Oral Surgery Simplified with Piezo Technology

You're listening to the Phil Klein Dental Podcast The advantage of piezo surgery is multifaceted. It's ideal for minimizing patient discomfort following virtually all oral surgery procedures. In many cases, it obviates the need to create a surgical flap. It helps protect adjacent teeth and restorations, especially veneers and ceramics during extraction procedures. It offers precise cutting of hard tissue while precluding injury to soft tissue. It also produces negligible heat, which is critical in maintaining vitality of adjacent tissue. And these are just a few of the benefits of using piezo technology in oral surgery and periodontics. To tell us more about this is our guest, Dr. Todd Engel. Dr. Engel has extensive experience in dental implants, CT-guided surgical design, complex treatment planning, as well as full mouth rehabilitation. Dr. Engel established the Engel Institute, located in Charlotte, North Carolina, which focuses on live patient education with topics ranging from implant placement, grafting, and full-arch conversion surgery. The Institute's implant courses have been taught across the U.S., and its alumni consist of over 12,000 dental professionals. Dr. Engel, it's a pleasure to have you on the show. Well, thank you, Phil. It is a delight to be here and be your guest. Yeah, so we're going to be talking about... piezo surgery and piezo instruments that are really designed to bring an atraumatic experience to the surgical site and also to the patient postoperatively, which is really important. So to begin, if you could tell us a little background briefly in a minute or so about the evolution of piezo technology and how it's replaced in many ways the typical rotary methodology that was used for osteosurgery. Absolutely. So when we generally talk about piezo, I guess it's important to know that it's somewhat newer technology, Phil, in that it started actually in dentistry not too long ago. It was mid-80s, late 80s. And it was developed by an Italian team that was looking at the general piezo approach, looking at how can we implement a way in surgery. to be less obtrusive to teeth vessels, to vasculature, to membranes, and be more comfortable for the patient. And lo and behold, they did. And basically, if we were just to do just a plain Jane kind of comparison, whereas you have rotary that gets in there dark, deep and dirty and just starts cutting like we're used to as dentists on teeth, and it cuts anything in its way. And sometimes that's efficient. Sometimes that's fast. sometimes economically would make more sense. When we looked at, as you know, in our field, when they looked at ways to help improve not only the patient experience, but also improve the surgical outcome, what they came up with was essentially surgical vibration. So instead of cutting everything in its way, getting in a tractor and just running through anything that's in front of you, what they did was they designed a vibration technique, whereas it would create this vibration. So things that didn't intend to be cut, like a membrane or a nerve or something of that nature, could essentially have the chance to bounce off of this vibration. To bring it home, if you ever go to a dental meeting or you visit a dental trade booth where they have piezo technology, lots of times they'll have something like an egg and it will show you how it will cut through the shell, but typically not affect the membrane. So cut the things that stay in your way, bounce on the things that could be bounced upon to move out of your way. The surgical benefits are just amazing with this type of technology. And I can't imagine how you even did. osteosurgery before this, before the advent of piezo surgery, especially you have your Engel Institute. You mentioned to me offline, you have 17,000 alum that have gone through your program. I guess all your cases, you use piezo surgery. Talk about how it's transformed the way you practice and how you explain the benefits to the patient and how that's also been a big factor in your entire growth of your practice. Yeah, it's a great question and one that I love. In this day and age, not only do we all want to improve on how our work is done and our results as artists, but I think one of the things about dentistry is the ongoing myth about patients hating to go to the dentist and why. I think now, with the minds and the powers that be behind the growing technology in our field, we have the ability to really give a patient a truly comfortable experience. We really do. And my practice is focused a lot on full arch, and I see things done today, even in my hands, that postoperatively are way more comfortable than an approach 15 or 20, 30 years ago in an ulterior method. So I use it to communicate with my patients, and I like to reduce their fears, and albeit I can't make the pain completely go away, we can really significantly minimize that. And we get into some of the things on the benefits of the actual surgical approach itself. But I think for me, post-op, post-op inflammation, post-op pain, time, time, heating up structures like bone, this all kind of produces ultimately a greater experience. And the patient doesn't know this until they're in it, right? And so explaining things, the befores and the nows and what they should expect. keyword expectations when they're done really has supported a lot of what I do in my communication. Post-operative discomfort is not a good thing for patients as far as word of mouth. And of course, I'm sure this communication you have with your patients on the front end of your surgeries certainly increases case acceptance by saying that you're using technology that is designed really to make them more comfortable post-operatively. So let's talk about your chair time and how you schedule your surgical day. How has piezo surgery affected that? Yeah. So I think, you know, piezo has the ability to make, you know, any procedure smooth, but then there's the operator as well, right? So we all approach things differently, have different opinions on how things