the keyless partially guided implant protocol · the journal of implant & advanced clinical...

The Journal of Implant & Advanced Clinical Dentistry

Volume 7, No. 8 october 2015

The Keyless Partially Guided Implant Protocol

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The Journal of Implant & Advanced Clinical Dentistry • 3

The Journal of Implant & Advanced Clinical DentistryVolume 7, No. 8 • october 2015

Table of Contents

11 Utilization of the Co-Axis Dental Implant to Avoid Sinus Augmentation: A Case Report Gregori M. Kurtzman, Douglas F. Dompkowski

25 The Keyless Partially Guided Implant Placement Protocol: Success Rate and Complications Amr Hosny Elkhadem

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Table of Contents

For more information, contact BioHorizonsCustomer Care: 1.888.246.8338 or shop online at www.biohorizons.com

SPMP12245 REV A SEP 2012

make the switch

The Tapered Plus implant system offers all the great benefits of BioHorizons highly successful Tapered Internal system PLUS it features a Laser-Lok treated beveled-collar for bone and soft tissue attachment and platform switching designed for increased soft tissue volume.

Laser-Lok® zoneCreates a connective tissue seal and maintains crestal bone

platform switchingDesigned to increase soft tissue volume around the implant connection

optimized threadformButtress thread for primary stability and maximum bone compression

prosthetic indexingConical connection with internal hex; color-coded for easy identification

33 Immediate Implant Placement with a Novel Approach to get Adequate Soft Tissue Coverage: A Case Report Dr. Ahmed Yaseen Alqutaibi, Dr. Iman Radi, Dr. Ahmed Fyad, Dr. Khalid Zekry

39 Factors Influencing Patients’ Acceptance of Treatment Plans at a Private Periodontal Practice Ahmad Soolari, Nafiseh Soolari, Habibeh Shams, Jasim M. Albandar

49 There is no Appropriate Evidence to Recommend or Discourage the use of Tilted Dental Implants to Enhance the Survival Rate of Dental Implants in Atrophic Jaws Dr. Ali Abdulghani Alsourori, Dr. Adnan Abdullah Naje Alfahd

42 • Vol. 7, No. 7 • September 2015

rated their economic status as “average.” Treatments performed included nonsurgical

methods, crown lengthening, osseous surgery, soft tissue grafting, periodontal tissue regen-eration, alveolar ridge augmentation, implant placement or treatment of implant-related com-plications, extractions of teeth, and/or prepro-sthetic surgery. Ninety-five percent of patients

completed treatment in 7 or fewer visits. The cost of treatment ranged from US$890 to US$37,000. Most patients had some insur-ance coverage but were still financially respon-sible for a substantial portion of treatment. On average, insurance covered only 28.3% of the treatment cost. Eighty-six percent of the patients had been referred by general dentists.

Table 1: Demographics of Patients who Accepted or Declined the Recommended Periodontal Tretment Plan

Response to Recommended Treatment Plan

Demographics Accepted Declined p

Gender Females No. 56 9

% 46.7 50.0 0.8

Males No. 64 9

% 53.3 50.0

Ethnicity Caucasian No. 51 0 0.0008

% 42.5 0

African-American No. 34 11

% 28.3 61.1

Hispanic or No. 22 2

Mexican-American % 18.3 11.1

Others* No. 13 5

% 10.8 27.8

Age (years) Mean 54.8 47.3 0.04

S.D. 14.4 14.0

* Mainly Middle-Eastern or Asian

Soolari et al

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Kurtzman et al

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Kurtzman et al

Typically as teeth are lost in the poste-rior maxilla, the maxillary sinus enlarges (pneumatization) over time. This phe-

nomenon also occurs with aging. Enlargement of the sinus presents challenges to implant placement in the posterior and frequently aug-mentation of the sinus is required to provide sufficient bone circumferentially around the implant. Sinus augmentation delays loading of the implant as the bone graft needs to mature and increase in density around the implant when placed simultaneously at implant place-

ment. Mesial or distal tipping of a standard implant avoiding the sinus because it requires the fabrication of custom abutments in an attempt to achieve a parallel path of draw for the prosthesis whether a cement or screw retained prosthesis is to be employed. The Co-Axis implant (Keystone Dental, Inc. Bur-lington, MA), a unique implant incorporates an angle correction in the platform which allows off-axis placement to avoid anatomical features such as the maxillary sinus. The following case report demonstrates use of this implant system.

Utilization of the Co-Axis Dental Implant to Avoid Sinus Augmentation: A Case Report

Gregori M. Kurtzman, DDS, MAGD, DICOI1 • Douglas F. Dompkowski, DDS2

1. Private practice, Silver Spring, Maryland, USA

2. Private practice, Bethesda, Maryland, USA

Abstract

KEY WORDS: Dental implant, maxillary sinus, off-axis, tilting


12 • Vol. 7, No. 8 • October 2015

INTRODUCTION:Typically as teeth are lost in the posterior max-illa, the maxillary sinus enlarges (pneumatiza-tion) over time. This phenomenon also occurs with aging. Enlargement of the sinus pres-ents challenges to implant placement in the posterior and frequently augmentation of the sinus is required to provide sufficient bone cir-cumferentially around the implant. Sinus aug-mentation delays loading of the implant as the bone graft needs to mature and increase in density around the implant when placed simultaneously at implant placement.1,2 This sometimes is not possible when insufficient bone height is present for initial stability of the implant at placement leading to further delays to completing treatment. Additionally, grafting increases the costs associated with treatment.

A SOLUTION TO SINUS AVOIDANCE

Mesial or distal tipping of a standard implant avoiding the sinus because it requires the fab-rication of custom abutments in an attempt to achieve a parallel path of draw for the prosthe-sis whether a cement or screw retained pros-thesis is to be employed. Off-axis or “tilted” implant placement has been utilized for many years to work around the patient’s anatomy.3,4

However, these have created prosthetic com-plications related to the angulation of the implant plateform often requiring use of additional parts (i.e.multi-abutments) that decreases the avail-able vertical height for the prosthetics and increases the cost of restoration of the implants.5

Implants placed into the pterygomaxillary region were have been used for more than 20 years in an attempt to avoid an enlarged max-illary sinus.6 These pterygomaxillary implants

Figure 1: Co-Axis implants demonstrating the 12 degree (left) and 24 degree (right) implants fixture and prosthetic axis in relation to the implants platform.

Figure 2: Co-Axis implant with fixture mount and orientation dimple to aid during placement to angle the plateform in the desired direction.

Kurtzman et al


allow for the placement of implants in the poste-rior maxilla without the use of sinus augmentation procedures or other types of bone grafts. Zygo-matic implants have also been proposed to avoid the sinus with placement into the zygoma using very long implants with angle corrections in the implants platform to accommodate the drastic angle these implant need to be placed. Prosthetic platforms of these implants often emerge palatal to the crestal midline complicating restoration and

may narrow the arch width with the prosthesis.7 The Co-Axis implant (Keystone Dental, Inc.

Burlington, MA), a unique implant incorporates an angle correction in the platform which allows off-axis placement to avoid anatomical features such as the maxillary sinus8,9 (Figure 1). This implant was introduced in Europe in 2003 and approved in 2007 by the FDA for use in the USA. The implant is available with an external hex connec-tor in 4.0, 5.0 and 6.0mm diameter (12 degree

Figure 3: Co-Axis implants placed into the pterygoid area of the tuberosity and angled anteriorly to avoid the enlarged maxillary sinus while maintaining parallel prosthetic axis.

Figure 4: Patient without her maxillary removable partial denture and prior crowns present on the lateral incisors which do not match the shade of the natural central incisors.

Figure 5: CBCT panoramic view with clear surgical guide with markers embedded in the guide.

Figure 6: Clear replica of the patient’s partial denture with gutta percha cones at the sites and an angled cone in posterior to check orientation of the mesial wall of the sinus.

Kurtzman et al

14 • Vol. 7, No. 8 • October 2015

correction) and 5.0 and 6.0mm diameter (24 degree correction). A trilobe connector is avail-able in a 12 degree in both a 4.3mm (plat-form is a 3.5mm) and a 5.0mm (platform is a 4.3mm). Also an internal octagon (hex) is avail-able in a 5.0mm (platform is a 4.8mm) option.

Surgical placement of this unique implant does require minor modifications to the pro-cedure when placing the fixture. An orienta-tion dimple is found on the fixture mount, which

is rotated as the implant is placed to orien-tate the angled platform. This is performed so that the implants achieve parallelism between the implant platforms regardless which direc-tion the fixture axis is oriented (Figure 2). With proper orientation a screw-retained prosthe-sis may be utilized with the screw access holes on the occlusal surface of the abutment crowns. If a cemented prosthesis is desired, often stock abutments may be used instead of

Figure 7: Clear replica of the patients partial denture with gutta percha markers being used as a surgical guide to start osteotomies on the right quadrant.

Figure 8: Pilot drill forming initial osteotomy at site #6.

Figure 9: Osteotomy being prepared at site #3 with a pilot drill and guide pin at site #6.

Figure 10: A 24 degree guide pin in site #3 and 12 degree guide pin in site #6 checking parallelism after pilot drill use.

Kurtzman et al


custom abutments lower the restorative costs. The Co-Axis implant may be placed by

tipping the posterior fixture mesially and the anterior fixture distally, bridging the enlarged sinus when adequate bone is avail-able mesial and distal to the sinus (Fig-ure 3). This permits the prosthetic axis of the implants to be parallel, simplifying the restorative phase and eliminating the need for multi-abutments or custom abutments.

