I will chime in that I am wholeheartedly against teaching implant placement to dental students as a tool they can use upon graduation. Here is my reasoning:
1. Although it is fairly easy to place implants in 30 and 19 spots, everywhere else can be problematic. 2nd molar region requires the patient to be open very wide for a long time to fit that large drill in to make the osteotomy, which is where conscious sedation (a tool most graduating DS students do not have)comes in.
2. Easy sinus lifts are no longer easy if the sinus membrane perfs (do enough and it happens). GP's are not trained to do lateral windows, and evacuation of a sinus can be tricky...best left to OMFS
3. Bone grafting to augment buccal plate in anterior aesthetic zone is a true art. Done incorrectly, you will loose 1-2mm of verical height and may not get the desired buccal plate enhancement to boot. Well trained periodontists who do this all the time get excellent results, making restoration a breeze.
4. High quality grafting material, membranes, BMP, are all quite expensive to have lying around, and are perishable. If you are not using the material on a very regular basis, it gets thrown away.
5. While I do see the validity of having a CBCT in a GP office, it is an expensive item.
6. Not all implants are the same, and discount items may not have the same integration success as name brand, the coating being a major factor.
7. Long term sucess of implants is the goal, and until you have seen the 10 year success rate of your own surgeries, you will not know what your perimplantitis/perimucositis rate may be. Many factors go into this morbidity.
8. Maintenace of the osteotomy drills is very important when placing implants. They need to be changed frequently and are expensive. More than a 557.
9. Patching buccal plates are not as easy as it appears, and if a fenestration occurs and threads are showing, this can be a real problem.
10. Implants in the aesthetic zone may often require connective tissue grafting to create a pleasing smile symmetry. Another perio procedure that I would not do from a youtube video.
11. Not all guides are created equally, and although they work the majoity of the time, there will be that moment when the CBCT did not detect fibrous tissue where it appeared there was bone, and the guide becomes useless. The experienced operator knows what to do. The inexperienced may not even recognize a problem.
In the end, GP dentists have so many procedures they can do, that implant placement seems like just another skill that is not really necessary. $999 for an implant and crown seems not only ridiculously low for the procedure, but is a cautionary tale to new doctors. When we undercut eachother by providing discount services with cheap, less than optimal armementarium, we are not creating more access, simply diminishing our own worth. Even the best products under optimal conditions fail, we are after all working on people who are not perfect. Why take chances with shortcuts and products which may be suspect. My respect to TanMan, who once again has proven to be a super dentist with all the answers and no failures. I am sure we all aspire to those lofty regions.
Although you make many good points, I think it's naive to think that if you don't teach dental students certain skills, that they will refrain from performing the procedures. This is why I respect endodontics and their field. They aren't territorial like their specialist counterparts. And contrary to your sarcasm, I do have failures and I learn from my failures. As doctor(s), we should have sufficient knowledge base to draw upon to know what to do when we mess up. Otherwise, we are no more a doctor than a tooth monkey. As I've always said, you will have failures in your clinical career, and how you manage the patient and the failure is the most important aspect. Learning from those failures are key. When I focus on single tooth restorations, my failure is limited to that... single teeth. That's why I don't do all on X's and such, because I am managing my risk and failures. Fixing a whole mouth that's failing is a lot more time consuming than fixing a single tooth.
I'm going through some of your points to agree/disagree on them. While you do make a lot of good points, we do have different practice styles. I am a little more aggressive and you are a bit more conservative. I don't think there's a right and wrong way, but just different ways of practicing.
1. Although it is fairly easy to place implants in 30 and 19 spots, everywhere else can be problematic. 2nd molar region requires the patient to be open very wide for a long time to fit that large drill in to make the osteotomy, which is where conscious sedation (a tool most graduating DS students do not have)comes in.
This is true, not only that, you have to make sure you respect the lingual concavity of #18/31 and with the added bulk of a surgical guide, performing an osteotomy can be difficult. I use a side entry type of surgical guide to increase access, shorter drills, and improve irrigation. However, even if sedated, I think we still have to respect the patient's normal anatomical opening and not force your way open.
