Beyond the limits with István Urban

[Music] You are listening to the Clinical Matters podcast with Lucas Fuhrhauser and me Nikol Vinitsky. Welcome to our brand new show. Yes, welcome to our brand new show Clinical Matters. It's brought to you by the European Association for Oso Integration, the EO, a community of leading scientific minds in implant industry. Lucas, we have chosen to call this podcast Clinical Matters. Could you please explain to our colleagues and listeners why we would choose that name? Well, first due to our backgrounds, I'm a true clinician, working every day in my clinics, treating patients, stealing with complications, complex cases, so I know how much knowledge there is out there, and how hard it is to keep up to date with research and development occurring so fast in dentistry and especially in implant dentistry. And, Unicol, you have one foot in the clinical world and one foot in the research world. Yes, I am a semirefect. I do. I work three days a week with patients clinically and the other two days I spend at research, podcasting, lecturing, and all other kind of fun stuff. What we want to achieve with this podcast is to condense clinical expertise and scientific knowledge so that the listener to the podcast can take straight back into the daily practice new fresh knowledge to be used. But we don't intend to do this on our own. We intend to in each episode invite outstanding guests who will share their latest research and ideas and always with the focus on how to apply this directly into clinical practice. So whether you are driving to the clinic by your car, biking home from work, picking up your kids from school or even relaxing on holidays at the beach. So this is a great chance to keep up learning. Each episode will focus on clinical relevant knowledge knowledge that you can actually take to your private practice and make us better in everyday practice. That's why we here. So we want to say that this podcast is for everyone who wants to improve as a dentist to help our patients even better. Yeah, exactly. Let's go. So let's do it. So today we are talking about bone augmentation and we couldn't have a better guest in this episode. We will talk, we'll be talking to the famous surgeon and educator, is from urban. It's a great pleasure. Ishtwen you received your medical and dental degree at the Samilwise University in Budapest, Hungary. And then you moved to the US to the UCLA and the Loma Linda University. And you're really a pioneer and one of the leading voices regarding bone augmentation and it's wonderful to have you on this show. Thank you. Great. Let's get into it. First of all, thank you very much for having me in the show. I really appreciate the invitation. You are more than welcome and we are so honored to have you. Listening and listening to your talking and looking at your lectures, I really want to describe you as an artist. Watching your surgery is like seeing an artist painting. It really is. And I would even go so far as to say that you would be the Picasso of hard and soft tissue management. It's really amazing to see you work. Thank you so much. So ishtwen you are well known for your expertise in bone regeneration. Could you take us on a journey through the development of your augmentation techniques. And what has changed in your approach over the years of your experience? So that's a long story. After I finished dental school, I wasn't one of the scientists, I was satisfied with everything. And then I started the program in oral surgery and medical school at the same time. And by the time I finished, I had a lot of surgical expertise, but I didn't do any grafting. I didn't even hear about really bo-grafting. But I had a lot of surgical expertise. And then when I moved to the United States, I had two mentors. First, at UCLA, one was Dr. Henry Takay. The other one was Dr. Sasha Giovanovic. And Dr. Henry Takay is like a master of soft tissue and Dr. Giovanovic was one of the masters of membranes. And then I moved to Lomalinda and there I had a lot of support from the university by the program director Jaime Lozada and you know the whole program. And that's where it always started. Right. Right. And that would be a very long answer, but I think we can come back to this. And I can tell you like these stories about my first monograph, for example. Yes, please. And maybe you can take us a little bit on the journey, how your techniques are developed in the past and over the years. So you're famous for molar area, especially molar area in the mandible. This is really famous. So maybe you can describe it a little bit for us, for the listeners. So when I went to Lomalinda, I felt like I've seen a couple of membrane cases and I've seen that the flap has to be advanced. And I was like, OK, I know how to advance the flap. Then, but I really learned over there, like I saw how to fix it the membrane. And then I thought, you know, I can do vertical augmentation. And in the first week, I had launched with the program director Jaime Lozada. And when I tell him, I told him, look, I want to do vertical augmentation. And seriously, the spoon stops in his hand. 1999, 1999 is looking at me on a human. And I said, yes, I was like, but he just computing and it was not much talking anymore. And I was asking, asking, asking two months later, he said, OK, I'll give you a patient. So no one did vertical bone augmentation at this time. Or I mean, not me, but Dr. Simion in Italy and Dr. Jovano, they started to do it already with memories. I've seen a few, but me, no, I never, I never done it. And you're I was a resident. And but I've never seen a mandible bone wrapped in my life and never did one. Never did an article had to do it. I was just like, in my first case that I got was an entire mandible. And it was a 28 year old patient. And you know, I was like, OK, well, patient asked me, how many have you done? But nobody wants to read me. How many have you done? And I said, look, I haven't done any, but I know how to do it. And I really fed that I know how to do it. And the surgery was four and a half hours. I was in a worse shape than the patient at the end. Almost needed an ID. I really still remember getting out of the operating. But the patient here perfectly. And it looks like the old education I had, I was able to put it