CASE REPORT:A 74 year old female presented with the com-plaint that her maxillary removable partial denture was bothering her with minimal retention and she was interested in a fixed implant bridge bilater-ally. Examination noted the only remaining teeth in the maxillary arch were the lateral and central incisors bilaterally. The incisors demonstrated no mobility or bleeding on probing. The laterals had been restored previously by another dentist with

Figure 11: 24 degree guide pin inserted into preliminary osteotomy made with pilot drill to check orientation in relation the mesial wall of the maxillary sinus on the right quadrant.

Figure 12: Osteotomy being completed at site #6 with angulation palatally.

Figure 13: 12 degree 5.0mm wide Co-Axis implant with fixture mount in handpiece ready to be inserted.

Figure 14: 12 degree 5.0mm Co-Axis implant placed into site #6 (fixture mount still attached).

Kurtzman et al

16 • Vol. 7, No. 8 • October 2015

PFM crowns which were much whiter then her natural teeth. The patient expressed she was not interested in changing the crowns to a shade matching the central incisors and indicated she wished the bridges to be fabricated to match the shade of the two crowns (Figure 4). A panoramic radiograph was taken to access available bone and the maxillary sinus (Figure 5). Radiographi-cally, fully impacted 3rd molars bilaterally were identified. Due to the lack of pathology and the patient’s age it was decided to not treat the 3rd maxillary molars and keep them under observation.

A replica of the current maxillary remov-able partial denture was created using a Lang denture duplicator (Lang Dental Manufacturing Co, Wheeling, IL) and clear Jet Tooth Shade™ acrylic (Lang Dental Manufacturing Co.). Gutta percha cones were luted to the clear denture replica at the canines and the 1st molars bilater-ally, with a cone at the estimated location based on the panoramic of the mesial wall of the sinus (Figure 6). A cone beam radiograph (CBCT) was taken and the cone positions were evalu-ated in relation to the sinus and other anatomy.

Figure 15: 24 degree guide pin placed into site #3 to check parallelism with the prosthetic axis of implant at site #6.

Figure 16: Osteotomy being completed for site #3 being completed to accept a 5.0mm diameter 24 degree Co-Axis implant.

Figure 17: 5.0mm diameter 24 degree Co-Axis implant with fixture mount on the handpiece ready to be inserted.

Figure 18: Implant being inserted with the handpiece into site #3.

Kurtzman et al


Figure 19: Occlusal view of the right quadrant following implant placement with fixture mount on both implants showing the orientation of the fixture and the corrected prosthetic axis.

Figure 20: Hand drivers engaging the implants at sites #3 and #6 demonstrating parallelism of the prosthetic axis.

Figure 21: 24 degree 5.0mm Co-Axis implant placed at site #3 skirting the mesial wall of the maxillary sinus.

The patient was scheduled for implant sur-gery and a local anesthetic (4% Septocaine with 1:100,000 epi) was administered at the appoint-ment using local infiltration. The clear replica which had parallel holes drilled at the canine and 1st molar locations through the acrylic bilaterally was inserted and a pilot hole just penetrating the crestal bone was made with a 2.0mm pilot drill at the two sites in the right quadrant (Figure 7). The surgical guide was removed and the osteotomy at site #6 was corrected to a 12 degree orientation with tipping the site to the palatal (Figure 8). The osteotomy at site #3 was oriented at 24 degrees tipping the site to the distal to skirt the mesial wall of the sinus to a depth of 4mm. A 12 degree guide pin was placed into site #6 and a 24 degree pin

inserted into site #3 and periapical radiographs taken to check the initial osteotomies in relation to the mesial sinus wall and other anatomy (Fig-ures 9 - 11). A mid-crestal incision was made with a vertical releasing incision distal to the lat-eral incisor and a full thickness flap was reflected.

Sequential osteotomy drills were utilized to prepare site #6 to accommodate a 5.0mm x 11.5mm implant (Figure 12). A 12 degree Co-Axis implant with an external hex connection was

Kurtzman et al

18 • Vol. 7, No. 8 • October 2015

Figure 22: 12 degree 5.0mm Co-Axis implant placed at site #6.

Figure 23: 12 degree 5.0mm Co-Axis implant placed at site #11.

carried to the mouth on the fixture mount in the handpiece (Figure 13) and inserted at 20 rpm until the surgical motor reached 45 Ncm (Fig-ure 13). Final insertion was made with a hand wrench until the implant was seated and the ori-entation dimple was centered on the mid-facial orienting the prosthetic axis to the vertical axis (Figure 14). The 24 degree guide pin was placed into site #3 to verify that the orientation would be parallel with the prosthetic axis of the implant at site #6 (Figure 15). The osteotomy was com-pleted at site #3 to accommodate a 5.0mm x 13mm implant (Figure 16). A 24 degree Co-

Axis implant with an external hex connector with a fixture mount attached was placed into a hand-piece (Figure 17) and inserted into the osteotomy to full depth (Figure 18). The orientation dimple was placed at the distal to orient the prosthetic axis to be parallel with the implant at the canine site (Figure 19). Hex wrenches were inserted into both implants to verify parallelism (Figure 20).

A periapical radiograph was taken of the implant at site #3 which demonstrated the implant placement paralleled the mesial sinus wall with-out perforating the sinus during placement (Fig-ure 21). A radiograph was taken of the implant

Kurtzman et al


Figure 24: 24 degree 5.0mm Co-Axis implant placed at site #14 skirting the mesial wall of the maxillary sinus.

Figure 25: CBCT panoramic view following 4 months of healing of the implants demonstrating integration and ready to begin the restorative phase of treatment.

Figure 26: Completed screw retained zirconia bridges on the master model with soft tissue removed.

Figure 27: Radiograph verifying the fit of the prosthetics in the upper right quadrant to the Co-Axis implants that have been platform switched.

at site #6 to verify placement (Figure 22). Cover screws were placed and the site was closed with interrupted sutures. The surgical guide was rein-serted and the procedure was repeated in the left quadrant. Periapical radiographs were taken

of the implant at site #11 (Figure 23) and site #14 (Figure 24) demonstrating placement of the molar implant avoided the left mesial wall of the sinus. The quadrant was again sutured to close the flap. All implants were treated in a two stage

Kurtzman et al

20 • Vol. 7, No. 8 • October 2015

Figure 28: Radiograph verifying the fit of the prosthetics in the upper left quadrant to the Co-Axis implants that have been platform switched.

Figure 29: Buccal view of the screw retained zirconia bridges on canine to 1st molar bilaterally matching the shade of the patient’s current crowns on the lateral incisors.

protocol. The old partial was relined with a soft silicone denture liner (GC RELINE™ Ultra Soft, GC America) to avoid premature loading of the implants during the healing phase of treatment.

Following four months of healing, a new CBCT scan was performed to check integra-tion of the implants (Figure 25). Local anesthetic (4% Septocaine with 1:100,000 epi) was admin-istered and a mid-crestal incision was made and the soft tissue reflected to expose the cover screw on each implant. The cover screw was removed and a 4mm tall healing abutment was inserted and full seating verified by radiograph. It was noted that the healing abutment at site #6 was not seated fully and it was removed and the bone was recontoured on the mesial aspect to allow the healing abutment to completely seat and a new radiograph was taken. The 5.0mm diameter implants were platform switched to a 4.0mm restorative platform.10 Sutures were placed adapting the soft tissue around the heal-

ing abutments and the patient was dismissed.A week later the patient presented and

sutures were removed and the tissue was allowed to further mature for 2 additional weeks. At this appointment, the healing abutments were removed and open tray impression abutments were inserted into each implant and seating was verified radiographically. A Miratray Advanced impression tray (Hager Worldwide, Hickory, NC) was filled with Aquasil Ultra heavy superfast set VPS (Dentsply Caulk, Milford, DE) was dispensed from an automix cartridge into the tray and Aqua-sil LV superfast set VPS (Dentsply Caulk) was syringed around the gingival aspect of each of the impression abutments intraorally. The tray was seated until the long pins on the impression abut-ments pierced the clear plastic on the occlusal aspect of the Miratray and allowed to set. Upon setting, the pins were unscrewed and the tray was removed. The healing abutments were rein-serted and an interocclusal record was taken with

Kurtzman et al


Regisil® Rigid bite registration VPS (Dentsply Caulk) with the patient occluding with her ante-rior natural maxillary incisors in contact with the lower anterior teeth. A counter full arch impres-sion was taken and sent to the lab for fabrication of the prosthetics. A shade had been selected to match the crowns present on the maxillary lateral incisors per the patient’s request. The existing partial denture was relieved to allow the remov-able prosthesis to seat fully without contact on the healing abutments. Permasoft™ (Dentsply Prosthetics, York, PA) soft denture reline material was mixed to a thicker consistency and placed into the saddle area bilaterally and the partial denture was reseated and patient instructed to occlude. Upon setting the relined prosthesis was removed and excess material trimmed with a scalpel. The provisional partial denture was rein-serted and checked for comfort and occlusion.

