Mastering the Artistry of Implants

Allison M. DiMatteo, BA, MPS; Lisa Neuman

The number of implants placed by general dental practitioners is nearly exceeding the number of implants placed by specialists.¹ For GPs already placing implants and those considering adding this treatment modality to their practices, the key to sustainable success could be the right combination of training, teamwork, and technology. Inside Dentistry leads you through four questions to help you execute confident, predictable treatment plans that will grow your implant expertise and optimize this aspect of your practice.

There are a number of factors contributing to the growing trend of general practitioners placing dental implants. A number of new implant systems are marketed as being easier to place, especially with the help of digital technology tools, and there are myriad shortterm training courses, workshops, and conferences that are specifically focused on getting GPs up and running— quickly—using those systems. But one of the strongest factors most likely driving this trend is patient demand itself. As people live longer and their oral health awareness continues to increase, the days of simply fitting elderly edentulous patients with a full set of dentures fades further away into the past. That factor leads to the very first question any GP considering implant dentistry might want to ask.

Can You Even Sell Implant Dentistry?

The simple answer is yes. For dentists who do it successfully, adding implant placement to their treatment mix can be a robust marketing opportunity for their practices. According to statistics from the American College of Prosthodontists, more than 35 million Americans are completely edentulous—90% of whom have been fitted for dentures—and another 178 million are partially edentulous.¹ Most, if not all, dentists have seen the most common problems associated with missing teeth or poorly fitting prostheses, eg, difficulty eating or speaking, low self-esteem issues stemming from poor appearance, social anxiety or an avoidance of social situations altogether. Malnutrition can result from eating a poorly balanced diet of mostly soft foods; eating fruits, vegetables, or other healthy, crunchy food is too difficult, painful, or otherwise inconvenient for someone with missing teeth or ill-fitting prostheses. Then there could be the more serious effects of edentulism to contend with—the increased risks of systemic diseases such as cardiovascular disease or diabetes.

By creating value for these patients through a resolution of their oral disability and an improvement in their quality of life, general practitioners can indeed set themselves up for great success if they can truly focus their patients’ attention on the long-term benefits of a treatment plan that includes implant-supported prostheses or restorations to replace missing teeth. Rather than taking a somewhat passive approach and trying to convince (or “sell”) a patient to accept (or “buy”) an expensive and time-consuming treatment plan as simply being what’s best for their oral and overall health, or trying to promote the outcome of implant surgery and prosthodontic/restorative treatment as being an investment worth an eventual reward, general dentists would do much better to concentrate on speaking to the patient’s emotions on what his or her life will be like when their pain and discomfort is gone, and their detrimental quality-of-life issues around eating and nourishment, speech difficulties, appearance, and self-esteem/social anxiety are permanently resolved.

Patients have made this a somewhat easier task, thanks to possessing their own higher dental intelligence than they’ve had in the past. Today patients look for their general dental practitioners to be not only drill-and-fill dentists, but complete oral healthcare providers. There is already an expectation that their GP will give them the best correct diagnosis of their problem and offer the best comprehensive treatment plan to solve that problem. One of the biggest obstacles to accepting an implant-based treatment plan, the patient’s ability to pay, can be worked out with creative financing options, whether practitioners choose to offer those options internally or use third-party services.

Once you have decided to offer implants in your treatment mix—and you’ve obtained the proper training and credentialing to perform these procedures—enlisting the services of a practice management consultant can help you craft your marketing message and maximize your promotional budget to help re-educate your existing patient base and bring in those valuable new patients.

Do You Know Enough to Do Implant Dentistry?

With the wide variety of implant products and designs available, training that is not limited to a single system will ultimately benefit dentists—and their patients—the most. Unfortunately, it’s not always easy to pinpoint what differentiates one implant education opportunity from another. According to Andrea Schreiber, DMD, associate dean for postgraduate and graduate programs and clinical professor of oral and maxillofacial surgery at New York University College of Dentistry, there is no “one size fits all” course.

“The field of educational opportunities in implant dentistry varies as greatly as the needs, knowledge, skills, and desires of each individual,” Schreiber says. “Everyone must recognize their own limitations and the differences between continuing education courses, the rigors of advanced education/residency programs that span 3 to 6 years, and the different levels of knowledge and skill that can be gleaned from each of those alternatives.”

