2011 Dental Implants Version

8/19/2019 2011 Dental Implants Version

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3251 Riverport LaneMaryland Heights, Missouri 63043

Dental Implants the Art and Science ISBN: 978-1-4160-5341-5

Copyright © 2011, 2001 by Saunders, an affiliate of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, withoutpermission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights Department:phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail: [email protected]. You may also complete your request on-line via the Elsevier website at http://www.elsevier.com/permissions.

Notice

Knowledge and best practice in this field are constantly changing. As new research and experience broaden ourknowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers areadvised to check the most current information provided (i) on procedures featured or (ii) by the manufacturerof each product to be administered, to verify the recommended dose or formula, the method and duration ofadministration, and contraindications. It is the responsibility of the practitioner, relying on their own experienceand knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individualpatient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher northe Authors assumes any liability for any injury and/or damage to persons or property arising out of or relatedto any use of the material contained in this book.

The Publisher

Library of Congress Cataloging-in-Publication Data

Dental implants : the art and science / [edited by] Charles A. Babbush … [et al.].—Ed. 2. p. ; cm.Includes bibliographical references and index.ISBN 978-1-4160-5341-5 (pbk. : alk. paper) 1. Dental implants. I. Babbush, Charles A. [DNLM: 1. Dental Implants. 2. Dental Implantation—methods. WU 640 D4142 2011]RK667.I45D485 2011617.6′9—dc22

2009045447

Vice President and Publisher: Linda DuncanExecutive Editor: John DolanSenior Developmental Editor: Courtney SprehePublishing Services Manager: Catherine JacksonSenior Project Manager: Rachel E. McMullenDesign Direction: Amy Buxton

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v

A B O U T T H E C O V E R

The cover of this book illustrates a variety of state-of-the-artconcepts that are representative of the content found in thetext. The background image is a cone beam CT scan of amaxillary and mandibular All-on-4 postoperative patient.

The six photographs in the right-hand vertical columnshow (from top to bottom):1. A Nobel Active implant before insertion

4 and 5. The 5-year follow-up panoramic radiograph andclinical photograph that demonstrates the results of toothextraction, immediate implant placement, immediate pro-visional restoration, and permanent restorations

2. A Lucite patient education model of a classical All-On-4

implant reconstruction

3. An example of a Procera plan from 3-D software withoutthe prosthesis or bone icon being active

6. A virtually created surgical guide, in which the parallelplacements of the implants can be visualized with the facialposition of fixation screws; the template of the maxillacompletes the plan


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In this, my fourth textbook, I feel it is only appropriate to dedicate it in several different categories.First, to my colleagues who have worked with me, and my patients, over these 42 years of implantreconstruction, I am deeply honored. I am even more honored by the dedication and loyalty of thethousands of patients who have trusted my skills, knowledge, and experience. In addition, I feel itonly appropriate to list some of my mentors and colleagues who also led the way in this field and

shared so generously: Paul Mentag, Leonard Lindow, Isiah Lew, Aaron Gershkoff, Norman Cranin, Axel Kirsch, P.I. Brånemark, and Jack Wimmer.

My family has supported, encouraged, complimented and even advised me, which ultimately has

allowed me to continually contribute to society and share this work, which also allows me tocontinue to change lives on a daily basis. Of these family members, my wife, Sandy has, for 50 years,been my chief critic, advisor, constant companion, as well as my best friend. Our children, Jill, Jeff, Amy, David, and Debbie are a great source of fun, love, understanding, and, now that they havematured, advice. Lastly, I thank my seven grandchildren, wonders of the world, Alex, Max, Lexie,

Joey, Sam, Sydney, and Grace, for the affection, enjoyment, and unlimited love.

Charles A. Babbush

I would like to dedicate my participation in this book to my wife of 47 years, Barbara, and mychildren, Julie, Jeff, and Greg, who were patient and supportive during my 39 years in implant

dentistry. I also want to thank the pioneers and teachers who were responsible for influencing myprofessional life.

Jack A. Hahn

I am extremely pleased to have been part of this exciting literary venture. I’d like to dedicate it toseveral people, and categories, who have had a profound influence on me and my career. My

co-authors: “Sir Charles” Babbush was one of my initial educational experiences in implant dentistry,and I can still remember his enthusiasm and passion for our field exemplified at his lecture at the

University of Miami in 1985. “Big Jack” Hahn, has been a mentor to me on many levels includingthe profession as well as a role model of the family man, who I’ve known for many years. JoelRosenlicht is my contemporary who has shared many of life’s ups and downs with me, and has

always been a true buddy. My co-authors are outstanding people and master clinicians.

My parents, Al and Sheila Krauser, have given me so many attributes, love, caring, insight, andconcepts of living a good life, that I can write a book about them. They were both schoolteachers,and as educators, I have always learned and known of the value of education … even worth more

than material things. They are active with friends and family in many cultural, travel, and athleticactivities and have set a wonderful model for my career and life.

A few colleagues in our field have been tremendously influential on many levels: my lecturing buddiesScott Ganz, Marius Steigmann, Team Atlanta, Mike Pikos, Ziv Mazor, and Bobby Horowitz. Myfoundational colleagues are Mort Amsterdam, Frank Matarazzo, Alan Levine, Clive Boner, Neil

Boner,Vincent Celenza, Andrew Schwartz, Al Mattia, Steve Feit, Michael Radu, Steve Norton, andBill Eickhoff.

Finally, my daughter Taylor, now in high school, may fully appreciate the efforts of these dedicateeson her life as well as mine. This soon to be classic text in implant dentistry will be an inspiration for

her.

Thank you also to the highly dedicated staff at Elsevier, who put up with my chapter delays!

Jack T. Krauser

Congratulations to Charles Babbush and the other editors of this wonderful text. These co-authorshave been inspirational and motivating for me in my journey with implant dentistry. I’d also like to

thank my wife, Doreen, and our children Jordan, Tyler, and Sarrah for their patience andunderstanding while being away from them while pursing my passion for implant dentistry. Lastly,

my parents, Bernice and Paul, whose vision and support encouraged me to be a dentist.

Joel L. Rosenlicht


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vii

C O N T R I B U T O R S

Ryaz Ansari, BSc, DDSRosenlicht and AnsairOral Facial Surgery CenterManchester, Connecticut

Debora Armellini, DDS, MSProsthodontistClearChoice Dental Implant Center—Washington DC

Washington, DC

Charles A. Babbush, DDS, MScDDirector, ClearChoice Dental Implant Center;Clinical Professor, Department of Oral and Maxillofacial

Surgery;Director, Dental Implant ResearchCase Western Reserve University School of Dental MedicineCleveland, Ohio

Stephen F. Balshi, II, MBEChief Operating OfficerCM Ceramics, USA Mahwah, New Jersey

Thomas J. Balshi, DDS, FACDChairman of BoardInstitute for Facial EstheticsFort Washington, Pennsylvania

Barry Kyle Bartee, DDS, MD Assistant Clinical ProfessorDepartment of Surgery Texas Tech University Health Sciences CenterSchool of Medicine;Private Practice in Implant PracticeLubbock, Texas

Edmond Bedrossian, DDS, FACD, FACOMS

Private Practice;Director, Implant Training University of PacificOMFS Residency ProgramSan Francisco, California

James R. Bowers, DDSClinical InstituteDepartment of Fixed ProsthodonticsKornberg School of Dentistry Temple University Philadelphia, Pennsylvania

L. Jackson Brown, DDS, PhDPresident, L. Jackson Brown Consulting, LLCLeesburg, Virginia;Editor, Journal of Dental EducationThe American Dental Educational Association

Washington, DC

Cameron M.L. Clokie, DDS, PhD, FRCD(C), Dipl.ABOMS

Professor and HeadDepartment Oral Maxillofacial Surgery University of TorontoToronto, Ontario, Canada

J. Neil Della Croce, MSTemple Dental Student DirectorSchool of Dentistry Temple University Philadelphia, Pennsylvania;Research Associate/Clinical Assistant/Student DirectorPI Dental Center at the Institute for Facial EstheticsFort Washington, Pennsylvania

Ophir Fromovich, DMDHead, Dental Implant Academy of ExcellencePetah-Teqva, Israel

