Latest / Straumann® ProTalk / Clinical edition: When soft tissue defines success in immediate implants with Dr. Gustavo Giordani

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Clinical edition: When soft tissue defines success in immediate implants with Dr. Gustavo Giordani · Straumann® ProTalk

0:00
Patients come to me and say, Hey, it's not about the bite, the first question.
0:03
It's about how it's going to be, how it's going to look.
0:06
And we live in a selfie world.
0:08
Wow.
0:09
Do you think of an example that knowing what you know today, you
0:12
would've done differently there?
0:13
I am a surgeon, as I said, and all the time I was like, oh, the sutures and
0:18
the grafts and the minimal invasive approach, buying blades, like being
0:23
the best of the best of surgeries.
0:25
That was my goal.
0:26
Then I just realized that after many years, the prosthetic design is-
0:46
Gustavo Giordani, what a joy to have you with us at Straumann ProTalk Clinical.
0:51
It's a pleasure, actually.
0:52
It's an honor with you.
0:54
It's a pleasure, really.
0:55
Thank you very much.
0:56
I would like to start with the fundamentals when we talk about
1:00
immediate implant in aesthetic region with soft tissue management.
1:04
Perfect.
1:05
There are a lot of steps in between, but if we have an opportunity to define, how
1:10
would you define what is a successful outcome when we approach this technique?
1:14
Oh, when I started the implantology came from my father and of course,
1:19
functional result was the goal.
1:22
Okay.
1:22
Replace the bridge to an implant.
1:24
And then when I start to understand the importance of
1:28
the combination of function on.
1:30
Aesthetic result, everything changes for me.
1:33
And I came from the maxillofacial field but not get like very
1:37
used with soft tissue grafts.
1:39
So when I went to Belgium to be trained by Eric Van Dooren everything changed and
1:44
I started to understand how important it is to work with soft tissue, how important
1:48
it is to graft around the implants.
1:50
And if I can just, target the perfect result for implants today, it's really
1:57
this combination of functional result, functional- let's say biological
2:03
result and a beautiful look that nobody can see that is an implant and soft
2:09
tissue is very important for that.
2:10
If we could quantify, let's assume, what are the biological parameters?
2:15
Is it volume?
2:16
Is it counter?
2:16
How is it papilla?
2:18
Yeah.
2:18
How do you say, alright, this is a good outcome?
2:21
I think when you think about aesthetics it's really, it's pretty
2:24
much a lot of things together.
2:26
It's a combination.
2:27
When you think about a natural tooth, you'll see a nice
2:31
emergence profile, not a fake one.
2:32
That the tissue is really touching the tooth in a very nice position.
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The popula are perfectly in position.
2:40
The combination of this pink and white aesthetic, it's, I think it's
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really the key when I have patients coming into my office say, okay.
2:48
I need to extract your central.
2:50
Doesn't matter why like a fracture or something.
2:53
Patients come to me and say, Hey, it's not about the bite, the first question.
2:57
It's about how it's going to be, how it's going to look.
3:00
So if I say the nice result and aesthetic is really that perfect emergence profile.
3:05
The volume, the color of the tissue, the populous, and of course without scars.
3:12
Without any interference of color or like a fibrous tissue.
3:17
So it's pretty much a natural look of tissue and emergence profile of the teeth.
3:23
I like what you say because if we look at every single mobile phone company today,
3:28
every launch they go through, it's very minimally related to the functionality.
3:34
How you can talk to your loved ones.
3:35
Yes.
3:36
It's about how good your camera is today.
3:38
Perfect.
3:38
And we live in a selfie world and the patient experience matter
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how they look in the end matters.
3:45
And it's all reflected in also how we should also approach our cases.
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And this is a perfect opportunity because we often hear clinicians
3:55
say, I grafted in bone substitute.
3:58
I'm done.
3:58
But it's not quite like that.
4:00
Why do you think today we may have this gap in between the understanding
4:04
or do you think it's underrated or underestimated the need graft
4:10
in, grafted out type of approach.
