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Dental Implants

Shredded nerves? Numb lip? Constant pain? Perforated sinus?
Not if you...

get prepared with CBCT
Copyright 2008/2009 by Murry Shohat. All Rights Reserved

Patients make better decisions when they receive good information. The dental community has an obligation to deliver good dental implant information.

Dental Implants
Get prepared with CBCT
Excellent results from increasingly popular but expensive dental implant surgery can be assured. Technology that your dentist should be telling you about will preclude nerve injuries, permanent numbness, involuntary drooling, perforated sinuses, incorrect tooth angles and broken jawbones. Here’s why and how to protect yourself. By Murry Shohat Download the article to activate the links
Once again, science and technology to the rescue! Standard dental implants are now the preferred way to replace missing and damaged teeth, regain lost chewing function and rebuild confidence after a long period without teeth. For front teeth, implants offer an even more cosmetically attractive smile than veneers, in what dentists call the esthetic zone. For these reasons, implants have rapidly become a mainstream but expensive treatment. Is your dentist properly trained to offer them? connects to a denture (the process is called restoration). Restored implants often function better than healthy teeth (they don't get cavities). With excellent patient care, properly restored implants can last decades.

The illustration below conceptualizes a restored single implant. The gap below its tip illustrates required procedural drilling depth of the osteotomy. The implant must be carefully torqued into the osteotomy to establish ideal Fig. 1 is a representation of a tapered tita- conditions for osseointegration. nium implant, magnified. Standard implants measure 4 - 6mm wide by 5 - 15mm The gap ultimately fills in with new long (6.35mm = ¼"; a U.S. dime is Fig. 1 1.35mm thick). It's not unusual for patients bone growth. to receive several. Under proper condiImplants are now tions, fully edentulous patients (no teeth) can receive a being placed by mouthful of these long lasting cylindrical tooth root replaceoral surgeons, pements. Candidates include patients who are missing one or riodontists (gum several teeth or wear partial or full dentures or bridges. specialists), prostThese patients want a much more stable chewing solution. hodontists For others, an implant is sometimes useful to immediately (denture specialreplace a tooth that has to be pulled. In some cases, an ists) and regular implant is an alternative treatment for a root canal. restorative / cosmetic dentists. Although mini dental implants are similar, they are not ofEven endodontists ten used to replace whole teeth and are therefore not the subject of this article. Mini dental implants are very narrow (root canal Fig. 2: Implant supported crown specialists) – 2mm or smaller. A growing debate characterizes dental recommend an implant instead of a root canal in certain opinions on the use of mini implants as temporary or percases. manent solutions for tooth replacement and denture support. The most experienced implantologists use them in Be sure to read the revised version of this article limited situations, observing warnings like this one: http://dental-implants.com/cms/frequently_asked_questions/faqs. and its companion directory: http://knol.google.com/k/murry-shohat/ Based on tooth root-shaped titanium cylinders that are machined with screw threads as shown in the photos on this page, standard implants are surgically placed in jawbone, below the gum after careful drilling and preparation. The titanium implant is literally screwed into the prepared hole (the osteotomy), where it bonds with jawbone over several months. The bonding is a unique property of titanium. Because a single implant can cost upwards of $3,000 to $5,000 including restoration with a custom ceramic crown, the dental profession loves the cash flow. Worldwide, dentists are rushing to offer implants. However, it's your mouth and money. Careful advance preparation protects your dental and financial interests. Each case benefits from paBonded or osseointegrated implants then receive a metal tient education (the mission of this article). The knowledge abutment or anchor post, permanently inserted in the top. It enables you to ask good questions and to take advantage extends through and above the gum. The abutment either of widely available precision technology, which includes receives a temporary or permanent ceramic crown or firmly 2

three-dimensional or 3D cone beam X-rays for comprehensive diagnosis and safety and precision computermanufactured surgical guides that assure proper drilling. A 3D digital X-ray is the dental equivalent of a CT scan (dentists call it CBCT). It fully reveals your jawbone structure and can guide the actual surgery with precision far superior to 2D dental office X-rays. Many patients should not proceed without the benefits of 3D because it prevents mistakes like drilling at wrong angles or into dental nerves or other vital structures of the jawbone. Given each implant's cost, another $300 - $500 for a CBCT is a moderately priced insurance policy. And the cost is dropping as companies like PreXion, Planmeca and others convince dental practices to add 3D scanners.

