Implant Practice US Summer 2022 Vol 15 No 2 by MedMark, LLC

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INTRODUCTION

A mental fitness mindset Summer 2022

Volume 15 Number 2

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 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 2022. 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 Endodontic Practice US or the publisher.

o you remember hearing your inner voice during your last surgery? What about your reflections later that night? I know that anxious thoughts don’t feel great when your mind replays them. “I hope my patients gave their full health history and follow my post-op instructions.” “There’s a little extra bleeding. Let me check a few more times to make sure I didn’t perforate the lingual plate.” “I hope Mr. Smith doesn’t have a numb lip tonight when the anesthesia wears off.” We all have these thoughts no matter how skilled we are. As my colleague Dr. Ramsey Amin says, “The full arch practice ain’t for the faint of heart.” Prioritizing your mental fitness is as important to your success as hand skills and literature reviews. I invite you to reassess the difference between normal internal provocations and intrusive or unproductive thoughts, while providing you with helpful tips. Once upon a time, I envisioned being in a practice strictly limited to dental implants with an emphasis on full arch rehabilitations. After hours of literature review and clinical education and practice, I’m a Diplomate of the American Board of Oral Implantology and owner of a thriving implantology practice. I live and practice my passion every day. But with the shift from “a general dentistry practice that offered implants” to “a practice limited to implants and dentures,” I’ve felt the realities of the mental load. I’ve realized the power in reframing my mental health from something I focus on in times of crisis to something I proactively practice to maintain peak performance in all parts of life. Here are some tips to ease your implant journey. For prep — Manage the patient’s surgical and prosthetic expectations. Sharing realistic information before the plan goes awry is always easier than explaining it after. It pays off twofold: First, when in surgery and you need to pivot from the plan, you can already quiet that internal voice, which begins nagging that “the patient won’t be happy.” Second, it’s easier for the informed patient to accept your new plan with confidence instead of second-guessing your skills. For surgery — The best surgeons have a profound understanding of head and neck anatomy. To stave off intrusive thoughts, double-check your progress against the anatomy facts you know. Checklists serve well here. If you still find the thoughts lingering, try asking yourself, “Am I in a loop with these irrational scenarios?” Acknowledge unproductive thoughts (since you physically can’t ignore them); then work to refocus on advancing your procedure. For the office — Enroll your team. Make sure the front desk knows what’s normal for post-op calls. Train them to clearly and calmly articulate patient’s concerns at the appropriate moment. Comments such as “Hey, Dr. Caputo, yesterday’s patient doesn’t like the teeth and is upset” can quickly dilute your focus in the operatory and trigger unproductive narratives in your head when you can’t address the issue. For your fullest life — Be proactive, and find a therapist. Working on yourself in therapy is not just reserved for crisis. It’s a powerful path to high mental fitness and can increase fulfillment in your professional and personal life. The goal is to find balance and have tools to quiet or stop internal anxieties, so you can deliver consistent results. These are personal reflections, not medical advice, and I hope you’ve found them helpful. Bonus tip — never underestimate the power of being overprepared for every procedure. As Dr. Amin (and Louis Pasteur) says, “Luck favors the prepared.”

Frank Caputo, DDS, graduated from Marquette University School of Dentistry in 2011. He is a Diplomate of the American Board of Oral Implantology and Fellow of the American Academy of Implant Dentistry. He has a dental implant practice located in Milwaukee, Wisconsin. He is the co-director of the soon-to-launch AAID Chicago MaxiCourses® and is a faculty member for Implant Pathway in Tempe, Arizona.

ISSN number 2372-6245

implantpracticeus.com

Volume 15 Number 2

TABLE OF CONTENTS

PUBLISHER’S PERSPECTIVE

A little bit of summer

Lisa Moler, Founder/CEO, MedMark Media............................... 6

COVER STORY

M. Joe Mehranfar, DMD, MS “The real reward is in the patient experience”

IMPLANT CONCEPTS

Histological analysis of autologous toothderived bone graft Drs. Lanka Mahesh, Gregori M. Kurtzman, Varun Raj Kumar, Anshi Jain, Saurabh Juneja, and Yuvika Raj Kumar discuss the efficacy of human extracted teeth as an alternative.................14

Cover image courtesy of DEXIS.

TECHNIQUE

An innovative treatment option for rehabilitation of the atrophic anterior maxilla

IMPLANT CONCEPTS

The new standard of communication in implant dentistry

Dr. Kenneth Goldberg describes a new open platform dental implant registry Implant Practice US

Volume 15 Number 2

Dr. Arun K. Garg discusses a new and novel biomaterial................ 19

PRACTICE MANAGEMENT

How to handle negative reviews

Dr. Len Tau discusses how to soothe the sting of a negative review.................................................22

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CONTINUING EDUCATION

PRODUCT PROFILE

Cool Jaw®

Medico® International Inc. — a new generation of hot/cold therapy............................................... 36

CONTINUING EDUCATION

Ultra-narrow diameter implants for the treatment of mandibular anterior external resorption Dr. Paul Mozer discusses guided implant surgery with narrow diameter implants

PRODUCT PROFILE

NovaBone Morsels (Porous Granules) ®

Promising progress in the treatment of peri-implantitis defects............................................... 38

PRODUCT DEBUT

Elevate your overdenture treatment protocol with ENCOMPASS™ Zest streamlines overdenture procedures and creates costsaving opportunities.................... 40

*Paid subscribers can earn 4 continuing education credits per issue by passing the 2 CE article quizzes online at https://implantpracticeus.com/category/continuing-education/

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Implant Practice US

Volume 15 Number 2

PUBLISHER’S PERSPECTIVE

A little bit of summer

hile writing my message for this summer issue, John Mayer’s song “Wildfire” started playing on the radio. It started me thinking about what summer means. The song says, “… a little bit of summer is what the whole year’s all about.” After the past 2 years of rethinking, regrouping, and reopening, we’ve all worked so hard to get back to business. Working hard is what dentists do best — outfitting the office with the best equipment, taking continuing education courses, and learning new management techniques to keep the offices running smoothly. Lisa Moler All the while keeping patients happy and offering the best Founder/Publisher, dental care. Throwing your practice into high gear takes lots MedMark Media of energy and diligence. But we also must remember to take a step back and at least for a little while, enjoy some of the joys of summer. An article in Forbes titled, “The Evolving Definition of Work-Life Balance,” says that “maintaining work-life balance helps reduce stress and helps prevent burnout in the workplace.” The article continues, saying that stress is one of the most common health issues in the workplace, leading to high blood pressure, stomach issues, aches, pains, and heart problems. Emotionally, stress can lead to depression, anxiety, insomnia, irritability, and low work performance.1 Balance means different things to different people. To alleviate stress, some people just like to spend some quality time with family or friends; some want to hop back on that cruise ship; and others like to hit the hiking trails and commune with nature. Whatever brings a smile to your face will keep summer in your heart and mind for the rest of the year. Take us with you! Whether you are on vacation or on your backyard deck, you can still consider new concepts to bring back to your office. Whether you read our publications in print, on your laptop, iPad, or phone, our articles are meant to inform, intrigue, and inspire you to new techniques, products, and services that promote success. The Cover Story in our summer issue focuses on Dr. M. Joe Mehranfar, educator, mentor, humanitarian, and implant expert. He discusses the philosophies and technologies that deliver the highest outcomes for patients. The CE by Dr. Paul Mozer discusses guided implant surgery with narrow diameter implants. Learn more about using ultra-narrow diameter implants to treat narrow edentulous spaces without additional bone-grafting procedures. In our Implant Concepts column, Drs. Lanka Mahesh, Gregori M. Kurtzman, Varun Raj Kumar, Anshi Jain, Saurabh Juneja, and Yuvika Raj Kumar test the efficacy of using the human extracted tooth as an alternative to other bone graft materials. How do you know when to take a step back so that you can continue moving forward? Here are a few tips: • Be aware of your feelings. If you start to feel more sad or grouchy than energized and content, it’s time to figure out why. • Consider your priorities. What is most important to you in life? Do you need more time for yourself, friends, family, or just your pet? • Don’t be afraid to change. Once you decide on a plan — do it! Change or rearrange your office duties to help create a calmer or more effective workplace. We love our work. But we also have to remember to include a bit of play. At work, you are changing lives, and at play, you are making memories. We need to rest and rejuvenate to create. John Mayer’s lyrics sum it up so well — “a little bit of summer makes a lot of history.” To your best success! 1.

Kohll A. The Evolving Definition of Work-Life Balance. Forbes. March 27, 2018. Accessed April 21, 2022. https:// www.forbes.com/sites/alankohll/2018/03/27/the-evolving-definition-of-work-life-balance/?sh=78c3e10d9ed3.

Implant Practice US

Volume 15 Number 2

Published by

Publisher Lisa Moler lmoler@medmarkmedia.com Managing Editor Mali Schantz-Feld, MA, CDE mali@medmarkmedia.com Tel: (727) 515-5118 Assistant Editor Elizabeth Romanek betty@medmarkmedia.com National Account Manager Adrienne Good agood@medmarkmedia.com Sales Assistant & Client Services Melissa Minnick melissa@medmarkmedia.com Creative Director/Production Manager Amanda Culver amanda@medmarkmedia.com Marketing & Digital Strategy Amzi Koury amzi@medmarkmedia.com Digital Marketing Assistant Hana Kahn support@medmarkmedia.com Webmaster Mike Campbell webmaster@medmarkmedia.com eMedia Coordinator Michelle Britzius emedia@medmarkmedia.com Social Media Manager April Gutierrez socialmedia@medmarkmedia.com Operations Manager Teresa Heiler teresa@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Toll-free: (866) 579-9496 www.medmarkmedia.com www.implantpracticeus.com Subscription Rate 1 year (4 issues) $149 https://implantpracticeus.com/subscribe/

AUTHOR GUIDELINES

How to submit an article to Implant Practice US Implant Practice US is a peer-reviewed, quarterly publication containing articles by leading authors from around the world. Implant Practice US is designed to be read by specialists in Periodontics, Oral Surgery, and Prosthodontics.

ance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example:

Submitting articles

Journals: (Print) White LW. Pearls from Dr. Larry White. Int J Orthod Milwaukee. 2016;27(1):7-8.

Implant Practice US requires original, unpublished article submissions on implant topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 2,400 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Implant Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses.

(Online) Author(s). Article title. Journal Name. Year; vol(issue#):inclusive pages. URL. Accessed [date]. Or in the case of a book: Pedetta F. New Straight Wire. Quintessence Publishing; 2017. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) (Multiple) Doe JF Doe JF, Roe JP

Permissions

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

Disclosure of financial interest

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

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

Manuscript review

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

Pictures/images

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

Proofing

Tables

Articles should be submitted to:

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

Ensure that each table is cited in the text. Number tables consecutively, and provide a brief title and caption (if appropriate) for each.

Mali Schantz-Feld, managing editor, at mali@medmarkmedia.com

Reprints/Extra issues

References

If reprints or additional issues are desired, they must be ordered from the publisher when the page proofs are reviewed by the authors. The publisher does not stock reprints; however, back issues can be purchased.

References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearimplantpracticeus.com

Volume 15 Number 2

COVER STORY

M. Joe Mehranfar, DMD, MS “The real reward is in the patient experience” Can you tell us about your practice? I’m the founder and owner of Mehranfar Dental Group based in Phoenix, Arizona. We specialize in cutting-edge implant treatment but have general dentists’ offices across Arizona as well. We perform a high volume of full-arch reconstructions and employ a full gamut of digital technologies to ensure that we deliver the highest possible outcomes for our patients. I’m also a big proponent of education and am honored to serve as the Chairperson-Elect of the implant division of the American Dental Education Association. As the Director of Dental Implant Education at the Brighter Way Institute, I enjoy mentoring residents and conducting live implant training. I’m also the Clinical Director of the Dental/Partner Implant Education Company.

