Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
How to perform dentistry faster, easier, higher in quality and lower in cost.
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162 Should You Place Implants? with Mihnea Cafadaru : Dentistry Uncensored with Howard Farran

162 Should You Place Implants? with Mihnea Cafadaru : Dentistry Uncensored with Howard Farran

9/24/2015 2:00:00 AM   |   Comments: 0   |   Views: 627

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AUDIO - HSP #162 - Mihnea Cafadaru

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VIDEO - HSP #162 - Mihnea Cafadaru

The laws dictating what dentists can and can't do are different in Europe than in the US. Mihnea Cafadaru, DDS shares their unique approach.


Dr. Mihnea Cafadaru graduated from the University Victor Babes Timisoara-Romania in 2007. He then started training in implant dentistry and periodontology. In 2008 he finished a one-year specialization in implant dentistry, under the authority of Professor Bratu Emanuel in Timisoara-Romania. Since then, Dr. Cafadaru has focused on learning from the best trainers in Europe, including Inaki Gamborena, Marius Steigmann, Anton Sculean, and Mauro Fradeani.

Dr. Cafadaru’s main focus is clinical periodontology and implant dentistry, along with microscope-enhanced dentistry. 

In 2013, he started a new project called Dental Clinique by Dr. Cafadaru in Arad, Romania. The dental clinic specializes in implant dentistry, esthetic dentistry, prosthodontics, and periodontal treatments. Also it focuses on LIVE OP TRAINING for doctors from inside and outside Romania.

Phone: 0040724.250.160



Howard: I am so excited to be podcast-interviewing you. Not only am I a big fan of your implants and periodontal and high tech but it's so amazing to be interviewing a dentist all the way from Romania. You're from Arad, Romania, correct?

Mihnea: Yes, yes.

Howard: You do you pronounce your name? I'm not even going to try because I am so bad at languages. How do you pronounce your name?

Mihnea: My name? "Kafa-daru Meeh-nah." Mihnea Cafadaru.

Howard: "Mish-nah Kafa-daro."

Mihnea: Something like that. It's okay.

Howard: I know. I have to admit to everyone, and I've told everyone, the only D I ever made in my entire life was in Spanish, and my teacher's name was San Martin, and he told my mother I was linguistically retarded. That was his words in high school. The happiest day of my life was not when any of my four boys were born, it was when my mother told me I no longer had to take piano lessons, and my piano teacher told my mom that I couldn't carry a tune in a lunchbox. 

Speaking of tunes, when I think of Romania, I'm sorry, I'm sure there's a lot of great reasons to think of your country, but I always think of the greatest Michael Jackson concert that was ever done, which was in Bucharest, Romania, not to be confused with Budapest, Hungary, but that concert, in fact, my go-to when I'm on television or I'm at home and I just want to listen to Michael Jackson, I always throw the Live in Bucharest, Romania concert. That was his magnum opus. That was just the greatest.

Mihnea: I heard that was great. I heard that.

Howard: You heard that was great? Yeah. I think it was his cat's meow, his bee's knees. I think that was the best work he ever did.

Thank you so much for ... It's 10:00 in the morning here and it's 8:00 PM there, so you're 10 hours ahead, which means you're probably 10,000, 12,000 miles away. I love this internet. I love podcasts. Here's some dentist anywhere around the world, they might be driving to work, driving home from work, they might be who knows. This is outstanding.

Tell me, the first thing I want to ask first, for the viewers around the world, tell us about what is it like, dentistry in Romania? Do they have water fluoridation? From what you see, is there more decay now than there was 20 years ago because they're eating and drinking more sugar? What is it like being a dentist in Romania that you think other dentists from around the world might not know about practicing dentistry in Romania versus their country of, say, Canada or Australia or America or England or ...?

Mihnea: I don't know how dentistry is in America, because I never practiced it there, or in Canada. In Europe, it's a bit different because the rules are a bit different. 

We get to try different materials that in America are not available because of the FDA, probably. We get to try different methods than in America that Americans are not used to try because we are allowed to. For example, the PRF clot from the blood, I've heard that in some states in America, it's not allowed, they are not allowed to use it, but I'm not sure if I'm right with this information. 

In general, we do the same stuff. We do implants, we do fillings, we do root planing, we do canals, we do all stuff that in America they are doing.

Howard: How many people live in Romania and how many dentists are there?

Mihnea: I don't know exactly.