together in my head somehow. But going back to your your question about, you know, how it improved because seriously, I mean, I got really lucky. I'm so thankful that they gave me this patient. I'm so thankful for for everything that that patient worked out because then at this university supported me with more patients. I started to do it. But honestly, looking back, I had no idea what I was doing. I just advanced the flap. You know, I got lucky. But now, you know, then it really changed because then you know, I was like doing the, I went from the lingua, you know, in the mandible. And then I started to teach and I was like, OK, how do I teach something that I don't even know how I do it? I just do it like intuitively. And that's so I went back and started to investigate, you know, the anatomy. And then I recognize you know, the anatomy what I'm doing is like, well, this is pretty accidentally pretty, pretty good. But how can I improve it more? And then then this is how it came up with that I put together my experience and the anatomical knowledge. And I said, OK, well, this is what I do. This is the first step. This is the second step. This is the third step. And this way is going to work. And now I can teach it to other people. And that was one of the big steps. And that was other big steps in my development. And this one for the listeners who haven't seen your wonderful presentations, could you maybe give us a short journey through your bone augmentation. So step for step in a short way. Yeah. Is this possible for you? Like a technical. Yeah. So that everybody can understand this on the audio way. OK, so yeah, it is so I would start like talking maybe I would go for the mandible. Perfect. Yeah, the Moxilla is very different. Yeah. In the mandible, posterior mandible, like that you have we know that there's one thing this so lucky with that we have like the artery, the sublingual artery. We have the lingonurve, the water duct and the sublingual gland. This for I mean mostly what we're very lucky with that all embedded in a very dense connective tissue, which I always say it was developed by nature, by God, put it in there to protect the patient from the dentist. And so that's what happened with me because that's how you know That's how I got lucky because the dance connective is dance connective is not there. I'm not sitting here for sure. Okay, I would be sitting somewhere in a very different place in a very locked like this wall box, baby. Anyway, so the dance connective tissue. So that's number one. You have to know the dance connective tissue. Number two, you want to know that what you, I mean, you don't want to damage any of this and you don't want to damage, you know, the diaphragm, which is the muscle insertion. And so we came up that there are three zones in the mandible. Okay, and so we raise a flap, which is crest on incision, two verteon incisions, and we do a mini verteon incision on the lingua to elevate the lingua flap. And we elevate the lingua flap until we see the myelohide muscle insertion, which is in from the retro molar pad until the second premolar is very close to the crest. And that's what we call the second zone, the high myelod attachment or insertion. Behind that, that is the retro molar pad. And we know that about six millimeters apico from the retro molar pad is where the lingua nerve is. So the retro molar pad is something that's holding the flap back. So if I just tunnel and lift, which is my next step, then I tunnel and lift away from the lingua nerve, but is deencering the flap. Then up to the second premolar, the muscle is very close to the crest. And in front of that, the muscle goes down. So up to the second premolar, where I see the muscle insertion, instead of removing the muscle from the mandible, which would be not very, I don't want anybody to do it on me, I'm just gently reflecting the muscle from the flap from the muscle. That's what we call myelod separation. We keep the myelod in intact, we just separate the flap from it. The more anteriorly is the only thing which is more complicated, where the muscle becomes far away. And there, there's a long period still layer, which is now making the flap very unregid. And I just go parallel to the flap and I just crutch through the period stamp and the whole flap comes up done. On the back, which you have to know is that you advance the flap at the very beginning, very end, not at the beginning, because you have the nerve. And you advance the flap, you cut the period stamp at the beginning, that your assistance can accidentally damage with the retractors. So I do it very end. So after I did the lingua flap, I scraped some bone or I take a refine, put the bone meal, mix it by material, take a membrane and I fix it the membrane of the lingua. For the membrane fixation of the lingua, I have a hand piece and a screw and I have pen. Thanks. Once I did that, I applied the bone graft, fixed it on the buckle, that's pretty easy. And then I advance the buckle flap. Now, advancing the buckle flap is maybe, is one, a little bit, could we go a little bit back, which membrane you're using because it has to be stable. Yeah. So it depends what I'm doing. Okay. One is that we call the sausage that I, that's a history for it. So I would please give it to us. Yeah, I would maybe, yeah. After this. So if it's a horizontal augmentation that I want to make it wider, I use a collagen membrane and I really stretch it out. Yeah. If it's a vertical augmentation, I'm using a, still a PTFE membrane today, be perforated with a titanium reinforcement. But you can use a titanium mesh. You can use some people like to use like a block or something, you know. I think the flap should be the same. Okay. So membrane, if it's a vertical, a titanium reinforcement membrane, that's what I use. And I like that I can only just scrape some bone and so it's not so traumatic to the patient. Then at the very end, when I'm advancing the flap around the nerve, around the nerve, there are two things that I'm looking at. The length of the flap. In a big defect, the length of the flap can be very short, which is not the first thing you want to do in your life. So you want to start the patient, which doesn't have a huge defect, so it's a longer flap. Because it's a longer flap, you can go with your incision