Immediate implants and loading with Gil Alcoforado

[Music] You are listening to the Clinical Matters Podcasts with Lucas Fouhrhouser and me, Nikol Vinitsky. Welcome to our brand new show. Yeah, welcome to Clinical Matters. It's a great excitement to be on a new show. It's brought to you by the European Association of Osset Integration, the EO, a community of the leading scientific minds in plantandistry. Lucas, we have chosen to call this podcast Clinical Matters. Could you please explain to our colleagues that are listening why we choose that name? Well, first, you to our backgrounds. I'm a true clinician working every day in our clinic in Vienna, treating patients, dealing 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 the research and developments occurring in the industry and especially in the implant industry. And, you have one foot in the clinical world and one foot in the research world? Yes, I do. I work three days a week with clinical, clinically with patients. And two days a week I work with research. And also the research I did up until now has been a very clinically oriented research. And it's really in my heart to do what we're trying to do here now to condense the scientific knowledge and to really spread it to make the clinicians understand how we can use this knowledge to improve the treatments for our patients. But we're not going to do this on our own. We are in each episode being joined by outstanding guests. They will share their latest research and ideas and always with the focus on how it applies directly to clinical practice. So the idea of this podcast was whether you're driving to your clinic, biking home from work, picking up your kids from school or even if you're relaxing on your holidays on the beach. This podcast should be a great chance to keep learning. Each episode will focus clinically relevant knowledge. So knowledge that you can actually take to your to your private practice and makes you better in your everyday practice. So that's why we are here. So we would like to say that this podcast is for everyone who wants to improve as a dentist so that we can help our patients to receive better treatments. Yes, exactly. So let's get started. The topic of the episode today is immediate implants and immediate loading and we have a wonderful guest today. It's Jill Alcaforado, our current EEO president. He is the dean of the EGAS Moniz University in Portugal and he is a legend in our field. He has an experience of 40 years in periodontology and implant dentistry. It's a really honor to have you here on the show. Hi, Jill. Warmly welcome to clinical matters. Could you please share a few words about EEO and what its role is in implantology today? EEO I think has committed itself to transmit science so the clinicians can understand it better and can use it on a daily basis. And I think this is extremely important and that's probably one of the reasons why this podcast exists among many other EO activities. So this is really the mission of educating people that want to improve. And I think the EEO has been doing a very, very good job in that area. So do we. So but if we go a little bit more into immediate implant placement and loading, which is the topic of the episode today. The first question that I would like to ask you is why do you think that immediate implant placement and loading is contributing to implantology? What difference does it make? I like to follow things that are really well established scientifically first. I mean, I was formed. I was formatted in Scandinavia. So that's probably that says it all. I know all about that. So the pressure from the patients was big. The provisionalization after placement of implants, even if they are not going to be prosodontically treated immediately, was a problem. Some patients had a very close bite. So the Maryland bridge was a difficult thing. Then patients used partial dentures that are tremendously horrible for the stages for our integration. It's probably the worst. And then I realized, look, this is probably it's it's it's better even though we don't know. But could have some pressure on the implant. If the implant is stable, it could actually have an effect in a case that I saw at the Buron Mark clinic of an extreme case of osteoporosis and also process in mandible is something that it doesn't happen very often. But they showed me where they placed the implants. Obviously they didn't place anything on top, not even a prosthesis. They kept the patient like that for a full year. Then they placed the implants also integrated, even though we could barely see the bone on the panorax. And then after six months, you could see court that the bone condensating radially around the implant. Showing that the pressure of the implant was actually helping to have a more condensated bone. And this is something that gave me as well probably. I'm trying to avoid to do immediate, immediate placement. And I started very carefully, freehand this many years ago. And following the principles at that time that we were understanding that placing two big diameter implants was something that we should not do. And so I placed it, I mean, the technique that exists now. And I started doing immediate loads, especially in the static zone from premolar to premolar upper, or a sexual in the upper, but then also sometimes in the lower in around the molars. I didn't do that that many on the contrary. And I started to be very successful and with very little very few problems. And maybe one of the most important factors for immediate placement is the patient selections. So you are a leading voice in parodontology. So you how you choose your the right patient and the right side for an immediate implant. I work with four hygienists that are leopards on top of the patients in what concerns oral hygiene. And the preparation of a patient. A patient that has gingivitis should not go through implant therapy, not even gingivitis. So this has to be treated first. Of course, parodontitis is obvious. So this has to be treated. But the fact is that when I did my last statistics or ten years statistics, I had realized that I had placed implants 24.6% of the implants placed were done immediate after extraction with immediate loading. And the rate of problems were exactly the same as the others. And so I actually feel very comfortable in having I feel more comfortable in having a crown placed on an on an implant than having a provisional removable in those cases. This is for me, I know no. So Jill, where would you draw the line between when you choose to use the immediate pathway and when you choose not to. During surgery, which means that the patient has to be informed prior. to the surgery. The patient has to give me the freedom to do it or not do it depending on the situation because one thing is seeing on the CBCT that we have planned your bone but sometimes the bone is not as dense as we thought and then if I don't have primary