Efficient, Simplified and Productive Implant Techniques for the General Practitioner

Demystifying Implantology and demonstrating how a $10,000 hourly production is achievable (even for a beginner) by Bradford Frank, DDS Remember the days of old when you scheduled an hour and a half for a crown prep? When endo was a two to three appointment ordeal? Before rotary, endo was a 3 to 5 appointment process. Yes, bonding with composite resins was once a 2 to 3 step process and, ahhh yes, to light cure took thirty seconds or more. Enter new school dental implants! Implant placement for the general dentist has become efficient and simplified in recent years and old school techniques are history. What was once a mystical and technique sensitive process is now routine, predictable, forgiving and profitable. Many techniques from orthopedic surgery have seeped into the dental implant field allowing for simplified treatment approaches. Theres nothing hotter in dentistry right now than efficient dental implant placement and restoration, from both a clinician's and a patient's perspective. To leverage is to improve, enhance or to make more efficient while efficiency is to eliminate redundant steps, reduce the time involved for each step, and to prevent redo work by doing quality work the first time. The techniques you will learn in this article will allow you to leverage all three aspects of the efficiency equation. If you already perform molar endo and extractions in your practice, implants are a very easy transition. If you already place dozens of implants monthly in your practice, you wont believe how much more efficient you can become with a few new techniques. As you become more efficient, you will simultaneously improve and enhance the implant procedure, your patients will have a better experience, and your internal referrals will go through the roof. In fact, in the Summer 2012 issue of The Profitable Dentist, Dr. Abernathy makes a statement regarding the procedure mix of the "Super General Practice". He states, "services will include Implants, C&B, sedation, TMJ, oral surgery, limited perio, orthodontics and all of the normal

general practice services." Efficient implants are one of the fastest growing sectors of the general practice today. Over the last six years of training other dentists, I have developed what I call the "universal protocols for simplified and efficient implant placement for the GP". I would like to go over some of these protocols so that you can immediately increase the level of patient care and efficiency in your practice. Debunking the Myths of Implants First, if you do little or no implants currently, I would like to debunk some "myths" about implant placement in the general practice. Myth: My specialists won't be my friends anymore.

Fact: As I have trained GPs for the last six years on how to efficiently place implants, I have discovered that GPs actually refer MORE when they begin placing implants themselves. Its all about following the 80/20 rule. Refer out 20% of your dental implant cases that could be termed "risky" or "complicated". The 80% of patients you work with will refer others. If you double or triple the overall number of patients you see, that 20% referral number becomes significant and voila, your specialists actually receive more referrals. Myth: It will interfere with my already busy practice.

Fact: Using some of the protocols in this article, a close friend of mine placed two implants with locators for a lower denture patient in an open hygiene room in less than 15 minutes total treatment time (see www.osteocoredentalimplants.com, click on videos). Using efficient techniques which lend themselves to the typical general dentistry set-up, implants should become even more routine than root canals. In fact, today the average implant placement takes 75-85% less time than the average root canal (these percentages are based on a Implant Efficiency Institute polling of GPs throughout the nation). No-Drill Implants with an Osteoconverter

