Transcript

Speaker: Whether you are in training, in practice or in research, the Journal of Periodontology and Clinical Advances in Periodontics have something new for you. Hello everyone, I'm Dr. Effio Anidou and I'm the Editor-in-Chief of the Journal of Periodontology and Clinical Advances in Periodontics.

Speaker: Tune with our team to Probing Perio, the podcast that aims to discuss advances and innovation in periodontology and implantology.

Speaker: Hello everyone. I'm Flavia Pitti, a co-editor of the Clinical Advances in Periodontics. Welcome to a special series of Probing Perio. Today, we explore Lift with Precision, Microsurgical Application in Maxillary Sinus Elevation. from clinical advances in periodontics, special issue microsurgery in periodontology and implant therapy.

Speaker: These articles bring together international experts who examine how magnification, precision instrumentation, advanced imaging, and refined surgical techniques are transforming periodontal and implant care.

Speaker: From historical perspectives and educational frameworks to innovative regenerative procedures and complex implant management, this issue highlights both the science and artistry of microsurgical practice.

Speaker: Whether you are an experienced microsurgeon, a clinician considering magnification-enhanced techniques, or a student seeking to understand the future of periodontal implant therapy, this collection offers valuable insights and practical guidance. So before we start, I'll have our guests introduce themselves.

Speaker: Hello, Palabia. Thank you so much for having us on. I'm Dr. Teresa Sun. I'm a periodontal specialist and I'm practicing in Taipei, Taiwan right now in McKay Memorial Hospital.

Speaker: Hello everyone. First of all, thank you, Dr. Pari, for this incredible opportunity. I'm Ken Wei-Tiu, born raised graduated from Taiwan.

Speaker: i After finished my periodontist residency back home, I really want to inverse more periodontology. So now I'm studying in the University of Michigan as a first year resident there.

Speaker: I'm super excited to today's topic because sinus occultation is one of my favorite procedures. Oh, wow. Okay. Well, welcome. And so I think you answered sort of a little bit. So what clinical challenges or knowledge gap motivated you to do this work, microsurgery with sinus lifts?

Speaker: So to begin with, once we see there's a special issue that's focusing and dedicating to the micro surgery, that was the time that we were thinking, oh, in our daily practice, what is a procedure that's related to implant surgery? And then we use the most on when it's related to the micro surgery. And then immediately we were thinking, oh, surgery that's related to sinus lip procedure that will be an interesting topic to direct our focus on. So that was the time that we started to think it will be interesting to review some of the literature and also to provide some of the clinical guidelines and suggestions regarding this specific topic.

Speaker: and Okay. And if you were to let our audience know, what is the single most important message clinicians should take away from your paper?

Speaker: So I think the single most important takeaway message in our article is I think the microsurgical approach that's helping on sinus elevation to achieve a better precision.

Speaker: And of course, it will provide an outcome that's mostly for patient benefit, for patient comforts, and for the clinicians to be thinking and a more minimally invasive way and of the procedure.

Speaker: And what are the key factors to determine success when applying this concept? So one of the key complications that we've noticed and then during the sinus procedure is probably perforation, right? Yeah, that's the perforation. So sort of for the membrane perforations and for microsysuses on procedure, that will be a significant benefit that will be coming from a direct inspections that you can see visually by increasing the magnification and also ah better illuminations while using the microscope.

Speaker: Okay, so I assume using the microscope is quite a challenging and technique sensitive, and it takes a ah very long learning curve. And so can you go over the learning curve a little bit with us?

Speaker: Yeah, so i think on I think most of the surgeons are more comfortable using LOOP. So what do you think, Dr. do I think like when we're learning how to do the surgery, we should start it from the confessional ways. Like we need to put the passion in the center of our treatment. So as a beginner, you should you need to establish the correct surgical sequence and to no understand how to protect the passion, safety, and comfort. However, you can definitely start to learn how to like

Speaker: preparing for your microsurgery. You can learn how to use the straight smooth forceps and with Castroviejo needle holder to practice your instrument tight, like for the microsurgery, that's very crucial.

Speaker: So fundamental surgical principle is still essential. And on top of it, on microscope can be a helpful tool to increase your precisions, and then the flow on in terms of the entire treatment.

Speaker: Okay. So one of the major themes of your paper microsurgery allows us to create a smaller lateral window. So can you go over why that is important? How small can we realistically make that window without compromising access and visualization?

