Bisphosphonate Related Osteonecrosis of the Jaw

Mazor et al

Minimally Invasive Antral Membrane Mazor et al Balloon Elevation to Treat Previous Sinus Augmentation Failure: A Case Report Ziv Mazor, DMD1 2 Abstract Background: Successful implant placement in Results: The procedure went smoothly with the atrophic posterior maxilla is often complicated no complications. Postsurgical healing was by the quality and volume of available bone. Sinus uneventful. Six months following the surgical floor elevation is advocated in these cases in order procedure, periapical radiographs were per- to gain sufficient bone around the implants. Sinus formed and prosthetic rehabilitation was initiated. elevation can be done either by an open lateral win- dow approach or by a closed osteotome approach Conclusion: MIAMBE can be applied to patients depending on the available bone height. This case in need of posterior maxilla bone augmentation. report demonstrates the feasibility and safety of Absence of patient morbidity and satisfactory minimally- invasive antral membrane balloon eleva- bone augmentation with this minimally invasive tion (MIAMBE), followed by bone augmentation and procedure suggests that MIAMBE should be implant fixation in a patient who had previous sinus considered as an alternative to the currently augmentation failure done by a lateral approach. employed methods of maxillary bone augmentation. Methods: A 55 year old male patient was referred for a second posterior maxillary bone augmenta- tion. After undergoing pre-procedural assess- ment and signing an informed consent, the patient underwent alveolar crest exposure and osteot- omy (3 mm diameter), followed MIAMBE. PRF (platelet rich fibrin) and xenograft bone substi- tute were injected into the sinus under the antral membrane and implant placement was performed. KEY WORDS: Sinus lift, antral membrane, maxillary sinus, dental implants 1. Private practice limited to Periodontics and Implant Dentistry, Ra’anana Israel 2. Private practice, Petach Tikva Israel The Journal of Implant & Advanced Clinical Dentistry 49

Mazor et al INTRODUCTION potential complications (membrane tear, bleed- ing, infection and sinus obstruction), swell- Successful implant placement in the atrophic ing and discomfort, relative contra-indications posterior maxilla is often complicated by the (sinus convolution septum or narrow sinus and quality and volume of available bone. Types previous sinus surgery). The lateral maxillary 3 and 4 bone tend to predominate in the pos- window technique also requires considerable terior maxilla making this region typically the surgical skill, specialized equipment, and time. least dense bone in the oral cavity.1 Postex- traction resorption patterns, use of a remov- The osteotome technique as introduced able prosthesis, physical trauma, periodontal by Summers,13 also called bone added disease, and pneumatization of the maxil- osteotome sinus floor elevation (BAOSFE), lary sinus can significantly reduce or eliminate is an alternative approach for sinus eleva- the height and width of the residual alveolar tion in cases where a small amount of bone ridge. In the atrophic posterior maxilla, lon- height is missing.14 BAOSFE can be compli- ger and wider implants are needed to enhance cated by membrane perforation and tearing,15 long-term survival. As such, this area often which can be somewhat reduced with expert requires bone augmentation beneath the technique and dedicated instrumentation.16 sinus to increase the vertical height of bone. The minimally-invasive antral membrane bal- The subantral augmentation, or “sinus lift” loon elevation (MIAMBE) technique is a modi- procedure, was first reported by Tatum and has fication of the BAOSFE method in which antral evolved over the last 25 years. A lateral win- membrane elevation is executed through the dow (modified Caldwell-Luc) approach to the osteotomy site (of 3.5 mm) using a dedicated maxillary sinus is used, and has shown such balloon. Former reports have demonstrated favorable results that the posterior maxilla is the use of this technique as an alternative to often considered one of the most predicable conventional procedures. This manuscript regions for grafting prior to or simultaneously describes a case of using this treatment modal- with implant placement.2-7 The basic technique ity and its advantages in a case previously involves creation of a hinged window in the lat- treated with an open approach that failed. eral wall of the maxilla.8 When completed, the window is gently pressed inward and upward MATERIALS AND METHODS into the sinus cavity, which lifts the Schneide- rian membrane and serves as a new sinus floor. Patient: A 55 year old male (non- The void between the elevated tissues and the contributory medical history) with a original sinus floor is filled with bone graft mate- history of previous failed open sinus aug- rial. Implants may be simultaneously placed, or mentation was referred for treatment. the graft may be allowed to heal prior to implant placement.9-12 The lateral maxillary window Materials: offers average implant survival of 91.8% (rang- (a) MIAMBE balloon harboring device ing from 61.7-100%).17 This method involves (MIAMBE, Netanya, Israel) – This is a stainless steel tube that connects on its proximal end to 50 Vol. 1, No. 7 October 2009

Mazor et al Figure 1: Balloon harboring device with Holtem stoppers. Figure 2: Silicone balloon during in ation. Figure 3a: Presurgical panoramic radiograph. Figure 3b: Presurgical CBCT scan showing ridge height Figure 4: Full thickness mucoperiostal ap re ection with and previous sinus window. two small vertical incisions. the dedicated inflation syringe, and on its dis- tal portion has a screw-in mechanism, which secures the device into the osteotomy site (fig- ure 1). The single use balloon is concealed in the distal end until it is inflated (figure 2). (b) Dedicated “MIAMBE kit” including bone graft injector, osteotome, screw-tap and a suction syringe device (MIAMBE) (c) Coronary angioplasty inflation syringe (Merit Medical, Galway, Ireland) – filled with diluted contrast material (Ultrav- The Journal of Implant & Advanced Clinical Dentistry 51

Mazor et al Figure 5a: Drilling with piezosurgery diamond tip 1 mm Figure 5b: Periapical radiograph with osteotome verifying short of the sinus oor. position of sinus oor. Figure 6a: PRF is inserted to the osteotomy site. Figure 6b: The sinus oor is upfractured using MIAMBE osteotome. 52 Vol. 1, No. 7 October 2009 Figure 7: The metal sleeve of the balloon-harboring device is inserted into the osteotomy 1 mm beyond the sinus oor (depth control by Te on stopper).

