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 innovation in periodontology and implantology.
Speaker: And hello everyone, welcome to this special series of Probing Period. Today we explore a microsurgical approach to implant mechanical rescue from the new clinical advances in periodontics, the 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 perspective 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 modification-enhanced techniques, or a student seeking to understand future periodontal and implant therapy, this collection offers valuable insights and practical guidance.
Speaker: Today, we're very fortunate to have our guest as Dr. Charles Mastrovich, who received his DDS degree from Northwestern University Dental School in Chicago. He went on to complete a postdoctoral general practice residency at Sepulveda Veterans Administration Hospital in l LA.
Speaker: In 1978, he his dental practice in the North San Diego County in beautiful San Diego. Dr. Mastrovich continues to be recognized for his excell excellence in dental care and lectures throughout the U.S. on his innovations in solving complex restorative cases in rescuing broken implant screws and abutment utilizing a high-powered microscope, which enables him to see the broken parts and use specialized instruments he designed to remove them.
Speaker: Using this microscope allows for more clarity to the diagnosis and further enables him to educate patients on treatment options. Without further ado, Dr. Mastrovich, Charlie, thank you for joining us. Thank you for your contribution with this special issue.
Speaker: And let's get started with some questions. I wanted to ask you, looking at your your historical development, you treated your first rescue case 25 years ago or so.
Speaker: And I'm curious, how was the learning curve? And how did you get better at managing these cases? Well, first of all, thank you for having me on today. It's a pleasure to finally see you. We've we've communicated quite a bit in the past. It's kind of a complex history for over 25 plus years, and the first case was a broken Abudman case. But you have to understand that throughout my career, I've kind of gotten cases like this.
Speaker: And as implant dentistry rose, so has the number of problematic cases that came into my office. So with that, at first it was like one or two cases a year and then pretty soon it was five or six and then 15.
Speaker: And that's escalated to the last few years. We do about 220 implant rescue. And by that we mean, you know, There's a various aspects to it. Broken screws is one thing. Broken abutments is another.
Speaker: Screws that have lost drive geometry. A lot of people call them strip screws. Getting those out, maybe um there's a lot of all in X cases now that have a lot more prosthetic screws and deal with, and they seem to get fouled up.
Speaker: And then there's this identification issue. We don't just do identifications unless there's a failure. It's amazing how many implant identification problems there are that have failed and now The patients out there in the cold with no possibility of, our they just don't have an answer. So we run into those quite a bit too. So it's been a complex journey. At first, there are a lot of times patients would come in and out two or three times before we could get the the right tooling figured out and and get them recovered. Fortunately, and and in about 1,500 cases now, we have not lost an implant.
Speaker: because of something we have done. We've come close a couple times. Then these cases are, we'll go into the other aspects of how to diagnose stuff, but the difficult cases that come in are, seem to still be there. So we keep trying to innovate different tooling and whatever to handle this stuff.
Speaker: Thank you, Charlie. One of the most important parts of your article is the description of this diagnostic algorithm in which you identify two components one is the threat position and the other one is a fragment mobility as the key variables could you please explain this algorithm and and how did you come to just focus on these two variables Okay, well, it becomes obvious after you do some cases that some are more difficult than others.
Speaker: Also, it becomes obvious some of these screws are fractured down in the threads. A lot of them are right at the top ah top implant thread and some of them are above.
Speaker: So I needed a way of diagnostically categorize things to direct treatment. So we just came up with a four part algorithm and it's separated with either a screw is mobile or it's not.
Speaker: And a screw is either above the implant thread or below, and it has different ramifications. So the super easy ones are the ones that are fractured above and they're still mobile and they you get those out without without issue. Then sometimes they're above but not mobile.
Speaker: Those can be stinkers. And below the threads, below the top thread is type three, and that's mobile. And that's only dangerous because without the right approach, you can ding a thread, mess up a thread, and then it becomes a four. So threes tend to go to fours.
Speaker: Ones can become one one's a pretty straightforward as long as you don't do a lot of stuff to them. and And so therefore, those are the four basic ones. Now we started Categorizing like this, I think I first lectured on it in about 2014. I've been making the wildlife since about 2010, I suppose. Lately, in the last few years, we've added two more categories, five and six.
Speaker: Five is an implant that's been already damaged. If we can cover the screws, then we have a situation where it can be restored with OEM components, standard screws. There's still enough left, in other words.
