Dental Implants

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

get prepared
with CBCT
Patients make better decisions when they receive good information. The
dental community has an obligation to deliver good dental implant information.
Copyright 2008/2009 by Murry Shohat. All Rights Reserved
 Dental Implants
Get prepared with CBCT
Excellent results from increasingly popular but expensive dental implant surgery can be as-
sured. Technology that your dentist should be telling you about will preclude nerve injuries, per-
manent numbness, involuntary drooling, perforated sinuses, incorrect tooth angles and broken
jawbones. Here’s why and how to protect yourself.

By Murryto
Download the article Shohat
activate the links
Once again, science and technology to connects to a denture (the process is called restoration).
the rescue! Standard dental implants are Restored implants often function better than healthy teeth
now the preferred way to replace missing (they don't get cavities). With excellent patient care, prop-
and damaged teeth, regain lost chewing erly restored implants can last decades.
function and rebuild confidence after a
The illustration below conceptualizes a restored single im-
long period without teeth. For front teeth,
plant. The gap below its tip illustrates required procedural
implants offer an even more cosmetically
drilling depth of the
attractive smile than veneers, in what den-
osteotomy. The
tists call the esthetic zone. For these rea-
implant must be
sons, implants have rapidly become a
carefully torqued
mainstream but expensive treatment. Is
into the osteotomy
your dentist properly trained to offer them?
to establish ideal
Fig. 1 is a representation of a tapered tita- conditions for os-
nium implant, magnified. Standard im- seointegration.
plants measure 4 - 6mm wide by 5 - 15mm The gap ultimately
long (6.35mm = ¼"; a U.S. dime is fills in with new
Fig. 1 1.35mm thick). It's not unusual for patients bone growth.
to receive several. Under proper condi-
Implants are now
tions, fully edentulous patients (no teeth) can receive a
being placed by
mouthful of these long lasting cylindrical tooth root replace-
oral surgeons, pe-
ments. Candidates include patients who are missing one or
riodontists (gum
several teeth or wear partial or full dentures or bridges.
specialists), prost-
These patients want a much more stable chewing solution.
hodontists
For others, an implant is sometimes useful to immediately
(denture special-
replace a tooth that has to be pulled. In some cases, an
ists) and regular
implant is an alternative treatment for a root canal.
restorative / cos-
Although mini dental implants are similar, they are not of- metic dentists.
ten used to replace whole teeth and are therefore not the Even endodontists
subject of this article. Mini dental implants are very narrow (root canal Fig. 2: Implant supported crown
– 2mm or smaller. A growing debate characterizes dental specialists)
opinions on the use of mini implants as temporary or per- recommend an implant instead of a root canal in certain
manent solutions for tooth replacement and denture sup- cases.
port. The most experienced implantologists use them in
limited situations, observing warnings like this one: Be sure to read the revised version of this article
http://dental-implants.com/cms/frequently_asked_questions/faqs. and its companion directory:
Based on tooth root-shaped titanium cylinders that are ma- http://knol.google.com/k/murry-shohat/
chined with screw threads as shown in the photos on this
page, standard implants are surgically placed in jawbone, Because a single implant can cost upwards of $3,000 to
below the gum after careful drilling and preparation. The $5,000 including restoration with a custom ceramic crown,
titanium implant is literally screwed into the prepared hole the dental profession loves the cash flow. Worldwide, den-
(the osteotomy), where it bonds with jawbone over several tists are rushing to offer implants. However, it's your mouth
months. The bonding is a unique property of titanium. and money. Careful advance preparation protects your
dental and financial interests. Each case benefits from pa-
Bonded 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 comprehen- ProMax, PreXion, Accu-i-Tomo, NewTom 3G, i-Cat and
sive diagnosis and safety and precision computer- several others.
manufactured surgical guides that assure proper drilling. A
Unless your case is simple, a CBCT is the most important
3D digital X-ray is the dental equivalent of a CT scan
thing you'll need. It enables clinicians to see inside your
(dentists call it CBCT). It fully reveals your jawbone struc-
jawbone with an accuracy as small as 0.07mm (less than
ture and can guide the actual surgery with precision far su-
the width of an average human hair), and to avoid the prob-
perior to 2D dental office X-rays.
lem shown at left. This illustration portrays three implants,
Many patients should not proceed without the benefits of two of which have been drilled and placed into the nerve
3D because it prevents mistakes like drilling at wrong an- canal inside the mandible (lower jaw). This nerve serves
gles or into dental nerves or other vital structures of the each tooth and "enervates" the lip and chin through a
jawbone. Given each branch called the
implant's cost, an- mental nerve. Our
other $300 - $500 for ability to sense
a CBCT is a moder- touch, heat, cold and
ately priced insur- pain is this nerve's
ance policy. And the function. A patient's
cost is dropping as complaint (after sur-
companies like PreX- gical anesthesia
ion, Planmeca and wears off) might be
others convince den- "my (right or left side)
tal practices to add lip and chin are pain-
3D scanners. fully numb, and I
can't stop drooling
Initial Prepara- because I can't feel it
tion to control it."
For most cases, first Figure 3B provides a
and second opinions close up of the for-
top the list of things ward implant striking
to do before surgery. the mental nerve.
When your dentist The drills used to
recommends im- prepare the osteot-
plants (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. Ex-
two restorative/cosmetic treme pain for days, weeks or months may follow. Numb-
dentists 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 sur- As you prepare for im-
geon who surgically installs the implants. If your dentist plants, you’ll also need an
also plans to do the surgery, you'll want an opinion from a appreciation for the sur-
clinician who does not place implants. Oral surgeons and geries in the treatment
other implantologists — even cosmetic dentists — who plan. Some implant cases
make a living from implant surgery are biased. Seek an require advance bone
opinion from a dentist who does not rely on implants as a graft surgery (with ample
way to send kids to college or buy a yacht or vineyard. healing time before im-
plants 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 of- time 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
Some forward-looking dentists and implantologists are in- not unusual for implant prep, sur-
stalling CBCT units in their offices. These clinicians know geries and restoration to span more than a year. A full
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 attor- Prudent 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 com- The X-ray in Fig. 4A demonstrates why some of these
puter-aided production of a surgical guide that helps the questions are needed. An oral surgeon's 2D panoramic X-
implantologist drill with precision into your jawbone. ray machine took this image. By his testimony in a malprac-