Howard: You don't know exactly?

Mihnea: No. No, no. I don't know. In the capital only are two million inhabitants, so maybe they have 10,000 dentists. I'm not sure. I don't know.

Howard: Romania has two million people, you said?

Mihnea: No. Bucharest only.

Howard: Oh, Bucharest only has two million.

Mihnea: If we think about the entire Romania, I can Google it, but there's a lot of dentists, because we have I think eight or 10 dentistry schools, which bring a lot of dentists every year. There's a lot of work, but ...

Howard: When you graduated from your dental school in Romania, you then went all over Europe training under many great implantologists. How did that happen in your journey? What made you go around Europe and ... You'll have to pronounce some of these names: Inaki Gamborena, Marius Steigmann, Anton Sculean, Mauro Fradeani.

Mihnea: I met a guy, a dentist, when I graduated that gave me the big push. I was working with him at that time in 2007. I worked with him until 2011, I think. In this period of time, when he was going to an event, I was going with him. When he was going to a course, I was going with him, in Germany, in Europe in general, or in Romania. 

He gave me this taste of dentistry. I was looking only implants, implants, I have to see implants, I have to do implants. He told me, "If you want to make a great implant, you have to do a perfect dental fitting first." He tried to make me look at dentistry that is all benefits, not only what I was thinking I used to like. 

My English is not really great. I hope you understand me.

Howard: I think your English is outstanding. I don't know a single word of another language, so my hat is so off to anybody who can carry on a dental conversation in another language. That blows my mind.

Mihnea: This guy who told me that if a patient come to my office, first of all, he will ask to take away his pain and to do a dental filling or to do a root canal maybe. Only after that, after I will gain his trust, he will maybe let me put an implant in his mouth. From that moment, I started to look at dentistry at a different level. I was going with him everywhere he was going.

Howard: Was he a classmate or what was his-

Mihnea: He was 10 years bigger than me. He was my boss at that time, my [employee 00:07:40]. He gave me all the credit to make a great dentistry at his clinic. He owned this great clinic in Timisoara next to our city. He told me that I can be a great dentist if I want to, but I have to be a dentist, not an implantologist.

Howard: That is so amazing that you have a mentor like that. It's so a big piece of advice to the listeners is all dentists by and large are shy, introvert. They remind me more of Physics majors, Math teachers, professors. 

So many times, I can't count, over a hundred times, I've gone into a dental building where they have six or seven offices, I'm talking to the dentist there and I say, "When was the last time you went to lunch with any of the other six dentists in the same exact building?" and they almost every time say, "I've never done that ever." I'm like, "Oh." 

Dentaltown was such a success because they're more natural to talk to you online because you're far away, but the dentist next-door in their building, they see as, "Maybe this is my competitor," and this and that, and it's just silly. 

When I find a dentist who's happy, healthy and just doing everything right, they always have lots of friends in their same city. I can't emphasize enough how many times have you just walked into the dental office and say, "Hey, let's go to lunch!" and just press the flush, you're not competitors. The only thing we're competing against is these people buying iPhones and computers and trips to Germany, not the dentist across the street.

In America, 95% of the general dentists have never placed one implant in their life. When you go to other countries, three out of four dentists have placed implants in South Korea or Germany. What percent of the dentists in Romania would you say have placed a dental implant in the last one year?

Mihnea: I think 60% or 70%.

Howard: A big part of my audience is the United States. What would you tell a dentist listening to you right now for an hour who's never placed an implant? What would you tell that dentist?

Mihnea: He should not be attracted by the concept of surgery before he understands the real benefit of a dental implant and how to integrate a dental implant inside the mouth. Because we see nice pictures, we see nice results, we see nice books, because the books are meant to be attractive, we get a chapter with complications but it's the last one in general. It's the last one. I know a book which, I don't remember exactly the title, but the titles entire about complications, but I think it's the only book. 

They have to be aware, we have to be aware that we are placing a dental implant that doesn't belong to the mouth, and besides the financial benefits and maybe some trust-gaining from our colleagues and from our patients, we should see 10 years ahead what is going to happen with this dental implant.

Because it's easy to drill a hole and set an implant, place a crown, the dental technician is maybe a great technician here to get us out of trouble, but in general we have to be aware that 10 years ahead, something is going to happen. It's like a microwave machine that you are turning the timer and it's going to close one day. Something's going to happen.

