Dr. Sanda seminar on Nobel Biocare’s Ceramic Dental Implants

Thank you very much for coming and for being here. I guess a lot of people are interested in the new ceramic dental implants because there's a lot of confusion out there. Is it good enough? I heard a lot of it is breaking. So what is new today and why are more and more companies offering the option of a ceramic dental implant? And why is there a need in our patients? So those are some of the things I'm going to address. Also, we are using Facebook Live. This is my team here, Lexi, and we are putting everything on Facebook and I think it's gonna be on LinkedIn as well. If you want to view this lecture on LinkedIn, you can follow us at. Dr. Sanda. So Nobel Pearl, how many of you have used it? And thank you to Noble Biocare for sponsoring tonight's event. Thank you, Carol. You know, thank you for inviting me again, Dr. Hale, and for trusting my, my expertise in this field. Is that better? I think so. I like it. The red stripe lights. Yes. So we have dances. I see. Okay, fantastic. I mean, it is Thursday night after all. So how do I get involved with ceramic dental implants? It really came from a need in my patients. I had more and more patients coming to ask me, can I have a metal free option. And this was back probably about six years ago that I started using ceramic dental implants. And these are patients that have a lot of sensitivities, for example, a lot of sensitivities to different metals, a lot of food allergies. Circles. Since I became a nutritionist in 2007, I am getting referrals from a lot of physicians with patients that are chronically fatigued or have chronic diseases. I think this mic is going in and out and I'm not sure why that is. Is that me? That's good. Okay, I'll try it on for them. Yeah, so. So I'm gonna project. Can you hear? I think you probably could. So essentially I started working with physicians and they were asking me for metal free options. So I started using a one piece ceramic dental implant six, seven years ago. It was the only implant that we had on the market back then. Who was using ceramic dental implants at all here in the groove? Nobody. Okay, so I'll tell you about my experience because I've used about three other dental ceramic implant systems before I use Nobel. And I have to tell you, the Nobel Pearl is not only the easiest to use, but it engages the best in the bone. The one thing about the ceramic dental implants, we have to be very careful with the placement because you can actually put too much pressure on the bone so you can get pressure necrosis. That's compared to titanium. So they're a lot more sensitive with placement. But what I've noticed is with a one piece system we also have prosthetic issues like how many of you have restored one piece implant systems. Okay, so you know already what kind of problems come with one piece systems. Number one, the abutment is not necessarily in the right place. It's too short, too long. The implants angle. Then you have cement problems. Cements are getting stuck under the tissue. If you have especially a highly scalloped, now all of a sudden you can't clean the cement. So same thing with the one piece. The other problem with the one piece ceramic systems is breakage. Once the implant breaks implanted abutment interface, there's no way to fix it. So now we're left with removing the entire implant and starting all over again. And of course that has happened to me. So I decided never again will I use a one piece implant system. Because once it's happened, once it's. Then I went to a two piece cementable system which some of you may have used. And the problem with that is that you actually are cementing the abutment on top of the implant. Now also the problem with that is that the bonding of that abutment number one and again breakage. And both of them have happened to me. So I always wanted something that's screw retained. And that's the nice thing about the Nobel pearl. It actually is a screw retained system and it is metal free because the screw itself is carbon fiber, it's not metal. So I'm going to start with the first patient story with Paula. So Paula has been in pain for about two years. She saw a specialist here in the valley for orofacial pain who made her a device to wear to relieve the pressure off of the tooth. She mentioned that whenever she was eating tooth number 12, she'd feel a pain and then the pain would trigger all the way to the eye and to the top of the head. Now you can see here, number 12 actually has a root canal. She went to an endodontist and said there's nothing wrong with tooth number 12. It must be just orofacial pain. Continue wearing your device. And then finally she came to our office. The CT scan is not fully conclusive. You haven't already looked at it? Barely a lesion at the tip. So I could see why the endodontist. But it was clear that the pain would start in the tooth and she Said when I pressed on the tooth, it felt bad. So what we ended up doing is removing tooth number 12, cleaning the area, putting priority. So here's her tooth. And this is a two rooted tooth, right? This is a premolar. It's the first premolar. And we decided because she had autoimmune disease and actually she was breast cancer survivor, she did not want any metal and she wanted a ceramic option. So eight weeks later, her pain was totally gone. Actually, her pain was gone within the first week. She never had to wear her device again, which she wore for almost a year in hopes that her pain will get better. And when I took out this tooth, there was a micro fracture on the palatal root. So this is one lesson to learn from this case is listen to your patients if they're telling you the pain starts in the tooth, even though there's no radiographic evidence that's evident. I told her, let's take out your tooth. And she was so over her pain that she was happy to do it by that point. So we decided to take out the tooth. PRF was placed. I don't like to put bone grafts, especially in areas of chronic inflammation. For a long time and eight weeks post extraction, we