Transcript
Speaker: Whether you're 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 Periodontology and Clinical Advances in Periodontics.
Speaker: Welcome to this special series of Probing Perio. Today, we explore implantoplasty combined with soft tissue grafting for the management of complex cases, a microsurgical approach from the new clinical advances in perillotics, a special issue microsurgery in perillotology 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 and implant therapy, this collection offers valuable insights and practical guidance. I'm very excited about today. We have our guest.
Speaker: His name is Dr. Joao Batista Cezarneto. Joao earned his DDS degree from the University of Campinas, followed by an MS and a PhD in periodontology from the same institution.
Speaker: He has served as chairman of the Osteology Group Brazil, and he is currently associate professor in the Department of Periodontology at the University of Sao Paulo School of Dentistry.
Speaker: He teaches at both undergraduate and graduate levels and coordinates the postgraduate specialization program in implant therapy. In addition to his academic career, he maintains a private clinical practice focused on periodontology and implant dentistry.
Speaker: So again, it is a true pleasure and honor to introduce to you a colleague and a friend who was very accomplished, who's embraced microsurgery passionately.
Speaker: And he produced this paper that we're going to be discussing today in combination with the group of his colleagues, including Dr. Rafael Lazarin, Enrique Rinaldi Mateus, Emerson Santiago, and Dr. Giuseppe Romito.
Speaker: So with that said, thank you so much for joining us, Joao. And I'm going to start getting into some of the topics that you cover in your article. And I'm going to be specific, and I'm going to start from the get-go with something that concerns me any time that I read the word implantoplasty.
Speaker: And I would like to ask about your opinion about any concerns that you may have with titanium particles during implantoplasty during this procedure. What are your thoughts about that?
Speaker: Hi, Diego. It's a pleasure to be here. I'm truly honored to be invited for this podcast. It's always very good to be with such a nice guy and an expert to discuss Perio, and in any particular, my paper.
Speaker: I really like your question, and you were right in being concerned about particles, and it's a true concern. What can happen is if you leave these particles there, you can have staining and a gray color, and this is not pleasant for the patient.
Speaker: So what do we try to do is to saline, lot of saline during the surgical procedure, And what I usually do afterwards is to check with high magnification if I see some particle in some region that is at risk of gray color, and I put more saline there, and at the end,
Speaker: What I use is a DTA to clean everything and to decrease the the chance. And in my personal experience, I never had a case of gray color using this standard.
Speaker: And I did several cases of implantoplasty. And I think it moves the situation to safe level if you work this way.
Speaker: Another point that is important is every time I send a paper to a journal and anything involves implantoplasty, foreign body reaction is always a question that comes.
Speaker: And what I usually respond to the reviewers is that I'm more afraid of black and gray than foreign body reaction.
Speaker: So usually clinically, my cases are doing well. I don't have probing. I don't have bleeding. and if If the patient, of course, collaborates it with maintenance.
Speaker: So this is my general overview of this topic. Thank you, Joao. I'm glad you covered also the foreign body reaction because I was going to follow up with that. I had a question for our audience. What type of EDTA are you using? What is the concentration of EDTA? Are you using a gel? Is this a liquid form? How how are you applying it in order to remove this, which is a very good clinical application. And if you can please share that pearl.
Speaker: I use the gel that is provided by Strauman, the one that is made for endogain. I use that one. And the application, are you using like a cotton pellet, sterilized cotton pellet, or are you just applying it and letting it soak the particles?
Speaker: With the needle and syringe on top of the implant in adjacent areas, and I leave it there for one minute and then wash. If I it's necessary, put some more, but usually one minute is enough.
Speaker: and it's working fine. Fantastic. Thank you. Appreciate that information. So during your explanation about the implantoplasty and and how you operate during these procedures, you mentioned you use the microscope.
Speaker: The follow-up question that I have is, is the microscope essential for these procedures, or why not to use a high-power pair of loop? What is the advantage of the microscope? Why did you decide to utilize this microscope or the operating microscope for this type of application youll out The light is way better. It's much better.
