2 News I am always worried about the graft being just incorporated into a meshwork, looking like bone and then, over time, disappearing once the implant is loaded. I have had the opportunity to receive core biopsies from se- veral clinicians in India and ab- road for histological evaluation with all kinds of materials, in- cluding Autologous bone with stem cells, Allografts, Alloplasts, Xenografts, PRF, and Dentin au- tograft. In all these, I can tell you that the material that seems to show the least tendency to tur- nover is Anorganic Bovine Bone Mineral, which tends to remain and gets encapsulated in soft tis- sues. All other materials show ro- bust regenerative response with variable turnover times, while Dentin shows a unique pheno- menon of ankylosis, followed by replacement resorption, not un- like that of a replanted tooth. What have your experiences with the dentine graft been like? With the limited experience I have had with Dentin autografts, I have found the clinical outco- mes to be extremely satisfactory, with very convincing radiogra- phic evidence of its integration. Soft tissue augmentation: Being a periodontist, soft tissue augmentation is very close to my heart. In post- graduation, we used to study that teeth can survive perfectly well without attached gingiva, but one should intervene if there is marginal inflammation. The paradigm for implants could be different. What algorithm or mental model do you use to decide whether the case may benefit from soft tissue graft? Of course, it is clear when there is no attached tissue - but is there something else to look for, where you give one glance and say - if I do not augment the tissue now, there will be issues later? Great question. The more I do, the more I see the room and need for enhancing soft tissues around implants. There is the obvious need for attached tissue lateral to the implant, i.e., buccal and lingual, but perhaps of greater importance is the vertical thickness of attached tissue on the ridge itself, as also the contour of the tissue in relation to the final restoration. Locations like the posterior mandible where the crestal tissue tends to be thin, attached tissue on the lateral aspects are often deficient, and muscle pulls are prominent, set off the alarm bells. How do you deal with the deficiency of Lingual attached tissue, full arch cases which have been edentulous for a long while? especially in tissue Lingual attached tissue is a problem, very difficult to augment successfully. One often ends up with some mobile keratinized around these implants. My approach to augmenting or not is often related to the patient’s overall ability to withstand additional surgical procedures. My go-to technique for these cases would be an overlay free gingival graft (FGG) with apically positioned flaps. I agree. It often depends on consent and the patient’s willingness. Do you think the currently available soft tissue substitutes have a role to play during implant surgeries in such cases? For example, say I know there is less attached tissue on the lingual during implants in the posterior mandible. Should I stuff in a soft tissue substitute during surgery between the bone and the mucosa? I have had mixed results with substitutes for soft tissue augmentation. And let’s not forget that we need a source of the keratinized epithelium at the edge of the wound to start with, so I’m not sure just stuffing a substitute is the answer for those cases. It needs a more algorithmic approach tissue augmentation prior to implant placement, and if it is after the fact, one may even need to re- submerge the implant to gain the tissue and then distribute it. soft of This is a question for the academician in you. Is there something called attached non keratinized tissue? Could there be something like movable keratinized tissue? Yes, you can have tissue that is keratinized and mobile- classically seen on flabby ridges, and of course, lining mucosa that gets keratinized due to friction like the Line alba (We will not consider pathologies here- that is dyskeratosis). Around implants, with deep sulci, all the marginal tissue is actually keratinized but not attached. Conversely, it is possible to see attached non keratinized tissue- the junctional epithelium to start with, and on a more macroscopic level, most of the erythematous tissue you see on pontic sites when you get old bridges off is attached but non keratinized. If there is one soft tissue grafting skill a beginner should master, what would it be? 10/21 About: Dr Narayan Venkataraman Dr. Narayan Venkataraman did his post-graduation in Oral Pathology from Nair Hospital Dental College, Mumbai in 1996. He then taught Oral Pathology for two years after which he started his own practice in 1999 while continuing to be active in academia till 2013. He is trained in Implant Dentistry at Berlin, Seoul, and DGI (Germany). He is a Fellow and Diplomate of the prestigious International Congress of Oral Implantologists (ICOI). He is also the Founder Director of the International Team for Implantology’s (ITI) study club in Bangalore where he is also a certified speaker. He is on the Editorial Board of Quintessence India journal and also an expert on Dental XP, the premier online dental education portal. Being one of the most sought-after experts in this field Dr. Narayan is also a key opinion leader for 3MESPE and Novabone. He has also embarked on a parallel consulting of Oral & Maxillofacial Pathology. Dr. Pinak Kapadia One of the leading periodontists and implantologists from Surat, Dr. Pinak practices exclusive periodontics and implantology. He was an associate professor at Vaidik Dental College Daman in periodontics. He is an avid reader, a bookaholic, and a trekker. it, loose, tighten region with a crestal lift for an elderly gentleman and left the cover-screw on, something that I rarely do with immediate implants. 