Howard: Let's start getting into specifics. Let's talk to a dentist who's never placed implant. What would you recommend for their training? Do you think this is something they can learn on a weekend course? How would you recommend someone go from "I've never placed a dental implant" to "I want to start placing a dental implant?"

Mihnea: I want to talk about myself for this question because I was so, so into dental implants, so into oral surgery, I was loving this area and I love this area right now, but I love it because different reasons appear. At the first, there are some blood, some adrenaline rush, something that I was thinking of myself that I'm above the others because I place implants, I make a cut, I suture and I do something that not everyone does gave me this rush of dental implants, if I can say it like that. 

After a while, I started to see, fortunately not many of my cases, but I started to see dentistry and implant dentistry different. For a beginner in implant dentistry, an implant should be placed only after proper training and only after mastering different techniques on hands-on, on simple cases, really simple cases, like a simple implant between the teeth with bone height and width enough so no problems can come from that surgery.

If we try to be smart and if we try to make a sinus lift because we saw it on YouTube or on a webinar, on a seminar, on a weekend training, I think a lot of problems can appear. If we are not able to manage the potential problems, we are going to be in trouble. The patient is going to get infected or a high risk or different local or general complications.

I think this is the start: a simple dental implant placed where the bone is under surveillance from an expert or from a dentist that have more experience. That should be a start. Never try complicated subjects. It's a big subject. It's a sensitive subject, because in Europe, it's a bit different than in America. We are not yet huge, as easy as in America.

Howard: America, it's sad because we actually have over one million attorneys, but only 900,000 physicians and 150,000 dentists. Any country that has more lawyers than doctors has got their priorities mixed up.

You're actually teaching live implant training in your office for dentists inside and outside Romania, correct?

Mihnea: Yes. We are beginners in this area. We try to attract some clinicians that they have some time to spend and are not confusing our work with something that we stand for. We are trying to attract a few dentists that are really passionate about microsurgery, about surgery in general, about dentistry.

Howard: You also use a microscope. Do you use a microscope during endodontic root canals or are you using microscopes during implant surgery?

Mihnea: I try to use the microscope for all my surgery. It's a bit difficult because sometimes I don't have a straight access. I have to look in the mirror. Maybe dental implants in the posterior area are not a great idea to be placed with the dental microscope, but I can do certain parts of the surgery with a dental microscope. I can check my flap, I can raise my flap, I can close the flap. I can make a sinus lift with it. I can do a lot of things, and in general dentistry also. We use it for 99% of our dentistry.

Howard: Seeing is amazing. A dentist that uses the naked eye does not know what they're missing compared to ... My first journey was 2.5 loupes, then it's 3.8 loupes. What I like the most about the CAD/CAM dentistry is seeing your prep 40 times larger. Which microscope did you buy? Which one did you go with?

Mihnea: I have a Labomed from the US. 

Howard: What's it called?

Mihnea: Labomed.

Howard: Can you spell it?

Mihnea: L-A-B-O-M-E-D.

Howard: Huh, "Labomeb."

Mihnea: Yes, Labomed.

Howard: How do you like that one?

Mihnea: I like it. It can be improved. I don't get a lot of lighting behind the camera, but that's my fault. The optics are great. It's a good view for the mouth.

Howard: What magnification are you using your microscope at, 10x, 15x? How-

Mihnea: 6x for the surgery, 10x for the fillings and root canals. I don't do a lot of root canals. My colleagues are doing it. When I do exploring and cleaning, I do 10x, 16x only for checking, 24x almost never, because even if the wind is blowing, I'm going to get some confusion.

Howard: What do you use the 16x for?

Mihnea: For checking. I check my cementation. I check my sinus with small mirrors. After an extraction, I check the socket. I check my sutures. 10x or 16x is the most.

Howard: Going back to implants, it's very confusing for dentists because there were over 275 dental implant companies last year at the Cologne meeting in Germany. How would you help a dentist pick a system when there's so many systems out there? Which system did you go with?

Mihnea: I have a lot of systems.

Howard: Boys and their toys.

Mihnea: Yes. I tried different strategies. At that time at the beginning I tried the internal hex with bone level. After that, I've tried the cone with Morse taper. I've tried the company Megagen, the Megagen company. I've tried different types of implants, Implant Direct. It's a great implant. 

I've tried to place it at the bone level, I've tried to place it under the bone. I have some aesthetic parts for external hex. I never placed an external hex implant, but I have some crowns made on external hex platform, which in some ways are great implants if we can manage the soft tissue around. 

