Implant Practice US December 2016 January 2017 Vol 9, No 6 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews December 2016/January 2017 – Vol 9 No 6

Atraumatic extraction of mandibular third molars

Drs. Brenda Baker and David Reaney

Professor Loris Prosper and Nicolas Zunica

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What happens when your real teeth give up? Dr. Justin Moody

Practice profile Dr. Olajumoke Adedoyin

Practice profile Dr. Bryan Laskin To learn more, please visit our website at www.zestdent.com/FTx or call 800.262.2310.

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INTRODUCTION

Leading the way for excellence in implantology

hings have changed a lot since I was in surgical residency. Back then, implantology was in its relative adolescence. We took a panoramic radiograph, did a thorough clinical exam, flapped open the ridge, and placed the fixture where it seemed to belong. If we wanted to be fancy, the restorative dentist would wax-up a surgical guide, which we might use or not — a modest attempt to find where the implant should be placed based on the desired prosthetic result. But, for the most part, the restorative phase was a surgical afterthought. Now, 3D technologies, including cone beam computerized tomography, CAD/CAM scanning and milling, and 3D printing, have revolutionized not only the workflow of implantology but also our approach Dr. Jay B. Reznick to treatment planning. The concept of restoratively driven treatment planning is increasingly becoming a topic of discussion at dental meetings and in the literature. This means starting with the final restorative outcome in mind and working backward from there to develop treatment plan options that make the ideal result possible. If bone and/or soft tissue are deficient, then planning includes procedures to optimize the ridge, so that implants can be placed in the ideal sites and positions for the final prosthesis to be successful both functionally and esthetically. The position, angulation, and depth of each osteotomy and fixture placement is precisely controlled using milled or stereolithographically printed surgical guides and specifically designed guided surgery drills and instruments. As a result, complex dental implant treatment is becoming more predictable and common. Efficiency is improved, surgical times shortened, and implant position is less vulnerable to the inaccuracies that can result from freehand placement. For the less-experienced clinician, the anxiety associated with implant surgery is also significantly reduced. The technological advances that have changed the accuracy and efficiency of complex implant procedures has had an unprecedented side effect. Whereas traditionally, only surgical specialists placed implants, and restorative specialists provided the prosthetic component, now a growing core of general dentists have begun to place dental implants. Clinicians cannot argue that economic pressures have been a component of this shift, but when general dentists are questioned, another motivation becomes apparent. And this is one that many surgical specialists fail to admit or even acknowledge. Restorative dentists have become frustrated with having to attempt to restore implants that were placed in positions and at angles that make the prosthetic design difficult, if not impossible. And so, clinicians are increasingly deciding to avail themselves of the latest technology, performing their own implant surgeries in an attempt to facilitate predictable restorative outcomes. Surgeons are trained to understand that performing surgery on another human being is a privilege that carries great responsibility. Many implant-training courses geared toward general practitioners are taught by clinicians who lack formal surgical training, so this philosophy is often neglected in deference to presenting implant surgery as something that anyone can do. This approach has generated angst among surgical specialists, who believe that 3D technology is merely a “crutch” for undertrained practitioners to place implants. As a highly trained and experienced surgical specialist who utilizes these technologies extensively in practice, I see things a little differently. CAD/CAM, CBCT, and 3D printing raise the bar for all of us. These incredible tools allow us to imagine and execute complicated implant treatment plans with accuracy and predictability that we previously could not consistently achieve. This also gives us a tremendous opportunity. There are plenty of patients for both surgical specialists and general dentists to treat. It is my belief that as highly trained and experienced specialists, it is our obligation and responsibility to assume the role of teaching implantology to general practitioners following the philosophy instilled in us in our training programs. First, start with the basics, and then build slowly from there. Next, only treat cases where you are 110% confident in the outcome. Work closely with your surgical specialists. Above all, always, always do what is best for your patient. We can no longer stick our heads in the sand and hope that things will get better. We are the leaders in implantology. Let’s act that way.

Jay B. Reznick, DMD, MD, is a Diplomate of the American Board of Oral and Maxillofacial Surgery and practices in Tarzana, California.

2 Implant practice

December 2016/January 2017 - Volume 9 Number 6

EDITORIAL ADVISORS Steve Barter, BDS, MSurgDent RCS Anthony Bendkowsk,i BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent Philip Bennett, BDS, LDS RCS, FICOI Stephen Byfield, BDS, MFGDP, FICD Sanjay Chopra, BDS Andrew Dawood, BDS, MSc, MRD RCS Professor Nikolaos Donos, DDS, MS, PhD Abid Faqir, BDS, MFDS RCS, MSc (MedSci) Koray Feran, BDS, MSC, LDS RCS, FDS RCS Philip Freiburger, BDS, MFGDP (UK) Jeffrey Ganeles, DMD, FACD Mark Hamburger, BDS, BChD Mark Haswell, BDS, MSc Gareth Jenkins, BDS, FDS RCS, MScD Stephen Jones, BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack, DDS, CertPerio, FCDS Samuel Lee, DDS David Little, DDS Andrew Moore, BDS, Dip Imp Dent RCS Ara Nazarian, DDS Ken Nicholson, BDS, MSc Michael R. Norton, BDS, FDS RCS(ed) Rob Oretti, BDS, MGDS RCS Christopher Orr, BDS, BSc Fazeela Khan-Osborne, BDS, LDS RCS, BSc, MSc Jay B. Reznick, DMD, MD Nigel Saynor, BDS Malcolm Schaller, BDS Ashok Sethi, BDS, DGDP, MGDS RCS, DUI Harry Shiers, BDS, MSc, MGDS, MFDS Harris Sidelsky, BDS, LDS RCS, MSc Paul Tipton, BDS, MSc, DGDP(UK) Clive Waterman, BDS, MDc, DGDP (UK) Peter Young, BDS, PhD Brian T. Young, DDS, MS

CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day, BDS, VT Julian English, BA (Hons), editorial director FMC Dr. Paul Langmaid, CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul, BDS, LDS, FFGDP (UK), FICD, editor-inchief Private Dentistry Dr. Chris Potts, BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers, BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

© FMC 2016. All rights reserved. FMC is part of the specialist publishing group Springer Science+ Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproducedvw in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Implant Practice or the publisher.

Volume 9 Number 6

TABLE OF CONTENTS

Financial focus

Practice profile Bryan Laskin, DDS

Are high 401(k) fees putting your retirement at risk? Tom Zgainer discusses how hidden fees can drain money from your account........................................... 20

Case report

Elevating the patient experience

Immediate loading dental implants for todayâ&#x20AC;&#x2122;s patient Dr. Ara Nazarian illustrates a comprehensive implant treatment plan .......................................................22

Case study Immediate placement of a large diameter implant in a maxillary first-molar site: a case study Dr. Charles D. Schlesinger discusses reduced healing time after extraction and immediate placement............... 26

Practice profile

Olajumoke Adedoyin, DDS, MICOI, MAAIP

ON THE COVER

Keeping implants within reach

Cover photo courtesy of Dr. Justin Moody. Article begins on page 48.

4 Implant practice

Volume 9 Number 6

NEITHER IS THE ANATOMY OF YOUR IMPLANT PATIENTS Your world is already full of clinical challenges so why work harder because of conventional thinking? Instead of augmenting sloped ridges to accommodate flat-top implants, it’s time to discover a simpler solution by using an implant that follows the bone. Because sloped-ridge situations call for anatomically designed sloped implants.

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It’s time to challenge conventional thinking

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TABLE OF CONTENTS

Continuing education Implant-supported overdentures Drs. Brenda Baker and David Reaney discuss the factors to consider during overdenture treatment planning

Continuing education

Atraumatic extraction of mandibular third molars

Professor Loris Prosper and Nicolas Zunica discuss a case report preventing iatrogenic damage to the inferior alveolar and lingual nerves during third mandibular molar extraction

.................................................36

Educator insight Everything you wanted to know about an implant study club but were afraid to ask

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com

Dr. John C. Minichetti discusses the

GENERAL MANAGER | Alan Lobock Email: alobock@medmarkaz.com

many benefits of study clubs.........40

MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com | Tel: (727) 515-5118

Practice development Industry news.............45 Online case collaboration provides key information

Dr. Bryan Laskin discusses how to eliminate frustration in communicating with referring clinicians..................42

What you need to know about online reviews for your practice Ian McNickle, MBA, discusses the importance of a strong online presence.....................................44

Materials & equipment......................46 On the horizon What happens when your real teeth give up? Dr. Justin Moody discusses solutions for a difficult diagnosis..................48

ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez Email: celeste@medmarkaz.com MANAGER â&#x20AC;&#x201C; CLIENT SERVICES | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkaz.com WEBSITE MANAGER | Anne Watson-Barber Email: anne@medmarkaz.com E-MEDIA PROJECT COORDINATOR | Michelle Kang Email: michellekang@medmarkaz.com FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.implantpracticeus.com | www.medmarkaz.com SUBSCRIPTION RATES 1 year (6 issues) $149 | 3 years (18 issues) $399

6 Implant practice

Volume 9 Number 6

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PRACTICE PROFILE

Bryan Laskin, DDS Elevating the patient experience What can you tell us about your background? I graduated from the University of Wisconsin-Madison and the University of Minnesota School of Dentistry. In 2001, I opened my own practice, Lake Minnetonka Dental, wanting to provide the highest quality dentistry available using the latest technology. Because of this passion for technology, I’ve worked as a basic, advanced, and in-office Patterson-certified CEREC trainer and co-founded the Minnesota CEREC Study Club. My passion for elevating the patient experience and quality of care in my practice led me to recognize voids in the tools we use in dentistry, so I was inspired to develop a software company that provides tools to improve my patients’ lives. I’m an active member of the American Dental Association, Minnesota Dental Association, Minneapolis District Dental Society, and several continuing education organizations.

Is your practice limited to implants? No. Alongside my six associates, I provide full-service care from restorative needs to RCT to implants. We have a keen focus on creating quality care, while listening to patients’ desires. When we feel a case is too involved or complicated, we have strong relationships with nearby specialists and have developed elegant communication systems to coordinate the care for our mutual patients.

Why did you decide to focus on implantology? Implantology has come such a long way due to technology. With guided implant surgery, it’s become so much less risky to place implants in the office. I decided to focus on implantology when I saw a few misplaced implants from very experienced surgeons whom I work with; they were not involved in guided surgery. I then purchased a Sirona ORTHOPHOS XG 3D/Galileos CBCT scanner and asked a friend of mine, who had a lot of implant placement experience, if he would want to come into my office and start placing guided implants. Restoring implants also makes it much more fun to practice dentistry. 8 Implant practice

Dr. Bryan Laskin

How long have you been practicing, and what systems do you use? I don’t personally place the implants, but I am very involved in the planning. We place Nobel Biocare® and Keystone Dental implants in our practice, but I have restored virtually all the systems, as many specialists I work with work with other systems. Implant restoration is progressing so quickly that it Volume 9 Number 6

What training have you undertaken? Being a Sirona and Patterson trainer and former CEREC beta tester, I was involved early on in CBCT imaging and guided surgical guide fabrication. This advancement allows me, as the restorative dentist, to maintain more control of the final prosthetic outcome. I have learned from many talented surgeons and periodontists whom I work with, but most of my training comes from Sirona and Patterson courses

centered around CAD/CAM and CBCT imaging technology.

Who has inspired you? Personally, I am inspired by inventors and people who think progressively. Outside of dentistry, I would say Albert Einstein, Richard Branson, Elon Musk, and Bruce Lee are inspirations. Within dentistry, I would say Dr. Paul Homoly has influenced me the most. I have learned a ton about educating others, treatment planning, presentation, and the patient perspective from Dr. Homoly. He was also the inspiration for me to start restoring fully edentulous arches with implants.

What is the most satisfying aspect of your practice? I think there are two separate but equal

parts of satisfaction with this profession. The first part is getting to use technology and emerging techniques to see an immediate and elevated quality of clinical work. The second is the how much happier the patients are when their dental experience is smooth and easy. When you can get both of those happening in one case, itâ&#x20AC;&#x2122;s a home run.

Professionally, what are you most proud of? I created a software application, Opera DDSâ&#x201E;˘, for better communication within my office and with my patients. I wanted that seamless flow of communication to create a comfortable patient experience while using technology that made sense instead of old, archaic practices. With this software, you can communicate simply and securely with

CBCT imaging and guided surgical guide fabrication allows me, as the restorative dentist, to maintain more control of the final prosthetic outcome.

The Lake Minnetonka Dental Team Volume 9 Number 6

Implant practice 9

PRACTICE PROFILE

seems there is a great new feature every year to incorporate! I would love to place implants, but unfortunately there are only 365 days in a year, and my software company is growing so rapidly that it makes sense for me to delegate that wonderful practice to my associates.

PRACTICE PROFILE

Top 10 favorites 1. My wife, kids, and friends 2. Lake Minnetonka Dental’s amazing staff 3. OperaDDS™, DentalTNT (software development) 4. Coffee 5. “Star Wars”

Better communication = happier staff and elevated care

staff, patients, and colleagues. It’s HIPAAcompliant and easy to use. When other offices started inquiring about what I used and adopting the software in their own practices, I started marketing and selling the application. Now, OperaDDS is in more than 2,000 offices, and we hear testimonials about how much easier it makes dentistry. I love technology that makes it so everybody it touches wins. With OperaDDS, patients get better care, staff have less stress, the office can produce more, and it costs far less than any comparable systems you would have to cobble together to do similar tasks. So everyone wins. That’s something I’m really proud of.

What do you think is unique about your practice? Part of the OperaDDS software is PAGER, an office messaging system. It’s the 10 Implant practice

6. CEREC only paging system with custom checklist messaging. When I’m paged somewhere, I know exactly what I’m walking into in the order I want to know it. That way, I’m not wasting time discussing what was already said before I entered the room. Also, if we are in the middle of placing an implant, I can be notified by a buzz on my wrist from my Apple Watch® and assess if it’s an emergency, or if I can stay to finish the procedure.

What has been your biggest challenge? Balance. I love growing my practice and trying new things clinically. But I’m also a husband and father to two great kids. Add a software company to the mix, and it can get a little hectic. But I’m lucky to have the support of my family and my staff, all of whom try to keep my work/life balance intact — as much as I let them.

7. Sirona ORTHOPHOS XG 3D/ Galileos 8. Snowboarding 9. Restoring edentulous arches with implants 10. Guitars

What would you have become if you had not become a dentist? An animator. I love drawing and have always been fascinated by art in motion. It is also a good confluence of art and technology, which is what I love about dentistry.

What is the future of implants and dentistry? Technology and regulations aren’t going away. If you don’t evolve, you not only are going to get left behind, but also are going to be putting patients’ health at risk. I think Volume 9 Number 6

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PRACTICE PROFILE

Balancing family time and work

technology in the future in dentistry will work to deepen the doctor/patient connection instead of detracting as it does today. There has been research that the average doctors spend roughly 50% of their time looking at a screen today, instead of the patient. In my opinion, this has to change.

