nysmiles

Who Should Place Your Implants?

Sat, 07 Jun 2025 17:18:09 GMT

What to consider when shopping for implants

Finding a healthcare provider is often a time-consuming process in which various candidates are compared and contrasted on criteria such as education, skills, experience, location, specialized equipment, recommendations, online reviews, and special offers.

Many people engage in this evaluation when they begin a search for a dental professional to provide them with dental implants. As the popularity of dental implants as replacements for missing, damaged, or unsalvageable natural teeth has soared, so too has the number of dental professionals who are promoting their practices as the place to go to receive these state-of-the-art restorations.

Ultimately, the choice of a dental implant provider comes down to the patient’s decision – one based on his or her individual needs. A little bit of guidance can help.

Implant Dentist Vs. Implantologist

Dentists in a wide range of specialties offer dental implant placement, including general dentists, periodontists, prosthodontists, and oral surgeons. Regardless of the specialty, placing dental implants requires specific additional training in techniques, technologies, and philosophies specific to designing a dental implant treatment plan and then executing it safely and successfully.

The terms “implant dentist,” “dental implant dentist,” and “dental implant specialist” are all used to refer to a dentist who places dental implants, but none of them is a recognized dental specialty. The various terms can be confusing, and prospective patients wonder what the differences are and which one they should choose.

Another term, “implantologist,” offers more insight into the dentist’s level of training and experience. An implantologist is a dentist who has completed extensive training in the techniques involved in designing and completing the replacement of missing teeth with dental implants. In addition, he or she has substantial experience in placing dental implants in actual patients.

Dentists who have been certified and credentialed by the American Academy of Implant Dentistry (AAID) often describe themselves as “implantologists” to differentiate themselves from other dentists who place dental implants but haven’t completed such structured and sanctioned training.

Training and Qualifications

Dental implant placement is not included in the curricula of most dental schools, so dentists wishing to offer dental implant placement in their practices must obtain additional training in the specialty. Many general dentists attend a few days of seminars or a single weekend of studying to receive this training, but there are real concerns about whether or not this quick, brief amount of continuing education is sufficient to be able to place dental implants with all the safety, comfort, and excellent results that patients desire and deserve.

What’s clear is that these continuing education opportunities cannot provide the same level of intensive and thorough instruction and training in dental implantology as the courses that meet the standards outlined by the American Association of Oral and Maxillofacial Surgeons (AAOMS).

Why Location Is Important

When it comes to their healthcare, many people won’t settle for anything less than the best, and if that means paying a little more or traveling a little farther to get it, they’re willing to do that.

That said, it’s important to consider how close a prospective provider’s office is to your home or place of employment. Completing teeth replacement with dental implants requires several appointments prior to the actual day of surgery and then a certain number of follow-up appointments after the surgery. You may end up realizing that having chosen a provider whose office is 25, 50, or more miles away from your home or workplace has become quite inconvenient. Having to rescheduled appointments will delay the completion of your dental implant treatment, and cancelling appointments – or missing them altogether – may end up costing your additional money if the provider charges for cancelations made less than a given number of hours prior to the scheduled appointment.

What Technology Should the Provider Have?

Successful placement of dental implants depends on the quality of the treatment planning that takes place beforehand. Critical to this are 3-D images of your jaws and teeth. These images allow the implant provider to visualize and measure the amount of bone you have in the areas where the implants will be anchored, as well as the locations of your remaining teeth and any other physical structures such as nerves and blood vessels.

Most often, these images are obtained using a cone beam computed tomography scan (CBCT). Whether a provider has this equipment in his or her office or refers patients to an imaging center, these images are critical to planning your dental implant treatment.

Your provider should also be able to obtain any specialized dental implants that may be indicated by your particular anatomy or preferences. While standard dental implants are sufficient to treat a wide range of patients, some patients require dental implants that are shorter, wider, or designed to be anchored in structures other than the jawbone.

The provider you choose should be able to obtain these specialized dental implants and be properly trained and experienced in placing them correctly.

Are the Provider’s Techniques Up-to-Date?

It may be difficult for most patients to know the most current techniques for the placement of dental implants without doing a fair amount of research, and that research is well worth doing. In general, though, the “standard of care” or “best practices” are focused on performing an implant surgery that is more comfortable for the patient; less disruptive to the patient’s bone, gums, and adjacent teeth; and allows for a faster recovery and a more aesthetic, functional, and long-lasting result. Once you’ve spoken with several potential dental implant providers, you may have a better understanding of which ones propose a treatment plan for you that is most likely to achieve those goals.

What Questions to Ask Potential Providers

One important question to ask a dental implant provider is whether he or she can provide sedation, either oral (a pill) or I.V., prior to the implant procedure. For patients who tend to be anxious in a dentist’s chair, or full-fledged dentalphobics, this option may be essential to completing their dental implant procedure free of apprehension.

Another important question is, “How many dental implants do you place in a month?” The answer not only gives you an insight into the amount of experience the provider has in placing dental implants but also into the amount you may pay. A general dentist who places one dental implant a month has to charge the patient more for implants than does an implantologist who places three implants every day his or her office is open. The implantologist is able to buy dental implants at a lower cost because he or she buys them in volume and can pass the savings on to the patients.

