May 2019

R E F E R E N C E
eBOOK
G U I D E

A P R I M E R O N I M P L A N T T R E AT M E N T

Dental Implantology:
Numbers Clinicians Need to Know
Gary Greenstein, DDS, MS; John Cavallaro, DDS; and Dennis Tarnow, DDS
 R E F E R E N C E
Dental Implantology: Numbers Clinicians Need to Know
Gary Greenstein, DDS, MS; John Cavallaro, DDS; and Dennis Tarnow, DDS
ABSTRACT
Dental implantology is a discipline that merges knowledge regarding treatment planning, surgical procedures, and prosthetic endeavors. To attain optimal results many
numbers pertaining to different facets of therapy are integrated into treating patients. This article outlines a wide range of digits that may assist clinicians in enhancing
the performance of implant dentistry. Important integers are presented in three segments related to the sequence of therapy: pre-procedural assessments, surgical
therapy, and postsurgical patient management.
N
umerous dental implant procedures can be facilitated by
knowing numbers related to characteristics of biological
structures, biomechanical relationships, and research data.
Integers are like letters; alone they are meaningless, but
when integrated into therapeutic endeavors they provide a
relevant basis for procedural planning and execution of therapy. This
article provides lists of digits that clinicians should be acquainted
with when performing implant dentistry. Pertinent facts related to
many presented integers are described. When several studies as-
sessed a specific subject, important digits were selected to represent
essential information. Some of the discussed numbers are means
and are not intended to represent all responses that clinicians may
experience when treating patients. Data are organized into three
sections and discussed with respect to chronology of treatment:
numbers related to pre-procedural assessments and treatment plan-
ning, integers to be used during surgical therapy, and digits related
to postsurgical patient management.
SECTION I: NUMBERS RELATED TO PRE-PROCEDURAL
ASSESSMENTS AND TREATMENT PLANNING
PERIODONTAL AND PERI-IMPLANT DIAGNOSTIC
CONSIDERATIONS
A. Probing Depth Evaluations
When interpreting probing measurements around teeth and im-
plants, the following explanations should be considered:
1. Teeth: Probing depths of 1 mm to 3 mm are normal; 4 mm
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determinations reflect the gray zone; at 5 mm, there is con-
cern, but not overly if tissues are pink, there is no bleeding on
probing, and the probing depths are not getting deeper. At ≥6
mm probing depth, surgical intervention may be necessary if a
patient persistently manifests inflammation or increased pock-
eting, despite conservative therapy.1
2. Implants: Desirable probing depths around dental implants are
2.5 mm to 4 mm, but deeper assessments can be associated
with healthy peri-implant mucosa.2 In general, probing evalua-
tions may be greater around implants than teeth, because there
are no connective tissue fibers inserting into implants and con-
nective tissue adhesions adjacent to implants do not impede
probe penetration similarly to the connective tissue attachment
to teeth.3
3. A gentle periodontal probing force of 25 grams or 0.25 New-
tons (one Newton = approximately 100 gm forces) should be
used to evaluate bleeding on probing.4 This force is roughly the
pressure needed for a periodontal probe to blanch a fingernail.
B. Prognosticating Tooth and Implant Survival Based on the
Amount of Alveolar Bone
1. Teeth: Despite periodontitis, teeth with 50% bone loss are not a
clinical challenge to treat and retain.5 This contention is supported
by numerous studies that addressed long-term retention of teeth
with advanced bone resorption that were successfully treated.5-7
Ultimately, it is a judgment call as to the magnitude of bone loss
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and concurrent issues that condemns a tooth to extraction.
2. Implants: It has been suggested that if an implant manifests
≥50% bone loss it should be removed before additional bone
resorption occurs.8 However, this threshold is not sacrosanct
and therapy may be considered even if there is >50% bone
diminishment around an implant.9
FURCATION LOCATIONS:
MAXILLARY AND MANDIBULAR MOLARS
Knowing the depth and location of furcations aids in sectioning a
tooth prior to extraction and helps avoid unnecessary loss of in-
terradicular bone. The mesial maxillary molar furcation is located
one-third of the way from the palate to the buccal side of a tooth,
and the distal furcation is found half the span from the palate to the
buccal (Figure 1). It is easier to probe maxillary furcations from
the palatal aspect of teeth. Table 1 lists distances from furcation
roofs to the level of the cementoenamel junction (CEJ).10
ENDODONTICS
Non-vital teeth that have not undergone root canal therapy but are
associated with other issues (eg, periodontitis, large apical patho-
sis) may be candidates for extraction and implant replacement or
endodontic and periodontal treatment.
G U I D E
ESTHETICS
Assessing the clinical smile line and its relationship to papillary
display is critical when planning anterior restorations.
A. Age Population: 20 to 30 Years Old
1. Average smile line: 75% to 100% of maxillary incisors are vis-
ible. 69% of patients have an average smile line.16
2. High smile line: Additional exposure of gingiva is noted. 11%
of individuals have a high smile line, and this occurs two times
more often among women than men.16
3. Low smile line: <75% of teeth are exposed. 20% of people
have a low smile line.16
B. Age Population: 10 to 89 Years Old
In an older population, when patients are maximally smiling, dis-
play of midfacial gingival tissues and interdental papillae are seen
as follows:
1. 72% of individuals have a low smile line (do not reveal midfa-
cial gingival tissues) and 28% have a high smile line (demon-
strate midfacial gingiva).17
2. 91% of all patients show their papillae when smiling.17
3. 87% of people with a low smile line reveal their papillae when
they grin.17

A. Incidence of Tooth Non-vitality After Crowns Are

Prepared or Post Periodontal Surgery
Table 1. Distances From Furcation Roofs to the Level of the CEJ
During a 3- to 30-year period, 13.3% of teeth restored with crowns
can become non-vital.11 Among patients with advanced periodon- Tooth Location Furcation:
tal disease, 9% of crowned and 2% of uncrowned teeth may devel- Distance to CEJ
op non-vitality after periodontal surgery.12
Mandibular Buccal 3 mm
first molar
B. Apicoectomies
Mandibular Lingual 4 mm
Though the success and survival rates of teeth treated with api- first molar
coectomies may vary depending on different studies, apicoecto-
Maxillary Buccal 4 mm
mies have a success rate of around 74% and a survival rate of ap-
first molar
proximately 91%.13 Survival rates are higher because they denote
retention of teeth that are non-symptomatic and may have residual Mesial 4 mm to 5 mm
apical radiolucencies. In contrast, success rates indicate that sur- Distal 5 mm to 6 mm
geries achieved complete apical radiographic bone fill. Another Maxillary Buccal 6 mm
article reported that the success rate after retreatment of a failed second molar
apicoectomy is 36%.14 Currently, with use of mineral trioxide ag- Mesial >6 mm
gregate and microsurgical procedures the success rate of apicoec-
Distal >6 mm
tomies has significantly increased (88%).15

1 2

FIG 1. Trisection of a maxillary left first molar. Photograph demonstrates that from the palatal aspect, the mesial furcation is two-thirds of the way to the buccal, and the
distal furcation is half the distance to the buccal. FIG 2. Skull of a maxilla arch. Interdental osseous crest between teeth Nos. 8 and 9 is 3 mm coronal to facial bone height.

