.g., peri-implant mucositis, periimplantitis, fistula, or abscess ° mechanical or prosthetic complications — e.g., fracture of the implant and/or of any prosthetic component, screw loosening.

Radiographic evaluation Periapical radiographs were taken for all patients preoperatively, immediately postoperatively, and 6 months after implant placement. The known distance between the screw threads or the length of the implant was used to calibrate each image. The implant platform was used as the reference for each measurement.

Radiographs taken at the prosthesis delivery served as the baseline for evaluation of the marginal bone level change over the study period. The linear axial distance between implant platform and the most coronal bone-to-implant contact was measured. To have a single value for each implant, mesial and distal values were averaged.

Oral hygiene level The presence of plaque and bleeding on probing was evaluated at four surfaces for each tooth or implant and expressed as percentage of positive sites over total sites (full-mouth score).

30 Implant practice

Figure 15: Cylinder chart representing mean amounts of bone loss in the two groups

Table 1: Descriptive statistics and results of comparison between demographic data in the two groups Demographics

Single drill (n=31)

Sequential drilling (n=30)

P-value

Age (mean ± SD)

34.1 ± 12.511

33.2 ± 11.8

0.782

Female [n (%)]

16/31 (51.6%)

11/30 (36.7%)

Male [n (%)]

15/31 (48.4%)

19/30 (63.3%)

Postoperative course One week after surgery, patients were asked to complete a short survey to investigate the most common indicators of quality of life in the postsurgical period. Indicators included: • Pain (on a zero-to-100 visual analogue scale [VAS]) (Hawker, et al., 2011) • Tissue swelling • Analgesic drugs taken Implant success The success criteria proposed by Buser, et al. (1997), and Cochran, et al. (2002), were adopted at each follow-up visit for each implant. These criteria follow: • No clinically detectable mobility when tested with Periotest M • No evidence of peri-implant radiolucency • No recurrent or persistent periimplant infection • No complaint of pain • No complaint of neuropathies or paresthesia.

Patient satisfaction Esthetics, mastication function, and phonetics were assessed using a questionnaire 6 months following placement. The possible answers — excellent, very good, good, sufficient, or poor — were evaluated.

Statistical analysis Numerical data was explored for normality by checking the distribution of data and using tests of normality (Kolmogorov-Smirnov and

0.180

Shapiro-Wilk tests). Age data showed normal (parametric) distribution, while bone loss data showed non-normal (non-parametric) distribution.

Data was presented as mean, median, standard deviation (SD), and range values.

For parametric data, the Student’s t-test was used to compare the two groups. For non-parametric data, the Mann-Whitney U test was used. Qualitative data was presented as frequencies and percentages.

The Chi-square test (or Fisher’s Exact test when applicable) was used for comparisons regarding qualitative data. The significance level was set at p ≤ 0.05. Statistical analysis was performed with IBM SPSS Statistics Version 20 for Windows.

Results No biological complications such as periimplant mucositis, peri-implantitis, fistula, or abscess were aberrant. Also, no mechanical or prosthetic complications such as fracture of the implant and/or of any prosthetic component, screw loosening were detected.

There was no statistically significant difference between mean age values in the two groups (Table 1). There was also no statistically significant difference between gender distributions in the two groups.

Three implants failed to osseointegrate with bone; mean survival of the implants was 98.2% at the 6-month follow-up. All the remaining implants were in function and stable.

No evidence of peri-implant radiolucency, no suppuration or pain at the Volume 13 Number 2

Implant success [n, (%)]

Single drill (n=82)

Sequential drilling (n=79) P-value

Success

80/82 (97.6%)

78/79 (98.7%)

Failure

2/82 (2.4%)

1/79 (1.3%)

0.514

Table 3: Descriptive statistics and results of Mann-Whitney U test for comparison between amounts of bone loss in the two groups

Figure 16: Cylinder chart representing patients’ satisfaction in the two groups

implant site, or ongoing pathologic processes were detected.

There was no statistically significant difference between implant successes, bone loss, or patient satisfaction in the two groups (Tables 2, 3, and 4).

Bone loss (mm)

Single drill (n=82)

Sequential drilling (n=79) P-value

MEAN ± SD

0.052 ± 0.012

0.053 ± 0.013

MEDIAN (IQ)

0.054 (0.050- 0.059)

0.058 (0.048- 0.059)

Table 4: Descriptive statistics and results of comparison between patients’ satisfaction in the two groups Patient satisfaction [n, (%)] Single drill (n=31)

Sequential drilling (n=30)

Excellent

22/31 (71%)

15/30 (50%)

Very Good

4/31 (12.9%)

7/30 (23.3%)

Discussion

Good

5/31 (16.1%)

6/30 (20%)

This study reports excellent clinical and radiographic results using a single drill for the preparation of the implant site. Because of fast osteotomy preparation and reduced surgical time, tissues were more preserved, and the postoperative complaints were reduced, providing increased patient satisfaction of the treatment. This could be due to decrease of the osteotomy site temperature (Rafel, 1962).

The Ultra drill is designed to be used with external irrigation, especially at compact cortical bone surfaces where most resistance is found. This allows bone temperature to be kept below the threshold of thermal bone necrosis of 47°C. Maintaining such a high temperature for 1 minute will cause bone resorption and anchorage disturbance of the subsequent implant.

