Oct15 - Co Axis Implantto Avoid Sinus Grafting

Volume 7, N o.
8 O ctober 2015
The Journal of Implant & Advanced Clinical Dentistry
The Keyless
Partially Guided
Implant Protocol
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Volume 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 T he Keyless Partially Guided
Implant Placement Protocol:

Success Rate and Complications
Amr Hosny Elkhadem
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Table of Contents
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
Soolari et al
39 F actors Influencing Patients
Acceptance of Treatment Plans

at a Private Periodontal Practice
Table 1: Demographics of Patients who Accepted or

Declined the Recommended Periodontal Tretment Plan
Response to Recommended Treatment Plan
Demographics
Gender
Ahmad Soolari, Nafiseh Soolari,

Habibeh Shams, Jasim M. Albandar
Ethnicity
Accepted
Declined
Females
No.
56
46.7
50.0
Males
No.
64
53.3
50.0
No.
51
42.5
Caucasian
African-American
Hispanic or
Mexican-American
Others*
49 T here 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
Age (years)
No.
34
11
28.3
61.1
No.
22
18.3
11.1
No.
13
10.8
27.8
Mean
54.8
47.3
S.D.
14.4
14.0
p
0.8
0.0008
0.04
* Mainly Middle-Eastern or Asian
rated their economic status as average.

Treatments performed included nonsurgical
methods, crown lengthening, osseous surgery,
soft tissue grafting, periodontal tissue regeneration, alveolar ridge augmentation, implant
placement or treatment of implant-related complications, extractions of teeth, and/or preprosthetic surgery. Ninety-five percent of patients
42
Vol. 7, No. 7
completed treatment in 7 or fewer visits. The

cost of treatment ranged from US$890 to
US$37,000. Most patients had some insurance coverage but were still financially responsible 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.
September 2015
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Kurtzman et al
Utilization of the Co-Axis Dental Implant

to Avoid Sinus Augmentation: A Case Report
Gregori M. Kurtzman, DDS, MAGD, DICOI1 Douglas F. Dompkowski, DDS2

Abstract
ypically as teeth are lost in the posterior maxilla, the maxillary sinus enlarges
(pneumatization) over time. This phenomenon also occurs with aging. Enlargement
of the sinus presents challenges to implant
placement in the posterior and frequently augmentation 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. 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 sinus. The following case
report demonstrates use of this implant system.
KEY WORDS: Dental implant, maxillary sinus, off-axis, tilting

1. Private practice, Silver Spring, Maryland, USA
2. Private practice, Bethesda, Maryland, USA
11
Kurtzman et al
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.
INTRODUCTION:
Typically as teeth are lost in the posterior maxilla, the maxillary sinus enlarges (pneumatization) over time. This phenomenon also occurs
with aging. Enlargement of the sinus presents challenges to implant placement in the
posterior and frequently augmentation 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 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.
12
Vol. 7, No. 8
October 2015
Figure 2: Co-Axis implant with fixture mount and

orientation dimple to aid during placement to angle the
plateform in the desired direction.
A SOLUTION TO
SINUS AVOIDANCE
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. Off-axis or tilted
implant placement has been utilized for many
years to work around the patients anatomy.3,4
However, these have created prosthetic complications related to the angulation of the implant
plateform often requiring use of additional parts
(i.e.multi-abutments) that decreases the available 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 maxillary sinus.6
These pterygomaxillary implants
Kurtzman et al
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 patients 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.
allow for the placement of implants in the posterior maxilla without the use of sinus augmentation
procedures or other types of bone grafts. Zygomatic 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 offaxis 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 connector in 4.0, 5.0 and 6.0mm diameter (12 degree
13
Kurtzman et al
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.
correction) and 5.0 and 6.0mm diameter (24

