Needful Things by Dr. Jay B. Reznick

The importance of proper education in implant surgery

by Jay B. Reznick, DMD, MD

I once overheard a dentist who was a speaking at a 3D technology conference tell one of the attendees, “If you are a dentist and you can drill a hole, then you can do implants.”

At first, I understood what he was talking about: If you were smart enough to get into dental school and graduate, and have the manual dexterity to master restorative dentistry, root canal therapy and periodontal care, then you have what it takes to bring implant surgery into your practice. But the thing is, placing a biocompatible prosthetic anchorage device traversing the oral mucosa into the bone of a living, breathing human is a lot more than just drilling a hole and sticking a screw into it.

And that is a major problem we have in dentistry today—the “dumbing down” of implantology education to bring it to the masses. After all, dental implant surgery is surgery. And performing surgery in the face and jaws is much different from performing a restorative procedure on a tooth. Performing a surgical procedure on a patient is a privilege that needs to be regarded with tremendous respect.

Surgical specialist training is much different from a weekend course or a “mini-residency.” One of the first things we are taught is that we do not attempt a surgical procedure until we completely understand the anatomy and physiology involved, the treatment options, the potential complications of the procedure and how to avoid those complications, as well as what to do if they should occur.

You never begin a surgery unless you are prepared to take it to completion, without anyone else having to get you out of trouble.

You also know how to manage postoperative care and complications. The progression of the complexity of surgical procedures is slowly and deliberately advanced: First year is filled with hundreds of “simple” surgeries and experience observing and holding retractors in the operating room. It is not until the senior years, after thousands of hours of training, that surgical residents are allowed to start doing more complicated procedures.

I see more and more courses these days aimed at general dentists, who may have had minimal surgical training in dental school. These courses promise dentists that they’ll be doing fully edentulous cases, bone grafting and other procedures after the equivalent of one week or less of surgical residency.

Doctors are led to believe that after placing a few implants in a patient they’ll never see again, they’re qualified to do advanced cases in their own practices. They’re told that they can do anything that specialists can do. This is just not realistic, successful or safe for our patients. Dentists who want to learn to place implants must not look to fast-track their surgical training, but approach it in the same way specialists get their advanced education.

First, it is critical to learn from educators who are truly experienced and credentialed in the topics and procedures they’re teaching. The best teachers I had in surgical residency were not fellow residents a year or two ahead of me; they were the experienced attending surgeons who not only had completed training but also had many years of managing a wide range of patients and cases and had learned what to do and what not to do. Working with them, although much more intimidating than working with my peers, is what made me become a more confident and competent clinician.

Case 1

Many years ago, I helped in the design of a guided implant surgery system that is now in use. I was frequently contacted by sales reps of that implant company to help doctors who had questions or issues with their implant surgeries.

Fig. 1

One afternoon, I was called by a dentist who was very concerned about her recent implant case. She had done it fully guided and thought that there was a problem with her guided surgery kit. She sent me the two-month postoperative radiographs (Fig. 1) to review.

I asked her many questions about her training and how she worked up the case and did the surgery, from a technical aspect.

She had taken a five-day implant course in Mexico about three years prior. She said that she placed about a dozen implants in that course and that she hadn’t taken any implant courses since. She didn’t have her own CBCT, so she used a mobile CBCT that came to her office parking lot. She didn’t have implant planning software, so the mobile CBCT lab also did the treatment planning and made the surgical guide for her.

The patient was fully edentulous, and there was no index to position the surgical guide, nor skeletal fixation screws to stabilize the stent. I was beginning to formulate etiology of her far-from-ideally-placed implants when I asked her how many implant cases she had done since her course three years ago. Her answer: “Oh, this is my first case.”

So, what can we learn from this example? I don’t know the details about her implant training course, but I can guess that it was decent—but I have trouble remembering things from courses I take unless I implement what I learned soon afterward. Three years is a long time to remember what she was taught about implant planning and surgical technique, given that this was the first time she had used this knowledge in actual practice.

There are some implant planning services that use only well-trained technicians and are very good at knowing which criteria are used when positioning an implant in the CBCT planning software. Relying on a local lab technician with unknown expertise and clinical knowledge can be very risky. This doctor stated that she was given the opportunity to review the treatment plan before stent fabrication, but she declined.

Remember, the clinician doing the procedure is the one who is legally responsible for all aspects of the patient’s treatment. It is imperative for the doctor to review the treatment plan personally for accuracy and appropriateness before the surgical guide is made. And make sure to know all the nuances of the guided implant system that you’re using.

The other glaring issue here is patient selection. Fully edentulous cases can be much more complicated than they appear. There are no reference points to orient for the position of the implants, as there is with a partially edentulous case. Also, without teeth, the surgical guide has no inherent indexing or stability. The surgical stent needs to be oriented via an index to the opposing arch and held in place with fixation screws or pins.

This was not a good choice for someone’s first case! Patient selection is of paramount importance. As I discussed earlier, your first cases should be simple, straightforward and predictable.

