Understanding the Shift from Titanium to Zirconia Dental Implants with With Dr. Sammy Noumbissi

Hi everybody, I'm Dr. Sanda Moldovan, periodontist and nutritionist. Welcome to the Holistic Dentistry Podcast, the show that gives you the tips and tools to detoxify your mouth for a healthier body as we explore together the root cause of disease. Remember, you're not healthy until your mouth is healthy, so take care of it in the most natural way.

Hi everyone.

Welcome to another episode on the Holistic Dentistry Show. I'm your host, Dr. Sanda Moldovan, and we have a very interesting topic that brings along a lot of controversy usually. So I'm super excited because we have the expert in ceramic dental implants here with us today, Dr. Sami Noumbizi, and he earned his doctorate degree from Howard University College of Dentistry in Washington, DC. And afterwards pursued advanced training in implant dentistry to the 3-year graduate program in implant dentistry at Loma Linda University, where he was awarded a certificate in implant dentistry and a Master of Science degree in implant surgery. Dr. Nemvizi is the author of multiple book chapters and has published more than 60 scientific and clinical articles in the field of dental implantology with a particular focus on ceramic implants. In 2009, he became one of the first clinicians in North America to introduce and implement ceramic implant therapy in private practice. So, Dr. Sami Numbizi, thank you so much. Welcome to the show.

Thanks for having me.

I'm so curious, you know, you started this in 2009. I don't think at that time I was placing ceramic implants because in my residency I was really learning titanium implants. So I'm curious, how did you stumble upon, after you finished your master's and you got your certificate in implant dentistry. At what point did you learn about ceramic implants?

Well, first of all, you're not alone because we all learned titanium first.

Okay.

Yes. I graduated from residency in 2002 and up until 2009, 2010, I was doing titanium implants like everybody else. And I practiced for about 3 or 4 years just how I'd been trained. And then I got the opportunity to purchase a practice and it was one of the very few biological dentistry practices in the Washington, DC area. And so I I had no clue what biological dentistry was, what it entailed. I mean, I was just, I was a businessman. I was just thinking business. So I asked the owner, I said, look, I need you to stay here because I don't know what you do. I need you in the practice with me, transition me for at least a year, even more if you want. And he was very flexible. And I started watching in practice and, you know, paying attention to the materials, all these things. And My role was to be the practice owner, of course, but also to be the implant dentist in residence, right? And one day he refers a patient to me to finally, he had finally removed the amalgams, cleaned up all the metals, detoxified the patient, patient ready to go, sends the patients over to me and says, well, he's ready to get his spaces filled, his gaps filled. Okay. So I sit down, I start talking to the patient. The patient looks at me, he says, doc, I just removed all the metals out of my head and now you want to put some more in my head. Literally, he said it like that. And I looked at her, I said, well, there's no other way to do it. And he looked back at me and said, well, I was online. This is 2002 now, 2012, I'm sorry. Yeah, 2012, I'm sorry. And he looks at me and he says, well, I went online and I saw an implant system, a ceramic implant. I said, okay, what, what is that? So he, he shares information with me. I find out that it's this ceramic implant out of Spain, CeraRoot, and I decide to go up there and get some training. So make a long story short, I don't want to be too long with this. I learn about ceramic implants from the patient.

Wow. Because there's a— Yes.

Yeah. Yeah. And, and, you know, in residency we, we went over that, but it was the older ceramic implants that were notorious for fractures and not also integrating. That were not just a good material implants at the time. So in my head, this was not even something that needs to be considered. And when this guy looked at me and said, I have something for you, pretty much. And before he left, he looked at me, he says, when you can place these, I'll come back and get some implants. And that's actually what happened.

Now, back in 2002, were ceramic implants or zirconia implants even FDA approved at that time or not yet?

No, no, no. Just in Europe. I think the first US-approved ceramic implant was probably in 2009, 2008.

Something like that, because I think it was, and I think it was a Z-Systems. They were the first ones.

It was Z-Systems, correct.

To get—

Actually, I think the CeraRoot was before, or they work right around the same time, but Z-Systems is the one that was just, just came out out unapologetically saying, we have ceramic implants. This is good for you and for your practice and your patients. And yeah, it was easy since 2009. You're right. Absolutely.

