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Failure Pattern in Three-Implant Splinted Prostheses with Dr. Douglas Deporter
179 Plays3 months ago
Listen to Dr. Diego Velasquez and Dr. Douglas Deporter discuss the findings of a pattern of failed middle implants in three-implant splinted protheses. Listen in for an informative discussion on why middle implants may fail, whether or not to use splinted implants, and the factors affecting implant placement.
Read the full article here. https://aap.onlinelibrary.wiley.com/doi/10.1002/cap.10274
This podcast is produced by the American Academy of Periodontology (AAP). To learn more visit perio.org
The views expressed in this podcast episode are those of the participants and not necessarily those of the AAP.
Music Credit: Groove Nation by OctoSound
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Transcript
Introduction to Dr. Douglas DePorter and His Research
00:00:00
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.
00:00:35
Speaker
Well, hello everyone. I have the privilege today to be sitting together with Dr. Douglas DePorter. He's faculty at the University of Toronto.
00:00:47
Speaker
And he published a very interesting paper recently in CAP, titled, A Pattern of Perimplantitis Affecting Middle Implants in Three-Implant Splinted Prosthesis.
00:01:00
Speaker
The reason I was excited about this paper is because it made a series of observations that I think are very relevant for us clinicians who are working with implants and also for us who are involved with communities in which we interact with general practitioners, restorative dentists, prosthodontists, and this type of knowledge is going to be very valuable for us to help guide some of the prosthetic designs when we are dealing with implants that are together, three implants that are splinted together.
00:01:32
Speaker
And without any further ado, I just wanted to introduce our guest today, Dr. Douglas DePorter. If you could please introduce yourself and also introduce the co-authors of the paper that we are going to be discussing today.
Career Reflections and Co-Authors
00:01:45
Speaker
Sure. i I'm happy to introduce myself. i um I was just thinking, actually, that i ah next year I will have been in the position at the University of Toronto for 50 years, imagine.
00:02:00
Speaker
50 years. years Congratulations to that. um Congratulations to that and for the dedication. Thank you so much. Who wants to retire? Not me. Anyway, um yeah, so um I've been in the faculty all those years, and I'll probably explain a little bit more about my involvement in implant dentistry as we go along.
00:02:24
Speaker
But
00:02:27
Speaker
the other authors were all students at the time. So in our graduate periodontal program, we actually, as far as I understand, have the oldest periodontal department in North America.
00:02:41
Speaker
Oh. And we have our 150th anniversary this year. At any rate, the other three were students. They're periodontal residents. One of them is Brayden Prette. He's the first author.
00:02:54
Speaker
And he's currently of of a third-year resident. Okay. The other two, Michael and Brian, are both were both um members of our program, but they graduated last year, and they were excellent clinicians. Well, they're all excellent clinicians. In fact, you know, one of the reasons I'm not retired is it's such a pleasure to deal with the kind of talent that we get in our and these specialty programs.
Serendipitous Observations on Peri-Implantitis
00:03:22
Speaker
It's amazing. It's humbling. And, you know, as a result, I learn something every day. so That is such a privilege. and it is a It's a real privilege. It is.
00:03:34
Speaker
that is something that I share and of course University of Toronto has such a great reputation historically speaking of course we know that that is where a lot of things started and came to North America was through the University of Toronto with George Zarb at that time and of course you have played your your very important role you've been ah a very prolific author so it's an honor for me to be um sharing this space with you today Dr. De Porter and thank you for giving credit to the co-authors of the paper residents that are very accomplished and in private practice or perhaps teaching right now, perhaps in Canada. I don't know where they, do you know where they they are right now? Well, yes, they're, well, Brayden is still here. Michael, um Michael Silva is practicing um not too far from Toronto and Brian, ah Brian Wong is practicing again close to Toronto, but he also is coming um infrequently. yeah
00:04:30
Speaker
to teach in our graduate program because he was so accomplished when he graduated that we invited him right away as a part-time instructor. Fantastic. And this is such a beautiful accomplishment now to have a publication and share the title with you as well. I was wondering, could you please be so kind to to share the background of this paper? What triggered your group to focus on this particular topic?
00:04:55
Speaker
Because I found it very interesting and I would like to to know what triggered this for you guys. Right.