What is the most rewarding aspect of your practice? For me, the real reward is in the patient experience. I started in general dentistry over 20 years ago but found my true passion for implant dentistry Dr. M. Joe Mehranfar, Clinical Director of Dental/Partner Implant Education Company after realizing how transformative these procedures can be. A full-arch reconstruction can completely change not just a person’s smile, but their entire life. I see this in private practice fees. We offer no-fee extractions, bone grafting, particular in the procedures I perform for veterans and low-insinus lifts, and dental implant surgery; and patients pay for what come residents through my nonprofit center, Dental Hearts. goes on top of the implants at a discounted rate. Patients have come to us saying that they’re too embarrassed to smile, that their grandkids are scared of their missing teeth, or that they Can you tell us more about Dental Hearts? don’t have the confidence to go on job interviews. It’s incredibly I cofounded Dental Hearts as a nonprofit implant practice rewarding to help these heroes turn their lives around and give that serves Arizona’s large population of low-income veterans them back their smiles. and other underserved individuals, many of whom cannot afford

Dr. M. Joe Mehranfar teaching doctors an implant procedure (left) and case planning with a patient (right) Implant Practice US

Volume 15 Number 2

COVER STORY

DTX Studio case planning

What do you enjoy about teaching other doctors? As pioneers in this field, I feel it’s only right and fair for us to keep the doors open and not to pull up the ladder behind us. By teaching other doctors more advanced implant procedures and surgeries, we’re doing more than helping them advance their careers. We’re helping them treat more patients better, and that’s good for the population. My teaching practice through my Dental/Partner Implant Education Company goes hand-in-hand with my nonprofit Dental Hearts as well. It’s what allows me to offer free dental services and surgeries to this underserved population while teaching doctors to perform these procedures.

Why is it important to teach others what you know? Before dental school, I completed two master’s degrees. I also had the opportunity to teach nursing students and really enjoyed passing knowledge on to them. I understand firsthand the power of teaching. I am where I am today because of others took the time to teach me. So I’m passing it forward.

the OP 3D™ imaging X-ray system for panoramic images, the smart DEXIS Titanium intraoral sensors, all integrated with DTX Studio™ treatment planning software, and X-Guide™ by X-Nav for navigated surgery. DEXIS solutions work together to create a seamless digital workflow from preplanning to surgery to final delivery.

What do your colleagues say about your courses?

What does your digital workflow look like?

What I hear most from doctors who participate in my courses is that live training is key for them. Working on actual patients gives them the confidence that they can perform these procedures in their own practices. We know they’re not going to become experts over a few days. But the courses we offer are a part of that journey to becoming better doctors. When they’ve completed the course, they go back to their practices, and they’re comfortable and confident that they can continue that journey.

I started introducing digital technology into my practice back in 2008 with intraoral scanners. Today my workflow is entirely digital. We start by capturing a CBCT scan with the i-CAT or panoramic image with the OP 3D imaging system and utilize DTX Suite for surgical preplanning. We can then merge images captured with our intraoral scanners inside the DTX Studio Implant for a complete picture and use that to create a prosthetic on the spot. Using photogrammetry as well, we have all the dimensions we need minutes after surgery to make sure patients can leave the same day with a prosthesis that they can comfortably wear.

When do you begin using digital technologies? I started like most implant dentists with 2D X-rays and stone models to bone-map what we could do. Around 2008, I introduced intraoral scanners into my practice and have never looked back. For full-arch procedures, digital technology is a must. My digital brand of choice is DEXIS™ — the i-CAT™ CBCT scanner, implantpracticeus.com

How has digital technology transformed your practice? The DEXIS digital technology has turned our world upside

Volume 15 Number 2

COVER STORY

down, especially when it comes to full By teaching other doctors more advanced implant arches. The level of detail in the images we capture is unheard of. Having all the procedures and surgeries, we’re doing more than digital technology we need to preplan the helping them advance their careers. surgery, perform the guided procedures, design and deliver temporary prosthesis on-site all on the same day has allowed us to be a one-stop shop and keep everything inside our practice. I don’t have to send How did you become interested in photopatients elsewhere. That’s the true power of DEXIS technology.

grammetry?

How do you ensure the success of your full-arch procedures?

I was introduced to photogrammetry by my mentor. I really saw how amazing it is when it was brought into the homeless shelter where I was treating patients. Within seconds, I had collected the data needed to design and create a prosthesis that fit almost perfectly. It blew my mind, and it’s been a key component of my practice ever since.

Patient selection is key. You must first assess the patients’ medical state and their readiness for surgery. I look at the CBCT scan from my i-CAT to assess available bone. I’m looking to make sure that the procedure can be done in one sitting, and that the patients can walk out that day with a temporary prosthesis. Positioning is also critical, and that’s where X-Guide and DTX Suite come into play.

What do your patients think of your digital technology? To be honest, when patients first come in, they don’t notice or care whether you’re using the latest digital technology. They just want their teeth fixed. But then once you start showing patients the incredible images that you capture so quickly with the intraoral scanners or i-CAT CBCT scanner right at their side, they will leave with a prosthesis. That’s when it clicks that your practice is something special. There’s a wow factor.

How do DTX Suite and X-Guide help you improve outcomes? Working together, DTX Suite and X-Guide allow me to plan the implant virtually and then with guided surgery, navigate the implant more precisely. With 3D navigation, I get turn-by-turn guidance that results in greater precision. I also get a 360° view of the drill position, and can then apply my 3D treatment plan to the patient. If I’m performing surgery without that dynamic guide or navigation, there’s no way I can tell if I’m accurate or inaccurate in my positioning. With DTX Suite and X-Guide, I can pick a spot and hit that spot 10 out of 10 times. Drilling freehand, you don’t realize how much vibration, movement, and tilt can affect your accuracy. With X-Guide, that’s no longer an issue, and you don’t have to worry about overdrilling. You’re consistently accurate.

What advice would you give dentists who perform implants? I would say to definitely invest in the digital technology. It’s worth it. DTX software is robust, but embracing it has made my life easier. There’s a bit of a learning curve for intraoral scanners and the i-CAT CBCT scanner, but the benefits of these products show after you adapt to the curve. Photogrammetry is probably the easiest to learn and use — just point and go, and within 20 seconds all the data is there. With DTX Studio Implant, all you need to do is press a few buttons and print. After a few cases, using the technology becomes second nature. If you’re looking to be competitive, self-sufficient, and economically successful in the full-arch world, then investing in these technologies and capabilities in-house is the way to go. I would add that investing in digital technology, including X-Guide with DTX Studio, can be an effective way to lower your exposure to litigation by avoiding nerve injury and misplacement of the implant.

What is the future direction of implant dentistry? I’d like to think it’s going the direction our practice has gone with a full embrace of digital technology. I see even more advancements and developments in terms of the digital practice, with AI-assisted planning and guided surgeries. I envision DTX Studio Suite merging data from other emerging digital technologies with fantastic results. It’s very exciting. IP

Dr. M. Joe Mehranfar in the operatory with a patient Implant Practice US

Volume 15 Number 2

IMPLANT CONCEPTS

The new standard of communication in implant dentistry Dr. Kenneth Goldberg describes a new open platform dental implant registry

ouldn’t it be great if we could quickly and easily identify all of our patients’ implants on a single open platform database? No need to call other offices, upload X-rays, and waste very valuable chair time. The good news is this platform exists and is ready for us to use every day. It is a free application that will change the way you manage your patients’ implant information and bring dentistry to the forefront of open portal communication. The website is Lumifi Dental and can be accessed at www.lumifidental.com. As a full-time private practice oral surgeon, I have been constantly presented with implants that need treatment. Whether it’s for peri-implantitis, a loose or broken abutment screw, a fractured abutment, or a loose restoration, the recurring problem is not being able to identify the existing implant system. When dealing with implants every day, this is a huge problem, which is only going to get worse. There are over 5 million implants placed every year in the U.S. alone, and each one will require treatment by a dentist or dental specialist. With multiple implant manufacturFigure 1: Lumifi features ers, each with different implant designs and sizes, the problem grows exponentially. Compounding the problem is that patients infrequently remember who placed their implant, when it was done, and where. Even when they do remember, getting the information is time-consuming and often not successful. This is a significant inefficiency for us and inconvenient for the patients. The simple solution is for all implant providers to utilize the open platform dental implant registry. The appropriate dental implant data would be instantly accessible by any dental professional and able to be updated as treatment progresses. This portal concept of information sharing is already in use in medicine and in large hospital systems. It is time for dentistry to be part of the next generation of information sharing. Figure 2: Lumifi Doctor’s Home page I have incorporated the use of the platform into my surgical practice over the last year, and it has streamlined my information is entered onto the Patient Data window platform (Figure 3), systems and communication with my referrals. We log in to the the referring doctor receives an email with the patient’s implant site in the morning to the Doctor’s Home page (Figure 2), and my information. Now I have paperless communication with my staff enters each patient at the time of surgery. Once the patient referrals, which also saves staff time and postage. When the implant gets restored, the doctor enters the date the implant is restored and any pertinent information that any future treating dentist should know. If an abutment screw is changed, peri-implantitis occurs and is treated; or if an implant is removed, this information is entered into the patient record. Now any practitioner will know the history of that implant and have instant and secure access.

Kenneth Goldberg, DMD, is a Board-certified oral/maxillofacial surgeon in private practice in Central California. He is the founder and CEO of Lumifi Dental, which is a not-for-profit entity. Dr. Goldberg and his partner have a full-scope practice with a focus on implants and implant reconstruction.

Implant Practice US

Volume 15 Number 2

IMPLANT CONCEPTS

The Features and Benefits of the platform are explained on the landing page (Figures 1 and 4). Only doctors can access the platform, which is verified in the registration. The platform becomes increasingly useful the more we all participate and expand the database. Previous patients can be entered into the platform at any time. Send your patient list, and it will be entered into the system for you. It is a win-win for doctors and patients. We save valuable chair time and have created a permanent and secure implant record, and the patient receives a value-added service at no cost. The patients are also given access to their own implant data. When their implant is registered on the platform, the patients receive an email notification. They are given a temporary password to create an account. This is a separate patient portal that allows the patients accessibility to their personal data anytime and from anywhere. Patients responses have been overwhelmingly positive. Patients understand the open portal concept and appreciate the valuable service that we provided. With active participation by surgeons and dentists, we can dramatically improve our method of communicating with each other and become more efficient. Chair time is our most valuable asset as dentists. To waste that commodity trying to match X-rays or calling other offices is not in our best interest or helpful to our patients. If we, as clinical practitioners, change the way we store, retrieve, share, and update our patients’ dental implant information, we will create the paradigm shift needed to bring implant dentistry to the next generation of open platform communication. You can be part of the new standard of care at www.lumifidental.com. Registration and use of the database are free. IP

Figure 3: Lumifi Patient’s Data window

Figure 4: Lumifi benefits

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IMPLANT CONCEPTS

Histological analysis of autologous tooth-derived bone graft Drs. Lanka Mahesh, Gregori M. Kurtzman, Varun Raj Kumar, Anshi Jain, Saurabh Juneja, and Yuvika Raj Kumar discuss the efficacy of human extracted teeth as an alternative Abstract Objective

To test the efficacy of human extracted tooth for use as bone graft material as an alternate to other synthetic, allogenic, or xenogenic bone graft materials.

Study design Freshly extracted teeth were cleaned of all debris and calculus and were placed in a “smart dentin grinder,” which is a device used to grind and sort extracted teeth into a specific-sized dentin particulate. Dentin particulate material was then placed in surgical sites to be used as graft material and were tested histologically.

Results

Figure 1: The patient following extractions in the maxillary anterior

Histological analysis showed the presence of remaining graft material and forming dentin around graft material. Section further revealed the formation of lamellar bone around the dentin surface. Lamellar bone showed the presence of plump osteoblastic rimming, entrapped osteocytes in lacunae. Different stages of mineralization also were evident in our case where dentin was placed as a bone graft material.

Introduction A variety of materials have been commercialized for use in different treatment procedures in maxillofacial, periodontal, and dental implant surgery. In particular, bone grafts are used to stabilize blood clotting, increase alveolar bone volume, and restore its original volumetric structure, function, and appearance. A range of biomaterials have been developed for grafting and bone regeneration as alternatives to autogenous bone grafts. These offer good osteoinductive and osteoconductive capacities but suffer some risk of negative host response. Synthetic materials are an alternative graft material that offers osteoconductive capacities and can be supplied in unlimited quantities.1 Alternative graft materials, including allografts, xenografts, and alloplastic bone grafts, are clinically used, but they have disadvantages such as lacking osteoproliferation and having high-material cost and limited osteoinductivity.2 Therefore, development of an alternative graft material that surpasses all these limitations is desired. Recently, bone graft materials using permanent teeth from the patient receiving the graft, which has been processed, have come to light. Clinical and histological outcomes of this autogenous tooth-derived graft material have been confirmed by some studies. Tooth components are very similar to alveolar bone components, which has led to consideration as a bone graft material using the organic and inorganic components of extracted teeth.3 Additionally, since they are derived from the patient, all potential for autoimmune-type reactions to the graft material are eliminated.