It's a really, really hard task to choose an implant, as you said, because the companies are spending more on advertising and more on promoting few extra benefits or few extra ... How do you say it?

Howard: Features or benefits?

Mihnea: Features, exactly. They are spending more on these than on proper training for the dentists. I will always like a company that brings me experienced dentists that have placed thousands or hundreds of implants from their production and those guys are telling me what to do here, what to do here, not to do in that case. 

I like this strategy more than only advertising the best platform or the best bone-to-implant contact, but those are just marketing and stuff. It's easy to perform with any dental implant as long as we accept some limitations from that system.

Howard: Are you talking about you're using the implant system that has someone locally in Romania to help you with questions? Are you talking about the support is online?

Mihnea: Yes. I have a lot of people that I can ask.

Howard: In your city, Arad, Romania?

Mihnea: To be honest, no, not in Arad, because I'm not in contact with a lot of people in Arad. I'm too busy in my office, so I don't get out very often. I know people that I am contacting via internet or by phone from Timisoara, from Bucharest, from outside the country. If I have a question, if I have a tough situation, I will most certainly ask them to guide me. Then it's a better idea than do it by myself.

Howard: What system are you with now?

Mihnea: I have a system, Implant Direct.

Howard: Implant Direct, which is online?

Mihnea: Yes.

Howard: That's what you mostly use, Implant Direct?

Mihnea: Yes. I use it because I have two types of implants. I have a bone level and I have a submerged. 

Howard: Please explain that for our viewers. My job is to try to ask questions. I'm trying to guess what people- There's some guy driving to work and he's saying, "What's the difference between a bone-level implant and a submerged implant?" Can you talk about that?

Mihnea: It's a large debate on what type of implants should we use, if we use it in the lateral part of the mouth, if you use it in the lower jaw, if you use it in the upper jaw, if you use it for aesthetic reasons, if you use it over denture.

For example, if I use it for lateral part of the mouth, I will most certainly use a bone-level implant. It's not ideal. Some people are saying that supragingival-level implants are the best because we don't get too much connection, connect-disconnect the abutment from the implant, so I'm not going to lose attachment. 

I use the bone-level implant. That means that I will get some bone injection after uncovering of the implant. If I manage to stabilize the soft tissue, I will get away with it even if I lose one or two milliliters of bone, which is not great, but these are the options that we have for now.

If I want to use an implant for a sinus, for example, or for a soft bone, I want to use a more tapered implant, for example. I like to use it, submerge it one millimeter under the bone because I want some bone-jumping over the margin of the implant. Of course, we need the proper prosthetic part for that type of implant, which is a platform switching or a cone. That cone, that allows me to get some tissue over at the margin of the implant.

If I want to use an anterior reconstruction, I will most certainly have to use an implant that have proper prosthetic parts like the cone [inaudible 00:25:57], like Nobel have Procera abutments. I don't use Nobel because in my country and in my city especially, it's not that easy to place such an exclusive implant, but we have this option for cone with Cone Connection and it works great for the aesthetic part of the mouth.

The implant is not the only issue. What we do with the tissue around the implant, it's important.

Howard: Before you go into the tissue and come back to that, originally you said you use the internal hex and then you use the external hex. Describes your lessons you've learned and what's the difference between an internal hex, external hex and what your takeaway was of that, and then also talk about the Morse taper. Explain what that is and what your experience is with that.

Mihnea: That taper connection allows me to have a better fit of the abutment inside the implant and I'm not going to have a microleakage because the cone is three or four degrees at width and I will get the best fit between those parts, between the implant and the abutment.

After that benefit, the benefit of bone-jumping and tissue-jumping. I will get a tissue growing between the edge, the marginal part of the implant and the Morse abutment. I will get some tissue there for [inaudible 00:27:51]. I get some tissue for [inaudible 00:27:56].

Howard: Are you using a Morse taper now?

Mihnea: Yes. It's not really Morse. It's like a cone. I have to check the exactly degree of the cone, but it's a cone which is really, really, it's better than a standard internal hex connection. It's a cone inside it. I have to check the degree, but it's tapered and I don't get microleakage as far as I observed in doing that.

Howard: Explain for our listener who might not be clear about the difference between an internal hex and an external hex and what you like about the differences between an internal hex and an external hex, your takeaway lessons from that.