Mazor et al Figure 8a: Initial balloon in ation pressure (2 atm). Figure 8b: Once the balloon emerges from the metal sleeve apical to the sinus membrane, the pressure drops to 0.5 atm. Figure 9: The balloon in ation and membrane elevation Figure 10: Membrane integrity is assessed by direct are evaluated by a periapical X-ray. visualization during inspiration. ist 300 by Schering AG, Berlin, Germany) Clinical protocol: Pre-procedural panoramic radiographs and (d) PRF autologous platelet rich fibrin - obtained computed tomography (CT) scans (figures 3a, by centrifugation of 10 ml divided into 4 test 3b) were used to assess the following: mucosa tubes and spun for 10 minutes at 2700 RPM. thickness and pathology, bone height and thick- ness, sinus structure, and major blood vessels. (e) Xenograft bone graft (Endobone, Biomet 3I) The patient received an oral explanation regard- The Journal of Implant & Advanced Clinical Dentistry 53

Mazor et al Figure 11a: Bone graft material consisted of Xenograft Figure 11b: Bone syringe lled with the grafting material. (Endobone Biomet 3I) and PRF. Figure 12a: Osteotomy and sinus lled with grafting Figure 12b: Periapical radiograph showing bone ll of the material. sinus. ing the procedure and signed an informed using 2% Lidocaine. 40ml of the patient’s blood consent. A pre-procedural non-steroidal anti- was drawn by venous puncture and processed inflammatory agent and AUGMENTIN (clavulan- to obtain platelet rich fibrin (PRF). Under local ate potassium) 875 mg twice daily were initiated anesthesia, a horizontal full thickness flap with 24 hours prior to the procedure. Local anesthe- palatal bias followed by 2 small vertical inci- sia (infiltration of posterior, middle superior alve- sions to expose the alveolar crest were per- olar and greater palatine nerves) was performed formed (figure 4). Drilling was performed with 54 Vol. 1, No. 7 October 2009

Mazor et al Figure 13a: Implant xture delivery. Figure 13b: Implant xtures delivered to full depth. Piezosurgical tips in the center of the alveolar with progressively higher volumes of contrast crest to a point 1-2 mm short of the sinus floor. fluid (figures 8a, 8b). The balloon inflation and The depth of this initial drilling preparation was membrane elevation are evaluated by sequen- predetermined according to measurements tial periapical radiographs. Once the desired obtained from the CT scan and periapical x-rays elevation (usually >10 mm) is obtained, the (figures 5a, 5b). The osteotomy was enlarged balloon should be left inflated for five minutes from 2.0mm to 2.9 mm with the MIAMBE to reduce sinus membrane elasticity (figure 9). Osteotome. Bone graft material and PRF were After five minutes, the balloon is deflated and inserted into the osteotomy followed by upfrac- removed and membrane integrity is assessed turing of the sinus floor with osteotomes limited by: 1) Valsalva maneuver; 2) Respiratory by Teflon stoppers (figures 6a, 6b). After remov- movement of blood within the osteotomy; 3) ing the osteotome, Schneiderian membrane Direct visualization into osteotomy (figure 10). integrity was assessed by Valsalva maneuver. After confirming Schneiderian membrane The metal sleeve of the balloon-harboring integrity, the bone substitute (Endobon, Biomet device was inserted into the osteotomy 1 mm 3i) is injected through the osteotomy filling the beyond the sinus floor with overextension pre- space created beneath the Antral membrane vention by a Teflon stopper (figure 7). The (figures 11a, 11b, 12a, 12b). After addition of balloon was slowly inflated to two standard the bone graft, dental implant fixtures (Nanotite atmospheres (atm). With this technique, once Certain, Biomet 3i) were delivered in the stan- the balloon emerges from the metal sleeve api- dard fashion (figures 13a, 13b). The flap was cal to the sinus membrane, the pressure drops then primarily closed and periapical radiographs to 0.5 atm. Subsequently, the balloon is inflated verified Implant and graft placement (figure 14a). The Journal of Implant & Advanced Clinical Dentistry 55

Mazor et al Figure 14a: Periapical radiograph immediately post-op. Figure 14b: Periapical radiograph 5 months post-op. Results: augmentation, requires considerable skills, Initial healing following surgery was uneventful. and may frequently result in membrane tear.21 Six months following the surgical procedure, periapical radiographs were performed (figure CONCLUSION 14b) and prosthetic rehabilitation was initiated. MIAMBE appears to be a safe and effec- Discussion: tive way to perform antral membrane This case report supports the notion18,19 that elevation and posterior maxillary bone aug- MIAMBE, a minimally invasive single sitting mentation. The procedure is minimally inva- procedure of maxillary bone augmentation and sive, produces mild patient discomfort, and implant placement can be executed even in a delivers satisfactory augmentation results. case where previous conventional sinus augmen- tation has failed. The “osteotome technique” is Correspondence: truly minimally invasive, but not recommended Ziv Mazor, DMD if the residual ridge height is 4mm.20 The 142 Ahuza st Ra’anana Israel 43300 osteotome technique, even when selectively Tel: 972-97400336,Fax: 972-97602839 applied and endoscopically controlled, yields Email: [email protected] modest antral membrane elevation and bone 56 Vol. 1, No. 7 October 2009

Mazor et al Disclosure The Journal of Implant & Advanced Clinical Dentistry The authors report no conflicts of interest with anything mentioned in this article. your article! References For complete details 1. Truhlar RS, Orenstein IH, Morris HF, Ochi S. Distribution of bone quality regarding publication in in patients receiving endosseous dental implants. J Oral Maxillofac 1987; JIACD, please refer 55(Suppl 5): 38-45. to our author guidelines at 2. Tatum H. Maxillary and sinus implant reconstructions. Dent Clin North Am 1986; 30: 207-229. the following link: 3. Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous http://www.jiacd.com/ marrow and bone. J Oral Surg 1980; 38: 613-616. 4. Misch CE. Maxillary sinus augmentation for endosteal implants: Organized authorinfo/ alternative treatment plans. Int J Oral Implantol 1987; 4: 49-58. author-guidelines.pdf 5. Block MS, Kent JN, Kallukaran FU, Thunthy K, Weinberg R. Bone maintenance 5 to 10 years after sinus grafting. J Oral Maxillofac Surg or email us at: 1998; 56: 706-714. [email protected] 6. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on the survival of endosseous dental implants: A systematic review. Ann Periodontol 2003; 8(1): 328-343. 7. Peleg M, Garg AK, Mazor Z. Predictability of simultaneous implant placement in the severely atrophic posterior maxilla: A 9-year longitudinal experience study of 2132 implants placed into 731 human sinus grafts. Int J Oral Maxillofac Implants 2006; 21(1): 94-102. 8. Friberg B, Nilson H, Olsson M, Palmquist C. MkII: The self-tapping Branemark implant: 5-year results of a prospective 3-center study. Clin Oral Impl Res 1997; 8: 279-285. 9. roum SJ, Tarnow DP, Wallace SS, Rohrer MD, Cho SC. Sinus floor elevation using anorganic bovine bone matrix (OstoGraf/N) with and without autogenous bone: A clinical, histologic, radiographic, and histomorphometric analysis—Part 2 of an ongoing study. Int J Periodont Rest Dent 1998; 18: 529-543. 10. Peleg M, Chaushu G, Mazor Z, Ardekian L, Bakoon M. Radiological findings of the post-sinus lift maxillary sinus: A computerized tomography follow-up. J Periodontol 1999; 70: 1564-1573. 11. Smiler DG. The sinus lift graft: Basic technique and variations. Pract Periodontics Aesthet Dent 1997; 9: 885-893. 12. Peleg M, Mazor Z, Chaushu G, Garg AK. Sinus floor augmentation with simultaneous implant placement in the severely atrophic maxilla. J Periodontol 1998; 69: 1397-1403. 13. Summers RB. Sinus floor elevation with osteotomes. J Esthet Dent 1998; 10: 164-171. 14. Nkenke E, Schlegel A, Schultze-Mosgau S, Neukam FW, Wiltfang J. The endoscopically controlled osteotome sinus floor elevation: a preliminary prospective study. Int J Oral Maxilofac Implants 2002; 17: 557-566. 15. Berengo M, Sivolella S, Majzoub Z, Cordioli G. Endoscopic evaluation of the bone-added osteotome sinus floor elevation procedure. Int J Oral Maxillofac Surg 2004; 33: 189-194. 16. Toffler M. Staged sinus augmentation using a crestal core elevation procedure and modified osteotomes to minimize membrane perforation. Pract Proced Aesthet Dent 2002; 14: 767-774. 17. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review. Ann Periodontol 2003; 8: 328-343. 18. Kfir E, Kfir V, Mijiritsky E, Rafaeloff R, Kaluski E. Minimally invasive antral membrane balloon elevation followed by maxillary bone augmentation and implant fixation. J Oral Implantol 2006; 32(1): 26-33. 19. Kfir E, Kfir V, Eliav E, Kaluski E. Minimally invasive antral membrane balloon elevation: report of 36 procedures. J Periodontol 2007; 78(10): 2032-2035. 20. Rosen PS, Summers R, Mellado JR, Salkin LM, Shanaman RH, Marks MH,Fugazzotto PA. The bone-added osteotome sinus floor elevation technique: multicenter retrospective report of consecutively treated patients. Int J Oral Maxillofac Implants 1999; 14(6): 853-858. 21. Fugazzotto PA. Augmentation of the posterior maxilla: a proposed hierarchy of treatment selection. J Periodontol 2003; 74(11): 1682-1691. The Journal of Implant & Advanced Clinical Dentistry 57