Another important factor when preparing an osteotomy is control of the drill at the start of the procedure, which is usually difficult to achieve when using one-stage drills.

Preventing slippage of the drill will eliminate the risk of injuring the patient and prevent the uncontrolled widening of the osteotomy, which can adversely affect the initial stability of the implant and the final result of implant success. Usual solutions to this are to use site markers to pierce the mucosa and outer layer of bone or to use small diameter pilot drills, but both techniques reduce the advantage of one-stage drilling.

With the Ultra drill design, the piercing tip of the drill is used to penetrate the soft tissue, when using flapless implant technique, and

Unsatisfied

0/31 (0%)

2/30 (6.7%)

Volume 13 Number 2

0.628

form an indent in the top layer of bone, preventing slipping even on curved bony surfaces. This is accomplished by the first set of drilling surfaces being at a more acute angle and having only one-fifth of the diameter of the second set of drilling surfaces.

This allows the first drilling plane to act as a guide for the second.

The use of multiset drill points will also eliminate the vibrations that accompany the procedure caused by using the tip of the drill for support on the patient’s bone ridge.

This, if combined with shifting from working with a typically complex sequential drilling technique to an enhanced single drilling technique, reduces the working time and the discomfort for the patient. Moreover, due to the design of the Ultra drill and the high angle of the first drill plane, there is a reduction of axial drilling force exerted on the bone by the operator for the osteotomy to be prepared.

The Ultra drill is based on the design to core out the root from the root canal peripherally, but with the added advantage of not requiring an exposed socket. The advantages of the Ultra drill not only affect the practitioner’s work outcome, but also have a positive influence on the patient who experiences shorter procedure times, less pressure forces during osteotomy preparation, and the likelihood of a higher implant success rate (Garber, et al., 2001).

P-value

0.239

One of the factors that could increase the osteotomy site temperature is the quality of the bone, as the more cortical part may increase the bone density, and the temperature of bone cutting may increase the temperature (Misch, et al., 1999). The conventional way of preparing the implant bed consists of using successive drills increasing in diameter. It’s important to use sharp drills with high-rotational speed to minimize the time of osteotomy and temperature rise.

Conventional protocols consist of different numbers, types of drills used, and different rotation speeds. It has been observed that the use of sharp drills, in combination with high rotation speed, allows the creation of the implant site in a very short time, reducing the risk of developing excessive heat (Tehemar, 1999). The present study found minimum bone loss around the implants using OsteoCare drills (either the sequential or the single drill).

The results of this study showed minimum postoperative complaints (pain, swelling, and bleeding) and minimal use of analgesics due to the minimally invasive approaches either by flapless implant placement or by using the single drill in the test group.

The patients completed a questionnaire at the 6-month follow-up review, and the results showed great satisfaction of the treatment, with no statistically significant difference between the two groups even with the Implant practice 31

CONTINUING EDUCATION

Table 2: Descriptive statistics and results of Fisher’s Exact test for comparison between implant success in the two groups

CONTINUING EDUCATION failed implants, which were replaced with new ones after 3 months of healing.

The new era of implant placement regarding the patient-reported outcomes aims to use simplified techniques and quick implant placement, and results in more tissue preservation and patient preference due to the minimal operative and postoperative complications, and maximum osseointegration, functional, and esthetic outcomes.

Conclusion The use of the Ultra 3.25 mm single drill is considered an effective approach in implant placement. The clinician benefits are a speedy and simplified technique, while the patient benefits from minimal postoperative symptoms, and maximum functional and esthetic restoration of their lost teeth. For dense bone (D1) in the lower posterior areas, it is advised to combine the single drill technique with sequential drilling. IP

One of the factors that could increase the osteotomy site temperature is the quality of the bone. drill guide for dental implants. Int J Oral Maxillofac Implants.

2012;27(6):1456-1460.

post-loading results of a multicenter randomised controlled trial. Eur J Oral Implantol. 2015;8(3):283-290.

3. Buser D, Mericske-Stern R, Bernard JP, et al. Long-term evaluation of non-submerged ITI implants. Part 1: 8-year life table analysis of a prospective multi-center study with 2359 implants. Clin Oral Implants Res. 1997; 8(3):161-172.

12. Hawker G, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken). 2011; 63(Suppl 11):S240-S252.

4. Cochran DL, Buser D, ten Bruggenkate CM, et al. The use of reduced healing times on ITI implants with a sandblasted and acid-etched (SLA) surface: early results from clinical trials on ITI SLA implants. Clin Oral Implants Res. 2002;13(2):144-153.

5. Cordioli G, Majzoub Z. Heat generation during implant site preparation: an in vitro study. Int J Oral Maxillofac Implants.

1997;12(2):186-193.

6. Eriksson A, Albrektsson T, Grane B, McQueen D. Thermal injury to bone. A vital-microscopic description of heat effects. Int J Oral Surg. 1982;11(2):115-121.

7. Eriksson A, Albrektsson T. The effect of heat on bone regeneration: an experimental study in the rabbit using the bone growth chamber. J Oral Maxillofac Surg.

1984;42(11):705-711.

