Implant Practice

Figure 1. The patient reception room at Goldstein, Garber & Salama.

INTRODUCTION
The clinicians of Team Atlanta have been placing and restoring im­plants for more than 20 years. Throughout this time, our team has seen many aspects of implant dentistry change and improve; the basic concepts for organizing, building, and maintaining a successful implant practice, however, remain the same. At our practice, this means building an effective team in order to provide an excellent patient experience. This article will focus on the administrative and clinical protocols followed in our implant practice at Goldstein, Garber & Salama (goldsteingarber.com).

Building an Effective Team
When discussing the “implant team,” most people consider the surgical and restorative clinicians. Truly, the complete team is much larger—from the first face the patient meets at the front desk, to the financial coordinator, to the hygienists that maintain our work. Building a team that you trust, and in which everybody has the same standards and expectations, is critical, and it starts with hiring the right people.

Our practice is fortunate to have a great staff with low turnover. We have several team members who have been with the practice for more than 20 years. As such, our staff is like a family; it is crucial that any new team members can respectfully partner with the “veterans” to strive toward our common goal of providing mastery level dentistry with an exceptional patient experience.

Once a hired employee is determined to be a perfect fit, he or she will attend business courses as well as communications courses to better understand the “business of dentistry.” Our practice is affiliated with Heartland Dental, who assists in our recruiting process and encourages and supports continuing education for all team members. This partnership allows doctors to focus on providing the highest level of dental care by assisting with human resources and management. Clinical team members are also encouraged by the doctors to watch specific videos on DentalXP (dentalxp.com) to take their clinical skills to the next level.

Our practice is large, with 8 doctors and 5 hygienists. Thus, we have 2 front desk assistants and 2 scheduling coordinators to divide the duties and make sure our patients’ needs are addressed quickly. We also have 2 treatment plan coordinators, who present treatment options and serve as the liaison between the patient and the clinical team.

The Patient Experience
The practice was originally established in 1929 by Dr. Irving H. Goldstein, and his son, Dr. Ronald Goldstein, has been practicing with the team for more than 55 years. He will often remind the complete team that we should each strive to provide the “Ritz-Carlton experience” to our patients. He instills in the staff the belief that they should treat each patient, and each other, with the utmost courtesy and respect. Every team member truly takes pride in being a part of our team, and in providing the highest quality care to our patients.

The patient experience begins with the initial telephone conversation with our receptionist and then our appointment coordinator. Just as important is the impression as the patient walks into our office (Figure 1). We strive to showcase our cutting-edge technology while maintaining an inviting and relaxed atmosphere.¹

Although our staff is large, we work in small teams to provide a familiar face to each patient. Each team member focuses on building rapport and relationships with each patient, so the patient can feel comfortable discussing treatment and asking questions. We strive to educate and inform our patients, so they become part of the process, part of the team, and feel in control of their dental implant experience. The team’s synergy and personalized approach to patient care allows us to identify each patient’s motivations and goals, as well as their fears and hesitations.

The following case report will illustrate the dynamics among all team members for our implant patients.

CASE REPORT
A new patient, Roger, called our office and spoke to one of our front desk assistants. In this call, the assistant not only asked what type of treatment he was interested in, but also what he was looking for in a practice. During this initial conversation, she discussed what new technologies we could introduce him to, and tried to identify his personality type so that we could start catering his treatment immediately. Roger had heard about our One Day Implants option (onedayimplants.com), and was scheduled with our hygiene team on a day that our implant surgeon, Dr. Maurice Salama, as well as prosthodontists Drs. David Garber and Wendy Clark, were available for consultation.

Figure 2. Roger had been wearing an upper complete denture and lower partial denture for many years. He complained of retention issues and difficulty chewing. CBCT analysis revealed adequate bone for an “all-on-4” type prosthesis.	Figure 3. Final impression and records for digital denture (DENTCA).