stability, well, if I don't have primary stability, I don't even leave the implant there. I'm very careful in those type of things. But what you're saying about your experience can help you to feel when the implant is stable enough. I think about all the young implant and young dentists out there starting with implants now. What do you say about the importance of using high-speed? I would remove the term enough, stable enough. No, either stable or not stable. If the implant is stable and I can actually move the head with it and this really gives the certainty that you can go ahead. So a lot of interesting knowledge from Jill here. We will be back with you shortly after this bridge. Enhance your career with world-class education from EIO. Sign up now for the EIO first and second certificates in implant dentistry. The first certificate is EIO's fundamental course and brand new for 2026. EIO is now launching the second certificate, the advanced level. With both courses running online only, you can study when you want to, at your own pace, and at the right time for you. Find out more at eio.org. So welcome back to clinical matters with our topic immediate implants and immediate loading with our wonderful guest Jill Alcovarato, the current EIO president. Jill, when you're placing an immediate implant in the study so on, do you always do a soft tissue graft? Collecting soft tissue from the pallet is something nowadays, it's very easy. It is something that we should do on a regular basis. If you have a very thick tissue then probably not. But I mean it's the most type of very thick tissues are not in very common. You would say that that will make the treatment outcome more predictable. Is that why you? Yes, I think so, especially on this static point of view. What about gap graft in the jumping distance? Jumping distance? Which particular side do you use? Less than two millimeters. We are able not to do it. That's what the research has shown. But I always graft. Sometimes I graft inside the gap and outside the buckle both. I graft and I pack very carefully with very thin instruments with the probe to make sure that the scenograph is together with the autogenous bone is packed in that area. It's probably also going to help mechanically at the beginning, at the first few days or weeks, the stability of the implant. It could eventually help. But this is something that has still to be proven, of course. This is leading to the next question. You always raise a flap or not because you were telling you I augmenting also from the buckle side. Even though I don't like very much flapless situations. But when you extract, it's not flapless in my point of view. Because you have the area after my CBCT. I see that the bone is there. If I am after all the manipulation of the hard tissue, my buckle bone is intact, then I graft without opening a flap. Opening a flap in those situations are for me the exceptions and not a rule. What clinical advice you would give to our maybe young identists regarding this area, so immediate implant? Well, first of all, the tissue around the tooth that we are going to extract, well, even before. Just make sure that the tooth cannot be saved. That's a good one. This is the first thing. If we really have to extract the tooth, the tissue around that area, the soft tissue has to be non-inflated, healthy. So if it's inflamed, we have to treat it. First, to remove, to control the inflammation. Then we have to do the extraction very, very carefully to make sure that we are able to maintain the whole walls of the alveils. Then we have to know how to place the implant, guided surgery on those cases is probably something that should be done on a more frequent basis. It's not an easy procedure to do freehand. I did it many years ago and actually now a day, I'm relying less in my experience. How do you have a lot of issues? Yes, and that's because when you start relying too much on your experience, you are going to start making mistakes and mistakes that are easy to avoid. I think this is something that also it's a good message for the youngsters and then not so young than this either. And then make sure that you take a lot of time cleaning the alveilers, this infecting, and then try to engage virgin bone. If you have any doubt, do some preservation of the residual bone and place the implant at the latest stage. I think that I want to ask you, if you could give like three advices to the dentist out there to bring with them regarding immediacy, what would be the most important advices? The diagnosis and the study of the case is very important. The patient has to be informed of the different alternatives. So to make sure that the surgeon doesn't go into the surgery, expecting that he will have to do immediate loading. And sometimes during the surgery, you realize that immediate loading is not an alternative, or even the immediate placement is not an alternative, it's not the best alternative. And then you have to have to free them from the patient beforehand to change the protocol while you do the surgery. And then of course make sure that you study well the area where you're going to place the implant. At least I don't have to do fully guided, but at least guided the first where it would be something important. And then probably follow up closely the patient afterwards. So with that, Jill, we would like to thank you so much for guessing the Clinical Matters podcast. It was a pleasure. It's been really fascinating and interesting to hear your talk on this topic. There is so much out here for the community to listen to and learn from. Wow, Lucas. That was a really nice conversation. I'm thinking that we should wrap up this episode now with giving some takeaways from what we found really relevant in the episodes. So the first thing would be for me before you place an immediate implant, control the inflammation. This is really important. And I think it's really important that you trust yourself and your judgment on what root to go when you treat the patients. Even if you started up to plan for a certain kind of treatment and you realize in the middle that I might be better off going somewhere else, you have to allow yourself to change the root. But in order to do that, you also need to inform your patient in beforehand that there might be a different kind of treatment that you have been talking about. There are different options. Yeah. And the third thing would be for me, try to avoid removable dentures in the provisional phase when you have placed immediate implants. So this is also something I took from our conversation. So we're at the end of the show. We hope you enjoyed the show. Join us next time for more great insights and tips helping to deliver great care for your patients. And for all of you out there, keep doing the great work that you're doing. And in the meantime, please follow, rate and review the podcast. It truly helps others to find it. See you next time. Bye for now.