Implant Practice US Fall 2021 Vol 14 No 3 by MedMark, LLC

Fall 2021 – Vol 14 No 3 • implantpracticeus.com

PROMOTING EXCELLENCE IN IMPLANTOLOGY The dawn of the robotic era in dentistry

Clinician spotlight Nirjal Patel, DMD

CBCT: Recognizing the anatomic structures before implant surgery Dr. John Pasicznyk

A serious and emerging complication in implant dentistry Dr. Randolph R. Resnik

Coast-to-Coast Opportunities PracticeOwners, Owners,Associate AssociateDentists Dentists&&Locum LocumTenens Tenens at at the the Coast-to-Coast Opportunities forforPractice Nation’s Largest Network of Implant Providers. Begin Your #LifeatADI Today! Nation’s Largest Network of Implant Providers. Begin Your #LifeatADI Today!

clinical articles • management advice • practice profiles • technology reviews

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EDITORIAL ADVISORS Jeffrey Ganeles, DMD, FACD Gregori M. Kurtzman, DDS Jonathan Lack, DDS, CertPerio, FCDS Samuel Lee, DDS David Little, DDS Ara Nazarian, DDS Jay B. Reznick, DMD, MD Steven Vorholt, DDS Brian T. Young, DDS, MS

CE QUALITY ASSURANCE ADVISORY BOARD Bradford N. Edgren, DDS, MS, FACD Fred Stewart Feld, DMD Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA Justin D. Moody, DDS, DABOI, DICOI Lisa Moler (Publisher) Mali Schantz-Feld, MA, CDE (Managing Editor) Lou Shuman, DMD, CAGS

© MedMark, LLC 2021. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced 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 US or the publisher.

“I

’ve been to five other dental offices, and all have said I don’t have enough bone for dental implants, so I guess I’ll just have to deal with these loose dentures for the rest of my life,” solemnly explained 79-year-old Ms. Mary. Embarrassed and disappointed, she sank deeper and deeper into the dental chair during her consultation visit. However, as a new patient to the practice, she was required to undergo a radiographic examination. Consequently, her CBCT scan illustrated bilateral severe mandibular atrophy with diminished soft tissue keratinization and, consequently, a protrusive Class III malocclusion. I entered the room, thoroughly assessed her 3D imaging, turned to Mary, and unequivocally asserted that it was possible Daniel Fenton, DMD, FAGD, AFAAID, to place dental implants, and all she was required to do was DICOI, decide whether she wanted two or four of them, and if she wanted her new teeth to be fixed or removable. Her conviction that dental implants were a mere impossibility had vanished faster than her eyebrows raised in disbelief upon hearing my assessment of her periodontium. Novel technologies, techniques, and ridge-specific implant fixtures are to thank for increasing patient candidacy for patients like Mary. The use of 3D imaging — in conjunction with implants of unconventional diameters, heights, tapers, and thread designs — is now utilized to achieve optimal prosthetic outcomes and increase the quality of life for patients who struggled to smile, speak, and/or function. Shorter, wider implants like the BioHorizons® Tapered Short portfolio or the Neodent® 5.0 mm x 8 mm GM as well as taller, narrower fixtures like the BioHorizons 3.0 mm x 15 mm or the Zest Dental Solutions® Lodi 2.4 mm x 14 mm allow for dental implant placement to accommodate for compromised bone volumes. The bony topographies most applicable to receive the aid of these ridge-specific implants are reflective of the Lekholm and Zarb Classification Types D and E (height deficient) as well as the Seibert Type I ridge defects (width deficient). Often the surgical intervention with these dental implants is minimally invasive with use of smaller/no-flap reflection that preserves diminished attached epithelium, facilitates immediate loading of provisional prostheses, and mitigates postoperative discomfort. In turn, due to the limited bone volume of these patients, this faction of dental implants not only requires significantly accurate placement to avoid vital structures, but also must predictably exist in locations that result in restorative longevity. In turn, guided and/or semiguided surgery protocols and workflows are an advantageous adjunct to the scrupulous nature of these surgeries. Most notably, the service bestowed upon the patient is a truly life changing. Regardless if the dentition is implant retained or implant supported, the positive impact made on patients’ lives by employing these exceptional modalities results in happier and healthier individuals. Those individuals fortuitously turn out to be both the doctor and patient — I would beg to differ with Ms. Mary, which one of us felt the greater sense of gratification following the completion of her transformation! Dr. Daniel Fenton

Daniel Fenton, DMD, FAGD, AFAAID, DICOI, is a 2010 graduate of Nova Southeastern University College of Dental Medicine. He has Affordable Dentures & Implants practices in Port St. Lucie and Miami Lakes, Florida, and is faculty at Implant Pathway in Scottsdale, Arizona. Dr. Fenton holds Diplomate status within the International Congress of Oral Implantologists, Misch International Implant Association, and International Dental Implant Association, as well as Fellowship status within the Academy of General Dentistry, American Academy of Implant Prosthetics and Associate Fellow within American Academy of Implant Dentistry.

ISSN number 2372-9058

Volume 14 Number 3

Implant practice 1

INTRODUCTION

Fall 2021 - Volume 14 Number 3

Never say never: the impact of dental technologies on biologic ridge deficiencies

TABLE OF CONTENTS Publisher’s perspective Off the roller coaster — a positive outlook, fresh goals, and renewed focus on success Lisa Moler, Founder/CEO, MedMark Media................................ 6

Clinician spotlight Nirjal Patel, DMD

Case study Saving a failing implant Dr. Charles D. Schlesinger discusses a technique to increase implant predictability....................................14

Being unexceptional is unacceptable

Industry news............... 19

Technique

Cover story The dawn of the robotic era in dentistry

Oral surgeons Bradley Pinker, DDS, MD, and Roger R. Thayer, DMD, MA, share their experience with the Yomi® Robotic System

Predictable immediate guided-implant placement and provisionalization within your practice Dr. Ara Nazarian discusses his technique for questionable and/ or non-restorable teeth requiring full mouth extractions........................ 20

ON THE COVER Cover image courtesy of Neocis. Article begins on page 10.

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Volume 14 Number 3

TABLE OF CONTENTS

Continuing education CBCT: Recognizing the anatomic structures before implant surgery Dr. John Pasicznyk discusses the decreased risk of complications when planning implants with CBCT......... 28

Continuing education

Product profiles ULT™ — The Ultimate™ Implant by Ditron Dental USA An implant system that checks all the boxes..............................................33 Boyd Industries’ featured products........................................34

Cool Jaw®....................................36

On the horizon

Service profile

Predictable, safe implant placement aided by CBCT

Medical-billing services by Vivos

Dr. Justin D. Moody discusses 3D imaging and its profound impact on implant decisions..........................38

How comprehensive billing intelligence software can help you provide top-ofthe-line patient care.........................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

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4 Implant practice

Volume 14 Number 3

Mentoring Transformations

Navigating Complications

Global Perspectives

Clinical Innovations

Registration Is Open! PURSUE YOUR IMPLANT EDUCATION BY ATTENDING IN PERSON OR VIRTUALLY CHOOSE FROM MORE THAN 55 WORKSHOPS, SEMINARS, AND LECTURES

MENTORING

NAVIGATING COMPLICATIONS

GLOBAL PERSPECTIVES

CLINCAL INNOVATIONS

Dr. Duke Heller/Dr. Rob Heller Dr. Arnie Weisgold/Dr. Howard Fraiman Dr. O. Hilt Tatum/Dr. Jose Pedroza

Dr. Ramsey Amin Dr. Frank LaMar Jr. Dr. Joe Massad Dr. Paul Rosen Dr. Len Tolstunov

Dr. Fouad Khoury Dr. Andre Saadoun Dr. Tomas Vercelloti

Dr. Jason Kim Dr. Isaac Tawil

*Speakers are subject to change

Join us November 10 to 13, 2021 at the Hyatt Regency Chicago or attend online!

EVENT INCLUDES: World-Class Speakers Hands-On Workshops Dedicated Team Program Implant Expo Networking Cadaver Course Virtual Learning Options

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PUBLISHER’S PERSPECTIVE

Off the roller coaster — a positive outlook, fresh goals, and renewed focus on success

n looking back, most of us felt that last year was a roller coaster ride. We got shoved into that buggy, fastened our seat belts, and hung on. Dentists hurtled around all of the new rules and regulations that were unveiled each day. You skidded around corners that held unknown aerosol dangers, careened past roadblocks to business operations, and avoided the twists and turns of offering emergency care to patients when the definition of emergency care was still evolving. It was a white-knuckle ride, for sure. But through the highs and lows and learning curves, we emerged definitely wiser and more resilient. Here at MedMark, even at the height of the pandemic, Lisa Moler we brought you the most up-to-date information on how to Founder/Publisher, MedMark Media protect your patients and staff and prepare for reopening. We anticipated and tracked the new trends and technologies that patients would be expecting. We checked on our readers and authors through emails, texts, and Zooms. We saw you calmly focus on keeping in touch with patients through teledentistry, informative texts, and website updates. You prepared protective equipment to be able to provide emergency care, consulting, and treatment plans for when the crisis was over. Now we are joyfully hearing about your safe returns to business. And our articles reflect our goal of helping you flourish in the future. Our two CEs show how to maximize safety during implant procedures. Dr. John Pasicznyk writes about CBCT and how it helps you to recognize anatomic structures before implant surgery. Dr. Randolph R. Resnik offers guidance on possible serious complications during implant surgery — avoiding aspiration or ingestion of implant components. In implant procedures, predictability is key to success. Dr. Ara Nazarian shows how to facilitate predictable immediate guided implant placement, and Dr. Charles D. Schlesinger writes how to save a failing implant. With this fall issue, the new view from the top is exciting. We are thrilled to be able to say that we made it. We’re no longer anticipating what is coming around each bend. And we are ready to take a new plunge — into the future. I’m proud and amazed at the perseverance and courage that we all saw in the dental profession. With a positive outlook, fresh goals, and renewed focus on success — the MedMark team is bracing for new adventures! To your best success, Lisa Moler Founder/Publisher MedMark Media

Published by

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 Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING & DIGITAL STRATEGY Amzi Koury amzi@medmarkmedia.com WEBMASTER Mike Campbell webmaster@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 14 Number 3

JOIN THE NATION’S LARGEST NETWORK OF IMPLANT PROVIDERS The turning leaves are a reminder to us that change is inevitable. The field of dentistry is no different. As the industry evolves, it’s imperative that you evolve with it. A career with Affordable Dentures & Implants (AD&I) gives you that opportunity. Praised for its world-class implant training, clinically-led guidance, a fostered sense of community and a steadfast commitment to innovation, your career at AD&I knows no bounds. Now is the time to join the nation’s largest network of implant providers and become part of our mission to not only change smiles, but countless lives. AD&I Welcomes You...

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To learn more about nationwide dentist careers & ownership please visit careers.affordabledentures.com. We also invite you to contact Sallie Henry, Clinical Director of Recruitment at sallie.henry@affordablecare.com or call her directly at 314-779-5969.