New patients start with one of our hygienists, who is briefed by the front desk assistant as to why the patient is presenting, and what the patient is looking for in a practice. Not only does our hygiene team take thorough diagnostic records and provide hygiene services, they also work to build relationships and trust with our patients. As is always done in front of the patient, our hygienist then reviewed her findings and Roger’s concerns and desires with the surgical assistant. This transfer of information demonstrates the effective communication within our team, building continued trust.

At the implant consultation, the assistants take a CBCT (CS 9300 [Care­stream], Rayscan [LED]), and a series of clinical photographs (Figure 2) for the surgeon and prosthodontist to review before entering the room. The dental assistants also reviewed Roger’s concerns and history with the surgeon and prosthodontist as they met the patient.

We learned that Roger had been diagnosed with a life-threatening blood disorder, and that his treatment required the extraction of most of his dentition. Like so many patients, his upper denture did not meet his expectations; he noted a decrease in his quality of life while eating, speaking, and smiling.^2,3 He wanted to be out of his upper denture as soon as possible. At this point, the surgeon and the prosthodontists complete their clinical and radiographic examination to determine a customized treatment plan. For Roger, we determined he would be a good candidate for an immediate-load maxillary fixed provisional. Roger had low force factors, plenty of interocclusal space, and it would be opposing a combination of anterior natural dentition and posterior implant crowns. With this in mind, we recommended finalizing with a Prettau Zirconia Implant Bridge (Tischler Dental) with functional surfaces in polished zirconia.^4-6 Roger appreciated that he could have his hygiene, surgical, and prosthetic teams under one roof.

After answering his clinical questions, the assistants introduced Roger to our treatment plan coordinator, who reiterated the sequence and procedures, as well as reviewing the financing options. This is done with an assistant or doctor in the room, in case there are any more clinical questions. As a fee-for-service practice, most patients pay with cash or check. If needed, the treatment coordinator will offer CareCredit. Typically, patients will know if they are approved in a matter of minutes, allowing them to make treatment decisions as quickly as they choose. Many of our patients travel from around the country and the world, so same-day conversions are common in our practice.

Roger lived locally and wanted to start treatment the same day, if possible. We completed our aesthetic analysis and started fabrication of a provisional denture to confirm tooth position. As is typical for our conversion cases, we started with fabrication of a CAD/CAM denture (DENTCA). Digital dentures have been growing in popularity during the last several years; they streamline the complete denture process and have shown improved predictability and repeatability compared to conventionally fabricated complete dentures.^7,8 Most important to Roger, this greatly sped up the process by allowing final impressions and maxillo-mandibular records at the first visit so we could get the denture back in less than 2 weeks at the second visit (Figure 3).
With our aesthetic analysis, we determined that due to excessive gingival display at high smile, about 3.0 mm of bone needed to be removed to hide the “pink transition”^9,10 (Figure 4a). This position was incorporated into the SIMPLANT (Dentsply Sirona Implants) digital implant placement. Once the denture was fabricated and aesthetics confirmed, a CAD/CAM surgical guide (360ips [360imaging]) was fabricated based on a dual scan and our SIMPLANT planning. The surgery with conversion was scheduled with our scheduling coordinators. For large procedures, the treatment plan coordinator will call the patient 2 weeks before surgery; the coordinator will answer any questions and collect payment at that time. This creates a smoother work flow the day of a large procedure.

Per our digital planning, the ridge reduction was completed and 4 Zimmer TSV implants (Zimmer Biomet) were placed in an “all-on-4” type configuration (Figures 4b and 4c). The prosthetic team was available throughout the surgery to ensure everything was ideal before finalizing placement and suturing. Since primary stability was present on all implants, we proceeded with the immediate load protocol.^11,12 Multiunit abutments and provisional cylinders were placed (Figure 5a), and the denture was relieved and attached with acrylic, converting it to a fixed implant bridge (Figures 5b and 5c). As after any surgery or large procedure, a clinical team member called the patient within 24 hours to follow up and make sure that he was doing well and had no maintenance questions.

After healing, the patient was ready to move to final prosthesis. Our scheduling coordinator reached out to the patient and scheduled all of the restorative visits: (1) final impression and scan, (2) verification, and (3) delivery.