degree correction). A trilobe connector is available in a 12 degree in both a 4.3mm (platform is a 3.5mm) and a 5.0mm (platform is a
4.3mm). Also an internal octagon (hex) is available in a 5.0mm (platform is a 4.8mm) option.
Surgical placement of this unique implant
does require minor modifications to the procedure when placing the fixture. An orientation dimple is found on the fixture mount, which
is rotated as the implant is placed to orientate the angled platform. This is performed so
that the implants achieve parallelism between
the implant platforms regardless which direction the fixture axis is oriented (Figure 2). With
proper orientation a screw-retained prosthesis 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
14
Vol. 7, No. 8
October 2015
Kurtzman et al
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).
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 available mesial and distal to the sinus (Figure 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 complaint that her maxillary removable partial denture
was bothering her with minimal retention and she
was interested in a fixed implant bridge bilaterally. 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
15
Kurtzman et al
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.
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). Radiographically, fully impacted 3rd molars bilaterally were
identified. Due to the lack of pathology and the
patients age it was decided to not treat the 3rd
maxillary molars and keep them under observation.
A replica of the current maxillary removable 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 bilaterally, 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 evaluated in relation to the sinus and other anatomy.
16
Vol. 7, No. 8
October 2015
Kurtzman et al
Figure 20: Hand drivers engaging the implants at sites #3

and #6 demonstrating parallelism of the prosthetic axis.
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.
The patient was scheduled for implant surgery and a local anesthetic (4% Septocaine with
1:100,000 epi) was administered at the appointment 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
Figure 21: 24 degree 5.0mm Co-Axis implant placed at site

#3 skirting the mesial wall of the maxillary sinus.
inserted into site #3 and periapical radiographs

taken to check the initial osteotomies in relation
to the mesial sinus wall and other anatomy (Figures 9 - 11). A mid-crestal incision was made
with a vertical releasing incision distal to the lateral 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 CoAxis implant with an external hex connection was
17
Kurtzman et al
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 (Figure 13). Final insertion was made with a hand
wrench until the implant was seated and the orientation 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 completed 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 handpiece (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 without perforating the sinus during placement (Figure 21). A radiograph was taken of the implant
18
Vol. 7, No. 8
October 2015
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 reinserted 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
19
Kurtzman et al
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 patients 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 integration of the implants (Figure 25). Local anesthetic
(4% Septocaine with 1:100,000 epi) was administered 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 Aquasil 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 abutments 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 reinserted and an interocclusal record was taken with
20
Vol. 7, No. 8
October 2015
Kurtzman et al
Regisil Rigid bite registration VPS (Dentsply

Caulk) with the patient occluding with her anterior natural maxillary incisors in contact with the
lower anterior teeth. A counter full arch impression 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 patients request. The existing
partial denture was relieved to allow the removable 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 reinserted 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 impression abutments within the impression. The case
was mounted with the provided interocclusal
record. A scanning base (Glidewell Labs, Newport 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 bonding surfaces of the base and the ceramic structure. 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 glycerine 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 healing abutments were removed on the right quadrant. 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
21
Kurtzman et al
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 matching 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 available 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 platform. This allows angled placement of the
implant with proper positioning of the prosthetic axis in the ideal position of the occlusal or lingual surfaces. This provides a simpler
prosthetic fabrication with maximized esthetics and lower treatment costs to the patient.
Correspondence:
Dr. Gregori Kurtzman
3810 International Drive
Suite 102
Silver Spring, MD 20906
drimplants@aol.com
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:e1837. 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):14970. 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 posterior maxilla. Int J Periodontics Restorative Dent. 1994;14(6):512-523.
7. F
arzad 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 treatment. 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 CoAxis 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:e12638. doi: 10.1111/j.1708-8208.2011.00391.x. Epub 2011 Oct 18.
10. C
hrcanovic BR, Albrektsson T, Wennerberg A.: Platform switch
and dental implants: A meta-analysis. J Dent. 2015 Jun;43(6):62946. doi: 10.1016/j.jdent.2014.12.013. Epub 2015 Jan 2.
22
Vol. 7, No. 8
October 2015
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
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Elkhadem et al
The Keyless Partially Guided Implant

