Implant Training and the Latest Implant Techniques and Systems

Dr. Rosenlicht is an Oral and Maxillofaical Surgeon with a prosthetic background. He graduated from Fairleigh Dickson University Dental School and completed OMS training at the combined programs of Tufts University and Boston University School of Graduate Dental Medicine. Dr. Rosenlicht has published numerous articles and contributed to three textbooks. He operates a full scope private practice with emphasis on bone augmentation and implants. As well, Dr. Rosenlicht heads the Connecticut Dental Implant Institute. In March 2008 the Connecticut Dental Implant Institute will be hosting it’s 21st Annual Ski Symposium. The topic this year: Jumping the Crevasse: Traditional to Technological Dentistry. Click Here to find out more about this Symposium.
Osseonews: When did you first become interested in dental implants?

Dr. Rosenlicht: Implant dentistry really goes back a long way. My first experience with dental implants happened in dental school around 1972 or 1973 when I became involved with a small study that the school was doing utilizing titanium endodontics stabilizers. I thought that this really would be a way of salvaging natural teeth only to find out that the residual roots did fail and the endodontics stabilizers really remained well integrated and almost impossible to remove once they have healed.

Osseonews: How much formal training in implant dentistry did you receive in your residency?

Dr. Rosenlicht: Actually during our residency in oral and maxillofacial surgery we received very little training as at that time implant dentistry really had not been well grasped the by general dental population. I left my residency program in 1978 and the real surge in dental implants began in the early 1980s.

Osseonews: Could you discuss your approach to immediate placement and immediate provisionalization. What are the indications and contraindications?

Dr. Rosenlicht: This is a question that really does require a fair amount of time to truly explain. However, the short answer is that we really do like the immediate placement of implants and immediate provisionalization. Quite interestingly in the late 1970s early 1980s when I became involved with dental implants all the implants that we were placing at that time were immediately provisionally loaded and appeared to be extremely successful. Those early cases were the titanium plasma sprayed screw. We were also doing a fair amount of sub-periosteal implants which even today I find to be successful as I look back on some of these cases that have continued to come in for follow-up. As far as managing these patients, occlusion, the quality of the bone are the intricate factors, as well as, educating the patient not to abuse these implants during integration in order to determine whether they would be good candidates for immediate placement and provisionalization.

Osseonews: In working with general dentists who refer cases to you for implant placement, what do you expect in the way of diagnostic casts and surgical guide stents?

Dr. Rosenlicht: Today with the advent of office based Cone Beam scanning we are able to fabricate surgical guides for our patients. We do ask our referring dentist to provide radiographic diagnostics set-ups when appropriate. I do not believe that guided surgery is always necessary. However, when we do have the availability of diagnostic stents and patients who we feel would be better treated with minimally evasive procedures this really is a wonderful technological advancement not only for implant dentistry but also for many of the surgical procedures that we are doing with guided methodology.

Osseonews: Do you use Cone Beam Volumetric Tomography to plan your implant cases?

Dr. Rosenlicht: Yes. Most of the cases we are seeing today we utilize our iCAT Cone Beam scanner in order to give us the 3-dimensional radiographic interpretation that only a CAT scan can truly give. Having this technology really has improved the level of care that we feel we can deliver to our patients in all aspects of dentistry, most importantly with implant dental cases.

Osseonews: What software programs do you use to analyze the tomographic scans?

Dr. Rosenlicht: The planning software that are out in the market are plentiful and sometimes become extremely confusing. All of our initial planning is done with iCAT Vision which is the generic software that is in the iCAT unit. It allows us to take adequate measurements of height as well as width. It allows us to easily visualize all of the anatomical structures so that we can carefully determine at that point whether or not we want to proceed with surgical guides for minimally invasive procedures and/or immediate provisional restorations. In regards to those planning programs we are currently using the Procera software by Nobel Biocare and Easyguide software from Keystone Dental.

Osseonews: Which tomographic views do you find most helpful in planning cases?

Dr. Rosenlicht: The tomographic views that are generated off the panoramic are the ones that we use most frequently in planning our dental implant cases. Certainly now with the availability of 3 dimensional modeling within the software programs and our ability to rotate these models we also can find great value in these views as well as being able to show those potential problems for patients which they can easily visualize and understand the treatment we are presenting to them.

Osseonews: Could you compare and contrast panoramic radiographs to Cone Beam Volumetric Tomography. Are panoramic radiographs of any value when Cone Beam Volumetric Tomography is so readily available?