4:12
Yes.
4:12
I think it's because of the huge path we have with biomaterials and
4:17
growing bone and bone to play implant.
4:19
And this, if you go to universities and all the teaching process, you're
4:25
going to see a lot of big surgeries, a lot of bone around the implants big
4:29
approaches of bone reconstruction.
4:32
And now, today.
4:33
Not today, but for many years ago, we started to look at the tissue and
4:36
understand how important it is to have a good amount or good volume of connected
4:41
tissue graft, which is not physiological.
4:44
It's not that you're going to extract a tooth and patient will come with
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three millimeters of soft tissue.
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You really need to add something and it's very important to do that.
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And we understood that.
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And I think this, i'm not going to use the term revolution.
4:58
No.
4:59
But this let's say path, this direction came because the aesthetic look is pretty
5:05
important as the functional result.
5:07
So I don't want to just create a nice functional result for my patient
5:12
and see a concavity and start to see after extraction and maybe.
5:18
Few months or years later like a gray color of the tissue, a small recession.
5:24
And we know today to really create that dis stability and this aesthetic,
5:29
look, I need soft tissue, right?
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Not like 10 millimeters of bone around the implant, but just bone and off
5:36
and nice connective tissue graft around the implants to create that
5:39
stability and the aesthetic look.
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And I think everything is changing with the papers and
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everything with the, of course.
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Patients coming to you saying, Hey I did this 2, 10, 15 years ago,
5:55
and it's not okay, what happened?
5:58
And now you see that the majority of the problems, it's concavity,
6:02
it's the color and means lack of connective tissue, lack of tissue.
6:07
The techniques also have changed drastically.
6:09
In the past when immediate implants in aesthetic zone started.
6:13
It was idealized.
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The implant should be a cork.
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You should plug that socket.
6:17
Yes.
6:17
Later down the road we find out that, the narrow, the better,
6:20
not the wider the better.
6:22
It's not about that.
6:23
Yes.
6:23
So it's not we have to be also how would I say, to be respectful with how
6:29
things evolve that we don't always know.
6:31
We think we know but we don't know what's next.
6:33
Yes.
6:34
And I am pretty sure that.
6:36
After 10 years, if you start this conversation like 10 years more, we are
6:40
going to change a lot of things that we are talking now, and this is the reality.
6:44
This is evolution.
6:44
Yeah.
6:45
So I think we need to be very thankful of all the mistakes we did in the past.
6:50
Yeah.
6:50
Because we learned from them and we are still learning.
6:54
When you think about grafting, connective tissue graft, I remember 10 years ago
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or maybe more when I started to do this I started to graft a lot and then now
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I see my results and I see that maybe the result it's too much or it's too
7:10
aggressive or the tissue is growing.
7:13
So you always adapt your technique and.
7:16
Of course you learn from the mistakes you did, but it's a learning curve.
7:22
I remember seeing like so many nice lectures from Buser, from Kan, from
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many amazing speakers like doing amazing things that, we today say,
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no, this is not the way to go.
7:36
Yeah.
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But we learn from them.
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Yeah.
7:37
And then now we know how to avoid the mistakes and more and more.
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And in the future maybe, more and more, I don't know.
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Yeah I always highlight this one conversation, Joseph Kan, he always
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brings to his lectures that he published a nice article saying this
7:53
is what I did with immediate solution.
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Look how nice it looks.
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This is what you should do.
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Then the patient calls him back.
8:00
Yeah.
8:00
10 years after.
8:01
Yes.
8:01
Dr. Khan, I need to see you urgently.
8:05
Yes.
8:05
And when he heard that word 'urgently', the back of the back hair stood up and
8:10
it said urgently is normally a problem.
8:12
And that was this big recession.
8:14
And then he was treated again with smaller diameter implant graft
8:17
in, graft out a nice alternative.
8:19
And then he was kind enough to publish another article saying, look, what I
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wrote back then, please forget that.
8:27
Yes.
