Computer Guided Template-Based Dental Implant

Computer Guided Template-Based Dental Implant Abstract: The introduction of implants to dentistry has helped many edentulous patients to have a more reliable functional and esthetic alternative to fixed and removable prosthetic appliances. The optimal 3-dimensional positioning of the implants secures the best function and esthetic of the final restoration and at the same time avoids the biomechanical complications and failure that might take place subsequent to the wrong positioning of the implants. The aim of this project: is to highlight the importance of placing the implants in the optimal 3-D position. Computer guided template-based implant placement will be discussed as a precise and predictable tool in the planning and in the execution of the implant placement. The objective: is to enable the placement of the implant in a way that secures the highest predictable success with the least complications. Materials and Methods: Out of 350 downloaded relevant articles only 161 articles were chosen and referenced. The excluded articles were either written in languages other than English, descriptive of new fabrication methods of surgical guides, single case reports or experimental done on small sample size{less than 5}. Results: Most of the revised papers are case series or experimental studies done on animals or cadavers. Even the systematic reviews were based on those articles. Computerized tomography (CT) and interactive software programs are proven to be important for accurate treatment planning. The accuracy of transferring the treatment plan precisely by the aid of CAD/CAM fabricated surgical guide to the patient mouth are reported to be more predictable than free hand implant placement especially in the compromised cases. Conclusion: The published literature highlighted the higher predictability, accuracy and precision of computer guided template based implant placement over conventional free hand placement; but supporting strong evidence is lacking. Good controlled clinical studies with long term follow up is needed in this regard. For the time being and with the reported high success of conventional free hand implant placement, it seems that free hand implant placement seems to be predictable at least in the hands of experts or with the uncompromised cases. Introduction: In the 19th century many aspects of life were affected by the industrial revolution, especially in sciences and manufacturing. Dentistry was not an exception of this. However, it was in the Victorian era when the basis of modern dental care was first set. A large number of the developments in dentistry were just modifications of industrial inventions. Many of such developments were impossible before the introduction and use of electricity, which led to the invention of more complex surgery equipments {Gelbier S, 2005}. Another very important development took place as a consequence of the invention and the use of computers in the various fields of dentistry {Schleyer Titus K.L., 1999}.Computer guided implant placement is one of the aspects that shows how dentistry has got use to the computer and its science { Azari A. and Nikzad S.; 2008}. In fact, it is true that the advancement in dentistry and the increased public awareness public of the importance of keeping their teeth healthy have led to the decreased frequency of edentulism. Such declination varies not only among different countries but also among the different geographic regions within the same country and among the different groups of people of different cultural and social backgrounds. However, it is predicted that in the next few decades, there will be very low proportions of edentulism in elderly persons (over 65 years). Teeth loss increases with age, this means that in the future edentulism will occur at later stages in life {Lang NP Muller F. 2007; Lang N.P. De Bruyn H., 2009}. In such situations and in addition to the natural delays in the healing of elder individuals {Goodson 3rd WH Hunt TK 1979}; the patients at that age will be most properly affected by co-morbidities and unfavorable ageing conditions like osteoporosis, uncontrolled diabetes mellitus , hypothyroidism and chronic renal disease which are among the diseases that negatively affect the bone quality and consequently implant success. Some older age related diseases like Parkinsonism, Alzheimer can affect the ability to perform adequate oral hygiene and this may lead to inflammation and bone loss around implants {Roberts WE. et al.1992; Elsubeihi ES. Zarb GA. 2002; Marder MZ. 2004}.For this, dental professionals need to develop their skills and to use new techniques that offer the patients with the safest, accurate results and the least morbidity and to be able to manage such elder patients and their unfavorable conditions which sometimes may preclude the placement of the implants {Lang NP Muller F, 2007; Lang N.P. De Bruyn H., 2009}. Back ground: Traditionally, lost teeth were replaced by removable partial dentures {RPD}, fixed partial dentures {FPD} and complete dentures in cases of full edentulism { Bragger U et al 2005}. Since the introduction of implants to dentistry by Branemark{1977}, many of the edentulous patients have been able to have more reliable functional and esthetic alternative to fixed and removable prosthetic appliances{Lang N.P. De Bruyn H., 2009}. The increasing Demand for implant retained restorations in the last few decades resulted in the need for new improved techniques to ensure the most proper implant position to restore the patient properly {Ganz S.D,2001} . Historically the implants were placed where there is bone { Kopp et al 2003}. They were considered successful when integration is achieved {Branemark et al.1977}. However, as the functional and esthetic demands of the patients have increased significantly; the success of implant-supported restorations is no more only related to the level of implant integration in the bone but also to the proper positioning of the implants and subsequent prosthetic outcome{ Lal et al.2006}. For this proper treatment planning has become mandatory. The main goal of the treatment plan is to place the implants in the optimal position as dictated by function and esthetics of the definitive restoration. This in turn avoids the biomechanical complications and failure that might take place subsequent to the wrong positioning of the implants {Garber DA Belser UC. 1995; Kopp et al. 2003 Park et al. 2009}. The aim of this project: is to highlight the importance of placing the implants in the optimal 3-D position. Computer guided template-based implant placement will be discussed as a precise and predictable tool in the planning and in the execution of the implant placement. The objective is to enable the placement of the implant in a way that secures the highest predictable success with the least complications. Materials and Methods: Multiple searches have been made through Science Direct and Google Scholar. The following key words were used with different combinations: systematic review, computer-guided, computer-assisted, image-guided, robots, dental implants, complications, treatment planning, radiography, computerized tomography, accuracy, flapless surgery, zygomatic implant, bone density, augmentation volume, immediate loading, free hand surgery, Steriolithographic templates. As the topic of computer guided implant placement is a modern topic; the selected articles were limited to the articles published from the year 2000 up to 2010. However some older but relevant