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4. In the group with high smile lines (28% of all patients), women
show midfacial gingiva more often than men (76% vs 24%).17
DIMENSIONS OF GINGIVA AND BONE IN THE ESTHETIC ZONE
A. Recognizing Differences Between Normal and
Deficient Dimensions of Anatomic Structures Helps Treatment
Planning
1. Buccal and lingual osseous crests are usually located 2 mm to
3 mm apical to gingival margins.18
2. Interproximally, maxillary anterior interdental bony crests are
around 3 mm (range 2.1 mm to 4.1 mm) coronal to facial bone
heights (Figure 2).19
3. Interproximally, between maxillary central incisors, the inter-
dental papilla is 4.5 mm to 5 mm coronal to the osseous crest.20
This large papilla is due to papillary hypertrophy. Thus, main-
taining supragingival fibers helps reduce or eliminate postsur-
gical papillary shrinkage.
4. In general, papillary size is around 40% of crown height.21
5. For maxillary anterior teeth, the mean gingival zenith position
(GZP) distal to a vertically bisected midline is as follows: cen-
tral incisors, 1 mm; lateral incisors, 0.4 mm; and canine GZP is
at the midline.22
B. Dimensions of Teeth in Esthetic Zone
1. The length of a maxillary central incisor is usually 10 mm to
12 mm.23 Women’s incisors are typically shorter than men’s by
1 mm.23 Maxillary lateral incisors are 1 mm shorter cervically
and incisally than central incisors. Canines are at the same lev-
el as central incisors cervically and incisally.24
2. Among the maxillary anterior dentition, the width of central
incisors ranges from 7 mm to 10 mm (mean 8.5 mm), lateral
incisors vary from 5.5 mm to 8 mm (mean 6.5 mm), and ca-
nines range from 6.5 mm to 9 mm (mean 7.5 mm).25
3. The three types of front teeth (central and lateral incisors, ca-
nine) manifest the “golden ratio” with respect to their height
and width. The width of maxillary anterior teeth is about 81%
of their height.23
4. Mean dimensions of proximal contact areas between maxillary
anterior teeth are as follows: central incisors, 4.2 mm; central
and lateral incisors, 2.9 mm; lateral incisors and canines, 2
mm; and canines and first premolars, 1.5 mm.26
The widths of all teeth are listed in Table 2.27,28
PRESURGICAL MEDICAL CONSIDERATIONS
A. Platelet Count
Normal platelet count is 200,000 to 300,000 platelets per microliter
of blood. Clinical problems can arise if the count is under 100,000.
If it is less than 25,000 platelets per microliter, spontaneous bleed-
ing can occur. Surgery should not be done until the platelet count is
at least 60,000 or bleeding that is difficult to control may ensue.29
B. Medications That May Need to Be Suspended Prior to
Implant Surgery
Patients should refrain from taking the following medications at
certain times to exclude their effects on bleeding:
1. Though aspirin irreversibly affects platelets, it is usually unnec-
essary to avoid taking aspirin before dental surgery.30 However,
for a procedure such as a sinus lift, it may be prudent to have a
patient stop aspirin ingestion 5 to 7 days prior to surgery.
2. Plavix® irrevocably alters platelets but typically does not need
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to be suspended 5 to 7 days before dental surgery.30 However,
the same precaution noted above applies to Plavix ingestion.
3. With a physician’s permission, Coumadin® may or may be not
be stopped or decreased 3 days prior to surgery.30
4. Pradaxa®, Xerelto®, and Eliquis®: These drugs must be ab-
stained from for 2 days for them to have no effect. These med-
ications sometimes are stopped for 1 day prior to surgery or
not stopped. Refrain from these medications is done in accor-
dance with a physician’s recommendations. Half-life of these
drugs are 13 hours; therefore, after 13 hours 50% of the drug
remains, after 26 hours 75% is gone, after 39 hours 87.5% has
been eliminated, and subsequent to 52 hours 93.75% of the
drug has been removed.31
C. Steroid Utilization to Inhibit Edema
If it is anticipated that a surgical procedure will induce significant
edema, steroid therapy may be initiated, unless medically contra-
indicated, a day prior to surgery to ensure there is an effective drug
blood and tissue level. Several examples of steroid protocols are
enumerated:
1. Medrol® Dosepak consists of 21 tablets, 4 mg, methylprednis-
olone; six are taken 1 day before surgery. Then, for the next 5
days, one less tablet is taken each day (5-4-3-2-1).32
2. Other techniques to prescribe steroids include: 40 mg of pred-
nisone for 5 days; sequentially 50, 40, 30, 20, and 10 mg over
5 days; and 10 mg three times a day for 7 days.32,33 In general,
titrating down steroids is unnecessary if the medication is tak-
en less than 10 days.32
D. Pre-procedural Rinsing to Reduce Bacteria in Saliva
and Aerosols
Microbes in saliva and bacterial aerosols caused by a handpiece or an
ultrasonic tip can be reduced more than 90% by rinsing with chlorhex-
idine (0.12%)34 or Listerine® for 30 seconds before initiating therapy.35
RADIOGRAPHS
A. X-ray Interpretations
1. A radiograph is a snapshot of one moment in time. Multiple films
are required to demonstrate ongoing disease activity, and past
bone resorption is not a sensitive indicator of future bone loss.36-38
2. Radiographs underestimate the magnitude of bone resorption
9% to 20%.36
3. Four mm of clinical attachment loss occurs before bone deteri-
oration is detected around teeth on radiographs.37
Table 2. Width of All Teeth (mm)
Mandible Maxilla
Central incisor 5.4 9
Lateral incisor 5.9 6.4
Cuspid 6.9 7.6
First bicuspid 6.9 7.2
Second bicuspid 7.1 6.8
First molar 11.2 10.7
Second molar 10.7 9.2
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4. A 30% to 40% decrease in bone mineralization occurs before
alterations in bone density are detected on an x-ray.38
B. Radiographic Measurement Error
1. Bone level assessments using x-ray paralleling technique has
a precision of around 0.5 mm.39 Thus, when radiographs taken
with a Rinn holder are referred to as standardized, they actual-
ly are non-standardized and prone to error.
2. If a film holder allows 1 degree of vertical angular variation
among serial films, this can result in a 0.17-mm error with re-
spect to alveolar bone height.40
3. When the horizontal radiographic angulation is correct, the
threads on an x-ray are clear on both sides of an implant. An
incorrect radiographic angle of 10 degrees causes one side of
an implant’s threads to be blurry, and a 20-degree error results
in no clearly visible threads.41
4. Radiographic distortions occur with different x-ray techniques.
Typical distortions are listed in Table 3.42
G U I D E
SECTION II: INTEGERS THAT CAN BE USED
DURING SURGICAL THERAPY
ANATOMY
Awareness of anatomical dimensions is critically important for exe-
cuting procedures in a safe and efficient manner. The following sub-
sections provide important numbers related to anatomical structures.
A. Maxillary Sinus
1. The maxillary sinus is the largest of the paranasal sinuses. Typ-
ical dimensions are: height 36 mm to 45 mm, width mesio-dis-
tally 25 mm to 35 mm, and depth 38 mm to 45 mm (lateral-
ly-medially).52
2. The ostium’s mean width is 2.4 mm.53 This is the opening
between the maxillary sinus and the middle meatus of the
nose.53 The mean distance from the antral floor to the ostium
Table 3. Typical Radiographic Distortions