Historical Challenges in Implant Stability
00:05:02
Speaker
Well, it's a bit of a long story, but I'll try to make it as short as possible. um As I said, I've been around in implant dentistry for 40 years now. In fact, right from the beginning of the current concepts of osseointegrated implants.
00:05:21
Speaker
In fact, I actually visited Professor um Branemark with George Zarb, oh many years ago now, before Zarr started his replication study in Toronto.
00:05:37
Speaker
Anyway, so I was at that meeting along with some colleagues of mine, and one of my colleagues actually was a metallurgist, and he he actually invented the cementless joint processes.
00:05:52
Speaker
Okay. okay Which is now, of course, we don't use cemented cemented prostheses anymore. ah We use um ah this a cementless one, which was designed ah to have a surface layer, surface multilayer actually, ah of spherical particles of metal of a certain size range so that bone and vascular tissue could grow in and interlock with the implant system. So it was a very it was a very stable, ah secure implant system.
00:06:28
Speaker
In fact, it was so stable, I used to use implants that were at a ah ah designed intra-bony length of five millimeters. Way back when, everybody said, oh, you're crazy, because insured implants will never work.
00:06:42
Speaker
Anyway, so,
Middle Implant Failure and Non-Splinted Preferences
00:06:44
Speaker
i don't know. i I first saw this um issue with metal implants probably about 25 years ago. And it wasn't something that ah struck me at the time as being important,
00:06:59
Speaker
I was looking, of course, at centered surface dental implants, which we called the endopore. um And there's lots of information on that in in the literature, of course.
00:07:10
Speaker
And in in the partially edentulous patients, um we did we looked we looked at single implants. We looked at ah implants, you know, prostheses that were two units.
00:07:23
Speaker
And we used three units. But we also compared splinted and non-splinted. So there weren't that many cases where there were three splinted implants in ah in one quadrant um yeah because ah there just weren't that many patients. I mean, we were all only dealing with something like 52 patients at the time or seventy maybe 72 patients.
00:07:48
Speaker
Anyway, yeah. So once or to twice, I saw this ah situation with the middle implant developing peri-implantitis. I don't even know if we called it peri-implantitis way back when.
00:08:01
Speaker
But I noticed this and I thought, hmm, isn't that interesting? Three splinted implants and the middle one is going south. And why is that?
00:08:13
Speaker
So we discussed it among ourselves and we came up with the idea, well, this implant, it was so secure, and putting three in a row, maybe the middle one was suffering from disused atrophy.
00:08:27
Speaker
and you lost a bone because of wasn't being stimulated enough. So after I saw that, I started thinking, well, you know what? If possible, I'm always going to do non-splinted implants.
00:08:39
Speaker
And that's what I undertook. And I still believe that, not you know, given the right implant design, that non-splinted are best.
Debate Over Splinting Efficacy
00:08:49
Speaker
So that's that's the background.
00:08:52
Speaker
It came basically from a serendipitous observation. But then more recently, um i teach i teach a bit in the graduate periodontal clinic.
00:09:03
Speaker
And yeah, a couple of residents said, look at this. We've got three implants in a row. course, they're threaded implants. and And the typical threaded implants, of course, are the ones with the moderately rough surface now.
00:09:17
Speaker
But the middle implant was going south. And in all all three cases, and we only saw three cases um because we haven't gone back to look at all of the cases that we've done over the last 20 years to see how often we can find this happening.
00:09:33
Speaker
um But yeah, it's suddenly, i remembered those three centered porous surface implants and I thought, hmm, now why is this happening? I don't think it's because of stress shielding.
00:09:45
Speaker
So how, you know, what's going on here? So that's the background. um
00:09:52
Speaker
the background of where we got to, you know, why I thought, well, this is interesting, we should publish it. That is fascinating. Again, those observations, I think that is what probably opens the door sometimes to further questions and trying to make some conclusions like what you did on your paper. And in your paper, I was reading it, and I was very fascinated by this because splinting implants is not easy at all from a prosthetic point of view. And one of the big topics or big items that we try to look after is passivity of fit.
00:10:22
Speaker
And it is not easy to achieve. and And I was wondering, in your opinion, in your experience, what type of role does that passivity of fit, that prosthetic fit passivity, play on osseointegration or loss of osseointegration, complications with with the bone-to-implant interface?
00:10:42
Speaker
Yeah.