Scott D. Ganz, DMDPrivate Practice in Prosthodontics, Maxillofacial Prosthetics,

and Implant Dentistry Fort Lee, New Jersey

Adi A. Garfunkel, DMDProfessor;Former Head Department of Oral Medicine;Dean EmeritusHadassah School of Dental MedicineThe Hebrew University

Jerusalem, Israel


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viii Contributors

Arun K. Garg, DMDProfessorDepartment of Oral and Maxillofacial Surgery;School of MedicineUniversity of MiamiMiami, Florida;Director,Center for Dental Implants of South Florida

Aventura, Florida

Michelle Soltan Ghostine, MDResident PhysicianDepartment of Otolaryngology, Head and Neck Surgery Loma Linda University Loma Linda, California

Jack A. Hahn, DDSThe Cosmetic and Implant Dental Center of CincinnatiCincinnati, Ohio

Sven Jesse, DLT Jesse and Frichtel Dental LabsPittsburgh, Pennsylvania

Benny Karmon, DMDPrivate PracticePetach-Tikva, Israel

Jack T. Krauser, DMDPrivate Practice in PeriodonticsBoca Raton, Florida, and North Palm Beach, Florida;Faculty, Division of Oral and Maxillofacial Surgery University of Miami School of Medicine

Miami, Florida

Richard A. Kraut, DDSChairmanDepartment of Dentistry;DirectorOral and Maxillofacial Residency Program;

Associate ProfessorDepartment of Dentistry

Albert Einstein College of MedicineMontefiore Medical CenterBronx, New York

Jan LeBeauMoorpark, California

Isabel Lopes, DDSClinical InstructorDepartment of Oral Surgery School of Dental MedicineUniversity of LisbonMaló ClinicLisbon, Portugal

Celso Leite Machado, DDSChief Clinical Professor of TMJ Arthroscopy Surgery Miami Arthroscopy Research, Inc.Miami, Florida;Director, International Research/Medical Workshop,Coordinator, International Biological Inc.Grosse Pointe Farms, Michigan;Director of Cosmetic and Implant Dentistry, SPA-MED

Guaruja, São Paulo, Brazil

Paulo Maló, DDSMaló ClinicLisbon, Portugal

Ronald A. Mingus, JDShareholderReminger Co., LPA Cleveland, Ohio

Craig M. Misch, DDS, MDSPrivate PracticeProsthodontics and Oral and Maxillofacial Surgery;Sarasota, Florida;

Associate ProfessorDavid B. Kriser Dental CenterDepartment of Implantology New York University New York, New York

Miguel de Araújo Nobre, RDHDirectorDepartment of Research and DevelopmentMaló Clinic

Lisbon, Portugal

Marcelo Ferraz de Oliveira, DDSClínica Groot Oliveira São Paulo, Brazil;Coordinator, Craniofacial Prosthetic RehabilitationP-I Brånemark InstituteBauru, Brazil

Loretta De Groot Oliveira, BSC, BMCClínica Groot Oliveira São Paulo, Brazil

Stephen M. Parel, DDSProsthodontistPrivate Practice, Implant Surgery Dallas, Texas

Arthur L. Rathburn, MSFounder and Research DirectorDepartment of Continuing Education and ResearchInternational Biological Inc.Grosse Pointe Farms, Michigan


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Contributors ix

Eric Rompen, DDS, PhDProfessor and HeadDepartment of Periodontology/Dental Surgery University of LiègeLiège, Belgium

Joel L. Rosenlicht, DMDPrivate Practice

Oral and Maxillofacial Surgery Manchester, Connecticut;

Assistant Clinical ProfessorDepartment of Implant Dentistry College of Dentistry New York University New York, New York

Richard J. Rymond, JD Adjunct Assistant ProfessorDepartment of Community Dentistry School of Dental MedicineCase Western Reserve University;Sharesholder, Secretary, Vice PresidentChair, Dental Liability Reminger and Reminger Co, LPA Cleveland, Ohio

Bob Salvin, BSFounder and CEOSalvin Dental Specialites, Inc.Charlotte, North Carolina

George K.B. Sándor, MD, DDS, FRCDC,FRCSC, FACS

ProfessorThe Hospital for Sick ChildrenToronto, Ontario, Canada

Dennis G. Smiler, DDS, MScDPrivate PracticeEncino, California

Muna Soltan, DDS, FAGDPrivate PracticeRiverside, California

Samuel M. Strong, DDS, Dipl. ICOI, ABDSM

Adjunct ProfessorDental SchoolUniversity of Oklahoma Oklahoma City, Oklahoma;Private PracticeLittle Rock, Arkansas

Stephanie S. Strong, RDH, BSPrivate PracticeLittle Rock, Arkansas

Lynn D. Terraccianao-Mortilla, RDH Adjunct Clinical ProfessorDepartment of Periodontology and Oral Implantology Kornberg School of Dentistry Temple University Philadelphia, Pennsylvania

Evan D. Tetelman, DDS

Assistant Clinical ProfessorDepartment of Comprehensive CareSchool of Dental MedicineCase Western Reserve University Cleveland, Ohio

Konstantin D. Valavanis, DDSPrivate PracticeICOI Diplomate

Athens, Greece

Eric Van Dooren, DDSVisiting ProfessorDepartment of Periodontology and Implantology Université de LiégeLiége, Belgium

Tomaso Vercellotti, MD, DDSInventor, Piezoelectric Bone Surgery,Honorary ProfessorPeriodontal DepartmentEastman Dental InstituteLondon, United Kingdom;Visiting ProfessorPeriodontal Department

University of Bologna Bologna, Italy

James A. Ward, DMDFormer Chief Resident;Department of Oral and Maxillofacial Surgery Temple University HospitalPhiladelphia, Pennsylvania;

Associate PhysicianDepartment of Oral Surgery Saint Mary’s Medical CenterLanghorne, Pennsylvania

Glenn J. Wolfinger, DMD, FACDBoard of DirectorsInstitute for Facial EstheticsFort Washington, Pennsylvania


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x

F O R E W O R D

Googling the name “Dr. Charles Babbush” results in 10 pagesof references to the oral surgeon from Cleveland, Ohio, andto his contributions to the field of dental implantology. In asociety that glorifies the “here and now,” Dr. Babbush has helda prominent place on the dental implant stage for more than40 years. The impact Dr. Babbush has had in the field ofdental implants, as a clinician and a teacher, is undeniable.That he again has taken the time to edit an additional text,co-authoring it with such prominent clinicians and teachers asDrs. Jack Hahn, Jack Krauser, and Joel Rosenlicht is a testa-ment to his devotion and dedication to his profession.

The first edition of this text has a prominent place on myshelf. The word “art” embraces many facets and influences,

whereas the word “science” incorporates many known facts. Although art may be in the eyes of the beholder, science pro-mulgates accepted knowledge. It is fitting that a dentist withthe broad background and scientific experience of Dr. Babbushaccepted the challenge of bringing these topics together in oneplace as a resource for dentistry. Not only has he broughttogether a virtual “who’s who” in implant dentistry for thisedition, he has also contributed significantly himself.

The reader will find in this volume a thorough review ofimplant dentistry. Dr. Babbush has taken a sound approachby starting with a discussion of the demand for dental implantsby consumers and the master planning of the potential dentalimplant patient. He includes a detailed discussion of surgicaland prosthetic procedures. The often overlooked subjects ofthe business of implant dentistry and systems for team successin the implant practice are also discussed.

Technological advancements in dentistry envelope us at afurious pace, and these are nowhere more evident than in areasof CT/CBCT use and guided implant placement. This editionand its authors strive to meld this area of rapidly developingscience with the art of the esthetic restoration that consumersdemand. The subject of immediate implant function andesthetics is presented by leading experts in the field, who sharethe current science of this treatment so beneficial to patients.

In addition to these scholarly contributions, this volumecontinues to add pertinent information to the scientific knowl-edge base with a discussion of newer clinical procedures, angledimplants, and new implant design, and concludes with areview of maintenance issues, complications, and failures by

highly experienced dental implant professionals.Implant dentistry is no longer an art conducted solely by

dental specialists. Instead it is shared by general dentists who,along with specialists, dedicate themselves to the “art andscience” of this field. Dr. Babbush and his co-authors havecreated a significant work of interest to all disciplines. Thesheer depth of this work, along with the illustrious contribu-tors, should ensure its relevancy to all of our practices for yearsto come.