started to place a ceramic dental implant. So in this case, I decided to do the procedure flapless. And you can see when I was actually using my periodontal probe. At eight weeks, the bone is still soft. So we're not gonna have solid bone, but we have a lot of growth factors. At eight weeks, they're closing that socket. So the sequence with the ceramic dental implant, Noble Pearl is actually very similar to the replace sequence. This is a tapered drill. And I like, you can see here the blood, how it seeps up on the implant because it has a hydrophilic surface. So the hydrophilic surface promotes blood to spin around the end one. And it has a transmucosal collar, so we don't have to put it at the bone level. The connection is actually at the gingival line. This is a temporary abutment with a, it's actually a plastic screw that we put over the top in order to fabricate a temporary tooth. I am not a big fan of removable frosty stuff, even temporarily, because I see a lot of problems, you know, with, with the papilla getting squished, then we have recession around the teeth. So whenever I can actually place a fixed temporary, this is coroutine. And I did bond it to the neighboring tooth just to ensure additional stability. So this is what patients want from us today. This is a temporary here we already I'm expecting to see a little bit of creeping periodontal attachment, especially creeping gingiva. So she's still in healing at this point. So why Noble Pearl? Why the need for it? So number one, it's soft tissue friendly but it's a great alternative to titanium today. And I'm gonna go over some studies to show you exactly why we say them it is cement free cement we know causes a lot of peri implant problems, peri implantitis, especially in the titanium. That's why we're moving more towards scour retain. I do some of my own restorations for single and multiple dental implants and 99% of the time there's scrutiny. I do not want to deal with cement, especially after the history we've had with cements. Throughout my lecture I want to talk a little bit about the history of ceramic implants and how did it come about? I mean we've had them now since the 70s and we don't just use them for teeth but we have hip ceramic implants, we have knee ceramic implants for people that are allergic. We actually have a dentist colleague of ours, he has both hips in ceramics. The types of dental implants, I already mentioned some of them that I used. I'm going to go over some of their implant research. What's up to date regarding ceramics. We can no longer say that ceramic dental implants are very brittle and they're going to break. That's not what the studies show. I'm going to review the Nobel pearl parts to get you familiar with it. But I do. We're going to have a hands on course in Yorba Linda in July for those of you that are interested in the prosthetic aspect of the implant to get more familiar with the system. Challenges. What are some of the challenges that we should watch out for? And I'm going to show some videos throughout my presentation about certain cases that I've done in the practice so far. The Noble Pearl has been available now since end of December. So it's a newer system, FDA approved in the United States. However, the system has been in Europe for years before that. So that's where the studies come from. We have five year studies that come from Europe essentially. So how do implants get made? They actually start as this cylinder here and these cylinders actually get cut, carved into dental implants. The zirconia based ceramic material was first created in 1975, so it's been around a long time. However, the structure of it kept Changing at that time, the issue they were having is with the brittleness of the ceramic. So they were breaking a lot easier than they are now. It was first used in hip replacement. And then in 1990, Professor Stanhouse, and he's actually still with us. If you ever go to the Ceramic Academy of Oral Implantology, how many of you have attended that meeting? It's actually once a year, he sometimes actually give presentations. First ceramic implant made from aluminum oxide. And you know, aluminum oxide because you're restorative doctors and you probably have used aluminum oxide in your crown. So aluminum oxide is a ceramic and it is introduced in the zirconia in order to give it strength. So in 1975, we placed the first implants of this material to maximize soft tissue preservation. So you see, ceramic dental implants are nothing new. They're just been getting perfected. In early 2000s, the most common type of zirconia was actually an yttria stabilized ceramic. And it just has to do with the way the crystals come together. That's really what it has to do with. So they found a way to actually combine the crystals of the ceramic so that they overlap themselves to the point that they've gained a lot more strength in the implants. So they've been used in Europe since 1987, but in the United States, who knows when the first ceramic implant system got FDA approved? I'll give you a free copy of my book. Anybody knows what year? Gina? Yes, what year? She says five years ago. Nope. Okay. Good guess though. 