Type of Mean (Range) % Error

VERTICAL RESTORATIVE SPACE REQUIRED FOR DIFFERENT Radiograph
TYPES OF IMPLANT PROSTHESES
There is a 3-dimensional hierarchy of space required for different Periapical 1.9 mm (0 mm to 14%
types of implant prostheses. Knowing restorative space requirements 5 mm)
for each type of construct facilitates treatment planning. The
Panoramic 3 mm (0.5 mm to 23%
minimum amount of vertical space needed from implant platform 7.5 mm)
to the opposing dentition for components of different types of
prostheses are as follows43,44: fixed screw-retained (implant level), 4 CT scan 0.2 mm (0 mm to 1.8%
mm to 5 mm; fixed screw-retained (abutment level), 7.5 mm; fixed 0.5 mm)
cement-retained, 7 mm to 8 mm; unsplinted overdenture, 7 mm; bar
overdenture, 11 mm; fixed screw-retained hybrid, 15 mm.

MINIMUM NUMBER OF IMPLANTS REQUIRED FOR MANDIBULAR

AND MAXILLARY RECONSTRUCTIONS OF EDENTATE ARCHES
The treatment planning of implant prostheses is dependent on the
number of missing teeth, availability of bone, and patient preferences.
Mandibular overdenture: Two implants for an implant-retained
overdenture and four for an implant-retained and -supported overden-
ture.45 One implant can also provide some benefits.46
Mandibular fixed prosthesis: Four implants, but many clinicians pre-
fer five or more implants.47
Maxillary overdenture: Four implants.48
Maxillary arch fixed prosthesis: Four implants, though many thera-
3
pists advocate more.47
Anterior-posterior (A-P) spread: This is the distance from the center
of the two most anterior implants to the distal aspect of the most pos-
terior implants in the arch. Cantilever length that can be created distal
to the implants bilaterally is determined by assessing the A-P spread
and multiplying it by 1.5.49

DIAMETER OF IMPLANTS
Increasing the diameter of an implant one size (eg, from 3.3 mm
diameter to 4.1 mm diameter) increases the implant’s surface area
approximately 30%; this is equivalent to extending the implant’s
length by 3 mm.50

LENGTH OF IMPLANTS
Short textured implants can reliably support posterior prostheses.
Nevertheless, implants with length less than 8 mm (4 mm to 7
mm) should be used cautiously, because they demonstrate greater
failure risks compared to standard implants.51
4 5
FIG 3. Intraosseous artery in the buccal plate, opposite the left maxillary sinus, has
been exposed using piezosurgery. FIG 4. Implant placed 2 mm from the inferior
alveolar nerve. FIG 5. Hourglass mandible at site No. 20 is an uncommon finding
and can only be detected on a CBCT scan.