Conclusion Though there is still insufficient data regarding use of extracted teeth for bone grafting, it may be considered as a useful biomaterial and an alternative to synthetic, allogenic, or xenogenic bone grafts for socket preservation, and filling other bony defects. It is autogenous, clinically safe, shows no adverse reactions, and has good bone regeneration potential.

Lanka Mahesh, BDS, and Varun Raj Kumar, MDS, are from The Specialist Clinic, New Delhi, India. Anshi Jain, MDS, is from ITS Dental College, Muradnagar, Ghazhibad, Uttar Pradesh, India. Gregori M. Kurtzman, DDS, MAGD, is in private practice in Silver Spring, Maryland. Saurabh Juneja, MDS, is from ITS Dental College, Muradnagar, Ghazhibad, Uttar Pradesh, India. Yuvika Raj Kumar, MDS, is in private practice in Manchester, Connecticut.

Implant Practice US

Volume 15 Number 2

BIOACTIVE RESORBABLE CALCIUM APATITE CRYSTAL CLUSTERS

OVER 35 YEARS OF BIOACTIVITY

NON-CERAMIC & RESORBABLE BONE GRAFT

OsteoGen ® is a bioactive, non-ceramic & resorbable calcium phosphate crystal that is physicochemically and crystalographically similar to human cancellous mineral Ca5[PO4]3OH.1-6 The process of growing a crystal yields a unique Ca:P ratio that is NOT a ß-TCP and NOT a dense ceramic HA, nor is it a biphasic mixture of the two.

The OsteoGen® bioactive crystal clusters control migration of connective tissue and form a strong bond with newly growing bone as the graft resorbs. The result is predictable bone formation for general grafting & use with implants.1-6

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BIOACTIVITY

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RADIOLUCENT TO RADIOPAQUE

HYDROPHILIC CRYSTAL CLUSTER STRUCTURE

The crystallographic structure and geometry of a bone graft matters. OsteoGen® non-ceramic crystal clusters intertwine to form a hydrophilic 3D matrix leading to the immediate absorption of blood flow. This is critical for the initiation of bone formation, early angiogenesis and bone bridging even across 8.0mm critical size defects.3-5 1. Ganz (2002) 2. Artzi (2003) 3. Valen (2002) 4. Spivak (1990) 5. Ricci (1992) 6. Jensen (1998) Radiographs courtesy of German Murias DDS, ABOI/ID

The x-ray reveals when sufficient bone has formed and the site is ready for implant placement. OsteoGen® non-ceramic crystals are radiolucent on the day of placement & radiopaque in ~4-6 months following resorption and host bone formation.1-4

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IMPLANT CONCEPTS

Extractions are one of the most widely performed procedures in dentistry, yielding teeth that are discarded as clinical waste. But teeth could be recycled to produce an effective graft material. Dentists have been transplanting teeth for many years, and tooth ankylosis is a well-studied principle.4 In recent years, several research teams have assessed the potential uses of extracted teeth.5,6 Autogenous dental bone graft material, a human demineralized dentin matrix derived from extracted human teeth, was first developed in 2008, and its osteoinductive, osteoconductive, and remodeling capacities in implant dentistry have been evaluated.7

grind extracted teeth into a specific-sized dentin particulate. A chemical cleanser is then applied to process the dentin particulate into a bacteria-free graft during a 15-20 minute time frame. This novel procedure is indicated mainly in cases when teeth are extracted because of periodontal reasons or when impacted teeth require extraction. Teeth that have undergone root canal treatment should not be employed in this procedure because the obturation material present may lead to foreign material contamination of the resulting graft material. On the other hand, if teeth have crowns present, the restoration can be removed prior to processing, and direct filling materials such as amalgam or composite can be ground out of the tooth prior to processing.6 The teeth are extracted atraumatically to maintain integrity of the socket (Figure 1). Any restorative materials are removed from the extracted teeth with a handpiece and burs in preparation for processing the dentin (Figure 2).

Methodology Freshly extracted teeth were taken and were processed into a bacteria-free particulate autogenous mineralized dentin for immediate grafting into that same patient who had just undergone the extraction. A Smart Dentin Grinder (KometaBio, Fort Lee, New Jersey) was devised, which is utilized to

Figure 3: Preparation of the ground natural teeth in preparation for placement as a graft

Figure 2: Extracted teeth from the patient’s maxillary anterior

Figure 4: A full-thickness flap is elevated to expose the sockets of the extraction sites and to allow soft tissue mobility to close the area following socket grafting. Figure 5: Osteotomies were prepared at the canine sites bilaterally and implants placed

Figure 6: Implants have been placed at the canine sites bilaterally

Implant Practice US

Figure 7: The flap was repositioned to get primary closure and secured with sutures

Volume 15 Number 2

IMPLANT CONCEPTS

Figures 8 (left and middle) and 9 (right): 8A and 8B. Submitted H and E stained section shows the presence of dentin (yellow arrow) and remaining graft material (black arrow). 9. H and E stained section shows forming bone with entrapped osteocytes and surrounding osteoid (blue arrow)

The teeth are then processed to create dentin particles and hydrated appropriately (Figure 3). The area at the sites to receive the dentin grafting is flapped to expose the sockets (Figure 4). Immediate implant placement was planned, and the osteotomies were created. Ground dentin particulate was placed into the osteotomies and extraction sockets that would not receive implants, and implants were placed into the planned sites (Figures 5 and 6). The flap was repositioned to cover the area Figures 10 (left) and 11 (right): 10. Photomicrograph of methylene blue aldehyde fuschin shows the preswith primary closure of the soft tissue, ence of forming dentin. 11. Photomicrograph of Masson’s trichrome stain shows the presence of resorbing and sutures were placed (Figure 7). The graft material and formation of dentin patient was recalled after 3 months to methylene blue and aldehyde fuchsin, were also performed, check osteointegration of the implants, and the socket grafting which showed the presence of resorbing graft material and formwas evaluated. The area was flapped and a core sample taken ing dentin (Figures 10 and 11). at the previously grafted sockets with a trephine for histological analysis of the dentin graft material.

Discussion

Histological analysis

Bone and dentin resemble each other in composition and mechanism of formation. In addition to major levels of Type I collagen, both tissues contain non-collagenous proteins (NCPs). The NCPs are believed to play key biological roles in osteogenesis and dentinogenesis. Among these NCPs, dentin phosphoprotein (DPP) and dentin sialoprotein (DSP) have been thought to be uniquely involved in dentinogenesis. In dentin extracellular matrix, Type I collagen is the most abundant organic constituent, while DPP is the second-most plentiful protein. The most unusual feature of DPP is the occurrence of large amounts of aspartic acid (Asp) and phosphoserine (Pse) largely present in repeating sequences of (Asp-Pse-Pse)n and (Asp-Pse)n. These repeating sequences assume extended backbone structures with relatively long ridges of carboxylate and phosphate groups on each side of the peptide backbone7 (dentin). Autogenous bone grafting is the gold standard for bone augmentation because of its excellent osteoinductivity and osteoconductivity, but it has some impediments such as limited

After the process of implant placement, histological analysis was done in which the specimens were fixed with 4% paraformaldehyde in 0.1M PBS (pH 7.4), and decalcified in 0.5M EDTA (pH7.8) for 10 days. After decalcification, each specimen was transversally divided into two blocks, exactly along the center of the original surgical defect, processed, and embedded in paraffin. Then transverse serial sections of 5 μm thickness were prepared. The sections were stained with hematoxylin and eosin (HE) and showed the presence of remaining graft material and forming dentin around graft material (Figure 8). The section further revealed the formation of lamellar bone around the dentin surface. Lamellar bone showed the presence of plump osteoblastic rimming, entrapped osteocytes in lacunae (Figure 9). Different stages of mineralization were also evident in the case where dentin was placed as a bone graft material. The stroma is fibrovascular in nature with very mild chronic inflammatory reaction in the background. Special stains, including eosin (HE) implantpracticeus.com

Volume 15 Number 2

IMPLANT CONCEPTS

availability, donor site morbidity, and also In particular, bone grafts are used to stabilize blood high-resorption rates of up to 50%.8 The osteogenic capacity of a deminerclotting, increase alveolar bone volume, and restore its alized tooth was verified as early as 1967,9 original volumetric structure, function, and appearance. and was first introduced by R&D Institute Korea Tooth Bank (Seoul, Korea). The tooth graft has satisfied many clinicians and patients for its osteoconduction as well In tooth-based graft materials, there are higher mineralization as osteoinduction capacity. Nampo, et al.,5 reported that dentin, and crystallinity when compared with bone. However, tooth when used as a bone graft, promotes bone formation as it contains demineralization is time-consuming (usually 2 to 6 days), thus proteins such as osteopontin (OPN). On immunohistochemical limiting the use of fresh demineralized tooth (FDT) as a graft matestaining with anti-DSP antibody, the positive reaction was localrial. Nevertheless, FDT has shown great potential in alveolar bone ized to the dentin of the extracted tooth fragments incorporated regeneration. In an animal study performed by Al-Asfour, et al.,11 into the new bone at 6 weeks, suggesting that dentin has a high human dentin graft was compared with tibia bone graft. The authors affinity for and marked osteoconductive effect on jawbone. The reported that demineralized xenogenic dentin onlay grafts showed structure and composition of dentin are similar to that of bone, similar resorption characteristics as autogenous bone onlay grafts, consisting of collagen (20%), hydroxyapatite (70%), and body being resorbed in a similar rate during 12 weeks. This is in contrast fluid (10%) in weight; and having a significant osteoconductivity. with Zitzmann, et al., who reported a remaining amount of BioFurthermore, dentin matrix has some osteoinductivity because it Oss® (Geistlich Pharma North America Inc.) of 37% at 6 months contains BMPs. Thus, dentin or dentin matrix is expected to serve after grafting Bio-Oss.12 Moreover, in the study done by Kim, et as a bone substitute. Some studies have shown that mineralized al., autogenous teeth (AutoBT) showed gradual resorption during dentin matrix possesses excellent biocompatibility. However, it the first three months. At 6 months, new bone was replaced with was also observed that the dentin matrix promoted the formation trabecular bone with resorption of most graft material.13 Osteoinof a more homogenous and uniform trabecular bone in the threeduction and osteoconduction were observed, which were similar thirds of the dental socket during the 15-day and 30-day periods to the histologic analysis of other’s papers.14,15,16 of healing, characterizing its osteoconductive property in dental socket repair.8 Therefore, dentin tooth can be classified into three Conclusion groups according to the degree of demineralization: undemineralAlthough there is still insufficient data regarding use of ized dentin (UDD), partially demineralized dentin matrix (PDDM) extracted teeth for bone grafting, it may be considered as a useful (70% decalcified), and demineralized dentin matrix (DDM). It has biomaterial and alternative to synthetic, allogenic, or xenogenic bone grafts for socket preservation and filling other bony defects. been shown that UDD is less effective in bone formation, whereas Being autogenous, it is clinically safe, shows no adverse reacother studies have shown that DDM is biocompatible and also tions, and has a good bone regeneration potential. IP osteoinductive, similar to demineralized bone matrix.10 REFERENCES 1.

Calvo-Guirado JL, Pino PC, Sapoznikov L, et al. A new procedure for processing extracted teeth for immediate grafting in post extraction sockets. An experimental study in American Fox Hound dogs. Ann Anat. 2018;217:14-23.

Koga T, Minamizato T, Kawai Y, et al. Bone Regeneration Using Dentin Matrix Depends on the Degree of Demineralization and Particle Size. PLoS One. 2016;11(1):e0147235.

Vaqués PG, Yanes CP, Devesa AE, et al. Autogenous teeth used for bone grafting: A systematic review. Med Oral Patol Oral Cir Bucal. 2018;23(1):e112-e119.

Pape HD, Heiss R. Zur Geschichte der Zahntransplantation [History of tooth transplantation]. Fortschr Kiefer Gesichtschir. 1976;20:121-125.

Nampo T, Watahiki J, Enomoto A, et al. A new method for alveolar bone repair using extracted teeth for the graft material. J Periodontol. 2010;81(19):1264-1272.

Kuperschlag A, Keršyte G, Kurtzman GM, Horowitz RA. Autogenous Dentin Grafting of Osseous Defects Distal to Mandibular Second Molars After Extraction of Impacted Third Molars. Compend Contin Educ Dent. 2020;41(2):76-83.

Yeomans JD, Urist MR. Bone induction by decalcified dentine implanted into oral, osseous and muscle tissues. Arch Oral Biol. 1967;12(8):999-1008.

Calvo-Guirado JL, Sánchez de Val JEM, Oltra MLR, Martínez CPA, Fernández MPR, Gosálvez MM. The Use of Tooth Particles as a Biomaterial in Post-Extraction Sockets. Experimental Study in Dogs. Dent. J. 2018;6:12-22.