2007 was the first FDA approved ceramic dental implant system. So that's 12 years ago that we have ceramic implant systems in the United States. So what kind of implants are on the market today? We have the one piece system, then we have the two piece cementable. So this abutment actually cements inside the implant system. So they come in two different sizes. They come in angled or they come in straight. So this was a little bit better than the original one piece because it allows us to, to play a little bit with the top, with the prosthetics, with the ambulation. Then we had a two piece crew retained implant system. And if anybody recognizes this, what kind of body is that? What kind of implant does it look like? Straumann. This looks like Straumann body with a thread and with a rounded bottom. So the problem with this implant is that it doesn't get good practice primary stability because of the threading system. So the recommendation for this particular implant is to use it in delayed extractions you can never use it for immediate extractions because we cannot anchor it. And all medicine is moving towards more immediate things. People don't want to wait for teeth necessarily. So this is more of an archaic system. But the good thing about it is that it had an abutment with a carbon fiber screen through that connected so we can have that flexibility with the prosthetics. And I've used all these three systems. So the way this connects here, this is an aluminum top and zirconia, by the way. So what does that mean? It has 76% zirconia, 20% aluminum oxide, 4% retrieval. So that's what gives it its strength. The connection here we're going to go over has a little space between the abutment and the implant to allows it to allow a little bit of give because the carbon fiber screws have a little give to them. So titanium versus ceramic, why do we change the system if it works so well? Why would you change anything in your practice and introduce something new if it works so well? Usually because there's a need. So I usually ask myself three questions if I'm going to pick a new system, because who needs more parts, right? I certainly have enough in my office. We have enough technology. I ask myself, is it predictable? Is it easy to use? And the third, does it serve a need for my patients if any of these are? No, I usually don't use them. So I want to answer these three questions for you. Is it predictable? Is it easy to use? Does it serve a need for my patients? And we look at osseointegration of titanium. Then we have alumina cup and zirconia, which is essentially Nobel pearl. And then we have zirconia on its own. And what we can see after four weeks of healing, all of them are integrated. So there's no longer a question, does zirconia integrate at 4 weeks? If you actually take a closer look, here's the implant surface. This basically shows the mineralized bone matrix is in direct contact with the implant. And eight weeks, this continues to mature. When we look at the bone to implant contact, which is so important for us especially for that primary stability at four weeks, this is titanium, this is noble pearl like implant. And this is just zirconia on its own. And we look at the bone to implant contact, the titanium, we get 10% more bone to implant contact. We don't know the reason why that is. But then we also have about 60 to 70% bone to implant contact on the Nobel pearl, like implants. So is it predictable? Let's look at the first question that I asked. Is the system predictable? What do we know? This is Deirdre. Hi everyone. Dr. Moldovan's hygienist. Yes, thanks for coming. She has a little baby and she's here, I'm here. And Deirdre, she's been my assistant 12, 13 years ago. And then she decided to go to hygiene school and she's studying to be a nutritionist. So awesome. Thanks to her influence. So is this Nobel Pearl predictable? This is a study that looks at retrospective statistical analysis of 15,000 implants. That's a lot of implants. It looked at patients that were treated 2010 and 2014 in Europe and it's a retrospective study. What does that mean? Implants were placed and after they were in function they went back and looked at those cases and see which one fails and which one didn't. All these implants had a zero fill surface, which is what Nobel Pearl has. And I'm going to go into the surface morphology and this particular study, under the Zarafield surface, they had three different designs. They had the original design, a middle design, and then more like an aggressive thread like the Noble Pearl design. And the success rate over a four year period was between 96.7 and 99.4% success, which is very similar to the titanium denominator. That's why today we can see, say zirconia dental implants are just as successful as titanium dental implants. This is a nine year study. 596 patients with 2,300 plus implants. This study was actually published in 2015. These patients were examined after nine years. Also Xerofield surface. Early implant loss occurred in 4.4% of patients. What does early implant loss mean? Usually within the first couple of months. And we see the same kind of ratio around titanium dental implants. 4.2% of patients presented with late implant loss, meaning after they were loaded. So of course higher odds ratio was seen in smokers. We see the same thing with titanium and also patients with an initial diagnosis of periodontitis. And we know the studies show the same thing for titanium. Typically there's a 10% difference in patients that have their smokers versus non smokers in terms of success rate. So I still encourage patients very much to quit smoking. What we do know is that the nicotine. What does nicotine do? So the cells exactly slows down the healing. It kind of retards the progression of the cells in the osteointegration. So I encourage them to Quit smoking at least two weeks before and stay not smoking for as long as possible after surgery. And also implants shorter than 10 millimeters, these have a higher odd ratio for early implant loss. And we do see the same thing also with titanium. So data is pretty clear. These are just a couple of the studies that I chose because there were the longer term studies success rate of this particular ceramic dental implant just as good as titanium over time. But I want to spend some time talking about peri implementation implant infections. And the reason is the zirconia dental implants have gotten attention because they attract less plaque around them. And some of you may have seen this. When you place actually the zirconia dental implant crowns or just the zirconia crowns on teeth, you're going to notice that the soft tissue around those crowns looks better. It attracts less plaque. So same thing here. This actually includes one of my patients that came in had titanium implants. And this is actually a ceramic dental implant. This happens to be one piece implant system. And basically these are the three implants. This is actually