away from the nerve. Scale up it away. And then I look at the quality of the tissue. The quality of the tissue can be normal, native tissue. Select a patient like that who never had surgery, because then your job is easy. So long flap native tissue is your first patient. When you're going to scale up the incision and you scale up through the periostone only, which is less than 0.4 millimeters. And you go, if it's 0.3775, you go 0.376. Okay, so you don't cut the because the nerve is right there. Then we do something which goes the dibando around the nerve, the runs like this little cross fibers. We do research on it. Some of them are micro nerves to the periostone, by the way. And we just play the guitar. Tong, tong, tong, and that is eliminated. And then I put a blunt instrument and stretch. And I don't want to use any more the blade for the advancement here. The blade is just opening the door and a very superficial stretch. And the whole flap comes up. And that makes the mandible at the end one of the easiest. Right. Because now you have two flaps to close. Yeah. But what you're saying now, you make it sound quite simple, but it requires so much knowledge from your side about the anatomy. And also, you know, the gentle touch how to handle the tissues, because if you just handle them a little bit too hard or cut a little bit too deep, you will not be able to reach the results that you're doing. No, no, it says very, very important that it's like super. I say that that, for example, when I elevate the flap in the mandible, I don't even use a periosteller instrument. I make the incision. Then I go back with the curette, reinforced incision, and very gently start to pull with the curette and the flap comes out. Periostum is perfectly intact. So that is, you have a beautiful flap. You look at the beautiful flap. And then when you just basically scratch through the tissue, this beautiful incision away from the nerve, you see the beautiful debondling. You stretch and you're like, okay, and the nerve is perfectly protected. So you can sleep better. And to cut the periostum, you use the back of the knife or so on the lingua side, easily. Yes. Here, I'm using a brand new 15-cylind blade. I put a bi-block to the patient's mouth. So when I'm doing this, the patient's not going to extend it close. That's a good recommendation. Good recommendation. Yeah. And again, I have to come back to your artistry in this. Because hearing you talk about this is like you're writing a musical part or something. It's really, really amazing. You can see how this is really new. Now, I wish I could tell this to myself 25 years ago. Because that was the, that was a little bit of a development here. So we heard about the membranes and titanium or titanium mesh we could use in this situation. What do you think about bone substitutes? Do you, we heard your grafting bone? So you're taking autogenous bone in which how you combine it in which ratio, do you use bone substitute? And which, I started with autogenous bone. I was like a biggest believer in fully autogenous bone graft. Then early 2000s, about 2003 when we started to add biomethary, scynojetic bone graft into the autogenous bone. And you've started to do like a one-to-one mixture. We still do that. But then you know 25 years passed almost. Yeah. And so I always believe that you know, especially last 10 years that you know autogenous bone should disappear. Because we like we're here. And everything is digital. Everything is like why can't why do we still have to take some more? But we still not there. But I think industry and you know research is getting very, very strong not to use. And if we use maybe like different types of growth factors, cells, mesenchymal cell research is ongoing, I think it should come in. But still today I would say even saying the new gold standard, his autogenous bone, mixed with the biomethary. Yeah. And do you think this is more stable than autogenous bone alone or how was it in so all the years? What we have seen and we were we thought it's never gonna happen. That if a patient was very, very thin phenotype, thin bone. And you did this beautiful bone. And it's like perfect vital. You put your implants in. And all of a sudden in some of them you will see that the results that the genetics is very powerful. What if it was narrow, it wants to be narrow. Okay. It's like I mean if somebody is a big it's very difficult to take to diet for some people. You know as and some people is just thin. And it's they don't get you know big. So it's a little bit like that. So there's a lot of genetics in that. And I think the biomethary is which we use is not so you know they're not really reserving. And that I think helps a little bit to compensate for the genetics. They're interesting. But when you're saying that I would also like us to move a little bit into patient selection. You said then early that you want the specific kind of graft and it should be healthy non-scarred tissue. But what else? What kind of patient is suitable for this? Would you treat smokers? Would you treat people patients with parryoproblems or where's the limitations? So I today I would say I almost never refuse to treat the patient. Unless I would say that the psychologically the patient is not ready for this. If the patient is parynal to disease with treat parytonal to disease. If the patient is smoker the first thing I'm going to tell the patient I am not doing the surgery. I mean I'm going to do the surgery after you did the last cigarette three months later. And I will tell them, look, if you smoke, let's say a pack of cigarettes, lucky enough in, you know, my, it's very rare that patients come here anymore. I mean, before it was very frequent, not anymore. Then if you reduce it to two, there is like some very old studies show that, you know, the, the computer is not opening up. So I tell them zero. Okay, the last one is, and I think that one of my biggest success is to quit patient smoking. So smoking to me is a big no no. - Good, you're doing something for the world and for the populations. - Now I have to do a very good job because you live longer. (laughing) - So, yeah, that's true. - Could you walk us through the role of the soft tissue management? This is a big topic for bone augmentation. So could you walk us a little bit