The lab created a soft tissue model of the maxillary arch utilizing the open tray impression after analogs had been attached to the impres-sion abutments within the impression. The case was mounted with the provided interocclusal record. A scanning base (Glidewell Labs, New-port Beach, CA) specific to each implant were inserted into each implant analog and the model was scanned to create a virtual model. Upon that a full contour bridge was created in the computer and sent for milling. The milling center milled the zirconia full contour bridges and returned them to the lab. The lab removed the soft tissue from the model and inserted a titanium base (Glidewell Labs) on each analog. The interior of the zirconia bridge where it would contact the titanium base was cleaned by means of blasting with Al2O3. Monobond Plus (Ivoclar Vivadent Inc., Amherst, NY) was applied on the clean bonding surface of

the zirconia and to the titanium base and allowed to react for 60 seconds then air dried. The screw access hole in the titanium base was blocked by wax to prevent resin from occluding the screw and a thin layer of Multilink® Hybrid Abutment resin cement (Ivoclar Vivadent Inc.) was applied from the automix syringe directly to the bond-ing surfaces of the base and the ceramic struc-ture. The parts are lightly pressed together in the correct relative position of the components and held together for 5 seconds. Glycerine gel was applied on the cementation joint to prevent the formation of an inhibition layer and the cement was allowed to auto polymerize for 7 minutes. After auto-polymerization completed, the glycer-ine gel was rinsed off with water. Any cement in the screw access hole was removed as well as the wax and the bridge was removed from the model. The cementation joint was then polished with rubber polishers at a low speed (< 5,000 rpm) to avoid overheating and the bridges were returned to the dentist for insertion (Figure 26).

The bridges were returned and the heal-ing abutments were removed on the right quad-rant. The right side bridge was inserted and two titanium fixation screws specific to the Co-Axis implants where tightened by hand. Radiographs were taken to verify complete seating of the bridge with the implants (Figure 27). The fixation screws were tightened to 30Ncm with a torque wrench. The process was repeated for the left quadrant (Figure 28). A piece of teflone (plumbers) tape was made into a ball and inserted into each of the bridges screw access holes. GRADIA® DIRECT LoFlo (GC America, Alsip, IL) a light-cured, high viscosity flowable microfilled hybrid composite was injected to fill each screw access hole to the occlusal level and then light-cured. Occlusion was

Kurtzman et al

22 • Vol. 7, No. 8 • October 2015

checked and adjusted as needed (Figure 29). The patient returned at 1-week post insertion to check the occlusion. At this time she indicated she was comfortable and reported no issues with the prosthetics. No occlusal adjustment was needed after verification with articulating film.

CONCLUSION:Utilization of angled implants to bypass the need for sinus augmentation has been shown to decrease the treatment needed as well as the time required to complete treatment and costs involved. Yet, prosthetic complications can result in restoring the case as the prosthetic axis match-ing the fixture axis may preclude a screw retained prosthesis due to emergence of the screw hole at the buccal/facial leading to esthetic issues or the distal making it difficult to insert the wrench. Multi-abutments can be utilized but this increases the cost of treatment and decreases the avail-able interarch space available for the prosthetics.

The Co-Axis implant circumvents these potential issues with its 12 or 24 degree angle correction incorporated into the implant plat-form. This allows angled placement of the implant with proper positioning of the pros-thetic axis in the ideal position of the occlu-sal or lingual surfaces. This provides a simpler prosthetic fabrication with maximized esthet-ics and lower treatment costs to the patient. ●

Correspondence:Dr. Gregori Kurtzman3810 International DriveSuite 102Silver Spring, MD [email protected]

Acknowledgment:The authors would like to thank Rick Knecht at RGK Dental Labs (www.rgkdentallab.com) for the prosthetic fabrication of the case illustrated.

References:1. Gulsahi A.: Bone Quality Assessment for Dental Implants. Implant Dentistry

– The Most Promising Discipline of Dentistry, 2011, Chap 20, 439-452.

2. Sogo M, Ikebe K, Yang TC, et. al.: Assessment of bone density in the posterior maxilla based on Hounsfield units to enhance the initial stability of implants. Clin Implant Dent Relat Res. 2012 May;14 Suppl 1:e183-7. doi: 10.1111/j.1708-8208.2011.00423.x. Epub 2011 Dec 16.

3. Barnea E, Tal H, Nissan J, et. al.: The Use of Tilted Implant for Posterior Atrophic Maxilla. Clin Implant Dent Relat Res. 2015 Apr 8. doi: 10.1111/cid.12342.

4. Chrcanovic BR, Albrektsson T, Wennerberg A.: Tilted versus axially placed dental implants: a meta-analysis. J Dent. 2015 Feb;43(2):149-70. doi: 10.1016/j.jdent.2014.09.002. Epub 2014 Sep 17.

5. Jivraj S, Chee W.: Treatment planning of implants in posterior quadrants. British Dental Journal 201, 13 - 23 (2006) doi:10.1038/sj.bdj.4813766

6. Graves SL. The pterygoid plate implant: a solution for restoring the poste-rior maxilla. Int J Periodontics Restorative Dent. 1994;14(6):512-523.

7. Farzad P, Andersson L, Gunnarsson S, Johansson B.: Rehabilitation of severely resorbed maxillae with zygomatic implants: an evaluation of implant stability, tissue conditions, and patients’ opinion before and after treat-ment. Int J Oral Maxillofac Implants. 2006 May-Jun;21(3):399-404.

8. Kurtzman GM, Dompkowski DF, Mahler BA, Howes DG.: Off-Axis Implant Placement for Anatomical Considerations Using the Co-Axis Implant. Inside Dentistry May 2008, Volume 4, Issue 5

9. Vandeweghe S, Cosyn J, Thevissen E, Van den Berghe L, De Bruyn H.: A 1-year prospective study on Co-Axis implants immediately loaded with a full ceramic crown. Clin Implant Dent Relat Res. 2012 May;14 Suppl 1:e126-38. doi: 10.1111/j.1708-8208.2011.00391.x. Epub 2011 Oct 18.

10. Chrcanovic BR, Albrektsson T, Wennerberg A.: Platform switch and dental implants: A meta-analysis. J Dent. 2015 Jun;43(6):629-46. doi: 10.1016/j.jdent.2014.12.013. Epub 2015 Jan 2.

Kurtzman et al

The Journal of Implant & Advanced Clinical Dentistry • XX

Kurtzman et al

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References: 1Sanz M, et. al., J Clin Periodontol 2009; 36: 868-876. 2McGuire MK, Scheyer ET, J Periodontol 2010; 81: 1108-1117. 3Herford AS., et. al., J Oral Maxillofac Surg 2010; 68: 1463-1470. Mucograft® is a registered trademark of Ed. Geistlich Söhne Ag Fur Chemische Industrie and are marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. ©2010 Luitpold Pharmaceuticals, Inc. OHD240 Iss. 10/2010

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Elkhadem et al

Elkhadem et al

Background: to describe the con-cept and use of a simplified keyless guided implant placement system in partially and completely edentulous patients.

Methods: 89 implants were placed in 23 patients (7 complete, and 16 partial cases) using the universal simple guide kit. After CBCT and virtual implant planning, surgi-cal guides with c-shaped sleeves were con-structed. The implants were placed using flap or flapless approach according to the need for soft or hard tissue augmentation. The intra-operative complications, post-operative com-plains and implant survival rate were reported.

Results: All implants demonstrated insertion torque values greater than 30 Ncm. Only few postoperative complications were reported. 98.9% of the placed implants integrated.

Conclusions: The keyless partial guid-ance using the simple guide kit and c-shaped sleeves is a promising economic alterna-tive to conventional guided approach. Fur-ther investigations are required to evaluate its accuracy and long term success rates.

The Keyless Partially Guided Implant Placement Protocol: Success Rate

and Complications

Amr Hosny Elkhadem, DDS, MSc1

1. Lecturer, Prosthodontics, Faculty of Oral & Dental medicine, Cairo University

Abstract

KEY WORDS: Computer-aided Implantology, surgical guide, open sleeve, tolerance


26 • Vol. 7, No. 8 • October 2015

INTRODUCTIONThe use of CT scans combined with computer software to plan implant cases has been pro-posed since the 1990s.1 The technique aims to provide correlation between the bone anat-omy and the desired tooth position allowing for predictable aesthetic and functional out-comes. Many authors refer to guided implant placement as a protocol that enhances the accuracy and safety of implant placement.2-4

Moreover, it allows for the minimally invasive flapless technique in many situations, which minimizes the intra-operative time, postopera-tive pain and postoperative complications.4,5

Despite of the aforementioned advan-tages the techniques is not popular among implant practitioners. This might be attributed to the higher cost and time required to plan the cases and fabricate the guides. Expensive guided implant kits with complex assortment are also mandatory.6 Additionally, the control over implant direction is usually achieved with a closed circular configuration with small drill tolerance. Using the relatively longer drills for guided systems through such closed configu-ration was always associated with accessibil-

ity problems in the posterior region for dentate patients. Such a small tolerance is manda-tory to provide accuracy, yet it is thought to block the passage of the irrigation and might cause increased incidence of implant fail-ure in dense bone and deep osteotomies7

Moreover, there is an uprising question related to the accuracy imposed by the mechan-ical tolerance of the machined components. To provide adequate precision of the guided sys-tems, a small gap of approximately 20 microns is provided between the main sleeve fixed in the guide and the removable, diameter spe-cific, keys. A similar tolerance gap is designed between the removable keys and the drills. The friction during repeated use of the keys and the drills increases the gap obviously which might contribute to increases linear and angu-lar deviation with these guided systems.8,9

When weighing the merits and demer-

Figure 1: The simple guide kit. (a) cortical drill, (b) 2.3 mm starter drill, (c,d,e) 2.2 mm pilot drill with variable lengths, (f) 2.8 mm intermediate drill.