CLINICIAN SPOTLIGHT

Nirjal Patel, DMD Being unexceptional is unacceptable

incent Van Gogh. Andrew Carnegie. Henry Ford. Will Smith. Aside from being public figures, the one thing these gentlemen have in common is their denouncement of mediocrity. Even in dentistry, perhaps especially so, mediocrity just won’t cut it. Dr. Nirjal Patel, one of the newest dentists to join the Affordable Dentures & Implants (AD&I) ranks, will emphatically tell you that. “I don’t like mediocrity — being average is not who I am.” says Dr. Patel, “Would I want an average dentist working on me? No. I’ve never thought, let’s make an average denture.” On the contrary, he explains it’s all about, “dedication, hard work, and doing your best. Every day. Day in. Day out.” Being unexceptional is unacceptable. Perhaps his commitment to excellence is the reason behind Dr. Patel’s swift rise, not only at AD&I, but also in the dentistry field at large. It was only 2½ years ago when Nirjal Patel became Nirjal Patel, DMD, upon graduating from Temple University’s Kornberg School of Dentistry. And it was a mere 9 months ago when he became the practice owner of the AD&I-affiliated practice in Kinston, North Carolina. Talk about progress. Talk about achievement. Every dentist has a reason for entering the field. Without hesitation, Dr. Patel can recall exactly why and when implant dentistry became his calling. “It began when my uncle got dentures. Our family would all sit around the dinner table eating great food while he was eating grinded food. Then he got implants.” The immediate countless benefits that implants brought his uncle didn’t go unnoticed. “From that time, I wanted to be an implant dentist — someone who performs surgery and gives teeth back. Anybody can take teeth away, but not everybody can give teeth back. At AD&I, that’s what we do. We give teeth back.” AD&I entered the picture 2 years into Dr. Patel’s career while he was working as a senior associate at a prosthodontist office in Houston, Texas. At the time, Dr. Patel, the forever-learner, was enrolled in the TexMAX® AAID MaxiCourse®, where he mentioned his desire to focus on implants and dental 8 Implant practice

Nirjal Patel, DMD

surgery. A colleague immediately referred him to a friend who was an AD&I-affiliated dentist. “He told me how he was able to do the dentistry that he likes to do; that he had clinical autonomy; that he made a good living. At that point, the only person I wanted to work for was myself or Affordable,” Dr. Patel remembers. In June 2020, he got both. Dr. Patel has experienced tremendous success already, fortunate to place his two feet on the summit and stand “on top of the world” for a while. However, he’s realistic, ever-conscious of the downs that can accompany the ups. If he and his staff have a tough day, he tells them, “Today is just a valley.” And when Dr. Patel and his staff reach a peak, it is celebrated. In the first week of December, for example, he was thrilled to learn that his Kinston practice ranked 10th in the nation and No.1 in North Carolina in regards to revenue. “I told my team, ‘This is an achievement.’ I told the lab, ‘You guys made [the prosthesis]. I may have [done the extractions], but you made them.’ I’m thankful for the lab and for the staff. It was a proud moment — like, we can do it. See! Here we are!” He was able to get here for a few reasons. First, by keeping his uncle, his entire family, in fact, in mind as he works. He makes a

concerted effort to treat his patients as if they were his own family. “That’s when it becomes, and that’s when you see success. You start thinking, ‘OK, what would I choose to do if this person were my own blood? Would I put an implant this close to a nerve or would I not?’” Dr. Patel says. Along with patient care, another piece of the success puzzle is resourcefulness. One of the many benefits of being part of the AD&I network is the network itself. Once again, Dr. Patel, that forever-learner, jumps at the many opportunities the network presents. “Learning from others is something that I do, and I’ve done it here. I look at the other successful AD&I practices. I’ve seen what the doctors there have done, how the teams work, the attributes of AD&I, and how to maximize potential. If I want to get there, and if others are already doing it, then I can do it,” Dr. Patel says. Completing the success puzzle is talent and experience. Dr. Patel has over 500 hours of implant training. And in only 2 months, he placed a whopping 70 implants. “Doing this more and more often just takes you to the next level in this discipline. It makes you a really good surgeon.” Dr. Patel is proud to be in Kinston, the same town where Affordable Dentures began Volume 14 Number 3

CLINICIAN SPOTLIGHT

back in 1975. It’s heartwarming for him when a patient comes in who tells him that his grandmother came to AD&I, and then his mom before him. He enjoys knowing there is longevity here, that there are “three generations of a patient pool,” he says, “Who else can claim that?” The Kinston practice has gotten so busy, in fact, that Dr. Patel has called in a recruit, his classmate and best friend from Temple University. Dr. Philip Afshar will be working alongside Dr. Patel as an Associate Dentist. Dr. Patel is looking forward to this partnership, for both himself and Dr. Afshar. “I think it’s going to be a good relationship, and if he wants to have his own AD&I-affiliated practice one day, he can do that.” And so, here is Dr. Patel. Only a few years into his dentistry career and already a practice owner. Though mediocrity is restricted from entering the practice, outside of work, Dr. Patel lets himself unwind and “forget about dentistry for a while.” He spends his time with friends and family, traveling, watching sports, and, as a recent transplant to North Carolina, furnishing and settling into his new home.

It’s all about “dedication, hard work, and doing your best. Every day. Day in. Day out.”

“You have to work hard. You have to keep learning if you want to achieve the success you’re after.” By fulfilling what he set out to do, Dr. Patel is now able to live out this new phase of life. “Finally, it has all come to fruition for me. Now is the time to enjoy my life. I don’t think it gets any better than this.” IP This information was provided by Affordable Dentures & Implants (AD&I).

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Implant practice 9

COVER STORY

The dawn of the robotic era in dentistry

obotic assistance is fast becoming a standard of care across surgical disciplines, used to help treat over 1 million patients every year. Robotic surgery has been seen to enhance and augment surgical practice across many specialties, enabling virtual procedure planning, augmented anatomical visualization, guided instrument placement, clinical insights, and user ergonomics not available with standard procedures. Yomi® by Neocis is the first and only FDA-cleared robotic device for dental implant surgery. It is designed to bring the benefits of robotic assistance to dental implant surgery, promoting thriving dental practices and beautiful smiles. Unique to Yomi in dentistry are the provided physical cues that guide the dental surgeon’s hand to the precise angulation and location for the planned osteotomy. Once in position, Yomi securely maintains handpiece trajectory, preventing unintended deviation from the plan. Should the patient move, Yomi tracks and follows patient motion. When the drill bit reaches planned depth, Yomi provides the dental surgeon with the solid confidence of a physical “hard stop.” There are over 50 Yomi-enabled practices in the United States, putting Yomi in the hands of leading dental surgeons who share the desire to elevate their dental practices and bring a new level of care to dental implant surgery. Oral surgeons Bradley Pinker, DDS, MD, and Roger R. Thayer, DMD, MA, share their experience with the Yomi® Robotic System. Here’s what they had to say.

Tell us about yourself and your practice Dr. Pinker: I am Bradley Pinker, DDS, MD, a Board-certified Oral and Maxillofacial

Dr. Pinker utilizing the Yomi® Robotic System

Bradley Pinker, DDS MD, is a Board-certified Oral and Maxillofacial Surgeon. He is originally from Carlisle, Pennsylvania. He attended the University of Miami, Florida, where he obtained a Bachelor of Science in Biology. He then went on to complete his requirements for Doctor of Dental Surgery at Columbia University College of Dental Medicine in New York. Dr. Pinker concluded his training in oral and maxillofacial surgery at the University of North Carolina at Chapel Hill. During this time he obtained a Doctor of Medicine at the University of North Carolina at Chapel Hill and completed a general surgery internship. His professional interests within the field of oral and maxillofacial surgery include orthognathic surgery, robot-assisted dental implant surgery, dentoalveolar surgery, maxillofacial pathology, and maxillofacial trauma. Dr. Pinker is a Diplomate of the American Board of Oral and Maxillofacial Surgery. He is also a member of the American Association of Oral and Maxillofacial Surgeons, American College of Oral and Maxillofacial Surgeons, and the American Dental Association. Roger R. Thayer, DMD, MA, is a highly qualified and experienced surgeon. Dr. Thayer obtained his DMD and his Oral and Maxillofacial Surgery Residency at Nova Southeastern University/College of Dental Medicine. He obtained his Master of Arts in Biology (1999) and his Bachelor of Science-Business Administration (1994) at the City University of New York City College. Dr. Thayer served 3 years in the United States Navy, 2nd Dental Battalion, as a general dentist for the Marine Corps Air Wing. He did a GPR at National Naval Medical Center in Bethesda, Maryland. Dr. Thayer is committed to providing his patients with the utmost care and latest technology. Dr. Thayer has written numerous publications and frequently lectures for his peers.

10 Implant practice

Surgeon at Florida Oral & Facial Surgical Associates. We have a total of three offices (Daytona Beach, Palm Coast, and New Smyrna Beach, Florida). I have been in practice for approximately 3 years. The scope of our practice includes dentoalveolar surgery, implant surgery, benign pathology, facial trauma, orthognathic surgery, some TMJ procedures, and cosmetic surgery. We are affiliated with Halifax Health Medical Center in Daytona Beach, Florida. Dr. Thayer: I graduated from dental school in 2004 and completed my residency in Oral and Maxillofacial Surgery from Volume 14 Number 3

Dr. Thayer: Our office has been at the forefront of incorporating technology in a state-of-the-art environment for providing innovative full-scope oral and maxillofacial surgical services for our patients for over 60 years. Yomi is a perfect addition to our office as it helps us provide exceptional and precise results in the placement of dental implants. Our referring doctors love our results because it helps them restore the implants with crowns and dentures with ease and provides the best outcome for the patients.

What is Yomi?

What has Yomi done for you as a clinician?

Dr. Pinker: Our practice has been using Yomi for over 2 years. Yomi is essentially a hand-assisted/guided robot that allows the surgeon to place a dental implant in a planned position using a preoperative cone beam CT. Dr. Thayer: Yomi is an innovative technology that can enable minimally invasive techniques to place dental implants with precision, which results in less discomfort to the patient.

What made you decide to add the Yomi robot to your practice? Dr. Pinker: At Florida Oral & Facial Surgical Associates, our mission statement includes the incorporation of the latest technology in our practice to give our patients the best clinical outcomes and experience. The advances in the technology of the Yomi robot closely align with our mission statement.

Dr. Pinker: Yomi has allowed me to collaborate with other dentists easily regarding planning cases. It has allowed me to place same-day implants without a surgical guide. It has improved several of my patient outcomes due to performing the surgeries flapless and accessing areas of the mouth with limited visibility. It saves a great deal of time when placing multiple implants for locators or for fixed hybrid restorations. Dr. Thayer: As a surgeon, I strive to provide the best treatment and results for our patients. Yomi allows us to provide a minimally invasive and flapless surgical approach in placing dental implants. The patients benefit because there are excellent esthetic results, less surgical site discomfort, and faster recovery. This is especially

true in patients with compromised bone anatomy as I can place these implants, as if I am threading a needle, with precision.

What is your favorite aspect of being a robotic clinician? Dr. Pinker: Being able to provide the latest technology to our patients to help speed up their recovery with a goal of improving outcomes. Not to mention, the surgical procedure is more fun using the robot. Dr. Thayer: We enjoy using Yomi in our practice because it is a beneficial and innovative way to place dental implants. It assists us in providing our patients the best results with minimal discomfort and faster recovery. We have the ability to preplan the implant on the 3D software, which incorporates placing the implant, abutment, and the crown prior to the procedure. We can share and discuss the images with

Dr. Pinker and his team Volume 14 Number 3

Implant practice 11

COVER STORY

Nova Southeastern University/Broward General Medical Center in 2011. It was also my privilege to serve in the U.S. Navy as a Dental Officer at the National Naval Medical Center in Bethesda, Maryland, and at Camp Lejeune, North Carolina. I have been in private practice since 2011 at Florida Oral & Facial Surgical Associates in Daytona Beach Florida. In our community, our office has been an icon for providing exceptional full-scope oral and maxillofacial surgical services for over 60 years.

COVER STORY

Dr. Thayer and his team

Dr. Thayer: In many cases, I used to open a flap at the surgical site to visualize the bone and place the implants. We also used surgical guides, especially for full-arch cases. There were many times that the implant placement was not as precise because the surgical guide concealed the direct visualization and the ability to accurately use direction indicators and, most importantly, to correct and make changes intraoperatively. Yomi removes these obstacles and helps us achieve the best results in our practice for our patients. I can change the position of the osteotomy intraoperatively, feel the density of the bone, and have direct visualization of the patient and the operative site. the dentists and get their recommendations and input prior to placing the implant.

What method(s) were you using to perform implant procedures before Yomi, and what would you say to a peer using that method now that you have Yomi? Dr. Pinker: I typically placed implants with a surgical guide or freehanded. I have learned in practice that surgical guides may not be the most accurate after converting digital data obtained from an intraoral scan or cone beam CT scan to an analog-printed guide. The access to second molar sites and the visualization is much easier with Yomi. 12 Implant practice

How would you describe the learning curve for the Yomi robotic system? Dr. Pinker: Initially challenging when the technology was in its infancy, but with the advances of the robotic technology (both hardware and software) over the past 2 years, the steepness of the learning curve continues to decrease. Dr. Thayer: We have been using Yomi for the past 2 years, and the technology, both the hardware and software, has improved significantly. The learning curve gets easier as the surgeon and the team place more implants. It has become a routine part of the day. Our Yomi support team — from the CEO

to the clinical support team and the countless engineers — have become a major part of our robotic family. Their support and constant pursuit of perfection in improving the robotic system and technology help the surgeon and the patient experience better outcomes. Finally, you must have a team of assistants who embrace this technology and are excited to help place the implants using Yomi. I am fortunate to have my assistants Kathy, Carol, Jill, and Katrina; without them, I would not be able to use Yomi to its full potential.