ProMax, PreXion, Accu-i-Tomo, NewTom 3G, i-Cat and several others. Unless your case is simple, a CBCT is the most important thing you'll need. It enables clinicians to see inside your jawbone with an accuracy as small as 0.07mm (less than the width of an average human hair), and to avoid the problem shown at left. This illustration portrays three implants, two of which have been drilled and placed into the nerve canal inside the mandible (lower jaw). This nerve serves each tooth and "enervates" the lip and chin through a branch called the mental nerve. Our ability to sense touch, heat, cold and pain is this nerve's function. A patient's complaint (after surgical anesthesia wears off) might be "my (right or left side) lip and chin are painfully numb, and I can't stop drooling because I can't feel it to control it."

Initial Preparation

For most cases, first Figure 3B provides a and second opinions close up of the fortop the list of things ward implant striking to do before surgery. the mental nerve. When your dentist The drills used to recommends imprepare the osteotplants (or you ask for omy would shred or them), you'll want a cut the nerve first, full discussion and a and the patient, even second opinion. under deep sedation, Figure 3A: Two of three implants impinge nerve Seek full disclosure from might moan or cry out. Extwo restorative/cosmetic treme pain for days, weeks or months may follow. Numbdentists even before you speak with an implantologist. The ness may be irreparably balance of this article will help you organize questions. permanent. Begin by understanding the role of the dentist or oral surgeon who surgically installs the implants. If your dentist also plans to do the surgery, you'll want an opinion from a clinician who does not place implants. Oral surgeons and other implantologists — even cosmetic dentists — who make a living from implant surgery are biased. Seek an opinion from a dentist who does not rely on implants as a way to send kids to college or buy a yacht or vineyard. As you prepare for implants, you’ll also need an appreciation for the surgeries in the treatment plan. Some implant cases require advance bone graft surgery (with ample healing time before implants can be placed). If The most effective way to assure excellent dental opinions you're replacing an old is a CBCT, which has quickly become the standard of care implant, additional healing for many implant cases. This type of X-ray has been oftime is needed to allow fered for years by specialized clinics located in urban areas jawbone to remodel and at schools of dentistry. As you'll learn, CBCT is worth (jawbone regrows under every penny. the right conditions). It's Fig. 3B not unusual for implant prep, surSome forward-looking dentists and implantologists are ingeries and restoration to span more than a year. A full stalling CBCT units in their offices. These clinicians know that 3D is becoming the standard of care. Be suspicious if a mouth can take longer. dentist claims this isn't true (any dental malpractice attorPrudent implantologists facing a complex case will refer the ney will affirm). Brand names to look for include Planmeca patient for a CBCT as the leading diagnostic, planning and 3

surgical preparation tool. A bonus described later is computer-aided production of a surgical guide that helps the implantologist drill with precision into your jawbone. A note about teeth in an hour advertising. Very simple cases may employ technology that installs both the implant and crown in a single surgery. Patients are admonished to avoid full chewing for several months in order to give the implant time to bond with the jawbone. Although "teeth in an hour" has strong appeal in our instant gratification society, few patients qualify. A moment of forgetfulness when chewing through a sticky caramel or tough piece of meat can have a bad outcome.

The X-ray in Fig. 4A demonstrates why some of these questions are needed. An oral surgeon's 2D panoramic Xray machine took this image. By his testimony in a malprac-

Question your Clinicians
Implants made their way into the dental toolkit more than 30 years ago and have seen steady progress as the preferred way to replace missing and damaged teeth. Because titanium forms a strong bond with jawbone, even foodgrinding molars can be replaced. So, don't be surprised when your dentist recommends an implant. It's an ideal solution under proper conditions. But, be prepared. Here are some key questions to pose. You should schedule a consult on them when the dentist isn't busy. Take notes or record the conversation. ♦ What other solutions are available? ♦ Does my dental insurance cover the procedure? ♦ What are the cost differences among available solutions? ♦ What are the functional differences? ♦ What happens if nothing is done? ♦ Am I a candidate for teeth in an hour? ♦ How can I be sure that implants are really needed? What's the basis for your diagnosis? ♦ Who do you recommend to do the surgery, and why? ♦ How much experience have you had with the recommended implantologist? ♦ Do you know if the implantologist has a clean malpractice history? ♦ Can you recommend more than one surgeon and let me decide? ♦ Do I have enough jawbone to achieve a crown to root ratio of 1:1 or better? What are the tradeoffs if the ratio can't be achieved? (A short implant life with risk of a cracked jaw is one tradeoff!) ♦ What kind of life cycle can I expect for the types of implants recommended for me? ♦ Are implant placement angles a problem in my case? How will you assure correct angulation? ♦ Does the standard of care for my case require a 3D X-ray? ♦ Will a CBCT guarantee the correct angulations and drilling depths?