Figure 2: Surgical guide with c-shaped sleeve establishing 3 mm facial openings for side approach of the drills.

Elkhadem et al


its of conventional guided systems one can understand why such protocol is not so pop-ular. Hence, there is a great need to pro-vide modification in the concept and design of guided surgical approach to overcome the drawbacks and maximize the benefits.

MATERIALS AND METHODSThe technique utilizes a simplified universal kit design (Simple guide kit, Dentis Co.-Ltd, Daegu, South Korea) and a modified C-shaped main sleeve. The kit design eliminates the removable keys used in conventional guided kits, and adopt the concept of guidance for the pilot and inter-mediate drills only. For all cases, the final drill-ing is done after removing the surgical guide using the conventional non-guided final drills.

The design and sequence of the simplified

kit is different from the regular guided implant drills (Fig 1). All drills are composed of cutting flutes and a smooth guiding shaft that is com-patible in size with the main sleeve of the surgi-cal guide with no removable key in between. The drilling sequences starts with a pointed drill for penetration of the cortical bone. A starter drill (2.3x8mm) is used to create an initial osteotomy inside the bone. This is followed by the use of pilot drills (2.2mm in diameter). The pilot drills have variable lengths according to the desired implant to be placed. As the pilot drill diameter is smaller than the initial osteotomy created by the starter drill, it will snap into the osteotomy engag-ing 8 mm of vertical bone height and part of its guiding shaft will engage the main sleeve of the guide. In all scenarios, a 2.8x8mm intermediate drill is used afterwards to prepare the coronal

Figure 3: Virtual implant planning for an edentulous case. Implants were placed in relation to the required prosthetic position guided by the radio-opaque scan appliance.

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28 • Vol. 7, No. 8 • October 2015

8 mm of the osteotomy. As the osteotomy path is shaped the surgical guide is removed and the final drill of the conventional kit is used to cre-ate the final osteotomy shape. This is followed by inserting the implant in the conventional non guided fashion. Additionally, the surgical guide is designed with a c-shaped metal sleeve with a facial opening (Fig 2). The opening allows for side approach of the drills and unrestricted access of the coolant. In this report, 23 cases were oper-ated. 89 implants were installed in 7 completely edentulous and 16 partially edentulous cases.

COMPLETELY EDENTULOUS CASES

37 implants were installed in 7 completely edentulous cases (two mandibular and 5 max-illary) using this technique. Preparation started by duplicating the patient denture into radio-

opaque scan appliance (Barium sulphate to acrylic resin 1:4). Holes were prepared in the tooth centre of the proposed site to facilitate its identification on the CT scan. Double scan tech-nique was performed. The first scan was done with the patient wearing the scan appliance and biting on cotton rolls allowing for teeth separation. The second scan was made for the scan appliance alone. Virtual planning was performed using Blue sky Plan (Bluesky Bio, LLD – USA). The virtual implants were placed in the required anatomical sites after correlat-ing them to the desired tooth positions (Fig 3). 3D superimposition of the scan appliance was done over the patient CT scan using a point registration technique (Fig 4). After defining the diameter, height and offset of the guiding tubes the software generated the virtual guide by binding the scan appliance to the guiding

Figure 4: Point registration of the scan appliance over the patient scan. Several points are selected to minimize the superimposition errors.

Elkhadem et al


tubes. The STL file of the guide was fabricated using additive manufacturing. C-shaped sleeves were fixed in the surgical guide and the guid-ing tubes were opened facially opposite to the sleeve openings (Fig 2). The guide was fixed in the patient mouth with 3 fixation screws and the suggested drilling sequence was applied.

PARTIALLY EDENTULOUS CASES

52 implants in 16 partially edentulous cases (7 mandibular and 9 maxillary) were placed. Patient scanning protocol differed according to the number of missing teeth and the presence of metallic restorations. In cases with few miss-ing teeth and few or no metallic restoration, the patient received a CBCT with no scan appli-ance. The patient model was scanned using a laser scanner. When the patient had multiple missing teeth and /or numerous metallic resto-rations a scan appliance with radiopaque mark-ers was first prepared. The patient had a CBCT wearing the scan appliance. Afterwards, a CBCT for the patient model with the scan appli-

ance was made for superimposition purposes. Virtual planning was done after correlating the prosthetic position to the underlying bone anat-omy. When no scan appliance existed virtual tooth setting was utilized. When designing the guide, extension over the adjacent teeth as well as part of the palatal and lingual mucosa was required to assure proper stability. All cases not requiring grafting were done in a flapless man-ner (Fig 5). In cases requiring bone grafting a flap was first raised and the guide was then used for implant placement (Fig 6). When extra security was required to fix the guide in place light-cured flowable composite was used to tem-porarily bond the guide to the supporting teeth.

RESULTSNo major intra-operative complications or problems were reported in either flap or flap-less cases. In few cases the c-shaped sleeves were detached off the guide when contact-ing the drills. The sleeves were replaced and the procedure completed. All implants dem-onstrated acceptable implant stability at inser-

Figure 5: A bilateral flapless maxillary case. Plan was made to avoid enlarged sinus on the left side (a). The guide design allowed implant placement at the tuberosity region (b).

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30 • Vol. 7, No. 8 • October 2015

Figure 6: An anterior maxillary case with labial bone deficiency. The guide was placed after flap elevation to guide ideal implant drilling (a), which was followed by GBR procedures (b).

tion (more than 30 Ncm). There was no reports of postoperative infections among all partici-pants. Only 4 patients reported postoperative pain that lasted more than one week after the surgery. The rest of the patients reported no postoperative pain or mild pain for few days. Only two case (one flap and one flapless) reported transient post-operative oedema. At the second stage, only one maxillary implant failed with overall success rate of 98.9%.

DISCUSSIONThe keyless partially guided technique seems to offer numerous advantages. First, the elimi-nation of the removable keys together with the open shaped sleeves allowed for better acces-sibility during surgery especially in the poste-rior region up to the maxillary tuberosity. The open guiding sleeves allowed also for unre-stricted access of the irrigation during drilling.

The proposed simplified approach did not compromise the control over osteotomy prep-aration at all stages of drilling. The use of a

short starter (2.3x8mm) drill created an ini-tial osteotomy channel that accommodated the smaller pilot drill. This assured dual guid-ance of the pilot drill by engaging the initial osteotomy apically and the guiding sleeve cor-onally. The path created by the pilot and inter-mediate drill is so definite that it guides further drilling with minor possibilities of introduce a change in the osteotomy direction or depth. Final drills with blunt non cutting tip are usu-ally preferred because they seem to be safer.

By eliminating the removable keys only one mechanical tolerance is present instead of the two gaps in the conventional guided approaches. Theoretically, this will reduce the mechanical tolerance error to the half. Minimiz-ing the error introduced by the bur sleeve gap is thought to be a crucial factor in reducing the intrinsic errors imposed by guided surgery 8-9

As the majority of cases were flapless, the incidence of post-operative pain and compli-cations were less.10-11 As the guide are based on 3D implant planning on CBCT, direct expo-

Elkhadem et al


sure of bone was not utilized unless soft and / or hard tissue augmentation was required. Moreover, conservative transmucosal drill-ing was used. Tissue punch was not used as there is no proven clinical advantage or impact on the implant success rate when com-pared to transmucosal drilling. On the con-trary, the increase in the size of the punched tissue is thought to increase the probing depth and crestal bone loss around implants.12

A debate exist about the accuracy of partial guidance in comparison to classical fully guided systems. While some practitioners might believe that guided final drilling and insertion signifi-cantly affect the accuracy others believe that guidance of the initial osteotomy provides suf-ficient guidance to the rest of the procedures. The clinical data regarding the survival rate and accuracy of partial versus full guidance is still sparse.13 Kuhl et al.14 evaluated the accu-racy of half versus fully guided techniques on cadaver model. They found no statistical sig-nificant difference between the two protocols. Yet, there is a need to conduct more clinical tri-als to evaluate the accuracy of both systems.

CONCLUSIONThe use of the simplified partially guided key-less approach seems to be a promising alter-native to conventional guided surgery. The technique allowed easy access to the poste-rior region with efficient delivery of the irriga-tion during drilling. The use of a small economic universal kit might encourage many practitio-ners to utilize guided surgery. Further stud-ies are required to compare the accuracy and success rate versus the conventional guided techniques and manual techniques. ●

Correspondence:Dr. Amr Hosny Elkhademe-mail: [email protected] Address: 5 jasmine buildings zahraa elmaadi- Cairo – EgyptPostal code: 11435

DisclosureThe author reports no conflicts of interest with anything mentioned in this article.

References1. Verstreken K, Van Cleynenbreugel J, Martens K, Marchal G, van Steenberghe

D, Suetens P. An image-guided planning system for endosseous oral implants. IEEE Trans Med Imaging 1998;17(5):842-852.

2. Rosenfeld AL, Mandelaris GA, Tardieu PB. Prosthetically directed implant placement using computer software to ensure precise placement and predictable prosthetic outcomes. Part 1: diagnostics, imaging, and collaborative accountability. Int J Periodontics Restorative Dent 2006;26(3):215-221.