What are your patients saying about Yomi? Dr. Pinker: In general, they are experiencing a faster recovery and reduced pain postoperatively. I attribute this to minimizing actual surgical time and many times being able to perform placement of the implants using a flapless technique. Dr. Thayer: They are very receptive and amazed about this new forefront in dental robotics and technology. Our patients have shared their positive experiences with their friends and family through social media. One of my patients was discussing their positive experience with friends in New Zealand. If you would like to learn more about Yomi or schedule a demo to see this technology for yourself, please visit yomirobot.com. IP This information was provided by Neocis.

Volume 14 Number 3

Set Your Practice Apart with Yomi Dental Robotics

The FIRST and ONLY robot-assisted technology for dental surgery

Unsurpassed precision

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3D anatomical visualization

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FDA cleared for full-arch

REQUEST A LIVE DEMONSTRATION Yomi® is the first and only FDA-cleared robot-assisted dental surgery system. Indications for Use: Yomi is a computerized navigational system intended to provide assistance in both the planning (preoperative) and the surgical (intraoperative) phases of dental implantation surgery. The system provides software to preoperatively plan dental implantation procedures and provides navigational guidance of the surgical instruments. Yomi is intended for use in partially edentulous and fully edentulous adult patients who qualify for dental implants. When YomiPlan 2.1 is used for preplanning on third party PCs, it is intended to perform the planning (pre-operative) phase of dental implantation surgery. YomiPlan 2.1 provides pre-operative planning for dental implantation procedures. The output of YomiPlan 2.1 is to be used with the Yomi System. © 2021 Neocis, Inc. NEOCIS and YOMI are registered trademarks of Neocis, Inc. All rights reserved. LB-0327 Rev A

CASE STUDY

Saving a failing implant Dr. Charles D. Schlesinger discusses a technique to increase implant predictability

mplant treatment is a very predictable clinical procedure with a 10-year success rate reported to be 94.6%1; but sometimes unexpected sequelae can interfere with this high success rate. The possible causes of failure can run the gamut from iatrogenic damage by the clinician who placed the implant, failure to properly manage existing bone loss, management of soft tissue, and the inability to achieve sufficient primary stability. Immediate implantation at the time of extraction has many advantages. One of the biggest advantages is the drastic decrease in overall treatment time for the patient. In today’s world of instant gratification, an average decrease in treatment time from 7 to 8 months in traditional extract/graft/wait/ place/wait protocol to a much more palatable 3 to 4 months is a true practice builder.2 Immediate implant placement has been shown to be as successful as delayed placement. The key to being able to provide either one of these treatment options is having the ability to achieve outstanding primary stability of the implant upon placement.3 This primary stability is necessary for successful osseointegration of the dental implant. Without it, micromovement of as little as 100 microns can result in soft tissue encapsulation and failure. When done correctly, immediate implantation is as successful as delayed placements. Mijiritsky, et al., investigated the longterm survival of single-tooth implants immediately placed in fresh extraction sites with a 6-year follow-up. In this study, 24 implants were placed in fresh extraction sites in 16

Figure 1: 1.5-month post-placement of implant

patients. The results demonstrated an overall implant survival rate of 95.8%. The study concluded that successful osseointegration can be accomplished with IL implants in fresh extraction sites. The peri-implant conditions were also stable till the 6th year of follow-up.4

Case study A 78-year-old male patient presented to the office with a failed tooth No. 30, which was unrestorable due to the periodontal bone loss associated with it. A treatment plan discussion with the patient covered options such as extraction with grafting and eventually placing an implant 3 to 4 months later versus extraction with immediate placement.

Charles D. Schlesinger, DDS, FICOI, is a dental implant educator and clinician who lectured internationally throughout the United States, Canada, China, Saudi Arabia, Southeast Asia, and the United Kingdom for the past 16 years. He graduated with honors from The Ohio State College of Dentistry in 1996. After graduation, he completed a General Practice residency at the San Diego VA Medical Center (VAMC) and then went on to become the Chief Resident at the VAMC West Los Angeles. During his time in Los Angeles, he completed extensive training in oral surgery, implantology, and advanced restorative treatment. Once he completed his residency, Dr. Schlesinger maintained a thriving restorative and implant practice in San Diego, California for 14 years. In 2012, he relocated to Albuquerque, New Mexico to become the Director of Education and Clinical Affairs for a dental implant manufacturer. In 2013, he took over as Chief Operating Officer along with his clinical responsibilities. In 2016, Dr. Schlesinger returned to private practice ,and in 2018 he co-founded Comfortable Dentistry 4U, a multi-office dental group, where he continues to provide comprehensive implant care to patients in a private practice setting in Albuquerque. Disclosure: Dr. Schlesinger is a key opinion leader and educator for the Hahn™ Implant System and Impladent Ltd.

14 Implant practice

The patient chose to have the implant placed at the same time as the tooth removal, and since the success rate of immediately placed implants is very high, this decision was a prudent one. After thorough review of the medical history, the patient’s only pertinent medical issue was Type 2 diabetes, which was under control. Implant survival in diabetics is 96.4%. Patients with poorly controlled diabetes have lower stability at the first 2 to 6 weeks. In the following weeks, stability reaches the baseline again, but reaching baseline takes 2 times the duration it needs in the healthy treatment group. Looking at the implant stability 1 year after implantation, there is no difference between the groups.5 After profound anesthesia with an inferior alveolar block and a long buccal infiltrate using 2% lidocaine with 1:100K epinephrine, a periotome was used to first sever the soft tissue interface around the tooth. A spade proximator, followed by 301 and 34 elevators, was used to luxate the tooth. Finally, a 151 forceps was used to facilitate the removal the tooth. The resulting socket was thoroughly debrided using a small curette and aggressive round diamond burs (Impladent Ltd.) on a surgical handpiece Volume 14 Number 3

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CASE STUDY with irrigation. The buccal plate at the crest was thin, but intact. Following recommended protocol, a 7 mm x 8 mm Hahn™ Tapered Implant (Glidewell) was placed with 45N/cm of torque and an ISQ values of 63/63. The resulting gap was grafted with allograft cortical/cancellous particulate (Newport Medical) and covered with a resorbable 3 to 4 month collagen membrane (Newport Medical) and sutured with 4.0 PGA suture. Unfortunately, when the patient returned at his 2.5-week postoperative check, he had torn loose a few of his sutures (while eating caramel corn and getting it stuck in the sutures), and the underlying membrane now was exposed. The tissue had already gone through wound contracture, so resuturing was not an option at that point. A 0.12% chlorhexidine rinse (Henry Schein®) was added at this time to the patient’s daily regimen, and the patient was scheduled for a follow-up in 1 month to evaluate healing.

Follow-up Unfortunately, when the patient returned, we were faced with bone loss and subsequent soft tissue loss which exposed the micro-threads of the implant to the oral environment (Figure 1). The collagen membrane was dissolved due to the harsh environment of the oral cavity. Once this occurs, biofilm contaminated the roughened implant surface, and then bone or soft tissue loss likely continued. A radiograph showed the current condition of the implant (Figure 2) with evidence of bone loss. Treatment options were discussed with the patient; either remove the implant or try and save it. He decided to try and save the implant. After local anesthesia was attained with an infiltrate of 4% Septocaine® w/1:100K epi (Septodont), the soft tissue was first reflected to expose the top of the implant (Figure 3) and then crestal bone beyond the defect. The resulting defect exposed the micro-threads along with 2 mm of

macro-threads (Figure 4). All granulation tissue was removed from the site and the implant body with mechanical debridement using curettes and a small wire brush. After flushing with copious amounts of saline, a Sol® diode laser (DenMat) (Figure 5) was set to the perio setting, which is 1.5W. The implant surface was decontaminated with short pulses (Figure 6) until the surface appeared clean of any debris (Figure 7). It is important to make sure that you do not heat up the implant while doing this. Finally, the surface was wiped down with EDTA on a cotton pledget and finally rinsed with sterile saline. The surrounding bone was decorticated with a No. 2 carbide round bur to induce bleeding and stimulate new bone growth. The site was grafted with OsteoGen® plug alloplastic material (Figure 8) and then covered with a BioXclude® amnion-chorion membrane (Snoasis). The BioXclude membrane provides growth hormones and

Figure 3: Papilla-sparing reflection

Figure 4: Full reflection with degranulation of bone

Figure 6: Disinfection the surface of the implant

Figure 7: Cleaned implant surface

Figure 8: OsteoGen strip alloplastic graft placed

Figure 9: BioXclude membrane

Figure 2: Radiograph at 1.5-month postoperative check

Figure 5: Sol diode laser 16 Implant practice

Volume 14 Number 3

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RESORBABLE MINERALIZED COLLAGEN BONE GRAFTING STRIP CALL TODAY OR SHOP ONLINE & USE CODE OGX808 OSTEOGEN® BIOACTIVE RESORBABLE CALCIUM APATITE CRYSTALS & TYPE I BOVINE ACHILLES TENDON COLLAGEN

The Impladent Ltd OsteoGen® Bone Grafting Strip infuses OsteoGen® bone graft crystals into a collagen sheet which eliminates issues associated with particulate migration. The OsteoGen® Strips are a predictable solution for grafting gaps around immediately placed implants and can be utilized in the sinus or anywhere particulates are typically used.

CLINICAL CASE EXAMPLE

Implant is placed lingually following extraction. OsteoGen® Strip will be used to fill gaps and to reinforce the buccal wall

The OsteoGen® Strip is a hydrophilic material that can be hydrated with patients blood and substantially compressed to fill a variety of defects

OsteoGen® Strip is hydrated with patients blood from the surgical site and, if desired, autologous plasma or other growth factors prior to delivery

OsteoGen® Strip can be folded after hydration and prior to or during placement with a blunt instrument for additional bone width and stability

Buccal plate is reinforced by feeding the OsteoGen® Strip downwards in between the implant and the buccal wall

OsteoGen® Strip is in place which reinforces the buccal wall while grafting the gaps between the buccal plate and the implant

Clinical images courtesy of Robert Miller, MA, DDS, FACD, DABOI

Contact 800-526-9343 or Shop Online at www.impladentltd.com

CASE STUDY

Figure 10: Site closed with PTFE sutures

Figure 11: Initial healing after placement of healing abutment

Figure 12: Restoration at placement

Implant treatment is a very predictable clinical procedure with a 10-year success rate reported to be 94.6% has been shown to help with accelerating the soft tissue wound closure (Figure 9). The choice to use an alloplastic material instead of allograft for this revision surgery was just a personal choice. The OsteoGen material does not migrate like particulate, and this is important since the BioXclude is not robust enough to effectively contain large amounts of graft material. Literature has shown that both categories of grafting material are equally effective in regenerating bone in both quantity and quality.6 Finally, the soft tissue was closed with 4.0 PTFE suture (Figure 10) after placing a flat healing screw. The platform of the implant provided a tenting aspect to the site to alleviate any downward pressure on the graft by the healing soft tissue. Postoperative instructions included rinsing with 0.12% chlorhexidine in addition to normal oral hygiene. The site was allowed to heal for 3 weeks before suture removal and then an additional 3.5 months before placement of a healing abutment. Keratinized tissue was laterally moved at this time to facilitate a ring of keratinized tissue around the healing abutment. The concave design of the Hahn healing abutments allows the tissue to be sutured in position and hold the level nicely. Once the soft tissue healed (Figure 11), we moved to the impression phase. VPS impressions were taken followed by placement of a final BruxZir® Esthetic screw-retained restoration (Glidewell Lab) (Figure 12). 18 Implant practice

Figure 13: 1.5-year postop of implant site No. 30

At the 1.5 year follow-up, the hard and soft tissues were healthy (Figure 13), and the patient had reported no issues in the ensuing time period.

Conclusion The keys to be successful in this kind of treatment are to start with an implant with excellent primary stability, the ability to thoroughly decontaminate the implant surface, providing adequate blood supply for regeneration, and finally assuring that soft tissue pressure will not impede bone growth. Primary stability is paramount to the success of any implant treatment. The initial ISQ of 63/63 was excellent, and followup ISQ readings were 68/70 at the repair surgery and 77/77 at the time of restoration. In order to provide an adequate framework for new bone growth onto the implant body, the surface of the implant must be brought as close to the cleanliness of a new sterile implant as possible. By the nature of implant surfaces, which are extremely porous due to the osteoconductive surface treatments provided by manufacturers, it is difficult to completely remove all presence of organic substances from the microtopography.