articles were hand searched, selected and referenced. Almost 350 articles were found to be relevant to the different points to be covered in the project were downloaded; after reading their abstracts it was found that many of them were either clinical case series and reports or experimental studies made on animals or cadavers, many of the systemat ic reviews were found but again nearly all of them were based on the mentioned articles. The articles of single case reports and the experimental studies with very small sample {less than five} size were excluded. Also, the articles that focus on the fabrication of new surgical guides were excluded. Articles in languages other than English are excluded too. Only 161 were selected and referenced in this project. Results: Most of the revised articles concerning the accuracy of CAD/CAM template based implant placement are case series or experimental studies done on animals or cadavers. Even the systematic reviews were based on those articles. Based on the revised articles; computerized tomography (CT) and interactive software programs are proven to be important for accurate treatment planning. The accuracy of transferring the treatment plan precisely by the aid of CAD/CAM fabricated surgical guide to the patient mouth are reported to be more predictable than free hand implant placement especially in the compromised cases. Discussion: Complications associated with improper implant positioning: Marginal bone loss and consequent mechanical and esthetic problems: The correlation of marginal bone loss and improper positioning of the implant is reported in the literature. The wrong angulation of the implant is usually compensated by the use of angled abutments, in this situation the load carried by the implant is mostly off-axis, such unfavorable load leads to the bone destruction around the implant and other mechanical complications like screw loosening, fracture and/or implant fracture {Chun-Li Lin et al., 2005 Saab X. E. et al 2007}.The improper placement labially, will lead to thin labial bone and subsequent bone loss and gum recession{Buser D. et al. 2004}, lingually, in addition to the thinning of lingula bone it results in emergence problems as seen with ridge-lap restorations. Such restorations are difficult to maintain and consequent inflammation and bone loss is unavoidable {Tarnow DP. 1995; Belser UC. et al. 1998}. The placement of the implant too close to the adjacent tooth can cause resorption of the inter-proximal alveolar crest {Esposito M. et al. 1993; Thilander B. et al. 1999}. If the implant is placed too far apically using extensive countersinking, the polished implant collar will come into contact with the bone and this in turn induces bone resorption because polished surface does not integrate {Buser D. et al. 1991a; HÃÆ'Â ¤mmerle et al. 1996}, also the micro gap will come closer to bone and unnecessary bone loss will take place. Disuse atrophy due to subnormal mechanical stimulation is another explanation for bone loss around polished implant neck or crest modulous {Al-Sayyed, A. et al. 1994; Vidyasagar L. Apse P. 2004}. Nerve injury: Altered sensation of the lower lip as a result of inferior alveolar nerve injury is one of the serious complications of mandibular implant osteotomies {Bartling et a. 1999; Vazquez L. et al. 2007}.This is especially if the magnification factor on the panoramic radiograph is misinterpreted {Vazquez L. et al. 2007}. The injury of the mental nerve can also lead to the same symptoms; the mental foramen is an important landmark during surgical procedures in the lower premolar area. it is usually located at the apex of the second mandibular premolar or between apices of thetwo premolars. However, in some cases its location can vary from the mandibular canine to the first molar. Unfortunately, The foramen may not appear on conventional two dimensional radiographs, in this condition a computerized tomography (CT) scans are important as they are more accurate for the detection of the mental foramen than conventional radiographs { Bartling et a. 1999 , Greenstein Tarnow, 2006}. Lingual bundle: Though it is rare complication, the wrong implant placement in the mandible may lead to the perforation of lingual cortex with a great possibility of lingual bundle injury with a subsequent fatal bleeding and hematoma formation. Under the effect of profuse bleeding and as a result of the progressive expansion of the lingual, sublingual, sub- mandibular, and sub-mental hematomas ; the tongue and the floor of the mouth can be displaced leading to the rapid and complete obstruction of the airway {Mordenfeld A et al. 1997 and Kalpidis Setayesh , 2004}. Devitalization of the adjacent teeth: In addition to the risk of losing the inter-proximal bone {Esposito M. et al. 1993; Thilander B. et al. 1999}; the placement of the implants in close proximity to the adjacent teeth may lead to the loss of the teeth vitality especially if the roots are injured during drilling for implant placement {Jemt T. Pettersson P. 1993; Rubenstein J.E. Taylor T.D. 1997; Goodacre CJ. et al. 1999 Schwartz-Arad D. et al. 2004}. Other possible rare but serious complications: Some other rare complications can take place due to poor treatment plan and wrong implant placement like perforation of nasal and sinus floor {Nahlieli O. et al 2008},injury of the submandibular and/or sublingual salivary glands {Nahlieli O. et al 2008},mandibular fracture especially in osteoporotic and atrophied mandible{ Raghoebar G.M. et al.2000 Meijer H.J.A. et al. 2003}. Criteria of optimal implant position: The ideally placed implant should be surrounded by uniform bone volume and density; this provides the implant with a good bony support against the multi directional long term loading. A minimum of more than 1 mm bone thickness is recommended to keep around the body of the implants {Nancy L.C., 1993}. In addition, the implant ideally should be placed in the geometric centre of the crown; this reduces the off axis loading and prevents many of the biomechanical complications and its subsequent poor esthetic outcomes {Galanis C.C et al. 2005 2007}. Implant tooth distance: A minimum of 1- 1.5 mm distance between the implant surface and the adjacent teeth needs to be respected {Buser D. et al 2004}. However, a 3 mm distance between the implant and an adjacent natural tooth is recommended to minimize the potential for damage to the supporting structures of the natural teeth {Adell et al, 1986; Hobo et al, 1989}. Implant to implant distance: To avoid bone resorption in-between the adjacent implants; a minimum of 3 mm inter-implant distance is recommended {Hobo et al, 1989 Traini et al. 2007}. Implant to vital structure distance: To avoid nerve injury during implant surgery in the mandible, some guidelines should be considered with respect to verifying the position of the mandibular and/ or the mental foramen and to validate the presence of the anterior loop of the mental nerve. These guidelines included leaving a 2 mm as safety zone between the implant and the nerve. Once the safety zone is identified, implants can be placed safely; and before the placement of any implant anterior to the mental foramen that is deeper than the safety zone, the mental foramen must be explored to verify the possibility that an anterior loop is there {Buser Von Arx 2000, Greenstein Tarnow, 2006}. In consideration of the risk of surgical complications during implant placement, bone grafting or other surgical procedures where risk is anticipated, a CT examination should routinely be performed