Latest / Straumann® ProTalk / Clinical edition: Dr. Alejandro Lanis on "Invisible" implant aesthetics and FP1 workflows

Transcript

Clinical edition: Dr. Alejandro Lanis on "Invisible" implant aesthetics and FP1 workflows · Straumann® ProTalk

0:00
Honestly, I think aesthetics should be a consequence of function.
0:04
Most of the times patients, they want to look good and they
0:07
don't care about functionality.
0:08
But if something looks good and it doesn't function, it doesn't make any sense.
0:12
So it needs to function, look good, but also if we could say look invisible.
0:17
It should not highlight and say, "Oh, I have something here."
0:19
Yeah.
0:19
That's exactly my point.
0:20
But I don't want you to be walking in the street and someone to come and
0:23
say, "Hey, you did something." no.
0:25
It has to be something natural.
0:26
"Hey, you did something in your hair.
0:28
Something looks better.
0:30
Something looks different.
0:31
I can see that you look good and better, but I don't know what it is." Yeah.
0:50
Alejandro Lanis.
0:52
Ale for the ones that are your friend.
0:54
What an honor to have you at Straumann ProTalk Clinical.
0:56
Thanks for coming all the way from Chile to join us.
0:59
Thank you very much for having me.
1:01
What a pleasure.
1:03
I would like to start with the fundamentals.
1:06
implant dentistry, especially more dedicated to aesthetics in implant
1:10
dentistry, have moved long ways.
1:12
We shifted from functionality back in the '80s, where surfaces
1:16
and material was the gold rush.
1:18
Now we already take as a given.
1:20
We know things work.
1:22
People want to function, but they also want to look good.
1:25
If we have to shift the definition of success to the standards of today,
1:29
how can we define it in aesthetics?
1:34
This is a very good question because, honestly, I think aesthetics should
1:39
be a consequence of function.
1:41
Most of the times patients, they want to look good, and they don't
1:45
care about functionality, but if something looks good and it doesn't
1:49
function- it doesn't make any sense.
1:51
So I always talk to the patients.
1:53
I say, "Look, this is gonna look good, but it has to work properly." Now, talking
1:58
about aesthetics, I think, a- at least from the way I, learn, aesthetics is
2:04
not something that looks, strange into your mouth, even when it looks good.
2:09
It has to look natural and integrate to your face, to your smile, to
2:15
your, to the shade of the rest of your teeth that you have.
2:18
if you're doing a full arch, it l- it has to adapt to your face and smile,
2:23
so that's why we are working that much with, face analysis with photography,
2:29
with Smilecloud and all these tools that we have today that help us a lot
2:32
to integrate the smile and the teeth of the patient into a more complex, thing.
2:39
So it needs to function, look good, but also if we could say look invisible.
2:45
It should not highlight and say, "Oh, I have something here."
2:47
Yeah.
2:48
That's exactly my point.
2:49
So when my patients come to my office and they say, "Look, I want to improve
2:53
my smile or my teeth or, the shade," I say, "Look, my, my idea here is that of
3:01
course we are gonna improve or inc- or increase your satisfaction in terms of
3:05
your smile, but I don't want you to be walking in the street and some- someone
3:09
to come and say, 'Hey, you did something.'
3:11
No.
3:12
It has to be something natural.
3:13
'Hey, you did something in your hair.
3:16
Something looks better.
3:17
So- something looks different.
3:18
I can see that you look good and better, but I don't know what it is.'"
3:22
Yeah.
3:22
And I think that- Good point … yeah.
3:23
And I think that's the main goal of aesthetic dentistry.
3:28
Lanis, and I know you've been investing a lot of time improving your full
3:33
arch treatments more towards the FP1.
3:37
Which it's a completely different ballgame.
3:40
When we're talking about full arch, for example, in FP3, and I
3:43
don't mean in any way that FP3s are easy, because they're not.
3:47
No.
3:48
However, when y- when it comes to reaching good aesthetic outcome, FP1
3:53
represents honestly, the highest level of complexity because as you mentioned,
3:59
aesthetic, it needs to disappear in the mouth, it needs to be harmonious,
4:05
aesthetically pleasing, and functioning.
4:09
Now, when we talk about a full arch You extrapolate this to many teeth at once.
4:16
You have to worry about many factors, speaker, smile line, papilla design,
4:22
and on and how can we define the fundamentals of aesthetic, a successful
4:28
aesthetic outcome in FP1 as well,
4:32
as you said, I think the FP1, that is a term that was described by Carmish
4:37
several years ago, it's probably the most complex treatment, when you
4:44
are talking about full arches, okay?
4:46
and for that, I think the planning phase, and the first, the diagnostic phase is
4:50
es- essential, and then the planning has to be very, accurate because moving
4:58
the implant in one millimeter distal or mesial can compromise your papilla or not,
5:04
can compromise the aesthetic result, can compromise the w- the, what the patient
5:09
is gonna show when smiling, smile line, lip movement, facial analysis, mimics.
5:15
Everything is important.
5:18
and that's why the whole c- case analysis in here, it's a
5:24
cornerstone of, the whole, treatment.
5:27
Without a good planning, it's impossible to get to, the
5:30
result that you're expecting.
5:32
That's why digital planning for me, it's a mandatory thing in these type of cases.
5:37
I couldn't go freehand in any case.
5:41
You could or could not?
5:42
Could not.
5:43
Yeah.
5:43
No.
5:44
I think it's a, it's a risk that I don't need to take, and we have the
5:48
tools available to do everything in a very precise way just by transferring
5:53
everything that you have in the computer to the patient's mouth in advance.
5:58
that's why, we simulate all the s- the surgical procedures before
6:02
in a safe and virtual environment.
6:07
but you're right.
6:08
it's a complex situation.
6:10
and, but I like it.
6:12
I like it because,
6:15
you need, I'm not talking about skills or dental skills.
6:19
I need, it's a combination between knowledge and also
6:23
skills and, taste and good eye.