At the first visit, we took an abutment level impression. Since we were happy with the function and aesthetics of the provisional, we also intraorally scanned with our TRIOS scanner (3Shape) and sent the images to Tischler Dental (Woodstock, NY) (Figure 6). With the clinical scans, the technicians were able to replicate the tooth position in the design for the final Prettau Zirconia Implant Bridge (Figure 7). At the verification appointment, we tried in an acrylic mockup, checked the bite and aesthetics, and verified a passive fit. We also tried the provisional bridge on the master cast to confirm complete fit and passivity.

Figure 5c. Flanges removed and polished to allow for cleansability.

The transition for the patient to the final prosthesis was easy, as the contours replicated his provisional (Figure 8a). The approved anterior aesthetics were also replicated, and the pink transition was hidden in high smile per our aesthetic and digital analysis (Figure 8b).¹³

At this point, we reviewed maintenance, demonstrated how to floss around the implants, and dispensed an oral irrigator to keep the abutments and bridge clean (HYDRO FLOSS).¹⁴ Since he has a combination of implants and natural teeth on the lower arch, Roger maintains a 4-month recall with our hygiene team, which is highly trained in implant maintenance. Once a year, his upper bridge is removed and cleaned, and the multiunit abutments are then cleaned and re-torqued.

Figure 7. CAD imaging overlaying the bridge design and the implant placement.

Figure 8a. Occlusal view of the seated Prettau Zirconia Implant Bridge (Tischler Dental).	Figure 8b. Seated bridge with high smile, showing the hidden pink transition.

CLOSING COMMENTS
As a team in our practice, we strive to understand all patients’ motivations and hesitations regarding their dental care. With this knowledge and mindfulness, we can provide a customized treatment experience that is most likely to meet (or exceed) their expectations. We best accomplish this by hiring and training the right staff members for the job, focusing on consistent communication, and utilizing the most cutting-edge technology to streamline the process.

References

1. Goldstein RE, Salama MA. Treatment planning. In: Goldstein RE, ed. Esthetics in Dentistry. Hoboken, NJ: Wiley. In press.
2. Marachlioglou CR, Dos Santos JF, Cunha VP, et al. Expectations and final evaluation of complete dentures by patients, dentist and dental technician. J Oral Rehabil. 2010;37:518-524.
3. Thomason JM, Lund JP, Chehade A, et al. Patient satisfaction with mandibular implant overdentures and conventional dentures 6 months after delivery. Int J Prosthodont. 2003;16:467-473.
4. Janyavula S, Lawson N, Cakir D, et al. The wear of polished and glazed zirconia against enamel. J Prosthet Dent. 2013;109:22-29.
5. Papaspyridakos P, Lal K. Computer-assisted de­sign/computer-assisted manufacturing zirconia implant fixed complete prostheses: clinical results and technical complications up to 4 years of function. Clin Oral Implants Res. 2013;24:659-665.
6. Rojas-Vizcaya F. Full zirconia fixed detachable implant-retained restorations manufactured from monolithic zirconia: clinical report after two years in service. J Prosthodont. 2011;20:570-576.
7. Goodacre CJ, Garbacea A, Naylor WP, et al. CAD/CAM fabricated complete dentures: concepts and clinical methods of obtaining required morphological data. J Prosthet Dent. 2012;107:34-46.
8. Kattadiyil MT, Goodacre CJ, Baba NZ. CAD/CAM complete dentures: a review of two commercial fabrication systems. J Calif Dent Assoc. 2013;41:407-416.
9. Salama M, Coachman C, Garber D, et al. Prosthetic gingival reconstruction in the fixed partial restoration. Part 2: diagnosis and treatment planning. Int J Periodontics Restorative Dent. 2009;29:573-581.
10. Coachman C, Calamita MA. Virtual esthetic smile de­sign: driving the restorative plan. J Cosmet Dent. 2014;29:102-116. dentalxp.com/con­tent/­2449/9766ef49-b27b-4310-bbfc-77a21d9ab829.pdf. Accessed on January 28, 2016.
11. Maló P, de Araújo Nobre M, Lopes A, et al. “All-on-4” immediate-function concept for completely edentulous maxillae: a clinical report on the medium (3 years) and long-term (5 years) outcomes. Clin Implant Dent Relat Res. 2012;14(suppl 1):e139-e150.
12. Testori T, Del Fabbro M, Capelli M, et al. Immediate occlusal loading and tilted implants for the rehabilitation of the atrophic edentulous maxilla: 1-year interim results of a multicenter prospective study. Clin Oral Implants Res. 2008;19:227-232.
13. McLaren EA, Cao PT. Smile analysis and esthetic design: “In the zone.” Inside Dentistry. 2009;5:44-48.
14. Watt DL, Rosenfelder C, Sutton CD. The effect of oral irrigation with a magnetic water treatment device on plaque and calculus. J Clin Periodontol. 1993;20:314-317.

