Jeff Lineberry, DDS, AAACD

	When I was in dental school 20 years ago, dental implants were a bit “taboo,” if you will. They weren’t the most sought-after procedure, but they were being placed in our periodontal and oral surgery clinics from time to time. In fact, implant dentistry got its start here in the United States when implant courses were available to surgeons only - they weren’t even offered to general practitioners. Today, there are implant courses for all levels of practitioners and these vary from courses that are a few days long to ones that last a year or more.

	Years ago when implants were being placed, a “surgical” guide or template was fabricated to help “guide” the placement of the implant/implants. This was used to place radiographic markers such as lead foil and metal marking balls, and then a panoramic 2D X-ray was taken, or, if you were really high-tech or had it available, you could get a tomogram done to look at the bone in a new dimension.

	This was then taken to the patient’s mouth where we would anesthetize the patient, make a nice incision and expose the bony ridge, hoping to find enough bone where we were going to place the implant. We’d use the “guide” for the initial osteotomy, and then overlay the surgical guide over guide pins to help “verify” the placement of the implant.  

	My journey in implant dentistry started right after school by working with surgeons who were placing them on a regular basis, and then I simply restored the patient. After a few years, I took the plunge and completed a nine-month-long surgical implant course. Over the years, I went from placing implants with  panoramic X-rays like I described earlier to now having a CBCT in my office with guided implant software and having milled guides made where I place the implants without a flap. 

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	If we look at how implant placement and surgeries have evolved over the past 20 years, the advent of technologies such as CBCT 3D scans and the ability to mill or print surgical guides have revolutionized and streamlined the process. So much so that everything from placing the implant virtually in the bone to the final restoration design can be completely “worked” out before we even do the surgery and with “safe” guides that help overpreparing implant sites. I mean, how hard can it be to place an implant? After placing implants as a GP for more than 10 years, it’s like the old saying goes, “It depends.”

So, what have I learned over the years of placing implants as a GP? Here are some words of wisdom that I’ve gained if you want to surgically place implants:

	Proper education is key, like everything else we do in dentistry. Like the old saying goes, “You only know what you know, and you only see what you know.” In my opinion, a quick two-day course can’t help you “know” everything you need to “see” in implant surgery. So, find a respected course that allows you ample time to learn the principles of proper implant placement.

	As Clint Eastwood wisely said once, “A man has to know his limitations.” The same is true in all of dentistry whether it’s root canals or implants. In order to know your limitations, you have to “know” and “see” things at a level to be able to do this.

	Surgical principles don’t change whether it’s a guided surgery or not. In other words, you have to be comfortable with doing the surgery, know the ins and outs of anatomy, bone and tissue support that’s required, and all of the steps involved. You also have to be able to manage the potential complications that arise during and after the surgery.  If not, then you should reconsider doing the surgery or get training to help you be more competent and comfortable.

	3D scans and proper presurgical treatment planning are standard of care, period. Surgical guides aren’t “foolproof!” Remember, even if you have a lab or company fabricate the guide, ultimately, you’re responsible for the end result.
	Start out simple and find a specialist who you can refer more difficult cases to and work alongside him or her. It’s amazing to me how many general dentists will send out difficult cases to their specialists, but they will not approach the same specialist for help and guidance, fearing that he or she will be chastised for doing the surgery.

	I’ve found most, if not all, specialists who I’ve worked with are more than happy to help you when it comes to the surgical aspect of things. This relationship that’s built upon discussing challenges and difficulties among general dentists and specialists leads to a better understanding and growth between both parties and, ultimately, leads to better patient care.

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	When patients come to us to improve their smile, they’re looking for a change.

	Patients seeking cosmetic dentistry are not only looking for dazzling end results, but they want conservative treatment involving little to no tooth preparation. And as professionals, we want to be able to provide beautiful results to our patients in a predictable yet conservative manner. Here are five things to consider before starting cosmetic treatment on your patients.

	1. Determine the final goals before starting treatment

	Starting treatment before you and your patient are clear on the goals and expected outcomes can not only lead to unnecessary treatment and poor outcomes, but it can leave you and your patient both unhappy in the end.

	2. Obtain records either with impressions or with the use of a digital scanner

	The use of digital photography is essential to help communicate clearly with your dental lab. Your dental lab can use these records to develop a digital or analog diagnostic wax/work up of the desired treatment outcome. This allows the practitioner and the patient to visualize the final end result. We can also determine which teeth will need to be prepared and we gain insight on how we’ll need to prepare the teeth to obtain the desired result. Using the diagnostic wax up/model to develop preparation guides allows the removal of only the tooth structure that’s needed - not too much or too little.