Another important consideration in choosing a dental implant provider is the technology he or she uses. The desire to provide the best possible care and outcomes for their patients – as well as the business demands to stay competitive – encourages many dental implant providers to stay current with the latest technological advances in implantology. And while it’s natural for many patients to want to have the latest and greatest devices available for their dental implant procedures, it isn’t always necessary to achieve a highly successful and satisfactory result.

For example, many implant providers use surgical guides as part of the treatment-planning process. Prior to the implant procedure, the dentist will make an impression of your mouth and send it to a dental lab to fabricate a plastic device with metal inserts that contain pre-drilled holes. The device is then anchored in your mouth during the implant procedure to guide the insertion of each implant, ensuring they are positioned at exactly the right location and angle that were determined in the treatment plan.

Using surgical guides will increase the cost and duration of the implant procedure, so if a prospective dental implant provider plans to use them, ask why they are important for the successful placement of your implants. After asking that question of several providers, you may conclude that surgical guides aren’t necessary for you to obtain a successful result, and you can spend less money.

Finally, ask the provider if he or she has any dental implant patients who would be willing to talk with you about their experiences undergoing dental implant placement. If the provider has patients who are willing to talk with you, you can ask questions that are best answered by someone who has actually gone through the surgery. If the provider doesn’t have any patients who are willing to talk with you about their experiences, ask yourself why that’s the case.

Comfort Is Key

Whichever type of provider you choose to place your dental implants, it’s important that you be completely comfortable with that professional and the treatment plan he or she proposes for you. Balancing cost, location, training, experience, technique, and technology in a way that meets your budget, time requirements, and desired results may take a considerable commitment of time and energy, but the reward is reclaiming the look, feel, and function of natural teeth and the confidence that they restore.

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Immediate Extraction and Implant Placement

Sat, 07 Jun 2025 14:10:11 GMT

Can help reduce treatment time by months

When a patient goes to a dentist and is told that one of their teeth cannot be saved, it is very unwelcome news, especially if it is one of the teeth easily visible to others. Often, the patient’s first thought is, “I’m going to have to walk around with a missing tooth!” That unpleasant thought is followed quickly by concerns about the time and cost involved in replacing that extracted tooth. The patient also worries about having to wear a partial denture, flipper, or bridge temporarily until their extraction site heals and a permanent tooth replacement can be fitted. These types of temporary tooth replacements may not match the patient’s other teeth very well, may not fit very well, and may come loose when the patient is talking, eating, smiling, or laughing.

For several decades, dental implants have been at the forefront of tooth replacement options. They provide a way to restore a natural-looking, functional smile that frees the patient of all the worries that accompany tooth restoration with a removable appliance. One of the main drawbacks of dental implants, though, is that the patient has to wait ten to twelve weeks following the extraction of the unsalvageable tooth before he or she can have a dental implant placed.

Once the implant is placed, the patient continues to wear a removeable prosthesis to maintain an aesthetically acceptable appearance. However, the patient still has to wait four more months for the implant and bone to join together and the surgical site to heal before a permanent crown can be attached to the dental implant. Fortunately, for qualifying patients, that months-long wait is no longer necessary.

The advantages of immediate implant placement following tooth extraction

Advances in surgical techniques, along with a fuller understanding of how extraction sites heal, has allowed dentists with specialized training to perform both the extraction of a diseased or fractured tooth and the placement of a dental implant during the same office visit. This is a less invasive approach to treatment because it requires just one surgery.

This combination of immediate extraction and immediate implant placement allows the patient to shorten the overall treatment time by months.

Sometimes, the dentist is able to attach a temporary crown to the dental implant during the surgical appointment. In these cases, the patient enjoys the added benefit of not having to go out in public with a missing tooth and not having to wear a temporary dental prosthesis, which some patients find unsightly, uncomfortable, or poor-fitting.

Am I a Candidate?

Candidates for immediate extraction and immediate dental implant placement are those who have a tooth in need of extraction and whose bone surrounding the tooth is otherwise mostly free of infection, is present in sufficient quantity, and is of acceptable quality. Even patients who need multiple teeth extracted may qualify to have implants placed immediately following the extractions.

What To Expect?

There will be four appointments to complete the treatment plan from start to finish:

Pre-Surgical Appointment: During this office visit, the dentist will go over your current state of health as well as all the medications and supplements you are taking at the time. He or she will review options for sedation, and you will choose one. Any medications that you will need to take before or after the surgery – such as anti-inflammatories and antibiotics – will be prescribed, and directions on when and how to take them will be provided.

Many patients do not require any sedatives or pain medication following surgery; however, if you and your dentist decide that your treatment plan will include them, he or she will direct you on when and how to take them.

Finally, if your dentist requires any study models, those will be taken during this appointment.

Surgery Day: You will receive I.V. or oral sedation prior to the start of the extraction and dental implant placement procedure. You will also receive topical anesthetic and local anesthesia. Any additional dental impressions your dentist may want will be taken prior to the start of the surgical procedure. The dentist will remove the unsalvageable tooth with great care so that as little damage as possible is done to the bone that lines the socket. The dentist will then examine the socket carefully and clean it of any infection. He or she will then prepare the socket to receive the dental implant, and the implant will be placed into it.

Patient before complete extraction of all teeth.

At this point, the dentist will evaluate the stability of the dental implant in the socket. If he or she determines that the dental implant is secure enough to receive a dental restoration, such as a crown, at that time, the dentist will attach a connective device called an “abutment” to the dental implant and attach the temporary crown to the abutment. This process is called “immediate loading.” Then, you will go home with your fully restored smile to rest and begin healing.