6:27
There are so many details that you need to take in consideration, and of
6:30
course, I have learned all of these things by other people like Eric
6:34
van Dooren, like Florin Cofar, Wael Att, David Norre, all these friends
6:41
that they are masters in this field.
6:45
and I have learned h- sometimes maybe just by moving the implant a little bit upper,
6:52
and hide a little bit certain areas, it's gonna change the whole picture.
6:56
So I think these type of treatments are made by details, and that's why
7:01
it's so important all this clinical analysis before touching the patient.
7:06
I like how you describe it.
7:08
and when we talk about… you've been recently, involved
7:13
in the academic setting-
7:15
first in Chile, then in the US, in Harvard, and you've dealt
7:20
with a whole lot of colleagues in many different skill sets.
7:24
Yeah.
7:24
And we talk about consistency and reproducibility in such a
7:29
demanding type of indication.
7:31
What do you think is still lacking that we can do it more consistent?
7:36
Is it in the planning?
7:37
Is it in the, a better understanding of the prosthetic resolution so
7:42
you know where you wanna get, so you back plan all of this till you
7:46
get there, like a GPS, for example?
7:50
what are the roadblocks that you see?
7:53
I think in here, as I said before, diagnosis is a word
7:57
that we don't use much today.
8:00
We skip directly to planning, and we need to understand a little bit what is
8:03
h- why the patient got to the situation where he is right- he or she is right now.
8:09
And then the planning phase, considering the, face of the patient as an im-
8:18
as an important role of our treatments, something that wasn't
8:19
happening maybe 20 years ago.
8:20
We were m- we were focused on functionality and not of, on this
8:25
integration of this prosthetic structure into the patient's mouth.
8:31
face, sorry.
8:33
and the other thing I believe is important is it's very difficult for
8:37
me to separate the surgical aspect of implant dentistry from the restorative
8:43
as- aspect of implant dentistry because both things are linked together.
8:46
One affects the other.
8:48
so if you are a surgeon, for example, and you are gonna do the surgical
8:53
part of the treatment, and you don't know anything about the future
8:57
restoration of the patient, then there is a lack of information that
9:00
is gonna affect the overall result.
9:03
If you are working only in the restorative part and the implants are placed
9:07
anywhere, then of course you are gonna have problems restoring those cases.
9:11
But if you work with, as a part of a team, where you have good communication,
9:17
and you, let, the surgeon know exactly where you want to, your implants because
9:22
of a restorative purpose, of course the things are gonna work better.
9:27
The opposite, if you are the restorative dentist, then… Or the
9:30
surgeon, you need, you wanna know what the other one is expecting.
9:35
So in my case, I do both things, and that's why I think it's easier for my,
9:38
for me to deliver these type of cases.
9:40
But if not, digital technologies are the best tool available to communicate
9:45
in real time, even with someone that is in a different country or a different
9:49
continent, but you are both talking the same language, and preparing the case
9:54
together, something that is very important to have in this particular treatment.
9:59
Yeah.
10:00
So if I hear you well- Two, two streams need to be in place in order
10:07
to reach consistently good results.
10:09
If you are a single practitioner and you predominantly focus on
10:13
surgeon, on surgery, you need to improve the restorative,
10:19
execution and planning, right?
10:21
So they're complementary.
10:22
Or work in a multidisciplinary environment where you- Yeah
10:25
can work in real time together, and that's how probably will be
10:29
the best way to move forward.
10:32
Exactly.
10:33
In fact, even for example, for the selection of the abutments, I'm going
10:37
into a very technical topic now, but we, know now, and, this is something
10:41
that we have published and others like the team from Ronnie Yang in Zurich,
10:47
Franz Strauss and others, they have already published and demonstrated that
10:51
the selection of the abutment influence the result or the aesthetic result
10:55
because you can remodel the bone or the sur- the tissues around the implant
10:59
just by compressing those tissues by the selection of the wrong abutment.
11:04
And we were used to select the abutments after the implants were already placed.
11:09
Today, we select the abutments during our surgical planning, and
11:13
that's why using these digital sy- technologies are so nice, because
11:17
they give you the opportunity to prepare everything in advance.
11:20
Yeah.
11:20
Se- and play with this abutment and select the, proper one and measure the
11:24
spaces, because when you're working or, preparing for an FP1, every
11:31
s- every millimeter is important-
11:33
Right
11:33
in every single direction of the space.
11:35
And I learned this from Florine.
11:37
We were working on… This is, al- almost anecdotic, but we were working on a case
11:42
in Romania, and he told me, "Me- look, in here, I think you made a mistake
11:46
because if you measure from this platform to this platform, you're gonna see that
11:50
instead of two millimeters, you have 2.2."
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And when we were checking on the case later, I realized that we lost that
11:59
papilla because of this minor mistake.
12:02
Wow.
12:02
So you can see that in this situation, every single detail is important.
12:06
It is.
12:07
And you touch a very good point.
12:08
With the digital technologies today, Ale- I was gonna say Launis, but you,
12:13
I know you already, pierced my ears.
12:18
I see, high-performance sports like FP1, FP1, F1 Formula 1, or
12:26
even, commercial pilots, they rehearse tremendously on simulator.
12:32
With digital technology, we have an unique opportunity today to
12:36
rehearse in many different ways.
12:38
We don't see the impact immediately, but we can anticipate if a
12:42
certain gingival height, if the distances are properly selected,
12:47
which we didn't have in the past.
12:50
it bugs me to think that colleagues are still not embracing this and
12:55
moving forward with the, I think you- … upgrading their skills
12:59
… you used a, very good example, pilots, okay?
13:04
they prepare a lot in simulators.
13:06
It doesn't mean that they can have a complication during the flight.
13:10
Of course, for us it's the same.
13:11
You can prepare everything in advance and c- you can still have a
13:14
complication, but the good thing is that you're gonna know how to deal
13:16
with this complication in advance, too.
13:20
dig- digital technology, digital planning, surgical planning in a computer
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is gonna give you that opportunity to play in advance and to prepare
13:28
everything before you touch the patient.
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And in my case, and this is what I do in my practice, is I talk to
13:34
the patient once I have already gathered all the information.