8:28
Things are different.
8:28
And this is amazing.
8:30
And this is amazing.
8:31
And I, I am a big fan of my mentor, Eric Van Dooren.
8:34
And Eric today is lecturing a lot of problems that he's like checking with
8:40
his patients after 15, 20, 25, 30 years.
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And, and I remember many cases that he's retreating now.
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I was there living in Belgium saying, wow, amazing approach.
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And now, 15 years later, okay, maybe I should change something.
8:57
And this is amazing, and the opportunity to learn from these
9:01
masters and how they behave today.
9:04
Okay, I made a mistake.
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What I have to do to, let's say, avoid or try to control or minimize the
9:14
facts of the mistakes, I think this is really the key point of a mentor
9:18
and for me it's learning from them.
9:20
Yeah.
9:20
And I'm trying now and seeing my patients after 7, 8, 10 12 years.
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I said, okay, I'm starting to retreat a little bit now.
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And this is life, man.
9:33
It's it's moving all the time and we are learning all the time.
9:36
All the time.
9:37
And with what you know now, since we're talking about learning with
9:40
what you know now, what would be today pitfalls that clinicians starting
9:46
in this area immediately implanted with immediate restoration and then
9:50
grafting- not grafting, managing soft tissue in that regards, what are the
9:56
pitfalls they should watch out for?
9:58
I always talk in my presentations or courses about four very important topics.
10:04
The first one, it's always a minimal invasive approach.
10:07
We always avoid like huge surgeries, so when we face a case in aesthetic zone that
10:12
you need to extract a tooth and place an implant, we always avoid big approaches.
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So we never lose tissue in order to graft a lot after.
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So we try to at say, compensate or.
10:25
With a socket preservation or with an immediate implant and grafting,
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but try to be gentle with the tissue in a minimal invasive approach.
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The second thing, do not negotiate the 3D ideal position of your implant, right?
10:38
And of course, relate this position with your system.
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Okay?
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What you are, use it what the technology can offer to you.
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But, do not negotiate this because a wrong position of your implant, it will lead
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you to a very bad complication at the end.
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Okay?
10:53
That's,
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and it's of a great percentage of the failure related to 3D.
10:57
100%. That's why today I highly recommend, do everything guided, do
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everything that doesn't make any sense today, almost 2026, to not do this like
11:08
a virtual plan and a guided surgery.
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Today, we have so many nice kits in the market, the new kit from Straumann.
11:15
This is really fantastic and help you a lot to avoid this kind of a big mistake.
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I love what you say there because it doesn't make you less of a surgeon.
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No zero.
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There's no ego in that.
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Zero.
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It just makes you a better one.
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Yes.
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And I had difficulties to understand that.
11:31
Yeah.
11:32
I was living with Eric, one of the best surgeon I know, and he
11:35
started to do guided surgeon.
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I said, why?
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Why he's doing this?
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He's so good manually.
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And then I understood.
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And today I will say a hundred percent of my case, a hundred.
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They are guided, always and guided by the prosthetic final result,
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which is the topic number three.
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Always be guided or use your healing process with a perfect,
11:57
provisional, perfect design and relate that implant with that design.
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So prosthetic support, it's really the key to have a nice healing and to
12:07
drive, of course, all your process.
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So virtual plan, according with the final restoration and the final
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topic it'll be the tissue management.
12:17
It's important we know from the literature to work with biomaterials
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and connective tissue graft.
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Why?
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If we are talking here in aesthetic zone, after extraction,
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you always lose tooth, tissue.
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Okay.
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This is physiological.
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And in anesthetic zone, usually you are facing a thin environment,
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a thin soft tissue, thin bone, which is normal for the area.
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Of course, change for patient to patient, but it's usually your situation.
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You don't extract just as extract a central okay, the
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color is not good, I extract.
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No, usually you have.
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Trauma.
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You did vasectomy, you had some peri infection.
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So usually it's like a delicate situation.
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So it's thin, it's delicate, and after extraction is going to be more delicate.