Yeah. So when you went to school—

So like you, I practiced about 10 years, 8, 10 years of titanium implantology.

Yeah. So I'm sure you were a skeptic going into this thinking, okay, these are probably going to break, but I'm going to learn about them anyway.

Yep.

Okay. And what was your experience right in the beginning? Because I know we have people that are listening, dentists as well, thinking, okay, maybe I want to dabble into ceramic. Implants. So do you feel like it's required? Like, did it really help you the fact that you already had a lot of extensive training in titanium implants? Is it similar in terms of placement? Did it feel similar to you?

Well, the act of placing is similar, but the whole concept and philosophy behind it is, it's a little different because my, like I was telling you, I went to Europe a lot to get myself better in it. And there was a saying in Europe, zirconia is a diva.

I love it. I've never heard that before.

You've never heard? It's a diva because it's a material that's very sensitive, that needs to be understood and to a certain extent be respected. So if you're a surgeon, you've been doing implants for 10, 15 years and you've had great success. If you're not careful, if you do not seek some level of training or understanding of how the material performs, you'll be humbled because, and it's not humbled by fractures, but also even by failures because these implants require a healthy recipient. The patient has to be healthy. The patient has to be optimized. The surgeon has to be very meticulous and, yeah, very meticulous in planning. It's the act of placing it is the same, but there's a lot that comes behind these implants, which you probably know that make it quite, can make it quite different.

Yeah. I agree with you 100% because I, like you, started placing titanium implants after my residency when then zirconia does require, you can't force it in. Like titanium has, you have a lot more flexibility. You, it has to be like precise torquing. You can't have too much pressure. You get bone necrosis. So it's gotta be right, right on the spot.

Yeah. A diva.

Exactly. So, uh, where did you go from there? Are you now completely doing ceramic implants? Are you still doing titanium?

Well, in, uh, 2000, when I started, I was doing 50-50 because my whole training, my whole approach to implantology was titanium. So when I brought the ceramics into the practice, I was doing 50/50 and this is how it went. Very interesting. I would sit down and I'll look at a patient. I say, well, in this practice we do two types of implants. We do the titanium, here are the pluses and the minuses. We do the ceramic, here are the pluses and minuses. And it's probably gonna cost you an extra 30%, 20% on what you're accustomed to pay for a regular titanium implant. And I tell you about 80, 85% of the time, patients were willing to pay a little more. To have a ceramic implant. And one response that, or comment that came about maybe 1 out of 5 times, I always wondered if these implants will not corrode in my mouth. This is, this is lay people thinking like that. I never thought with all the training I got, and you probably didn't, I don't know. I never thought that an implant could have a corrosion problem.

Yeah.

I had a patient.

I was never taught that.

No. Yeah. But I had a patient who was in a chair or a couple. Just using their, I guess, common sense, if I may say. When that comes from a layperson who's coming looking for your expertise, you gotta step up, you know?

For sure. Yeah. So what is the answer to that question actually? I'm sure some people are dying to hear this.

Well, I, I, I, the answer to, I wonder, did it ever corrode it? That's what you're asking?

Yes.

I told him yes. I had to tell him because the literature is there.

Yeah.

There's literature even back to the '80s, '70s that say these, these, these, these these materials can corrode. And the most clinicians wonder, but how? Because we were always taught that titanium is the best thing available. No corrosion to it. It's the best thing that has ever been invented. But if you look even at the orthopedic literature, medical orthopedics, they have known this since the '60s, that at some point there's a corrosion problem. And in implant dentistry, it's even more, I think it's probably even worse. Not because of, because, well, mainly because I, and that's me just Putting together the literature that I've read and what I understand is that we, what do we do in implant dentistry? We have an implant, which is titanium alloy these days for the most part. Then we have an abutment, which is another metal. Then we have a screw, which is probably another alloy. Then we have sometimes a coping, which is a different alloy. So what do we do? We sometimes probably stack up 3 to 4 dissimilar metals. And guess what happens when you do that? Galvanism. And what's a consequence of galvanism? Corrosion. Release of metal ions into the peri-implant tissue. So we in implant dentistry, we've always looked at the end solution and not always at, okay, what happens in between when I place that implant and when the patient comes back with inflamed soft tissue, for example, you know, what happened in between? Well, we were trained to say it's your hygiene, you're a smoker. Yes, those things contribute, but the material, the implant material today is something that clinicians have to start looking about. At very, very seriously.