00:10:45
Speaker
Well, passive fit, I'm not a prosthodontist, but, yeah, people constantly remind me that passive fit is very important. And because if you have three implants together, it's probably, the one in the middle is probably challenged quite a bit, particularly with off-axis loading, um because it it's um could be ah receiving forces that are and greater than it wants to tolerate, um particularly if, for example,
00:11:21
Speaker
in addition to passive fit, the platforms of the the prosthetic platforms are not level with each other. um and in fact, we found that the the implants, the middle implants that failed in this paper that we reported, that there were just subtle differences, at least it appeared in radiographs, so that the middle implants were a bit higher, which would suggest that um they might be loaded first or heaviest, whatever.
00:11:53
Speaker
Yeah, so the passivity just is like the the beginning for sure. But if the implants are also slightly at different levels right and maybe at different angles slightly, and it doesn't have to be huge, I'm sure, then it's very possible that the middle implant is a problem because it's being overloaded.
00:12:17
Speaker
We know, of course, you can overload an implant. And if it's three units in a row and the middle one is particularly affected by the past lack of passive fit, well, it's a it's ah I think it would be at serious risk.
00:12:36
Speaker
I agree that it's always a conundrum there. And what you mentioned, and you made a very good point as far as you avoid nowadays, you avoid a s splinting implants. Oh, yeah. to To what do you adjudicate some of those discrepancies that we see in the literature? Some papers are going to be very strongly advocators of e splinting implants, and some other authors in the literature are trying to prevent us from doing that.
00:13:03
Speaker
What do you think about that? Right. why do we Why do people splint? Well, because they're afraid that, particularly if implants are short, they might fail if they stand alone.
00:13:15
Speaker
And, you know, certainly with certain designs, that that is a risk. But if you look in the literature, you find that there are a number of literature reviews, of course, and meta-analyses, and they they're it's very difficult to detect detect any significant difference between splinted announcement.
00:13:37
Speaker
um And you know that probably I often think that in so literature reviews lot of important information is lost because everything is bunched together and it's it's possible that you're losing some significant information that would indicate a difference.
00:13:56
Speaker
We did see a difference years ago um when we splinted endopore implants um and And in fact, we did quite a a master's thesis was done on the topic.
00:14:13
Speaker
And we did find a significant difference between splinted and non-splinted. The splinted had greater bone loss. But it was only, it was statistically significant, but clinically significant, you know, the mean was like 0.3 millimeters or something, which, you know, in the long run, it doesn't tell you very much at all. So,
Impact of Vertical Discrepancies
00:14:36
Speaker
I don't know. I think that the splinting is basically just a um hanging over from ah years ago when people were afraid to to use short implants.
00:14:49
Speaker
That's fair. DePortre, you were starting to talk a little bit about the ah the discrepancy of the height of the platforms, of the implant platforms, and how this was identified as one of the the problems on this article.
00:15:05
Speaker
Following that that train of thought, I wanted to ask you to please elaborate a little bit more on that. For instance, how can vertical discrepancies of these prosthetic platforms be measured, be quantified?
00:15:18
Speaker
And what what type of ah phenomena are we observing with these type of discrepancies when it comes to loss? Yeah, well, I actually have discussed this with a number of people.
00:15:34
Speaker
um i Of course, i I don't know why those middle implants were at risk rather than the other two.
00:15:45
Speaker
So we' we're actually beginning with some colleagues in Italy, with Professor Piatelli, I'm sure you know Professor Piatelli. Yes, of course. To use some 3D FEA to if we can look at subtle factors.
00:16:00
Speaker
And I think it you know the the difference in platform height could be very could be very small. um and still have an impact. And in fact, one of his, one of Professor Piatelli's colleagues and working in his research group is a gentleman called Luca Camuzzi.
00:16:22
Speaker
Luca's a periodontist, and he's in and northern Italy, near the Dolomites, I think. And oh ah one I was having dinner with a group of them, because I went recently to a small meeting that Professor Piatelli had in Lecce, in the south of Italy, which is, by the way, if you've never been an incredibly beautiful ah ancient city.
00:16:46
Speaker
um And so he I hadn't even brought up this paper. And he said, oh Dr. DeBorder, have you ever seen situations where three implants are splintered together and the middle one is failing?
00:17:00
Speaker
I said, yes. In fact, he just published a little paper on that, right? So he went back and and I heard this week from Professor Piatelli, he's found 10 cases in his private practice where this happened.
