Implant Practice US Winter 2020 Vol 13 No 4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

PROMOTING EXCELLENCE IN IMPLANTOLOGY Zimmer Biomet Dental + U A partnership for innovative solutions

Practice profile Daniel Driskill, DDS, FAGD

Essential guidelines for using CBCT in implant dentistry — radiation dose, risks, and ethical considerations: part 4 Dr. Johan Hartshorne

Esthetic and periodontal benefits of zirconia implants

Beautiful smiles all around.

Drs. Paresh Patel, Apolinar Madrigal, and Gregori M. Kurtzman

What happens when you bring science and innovation together with a legacy of industry leadership? More smiles. As dental professionals, our focus never changes: a functionally sound, aesthetically beautiful restoration, a happy patient, and a practice that thrives. Which is why we’re fiercely focused on empowering our partners every step of the way. From initial consultation to seating the final prosthesis, we are committed to making each step of the journey more simple, more sure and more pleasant.

Rehabilitation of a severely A complete range of best-in-class surgical, restorative and regenerative products—as well as dental-phobic patient innovative digital solutions designed to streamline your workflows. Combine these products with industry-leading education and personalized sales support and customer service. Our goal is simple: Beautiful smiles. It’s what happens when Zimmer Biomet Dental + U get together. To learn more: 1-855-ZBDandU | ZBDandU.com Unless otherwise indicated, as referenced herein, all trademarks are the property of Zimmer Biomet; and all products are manufactured by one or more of the dental subsidiaries of Zimmer Biomet Holdings, Inc. and marketed and distributed by Zimmer Biomet Dental and its authorized marketing partners. Puros Allografts are manufactured by RTI Surgical, Inc. For additional product information, please refer to the individual product labeling or instructions for use. Product clearance and availability may be limited to certain countries/ regions. This material is intended for clinicians only and does not comprise medical advice or recommendations. Distribution to any other recipient is prohibited. This material may not be copied or reprinted without the express written consent of Zimmer Biomet Dental. ZB1039 REV A 03/20 ©2020 Zimmer Biomet. All rights reserved.

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION CREDITS PER YEAR!

Drs. S.K. El-Ebrashi and J.M. Burstein, and Mr. E. Mazone

We We all all want want the the same same thing. thing.

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Winter 2020 - Volume 13 Number 4 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.

“T

he secret of change is to focus all of your energy not on fighting the old, but on building the new.” — Socrates It is time to rebuild. 2020 has definitely put life into perspective. I am choosing to follow the wise words of Socrates and focus on the new. My practice today looks very different than it did in the beginning of 2020. Some team members did not return, which at first devastated me. I didn’t know how we would make up for months of canceled appointments without exhausting my team. We also questioned if patients would actually feel safe returning to the dental office. There were tough team meetings, trying to meet the demands of both patients and team members. We made changes that felt backward at the time, but today I feel Dr. Kristine Aadland as though we have a stronger team than ever before. Patients are excited to come in and grateful to be cared for. Clinically, my practice changed as well. Having extra time to work “on” my practice while not working “in” my practice, I evaluated my time value. For the past 10 years, my practice has been highly focused on technology and CAD/CAM but predominantly restorative-based. One of my dearest friends, Dr. Mona Patel, took an implant continuum a few years ago and mentioned the growth her practice has had both monetarily and emotionally. She was rejuvenated, her team was excited, and her patients were grateful they could have implants done in the practice. After we talked, I sat down to evaluate the tangible ROI for doing surgery and placing implants in my practice. I first calculated my average hourly production. To determine this, take your average daily production (found in your practice software) and divide it by the amount of hours you work chairside. Let’s say my average daily production is $5,500, and I work 7 hours a day; this puts my average hourly production at $785. Why does this matter? If I do a quadrant of fillings in an hour, I can produce an average of $800. It’s great because this is over my average hourly production, but this typically consists of about 45 minutes of my own personal chair time. If I do a crown and buildup, I produce an average of $1,500. We tend to schedule this for 90 minutes of chair time, but worst case, this is 45 minutes of my dedicated time. I use CEREC to complete my restorations same day, so while my crowns are fabricating, I’m typically with another patient starting my next procedure — immensely increasing my hourly production. Implant restorations have always been my biggest ROI. Implant crowns take a little longer to mill than a regular crown, especially when making a custom abutment and a crown versus a screw-retained crown, so I split this up into two 30-minute appointments. The production for this averages $1,850, and my personal chair time is about 30 minutes. Now imagine if I can do more of that by placing implants in my own practice too! Technology has made surgery so much easier as well. Having a CBCT gives me confidence in what I will find during surgery. I can plan the placement of my implants virtually and even print or mill guides in my office. I can take digital impressions at the time of placement and have a restoration ready to go, eliminating an extra appointment. These technological guides have vastly reduced the anxiety I used to associate with surgery, and now when I see implants on our schedule, there is a just buzz of excitement. There is nothing like that surgical high! If you are not sure of where to start on placing implants, please reach out — I am happy to share my journey (the good and the bad) and recommend some live-patient training options. I am so grateful that this year has pushed me to step out of my comfort zone and expand the services that I offer. It’s been an adventure that I do not regret. Dr. Kristine Aadland

Kristine Aadland, DMD, completed her undergraduate work at Oregon State University and subsequently went to Oregon Health Sciences University for dental school. In 2006, she graduated with Clinical Honors and returned to her hometown to start practicing.

ISSN number 2372-9058

Volume 13 Number 4

Implant practice 1

INTRODUCTION

Time to focus on the new

TABLE OF CONTENTS

Practice profile Daniel Driskill, DDS, FAGD

Publisherâ&#x20AC;&#x2122;s perspective Looking forward to 2021! Lisa Moler, Founder/CEO, MedMark Media................................6

Seeing that first smile

Case study Rehabilitation of a severely dental-phobic patient with a maxillary removable prosthesis and a mandibular fixeddetachable hybrid prosthesis

Case report

Drs. S.K. El-Ebrashi and J.M. Burstein, and Mr. E. Mazone illustrate a collaborative effort while treating a patient with high dental anxiety........ 14

High-frequency vibration (HFV) to enhance socket preservation in anticipation of implant placement: case reports â&#x20AC;&#x201D; part 1 Drs. David W. Engen, Gregori M. Kurtzman, and Tarek El-Bialy discuss the rationale for using HFV

ON THE COVER Cover image courtesy of Affordable Dentures & Implants and Raven House Media. Article begins on page 7.

2 Implant practice

Volume 13 Number 4

TABLE OF CONTENTS

Continuing education Essential guidelines for using CBCT in implant dentistry — radiation dose, risks, and ethical considerations: part 4 Dr. Johan Hartshorne assesses the clinician liability and patient risk from radiation when using CBCT imaging by looking at the potential pitfalls and limitations.....................................25

Product profile

Continuing education

Esthetic and periodontal benefits of zirconia implants

Drs. Paresh Patel, Apolinar Madrigal, and Gregori M. Kurtzman discuss challenges with implants in the esthetic zone

Stress-free dentistry delivered Zimmer Biomet Dental introduces SmileZ Today™ Box........................ 32

Service profile Silent partners cut your implant bill in half, or your competitors’ Chip Fichtner discusses how to build a strategy for growing your practice ...................................................... 34

Marketing momentum On the horizon Telemedicine marketing checklist: 10 things dentists should do Marketer Rachael Sauceman discusses safe and effective marketing evolving after the COVID-19 crisis................ 36

The lost art of the lateral wall sinus augmentation Dr. Justin D. Moody discusses reliable and predictable bone growth

..................................................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 4

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PUBLISHER’S PERSPECTIVE

Looking forward to 2021!

Published by

hrough all of the challenges and changes of 2020, I look forward to 2021 as a year of renewal and rejuvenation. 2020 changed our perspectives on patient care and the way we run our businesses. Sanitizing and masking have become part of daily routines, and new methods of communicating with patients and sharing information with colleagues have brought new efficiencies to dental practices. 2020 also has taught us that managing our offices efficiently can navigate us through hard times and make the good times even better. This year dentists discovered that teledentistry can keep them clinically connected with patients as well as keeping information flowing. The American TeleDentistry Association Lisa Moler notes that teledentistry can: Founder/Publisher, MedMark Media • Improve dental hygiene of patients • Reduce the cost of care and increase efficiency through reduced travel times, shared professional staffing, and fewer in-person appointments • Be an innovative solution for the mainstream healthcare industry • Improve access to care for patients • Reduce the amount of time patients need to spend away from their offices • Make in-office appointment times more accessible • Make in-office appointment times more accessible to patients who really need them In addition, PPE and aerosol containment policies and other safety precautions will allow you to make future plans to expand your skills and techniques. Implant Practice US continues to be a trusted source for introspection, invention, implementation, and innovation for your dental practice. Your strength and dedication to your craft and your teams are truly inspirational. In this issue, we feature a CE on esthetic and periodontal benefits of zirconia implants as well as our other CE on essential guidelines for using CBCT as an imaging method for implant procedures. Our marketing column discusses the 10 things dentists should include on their marketing checklist after the COVID-19 crisis, and a case report explains using high-frequency vibration to enhance socket preservation in anticipation of implant placement. This is our last issue for this year, and I think I am joined by all of you in saying that 2021 can’t get here fast enough! We look forward to starting the next year with healing, hope, and vision for a profitable future. As I have said before, stay positive, stay focused, and stay with us as you have over the years. We appreciate and value you, and invite you to contact us regarding submitting articles in 2021. To your best success! Lisa Moler Founder/Publisher MedMark Media

PUBLISHER Lisa Moler lmoler@medmarkmedia.com DIRECTOR OF OPERATIONS Don Gardner don@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA, CDE 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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6 Implant practice

Volume 13 Number 4

PRACTICE PROFILE

Daniel Driskill, DDS, FAGD Seeing that first smile

What can you tell us about your background? I grew up in a small town in the foothills of North Carolina called Mount Airy, the hometown of America’s favorite sheriff, Andy Griffith. My parents and grandparents instilled in me the importance of hard work and dedication — my mother and father attended night school to become a registered nurse and industrial mechanic, respectively. I learned by their example and am gratified to be able to provide top quality healthcare like my mother and work with my hands like my father. Ever since the eighth grade, I knew I wanted to be a dentist. I started out by shadowing the local dentist in my small town of Mount Airy, North Carolina, and was convinced I’d end up being the neighborhood dentist one day. I went to community college before moving on to UNC Chapel Hill, Volume 13 Number 4

and from there went to dental school at the University of Maryland in Baltimore. While I was in college, I met my wife. We spent 5 years in Maryland but always wanted to come back home to North Carolina. After I completed a 1-year general practice residency in York, Pennsylvania, in 2013, we moved to Raleigh, North Carolina, where I began my career as an associate in general dentistry. It was during this time that I really learned how to talk to people, how to empathize, how to relate, and how to build rapport. I decided to venture out on my own, so I bought an existing general dentistry practice. However, implants had always been part of my treatment-planning philosophy, and I was limited in what I could offer my Medicaid patients. A few years later, I received an email from Affordable Dentures & Implants (AD&I) with an opportunity to become a practice owner,

“Tell your patients what they need and give them what they want,” Dr. Driskill says

which would allow me to deliver dentures and implants on a daily basis. I shadowed a fellow practice owner and fell in love with the work there. I have been a practice owner with AD&I for over a year now, and it’s awesome. This practice proudly has nine operatories, five dental assistants, two front desk assistants, Implant practice 7

PRACTICE PROFILE a practice manager, five laboratory staff, and three dentists, including me. I get to do what I love to do every single day.

When did you become a specialist, and why? After 8 years in general dentistry, I witnessed many successful cases, but there were many failures too. There are a number of reasons behind these failures, but the main cause is often a patient’s lack of self-care and routine dental visits. Dentures minimize a patient’s neglect and, ultimately, provide that patient with a beautiful smile. I’m blessed with the opportunity to limit my practice to offering extractions, dentures, and implants. In essence, it’s the simplicity of it all. I love that I get to treat the whole patient instead of one tooth at a time.

Why did you decide to focus on implant dentistry? I believe it’s the standard of care for tooth replacement. We haven’t been able to come up with anything better yet.

Do your patients come through referrals? We have a lot of word-of-mouth referrals. AD&I has a fantastic marketing team, and we have great brand recognition in this area. My practice has been here since the 1970s, so people just know it. Years ago, right after I graduated, I was practicing general dentistry about 5 miles down the road, and I actually referred several patients to this office. I knew that AD&I was able to turn around a denture in a day, compared to the majority of specialists with outside labs where it takes multiple

appointments and 6 weeks for a denture to be delivered. After receiving positive feedback from the patients I referred, I ended up referring even more patients to AD&I.

How long have you been practicing implant dentistry, and what systems do you use? I have been practicing implant dentistry since 2012. In my residency program, I started out using Zimmer, and when I went out into private practice, I learned about Implant Direct™. Here at AD&I we use BioHorizons®.

What training have you undertaken? I did most of my implant training during my residency. I’ve also trained with Bicon® Dental Implants (hands-on practical course); Glidewell (CBCT-guided surgery, complete dentures: clinical procedures, principles of implant occlusion, incorporating sleep medicine into your practice, full arch implant placement — the healed ridge); and the Seattle Study Club® (alternative therapies for TMJ disorders, airway and obstructive sleep apnea, doctor-ceramist communication).

Who has inspired you?

Dr. Daniel Driskill’s forward-thinking mindset is evident by his philosophy of treating the whole patient, instead of one tooth at a time

Dr. Driskill confers with dental assistant, Stephanie Fox, on a patient’s treatment plan 8 Implant practice

I worked for Dr. Chris Martin in Raleigh, North Carolina, and he was the one who opened my eyes to see that it’s really not a single-person circus. His philosophy was to rely on the team — to hire the best of the best, to compensate team members well, to really empower them, and to rely on them to confidently discuss treatment options with patients. I also had the pleasure of working with Dr. Jim Bohn, whose philosophy was based on the Golden Rule. Treat others how you want to be treated. Think about what you would want if you were the patient.

Dr. Driskill discusses various treatment options with a patient from conventional dentures, implant overdentures, and fixed full arch solutions Volume 13 Number 4

PRACTICE PROFILE

Top 10 favorites

Early on in his career, Dr. Driskill learned the importance of hiring the best team and empowering them through delegation, autonomy, and recognition

What is the most satisfying aspect of your practice? The smile. That first smile. I love when patients come in, and we begin with extractions. At first, it’s an unpleasant experience, but it’s nothing that we can’t get them through. And then when we put that denture in, hand them the mirror, and stand back, that’s when we get to watch patients see themselves for the first time.

Professionally, what are you most proud of? Being able to walk into a room with a patient and to confidently, and with good precision, say exactly what I think would improve his/her life the most.

What do you think is unique about your practice? First, we try our best to focus on the whole patient and again, to get away from the one-tooth-at-a-time scenario. I believe that nature loves symmetry. If we can mimic that in the patient’s mouth, we will have a more stable prosthesis. If patients come in and say that they want a whole section of teeth removed on one side and a partial denture, I try to talk them out of it. Second, we try to think ahead here. If a patient has healthy teeth but wants to Volume 13 Number 4

replace missing teeth with implants, I try to set those implants up in such a way that if the natural teeth fail 5 to 10 years down the road, we can transition to a different type of prosthesis later on.

What has been your biggest challenge? I put a lot on my staff. Setting expectations that are less than my own expectations has been challenging for me. I work closely with staff members to get them to a place where they can present treatment plans for 90% of our cases.

What is the future of implants and dentistry? Implants will become the standard of care for tooth replacement. I believe they will replace the fixed partial denture and will take over a larger segment of the market than root canals. In fact, many endodontists are placing implants now. We will get to a place where implants will be affordable for all and replace the denture.

1. Orascoptic HiRes Plus™ 3.8x loupes with Endeavor XL™ headlight 2. EASy (Electronic Anesthesia System) for Open Dental 3. Innerspace Tempo Procedure Carts 4. Kenwood ProTalk radios by Kisco Dental 5. BioHorizons® Tapered Pro dental implant system 6. Canon G16 Digital Dental Camera System by PhotoMed 7. 3M Impregum™ Penta™ polyether impression material 8. Benco Dental emulate® Color Change Alginate 9. Ram Products, Inc.® PB50 Lab Handpiece 10. Baldor polishing lathe

What advice would you give to a budding implant dentist? Start with the end in mind. Be mindful of what the final tooth replacement or prosthesis is going to be.

What would you have been if you didn’t become a dentist? An airline pilot.

What are your tips for maintaining a successful specialty practice?

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

Keep it simple. Nature loves symmetry. Tell people what they need, and give them what they want. Practice the Golden Rule.