Yeah. You know, I agree with you. Now, when we look at ceramic implants, and oftentimes in my patients too, I see healthier gum tissues. There, we, to my knowledge, we don't yet have enough data to see, okay, what is the exact percentage of peri-implantitis? But we know titanium implants, peri-implantitis is 1 in 5 patients will get peri-implantitis within 5 years of placement. What do you see in your practice in terms of peri-implantitis around ceramic implants? Okay.

It would probably sound a little strange, but I don't think I've ever seen peri-implantitis around a ceramic implant. That's not to say, because people are gonna jump on this, ceramic implants can also fail. They can also lose osseointegration. It happens. Okay? So it's not a perfect product that's a 100% success rate. But peri-implantitis has defined in most of the literature where you have soft tissue irritation, maybe, which starts as a perimucositis and then evolves into bone loss. That's very rare. Usually you lose the implant, in my experience, before that happens. So, I've always found that the failures, my failures over the last 15 years on ceramic implants were always early. Whatever failed was early. Once they integrated, once the soft tissue attached well to the implant transgingival collar, usually, and again, I have a background about 15 years. I think it's enough to be able to say something about that. 10 years ago, I wouldn't stick my neck out like that, but now I'm 15 years out, 14 years out, I can say I've I don't remember seeing peri-implantitis as defined on a ceramic implant. I don't know about you, but for me, no.

Yeah. No, I'm with you on that one. I don't see that level of peri-implantitis. And if I do see inflammation of the tissue because the patient's not brushing, you know, that's another story. But it's not, I don't really see that kind of bone loss pattern like titanium implants. And, you know, it makes sense in a way because we know it's that corrosion. So going back to what corrosion is, it's actually titanium particles coming off the titanium implants and just traveling throughout the peri-implant tissues. So we don't have that. Yeah.

And triggering an inflammatory cascade. See, again, that's the biology side of things of implantology. Understanding what the material, how the material behaves in a host and how the host responds to that material. So like you were saying, when a corrosion happens and now you have that release of ions, you trigger an inflammatory response. Then you have these macrophages coming, trying to clean up. They can't clean up. Then you have giant nuclear giant cells, and then it just goes on and on, on and on. IL-6, you name it, and you start having an inflammatory cascade. So yeah, the material is very important.

Absolutely. And you know, I'm glad you're bringing up the material because sometimes when I do a post on Instagram, somebody corrects me, no, zirconia is a metal. So I really want to dive a little bit into this just to clarify it for everyone listening. If you can explain that to us.

Yes.

Okay.

Zirconia can also be called zirconium dioxide. So it's an oxide of the metal called zirconium. Okay, so we understand that. Same thing with alumina. Aluminum dioxide is alumina. In implant dentistry, we talked about, we always talk about the oxide layer. Open your implant, expose it to oxygen, oxide layer forms, and you place the implant. What's that oxide layer? It's titanium oxide. It's a ceramic layer that forms on the surface of that metal implant as a result of exposure of the titanium, which is metal, to oxygen and becomes titania, N-I-A. So when you have, so when you, when we talk about This is how sometimes I make it easier for people to understand. I say, well, when you place a zirconia crown in your patient's mouth, how do you treatment plan it? As a porcelain fused to metal crown? As a gold crown? As a metal crown? Or you treatment plan it as a ceramic crown?

Okay.

As a ceramic crown. What do you tell your patient that they got? A metal crown or a ceramic crown? Got a ceramic? So the crown is zirconia, therefore it's ceramic crown. Perfect. How about when the implant is zirconia? Why is it that all of a sudden it's a metal? It's the same material at few chemical links difference. So zirconia is a ceramic. It's an oxide of the metal zirconium. But once it goes, undergoes oxidation, it does, it loses its metallic properties, namely ability to conduct electricity. So you don't have galvanism with ceramics and also its surface energy. That's another aspect of materials that is not talked about. The surface energy of zirconia is very low. That's why plaque doesn't attach to it that well. Whereas the surface energy of metals and titanium and titanium alloys is high. That's why you can find a lot of plaque attached to abutments or to exposed implant collars because that surface is just charged in a way that it attracts plaque.

Exactly. So there's no corrosion possible with zirconia implants.