What’s happening in implant dentistry today is also impacting the whole profession—in which there are seven or eight times more general dentists than implant specialists. Patient demand for more stable, predictable, and esthetic prosthodontic treatments (eg, implant-supported full dentures or partials) is definitely growing. The trend is understandable, yet somewhat uncertain.

“Looking ahead, there’s no telling what the future holds,” notes Wayne A. Aldredge, DMD, a periodontist from Holmdel, New Jersey, and the current president of the American Academy of Periodontology (AAP). “However, a goal should be to educate the public about dental implants and the importance of having them placed and cared for by a specialist trained in their installation and maintenance.”

To ready new and seasoned dentists alike for providing implant treatments, dental schools offer undergraduate, graduate, and postgraduate curricula. According to Schreiber, the curricula for both predoctoral and advanced education programs like those at NYU College of Dentistry—and dental schools in general—prepare new dentists to incorporate implants into the treatment plans for their patients by providing students with the necessary background and training. Topics include bone physiology and morphology, biomaterials (including regenerative agents), wound healing, principles of osseointegration and evidence-based practice, diagnosis and treatment planning, esthetic and functional requirements, and surgical and restorative techniques and skills.

“Today’s graduates have the basic knowledge and skills to evaluate their patients’ candidacy for implant-supported restorations,” Schreiber observes. Students are all required to restore dental implants as part of their management of fully or partially edentulous patients. Similarly, they all observe or assist in implant surgical procedures. “They are trained to consider scientific evidence, individual physiologic factors, patients’ desires, and their own level of experience and expertise before embarking on a treatment plan, or deciding to refer to a specialist for complex care.”

This foundation of fundamental knowledge, explains Jack Dillenberg, DDS, MPH, dean of Arizona School of Dentistry & Oral Health, instills competence in the diagnosis, treatment planning, and restoration of implant cases. More education is still required for the implant placement component because it’s impractical to expect a new dental school graduate to be prepared to practice implant dentistry at a highly competent level immediately after graduation, he says.

Therein lies the quandary for already-practicing general dentists eager to add implant treat­ment to their service mix. As Schreiber points out, how well continuing education opportunities prepare dentists for placing implants and dealing with potential complications depends on their level of prior surgical training.

“They’ve gradua-ted with various levels of expertise and foundational experience—and may have never placed or restored implants before—so the best types of programs are didactic and clinical, hands-on continuum courses ranging from 12 to 18 months that cover topics spanning surgical to prosthetic aspects of implant dentistry,” Dillenberg says. “Because 90% of dentists practicing in the United States didn’t learn about implants in dental school, they must be aware of their own limitations and not attempt cases of advanced complexity early in their journey toward becoming competent with implant dentistry.”

That’s why, when seeking to elevate their competency, Sharon Bennett, executive director of the American Academy of Implant Dentistry (AAID), notes that dentists should look for dental implant education that is comprehensive and well balanced in its coverage to receive a well-rounded implant education, rather than one-time courses that provide a snapshot of a topic or treatment.

John C. Minichetti, DMD, a diplomate of the American Board of Oral Implantology and past-president of the AAID, agrees, adding that it’s essential for general practitioners looking to become involved with implant dentistry—as with any other dental specialty—to realize that education cannot be achieved in one or two weekends.

“Because there are so many treatment options, the AAID structures its education to cover multiple modalities,” Bennett says, adding that training should be practical, designed for practicing implant dentists, and enable dentists to learn something that he or she can incorporate into practice after the course is over. “The education should be available in a variety of delivery mechanisms to accommodate different learning styles so that doctors who learn differently can learn best.”

Therefore, when considering implant training and education opportunities, Schreiber advises dentists to look for programs that set reasonable goals and learning objectives for the time allotted for the course, are free of bias, and are ideally taught by a multidisciplinary team of expert specialists. To ensure quality educa­tion, Bennett encourages dentists to be sure that the education provider has been vetted or is accredited by an independent third party (eg, ADA CERP or AGD PACE). Ad­ditionally, for those seeking to achieve a credential in implant dentistry (eg, AAID’s Associate Fellow or Fellow), dentists should double check that the course(s) they are taking satisfy the requirements of the specific credentialing program.

Do You Have the Team to Support Implant Dentistry?