Mark W. Adams, DDS, MSDirector of Prosthodontics

ClearChoice Dental Implant Center—DenverDenver, Colorado

I first met Dr. Babbush more than 40 years ago when he wasmy teacher at Case Western Reserve School of Medicine. Hehas served on our faculty over all these years, and we have

become professional colleagues as well as friends. As our rela-tionship has grown, so has his capacity as an educator,researcher, and advisor.

His ability to relate to students, faculty, and peers is impres-sive. This is evidenced by his many awards and honors thatinclude numerous visiting professorships such as NipponDental University, Nigata, Japan; College of Stomatology,Sichuan University, Chengdu, China; University of Miami,School of Medicine Department of Surgery, Miami, Florida;and Sri Sai College of Dental Surgery, Hyderabad, India. Hispassion for continual improvement of himself and his profes-

sion keeps him on the cutting edge of implant dentistry. Heis distinguished by his willingness to honestly share his experi-ences and knowledge, which is a hallmark of a true educator.

He does this for the betterment of his peers.Dr. Babbush’s excitement for the field of implant dentistry

is evident in his fourth textbook, in addition to As Good asNew: A Consumer’s Guide to Dental Implants . He and his newco-authors have gathered together a real “who’s who” ofimplant dentistry.

This broad scope of work is applicable not only to the basicsfor the pre-doctoral students, but also to the specialist. Itshould even be of interest to the experienced practitioner. Thisbook, like his others, is noteworthy for its clarity, organization,intellectual approach, and generosity. The book not only


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Foreword xi

features the most progressive approaches to treatment, but alsoapplies Dr. Babbush’s 42 years of implant experience, along

with the massive number of years of expertise of his partici-pants, to look into problems, complications, and accompany-ing suggested solutions.

Dental Implants: The Art and Science, Second Edition pres-ents new refreshing subject matter not routinely covered indental implant textbooks. It covers demographics, the need for

dental implants, and the business of dental implants. It is atotal tutorial of the field, not just a how to do it book. Thechapter on legal matters is updated and well documented. The

chapter on essential systems for team training is cutting edgein its approach. It is evident that in this book, as with his priorpublications, Dr. Babbush derives personal pleasure frompassing on what he has learned.

Jerold S. Goldberg, DDSDean

School of Dental Medicine

Case Western Reserve University Cleveland, Ohio

When a distinguished lecturer, author, and scientist with morethan 40 years of clinical experience in the field of dentalimplants writes a fifth book, a summary, all inclusive text, anyrestorative dentist should stop what they are doing and beginturning the pages.

From the earliest days of modern implantology when bladeimplants were first attempted, Dr. Babbush has kept strivingfor the elusive goal of tooth replacement and reconstructiverestorative surgery to optimize implant placement. He hasfrequently been a leader in applying new techniques forstandardized application. One thing mastered in this updatedsecond edition is the treatment planning concept, making surethat clinicians work in concert with each other to optimizedesired treatment goals.

The core values Dr. Babbush so aptly expresses is that careshould be taken before one begins, that the surgeon shouldnever work alone but in collaboration with colleagues, that thehighest available technology should be employed, and that thesafety of the patient be observed.

Clinicians in the field of implant dentistry will gain clinicalknowledge, if not wisdom, in the study of this timely book.

Ole T. Jensen, DDS, MS Assistant Clinical Professor

University of Michigan Ann Arbor, Michigan

I first met Dr. Charles Babbush in Paris, France. It was1972, and he was serving as program chairman for ICOI’s first

World Congress. We had taken very different educationalpaths. I had mentored in surgical prosthodontics with Dr.Isiah Lew from New York, and Dr. Babbush had pursuedclassical oral and maxillofacial surgery training. Together weexperienced the painful birthing, initial rejection, and begin-ning acceptance of dental implants by the Food and Drug

Administration (FDA), then by the National Institutes ofHealth (NIH) in 1978, and ultimately by the American Dental

Association (ADA).Simply stated, however, no matter how many people have

made significant contributions to the field of oral and facialimplant therapy, few people can claim themselves as an activeparticipant in clinical treatment, research, and education formore than four decades so thoroughly as Dr. Babbush. Forbringing us his wealth of experience in his latest text, DentalImplants: The Art and Science, Second Edition, he deserves thegratitude of our profession, specialty groups as well as general-ists, researchers, laboratory technicians, and auxiliaries—inessence the total dental team.

What is not communicated in this text is the extent to which Dr. Babbush has been a significant force in worldwideimplant education, returning again and again to numerouscountries, venues, implant societies, and universities to intro-duce, modify, and ultimately reinforce his concepts. The resultis much needed research-based information.

Few people can assemble and work with authors from allareas of dentistry related to oral and facial implant therapy andorganize his own and their contributions in such a way thatthe reader is enthralled. This is a text, which for its complete-

ness and excellence, is to be read, savored, and then reread.My sincere congratulations to all contributors.

Kenneth W.M. Judy, DDS,PhD (hc, multi), FACD, FICD

Co-Chair, International Congressof Oral Implantologists

New York, New York


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xii Foreword

The term “pioneer” is reserved for a few select individualsin the world of implant dentistry. I was honored to have oneof these individuals, Professor P.I. Brånemark, author a forwardin several books I wrote on osseointegration, and I am honoredto provide these remarks for another true pioneer, Dr. CharlesBabbush, as an introduction to this remarkable text.

Their early careers could not have been more divergent, onedoing medical orthopedic research in Sweden, while the other

was evolving early implant dentistry as a practicing oral andmaxillofacial surgeon. Both found a common ground in theearly 1980s with the introduction of osseointegration toNorth America, and both have continued to make significantcontributions over a nearly unprecedented period of fourdecades.

This textbook, Dental Implants: The Art and Science, SecondEdition, is a perfect example. It is rare today to find a seminalpublication of any kind in the field of implant dentistry, butgiven the scope of topical exposure, the international reputa-

tions of the chapter contributors, and Dr. Babbush’s personal writings and insight, this book certainly qualifies as one ofthose rare contributions to the field. If you can put “enjoyable”and “required” reading in the same sentence, it would certainlyapply here. Anyone with an interest in implant dentistry at anylevel, from those just starting out, to surgeons, restorativedentists, assistants, hygienists, and lab technicians, will findtake-home value in every chapter.

My congratulations to Dr. Babbush and to his co-authorsfor providing us with this remarkable text, and my gratitudeto them for providing us with an encyclopedic reference sourcein one volume. I can’t wait for the third edition.

Stephen M. Parel, DDSProsthodontist

Private Practice, Implant Surgery Dallas, Texas


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xiii

P R E F A C E

The year 2010 is the 48th year since my graduation from theUniversity of Detroit, School of Dentistry. Additionally, it isthe 42nd year since I placed my first implant (a Blade-Vent)in the left maxillary second bicuspid first molar region of a20-something female patient. To the best of my knowledge,that implant survives to this day somewhere in California. Inever cease to be amazed by the survival of implant cases whichI did 20 … 25 … 30 … 35+ years ago using almost primitivedesigns, materials, techniques, and concepts of surgery andrestorative procedures.

Throughout my career, I have continually sought out thebest materials, designs, and technology in order to improveupon the outcome, prognosis, and survival of these cases. My

first endeavor encompassed the blade-vent concept; from thereI moved on to the mandibular full-arch subperiosteal implantas well as to vitreous and pyrolyte carbon, aluminum oxide,ramus frame, mandibular staple bone plate, and more advanceddesigns of the blade-vent implant. The next step in my careertook me into more contemporary times with the TPS SwissScrew and the original design of the ITI Strauman conceptimplants. This was followed by a strong position using two-stage osseointegrated root form implants of the IMZ designfollowed closely by Steri-Oss and Frialit screw-type designs.The NobelReplace Implant System came next, and ultimately,I have settled on the NobelActive Implant System, which hasled me to the most incredible surgical prosthetic outcomes inthe most challenging of patients and anatomical situations.