Post-Operative Follow-Up: Your next office visit will be a brief one and scheduled for two weeks after your surgery. The dentist will examine your surgical site to evaluate how well it is healing and ask you if you have experienced any problems. At this visit, you will also schedule the fourth appointment for three months later so that your permanent dental restoration can be fabricated.

Two hours later: 12 implants placed and temporary restorations.

Permanent Restoration Creation: Your dentist will take an impression of your surgical site and send this to a dental lab to have your permanent dental restoration fabricated. If your dentist has the ability to fabricate restorations right in his or her office, you may be able to have the permanent dental restoration created and attached to your dental implant during this same visit. Otherwise, a fifth appointment will be scheduled for the dentist to remove the temporary dental restoration from your implant, attach the permanent restoration received from the dental lab, and make any minor adjustments to it.

When it is all said and done, you could reduce your treatment time by as many as four months by choosing the immediate extraction and immediate dental implant procedure.

Three months later: Patient with permanent restorations. (Photos courtesy of Dr. Andrei Mark )

Disadvantages of the Procedure

There are disadvantages to the immediate extraction and immediate dental implant placement course of treatment. The most significant is the elevated risk of implant failure due to inadequate integration between the bone and the dental implant. When this does occur, it is often the result of the bone not being given enough time to fuse with the dental implant properly.

Immediate dental implant placement can also involve less predictability of the levels of soft and hard tissue the patient will have available in the future, as well as challenges in attaining primary stability of the dental implant. Primary stability is the degree of mechanical engagement of the dental implant with the bone when it is first placed into the socket. Sufficient primary stability is what allows for immediate loading.

Primary stability is also important because it literally forms the foundation for the development of secondary stability. This is the degree of unity between the dental implant and the bone after osseointegration – or fusion of the two – has finished. Secondary stability is essential to the longevity of the dental implant.

Choosing a Dentist

As with any surgical procedure, choosing the right surgeon is key to avoiding complications and achieving the best results. For example, immediate loading is not considered a routine procedure in implant dentistry, so it is important to choose a dentist who is highly experienced in this specific procedure to maximize the chances of a successful outcome. For additional help in selecting the right implant dentist, see the blog: Choosing a Dental Implant Provider .

The other key to success is for the dentist to review a patient’s case carefully and to offer immediate extraction and immediate dental implant placement only if that individual meets the criteria for being a good candidate. Once a qualifying patient chooses immediate extraction and immediate dental implant placement, the dentist should plan each step of the treatment process meticulously to ensure the result is structurally, functionally, and aesthetically ideal.

Conclusion

For patients confronted with the need to have a tooth extracted as part of a plan to restore the function, appearance, and/or health of their teeth, immediate extraction and immediate dental implant placement might be the ideal treatment choice. It provides a faster, more comfortable, and less invasive solution.

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Treatment of Myofascial Pain with Neuromodulators

Thu, 24 Mar 2022 08:45:04 GMT

Dr. Mizrahi explores the therapeutic use of neuromodulators in the treatment of myofascial pain

Myofascial pain is attributed to the overuse of the muscles of mastication, primarily the masseters and the temporalis muscles. Chronic overuse results in myositis, or inflammation of the muscle, which leads to continuous pain and discomfort. It can also lead to hypertrophy of the muscles, producing a widened square posterior jaw contour.

The use of neuromodulators for treatment of myofascial pain is becoming increasingly popular.

Neuromodulators (such as Botox or Jeuveau) function primarily by inhibiting the release of acetylcholine at the neuromuscular junction, effectively limiting the muscle from functioning to its fullest extent. This forced relaxation of the muscle provides pain relief for the patient if dosed correctly and injected appropriately.

Identifying pain origin

Prior to treatment with neuromodulators, it should be verified that the patient’s pain is myofascial in nature, and not arthrogenic. Arthrogenic temporomandibular disorders, which originate from within the joint itself, include issues such as disc displacement, perforation, or other intracapsular pathology. Evaluation and treatment for the two differ greatly. If an arthrogenic source of pain is suspected, an MRI may be indicated to visualize the position and condition of the disc, and the treatment is often more surgical in nature.

Patient history

A thorough history and physical examination should be completed. Patients should be asked about any history of trauma, bruxism, constant headaches, pain that is worst in the morning, and inability to chew hard foods. Methods they have attempted to use to control their pain should be discussed. A physical examination evaluates maximum incisal opening, deviation on opening, protrusive and excursive movements, audible or palpable clicking or popping of the joint, and palpation of the temporalis, temporalis tendons, and masseters. Palpating for trigger points in these muscles usually elicits a response from the patient if the source of pain is myofascial.

Effective adjuvant therapy

Conservative treatment recommendations for myofascial pain include maintaining a soft diet, using warm compresses, and the use of an occlusal guard. Pharmacologic treatment may include the use of non-steroidal anti-inflammatory drugs or tricyclic antidepressants. Neuromodulators are a good adjuvant therapy in situations where conservative and pharmacologic treatment measures have failed to relieve myofascial pain.

Injection site planning

To determine where to inject the masseters, a line is drawn from the commissure of the lip to just below the tragus. Another horizontal line is drawn several millimeters below the first. Then two vertical lines are drawn, surrounding the bulk of the masseter muscle. Trigger points are palpated and marked, usually about four sites per masseter muscle. The neuromodulator is injected in doses of 5-10 units per site. Approximately 20-30 units are generally placed per masseter muscle, though dosing is adjusted based on clinical exam and the desired end goal (Figure 1, 2).