A note about teeth in an hour advertising. Very sim-

ple 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.

Question your Clinicians

Implants made their way into the dental toolkit more than
30 years ago and have seen steady progress as the pre-
ferred way to replace missing and damaged teeth. Because
titanium forms a strong bond with jawbone, even food-
grinding molars can be replaced. So, don't be surprised Fig. 4A 2D X-ray fails to reveal nerve impingement,
when your dentist recommends an implant. It's an ideal says surgeon. An expert radiologist disagreed.
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 tice lawsuit, the image did not reveal to the surgeon that
record the conversation. two of the implants had been drilled and placed into the
patient's nerve.
♦ What other solutions are available?
♦ Does my dental insurance cover the procedure? Look again at the illustrations (Fig. 3A and 3B, previous
page). They are based on this X-ray. Fig. 4B illustrates the
♦ What are the cost differences among available solutions? jawbone’s front
♦ What are the functional differences? to rear depth,
♦ What happens if nothing is done? (the third di-
mension), and
♦ Am I a candidate for teeth in an hour? shows one of
♦ How can I be sure that implants are really needed? What's the basis the drills used
for your diagnosis? to prepare the
♦ Who do you recommend to do the surgery, and why? osteotomy im-
pinging on the
♦ How much experience have you had with the recommended implan-
nerve. This
tologist?
view is based
♦ Do you know if the implantologist has a clean malpractice history? on Fig. 5 (next
♦ Can you recommend more than one surgeon and let me decide? page), a preci-
sion CBCT X-
♦ Do I have enough jawbone to achieve a crown to root ratio of 1:1 or
ray image of
better? What are the tradeoffs if the ratio can't be achieved? (A short
the patient’s
implant life with risk of a cracked jaw is one tradeoff!)
mandible. Don't
♦ What kind of life cycle can I expect for the types of implants recom- you want to ask those Fig. 4B: Drill strikes nerve
mended for me? questions to avoid
♦ Are implant placement angles a problem in my case? How will you this outcome?
assure correct angulation?
Get That 3D X-ray and 2nd Opinion
♦ Does the standard of care for my case require a 3D X-ray? If your dentist’s opinion favored a CBCT, get it now. Your
♦ Will a CBCT guarantee the correct angulations and drilling depths? 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
wasting money? your dentist says 3D is unnecessary, this becomes ques-
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 deliv-
nearest 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 Reach Out with Caution
on a computer. Your dentist may be able to demonstrate There's no shortage of implant information on the Internet.
concerns by displaying the images on a chairside monitor. One reasonably scholarly source is Wikipedia:
But you can be briefed with the excellent paper image set http://en.wikipedia.org/wiki/Dental_implants. You may dis-
produced by the CBCT. cover important information specific to your case (for exam-
CBCT imaging centers usually offer the services of a ple, the relationship between intravenous treatment for cer-
Board-certified radiologist to review the scan, opine on tain types of cancer and many other contraindications for
available bone depth, width and height, and any signs of implant surgery are discussed in the article).
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 tu-
mor or other incipient condition).
Difficult cases, or cases that display unusual artifacts are
sometimes referred to top dental radiology professors at