As I entered this incredible phase of my practice, I haveutilized the latest and greatest techniques as well as the mostcutting-edge technology. The latest generation of the conebeam CT scanner is used with every patient. This helps us toaccurately determine bone quality and bone quantity. It alsoprovides for the visualization of interactive 3-D modeling,

which allows for the development of surgery and prosthetictreatment plans before ever entering the operating room as well

as the fabrication of surgical guides when indicated. The useof digital periapical and panoramic imaging has reducedradiation exposure, improved imagery capability and allowedfor computer-to-computer Internet messaging, which hashelped to broaden the exchange of information andcommunication.

Consolidation of the number of procedures necessary toachieve preliminary immediate reconstruction for the patient,as well as the definitive prosthetic results, has made a signifi-cant impact on patient acceptance and long-term results.Implants that we are currently using offer a tremendousincrease in initial stability, which allows not only placementafter extraction but also immediate loading in a vast majority

of cases. As previously stated, with all of these concepts we willbe able to provide improved treatment to the public, who, inmany instances, are in a state of end-point crippling disease.The procedures include, but are not limited to, the eliminationof chronic pain, neurological deficit, and various levels ofdysfunction. These individuals may also be the victims of ter-rible social rejection, which includes loss of self-confidence andself esteem resulting from the overshadowing aspects of severeadvanced atrophy of the maxillofacial skeleton.

As we enter this new millennium and its accompanyingrealm of technological advances, it is evident that an individual

who has the need, time, desire, and interest to have this recon-struction can certainly be brought back into the mainstreamof function, improved aesthetics, alleviation of pain, and elimi-nation of the terrible emotional and psychiatric depression. Weknow that the quality of care, along with improved technolo-gies, will enable those of us in the healthcare field to recon-struct the oral mechanisms for a greater number of thepopulation with higher levels of efficacy and improved long-term survivals than ever before.

Charles A. Babbush


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xiv

A C K N O W L E D G M E N T S

Once again, in this, my fourth textbook, I want to thank myoffice staff members who continue, to contribute on a dailybasis to my work: Sherry Greufe, Ella Mae Shaker, MaryNapp, Lori Ruiz-Bueno, Pat Zabukovec, and Faith Drozin,

who have been with me for decades. Additionally, I wish tothank the newer members of our clinical staff: Jennifer Sanzo,Kim Middleton, Rebecca Bowman, and Wendy Rauch as wellas our outstanding laboratory technicians, Paul Brechelmacherand Alan McGary. A special thank you goes to Ella MaeShaker for the massive amount of typing for this book overthe last several years.

Over the past 42 years many colleagues from near and farhave collaborated with me in this work. They have shared their

knowledge and experience, as well as their patients, in numer-ous instances, and for all of this I think of you often and thankyou for your participation and support.

The man who actually gave me a few implants in 1968 inorder to carry out my original blade-vent research is Dr. Jack

Wimmer, President of Park Dental Research in New YorkCity. Over the years he has continued to be a colleague, amentor, and, most of all, my friend. For this, I am greatlyindebted and thank you for all you have done for me, as wellas the field of implant dentistry.

The staff of Elsevier has contributed, as usual, their mostprofessional support, advice, and hard work related to thisbook. From the cover through the editing and layout to thelast page John Dolan, Executive Editor, has been the all-timesupreme professional, and in a similar manner, so haveCourtney Sprehe, Senior Development Editor and RachelMcMullen, Senior Project Manager.

The amazing group of contributors who have come togetherto share their extensive knowledge, talent, skill, and experiencerivals and, I believe, surpasses any work yet published in thisfield. For all of them we lift our collective hats and appreciationfor their efforts.

I wish to thank an amazing group of individuals whohave entered my life and career in the past several years. Theycomprise the group at ClearChoice Dental Implant Centers inDenver, Colorado. Dr. Don Miloni had the original vision andconcept and he bid Mr. Steve Boyd to join him to create theoriginal business entity, which has expanded to now includea wonderful group of people: Margaret McGuckin, LarryDeutsch, Dan Christopher, John Walton, and Bobby Turner,

just to name a few. I thank them for their leadership, businessexperience, friendship, and corporate culture. In the sameconcept, I wish to thank ClearChoice for bringing Dr. GaryKutsko, Prosthodontist, and myself together in the ClevelandClearChoice Center. He is creative, innovative, and continues

to make our work together a joy on a daily basis. Dr. JohnBrokloff has also joined our staff as an oral and maxillofacialsurgeon. It is truly a pleasure to have him participate, and Iknow our staff and patients have all enjoyed his technical skilland wonderful patient management.

At this time I want to thank Jack Hahn, Jack Krauser, and Joel Rosenlicht for joining me and sharing this work with youin this book. They bring over 125 years of combined clinicalpractice, research, and education to Dental Implants: The Artand Science, Second Edition. After all, we have had the samecommon goals over all these years of advancing the field ofimplant reconstruction for our patients as well as colleagues.

Lastly, I wish to thank my distinguished colleagues andfriends: Dean Jerold Goldberg, Drs. Steven Parel, Ole Jensen,Mark Adams, and Ken Judy, who responded to my invitationto write the forwards for this book in such an eloquent manner.

All of you have made significant contributions to me, to thisbook and to the field of implant reconstruction in order tocontinue to be able to change lives on a daily basis.

Charles A. Babbush


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xv

C O N T E N T S

CHAPTER 1: The Future Need and Demand for Dental Implants 1L. Jackson Brown, Charles A. Babbush

CHAPTER 2: The Business of Implant Dentistry 17Bob Salvin

CHAPTER 3: Essential Systems for Team Training in the Dental ImplantPractice 25Samuel M. Strong, Stephanie S. Strong

CHAPTER 4: Dental Risk Management 40Richard J. Rymond, Ronald A. Mingus, Charles A. Babbush

CHAPTER 5: Master Planning of the Implant Case 60Charles A. Babbush, Joel L. Rosenlicht

CHAPTER 6: Dental Implant Therapy for Medically Complex Patients 86Adi A. Garfunkel

CHAPTER 7: Surgical Anatomical Considerations for Dental ImplantReconstruction 98Celso Leite Machado, Charles A. Babbush, Arthur L. Rathburn

CHAPTER 8: Contemporary Radiographic Evaluation of the ImplantCandidate 110Joel L. Rosenlicht, Ryaz Ansari

CHAPTER 9: Bone: Present and Future 124Cameron M.L. Clokie, George K.B. Sándor

CHAPTER 10: The Use of CT/CBCT and Interactive Virtual Treatment Planningand the Triangle of Bone: Defining New Paradigms for Assessment of ImplantReceptor Sites 146Scott D. Ganz

CHAPTER 11: Peri-implant Soft Tissues 167Eric Rompen, Eric Van Dooren, Konstantin D. Valavanis

CHAPTER 12: Membrane Barriers for Guided Tissue Regeneration 181Jack T. Krauser, Barry Kyle Bartee, Arun K. Garg

CHAPTER 13: Contemporary Subantral Sinus Surgery and GraftingTechniques 216Dennis G. Smiler, Muna Soltan, Michelle Soltan Ghostine

CHAPTER 14: Inferior Alveolar Nerve Lateralization and Mental NeurovascularDistalization 232Charles A. Babbush, Joel L. Rosenlicht

CHAPTER 15: Graftless Solutions for Atrophic Maxilla 251Edmond Bedrossian


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xvi Contents

CHAPTER 16: Complex Implant Restorative Therapy 260Evan D. Tetelman, Charles A. Babbush

CHAPTER 17: Intraoral Bone Grafts for Dental Implants 276Craig M. Misch

CHAPTER 18: The Use of Computerized Treatment Planning and a CustomizedSurgical Template to Achieve Optimal Implant Placement: An Introduction to

Guided Implant Surgery 292Jack T. Krauser, Joel L. Rosenlicht

CHAPTER 19: Teeth In A Day and Teeth In An Hour: Implant Protocols forImmediate Function and Aesthetics 300Thomas J. Balshi, Glenn J. Wolfinger, Stephen F. Balshi, James R. Bowers, J. Neil Della Croce

CHAPTER 20: Extraction Immediate Implant Reconstruction: Single Tooth to FullMouth 313Charles A. Babbush, Jack A. Hahn

CHAPTER 21: Immediate Loading of Dental Implants 340Joel L. Rosenlicht, James A. Ward, Jack T. Krauser

CHAPTER 22: Management of Patients With Facial Disfigurement 355Marcelo Ferraz de Oliveira, Loretta De Groot Oliveira