should be done, et cetera, as well as technology. And I think for me in my hands, 100% with piezo, in my case, the cube from Action, is far less hiccups, breaking of roots, tearing of tissue. In most cases, I don't even need to create a flap because the way that this is designed to enter between bone and tooth with these slim little tips, it allows you to remove ankylosed endo teeth broken off the gum line without a flap. When my team knows that there's an extraction or something like this schedule, they absolutely put the technology right behind me because they know it will only help me. So it sounds like to me there's a huge savings of chairside time in your schedule compared to conventional methods. Well, I can tell you on average, anything that I had done before that I do now with Piezo, the time is significantly decreased. For instance, you just take a simple extraction. Okay, let's say your favorite extraction, we'll call it a tooth broken at the gum line that maybe is ankylosed and previously endo, right? You can actually remove these teeth frequently without any complications. been elevating a flap in a lot of cases. So you take a patient who's petrified about the opening up and the digging and the noises and the cutting and all that, and you tell the patient on the day of meeting, hey, you know what? We probably won't even need to cut you open or give you sutures with this because the piezo tip that comes with my unit allows me to get between the tooth and the bone in the PDL space, negating the flap in many cases. But the time, And the consistency of complete extraction is quite high. So what about the heat that's produced from the ultrasonic vibration at the tip compared to conventional rotary methods? It's actually feel almost negligible. If you were to run this technology, at least the one that I have, and you just shut the water, your fingers wouldn't even really... burn if you touch the end of it. The key is to add a lot of water. That's one of the keys of piezo. So you don't increase temp and burn. Yeah, great point. So it seems pretty evident that piezo technology is a real boost to productivity in the practice. Well, this is multifold. You know, if you took an average molar, and let's just say, you know, in anyone's hands, three out of 10 cases, you have some type of root fracture. This is a 20 to 30 minute deal. um with with my instrument i'm talking about on average these teeth come out routinely in less than 10 minutes but you hit on something very important and that was heat and we know that you know bone death is very traumatic for anything that you're going to do right a bone graft or an implant etc so if we can keep temperature down and keep all the cells vital this will really significantly plays a part in the discomfort or the lack of it, as well as the prognosis of the future graft or implant. In the old days in dental school, they taught us to compress the buckle plate after an extraction. And I guess that was an anticipation of a denture or an abutment and they wanted to push the buckle plate in. But today we know how important that buckle plate is to the prognosis down the road. So tell us how piezo technology helps preserve that buckle plate. Yeah, it's good. So now, I would say that pushing into the buckle plate is somewhat older thinking. We know, to me, that buckle plate is the most important plate, to be honest with you, because it's typically the thinnest, therefore the weakest, yeah? And so you want to leave that as is, and anything that's going to go inside is the nutritious part of things that supports the implant. The buckle plate is there to protect. the graft and or implant. As far as what it does to the buccal plate, when I use the cube and I talk in my courses and my extraction courses, my grafting courses, and I talk about piezo and using this instrument for all extractions, I tell them to avoid the buccal plate. I tell them to start mesial and distal. Let's see if we can get a little mobility and roll the thing out. If you can't, then what I would prefer you do is go lingual cautiously or go palatal. cautiously with the slope of the ridge and again try to kind of move the tooth to get it out that way versus going buckle because the buckle wall is very thin as we know it resorbs to just what we need to masticate no more and we don't want to penetrate that so yeah phil you're right about all of that the buckle plate is key easiest one to break therefore to me the most important one to maintain. And with these tips, even if you have a full complement of teeth, you can get in between teeth quite well mesial distal to get this thing to a two plus mobility. Do you think piezo technology has been the greatest game changer and breakthrough in oral surgery procedures regarding atraumatic extractions? And also, what about the adjacent teeth, crowns and veneers? Because those also were often damaged from the days of the past where we had to muscle some of these teeth out where we didn't have the benefit of the piezo technology. You know, I would say one of the most deleterious effects of all of this is breaking teeth that you didn't intend to break, right? And this comes with luxation, right? When you lean on other teeth or push against other teeth. And nowadays, there's a lot of... that are going away from all metals. They're going to Zirconian or Porcelain or, you know, Emax in the anterior, what have it. And these are gorgeous, beautiful, you know, restorations that are not designed to be leaned upon. And so one of the keys here is that the technology does allow you to get mobility, mobility, excuse me, and accomplish that quite well. I've been doing it for many years. um without touching adjacent teeth i do not touch anything that's not natural when i have to rotate um so you would ask the beginning is this like the greatest you know kind of invention or in some form of way you know and i look at it like almost like cruise control in the car right you're going long distance then cruise control is the greatest thing that's come to man right but do we use it can we drive without