I like to build drones. It’s a lot of fun to put those goggles on and watch the trees just fly by. It’s pretty spectacular. IP Implant practice 9

Zimmer Biomet Dental + U A partnership for innovative solutions

Unless otherwise indicated, as referenced herein, all trademarks are the property of Zimmer Biomet; and all products are manufactured by one or more of the dental subsidiaries of Zimmer Biom its authorized marketing partners. This material is intended for clinicians only and does not comprise medical advice or recommendations. Distribution to any other recipient is prohibited. This m Zimmer Biomet Dental. ZB1101 REV A 04/20 ÂŠ2020 Zimmer Biomet. All rights reserved.

er Biomet Holdings, Inc. and marketed and distributed by Zimmer Biomet Dental and d. This material may not be copied or reprinted without the express written consent of

We all want the same thing.

Complimentary, convenient CE. What happens when you connect to the Zimmer Biomet Institute? Youâ&#x20AC;&#x2122;ll have world-class educational opportunities at your fingertips. From live and on-demand web-based programs to live clinical procedural streaming and how-to technique videos, our virtual learning programs provide premium-quality education in the convenience of your own home, office, or anywhere you choose to stream these events. Designed to fit varying learning styles and lifestyles of the modern dental professional. Whether your interest is in emerging digital dentistry innovations or the latest techniques in restorative and implant dentistry with industry leading regenerative solutions. There is something for everyone. Stay connected. Any time. Anywhere. Itâ&#x20AC;&#x2122;s what happens when Zimmer Biomet Dental + U get together. Download the Zimmer Biomet Dental Education app or visit: zimmerbiometdental.com/education

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CASE REPORT

High-frequency vibration (HFV) to enhance socket preservation in anticipation of implant placement: case reports — part 1 Drs. David W. Engen, Gregori M. Kurtzman, and Tarek El-Bialy discuss the rationale for using HFV Introduction In implant dentistry, having adequate bone is imperative to the success of treatment. Patients lose teeth for a variety of reasons, including trauma, nonrestorable decay, endodontic involvement, and periodontal disease. When the decision is made that a tooth must be extracted and that the final goal is a dental implant, two of the major considerations are ridge/socket preservation and ridge/socket augmentation in preparation for the future dental implant. Socket preservation also becomes a consideration when fixed prosthetics will be placed over the edentulous site or when removable nonimplant prosthetics is planned. Ridge or socket preservation can be presented in many forms depending on the nature of the defect. If the socket is

well preserved, the socket may simply be allowed to heal on its own. Araujo and Lindhe showed processes of modeling and remodeling during socket healing that resulted in qualitative and quantitative changes at the edentulous site over an 8-week period. The study reported that dimensional alterations of the alveolar ridge that occurred following tooth extraction as well as bone modeling and remodeling are associated with such change. The study found marked dimensional alterations during the first 8 weeks following the extraction of mandibular premolars. During this time, a marked osteoclastic activity resulted in resorption of the crestal region of both the buccal and the lingual bone wall. The reduction of the height of the walls was more pronounced at the buccal than at the lingual aspect of the extraction socket.

David W. Engen, DDS, MSD, is a board-certified periodontist in private practice in Spokane, Washington. He has a master’s degree in bone physiology, as well as dual training in both Periodontics and Orthodontics. He is a graduate of Indiana University School of Dentistry and received his specialty training there as well. His master’s thesis was observing bone micro-damage around dental implants in the alveolar bone of dogs treated with various bisphosphonates. Gregori M. Kurtzman, DDS, is in private general dental practice in Silver Spring, Maryland, and a former Assistant Clinical Professor at University of Maryland in the department of Restorative Dentistry and Endodontics, and a former AAID Implant Maxi-Course assistant program director at Howard University College of Dentistry. He has lectured internationally on the topics of Restorative dentistry, Endodontics and Implant surgery and prosthetics, removable and fixed prosthetics, Periodontics, and has over 700 published articles globally, as well as several ebooks and textbook chapters. He has earned a Fellowship in the AGD, American College of Dentists (ACD), International Congress of Oral Implantology (ICOI), Pierre Fauchard, ADI, Mastership in the AGD and ICOI and Diplomat status in the ICOI, American Dental Implant Association (ADIA), International Dental Implant Association (IDIA). A consultant and evaluator for multiple dental companies, Dr. Kurtzman has been honored to be included in the “Top Leaders in Continuing Education” by Dentistry Today annually since 2006 and was featured on the June 2012 cover. He can be reached at dr_kurtzman@maryland-implants.com Tarek El-Bialy, BDS MS PhD, is a tenured full-time professor of orthodontics and biomedical engineering at the University of Alberta, Canada. He received a BDS from Tanta University, Egypt, in 1987 and completed a Master’s degree in Orthodontics at Tanta University, Egypt. He received a law degree from Tanta University in 1994. He has successfully completed a certificate of specialty in Orthodontics, Master’s Degree in Oral Sciences and a PhD in Bioengineering at the University of Illinois at Chicago in 2000 and 2001. In addition, he completed an Executive Masters of Business and Administration (EMBA) at the University of Alberta, Canada in 2012. In addition, he recently (June 2019) received a doctoral degree from university of Bonn, Germany. A significant part of Dr. El-Bialy’s work was devoted to repair of orthodontically induced root resorption and biomechanics. Dr. El-Bialy is a fellow of the Royal College of Dentists of Canada (RCDC) and Diplomat of the American Board of Orthodontics. In addition, he is a senior research fellow, von Humboldt Foundation, Germany, since 2013. He also is the director of orthodontics at the RCDC board of directors. Dr. El-Bialy is the past-past president of the Alberta Society of Orthodontists. He has over 100 peerreviewed publications, 12 book chapters, and three books. Disclosure: Dr. David Engen received no compensation, nor has any financial interest in the HFV device. He received five VPro™ units from Propel Orthodontics at no charge. Patients paid full price for the extraction, but no charge for either the HFV or the CBCT scans.

12 Implant practice

Alternatively, post-extraction, the socket may be cleaned of any residual tissue associated with the failed tooth and preserved with a membrane over the top to prevent tissue ingress and to promote clot formation; ultimately, bone growth within the socket will result. Another option is to augment the socket with a collagen plug to act as a scaffold to the blood clot that will form in the socket.3 Finally, the gold standard would be bone augmentation using either human, bovine, or synthetic materials and covering the site with a membrane.4,5 Overall, 25 systematic reviews conclude that ridge preservation reduces post-extraction bone loss and decreases between 55% to 100% of the need for further treatment. Ridge preservation techniques are effective in reducing ridge resorption with varying levels of success.6-29 Some of these include coronal advancement of a buccal flap, rotating grafts from tissue adjacent to cover the defect, or using free gingival or subepithelial connective tissue grafts. A new, novel approach has been suggested to use high-frequency vibration (HFV) to stimulate bone growth. In preclinical studies, HFV has demonstrated a significant increase in osteoblasts and fibroblasts within the periodontal ligament. A study by Alansari, et al., noted that HFV increased the concentration of growth factors such as bone morphogenetic protein (BMP) and platelet-derived growth factor (PDGF).31 Another study found that HFV could potentially enhance osseointegration of implants.32 Alikhani demonstrated an increase in bone volume and an ability for HFV to preserve alveolar bone width and height.33 In a recent case study by Hallas, HFV was used as adjunctive therapy in ridge augmentation in preparation for future implant placement.34 Five patients who are being presented all underwent extraction, followed by a healing period prior to allowing implant placement. The sites were each treated by healing without socket grafting to allow Volume 13 Number 4

13. Bianconi S, Bozzoli P, Del Fabbro M. Treatment of Postextraction Sites With Allograft-Stabilized Dental Implants: A Clinical Case Series. Implant Dent. 2017;26(1):37-45. 14. Horváth A, Mardas N, Mezzomo LA, Needleman IG, Donos N. Alveolar ridge preservation. A systematic review. Clin Oral Investig. 2013;17(2):341-363. 15. Jambhekar S, Kernen F, Bidra AS. Clinical and histologic outcomes of socket grafting after flapless tooth extraction: a systematic review of randomized controlled clinical trials. J Prosthet Dent. 2015;113(5):371-382. 16. Lee JS, Cha JK, Kim CS. Alveolar ridge regeneration of damaged extraction sockets using deproteinized porcine versus bovine bone minerals: A randomized clinical trial. Clin Implant Dent Relat Res. 2018;20(5):729-737. 17. Lee JS, Choe SH, Cha JK, Seo GY, Kim CS. Radiographic and histologic observations of sequential healing processes following ridge augmentation after tooth extraction in buccal-bone-deficient extraction sockets in beagle dogs. J Clin Periodontol. 2018;45(11):1388-1397.

VPro in use (photo courtesy of Dr. Victor Soria)

organization of the resulting clot and bone fill prior to implant placement. The patients were all premedicated with 500 mg Amoxicillin 3 times daily, beginning the night before the extraction. Following extraction of the tooth, the sockets were thoroughly degranulated and a post-extraction CBCT was taken. All five patients had an extraction, with no socket augmentation and were given an HFV device (VPro™, Propel Orthodontics) used for 5 minutes daily post-extraction until the sites were ready for implant placement. The patients returned 4 to 6 months later at which time another CBCT (pre-implant) was taken for site comparison purposes. The dental implants were placed. These patients were informed that should the HFV not produce sufficient bone for their future implant that any post-test, pre-implant bone grafting necessary would be performed at no additional charge. Part 2 of this two-part article will review the five patient cases that follow what has been discussed here. The patients were examined by CBCT immediately following extraction, wherein density was determined (Hounsfield units) for the extraction socket and a reference at the adjacent cortical bone of the socket wall. Following a 4- to 6-month healing period (patient specific), a new CBCT was acquired, and a density determination was taken at the same spot in the extraction socket as in the prior CBCT scan as well as the same adjacent point on the cortical socket wall. The reference point was used to confirm that the cortical density was similar in both scans so that a determination of the effects of HFV on the socket contents could be ascertained and confirm whether the area increased in density. The results confirm that Volume 13 Number 4

Propel Orthodontics VPro

HFV has a positive effect on bone formation and increases its density, accelerating socket bone maturation. IP

18. MacBeth N, Trullenque-Eriksson A, Donos N, Mardas N. Hard and soft tissue changes following alveolar ridge preservation: a systematic review. Clin Oral Implants Res. 2017;28(8):982-1004. 19. Mardas N, Trullenque-Eriksson A, MacBeth N, Petrie A, Donos N. Does ridge preservation following tooth extraction improve implant treatment outcomes: a systematic review: Group 4: Therapeutic concepts & methods. Clin Oral Implants Res. 2015;26(suppl 11):180-201. 20. Moraschini V, Barboza Edos S. Quality assessment of systematic reviews on alveolar socket preservation. Int J Oral Maxillofac Surg. 2016;45(9):1126-1134. 21. Moraschini V, Barboza ES. Effect of autologous platelet concentrates for alveolar socket preservation: a systematic review. Int J Oral Maxillofac Surg. 2015;44(5):632-41.

REFERENCES 1. Araujo M, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Perio. 2005;32(2)212-218

22. Chan HL, Lin GH, Fu JH, Wang HL. Alterations in bone quality after socket preservation with grafting materials: a systematic review. Int J Oral Maxillofac Implants. 2013;28(3):710-720.

2. Faria-Almeida R, et al. Extraction socket preservation with or without membranes, soft tissue influence on post extraction alveolar ridge preservation: a systematic review. J Oral Maxillofac Res. 2019;10(3):e5.

23. Morjaria KR, Wilson R, Palmer RM. Bone healing after tooth extraction with or without an intervention: a systematic review of randomized controlled trials. Clin Implant Dent Relat Res. 2014;16(1):1-20.

3. Nisar N, Nilesh K, Parkar MI, Punde P. Extraction socket preservation using a collagen plug combined with plateletrich plasma (PRP): A comparative clinico-radiographic study. J Dent Res Dent Clin Dent Prospects. 2020;14(2):139-145.

24. Moslemi N, Khoshkam V, Rafiei SC, Bahrami N, Aslroosta H. Outcomes of Alveolar Ridge Preservation With Recombinant Human Bone Morphogenetic Protein-2: A Systematic Review. Implant Dent. 2018;27(3):351-362.

4. Sakkas, A, Wilde F, Heufelder M, Winter K, Schramm A. Autogenous bone grafts in oral implantology — is it still a “gold standard”? A consecutive review of 279 patients with 456 clinical procedures. Int J Implant Dent. 2017;3(1):23.

25. Natto ZS, Parashis A, Steffensen B, et al. Efficacy of collagen matrix seal and collagen sponge on ridge preservation in combination with bone allograft: A randomized controlled clinical trial. J Clin Periodontol. 2017;44(6):649-659.

5. Spagnoli DB, Niquette CC Jr. Reconstruction of the Extraction Socket: Methods, Manipulations, and Management. Oral Maxillofac Surg Clin North Am. 2020;32(4):593-609.

26. Ten Heggeler JM, Slot DE, Van der Weijden GA. Effect of socket preservation therapies following tooth extraction in non-molar regions in humans: a systematic review. Clin Oral Implants Res. 2011;22(8):779-788.

6. Atieh MA, Alsabeeha NH, Payne AG, et al. Interventions for replacing missing teeth: alveolar ridge preservation techniques for dental implant site development. Cochrane Database Syst Rev. 2015;2015(5):CD010176.

27. Vignoletti F, Matesanz P, Rodrigo D, et al. Surgical protocols for ridge preservation after tooth extraction. A systematic review. Clin Oral Implants Res. 2012;23(suppl 5):22-38.

7. Avila-Ortiz G, Elangovan S, Kramer KW, Blanchette D, Dawson DV. Effect of alveolar ridge preservation after tooth extraction: a systematic review and meta-analysis. J Dent Res. 2014;93(10):950-958.

28. Vittorini Orgeas G, Clementini M, De Risi V, de Sanctis M. Surgical techniques for alveolar socket preservation: a systematic review. Int J Oral Maxillofac Implants. 2013;28(4):1049-1061.

8. Avila-Ortiz G, Chambrone L, Vignoletti F. Effect of alveolar ridge preservation interventions following tooth extraction: A systematic review and meta-analysis. J Clin Periodontol. 2019;46(suppl 21):195-223. Erratum in: J Clin Periodontol. 2020 Jan;47(1):129.

29. Willenbacher M, Al-Nawas B, Berres M, Kämmerer PW, Schiegnitz E. The Effects of Alveolar Ridge Preservation: A Meta-Analysis. Clin Implant Dent Relat Res. 2016;18(6):1248-1268.

9. Castro AB, Meschi N, Temmerman A, et al. Regenerative potential of leucocyte- and platelet-rich fibrin. Part B: sinus floor elevation, alveolar ridge preservation and implant therapy. A systematic review. J Clin Periodontol. 2017;44(2):225-234. 10. Corbella S, Taschieri S, Francetti L, Weinstein R, Del Fabbro M. Histomorphometric Results After Postextraction Socket Healing with Different Biomaterials: A Systematic Review of the Literature and Meta-Analysis. Int J Oral Maxillofac Implants. 2017;32(5):1001–1017.

30. Judex S, Pongkitwitoon S. Differential efficacy of 2 vibrating orthodontic device to alter the cellular response in osteoblasts, fibroblasts, and osteoclasts. Dose Response. 2018; 16(3)1-8. 31. Alansari S, Antiqu MI, Gomez JP, et al. the effects of brief daily vibration on clear aligner orthodontic treatment. J World Fed Orthod. 2018;7(4)134-140. 32. Akca k, Sarac E, Baysal U, et al. Micro-morphologic changes around biophysically-stimulated titanium implants in ovariectomized rats. Head Face med. 2007;3:28.

11. Chan HL, Lin GH, Fu JH, Wang HL. Alterations in bone quality after socket preservation with grafting materials: a systematic review. Int J Oral Maxillofac Implants. 2013;28(3):710-20.

33. Alikhani M, Khoo E, Alyami B, Raptis M, Salgueiro JM, Oliveira SM, Boskey A, Teixeira CC. Osteogenic effect of high-frequency acceleration on alveolar bone. J Dent Res. 2012;91(4)413-419.

12. De Risi V, Clementini M, Vittorini G, Mannocci A, De Sanctis M. Alveolar ridge preservation techniques: a systematic review and meta-analysis of histological and

34. Hallas M. High-frequency vibration for normalizing tooth mobility and improving bone for implant: a case study. Implant Practice US. 2020;13(1):8-20.

Implant practice 13

CASE REPORT

histomorphometrical data. Clin Oral Implants Res. 2015 Jan;26(1):50-68. doi: 10.1111/clr.12288. Epub 2013 Nov 1. PMID: 27007188.