CHAPTER 23: The Evolution of the Angled Implant 370Stephen M. Parel

CHAPTER 24: Implants for Children 389Richard A. Kraut

CHAPTER 25: Piezosurgery Related to Implant Reconstruction 403Tomaso Vercellotti

CHAPTER 26: A New Concept of Tapered Dental Implants: Physiology,Engineering, and Design 414Ophir Fromovich, Benny Karmon, Debora Armellini

CHAPTER 27: The All-on-4 Concept 435Paulo Maló, Isabel Lopes, Miguel de Araújo Nobre

CHAPTER 28: Laboratory Procedures as They Pertain to ImplantReconstruction 448Sven Jesse

CHAPTER 29: Complications and Failures: Treatment and/or Prevention 467

Charles A. Babbush

CHAPTER 30: Hygiene and Soft Tissue Management: Two Perspectives 492Jack T. Krauser, Lynn D. Terraccianao-Mortilla, Jan LeBeau


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1

C H A P T E R 1

THE FUTURE NEED AND

DEMAND FOR DENTAL

IMPLANTS

This chapter reviews the present and probable future need anddemand for dental implants. A dental implant is defined as anartificial tooth root replacement and is used to support restora-tions that resemble a natural tooth or group of natural teeth(Figure 1-1).1

Implants can be necessary when natural teeth are lost.

When tooth loss occurs, masticatory function is diminished; when the underlying bone of the jaws is not under normalfunction it can slowly lose its mass and density, which can leadto fractures of the mandible and reduction of the verticaldimension of the middle face. Frequently, the physical appear-ance of the person is noticeably affected (Figure 1-2).1

To understand the growth in the use of dental implants inrecent years and their probable future need and demand,several topics require review. The background section of thischapter provides a general description of tooth loss and itsconsequences, the technical options that are available forreplacing missing teeth, and the circumstances in which eachoption is appropriate. Following the general background, the

discussion section systemically addresses the various factorsthat influence the need and demand for tooth replacement.The final sections of the chapter assess the recent growth indental implants and their likely trend for the future.

Background

Tooth Loss

Humans have lost their natural teeth throughout history.Teeth are lost for a variety of reasons.2-4 In primitive societies

most teeth are lost as the result of trauma. Some areintentionally removed for sacred rituals or for cosmetic reasons(Figure 1-3).

Oral diseases, mostly dental caries and periodontal disease,have attacked human dentitions throughout mankind’s longexistence. In primitive cultures, both extant and past, peri-

odontal disease is known to have occurred. Signs of periodon-tal bone loss are often prevalent in the fossil records and aredetected by physical and radiographic examination in indi-viduals from existing primitive cultures. Dental caries, themost common dental disease of recent centuries, occurred inthese cultures but was not as prevalent as it became in moderntimes.

In contrast to primitive societies, oral diseases and theirsequelae have become the predominant cause of tooth loss inmodern societies of the 20th and 21st centuries. Trauma stillplays an important part in tooth loss, but less than that of oraldiseases. A major reason for the increase in the role of diseasein tooth loss in modern societies is the expanded proportion

of refined sugar and other cariogenic food items that make upthe diets of industrialized societies.5 This change in diet was amajor contributing factor in an epidemic of dental cariesduring the first three quarters of the 20th century. The epi-demic continued unabated until the deployment of modernpreventive dentistry beginning around the middle of the 20thcentury.

This epidemic of caries, along with more available profes-sional dental care, led to a concomitant increase in the extrac-tion of teeth by dental health professionals. Partial tooth loss

was almost ubiquitous. Total tooth loss, edentulism, was not

L. Jackson Brown

Charles A. Babbush


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2 Chapter 1 The Future Need and Demand for Dental Implants

Figure 1-1. Comparison of natural tooth and crown with

implant and crown. (From Babbush CA: As good as new: aconsumer’s guide to dental implants, Lyndhurst, OH, 2004, TheDental Implant Center Press.)

Crown

Gum

Bone

ImplantRoot

Bone

Gum

Crown

Figure 1-2. A and B, This patient has lost all of her upper and lower teeth and has a moderateamount of subsequent jaw shrinkage as well as a decrease in facial structure both in the frontal andlateral view. (From Babbush CA: As good as new: a consumer’s guide to dental implants, Lyndhurst,OH, 2004, The Dental Implant Center Press.)

BA

uncommon among young adults and became the predominantcondition among elderly populations. More detail on the pastand likely future trends in tooth loss are provided in the lastsection of this chapter.

Options for Replacementof Lost Teeth

When a tooth is lost, the individual and the dentist face twochoices. The first choice is: should I replace the missing tooth?

The second is: what is the best way to replace it? Althoughthese decisions may seem sequential, they are interrelated inimportant ways. The technical options available can influencethe decision to replace a tooth, and modern science has pro-duced more and better options for tooth replacement in manycircumstances.6-8 The age and general health of the patient arecritical. The condition of the remaining dentition, its configu-ration in the mouth, and its periodontal support are very

important aspects of the decision to replace.1,6 Finally, the rela-tive cost of options can play a role, but should not be disposi-tive for a treatment plan. In making these decisions, the dentistand patient must evaluate all of these factors to reach the besttreatment for a particular patient.5

A number of restorative options for the treatment of missingteeth are recognized as accepted dental therapy, depending onparticular circumstances the patient presents. These include:

1. Tissue-supported removable partial dentures9 (Figure1-4)

2. Tooth-supported bridges (Figure 1-5)10

3. Implant-supported teeth (Figure 1-6)8

Likewise, there are two basic options for replacing teeth in acompletely edentulous arch:

1. Tissue-supported removable complete dentures11 (Figure1-7)

2. Implant-supported over-dentures12,13 (Figure 1-8) All these therapies have their indications for use; a brief

review of their indicators, strengths, and limitations follows.

Tissue-Supported Prostheses: Partialand Complete Dentures

Removable dentures, whether partial or complete, are sup-ported by the bone of the jaw and the soft oral mucosa cover-

ing the jaw.

9,11

Removable partial dentures frequently are heldin place by metal clasps that clip onto teeth or by precisionattachments that insert into specially designed receptacles on


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Chapter 1 The Future Need and Demand for Dental Implants 3

Figure 1-3. A, A wrought-iron tooth implant in the upper jaw of an ancient warrior in Gaul. B, A radiograph of the metal implant.C, A typical warrior of Gaul. (From Babbush CA: As good as new: a consumer’s guide to dental implants, Lyndhurst, OH, 2004,

The Dental Implant Center Press.)

A

B C

Figure 1-4. A typical collection of prosthetic devices, includingflippers, removable partial dentures, and full dentures. (FromBabbush CA: As good as new: a consumer’s guide to dentalimplants, Lyndhurst, OH, 2004, The Dental Implant CenterPress.)

Figure 1-5. A panoramic radiograph demonstrating three-unitbridges in the left maxilla and in the right posterior aspect ofthe mandible.

R L


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Figure 1-6. A, A panoramic radiograph with a single tooth implant reconstruction in the left mandible.B, A panoramic radiograph demonstrating full arch, maxillary, and mandibular reconstruction with fixedprosthetic appliances.

A B

Figure 1-7. Many dentures become so unsatisfactory they areleft in a glass of water. (From Babbush CA: As good as new:a consumer’s guide to dental implants, Lyndhurst, OH, 2004,The Dental Implant Center Press.)

Figure 1-8. A model of a four-implant connector bar with anoverdenture and internal clip fixation. (From Babbush CA: Asgood as new: a consumer’s guide to dental implants, Lyndhurst,OH, 2004, The Dental Implant Center Press.)

artificial crowns placed on teeth adjacent to the space createdby the missing tooth or teeth. Patients need to take theseremovable partial prostheses in and out regularly for cleaningafter eating and at night.

Removable prostheses have a long history as a practicalanswer to partial and complete tooth loss. For a long time they

were the only option available for complete-arch edentulismand partial edentulism without posterior supporting teeth. Amajor advantage of tissue-supported prostheses compared withtooth-supported prostheses or dental implants is that they areless invasive and require less sacrifice of oral tissues to place inthe mouth.