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So in order to compensate these in a long term soft tissue is so important.
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So it's pretty much that combination of minimally invasive approach, 3D
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position, virtual plan, guided surgery, prosthetic design, and soft tissue.
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I think this is really the key to avoid problems in the, in this path.
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I love how you contextualize these four pillars.
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Of course, there are learning curves for each of those.
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Yes.
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But I like this very much and it takes me, it's a perfect segue to your
13:32
next question I would like to drive.
13:35
Alright.
13:35
Okay.
13:36
I'm walking in here.
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I stumble.
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I bang my front tooth.
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I'm looking for Gustavo.
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Okay.
13:43
I need your help.
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How would you walk me through your workflow today?
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Okay.
13:47
First thing, it's always put all the data together.
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So the main point today, it's the virtual plan for me with Smilecloud, with the
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coDiagnostiX®, with all the virtual plan.
13:59
For me, it's really the most important thing.
14:01
So if you arrive to me, the first thing I'm going to do is scan your mouth.
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Even if you are like with a mobile tool, maybe I will splint, okay?
14:10
I will scan you.
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I take a tomography, I take pictures and I put everything in Smilecloud.
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Today I put everything in 3DNA and I check exactly what I have there to understand.
14:21
If it's going to be an immediate implant case, if I need a reconstruction,
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which is going to be my reconstruction.
14:27
So I see you in a 3D environment, and I remember many years
14:33
ago this was difficult.
14:34
You need the specialized people to put everything together.
14:37
Big labs today.
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When you add everything, artificial intelligence help you to put everything
14:43
together and to match all the files.
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You start to see the patient 3D, and you avoid a lot of
14:49
mistakes of the decision process.
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So I will digitalize you fast, put everything Smilecloud, analyze and
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talk with you like Christian, you have.
15:00
An occasion for extraction.
15:02
Let me check if you are ready for the implant.
15:05
I'm a candidate.
15:06
Exactly.
15:07
Because sometimes you have an open bite.
15:09
You have a deviation of your midline.
15:12
You have something to maybe do before the implant.
15:15
And I need to have this discussion with you now because if I am okay,
15:21
bone and tissue, nice implant, and then you want to, or you need to do it.
15:26
Cosmetic surgery ortho treatment, I don't know.
15:29
I will lock the position.
15:30
So I need to have this conversation with you, right?
15:33
So I digitalize you, I understand your case, and then I move on
15:37
to the direction it's necessary.
15:38
So this is really my protocol when you say yes.
15:41
And I think that is a case for implant.
15:44
Then we go to the process of guided surgery, placing the implant in the
15:49
correct deposition, select my system, select my prosthetic component, design my
15:54
nice provisional to support everything, plan my graft, everything virtually.
15:59
And when I go to the surgery, I have everything prepared to treat
16:02
you in a very predictable way.
16:04
That is really the direction.
16:06
Yeah,
16:07
I like this very much.
16:08
And then surgically speaking, is there any preferred way you
16:11
like to approach diameter wise?
16:14
Lengthwise?
16:15
How is you Jordan selection process.
16:17
Okay, perfect.
16:17
The decision making process.
16:18
Perfect.
16:19
The first thing is first design the tooth.
16:21
I need to understand first if it's going to be a oral rehabilitation,
16:25
if I'm going to change everything.
16:27
Anything or if it's going to just copy the actual situation.
16:31
When I design everything perfectly, I go to the software and understand
16:35
the bone quantity and quality.
16:38
To understand the system I'm going to use, let's say if I go to BLX
16:41
or if I go to BLC, I prefer BLC because I like a lot the design.
16:47
I'm a little bit more used to with that design, but I'm learning the yours one.
16:52
And I try to select not a wider or a narrow implant.
16:56
I always try to respect the measurements.
16:58
So in the virtual plan, I will check like the gap I need.
17:03
Between two to three millimeters, understanding the spaces is necessary,
17:07
like from implant to adjacent tooth, let's say the nerves and everything around.