Fig. 4A 2D X-ray fails to reveal nerve impingement, says surgeon. An expert radiologist disagreed. tice lawsuit, the image did not reveal to the surgeon that two of the implants had been drilled and placed into the patient's nerve. Look again at the illustrations (Fig. 3A and 3B, previous page). They are based on this X-ray. Fig. 4B illustrates the jawbone’s front to rear depth, (the third dimension), and shows one of the drills used to prepare the osteotomy impinging on the nerve. This view is based on Fig. 5 (next page), a precision CBCT Xray image of the patient’s mandible. Don't Fig. 4B: Drill strikes nerve you want to ask those questions to avoid this outcome?

Get That 3D X-ray and 2nd Opinion

If your dentist’s opinion favored a CBCT, get it now. Your dentist will write the referral Rx and may also direct that a ♦ If the answer is no, would the surgery benefit from a CBCT or will I be Board-certified radiologist read and report on it. However, if your dentist says 3D is unnecessary, this becomes queswasting money? tion #1 for that second opinion. Avoiding the outcome ♦ Can/will you refer me to a CBCT lab or clinic? What are the choices shown in Figs. 4A and 4B is the purpose. and tradeoffs among different systems offered by these centers? Let’s say you get the CBCT. Your dentist will review it and ♦ Since my case is challenging, will you refer me to an expert at the may revise the treatment plan. CBCT’s are usually delivnearest accredited dental school, so I can get an enriched opinion? ered both as a photographic image set and a digital CD or 4

DVD that includes software to allow review by your dentist on a computer. Your dentist may be able to demonstrate concerns by displaying the images on a chairside monitor. But you can be briefed with the excellent paper image set produced by the CBCT. CBCT imaging centers usually offer the services of a Board-certified radiologist to review the scan, opine on available bone depth, width and height, and any signs of trouble (such as a dangerous nerve loop or unanticipated rise near the implant site; anatomical structures that must be avoided during drilling; too-soft or extra hard bone that can be measured in a cone beam X-ray; even a small tumor or other incipient condition). Difficult cases, or cases that display unusual artifacts are sometimes referred to top dental radiology professors at

Reach Out with Caution
There's no shortage of implant information on the Internet. One reasonably scholarly source is Wikipedia: http://en.wikipedia.org/wiki/Dental_implants. You may discover important information specific to your case (for example, the relationship between intravenous treatment for certain types of cancer and many other contraindications for implant surgery are discussed in the article).

A 3D X-ray rotates around your head as you lay prone or sit up, depending on the manufacturer. A typical scan takes under 30 seconds and captures precision digital detail of your full jawbone and teeth (and surrounding head and neck), not just the region for implants. This data has occasionally revealed hidden health concerns (like tumors) and thus helps save patient lives. Clinicians who seek training in the analysis of 3D X-rays are also being taught how to recognize problems that would otherwise go undetected until symptoms appeared.

dental schools. CBCT offers clear advantages to arrive at the best diagnosis and treatment plan. If your dentist is unfamiliar with CBCT, don’t be surprised if he or she expresses appreciation for the detail and clarity (the upside), and discovers issues and conditions that impact other teeth (a downside that becomes an upside via improved treatment). Companies that make in-office dental X-ray equipment, like PreXion and Planmeca, are offering 3D units that are now more affordable for individual dental and surgical practices. Training courses conducted by recognized experts are now front and center in the dental profession and dental schools. A sea change is coming as CBCT gains traction. With or without a 3D X-ray, get another opinion. Friends and co-workers are reliable sources of dentist recommendations, or consult a dental school. If you implicitly trust your dentist, he or she will be happy to suggest another clinician. Be sure to bring the X-rays used for the initial diagnosis. And, if you've proceeded with a CBCT, bring the CD/DVD, the paper image set and radiologist report. The following images, taken with a NewTom 3G CBCT scanner after a failed surgery, show an implant impinging on the nerve canal (red line traces the top border) in both a frontal (left) and cross section view (right). If only these images had been available to patient and implantologist before surgery! These images and others led to a settlement as a malpractice trial was getting underway. 5