through and what importance for you has the characterized tissue after what's around your implants? - Very good question. So, you know, when I was trained originally, you know, I was like, I, we had literature reviews in the United States every day. And I really like some of the classical papers. But many of the classical papers were from machine implants. I was like 1994, you know, from Gutenberg. And it was talking about the, you know, the need of, the need of keratinized tissue. And for machine implants keratinized tissue was like, at UCI everyone was like, it was super important for them. But we felt, you know, that maybe not so important because of some of the, the, the, the, the, the Swedish studies. But I was trained like that is very important. And now to me, it's very, very important, especially in the mandible, especially in the lingua. But also on the, on the, on the facial. But for me, what is not important to have keratinized tissue to do a bone graft. If the vision doesn't have, I don't, I'm never gonna do a free gingerbread before a bone graft. But after to do like keratinized tissue is, is almost every single time. - Yeah. - And how you, you do it afterwards. It's, it's, this is very interesting, I think for our audience. Now you're gonna be very surprised. Maybe in a lot of people are not gonna like me. When I went to UCI in 1998, Dr. Takedo, he told us that we are not really doing free gingerbread anymore because it's outdated, he said. And instead of that, in the aesthetic zone, we're recommended to do a connective tissue open to make it nicer looking. And for the posterior, instead of one big free gingerbread because of the palate of the patient, especially on a Los Angeles patients are very, very sensitive for that. We started to take little and that was Han and Takaib published, little strip gingerbread. So instead of one big like two, three small ones, which is very technically, technically, you're in a styrofoam. But that's what we, that was originally, that's very hard. - And very hard technically. - Like to shape them, to move them and to attach them. - Yeah, yeah, yeah. And one strip, now take another strip. And so, but that helped me a lot because when, one of the college matrix came out to substitute, we started to use it. Okay, now I've put it in and I don't have to do anything. And it was beautiful, beautiful, and on three months, there's nothing. Why? Because then we understood that this is a perfect material to collect cells. And what was it collecting? You go, so. And so then we were thinking a lot about it and they were like, they're also the companies asking me, "Okay, what can we do with this?" I said, "Well, you know what? What if we put the strip around it?" And if we put the strip around it, the tissue will migrate from the strip and that's, I do a lot of those. - So like to give it the information. - Yeah. - Yeah, it just basically an information, it puts the foot down, not because I cannot come back. Plus, it gives the biotech information. - So it's like attracting the tissue around it. - It's just, it's just migrating into it. - So now we're talking about all these small details that we love to talk about because that's what's really important in dentistry, but I also wanna, wanna look at the bigger picture. Like what does it mean for the patient? How many surgeries are they going through? How long is the healing procedure? - What does it generally look like? - It's a good question. So number one, prevention is the best. Okay? That means like reach preservation for 10 phenotype patients. Okay? You extract in teeth and then it's like the whole thing will disappear. So reach preservation for those patients, I think it's important. 'Cause once you have a patient who has like a big, you know, etrophy, it's gonna take time. And you know, it is like a pregnancy. Okay? And even, you know, in countries where they do everything fast is nine months for a human. Okay? So bone regeneration, you cannot make it faster. You can place an implant faster, but it doesn't mean that bone is mature. Okay? Okay? - By ology. - Yeah, you put a piece of block in there in one month, you place an implant. What? Well, I mean the implant is there, so you did place. But did you have bone? That's another question. But in general, so depends on the defect, but let's call it a vertical defect. Classically it was nine months, like a pregnancy time. And it was like before I always told them, patient, this is like a pregnancy. A patient under a stroke, it was no more explanation needed. This is not faster because of we have different membranes, because we have, maybe we can be reduced it two months, okay? Or three months, let's say six months, but we cannot really reduce it less. Because it just, it doesn't mix, plus it doesn't take that much of a sense when you want to this. I mean, now we're looking at patients for 20 years. - Yes. - I mean, who cares about two months? - I totally agree. - And you mentioned before, growth factors, because this is also very interesting. What are you using for growth factors? And where are you putting it in to enhance your healing and maybe to make healing faster? So, growth factors also like where I was in the United States was already like really researched a lot. I mean, the first one we used for amylegeny, okay, for perinotory generation. And most of what was one of my, you know, love affair, I mean, it's like really love the papilla, and we wanted to grab papilla, but connect it to you and the end of the game. But end of the game is available for everybody. Then the BMPs were studied when I went to Lomolinda, Dr. Philippe Boyne was one of the first one who did the big randomized treatment trial. That's how they got the FDA approval for dental. So BMP2 was something that was very, very interested. Unfortunately, BMP2, however, is available in Europe for neurosurgery, the same product and for orthopaedics. And we, I knock it off, but I'm very thankful because now we just submitted a big, like we're submitting, I mean, submitted for ethical approval. A big randomized clinical trial in Budapest for microdose of BMP2 in vertical rejuvantation. And don't tell anybody why I open it. - They won't tell anyone. - I mean, I think you know, it's the, some of us group dentists really behind it. I do it with Peter