To mark out the area of the temporalis, the patient is asked to clench and is palpated for trigger points. Approximately 3-5 units per site are generally injected.

Patients should be given a follow up appointment at two weeks to determine whether additional treatment may be indicated. Patients return for follow-up again at three to four months as their neuromodulator wears off, and may require additional treatment at that time.

Potential complications are avoided by paying careful attention to the facial anatomy, and avoiding inadvertent injection into unintended muscle groups. For example, injecting too superiorly can lead to an asymmetric smile, which will return to baseline as the neuromodulator wears off.

Cosmetic applications

Injection of the hypertrophic masseter muscles with neuromodulators can also be used for jawline recontouring. It is injected in the same fashion, but varying doses and different intervals may be required to achieve the cosmetic result the patient is seeking.

Neuromodulators are an effective treatment for myofascial pain, and are useful to offer to patients in conjunction with the standard conservative treatments. ■

Ailing and Failing Implants

Wed, 02 Feb 2022 17:01:46 GMT

Dr. Andrei Mark discusses some of the most common causes of ailing and failing implants and prevention strategies.

There is always the risk, however remote, that a dental implant may fail after therapy. On the other hand, there is a clear difference between a failed implant and one that is ailing. The distinction is that with prompt intervention it is possible to prevent an ailing implant from failing completely. The purpose of this article is to distinguish between an ailing and failing implant, as well as some of the most common reasons of failed implants, with the goal of preventing future failures and identifying potential treatment options. Additionally, this article will discuss the most effective diagnostic procedures for identifying failing implants and the recommended treatment options for reviving the implant.

Ailing vs. Failing

When an implant develops peri-implant mucositis without resulting in bone loss, it is referred to as "ailing." A "failing" implant, on the other hand, is one that is affected by peri-implantitis and significant bone loss. Survivability of the implant is highly dependent on the amount of bone loss, the state of the surrounding soft tissue, and the treatment method used.

Failing implants: Common causes

Cement . Improper cement application is a frequent cause of implant failure. This can happen if cement leaks from the crown during placement and becomes lodged below the gumline. If left untreated, the hardened cement can cause gum irritation, which can progress to infection and eventual bone loss. When placing crowns on abutments, dentists should use the thinnest possible coat of cement and remove any excess before fitting the crown in place.

Insufficient bone . Inadequate bone at the time of implant placement is one possible cause of failure. We prefer that the implant has a minimum of two millimeters of bone on all sides to ensure proper positioning and osteointegration. When an ailing or failing implant case is presented to us, we evaluate it to ascertain the cause and then tailor our treatment plan accordingly. Unfortunately, not every failing implant can be resurrected.

Inflammation. Poor oral hygiene is another common cause of failing implants due to infection and inflammation. Patients need to be reminded that implant restorations require the same good oral hygiene as natural teeth, along with routine visits to the dentist.

Diagnosing ailing implants

There are several symptoms that indicate ailing or failing implants—pain is a frequent one. Additionally, gum swelling, difficulty chewing, severe gum recession, and implant mobility are also common.

When a patient presents with a ailing implant, we take a 3D CT image. This allows us to view the implant and surrounding bone structure from any angle. If there is significant bone loss around the implant, the best therapy for an ailing or failing implant is to remove it using reverse torque where applicable. (see Figure 1.)

Ailing implant treatment options

When an ailing implant has experienced marginal bone loss, bone grafting techniques may be used to restore functionality. Once the implant surface has been cleansed meticulously on all surfaces and all unhealthy tissue removed, it is ready to receive a bone graft. In this instance, I choose to use the mineralized human bone mixed with PRF (Platelet-Rich Fibrin). My approach for making PRF involves drawing a small amount of blood from the patient and spinning it in a centrifuge to extract the platelets. After placement of the graft, the flap is sutured back in place. I like to allow three months for osteointegration of the bone graft and implant. (see Figure 2.)

Failing implant treatment options

In cases where a failing implant results in significant bone loss, the only option is to remove it. (see Figure 3.) The technique for removal will depend largely on the condition of the implant and the surrounding tissue. Once removed, the next stage is to debride the unhealthy granulation tissue, reach a stable base of bone, and then graft the region to grow more bone utilizing that base. Once again, the graft material I use consists of PRF with mineralized freeze-dried bone. In my experience, the bone in these areas grows back once the offending implant, which was the source of the irritation, is removed. Then, after three months, we reassess to determine how much bone has grown back before starting over with a new implant.

Predictable results

Now, unlike a natural tooth, which will be very loose with a few millimeters of bone attached to the root, well integrated implants with a few millimeters of bone can be very stable. An implant with five millimeters of bone attached to it is almost impossible to remove without a lot of force, reverse torque, or trephining the bone. These implants, in my experience, can still retain the prosthesis if the patient can reach in and maintain good oral hygiene. Additionally, if multiple implants are placed and splinted together, they will be extremely solid and will not move even when severe bone loss has occurred.