Absolutely not. Not with zirconia. Not at all.

Yeah. You know what's interesting about you is that you're actually placing the implants and then you're also doing the restorations, correct?

That's correct. Yes.

Yeah. So, you know, I'm actually the placement portion, but then I have the prosthodontist who is actually dealing with a restoration on top. What kind of indications are you using the zirconia implants for? Is it single crowns? Is it bridges? Do you do full arch cases?

The most cases I do, I do all, all across from singles to full arch. But what I run into the most and that I'm willing to do with ceramic implants are the singles, the true doubles, the triples. You know, never do bridges on ceramic implants ever at all. I just don't think the materials are designed for that. So if there's 3 consecutive missing, we get 3 consecutive ceramic implants. Now, your question is very good because I like the question because those of us or our listeners that are going to get into ceramic implants need to realize this. You're going to receive a lot of people who are, who have taken ownership of their health. So there's not a lot of people that come in requesting ceramic implants that are missing a full arch of teeth or full mouth of teeth. They usually have taken good care of themselves. They're of a certain age group and they need maybe 2, maybe 1, maybe 3 here or there, here or there. Now, there's cases where there's always an oddball. Somebody comes in and they say, well, I need a full mouth of teeth and I want it to be metal-free. And that's where you have to make a decision because ceramic implants today, compared to when I started anyway, they have evolved a lot. There's a lot of prosthetic solutions that I didn't have when I started ceramic implants. They were all one-piece implants. And I still found a few full arches to do with one-piece implants, but it was hard, right?

Yeah.

And now you have some ceramic implants that are coming up with MUAs. They're not FDA approved yet, but it's coming. You have angled abutments, they're already available. You know, now with guided surgery, you can really get those implants in positions that are very biomechanically favorable to full arch restorations. So full arch arches are possible with ceramic implants. It just requires a lot of diligence and you cannot always use it on every patient. Because for example, I can tell you where, if you have a patient who has a severe bimaxillary protrusion, it's hard to do ceramic implants on people like that because if you go one piece, then there's too much protrusion. Then you have a lot of a lot of the implant to shave down and things like that. If you go two-piece, then you start going to angles. What happens over time? You know, so they apply, you can apply them to a broad range of cases today compared to even 5 years ago because the technology is catching up pretty fast. I mean, now we coming very soon into what is called bendable ceramics. Those are coming soon.

Yes. Amazing.

There, the INSA Lyon in France where I'm a guest faculty, also a guest researcher. They have been working on this for a couple years and they're close, very close. I want to say bendable, it's not like a rubber band, okay? It's more like a ceramic that can bend equally or more than a titanium, a piece of metal, right? And that's going to revolutionize everything because now we're going to be able to go beyond because ceramic implants now, the angle abutments, I think the greatest angle I think is 25 degrees or something like, or 15.

15 degrees is what I know. 15. Yeah.

Yeah. It's 15. That's right. Well, now we're probably going to be able to go to 25 or 30 on ceramics. So there's good things coming up. But to answer your question, you can apply them in a wide range of procedures. It's treatment planning that's—

Yeah, absolutely. Because I had a couple of patients, not a lot, that wanted a full arch. They had a full arch edentulous, basically no teeth. And our prosthodontist was wanting to place actually 4 individual bridges instead of 1 full arch prosthesis, just for the ease of dealing with the abutment, even though I do prefer screw retained, definitely over the one piece. I can't get that out of my residency teaching.

No, no, it's, and I don't think it's a flaw because honestly, I also like one piece and there's one ceramic implant on the market available now that allows you to do screw retained. The problem is that the screw is metal and the majority of patients who come asking for ceramic implants, they don't like the idea of any metal component in the whole assembly, abutment, crown. Implant, but it exists. And I've done a few because, you know, as these implants also become very popular, you'll find that there's the demographics asking for ceramic implants is widening. So what does that mean? It means that you have very philosophical people who say, hey, you know, I just want something ceramic. If the screw inside is metal, I don't care. And then on the other extreme, you have, well, not an extreme, on the other side, you have a group of people who say no metals, period. And we have doctors too who say no metals, period. So, It's, but it's available. It can be done screw-retained ceramic implant, but you're gonna have to accept a metal screw.