8. Garber DA, Salama MA, Salama H. Immediate total tooth replacement. Compend Contin Educ in Dent.

2001;22(3):210-216.

REFERENCES 1. Brightman VJ. Rational procedure for diagnosis and medical risk assessment. In: Lynch MS, Brightman VJ, Greenberg MS. Burket’s Oral Medicine: Diagnosis and Treatment. 9th ed. Philadelphia, PA: Lippincott; 1994.

2. Bulloch SE, Olsen RG, Bulloch B. Comparison of heat generation between internally guided (cannulated) single drill and traditional sequential drilling with and without a

32 Implant practice

9. Gehrke SA, Bettach R, Taschieri S, et al. Temperature changes in cortical bone after implant site preparation using a single bur versus multiple drilling steps: an in vitro investigation. Clin Implant Dent Relat Res. 2015;17(4):700-707.

10. Glavind L, LĂśe H. Errors in the clinical assessment of periodontal destruction. J Periodontal Res. 1967;2(3):180-184.

11. Guazzi P, Grandi T, Grandi G. Implant site preparation using a single bur versus multiple drilling steps: four-month

13. Jimbo R, Giro G, Marin C, Granato R, et al. Simplified drilling technique does not decrease dental implant osseointegration: a preliminary report. J Periodontol.

2013;84(11):1599-1605.

14. Karaca F, Aksakal B. Effects of various drilling parameters on bone during implantology: an in vitro experimental study.

Acta Bioeng Biomech. 2013;15(4):25-32.

15. Misch CE, Dietsh-Misch F, Hoar J, Beck G, et al. A bone quality-based implant system: first year of prosthetic loading. J Oral Implantol. 1999;25(3):185-197.

16. Misch CE, Qu Z, Bidez MW. Mechanical properties of trabecular bone in the human mandible: implications for dental implant treatment planning and surgical placement.

J Oral Maxillofac Surg. 1999;57(6):700-706.

17. Rafel SS. Temperature changes during high-speed drilling on bone. J Oral Surg Anesth Hosp Dent Serv. 1962;20:475-477.

18. Sharawy M, Misch CE, Weller N, Tehemar S. Heat generation during implant drilling: the significance of motor speed. Int J Oral Maxillofac Implants. 2002;60(10):1160-1169.

19. Tehemar SH. Factors affecting heat generation during implant site preparation: a review of biologic observations and future considerations. Int J Oral Maxillofac Implants.

1999;14(1):127-136

Volume 13 Number 2

REF: IP V13.2 ZAHRAN, ET AL.

FULL NAME

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $149; call 866-579-9496 or visit www.implantpracticeus.com to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Implant Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

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Implant placement using a newly designed single drill versus conventional sequential drills ZAHRAN, ET AL.

1.

Current research is focusing on _______. a. decreasing the number of instruments used b. shortening of the operation time c. performing flapless approaches for implant placement whenever possible d. all of the above

2. Using surgical drills ________, the implant fixture is placed into bone through preparation of the alveolar bone bed. a. under specific rotational speed b. under specific torque c. with copious amounts of irrigation d. all of the above 3. The osteotomy preparation is usually performed by _______ or by a simplified osteotomy protocol using a reduced number of drills (only pilot and final drill). a. a sequential set of drills decreasing in diameter size b. a sequential set of drills increasing in diameter size c. a set of nonsequential drills in varying diameter sizes d. a sequence of two diameter sizes 4.

Guazzi, et al. (2013), examined the use of a single bur compared to sequential drilling for the preparation of the implant bed. They found both techniques resulted in implant osseointegration, but the single-bur technique ________. a. required less surgical time but revealed more

Volume 13 Number 2

postoperative morbidity b. required more surgical time and revealed less postoperative morbidity c. required less surgical time and revealed less postoperative morbidity d. required more surgical time and revealed more postoperative morbidity 5. When considering drill geometry in general, _______ are used to prepare sites for screw-shaped implants, and triflute drills are used to prepare sites for cylindrical implants. a. twist drills b. taps c triflute drills d. both a and b 6. The Ultra drill is designed to be used with external irrigation, especially at compact cortical bone surfaces where most resistance is found. This allows bone temperature to be kept below the threshold of thermal bone necrosis of _____. a. 10°C b. 47°C c. 57°C d. 70°C 7. Another important factor when preparing an osteotomy is control of the drill ______, which is usually difficult to achieve when using one-stage drills. a. mid-procedure

b. at the end of the procedure c. at the start of the procedure d. at any stopping point during the procedure 8. It’s important to use _______ to minimize the time of osteotomy and temperature rise. a. sharp drills with high-rotational speed b. sharp drills with low-rotational speed c. blunt drills with high-rotational speed d. triangular drills with high-rotational speed 9. The patients completed a questionnaire at the 6-month follow-up review, and the results showed great satisfaction of the treatment, with no statistically significant difference between the two groups even with the failed implants, ________. a. which were unable to be replaced b. which were replaced with new ones after 3 months of healing c. which were replaced with new ones after 6 months of healing d. which were replaced with new ones after 9 months of healing 10. For dense bone (D1) in the lower posterior areas, it is advised to _______. a. use only the single drill technique b. use only the sequential drilling technique c. combine the single drill technique with sequential drilling d. use a lower rotation speed

Implant practice 33

CE CREDITS

IMPLANT PRACTICE CE

SERVICE PROFILE

Silent partners provide unique benefits for implant focused practices Chip Fichtner discusses how to grow a practice bigger, better, and faster

T

housands of doctors across the United States have chosen to quietly sell a part, but not all, of their larger practices to Invisible Dental Support Organizations (IDSOs).