The combination of mechanical, laser, and chemical means provides a way to clean the surface to a point that new bone growth will occur. Although removing the implant at the early stage of healing would not have been a bad option and likely would have carried with it better overall chance of success, the ability to do large repairs like this can instill the confidence needed to routinely take on small grafting needs when healing does not proceed as planned. IP

REFERENCES 1. Moraschini V, Poubel LA, Ferreira VF, Barboza E. Evaluation of survival and success rates of dental implants reported in longitudinal studies with a follow-up period of at least 10 years: a systematic review. Int J Oral Maxillofac Surg. 2015;44(3):377-388. 2. Schlesinger C. Immediate implant Placement: cutting treatment time in half. Implant Practice US. 2015;8(5):20-24. 3. Schlesinger C. Immediate Placement of Dental Implants: A Safe, A Predictable Treatment Option. J Dent Sci. 2016;4(3):146-152. 4. Mijiritsky E , Mardinger O, Mazor Z, Chaushu G.. Immediate provisionalization of single-tooth implants in fresh-extraction sites at the maxillary esthetic zone: up to 6 years of followup. Implant Dent. 2009;18(4):326-333. 5. Naujokat H, Kunzendorf B, Wiltfang J. Dental implants and diabetes mellitus—a systematic review. Int J Implant Dent. 2016; 2(1):5. 6. Sezavar M, Bohlouli B, Hosein M, et al. Socket Preservation: Allograft vs. Alloplast. J Cytol Hist. 2015;S3(1).

Volume 14 Number 3

The AO’s Certificate in Implant Dentistry provides members the opportunity to demonstrate their comprehensive education and clinical experience and to expand their core knowledge in the field of implant dentistry. It also allows them to demonstrate their commitment to AO. Due to the COVID-19 cancellation of its 2020 Annual Meeting, members who have qualified for this certificate from last year and this year were recently recognized for having achieved the Certificate are listed below. Yuen Lok Loretta Ching, BDS, MSD, is assistant clinical professor, Department of General Dentistry, School of Dentistry, Loma Linda University. Jorge Mauricio Hervas, DDS, MS, graduated from The Ohio State University College of Dentistry. A member of the Academy for the last 16 years, he remains active in his private practice and the various faculty positions he holds at Nova Southern University. Robert H. Sattler, DMD, is a general practitioner in a family private practice in Southampton, Pennsylvania. He graduated from Temple University School of Dentistry and is also in private practice. Dr. Sattler has been a member of the Academy for more than 20 years and remains very active his community. Amerian D. Sones, DMD, MS, prosthodontist and AO Board of Directors Vice President, is director of the Department of Continuing Education at the University of Texas A&M and graduated from UCLA School of Dentistry. In addition to also serving as the Global University Task Force Lead, Dr. Sones has been the main driver of the Certificate program since its inception. For more information, visit www.osseo.org

New Elevate™ multi-specialty dental chair ASI’s new Elevate™ dental patient chair provides advanced treatment capabilities. A combination of features allows the patient positioning to be optimized for specialized procedures, including endodontics to implants, while providing full restorative treatment. Smooth-acting swivel features allow side to side movement with a 60º range. The traverse movement allows the chair to glide forward and backward. For more information on the dual articulation headrest, backrest, programmable membrane chair control, and more, visit https:// asidental.com/asi-elevate-multi-specialty-dental-chair.

Volume 14 Number 3

imes-icore® and 3DISC partner to meet global demand imes-icore® announced a new partnership with 3DISC to advance digitalization within dentistry. Together, imes-icore and 3DISC are excited to bring together the best of German, French, and American ingenuity to provide dental professionals with the latest in scanning technology. 3DISC is an agile American manufacturer and global provider of inclusively digital IOS solutions. With headquarters in the United States and France, 3DISC’s multidisciplinary team of digital experts are committed to taking digital beyond by delivering relevant clinical benefits to dental professionals worldwide. imesicore, a German company, is able to provide the world’s largest product portfolio in dental milling and professional solutions in labs and milling centers. Now imes-icore takes the next step toward digitalization, taking advantage of high-quality digital scanning to improve the workflow for all dental professionals. For more information, visit https://www.imes-icore.de/eng.

Henry Schein® Medical enters into distribution agreement with Black Talon Security Henry Schein® Medical, the medical business of Henry Schein, Inc., has entered into a distribution agreement with Black Talon Security, LLC, one of the leading providers of cybersecurity solutions and data breach security for the healthcare market. The cybersecurity company is focused on protecting health care providers and practices from cybersecurity incidents and data breach security while helping practitioners with compliance through education, training, cyber investigations, and documentation. Black Talon offers advanced solutions that can help mitigate ransomware attacks and encrypt critical files, while also helping avoid local and cloud backups from being destroyed or data from being stolen — resulting in lost revenue and productivity for physician practices. In addition, Black Talon offers three specific capabilities to help protect practice data: 1. vulnerability management tools, which locate known vulnerabilities on external and internal network devices 2. penetration tests, performed by Black Talon’s ethical hackers, to help identify exploitable systems not detected by vulnerability scans 3. use of its predictive threat intelligence software that enables Black Talon to proactively find “unlocked doors and windows” on a network To find out more about Black Talon’s cybersecurity solutions distributed by Henry Schein, visit https://www.henryscheinsolutionshub.com/. For more information on Black Talon, visit www. blacktalonsecurity.com.

Implant practice 19

INDUSTRY NEWS

Four members of the Academy of Osseointegration (AO) recognized with AO Certificate in Implant Dentistry

TECHNIQUE

Predictable immediate guided-implant placement and provisionalization within your practice Dr. Ara Nazarian discusses his technique for questionable and/or non-restorable teeth requiring full mouth extractions

hen a patient presents to your dental practice with questionable and/or non-restorable teeth requiring full mouth extractions, the biggest concern is whether or not implants can be placed at the same surgical visit, and if so, will the patient be able to walk out with fixed teeth. Using an implant, which allows you to load or progressively load so that this type of patient’s demands are met, allows you to position your practice to a whole new level. Of course, certain parameters must be met in order to facilitate this type of treatment. This includes, but is not limited to, the quality and quantity of bone, the presence of infection, the patient’s health, and the skills of the dental provider. Additionally, the selection of the most appropriate materials for the most ideal situation must be met. A patient presented to my practice for a consultation wanting to restore her dentition to proper form and function (Figure 1). She complained of generalized discomfort and mobility in these teeth apparently due to advanced periodontal disease. There were several teeth in both arches that had Class III mobility upon clinical examination. Also, there was hyper-eruption in the anterior mandibular dentition due to her jaw position with a deep impinging bite (Figure 2).

Planning The clinical evaluation included information regarding lip length and support, existing tooth position of the natural teeth, occlusion, restorative space, and phonetics. Ara Nazarian, DDS, DICOI, maintains a private practice in Troy, Michigan, with an emphasis on comprehensive and restorative care. He is a Diplomate in the International Congress of Oral Implantologists (ICOI). Dr. Nazarian has conducted lectures and hands-on workshops on esthetic materials, grafting, and dental implants throughout the United States, Europe, New Zealand, and Australia. Disclosure: Dr. Nazarian is the creator of the Reflector instrument. He has reported no other compensation for other products mentioned in this article.

20 Implant practice

Figure 1: Preoperative retracted frontal view

Figure 2: Preoperative retracted biting view

Figure 3: Preoperative panorex radiograph

In addition, digital images of frontal, side, and occlusal views of the dentition as well as facial shots were captured with a Nikon D7200 (PhotoMed). A CBCT scan and panorex, using the CS 8100 3D (Carestream Dental) (Figure 3), were taken to accurately capture the information needed to properly treatment plan this case ensuring the most ideal outcome, especially since the patient had discussed how disappointed she was with her existing smile. Using the CS 3D imaging software, dental implants were virtually planned in key positions in both maxillary and mandibular arches (Figure 4). To further develop a treatment plan, diagnostic model impressions were taken using Silginat® (Kettenbach) polyvinyl siloxane impression material, then poured up and

Figure 4: Planning with the CS 8100 3D

forwarded to the dental lab. These models were then mounted on an articulator (Stratos 100, Ivoclar Vivadent) for further analysis in order to meet the patient’s esthetic and functional needs. Financing options using a third-party payment option (LendingClub) were discussed with the patient. This discussion Volume 14 Number 3

general practitioner or specialist. Precision surgery reduces stress, decreases liability, and leads to a better outcome for the patient. The implants that would be utilized for this case were the Adin Touareg™ OS dental implants (Figure 6). The Touareg™ S & OS Spiral Implants are tapered with a spiral tap that condenses the bone during placement for immediate stability. There are two large variable threads and a tapered design for accurate implant placement, selfdrilling, improved esthetics, and better load distribution. They feature a special roundshaped apex that pushes the bone graft with minimal harm to anatomic structures. In addition, Touareg™ OS implants feature Adin’s biocompatible and osseoconductive OsseoFix™ implant surface. This has proven to achieve the desired roughness levels for optimal osseointegration, attains the highest implant surface purity levels, and increases the success rate of bone-to-implant contact (BIC). Once the virtual plan was orchestrated and fully confirmed, the next appointment would be the planned surgery with all the necessary components for the guided surgical approach. The patient was appropriately sedated with IV medications, and local anesthesia was administered in both arches. The tissue was then reflected using the Reflector (GoldenDent™) instrument so that the bone-leveling surgical guide would be fully seated and fixed with its respectful retention screws (Figure 7). Following the

positioning of the surgical guide, the maxillary teeth were atraumatically extracted utilizing the Physics Forceps® (GoldenDent). Once the appropriate bone leveling was accomplished with the surgical handpiece, the implant surgical guide (Figure 8) was positioned into the bone-leveling guide, and the sites for the implants was initiated with a designated pilot drill in the Adin Guided Surgery Drill Kit (Figure 9). Using precise orientation, depth, and direction, Adin’s Guided Surgical Kit provides fast, effective, and predictable preparation and placement of dental implants for dental practioners. It also features easy-to-follow layouts containing self-centering drills with built-in stoppers. The unique design of the Adin Guide ActiveFlow™ Irrigation Technology directs cooling saline through the guide, ensuring that irrigation reaches the bone, reducing the possibility for boneheating throughout the procedure. Sequential drill preparation was initiated utilizing the Mont Blanc® surgical handpiece and the Aseptico surgical motor (AEU 7000) at a speed of 800 rpm with copious amounts of sterile saline. Once the osteotomies were complete, the drivers in the Adin Guided Kit (Figure 10) were used to place the dental implants with precise timing so that the flat portion of the internal hex was positioned ideally for the receiving multiunit abutments. A baseline ISQ reading was taken of these implants utilizing the Penguin (Aseptico) RFA unit. Since the initial readings

Figure 5: Surgical guides and provisionals

Figure 6: Adin Touareg OS dental Implants

Figure 7: Maxillary bone-leveling foundation guide

Figure 8: Maxillary implant surgical guide Volume 14 Number 3

Figure 9: Adin Guided Dental Implant Kit Implant practice 21

TECHNIQUE

was a very important part of facilitating acceptance of her care, since it made the cost of treatment more feasible. A 3D virtual treatment plan was further developed from our planning with the CS 3D imaging (Carestream Dental) software and integrating it with the photos and models. A virtual online integrative meeting with the dental lab allowed for a comprehensive review of the assembled digital and clinical information formulating an optimal treatment plan that would fulfill the necessary requirements for esthetics, form, and function. Within a short amount of time, the dental lab had fabricated all the necessary guides for positioning, leveling, drilling, and implant placement in addition to the PMMA provisional restorations and backup dentures (Figure 5). It is my belief that surgical guides in implant dentistry increase the predictability of treatment outcomes as well as making the clinician extremely efficient. In the past, implant placement routinely occurred by freehand, but this technique heightened the risk of damage to anatomic structures while lengthening the duration of the surgery. I personally feel surgical guides give clinicians more confidence to accurately place implants in every case whether you are a

TECHNIQUE

Figure 10: Adin Touareg OS dental implant

Figure 11: Maxillary temporary cylinders isolated

Figure 12: Mandibular bone-leveling foundation guide

Figure 13: Mandibular implant surgical guide

Figure 14: Mandibular temporary cylinders isolated

Figure 15: Maxillary and mandibular provisional restorations

were all above 70 and the quality of bone after leveling was good, multiunit abutments (Adin) were tightened into the Touareg OS (Adin) dental implants at 30, followed by temporary cylinders at 15 Ncm. Any residual areas around the implants or in the sockets were grafted with a cortical mineralized and demineralized bone-grafting material (GoldenDent) to optimize the area for regeneration. The prefabricated immediate provisional arch restorations with predrilled access openings were inspected before being trying-in. The maxillary provisional restoration was tried-in to verify a passive fit over the temporary abutments. Once confirmed, trimmed rubber dam pieces were placed to avoid the restoration (Figure 11) from locking on during the relining procedure with Rebase III Fast Set (Tokuyama®) hard reline material. After the material polymerized, the immediate provisional restoration was removed, and any access material removed with the Torque Plus (Aseptico) lab handpiece and acrylic bur (Komet). The same procedures were accomplished in the lower arch (Figures 12-14). Once trimmed and polished, the provisional arch restorations were seated and tightened with a torque wrench at 15 Ncm (Figure 15). The access openings were filled ¾ of the way with Teflon® tape followed by Cavit™ (3M™) filling material. A postoperative panorex radiograph was taken immediately after the surgery (Figure 16). 22 Implant practice

Figure 16: Postoperative panorex radiograph

A few days later, the patient returned for her postoperative appointment with very little discomfort, swelling, or bruising. She was very pleased with her new upperand lower-fixed provisional restorations. The occlusion was further checked and adjusted to confirm there were no interferences in lateral or protrusive movements. The next step in her treatment would consist of full arch impressions for the definitive restorations approximately 4 to 5 months postoperatively.