Well, one of the systems that I'm using right now, Xeromex, actually has a carbon fiber screw inside. Yes. You know, pluses and minuses with that. So that's what we're using. I'm not using, I think the other one with the screw system is a Neodent.

Neodent is the one with the metal screw. Yes.

With the metal screw. Yeah. I haven't used that one, but the carbon fiber screw, it's definitely softer than a titanium screw. So definitely a lot easier to strip. I guess the good news is if you do end up stripping it, it's easier to remove because you could just drill into it. It's pretty soft.

Yeah.

So the only problem I'm seeing right now, and I don't know if you're seeing this in, if you're using 2P systems with a screw-retained is always the weakest link is the abutment. So if the bite is off, that's the part that tends to break.

Yes, because I agree with you that the implants themselves seldomly break. It's usually the abutment that snaps. And once you see that, it Most of the time it's a biomechanical problem. Some forces were off or something, they, you know, their angles were not that great. Or simply also maybe the patient just has a, was not aware at the time or never disclosed that they probably have a clenching problem or grinding problem and then they end up beating. I've had patients restored everything and then they go somewhere else or move out of state and they get a night guard and then the night guard engages the implant and then the abutment breaks. Well, it was going to break because zirconia is not like a tooth. It doesn't bend. No, it doesn't take force like that. So if you have, and this is probably a little for our colleagues, if you have a patient that has a ceramic implant and you now they come to your office and they say they want a night guard because they change dentists or they change cities or whatever, they move. If you make a night guard, do not engage your implant crown because especially if the implant is ceramic, because you, it's gonna break. It's just gonna break. It's not designed to tolerate those types of forces. But going to the Ceramix and the carbon fiber screw, it's an amazing technology, you know, and again, it's a technology that came from orthopedics, actually from back surgery, they've been using that carbon fiber screw for years because it's a screw that's capable of bending and dissipating the forces, the occlusal forces, because it, it, the, it's a screw that takes all the beating and all the bending versus the implant or the abutment, you know?

Yes, absolutely. Now, speaking of breakage, I remember this was 20 years ago. I went to the European Implant Conference and they were talking about studies that in the '80s and '90s that ceramic implants had like a 20% fracture rate. That has changed a lot today. So, And you address that. I know a lot of dentists still believe that they're not up to date with the studies that we have currently.

And the reason for that, Sanda, was because the original implants had a high alumina content. Okay? So alumina is very stiff, very rigid. It has a very low elasticity. So when the alumina content was high, very high, it made for ceramic implants that were not zirconia implants that were not, that didn't have flexibility. That's why you see less fractures because As the years have gone by, the flexibility has improved, you know? So now we have ceramics that can flex to some degree and we see less fractures.

Interesting. Yeah. So actually, Ceramex had a study, a 15-year study on their implants. Yeah. And their success rate was 97%. Yeah.

Yeah.

Similar to titanium.

They do as well as titanium implants.

Yeah.

The difference, the big differentiator with ceramic implants is planning. Placement and restoration. You know, how it just requires a little more detail into how you handle the case. And talking about fractures, and we're probably going to talk about it a little later, we're going to have a very good presentation about fractures by one of our colleagues at our next meeting, but we can talk about it a little later, but it'll be very interesting, her findings on fractures of dental implants and how you even can look at certain fractures and know what could have been the cause of that fracture. Was it Was it a crown that was too large? Was it a butt, an implant that was too short? It's amazing. It's the things that we still discovering, you know?

Is this going to be at the conference?

Yes, it's going to be at a conference.

So let's might as well talk about that now because this is very exciting. I know you always put so much effort into these conferences. So everyone, it's super important if you're interested, if you're in the dental profession, you're a dentist or specialist, the International Academy of Ceramic Implantology Annual Congress is coming up in September. We're going to post it in the show notes below, September 10th to 12th, 2026. Where is it going to be, Dr. Sanda Moldovanovanovanova?

It's going to be in Chantilly, Virginia. It's about 20 to 30 minutes out of—

Great. So you're going to have this presentation, anything you want to know about ceramic implantology. And also, if you sign up by the end of August, you're going to get an early bird registration. We're going to post that in the show notes below. And in terms of occlusion, like, okay, how do you adjust occlusion for your ceramic implants? Is it the same like teeth? Is it lighter? Is it, do you like a maximum intercuspation that you check it?