Fig. 5: CBCT shows width and height (left) and depth and height (right). Red line is the top border of the nerve canal. Nerve impingement caused chronic pain, permanent numbness and drooling. This was one of two implants where the osteotomy drills shredded the patient's nerve because the drills penetrated 1mm deeper than the implant..
Fig. 6: An Accu-iTomo CBCT image shows tip of implant penetrating nerve canal. Implantologists are warned during training and in surgery manuals that the drills are longer than the implant. Impingement by drill and implant was the opinion of two Board-certified radiologists.

Google searches are an excellent way for patients to acquire health information. Perhaps you found this article by searching dental implants. However, information that is both bias free and deeply biased results from Internet search. Don't rely on any single information source, including this article. Consider each website’s motive.
technologies/. Calling

One top-ranked site is http://www.yourdentistryguide.com/dentalitself The Consumer Guide to Dentistry, it provides a sponsored dentist directory (the motive). Although the site delivers extensive information, oddly it provides no easy access to guidance and information on

CBCT and surgical guides. Only by deep diving will you find this: CAT Scans: A 3-D image CAT scan is used to help implantologists (dentists who provide surgical and restorative implant services) view and work on the jawbone or surrounding bone structure to produce more accurate results. CAT scan technology has become increasingly specialized for dentistry as implants, rather than dentures, have become the standard of care for tooth replacement. This is typical for Google-like searches on implants, even as CBCT and surgical guides gain broad acceptance around the globe as the standard of care for a significant fraction of implant cases. It’s as if the dental community does not want patients to know about the technology. However, when you peruse the conversations at dentist-todentist websites, CBCT is gaining broad support (although some dentists label the scans suitable only in difficult

Since this website is written by clinicians — dentists and oral surgeons for dentists and oral surgeons — a lot of the content may be difficult to comprehend. Don’t be intimidated. The site's reputation is one of helpfulness, so jump into a forum. Ask for lay language answers. There are no dumb questions when it comes to medical and health procedures, just potentially poor outcomes when the knowable is not gained in advance. A linked list of other useful implant and CBCT websites is included at the end of the article.

Computer Aided Diagnosis and Manufacturing
CBCT X-rays have another key advantage: because they are digital, clinicians can use the data to create new accurate views in real time for treatment investigation, planning and the design of surgical guides. In Fig. 7, Simplant (simulated implant) software has allowed the dentist to use the patient's CBCT data to try in different implant sizes in a conveniently reformatted view. If the chosen size won't work (too long or wide), or the proper angulation can’t be achieved, an alarm sounds (which is the case here). The software presents three dimensional views (width, height and depth).

“It’s as if the dental community does not want patients to know about the technology”

cases). Acceptance of CBCT is also evident at the leading implant manufacturer's site, www.Nobelbiocare.com, where The dentist uses the computer mouse to select an implant from a manufacturer’s data base and attempts to place it in the topic receives direct menu selection under the name the patient's jawbone image, which is a 1:1 representation NobelGuide. of the actual jawbone with typical accuracy of 0.1mm It's a good practice to visit implantology websites for spe(PreXion claims accuracy of 0.07mm). The data for Fig. 7 cific information. One information-rich site, was supplied from a NewTom 3G cone beam X-ray CBCT. http://osseonews.com/, has a search tool just below the top For this patient, the result was to NOT attempt to place an right of the landing page. Enter terms for your chief conimplant at the location shown because it would collide with cerns. For example, enter bisphosphonates or osteoporosis a nerve (in actuality, the drills used to prepare the site if you’re concerned about oral and intravenous drugs for osteoporosis or osteopenia. Enter smoking if you have the habit (being a smoker impairs healing and reduces the success rate). Or enter CBCT or cone beam to learn more about 3D, or diabetes if you wish to know if implants are contraindicated. The site also includes a list of popular topics. You'll discover patients who are asking important questions. Clinicians who both favor CBCT and have doubts about it freely discuss opinions (the trend leans heavily in favor of 3D). You are encouraged to ask questions in the site's topic-oriented forums. You'll get answers from dentists, implantologists and civilians. As with any Internet site, caution and care should rule what you learn. Fig. 7: Simplant software (Materialize, Inc) adds the element of safety through precision use of the patient's CBCT data. Fig. 8 provides close-up detail of the nerve collision signified here (arrows). 6