Vindesh, who is a good friend of mine. And, but we did research and I did research on this with population on large animals that you, looks like. You need a microdose. And the position of the growth factor is gonna be key because what, what what happened when it was approved? That you know, it was like, okay, it was expensive, but they bought it and it pulled it everywhere. Patient looked like this because it was so much swelling and was very expensive. And the result was like, well, in the middle, there's a big hole. And we figured out what would be co-words because all these growth factors are communicating with not only the periostum, but anything soft in where there's mesenchymal cells. Looks like in the blood cells is not so much. So you put it in the middle of a bone graft, you're hiding it from the source. And so you don't need such a big dose, which would not be so expensive. And you put it outside, we call it lasagna. You put it outside, a microdose, and you see a much, much better result. And it's a very important part of the patient's brain, and it's very important to have a good patient, and it's very important to have a good patient. And so we had to have a good patient, and we had to have a good patient, and so many other things that we do, because it's not only what product and what material we use, it's also how we use it, which is really, really, really important for us to think about. I think how we use it, what more do we need to eat, can cause, what is the cost? And how it can be approved, and all the risks, and I think research, and also industry support, and policy, and this triangle, will work in a smarter way together, I think that will eliminate the touch of the bone. Yeah. Interesting. So we always want our procedures to be safe, and predictable as possible, and when listening to you, you say how important it is that we don't have any bacteria present. So I'm thinking, that both means having infections around in the sites, in the bone or wherever, but also the hygiene, the surgical hygiene. So do you think these are procedures that could be done in a private practice or do you need to be in a hospital environment? You can do this in private practice. So in the oral cavity there's bacteria. That's fine. But you should not have patients with, you know, dirt in the mouth, untreated parodontal disease. Like, you know, I'm not going to do a bone graft in here if I have a seven millimeter bleeding pocket in the upper left. Because bacteria, by the time you suture, you're infected with a bone graft. And so what I meant is like, and so you need to have a very clean mouth when you do the surgery and you need to have a closed flap, not to communicate with bacteria because that's food for bacteria. Also, it's very important how the neighboring teeth are. Like restorations, right? If you have a poor restoration neighboring tooth, don't get the surprise if you get an infection. And which antibiotic regime you have for your patients because this is also important for healing phase to you. Use it before or single shot. I don't think so, but or a long very good question. Yeah. And maybe what I do is not even it could be even improved. Anyway, let me space. So we do the same thing for the last 25 years, which is if the patient not already, mentally, and we give two grams of them, oboxicity, not augmenting, not with cleverness, it's just simple oboxicity. There is no infection, we're not treating anything, it's preventing. Then we close and we give for another week, 500 milligrams three times a day. But there is some article showing that even a single shot for a bone graft could be sufficient. And I think it's probably correct. Probably the two grams should be because the way you close it, I don't see any bacteria going in there. Yeah. So, we will go into a short break and we will be right back after that. Enhance your career with world class education from EEO. Sign up now for EEO's first and second certificates in implant dentistry. The first certificate is EEO's fundamental course and brand new for 2026 is EEO's second certificate, which is the advanced level. With these courses running online only, you can study when you want at your own pace and at the time that suits you. Find out more at EEO.org. Welcome back to Clinical Matters with our topic bone augmentation and our famous guest, Dr. Yustvan Urban. So let's dig into the sausage technique. That is something, I'm a prostadontist myself, so I don't do any surgery, but I always heard so much about the sausage technique. And yeah, you know, you're sorry about it. That's exactly the name, and I also saw you do it, but please, please give us all you have. Yeah, so it's not a medical terminology for sure. What happened was that, you know, we were doing bone grafts and we believed, I'm talking about 32,000s, that you have to use a non-resolver membrane for everything, for almost everything, except it's a tiny little defect, then we use the collagen membrane. But for rejuvantation. And I had a patient who in 2003 was my very first patient who had a complication, which was three-fistral tract. Flat-forced clothes, everything was closed, no pain or nothing, but three-fistral tract after three weeks. And you know, I couldn't sleep, then I went back, I called a patient, patient said, "Look, I have no problems, don't do anything." I said, "No, no, no, we have to remove the membrane because that's going to be a big problem." So I went back and removed the membrane. And then on the surface, like the surface of the bone graft was dead, I washed it out, but I thought the whole thing is going to come out because I removed the membrane. But the rest of the bone graft was surprisingly stable, sitting in a blood cut, and I like to say the membrane, the bone graft started to talk to me. And the bone graft said, "Don't spray me the cold water. Just give me a blanket." And the blanket we gave was a collagen membrane, not fixated because it was like already stable. But I thought the whole bone is going to disappear because there's no no-no-resolved membrane, so this has to be protected, the barrier effect and all that. And I told the patient, "There was no CBCT. I told the patient, "Look, probably we're going to have to redo this, but let's wait, let's see." Look at the extra, actually, it looked pretty