Simple and Economical yet guided…


Couple of decades ago there was the osseointegration revolution.  Then there was the bone grafting one.  The last decade has been all about two topics:  Soft tissue management in the esthetic zone and Guided implant placement. Guides are pretty common place today but not ubiquitous, although they should be.  Of course implants can be and are placed without guides.  But if given a chance everyone would like to have a guide for ease of placement and greater accuracy.  Then why don’t they?  Mainly due to the additional cost and the complexity of working up the case using software.  Well instead of having simplant or other CAD/CAM type guides made.  Here is a guided case done with a local lab.  The guide was made to the size of the final drill (nobel 4.5mm in this case).  The telescoping pieces slide in and out to make the drill hole 2mm and 3.5mm in diameters for the intermediate drills.  The precision placement allowed me to place this implant and immediately load it with a screw retained temporary crown for ideal soft tissue contours.  The cost of the guide – $100.  The two telescoping pieces are autoclavable and reusable for multiple cases.  No need for the guided kits from nobel or straumann, etc.  You can just use your normal surgical kit.



Coding for socket grafting…

I agree, coding is not what makes dentistry SEXY and reimbursement can be a puzzling topic.  Interestingly it can also make a significant difference in your bottom line.  Even if you have a practice that takes very little insurance, it’s still good to know how to bill correctly for maximum reimbursement.  Lot of practices will bill the extraction and graft as a bundled procedure.  This may not result in the reimbursement you were looking for.  The correct way to code is the following:


D7210 or D7140 for your extraction.

D7953 Ridge Preservation

D4266 Resorbable barrier or D4267 for non-resorbable barrier

as a bonus for reading this far, did you know there is a separate code for Emdogain.  If you use it email me and I’ll send you the code.  If you don’t use it you may want to look it up by clicking the link above.  If you don’t get proper reimbursement you may find you are losing money on certain procedures due to the high cost of materials involved.  Before you start socket grafting add up the cost of your materials!



Where will today’s implant companies be tomorrow?

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This may not be absolutely critical to torquing down your implant practice today… but maybe tomorrow!!  While we look for the right surface, taper, strength, and alloy research is producing some very interesting results.  I always thought that stem cell application  would start by creating a graft site and then seating the cells within, then guiding the tooth to occlusion orthodontically.  It appears that at least some research has taken a different approach.  Dr. Jeremy Mao of Columbia University has developed a tooth shaped scaffold which can be impregnated with stem cells resulting in a completely formed tooth in nine months.  It’s in alpha testing now but makes me think of where the implant companies of today will be tomorrow? Read the full story here…


Simplicity is the ultimate sophistication…


Sometimes I wonder why I couldn’t have thought of this myself!  I have used multiple lasers in the past and currently use the Deka laser.  One of the main purposes is to expose implants.  I was recently given the Ceratip from Komet.  Billed as “the poor man’s laser”,  it is a zirconia coated burr which works fabulously for exposing implants.  It works on


mechanical thermal principals.  Simply place it in your handpiece (turn the water off) and vaporize soft tissue to expose the implant.  I never believed it but after using it I highly recommend it.  It doesn’t replace the laser but gives 95% of the effect for exposing implants. And this is at a total cost of $50.  The laser cost $40K.  Also many times I may be in a operatory where my laser is not present and this burr will do the job!  You won’t believe it until you try it.  Let me know your experience?



Basics of Socket Grafting Part I

A four walled bony defect has excellent healing potential when grafted.  However, if left on it’s own has an equally good chance of resulting in a atrophied site which may require more complex and costly grafting.  Today the best means of ridge preservation is by immediate implant placement.  The second best is socket grafting. The most common question I am asked by my restorative colleagues is what I use for socket grafting and what is my technique.  I think it is a great question if someone is preforming extractions in their general practice.  When I started practice 10 years ago I had to take a leap of faith into socket grafting as it was an emerging procedure and technique.  Today we have volumes of literature supporting it’s success.

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I personally believe it should be considered negligent not to offer this benefit to a patient in 2010 as part of an informed consent.  Bone is a very difficult tissue to regenerate.  It’s preservation after tooth loss is beneficial not only as a foundation for future implant placement but also to preserve the youth of the facial form.  The sunken appearance of denture wearers is partially attributed to bone loss from extractions.  Below I give a summary of my technique with no academic support or detailed rationale for the technique.  I hope to do so in future entries.   My own preference is a 50:50 mix of cerasorb and puros packed moderately covered with a regentex membrane and silk sutures.  In one week I remove the sutures; in two weeks I peel off he membrane.  There is a three month healing time prior to flapless implant placement.  Local infiltration is critical for hemostasis or else your graft will float away.  The membrane is neatly tucked under the gingival margins or it will fall off within a few days.


Torquing by the book? Time to reconsider…

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It has been my experience that small diameter implants (3.5 or less) in the anterior maxilla can deintegrate easily when the final abutment is being torqued down.  Whenever this has happened it has been the result of torquing to a full 35 as recommended by the instruction manual that may accompany many implant systems.  However, what has really worked for me is to torque down to 20-25 and call it a day.  The abutment usually does not become loose after the crown is placed in function and the case is finished just fine.  Since we are talking of the anterior maxilla most cases will go through a temporary phase and this would still give the clinician a second chance to test out the torqued abutment and give the implant more time to integrate fully.