Comparison of Stress Patterns In and Sakthish et al Around Orthodontic Micro-implants: A Finite Element Study S. Sakthish, MDS1 23 Abstract Background: Conservation of anchorage has 60o and 90o angulations. All three angulations always been a priority for efficient orthodontics. brought about stresses within the physiologi- For this reason, temporary anchorage devices cal limits in bone. Stress produced in the sur- such as micro-implants have become popular. rounding bone was within physiological limits in While orthodontic miro-implants have been suc- both osseointegrated and non-osseointegrated cessfully used to withstand orthodontic force, micro-implant models with 200g of orthodontic their efficiency in withstanding heavier forces force application. With orthopaedic force (400g) such as orthopaedic force has not been tested. application, however, the stress produced in the surrounding bone in osseointegrated micro- Methods: Using finite element analysis mode implant models (205.14g) was within physi- of evaluation, this study aimed to compare: ological limits whereas the stress in surrounding i) the stress patterns in the surrounding bone bone in non-osseointegrated micro-implant mod- and micro implant when placed at angula- els (530.42g) exceeded physiological limits. tions of 30o, 60o, 90o; ii) Effect of orthodontic and orthopaedic forces on surrounding bone Conclusions: Both perpendicular and diagonal and micro-implants when tested on osseointe- placements of implants are acceptable and pro- grated and non–osseointegrated implant models. duce tolerable stress patterns. Both osseointe- grated and non-osseointegrated implants are Results: Micro-implant 30o angulation pro- acceptable for orthodontic force. However, duced better stress distribution on the sur- osseointegration of micro-implants is indicated rounding bone and micro-implant compared to for successful loading of orthopaedic forces. KEY WORDS: bone, osseointegration, orthodontic anchorage, microimplants, dental implants, temporary anchorage device 1. Former PG student, Sri Ramachandra Dental College 2. Professor, Dept. of Orthodontics, Sri Ramachandra Dental College 3. Prof and HOD, Dept. of Orthodontics, Sri Ramachandra Dental College The Journal of Implant & Advanced Clinical Dentistry 59

Sakthish et al INTRODUCTION tity of osseointegration. The efficiency of micro- implants has been evaluated in various studies Anchorage control is fundamental to successful and the general consensus is that even with orthodontic treatment and has been addressed immediate orthodontic loading, micro-implants in a variety of ways including: 1) increasing the are able to withstand forces of 200-300g.7,8 number of teeth in the anchorage unit; 2) altering the angulation of anchor teeth; 3) using extraoral While osseointegrated implants have been and intraoral anchorage devices. Intraoral used as anchors for orthopaedic devices, these anchorage devices may not provide absolute studies used conventional osseointegrated anchorage control, whereas extraoral appli- Branemark implants which were loaded with ances are dependent on patient compliance. orthopaedic forces up to 5N.9,10 However, there is no reported literature in the efficiency of TAD’s The advent of osseointegrated implants by used as anchors to apply orthopaedic force. the pioneer studies of Branemark1 changed the Recently, orthodontic micro-implants capable of scenario. The standard dental implants made of osseointegration have also been introduced.11 titanium have been used and have proved effec- tive for anchorage purposes,2,3 however they Finite element analysis (FEM) is a modern have draw backs such as bulk, osseointegration tool for numerical stress analysis, which has the wait time, and added cost. For these reasons, advantage of being applicable to solids of irreg- temporary anchorage devices (TAD’s) such as ular geometry that contain heterogeneous mate- micro/mini dental implants have become popu- rial properties. Finite element analysis provides lar for enhancing orthodontic anchorage. These the orthodontist with quantitative data that can devices reinforce anchorage by either supporting extend the understanding of physiologic reac- the reactive unit or by eliminating the need for tions that occur within the dentoalveolar com- the reactive unit altogether.4 Two types of micro- plex. Such numerical techniques may yield an implant placement have been recommended: improved understanding of the reactions and 1) diagonal placement; 2) perpendicular place- interactions of individual tissues.12 Concern- ment.5 Micro-implants are placed diagonally ing dental implants, finite element analysis has to the long axis of the tooth in order to avoid proven to be a precise and applicable tool injury to the roots, but there are no studies to for evaluating stress patterns in surrounding prove which micro implant angulation brings bone.14 Hence, FEM analysis was selected in about optimal stress in the surrounding bone. this study to assess the stress patterns in the surrounding bone and micro implant models. TAD’s can be fixed to the bone mechani- cally by cortical stabilization (or) biochemically Using FEM, This study sought to deter- by osseointegration.4,6 Most TAD’s are retained mine which micro-implant angulation achieves by primary stability where the maximum appli- optimal stress in the surrounding bone. Addi- cable load is proportional to the surface area tionally, stress in the surrounding bone was of the bone contact to the implant. With evaluated when osseointegrated and non- osseointegrated implants, on the other hand, osseointegrated micro-implants are used for the maximum load is proportional to the quan- orthodontic or orthopaedic anchorage purposes. 60 Vol. 1, No. 7 October 2009

