How to Successfully Combine Extraction and Immediate Implant Placement

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Compression of treatment time in oral implantology is a concept that is gaining popularity. Management of the dento-gingival complex and development of adequate biologic width are critical components in achieving ideal functional and aesthetic outcomes. Today, we'll be discussing surgical and prosthetic strategies to enhance clinical outcomes in extraction, immediate implant placement, including the use of a final definitive titanium abutment. Our guest is Dr. Robert J. Miller, a board certified diplomat of the American Board of Oral Implantology. He is director of the Center for Advanced Aesthetic and Implant Dentistry in Delray Beach, Florida. and co-director of the Pacific Institute for Advanced Dental Education. He maintains a full-time practice dedicated to implant dentistry and revision surgery. He has an active international lecture schedule, as well as being engaged in biomaterial, laser, and dental implant research. Dr. Miller, it's a pleasure to have you on Dental Talk. Hi, Dr. Klein. Thanks for the invitation. Yeah, we're happy to have you here. So a lot has changed since the Brandenmark days, where many of us practiced the traditional two-stage method, right? Delaying the prosthetic loading by the typical six months after the implantation to allow proper osteointegration. And two, having that traditional eight-week delay between an extraction and an implantation. So for sure, we are in a different era now. So tell us how long you've been placing implants and what are some of the things you've learned along the way? Well, my journey in oral implantology started about 35 years ago. And it's, of course, started in the Branemark days. And as you just mentioned, there was a strict protocol that Dr. Branemark had set up for implants for both healing and for the prosthetics. But clinicians, and you know this as a clinician as well, were always looking to compress treatment time. And part of compression of treatment time means getting away from the... parochial attitude in implant dentistry, seeing what we can do to perhaps combine steps, seeing what we can do to change the biology of the site, and then load our implants more quickly. And all of our strategies from 35 years ago to today have been based on that paradigm, trying as much as possible to get the same clinical outcome, just doing it in less time. Yeah, it reminds me of when I was in grad endo at Penn. I did this sacrosanct thing of completing a root canal in one visit, and it was just unheard of. Vital teeth, and getting into just for a second on this, vital teeth, it was somewhat accepted, but even not looked upon in a great way, especially as a grad endo student. But a non-vital tooth is just heresy. We didn't have the means to sterilize the canals at that time, all in one visit. And the materials that we use to obturate and finish a case were different as well. So this was your quest as an endodontist. And this, of course, is my quest as an implantologist. There's some similarities there for sure. So what are some of the things we as clinicians should be aware of before combining extraction, immediate implant placement with the final abutment? First, be aware that extraction site defects do not have the same biology as a healed site. In a healed site, of course, after removal of a disease tooth, we're waiting for the pathology to heal, for the defect to heal, for the pathogen load to essentially disappear, be cleared by the body. When we have an extraction site, we have everything working against us. We have a contaminated site. We have a site that's going to have a different geometry than the implant that we're placing, meaning there's going to be a gap there. We have to be concerned about soft tissue going down inside, salivary contamination, food contamination, soft tissue. getting onto the implant surface and preventing integration of that portion. And then we go one step farther. And that is, if we're going to reconstruct or provisionalize an implant immediately, how do we do that and not have a failure? So there's a lot, there's many more considerations in extraction, immediate implant placement than there would ever be in allowing a site to heal and placing an implant and bury it either in a one stage or two stage procedure, but not loaded with any prosthesis whatsoever. So when you're talking about a socket that's pathologically involved from a diseased tooth that's been extracted, what are the determining factors for saying, okay, in this visit, we're going to load this with an implant immediately, even though we know that tissue is diseased, how do we make that decision to say, okay, it's ready to load? Well, first of all, you have to be able to get initial stability. Initial stability means that whether you're going to load it or not, whether you're going to immediately provisionalize it. or provisionalize it in function, especially if you're going to cross-arch stabilize something. Initial stability is critical. If you have a defect that's way too large and you're afraid that when you put the implant in, there's going to be some slight mobility or there will be mobility, that's not a site to place an implant. But if we have a site that's relatively intact with a five-walled or even sometimes four-walled defect and you have enough apical bone to place it in and you get that initial stability, then I don't... hesitate to do that. But there's two parts to extraction-mediated implant placement. The first one is decontamination, which means that once that tooth is removed, have you removed all the apical pathology? If there's an apical granuloma, you must remove it completely. Otherwise, you get something called a retrograde peri -implantitis. You must remove all remnants of the periodontal ligament because bone will not adhere across soft tissue. It only grows from bone to the implant site. Next, you have to worry about how you're going to protect the gap. And in most cases, virtually in all cases, I'm going to be grafting with something. either a bone graft material or even something like PRF, a fibrin membrane that I use from the patient's blood. Only then, if I can determine I can get initial stability and deal with the extraction site defect, that gap, then I'll consider provisionalizing it. The provisionalization might be a temporary abutment with a temporary crown. It might be a final definitive abutment with a temporary crown. So there's all different possibilities here, but it's based on the site. It's based on how it's going to be used. It's based