good. And when I went back, the bone was completely survived and it was rock solid after six months. And that made me think that the good thing that I recommend to everybody, that I'm going to try to pick up the complications, to pick up the things that I opened it up. So then when I looked at the pictures and said, "I mean, what? I have the whole bone." So it looks like I don't need a no-resolved membrane for everything. And that was the initial thought behind the sausage. And so what is the sausage thing? And so basically then I said, "Well, I'm going to use a resorbable membrane to do a rejuvenation, at least horizontally. I told to my friends, "Well, that's the worst idea on the planet. This is never going to work. It's like, you need to use this membrane for that." So, okay, well, I don't think so. Because the thought that we're not stable enough or not stable enough, it will collapse and the resorption time. Yeah, it has to be pregnancy time, you know, it's like forever. And so that was 2000, and then I started to use first a synthetic resorbable like longer term and then switched in 2006 already for collagen. And I really recognize, okay, so if I want to make this work, I have to stabilize the bone graft on the crest. How do I stay by? I think, you know, this is stretchable when it's wet, it's stretchable. So I started to put pins like for the non-resorbable membrane. I knew that. And I started to stretch the membrane, push the bone graft up, stretch, stretch, push a lot of pins and went back and there was like better bone quality because of the communication through the collagen and perfectly bone. And that's, I said, "Okay, now I can touch for the membrane and touch the tooth." You know, everybody at that time was like afraid of because of its Gore-Tex membrane is difficult to use. And so let's make it more simple, let's make it easier for everybody less stressful and for other people to use it. And then, you know, it was 2000, you know, I take pictures of one of them like 2010 around. I said, "Why don't look like a sausage?" So I started to call it sausage. So you say that this is, you make it sound like it's kind of simple. Can everyone do this? This is, or how? I think so. I think it's a little bit artistic because you're like forming, you're shaping the titan reinforcement, the titanum as you put it in and it's like that. This one is like you're shaping, you're pushing, you're removing a pin, adding a little bit more here. It's like, but I think everybody can do it. And I think a lot of people are doing it very popular. So this is maybe very interesting. So would you recommend for a younger dentist or not a beginner, of course not? But if you're starting with a bigger bone augmentation, that you use pre-fabricated individual meshes because they help you, because you don't have to build the bone or to model the bone. So it's, or what would you recommend? Yes, I would recommend it and not. Depends on what, because I think they're overusing. Number one. Number two, the material is important. I don't want to use something, which is going to be difficult to remove. I don't want to use something that with a soft tissue is moving on. And if it's a thin phenotype, then you two months later, you're really surprised. You did a good job, but there's a big hole because now it just wrapped through the tissue and now start to take that out. Okay, where do you make the incision? Because the hole is like two millimeters, like 10 millimeters from the crest. Are you going to make the incision on the lingua now to take it out or you're making the crest and then the whole thing is just a big hole. So I think for that, for the beginner, okay, we're also looking into this and working on this and modifying, we're using like a printable materials that are resolving. Okay, but you know, how long is it going to result? And still the problem with those, because now we started to use them, is what I just explained. That in a thin tissue, it is moving around and maybe in two months, you see, you know, 10 millimeters from the head of the bone graft, a little exposure through. And then you have to take it out. So for this. And then can you do something with it or just start. I'm not going to take it out. No, no, I'm just thinking. If it's two, three months later, then you will get bone, but not perfect bone anymore. And plus it's a trauma, you know, it's like, okay, it's a complication, you have to go back in there, I don't want to do that. So. So therefore you don't want to choose the thin biotype patients. I do any biotype, but with the collagen membrane or the PTF membrane doesn't matter to me. Okay. But I think, you know, the development of this and that should be the future, because it's going to be easier, because what I'm printing, what we're printing now, you know, I put a couple of screws on the buckle and I put on the lingua just to. Because I want to. Okay. But maybe it's not going to be so much necessary. And it's going to be individual. Individualized. I think the future with this should be printable, resolvable, customized, but I would say, okay, this is the phenotype, this is the defect. I want a softer one. thinner one, clean that. And I've just had a computer boom. Okay, now, you know, it's a huge vertical defect. This is the phenotype. I need more stability. I need a little bit thicker one. - Yeah. So, we all working with clinical matters. We all know the complications are part of our reality. When you experience the wound, the he's senses. How do you manage those? - Okay, so wound the he's senses. I mean, I had not experienced a lot. I had one big one in the end here, maximum not in the incision line. One large one in the mandible, like two years ago. I thought we'd never have one. I don't know why I had it. But so I'm not the best person to ask. Because that is not a problem in our practice, honestly. But when it happened, one of them, I just, you know, it was an early, uncomplicated exposure. That means when you push the wound, there was no pass. And that you treat in a way that you look at the defect and then, okay, this is a horizontal defect. Okay, I would like to maintain this membrane there for the next six weeks, at least. Then I can take it out. What we have in the experience, the soft tissue grows underneath. And now you will get 