Conclusion Having the ability to take a patient from start to finish in a fewer amount of appointments within your practice allows you to position yourself as a provider who can fulfill

your patients’ surgical and restorative needs. With the proper training and appropriate materials, a dental provider may provide extraction, grafting, and implant placement within one appointment at one location. This type of service not only allows you to reduce the amount of visits for the patients, but also helps maintain the cost to the patients, since they are not seeing multiple dental providers. Most importantly, this enables the dental provider full control of the surgical and prosthetic outcome. Depending on the patients’ desires, the clinical conditions of the oral environment present, and the skills of the provider, a dentist may choose to extract teeth, level bone, and graft with guided dental implant placement within his/ her dental practice. IP Volume 14 Number 3

CONTINUING EDUCATION

A serious and emerging complication in implant dentistry: ingestion or aspiration of implant components Dr. Randolph R. Resnik discusses solutions for this unexpected and potentially life-threatening situation Introduction In the literature, there is an abundance of case reports and clinical studies describing the ingestion or aspiration of foreign bodies such as teeth, orthodontic brackets, retainers, burs, crowns, posts, impression material, endodontic files, and syringe tips. Most recently, an ever-increasing complication associated with implant procedures is the loss of dental implant components (implants, abutments, screws, attachments, etc.) in the oropharynx resulting in ingestion or aspiration. Unfortunately, these foreign objects can be of various sizes and shapes, which may lead to significant morbidity from displacement in the gastrointestinal (GI) or the respiratory tract. Therefore, when this complication occurs in an office setting, the implant clinician must be well-informed on the appropriate management of the complication to avoid serious life-threatening and medicolegal issues.

Educational aims and objectives

This self-instructional course for dentists aims to discuss appropriate management of ingestion or aspiration of foreign bodies during implant placement.

Expected outcomes

Implant Practice US subscribers can answer the CE questions by taking 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 some of the etiology behind the ingestion or aspiration of foreign bodies during implant placement.

•

Recognize some characteristics of ingestion of objects into the gastrointestinal tract during implant placement.

•

Recognize some characteristics of objects aspirated into the lungs during implant placement.

•

Realize some clinical strategies to avoid ingestion or aspiration of objects during dental implant procedures.

•

Recognize some immediate symptoms in determining if the foreign body was aspirated or ingested.

Etiology Due to the small and atypical size of implants, abutments, screws, drivers, and other implant components, this complication may easily occur at any time during implant procedures (surgical and prosthetic). Implant procedures are highly susceptible to these complications because of the difficulty in Figure 1: Abdominal CT scan images depicting foreign body in the small intestine Randolph R. Resnik, DMD, MDS, is a leading clinician, educator, researcher, and author in the field of Oral Implantology and Prosthodontics. Dr. Resnik completed his specialty training in Prosthodontics, Fellowship in Oral Implantology, and a Master’s degree in Oral Implantology/ Radiology from the University of Pittsburgh School of Dental Medicine. He is the director of the Misch Resnik Implant Institute as well as holds faculty positions at University of Pittsburgh (Graduate Prosthodontics), Temple University School of Dentistry (Graduate Periodontics and Oral Implantology), and Allegheny General Hospital in Pittsburgh, Pennsylvania (Oral and Maxillofacial Surgery). Along with his passion for lecturing and education, Dr. Resnik is also an accomplished author, having published over 100 articles and author of the two leading textbooks in Implant Dentistry: Avoiding Complications in Oral Implantology and the 4th edition of Contemporary Implant Dentistry.

24 Implant practice

handling of the small implant instruments and components that are often slippery due to saliva or blood. Most implant procedures, either surgical or prosthetic, are completed in a supine or semi-recumbent position, which may predispose to ingestion or aspiration. In addition, other contributing factors include the use of local anesthesia (loss of gag reflex), oral or intravenous sedation, unexpected patient movements, poor access and visualization, limited openings, and unexpected detachment of implant components. When an object is lost in the oropharynx, there exist two possibilities: patients may

swallow the foreign object into the stomach or aspirate the foreign body into the lungs. Clinical studies evaluating the prevalence of this complication have shown that approximately 80% of objects lost are ingested into the GI system, and 20% are aspirated into the lungs.1 Ingestion In most cases, ingested objects into the gastrointestinal tract usually result in no immediate symptoms from the patient. Approximately 90% of ingested objects usually pass through the gastrointestinal Volume 14 Number 3

Aspiration In most cases, any foreign object that is aspirated into the lungs should be treated as

a medical emergency. The foreign body could be located anywhere along the tracheobronchial tree; however, the right bronchus is the most common site because of its more vertical and wider anatomic configuration in comparison to the left bronchus.5 Usually, the patient will be symptomatic, exhibiting signs of laryngotracheal obstruction such as dyspnea, coughing, wheezing, stridor, or cyanosis. If airway obstruction is present, the clinician should immediately initiate CPR/ emergency airway obstruction protocols. Ideally, after location is confirmed, retrieval is necessary most commonly with flexible or rigid bronchoscopy. Bronchoscopy has been shown to be 99% effective in the removal of foreign objects; however, 1% require surgical retrieval. Long term retention of the foreign body in the respiratory system can be lifethreatening resulting in possible pneumonia, atelectasis, pneumothorax, hemorrhage, or lung abscess (Figures 1 and 2).

Figure 2: Chest radiograph showing ingested cover screw into the duodenum and implant driver into the terminal ileum

Figure 4: Ligatures — floss tied to direction indicators to facilitate easy removal from the oropharynx Volume 14 Number 3

Prevention Numerous clinical strategies exist to avoid ingestion or aspiration of objects during dental implant procedures. It is imperative the dental implant clinician integrate specific prevention treatment techniques and protocols to minimize the possibility of aspiration or ingestion of implant components. Unfortunately, there is no one technique that will guarantee this complication from occurring; however, extreme caution should always be exercised. Techniques to prevent swallowing or aspiration include: • Patient positioning: For implant procedures with an increased risk of ingestion or aspiration, the patient should be seated in a more upright position instead of supine position. • Throat packs or pharyngeal screens: The easiest and most common technique to avoid ingestion or aspiration

Figure 3: Throat pack — 4 x 4 is placed posterior to the area of treatment to provide a barrier from foreign body loss

Figure 5: EasyReach Prosthetic Wrench (Salvin®): Specially designed implant drivers allow for insertion and removal of screws Implant practice 25

CONTINUING EDUCATION

tract uneventfully in 4 to 6 days; however, irregularly shaped objects have been known to take up to 4 weeks. Studies have shown that objects will pass unimpeded through the gastrointestinal system (GI) in 80% of cases if the object is less than 3 cm.2 The management of ingested objects most commonly depends on the risk for GI perforation and will usually result in either (1) periodic monitoring or (2) removal (via endoscopy or laparotomy).3 Periodic monitoring will most commonly involve a radiographic survey to ascertain the movement of the object. The perforation rate in the GI system is directly related to the size and sharpness of the object where sharp, pointed, and elongated objects have been reported to have an approximate 15% – 35% perforation rate.4

CONTINUING EDUCATION

Figure 6: Kelly curved hemostats should be easily accessible to remove a dislodged implant component in the oropharynx

•

is the use of 4 x 4 surgical gauze. The gauze should be opened and positioned in the oral cavity distal to the area of treatment. A 2 x 2 gauze should never be used, as saliva or blood impregnation may lead to the gauze being aspirated or ingested due to its small size (Figure 3). Ligatures: Floss or suture material should be tied to any possible implant component so easy retrieval may be completed if an object is lost into the oropharynx (Figure 4). Special insertion tools: Use of special screw insertion tools and drivers which allow for manipulation outside of the oral cavity (Figure 5). High-vacuum suction: Can be used with a large aspirator if the foreign body is easily accessible. Curved Kelly hemostat: For retrieval of objects in oropharynx, ideally the hemostat should be located in the operatory for easy access (Figure 6). O-ring replacement: Implant components containing O-rings should periodically be evaluated for signs of wear or material fatigue and replacement when warranted (Figure 7). Surgical Gloves: Because of blood and saliva, it is not uncommon for surgical gloves to become slippery. Therefore, periodic glove replacement will prevent this complication.

Treatment If a foreign object is lost in the oropharynx, the patient should be instructed to not immediately sit straight up, as this will ensure the 26 Implant practice

Figure 7: O-ring replacement. Any implant driver or insertion tool that contains O-rings should be periodically evaluated for material fatigue and retention as they may detach from a thumb driver or torque wrench

It is imperative that clinicians have a strong understanding of the etiology and treatment of this complication along with integrating preventive protocols into their office.

ingestion or aspiration of the instrument. The patient should ideally turn to the side and attempt to “cough” the implant component up. If the foreign object is visible to the implant clinician, attempts to retrieve it with curved hemostats or a high-volume suction is indicated. However, care should be exercised to prevent further displacement deeper into the oropharynx. If the instrument is lost, immediate symptoms usually are a good indicator in determining if the foreign body was aspirated or ingested. If the patient exhibits coughing, wheezing, pain, and cyanosis symptoms, an immediate medical emergency protocol should be initiated, as this is indicative of aspiration. If the patient is asymptomatic, which usually indicates ingestion, it is mandatory the patient be referred to their physician or emergency room for immediate radiographs. Radiographic examination (usually chest and abdomen radiograph) is necessary for diagnosis of the location, size, and shape of the foreign body, as well as the need for immediate medical intervention

Conclusion In summary, any object or instrument placed into the oral cavity during a dental

implant procedure may be ingested or aspirated. Although this has been characterized as an infrequent complication in the office setting, with the recent popularity of implant procedures, it is definitely an emerging problem and complication. Clinicians should have a strong understanding of the etiology and treatment of this complication along with integrating preventive protocols into their office. Radiographic imaging and medical attention is critical in the determination of the foreign object’s location and the required course of medical treatment. If this complication is not treated properly in a timely fashion and managed appropriately, life-threatening consequences may result. IP

REFERENCES 1. Abusamaan M, Giannobile WV, Jhawar P, Gunaratnam NT. Swallowed and aspirated dental prostheses and instruments in clinical dental practice. J Am Dent Assoc. 2014;145(5),459-463. 2. Wazani EI, Nixon BP, Butterworth CJ. Accidental Ingestion of an Implant Screwdriver: A Case Report and Literature Review. Eur J Prosthodont Restor Dent. 2018; 26(4):18, 3. Black RE, Johnson DG, Matlak ME. Bronchoscopic removal of aspirated foreign bodies in children. J Pediatr Surg. 1994;29(5):682-684. 4. ASGE Standards of Practice Committee, et al. Management of ingested foreign bodies and food impactions Gastrointest Endosc. 2011;73(6):1085-1091. 5. Ireland AJ. Management of inhaled and swallowed foreign bodies. Dent Update. 2005;32:83-86, 89.

Volume 14 Number 3

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $149; call 866-579-9496 or visit https://implantpracticeus.com/subscribe/ to subscribe today.

