View from the Chairside: No Shortcuts to Implant Mastery
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For those who watch Dr. Belzycki’s presentations for the first time, Dr. Belzycki is a Toronto general dentist; and he regularly shares four decades of clinical experience with his colleagues. We always want to hear your thoughts and questions about this post and other topics. Leave a comment in the box below or send us your feedback by email or call us at 1-855-716-2747. Until next time! Chiraz Guessaier, CDA Oasis Manager |
Read/download the transcript of the conversation and the case presentation (PDF)
Previous Episode
- Episode 1: View from the Chairside: Mediocrity In Implants Requires No Effort
- Episode 3: View from the Chairside: “Let no one ignorant of geometry enter here” – Implant Cases Series
Dr. Belzycki’s Thoughts
“Should I get into implants and Where to begin?” has been the focus of a recent presentation on Oasis by Dr Mike Racich. We do not coordinate our topics and the fact that both presentations follow one another is purely coincidental. I am pleased to claim that I agree with his viewpoint and I would like to add to it.
You the reader surely have heard the accepted truism, “Practice makes Perfect.”
Some 30 years ago, I took up Olympic (International) Skeet Shooting. I was totally committed to becoming the best I could be; and so I concluded that endless hours of practice was the answer. Progress came slowly. Some years later, I attended my first competition and had a conversation with one of the best shooters in the world. My first question was”…What is the secret to becoming an accomplished Skeet shooter?” I naively thought a hidden shortcut was being kept from me. I informed him that I practiced mercilessly and my low score was not from lack of effect: “Doesn’t practice make perfect?” I asked. His response “…No it does not. Perfect Practice makes Perfect. You need to find out in great detail what the best shooters are doing and emulate them and then build on that. You must become totally immersed the sport. You will quickly realize they have struggled far more than you have.”
My series of mentorship presentations has several overarching themes. One is the need to internalize knowledge and skill into oneself. To immerse oneself into the Art of Dentistry. This can only be accomplished by a willingness to perform a given task to an ideal standard over and over again, coupled with an honest evaluation of the end result over a lengthy period of time.
One initially masters “simple” skills and then builds on those successes to undertake tasks of increasing complexity. The knowledge and artistry I developed through years of sculpting simple provisionals and resetting denture teeth in wax, guide the design principles elucidated in the complex implant overdenture case discussed in this post. This knowledge is neither expressly found in textbooks nor in computer algorithms. It is Somatic Knowledge; of and by the Hand. There are no shortcuts to “getting into Implants”.
Beautiful case. All is well that ends well.
The finer points of planning, designing and executing these types of cases does stem from experience. Unlike most other medical specialities that have some evidence based recommendations this type of work is artful and based on dogmatic experience.
There are however several points in the case that need to be stressed. The first is that the issue with the bar having an anterior metal bulk stems from lack of precise surgical planning. The implants are placed far facial and there is limited vertical space. Having had planned the final prosthesis contours and tooth positions prior to surgery would have helped in making sure implants are in the right orientation and mid lines are correct rather than solving these problems once the bar is milled and overdenture produced.
Secondly, correct restorative space would have allowed selection of locator attachments rather than the ball attachments used here.
Digital and analog modalities both play an important role in today’s planning and execution. Both must be utilized along with experience and evidence to deliver excellence.
Comments to these posts follow several themes. One theme is enthusiastic approval…a thumbs-up if you will. The other end of the spectrum is a definite thumbs-down…such as those I received on the use of amalgam…from the metal-free folks. Then, there is a comment theme I will label as “give and take”. Credit is first “given”, in this instance for a successful outcome, then credit is “taken away” with some criticism; and in this case, for a lack of “precise surgical planning”. Then, comments are made regarding patient-specific criteria and how treatment should have been better rendered. I find all this unimpressive in light of the fact that those replying have no first-hand knowledge of the case. They have not examined the patient nor their radiographs, nor have they access to the models, etc.
Let me assure all readers and viewers that an excellent oral surgeon placed these implants with the use of appropriate radiographic images and two decades of clinical experience.
I have heard the argument that no implant needs to be placed in a less-than-perfect angulation because through the magic of bone grafting, anatomy can be optimized to perfection. I have yet to be convinced of this level of certitude. My team of very experienced surgeons echo this sentiment. In addition, there’s always the consideration of what we can expect a patient to live through and afford.
My experience has taught me that the Organic World lacks the claimed precision of the digital realm. In more philosophically correct terms…there are issues with replicating perfectly the Organic World in a digital format. The first example that comes to mind is Human Intelligence versus Artificial Intelligence. That has been my experience; to seek no more precision in a system than it may admit to. To quote Richard Feynman, for a computer to accurately model Nature, it must be a quantum computer for the permutations of Reality from any starting point are fair too numerous. But I digress.
I have recently completed a case of nine implants in three quadrants, using the Fusion System by Nobelbiocare which “fuses” 3D scans of patient with a final prosthetic design. I sat quietly in a corner, while my surgeon and the Nobelbiocare representative planned out the case in the digital realm. This process took over an hour to refine implant angulation, spacing, and length while avoiding important anatomical structures. When they were satisfied, they turned to me and asked for my input. Every change I suggested from a prosthetic perspective, negatively impacted implant alignment. So, I laughed and made the following comment which I have made countless other times when it comes to implant placement:”Do what you gotta do, just get me in the ballpark..I’ll take it from there.”
Even with a computer-generated surgical guide, the prosthetic endeavour was not a “slam-dunk” affair as advertised. It too required “artistic tweaking” by a Human Intellect that has been fully immersed in the Art and Science of Dentistry to guide Human Hands.
I recently viewed a video by Straumann about their new 3D printer. A lab tech is shown working on a case. The statement was made…”We do all the work…you take all the credit”.
Still, I remain unconvinced, yet thank you Dan for the time spent to leave a comment.
Dr. Paul Belzycki, DDS