In my beginner guided implant surgery course, I tell doctors that their first two dozen cases should be single-tooth, from first molar to first premolar, and flapless (i.e., adequate bone and keratinized tissue volume).

Only after they have mastered these cases should they should come back and learn about flap design, suturing, simple bone grafting, multiple (no more than four) implants and anterior aesthetic zone implant surgery.

Many of my students have taken other implant courses and told me that my approach has brought them success. This is the same way that surgical specialists learn to master their surgical skills: slow and steady. The last thing you want to do is to spend thousands of dollars on an implant system and give up after your second case because of a poor result or complication. Implantology is a great addition to your clinical skills. If you stay within your training and comfort zone, you will enjoy doing implants and have many happy patients.

So in this case, was it the use of an outside technician to do the planning, poor surgical guide design, poor case selection or inadequate doctor training that caused a disaster? It was all of the above.

Case 2

A dentist in my neighborhood asked me to help him with an implant he had placed, which he was afraid was failing. This dentist tried to follow what I teach. He had taken the implant planning course that came with his CBCT and one weekend implant course.He started with a simple case in a young, healthy patient: a mandibular first molar, with plenty of bone and plenty of keratinized tissue.

He planned the case following what he was taught in the planning course, made sure that the surgical guide was accurately placed and stabilized, and placed the implant through a tissue punch with no problems. His postoperative radiograph (Fig. 2) shows acceptable implant placement. It was closer to, and parallel to, the tilted second molar. Ideally, though, it should have been closer to the second premolar and more parallel to it. The patient had an unremarkable recovery.

The patient began complaining of tenderness around the area of the implant about two months after placement. His dentist told him that this was normal and would get better. But it did not.

When the patient presented for the four-month postoperative visit, he was still having aching in the area, and his dentist noted that the implant was mobile. A periapical radiograph (Fig. 3) showed bone loss around the implant fixture. At that point, he called me for advice. He then referred the patient to my office.

On exam, the cover screw of the implant was exposed. There was redness and tenderness in the area, but no swelling. The implant could be easily moved with a perio probe and a small amount of pus could be expressed from around the fixture. There was no doubt that this implant had failed and was infected.

Why did this occur? We can only speculate that failure resulted from inadequate irrigation, prolonged drill-to-bone contact, excessive insertion torque and/or poor aseptic technique. All are possible. At this point, the proper plan is to start the patient on antibiotics, remove the implant, debride the site thoroughly and graft the site so a new implant can be placed in the edentulous site. That’s exactly what I did.

Why is this case noteworthy? There are two issues: First, the training of the dentist. Although he attended treatment-planning and implant placement courses, it’s likely that the implant course was a “how to place an implant” course, not a comprehensive course that discussed physiology, biomechanics, aseptic protocol and prosthetically driven planning. In other words, it taught him how to be a technician, not a clinician. Those concepts are critically important to know before you place your first implant.

The other issue is the dentist’s failure to recognize a problem until it was too late, and then how to manage it. It is important to listen to our patients. After a single flapless implant surgery, patients should have minimal discomfort that abates in a day or so. Prolonged tenderness or pain is a sign of a problem. We have to take our patients’ complaints seriously and not brush off their concerns. Listen to them!

It has been noted by many experienced clinicians that prolonged postsurgical pain is a harbinger of implant failure. Removal of an implant that is symptomatic six weeks after placement is becoming the recommendation, rather than waiting for frank implant failure and bone loss.

Just as the majority of implants are very successful, implant failure is part of practice. At the beginning of the article, I discussed that surgical residents are taught they should not do a procedure if they don’t know how to handle the most common complications without assistance. Clearly, this dentist was never taught this. He had no idea of what to do. He was not ready to place his first implant. I handled the complication for the dentist and explained to the patient that this sometimes happens, even in the best, most experienced hands.

I sent the dentist a bill for the implant removal and bone-graft procedure, at a significant discount. A few days later, he called to tell me that I should have billed the patient for this, because it was not his fault as the dentist that the implant failed.

I told him that it wasn’t the patient’s fault, either. Patients pay good money for implant treatment. If an implant fails years after the implant was placed, then the patient is generally charged for management. If it fails in the first year, most clinicians will absorb the cost to keep the patient happy. You don’t want to have an unhappy patient who just paid you lots of money. It is not good patient management—or good risk management. We can all learn a lot from this case.

Fig. 2

Fig. 3

Closing thoughts

I’ve been teaching nonsurgeon dentists how to do implants for a number of years. My goal is to make them successful and continue to do implants through their entire careers. That requires the proper approach to learning and to gradual progression of complexity of their cases.

Just as I learned the most from my senior attendings, look for courses taught by experienced specialists who understand the needs of a general practitioner and will teach you to understand all that you need to know about the right way to add surgery to your practice.

Don’t select the least intimidating instructors: They generally will not have the experience and knowledge to share that will allow you to provide the best care for your patients and enjoy implant surgery. Finally, remember that implant surgery is surgery. Respect it!