CASE STUDY

Rehabilitation of a severely dental-phobic patient with a maxillary removable prosthesis and a mandibular fixed-detachable hybrid prosthesis Drs. S.K. El-Ebrashi and J.M. Burstein, and Mr. E. Mazone illustrate a collaborative effort while treating a patient with high dental anxiety Introduction This clinical report demonstrates the management of a patient with dental anxiety and dental phobia due to a traumatic experience at the dentist as a child, in which a single-surgery approach was used and no local anesthetic for future appointments. The management of the patient was performed at the ClearChoice Dental Implant Center in Portland, Oregon. The entire dental team, lab, and staff were together in the same center, making the process collaborative, efficient, and helpful in managing the patientâ&#x20AC;&#x2122;s dental anxiety and phobia.

Traumatic dental experiences can make patients reluctant to seek care Many patients have had traumatic dental experiences as children, making them reluctant to pursue future dental treatment.1 Psychosocial factors that prevent patients from accessing dental care include their education levels, socioeconomic status, age, gender, ethnicity, dental anxiety, and perceived vulnerability.2 High dental anxiety may be the primary reason patients do not pursue dental treatment.3

Humans learn by conditioning There are techniques for helping patients overcome their dental anxiety. Hypnosis

Sameh K. El-Ebrashi, BDS, MS, FACP, is a Prosthodontist at ClearChoice Dental Implant Center of Portland, Oregon.

Jeffrey M. Burstein, DDS, MD, is an Oral and Maxillofacial Surgeon at ClearChoice Dental Implant Center of Portland, Oregon.

Eric Manzone, CDT, is a Certified Dental Technician.

14 Implant practice

Figure 2: Pretreatment close-up of smile

Figure 1: Pretreatment frontal view

maybe useful for some patients.4 Systematic desensitization is another approach used to gradually expose new procedures to calm a patientâ&#x20AC;&#x2122;s anxiety.5 Managing patients who are truly dental-phobic requires the use of a calming manner, anxiolytic medications prior to dental treatment, and intravenous medications for sedation during surgery.

Figure 3: Maxillary preoperative occlusal view

Clinical report A 40-year-old male patient presented to our clinic with a chief complaint of pain and embarrassment of his appearance. The patient hadnâ&#x20AC;&#x2122;t seen the dentist in more than 20 years and had many infected and broken teeth. Medical history was nonsignificant. Vital signs were normal.

Examination The patient was not under the care of a physician. He was extremely anxious regarding any dental appointments and was very needle-phobic. Extraoral examination The extraoral examination revealed a symmetrical face with a short upper lip

Figure 4: Mandibular preoperative occlusal view

(Figure 1). The patient had a gummy smile with significant exposure of maxillary gingival tissues (Figure 2). His range of motion and opening were normal, and no abnormality was detected with the temporomandibular joints or muscles of mastication. Intraoral examination The intraoral exam revealed a significant number of fractured, non-restorable teeth (Figures 3 and 4). Volume 13 Number 4

Imaging A cone beam computed tomography (CBCT) and a panoramic radiograph were obtained (Figure 6). They revealed multiple failing teeth with significant caries and multiple periapical radiolucent lesions around teeth Nos. 2 to 5, 11 to 14, 18, 19, 22, 30, and 31. There was ample mandibular bone for implants after extraction of all teeth and removal of infection. There was a lack of posterior maxillary bone for implants due to sinus pneumatization.

Diagnosis 1. Non-restorable maxillary and mandibular dentition 2. Class II malocclusion 3. Vertical maxillary excess 4. Posterior alveolar hyperplasia 5. Unacceptable esthetics

Treatment plan 1. Extraction of all teeth and alveoplasty of excessive maxillary bone prior to delivery of a maxillary immediate complete denture

Figure 5: Maximal intercuspal position

Figure 7: Presurgical arrangement Volume 13 Number 4

2. Extraction of all mandibular teeth and placement of four implants between the mental foramina. In the anterior mandible, implants were planned axially versus tilted posterior implants to avoid the mental foramen and increase the anterior-posterior (A-P) spread 3. After healing, fabrication of a cobaltchrome reinforced maxillary complete denture and a CAD/CAM titanium/ acrylic-fixed hybrid prosthesis 4. Follow-up with the patient every 6 months

Prosthetic phase After the review of the CBCT, adequate bone existed for mandibular implants after the creation of adequate prosthetic space by a pre-implant alveoplasty for a hybrid prosthesis. Impressions were made, and casts were articulated accordingly. Teeth were arranged in a Class I relationship (Figure 7). A maxillary immediate complete denture was fabricated. Heat-polymerized acrylic resin was used to fabricate a mandibular removable prosthesis that would be modified into a fixed provisional prosthesis. Both prostheses were duplicated in clear acrylic resin that served as the surgical template.

Surgical phase The patient was given a preoperative benzodiazepine to decrease anxiety prior

to surgery, followed by intravenous sedation administered by a certified registered nurse anesthetist (CRNA) with appropriate monitoring (EKG lead, pulse oximeter, blood pressure cuff, and carbon dioxide monitoring). Profound local anesthesia was achieved, all teeth were extracted, and bone was reduced according to the surgical templates. Four 13 mm long Nobel Biocareâ&#x201E;˘ (NobelActiveÂŽ) implants were placed in the mandible with a primary torque of 50 Ncm. Straight abutments were placed on the anterior implants, and 30-degree multi-unit abutments (MUAs) were placed on the tilted implants. White healing caps were placed, and continuous sutures helped obtain primary closure and ensure adequate hemostasis. Postoperative periapical radiographs were taken prior to the prosthodontics phase of treatment (Figure 8).

Prosthodontic phase High primary torque of the implants allowed for immediate prosthetic loading. A vinyl polysiloxane (VPS) putty material was used to make an abutment-level impression. Anterior abutment positions were indexed in the provisional prosthesis, and holes were drilled in the No. 23 and No. 26 positions. After attaching temporary copings in the No. 23 and No. 26 positions, auto-polymerizing acrylic resin was syringed to secure the copings to the prosthesis. Rigidity of the components in the prosthesis was verified

Figure 6: Preoperative panoramic radiograph

Figure 8: Postsurgical periapical radiographs Implant practice 15

CASE STUDY

Teeth Nos. 6 to 10 and 23 to 26 were mostly intact. The patient had a Class II Division II anterior malocclusion with a deep overbite. He also had posterior bony hyperplasia and super-eruption of posterior alveolar ridges with no interarch space in the maximum intercuspal position (Figure 5).

CASE STUDY

Figure 10: Wax try-in appointment

Figure 9: Four-month panoramic radiographs

Figure 12: Radiographs of mandibular titanium framework

Figure 13: Radiographs after 5 years postoperatively

Figure 11: Cameo surface of maxillary cobalt-chrome complete denture

before sending it to the dental laboratory for processing into a fixed-detachable prosthesis. The prosthesis was delivered, and periapical radiographs were taken to verify seating prior to occlusal adjustment.

Definitive prostheses Healing was uneventful, and 4 months later a panoramic radiograph was taken (Figure 9). The patient was asked about esthetic or functional changes to the definitive prostheses, and notes were made accordingly. New definitive impressions were made using custom trays for both prostheses. New master casts were fabricated and articulated on a semi-adjustable articulator. Teeth were rearranged for another wax try-in, verifying esthetics and the maxillomandibular relationship (Figure 10). After making appropriate changes to the teeth, the master casts were indexed prior to fabrication of a cobalt-chrome maxillary framework (Figure 11) and a mandibular CAD/CAM titanium framework. Both frameworks were fabricated and tried-in. Periapical radiographs were taken to verify a passive fit of the mandibular fixed hybrid prosthesis (Figure 12). 16 Implant practice

Figure 14: Occlusal view of the mandibular arch with multiunit abutments after 5 years

Both prostheses were processed according to the manufacturer’s instructions, and the occlusion was evaluated for centric relation and centric occlusion to be coincident using a bilateral balanced occlusal scheme. Home care instructions were given, and the use of a water flosser demonstrated. The patient was instructed to maintain good oral hygiene and return to the dentist for regular examinations. He was contacted 1 month later but failed to attend any appointments for 5 years. After 5 years, the patient was concerned a filling had come out from the lower prosthesis. Radiographs taken showed excellent bone levels around the implants (Figure 13), and clinically, the soft tissues were healthy (Figure 14).

Conclusion It is important to consider the consequences of dental phobia for our patients and how it impacts their daily lives. Patients do not wish to live with physical pain or

Figure 15: Five years posttreatment frontal view

isolation and must be treated with understanding. This case demonstrates the management of such a patient using sedation for surgery and an implant-supported hybrid prosthesis. IP

REFERENCES 1. Freeman R. Barriers to accessing dental care: Patient factors. Br Dent J. 1999;187(3): 141-144. 2. Nuttall N. Review of attendance behavior. Dent Update. 1997; 24(3):111–114. 3. Vassend O. Anxiety, pain and discomfort associated with dental treatment. Behav Res Ther. 1993; 31(7):659–666. 4. Armfield JM. Management of fear and anxiety in the dental clinic: A review. Aust Dent J. 2013; 58(4):390–407. 5. Berg M. Dental fear in children: clinical consequences. Suggested behavior management strategies in treating children with dental fear. Eur Arch Paediatr Dent. 2008;9 (Suppl 1):41–46.

Volume 13 Number 4

ZERAMEX 3.5 is THE COSMETIC IMPLANT

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www.ZeramexUSA.com/offer

Visit www.ZeramexUSA.com/offer or call 786 622 2016 to receive FREE patient education materials including a 1:6 scale model of the ZERAMEX XT system for in office patient demonstrations.

CONTINUING EDUCATION

Esthetic and periodontal benefits of zirconia implants Drs. Paresh Patel, Apolinar Madrigal, and Gregori M. Kurtzman discuss challenges with implants in the esthetic zone Introduction Esthetics can be challenging under normal circumstances around natural teeth. When teeth are to be replaced with implants, especially in the esthetic zone, gingival tissue can complicate the desired results. Patients with thin and/or translucent gingival tissue, referred to as “thin tissue biotype,” will allow show-through of the implant leading to a darker gingiva overlying that area and decrease the esthetics of the patient’s smile (Figure 1). Those patients who have been missing the anterior tooth for a period of time, resulting in resorption of the facial plate even with a thicker gingival tissue, will lead to less bone over the implant on the facial aspect of the ridge. The result, as with thin tissue biotypes, is a darker shadow over the underlying implant that hampers the esthetic result and does not blend with the adjacent tissue over the natural teeth.

Educational aims and objectives

This article aims to discuss challenges with implants in the esthetic zone and possible solutions to these issues.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 24 or take the quiz online at implantpracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Realize how some implant materials may appear as a gray shade and affect implant esthetics in patients with certain gingival types.

•

Identify how to prevent peri-implantitis issues that could affect the esthetics and long-term survival of implants and the restorations.

•

Realize some characteristics of the durability under function of zirconia implants.

•

Recognize some connections between implants and the possibility of developing peri-implantitis.

•

Observe how patients with certain biotypes can overcome certain esthetic challenges.

Paresh Patel, DDS, is a graduate of the University of North Carolina at Chapel Hill School of Dentistry and the Medical College of Georgia/AAID MaxiCourse. He is a fellow of the Misch International Implant Institute and a diplomate of the ICOI. Dr. Patel is in private general practice in Mooresville, North Carolina and can be reached at pareshpateldds2@gmail.com. Apolinar Madrigal, DDS, is a restorative dentist with practices in Ceres, California, as well as Leon, Mexico. He is focused on cosmetic and minimally invasive dentistry with special interest in functional. Dr. Madrigal is also an international lecturer with courses taught in the United States, Mexico, Italy, Abu Dhabi, and India. He can be reached at 87madrigal@gmail.com. Gregori M. Kurtzman, DDS, MAGD, FAAIP, FPFA, FACD, FADI, DICOI, DADIA, is in private general dental practice in Silver Spring, Maryland. He is a former Assistant Clinical Professor at University of Maryland in the department of Restorative Dentistry and Endodontics, and is a former AAID Implant Maxi-Course assistant program director at Howard University College of Dentistry. He has lectured internationally on the topics of restorative dentistry, endodontics, and implant surgery; and prosthetics, removable and fixed prosthetics, and periodontics. Dr. Kurtzman has over 700 published articles globally, several ebooks, and textbook chapters. He can be reached at dr_kurtzman@ maryland-implants.com. Disclosure: Drs. Patel and Madrigal are compensated speakers for Zeramex USA, and Dr. Kurtzman has received an honorarium for writing of the article.

18 Implant practice

Figure 1: Discoloration of the gingiva at the right central incisor related to titanium implant show-through on a patient with a thin tissue biotype

Esthetic issues with titanium implants in the esthetic zone The old axiom — “the bone sets the tone, but the tissue is the issue” — has been voiced in implant dentistry for decades. But what lies in the bone, the implant, has a direct effect on the resulting esthetics and goes hand-in-hand with the bone and soft tissue. Titanium implants, no matter the brand, are a gray shade and may affect esthetics in the esthetic zone of some patients. Studies have reported that under healthy periodontal conditions on natural teeth, the facial

thickness of bone covering the anterior roots is 1.73 mm or less.1 Other studies found a mean thickness of the labial alveolar bone overlying maxillary anterior teeth — between 1 mm to 1.2 mm and between 0.5 mm to 0.8 mm for mandibular anterior teeth — creating the potential for more esthetic issues when replacing missing or to-be extracted teeth in the lower anterior.2,3 Bone thickness around the maxillary anterior teeth at 4 mm and 6 mm apical to the cementoenamel junction (CEJ) was significantly different in thick and thin gingival biotypes. Volume 13 Number 4

Case examples Case 1: Anterior site with osseous defect following healing prior to implant placement This 42-year-old female patient presented seeking a replacement for a missing left maxillary central incisor that had been extracted, and the site had completely healed. A depression was noted on the facial of the extraction site-related resorption during healing (Figure 2). Examination noted that some gingival display was visible when the patient smiled that could affect overall esthetics related to the thin tissue biotype and implant shown through that area of the gingiva following implant placement (Figure Volume 13 Number 4

Figure 3: The patientâ&#x20AC;&#x2122;s smile line demonstrates gingival display at the missing left central incisor, which may potentially create an esthetic issue with her thin biotype and placement of a titanium implant Figure 2: Patient with a thin tissue biotype missing the left central incisor, which has been treatment planned for implant placement

Figure 5: Following a healing period to allow osseointegration of the implant, the implant was uncovered to initiate restoration of the zirconia implant. Note the facial concavity compared to the adjacent natural central incisor resulting from osseous resorption during the period of extraction and implant placement, spanning over a year with the thin tissue biotype over the entire anterior segment of the arch

Figure 4: A zirconia two-piece implant (ZERAMEX) has been placed at the missing left central incisor Figure 6: Zirconia abutment placed into the zirconia implant, noting lack of gingival discoloration related to the thin tissue biotype, which frequently occurs with placement of a titanium implant affecting the overall esthetics

Figure 7: Final esthetics at the left central incisor with placement of a zirconia implant (ZERAMEX), a zirconia abutment, and ceramic crown with prevention of gingival darkening in a thin tissue biotype, which often is found with titanium implant placement

Figure 8: Natural esthetics achieved in a patient with a thin tissue biotype with utilization of a zirconia implant (ZERAMEX) zirconia abutment and ceramic crown

3). Treatment options were discussed with the patient that included use of a zirconia implant to eliminate gingival darkening of the thin gingiva or use of a titanium implant that would require additional surgical procedures (connective tissue graft) to thicken the tissue and attempt to mask the darker implant placed at the site. After reviewing her options, the patient chose to pursue the zirconia implant without the need for connective tissue grafting.