3. Rosenfeld AL, Mandelaris GA, Tardieu PB. Prosthetically directed implant placement using computer software to ensure precise placement and predictable prosthetic outcomes. Part 2: rapid-prototype medical modeling and stereolithographic drilling guides requiring bone exposure. Int J Periodontics Restorative Dent 2006;26(4):347-353.

4. Rosenfeld AL, Mandelaris GA, Tardieu PB. Prosthetically directed implant placement using computer software to ensure precise placement and predictable prosthetic outcomes. Part 3: stereolithographic drilling guides that do not require bone exposure and the immediate delivery of teeth. Int J Periodontics Restorative Dent 2006;26(5):493-499.

5. van Steenberghe D, Glauser R, Blomback U, Andersson M, Schutyser F, Pettersson A, et al. A computed tomographic scan-derived customized surgical template and fixed prosthesis for flapless surgery and immediate loading of implants in fully edentulous maxillae: a prospective multicenter study. Clin Implant Dent Relat Res 2005;7 Suppl 1:S111-120.

6. Vercruyssen M, Hultin M, Van Assche N, Svensson K, Naert I, Quirynen M. Guided surgery: accuracy and efficacy. Periodontol 2000. 2014;66(1): 228-246.

7. Yong LT, Moy PK. Complications of computer-aided-design/computer-aided-machining-guided (NobelGuide) surgical implant placement: an evaluation of early clinical results. Clin Implant Dent Relat Res. 2008;10(3):123-127.

8. Cassetta M, Di Mambro A, Di Giorgio G, Stefanelli LV, Barbato E. The Influence of the Tolerance between Mechanical Components on the Accuracy of Implants Inserted with a Stereolithographic Surgical Guide: A Retrospective Clinical Study. Clin Implant Dent Relat Res. 2015;17(3):580-588.

9. Cassetta M, Di Mambro A, Giansanti M, Stefanelli LV, Cavallini C. The intrinsic error of a stereolithographic surgical template in implant guided surgery. Int J Oral Maxillofac Surg. 2013;42(2):264-75.

10. Hultin M1, Svensson KG, Trulsson M. Clinical advantages of computer-guided implant placement: a systematic review. Clin Oral Implants Res. 2012;23 Suppl 6:124-35.

11. Brodala N. Flapless surgery and its effect on dental implant outcomes. Int J Oral Maxillofac Implants 2009;24 Suppl:118-25.

12. Lee DH, Choi BH, Jeong SM, Xuan F, Kim HR, Mo DY. Effects of soft tissue punch size on the healing of peri-implant tissue in flapless implant surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(4):525-30.

13. Van Assche N, Vercruyssen M, Coucke W, Teughels W, Jacobs R, Quirynen M. Accuracy of computer-aided implant placement. Clin Oral Implants Res. 2012;23 Suppl 6:112-23

14. Kühl S, Zürcher S, Mahid T, Müller-Gerbl M, Filippi A, Cattin P. Accuracy of full guided vs. half-guided implant surgery. Clin Oral Implants Res. 2013;24(7):763-9.

Elkhadem et al

Alqutaibi et al

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Alqutaibi et al

One of the problems encountered with immediate implant placement is insuf-ficient soft tissue to achieve a ten-

sion free primary closure. In this case report a simple and recent approach was performed to provide sufficient primary closure at time of immediate implant placement. A 38-year-old nonsmoking medically fit female patient pre-sented to Prosthodontics Department, Faculty of Dentistry, Cairo University with a history of endodontic treatment in the maxillary left lateral incisor and repeated post fracture. The con-dition ended up with insufficient tooth struc-ture was to support a post core restoration.

Hence, it was decided to replace the tooth with an endosseous implant. Oral examination revealed that the remaining supra-gingival por-tion of the broken lateral incisor could hinder adequate primary closure at time of immediate implant placement. Therefore, it was decided to reduce the root 2mm below gingiva, leave it for 3 weeks to allow the exposed area for growth of the soft tissues and thereby provid-ing adequate soft tissue for primary closure after implant placement. This approach provides a tension free primary closure of the socket after immediate implant placement. This pro-tects the healing site from the oral environment.

Immediate Implant Placement with a Novel Approach to get Adequate

Soft Tissue Coverage: A Case Report

Dr. Ahmed Yaseen Alqutaibi1 • Dr. Iman Radi2 • Dr. Ahmed Fyad3 Dr. Khalid Zekry4

1. PhD Student, Department of prosthodontics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt

2. Assistant professor, Department prosthodontics, Faculty of Oral and Dental Medicine, IBB University, IBB, Yemen

3. Lecturer, Department of prosthodontics, Faculty of Oral and Dental Medicine, Cairo University

4. Professor of prosthodontics, Department of prosthodontics, Faculty of Oral and Dental Medicine, Cairo University

Abstract

KEY WORDS: Immediate implant placement, soft tissue coverage, case report


34 • Vol. 7, No. 8 • October 2015

INTRODUCTIONWith the continued impact of esthetics on den-tal treatment, the desire for patients to main-tain their dentition is critical. Immediate implants are a 1-stage surgical procedure designed to successfully place a dental implant after tooth extraction and site preparation, reducing the time spent between tooth loss and final resto-ration placement. Clinical studies have dem-

onstrated that successful osseointegration and optimal esthetics can be achieved with implants placed in fresh extraction sockets.1-3

One of the problems encountered with the immediate implant placement is insufficient soft tissue that could achieve a tension free pri-mary closure. This is particularly the case in the aesthetic zone where stabilization of the soft tissue profile becomes even more critical.4

Figure 1: Initial presentation. Figure 2: CBCT scan of endodontically treated maxillary lateral incisor.

Figure 3: Maxillary lateral incisor is reduced 2mm subgingivally.

Figure 4: Soft tissue coverage of reduced lateral incisor after 3 weeks.

Alqutaibi et al


CASE REPORTA 38-year-old nonsmoking medically fit female patient presented to Prosthodontics Depart-ment, Faculty of Dentistry, Cairo University with a history of endodontic treatment in the maxil-lary left lateral incisor and repeated post fracture (Figure 1). The condition ended up with insuffi-cient tooth structure was to support a post core restoration. Hence, it was decided to replace the

tooth with an endosseous implant. Oral examina-tion revealed that soft tissue around the remain-ing supra-gingival portion of the broken lateral incisor was deficient, so that adequate primary closure could be hindered at time of immedi-ate implant placement. The CBCT scan showed a retained left lateral incisor root with previous endodontic treatment and a prepared post chan-nel with an absence of radiolucency around root

Figure 5: Crestal incision at maxillary lateral incisor site. Figure 6: Removal of residual root.

Figure 7: Dental implant placement at maxillary lateral incisor site.

Figure 8: Tension free primary closure.

Alqutaibi et al

36 • Vol. 7, No. 8 • October 2015

Figure 9: Final master impression. Figure 10: Final implant restoration.

Figure 11: Patient is happy with the final implant restoration.

(Figure 2). After giving infiltration anesthesia, the retained root was reduced 2mm below gin-giva by round bur at low speed and high torque under coolant with cold normal saline (Figure 3). The patient was instructed to use chlorhexi-dine mouth wash three times daily and was

followed weekly for observation of soft tis-sue healing. After three weeks, the soft tis-sue totally covered the surgical area (Figure 4).

Once soft tissue coverage was achieved at the site of the reduced root, immediate implant place-ment was planned. Preoperative antibiotics were given orally 1 hour prior to surgery (amoxicillin, 2 g). Following local anesthesia, a crestal incision was done (Figure 5) and extraction was performed using periotomes (Figure 6) with appropriate pre-cautions to ensure that the labial plate of bone was not traumatized. The extraction socket was carefully examined for dehiscences and fenestra-tions and debrided of residual periodontal fibers using curettes. A self-tapping tapered implant of 4.1 mm diameter and 12 mm length (DENTIS, Korea) was placed after preparing an osteotomy along the palatal wall of the socket and 3 mm beyond the apex of the socket to ensure a pala-tal orientation of the implant (Figure 7). The inser-tion torque achieved was 40 Ncm and the gap between the implant crest and the labial plate in

Alqutaibi et al


addition to fenestrated buccal plate apically were filled with Bio- Oss (Geistlich, Switzerland). The flap was the replaced so that tension free closure of the implant and augmented site was achieved with 3.0 suture (Figure 8). The patient instructed to use chlorhexidine mouth wash three times daily. One week after the sutures were removed.

After 4 months of healing, a crestal inci-sion was performed and healing abutment was placed. An open tray impression with pick-up coping was performed using addition sili-cone (Elite, Zhermack) (Figure 9). The finished porcelain fused to metal crown was inserted (Figure 10) with a good aes-thetic result (Figure 11).

DISCUSSIONImmediate implant placement become an increas-ingly popular treatment modality particularly with teeth of poor prognosis in an otherwise healthy setting of the anterior maxilla.5 The most common complication with immediate implant placement is the soft tissue dehiscence and early exposure of the implant site.6 In this novel approach (by getting adequate soft tissue cover-ing before immediate implant placement) the sur-gical site is protected by sufficient soft tissue that could achieve a tension free primary closure. ●

Disclosure

The authors report no conflicts of interest with anything mentioned in this article.

References1. Rosenquist, B. and B. Grenthe, Immediate placement of implants into extraction

sockets: implant survival. International Journal of Oral and Maxillofacial Implants, 1996. 11(2): p. 205-209.