To provide feedback on this CE, please email us at education@medmarkmedia.com Legal disclaimer: Course expires 3 years from date of publication. The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

n To receive credit: Go online to https://implantpracticeus.com/continuing-education/, click on the article, then click on the take quiz button, and enter your test answers. AGD Code: 690 Date Published: August 30, 2021 Expiration Date: August 30, 2024

A serious and emerging complication in implant dentistry: ingestion or aspiration of implant components RESNIK

1. Most implant procedures, either surgical or prosthetic, are completed in a ________ position, which may predispose to ingestion or aspiration. a. supine b. semi-recumbent c. sitting straight-up d. both a and b 2. Other contributing factors to ingestion or aspiration include the use of local anesthesia (loss of gag reflex), _______, limited openings, and unexpected detachment of implant components. a. oral or intravenous sedation b. unexpected patient movements c. poor access and visualization d. all of the above 3. Clinical studies evaluating the prevalence of this complication have shown that approximately ______ of objects lost are ingested into the GI system, and 20% are aspirated into the lungs. a. 30% b. 50% c. 80% d. 98% 4. Approximately 90% of ingested objects

Volume 14 Number 3

usually pass through the gastrointestinal tract uneventfully in ______. a. 1-2 days b. 4-6 days c. 10-14 days d. 16-18 days 5. Studies have shown that objects will pass unimpeded through the gastrointestinal system (GI) in 80% of cases if the object is less than ______. a. 3 cm b. 6 cm c. 8 cm d. 10 cm 6. The perforation rate in the GI system is directly related to the size and sharpness of the object where sharp, pointed, and elongated objects have been reported to have an approximate ________ perforation rate. a. 5%-8% b. 15%-35% c. 40%-53% d. 62%-73% 7. Bronchoscopy has been shown to be ______ effective in the removal of foreign objects. a. 25%

b. 35% c. 99% d. 100% 8. ____ can be life threatening resulting in possible pneumonia, atelectasis, pneumothorax, hemorrhage, or lung abscess. a. Long-term retention of the foreign body in the respiratory system b. Bronchoscopy c. Surgical removal of foreign objects d. Laparotomy 9. The easiest and most common technique to avoid ingestion or aspiration is the use of ________ surgical gauze. a. 2 x 2 b. 3 x 3 c. 4 x 4 d. 6 x 6 10. If the patient exhibits coughing, wheezing, pain, and cyanosis symptoms, _______. a. the patient should immediately be sent home to lie down b. the patient should lie down in the office and told to be as still as possible c. an immediate medical emergency protocol should be initiated, as this is indicative of aspiration d. the dentist should take a radiograph

Implant practice 27

CE CREDITS

IMPLANT PRACTICE CE

CONTINUING EDUCATION

CBCT: Recognizing the anatomic structures before implant surgery Dr. John Pasicznyk discusses the decreased risk of complications when planning implants with CBCT

mplant dentistry is a rapidly growing aspect of the dental practice, with a greater number of clinicians providing implant therapy than ever before because of greater access to training. Additionally, technology like CBCT imaging, intraoral scanning, fully guided surgery, and even robotics, have improved quality of care and patient outcomes. CBCT imaging has a vital part in the initial treatment planning process for implant cases, allowing clinicians to critically think before a patient is even scheduled for treatment. Effective use of CBCT imaging changes the treatment planning process with clinicians having all the information needed to choose cases that are appropriate for the skill set and inform patients of anticipated complications prior to the surgical appointment.1 By utilizing CBCT imaging, clinicians have a comprehensive view of the anatomic field prior to surgery and, in turn, decreased risk of surgical and prosthetic complications and improved patient outcomes. It is important to understand some patient management benefits of using CBCT in implant planning. These are the ways we can help our patients before evaluating the patient’s anatomy and bone quantity/quality. Patients are more educated than ever before, doing research on procedures, and getting advice from their peers. In today’s society, patients are finding new technologies and procedures on the Internet, both in marketing from dental offices and online articles. Many patients have heard of CBCT imaging, and for those who haven’t, once they understand

Dr. John Pasicznyk practices at Britely Implant Studios in Naples, Florida. A 2010 graduate from Indiana University School of Dentistry, he built a group of technology-focused general dental practices before transitioning into owning his implant-only practice. A leader in digital implant dentistry, his mission is to provide the highest quality of care to his patients using the latest technology and innovative techniques. As a faculty member at 3D Dentists and mentor at Implant Pathways, Dr. Pasicznyk has devoted himself to improving dentists’ lives through education and mentoring on all things implants. Disclosure: Dr. John Pasicznyk is no longer affiliated with CBCT for Dentsply Sirona.

28 Implant practice

Educational aims and objectives

This self-instructional course for dentists aims to discuss the benefits of CBCT imaging in the process of implant placement.

Expected outcomes

Recognize the importance CBCT imaging plays in providing implant therapy.

•

Identify the anatomical structures that are necessary to avoid during implant surgery.

•

Recognize situations in which only CBCT imaging can identify the proximity of vital anatomic structures to the planned implant position.

•

Realize three options that can be planned prior to surgery if the bone dimension is inadequate.

•

Observe images where CBCT images allowed for a view of vital anatomical structures.

why we use it, they insist on this imaging modality. The confidence CBCT imaging gives the clinician to present a well thought out and safely planned implant case to the patient is without a doubt the largest benefit of CBCT imaging. Patients largely follow our treatment advice based on the confidence they have in us, and CBCT gives the doctor and team an added level of confidence in planning. When the clinician is able to clearly articulate why the patient is a good candidate for implant surgery and can reassure the patient that everything possible is being done to ensure the best outcome, it reduces barriers for patients to decline treatment, which allows us to provide more implant dentistry for our patients. Finally, having a full understanding of the patient’s specific situation allows the doctor and team to prepare fair financial arrangements prior to surgery, based on whether grafting or sinus augmentation is needed. Doctor and team can also provide a more realistic timeline of the process from start to finish by disclosing any situations that may lengthen healing or total treatment time. Safely executing a planned procedure should be the number one priority in any aspect of dentistry. This is especially important in surgery, where tissue is being displaced, incised, removed, and rebuilt. With a multitude of important vital structures

surrounding the surgical site, injury to any of these could lead to intraoperative complication that the clinician is unprepared to handle, unable to recognize, or unable to repair. This could lead to significant morbidity or even mortality. CBCT imaging is an imperative aspect of preimplant treatment planning from a standpoint of safety due to the knowledge is provides the clinician. This information is simply impossible to fully gain from a routine examination consisting of intraoral visual exam, palpation, and 2-dimensional radiography.

Five anatomic structures There are five anatomic structures that should be identified as part of any initial implant treatment plan. They follow in the order of importance: 1. Submandibular fossa 2. Inferior alveolar nerve (IAN) and anterior loop 3. Buccal plate 4. Maxillary sinus 5. Nasopalatine canal There are structures that will not be a consideration based on the planned case, i.e., for a treatment plan to replace tooth No. 14, the relative location of the submandibular fossa, IAN, and nasopalatine nerve will not influence the treatment plan, nor change the safety margins of the surgery. However, each Volume 14 Number 3

Figures 2 and 3: 10.5 mm implant planned in No. 18 healed site. From 2D imaging alone, there is no precise way to determine height of ridge. Implant plan changed to a 9 mm length and placed guided to ensure appropriate depth of placement

structure should be identified when appropriate, so clinicians can make the proper clinical decision whether their skill set allows them to move forward with the case.

Submandibular fossa The submandibular fossa lies within the concavity that occurs inferior to the cortical border of the mandible. Often times, the concavity is quite severe, and the scope of the concavity cannot be identified from palpation, visualization, and 2-dimensional radiography (Figures 1 – 3). This area contains a great number of blood vessels and nerves that if compromised, could create a significant bleed or paralysis. In many instances, the height from alveolar crest to the fossa is 8 mm-10 mm, which quite inconveniently, is the same dimension as very commonly used implant length in the lower molar region.2 It would be disastrous to unknowingly have a severe concavity apical to the planned surgical site, and begin preparing an osteotomy to the planned implant length, only to drill directly into the submandibular fossa. The results could range anywhere from excessive intraoperative bleeding to severe hemorrhage. Even if handled appropriately, either of these could, in rare circumstances, lead to a delayed submandibular swelling due to bleeding into fascial spaces. In this situation, CBCT imaging would have identified the anatomic situation, and virtually placing an implant with planning software would allow the clinician to plan for a shorter implant to avoid compromising the submandibular fossa.

Inferior alveolar nerve The inferior alveolar nerve (IAN) is a structure housed within a canal made up Volume 14 Number 3

Figures 4 and 5: Planned implant on the left encroaches on the IAN. Replanned with a short implant (7.5 mm) to avoid damaging the nerve. Precise measurement can be made revealing 2.31 mm between the apex of planned implant and IAN. Surgical guide fabricated to place implant guided, giving further control over depth of implant placement to avoid the IAN

of cortical bone, which lends it to typically be quite visible on both 2-dimensional and 3-dimensional radiographs. Unlike the submandibular fossa, compromising the IAN or canal will rarely cause a medical emergency. However, damaging the nerve and causing resulting loss of sensation could be a debilitating situation for the patient and create a serious medico-legal event for the clinician. Despite the ability to visualize the nerve canal on 2-dimensional radiography, CBCT imaging is the only way to precisely understand the exact height of bone coronal to the nerve. By viewing a CBCT slice, the clinician can determine the appropriate height of implant that can be used without coming near the IAN (Figure 4 and 5). When the nerve position does not allow the use of typical implant length, 8mm or greater,

a short implant can be used with success.3 Short implants, defined as implants less than 7.5 mm in length, are becoming more prevalent from manufacturers. To improve safety even more, fully guided surgery using a surgical guide fabricated from the CBCT imaging and a digitized dental model allows precisely placing the implant in the safely planned position and depth.

Buccal plate The buccal plate is a band of cortical bone in both the maxilla and mandible that encapsulates the more cancellous bone within. While violating the buccal plate may not have quite as drastic consequences as injury to the submandibular fossa or IAN, it will have a tremendous impact on the success of the implant surgery. Cortical bone derives most of its blood supply from Implant practice 29

CONTINUING EDUCATION

Figure 1: Pre-extraction ridge No. 18. Tooth removed and grafted. (All images were captured with a Denstply Sirona Orthophos SL-ai)

CONTINUING EDUCATION the periosteum, which means minimizing flap reflection when possible is imperative to preventing bone necrosis. Excessively disrupting the blood supply by denuding bone of its periosteum can cause cortical bone loss.4 This along with the biologic effects of osteotomy preparation, which is known to be a 1.5 mm-2.0 mm band of bone necrosis around the freshly placed implant body, can quickly lead to a dehiscence of bone around the implant body. When this happens, soft tissue can quickly invade the healing implant site, which leads to “spinners” or implants that fail to integrate due to soft tissue ingrowth. CBCT imaging and implant planning software with precise digital implant replicas

allow the surgeon to visualize an implant within the proposed site, and safely determine if the diameter of the implant causes a compromise of the 2.0 mm minimum boundary between implant and buccal plate. If the bone dimension is inadequate, there are three options that can be planned for prior to surgery: • First, a narrower implant could be selected if appropriate, and visualized on CBCT planning software (Figure 6 – 8). • Second, by sinking the implant slightly subcrestal, the thin “lip” of buccal plate can be avoided. • Third, ridge augmentation may be the only way to appropriately increase

Figure 6 and 7: Implant on the left is 4.6 mm width and compromises buccal plate. Planning for 3.8 mm implant on the right gives >1.5 mm of buccal plate thickness. Without the knowledge of how tight the space is during planning, surgery would appear to go well, but because there is less than 1.5 mm of buccal plate, it is possible to lose buccal plate and have an implant that fails to integrate

Figure 8: Digitized model of Figure 6 and 7 showing a ridge thickness of 8.44 mm. Palpation of this ridge without CBCT could easily mislead the clinician into believing there is adequate bone for a 4.6 mm implant centered in ridge. CBCT slices show bone thickness to be 6.8 mm 30 Implant practice

the volume of bone to adequately secure the implant. The benefit to both patient and clinician is that these considerations are being made prior to finalizing the implant treatment plan. Patients have peace of mind that they are receiving only necessary procedures, and clinicians can rest easy knowing what is coming their way on the day of surgery.

Maxillary sinus The maxillary sinus is a unique anatomic structure, exhibiting resilience and selfhealing capabilities, with a relatively lower risk of serious complications due to damage. Despite this, the sinus is still imperative to manage appropriately, as compromising this structure can significantly increase total time for treatment to be completed. Additionally, being prepared in advance for variation in sinus anatomy allows the clinician to appropriately plan for the procedure prior to the day of surgery.5 There are many instances where the maxillary sinus has pneumatized, which causes the floor of the sinus to impinge on an otherwise useful implant site. In these cases, a decision can be made whether a shorter implant is appropriate and avoids the sinus entirely, or the sinus can be moved out of the way, building bone in the space between the sinus lining and the maxilla (Figure 9 and 10). In any case, the sinus must be adequately visualized prior to implant surgery. While 2-dimensional radiography gives some information as to the extent of the borders of the sinus, it alone is not adequate to fully visualize septa, undulations, and the exact measurement of available bone from crest

Figures 9 and 10: 9 mm implant on the left, clearly compromising the sinus. Changing implant to 7.5 mm length still compromises sinus. Patient must be informed of need for sinus augmentation in order for implant surgery to be successful Volume 14 Number 3

Figures 13 and 14: Ideal implant width of 4.2 mm on the left compromises both buccal plate and nasopalatine canal. Implant changed to 3.4 mm width on the right, but even still, a compromise of buccal plate or nasopalatine canal is likely

to sinus (Figure 11 and 12). This measurement of available bone allows the clinician to determine whether the case meets their selection criteria, and ultimately, helps the patient understand the extent of treatment required.