1mm deeper than implant placement). After the fact, both a world-renowned Board certified dental radiologist and an This is portrayed In Fig. 8A, a blowup from the Simplant expert implantologist concluded that an implant should not image set. The clinician is attempting to find a correctly have been placed at this location due to the rising nerve sized implant that will fit at a specific depth and angle in the canal. Because the surgeon claimed this condition was not jawbone. The patient's CBCT data allows a thin "slice" of visible on the patient's 2D X-ray (Fig. 4A), and did not order the jawbone to be selected for the Simplant try-in, and the a CBCT beforehand, the surgery caused permanent injury. software reformats the proper image. This is shown by the Avoiding injury is the chief safety benefit of 3D. And here's light to medium gray peanut shape. It's a cross section of another: assuming that the try-in succeeded, the same digithe mandible (lower jaw) at a position near the first molar (squeeze your lower right jawbone between left thumb and tal data may be used to fabricate a precision surgical drilling and angulation guide after implant size, shape, forefinger to help visualize this image). angle and drilling depth are established with the software. The patient's lip is to the left, tongue to the right (neither is Through the try-in procedure, the clinician may arrive at visible). Note the dark opening on the left, under the hori one or more suitable solutions that includes implant seleczontal red line. This canal carries the mental nerve that ention from among many manufacturers. The treatment plan ervates the lip and chin, and it rises more than usual (only data is then sent to Simplant's laboratory, and an inexpena CBCT image reveals this). The opening is a standard sive in-mouth SurgiGuide is rapidly prototyped (quickly proanatomical feature named the mental foramen. duced in hard plastic). As its name suggests, the guide prevents drilling errors. The three overlapping red circles down the middle form a zone of safety of 2mm which must be avoided to eliminate would shred the nerve).

Fig. 8A: Try-in collision detail from Fig. 7

Fig. 8B: Artist’s conception of X-ray in Fig. 8a

the possibility of nerve damage. The yellow tapered cylinder shape (numeral 1) is the simulated implant, and it's In addition to Simplant, other makers of implants and treatbeen positioned high, 4mm above the top of the jawbone. ment planning software are offering this service (e.g., Nevertheless, the tip of the implant denoted by the white x NobelGuide). It's becoming standardized. fails to clear the topmost red circle. This causes an alarm to sound as a warning box pops onto the screen (left arrow in Fig. 7). Fig. 8B, an artist’s conception based on Fig 8a, provides a clearer view of what happened when an implant was actually drilled and placed in this exact situation (because of their shape and surgical protocols, drills penetrate about 7 Be sure to read the revised version of this article and its companion directory: http://knol.google.com/k/murry-shohat/

Experienced implantologists will tell you that surgical guides are not always the answer. In actual clinical practice, with the patient under sedation and the jawbone exposed, the surgeon may encounter bone that is too soft at