Placement Protocol: Success Rate
and Complications
Elkhadem et al
Amr Hosny Elkhadem, DDS, MSc1

Abstract
Background:
to
describe
the
concept and use of a simplified keyless
guided
implant
placement
system
in
partially and completely edentulous patients.
Results: All implants demonstrated insertion

torque values greater than 30 Ncm. Only few
postoperative complications were reported.
98.9% of the placed implants integrated.
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, surgical guides with c-shaped sleeves were constructed. The implants were placed using flap
or flapless approach according to the need
for soft or hard tissue augmentation. The intraoperative complications, post-operative complains and implant survival rate were reported.
Conclusions: The keyless partial guidance using the simple guide kit and c-shaped
sleeves is a promising economic alternative to conventional guided approach. Further investigations are required to evaluate
its accuracy and long term success rates.
KEY WORDS: Computer-aided Implantology, surgical guide, open sleeve, tolerance

1. Lecturer, Prosthodontics, Faculty of Oral & Dental medicine, Cairo University
25
Elkhadem et al
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.
INTRODUCTION
The use of CT scans combined with computer
software to plan implant cases has been proposed since the 1990s.1 The technique aims
to provide correlation between the bone anatomy and the desired tooth position allowing
for predictable aesthetic and functional outcomes. 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, postoperative pain and postoperative complications.4,5
Despite of the aforementioned advantages 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 configuration was always associated with accessibil-
26
Vol. 7, No. 8
October 2015
Figure 2: Surgical guide with c-shaped sleeve establishing

3 mm facial openings for side approach of the drills.
ity problems in the posterior region for dentate

patients. Such a small tolerance is mandatory to provide accuracy, yet it is thought to
block the passage of the irrigation and might
cause increased incidence of implant failure in dense bone and deep osteotomies7
Moreover, there is an uprising question
related to the accuracy imposed by the mechanical tolerance of the machined components. To
provide adequate precision of the guided systems, a small gap of approximately 20 microns
is provided between the main sleeve fixed in
the guide and the removable, diameter specific, 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 angular deviation with these guided systems.8,9
When weighing the merits and demer-
Elkhadem et al
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.
its of conventional guided systems one can

understand why such protocol is not so popular. Hence, there is a great need to provide modification in the concept and design
of guided surgical approach to overcome
the drawbacks and maximize the benefits.
MATERIALS AND METHODS

The 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 intermediate drills only. For all cases, the final drilling 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 compatible in size with the main sleeve of the surgical 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 engaging 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
27
Elkhadem et al
Figure 4: Point registration of the scan appliance over the patient scan. Several points are selected to minimize the
superimposition errors.
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 create 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 operated. 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 maxillary) using this technique. Preparation started
by duplicating the patient denture into radio-
28
Vol. 7, No. 8
October 2015
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 technique 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 correlating 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
Elkhadem et al
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).
tubes. The STL file of the guide was fabricated