A two-piece zirconia implant (ZERAMEXÂŽ, Spreitenbach, Switzerland) was placed under local anesthetic with minimal tissue reflection, a tissue-level healing abutment was placed, and the site closed to allow for healing (Figure 4). Following a 16-week healing period, the healing abutment was removed from the implant to begin the restorative phase. A lack of inflammation was noted in the soft tissue around the implant demonstrating biocompatibility and host response (Figure Implant practice 19

CONTINUING EDUCATION

Additionally, the thickness of crestal bone was significantly different between the two gingival biotypes with thinner bone in thin gingival biotype patients than in those with thicker gingival biotypes.4 So, what lies within the bone has an effect based on its color on the esthetics of the overlying gingiva. As titanium has a gray color, a darkening results unless a minimum of 3 mm thickness of gingiva is present. But that does not occur with zirconia implants, which are white in shade and have a neutral effect on the gingival tone. Attempts have been made to overlay the facial aspect of the ridge with osseous graft material or connective tissue to thicken what covers the implant within the bone to improve esthetics with titanium implants.5-7 This may work in some patients but has potential complications. Those include a facial that is thicker than adjacent areas affecting the esthetics (eliminate one problem but substitute another for it), increased number of surgical procedures, and the costs involved for treatment. When compared with titanium, zirconia has a favorable esthetic and periodontal response. These complex therapy concepts are unnecessary with zirconia implants. The peri-implant soft tissue around titanium and zirconia abutments showed color differences when compared to the soft tissue around natural teeth, and the peri-implant soft tissue around zirconia demonstrated a better color match to the soft tissue than titanium.8 This can be extrapolated to the esthetics of the color of the implant itself. Zirconia implants have been offered as an alternative to titanium implants in these esthetic situations, with the white shade of the implant eliminating any potential for darkening of the gingival tissue and providing a more natural final esthetic result than possible with titanium implants.9

CONTINUING EDUCATION 5). A closed-tray impression was taken for customization at the lab of the zirconia abutment and the final crown. A customized zirconia abutment was fabricated by the lab and fixated to the implant with a VICARBO® carbon fiber screw (ZERAMEX) (Figure 6). A BruxZir® zirconia ceramic crown (Glidewell Labs, Newport Beach, California) was returned from the lab and luted to the abutment head with Premier® Implant Cement™ (Premier Dental Products, Plymouth Meeting, Pennsylvania) with the resulting treatment providing a natural esthetic without gingival darkening from the underlying implant in this thin biotype patient and without the need for grafting to mask the implant within the bone (Figures 7 and 8). Case 2: Immediate implant placement A 37-year-old female patient presented with a nonrestorable right lateral incisor that presented with a vertical root fracture necessitating extraction. Placement of an implant at time of extraction was discussed with the patient and depending on insertion torque placement of an immediate provisional restoration. The patient had a thin tissue biotype and some discoloration related to showthrough of the dark root underlying the tissue and thin overlying bone at the site. The tooth was atraumatically extracted under local anesthetic in a flapless technique (Figure 9). The osteotomy was prepared and a 3.5 mm x 10 mm two-piece zirconia implant (ZERAMEX XT) was placed into the site (Figure 10). A two-piece zirconia implant offers comparable flexibility of titanium implants — the implant can be placed and allowed to heal before initiation of the restorative phase, and immediate loading required in one-piece zirconia implants is avoided. Additionally, the smaller diameter implant used in this case can accommodate narrower ridges and permit greater thickness of bone on the facial then achievable with wider diameter zirconia implants available. An osseous gap was noted crestally between the implant and facial extraction wall, which was filled with Geistlich Bio-Oss® (Geistlich Pharma, Zürich, Switzerland), and a provisional abutment was placed onto the implant and screw access hole filed with a piece of Teflon® tape to prevent provisional resin blockage to the fixation screw (Figures 11 and 12). A screw-retained provisional crown was fabricated intraorally, then removed, and contour was completed to develop the emergence profile extraorally (Figure 13). The screw-retained provisional restoration 20 Implant practice

Figure 9: Extraction of a failing right lateral incisor with plan to place immediate implant at the site

Figure 10: A zirconia implant (ZERAMEX) is being inserted into the prepared osteotomy in the immediate extraction socket

Figure 11: Osseous graft has been placed in the gap between the zirconia implant (ZERAMEX), which has a provisional abutment seated on the implant and facial socket wall

Figure 12: Facial view of the provisional abutment seated on the zirconia implant (ZERAMEX) at the immediate placement into the extraction socket following placement of osseous graft into the facial gap at the osteotomy

Figure 13: Provisional screw-retained crown with proper emergence profile ready to be placed on the immediate implant

Figure 14: Periapical radiograph of the immediate placed zirconia implant (ZERAMEX) and provisional restoration at the time of surgical placement Volume 13 Number 4

was inserted, and a radiograph was taken to verify mating of the provisional restoration and implant and to document bone levels at implant placement (Figure 14). Clinically, minimal inflammation was noted on the facial at the immediate placement, and the soft tissue support mimicked the tooth being replaced (Figure 15). Postoperative examination at 2-weeks post-implant placement and immediate provisionalization demonstrated a facial arch contour in harmony and gingival tone blending with the adjacent sites in this thintissue biotype patient (Figure 16). The final ceramic restoration was placed at 4 months post-implant immediate implant insertion demonstrating a natural tone to the gingiva and bone overlying the implant replicating natural esthetics (Figure 17).

Periodontal concerns Patients frequently require implant placement due to inadequate homecare over time leading to either periodontal disease of the natural tooth or structural breakdown related to caries and repeated restorations leaving insufficient tooth structure to maintain the tooth. Homecare may be improved by patients, but often they fall back into old habits. Providing replacement of the missing teeth with materials that are easier to maintain by patients in the case of implants aids in preventing peri-implantitis issues that will affect the esthetics and long-term survival of the implants and the restorations upon them. Dental implants that are made from titanium or zirconia are available, and both materials have demonstrated successful clinical Volume 13 Number 4

Figure 16: Two-week postoperative check of the immediately placed and provisionalized zirconia implant (ZERAMEX) demonstrating an absence of gingival inflammation, with healthy soft tissue at the site

use over long periods of time with similar biocompatibility and osseointegration.10 It is well accepted that the bacteria and their products in plaque (oral biofilm) are associated with periodontal inflammation around both natural teeth and dental implants. In the case of implants, this may lead to periimplantitis with associated bone loss and osseous support of the implant and potential loss of that implant. This relates to the difference in fiber orientation in the gingival attachment when comparing natural teeth to implants. Natural teeth have those fibers originating in the gingival tissue attached to the tooth’s root in a perpendicular direction to the tooth’s long axis creating a resistant barrier to bacterial progression apically. However, those fibers are oriented in a parallel direction around implants, providing a less resistant barrier to progression of periodontal issues that may lead to peri-implantitis.11-13 Peri-implantitis has been closely associated with the bacteria in oral biofilm and the inflammation that ensues when in proximation to the gingival tissues.14 Studies have demonstrated that biofilm adhesion on implants fabricated from zirconia are superior to titanium surfaces with respect to initial bacterial adhesion and biofilm formation.15-17 No inflamed or multinucleated cells were present in studies with zirconia implants, demonstrating their high biocompatible and osteoconductive properties.18 An increasingly troubling percentage of titanium implants are diagnosed with periimplantitis following 10 years in function, with a low number lost for primarily reasons other than biofilm-induced infection.19

Figure 17: Final ceramic restoration on the ZERAMEX zirconia implant demonstrating a natural tone to the gingiva and bone overlaying the implant replicating natural esthetics

The literature has reported that titanium may undergo corrosion and release of titanium ions. Although titanium is perceived to be “biocompatible” related to the presence of a passive oxide film over the metal surface, deterioration can lead to the release of titanium ions.20 This surface deterioration can result in peri-implant inflammation. Bacteria found in the oral biofilm creates an acidic environment that leads to corrosion of the implant surface supracrestal to the bone.21 It has been reported that greater levels of dissolved titanium have been detected in plaque around implants with peri-implantitis compared with healthy implants — thus, indicating an association between titanium dissolution and peri-implantitis.22-25 Zirconia has not been reported to have acidic breakdown from the bacteria in the biofilm and has no ion release that can contribute to inflammation and eventual onset or peri-implantitis. Surface modifications of the implant surface during manufacturing has been reported to result in higher hydrophilicity, further increasing the speed of Implant practice 21

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Figure 15: Screw-retained provisional crown on the immediate implant at time of surgical placement of the zirconia implant and provisionalization demonstrating inflammation at the gingiva

CONTINUING EDUCATION osseointegration of titanium and titaniumzirconium implants. Surface modifications of zirconia and alumina-toughened zirconia implants also have an influence on osseointegration speed. Zirconia implants with modified surfaces display features of osseointegration similar to those of titanium implants.26,27 The bio-inert properties of the zirconia implant aid in rapid proliferation of the gingival fibroblasts leading to formation of a stable mucosal barrier to prevent periodontal issues related to biofilm present gingivally.28,29 Zirconia implants have been reported to inhibit bacterial adhesion and biofilm formation on their surface. This relates to its hydrophobicity, bio-inert properties, with reduced surface free energy and surface wettability.30 Various studies have reported a reduction in the number of cocci and rods associated with zirconia implants (increase in levels of Streptococcus mutans with less Streptococcus sanguis) compared to titanium implants. This enhances perio-integration around zirconia implants, while preventing the development of peri-implant bone resorption and periimplant soft inflammation associated with peri-implantitis.31,32 Modified zirconia implants show a resistance to torque forces (improved stability in bone) similar to that of oxidized implants and a four- to fivefold increase compared with machined zirconia implants. The findings suggest that surface-modified zirconia implants can reach firm stability in bone.33 Modified zirconia surfaces demonstrate faster osseointegration than that on untreated zirconia implant surfaces.34 Additionally, bone-implant contact (BIC) and resistance torque (RT) of zirconia implants in most of the studies analyzed when compared with titanium implants did not show statistical differences.35,36 With submerged zirconia and titanium implants (two-piece), the implant surface showed an intimate connection to the adjacent bone, with both implant types achieving a BIC of 53%. For the non-submerged zirconia implants (one-piece), some crestal epithelial downgrowth was reported, with a resultant BIC of 48%. Highest relative periimplant bone-volume density (rBVD) values were reported for submerged zirconia (80%), followed by titanium (74%) and non-submerged zirconia (63%). The results suggest that unloaded zirconia and titanium implants osseointegrate comparably, within the healing period studied.37-38 22 Implant practice

Comparable osseointegration between the two implant materials, and with the availability of two-piece implants, zirconia implants are an alternative to traditional titanium implants.

Studies have reported success rates that are comparable between the two implant materials with no difference found in the rate of osseointegration between the different implant materials.39,40 No statistically significant differences between zirconia and titanium have been reported after a healing period of 4 and 12 weeks. The RT values of both implant types increased significantly from the 8-week to the 12-week healing period.41 Additionally, zirconia and titanium implants demonstrate a similar soft- and hard-tissue integration capacity providing comparable options from a biointegration and periodontal health standpoint.42 The overall implant success rate of zirconia implants after 5 years of follow-up was 95%.43 This is supported by other more recent studies reporting a survival rate was 98.5% at 3 years in function,44 and 94.3% at 5 years.45 Furthermore, a two-piece zirconia implant, ZERAMEX (ZERAMEX, Miami, Florida) exhibited an average success rate of 99.4%. A study indicated an average success rate of ZERAMEX T (96.4%) and of ZERALOCK™ (98.4%) demonstrating comparable success to reported values for titanium implants.46,47 The present two-piece zirconia implants show a similar bone integration compared to the titanium implant with similar surface morphology after 4 and 16 weeks of loading.48,49 This provides the option of a delayed loading approach that presented objections with some clinicians with onepiece zirconia implants. This is not available with one-piece zirconia implants that require immediate loading due to the supracrestal restorative head and presented objections with some clinicians. Additionally, orientation of the restorative head in a one-piece implant may complicate restoration due to the angulation of the head in relation to angle the implant was placed in the maxillary anterior, which itself relates to the “triangle of bone” present to accommodate the implant.

Durability under function Some practitioners have expressed concern about the durability of zirconia implants under functional loading in comparison to their titanium counterparts. Investigations of one-piece zirconia implants reported modification of the implant head resulted in a decrease in fracture strength. However, within the limits of in vitro investigations, it can be concluded that those zirconia implants will withstand functional loading over an estimated period of 20 years.50 Nevertheless, even the lowest values of mean fracture strength of these implants were able to withstand average occlusal forces even after an extended interval of loading.51 Two-piece zirconia implants demonstrate greater fracture resistance than one-piece implants.52 Two-piece implants also allow the practitioner to delay loading the implants and have custom abutments fabricated should angulation need correcting between the implant axis and prosthetic axis. Additionally, the carbon fiber reinforced fixation screw, the potential weak point compared to a metal fixation screw found that hydrothermal aging and dynamic loading did not result in screw fracture.53,54 Ensuring a durable connection between the implant and abutment.

Conclusion Patients who present with thin tissue biotypes can be challenging with implants in the esthetic zone related to dark showthrough of the implant. This can also be related to gingival tissue that is thin in consistency or translucent in masking ability of the underlying bone and what it contains. A thin facial plate over the implant even in those patients with adequate tissue thickness may also complicate esthetics. Zirconia implants offer a more esthetic alternative in those clinical situations with the “white” shade of the implant neutralizing any potential showthrough and allowing a better blend with the adjacent sites. These implants should be Volume 13 Number 4

REFERENCES 1. Ghassemian M, Nowzari H, Lajolo C, et al. The thickness of facial alveolar bone overlying healthy maxillary anterior teeth. J Periodontol. 2012;83(2):187-197. 2. Morad G, Behnia H, Motamedian SR, et al. Thickness of labial alveolar bone overlying healthy maxillary and mandibular anterior teeth. J Craniofac Surg. 2014;25(6):1985-1991. 3. Han Y, Li XG, Zhu J, et al. Hua Xi Kou Qiang Yi Xue Za Zhi. [Cone-beam computed tomography digital for measuring the inclination angle to the long axis of healthy maxillary anterior teeth and morphologically characterizing their labial bone plates] West China Journal of Stomatology. 2019;37(4):412-416.

11. Froum S, Kurtzman GM.: Top 5 anatomical differences between dental implants and teeth that influence treatment outcomes. Perio-implant Advisory. Sept. 12, 2017. 12. Dhir S, Mahesh L, Kurtzman GM, Vandana KL. Periimplant and periodontal tissues: a review of differences and similarities. Compend Contin Educ Dent. 2013;34(7):e69-e75. 13. Tetè S, Mastrangelo F, Bianchi A, Zizzari V, Scarano A. Collagen fiber orientation around machined titanium and zirconia dental implant necks: an animal study. Int J Oral Maxillofac Implants. 2009;24(1):52-58. 14. Fu JH, Wang HL. Breaking the wave of peri-implantitis. Periodontol 2000. 2020;84(1):145-160. 15. Al-Ahmad A, Karygianni L, et al. Bacterial adhesion and biofilm formation on yttria-stabilized, tetragonal zirconia and titanium oral implant materials with low surface roughness — an in situ study. J Med Microbiol. 2016;65(7):596-604. 16. Silva TSO, Freitas AR, Pinheiro MLL, et al. Oral Biofilm Formation on Different Materials for Dental Implants. J Vis Exp. 2018;(136). 17. Yoshinari M. Future prospects of zirconia for oral implants — a review. Dent Mater J. 2020;39(1):37-45. 18. Scarano A, Di Carlo F, Quaranta M, Piattelli A. Bone response to zirconia ceramic implants: an experimental study in rabbits. J Oral Implantol. 2003;29(1):8-12. 19. Bosshardt DD, Chappuis V, Buser D. Osseointegration of titanium, titanium alloy and zirconia dental implants: current knowledge and open questions. Periodontol 2000. 2017;73(1):22-40. 20. Addison O, Davenport AJ, Newport RJ, et al. Do “passive” medical titanium surfaces deteriorate in service in the absence of wear? J R Soc Interface. 2012;9(76):3161-3164. 21. Sridhar S, Wilson TG Jr, Palmer KL, et al. In Vitro Investigation of the Effect of Oral Bacteria in the Surface Oxidation of Dental Implants. Clin Implant Dent Relat Res. 2015;17(suppl 2):e562-e575. 22. Fretwurst T, Buzanich G, Nahles S, et al. Metal elements in tissue with dental peri-implantitis: a pilot study. Clin Oral Implants Res. 2016;27(9):1178-1186.

10. Möller B, Terheyden H, Açil Y, et al. A comparison of biocompatibility and osseointegration of ceramic and titanium implants: an in vivo and in vitro study. Int J Oral Maxillofac Surg. 2012;41(5):638-645.