Speaker: So this the first thing. And I don't like loops with a magnification higher than five. I can feel when I breathe and things move. I already tried them.
Speaker: But I think every time I have to work with a magnification higher than five times, I prefer the microscope. And I also have the possibility to adjust in a higher magnification if I find necessary.
Speaker: For example, 10 times or more. And in particular, for these cases of implantoplasty, Higher magnifications are very good to check the implant surface, so you can check irregularities if you need more polishing there, and also to check the particles of titanium that goes around. So I think for this situation, the microscope is much better than a loop, even a high magnification loop.
Speaker: How high of the magnification levels are you managing when you're working with inspecting, making sure that there are no particles left behind? How high you ah do you think you're going with your microscope?
Speaker: ah Sometimes, 15 times to check and for inspection. Power-up. Yeah, yeah, yeah. Very good.
Speaker: Now, I saw some of your cases and and by the way, congratulations, beautifully executed, a very nice outcomes, Joao, very impressive and and that's what I have seen during your career. You're very meticulous with your work.
Speaker: In some of these cases, you were dealing with implants that were malpositioned, all right, and some of these patients were malpositioned in the aesthetic area. The question that I wanted to ask you regarding some of these cases that you handle why just don't remove the implant and start from scratch? And how do you make the decision, or at least how do you advise a patient when the tipping point has been reached that is going to determine whether the implant is way too vocally placed and cannot be rescued the way you've been dealing with your cases?
Speaker: It's a very good question too. One point is discussing with the patient. In these three cases of the paper, particularly these three cases, all of them, discussed it with the patients the possibility of implant removal and in strip start from scratch.
Speaker: And you are right. They are malpositioned. They are too buckle. If you go to the guidelines that talk about the previsibility of soft tissue grafting implants, they are not in a good shape for a soft tissue graft. They are not in a good shape.
Speaker: But the patients... they prefer to have not the perfect statics, but and a less invasive approach.
Speaker: So this was something that I took into account for the decision. And another important topic was that some of those cases in particular, the third one was very dangerous case.
Speaker: The patient had an orthognetic surgery and bone tissues were very thin. And another point that I always discuss is what is the chance of getting into a situation that is worse than the one I have right now?
Speaker: And depending on the difficulty that you have to remove for the removal of the implant, you can... being in dangerous or difficult position.
Speaker: So i'm i'm not like the guy that says, oh, we have to remove all the implants or we have always to do, we should always do soft tissue.
Speaker: I try to listen to the patient and he I try to compromise patient between the clinical possibility of improvement and also what the patient wants. And once the patient knows, I agree that I will not have the perfect statics, but I want something less invasive, I can go to this direction.
Speaker: But... For all these cases, I talked to the patients that implantoplasty in a static region is not something common.
Speaker: That's why we send the the cases to the article because it's not common at all. And they knew that we were doing something that doesn't have precise recommendation by the literature.
Speaker: So everything was explained perfectly. And the patients decided that they would prefer for the approach with implantoplasty soft tissue graft. And something curious is that one of the the cases, I think the second one, no, the first one,
Speaker: The patient had twoprints two implants, two adjacent implants. And I saw the patient two weeks ago, and now she has perimplantitis in the adjacent implant, not the one that I did implantoplasty. The one that I did is fine, no probing, no bleeding, but the adjacent one has separation now. I have to do the implantoplasty in the adjacent one.
Speaker: And that will be something much easier for the patient to understand and to be able to appreciate the benefits since the patient has already gone through that and and it's already aware of of the improvement, which is important. draw So thank you for explaining that.
Speaker: And when would you say, forget it, this implant, it's not worth it. At what point do you advise the patient, look, I'm sorry, even though I would like to try to help you, this implant is in such bad placement, the position is so, so erroneous that I don't think I feel comfortable trying to offer you a rescue option.
Speaker: How do you determine that? So usually, and if I have, for example, an implant of 10 millimeters, If I have half of the implant with bone loss, I don't try implantoplasty.