Advanced techniques

I've seen hundreds of failed implant cases over the years, many with an extremely poor prognosis for implant survival. In many of these instances, the clinician providing the treatment lacked experience or was operating outside of his or her comfort zone. This is understandable given that the majority of dental implant training today is focused on placement. I've discovered that by combining advanced surgical techniques with bone grafting, we've been able to resurrect a large number of failing implants. ■

Benefits of PRF

Platelet rich fibrin (PRF) has been shown in several studies to be a healing biomaterial with a high potential for bone and soft tissue regeneration. It can be taken alone or in combination with bone transplants to promote hemostasis, bone growth, and maturation. In elderly patients, PRF looks to be a natural and useful aid in bone regenerative surgery, with excellent outcomes and few problems.

Practice Management with Filemaker

Wed, 18 Aug 2021 17:05:02 GMT

FileMaker has proven to be the perfect platform for developing advanced yet user-friendly iOS-compatible business solutions in a short period of time.

Filemaker 19 Starter Solution screen display.

A well crafted, custom-tailored suit can do much to elevate the image of its owner. In the same way, dental management software that is custom tailored to meet the specific needs of a practice can be a game changer for its owner. If you have outgrown the capabilities of your existing practice management software, you may want to consider creating your own custom solution with Claris FileMaker 19.

FileMaker 19 Advanced is a workplace innovation platform for creating database-driven solutions without special coding skills. It features cross-platform capability which means that solutions created with FileMaker will run on both Windows and Apple OS devices.

An Apple subsidiary

When FileMaker solutions are used on iPhones and iPads they take full advantage of the device's features and capabilities such as the camera, touchscreen and sensors. Because Claris is owned by Apple, one of the largest and most profitable companies in the world, you can be sure that it will be around when other tools may not. Claris invests in continual advancements and new features to the platform every year.

Henry Schein Dental adopts a custom FileMaker solution

Before developing a custom FileMaker solution Henry Schein Dental sales consultants had to lug around scores of sales literature and data sheets on the tens of thousands of products they offer to dentists. Today, the only sales tool they carry is an iPad that runs a custom FileMaker solution developed by MC Services , a Certified FileMaker Developer based in Milwaukee. The entire solution took just three months to create. Commenting on their success with FileMaker, Jon Baucom, Director of Marketing, Equipment and Technology Group, Henry Schein Dental, said, "FileMaker has proven to be the perfect platform for developing advanced yet user-friendly iOS-compatible business solutions in a short period of time."

No coding experience necessary

To help get you up and running, FileMaker 19 comes with Starter Solutions and templates you can use right away or modify to meet the specific needs of your practice. Unlike Microsoft Access or code-based application builders, you can create an entire business solution with no prior coding experience necessary. Instead of using cryptic code to perform database operations or program commands, FileMaker uses simple, everyday language to run script steps to manage data and perform different user tasks. Once you become acquainted with FileMaker's user interface, you will never go back to using a spreadsheet to manage data again.

For advanced solutions with HIPAA compliance, or if you don’t have the time to build your own solution in a DIY way, you can engage the services of over 1,200 FileMaker Business Alliance members as a technology partner to assist.

Website connectivity

Imagine managing appointment inquiries from your website on your iPad, iPhone or PC without visiting your website. Options exist to make FileMaker talk to your website as well. BrillantSync from LuminFire can assist with syncing information to and from your custom website with your FileMaker solution. For example, this could include appointment inquiries or payments.

A powerful database

FileMaker's database design lets you store, search, and share nearly any type of information. This could include patient records, diagnostic imaging files, and more.

Remote access capability

With FileMaker server, you can host your FileMaker solution on a cloud server giving you the ability to share files and applications over the internet. For example, a corporate practice with several offices could use FileMaker server to host a solution to manage each location.

Endless possibilities

There is virtually no limit to what you can do with FileMaker. There is a large community of certified FileMaker developers that can create an application for your practice, one that can grow as your needs change. This is often very costly and hard to accomplish with some of the practice management software on the market. So, before investing in off-the-shelf practice management software, you may want to consider financing a custom-tailored FileMaker solution. ■

Atraumatic Extraction Technique

Wed, 18 Aug 2021 16:07:00 GMT

The extraction of a fractured tooth near the gum line can be difficult. Dr. Mark proposes an innovative approach incorporating atraumatic extraction and rapid implant insertion in the case study below.

One day a 50 year-old patient and dentist friend of mine, (who already has multiple dental implants) came to my office and presented with a non-restorable fractured tooth number 8 (Figure 1) . As you can see from the photograph, this looked to be a complicated extraction. As always, my treatment plan consists of proper imaging. With dental implant cases it usually involves the i-CAT. (Figure 2)

The primary challenge was to remove tooth number 8, while maintaining the soft tissue and bone intact. As I have mentioned in previous articles, I will strategically plan out the entire case before beginning any procedures. The plan was to extract tooth #8 and place an immediate implant. Since there was no root to grab on to, and lifting a flap would compromise the buccal bone, I decided to utilize a new instrument on the market called Benex® Control, an atraumatic tooth extractor by Meisinger USA. I feel one has to have state-of -the-art tools and technology at their disposal for just the right application. This case was an ideal case for the Benex® Extractor. This device works like magic for removing single roots without lifting a flap or cutting bone.

The specific technique involves using a special bur to drill into the pulp chamber and then threading a matching anchor into the tooth (Figure 3) . A pulley system is utilized and a protective bite plate rests on the adjacent teeth and is attached to the anchor via a braided cable. By rotating a knob at the end of the instrument, pressure is applied in the vertical axis of the root. As you gently increase the pressure to the cable, it allows the periodontal ligament to stretch. The root is extracted from the socket when sufficient pressure is applied, making a popping noise (Figures 4) . When this works, it feels like magic. Left behind is an intact socket with the soft tissue and bone preserved and ready for immediate placement of a dental implant (Figure 5) .