These groups have been acquiring interests in larger practices of all specialties for decades. You have probably not heard of them as they are not the nationally branded chains. The practice values we have achieved for clients of 1.5X to over 4X collections have been shocking to many doctors.

Cash now, more later IDSOs typically purchase from 60% to 90% of a practice for cash upfront at longterm capital gains tax rates. The goal of the doctors and the IDSOs is to grow the practice bigger, better, and faster by utilizing a larger partners’ resources, benefiting both the doctors and their silent partner.

In these transactions, doctors continue to run the practice as owners under their brand, team, and leadership for years or decades into the future. Senior doctors view it as the first step to a transition. The younger doctors view an IDSO partner as an opportunity to build empires in which they have ownership, yet with no risk. The partner provides capital for expansion internally through new office build-outs or acquisitions of complementary or competitive practices. Doctors have options to exit their retained equity at a date in the future that is negotiated up front.

with other practices owned by the IDSO, and reduced supplies costs.

In the implant world, IDSOs that buy thousands or tens of thousands of implants from virtually all of the implant vendors are often paying half or less than what a typical single doctor might pay today. Size has its privileges.

Retained ownership upside The ownership retained by the doctor may be in the practice itself, the parent company, or in a combination of both. Doctors will make this decision based upon the partner they choose, the value offered, and the potential upside with their new IDSO partner. Historically, some doctors have made extraordinary gains far in excess of their initial practice value from parent equity. As the IDSOs grow, their investors harvest the value increase in the group, which can often benefit all of the doctors in the IDSO group.

Support not management Most IDSO operating philosophies are to invest in historically successful practices with great doctors and teams. Their goal is to help, but not micromanage. They count on the doctor to lead and grow the practice and do not dictate daily aspects of the practice including office hours, team members, marketing, or strategies. And none of them is involved clinically in any way whatsoever.

Secured future, reduced costs

Timing is everything

Doctors not only benefit from a secured financial future with millions of dollars in the bank and a known exit, but also access multiple support options provided by their IDSO partners. These resources include payer negotiation leverage, lower team benefit costs, superior marketing, synergies

While the U.S. economy and society has recently had its bumps, the demand from the IDSOs for great practices has not waned. To counterbalance recent practice disruptions, most IDSOs are offering creative purchase structure options. These can enable doctors to increase their transaction consideration for their practice performance after an initial 2020 transaction. Doctors should also be aware of the potential changes in federal tax rates, which may be impacted by the upcoming presidential election. Timing could be critical.

Smart doctors should understand the value of their practices to an IDSO today. LPS makes this possible through a confidential,

Chip Fichtner, is the founder of Large Practice Sales, which specializes in the transactions of Invisible Dental Service Organizations (IDSOs) for all practices. The company has completed more than $100 million of transactions in the past 6 months. Learn more at www. findmyimplantidso.com

34 Implant practice

IDSO s Invest in PART, not all, of large practices

1.5X to 4X Collections IDSOs Purchase

60% to 90%

YOUR

Brand Team Leadership

Continue to practice for

YEARS or DECADES

2020, 30, 40, 50...

IDSOs BRING

BIG MONEY LEVERAGE RESOURCES MARKETING BUYING POWER

no obligation, and free practice analysis. To schedule an initial information call, please contact Implant@largepracticesales.com or call us at 844-533-4373. IP Volume 13 Number 2

BEAT THE BUG! Now is the Time to Monetize Part of Your Practice Value

Silent Partners are Still Eager to Invest in Great Practices Invisible Dental Support Organizations (IDSO) buy 60% to 90% of your practice for cash up front.

You remain as an owner, operating your practice under your brand with your team.

Stay for five to twenty+ years with a known exit.

Large partners provide you with resources to grow bigger, better, faster, cheaper and compete more effectively.

We are still achieving unbelievable values for practices with a growth plan.

Recent Transactions

2X Collections, Two-Doctor General Practice, Age 30s, Sold 60%, Retained 40% 3.9X Collections, Four-Doctor Oral Surgery, Three Offices, Stunning Value 2.6X Collections, One-Doctor Periodontist and new partner will start a new office in six months.

1.875X Collections, Three-Doctor Endodontic Practice, Northeast Corridor To schedule a confidential call to learn more and get a FREE practice value analysis, call 844-533-4373 or Email Implant@LargePracticeSales.com.

Visit us at FindMyImplantIDSO.com.

