dentistry uncensored highlights partner content A Better View of Implants

Dr. Howard Farran and Dr. Ernest Orphanos discuss periodontics, implants and the importance of magnification at work

r. Ernest Orphanos began Ernest Orphanos: It’s inaccurate. other dynamic with respect to what practicing as a periodontist in There is a plethora of reasons why we can do to save teeth. But we also D1994 in Florida, where today he but, by virtue of understanding have to be aware of the longitudinal focuses his services on dental implants the literature, we know that the studies. We can’t base the treatment and procedures related to dental longitudinal studies of All-on-4— we provide on our feelings or our implants, including All-on-4. compared to All-on-6, immediate-load opinions. It really should be based on Orphanos, who is the visiting and delayed-loading—have the same the peer-reviewed literature. lecturer for the postgraduate 10-year success rate. HF: How can new dentists department of periodontics at Tufts That’s No. 1. No. 2 is, if you do have determine whether they should use University, lectures nationally and a failed implant, you can replace the old-school periodontal surgery or internationally on this procedure, implant and weld to the titanium bar titanium? which allows four implants, as well as within the prosthesis. No. 3 is because EO: One has to defer to experts to teeth, to be placed on the same day. you’re reducing the bone, and you’re really make the best clinical judgment He teaches other surgeons All-on-4 at reducing this alveolar ridge, you’re for the patient, but a variety of factors his educational center in Boca Raton, getting down into the better basal come into play. Age of the patient is which made him a perfect candidate bone, so you have less remodeling. You one. If I have a 25-, 30-year-old patient, to discuss the technique on a recent have thicker soft tissue. I’m going to do what it takes to keep episode of the Dentistry Uncensored HF: I think that your specialty, that tooth for as long as possible. I also with Howard Farran podcast. periodontics, has changed more in consider root morphology, furcation The conversation, recorded in June, the past 30 years than the other involvement, the root trunk size, also touched on the changing field of specialties combined. Do you agree? mobility and the opposing occlusion. periodontics, the importance of proper EO: Not only has it changed, it HF: Is All-on-4 moving toward magnification and other topics. An has become more all-encompassing. All-on-3? abridged version follows. When to extract the tooth is a very EO: It’s already coming out and Howard Farran: Some people say challenging question to address. The has been through a rigorous five-year “All-on-4” means “None-on-3.” What do advent of LANAP surgery, which we protocol. With All-on-3, a definitive you think of that pushback? use in my practice, brings in a whole prosthesis for the lower arch is

82 OCTOBER 2017 // dentaltown.com the visibility, the better the quality of care that can be rendered. I use OmniOptic loupes from Orascoptic. The optics on these particular loupes are fantastic because they’re magnetically held. They’re easily removed A dentist’s view and you can replace them with with no magnification varying magnifications, such as 2.5 to 3.5 to 4.5 to 5.5. HF: When do you need to be at 2.5, 3.5, 4.5 and 5.5? EO: The higher the magnification, the narrower the depth of field, and typically the narrower the width of field. Width of field is also related to proximity to the eyes, so the closer the lens is to your eye, the wider the width of field. I like to do my initial examinations with a 2.5. It gives me a good view of the entire arch. I’m not a “tooth- adontist”—I don’t look at single teeth; I assess mouths. For quadrant surgeries, I’d perhaps go with a 3.5. For a site- delivered the same day or the following specific area, I would use a 4.5. In the day. It’s unlike All-on-4, where you’re in event I break a root tip off and have provisionals for several months, and it’s to go and retrieve it, I pop in the 5.5. It limited to the lower arch. It’s basically a just makes my life very easy. It allows The same view treatment option for patients who can’t me the luxury that my microscope with 2.5x magnification afford the luxury of All-on-4. doesn’t. HF: You exclusively use Nobel HF: How hard is it to switch from implant products. Why is that? 2.5 to 3.5 to 4.5 to 5.5? EO: It’s a tried-and-true implant EO: Just pop off the magnetically system with a lot of great features, held optics. To change lenses out including excellent primary stability probably takes a second—two seconds and tolerance of prosthetic at most—per lens. components. Dentists should use HF: I’ve always felt anyone working premium products that have research in the mouth should use magnification. Hear the entire behind them. If you want to build a What do you think about the dentists podcast online! good reputation and a good practice, who use magnification but their This article includes just minimizing problems and maximizing assistant and their hygienist don’t? some of the highlights results is the ultimate goal. EO: Loupes are cheap enough of Dr. Ernest Orphanos’ hourlong conversation HF: Do you think magnification is nowadays. For assistants, you can do with Howard Farran. To directly related to better dentistry? the pop-up so it’s a one-size-fits-all, download the podcast, EO: There is a direct correlation as opposed to through the lens. Pretty watch the video or read a full transcript, between higher magnification and much everybody in my office, for the go to dentaltown.com/ the quality of dentistry. The better most part, wears loupes. EO-magnification.

