Book ReviewsClinical Manualof ImplantDentistry

Edited by: Davarpanah, Mithridade; Martinez, Henry;Kebir, Myriam; Tecucianu, Jean-Francois. QuintessencePublishing Co, Inc, Chicago, IL, 2003: ISBN:1-85097-049-1. (217 pages, 520 illustrations, 426 color;price $84)

This text is divided into thirteen chapters thatcover a broad spectrum of topics related to dentalimplant treatment, starting from treatment plan-ning and ending with a concise description ofdifferent implant loading concepts. The book isintended for the use of students and clinicianswho are new to implant dentistry. It provides thereader with practical and contemporary, yet basic,knowledge of the different phases of implant treat-ment.

The pages of this book are rich with tables,graphs, beautiful figures and illustrations. Althougha few are mislabeled (fig.3-33, fig.3-36a and 3-36b),the quality of the illustrations is impressive andserves to make the book easy to read and under-stand. The information presented is well supportedby complete literature citations throughout thebook.

The authors of the book begin wisely with asummarized but complete discussion of the factorsthat govern implant treatment planning. They in-troduce prosthetic success criteria for dental im-

plants, which proves to be important in this day andage where achieving osseointegration is no longerthe major obstacle in providing successful implanttreatment.

Chapters two and three are dedicated to thediscussion of implant placement technique and theutilization of implants with different diameters.The factors that aid the dentist in deciding whatimplant diameter to use are presented, and theinformation discussed is well supported by a com-plete literature review. Throughout the discussionof implant placement, very little emphasis is placedon the role of the restorative dentist in treatmentplanning, and the little discussion concerning theuse of a diagnostic wax up, or the use of a surgicalguide to aid the surgeon in implant placement, doesnot adequately reflect the importance of these stepsin achieving a successful functional and estheticimplant restoration.

A comprehensive but general description of therestorative aspects of implant treatment follows.The authors describe several different impressiontechniques utilized and provide a simplified accountfor the beginner to read and follow. Restorativeimplant components are presented, and the differ-ences between screw-retained and cemented pros-theses are discussed. The discussion provides thestudent with a step-by-step instruction on how torestore implants in different edentulous situations.Although the book is designed to be comprehensive,very important aspects relevant to the implanttreatment are missing. The discussion of occlusionand biomechanics of the implant restoration isclearly lacking. For example, the authors advocatesimultaneous contacts on the implant prosthesisand on the posterior teeth in partially edentuloussituations and neglect the fact that dental implantsare not supported by a periodontal ligament likenatural teeth.

The authors introduce a classification systemthat describes the prosthetic and surgical implanttreatment in the posterior maxillary and mandibu-

334 Journal of Prosthodontics, Vol 12, No 4 (December), 2003: pp 334-339

lar regions according to the available bone volumeand the prosthetic space. This classification simpli-fies implant treatment and makes it easier for theinexperienced clinician to evaluate implant sitesand reach the appropriate decisions concerning thetreatment. A chapter dedicated to specific surgicalprocedures introduces the reader to different waysof preserving alveolar bone and different graftingtechniques in the maxilla and mandible such assinus grafts, onlay bone grafts, and guided boneregeneration. The discussions cover the basics ofeach procedure, but some details are lacking. Thereader would have benefited more from a discus-sion classifying the different grafting materials ac-cording to their origin (autogenous, allograft, etc),and then comparing the different grafting materi-als and the clinical situations where each would beindicated. A brief description of the non-submergedimplant technique is presented in the book and auseful introduction to the surface properties of den-tal implants would have also served the readerbetter if those topics were introduced at the begin-ning of the book.

Throughout the book, a special emphasis isplaced on 3i implant system, and there is very littlemention of other competing implant systems.

Chapter eleven is devoted to a discussion ofimplants in the younger patient. The authors em-phasize the importance of understanding the skel-etal growth patterns in the maxilla and mandiblebefore implant placement and the special consider-ations for patients with genetic diseases such asectodermal dysplasia. Citing literature, they pro-vide the reader with a complete picture concerningindications and contraindications.

In the last chapter of the book, a simple gener-alized discussion of different loading concepts ispresented. The discussion is enough to provide thereader with an idea of the different concepts de-scribed in the literature, but does not reflect theimportance of the topic and the great interest cur-rently in the concept of immediate loading.