Urist MR. Bone: Formation by autoinduction. Science. 1965;150(3698):893-899.

10. Qin C, Brunn JC, Cadena E, et al. The expression of dentin sialophosphoprotein gene in bone. J Dent Res. 2002;81(6):392-394. 11. Al-Asfour A, Farzad P, Al-Musawi A, Dahlin C, Andersson L. Demineralized Xenogenic Dentin and Autogenous Bone as Onlay Grafts to Rabbit Tibia. Implant Dentistry. 2017;26(2):232-237. 12. Zitzmann NU, Sharer P, Marinello CP, Schupbach P, Berglundh T. Alveolar ridge augmentation with Bio-Oss: a histologic study in humans. Int J Periodontics Restorative Dent. 2001;21(3):288-295. 13. Kim YK, Kim SG, Byeon JH, Lee HJ, Um IU, Lim SC, Kim SY. Development of a novel bone grafting material using autogenous teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(4):496-503. 14. Gomes MF, de Abreu PP, Morosolli ARC, Araújo MM, Goulart MDGV. Densitometric analysis of the autogenous demineralized dentin matrix on the dental socket wound healing process in humans. Braz Oral Res. 2006;20(4):324-30. 15. Binderman I, Hallel G, Nardy C, Yaffe A, Sapoznikov L. A Novel Procedure to Process Extracted Teeth for Immediate Grafting of Autogenous Dentin. J Interdiscipl Med Dent Sci. 2014;2:6. 16. Reddy GV, Abhinav A, Malgikar S, et al. Clinical and Radiographic Evaluation of Autogenous Dentin Graft and Demineralized Freeze Dried Bone Allograft with Chorion Membrane in the Treatment of Grade II and III Furcation Defects‑: A Randomized Controlled Trial. Indian Journal of Dental Sciences. 2019;11(2):83-89.

Implant Practice US

Volume 15 Number 2

TECHNIQUE

An innovative treatment option for rehabilitation of the atrophic anterior maxilla Dr. Arun K. Garg discusses a new and novel biomaterial

oss of teeth in the anterior maxilla generally leads to severe resorption of the facial plate, resulting in osseous dimensions that will not accommodate implant placement. Resorption of the facial plate can also be an unexpected finding at the time of extraction when a tooth has undergone endodontic, periodontal, or structural changes. This condition is often complicated by the presence of natural dehiscences and fenestrations around healthy teeth that worsen when pathology arises. The treatment methods most commonly employed for reconstruction of the deficient anterior maxilla follow: • Onlay cortical bone blocks harvested intra- or extraorally and fixated with screws • Particulated autogenous bone contained by a titanium mesh cage • Ridge-split with interpositional bone grafting While ample evidence of the efficacy and predictability of these methods can be found in the literature, the disadvantages associated with them are equally well documented. Cortical blocks require a separate donor site, leading to greater morbidity and patient discomfort during healing. Furthermore, resorption has been reported to occur during healing in 5% to 28% of cases.1 Similarly, the use of titanium mesh to contain particulate bone requires a second surgery (with added pain and morbidity) to remove the metal mesh and screws, making this option unattractive for many patients. Moreover, premature exposure of the mesh is a major complication of this technique.2 Because it requires a minimum ridge width to be successful, ridge splitting as a treatment option is unavailable to many patients. And when adequate initial ridge width is present, wound dehiscence and fracture of the facial plate may occur as the result of a bad split.3 This article describes an innovative method of restoring the atrophic anterior maxilla using a novel biomaterial that is Arun K. Garg, DMD, completed both his engineering and dental degree at the University of Florida and subsequently, completed his residency training at University of Miami/Jackson Memorial Hospital. Dr. Garg served as a full-time Professor of Surgery in the Division of Oral/Maxillofacial Surgery at the University of Miami School of Medicine, and also served as Director of the Residency Training Program for 18 years. Currently, he is on the visiting faculty at the University of Florida College of Dentistry and has located his private practice for patient care in the Aventura area of Miami. Dr. Garg has authored eight textbooks, which have currently been translated into eight different languages, and has published well over 80 articles, and more than 12 book chapters. He is editor of a monthly newsletter, Dental Implantology Update, and serves on the editorial boards of four other leading journals. Disclosure: Dr. Garg is a volunteer clinical advisor for OsteoLife Biomedical.

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Figure 1: Facial view of the anterior maxilla resulting from resorption following tooth extraction 8 years earlier in a 52-year-old patient

Figure 2: The 15 mm × 30 mm Flexo-Plate Plus that will be used to contain and stabilize a particulate bone graft mixed with PRP to augment the ridge for second-stage implant placement

configured to avoid the disadvantages associated with current treatment options. In this method, sheets of partially decalcified allogeneic bone fabricated into flexible bone plates (FlexoPlate Plus, OsteoLife) are trimmed to conform to the osseous dimensions of the facial bone plate. Flexo-Plate Plus is a slightly malleable, 0.75 mm to 1.0 mm thick, partially decalcified allograft that comes with holes predrilled on the left and right aspects to accommodate fixation screws. Particulate bone graft material is placed over the defect, and the flexible bone plate is screw-fixated over it to stabilize the graft. Its matrix is gradually resorbed by the body and becomes part of the host bone, eliminating the need for surgical removal.

Volume 15 Number 2

TECHNIQUE

Plus has a very low risk of exposure because the body does not identify it as foreign. Moreover, it does not require surgical removal, as it converts to host bone during healing. Figures 1 to 4 present the pre- and posttreatment images of a 52-year-old patient who presented with an atrophic anterior maxilla following extraction of the left central and lateral incisors 8 years earlier. Two-stage treatment involved the use of a Flexo-Plate Plus to cover particulate bone shavings mixed Figures 3 and 4: 3. At stage 2 surgery prior to flap closure, the grafted, previously deficient ridge with platelet-rich plasma (PRP) to rebuild the shows ample thickness to support two implants and a lack of dehiscence on the facial aspect. 4. Predeficient ridge, followed by a 4-month healing and posttreatment cone beam CT scans demonstrate the amount of healthy new bone regenerated period prior to implant placement. As these using the Flexo-Plate Plus to cover a small amount of autogenous bone shavings mixed with PRP images show, adequate thickness of the facial bone was obtained to house and provide long-term stability for The biocompatible Flexo-Plate Plus is pliable enough to adapt to the contours of a skeletal defect yet strong enough two implants to replace the missing teeth. IP to serve as a scaffold for graft containment without the risk of displacement. Its advantage over the use of cortical blocks is REFERENCES that the resulting bone has a medullary quality with active bone 1. Lee HG, Kim YD. Volumetric stability of autogenous bone graft with mandibular body progenitor cells that come in contact with the implant surface. bone: Cone-beam computed tomography and three-dimensional reconstruction analIdeally, implants should be placed into medullary bone, which is ysis. J Korean Assoc Oral Maxillofac Surg. 2015;41:232-239. dynamic and active. Cortical bone is denser, but it contains few 2. Lim HC, Lee JS, Choi SH, Jung UW. The effect of overlaying titanium mesh with colif any osteoblasts and other bone-maintaining cells. After heallagen membrane for ridge preservation. J Periodontal Implant Sci. 2015;45:128-135. ing, the bone in contact with the implant may appear dense, but 3. Gurler G, Delilbasi C, Garip H, Tufekcioglu S. Comparison of alveolar ridge splitting and autogenous onlay bone grafting to enable implant placement in patients with it has less capacity to respond to changes related to the function atrophic jaw bones. Saudi Med J. 2017;38(12):1207-1212. of the implant. Compared with titanium mesh, the Flexo-Plate

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Implant Practice US

Volume 15 Number 2

PRACTICE MANAGEMENT

How to handle negative reviews Dr. Len Tau discusses how to soothe the sting of a negative review

o matter how much we try, negative reviews are inevitable. Every practice gets them. It’s only a matter of time. And with how hard we work as dentists to serve patients well, negative reviews can sting. Naturally, many dentists fear that each negative review will cause them to lose patients or turn away potential new patients. We all know how important reviews are to attracting new patients to your practice. Customers care about them. Almost 80% of consumers trust them as much as a personal referral. But that doesn’t mean one or two negative reviews will destroy your practice. While it’s possible for a potential patient or two to be turned away by a negative review, one or two negative reviews hardly ever cause that result. In fact, what you do in response to negative reviews is much more likely to impact your patient base than the negative review itself. So what do you do when you get the inevitable negative review?

Don’t get emotional Pause, take a deep breath, and relax after you receive a negative review. It’s hard, I know. It can ruin your breakfast to see someone leave a negative review about a practice you work so hard at. It’s especially hard when the review is scathing, unwarranted, unfair, or even an outright lie. No matter how wrong the review is, you need to pause. If you get too emotional, it can impact how you show up in your practice. It can impact how you treat your team. And it can impact how you and your team treat patients who come to your practice that day. And that can cause other patients to have poor experiences and lead to more negative reviews. It’s natural for a negative review to ruin your breakfast, but don’t let it ruin your lunch. And don’t let it impact how you show up to your practice that day. Len Tau, DMD, has dedicated his professional life to improving dentistry for both patients and other dentists. After purchasing the Pennsylvania Center for Dental Excellence in Philadelphia in 2007, Dr. Tau practiced full-time while consulting with other dental practices, training thousands of dentists about reputation marketing, leading the dental division of BirdEye, a reputation marketing platform, and hosting the popular Raving Patients podcast. He recently authored the book Raving Patients and the soon-to-be-released 100 Tips to 100 Reviews in 100 Days. In October 2021, Dr. Tau sold his dental practice but continues to practice 2 days per week while commuting from Parkland, Florida, where he has resided since October 2020. Dr. Tau lectures nationally and internationally on using internet marketing and social media; reputation marketing to make dental offices more visible and credible; and how to increase case acceptance. To reach Dr. Tau, email him at len@drlentau.com.

Implant Practice US

Avoid the natural reaction to respond to the review right away I have been very vocal about not publicly responding to the review. It can often be a recipe for disaster. The worst thing you can do is respond and get into a public back-and-forth with someone who was just upset enough to leave a negative review. If their review was unreasonable or wrong, there’s no predicting what else they’ll say in response to you if you reply publicly disagreeing with them. Even worse, dentists have inadvertently violated HIPAA in their responses to negative reviews. If you do respond, remember, you are not only responding to the reviewer, you are responding to everyone who will visit that review site in the future. Would your response make it more or less likely for patients to want you to be their dentist? A much safer approach is to try to take the conversation offline. Contact the patient to try to correct the problem. Taking the time to personally connect with the patient who left the negative review will show you care and are looking to help resolve their concerns. Frequently, when you reach out personally, the patient will even take the bad review down or update it to make it positive.

Never try to get legitimate bad reviews taken down If a review violates the rules of a platform, it’s possible to get a review taken down. However, many professionals, including in dentistry, have tried to take this concept way too far by requiring clients or patients to sign away their rights to reviews to the practice or by suing the reviewer in court for defamation or some other cause of action. While those professionals might technically have the right to sue or own the reviews and get them taken down, it inev-

Volume 15 Number 2

PRACTICE MANAGEMENT

itably backfires and causes what’s called A steady stream of recent positive reviews will have a the Streisand Effect, a social phenomenon caused when someone tries to hide, much greater impact on your practice than one or two remove, or censor negative information negative ones, especially as time passes. and it backfires, causing more attention to be paid to the negative information. It started when Barbra Streisand sued a website owner to get a photo of her resitions of most review sites, but it’s obvious to most people who dence removed from their website. Before the lawsuit, the image will see your reviews that the reviews are from people who never of her house had only been downloaded six times (two of which visited your practice. Just ask patients for feedback after their were by Streisand’s attorney). But the attention from the lawsuit appointments. After they tell you or your team members how caused the image to be seen more than 400,000 times. wonderful their experience was, ask if they’ll be willing to leave The same thing happens when a dentist sues a patient about you a review when they get back home or to the office if you a review. Your lawsuit will bring press, and not the kind you send them a direct link to do so easily. Then follow up and send want. Who wants to go to a dentist who sues a patient? them a link to your page by text (preferable) a short time later for Focus on getting positive reviews to push down the negative them to follow through on their promise to do so. ones (but don’t buy the positive reviews). Continue those efforts until generating a steady flow of posThe best defense to negative reviews is a good offense. If you itive reviews is the norm for your practice. Then any negative get a negative review, renew your focus on earning and asking patients to leave you positive reviews. A steady stream of recent reviews you receive will be quickly pushed down by all the positive reviews will have a much greater impact on your pracpositive things your patients have to say about you. When you tice than one or two negative ones, especially as time passes. do, having a few negative reviews among the positive ones can However, make sure your positive reviews are legitimate and actually be a good thing, as it makes it clear to people reviewing avoid buying them. Not only is it against the terms and condiit that your reviews are, in fact, real. IP

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Volume 15 Number 2

CONTINUING EDUCATION

Managing controlled substances in dental practice: prescribing and record keeping Tyler Dougherty, PharmD; Michael O’Neil, PharmD; and Nikki Sowards, PharmD; review key considerations when prescribing and storing controlled substances Introduction Prescription medication misuse, substance use disorder (SUD), and diversion continue to remain problematic across the United States. Dental practitioners are often targeted by patients since they are a potential source of potent prescription opioids. Additionally, dental practitioners are subject to investigations by the Drug Enforcement Agency (DEA) as part of routine inspections or for potential violations of the Federal Controlled Substance Act (CSA).1 Dental practitioner prescribing and office management of controlled substances require vigilance, careful scrutiny of all records, and well-organized record keeping of both patient medical records and controlled substance records. This article will review key considerations when prescribing and storing controlled substances. Tyler Dougherty, BA, PharmD, BCACP, received his Bachelor of Arts degree in Biochemistry from Maryville College in 2011 and his Doctor of Pharmacy degree from the University of Tennessee College of Pharmacy in 2015. He completed a postgraduate residency at South College School of Pharmacy in 2016. Dr. Dougherty is a Clinical Community Pharmacist and Assistant Professor of Pharmacy Practice where he specializes in community pharmacy practice and teaches ethics and pharmacy law. Dr. Dougherty is an invited speaker for healthcare professionals teaching ethics and law with emphasis on medication management.