Speaker: The class six is it cannot be restored with OEM components. And there are very few of those that get saved because it has to be a very high value implant.
Speaker: And you have, because once, let's just say the threads are gone in a screw or in an implant, then the question is, ah how are you going to make it work? You can re-tap some implants, but now all of a sudden your screws and restorative components don't fit. It will be a unique implant.
Speaker: So we've done a few, i think, less than 10 cases out of 1500 in sixes. And then once in while we run into one that doesn't have a prayer, you know, and so we give last rites and send it to the send it to you guys.
Speaker: That's fantastic that you are able to discern and make these differentiation. think the value of this protocol that you have developed. It is communication, being able to communicate and being able to have a ah framework that allows us to understand the situation we're dealing with.
Speaker: With that said, Charlie, what instruments or technologies are essential for success? And with that, I wanted to to to get your opinion as far as the utilization of loops. Let's say loops that have seven times magnification, 10 times magnification instead of a microscope. What are your what is your opinion about that?
Speaker: Well, I'm not militaristic about it, but I'm getting close. good i I have never done a case without a scope. Case one was done with a scope across the street. There was an endo office across the street.
Speaker: And so I'd borrow their scope on Fridays. i don't I see a lot of cases that were where no scope was available. Probably 95% of the cases I see, ah no scope was used.
Speaker: Now, some of them get fouled up because doctor can't see. You can't treat what you can't see. And so when you're down in an implant, the dimensions are small and the tolerances are tight and you have to be able to see. So really without, an and I say that microscope is my number one tool.
Speaker: And if it wasn't working, patients get reappointed. There's no question about it. Hasn't happened, but it you know that would be it. I cannot get a good diagnosis without seeing mobility and you can't see mobility. Now you bring up a 10 power. I normally and live between 16 and 25 and 10 is once in a while, I'll go to 10 for some things, but I'm always up there in the 16 to 25 range for diagnostic reasons.
Speaker: A lot of times they'll be referred in as a non-mobile, you know, mobile screw and ah someone's worked on it for two, three hours and we just roll it out because it's still mobile. they They just couldn't see.
Speaker: And so that's it. That's important. And I think it's also worth remembering and emphasizing that it's not only the magnification, but also the light source. I think when you're working with a microscope, you have that coaxial illumination that makes us, it allows us to see those deep constrained spaces much more with much more clarity.
Speaker: You know, there's ah there's one other factor here too, and and light is absolutely is as important as as magnification, truly. But we also have a camera, ah photo shooting on our on our microscope and documenting these cases from stem to stern, we do.
Speaker: I do not want to own someone else's issues. And we don't. We don't have to because we really document the cases, and that's good.
Speaker: That's very important that you mention that too. So, Charlie, in your paper, you also emphasize and or actually advise against the use of ultrasonic tools internally in implants. Could you please elaborate why? Because that's one of the ah the first things that we hear is that we're using ultrasonics to vibrate, and perhaps the parts are going to get loose and so on.
Speaker: What are your thoughts with that? yeah well, I see a lot of cases where ultrasonics were attempted. And some of them are, um amazingly, some of them I still recover without too much trouble.
Speaker: but the But the range goes to, it's deadly. And so I want to call the attention to our website, mastervichdental.com, that we have, there's like four cases that we log together in.
Speaker: that Those cases are all ultrasonic. issues from little bit to a lot and. I have no idea how effective it is because those cases would never come into me. They would never, that they're resolved. And I know in the literature, there's quite a few cases that people are, or various doctors are using ultrasonics.
Speaker: So they must get some of them out okay. But I do not know what percentage that is. All I get to see are the ones that aren't. And so I, there's a little, I wouldn't even call it a study, but it's a little, I couldn't understand.
Speaker: why I saw this floating or flowing disaster inside of implants. It's secondary to ultrasonic use. And I set up a case, it's on the website, it it's under one of the blogs, it's ultrasonic use. and And show you the pictures of it, how much destruction you can do in a couple minutes with an ultrasonic. I didn't believe it at first, but it's absolutely true. I did it on a on a model with, um I care broke a screw in a model and And unbelievable. I didn't get the screw out either. And ah what it does is it, because you know, these things go about 34,000 cycles a second, and you just hammer the titanium.