the ceramic implant system. These are the titaniums. Studies have been done to check the biofilm around implants. So what they notice is that a significantly lower biofilm adhesion than titanium. And I'm talking about the titanium polished abutments, not the roughened surface. We all know that attracts plaque. But the titanium polished abutment will attract more plaque than zirconia. We believe the reason why this is is because of the ions that are released from the titanium. Because bacteria also transmit certain they use the electrical stimuli between them to communicate. That's what the theory is. But nobody has been able to prove that. So a couple studies here from 2006 to 2008, they saw less inflammation around the peri implant tissues of zirconia ethanol implants when compared to titanium epithelial barrier formation has been shown to actually be stronger around zirconium than around titanium. Not as much inflammation. And also interestingly enough, there's better circulation microcirculation around the tissue around zirconia than around titanium. Again, we are not sure why that is. So what is the big difference here between zirconia and titanium? So zirconia has lighter body weight compared to titanium. No corrosion in zirconia. Can titanium corrode? I have the answer there. Yes, it can. And we have an oxide layer actually already on the titanium surface when it comes from the package. No conductivity at all. In zirconia, titanium has a low grade of conductivity. Is this clinically irrelevant? We don't know. We don't know yet. And from millions and millions of titanium implants that have been placed and thousands that I've placed, I haven't noticed a difference. However, I had a handful of patients that complained about sensitivity. And we sit, switch them over to zirconia and their sensitivity. 101. No ion release in zirconia. And then the flexural strength is between 1200 and 1500, whereas the flexural strength of titanium is actually lower. So zirconia is actually a stronger implant. Oral galvanism. I'm sure a lot of you are familiar with this. When you have titanium surface exposed, we know it's low conductivity, but in a mixture with other metals, you can actually measure an oral galvanism in the mouth. Same way as you have a metal crown, gold crown on the other side, mercury filling on the bottom, you're going to get galvanism in the mouth. Some of my patients are very sensitive to this and some are not. Again, we're all built differently. I want to solve the question about, well, zirconium is a metal. Yes, you're absolutely right. But zirconium is not a metal. Zirconium looks like a metal, is a metal that actually makes lots of bolts and nuts and screws from zirconium because it's a strong metal. But when you're looking at zirconium, it's zirconium oxide, which is a pure ceramic, it's powder ceramic. All the properties of it is a ceramic. So please do not tell your patients that zirconia implants are metal. That's wrong. This is ceramic properties that I'm interested in from a biological perspective. It doesn't release ions, it doesn't have any conductivity. It cannot go back to a metal. Those are the things that we're interested in. So that's the definition. We look at the properties of a substance to see what it is, and then we qualify it. Man and woman, right? We look at the different properties. Can we transform men into women? Sure, I guess that's possible. Right? But same kind of thing. You look at the properties of that substance at that particular time and how transformable is it back into a metal. To me, that's a ceramic. It's a metal free option for me when it comes to biologics. Okay, is it easy to use? That's the next question. Is this implant system easy to use? Luckily, it's familiar to all of you because you're already Using probably screw retainer restorations. So this is one of my patients, actually. She had four anterior failing teeth, and she's had these restorations now probably for about a year. Carbon fiber. And then we have, underneath is a ceramic dental implant. You can see here the health of the tissues. And even though she's getting a little bit of recession, we're not seeing any inflammatory issues around her gums. And you know, you can talk to Deirdre. She's seen the difference between the titanium implants and ceramic implants in terms of the health of the tissue when they come through for maintenance. So it's something that's familiar to us. We've used this before. Why is there a need for my patients to use this? Because there are patients that actually could not tolerate titanium, even contraindicate patients with autoimmune disease. To give you the short answer, there's articles that show that, like, what's autoimmune? Sjogren's. It shows no titanium. It actually can exacerbate the disease rheumatoid arthritis. These have been documented in literature and I'm gonna show you some of those studies. So here's the connection, and I'm going to talk more about those dimensions. But the connection itself is called an interx connection, specifically designed for ceramics. And then the bicarbo screw, this carbon fiber screw, it withstands the, like the, the forces. The carbon fibers are this way, oriented longitudinally to be able to withstand the pressure of the chewing forces. So when you're actually looking at the implant anatomy itself, the top here, this collar is 1.6 millimeters. So the top 0.6 is machined. Okay. So you could leave this even supra gingival, for example, because it's polished. And then the 1 millimeter is the transition zone, we call it. And this actually is a roughened surface. So this surface can be into the bone or into the tissue bone. So when we're talking about supra crestal is this platform right here should be at least 0.6 superacrest. So the xerophil surface, if you look at it under the microscope, is actually a sandblasted and acid etched. And we have the same thing for dental, for titanium dental implants, because it is the best surface that we see for osteointegration. And the studies that I was showing you earlier were done with