2. Chen, S.T., T.G. Wilson Jr, and C. Hammerle, Immediate or early placement of implants following tooth extraction: review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants, 2004. 19(19): p. 12-25.

3. Juodzbalys, G. and H. Wang, Soft and hard tissue assessment of immediate implant placement: a case series. Clinical Oral Implants Research, 2007. 18(2): p. 237-243.

4. Danesh-Meyer, M., Management of the extraction socket: Site preservation prior to implant placement. Australasian Dental Practice, 2008: p. 150-156.

5. Hamouda, N.I., et al., Immediate Implant Placement into Fresh Extraction Socket in the Mandibular Molar Sites: A Preliminary Study of a Modified Insertion Technique. Clinical implant dentistry and related research, 2013.

6. Esposito, M., et al., Interventions for replacing missing teeth: dental implants in fresh extraction sockets (immediate, immediate delayed and delayed implants). The Cochrane Library, 2010.

Alqutaibi et al

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Soolari et al

Background: There is little evidence about the factors that influence patients’ decisions to undergo recommended periodontal treatment. This study investigated these factors in patients seeking treatment at a private periodontal practice.

Methods: One hundred twenty patients who completed treatment at a private periodontal prac-tice were included. They were 17 to 93 years old (mean: 54.8 y); 53.3% were men and 46.7% were women; and 43% were Caucasians, 28% Afri-can Americans, 18% Hispanic or Mexican Ameri-cans, and 9% Asians. An additional 18 patients declined the treatment. A written questionnaire assessed various factors influencing patients’ decisions to approve the recommended treatment, including opinions on the treatment duration and options, office environment, available resources, financial issues, outcomes, roles of various team members, efficacy of diagnostic/educational tools, pain and anxiety control, and ease of scheduling.

Results: Average treatment cost per patient was US $8,030 (range: US$890–US$37,200). Patients cited the availability of suitable appoint-ments (98%), good doctor communication (99%), perception that pain and anxiety control during treatment would be adequate (98%), and con-viction that the treatment plan would yield the desired outcome (99%) most frequently as factors that led them to approve and complete treatment. Also important for >90% of patients were posi-tive staff behaviors, strong clinical skills, and the provision of education/communication throughout treatment. When asked to rate these factors, the likelihood that treatment would be effective (94%) and cost (71%) were rated “very important.”

Conclusions: Effective treatment plans, a good office environment, adequate communi-cation with the doctor and staff, and constant motivation and education of patients are key to treatment acceptance. The study also sug-gests that certain demographics may influ-ence the rate of treatment plan acceptance.

Factors Influencing Patients’ Acceptance of Treatment Plans at a Private Periodontal Practice

Ahmad Soolari, DMD, MS1 • Nafiseh Soolari, BA2 • Habibeh Shams3

Jasim M. Albandar4

1. Private Practice, Silver Spring and Gaithersburg, Maryland

2. Dental Hygiene Program at the Fortis College, Landover, MD

3. Office Manager, Silver Spring, MD

4. Department of Periodontology and Oral Implantology, Temple University School of Dentistry, Philadelphia, PA

Abstract

KEY WORDS: Treatment plans, treatment acceptance, patient questionnaire, periodontal treatment


40 • Vol. 7, No. 8 • October 2015

INTRODUCTIONThe attainment of a treatment plan relies to a large extent on acceptance of the plan by the patient and diligent follow-through by both the patient and the treating office staff. The phrase “treatment acceptance” has been mentioned over and over again in a broad spectrum of all-encompassing medical/dental procedures.[1] And conceivably, this is of utmost importance in the dental field, as there is less of a focus on, and understanding of, the correlation between oral health and an individual’s overall well-being.

It has been suggested that certain variables, including office design, insurance coverage, pay-ment methods, the constituents of the treatment plans offered, supporting materials, interactions with the office staff, and the doctor’s presenta-tion of the plan can significantly influence patient acceptance.[2, 3] It has also been postulated that effective presentation of treatment plans, including communication, imaging, and pay-ment options, can lead to a higher rate of case acceptance. Another postulate is that the front desk staff are an important factor in treatment acceptance and satisfaction, as they communi-cate with patients and play other roles, such as “shock absorbers, educators, translators, and psychologist” to meet the needs of patients.[4]

Successful treatment acceptance is criti-cal for increasing practice production and devel-oping a more rewarding and fulfilling business at a dental practice. However, there is scarce evidence-based information about the factors that promote treatment acceptance. The aim of this study was to investigate patients’ opin-ions about the characteristics that may influence their acceptance of recommended periodon-tal plans at a private periodontal practice.

MATERIALS AND METHODSThis study sample included patients seeking peri-odontal treatment at a private periodontal specialty clinic in Maryland, USA. The patients were either referred by another dentist or attended the clinic on their own, usually because they were advised by their dentist to seek periodontal treatment with a specialist. The inclusion criteria included patients 18 years of age and older who attended our clinic during a 3-year period (2012-2014), consented to participate in this study and to com-plete a questionnaire about the patient’s opinion regarding a treatment plan recommended by the treating periodontist. One-hundred-thirty-eight (138) patients participated in this study. Their age ranged between 17 and 93 years (mean 53.8 years), and included 65 females and 73 males.

Patients who completed the recommended treatment plan were interviewed at the end of the treatment phase. Data regarding the type of treatment performed, number of treatment vis-its, and the cost of treatment were obtained from patients’ charts. We developed a questionnaire form to gather demographic and other information not covered in the chart and to assess patients’ opinion about the factors that may have played a role in their decisions to approve and pursue the periodontal treatment plan recommended by the periodontist. The questionnaire form con-sisted mainly of closed-end questions. The ques-tions and statements used in the questionnaire were developed based on earlier interviews and discussions with five patients not involved with this study. The survey was designed as follows: ● In the first part, patients reported demographic

information, such as age, sex, ethnicity, edu-cational background, income level, method of referral, and payment information (insur-

Soolari et al


ance coverage, and method of payment if they held no dental insurance or their insur-ance plan did not cover the treatment in full).

● The next part of the questionnaire consisted of a series of statements about the office environment, their perception of the treat-ment and its outcome, and financial aspects. Patients were instructed to mark each state-ment as true or false. Examples include: “The demeanor and behavior of the staff played a role in my decision to receive treatment here,” “It was fairly easy to get appointments at times that would work with my schedule,” “Communication with the doctor and staff was easy,” “I was offered several different options for treatment and rationales for each,” “My fears regarding my treatment were adequately addressed,” “The costs of the various treat-ment options were presented clearly,” and “I was pleased with the outcome of treatment.”

● The next part of the questionnaire inquired about the importance of each of several fac-tors for the patients in accepting a treatment plan. These included the time it would take to complete treatment, options available for con-trolling pain, treatment cost, and convenience of appointment times. Respondents were instructed to mark each item as “very impor-tant,” “somewhat important,” or “not important.”

● Finally, the survey asked patients which staff member(s) (assistant, front office staff, hygien-ist, doctor) and what part of the treatment-planning process (photos, x-rays, study models, previous patient images, informa-tion from staff) was(were) most helpful in the decision to accept treatment. Patients were also asked about how easy or difficult the financing of their treatment had been.

Additional space was provided for free-form comments at the end of the survey.

Patients included in this study signed a con-sent form that described the purpose of the study and the methods. The data were tabu-lated and presented as frequency tables.

NONRESPONSE ANALYSISWe used the t-test and the Mantel-Haenszel test to test the hypothesis that there are no significant differences in age, gender, or ethnicity between subjects who accepted the recommended peri-odontal treatment plan and completed a full questionnaire, and those who declined the plan for any reason. Of the 138 patients who par-ticipated in the study, 18 declined treatment and were therefore not available for an interview. The analysis showed that patients who declined treatment were younger in age (p<0.05), of simi-lar gender, but had a significantly different eth-nicity profile (p=0.0008) compared to patients who approved the recommended treatment plan and completed the treatment (Table 1).

RESULTSOne-hundred-twenty patients who underwent treatment completed our survey. Patient age ranged from 17 to 93 years (mean: 54.8 years). Sixty-four patients (53.3%) were men and 56 (46.7%) were women. With respect to ethnic background, 42.5% of respondents were Cauca-sian, 28.3% African American, 18.3% Hispanic or Mexican American, 10.8% “other” (Table 1). Eighty-one percent had an American Society of Anesthesiologists (ASA) health status of I or II. Only one patient did not have a college educa-tion; all others had completed college or post-graduate studies. Ninety-four percent of patients

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42 • Vol. 7, No. 8 • October 2015

rated their economic status as “average.” Treatments performed included nonsurgical

methods, crown lengthening, osseous surgery, soft tissue grafting, periodontal tissue regen-eration, alveolar ridge augmentation, implant placement or treatment of implant-related com-plications, extractions of teeth, and/or prepro-sthetic surgery. Ninety-five percent of patients

completed treatment in 7 or fewer visits. The cost of treatment ranged from US$890 to US$37,000. Most patients had some insur-ance coverage but were still financially respon-sible for a substantial portion of treatment. On average, insurance covered only 28.3% of the treatment cost. Eighty-six percent of the patients had been referred by general dentists.