using additive manufacturing. C-shaped sleeves
were fixed in the surgical guide and the guiding 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 missing teeth and few or no metallic restoration, the
patient received a CBCT with no scan appliance. The patient model was scanned using a
laser scanner. When the patient had multiple
missing teeth and /or numerous metallic restorations a scan appliance with radiopaque markers 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 anatomy. 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 manner (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 temporarily bond the guide to the supporting teeth.
RESULTS
No major intra-operative complications or
problems were reported in either flap or flapless cases. In few cases the c-shaped sleeves
were detached off the guide when contacting the drills. The sleeves were replaced and
the procedure completed. All implants demonstrated acceptable implant stability at inser-
29
Elkhadem et al
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 participants. 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%.
DISCUSSION
The keyless partially guided technique seems
to offer numerous advantages. First, the elimination of the removable keys together with the
open shaped sleeves allowed for better accessibility during surgery especially in the posterior region up to the maxillary tuberosity. The
open guiding sleeves allowed also for unrestricted access of the irrigation during drilling.
The proposed simplified approach did not
compromise the control over osteotomy preparation at all stages of drilling. The use of a
30
Vol. 7, No. 8
October 2015
short starter (2.3x8mm) drill created an initial osteotomy channel that accommodated
the smaller pilot drill. This assured dual guidance of the pilot drill by engaging the initial
osteotomy apically and the guiding sleeve coronally. The path created by the pilot and intermediate 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 usually 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. Minimizing 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 complications 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 drilling was used. Tissue punch was not used
as there is no proven clinical advantage or
impact on the implant success rate when compared to transmucosal drilling. On the contrary, 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 significantly affect the accuracy others believe that
guidance of the initial osteotomy provides sufficient 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 accuracy of half versus fully guided techniques on
cadaver model. They found no statistical significant difference between the two protocols.
Yet, there is a need to conduct more clinical trials to evaluate the accuracy of both systems.
CONCLUSION
The use of the simplified partially guided keyless approach seems to be a promising alternative to conventional guided surgery. The
technique allowed easy access to the posterior region with efficient delivery of the irrigation during drilling. The use of a small economic
universal kit might encourage many practitioners to utilize guided surgery. Further studies are required to compare the accuracy
and success rate versus the conventional
guided techniques and manual techniques.
Correspondence:
Dr. Amr Hosny Elkhadem
e-mail: amrelkhadem@gmail.com
Address: 5 jasmine buildings zahraa elmaadiCairo Egypt
Postal code: 11435
Disclosure
The author reports no conflicts of interest with anything mentioned in this article.
References
1. 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.
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.
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-aidedmachining-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. Khl S, Zrcher S, Mahid T, Mller-Gerbl M, Filippi A, Cattin P. Accuracy
of full guided vs. half-guided implant surgery. Clin Oral Implants
Res. 2013;24(7):763-9.
31
Alqutaibi et al
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Immediate Implant Placement with

a Novel Approach to get Adequate
Soft Tissue Coverage: A Case Report
Alqutaibi et al
Dr. Ahmed Yaseen Alqutaibi1 Dr. Iman Radi2 Dr. Ahmed Fyad3
Dr. Khalid Zekry4
Abstract
ne of the problems encountered with

immediate implant placement is insufficient soft tissue to achieve a tension 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 presented 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 condition ended up with insufficient tooth structure 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 portion 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 providing 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 protects the healing site from the oral environment.
KEY WORDS: Immediate implant placement, soft tissue coverage, case report
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
33
Alqutaibi et al
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.
INTRODUCTION
With the continued impact of esthetics on dental treatment, the desire for patients to maintain 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 restoration placement. Clinical studies have dem-
34
Vol. 7, No. 8
October 2015
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 primary closure. This is particularly the case in
the aesthetic zone where stabilization of the
soft tissue profile becomes even more critical.4
Alqutaibi et al
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.
CASE REPORT
A 38-year-old nonsmoking medically fit female
patient presented to Prosthodontics Department, Faculty of Dentistry, Cairo University with
a history of endodontic treatment in the maxillary left lateral incisor and repeated post fracture
(Figure 1). The condition ended up with insufficient tooth structure was to support a post core
restoration. Hence, it was decided to replace the
tooth with an endosseous implant. Oral examination revealed that soft tissue around the remaining supra-gingival portion of the broken lateral
incisor was deficient, so that adequate primary
closure could be hindered at time of immediate implant placement. The CBCT scan showed
a retained left lateral incisor root with previous
endodontic treatment and a prepared post channel with an absence of radiolucency around root
35
Alqutaibi et al
Figure 9: Final master impression.
Figure 11: Patient is happy with the final implant