70% bone. Okay, not 100% bone. The other thing that I've seen, I don't know, on my patient, was on the lingua, that like a necrosis of the flap or something, so I get an exposure and an infection. When you have an exposure and infection, it's the worst because you have a soft tissue defect plus an infection. Now you have to get back in there immediately. If you see pass and then you will, you know, it's gonna be very difficult to save the bone graft. However, if you have an infection only without an exposure, then you could potentially do the something that we call the CPR of the bone graft. What is that? Cardiopulmonary resuscitation of the bone graft. (laughing) That bone graft. A serious thing. But how do you do it? What's the practical? I see is you go back in there. If you see, there's two types of infection. One is the low grade. The low grade infection is a fistula. In the fistula I see in the first two weeks, very red, but I would see, the fistula occurs between 10 to 21 days. Unless, rarely you would see it later because maybe the notice of a membrane doesn't allow. Okay, but anyway, then if you see it, let's say two weeks you see a fistula. I would take, you know, even if the city's can't see what's in there. And I would see a localized disintegration of the bone graft. Then it's a vertical defect. I don't really want to remove the membrane, if possible, then I would maintain that. I would give a course of antibiotics, maintain it, and go back in there five, six weeks. If I see it later, I just open, and you will get 80% bone. Your enemy is your high grade infection. And that's when you do CPR. So what is the CPR? When you see high grade infection, you have to immediately open. Okay, and now you will see a dead bone graft. See is clean. Okay, you irrigate, you wash out. What do you use for irrigation here? I would just use saline. Yeah. And maybe that's enough. And we have it completely empirical and not scientifically proven, but use a wide spectrum anti-inflammatory antibiotics that we just open a capsule, which is used at Oxysycline. We mix it and we put it on the surface. - Locally. - Okay. Okay, why? Because we say, okay, we cleaned that 90% but maybe there is some. And with the left of the bone graft, let's still see cleans. Okay, then we irrigate and relooks that. Then we go for pee. Why do we do this? Because anybody who wants to survive needs oxygen. So you want to be oxygen, perfect use with blood, which has oxygen. So we put that sterile blood, like sterile, you know, like from the neighborhood, we put some, you know, that's so it should be bleeding on it. So that's pee and then retain. We don't take it out, we are CPR. And we have pretty good results with that. But we don't see a lot. I mean, about 3%. Do you use, or should your patient use any chlorhexidine to rinse or something? We know all the complications with chlorhexidine and bone. What do you think about that? - I think it doesn't really matter. - Yeah. - It's my honest opinion, but my patients for the first 24 hours, they don't use anything, then they use it. So I don't see any negative effect. But I would be, if I would probably run, you know, a random asking you to try, I don't think that would be a difference, honestly. Because it's closed, it's closed. - I actually want to go back to what we talked about before with complications, because you said that you only have very few complications. So you are apparently doing the right thing to avoid complications. What is that that you're doing? - It's the patient preparation for complication, patient selection. Okay, heavy smoker, diabetic, uncontrolled, untreated, paranoid, or disease. You have a complication, 90% of cases, probably. Okay, so patient selection, patient preparation for surgery, I think it's one of the most, it's as important as the surgery. And that's what they're not looking into. Okay, how clean it is. We even cleaned the tongue of the patient before the bone grafts. - Yeah. - We just cut the grass. And you supply it, how much it's come out. They're looking for the bone grafts. (laughing) Okay, so patient preparation, then the surgery itself. The flap, how you flap design, how careful you do it, and how you close it. And then of course, the postoperative management, are you gonna put a removable denture on a bone graft? Or not? Probably not. - We actually wanted to ask that also about the provisional. - Yes. - What do you do with that? - Okay, provisional and I think digital improved it so much. For it, let me give you one example. Let's say I'm doing a bone graft in here. And there's like a bridge. Okay, good provisional bridge. Okay, what are you gonna do? They move it to be able to do bone graft. And then I go to do the bone graft and there's naked teeth. Okay, how do you clean them? You like, like blow some, you know, clean them off, like cleaning it. And then by you close the flap, you're like half of the tooth disappeared. Okay, how you gonna put the provisional back? So I don't wanna do that. So I will remove, we're gonna remove. And many times now you can print obviously the provisional. And I would like them to print two temporary crowns, which is perfect. And we cement them with permanent cement 'cause I don't want them to pop off during the surgery. Okay, and that's the margin is closed. So that helps a lot. Plus when I close it's gonna be very easy to print later. Okay, but for the first three weeks, we're not gonna put that bridge back. We're gonna make an SX. Okay, and I tell most of the patients that I don't want to put them in immediately. If you really demand it four days, you can have it. I can count on my- - After four days. - After four days. - But I can count on my two fingers, how many patients wanted in four days. - Because they understand we're going through such a procedure they also wanted to- - I don't want to redo it. I think it's a very big mistake to put it in immediately because that would be more swelling. And maybe it's gonna hit the- So anyway, maybe you put it in one week. Okay, you cut it back, it doesn't matter because it's like an SX. But then the tissue will settle for the next three weeks. And only after I will put the bridge back, then I'm gonna, you know, very carefully cut off the- if it's not coming out, cut off those, put the bridge back, perfect. If