Paste pic from catalog

No-drill implants using an Osteoconverter involves the extraction of a compromised tooth and the immediate placement of an implant without the use of a drill. The procedure is atraumatic and predictable. Why is this procedure preferred to using a drill in the fresh extraction site? The drilling action can fracture fragile bone around the extraction site or remove thin buccal/facial bone, which would ideally be retained around the implant. The Osteoconverter acts to expand the extraction site while keeping wanted bone intact. The Osteoconverter also scores the internal aspects of the extraction site in roughly 1mm increments which increases blood flow to the implant interface. This improves osseointegration and provides bone expansion which converts the irregular root circumference oval shape into a cylindrical shape that is accommodating to the implant. The Osteoconverter has a flat end much like an osteotomb so in areas just inferior to the maxillary sinus, it gently converts the socket site without damaging the fragile sinus floor. The Osteoconverter also serves as a measuring device; once the socket site has been converted, a simple measurement is made in order to select the correct size implant. It certainly sounds nice to avoid picking up a drill when placing implants, but what are some contraindications to this procedure? Perhaps the most common is acute infection around the apex of the tooth. Experienced Implantologists often clean out the infected area and place the implant directly into the area that had infection. In fact, The Journal of Periodontology published a study in 2001 with the following conclusion: "The present study shows that when a screw-type dental implant is placed without the use of barrier membranes or other regenerative materials into a fresh extraction socket with a bone-to-implant gap of 2 mm or less, the clinical outcome and degree of osteointegration does not differ from implants placed in healed, mature bone."1 Therefore the use of bone grafting materials or membranes is not necessary for superior outcomes. Interestingly the majority of the teeth had long-term infection associated with the tooth. It has been found that implants are very resistant to infection in socket sites due to the fact that bacteria can not feed on titanium so once the source of the infection is gone, the tooth, the area is quickly exterminated of remaining bacteria by killer T cells and lymphocytes. What if the root is too short to place what you think to be an ideal sized implant? Drilling beyond the apex for a sufficient length with the pilot drill will solve that issue. In these cases it is prudent to under prepare (use one size smaller drill) beyond the apex and use the Osteoconverter to convert the site. This will assure primary stability and an excellent success rate. If the apex of the socket site is right against the floor of the sinus, like many are, the Osteoconverter will gently push against the sinus floor and allow for the apex of the implant to be even with the floor

of the sinus or less than 2mm. The cells between the sinus membrane and bone on the sinus floor are highly bone-forming. This will provide for bone at the apex of the implant. This PANO of full maxillary extractions and four implants with locator abutments to retain an upper prosthesis was placed without the use of a drill. A general trend with implantologists today is to size the implant to accommodate available bone rather than manipulating the bone to accommodate a certain size implant. This basically means that you and I do not need to jump into a variety of advanced/technique sensitive procedures to successfully place implants in today's practice. This means we do not need to be bone grafting experts to successfully place implants. Additionally we do not need to press the limits with vital structures. Here is an example with which we can all relate. Case Study # 1 #15 on a bridge spanning #13-#15 is lost due to a combination of secondary decay and periodontal issues. Not long ago the preferred treatment for most would have been extraction of #15 and a sinus lift/bone graft procedure to create enough vertical bone for 10-13mm implants to be placed. A simplified approach involves 5.7mm wide by 8mm long implants to avoid more extensive, expensive and uncomfortable sinus bone grafting procedures for the patient. One may say, "Isnt the longevity of shorter implants compromised?" Multiple studies regarding the longevity of implants in relation to length have been conducted and all seem to point to a nearly identical, extremely high success rate. The JOMI in 2006 Published an article that proved both long and short term success rates to be around 97%. Most applications of "short implants" in the 8 mm range include the maxillary and mandibular posterior areas where the sinus and mandibular nerve come into play. Armed with studies proving the efficacy of "short" implants, a general dentist does not need to flirt with anatomical structures to provide great, predictable patient care. Always staying 3-4 mms away from the mandibular nerve and keeping the apex of the implant embedded in the cortical plate of the sinus are great rules of thumb to avoid anxiety. In fact, I often speak of the 6mm rule when the mandibular nerve is in the same sentence. Human error can be up to 3 mms so if you follow the 6 mm rule and always try to stay that distance from the nerve then if human error occurs you have at least a 3 mm safety zone.

Another key to implant efficiency is eliminating redundant steps. One of the luxuries of placing implants to accommodate available bone rather than grafting to try to create bone is the ability to be minimally invasive and reduce or eliminate the need for sutures. When flapless techniques are used, it makes sense to take the final prosthetic impression immediately after implant insertion. This saves the patient an appointment and allows the clinician to charge less for the total procedure, if desired. I have personally trained dozens of dentists over the shoulder on how to perform minimallyinvasive implant surgeries. I have found it to be much more efficient and user-friendly to incorporate commonly used general dentistry tools and equipment into the implant armamentarium. For instance, the initial gingival access and pilot hole can be most accurately performed using a high-speed hand piece and a special gingival contouring/bone removal bur (pictured close-up from implant tray set-up). This makes sense since the high-speed is almost part of the GPs anatomy and is within their comfort zone. I have found that a special composite instrument that is nearly as sharp as a bared-Parker blade is also an instrument of choice for minimally-invasive keritinized tissue repositioning. Case Study #2