An issue deserving mention is the use of bisphosphonates like Fosamax, Boniva and Actonel to treat osteoporosis and osteopenia. For several years prior to 2007, it a predetermined location. Now it's necessary to alter the appeared that dental implants should be avoided if oral and location of the osteotomy — or abandon placement. With intravenous bisphosphonates were being taken, due to an the patient's 3D X-ray on the chairside monitor during the unexpected condition called osteonecrosis of the jaw procedure, the implantologist in this situation is armed with (jawbone death) reported by several dentists. Since the the best technology to succeed. growth rate for oral bisphosphonate treatment has been accelerating, alarms went off because a contraindication Other Important Considerations Until dental offices acquire their own scanner, CBCT X-rays would eliminate a key demographic from treatment with implants – the huge population of women (and some men) require a prescription and referral to a lab. Whether your over 50. dentist recommends implants, or you decide to ask for them, have the discussion up front and get the Rx if appro- However, clinical studies launched by the American Dental priate. Ask about the need for a Board certified radiologist's Association (and reported in ADA's journal, JADA) as well report, which is highly recommended if the amount of avail- as by oral surgery trade associations around the world able jawbone is questionable or if drilling near anatomical helped the implant industry heave a collective sigh when structures like nerves and the mental foramen is contemoral bisphosphonates were exonerated. Clinicians have plated. now been advised that only intravenous administration of Because CBCT X-rays can be reformatted for different views by your dentist (using free or inexpensive software), the utility is amazing. First, the images are a one to one (1:1) full size precise representation of your jawbones, which means that they have no distortion or magnification (distortion and magnification in your dentist’s 2D X-rays will make them grossly inaccurate). Second, because cone beam X-rays are extremely precise, the zone of safety can be reliably reduced to 1mm in difficult cases. bisphosphonates (usually as an adjunctive treatment in certain cancer cases) is a contraindication for implants. More information on this topic is available in a Google Knol by Dr. Terry Shapiro. Yet another issue is dental tourism, the temptation to seek treatment outside of your region or nation because of the budget. You may save as much as 75% in Mexico, Hungary, India or South America and get a mini vacation in the process. What's the downside? Clearly, there are many reasons to NOT have implant surgery beyond your locality: Who delivers the critical follow up treatment, which can last for several months via regular office visits? The serious inflammatory condition called peri-implantitis can threaten your implants, necessitating aggressive treatment. If something goes terribly wrong after you've returned home (for example, an implant falls out or numbness develops and persists), from whom do you seek corrective treatment? If genuine malpractice occurred during your offshore treatment, how can you sue to win a fair recovery? It's difficult at best at home.

Experienced implantologists will tell you that surgical guides are not always the answer

bone. But vertical height is extremely difficult to achieve, so you'll want proof that it's been achieved before allowing the implantologist to drill. Proof is relatively easy to get using standard 2D X-rays (they show height and width, but not depth), available in every dental office. Have your implantologist take and show before and after views of the bone graft. If you can’t see added height, demand an explanation and fresh measurements for implant length and width.

Some implantologists resist the use of CBCT. This is regrettable and potentially hazardous. One implantologist ♦ testifying in a malpractice case stated he only uses [much older] single-tooth periapical X-rays even when several successive implants are being placed. This is like a carpenter choosing a hand saw when a power table saw is available nearby. If your dentist and/or implantologist fails to raise the 3D topic, bring it up yourself, letting the clinician ♦ know that safety, not expense, tops your list. Let's say that you proceed with implant surgery without a CBCT, and then suffer chronic pain and / or numbness after surgery. You'll want to insist on CBCT for ongoing diagnosis and treatment. If your implantologist balks, go to a hospital emergency room or to a dentist who agrees to help you get a CBCT for diagnosis leading to treatment. Refusing a diagnostic tool like 3D in this kind of situation could be motivated by a need to avoid evidence of malpractice. Do not make the mistake of trusting your clinician in this kind of dire situation. Another issue is bone grafting. If your implantologist recommends grafting in advance of implant surgery, find out how much vertical bone gain needs to be achieved. Grafting is most successful for adding horizontal width to jaw8

When the budget is limited, a better approach is to seek treatment at an accredited school of dentistry. In the U.S., a list is maintained at: http://www.dentalsite.com/dentists/densch.html Most dental schools offer implants. Some of the best clinicians are the supervising instructors. Costs are sometimes less than half the commercial rate. These schools also offer

Implantologists Who Support 3D

If something goes terribly wrong after you've returned home (for example, an implant falls out or numbness develops and persists), from whom do you seek corrective treatment?
3D X-rays as well as accompanying Board-certified radiology reports to help diagnose and guide the surgery. Patients in Northern California, for example, have a choice of UCSF and University of the Pacific, and both schools offer CBCT X-rays and Board-certified radiologists. CBCT: don’t do implants without due consideration.

3D technology continues to gain traction around the globe at the same time that an increasing number of general dentists are starting to place implants, often with minimal training. Before long, simple implants will be standard in most cosmetic dentistry practices while difficult cases continue to be the specialty of oral surgeons, periodontists and prosthodontists. As dentistry and medical schools train more professionals, the word is spreading about 3D, helping standardize its use. If you are an implantologist who wants patients to know that you employ 3D for the patient's benefit, please accept my invitation to list yourself in this section of the article in a future revision. Simply send an e-mail to: murry1@sbcglobal.net Include your contact information and locations.