2 weeks later, when I was away in Mumbai for a course, he met my then associate to get the sutures clipped off, and she, in her youthful enthusiasm, thought that the cover screw and decided looked to inadvertently displacing the implant into the sinus (This was on a Saturday afternoon). I received a phone call from the patient on Saturday night classic symptoms of an Oro-antral communication. All of Sunday was spent on tenterhooks at the course, where it did affect my clinical demonstration surgeries as well. I got back late Sunday night and saw him first thing on Monday to do a lateral window and extricate the implant. I think all of us learned some lasting lessons in those few days. describing This is an unappreciated aspect of surgical practice when you say the case affected your clinical demonstration surgeries as well. What could be said to be the difference between efficacy and effectiveness in procedures - something that’s possible only on the best days of the best people or in controlled conditions, or something that is possible routinely, even on average days. That is why I have become a big fan of crestal lifts and MITSA. I could have had an awful fight at home, my wife could have called me a few unpublishable names, and yet, that internal lift will go so smoothly. What is the boundary you have pushed in MITSA? 2 mm? 3 mm? Furthermore, what is the percentage of direct vs indirect in your practice now, and how has it evolved over time? I remember The most I have gone with the Crestal approach is in 1.5 mm RBH. the patient names and implant regions, number of implants, materials used, etc., for each and every lateral window case of mine over nearly two decades, out of hundreds of sinus floor elevations, so that must indicate the rarity of the procedure in my office. About 97-98% of my cases have been crestal, and it has stayed that way over time. Thank you Rajeev, for getting Pinak for thinking of me for this interview, and to frame these astute questions. I thoroughly enjoyed replying to them. My best regards to all the great teachers out there on this Teachers’ day. There are two soft tissue techniques that I think every beginner should learn even before starting to place implants (As a matter of fact, I believe that beginners should learn about bone grafting as well, before starting to place implants). is is the One simple yet Apically underutilized the Repositioned Flap, and second the versatile Free Gingival Graft harvest and stabilization. The FGG is simple to harvest, can be used as it is, in the epithelialized form or de- epithelialized for obtaining a free connective tissue, and the fact that it is easy to visualize, unlike the subepithelial harvest procedures, gives the operator more confidence in going to the palate to harvest tissue. Sinus augmentation: I have learned sinus lifts from you, and I have first-hand knowledge about the depths you have explored inside the sinus literally and metaphorically. So we will start with the most common belief about the sinus graft. Is it true that anything and everything works as a graft inside the sinus? Is there a first among equals, or is this a modern myth? Haha Yes!, I have heard that “even sand” works in the sinus: It just happens to be a very expensive sand called Bioactive glass. To an extent, the statement is true since we know that if the membrane is held up well and long enough, be it by an implant, bone graft, or any other kind of osteoconductive/inductive means, we will get bone in the sinus. Then it all comes down to the convenience of delivery, safety, Biological activity, regenerative potential and turnover rates, cost-effectiveness, etc. I would still like to see the material that I place in the sinus to turnover and get replaced with vital bone eventually, and for this reason, my first choice (Lateral window) when available is a Cortico- Cancellous Allograft with at least 30-40% Autologous Cortical chips/shavings, followed by Carbonate Apatite Xenograft with 50% Autologous, particulate Alloplasts with 50% Auto, and if push comes to shove, ABBM with >50% auto. For the crestal approach, my default material is a Calcium Phosphosilicate Putty for its hydraulic capabilities more than any other reason. I would like to know about your worst sinus lift failure too My worst Sinus failure was when an implant got displaced into the sinus two weeks after a crestal lift. I had placed an immediate implant in the 17