	Many patients desire whiter and brighter teeth. The bigger the shade difference, the more challenging it is do to this in a conservative, life-like manner. The more shade change, the more thickness is needed in the final restoration to achieve excellent final results. Whitening before treatment can close the gap between the beginning and end results, leading to less tooth structure removal required to achieve a beautiful, brighter smile. 

Some patients want to change the appearance of teeth that are rotated, tipped or poorly positioned. Patients desire to “instantly” straighten or correct these teeth, but this can lead to unnecessary tooth structure removal. By discussing the benefit of orthodontics to our patients, we can help the patient achieve a smile that’s very conservative and may not even require any tooth removal at all. And in cases where patients still require cosmetic dentistry to achieve the final desired result, we can position the teeth using shorter orthodontic treatment times in a place that allows for more conservative preparations in the final treatment.  

	5. Consider adhesive dentistry and/or direct bonding

	In many cases, direct bonding can allow for little to no tooth structure removal needed to achieve the desired result. Because dental resin can be placed in undercuts and areas that are challenging to cover up, there’s no need to develop a path of draw/insertion that’s required in many indirect restorations. When properly placed and polished, it’s possible to achieve beautiful restorations that can last our patients for years. With many of the newer resins on the market, adhesive dentistry and direct bonding is a great option. Take courses and take the time to become a master at tooth-colored resin restorations as it will pay it forward in many ways. 

	Cosmetic dentistry is alive and well today in the dental marketplace and patients nowadays are more informed and educated than ever. And they’re looking for beautiful results with little to no drilling. In cosmetic dentistry today: Less is more! 

Cosmetic dentistry doesn't have to be a challenge; here's how to make the process easier.

The top 5 ways to simplify cosmetic dentistry

	Are you looking for ways to make your practice more exciting? Are you eager to expand your skill set? Would you like to increase the number of cash procedures you perform?

 could be the solution to all your problems.

	Makes your practice more enjoyable and satisfying

	One of the most challenging (not satisfying!) things we do every day as dental providers is work in a highly sensitive, confined place. What makes it even more challenging is that many of our patients have no desire to be in our offices! Cosmetic dentistry can be very rewarding, however, since most patients seeking these services want (yes, want) to be in your office. And, when it’s all said and done, many patients are very happy to see you. And the cherry on top of it all - you can help change the lives and confidence of your patients! (When was the last time a patient jumped up and gave you a big hug with tears in their eyes for that MOD you just did?)

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	Most, if not all, cosmetic dental procedures are ones that are not covered by insurance but are wanted by patients. When someone wants something, they value it and they pay for it! Many of these procedures are paid out of pocket by the patients at the time of service without involving insurance plans and payments. Also, patients who are focused on esthetics are more likely to do other elective procedures, creating more revenue. 

	Helps grow your practice and referrals 

	When we do our normal bread-and-butter dentistry every day, we will get the occasional patient who is happy with having a couple of fillings done or a crown. But when it comes to satisfied cosmetic dentistry patients, they not only are a walking billboard with their new smile and new-found confidence, but they are more than happy to share with others what they had done, along with your office name. This can lead to other cosmetic dental patients and procedures. As the old saying goes, “Birds of a feather, flock together!” 

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	Helps you improve you overall skill set and express your artistic side 

	When we graduate dental school, we have sufficient skills to complete simple restorative and surgical procedures. As time goes on, many dental professionals reach out to other sources of continuing education. This combination of learning new skills, and the confidence that comes with it, leads you as a dental professional to seek out and do more complicated procedures, including cosmetic dentistry. When we do cosmetic dentistry, we are, in fact, bringing out the artist within when we create a new smile all the way down to doing a direct anterior resin that has multiple shades and characteristics. All of this helps push you to be a better clinician and improve overall. 

	I have noticed that when patients are engaged in how they look and how their smiles impact their overall appearance, they have a different perceived value of their oral health. This can lead to them coming in for their regular routine maintenance visits and not canceling or breaking their appointments. And when things do come up, they are often more proactive about doing treatment since they have a high value for their oral health

How cosmetic dentistry can help your bottom line, increase your skill set and make for happier patients.