13:37
We have a coffee together, and I say, "Look, this is my computer.
13:41
This is your case.
13:43
This is your surgery.
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I already did your surgery in the computer.
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What I have to do now is to transfer this inf- this surgical planning to
13:51
your mouth through a surgical template."
13:53
If I go… If I'm gonna do it guided.
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If I'm gonna do navigation, maybe it's a little bit different,
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but I already prepare and did your surgery in the computer.
14:04
So this is the safest way to have everything prepared in
14:08
advance because I already did it.
14:10
I know what can happen.
14:12
I have my plan A, B, C, but this is your surgery.
14:16
So they a- they also feel part of the treatment, and of course, they
14:20
feel s- maybe safer in terms of the amount of information that they manage
14:26
before going to the dental chair and start, and I start working with them.
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So I believe it's super, super important in modern implant dentistry to have access
14:37
to these things, and if you are not doing it yet, I really recommend you to start
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because it's gonna change the way you treat your patients and the amount of
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information that you can manage before.
14:50
Yeah.
14:51
I'm with you on this.
14:53
Lenny is- Ale.
14:59
If I had a problem, I tell everybody honestly, I would go to Chile because
15:04
I, I really the way you work, and the quality and the standard of your work.
15:08
And if, speaking of pilot and simulating, I would like to pick your brain.
15:12
The learning's approach, right?
15:14
Let's assume I have a… Let's not put you on a spot.
15:18
Not a low, not a high, but a mid smile line, and I have already
15:24
lost a few teeth left and right, and I have a terminal dentition.
15:29
And I come to your office, and I ask your help.
15:32
Let's assume I'm, about to become a full arch patient.
15:37
And there's an option that I can- we can go either FP1 or FP2 compensated-
15:43
or FP3.
15:44
If I have to reduce bone- if my smile line.
15:47
How would you walk me through your workflow?
15:49
What is the learnings approach from very
15:52
first step?
15:55
so this is the way- We have time.
15:58
No, So this is the way- Take- … I, work, and it doesn't mean that it's
16:01
the right way to do it, but it's the w- the, way I like to do it.
16:06
the first appointment with the patient is always about gathering information, okay?
16:11
It's about, knowing the patient, know their, h- his or her expectations,
16:20
previous stories, et cetera, the medical history, whatever.
16:25
And then, I do an examination, internal scanners.
16:29
I try to get all the information that is gonna be useful for my analysis.
16:35
I take, I have a small setting for photography, so I take portrait photos.
16:40
Sometimes I take videos just to s- analyze a little bit how the
16:44
lips move when patient is talking.
16:46
Because if you talk to a patient with a, with p- a problem in, in, in his
16:51
or her mouth and you ask for a smile, probably they're not gonna smile well
16:54
because they feel ashamed sometimes.
16:58
so I, if you record a video, at some point, because technically a video is
17:03
a s- a set of photograph it's in time.
17:05
So you can stop, the video at, certain point and see the full smile, and
17:10
then you can see if you are gonna see some things or this transition
17:13
between the future, structure with their, own tissues, et cetera.
17:19
Once I have everything together, I get together with the patient
17:24
again in a different appointment.
17:26
I already have prepared everything to show to the patient, and also I have done
17:29
my own analysis, diagnosis, my treatment planning, and I have all the information
17:36
to give to the patient to understand what I, what is my plan or what I want to do.
17:41
and then depending on their situation, we can, choose between different options.
17:48
I always try, if possible, to keep with the FP1.
17:54
I think I don't like to remove bone.
17:56
I don't think, I don't think it's a good idea to remove bone unless
18:01
you have specific indications.
18:03
One, you have a knife-edge ridge that where you cannot place the implants in
18:08
at the proper depth, or you can level all the implants at the same, depth too.
18:15
So in those situations, maybe it's a right indication.
18:18
Transition.
18:18
Then transition line.
18:20
High smile line where you're gonna see the transition between the
18:24
structure o- and the, prosthetic structure and the patient's tissues.
18:29
And third, and it's very rare when you have a class III with a Kelly
18:34
syndrome, and you need to remove a little bit of the lower, the, anterior
18:39
part of the lower jaw or the mandible.
18:42
but in the re- the rest, this concept of prosthetic space that I
18:46
need to create prosthetic space, if the patient had teeth before, the
18:51
prosthetic space is already there.
18:54
This concept of prosthetic space, was, created or published when materials
19:02
needed more thickness because of the-
19:05
Resistance
19:05
resistance, et cetera.
19:07
But with the materials that we are working today, you don't need this 20 millimeters
19:12
of space to create a very stiff bar.
19:15
We can do something very small, and if the patient had teeth before, and the
19:20
central incisor measures in average 10 millimeters, and you have already those 10
19:25
millimeters or 12, you have enough space to use an, FP1 modality of treatment.
19:33
Now, in the case that you were describing, where maybe in the posterior sides you
19:37
are gonna have more space, you can create a combination between an FP2 and an
19:42
FP1, or but going back to the, to your question, I prefer or try not to remove
19:49
bone, because once you have removed bone, reconstruct that bone is very difficult.
19:55
and there is a trend to just chop the bone down.
20:00
Remove two centimeters bone and then place implants to give an FP3 to the patient
20:06
that maybe needed just a periodontal treatment and maybe a couple of implants.
20:11
and this is something that I believe it's, it's n- a little bit neglected
20:15
be- because once you have removed all this tissue, let's suppose that
20:19
you have a complication, you're not gonna have any tools to…
20:23
Unless you are gonna place zygomatic implants-
20:25
Yeah
20:26
… or a remote anchorage.
20:27
You don't have too many solutions to deal with this complication.
20:31
So I, that's why I try to keep the bone as possible.
20:36
And, for the surgical part in terms of implant positioning
20:40
from there, so you, show
20:44
Where you wanna get, right?
20:45
To the patient.
20:46
Let's assume now the patient said, "Let's go for it." What's next?
20:53
of course, you are preparing everything with the, your
20:56
surgical templates, et cetera.