Sakthish et al MATERIALS AND METHODS Figure 1: Finite element model of maxilla with orthodontic micro-implant. The objectives of this study were as follows: 1) To compare stress patterns in the surround- with the dental software EZDICOM (Source- ing bone and micro-implant when placed at Forge, Incorporated, Mountain View, Califor- angulations of 30o, 60o and 90o; 2) To com- nia, USA). These images were then copied pare the stress patterns affected by orthodon- to AUTOCAD®(Autodesk, Incorporated, San tic and orthopaedic force on the microimplant Rafael, California, USA) and traced. This proce- and surrounding bone in both osseointegrated dure was done for each slice. The traces were and non-osseointegrated models. To achieve arranged in a complete set to make a single unit such, this study was carried out in two parts. using the modelling software PRO/ENGINEER (Parametric Technology Corporation, Needham, In the first part of the study a finite element Massachusetts, USA). The maxilla, maxillary model of the maxillary arch with all of the teeth dentition, and alveolar bone were modelled geo- except the first premolars was constructed. A metrically. The first premolars were removed for model of a non-osseointegrated micro-implant our study purpose. The region of maxillary first was traced and placed in the alveolar bone molar, second premolar, alveolar bone and the distal to the roots of the second premolar at micro implants were taken for this study. The three different angulations (30o, 60o, 90o) to assembly of single unit was transferred to the the long axis of the teeth. An orthodontic force finite element analysis software ANSYS (ANSYS, of 200g was applied in the direction simulat- Incorporated, Cononsburg, Pennsylvania, USA) ing anterior retraction and the stress patterns to create elements and nodes for the teeth, alve- in the surrounding bone and micro implant olar bone, periodontal ligament, and the micro models were studied. In the second part of implant. The geometric model was converted to the study, micro-implants with and without finite element model by connecting the elements osseointegration were modelled. An orthodon- with the nodes in all the directions (Figure 1). tic force of 200g was applied from the head of the micro implant in a direction simulating maxillary anterior retraction and an orthopae- dic force of 400g was also applied from the head of the implant simulating the force from the protraction face mask in both the mod- els. The stress patterns in the micro implant models and surrounding bone were studied. Geometric modelling of the maxilla and the maxillary dentition was accomplished in a num- ber of steps. First, a computerized tomogram (CT) scan of a patient maxilla and the dentition was acquired with images taken at 1mm inter- vals. Next, the scanned images were viewed The Journal of Implant & Advanced Clinical Dentistry 61

Sakthish et al Figure 2: Simulation of non-osseointegrated micro- Figure 3: Simulation of osseointegrated micro-implant implant model. model. A micro implant similar to Absoanchor simulated as the entire surface of the threads No.1312-07 (Dentos India Pvt. Ltd), taper type of micro-implant getting fused with the sur- with a length of 7mm and diameter of 1.3 mm rounding bone (Figure 3). Geometric model- at the base and 1.2 mm at apex was modelled ling of the micro-implant was accomplished by which was then traced to create a geometric placing the traced micro implants distal to the and finite element model. Simulation of micro roots of the second premolar at 30o, 60o, 90o implant model without osseointegration was angulations to the long axis of the tooth, with simulated as only the upper part of threads of the head oriented towards the crown (Figure micro-implant surface in contact with the sur- 4). A line passing through the long axis of the rounding bone (Figure 2). Simulation of the second premolar was traced in ANSYS that micro-implant model with osseointegration was was used as a reference plane for placing the 62 Vol. 1, No. 7 October 2009

Sakthish et al Figure 4: Model of the maxillary arch with micro-implants the non-osseointegrated micro-implant the num- at angulations of 30o, 60o, and 90o. ber of elements was 212,266 and 36,777 nodes. micro implant in various angulations. Finite The material properties (Table 1) were element modelling of micro implant was accom- assigned to the various structures such as the plished by converting the geometric model into a implant, alveolar bone, tooth, and periodontal finite element model by connecting the elements ligament in the finite element model.15 Boundary with the nodes in all the directions. The finite ele- conditions of the maxillary model were restrained ment model of the osseointegrated micro-implant at the superior border of the maxilla in order to had 237,833 elements and 40,197 nodes. For avoid any movement against the loads imposed on the dentoalveolar structure. Concerning application of force, 200g of force was applied on the models simulating non-osseointegrated and osseointegrated micro-implants placed at 30o, 60o and 90o angulations to the long axis of the tooth. For orthopaedic force, 400g of force was applied on the models (Figures 5a,5b). RESULTS Part I In the peri-implant region, maximum compres- sive stresses were observed in the mesial side of implant neck and minimum compressive stresses were observed in the distal side of implant apex. Maximum tensile stresses were observed in the distal side of the implant neck and minimum ten- sile stresses were observed in the mesial side of the implant apex. This was a common observation Materials Young’s Modulus Poisson’s Ratio Titanium 1.10E + 05 3.0E – 01 Alveolar Bone 1.37E + 03 3.0E – 01 Periodontal Ligament 6.67E – 01 4.5E – 01 Tooth 1.96E + 04 3.0E – 01 The Journal of Implant & Advanced Clinical Dentistry 63

Sakthish et al Figure 5a: Orthodontic force nite element model. Figure 5b: Orthopaedic force nite element model. for all three angulations of implants (Table 2). pattern of stress distribution was also observed Of the three angulations, the least amount in the non–osseointegrated micro-implant, but of stress was observed in the implant in the osseointegrated micro-implant showed the bone and peri-implant region when a more even stress distribution in the peri- the implant was placed at 300 (Table 3). implant region although stresses were more on the mesial side in the direction of the force Part II application (Table 4). The osseointegrated On orthodontic force application, the osseointe- model showed less stress in the microimplant grated implant model showed the maximum and in the surrounding bone as compared and minimum compressive stresses on the to the non-osseointegrated model (Table 5). mesial sides of the implant neck and apex respectively. Maximum and minimum tensile On orthopaedic force application, the stress stresses were observed in the distal sides of patterns were similar to that of orthodontic the implant neck and apex respectively. This force application but with higher stress values due to increased force magnitudes. The mag- Various Compressive Stress Tensile Stress Angulations Neck Apex Neck Apex 30O 60O -281.69g -0.01128g 209.25g 5.36g 90O -285.35g -0.02016g 215.26g 4.19g 64 Vol. 1, No. 7 October 2009 -289.28g 0.02093g 223.57g 2.91g

Sakthish et al Various Angulation Placement Stress in Surrounding Bone Stress in Micro Implant 30o 255.21g 4420g 60o 267.21g 90o 276.12g 4515.21g 4595.22g Micro-Implant Compressive Stress Tensile Stress Model Neck Apex Neck Apex Osseointegrated -102.59g -0.02276g 97.47g 2.56g Non-Osseointegrated -281.69g -0.01128g 209.25g 5.36g Micro Implant at 30o Stress in Stress in (Orthodontic force – 200g) Surrounding Bone Micro Implant Osseointegrated 100.56g 4395g Non-Osseointegrated 255.21g 4420g nitude of compressive and tensile stresses DISCUSSION in the peri-implant region were found to be less in the osseointegrated implant model Temporary anchorage devices like screws and as compared to non-osseointegrated implant plates have become popular because they have model (Table 6). Similarly the osseointegrated the advantages of smaller size and the capa- model also showed less stress in the micro- bility for immediate loading. Additionally, they implant and in the surrounding bone (Table 7) are relatively inexpensive, increase patient comfort, and are easy to place and remove. The Journal of Implant & Advanced Clinical Dentistry 65