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6 7
FIG 6. Superior genial tubercle. FIG 7. Nasopalatine canal, usually located palatal and in between the central incisors, contains descending palatine artery and nasopalatine
nerve. FIG 8. Unusually large maxillary septum found in the right maxillary sinus.
is 28.5 mm and the minimal extent is 20 mm.54 Thus, when
a sinus lift is being performed, the Schneiderian membrane
should not be elevated to a height that could occlude the
ostium.
3. The quantity of pneumatization (internal sinus bone loss) that
occurs under the sinus after an extraction is greater if multiple
extractions are performed versus single extractions (2.22 mm
vs 0.54 mm). Pneumatization usually happens within 6 months
of an extraction.55
B. Intraosseous Artery Adjacent to the Maxillary Sinus
The artery in the lateral wall of the maxillary sinus is located with-
in 16 mm of the osseous crest 20% of the time (Figure 3).56 This
blood vessel is created by an anastomosis of the infraorbital and
the posterior superior arteries. Thus, in 80% of patients, the ar-
tery’s position is not a concern when performing a sinus lift. An
anatomic study on cadavers identified this vessel in 100% of spec-
imens; however, it could only be visualized in 53% of computed
tomography (CT) scans.56
C. Mandibular Foramen and Canal
1. When administering a mandibular block injection, it is advisable
to insert the needle into the pterygotemporal groove 6 mm to 10
mm above the occlusal plane,57 because the mandibular foramen
is coronal to the occlusal plane 2.5% to 25% of the time.58,59
2. The mandibular canal is approximately 3.4 mm wide, and the
inferior alveolar nerve is about 2.2 mm thick.60
3. The mandibular anterior loop is present in 71% of patients, and
5% of the time it is ≥5 mm long.61
4. For safety, an osteotomy created over the inferior alveolar
nerve should stop at least 2 mm from the nerve (Figure 4).62
5. One percent of mandibular canals bifurcate, inferior superiorly
or medial-laterally, and this may not be seen on panoramic or
periapical films.63
D. Size, Shape, Location of Mental Foramen
1. The shape of the mental foramen is round 34% to 45% of the
time and oval 56% to 65% of the time. Its size (mm height/
width) is: mean 3.47 mm, range 2 mm to 5.5 mm.64
2. The location of the mental foramen in the vertical plane with
respect to the mandibular first bicuspid’s apex is as follows (%
of time at a location)65: apical to the apex, 46%; at the apex,
15.4%; coronal to level of the apex, 38.6%. For the second
6 COMPENDIUM EBOOK
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8
bicuspid the mental foramen is coronal to the apex 61.6% of
the time. The finding that the foramen at the first and second
bicuspid is often coronal to the apex dictates that caution must
be exercised when placing an immediate implant in this loca-
tion. It is prudent to assess a CBCT scan prior to implantation.
Alternately, a delayed approach can be utilized for implant
placement.
3. The mental foramen’s horizontal locations differ among ethnic
groups. In Caucasians, 70% of the time they are located be-
tween bicuspids, and among Asian Americans they are found
above the second bicuspid in 59% of patients.62
4. The mean distance from alveolar crest to the mental foramen is
14 mm (non-resorbed ridge),66 and from mental foramen to the
symphysis it is 25 mm.67
E. Hourglass-Shaped Mandibles
It is estimated that 3.9% of mandibles have an hourglass configuration
(Figure 5).68 A cone-beam scan is necessary to detect this structure.
F. Submandibular Fossa
Submandibular concavities with a horizontal depth of 6 mm oc-
cur in 2.4% of assessed jaws.69 Approximately 52% of patients
manifest lingual fossae that are 2 mm to 3 mm horizontally deep,
and 28% demonstrate concavities >3 mm.70 If a large undercut is
present, it may be prudent to place an instrument (eg, periosteal
elevator) into and parallel to the concavity to facilitate drilling an
osteotomy that avoids lingual plate perforation and entering the
submandibular fossa.
G. Genial Tubercle
There is a superior and an inferior genial tubercle. Height of the
superior genial tubercle is 6.17 mm and its width is 7.01 mm (Fig-
ure 6).71 Distance from apices of the lower central incisors to the
superior tubercle is 15.4 mm.72 The genioglossus muscle attaches
to the superior tubercle and should not be elevated off the tuber-
cle when exposing the mandible to place an implant in a severely
resorbed ridge.
H. Gingival and Palatal Tissue Thickness
1. Epithelium is 0.3 mm thick.73 In this regard, if a flap dehisces and
the wound’s edges have been apart for several days, epithelium
should be scraped off the flap margins until bleeding points are
detected (exposed connective tissue) before flaps are resutured.
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2. Gingival thickness ranges from 0.53 mm to 2.62 mm (mean
1.56 mm).74
3. Palatal tissue thickness varies from 2 mm to 3.7 mm (mean
2.8 mm).75 The best location for harvesting a connective tissue
graft is the maxillary premolar region or posterior tuberosity.
I. Nasopalatine (Incisive) Foramen
The nasopalatine foramen is located lingual to the central incisors
and has a mean length of 8.1 mm. The nasopalatine nerve and de-
scending palatine blood vessels exit the foramen (Figure 7). Within
this structure, two incisive canals often are observed, however one
to four may be seen. The mean width of the canal is 4.9 mm and the
foramen is usually about 7.4 mm palatal to the buccal bony plate.
J. Distances to the Lingual Nerve From the Lingual Plate and
Osseous Crest of the Mandible (Third Molar Region)
The horizontal distance is 2.06 mm, with a range of 0 mm to 3.2
mm; the vertical distance is 3.01 mm with a range of 1.7 mm to 4
mm.76 The lingual nerve is above the crest 14% of the time, and in
22% of patients it directly contacts the lingual plate.76
K. Other Key Anatomical Structures
1. The greater palatine foramen is usually located opposite the
maxillary third molar (86% of the time) and is found between
the second and third maxillary molars in 13% of patients.77
2. The infraorbital canal is located about 5 mm below the infraor-
bital notch.78
3. The Schneiderian membrane is around 0.8 mm thick.79
4. The width of the sublingual artery is approximately 2 mm.80
5. The width of the periodontal ligament averages 0.25 mm.81
6. Septa are found in 28.4% of all sinuses, and complete septa
(horizontal and vertical) occur 0.3% of the time (Figure 8).82
SURGICAL ORTHODONTIC EXTRUSION OF TEETH
Sometimes a hopeless tooth with advanced recession and bone
loss is not a useless tooth. With extrusion, reduced gingival and
osseous levels can be restored to normal or improved prior to im-
plant procedures. A tooth can be extruded about 1 mm to 2 mm per