Speaker: And there's one exception. If the implant is in a multiple, one of the pillars of ah prosthesis is more than one implant. So sometimes I can try in a situation like that. But usually if if I have a single crown in a single implant,
Speaker: more than 50% of the length of the implant, I prefer to remove the implant. Very good, João. Thank you. The next question, I think you might have partially answered some of this. And what I wanted to know is what motivated you to pursue this line of of clinical treatment, this type of approach?
Speaker: Was there a ah knowledge gap that you realized existed in the literature? And you mentioned that already that in your opinion there was. That motivated you to do this type of work?
Speaker: So first, five years ago, i was treating my perioplantitis cases, even in a static zone, with GBR, bone particles in the membrane.
Speaker: And I had some statical concerns, statical problems with some patients. And i was trying to to find a better solution.
Speaker: And one of these patients came to me and I was doing very nice work with root coverage with soft teeth tissue grafts, and I decided to work the same manner with the implants.
Speaker: And i had a previous experience with implantoplasty, and I like very much odontoplasty in some cases of root coverage. And I decided to apply in an implant the theory that we use in tooth for the implants and also with the implantoplasty, that is something that we use to decontaminate.
Speaker: So it came to my mind that would be a nice idea to combine both. And once I like very much the way the microscope helps us to decontaminate and make the the implantoplasty a precise effect,
Speaker: So these three points were the ones that i put together to develop the this approach we published in this paper. There is an evolution and you can see how your wheels were turning when you were dealing with these cases on the natural dentition and you extrapolated, you translated that experience with the implants, which makes sense.
Speaker: Can I made make another comment? Of course, please In my practice, I see many, many patients a older than 75, 80 years.
Speaker: so for these patients we can find an alternative because they are not in the mood of invasive procedures anymore.
Speaker: So we have to find ah an alternative. And I always think about these patients when I think about lesss invasive procedures.
Speaker: treatment plannings. And it's important to to take into account also the patient, but ah not only the opinion, but the overall condition.
Speaker: If you have to do something faster because the patient is not in a good health, if the patient is in a wheelchair, if the patient has difficulties to walk. So sometimes for the patient to come to the practice is a and we should always consider that too.
Speaker: And that is a very important factor. Thank you for adding that information, Joao. Joao, the following question will be much more out of curiosity. Perhaps when you started doing this type of of work,
Speaker: you were not implementing the current protocol that you're following right now. And understanding that the microsurgical approach goes beyond using an operating microscope.
Speaker: There are also some other items that are very important, some other elements that are very important, like tissue manipulation, the size of the sutures that you're using, the needles that you're using, the armamentarium that you're incorporating.
Speaker: I just wanted to know how is All of this work that you're doing, how does that change your current clinical practice compared to what you were doing, i don't know, five, seven, eight, 10 years ago? Once you enter in this world of microsurgery, you see the benefits of what you are doing and how better your work is with a higher magnification.
Speaker: And when I started, I didn't know exactly if it it would work in the first case in in soft tissue and implantoplasty in platolasty in a static areas.
Speaker: And now with thin needles, thin sutures, delicate pliers, delicate blades, I remember a case I operated four months ago, and we did the post-op.
Speaker: It was a case at the university. And the patient had a very tiny papilla, narrow and height. And it it it was an infection.
Speaker: It was not possible to avoid incision there to to decontaminate the area. And I had to do a design of coronally advanced with an incision and then depitalization.
Speaker: But it was so delicate and the sutures that we that I did afterwards in high magnification were so delicate and I didn't have almost any impact in terms of papilla loss. a combination of the correct aromamentarium, the tissue management, and then being effective in very, very high magnification, a zoom on the threads, and then decontaminating everything.
Speaker: At the end, I added a CT graft, moved everything coronally, and the result's very nice, very nice. So, After this series, i already did two more cases. I'm trying to increase my cases to publish a second paper afterwards with more cases.