Sakthish et al Micro-Implant Compressive Stress Tensile Stress Model Neck Apex Neck Apex Osseointegrated -214.78g -0.02357g 193.48g 2.90g Non-Osseointegrated -578.25g -0.04531g 491.36g 7.28g Micro Implant at 30o Stress in Stress in (Orthodontic force – 400g) Surrounding Bone Micro Implant Osseointegrated 205.14g 8618g Non-Osseointegrated 530.42g 8856g FEM has been used extensively in the pre- in turn, is dependent on the appropriate level of diction of biomechanical performance of dental bone remodelling that occurs in response to the implant systems.14,16 These studies have evaluated stress in the surrounding bone and implant.12 The osseointegrated implants in response to occlusal stress in the surrounding bone should be within forces which may be axial, non–axial, or oblique range of physiologic homeostasis. The range of occlusal. However, there are not many FEM stud- acceptable compressive stress needed for healthy ies evaluating the performance of orthodontic micro maintenance of bone appears to be between 1.4 implants. In contrast to dental implants, these to 5 Mpa (140 to 500g).14,17 Stresses exceed- microimplants are generally non-osseointegrated ing this range have been reported to cause bone and are subjected to forces in a non-axial direction. resorption and fatigue failure of the implant. The magnitude of force is also significantly less than those placed on dental implants. Immediate load- Bone is a porous material with complex, non- ing of these micro/mini implants is recommended homogenous anisotropic microstructure. Cortical if the force applied is less then two Newtons.7,8 bone has the highest load bearing capacity due to its dense nature when compared to porous trabe- The long-term clinical performance of a dental cular bone.18 In cortical bone, stress dissipation implant is dependent upon the preservation of good is restricted to the immediate area of bone sur- quality of bone in the peri-implant region which, rounding the implant where as in trabecular bone, 66 Vol. 1, No. 7 October 2009

Sakthish et al Figure 6a: Stress patterns in surrounding bone at 30º Figure 6b: Stress patterns in surrounding bone at 60º angulation. angulation. Figure 6c: Stress patterns in surrounding bone at 90º perpendicular loading and diagonal loading have angulation. been advocated for orthodontic implants, there is no literature documenting which angulation pro- a fairly broader distant stress distribution occurs. duces optimal stress in the bone. The first part One must keep this in mind when planning place- of the study evaluated stress patterns in relation ment of micro-implants for orthodontic purposes to various angulation placements and found that as the nature of bone varies in different areas of 30o angulation placement of non-osseointegrated maxilla and mandible.19 For orthodontic retrac- micro-implant model produced the less amount of tion of the anterior segment, micro-implants are stress in the peri-implant region when compared typically placed between the premolar and molar. to 60o and 90o angulation placement. It was also Accordingly, in this study, D4 bone (posterior max- found that the stresses in the surrounding bone illa) was simulated for studying stress patterns. (Figures 6a-c) and non-osseointegrated micro- implant were comparatively less at 30o angula- Micro-implants aid retention by mechanical tion when compared to 60o and 90o. However, means rather than osseointegration. While both the difference among all of these stress patterns was not statistically significant and all three angu- lation placements brought about stress levels within physiological limits. Maximum compressive stresses were observed in the mesial side of neck of implant towards the direction of force applica- tion and maximum tensile stresses were observed in the distal side of neck in the direction opposite of force application. This was true for all three angula- tion placements with minor variations in magnitude. The Journal of Implant & Advanced Clinical Dentistry

Sakthish et al Figure 7a: Stress patterns in the osseointegrated micro- Figure 7b: Stress patterns in the non-osseointegrated implant with orthodontic force application. micro-implant with orthodontic force application. The second part of study demonstrates that With both the orthodontic and orthopaedic with orthodontic force application, the stresses force models demonstrating reduced stress pat- produced in the peri-implant region, surround- terns in the osseointegrated micro-implants ver- ing bone, and micro-implant were less in the sus non-osseointegrated micro-implants, contact osseointegrated model than in the non-osseointe- patterns between the implants and bone must be grated model. Both models demonstrate maximum considered. In the osseointegrated model, the compressive stresses at the implant neck in the entire surface of the micro-implant interfaces with direction of force application while maximum ten- the surrounding bone and distributes force over a sile stress was observed at the implant neck in the greater surface area. This does not occur in the direction opposite of force application. While the non-osseointegrated model. Skalak et al20 noted stress patterns appeared more evenly distributed that the close apposition of bone to the implant around the implant neck of the osseointegrated surface means that under loading, the interface model as compared to the non-osseointegrated moves as a unit without any relative motion, which model (Figures 7a,7b), the stresses in both mod- is essential for transmission of stresses. Our els were found to be within the physiological limits. study model appears to support this assessment. With orthopedic force application, the stresses CONCLUSION in the peri-implant region in the non-osseointe- grated micro-implant models were found to exceed From this study, it was found that: 1) Placement of physiological limits in contrast to the osseointe- non-osseointegrated micro-implants at a 30o angu- grated implant model. Like the orthodontic force lation model produced better stress distribution on model, stresses for the orthopaedic force model the surrounding bone and micro-implant compared also appeared more evenly distributed around the to 60o and 90o angulation placements. All three osseointegrated microimplant than in the non- angulation placements brought about stresses osseointegrated micro-implant (Figures 8a,8b). within physiological limits of bone with minimal 68 Vol. 1, No. 7 October 2009