month, and its incisal edge should be equilibrated every 2 weeks.83
As the tooth is extruded, the sulcular epithelium everts and re-
mains present for 28 to 42 days and then a new sulcus forms. After
desired results are attained, the bone should be allowed to miner-
alize for 3 to 6 months before tooth extraction and implantation.83
The amount of needed tooth extrusion should be over-corrected by
25% to compensate for post-extraction bone resorption.83
CALCULATING CONTENTS IN ANESTHETIC CARPULES
It is important to be able to compute the quantity of lidocaine and epi-
nephrine in each carpule so dental anesthesia can be administered safely.
A. Lidocaine 2% in a Carpule
100 gm/100 ml is a 100% solution. 1 gm/100 ml = 1% solution
= 10 mg/ml. A cartridge with 1.8 ml of 2% lidocaine contains 36
mg of lidocaine. A toxic dose of lidocaine is 500 mg.84 The recom-
mended dose of lidocaine should not exceed 300 mg. Thus, eight
carpules is a safe dose of 2% lidocaine. Anesthesia with lidocaine
plus epinephrine usually lasts 2 to 3 hours.84
B. A Carpule With 1/100,000 Epinephrine
1 gm/100,000 ml = 1000 mg/100,000 ml = .01 mg/ml.84 A car-
7 COMPENDIUM EBOOK
G U I D E
tridge with 1.8 ml contains .018 mg of epinephrine. A therapeutic
dose of epinephrine of 0.3 mg is given to cardiac arrest patients
to stimulate their hearts. During dental procedures, the recom-
mended level of epinephrine should not exceed 0.2 mg or ap-
proximately 10 carpules. Individuals who are sensitive to epi-
nephrine should receive anesthetics that do not contain it (eg,
Carbocaine®).84
C. 1/50,000 Epinephrine in a Carpule
A 1/50,000 epinephrine solution contains .02 mg/ml, which trans-
lates into .036 mg per 1.8 ml carpule.84 Therefore, 5.5 carpules
containing 1/50,000 epinephrine (0.198 mg) is safe to adminis-
ter to a patient who does not have cardiac issues. Note, the above
maximal dosages addressing 2% lidocaine and epinephrine can be
increased if procedures are prolonged.
D. Quantity of Anesthetic Solution Usually Needed to Achieve
Dental Anesthesia
Infiltration: 1 ml; regional block: 1.5 ml; palatal block: 0.2 ml to
0.5 ml; long buccal block: 0.2 ml to 0.5 ml.85
SURGICAL AIDS FOR MEASURING INCISION DEPTHS
A. Blade Length
A #15 or #15c blade is 10 mm in length and can be used as a mea-
suring device when harvesting a palatal connective tissue graft.
For safety, when garnering a connective tissue graft, a distance of
2 mm should be left between the dissection’s end and the greater
palatine groove, which contains the greater palatine artery. Vault
heights (CEJ to greater palatine groove) are: shallow vault (flat), 7
mm; average palate, 12 mm; and high vault (u-shaped), 17 mm.86
B. Blade Bevel
The periosteum is about 0.36 mm thick87; therefore, the bevel of a
#15 or #15c blade that is 1 mm wide can be used as a depth guide
when performing a periosteal fenestration to aid flap advancement
(Figure 9).
TOOTH EXTRACTION ISSUES
A. Management of Perforations Into the Maxillary Sinus When
Extracting Teeth
After an extraction, if a small hole into the sinus (≤2 mm) is present
at the apical or lateral end of the socket, it can be ignored, because
a clot will usually form and heal uneventfully. If a perforation is
>2 mm, a piece of a resorbable barrier (eg, BioGide®, Geistlich,
geistlich-na.com) should be placed over the puncture before bone
grafting over it.88
B. Bone Resorption After Extractions
Six months after tooth removal that includes flap elevation, sockets
manifest a mean 1.24 mm vertical bone loss (range 0.9 mm to 3.6
mm) and there is approximately 3.79 mm less horizontal bone (range
2.46 mm to 4.56 mm).89 In contrast, after a flapless extraction, there
is approximately 1 mm vertical and horizontal bone loss.90
C. Dry Sockets
A small percentage of extraction sites (3.2%) develop a local os-
teitis after tooth removal, and this occurs most often in mandib-
ular molar areas.91 Pain frequently manifests 3 days after an ex-
traction.92 Patients may need to be medicated for 3 to 10 days to
eliminate discomfort (eg, dry socket paste).
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9 10
FIG 9. Periosteal fenestration is performed in the maxillary anterior segment using the bevel of the blade to sever the periosteum. FIG 10. Bone marrow space at site No. 30
that is greater that 2 mm tall and wide. FIG 11. The implant at site No. 29 is a bone-level implant, which develops a subcrestal biologic width and manifests bone loss. At
site No. 30, there is a tissue-level implant with a polished collar that forms a supracrestal biologic width and it is associated with minor bone loss.
RESORPTION TIME (IN MONTHS) FOR SUBMERGED
COLLAGEN BARRIERS
Barriers are routinely used during guided bone regeneration proce-
dures. Their degradation times vary: BioMend® (Zimmer Biomet,
zimmerbiometdental.com), 2 months; BioMend® Extend™ (Zim-
mer Biomet), 4.5 months; BioGide® (Geistlich), 3 to 4 months;
Ossix® (OraPharma, orapharma.com), 6 months; Resolute® (W.L.
Gore & Associates, goremedical.com), 4 to 6 months; NeoMend
(NeoMend Inc), 6 to 9 months.93 Other types of barriers are com-
mercially available.93 Clinicians should note that if a resorbable bar-
rier is left exposed to saliva, it deteriorates within several weeks.94
DEGRADATION TIME FOR RESORBABLE SUTURES
After mucoperiosteal flap procedures, resorbable sutures usually
are selected based on their duration of tensile strength: gut (5 to
7 days) or chromic gut (7 to 10 days). When it is desirable to re-
tain stitches for 21 days (eg, guided bone regeneration procedures)
vicryl sutures are often used.95 Other types of sutures are commer-
cially available.95
ALVEOLAR BONE
A. Unique Features of Bone
Several characteristics of bone need to be considered when treat-
ing patients. In cortical bone the percentage of bone porosities
ranges from 5% to 10%; in trabecular bone the range spans from
75% to 95%.96 Porosity levels affect bone density and, thereby,
drilling protocols for osteotomy development. Accordingly, when
preparing an osteotomy, if bone does not feel dense, the osteoto-
my should be undersized to facilitate frictional retention to help
achieve primary stability.96
Bone is 30% organic and 70% inorganic.96 It is the organic bone
that allows ridges to expand when extracting teeth. Marrow spaces
in trabecular bone range from 200 µm to 2000 µm (Figure 10), and
when a marrow space is entered a bur may appear to sink without
resistance.96
B. Types of Alveolar Bone Found in the Maxilla and Mandible
1. Thickness of cortical bone and feel of trabecular bone com-
8 COMPENDIUM EBOOK
G U I D E
11
pared to innate objects: type I – cortical bone, feels like oak
wood; type II – 2.5 mm to 4 mm cortical bone, dense trabecu-
lar bone’s texture is like plywood; type III – 1.5 mm to 2 mm