However, they have distinct problems for the individual who wears them. Tissue-supported prostheses continuallystress the oral tissues.14 Over time, the weight-bearing stress

caused by mastication—and to a lesser extent, other activitiessuch as bruxism—can cause the underlying bone to resorb,reducing the bony mass of the jaws. If this bony resorption isextensive enough it can lead to fracture of the mandible. This

bony pathology frequently is accompanied by local mucosallesions created by the prosthesis. Sometimes the oral tissuescannot continue to support neither an existing tissue sup-ported prosthesis nor a new prosthesis to replace the existingone (Figure 1-9).

Tooth-Supported Prostheses:Fixed Bridges

Tooth-supported fixed prostheses (bridges) rely on the adja-cent teeth for support. The teeth next to the missing tooth


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space(s) are anatomically prepared to receive, in most cases, aporcelain, gold, or porcelain-fused-to-gold crown.10 After theteeth are prepared and a negative impression is taken, the fixedprosthesis is constructed by a dental laboratory. When thefinished bridge is returned to the dentist, it is cemented ontothe prepared abutment teeth. This prosthesis is fixed in place;it does not come in and out. It relies on the integrity of theadjacent teeth for support.

Fixed prostheses also have a long history in dental practice.The stresses of mastication are passed down through thesupport structure to the abutment teeth. These tissues arecapable of absorbing the stress of mastication because that ispart of their natural function. However, the longer the spanof replaced teeth, the greater the stress placed on the abutmentteeth. In addition, the crowned abutment teeth are at risk forcaries under the crown and along its margin with the toothstructure. If the periodontal health of the abutment teethdeteriorates, the entire support for the fixed bridge can be

compromised.

Bone-Supported Prostheses:Dental Implants

The final method of tooth replacement is the dental implant,8 which is a replacement for the root of a tooth. The implant isplaced where the root of the missing tooth used to be. Thereplacement root is then used to attach a replacement tooth.Like the other options, dental implants are used to replacemissing teeth and restore masticatory function to an individ-ual’s dentition.

The major types of dental implants are osseointegrated and

fibrointegrated implants.8

Earlier implants, such as the sub-periosteal implant and the blade implant, were usually fibro-integrated. The most widely accepted and successful implanttoday is the osseointegrated implant. Examples of endosseousimplants (implants embedded into bone) date back over 1350years. While excavating Mayan burial sites in Honduras in1931, archaeologists found a fragment of mandible with anendosseous implant of Mayan origin, dating from about600 ad (Figure 1-10).

Widespread use of osseointegrated dental implants is morerecent. Modern dental implantology developed out of the

landmark studies of bone healing and regeneration conductedin the 1950s and 1960s by Swedish orthopedic surgeon P. I.Brånemark.15 This therapy is based on the discovery that tita-nium can be successfully fused with bone when osteoblastsgrow on and into the rough surface of the implanted titanium.This forms a structural and functional connection between theliving bone and the implant. A variation on the implant pro-cedure is the implant-supported bridge, or implant-supporteddenture.

Today’s dental implants are strong, durable, and natural inappearance. They offer a long-term solution to tooth loss.Dental implants are among the most successful procedures indentistry.16-20 Studies have shown a 5-year success rate of 95%for lower jaw implants and 90% for upper jaw implants. Thesuccess rate for upper jaw implants is slightly lower because

the upper jaw (especially the posterior section) is less densethan the lower jaw, making successful implantation and osseo-integration potentially more difficult to achieve. Lower poste-rior implantation has the highest success rate of all dentalimplants.

Dental implants are less dependent than tooth- or tissue-supported prostheses on the configuration of the remainingnatural teeth in the arch. They can be used to support pros-theses for a completely edentulous arch, for an arch that doesnot have posterior tooth support, and for almost any configu-ration of partial edentulism with tooth support on both sidesof the edentulous space.

Additionally, dental implants may be used in conjunction

with other restorative procedures for maximum effectiveness.21

For example, a single implant can serve to support a crownreplacing a single missing tooth. Implants also can be used tosupport a dental bridge for the replacement of multiple missingteeth, and can be used with dentures to increase stability andreduce gum tissue irritation. Another strategy for implantplacement within narrow spaces is the incorporation of themini-implant. Mini-implants may be used for small teeth andincisors.

Modern dental implants are virtually indistinguishablefrom natural teeth. They are typically placed in a single sitting

Figure 1-9. A panoramic radiograph demonstrating severeadvanced atrophy of both the maxilla and mandible. Figure 1-10. A Mayan lower jaw, dating from 600 AD, with

three tooth implants carved from shells. (From the PeabodyMuseum of Archaeology and Ethnology, Harvard University,Cambridge, Mass.)


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but require a period of osseointegration. This integration withthe bone of the jaws takes anywhere from 3 to 6 months toanchor and heal.22,23 After that period of time a dentist placesa permanent restoration for the missing crown of the tooth onthe implant.

Although they demonstrate a very high success rate, dentalimplants may fail for a number of reasons, often related to afailure in the osseointegration process.24-30 For example, if the

implant is placed in a poor position, osseointegration may nottake place. Dental implants may break or become infected (likenatural teeth) and crowns may become loose. Dental implantsare not susceptible to caries attack, but poor oral hygiene canlead to the development of peri-implantitis around dentalimplants. This disease is tantamount to the development ofperiodontitis (severe gum disease) around a natural tooth.

Dental implant reconstruction may be indicated for toothreplacement any time after bone growth is complete. Certainmedical conditions, such as active diabetes, cancer, or peri-odontal disease, may require additional treatment before theimplant procedure can be performed. In some cases in whichextensive bone loss has occurred in a jaw due to periodontaldisease, implants may not be advised. Under proper circum-stances, bone grafting may be used to augment the existingbone in a jaw prior to or in conjunction with placement.

Need and Demand for ToothReplacement

Two general approaches are available to estimate the numberof dental implants that will be placed.2,3 The first is a needs-based approach based on an estimation of unmet needs in apopulation. Workforce assessment starts with estimates of oralhealth personnel required to treat all oral disease or a specified

proportion of that disease. A variation on this approach is toadjust those estimates downward based on the anticipatedutilization of dental services by the populace.

The second approach is a demand-based approach that usesthe demand for dental services as the starting point to estimaterequired oral health personnel. This approach relies on eco-nomic theory to identify important factors that influencesupply and demand for dental services. Future trends for thesefactors are used to forecast workforce requirements. A cleardistinction must be drawn between demand and unmet needfor services in order to understand future access to care and

what interventions are likely to be effective in improving accessto care for some subpopulations.

The Concept and Measurementof Need

Need for care generally arises because of the existence ofuntreated disease. The scientific basis for efficacious therapymust also exist.2,3 Untreated disease in affluent societies usuallycoexists, with the majority of patients receiving the highestquality of care. In less affluent societies, a preponderance ofdisease may go without therapeutic intervention. The need-based approach uses normative judgments regarding theamount and kind of services required by an individual in order

to attain or maintain some level of health. The level of unmetneed in a society is usually determined from health level mea-surements based on epidemiological or other research identify-ing untreated dental disease. The underlying assumption is thatthose in need should receive appropriate care. Once the levelof need is determined, the quantity of resources is then deter-mined based on matching unmet need with appropriate care.

Evaluation of unmet need is important for identifying

populations in which access, for whatever reason, may be aproblem. Epidemiological and health research in dentistry aredesigned to identify population-based dental care problemssuch as segments of the population with unmet need. Anunderstanding of the economic and social conditions sur-rounding such groups, their reasons for not seeking profes-sional dental care, and the role that price plays in determiningeffective demand helps analysts identify weaknesses in theexisting care system and establish a foundation for effectiveremedies.

In addition, need assessment requires a normative judg-ment as to the amount and kind of services required by anindividual to attain or maintain some level of health. Funda-mentally, the need assessment focuses on which, and howmany, services should be utilized. In almost all circumstances,this will differ from the services actually utilized. Oliver,Brown, and Löe31,32 provide a thorough discussion of dentaltreatment needs as well as a review of studies that estimatedental treatment needs.

The Concept and Measurementof Demand

In the United States, professionally trained dentists providemost dental services. These services are delivered through

private markets shaped by supply and demand.

2,3

Under amarket system, dental services are provided to those who are willing and able to pay the dentist’s standard fee for the servicesrendered. This makes an assessment of demand for dentalservices essential for understanding the actual delivery of care.