Sakthish et al Figure 8a: Stress patterns in the osseointegrated micro- Figure 8b: Stress patterns in the non-osseointegrated implant with orthopaedic force application. micro-implant with orthopaedic force application. variations in the stress values. Thus, both per- Disclosure pendicular and diagonal placements of implants The authors report no conflicts of interest with anything mentioned in this article. are acceptable. 2) It was found that with 200g References of orthodontic force application, stress produced 1. Branemark P. Osseointegration and its experimental background. J Prosthet in the surrounding bone was within physiological limits in both osseointegrated and non-osseointe- Dent 1983; 50(3):399-410. grated micro-implant models. However, with 400g 2. Mazzocchi AR, Bernini S. Osseointegrated implants for maximum orthodontic of orthopaedic force application, the stress pro- duced in the surrounding bone in the osseointe- anchorage. J Clin Orthod 1998; 7(7):412-415. grated micro-implant model (205.14g) was within 3. Roberts WE, Marshall KJ, Mozsary PG. Rigid endosseous implant utilized as physiological limits whereas the stress generated in the non-osseointegrated micro-implant model anchorage to protract molar and close an atrophic extraction site. Angle Orthod (530.42g) exceeded physiological limits. Hence 1990; 60(2):135-152. osseointegration of micro-implants is recommended 4. Mah J, Bergstrand F. Temporary anchorage devices: A status report. J Clin for successful loading of orthopaedic force. Orthod 2005; 39(3):132-136. 5. Kyung H, Park H, Bae S, Sung J, Kim I. Development of orthodontic micro Correspondence: implants for intra oral anchorage. J Clin Orthod 2003; 37(6):321-328. Dr. Sridevi Padmanabhan 6. Cope JB. Temporary anchorage devices in orthodontics: A paradigm shift. Professor, Dept. of Orthodontics Seminars in Orthodontics 2005; 11(1):3-9. Sri Ramachandra Dental College 7. Bae S, Park H, kyung H, Kwon O, Sung J. Clinical application of micro implant Porur,1, Ramachandra Nagar, Chennai-600116 anchorage. J Clin Orthod 2002; 36(5):298–302. Ph: 044-28156665;9600077428 8. Miyawaki S, koyama I, Inoue M, Mishima K, Sugahara T, Takano-Yamamoto T. e-mail: [email protected] Factors associated with the stability of titanium screws placed in the posterior region for orthodontic anchorage. Am J Orthod 2003; 124(4):373-378. 9. De Pauw GAM, Dermaut L, De Bruyn H, Johansson C. Stability of implants as anchorage for orthopedic traction. Angle Orthod 1999; 69(5):401-407. 10. Singer SL, Henry PJ, Rosenberg I. Osseointegrated implants as an adjunct to face mask: A case report. Angle Orthod 2000; 70:253-260. 11. Chung K, Kim S, Kook Y. The C-Orthodontic microimplants. J Clin Orthod 2004; 38(9):478-486. 12. Geng J, Tan KBC, Liu G. Application of finite element analysis in implant dentistry: A review of the literature. J Prosthet Dent 2001; 85(6):585-598. 13. Tanne K, Sakuda M, Burstone CJ. Three dimensional finite element analysis for stress in the periodontal tissues by orthodontic forces. Am J Orthod 1987; 92:499-505. 14. Holmgren EP, Seckinger RJ, Kilgren LM, Mante F. Evaluating parameter of osseointegrated dental implant using finite element analysis: A two dimensional comparative study examining the effects of implants diameter, implant shape and load direction. J Oral Implantology 1998; 24(2):80-88. 15. Vasquez M, Calao E, Becerra, Ossa J, Enriquez C, Fresneda C. Initial stress differences between sliding and sectional mechanics with an endosseous implant as anchorage: A 3-D FEM analysis. Angle Orthod 2001; 71:247-255. 16. Rieger MR, Mayberrt M, Brose MO. Finite element analysis of six endosseous implants. J Prosthet Dent 1990; 63:671-676. 17. Bozkaya D, Muftu S, Muftu A. Evaluation of load transfer characteristics of five different implants in compact bone at different load levels by finite element analysis. J Prosthet Dent 2004; 92(6):523-530. 18. Martin RB, Burr DB, Sharkey NA. Skeletal tissue mechanics. 1st edition New York; 1998:127-178. 19. Lin JC, Liou EW. A new bone screw for orthodontic anchorage. J Clin Orthod 2003; 37(12):676-681. 20. Skalak R.Biomechanical considerations in osseointegrated prostheses. J Prosthet Dent 1983; 49:843-848. The Journal of Implant & Advanced Clinical Dentistry 69

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Dental 3D Imaging Centers - Usage and FindingsW:inter et al Part II – Anatomical Features of the Lingual Artery Alan A. Winter, DDS1 23 45 6 Abstract Background: This is part 2 of a 5 part study having vessels inserting in the premolar areas. evaluating data obtained from dental refer- 87.2% had either one or two lingual arteries ral usage of radiological labs for three dimen- with the superior most vessel inserting through sional (3D) anatomical scans. The purpose the middle of the lingual plate in 88.5% of the of this portion of the study was to gather patients. Over 91% of the vessels inserted detailed data on the lingual artery and discuss above the genial tubercle and 80.3% of the its potential impact on dental implant delivery. vessels were less than 1mm in diameter. Methods: Data from 500 consecutive patients Conclusions: Implant placement in the man- sent to i-dontics dental radiological centers dibular anterior region is most often a benign from 9 centers locations in 3 states were eval- procedure. However, clinicians should bear uated. This study evaluated the presence, in mind the potential risk of piercing the lin- location, length, and diameter of the inser- gual plate and injuring the lingual artery. This tion of the lingual artery into the mandible. review of 296 CBCT scans demonstrates the value of 3D CBCT scans in identifying the Results: Of the 500 scans in this study, 296 presence, location, length, and diameter of the were of the mandible. 98% of the patients had insertion of the lingual artery into the mandible. identifiable lingual arteries, with the remainder KEY WORDS: Cone beam computed tomography, lingual artery, mandible, dental implants 1. Assistant Clinical Professor, Department of Periodontics and Implant Dentistry, New York University College of Dentistry 2. Private practice, New York, USA 3. Private practice, New York, USA 4. Private practice, New York, USA 5. Private practice, New York, USA 6. Director Maxillofacial Dental Radiology and Associate Professor of Clinical Dentistry, Columbia School of Dental Medicine The Journal of Implant & Advanced Clinical Dentistry 71

Winter et al INTRODUCTION the data was converted to SimPlant™ version 10. The current study evaluated data con- The recent advent of cone beam computed tomography (CBCT) technology has vastly cerning the lingual artery including: the radio- increased the diagnostic options for dental graphic presence or absence of the lingual treatment. While this technology is continu- artery, the location of its insertion into the man- ally improving in terms of quality, equipment dible, how many branches of the lingual artery size, and cost, most dental offices do not were present, and what was the diameter of own CBCT scanners at this time. Accord- the most superior branch of the lingual artery. ingly, many practices currently refer patients to freestanding dental radiological labs for RESULTS three dimensional (3D) anatomical scans. The purpose of this series of studies was to CT scans from 500 consecutive patients determine how and for what reason dentists requiring cone beam scans were included in currently utilize dental 3D imaging centers. this study. Of these scans, 296 were of the mandible. 98% (290/296) had observable Part one of this study series evaluated demo- insertions of the lingual artery into the man- graphic data and the reasons why patients were dible. The following observations were noted: referred for 3D evaluation. The purpose of this current study was to gather detailed data on the Number of lingual arteries: lingual artery and discuss its potential impact on 1. 40.2% (119/296) had one lingual artery dental implant delivery. Specifically, the follow- 2. 47% (139/296) had 2 lingual arteries ing parameters of the lingual artery were evalu- 3. 10.7% (31/296) had 3 lingual arteries ated: the radiographic presence or absence of 4. 0.34% (1/296) had four lingual arteries the lingual artery, the location of its insertion into the mandible, how many branches of the lingual Average length of the lingual artery: artery were present, and what was the diameter 1. Average length of lingual artery inserted of the most superior branch of the lingual artery. into the alveolar bone = 9.6mm MATERIALS AND METHODS Location of insertion of lingual artery CBCT scans of the dental arches from 500 con- relative to mandibular height: secutive patients taken in 9 centers located in 3 1. Insertion in crestal 1/3 of madible = 3.44% states were uploaded to the main processing cen- ter of a single dental radiological practice (i-don- (10/296) tics, LLC., New York, NY) which is limited to taking 2. Insertion in middle 1/3 of madible = 88.5% and processing 3D CT images for the dental com- munity. Scans were taken on either i-CAT scan- (262/296) ners (8 centers) or on a (1) NewTom 3G scanner. 3. Insertion in apical 1/3 of madible = 59.45% All studies were converted to SimPlant™ (Mate- rialise, Glen Burnie, MD). When not specified, (176/296) * Cumulative percentages exceed 100% due to some patients having multiple branches of the lingual artery. 72 Vol. 1, No. 7 October 2009