The implant osteotomy is performed slightly palatal to allow a small minimal gap between the future implant and the buccal bone. The pilot drill with the MIS implant system is used to start the osteotomy. Then the next two larger drill sizes are used to enlarge the osteotomy site further. The implant I chose was a MIS 7 implant 3.75 x 11.5 mm tapered implant with aggressive threads that finds its way by self-tapping into the osteotomy.

After placing the implant and filling the small buccal gap between the implant and the bone with a bone graft, I placed a 3-mm healing screw to maintain the gingival anatomy. As you can see (Figure 6) the soft tissue anatomy is identical to the pre-op photo. The patient will wear her temporary bridge for the next three months, at which point a final prosthesis, including the implant in position number 8 will be fabricated.

Having the right tool at the right time can make all the difference in the patient’s final treatment outcome. I strive to have the latest technology and techniques available at my fingertips. This way, I have a greater predictability of the results of my treatment plan each and every time. ■

Fixing a failed implant procedure in a single visit

Sun, 15 Aug 2021 18:54:20 GMT

Improper placement of dental implants can severely impact a patient’s health and well being. While there are dentists who can successfully perform placement of dental implants, there are occasions when a dentist should hand off a case to a more experienced implantologist. The following is a review of a failed implant procedure performed by a dentist and how Dr. Mark successfully completed the case.

Dr. Andrei Mark is frequently asked to do second opinions on difficult dental implant cases. Most often this is the case when implants fail or are placed improperly. This was true in the case when a 53-year patient visited Dr. Mark after she had two front teeth extracted (#8 and #9) followed by bone grafting and placement of two implants. She was very unhappy because one implant fell out (#8) and she was very unsure about the remaining implant (#9).

Diagnosing the case
After taking a CAT screen Dr. Mark noticed that #9 was not placed in bone but was free floating in the soft tissue (Figures: A, B) and it too would fail. The patient informed Dr. Mark that she was told that she would need more bone grafting followed by another six months of waiting before new implants could be placed by the original dentist. Commenting on the proposed treatment plan, Dr. Mark said: “Upon examination of the patient and detailed review of the 3D anatomy of the anterior region of the maxilla, I concluded that a ridge splitting technique would be the best option moving forward.” He went on to inform the patient that if the ridge spitting was successful, he would be able to place the implants at the same time. The patient agreed to the procedure and was amazed that the entire process could be completed in one visit.

The procedure

“On the day of the procedure, we anesthetized the patient and opened a large flap in the interior region with horizontal and two vertical releases,” said Dr. Mark. “I located the vertical releases two teeth away from the area where I would operate to allow for a tension-free flap post surgery. The failing implant could be clearly seen touching the surface of the bone (Figure: C) which was then removed without incident.

Detailing the ridge splitting Dr. Mark said: “Using a piezo-electric surgical instrument, a clamshell-type incision was made with two vertical releases near teeth #7 and #10. A horizontal incision was then made through the crestal bone to a depth of about 11 mm creating an oyster-like cavity which can be expanded with dilators, chisels and osteotomies.” (See Figures: D, E, F) .

Once the chisels and dilators were used, Dr. Mark now spread the opening to a width of 2 – 3 mm due to the elasticity of the bone. “This allowed plenty of room for placement of two MIS 3.75 x 11.5 mm implants (Figures: G, H) which were completely encased in the new boney architecture,” says Dr. Mark (Figures: I, J) . “The incisions made in the bone were covered with platelet-rich fibrin and granular, mineralized cortical bone (Figure: K) to create a scaffold for the development of new anatomy.”

The entire surgical site was then covered with PRF membrane created from the blood spin and the flap was released from tension and sutured tension free. The patient returned a week later for a follow up and was healing nicely (Figure: L) . Three months later the patient returned to prepare the implants for the final restoration (Figure: M).

The caution

A growing number of dentists looking to grow their practice are placing dental implants themselves. Without the proper training, experience and diagnostic tools, a dentist may risk harm to his patient and practice with a failed implant procedure. One failed procedure could result in malpractice litigation that could ruin a practice. In a study of 242 dental malpractice cases, 24 were dental implant cases—23 of which were performed by general dentists and the remaining one by a periodontist. Given this fact, it would be the course of wisdom to consult with a more experienced implantologist when encountering a case that resides outside of your comfort zone. ■

mergers and acquisitions

Sun, 15 Aug 2021 12:32:08 GMT

With aligned interests, a merged practice can potentially have greater profitability and success.

The dental profession, driven by the consumer, has changed enormously over the last thirty years. Corporate dentistry is here and private practitioners must adapt to a business environment vastly different from where it was thirty years ago. Dentists need to consider the future of their profession.

What do dental consumers want today? They want better, faster dentistry. They want affordability and convenience. The practices that remain on the cutting edge are positioned for lasting success. The ones that don’t meet market demands will see their profitability erode.

Approximately, thirty years ago, MDs began to form group practices. The evolution is underway, it’s simply the reality of where the dental profession is going. This article will provoke thought because the future of dentistry offers enormous opportunity.