This self-instructional course for dentists aims to provide an overview of necessary practices to consider when prescribing and storing controlled substances.

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: • Define key terms used when prescribing and storing controlled substances. • List methods to minimize diversion and fraud of controlled substances. • Outline federal requirements for storing controlled substances. • Identify specific records that must be readily retrievable should a dental practice be audited or investigated. • List common violations of the Controlled Substance Act by dental practitioners.

Michael O’Neil, PharmD, received his Doctor of Pharmacy from the University of North Carolina at Chapel Hill, North Carolina. Dr. O’Neil has extensive experience in pain management, substance misuse, and medication diversion. Dr. O’Neil was editor and lead author for the American Dental Association’s book titled The ADA Practical Guide to Substance Use Disorders and Safe Prescribing, published in 2015. Dr. O’Neil has served as a consultant for prescription drug misuse and diversion for several entities including the Federal Drug Enforcement Agency. He is currently Professor and Chair of Pharmacy Practice at South College School of Pharmacy in Knoxville, Tennessee.

2 CE CREDITS

Nikki Sowards, PharmD, earned her Doctor of Pharmacy degree in 2012 from the University of Tennessee College of Pharmacy in Memphis, Tennessee. She completed a PGY-1 Pharmacy Practice residency in Knoxville, Tennessee. Dr. Sowards joined South College School of Pharmacy as an Assistant Professor in 2013. In 2015, Dr. Sowards worked as a Director of Hospital Pharmacy in Knoxville, Tennessee. Dr. Sowards is currently an Assistant Professor of Pharmacy Practice at South College School of Pharmacy. She practices at Blount Memorial Hospital where she focuses on pharmacy operations and pharmacy management.

Implant Practice US

Educational aims and objectives

Definitions Understanding of medical and legal terminology surrounding controlled substances is important when interpreting the medical/legal literature, and when trying to maintain compliance with state and federal statutes and regulations. The following terminologies provide guidance regarding safe and effective controlled substance management and prescribing practices.

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Prescription Medication Misuse

Table 1: Common “Red Flags”

Prescription medication misuse may be defined as taking a prescription medication outside of the boundaries of the initial prescription’s “intent for use” or directions. This may include a different diagnosis, taking the medication in larger doses or more often than prescribed, or to significantly alter/enhance one’s mental status.2

Patients traveling extremely long distances between dental practicehome-pharmacy Early refills Utilizing multiple prescribers (emergency medicine, dental practices, hospitals, private practices)

Substance Use Disorder (SUD)

Out-of-state patients

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), no longer uses the terms substance abuse and substance dependence. Rather, it refers to substance use disorders, which are classified as mild, moderate, or severe. The level of severity is determined by the number of diagnostic criteria met by an individual.”3

Random, escalating/de-escalating doses of opioids or benzodiazepines Common “cocktails” consisting of opioids, benzodiazepines, muscle relaxants, and sedative hypnotics Morphine-Equivalent Daily Doses (MEDD) exceeding 90 mg/day Patients presenting “old” dental injuries as “new” injuries

Prescription Medication Diversion

Utilizing only cash payments for medications

The movement of a prescription medication in any direction other than how legally allowed to be transferred by law.4

Prescription Drug Monitoring Program (PDMP) Prescription Drug Monitoring Programs are state-regulated electronic databases that store outpatient dispensing records for specific controlled substances.5

Red Flags Red flags are observations that potentially may deter prescribing or dispensing of a medication. Red flags require further questioning of the patient or clarification prior to writing or dispensing a prescription medication.6

Due Diligence “The practice of performing reasonable verification that the information presented is accurate and reliable in order to prevent deceptive or criminal practices. Reasonable implies that the practitioner is doing what any practitioner would and should do in the routine activities of the healthcare professional.”7

Readily Retrievable “Readily retrievable means the record is kept or maintained in such a manner that it can be separated out from all other records in a reasonable time or that it is identified by an asterisk, redline, or some other identifiable manner such that it is easily distinguishable from all other records.”7

Prescribing controlled substances Many dental practices prescribe controlled substance analgesics and anxiolytics prior to performing procedures and postoperatively. Recognition of attempts by patients to illegally obtain controlled substances is necessary to decrease risks to the dental practitioner and the dental practice. State and federal agencies require prescribers to practice “due diligence” when prescribing or dispensing prescription medications. The practice of performing “due diligence” for dental practitioners when prescribing controlled substances includes careful review of the patient’s medical history, review of previously prescribed conimplantpracticeus.com

trolled substances such as that found in the PDMP, evaluation of patient behaviors, patient interviewing, refusing to prescribe or dispense when diversion or fraud is suspected, and reporting these behaviors accordingly. Currently, many states now require prescribers to evaluate a patient’s PDMP report prior to prescribing controlled substances. (For a more in-depth review of utilizing a state PDMP, see the continuing education article in Implant Practice US: “Practical Considerations for Utilizing Prescription Drug Monitoring Programs — A Primer.”) The PDMP provides controlled substances prescribed for patients that have been dispensed from a community pharmacy or outpatient clinic for a specific state. The PDMP is a helpful tool to optimize therapeutic decisions as well as to detect “red flags” that lead to further questioning prior to prescribing. Table 1 lists red flags commonly detected in a PDMP report.8 Dental practitioners should analyze this report for active controlled substances, recent controlled substance prescriptions from other prescribers, duplicate prescriptions, and early refills. It is important to recognize that any anomalies found should lead to further questioning of the patient since the information provided in the PDMP has not been validated by a secondary source and may have errors that occurred at the time of processing the prescription. Any verified abnormal findings should be thoroughly documented in the patient’s medical record. Other methods to divert controlled substances from dental practices include altering written prescriptions or falsifying phone-in prescriptions. Tampering of prescriptions is limited by use of tamper-proof prescription pads, and copying of prescriptions is minimized by utilizing embedded watermarks or photocopying resistant paper. The use of preprinted prescriptions with the medication name, medication strength, dosage, and directions is highly discouraged. The use of presigned prescriptions by the prescriber is illegal. Controlled substance prescriptions should be signed the day the written prescription is provided to the patient. Additionally, utilization of ePrescribing can minimize these types of diversion and fraud.

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ePrescribing

Dental practitioner prescribing and office manage-

Electronic prescribing of prescription ment of controlled substances require vigilance, caremedications, also known as ePrescribing, began after the passing of the Medicare ful scrutiny of all records, and well-organized record Modernization Act (MMA) of 2003. The keeping of both patient medical records and controlled MMA aimed to enhance the quality of patient care while also increasing the substance records. utilization of electronic medical records. It wasn’t until 2006, when the Institute of Medicine’s July report discussing the role ePrescribing can play on reducing medication errors, that ePrescribing began to the pain medication prescription to the pharmacy and not fill the be widely used.9 antibiotic. Finally, ePrescribing enhances and further improves In 2018, Congress passed the Substance Use-Disorder electronic health record information and exchanges of that inforPrevention that Promotes Opioid Recovery and Treatment for mation. The exchange of electronic health records is becoming Patients and Communities Act (SUPPORT Act), which aimed more vital as healthcare providers, patients, and insurance comto address the opioid epidemic. In addition, this legislation panies look to increase communication to better patient care. required Schedule II-V controlled substances for Medicare Part 10 D beneficiaries be ePrescribed beginning January 1, 2021. The Record keeping Centers for Medicare and Medicaid Services (CMS) has since Laws and regulations for prescribing, storing, administerdelayed the enforcement of the ePrescribing rule until January ing, and disposing of controlled substances are defined at the 1, 2022. Dental practices and other healthcare providers would federal level in Title 21, Code of Federal Regulations (CFR), clearly find it difficult to delineate Medicare and non-Medicare sections 1300-1316.13 The federal Drug Enforcement Agency beneficiary prescriptions, meaning the prescribing of controlled (DEA) is mandated to ensure compliance to these laws and substances must be electronic for all patients going forward. regulations. Compliance is usually under control of the state’s However, individual states are already implementing ePrescribBoards of Pharmacy and Dentistry. Controlled substances laws ing requirements for controlled substances. Currently, 25 states and regulations frequently mirror federal laws and regulations. require ePrescribing with some provider exemptions. More Required records for controlled substances — e.g., purchase states are expected to pass or implement legislation requiring receipts, invoices, DEA222 transfer forms, DEA106 theft loss ePrescribing starting in 2022 and beyond.11 The Centers for forms, and records of detailed disposed controlled substances Medicare and Medicaid Services (CMS) policy does allow for such as wastage or damaged product — must be maintained prescribers to be exempt from ePrescribing controlled subfor 2 years and must be “readily retrievable” should a dental stances in the following situations: The prescriber and dispensing practitioner be audited or investigated. It is also important that pharmacy are the same entity, the prescriber issues 100 or fewer providers remember to take a biennial inventory of all controlled controlled substance prescriptions per year for Medicare Part D substances. Individual states can have stricter requirements surpatients, or circumstances surrounding natural disasters.12 rounding how often inventories must be taken. Dental practices should begin to adopt ePrescribing for all prescriptions, controlled and non-controlled substances, for multiple reasons. Although the federal requirements center around Medicare beneficiaries, the combination of state specific regulations make it logistically difficult for practices to issue prescriptions in two different formats. Adopting ePrescribing can potentially improve medication safety while also preventing prescribing errors. For example, handwritten prescriptions can oftentimes be illegible or difficult to interpret, requiring pharmacists to make judgement calls or delay care for the patient in order to confirm the prescription information. Also, different state and federal requirements exist on the information that must be included on a prescription, including the address of the patient, phone number or address of the practice, and DEA number of the prescriber (for a controlled substance). This information would automatically be included with standardized ePrescribing systems. In addition, electronic prescribing can help with controlled substance diversion or patient selection of medications they want filled or not filled. For example, a patient who is prescribed two handwritten prescriptions for an antibiotic and a pain medication post-dental procedure could provide only Implant Practice US

Ordering and transferring controlled substances 21 CFR 1305.04 and 1305.05 require dental practitioners to be registered with the DEA if they intend to order Schedule II controlled substances (hydrocodone, oxycodone, etc.). They are referred to as a DEA registrant and are assigned a specific DEA registration number. The registrant may give authorization to other individuals to order Schedule II controlled substances through power of attorney. The ordering and transferring of Schedule II controlled substances requires the DEA222 form. The triplicate DEA222 form has been replaced with a single-sheet DEA222 form effective October 2021. The ordering of controlled substance medication Schedules III-V does not require transfer of the medications with the DEA222 form; however, the entities supplying and receiving the controlled substance must maintain records of the transactions.14,15

Storing and access of controlled substances Title 21, CFR Section 1301.71(a) specifies considerations for storing controlled substances at a business or practice site. Volume 15 Number 2

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Some of these include the type of building, type/quantity of controlled substances to be stored, type of safe, vault or locked steel cabinet, and alarm systems. Controlled substances purchased for dental office practices must be kept in a “locked, well-constructed metal cabinet or safe.” Access to controlled substances should be limited. Equally important is determining who may have access to controlled substances within the dental practice. The DEA lists very specific individuals who may not have access. This list includes the following: 1. Any person who has been convicted of a felony offense related to controlled substances 2. Any person who has been denied a DEA registration 3. Any person who has had a DEA registration revoked 4. Any person who has surrendered a DEA registration for cause Prior to hiring of personnel for the dental practice, it is prudent to complete thorough background investigations and screen for potential exclusions in this list.16

Summary

The controlled substances act. DEA. https://www.dea.gov/drug-information/csa. Accessed December 22, 2021.