17:13
So I respect, select the implant diameter.
17:17
I like to work with an implant a little bit deeper, like five, four millimeters
17:22
away from the future gingival margin.
17:25
I select my prosthetic component and then, or I print my provisional to
17:31
just rely on everything during the surgery, which is my preference.
17:35
Let's say till now.
17:37
And now from now on, I'm starting to move chairside with my design.
17:42
Started to do this workflow of extraction, immediate implant placement scan.
17:48
After scanning, I go there, design the provisional.
17:51
Print provisional, 10 minutes.
17:53
Then I have a dentist working with me, like lining everything,
17:56
polishing everything very well fast.
17:59
Then soft tissue reconstruction, bone reconstruction with biomaterial and finish
18:04
with a very nice printed provisional.
18:06
And if you ask me, this is the most amazing feeling I have in my clinic
18:12
is to do this kind of treatment.
18:14
We're gonna get there, we're gonna get to this question very soon.
18:18
You mentioned some of your mentors.
18:20
And um, Van Dooren and so many others that came and helped you shape.
18:25
And I have this session that is called, it's not what I think, it's what I know.
18:30
Perfect.
18:30
And it's not based on assumptions, things that may be work in my hands,
18:34
but things that are evidence-based.
18:37
And I would like you to reflect and if you could share with your
18:39
audience if there was an article, a book, a case or a mentor.
18:44
Perfect.
18:45
That at some point that was a turning point it made you look from east to
18:49
west in the way you approach your cases.
18:51
Why was that 'ah-ha' moment?
18:52
Wow.
18:53
Tough question, but I'm not going to give to you here like one article
18:58
because it's not about that for me.
19:00
I will say mentors that changed everything for me.
19:03
As I said, I came from a maxillofacial field with my mentor,
19:07
Marcos Pitta, and then I start in Brazil studying with Implanter.
19:13
Jolie, Paul and Hubbard.
19:14
They are amazing and they, let's say, brought this to Brazil how
19:18
to work with soft tissue in a minimally invasive way with implant.
19:22
So they change it a lot for me.
19:23
Amazing groups.
19:24
And their book.
19:25
It was fantastic.
19:26
The, I think was the first and the second one, I don't remember, but the gray one
19:31
was amazing and I read like everything, and this changed it a lot for me.
19:36
I would say for sure Eric and his articles and the opportunity he gave
19:40
to me to stay with him in Belgium to really learn from the phone.
19:45
So he's the persona for me, and I will also add the Iñaki Gamborena
19:50
book and also lectures because Iñaki really showed us how to really
19:56
work with tissue and the importance of the tissue around the implant.
20:00
So I will put the three groups here that open my mind and make
20:06
everything for me easier with all the.
20:09
All the tips and tricks and experience, let's say.
20:12
Isn't it amazing?
20:13
I love the fact that we all get inspired by someone or somewhat.
20:18
Yeah.
20:19
I think they, they give us shortcuts.
20:22
Yes.
20:23
If I just say, okay, I will do by myself.
20:25
I think I am the one.
20:26
I'm going to take like years and years and a lot of mistakes.
20:30
When I see these kind of peoples that really use their time to
20:35
teach someone, Eric just opened his clinic for me, for Victor.
20:39
We stay with him.
20:40
Like here there, like spending the time doing shortcuts for us.
20:45
Hey.
20:46
Don't go to this way.
20:47
I already did that and it's wrong.
20:50
Or it's not the best one.
20:52
Come here.
20:53
There's short.
20:53
If you're wise enough, you'll listen.
20:54
Mentors for me is they are really the way for me to achieve a nice short and
21:02
predictable learning curve in dentistry.
21:04
Mentors for me are pretty the way.
21:06
And speaking of experience, you said the mentors, shortcuts.
21:11
But things today that you did know back then.
21:14
Yes.
21:15
Now, and you probably, as you said, you were going through some of the
21:19
cases that you did a few years back.
21:20
Yes.
21:21
And outcome could be with your today standard, a big questionable.