before any surgical approach { Ganz S.D,2001; Scaravilli MS, et al 2009 Naitoh et al. 2010}. To reduce the probability of such serious complication, some preventive measures should be taken before, during, and after implant placement in the anterior part of the mandible, among such measures are the awareness of the regional arterial anatomy, proper treatment planning through radiographic and clinical evaluation of the osseous morphology, and the right angulation and length of the selected implant and finally the skill of the surgeon {Kalpidis Setayesh , 2004}. Dental CT is a valuable tool for the assessment of jaw bone anatomy and can easily demonstrate the occurrence, position, diameter and course of the lingual vascular canals of the mandible; for this, a CT examination should routinely be performed before any surgical procedure to the anterior region of the mandible to verify the presence of the mandibular lingual vascular canal {MLVC} and to evaluate the lingual cortical bone thickness and density to avoid perforations and the life threatening bleeding {Scaravilli MS, et al 2009 Naitoh et al. 2010}. Distribution of the implants in edentulous jaws: Ideal implant distribution and placement is critical in order to secure the optimal mechanical and esthetic outcome of the definitive restorations as well as enabling the patients to maintain proper hygiene. The placement of the implants in the inter-proximal positions may cause problems from an aesthetic, mechanical and hygiene perspective {Jivarj S., 2006}. Also, the antero-posterior distribution of the implants should allow equal distribution of load over a wide area with minimal cantilever length {Adell R et al. 1990; Palmqvist S et al 1994 Jivarj S., 2006}. When multiple implants are placed to retain a prosthetic appliance; parallelism between the implants should be secured otherwise the unfavorable off-axis loading will not be avoidable {Arfai N.K. Kiat-amnuay S. 2007}. In the case of implant and tissue supported overdentures both implant placement and distribution become critical; where the Implants have to be placed so that when a bar is constructed it has a straight line c onnection between the implants and does not encroach on the palatal/lingual denture bearing area. The distribution of implants should also be in the way so that adequate space is available for the clip {Jivarj S., 2006}. When more force from the opposing occlusion- on the implants are anticipated more implants should be placed to share the load {Jivarj S., 2006}. Treatment planning: Until recently the main concern was directed to the surgical aspect of implant placement {Ganz S.D, 2001}. The implants were planned to be placed where the bone is found {Kopp et al 2003}. The esthetic and functional outcome of the final prosthesis was not much considered {Ganz S.D, 2001}. The new concept of prosthetically driven treatment planning and implant placement requires careful evaluation of the surgical site. In addition, it must relate the 3-D location of the future prosthetic restoration to the optimal 3-D implant position. This position must be discussed and agreed on between the restorative dentist and the dental surgeon {Garber DA Belser UC, 1995, Kopp et al 2003 Park et al. 2009}. In the early days dentists who were believing in this concept {prosthetic driven} were mostly dependant on conventional radiography, wax-up prostheses and/or surgical templates made on the hard stony surfaces of the study casts, and to overcome the problem of transferring the plan to the operative site, customized radiographic and surgical templates have become an integral part of treatment (Becker CM Kaiser DA. 2000, Almog DM et al.2001}. Very soon later, it was found that the hard surface of casts is not equal to the soft tissue surface of the oral cavity, and this method may not be as accurate as necessary for treatment purposes. Additionally, it was established that templates fabricated on the study cast without knowledge of the exact anatomy below the surface cannot be considered reliable {Lal K. et al. 2006 and Widmann G Bale JR 2006}. The traditional tools for the treatment planning of dental implants include detailed clinical examination, panoramic, cephalometric and peri-apical x-ray films, diagnostic wax-up and articulated study models. Other diagnostic aids may include photography and ridge mapping technique for the assessment of the implant bone sites. Advanced diagnostic tools such as tomography, digital radiography, and CT scan film allow for a more accurate pre-surgical evaluation sites { Traxler M. 1992, Tyndall D. A. et al. 2000, Flanagan D. 2001, Ganz S.D,2001, Perez A.M. et al 2005, Guerrero M. E. 2006, Chen Lung-Cheng 2008, Loubele M. et al 2008}. Study models: Accurately mounted casts are critical in assessing prosthetic and inter-occlusal space limitations. Spatial constraints must be considered as a matter of practicality {Jivraj S et al 2006}. Study casts are also valuable tool to evaluate occlusion {Hayasaki et al. 2005 } and to help in the treatment planning through diagnostic wax- up {Katsoulis J. et al. 2008}. Moreover, radiographic and surgical templates can be constructed out of such study models {Lal K.et al. 2006; Katsoulis J. et al. 2008 Rubio-Serrano M. et al 2008}. Bone sounding No doubt that the direct measurement {DM} of the ridge size is the most accurate diagnostic tool. However, treatment planning especially in the big cases calls for collecting information before surgery. This saves time and money, avoids the unexpected complicated surgeries like harvesting bone for ridge augmentation and increases the predictability of the treatment. When ridge mapping {RM} is compared to direct measurement {DM} of the ridge size and to Linear tomography {LT} cone beam computerized tomography {CBCT}; ridge mapping {RM} seems to be the most reliable pre- operative clinical method to determine the ridge size {Perez L.A. 2005 Chen L.C. 2008}., linear tomography is reported to underestimate the ridge size {Perez L.A. 2005} while cone beam computerized tomography is reported to overestimate the ridge measurements {Chen L.C. 2008}. However, ridge mapping is not only an invasive procedure but also a difficult to use in the cases of shallow labial and/or lingual vestibules. Additionally, in ridge mapping the actual position of the inferior alveolar nerve cannot be verified {Perez L.A. 2005 Chen L.C. 2008}. Conventional two dimensional radiography: Actually, conventional 2-D radiography {panoramic, cephalometric and intraoral views}, which is widely used for the treatment planning, has important diagnostic limitations, such as magnification and distortion, setting errors and position artifacts {Tyndall D.A. Brooks S.L.; 2000 White SC et al, 2001}. Moreover, these 2-D radiographs do not show lingual anatomy or provide complete three dimensional (3-D) information about the dental arch {Nikzad and Azari. 