As more general dental professionals gain insight into implant placement and offer this service to patients, ensuring the successful integration of this treatment modality within the practice could be predicated on a team approach—a factor credited with contributing to the overall predictability of the final outcome. Many implant cases, in particular, require a collaborative approach and typically more than one person sitting in an office by themselves in order to be treated well, explains Frank Spear, DDS, MSD, founder and director of Spear Education and an affiliate professor of graduate prosthodontics at the University of Washington.

“One way to define the team is examining the types of cases that members feel competent treating and what cases they feel they probably shouldn’t be doing or may not want to do. In those situations, the team works very well,” Spear has observed. “Team members are well defined in the roles they each have, and they are also very clear about what needs to happen in terms of acquiring records, disseminating records and patient information, identifying the outcome(s) for the case, and who is responsible for what phase of treatment.”

In recent years, laboratories have played increasingly significant roles in collaborative teams, serving as technology-empowered resources and partners to help drive the planning, placement, and restorative workflows, explains Conrad Rensburg, owner and head of dental implants at Absolute Dental Services in North Carolina. Armed with implant-planning software, digital design and fabrication technologies, and the anatomical/biological and material expertise to support specific recommendations, laboratories are bringing a new level of value to the implant treatment team.

“It’s extremely important today for laboratories to be a kind of glue that [helps to] bind the surgical and restorative partnership,” Rensburg says. “We do have the knowledge of, and we do understand, where the implant needs to be and where [the surgical-restorative team is] going prosthodontically, so this collaborative approach between surgeon, technician, and clinician is now giving our patients a better outcome.”

When dentists are ready to move forward with implant treatments, Spear shares his own experience as an example of how to approach a collaborative model and, simultaneously, nurture ongoing skills development. Following a monthly study club model—where between six to eight general practitioners, laboratory technicians, surgeons, and orthodontists meet to collaborate on cases that each dentist is struggling with—provides a face-to-face opportunity to problem solve and treatment plan as a group. Spear says that a well-defined collaborative team requires identifying roles, determining how records will be disseminated, and agreeing how decisions will be made among team members. “Who performs treatment? What happens first? Who does it? What happens second, and who does that?”

“The best thing contributing to a great, collaborative team approach process is identifying patients who are predictable to treat versus those who may not be predictable or, in fact, who can’t be treated without extensive bone or soft-tissue grafting, orthodontic movement, etc.,” Spear observes. “Often, especially if it’s a surgical case, or a case involving orthodontics and implant restorations, the patient may see multiple different clinicians over the course of 6 months to 2 years before the final implant placement and final restorations.”

In general, however, collaborative care is most effective when it is built around the patient experience, says Filippo Impieri, vice president of marketing, North America, for KaVo Kerr Group, Dental Technologies. Facilitating collaborative analysis and decision-making are technologies such as low-radiation CBCT [cone-beam computed tomography] units, which produce scans that can provide highly accurate 3D images of a patient’s anatomy. For implant dentistry, the data a CBCT scan provides about available bone and other aspects of the patient’s jaw and anatomical limitations can be easily enhanced, shared, and are more easily understood by patients, Impieri explains. This ultimately leads to smarter treatment planning, greater precision, and results that are better for the patient. “Just as important as any of the technological advances in CBCT is the way those advances facilitate communication with team members, specialists, and patients, providing a common language for treatment planning and care,” he says.

Do You Have the Technology for Implant Dentistry?

Facilitating efficient and timely multispecialty team collaborations are technologies used to enhance case analysis, treatment planning, and implant placement and restoration execution throughout the process. For example, the predictability of implant dentistry improves when CBCT, implant-planning software, and surgical guides are properly integrated into the workflow.

In fact, the implant-planning process often begins by taking a CBCT scan, “which serves as a rich communication medium among collaborating team members and enables the subsequent fabrication of implant surgical guides. Combined, these advances contribute to a more predictable and stress-free implant placement process,” Impieri explains.

“Knowledge is power, and CBCT provides more knowledge—information that builds clinician confidence, drives smarter treatment planning, and meaningfully engages the patient,” Impieri observes. “As the demand for implant dentistry continues to grow, CBCT is an essential tool in providing the highest quality care with reliability and confidence.”