Disposal of controlled substances

O’Neil M. Common Substances and Medications of Abuse. In: The ADA Practical Guide to Substance Use Disorders and Safe Prescribing. Wiley Blackwell; 2015.

Key terms and definitions. SAMHSA. https://www.samhsa.gov/section-223/certification-resource-guides/key-terms-definitions. Accessed December 21, 2021. Accessed March 21, 2022.

Melton S, Orr R. Detection and Deterrence of Substance Use Disorders and Drug Diversion in Dental Practice. In: The ADA Practical Guide to Substance Use Disorders and Safe Prescribing. Wiley Blackwell; 2015.

Prescription Drug Monitoring Programs (pdmps). Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/pdmp/index.html. Published May 19, 2021. Accessed March 21, 2022.

O’Neil M, Winbigler B, Sowards N. Prescription Medication Diversion: Detection and Deterrence. Journal California Dental Association. 2019;47(3):179-185.

Aquinos C. Office Management of Controlled Substances. In: The ADA Practical Guide to Substance Use Disorders and Safe Prescribing. Wiley Blackwell; 2015.

E-Prescribing. Centers for Medicare and Medicaid Services. https://www.cms.gov/ Medicare/E-Health/Eprescribing. Accessed March 21, 2022.

How to appropriately dispose of controlled substances and document the disposals are critical considerations when handling these medications. Whenever controlled substances need to be destroyed due to being leftover following patient administration, are found broken, have become contaminated, or have expired, the risk for potential diversion is high. Ideally, these medications should be transferred to a designated “take-back” facility commonly known as reverse distributors. An alternative method involves having the DEA Special Agent in the practitioners’ area destroy the medications on-site. Other alternative methods for destruction may be found in the controlled Substance Act 21 CFR Part 1317. These records must be “readily retrievable” and maintained for 2 years.17

In summary, management of controlled-substance prescribing practices and record keeping require a comprehensive knowledge regarding methods to detect and deter attempts to divert medications from dental practices. Two important methods to optimize prescribing include use of the state’s PDMP and implementation of ePrescribing. Maintaining detailed records for storage, transfer, and disposal of controlled substances is also necessary to ensure adherence to federal, state, and dental board statutes and regulations. Dental practitioners should only prescribe medications to patients registered with their dental practice. IP

REFERENCES

Reporting theft or loss of controlled substances When dental practitioners suspect theft or loss of controlled substances, they should complete an inventory of controlled substances and immediately file a DEA 106 Theft/Loss form, which is available online or through a downloadable PDF. If theft is suspected by burglary or employee pilfering, local law enforcement should also be notified.

Common violations by dental practitioners Dental practitioners may be investigated and ultimately prosecuted for a variety of reasons. Frequently, this may involve being nonadherent to federal regulations — e.g., failing to maintain up-to-date inventory records, failure to store controlled substances safely, failure to dispose of controlled substances appropriately, and failing to renew registrant license. Out of convenience, dental practitioners may prescribe medications for nondental-related issues. For example, prescribing oral contraceptives for pregnancy prevention or potent analgesics for migraines would be considered prescribing outside the scope-ofpractice. Any prescription ordered by dental practitioners should be within their scope of practice and for a patient with records at the practice site.7 implantpracticeus.com

10. H.R.6 – SUPPORT for Patients and Communities Act. Public Law 10/24/2018. https:// www.congress.gov/bill/115th-congress/house-bill/6/text. Accessed March 21, 2022. 11. Carter L. 2021 Survey of Pharmacy Law. National Association of Boards of Pharmacy. www.nabp.pharmacy. Accessed March 21, 2022. 12. E-prescribing. Centers for Medicare and Medicaid Services. https://www.cms.gov/ Medicare/E-Health/Eprescribing. Accessed March 21, 2022. 13. eCFR: 21 CFR Chapter II -- Drug Enforcement ... https://www.ecfr.gov/current/title-21/ chapter-II. Accessed March 21, 2022. 14. eCFR :: 21 CFR part 1305 -- orders for schedule I and II ... https://www.ecfr.gov/ current/title-21/chapter-II/part-1305. https://www.ecfr.gov/current/title-21/chapter-II/ part-1305/subpart-A/section-1305.04. Accessed March 21, 2022. 15. eCFR :: 21 CFR part 1305 -- orders for schedule I and II ... https://www.ecfr.gov/current/ title-21/chapter-II/part-1305. Accessed March 21, 2022. 16. eCFR :: 21 CFR 1301.71 -- security requirements generally. https://www.ecfr.gov/ current/title-21/chapter-II/part-1301/subject-group-ECFRa7ff8142033a7a2/section-1301.71. Accessed March 21, 2022. 17. eCFR :: 21 CFR Part 1317 -- disposal. https://www.ecfr.gov/current/title-21/chapter-II/ part-1317. Accessed March 21, 2022. 18. Theft/Loss Reporting. Significant Theft or Loss Reporting of Controlled Substances. Diversion Control Division: https://www.deadiversion.usdoj.gov/21cfr_reports/theft/. Accessed March 21, 2022.

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Continuing Education Quiz Managing controlled substances in dental practice: prescribing and record keeping DOUGHERTY/O’NEIL/SOWARDS

_______ may be defined as taking a prescription medication outside of the boundaries of the initial prescription’s “intent for use” or directions. a. Prescription medication misuse b. Medication diversion c. Substance abuse/misuse d. Red flag indicator

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), no longer uses the terms substance abuse and substance dependence. Rather, it refers to ________. a. substance misuse b. substance use disorders c. prescription misorder d. prescription diversion

n To receive credit: Go online to https://implantpracticeus.com/continuingeducation/, click on the article, then click on the take quiz button, and enter your test answers. AGD Code: 157 Date Published: May 20, 2022 Expiration Date: May 20, 2025

________ is the movement of a prescription medication in any direction other than how legally allowed to be transferred by law. a. Due diligence b. Prescription Medication Diversion c. Substance mis-transfer d. Controlled substance misuse

_________ is the practice of performing reasonable verification that the information presented is accurate and reliable in order to prevent deceptive or criminal practices. a. Red flag deterrence b. Drug program monitoring c. Due diligence d. Dose Monitoring

________ means the record is kept or maintained in such a manner that it can be separated out from all other records in a reasonable time or that it is identified by an asterisk, redline, or some other identifiable manner such that it is easily distinguishable from all other records. a. Readily retrievable b. Due diligence c. Redline ready d. On file

Dental practitioners should analyze the Prescription Drug Monitoring Program (PDMP) report for _________ and early refills. a. active controlled substances b. recent controlled substance prescriptions from other prescribers c. duplicate prescriptions d. all of the above

2 CE CREDITS

The use of preprinted prescriptions with the medication name, medication strength, dosage, and directions is ________. a. highly discouraged b. always encouraged c. illegal d. mandated by the PDMP

According to Title 21, CFR Section 1301.71(a) specifies considerations for storing controlled substances at a business or practice site. … Controlled substances purchased for dental office practices must be kept in _______. a. a cabinet that may be unlocked, depending on its location b. a locked, well-constructed metal cabinet or safe c. a cabinet or box marked “controlled substances” d. a refrigerator that patients cannot see

Dental practitioners may be investigated and ultimately prosecuted for a variety of reasons. Frequently, this may involve being nonadherent to federal regulations — e.g., _________ and failing to renew registrant license. a. failing to maintain up-to-date inventory records b. failure to store controlled substances safely c. failure to dispose of controlled substances appropriately d. all of the above

10. Any prescription ordered by dental practitioners should be ________. a. within their scope of practice b. for a patient with records at the practice site c. handwritten for controlled substances only d. both a and b

To provide feedback on 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.

Implant Practice US

Volume 15 Number 2

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CONTINUING EDUCATION

Ultra-narrow diameter implants for the treatment of mandibular anterior external resorption Dr. Paul Mozer discusses guided implant surgery with narrow diameter implants

uccessful implant surgery is in large measure reliant upon the accurate position of the implant and its prosthetic components.1,2 The overloading of the implant body or its prosthetics have been considered by several studies that specifically addressed the concerns that arise from poor implant positioning. Weinberg, et al., in 1995 articulated the force magnifiers that resulted from improper implant placement and described the concepts of cuspal inclination, implant inclination, horizontal implant offset, and apical implant offset.3 Directional displacement of the implant away from its intended position resulting from variations in vertical, horizontal, and depth positioning resulted in substantial increases in force transmitted to the implant and its prosthetics. These increased forces can lead to premature prosthetic component wear, prosthetic failure, bone loss, and implant loss.3 Historically, clinicians used two-dimensional panoramic X-rays, bone mapping using ridge calipers, and open-flap measurements, among other techniques to measure the width and height of the residual ridge before and during implant placement. Most often final implant size and position were determined chairside with the surgical site flapped open. These approaches alone or in combination all yielded significant gaps in critical clinical information since these methods all lacked the appreciation of the three-dimensionality of bone.4,5,6 Many studies have described the challenges of freehand implant surgery under normal conditions. Hoffman, et al., performed a model-based study in which the mean angle deviation between planned implants and final implant placement was 11

Paul Mozer, DDS, MSc, DICOI, graduated from University at Buffalo School of Dental Medicine where he received academic distinction and clinical commendations. He conducted oral cancer research at Roswell Park Cancer Institute and completed a residency at New York Medical College. Dr. Mozer has a Master of Science Degree in Oral Implantology from the University of Frankfurt Goethe Dental School, where he is on faculty lecturing on guided implant surgery and serves as a Clinical Supervisor and Advisor to Master Thesis candidates. Dr. Mozer is also on the faculty of the AAID MaxiCourse® in Boston, Massachusetts; St. Peters Hospital in Albany, New York; and the VA Hospital in Buffalo, New York. He has conducted clinical research in static and robotic guided implant surgery and is both a Diplomate and Fellow in International Congress of Oral Implantologists. Disclosure: Dr. Mozer has no financial interest in any of the companies mentioned in this article and has not received compensation for this article. Dr. Mozer is a key opinion leader for Adin Implants and 360Imaging.

Implant Practice US

Educational aims and objectives

This self-instructional course for dentists aims to discuss the usage of ultra-narrow diameter implants to treat narrow edentulous spaces without additional bone grafting procedures.

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: • Review limitations of freehand implant surgery. • Identify static-guided implant surgery workflows. • Recognize limitations of conventional-sized implants in narrow edentulous spaces. • Realize the benefits of guided implant surgery in idealizing positioning of ultra-narrow diameter implants.

2 CE CREDITS

degrees with a range from 4.1 to 25.3 degrees.7 A malpositioned implant with an 11-degree angulation would have potentially significant and long-lasting consequences on the implant and its prosthetics. Three-dimensional cone beam imaging has opened the door for clinicians to assess bone density and volume before performing the implant procedure.5,6 Computer-aided design and manufacturing (CAD/CAM) can be utilized to plan ideal implant positions in implant software and bring those ideal surgical plans to the patient using static stereolithographic (STL) static surgical guides.7,8 Surgical guides allow clinicians to increase the predictability of implant placement8 while limiting the negative outcomes of implant malposition and force multipliers. Guided surgery drill kits provided by the implant manufacturer restrict the drill path by engaging the guide sleeve within the STL surgical guide.13 Studies by Hoffman, et al., and Choi, et al., show a 50% or greater improvement in implant position accuracy utilizing static surgical guides over freehand methods. The advantages of guided surgery become critical in complicated cases where bone volume or bone density require precision that can be difficult to achieve with freehand implant placement.7,14 Edentulous areas with a narrow ridge that is deficient in width and/or height have traditionally undergone a bone

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Figures 1A and 1B: 1A. cone beam of lower anterior. 1B. Cone beam showing external resorption of the three affected teeth Nos. 25, 26, 27

Figure 2: Periapical X-rays showing external resorption undermining roots of mandibular incisors and lower right canine

augmentation procedure prior to implant placement. Augmentation with bone blocks, bone plates, or ridge-splitting procedures are technique-sensitive, costly, and can result in comorbidities such as a second surgical site dehiscence or a final implant site with a remaining width deficiency.11 Narrow interdental edentulous spaces such as maxillary lateral incisors and mandibular incisors are unique in that except for orthodontic arch expansion, the adjacent teeth prevent bone grafting as a solution to gain more space for a larger implant diameter. As implant material science has advanced, narrow diameter two-piece implant designs have allowed clinicians and patients to set aside traditional grafting techniques and utilize narrow (3.0 mm-3.25 mm) and ultranarrow (2.75 mm) diameter implants with measurable success. A systematic review by Schiegnitz and a study by Grandi both show the success of ultra-narrow diameter 2.75 mm implants to be between 94.7 and 97.6%, results that are consistent with the success of more traditional sized implants.16,17

Figure 3: Screenshots of treatment planning of Adin 2.75 mm implants in narrow and dense ridge with 360dps software (360Imaging)

Clinical case included the options of onlay block grafting with delayed implant placement and the disadvantages of a second surgical site, comorbidities, and technique-sensitive surgical procedures. The traditional prosthetic dental options of a lower partial denture and fixed bridge were alternatives that were less than desirable for the patient. The patient ultimately opted for implant placements.