Well, the first thing I try to have is at the time of placement, I try to have enough occlusal space because ceramics do well if there's enough bulk. When you start to be too thin, that's when you start having fractures, you start having cracks and things like that. So I like to have bulk. So for example, from the top of the implant to the occlusal, occlusion of the opposing tooth, for example, I like to have anywhere close, at least 4 millimeters.

Okay.

At least because by the time I have an abutment, that's maybe 2.5, maybe 3. Okay. And then I need that bulk at the top of it and then around it. So you need space. So space is very critical.

Okay.

Because that allows, space allows bulk in the terms of the crown. And that gives you more material to be able to adjust in case occlusion needs to be adjusted.

It. Okay.

So again, the occlusal schemes and adjustments, very similar to what we do with conventional implants or teeth. But for example, if you go into a full arch scheme, for example, or a full mouth scheme, definitely you want to have group occlusion. You know, you can't have too much sliding because again, ceramics, if you have sliding, that means you have some thin edges somewhere, which are likely to break. So usually you have a flat occlusion, group function. That's what I meant. And you tend to have less complications. So not very different. Just being aware of what the material can tolerate in terms of thickness and in terms of angles and all that kind of, all those details.

Yeah. I like that because, you know, I really want to, the one thing that most dentists still misunderstand about ceramic implants is like they don't break. Similar, like with everything else, but they don't break. They don't have a high rate of fracture.

No.

Yeah.

And there's no flowering, like with titanium, for example.

Yeah, true.

Yeah.

Now you place thousands of ceramic implants probably by now. So is there something that surprised you the most after placing all these implants when you look back at your cases?

Couple things. The one thing that I've really, that was a surprise, but also a good thing to see happen is a low plaque accumulation. They just stay clean. One, there's seldomly any inflammation around them and the soft tissue attaches very well to their surface also. So what, one thing that I really And that's why I always say ceramic implants should be, every periodontist should be doing ceramic implants all the time because these implants are so into your realm of practice. I mean, hemidesmosomal attachment to the surface of an implant material. That's unbelievable. I mean, you see that with zirconia, you know? So that means these implants give you the closest thing to a natural tooth because you have a collar. You have pretty much a separation between the intraoral and the subgingival because this hemidesmosomal attachment, implant, especially to the smooth collar, the transigival collars of these implants, because most of them are tissue level. It's amazing. So that's one thing that surprised me a lot. And one surprise I made, and it's a technical chairside surprise that I had never seen happen with titanium implants, is that sometimes, and I'm collecting data, enough data to publish it, I've seen ceramic implants get loose maybe a week or two after placement, and then I retighten them and they also integrate. Don't ask me how, why. Sometimes out of desperation, we discover things.

It's not that we go out there That has happened to me too, by the way. 100%. Yeah.

And I want the world to know this because there's no embarrassment in that happening. I mean, the implant got loose. Okay. Why? I don't know. I'm desperate enough that I say, well, patient, it's a little loose, but I'm going to tighten it. It's only been a week or two out. Let's see. And then you do this like 5, 6, 7, 10, 15 times. Like, okay, what's behind all this? And nobody knows. I have colleagues in Europe that have placed 5 times more ceramic implants than I do. I have, and they can't explain. So that was one thing that I discovered, or discovered, that I encountered, if I may say. I was like, wow, this, this, this material, there's something about this material that we, we still don't understand.

It's true.

Because I've never retightened a titanium implant and have it also integrate. Correct. Yeah.

I agree with you on that. And you also, I noticed when the implant is loose and I retighten and there's no inflammation around it, like the soft tissue. Exactly. You're seeing it. Yeah.

Yeah. Unique material. Yeah.

Yeah. Very much so. Well, this has been very interesting. I know we have some dentists that are like new to this. Where would you recommend they start to learn about ceramic dental implants?

You know, we're all busy and, you know, there's a lot of things happening in our practices, but I always recommend take a little bit of time just to at least be around people who have done a few. Now, there's a lot of people like us who go online and record things and post videos. Okay, that's good. But I think at least observing somebody who has done it before, or if you don't have time to do that, start slow. Like in residency, start with your premaxillary premolar straight off, right?

Yeah.

Good idea. That was always the first implant when I was a resident. Maxillary premolar. You know, start with an easy case. The most dangerous case would be an anterior maxilla, for example. People think it's easy because it's one root.