2008 }. These limitations make the 2-d radiography is less than optimal tool for the diagnosis and treatment planning of dental implants; where according to recommendations provided by The American Academy of Oral and Maxillofacial Radiology (AAMOR), The aim of the preoperative dental implant treatment planning is to place the optimum number and size of implants to secure the best prosthetic outcome. This can be achieved only if a thorough knowledge of the patients bony anatomy in 3- dimensions is provided in the radiographic exa mination . Proper treatment planning requires that the clinician evaluate the suitability of the remaining bone for placement of implants. The clinician must determine if there is enough height, density, width of bone, and an appropriate axis of orientation for a successful prosthetic outcome { Tyndall D.A. Brooks S.L 2000 White SC et al, 2001}. CT scanning Although Computerized Tomography {CT} scans have been used in the medical field since 1973; it was not before 1987 when this new technology became available for dental purpose {Ganz S.D, 2001}. In implant dentistry; Computerized Tomography {CT} scan is one of the most important diagnostic tools which significantly improved the clinicians ability to diagnose and to put accurate treatment plan because it helps in viewing the anatomy and dental related anomalies of the jaws {Dula K. et al. 1994; Abrahams JJ Berger SB,1998 AbrahamsJ.J. Hayt M.W.,1999 Lal K. et al. 2006}and in the proper choice of implant size and angulation and this in turn helps to avoid injury of critical structures such as the mandibular canal or maxillary sinus {Ganz S.D,2001; Scaravilli MS, et al 2009 Naitoh et al. 2010}. Moreover the CT scan allows the visualization of the scanned jaw bone in a series of cross sectional, axial and panoramic views .This makes the planning of implant placement more precise in relation to the bone and future prosthesis especially when the a radiographic template {scano-guide} is used during scanning{Lal K.et al. 2006 Rubio-Serrano M. et al 2008 }.However CT scan by itself is nothing but series of axial and coronal 2-D images and the clinician needs to integrate such images in his mind to gain the desired information in 3-D {Gillespie J.E. Isherwood I.1986}. Interactive software programs: The present development of clinical computer applications allows the clinicians to obtain 3-D models to plan virtually real situations {Rubio-Serrano M. et al 2008}. Interactive computer software is now increasingly used as a tool for implant diagnosis, planning and treatment execution. Firstly, it is used in connection with imaging techniques, such as computerized tomography (CT) or magnetic resonance imaging (MRI) { Hassfeld S, MÃ ¼hling J 2001}. Secondly, it is used for the construction of surgical templates carrying the information necessary to transfer that planning to the mouth of the patient. In most of the cases, this procedure is based on stereolithographic models { Ewers R . et al 2005 Ganz S.D. 2005 , Schneider D. et al 2009 }. There are different commercialized soft ware programs are available, such as: Implametric, SimPlant { Ganz S.D. 2005 Parel SM Triplett RG 2004}, Nobel Guide {Rocci A et al. 2003}, med3D { Engelke W Capobianco M. 2005}, etc. Most of the programs display an axial cut and a panoramic cut with multiple bucco-lingual cuts {parasagittal} and reformatted 3-D image {Parel SM Triplett RG 2004}. In the 3D image, bony structures are visualized with the possibility of incorporating other anatomical structures or even soft tissues {Schneider D. et al 2009}. Bone density One of the good tools in the software programs is the ability to evaluate the bone density {quality} during the analysis of CT data. The importance of bone quality {density} for the success of dental implants is agreed on in the literature { Jemt T, Lekholm U 1995; Esposito M et al 1998; Shahlaie et al 2003 Park et al 2008}.As suggested by Lindh et al.1996 Site-specific measurements are important, not only for a general prediction of treatment prognosis but also in the evaluation of how long of an interval between first- and second-stage surgical procedure and loading is needed { Friberg B et al 1991,1995a 1995b}. Moreover, to have accurate preoperative measurements of the bone density helps in avoiding the placement of the implants in the areas of poor quality {Norton M.R. and Gamble C. 2001 Shahlaie et al 2003}. The strong correlation between the average CT number and the concentration of hydroxyapatite in bone is reported {Maki et al 1997}, and the quantitative CT in Hounsfield units {HU} are accepted as a valuable supplement to the subjective bone density classification defined by Lekholm and Zarb {1985}. The Hounsfield index is a standardized scale for reporting the reconstructed CT values. It is a measure of the attenuation coefficient which varies among different tissues, it is based on the density of air (-1000),water (0) and dense bone(1000){ Shapurian T. et al. 2006}. Misch CE {1993} stated that the bone density measurements using CT scan is more accurate than radiographic assessment. And he classified bones into 5 categories according to density: D1 bone had density above 1250 HU; D2 = 850-1250 HU; D3 = 350-850 HU; D4 = 150-350 HU; and D5, below150 HU. For this, the use of CT scanning and interactive software programs is considered as a viable and accurate method to measure bone den sity {Norton M.R. and Gamble C. 2001 Shahlaie et al 2003}. Recently, efforts in the oral imaging field have focused on developing tools that accurately and automatically measure bone density by measurements of x-ray absorption{ de Oliveira R. C. G. et al. 2008}. Thanks to such efforts, now the CT images in DICOM {Digital Imaging and Communications in Medicine} format contain the required data of bone density which enables the different software programs can measure it {Norton M.R. and Gamble C. 2001 Park et al 2008}. Bone graft volume Accurate evaluation of the 3-D bone volume before surgery is another advantage of the use of soft ware programs in the treatment planning in implant dentistry. The lack of enough bone volume frequently precludes the conventional implant placement. In this condition the bone volume needs to be improved by different augmentation techniques and /or materials {Esposito M. et al, 2008}.The detailed information about the needed bone volume before surgery is of much help in determining the best donor site { Krennmair G. et al 2006 Verdugo F. et al 2009} and can help in estimating the amount and costs of the xenographic bone substitute required for the augmentation surgery{Clavero J. Lundgren S. 2003}. Moreover, knowing the needed bone volume in advance helps in minimizing the duration of the surgery and this in turn minimizes the chances of complications and reduces the expenses for the patients {Cricchio G. Lundgren S.2003}. The computerized tomography {CT} can produce series of accurate cross sectional images and by the aid of soft ware programs like Simplant {Materialise, Leuven, Belgium} the 3-D volume of area to be augmented can be calculated {Hatano N. et al. 2004 Krennmair G. et al. 2006}. Flapless implant surgery: Predictable flapless implant surgery is one of the fruits of the application of modern technology like CT scan, interactive software programs and CAD/CAM fabricated surgical guides {Sclar A.G. 2007}. Minimal invasive surgery techniques are applied to a wide variety of interventions. The main aim is to reduce the costs of the treatment and patient healing time {Rubio-Serrano M et al 2008 Valente F. et al 2009}. The traditional implant protocol set by Branemark requires a duration of a few months for osseointegration of the endosseous implants before the connection of definitive dental prostheses {Adell R. et al 1981; Branemark PI 1983 Lindquist LW et al 1996}. When compared with the surgical phases, implant prosthesis fabrication is relatively time consuming {Rodrigues AH et al, 2003}. When implants are placed without flap elevation, both the amount of osseointegration and bone height around the implants are significantly greater than in implants placed with flap elevation. This enhancement is most probably due to the preservation of bone vascularization {Pennel B.M. et al 1967; Wilderman M.N et al. 1970 Jeong S-M et al 2007}. Moreover, the small sized punched mucosa lead to small, clean, closed wounds are known to heal quickly with little scar formation, whereas large open wounds heal slowly and with significant scarring{ Mathes S.J.,2006 Lee D-H et al. 2009}.18 D.C. Sabiston and H.K. Lyerly, Textbook of previous termsurgery,next term Saunders, The biological basis of modern surgical practice. Philadelphia (1997) p. 207-20. Recently, the use of flapless surgery for implant placement has become popular. This can be attributed to its numerous advantages that include improved patient comfort and healing, decreased surgical time, and the ability to resume normal hygiene procedures immediately following surgery. However, the flapless approach is only indicated when the surgeon is confident that the underlying osseous anatomy is ideal relative to the planned implant size and its 3-D position in the alveolus. If this is not the case; many problems may arise like: injury of the unseen vital structures, thermal damage secondary to inadequate irrigation during osteotomy preparation, malposed angle or depth of implant placement, and inability to appropriately contour osseous topography to facilitate restorative procedures {Sclar A.G. 2007 Van De Velde T. et al. 2007}. For this, the use of the conventional flapless implant placement should be limited to clinicians with advanced clinical experience and good surgical assessment {Sclar A.G. 2007}. By no

Ebags Case Study

eBags Case Study BUSI: 2003 Operations Management 11/16/2012 The eBags Corporation The purpose of this paper is analyze the business operations of the eBags Corporation, and provide recommendations for both the European luggage market and footwear industry based on current strengths and weaknesses eBags demonstrates. Through research and analysis, as a group we will map out the managing growth of the eBags Corporation. eBags is known for their innovative breakthrough of one stop shopping for luggage such as traditional travel bags and suitcases in addition to travel accessories like handbags, computer cases, and briefcases just to name a few.Operations management is a key component to the success of the eBags Corporation, and eBags has demonstrated innovative and cost effective business strategies by utilizing cross functional teams within their organization. With business growing, eBags has been able to increase their manufacturers from 10 to 300 and product lines increasing from 10 00 Stock Keeping Units (SKU’s) to over 15,000 SKU’s (Schroeder, Goldstein, & Rungusanatham, 2011).Due to the level of success eBags has accomplished they were able to create the eBags product line to consumers seeking low end luggage at an affordable price; the private label consisted of 1000 SKU’s held in a warehouse in Dallas, TX (Schroeder, Goldstein, & Rungusanatham, 2011) With desires of expanding their business eBags faces a number of hurdles in deciding which line of business will best suit their organization, their suppliers and manufacturers, their customers, all while generating the highest profit for their company. eBags Current Product Flow Process AnalysisTo maintain competitive in today’s market companies need to implement effective process flows. With options such as assembly lines, continuous, batch flow, and job shop it is important for companies to chose the option that is best going to fit both production needs and budget constraints. M aking the wrong choice for the product flow process can be very costly for any company; however, implementing the right process can reduce costs and speed up production time. The purpose of eBags is to create one stop shopping for luggage needs and in order to do so a wide variety of products should be available to their consumers. Bag and their manufactures use a made to stock order fulfillment process, and with various manufacturers and the eBags private label produced, eBags felt best to utilize the batch flow or batch production product flow process. This allowed products to be produced in lower volumes while still offering consumers a wide variety of products to choose from. By utilizing the batch flow process, it requires the use of general purpose equipment that does not specialize in making one specific product, which if loaded to full capacity could create a jumbled flow of products (Schroeder, Goldstein, & Rungusanatham, 2011).In order to maintain accurate inventory levels , eBags created the eBags Partner Network (EPN) which allows for the manufactures to post up to date product information to consumers ensuring that discontinued items don’t show available for purchase and consumers know the time needed for back order fulfillment. Analysis of eBags in the Footwear Industry and Recommended Product Flow Process Based on Type of Customer OrderWith such success rates in the luggage industry, eBags saw an opportunity to expand their business into foreign terrain, the footwear industry. With the footwear industry being a well known fragmented market, like the luggage market, allowing for flexibility to produce various different styles, designs, qualities, sizes, and colors while maintaining a competitive price. According to Schroeder, Goldstein, & Rungusanatham (2011), the footwear industry is three times the size of the luggage industry, so venturing into this market would not be an easy task.Some of the challenges that eBags faced in this market t hat they did not in the luggage market included: making consumers aware of the ability purchase footwear through an online channel and consumers generally want to try their shoes on to make they are getting the right product before purchasing (Schroeder, Goldstein, & Rungusanatham, 2011). However, eBags identified that if they could overcome the hurdles associated with this market they could expand even further with apparel and clothing which Schroeder, Goldstein, & Rungusanatham (2011), described as the largest online retail market.With hopes to exploit the footwear industry with one stop shopping, eBags should continue to utilize the batch flow process for their product flow process of footwear. With the footwear industry being similarly fragmented to the luggage industry, by using the batch flow process eBags will be able to produce at low to medium volumes allowing for an equally wide line of products to choose from. This will allow customer to order multiple pairs of shoes simu ltaneously so they can try them one and decide which pair is going to best fit their style and comfort needs.With this approach, eBags can also implement the EPN with footwear manufacturers to ensure that up to date products are available eliminating issues of consumers trying to order out of stock or discontinued merchandise. Analysis of eBags in the European Luggage Market and Recommended Product-Process Strategy According to a 2002 report, â€Å"190 million internet users had spread across Europe and surpassed the 165 million internet users in the United States† (Schroeder, Goldstein, & Rungusanatham, 2011, p. 513). Expanding the current line of business would be safe and effective business strategy for eBags with minor hurdles to consider.The luggage industry is not a foreign concept for eBags, so to be able to expand their products into the European market would require similar business strategies that they are currently using. No one consumer is the same therefore their product needs, including luggage will generally not be the same. The goal is to create one stop shopping for consumers in the European market