The patient presented with the diagnosis of unrestorable external resorption of teeth Nos. 25, 26, 27 in the anterior mandible. A cone beam image was taken using the i-CAT™ FLX (Imaging Sciences, Hatfield, Pennsylvania). Analysis showed very thin bone surrounding the existing teeth with a density of 1243-1383 Hounsfield units, suggesting very dense Type I bone. Treatment-planning options for a narrow ridge implantpracticeus.com

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CONTINUING EDUCATION

Figure 5: Clinical picture at time of healing abutment removal and impression Figure 4: Postoperative periapical X-ray showing implant placements with cover screws and bone grafts

In this case, the ultra-narrow platform Adin Touareg CloseFit™ 2.75mm diameter implants (Adin Implants Afula, Israel) were treatment planned for guided surgery using 360Imaging™ (Atlanta, Georgia) surgical guides. The workflow included a three dimensional cone beam image taken at the consultation appointment along with physical polyvinyl siloxane impressions (3M™, St. Paul, Minnesota) for interim prosthesis fabrication and a digital impression of the clinical arch (Cerec Omnicam, Dentsply Sirona, Salzburg, Austria) for surgical guide planning. The collected data was sent to 360Imaging through its online courier service for analysis and treatment planning. Treatment planning was performed collaboratively between the clinician and the dentist treatment planners at 360Imaging via Zoom (San Jose, California) and screenshare technology. The teeth were digitally extracted, and the final implant positions were planned in 360dps software (360Imaging, Atlanta, Georgia). Static STL surgical guides were fabricated and delivered to the clinician’s practice within a few days. The day of the procedure, consent was obtained, amoxicillin 2G was given to the patient before the procedure and 2.5 carpules of articaine 4% 1:100k epinephrine local anesthetic was administered (Septodont, Lancaster, Pennsylvania). The affected teeth were extracted as atraumatically as possible using forceps. The positive seating of the surgical guided was verified clinically, and three Adin Touareg CloseFit 2.75 mm ultra-narrow diameter implants were immediately placed using the static surgical guides and Adin’s keyless guided surgery kit (Adin Implants, Afula, Israel). Cover screws were placed and torqued to 15Ncm, and particulate bone grafts with BioOss® (Geistlich, Wolhusen, Switzerland) were placed with aPRF and iPRF using the Choukroun Duo Quattro PRF™ Centrifuge (Advanced Platelet Rich Fibrin, Choukroun Centrifuge Nice, France). A BioGide® cross-linked collagen membrane (Geistlich, Wolhusen, Switzerland) was placed over the grafted site and tension-free PGA (polyglycolic acid) sutures were placed. Hemostasis was observed. The previously fabricated temporary removable prosthesis was adjusted chairside and delivered to the patient, makImplant Practice US

Figure 6: Final post-prosthetic X-ray of implants with final prosthetics in place

ing sure that there was no positive pressure on the ridge from the interim prosthesis. The patient was placed on a postoperative regimen of Ibuprofen 800mg every 4 hours for the first 24 hours and Amoxicillin 500mg 3 times daily, warm salt water rinses 5-6 times per day, and 0.12% Chlorhexidine rinses twice daily for 7 days. The patient was seen for suture removal 10 days after the procedure, and oral hygiene instructions were reinforced. After 4 months of healing, the site was uncovered, healing abutments placed for tissue contouring, and an open tray impression was taken with Impregum™ (3M™, St. Paul, Minnesota). Three splinted screw-retained crowns were inserted and torqued to 35Ncm. The lingual screw accesses were covered with PTFE Teflon tape, resin restorations were placed, and the Volume 15 Number 2

CONTINUING EDUCATION

In a freehand implant placement surgical approach, obtaining optimal positioning in Type I bone can be clinically challenging for a single implant.

occlusion was adjusted where necessary. Oral hygiene was reviewed, and the patient was seen 3 weeks later for an occlusal reassessment. In a freehand implant placement surgical approach, obtaining optimal positioning in Type I bone can be clinically challenging for a single implant. In this particular case, the patient presented with a narrow mandibular anterior edentulous space that required precision placement of three implants in narrow and dense bone. The ability to achieve the ideal placement required for multiple placements of ultra-narrow implants with screw-retained crowns would have proven very difficult. As indicated in Figure 7B, screw access was through the cingulum on the lingual aspect of the prosthetics. Static-guided implant surgery utilizing the Adin’s ultra-narrow 2.75 mm implants allows implant placements in dense thin bone to be as predictable as 5.0 mm implants in a wide edentulous ridge. IP

REFERENCES

Becker CM, Kaiser DA. Surgical guide for dental implant placement. J Prosthet Dent. 2000;83(2):248-251.

Garber DA, Belser UC. Restoration-driven implant placement with restoration-generated site development. Compend Contin Educ Dent. 1995;16(8):796,798-802,804.

Weinberg LA, Kruger B. A comparison of implant/prosthesis loading with four clinical variables. Int J Prosthodont. 1995;8(5):421-433.

Gahleitner A, Watzek G, Imhof H. Dental CT: imaging technique, anatomy, and pathologic conditions of the jaws. Eur Radiol. 2003;13(2):366-376.

Nickenig HJ, Eitner S. Reliability of implant placement after virtual planning of implant positions using cone beam CT data and surgical (guide) templates. J Craniomaxillofac Surg. 2007; 35(4-5):207-211.

Ozan O, Turkyilmaz I, Ersoy AE, et al., Clinical accuracy of 3 different types of computed tomography-derived stereolithographic surgical guides in implant placement. J Oral Maxillofac Surg. 2009;67(2):394-401.

Hoffmann J, Westendorff C, Gomez-Roman G, Reinert S. Accuracy of navigation-guided socket drilling before implant installation compared to the conventional free-hand method in a synthetic edentulous lower jaw model. Clin Oral Implants Res. 2005;16(5):609-614.

D’Souza KM, Aras MA. Types of implant surgical guides in dentistry: a review. J Oral Implantol. 2012;38(5):643-652.

Cassetta M, Stefanelli LV, Giansanti M, Di Mambro A, Calasso S. Depth deviation and occurrence of early surgical complications or unexpected events using a single stereolithographic surgi-guide. Int J Oral Maxillofac Surg. 2011;40(12):1377-1387.

10. Marchack CB. CAD/CAM-guided implant surgery and fabrication of an immediately loaded prosthesis for a partially edentulous patient. J Prosthet Dent. 2007;97(6):389-394. 11. Park C, Raigrodski AJ, Rosen J, Spiekerman C, London RM. Accuracy of implant placement using precision surgical guides with varying occlusogingival heights: an in vitro study. J Prosthet Dent. 2009;101(6):372-381. 12. Holst S, Blatz MB, Eitner S. Precision for computer-guided implant placement: using 3D planning software and fixed intraoral reference points. J Oral Maxillofac Surg. 2007;65(3):393-399. 13. Koop R, Vercruyssen M, Vermeulen K, Quirynen M. Tolerance within the sleeve inserts of different surgical guides for guided implant surgery. Clin Oral Implants Res. 2013;24(6):630-634. 14. Choi W, Nguyen BC, Doan A, Girod S, Gaudilliere B, Gaudilliere D. Freehand Versus Guided Surgery: Factors Influencing Accuracy of Dental Implant Placement. Implant Dent. 2017;26(4):500-509. 15. Esposito M, Grusovin MG, Felice P, Karatzopoulos G, Worthington HV, Coulthard P. The efficacy of horizontal and vertical bone augmentation procedures for dental implants—a Cochrane systematic review. Eur J Oral Implantol. 2009;2(3):167-184 16. Schiegnitz E, Al-Nawas B. Narrow-diameter implants: A systematic review and meta-analysis. Clin Oral Implants Res. 2018;29(Suppl 16):21-40.

C. Figures 7A-7C: Clinical pictures of final implant supported screw-retained prosthetics

implantpracticeus.com

17. Grandi T, Svezia L, Grandi G. Narrow implants (2.75 and 3.25 mm diameter) supporting a fixed splinted prostheses in posterior regions of mandible: one-year results from a prospective cohort study. Int J Implant Dent. 2017;3(1):43.

Volume 15 Number 2

CONTINUING EDUCATION

Continuing Education Quiz Ultra-narrow diameter implants for the treatment of mandibular anterior external resorption MOZER

Directional displacement of the implant away from its intended position resulting from variations in vertical, horizontal, and depth positioning resulted in _______ transmitted to the implant and its prosthetics. a. substantial increases in force b. substantial decreases in force c. no changes in force d. none of the above

These increased forces (transmitted to the implant and its prosthetics) can lead to _______ and implant loss. a. premature prosthetic component wear b. prosthetic failure c. bone loss d. all of the above

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 866579-9496, or visit https://implantpracticeus.com/subscribe/ to subscribe today. n To receive credit: Go online to https://implantpracticeus.com/continuingeducation/, click on the article, then click on the take quiz button, and enter your test answers. AGD Code: 690 Date Published: May 20, 2022 Expiration Date: May 20, 2025

Historically, clinicians used _______, bone mapping using ridge calipers, and open-flap measurements, among other techniques to measure the width and height of the residual ridge before and during implant placement. a. 3D CBCT scans b. two-dimensional panoramic X-rays c. CAD/CAM d. guided splints

2 CE CREDITS

result in comorbidities such as a second surgical site dehiscence or a final implant site with a remaining width deficiency. a. bone blocks b. bone plates c. ridge-splitting procedures d. all of the above

_________ has/have opened the door for clinicians to assess bone density and volume before performing the implant procedure. a. Three-dimensional cone beam imaging b. Ridge calipers c. Two-dimensional panoramic imaging d. Surgical operating microscopes ________ allow(s) clinicians to increase the predictability of implant placement while limiting the negative outcomes of implant malposition and force multipliers. a. Implant mapping b. Surgical guides c. Mean angle deviation mapping d. Periapical X-rays Studies by Hoffman, et al., and Choi, et al., show a ________ or greater improvement in implant position accuracy utilizing static surgical guides over freehand methods. a. 5% b. 10% c. 50% d. 60%

Narrow interdental edentulous spaces such as _______ are unique in that except for orthodontic arch expansion, the adjacent teeth prevent bone grafting as a solution to gain more space for a larger implant diameter. a. maxillary lateral incisors b. mandibular incisors c. maxillary bicuspids d. both a and b

A systematic review by Schiegnitz and a study by Grandi both show the success of ultra-narrow diameter 2.75 mm implants to be between ________, results that are consistent with the success of more traditionalsized implants. a. 32% and 36% b. 53% and 57% c. 72% and 75% d. 94.7 and 97.6%

10. In a freehand implant placement surgical approach, obtaining optimal positioning in _____ bone can be clinically challenging for a single implant. a. Type I b. Type 2 c. Type 3 d. Type 4