00:17:15
Speaker
um Yeah, so we're looking to, um i don't, we're still designing, in fact they're designing um the FEA experiments with a couple of experts in Sicily.
00:17:28
Speaker
um But we're hoping that maybe we can get some information from those models. ah Certainly, i I found one paper where um the it was an FEA study, and the three implants were were set up in perfect alignment with each other.
00:17:49
Speaker
That never happens in reality. But where that was the case, then those three implants per implant had lower stresses than two implants split together.
00:18:02
Speaker
All right? So but there is the opportunity then ah with f FEA to investigate it further. And i I don't know, I asked a radiologist, could we use CBCTs to do this?
00:18:16
Speaker
And, well, he didn't know that there was any information or any publications on that. suspected not. But he suggested, well, you know, given the um health issues with CBCTs, we'd have to start that in um in vitro.
00:18:33
Speaker
So hopefully we'll try to do that too, or someone else will try to do that to see if CBCTs actually could allow you to measure such subtle differences in height and angulation and so on.
00:18:47
Speaker
Again, I find that fascinating, and I'm glad to hear that Dr. Piatelli is on board with this as
Bone Quality Challenges and Planning
00:18:52
Speaker
well. It's interesting to see what type of commonalities you find through that collaborative effort, especially because it is something that as surgeons, we need to be aware of that. We're always...
00:19:04
Speaker
being very focused on the spaces in between implants, in between the tooth and actual tooth and the implant, of course, all the anatomical landmarks that we have to be careful about. But sometimes those subtleties are obviated, or perhaps perhaps it it is not in our radar.
00:19:21
Speaker
And especially for those young practitioners, those residents right now, it is, I think, a very important piece of information. And as a follow-up, Have you noticed, or from what you have read or from your communications with other colleagues, is there any difference in between the maxillary arch and the mandibular arch? You have in your case, you have a case, I believe, that happened on the maxilla and a couple of cases happened on the mandible.
00:19:49
Speaker
Any observations or any thoughts as far as the ah the the nature of bone on those particular jaws or even in anterior portions of the mandible compared to posterior portions of the mandible? Any thoughts on that as far as the quality of bone and the quantity of bone in relationship to this type of issue?
00:20:10
Speaker
Well, as far as I know, I've never seen something similar in the anterior. It's always been in the posterior. um Yeah, we have we have to go back through, know, 20 years of implant treatment in our clinics um to see how often it appears, how it's more common in one one jaw than the other. But I suspect it will always be in the posterior because of the greater forces um that are received during chewing in the posterior parts of the jaw, jaws.
00:20:46
Speaker
So... Yeah, so I can't make a comment on whether what it's more common in either jaw, but I don't think it's the same thing in the anterior.
00:20:59
Speaker
That's fair. that That is fair. And I think that would be probably a very interesting project to perhaps a resident to go retrospectively and you start looking at some
Prosthetic Design Factors
00:21:09
Speaker
of that data. As I said, this is valuable.
00:21:11
Speaker
Yeah, actually, I was thinking thinking of engaging ah summer student to start it this year, actually. That be great. That would be a very interesting topic to cover. As far as any commonalities when it comes to the prosthetic nature of these restorations, have you been able to observe? And again, this is a limited N. I am aware of that.
00:21:31
Speaker
But were there any commonalities with these prostheses as far as their way of retention? Were they all cement retained? Were they screw retained? Do you think that plays a factor as well?
00:21:41
Speaker
Well, I wondered about that. They were all screw retained. All this good thing. And of course, you know, it's only three patients, so we don't have the didn't have the opportunity to look at various factors like emergence profile and inter-implant distance and all those things that can play a role.
00:21:58
Speaker
um So, you know, I can't really make any comment on that with any confidence. You brought a key word that has always been very interesting to me, and it is the emergence profile. And we know that that is going to be detrimental sometimes as far as being able to even record data, being able to probe around an implant because of the emergence profile and its discrepancies.
00:22:25
Speaker
Any thoughts as far as that needle implant posing a special challenge because perhaps the the emergence profile as far as hygiene for the patient We have an area that might be a little trickier for those patients to to clean.
00:22:38
Speaker
Any thoughts on that?
Patient Hygiene and Prosthetic Design
00:22:40
Speaker
Oh, sure. I mean, prosthetic design is is really important so that the patient has to have good access for cleaning.