cortical bone, spongy trabecular bone’s consistency is like soft
pine wood; type IV – 1 mm or less cortical bone, sparse trabec-
ular bone feels like balsa wood.97
2. Type I bone is not often detected. It is found most frequently in
the anterior segment of the mandible (about 6% of the time).97
C. Bone Loss After Implant Placement
1. Bone resorption around non-platform-switched bone-level im-
plants is usually 1.5 mm to 2 mm and occurs due to biologic
width formation.98
2. Increased peri-implant bone loss occurs around plat-
form-switched implants when the peri-mucosal tissue is <2
mm thick.99 Bone loss for thin (<2 mm) versus thick gingiva
(≥2 mm) after implantation is, respectively, 1.17 mm versus
0.21 mm. This occurs regardless of the microgap’s position.99
D. Bone Remodeling
The replacement rate of cortical and cancellous bone annually is,
respectively, 7.7% and 17.7%.100 Others reported that 3% of cor-
tical and 24% of cancellous bone remodel yearly.101 The numbers
vary, but the trend is apparent. These data provide an explanation
as to why medications that alter bone physiologically (eg, bisphos-
phonates) require extended time to be eliminated from the host.
E. Quantity of Circumferential Bone Desired Around an Implant
When flaps are used to help implant insertion into an intact ridge, if
there is <1.8 mm circumferential bone around the implant, vertical
bone height is lost.102 After implant placement it is suggested that there
be at least 1 mm of bone circumferentially surrounding the implant.103
BIOLOGIC WIDTH
Biologic width around teeth is approximately 2 mm and consists
of 1 mm connective tissue and 1 mm of junctional epithelium.104
Its length ranges between 1 mm to 4 mm.105 Biologic width is
usually supracrestal around healthy teeth and can be subcrestal or
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 R E F E R E N C E
supracrestal around implants (1.5 mm to 2 mm height) (Figure 11).
With respect to implants, the amount of induced bone resorption
associated with biologic width formation depends on where implant
collars are placed. Subcrestal collar placement results in more bone
loss than supracrestal positioning.98 Upon placement, if an implant is
submerged under soft tissue, the biologic width does not form; how-
ever, after it is exposed and an abutment is placed, biologic width
develops in about 30 days.98
BLEEDING ASSOCIATED WITH ORAL SURGERY
A. Ecchymosis
As anesthesia wears off after dental surgery, if epinephrine is con-
tained within the anesthetic there is vasodilation of blood vessels.
If postoperative bleeding occurs, blood may advance along facial
planes and cause an ecchymosis, whose pattern can vary. Tissue
discoloration may appear adjacent to a surgical site or, due to grav-
ity, extend down as far as the pectoral muscles (Figure 12). There
is a predictable chronology of color change related to hemoglobin
breakdown. Initially, tissue will appear reddish. After several hours,
it may be black/blue. By day 6 its color changes to green (hemo-
globin converted to biliverdin), and by day 8 to 9 it may be yellow-
ish-brown (bilirubin present). In general, the body resorbs hemoglo-
bin and hemoglobin by-products in 2 to 3 weeks.106
B. Blood Loss After Dental Surgery
An average person has around 5000 ml of blood (5 liters). One pint is
473 ml. After periodontal surgery that lasts less than 2 hours, blood loss
is usually <125 ml (maxilla 110 ml, mandible 151 ml).107 Average hem-
orrhage per sextant is 134 ml (range 16 ml to 592 ml).107 If a patient’s
blood pressure drops 20 mg or blood loss is >500 ml, or there is an
increased heart rate by 20%, intravenous solutions may be required.108
TORQUE FORCES
A. Torque Forces Related to Procedures
The minimum torque that can be employed to attain primary stability
is undefined.109 Forces ≥30 Ncm are routinely used to place implants
into healed ridges and fresh extraction sockets prior to immediate
temporization of implants.109 Increased insertion torque (≥50 Ncm)
reduces micromotion, but does not appear to damage bone.109 The
force generated by fingers when a screwdriver is used is 10 Ncm to 15
Ncm.109 Torque force used to place prosthetic screws is manufactur-
er-dependent and screws should be placed using a torque wrench.109
12 13
FIG 12. Ecchymosis extending down facial planes to the pectoral muscles.
FIG 13. Maxillary canine at site No. 11 has an 11-degree distal tilt. Implants placed
in the first bicuspid area, site No. 12, need to be placed parallel to the canine.
9 COMPENDIUM EBOOK
G U I D E
B. Implant Stability Quotient (ISQ)
ISQ ranges from 1 to 100. Investigators often use a threshold 65.5
ISQ to indicate primary stability, and implants that achieve this can
be temporized.110
PLATFORM SWITCHING
A systematic review indicated that platform switching (abutment
narrower than implant platform) results in less vertical bone loss
around implants than implants restored without platform switching,
respectively 0.055 mm to 0.99 mm versus 0.19 mm to 1.67 mm.111
PROPER DISTANCES BETWEEN TEETH AND IMPLANTS AND
BETWEEN IMPLANTS
A. Span Between a Tooth and an Implant
This span should be at least 1.5 mm to 2 mm for non-platform-
switched implants.112 Bone loss is inversely proportional to how
close an implant is to a tooth.113
B. Minimum Space Between Two Implants
To maintain interproximal bone height for non-platform-switched im-
plants, 3 mm is needed between the implants. If the expanse is ≤3 mm,
the mean vertical bone decrease is 1.04 mm, and if the inter-implant
space is >3 mm, the expected vertical bone resorption is 0.45 mm.114
Platform-switched implants can be placed slightly closer together. (At
a 1 mm distance, the mean vertical bone lessening is 0.43 mm.)115
C. Space Required for a 4-mm Diameter Implant
To place a 4-mm diameter implant, a span of 7 mm mesiodistally is
needed between adjacent teeth at the coronal region.116,117
IMMEDIATE IMPLANT PLACEMENT
A. Maxillary Anterior Teeth
When placing an immediate implant in the maxillary anterior re-
gion, an osteotomy should be created that is half to two-thirds up
the palatal aspect of the socket or 2 mm to 3 mm from the apex to
utilize palatal bone of the socket to attain primary stability.118
B. Sink Depth
Ideally, an implant’s platform should be placed 3 mm below the fa-
cial zenith of the soft tissue in the esthetic zone.119 This is referred
to as the implant’s sink depth (surgical term). Prosthetically, this
distance is referred to as “running room” and it facilitates creation
of an ideal crown emergence profile.
C. Tooth Position
1. A maxillary canine usually tilts 11 degrees distally and the root
is distally dilacerated 32% of the time (Figure 13).120 There-
fore, when replacing a maxillary first bicuspid with an implant,