Augmentation with ___________ are technique-sensitive, costly, and can

Implant Practice US

Volume 15 Number 2

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PRODUCT PROFILE

Cool Jaw® Medico® International Inc. — a new generation of hot/cold therapy

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, handsfree 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. Our most popular wrap (T-800C) utilizes a unique, patented pocket design that allows patients to fulfill 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 T-430 Soft-sided Round Gel packs for a fully adjustable fit. Cool Jaw’s implants and cosmetic injections such hands-free hot/cold therapy system as Botox®. These packs come in a variety helps promote patient compliance of color options to match your office or and reduce post-op complications. simply to add an element of FUN to any Our Clear Cold Gel Packs (T-400) procedure. Choose from bright solid colare ideal for a variety of cold therapy ors as well as eye-catching glitters. These applications. These sturdy reusable reusable gel packs are 4" in diameter and gel packs freeze solid and remain remain flexible when frozen, allowing for cold for extended periods of time — uniform cold therapy. They feature one up to an hour! soft-sided surface that shields the skin from All 3x6 Hot/Cold Gel Packs (T-420 direct contact with the frozen pack. and T-425) remain pliable when frozen, T-800CBLU with Pink Glitter gel packs Customization is a subtle, yet effective contour to the face, and provide patients way to promote your practice and enhance with more post-op therapy options, your professional image. Cool Jaw helps you to continue proincluding heat. These reusable gel packs shape to the patient’s face, moting your practice long after the surgery date. Cool Jaw’s allowing for comfortable, continuous hot/cold therapy. designers work seamlessly with your staff to help you choose Cool Jaw’s reusable hands-free system arrives ready to hand the best colors and layout to ensure your brand shines. Since our out to your patients, including preprinted, patient-friendly products are reusable, patients tend to save them “just in case.” instructions for added convenience. Each Cool Jaw system As result, your information is easy to find, and referrals increase. is packaged with your choice of either two or four gel packs. All of our products can be customized with your practice logo Ordering a wrap with four gel packs allows patients to alternate and information for long-lasting promotion. Let your practice gel packs between freezings/heatings and ensures a seamless speak for itself! IP recovery period. Our Soft-sided Round Gel packs are a convenient, post-op This information was provided by Medico® International Inc. cold therapy option for after numerous procedures, including Implant Practice US

Volume 15 Number 2

PRODUCT PROFILE

NovaBone® Morsels (Porous Granules) Promising progress in the treatment of peri-implantitis defects

nflammation around a dental implant that progresses to the peri-implantitis stage typically requires surgical intervention to decontaminate the implant surface and graft the site to regenerate bone for implant stability and pocket reduction. The materials and methods for the treatment of peri-implantitis vary. Prominent researcher Dr. George Kotsakis — the Rolland E. Meffert Endowed Professor in Implant Dentistry and Director of ITI Implantology Program at the UT Health San Antonio — is leading ongoing human clinical trials and preclinical animal studies to identify the optimal parameters for peri-implant bone Figures 1 and 2: 1. Cleaned peri-implant defect before the grafting. 2. Grafting with Novaregeneration. Findings from these projects Bone® Morsels (porous granules) and placement of a membrane to achieve peri-implant regeneration. (Images courtesy of George Kotsakis, DDS, MS) and his clinical experience have allowed Dr. Kotsakis to develop a promising evidence-based peri-implantitis treatment protocol. Research shows that simple nonabrasive surface-cleaning Viable attachment of osteoblasts to the treated titanium strategies, such as the use of pressurized saline and polymer surface in the early phases of wound healing is critical brushes, are most effective for cleaning the exposed implant to preventing the formation of long junctional epithelium surface. Metallic brushes or instrumentation can permanently on the implant surface. damage the passivation layer on the implant surface, negatively • Research shows this class of bioactive glass has some impacting its cellular compatibility. This damage to the titanium antimicrobial effect, perhaps related to changes in the surface leads to the release of titanium microparticles in the local pH during the material’s dissolution. If the titanium peri-implant tissue, which has pro-inflammatory and osteoclastic surface has any remaining biofilm contaminants, this effects and negatively impacts regeneration. Dr. Kotsakis limits antimicrobial effect may provide sufficient prophylaxis to the use of therapeutic agents (threefold dilution of NaOCl is his allow for osteoblasts to attach and thrive on the implant preference) only to areas of the implant surface exposed to the surface. gingival sulcus. Chlorhexidine is not preferred as it negatively • The NovaBone porous granules offer sufficient stability impacts cell attachment to the titanium surface and may inhibit in the defect site. The material has been used clinically cell proliferation. in extraction sockets, sinus augmentations, peri-implant For bone grafts, Dr. Kotsakis uses NovaBone® Morsels (porous defects, and localized ridge augmentations. granules) for their osteostimulative properties. The graft will be The NovaBone portfolio is distributed by Osteogenics Biocontained/protected with a membrane per classic guided-bone medical in the U.S./Canada and through a network of distributors regeneration procedures. This bone graft is a synthetic calcium internationally. To learn more, visit www.novabonedental.com. IP phosphosilicate (CPS) material with bimodal particle distribution and interconnected porosity. His selection of this material is REFERENCES predicated on the following: 1. Hill RG, Brauer DS. Predicting the bioactivity of glasses using the network connectivity • NovaBone’s CPS material is a bioactive glass. Its formuor split network models. J Non-Cryst Solids. 2011;357:3884-3887. lation is osteostimulatory. As the material breaks down 2. Karoussis I, Kyriakidou K, Papaparaskevas J, et al. Osteostimulative calcium phosin vivo, elemental ions are released that attract osteoprophosilicate biomaterials partially restore the cytocompatibility of decontaminated titanium surfaces in a peri-implantitis model. J Biomed Mater Res B Appl Biomater. genitor cells. Most other synthetics and xenografts only 2018;106(7):2645-2652. serve as an osseoconductive scaffold and have no stimu3. Kotsakis GA, Black R, Kum J, et al. Effect of implant cleaning on titanium particle latory mechanism of action. dissolution and cytocompatibility. J Periodontol. 2021;92(4):580-591. • An in vitro study conducted by Dr. Kotsakis demonstrated 4. Singh S, Patil A, Mali S, Jaiswal H. Bioglass: A New Era in Modern Dentistry. Eur J Gen Dent. 2022;11:1-6. that the NovaBone graft material showed an incremental chemotactic effect on osteoblasts and increased cell 5. Stoor P, Söderling E, Salonen JI. Antibacterial effects of a bioactive glass paste on oral microorganisms. Acta Odontol Scand. 1998;56 (3):161-165. attachment and viability compared to the control and a test group incorporating beta-tricalcium phosphate. This information was provided by NovaBone Products. Implant Practice US

Volume 15 Number 2

OSTEOSTIMULATIVE BONE GRAFTING PUTTY NovaBone® is 100% synthetic, fully resorbable, and bioactive. Disposable uni-dose cartridges simplify dispensing of the graft, especially in hard-to-reach areas, thus facilitating minimally invasive techniques like ridge preservation and

Minimally Invasive Transcrestal Sinus Augmentation with NovaBone® Cartridge System1,2,3

▼

crestal-approach sinus lifts.

Step 1: An osteotomy is prepared to less than 1 mm from the sinus ﬂoor. Step 2: An osteotome is then used to gently fracture the bone at the apex of the osteotomy.

NovaBone’s unique cartridge delivery system makes it an ideal choice for

crestal sinus elevation. The 2.8 mm cannula attached to the cartridge is designed to ﬁt directly into osteotomy. The hydraulic pressure created when the putty is

Step 3: The cannula from the cartridge tip can be pressed against the surface of the bone, and the putty can then be injected into the area, resulting in membrane elevation with hydraulic pressure from the putty.

being delivered to the site safely lifts the Schneiderian membrane. Case image courtesy of Dr. Philip M. Walton

Step 4: An implant may then be placed in the augmented area.

1. Kotsakis GA, Mazor Z. A Simpliﬁed Approach to the Minimally Invasive Antral Membrane Elevation Technique Utilizing a Viscoelastic Medium for Hydraulic Sinus Floor Elevation. Oral Maxillofac Surg. 2015 Mar;19(1):97-101. 2. Mazor Z, Ioannou A, Venkataraman N, Kotsakis G, Kher U. Minimally Invasive Crestal Approach Technique for Sinus Elevation Utilizing a Cartridge Delivery System. Impl Implant Practice. 2013;6(4):20-24. 3. Mazor Z, Ioannou A, Venkataraman N, Kotsak Kotsakis G. A Minimally Invasive Sinus Augmentation Technique using a Novel Bone Graft Delivery System. Int J Oral Implantol Clin Res 2013;4(2):78-82.

1.888.796.1923 or go to osteogenics.com/NovaBone

To order, call

PRODUCT DEBUT

Elevate your overdenture treatment protocol with ENCOMPASS™ Zest streamlines overdenture procedures and creates cost-saving opportunities

est Dental Solutions® — the only manufacturer of the Zest LOCATOR® Family of Abutment Systems, including the Zest LOCATOR Implant System, and provider of clinician-trusted dental materials and small equipment — has made it easier than ever to deliver a world-class overdenture treatment experience to patients with ENCOMPASS™ — an all-inclusive, digitally powered overdenture treatment solution — through a partnership with Absolute Dental Services. Driven by precision and efficiency, ENCOMPASS can reduce patients visits by 50% while providing them with customized, high-quality overdentures. This reduction in chair time can mean savings for the clinician, patient, or both, as well as the opportunity for practice growth. Each ENCOMPASS bundle box comes pre-stocked with an Absolute NavaGation™ Pilot Guide and treatment plan; two, four, or six all-in-one Zest LOCATOR Implants and Abutments with processing pack; a premium Absolute Forever Denture™; CHAIRSIDE Attachment Processing Material; Denture Removal Tool; CHAIRSIDE Rubber Finishing and Tapered Carbide Burs; Fixation; and a Denture ID microchip. The end result is a comprehensive solution focused on precision and efficiency that is unlike anything else in the industry. “ENCOMPASS is a game-changer,” said Tom Stratton, Zest Dental Solutions CEO. “Zest is focused on exceptional products that deliver proven and predictable results. We’ve really captured that approach with ENCOMPASS and housed it all in a single box. Clinicians now have everything at their fingertips to confidently treat overdenture patients, and they can do it faster and with greater precision, cutting visits in half. These time and cost savings can be passed along to patients and used to drive practice growth.” Cloud-based, digital workflow delivers enhanced case planning and efficiency for the clinician, streamlining the entire process to help reduce patient visits by as much as 50%, thereby freeing up valuable chair time and creating an overall better patient experience. The ENCOMPASS Pilot Surgical Guide further adds to this precision and consistency, allowing the clinician to maintain the correct depth and placement for optimum overdenture support and patient comfort. Each ENCOMPASS box also includes a Lucitone™ 3D Carbon Printed, Absolute Forever Denture. This 3D, custom-printed overdenture is 3 times stronger than the minimum ISO strength standard for a denture. Created on a Carbon® M2 printer, each Implant Practice US

ENCOMPASS™ — an all-inclusive, digitally powered overdenture treatment solution

overdenture is the perfect combination of precision, strength, and esthetics. The ability to customize the tissue portion with five different shades adds to the realistic outcome and patient satisfaction. Zest is excited to be partnering with Absolute Dental Services, which was the 2019 NADL Lab of the Year and has been in business for 26 years with four U.S. locations. “Absolute Dental Services is excited to be partnering with Zest,” said Conrad Rensburg, Absolute Dental Services owner. “Our commitment to dental lab precision, consistency, and efficiency meshes perfectly with Zest and its commitment to excellence and leadership in the overdenture space. This collaboration gave way to ENCOMPASS, an end-to-end laboratoryenabled overdenture solution that promises to deliver patients with best-in-class, customized Absolute overdenture.” The precision overdentures are then confidently held in place with two, four, or six genuine LOCATOR abutments and implants. The progressive diameter design, self-tapping tip, and RBM-treated surface allow the clinician to place Zest implants with confidence in both standard and narrow ridges (available in 2.4 mm, 2.9 mm, 3.5 mm, 3.9 mm, 4.4 mm, and 4.9 mm). When paired with LOCATOR abutments, an unmatched clinical combination is born, one which is globally trusted and universally accepted. To learn more about how ENCOMPASS can help you exceed patient expectations and grow your practice, call 855-868-LODI (5634), or visit https://bit.ly/3gAk5uB. IP This information was provided by Zest Dental Solutions®.

Volume 15 Number 2

Dream it. Design it. Deliver it.

Take the Overhead Out of Overdentures Expand your clinical and financial reach by providing boutique-quality overdentures to the sizable segment of underserved edentulous patients at a financially accessible fee. ENCOMPASS™ is the inclusive way to simplify and streamline overdenture treatment which saves chairtime and reduces the number of appointments from 4-6 to 2-3. Digitally driven, this all-encompassing approach includes a Premium 3D printed denture, LOCATOR® implants and LOCATOR® abutments, pilot surgical guide, processing materials and a digitally planned surgical blueprint to give you the confidence to deliver high quality results. For beginners to experts, embrace the future of dentistry with ENCOMPASS—the all-encompassing overdenture solution.

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