a sandblasted acid edge surface. So we have different dimensions with this. We don't have yet a narrow platform implant, but we do have a regular platform which is a 4.2 and then a 5.5. So 5.5 is good. Obviously for posterior teeth. They are intended for delayed loading. So any time, eight weeks plus I have used them in immediate sockets. I haven't had a problem yet. But the recommendation from Nobel is delayed. I'm going to talk about these metal allergies and intolerances because I wasn't clear about it either. Twice a year I go to medical conferences just to see what our colleagues are doing from especially alternative medicine, environmental medicine, and functional medicine. And why is it important for our patients? Unfortunately, more and more of our patients are sick today. I get more and more patients with chronic diseases, lots of intolerances, chronically fatigued, and, you know, a lot of them cannot tolerate certain things that we do in dentistry. So here's what we have available in terms of sizes. We do have 8 millimeters. I would advise you to go 10 plus. Especially if you look at some of the studies. We know there's higher odds ratio of implants being lost department, but 10, 12, 14. Some of the other implant systems don't have a 14 millimeter. So it's nice to actually have this one available. So you have to keep in mind that this collar right here, since it's a transgingival collar, so we have to know the total length of the implant. If it says 10 millimeters last second, the total length is actually 11.6, because a 10 millimeter. So that's one thing we have to keep in mind when we place it. And here's a surgical kit. I don't just have to go shy with that since implants, but here is a schematic. You can see how this implant's been placed. This is the 1.6. That's super presto. Okay. And the rest is in the bone, but you can get this deeper. So you have room here to play with this 1.6, which is actually a nice part about it. And how do we decide that really based on the gingiva? If it's a thinner gingiva, you can drive it deeper. If you have thicker gingiva, you can leave it shallower. That's really what that allows us to to do. But one thing to keep in mind, which is the nice part about the system, it has actually a fracture point when we actually insert the implant. So if you're going to with too much torque, this will snap, which is good. It's a protection mechanism for the ones that are placing implants. So we have what is called a rescue driver. It's gonna Help you kind of back up. What is this torque that really 20 to 45 Newton centimeters. We don't want to torque it more than that. Because zirconia is such a hard material. You're going to create pressure necrosis. And if you ever want to play with placing implants, your Belinda Hands on July 20th. But here's the package again, color coded, very similar to replaced. So it's easy for you to, you know, when you get the parts to understand what you're dealing with. We have, of course, magenta, which is narrow yellow, regular white is blue deca bottoms. They come in different heights depending, again, on the height of the tissue. A lot of times, if you leave this transgingival, I actually like to use the screw itself to cover the implant. You don't need any height on it. Or you could use the 3 millimeter or the 4 millimeter abutment. Most of the time I do like to use straight, the temporary abutment. Just to help create that gingival profile to get it ready for the final cut. Most of the implants that I place are one stage. I don't do two stage. What does that mean? To cover the implant 100% and then come back, you know, six months later for uncovering. But that's certainly an option with the system. The only thing in that case, you just have to drive the implant deep enough to stay covered. The healing time typical to titanium, three months on the mandible, six months on the maxilla. But again, it depends on the patient, right? You have a young patient gonna heal a lot faster than somebody who's 70 years old. The abutments, we have the straight abutment 15 degrees. And then we have a ceramic base for screw retain. And that would be my choice to make screw retain restorations. I mean, there's no reason today to really have cementable restorations. If you're placing the implant the right place, we can discrete it. Now, the one thing with the system is that the base of the screw is actually slightly wider Than the titanium screw that you're used to. So the screw access hole will be slightly bigger, maybe half a millimeter in diameter bigger. But that's enough sometimes to make a difference when you're working with lateral incisor that you don't want to do screw retain. So in those kind of cases, when you make the screw axis hole too large. And endangers the crown itself into breaking, then we switch to cementable. So the nice thing about the carbon fiber is that it actually meshes with the end internal Part of the implant, as you torque it down so it distorts. So what does that mean? With a carbon fiber screw, you cannot reuse it. You torqued it once, that's it. If you need to undo, undo the torque, you need to change the screw. That's very, very important because that's when you run into problems that you can break a fracture a screw. And how many of you have had to remove fracture screws before? Yeah, so we know those appointments, you never know how long they take. And now we have to deal with carbon fiber. Very similar. You use the same screw removal kit. If that happens to you or if you strip it. Elastic modules. And I'm not into the engineering part of screws. But similar to the titanium screws. Again, this is 2.8 millimeter, just slightly larger than the titanium ones. The driver itself is different. It actually has four prongs at the end. So it's different than anything else you probably have. This is actually a plastic screw. It's not carbon fiber in the temporary. Okay. So it's only need to be meant to be torqued down at about 10-15 Newton centimeters when using a temporary near session. This is Chris. She has an upper right area