| Part Two
Part Two – Implant Seminar Gives General Dentists the Basics
By: Jean Johnson for Dental1
More than 25 percent of the general dentists who Nader Rassouli, D.D.S, M.S. tried to interest in taking a course on implant basics have taken him up on the offer. All 12 of them are there at 8 a.m. on a Friday morning. The session will run the length of the day, and then again for eight hours on Saturday.
| Doing Your Part When Getting Dental Implants|
The American Dental Association literature suggests that patients who are considering dental implants should be sure that:
You have healthy gums.
You are in good health overall.
You are committed to thorough oral hygiene to keep your mouth healthy and free of infection during the process.
You are willing and able to schedule regular dental appointments.
Getting dental implants is an extended process over many weeks, and a commitment from the patient will ensure the best outcome for the dental implants.
The group is a cross-section of folks – different ages and cultures. They look as bright and refreshed as possible at the end of a four-day work week.
Rassouli begins the intensive course with a promise. “When we are done, you should be able to do a single tooth posterior, and for denture wearers, lower anterior implants,” he said. “Also, you will be able to bring your patients into my office for one-on-one tutoring while I walk you through your first case.
“Fear is the main thing that prevents someone from exploring a new frontier like this, but once we overcome that, the possibilities are endless,” he went on. “Implant surgery is not difficult. The fear surrounding it has come either from the referring surgeon or your own prohibitions.”
With his distinctive sense of humor, Rassouli reassures his group not to worry because they will get manuals when they buy their implant drill and kits. “But do not keep them out because it makes the patient nervous,” he said. His students reward him with a round of laughter, so he pushes the fun factor a bit more. “I usually keep mine on the floor and turn it with my foot.”
With the mood lightened, he quickly returns to business and reiterates the goals of the course.
“Cases in which a single molar in the back is missing can be easily and safely done by general dentists,” Rassouli said. “The technique is not that difficult where only a single posterior tooth is missing or where a patient that wears dentures wants some lower anterior implants placed to stabilize their prosthesis.”
Rassouli also underscores his ideas on how useful it is to have the dentist who will be doing the restoration also place the implant. From the very beginning of the planning, he says, dentists who will be responsible for placing the crowns will think restoratively. In his view, the outcome will be superior to cases in which one dentist does the implant surgery and then a second completes the restoration of the teeth.
| Put it into Perspective|
Today’s modern titanium implants, first discovered by Sweden’s Per Branemark in 1953 and applied in 1965, are only the most recent developments in the history of humans trying to replace missing teeth.
During the Egyptian era, sea shells were used with apparent degrees of success. The sea shells were hammered in the bone of patients who were missing teeth.
Titanium dental implants began to take off in the United States and around the world in the early 1980s.
As the baby boomer generation begins to age, market watchers expect to see interest in dental implants increase by between 12 and 15 percent per year.
He also coaches the group on how, particularly at first, they should choose their patients wisely. “Initially you need to do only sites that do not require bone grafting or that have other complications,” he said. “Five years from now you might be ready to do those cases, but now the posterior implant is the way in the door.”
The room darkens for a short video that shows a posterior implant being placed on a patient by a dentist. Once the lights come back on and the graphic visuals of surgical sites fade, Rassouli has his charges check out the implant drill units and tool kits.
There is the drill itself: A cold, stainless steel affair reminiscent of a sculpted golf club iron. Then there’s the foot pedal for the drill with big round color-coded control buttons. Finally, the small box containing an array of technology for the trade: Drill bits, implant screws, abutments, and a petite, calibrated torque wrench.
While the family-practice dentists seated before Rassouli are exploring the new technology, he tells them to think about implants much in the same way they think about doing a root canal.
“First you start the osteotomy with a 2.0 mm drill that you line up exactly in the middle between the two teeth. The drill is marked with lines that correspond to the depth you are drilling,” he said. “You also will take an X-ray to check your angulation and make sure you are equidistant and parallel to the adjacent tooth roots. If you are off at that point, you can go back and make the correction. What you do not want to do is enlarge the initial hole until you are sure you are lined up with the central fossa and in the center.”
The course is filled with talk and terms like this, as well as discussions of things like the alveolar nerve and the sinus cavity, both structures which need to be avoided when placing dental implants into a human being’s jawbone. But once the dentists pick up their scalpels and start practicing on their models, the discussion soon gives way to studied silence that envelops the room. Soon after, the soft chugging of the implant drills and the crinkly sounds of wrappers coming off dummy dental implant vials can be heard.
Rassouli also talks about how much measuring is involved in placing an implant – from the panorama X-ray of the patient’s mouth mounted on the light board, to the drill, to the mouth and then back again. “But the last piece is done without water. It’s quiet then, and the best feeling,” he said, laughing about how he needed to get a life. “It’s like hanging a piece of art work on the wall. You measure and measure and then finally, the painting goes up. That’s what it’s like when you place the implant. It’s great.”
While his students practice, he encourages them even as he skirts back around to the meticulous perfection that dentists who place implants need to bring to the task.
“If you are not happy with the positioning, you need to address it,” he said. “If you place a bad implant in one of your patients, you’re going to have to look at that the rest of your career.”
Again, he says that the best time to adjust a pilot hole that isn’t quite right is immediately after the X-ray. “A small mistake only gets bigger as we move forward,” he said, also coaching the group about how they need to let the drills complete with irrigation do the work and not rush things. “The bone needs to stay cool while you are drilling since the cells will die if they get hot and the implant won’t integrate.”
There are beeping sounds as some of those in the group back their drills out of the models. Then there’s more technical talk about how dentists should not force the implants into place but instead carefully hand-tighten them and then use a dental-sized calibrated torque wrench to tighten according to specification. “You could break a screw inside the implant if you torque too hard,” Rassouli said. “If the implant is not flush with the top of the gum, don’t force. Back it out, and do a little more drilling. Then go back to placing the implant again.”
Implants are part science, part art, and a lot of tending to meticulous details. Also, case selection pays off, Rassouli says, listing health parameters that give implants the best chances for success. The two-day course is full of admonitions, information, and most of all support.
In the end, though, he circles back around to what he’s been advocating the entire session. “People don’t like to travel around. They want their own dentist to do their implants if it is indicated. They feel more secure that way.”