on how much healing time you're going to have, whether it's a single tooth, whether it's multiple teeth or cross-arch full-arch stabilization. So a lot of factors there. Is this a job for a GP that likes doing implants? All these decisions that have to be made on the spot, is this more for an oral surgeon or a periodontist who does many more of these complex cases? Well, the word is complexity. And what I say to the general practitioners when they're contemplating getting involved in the implant world is select your cases carefully. Start with easier cases. Start with single-tooth cases. Start with single-tooth cases in sites that are already healed. And then as you feel more comfortable and you gain the surgical and the prosthetic skills to successfully complete those cases. Then you get the training to go to more complex cases, more complex single tooth cases, then quadrant cases, and then ultimately the full arch cases. And in my practice for 35 years, 50% or greater of my practice is revision surgery. So I get all the failures and the failing cases of either recently completed implant cases or implant cases that were completed. a decade two decades or three decades earlier and are now failing so that that requires a different set of skills and a different experience work experience to be able to do those comfortably, but start with easier cases, things that have a high degree of predictability. And when you get your confidence that you're going to be able to complete those cases, then go on in terms of complexity. As far as the failures that you've seen coming back to you, you mentioned revision surgery. How much of that is retrograde implantitis? Do you see a lot of that? You don't see a lot of retrograde peri-implantitis, but you see it often enough. to understand that if you're going to be placing an implant in an extraction site, all apical disease must be removed. And you can remove that with surgical curates, round burrs. My favorite device happens to be a laser, especially in very, very deep defects and defects that have sort of a balloon anatomy at the end. They're wider than the osteotomy itself. And it's very difficult to get into those areas with a surgical curette, with a spoon excavator. So when I use a laser that has perhaps a radially firing or side firing tip, I can clear that tissue easily and definitively before I place my implant. But all apical disease must be removed. Or instead of getting the crustal peri-implantitis, you actually get the disease process starting in the apex and then moving coronally. Is that something that would cause an early failure? if that wasn't cleaned out properly? Well, when you say early, early to me might mean within the first six months. Absolutely. It would certainly contribute to that because that's where you lose your initial stability. Right. That's not going to happen once the implant is in there for five years and then you see the case as a failure. You're not going to think it's a retrograde peri -implantitis because that would have happened already, most likely. Absolutely. Retrograde peri -implantitis is going to happen immediately. Putting your apex of your implant through disease, it's going to start the process immediately. Crestal problems, crestal peri-implantitis, that can occur at any time after that. It can occur 10, 15, 20 years or longer after that because of changes in what we call the dento-gingival complex. The hermetic seal, that seal of the soft tissue around the neck of the implant, once that starts to degrade. Because of inflammation, bacterial buildup, plaque, calculus, debris, that's when you start to see the crustal changes. But you have to be able to recognize that as well and treat that early in the process. So there's no question, you know, the trend of implants, it's a different ballgame than it was five years ago, 10 years ago, 15 years ago. And there are a lot of companies making implants. You can get them from dental distributors now. You can get them from China. How does a dentist... between implant systems, because they all claim to be good, and some are certainly less expensive than others. What's the discerning factor here, and what do you recommend? Well, let me begin by giving you some statistics. There are literally thousands of implant companies around the world, and the vast majority of them are small jobbers, people with a CNC machine in a garage somewhere turning titanium bars. Those are the best ones. Those are the ones I want to buy. I'm only kidding. And they're the least expensive as well. So if you're looking to save money, that would be the point to go. But if you're a certain clinician as I am, especially after doing this for 35 years, and having used more than 20 implant systems in my practice, there are distinct things that I'm looking for in an implant system. When I started with my first implant system 35 years ago, I was just looking to get one of the few that were available that my colleagues were using. And to be within the group, I had to use what everybody else was using. And that was my decision-making factor. Today, however, the implant systems have become very sophisticated because everyone learns from everyone else and everyone's trying to build a better mousetrap. So when someone comes out with a better surface, everyone's driven to make a better surface. We had problems with abutment connections in the past. Everyone came up with a better implant abutment connection. So it's a give and a take between the major players. But each one trying to create a better mousetrap, each one trying to get better features so that the discerning clinician will go out and say, you know what, this is the implant I'm going to use right now because it meets the requirements that I have for my clinical outcomes. And there's only a few in my mind that do that. Yeah, could you give us some examples? Our audience always likes to hear what the KLOs are using. If you want to go back in my history, I mean, I've used virtually every one of the major systems. And in their time, they were great. because they were better than the system I was using previously. There's a particular implant system that I use today. It's called DITRON. That is my 21st system that I brought into my practice. So, you know, every, on average, every couple of years, I added a new implant system to my practice. I didn't do it on purpose. I didn't have any idea, any inkling that I was going to go that route. But I kept looking at it and saying, My clinical outcomes are good, but I could do better than this. And when an implant system comes out with this feature, I'm going to buy it. Well, I