This book serves its purpose well as a contem-porary introduction to implant treatment. It is mostvaluable to students and dentists who are new tothe implant field and can serve as a quick concisereference for clinical implant procedures, yet itlacks key components of implant treatment as pre-viously mentioned in this review. While it is wellwritten and contains very useful and relevant infor-

mation, it lacks the depth that would make it moreappealing to trained specialists.

Radi Masri, BDS, MSClinical InstructorDepartment of Restorative DentistryBaltimore College of Dental SurgeryUniversity of MarylandBaltimore, MD.

Law and RiskManagement inDental Practice

Burton R. Pollack. Quintessence, Chicago, IL, 2002:ISBN 0-86715-416-0 (272 pp; soft cover; $49.00)

Dental jurisprudence is defined as the applica-tion of law to the dental practice. This handbookcovers the described field of dental jurisprudence.While some may think it is a strange combination,Dr. Pollack is the recognized “Dean” of dentist/attorneys, and he makes a very strong case forshared knowledge between the disciplines.

The stated purpose of the book is to presentlegal trends as they relate to dental practice. Thetext is not intended to provide legal advice. Thetext highlights the published views in various statesthat have differing laws, rules, and regulations asthey pertain to the practice of dentistry. Whilemany readers may be familiar with the old adage“ignorance of the law is no excuse,” finding the lawsregulating dental practice in one’s own state isoften very difficult. Fifty-four different jurisdictionsincluding the fifty states, Puerto Rico, the VirginIslands, and the federal government, have all exer-cised their right to regulate the health professions,including dentistry. For example, a dentist in NewYork can lawfully send a patient to a dental lab toselect a shade for a crown, while in Massachusettsthat same act is a violation of the law.

The book contains three Tables, twelve CaseReports, and numerous examples of lower court,

335December 2003, Volume 12, Number 4

appellate court, and supreme court decisions. Ex-amples of New York state court decisions seemed tobe the dominant examples, and their laws may wellbe significantly different from the laws in the homestate of the reader.

Chapter 3 has a wonderful discussion on con-tracts and the dentist-patient relationship. In-cluded within the discussion is an explanation ofexculpatory clauses, where the patient agrees not tosue for any further negligence. The reader shouldbe aware that these clauses are sometimes seen inhealth facilities and dental school contracts, butthey have often been historically held invalid by thecourts as being contrary to public policy.

A common question that arises in situationsinvolving dentistry and legalities is, “Is it negli-gence, malpractice, or breach of contract, and whatare their statute of limitations?” The author does agreat job of clarifying these concepts. Included is atable illustrating the length of the statute of limi-tations, and the rules for determining when thestatute begins to run for all of the states andterritories. There is also a table of the length of thestatute of repose by state. There are twenty-onejurisdictions that enforce this outer limit to thetime in which the injured party can enter suit,regardless of the circumstances.

The author also illustrates that in dental mal-practice cases, the standard of care will dependsolely upon whom the trial judge will permit toqualify as an expert. Sometimes a general dentistmay be held to the same standard of care estab-lished for a specialist. Therefore, it may be difficultto predict who is qualified to appear as an expertwitness. The text also contains a concise explana-tion concerning the theories of vicarious liabilityand respondeat superior (“let the master answer”),where the courts will hold an innocent party liablefor someone else’s negligence.

The common question of “Does the dentist haveto treat?” is addressed with some examples of courtrulings and a reminder that the enactment of theAmericans with Disabilities Act declared all officesof health professionals as places of public accom-modation. The concepts of consent, informed con-sent, informed refusal, abandonment, and dis-missal of a patient are additionally presented in aclear and concise manner. These discussions areinvaluable in reducing the legal risks in the dentaloffice.

There is strong evidence presented for the con-cept of “loss without fault,” where there is no

evidence of dental malpractice, yet the legal adviceis that the suit could not be successfully defended.Major factors leading to the decision to seek settle-ment are presented, which include: poor or lackingtreatment records, including, but not limited to,omissions, illegible entries, and generally poor doc-umentation; professional arrogance of the dentist;the clinician’s lack of sufficient training or experi-ence; the practitioner’s inability to answer ques-tions intelligently; and poor demeanor and appear-ance of the care provider. The author includes ahost of other reasons or situations where the dentistmay be a poor witness.