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 Fig. 5: CBCT shows width and height (left) and depth
being taught how to recognize problems that would oth- and height (right). Red line is the top border of the
erwise go undetected until symptoms appeared. 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
dental schools. CBCT offers clear advantages to arrive at deeper than the implant..
the best diagnosis and treatment plan.
If your dentist is unfamiliar with CBCT, don’t be surprised if Fig. 6: An Accu-i-
he or she expresses appreciation for the detail and clarity Tomo CBCT image
(the upside), and discovers issues and conditions that im- shows tip of implant
pact other teeth (a downside that becomes an upside via penetrating nerve ca-
improved treatment). Companies that make in-office dental nal. Implantologists
X-ray equipment, like PreXion and Planmeca, are offering are warned during
training and in surgery
3D units that are now more affordable for individual dental
manuals that the drills
and surgical practices. Training courses conducted by rec-
are longer than the
ognized experts are now front and center in the dental pro- implant. Impingement
fession and dental schools. A sea change is coming as by drill and implant
CBCT gains traction. was the opinion of two
Board-certified radi-
With or without a 3D X-ray, get another opinion. Friends
ologists.
and co-workers are reliable sources of dentist recommen-
Google searches are an excellent
dations, or consult a dental school. If you implicitly trust
way for patients to acquire health information. Perhaps you
your dentist, he or she will be happy to suggest another
found this article by searching dental implants. However,
clinician. Be sure to bring the X-rays used for the initial di-
information that is both bias free and deeply biased results
agnosis. And, if you've proceeded with a CBCT, bring the
from Internet search. Don't rely on any single information
CD/DVD, the paper image set and radiologist report.
source, including this article. Consider each website’s mo-
The following images, taken with a NewTom 3G CBCT tive.
scanner after a failed surgery, show an implant impinging
One top-ranked site is http://www.yourdentistryguide.com/dental-
on the nerve canal (red line traces the top border) in both a
technologies/. Calling
itself The Consumer Guide to Dentistry,
frontal (left) and cross section view (right). If only these im-
it provides a sponsored dentist directory (the motive). Al-
ages had been available to patient and implantologist be-
though the site delivers extensive information, oddly it pro-
fore surgery! These images and others led to a settlement
vides no easy access to guidance and information on
as a malpractice trial was getting underway.

5
CBCT and surgical guides. Only by deep diving will you Since this website is written by clinicians — dentists and
find this: oral surgeons for dentists and oral surgeons — a lot of the
CAT Scans: A 3-D image CAT scan is used to help implantolo- content may be difficult to comprehend. Don’t be intimi-
gists (dentists who provide surgical and restorative implant ser- dated. The site's reputation is one of helpfulness, so jump
vices) view and work on the jawbone or surrounding bone struc- into a forum. Ask for lay language answers. There are no
ture to produce more accurate results. CAT scan technology has dumb questions when it comes to medical and health pro-
become increasingly specialized for dentistry as implants, rather cedures, just potentially poor outcomes when the knowable
than dentures, have become the standard of care for tooth re- is not gained in advance.
placement. A linked list of other useful implant and CBCT
websites is included at the end of the article.
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 Computer Aided Diagnosis and Manufacturing
fraction of implant cases. It’s as if the dental community CBCT X-rays have another key advantage: because they
does not want patients to know about the technology. are digital, clinicians can use the data to create new accu-
However, when you peruse the conversations at dentist-to- rate views in real time for treatment investigation, planning
dentist websites, CBCT is gaining broad support (although and the design of surgical guides.
some dentists label the scans suitable only in difficult
In Fig. 7, Simplant (simulated implant) software has al-
lowed the dentist to use the patient's CBCT data to try in
different implant sizes in a conveniently reformatted view. If
“It’s as if the dental community does not the chosen size won't work (too long or wide), or the proper
want patients to know about the technology” angulation can’t be achieved, an alarm sounds (which is
the case here). The software presents three dimensional
views (width, height and depth).
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
the topic receives direct menu selection under the name from a manufacturer’s data base and attempts to place it in
NobelGuide. the patient's jawbone image, which is a 1:1 representation
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 con-
implant 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 suc-
cess 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 top-
ics.
You'll discover patients who
are asking important ques-
tions. 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 den-
tists, implantologists and civil- Fig. 7: Simplant software (Materialize, Inc) adds the element of
ians. As with any Internet site, caution safety through precision use of the patient's CBCT data. Fig. 8 pro-
and care should rule what you learn. vides close-up detail of the nerve collision signified here (arrows).
6
would shred the nerve). 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
light to medium gray peanut shape. It's a cross section of Avoiding injury is the chief safety benefit of 3D. And here's
the mandible (lower jaw) at a position near the first molar another: assuming that the try-in succeeded, the same digi-
(squeeze your lower right jawbone between left thumb and tal data may be used to fabricate a precision surgical
forefinger to help visualize this image). drilling and angulation guide after implant size, shape,
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 selec-
zontal red line. This canal carries the mental nerve that en-
tion 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 inexpen-
a CBCT image reveals this). The opening is a standard
sive in-mouth SurgiGuide is rapidly prototyped (quickly pro-
anatomical feature named the mental foramen.
duced in hard plastic). As its name suggests, the guide pre-
The three overlapping red circles down the middle form a vents drilling errors.
zone of safety of 2mm which must be avoided to eliminate