To help members of the team maximize the potential of CBCT—as well as maintain a seamless workflow and better employ digitally based tools (eg, design software, treatment-planning software, surgical-guide fabrication) when they are not otherwise readily available—virtually based HIPAA-compliant resources can fill the void. Depending on a case’s specific requirements, these services can be used for radiology interpretations, CBCT scan protocols, developing patient-specific treatment workflows, determining ideal implant placement, fabricating surgical guides, and digitally designing restorations.

One such service is Implant Concierge. While it is physically located in San Antonio, Texas, through its proprietary, web-based software program Virtual Treatment Plan Coordinators can assist clinicians on implant cases by consolidating and coordinating CBCT solutions and guided implant surgical services regardless of the clinician’s geographic location. Its chief executive officer, Bret E. Royal, says, “Computer-guided implant surgery, virtual implant planning, and CAD/CAM-generated surgical guides are powerful tools that allow general practitioners to fully understand all of the anatomical considerations before they lay a flap. Technology obviously does not replace surgical skill and experience, but it does enable dentists with varying degrees of experience and training to properly vet which cases match their skill sets according to the complexity of those cases.”

Digital technologies certainly have changed the professional and dental laboratory industries—and rapidly, Rensburg says. In fact, what can be accomplished today is phenomenal, Spear says, from online collaboration where all team members can view real-time, virtual implant-placement manipulation to restoration design, all before the implant is even placed.

“It’s hard to deny that technology has altered the way we can analyze a patient in terms of the possibilities for implant placement,” Spear admits. “What we often don’t think or talk about, however, is how it actually allows us to monitor and compare a condition over time very accurately for long-term diagnosis and treatment planning.”

So, Are You Ready for Implant Dentistry?

Whether dentists choose to perform both surgical and restorative phases of implant-supported prosthodontic treatments, or just one phase as part of a collaborative team, the final result for the patient should seamlessly meld the two, Bennett says. Education and training help make that possible, as do the integration of relevant technologies, collaboration, and/or the use of implant treatment-planning services. Ultimately, however, competency is the defining factor when determining who should be placing and restoring dental implants. A surgical procedure that can have some potentially untoward effects, dental implant placement requires a competency level that must be achieved through more than just the occasional course here or there—many times through postdoctoral education and comprehensive training programs, Aldredge emphasizes.

Reference

1. Market research in Germany, Italy, Spain, and the United States. Exevia. 2014.

Help! I’m In Over My Head

Or, how to avoid trouble before it starts

Collaboration and technology-supported resources aside, there remains no substitute for requisite competency in appropriately diagnosing and evaluating suitable cases—and ensuring diligent follow-up and maintenance care—to increase the likelihood of achieving predictable outcomes and avoiding complications. Placing implants in the right patient, in the right position, and at the right time depends upon a complete, correct diagnosis and a top-down treatment-planning approach—or beginning with the end in mind, explains Michael Sonick, DMD, a full-time practicing periodontist and implant surgeon in Fairfield, Connecticut, and a guest lecturer for the International Dental Program at NYU College of Dentistry.

“The lack of a comprehensive examination and complete diagnosis leads to the biggest complications,” Sonick says. “If someone is prone to or has untreated periodontal disease, that person will be more prone to bone loss around the implants, peri-implantitis, and/or mucositis.”

What Could Possibly Go Wrong?

After serving dentistry and patients for more than 30 years, dental implants have demonstrated a 95% to 99% overall success rate. Contributing to predictable results are the dentist’s clinical and surgical skills, implant materials and designs (eg, micro- and macro-retentive surfaces, among others), and proper patient selection. It’s the latter that could be problematic and present the greatest number of unknowns affecting treatment success.

“Many times it’s the patient who’s the modifier,” explains current president of the American Academy of Periodontology, Wayne A. Aldredge, DMD. “Is there an underlying systemic problem? Are they an undiagnosed diabetic? Do they have a collagen disorder? These are some factors that can modify the dental implant success rate.”

Among the complications affecting implant treatment success are malpositioned implants and peri-implantitis (ie, the inflammatory process around an implant involving soft tissue and a progressive loss of the bone supporting the implant). Aldredge has observed that these can be avoided when implant placement and prosthodontic/restorative treatment are undertaken in a collaborative, team approach; if the clinician and surgeon possess the requisite surgical and restorative expertise and skills; and when the treatment is combined with regular maintenance and monitoring of the implant site so that any breakdown of bone or soft tissue or signs of peri-implantitis can be treated early and effectively.