PRODUCT PROFILE

Boyd Industries Dependability, Respect, and Loyalty to our dental specialist community

“B

uilt to Last. Built for You. Built by Boyd is more than a tagline; it signifies the commitment that everyone at Boyd makes to each and every one of our customers. As COVID-19 disrupts life and business worldwide, Boyd Industries stands by our core values of Dependability, Respect, and Loyalty to our dental specialist community. To continue supporting the growth and success of dental professionals, Boyd remains operational and able to fulfill your dental equipment needs without disruption or delay, being designated an essential business by the federal government. Additionally, in light of industry meetings and show cancellations, we have extended our trade show exhibitions’ promotional pricing to all customers. The Boyd team takes great pride in the craftsmanship and longevity of all products built at our U.S.-based facility — including exam and treatment chairs, surgery tables, mobile storage, and clinical cabinetry — so you can take pride in your office for years to come.

Featured Product: S2614 Oral Surgery Chair

Boyd’s flagship S2614 Surgical Chair is the profession’s benchmark for oral surgery.

Designed specifically for your needs, the S2614 Surgical Chair combines ergonomic, reliable functionality with elegant design. Like the majority of Boyd Industries’ products, the S2614 Surgical Chair can be personalized to best suit your office, just as its design will best suit your specialization’s needs.

What makes the S2614 design unique?

• Ergonomic and reliable design. The S2614’s thin, tapered-style back was created for ease-of-access to the oral cavity and with your long-term comfort in mind. Dual-articulating headrest included.

• Cantilevered-style lift base with 14" of vertical travel and independentpowered seat tilt for Trendelenburg positioning. Runs on low-voltage DC motors. Additionally, the chair’s durable all-steel frame will last the test of time and frequent use.

• Quad-function foot control for convenient movement of the chair. Enjoy personalized, convenient settings with 36 Implant practice

S2614 Oral Surgery Chair

three (3) operator-designated pre-set positions, and an automatic “return to home” switch. We prioritize safety with a built-in power “lock-out” switch.

• Integrated medical-grade duplex 115vAC outlet to accommodate your electrical needs.

• Additional standard features include: “On-Track” surgical arm board/ accessory rail system, choice of dual-articulating headrests, snap-on/ snap-off upholstery, vinyl foot protector, and body restraint strap.

• Options include: upholstery style, base color (standard “Putty” or “Black”), and choice of IV and patient arm boards.

Featured Product: Dental Implant Cart Like the S2614, this mobile operatory cart is prepared to perfectly fit into your practice. This Prestige Dental Implant Cart has been fitted with a durable steel body and all the features you need: sectioned drawers for intuitive organization, a full powder coat to withstand medical-grade cleaners, and a sleek, contemporary esthetic. It matches

Dental Implant Cart

seamlessly with the rest of our Prestige suite, including the Surgical Care Cart and Surgical Devices Cart.

Standard Features: • Three 3"-deep drawers and two 6"-deep drawers with soft-close ball-bearing technology. Integrated key lock to safeguard high-value implants.

• Adjustable drawer dividers designed for efficient organization of your implant inventory.

• A removable plastic top designed for easy disinfection, alongside a slideout surface for added work space.

• Lockable, 5" easy-rolling casters for smooth transit from patient to patient.

• Durable, scratch-resistant, nylonreinforced polycarbonate bumper to protect cart wheels and exterior.

The Boyd team has made every effort to create specialized products that are truly Built for You. These featured products can be combined with additional products— such as our PTC653 Patient Transfer Chair or S200 LED Surgery Light — as well as Boyd’s custom clinical and office cabinetry to create a fully cohesive office space. Personalize your office with nearly limitless combinations of color and print laminates and the widest range of upholstery choices on the market. Reach out to your regional sales representative today to get started!

To learn more, visit us at www.boyd industries.com, or follow us on Instagram and Twitter @BoydIndustries.

Boyd Industries is an ISO 13485:2016 certified company. IP This information was provided by Boyd Industries.

Volume 13 Number 2

Rose Nierman offers tips on beginning your medical-billing journey with the right tools

G

reat news! Becoming a cross-coding office increases access to care. With assistance from medical insurance, many patients can move forward with needed treatment. Medical plans do not have the $1,000 yearly limits and frequency rules for exams and imaging that you see with dental plans. The icing on the cake is that when medical insurance reimburses for oral surgeries, you save dental insurance benefits for routine dental procedures.

Begin your medical-billing journey with the right tools, starting with International Classification of Diseases (ICD-10) codes.

A checklist of ICD-10 codes helps document conditions, symptoms, and diseases. During your exam, document conditions such as bone atrophy, jaw pain, osteitis, or difficulty masticating, and then assign an appropriate ICD code.

Procedure codes in medical billing are referred to as Current Procedural Terminology (CPT) for exams, radiographs, surgeries, and appliances. Just like dental has its own claim form, so does medical (CMS-1500 claim form). Claims can also be submitted electronically. For the best results, be sure to send a narrative report of medical necessity with the claim or preauthorization.

Medical insurance may consider the following services as medically necessary: 1. CBCT, panorex, or tomography 2. Screening exams 3. Bone grafts and implants 4. Third molars and surgical extractions 5. Oral infection or cysts 6. Sleep apnea appliances

Rose Nierman is a pioneer and leading expert in cross-coding and medical billing in dentistry.

She made it her mission to help dentists get paid by medical insurance and, in 1988, founded Nierman Practice Management. Ms. Nierman has educated thousands of practices to become successful cross-coders, created the leading software system DentalWriter™ that transforms specific questionnaire and exam data into narrative reports and medical claims, and launched Nierman Medical Billing Service to streamline the reimbursement process for dental practices. Contact Nierman Practice Management at contactus@dentalwriter.com or 1-800-879-6468.