Mihnea: We have so little benefits for the external hex. The external hex is an old-timer, as I can say, but I saw some tissue stability because the connection is a bit above the bone level, so I don't get too much inflammation if I remove the prosthetic part. The external hex have the benefit of checking the connection between the abutment ... I told you my English is not great.

Howard: Your English is amazing! If the others can't understand you, I'd like to hear the Romanian.

Mihnea: The English is great, but the words are not really ...

Howard: I think you're doing fantastic. I think you're doing amazing. 

Mihnea: The external hex gave me the benefit of controlling what's inside the implant much easier than with the internal hex. If I am contaminating it in an accident, if I contaminate it, it will be harder to clean the inside part of that implant.

The implants are not used today because that is a more unstable connection because the external hex is about half a millimeter or maybe a millimeter, so the connection, it's lost easily during the [inaudible 00:30:33] that opens and forces. 

I also think that an internal hex gave me the possibility of better fit than the external hex. I don't know, I didn't study that subject too much because I never use it. I only used it three times for the prosthetic part. I saw tissue stability, but I didn't saw bone around that area. The bone was also one or two millimeters down under the [inaudible 00:31:10].

Howard: So then you want to talk about tissue. What you're saying is more important. What are your thoughts on the tissue around the implant?

Mihnea: If I want a stable bone around the implant, I have to get some stable gingival level. I have to get a stable and thick gingival around the implant. If I cannot manage that, my implant is going to be lost in a few years because I will get some pocket and maybe have peri-implantitis develop in years and I will lose my implant much, much earlier than with the proper soft tissue around it. I'm trying to get a lot of soft tissue around the implant, a lot of bone around the implant and soft tissue around.

Howard: Talk about, do you ever just punch a hole through the tissue versus laying a flap?

Mihnea: I'm going to lay a micro-flap. I'm not going to lay a flap if I don't have to, because the flap around the implant, after placing the implant, I don't want to disturb the tissue that is around it, but punching a hole is going to destroy some keratinized tissue that I maybe need for a proper architecture around it. I will always make a small cut and try to manage the tissue versus punching a hole. It's a higher-demanding skill, but it's not a life-threatening brain surgery.

Howard: Describe a micro-flap surgery versus a traditional full-flap surgery. How are you actually doing it?

Mihnea: First of all, we need magnification, not a microscope, but we need at least dental loupes with a certain magnification at least 4x, for example, because I want to see my 6/0 and my 7/0. Otherwise, I'm not going to manage it. If you are trying to suture with 7/0 with your naked eyes, you will see that it's hard to suture with it. 

For a micro concept, we are trying to use micro blades and micro instruments. I don't know, it's a general term, "micro," but we try to stay minimally invasive in that area so we don't disturb the biologytoo much. That's the micro concept. 

Other colleagues are arguing because they are not doing anything micro, they are not doing it with micro, but we are trying to stay as small as possible even with our healing caps, even with our suture material, even with our [bars 00:34:22] developed.

Howard: What do you think are the main reasons, the top reasons that an implant fails? Do you think it's peri-implantitis? Do you think it's occlusion? First of all, what do you think is your success rate of implants? When implants fail, why do you think they do get into trouble?

Mihnea: I only use implants when I try different things other than I used to do. If I'm trying to immediate loading an implant that doesn't have proper torque, I will maybe get a loose implant and I will have to remove it and place another one.

My failure rate is low because I'm always trying to be patient. I don't like patients that are in a rush, like patients that come from abroad and they want everything in three weeks. I don't do that. I do implants in three weeks, but I do submerged implants in three weeks. I don't do provisionals if I'm not sure that my implants are stable. If I'm not going to use a proper guide, guided implant for surgery, I'm not going to use provisionals at the first stage of the surgery because it's much safer.

Of course, this is a limitation maybe, but I'm getting with this way. I don't have complaints. I prefer to make my patients wait for three or four months, even if my patients, some would cause some pressure on me, but I think my success rates are based on that patients.

Howard: Do you use CBCT, three-dimensional radiography for all your implants?

Mihnea: I use it for 90% of my implants because I get surprises from time to time, a lingual concavity that I was not aware of it, a large amount of bone. If I'm doing only standard radiographs like panoramic radiographs, I will see a lot of bone. If I'm checking intraorally, I will see a lot of bone, and on the CBCT I will see a big concavity in the lingual part. There, I will be in trouble if I'm not going to use proper guidance.