Outside Reading Links
♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ Wikipedia http://en.wikipedia.org/wiki/Dental_implants OsseoNews http://osseonews.com/ American Dental Association http://ada.org/ 3D Cone Beam X-rays http://www.conebeam.com/?q=cbctclinician/verDental Implant Patient Animated Movie http://www.bicon.com/patient/video.html Nobel Biocare website http://www.nobelsmile.us/en_us/ Planmeca Office 3D website http://www.planmeca.com/index.php?page=00301&lng=1 Materialise Simplant website http://materialise.com/materialise/view/en/84113Dental+homepage.html

Dental Malpractice
Various studies place the success rate for implant surgery above 95%, an excellent outcome. But that leaves several patients out of every hundred in the negative column. As the number of dentists placing implants grows, the success rate may fall due to what appears to be a “gold rush” mentality, accompanied by too little training. Sadly, some fraction will be victims of negligence. For example, the patient involved in the nerve penetration situation portrayed in many of this article's examples discovered that the implantologist rushed through the surgery, including all of these steps in a mere 30 minutes: ♦ ♦ ♦ Anesthesia Surgical flapping of the gingiva (gum) and retraction to fully expose mandibular jawbone Under a written protocol of caution to prevent overheating of bone and warnings that the drills are longer than the implants being placed, drilling and placement of the first implant (up to six drilling steps) Drilling and placement of the second implant (up to six drilling steps) Drilling and placement of the third implant (up to six drilling steps) Placement of three healing caps Surgical suturing of the gingiva over the implants to foreclose the possibility of germ entry (often calls for careful placement of a special membrane) Oral cavity cleanup

Useful 3D cone beam X-ray websites
♦ American Society of Radiologic Technologists https://www.asrt.org/content/News/IndustryNewsBriefs/CT/CTDenta ♦ lSy050222.aspx Straumann video on measurement and analysis procedure for ♦ treatment planning http://www.straumann.us/us_index/pc_us_products/pc_us_archive. ♦ htm/pc_us_archive?func=movie&type=9864 ♦ PreXion http://www.prexion3d.com/dental_index.html Planmeca http://www.planmecausa.com/index.php?page=00343 NewTom 3G http://www.afpimaging.com/newtom Accu-i-Tomo http://www.jmoritamfg.com/en/en_products_diagnostics_general_3d_accuitomo.htm Comprehensive 2001 implant article: http://radiology.rsnajnls.org/cgi/content/full/219/2/334 Nobel Biocare NobelGuide http://www.nobelbiocare.com/global/en/ClinicalProcedures/NobelG uide/default.htm?flash=false C-Dental X-ray Laboratory http://www.cdental.com/index.php?action=tech 9 ♦

♦ ♦ ♦ ♦ ♦ ♦

Was the oral surgeon in a race? Had he made a speed bet with another surgeon? Did he have a balloon payment coming due on his vineyard? Expert testimony in the subsequent malpractice case supported safe surgical times averaging about 45 - 60 minutes per implant, not 30 minutes for all three. If your outcome is not in the 95% column, you may wish to consult an attorney who specializes in dental malpractice.

Some attorneys are also licensed dentists, imparting unusual expertise to their legal practice. This section is an open invitation for malpractice attorneys to list themselves in a future revision. Simply send an e-mail to: murry1@sbcglobal.net Include contact information and locations.

Attorney Listings
1. http://www.dentalaw.com/

Thanks for reading and good fortune on your implantology!
Copyright 2008/2009 by Murry Shohat. All Rights Reserved.

TIP Google “dental malpractice + city” to begin a search for qualified attorneys

A updated version of this article as well as a companion directory of CBCT implantologists, Universities and private labs around the world are maintained at Knol, Google’s new Internet knowledgepedia. Read, benefit and rate them
http://knol.google.com/k/murry-shohat/dental-implants/2srzofgvr8kjr/4 http://knol.google.com/k/murry-shohat/cbct-x-ray-services-directory/2srzofgvr8kjr/12#

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