Speaker: This is a very interesting point that when I see a lot of the time when we are treating a patient that requires sinus lip, sometimes it can be limited to a very small surgical site, let's say a size that's only related to a single tooth area. In that specific indication, sometimes you will be much more benefit to create the window that's only located, let's say, apically to that specific edentulous reach area. And you will find the adjacent tooth that's very close to the surgical area that the root is very in close proximity.

Speaker: In that case, we can produce a sinus window that's on in a very smaller size and by using a microscope that you can still see very clearly under a higher magnification.

Speaker: So when again utilizing the microscope from a clinician treatment planning point of view of a posterior maxillary implant, how do you decide between a transcrestal sinus elevation and a lateral window approach?

Speaker: Back to the literature review, like in 2008, Dr. Wong's classification, it determined the residual bone height, like more than 5 mm, he would recommend to use trans-crasal approach, but less than 5 mm, he would recommend to use lateral window technique.

Speaker: So if we look at number as a general rule, it's sort of a guideline. If you're ah looking more comprehensively, let's say radiographically, you can use CBCT as a diagnostic tools. And on top of the height of the residual bone, you can also inspect ah the thickness of the lateral wall, and the numbers of the implants that's required to be placed, the angle of the sinus, and then also if there's any specific anatomical structure that's a septum or vessels that's running through your lateral wall. These can all potentially be on the points that you will be considering while you're trans ah where you're

Speaker: performing decision-making to choose in between the two techniques. And nowadays, I think with the transgressive approach, we have much more tools that we can use, such piezo surgery, osteodesiccation systems, or balloon systems. So this boundary, it's actually become more vague, and then we have much more freedoms. And of course, by using microscope, that you will have much more confidence because you will have more direct we were using all of these different materials and methods and that can that can be available. I think now it is between these two techniques, the boundary is overlap a little bit. like

Speaker: Based on the literature review, for the trans-crust technique, maybe you can still gain, like the mean average would be 7mm vertical bone height, but for lateral window technique, it's 9mm or more vertical bone gain.

Speaker: that's overlap a little bit as based on the clinical scenarios. yeah I think also also for surgical surgeons preference, let's say if you feel more comfortable using one tool over the others, this can also be on your decision point. All right, excellent. so I think you would agree with me that membrane perforation is perhaps the complication we as clinicians worry the most. And so does magnification primarily help us prevent a perforation or the biggest advantage is actually allowing us to recognize a very small perforation when it happens?

Speaker: Yeah, so first of all, I think from a lot of literature and then also from clinical experience as well, that we can all agree that sometimes the perforation is actually overlooked. So if we don't see it doesn't mean that it doesn't exist.

Speaker: So big advantage of using Microsoft that you can inspect more and then to see it more clearly. and It makes much more um differences when you are using an internal, which is transgressive approach when compared to external, because external you have larger field, be much more easier for you to see.

Speaker: So for internal, you can say that almost impossible to really see it without the end of the micrification. So you can barely see it with your native eye, let's say. Okay. And the direct inspection is not for for Zolva maneuver, not for observing movements while respiratories. It's for the integrity of the membrane.

Speaker: Okay. Yeah, excellent. So I think in addition to being able to visualize the field a lot better with the microscope, you also mentioned ergonomics. So can you let us know or walk us through the benefits, the ergonomic benefits of using the microscope?

Speaker: So when I was a restaurant, of course, that we were all very excited. So we purchased a loop and we start using it as a learning curve. We love the loop. We can see better. But once I started to use microscope, that's the time that I feel like, oh, wow, this tool really free my neck.

Speaker: So I think we all agree that as a periodontist, that this is a profession that requires you have to stay in a steady position for such a long time when performing the surgery. So definitely on the ergonomics is one of the big issue if you wanted to have a very prolonged professional life. And how long have you been using the microscope in your practice?

Speaker: For me, I'm using it on since so I have graduated from my residency for roughly more than 10 years, but I started to use it lately within these five years after graduating. For me, it's during my residency in Taiwan, so almost three years. Three years. And what percent of your practice do you would you say you use the microscope?