Probably the most important issue in any dentalmalpractice, negligence, or breach of contract caseis the written record. If it is not written down, thenit probably did not happen or is assumed that it didnot happen. While this book leans more towardbeing a law book than a dental book, the twochapters on “Taking the Medical-Dental History”and “Patient Records” should be considered a mustread for all practicing dentists.

If one is ever involved in a legal action, theauthor includes a detailed road map through anexample presented of a trial involving a suit indental malpractice with sections on res ipsa loqui-tur (“the thing speaks for itself”), hearsay evidence,and contributing and comparative negligence. Thereader is led from summons to verdict with veryeasy to read explanations of the steps along theway. Of note is what to do, and what not to do if oneis sued, and how to prepare for a trial or deposition,including advice on appearance and how to actwhile giving testimony. In an effort to lessen therisk of a suit or lessen the resulting losses, there areforty-three pages of questions and answers de-signed to help the general dentist assess the riskmanagement involved with the practice of den-tistry.

The final chapter has to do with professionalliability insurance for the dentist. This is informa-tion that is critical to all care providers, but unfor-tunately, often does not surface until one is involvedin a legal action. The appendix also includes anextensive list of legal terms as they relate to dentalapplications. The book is great reading for bothstudents of dentistry and the law. If one does be-come involved in a legal action, this text is highlyrecommended for both the dentist and the repre-senting legal counsel. The information presentedon risk management and risk assessment alone

336 Book Reviews

would also serve to make one a more informed andbetter practicing dentist.

James F. Smith, DDS, JD, FACP, FICDPrivate PracticeOmaha, NE.

Stewart’s ClinicalRemovablePartialProsthodontics

Rodney D. Phoenix, David R. Cagna, and Charles F.DeFreest. Quintessence Publishing Co. Inc., Chicago, IL2003: ISBN 0-86715-417-9. (525 pages, 1,279 illus,$89.00).

This textbook follows in the tradition of excel-lence set by Drs’ Stewart, Rudd, and Kuebker in theprevious such editions (1st Ed.1983, 2nd Ed.1992).The current authors have maintained the basicchapter headings while updating the book withcurrent material, references, and terminology. Thechapter on Removable Partial Dentures in Maxil-lofacial Prosthetics was dropped, which is appropri-ate for this text as this information is adequatelycovered in texts specific to the maxillofacial patient.Both color and black and white illustrations arepresented throughout the text, and they are clear,sharp, and sequential in the treatment process.

Chapters 1-4 focus on the basic principles andtreatment planning and are easy to follow and veryappropriate for dental students. References andhistorical items also lend themselves well to prosth-odontic residents as a source of countless informa-tion. The American College of Prosthodontists’Classification for Partial Edentulism design1 is ab-sent, as this book no doubt went to press prior to itsrelease. However, the more commonly usedKennedy Classification is presented very ade-quately.

Chapters 5-7 involve the collection of diagnosticinformation that is deemed critical to successfulfabrication of removable partial dentures. Tables

5-1 and 5-2 are superbly presented to the reader toallow effective troubleshooting of both impression-making and problems with master casts. Step-by-step photos present techniques that create accu-rate, articulated study casts and the rationale forthese modalities. The illustrations in chapter 7 arein color to better allow the reader to visualize andmore completely comprehend the steps that arerequired in proper treatment planning.

Chapter 8 is devoted entirely to the use of theI-bar for the distal extension RPD with excellentillustrations to document the philosophies ofKratochvil and Krol. The chapter would be morecomplete if the recommendations of Demer2 to theoriginal design were included, but it is still veryeffective in the discussion of an alternative to thedistal rest concept discussed earlier in the book.The remaining chapters focus on clinical treatmentranging from mouth preparations through the post-insertion visits. Again, the authors have presentedtheir material in an easy to follow manner throughthe effective use of text and illustrations. The chap-ter on laboratory fabrication is an excellent sourcefor the reader to become familiar with the varioussteps required in this process, as this is rarelytaught at the dental school level and not taught inall prosthodontic specialty training programs. Oc-clusion is superbly addressed with emphasis on thefact that knowledge of tooth position is critical tothe placement of the various components of theunderlying framework.