that she wants taken care of. And actually she would love a lot more than that. But for now we started with her upper right. She came to us actually from Santa Barbara. She wanted a metal free restoration for absolutely no reason. Just for the fact that she wants metal free. So tooth number read number four. Guarded prognosis. So we decided to just cut off the contact and start getting it ready for three individual crowns. This is what we have three months after placement. You see here the nice soft tissue around the implant looks better than around the neighboring teeth. So the prosthetic part of things, I wanted to go over that. Very similar to what you've known before. Closed stay and open tray impressions. So close tray, very straightforward, color coded. Then you have here the analog. You can pour out the impression or I still prefer to do open tray impressions. Especially when you have multiple implants because you never know near the angle. It can never be completely parallel. So this is what the open trade pressures look like. They're slightly larger. The difficult part with these, when you're working in the posterior portion that you actually. These have a groove on the top. But the easiest way to actually remove that is with a hemostat, to actually turn that. Because this part is flaccid. This is a lap screw. It's yellow. So please remember to send this to the lab and Keep the carbon fiber screw in your office because I guarantee you they will use your carbon fiber screw. Then you have to replace it. The abutment itself, this part right here, the top 3 millimeters, you can prep it down, but not the base of it. So only the top 3 millimeters, 25 Newton centimeters. Remember, that's the torque that you want to use, the maximum torque, and only once. Very, very important, the dust screw. So highly advise you to keep some extra carbon fiber screws in your office. So last part here. Does it serve a need for my patients to actually have a knee implant system? What's the point of it? Well, besides the soft tissue benefits, and we already talked about this natural aesthetics, low plaque, soft tissue attachment, and definitely more vascularity around zirconia. But what would be other reasons why you would want to have this? Number one is the recent literature that we had with autoimmune patients. This particular article was actually published in 2018. The rate type hypersensitivity of metals in connective tissue disease and fibromyalgia. What is connective tissue disease? Disease? It's actually a group of diseases. So we have Sjogren's, we have rheumatoid arthritis, we have Raynaud's, we have mixed connective tissue disease. So this is the lupus overlap disease. All these patients, the recommendation here is that don't use any kind of metals because these particular diseases are accompanied by sensitivity to metals and any kind of metals and they have an increased frequency of metal delayed type hypersensitivity, type 4 allergies. And if you actually introduce metal in these patients, you're going to see an exacerbated inflammatory response. And this is not the only article. There are several articles of this type when we're looking at connective tissue disease. So for these particular patients now I no longer recommend titanium implants. We recommend ceramic. When we look at a aesthetics, this is another way to improve aesthetics in the anterior zone. If you have some recession in the inferior, then you're not worried about the metal. So I put this camera out here. One piece implant system and ceramic, two piece. This patient's gonna have it all, but all ceramic. Let's look at Suzanne's case here. She had two anterior teeth that were failing large radiolucency above number nine. Can we do immediate in this case? And you know, I was even wondering she should I do a two stage approach in her case? And then this is Suzanne. This is four months after healing. So we're able to maintain this papilla. We got maybe A little bit of collapse from where we were. But the goal is to just maintain this architecture as much as possible before she goes to define. And these are her implants, four 14 millimeters. And then we have a 12 millimeter. And the reason why this is longer, just because I had so much bone loss in that side. So we need to have more, more stability. But the one thing I'm impressed with this implant is the stability that I'm able to get compared to all the other implant systems that I've used that are ceramic up to nail. And that's partly because of the thread anatomy. When you look here, we have a lot more threads than the previous systems that I was showing you. And that allows me to. To engage the implant better in the bone and also have more surface area. So we know zirconia has better aesthetics overall, but doesn't matter if you have a titanium implant and just a zirconia abutment. Does it matter or not matter? So actually we found this. I found this article that actually looked this, used this colorimeter to measure the color of the tissue. And the nice thing about this case or the cases that they used here is that they took the measurements here. This is some of their patients here. So they used not only a zirconia abutment, but they also use a titanium abutment. And then they measured it 1 millimeter, 2 millimeter, 3 millimeter down from the gingival margin, just to see if there's actually a color difference even when compared to natural teeth. Because is zirconia really similar to natural teeth? Is it the same? It's not exactly the same. It's actually slightly different, but it's just more pleasing in general. So what they actually found that when you look at the numbers, titanium versus zirconium at 1 millimeter, titanium was quite off compared to the zirconium. And when you go to 3 millimeters from the gingival margin, they're kind of starting to get a little bit closer. But still there's a difference in the number. So compared to titanium, there were fewer color differences registered for zirconium. Now I want to talk about this issue of autoimmunity and of allergies. I work with a couple