What are your top tips for maintaining a successful practice? Hiring staff with a focus on looking for leadership capacity and letting go of staff who do not keep up with your expectations. My staff will now tell me after 1 day if a new staff member will be a good fit. I expect a lot from everyone who works for me, and I’m prepared to give a lot to maintain quality staff. I’m a big believer in communicating what’s expected and rewarding. I have a great bonus system in my office that motivates my staff so much that somedays I’m convinced they’re trying to work me to death! 12 Implant practice

What advice would you give to budding implantologists? Learn from great mentors. There are not only great technologies out there, but there are a lot of great dentists who are willing to share their experiences and give you tips. Take courses from those who are interested in collaborating, not just going through slides and leaving you on your own. If you are coordinating care with others, use an online platform that allows a convenient place for everyone to place comments and images. This completely changes the game. No more phone calls, emails, or wondering what stage the patient is in.

What are your hobbies, and what do you do in your spare time? I make sure to have downtime from the office, so I can hang out with my wife, Tesa, and our two children. When I can, I love to participate in martial arts, snowboarding, and guitar. IP Volume 9 Number 6

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PRACTICE PROFILE

Olajumoke Adedoyin, DDS, MICOI, MAAIP Keeping implants within reach What can you tell us about your background? I was born and spent my childhood in Lagos, Nigeria. I have two older brothers who are both doctors, so I guess you could say the medical field runs in our family. I moved to Georgia, where I attended Clark Atlanta University and then Howard University College of Dentistry, where I graduated number one in my class in 2001. I started my career working briefly as an associate dentist and then transitioned into running my own successful private practice for several years. In 2009, I chose to affiliate with Affordable Dentures & Implants, and I opened the doors to my practice in Cartersville, Georgia, and have been there to this day. I am married to my husband, Charles; we have three boys, Jimi, 15; Femi, 11; and Seun, 7 — yes, I’m a soccer mom too!

When did you become a specialist, and why? I loved removable prosthetics in dental school. I didn’t have the same affinity for surgery yet, but somehow I discovered that it came easy for me. The more involved I got, the more my passion grew for this aspect of dentistry. Eventually, it became the focus of my practice and my true passion.

Is your practice limited solely to implants, or do you practice other types of dentistry? We focus on tooth replacement as a whole, which includes dentures, partials, extractions, and implants. We present a multitude of options, and our goal is to always deliver the best treatment for each patient. I perform mostly implant overdentures, full arches, and single tooth systems.

Why did you decide to focus on implant dentistry? I enjoy removable prosthodontics; I would say that my dental career has been somewhat skewed toward this area of practice. Therefore, owning my own practice with a focus on implant dentistry and tooth 14 Implant practice

Top: Dr. Adedoyin with patient. Bottom: Dr. Adedoyin in front of her practice Volume 9 Number 6

PRACTICE PROFILE

replacement services was a natural progression for me.

Do your patients come through referrals? Most of my implant patients do come from referrals. It’s primarily word-of-mouth from my patients, although we do advertise our implant services. The biggest compliment a clinician can receive, I believe, is a satisfied patient who tells a family member to go see you.

How long have you been practicing implant dentistry, and what systems do you use? I began taking implant training courses in 2004. I started off placing mini implants, but now I use BioHorizons®, as well as Implant Direct’s Legacy™ systems.

Dr. Adedoyin with her office manager, Christy Chubb

Dr. Adedoyin with dental assistant Kadian Dayes using the Carestream CS 8100 cone beam imaging system

I love to use the BioHorizons Laser-Lok® implant, particularly in the esthetic zone. I believe it provides a better attachment at the coronal portion of the implant and has provided a fantastic result for my patients.

What training you have undertaken? I attended a number of three-day MDI courses in the beginning. But the real turning point for me was attending a 10-day live implant training course taught by Dr. Virgil Mongalo with several fellow Affordable Dentures & Implants practice owners. I enjoy continuing to learn all that I can about implants — and never stopping. I am attending a complications course with Dr. Justin Moody in Denver soon, and I am really Volume 9 Number 6

looking forward to it. Following that, I plan to attend another live training course through Brighter Way Institute in Phoenix. I would still like to expand upon my sinus lift skills to increase the volume and variety of patients who seek treatment at my practice. I want to be able to help those patients to the best of my ability, and changing the lives of patients is the joy of my practice.

Who has inspired you? Personally, my father, hands down. He was a very meticulous person and always inspired me to do my best at whatever I did. I am also fortunate to have a wonderful husband who has always supported me to keep trying. I have never seen him accept defeat.

On a professional level, I can’t talk about inspirations without mentioning Dr. Rueben Warren. I met him during an externship at the Agency for Toxic Substances and Disease Registry (ATSDR) in Atlanta. He is an amazing dentist who mentored me throughout dental school and was a great support system. Dr. Justin Moody has been a phenomenal mentor. He really takes the time to pour his wealth of knowledge into me. He’s never too busy to take my call and out of the blue will send me a note of encouragement when I need it most. Dr. Charles Sanders, who served as dean of the dental school at Howard, would push me to no end and never let me slack. At the time, I thought that he was just mean, but now I see it — he pushed me because he saw something special in me. Today, when I reflect back on those moments, I am grateful. He gave me the work ethic to never back down.

What is the most satisfying aspect of your practice? For me, it’s definitely that point when we achieved the result that patients could only dream about. When the case is complete, and we hand them the mirror, more times than I can count, there are tears of joy. I’m emotionally invested in my patients. It’s one of the best feelings when you make someone’s day.

Professionally, what are you most proud of?

Professionally, I proudly serve on Dr. Moody’s faculty for lectures and live training. Implant practice 15

PRACTICE PROFILE I also have earned masterships in both the International Congress of Oral Implantologists and the American Academy of Implant Prosthodontics. I am big on continuing education, so I was proud to earn fellowships and then masterships in both those organizations. Implantology is really a passion of mine. Because I affiliated with Affordable Dentures & Implants, I am able to provide these kinds of services to my patients at fees within their reach. It’s truly life changing for them, and I’m really proud of that.

What do you think is unique about your practice? This is an easy question for me — it’s my practice team! We work together seamlessly, so I can be my best all the time. I also have a superb on-site lab and we work extremely well together. We minimize downtime as much as possible, and I think our patients appreciate that.

What has been your biggest challenge? When working with edentulous patients frequently, setting realistic expectations can be difficult. We try to help our patients understand in plain terms the aging process and how the mandible can experience a significant amount of bone resorption. We want our patients to be happy with their decision, so my team strives to be empathetic while providing a consistent educational message.

Top 10 favorites 1. 2. 3. 4. 5. 6. 7. 8.

Top image: Dr. Adedoyin with lab technician Linny Guerrieri. Bottom image: Dr. Adedoyin with her staff — Chrmisse Wood, Christy Chubb, Kadian Dayes, Jessica Johnson, and Latoya Frederick 16 Implant practice

10.

God My husband and children Placing implants Going to watch my kids play soccer Going to the gym BioHorizons® Tapered Internal implants Traveling Carestream CS 8100 — it has changed the way I place implants. I plan everything before the patient is in the chair. It makes such a big difference when you know what you’re getting into. I feel more accurate, so I’m more confident. Delivering my zirconia fixed cases. When you have an excellent lab, the stress of delivery on these cases is almost nonexistent. I enjoy the moments when the patients are just truly happy (I use Adar Lab here in Atlanta). Fashion Volume 9 Number 6

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PRACTICE PROFILE Patients today do their homework when it comes to tooth replacement, so the challenge is not as big as it was 3 years ago.

What would you have been if you didn’t become a dentist? Oh boy! My dad wanted me to be an accountant, so maybe an accountant? I can’t imagine being anything other than a dentist! But I do enjoy and have an eye for great fashion, so maybe something along that line. Scrub fashion couture is a real thing!

What is the future of implants and dentistry? I can’t even begin to imagine what the future of implants might look like. There are more than 180 million Americans suffering from tooth loss, and we are still only placing implants in a tiny percentage of that “edentulous real estate.” These used to be services that only the rich could afford. My fee structure is designed for the future, so everyone can afford treatment now. I have noticed that

patients across the socioeconomic spectrum are more aware and educated about implants than they used to be — they often come in specifically wanting implants now.

What are your top tips for maintaining a successful specialty practice? Listening to your patients is number one. Second to that would be training your staff to possess a wide knowledge base. Providing a consistent message is key. From the moment a patient calls to the last person they encounter, my staff is prepared. We also try to keep things fun. You spend at least 8 hours a day with your staff, so you have to cultivate camaraderie. We try and have a team building activity every quarter. Last time we went to Project Escape and had a blast!

After attending an implant course, don’t wait 5 weeks to schedule your next implant patient — jump right in. Use it, or lose it. One thing that has always stuck with me is to align yourself with the best people, to never be an island. Surround yourself with doctors who are only a phone call away and whom you also feel comfortable calling before surgery to say, “This is what I’m stuck on,” and bounce ideas off each other.

What are your hobbies, and what do you do in your spare time? Having three boys, it’s probably no surprise that I love taking naps. But we go to a lot of soccer games on the weekends. I also love to shop and travel. We just got back from Jamaica and the Bahamas. Another one of my passions is working out. I go at least 4 days a week during my lunch. IP

What advice would you give to budding implant dentists? Don’t be scared. Even the biggest and most experienced implant dentists make mistakes.

Dr. Adedoyin with her family 18 Implant practice

Volume 9 Number 6

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FINANCIAL FOCUS

Are high 401(k) fees putting your retirement at risk? Tom Zgainer discusses how hidden fees can drain money from your account

f you contribute to a 401(k) plan, you’re one of more than 88 million Americans who invest in workplace retirement savings programs — many of whom will rely on the savings from those plans to support them financially in retirement.

In 2015, the Obama administration announced that hidden fees in retirement plans were costing Americans $17 billion per year. HBO’s John Oliver sounded the alarm in a great segment on “Last Week Tonight.”

So what? According to research from the nonprofit National Association of Retirement Plan Participants, approximately 60% of people don’t know they’re paying any fees at all in their 401(k) plan. But they’re wrong! We all pay fees, and over time, those fees can eat away at investments, leaving plan participants with far less money to live on in retirement than if there really were no fees involved. Low-cost index funds like Vanguard charge between 0.10% and 0.20% in fees. Vanguard’s fees are 0.13% on average, according to their website. That works out to $13 for every $10,000 you invest. But the dominant providers in the retirement plan space, including many brandname insurance and payroll companies, often charge 7 to 10 times as much for the same or comparable investments. The difference goes into their pockets — and they get away with it because most of us never bother to do this math. Compounded over many years of investing, a fee that looks small — for example, 2% of investments — can reduce your total potential nest egg by as much as two-thirds. If two people have the same 7% return over time but one pays 1% in fees while the other pays 2%, the latter will run out of money 10 years earlier.

Tom Zgainer is CEO and founder of America’s Best 401(k) and has helped thousands of companies repair or rescue their retirement plans over the past 15 years. You can learn more at http://americasbest401k.com/feechecker-medmark.

20 Implant practice

Last year, the Obama administration announced that hidden fees and backdoor payments were costing Americans $17 billion per year. And that’s not counting the excessive “out-in-the-open” fees that are draining our retirement accounts. “The corrosive power of fine print and buried fees can eat away like a chronic illness at a person’s savings,” said U.S. Secretary of Labor Thomas E. Perez.

Why are the fees so high? Many retirement plans are plagued with huge commissions, very high expense ratios, and a laundry list of other — often hidden — layers of fees. They might be labeled “assetmanagement charges” or “contract asset charges.” They often add up to 1% or more and are buried in the fine print of plan disclosures. On top of that, the majority of retirement plan providers accept payments from the mutual funds offered in the plans they sell to businesses. This is called “revenue sharing” (or, more aptly, paying to play). As a result, the investments you have to choose from in your 401(k) plan are usually the funds that pay the provider the most — these are rarely the best-performing options out there, and they are almost never the lowest in cost. For example, in a recent 401(k) plan I reviewed, one of the leading payroll companies in the United States receives 0.40% annually in revenue sharing from the company whose mutual funds are included in the plan they offer. This means the payroll company makes 135% more than the actual 0.17% cost of the fund — thanks to its revenue-sharing agreement. Finally, retirement plan providers often restrict low-cost funds to plans that exceed a certain dollar amount of assets. Since the providers don’t make much of a profit on these lower-cost funds, they mark them up.

One major insurance company is offering an S&P 500 index fund for more than 1% annually, when the actual cost is .05%. That’s a 2,000% markup. And because of the aforementioned minimum asset requirements, employees of smaller companies are often forced to invest in funds with higher fees.

What can I do about it? Often a 401(k) provider is chosen as a matter of convenience — integration with a payroll provider’s offering, for example. More often it is through an introduction, via a colleague or friend who “knows a guy.” Not enough due diligence may have been completed to see the long-term ramifications of the choice or providers, or even related to their expertise. Even though employers have good intentions, they are deeply focused on running their businesses. And they are probably not experts in investing for retirement or in the 401(k) industry. So it’s up to you, the employer who sponsors the 401(k) plan, to educate yourself on how your plan works and where your money is going. Look closely at your paperwork. Compare the expense ratios and other fees in your plan documents to those charged for similar investments from other providers. This is tedious, but important. If you’re concerned about the fees you’re paying, start by completing a thorough benchmark of your plans’ fees to alternatives. You have a legal responsibility to make sure that your 401(k) plan puts your participants’ best interests FIRST, and this benchmark will help you clearly see if a near-term change might be in the best interests of all those participating in your plan. Take action — your financial future, and those of your employees and their families, may depend on it. IP

Take control; start here: http://americasbest401k.com/fee-checker-medmark. Volume 9 Number 6

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CASE REPORT

Immediate loading dental implants for today’s patient Dr. Ara Nazarian illustrates a comprehensive implant treatment plan

hen patients present to your dental practice with non-restorable teeth requiring full mouth extractions, the biggest concern is whether or not implants can be placed at the same surgical visit and, if so, will patients be able to walk out with fixed teeth? Having an implant within your practice that allows you to load or progressively load, so that these patients’ demands are met, allows you to position your practice to a whole new level. Of course, certain parameters must be met in order to facilitate this type of treatment. This includes, but is not limited to, the quality and quantity of bone, the presence of infection, the patient’s health, and the skills of the dental provider. Additionally, the selection of the most appropriate materials for the most ideal situation must be met.

A patient presented to my practice for a consultation wanting to restore his smile (Figure 1). He complained of generalized discomfort in his entire dentition probably due to the caries and periodontal disease that was already present (Figures 2-3). Having already visited multiple providers for an evaluation, he was very frustrated with conflicting treatment options offered. Either the suggested treatment would require multiple surgical and restorative visits that would extend for a very long time, or dental treatment would require a team approach where little coordination by dentist and specialist was communicated to the patient. Since many of these options

did not appeal to him, the patient decided to have me provide comprehensive treatment that would include extractions, bone leveling, grafting, dental implant placement, immediate provisionalization, and prosthetic rehabilitation within my own practice. When presenting cases like this to my patients, I will always use the Dine Digital Solution camera (Lester A. Dine, Inc.). This camera not only is small, light, and waterproof, but also is very effective and clear in taking close-up photos as well as full-face shots. Additionally, I will always offer my patients a third-party payment option like the Lending Club (San Francisco, California) for

Figure 2: Preoperative smile

Figure 1: Preoperative full-face view Ara Nazarian, DDS, DICOI, maintains a private practice in Troy, Michigan, with an emphasis on comprehensive and restorative care. He is a Diplomate in the International Congress of Oral Implantologists (ICOI). His articles have been published in many of today’s popular dental publications. Dr. Nazarian is the director of the Reconstructive Dentistry Institute. He has conducted lectures and hands-on workshops on esthetic materials and dental implants throughout the United States, Europe, New Zealand, and Australia. He can be reached at 248-457-0500 or online at www.aranazariandds.com.