Winter et al Location of insertion of lingual artery Figure 1: Lingual artery distribution. relative to the genial tubercle: 1. Insertion coronal to genial tubercle = near-fatal airway obstruction which resulted from sublingual bleeding following implant 91.55% (271/296) placement.2 An additional case was described 2. Insertion below genial tubecle = by Isaacson3 in which sublingual hematoma likely resulted from dental implant perforation 57.43% (170/296) of the lingual cortex and violation of one of 3. Insertion equal to genial tubercle = the branches of the sublingual or facial arter- ies. A review of the literature revealed that 12.76% (37/296) these occurrences could be life-threatening.4-15 * Cumulative percentages exceed 100% due to some patients having multiple branches of the The current article and those just men- lingual artery. tioned demonstrate the value of 3D imaging in preparation for anterior mandibular implant Diameter of lingual artery: placement. Figure 2 is a panoramic view of a 1. Less than 1mm diameter = 80.3% (233/296) mandibular anterior edentulous site where den- 2. Greater than 1mm in diameter = tal implants were to be considered for inser- tion. In the 2D image, there is no sense of 19.7% (57/296) either the width of available bone or where the lingual artery inserts into the mandible. Figure DISCUSSION 3 is a transaxial view through the #25 site. It reveals a narrow, spinous crest of bone that Schick et al1 scanned 32 patients scheduled for contains very little cancellous bone. Midway mandibular implants to determine if CT scans down the lingual plate, the lingual artery can could depict the presence, diameter, position, be observed inserting into the mandible. This direction and frequency of vessels. In their artery is not very wide but may be of concern study, lingual vascular canals were demon- strated in all patients. Most lingual canals were located in the midline and the mean diameter of the lingual canals was 0.7mm. Similar studies in 3 cadavers confirmed these findings, conclud- ing that the occurrence, position and size of the lingual vessels could be depicted on CT scans. As more patients seek implant placement in order to avoid or stabilize mandibular den- tures, it is important for clinicians to under- stand the limitations of two-dimensional (2D) imaging, especially when it comes to identify- ing the presence, location, and diameter of the lingual artery in respect to its insertion into the mandible. The importance of this was dem- onstrated when Niamtu described a case of a The Journal of Implant & Advanced Clinical Dentistry 73

Winter et al Figure 2: 2D Panoramic view does not reveal osseous width or location of mandibular insertion of the lingual artery. should it be violated during implant placement. the potential risk of piercing the lingual plate This information was not clinically evident nor and injuring the lingual artery. This review of was it indicated on conventional 2D imaging. 296 CBCT scans demonstrates the value of Figure 4 is an example (no implant is planned in 3D CBCT scans in identifying the presence, this case) of a wide-diameter lingual artery that location, length, and diameter of the inser- puts the patient in jeopardy should it be sev- tion of the lingual artery into the mandible. ered during implant surgery. This is an example of how a critical anatomic structure may not be Correspondence: observed through conventional 2D imaging but Dr. Alan Winter is readily apparent in transaxial (cross-sectional) [email protected] views from medical and dental CT scanners. Disclosure While cases of atrophy compromise Support for this study was generously given by NobelBiocare, Mahwah, NJ and any edentulous area that is adjacent or Imaging Sciences Inc., Hatfield, PA. proximal to key anatomic structures, the References mandibular anterior region is particularly vul- 1. Schick S, Zauza K, Watzek G. Lingual Vascular Canals of the Mandible: nerable to potential risk relative to the width and insertion of the lingual artery. Seem- Evaluation with Dental CT. Radiology 2001; 220(1):186-189. ingly innocuous perforations can lead to large 2. Niamtu, J. Near-fatal airway obstruction after routine implant placement. Oral hematomas or life threatening arterial bleeds. Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 92(6): 597-600. CONCLUSION 3. Isaacson, T. Sublingual hematoma formation during immediate placement of Implant placement in the mandibular ante- mandibular endosseous implants. J Am Dent Assoc 2004; 135: 168-172. rior region is most often a benign proce- 4. Goldstein B. Acute dissecting hematoma: A complication of oral and dure. However, clinicians should bear in mind maxillofacial surgery. J Oral Surg 1981; 39(1): 40-43. 5. Mordenfield A, Andersson L, Bergstrom B. Hemorrhage in the floor of mouth during implant placement in the edentulous mandible: A case report. Int J Oral Maxillofac Implants 1997; 12: 558–561. 74 Vol. 1, No. 7 October 2009

Winter et al Figure 3: Transaxial (cross-sectional) view demonstrates Figure 4: An example of a wide lingual artery viewed in the value of 3D imaging by exposing the narrow width of cross-section than cannot be seen in 2D images. the crestal bone and the location where the lingual artery inserts into the mandible. 6. ten Bruggenkate CM, Krekeler G, Kraaijenhagen HA, Foitzik C, Oosterbeek HS. 11. Laboda G. Life-threatening hemorrhage after placement of an endosseous Hemorrhage of the floor of the mouth resulting from lingual perforation during implant: Report of case. J Am Dent Assoc 1990; 121: 599–600. implant placement: A clinical report. Int J Oral Maxillofac Implants 1993; 8: 329–334. 12. Darriba MA, Mendonca-Caridad JJ. Profuse bleeding and life-threatening airway obstruction after placement of mandibular dental implants. J Oral Maxillofac 7. Mason ME, Triplett RG, Alfonso WF. Life-threatening hemorrhage from placement Surg 1997; 55: 1328–1330. of a dental implant. J Oral Maxillofac Surg 1990; 48: 201–204. 13. Panula K, Oikarinen K. Severe hemorrhage after implant surgery. Oral Surg Oral 8. Givol N, Chaushu G, Halamish-Shani T, Taicher S. Emergency tracheostomy Med Oral Pathol Oral Radiol Endod 1999; 87(1): 2. following life-threatening hemorrhage in the floor of the mouth during immediate implant placement in the mandibular canine region. J Periodontol 2000; 14. Mardinger O, Manor Y, Mijiritsky E, Hirshberg A. Lingual perimandibular 71:1893–1895. vessels associated with life-threatening bleeding: An anatomic study. Int J Oral Maxillofac Implants 2007; 22(1): 127-131. 9. Burke R, Masch G. Lingual artery hemorrhage. Oral Surg Oral Med Oral Pathol 1986; 62: 258–261. 15. Kattan B, Snyder H. Lingual artery hematoma resulting in upper airway obstruction. J Emerg Med 1991; 9: 421-424. 10. Krenkel C, Holzner K. Lingual bone perforation as causal factor in a threatening hemorrhage of the mouth floor due to a single tooth implant in the canine region. Quintessence 1986; 37: 1003–1008. The Journal of Implant & Advanced Clinical Dentistry 75