of environmental MDs. Have you guys ever environmental medicine? Anybody's have to go see environmental medicine. Some of you. So they're not well known yet, but there's a lot of MDs now that are specializing in environmental medicine. And next year. Yeah, you've got one. We actually have a conference which Is we have biological dentistry and environmental medicine. They're having a mutual conference. So that's always interesting to see because we use a lot of chemicals in dentistry and some of them can affect our patients. And we have better tests now to identify before you even start doing the procedures, hey, are these metals or are these materials safe for my patient? Because you know, you'll see those cases when you cement a crown and then all of a sudden the patient is all inflamed and you have no idea why. I've seen those cases. As a periodontist, I get those kind of referrals usually has to do also with a reaction to the kind of material that was placed. So Dr. Von Baer, Environmental indeed. And he gave a really nice presentation a few years back at one of the conferences I was at about is there a true titanium allergy? Some patients actually believe that that can even happen, so. So according to him, no, there cannot be a true titanium allergy because of the size of the titanium particle. So the titanium particle, we know there's titanium particles coming off the implants. How do they come off the implants? Hygiene department. Right. You're scaling, definitely. You have titanium particles coming off the implants. How else? This is an article from, from J. Perio 2012. They actually showed the titanium particles around the Peri implant tissues. And we've also found titanium particles in lymph nodes. Is that clinically relevant? We don't know. We don't know. I mean, I'm sure we have a lot of other things in our bodies. You know, the newborn has an average of 360 chemicals in their body when they're born. So God knows how many we have. Right, because that's how it is. We, we're living, we're picking things up from the environment up to a threshold. And when that threshold doesn't reach, our body can no longer keep up with these chemicals. And we have 70,000 plus chemicals on this planet that are man made. That's why we need environmental doctors. Because when you're sick and I have patients that feel horrible, they go to the doctor and they say, oh, you look fine, there's nothing wrong with you. Then they go to environmental medicine to figure out what kind of toxins their bodies have accumulated to help them detoxify. So titanium is probably the least of our problems. Right, but there are titanium particles that are found around the tissues and in the lymph nodes. For some patients you can trigger reactions, but for most of us it's okay. These titanium particles that are coming off the implants, the macrophages actually pick up the particles and they can induce an unspecific inflammatory reaction. So macrophages are not specific. So what is a nonspecific inflammatory reaction? Like, almost like, you know, you have a splinter and you get some inflammation. It's the same kind of thing. This is just a micro splinter. So we're talking about titanium ions here. But macrophages release TNF alpha, IL1, then the osteoclast activation happens, and then you start seeing bone degradation. But the interesting part, it's okay, we need to find out which patients are prone to this. So Dr. Von Baer, actually and a lot of other environmental doctors are looking genetically at their patients to see what kind of genetic phenotype they have in order to induce this reaction. So this article actually talks about smoking positive IL1a, IL1b genotype associated with marginal bone loss. So IL1a, IL1 polymorphism predisposes patients to bone loss. Do we regularly monitor that in our patients? No, we don't. We don't really look and see before we place implants. What are your genetics? Maybe in the future we will, but we don't do that now. It's not the standard of care. And the other interesting thing is, like, if there are titanium ions in the area, and now we have macrophages that have been primed with lps, there's even more of a reaction. So what is lps? It's a toxin that's released by bacteria. So if you have peri implantitis or you have certain bugs in the mouth, and now you have a patient with a genotype that's positive to IL1A, it's even worse. That's what that means. Here's another study looking at the same thing. Polymorphism and IL1a, IL1b1rn genes that affect peri implantitis. So if you have a patient that have all these three genetic defects, most likely gonna have peri implantitis with titanium. Again, we don't measure for that today, but in the future we're probably going to be doing that. I mean, it's not hard to do a saliva test today. How many of you have had 23andMe? Maybe some of you, because that's where it's heading. Even in nutrition, we do personalized nutrition based on salivary testing for genetics. That's what we do. So if you haven't had any genetic testing yet, especially when it comes to how you're digesting your food, I highly suggest you eat A because it helps you live better, healthier, you know, you understand how your body works. I mean, every single one of us has a personalized genetic makeup. We digest food differently. So just to give you an idea for coffee itself, okay, there's two different polymorphisms. One which, the one I have, if I drink more than one cup of coffee, it lowers my risk of heart attacks and strokes, so I can drink more than one cup of coffee. Someone else with the other polymorphism, if they drink more than one cup of coffee, it triples their risk of cardiovascular disease. So this thing that you hear on the news, coffee is good for you, coffee is bad for you. It's both Depends who you are. That's where we're heading today. And you know, dentistry is not exactly very personalized today, but. But it will become more personalized when we look at biologics for sure, because data like this so getting per implantitis and they're losing bone. No matter what you do, we