Speaker: But I'm very excited with the idea because it's working well. And even if you have a defect under the papilla, like this case I was mentioning, the proper management and also the CT graft was very effective in avoiding papilla loss and tissue loss.
Speaker: Tremendous. I can see that evolution. And what do you think are the key factors that are going to determine success when applying this type of approach in your in your mind, Joao?
Speaker: ah First of all, is the capacity of cleaning the threads Well, in my perspective, microsurgery and treatment of perempplantitis are things made to each other.
Speaker: Because I remember some years ago, and I was discussing with a professor, um he's retired right now from the University of São Paulo, Professor Marcio Greise. And he is one of the precursors of microsurgery in Brazil.
Speaker: And he has very good cases of periodontal regeneration. And I went to one of his courses and i asked him, oh, Dr. Greasy, why do you think you have so nice results with periodontal regeneration?
Speaker: And I was wondering, he would say, oh the suture, the endogaine, some particular membrane or biomaterial. And he said, I think that when I start using the microscope, I clean the root better.
Speaker: And that's the main reason I have nice results, because I can see that the root is clean. There's no calculus and like on the root.
Speaker: And... If we do a parallel with perimplantitis treatment, something very important, very important. If you clean well, and if the patient is able to clean afterwards the supragingival margin, we're done.
Speaker: We're done. Everything will work. And I think most of the case that failure is because the patient doesn't clean well afterwards, sometimes because you have gingival recession and the threads are exposed.
Speaker: And if you have a risk of that, you can use implantoplasty to facilitate maintenance of the patient and your maintenance ah as a clinician. And also when you are...
Speaker: using the the tips of ultrasound or decontaminating the threads itself, if you are in higher magnification, you can be much more effective. You can be much more meticulous and you can see details that are not possible to be observed in a naked eye or with a loop.
Speaker: Manuel Rivera- Thank you, Joe very, very true what you're saying as far as the capacity to see and how that is so essential for us to be able to make sure that those surfaces are. Manuel Rivera- completely decontaminated and I think that applies, as you said, very well for applies to both natural teeth and natural dentition on implants to all, how do you.
Speaker: How do you define the learning curve with these TASPOP procedures? Is there a steep learning curve? How can clinicians develop proficiency? You you are a a faculty member. You are educating dental students and graduate students.
Speaker: How do you convey this information? What challenges do you see on your students and what is your advice for them to be able to overcome the learning curve, steep or not steep in your opinion, but what do you do?
Speaker: I can tell a little bit about my story with magnification and microscope. So I started, I think, eight years ago. And i started by my own.
Speaker: And then i was looking for people that could help me. And then I read some books and I started looking for courses. And I did some very nice courses here in Brazil of Professor Glessio, Professor Grise. Then we got in contact. I could take your course in the U.S. And I think the most important is practice and find good mentors.
Speaker: So if you practice and find good mentors, of course, you're going to have a learning curve. But you have the discipline to practice and also the possibility to discuss with people that are more experienced than you. Naturally, things will happen, but you have to be persistent.
Speaker: Because sometimes you're going to hurt and you will try and things will not work out. the not workout and But I really like your concept that I learned from you of deliberate practice. And I think this is fundamental.
Speaker: Sometimes I don't have chance to practice practice. as i the the amount of time that I would like to practice. But what I try to do is every time I have a simple procedure, for example, an extraction, when I go to the suture, I got a micro suture with the microscope and I practice the suture after extraction or frenum with the same simple procedures that you can practice. And also what I try to do is every time that I i teach my students,
Speaker: Instead of recording an exercise, i do it live. So I tell them it's the chance that I have to practice. So I have to do it in front of you and then I will practice. And these small things are, I think, are helping me to get better.
Speaker: And this is something that I would suggest to to a young person, a young student or a young clinician or someone that wants to start in microsurgery. First, be persistent, find good mentors, practice and use the chances that you have to practice.
Speaker: For example, in simple procedures in your practice, get the scope, the the needle holder, the wire and do a micro suture, even if the case is not necessary, micro surgery, but you would do it for practicing.