Table 1: Demographics of Patients who Accepted or Declined the Recommended Periodontal Tretment Plan

Response to Recommended Treatment Plan

Demographics Accepted Declined p

Gender Females No. 56 9

% 46.7 50.0 0.8

Males No. 64 9

% 53.3 50.0

Ethnicity Caucasian No. 51 0 0.0008

% 42.5 0

African-American No. 34 11

% 28.3 61.1

Hispanic or No. 22 2

Mexican-American % 18.3 11.1

Others* No. 13 5

% 10.8 27.8

Age (years) Mean 54.8 47.3 0.04

S.D. 14.4 14.0

* Mainly Middle-Eastern or Asian

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Effect of office environment on treatment plan acceptanceThe vast majority of respondents agreed that staff behavior (88%), staff skills (91%), the availability of suitable appointments (98%), and doctor communication skills (98%) were important factors in leading them to accept treatment. Also important in treatment accep-tance for at least 90% of patients were the initial visit to discuss treatment (93%), edu-cation from (90%) and answers to questions (90%) by staff during regular visits, answers regarding concerns about treatment and pain control (93%), and the provision of clear infor-mation regarding the expected length and out-come of treatment (95%). Ninety percent of the patients felt that the treatment was effec-tive, 91% were pleased with the outcome, and 93% would refer a friend or family member to the treating office. In free-form comments, patients frequently mentioned the positive atti-tude of the staff and their professionalism in carrying out their work, as well as the quality of information given during treatment and the inter-est of the entire staff in patients’ well-being.

Most important factors in accepting a treatment planWhen asked which factors were “very impor-tant” in leading to treatment acceptance, 93% of patients cited the likelihood that the treat-ment would be effective. The cost of treat-ment was very important (71%) or somewhat important (24%) for 95% of patients, and most patients felt that financing their treatment was “easy” (39%) or “fair” (50%). Somewhat fewer patients agreed that the following factors were “very important” in their treatment decision:

options for pain control (51% very important, 38% somewhat important), the presentation of several treatment options (63% very impor-tant, 26% somewhat important), and the avail-ability of convenient appointments (67.5% very important, 25% somewhat important).

For 96% of respondents, the doctor was the most significant person in the office in help-ing them decide on treatment. Among the tools made available during diagnosis and treatment planning, the willingness of staff to answer questions was the most influential (51%); x-rays (50%) and photos (40%) were also fairly help-ful in bringing patients to make a decision. Other tools, such as computed tomography (13%), guru animated treatment films (4%), models (8%), and previous patient slides (8%), were important for only a few patients in help-ing them decide to proceed with treatment.

Forty-four percent of the patients reported that the office Web site was help-ful, and 13% did not visit the Web site.

DISCUSSIONDentists’ clinical training and experience have a strong influence on their patients’ choice of treatment,[5, 6] as the dentist is expected to have adequate professional competency and knowl-edge of the treatment need of the patient and what would work. However, it seems clear from this and other studies that doctors and their staff members can increase patient satisfac-tion and treatment acceptance by striving for quality communication with patients and among themselves. This includes direct and indirect communication, such as the appearance of the staff and doctors, cleanliness of the office, total wait time, quality of dental care, and the

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44 • Vol. 7, No. 8 • October 2015

manner in which care is given. Most patients do not understand, nor are they able to evalu-ate, the clinical skills of a dentist; therefore, they usually rely on other criteria, such as com-munication with the dentist and the dentist’s interactions with the entire staff to help them choose one office over another. Other studies also found that good communication between dentists and patients led to greater treat-ment acceptance and patient satisfaction.[7, 8]

Dilatush and Horrocks[3] stated that patients use four criteria to select a dentist: price, technology, convenience, and pub-lic relations. Their findings are consistent with the results of our survey, in which over 90% of our patients stated that their treat-ment decision was influenced by factors such as good communication with the office staff, the availability of convenient appointments, cost of treatment, the relative ease of pay-ing for treatment, and confidence that the dentist could produce the desired outcome.

One barrier to effective communications is language. A dental office staff that is reflective of the demographics of the patient population helps to reduce barriers to good communica-tion. For instance, approximately a third of our patients speak Spanish, and we have made sure that at least one member of our staff is bilingual. The presence of Spanish-speaking staff helps bilingual patients better relate to the office and understand that the doctor went the extra mile to help patients. Any language barrier can manifest itself in a negative way in sched-uling, providing medical and dental history, consenting to treatment, and following the den-tist’s instructions during or after procedures.

Levin[6,9] recommended building better rela-

tionships with patients to help a practice grow and emphasized an “internal marketing pro-gram” for the entire office staff. Interpersonal relationships are a critical component of “inter-nal marketing,” and practice success and the entire referral process depend on the quality of interpersonal relationships. Effective internal marketing, from this point of view, consists of necessary staff training to use the right wording in a warm and vivid way to establish a strong bond between the patient and the office, which eventually leads to increased patient flow. It is also recommended that questions from patients be encouraged.[10] McInnes,[2] work-ing in the field of cardiology, echoed these sentiments, noting that involving the patient in treatment planning, paying attention to patient needs, making frequent contact with the patient, setting clear goals, and sticking to a clear treatment plan resulted in better patient acceptance of and compliance with treatment.

Seidel-Bittke[11] noted that many patients simply do not realize the importance of treat-ment, especially regular preventive care. Plenty of education based on good research and a plethora of good materials to present to patients can help convince and motivate patients to undergo and complete treatment. Rosedale and Strauss[12] used a diabetes patient-screen-ing program to emphasize the impact of over-all health on dental health, and vice versa. In the present study, the patients felt they were given adequate knowledge about the benefits of treatment on their general and dental health.

Many authors noted the influence of treat-ment costs on the acceptance of treatment plans. Levoy[4] recommended that dentists make third-party financing available. Seidel-Bittke[11]

Soolari et al


also recommended that dentists make many payment plans available to patients, in addi-tion to stressing to patients that the choice to spend money to improve their health is valid. In our study, 89% of patients stated that the financing of their treatment was “easy” or “fair.”

Dilatush and Horrocks[3] recommended creating a dominant Internet presence for the dental office by means of a Web site that fea-tures user-friendly navigation/organization, well-written words, and clear pictures; is not overly clinical; has a “meet the dentist” page; and has good management with regard to search engine optimization and connections with social media. Levoy[4] emphasized that a dentist’s Web site needs to be patient friendly and not overly complicated or overloaded with technical wizardry. In this study, 44% of the patients deemed the office Web site helpful.

Interestingly, although about half the patients in this study stated that photographs and radiographs did help them decide to pro-ceed with treatment, relatively few patients were swayed by the so-called “high-tech” tools such as computed tomography (13%) or guru animated treatment films (4%), although 94% of these patients used these tools. It would be useful to learn more about what was lack-ing in these devices that minimized their influ-ence on patient acceptance in this study.

This study has some limitations. First, we used a novel, opinion-based questionnaire to gather our data. Patient opinions will, of course, always be subjective and qualitative by their very nature, but a stronger approach would have been to use a previously validated ques-tionnaire regarding patient treatment accep-tance. To our best knowledge, there are no such

validated surveys in the peer-reviewed litera-ture on treatment acceptance in periodontics, although many commentaries and editorials have been written by experienced clinicians on patient acceptance of dental treatment. A pilot study of the ACCEPT questionnaire[13] studied patient acceptance of the use of prescribed medication. A fully tested and validated sur-vey would be preferable, and it would provide a more complete picture regarding the rea-sons that patients accept or refuse treatment. Our survey included only 120 responses from a particular patient population at one periodon-tal practice. To generalize the findings, a larger and more representative sample of patients and practices may be required. Populations with a broad range of demographics, including repre-sentative socioeconomic status, education, and ethnic/racial makeup, may have answered the survey differently. On the other hand, the inclu-sion of multiple practices might have created other issues. For example, different practices may have different procedures for communica-tion with patients, treatment planning, etc., and these differences would inevitably influence the responses to the survey. Another limitation of this study is that responses from patients who did not accept the treatment plan and did not follow through with the treatment were not included. These responses may provide useful information not observed in this study.

In addition to having adequate clinical skills, a successful dentist/periodontist must also be a good communicator. To be a good communi-cator, the dentist needs to be a good listener. A patient’s chief complaints should be taken into consideration when developing a treat-ment plan. Furthermore, the clinician should

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46 • Vol. 7, No. 8 • October 2015

Soolari et al

educate, motivate, and address the ques-tions and concerns raised by the patient. With good communication from the doctor and staff, patients will have confidence in the treat-ment plan and be motivated to follow through with the recommended treatment. In addition, patients appreciate sufficient information about the cost of treatment, the duration of proce-dures, methods for pain control, the availability of alternative treatment options, and the pre-dictability of the outcome of treatment. Gen-erally, the treatment outcome should be the

restoration of function and/or esthetics, and it should be stable and reasonably predictable. ●

Correspondence:Dr Ahmad Soolari11616 Toulone DrivePotomac, MD 20854Phone: 301-674-9815fax: 240-845-1087email: [email protected]

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

References1. S.C. Hayes, M.E. Levin, J. Plumb-Vilardaga,

J.L. Villatte, and J. Pistorello. “Acceptance and commitment therapy and contextual behavioral science: examining the progress of a distinctive model of behavioral and cognitive therapy,” Behav Ther, vol. 44, no. 2, pp. 180-198, 2013.

2. G.T. McInnes. “Integrated approaches to man-agement of hypertension: promoting treatment acceptance,” Am Heart J, vol. 138, no. 3 Pt 2, pp. 252-255, 1999.