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 cylin-

der shape (numeral 1) is the simulated implant, and it's In addition to Simplant, other makers of implants and treat-
been 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 Be sure to read the revised version of this article
clearer view of what happened when an implant was actu- and its companion directory:
ally drilled and placed in this exact situation (because of http://knol.google.com/k/murry-shohat/
their shape and surgical protocols, drills penetrate about
7
Experienced implantologists will tell you that surgical
guides are not always the answer. In actual clinical prac-
tice, with the patient under sedation and the jawbone ex-
posed, the surgeon may encounter bone that is too soft at
Experienced implantologists will tell
you that surgical guides are not al-
ways the answer
a predetermined location. Now it's necessary to alter the
location of the osteotomy — or abandon placement. With
the patient's 3D X-ray on the chairside monitor during the
procedure, the implantologist in this situation is armed with
the best technology to succeed.
Other Important Considerations
Until dental offices acquire their own scanner, CBCT X-rays would eliminate a key demographic from treatment with
require a prescription and referral to a lab. Whether your
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
structures like nerves and the mental foramen is contem-
plated.
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.
Some implantologists resist the use of CBCT. This is re-
grettable 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 carpen-
ter choosing a hand saw when a power table saw is avail-
able 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 af-
ter surgery. You'll want to insist on CBCT for ongoing diag-
nosis 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. Refus-
ing 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 rec-
ommends grafting in advance of implant surgery, find out
how much vertical bone gain needs to be achieved. Graft-
ing is most successful for adding horizontal width to jaw-
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 implan-
tologist 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.
An issue deserving mention is the use of bisphospho-
nates like Fosamax, Boniva and Actonel to treat osteopo-
rosis and osteopenia. For several years prior to 2007, it
appeared that dental implants should be avoided if oral and
intravenous bisphosphonates were being taken, due to an
unexpected condition called osteonecrosis of the jaw
(jawbone death) reported by several dentists. Since the
growth rate for oral bisphosphonate treatment has been
accelerating, alarms went off because a contraindication
implants – the huge population of women (and some men)
over 50.
helped the implant industry heave a collective sigh when
oral bisphosphonates were exonerated. Clinicians have
now been advised that only intravenous administration of
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, Hun-
gary, 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 correc-
tive 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.
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 clini-
cians are the supervising instructors. Costs are sometimes
less than half the commercial rate. These schools also offer
8

If something goes terribly wrong
after you've returned home (for ex-
ample, 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 radiol-
ogy reports to help diagnose and guide the surgery. Pa-
tients 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.
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=cbct-
clinician/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/84113-
Dental+homepage.html
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.jmorita-
mfg.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
Implantologists Who Support 3D
3D technology continues to gain traction around the globe
at the same time that an increasing number of general den-
tists are starting to place implants, often with minimal train-
ing. 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 prost-
hodontists.
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 arti-
cle in a future revision. Simply send an e-mail to:
murry1@sbcglobal.net
Include your contact information and locations.
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” men-
tality, accompanied by too little training.
Sadly, some fraction will be victims of negligence. For ex-
ample, the patient involved in the nerve penetration situa-
tion portrayed in many of this article's examples discovered
that the implantologist rushed through the surgery, includ-
ing 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 overheat-
ing 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
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 sub-
sequent 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.
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Some attorneys are also licensed dentists, im-
parting 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
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A updated version of this article as well as a companion directory of CBCT implantolo-

gists, 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

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