My Surgical Training in Implant Placement

I was recently approached by a student that he is interested in pursuing prosthodontics as a specialty and asked me about the surgical training during my residency.  He also told me that he is aware that some prosthodontists do their own surgeries and some do not. He wants to know if he should be considering periodontics instead of prosthodontics as he also wants to be involved in the surgical phase of implant therapy.

I received my surgical training in implant placement during my prosthodontic residency.  The program had a long history of training prosthodontic residents in implants placement.  In fact, they were doing subperiosteal and blade implants before endosseous implants became mainstream.  At the time, I know I had a lot more surgical training than some of the prosthodontic colleagues trained under other programs.  But now, most of the prosthodontic programs offer some form of surgical training in the residency program.  For me, since graduation, I have also taken several surgical courses to fine tune my surgical skills.  So, while I do place implants in practice, I consider myself a prosthodontist at heart.  I rarely post anything about my surgeries.  In fact, I do not take the time to document my surgeries the way I take the time to document my prosthetic procedures.  So here, I am offering my biased view of how my surgical treatment and training fits into my world of implant dentistry.

Implant dentistry has evolved so much during the last twenty years that there are many facets of learning that needs to take place. To me, there are the treatment planning phase, the surgical phase, the prosthetic phase and also the understanding of how all the components interact with one another factoring in all the types of implant connections, different laboratory processes and procedures available. But what I believe most people don’t realize is that people requiring implant dentistry have more than a problem of a missing tooth or multiple missing teeth.  The more teeth missing, the more of an underlying occlusal or prosthodontic problem that I believe the patient may have and require treatment planning of not just the edentulous areas but that other teeth may require further prosthodontic treatment.  This is where I believe my prosthodontic training comes in handy to be able to offer an objective evaluation of what I believe is the most suitable treatment option for the patient. This aspect of planning is the most challenging as it involves patient consideration, understanding of occlusal function and the prognosis of the remaining teeth.

But if you look at the available continuing education courses, there are many surgical courses along with great mentors out there teaching you a very specific skill set or treatment modality in implant dentistry.   Any dentists or dental specialists can pick and choose these courses to widen their scope of practice.  But there are not so many courses on the other aspects of implant therapy: the treatment planning aspect, the optimal sequencing of procedures factoring in the patient’s comfort, occlusal function and the selection of components to facilitate your implant treatment.  This requires so much more understanding of the other areas where you cannot just teach it or acquire over one or two continuing education courses.    This is where I feel my prosthodontic training has provided me the foundation to help the patients’ various needs I see regularly.  My patients are all unique and require different approach to treatment planning.   I don’t try to fit all my patients to one type of treatment modality.

If you ask me how my surgical training influenced my practice, I will say that it has allowed me to provide a more comprehensive approach to implant dentistry where everything is done in one place from the treatment planning phase, the surgical phase and the prosthetic phase.  The communication between the patients and the office becomes much easier to control.  This is especially important where the patient’s treatment is so complicated and you want to remove all types of barriers whether it be fear, travel or other unknowns.  So I see myself offering surgical treatment to facilitate their overall care.

But I also work with many great specialists.  I simply can’t be all things to everybody.  As much as I want, I believe my surgical colleagues are better at managing soft tissues and hard tissues than me.  I believe they are also more skilled at looking after the medically compromised patients who require extensive procedures under sedation and require close monitoring of their medical status.  So as much as I want to create an environment where it is a one shop stop, I know my limits and know when to refer.

By having the training and experience in surgical placement in implants, it also allows me to be more practical and realistic of what my surgeons can achieve.  I plan for a prosthetic solution that will give me the flexibility of outcomes depending on the surgical and medical challenges there are and manage the patient’s expectation from the get go.  It makes me a lot more forgiving if the implants are not exactly where I want them to be, knowing the challenges the surgeons may face.

This is how I evolved as a clinician based on my own interests and skill sets I want to develop.  I do believe that it does take years of training and practice to be good in prosthodontics.  If you want to do surgeries and do full arch implant treatment and have little interest in other aspect of prosthodontics except implant dentistry, I do not recommend pursuing the specialty in prosthodontics.  I believe it will be a miserable experience.  But if you really want to be involved in complex rehabilitations, you have to know everything.  By that, I mean you have to get your hands dirty and understand every aspect of prosthodontic treatment including the laboratory phase, clinical phase, patient management, fixed, removable, implants and occlusion… It will definitely make you a better clinician when you are planning for full arch implant cases.

After three years of prosthodontics training, it really is just the tip of the iceberg to know what you don’t know.  It is only under close observations of seeing how your work behave over the years do you understand some of the classic concepts in prosthodontics.  I am really grateful for all the trainings I have had and I really do believe the surgical training has helped me be a better clinician.  It has helped me in improving the patient’s experience and allowed me to be a better team member with the surgical colleagues in some of my multidisciplinary cases.  I do enjoy doing surgeries but I also enjoy my prosthodontic procedures.  I hope this post will give new insights and help those in choosing their right career paths.