Speaker: And it's often cited that, know, don't use ultrasonics on the outside of an implant. Why in the world did you do use it on the inside of an implant too? Because it's it you can't even see in that study that we have on our website, you can't even see the screw, the threads and the implant are joined. It's like hammered weld. it it it It will lock a screw in so fast.
Speaker: So I'm totally against it. I have never used an ultrasonic unit in practice inside an implant. We've used it a couple of times on stuck healing abutments as a way of vibrating a healing abutment loose, but never ah inside an implant.
Speaker: I just don't need it if you have a scope. An ultrasonic is not a substitute for a microscope, and that's absolutely true. Very good. Very well made point. Now, you mentioned as well concentric techniques in your paper.
Speaker: And I just wanted for you to elaborate that concept. What what is this about utilizing concentric techniques when dealing with these broken components? and I'm not a mechanical engineer, but I've been around mechanical stuff for a long time.
Speaker: And when you see a screw that's not mobile in there, you need to be able to put torque on it and mobilize it. And it's always easier to take one of these fragments out in one piece than it is to drill it out and take out the fragments and clear out the threads.
Speaker: You're asking for two or three hours of real hard work, and then it puts the implant more at risk. so we try we take ah very high percentage of these out without anything, so you don't need to do mobile cases, but with non-mobile cases, you have to have a way of mobilizing.
Speaker: The only thing that made sense to me was to concentrically drill a screw fragment because that's a safe area. the Most you'll be away from the threads is in that area.
Speaker: Once you deviate and go eccentric, then threads become at risk. So let me give you a little couple of numbers. See if you have a metric 1.6 screw, 1.6 millimeters, the the center, the pre-drilling core, when they made that implant, was done with a 1.25 millimeter bit.
Speaker: And then the threads are single point into to the sidewalls of the implant. So at 1.25, that is the biggest diameter you can use to, and if you are totally concentric, that would take out the whole core of the screw.
Speaker: Well, we drill like with 0.6 and 0.8 millimeter drills left hand because sometimes we take them out. But these are screws that are that are not mobile with our hand instruments. By the way, we have a bog on our inside about what hand instruments you need.
Speaker: And all these techniques are on there. If someone really, really wanted to learn some of stuff going through those, I think there's 45 case studies on there now. I could probably have a stack of another 40 that I haven't done yet.
Speaker: And those all that is um layered learning on there and you can pick up a lot. but So the the question is, the twos and the fours of the non-mobile screws, we immediately go to concentric drilling techniques, but you have to have control to do it. You can't concentrically drill by hand without good guides and with without following a case through treatment with a microscope.
Speaker: Not free handed for sure. And that's probably is a good segue for my next question. I know you like to tinker on your own tools. You have created some of your own tools as well. Could you please share with us what what took you to do that and what have you come up with? and Is this available or is this how can we get access to these these tools that you have designed?
Speaker: Great question. First time I was at AO speaking, i knew what the first question was going to be. and sure enough, right to the microphone, Dr. You have all these specialized tools, what am I going to use you know that's that's true course.
Speaker: Dr. And I have my own machine shop at home, and so I reverse engineer the implants. But by doing that I understand what the tolerances are what are the dimensions inside an implant are and and I understand the environment on on all these systems so it keeps me out of a lot of trouble, but to answer your question a little more directly.
Speaker: i i do I have a prototype tooling for sure. I use a few things from here and there, and we're always looking to improve. But the big issue is if you have a stuck screw, you have to concentrically drill. You have to have a drill guide that is made with some precision.
Speaker: And we we have the screw the drills to the The tolerances between our drills and our guides are very tight. And that allows me to, I've put center holes down a one-four screw with a 0.6 millimeter drill, and you do not have a lot of room to be eccentric. yeah So every now and then we have to do it.
Speaker: Probably once a week we're drilling a bit. And so we made up our own drills and we made up our own guides. and And I'll just make a ah generalized statement that The tooling out there, various companies have various kits with various names.
Speaker: And generally speaking, i see cases where those have been used and have not stayed concentric. So you're only as good as your tools. Like I say, you don't see really fine craftsmen in Harbor Freight getting their woodworking tools.
Speaker: And likewise, these companies have have that they treat these cases like second class citizens because they're more of a bother than they are a profit center, I suppose.
Speaker: So the tooling is pretty skim out there. We have a plan and we've been fortifying the tools and whatever for a long time and to make them available to only the people that are actually trained how to use them. Can't make endophiles if someone doesn't know use them. So it's the same thing. We're doing endo and implants.