No.

So start with simple cases. I will even say delayed placement. Ideal bone. The manufacturers, most ceramic implants today, designed and developed by dentists. So these are people who have, who design these implants based on their clinical experience. And a lot of manufacturers have very detailed protocols on how to place their ceramic implants. And I promise you, if you follow those, your complications are gonna be a lot less starting out than if you just were placing a bunch of titanium. Some patient puts some pressure on you to use ceramic, you buy the kit, you put them in and you do certain things. It's little subtle things, and then you start having failures. 'Cause I've seen a lot of colleagues like that. They bought the kit, placed them, fail. Oh, they don't fit. They don't integrate. They don't work well. They fracture. Well, no, there's certain details that were not, you know, you didn't pay attention to certain details. So start with the simple cases. And I say delayed. Immediate is even dangerous because it's just a lot of bad things can happen in a socket, you know, especially if, you know, even if you've done a lot of, because, and I wanna add this because for example, most ceramic implants, the threads are not as aggressive as on titanium implants. Implants. Although that has changed. For example, you look at SDS now, they are very aggressive threads. That did not exist 10 years ago, not even 8 years ago. Because again, you cannot afford to have very sharp threads because if you have a sharp thread, it's a thin part of the implant that's likely to fracture. But now the material has evolved. Now they have aggressive threads. It's a lot better. You can, and it was even designed for immediate placement. But the previous ones before that, they all had rounded threads. They didn't give you the best primary stability, or if they did, that means you cranked it in too hard. The torque was too high, and now you start choking bone and you're losing implant once again. So it's just go with a simple, I say straight answer, delayed simple cases and then grow into it slowly.

Yeah, that's a great advice. I remember when I was placing the body of like Z-Systems, even Ceramikes, their initial body was like a Straumann body. The initial Straumann implants with very little primary stability, you know, it was very more difficult. So, and at the same time, respect the details. I like that you said that. And is there going to be any kind of hands-on experience that dentists can sign up for at the at a conference?

At a conference on ceramic implants, no. There's going to be a laser program on periodontal laser surgery, and there's going to be a PRF program with our friend Rick Myron. But we have other, the IOCI, we have programs all year long. One of which is in North Carolina at the Phelps Institute with Dr. Chris Phelps, who's going to also going to be a speaker. He speaks more on the business of ceramic implants, how to market them, how to sell them to your patients. Because now a lot of doctors are having patients asking for these implants and they don't know how to, what to say, how to present it, how to promote Got it. So Dr. Phelps has a, at the Phelps Institute, we have a program where doctors can come, US licensed dentists can come and place implants on live patients. It's a 2-day course where we do didactic on the bench and a full day of surgery. And each doctor gets to place anywhere between 2 to 4 or 5 implants. You know, so that's on the mainland. That's what's available. It's very, again, ceramic implants, like I said, you know, I started very early, as you know, and going abroad and just placing a bunch of them in people, that will set you up for a lot of failure because they behave so differently. Patients have to be optimized.

Yeah.

And the education for that has to be done in a very, very controlled environment where every patient is assessed, not only for by their medical history, but also sometimes a little bit of blood work, you know, sometimes some supplementation, get them to a good vitamin D level, all those little things that that we typically don't even think about that really affect the success rate with ceramic implants, you know?

Absolutely. And I think that should be the standard of care, especially with people that are going to be doing surgery because, you know, blood testing now is easier than ever. You could do blood spot testing on vitamin D. You could do— I was just at a conference actually. They had a kit that you can attach to the side of the arm that draws blood from the capillaries. So you don't even need to do venipuncture. So I think we're entering a good time where testing Medical testing is becoming very easy even for us to do in the dental office.

But think about it. If you or I were to lose consciousness now, an ambulance came and we went to the hospital. What's the first thing they do? Blood work. Which, which, which medical surgeon is gonna do a surgery on any patient without having done some blood work to find out, can this withstand the surgery? Can they heal from that surgery? Now, I'm not saying in dentistry we should systematically do blood work, but again, to your point, it's becoming easier and easier to do blood work. So I find, you know, and a lot of people who have done ceramic implants for a little amount of time, would tell you, if there's certain things that are optimized in the blood, the success rate of your procedures just exponentially rises because the patient is ready. They're ready and able to receive that implant and keep it in there. And it's the same thing, you know, physicians do that every day. You don't get any surgery without blood work. We do that and usually it works, but we get lucky.