restoration.
(Figure 2).
After giving infiltration anesthesia,
the retained root was reduced 2mm below gingiva by round bur at low speed and high torque
under coolant with cold normal saline (Figure
3). The patient was instructed to use chlorhexidine mouth wash three times daily and was
36
Vol. 7, No. 8
October 2015
Figure 10: Final implant restoration.
followed weekly for observation of soft tissue healing. After three weeks, the soft tissue totally covered the surgical area (Figure 4).
Once soft tissue coverage was achieved at the
site of the reduced root, immediate implant placement 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 precautions to ensure that the labial plate of bone
was not traumatized. The extraction socket was
carefully examined for dehiscences and fenestrations 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 palatal orientation of the implant (Figure 7). The insertion 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 incision was performed and healing abutment was
placed. An open tray impression with pickup coping was performed using addition silicone (Elite, Zhermack) (Figure 9). The finished
porcelain fused to metal crown was inserted
(Figure
10)
with
a
good
aesthetic
result
(Figure
11).
Disclosure
The authors report no conflicts of interest with anything mentioned in this article.
References
1. 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.
DISCUSSION
Immediate implant placement become an increasingly 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 covering before immediate implant placement) the surgical site is protected by sufficient soft tissue that
could achieve a tension free primary closure.
37
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Soolari et al
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Soolari et al
Factors Influencing Patients Acceptance

of Treatment Plans at a Private Periodontal Practice
Ahmad Soolari, DMD, MS1 Nafiseh Soolari, BA2 Habibeh Shams3

Jasim M. Albandar4
Abstract
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 practice 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% African Americans, 18% Hispanic or Mexican Americans, 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$890US$37,200).
Patients cited the availability of suitable appointments (98%), good doctor communication (99%),
perception that pain and anxiety control during
treatment would be adequate (98%), and conviction 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 positive 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 communication with the doctor and staff, and constant
motivation and education of patients are key
to treatment acceptance. The study also suggests that certain demographics may influence the rate of treatment plan acceptance.
KEY WORDS: Treatment plans, treatment acceptance, patient questionnaire, periodontal treatment
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
39
Soolari et al
INTRODUCTION
The 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 allencompassing
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 individuals overall well-being.
It has been suggested that certain variables,
including office design, insurance coverage, payment methods, the constituents of the treatment
plans offered, supporting materials, interactions
with the office staff, and the doctors presentation 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 payment 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 communicate 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 critical for increasing practice production and developing 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 opinions about the characteristics that may influence
their acceptance of recommended periodontal plans at a private periodontal practice.
This study sample included patients seeking periodontal 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 complete a questionnaire about the patients 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 visits, 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 consisted mainly of closed-end questions. The questions 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, educational background, income level, method
of referral, and payment information (insur-
40
Vol. 7, No. 8
October 2015
Soolari et al
ance coverage, and method of payment if

they held no dental insurance or their insurance plan did not cover the treatment in full).
T
he next part of the questionnaire consisted
of a series of statements about the office
environment, their perception of the treatment and its outcome, and financial aspects.
Patients were instructed to mark each statement 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 treatment options were presented clearly, and I
was pleased with the outcome of treatment.
T
he next part of the questionnaire inquired
about the importance of each of several factors for the patients in accepting a treatment
plan. These included the time it would take to
complete treatment, options available for controlling pain, treatment cost, and convenience
of appointment times. Respondents were
instructed to mark each item as very important, somewhat important, or not important.
F
inally, the survey asked patients which staff
member(s) (assistant, front office staff, hygienist, doctor) and what part of the treatmentplanning process (photos, x-rays, study
models, previous patient images, information 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 freeform comments at the end of the survey.
Patients included in this study signed a consent form that described the purpose of the
study and the methods. The data were tabulated and presented as frequency tables.
NONRESPONSE ANALYSIS
We 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 periodontal treatment plan and completed a full
questionnaire, and those who declined the plan
for any reason. Of the 138 patients who participated 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 similar gender, but had a significantly different ethnicity profile (p=0.0008) compared to patients
who approved the recommended treatment
plan and completed the treatment (Table 1).
RESULTS
One-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 Caucasian, 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 education; all others had completed college or postgraduate studies. Ninety-four percent of patients
41
Soolari et al
Table 1: Demographics of Patients who Accepted or

Declined the Recommended Periodontal Tretment Plan

Response to Recommended Treatment Plan
Demographics
Gender Females
Males
Ethnicity Caucasian
African-American
Hispanic or
Mexican-American
Others*
Age (years)
Accepted Declined
No. 56 9
%
46.7
50.0
No.
64
53.3
50.0
No. 51
0 0.0008
42.5
No.
34
11
28.3
61.1
No.
22
0.8
18.3
11.1
No.
13
10.8
27.8
Mean 54.8 47.3 0.04

S.D.
14.4
14.0
* Mainly Middle-Eastern or Asian
rated their economic status as average.