Volume 13 Number 2

Medical billing may help patients get needed treatment and help your practice with case acceptance.

Every dental practice can do it!

7. TMJ appliances 8. Accidents to teeth 9. Mucositis and stomatitis 10. Frenectomy 11. Biopsies 12. Botox injections

Getting started with medical billing Cross-coding courses and manuals are available to learn the process of medical billing. Nierman CE+, an online medical billing course for dental practices, was recently launched for offices interested in remote training. In today’s economy, it’s essential for dental offices to maximize insurance.

Medical billing may help patients get needed

treatment and help your practice with case acceptance. Every dental practice can do it!

About Nierman Practice Management Rose Nierman’s online medical billing course series, Nierman CE+ and her live crosscoding continuing education courses have helped thousands of dental practices learn and apply medical billing. Her company, Nierman Practice Management, created DentalWriter™ software to generate medical claims and narrative reports, and Nierman Medical Billing Service to handle the insurance communication for clients. Ms. Nierman and her company have been dedicated to helping dentists and their teams for 32 years. IP Implant practice 37

PRACTICE MANAGEMENT

Medical billing for bone grafts, oral implants, and CBCT

GOING VIRAL

The other biggest risk to your practice Thomas Terronez discusses the security of vital practice data

W

hen you think about your day-to-day concerns in your practice, cybersecurity is not likely one of them. If computers are working, and no one is complaining, then all is well, right? False. You are ignoring cybersecurity risks and leaving your practice vulnerable to a cyberattack that could shut down your business permanently through one incident. To clarify, we are not talking about HIPAA; we are talking about the security of your practice data that is vital to operating your business.

Why is it the other biggest risk? Your practice leadership lacks understanding of what should be done to protect the practice. So many practices partner with an IT vendor and assume this means they are covered. Many IT providers are not focusing on security, which increases the likelihood of a system being compromised. With cybercriminals being more successful now than ever, the scope of the compromise is far worse than it has been in the past.

As a security-focused dental IT provider, we have the advantage to see practice risks firsthand. Last year we conducted an assessment in which we analyzed general dentists, orthodontists, oral surgeons, and other specialties. We found that 60% of practices with security vulnerabilities believed they were contracted with a vendor to manage cybersecurity but were not. Through our assessment and general experience, here are the most common cybersecurity risk points: • Lack of proper IT security structure

Thomas Terronez is a dental IT specialist, national presenter, and hands-on leader who strives to aid practices to reach peak efficiency and IT security potential. Since founding two technology companies (Medix Dental IT and Terrostar Interactive Media) in the early 2000s, Thomas has been regarded as one of the field’s most respected experts, locally and nationally. Thomas’ mission is to help practices mitigate risk, protect patients, and maximize overall success. Thomas takes great pride in being the board chair for a rapidly expanding financial institution and a mentor in an executive education program at Stanford University. For more information, call 877-885-1010, email team@medixdental.com, or visit medixdental.com.

38 Implant practice

• Not understanding and verifying IT vendor risks • Lack of staff training • Insufficient insurance protection

Lack of proper IT security structure Several factors contribute to a weak IT security structure. In our assessment of cybersecurity, we found that the three most common vulnerabilities were firewalls, backups, and endpoints.

Of practices we assessed, 35% had no firewall. They only had the modem and router that came with their Internet connection. A firewall, also known as a security appliance, is your first line of defense from malicious Internet traffic. Using an enterprise-grade security appliance versus a simple router will help you avoid malicious attacks.

An adequate firewall should have the following: • Intrusion prevention system (IPS) — continuously monitors Internet traffic to your network and blocks possible malicious incidents and then captures information about them.

• Gateway malware protection — scans and filters Internet traffic for viruses and malicious software.

• Geo IP filtering — blocks all traffic to specific countries or regions.

• Content filtering — controls what type of websites can be accessed.

• Audit logging — records all Internet activities and is vital for security monitoring.

If your security appliance is lacking in any of the preceding features, your practice may be at risk. It is important to note that any product, which has a renewal investment for its improvements and updates, is worth it.

Inadequate backup structure and segmentation also contribute to a weak IT security structure. Backing up your data to only a local device allows for it to be compromised through an attack. We recommend a disaster-recovery appliance that is segmented from your normal network. This will securely back up your data off-site to better protect your practice.

Another attribute to weak IT security is a lack of or free endpoint security software.

Of practices we assessed, 50% used the inadequate free protection that came with their computer. Endpoint security software is an application control that includes antivirus and antimalware functions to secure devices accessing your network. While complete protection does not exist, enterprise-grade products provide better protection than personal or free offerings.

No proactive system monitoring If your systems are not proactively monitored, more than likely the only time you pay attention to them is when something is not working. This reactive approach not only can put you at risk, but also increases your expenses. Well-executed compromises or attacks do not impact the system function until their damage is done, possibly leaving your practice inoperable.