there's no abutments. Again, SX and a Maryland bridge up to 40. If it's more than 40, like gigantic defects, you know, those patients are accident patients or something like that. You keep them in SX, a rigid SX. And you know, in my experience, they perfectly fine with it number one. Number two, because of the bone graft, the face will improve so much that all they're telling me, please doctor, wait longer, make sure it stays like this, make sure it's not going to, you know, because they like what they see. They see the difference already. - Very interesting. You have overseen countless of years of bone augmentation cases. How you see the long-term outcomes. And do you think short implants could be an alternative? Do you use short implants? - So when I'm doing surgery, in my mind, 1000 surgery goes on. When I do something and I make a decision, it comes off. This is what I did, this is what happens, okay? Then I know exactly today what makes it. I don't wanna say everlasting, but that's what I wanna do. I wanna achieve everlasting. And what mistakes that I've done that gave me like a complication. For example, depending on that, is we don't see a lot in regenerative bone. That every time I see one, like my heart is like, and I see like what I could have done differently. And I see what I could have done differently. Okay, we can talk about that. And but I see then, so we record all my first 36 patients that's from Malinda. And then from Budapest, there was 36 patients we published 2009 or so, six years. Now we record anybody who's still alive and I can get it. And we got a good number. And still up to 20 years, there was not much of a difference between the implants. But however, our patients, coming three to four times your hygienist, we take every year like we do an X-ray every year and then every second year after you know decade. So I see a very good outcome with this. But of course, and I used I do think that short implants have a role. So when would I use short implants? You know, especially posterior mandible, but I would look for a couple of things. Recently, there was a publication and when they look at this and I completely agree with this and I already knew this by myself that there's a big difference in success. If in terms of like let's say you have the most posterior tooth, you have the bone and if it's like more than four or five millimeters jump down and there's an implant, that's going to be a problem. I mean, that is a big precursor for parent plantitis. So let's say, if I would have that, I would, let's say this is my bone, I would, that I would, so you're talking about just to be clear, the bone level of the adjacent teeth in the big comparison to where the bone level is, where you're going to place the implants. So I would rather skip that spot and put it behind let's say, to implant and amizio cantilever to get a more natural and gradual. And that's what I, in general, short implants maybe you know in posterior mandible, yes, but not like, I would, you know, in the young person, I would put in four millimeter implants with big, you know, misalignments, maybe not. Short implants. Okay, where? Short implants. Where? Like here, there's a, there's a can I put that implant down here and up here? So that's showing the lower mandible anterior and posterior and maxilla upper maxilla like anterior. You can do that. It's more posterior indications. So posterior areas both mandibular and maxillary could be an option. But many times, many times your bone is narrow. It's all the way down here and then it's young, okay, and it's usually wide. And it's usually wider, so you need the, you know, your augmentation again. Yeah. Great. I think we have learned so much and it's been so inspiring to listen to you. I just love how you want to do things in the best way possible. And one last question that we would like to ask. If you look into the future, how do you see bone augmentation in say 10 years? I think, you know, like an ideal is to go for me would be to, to have materials which can be, you know, biologics, cells, whatever that I don't have to harvest anything from the patient. And personalized as I described, maybe personalized between phenotype, capacity of the host, the defect. And I personalized can push a button. Okay, this is what I want. And then I can manage that closure and theoretically, which is not going to happen, not even to be able to close that, that don't have to close the flat. And then I can leave it open because it will resist any infection. But do you think the cells in it is important? So we have to find the cells before to put it in this substitute. Or yeah, yeah, says harvested from the agrofactor you know, controlled agrofactors. Okay, this this crow factor is going to call this guy and this cell to come in and do this. So we've now listened to you and you have so many interesting things to share. If you should pick three takeaways for the listeners, what would that be? I think one of them would be to have a little bit of like listen to my history that you can see that that, you know, anybody can become what they dream of. I think the dream is much more important than anything else and that your willingness to go through your dream. And my dream was to make a very good bone graft. The second one is that I think you should also be always, you know, look at the best interest of the patient and try to progress. And how the third one would be is how important the whole process is from patient preparation until, you know, the whole process that you go through every time that you don't skip the step. No, you can't skip a step. Fantastic. Thank you so much. Very interesting. Thank you so much. It was a great, great session. It was really fascinating. Yeah. Thank you very much for having me. Thank you so much for coming. Thank you. That was a really fascinating conversation. Yeah, it was really great. So for all you that have listened to this podcast, thank you for joining us on Clinical Matters. It's been a real pressure having you with us. Join us next time for more great insights and tips. Also help you deliver excellent care to your patients. And keep doing the work you do. And in the meantime, please follow, rate and review the podcast. It really helps others to find it. See you next time. Bye for now. [BLANK_AUDIO]