for their luggage needs and in order to accomplish this, eBags will need to provide a variety of products and lines for their new customers to choose from.Some of the issues that eBags faces, according to Schroeder, Goldstein, & Rungusanatham (2011), are language barriers involved in international shipping, shipping requirements, brand awareness, and maintaining the EPN. To overcome the hurdle of international shipping, eBags can create relationships with manufacturers domestic to the European market. eBags will be able to incur the cost of shipping without having to pay the expenses associated with international shipping unless they made their private label available to the European market.Also, this will allow eBags to mirror the drop ship model that contributed significantly to the success of their organization. To achieve the success eBag s is looking for in this market, it is recommended that eBags continues to utilize the batch flow process for product flow. This also allows for incorporation the EPN into the new market still allowing for their consumers to have up to date product information. This process will continue to meet the business needs of the luggage industry by producing at low volumes but offering flexibility to accommodate products that meet the low, middle and high end of the market.As with the American luggage industry, eBags products will use a made to stock order fulfillment and the manufacturer will be able to control the inventory by using the EPN. Customer Contact Matrix Analysis of eBags: Strengths and Weaknesses of eBags Processes The level of customer contact for eBags is low which puts them at the high end of a buffered system and the low end of the permeable system on the customer contact matrix. The eBags website is set up to help consumers be self sufficient during the ordering process f rom beginning to end, and because there is no interaction involved their customer service is buffered.In the event the consumer needs additional assistance, they can call the customer service center and the phone interaction would fall under permeable on the customer matrix. This can be considered as strength for eBags because â€Å"separating the customer from the service production system allows for greater standardization of processes and therefore better efficiency† (Schroeder, Goldstein, & Rungusanatham, 2011, p. 91). eBags is able to focus their attention on product production and quality management of their products without having consumer interruptions.This is what Schroeder, Goldstein, & Rungusanatham, (2011), refers to as variability from uncertainty, specifically arrival variability. With a made to stock fulfillment, consumers use the eBags website to choose from preselected inventory decided by the manufacturer. This process is also built to have low level custome r contact to eliminate the request variability, which puts eBags at the advantage of having a high efficient system because orders are completed away from the customer. Weaknesses with a low level customer ontact causes eBags to miss out additional business opportunities. According to Schroeder, Goldstein, & Rungusanatham (2011), high customer contact allows for opportunities to up-sell the customer with accessories or additional sale items in creating more revenue for the company. If eBags entered the footwear industry, eventually expanding into apparel and clothing, they will miss out on great deal of potential revenue. Secondly, consumers who have difficulties navigating through the eBags website will cost eBags a sale resulting in loss of business.Analysis of eBags Use of Technology in Providing Competitive Customer Service Technology it vital to business of eBags as all of their business transactions occur through the internet, so it is important that eBags employs a high skill ed technology department to ensure business runs smoothly. The systematic technology used allows the consumer to filter their results by type brand, features, color, price, by size, etc, making it easy and quick to find the right product (Horwitt, 2011). To enhance the customer experience eBags has invested a great deal into the online shopping experience for their consumers.According to PRNewswire (2012), eBags has implemented the FreeFlow system, which has allowed them to provide better rich product information to their consumers with limited interruptions in website downloads. eBags also incorporated what is referred to as ColdFusion software, which will create the ultimate customer experience by creating personalized stores for their consumers (PRNewswire, 2012). The personalized store will track the customers spending habits and provide product recommendations based on previous purchased items. Another important way the internet is used to provide competitive customer service i s through the EPN.The EPN is a way to connect the consumer with up to date product information, and with the scorecard system the manufacturers can track product sales, returns, and customer feedback (Schroeder, Goldstein, & Rungusanatham, 2011). Analysis of eBags’ Useof Three Aspects of the â€Å"Philosophy of Lean† Lean business practices are important to corporation survival in today’s business market. Companies are looking for ways to stay in business by bringing new products to the market with faster delivery times and higher standards of quality.In order to stay in competition with the surrounding market most of today’s businesses have incorporated lean thinking into their business practices by adopting some if not all of the five lean tenets. The five tenets are: 1) what about product or service creates value, 2) improve value stream for each product or service, 3) flow within a process is simple, smooth, and error free, reducing waste, 4) produce only what is pulled by the customer, 5) strive for perfection ((Schroeder, Goldstein, & Rungusanatham, 2011).The first tenet that eBags demonstrates is creating both a product and a service that adds value for their consumers. eBags carries a wide selection of products and labels to choose from all while offering their customers the convenience to one stop shop from anywhere with an internet connection. This has saved eBags’ customers time and money from having to travel to a retail store that may or may not have what they are looking for.According to Schroeder, Goldstein, & Rungusanatham (2011), this lean tenet has allowed eBags to compete on product breadth, selection, and convenience instead of price. The second tenet that eBags demonstrates is improvement of value stream mapping by incorporated the drop-ship model, which is another way putting the customer in contact with the manufacturer by eliminating the middleman. With the customer orders going directly to the manufac turer, eBags was able to eliminate the middle man (retail merchant location), and create a direct customer-manufacturer relationship.The visual representation described on page 509 of Schroeder, Goldstein, & Rungusanatham (2011), shows the customer placing their order on the eBags website, eBags then sends the order to the manufacturer electronically, the manufacturer ships the merchandise to the customer, eBags provides the customer with the shipping tracking number and customer is billed for the merchandise, the manufacturer sends eBags an invoice, and finally the manufacturer is paid.The third tenet seen by eBags is the creating simple, smooth, and error free process flows that reduce waste, which can be seen through the incorporation of EPN. Because this system allows the manufacturers to control inventory