still see bone loss. And I have very few of those patients, but I do have in my practice, they probably have all these three column organisms and there's not much we can do. That's basically the bottom line. They're predisposed to that. What we can do, switch to zirconia because we know we don't have iron release. So what is the problem though, with having, you know, top and bottom implants, especially zirconia, speaking of full arch cases, it's a very dense material. So the proprioception right now, all of a sudden you're dealing with, you know, very hard, that stress is gonna be driven straight to the bone. So we definitely need to provide night guards for these patients. So I automatically include that in my treatment plan. The other thing is zirconia and natural teeth wear at different rates. So in the hygiene department especially, it's important when you do your annual exam to check for the occlusion on these patients with nix dentition because now all of a sudden they worn down the enamel. But zirconia hasn't been worn down. So you end up with an implant and hyper occlusion. So just keep in mind and remember to just annually actually check the occlusion on the implants. So these are some of my cases actually that I've not gone so well. One piece implant. I had to remove it because it broke in the mouth. It was number 15. So what can you do at that point? Nothing. We have to remove it. So how do we remove this? I actually have to trephine it out. So we use a Trephine, we core it out essentially. But it's traumatic for the patient. I mean it was in function for about a year. She wasn't wearing her night guard like so, you know, you know, broken implants, so you have to start all over again. So even now I inform patients, you know, there's always a chance of fracture, even with titanium. How many of you have seen fractured titanium implants? Yeah, I mean it can happen. We fractured teeth, we fractured titanium fracture, zirconia, anything. So just make sure you let your patients know that we have some kind of policy in terms of fracturing crown, just like you do for crowns or restorations. This is an interesting case here. Actually had an implant that fractured at the tip. So this particular implant was actually already integrated. We offelled it, it looked good. This was actually a one piece implant. So the patient says, you know, I heard a click in my, you know, when I ate something, I heard like something snapped. So sure enough, the implant was just slightly loose and then the implant broke at the tip. I have never seen this, Never, never seen this before. Yeah, so that's, that's the problem with some of the previous environment. And if you look at this, it's actually very narrow at the top. So that's one of the problems with the biomechanics. I think we went over that. Till essentially, ceramic dental implants behave very much like titanium. Same thing. Good oral care routine is important in office maintenance therapy. What do we use in our office that works really well for implants is airflow with glycine. How many of you use that here? Airflow. So airflow with glycine is very much like pro rejects, but it uses glycine instead of the powder. So the glycine is like around 25 micron, is an amino acid which is anti inflammatory. So it removes soft plaque without the scraping. So when I first started practicing as a periodontist Back in 2004, 2005, I went to a couple offices. They're actually scaling around implants on a regular basis. So yes, we need to probe yearly. And maybe some of you have heard me talk about the dental and blonde maintenance. Last time I was with Dr. Hale. So you need to probe years, that's for sure. But you know, be gentle and don't scrape subgingivally. Use more delicate things. Now we have such good tools and hygiene like the airflow. And you could go up to 4 millimeters subgingivally. It's got a special tip for that. There's no reason to use a scaler unless you have tartar and then when you have calculus, of course now you can use ultrasonics. Even the ultrasonic tips have gotten so much finer to use. Yeah. So when you're talking about even titanium implants, if you're going to use ultrasonics and scalars, you are going to dislodge more and more titanium particles. Another thing now we have to worry about. Before we weren't thinking about that, but now we have to be more careful about it. And glycine being an amino acid is also anti inflammatory. So you're actually doing an anti inflammatory treatment for your patients. If you're going to the cda, they do have it there that you really. So you could play with it. Yeah, I think there's still a lot we don't know, especially with environmental medicine. I mean it's a whole other field of understanding how certain, how the environment affects us because it does affect us, you know. Now the latest thing is this Wi Fi G5G or whatever they're called. You know, a lot of physicians I work with are worried about it in terms of our health because energy affects us. Right. So, so how, how is it going to affect us? We don't have any studies, unfortunately how a 5G will affect health. We have no studies. And they're going to, they're releasing. I think it's been released. No, this is the 5G. It's out, it's released. So I had one physician, I was actually over the weekend at a summit in Arizona and one physician from Minnesota was saying that this family installed it in their house and both the kids had seizures and they've never had seizures. Okay. So we have a hands on course as I mentioned to you. It's a nurba Linda for a dentist if you want to learn a prosthetics and more about the Noble Pearl itself. It's on July 20th, it's a Saturday. And Noble Biocare has a beautiful teaching center there. Have you ever been there? It's beautiful. Did you like it? That's really gorgeous. So if you've never been, come and visit. They'll give you a tour of how they produce dental implants. Every, every time we have a tour in which you can see how the dental implants are being manufactured. It's a field. Okay, thank you very much. It's been nice to be.