20:58
Once the planning is ready, you need to transfer this information from
21:01
the computer to the patient's mouth, and here's where you have to be very
21:05
precise because as, I was saying before, if you are working with an
21:09
FP1 approach, moving or having the implant one millimeter distal or mesial
21:14
can change completely the result.
21:17
so you have to be very precise.
21:20
Something that I learned from these people that I told you before is you have to
21:26
expect that after the extraction of these remaining teeth, there are gonna be some
21:31
type of, resorption or bone remodeling.
21:35
This is some- something that is gonna happen always because of the loss
21:38
of vascularity to the vandal bone.
21:42
so to compensate this situation, what we like to do is to place
21:46
the implants a little bit deeper and a little bit palatal if w- I'm
21:50
talking about the maxilla because in that way, you are gonna, preparing
21:56
advance to contract to this potential resorption that is gonna happen anyway.
22:01
Of course, if you use a grafting material in the gap between the implant and the
22:06
buccal bone wall, or you use a soft tissue grafting or other techniques, you are
22:10
gonna help to, to this, to prevent this situation, but it's gonna happen anyway.
22:17
So implant positioning, positioning for these situations, it's a
22:21
little bit different than where you place your implant for an FP3, for
22:25
example, where- I see … you are gonna cover everything with the same
22:30
structure, prosthetic structure.
22:31
It doesn't matter if the implant is in the midline or not, you
22:34
can play with statics anyway.
22:36
Yeah.
22:37
and if you have a good technician, it's not a big deal.
22:40
But papillas and the integration of these pontics into the soft tissue-
22:45
is something difficult to do.
22:48
And for that, I always recommend the same.
22:50
You need volume of tissues.
22:53
You need good management with the pontics to give enough pressure
22:58
and space- and to know this, how to play with this balance- to create
23:02
these papillas, and you need time.
23:07
Time, because you cannot rush biology.
23:11
It has its own times, and if you rush, you're not gonna get the
23:15
result that you're expecting for.
23:16
I see.
23:18
So if I have to take one year with the patient or two years, it's
23:22
part of the deal a- and this is the sacrifice to get that result.
23:27
You always need to give something, to you take and you give, and-
23:31
Yeah
23:32
… this is the way I see it.
23:34
Lenis, I, Ale I like very much how you contextualize first in the beginning in
23:42
the, in the sense that, the indication you're aiming to is an FP1, but it's
23:50
perfectly fine to blend if a f- if certain sites are not optimal, dimension-wise-
23:57
to make it with artificial gingiva there is not gonna make less of an FP1, but
24:03
it's gonna be a much better of a overall aesthetically pleasing treatment if
24:08
you blend a bit with FP1 purely dentate
24:12
with- Yeah.
24:12
You're right.
24:13
So the thing here is, everything is, it's, talked first with the
24:20
patient, of course, because always you c- you have other options.
24:23
You can graft in the posterior sites, but it's always, difficult.
24:27
You don't have too much, area to support your grafting.
24:32
So it's not that simple.
24:34
You can do it, but it's not that simple.
24:36
Sometimes you can manage everything with just soft tissue grafting, and then
24:39
you can create these pontics and manage everything with an FP2 type of structure,
24:44
and everything g- is gonna look good.
24:46
Now, yeah, if I'm gonna do a combination between an FP1 and F- an FP2 or 3 in
24:52
the posterior area, and everything's gonna look good, and the patient's
24:56
gonna be happy, and it function, and it's cleanable- Yeah … I
25:00
don't see any problem with it.
25:03
unless you want to show this in a huge stage where you want to talk about FP1
25:08
and how good you are as a clinician.
25:10
But from a patient perspective-
25:14
Yeah
25:14
… for him, an FP1 and FP3 is, are just acronyms.
25:19
Yeah.
25:19
They don't mean anything.
25:20
They don't know.
25:21
Yeah.
25:21
And it's important to always have this transparent and honest
25:24
conversation- Yeah … about where you
25:25
wanna get.
25:25
But that's the thing.
25:26
Y- I talked with them before because everything that you do
25:29
in a, everything that you explain in a- in advance is just a,
25:35
an explanation or an indication of what you're gonna do.
25:39
Everything that you explain after is an excuse.
25:42
Yeah.
25:42
So you have to be careful because patients sometimes their expectations
25:46
are super high, and you forget to say something in advance knowing that
25:50
it's gonna happen, and then they say, "Look, doctor, but what happened in
25:53
here that this part of my mou- of my restoration is different than the one…"
25:58
And then you have to explain, and then it sounds like an excuse.
26:01
So if you are transparent and you… But this is simple because you ha- you are
26:05
watching everything in screen in advance.
26:08
Yeah.
26:08
So it's very difficult not to see these type of things.
26:12
It's not because I'm a, I'm an astronaut.
26:14
It's because it's super simple.
26:15
It's in the com- computer.
26:17
It's in the screen of the computer.
26:21
Ali, you mentioned the such
26:25
a precision level as you mentioned the discussion with, Florin Cofar about
26:30
2.2- two millimeter, and how important is the precise implant positioning?
26:37
You mentioned also, just shortly back about in, let's
26:44
continue on this topic quickly.
26:45
On FP1, your implant positioning will also be different because you will
26:49
like to anticipate, you will like to have more biology- less metal.
26:53
You, you- voluntarily want to give some space-
26:56
maintain volume.
26:58
So how critical precise implant positioning is in order to reach
27:04
everything that you wanna do after, and how do you get there?
27:06
Is it guided surgery?
27:08
In an FP1?
27:09
In everything.
27:10
So
27:12
I like to be the precise as possible in, in every type of treatment that I do.
27:17
but there are certain situations where 3D implant positioning is
27:24
very important.
27:25
' Cause you mentioned 0.2.
27:27
Yeah.
27:28
Yeah.
27:28
From two to 2.2- Yeah, makes already a big difference in the papilla.
27:32
Yeah.
27:32
So FP1 guided will play a big role.
27:36
I think it's, with based on the tools that we have today, not doing it guided, it's,
27:44
it's a mis- I don't see any reason not to.