Dr. Rosenlicht: This is a question that really is dependent on the type of problem that each patient presents. There is no question that panoramic x- rays offer a tremendous amount of value for diagnosis and treatment planning for dental implant cases. However, when comparing the panoramic to the patients clinical examination and areas of concern, with significant atrophy or concerns of anatomic structures, then there is no question that the availability of Cone Beam Volumetric Tomography is certainly going to be much more beneficial.

Osseonews: What implant systems do you prefer?

Dr. Rosenlicht: There are so many good implant systems out there, that question is certainly one that becomes personal and is a challenge. We at this time are using mostly Zimmer implants, approximately 60% of our cases with Nobel Biocare and other specific implant systems for special areas of concern the rest of the time. I like using provisional implants for the stabilization of provisional restorations.

Osseonews: What implant systems do you prefer not to use?

Dr. Rosenlicht: My reason for omitting other implant systems is not quite so much for implants that we don’t feel comfortable using but more as a matter of which implants fit the majority of our patient needs and in an attempt to keep the inventory and parts and pieces to a minimum which in today’s world of implant dentistry is getting harder and harder to do.

Osseonews: Do you feel that general practitioners can achieve sufficient competency to place multiple implants?

Dr. Rosenlicht: I have always been impressed with the level of skill that all dentists have if they take the time and effort to get the proper education and training. There is no question that there are some general dentists that are extremely skilled and can certainly place multiple implants with a great deal of precision and success. My concern today really as it pertains to general practitioners doing implants is that the education is so sporadic and the understanding of what is good for patients may vary.

I do feel that today with the advent of all the technologies that are being brought to the general dental population that there is a concern that the generalist can do many of previously referred out procedures without true specialized training. This does present a great concern to me as the real understanding of the comprehensive needs of the patient are often lost when patients are being treated by a non-specialist.

I also think being a specialist it is important to let the general practitioners know that they do have a tremendous amount of responsibility as what I believe are the gate keepers for dental treatment to be referred to dental specialists. There is tremendous pressure on general dentists to keep as much dentistry in house as possible for economic reasons. Unfortunately, many times when this is done the patient in the long term, I believe, may suffer from inadequate diagnosis and/or treatment that would have been rendered by specialty care.

Osseonews: If a general practitioner attempts to place an implant and encounters a serious complication like paresthesia or perforation of the maxillary sinus, would you advise referral to an oral surgeon?

Dr. Rosenlicht: There is no question today that as more and more general practitioners do attempt to do sophisticated dental implant treatment especially on compromised patients they are encountering and will continue to encounter serious problems, not only with paresthesia but also with bone grafting procedures that do not remodel, implants that do not integrate and situations where the failure of the implant may result in some significant bone loss or catastrophic failures.

This statement does not mean that implant problems do not occur with specialists but whenever a problem does arise it certainly would be prudent to be able to have the practitioner who does those treatments be able to handle those complications. I think that is one of the indications to be directed to the previous question on whether or not general practitioners should be placing implants in compromised patients.

Osseonews: What are your views on hydroxyapatite coated implants?

Dr. Rosenlicht: I was involved in some of the earlier studies with the Sterioss implant that were coated with hydroxyapatite. My feelings are that hydroxyapatite was and still is a great coating to have on a dental implant surface. There is no question that history does show that inappropriate types of HA applied to a morphological surface that may not be the best suited for HA coating can lead to some problems. The dental implants that we have used with hydroxyapatite coating appear in our practice to be equally successful to some of the other surface treatments that we are presently seeing on the newer generation implants. In our experience the HA coated implants do not seem to present any significant problems with bone loss more than some of the other implants that we are using.

Osseonews: Do you prefer to use tapered or cylindrical implants?

Dr. Rosenlicht: At this point in time we are using all treaded more often than not tapered implants and really have not used any cylindrical implants in quite a while. That being said I most recently did see a case in our practice where we did 6 IMZ implants in the middle 1980s. They appear to be extremely well integrated with a prosthesis that is now 18 years old and functioning extremely well. I do believe it is not necessarily the shape of the implant but some of those very difficult assessments such as bone quality, opposing occlusion and other variables that make implants successful.

Osseonews: What are your views on one–piece implant-abutments?