the implant should be placed parallel to the maxillary canine to
avoid contacting the canine’s apex.
2. Maxillary central incisors are positioned at about a 110-degree
angle with respect to the horizontal plane of the palate.121
3. Mandibular posterior teeth are lingually inclined as follows:
second bicuspid, 10 degrees; first molar, 15 degrees; second
molar, 20 degrees.121
D. Gap Management
(Also Referred to as the “Jumping Distance”)
At the time of immediate implant placement, if the jumping distance
between an implant and the adjacent bone is ≥2 mm, some clinicians
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 R E F E R E N C E
recommend placing a bone graft into the gap. However, this is
122
controversial, because others believe that a gap ≥2 mm, if left open,
can fill with bone and heal by secondary intention.123
SECTION III: DIGITS RELATED TO
POSTSURGICAL MANAGEMENT OF PATIENTS
COLD THERAPY AFTER SURGERY
A. Customary Temperatures
Normal body temperature is 37°C; typical skin temperature is
33°C; and skin freezes at 25°C.124
B. Therapeutic Threshold Levels
Physiologic responses are attained if temperature is reduced as fol-
lows: blood flow decreases at 17°C; nerve conduction diminishes
at 13.6°C; metabolism reduces at 10°C to 15°C; and edema is im-
peded at 12.8°C to 15.6°C.124
C. Duration of Time for Cold Application
Ice applied for 15 minutes on and 15 minutes off in a hand towel
is recommended postsurgically for hours (precise number of hours
is undetermined).124
D. Effective Distance of Cold Therapy
There is no change in skin temperature 1 cm proximal to ice ap-
plication.124
INFECTIONS
A. Incubation Time for an Infection
An infection usually takes >2 days to manifest signs of redness,
pain, etc.125
B. Time to Peak Edema
Edema peaks on the second or third day after surgery and needs to be
differentiated from swelling associated with an infection. In general,
edema is not painful upon palpation and decreases with time, whereas
an infection is painful when touched and worsens if not treated.125
C. Tissue pH
The pH of normal tissue is 7.4 and infected tissue manifests a pH
of around 5.5. Bone resorbs quickly in an acidic environment.126
D. Prophylactic Antibiotic Coverage
After implant placement, infections occur infrequently and anti-
biotic coverage does not reduce the incidence of postoperative in-
fections in healthy patients.127 However, it has been suggested that
clinicians prescribe a single dose of 2 gm of prophylactic amox-
icillin, 1 hour before placing dental implants. If this protocol is
followed for 25 patients, it prevents one person from experiencing
an early implant failure.127
E. Time Necessary to Attain Blood and Tissue Levels
of Antibiotics
If antibiotics are prescribed for an infection, it takes 24 to 48 hours
to achieve a high tissue level; an affective blood level is attained
within 1 hour.128
RATE OF HEALING AFTER SURGICAL PROCEDURES
A. Healing Time for Soft Tissues
There is a 12-hour lag time before epithelial healing commences
after surgery, and then the healing extends at 0.5 mm to 1 mm daily
10 COMPENDIUM EBOOK
G U I D E
from the wound’s edges.129 Connective tissue regenerates approxi-
mately 0.5 mm per day.130
B. Time for Flaps to Become Bound Down
After surgery, initially a flap is attached to bone by a blood clot (for
0 to 24 hours). At 1 week, there is granulation tissue. After 2 weeks,
a flap is connected to bone via immature collagen fibers. In a dog
model, the force required to separate a flap from bone at 2 to 3 days
postoperative is 225 grams, at 1 week it is 340 grams, and at 2 weeks
a 1700 grams force could not displace the flap.131 In general, flaps
are attached in 10 days (dog model). Sigma (healing speed) of dogs
versus humans is 1.5 (faster in dogs). Thus, in humans it takes about
2 weeks for a flap to be strongly fastened to bone.
C. Post Extractions: Bone and Soft-Tissue Maturation
The following events occur after tooth removal: blood clot; gran-
ulation tissue is present in 96 hours; connective tissue is present
by the 28th day; epithelium covers the socket after 5 weeks; wo-
ven bone exists at 3 months; and lamellar bone is present by 4
months.132
D. Bone Grafts and Osseointegration: Healing Time
1. Bone calcification advances 50 µm per day (1.5 mm per
month).133
2. After a particulate bone graft is placed to regenerate a missing
bony wall, 4 to 6 months is needed for graft calcification before
an implant should be inserted.134
3. After a cortical block graft is placed, 4 to 5 months is required
for bone healing.135
4. In type 4 bone, it is prudent to let an implant osseointegrate for
6 months before loading it.136
5. In dense bone, the clinician can load the implant in 3 months
(or less) after its placement.137
6. Six months should be allowed for osseointegration if an im-
plant is a “spinner” or if a transcrestal sinus floor elevation
graft is placed in conjunction with an implant.137
7. Native bone below the sinus is composed of 25% bone and 75%
marrow.138 Regenerated osseous bone after a lateral wall sinus lift
consists of approximately 25% vital bone, 25% graft material, and
50% marrow.139 The regenerated bone does not have a higher per-
centage of vital bone than the bone adjacent to the graft site.139
8. Lateral window sinus lift bone graft mineralizes 1 mm to 2 mm
bone per month from each bony wall.140
E. Contraction of Soft Tissue and Bone Grafts Postsurgically
Soft tissue and osseous grafts routinely diminish in size over time,
and this should be factored in when performing therapy. The fol-
lowing are examples of the magnitude of shrinkage that occurs
after graft procedures: gingival grafts are reduced 16.5% by 3
months141; connective tissue grafts may shrink 25% to 45% after 1
month142; 4 months subsequent to guided bone regeneration there
is non-uniform contraction in bone graft height and width ranging
from 39.1% to 76.3%143; and after a transcrestal sinus floor eleva-
tion, the sinus graft diminishes by 1.9 mm after 5 years.144
F. Repair After Nerve Damage
Specific terms are used to describe nerve injuries and the time nec-
essary for their repair145:
1. Neurapraxia—This term denotes that there is no loss of nerve
continuity; the nerve has been stretched, or underwent blunt
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 R E F E R E N C E
trauma. Resultant paresthesia will subside and feeling will re-
turn in days to weeks.
2. Axonotmesis—The nerve is damaged, but not severed. Feeling
usually returns within 2 to 6 months.
3. Neurotmesis—The nerve is severed. There is a poor prognosis
for resolution of the induced paresthesia.
G. Reduction of Tooth Hypermobility After Therapy
When placing implants, there are occasions when teeth with peri-
odontal issues adjacent to implant sites are treated concurrently. Af-