“Complications occur in both the surgical placement of dental implants and the reconstructive phase, and most are due to poor planning and are preventable,” warns John C. Minichetti, DMD, a diplomate of the American Board of Oral Implantology and past-president of the American Academy of Implant Dentistry.

Essential to properly treatment planning implants—and avoiding complications—is examining four key considerations, Sonick says. These include bone (ie, adequate quality and quantity, which determines if grafting is needed and where); implant position (ideally requires adequate bone quantity and quality, as well as a prosthodontic plan for proper angulation); soft tissue (ie, an adequate band of keratinized tissue to resist inflammation; a possible need for connective tissue grafts; a specific flap position); and the final restoration (ideally with proper subgingival contours). “The key to dealing with potential complications is avoiding them,” advises Andrea Schreiber, DMD, associate dean for postgraduate and graduate programs and clinical professor of oral and maxillofacial surgery at New York University College of Dentistry. “In some cases, that means referring a case to specialists.”

Implant Education Resource Guide

Are you ready to add implants to your practice? If so, you will need the proper education and skills to hone your craft. This reader resource guide gives you the opportunity to take action and get started with (or continue) your implant education.

Hands-On Training

The Dawson Academy
http://thedawsonacademy.com/courses/

Dentsply Implants Education Center
www.dentsplyimplants.com/en/Courses-and-events/Our-Education-Center

Hands On Training
www.handsontraining.com/schedules/

The Implant Learning Center
www.theimplantlearningcenter.com/#!course-catalogue/drsy0

Misch International Implant Institute
http://misch.com/courses/

The Dental Implant Learning Center
www.dentalimplantlearningcenter.com

Online Courses

AAID Dental Campus Partnership
www.aaid.com/education/ Multimedia.html

Glidewell Laboratories online CE courses
www.glidewelldental.com/dentist/education/ce-course-index.aspx

Global Institute for Dental Education (gIDE)
www.gidedental.com/

Certificate-Courses

Stony Brook School of Dental Medicine Dental XP Online Implant Externship Program http://dentistry.stonybrookmedicine.edu/coned/online/courses

Academia

Augusta University Clinical Fellowship in Esthetic and Implant Dentistry
www.implanteducation.net/1-year-fellowship-program.html

California Implant Institute
www.implanteducation.net/1-year-fellowship-program.html

Indiana University Dental Implants Fellowship
www.dentistry.iu.edu/index.php/departments/restorative-dentistry/iu-school-dentistry-implant-center/dental-implants-fellowship/

Loma Linda University School of Dentistry Advanced Education in Implant Dentistry Program http://dentistry.llu.edu/future-students/specialty-programs/advanced-educationprogram-implant-dentistry

LSU Health New Orleans School of Dentistry Implant Prosthodontics Fellowship Program
www.implanteducation.net/1-year-fellowship-program.html

Rutgers University School of Dental Medicine Surgical Implant Dentistry Fellowship
http://sdm.rutgers.edu/students/prospective/postdoctoral/other/Surgical_implant_dentistry_fellowship.html

Tufts University Dental Implants Fellowship
http://dental.tufts.edu/academics/advanced-and-graduate-education/implant-dentistry/

UCLA School of Dentistry Advanced Surgical Implant Dentistry Program
www.dentistry.ucla.edu/learning/advanced-surgical-implant-dentistry

Symposia and Conferences

AAOMS Dental Implant Conference
www.aaoms.org/meetings-exhibitions/dental-implant-conference

American Academy of Implant Dentistry Annual Conference
www.aaid.com/Annual_Conference/index.html

American Academy of Periodontology Annual Meeting
www.perio.org/meetings/AM2016

American Dental Association Annual Meeting
www.ada.org/en/meeting

Academy of Osseointegration Annual Meeting
http://meetings.osseo.org/

Manufacturers

ids-integrated dental systems
www.megagenids.com/AnyRidge

KaVo Kerr group
www.kavokerrgroup.com/

Nobel Biocare
www.nobelbiocare.com/us/en/home.html

Straumann USA
www.straumann.us/en/

ZEST Anchors
www.zestanchors.com/

Please note that this is not a comprehensive list, but rather a sampling of educational resources at your disposal. For even more educational opportunities, please visit dentalaegis.com/go/id1157.