Figure 3: Preoperative retracted view 22 Implant practice

Volume 9 Number 6

Planning A CBCT scan using the CS 8100 3D (Carestream Dental) was taken to accurately treatment plan this case to make certain that no complications would arise from doing all the procedures (extract, graft, and implant placement) within one visit. Since his entire dentition had caries as well as periodontal disease, his treatment would require extracting all his remaining teeth. To further develop a treatment plan, diagnostic models were forwarded to the dental lab and mounted on the articulator for further analysis in order to meet the patient’s esthetic and functional needs. Additionally, a 3D virtual treatment plan was created with the assistance of 3DDX (Figure 4). The patient desired having fixed restorations supported by dental implants in both maxillary and mandibular arches. All risks, benefits, and alternatives of various treatment options were reviewed with the patient, including dentures, overdentures, and fixed restorations. His treatment plan of choice would consist of fixed hybrid restorations

Figure 4: Virtual treatment plan

Figure 6: Edentulous ridge Volume 9 Number 6

supported by tilted implants in the upper arch to avoid the sinus cavities and axially placed implants in the lower arch. The implants utilized in this case were OCO Biomedical Engage™ dental implants. These implants are known for their unchallenged high implant stability at placement, which is a critical success factor in these immediate load cases. With the combination of their patented Bull Nose Auger™ tip and mini Cortic-O Thread™, the Engage™ implant system offers practitioners a bone level implant with high initial stability for selective loading options. The Engage™ implant is self-tapping for an enhanced mechanical lock in the bone. The Bull Nose Auger™ tip will not proceed any deeper than the initial pilot drill preparation locking into the base of the osteotomy. Engage™ implants have a proprietary surface treatment designed to increase the surface area of the implant for optimal bone in-growth and stability. Other dental implant systems in the market with high initial stability may include but are not limited to Hahn (Glidewell Direct), Nobel-Active (Nobel Biocare®), Seven (MIS®), I5 (AB™ Dental USA), Conus 12 (Blue Sky Bio), and AnyRidge® (Megagen). When performing this many procedures in one visit, I will utilize IV sedation to make the procedure more efficient and

comfortable for the patient as well as for myself. Since the patient is sedated, a mouth prop, Logibloc® (Common Sense Dental Products), is used to keep the mouth open. Logibloc’s unique design stabilizes and comfortably supports the jaw while allowing unrestricted visual and physical access to the working area for the provider. Once the patient was completely sedated and anesthetized, the teeth were extracted in a systematic manner working in sections at a time starting from the anterior maxillary teeth. Acting like a modified Class I lever, the Physics Forceps® (Golden Dental Solutions) were used to atraumatically extract the teeth with the goal of trying not to disturb the underlying bone. The beak of the forceps was placed on the lingual cervical portion of each tooth, where the soft bumper portion was placed on the buccal alveolar ridge at the approximate location of the muco-gingival junction. During the extraction process, the beak grasps the tooth, and the bumper acts as the fulcrum. Extractions were accomplished with only slight wrist action in a buccal direction taking about 40-60 seconds each, depending on the tooth morphology and density of bone (Figure 5). Once the teeth were extracted, the tissue was reflected (Figure 6) in order to get the surgical guides seated and fixed with their respectful retention pins. Using these universal surgical guides (Figure 7) provided by 3D Diagnostix, the sites for the implants were begun with a designated 1.8 mm pilot drill from the OCO Biomedical Guided Kit utilizing the Mont Blanc surgical handpiece and Aseptico surgical motor at a speed of 1,200 rpm with copious amounts of sterile saline. Sequential osteotomy formers from the OCO

Figure 5: Atraumatic extractions

Figure 7: 3DDX Universal Guide Implant practice 23

CASE REPORT

their treatment. Lending Club Patient Solutions provides patients great funding flexibility with very low rates and high approvals. Most of all, the support from their staff has been very professional.

CASE REPORT Biomedical Guided Kit were then used to shape the final osteotomies (Figure 8). Once the osteotomies were complete, an implant driver was used to place the dental implants until increased torque was necessary (Figure 9). The ratchet wrench was then connected to the adapter and the implants torqued to final depths reaching a torque level of about 40-50 Ncm. In the upper arch, four 4.0 mm x 14 mm Engage (OCO Biomedical) dental implants

Figure 8: OCO Biomedical Guided Kit

were placed in the areas of teeth Nos. 4, 7, 10, and 13 (Figure 10) to support an All-on-4ÂŽ restoration. The most distal implants were angled in order to avoid the maxillary sinus cavities and any augmentation in that area. In the lower arch, several different widths and lengths of the Engage (OCO Biomedical) dental implants were placed axially in the remaining ridge. A baseline ISQ reading was taken of these implants utilizing the Osstell ISQ unit.

Since the initial readings were all above 65, and the quality of bone after leveling was good, the multiunit abutments (OCO Biomedical) were tightened into the Engage (OCO Biomedical) dental implants for immediate provisionalization (Figure 11). Any residual areas around the implants or in the sockets were grafted with a cortical mineralized and demineralized bone grafting material (OCO Biomedical) to optimize the area for regeneration (Figure 12). Primary

Figure 9: Placement of Engage dental implants

Figure 10: Implants in All-on-4 configuration

Figure 11: Multiunit abutment

Figure 12: Placement of grafting material

Figure 13: Identification of implant positions

24 Implant practice

Volume 9 Number 6

CASE REPORT

Figure 14: Block out of temporary abutments

Figure 15: Pickup of provisional restoration

Figure 16: Provisional trimmed and polished

Figure 18: Postoperative full-face view

Figure 17: Maxillary and mandibular provisionals

Conclusion closure was achieved by suturing the tissue with resorbable sutures. Using Blu-Mousse® (Parkell) bite registration material, the positions of the dental implants was transferred to the record base of the immediate denture (Figure 13) and relieved with a No. 8 round bur (Komet). The immediate provisional restoration was tried in to ensure a passive fit over the temporary abutments. Once confirmed, rubber dam material was placed to avoid the restoration from locking on (Figure 14) and chairside hard reline material (Rebase II, Tokuyama®) placed within recesses around the temporary abutments to pick up the restoration. After the material completely set, the immediate provisional restoration was removed (Figure 15), and any access material trimmed and polished (Figure 16) with the Torque Plus (Aseptico) lab handpiece and acrylic bur (Komet). A similar series of steps was utilized for the mandibular arch and then the bite articulated. Volume 9 Number 6

Once the patient awakened from the procedure, a panorex was taken with the CS 8100 3D (Carestream Dental) to confirm the placement and position of the dental implants with their corresponding multiunit abutments and temporary cylinders. The patient could not believe that we were able to extract, level, graft, and place dental implants with corresponding fixed provisional restorations within his surgical appointment (Figure 17). The patient returned 7 days postoperatively with very little discomfort, swelling, or bruising. He was very pleased with his fixed provisional restorations (Figure 18). Now that the patient was no longer anesthetized, the occlusion was checked again to confirm there were no interferences in lateral and protrusive movements. The next step in his treatment would consist of impressions for the definitive upper and lower restorations approximately 4-5 months postoperatively.

Having the ability to take a patient from start to finish in a fewer amount of appointments within your practice allows you to position yourself as a provider that can fulfill your patient’s surgical and restorative needs. With the proper training and appropriate materials, a dental provider may provide extraction, grafting, and implant placement within one appointment at one location. Not only does this type of service allow you to reduce the amount of visits for the patient, but also helps maintain the cost to the patient since he/she is not seeing multiple dental providers. Most importantly, this enables the dental provider full control of the surgical and prosthetic outcome. Depending on the patient’s desires, the clinical conditions of the oral environment present, and the skills of the provider, a dentist may choose to extract teeth, level bone, and graft with guided dental implant placement within his/her dental practice. IP Implant practice 25

CASE STUDY

Immediate placement of a large diameter implant in a maxillary first-molar site: a case study Dr. Charles D. Schlesinger discusses reduced healing time after extraction and immediate placement Introduction In todayâ&#x20AC;&#x2122;s competitive dental market, patients are always looking for a differentiating factor when choosing a dentist. Today, implants are the fastest growing procedure category of the general practitionerâ&#x20AC;&#x2122;s practice.1 You cannot walk down a street in America or look online without seeing an advertisement for dental implants. So, with all this competition, what is a practitioner to do? The key, in my opinion, is patient satisfaction. To me, that means providing sound treatment that will last a lifetime and doing it in an expedient manner. With modern implant protocols, the healing time has been shortened dramatically,2 but when faced with a patient that presents with a tooth that must be extracted first, the clinician must decide which treatment path to follow. Do you extract, wait 3-4 months for bone regeneration, and then place the implant; or do you extract the tooth and immediately place the dental implant? In this article, I will not go into the protocols that revolve around immediate loading. I am just speaking of extraction and immediate placement where we can save the patient

3 to 4 months of healing time, thereby cutting treatment time by half.

Clinical case A 63 year-old-male patient presented to the office with a non-restorable tooth No. 3. The tooth exhibited buccal recession with concomitant abfraction lesions and recurrent decay (Figure 1). Radiographs showed furcal involvement (Figure 2). The patientâ&#x20AC;&#x2122;s medical

history was non-contributory, and the decision to extract the tooth and place a dental implant was decided upon after all options were discussed with the patient. A CBCT study was done and revealed that there would be sufficient bone between the three roots to immediately place a dental implant at the time of extraction (Figure 3). Using interradicular bone to stabilize an implant is well documented3 and will allow the implant to

Figure 1: Intraoral presentation

Figure 2: Pre-op PA Charles Schlesinger, DDS, FICOI, is the founder and CEO of The C.D. Schlesinger Group, a dental implant consulting company. For the past 10 years, he has been an internationally renowned implant educator, teaching implantology based upon his years in private practice and his work as an implant company executive.

Figure 3: Pre-op CBCT 26 Implant practice

Volume 9 Number 6

CASE STUDY

Figure 4: Preservation of inter-radicular bone

Figure 5: Purchase point created with surgical carbide

Figure 6: 1.5 pilot drill

Figure 7: 1.5/2.4 pilot drill

Figure 8: 3.0 twist drill

Figure 9: 4.3 mm x 8 mm final drill

Figure 11: 7 mm x 8 mm final drill

Figure 10: 5 mm x 8 mm final drill Volume 9 Number 6

be stabilized and in bony contact all along its length from apex to crest. After profound anesthesia was attained using 2% lidocaine with 1:100K epinephrine, a spade proximator was utilized to create a space between the alveolus and the tooth roots. The tooth was then extracted with a 301 elevator and a 150 forceps. Careful attention was taken to prevent any damage to the potentially fragile buccal plate and crucially needed inter-radicular bone (Figure 4). The sockets were debrided with a serrated

curette to remove any periodontal ligament remnants and induce sufficient bleeding to encourage bone growth and regeneration. The extraction site was then irrigated with sterile saline to flush out any debris. A high-speed handpiece with a longshanked 703 surgical-carbide bur was used to create a purchase point for the initial pilot drill (Figure 5). A 1.5 mm pilot drill was used to a depth of 8 mm (Figure 6). This will put the tip of the pilot within 1 mm of the sinus floor, thus allowing the implant to â&#x20AC;&#x153;bumpâ&#x20AC;? the sinus floor when seated to its final position. Next, a 1.5/2.4 mm pilot drill followed the initial trajectory of the 1.5 mm pilot to open the osteotomy (Figure 7) allowing the use of a 3.0 mm twist drill (Figure 8). Following the surgical protocol outlined for the Hahn Tapered Implant system, the osteotomy was serially opened up to a diameter of 7 mm using the length-specific drills (Figures 9-11). The incorporation of length-specific drills into the system negates the need for drill stops and makes depth assessment easy. The final osteotomy can be seen with some communication with the Implant practice 27

CASE STUDY

Figure 12: Osteotomy

Figure 13: 7 mm x 8 mm Hahn Tapered Implant

Figure 14: Implant placed into socket

Figure 15: Torquing implant to final position

Figure 16: Concave healing abutment

Figure 17: Healing abutment in place

Figure 18: Allograft placed in gaps

Figure 19: Closure with PTFE suture

easy recognition at either the impression or restoration phases of treatment. A 3 mm concave-sided healing abutment was placed (Figure 16), and approximately 0.5 cc of particulate allograft (Newport Biologicsâ&#x201E;˘) mixed with blood was placed into the sockets and the gaps between the implant body and the buccal-palatal bone (Figure 18). The use of this wide-body implant minimized the amount of material

necessary to graft the site. The 7 mm x 8 mm implant body provides a tremendous amount of surface area for osseointegration and ultimately contributes greatly to longterm resistance of occlusal loads. The soft tissue was sutured with a 4.0 PTFE suture (Figure 19). The spaces between the approximated tissue will granulate in by secondary intention, thereby producing keratinized tissue around the abutment.

remaining root sockets (Figure 12). As stated earlier, the implant will be stabilized apically and at the point where it comes in contact with bone within the site. A 7 mm x 8 mm Hahnâ&#x201E;˘ Tapered Implant (Glidewell Direct) (Figure 13) was delivered to the osteotomy using an implant handpiece set at 25 rpm and maximal torque. The AsepticoÂŽ AEU-6000 drilling unit has a top end torque limit of 55 N/cm, and the implant attained approximately 50 N/cm at placement (Figure 14). Since the implant restoration will be platform-switched, the final position, approximately 1 mm below the buccal crest, was done by hand with a torque wrench, making sure to position the flat of the long tapered internal hex toward the buccal (Figure 15). This normally does not matter unless you are using a stock angled abutment or a multi-unit abutment, but I prefer to place all my implants this way for consistency. It also makes it easier to line up impression copings and abutments when you cannot directly visualize the internal connection position. The internal connection on these implants is color-coded to correspond to platform restorative size for 28 Implant practice

Volume 9 Number 6

CASE STUDY

Designed for Easy Placement

Figure 20: Final radiograph

Once the coated granules of GUIDOR® easy-graft ® are syringed into the bone defect and come in contact with blood, they change in approximately one minute from a moldable material to a rigid, porous scaffold. • Designed for ease of use and predictability • 100% synthetic and fully resorbable • Ideal for ridge preservation and filling voids around immediate implant placements This product should not be used in pregnant or nursing women.

Figure 21: 10-day post-op healing

The final radiograph shows an implant in excellent position to facilitate a cosmetically pleasing and well-functioning final restoration (Figure 20). The patient returned to the office for a 10-day postoperative check and suture removal. The site is healing as expected (Figure 21), and impressions for the final restoration will be taken in 2.5 months.