A clear distinction must be drawn between demand and unmetneed for services in order to understand future access to careand what interventions are likely to be effective in alteringaccess to care for some subpopulations.

In assessing demand, the consumer is the primary sourcedriving the use of dental services. The demand for dental carereflects the amount of care desired by patients at alternativeprices. The quantity of dental services desired is negatively

related to price, and changes in the quantity of care demandedare significantly responsive to changes in dental fees. Otherfactors can influence the level of demand, including income,family size, population size, education level, insurance cover-age, health history, ethnicity, age, and other conditions.Demand-related policies can be used to alter market condi-tions and the distribution of care.

Supply, as well as demand, influences the ability of thedental workforce to adequately and efficiently provide dentalcare to a U.S. population growing in size and diversity. Thecapacity of the dental workforce to provide care is influencedby enhancements in productivity, numbers of dental health


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personnel, and dental workforce demographic and practicecharacteristics. The full impact of these changes is difficult topredict.

A limitation of the market delivery system is that individu-als with unmet needs who are unable or unwilling to pay theprovider’s fee generally do not effectively demand care fromthe private practice sector. Individuals often cannot expresstheir demand for care because of their economic disadvantage.

Stated plainly, these people are poor and cannot afford expen-sive dental services. From a societal perspective, it may be verydesirable that these individuals have full access to dental ser-vices, including the replacement of their missing teeth. Toprovide that needed care, the demand for care among theeconomically disadvantaged must be supported in one of three

ways: through pro bono care offered by dentists, through insti-tutional philanthropic funding, or through public funding. Ifpublic funding for dental services, including tooth replace-ment, is meager, then effective demand for those services willalso remain meager.2,3

Factors that Affect Need and Demandfor Tooth Replacement

The factors that affect the need and demand for dental implantscan be described as macro (large-group) factors and individualfactors. Macro factors are so named because, though they affectindividuals, their cumulative impact (for the entire country orlarge sections of the country) is most relevant for the totalnumber of dental implants that will be needed and demanded.These macro factors include (1) overall population grown anddemographics (age, gender, and racial/ethnic profile), (2)growth in disposable per capita income and improvement ineducational levels, (3) the extent and severity of oral diseases

that can result in tooth loss, and (4) tooth loss itself.Individual factors influence whether or not a particularperson will (1) experience a missing tooth, (2) decide whether tohave a replacement or leave the space vacant, and (3) choose adental implant or one of the alternatives as the replacement.

Macro FactorsPopulation Growth and Composition

Table 1-1 provides estimates of the United States populationby age in 2000, and projects population through 2050. Total

population has increased by about 50 million since 1980 andis expected to grow by almost 50% between 2000 and 2050.

Almost one half of that growth will occur in three states:California, Florida, and Texas.33-35

Along with an increase in size, the population will alsoexperience significant changes in its distribution by age. As apercent of the total, the elderly comprise 12.4% of the totalpopulation. By 2050 the elderly will make up 20.6% of the

total population.Baby-boomers are another important component of the

U.S. population. Born between 1945 and 1964, the leadingedge of baby-boomers was in their mid-30s in 1980, mid-50sin 2000, and will be in their mid-70s in 2020 (Figure 1-11).This change in the age distribution of the nation’s populationis important in assessing the potential need for dental services.Different age groups require different types of dental services.Older individuals require more replacement restorations andreplacement of teeth. The majority of endodontic services areperformed on individuals between the ages of 35 and 74 years.

As of 2000, the youngest of the baby-boomers were in theirlate 30s.

The most important time of life for expenditures for dentalservices has always been between 45 and 64 years of age. Thepopulation group 45 to 54 years of age has experienced sub-stantial growth since 1980, especially during the past 10 years.This age cohort will continue to increase in numbers through2010 when it will begin to decline as the youngest baby-boomers age out of this age group and are replaced by thenumerically smaller generation that follows them. In contrast,the number of people aged 55 to 64 years has increased onlyslightly since 1980 but will experience marked growth duringthe next 20 years with the arrival of the bulk of thebaby-boomers.

An age group with a somewhat lower utilization, but a highdisease level, is the 65 years and older age group. This agegroup is expected to increase by more than 50% between 2000and 2020. Utilization of dental services by this age group willincrease if, as predicted, this age group in 2020 retains moreof their teeth than did previous generations and/or continues

working longer.Changes in the population’s racial and ethnic composition

also are expected to be important. For example, the Hispanicpopulation will increase from 12.6% in 2000 to 24.4% ofthe total population by 2050. The white, non-Hispanic

TABLE 1-1 Projected growth and changes in U.S. population (in thousands), 2000-2050

2000 2010 2020 2030 2040 2050 Total change

Total Population 282,125 308,936 335,805 363,584 391,946 419,854 48.8%

5 to 19 Years Old 61,331 61,810 65,955 70,832 75,326 81,067 32.2%

65 Years and Older 35,061 40,243 54,632 71,453 80,049 86,705 147.3%

White, not Hispanic 195,729 201,112 205,936 209,176 210,331 210,283 7.4%

Black Alone 35,818 40,454 45,365 50,442 55,876 61,361 71.3%

Asian Alone 10,684 14,241 17,988 22,580 27,992 33,430 212.9%

From the U.S. Census Bureau, 2004.


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Figure 1-11. A, Change in the U.S. population by age group from 1980 to 2000. B, Projectedchange in the U.S. population by age group from 2000 to 2020. (From the U.S. Census Bureau,2005.)

M i l l i o n s

12

10

8

6

4

2

0

–2

–4

–6

3.7

0 – 4

2.1

5 – 9

1.3

1 0 – 1 4

1.2

Age GroupB

1 5 – 1 9

1.6

2 0 – 2 4

3.1

2 5 – 2 9

2.2

3 0 – 3 4

–0.5

3 5 – 3 9

–1.8

4 0 – 4

4

0.0

4 5 – 4 9

2.9

5 0 – 5 4

8.3

5 5 – 5 9

10.0

6 0 – 6 4

8.1

6 5 – 6 9

5.3

7 0 – 7 4

6.0

7 5 +

M i l l i o n s

12

10

8

6

4

2

0

–2

–4

–6

2.8

0 – 4

3.9

5 – 9

2.4

1 0 – 1 4

–0.9

Age GroupA

1 5 – 1 9

–2.4

2 0 – 2 4

–0.5

2 5 – 2 9

2.8

3 0 – 3 4

8.5

3 5 – 3 9

10.8

4 0 – 4 4

9.2

4 5 – 4 9

6.1

5 0 – 5 4

1.9

5 5 – 5 9

0.7

6 0 – 6 4

0.7

6 5 – 6 9

2.0

7 0 – 7 4

6.6

7 5 +

population is expected to decrease from 69.4% to 50.1% ofthe total. These shifts in the age and racial/ethnic compositionof the U.S. population probably will be concentrated in

selected regions and states.Total population growth is another important factor in

determining the growth of dental implants: the larger thepopulation, the more teeth are at risk to be lost. Holdingothers factors constant, a larger population generates morepotential need for implants. Moreover, the loss of teeth iscumulative and nonreversible. For a particular birth cohort,the number of missing teeth will never decline as these indi-viduals age. Although not biologically inevitable, the numberof missing teeth in a group has always increased as the groupages.

Growth in Per Capita Income

Despite periods of slow growth or economic contraction, theU.S. economy has grown steadily since the formation of the

nation. The post–World War II period, particularly, has beena period of rising affluence for Americans.

Using data from the Bureau of Economic Analysis(BEA),36-39 trends in real disposable per capita personal incomefrom 1960 to 2005 are presented in Figure 1-12. In real terms,disposable per capita personal income in the United Statesincreased from $9,735 in 1960 to $27,370 in 2005, represent-ing an overall increase of 180% and an average annual growthof 4.0% (Figure 1-12).

All parts of the United States shared in the growing afflu-ence. In 1929 the richest state in the union was New York


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(with per capita income of $9717). Figure 1-13, A shows howthe other states compared to New York in that year. Thepoorest state at the time was South Carolina, where per capitaincome was $2282. The richest state (New York) was morethan four times richer than the poorest state (South Carolina).Moreover, 20 of the 48 states had incomes that were less than50% of the richest state.