What I have seen in my experience is that private-practitioner dentistry has typically been one dentist working their own practice four days per week averaging top-line collections of about $800,000 per year. Assuming a 72 percent operating overhead, the typical dentist earns $224,000 annually before taxes. One challenge with this model is the high overhead to manage; more importantly, this model no longer matches what the modern dental consumer wants. Consumer demand has changed.

That dental practice, open four days a week, mornings and afternoons, is not offering convenient care for most dental consumers. Corporate dentistry has risen to fill this void. Convenience has become a big part of marketing for dental practices, and many consumers are gravitating to convenience. The easiest hygiene appointments to sell in metro areas today are six, seven, and eight o’clock at night. Consumers today are looking for practices with extended hours, where insurance is accepted and payment plans are available, and where top-notch care is delivered with modern technology and multiple specialists under one roof.

If you’re in business today, you’d better find out what’s most important to your customers, and how to deliver it—and then deliver it really, really well.

When doctors form group practices, the result is higher quality and convenience for patients, and more money and better quality of life for the doctors. This evolution of dentistry may potentially provide enormous upside for any doctor with an entrepreneurial bent, those who just want to grow their practices or those who are looking to retire.

With aligned interests, a merged practice can potentially have greater profitability and success. Private doctors can potentially merge into a much more efficient business model without giving up their private- practitioner status or the opportunity to build equity in a practice.

Merging under one roof creates economy of scale. For example, a dentist with a $1 million practice is probably taking home around $300,000. By showing that dentist how to buy another $1 million practice, we can help them work toward that 40 percent of the money going to the bottom line with little to no risk. Now, that doctor who was making $300,000 is now making $700,000. You’ve got the revenue from two practices coming in with the fixed overhead of one facility.

Keep in mind that it doesn’t always have to be a sale. The future of dentistry is to practice in groups. If you take two practices each doing a million dollars a year and merge them properly, one plus one does not equal two in that equation. You take two million, put it under one roof with one staff, one fixed set of costs, and great coaching, and both doctors make more. It’s not just about acquisitions or sales; mergers are going to be a big part of dentistry’s future as well. ■

Collaborative Implant Dentistry

Sat, 14 Aug 2021 13:08:45 GMT

Dr. Andrei Mark, one of the most respected and experienced dental implantologists discusses the real advantages of collaborative dental implant surgery in growing a general dental practice.

The ever-increasing popularity of dental implants today has seen more general dentists and other specialists adding implants to their list of patient services. After all, dental implants, when performed safely and properly, can be very lucrative.

Along with the potential financial rewards associated with dental implants come potential risks. One poorly executed implant procedure can result in patient harm along with litigation and financial penalties that can ruin a successful practice. The goal of this article is to provide some practical advice and cautions that can help dentists place implants while minimizing any potential risks.

Look for land mines

You wouldn't walk through a live mine field without an experienced guide or mine sweeper. Likewise, looking for any potential hazards or complications before placing implants can save you from financial trauma. Commenting on the matter, Dr. Mark had this to say: "Considerable care and caution must be exercised when placing implants near vital structures, such as the inferior alveolar nerve, maxillary sinus or the nasal cavity. You need to know what could go wrong before beginning the procedure." He continues: "Placing implants in these instances requires considerable knowledge and skill that only comes with years of education and practice."

Standing still in a mine field

While hiking through open country you suddenly discover you are in a live minefield, what would you do? You certainly wouldn't keep walking. Likewise, the same is true of implant dentistry. If while performing a "routine" implant procedure you find yourself in a mine field, it is best to stop and reassess your situation immediately. "You have to know how to bail out when you run into trouble," says Dr. Mark. "You have to explore your options and act decisively. For example, 'Do I stop the procedure, bone graft, wait for the healing and then finish the case later. Or, do I stop the case, call for advice and then complete the procedure? Or, do I stop the procedure and make arrangements for the patient to see a surgeon to complete the case?'" says Dr. Mark.

Having a bailout plan in advance of a difficult case can make the difference between running a successful dental practice or becoming cannon fodder for a malpractice attorney in a legal mine field.

Navigating the mine field

In the world of dental implantology, there really is no "routine" procedure. Every procedure has the potential to become a potential mine field. "Collaborative implant dentistry is one of the best ways to help navigate around the potential pitfalls associated with dental implantology," suggests Dr. Mark. To help illustrate the point Dr. Mark highlights the important role that proper implant selection plays in the success of a case. "Different situations require the use of different implants, if not from the same manufacturer then from other vendors. For instance, an immediate extraction, immediate load situation will require an aggressive thread implant that will provide initial stability," says Dr. Mark. "This same implant would not but suitable for use in D1 density bone since it would not penetrate such hard tissue. On the other hand, this aggressive thread pattern would be well suited for bone grafted areas and sinus lift or soft bone in the maxilla. The AnyRidge® dental implant from MegaGen , with its wide flutes, offers greater osseointegration for increased stability in soft or in bone with minimal height."

When you consider the wide array of dental implants to choose from, making the right selection for each case can become a real challenge. "Understanding the various strengths and weaknesses of different implant systems is a major learning curve," comments Dr. Mark. He continues, "For example, if you are using one type of implant from a single manufacturer, you will be greatly limited in the number cases you will be able to successfully complete."

In addition to proper implant selection, there are a number of other instances where collaborating with a highly-experienced implantologist can be a real asset.