Howard: Which CBCT did you go with? There's so many on the market.

Mihnea: I have a company that provide me with Galileos, a company that provides me with Kodak.

Howard: Kodak, and what was the other one? Iteros?

Mihnea: No, Galileos. 

Howard: Oh, Galileos.

Mihnea: Yes. 

Howard: Galileos from Sirona, and the other one ...

Mihnea: Yes, Sirona.

Howard: ... was Kodak.

Mihnea: Yes. I don't know the machine. I don't have it in my office. I have it in ...

Howard: Does it matter to you if they come back to your office from the radiological center and they come back with a CBCT from Galileos, Sirona or Kodak, Carestream? Does it matter to you or can you-

Mihnea: It matters if I'm trying to make a specific measure and I'm not used to that software, but in general, I use both. All the software are [inaudible 00:38:31] today and it's easy to work with CBCT.

Howard: You use a CBCT on 90% of your implants. What percent of your implants do you use a surgical guide?

Mihnea: I have a low percentage of surgical guide because in my ...

Howard: How low?

Mihnea: ... city, they didn't develop this strategy. The companies are not providing me with this logistic. I have to ask from other cities to provide me with measures and with the guidance. My patients have to make some travel to take some ... I don't know how to say it in English.

Howard: Impressions?

Mihnea: Yes, yes. It's a bit hard, but I never had big problems, but this is not an advice. I should use more proper guidance for my implants. To be fair, I think 80% of the dentists are placing implants without guide, without guided surgery.

Howard: Is that 80% in Romania or 80%-

Mihnea: I don't know, it's a number, but I see that it's not a lot of publicity made from our companies in that direction, so I can see that only a few people are making proper guided surgery. 

Howard: It sounds like it's a great business advice ...

Mihnea: It is, and ...

Howard: ... for someone-

Mihnea: ... it's developing-

Howard: Somebody listening to this podcast should take a surgical guide company and set it up in Bucharest and they'd probably have a flourishing business.

Mihnea: It's a developing business. I get an offer from Megagen, for example. They have this R2 GATE system, which is a great system. They are developing it in Bucharest, in the capital city. I'm in discussions with this company because I'm going to try their guided surgery machine. They have also these abutments.

Howard: You're going to try the new Megagen guided surgery technique?

Mihnea: Yes. I think it's great because they also do some individualized abutments with provisionals, so I can do one abutment-one time technique. Otherwise, it's hard because you don't know where to place the margin of abutment. They do this.

It has certain limitations because you have to raise the minimal invasive flap. If you do a large flap with bone grafting and soft tissue grafting, they are never going to be able to provide you with the one-time abutment strategy. It's not possible. You have to remove that abutment to place the correct gingival layer on the final prosthetics.

It's a promising technique, to use this R2 GATE system. I think Dr. Roberto Rossi is using it a lot and he has a lot of great success with this type of treatment. 

Howard: Dr. "Bel Rossi?"

Mihnea: Yes, Dr. Rossi.

Howard: In Italy?

Mihnea: Yes, in Italy. I like his work. He's doing a great job. I was talking with him about this strategy and he told me that they do a great job, those guys from Megagen.

In general, I use guided surgery, guided placement based on my wax-up and my mockups. I'm trying to use a certain amount of guidance for my wax-up mockup system.

Howard: On your implants, with the final restoration, are you cementing or screwing them down?

Mihnea: I was cementing everything, until one day I'll be around the final prosthetic parts, I did some soft tissue augmentation, and under microscope, I saw a lot of cement, even if I was cementing it with reflection [court 00:43:32] and under magnification. I saw a lot of cement. 

It was cemented I think two months before the surgery. I saw a lot of cement under it. From that time, I never did cemented the restorations besides on the zirconia abutments. There I can do a bunch of checking. I do a lot of [inaudible 00:44:03] installations from [that part 00:44:06].

Howard: What are your thoughts on preventing and controlling peri-implantitis?

Mihnea: First of all, I do this type of restorations. I do [inaudible 00:44:20] restorations. I do six months or four months screening after implant placement and after seating the provisionals and after seating the final resolutions. 

We have a call center that have control over the patients. We are trained to tell our patients what to do at home, because we have a certain control in the office, but after the patient leaves, it's not in our hands. The hygiene is not in our hands anymore. 

