Each individual insert is divided into four distinct section:
The wide square handle with the orientation indicia indicate the direction of the guide post; The middle sleeve holder is the round section just beyond the square section. The sleeve holder holds the middle sleeve that directs the drills that determines the implant direction. It is this metal sleeve that is ultimately going to be bonded to the pre-made jig; The third section, the widest section is referred to as the ‘platform stop’. When the metal sleeve is placed over the sleeve holder, it can go as far as the platform stop; The final section is referred to as the ‘measuring post’. This narrow, tapered end has 3 mm calibrations that are used as a reference to calculate the vertical height of the bone and the socket. Excess of 3 mm sections are cut off to ensure that the platform stop is level with the crest of the socket or level with the gingiva just about the socket.
There are direction bumps or indicia on the handle of many of the inserts. When the arrow is aiming downwards, it means that the tip of the mesaruing post is actually behind the handle. When the arrow is facing upwards, it means the tip of the measuring post is in front of the handle.
When the elongated rectangle slopes down from the top right to the lower left, it means that the tip of the measuring post is to the left of the handle. When the elongated rectangle goes from the top left to the lower right, it means that the post tip is to the right of the handle.
Ideal positioning: How to use the inserts
Each insert has two main functions. The function of the measuring post is to use as a reference to measure the available bone height on x-ray and the round sleeve guide is to direct the metal sleeve and position it correctly into the jig.
The insert is ideal when the sleeve guide (the round, cylindrical section) is aiming in the direction of the ideal location in the bone where you would like the implant to be placed. The platform, the widest section, should be level with the gingiva and the measuring post should approximate the depth of the socket. The length of the measuring post and the depth of the socket should be almost the same.
There will be daisy elastics around the measuring posts and these daisy elastics will engage the socket wall and hold the inserts steady so that the metal sleeve can be bonded to the pre-made jig with ease.
In order to place the metal sleeve correctly, the measuring post should be stable, firm and centered in the socket. In order to achieve this, daisy elastics are placed around the measuring post. These daisy elastics will center the post in the socket and not traumatize the bony wall.
When placing the elastic on the measuring post, hold the insert close to the free end where you’re attaching the daisy elastic. Do not remove the daisy elastic from the large circle where all the daisy elastics are attached. The daisy elastic must be attached to the circle.
Push the free end through the hole in the center of the daisy against your fingertip. When the end of the measuring post goes through the hole in the center, only at that point in time will it detach the elastic from the round circle where they are all attached.
We’ll hold it towards the end and rotate it slowly, pushing the point through the daisy. Do not hold the insert on the other end. If you hold it too far from the end where you are placing the elastic, the measuring post will snap. Inserts should be adapted to match the sockets where they’re being used. The post length approximates the depth of the socket. The platform (which is the widest part of the post) should be level with the gingiva or slightly above the socket crest.
To adapt the post length, remove 3 mm sections. Cut them off with your burr, with a scissors and try to snap them off with your fingers. Place the insert in the socket and check the length of the measuring post to the length of the socket. In this instance, we can see that the insert is 6 mm too long, so we remove the insert from the socket and cut off two 3 mm sections. And then we can place it back into the socket and we will see that the platform is now level with the gingiva.
When you have attached the metal sleeve to the jig, you can then take an x-ray of the entire assembly in the mouth. You’re going to use this x-ray to calculate the bone height and the depth of the socket. The 3 mm calibration show up very clearly on the rather opaque insert. Each insert has two main functions. The function of the measuring post is to use as a reference to measure the available bone height on x-ray and the round sleeve guide is to direct the metal sleeve and position it correctly into the jig.
The inserts are selected from the kit (and the drill) at a predetermined site on the jaw bone. The straight red insert will center the implant in the same location as the extracted tooth. The calibrated tapered end is centered in the socket by the orange elastic around the post. This end is cut to length so that the wide platform is leveled with the gingiva above the socket crest. The middle sleeve on the insert is then bonded to the premade jig.
The green insert will position the implant drill parallel to the socket interseptal bone. The blue insert will angle the drill away from the socket’s center as required in the anterior teeth with limited facial bone. The purple insert is useful on divergent root sockets.
Ideally, we would like to see the implant emerge centered in the space that was occupied by the extracted tooth. An insert will be selected to place the drill exactly into the ideal location centered between the adjacent teeth. The longest, straightest socket will be selected, the measuring post will be cut to length and will be placed into the socket.
All Safegide inserts and verification point show up well on x-ray, so it is easy to calculate drill depth with the Safegide system. It is important to drill to an exact depth so that no vital or sensitive anatomical structures are damaged and your implant is correctly placed.
Drill stops are not universal. You need to select the type that matches the manufacturer of the drill that you are using. Also, when you place the drill stop onto the drill, you place it on the latch shaft side. You do not slide it over the cutting end of the drill.
Drill stops come in a range of sizes. In order to calculate the ideal drill stop size, one adds up the height of the metal sleeve, the gingiva and the bone and any additional depth where one intends placing the implant. One totals up all these measurements and subtracts that from the length of the drill that emerges from the hand piece. That difference will give you the height of the stop to place on the burr.
The metal sleeve on the drill guide will direct the drill exactly where it is supposed to go. When the plastic drill stop hits the metal, it will prevent the drill from going any deeper into the bone.