Speaker: So my philosophy is I think they will be really helpful to use them in some certain steps of your surgical procedure. So especially for beginner, my recommendation is to select the surgical procedure. that you are used on you want to use a microscope. You don't have to use it 100% of the time. So if you're only placing implants or you're doing, on let's say, extractions, then perhaps that you can do implant the preparation entirely with other methods, but just come back and in instead inspect your transgressive approach solid when you are performing up to certain steps. So I think it can be really free. You don't have to limit yourself to say that you have to use it 100% of the time. Yeah, it's very hard to use microscope for 100% during the procedure when you are a a beginner. yeah So maybe in some certain points you can check. So, yeah, so I think we use it in certain parts of the procedure, not all, not throughout the entire day, I guess certain procedures are probably still don't use the microscope. But you also in your paper mentioned changing the importance of changing the magnification during the surgical procedure. Let's say if you opt to use the microscope for the entire time, you mentioned that for sinus augmentation specifically, you use different magnifications. Can you go over that a little bit with us?

Speaker: Yeah, so I'll take external sinus lift as an example to start with. So when you are doing your incision and flap elevation, this is the time point that you will require a larger field.

Speaker: on to see the entire picture of your surgical area. So this is a time that you should use a magnification that's less, let's say um four times or ten or five times only. And then up to the point that you are starting preparing your window to outline it, you should still stay in the larger field. so Once you start using, let's say, piezo's instrument or rotary to really shaping your window, that's the time that you wanted to distinguish and see very clearly how close you are towards to the sinus membrane. So this is time you can change into 10 times or even more, 15 times, 20 times.

Speaker: And once you successively elevate the entire sinus membrane, you can also stay with a larger magnification to inspect if you have fully elevated your membrane toward the medial wall. And after packing over the bone graft, then you can slowly go back to a smaller, let's say four times or five times, communications compared to the time frame that you really need to see it so clearly.

Speaker: And on to moving to the transgressive approach, usually, as I mentioned before, that with the implant preparation, i don't use magnitation up to the point that when you were on surgical burr is so close to the sinus floor and you really wanted to see if the integrity of the sinus floor still exists and then to see how work break the points of the floor, that's the time that you will use a dental mirror as an indirect view. And you can use a very high magnation up to 10 times or 20 times to really see on the membrane and during that period of time. And obviously there's a huge investment in a practice if you were to own a microscope. So, I mean, it's, I think it's, it's quite obvious, you know, not just the cost, but also training the staff, the workflow of the clinic. So for the average periopractice, do you think the clinical benefits justify the investment?

Speaker: Okay, a that's really interesting question. I think using a microscope is not just a simple investment. It's like more like ah pursuing your personal achievements. It's more spiritual aspects. As a periodontist, we always want to perform as ah traumatic and precise as possible.

Speaker: I think Dr. Du is a great example of pursuing life excellence since he's doing his second residency in Michigan. I think um I really like you raising this question because it It really depends on what's your goal in practicing, right? If you are thinking about to make a maximum profit out of your business, I don't think this is the equipment that you will be thinking to pursuing. However, if you are thinking about on to improve your workflow and then to enhance the way you are thinking and performing surgery. So it's also your mindset, how you prepare yourself and then how you improve the surgical skills set by um performing it. And ultimately, i think once you have incorporated some of this more minimally invasive surgical concept and technique into your daily practice, as a clinician and also patient, you'll probably benefit more from this equipment. So it's a little bit more...

Speaker: I think it's more spiritual or personal pursuing compared to being very profitable. But so far, I'm very enjoying and using this tool. I guess it's the pursuit of perfection and providing our patients with the best we can, right? So yeah being as precise as we can, as minimumally minimally invasive as we can. So yeah, that's that's super exciting. And any questions we have I haven't asked you that you would like us to bring up or any points you'd like to bring up?

Speaker: So in conclusion, I think from our review, It's actually interesting to see that if we are looking at evidence-based point of view, if we're looking at all of the periodontal procedure that's benefit from microscope the most, and then it's more evidence is supported, it's probably, let's say, guided tissue regenerations that we have extensive of RCT that supports the outcome.

Speaker: For sinus, probably still quite limited, but as a clinician, I find it very appealing and then it can be a very interesting potential use if you have these tools in your practice and then it will be very helpful for you.

Speaker: Okay. All right. Super exciting. And thank you guys for for joining us and thank you for joining us as we explore microsurgery and periodontology and implant therapy.

Speaker: And stay tuned for more upcoming episodes exploiting other papers in this special issue. We hope we have encouraged you to dive deeper into this special issue of clinical advances in periodontics until next time.

Speaker: Thank you, guys. Thank you, Dr. Pari. Thank you.

Speaker: Thank you for joining our episode today. If you like this episode, share it with a friend. Don't forget to subscribe to the podcast wherever you're listening so you get the latest episodes.