Speaker: So with that mind, we are structuring an education program to help get those tools to the right people at the right time.
Speaker: And maybe it's one of those situations where most people don't even want to do this. And maybe there's most people shouldn't do it. know It's sort of a weird niche I have. So I don't know.
Speaker: We'll see. a very necessary skill and that is why i was so passionate when i saw your presentation and i invited you to to be part of this special issue um i guess probably something that we could do is guide our our listeners to your website at mastrovichdental.com and that that's where individuals can get information as far as perhaps further training But with that said, as far as the learning curve and and so on, what advice would you give to someone who, let's let's say, is getting into this for the first time? They are dealing with their first broken component.
Speaker: They're doing this for the first time. What type of advice would you give them? What mistakes or pitfalls should clinicians avoid when encountering these situations? Well, first of all, if you don't have a microscope, you're very limited on what you can do.
Speaker: if you If you have very high power loops, I think you're still limited about what you're going to do. That said, if there's a high percentage of these cases that are mobile, like but let's talk about screws now. Abuntments, they go from insanely easy, I'd never see those cases, to extremely difficult in some of the really tight conical connections.
Speaker: And we have to drill, distract, drill, tap, distract the pieces out. It's a whole nother program protocol. But also the the basic hand tools, you cannot hurt somebody if you're using the hand tools that I've got on the website.
Speaker: If you have those hand tools and you have reasonable magnification, And if you're the first person in there, ah not the second or third, you can rotate these out. Just remember that they look like you're screwing them in, not the mirror image. It takes a little while to, it looks like you're going righty-tighty and you're actually going lefty-loosey in a mirror.
Speaker: And we're used to that with a microscope, but until you kind of get used to it. So I would suggest that if someone's in that category, they use hand instruments only.
Speaker: no ultrasonics, I mean no ultrasonics inside an implant, and no rotary instruments that are unguided. And since the guiding, I would not, if you don't understand the dimensional fit of your guides, and you're going to be opening up some analogs to or some practice implants to see what your tolerances are and how your guides fit.
Speaker: And that's a stepping stone. Now, if I think if you have about if you have a microscope and all you have is hand instruments, you don't have the tools.
Speaker: I think yeah with screws, I think probably 70% of them, if you're the first one in, ah you can probably get that. It's the stuck ones, it's the 30% that takes serious layered learning.
Speaker: And it's like that in a lot of things, I think. But we've designed an education program that's, we're just launching it in the next, I believe the first practice videos or the first, why use a microscope in, in IMR, implant mechanical rescue? Is it for you in your practice? Or do you want want to tempt this? And do you want to spend the time to to be good with it?
Speaker: And if you do, and there's a lot of value to doing that, then I think then it's worthy of going down the road. If not, do the easy ones and refer the hard ones. But the question is, who do you refer to?
Speaker: So absolutely, yeah the surgeon that put the implant in may not be the guy that that cleans this up because he's he might grab for an ultrasonic unit because of just, it's just not that he doesn't want to do a god job, it's just ignorance of what it can do.
Speaker: It's amazing. So with that in mind, that's easy stuff. If you want, we're going to have ah like a study club format as well to do the layered learning, review cases and do that kind of thing. And that's why I've been setting up this webinar studio to pull off more of a virtual classroom to do.
Speaker: So it's kind of in in flux. we have to it's ah It's fighting a two-front battle, really, to get people trained. First part is you have to reconcile by the microscope. And if you only do one case a year, the ROIC on your microscope is pretty tough, unless you're using it for other things. And then pretty soon, that's a pretty good idea.
Speaker: Second of all is the is the tooling that you brought up already, and we are diligent. The problem with tooling is, let's say drill guides, for instance. You know worldwide, there's about 600 systems worldwide.
Speaker: And I think the FDA has approved about 100, a little over maybe now. So some of them are duplicates of others when they come off patent and some of them aren't.
Speaker: And if you start putting in guides that were made for one thing, probably not to our specifications as far as tolerance fit, then you have a situation where you have no guidance at all. And that's what happens.
Speaker: The tooling will be a big big part of this to get precision stuff to the right people. And I envision this, there probably will be a few people at first, hopefully scattered across the country. It's just sort of silly that people have to fly over here to do take out a screw, but they have.