21:26
Wow.
21:26
Do you think of an example that knowing what you know today, you
21:30
would've done differently there?
21:31
Can you share something with us?
21:32
Yes, 100%.
21:34
Man.
21:34
This is really the learning, the prosthetic phase.
21:37
We always remember that one.
21:38
I remember not that one, like the majority of the cases.
21:42
And listen, I am a surgeon, as I said, and all the time I was like, oh, the
21:47
sutures and the grafts and the minimal invasive approach, buying blades,
21:52
like being the best of surgeries.
21:54
That was my goal.
21:56
And then I just realized that after many years.
22:00
Because of Eric, because of Florin Cofar, the prosthetic design is really
22:04
the key to have a very nice healing and of course a longevity of your case.
22:10
It's one of the big keys.
22:12
And as a surgeon, I was like, the prosthetic part is not for me.
22:16
Okay, provisional, you do, or whatever.
22:19
It doesn't matter.
22:20
Doesn't matter.
22:21
And I saw so many mistakes I did, and all the time I checked the mistake and said,
22:26
maybe next time I do one more suture.
22:29
And then what's the prosthetic design?
22:30
So if I can talk with me, with Gustavo from 10 years, I will say,
22:36
Hey, study focus and understand the prosthetic support to drive
22:43
your healing, to drive your tissue.
22:44
That is something that I learned now.
22:48
And speaking of passion, because as dentists, given your example.
22:53
You chose perio as a path to go.
22:55
Yeah.
22:56
But not only that, you master soft tissue management in a
22:59
context of a rehabilitation.
23:01
So there are always indications that we sometimes, 'cause in the
23:06
end, we're always kids, right?
23:07
Yeah.
23:07
The only, it's the size of the toy that changes.
23:09
Yes.
23:10
And how expensive they get.
23:11
But we're all kids in the end.
23:12
And there's this one indication that sometimes when the patient comes
23:15
in and it's, there's a diagnosis.
23:18
You go to the office today with a smile from your two years, I'm
23:22
gonna do that one that I like a lot.
23:24
Yes.
23:24
Which one is it?
23:25
Man, if I stay in my office and I talk this a lot with victory, if
23:28
I stay in my office doing implant and aesthetics on every single day,
23:32
I'll be the happiest person ever.
23:34
Like of course, I don't want to say to the patient that I need to extract your
23:38
Centro, but when I need to say that- nice.
23:43
This is the best moment for me.
23:44
I know it's, it's very challenge, but I like a lot and if I can talk
23:50
and stay in single Centrals, I will be very happy every single day.
23:55
Yes.
23:56
I love this.
23:57
Yes,
23:57
Gustavo, this was a masterclass.
24:01
We're all big fans of your work.
24:02
Thank you.
24:03
And thank you very much once again, if to everybody who's watching us, who
24:08
would like to learn more 'cause I know in your practice I've been there in Sao
24:11
Paulo, you have a training institute.
24:13
Yeah.
24:14
If they would like to learn more about immediate implants in
24:16
aesthetic zone with soft tissue grafting, how they can find you?
24:19
Thank you.
24:20
I have a training center in Sao Paulo, Brazil.
24:23
They call it calls like Studio Giordani.
24:26
If you want to check on Instagram is Studio Giordani
24:30
TC, which is training center.
24:32
And we have also a website.
24:34
It's studiojordani.com.br.
24:37
And social media.
24:38
It would be a pleasure.
24:38
Social media.
24:39
It's @studiogiordanitc, the Instagram.
24:42
It's a pleasure to have you there.
24:44
Yes.
24:46
Thank you very much.
24:47
My pleasure, my friend.
24:48
Thank you.
24:49
And to all of you, if this content, I'm sure it was for me, it was amazing.
24:53
If this was valuable to you, make sure as everything online to be
24:57
relevant, we have to stay relevant.
24:59
Give it a like, share with your friends.
25:01
Sharing is caring and until the next episode,
25:12
Ciao.