Dr. Clark earned her doctoral degree from the Marquette University School of Dentistry in Milwaukee, Wis, and her master’s degree and certificate in post-graduate prosthodontics from the University of Alabama at Birmingham. She currently practices prosthodontics full time in Atlanta and is pursuing certification from the American Board of Prosthodontics. In addition to poster presentations at national meetings, she has co-authored articles published in journals including The Journal of Prosthetic Dentistry, The Journal of Prosthodontics, and Compendium. She is an expert speaker on DentalXP and lectures nationally. She can be reached via email at wendyauclair@gmail.com.

Dr. Garber is a past president of the American Academy of Esthetic Dentistry (AAED) and has served on the boards of both the AAED and the American Academy of Fixed Prosthodontics. He is a dual-trained clinician and professor in the departments of periodontics and oral rehabilitation at the Medical College of Georgia. He is a clinical professor in the department of prosthodontics at Louisiana State University and a clinical professor in the department of restorative dentistry at the University of Texas at San Antonio. He is past editor of the Journal of Esthetic Dentistry, co-author of Porcelain Laminate Veneers, Bleaching Teeth, Porcelain and Composite Inlays and Onlays, and Complete Dental Bleaching, and he has published many articles and textbook chapters. He is an honorary member of the Kois Center. He can be reached at dgarber@goldsteingarber.com.

Dr. Salama received his BS in biology at the State University of New York at Binghamton and received his DMD from the University of Pennsylvania (UPenn) School of Dental Medicine, where he later received his dual-specialty certification in orthodontics and periodontics as well as his implant training at the Brånemark Center at UPenn. He is currently on the faculties of the University of Pennsylvania and the Medical College of Georgia as clinical assistant professor of periodontics. He a permanent member of the scientific committee of the world’s leading online dental education website, dentalxp.com. He can be reached via email at the address goldstein­garber@goldsteingarber.com.

Dr. Goldstein is currently clinical professor of oral rehabilitation at Georgia Regents University School of Dentistry (Augusta), adjunct clinical professor of prosthodontics at Boston University Henry M. Goldman School of Dental Medicine, and an adjunct professor of restorative dentistry at The University of Texas Health Science Center at San Antonio. He has presented continuing education courses at more than 20 universities and lectured at more than 700 dental meetings worldwide. He is a contributor to 10 published texts and author of many textbooks, including the third edition of Esthetics In Dentistry to be published by Wiley in 2016. His best-selling consumer book for the public, entitled Change Your Smile, now in its fourth edition published by Quintessence, has been read by more than 2 million people and has been translated into 12 languages. He can be reached via email at rgoldstein@goldsteingarber.com.

Disclosure: The authors disclose that they have all been active in the clinical research of aesthetic restorative materials, implants, and regenerative periodontal techniques. As such, they have been consultants, lecturers, and/or principal investigators or co-investigators in numerous clinical and laboratory studies and product evaluations sponsored through contractual relationships with various companies, which include Zimmer, 3D Diagnostix, Carestream Dental, DENTSPLY, and others not mentioned in this article.