If we see that the patient doesn't clean the area correctly, they are trained to perform some maintenance and some guidance for them in order to perfect their hygiene properly. I have a specialist on oral hygiene that is doing the proper cleaning and proper training for the patients.

Howard: Do you find more peri-implantitis with people who lost their teeth from gum disease as opposed to people who lost their teeth from a cavity dental decay?

Mihnea: The studies show that it's a difference because the gingival [inaudible 00:45:44] and the gingival health play a huge role, but I didn't pay attention exactly at that detail because I'm trying to make my patients to clean in the proper way. I'm trying to stop the periodontal disease prior placing implants. 

If I have trouble with a patient that is not cleaning right or it doesn't respond to our medication, I'm not going to place the implant until I'm sure that he can manage the hygiene around it. I have to stop the periodontal disease, have almost zero inflammation or zero inflammation, and only after that I will do the implant or treatment. 

I didn't pay attention to it at that detail to make that difference. Yeah, the studies show that it is a difference, a big one.

Howard: I think the biggest problem about implants is that the people who need the implants the most had the least amount of home care. You and I aren't missing any teeth and the people in my practice that are missing most of their teeth, there's reasons they're missing a lot of teeth. They're not good with brushing and flossing, they're not good with coming in every six months for cleaning. 

I want now to switch subjects. I've only got you 10 more minutes. Talking about as far as sinus lifts, what are your thoughts on sinus lifts?

Mihnea: I'm trying to avoid it, but I have a lot of patients that have two or three millimeters of bone in that area. Most of the time, when I'm placing an implant and I do an external sinus lift, I'm asked even on prestigious forums like yours or Dental XP or when I place my case presentations, I'm always asked about the other specialists, why didn't I perform the internal sinus procedure. Because I'm not sure that it will work.

If I perforate the membrane, I will be in a bigger problem than if I do a micro [inaudible 00:48:20] in the bone and I raise that Schneiderian membrane. I do external sinus lift because I have a lot of patients with almost zero bone there. I have to be sure. A lot of people do internal sinus lift. If they have two or three millimeters of bone, they do internal sinus lift. I'm not sure that works in every case. I do external.

Howard: My job is to ask the questions that someone's out there, they're listening. Explain the difference between an internal and an external sinus lift, for someone who doesn't understand what that means.

Mihnea: The external sinus lift, it's the procedure where they place a small window in the lateral part of the maxilla in order to gain access to the Schneiderian membrane, which is inside the sinus. 

We are trying to elevate it with proper tools, with [inaudible 00:49:27], in order to make room for some bone to grow inside the sinus. We place artificial bone like bovine inside it. Some people use only PRF or only PRGF inside the sinus, but we are trying to get some bone, some stable substitute or bone substitute, which is inserted to that window.

In the internal sinus lift procedure, we do the elevation of the Schneiderian membrane through the hole for the implant placement. We drill the hole for the implant and we try to elevate the membrane through that small hole. 

It works, but it works when we have a clean sinus floor without a septum, without a rough surface, which we can now often see on the CBCT. It works, but I'm not sure that I want to try it in sinus. When we try to use that treatment, for example, in that sinus, I don't want to elevate the membrane through the implant hole. It's too risky.

External sinus lift, it's through the window that we make in the lateral part of the maxilla. The internal sinus lift is through the implant hole. 

Howard: Now, when I was little, when I got out of school in '87, the big name on the external sinus lift was Dr. Tatum. Have you ever heard of his name? He was a dentist here in Florida that was teaching everybody how to do that. 

Mihnea: I'm not sure.

Howard: I think he moved to Europe.

Back to bone grafting. You used a lot of terms and I'm thinking some of these terms are missing that. Explain, you were saying bovine and, what did you say, PRGF?

Mihnea: Bovine bone is a bone substitute, which is made from bovine bone. This is the small particles of bone that are [inaudible 00:51:50] and deproteinized. It doesn't get reaction from the host, from the human body. We are inserting this type of bone in order to gain volume for the human bone to grow from underneath. In other words, we are placing this particulated bone in a manner that we get some space maintenance to grow bone from under. I don't know how to explain it to you in English.

Howard: Just for the audience, bovine means cow. Cattle. Buffalo.

Mihnea: Bovine mineral is bone made from bovine bone, which is particulated and placed over the human bone in order to get some bone volume later on after the healing period.

Howard: The other two types you said, PRF and PRGF?