3. M. Dilatush and H. Horrocks. “Creating a dominant internet presence for your practice,” Compend Contin Educ Dent, vol. 33, no. 10, pp. 718-719, 2012.

4. B. Levoy. “7 ways to make your dental practice easy to do business with,” Dent Pract Manage, no. May 52014.

5. D. Grembowski, P. Milgrom, and L. Fiset. “Fac-tors influencing dental decision making,” J Public Health Dent, vol. 48, no. 3, pp. 159-167, 1988.

6. J.S. Kalsi and K. Hemmings. “The influence of patients’ decisions on treatment planning in re-storative dentistry,” Dent Update, vol. 40, no. 9, pp. 698-700, 702-694, 707-698, 710, 2013.

7. M. Redford and H.C. Gift. “Dentist-patient interac-tions in treatment decision-making: a qualitative study,” J Dent Educ, vol. 61, no. 1, pp. 16-21, 1997.

8. B.C. Schouten, M.A. Eijkman, and J. Hoogstraten. “Dentists’ and patients’ communicative behaviour and their satisfaction with the dental encounter,” Community Dent Health, vol. 20, no. 1, pp. 11-15, 2003.

9. R. Levin. “Building better relationships will grow your practice,” Inside Dent, vol. 7, no. 102011.

10. R.P. Levin. “4 steps to greater case acceptance in your dental practice,” Dent Pract Manage, no. May 92014.

11. D. Seidel-Bittke. “Get a “yes!” for nonsurgical periodontal treatment,” Dent Today, vol. 31, no. 5, pp. 76, 78, 80 passim, 2012.

12. M.T. Rosedale and S.M. Strauss. “Diabetes screening at the periodontal visit: patient and provider experiences with two screening ap-proaches,” Int J Dent Hyg, vol. 10, no. 4, pp. 250-258, 2012.

13. C. Marant, J. Longin, R. Gauchoux, et al. “Long-term treatment acceptance: what is it, and how can it be assessed?,” Patient, vol. 5, no. 4, pp. 239-249, 2012.

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Alsourori et al

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Alsourori et al

The purpose of this review was to test the null hypothesis of no difference in the implant failure rate, marginal bone loss, and

postoperative infection for patients being rehabili-tated by tilted or by axially placed dental implants, against the alternative hypothesis of a difference.

There is no Appropriate Evidence to Recommend or Discourage the use of Tilted Dental Implants

to Enhance the Survival Rate of Dental Implants in Atrophic Jaws

Dr. Ali Abdulghani Alsourori1 • Dr. Adnan Abdullah Naje Alfahd2

1. Prosthodontics Department, Faculty of Oral and Dental Medicine, Cairo University, Assistant Lecturer, Department of Prosthodontics, Faculty of Oral and Dental Medicine, IBB University, IBB, Yemen.

2. Prosthodontics Department, Faculty of Oral and Dental Medicine, Cairo University, Assistant Lecturer, Department of Prosthodontics, Faculty of Oral and Dental Medicine, IBB University, IBB, Yemen.

Abstract

KEY WORDS: Dental implants, tilted, off-axis, review, analysis


50 • Vol. 7, No. 8 • October 2015

BACKGROUNDThe purpose of this review was to test the null hypothesis of no difference in the implant fail-ure rate, marginal bone loss, and postopera-tive infection for patients being rehabilitated by tilted or by axially placed dental implants, against the alternative hypothesis of a difference.

MATERIALS AND METHODSAn electronic search without time restrictions was undertaken (and last checked) in July 2014 in the following databases: PubMed, Web of Sci-ence, and the Cochrane Oral Health Group Trials Register. The following terms were used in the search strategy on PubMed: (((dental implant) OR oral implant)) AND ((((tilted) OR angulated) OR axial) OR upright) [all fields]. The following terms were used in the search strategy on Web of Sci-ence, in all databases: (((dental implant) OR oral implant)) AND ((((tilted) OR angulated) OR axial) OR upright) [topic]) The following terms were used in the search strategy on the Cochrane Oral Health Group Trials Register: (dental implant OR oral implant AND (tilted OR angulated OR axial OR upright)) A manual search of dental implants-related journals was also performed. The reference list of the identified studies and the relevant reviews on the subject were also scanned for possible addi-tional studies. Moreover, online databases provid-ing information about clinical trials in progress were checked (clinicaltrials.gov; www.centerwatch.com/clinicaltrials; www.clinicalconnection.com). Eligi-bility criteria included clinical human studies, either randomized or not, interventional or observational, comparing implant failure rates in any group of patients receiving tilted or axially placed dental implants. Zygomatic implants were not considered. For this review, implant failure represents the com-

plete loss of the implant. Exclusion criteria were case reports, technical reports, animal studies, in vitro studies, biomechanical studies, finite ele-ment analysis (FEA) studies, and reviews papers. The following primary outcomes were measured: 1) implant failure rate: implant failure represents the complete loss of the implant; 2) Progression of the marginal bone loss; 3) postoperative infection.

RESULTSThe search strategy resulted in 44 publications. A total of 5029 dental implants were tilted (82 fail-ures; 1.63%), and 5732 implants were axially placed (104 failures; 1.81%). The difference between the procedures did not significantly affect the implant failure rates (P = 0.40), with a RR of 1.14 (95% CI 0.84–1.56). A statistically significant difference was found for implant failures when studies evalu-ating implants inserted in maxillae only were pooled (RR 1.70, 95% CI 1.05–2.74; P = 0.03), the same not happening for the mandible (RR 0.77, 95% CI 0.39–1.52; P = 0.45). There were no appar-ent significant effects of tilted dental implants on the occurrence of marginal bone loss (MD 0.03, 95% CI _0.03 to 0.08; P = 0.32). Due to lack of satisfactory information, meta-analysis for the out-come ‘postoperative infection’ was not performed.

DISCUSSION The use of tilted implants to support prostheses for the rehabilitation of compromised atrophic edentulous jaws can be considered a predictable technique, with an excellent prognosis in the short-medium term. However, there is lack of randomized long-term trials to determine the efficacy of this sur-gical approach. In atrophic edentulous jaws, tilting of the implants may represent a feasible treatment option to overcome placement of implant in specific

Alsourori et al


anatomical areas, such as the pterygoid region, the tuber, or the zygoma or bone-grafting procedures which demanding surgical procedures and can be associated with complications, morbidity, and high costs. Moreover, implants of conventional length can be placed, allowing engagement of as much cortical bone as possible, thus increasing primary stability.1 Tilting of the implants may allow using longer implants that may engage greater quan-tity of residual bone, which may be beneficial to implant stability. Moreover, a more even distribu-tion of stress around implants is achieved when implants with longer lengths are used.2,3 Regard-ing This meta-analysis, No RCTs were included. The forty-four included articles were twenty-five prospective studies and nineteen retrospective analyses. Thirty-six studies were of high quality, and eight of moderate quality. Quality assess-ment of the studies was achieved according to the Newcastle-Ottawa scale (NOS).4 All the meth-odology procedures of this Meta-analysis review were performed starting from clear focus answer-able question and extensive systematic search to proper meta-analysis performance. As well as data interpretation were done with caution due to the presence of uncontrolled confounding factors in the included studies, none of them randomized.

The aim of this review was to test to com-pare the survival rate of dental implants, post-operative infection, and marginal bone loss of tilted and axially placed dental implants.

The results of this review indicate that, the insertion of dental implants in a tilted position did not statistically affect the implant failure rates in relation to axially placed implants. This sug-gests that tilted implants may achieve the same outcome as implants placed in a straight man-ner. In addition the study did not find an appar-

ent significant effect of tilted dental implants on the occurrence of greater marginal bone loss in comparison with axially placed implants.

CONCLUSIONS It is suggested that the differences in angulation of dental implants might not affect the implant sur-vival or the marginal bone loss. The reliability and validity of the data collected and the potential for biases and confounding factors are some of the shortcomings of the present study. There is lack of strong evidence to recommend the placement of tilted implants as an alternative option for reha-bilitation of atrophic edentulous jaws. Hence, well performed pragmatic randomized controlled trials are still needed to evaluate the benefit or harm of this treatment option in comparison with axially placed implant with bone grafting. ●

DisclosureThe authors report no conflicts of interest with anything mentioned in this article

References1. Aparicio C, Perales P, Rangert B. Tilted implants as an alternative to maxillary

sinus grafting: a clinical, radiologic, and periotest study. Clin Implant Dent Relat Res. 2001;3(1):39-49. doi:10.1111/j.1708-8208.2001.tb00127.x.

2. DE Vico G, Bonino M, Spinelli D, et al. Rationale for tilted implants: FEA considerations and clinical reports. Oral Implantol (Rome). 2011;4(3-4):23-33. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3530969&tool=pmcentrez&rendertype=abstract.

3. Petrie CS, Williams JL. Comparative evaluation of implant designs: Influence of diameter, length, and taper on strains in the alveolar crest - A three-dimen-sional finite-element analysis. Clin Oral Implants Res. 2005;16(4):486-494. doi:10.1111/j.1600-0501.2005.01132.x.

4. Wells G a, Shea B, Connell DO, et al. The Newcastle-Ottawa Scale ( NOS ) for assessing the quality of nonrandomised studies in meta- analyses. 2000.

Alsourori et al

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