Perspectives on Modern Implant Dentistry
The Roundtable is a new forum for debate on key topics, trends, and techniques in dentistry. Every other month, a panel of experts will take on a subject to help expand your knowledge and boost your practice. This month, our panel discusses all things implant dentistry, a selection of which is presented here.
Watch the whole conversation at insidedentistry.net/roundtable.
About Our Panel
John C. Minichetti, DMD, is the immediate past president of the AAID, a diplomate of the ABOI, and a general dentist practicing in Englewood, New Jersey.
Sanda Moldovan, DDS, MS, CNS, is a periodontist and nutritionist and a member of the Inside Dentistry Editorial Advisory Board. She is in private practice in Beverly Hills, California.
Isaac Tawil, DDS, is a general dentist and a diplomate of the IADI, fellow of ICOI, and a member of the AO, ADA, and AAID. He is in private practice in Brooklyn, New York.
INSIDE DENTISTRY (ID): What are the advantages and/or disadvantages to immediate load of implants versus the more traditional delayed load?
Dr. John Minichetti: Let’s start with immediate load, immediate placement. This became very popular about a decade ago, and some of the literature that first came out showed that these procedures had equal success rates and really no advantages or disadvantages esthetically.
But I think what we see now reported in the literature is that some procedures actually may have more complications when we are factoring in what type of immediate-load case it is—is it a single tooth that may have a lot of pressure with the deep bite versus a whole arch splinting case? So, I think those cases, although warranted, need to be carefully selected. As I talk to my students throughout the country when I lecture, I also tell them that it is based upon the doctor’s experience, because those with less experience should not tackle these types of cases.
Dr. Isaac Tawil: I would like to add, though, that there have been some amazing advancements in technology over the past 5 to 10 years that can give us more of an effective way of determining whether or not we should be loading these implants. I think case selection is paramount. Without proper case selection, we cannot go forward. When we are comparing cross-arch splinting as opposed to a single tooth, we know we can get away with a little bit more. But having devices that give us some sort of feedback mechanism so that we can then compare it and see when our implants are ready—that, I think, is the determining factor now, along with advancements in new dental technology. The implants have certainly changed, and the platform switching has changed. So, having that immediate implant when it is in the right situation can actually provide a very positive soft tissue foundation for our future implant restorations.
ID: Dr. Moldovan, from a periodontist’s perspective, what are your thoughts?
Dr. Sanda Moldovan: I could not agree with both of you more, and I think for those of you out there who are not doing immediate load, you should be, because it really is the way of the future, and that is what our patients want. Let’s face it—everybody wants immediate results, but one big problem that I see out there is cement versus screw-retained. We run into problems in getting that cement subgingivally, so that tissue is going to have inflammatory response. I highly encourage going toward screw-retained more than cement. If you can get rid of it completely, that would be ideal from a periodontal standpoint.
Minichetti: I can give you my opinion on cement and its advantages and disadvantages. Certainly, if you are doing immediate load on a full upper case where you are reducing the bone, you have a flap with access for clean up, so it is a total different story. I think what Dr. Moldovan is referring to are the closed-flap cases such as a single-tooth implant restoration, in which the doctor just placed the crown and it compresses this cement in that area—it is now becoming a problematic situation for a lot of doctors.
Tawil: I think that cement is a huge problem. In advanced cases, we are actually able to provide zirconia abutments the same day, and when we can do that, we are actually able to keep on margins either at the gingival crest or even in a lot of cases supragingivally. If we can keep them supragingivally, then we have access to clean that cement. I think the biggest problem is when we have dentists who are sinking the implants very, very deep because they are afraid of future bone loss, and then they go ahead and cement in those type of cases, and that is when they end up in Dr. Moldovan’s office, and they have inflammatory response. Usually at that point, we have done a lot of damage.
Moldovan: Yes, my prediction is that peri-implantitis is going to be on the rise in the years to come. As a teacher of general dentists who place implants at UCLA, I see more and more dentists doing dental implants, and what is happening is some of them just take a weekend course, and that is when we run into problems. I do not believe that a weekend course is good enough to teach cementable versus screw-retained, and Dr. Minichetti, unfortunately, I do not see it just around single implants. I am starting to see full-arch cemented restoration. I do not know how that happened.
Minichetti: Oh, as far as the courses—absolutely. My opinion is this is a really involved specialty. This is a multi-specialty. This is the whole topic of those qualified general dentists who have a great background in order to do this and have they been tested on that background. It is something I have been passionate about over the past 20 years. Even some of the specialists may not have all of the nuances from a periodontal prosthetics standpoint that you need to have. We have endodontists who are taking our courses and I am proud that some of them have sought the American Academy of Implant Dentistry for a MaxiCourse for 300 hours of continued education because they are specialists. They are not just going to take this course on the weekend without having restorative background or without having proper surgical background. This is a long-term commitment, and I think that it is quite important that we talk about public safety and also realistically successful treatment.
ID: Dr. Moldovan, in your practice as a periodontist, you are not restoring the implants, so you are using a team approach. Can you explain this approach and why you chose to build your practice in this manner?
Moldovan: So, the way I built my practice is really working as a group practice where I do the foundation or the building blocks for surgical approach, and then I have two restorative dentists working with me and under the same roof so we can do a lot of the immediate-load cases. I think it is critically important that in the future we will see more of this model, where we have multiple specialties working under the same roof. It is so important as you said earlier about specialists, especially surgical specialists learning restorative. They have to already picture the final result, as it is going to be before they even start cutting into a patient or cutting a flap or opening a flap. In Europe, we are already seeing this. They have this multi-specialty approach in their practices. The United States has been a little bit slower in adapting that, but I do that see that more and more happening, especially in California. Even myself as a specialist now, I still take courses from different practitioners who may be doing things differently to constantly learn and improving my skills, and I have been in practice now for over 10 years. So, I think what you are saying is right, continue to build up upon that base that we got in the beginning.
Minichetti: Well, I really think that the field is still growing, and like Sanda said, you’ve got to keep up on education constantly. If not, you will just fall behind, but I think some of the future is really in regenerative protocols. We see some new response coming out with bone graft, allograft, soft tissue. I think that is really where the future is—biomaterials and regenerative materials.
Tawil: I have to agree with Dr. Minichetti. Every day, across my desk, I see something remarkable. In the last year or so, I have been grinding up teeth and using that for a bone graft. There are remarkable things that are changing. I think we are really on the cusp of technology. We are kind of on the start of the incline of technology. We think that we have hit it, but we really have not. We have all this data, all this technology, and we are just starting to get used to it, and implementing in our practices. We see it everywhere around us but not everyone has implemented it just yet. The research is incredible partly because of the companies that are out there trying to find the next great thing, and it is out there. We should see even more innovation in the next 10 years, probably three times the amount that we have seen in just the past 5 years.