This text is a must for all those associated withremovable partial dentures, from dental studentsthrough laboratory technicians to prosthodontists.It is easy to follow, and the illustrations are superb.The authors are to be congratulated on their excel-lent efforts.

Carl F. Driscoll, DMDAssociate ProfessorDirector, Prosthodontic ResidencyUniversity of Maryland School of DentistryDepartment of Restorative DentistryBaltimore, MD.

References1. McGarry T, Nimmo A, Skiba J, Ahlstrom R, Smith C,

Koumjian J, et al: Classification system for partial edentu-lism. J Prosthodont 2002;11:181-193

2. Demer W: An analysis of mesial rest-I bar clasp designs. JProsthet Dent 1976;36:243-253

337December 2003, Volume 12, Number 4

Principles andPractice ofImplant Dentistry

Charles M. Weiss and Adam Weiss. Mosby PublishingCo., St. Louis, MO, 2003: ISBN 0-323-00767-8 (445pages with 790 illustrations)

One purpose of this book appears to be to definea mainstream case involving a partially edentulousspace that could be restored by the implant modal-ities presented. Another purpose seems to be forthe practitioner to be better able to recognize andtreat such a mainstream case. The five implanttreatment modalities included are: root form os-seointegrated implants, blade implants, subperios-teal implants, endodontic stabilizers, and intramu-cosal inserts. Three different implant systems werepresented for the root form implants (Nobel Bio-care/Steri-Oss Immediate Impression Implant Sys-tem, Innova Endopore, and Friadent Frialit-2). Onesystem is discussed for the plate/blade implants(Oratronics Weiss Osteo-Loc Standard One-StagePlate/Blade Form Implant System) and one systemis presented for the endodontic stabilizers (Ora-tronics Osteo-Loc) . The textbook was written forstudents and practitioners of all levels.

The authors’ thorough knowledge of the surgi-cal, as well as the restorative aspects of implantdentistry, due in large part to practicing implantdentistry for 40� years, contribute to a well-writtenand well-illustrated textbook. One of the manypositive aspects of the 790 illustrations was that avery high percentage of them are on the same pageto which they are referred.

A mainstream implant case is defined as being“safe and predictable, represents the majority ofwhat practitioners encounter, and can be routinelytreated by a competent practitioner.” The authorsdistinguish between a mainstream case and a main-stream modality. Because the modalities presentedin his textbook (excluding root form osseointe-grated implants) are not readily perceived to be

mainstream treatment options, the reader muststrive to maintain an open mind. The other de-scribed implant treatment modalities are well-ref-erenced in the dental literature, but many of thesereports might not stand up well in the currentatmosphere of more scientifically based studies.Still, they make for interesting reading.

The text is divided into five sections: Fundamen-tals of Implant Dentistry (six devoted chapters),Evidence-Based Validation of Safety and Efficacy(two devoted chapters), Clinical Practice of theMainstream Implant Dentist (10 devoted chap-ters), Non-Abutment-Providing Modalities (two de-voted chapters), and Practice Management (threedevoted chapters). The first section on the funda-mentals of implant dentistry takes an in-depth lookat the usual topics of nomenclature, classificationand examples of implants, implant materials, fix-ture design and fabrication, evaluating availablebone and implant fixture insertion, and healing.The authors also discuss and illustrate the exis-tence of modes of tissue integration around each ofthe implant treatment modalities presented. Theseinclude osteointegration around endosseous im-plants, osteopreservation around blade implant andendodontic stabilizers, and periosteal integrationaround subperiosteal implants. The chapter on tis-sue integration is well referenced with 64 differentcitations offered. The review of osseous healing,along with the factors influencing osseous healingand factors stimulating bone repair, are clearlywritten and will serve alone as a great future ref-erence.

Interestingly, the authors contend that the col-lagen fibers that invest the plate/blade form im-plants and endodontic stabilizers act similar as aperiodontal ligament that surrounds a naturaltooth. They contend that loading of these fibers willelicit an osteostimulatory effect in the surroundingbone into which the collagenous fibers attach. Thisbone will remain healthy and strong if biomechani-cally stressed within its physiologic limits, thus theterminology of osteopreservation. The authors ac-knowledge that this is a controversial area becauseit conflicts with the premise of osseointegrationthat maintains that intimate bone/implant contactresults in long-term stability of implants.