ter scaling and root planing, a reduction of tooth mobility is usually
noted after 2 weeks.146 After periodontal flap surgery the following
events often occur: at 1 week, the level of tooth hypermobility may
be increased; at 6 weeks postoperatively, tooth looseness may return
to the preoperative level; and at 6 months, hypermobility may be
decreased compared to immediately after surgery.147
NUMBERS ASSOCIATED WITH PROSTHETIC ISSUES
A. Abutment Height
A 5-mm tall abutment is desired for retention of a cementable
implant crown.148 The minimum abutment heights necessary to
provide adequate retention for narrow-platform (3.5 mm) and wide-
platform (5 mm) implants restored with single cement-retained
restorations (cemented with Temp-Bond™, Kerr, kerrdental.com)
are respectively, 3 mm and 4 mm.149 A 2 mm increase in abutment
height amplifies retention by 40%.148
B. Occlusal Clearance Necessary for Different Restorative
Materials
At least 2 mm of space is required to provide room for porcelain-
fused-to-metal (PFM) occlusal materials (opaque, 0.3 mm; metal,
0.5 mm; and porcelain, 1 mm).150 Monolithic zirconia or lithium-
disilicate crowns (press or CAD/CAM) require less vertical space
than PFM crowns. This is due to the fact that restorations made
with these materials need as little as 1 mm occlusal clearance,
because no space is required for metal understructures.151
C. Crown Margin Placement
It is difficult to remove subgingival cement entirely around a crown
placed deeper than 1 mm into the sulcus.152 Therefore, implant
margins of cementable crowns should not be placed more than 1
14
FIG 14. Crown-to-implant ratio of 2:1 at site Nos. 20 through 18.
11 COMPENDIUM EBOOK
G U I D E
mm subgingivally. Ideally, margins should be placed as follows:
posterior implants, 0.5 mm subgingivally on the mid-buccal,
mesio-buccal, and mesio-lingual, 0 mm at other locations; anterior
implants, 1 mm subgingivally mid-bucally, 0.5 mm subgingivally
mesio and disto-buccally, and 0 mm lingually.152
PAPILLAE
A. Return of Papillary Height After Crown Placement
on an Implant
After a transitional partial restoration is worn and a crown is initially
placed, 90% of the time there is an open area under the contact point
between the crown and adjacent tooth.153 Within 1 year, about 80%
of papillae rebound and fill the interproximal space.153 This is due to
reformation of the gingival col under the contact area.
B. Papillary Tallness Between Implants
Average height of a papilla between two implants is 3.4 mm, and
>50% of papillae between implants are ≤3 mm high.154
C. Papillary Size Between an Implant and a Tooth
The mean distance from osseous bony crest to the papilla tip is
3.85 mm to 4.2 mm.155,156
D. Interproximal Papillary Recession After Implant Surgery
When thick and thin periodontal phenotypes are compared with
respect to alterations of papillary and facial tissue height after sin-
gle-tooth implant placement that included flap surgery, the thin
phenotype demonstrates shorter papillae by approximately 0.7
mm.157 Facial tissue height is also about 0.4 mm less than tissues
associated with a thick phenotype.157
ANGLED ABUTMENTS
Fifteen-degree and 25-degree angulated abutments can be used to
correct occlusal relationships 1.5 mm and 2.5 mm, respectively.158
CROWN-TO-IMPLANT RATIO
Unsplinted dental implants with a crown/root ratio of 2:1 (Figure
14) can successfully be restored, despite increased stress on the
prosthesis.159
CANTILEVERED PONTIC OFF TWO IMPLANTS
The success rate of prostheses with one cantilevered pontic off two
implants after 10 years is 88.9%, and the success rate of implant-sup-
ported prostheses after 10 years is 86.7%.160 The size of a cantilevered
pontic off two implants should be approximately 8 mm.160
ORAL HYGIENE
Oral hygiene is essential to maintaining periodontal and peri-im-
plant health. Different hygiene devices penetrate to diverse depths
subgingivally to reduce biofilms:
1. Toothbrush penetration under the gingiva is approximately 0.9
mm.161 Sonicare (Philips, philips.com) removes plaque subgin-
givally 1 mm to 3 mm.162,163
2. Oral rinses enter the sulcus <2 mm depth.164
3. Interproximally, flossing reaches subgingivally about 3 mm.165
4. Standard irrigation tips project fluid roughly 44% of depth in 4
mm to 7 mm probing depths.166
OPEN CONTACT BETWEEN TEETH AND DENTAL IMPLANTS
After an implant restoration is inserted next to a natural tooth, an
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 R E F E R E N C E
interproximal gap develops 34% to 66% of the time. This
167-169
event often occurs on the mesial aspect of an implant restoration
due to mesial migration of teeth, and this happens as early as 3
months after prosthetic rehabilitation.
PERI-IMPLANTITIS
A systematic review indicated that 18.8% of patients (9.6% of the
implants) develop peri-implantitis.170 However, this number varies
in the literature, because it depends on the quantity of bone loss
used to define peri-implantitis.
IMPLANT FAILURE RATES
About 2% to 3% of implants are lost prior to prosthetic loading, and
another 2% to 3% that supported fixed partial dentures failed within
5 years.171 A systematic review retrospectively evaluated 10 long-
term studies (>15 years), and it was noted that implant survival rates
among studies ranged from 70% to 100%. Nevertheless, eight of the
10 studies indicated implant survival rates were >90%.172
CONCLUSION
The objective of this article was to enumerate and share clinical
numbers needed to treat dental implant patients. It presented digits
that may be helpful during surgical and postsurgical therapy. Cli-
nicians should bear in mind that many of the presented integers
reflect mean data and the range of results may vary when manag-
ing different patients. In conclusion, when applying numbers ad-
dressed in this primer, the following axioms should be observed:
always adhere to sound biologic principles, keep the therapeutic
plan as simple as possible, be prepared to improvise, maintain
a standard of excellence, and, finally, treat patients the way you
would like to be treated.
ABOUT THE AUTHORS
Gary Greenstein, DDS, MS
Clinical Professor, Department of Periodontics, College of Dental
Medicine, Columbia University; Private Practice, Surgical Im-
plantology and Periodontics, Freehold, New Jersey
John Cavallaro, DDS
Clinical Professor, Department of Prosthodontics, College of Den-
tal Medicine, Columbia University; Private Practice, Surgical Im-
plantology and Prosthodontics, Brooklyn, New York
Dennis Tarnow, DDS
Clinical Professor, Department of Periodontics, Director of Im-
plant Education, College of Dental Medicine, Columbia Universi-
ty; Private Practice, Surgical Implantology and Periodontics, New
York, New York
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