Cultivating Your Online Mackey Dental Reputation with Blogs Shannon Mackey1 INTRODUCTION series of “how to” online marketing thoughts born out of my personal experience as Co-Owner and Let’s face it: to a clinical dentist whose exper- Customer Relations Director for Roadside Mul- tise lies primarily inside the human mouth, suc- timedia, one of the nation’s leading professional cess on the Web can be a daunting, elusive goal. dental website providers. The specific focus of For that matter, Web success can be a daunt- this article is how to utilize “blogs” to effectively ing objective for even the most seasoned, savvy communicate to your customer and referral base. online marketers. Why? Consider the following: THE BLOG: The internet is a vast, growing reposi- AN INDISPENSABLE ASSET tory of information and communication — as of March 31st, 2009, the U.S Census Your website is one of the most indispensible Bureau and Nielsen Online estimated that there assets of your dental practice. In many cases, were 1.6 billion users of the World Wide a customer’s first impression of your practice Web. That is 24% of the world’s population! will come from your website. When a patient is referred to your practice, whether it be from The technology powering the Web another dentist, or better yet by another patient, is constantly changing — as companies they will often research your background by vie for financial success by creating innova- visiting your website. When they visit your tive experiences for us to enjoy, new tech- site, what message is the patient receiving? nologies in support of those experiences continue to reshape the way we utilize the Web. First and foremost, you must realize that your website does not exist primarily to make The Web is an untamed, evolving organ- money. Sound contradictory? While it is true ism — although governed by a fundamental that the ultimate goal of your website is to indi- architecture, many people across the world rectly raise revenue via the recruitment of new use the Internet but no one entity controls it. patients, revenue generation should always be a result of your online reputation and the When properly utilized, the internet is offers message that you convey to your patients. the opportunity to showcase your practice in nearly any reflection of your identity that you Online recruitment of new patients requires desire. To achieve such, you must think in creative persuasive and authentic communication. One and ingenious ways. This article is the first in a effective method to achieve such communica- tion with prospective patients is via blogging. As 1. Owner & Customer Relations Director Roadside Multimedia, Marysville, WA The Journal of Implant & Advanced Clinical Dentistry 77

Mackey recently as 2006, “web-logs” (as they were first no longer be related to the restorative or surgical termed) were viewed as nothing more than a curi- care alone; the entire treatment experience is what ous quasi-voyeuristic method of online journal- determines success or failure in the patient’s mind. ism, a brief online phenomenon, or narcissistic personal hobby. Make no mistake, blogging is Blogging affords practitioners the oppor- much more than a passing fad. It is here to stay tunity to convey messages to prospective and and will continue to grow with time. Accord- current patients in a format that is comfort- ingly, taking advantage of blogging to enhance able and non-threatening. Patients can access our online reputation demands our attention. this information from the familiarity and safety of their home and have adequate time to pro- The exploding popularity of blogs represents a cess this information without feeling pressured. major shift in how consumers prefer to research This sincerity makes the blog significantly more and buy goods and services. No longer are there trustworthy than your average website mar- invisible lines of protocol between seller and buyer. keting lingo or hollow-sounding sales-speak. The internet has allowed consumers to become much more educated about the goods and services This concept is not new, but the medium is. they intend to purchase. As such, many consum- You are already doing this every day in your office. ers no longer passively listen to salespersons, or When a patient arrives at your office, the sales their treatment provider for that matter. With their process begins. When the patient parks their car newfound knowledge, consumers and patients in your parking lot, the aesthetic exterior of your often actively engage in discussions regard- building affects the patient’s perception of your ing their potential purchase or healthcare plan. practice. When a patient enters your waiting area, the cleanliness of the building, the friendliness of In early online sales models, the product was the staff, and a cornucopia of other factors affect the focus; now, the experience is the focus. While the patient’s psyche. Your website is no different. eventual purchase of a good or service is always Your website is often the very first impression that the ultimate goal, the quality of the sales experi- a patient. Anything you can do to enhance the ence plays a much larger role in the overall suc- patient’s experience on your website will ultimately cess of the product. For example, how many times benefit your patient attraction and retention goals. have you seen poor quality dentistry on a patient that raves about how they have or had a great Something blogs also do very well, which dentist? Even though the dentistry was of poor is central to any effective marketing effort, is to quality, the patient was happy because of the way gently open the door and establish a dialogue they were treated. The overall success for this between you and a new prospect. Once that patient was largely fashioned by factors external to basic rapport has developed and the door is open, the actual dental restoration. On the other hand, the opportunity to sell increases dramatically. patients that receive quality care sometimes are Trust and confidence are the keys. Once you dissatisfied with their dentist due to factors com- have gained the patient’s trust and confidence, pletely unrelated to the actual dental restoration. the door will open. Blogs can help you accom- Truly, the overall success of dental treatment can plish as much. Basic steps can you take to cul- tivate your online reputation via blogging include: 78 Vol. 1, No. 7 October 2009

Mackey Establish a blog through your website company hygienist, treatment coordinator, dental assis- or at www.blogger.com tants and other office staff to begin writing blog Send an email to your existing patients to entries. It is recommended that you preview announce the blog. each blog prior to publication on your web- Avoid canned commerciaism or a “sales-like” site. Depending on typing speed, it shouldn’t tone. take any longer than 15-20 minutes for your Speak your mind on a variety of dental topics, team members to write a few paragraphs. both the esoteric and the mundane. Answer commonly asked dental questions. As your team begins to craft a unique online This may end up saving you time by eliminating narrative of their lives at your practice, give your repetitive questions. patients every opportunity to have their voices Express your personality through your writings. heard. Be the gentle, knowledgeable, respect- Patients may develop a bond with you by simply ful expert you are. You might want to conduct identifying with the manner in which you write. an online promotion aimed exclusively at your Think from the patient’s perspective. What blog community. You might ask other local information do they seek? dentists to participate in your blog to enrich Communicate practice news and updates. the conversation and expand the site’s scope Announce your awards, speaking and influence. The possibilities are endless. engagements, and publications. Establish a sense of community. Show your CONCLUSION involvement with local people, businesses, volunteer efforts, and social/sports activities. As more traditional advertising and market- Use hyperlinks to integrate your blog with your ing vehicles continue to lose market share to dental website. their digital counterparts, consider utilization of Correctly designed, properly maintained and blogs for your website. It should be an essen- routinely updated, a blog can become a traffic-gen- tial aspect of your marketing plan. Does it take erating powerhouse. It is capable of establishing some time to write? Yes. Is it new and a little your personality, improving your visibility, building unnatural? Of course. Will it complement your a sense of community, maintaining an open dia- online marketing plan? Most definitely. Sim- logue between you and your patients, and keeping ply put, if you blog on a regular basis, it’s going them fully informed. Blogging remains an effective to spell success for your dental practice. tool for use in conjunction with a myriad of other online innovations such as search-engine optimi- Correspondence: zation and webcasts to strengthen your overall Shannon Mackey marketing strategy and enable a dental experi- Owner & Customer Relations Director ence that fully satisfy your patient’s expectations. Roadside Multimedia Blogging doesn’t have to be a time consum- [email protected] ing activity for the practicing dentist. Ask your (425) 530-1848 Direct Line (801) 996-0758 Fax The Journal of Implant & Advanced Clinical Dentistry 79