Yeah, definitely some things to test there will become easier and easier. And I'll be talking a little bit about that and soft tissue optimization around the aesthetic zone and ceramic implants. So definitely join us for the International Academy of Ceramic Implantology Annual Congress, September 10th to 12th. And before we close, Dr. Sami, I'm glad we had this conversation because it was super enlightening, not just for me, but I think for a lot of people listening. Any other words of wisdom that you want to say either to patients or dentists listening regarding this topic?

To dentists I'll start with the colleagues. To dentists, I'll say, if you want to get into ceramic implants, don't hesitate. It's a very, very good modality. It's a good option. Just humble yourself and you have to up your game. We were just talking about blood work. I never, for 10 years, I never did blood work on anybody. There were some people who bring their blood work to me, but I never requested blood work until I got into the ceramic implants. I got into biological dentistry and I started realizing that, okay, all this talk about mouth-body connection, this stuff is real. It's not only about diabetes. It's not only about low birth weight. It's not only about those things, it's about a lot of things, if not just about everything in, in, in general health. So to the colleagues, if you're gonna get into ceramic implants, just up your game, be a little more diligent, get a little more thorough because you gotta remember ceramic implants don't have coatings. The osseointegration of a ceramic implant is directly to the ceramic. There's no coating, there's no HA, there's no RBM that can be to some degree osteoinductive or conductive. There's none of that. So the host has to be healthy. Healthy. And the only way the host is healthy, if it's you, the clinician, make sure or verify that they can take, they can handle the procedure, but also heal from that procedure. Okay. To the patients, ceramic implants are very good. They're one of the best materials that we have now in implant dentistry. Hypoallergenic, very hygienic. They don't get, they don't pick up plaque and things like that. They don't harbor a lot of bacteria, but they're not for everybody. There's some cases where even if you wanted a ceramic implant, with what we have so far today, you might not be a good candidate. Okay? Because there's not enough bone or the amount of bone that needs to be rebuilt is beyond a certain point where it's difficult to place a ceramic implant. But things change very fast. I've seen things evolve and I think in less than 5 years, it won't matter which case you're dealing with, you'll be able to rehabilitate or get ceramic implants for just about any range of procedures in all cases.

Yeah. Yeah, that's good advice. Good advice. Thank you very much. That's both for patients and dentists. Yes. And I agree. I think the world of ceramic implantology is only gonna get bigger and bigger. More and more patients are going to be asking for this. And it's up to us as dental professionals to up our game.

Yes. Yes, indeed. I mean, look at how many organic supermarkets are around.

Yeah, absolutely.

Now we have 5 or 6 brands of organic supermarkets and, and yeah, go ahead.

Where, where can people find you? Where do you practice?

I practice in Silver Spring, Maryland.

Okay. Fantastic.

Incidentally, next to Whole Foods. Food supermarket. That was, that wasn't by design. I just happened to be there. But what I tell people all the time, I say, look at the changes in, in mindset. A guy came to clean my office the other day. He had these biomaterials. He says, well, I use this now because the, the ones I used to use, which I still think were better, were just toxic. They would smell for days in, in the building. Now I'm using this. So it's all over the place. It's not a fad. It's not something that's gonna go away. And my dear colleagues, they're coming. These patients are gonna come in bigger and bigger and bigger numbers. And don't let a patient educate you on this stuff. You know, go out and learn.

Absolutely. Don't get left behind.

Don't get left behind.

Yeah. Very good. All right, Dr. Sami, I'll see you in September.

Yes.

And until then, everybody check out the Implantology website. We're gonna put it right at the bottom there so you can join the Congress in September and also information where you can find Dr. Numbizi. Thank you very much.

Thank you.

Keep smiling, everyone.

Keep smiling. That's right.

Thank you so much for joining me this week. Please make sure you check out the show notes for any links mentioned in the show. If you like today's show, please invite your friends to listen as well. That would mean a lot to me. Do you have a question you'd like me to answer? Message me on Instagram @DrSandaMoldovanovan. This is Dr. Sanda Moldovanova, and remember, your mouth is the gateway to your health, so take care of it in the most natural and best way possible.