The PAN pictured is an example of a flapless lower four implant case on an edentulous

individual who was having trouble retaining a lower denture. Several efficiency techniques were used which allowed this case to be completed in 20 minuted of surgical time. Mental foramen locators were used after the patient was anesthetized to confidently position the implants. The MFLs were inserted into the keratinized gum tissue after palpating the mental foramen with the index finger (feels like a depression with a small, movable cyst). The brass MFL locators allow a clinician to accurately assimilate the location of the mental foramen without laying a flap. This was a technique I developed in 2005 and have placed thousands of implants since then on edentulous ridges without mandibular nerve issues. (E-mail if you would like to view top advertisements to attract patients like this.) No flap benefits include decreased healing time, increased patient comfort, and reduced time in the chair and reduced chance of infection. Implant surgery has evolved to be less invasive. Just like many medical procedures, techniques have developed where point-of-entry incisions are much smaller. Arthroscopic surgery requires

very small incisions, like in the case of "flap-less" implant placement. I will go over the top 5 "flap-less" techniques most general dentists prefer in the US today. Let's discuss the benefits to both the patient and clinician associated with the 5 non-flap approaches. First, reduced treatment time is better for both doctor and patient. Experienced general practitioners are able to complete the entire implant surgical procedure in the same amount of time or less than it takes to complete an occlusal resin. Second, minimal bone exposure related to non-flap procedures reduces the opportunity for oral microflora to contaminate the site. Thirdly, because most post-operative discomfort associated with implants is related to soft tissue manipulation rather than bone, there is much less postoperative pain associated with the non-flap, non-suture procedures. Fourthly, final impressions may be taken immediately after implant placement as there are no sutures to capture in the impression and soft tissue remains relatively undisturbed. Finally, with increased time savings patients benefit by reduced procedure fees. Thus, implant dentistry becomes more available to the general public. Non-flap (flapless) Approaches

In 2002 The Journal of Maxilofacial Implants published a retrospective clinical analysis of implants placed with a flapless approach and found the implants to have a nearly identical success rate to those placed with a flap. 3

1) High-speed approach: One of the advantages of being a general dentist is that we get good at using the high-speed hand piece. In fact, it is the tool that dentists use that can be the most exacting in our hands. I have found that dentists using this technique are both efficient and have excellent placement of the implant from both a surgical and prosthetic standpoint. Basically, both the soft tissue entry and the initial 3-6 mms of the pilot hole are performed at the same time with the

same bur. The high speed approach was used in the implant bridge pictures #12-#15 adjacent. a) Benefits to patient over traditional flap: much faster healing time and less discomfort due to minimal soft tissue trauma. a) Benefits to clinician: efficient, fewer instruments used, less chance of infection, more assistant-friendly and opportunity to take final impression for crown/other prosthetics immediately after implant is placed. a) Contraindications: As we all know, it is important to maintain a sufficient buccal/facial cuff of keritinized tissue around the implant. If keritinized tissue is minimal, then the high-speed approach may be combined with a mini-envelope incision. A friend of mine, Dr. Chris Griffin, made the below comment at the end of his first day of implants. Many of his procedures involved the highspeed technique above. I just want to thank Dr. Brady Frank so much. Id never done one implant in my whole life , Id always been too scared. But Dr. Frank came down here today and from 8:00am to 3:00pm we did 14 implants, $60,000 worth of production this is amazing! Ive never done anything like this before. I cant wait to do more of them. 2) Mini-envelope incision: In simple terms, a mesio-distal incision is made with the goal of maintaining at least 2 mms of keritinized tissue on the buccal/facial. An instrument is used to release the attached tissue from the bone . Then the pilot hole may be initiated through the envelope directly on the bone. This technique is most commonly used on the mandible. Notice in the picture of #18 and #19 shortly after implant placement that there is no blood and tissue is in ideal condition for a final prosthetic impression. 3) Frank finger graft: This is a wonderful technique for providing soft tissue closure in the case of immediate placement into an extraction socket. After the implant is placed simply incise a 3mm band of keritinized tissue adjacent to the area where the most space exists between the implant and socket wall. Here is the key, leave one side of the band of tissue attached to maintain blood supply and to allow for easy manipulation around the implant. This will also aid in the retention of any bone graft material that is placed in the socket. This procedure facilitates a one vs. two stage surgery.