Treatments performed included nonsurgical
methods, crown lengthening, osseous surgery,
soft tissue grafting, periodontal tissue regeneration, alveolar ridge augmentation, implant
placement or treatment of implant-related complications, extractions of teeth, and/or preprosthetic surgery. Ninety-five percent of patients
42
Vol. 7, No. 8
October 2015
completed treatment in 7 or fewer visits. The

cost of treatment ranged from US$890 to
US$37,000. Most patients had some insurance coverage but were still financially responsible 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.
Soolari et al
Effect of office environment on

treatment plan acceptance
The 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 acceptance for at least 90% of patients were the
initial visit to discuss treatment (93%), education 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 information regarding the expected length and outcome of treatment (95%). Ninety percent of
the patients felt that the treatment was effective, 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 attitude of the staff and their professionalism in
carrying out their work, as well as the quality of
information given during treatment and the interest of the entire staff in patients well-being.
Most important factors in accepting
a treatment plan
When asked which factors were very important in leading to treatment acceptance, 93%
of patients cited the likelihood that the treatment would be effective. The cost of treatment 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 important, 26% somewhat important), and the availability 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 helping 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 helpful 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 helping them decide to proceed with treatment.
Forty-four
percent
of
the
patients
reported that the office Web site was helpful, and 13% did not visit the Web site.
DISCUSSION
Dentists 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 knowledge 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 satisfaction 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
43
Soolari et al
manner in which care is given. Most patients

do not understand, nor are they able to evaluate, the clinical skills of a dentist; therefore,
they usually rely on other criteria, such as communication with the dentist and the dentists
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 treatment acceptance and patient satisfaction.[7, 8]
Dilatush and Horrocks[3] stated that
patients use four criteria to select a dentist:
price, technology, convenience, and public relations. Their findings are consistent
with the results of our survey, in which over
90% of our patients stated that their treatment 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 paying 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 communication. 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 scheduling, providing medical and dental history,
consenting to treatment, and following the dentists instructions during or after procedures.
Levin[6,9] recommended building better rela-
44
Vol. 7, No. 8
October 2015
tionships with patients to help a practice grow

and emphasized an internal marketing program for the entire office staff. Interpersonal
relationships are a critical component of internal 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] working 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 treatment, 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-screening program to emphasize the impact of overall 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 treatment 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 addition 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 features
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
dentists 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 proceed 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 lacking in these devices that minimized their influence 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 questionnaire regarding patient treatment acceptance. To our best knowledge, there are no such
validated surveys in the peer-reviewed literature 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 survey would be preferable, and it would provide
a more complete picture regarding the reasons that patients accept or refuse treatment.
Our survey included only 120 responses from
a particular patient population at one periodontal 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 representative socioeconomic status, education, and
ethnic/racial makeup, may have answered the
survey differently. On the other hand, the inclusion of multiple practices might have created
other issues. For example, different practices
may have different procedures for communication 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 communicator, the dentist needs to be a good listener.
A patients chief complaints should be taken
into consideration when developing a treatment plan. Furthermore, the clinician should
45
Soolari et al
educate, motivate, and address the questions and concerns raised by the patient. With
good communication from the doctor and
staff, patients will have confidence in the treatment 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 procedures, methods for pain control, the availability
of alternative treatment options, and the predictability of the outcome of treatment. Generally, the treatment outcome should be the
restoration of function and/or esthetics, and it