did that 21 times. That's unbelievable. I mean, hopefully by the time this podcast gets published, you won't be using something different than Dytron implants. I'm looking at my clinical outcomes right now, and I've really not been able to get the kind of clinical outcomes that I'm getting right now with this particular system, which is amazing to me. I never expected it. And when some people from the industry came to me and said, Robert, I know that, you know, you're head of a department, you teach, you lecture. I would like you to try this system and tell me what you think. And, you know, when a new system comes out and I look at it and it seems reasonable in terms of design and features and other, you know, previous clinicians' outcomes, I'll go ahead and I'll place it in my implants and I'll give them my feedback. I was more than pleasantly surprised. When I started looking at things, I was able to load my implants faster. I was not getting crestal bone loss as I was with some of the previous systems. In some cases, I went to my final definitive titanium abutment rather than a peak provisional abutment and prepared it intra-orally. And I'm getting some pretty exquisite results right now. Yeah. And I do want to say to the audience, you have a webinar coming up on Viva Learning on September 1st, 7 p.m. Eastern time. And I think you will be talking about that titanium abutment process. It's titled Combining Extraction Immediate Implant Placement with a Final Titanium Abutment. So we're looking forward to that, Dr. Miller. So let me ask you this before you go further on about DITRON, because I want to hear some of the attributes of DITRON that you actually think. make a difference compared to other systems. For most doctors, do you think one implant system versus another, and we're talking about the high quality ones, is that really going to make a major difference in their success, their predictable success down the road compared to the value of the actual clinical technique and also the diagnostic expertise that you bring to the table? Because you're so advanced in implants, maybe an implant system could give you a little bit of an edge, like a professional baseball player. using a bat that's a little bit better. For most of us, it doesn't matter what bat we use, right? We're still going to swing and miss these pitches. Or a set of golf clubs. Yeah, or a set of golf clubs or a tennis racket. So my question is for the guy out there or woman out there that's going out there to do implants, you know, 99.9% of them, and I'm not trying to patronize you, they're not as good as you. You've been doing this, you know, you're a board certified diplomat and you're educator KOL and you've done it all. are they getting an edge using for instance you're talking about DITRON does that give them an edge? It gives you an edge in in one particular way and that is if you're if you're early in the process of your training it's a much easier system to use it's a linear system you basically you look at their drill kit and the drill kit is linear you don't have to worry about multiple drills for different sizes different shaped implants it's a very simple drill kit to use you just Pick the drill series down to the color-coded drill that you need for your final implant size, and you are done. Second, all the abutment connections are the same. So you don't have to worry about multiple abutment sizes. So you keep a very simple inventory. These are big things. And this is actually the trend in dentistry as a whole, reducing kits that are direct composites that have 25 shades in it. Now there's only one shade. Yeah, there's just a huge amount of R&D from the intellectual property side of manufacturing today in dentistry. The goal is to reduce inventory, reduce the number of products, reduce cross-infection between handling these products, reduce the amount of stuff that goes on a tray. So this does go along with that concept, which is good to hear. That's a case in point. And for me, I really don't care. I'm used to complexity. But you know what? At this point, 35 years later, I like simple. You know, I don't have to go searching through a drill kit or searching through my inventory and realize that I was short one abutment because I didn't remember to purchase that size. I was out of that size last time. I forgot to reorder. But it's a joy to be able to just reach into my little box, my toolbox, and say, I need an abutment. It doesn't matter what size implant I placed. All the abutments fit into every implant that they have. Yeah, that's a major, major advantage. The simplicity of the way you're describing this system is excellent, not only for someone who's been doing it for 35 years, that's looking for simplicity, not only in dentistry, but in their whole life, everything you do, but also for the newcomer. You don't want something more complex than you need to have as an entry-level surgeon or GP who's doing this. So yeah, that's a very good point. That's speaking just to the entry level. That's to make people more comfortable in bringing on a system into your practice. But it's more important than that. And that is that the precision of their abutment devices are just awesome. Dytron manufactures for companies like Mercedes-Benz and automotive and aeronautics. Their tolerances have to be exacting within three microns. that those tolerances to implantology. So your abutment to implant connection is extraordinarily secure. I have not had an abutment come loose. It goes in firmly. And that's why I'm not afraid now to put a final definitive abutment on an immediately placed implant because I know it's not going to loosen. I'm not going to have a problem. And I can prepare it down to where the tissue's healed after final healing. And it's going to be very, very stable. I love that. Pleasure working. company that respects the precision manufacturing techniques. They do this for aircraft and for automotive, and they don't lose anything in the translation when they come to oral implantology. They want to manufacture the highest quality precision devices for oral implantology as they do for everything else, and I respect that. I like that. Yeah, well said, well said. So, you know, there's no question there's always a better mousetrap out there. We have heard great things about DITRON. For those who are interested, you could Google DITRON Dental, D-I -T-R-O-N, Dental, and that's the name of the company. And you can get more information about that and appreciate everything you've shared with us, Dr. Miller, today. Have a great night. Thank you very much for your input. Thank you very much.