Conclusion As treating doctors, every step we can take to decrease treatment time, increase long-term success, and satisfy our patients will go a long way toward assuring our own success as practitioners. The use of a wide body implant immediately placed in conjunction with extraction is a viable and predictable treatment option to help you stand out in a competitive dental world. IP

REFERENCES 1. Specialty care in the general dental practice. Decisions™ in Dentistry. Dec 2015. http://decisionsindentistry.com/article/ specialty-care-in-the-general-dental-practice/. Accessed November 18, 2016. 2. Dichter D. Loading Protocols for Dental Implants. Spear® Education. April 26, 2016. https://www.speareducation. com/spear-review/2016/04/loading-protocols-for-dentalimplants-1. Accessed November 18, 2016. 3. Schlesinger C. Immediate implant Placement: cutting treatment time in half. Implant Practice US. 2015;8(5):20-24.

Volume 9 Number 6

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Implant practice 29

CONTINUING EDUCATION

Atraumatic extraction of mandibular third molars Professor Loris Prosper and Nicolas Zunica discuss a case report preventing iatrogenic damage to the inferior alveolar and lingual nerves during third mandibular molar extraction

he inferior alveolar nerve (IAN) is a sensitive nerve made of parallel nervous fibers (central/peripheric). It originates from the posterior terminal end of the posterior mandibular nerve while the lingual nerve (LN) is a branch of the mandibular division of the trigeminal nerve. The IAN and the LN are the nerves presenting more risk of unintended iatrogenic injury lesion during mandibular molar extraction. These nerve injuries were first classified in 1943 in three categories (Sunderland, 1951; Andrew and Churchill, 1991; Greenberg, 1994). Neuropraxia: An interruption in conduction of the impulse down the nerve fiber. The recovery in such cases takes place without Wallerian degeneration; hence, it is considered to be the mildest form of nerve injury. Axonotmesis: Loss of the relative continuity of the axon and its covering of myelin, but preservation of the connective tissue framework of the nerve. Neurotmesis: Loss of continuity of not only the axon, but also the encapsulating connective tissue. The International Association for Study of Pain (IASP) distinguished the following symptoms: • Anesthesia: total absence of sensibility • Paresthesia: alteration of sensibility implying a sensation of tingling, tickling, prickling, pricking, or burning • Hypoesthesia: a reduced sense of touch or sensation, or a partial loss of sensitivity to sensory stimuli • Hyperesthesia: a condition that involves an abnormal increase in sensitivity to stimuli Professor Loris Prosper is a professor at G D’Annunzio University in Chieti, Italy. He is a teacher in dental prosthetics at Vita-Salute San Raffaele University in Milan and responsible for the Aesthetic Odontology Department of San Raffaele Hospital in Milan. He is the author of various scientific publications on international odontology Nicolas Zunica is a dental technician and dental hygienist with a degree obtained from Vita-Salute San Raffaele University. He cooperates with Professor Prosper’s dental studio in Monza and Milan and is currently researching on esthetic materials with Professor Prosper.

30 Implant practice

Educational aims and objectives

This clinical article aims to discuss a treatment method for prevention of iatrogenic damage to the inferior alveolar and lingual nerves during third mandibular molar extraction

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 35 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify several types of inferior alveolar and lingual nerve injuries. •

Recognize some symptoms of iatrogenic nerve injuries.

•

Realize some significant risk factors for IAN damage.

•

Realize some surgical factors that may result in permanent lingual nerve injury.

Figure 1: OCT performed with phosphor system CT

• Dysesthesia: abnormal sense of touch involving sensations such as burning, wetness, itching, electric shock, and pins and needles. The incidence of reported postoperative damage to the IAN and LN varies widely in the literature. A 2005 survey involving all oral surgeons in California and aiming to estimate the occurrence of neurologic damage to the inferior alveolar and the lingual nerve surgical shows that 94.5% of the 535 surgeons answering the survey reported damage to the inferior alveolar nerve and 56% to the lingual nerve (Robert, Bacchetti, and Pogrel, 2005). In a study published by Gargallo-Albiol and colleagues, the incidence of temporary disturbances affecting the IAN or the LN

was found to be in the range from 0.278% to 13% (2000). In another study by Zuniga, the incidence of permanent injury to the IAN and LN has been mentioned to fall in the range between 0.4% and 25% and 0.04% and 0.6%, respectively (2009).

Risk factors Two important factors can significantly increase the risk of IAN damage: anatomy and old age. By anatomy, we mean the relationship between neurovascular bundle and roots of the third mandibular tooth, identifiable through orthopantomogram (OPG). As early as 1990, Rood and Shehab identified a list of clear indications for significantly higher risks for the inferior alveolar nerve, all identifiable through OPG. See Table 1 “Indicators Volume 9 Number 6

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of risk factors of IAN damage” for more information. The importance of these risk indicators was recently confirmed by Blaeser and colleagues (2003), who calculated the value of some of Rood and Shehab’s indicators, such as: 1. Deviation of the mandibular alveolar canal 2. Root radiolucency 3. Interruption of the radiopaque lines that mark the alveolar canal. In the presence of these conditions, the neurologic damage is between 1.4% and 2.7%, so at least 40% higher than the general risk probability. Sedaghafar and colleagues take the clinic-radiographic evaluation a step further, showing that the damage forecast is even more accurate if further information is taken into account such as the development of roots and their shape, deepness of the inclusion, etc. (2005; Rood and Shehab, 1990). A study carried out by Andrew and Wee to determine the incidence of inferior alveolar nerve paresthesia during third molar surgery in patients with an exposed inferior alveolar nerve bundle concluded that such a situation hints a high probability of intimate relationship of the nerve with the tooth and carries a 20% risk of paresthesia with a 70% chance of recovery by 1 year from surgery (2004).

The patient’s age The patient’s age is another significant risk factor. The literature shows that postextraction complications are more frequent after the age of 25 (Chuang, et al., 2007; Bruce, Frederickson, and Small, 1980; Chiapasco, De Cicco, and Marrone, 1993). A recent retrospective survey carried out on 4,995 extractions performed on 3,513 patients reported neurologic damage in 55 cases (1.1%). Most of the times, the damage was reversible, but 50% of patients recovered in 6 months; in some cases, it took over a year to recover full sensibility. A partial recovery of sensibility was more frequently observed in older patients (Queral-Godoy, et al., 2005).

Preoperative diagnosis Preoperative diagnosis includes orthopantomogram (OPG) and three-dimensional imaging. OPT clearly shows the tooth position, eventual diseases such as caries and cysts, and risks for the mandibular alveolar nerve according to Rood and Shehab’s indicators (complete overlapping of the roots to the alveolar canal, alveolar canal that crosses Volume 9 Number 6

Figure 2: CT scan performed with Dental Scan to assess the shape of the inferior alveolar nerve (IAN) and root morphology

Table 1: Indicators of risk factors of IAN damage Rood and Shehab identified certain key risk factors for nerve damage as early as 1990. • Angled roots by the alveolar canal • Interruption of the radiopaque lines that mark the alveolar canal • Root radiolucency of the alveolar canal • Narrowing of the mandibular alveolar canal by the roots • Radiolucent and bifid root • Narrowing of roots by the alveolar canal • Deviation of the mandibular alveolar canal Implant practice 31

CONTINUING EDUCATION the roots near to the bifurcation) but does not show the buccolingual position of roots and neurovascular bundle. Three-dimensional imaging and particularly cone beam technology proves very useful by indicating the exact position of the alveolar canal and allows for planning of a correct bone resection and odontotomy. Three-dimensional imaging is seldom indicated for patients below 25 years of age because there are less risks of neurologic damage and because there is generally less need for extraction instruments to penetrate as deep in the root apex.

Surgical factors

Figure 3: Localization of the nerve at root level by CT

While several studies come to the general conclusion that the deeper the third molar, the higher the rate of nerve damage, other authors stress the importance of surgical factors as being significant contributors to nerve injury. An investigation carried out in 2001 by Renton and colleagues concluded that the predictors for permanent lingual nerve injury, in order of importance, were perforation of the lingual plate during surgery, the skill of the surgeon, difficulty of the case (distoangular impactions), exposure of the nerve, and an increased age of the patient. The authors further stated that the surgical factors are the main contributors to lingual nerve injury during third molar extraction (2001). Some authors even conclude that, rather than the mandibular depth of third molar, the true cause of nerve damage is the surgical maneuver required during extraction such as lingual flap retraction, osteotomy, and tooth sectioning (Carmichael and McGowan, 1992; Fielding, Rachiele, and Frazier, 1997; Waseem, et al., 2010; Mason, 1988). The

Figures 4 and 5: Surgical maneuver through the use of Luxator LX 360Â° teeth 32 Implant practice

Volume 9 Number 6

Case report Instruments and methodology Extraction technique when removing an impacted or semi-impacted mandibular third molar is extremely important in order to prevent damage to the surrounding anatomical structures such as the lingual nerve, the inferior alveolar nerve, and the periodontium of the second molar. The surgical instruments used are of paramount importance. In the case that

follows, an innovative instrument, the mechanical periotome Luxator LXÂŽ (Directa) was used to perform a mandibular third molar extraction. The instrument allows to cut the Sharpey fibers surrounding the tooth between cement and alveolar bone (Feneiss, et al., 1952) by luxating the periodontal ligament as seen in Figures 4 to 6. Presentation The patient was a 22-year-old female in good health. She visited our clinic in Monza (Italy), reporting pain coming from the LL8 and spreading through the whole lower arch. The first panoramic picture shows

compression of the mandibular nerve that touches the lower roots of the LL8 â&#x20AC;&#x201D; physical inclusion of the mucosa and partial bone inclusion in close correlation with the inferior alveolar nerve. Physical examination showed edematous and erythematous mucosa distal to the LL7. No sensibility alteration in the emiarch concerned. A second X-ray showed the position of the inferior alveolar nerve at the distolingual apex as confirmed by CT. Treatment The patient was given anesthesia and plexus nerve block with a 2% vasoconstrictor. The LL8 was exposed, and an

Figures 6: Radiograph with the Luxator LX tip showing the depth of the socket

Figure 7: Suture flap

Figure 8: Control radiograph. No residue is left in the socket despite abnormal root morphology

Figure 9: Extracted tooth showing complex crown and root morphology

Volume 9 Number 6

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technique used would, in other words, determine at least to some extent the probability of nerve injury.

CONTINUING EDUCATION intrasulcular incision with drainage to the LL7 was made. The distal discharge should be performed at a 45° angle to the second molar, remaining in the first portion of a full thickness, then finished at partial thickness. This incision avoids the risk of sectioning the lingual nerve and is the junction of the flap. After skeletonizing the jaw and placing tongue protection, the Sharpey’s fibers were cut using the mechanical periotome Luxator LX following the tooth circumference and luxating the periodontal ligament as in Figures 4 and 5. The tooth is subsequently extracted using an elevator without luxating the surrounding tissues and, above all, with no damage to the mandibular nerve. The controlled reciprocating movement of the Luxator LX helps it penetrate the space that lodges the periodontal ligament (0.15 mm-0.38 mm) and separates the fiber bundle in the least traumatic way for the tooth. The gentle vertical movement applied to the periodontium does not cause neural trauma. Using this mechanical periotome, we managed to perform the extraction with no tissue damage and, most importantly, with no damage to the mandibular nerve. The periapical X-ray (Figure 6) shows how the Luxator LX blade — detached from the contra-angle to facilitate the X-ray — penetrates into the alveolus facilitating tooth removal. Figure 8 shows the absence of root rests. The extraction was performed without sectioning/dividing the tooth. Figure 9 shows that the tooth was extracted in one piece. No traumatic operations to search for root rests were needed. The alveolus was cleaned, washed with cold physiologic solution, and sutured with silk thread 4/0-. The edge could be sutured enabling the patient to recover without postoperative pain. Seven days later, the suture stitches were removed. The patient reported a good postoperative recovery with slight pain during the first 3 days mitigated by common painkillers. The patient was instructed to use a toothpaste gel (Hobagel by Hobama) that contains a mix of humectant and antibacterial substances (such as cetylpyridinium chloride, triclosan, essential oils) in technologically innovative microcapsules designed to significantly lower periodontal plaque and bleeding. Its medium-low RDA (+/-30) is less abrasive on natural tooth and restoration material (Pasini, et al., 2012). The dental hygienist should focus on reducing plaque close to the postoperative recovery areas, detect poor home hygiene, and promptly intervene to correct them. 34 Implant practice

The surgical approach used is of paramount importance to minimize tissue damage and neurosensory impairment.

Professional dental hygiene sessions are extremely important to remove bacteria around the tooth, preferably by air polish (EMS) with glycine powder to preserve the health of gingival tissues. Final polishing is of extreme importance to leave a smooth surface as a rough surface will be more receptive for bacteria. A silica-based polishing paste with a low RDA such as prophy paste CCS Yellow RDA 40 (Directa) is recommended (Prosper, et al., 2013).

Conclusion Mandibular third molar extractions are undoubtedly associated with neural injury

risks that can cause temporary or permanent discomfort for the patient and legal actions for the dentist. A thorough preoperative diagnosis is mandatory, and complication factors such as age and anatomy — i.e., depth of impaction and presence of overlying ramus bone — need to be taken into account. The surgical approach used is of paramount importance to minimize tissue damage and neurosensory impairment. The mechanical Periotome Luxator LX proves to be a valid tool in surgical extractions allowing minimal trauma and significant reduction of postoperative discomfort. IP

REFERENCES 1. Andrew BGT, Wee SG. Effect of exposed inferior alveolar neurovascular bundle during surgical removal of impacted lower third molars. J Oral Maxillofac Surg. 2004; 62(5):592-600. 2. Andrew K, Churchill L. Classification of nerve injuries. Essential Neurosurgery. 1991; 333-334. 3. Blaeser BF, August MA, Donoff RB, Kaban LB, Dodson TB. Panoramic radiographic risk factors for inferior alveolar nerve injury after third molar extraction. J Oral Maxillofac Surg. 2003; 61(4):417-421. 4. Bruce RA, Frederickson GC, Small GS. Age of patients and morbidity associated with mandibular third molar surgery. J Am Dent Assoc. 1980;101(2):240-45. 5. Carmichael FA, McGowan DA. Incidence of nerve damage following third molar removal: a West of Scotland oral surgery research group study. Br J Oral Maxillofac Surg. 1992;30(2):78-82. 6. Chiapasco M, De Cicco L, Marrone G. Side effect complications associated with third molar surgery. Oral Surg Oral Med Oral Pathol. 1993; 76(4):412-420. 7. Chuang SK, Perrott DH, Susarla SM, Dodson TB. Age as a risk factor for third molar surgery complications. J Oral Maxillofac Surg. 2007;65(9):1685-1692. 8. Fielding AF, Rachiele DP, Frazier G. Lingual nerve paresthesia following third molar surgery. a retrospective clinical study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;84(4):345-348. 9. Gargallo-Albiol J, Buenechea-Imaz R, Gay-Escoda C. Lingual nerve protection during surgical removal of lower third molars. a prospective randomized study. Int J Oral Maxillofac Surg. 2000;29(4):268-271. 10. Greenberg, MS. Injury Classification System. Handbook of Neurosurgery. 3rd ed. Lakeland, FL: Greenberg Graphics Inc; 1994. 11. Mason DA. Lingual nerve damage following lower third molar surgery. Int J Oral Maxillofac Surg. 1988;17(5):290-294. 12. Pasini G, Zorzo C, Gola G, Polizzi E. Valutazione clinica di un gruppo di pazienti, affetti da gengivite, dopo utilizzo di un gel a base di cetil- piridinio cloruro, triclosan e olii essenziali. Quintessenza Internazionale. 2012;1:23-30. 13. Prosper L, Setaro I, Polizzi E, Zunica N, Cassinelli E, Cortella CA. Materiali estetici restaurativi: analisi in vistro sull’adesione batterica e danni iatrogeni indotti dalle tecniche d’igiene professionale. Quintessenza Internazionale. 2013;3:43-51. 14. Queral-Godoy E, Valmaseda-Castellón E, Berini-Aytés L, Gay-Escoda C. Incidence and evolution of inferior alveolar nerve lesions following lower third molar extraction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;99(3):259-264. 15. Renton T, McGurk M. Evaluation of factors predictive of lingual nerve injury in third molar surgery. Br J Oral Maxillofac Surg. 2001;39(6):423–428. 16. Robert RC, Bacchetti P, Pogrel MA. Frequency of trigeminal nerve injuries following third molar removal. J Oral Maxillofac Surg. 2005;63(6):732-735. 17. Rood JP, Shehab BA. The radiological prediction of inferior alveolar nerve injury during third molar surgery. Br J Oral Maxillofac Surg. 1990;28(1):20-25. 18. Sedaghatfar M, August MA, Dodson TB. Panoramic radiographic findings as predictors of inferior alveolar nerve exposure following third molar extraction. J Oral Maxillofacial Surg. 2005;63(1):3-7. 19. Sunderland S. A classification of peripheral nerve injuries producing loss of function. Brain. 1951;74(4):491-516. 20. Jerjes W, Upile T, Shah P, Nhembe F, Gudka D, Kafas P, et al. Risk factors associated with injury to the inferior alveolar and lingual nerves following third molar surgery – revisited. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(3):335-345. 21. Zuniga JR. Management of third molar-related nerve injuries: observe or treat? Alpha Omegan. 2009;102(2):79-84.