Nasopalatine canal The final anatomic structure to discuss in implant planning is the nasopalatine canal. This structure carries a mixed vascular-neural bundle that exits on the midline palatal to the central incisors. Interestingly, despite being a neurovascular bundle, there is little to no sensory innervation, which reduces the risk of compromising the tissue contained within. In fact, it is the one anatomic structure discussed that can be, and occasionally is required to be, removed entirely.6 Central incisor implants often come close to invading the space of the nasopalatine canal, and care must be given to avoid unintentionally placing an implant in the canal. The borders Volume 14 Number 3

of the canal are made of cortical bone and will react and atrophy in a similar fashion to the buccal plate if the implant is placed in too close proximity. By utilizing CBCT slices, one can visualize the proximity of the canal to the planned implant position, and adjust the proposed size or the position of the implant in order to avoid the canal (Figure 13 and 14). In cases with such limited space, the implant is placed in the ideal position, even if that means compromising the canal. During implant surgery, the canal will be intentionally exposed and the contents within obliterated entirely to allow for bone grafting material to fill the canal and stabilize the implant (Figure 15). Implant dentistry is one of the most rapidly growing clinical aspects of dentistry, and this is driven by many barriers of entry being lowered or eliminated. CBCT imaging is arguably the most useful piece of technology to an implant practice, and its routine use in treatment planning will provide the doctor and team many advantages in

Figure 15: 4.2 mm width implant planned intentionally compromising nasopalatine canal and avoiding buccal plate. Canal will be obliterated and grafted during surgery

patient communication and surgical execution. Effective use of CBCT in pre-surgical treatment planning leads decreased risk of complications and increased patient safety, which will help an implant practice and clinician no matter how far along they are in their implant journey. IP

REFERENCES 1. Karthik K, Sivaraj S, Thangaswamy V. Evaluation of implant success: A review of past and present concepts. J Pharm Bioallied Sci. 2013;5(5):117-119. 2. Parnia F, Fard EM, Mahboub F, Hafezeqoran A, Gavgani FE. Tomographic volume evaluation of submandibular fossa in patients requiring dental implants. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(1):e32-e36. 3. Karthikeyan I, Desai SR, Singh R. Short implants: A systematic review. J Indian Soc Periodontol. 2012;16(3):302-312. 4. Mehta H, Shah S. Management of Buccal Gap and Resorption of Buccal Plate in Immediate Implant Placement: A Clinical Case Report. J Int Oral Health. 2015;7(Suppl 1):72-75. 5. Kim GS, Lee JW, Chong JH, et al. Evaluation of clinical outcomes of implants placed into the maxillary sinus with a perforated sinus membrane: a retrospective study. Maxillofac Plast Reconstr Surg. 2016;38(1):50. 6. Verardi S, Pastagia J. Obliteration of the nasopalatine canal in conjunction with horizontal ridge augmentation. Compend Contin Educ Dent. 2012;33(2):116-20,122.

Implant practice 31

CONTINUING EDUCATION

Figures 11 and 12: Panoramic projection shows outline of right maxillary sinus, but only CBCT slice can give exact measurement of ridge height, in this case 6.58 mm

n To receive credit: Go online to https://implantpracticeus.com/continuing-education/, click on the article, then click on the take quiz button, and enter your test answers. AGD Code: 730 Date Published: August 30, 2021 Expiration Date: August 30, 2024

CBCT: Recognizing the anatomic structures before implant surgery PASICZNYK

1. The ________ lies within the concavity that occurs inferior to the cortical border of the mandible. a. submandibular fossa b. inferior alveolar nerve c. buccal plate d. nasopalatine canal 2. In many instances, the height from alveolar crest to the fossa is ________, which quite inconveniently is the same dimension as very commonly used implant length in the lower molar region. a. 1 mm-2 mm b. 5 mm-6 mm c. 8 mm-10 mm d. 11 mm-13 mm 3. The ________ is a structure housed within a canal made up of cortical bone, which lends it to typically be quite visible on both 2-dimensional and 3-dimensional radiographs. a. submandibular fossa b. inferior alveolar nerve c. buccal plate d. nasopalatine canal 4. _______ is the only way to precisely understand the exact height of bone coronal to the nerve. a. CBCT imaging b. Tomography

32 Implant practice

c. Palpation d. A surgical procedure 5. When the nerve position does not allow the use of typical implant length, _______, a short implant can be used with success. a. 4 mm b. 5 mm c. 6 mm d. 8 mm 6. The _______ is a band of cortical bone in both the maxilla and mandible that encapsulates the more cancellous bone within. a. submandibular fossa b. inferior alveolar nerve c. buccal plate d. nasopalatine canal 7. Excessively disrupting the blood supply by denuding bone of its periosteum can cause cortical bone loss. This along with the biologic effects of osteotomy preparation, which is known to be a ______ band of bone necrosis around the freshly placed implant body, can quickly lead to a dehiscence of bone around the implant body. a. 1.5 mm-2.0 mm b. 2.3 mm–3.3 mm

c. 3.8 mm-4.0 mm d. 5.2 mm-5.8 mm 8. CBCT imaging and implant planning software with precise digital implant replicas allow the surgeon to visualize an implant within the proposed site, and safely determine if the diameter of the implant causes a compromise of the ________ minimum boundary between implant and buccal plate. a. 2 mm b. 4 mm c. 6 mm d. 8 mm 9. While 2-dimensional radiography gives some information as to the extent of the borders of the sinus, it alone is not adequate to fully visualize ______. a. septa b. undulations c. the exact measurement of available bone from crest to sinus d. all of the above 10. The _______ carries a mixed vascularneural bundle that exits on the midline palatal to the central incisors. a. submandibular fossa b. inferior alveolar nerve c. buccal plate d. nasopalatine canal

Volume 14 Number 3

CE CREDITS

IMPLANT PRACTICE CE

An implant system that checks all the boxes

ounded by Brånemark award-winning oral surgeon, Dr. Ole T. Jensen, Ditron Dental USA is a dental implant company guided by a Clinical Advisory Board comprised of dental leaders. Ditron’s roots date back more than a half-century, when Ditron Precision Ltd, a precision machining world leader, and the parent company for Ditron Dental and Ditron Dental USA, was founded to supply components for the aerospace and automotive industries, where failure is not an option. Today, engineers, micro-machining specialists, and top-notch clinicians drive the company’s research, development, and production of high-end dental implantbased solutions. Ditron Dental USA’s strong legacy of precision and relentless pursuit of innovation is behind its flagship product, ULT™ — The Ultimate Implant. The Ultimate Implant was designed by legendary implant pioneer, the late Dr. Matteo Danza. He spent years searching for a manufacturer with the capabilities to fulfill his vision. Once he learned of Ditron’s ability to manufacture to tolerances of less than three microns, he knew he had found his solution. In 2020 Dr. Jensen introduced this exciting technology to America. “When I was introduced to Ditron Dental USA, I was amazed to see that this company had checked all the boxes necessary for an extraordinary implant system.” Said Dr. Wayne R. Harrison, clinical advisor for Ditron Dental USA. According to Dr. Harrison, attention to detail is the hallmark of a great implant company. Clinicians looking for an implant with greater initial stability for immediate load will find it with the ULT. The ULT’s distinctive benefits include:

MolecuLock™ Technology Ditron’s precision and high-quality manufacturing ensures a tight implant-abutment connection, reducing the risks of micromovements under mechanical load that can lead to microbial leakage and implant failure. The tight fit also protects crestal bone and soft tissue from the risks of peri-implant disease. Volume 14 Number 3

Dr. Harrison says, “Form follows function. With this molecular precision, under the most adverse mechanical loads, you can reduce the chances of screw loosening, microgap and microleakage, and therefore mitigate the factors that lead to peri-implant disease.”

Reverse Concave Neck (RCN) Dr. Danza sought to create a dental implant-abutment connection that leaves a constant horizontal progressive space that prevents coronal bone resorption and promotes soft-tissue growth, a concept known as platform bone switching. The Reverse Concave Neck (RCN) with microthreads creates an atraumatic dental implantto-bone contact that resists axial loads. This decreases the pressure on the cortical bone while avoiding vascular compression that preserves the peri-implant marginal bone and soft tissue.

Double-Stressless Sharp Threads (DSST) The threads with the concave profile have an apical-coronal incremental thickness. DSST combined with the descending concave profile between the threads generates a gentle and progressive horizontal and vertical bone compaction that preserves the vascularity of the osteotomy, maintains the peri-implant marginal bone and soft tissue, and enables greater initial stability for immediate load. Dr. Harrison says that helical apicocoronal slots serve an important function when placing the implant in the osteotomy. Instead of producing a plunger effect that pushes all the blood and bone to the bottom of the osteotomy, the ULT slots allow the blood and bone fragments in the osteotomy to wash up the side of the implant.

One-Size Platform All implant sizes share a common platform, providing convenience, ease of use, and less inventory. This is one of ULT implant’s most popular features — and unique to Ditron Dental USA. ULT comes

in a single 2.45 mm platform regardless of the diameter of the implant. The common platform simplifies the restorative process. Dr. Harrison adds, “The ULT implant is a comprehensive restorative solution with fewer parts and pieces. The one-size platform means you don’t need to choose between narrow, regular, or wide platforms. Instrumentation also is simplified. There is a single implant insertion driver and single abutment driver. No more confusing choices.”

Surface Integrity Ditron Dental USA’s advanced quality assurance system has resulted in the product’s performance of zero defects per million parts in a NAMSA study*. This phenomenal recorded performance is verifiable and sustained. Dr. Harrison notes, “The quality and inspection in the Ditron Dental USA manufacturing process is pristine. Their attention to detail is off the charts.” Schedule a private virtual consultation with Dr. Wayne R. Harrison at ditrondental usa.com to learn more. IP *Data on file This information was provided by Ditron Dental USA.

Implant practice 33

PRODUCT PROFILE

ULT™ — The Ultimate™ Implant by Ditron Dental USA

PRODUCT SHOWCASE

Boyd Industries’ featured products “Built to Last. Built for You. Built by Boyd” is more than a tagline; it signifies the commitment that the Boyd team makes to each and every one of our customers. Best known for the durability and reliability of our products — including treatment and surgical chairs, mobile storage, and custom cabinetry — we combine over 60 years of design and manufacturing expertise to create personalized products that perfectly fit your unique space and esthetic preferences. We take great pride in the craftsmanship and longevity of all products built at our U.S.-based facility, so you can have confidence in your equipment for years to come.