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37. Hafezeqoran A, Koodaryan R. Effect of Zirconia Dental Implant Surfaces on Bone Integration: A Systematic Review and Meta-Analysis. Biomed Res Int. 2017;2017:9246721. 38. Andreiotelli M, Wenz HJ, Kohal RJ. Are ceramic implants a viable alternative to titanium implants? A systematic literature review. Clin Oral Implants Res. 2009;20 (suppl 4):32-47. 39. Hashim D, Cionca N, Courvoisier DS, Mombelli A. A systematic review of the clinical survival of zirconia implants. Clin Oral Investig. 2016;20(7):1403-1417. 40. Bormann KH, Gellrich NC, Kniha H, et al. Biomechanical evaluation of a microstructured zirconia implant by a removal torque comparison with a standard Ti-SLA implant. Clin Oral Implants Res. 2012;23(10):1210-1216. 41. Roehling S, Schlegel KA, Woelfler H, Gahlert M. Zirconia compared to titanium dental implants in preclinical studies-A systematic review and meta-analysis. Clin Oral Implants Res. 2019;30(5):365-395. 42. Oliva J, Oliva X, Oliva JD. Five-year success rate of 831 consecutively placed Zirconia dental implants in humans: a comparison of three different rough surfaces. Int J Oral Maxillofac Implants. 2010;25(2):336-344. 43. Balmer M, Spies BC, Vach K, et al. Three-year analysis of zirconia implants used for single-tooth replacement and three-unit fixed dental prostheses: A prospective multicenter study. Clin Oral Implants Res. 2018;29(3):290-299.

45. Schünemann FH, Galárraga-Vinueza ME, Magini R, et al. Zirconia surface modifications for implant dentistry. Mater Sci Eng C Mater Biol Appl. 2019;98:1294-1305.

25. Pettersson M, Pettersson J, Johansson A, Molin Thorén M. Titanium release in peri-implantitis. J Oral Rehabil. 2019;46(2):179-188.

46. Manzano G, Herrero LR, Montero J. Comparison of clinical performance of zirconia implants and titanium implants in animal models: a systematic review. Int J Oral Maxillofac Implants. 2014;29(2):311-320.

27. Depprich R, Zipprich H, Ommerborn M, et al. Osseointegration of zirconia implants compared with titanium: an in vivo study. Head Face Med. 2008;4:30.

9. Yoshinari M. Future prospects of zirconia for oral implants — a review. Dent Mater J. 2020;39(1):37-45.

36. Gahlert M, Roehling S, Sprecher CM, et al. In vivo performance of zirconia and titanium implants: a histomorphometric study in mini pig maxillae. Clin Oral Implants Res. 2012;23(3):281-286.

24. Noronha Oliveira M, Schunemann WVH, Mathew MT, et al. Can degradation products released from dental implants affect peri-implant tissues? J Periodontal Res. 2018;53(1):1-11.

5. Waki T, Kan JY. Immediate placement and provisionalization of maxillary anterior single implant with guided bone regeneration, connective tissue graft, and coronally positioned flap procedures. Int J Esthet Dent. 2016;11(2):174-185.

8. Cosgarea R, Gasparik C, Dudea D, Culic B, Dannewitz B, Sculean A. Peri-implant soft tissue colour around titanium and zirconia abutments: a prospective randomized controlled clinical study. Clin Oral Implants Res. 2015;26(5):537-544.

35. Stadlinger B, Hennig M, Eckelt U, Kuhlisch E, Mai R. Comparison of zirconia and titanium implants after a short healing period. A pilot study in minipigs. Int J Oral Maxillofac Surg. 2010;39(6):585-592.

44. Sennerby L, Dasmah A, Larsson B, Iverhed M. Bone tissue responses to surface-modified zirconia implants: A histomorphometric and removal torque study in the rabbit. Clin Implant Dent Relat Res. 2005;7(suppl 1):13-20.

26. Kubasiewicz-Ross P, Hadzik J, Dominiak M. Osseointegration of zirconia implants with 3 varying surface textures and a titanium implant: A histological and microCT study. Adv Clin Exp Med. 2018;27(9):1173-1179.

7. Mau JL, Grodin E, Lin JJ, Chen MC, Ho CH, Cochran D. A comparative, randomized, prospective, two-center clinical study to evaluate the clinical and esthetic outcomes of two different bone grafting techniques in early implant placement. J Periodontol. 2019;90(3):247-255.

34. Hafezeqoran A, Koodaryan R. Effect of Zirconia Dental Implant Surfaces on Bone Integration: A Systematic Review and Meta-Analysis. Biomed Res Int. 2017;2017:9246721.

23. Safioti LM, Kotsakis GA, Pozhitkov AE, Chung WO, Daubert DM. Increased Levels of Dissolved Titanium Are Associated With Peri-Implantitis — A Cross-Sectional Study. J Periodontol. 2017;88(5):436-442.

4. Amid R, Mirakhori M, Safi Y, et al. Assessment of gingival biotype and facial hard/soft tissue dimensions in the maxillary anterior teeth region using cone beam computed tomography. Arch Oral Biol. 2017;79:1-6.

6. Migliorati M, Amorfini L, Signori A, Biavati AS, Benedicenti S. Clinical and Esthetic Outcome with Post-Extractive Implants with or without Soft Tissue Augmentation: a 2-Year Randomized Clinical Trial. Clin Implant Dent Relat Res. 2015;17(5):983-995.

implants: A preclinical histometric study. Clin Oral Implants Res. 2018;29(3):277-289.

28. Welander M, Abrahamsson I, Berglundh T. The mucosal barrier at implant abutments of different materials. Clin Oral Implants Res. 2008;19(7):635-641. 29. Yamano S, Ma AK, Shanti RM, et al. The influence of different implant materials on human gingival fibroblast morphology, proliferation, and gene expression. Int J Oral Maxillofac Implants. 2011;26(6):1247-1255. 30. Cionca N, Hashim D, Cancela J, Giannopoulou C, Mombelli A. Pro-inflammatory cytokines at zirconia implants and teeth. A cross-sectional assessment. Clin Oral Investig. 2016;20(8):2285-2291. 31. Degidi M, Artese L, Scarano A, et al. Inflammatory infiltrate microvessel density, nitric oxide synthase expression, vascular endothelial growth factor expression, and proliferative activity in peri-implant soft tissues around titanium and zirconium oxide healing caps J Periodontol. 2006;77(1):73-80. 32. Sivaraman K, Chopra A, Narayan AI, Balakrishnan D. Is zirconia a viable alternative to titanium for oral implant? A critical review. J Prosthodont Res. 2018;62(2):121-133. 33. Janner SFM, Gahlert M, Bosshardt DD, et al. Bone response to functionally loaded, two-piece zirconia

47. Siddiqi A, Khan AS, Zafar S. Thirty Years of Translational Research in Zirconia Dental Implants: A Systematic Review of the Literature. J Oral Implantol. 2017;43(4):314-325. 48. Kohal RJ, Spies BC, Vach K, Balmer M, Pieralli S. A Prospective Clinical Cohort Investigation on Zirconia Implants: 5-Year Results. J Clin Med. 2020;9(8):2585. 49. Jank S, Hochgatterer G. Success Rate of Two-Piece Zirconia Implants: A Retrospective Statistical Analysis. Implant Dent. 2016;25(2):193-198. 50. Kohal RJ, Wolkewitz M, Mueller C. Alumina-reinforced zirconia implants: survival rate and fracture strength in a masticatory simulation trial. Clin Oral Implants Res. 2010;21(12):1345-1352. 51. Andreiotelli M, Kohal RJ. Fracture strength of zirconia implants after artificial aging. Clin Implant Dent Relat Res. 2009;11(2):158-166. 52. Kohal RJ, Wolkewitz M, Tsakona A. The effects of cyclic loading and preparation on the fracture strength of zirconium-dioxide implants: an in vitro investigation. Clin Oral Implants Res. 2011;22(8):808-814. 53. Bethke A, Pieralli S, Kohal RJ, et al. Fracture Resistance of Zirconia Oral Implants In Vitro: A Systematic Review and Meta-Analysis. Materials (Basel). 2020;13(3):562. 54. Spies BC, Fross A, Adolfsson E, et al. Stability and aging resistance of a zirconia oral implant using a carbon fiberreinforced screw for implant-abutment connection. Dent Mater. 2018;34(10):1585-1595.

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considered in those patients where placement of a titanium implant can hamper the esthetics related to darkening of the gingiva and bone covering the implant. Implants fabricated from zirconia demonstrate lower biofilm than titanium implants. Oral biofilm has been intricately linked to periodontal disease around natural teeth as well as implants. Implants, whether fabricated from zirconia or titanium, demonstrate lower oral biofilm adhesion than around natural teeth, allowing the patient with consistent oral homecare to maintain implants of either material long-term. Clinical long-term success and fracture resistance of two-piece zirconia implants has been reported that is comparable under functional loading with implants fabricated of titanium. Comparable osseointegration between the two implant materials, and with the availability of twopiece implants, zirconia implants are an alternative to traditional titanium implants. As zirconia implants do not undergo corrosion and ion release, peri-implantitis is eliminated from that potential periodontal avenue. IP

REF: IP V13.4 PATEL, ET AL.

FULL NAME

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Esthetic and periodontal benefits of zirconia implants PATEL, ET AL.

1. The old axiom — “the bone sets the tone, but ________” — has been voiced in implant dentistry for decades. a. the tissue is the issue b. the tooth tells the truth c. the bone’s not alone d. the graft shows the craft 2. Studies have reported that under healthy periodontal conditions on natural teeth, the facial thickness of bone covering the anterior roots is ______. a. 1.90 mm or more b. 1.73 mm or less c. 2.0 mm or more d. 2.5 mm or more

a. b. c. d.

1 mm 2 mm 3 mm 4 mm

5. Patients frequently require implant placement due to inadequate homecare over time leading to _______ leaving insufficient tooth structure to maintain the tooth. a. periodontal disease of the natural tooth b. structural breakdown related to caries and repeated restorations c. root resorption d. both a and b

3. Bone thickness around the maxillary anterior teeth at _______ apical to the cementoenamel junction (CEJ) was significantly different in thick and thin gingival biotypes. a. 1 mm and 3 mm b. 2 mm and 5 mm c. 4 mm and 6 mm d. 7 mm and 9 mm

6. Natural teeth have those fibers originating in the gingival tissue attached to the tooth’s root in a ________ direction to the tooth’s long axis creating a resistant barrier to bacterial progression apically. a. perpendicular b. parallel c. divergent d. tangential

4. As titanium has a gray color, a darkening results unless a minimum of _______ thickness of gingiva is present.

7. _______ has been closely associated with the bacteria in oral biofilm and the inflammation that ensues when in proximation to the gingival

24 Implant practice

tissues. a. Gingival fibroma b. Peri-implantitis c. Verrucous leukoplakia d. Gingival enlargement 8. Zirconia implants have been reported to inhibit bacterial adhesion and biofilm formation on their surface. This relates to _______ with reduced surface free energy and surface wettability. a. its hydrophobicity b. its bio-inert properties c. hydrophilicity d. both a and b 9. The overall implant success rate of zirconia implants after 5 years of follow-up was ______. a. 75% b. 80% c. 85% d. 95% 10. Implants fabricated from zirconia demonstrate ______ titanium implants. a. lower biofilm than b. higher biofilm than c. equal biofilm to d. less fracture resistance to

Volume 13 Number 4

CE CREDITS

IMPLANT PRACTICE CE

Dr. Johan Hartshorne assesses the clinician liability and patient risk from radiation when using CBCT imaging by looking at the potential pitfalls and limitations Introduction The role of 3D cone beam computed tomography (CBCT) imaging as a new diagnostic tool in modern-day dentistry cannot be overemphasized and has increasingly been referred to as the new professional “standard of care” for diagnostic maxillofacial imaging (Curley and Hatcher, 2009; Tipton and Metz, 2008; 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 (Hatcher, et al., 2003; Kobayashi, et al., 2004; Sato, et al., 2004). However, CBCT technology does not come without pitfalls, liabilities, and risks. Understanding the radiation dose imparted by CBCT and potential biological risks to the patient is an important patient safety issue. Appropriate selection criteria must be used with the minimum radiation exposures that result in images of acceptable diagnostic qualities (Carter, et al., 2008; Horner, et al., 2009). 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. An important basic requirement of using CBCT imaging as a diagnostic and treatment planning tool is that practitioners should have appropriate training and competencies to ensure safe and effective use of a CBCT unit that will best serve the patient’s interests, while optimizing patient safety and minimizing radiation-related patient risk.

Purpose The purpose of this article (the fourth and final part of this series) is to provide an overview of the following topics:

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.

Volume 13 Number 4

Educational aims and objectives

This article aims to describe the essential guidelines for using CBCT in implant dentistry.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 31 or take the quiz online at implantpracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify radiation dose and optimization of exposure.

•

Recognize the biological risks of irradiation.

•

Realize radiation protection and the core standards for safe and effective use of CBCT technology.

•

Identify the ethical and medicolegal considerations pertaining to the clinical application of CBCT scanners in implant dentistry.

•

Realize how to maximize the diagnostic and treatment planning benefits of CBCT to best serve the interests of the patient, optimize patient safety, and minimize radiation-related patient risk.

1. Radiation dose and optimization of exposure 2. The biological risks of irradiation 3. Radiation protection and the core standards for safe and effective use of CBCT technology 4. The ethical and medicolegal considerations pertaining to the clinical application of CBCT scanners in implant dentistry This knowledge will enhance a practitioner’s understanding of how to maximize the diagnostic and treatment planning benefits of this technology that best serve the interests of the patient, while optimizing patient safety and minimizing radiation-related patient risk.

Radiation dose, risks, safety considerations, and optimization of exposure Radiation dose and optimization of exposure Among the many risks to which we are prone is the normal background radiation with a world average of about 2.4mSv per individual and year. Medical exposures now contribute to around 20% of the average annual per head effective dose of the global population. Medical diagnostic X-ray examinations result in per head effective dose of

0.6mSv of which dental radiology contributes only a small fraction (0.01mSv) (Harris, et al., 2012; United Nations Scientific Committee on the Effects of Atomic Radiation, 2010). Understanding the radiation dose imparted to the patient by dental radiology is an important safety issue. Appropriate selection criteria must be used with the minimum radiation exposures that result in images of acceptable diagnostic quality (Figure 1) (Carter, et al., 2008; Horner, et al., 2009). This concept is known as “as low as reasonably achievable” (ALARA) (Figure 2) (Farman, 2005; Tyndall, et al., 2012). In general, imaging parameters (such as kV, mAs, and field of view [FOV] size) have an effect on the effective radiation dose, as well as image quality parameters (spatial resolution, contrast, noise, and artifacts) (Pauwels, et al., 2012; 2015). In terms of optimization of exposure, the most straightforward imaging parameter is FOV size, as larger FOVs increase radiation dose to the patient. Effective doses for different CBCT devices exhibit a wide range, but for all devices, significant dose reduction can be achieved by reducing the FOV to the actual region of interest (Bornstein, et al., 2014). In addition, larger FOVs increase the relative amount of scattered radiation reaching Implant practice 25

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Essential guidelines for using CBCT in implant dentistry — radiation dose, risks, and ethical considerations: part 4

CONTINUING EDUCATION the detector, leading to an increase in noise and artifacts, thus affecting the quality of the image. Therefore, FOVs should always be kept as small as possible, covering only the area of interest (SEDENTEXCT, 2011). Increased radiation dose risk Patient risk and clinician liability from radiation has been a continuing concern in oral and maxillofacial imaging, due to the frequency of radiographic examinations in dental practice (Friedland and Miles, 2014). With the increased use of CBCT imaging in dental practice, clinicians must be made aware that patient radiation doses associated with CBCT imaging are higher than those of conventional radiographic techniques (Figure 1). Therefore, routine replacement of current radiographic techniques must be considered with great care (Bornstein, et al., 2014). The average effective radiation dose for a CBCT corresponding to a small FOV

is 34µSv, medium FOV is 88µSv, and a large FOV is 131µSv with the medium and large FOVs showing the largest variability of doses (Pauwels et al, 2012). In general, CBCT imaging results in higher patient doses than standard radiographic methods used in dental practice for dental therapy, but remain well below those reported for common multidetector computed tomography protocols (280µSv to 1410µSv) (Bornstein, et al., 2014; SEDENTEXCT, 2011). The effective radiation dose for a CBCT is 2- to 4-times greater than for a cephalometric X-ray (<6µSv); 3- to 6-times greater than a panoramic X-ray (2.7µSv to 24.3µSv); and 9- to 14-times greater than a periapical X-ray (<1.5µSv) (Bornstein, et al., 2014; SEDENTEXCT, 2011). Risks have also been noted in the radiation dose needed with CBCT, although it is generally believed the radiation dose of CBCT is significantly lower than a conventional CT (Schulze, et al., 2004).