Whenever I have gotten the call that it seems that the implant just moved on torquing (usually because the abutment loses it’s correct position by rotation of the implant) there are usually three choices to proceed.

  1. Reposition implant as closely as possible to it’s original position.  Leave the final abutment on.   Cement final crown temporarily or replace the temporary crown that was on.  PUT THE TOOTH OUT OF OCCLUSION.  And hope for

    Untitled.jpgreintegration…  (this can and does work )

  2. Remove it, debride the socket and regraft and replace implant after graft healing  
  3. Remove the implant and place a wider implant, wait for integration and remake final abutment.

When this happened to one of my restoring dentists, my solution was to remove the implant. Gently examine the socket. Then replace with an implant of the same width but longer (16mm instead of the previous 13mm).  I could not place a wider implant due to space restrictions in the esthetic zone.  I indexed it in the same way and also eyeballed the vertical depth to as close as possible to the previously placed implant. This allowed me to use the already fabricated final abutment and crown (taken out of occlusion) during implant reintegration.  So please be prudent when torquing down implants to the exact requirements by the implant company. If in soft bone, working in the anterior maxilla, implants within sinus grafts, or working with narrow implants (<3.5mm) you may just want to hand tighten the final abutment (8 newtons of force) or just go up to 20 Ncm. Also keep some long (16mm) implants in your inventory for a rainy day like the one I was having.  In the posterior mandible by all means you can swing off that torque wrench and I won’t mind!  



What Implant is that?!

weird.pngThere are 318 implant manufacturers in existence today! That means tons of different connections, grooves, threads, tapers, collars, and surfaces. How to keep track of it all? Specially if you get a patient who has moved from another area of the country or the world for that matter. Or someone who had work done and can’t find their records and now you have to tighten a loose abutment or restore the over denture. Well I have come across two excellent resources and they are absolutely free! has a set of question filters. As you answer more it narrows your search providing pictures of the implant until you have found the exact one. You can also match it to different images (x-rays). Along the same lines a website I just came across yesterday is Both are excellent resources and fill a much needed gap as implant manufacturing becomes a worldwide phenomenon! Please remember there are implant companies out there which are not going to be around in the next five years, let alone ten. So before you buy the cheapest ones out there to make the biggest profit, think about whether you are really doing the patient a service when they need the parts for it in the future. My advice: stick to the big four (whichever they maybe).


The magical luxators…

I have spoken with many clinicians who don’t use either of these tools and it always shocks me! Today with implants well on their way to being the gold standard for tooth replacement and immediate implants enjoying functional and esthetic success in the 90 percent range it is even more critical to extract teeth atraumatically. The choice of tools are then either luxators, proximators, a periotome, or a powertome. I have used all of these and the one that now sits on every one of my extraction trays is the luxator. What makes it stand out is the large handle that allows forces to be transmitted with ease. This just can’t be achieved with the proximator or periotome without using a mallet. Untitled1.jpgThe powertome on the other hand creates too much noise for my liking. The luxators have very fine but yet durable tips that fit right into the PDL space. I take it all around the tooth going deeper each time until the tooth is loose. It is the quickest and easiest way to get that tooth out! (Atraumatically that is…) I even use it for wisdom teeth. Eventhough they are not elevators, and the manufacturer makes sure you are aware of that… it is hard to resist. This has led to multiple orders of the instruments as the tips will fracture or shred. So remember just apical forces and minimal torquing forces. Buy the plastic handled ones over the metal version and a pack of three maybe just as good to start. The real set comes as a pack of seven and has a greater variety of tips and angles. I find that I end up using three to four anyway most of the time. If you have picked up a drill to remove maxiallary teeth in the past five years then this bud is for you!


Outsource your treatment planning…

I just treatment planned a four implant, truly guided case – over the phone. The most brilliant thing was that the person on the other end was halfway across the world! The world is indeed flat. I have been using an iCAT to place implants since we got one in 2004. I used iCAT vision, the software that came packaged with the machine. This gave a lot of information but did not allow me to do virtual surgery on the images (i.e. place mock implants where they should go). I started doing this with the third party software, Keystone Dental’s EasyGuide.

Last month I came across a company 3D Diagnostix based out of Boston. Theirs is a truly brilliant concept. You send them the iCAT and they do the treatment planning (by a qualified surgeon). Then you have a meeting with them over the web to verify that you like the plan. You can also involve the restorative dentist and the lab in this. I gotta tell you it is kind of cool to just have to tell someone over the phone where you want to move the implant to, and a second later it’s done right there on your screen. The whole process has been seamless so far. Very impressive! The concept here is to basically outsource your treatment planning as you would your accounting or your lab work but still retain complete control over it. Once approved a surgical guide is fabricated and mailed to you!


In Print… Dental Implants, The Art and Science

bookcover.jpegYes, this is the beginning of a whole new decade. TIME magazine wrote that the last decade would be remembered for 9/11, two wars, and two economic meltdowns. But I like to look on the positive side of things. To me the last decade was all about the iPod, iPhone and the iCAT. I use the iCAT for every implant case I do. It is unimaginable to me that this technology was just not available a few years back. I think it ranks right up there with the discovery of anesthesia and x-rays. This month a new textbook was released. It is comprehensive in scope and detailed in content and comes highly recommended based on previous editions. Dental Implants, The Art and Science. Edited by Babbush, Hahn, Krauser, and Rosenlicht. Chapter 8 covers the radiographic assessment of the implant patient, and is co-authored by myself. It’s well worth a look.