Speaker: understand. Those are very good tips, I think, and they're all very important. And I think it's interesting when we are traveling our own paths or our own journeys of learning, some of these ingredients are going to come together. And I think it is very important for us to be able to pursue those individuals that are going to help us learn, to pursue opportunities for learning.
Speaker: But as you said, I think the practice aspect aspect aspect is essential, is fundamental. And again, i'm I'm very happy and I wanted to use the opportunity to say that Brazil is such a powerhouse.
Speaker: You have so much talent in your country and you have many of the pioneers and leaders in this discipline that have been spreading that type of knowledge, not only in your own country, but also in South America and all around the world.
Speaker: So again, and I think you're you're part of that. Ramos, M.D. That pile of of talent as well. I wanted to to ask you because in your paper, I was very impressed of the ah fine suturing work that you're doing.
Speaker: at one point in some of these cases where you are incorporating the connective tissue and how you fixate this connective tissue to this to to the supporting surrounding mucosa.
Speaker: I just wanted to ask you, what are the instruments and technologies that are essential for success? And how how challenging is it for you to start working with these very small needles and very small threads of biotextiles throughout?
Speaker: So I'll tell you interesting. When I went to your course in Brazil, and I had the chance to to to test and use very nice instruments.
Speaker: But we didn't have any my manufacturer in Brazil that built those instruments. And then i got I got in contact because i went I wanted to teach that to my students.
Speaker: But I knew that they wouldn't be able to buy the instruments because we didn't have them manufactured in Brazil. And then we developed... some instruments that were similar to the ones that you had and that you showed to us in that course. So it was something that had an impact also the way we teach here Brazil because we made some instruments that were possible to the students to start. That was very nice.
Speaker: that was very nice Brazil has that potential. you know You have industry, you have good craftsmanship that that will allow you to produce these instruments. Very nice for sharing. Thank you.
Speaker: So going back to the sutures and I think it was it is difficult in the beginning. I had the chance to see you working. And i think when you see someone working well and if you pay attention,
Speaker: you can have a shortcut in your learning curve. So I was persistent, by but I also had the chance to find my shortcuts and my mentors.
Speaker: and So I was like paying attention, taking pictures when I had the chance to see you working. And I think this is also important.
Speaker: What I try to do is when someone who asks, tool to come. I try to retribute the ones that were generous to me and let me watch.
Speaker: So I invite people to come again as you did with me. And ah i always tell to the students, pay attention this detail, ah the way you use both hands, practicing your not non-dominant hand is essential.
Speaker: It's something that you... I always give the example. I have a young kid. He's... He's 36 years old now. And he goes to the soccer school. Everything that he does with the right leg, he does the same with the left leg.
Speaker: So the teacher goes right away and kicks with the right foot. And now goes left side and kicks with the left foot. And we should do the same. Sometimes we will not have the same capacity to do exactly the same things with both hands. But it will help a lot, definitely.
Speaker: That is so true. And I think it is so important to think when we sometimes talk about technologies and tools and biomaterials and stuff, we sometimes forget the human factor and how important it is for us to invest in our own development, your own growth, enhancing our skills, because I think there is so much potential and a lot of our skills are dormant.
Speaker: And I think we just need to find ways to stimulate and, for instance, working bimanual instrumentation, for instance, and that work in dexterity, developing the dexterity of sometimes the non-dominant hand. I think it is so important for what we do in our field.
Speaker: So thank you for bringing that up. And that's a great example. Let me make another comment. Sometimes you you work your entire life doing something that you are your comfort zone.
Speaker: But you have to find someone that sometimes gives you a suggestion. Why don't you try your other hand, for example? And this is something we don't do in dentistry. Nobody says, try your left hand, try your non-dominant hand. And it's so simple that the the soccer teacher of a six-year-old boy tells him all the time and why not us dentists that are practicing all day long we don't practice the basic that is trying to do some simple stuff with both hands that is so true some of his basic approaches i like that joao looking at and
Speaker: your learning curve and that where you are right now, what do you think, what type of patients do you think will be the best candidates for this approach? Are you looking at a patient and let's say this patient perhaps and has some, some social habits that is going to make a patient, not a good candidate for this type of procedure.