Figure 1: Comparison of effective radiation dose by type of X-ray used

Figure 2: The ALARA principle – limiting patient radiation dose to “as low as reasonably achievable” 26 Implant practice

Effective radiation doses of typical dentomaxillofacial applications are relatively low when compared with the worldwide annual background radiation of 200µSv to 4500µSv (Green, et al., 1992; Jacobs and Quirynen, 2014). The effective radiation dose of CBCT can be affected to an order of magnitude by patient size, FOV, region of interest, and resolution. A careful selection of all these parameters is needed to optimize diagnostic information and reduce the patient’s radiation exposure (Figure 2) (European Academy of Dental and Maxillofacial Radiology, 2012). Biological risks of irradiation The biologic effects of ionizing radiation maybe divided into two categories: tissue reactions (previously called deterministic effects) and chromosomal effects (also known as stochastic effects) (International Commission on Radiological Protection, 2007). Tissue reactions are proportional to the dose and occur in all individuals when the dose is large enough. They result in cell death or cell malfunction, and the severity of the effects increases with the dose. Tissue reactions — such as cataract formation, skin erythema, and effects — on fertility occur only above threshold doses that are far greater than those given in dental radiology. Chromosomal effects can be considered as “chance” (or stochastic) effects, where the magnitude of the risk is proportional to the radiation dose (SEDENTEXCT, 2011). Chromosomal or stochastic effects include the detriment-adjusted nominal risk of cancer and hereditable effects owing to mutation of reproductive cells. The detriment-adjusted risk factor for the whole population is 5% per Sv. In case of cancer, epidemiological and experimental studies provide evidence of radiation risk, albeit with uncertainties at low doses (<100mSv). The probabilistic nature of stochastic effects makes the distinction between “safe” and “harmful” exposures to radiation impossible (International Commission on Radiological Protection, 2007; SEDENTEXCT, 2011). The biological risk from irradiation is agedependent, being highest for the young and least for the elderly (SEDENTEXCT, 2011). The risk for small children is 3 times the risk for an adult at 30 years of age. Radiation protection — limiting the dose and risk from X-ray imaging Radiation protection in clinical practice is based on two fundamental principles (International Commission on Radiological Protection, 2007). The first principle is that Volume 13 Number 4

Basic principles and core standards for safe and effective practice The clinician performing or interpreting CBCT scans for implant dentistry should take into consideration current radiologic guidelines for safe and effective use of CBCT. The European Association of Dental and Maxillofacial Radiology developed the following consensus-based core standards for safe and effective use of dental CBCT (Horner, et al., 2009). These basic principles are not in conflict with the current evidencebased guidelines as set by SEDENTEXCT, a collaborative project of the European Union (SEDENTEXCT, 2011). Justification • CBCT examinations must not be carried out unless a history and clinical examination has been performed. • CBCT examinations must be justified for each patient to demonstrate that the benefits outweigh the risks. • CBCT examinations should potentially add new information to aid the patient’s treatment management. • CBCT should not be repeated routinely on a patient without a new risk/benefit assessment having been performed. • When accepting referrals from other dentists for CBCT examinations, the Volume 13 Number 4

referring dentist must supply sufficient clinical information to allow the CBCT practitioner to perform the justification process. • CBCT should only be used when conventional (lower dose) radiography does not provide adequate information for the question at stake. • CBCT images must undergo a thorough clinical evaluation of the entire image data set. • Where it is likely that the evaluation of the soft tissues will be required as part of the patient’s radiological assessment, the appropriate imaging should then be conventional CT or MR, rather than CBCT. Optimization • CBCT examinations must use the smallest volume size (FOV that is compatible with the clinical situation). • Where CBCT equipment offers a choice of resolution, the resolution compatible with adequate diagnosis and the lowest achievable dose should be used. • A quality assurance program must be established and implemented for each CBCT facility, including equipment, techniques, and quality control procedures. • Aids to accurate positioning, such as light beam markers, must always be used. Quality standards and assurance • All new installations of CBCT equipment should undergo a critical assessment and detailed acceptance tests before use to ensure that radiation protection for staff, members of public, and patients are optimal. • CBCT equipment should undergo regular routine tests to ensure that radiation protection for both practice/facility users and patients has not deteriorated. Staff protection • For staff protection from CBCT equipment, the guidelines in Section 6 of the European Commission document, European guidelines on radiation protection in dental radiology should be followed (European Commission, 2004). • A qualified expert should oversee the installation and use of CBCT to ensure staff doses are ALARA and

all relevant national requirements are met (SEDENTEXCT, 2011). • CBCT equipment should be installed in a protected enclosure and the entire enclosure designated a controlled area. The provision of personal monitoring should be considered (SEDENTEXCT, 2011). Training and competence • All those involved with CBCT must have received adequate theoretical and practical training for the purpose of radiological practices and relevant competence in radiation protection. • Continuing education and training after qualification are required, particularly when new CBCT equipment or techniques are adopted. • Dentists responsible for CBCT facilities who have not previously received adequate theoretical or practical training should undergo a period of additional theoretical and practical training that has been validated by an accredited academic institution. • For dentoalveolar CBCT images of teeth, their supporting structures, the mandible and the maxilla up to the floor of the nose (such as 8 cm x 8 cm FOV), clinical evaluation should be made by a specially trained dentomaxillofacial radiologist or where this is impracticable, an adequately trained general dental practitioner. • For non-dentoalveolar small FOV (such as temporal bone) and all craniofacial CBCT images (FOV extending beyond the teeth, their supporting structures, the mandible, including temporomandibular joint disorders and the maxilla up to the floor of the nose), clinical evaluation should be made by a specially trained dentomaxillofacial radiologist or by a medical radiologist.

CBCT: Ethical and medicolegal considerations As CBCT technology advances in dentistry, clinicians who embrace it should understand the potential liabilities and risks associated with the technology, as well their ethical obligations toward the patient and profession. Competency and serving the best interest of the patient Given that a single CBCT scan uses ionizing radiation at levels exceeding any Implant practice 27

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of justification. The clinician has an obligation to ensure that there must be a net benefit for the individual who is being exposed; for example, potential benefits must outweigh the potential risks (Harris, et al., 2012). The second principle is that of optimization of radiation exposure; namely, it should be as low as reasonably achievable to minimize the risk of cancer or tissue effects (Figure 2) (Harris, et al., 2012; International Commission on Radiological Protection, 1977). It is obvious that CBCT should not be carried out without proper optimization strategies to maintain the correct balance between cost and radiation dose on the one hand, and information required, on the other hand. Therefore, the scanned area should not exceed the area of interest. This would substantially limit the dose of radiation, while justifying the use of CBCT in preparing for implant surgery (Jacobs and Quirynen, 2014). The FOV of the CBCT examination should be restricted to the region of interest (ROI) whenever possible. Patient and equipmentspecific dose reduction measures should be used at all times (Bornstein, et al., 2014).

CONTINUING EDUCATION 2D dental-imaging modalities, it is timely to recommend the development of rigorous training standards in maxillofacial CBCT imaging in the interests of our patients who deserve to have imaging performed by competent clinicians (Scarfe, et al., 2006). Furthermore, there is mounting concern among oral and maxillofacial radiologists, based on issues of quality and patient safety, that dentists with inadequate training and experience should not perform interpretation of extended FOV diagnostic imaging studies using CBCT (Scarfe, et al., 2006). The view has also been expressed by the American Association of Oral and Maxillofacial Radiology that non-radiologist dentists should not be excluded from performing CBCT imaging, provided they have appropriate and documented training and experience (Scarfe, et al., 2006). If dentists or non-radiologist dental specialists decide to examine their own volumes, then they are held to the same standard of care as an oral maxillofacial radiologist and required to find and report any unusual conditions or incidental findings that may reside in that volume. This is a significant responsibility, one that might require additional training for some dentists (Miles and Danforth, 2014). Unfortunately, many dentists who acquire a CBCT unit for their practice are not adequately trained to fully understand and take advantage of its capabilities. Common errors include a scan with an FOV that is too large or too small. A larger FOV than is necessary has at least two deleterious effects. It results in a less optimal image (the larger the FOV, the greater the scatter and the less detailed the image) and a greater patient dose. Although increased scatter and dose are not likely to result in liability, a wider FOV than is necessary does have medicolegal implications as far as interpretation of the image is concerned (Friedland and Miles, 2014). The potential liability issue that arises is that the dentist is responsible for reading the entire scan. Thus, even though the maxilla and skull were not required in this case, once they are included in the scan, the dentist is responsible for pathology missed in either location (Friedland and Miles, 2014). Practitioners should have appropriate training in operating a CBCT unit and competence in interpreting images. This training and competence should be maintained through continuing dental education courses. Such training should include a thorough review of normal maxillofacial anatomy, common 28 Implant practice

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 FOVs (Carter, et al., 2008). Clinicians who do not have adequate experience in interpreting a CBCT scan should rather refer the scan to a specialist radiologist or radiographer for reviewing, or refer the patient to a specialist oral and maxillofacial radiologists for the CBCT scan and reviewing. Ethical obligation of beneficence Dentistry exposes practitioners at each patient encounter to an ethical obligation of beneficence; namely, will the image serve the patientâ&#x20AC;&#x2122;s best interests? Practitioners are obliged ethically and morally to measure the benefit from using a CBCT scan versus the potential risk from radiation before a decision is made to take a CBCT scan (SEDENTEXCT, 2011). Dentists may also have legal responsibilities and duties that overlap with ethical considerations to some degree (Scarfe, 2011). When a patient undergoes an X-ray examination, millions of photons pass through their body. These can damage any molecules by ionization, but damage to DNA in the chromosome, although rare, is of particular importance because a chromosome can be permanently altered in the process, ultimately leading to the formation of a tumor (SEDENTEXCT, 2011). While doses and risks for dental radiology are small, a number of epidemiological studies have provided some limited evidence of an increased risk of brain (Longstreth, et al., 1993; Claus, et al., 2012), salivary gland (Horn-Ross, et al., 1999), and thyroid tumors (Memron, et al., 2010) for dental radiographs. Any radiation exposure entails a risk to the patient. Under normal circumstances, however, the risk from dental radiography is very low. The basic premise that justifies the use of CBCT is that the benefits provided by the radiographic examination must far outweigh the potential risks associated with radiation exposure (SEDENTEXCT, 2011). Such benefits may be in the form of increased diagnostic efficacy, enhanced treatment planning, or better therapeutic outcomes (Harris, et al., 2012; Mallya, 2015).The clinician has an obligation to ensure appropriate measures are taken at all instances to limit radiation dose and risk to the patient through justification and optimization processes. A CBCT examination should, at all times, add new

information to aid the patientâ&#x20AC;&#x2122;s treatment (SEDENTEXCT, 2011). The ALARA principle must also be applied, taking into account any alternative techniques that might achieve the same objectives (Harris, et al., 2012). Informed patient consent Reporting the findings in a CBCT volume is probably the most essential process in the total diagnostic evaluation of a patient, even if it is something as simple as implant planning (Miles and Danforth, 2014). It is the responsibility of healthcare providers to acquire information data from patients to best determine the health status of patients, and if treatment is indicated, to provide a basis for treatment planning and informed patient consent (Miles and Danforth, 2014). The CBCT report, therefore, becomes an important component of information for patients to make informed decisions about their health or dental care and treatment, and to facilitate giving informed consent standard of care. A CBCT could give the clinician the opportunity to visualize, plan, and explain the situation to the patient more clearly. Hence, the standard of care by definition involves that, in all the cases where it is required and possible, the CBCT or some 3D technique should be offered to the patient. In the case that the patient declines after being informed of the risks, benefits, and alternatives, then informed refusal should be obtained and documented (Curley and Hatcher, 2009). Medicolegal issues on reviewing and reporting The interpretation of CBCT images remains one of the most vexing problems and greatest source of liability for practitioners who take their own scans (Friedland and Miles, 2014). The use of CBCT carries with it medicolegal risks of which the dental practitioner should be aware. These include licensing and malpractice liability concerns (Friedland and Miles, 2014). The quality, accuracy, and use of the CBCT report or findings are subject to medicolegal scrutiny, and knowledge of such issues determines whether or not a primary provider or a secondary radiology reader evaluates the image data and issues the final report (Miles and Danforth, 2014). If dental practitioners own a CBCT machine and take scans not only for their own patients, but also for those referred from outside, they must ensure in the latter situation that they do not lack malpractice coverage in the event of a lawsuit. Volume 13 Number 4

Medicolegal assurance Adequate and appropriate records and documentation have become essential for medical aid reimbursements, as well as to prevent legal recourse. Having performed the CBCT scans provides the dental practitioner with the necessary information to prove the procedure was performed above the standard of care. Having this documentation can help prevent any litigation that may occur in association with negative outcomes that could not be avoided. CBCT technology provides that supporting documentation needed for insurance reimbursement, as well as legal purposes. Using the CBCT for evaluating patients who wish to receive dental implants is essential to protect the patients and practitioner. There are legal cases in which healthcare providers have been sued because of implant failure. Implant failure can still occur no matter the technology used; however, with CBCT, the dentist can provide the most precise information to prove his or her reasoning, if questioned in the future about why he or she chose to place dental implants. Standard of care One important term in the medicolegal area is “standard of care,” which generally Volume 13 Number 4

is defined as what a rational and judicious health professional would do or should have done. In the area of dentistry, it is supposed that the dentist meets or exceeds the standard of care. Presenting all the possible alternative treatments, as well as all the techniques available to the patient, makes this a successful protocol that follows the standard of care principle. The failure to practice this standard of care could be considered as professional negligence or malpractice. In this regard, CBCT has been qualified as a standard of care technology (Curley and Hatcher, 2009). The standard to which the dental profession is held by the public and among us transcends legal (standard of care) and technical (gold standard) definitions. The professional standard for CBCT is appropriate care to choose CBCT imaging for each patient “wisely,” based on selection criteria derived from the best available evidence (Scarfe, 2011). Self-referred and overprescription of CBCTs Dental practitioners have commonly self-referred radiographic procedures, and many dental procedures require that immediate radiography be available (Farman, 2009). Depending on the number and price charged for each CBCT imaging procedures performed, a rush to achieve return on investment could well lead to unethical overprescription of procedures. This prescription could have impacts on healthcare costs and radiation exposure load to the patient (Farman, 2009). Hillman (1992), in studying physicians’ use and charges for outpatient diagnostic imaging, found self-referral resulted, depending on physician specialty, in 1.7 to 7.7 times more frequent performance of imaging examinations than radiologist referral. This difference was statistically significant (p <0.01) across all presentations. Within all physician specialties, selfreferral uniformly led to greater use of diagnostic imaging than radiologist referral, with mean imaging charges per episode of medical care 1.6 to 6.2 times greater when self-referral applied. While self-referral can have economic implications, there is also the question of training and experience to accurately interpret the diagnostic images that are made. As the tissues included in the imaged volume need to be read to maximize the diagnostic yield potential relative to the exposure given, it can be questioned whether all individuals who presently own CBCT

systems are trained to a level of competency to evaluate the images they produce. Referral of these images for reading by specialists in oral and maxillofacial radiology might be necessary, but this can also add to the cost of healthcare (Farman, 2009).

Conclusion CBCT has become the new standard of care as imaging modality for diagnosis and presurgical planning in implant dentistry. However, CBCT it is not without its potential pitfalls, limitations, risks, and liabilities. The potential diagnostic and presurgical treatment planning benefits are undisputed. However, due to additional radiation exposure, dental practitioners have an obligation to ensure every CBCT scan is justified and to optimize exposure to radiation by always using the smallest FOV possible for that area of interest. Practitioners taking CBCTs should ensure they have appropriate training in operating radiographic equipment and are competent in interpreting images, which should be maintained through continuing professional development. Clinicians who embrace CBCT should understand the potential liabilities and risks associated with the technology, and ensure they meet the requirements for licensing, adequate training and competencies, and malpractice liability coverage from their malpractice insurance carriers. When mastered, use of CBCT makes it indispensable diagnostic and presurgical treatment planning and communication tool in implant dentistry, and, therefore, improved patient care and satisfaction. However, as with all clinical procedures, the selection of CBCT as an imaging modality should be guided and justified by patient symptoms, findings of the clinical examination, and the information needed to allow a proper diagnosis and presurgical treatment planning. With this technology, adequately trained clinicians can enhance their practice and best serve the interests of their patients. Note: Dentists practicing in the United States may need to adhere to different guidelines. IP REFERENCES 1. Bornstein MM, Scarfe WC, Vaughn VM, Jacobs R (2014) Cone beam computed tomography in implant dentistry: a systematic review focusing on guidelines, indications, and radiation dose risks. Int J Oral Maxillofac Implants. 29(Suppl):55-77. 2. Carter L, Farman AG, Geist J, et al. Academy of Oral and Maxillofacial Radiology executive opinion statement on performing and interpreting diagnostic cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(4):561-562. 3. Claus EB, Calvocoressi L, Bondy ML, et al. Dental x-rays

Implant practice 29

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Some malpractice carriers have explicit limitations and will defend a dental practitioner for CBCT-related diagnostic issues only if the suit is brought by one of the dentist’s own patients. If a patient who was referred from outside solely for a CBCT scan brings a lawsuit for a misdiagnosis, then malpractice coverage can be denied (Friedland and Miles, 2014). When examining a CBCT scan, the dental practitioner has the legal responsibility to examine every cross section to ensure that no pathosis is overlooked. The accepted standard of care is that the dentist reviewing/ reading the CBCT is obligated to read the entire scan included in the FOV (Friedland, 2009). Dentists cannot read only part of the scan that is related to the area of interest where an implant will be placed. Reviewing practitioners cannot afford to miss an important finding or fail to communicate these findings to referring clinicians. For those individuals to examine their own data, this is also true. No clinician would be in trouble for misdiagnosing a condition or problem, but that same clinician is definitely placing himself/herself at risk for not examining the volume for these occult findings (Miles and Danforth, 2014).