should be stable and reasonably predictable.
Correspondence:
Dr Ahmad Soolari
11616 Toulone Drive
Potomac, MD 20854
Phone: 301-674-9815
fax: 240-845-1087
email: asoolari@gmail.com
Disclosure
The authors report no conflicts of interest with
anything mentioned in this article.
5. D. Grembowski, P. Milgrom, and L. Fiset. Factors influencing dental decision making, J Public
Health Dent, vol. 48, no. 3, pp. 159-167, 1988.
10. R
.P. Levin. 4 steps to greater case acceptance
in your dental practice, Dent Pract Manage, no.
May 92014.
References
1. 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.
6. J.S. Kalsi and K. Hemmings. The influence of

patients decisions on treatment planning in restorative dentistry, Dent Update, vol. 40, no. 9,
pp. 698-700, 702-694, 707-698, 710, 2013.
11. D
. Seidel-Bittke. Get a yes! for nonsurgical
periodontal treatment, Dent Today, vol. 31, no.
5, pp. 76, 78, 80 passim, 2012.
2. G.T. McInnes. Integrated approaches to management 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.
46
Vol. 7, No. 8
October 2015
7. M
. Redford and H.C. Gift. Dentist-patient interactions 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.
12. M
.T. Rosedale and S.M. Strauss. Diabetes
screening at the periodontal visit: patient and
provider experiences with two screening approaches, Int J Dent Hyg, vol. 10, no. 4, pp.
250-258, 2012.
13. C
. Marant, J. Longin, R. Gauchoux, et al. Longterm treatment acceptance: what is it, and how
can it be assessed?, Patient, vol. 5, no. 4, pp.
239-249, 2012.
Alsourori et al
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Alsourori et al
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

Abstract
he 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 rehabilitated by tilted or by axially placed dental implants,
against the alternative hypothesis of a difference.
KEY WORDS: Dental implants, tilted, off-axis, review, analysis

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.
49
Alsourori et al
BACKGROUND
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 rehabilitated
by tilted or by axially placed dental implants,
against the alternative hypothesis of a difference.

An electronic search without time restrictions
was undertaken (and last checked) in July 2014
in the following databases: PubMed, Web of Science, 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 Science, 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 implantsrelated journals was also performed. The reference
list of the identified studies and the relevant reviews
on the subject were also scanned for possible additional studies. Moreover, online databases providing information about clinical trials in progress were
checked (clinicaltrials.gov; www.centerwatch.com/
clinicaltrials; www.clinicalconnection.com). Eligibility 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-
50
Vol. 7, No. 8
October 2015
plete loss of the implant. Exclusion criteria were

case reports, technical reports, animal studies,
in vitro studies, biomechanical studies, finite element 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.
RESULTS
The search strategy resulted in 44 publications.
A total of 5029 dental implants were tilted (82 failures; 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 0.841.56). A statistically significant difference
was found for implant failures when studies evaluating implants inserted in maxillae only were pooled
(RR 1.70, 95% CI 1.052.74; P = 0.03), the same
not happening for the mandible (RR 0.77, 95%
CI 0.391.52; P = 0.45). There were no apparent 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 outcome 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 shortmedium term. However, there is lack of randomized
long-term trials to determine the efficacy of this surgical 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 quantity of residual bone, which may be beneficial to
implant stability. Moreover, a more even distribution of stress around implants is achieved when
implants with longer lengths are used.2,3 Regarding 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 assessment of the studies was achieved according to the
Newcastle-Ottawa scale (NOS).4 All the methodology procedures of this Meta-analysis review
were performed starting from clear focus answerable 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 compare the survival rate of dental implants, postoperative 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 suggests that tilted implants may achieve the same
outcome as implants placed in a straight manner. 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 survival 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 rehabilitation 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.
Disclosure
The authors report no conflicts of interest with anything mentioned in this article
References
1. 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=pm
centrez&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-dimensional 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.
51
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The Journal of Implant & Advanced Clinical Dentistry

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

The Journal of Implant & Advanced Clinical Dentistry

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The Journal of Implant & Advanced Clinical Dentistry

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11 Utilization of the Co-Axis

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