The second section of chapters, devoted to evi-dence-based validation of safety and efficacy, dealwith the criteria for scientific and clinical accept-ability of an implant system and the seminal studiesthat support such a system. The authors’ criteria

338 Book Reviews

for acceptability encompass well-accepted modali-ties but are not nearly as rigorous as Albrektsson’sand Zarb’s criteria of success for endosseous rootform implants. For example, there is no mention ofmobility, radiographic radiolucency, or quantitativemeasure of bone loss for clinical acceptability. Theauthors also note: “How long is long enough for animplant to survive?. That an implant can survive for20 years or more may not even be relevant for ouroldest patients. If a patient can be offered 10, oreven 5 years of enhanced function, implant den-tistry can provide a great service and improvementin the quality of life.”

The third grouping of chapters addresses theclinical practice of mainstream implant dentistry ina very precise, step-by-step guide. These include:the work-up and presentation of the case to thepatient; the pre-surgical, surgical, and post-surgicaltechniques and protocols; actual restorative andmaintenance procedures; complicated and atypicalclinical conditions; bone enhancement; treatmentof both reversible and irreversible complications;and, finally, examples of intermediate and ad-vanced cases associated with endosteal root formand blade implants, as well as unilateral subperios-teal implants. The authors have placed highlightedareas within each step that relate a helpful thoughtprocess or further emphasize a key bit of informa-tion that is relevant to the procedure. For example,while explaining the surgical aspect of the stage IIuncovering of a 4.1 mm. diameter implant, thehigh-lighted area mentions the use of a standardstraight transfer coping for a typical bicuspid.

The text continues on to present that the use ofa more flared transfer coping would be more appro-priate when working with a tooth with a largercervical area. For this reviewer, the crux of thetextbook was the chapter on choosing the appropri-ate implant modality, based primarly on the avail-able bone. The authors also list the overlappingareas of use for the different implant types, andguidelines are provided for choosing a specific ap-proach.

The forth section deals with implant treatmentmodalities that do not utilize separate abutments,the endodontic stabilizers and intramucosal inserts.Concerning the endodontic stabilizers, the authorscontend that previous problems of “retention of thestabilizer within the root, a reliable endodontically

oriented seal, the preventing of cement expressionbeyond the apex at time of insertion and long termbone maintainence around the portion of the sta-bilizer that projects beyond the tooth apex, havebeen overcome with the improvements in design.”The authors provide only one reference, however,for this claim. Intramucosal inserts are additionallydescribed with a discussion of their advantages anddisadvantages.

The fifth and final grouping of chapters pertainto practice management. The topics are straight-forward and reiterate common themes, includingdiagnostic considerations, formulation of goal ori-ented treatment plans, establishing the need andcreating the desire for optimal care, and communi-cating precise answers to common patient ques-tions and concerns. While root form endosseousimplants certainly compromise the majority of theimplants currently being placed today, concomitantwith their use is an explosion of hard and soft tissueaugmentation surgeries often advocated as neces-sary for proper, prosthetically driven, implantplacement. It is argued that these surgeries areinvasive and add additional cost to the patient’streatment. The authors contend that in some cases,other implant modalities presented may be utilizedif some compromises in esthetics and the accep-tance of osteopreservation, rather than osteointe-gration, are deemed acceptable.

Because of the provided in-depth review of basicimplant subject matter (treatment planning bonehealing, quantifying remaining bone, implant ma-terials and design, etc.), the book would be a goodaddition to the library of both the inexperiencedstudent as well as the seasoned practitioner. Thetext would also be a good reference for the practi-tioner looking to incorporate, or otherwise becomemore familiar with, other modalities of dental im-plant therapy. Indications and contraindications forthe surgical and restorative aspects of other, lesscommonly used implant protocols and designs arewell presented.

William C. Betzhold, DDSAssistant ProfessorDepartment of ProsthodonticsVirginia Commonwealth University, School of

DentistryRichmond, Virginia, 23298-0566.

339December 2003, Volume 12, Number 4