27:48
you're just gonna… I'm not saying that you cannot.
27:51
Of course you can, and I know people that they're super skilled, and they are gonna
27:56
be able to do it without any problem.
27:58
But n- for normal humans like me, like myself, why I'm gonna take
28:02
this risk if I have the tools just to transfer everything in the more
28:07
or less exactly the same position?
28:09
It's not 100% precise.
28:11
We know this because of research, but it's very close
28:17
to that, precision, to the 100%.
28:20
And,
28:22
Yeah.
28:23
I, don't see any reason
28:26
not
28:26
to, take this opportunity.
28:28
Ale, I like how you phrase it because look, I'm a big fan of your work,
28:33
and yet you have no, no shame of saying that regardless of how good
28:40
you are, you, trust guided surgery.
28:44
It doesn't make you less of a surgeon because of that.
28:47
I Because we sometimes hear this ego conversation of- oh, I brag myself
28:51
of being a good surgeon.
28:53
let me tell you so- this is also, almost anecdotic.
28:58
I was in a meeting several years ago, and there was a very famous doctor, talking
29:03
about, implant placement, and s- he said something that, I never forg- I forgot.
29:09
he said something like, "Today all my implants are flapless." So when you
29:15
say, when you… Or he said something like, "I always go flapless now." When
29:21
you say, or when you use the always or, the never, there's always something
29:26
stra- always something strange.
29:29
Because today we know that flapless implant surgery has its own indications.
29:34
And very, and they're, I would say, limited.
29:36
So today I, raise more flaps than maybe 10 years ago because I know
29:44
the importance of s- the soft tissue- Soft tissue … around the implants.
29:46
Yeah.
29:48
with, guided surgery, the same.
29:51
I'm not saying that you cannot do it.
29:54
of course you can do freehand surgery, but evidence shows that when you are
30:00
doing your procedures fully guided, you are more precise than even when
30:04
you're doing your osteotomies guided and freehand implant placement.
30:07
So even in that situation, you are more precise when you are
30:10
doing a fully guided approach.
30:12
So why to take this risk?
30:14
Yeah.
30:15
and of course, between surgeons, they say, "Look, if I place all my implants freehand
30:19
because I'm a great surgeon, This is like going to, y- if you go to, to do, to have
30:26
surgery on your knee, what do you prefer?
30:28
Someone who says, "Look, I'm the great s- the greatest surgeon in the world because
30:32
I'm gonna open a huge flap, and I'm gonna do everything by hand," or someone
30:36
that says, "Look, I'm gonna take or get advantage of all the technology available,
30:40
and I'm gonna use a robo- a, a robotic arm that is gonna be very, non-invasive"?
30:46
What is your, choice?
30:48
The second one.
30:49
For us, it's the same.
30:49
No-brainer.
30:51
For us, it's exactly the same, at least the way I, see it.
30:55
Maybe I'm wrong, but this is the way I see it, and it,
30:58
for me, it works.
31:00
Speaking of the advancements, we have this block that is called, and
31:05
I know you're very scientifically oriented, it's not what we think.
31:10
Partially is.
31:11
But it's of what we know, right?
31:14
It's not what we think.
31:14
It's what we know, evidence-based and literature, what's on
31:18
the table at the moment.
31:19
And if there's one piece of evidence that you say, this opened my eyes to
31:24
the way I work today," or, "This changed the way I do things," sp- in the context
31:31
of aesthetic outcome in full-arch treatments, what would be this one that
31:37
impacted Lanis that you say, "I think the dental community should know"?
31:40
f- at first, Ale, what I, have happened to me is that the more I do,
31:47
the less I think I know, and this is something that comes with experience.
31:50
I'm not that old, but I have been working for a while now in this field.
31:57
and that's why all these details, get more important because you can see that
32:03
there are certain things that for some reason they're not working the way you
32:06
want, and you cannot find the solution.
32:08
Then you talk to a friend or a colleague with more experience, and
32:10
then you understand a little bit more.
32:11
Yeah.
32:12
And talking about a specific article or philosophy or something
32:17
that changed a little bit the way I'm working, I would say that
32:23
when I got involved with the ITI-
32:26
you know that I'm very involved with ITI.
32:29
it's like a m- a family for me.
32:32
their philosophy and the way they were, the way they're,
32:37
they were showing how to document things, all these strict analysis of every, of all
32:42
the cases before touching the patient, in some way it changed the way I was working.
32:49
And then I came up with one of the treatment guides.
32:53
I, I don't remember the number right now.
32:55
I think it's number four, about full arches and full mouth reconstruction.
33:00
and then I realized how important are all these details before going to the surgery.
33:07
the spaces between implants, the space or the, type of abutment that
33:11
you are going to use in this specific situation, intermaxillary relationship,
33:16
the skeletal class, all these things that sometimes we don't take care of-
33:24
Right
33:24
are super important to have a predictable result.
33:28
so yeah, I, if I have to define a specific m- I wouldn't say a moment, but a specific
33:34
thing that changed the way I'm working, w- would probably my relationship with ITI.
33:41
The relationship plus also the treatment
33:43
guides Yeah, the treatment guide and all their publications, yeah
33:46
And it's funny that you mention, the treatment guide number four.
33:52
w- we have to check if it's
33:54
number four
33:55
Maybe it's not four, but I think it's number four.
33:56
But it's still, it goes many years back and still very relevant.
34:01
I remember this treatment guide very well talking about implant
34:04
distribution, segmentation, and all the selections that is still, textbook
34:11
Follow, you have nothing to regret.
34:14
Exactly.
34:15
A- and the good thing about, this
34:17
specific, book is that it's still ongoing.
34:23
actually, we are writing the treatment guide 16 that is called The Virtual
34:27
Patient, and hopefully it's gonna get released at, by the end of the year.
34:32
and I know that the 17 is coming, 18, so it's not only about what was
34:37
happening at that time, it's how to…
34:40
Because the last year, the 15 was published, and it
34:43
was also about full arches.
34:44
Correct.