A lot of compromises are multistep and can be prevented if your network and devices are proactively monitored. Monitoring your systems can save you from a potential breach and ensure your data backups are performing effectively. Protecting your patient data is not only important to you — it is important to your patients. They need to know their privacy is being protected.

Volume 13 Number 2

GOING VIRAL

Not understanding and verifying IT vendor risks All practice owners should trust their IT vendors but always verify their work to ensure they are properly doing their job.

The problem is practice staff lacks understanding of what risks to verify. Here are four simple requirements you should have for your IT vendors: 1. Require that they use two or multifactor authentication on all their software systems. If IT vendors do not do this, and a malicious actor obtains a password in use by any employee, it may be able to obtain full access and compromise your whole system. It is best practice to have this documented just in case an incident occurs.

2. Ensure client backup tools are not controlled by or manageable through their remote management tools. It is convenient to manage everything from one location; however, if that location becomes compromised, then it creates one large vulnerability point and puts your practice at risk. This should also be documented for your records.

3. Confirm they have a third party conduct penetration and vulnerability testing on their systems at least annually. If cybersecurity is not your IT vendors’ core business, they should pay experts to try to gain access to their systems. This needs to be completed at random to ensure their company’s security.

This allows them to see where their vulnerabilities are and make the appropriate improvements. Many IT vendors tend to not do this because it is expensive, and they assume they are not a target. However, what cybercriminal wouldn’t want to gain access to multiple client data through hacking one IT vendor? With the average cost to recover from a security breach costing $429 per patient, your IT providers should be doing everything they can to ensure you are protected. You should obtain a summary of the cybersecurity reports for your documentation, confirming that this is happening throughout your partnership agreement.

4. Verify that they have adequate insurance to pay your associated fees and compensate your Volume 13 Number 2

practice for business interruption if they are at fault. Good IT vendors will have their coverage, which should exceed gaps in your practice’s cyber policy. As always, ask for documentation of their coverage for your records.

Lack of staff training Cyberattack trends and approaches change daily, with constant new methodologies being created to ensure their hacks are actively working. Cybercriminals will never miss the opportunity to capitalize on human emotion. Even with a decent IT security structure, your staff can allow compromises.

For example, COVID-19 provided hackers with easy access through phishing emails sent to staff members, posing as world health organizations providing critical updates. Since practice staff often lack understanding of cybersecurity, they unintentionally let hackers in.

While HIPAA training touches on cybersecurity, it is not adequate for this in-depth, diverse topic. Enrolling your staff into cybersecurity training and testing should be mandatory. This should be conducted at least annually; however, we recommend this is completed quarterly.

Insufficient insurance protection Practices frequently lack cybersecurity insurance. Cyber liability insurance covers financial losses that occur from data breaches and other cyber events. If your IT vendor does not have this coverage, you might be responsible for any related expenses should a cyber incident occur at your practice.

It is not a default policy for practices, but a good insurer will bundle it with other

coverages. It’s important to note that some policies exclude self-inflicted incidents, or vendor-inflicted. Cyber liability insurance should not consist of exclusions for staff (self-inflicted) errors and should protect you in worst-case scenarios, including lost revenue. The IT world has seen several firsts in cybersecurity and dental organizations in the last year; you can no longer think it won’t happen to you.

In the last year, over 600 practices were compromised and shut down because of their IT vendors. This left most of the practices inoperable with no access to their data for several weeks and some several months. Most of the incidents could have been prevented if the IT vendors had two or multifactor authentication in place for their remote access software.

These recent incidents show that poor preparation leads to the worst outcomes.

Taking a proactive approach to cybersecurity to minimize your risks will pay dividends, and you will likely never know the true value of because you will not face a major compromise. However, if you take a reactive approach to cybersecurity, it may be impossible to recover from a single incident.

Prevention can never be 100%, but you should take the steps to minimize risk as much as possible. Your practice is your livelihood and should be protected the same way. While you may like your current IT providers because the company supports you well, taking their word is not enough when it is your business and primary source of income. Trust your IT providers, but always verify that they are properly protecting your business. With cyberattacks on the rise, don’t let cybersecurity be a risk to your practice. IP Implant practice 39

ON THE HORIZON

Opportunity is on the horizon Dr. Justin D. Moody reflects on quarantine and a new outlook after the COVID-19 crisis

A

s I sit down to right this column, I’m reflecting on the rapid and drastic changes that we have all experienced. At the time that I am writing this, dental offices are all closed, everyone is sheltering in place to help lower the outbreak of COVID-19, and the world has turned to social media to answer all its questions. I have to admit that the first 10 days or so of being home have been like a real life version of the movie “Groundhog Day.” Now that I have watched “Tiger King” and “Ozark” and joined every Facebook group known to man, it is time to focus on what is going to be important moving forward. Amazing opportunities and (hopefully) better human beings will arise out of these trying times. Family is always what grounds us, and I am sure that everyone has a new outlook on that, but what about ourselves? As the leaders in our offices, we have the weight of the world on our shoulders. We worry about our team, our patients, and the financial stability of our practices.

Our team: What they need more than anything right now is your leadership, reassurance, and calm. During this time that our offices are closed, check in on the team.

Engage them to help build a plan to come back better than ever. What we know is that there will be a new normal that comes from this within our office that will most likely come in the form of heightened personal protective equipment (PPE) requirements, social distancing in the waiting rooms, and countless gallons of hand sanitizer!