levels eBags has been able to avoid any waste associated with inventory costs and reduce overhead costs. Also, according to Schroeder, Goldstein, & Rungusanatham (2011), eBags was able to effectively market their products by removing items that were out of order or discontinued. Bags’ Service Blueprint for Current Product Line Analysis and Recommendation Regarding Business Process Reengineering The basic service blue print is as follows: Based on the group analysis of this service blueprint it is not recommended for eBags to consider a process reengineering. The goal of a process reengineering is to redesign and integrate the business process to increase customer satisfaction. eBags have set themselves apart from their competition with their service blueprint, and any changes can be considered a waste.Footwear Industry Quality Control Analysis and Recommendations The footwear industry is very different from the luggage industry, shoes will be on a person and a level of comfort is important when configuring quality control. One step in maintaining quality control in the footwear industry is to recruit manufacturers with reputable quality assurance guidelines such as material inspection, testing, and final inspections of product before shipped to the consumer. It is also important that the manufacturers hire knowledgeable, competent, and skilled staff to ensure that all quality standards are being met.A second step in quality control, according to Schroeder, Goldstein, & Rungusanatham (2011), is to clearly identify the needs of the consumers. Once consumer needs are identified the consumer is not lost from the picture, consumer input is needed design specifications with the use of quality function deployment. This can also include information regarding consumer identified life expectancy of the shoes being produced consumers are not going to spend money on shoes that they are going to have to replace every 6 months. Malcolm Baldrige Award Analysis and Recommendation(s)Established in 1987, the Malcolm Baldrige Awarad was created to encourage businesses to strive for higher quality performance through management practices and im proved quality results (Schroeder, Goldstein, & Rungusanatham, 2011). Spread between seven (7) categories: 1) leadership, 2) strategic planning, 3) customer focus, 4) measurement, analysis, and knowledge management, 5) workforce focus, 6) process management, 7) results; the Malcolm Baldrige Award allows for 1000 total points combined between the seven categories measuring quality assurance.As judges for the Malcolm Baldrige Award, our assessment of eBags Incorporated for this strategic award is as follows: Category and Items (2010):| Points| Comments| | | | | 1. Leadership| | | 1. 1. | Senior Leadership| 70| Senior management work collaboratively to analyze previous results and asses future business ventures| 1. 2. |   Governance and Social Responsibilities| 50| According to PRNews (2012), eBags partnered with Susan G Komen to create â€Å"pink program†. Over 900 pink items offered that eBags contributes 10% of retail sales to the Komen Foundation. | 2. Strategic Planning| | | 2. | Strategy Development| 40| Created one-stop shopping for consumers, incorporated the drop-ship model, and added EPN and vendor scorecard to website to keep consumers informed| 2. 2| Strategy Deployment| 30| Meeting to discuss future business plans for eBags (Footwear Industry or European Market) based on previous years sales numbers| 3. Customer Focus| | | 3. 1| Customer Engagement| 40| Customer engagement can be seen in what Yahoo (2012), called the â€Å"Bag an iPad† campaign that created flexibility in customer interaction by expanding to the channels that consumers use most to communicate. 3. 2| Voice of the Customer| 45| Voice of the customer can be seen through the EPN, manufactures and other consumers can read reviews and testimonials. This gives eBags an opportunity to learn what consumers want and make changes to their products and prcesses if needed. | 4. Measurement, Analysis, and Knowledge Management| | 4. 1| Measurement, Analysis, and Improvement of Organ ization Performance| 40| This category reiterates the EPN and vendor score card system. Manufacturers are able to measure performance and use feedback to incorporate innovated ways to increase sales| 4. | Management of Information, Knowledge, and information technology| 40| ExtractTarget program, consumers receive up to date product and sales information, consumer reviews, and receive discount coupons. | 5. Workforce Focus| | | 5. 1| Workforce Engagement| 10| No information provided to support this category| 5. 2| Workforce Environment| 10| No information provided to support this category| 6. Process Management| | | 6. 1| Work Systems| 30| Maintaining the internet to avoid congestion within the website.Flow of the drop ship model| 6. 2| Work Processes| 45| eBags work processes is reflected through their improvement of work systems. | 7. Results| | | 7. 1| Product Outcomes| 90| I believe eBags has a strong product outcome by offering the customers products in the high, middle, and lo w end of the market| 7. 2| Customer-Focused Outcomes| 70| The process of the drop-ship model from eBags demonstrates how effective the experience is with the company, from shopping, to delivery to the vendor getting paid. 7. 3| Financial and Market Outcomes| 65| The financial and market outcomes at eBags have been set by their determination to offer more than 700 different brands to its market. This is done through cross functional teams within each department of eBags| 7. 4| Workforce-Focused Outcomes| 65| | 7. 5| Process Effectiveness Outcomes| 70| The process of the drop-ship model from eBags demonstrates how effective the experience is with the company, from shopping, to delivery to the vendor getting paid. | 7. | Leadership Outcomes| 70| By utilizing cross functional teams to create efficient and effective product and process flows, eBags has been able to shine among the industry setting precedence for future businesses. | | | | | | Total | 880| | In conclusion even though eBag s has some strong characteristics that can be appreciated in quality management it also has some weaknesses that can be improved on. These weaknesses impede eBags attempts at trying to win the Malcolm Baldridge Award. Analysis and Recommendation(s) for eBags Supply Chain Improvements The supply chain of eBags has been slimmed down as low as it can get.By implementing the drop ship model and EPN, all those involved in the supply chain are needed and the current processes are keeping consumers happy with wide selections of merchandise that can fit any style. It is recommendation that eBags is not in need of improvement in structure or infrastructure. By maintaining cross functional teams in product and process development eBags can stay on top of the competition by implementing innovative ways to improve process flows. Conclusion Over the years eBags has made a big name for itself being named Internet Retailer Magazine’s Top 50 Websites (Schroeder, Goldstein, & Rungusanatham, 2 011).With hopes to expand, eBags can venture into a brand new industry that can eventually open more doors or they can expand their current market into the unknown terrain of Europe. Both ventures will require cross functional teams to ensure that consumer wants and needs are addressed while creating process flows that will generate revenue for the company. Regardless of the industry eBags continues to expand in, the use of batch flow process and made to stock order process will accommodate