Speaker: And there's another doctor in Florida that Dr. Como that's done a significant number of cases and he's 100% microscope, used a microscope for years.
Speaker: And I just talked to someone in Lithuania that she's an endodontist that's done a couple of hundred cases and she's hungry to get more information. So I think it's going to spread. I think that a few at a time, that's fine. If we can get that network set up so that we can get people referred to the right places, excellent. that would be That's what they need. So, you know, there's one other real quick thing I'm going to bring up. please We've only talked about the hows, you know, how to recover at this point in time. Very good.
Speaker: We have not talked about maybe the important most important question, that's why did it happen? And in my career of over these years, I say that almost all my time was spent on hows. I've got this patient in front of me. How am I going to get this thing out? how am going to do this? And how am I going to do that?
Speaker: And pretty soon it starts becoming routine, like a lot of things. But the real question is, why did it happen in the first place? Because if you don't change that, what you have is another one in a couple of years, three years.
Speaker: And so I think we have to teach people the whys. And if we teach these doctors whys, I truly believe that 70% of this can be eliminated just in good treatment. And the systems you use, why you use a system in a certain place.
Speaker: And I think that's that's really important. One thing that i I've seen that we're going to be talking about more and more in this future is many systems are going to universal connections on the whole system.
Speaker: Well, maybe on an all-nx case where you don't have the torsional loading issues and split up case issues might be just fine, as long as you have passive fit frameworks, et cetera. But you take that same implant and you put it in a single tooth molar.
Speaker: And probably 80% of the cases I do are single tooth molars. And you're asking for abutment failures, screw fractures, depending on the stability the joints.
Speaker: And that's what comes back in bite-ship. So it's it's knowing the whys. And that's what we've been spending a lot of time on, too, tracking the cases and doing that stuff. So those are the areas.
Speaker: Maybe one little last thing I'll squeak in. Please. If you have failure fast, It's happened in just a few weeks or a few days sometimes. Think iatrogenics.
Speaker: Think situations where those patients hardly use this. There's no time for load cycles, cyclic loading to destroy the parts. It is really and an iatrogenic problem. Now, I can't tell you right away what it is.
Speaker: But we are looking for it right away when they come in after two weeks, two months, even maybe a year sometimes. It might not be atrogenics what the dentist did. It might be the surgical placement of the implant, or it might be the kind of implant that was used in this site. i those those are all valid issues and those need to be, I think those need to be addressed. And some of those issues are hard to change once you have an integrated implant, you know, and the bones around it and the sites narrow and all kinds of problems.
Speaker: try to avoid them. That has been very enlightening, and I think the why's and doing forensics when you have this type of failure is not easy most of the time, as you said. There are so many factors that could be related to the etiology of these failures. Occlusion, of course, the placement of the implant, the alignment within the arch are just a few. And then you add the other factors, the other components, the other elements as the the tolerances between the engineered parts of the implant. itself i think there are so many elements that are involved that i think will make a very exciting perhaps potential next paper for you charlie i'm just still recovering from the first one it was it was in hindsight it's not too bad it in foresighted or the way you're doing it that's a little more anyway i think that's word to the wise when you talk tolerance fit in these there's another thing that happens oftentimes
Speaker: There's a big well world leader implant company out there. then then They can only account for 30% of their implants restored with OEM components.
Speaker: One of their sister companies from Brazil, um they can only account for 5%. Wow.
Speaker: Now you put that. Now the question is, that may not all be bad. The question is, how do you know if it's good? and And who takes the responsibility when it fails? That's right.
Speaker: That is a big issue that we're dealing with. It's all this componentry that is coming, like aftermarket or secondary sources and so on, that obviously there is not much research available looking at tolerances between componentry, but that's what we are seeing in patients' mouths nowadays.
Speaker: Charlie, this has been very enlightening. think it's a good spot for us to finish. I just wanted to thank you all for joining us as we explore this microsurgery in periodontology and implant therapy.
Speaker: And please stay tuned for more upcoming episodes exploring 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, Charlie, thank you so much for your time.
Speaker: Thank you, Diego. Thank you for sharing your knowledge with all of us. And again, thank you so much for your contribution with this special issue, Charlie. Yeah, thank you for inviting me. It's been a pleasure. Thank you, sir.
Speaker: Bye-bye. Bye-bye. Thank you for joining our episodes 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.
Speaker: Thank you.