Volume 9 Number 6

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Atraumatic extraction of mandibular third molars

Implant-supported overdentures

They (implant-supported overdentures) may be indicated in patients with ________ or considerable ridge resorption. a. changed anatomy b. neuromuscular disorders c. significant gag reflexes d. all of the above

The success of the implant-supported overdenture will depend on the ________ of the supporting implants. a. correct position b. distribution c. material d. both a and b

A milled bar is classified as a _________ attachment. a. flexible b. rigid c. bendable d. semi-movable

Resilient bars, when appropriately designed, allow __________. a. a single axis of rotation b. use greater mucosal support c. offer greater protection to the retentive attachments d. all of the above

PROSPER/NUNICA

The _________ is/are the nerve(s) presenting more risk of unintended iatrogenic injury lesion during mandibular molar extraction. a. inferior alveolar nerve (IAN) b. lingual nerve (LN) c. maxillary nerve (MN) d. both a and b (Regarding neuropraxia) The recovery in such cases takes place without Wallerian degeneration; hence, it is considered to be the ________ of nerve injury. a. mildest form b. most painful c. harshest form d. most sensitive A 2005 survey involving all oral surgeons in California and aiming to estimate the occurrence of neurologic damage to the inferior alveolar and the lingual nerve surgical shows that ______ of the 535 surgeons answering the survey reported damage to the inferior alveolar nerve and 56% to the lingual nerve. a. 43% b. 67% c. 94.5% d. 98.6% A study carried out by Andrew and Wee to determine the incidence of inferior alveolar nerve paresthesia during third molar surgery in patients with an exposed inferior alveolar nerve bundle concluded that such a situation hints a high probability of intimate relationship of the nerve with the tooth and carries a _______ with a 70% chance of recovery by 1 year from surgery. a. 15% risk of hyperesthesia b. 20% risk of hypoesthesia c. 20% risk of paresthesia d. 30% risk of anesthesia In the presence of these conditions, the neurologic damage is between 1.4% and 2.7%, so a least ____ higher than the general risk probability. a. 10%

Volume 9 Number 6

b. 20% c. 30% d. 40% 6.

The patient’s age is another significant risk factor. The literature shows that post-extraction complications are more frequent after the age of ___. a. 16 b. 18 c. 20 d. 25

Preoperative diagnosis includes ________ . a. magnetic resonance imaging (MRI) b. orthopantomogram (OPG) c. three-dimensional imaging d. both b and c

Three-dimensional imaging is seldom indicated for patients _____ years of age because there are less risks of neurologic damage and because there is generally less need for extraction instruments to penetrate as deep in the root apex. a. above 45 b. above 35 c. below 25 d. below 18

While several studies come to the general conclusion that the deeper the third molar, _____, other authors stress the importance of surgical factors as being significant contributors to nerve injury. a. the higher the rate of nerve damage b. the lower the rate of nerve damage c. the greater the chance for perforation of the lingual plate d. the greater the need for lingual flap retraction

10.

Some authors even conclude that, rather than the mandibular depth of third molar, the true cause of nerve damage is the surgical maneuver required during extraction such as ________. a. lingual flap retraction b. osteotomy c. tooth sectioning d. all of the above

BAKER/REANEY

However, they (rigid and resilient bars) need at least ___ of interocclusal clearance and should not be used when vertical space is limited. a. 4 mm b. 6 mm c. 8 mm d . 10 mm (When considering mandibular implant overdentures) The average annual bony ridge height

physiological shrinkage is about ____ in the edentulous anterior mandible. a. 0.2 mm b. 0.4 mm c. 0.6 mm d. 1.0 mm 7.

Vere, Bhakta, and Patel stated: “____ freestanding implants in the canine regions, as the simplest option, would appear to be the treatment of choice to retain an overdenture in the edentulous mandible.” a. Two b. Three c. Four d. Five

The anterior mandibular bone under an implant overdenture may resorb at the rate of 0.5 mm over ______, and long-term resorption may remain at 0.1 mm per annum. a. 1 year b. 2 years c. 4 years d. 5 years

Maxillary implant overdentures have a higher rate of implant loss than any other implant procedures. This has been thought to be a result of __________. a. relatively poor bone quality and quantity b. increased implant-to-abutment ratios c. non-axial loading d. all of the above

10. There has been _________ implant failure reported when severely resorbed maxillae are augmented with sinus grafts. a. low b. high c. significant d. no

Implant practice 35

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IMPLANT PRACTICE CE

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Implant-supported overdentures Drs. Brenda Baker and David Reaney discuss the factors to consider during overdenture treatment planning

n implant-retained overdenture is a removable dental prosthesis that is supported by the residual oral tissues and employs dental implants for retention. Implant-retained overdentures are a treatment alternative for many patients for whom conventional dentures are poorly tolerated. They may be indicated in patients with changed anatomy, neuromuscular disorders, significant gag reflexes, or considerable ridge resorption (Vere, Bhakta, and Patel, 2012). Life expectancy is increasing globally, and people are becoming edentulous at later stages, so partial edentulism is becoming more commonplace until old age (Vasant and Vasant, 2013). Implant-retained overdentures may reduce residual ridge resorption and enhance mastication and hence nutritional status, improve speech, and patient selfesteem (Doundoulakis, et al., 2003). Factors that govern the planning of the overdenture treatment follow: • The number and length of the implants • Quality and quantity of the anchoring bone tissue • Economic constraints Indications for attachment-retained treatment (Dentsply): • An unfavorable jaw relation that makes treatment with a fixed bridge restoration difficult • Esthetic problems, e.g., the need for lip support in the upper jaw • Phonetic problems due to loss of alveolar bone in the upper jaw • Patient dissatisfaction with removable denture due to oral irritations and/or loss of bone for denture fixation • A bridge option makes satisfactory oral hygiene impossible or extremely difficult to achieve

Educational aims and objectives

This clinical article aims to discuss factors to consider during overdenture treatment planning.

Expected outcomes

Implant Practice US subscribers can answer the CE questions on page 35 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify factors that govern the planning of the overdenture treatment. •

Recognize indications for attachment-retained treatment.

•

Realize conditions that should exist to ensure optimized restorative treatment.

•

Identify some forms of retention for implant-retained overdentures.

•

Identify some attachment selection alternatives.

•

Realize various treatment considerations for maxillary and mandibular implant overdentures.

• Edentulous patients with a cleft palate To ensure an optimized restorative treatment, the following conditions should exist: • Parallel implants • If a rigid bar connector is used, ensure there are no large distances between implants • Appropriate length of extension bars, not too long • Adequate resilience of the mucosa; the mucosa should not be too soft • Provide an even load on the mucosa when the prosthesis is in function

Retention of implant-retained overdentures Overdentures may be retained by a number of different implants, which can be splinted or separate (Dudic and MerickseStern, 2002). Authors have reported high implant survival rates for mandibular overdentures, and thus, successful treatment outcomes when overdentures are retained by two implants (Meijer, et al., 2009) splinted or non-splinted. In the maxilla, the evidence base supports the use of four to six implants

Brenda Baker, BDS (Hons), MSc, graduated from Sydney University with honors and completed a master’s degree in conservative dentistry from Eastman Dental College. She has taught in the prosthetic faculty at Sydney University and pursued a preventively oriented career in private practice. Dr. Baker is currently director of clinical education for Southern Cross Dental. David Reaney, BDS (Edin), DGDP(UK), MClinDent (Prosthodontics), graduated with distinction from the University of Edinburgh. He has held the position of clinical lecturer at the School of Dentistry, Royal Victoria Hospital in Belfast and is currently in private practice in Moy, Northern Ireland. Dr. Reaney is general manager of Southern Cross Dental.

36 Implant practice

splinted with a bar, although free-standing abutments are increasing in popularity (Galluci, Morton, and Weber, 2008). There are various prosthetic options and attachments that are available to provide a satisfactory overdenture. The success of the implant-supported overdenture will depend on the correct position and distribution of the supporting implants. These considerations have a direct effect on the selection of the attachment for each particular situation.

Attachment selection The different attachment assemblies follow. Bar and clip systems The major bar types come with matching clips. These are incorporated into the prosthesis, either at the time of processing or afterwards as a pickup procedure. Some systems include a spacer that can be incorporated at processing. The use of the spacer enables a space between the clip and the bar when the prosthesis is at rest in the patient’s mouth. Upon biting, the denture is capable of some vertical movement so that there is some support for occlusal loads instead of purely implant support. A milled bar is classified as a rigid attachment. Milled bars do not allow movement of the denture base and can provide relief over painful areas such as superficial mental nerves (Dudic and Merickse-Stern, 2002). A cast bar may be made including proprietary Volume 9 Number 6

Studs If stud attachments are used, there are important considerations regarding stud attachment alignment: • All stud attachments should be parallel to each other, and the attachments should not interfere with the path of insertion of the overdenture. • It is harder to achieve an ideal alignment with taller attachments than shorter ones. Either synthetic rubber rings or metal lamellae are included in the prosthesis. When the prosthesis is inserted, they flex sufficiently to engage into a circular undercut on a metal post that is part of an abutment screwed into an implant. The LOCATOR® Overdenture stud attachment (Zest Dental Solutions™) was designed for easy insertion and removal, dual retention, a low vertical profile, and its pivoting ability, so it was resilient and tolerant for implant divergence. Many patients can bite their overdenture into place at an angle and can cause damage, which may require replacement. For this reason, the LOCATOR attachment was designed to be self-aligning. As a result of these design features, in 2010 it became available for many different implants from varied manufacturers. A new generation of implants called overdenture implants has been introduced into implant dentistry (Mericske-Stern, et al., 2000). The Volume 9 Number 6

CONTINUING EDUCATION

components, or a custom design can be fabricated. Subsequently, the denture is made to fit over the custom design. Resilient bars, when appropriately designed, allow a single axis of rotation, use greater mucosal support, and offer greater protection to the retentive attachments. Both rigid and resilient bars can be used to align nonparallel implants. However, they need at least 10 mm of interocclusal clearance and should not be used when vertical space is limited (Chee and Jivraj, 2006). The Hader Bar, which is a semi-precision bar attachment that provides hinge movement provided by only a single Hader Bar, has been used in the attachment assembly design (Shafie, 2007). The Dolder Bar is a prefabricated precision bar attachment that comes in two forms: • The rigid form is U-shaped with parallel walls. The resilient form is egg-shaped in cross section and provides vertical and hinge resiliency. • The resilient Dolder Bar is also called a bar joint. The Dolder Bar is indicated for overdenture patients with adequate or relatively large interridge space.

Figure 1: Simulated implant-supported dentures

main design difference between overdenture implants and traditional implants is that part of the stud attachment either male or female has been combined in the implant body. Magnets Magnets provide the least retention and have two main disadvantages: • The retentive force produced reduces sharply as the distance between the elements increases beyond very close contact (100 microns). • Over a period of time, there is a loss of magnetic attraction, sometimes accompanied by corrosion (Preiskel and Preiskel, 2009). Telescopic copings (rigid and nonrigid) Note: Patients with advanced resorption of the ridge are suitable for bar or telescopic attachment assemblies that offer horizontal stability. Patients with minimal alveolar resorption of the ridge are suitable for studs or magnetic attachment assemblies. Maxillary implant overdentures have different treatment considerations than mandibular implant overdentures — as when maxillary bone resorbs and atrophies, this may restrict implant placement. The resorption of the residual ridge area in the mandible, however, may often allow the use of implants anteriorly due to substantial basal bone in terms of width and depth in that area.

Treatment considerations for mandibular implant overdentures The following treatment concepts have been summarized by Sadowsky (2001). The mandibular overdenture retained by implants in the area between the foramina maintains bone in the anterior mandible. The average annual bony ridge height

Figure 2: Implant-supported bar and clip mandibular overdenture

physiological shrinkage is about 0.4 mm in the edentulous anterior mandible. Studies have revealed better patient-based results when two-implant supported mandibular overdentures have been used compared with conventional lower dentures. In 2002, McGill consensus published that the treatment modality of choice for the edentulous mandible should be a two-implant retained overdenture (Feine, et al., 2002). Vere, Bhakta, and Patel stated: “Two freestanding implants in the canine regions, as the simplest option, would appear to be the treatment of choice to retain an overdenture in the edentulous mandible” (2012). The anterior mandibular bone under an implant overdenture may resorb at the rate of 0.5 mm over 5 years, and long-term resorption may remain at 0.1 mm per annum (Jemt, et al., 1996; Quirynen, et al., 1992; Naert, et al., 1998). Bone undergoes remodeling in the anterior mandible as a result of more functional loading with implants. In younger patients or those edentulous for less than 10 years, a fixed implant denture may preserve posterior bone better than an implant overdenture in the lower jaw. Many patients with mandibular implant overdentures can experience a loss of fit of their Implant practice 37

CONTINUING EDUCATION maxillary complete dentures and need upper full denture relines. There can be a transfer of significant occlusal forces onto the anterior maxilla with maxillary bone resorption and soft tissue inflammation. The deleterious forces could generate more midline fractures in the maxillary denture. There should be no anterior contact in the centric relation position and minimal anterior contact in lower excursive movements. Frequent recalls to assess stability and retention should be scheduled. Retention, stability, and chewing function improve only slightly with an implantsupported mandibular overdenture as compared with an implant-mucosa– supported overdenture. Multiple implants can be recommended for the mandibular overdenture when there is a/an: • Dentate maxilla • High-retention needs • Implant length less than 8.0 mm • Implant width less than 3.5 mm When two implants are used in the anterior mandible to retain an overdenture, solitary ball attachments are more economical, easier to clean than bars that are more retentive, less technique sensitive, and more suitable for tapered arches. Mucosal hyperplasia is less likely to develop with solitary ball attachments. Overdentures retained by two implants in the anterior mandible need more maintenance during the first year than in later years. Whether the ball or bar design requires more maintenance is controversial. There appears to be no statistical difference when comparing long-term maintenance of mandibular implant overdentures retained by two implants in contrast to those retained by three or more implants. Patients are happier with mandibular implant overdentures than with complete dentures, even when patients had preprosthetic surgery. Magnets retaining mandibular implant overdentures are associated with less happy patients than those who wear bars or ball attachments as there are more post-insertion visits due to corrosion or wear. Patients appear to be equally happy with a fixed implant complete denture or a removable implant overdenture on the mandible. Patients who value stability more than hygiene select a fixed prosthesis.

Treatment considerations for maxillary implant overdentures A systematic literature review by Sadowsky SJ (2007) sought evidence to establish criteria to treat the edentulous 38 Implant practice

maxilla with implant overdentures. The following findings were reported. Maxillary implant overdentures have a higher rate of implant loss than any other implant procedures. This has been thought to be a result of relatively poor bone quality and quantity, increased implant-toabutment ratios, and non-axial loading. For this reason, more implants are placed in the maxilla. Delayed loading of four to six splinted implants in the maxilla is advised by Galluci, Morton, and Weber, who reported implant survival rates of 94.8%-97.7% after 10 years (2009). Ideally, implants in the maxilla should be widely distributed symmetrically about the arch, but this may be compromised by various anatomical issues such as pneumatization of the maxillary sinus, alveolar orientation, and the shape of the ridge. Maxillary implant overdenture treatment is often compromised by reduced bone quantity/quality, and higher biomechanical forces occur. Maxillary implants are often angled buccally due to resorption. The replaced teeth are usually arranged anterior and inferior to the residual ridge. The implants are often opposed by natural teeth in the anterior and premolar regions, and the cantilever forces can be destructive. As there is limited space in the maxilla, flexible bar designs may increase bending moments. As the masticatory mucosa is thicker on the maxilla, longer implant abutments are often needed, which increases the lever arm. Thin buccal bone of the rigid maxilla may not tolerate the applied forces as well as the mandible. There are no specific recommendations for the number of implants needed to support a maxillary overdenture. If the design of the denture is such that there is no palatal coverage, then a minimum of four implants is considered necessary. Grafting procedures and modified implant placements have been done to overcome compromised maxillary jaw volume limiting implant length. There has been low implant failure reported when severely resorbed maxillae are augmented with sinus grafts. The placement of implants in an angulated position has been suggested if implants are splinted. The use of the zygomatic or pterygomaxillary implants have been well documented in the atrophied maxilla with the use of fixed restorations. Palatal placement of zygomatic implants can cause overcontouring and unusual substructure designs for overdenture patients with the possible need for angled abutments and/or placement of the connecting bar buccally to the

abutment. Zygomatic implants can be useful where there is extensive pneumatization of the maxillary sinuses (Jivraj, Chee, and Corrado, 2006). A broadly distributed implant-supported design across the anterior premolar region and tuberosities produces better stress transfer to the underlying bone than a dense number of implants in the anterior region supporting a cantilever. Bars with distal cantilevers can increase the forces on the terminal implants by more than 3 times. Unsplinted anchorage systems may need less space within the prosthesis, facilitate hygiene, be more cost-effective, less technique sensitive, and easier to manage than splinted designs. There is no significant difference in mean bone loss between subjects with ball- or bar-retained overdentures. At least 13.0 mm-14.0mm is needed from the implant platform to incisal edge for a bar design. This is comprised of 4.0 mm for the bar, 1.00 mm below the bar, and room for clip and acrylic/ tooth assembly. The span length should not exceed 18.0 mm, with a 2.0 mm vertical stiffener height below the round portion. The use of attaching mechanisms such as a bar clip requires a minimum distance of 10.0 mm-12.0 mm between implants, or a milled bar with a frictional fit superstructure is needed. A single anchor will need 10.0 mm-11.0 mm space above the implant platform to the incisal tip and permit more flexibility with location. Bars provide more retention than solitary anchors when loaded with both vertical and oblique forces. Implant angulation may compromise the retention of solitary anchors. Magnets have poor retention but may be suitable for bruxers or patients with difficulty manipulating the prosthesis. Patients appear to be equally satisfied with bars or solitary anchors retaining a maxillary implant overdenture. There is a high incidence of hyperplasia with bars. Maxillary implant overdentures have a high rate of complications and may need more post-insertion maintenance than implant-supported bridges. Most complications occur in the first year. Mucosal inflammation and mechanical problems (especially in cases without palatal coverage) occur more often in the maxilla than the mandible. This may be due to bigger stresses in the maxilla from the opposing dentition or fixed restorations. The most common complication occurs as there is a change in the retention system due to loosening or fracture. Many retention system fractures occur Volume 9 Number 6

Volume 9 Number 6

are available. Some systems link implants while others do not. When a system is selected, the dentist and support teams have to consider the medical history and general wellness of the patient, biofunctional, maintenance, and financial requirements. IP

REFERENCES 1. Jivraj S, Chee W, Corrado P. Treatment planning of the edentulous mandible. Br Dent J. 2006; 201(5):261-279. 2. Attachment-retained restorations: ASTRA TECH Implant System™ EV [Clinical and laboratory manual]. United States: DENTSPLY International; 2015. EV [online] available at http://www.dentsplyimplants.com.au/~/media/M3%20 Media/DENTSPLY%20IMPLANTS/Product/1219974%20 Attachment_retained%20restorations%20ASTRA%20 TECH%20Implant%20System%20EV.ashx. Accessed November 3, 2016. 3. Doundoulakis JH, Eckert SE, Lindquist CC, Jeffcoat MK. The implant-supported overdenture as an alternative to the complete mandibular denture. J Am Dent Assoc. 2003;134(11):1455-1458. 4. Dudic A, Mericske-Stern R. Retention mechanisms and prosthetic complications of implant-supported mandibular overdentures: long-term results. Clin Implant Dent Relat Res. 2006;4(4): 212-219. 5. Feine JS, Carlsson GE, Awad MA, Chehade A, Duncan WJ, Gizani S, et al. The McGill consensus statement on overdentures. Montreal, Quebec, Canada. Int J Prosthodont. 2002;15(4):413-414. 6. Gallucci GO, Morton D, Weber HP. Loading protocols for dental implants in edentulous patients. Int J Oral Maxillofac Implants. 2008;24(suppl):132-146.

7. Jemt T, Chai J, Harnett J, Heath MR, Hutton JE, Johns RB, et al. A 5-year prospective multicenter follow-up report on overdentures supported by osseointegrated implants. Int J Oral Maxillofac Implants. 1996;11(3):291-298. 8. Jivraj S, Chee W, Corrado P. Treatment planning of the edentulous maxilla. Br Dent J. 2006;201(5):261-279. 9. Meijer HJ, Raghoebar GM, Batenburg RH, Vissink A. Mandibular overdentures supported by two Brånemark, IMZ or ITI implants: a ten-year prospective randomized study. J of Clin Periodont. 2009; 36(9):799-806. 10. Mericske-Stern R, Venetz E, Fahrländer F, Bürgin W. In vivo force measurements on maxillary implants supporting a fixed prosthesis or an overdenture: a pilot study. J Prosthet Dent. 2000;84(5):535-547. 11. Naert I, Gizani S, Vuylsteke M, van Steenberghe D. A 5-year randomized clinical trial on the influence of splinted and unsplinted oral implants in the mandibular overdenture therapy. Part I: Peri-implant outcome. Clin Oral Implants Res. 1998;9(3):170-177. 12. Preiskel HW, Preiskel A. Precision attachments for the 21st century. Dent Update. 2009;36(4):221-227. 13. Quirynen M, Naert I, van Steenberghe D, Dekeyser C, Callens A. Periodontal aspects of osseointegrated fixtures supporting a partial bridge. An up to 6-years retrospective study. J Clin Periodontol. 1992;19(2): 118-126. 14. Sadowsky, SJ. Mandibular implant-retained overdentures: a literature review. J Prosthet Dent. 2001; 86(5):468-473. 15. Sadowsky, S J. Treatment considerations for maxillary implant overdentures: a systematic review. J Prosthet Dent. 2007;97(6):340-348. 16. Shafie HR. Clinical and Laboratory Manual of Implant Overdentures. John Wiley & Sons; 2013. 17. Vasant R, Vasant MK. Retention systems for implantretained overdentures. Dent Update. 2012; 40(1):28-31. 18. Vere J, Bhakta S, Patel R. Implant-retained overdentures: a review. Dent Update. 2012; 39(5): 370-372.

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CONTINUING EDUCATION

in bruxers. There may be limitations in the design and material failure due to insufficient vertical space for prosthetic parts as well as morphological and speech factors. Bars are recommended when restoring divergent implants of more than 10 degrees. Patients prefer a palateless long-bar overdenture design to a fixed implant denture. Most patients prefer a removable prosthetic design as they are familiar with the shape, and it is easier phonetically. A tissueborne overdenture needs fewer implants than a fixed complete denture and may be more attractive economically. In patients who have a moderate to severe resorption in the maxilla who want a rigid prosthesis that is esthetic and cleansable may find a milled bar-retained implant-supported prosthesis suitable. Studies have shown that the individual length of implants is more critical than the complete length of supporting implants for implant survival. Implant-retained overdentures are a most important and useful treatment modality for many patients. A variety of retention systems

EDUCATOR INSIGHT

Everything you wanted to know about an implant study club but were afraid to ask Dr. John C. Minichetti discusses the many benefits of study clubs

ith the increased utilizing and technological advances in implant dentistry, it’s hard to keep up. The dental implant study club is a way in which clinicians can get together on a regular informal basis to share scientific, practical, and clinical information. The knowledge and techniques gained from such group sessions benefit all participants involved.

History Dr. Michael Cohen, the founder of the Seattle Study Club®, reported (Cohen 1992) the advantages of the dental implant study group on the local level as a means to educate and increase patient referrals to the implant dentist. His initial concept was based on the team approach to implant dentistry with the surgical specialist training and educating his various referring dentists in multiply facets of implant dentistry. Ken W. M. Judy, DDS , Chairman of the International Congress of Oral Implantology (ICOI), created the concept of the dental implant study club supported by a worldwide implant organization in the early 1990s. Through the ICOI national networking organization, local various study clubs emerged that were “ICOI sponsored.” This sponsorship was helpful to the local study clubs in providing continuing education credits, speaker lists, agenda topics, certificates, club stationery, and other various ideas to create and continue a local program. The ICOI abandoned sponsorship of study clubs after almost a decade of support due to limited return in new members.

Rubenstein (1996) and several other well-known clinicians have advocated the concept of the dental study club. According to Christensen (Christensen 2001), dental study clubs provide a major opportunity for dentists to interact with other dentists and dental team members to learn in a friendly, non-threatening environment. In his opinion, they afford members the opportunity to increase their knowledge and clinical skills in using new concepts, materials, techniques, and devices. Christensen strongly supports the study club concept and feels it should be encouraged in all clinical disciplines throughout the country. Well-known author and speaker Frank Spear (Spear 2002), has taught numerous continuing education courses utilizing the study club concept. He identified the following criteria for success: • a respected mentor • open feedback • multiple points of view • a clear mission and structure • attention to the changing needs of the participants over time In 2004, the American Academy of Implant Dentistry (AAID) began sponsorship of implant study clubs. Its mission was to help promote a national and worldwide support system to the existing local implant study groups by its credentialed members. The role of the AAID is to supply the local organization with ADA/AGD-approved credits if needed, speaker lists, support, and marketing. To date, there are over 50 dental implant study clubs under the AAID umbrella.

John C. Minichetti, DMD, is a general dentist who has been placing and restoring implants for over 25 years. He is a fellow of the Academy of General Dentistry (AGD) and the American Academy of Implant Dentistry (AAID). He is also an honored fellow of the American Academy of Implant Dentistry and a Diplomate of the American Board of Oral Implantology/Implant Dentistry. Dr. Minichetti is a former faculty member of Fairleigh Dickenson University and Mt. Sinai Medical School and an attending at Englewood Hospital. He is Past President of the Northeast district of the AAID and President of the Bergen County Dental Implant Study Group, past Co-Director of the NY AAID Study Club at NYU, and Past Chairman of the AAID Research Foundation. Dr. Minichetti is a Past-President of the AAID. Dr. Minichetti is the Director of the Dental Implant Learning Center where he instructs a yearlong “mini-residency” for dentists teaching both implant surgery and restoration. He is also the Director of the Las Vegas AAID MaxiCourses® in Implant Dentistry at UNLV, School of Dental Medicine and is on the faculty at the Zimmer Biomet Institute. He has published numerous scientific articles and lectures worldwide and can be reached at DrMinichetti@EnglewoodDental.com.

40 Implant practice

The study club model The formation of an implant study group is a win-win for the organizers and members. The organizer (implant study club president) helps to set the programming and study club format. The study club could be organized in a number of formats — full day/half-day programs, lab programs, product update sessions, staff training, hands-on manufacturer programs, or even clinical sessions. The most popular study club scenario seems to be the evening session meeting. This allows doctors to attend the study club after work hours, without losing time from their busy practices. The total number of sessions over the year varies from club to club. Continuing education credits are awarded by a sponsoring organization based on the attendance hours of each session (available from the AAID, AGD, ADA, etc.) to their members. Most evening meetings provide food to the participants to allow direct access to the meeting from their offices. The group meetings can be held at a local dental office, conference center, restaurant, hotel, hospital, or school depending upon the number of participants and budget of the group. Facility fees are passed on to the implant study group members through dues or registration fees. Most dental implant study clubs have an officer or advisory board. This was originally recommended by (Cohen 1992) who proposed the surgical specialist creating a referral source. The AAID elevated this concept to a study club president, “who is a credentialed associate fellow of their Academy.” This provides a leader of the club who has a level of knowledge and clinical experience in both the surgery and prosthetics who can organize the educational needs of the group. As mentioned by Spear (2002), it is important to have a good mentor in charge of the study club. Credentialed members of the AAID or specialists help serve in this capacity. Many dental implant study clubs have local names for the group, often regional in designation. Volume 9 Number 6

EDUCATOR INSIGHT

Although not necessary, individual study groups can draft bylaws for their clubs. Elections for a change of position of officers at the study club should be available to allow for continued existence. Often it’s beneficial for the president or organizer to remain as long as not contested, so as to provide continuity in leadership, mentoring, communication with the group, and CE-sponsoring abilities. Dues are usually collected by the organizer, determined by the costs of operation which cover speakers’ fees, food and beverage, facility fees, audiovisual needs, etc. The club can apply for nonprofit status, although the club organizer should check with his/her accountant. Some clubs have corporate sponsors at their meetings. Implant representatives, dental supply companies, dental laboratories, marketing companies, website companies, and financial corporations are excellent sponsors that can help defray study club costs and contribute to the educational process.

The dental implant study club is a way in which clinicians can get together on a regular informal basis to share scientific, practical, and clinical information.

The study club meetings The implant study club allows a small group of doctors to meet locally and discuss a number of topics. Lecture formats seem to be the most popular. If they can be incorporated, clinical sessions are an excellent adjunct to the study club format. The smaller size of the local study group often allows for participatory involvement with either laboratory work or the “hands-on” model-type education. Case presentations by the members engage the audience and allow for the sharing of complications and troubleshooting. For a newly formed club, literature review is an excellent way to kick off the group. The president could start his/her meeting with discussion of the articles. This not only shares important information, but also helps prepare members for credentialing in their organization. Conducting a meeting is simple. The meeting is called to order before or during food service. Business news is announced, and opinions for future sessions are suggested. Case presentation can be performed by individual members prior to the main speaker or topic of the session. Introduction of speakers or lecture topics would follow. Any lab or clinical hands-on could then ensue. With all the developments in implant dentistry, there are so many topics to present to the group. All aspects of implant dentistry are advocated. The use of various implant manufacturers’ systems can be presented. Volume 9 Number 6

Topics on dental implant treatment planning, marketing, implant surgery, prosthetics, staff training, diagnosis, medical evaluation, anesthesia, CBCT diagnostics, CAD/CAM technology, and other implant-related topics could be discussed. Some clubs may find it beneficial to discuss financial planning, practice management, general dentistry, or specialty courses in their program. The small size of an implant study club allows for open discussion of topics, techniques, or case complications in a non-threatening arena.

Study club organization The local study club president as the organizer, takes attendance, keeps a list of members’ names, office addresses, email addresses, and phone numbers. The local study group should market and make efforts to promote the attendance of the club members. The officers are responsible for awarding continuing education credits to the members and documenting attendance. Speaker surveys are a must to ensure quality of the presentations and programs, as well as to allow for planning topics of interest. SurveyMonkey® is an easy-to-use online survey service, although paper forms work for many groups. The study club president can market his/ her club to the group via emails or social media. By marketing the implant study club, the organizer or president promotes himself/

herself as a leader in the dental implant field enhancing his/her image in the local community among patients and colleagues. The AAID can support or supply local news press releases regarding the formation of an AAID study club. A newsletter can be produced by the club with abstract articles, announcements of AAID meetings course, etc. The newsletter would be distributed by the club to members and could also be used as marketing tool for non-members of the study club. Remember that new membership is necessary to keep the club alive. Some of the country’s leading clinicians have recommended the implant study club method of education as a great way for dentists to gather locally. This is a great way to share information with colleagues while gaining knowledge and camaraderie. With implant dentistry developing at an exponential rate, it may be time to consider the benefits of starting a dental implant study club. IP

REFERENCES 1. E Cohen, M: Study club creates more interest in implants. Dental Economics July 1992 2. Judy KW. The future of implant education: a prediction. Implant Dent. 1993;2(1):1. 3. Rubenstein JE, Corbett SM. The study club as a continuing education format for training in implant dentistry. J Dent Educ. 1996;60(3):297-301. 4. Christensen GJ. It’s time to revive dental study clubs. J Am Dent Assoc. 2001;132(5):677-679. 5. Spear FM. My growing involvement in dental study groups. J Am Coll Dent. 2002:69(4):22-24.

Implant practice 41

PRACTICE DEVELOPMENT

Online case collaboration provides key information Dr. Bryan Laskin discusses how to eliminate frustration in communicating with referring clinicians

he world of case collaboration can be frustrating to say the least. Tracking down misplaced faxes, snail mail, and unreadable “chicken scratch” handwriting prolongs and complicates the overall process. Knowing there is an all-in-one online HIPAA-compliant solution to correspond with specialists, labs, and patients alleviates the pains of collaboration and streamlines the entire process. Using OperaDDS can solve the problems in collaborating cases resulting in better patient care, better preparedness, and better efficiency. To demonstrate the benefits of online case collaboration, let’s explore a less than ideal, but certainly not uncommon case. A patient presents to the clinic with a dull ache on the lower left, no obvious trauma with the exception of 19 MOD composite done approximately 6 years prior. The patient indicates the filling was done to replace a DO amalgam and repair mesial caries. After diagnostic testing and inconclusive results, a 6-mm pocket is found, indicating a potential periodontal abscess. The clinician has a conversation with the patient and recommends that the patient sees a periodontist to evaluate and treat the area in question. A written referral to the periodontist is completed, and radiographs are sent with the patient, per his/her request, indicating the requested treatment for the patient. After the patient leaves, the GP creates an online referral prescription via Chorus and instantly uploads the radiograph to the periodontist, ensuring the information will be ready and waiting when the patient arrives. The patient is then seen at the periodontist with the expectation that all the information he/she needs is in the specialist’s hands. Unfortunately, it is extremely common for the referred office to not have the information necessary

when the patient presents for treatment. With online, secure case collaboration, the periodontist is able to acquire any missing information by accessing the patient’s Chorus referral and seeing the findings from the GP. In this case, the periodontist evaluates the tooth in question and finds the tooth to be vital with no significant findings, and the patient is referred back to the general dentist to further evaluate with a suggestion that he/ she see an endodontist. The periodontist returns to Chorus to input his/her findings and recommendations, instantly being available to the GP. The saga continues when the patient realizes that the periodontist and his/her general dentist are just down the block from each other — why not pop right in for a quick look, right? A walk-in consult appointment can throw a kink in any schedule, especially a consult with no communication from the

Bryan Laskin, DDS, is a 1999 graduate of the University of Minnesota Dental School. He operates Lake Minnetonka Dental, a successful private practice in Wayzata, Minnesota, that has a keen focus on efficient, esthetic restorative dentistry. The goal of the practice is to exceed expectations, using the latest technology in a friendly, comforting environment. Dr. Laskin is an advanced Patterson-certified CEREC trainer and founder of the Minnesota CEREC and Galileos Study Club, as well as developer of the OperaDDS suite of communication tools — bringing secure email, collaboration, smooth intra-office messaging, and simplified patient recall to dental offices affordably. Disclosure: Dr. Laskin is the founder and CEO of Prehensile Software, the company that makes OperaDDS.

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specialist. Now it is in the hands of the patient to relay the findings of the periodontist, and we all know how that goes. As the general dentist continues to gather the information and recall the previous findings of the case, he/she obtains the information from the specialist via Chorus and has the auxiliary staff relay the next route is to see an endodontist. No need for the patient to set foot in the operatory. The information is added to the existing referral with all the correspondences, and the endodontist’s contact information is printed directly from the online referral and delivered to the patient. The communication continues to snowball when the patient presents to the endodontist with a referral from the general dentist requesting the evaluation of tooth No. 19. The endodontist has viewed the Chorus referral and knows that this patient is frustrated with the runaround and continued pain. The patient communicates that he/she has no information to relay because there have been numerous visits and inconclusive results. Unbeknown to the patient, the communication is there and complete. The endodontist informs the patient of the previous findings and recommends the following treatment: Proceed with RCT to alleviate pain, knowing it may not be the source, or return to the GP for antibiotics and wait it out. The patient has had enough Volume 9 Number 6

Volume 9 Number 6

and the recommended treatment by the endodontist and himself/herself. As the patient presents to the oral surgeonâ&#x20AC;&#x2122;s office for evaluation, he/she is again presenting with limited information to hand over to the surgeon. The oral surgeon, well versed on the case attributable to the thorough collaboration of the online portal, is recommending an implant be placed to restore the missing tooth and is confident that the patient is aware of the situation. The patient is apprehensive because of the multiple appointments and specialists, but through the real-time information, the oral surgeon quickly reviews the case findings with the patient and eases his/her mind. Feeling confident with the information given, the patient agrees to proceed with treatment. Months later, the GP contacts the patient to restore the implant. The oral surgeon added the implant information to the Chorus case, enabling the GP to be prepared for the restorative phase. The patient presents with flawless sequencing, all because the information was thoroughly and cleanly provided to the dentist in a timely manner. There is in no deciphering poor penmanship as to what type or size of implant parts are needed. Additionally, the GP uses Chorus to write a lab prescription and inform them the case is ready for pickup. The lab is notified

of the case and hurries over to receive it and begin working on it. Using Chorus takes the guesswork out of case returns; utilizing the status update feature allows the dental office to see in real time that the case is on the way back from the lab, and the receptionist is able to call the patient to schedule and expedite the crown seat appointment. The patient is finally complete. While the diagnosis and treatment planning were less than ideal in this case, it could have been a much lengthier and messier collaboration if the information was passed in a more traditional phone and snail-mail manner. As illustrated with this case, communication is key to providing excellent patient care, especially when it involves case collaboration. A breakdown in communication between the primary dentist and the specialists can be unfavorable to patientsâ&#x20AC;&#x2122; overall dental care. Utilizing the latest technology to communicate with all parties regarding a patient case will streamline the case process, in turn providing better patient care. With online case collaboration tools, the collapse in communication can be avoided. Utilizing OperaDDS to orchestrate the complicated world of case collaboration is the solution to providing excellent and thorough dentistry to your patients. IP

Implant practice 43

PRACTICE DEVELOPMENT

of the pain and wants the treatment done but is indecisive on the best course of treatment, looking to the endodontist for recommendations. The endodontist directs to the online case portal and informs the general GP of recommendations for the patient. With the easy ability to communicate with the GP at his/her fingertips, the endodontist is confident that the patient will receive the care he/she is seeking. Within minutes, the endodontist returns to the patient with the recommendations of the GP and discusses what is in the patientâ&#x20AC;&#x2122;s best interest. Together they proceed with the root canal therapy, confident the patient will be pleased with the results. Unfortunately, the outcome is unfavorable; the tooth appears to have vertical root fracture, and the tooth is unrestorable. The endodontist informs the patient and proceeds with adding the information to the Chorus referral. There is no need for the patient to contact the GP because the information is already available to him/her and he/she can call the patient with the oral surgeon contact information. In addition, the GP emails the patient via secure email the recommended treatment and patient education forms regarding the procedures. The dentist contacts the patient to relay the contact information to the oral surgeon

PRACTICE DEVELOPMENT

What you need to know about online reviews for your practice Ian McNickle, MBA, discusses the importance of a strong online presence

magine you’ve just arrived in a city you’re not very familiar with, and it’s dinnertime. What do you do? Well, if you’re like most people these days, you’ll pull out your smartphone and search online review sites such as Yelp for nearby restaurant reviews. In fact, over 90% of consumers now read online reviews to help them decide where to go and what to buy.* While it is true the most commonly searched category for online reviews are restaurants, most people don’t realize the second most commonly searched category for online reviews is dentists/doctors.* The days of ignoring your online reviews are over.

Why do reviews matter? There is a major trend toward patients researching their healthcare providers before visiting an office, even if they were referred by a friend or another healthcare provider. In fact, recent surveys have found that 80% of consumers trust online reviews just as much as personal recommendations from someone they know.* For many people, this is an amazing statement, but the reality is our society is changing at a rapid pace, and dental practices simply must focus on their online reviews and online reputation.

The “Big Four” review sites for dentistry In the dental industry, the most important review sites are Google+, Yelp, Healthgrades®, and Facebook®. Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a co-founder and partner at WEO Media, winner of the 2016 Cellerant “Best of Class” Award for Dental Marketing and Dental Websites. If you have questions about any marketing related topic, please contact Ian McNickle directly at ian@weomedia.com, or by calling 888-246-6906. For more information, you can visit WEO Media online at www.weodental.com.

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Google represents about 65% of all online search traffic and features its own reviews from Google+, so those reviews will generally attract more readers than other review sites. Reviews on Google+ have the added benefit of helping your website SEO perform better in online searches related to dentistry. Yelp has become one of the leading review sites in the country and regularly ranks highly in local search results when people search for dentists. In addition, the Bing search engine displays Yelp reviews as its primary reviews shown in search results. Healthgrades is the largest healthcare directory and review site in North America and has over 1,000,000 visitors per day. As with Google+ and Yelp, a solid Healthgrades profile helps both online reputation and website SEO. Over the last few years, Facebook reviews have become increasingly important since Facebook is the dominant social media site. Facebook has over 1.7 billion regular users, and most of them look at reviews on Facebook business pages when researching a business.

What can you do for your dental practice? To get the maximum benefit from these review sites, we recommend the following strategies:

1. Completely fill out your review site profile pages with business information, photos, videos, office hours, specials, and any other relevant information about your practice. 2. Link to your review sites from your website to encourage existing patients to write reviews, and potential new patients to read your reviews. 3. Implement a proactive strategy to generate more patient reviews on these review sites. However, we highly recommend you contact your state dental association or Dental Board to make sure you understand the rules for soliciting reviews from patients in your state. 4. Embed your positive patient reviews directly into your website.

Marketing consultation If you have questions about your website, social media, or online marketing, you may contact WEO Media for a consultation to learn more about the latest industry trends and strategies. The consultation is FREE if you identify yourself as a reader of this publication. IP

REFERENCE *

Bright Little Light, Ltd. Local consumer review survey 2015. BrightLocal. https://www.brightlocal.com/learn/localconsumer-review-survey/. Accessed September 22, 2016.

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com Volume 9 Number 6

REPLICATE™ Immediate Tooth Replacement System to be featured and demonstrated at ACTA, Amsterdam

On September 9, during the General Assembly of the 2016 FDI World Parliament in Poznan, Poland, The Academy of Osseointegration (AO) was elected to Affiliate Member status, following 5 years as a Supporting Member. FDI Affiliate Members are not-forprofit international dental associations with significant international membership and interests, representing dental organizations whose missions are in line with those of FDI. In 2017, AO will participate in its inaugural regional engagement in the FDI Global CE Program (FDI GCEP) held September 21-24, 2017, in Shanghai, China. Also, the program for the AO’s 2017 Annual Meeting is now available on the Academy’s website. AO’s 32nd Annual Meeting, being held March 15-18, 2017, in Orlando, Florida, is themed “GOOD TO GREAT®,” an idea inspired by the book, Good to Great: Why Some Companies Make the Leap … and Others Don’t, by Jim Collins. The event will be a collaboration with the American Association of Oral and Maxillofacial Surgeons (AAOMS), the American Academy of Periodontology (AAP), and the American College of Prosthodontics (ACP). For more information, visit https://osseo.org/.

Natural Dental Implants (NDI), AG announced that its REPLICATE™ Immediate Tooth Replacement System 2.0, which is currently seeking FDA approval, would be featured and demonstrated during the upcoming first Root Analogue Implant REPLICATE™ Tooth Congress at the Academisch Centrum Tandheelkunde Amsterdam (ACTA) in November 2016. The REPLICATE™ System 2.0 features the REPLICATE™ Tooth, an anatomically shaped, 100% customized, titanium-zirconia tooth, and the REPLICATE™ Temporary Protective Crown, a customized cover shield designed to protect the REPLICATE™ Tooth during the healing process. This new approach to single-tooth replacement offers patients an immediate, minimally invasive alternative to traditional dental implants and three-unit bridges. Visit www.replicatetooth.com to learn more.

Osstell Partners with W&H to bring innovative and integrated solution to dental implant procedures Osstell announced its partnership with the Austrian familyrun dental company, W&H Dentalwerk Bürmoos GmbH. The first result of this partnership is now being introduced in the form of W&H’s latest generation surgical device, Implantmed, where an integrated Osstell ISQ (Implant Stability Quotient) module is available. This unique combination of technologies W&H Managing Director Peter Malata and offers significant benefits in terms Osstell CEO Jonas Ehinger of functionality and optimum efficiency during treatment. The integration of the proprietary Osstell ISQ technology in the new Implantmed device allows the user to benefit from noninvasive monitoring of osseointegration. Knowing the right time to load an implant is becoming increasingly complex due to all the key parameters and risk factors that need to be considered for each patient. The ISQ measurements allow clinicians to make decisions based on reliable and objective stability values when determining the course of implant treatment for each patient. This procedure can be used to measure primary implant stability, observe osseointegration on the basis of secondary stability readings, and determine the best possible time for loading the implant, thereby helping to prevent failures and ensuring high quality. For more information about Osstell, please visit Osstell.com. To learn more about Implantmed, visit http://www.wh.com/en_ global/dental-products/oralsurgery-implantology/surgical-devices/ implantmed/.

Volume 9 Number 6

AAID legal victory opens path for additional dental specialties The American Dental Association’s House of Delegates enacted amendments to the ADA Principles of Ethics and Code of Professional Conduct that acknowledge dental specialties recognized in a practitioner’s jurisdiction even if not formally recognized by the ADA. According to the rationale distributed by the ADA Council of Ethics, Bylaws and Judicial Affairs, “Over the past several years, compelled by court decisions, states have begun to recognize specialties beyond the nine dental specialties recognized by the ADA.” The amendment to Section 5.H. of the Code would permit educationally qualified dentists practicing in areas of dentistry recognized as specialties in their jurisdictions but not by the ADA to announce as specialists. Frank Recker, DDS, JD, attorney for the American Academy of Implant Dentistry (AAID), noted, “The American Academy of Implant Dentistry has been successful in pursuing the rights of dentists to advertise their credentials earned from bona fide organizations in specialties not recognized by the ADA. I believe that AAID’s recent victory in the state of Texas, in which a Federal District Court ruled that the state’s regulation that deferred only to the ADA specialties as unconstitutional, was a significant reason for the change voted on by the ADA House of Delegates.” Also, the AAID recognized three dentists with the highest awards given by the Academy during its recently concluded 65th Annual Conference. Art Molzan, DDS, FAAID, DABOI/ID, was recipient of the Aaron Gershkoff/Norman Goldberg Memorial Award; Sebastiano Andreana, DDS, MSc, received the Isaih Lew Memorial Research Award; and David Gimer, DDS, FAAID, DABOI/ID, has been named the recipient of the 2016 Paul Johnson Service Award. For more information, please visit www.aaid.com, or call 312-335-1550.

Implant practice 45

INDUSTRY NEWS

AO reaches next level in FDI global partnership and unveils AO’s 2017 Annual Meeting schedule

INDUSTRY OVERVIEW Global cosmetic dentistry expected to reach $27.95 billion by 2024 The growing focus on cosmetic dentistry is not isolated to the United States. In fact, one report forecasts that the global cosmetic dentistry market is expected to reach $27.95 billion by the year 2024.1 The demand for cosmetic dentistry across the nation — and even worldwide — represents the newest growth sector in dentistry. Cosmetic dentistry comprises dental procedures or products that change and improve the look of a person’s teeth, gums, or bite. Last year, cosmetic dentistry in the U.S. generated an estimated $16 billion in revenue.2 It’s not just millennial consumers who are looking for cosmetic upgrades. Aging baby boomers who have more financial resources are expanding the market for more dental products.3 The American Association of Oral and Maxillofacial Surgeons has estimated that 69% of adults between the ages of 35 and 44 have lost at least one permanent tooth. The increased focus on esthetics has led to a growing number of adults seeking tooth replacement options such as dentures, crowns, bridges, and implants. They want to keep their smiles esthetically pleasing and are willing to use more of their discretionary income on cosmetic treatments and procedures. As a result, more dental practices are seeking to upgrade or replace their existing dental equipment. Dental design technology systems can be used for a variety of cosmetic purposes, such as mapping a patient’s teeth using 3D graphics to better visualize where implants or other dental

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT 3Shape Launches TRIOS® 3 Mono intraoral scanner 3Shape has launched TRIOS® 3 Mono — a new entry-level version of its award-winning TRIOS 3 intraoral scanner. TRIOS 3 Mono delivers the same documented-accuracy, speed, and ease of use of all TRIOS intraoral scanners but takes digital impressions without color. It will sell at an extremely competitive price point at nearly 40% less than TRIOS 3 color models. TRIOS Mono delivers many of the same award-winning features of TRIOS 3 color models, including the widest range of indications, texture and stone model scans, and HD photos. Doctors can offer same-day dentistry using optional 3Shape practice lab. As a special bonus, the TRIOS 3 Mono is upgradable to a TRIOS 3 color model at any time. The cost of the upgrade is the price difference between the two scanners and a service fee. When upgrading to a TRIOS color model, the upgrade includes RealColor™ scanning, digital shade measurement, and an integrated intraoral camera. Learn more about TRIOS at http://www.3shape.com/ TRIOS.

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products might be used. Forward-thinking dentists are already looking for ways to integrate the newest and best cosmetic dental equipment. However, the high cost of some of these systems is preventing some practices from keeping up with current trends. Additionally, many cosmetic procedures are not currently reimbursed by insurance, which could limit the market’s growth if some providers choose not to take advantage of this growing consumer base. Adrian LaTrace, CEO of Boyd Industries, designer and manufacturer of specialty dental and medical operatory equipment, points out, “To be modern — to keep up with the demands of your patients and set yourself apart from your competition — you have to be willing to update your old dental equipment and position your practice to be able to provide cosmetic dentistry services.” He explains that this is the way the market is trending, and if one is not prepared to move with it, one’s practice could be left behind. 1. Grand View Research Inc. Cosmetic dentistry market to reach $27.95 billion by 2024. July 2016. https://www.grandviewresearch.com/press-release/global-cosmetic-dentistry-market. Accessed November 10, 2016. 2. Cosmetic Dentistry Market Forecast to 2024—Segmented by Product & Region—Research and Markets. Business Wire. September 9, 2016. 3. Brocair Partners. Dental Products Industry Perspective. November 2014. http://www. brocair.com/pdfs/Dental%20Products%20Industry%20Perspective%202014.pdf. Accessed November 10, 2016.

LED Medical Diagnostics announces launch of RAYSCAN Alpha Plus imaging system LED Medical Diagnostics Inc., through its wholly owned U.S. and Canadian operating subsidiaries, LED Dental Inc./LED Dental Ltd., has announced the launch of the RAYSCAN Alpha Plus, a next-generation extraoral imaging system that is the latest innovation from former Samsung Electronics subsidiary RAY Company. Clinicians can utilize the RAYSCAN Alpha Plus to capture high-resolution panoramic, cephalometric, and cone beam computed tomography images. The panoramic modality allows for a variety of 2D panoramic examinations, including standard pano and segmented pano acquisitions, in addition to an extraoral bitewing feature. The CBCT modality includes an innovative light-guided field-of-view that simplifies patient positioning to reduce errors and retakes. The system also utilizes Free FOV technology, which makes the field-of-view completely customizable from 4 x 3 cm to 16 x 10 cm. The RAYSCAN Alpha Plus allows practitioners to collimate the field-of-view to any size, limiting radiation exposure to the smallest area possible to still acquire the needed anatomy. The CBCT modality delivers voxel resolutions as small as 70 μm, and new proprietary algorithms allow for images to be reconstructed in as little as 4.9 seconds. The optional cephalometric module is available in either scanning or one-shot options, with the one-shot module acquiring images in less than 1 second to further reduce image distortion and reduce radiation dose. For more information, call 844-952-7327, or visit www. leddental.com.

Volume 9 Number 6

Dr. Justin Moody and his faculty will mentor and guide you down the implant pathway. You’ll learn... ✔

Live Implant Surgery and Restorations Done by YOU

✔ Patient Selection, Medical History and Pharmacology ✔ Treatment Planning and Case Acceptance ✔ Surgical Implant Placement

✔ Ridge Preservation and Bone Grafting ✔ Guided Implant Surgery

✔ Complications When It Don’t Go Right

San Francisco

Denver

Orange County

Dallas

My Clinical Pathway (MCP) is an ADA CERP provider. CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/goto/cerp. Approval Term: 5/1/2015 through 6/30/2019

save with early bird registration only at

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five cities four sessions one goal learn implant dentistry

Phoenix

My Clinical Pathway (MCP) is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 4-1-2015 to 3-31-2019. Provider #: 342679

DO YOU KNOw how to TREATMENT PLAN and deliver implant dentistry TO YOUR PATIENTS?

Diplomate - American Board of Oral Implantology Diplomate, Master and Fellow - International Congress of Oral Implantologists Fellow and Associate Fellow - American Academy of Implant Dentistry Master and Fellow - Misch International Implant Institute Adjunct Professor - University of Nebraska Medical Center Mentor - Kois Center

Learn more at justinmoodydds.com

ON THE HORIZON

What happens when your real teeth give up? Dr. Justin Moody discusses solutions for a difficult diagnosis

he hardest decision for any patient is whether to remove all of his/her teeth. Communicating the diagnosis of a terminal dentition and how you approach this dilemma with the patients make all the difference in their solution — whether they lean toward a denture or a fixed apparatus on implants as a true tooth replacement. We all succumb to the “break a tooth-fix a tooth model” at some point in our careers, and our patients can be very persuasive in getting us to fix these teeth or just buy them some time by patching them up. If we really look at our patients’ time as money, you quickly notice that the cost of all these appointments for the patients adds up to many times over the most prudent solution. What is real tooth replacement? It’s placing enough dental implants to maintain bone throughout the arch as well as teeth that are secure enough so that the patient can eat for proper nutrition. The removal of the terminal dentition and placement of a secure treatment prosthesis held in place with dental implants is for many the ideal treatment. In order to provide these treatment plans, clinicians must understand the patients’ desires and their own skill set. In my practice, the use of the BioHorizons® TeethXpress® protocol for immediate loading has streamlined this process and allowed me to treat more patients efficiently. The use of 3D imaging, proper treatment planning, and good prosthetic planning allows for reliable and predictable results. Prosthetic solutions range from hybrid acrylic screw-retained restorations to full arch hand-stacked zirconia bridges. I have been using Pro Zirconia from Prosmiles Dental Studio for my final restorations; the results have been so much better than acrylic as I just got tired of dealing with broken acrylic

Figure 1: Terminal dentition on a 67-year-old white male

Figure 3: Full upper and lower Pro Zirconia bridges from ProSmiles Dental Studio

Figure 4: High-translucent monolithic zirconia with cut back gingiva and hand-stacked porcelain from ProSmiles Dental Studio

Figure 5: Post-prosthetic pano showing the density of the zirconia taken with the Carestream 8100

Figure 6: 3D volume rendering using the Carestream 8100

Justin Moody, DDS, DICOI, DABOI, is a Diplomate of the American Board of Oral Implantology and of the International Congress of Oral Implantologists, Fellow and Associate Fellow of the American Academy of Implant Dentistry, and Adjunct Professor at the University of Nebraska Medical College. He is an international speaker and is in private practice at The Dental Implant Center in Rapid City, South Dakota. He can be reached at justin@justinmoodydds.com or at www.justinmoodydds.com. Disclosure: Dr. Moody is a paid speaker for BioHorizons®.

48 Implant practice

Figure 2: Six upper BioHorizons® Tapered PLUS dental implants with multi-unit abutments

Figure 7: Life-changing results

and worn teeth. It’s nice to tell the patient that we have a more permanent solution with less wear and breakage and increased esthetics! IP Volume 9 Number 6

no more

compromises

The Tapered Internal family of dental implants provides excellent primary stability, maximum bone maintenance and soft tissue attachment for predictable results. All implant diameters from 3.0 to 5.8 can be placed with the same instrument kit providing you surgical convenience and flexibility to choose the ideal implants for each patientâ&#x20AC;&#x2122;s needs. With all these features, you no longer have to accept the clinical compromises that come with other implant systems.

restorative ease

universal surgical kit

45Â° conical internal hex connection creates a robust, biologic seal and is color-coded for quick identification and component matching

intuitive color-coded instrumentation used to place all BioHorizons tapered implants*

connective tissue attachment Laser-Lok uniquely creates a physical connective tissue attachment and biologic seal

bone attachment Laser-LokÂŽ microchannels achieve superior osseointegration

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

Made in the USA

*Tapered Plus, Tapered Tissue Level, Tapered Internal and Tapered 3.0 SPMP13154 REV F JUL 2016

InterActive™ Nobel Biocare® Compatible* Simply Smarter Conical Connection

IQity Impression Technique™ Patent pending fixture-mount design provides:

Simply Smarter Restorations

• The ease of a closed-tray impression • The accuracy of an open-tray impression • The versatility to create impression at either implant-level or abutment-level

Neck Matched to Major Diameter • Seals opening at crest of ridge reducing need for bone grafting

Matched Concave Transgingival Profile on Abutments & Components • Shape soft tissue for improved esthetics Compatible Abutments with Longer Hex/Shorter Bevel • Reduce the need to confirm seating with X-rays Two Color-coded Implant Platforms for Four Implant Diameters & Six Lengths • Restore more implants with a smaller prosthetic inventory and easily identify the correct size

Simply Smarter Surgery

Domed Apex • Less aggressive apex reduces risk during insertion of implant diverging from path created by drilling Apical 1/3rd Tapers 2º • Slight body taper increases initial stability without over-compression and facilitates self-tapping insertion in dense bone Micro-threads and Grooves • Micro-grooves and micro-threads to increase stability as well as reduce stress in crestal bone area

Packaging Options

All-in-1 Packaging

Includes implant, cover screw, healing collar & new fixture-mount – $225 SBM

NEW simplyInterActive includes mountfree implant, cover screw & 3mm healing collar – $195 SBM, $175 if SMART PACK purchased at same time Plastic simplyfixed Ball SMART PACK simplycrown & bridge Laboratory Straight 15° Angled Gold/ Zirconia Temporary LOCATOR® Abutment Contoured Abutment Plastic Straight Angled Contoured Abutment Abutment Abutment SMART PACK

*Nobel Biocare® NP & RP compatible. All trademarks are property of their respective companies. Measurements based upon 4.3mm diameter, 13mm length implants. Dimensions can vary. All prices shown in USD. Pricing and product availability subject to change without notice. Not all products shown are available in all countries.