any needs within any industry. Bags has set precedence for their innovate ways of conducting business such as with the drop ship model, EPN, vendor scorecard system, private label, and one stop shopping with the use of technology. eBags has also adapted well to current business practices and implanted the five tenets of lean which was a vital part of their success during a time of economic crisis. By conducting all business transactions, eBags has been deemed a low customer contact company becaus e all contact is done through the eBags website or on the phone with customer service representatives.Although eBags is missing out on opportunities for up-sale because of limited customer engagement, they make up their losses by saving consumers time and money from having to travel for their luggage needs. eBags scored rather high with the Malcolm Baldrige Award but was not quite at the mark to win. The category that had the biggest impact was workforce focus and very little information was available to support a higher score in this category. eBags can work on all areas in this category for improvement to secure a win of the Malcolm Baldrige Award.References: PRNewswire. (2012). eBags. com Raises Breast Cancer Awareness Year-Round with Pick Pink Program. Retrieved November 9, 2012 from http://www. prnewswire. com/news-releases/ebagscom-raises-breast-cancer-awareness-year-round-with-pick-pink-program-57176017. html PRNewswire. (2012). eBags. com Redefines Customer Service with Cutt ing-Edge Internet Technology. Retrieved November 2, 2012 from http://www. prnewswire. com/news- releases/ebagscom-redefines-customer-service-with-cutting-edge-internet-technology-73251862. html Horwitt, E. (2011).The Systematic Web gets Down to Business. Retrieved November 3, 2012 from http://www. computerworld. com/s/article/9209118/The_semantic_Web_gets_down_to_business Schroeder, R. G. , Goldstein, S. M. , & Rungusanatham, M. J. (2011). Operations management: contemporary concepts and cases. (5th ed. ). New York: McGraw-Hill/Irwin. Yahoo Finance. (2012). eBags Boosts Fall Sales with New ExactTarget-Powered Cross Channel Marketing on Facebook, Email, and Mobile. Retrieved November 10, 2012 from http://finance. yahoo. com/news/ebags-boosts-fall-sales-exacttarget-153000369. html.

The Argument About Example of Term Paper

The Argument About Example of Term Paper From a good example term paper, you're able to learn many essential things. In addition, there are cases when a student can't even produce a topic because of his term paper. Should you need expert writing help, don't hesitate to visit EssayPro.com. There are lots of paper templates to pick from, but the majority of the time your instructor will require a particular format for the entire class to follow. Custom made term papers permit you to incorporate the experience and knowledge of professionals, into the expression paper, as stated by the needs of your university, college, or higher school. A term paper is a type of students' works they write during their semester. It's quite helpful to read a good example term paper, or two, before you commence writing your own, especially, if they're related or have similar topics. Every examples term paper, at our website, is supposed to underline the high degree of professionalism which our writers have and to demonstrate their proficiency. The third paragraph produces a transition from the introduction to the remainder of the paper, telling us what they are likely to discuss. You will see from the expression paper introduction sample a fantastic document starts with a hook, which ropes in your audience to the remainder of the paper. With what has been gathered, somebody may then compose a comprehensive essay about the exchange. A good a couple of sentence thesis statement is required before they end their introduction. A Startling Fact about Example of Term Paper Uncovered Some folks claim they can write a term paper with no planning. The logic is extremely easy, as soon as a country produces certain goods in great quantities, it can put them up for sale or exchange on goods it requires. Any negative problems that may emerge on account of the thought of foreign products flooding a specific country's market can be overcome. Some people decide to visit the library and look for facts on a particular subject, while others like to concentrate on gathering information through personal statements. The exceptional considerations about the expression paper topics on child abuse can be grouped into different disciplines. A term paper on child abuse may also concentrate on the way in which the society or societal structures can assist children to recuperate quickly in the event of abuse. It is possible to still revise your topic if you believe your present one isn't good enough. Be ready to modify the topic if you find out your research isn't going anywhere. The Battle Over Example of Term Paper and How to Win It Fortunately, our samples can allow you to get started with the practice of producing your own paper. For instance, some of them just have zero time to deal with dozens of assignments that keep bombarding from every side. There you are able to learn to construct the structure and its elements. From our term paper proposal sample, you might also learn the suitable structure of an excellent project. After every step is completed, have a look at your outline again and think of what you could add or remove. Your brain will have the time to process the info, and you will be able to check at it using a fresh view. First, the method begins by completing the purchase form. The practice of earning an order is a simple and simple one. Any information that will make a credible image for your interviewee will be critical. Our collection gives a fantastic diversity of examples and makes it possible to select the information which you will need for your research. Whenever you have researched on a specific topic, you're expected to use a particular citation style. Based on your topic you might need to trust the scientific report style or literature review styles, or a mixture of the two. Just follow instructions and you ought to find the desired effects. Additionally, most or all the expenses of opening the business employing the trademark falls to the franchisee. Nevertheless, there's no peer review of the internet. While every student wants to finish their assignment with no external aid, there are frequently circumstances beyond their control that limit their capacity to achieve that.

Customer Service At A Retail Shop Essay - 1750 Words

INTRODUCTION Customer service is a service a person receives before, during and after purchasing the item. The success of a company partially depends on the customer service they offer, which can make customers spend more, give a positive review or even be a frequent customer to that business or organization. A company that values customer service spends more time and money training their employees on customer services or taking feedbacks on their services from the customers. At a tender age was taught the art of customer service by my uncle whom I worked for during the holidays at a retail shop. Learned that customer service involves attentively listening to customers, being patient with them also having a clear communication to avoid misunderstandings, among others lessons. Learning Discussions Throughout this discussion, we shall see the course objectives and discuss how I have demonstrated the knowledge of customer service. 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