CONTINUING EDUCATION and risk of meningioma. Cancer. 2012;118(18):4530-4537. 4. Curley A, Hatcher DC. Cone beam CT — anatomic assessment and legal issues: the new standards of care. J Calif Dent Assoc. 2009;37(9):653-662. 5. Horner K, Islam M, Flygare L, Tsiklakis K, Whaites E. (2012) Basic principles for use of dental cone beam computed tomography: consensus guidelines of the European Academy of Dental and Maxillofacial Radiology. Dentomaxillofac Radiol. 2009;38(4):187-195. 6. European Commission. Radiation Protection 136. European guidelines on radiation protection in dental radiology. Luxembourg: Office for Official Publications of the EC; 2004. 7. Farman AG. ALARA still applies. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100(4):395-397. 8. Farman AG. Self-referral: an ethical concern with respect to multidimensional imaging in dentistry? J Appl Oral Sci. 2009;17(5):i. 9. Friedland B. Medicolegal issues related to cone beam CT. ˆ2009;15(1):77-84. 10. Friedland B, Miles DA. Liabilities and risks of using cone beam computed tomography. Dent Clin N Am. 2014;58(3):671-685. 11. Harris D, Horner K, Gröndahl K, et al. EAO 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.

tomography: consensus guidelines of the European Academy of Dental and Maxillofacial Radiology. Dentomaxillofac Radiol. 2009;38(4):187-195. 16. Horn-Ross PL, Ljung BM, Morrow M. Environmental factors and the risk of salivary gland cancer. Epidemiology. 1999;8(4):414-419. 17. International ICRP, 2007. The 2007 Recommendations of the International Commission on Radiological Protection. ICRP Publication 103. Ann. ICRP 37 (2-4).

28. 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.

18. ICRP, 1977. Recommendations of the International Commission on Radiological Protection. ICRP Publication 26. Ann. ICRP 1 (3).

29. Scarfe WC, Farman AG, Sukovic P. Clinical applications of cone-beam computed tomography in dental practice. J Can Dent Assoc. 2006;72(1):75-80.

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

30. Scarfe WC. “All that glitters is not gold”: standards for conebeam computerized tomographic imaging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;111(4):402-408

20. 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.

31. Tipton WL, Metz P. Three dimensional computed technology — a new standard of care. Int J Orthod Milw. 2008;19(1):15-21.

21. Longstreth WT, Dennis LK, McGuire VM, Drangsholt MT, Koepsell TD. Epidemiology on intracranial meningioma. Cancer. 1993;72(3):639-648. 22. Mallya SM. Evidence and Professional Guidelines for Appropriate Use of Cone Beam Computed Tomography. J Calif Dent Assoc. 2015;43(9):512-520. 23. Memron A, Godward S, Williams D, Siddique I, Al-Saleh K. Dental x-rays and the risk of thyroid cancer: a case-control study. Acta Oncol. 2010; 49(4):447-453.

12. Hatcher DC, Dial C, Mayorga C. Cone beam CT for presurgical assessment of implant sites. J Calif Dent Assoc. 2003;31(11):825-833.

24. Miles DA, Danforth RA. Reporting findings in the cone beam computed tomography volume. Dent Clin N Am. 2014;58(3):687-709.

13. Green BMR, Hughes JS, Lomas PR, Janssens A. Natural X-ray atlas of Europe. Radiat Prot Dosimetry. 1992; 45:491-493.

25. Pauwels R, Beinsberger J, Collaert B, et al. The SEDENTEXCT Project Consortium. Effective dose range for dental cone beam computed tomography scanners. Eur J Radiol. 2012;81(2):267-271.

14. Hillman BJ. Self-referral for diagnostic imaging. Radiology. 1992;185:633-634. 15. Horner K, Islam M, Flygare L, Tsiklakis K, Whaites E. Basic principles for use of dental cone beam computed

2012;114(1):127-135. 27. Pauwels R, Araki K, Siewerdsen JH, Thongvigitmanee SS. Technical aspects of dental CBCT: state of the art. J Dentomaxillofac Radiol. 2015;44(1): 20140224

26. Pauwels R, Beinsberger J, Stamatakis H, et al. SEDENTEXCT Project Consortium. Comparison of spatial and contrast resolution for cone beam computed tomography scanners. Oral Surg Oral Med Oral Pathol Oral Radiol.

32. Schulze D, Heiland M, Thurmann H, Adam G. Radiation exposure during midfacial imaging using 4- and 16-slice computed tomography: cone beam computed tomography systems and conventional tomography. J Dentomaxillofac Radiol. 2004;33(2):83-86. 33. SEDENTEXCT Radiation Protection No 172. Cone Beam CT for Dental and Maxillofacial Radiology (Evidence-based Guidelines); 2011. 34. Tyndall DA, Price JB, Tetradis S, et al. Position statement of the American Academy of Oral and Maxillofacial Radiology on selection criteria for the use of radiology in dental implantology with emphasis on cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;113(6):817-826. 35. United Nations Scientific Committee on the Effects of Atomic Radiation. UNSCEAR 2008 Report: Sources and Effects of Ionizing Radiation. Vol 1. Sources, United Nations Publication, New York; 2010. 36. Zinman EJ, White SC, Tetradis S. Legal considerations in the use of cone beam computer tomography imaging. J Calif Dent Assoc. 2010;38(1):49-56.

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Essential guidelines for using CBCT in implant dentistry — radiation dose, risks, and ethical considerations: part 4 HARTSHONRE 1.

In general, imaging parameters, such as _______, have an effect on the effective radiation dose, as well as image quality parameters (spatial resolution, contrast, noise, and artifacts). a. kV b. mAs c. field of view (FOV) size d. all of the above

2. Effective doses for different CBCT devices exhibit a wide range, but for all devices, ________ by reducing the FOV to the actual region of interest. a. significant dose reduction can be achieved b. the patient can receive too much focused radiation c. the image quality can be significantly reduced d. the image will not be clinically useful 3. It is generally believed the radiation dose of CBCT is ________ a conventional CT. a. equal to b. significantly higher than c. significantly lower than d. more harmful than 4.

The second principle is that of optimization of radiation exposure; namely, it should be ________ to minimize the risk of cancer or tissue effects. a. as low as reasonably achievable b. on the lowest setting the unit will allow

Volume 13 Number 4

c. on the fastest setting d. as high as reasonably advised 5. The view has also been expressed by the American Association of Oral and Maxillofacial Radiology that non-radiologist dentists should not be excluded from performing CBCT imaging, provided they have _______. a. appropriate and documented training and experience b. enough financial backing to obtain the unit c. spoken to a radiologist before obtaining the unit d. learned about CBCT in dental school 6. Clinicians who do not have adequate experience in interpreting a CBCT scan should _______. a. refer the scan to a specialist radiologist or radiographer for reviewing b. refer the patient to a specialist oral and maxillofacial radiologists for the CBCT scan and reviewing c. review to the best of their ability d. both a and b 7. A CBCT could give the clinician the opportunity to _______ the situation to the patient more clearly. a. visualize b. plan c. explain d. all of the above

8. In the case that the patient declines after being informed of the risks, benefits, and alternatives, then _______. a. the clinician should always refuse to treat the patient for that procedure b. informed refusal should be obtained and documented c. the clinician’s decision to 3D image should supersede the patients’ choice. d. the patient should be dismissed from the practice for any other procedures 9. ________ remains one of the most vexing problems and greatest source of liability for practitioners who take their own scans. a. Correct patient positioning b. The decision regarding which FOV to choose c. The interpretation of CBCT images d. Artifacts 10. If dental practitioners own a CBCT machine and take scans not only for their own patients, but also for those referred from outside, they must ensure in the latter situation that they ________. a. do not contradict the referring dentist’s diagnosis b. do not lack malpractice coverage in the event of a lawsuit c. only take the largest FOV possible d. scan more than the area of interest so they don’t miss anything

Implant practice 31

CE CREDITS

IMPLANT PRACTICE CE

PRODUCT PROFILE

Stress-free dentistry delivered Zimmer Biomet Dental introduces SmileZ Today™ Box

ver the last decade, the field of implant dentistry has embraced a rapid adoption of digital technologies. Innovations in imaging systems, CAD/CAM software, guided surgery, 3D printing, and patientspecific restorations offer alternatives to traditional techniques to enable more practice and workflow efficiencies and to improve overall patients’ experiences and outcomes. Since pioneering the first 3-in-1 healing abutment, impression coping, and scan body in 2004, Zimmer Biomet Dental has been a front-runner in advancing digital dentistry. Recently, the company introduced a number of significant contributions in this area through industry partnerships and new product development. “We anticipate the market’s demand for digital technology will only increase because it simplifies implant dentistry and reduces chair time while improving outcomes,” said Indraneel Kanaglekar, vice president and general manager at Zimmer Biomet Dental. “Zimmer Biomet Dental is focused on delivering end-to-end solutions that are backed by science and clinical evidence to support the future of implant therapy.” Earlier this year, the company began offering guided surgical services and solutions powered by San Antonio-based company Implant Concierge. Since its beginnings in 2006, Implant Concierge’s Virtual Treatment Plan Coordinator™ has assisted thousands of dentists with their

SmileZ Today™ Box

CAD/CAM surgical guide needs — from simple to complex cases — by acting as a Virtual Treatment Plan Coordinator™. Services include a proprietary, web-based platform that synchronizes and simplifies the digital implant workflow using a centralized, HIPAA-compliant tool to communicate, streamline, and coordinate guided implant surgical services. The platform offers fully automated, patient-specific workflows with real-time updates on a patient’s case with an accurate financial summary in minutes.

3-in-1 BellaTek® Encode® Healing Abutment

Surgery-ready provisional

Virtual implant planning 32 Implant practice

Surgical guide Volume 13 Number 4

Volume 13 Number 4

“This case-in-a-box concept, like Zimmer Biomet’s other leading digital dentistry technologies, is really about streamlining and optimizing the customer and patient experience.” – Nan Meehan, Zimmer Biomet Dental’s General Manager for North America

iTero 5D Intraoral Scanner

Certain® BellaTek® Flex Abutment

Puros® Ci Particulate Allograft

offers. Other innovations include unrivaled flexibility with the Certain BellaTek Flex Abutment, which provides a unique 12 mm post for cases that demand taller heights with greater surface for bonding to the crown, and the launch of iTero 5D Intraoral Scanners through the company’s partnership with Align Technology. The new 5D is one of several iTero scanner models that Zimmer Biomet distributes directly through its sales force. In addition to its growth in digital offerings, Zimmer Biomet Dental maintains

strength in the breadth of a diverse biomaterials portfolio. Most recently, it expanded with Puros® Ci Particulate Allograft, a bone graft substitute now available in the United States. To customize a SmileZ Today Box, visit the contact page or access the live chat feature at www.implantconcierge.com. For more information on other Zimmer Biomet Dental solutions and continuing education opportunities, visit www.zimmerbiometdental.com. IP This information was provided by Zimmer Biomet Dental.

Implant practice 33

PRODUCT PROFILE

In September 2020, Zimmer Biomet Dental and Implant Concierge teamed up to launch the SmileZ Today™ Box, which integrates the clinical benefits of guided surgery with the goal of improved esthetics. Leveraging the Implant Concierge guided platform with Zimmer Biomet Dental’s suite of implant therapy solutions, this new offering provides clinicians with everything needed for a guided single-unit implant case together in one compact and organized package. A fully customizable, patient-specific box is available for Zimmer Biomet Dental’s Certain® Internal and External Hex Connections and the TSV® and Trabecular Metal™ Implant Systems. How does it work? The Implant Concierge portal provides clinicians with an intuitive, simplified ordering procedure with one-stop shop ordering. There is no need to inventory components or spend valuable time looking through a catalog to decipher which products to order. Clinicians can choose to include the following products inside the box: dental implant, 3-in-1 BellaTek® Encode® Healing Abutment, a surgery-ready provisional, surgical guide, surgical protocol, BellaChek® Coupon for a definitive BellaTek Abutment, and a 3D-printed model based on a patient’s individual needs. “This case-in-a-box concept, like Zimmer Biomet’s other leading digital dentistry technologies, is really about streamlining and optimizing the customer and patient experience,” said Nan Meehan, Zimmer Biomet Dental’s General Manager for North America. “It allows our customers to purchase only what they need and tailor it to each patient.” Surgery-ready provisionals, which are available as a custom tissue former similar to an anatomical healing abutment or an esthetic tooth for cases with high esthetic demands, improve efficiency and allow surgeons to provide this value-added service to the restorative clinician. Delivery times for the box are fast and predictable, so clinicians can have confidence that they will receive their case on time and be ready for their patients. Additionally, the SmileZ Today Box reduces chair time for both the implant placer and the patient, which is especially important during the pandemic. It is also minimally invasive and enables same-day teeth, creating an experience that may increase patient acceptance and confidence as well as potentially improve outcomes. The SmileZ Today Box is a complementary addition to the armamentarium of digital solutions that Zimmer Biomet Dental

SERVICE PROFILE

Silent partners cut your implant bill in half, or your competitors’ Chip Fichtner discusses how to build a strategy for growing your practice

arger practices still have the opportunity to sell part of their practice at an unbelievable value to a silent partner — an Invisible Dental Support Organization (IDSO). Large Practice Sales (LPS) will complete over $400 million of these transactions in 2020 for doctors of all specialties across the U.S. Values vary based upon numerous factors, but even during COVID-19, we have completed many transactions at well over 2X collections. IDSOs are still eager to become supporting, but silent, partners with growing practices. In an IDSO transaction, doctors sell between 60% and 90% of their practice for cash now and retain ownership in either the practice or the parent. Doctors continue to lead the practice with their brand, team, and strategy for years or decades into the future. The practice benefits from the multiple resources of a larger partner. Doctors secure their financial future at today’s lower tax rates and continue to have significant upside value potential from their retained ownership. As a bonus, doctors gain a known exit path when they are ready. The resources of an IDSO differ from group to group, but they are all exceptionally adept at reducing the cost of implant systems. Typically, a larger IDSO is paying half or less for the same implants you are buying today. This resource alone can have a significant impact on the profitability of larger implant-focused practices. Other cost reductions are possible in supplies and team benefits. But the real growth potential may

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. After careers at Merrill Lynch and Bear Stearns, he began buying and selling businesses of all types for his own portfolio. Mr. Fichtner has been the Chairman and/or CEO of multiple publicly traded companies and has presented at conferences on investing and marketing from Hong Kong to Monaco. Learn more at www.findmyimplantidso.com

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In an IDSO transaction, doctors continue to lead the practice with their brand, team, and strategy for years or decades into the future.

lie in synergies with other partner practices in the area, now or in the future, and professional marketing. IDSOs prefer to buy multiple practices in an area and create synergies among the individually branded practices. As an example, we complete many transactions where IDSOs acquire a pediatric specialist, an orthodontist, and an oral and maxillofacial surgery (OMFS) practice in the same area. The natural referral pattern is for doctors to refer to other doctors within the group. The OMFS practices are usually the greatest beneficiaries of these transactions. Implants have to some degree become a direct-to-consumer marketing challenge for many dentists. Groups like ClearChoice® Dental Implant Centers have spread the message of the life-changing benefits of implants and raised the consumer interest level benefiting all doctors. Smart doctors have focused their marketing to attract these patients. However, many doctors do not have the time, skills, or resources to manage sophisticated marketing campaigns. The IDSOs often have in-house marketing teams focused solely on improving the performance of their partner practices’ new-patient generation approaches. In many cases, the IDSOs’ size also enables them to negotiate higher reimbursement rates from payors for their partner practices. As in implant purchasing, there is strength in volume and size. If you are on the receiving side of this resource, it is great for you. On the other hand, if you are competing with an IDSO in your area, you may have

a formidable competitor with lower costs, higher reimbursement rates, and better team recruiting and retention tools. Doctors who are the first in their area to partner with an IDSO will typically achieve the highest value. You want to be the launch practice in your area for an IDSO. The next practices acquired will command lower values from the same IDSO. Contrary to popular belief, IDSOs have no interest in operating your practice. They want to silently invest in great doctors and to support their growth and expansion. The changes you will experience will vary from partner to partner. It is critical that you are introduced to multiple prospective partners to understand which is the best fit for you both short- and long-term. This is a marriage, not a one-night stand. The real value in these transactions is long-term equity growth. IDSOs want to build long-term relationships with doctors who want to grow, not slow down. In multi-doctor, group practices, consideration per doctor can differ based upon his/her age and time horizon. IDSO transactions are becoming more attractive to younger doctors who value the security of a partner who can facilitate growth. Our average doctor-client age this quarter is 47. While an IDSO partnership is not for every doctor, it will pay to understand the potential value of your practice to enable you to make an educated decision. To discover the value of your practice, LPS provides a confidential, free, and no-obligation process, which typically takes about 2 weeks. IP Volume 13 Number 4

Silent Partners are Eager to Invest in Large Dental Specialty Groups With Collections Over $1,500,000 and General Dentist Groups in Excess of $2,000,000 In 2020, LPS will advise larger practices on over $400,000,000 of transactions with Invisible Dental Support Organizations (IDSO). Even with the impact of Covid-19, we are still achieving record values for clients across the country.