Learn about our Featured Products New in 2021, we have proudly launched the E3010LS Exam Chairs — perfect for an oral surgery consultation or exam room. Our new chairs provide the same synchronized drop-toe design as our LC series — giving your patients the most natural seated position during consultations or minor exams. The new series sits 2" lower at the home position than its predecessor, allowing more petite patients to enter and exit the chair comfortably. This more comprehensive range of positioning also provides adequate comfort to doctors or assistants of all heights. Additionally, our new LS series reclines up to 35% faster than our previous models; pair this with our programmable foot control for increased office efficiency. This series of chairs comes standard with all-steel frame construction, ergonomic winged backs, integrated full-function foot control, and more. Enhance these chairs with Ultraleather Pro™

upholstery and memory foam cushioning for maximum comfort. Boyd’s flagship, the S2601 Oral Surgery Table, is the profession’s benchmark for oral surgery. There are many key features that make this chair a must-have for your surgery room, including an ergonomic thin, tapered back and drop-toe design, motorized vertical lift base with 16" vertical stroke, surgical armboard/accessory rail mount system, and more. Like all our other offerings, build it how you want with your choice of upholstery, dual articulating headrests, IV and patient armboards, 160-degree swivel, and more. In the past year, we introduced the new S300 Surgery Light to our Oral Surgery product offerings. Our newest surgical light adopts the latest, most innovative surgery light technology — featuring crystal-clear lighting in three different illumination modes (Surgery, Examination, or Dental) at three different color temperatures (3,800K, 4,300K, and 4,800K). Our new light also utilizes a high Color Rendering Index (CRI) of Ra95, which gives a clearer and naturelike color, a setting that helps reduce eye fatigue compared with lower CRI lights. To complement your exam and surgical rooms, Boyd has a line of Prestige Operatory Carts to assist you with much needed organization during procedures. Choose from carts, including our Dental Implant, Surgical Care, Anesthesia Supply Cart, and more. Prestige Operatory Carts in each room allow you to

E3010LS Exam Chair

keep tools and instruments clean in a designated spot for each procedure — adding to office efficiency. It truly is all in the details. Complete your office space with a Sterilization Center, which is offered in standard and custom builds. Our sterilization centers are not pre-built or limited in size or design — they are simply built to suit your space. Choose from countless laminates or solid surface combinations to seamlessly complete the clinical space. The Boyd team has made every effort to create specialized products that are truly Built for You. These featured oral surgery products can be combined with Boyd’s custom clinical and office cabinetry — with nearly limitless combinations of color and print laminates — to create a fully cohesive office space. When you work with the Boyd team, we recognize your unique needs and offer the widest range of personalization options in the industry, so feel free to consult your sales representative about your new project. Start the conversation today! To learn more, visit us at www.boyd industries.com. You can also follow us on Instagram and Twitter @BoydIndustries. Boyd Industries is an ISO 13485:2016 certified company. IP This information was provided by Boyd Industries.

S300 Surgery Light 34 Implant practice

Dental Implant Cart Volume 14 Number 3

PRODUCT PROFILE

Cool Jaw®

n the early 1990s, Medico International Inc.® partnered with leading oral and maxillofacial surgeons to develop a new generation of hot/cold therapy. Cool Jaw® has paved the way to postoperative hot/cold therapy through the creation of our exclusive, hands-free wraps patented design. The hands-free Cool Jaw system reduces postoperative swelling and discomfort, and allows patients to recover in a convenient manner. Choose from multiple styles of Cool Jaw facial wraps in several colors and varying compression levels. Combine with our extensive variety of hot/cold gel packs to create a post-op recovery solution that best suits your patients.

Cool Jaw gel packs and wraps are customizable

Cool Jaw facial wrap

Our most popular wrap (T-800C) utilizes a unique, patented pocket design that allows patients to fulfil their postoperative care instructions easily without compromising compression. The wraps are fully adjustable, ensuring a perfect fit for your patients. Simply slip your frozen or heated gel packs into the patented pocket design, and they remain in place over the recovery area. They also feature a built-in chin cup that helps maintain proper positioning and reduce slippage. All of our wraps are washable and feature Velcro® on top of the head for a fully adjustable fit. Cool Jaw’s hands-free hot/cold therapy system helps promote patient compliance and reduce postoperative complications. Our Clear Cold Gel Packs (T-400) are ideal for a variety of cold therapy applications. These sturdy reusable gel packs freeze 36 Implant practice

solid and remain cold for extended cold therapy. They feature one soft-sided surface that shields the skin from direct periods of time — up to an hour! All 3" × 6" Hot/Cold Gel Packs contact with the frozen pack. (T-420 and T-425) remain pliable Customization is a subtle, yet effective when frozen, contour to the face, and way to promote your practice and enhance provide patients with more post-op your professional image. Cool Jaw helps therapy options, including heat. These you continue promoting your practice long after the surgery date. Cool Jaw’s designers reusable gel packs shape to the work seamlessly with your staff to help you patient’s face, allowing for comfortchoose the best colors and layout to ensure able, continuous hot/cold therapy. Cool Jaw’s reusable hands-free your brand shines. Since our products are system arrives ready to hand out to reusable, patients tend to save them “just in case.” As result, your information is easy to your patients, including preprinted, find, and referrals increase. All of our prodpatient-friendly instructions for added ucts can be customized with your practice convenience. Each Cool Jaw system is packaged with your choice of either logo and information for long-lasting promotwo or four gel packs. Ordering a wrap with tion. Let your practice speak for itself! IP four gel packs allows patients to alternate gel packs between freezing/heating and ensures This information was provided by Medico International Inc. a seamless recovery period. Our Soft-Sided Round Gel Packs (T-330 and T-440) are a convenient, post-op cold therapy option for after numerous procedures, including implants and cosmetic injections such as Botox®. These packs come in a variety of color options to match your office or simply add an element of fun to any procedure. Choose from bright solid colors as well as eye-catching glitters. These reusable gel packs are either 4" or 6" in diameter and remain flexible when frozen, allowing for uniform Cool Jaw Soft-Sided Round Gel Packs Volume 14 Number 3

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T-430 Soft-sided Gel Packs

ON THE HORIZON

Predictable, safe implant placement aided by CBCT Dr. Justin D. Moody discusses 3D imaging and its profound impact on implant decisions

mplant dentistry has been changed forever by the development of cone beam CT for the diagnosis and treatment planning of dental implants. From the introduction of this technology, we began to view implant surgery differently. No longer did we have to reflect large flaps to visualize the mental foramen or use calipers to acquire the width of the ridge. Today we use this technology to visualize the anatomy, making surgery more predictable and safer. This imaging modality offers the ability to create surgical guides, which are so prosthetically driven that temporary restorations and, even in

certain situations, the final prosthetic can be delivered at the time of surgery. Today in my practice, the CBCT unit is the patient’s first stop, as there is no need to enter into a consultation without this information. Imagine the time you can save during your initial exam when you have already seen the anatomy, nerve, and virtual implant placement positions. Knowing this information allows you to concentrate on the patient’s health history, chief complaint, and desired prosthetic outcome. Recently, I was reviewing the CBCT from a new patient who was here for full-arch

Figures 1 and 2: 1. 3D rendering of the mandible done with ACTEON AIS software. 2.Cross section of CBCT showing bifurcation of the mental foramen

restorations. In reviewing the 3D rendering, I noticed that there were three openings on the patient’s left mandible. I had not seen this before, so it had my full attention. Upon mapping out the nerve in the ACTEON® AIS software, I discovered that the patient actually had three mental foramens on the left side. My review of the left side showed that there was a distinct incisal canal traveling forward from the mental foreman as well. These are all very important discoveries in the treatment planning of an all-on-X; implant positions are critical in maintaining proper A-P spread as well as screw-access openings.

Figure 3: ACTEON AIS software makes it easy to draw the IA nerve on the mandible; it even allows for interesting anatomy such as this case with three foramens

Figures 4-6: 4. 3D rendering showing the three exits of the nerve in the case. 5. Virtual placement of the this BioHorizons 4.6 mm x 12 mm Tapered Pro implant. Measurements can be made to determine the restorative space needed and to estimate how much alveoloplasty this ridge will need. 6.The entire mandible plan is made possible by ACTEON’s extensive library in cooperation with companies like BioHorizons that give them the files to allow for such precise placement

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 is a paid consultant for BioHorizons®. Dr. Moody has no contract or financial interest in ACTEON®.

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Figure 7: Trajectory of the implants can be seen here. This allows us to see where the screw-access holes could be and the positions

The ability to use the manufacturer’s virtual implant is important in the process. In this case, I have six BioHorizons® Tapered Pro line implants planned. Virtually planning and reviewing make the surgery go more smoothly, eliminating as many of the unknowns as possible, and making implant placement a “non-event” in your practice. If you are placing dental implants and have not embraced this technology, what are you waiting for? My first CBCT in 2006 was nearly $225,000; recently, we upgraded this machine with the ACTEON Prime CBCT for only $50,000. You can’t afford to not have this in your practice. IP Volume 14 Number 3

CONELOG® PROGRESSIVE conical performance at bone level

CONELOG® connection benefits: • long conus for reduced micromovements1 • superior positional stability in comparison to other conical systems2,3 • easy positioning with tactile feedback • integrated platform switching • “vertical fit feature” designed to minimize vertical discrepancy during workflow

For more information, contact BioHorizons Customer Care: 888.246.8338 or shop online at www.biohorizons.com

1. Hogg WS, Zulauf K, Mehrhof J, Nelson K. The Influence of Torque Tightening on the Position Stability of the Abutment in Conical Implant-Abutment Connections. Int J Prosthodont. 2015 Sep-Oct;28(5):538-41. 2. Schwarz F, Alcoforado G, Nelson K, Schaer A, Taylor T, Beuer F, Strietzel FP. Impact of implant–abutment connection, positioning of the machined collar/microgap, and platform switching on crestal bone level changes. CAMLOG Foundation Consensus Report. Clin. Oral Impl. Res. 2014; 25(11): 1301-1303. 3. Semper-Hogg, W, Kraft, S, Stiller, S et al. Analytical and experimental position stability of the abutment in different dental implant systems with a conical implant–abutment connection. Clin Oral Invest (2013) 17: 1017.

Not all products are available in all countries. BioHorizons® is a registered trademark of BioHorizons.

SPMP21097 REV A MAY 2021

SERVICE PROFILE

Medical-billing services by Vivos How comprehensive billing intelligence software can help you provide top-of-the-line patient care

urrent events such as the COVID-19 pandemic have left dentists searching for more comprehensive solutions to their financial woes. According to a recent study, most practices have reported that finances and patient volume were the two most significant challenges they faced due to the COVID-19 pandemic; however, only about 17% of dentists said that they would likely invest in practice management technology in 2021.1 Despite their hesitation to adopt these solutions, the right services and software could help them address both of these issues simultaneously. Like all healthcare professionals, dentists must be able to prioritize exceptional patient care — not only to help patients take better care of their teeth and overall wellness, but also to succeed financially and continue their services. Providing great patient care allows you to retain patients longer, find more patients through referrals, and expand your services even further. Looking for a way to streamline your processes and provide a better patient experience? Here are three features to look for in a medical-billing service and software that will help you do just that, leaving your patients happier with your service than ever before.

Billing and insurance management A great medical-billing service for dentists will have all the tools needed to help you manage anything related to medical billing and insurance, so you can seamlessly organize everything for your staff and patients. For example, with AireO2 and the Billing Intelligence Service powered by Vivos, dentists have access to features, including the following: • Unlimited verification of benefits and pre-authorizations • A dedicated account manager • ICD 10 medical billers

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• Electronic claim submission • Supportive documentation templates for oral surgery, implants, and more • Customized analytics and weekly reporting • Payment management ledger and calendar • Cloud-based EHR • Billing software packages available for the small, medium, and large practice • And more Take a breath and leave the details to AireO2. This first-of-its-kind, cloud-based EHR designed for dentists by dentists only requires internet access to provide the full support you need to make medical billing easy.

HIPAA-compliant patient records A medical-billing solution like AireO2 can also help you keep track of complete patient records and collect protected health information while ensuring compliance with ever-evolving HIPAA regulations. With this cloud-based EHR, all relevant patient data is stored in one centralized place, allowing you to access information about patient benefits, manage claim submissions, and ultimately reduce the complexity of these processes. A software like this not only relieves some of the responsibilities of you and your staff, but also implements a repeatable and reliable process for billing and patient management, which means compliance approval runs

more smoothly when you can easily point to your processes and replicate them.

Patient encounters and electronic forms

Patients want integrated digital solutions for nearly everything — healthcare included. With the Billing Intelligence Service and Aire02, you can help streamline patient encounters and provide more digital options to your patients. With features such as integrated telemedicine, automated patient text messaging, electronic forms, and intuitive patient encounters, your patients can access your services through whichever means is most convenient for them. At the end of the day, the best way to provide exceptional service to your patients is to spend quality time doing what you do best: caring for the oral health of your patients. Whether you’re caring for your patients through dental implants, oral surgery, exams, or diagnostics, or simply being there to answer their questions, AireO2 powered by the Billing Intelligence Service is there to simplify your complex workflows so you can build stronger patient connections. IP REFERENCES 1. Dentistry Today. The Pandemic Will Continue to Affect Dental Practices in 2021. Published January 6, 2021. https://www.dentistrytoday.com/news/industrynews/ item/7599-the-pandemic-will-continue-to-affect-dentalpractices-in-2021. Accessed July 7, 2021. 2. Healthcare IT News. How to Build a Patient Experience We All Want and Need. Published January 15, 2021. https:// www.healthcareitnews.com/news/how-build-patient-experience-we-all-want-and-need. Accessed July 7, 2021.

This information was provided by Vivos.

Volume 14 Number 3

Pain-Free Medical Billing Easier Than a Routine Checkup Take a Breath with AireO2, the Cloud-Based Software Designed for Dentists

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