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the fault was my own for not getting an ENT clearance to check the drainage of the ostiomeatal complex. If we do not have proper cone beam technology Orphanos uses OmniOptic loupes from Orascoptic. “The optics on to understand what we’re looking at, these particular loupes are fantastic because they’re magnetically we shouldn’t be messing with the held,” he says. “They’re easily removed and you can replace them sinus. If we’re messing with the sinus, with varying magnifications.” we should get clearance from an ENT because just the trauma to a sinus is going to cause inflammation, and that HF: What technologies are you Why? Because they get the results inflammation can block the ostiomeatal passionate about? they want. They get the soft-tissue complex. You need to make sure you EO: First, good loupes. If you response. They have the architecture. have a patent ostiomeatal complex. If can’t see your dentistry, you can’t They have the prosthetics that allows you do these things, your success rate do your dentistry. I’m also a big fan for a beautiful result. I understand why for implants in the posterior will be of 3-D technology. It improves our some clinicians don’t refer—it’s an issue through the roof. diagnostic capabilities. I would tell of, “Am I going to lose a patient?” It’s an Now, on the flip side of the coin, am young clinicians to stay away from issue of money, but I can tell you this: I opposed to three-unit bridges? Let’s intraoral scanners for now. Soon The finest clinicians in the world—many be more specific. Do any of those teeth they’ll be able to do full-arch scanning of whom I work with and many of have endodontics on them? Because and capture soft tissue. CAD/CAM is whom I know—always refer out crown if they do, your success rate drops very expensive, so put that on the lengthening. precipitously. back burner for now as well. The goal HF: Some dentists say if you place If there’s endo on those teeth, on for young clinicians is diagnostics and the crown and the margins on the an abutment tooth, you might want to carrying out good, basic dental care. bone, the human body automatically reconsider a three-unit bridge. There is From a clinical standpoint, as a does a crown-lengthening procedure. a time and a place for an implant with a periodontist, loupes and cone beam EO: Those dentists don’t sinus procedure, and there’s a time and are essential. I can’t tell you how many understand what crown lengthening a place for a three-unit bridge. times I’ve diagnosed periodontic truly is. It’s not just vertically reducing HF: What knowledge could you lesions that were never picked up and the bone and the soft tissue. It’s also impart on All-on-4 that you think the prevalence of missed MB2 canals. horizontally recontouring the tissue, dentists might not get? I know these young clinicians want to such that you have a nice, scalloped EO: With my approach, All-on-4 treat maxillary first molars with endo contour. Think about crown margins is about facial analysis and restoring because it’s a lucrative procedure, but today. How do you get a good crown the face. If you go to my website, if you don’t have loupes and you don’t margin if you can’t see it? How do you center4smiles.com, and visit the gallery have cone beam, you’re going to miss seal that crown margin if you don’t in the All-on-4 section, you will see it’s those MB2 canals, which are present have a great impression? How do you not based on teeth; I diagnosis from about 90 percent of the time. remove the cement? That’s just such a the face on in, and not from the bone HF: It seems like 10 percent of weak argument, and from a biological on out. I also have a training center dentists refer all crown-lengthening standpoint it’s frighteningly wrong. where I train surgeons and dentists on procedures to periodontists and the HF: What is your religion of the the approach. All-on-4 is probably one other 90 percent don’t refer at all. What sinus? of the most misunderstood concepts, does this say about crown lengthening? EO: I’ve been a periodontist for and if you’re not adequately trained, EO: The most successful clinicians I 23 years. I’ve had three sinus postop you’re going to get yourself into work with refer for crown lengthening. complications during sinus surgery, and trouble. ■

84 OCTOBER 2017 // dentaltown.com