Dental Implant Interview Two

Dr. Eberts: What do you think may be completely misunderstood (even criminally misunderstood) related to dental implants? For example, we were just talking about the titanium issue. Is there anything else that might be misunderstood by the general public or even the general dentist?

Dr. Sambataro: Well I think certainly the bio-compatibility issue. Too, what we would call criminal or unethical, placing implants into jaw bones that are not healthy. Not doing the proper pre-treatment, pre-evaluation and assessment to see if this patient really is a candidate.

So I think there is probably a lot of implants that are been placed on people when the jaw bone is not healthy, but they are going to be able to produce some income from it.

Two would be the over abundance of implants being placed. I think that is going to be a concern and maybe another factor we may see coming up in the future.

Not using the technology that is available today through something called a guided surgical stent. You can create with a 3D x-ray a guided surgical stent that will show you exactly, three dimensionally where the implant should be placed.

I have looked at some of the things that can happen with implants, and you start seeing all sorts of things. Just for example, if you are going to place two implants next to each other, ideally you would want to have them parallel. And I have seen x-ray after x-ray where they are crooked.

That is almost criminal because it is not providing the best service for the patient. It is not going to allow the implant to be loaded properly due to the force of the closure or the bite is not parallel. Plus you have two implants that are not parallel and trying to put crowns on there is almost impossible. There is no draw so you have got to shave the crowns down.

Which is another thing to consider - why would you go to a surgeon versus a general dentist? One, going to a general dentist you are keeping it in the same office and the general dentist is the one who restores the implant. So, they are the ones who are putting the crowns on there. That general dentist is going to be a lot more aware of what has to happen in terms of restoring the implant. The surgeon never restores the implant. This is not to bad mouth surgeons but when you are not doing the final piece of it, you are not going to be as concerned about the placement of that implant.

Dr. Eberts: Because you will have to deal with your own mistakes then, if you do make a mistake you have to rectify it. Whereas, if the surgeon makes a mistake, he or she does not.

Dr. Sambataro: It is sort of like a carpenter. The one who does the finish work versus the one that puts the studs in. The guy that has to come back and finish goes “well the wall is out of balance. I cannot really make this look even.” So they do it by shimming this or shimming that so they make it look aesthetically okay, so that is an issue. The other thing is that not using technology like the 3D Cone Beam. There are some anatomical issues with placing implants. If you are not using the 3D Cone Beam you could place an implant into the sinus.

Dr. Eberts: Tell me about that. What is the 3D Cone Beam?

Dr. Sambataro: It is a CAT Scan that is becoming common technology in the dental office. So in a typical x-ray you are taking a two dimensional picture. With the 3D Cone Beam we can see height, width, length...

Dr. Eberts: So it is three dimensional...

Dr. Sambataro: It is three dimensional. You can actually move the image. For example, if you are looking at the placement of an implant near a nerve, in the two dimensional picture you do not know is that implant going to be in front of the nerve, in the nerve, behind the nerve?

You would want to know that ahead of time. Same thing with the sinus. If you are not using that technology, that would be almost criminal. You are doing this procedure that requires a lot of training and you are not using the technology that is available. Why wouldn't you?

And the patient is the one who is going to suffer from it, and if you take an implant and place it into a nerve that is potentially going to cause parathesia. If it is in the sinus it could create an ongoing infection. There are a number of things that can happen that cause implants to fail. In today's dental world with modern technology, that should not happen.

Dr. Eberts: It should not happen. In other words these are potential mistakes that can be avoided?

Dr. Sambataro: Yes

Dr. Eberts: With the right training and the right equipment?

Dr. Sambataro: Yes, I mean there are surgeons out there that still say “we can eye ball it.” They actually use that term “we can eye ball it.” That would be like an engineer building a building without ...

Dr. Eberts: I am going to put this bridge up and eye ball it...Looks level.

Dr. Sambataro: If you did not have that technology it would be different, but it is available why wouldn't you use it?

Dr. Eberts: So what are some of the coolest things you have recently discovered that you are looking into as far as dental implants are concerned?

Dr. Sambataro: Well I think the most exciting thing is the zirconia, which is bio-compatible. Another interesting thing is that, with the titanium you had to place the implant and then you had to bury it under the gum tissue and allow it to heal. With the zirconia because the gum tissue reacts so favourably, you can take the tooth out put the implant in the same day, suture the gum tissue around it, and then it heals beautifully.

Dr. Eberts: So you really could have a same day surgery?

Dr. Sambataro: Absolutely

Dr. Eberts: Now that is certainly not the case if you have a missing tooth? It is only when you have an extraction that you then can...

Dr. Sambataro: Well even if you already had the missing tooth, traditionally what would happen is you would go in and flap the gum back, drill a hole, put the implant in and put the gum back. Wait three months, come back and then do the rest of the implant.

Dr. Eberts: How is that different now with the zirconia?

Dr. Sambataro: There is a two piece implant and a one piece implant. The two piece implant is all titanium. They plant the implant then they come back after three months, put a post in the implant. Zirconia is a one piece implant and the post is already done. So you can actually put a temporary crown on there.

You are still going to want to wait for the bone to integrate. With zirconia that happens more rapidly because the body integrates better with the ceramic than it does the titanium. So everything is much faster.

I think that has been one of the reasons why people do not move forward with implants. Because, one scenario would be I get an extraction today. I am going to come back for several follow-up appointments. At three months we will evaluate whether you are ready for an implant, but it could be actually six months. Say it is six months, we put the implant in at six months, and then we have to wait another three months or six months for that implant to heal. Then we uncover that implant, then we put the post in there, then we send that impression off to make a crown. You come back three or four weeks later, we put the crown. The whole process from start to finish could be a year.

Now you can have an implant placed immediately. Now you cannot load it (bite on it). Some of the research shows an immediate loading of these implants is okay. However, I am just not comfortable with it as yet, so I want to see the thing integrate and then you can load it.

Dr. Eberts: Sure, better to err on the side of caution.

Dr. Sambataro: Especially if you are taking about the front tooth. What I hear quite often, especially when we are taking about root canals (we really do not recommend root canals). One of the things I am seeing is that people are hesitant to remove a root canal if it is a front tooth. A lot of them will say that if the root canal was a back tooth, they would be in here tomorrow to take it out. So they know the dangers of the root canal, but they do not want to go without their front tooth.

Dr. Eberts: That is understandable I guess.

Dr. Sambataro: I don’t think I would. But what if I said to you the day we take your tooth out you will walk out with a new tooth. And I am not taking something that flips in and out ...

Dr. Eberts: A permanent tooth

Dr. Sambataro: A permanent tooth, the only thing you would have to come back in several months and we will put a permanent crown on there. Aesthetically no-one is going to know. It is no different than if we did a crown on it, you would have a temporary crown. So that sounds more favourable. I think that is going to be a big plus that you really could not do with the titanium. The other big thing zirconia is what colour?

Dr. Eberts: White

Dr. Sambataro: And titanium is?

Dr. Eberts: Grey

Dr. Sambataro: So even if you got a little bit of recession or something around the zirconia implant, aesthetically it is going to be better. That is the other problem I see with these titanium implants - a lot of the time you will get recession around them.

Dr. Eberts: Recession is the gum pulling...

Dr. Sambataro: The gum pulls away and then you see this big metal titanium. So even if it did recede with the zirconia, aesthetically it is still going to look better. But we are finding from the research I have seen, you do not get a type of recession because of the body's favourable acceptance of the zirconia over the titanium.