4) Tissue punch (trephine bur or cookie-cutter): Essentially this technique removes a circular piece of tissue from the intended osteotomy site. This may seem easy enough but there are a couple of contraindications to this approach. First, it does not allow for the maximal retention of keritinized tissue. Secondly, if the initial pilot drill is not centered exactly in the middle of the punch site, the implant may impinge tissue on one side and be void of tissue on the other. I believe a superior approach to be the "highspeed" approach with a special implant bur in the highspeed. Direct Approach This approach tends to be the most favored by the dentists I have trained. It involves both the soft tissue access and the initial pilot hole in the bone (osteotomy) in the same motion. Killing two birds with one stone certainly makes more sense from an efficiency standpoint. For the general dentist, this is the most accurate and minimally invasive route. When a high speed, or initial implant twist drill is used to access tissue there are numerous tissue outcroppings resembling papillae which aid in a tissue seal around the implant-healing collar.

Dental Implants Trending Up Implants are the hottest topic for dental patients today so marketing is extremely effective in bringing in an abundance of new patients. Last week I was training with a practice in the Midwest. A small 4 x 6 newspaper ad for $1,100 brought over 100 calls and resulted in multiple implant cases. If you would like a copy of this ad or any other marketing material, I would be happy to share what I use in my practices. Author Bio

Bradford Frank DDS Bio.

Over the last ten years, Dr. Frank has owned and managed multiple practices. Dr. Frank is a sought after speaker and Continuing Education trainer, and has addressed thousands of dentists at popular seminars throughout the country including Excellence in Dentistry,Phasing-Out Seminars (over 20 presentations delivered), and Schein/Camlog

Seminars. Dr. Franks topics include Implantology, Dental Transitions, and Entrepreneurial Satellite Practice Ownership. Dr. Frank's implant efficiency training at the Implant efficiency Institute has been called the best in the industry. After completing the training, the average dental practice increased by twenty six percent in the first year. Dr. Frank's unique 12 module system allows a general dentist to become completely comfortable and confident in providing simplified, efficient, lifetime implant solutions to patients. Dr. Frank is uniquely qualified as an implant trainer in that he has placed thousands of implants in his home practices and has contributed several inventions to the field of implant dentistry. Graduates of Dr. Frank's 2-day mini-residency become well versed in no-drill implants, the 5-minute implant, abutment and crown procedure and the top 5 flapless/no-suture/minimally-invasive implant techniques. Dr. Frank is Chairman of the Board of Advisors for OsteoCore Dental Implants, a cutting-edge implant company emphasizing a simplified approach with interchangeable prosthetic abutments to predictably and efficiently address any clinical situation. To reach author email info@osteocoredentalimplants.com or call Kelli 541-864-0312

1. Immediate Implantation in Fresh Extraction Sockets. A Controlled Clinical and Histological Study in Man Dr. Michele Paolantonio, Marco Dolci, Antonio Scarano, Domenico D'Archivio, Giacinto Di Placido, Vincenzo, Adriano Piattelli Journal of Periodontology Vol. 72, No. 11, 1560-1571(Volume publication date: November 2001) DOI: 10.1902/jop.2001.72.11.1560 2: Murray Arlin published an article in JOMI 2006 Sep-Oct; 21(5):769-76).

3: Int J Oral Maxillofac Implants. 2002 Mar-Apr;17(2):271-6. Flapless implant surgery: a 10-year clinical retrospective analysis. Campelo LD, Camara JR. ref http://bradyfrankdentist.wordpress.com/2012/06/20/brady-frankdentist-course-description/