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The same thing is happening in Europe
right now. Some of my graduate students
who are in top practices in
Spain, for example, are in such tough
situations because people are just not
spending. They don’t know what’s happening
to the euro; they don’t know
what’s happening to the economy.
Patients are not coming in except for
the most critical needs — and I’m talking
about really established practices,
not clinicians who are just starting out.
So, clearly, if the economy is affected,
people are going to say: “Hey, can I
get the same quality for less money?
And if it happens to be a company in
my own nation, even better.”
DC: That’s an interesting take on things.
If we look at research for a second, and
the library’s worth of articles you’ve
written over the last several years, we see
that many of the papers you’ve authored
have changed the way doctors treat patients
when it comes to dental implants.
DT: Hopefully, for the better [laughs].
DC: Well, we all think so. One of the
articles that comes to mind for me is
that first paper in 1997 that refers to
immediate loading. 1 It was the first paper
that had good long-term data showing
pretty good results with immediate
loading and immediate function given
the right parameters. What’s your take
on immediate loading now, immediate
provisionalization? Has it changed?
DT: Dr. Paul Schnitman was the first
to do something like that for implants.
He did seven cases and published an
article — in 1990. 2 He published that
article with seven cases with three
implants: one in the midline and
two small ones in the back. And he
buried the other five in the front. So
if the three failed, the patient would
still have five implants to finish that
case — a regular hybrid case. So 21
implants were loaded. And when I read
that, I nearly fell off my chair. Why?
Because this was 1990, and we were
all doing Brånemark-style implants
and we submerged everything. Here
he took three implants and an old
denture — the previous denture —
and just secured it like a tripod, with
one implant in the front and two in
the back. And we assumed that all
of those implants would fail because
it went against every principle that
Brånemark had taught us: no loading,
submergence — all of the things that
Brånemark taught us were being
violated for those three implants.
Immediate loading. Non-submerged.
Everything was wrong. And yet the
three implants took. Everybody said,
“Overall, three out of 21 have failed,
so it wasn’t a high success rate.” But
I was amazed that 18 survived! I’m a
glass-half-full kind of guy. For me the
amazing thing was that 18 survived.
They were not supposed to survive.
In fact, Dr. Leonard Linkow was teaching
with me at New York University
when I inherited the job as director
of implantology. Lenny is one of the
fathers, or pioneers, of implants. He
was involved with blades and screws
— many people don’t know he had
patents on screws. Anyway, I was so
amazed that 18 of the implants hadn’t
failed, that they osseointegrated — not
fibrous encapsulation. So I said to Lenny,
“Look at what Schnitman is doing.”
And he said, “Yeah, well, that works.”
“Really?” I asked. And he went on to
say: “I’ve been doing it for years. I may
have more failures than anybody else,
but I also have more successes than
anybody else.” When I asked him why
it worked, he said: “It went around
the turn of the arch. As long as you
go around the turn of the arch, you’ll
have a high success rate. It doesn’t
matter. Just don’t move or take off the
temporary and everything will be fine.
Wait three or four months, and then,
even if you have to drill the temporary
off, the implants are going to be tight.”
And I said, “Tight, like osseointegrated
tight?” He said: “Yeah, osseointegrated
tight. No problem.”
So right after this, I started the process
of looking at a very standardized
way of going about this. The biggest
problem that Schnitman said he had
on these three was that they were
short implants. The extra ones he put
posteriorly behind the mental foramen
were short, and in softer bone. So I
said: “What if we loaded four or
five? Let’s pick mandibles that have
plenty of bone.” So as a process at
the school, we picked mandibles that
we could put lots of implants in, 8 or
10 — more than we would normally
need — but we would load half of
them and submerge the other half. So,
medical-legally, the patient would be
good either way. So we loaded four to
six implants on these 10 consecutive
cases over five years. And what was
amazing to us is we had success after
success after success. By going around
the turn of the arch we had enough
support. It was more than just a tripod
effect. By having something similar
to the legs on a chair, we had a good
A-P spread, as we call it, or a good
anterior-posterior spread. The farther
forward the anterior implants are, and
the farther back the implants are in the
posterior, the more stable they are, just
like a chair. So we realized that as long
as you can decrease the torque during
loading, lateral forces get diminished.
And today we know that if there is less
than 150 microns of lateral motion
during the healing phase, we don’t
If you go around
the turn of an
arch with a good
A-P spread,
during the
healing phase
the implants will
take. I am very
comfortable
saying that.
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