00:22:50
Speaker
um There has to be adequate space between the the implants. um Yeah, I can certainly imagine that happening because emergence profile is becoming more and more important. In fact, I just read yesterday, I wouldn't be able to find it quickly on my desk, but an FEA study with looking at emergence profile.
00:23:13
Speaker
And yeah, they certainly show that um difference in the angulation has an impact on the stresses to crestal bone, right? Absolutely. And also the effect of hygiene. I mean, there are some, I i wouldn't, I don't want to wish to be critical, but there's a lot of pro fixed for prosthetics done on implants that is certainly not ideal in terms of patient ability to clean yes and um other features like ridge lap and so on and so forth.
00:23:48
Speaker
um So, yeah, I don't have anything else to say on that. No, I'm glad you brought that up because I agree with you. I think one of the biggest... Objections that I've had to some of these fixed prostheses that are not removable by the patient ah is the lack of access for hygiene. And I think we see several sources of problems with this type of design and this type of of protocol.
00:24:14
Speaker
Yeah, and there's lots of evidence published in terms of literature reviews too, right? That is correct. That is correct.
Soft Tissue's Evolving Role
00:24:20
Speaker
So I would be remiss if I didn't bring up to this conversation soft tissue.
00:24:26
Speaker
And I was wondering if you could comment or or any observations that perhaps... could be related to the quality of that soft tissue, whether it is attached tissue, keratinized tissue, the presence of mucosa on that particular middle implant that was getting in trouble. If you were able to observe any discrepancies that were obvious to you that could be related to that middle implant getting in trouble. In other words, if that discrepancy of the prosthetic platform heights would have any repercussions with the quality of tissue.
00:25:01
Speaker
Soft tissue. Well, we haven't looked at enough cases to have much information on that. We do know, of course, now how important soft tissues are.
00:25:12
Speaker
When I first started, what, 40 years ago, the consensus, particularly driven by Professor Zarb, was, oh, soft tissue doesn't matter, not important.
00:25:25
Speaker
But it does matter a lot. And we're seeing that more and more, the thickness, the height, And you can imagine that if, I don't know whether subtle differences in height of the platform might make a difference, but you know if if the soft tissue is somewhat higher on the yeah um one of the implants, it's possible that hygiene is impacted by that.
00:25:50
Speaker
I don't know. So there's so many unknowns, so many factors. I mean, goodness me, as I said years ago, we ah We never even thought to be looking at soft tissue because we were told that it's all bone. It's all a matter of bone. If you have the proper bone, away you go, and it it'll last for a long time. But now we know that that's not the case.
00:26:15
Speaker
And certainly we teach our residents now to pay very special attention to the the phenotype of the soft tissue and the width of the soft tissue and and the height of the soft tissue.
00:26:33
Speaker
in every case, right? So this is another where area where single implants do provide ah some benefit, I think, right? That access for home care is much better if there are subtle differences in soft tissue. As long as there's adequate soft tissue on each implant, it shouldn't make a difference.
00:26:52
Speaker
But, you know, with a three-unit fixed prosthesis, the situation becomes potentially very complicated. the impact of soft tissue. I agree with you and that i e i I share with you my fascination for this evolution
Advice and Considerations for Implant Success
00:27:08
Speaker
of knowledge. Some things that we, it is so true that we don't know what we don't know and some of these things have become more clear with time but in the beginning as you said historically when OSI integration was introduced to our communities there were so many unknowns and over the years we've been learning
00:27:25
Speaker
and i that's why I'm fascinated by your contribution, because again, this is another variable that it can have a ah big impact. And with that in mind... Depth of placement is so important. The of placement. and And with that in mind, what would be your advice when you're teaching to your residents as far as they are going to be placing three implants contiguously, they're going to be next to each other.
00:27:49
Speaker
how What type of advice are you giving your residents right now as far as perhaps flattening the bone, the recipient bone, before they're going to be placing the the multiple implants, taking care of those aspects, perhaps making sure that the bone is going to be as flat as they can have it, spend some time doing some osteoplasty before they place the implants. And more important, um you are an advocate of nose splinting.
00:28:14
Speaker
Could you please elaborate on the instructions that you would share with your residents? Well, I would share with my residents never to flatten the reach, never take away bone.
00:28:26
Speaker
mean We need more bone, not less bone. And you'll never be able you'll never be able to align your implants perfectly in terms of height of prosthetic platforms.