Dr. Rosenlicht: As I stated previously, I began my life as an implant dentist using one piece titanium plasma sprayed screws which were also immediately or very quickly loaded, this being said and coming from a history of those implants being successful what I see now is a return of what we had previously done in implantology in the 1960s and 1970s and then stopped when two stage implants became more popular only now to return to one piece, one stage immediate provisional loading much more commonly.

Osseonews: Are there any indications for mini implants?

Dr. Rosenlicht: There certainly are indications for mini implants as well as transitional implants. The application of those again is based on the type of prosthesis that is going to be fabricated, or the need to avoid any overlying pressures in certain areas and/or to support an existing provisional prosthesis.

Osseonews: In your experience, how do mini implants compare to conventional implants for long term use?

Dr. Rosenlicht: In my experience mini implants have a place for use. I do use mini transitionals for temporary support of overlying prosthesis but refer to remove them once the more conventional implants have fully integrated and can support the restoration. I have been surprised, however, just how well retained and integrated some of these smaller diameter implants are and do feel that they can function well as long as the stress that is placed on these implants is such that over time metal fatigue or stress fractures are avoided.

Osseonews: What is your preferred technique for performing a sinus lift?

Dr. Rosenlicht: The question again is one where the sophistication and understanding of the operator is very important. When looking at a patient based on the prevailing anatomy, the amount of residual bone I typically will make a decision to either do a standard lateral approach to the maxillary sinus with very careful osteotomies. We are using ultrasonic bone cutting instruments such as the peizosurgery unit. Once the bone is ostotomized care with currets and ultrasonic separators maintain the integrity of the maxillary sinus. What is important I think with the question that you asked is that once the sinus membrane is elevated graft material is best. We base our choice on the size of the graft, the age of the patient whether or not a perforation may have developed and/or a repair was necessary. Today we are doing a fair amount of sinus intrusions with osteotome techniques. I prefer to do that when we have a residual amount of bone greater than 5-6 mm. Below 5-6 mm. typically my preference is to do a conventional sinus graft. Our success rate with these procedures has been extremely high. The success of these implants into these grafts extremely gratifying.

Osseonews: What is your preferred material for bone grafts?

Dr. Rosenlicht: In the maxillary sinus I prefer to use a combination of mineralized freeze dried bone most commonly Puros combining that with tricalcium phosphate Cerasorb. Our graft materials are homogenly mixed and we use platelet rich plasma as an autograft in conjunction with local autogenous bone that we have collected from the site for these procedures. Again, the healing characteristics with the platelet rich plasma as well as the protein factors that are now made available significantly helps not only the hard tissue remodel but more importantly the soft tissue healing to ensure a greater degree of success.

In doing socket or onlay grafts again depending on the size of the defect and the age and quality of the patient we use a variety of different types of materials. Many times we are mixing some of our grafts with Orthoblast II or Dynagraft which comes in a reverse phase matrix. We find that using this material in sockets or in combination with other particulate material allows us to control the application of the graft. In situations where there is significant need for horizontal or vertical grafting either using block grafts or rigid membranes at that point becomes an option that needs to be considered.

Osseonews: What is your preferred technique for stabilizing a bone graft?

Dr. Rosenlicht: All of our block grafts are secured with self tapping bone screws done in a Lag screw fashion. Onlay grafts using particulate material are stabilized with titanium mesh firmly secured to the underlying native bone with multiple bone screws and tacks.

Osseonews: What advice would you give to a general practitioner who would like to learn how to place implants?

Dr. Rosenlicht: I have always been a strong believer that education is always the way to increase the quality of our patient care. The American Academy of Implant Dentistry is an excellent way for general dentists as well as specialists to get involved with dental implants and receiving the education necessary to be able to do both simple and complex procedures. The American Academy of Implant Dentistry is the oldest dental implant organization and has extremely excellent educational criteria for different levels of competence. I am proud to say that I am an Officer within the American Academy of Implant Dentistry and also a Diplomat of the American Board of Implant Dentistry/Implantology, which I believe is one of the better ways of acknowledging and verifying competency of dental implant education. It is important for all dentists to go out and seek the advice and take courses by those practitioners who have a variety of approaches to certain types of treatments. There is no question that implant dentistry certainly is an art as well as a science as is many of the procedures that we are doing in dentistry today.

Osseonews: On behalf of Osseonews.com I would like to thank you for taking time out of your busy schedule for this interview. The insights and recommendations you have made will be of value to our readers.

Interview conducted by:

Gary J. Kaplowitz, DDS, MA , M Ed, ABGD

Editor-in-Chief, Osseonews.com