34:45
That's what I was gonna,
34:46
but using the new technology that wasn't available at that time.
34:49
So they are refreshing and updating all these topics that are still, the
34:53
concept is still the same, but the way to get to that result is different.
34:58
Yeah.
34:58
And this is the nice thing about it.
35:00
It's evolving with the field.
35:02
Yeah.
35:03
And I, think this is unbelievable,
35:05
yeah.
35:05
Evolving without losing the basic fundamentals-
35:08
Exactly … that we should respect.
35:09
Yeah, because dentistry is, still dentistry.
35:12
The way we are dealing with it is different.
35:14
My dad was a dentist, but the way I'm doing things today is completely different
35:18
to what he was doing 20 years ago.
35:21
It's a different field in terms of the execution of things, but
35:27
the concept, biology, physiology, and anatomy are exactly the same.
35:33
Yeah.
35:34
Leniz, I would like to shift… I keep k- You,
35:37
can call me whatever you want.
35:38
I'll get there by the last question.
35:40
Ale, shift gears a little bit.
35:44
Dental photography.
35:45
Honestly, once again, I, cannot stress enough how much of a fan I am because your
35:50
photography skills is really pristine.
35:53
You take meticulous care of your photography, your clinical
35:58
photography documentation.
36:00
And this inspires a lot in many ways.
36:03
First, to step up our game in terms of photography, and also to see the steps in
36:10
between your treatments and how you plan, how you execute, how you follow them up.
36:15
Clinical documentation inspire us to also wanna do better clinically
36:20
as well, so thank you for that.
36:22
No,
36:22
thank you for your
36:23
comment.
36:24
And in that sense- Do you think clinical photography will change if people upgrade
36:33
their clinical skills, will change the way they also plan things and get to
36:38
their results, or just a nice to have?
36:41
Because today, if I continue, I don't want to hijack your question, but I see
36:46
each time more how much information you gather, better input, better output.
36:52
Of course.
36:53
And how do you see the dental photography element within clinical practice today?
36:58
It's not a nice to have, right?
37:00
For m- for me it's a must, okay?
37:04
And
37:04
not because I like to, share my photos in social media.
37:10
It's not about that.
37:11
It's because- macro photography gives you information that
37:17
the eye cannot see right away.
37:20
So what I do is if I have doubts or I want to analyze something, I go to my computer,
37:25
I enlarge the f- the picture that I took before, and I can see things that my
37:31
eye cannot see, even with loops, okay?
37:33
Because, and I c- I can enlarge it whatever I want.
37:36
And sometimes you're paying attention to so many moving parts,
37:38
right?
37:38
yeah.
37:39
You are doing surgery, there are so many things happening at the same time
37:42
that th- then the photo's gonna give you that information or that piece
37:46
of information that maybe is missing.
37:49
but also from a diagnosis, diagnostic standpoint, or also from, a planning
37:53
standpoint, it's gonna give you a lot of information to manage and plan your case.
38:00
there are people that, they… Because if you go to my office, you're gonna see
38:04
that I have a bunch of cameras and stuff.
38:06
It's because al- I also like it.
38:09
but they say, why do you have all of this?" and it's because I have a camera
38:12
for internal photos, I have a camera for surgery, I have a cam- because
38:15
I like to have the setting ready and not to start changing and playing
38:19
with the setting during the procedure.
38:20
I see.
38:21
So I have different cameras for different things- Interesting … and purposes.
38:23
But this is, Okay … I'm a little bit crazy too, maybe.
38:29
but honestly, and this is, something that I learned from another doctor
38:34
who taught me a little bit how to take photos, and then I was just watching him
38:38
working and I, l- I learned by myself.
38:41
I think photography w- was one of the things that changed completely the way
38:45
I was working, because I was taking in consideration details that I wasn't
38:51
taking into consideration before.
38:53
So everything changed from that specific point.
38:56
And then I started to like it because I could see that my photos
38:59
were improving and, my photos at the beginning were terrible, like
39:04
everyone's when, they are starting.
39:07
Yeah.
39:08
and I couldn't say that they are perfect now.
39:10
They're… I, and also I take 200 photos and I select two.
39:14
That's the, beauty of the photography too.
39:16
You can just choose.
39:18
Yeah, digital, especially digital.
39:18
Yeah, you can pick the one that you like.
39:21
but they help a lot to improve the way you work.
39:25
they, they also work to transfer or to communicate with others.
39:32
when I'm lecturing, when I'm, trying to explain something to a patient, when
39:37
I'm talking with the lab technician- Yeah … and I want him to see
39:40
something specific, I, think it's a very good way to communicate things.
39:45
And people say an image, it's worth more than-
39:49
S-
39:49
thousand words … speaks more
39:50
than a thousand words.
39:51
Yeah.
39:51
This is exactly the reason I work with photography, and also because I like it.
39:56
Yeah.
39:57
It's amazing how, it's, it's something that it grows in us, right?
40:02
The dental photography.
40:04
And, I like how you phrased it in a sense that we start improving
40:08
and improving because- Any picture is better than no picture.
40:13
But sometimes we see pictures that look like a crime scene, right?
40:18
It's a, you would have, especially the surgical ones too, it's not just like
40:22
a photojournalism that th- something is happening and, you're just observing.
40:28
You have to really take proper care of that so you can refer back to that
40:32
picture and have a sense of what you did.
40:35
Otherwise, it's so much information that not necessarily
40:38
what you wanna get out of it.
40:40
Yeah.
40:40
Yeah.
40:40
Yeah.
40:41
You're right.
40:43
You're, completely right.
40:45
and I always talk to my, when I'm doing surgery to this person who's helping
40:51
me, the doctor or as- my assistant.
40:54
When you are taking photos and then you are gonna show these photos to an
40:59
audience, for example, if I'm gonna have to lecture or, in an article.
41:03
When you're working and everything is full of blood, it looks
41:06
like you are a dirty surgeon.
41:08
Yeah.
41:09
So I prefer just to clean everything.
41:11
It doesn't mean that my sur- my surgeries you, are not gonna find blood.