2. Easy sinus lifts are no longer easy if the sinus membrane perfs (do enough and it happens). GP's are not trained to do lateral windows, and evacuation of a sinus can be tricky...best left to OMFS
This is where a guide helps tremendously. Indirect sinus lifts are relatively easy and the versah bur system helps make indirect lifts very easy. Basic surgical skills of sinus perf during an indirect lift are critical and identifying a perf vs lift.
3. Bone grafting to augment buccal plate in anterior aesthetic zone is a true art. Done incorrectly, you will loose 1-2mm of verical height and may not get the desired buccal plate enhancement to boot. Well trained periodontists who do this all the time get excellent results, making restoration a breeze.
Pick your battles. If it requires a soft tissue grafting/keratinized tissue, leave it to perio. As a GP, we should be doing easy cases, not difficult/time consuming cases.
4. High quality grafting material, membranes, BMP, are all quite expensive to have lying around, and are perishable. If you are not using the material on a very regular basis, it gets thrown away.
What you're describing is essentially inventory management. Any office should be doing this anyway. Buy enough so that you can get volume discounts when applicable based on expiration dates, but not so much that you end up having to throw out material.
5. While I do see the validity of having a CBCT in a GP office, it is an expensive item.
Expensive, but an important tool for a GP that wants to place implants seamlessly. You could always do a flap when in doubt, but if you're trying to go flapless, CBCT is important.
6. Not all implants are the same, and discount items may not have the same integration success as name brand, the coating being a major factor.
This is definitely true. I use certain implants for certain sites. My favorite so far are the biohorizons laser-lok 3.0. Not all implants are made the same, and some are better than others, even within different implant lines. For example, I see consistent bone loss on the nobel replace select tri-lobes over a period of a few years, whereas I see much better results with the nobel replace conical connections.
7. Long term sucess of implants is the goal, and until you have seen the 10 year success rate of your own surgeries, you will not know what your perimplantitis/perimucositis rate may be. Many factors go into this morbidity.
True. I haven't been practicing long enough to know the 10yr+ success rate of my implants. Am I going to be around that long? I'm not too sure. Is it realistic to expect dental work to last a lifetime? I don't think so. If nature couldn't get these teeth to last forever, what makes us think that manmade materials would do the same.
8. Maintenace of the osteotomy drills is very important when placing implants. They need to be changed frequently and are expensive. More than a 557.
Either use a new one each time or count how many times you use them before throwing them out. Once you feel a difference in cutting, toss them out. Same thing like burs. You want a nice cutting bur to reduce friction/heat generation. Instead of heating up the pulp, you're heating up the bone. I'm not sure how this is a point, this is something a regular gp can relate to.
9. Patching buccal plates are not as easy as it appears, and if a fenestration occurs and threads are showing, this can be a real problem.
Yes, it's annoyingly time consuming to do. Never happened to me yet, but this is where you should have good specialist connections to bail you out if you really need to. As I've outlined before, develop positive relationships with your specialists. Give them easy and hard cases. There are protocols to fix buccal fenestrations, I just haven't had a chance to fix one yet, nor would I want to fix someone else's implant problems.
10. Implants in the aesthetic zone may often require connective tissue grafting to create a pleasing smile symmetry. Another perio procedure that I would not do from a youtube video.
I definitely agree with this one. Leave perio surgery to the periodontists. Otherwise, you're going to have to depend on pink porcelain to try and manage the defect and the results are not all too great.
11. Not all guides are created equally, and although they work the majoity of the time, there will be that moment when the CBCT did not detect fibrous tissue where it appeared there was bone, and the guide becomes useless. The experienced operator knows what to do. The inexperienced may not even recognize a problem.
That's where tactile sensation comes into play, looking at what you're removing from your osteotomy, and the feel of the walls. This would all depend on the extent of the defect/lack of bone and where to go from there.
Edit: I forgot to address your last sentence. I don't have all the answers to every clinical problem. I have the answers on how to become a profitable GP that knows what cases to take on and which to pass on. Procedures fail and the single most important advice I have for aspiring dentists and dentists alike is how you talk to your patients. All your clinical skill does you no good if you don't know how to relate and talk to your patients. If patients love you, they'll stick with you through thick and thin, even with repeated failures.