"There are many instances in implant dentistry where collaborating with a surgical expert can have huge advantages," recommends Dr. Mark. "For example, what do you do when the implant is spinning in the bone? Is the case suitable for immediate loading? Is there sufficient bone for a wide diameter implant? These are questions that only an expert with many years of experience and who has successfully resolved these problems can address.

"The ability to begin a case from the planning stage to the final restoration under the guidance of an implant expert with over 30 years of experience can yield real benefits to both the dentist and the patient."

Avoiding land mines

What advice does Dr. Mark offer to dentists performing placement of dental implants? "The best way to avoid trouble is to know and respect your limitations," says Dr. Mark. "This will help you to avoid situations that might be outside your comfort zone that could put the patient, and your practice, at risk.

How would a dentist use the collaborative approach to placing dental implants in their practice? "There are several options open to dentists who want to use this team approach to placing implants. For example, a dentist with a potentially difficult case could send the patient to me for a CT scan. I would review the scans and make a recommendation on how to proceed with the case."

What option is available to dentists with difficult cases but are looking to learn how to tackle them themselves? "Mentoring is another example of collaboration that I offer dentists with difficult implant cases," says Dr. Mark. "In this instance I would perform the surgery in my practice while walking dentists through the entire procedure from start to finish."

"Another way that dentists can learn how to handle more complicated implant cases is to join a dental study club, " suggests Dr. Mark. "It's a great way to find out about new implant products and techniques as well as getting suggestions on how to place implants in tricky or more challenging

locations." ■

Dental implant failure rates higher among general practices and by less experienced dentists

A study by Loma Lima University School of Dentistry revealed that the failure rate of implant supported fixed complete dentures (ISFCDs) was higher among surgeons with ≤5 years of experience. This retrospective study evaluated the implant success rates of immediately loaded maxillary and/or mandibular ISFCD. The study group consisted of 50 full-arch maxillary and/or mandibular implant-supported fixed complete dentures. The failure rate among less-experienced surgeons (≤5 years) was 12.2% vs. 2.4% by surgeons with more experience.

Making The Case for Early Removal of Wisdom Teeth

Mon, 10 May 2021 03:56:23 GMT

Recently I conducted a survey of my general dentistry colleagues regarding wisdom teeth extractions. The results of the survey indicated that they tend to shy away from recommending removal of third molars if they are asymptomatic. One of the excuses they used was…let's just watch them. To that I say, watch them do what? Watch them develop pericoronitis, watch them damage adjacent teeth, watch them lose periodontal attachment, watch them form cysts or develop tumors. No!

Knowing that approximately 85% of all wisdom teeth will need to be extracted, and that the longer you wait to extract the more difficult it will be, I recommend prophy-lactic extraction of wisdom teeth between the ages of 14 and 25. Removing wisdom teeth before the full maturation of the roots will help minimize some of the more serious complications of wisdom teeth removal, such as numbness of the lower lip, chin, gum or tongue. The younger a person is, the faster the healing time; therefore, your typical teenagers will heal much faster than your middle-aged person with difficult impacted wisdom teeth.

I have chosen two case examples of wisdom teeth causing complications in adults. Case number one is a 42-year-old female with one single remaining impacted wisdom tooth, number 32. This patient presented with acute pericoronitis in the area of tooth number 32. An i-CAT was taken and revealed a full bony impacted tooth number 32 with the roots almost at the angle of the mandible with a large cystic lesion above. There was extensive periodontal bone destruction on the distal of tooth number 31. Risks, complications, benefits and alternatives of removing the impacted wisdom tooth were all explained to the patient. The proximity of the inferior alveolar nerve in relation to the roots of this impacted wisdom tooth was also explained to the patient and the CAT scan illustrated the position of the nerve for the patient. The tooth was removed in segments and the inferior alveolar nerve was seen deep and lingual to the roots. A thin-walled cystic lesion was peeled out of the bone and curetted to healthy bleeding bone. The biopsy report came back as a cyst of the mandible. This patient was extremely fortunate that she did not develop any complications from this extraction.

Case number two is that of a 62-year-old male referred to me by his dentist, to evaluate a radiolucency in the right mandible. The panoramic x-ray revealed a large radiolucency extending from the impacted tooth number 32, which is facing inferiorly and a quarter of the way up the ramus of the mandible and extending anteriorly, undermining teeth number 31, number 30, and number 29 respectively. There are only 4 mm of bone thickness to the inferior border of the mandible. Extensive consultation with the patient regarding the nature of the lesion was conducted and the proposed treatment plan was presented. Some of the differential diagnosis for this lesion would be an odontogenic keratocyst, ameloblastoma or a mixed tumor. The lesion was biopsied and a thick cystic lining was encountered and when perforated, a heavy mucoid, cheese-like material was found in the entire cavity. The biopsy results, again, showed a cyst of the mandible with inflammation.

Due to the large size of the cyst, I decided to use decompression. Decompression is a technique used to remove all the pressure from the system, thereby enabling the lesion to shrink to more manageable size. This particular patient was not as lucky as the patient in the first case. Unfortunately, this patient developed numbness of his lip, chin and gum which slowly resolved over a one-year period.

These are just two cases that I selected out of a large file of difficult impacted wisdom teeth, in mature individuals. I would strongly suggest that most wisdom teeth be evaluated by an oral surgeon for possible extraction. Oral and maxillofacial surgeons are best equipped to make the proper determination of when and how to remove impacted wisdom teeth. ■