41:14
Of course, all the patients are bleeding.
41:16
They are alive.
41:17
But as soon as I know that I'm gonna take a photo, I clean everything.
41:20
I prepare the setting, and then I take the photo.
41:22
Yeah.
41:23
Because of respect for the audience, also because you want to highlight
41:26
certain details that if they're covered by blood, it's impossible.
41:30
Yeah.
41:30
so there is a, preparation.
41:32
It's not automatic, of course.
41:34
It takes some time, but then your team is already trained.
41:37
They know what to do.
41:39
So I said, "Photo." I take the camera.
41:41
Boom.
41:42
Yeah.
41:42
Done.
41:43
Very fast because I cannot stay for hours with the patient
41:46
when, while I'm doing surgery.
41:48
Yeah, I agree with you completely.
41:50
Honestly, the quality of your photo documentation is equally proportional
41:56
of the quality of your work.
42:00
Thank you.
42:01
Thank you.
42:01
Thank you
42:04
Ale, there's a section that we call Experience Taught Me This.
42:08
Today, you work at the highest level in terms restorative speaking, surgically
42:14
speaking, but you haven't always been to this level of performance.
42:19
There was a learning curve- No … and a very long one, in which you stumbled,
42:23
I'm sure, upon many circumstances and situations that you say, "Oh, boy,
42:28
I wish I knew then what I know now.
42:30
I wish I had the resources then w- that I have now." Can you remember of
42:35
a situation that it was like it still haunts you? Not haunts you, let's not
42:38
put it that way, that you say, this one particular case, I wish I could
42:43
go back there again and redo it"?
42:45
Can you remember one that-
42:46
Oh … that
42:47
it was a big learning?
42:47
I, know I have several, but-
42:51
I think that, today I'm, Of course, this is about the experience, but I'm
42:56
more cautious than what I was before.
43:00
And if I could go back, there are certain cases that maybe I move forward
43:05
with a, for example, an immediate implant placement, where I think today
43:09
I could go with a different approach.
43:11
I would go with a delayed implant place- or a, early implant placement.
43:16
when you are young and you don't know much or less, yeah, you scare
43:21
less, and then you take these risks because n- not because you're a risky
43:26
person, it's because you don't know.
43:28
And now that I can see those results, or maybe I had to intervene again to
43:33
solve some issues, I could have done it in a different way, maybe be- being more
43:39
cautious of what I was doing at that time.
43:42
And we like to… when I heard something sometimes, it's we like to
43:48
do all the miracles at the same time.
43:50
Yeah.
43:51
Today, I know that's a very difficult thing to do.
43:53
I prefer, if possible, of course, you can do it, but if I'm gonna take some
43:57
risk just by doing everything at the same time, I prefer to go step by step
44:00
because you are always gonna have m- another opportunity to improve the case.
44:06
But if you do everything at once, then you don't have too many
44:09
chances to improve it anymore.
44:11
So I prefer to go in a more cautious way.
44:14
And the other thing, and this is something that I was sharing my, with my
44:18
residents when I was working in Boston Always give time for the tissue to heal.
44:24
If you rush, then you're not gonna get what you're expecting.
44:28
And at that time, I remember some of, my residents… I don't know if we
44:32
have time, but at that time- No, we're good … some of my residents were
44:34
asking me, "Hey, doctor, can I take the impression, the definitive impression?
44:38
Because I think we're ready to move forward with the definitive…" Because
44:40
of course, they needed to graduate.
44:42
Yeah.
44:43
and I was keep saying, "Let's wait.
44:46
Let's give this patient one more month or maybe two weeks.
44:49
Let's see what happens with these p- these papillas.
44:51
Maybe they're gonna go down a little bit more.
44:53
Let's give s- more space." And they were frustrated because they didn't know if
44:58
they were, going to be able to graduate.
45:00
And I said, "Look, guys, I'm the one who's gonna sign for your graduation.
45:03
Don't worry about that. But let's try to deliver the best treatment as
45:07
possible, and for that we need time."
45:09
Yeah.
45:10
And then, yeah, at the end they realized that I was right.
45:14
and they graduated anyway.
45:18
but if you rush, biology is gonna react.
45:22
And that's why we need to give the proper time for the tissues to heal, to
45:28
relocate, to mature, mature, yeah, until we, we get what we're expecting for.
45:35
I like how you phrased this, Ale, because look, there are so many… The, benefits
45:41
of immediate solutions are vast, right?
45:44
There we can, preserve certain, certain structures.
45:48
We can, influence the healing pattern over certain, papillas- contours.
45:55
However, we should never forget that if an implant also integrate, doesn't mean we
46:00
have soft tissue maturation, and that can backfire towards the final restoration.
46:05
Exactly.
46:06
Exactly.
46:06
Exactly.
46:07
So we, at le- look, the way I see it is if you are gonna go with an immediate
46:12
implant placement, something that is, it's very trendy again, and I think
46:17
it's something that is very beneficial for the patient in certain situations.
46:21
But the main purpose of doing an immediate implant placement is to preserve the
46:27
preexisting emergence profile of the tooth that was in there before the extraction.
46:32
So if you're gonna do an extraction, and you're gonna place an implant,
46:34
and you don't have any, purpose of loading that implant- Yeah … or at
46:38
least placing a customized healing abutment, what is the main r- the, what
46:44
is the reason or the purpose to do it?
46:46
You are just taking a risk.
46:48
If that's the situation, you don't have any plan to load that implant right away,
46:52
then maybe the best option is to wait until the soft tissue is healed, and
46:56
you go with an early implant placement that has been described for more than
47:00
30 years, where Danny Buser has All these, papers and publications about that
47:07
specific protocol that is probably w- the most well-described protocol in- Yeah
47:12
implant dentistry, and you know that you're gonna go safe.
47:16
But f- from the other side, if your plan is to preserve that structure
47:21
and to preserve that profile, then the indica- if the indication is the right
47:25
one in terms- Yeah … of the anatomy of the site, yeah, of course, it's a
47:29
beneficial situation for the patient.
47:31
Yeah.