– Dr Howard Katz
I am going to give you a very quick course. I am going to show you very quickly how to add another step when you are doing your socket preservation that will enable you to always place accurate implants without the risks of nerve or bone perforation. Very few of you may be doing implants because of the risks, technology and cost. Before I start here are some quick pointers to reduce most of the risks. Don’t place implants above the mental foramen, in the upper and lower 2nd molar areas, and try always use short implants with platform switching (The abutment is narrower than the implant. But as I said this is not an implant course. This is just to show you another step that you should do be doing when you do socket preservation.
So the easiest time to accurately place an implant is when you take out the tooth and the reason for that is that you are able to see inside the socket.It’s not always convenient to place the implant at the time of extraction. There may be infection, a socket wall defect or the patient does not want the implant on that day. Regardless every time you pull out a tooth you should be recording and preserving the socket. Let me show you why.
When the inside of a socket is visible you can center the implant in the socket, or into the septal plate, or to offset it lingually if there is deficient facial bone; there are a variety of Safegide pegs that will allow you to preselect any position in relation to the open socket. Before you position the bone replacement material into the socket, record or “pick up” the socket dimensions and relationship with a disposable Safegide socket insert and bite registration material.
So at the time of extraction you pull out the tooth and you insert a little plastic insert that looks like a peg into the socket. These plastic pegs are made out of a special proprietary type of plastic that is antibacterial and shows up in 3D on a regular x-ray. If the peg is too long it can be snapped to size with your fingers. The peg has 3mm markings like a perio probe that show up on an x-ray. This allows you to measure bone height easily so that you canselect the right length implant. The metal ring on top that sticks out the socket becomes a drill guide.
So you pretty much take a piece of plastic, snap it so that the bottom of the metal part is level with the bone crest, and take your bite registration with a very rigid material.Your pick up gives a very accurate representation of where the socket is, the angle of the socket, the depth of the socket, all the information that you need to do the implant at a later date. Then you remove the plastic peg which will leave the metal ring attached to bite registration material. On the day you want to place the implant simply place the bite registration in the mouth and drill to your desired length. The guide will also show you where to remove gingiva if you do not want to raise a flap.Another reason to use this technique is you may want a guide to use on the day of extraction simply to stabilize your drill. It will take a week or two plus many hundreds of dollars to have a laboratory fabricate a guide that you can easily do in a few seconds for less than the cost of a pizza. Your cost and time are low enough that I suggest that you make a guide with every extraction for free. This gives you another wayto put a ring on your patients finger so that they come back to you for the implants. If you are not taking out the tooth on the day you make your diagnosis then you can simply take impressions for a working cast model. Then make a plastic jig out of triad on the model with a hole in the Triad above the tooth to be extracted. Or make a jig in the mouth using Triad and your curing light. Complete the guide on the day the patient comes in for the extraction.
There are many reasons why you should have a guide if you want to place an implant, that’s because it makes things very safe and very easy. The alternatives for the patient are a CT scan and a lab fabricated guide. This may be inconvenient and adds an extra $1000 on an implant which may make the procedure unaffordable.
State laws vary so dramatically regarding Botox and dermal fillers that it is hard to know whether you are allowed to perform these procedures as a dentist, and if you are, under what circumstances. Here is a partial summary of what the law is regarding the use of Botox by dentists in 27 states.
In the states of Mississippi and Virginia, the use of Botox in dentistry is restricted to oral and maxillofacial surgeons who have completed a specific residency.
In many states, use of Botox by dentists is permitted, but restricts its use to dental treatments only and only by dentists who have completed a course of study by a program that is accredited by the American Dental Association and/or the dental board of that state. These states include: Alaska, Connecticut, Florida, Idaho, Iowa, Kansas, Maryland, Nevada, New Hampshire, New York (see our New York Botox training program), North Carolina, Texas, Washington, West Virginia and Wisconsin. The wording of these laws varies by state and a few of them do not address Botox specifically, but do contain verbiage that restricts dental practice to procedures involving the mouth, its contents and associates structures and tissues.
In other states, use of Botox by dentists is not restricted beyond a requirement that the dentist completes a course of study by a program that is accredited by the American Dental Association and/or the dental board of that state. These states include Arkansas and Louisiana. These two states in particular further set forth that the training course must cover certain topics to include consulting with and assessing patients, uses and contraindications of Botox, potential risks and side effects associated with Botox and related treatments and how to manage them, preparation and administration of the injections, therapeutic uses of the drugs, hands on training with actual patients. These states further restrict use of Botox by dentists to their dental office and forbid administration from support staff, such as dental nurses and hygienists.
Some states currently have no regulations regarding use of Botox by dentists. These states include: Massachusetts, New Mexico, Pennsylvania, South Carolina, South Dakota, and Wyoming. It should be noted that many malpractice insurance carriers still require that anyone administering Botox or dermal fillers complete an appropriate course of training (see our Online Botox Training Program). A few of these states, while they do not currently have any restrictions, are considering or may soon consider regulations in this area.
Finally, Delaware has taken rather a unique stance on use of Botox by dentists. The Board of Dentistry and Dental Hygiene in Delaware has responded to inquiries regarding Botox by refusing to take a position. At the current time, Delaware treats possible violations regarding dentists administering Botox on a case by case basis.
It is important to note that these regulations are politically motivated, not a reflection of the ability of Dentists to perform Botox – in fact, Dr. Katz is a dentist, and pioneered the use of Botox for the face.
For a full list of state regulations, visit: http://dentox.com/state-by-state-dental-botox-regulations/