00:28:38
Speaker
So... Don't split three implants together. Use a two unit or use ah two implants with a three-unit prosthesis if you can't do it with single implants.
00:28:50
Speaker
But first and foremost, I would prefer a single implants, and that's what I teach my residents. um and if If that's not possible for financial reasons or ah any other reasons, well, use don't don't go more than two implants at a time if possible and have a pontic in between them.
00:29:10
Speaker
That's very practical. Yeah, better. i mean, yeah, it's it's it's a simple approach. But based on, you know, 40 years of experience, I don't like a lot of splinted implants for sure.
00:29:24
Speaker
But it's very clear and very practical. One last question, i and and this is a personal question. When I was reading your paper, I saw one of the patients, patient identified in the paper as patient number four.
00:29:35
Speaker
This patient had a yeah ah bone island, a very dense area. And I just wanted to hear from you. What is your advice when you find a place like this in the jaw, when you're going to be preparing your ostectomy?
00:29:51
Speaker
um Any special caution, any special protocols that you follow, any special advice as far as having these implants be followed up closely? What would you expect as far as um this type of situation presenting in in a patient?
00:30:07
Speaker
Well, we we know a dense bone island is very poor, very low in vascularity, right? So, yeah, that was a mistake to put that implant in the dense bone island for sure.
00:30:19
Speaker
um And it could have easily been avoided, the whole thing avoided, by using two implants and a three-unit prosthesis. What would you advise if, let's say, there is a a dense area and that is the only space that you have to place an implant? Okay.
00:30:35
Speaker
Well, if that's the case, first of all, I would be telling the patient that there was a much higher risk of failure. Great. um And secondly, I would be drawing blood and collecting liquid PRP. Uh-huh.
00:30:49
Speaker
coating the implant with that and irrigating the um osteotomy well with it before just immediately before I place the implant because just like the situation with patients who've been on bisphosphonates yes this morning we we did one patient where we used well we don't use PRP we use the Italian equivalent um which is called CGF but Anyway, yeah, I would definitely try to promote new bone formation as much as possible.
00:31:25
Speaker
If I can't avoid the dense bone island, i think i have to maybe I have to forget about an implant. That's it. But if I was taking the chance because the patient insisted, then I would definitely be using PRP.
00:31:40
Speaker
Fantastic good advice. late low rich Well, you know, platelet-rich PRF, I guess we call it now, because PRP wasn't very effective all those years ago. That is correct, the PRF right now. Well, Dr. DePorter, this has been a pleasure. i just wanted to ask you, before we wrap things up, is there anything else that you would like to share with the audience, something that perhaps we didn't discuss on your paper, or any any words of advice, any comments?
00:32:09
Speaker
No, not nothing that I haven't said already, but except that please, please, please don't be manipulated to do, to be constantly doing splinting on implants because it's, we now know, know, as I said, 40 years ago, people laughed at me when I said I could use a short implant. And the same thing was with Bicon too.
00:32:32
Speaker
um And, you know, people were afraid that using a short implant would lead to to a failure because of occlusal overload.
00:32:46
Speaker
But with the proper design, it won't or it shouldn't. ah Assuming that all other things are equal, that the soft tissue is adequate, that the patient's home care is adequate, that the patient is, you know, relatively healthy and so on.
00:33:02
Speaker
Yeah. Yeah. No, I like that. That was very good. That's a very good way to to finish it. Again, thank you so much for your time. I'm very looking much forward to perhaps meeting you in person during the annual meeting that is going to take place in Toronto.
00:33:18
Speaker
the american Oh, yes, that'll be next year, won't it? This year at the end. We're going to be there. Oh, it's this year. I hope it's a good meeting, and I i hope you can enjoy Toronto. You've been here before, of course.
00:33:32
Speaker
Yes, sir. Yeah. so um So I wish you the best. Thank you for the opportunity here. And, you know, I'll be ah working with Professor Piateli and his fine group of people to see if we can understand this better.
00:33:48
Speaker
We'll try anyway. And I look forward to reading your your future collaborations and the future work that is going to come out of those collaborations. And again, thank you so much for making time for us. Thank you. Congratulations on your coming 50 years of dedication to academia and teaching our our future generations of periodontists. That's something that is commendable. Thank you so much. Imagine I've been here for one third of the 150
00:34:16
Speaker
ah You earned That is fantastic. Thank you again for your time.
00:34:22
Speaker
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