47:32
But then you need to ba- put in the balance what do you wanna achieve, and
47:37
how is the pa- the condition of the patient, if it's appro- appropriate
47:40
case for this specific indication.
47:44
No, I agree completely.
47:46
As long as the indication is on the table, that's a viable and, the right
47:51
solution to go, but we should not cut corners just for the sake of speed.
47:56
This is
47:57
the,
47:57
same thing that I was saying before.
47:59
If you hear something, hear someone… Sorry, someone saying, "I always
48:03
place immediate implants," this always- … is when I start doubting.
48:10
It is trouble.
48:11
Everything has its own indication.
48:12
Biomaterials, they have their own indication.
48:15
Type of implants, they have their own indication.
48:18
That's why we call it personalized, in, in personalized dentistry
48:21
or personalized medicine.
48:22
Today, we have the tools to prepare or to tailor every single treatment
48:27
for, every specific patient.
48:30
We have that tools, and we have the information.
48:32
We just need to manage it and diagnose, plan, and
48:36
execute.
48:39
Ale, we are already, as we said about the pilot, cabin crew prepare for landing.
48:45
We're starting to descend.
48:47
If we now start going not in a dreamer mode, because I could say,
48:52
for example, artificial reality… artificial intelligence is already
48:55
a reali- a reality, and we have so many things coming our way.
49:01
If we're talking about, implant aesthetics, can you anticipate looking
49:09
from… You're very involved with research, with the latest technologies.
49:13
Can you anticipate what clinicians should be paying attention to or
49:17
get prepared skill-wise to confront, not to confront, but to be walking
49:23
hand-in-hand with the new advancements in the next five, 10 years?
49:27
this is a difficult question because it's very difficult to predict the future.
49:31
But what I think is gonna happen, is, technologies are evolving so fast.
49:37
J- just imagine what was happening, I don't know, 20 years ago
49:41
with the iPhone and the type of cell phones that we have today.
49:45
Yeah.
49:47
probably technology in our field is gonna evolve even faster.
49:51
This is an exponential growth.
49:54
so probably what I think is AI is gonna be an im- very important
49:59
part of the diagnostic, diagnosis and also from the planning phase.
50:03
we're, I think we are not gonna need to do our, all the planning ourselves.
50:07
I think you're gonna just click one button, and then you're gonna
50:10
approve or change or do a, like a fine-tuning of the planning.
50:15
Validate.
50:15
Validate, because that's the thing.
50:17
We are w- the software always gonna need a validation from a professional.
50:23
That's a value that we have or we are gonna keep having, luckily.
50:30
so I think it's gonna be an important, factor, or tool that
50:35
we are gonna get, in our planning.
50:38
And then of course, the way we are gonna execute things is gonna be different.
50:41
I think navigation, that is, is something that is already happening.
50:45
Then robotic surgery is gonna, it's gonna come.
50:48
This is something that is in- inevitable.
50:49
It's gonna happen.
50:51
And maybe we are gonna work remotely later, and we are gonna have a…
50:54
In my, in the way I see it in the future, and maybe I'm a little bit crazy, but
50:59
I see people in their houses, with a center with, several robots, and you
51:06
are gonna be just Working from home.
51:10
Maybe hopefully in the pool having a beer and just touching certain things, and the
51:16
robot is gonna be doing it, everything.
51:19
I think this is gonna happen.
51:20
I don't know when.
51:21
Yeah.
51:22
but I think that's the future.
51:23
It's an integration between robots, artificial intelligence,
51:27
and all the knowledge that we have that is not gonna change.
51:30
Knowledge is exactly- The same … the same in terms of the concepts.
51:33
Dentistry is gonna still go- being dentistry.
51:35
The way we're gonna face these treatments is gonna be different.
51:39
Yeah.
51:39
What we see around us seems to be pointing to that direction.
51:44
Exactly.
51:45
Let's see what happens.
51:47
Alejandro, it was an honor.
51:51
Once again, I cannot stress how much of a fan I am, and I can only thank
51:56
you very much and to the dental community that is watching us.
52:00
Where can they find most, can th- they find you and learn from you and le-
52:06
see all of the work you've been doing privately with ITI, research, lectures?
52:12
fir- first-
52:12
The camera is yours
52:13
… first, thank you very much for having me here.
52:15
It's, it's my pleasure.
52:17
It's my honor.
52:17
The Straumann is, like my, house too.
52:21
I, I, every time that I come, they treat me so well.
52:25
and if you want to find me or to see what I'm doing, of course, I'm based in Chile.
52:30
I have my own practice.
52:31
But, we are doing certain courses or several courses once in a while.
52:36
I'm very involved with the ITI.
52:38
We're gonna launch the new, ITI Treatment Guide very soon with
52:42
Vincent Fehmer and Ali Murat Cocat.
52:44
Nice.
52:47
we are gonna be soon in Istanbul for the annual conference.
52:51
Next year we have the ITI World Symposium in Milan, so I think
52:56
we are gonna see each other soon.
52:58
And let's keep in touch.
53:00
This is-
53:00
Can they connect to you with social media?
53:02
Yeah.
53:02
My… I have an Instagram account that is only for professional stuff.
53:07
That is Ale, A-L-E, Ale … underscore… No, it's doctor, dr.ale_lanis.
53:17
We're gonna leave
53:18
the- Yeah … the account listed below.
53:19
It's in here now.
53:20
Yeah.
53:22
No, but thank you very much for everything, and it's,
53:24
it has been a pleasure.
53:25
Ale, thanks again.
53:29
And to all of you watching us, if you liked this episode, give it a If
53:33
you didn't like, give it a dislike.
53:35
And honestly, we would love to learn if we're doing things right or wrong.
53:39
Please comment.
53:40
Leave a comment below.
53:41
It doesn't hurt.
53:42
And if you think a friend will benefit from this episode,
53:45
send it to him, send it to her.
53:47
In the end, sharing is caring.
53:49
I would love to see you in the next episode of Straumann ProTalk Clinico.
53:53
Until then, stay safe.
53:56
Bye-bye.