Speaker: What type of cutoff point do you have as far as the patient conditions themselves?
Speaker: is This is, I think, something difficult to to define. But I would say that the limits that we have for microsurgery, sometimes we have patients that are not able to stay quiet, stay steady,
Speaker: So if the patient ah is able to stay steady, quiet, not shaking, I think is candidate because if the patient is a little older, but he stays steady, you can work because it's not a a huge procedure.
Speaker: The microscope facilitates that we can work in a small surgical field and it's not something like that is invasive to that patient.
Speaker: So for me, The biggest limitation for a patient in general is health condition. So if the patient is not in a good health, and this is a limitation.
Speaker: But if the patient is in a good health and can stay quiet, steady, we can move on. Fantastic. I like that. That stability is so essential to have a patient that is stable, as you said, for us to be able to, to, uh, act and, uh, and execute.
Speaker: That is very important to all to wrap things up. I just wanted to hear your opinion and your vision, more of your vision, as far as what do you think of the future research, um, areas? What what do you think are the, uh, the developments that you anticipate to happen?
Speaker: in this field, working with a microscope, working around implants, performing, rescuing implants from a mechanical, from an aesthetic point of view. Where do you think we're heading? What is going to be the next the next big thing coming down our pipeline? I would separate in two stuff. First, microsurgery and then implants in static areas with like perimplant types.
Speaker: So for microsurgery, I think we should document the healing, how things heal faster and well. And for me, we should find a manner to evaluate healing and vascularization. For me, the key is vascularization.
Speaker: And once we have the possibility, for example, to understand better how is the nutrition of the tissues and how our and working impacts on the nutrition, for example, if we work with small decisions and are very delicate, we get a better blood flow at the end in comparison when we work with a big instrument and are not so delicate or not under magnification.
Speaker: And for cases like the ones I showed in the study, I would say that we should do more cases.
Speaker: more case series with more cases and a longer follow-up. And if it's possible the future, some randomized clinical trials, comparing different approaches, but in the perspective of the patient, because I think when's go what's gonna happen and is more important for this particular approach is the perspective of the patient.
Speaker: Because if you've if you are able to keep an implant in the mouth with one or two small soft tissue grafts, it's much more comfortable than removing an implant, bone graft, another implant, sometimes another soft tissue graft and provisional for one year.
Speaker: So this is, at the end, what we discussing with the patients. So the patient wants to know how long i I'm going to stay with a provisional, how many surgeries I will have to do, how many days I will have to rest, how many days I will be off of the work.
Speaker: So these are the the questions patients ask us all the time. So I think this is my my perspective for improving microsurgery and also applying this kind of technique I propose in the paper.
Speaker: Very good, João. And I think all of this is very enticing and very exciting because I personally, I look forward for your future contributions. You've been very active with your group. You are publishing relevant material, things that are applicable for us clinicians as well.
Speaker: So thank you for your past corporations and that looking forward to future corporations, of course. I think this is a great time for us to wrap things up, Joao. Thank you so much for making time with your busy schedule, not only at work, but also with your family.
Speaker: And to all our listeners, thank you so much for joining us as we explore microsurgery in periodontology and implant therapy. And please stay tuned for more upcoming episodes exploring all the papers in this special issue.
Speaker: We hope we have encouraged you to dive deeper into this special issue of clinical advances in periodontics. Until next time, thank you so much, everyone. Thank you, Joao.
Speaker: Thank you, Diego, for the invitation. It's an honor. Honor is ours. Thank you so much. Bye-bye. Thank you for joining our episodes today. If you like this episode, share it with a friend.
Speaker: Don't forget subscribe to the podcast wherever you're listening so you get the latest episodes.