By the year 2003 a lot had changed, including the distribu-

tion of income across the states. Figure 1-13,B

shows thatthe gap between the richest state (Connecticut, $40,990) andthe poorest state (Mississippi, $22,262) has declined—theratio in 2003 was 1.84. Moreover, many states make less than50% of the richest state’s income. So, while the rich havegotten richer—real per capita income for New York (therichest state in 1929) rose by a factor of 3.5—the poor havegotten richer at a faster rate—real per capita income in SouthCarolina (the poorest state in 1929) increased by a factorof 10.

These data show that expansion of discretionary income hasaugmented the U.S. population’s capacity to buy expensivediscretionary items such as tooth replacement prostheses,

including dental implants. The rising living standards are widespread, affecting all parts of the United States.

Improvement in Educational Attainment

Education is an important determinant of the demand fordental services. Logistical models of the likelihood of a dentalvisit during the past year show that education level may be thestrongest determinant of demand after controlling for incomeand other variables.

As shown in Figure 1-14, the percentage of the U.S. popu-lation with at least a high school diploma doubled from 41.1%

in 1960 to 84.1% in 2000. The increase in the percentage ofthe population with a college degree or higher tripled from7.7% in 1960 to 25.6% in 2000.36-38

Figure 1-15 shows differences in the percentages of people with a college degree or more by race and Hispanic origin. Theannual rate of growth for whites between 1995 and 2002 was1.8%; for African Americans, 3.68%; and for Hispanics,2.56%. If these higher growth rates for the Hispanic popula-

tion continue, the educational gap between whites and His-panics will be reduced.Note that the Hispanic population is not a homogeneous

group with respect to dental service demand. Hispanic sub-groups (e.g., Mexicans, Puerto Ricans, and Cubans) reportsignificant differences in the percentage of members who hada dental visit during the past year.

The overall rise in educational level is very importantbecause educational attainment is such a potent predictor ofthe use of dental services, especially big-ticket items such asdental implants. The remaining disparities in educationalattainment by race and ethnicity also correlate with the differ-ences in demand for dental care among these groups. If these

education disparities are narrowed in the future, it may indi-cate a broader market for dental implants because economicdisadvantage, educational attainment, and tooth loss are allcorrelated and are together extremely powerful predictors ofthe use of and expenditures for dental services.

Trends in Dental Caries and Tooth Loss

Dental caries, which creates a biological need for care, has beenthe primary foundation of the demand for dental services inmodern times. The prevention and treatment of caries and itssequelae are large components of demand. Among adults, and

Figure 1-12. Real disposable per capita income, 1960-2005. (From the U.S. Department of Com-merce, Bureau of Economic Analysis.)

30,000

25,000

20,000

15,000

10,000

5,000

0

9 ,

7 3 5

1 9 6 0

1 1 ,

5 9 4

1 9 6 5

1 3 ,

5 6 3

1 9 7 0

1 5 , 2

9 1

1 9 7 5

1

6 ,

9 4 0

1 9 8 0

1

7 ,

2 1 7

1 9 8 1

1 7 ,

4 1 8

1 9 8 2

1 7 ,

8 2 8

1 9 8 3

1 9 ,

0 1 1

1 9 8 4

1 9 ,

4 7 6

1 9 8 5

1 9 ,

9 0 6

1 9 8 6

2 0 ,

0 7 2

1 9 8 7

2 0 ,

7 4 0

2 1 ,

1 2 0

2 1 ,

2 8 1

2 1 ,

1 0 9

2 1 ,

5 4 8

2 1 ,

4 9 3

2 1 ,

8 1 2

2 2 ,

1 5 3

2 2 ,

5 4 6

2 3 ,

0 6 5

2 4 ,

1 3 1

2 4 ,

5 6 4

2 5 ,

4 7 2

2 5 ,

6 9 7

2 6 ,

2 3 5

2 6 ,

5 9 4

2 7 ,

2 3 2

2 7 ,

3 7 0

1 9 8 8

1 9 8 9

1 9 9 0

1 9 9 1

1 9 9 2

1 9 9 3

1 9 9 4

1 9 9 5

1 9 9 6

1 9 9 7

1 9 9 8

1 9 9 9

2 0 0 0

2 0 0 1

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5


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1400

1200

1000

800

600

400

200

0

A

2 6 7

0

2 7 9 3 0 5

3 2 8

3 2 0

3 4 3 3 7 4

3 7 7

3 8 8

4 0 4

4 1 0

4 1 6 4 3 2 4 5 2

4 5 9 4 7 6 5 0 0 5 1 7 5 2 8 5 4 7 5 7 2 5 8 6

5 9 0

5 9 4

5 9 7

5 9 8

6 0 4 6 1 8 6 3 0

6 3 0 6 6 5

6 6 9

6 7 0 6 8 5 7 3 9 7 6 9

7 7 1

7 7 3 7 9 1 8 6

8

8 7

6 9 0 7 9 2 0 9 4 9 9 9 3 1

, 0 2 7

1 , 0

3 1 1 , 1

5 1

1 , 2

7 3

S C M S A Z A L N C G A T N N D K Y N M L A S D V A O K W V T X I D F

L K S U T I A

N E M T M N A K M E I N

M O C O V T O R W Y W I

N H W A M D O H P A M I N V R I

M A N L I L

C A C T D E N Y D C

70000

60000

50000

40000

30000

20000

10000

0 0

B M S W V U T A R N M K Y S C I D A

L A Z M T I N T

N G A N C M E M O M I

O H I A

O K O R S D L A N D N E W I K S T X V T F L P A H I N V R I A K D E I L

N M C O W A N H V A C A M D N Y W Y M A N J C T D C

6 1 ,

3 9 7

5 4 ,

9 8 4

4 9 ,

2 3 8

4 9 ,

1 4 2

4 7 ,

0 3 8

4 6 ,

6 6 4

4 6 ,

6 4 6

4 1 ,

5 8

0

4 1 ,

5 6

1

4 1 ,

4 4

4

4 1 ,

0 6

2

4 1 ,

0 1

9

4 0 ,

9 6

9

4 0 ,

9 1

9

4 0 ,

0 5 8

3 9 ,

9 3 4

3 9 ,

7 1 2

3 9 ,

6 4 9

3 9 ,

0 6 0

3 8 ,

7 4 0

3 8 ,

3 1 6

3 7 ,

4 4 6

3 7 ,

0 0 6

3 6 ,

4 8 3

3 6 ,

2 4 1

3 6 ,

1 8 9

3 5 ,

9 5 5

3 5 ,

7 7 0

3 5 ,

6 6 4

3 5 ,

0 2 7

3 4 ,

9 1 0

3 4 ,

7 9 6

3 4 ,

5 0 9

3 4 ,

3 4 2

3 3 ,

9 8 4

3 3 ,

9 6 2

3 3 ,

6 6 3

3 3 ,

4 1 6

3 3 ,

3 7 3

3 3 ,

1 5 2

3 3 ,

1 4 5

3 2 ,

9 0 0

3 2 ,

4 0 1

3 1 ,

7 0 3

3 1 ,

0 4 8

3 0 ,

7 8 7

3 0 ,

6 0 4

3 0 ,

1 0 0

3 0 ,

0 9 0

2 9 ,

2 9 3

2 8 ,

5 2 7

Figure 1-13. A, The variation in per capita income by state, 1929. B, The variation in per capitaincome by state, 2007. (From the U.S. Department of Commerce, Bureau of Economic Analysis.)


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Figure 1-14. Percent of the U.S. population 25 years and olderwith two levels of educational attainment, 1960-2000. (Fromthe U.S. Census Bureau, 2003.)

90%

80%

70%

60%

50%

41.1%

7.7% 10.7%

16.2%21.3%

25.6%

52.3%

High School Graduate or MoreCollege Graduate or More

66.5%

77.6%84.1%

40%

30%

20%10%

1960 1970 1980 19900%

2000

Figure 1-15. Percent of the U.S. population 25 years and olderwho were college graduates or had advanced degrees, by raceand Hispanic origin, 1995-2002. (From the U.S. CensusBureau, 2003.)

40%

35%

30%

24.0% 25.9%

13.2%15.4%

17.0%

11.1%10.9%9.3%

27.2%

25%

20%

White

Black

Hispanic

15%

10%

5%

1995 19971996 1998 1999 2000 20010%

2002

especially the elderly, primary caries does not usua

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