it right um i would say for what it does Piezo is the best growth under that platform of surgical dentistry. And I employ it. I love it. I use it. I teach it. I have great results and I have really happy patients. So in the back end of this podcast, I wanted to ask you a personal question about your voyage, your journey as a GP, becoming a really sought after educator. You have a successful learning institute, Angle Institute, where you train thousands of dentists. that come from all around the country, and they probably come from out of the country as well, to learn the tricks of the trade of oral surgery. You're not an oral surgeon, but you've really ascended to great heights, both as a practitioner and as an educator, and you focus primarily on oral surgery. Tell us about that journey. So, you know, it's a great question, and I thank you. It's been an incredible, magical run for me. I've always stayed true to my love of what I do, and I've always stayed true to my goal. And when I first started out, I did anything that I was trained to do that would put food on my plate for myself and for my family. But like I teach and I tell the doctors who come from all over the world, yes, and thank you for that. Just even though you might have to subsidize now with stuff that you don't love. Find out what it is that you do love and point the arrow in that direction and challenge yourself to go there. So for me, no, I don't work on teeth. I haven't worked on teeth for over 10 years. And it was just that. It was having a goal in mind of what I love to do and what I felt that I excelled at. And I'm there now. And I've thankfully, Phil, just found my niche, found my love. I love it so much that I just focus on my signature, on all my cases, making sure whoever I'm treating that I do the very, very best I can. And I employ that in all my classes. And I try to go back to the early days of whatever it is that you're teaching. And, you know, it's kind of like this, treat the patient, fix the mouth. And as long as you treat the patient and engineer the mouth. versus engineering the patient, and you work on what you do and you love what you do, you'll want to be better at it. I've loved my career. I love surgery. I've worked really long and hard on training myself. And I deliver the education for what I call Monday morning dentistry to my comrades. What do you think the level of expertise is? among GPs in general that come to your institute? Because I'm curious to know what they're learning in dental school. They come out as far as oral surgery goes and preparation for implants. Where do you think they're at before they actually, I mean, you know, it's kind of self-selective because they're coming to you because they want to get better. So it's a tough question, but it'd be interesting to hear where GPs are when they come to your institute. Well, I would say this in all fairness to anyone who may listen to this. If I have a dinner and I have three oral surgeons and three periodontists and three GPs all watching me right now answer this question, being truly fair, okay, I would say this. Most general dentists are not prepared for a life of surgery coming out of school, okay? Now, on the same note, I would say at the dinner table, All of them are capable of learning. And what I would say is, hey, GPs, the one thing that the surgeons have above you is the intellect of what they've learned in the four to six years that you did not go through. You cannot come out of dental school, put a blade in your hand when you barely understand anatomy and start cutting in people. Yeah, you can learn on YouTube and you could take, you know, online four hour courses and all that. You know, I'm not just saying come to me. I'm saying in order to have a command of the language, like Farsi or Korean or Hebrew or whatever it is that anyone speaks, it didn't happen in a weekend. It happened over a long period of time. And that's the same true here. And I'll end it with this, Phil. I'm a general dentist. I had to come out of school when I was done because I had a family to take care of. My love and my path would have been Oral Max simply because of my love for it. But I will say this. I worked really long. I worked really hard. I dedicated myself to it. And I am now a general dentist who I think performs surgery and performs it well. But I knew how to grow. And I knew what I should not do. And I knew the temple of growing. And I taught myself that. And if someone understands the temple of growing and how to grow and have small complications, that's okay. Because that's how we learn. Without shooting for the gusto on your third or fourth case, you should be fine. And there's plenty to go around. But I do understand the surgical arena's position when they say, what are these guys doing? Because this is a high-level procedure when you start flapping people open cheek to cheek and start tossing in titanium. I mean, this is a different world. And the doctor has to be compassionate enough, respectful enough, knowledgeable enough to handle not only the procedure, but any complication that may come. So I would say this in closing, learn, fly, be free, enjoy your journey, but be smart about how fast it comes to you. Very well said. Very well said. I'm glad I asked that question, Dr. Engel. Appreciate your time. Very insightful. If anybody wants more information from Dr. Engel, you can Google him. E-N-G-E-L is his last name, Todd Engel, and you'll find information on the Engel Institute. You could also follow him on Instagram at Todd Engel DDS. Thank you very much, Dr. Engel. We look forward to having you on future programs. Phil, it's been my pleasure. Congrats on all of your success. Thank you and Viva Learning for continuing to educate all the guys and girls out there like me. I hope you have a wonderful holiday. Yeah, you too. Thank you. If you're enjoying this podcast, please leave a review or follow us on your favorite podcast platform. It's a great way to support our program and spread the word to others. Thanks so much for listening. See you in the next episode.