Recent Transactions 2.6X Collections, One-Doctor Periodontist 3.9X Collections, Four-Doctor Oral Surgery, Three Offices, Stunning Value 2X Collections, Two-Doctor General Practice, Age 30s, Sold 60%, Retained 40% 2.1X Collections, Single Doctor Oral Surgeon (During Covid) 1.8X Collections, Two-Doctor Oral Surgeon (During Covid)

SILENT PARTNERS INVESTING IN IMPLANT-FOCUSED PRACTICES; CASH NOW, WEALTH LATER

To schedule a confidential call, and get a FREE practice value analysis, call 844-533-4373 or Email Implant@LargePracticeSales.com Webinar On Demand at FindMyImplantIDSO.com

MARKETING MOMENTUM

Telemedicine marketing checklist: 10 things dentists should do Marketer Rachael Sauceman discusses safe and effective marketing evolving after the COVID-19 crisis

o say that the COVID-19 pandemic has been a catalyst for change across all industries is an understatement. Earlier this year, dental practices across the nation were struggling to maintain revenue while abiding by state regulations, as well as recommendations set forth by medical associations such as the Centers for Disease Control and Prevention, the American Dental Association, and others. Many states deemed emergency dental care essential — and at this stage, all states have reinstated elective dental care, according to the ADA’s Center for Professional Success.1 Although this reopening is somewhat of a “return to normal” at the surface level, it’s safe to say that dental practices of all types will continue to face challenges as they work to deliver quality care in a way that offers a safe environment for patients, doctors, and staff members. One advancement we’ve seen in this area is the rapid shift toward virtual consultations. Across the entire healthcare vertical, we’re seeing an unprecedented adoption of telemedicine as a way to continue serving patients. Telemedicine has long been a trend as younger generations prefer to access care on their own terms, but red tape from regulations and payers, as well as growing pains from the implementation process, have held back a lot of practices from adopting telemedicine. But in today’s environment, telemedicine is helping many practices and patients weather the storm. Whether you’ve implemented a teledentistry solution already or you’re considering one, ensuring patients are aware of this new offering is just as crucial as implementing

Rachael Sauceman is the Head of Strategic Initiatives for Full Media, a Chattanooga, Tennessee-based digital marketing agency specializing in healthcare. Full Media offers a full spectrum of digital marketing capabilities within the healthcare space, including website design, online advertising, SEO, patient experience optimization, and analytics.

36 Implant practice

the technology. This 10-step checklist offers guidance to help market virtual appointments from your dental practice.

1. Update your website. Especially during the COVID-19 pandemic, prospective patients are looking for detailed information about your practice’s current operations. And because different patients may consume information differently, it’s important to have your COVID-19 statement and telemedicine offerings accessible in multiple ways. If you already have a COVID-19 statement on your website, be sure to provide information regarding telemedicine options from that page — and while it may seem like a big project if you’re in a hurry to add virtual appointment details to your website, it’s important to have a specific page dedicated to telemedicine offerings. Although your existing patients would probably search for your specific practice, this may also be an opportunity to gain new patients who are uncomfortable returning to in-office appointments. Having a dedicated telemedicine page ensures you can capture both types of searches. We like this example from Aspen Dental.2 The Virtual Care page is linked directly from the homepage in an easy-to-find section. The page addresses cost, scheduling options, and explains how a virtual appointment works.

2. Make sure patients understand what to expect. The more questions you can answer for patients in advance, the more likely they are to be comfortable with a virtual appointment. Some common questions you might be able to address in an FAQ section on your telemedicine page include: • Are you currently seeing existing patients only, or can new patients schedule a virtual appointment? • What types of issues can be addressed with a virtual appointment?

Figure 1: This Facebook post from Dentists of East Brainerd lets patients know about their new service

• What types of dental problems are considered to be emergent? • Will my insurance cover this appointment? • How do I schedule a virtual appointment? • What is the process to connect with a provider at the time of my appointment?

3. Contact existing patients. Since existing patients are more familiar with your pre-COVID-19 processes and procedures, they may be unaware that telemedicine is an option. Send an email with details and a link to your new telemedicine page through an existing platform if you have one, or consider reaching out to patients individually with short phone calls.

4. Promote on social media. Although it can’t be your only form of outreach, be sure to notify your followers on social media. Since the average post on a Facebook business page only reaches 6.4% of all the people who like the page,3 it’s a good idea to consider boosting your Facebook posts. If Volume 13 Number 4

Since the average post on a Facebook business page only reaches 6.4% of all the people who like the page,3 it’s a good idea to consider boosting your Facebook posts.

5. Consider Google Search Ads. Search ads offer highly effective marketing because they’re displayed to patients and prospective patients as they’re actually searching for you. As dental offices reopen before some people may feel comfortable with making a trip to a physical office, there’s a good chance that some of those individuals may search for telemedicine consultations. By implementing Google Search Ads for your teledentistry offerings, you’ll have a high likelihood of pulling this type of patient to your website. For example, dentists can’t target people who are experiencing tooth pain on Facebook. But they can target people who are searching for a virtual appointment for tooth pain on Google Search. If you are rolling out a new virtual appointment offering, we suggest that you take these steps: • Start with branded advertising. Existing patients and those who may already be familiar with your brand will likely search for your practice specifically. Having an ad that references your virtual offerings will ensure those individuals are made aware of this new option. • Create ads to answer FAQs. As a dental specialist, the types of problems you may see are fairly specific. Do patients often ask you about specific types of tooth pain? Create ads that target the types of concerns patients may search for. • Implement more general ads. Since some patients may simply search for virtual dental appointments, teledentistry visits, etc., ensure some of your ads focus on these general terms and topics. • Broaden geographic targeting. While advertising for in-office visits should be more targeted, patients from more distant or remote locations may be interested in your virtual consultations. Volume 13 Number 4

Figure 2: Using search ads on Google Ads, you can ensure that your telehealth service shows up exactly when patients are looking for you

Figure 3: Patients are spending more time surfing the web, viewing news and videos, and shopping online at this time

6. Be where your customers are going for information. COVID-19 has changed essentially everything — the way we communicate, the way we work, our purchasing habits, and so on. It has also impacted the way users search for and consume content. Data from WordStream shows that search volume is down, but content consumption on the Google Display Network and YouTube is booming.4 The Google Display Network enables advertisers to show ads on content throughout the web, like local and national news websites, lifestyle blogs, YouTube videos, mobile apps, and games, and may be a good place for your practice to advertise. You may also choose to begin creating video content that you can upload to YouTube

and embed into blogs or relevant pages on your website. Cell phone cameras can record video of decent enough quality without having to invest in high-dollar productions. (Online retailers offer cell phone tripods and/ or light rings that can enhance the quality of your video.) Topics to consider include: • Educating patients about the telemedicine platform you’re using. Walk them through what to expect during a virtual consultation, and be sure to cover topics such as why you chose the particular platform you’re using, as well as patient privacy. Once you’ve uploaded this video to YouTube, be sure to embed it on your teledentistry webpage. • Introducing yourself to prospective new patients (if you’re taking Implant practice 37

MARKETING MOMENTUM

you’d like to implement a more sophisticated marketing plan, you may decide to invest in ads on Facebook, Instagram, and Twitter — or whichever platforms currently draw the most engagement. Social media ads not only help your content display to more of your existing followers, but also draw in prospective patients who may not be familiar with your practice.

MARKETING MOMENTUM them). Talk about the immediate needs for telemedicine as it relates to COVID-19, and explain your plans for the future. Offer an overview of the types of services you offer, and let patients know what they can expect during a visit to your practice. • Offering helpful tutorials that can prevent patients from needing emergent care. Do your patients have common symptoms and complaints? Could many of them be solved with better dental hygiene or compliance in their treatment plan? Make videos to address these topics. Even after COVID-19 is no longer a consideration, video content on YouTube can benefit your search rankings.

7. Update your local listings. Did you know that more than 50% of searches result in no clicks whatsoever to a website?5 This means many prospective patients may take action by calling your practice or gaining other pertinent information directly from listings on Google, Bing, Yahoo! Maps, and Google My Business. Be sure to provide information about COVID-19 and virtual appointments in those listings (and keep track of what you’ve updated in a spreadsheet, so you can remove the COVID-19 details when appropriate). Google My Business is also currently allowing providers to add two unique links to local listings: a link to COVID-19 information and another to teledentistry information on your website. If your practice operates in more than one location, you’ll need to add the links to each profile, all of which can be found in your Google My Business dashboard.

Did you know that more than 50% of searches result in no clicks whatsoever to a website?5 This means many prospective patients may take action by calling your practice or gaining other pertinent information directly from listings on Google, Bing, Yahoo! Maps, and Google My Business.

8. Update Meta information on your website. Meta information is the blue link text and descriptive text underneath that appears directly in search results listings. While many websites have default Meta information that is pulled from the site’s page title and content, it can be customized to offer more detail for searchers. Meta information is also crawled by search engines, meaning that it can increase the likelihood of your website appearing to prospective patients. Although you may not need to update every page on your site, be sure key pages like your homepage, provider pages, and location pages make note of virtual appointment offerings.

9. Set up a direct mail campaign. Although it is not as quick to implement as a digital marketing campaign, direct mail often generates good results. Whether you are notifying existing patients about your new offering or trying to reach prospective patients in your community, direct mail can be an effective approach.

10. Let patients know about inperson care.

Figure 4: Google My Business has offered new options to medical practices to ensure that patients can easily access telehealth information on Google Maps

Not all care can be done virtually, especially in dental specialties. Many patients will understand that while they may be able to set up a virtual consultation with a dentist, they will eventually need to come into your office for a procedure.

Consider adding some information to your website that complements your telemedicine services, helping patients understand what precautions you are taking to keep them safe if and when they need to come in for care. Dental365™ in New York has a great example detailing the exact precautions they are taking to ensure that patients are safe.6 This practice has even gone the extra mile by including a video in the actual office showing their staff participating in safety measures. Patients want to know that you are taking steps to protect them from infection and that best practices, like social distancing and mask-wearing, will be enforced by your front-office staff. While you may feel as though you can explain these precautions over the phone or in a telemedicine visit, some patients may never even reach out and pay for a telemedicine consultation if they don’t feel like their entire care experience will be safe. By explaining your virtual and in-office services upfront, you can gain a competitive advantage and answer many doubts upfront that may be a deterrent for your patients. IP

REFERENCES 1. ADA Center for Professional Success. COVID-19 State Mandates and Recommendations. https://success.ada. org/en/practice-management/patients/covid-19-statemandates-and-recommendations. Accessed July 8, 2020. 2. Aspen Dental. Virtual Care. https://www.aspendental.com/ virtualcare. Accessed. July 8, 2020. 3. Bain P. 10 Need to Know Facebook Marketing Stats for 2019. Social Media Today. https://www.socialmediatoday. com/news/10-need-to-know-facebook-marketing-statsfor-2019/547488/. Posted February 5, 2019. Accessed July 8, 2020. 4. Irvine M. New Data Reveals PPC Ad Campaigns Are Rebounding. Wordstream. https://www.wordstream.com/ blog/ws/2020/05/04/ppc-rebound-covid-19-data. Updated July 2, 2020. Accessed July 8, 2020.

Figure 5: Dentists of East Brainerd has updated their website’s Meta information and provided a specific page on their website about teledentistry. 38 Implant practice

5. Nguyen G. Now, more than 50% of Google searches end without a click to other content, study finds. Search Engine Land. https://searchengineland.com/now-more-50of-google-searches-end-without-a-click-to-other-contentstudy-finds-320574. Posted August 14, 2019. Accessed July 8, 2020. 6. Dental 365. https://www.godental365.com/about-us/whydental-365/. Accessed July 8, 2020.

Volume 13 Number 4

ON THE HORIZON

The lost art of the lateral wall sinus augmentation Dr. Justin D. Moody discusses reliable and predictable bone growth

ince the beginning of implant dentistry, we have been on a quest to rebuild and restore lost bone from previously extracted molar sites. The mandible presents a greater challenge due to the inferior alveolar nerve position and the difficulty in horizontal/vertical bone grafting. Unlike its lower cousin, the maxillary molar, when lost has the maxillary sinus as a potential grafting site. This area is one of the most reliable and predictable places in the human body to grow bone. The lateral wall sinus augmentation graft technique was first introduced to us at least 45 years ago by Dr. Hilt Tatum and others. I am sure that he was first viewed as a crazy or cowboy-like, but today the science is clear on its success, and many of today’s leading surgeons perform these procedures routinely, such as Dr. Michael Pikos, who has written an entire textbook on the subject. Dental school would have you believe that if you are ever in the maxillary sinus with a root tip, dental implant, or grafting, your life will end along with the patients’. It is my favorite

Figures 1-3: 1. Using the ACTEON Piezotome Cube to create the window into the maxillary sinus. 2. Sinus curettes are used to elevate the membrane to create the space for the graft material. 3. Placement of a BioHorizons® dental implant at the same time of sinus grafting

Figure 4: CBCT scan taken with the ACTEON X-Mind Prime

Figure 6: Postoperative CBCT taken with the ACTEON X-Mind Prime

Figure 7: Postoperative CBCT slice using the AIS software to view position of the dental implant as well as graft placement

procedure to do as well as to teach for a number of reasons. First, technically it is not a difficult procedure at all. With the use of piezo technology, such as the ACTEON® Piezotome® Cube, the access through the lateral wall and elevation of the membrane can be done safely and predictably. Second, with

the use of the patient’s own growth factors obtained from a simple blood draw and the use of the IntraSpin® from BioHorizons®, we can have clinical results that allow for implant placement and ultimately tooth replacement solutions otherwise not possible. Adding this procedure to your practice

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. Disclosure: Dr. Moody has no contract or financial interest in ACTEON®.

40 Implant practice

Figure 5: AIS software from ACTEON is used to properly treatment plan the case

Figure 8: Using BioHorizons IntraSpin machine to harvest the patient’s own growth factors and mixing it with BioHorizons MinerOss® to create “sticky” bone to be placed into the sinus

will open up so many more implant sites and the ability to help many more patients. Find a course that offers live surgery training so that you can gain the experience needed to return with the confidence and skill set to serve your patients. IP Volume 13 Number 4

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

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What Ditron does…they make the most accurate machined parts in the world, for aerospace, for high performance cars such as Tesla, Maserati or BMW AND they make the most accurate, well-fitting dental implant.

The MolecuLock™ bioseal designed to reduce micro-gaps to less than 0.5 microns. This seal, minimizes micromovement and microleakage, preventing the ingress of bacteria.

Ole T. Jensen, DDS, MS Founder, Ditron Dental USA

DITRON DISTINCTION

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As a worldwide leader in ultraprecision machining, the company’s excellence is the result of over 50 years of experience in the design, production and delivery of mission critical products for the aerospace, aeronautical, automotive and medical device industries.

Our 3rd generation implant design incorporates many progressive design features, such as the MolecuLock™ biomechanical implant-abutment seal. The ULT is the clinician’s choice for those who demand Ultra precision, Progressive Design, Clinician Driven Innovation and Premium Quality.

We took this same precision and quality from the manufacturing of high-end, performance components and introduced it to the dental implant world.

To learn more, please visit our website: