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July 2013
incision bone graft
bone flap tissue
CT scan
SimPlant data
Dental
stent
periodontal ligament
osseous jawstereolithography
Implants
Bruxism
linkow
implant failure osteotomy
stent
root replacement saline ridge augmentation
guided bone CT scan
res
anchorage
alveolar bone
p
computed tomo
Immediate Loading
regeneration
peri-implantitis
mucosa X-ray bridge
IAN
prosthetic
placement framework
pilot hole
oral surge
endosseous
osteointegration
titanium screw
NobelGuide
mini implant dentistry
root-form
jawbone
branemark
titanium
crowns
CT scan
flap
atrophic maxilla
implant survival
teeth
CBCT
tooth replacement
implant loading
subperiosteal
patient
CAD/CAM
temporary anchorage device osteoblast
mandible
Drilling
periodontal ligament
immediate implant placement
prosthetic
cover screw
sinus lift surgery
dentistry
osteotomes
TEXAS DENTAL
maxillary sinus
inferior alveolar nerve osteotomy
inferior alveolar Texas Dental Journal l www.tda.org l July 2013 565 canal rehabilitation
Plan to Attend
Education
Participate in challenging, cutting-edge CE courses that fit into your schedule and budget
Exhibition
Research and purchase dental products and services at a discount
Connections
Advance the dental industry through the House of Delegates and mingle with colleagues
The ADA Annual Session is your national dental meeting. Visit ADA.org/session for more information and register May 1!
TEXAS DEnTAl JournAl Established February 1883
n
Vol 130, No 7
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July 2013
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SPECIAL ISSUE: IMPLANT DENTISTRY Implant dentistry requires careful and complete planning to ensure successful osseointegration and outcomes. New software and techniques allow implant options for the endentulous patient.
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A TECHNIQUE FOR FABRICATING A MILLED TITANIUM COMPLETEARCH FRAMEWORK USING A NEW CAD/CAM SOFTWARE AND SCANNER WITH LASER PROBE Ilser Turkyilmaz, DDS, PhD; and Neset Volkan Asar, DDS, PhD The authors’ report presents a milled titanium complete-arch mandibular framework using a new planning software and a new scanner using non-contact laser probe, which eliminates the need for wax pattern fabrication.
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PREDICTABLE IMMEDIATE LOADING OF MANDIBULAR IMPLANTS Kelvin I. Afrashtehfar, DDS, FADI; and Cyrus D.M. Afrashtehfar, MD The article addresses various aspects to be considered such as computed tomography, surgical guides, implant considerations for the endentulous patient, and considerations for immediate implant placement and loading.
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RESTORATION OF CONGENITALLY MISSING MAXILLARY LATERAL INCISORS USING MINI IMPLANTS Ron Collins, DDS, MAGD The author presents a case to demonstrate the usage of mini implants, or small diameter implants, for a narrow ridge application to restore congenitally missing maxillary lateral incisors.
MONTHLYFEATURES 572
President’s Message
622
Dental Artifacts
582
Oral and Maxillofacial Pathology Case
623
In Memoriam / TDA Smiles Foundation
of the Month
and Memorial and Honorarium Donors
595
TDA 143rd Annual Session 2013 TEXAS
624
Calendar of Events
Meeting Photo Contest
626
Value for Your Profession
618
Critically Appraised Topic of the Month
630
Advertising Briefs
620
Oral and Maxillofacial Pathology Case of
646
Index to Advertisers
the Month Diagnosis and Management
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Texas Dental Journal l www.tda.org l July 2013
TDA members, use your smartphone to scan this QR Code and access the online Texas Dental Journal.
Editorial Staff
Editorial Advisory Board
BOARD OF DIRECTORS TEXAS DENTAL ASSOCIATION
Stephen R. Matteson, DDS, Editor-in-Chief Daniel L. Jones, DDS, PhD, Associate Editor Harvey P. Kessler, DDS, MS, Associate Editor Nicole Scott, Managing Editor Lauren Oakley, Publications Coordinator Barbara Donovan, Art Director Paul H. Schlesinger, Consultant
Ronald C. Auvenshine, DDS, PhD Barry K. Bartee, DDS, MD Patricia L. Blanton, DDS, PhD William C. Bone, DDS Phillip M. Campbell, DDS, MSD Michaell A. Huber, DDS Arthur H. Jeske, DMD, PhD Larry D. Jones, DDS Paul A. Kennedy Jr, DDS, MS Scott R. Makins, DDS Daniel Perez, DDS William F. Wathen, DMD Robert C. White, DDS Leighton A. Wier, DDS Douglas B. Willingham, DDS
The Texas Dental Journal is a peer-reviewed publication. Texas Dental Association 1946 S IH-35 Ste 400, Austin, TX 78704-3698 Phone: 512-443-3675 • FAX: 512-443-3031 E-Mail: tda@tda.org • Website: tda.org Texas Dental Journal (ISSN 0040-4284) is published monthly, one issue will be a directory issue, by the Texas Dental Association, 1946 S IH-35, Austin, TX, 78704-3698, 512-443-3675. Periodicals Postage Paid at Austin, Texas and at additional mailing offices. POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S IH 35, Austin, TX 78704. Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, Out-ofstate ADA Affiliated $49.50. In-state Non-ADA Affiliated $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA Affiliated, $17 Non-ADA Affiliated, September issue $17 ADA Affiliated, $65 NonADA Affiliated. For in-state orders, add 8.25% sales tax. Contributions: Manuscripts and news items of interest to the membership of the society are solicited. Electronic submissions are required. Manuscripts should be typewritten, double spaced, and the original copy should be submitted. For more information, please refer to the Instructions for Contributors statement printed in the September Annual Membership Directory or on the TDA website: tda.org. All statements of opinion and of supposed facts are published on authority of the writer under whose name they appear and are not to be regarded as the views of the Texas Dental Association, unless such statements have been adopted by the Association. Articles are accepted with the understanding that they have not been published previously. Authors must disclose any financial or other interests they may have in products or services described in their articles. Advertisements: Publication of advertisements in this journal does not constitute a guarantee or endorsement by the Association of the quality of value of such product or of the claims made of it by Texas Dental Journal is a member of the its manufacturer. American Association of Dental Editors. Member Publication
PRESIDENT David A. Duncan, DDS 806-355-7401, davidduncandds@gmail.com PRESIDENT-ELECT David H. McCarley, DDS 972-562-0767, drdavid@mccarleydental.com IMMEDIATE PAST PRESIDENT Michael L. Stuart, DDS 972-226-6655, mstuartdds@sbcglobal.net VICE PRESIDENT, NORTHWEST David C. Woodburn, DDS 806-358-7471, olddave1@gmail.com VICE PRESIDENT, NORTHEAST Jean E. Bainbridge, DDS 214-388-4453, jbainbridgedds@sbcglobal.net VICE PRESIDENT, SOUTHEAST Gregory K. Oelfke, DDS 713-988-0492, greg@oelfke.com VICE PRESIDENT, SOUTHWEST Yvonne E. Maldonado, DDS 915-855-2337, yvonnedent2000@yahoo.com SENIOR DIRECTOR, NORTHWEST Steven J. Hill, DDS 806-783-8837, sjhilldds@aol.com SENIOR DIRECTOR, NORTHEAST Jerry J. Hopson, DDS 903-583-5715, dochop@verizon.net SENIOR DIRECTOR, SOUTHEAST William S. Nantz, DDS 409-866-7498, wn3798@sbcglobal.net SENIOR DIRECTOR, SOUTHWEST Joshua A. Austin, DDS 210-408-7999, jaustindds@me.com DIRECTOR, NORTHWEST Charles W. Miller, DDS 817-572-4497, cwdam@sbcglobal.net DIRECTOR, NORTHEAST William H. Gerlach, DDS 972-964-1855, drbill@gerlachdental.com DIRECTOR, SOUTHEAST Karen A. Walters, DDS 713-790-1111, kwalters@sms-houston.com DIRECTOR, SOUTHWEST John B. Mason, DDS 361-854-3159, jbmasondds@aol.com SECRETARY-TREASURER Ron Collins, DDS 281-983-5677, roncollinsdds@yahoo.com SPEAKER OF THE HOUSE John W. Baucum III, DDS 361-855-3900, jbaucum3@msn.com PARLIAMENTARIAN Michael Vaclav, DDS 806-355-7463, drvaclav@suddenlinkmail.com EDITOR Stephen R. Matteson, DDS 210-215-1515, texdented@gmail.com EXECUTIVE DIRECTOR Aaron Washburn 512-443-3675, aaron@tda.org LEGAL COUNSEL Mr. William H. Bingham 512-495-6000, bbingham@mcginnislaw.com
Texas Dental Journal l www.tda.org l July 2013
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Dr. Ed Silva, a Fortress Dentist.
When you choose Fortress Insurance Company for your professional
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Texas Dental Journal l www.tda.org l July 2013
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President’s Message David Duncan, DDS, TDA President
As a dentist, we are all skilled in different areas, whether we are a general dentist or a specialist. The more we know of the advancements in our profession, the better we are as a dentist.
The American Dental Association does not recognize implant dentistry as a specialty; however, it takes a special skill and techniques to establish a complete treatment plan for edentulous patients. As a general dentist, I often see patients who could use the help of a dentist who carries out implant treatments. I feel that I am really good at 1 or 2 things; however, I am not one of those dentists who choose to do everything. I am a great coordinator and even better at implementation of a treatment plan, a treatment plan that often requires the expertise of specialists. So, if I know my patient is in need of my peer’s expertise, I definitely issue a referral. To me, implants is just one of those areas. In this issue of the Texas Dental Journal, you will read 3 wonderful articles on implant dentistry. These original articles touch on new techniques for planning and fabrication, technological advances in the field of oral implantology, and the advantages that mini implants have over conventional root form implants. As a dentist, we are all skilled in different areas, whether we are a general dentist or a specialist. The more we know of the advancements in our profession, the better we are as a dentist.
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PRACTICES ARE SELLING FOR CASH NOW! INCREASE PRACTICE VALUE ANALYZE KEY AREAS OF YOUR PRACTICE
LOCATION
DEMOGRAPHICS STUDY
APPEARANCE OF YOUR OFFICE
TAKE PHOTOS OF EVERY AREA
SIZE OF PATIENT BASE
3 YEARS OF GROWTH TRENDS
NEW PATIENT FLOW
EXPLORE INTERNET MARKETING
ACTIVE RECALL
20% – 30% OF GROSS
“OPERATING PROFITS”
HYGIENE PROFITS MOST IMPORTANT
As an Appraiser/Consultant, I must know the practice in order to educate the Buyer concerning the practice future potential. A bunch of numbers/proformas do not give necessary information about your practice. My appraisals provide all the data above and more. Numbers alone rarely sell a practice. My appraisal is a 75 – 100 page Management Study with the Goodwill/Intangibles based upon comparable area practice sales (plus Tangibles). Routinely, our Practice Sales will bring 97% – 100% of the Appraised Value.
FOR OVER YEARS NO CHARGE FOR37REAL ESTATE YOU HAVE SEEN THE NAME…
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(Over 2,200 Dental Practice Sales for Comparison) OUR FEES LOW AS 3.75% – 5.75% IF YOU HAVE ASSOCIATE/BUYER • PMA MARKETING NETWORKS • 100% FUNDING AVAILABLE • NO DUAL REPRESENTATION • NEGOTIATE FAIR PRICE • PROCESS COMPLETE CLOSING • TAX STRATEGY • TRANSITION PLANNING • PARTNERSHIPS “I PERSONALLY HANDLE EVERY TRANSITION”
GARY CLINTON Senior Appraiser
Member of The Institue of Business Appraisers, Inc. CALL 1-800-583-7765 OR DFW AREA 214-503-9696
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Journal l www.tda.org l June 2011 2011 TexasTexas DentalDental Journal l www.tda.org l October
509 1103
Pre-screened vendors. Excellent customer service. Exclusive discounts and benefits.
FINANCIAL COLLECTIONS
TekCollect: (866) 652-6500, ext. 539
CREDIT CARD — TDA PERKS
CREDIT CARD PROCESSING
E-Claims & Eligibility Connect: (866) 325-2467
Bank of America: (800) 497-6076; Code: 1D7F3
PATIENT FINANCING
CareCredit: (800) 300-3046 ext. 4519
HUMAN RESOURCES EMPLOYMENT AGENCY, ONLINE DentalSpots.com: (800) 971-8008
MEDICAL PLAN, DISCOUNT
TDA Perks Card has three available packages. This is NOT insurance, nor is it intended to replace insurance. http://tinyurl.com/perkscard
COMPLIANCE/TRAINING
OSHA Review, Inc.: (800) 555-6248
GLOVES The Glove Group: (800) 570-1492
ELECTRONIC CLAIMS PROCESSING
OFFICE SUPPLIES
Office Depot: (512) 284-3392
OFFICE, SETUP/STARTUP
PHILIPS SONICARE, ZOOM! Philips Zoom!: (800) 422-9448 Philips Sonicare: (800) 676-7664
EQUIPMENT, USED (BUY, SELL)
Atlas Resell Managment: (512) 377-6077
REAL ESTATE (COMMERCIAL)
SEDATION EQUIPMENT, SUPPLIES
Dental Space Advisors: (972) 231-8900 Corporate Headquarters: Dallas/Ft. Worth (With Offices in Houston & Austin/San Antonio)
MARKETING
Sedation Resource: (800) 753-6376
OTHER AUTO LEASING
Autoflex Leasing: (800) 678-3539
ON-HOLD PHONE MESSAGING Ace Media Products: (800) 892-9179
ONLINE MARKETING AND COMMUNICATIONS Demandforce: (800) 210-0355
PRINTING, PROMOTIONAL PRODUCTS, DIRECT MAIL
TRAINING/RECERTIFICATION (ACLS, PALS, BLS, CPR)
WEBSITE DESIGN
HeartSafe America: (877) 731-7467
DISINFECTANT, SPORE TESTING
Insurance Answers Plus: (800) 683-2501
COMPLIANCE TRAINING (OSHA, HIPAA, HB300)
Smart Training, LLC: (469) 342-8300
HeartSafe America: (877) 731-7467
TDA Financial Services Insurance Program All types: office and personal: (800) 677-8644
INSURANCE INFORMATION
LOANS (PRACTICE)
DEFIBRILLATORS
INSURANCE
Bank of America Business: (866) 570-1601 (Code: UABOI9) Consumer: (800) 932-2775 (Code: VABQ92) Best Card: (877) 739-3952
SUPPLIES
INSURANCE
PrintCity.com: (800) 757-5110 ProSites: (888) 932-3644
DISPOSAL/RECYCLING
Scan the QR code above to learn more about TDA Perks.
AMALGAM SEPARATION Solmetex: (800) 216-5505
SCRAP PRECIOUS METAL RECOVERY D-MMEX: (800) 741-3174
For more information, call:
(512) 443-3675
Revised 06/26/13
Or visit Perks online:
tdaperks.com 575
Texas Dental Journal l www.tda.org l July 2013
YOUR PATIENTS TRUST YOU. YOUR PATIENTS TRUST YOU. WHO CAN YOU TRUST? WHO CAN YOU TRUST? If you or a dental colleague are experiencing impairment
If you a dental colleague are experiencing impairment due or to substance use or mental illness, The Professional dueRecovery to substance use or illness, support The Professional Network is mental here to provide and an Recoveryopportunity Network is for here to provide recovery. support and an confidential opportunity for confidential recovery.
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PRN Helpline (800) 727-5152 PRN Helpline www.tda.org l July 2013 (800) 727-5152
Visit us online www.txprn.com Visit us online www.txprn.com
Anesthesia Education & Safety Foundation, Inc. Call us at 214-384-0796 or e-mail us at sedationce@aol.com; website: www.sedationce.com
ACLS & PALS Now Available! Contact us for details. OUR MISSION: To provide affordable, quality anesthesia education with knowledgeable and experienced instructors, both in a clinical and academic manner while being a valuable resource to the practitioner after the programs. Courses are designed to meet the needs of the dental profession at all levels. OUR GOAL: To teach safe and effective anesthesia techniques and management of medical emergencies in an understandable manner. WHO WE ARE: We are licensed and practicing dentists in Texas, and we understand your needs. While other providers are in the process of contemplating program development, our courses have met the ADA Guidelines for more than 10 years. The new anesthesia guidelines were recently approved by the Texas State Board of Dental Examiners. As practicing dental anesthesiologists and educators, we have established continuing education programs to meet these needs.
McKinney, Texas: Credit: Time:
Approved PACE Program Provider FAGD/MAGD Credit. Approval does not imply acceptance by a state of provincial board of dentistry or AGD endorsement. 8/1/2011 to 7/31/2014. Provider ID# 217924.
Dr David Canfield
Dr Clark Whitmire
Nitrous Oxide/Oxygen Conscious Sedation Course for Dentists:
Each course date is by appointment with Dr. Canfield, please call for details 14 hours (clinicians must complete the online portion, first) 7:00 am – Registration; 7:30 am – 5:00 pm – Clinical Presentation
Level 1 and Level 2 Enteral Sedation Renewal Courses (only 1 day needed to renew):
McKinney, Texas: Houston, Texas: Austin, Texas: Credit: Time:
Friday, September 6, 2013 or Saturday, September 7, 2013 Friday, September 13, 2013 or Saturday, September 14, 2013 Friday, September 20, 2013 or Saturday, September 21, 2013 8 hours lecture 7:00 am – Registration; 7:30 am – 5:00 pm – Presentation
McKinney, Texas: Houston, Texas: Austin, Texas: Credit: Time:
Friday & Saturday, September 6-7, 2013 Friday & Saturday, September 13-14, 2013 Friday & Saturday, September 20-21, 2013 18 hours lecture with 20 clinical experiences 7:00 am – Registration; 7:30 am – 5:00 pm – Presentation
Level 1 Initial Minimal Sedation Permit Courses:
Level 1 to Level 2 Transitional Moderate Sedation Permit Course (must have a Level 1 permit):
McKinney, Texas: Sunday, September 8, 2013 Houston, Texas: Saturday, September 14, 2013 San Antonio, Texas: Friday, October 4, 2013 Credit: 8 lecture/participation hours with clinical experiences and 3 live sedations 7:00 am – Registration; 7:30 am – 4:30 pm – Presentation Time:
ACLS (Advanced Cardiac Life Support) & PALS (Pediatric Advanced Life Support) Program:
Austin, Texas: McKinney, Texas: Credit: Time:
Friday, August 2, 2013 Friday, September 27, 2013 8 hours lecture/Participation 7:30 am – Registration; 8:00 am – Presentation start time
Austin, Texas: McKinney, Texas: Credit: Time:
Friday and/or Saturday, August 2-3, 2013 Friday and/or Saturday, September 27-28, 2013 16 hours lecture for 2-day program; or 8 anesthesia hours for 1 day program 7:30 am – Registration; 8:00 am – 5:00 pm – Presentation
Level 3 & Level 4 Parenteral Sedation Permit Renewal & ACLS Course:
Level 2 Initial Moderate Sedation by Oral Administration Permit Course:
McKinney, Texas: Friday – Sunday, September 6-8, 2013 Houston, Texas: Thursday – Saturday, September 12-14, 2013 Austin, Texas: Friday & Saturday, September 20-21, 2013 & October 4, 2013 (San Antonio) Credit: 24 hours lecture/participation with clinical experiences and 3 live sedations Time: 7:00 am – Registration; 7:30 am – 5:00 pm – Presentation
AGD Codes for all programs: 132 Anesthesia & Pain Control; 163 Conscious Sedation; 164 Oral Sedation The above continuing education programs fulfill the TSBDE Rule 110 practitioner requirement in the process to obtain selected Sedation permits. We are continually adding programs to help you satisfy your requirements. This is only a partial listing of sedation courses. Please consult our website for updates and new programs. Find us on the web at www.sedationce.com Call us at 214-384-0796 to register for any program
Texas Dental Journal l www.tda.org l July 2013
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The Texas Dental Association’s ADA Golden Apple award-winning website is the official website of the Texas Dental Association. Log in using your ADA # with dashes (123-45-6789) and TX + license number for your password, with TX in caps (TX1234) The member side is for TDA member dentists and Texas dental students. It includes top stories and TDA news, an online job board, upcoming meetings and events, the online discussion group “Ask a Colleague,” online member dues, TDA publications and references, component society web pages, personal web pages, a searchable member directory and contact information. Members can also update their personal contact information online. The public side of TDA’s website is for patients and the public, non-member dentists and non-dentist dental professionals. It includes information about TDA, how to join TDA, general oral health information, resources for dental insurance, financial help, charitable activities, careers in dental health, TDA contact information, and a “Find a Dentist” search function.
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To go to a specific page on an affiliate website, simply mouseover the website name and a menu will appear. You can always get back to the homepage, by clicking on “Home” under each menu.
ARCHIVES Dr. John Findley Elected ADA President-elect New TDA Website!
In Memoriam
The DENPAC website (denpac.org) offers general information about DENPAC, legislative, leadership, and contact information, news articles and membership information. Users can also sign up as DENPAC club member online. The TDA Smiles website (tdasf.org / tdasmiles.org) includes program information on oral health education, Texas Mission of Mercy (TMOM), and Donated Dental Services (TXDDS). It also includes a calendar of upcoming events, history, and contact information. Users can also sign up for upcoming events and make contributions online. The Freedom-of-Choice Dental Plan website (freedom-of-choicedental.com / paiddental.com) offers detailed information on Direct Reimbursement and Paid Dental. The TDA Perks Program website (tdaperks.com / tdamemberbenefits.com) includes links to all TDA Member Benefits Endorsed Vendors, Board of Directors contact information, and additional helpful articles. The TEXAS Meeting website (texasmeeting.com) allows users to register for courses and housing for the TEXAS Meeting, as well as access general information, education, travel, special events, exhibits, and governance information. Contact: Stefanie Clegg (512) 443-3675 or stefanie@tda.org
ORAL and MAXILLOFACIAL PATHOLOGY LABORATORY Anne Cale Jones, DDS H. Stan McGuff, DDS
l
Affiliation with a major health center with a large general and special surgical pathology faculty
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Free local courier or overnight mail service
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24 hour turn-around time following receipt of specimens in the majority of cases
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Free biopsy bottles, cytological smear kits, consultation request forms, and biohazard bags
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Telephone consultation available For additional information, please call (888) 728-4211 or (210) 567-4073.
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Texas Dental Journal l www.tda.org l July 2013
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Oral and Maxillofacial Pathology Case of the Month Case Report A 60-year-old male with a past history of renal cell carcinoma presented with bilateral yellow-white non-moveable but relatively well-demarcated masses of the mandibular vestibule/lower lip region (Figure 1). The patient first noticed the lesions when brushing his teeth and reported that they were occasionally irritating. The lesions were firm and had a broad base. A mandibular exostosis was also noted as an incidental, unrelated finding on the facial area of tooth #23.
Assi
An incisional biopsy was performed on the lesion in the lower right lip. The lesional tissue was situated between the muscle and the mucosa and it was dissected with difficulty by undermining the lesion with scissors (Figure 2).
Pope
Kessler Dr Assi is senior resident in oral pathology, Texas A&M University Baylor College of Dentistry, Dallas, Texas. Dr Pope is private practice of periodontology, Dallas, Texas. Dr Kessler is professor of pathology, Texas A&M University Baylor College of Dentistry, Dallas, Texas.
Histologic examination revealed a soft tissue specimen that consisted of connective tissue containing an abundance of apparent foreign material. The foreign material was spherical with a granular appearance. Some of the spheres had a greenish tint (Figure 3). The foreign material was embedded in a background of fibrosis with occasional multinucleated foreign body giant cells (Figure 4). What is your diagnosis? See page 620 for the answer and discussion.
Figure 1. Bilateral mandibular vestibule lesions.
Figure 2. Surgical site exposure on incisional biopsy.
Figure 3. Low-power histologic section showing the granular spherical foreign material.
Figure 4. A high-power photomicrograph showing the foreign material in association with a multinucleated foreign body giant cell reaction.
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Southwest Dental Conference January 30 - February 1, 2014
9 MARK YOUR CALENDARS TODAY!
Kay Bailey Hutchison Convention Center Dallas, Texas Sponsored by Dallas County Dental Society
More information coming soon to swdentalconf.org
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A technique for fabricating a milled titanium completearch framework using a new CAD/CAM software and scanner with laser probe Ilser Turkyilmaz, DDS, PhD; and Neset Volkan Asar, DDS, PhD
INTRODUCTION
Implant dentistry has come a long way since 1982 when Per-Ingvar Br책nemark first presented his work on osseointegration of endosseous dental implants (1). In the last 3 decades, the use of dental implants has increased exponentially (2). As the treatment became more predictable, the benefits of therapy became evident. The tremendous demand for implants has fueled a rapid expansion of the market.
Abstract By using traditional casting procedures, accurately fitting of complete-arch frameworks that are screwed on multiple implants is difficult to achieve. The introduction of computer-aided design and manufacturing (CAD/CAM) techniques for fabricating custom 1-piece titanium frameworks simplifies this challenge and reduces time spent by the restorative dentist. This report presents a milled titanium complete-arch mandibular framework using a new planning software and a new scanner using non-contact laser probe, which eliminates the need for wax pattern fabrication.
Key Words: Implant, Cad/CAM, titanium, framework, fit, Nobel Procera Tex Dent J 2013;130(7): 586-592.
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Figure 1. Mandibular definitive cast was sprayed with zincoxide powder and zinc-oxide powder was cleaned from implant platforms before placing scanning abutments.
Dental implants can support many types of dental restorations, ranging from a single tooth to a complete-arch fixed restoration (3). The prosthetic design must take into consideration many factors, including number of teeth to be replaced, biomechnical considerations regarding how many implants are necessary to support the restoration, functional considerations such as the occlusal scheme and opposing dentition or restoration, and relative cost of the restorative materials (3). Traditional castings have a major limitation inherent in the process, which is distortion of the casting with increasing size of the pattern (4). Single implant restorations can be cast within this tolerance, because the distortion is limited based on size. Complete arch restorations, however, are difficult to cast successfully (4). Implant-supported prostheses must have a passive-fit to the implants. A misfit between a metal framework and an implant may cause mechanical and biologic problems, such as screw loosening, implant and prosthesis fractures, and loss of osseointegration (5,6). Complete passive-fit of a metal framework is rarely seen, especially, when fabricating complete-arch 1-piece frameworks using a traditional casting method (5). CAD/CAM technology has significantly enhanced both surgical and restorative aspects of implant dentistry (7,8). CAD/CAM fabrication of bars and frameworks has resulted in elimination of distortion, better fit, fewer fabrication steps, and faster turn-around (4,9). Other advantages of a CAD/CAM titanium framework include its light weight, biocompatibility, and low cost (10). There are few 3-D planning softwares to design and to fabricate frameworks and surgical guides available (8,11). A
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Figure 2. Trial denture was sprayed with zinc-oxide powder after placing it on definitive cast.
company (NobelBiocare USA, Yorba Linda, Calif) recently launched a new software (Procera, version 4.0.10.5, NobelBiocare USA, Yorba Linda, Calif) and a new scanner (Procera Forte, NobelBiocare USA, Yorba Linda, Calif) that are quite different from previous versions. The former version of the scanner required wax pattern fabrication for each framework before scanning (8). The probe of the scanner, a 2 mm ball, touched the wax pattern during scanning, which was one of the drawbacks of this process. However, the new scanner can fabricate most implant-supported framework designs without any wax pattern since it uses a non-contact laser. No clinical studies have been published regarding this
About the Authors Dr Turkyilmaz is an assistant professor, Department of Comprehensive Dentistry, University of Texas Health Science Center at San Antonio Dental School, San Antonio, Texas. Dr Asar is a visiting professor, Department of Comprehensive Dentistry, University of Texas Health Science Center at San Antonio Dental School, Texas; instructor, Department of Prosthodontics, Dental School, Gazi University, Ankara, Turkey. Corresponding author: Dr Ilser Turkyilmaz, Dental School Implant Clinic, Department of Comprehensive Dentistry, the University of Texas Health Science Center, 7703 Floyd Curl Dr, MSC 7912, San Antonio, TX 78229-3900. Phone: 210-567-6450; Fax: 210-567-6376; E-mail: turkyilmaz@uthscsa.edu. This manuscript has been peer reviewed. The authors have no declared potential conflicts of financial interest, relationships, and/or affiliations relevant to the subject matter or materials discussed in the manuscript.
new technique yet. This report aimed to introduce the new CAD/CAM software and scanner, and to describe the design and fabrication of an implant-supported screwretained fixed dental prosthesis (FDP) framework.
TECHNIQUE
A 70-year-old woman with an edentulous maxilla and mandible presented to the Prosthodontic Clinic at the University of Texas Health and Science Center at San Antonio (UTHSCSA) with complete maxillary and mandibular dentures. The patient’s chief complaint was the poor retention of her mandibular complete denture. Clinical examination and evaluation of the patient revealed a maxilla that could readily support and retain a conventional complete denture, and a mandibular residual ridge with resorption that would benefit from dental implants. A new maxillary complete denture and a mandibular implant-supported screw-retained FDP were proposed to the patient. The patient had a cone-beam computerized tomography (CBCT) scan (Ewoo Master 3D CBCT machine, Vatic, Bora-Dong, Giheung-Gu, Yongin-Si, Geeing-Do, Republic of Korea). Five mandibular implants were planned using 3-D implant planning software (Procera, NobelBiocare USA, Yorba Linda, CA). Then, 5 mandibular implants (NobelReplace Straight Groovy, 4×13mm (3), 4×15mm, Nobel Biocare USA, Yorba Linda, CA) were placed uneventfully (2). Healing abutments (Nobel Biocare USA, Yorba Linda, CA) were immediately screwed on the implants. The mandibular denture was relieved in the areas of the abutments and then was lined with a resilient liner (Lynal, Dentsply Caulk, Milford, DL) after implant placement. Three months after implant placement, the patient returned to the Prosthodontics Clinic for a new maxillary complete denture and an implant-supported screw-retained FDP. The maxillary complete denture was fabricated using traditional prosthetic methods. The following steps were followed to fabricate the mandibular implant-supported screw-retained FDP. 1. Make an implant-level impression of the mandible using the custom tray, closed-tray impression copings (Nobel Biocare USA, Yorba Linda, CA), and vinyl polysiloxane impression material (Aquasil, Dentsply Intl, York, PA). 2. Attach implant replicas (Nobel Biocare USA, Yorba Linda, CA) to the impression copings, and pour the mandibular definitive cast using Type IV dental stone (ResinRock, Whip Mix Corp, Louisville, KY). 3. Fabricate maxillary and mandibular trial dentures using traditional prosthetic methods.
Figure 3. Occlusal view of mandibular cast with implant positions after scanning process.
Figure 4. Occlusal view of mandibular cast and trial denture after scanning process.
Figure 5. Occlusal view of final design of mandibular framework. Note that each layer (item) can be easily seen by dentist as each layer has different color. Texas Dental Journal l www.tda.org l July 2013
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Figure 6. Frontal view of final design of mandibular framework. Height, width, and shape of framework can be determined according to scan of trial denture using special markers provided by software.
Figure 7. Occlusal view of CAD/CAM titanium framework screwed on implants.
4. Perform a trial denture insertion and verify centric occlusion, esthetics, phonetics, and occlusal vertical dimension. After approval by the patient, dismiss the patient. 5. Spray the mandibular definitive cast with zinc-oxide powder (Dr Scholl’s Spray Powder, MSD Consumer Care, Inc, Memphis, TN) (Figure 1), and then screw scanning abutments onto implant replicas. 6. Scan the mandibular definitive cast with scanning abutments. This allowed the software to locate the implant platforms. 7. Scan the mandibular definitive cast without scanning abutments. This allowed the software to register the tissue surface. 8. Scan the trial denture after it was sprayed with zinc-oxide powder (Dr Scholl’s Spray Powder, MSD Consumer Care, Inc, Memphis, Tenn) and seated on the definitive cast (Figure 2). If the scanning process was performed accurately, the planning software superimposes these different scans without any problems (Figures 3,4). Then, the dentist can see each item (layer) seperately or together, which allows him or her to design the framework. 9. Design a complete-arch framework using the software. The height, width, and shape of framework were determined according to the scan of the trial denture (Figures 5,6). Adequate space was provided, allowing for denture teeth and acrylic resin. This information was sent online to the Production Center in Mahwah, New Jersey. 10. A complete-arch titanium framework was milled from a titanium block using CAD/CAM technology in the
Production Center. It was returned to our clinic 3 days after the scanning. 11. Verify the fit of the titanium framework intraorally after confirming it on the definitive cast (Figures 7,8). Position the milled framework and secure with a single screw to an implant and verify accurate fit radiographically. 12. Transfer the denture teeth to the framework from the previously fabricated trial denture. An optional second trial denture insertion may be performed to evaluate centric occlusion, esthetics, phonetics, and occlusal vertical dimension. 13. Process, finish, and polish the mandibular implantsupported screw-retained FDP. 14. Insert the mandibular implant-supported screwretained FDP on the implants, and tighten the abutment screws using 35Ncm of torque. Cover screw access holes using cotton pellet and composite resin (Figures 9,10).
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CONCLUSION This report describes the fabrication of a CAD/CAM titanium framework using a newly available planning software and a new scanner using non-contact laser. This technique eliminates the need for a wax pattern before fabricating a metal framework as it uses a laser probe. The misfit that often occurs when delivering traditional cast frameworks can be minimized by using scanning and custom-milling technology to fabricate a milled complete arch titanium framework.
Figure 8. Clinical fit of mandibular framework was verified. Note striations created during the milling process and resin retention features created after completion of the milling process.
Figure 9. Intraoral view after both restorations were inserted. Convex design of the mandibular framework, which was positioned 1mm above the gingiva, allowed easier hygiene.
Figure 10. Panoramic radiograph of the completed mandibular FDP.
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References 1. Br책nemark PI, Albrektsson T. Titanium implants permanently penetrating human skin. Scand J Plast Reconstr Surg. 1982; 16:17-21. 2. Turkyilmaz I, Company AM, McGlumphy EA. Should edentulous patients be constrained to removable complete dentures? The use of dental implants to improve the quality of life for edentulous patients. Gerodontology. 2010;27:3-10. 3. Turkyilmaz I, Jones JD. Long term success of 6 implants supporting a mandibular screw-retained fixed dental prosthesis: a clinical report. J Prosthet Dent. 2012;107:280-3. 4. Takahashi T, Gunne J. Fit of implant frameworks: an in vitro comparison between two fabrication techniques. J Prosthet Dent. 2003; 89:256-60. 5. de Aguiar FA Jr, Tiossi R, Rodrigues RC, Mattos Mde G, Ribeiro RF. An alternative section method for casting and posterior laser welding of metallic frameworks for an implant-supported prosthesis. J Prosthodont. 2009;18:230-4. 6. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications with implants and implant prostheses. J Prosthet Dent. 2003;90:121-32. 7. Turbush SK, Turkyilmaz I. Accuracy of three different types of stereolithographic surgical guide in implant placement: an in vitro study. J Prosthet Dent. 2012;108:181-8. 8. Turkyilmaz I, Corrigan CL. A custom-milled titanium complete-arch mandibular framework and a maxillary complete denture fabricated in 3 appointments: a dental technique. Tex Dent J. 2012;129:695-701. 9. Al-Fadda SA, Zarb GA, Finer Y. A comparison of the accuracy of fit of 2 methods for fabricating implantprosthodontic frameworks. Int J Prosthodont. 2007;20:125-31. 10. Ehrenkranz H, Langer B, Marotta L. Complete-arch maxillary rehabilitation using a custom-designed and manufactured titanium framework: A clinical report. J Prosthet Dent. 2008;99:8-13. 11. Jung RE, Schneider D, Ganeles J, Wismeijer D, Zwahlen M, H채mmerle CH, Tahmaseb A. Computer technology applications in surgical implant dentistry: a systematic review. Int J Oral Maxillofac Implants. 2009;24 Suppl:92-109.
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Predictable Immediate Loading of Mandibular Implants Kelvin I. Afrashtehfar, DDS, FADI; José T. Cárdenas-Bahena, DDS; and Cyrus D.M. Afrashtehfar, MD
INTRODUCTION Three decades ago, in the field of oral implantology, osseointegration was postulated to require a healing time for at least 3 months in the mandible and 6 months in the maxilla. Early loading has been known to cause fibrous encapsulation that impedes the direct connection between the bone and the dental implant surface (1-3). However, the technological and biomechanical advancements have resulted in modern implant protocols that provide the possibility to immediately load implants in fresh extraction sockets while ensuring an adequate osseointegration. This approach includes a fixed implant-supported prosthesis within 24 hours following the surgical implant placement. This is why this treatment modality has been marketed as the “Teeth-in-a-Day” technique.
Abstract Technological advancements have resulted in modern dental implant protocols that provide the possibility to immediately load implants in fresh extraction sockets. This article briefly addresses various aspects to be considered such as computed tomography (CT), surgical guides, implant considerations for the edentulous patient, and considerations for immediate implant placement and loading. In this clinical case, immediate post-extraction implant placement with immediate loading was performed accurately because of the planning done with the CT scan. The use of a stereolithographic model and a surgical guide prevented technical difficulties and improved the predictability during the prosthetically driven surgery.
Key Words: post-extraction dental implant, immediate loading, implant-supported, overdenture, computed tomography. Tex Dent J 2013;130(7): 596-607.
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T
he purpose of this procedure is: 1) to decrease the patient’s dental office visits because it is done in a single appointment, 2) to reduce the patient’s financial investment by decreasing the number of visits, 3) to avoid the need of temporary complete dentures, and 4) to increase the likelihood of treatment acceptance. In addition, this may aid in better predictability for mandible edentulism therapy and decrease the continued resorption that might occur with conventional dentures (4-7). The facets to be considered are: computed tomography (CT), surgical guides, implant considerations for the edentulous patient, and considerations of immediate implant placement and immediate loading.
Computed Tomography The integration of innovative computer software helps to define new paradigms, such as better interpretation of the anatomy and surgical planning to improve the accuracy of the prosthesis achieving a predictable successful implant rehabilitation (8,9). Although CT has been used in medicine since 1973, this modality was made available for dentistry purposes only in 1987 (1013). CT is a radiographic technique that provides slices or sections of the anatomic structures in predetermined axes. The technological progress over the last couple of decades has ensured more favorable estimation of the position of dental implants and has reduced inadequate procedures associated with implant failure and/or patient’s discontent (8-11). During implant treatment planning, various parameters can be accessed through the use of CT. Among these are: approximate bone quality,
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the CT provides an approximation represented in Hounsfield units; bone volume, that is essential for primary fixation and vascularity around the implant; bone defects, for planning bone regeneration; size and shape of the dental implants, that allows identification of the ideal area for placement with the aid of the software; guided bone regeneration (GBR), to obtain more bone volume during or after the surgery (10-15). These are essential features in decision-making at time of the diagnosis and their diverse therapeutics. Furthermore, a wellinformed patient will be able to better understand the cost-benefit relation of the therapy and its implications (16).
Positive outcomes in
Implant surgery used with CT scanning and computer-guided planning allows the final prosthesis to be ready before surgery and delivered after implant insertion (17). The computer-guided
surgery seems to be useful for virtual planning of cases with severe bone resorption; however, the conventional surgical technique is more suitable (18).
immediate implant loading have been described in patients with potential risk factors such as smoking, type II diabetes, osteopenia, hyper-parathyroidism, xerostomia, etc.
About the Authors Dr K.I. Afrashtehfar has a postgraduate affiliation in the International College of Prosthodontists. His first textbook entitled Computerized Dental Occlusal Analysis for Temporomandibular Disorders will be released this year. He is currently a research trainee in oral and craniofacial sciences in Canada.
Dr Cárdenas graduated in Periodontics and Dental Implants from the prestigious National Autonomous University of Mexico. He currently has a private practice focused on periodontics and implantology in Mexico.
Dr C.D.M. Afrashtehfar is a Canadian physician who graduated with honors and received the National Academic Excellency award. Currently he is a resident of otolaryngology — head and neck surgery in Mexico.
Corresponding author: Dr Kelvin I. Afrashtehfar, Telephone: 438-936-7772, E-mail: kelvin.afrashtehfar@mail.mcgill This manuscript has been peer reviewed. The authors have no declared potential conflicts of financial interest, relationships, and/or affiliations relevant to the subject matter or materials discussed in the manuscript.
Surgical Guides
The surgical guide aids to insert the implants regardless of the
Using tooth-supported or bonesupported, and in some cases mucosasupported, surgical guides from stereolithographic models benefit the placement of multiple implants, especially in long edentulous areas. In addition, it promotes a preview of the final outcome and avoids unnecessary expenses incurred for correcting errors. Furthermore, it shortens the surgical and prosthetic times and increases overall treatment predictability (8,19,20,21-25).
surgical technique, and the success of immediate loading after
The surgical guide aids to insert the implants regardless of the surgical technique, and the success of immediate loading after computerguided surgery is determined by the accuracy of clinical and/or laboratorial steps (18). The primary goals of periodontal therapy are bone volume conservation, to avoid pain and maintain healthy, functional, aesthetic teeth (26-29).
Implant Considerations for the Edentulous Patient When planning for the implant placement, occlusogingival dimension has to be addressed. An absolute minimum of 10 mm of occlusogingival dimension is proposed to accommodate 4 mm of incisor length above the metallic bar, 4 mm for the prosthetic cylinders, metallic bar and retaining screws, and 2 mm to account for the transmucosal dimension of the abutment beyond the bone crest. This will guarantee an esthetic, phonetic, hygienic, and biomechanically full-bodied prosthesis (30).
computer-guided surgery is determined by the accuracy of clinical and/or laboratorial steps.
The literature indicates that the patient must have sufficient bone height (approximately 12 mm for a 10mm implant) and sufficient bone thickness (approximately 6 mm for at diameter implant of least a 3.75 mm). If the measurements are slightly lower or the patient is in a wellknown bruxer, then an additional implant can be provided for better support. Implant therapy may be contraindicated if these parameters are not satisfied and in patients with poor oral health, severe occlusal parafunction, and type IV bone quality (7,15,30-33). Positive outcomes in immediate implant loading have been described in patients with potential risk factors such as smoking, type II diabetes, osteopenia, hyperparathyroidism, xerostomia, etc. (34,35).
Immediate Placement Consideration Immediate implant placement is the treatment that can be done simultaneous to an atraumatic extraction resulting in a socket with minimal bone or soft tissue damage (36,37). The patient is usually premedicated with anti-inflammatory and antibiotics medications (15). The advantages of immediate placement of endosseous implants are the opportunity of conducting a
single surgical procedure, reducing treatment time since it is a fresh alveolus, and simultaneous ridge augmentation for marginal bone defects, as well as improvement in patient’s self-reported satisfaction with treatment (15,30). However, for patients requiring vestibular grafts, this treatment modality might not be most suitable. Also, it may increase the risk of dehiscence and recession in thin gingival biotypes (31). Results report that favorable marginal bone levels can be maintained (38). It must be followed a prosthodonticsdriven treatment planning concepts and guidelines for prevention of unfavorable positions and angulations (39). After examining casts at the precise vertical dimension of occlusion, any occlusogingival dimensional irregularities should be treated by consideration of an alveolectomy at the time of implant placement (30).
Considerations for Immediate Loading Better clinical understanding of the biomechanics of immediate loading protocols have resulted in an increase of such practice with commendable results. Immediate loading refers to restorations placed in occlusion with its antagonist within 48 hours after the dental implant placement. If the loading is done after 48 hours up to 3
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months post implant placement, it is referred to as early loading (31,36).
of a less reduction in bone loss supporting immediate loading (45).
Upon insertion, the implants essentially need to have satisfactory primary stability. Part of the protocol is to place, between the mental foramina, 4 to 5 implants in the anterior mandible (15). Abutments are added to the implants and the patient’s lower and a fixed implantsupported provisional prosthesis is placed, or in case of a denture wearer, the denture is converted into an immediate load provisional fixed prosthesis (15,40). Immediately loaded implants predictability have led to use the definitive implants and less number of them for support of the prosthesis (38,41-44).
The purpose of this document is to relate this review to a clinical case to demonstrate good clinical habits based on scientific knowledge. The clinical case used diagnostic assistance through CT for the elaboration of a restrictive surgical guide. Five endosseous implants were placed post-extraction in the interforaminal region, allowing the patient to receive an implant-supported prosthesis within a few hours.
The most evident advantages of immediate loading are eliminating the need and maintenance of removable provisional prostheses, reduced component costs, improved access for hygiene, prosthetic construction simplification, the emotional benefit to the patient, and improved bone healing due to the functional loading (15,30-33).
A Classical Immediate Loading Clinical Scenario A 59-year-old woman came to the dental office with chief complaints of difficulty in chewing food, missing teeth, and unsatisfaction with her existing prosthesis due to functional and aesthetic reasons. The medical history did not reveal any relevant signs or symptoms. Subsequently, a full photographic record was obtained. The intraoral examination and photographs showed
On the other hand, it is also important to consider possible compromise of primary stability, tender spots due to the denture, difficulty in chewing, painful postoperative periods and the number of visits to the dentist for restorative purposes (15,27). In case of the “denture conversion technique,” the final prosthesis is fabricated upon 3 months considering the implants’ osseointegration (15). A recent systematic review by the Cochrane Group found that when immediate loading was compared with conventional loading, there was no difference in prosthesis failure nor implant failure in the first year, but interestingly there is some evidence
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Figure 1. Initial intraoral photograph.
poorly fitting prostheses and color changes in the maxilla, while in the bilateral absence of the posterior segment in the lower arch without any rehabilitation (Figure 1).
Diagnosis
On periodontal examination, the patient was diagnosed with severe generalized chronic periodontitis in the lower segment and plaqueinduced gingivitis in the upper segment. Periapical and panoramic radiograph examination revealed absence of teeth #16, 18, 26, 28, 35, 36, 37, 38, 45, 46, 47, and 48, indicating a bilateral posterior symmetric absence and inadequate prosthesis and root canal treatment in teeth #12, 21, and 34 (Figure 2). On prosthodontic examination, the maxilla had a composite with metal frame fixed partial denture (FPD) in #13, 14, 15, 16, 17; porcelain fused to metal FPD in #24, 25, 26, 27, and single crowns in #12, 21, and 22. In the lower arch, a Class 1 Kennedy edentulism and fixed prostheses in #31 and 32 was observed.
Figure 2. Diagnostic panoramic radiograph.
Treatment After examining relevant medical information and clinical and radiographic details, the planned treatment comprised of removing the poorly fitting dentures in order to fabricate a diagnostic wax-up on preliminary diagnostic casts. This procedure also facilitated access to periodontal therapy, starting with the initial phase. Relevant indications were given to the patient so that she could maintain optimal periodontal health conditions. Initial phase. Upon removing the prostheses, periodontal and dental conditions could be observed better to access in periodontal conditions following the treatment. Laboratory. The initial step in the production of the provisional prostheses and surgical guide included taking impressions of both the arches. The resulting models were articulated and an analysis of the ideal occlusion and axial morphology was done.
Planning. Table 1 describes the comprehensive treatment plan that was planned for each arch. To facilitate parallelism of dental implants in the anterior mandible, a CT scan was taken. CT reconstruction scans provided valuable 3-D anatomic information by helping in recreating stereolithographic models to aid the manufacture of restrictive surgical guides (Figures 4 and 5). In the lateral view of the CT, a horizontal and vertical bilateral osseous deformity (Class 3 Seibert) was observed apart from malposed teeth with lack of osseous support (Figure 4). Surgical procedure. Multiple atraumatic teeth extractions were performed in the mandible and an intermentonian full thickness flap was elevated with caution to avoid any injury
The diagnostic wax-up models were used to display the planned restorations. This aids the clinicians during surgery to evaluate the restorative requirements that enable her to provide well-planned and longer lasting results, besides being aesthetic and functionally pleasing. Following this preprosthetic remodeling in the mandibular model was carried out for performing the implantsupported provisional prosthesis and its placement after surgery (Figure 3).
Figure 3. Diagnostic wax-up on the mandibular model.
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Table 1. Maxillary and Mandibular arch planning.
SUPERIOR
INFERIOR
Porcelain fused to metal prostheses placement: #17, 16, 15, 14, 24, 25, 26 and 27.
Five endosseous implants placed in the intermentonian region.
Porcelain fused to circonia prostheses placement: #13, 12, 11, 21, 22, 23.
Immediate fixed prosthesis screwed placement over the 5 implants. After the osseointegration period, the metal-acrylic fixed prosthesis is screwed over the 5 implants.
to the mental nerve. The anteroposterior view in the CT scan revealed an atrophic and irregular residual ridge after the extractions (Figure 4). Therefore, an osteoplasty and GBR were planned to facilitate the placement of the implants. The osteoplasty was performed with a low-speed handpiece and with abundant irrigation until a homogeneous ridge was obtained. Once the osteoplasty was completed, a surgical guide was placed on the vestibular cortical fixed with screws (ACE Surgical Supply, Brockton, MA) of dimensions 1.5mm x 10.5 mm (Figure 6). After fixing the surgical guide, drilling was carried out according to the commercial brand indications and 5 Nobel Biocare implants (Gothenburg, Sweden) of dimensions 4.3 mm x 13 mm were placed, achieving a torque of 30 N in all implants leading to an optimal primary stability (Figure 7). Thereafter, temporary prosthetic abutments were immediately placed and the height of the ridges was preserved with GBR by placing deproteinized bovine bone mineral (Geistlich Bio-Oss®, Geistlich Pharma AG, Wolhusen, Switzerland) in the alveoli and some areas with dehiscence. The site was covered with absorbable collagen membrane derived from type 1 bovine tendon (BioMend® Extend™, Zimmer Dental, Carlsbad, CA). Following this, suturing was done with coated vicryl 4-0 (Polyglactin 910, Ethicon, Somerville, NJ, USA) to obtain primary wound closure without tension (Figure 8). The patient was advised to use intraoral Amoxicillin (Ampliron, Siegfried Rhein, Roemmers, Argentina) 500 mg twice a day for 1 week and oral rinse containing 0.12% chlorhexidine gluconate twice a day for 3 weeks. The suture was removed after 15 days and the patient was advised to use an oral irrigator (Waterpik® Nano Water Flosser WP250, China).
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Figure 4. 3-D CBCT mandibular reconstruction. A) lateral view with teeth, B) rough ridge surface in simulated extraction sites, C) planning of the parallel implant placement. The images from the CBCT are in DICOM (Digital Imaging and Communications in Medicine) format to plan in Mimics 10.01 software. [Technician: Salvador Crespo]
Subsequently, a rubber dam was placed to isolate the surgical site and the denture was tested (Figure 9). The provisional denture was trimmed to make space for abutments and was then relined with light-cure acrylic resin for stabilization (Figure 10). A definitive prosthesis was later planned after 6 months and constructed to incorporate a rigid metal bar as shown in Figures 11 and 12.
Figure 5. Stereolithographic model.
Follow-up. One year after the treatment osseointegration and preservation of implants in good condition was observed during radiographic evaluation. The final prosthesis preserved its aesthetic and functional success (Figures 13 and 14).
CONCLUSIONS
Figure 6. Restrictive surgical guide fixed with screws.
The evidence that supports this review considers the post-extraction immediate loading implants as a predictable method for replacing missing teeth. The introduction of advanced imaging methods provides the clinician with a 3-D perspective and accurate understanding to aid in proper diagnosis and treatment planning that are very critical steps in the overall implant therapy. Once the treatment plan has been established and accepted by the patient, the surgical guide is constructed based on transferring accurately the planned implant positions to the surgical field. The treatment plan should carefully consider anatomical structures that will be the future implant receptor sites. Care must be taken to avoid damage to nerves, maxillary sinus, or adjacent teeth roots. Equally important is understanding the patient’s restorative needs in constructing a treatment plan. The final simulation is transferred with a precise surgical guide that aids in providing a prosthetically guided treatment.
Figure 7. Implant placement aided by restrictive surgical guide. Texas Dental Journal l www.tda.org l July 2013
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Figure 8. Post-extraction guided bone regeneration in alveolar sockets.
In conclusion, in this case, immediate post-extraction endosseous implant placement with immediate loading could be performed accurately because of the planning done using the CT. The manufacture and design of a surgical guide prevented technical difficulties during the prosthetically guided surgery. A proper diagnosis and a careful treatment planning will continue to be the key to success within the principles of complex oral rehabilitation. References 1. Mahesh L, Kurtzman GM, Afrashtehfar KI. [Malposed implants in the esthetic zone]. Implantol Act 2012; 6(11): 12-8. 2. Branemark PI, Zarb GA, Albrektsson T. Tissue-integrated prostheses: osseointegration in clinical dentistry. Chicago: Quintessence; 1985. 3. Branemark PI, Hansson BO, Adell R, Breine U, LindstrĂśm J, HallĂŠn O, Ohman A. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scand J Plast Reconstr Surg Suppl. 1977;16:1-132. 4. Petropoulos VC, Balshi TJ, Balshi SF, Wolfinger GJ. Extractions, implant placement, and immediate loading of mandibular implants: a case report of a functional fixed prosthesis in 5 hours. Implant Dent. 2003;12(4):283-90.
Figure 9. Provisional denture adjustment. A) rubber dam isolating the surgical site, B) polished provisional denture, C) occlusal view of the denture.
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A
B
C
A Figure 10. Functionally stable provisional mandibular denture and natural appearance according to patient’s characteristics like age and gender.
B Figure 11. Transfer with copings splinted with autopolymerizing acrylic resin (GC pattern resin, GC Corp, Tokyo, Japan) for impression, from the A) intra-oral build-up to the lab model transfer; B) a unique bar or framework design with a resin pattern was created with the technician.
Figure 12. Definitive mandibular screw-retained hybrid fixed denture. Occlusal view of intra oral try-in. Figure 13. One-year radiographic follow-up.
Figure 14. One-year follow-up. Final restorations.
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5. Barzilay I. Immediate Implants: their current status. Int J Prosthodont 1993;6:169-75. 6. Davis WH, Lam PS, Marshall MW, Dorchester W, Hochwald DA, Kaminishi RM. Using restorations borne totally by anterior implants to preserve the edentulous mandible. J Am Dent Assoc. 1999 Aug;130(8):1183-9. 7. Calvo MP, Muller E, Garg AK. Immediate loading of titanium hexed screw-type implants in the edentulous patient: case report. Implant Dent. 2000;9(4):351-7. 8. Afrashtehfar KI. [Using bidimensional and tri-dimensional radiography in Dentistry]. Rev ADM. 2012 May-Jun;69(3):114-9. 9. Silverstein LH, Melkonian RW, Kurtzman D, Garnick JJ, Lefkove MD. Linear tomography in conjunction with pantomography in the assessment of dental implant recipient sites. J Oral Implantol. 1994;20(2):111-7. 10. Ganz S. CT Scan technology. An evolving tool for avoiding complications and achieving predictable implant placement and restoration. International Magazine of Oral Implantology 2001;1: 6-13. 11. Ganz SD. Defining new paradigms for assessment of implant receptor sites. The use of CT/CBCT and interactive virtual treatment planning for congenitally missing lateral incisors. Compend Contin Educ Dent. 2008 Jun;29(5):256-67. 12. Klein M, Cranin AN, Sirakian A. A computerized tomography (CT) scan appliance for optimal presurgical and preprosthetic planning of the implant patient. Pract Periodontics Aesthet Dent. 1993 Aug;5(6):33-9.
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13. Tachibana H, Matsumoto K. Applicability of X-ray computerized tomography in endodontics. Endod Dent Traumatol 1990;6:16–20. 14. Amet EM, Ganz SD. Functional and aesthetic acceptance prior to computerized technology for implant placement. Implant Dent 1997; 6: 193–7. 36. 15. Misch CM. Immediate loading of definitive implants in the edentulous mandible using a fixed provisional prosthesis: The denture conversion technique. J Oral Maxillofac Surg. 2004 Sep;62(9 Suppl 2):106-15. 16. Zitzman NU, Marinello CP. Treatment Plan for Restoring the Edentulous Maxilla with Implant-Supported Restoration: Removable Overdenture versus Fixed Partial Design. J Prosthet Dent. 1999; 82: 188–96. 17. van Steenberghe D, Naert I, Andersson M, Brajnovic I, Van Cleynenbreugel J, Suetens P.A custom template and definitive prosthesis allowing immediate implant loading in the maxilla: a clinical report. Int J Oral Maxillofac Implants. 2002 SepOct;17(5):663-70. 18. de Almeida EO, Pellizzer EP, Goiatto MC, Margonar R, Rocha EP, Freitas AC Jr, Anchieta RB. Computer-guided surgery in implantology: review of basic concepts. J Craniofac Surg. 2010 Nov;21(6):1917-21. 19. Arısan V, Karabuda CZ, Ozdemir T. Implant surgery using bone and mucosa-supported stereolithographic guides in totally edentulous jaws: surgical and postoperative outcomes of computer-aided vs. standard techniques. Clin. Oral Impl. Res. 2010; 21: 980–8.
20. Ganz SD. Use of stereolithographic models as diagnostic and restorative aids for predictable immediate loading of implants. Pract Proced Aesthet Dent 2003; 15: 763–71. 21. Turbush SK, Turkyilmaz I. Accuracy of three different types of stereolithographic surgical guide in implant placement: an in vitro study. J Prosthet Dent. 2012 Sep;108(3):181-8. ) 22. Arisan V, Karabuda CZ, Mumcu E, Özdemir T. Implant positioning errors in freehand and computer-aided placement methods: a single-blind clinical comparative study. Int J Oral Maxillofac Implants. 2013 JanFeb;28(1):190-204. ) 23. Soares MM, Harari ND, Cardoso ES, Manso MC, Conz MB, Vidigal GM Jr. An in vitro model to evaluate the accuracy of guided surgery systems. Int J Oral Maxillofac Implants. 2012 JulAug;27(4):824-31. 24. Abboud M, Wahl G, Guirado JL, Orentlicher G. Application and success of two stereolithographic surgical guide systems for implant placement with immediate loading. Int J Oral Maxillofac Implants. 2012 MayJun;27(3):634-43. 25. Arisan V, Karabuda ZC, Pişkin B, Ozdemir T.Conventional MultiSlice Computed Tomography (CT) and Cone-Beam CT (CBCT) for Computer-Aided Implant Placement. Part II: Reliability of Mucosa-Supported Stereolithographic Guides. Clin Implant Dent Relat Res. 2012 Jan 11. [Epub ahead of print] 26. Koushyar-Partida KJ, HernándezAyala A. [Smoking - A risk factor for periodontal disease]. Rev ADM. 2010;67(3):101-13.
27. Flemming T. Beikler T. Decision making in implant dentistry: An evidencebased and decision-analysis approach. Periodontology 2000 2009;50:154–72. 28. Eickholz P, Kaltschmitt J. Tooth loss after active periodontal therapy: patient-related factors for risk, prognosis, and quality of outcome. J Clin Periodontol 2008;35: 165-74. 29. Chambrone L, Chambrone L. Tooth loss in well-maintained patients with cronic periodontitis during long term supportive therapy in Brazil. J Clin Periodontol 2006; 33: 759-64. 30. Cooper LF, Limmer BM, Gates WD. “Rules of 10”--guidelines for successful planning and treatment of mandibular edentulism using dental implants. Compend Contin Educ Dent. 2012 May;33(5):328-34; quiz 335-6. 31. Lazzara R. Testori T. Meltzer A. Mish C. Immediate occlusal loading (IOL) of dental implants: predictable results through DIEM guidelines. Pract Proced Aesthet Dent 2004;16:3-15. 32. Cooper LF, Rahman A, Moriarty J, et al. Immediate mandibular rehabilitation with endosseous implants: Simultaneous extraction, implant placement and loading. Int J Oral Maxillofac Implants 2002; 17: 517-25. 33. Testori T, Meltzer A, Fabbro MD, Zuffetti F, TroianoM, Francetti L, Weinstein RL. Immediate occlusal loading of Osseotite implants in the lower edentulous jaw. A multicenter prospective study. Clin. Oral Impl. Res. 15, 2004; 278–84. 34. Gapski R, Wang HL, Mascarenhas P, Lang NP. Critical review of immediate implant loading. Clin Oral Implants Res. 2003 Oct;14(5):515-27.
35. Tawil G, Younan R, Azar P, Sleilati G. Conventional and advanced implant treatment in the type II diabetic patient: surgical protocol and long-term clinical results. Int J Oral Maxillofac Implants. 2008 Jul-Aug;23(4):744-52. 36. Proceedings of the Third ITI (International Team for Implantology) Consensus Conference. Gstaad, Switzerland, August 2003. Int J Oral Maxillofac Implants. 2004;19 Suppl:7-154. 37. Afrashtehfar KI, Kurtzman GM, Mahesh L. Improving oral rehabilitation through the preservation of the tissues: Alveolar Preservation. J Adv Prosthodont. 2012 August; 4(3): 174–8. 38. Maló P, Nobre Mde A, Petersson U, Wigren S. A pilot study of complete edentulous rehabilitation with immediate function using a new implant design: case series. Clin Implant Dent Relat Res. 2006;8(4):223-32. 39. Bidra AS. Surgical and prosthodontic consequences of inadequate treatment planning for fixed implant-supported prosthesis in the edentulous mandible. J Oral Maxillofac Surg. 2010 Oct;68(10):2528-36. doi: 10.1016/j.joms.2010.05.054. Epub 2010 Jul 31. 40. Park EJ, Schrott A, Schnitman PA. Immediate loading as a vehicle for interdisciplinary training in implant placement and restoration. Int J Oral Maxillofac Implants. 2010 SepOct;25(5):1007-10. 41. Maló P, Rangert B, Nobre M. “All-on-Four” immediatefunction concept with Brånemark System implants for completely edentulous mandibles: a retrospective clinical study. Clin Implant Dent Relat Res. 2003;5 Suppl 1:2-9.
42. Malo P, Nobre Mde A, Lopes A. Immediate rehabilitation of completely edentulous arches with a four-implant prosthesis concept in difficult conditions: an open cohort study with a mean follow-up of 2 years. Int J Oral Maxillofac Implants. 2012 SepOct;27(5):1177-90. 43. Chow J, Hui E, Liu J, Li D, Wat P, Li W, Yau YK, Law H. The Hong Kong Bridge Protocol. Immediate loading of mandibular Brånemark fixtures using a fixed provisional prosthesis: preliminary results. Clin Implant Dent Relat Res. 2001;3(3):166-74. 44. Testori T, Del Fabbro M, SzmuklerMoncler S, Francetti L, Weinstein RL. Immediate occlusal loading of Osseotite implants in the completely edentulous mandible. Int J Oral Maxillofac Implants. 2003 Jul-Aug;18(4):544-51 45. Esposito M, Grusovin MG, Maghaireh H, Worthington HV. Interventions for replacing missing teeth: different times for loading dental implants. Cochrane Database Syst Rev. 2013 Mar 28;3:CD003878.
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Restoration of Congenitally Missing Maxillary Lateral Incisors Using Mini Implants Ron Collins, DDS, MAGD
INTRODUCTION Traditionally, so-called mini implants were developed to increase retention and stability under full denture restorations. These implants range in diameter from 1.8 mm to under 3 mm and they are constructed as single units that include the threaded implant as well as the supragingival abutment. These implants have been used very successfully for many years for their original intended design and as of late are being used to support single and multiple unit restorations (1).
Abstract In this author’s opinion, the advent of mini implants, or small diameter implants (SDIs) as they are more frequently being called, are becoming in many situations a viable alternative to the more traditional root form implants. They offer advantages of less cost, a more simplified placement technique, usually faster healing times, and generally less post-operative complications. A case presentation is given to demonstrate their usage for a narrow ridge application to restore congenitally missing maxillary lateral incisors.
Key Words:
Mini implants, SDI
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The mini implant is placed using a smaller diameter osteotomy than the diameter of the implant itself. Penetration is accomplished with a pilot drill using a slight pumping action into the bone and the depth is three-quarters to one-half the length of the final placement of the implant depending on the quality of the bone encountered. The threaded implant is then inserted into this initial osteotomy and is fully advanced into the remaining untapped bone using finger, thumb wrench, torque wrench, or rotary instrumentation. The mini has several advantages over conventional root form implants. It can be placed into narrow bone ridges frequently negating the need for ridge augmentation and because of the technique of advancing the threaded portion into the bone it can minimally widen the ridge without additional ridge expansion surgery (2). The placement time and cost of the implant and surgery is significantly less to the patient than conventional implants as it is a 1-stage procedure. Because of the technique of minimal bone preparation and minimal interruption to the blood supply, osseous integration occurs earlier than conventional implant techniques and immediate loading can be accomplished if sufficient bone support exists (approximately 35Ncm of final torque) while being
About the Author Dr Collins is a general dentist in Houston, Texas; 11540 Harwin Dr, Houston, TX 77072; Phone: 281-983-5677; E-mail: roncollinsdds@yahoo.com; Web: royaloaksdentistry.com. This manuscript has been peer reviewed. The author has no declared potential conflicts of financial interest, relationships and/or affiliations relevant to the subject matter or materials discussed in the manuscript.
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Figure 1. CBCT with stint #10 area.
aware of and limiting lateral forces of occlusion (3). It is this practitioner’s observation that post-operative pain and complications are greatly reduced as compared to his conventional implant placements. However, the mini has some restrictions. Since the implant is a singular unit, its axial inclination somewhat limits its use in single and multiple restorations because available bone may not allow the implant’s abutment to be aligned properly for final restoration as compared to angled abutment options in the more conventional implant restorations. Because their diameters are smaller than conventional implants and can be placed in areas of minimal bone, the question of loading forces (especially in cases of bruxism and heavy occlusion) must be addressed for any given situation relative to the support of the final restorations. In
10 years of placing mini implants, this practitioner has never observed a post-insertion fracture of the implant itself. The patient at the time of placement was a 22-year-old Caucasian female who had both congenitally missing maxillary lateral incisors. Some years earlier the patient had undergone full-banded orthodontic treatment with the intention of leaving the proper spacing for replacement of the missing incisors. At the beginning of orthodontic treatment, the parents were given several options for restoration of the missing incisors. Implants/crowns, conventional fixed bridges, bonded bridges, removable partials, or moving the cuspids forward into the lateral spaces and hybridizing them to appear as laterals were all considerations. It was mutually decided to leave the
Figure 2. #7 and #8 edentulous area.
Figure 3. Plastic carrier with Imtec 1.8x13 mm implant.
spaces and make a final decision after completion of the orthodontic treatment. Prior to de-banding, with consideration of the minimal amount of available bone, a consultation with the parents and patient was completed. A decision was made to place mini implants followed by restoration with transitional composite crowns for a period of about 6 months and ultimately placing porcelain to metal crowns. This operator uses cone beam tomography almost exclusively prior to placing any implants. The tomography series showed an hourglass-like maxillary alveolus with its narrowest constriction at the mid point of the available length of bone measuring about 3.5 millimeters in width (Figure 1). This narrow constriction precluded the use of a conventional implant without bone augmentation or a ridge splitting technique so a mini implant was chosen. Following local anesthetics with nitrous oxide inhalation/ oral sedation analgesia, the sites were initially bone sounded by puncturing the gingivae with a periodontal probe until bone was felt (Figure 2). Each site was penetrated with a small pilot drill using a slight pumping action until approximately one-half of the final intended depth was achieved. Two 1.8 mm x 13 mm Imtec implants with gingival collars were then hand twisted into the site with the included plastic carrier until enough resistance was reached so that the carrier slipped around the implant (Figures 3,4). At that point the carrier was removed from the implant, and a thumb wrench was used until significant resistance was met, at which time a torque wrench was used until the final desired depth was
Figure 4. Initial implant placement by twisting plastic carrier until slipping occurs.
It is this practitioner’s observation that post-operative pain and complications are greatly reduced as compared to his conventional implant placements. However, the mini has some restrictions.
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Figure 5. Thumb wrench tightening.
Figure 6. After thumb wrench and ready for final torque wrench.
Figure 7. Rubber dam placement over implant.
Figure 8. Trimmed composite crown former with interproximal cutouts ready for composite.
achieved (Figures 5,6). A clear crown form was fitted and trimmed to fit over the implant and a small piece of rubber dam with a small central hole in it was placed over the implant and pressed snugly around the implant against the gingivae (Figures 7,8). The crown form with 2 interproximal windows and small vent holes in the incisal edge was filled with the appropriately shaded composite and placed over the implant and light cured (Figure 9). The outer plastic form was removed and the occlusion was adjusted just out of any occlusal interferences. Any needed corrections
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were made with the same composite material and final polishing was completed (Figure 10). Finally, the rubber dam piece was removed and a radiograph was taken (Figure 11). The patient was then dismissed with appropriate medications and postoperative instruction to be seen the following week. The 1-week postoperative visit showed normal healing with some soreness and the patient was cautioned not to bite directly into the implant areas until next month’s follow-up visit that proved to be
uneventful. However, at 2 months the patient returned reporting she had bitten into something hard and experienced a popping sound on the left implant. Examination revealed the left lateral implant and composite crown to be slightly mobile. The composite crown was checked to make sure it was completely out of occlusion and secured to the implant. It was splinted with composite to the adjacent teeth and the patient was dismissed with an antibiotic prescription and placed on a liquid diet for 1 month at which time she was to return. At follow-up the
Figure 9. Crown former with composite being light-cured.
Figure 10. Right lateral following immeidate removal of plastic former and rubber dam before polishing. Left lateral after adjustment and polishing.
Figure 11. Radiograph of implant with composite crown at time of implant placement.
Figure 12. Facial view PVCs 5 years post placement.
implant had stabilized. The splint was removed at that time and the patient was allowed to resume a more normal diet while still avoiding directly biting hard onto the implant areas until instructed otherwise. After approximately 2 years the patient had been problem free and the composite crowns were replaced with conventional porcelain to metal veneer crowns. These were chosen to best hide the underlying metal of the abutment. The patient was last seen at 5 years after placement of implants with no further reported incidents or
Figure 13. Occlusal view final view PVCs. Texas Dental Journal l www.tda.org l July 2013
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Figure 14. Photo of patient on December Figure 15. Panograph before implant placement. 4, 2007.
Figure 16. Patient on January 23, 2013.
Figure 17. Panograph with final PVCs.
complaints. The presence of anterior gingivitis was noted and there was the possibility of the patient mouth breathing during sleep (Figures 12,13). The patient has been instructed in proper oral hygiene at recare visits and encouraged to be meticulous in home care as peri-implantitis can be a major reason for failure of implants long term. The patient’s before (Figures 14,15) and after (Figures 16,17) photos and panoramic views are shown for comparison. It is this author’s opinion that mini implants
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are beginning to be a more acceptable and viable option for many restorative situations that were previously considered only appropriate for conventional implants. References 1. T. Shatkin DDS, S. Shatkin DDS, B. Oppenheimer DDS, A. Oppenheimer MD. Mini Dental Implants for Long Term Fixed and Removable Prosthesis: A Retroactive Analysis of 2514 Implants Placed Over a Five-Year
Period. Compendium Continuing Education in Dentistry, Feb 2007; 28(2): 92-96. 2. Balaji A, Mohammed JB, Kaerisen R. A pilot study of mini implants as a treatment option for prosthetic rehabilitation of ridges with sub-optimal bone volume. Journal Maxillofacial Oral Surgery. 2010; 9(4): 334-338. 3. Lerner H. Minimal invasive implantology with smaller diameter implants. Implant Practice. 2009; 2(2): 30-35.
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Oral and Maxillofacial Pathology Diagnosis and Management
Foreign body giant cell reaction to cosmetic filler material Radiesse Oral and Maxillofacial Pathology Case of the Month (from page 582)
Discussion Radiesse (BioForm Medical Inc., San Mateo, CA) is an injectable subcutaneous cosmetic filler material approved by the U.S. Food and Drug Administration in 2003. Shortly thereafter it was introduced to the commercial market, being recommended for various cosmetic, reconstructive, and therapeutic applications (1). Initially, it was utilized for the augmentation of vocal folds in patients with unilateral or bilateral vocal cord paresis and for repair of oral and maxillofacial defects. It was also advocated as a radiographic tissue marker (2,3). In 2006, the FDA approval was expanded to include its use cosmetically as a dermal filler (2). It is now primarily used as a soft tissue filler to correct wrinkles, and to augment and contour folds, depressions, and defects of the facial area, particularly in the aging population (3). It is also used to treat facial lipoatrophy in HIV+ patients. Radiesse is composed of calcium hydroxyapatite microspheres of 25-45 Âľm diameter embedded within a water-based methylcelluose carrier gel. The gel, which is mainly composed of methylcellulose and glycerin, is absorbed slowly (4). The hydroxyapatite microspheres stimulate and facilitate the proliferation of fibroblasts and the generation of new collagen, thus acting as a scaffold (3). Radiesse is very durable and is reported to last
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up to 1 year in the facial region once injected. Periodic reinjections are often necessary (4). The material is biocompatible and typically produces little inflammation. Mild effects in the form of ecchymosis, edema, erythema, pain, and pruritus have been reported (5). Although adverse effects are generally transient and mild, occasional foreign body reactions to Radiesse injections have been reported (3). The use of these less invasive cosmetic injection procedures for facial augmentation has been increasing recently with more than 1 million syringes of Radiesse shipped worldwide since 2002 (3). Since cosmetic injection is being used more often among the aging population, it is important for dental practitioners to be aware of potentially adverse complications since the facial region is the most common site for use of the material (4). Compared with the other biodegradable cosmetic fillers, Radiesse is purported to be the most preferable due to its low prevalence of adverse effects and its high durability (6). Its sustained clinical effectiveness is attributed to its inductive ability on endogenous collagen (14). Although rare, delayed side effects from Radiesse have been reported to present clinically as nodules in the skin and, on microscopic examination, have proved to be foreign body granulomas (7, 8).
A few cases of Radiesse granulomas in the form of nodules have been reported in the oral and perioral region, occurring most commonly in the upper lip, lower lip vermillion, and wet line area (7, 9, 10). Lip nodules are reported to occur in 12.4% of patients receiving lip augmentation and in 3.7% of those receiving treatment for radial lip lines (11). Temporarily visible nodularity has been reported in 33% of patients who received Radiesse injections (12). However, chronic nodules can also develop due to injection of too much material or superficial injection of the filler (12). Four cases of Radiesse granulomas of the lower lip have been reported in the literature (1, 13). Radiesse is also detectable by radiography and computed tomography. It produces an opacity with a signal higher than that of soft tissue but lower than bone. Its density decreases with time. Although there is no evidence that Radiesse might be misdiagnosed as a tumor, it is important that patients who have had cosmetic Radiesse injections inform their health care professionals (2). In conclusion, this case report is an example of a foreign body reaction associated with the use of cosmetic dermal filler. As cosmetic procedures are becoming more common, dentists should be aware of any cosmetic procedures their patients may have undergone and consider them in the differential diagnosis (1). A biopsy is the best way to confirm or rule out
a foreign body reaction in patients presenting with a chronic mass lesion that have a clinical history of having received cosmetic injection. References 1. Sankar, V. and H.S. McGuff, Foreign body reaction to calcium hydroxylapatite after lip augmentation. J Am Dent Assoc, 2007. 138(8): p. 1093-6. 2. Vazquez, J. and D.I. Rosenthal, Bilateral, symmetrical soft tissue calcifications in the face. Skeletal Radiol, 2010. 39(4): p. 387-9. 3. Valiyaparambil, J., K. Rengasamy, and S.M. Mallya, An unusual soft tissue radiopacity--radiographic appearance of a dermal filler. Br Dent J, 2009. 207(5): p. 211-2. 4. Daley, T., et al., Oral lesions associated with injected hydroxyapatite cosmetic filler. Oral Surg Oral Med Oral Pathol Oral Radiol, 2012. 114(1): p. 107-11. 5. Silvers, S.L., et al., Prospective, open-label, 18-month trial of calcium hydroxylapatite
6.
7.
8.
9.
(Radiesse) for facial soft-tissue augmentation in patients with human immunodeficiency virusassociated lipoatrophy: one-year durability. Plast Reconstr Surg, 2006. 118(3 Suppl): p. 34S-45S. Moers-Carpi, M., et al., A multicenter, randomized trial comparing calcium hydroxylapatite to two hyaluronic acids for treatment of nasolabial folds. Dermatol Surg, 2007. 33 Suppl 2: p. S144-51. Requena, L., et al., Adverse reactions to injectable soft tissue fillers. J Am Acad Dermatol, 2011. 64(1): p. 1-34; quiz 35-6. Dadzie, O.E., et al., Adverse cutaneous reactions to soft tissue fillers — a review of the histological features. J Cutan Pathol, 2008. 35(6): p. 536-48. Lemperle, G., et al., Foreign body granulomas after all injectable dermal fillers: part 1. Possible causes. Plast Reconstr Surg, 2009. 123(6): p. 1842-63.
10. Roy, D., N. Sadick, and D. Mangat, Clinical trial of a novel filler material for soft tissue augmentation of the face containing synthetic calcium hydroxylapatite microspheres. Dermatol Surg, 2006. 32(9): p. 1134-9. 11. Jansen, D.A. and M.H. Graivier, Evaluation of a calcium hydroxylapatite-based implant (Radiesse) for facial soft-tissue augmentation. Plast Reconstr Surg, 2006. 118(3 Suppl): p. 22S-30S, discussion 31S-33S. 12. Godin, M.S., et al., Use of radiesse in combination with restylane for facial augmentation. Arch Facial Plast Surg, 2006. 8(2): p. 92-7. 13. Farahani S, H.M., Kabani S, Konys R, Sexton J, Woo S-B., Granulomatous foreign body reaction to calcium hydroxyapatite filler. Report of three cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2011. 112.
Are You Relying on Selling your Dental Practice for Retirement? Did you know that 80 percent of practices with the doctors over age 50 couldn’t be sold with the selling doctor continuing to work in his old practice? Let us help you protect your retirement and position yourself to work in your practice for as long as you wish.
Dental Practice Specialists is a Growth & Management Consulting Firm
Clyde Dollens, DDS cdollens@aftco.net 281-639-4703
We can help with: • Increased Schedule Production • Increased Hygiene Production • Staff Assessment and Coaching
www.DentalPracticeSpecialists.com Free Practice Appraisal and Evaluation Dental Transitions & Sales through the AFTCO Network
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Dental Artifacts Wilcox-Jewitt Obtunder Syringe Kim Freeman, MA, DMD, MS
Figure A.
O
ccasionally, non-recycled ideas come along in dentistry. The Wilcox-Jewitt Obtunder syringe (Figures A and B) is one that came to fruition about a century ago. What does obtunder mean? I had to look it up, and according to the American College Dictionary, the word is derived from obtund. Obtunder is not a derivation that meets with approval, however obtund means to blunt, dull, or deaden. Therefore the inventors must have inferred a technique meant to “deaden” pain from dental procedures.
Figure B.
In fact the label states that even pulp extirpation can be done painlessly using there technique with this syringe (Figure C). It involves drilling a hole into the enamel with a #1 round bur and then using a pinwheel and matching tip on the syringe to force a 5% cocaine solution through the dentinal tubules (Figure D). The solution was mixed and drawn into the syringe (apologies to Sir Arthur Conan Doyle) for dispensing. The wooden boxed kit was offered by Lee Smith and Company of Pittsburg.
Figure C.
I can’t imagine this met with much success except in very special circumstances. Difficulties would arise in drilling, without anesthesia into the dentine enamel complex. On the other hand if you were not used to any anesthesia for dental procedures, it would be better than nothing!
Photos courtesy Dr Griffin Murphey
Figure D.
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Memorial and Honorarium Donors to the Texas Dental Association Smiles Foundation
In Memory of: David McBurnett Dr Robert C Cody
Ronny Deaton Dr Don Lutes
In Honorarium: Patty Taylor Della Fitzhugh Harris
Your memorial contribution supports: • •
educating the public and profession about oral health; and improving access to dental care for the people of Texas.
Please make your check payable to:
TDA Smiles Foundation, 1946 S IH 35, Austin, TX 78704
In Memoriam Those in the dental community who have recently passed
Gaynor, Jay I. Lubbock, Texas May 13, 1924 – May 4, 2013 Good Fellow, 1982 Life, 1989 Fifty Year, 2000 Long, John Q. Odessa, Texas November 25, 1930 – May 24, 2013 Good Fellow, 1983 Life, 1995 Fifty Year, 2007 O’Shell, Vincent J. Beaumont, Texas May 10, 1927 – May 10, 2013 Good Fellow, 1980 Life, 1992 Reid, Bryce Z. Brownwood, Texas March 26, 1928 – May 15, 2013 Good Fellow, 1988 Life, 1993 Fifty Year, 2012 Richter, Charles E. Dallas, Texas February 4, 1922 – May 20, 2013 Good Fellow, 1979 Life, 1987 Woodruff, Don E. Corpus Christi, Texas December 29, 1932 – May 14, 2013 Life, 1999 Fifty Year, 2009
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CALENDAR OF EVENTS AUGUST2013 9-10
9-10
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The TDA Smiles Foundation will hold a 20-chair Texas Mission of Mercy in Texarkana. For more information, please contact Foundation Manager Judith Gonzalez at TDASF, 1946 S IH35 Ste 300, Austin, TX 78704; Phone: 512-448-2441; E-mail: judith@tda.org; Web: tdasmiles.org. The American Dental Association Political Action Committee will be hosting its 2013 Campaign School at The Mandarin Hotel in Washington, DC. For more information, please contact Sarah Milligan, ADPAC Director, 1111 14th Street NW Ste 1100 Washington, DC 20005. Phone: 202-789-5171; E-mail: milligans@ ada.org; Web: ada.org.
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The California Dental Association presents The Art and Science of Dentistry at Moscone West, in San Francisco CA. For more information, please contact Ms Deborah Irwin, CDA, 1201 “K� Street Mall, Sacramento, CA 95853. Phone: 916-443-3382 Ext 4470; FAX: 916-554-5937; E-mail: debi@cda.org; Web: cda.org.
SEPTEMBER2013 26-28
The Texas Academy of General Dentistry will host its annual Lone Star Dental Conference in Austin, Texas. For more information, please contact Laura Ceglio, Communications Coordinator, TAGD, 409 W Main St, Round Rock, TX 78664. Phone: 512-244-0577; FAX: 512-244-0476; E-mail: laura@tagd. org; Website: tagd.org.
OCTOBER2013 4-5
The TDA Smiles Foundation will hold a 40-chair Texas Mission of Mercy in Abilene. For more information, please contact Foundation Manager Judith Gonzalez at TDASF, 1946 S IH35 Ste 300, Austin, TX 78704; Phone: 512-448-2441; E-mail: judith@tda.org; Web: tdasmiles.org.
7-12
The American Association of Oral and Maxillofacial Surgeons will host its 95th annual meeting in Orlando, FL. For more information, please contact Dr Robert C. Rinaldi, AAOMS, 9700 W. Bryn Mawr, Rosemont, IL 60018. Phone: 847-678-6200; FAX: 847-6786286; Website: aaoms.org.
16-19
The American Student Dental Association will host its 37th Annual ASDA Conference in Naples, FL. For more information, please contact Dr Dan Ward, ASDA, 635 Madison Ave, New York, NY 10022. Phone: 800454-2732; E-mail: dward@columbus. rr.com; Website: asdatoday.com.
NOVEMBER2013 31-5
The American Dental Association will host its 154th Annual Session in New Orleans, LA. For more information, please contact ADA conference and meeting services, ADA, 211 East Chicago Ave Ste 730, Chicago, IL 60611-2678. Phone: 312-4402500; FAX: 312-440-2707 ; E-mail: annualsession@ada.org; Website: ada.org.
31-2
The Alliance of the American Dental Association will host its annual conference in New Orleans, LA. For more information, please contact Ms Patricia Rubik-Rothstein, AADA, 211 East Chicago Ave Ste 730, Chicago, IL 60611-2678. Phone: 312-4402865; FAX: 312-440-2587; E-mail: manager@allianceada.org; Website: allianceada.org.
JANUARY2014 26-28
The American Dental Association will host its annual president’s-elect conference in Chicago, IL. For more information, please contact the ADA, 211 East Chicago Ave Ste 730, Chicago, IL 60611-2678. Phone: 312-440-2500; FAX: 312-440-2707; Website: ada.org.
30-1
The Dallas County Dental Society will host its annual Southwest Dental Conference in Dallas, TX. For more information, please contact Jane Evans, Southwest Dental Conference Director, DCDS, 13633 Omega Rd, Dallas, TX 75244. Phone: 972386-5741; FAX: 972-233-8636; E-mail: jane@dcds.org; Website: swdentalconf.org.
The Texas Dental Journal’s Calendar will include only meetings, symposia, etc., of statewide, national, and international interest to Texas dentists. Because of space limitations, individual continuing education courses will not be listed. Readers are directed to the monthly advertisements of courses that appear elsewhere in the Journal.
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Provided by TDA Perks Program
value for your
profession
Why Having a Mobile-Friendly Website is So Important By the end of this year, it’s estimated that more people will browse the Internet on mobile devices than on desktop computers.
Lance McCollough CEO, ProSites
G
one is the day where simply having a website was enough to meet your patients’ and prospects’ demands. Now the mobile web is where people are researching products and services, reading reviews and purchasing daily deals from sites like Groupon. Mobile phones outnumber PCs 4:1, and 66% of people access the
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Internet on smartphones daily. This means your prospects are likely searching for dental services on their mobile devices, and you need to be marketing to them wherever they are. In April 2013 alone, the keywords “Texas Dentist” were searched more than 90,500 times from mobile devices.
The extraordinary growth of mobile search is reason enough for your practice to have a mobile-friendly website. But results from mobile-user studies underscore the importance of having a mobile-friendly site: •
More than half of all mobile searches were found to lead to action (such as calling to schedule an appointment) within 24 hours.
•
67% of mobile users said a mobile-friendly site makes them more likely to buy a product or use a service.
•
Of the 94% of smartphone users who’ve reported looking for local services on their mobile device within the past year (up from 80% reported the year prior), 90% contacted or hired the service for which they searched.
Not Having a MobileFriendly Website Can Hurt Your Practice. A mobile-friendly website is clearly a worthwhile investment, but not having one could mean the following: •
•
•
You could move down in mobile search-engine results. Google’s Smartphone Crawler is capable of determining which sites are mobile-friendly and which aren’t. It places mobile-friendly results higher, in an effort to provide mobile searchers with a better search experience. Your competitors could be snatching up your prospects. A recent Google study shows that 61% of mobile users agree that if they don’t find what they’re looking for right away on a mobile site, they’ll quickly move on to another site. The study also indicates that more than 50% of mobile users are less likely to engage with a company if it doesn’t have a mobile website or if they have a bad mobile experience. If you’re running Google Mobile Ads, you could be wasting marketing funds. The team at Google states “ads that have mobile landing pages will perform better in AdWords, generally driving more traffic at a lower cost.”
A Mobile-Friendly Site Makes Your Practice Information More Accessible. A mobile-friendly website is a way to provide patients better customer service. It provides an optimal viewing experience and easy access to information about your practice. When you shop for a mobile website provider, you’ll want to be sure the firm will deliver a site that provides patients superior service. Following are important features and functionality you should look for in a mobile website: •
Thumb-Friendly Buttons Because most mobile phones have touch screens, visitors must use their fingers to navigate a mobile site. Making sure buttons are large enough to be clicked with a single digit is extremely important. Nothing frustrates visitors more than not being able to access areas of a site.
•
Fast Page-Load Times Mobile users often access mobile sites out of convenience; they’re typically impatient and want information quickly (without having to wait more than 5 seconds for a page to load). Sites with compressed video and images will have increased page-load speed.
•
Aesthetically Pleasing Because mobile websites load on small screens, it’s important that text and images are formatted appropriately to ensure optimal viewing. Additionally, mobile website color schemes should be carefully selected to give text enough contrast to be seen in highand low-light situations. The text should also be large enough for visitors to read without needing to zoom in.
•
Accessible on Any Device Mobile sites are tricky to create because all mobile devices have different functionalities. A mobilefriendly website should display correctly across all mobile devices, and be viewable in any orientation — horizontal or vertical. Additionally, it should keep users in the same location as they flip orientations.
•
Displays Automatically A website should instantly send visitors to the mobilefriendly version when visitors are using a mobile device to access it and should use the same URL as its desktop Texas Dental Journal l www.tda.org l July 2013
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version. Users should also have the option to view the full desktop website if they wish. (This functionality is often included in the footer of a mobile website). •
Local Map View Users prefer an easily-accessible map that allows them to reference a practice’s location and obtain directions.
•
Simple Navigation Reducing user frustration is the main goal of a mobile-friendly website. Simple, concise navigation allows users to easily access areas of interest. Docked menus along the top of the page will enable users to navigate without excessive scrolling.
•
Simple Conversions A mobile website should make it easy for visitors to contact a practice with click-to-call and clickto-map functionality. These quick-contact buttons enable visitors to call or obtain directions with one click.
JKJ Pathology Oral Pathology Laboratory
John E Kacher, DDS • Available for consultation by phone or email • Color histology images on all reports • Expedited specimen shipping with
•
Cohesive A mobile website should let visitors experience and access the same information as the desktop website. The mobile site’s appearance should be cohesive with the practice’s branding, so visitors know the mobile website belongs to a particular business.
Having a mobile website is shifting from being a luxury to a necessity. If you don’t yet have a mobile website, you could be turning potential patients away. Lance McCollough is the founder and CEO of ProSites, a leading website design and Internet marketing company specializing in dental-practice marketing. Endorsed by TDA Perks Program, ProSites offers easy and affordable website solutions to help dentists successfully market their practice online. For more information, please call 888-541-6452 or visit www.prosites.com/TDA. For more information regarding TDA Perks Program, please visit tdaperks. com, or call 512-443-3675.
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tracking numbers • Reports available online through secure web interface
Professional, reliable service with hightechnology solutions so that you can better serve your patients. Call or email for free kits or consultation. jkjpathology.com 713-598-9284 (T) 281-292-7372 (F) johnkacher@jkjpathology.com
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ADVERTISING BRIEFS Practice OpportunitieS ABBEVILLE DENTISTRY: We are seeking an honest, hardworking, patient focused dentist who wants to contribute to a culture of caring, nurturing and skilled professionals. If you have the desire to be a part of a team where you can focus on patients and not worry about the headaches that come with the business side of dentistry, please call us. If you are seeking an environment that provides stability, growth and continuing education, we’d like to share with you how you can fit into that plan. Twenty years ago, I started my practice simply dedicated to serving my patients and community. Now, I’m privileged to guide over 10 practices and 80 wonderful staff. I’ve turned the administrative, operations and marketing efforts over to people who enjoy doing those sorts of things so our doctors and staff can focus on their patients. I’ve also been able to provide young doctors with an environment where they can grow and practice what they love doing without the worry of costly overhead or administrative headaches. At the same time, offering the potential for significant income and a great life balance. You’ll enjoy a great environment with no egos and no political barriers. We’re growing and need a few quality individuals to join us in creating something truly special. We’re forming a new, interactive, fun environment that kids and their parents will find refreshing and exciting. If you’d like to talk about this opportunity, please give me a call. I’d be happy to share the vision, the success and the expectations we have while answering your questions.
ADVERTISING BRIEF INFORMATION SUBMISSION AND CANCELLATION DEADLINE: 20th, 2 months prior to publication (eg, November 20th for January issue) MONTHLY RATES: First 30 words = $40; each additional word = 10¢ Ads must be submitted via e-mail, fax, or web and are not accepted by phone. Journal editors reserve the right to edit copy of classified advertisements. Any dentist advertising in the Texas Dental Journal must be a member of the American Dental Association. Advertisements must be not quote revenues or gross or net incomes; only generic language referencing income will be accepted.
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candidly and openly. I hope you’ll consider this position and give me a call. Britt Bostick, DDS, 806-438-5745, or email bbost35821@aol.com. ADS WATSON, BROWN & ASSOCIATES: Excellent practice acquisition and merger opportunities available. DALLAS AREA: 6 general dentistry practices available (Dallas, North Dallas, Highland Park, and Plano); 5 specialty practices available (2 ortho, 1 perio, 1 pedo). FORT WORTH AREA: 2 general dentistry practices (north Fort Worth and west of Fort Worth). CORPUS CHRISTI AREA: 1 general dentistry practice. CENTRAL TEXAS: 2 general dentistry practices (north of Austin and Bryan/College Station). NORTH TEXAS : 1 orthodontic practice. HOUSTON AREA: 3 general dentistry practices. EAST TEXAS AREA: 2 general dentistry practices and 1 pedo practice. WEST TEXAS: 3 general dentistry practices (El Paso and West Texas). NEW MEXICO: 2 general dentistry practices (Sante Fe, Albuquerque). For more information and current listings, please visit our website at www.adstexas.com or call ADS Watson, Brown & Associates at 469-222-3200. AMARILLO: General dentist for a locally owned practice looking to provide care for our patients as well as build their own patient base. Ownership opportunity available. Please contact Dr Britt Bostick, DDS, bbost35821@aol.com or call 806-438-5745. AMARILLO: Pediatric dentist for a locally owned practice looking to provide care for our patients as well as build their own patient base. Ownership opportunity available. Please contact Dr Britt Bostick, DDS, bbost35821@aol.com or call 806-438-5745. AMAZING Practice Sale: (Sherri L. Henderson & Associates, LLC) Northeastern Oklahoma green country. This great general practice draws from five large surrounding counties and is 35 minutes from Tulsa. Busy traffic location; 1,550 sq ft 2 ops, 1 hygiene op, and 1 additional shared hygiene op. The doctor is retiring after 45 years in practice. Great production potential and chance to own or lease the beautiful free standing building (3,100 sq ft). Pictures available — #3001. Call Sherri at 972-562-1072; www.slhdentalsales.com.
Anxious to sell in the CORPUS CHRISTI AREA: Sherri L. Henderson & Associates. The DDS is relocating to another city. The general practice was established in 1982 in a professional office complex with 1,400 sq ft and 3 existing treatment rooms. This location would make a great place for a start-up or satellite practice and it has plenty of space next door for expansion. The location is on one of the busiest streets with access to Padre Island Drive. This is a cash basis practice with a dedicated loyal staff and great revenue potential. The current owner has extensive experience with TMJ and sleep apnea and would be willing to return to the practice periodically if the new owner was interested. #3070 (Pictures available) Contact 972-562-1072 or e-mail sherri@slhdentalsales.com; www. slhdentalsales.com. ARLINGTON / FORT WORTH: Associate position available. Full-time dentist and specialist needed to join our successful dental group in Arlington and Fort Worth. Interested candidates should email CV to info@ ismiledental.net. ASSOCIATE FOR TYLER GENERAL DENTISTRY PRACTICE: Well-established general dentist in Tyler with over 30 years experience seeks a caring and motivated associate for his busy practice. This practice provides exceptional dental care for the entire family. The professional staff allows a doctor to focus on the needs of their patients. Our office is located in beautiful East Texas and provides all phases of quality dentistry in a friendly and compassionate atmosphere. The practice offers a tremendous opportunity to grow a solid foundation with the doctor. The practice offers excellent production and earning potential with a possible future equity position available. Our knowledgeable staff will support and enhance your growth and earning potential while helping create a smooth transition. Interested candidates should call 903-509-0505 and/or send an e-mail to steve.lebo@sbcglobal.net. Associate needed for dental office in small, quaint town. Potential for practice purchase. Call 361-6458148.
ASSOCIATES and PARTNERS AVAILABLE: Sherri L. Henderson & Associates. Is it time for you to add another provider? Is it time for you to go golfing or fishing more? Let us help you find the perfect associate and potential buyer. We have candidates ready in all parts of Texas looking for your specific practice profile. There are many graduates as well as very experienced dentists looking for the opportunity to transition into your already established practice. These dentists have great people skills, case presentation experience and can be a very valuable and reliable addition to your bottom line. If you are confused about the right timing or simply would like to talk about the opportunities, call us today for a complimentary consultation in person or by telephone. We are experienced in practice sales, associate and partner placement and can assist you in making that transition dream become a reality. Call 972-562-1072 or e-mail sherri@slhdentalsales.com; www.slhdentalsales.com. AUSTIN: Progressive, patient centric office is seeking an experienced dentist; must be friendly, caring and professional. Opportunity is available (if desire) for practice ownership. Serious inquiries e-mail: fahoosha@ gmail.com, or mike@miloinc.com. AUSTIN PEDIATRIC PRACTICE SEEKING FULL-TIME ASSOCIATE: Great benefits! Progressive, fast-paced practice. Capable caring staff. We are looking for a bright career-oriented pediatric dentist to join an organization committed to providing high quality dental care to children and adolescents. Our dental team strives to offer exceptional care with integrity. Send your confidential resume to dentalresume27@yahoo.com for consideration. AUSTIN, SAN ANTONIO & DALLAS AREA PRACTICE OPPORTUNITIES MCLERRAN & ASSOCIATES: SAN ANTONIO (ID #T214): Turn-key general family practice with large, fee-for-service/PPO patient base and high new monthly patient flow. This 4 operatory practice is well-equipped with digital X-ray and is computerized throughout. Practice revenue has been consistently in the high 6 figures with extremely strong cash flow.
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ADVERTISING BRIEFS SAN ANTONIO (ID #T212): Established general family practice with large, primarily fee-for-service/PPO patient base, healthy new patient flow, consistent annual revenue over 7 figures per year, 6 fully- equipped operatories and an experienced staff. The practice and real estate are both available for purchase. WEST TEXAS (ID #T211): Associate to purchase opportunity in this thriving, well-established periodontal specialty practice located in low competition and growing area. SAN ANTONIO (ID #T209): Located on the east central side of town in a medical center building, this established pediatric specialty practice has seen consistent revenue in the mid 6 figures with low overhead. Excellent stand-alone or satellite office! SAN ANTONIO (ID #T206): Established, 2-location general family practice with total collections in the mid-6 figures on a limited schedule and no external marketing. Low overhead and tremendous upside potential to make this a great starter opportunity. SAN ANTONIO (ID #T205): This is an opportunity to purchase an established general dentistry practice for much less than it would cost to start a practice from scratch! The practice has a fee-for-service/PPO patient base and has collections in the low 6 figures on a 2-day work week with no external marketing, providing tremendous upside potential through increasing operating days/hours and implementing a marketing plan to increase new patient flow. The office is located in a high traffic area in north/central San Antonio and features 3 fully equipped operatories with modern equipment and digital X-ray units (4th plumbed operatory available for expansion) and a very low monthly rental rate. SAN ANTONIO (ID #T201): Established practice offering general dentistry to a diverse patient base. Consistent revenues in the mid-6 figure range strictly through word of mouth and patient referrals. The office has 4 fully equipped operatories with room to add an additional 3 operatories. Excellent opportunity for less than the cost of a start up. SAN ANTONIO (ID #T185): Well-established periodontal specialty practice available for purchase. Contact us now for more information on this excellent opportunity. SAN ANTONIO (ID #T181): Low overhead general family practice located in 4 operatory, paperless and digital office. Large Medicaid/PPO patient base, well-established location and upside potential make this a solid opportunity. EAST OF SAN ANTONIO (ID #T140): Quality, comprehensive family practice located in
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freestanding building with 3 equipped operatories. This practice has seen strong growth the last 3 years and is a great opportunity for doctor looking for a practice in lower competition area near San Antonio. The practice and real estate are available for purchase. (ID #T113): Oral surgery specialty practice. Very good referral base. Almost new build out, great location and excellent equipment. Good gross and net! Transition available. SAN ANTONIO (ID #T060): Prosthodontic practice with almost new equipment and build out. Tremendous upside potential and beautiful office! Perfect for stand-alone or satellite office. AUSTIN (ID #T210): This large oral surgery practice has an established, diverse referral base and 2 attractive locations in the Austin area. The practice boasts incredibly strong gross collections and strong profitability over the past few years and still offers the opportunity for further growth. The sellers are looking for a dual degree doctor (DDS, MD) to purchase 50% or 100% of the practice and are willing to continue working part-time for several years following the sale to maintain production and transfer the referral relationships. WEST OF AUSTIN (ID #T208): This attractive, general dentistry practice is located in a beautiful, vibrant town in the Texas Hill Country approximately 1 hour west of Austin. The office is located in a charming craftsmen style bungalow situated on a busy street and encompassing 1,800 sq ft with 3 fully equipped operatories (the real estate is also for sale). The practice has a fee-for-service/PPO patient base and consistent annual revenue in the mid-6 figures. You can purchase this established practice for less than it would cost to start an office from scratch! AUSTIN/SANTONIO AREA (ID #T207): This established, general dentistry practice is located in a growing community along the I-35 corridor between Austin and San Antonio. The practice boasts a 100% fee-for-service patient base, annual revenues in the mid-6 figures, exceptional cash flow, 3 fully equipped operatories (with a 4th plumbed operatory), modern equipment and attractive dĂˆcor. AUSTIN (ID #T204): This established, general dentistry practice in North Austin has 5 operatories, a predominantly fee-for-service patient base, annual revenue in the mid-6 figures and outstanding net cash flow of over 50%. The practice also offers tremendous upside potential, as the office is open only 3.5 days per week and has no external marketing. KILLEEN AREA (ID
ADVERTISING BRIEFS #T213): This is an opportunity to purchase a small, established general dentistry practice with solid cash flow and a predominantly fee-for-service/PPO patient base. Even with reduced office hours, the office realized annual revenues of in the mid 6 figures over the last 3 years. This practice has tremendous upside potential, evidenced by the fact that it collected in the high-6 figures in 2009. The office has 4 fully equipped operatories and is located within a professional building right in the heart of a high traffic vicinity of the Killeen/Fort Hood area. This is a great starter practice for any motivated and eager dentist! AUSTIN (ID #T203): This small, fee-for-service general dentistry practice has been established for 90 years and has annual collections in the low-6 figures. The office is located in a professional building situated on 38th st in central Austin. The office space encompasses approx. 1,110 sq ft and features 2 fully equipped operatories and 1 additional plumbed operatory. This is a great starter practice, satellite office, or merger opportunity! CENTRAL TEXAS (ID #T191): Established general dentistry practice located in a great community 1 hour north of Austin. Annual collections near 7 figures with extremely strong cash flow. Four operatory facility in freestanding building with excellent visibility. Strong upside potential! AUSTIN, SOUTH (ID #T188): Practice owner is looking for a parttime associate doctor to work 2 to 3 days per week (with the potential to become a full-time position) in a large, established, fee-for-service practice in south Austin. The associate must be available to work on Friday, possess a strong clinical skill set, and have the ability to provide at least 3 of the following services: endodontics, implant placement, 3rd molar extractions, IV sedation, and periodontal surgery. WACO AREA (ID #T189): Well established family practice in low competition area. Minimal investment, strong upside and opportunity to own real estate make this attractive opportunity. WACO/ DALLAS AREA (ID #T134): General practice in low competition area. Fee-for-service practice with good patient flow. No competition. Can operate as a satellite or become a full-time office. NORTH TEXAS/ABILENE AREA (ID #T195): Small, established general family practice located in quickly growing small town community. Tremendous upside potential! VICTORIA/CORPUS CHRISTI AREA (ID #T171): Well-established, general family practice
with large patient base, strong number of new patients per month, committed staff, and solid upside potential, with gross income in mid-6 figures. Practice is located in freestanding building that is available for purchase with practice. Contact McLerran & Associates: Paul McLerran, DDS, David McLerran, or Brannon Moncrief in Austin 512-900-7989, San Antonio 210-37-0100, or Dallas 214-960-4461. Practice sales, appraisals, buyer representation, and lease negotiations. To request more information on our listings, register at www.dental-sales. com. Awesome practice in LONGVIEW, TEXAS: For sale — SLH Dental Sales is looking for a qualified buyer that would like the opportunity to immediately transition into a general dental office in this growing town of east Texas. The owner is willing to stay for a negotiated amount of time if necessary to insure a smooth transition. The location of the practice is near the hospital in a beautiful scenic area surrounded by many professional buildings. The staff is excited and ready for a future owner that will allow the current owner to pursue other opportunities. The office space is 1,500 sq ft with 4 treatment rooms equipped, 2 private offices, and 6 highly experienced employees. The owner occupies a portion of the building complex and is looking to transfer ownership of both patient base and the building space immediately. For more information, please contact our office at 972-5621072, e-mail sherri@slhdentalsales.com, or visit our website at www.slhdentalsales.com (pictures available). Listing #3050. BEAUMONT AREA: FOR SALE: Well-established 3 operatory, 17-year-old general practice. Great location with good visibility and high traffic flow. Modern equipment and computer system with Eagle Soft dental software. Staff is excellent and long standing. Practice is fully functional in all aspects and ready for buyer to step in seamlessly. Building is a free standing country style office in beautiful condition and seller will sell or lease. Please inquire via email at drbob.willis@henryschein.com. BEAUTIFUL EAST TEXAS: Long standing general practice in a stable community of over 14,000 with a great referral Texas Dental Journal l www.tda.org l July 2013
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ADVERTISING BRIEFS base. Three ops, full-time hygienist, and great staff. Doctor desires a quick sale and will aid in a smooth transition. Opportunity for ownership and start building equity for a minimal investment, with scheduled patients on day one. Contact Dr Guy Walker, Paragon Dental Transitions, 573225-2877, www.paragon.us.com.
DALLAS AREA: New and beautiful general dentistry practice on I-30 near Rockwall. Over 5 years of clinical experience required. Perfect for dentists who refer endo! Pay based on collections. PPO and Medicaid accepted. M-F 2:00 pm - 8:00 pm and Saturdays available; www. mockingbirddentalgroup.com.
BROWNSVILLE SEEKING ASSOCIATE: Established general dental office in Brownsville (30 minutes away from South Padre Island) is seeking a caring, energetic associate. We are a busy office providing dental care for mostly children. Our knowledgeable staff will support and enhance growth and earning potential allowing the associate to focus on patient dental care. Interested candidates should call 956546-8397.
DALLAS: Solo general practice in North Dallas serving local Asian community. Well-maintained facility on busy street with 3 ops and fourth plumbed. Doctor retiring and desires a quick transition. Long-time loyal staff. Mainly FFS with exceptional collection rate and low overhead. Contact Dr Guy Walker, Paragon Dental Transitions at 573-225-2877 www.paragon.us.com.
Consulting & Staging For Your Transition! SLH Dental Sales (Sherri L. Henderson & Associates) — Are you prepared for the future? Let us help you make a transition plan. We can analyze the market, review your current patient base, secure the staff, spruce up the office space, and much more. We specialize in practice transition consulting and can assist you in a plan to help you create all the right conditions to begin that step from retiring to starting up a new practice. Our team has decades of hands on experience in the dental market place as practice owners, employees and management advisors. We are here to help you prepare for an associate, partner, start-up or practice sale. We have a huge database of qualified applicants waiting and the time could not be better to begin the process. Our contact with you is strictly confidential and we are happy to schedule a complimentary consultation to discuss your options. Call 972-562-1072 or e-mail sherri@slhdentalsales.com; www. slhdentalsales.com. DALLAS / FORT WORTH: Area clinics seeking associates. Earn significantly above industry average income with paid health and malpractice insurance while working in a great environment. Fax 312-944-9499 or e-mail cjpatterson@ kosservices.com.
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DENTALONE PARTNERS is opening new offices in Austin and the surrounding areas. Each practice is unique in that it has an individual name like Preston Hollow Dental Care or Waterside Dental Care. Our patient base consists of approximately 70% PPO and 30% fee-for-service. All our offices have top-of-the-line Pelton and Crane equipment, digital X-rays, and intra-oral cameras. We offer competitive compensation packages with benefits. To learn more about working with one of DentalOne Partner practices, please contact Andrew Risolvato at 972-755-0838 or andrew.risolvato@dentalonepartners.com. DENTALONE PARTNERS is opening new offices in Dallas and the surrounding areas. Each practice is unique in that it has an individual name like Preston Hollow Dental Care or Waterside Dental Care. Our patient base consists of approximately 70% PPO and 30% fee-for-service. All our offices have top of the line Pelton and Crane equipment, digital X-rays and intra-oral cameras. We offer competitive compensation packages with benefits. To learn more about working with one of DentalOne Partner practices, please contact Andrew Risolvato at 972-755-0838 or andrew.risolvato@dentalonepartners.com.
ADVERTISING BRIEFS DENTALONE PARTNERS is opening new offices in San Antonio and the surrounding areas. Each practice is unique in that it has an individual name like Preston Hollow Dental Care or Waterside Dental Care. Our patient base consists of approximately 70% PPO and 30% fee-for-service. All our offices have top of the line Pelton and Crane equipment, digital X-rays, and intraoral cameras. We offer competitive compensation packages with benefits. To learn more about working with one of DentalOne Partner practices, please contact Andrew Risolvato at 972-755-0838 or andrew.risolvato@ dentalonepartners.com. DENTALONE PARTNERS is opening new offices in the upscale suburbs of Houston. Each practice is unique in that it has an individual name like Gulf Breeze Dental Care or Waterside Dental Care. All of our offices have top of the line Pelton and Crane equipment, digital X-rays, and intraoral cameras. Our patient base consists of approximately 70% PPO and 30% fee-for-service. We offer competitive compensation packages with benefits. To learn more about working with DentalOne Partner practices, please contact Andrew Risolvato at 972-755-0838 or andrew. risolvato@dentalonepartners.com. DFW AREA: Seeking general dentists and specialists. Our offices are located in the Dallas / Fort Worth area. We are looking for caring, energetic associates. New graduate and experienced dentists welcome. We offer benefits, a helpful working environment and an opportunity to grow. We accept most insurance and Medicaid. Please submit your resume via e-mail to jennifer@smileworkshop.com or call our office at 214-757-4500. DFW, AUSTIN, SAN ANTONIO, AND HOUSTON: ASSOCIATE DENTIST OPPORTUNITY: Pacific Dental Services and its supported owner dentists have exciting associateship opportunities throughout the state of Texas (DFW, Austin, San Antonio, and Houston). Practices are uniquely named (ie, The Woodlands Smiles Dentistry and Orthodontics) and owned by general dentists make all clinical decisions in a traditional, practice setting while PDS provides the business support services. Associates see 12 to 13 patients
a day in a PPO/FFS setting (no Medicaid). Practices are state-of-the-art, fully digital, and equipped with Cerec CAD/CAM 4.0 with Omnicam, lasers, and intraoral cameras. Exciting comp package with full benefits, CE, malpractice insurance, and partnership/ownership opportunities. To learn more, please visit www.jobs. pacificdentalservices.com. EL PASO/HORIZON: Orthodontist needed ASAP on the east side of El Paso and Horizon area. This is a part time position 2 days per week. Excellent salary. Great environment. Send resume to info@txkidsdental.com. EL PASO: Full-time position for a general dentist. Don’t waste your best years at dead-end jobs. Great earning potential and future partnership option. Affordable El Paso Dental is looking for a Texas-licensed dentist to work fulltime in our office in El Paso, TX. Applicant must be licensed in the state of Texas and have 1 year of experience. If interested please submit a resume to the following email address: drdarj@gmail.com. Please provide an accurate contact number and email address. EL PASO: General dentist / implantologist would like an associate to work with until he or she feels comfortable in taking over the practice. Plan to retire at the end of 2013. Cam-Log implants, bone grafts — will teach my associate these procedures. Also I do all other general dentistry procedures. Office has 3 operatories and 1,400 sq ft. Located in an attractive retail strip in east El Paso. Courteous, talented staff willing to stay with new doctor. Call Tony Marquez, DDS, PhD, at 915-594-4048 or e-mail me at marquezdental@gmail.com. EL PASO: Selling a state of the art general practice with orthodontic patients. Building is 6,000 sq ft for sale or lease. Whole building available. Partnership also available as well as many other options. Building is beautiful and only 1 year old with 11 ops fully equipped with digital X-rays, Softdent, Adec, Marcus equipment. Located on east side of El Paso. For more information please contact Dr Oscar Vargas at 915-276-2242.
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ADVERTISING BRIEFS EL PASO: We are hiring a skilled and compassionate dentist to join our stable and successful practice. We are seeking a highly professional dentist with a knack for general dentistry. Prospective candidates must be dynamic, fun loving, and looking for a long term commitment. Our practice is highly productive affording our providers an opportunity to attain competitive compensation. If interested, please forward your CV to annette@vistahillsfamilydental.com. FULLY EQUIPPED MODERN DENTAL OFFICE SPACE AVAILABLE FOR LEASE. Has 4 ops. Current doctor is only working 2 days a week. Great opportunity to start up new practice (ie, endo, perio, oral surgery). Available days are Monday, Tuesday, Thursday per week. If you are wanting an associate, please inquire. Call 214-315-4584 or e-mail ycsongdds@yahoo.com. GALVESTON: Well-established, successful practice of 35 years needs full-time associate dentist for FFS/PPO practice. Experienced staff, new equipment, Galveston. Senior owner loves to teach sedation, implants, and other surgical procedures. No Medicaid, No DHMO practice in 6 ops, 2 surgical suites, all operatories computerized with digital X-ray and intra-oral cameras; digital panoramic X-ray; paperless charts for easy documentation. Visit www. todaysdentistrytexas.com. The Galveston area is just south of Clear Lake 25 minutes which has planned communities with superior schools, multiple educational, recreational and cultural venues as well as access to all of the Houston cultural and sport venues, shopping and restaurants. We are minutes away from all types of water sports including several large marinas. http://goo.gl/maps/lWkF. Possibility of buy-in and partnership possible after an interim term. Interview today! E-mail CV to kkcarroll10@yahoo.com or call 832-385-8875. Gary Clinton Denton Pedo/Ortho Practice for Sale: Four-chair bay plus 2 operatories equipped; another bay unequipped for 4 more chairs; fast growing area; excellent opportunity. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the Institute of Business Appraisers, Inc., now the National Association
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of Certified Valuators and Analysts (“NACVA”). I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name, a name you can trust.” I personally handle every sale/ transition and complete Professional Certified Appraisals for which Congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available. DFW 214-503-9696. WATS 800-583-7765. Gary Clinton Houston Practices for Sale: H-1 Far North of Woodlands Area. Near 7-figure gross with 5 operatories; exceptional recall; well-established. Digital equipment. A premier practice. Hygiene profits will cover debt service. H-2 Southeast Houston/Pearland Area: Retiring dentist. Very desirable practice; digitally equipped with 4 operatories in professional center above average gross on 4 days. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the Institute of Business Appraisers, Inc., now the National Association of Certified Valuators and Analysts (“NACVA”). I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name, a name you can trust.” I personally handle every sale/transition and complete Professional Certified Appraisals for which Congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available. DFW 214-503-9696. WATS 800-5837765. Gary Clinton North of Dallas/Denton Area General Practices for sale: D-1 Denton Practice: Five operatories; nice equipment. 30-plus-year dentist retiring. Flexible transition; No low fee plans. D-2 Plano area practice: General dental practice; some implants;
ADVERTISING BRIEFS fee-for-service/PPO practice; Great visibility. Gross is in the 6-figure range D-3 Frisco/McKinney Area Practice: Well-established restorative/preventative practice; gross near 7 figures; 6 fully equipped operatories; beautiful office with windows overlooking creek. Will sell or lease building. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the Institute of Business Appraisers, Inc., now the National Association of Certified Valuators and Analysts (“NACVA”). I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name, a name you can trust.” I personally handle every sale/transition and complete Professional Certified Appraisals for which Congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available. DFW 214-503-9696. WATS 800-583-7765. Gary Clinton Practices for Sale: F-1 Fort Worth/ Weatherford Area. Fast growing area. Average gross; 6 operatories; excellent lease. Few dentists in area. Seller is relocating. Primarily fee-for-service. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the Institute of Business Appraisers, Inc., now the National Association of Certified Valuators and Analysts (“NACVA”). I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name, a name you can trust.” I personally handle every sale/ transition and complete Professional Certified Appraisals for which Congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available. DFW 214-503-9696. WATS 800-583-7765.
Gary Clinton Practices South of Dallas: Waco area near 7-figure gross 30+-year-old general practice for sale — Exceptional practice; Excellent recall; Cosmetic; Implants and restorative; Transition and/or complete sale; PRN transition. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the Institute of Business Appraisers, Inc., now the National Association of Certified Valuators and Analysts (“NACVA”). I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name, a name you can trust.” I personally handle every sale/transition and complete Professional Certified Appraisals for which Congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential. General and specialty appraisals and practice sales.100% funding available. DFW 214-503-9696. WATS 800-583-7765. Gary Clinton Texas 2 Oral Surgery Practices: SA-1 San Antonio Outlying Area. W-1 West Texas Central Area. Oral surgeons retiring; flexible transition. Sellers phase out. Each practice near or above 7 figures gross annually; each has high net over 50%. Both are in midsized communities. All confidential. Gary Clinton, oral surgery appraiser, 1-800-583-7765. Gary Clinton West Dallas Practice for Sale: Doctor retiring for health reasons; well-established 30+ year old practice. High demand lower income area. A free appraisal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27-year member of the Institute of Business Appraisers, Inc., now the National Association of Certified Valuators and Analysts (“NACVA”). I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name, a name you can trust.” I personally handle every sale/ transition and complete Professional Certified Appraisals for which Congress has set guidelines under the North Texas Dental Journal l www.tda.org l July 2013
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ADVERTISING BRIEFS American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available. DFW 214-503-9696. WATS 800-583-7765.
Real estate for sale. Single tenant, stand-alone building, 30 plus space parking bordered by 2 lane street and residential area. High patient growth. Patients from major employers such as Shell, DuPont, Texaco, Chevron and Shell. Call DDR at 800-930-8017 or www.ddrdental.com.
Gary Clinton West Texas “Big Country” Practice for Sale: Only dentist in small progressive community. Family dental high net practice. Upgraded equipment. Nice office. Doctor will sell or lease building. A free appriasal can be very costly to one party or both. Gary Clinton is a senior dental appraiser, a 27year member of the Institute of Business Appraisers, Inc., now the National Association of Certified Valuators and Analysts (“NACVA”). I follow the business valuation standards of the North American Business Valuation Standards Counsel, NABVSC. Experience is critical in this most complex of business transitions. “For almost 40 years you’ve seen the name, a name you can trust.” I personally handle every sale/transition and complete Professional Certified Appraisals for which Congress has set guidelines under the North American Business Valuation Standards Council. If buyer purchases your building with the practice, there is no additional charge. Every call is very confidential. General and specialty appraisals and practice sales. 100% funding available. DFW 214-503-9696. WATS 800-583-7765.
GENERAL — Houston (Bellaire/Post Oak): Terrific growth practice with great facilities nested in neighborhoods and schools. Fronts high traffic Chimney Rock. Interior and equipment rebuilt in 2009. Total of 8 operatories plumbed with 4 operatories in use. Freestanding building with 7,000 total sq ft, also for sale. Call DDR at 800-930-8017 or www.ddrdental.com.
Gary Clinton, Broker/Senior Appraiser/ Consultant with almost 40 years in dentistry: We need sellers — General and specialty practices! We have pre-qualified buyers. When we sell your practice, if you own your office, there is no real estate commission. Gary Clinton — PMA. I need practices in or near Austin, San Antonio, DFW, and Houston area and other metro Texas locations which are in high demand. Call me confidentially. 1-880-583 7765 or 214-503-9696 Dallas area. GENERAL — Golden Triangle (Port Arthur): Six figure gross and very high net income practice in small gulf coast town. Dentist earns 6 figures per year for work 4 days a week. 2,200 sq ft with 6 fully equipped operatories, 4 dentist and 2 hygiene. Extensively remodeled in 2001.
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GENERAL — Houston (I-45 North): Six-figure gross with high net income. Six-figure income for dentist. Growth opportunity within patient base. Well cared for facilities with 7 operatories. Call DDR at 800-930-8017 or www.ddrdental.com. Geriatric Dental is looking for dentists to work 1 to 3 days a week at nursing homes in the following areas: North Texas: Fort Worth/mid-cities; Central Texas: Waco/Temple; South Texas: Weslaco/McAllen/Brownsville (bilingual (Spanish) is desired). The days of work are flexible between Monday and Saturday and are typically 8:00 AM to 5:00 PM. The ideal candidate should be a licensed dentist with a background in geriatric dentistry and over 3 years of service. Dental Services Offered: cleanings, X-rays, fillings, extractions, dentures, and oral surgery. Description of services: comprehensive exams, explanation of treatment options, training of nursing home staff on proper daily oral hygiene. If you are interested in this position, please email jodywilliamson@gmail.com with your most current resume. You can contact him after submitting your resume at 512-695-3138. This is a contract job. Principals only. Recruiters, please don’t contact this job poster. Please do not contact job poster about other services, products, or commercial interests. GOLIAD: Associate/buy-in partnership opportunity available in high producing and high collection practice. 100% fee-for-service practice. If you have excellent communication skills, a light touch and above average
ADVERTISING BRIEFS skills, we should meet. Our practice uses Cerec technology, places and restores implants, is 100% digital and has a high emphasis on cosmetic dentistry. Great emphasis on patient comfort with oral sedation used extensively. Our town has an excellent school district and our patients have a great appreciation for quality dentistry. Visit our website at www.goliaddentalcare.com. Call Dr Dan Garza at 361645-2381 or email dmolar@sbcglobal.net. GP / ORTHODONTIC OPPORTUNITY IS KNOCKING! Are you a GP with orthodontic interests? Would you like to learn more about orthodontics with the possibility of limiting to orthodontics some day? Do you like the idea of small town living, no traffic jams, a paradise for outdoor activities and yet only a short ride to large town amenities? Here is your chance. In the small town of Tishomingo, OK, we have an opportunity for the right person to become an associate (with buyout future) to join a busy 9-chair GP-orthodontic clinic with currently over 600 orthodontic cases in progress. The goal is for the right person to start practicing restorative dentistry 90% and orthodontics 10% the first year, with each succeeding year moving forward toward a full orthodontic practice. Even if you have an orthodontic interest but are low on confidence, not a problem. Dr Austin has been teaching orthodontics to GPs for 20 years. If interested, please contact Dr Austin at 580-371-2396 or ronaustin79@gmail. com. HARLINGEN/Texas Valley. One full-time or 2 part-time positive, skillful general dentists needed. Well established practice, owned by Dr Joe B. Whitley, serves children ages 12 to 17 delivering preventive, restorative, and some prosthetic services. Excellent fee schedule no Medicaid or DMO’s. Virtually no down time and doctor compensated based on production, not collection. Please send all queries/CV’s to whitleydental@aol.com or call Pam at 361991-7207. HILL COUNTRY WEST AUSTIN AREA: Sherri L. Henderson & Associates, LLC - This is an exceptional opportunity for a general DDS to become an associate by February 2013 in the Lakeway area. (3,250 sq ft, 7 ops, in-house lab, paperless and 7 full-time staff members). Work
days: Tuesday - Friday and 1 Saturday per month (5 days per week available and a monthly guarantee if desired). Training in implants, endodontics and oral surgery would be a great benefit. Location pictures are available. Call Sherri @ 972-562-1072 or 214-697-6152. HOUSTON AND SAN ANTONIO: Care For Kids, a pediatric focused practice, is opening new practices in the San Antonio and Houston area. We are looking for energetic full-time general dentists and pediatric dentists to join our team. We offer a comprehensive compensation and benefits package including medical, life, long- and shortterm disability insurance, flexible spending, and 401(K) with employer contribution. New graduates and dentists with experience are welcome. Be a part of our outstanding team, providing care for Texas’ kids. Please contact Anna Robinson at 913-322-1447; e-mail arobinson@amdpi.com; FAX: 913-322-1459. HOUSTON AREA PRACTICE OPPORTUNITIES! MCLERRAN & ASSOCIATES: NEW! GALLERIA AREA: Established general/cosmetic practice located in retail center in the Galleria area of Houston with a very reasonable lease rate. Seller has invested heavily in remodeling expenses and new equipment in recent months. Four fully-equipped operatories, digital X-rays, and an upscale decor. Collections over mid-6 figs. in 2011. (#H158) NEW!! NORTH OF HOUSTON: Newly renovated 4 operatory paperless family practice with digital X-rays, intraoral camera, and digital panoramic X-ray. PPO/Fee for service revenue. Located in a busy commercial shopping plaza with high visibility. Produced mid 6 figures in 2011 on 3 doctor days. Great upside potential for a full-time doctor. (#H157) NEW! HOUSTON: General practice with beautiful buildout, 4 operatories with room for expansion, very nice equipment, revenue mid-6 figures in 2011. 1200+ active patients. (#H156) NEW! NORTH OF HOUSTON: Established general practice located professional medical office building, 3 operatories, 2 new dental chairs. Approx 1,200 active patients and low overhead, strong cash flow. Revenue was over mid 6 figures in 2011. With room to expand, this practice has solid upside potential. (#H155) NEW! HOUSTON: PPO/fee-for-service practice, 3 ops with 2 ready for expansion, revenue in mid 6 figures, Texas Dental Journal l www.tda.org l July 2013
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ADVERTISING BRIEFS retail location, 1,500+ active patients, very nice build out, Seller prefers to stay part-time after sale (#H154). NEW! THE WOODLANDS: Beautiful family and cosmetic feefor-service practice, retail location, 2,500 sq ft, 5 ops, 4 equipped, digital X-rays. Collections over mid-6 figures. Poised for growth (#H153). NEW! NORTH OF HOUSTON: Fee-for-service practice, strong hygiene program, 5 ops, revenue in mid-6 figures, real estate included in sale. Doctor is retiring (#H151). NEW! SOUTH OF HOUSTON: Well-established, 30-year-old practice, located in solid blue collar area. Office has been updated and is fully computerized. Strong new patient flow and excellent cash flow. Revenue in high-6 figures. Real estate is available for purchase (#H149). HOUSTON: Beautiful, modern 4 operatory general practice, upscale, high visibility retail location. Digital X-rays, digital pan, solid new patient flow. Production over mid-6 figures on only 3 doctor days per week (#H147). GOLDEN TRIANGLE AREA: Established PPO/fee-for-service, general practice that has a great reputation for family dentistry, as well as cosmetic and implant services. Production consistently over 6 figures. 2,000 sq ft, 6 operatories, digital X-rays, recently remodeled (#H145). SOUTHEAST OF HOUSTON: General, crown and bridge family oriented practice, established for 40 years, enjoys a loyal patient following. Gross was near mid-6 figures in 2010 with good cash flow and a strong hygiene program. 2011 revenue is trending +10%. There are 1,500+ active patients that are mainly fee-forservice and PPO. The 2,500 sq ft building is included in the sale and has 4 fully equipped operatories, with room to add 3 more. The office is fully computerized with digital radiography and has great upside potential (#H131). To see our most up to date listings, please go www.dentalsales.com. Contact McLerran & Associates in Houston: Tom Gugielmo and Patrick Johnston, 800-474-3049 OR 281-362-1707, houstoneasttx@dental-sales.com. Practice sales, appraisals, buyer representation, and partnership consulting. HOUSTON, DALLAS, SAN ANTONIO: HealthDrive is seeking part-time dentists. We are a mobile practice providing the highest standard of dental care to the elderly residents of extended care facilities. Please contact Tanya Jones at 857255-0293 or tjones@healthdrive.com.
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KILLEEN: Dental office building for sale in a very busy professional plaza, near Killeen Civic Center, 2,047 sq ft. Office condo, 5 ops, 1 steri center, 1 X-ray room for pano, 2 offices, 1 reception room, 1 patient waiting room, 1 break room, 2 storages, 1 unisex restroom, 5 telephones with voicemail, 9 speakers with amp. Entire office is networked with CAT-5. For details please call Laurie at 254-519-2875, e-mail cfdental1@gmail.com. MCALLEN AREA: Growing and expanding pediatric dental practice has immediate position for a full-time pediatric dentist. We are looking for an enthusiastic, skilled clinician with a strong work ethic. Our core value is to treat our patients as if they were our own family. Our office has state-of-the-art equipment including digital radiographs and computerized records. We offer conscious sedation in office and general anesthesia at local hospital. We have a well-trained staff. Our practice is located in one of the fastest communities in America. Rio Grande Valley offers a multitude of activities, a vibrant nightlife and is a short 1 hour drive to South Padre Island. Compensation based on collection. Desirable to be fluent in Spanish. We provide work visa/ green card sponsorship. Interested candidates please contact Dr Daniel Mego at 956-854-4146, dfmego@ gmail.com. MCKINNEY: Two-chair dental practice for sale. Primarily a Medicaid practice for over 10 years. Located in a nice office building close to 380 and 75. This place is ready to walk in a treat patients. Great for a new grad in a growing community. For more information, contact Tom at 214538-6560 or e-mail collincountydentalpractice@aol.com. Medical Center Area Practice for sale. Partnership dissolving. Priced below market. Call Jim Robertson, 713-688-1749. ORTHODONTIC PRACTICES FOR SALE: Five-chair orthodontic practice in McKinney. Eight-chair orthodontic office in Arlington. Texas Practice Transitions, Inc. Rich Nicely has been serving Texas dentists since 1990. Visit www.tx-pt.com or call at 214-460-4468; Rich@tx-pt.com.
ADVERTISING BRIEFS PARIS / WYLIE: Great opportunity for a pediatric dentist to join our expanding practice. We are actively looking for the right associate who is interested in a once in a lifetime opportunity. We are opening a third location to our practice just 1 hour outside of Dallas. The need for a pediatric dentist in the area is tremendous and we are the only pediatric office within 50 miles any direction. We are looking for someone who is personable, caring, energetic, loves a fast-paced working environment in a busy pediatric practice. We are willing to train the right individual if working with children is your ambition. If you join our team, you will be personally mentored by Dr Allen Pearson, a board certified pediatric dentist, and you will be given the opportunity to develop experience in all facets of pediatric dentistry, including: behavior management, using oral conscious sedation, IV sedation as well as practice and business management. Current associate is producing gross personal income of 6 figures plus on a 4 day work week, working only 11 months a year. For more information, please visit our web sites: www.wyliechildrensdentistry.com and www. parischildrensdentistry.com. Please e-mail your CV to allenp12345@gmail.com. PEDIATRIC PRACTICE FOR SALE: Very large private pediatric practice in large metropolitan area in Texas, mix of PPO and Medicaid in a beautiful, free-standing 5,000 sq ft building with 10 chairs. Highly profitable private practice established 30 years. Texas Practice Transitions, Inc. Rich Nicely has been serving Texas dentists since 1990. Visit www.tx-pt.com or call at 214-460-4468; rich@tx-pt. com. SAN ANGELO: For sale: Excellent 5 operatory, 35-year-old general practice. Recently remodeled location in a busy complex. Solid fee-for-service patient base. All modern equipment. Solid hygiene program. Mid- to high-6 figure collections consistently, 98% collections rate. Recent practice appraisal. Other unique perks to this practice. Doctor moving out of state, willing to negotiate on price, and transition details as well as sell/lease of building. Please inquire by e-mail at texasdentistry@hotmail.com.
SAN ANTONIO NORTH WEST: Associate needed. Established general dental practice seeking quality oriented associate. New graduate and experienced dentists welcome. GPR, AEGD preferred. Please contact Dr Henry Chu at 210-684-8033 or versed0101@yahoo.com. SUGAR LAND, CYPRESS, PEARLAND AND THE WOODLANDS: Full- and part-time positions available. Well established and rapidly growing practices that offer great financial opportunity. High income potential and future equity position. E-mail CV to Dr Mike Kesner, drkesner@ madeyasmile.com. Texas Practice Transitions, Inc. Rich Nicely has been serving Texas dentists since 1990. Visit www. tx-pt.com or call at 214-460-4468; Rich@tx-pt.com. ORTHODONTIC PRACTICES: 5 chair orthodontic practice in McKinney. Eight-chair orthodontic office in Arlington. PEDIATRIC: Very large private pediatric practice in large metropolitan area in Texas, mix of PPO and Medicaid in a beautiful, free standing 5,000 sq ft building with 10 chairs. Highly profitable private practice established 30 years. MCKINNEY: mid-sized collections in 5 treatment rooms in a beautifully finished facility, paperless, 100% digital practice with a digital pano. NORTH TEXAS: Large prosthodontic practice 30 minutes from Dallas, premier free-standing building with 7 ops, 100% digital, 100% full fee. RURAL 30 MINUTES FROM DALLAS. Smaller practice in a nice free standing building, digital X-rays, 100% full fee. DALLAS SUBURB: Large practice, 6 ops, 100% digital, 1,900 full fee patients, 8 days of hygiene. WEST TEXAS, small practice in Panhandle area. ONE HOUR NORTH OF HOUSTON: Medium sized full fee practice, free-standing building, digital X-rays. EAST TEXAS: Very low overhead, medium sized full fee practice in free standing building. THE HINDLEY GROUP, LLC: Dental Practice Sales– NORTHWEST HOUSTON GENERAL DENTAL PRACTICE: Well established, very traditional practice with moderate fee-for-service revenues and healthy profit margin. Open 4 days a week. 1,200 sq ft facility with 3 fully equipped operatories. Doctor retiring. NEW LISTING: NORTH OF HOUSTON GENERAL DENTAL PRACTICE: Very wellestablished practice in the same location for 31 years. Texas Dental Journal l www.tda.org l July 2013
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ADVERTISING BRIEFS Strong cash revenues with some PPO insurance. Practice open 4 days per week, 2,200 sq ft with 5 operatories. Loyal, experienced staff. Doctor is retiring. NEW LISTING — TEXAS PANHANDLE GENERAL DENTAL PRACTICE: Twenty-five-year established practice with strong high percentage restorative revenues and healthy profit margin. Open 3 full and 2 half days a week. Four fully-equipped operatories on busy I40 corridor with nice curb appeal! Building is also for sale. Significant Medicaid component. Motivated seller. ALBUQUERQUE, NEW MEXICO GENERAL DENTAL PRACTICE: Same location for 8 years. Three fully equipped operatories. Steady growth with 20-40 new patients per month. Significant Medicaid with growing PPO revenues. DALLAS GENERAL DENTAL PRACTICE: Very busy, thriving general dental practice with exceptional revenues and profit margin. Six fully-equipped operatories with OpTime digital X-ray system in 3,000 sq ft facility. New patients average 52 per month. Large Medicaid component. NORTH OF HOUSTON GENERAL DENTAL PRACTICE: Well-established 30+ year old general dental practice with high revenues on 4 days per week. Five fully equipped operatories with 2 dedicated to hygiene. ScanX digital X-ray system! Excellent staff and mentor! SOUTH OF HOUSTON ORTHODONTIC PRACTICE SALE: Recently opened orthodontic practice office in 3,500 sq ft building with 5 fully equipped treatment rooms! Mostly pediatric (40 cases in bands). Limited competition and motivated seller! Great opportunity for start up or satellite! Call 800-856-1955 or email jenny@thehindleygroup.com. THE HINDLEY GROUP, LLC: Associateship listings — SOUTH OF DALLAS ASSOCIATESHIP: Large thriving family general dental practice located in moderate size suburb south of Dallas. Associate wanted to join a 2 doctor practice and eventually buy-out interest of senior doctor. Beautiful new facility; fully digitized with 7 fullyequipped operatories and an additional 3 hygiene rooms and 2 portable hygiene carts. Very strong revenues and healthy profit margin. Outstanding staff and excellent mentors! Pre-determined buy-in terms. SOUTH TEXAS ASSOCIATESHIP: Busy general dental practice in small town near McAllen, Texas. Fully digital office, modern equipment, excellent, dedicated staff! Strong revenues.
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Doctor wishes to bring on a young Associate to train and mentor and eventually sell out 100%. Pre-determined buy-in terms secure guess-less opportunity for transition to ownership. SOUTHWEST OF HOUSTON ASSOCIATESHIP: Thriving family general dental practice located in small town approximately 30 minutes from the coast. Doctor has history in the area and good reputation which generates 50+ new patients per month. Beautiful new facility! Very strong one doctor revenues on 4 days per week. Excellent mentor! Pre-determined buy-in terms. Call 800-856-1955 or email jenny@thehindleygroup.com. WACO: Great associate opportunity. Waco practice looking for motivated associate with a desire to join a PPO/feefor-service practice. Great pay, great work environment with 2 other dentists and top notch staff. Please contact Dr Johnson at 435-237-2339 or email at johnson.2978@gmail. com. West Houston Practice for sale. Doctor retiring. All fee-for-service. Call Jim Robertson 713-688-1749.
Office Space ARLINGTON: Prime office suite for lease. Approx 2,594 sq ft. High visibility building with orthodontist and dentist on I-20 service road. Terrific opportunity. Call 817-269-3124. AUSTIN: Excellent office location just north of the Mueller development. This space not only close to Mueller households but also University Hills, Windsor Park, French Place, and other east Austin neighborhoods. Built in the late 60s/early 70s, this building is iconic for the period. Specifically built for dental/ orthodontist offices, it would be perfect for a dentist to move into with most of the infrastructure already in place. Simply install operatories and other equipment and you are ready to go. It can also be totally remodeled for your specific needs and taste. This property has 2 buildings. Building 2 stands alone and is 1,100 sq ft. Building 1 is currently set up as a duplex with separate electric meters. Each side is 1,150 sq ft. All space is currently available. Contact Greg Brooks 512-799-8973, tgregorybrooks@gmail.com.
ADVERTISING BRIEFS CARROLLTON: Great opportunity for orthodontist or pedodontist. Fully-equipped orthodontic office with 5 ops in main treatment area, separate private office, consult room, pano/ceph room, and lab. All dental chairs, units, equipment and furnishings included. Located in professional building with 4 general dentists and a board certified periodontist, all with established practices and would be good referral sources. An excellent opportunity for a new orthodontist, pedodontist or one seeking a satellite office. Ready to start patients tomorrow! Space is for rent and/or purchase. Premier location just 1 block south George Bush turnpike and 1 block north of Newman Smith High School. Please call 214-850-8087. DALLAS AND ROCKWALL: Orthodontic or other specialty office for lease to share with owner. Furnished and equipped. Dallas office is 4,000 sq ft in Lake Highlands
area. Rockwall office is 1,800 sq ft in antique building and furnishings. E-mail rcppc@sbcglobal.net. EAST TEXAS DENTAL PRACTICE: Malakoff, Texas, dental practice for sale. Malakoff is near Athens, Texas. Dentist retiring due to health. General practice established in this location in 1974. Location will make a great place for a start-up or satellite practice due to numerous surrounding small towns. The practice, equipment and real estate are available for purchase. Lot on main highway is also available for future office site. There is a great potential for growth. Current practice is only 3 days a week. For more information contact either of the following: Stanley Fulgham, 817-657-7239, 9:00 am to 8:00 pm Monday through Saturday or e-mail to stanleyf@sbcglobal.net. Donna Fulgham, 214-642-2038 9:00 am to 8:00 pm or e-mail to rodneyshouse@comcast.net.
DDR Dental Trust
Serving Texas Dentists for more than 40 Years
• Practice Appraisals • Practice Sales • Associate Agreements
800-930-8017
James L. Dunn, Trustee Texas Dental Journal l www.tda.org l July 2013
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ADVERTISING BRIEFS EL PASO: New dental offices for lease at Renova Plaza. Seeking complimentary specialties to 3 general practitioners and 1 periodontist. Suites can be finished to suit. Highest quality architecture and construction in upscale neighborhood; strong demographics. Agent: Etzold & Co, 915-845-6006. FORT WORTH / TCU DENTAL OFFICE FOR LEASE: Building has 4 dental offices and 1 unit available. Comes with 2 examining rooms with chairs, third room does not have a chair. Has a private office with a half bathroom, reception plus waiting area, lab room, approximately 1,200 sq ft. Great location near TCU. Very seldom does this building have a vacancy. Our current dentist is retiring. 2417 Park Hill Drive. Contact Sharon May at sharon@maysrealty.com or call at 817-721-3759. FORT WORTH: Fully-equipped dental suites for lease in growing north Fort Worth. Ideal for dental specialist — oral surgeon, endodontist or periodontist. Please contact Jennifer at 817-366-2268.
ROUND ROCK: Orthodontist needed next to dentist in high growth high traffic area in Round Rock, north of Austin in one of the fastest-growing counties. For more information, e-mail john@herronpartners.com or call 512-457-8206. SAN ANTONIO FOUR OPERATORY PRACTICE FOR SALE: We have outgrown the space, looking to relocate. Space is perfect for a specialist. Transition available. The space is located right off the Dominion Country Club golf course in San Antonio. Very modern, tranquil, pleasant location, granite countertops, plumbed for nitrous, second floor with balcony. Please contact Dr Stratton at 210-687-1150 or e-mail tiffini@dominiondentalspa.com.
For Sale EQUIPMENT FOR SALE: New handheld portable X-ray unit. New intraoral wall X-ray unit, new mobile X-ray on wheels. New chairs/units operatory packages, new implant motors. Everything is brand new, with warranty. Contact nycfreed@aol.com.
ADVERTISING BRIEFS Interim Services GRANBURY: Great location, high visibility and traffic. Approx 6,000 sq ft building, approx 3,000 sq ft of dental; 6 ops. For lease or possible sale. Call 817-263-9014 or e-mail jeremy@mirandadentistry.com.
NORTH TEXAS FOUR-OPERATORY DENTAL PRACTICE OPPORTUNITIES: SAN ANTONIO PRACTICE FOR SALE: Lewis Health Profession Services has multiple career We have outgrown the space, looking to relocate. Space opportunities available in the greater Dallas/Fort is perfect for a specialist. Transition available. The Worth space Practices forthe sale, associateCountry opportunities, isarea. located right off Dominion Club golffinished course inout San Antonio. Veryand modern, tranquil, pleasant location, dental offices, specialty practice opportunities. granite countertops, plumbed for has nitrous, second floor Lewis Health Profession Services 30 years experience with balcony. Please contact Dr Stratton at 210-687-1150 in dental practice transitions, with over 1,000 successful or e-mail tiffini@dominiondentalspa.com. transitions completed. Dentistry is our only business. We confidentially deal with all clients. Lewis Health Profession offers seller representation, buyer representation, opportunity assessments, associate placement and EQUIPMENT FOR SALE: New Please handheld portable strategic planning services. check out ourX-ray webunit. New intraoral wall X-ray unit, new mobile X-ray on wheels. site at www.lewishealth.com for current opportunities. New chairs/units operatory packages, new implant Contact Dan Lewis at Lewis Health Profession Services, motors. Everything is brand new, with warranty. Contact 972-437-1180 or dan@lewishealth.com for additional nycfreed@aol.com. information.
FOR SALE
INTERIM SERVICES 644 Texas Dental Journalforl vacations, www.tda.org l maternity July 2013 leave, illness. OFFICE COVERAGE Protect your practice and income. Forest Irons and Associates, 800-433-2603 (EST). Web: www.forestirons.
OFFICE COVERAGE for vacations, maternity leave, illness. Protect your practice and income. Forest Irons and Associates, 800-433-2603 (EST). Web: www.forestirons. com. “Dentists Helping Dentists Since 1983.”
MISCELLANEOUS
LOOKING TO HIRE A TRAINED DENTAL ASSISTANT? We have dental assistants graduating every 3 months in Dallas and Houston. To hire or to host a 32-hour externship, please call the National School of Dental Assisting at 800LOOKING Web: TO HIRE A TRAINED DENTAL ASSISTANT? We 383-3408; schoolofdentalassisting-northdallas.com. have dental assistants graduating every 3 months in Dallas THE OFhost DENTAL ASSISTING...NORTH and NATIONAL Houston. ToSCHOOL hire or to a 32-hour externship, DALLAS offers Texas RDA course and exam. Callat 800please call thethe National School of Dental Assisting 800383-3408 available dates. 383-3408;for Web: schoolofdentalassisting-northdallas.com.
Miscellaneous
THE NATIONAL SCHOOL OF DENTAL ASSISTING...NORTH DALLAS offers the Texas RDA course and exam. Call 800383-3408 for available dates.
Veatch consulting serVices
Starting a new practice? Do you need help with demographics, hiring staff, implementing systems, designing a logo and web site? Would you like to be guaranteed your practice will produce a half a million or more your first year or we will give you 110% of our fee back?
Would you like to grow your practice by more than 6 figures this year? Would you like help with office systems and insurance? If so, Veatch Consulting can help! We will guarantee in your first year of working with us we will grow your office by 6 figures in revenue or we will give you our fee back! Please call Matthew with Veatch Consulting for details at 303-621-5387 or e-mail at veatchconsulting@comcast.net. Also, please visit us at veatchconsulting.com.
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Your Patients Trust You. Who can YOU Trust? The Professional Recovery Network (PRN) addresses personal needs involving counseling services for dentists, hygienists, dental students and hygiene students with alcohol or chemical dependency, or any other mental or emotional difficulties. We provide impaired dental professionals with the support and means to confidential recovery. If you or another dental professional are concerned about a possible impairment, call the Professional Recovery Network and start the recovery process today. If you call to get help for someone in need, your name and location will not be divulged. The Professional Recovery Network staff will ask for your name and phone numbers so we may obtain more information and let you know that something is being done.
Statewide Toll-free Helpline 800-727-5152 Emergency 24-hour Cell: 512-496-7247
Professional Recovery Network 12007 Research Blvd. Suite 201 Austin, TX 78759 www.rxpert.org
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PROTECT... Your Income | Your Family | Your Lifestyle Against Career-Ending Accidents and Illnesses
Up To $1,000,000 of Lump Sum Disability Benefits for TDA Members
Will your disability insurance be enough? Texas Dental Association Members have a unique opportunity to obtain a special benefit with these key features: You will be paid up to $1,000,000 of lump sum benefits when an accident or illness prevents you from practicing in your specialty. Benefit is paid in addition to current in-force DI coverage with no offsets. No medical exam required or the need to answer medical questions.
Enroll online in less than five minutes:
www.TDAmemberinsure.com 648
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Enrollment period ends soon!