Our patients: They are confused about how dentistry fits into their total health today.

They are concerned about their safety at Justin D. Moody, DDS, DABOI, DICOI, is a Diplomate in the American Board of Oral Implantology, Diplomate in the International Congress of Oral Implantologists, Honored Fellow, Fellow, and Associate Fellow in the American Academy of Implant Dentistry, and Adjunct Faculty at the University of Nebraska Medical Center. He is an internationally known speaker, founder of the New Horizon Dental Center (nonprofit clinic), and Director of Implant Education for Implant Pathway. You can reach him at justin@justinmoodydds.com.

40 Implant practice

Figure 1: We will get back to helping those who need our help with dental implants Figure 2: Can’t wait to hug my beautiful nieces, Sawyer and Finley Moody, again

Figure 3: John Tyszka from Precision One Medical giving a tour of BioHorizons® manufacturing center in Oceanside, CA

Figure 4: Mentors, students, and family come together at Implant Pathway post-course events like this one at Top Golf in Scottsdale

Figure 5: Looking forward to getting back to teaching advanced courses like Sinus Augmentation

the office and will be more concerned about money as they likely have less disposable income. Reach out to them, and let them know that you will be open soon, that their health is still the most important thing to you, and that their teeth are a vital component to total health. Be understanding of their finances while educating them on the costs of no treatment and/or the wrong treatment.

You see the edentulous areas and nonrestorable teeth are still there. The challenge will be to show them the value and need for dental implants and a true tooth replacement solution.

Our financial security: This will come with doing the right thing for the patients every time. When they see that you are

Figure 6: New Horizon Dental and Affordable Dentures creating lab solutions for the amazing people of the Phoenix area

genuinely concerned and care for their well-being, your patients will likely choose the right treatment option. The new norm here may be to pay down debt, to invest in equipment and education that will make a real difference in the practice, and to always maintain a cash reserve or line of credit for when the next issue comes up, which it will.

Thank you to all for taking the time to read this column, to MedMark’s Implant Practice US team for this opportunity, and to my own family and friends for your continued support.

We will get back to the people and things we love! The future is still very bright! IP Volume 13 Number 2

don’t be fooled.

chairside system for the production of Leukocyte- and Platelet-Rich Fibrin

choose an FDA-cleared medical device for the production of L-PRF® no anticoagulant, heating, pipetting, second spin, chemical additives or expensive consumables • simple & economical1 • quality guarantee • quick three-step processing protocol • up to 80% reduction in undesirable vibrations2 • high quality German engineering and manufacturing For more information, contact BioHorizons Customer Care: 888.246.8338 or shop online at www.biohorizons.com 1.Intra-lock.com/scientific-literature.html. IntraSpin® and L-PRF® are trademarks of Intra-Lock® International Inc. 2. David M. Dohan Ehrenfest, Nelson R. Pinto, Andrea Pereda, Paula Jiménez, Marco Del Corso, Byung-Soo Kang, Mauricio Nally, Nicole Lanata, Hom-Lay Wang & Marc Quirynen (2017): The impact of the centrifuge characteristics and centrifugation protocols on the cells, growth factors, and fibrin architecture of a leukocyte- and platelet-rich fibrin (L-PRF) clot and membrane, Platelets, DOI: 10.1080/09537104.2017.1293812 SPMP18276 REV C FEB 2019

2020 CITIES

atlanta Georgia

chicago Illinois

tempe Arizona

ATLANTA, GEORGIA

Presented by Drs. Jumoke Adedoyin and Daniel Fenton

learn by doing

Session 2: July 17-18, 2020 Session 3: August 14-15, 2020

CHICAGO, ILLINOIS Session 2: August 28 and 29, 2020 Session 3: September 18 and 19, 2020 FAST TRACK: FALL Sessions 2-4: September 21 - 25, 2020 FAST TRACK: WINTER II Sessions 2-4: December 7 - 11, 2020 SESSION FOUR: LIVE SURGERY July 30 - August 1, 2020 September 10 - 12, 2020 October 22 - 24, 2020 December 3 - 5, 2020 ADDITIONAL IMPLANT COURSES Anterior Aesthetic Implants: Sept. 4 and 5, 2020 Complications: July 31 and August 1, 2020 Full Arch Guided Surgery: October 16 - 17, 2020 Res Digital Restorative Solutions: November 5 - 7, 2020 Soft Tissue Grafting: September 11 - 12, 2020 Conscious Oral Sedation: September 25 - 26, 2020

INSTRUCTOR

2020 SCHEDULE

live patient implant education

Justin D. Moody, DDS Founder & Clinical Director

Dr. Justin Moody is an internationally known dentist, entrepreneur, instructor and speaker in the fields of dentistry, practice management, technology and Implantology. Dr. Moody has practices in Nebraska and South Dakota and has made a name for himself as one of the leading Continued Education providers in the United States. D Dr. Moody knows how important dental continuing education is as well as the need for mentoring and hands-on training. His conversational, real-life approach solidifies his educational philosophy.

register online at

implantpathway.com Questions? Call us at (888) 309-2423

#implantsdoneright