Mihnea: PRF, it's a blood clot, the fibrin clot which is separated from the patient blood. We centrifuge it at a certain speed and we are separating the fibrin in order to use it as a healing accelerator. The PRGF is the same product, but it's not available in Europe. I don't know exactly the protocol. I've heard it [crosstalk 00:53:40] in America.

Howard: What percent of your bone grafts are you drawing the patients' blood and centrifuging and getting the-

Mihnea: I think 99% of the time.

Howard: Ninety-nine? Or ...

Mihnea: Yes.

Howard: ... 90?

Mihnea: I think 99. Today I did a bone graft without it, but I think this is the 1%. 

Howard: Do you think that increases your success rate with the bone grafting significantly?

Mihnea: Yes.

Howard: In your career, what was your success rate with bone grafting before you started drawing blood versus now you're bone grafting with drawing the patients' blood and doing this technique?

Mihnea: I didn't draw numbers, but I'm sure that if I bring fibrin, that is not going to get there through the capillarity. I will get a better healing, of course. I didn't check to see at that time how good it heals because the patient healed properly, but I see today that in two weeks I get a better healing that I was getting at that time without using the blood.

Howard: You're mostly noticing a faster healing time by drawing blood?

Mihnea: Fast tissue healing, not bone-healing time. I don't know the bone. The bone is under the soft tissue, but I see a better soft tissue healing, and that's good for me because the faster the soft tissue heals, the better the bone graft will react.

Howard: We have listeners to this podcast in 206 countries. If a dentist is listening to you right now and wants to go to Romania or to learn from you, how would they find information about you?

Mihnea: We are developing a new website. I don't have a proper website right now because we are developing it, but they can contact us via Facebook or via Google. They can Google us and they will find a lot of information about our clinic, and about my name, they can Google my name. 

I didn't pay attention to promoting us too much because we try to make our clinic a cozy place, not crowded, not overwhelmed. We are trying to make our reputation based on our results. That's why we didn't make a lot of publicity, but the website is developing and there it can have a proper section for training, but we are at the beginning in that area. I'm not going to say too much about it.

Howard: I would want to go just because I would love to see Romania. One of my goals before I die, I were to see every country on Earth. I've seen 50 and I want to see them all. I have heard that Romania is just beautiful. 

Mihnea: It's beautiful and you have a lot of landscapes, you have a lot of opportunities to visit, but you have to be prepared to travel a lot because you have all type of roads. The Romania roads are not like the American roads, but I think this is the beauty of it because you will get extra fun, extra adrenaline. 

You should come. You are most welcome. You will be amazed how great and how kind people are here.

Howard: Oh, I imagine. It's funny, when I go to Cologne and you buy a train pass, they always think you're German and they try to put you on a high-speed train that goes 100 miles an hour, and you have to stop them and say, "No, I'm a tourist. I want the old rickety train that's following the river, that's real slow with all the views," and they always say, "No, no, no. You have a first-class ticket. You could go to the high-speed." I don't want the high-speed. I want the slowest-speed.

I have to make one more point on roads. You know who has the best roads in the world? It's not the United States and it's not Germany's autobahns. You know who it is?

Mihnea: No.

Howard: It's Sydney, Australia, and I'll tell you why. They had a subway system. They had all the technology for building subways underground. Then when their streets got all congested, like in Phoenix, right now in my neighborhood, they're tearing down 100 homes to widen a freeway, 100 homes, and Sydney, Australia, since they had the technology to build subways, they just started building a whole bunch of tunnels underneath Sydney. In Sydney, you can just drop down in a tunnel, shoot clear across town and pop up on the other side. It is so cool how they've mastered tunneling. 

We are out of time. It is one hour. Thank you so much. I'm a big fan of yours. I think you're an amazing person. It's so exciting that the internet and podcasting and Dentaltown allows us to ... I feel like I just went to lunch with you, and we're 10,000 miles apart. Thank you for staying up with me tonight. I know you had a long day of surgery. It's just an honor and a privilege. Thank you so much for your time.

Mihnea: Thank you. Thank you for inviting me. Thank you for your time. Thank you for understanding in my bad English. You had a lot patience and you knew how to ask the proper questions in order to not make me look like a dentist who doesn't know English at all. Thank you.

Howard: I'll tell you, my favorite joke is, what do you call someone who speaks two languages? Bilingual. What do you call someone who only speaks one language? An American. Thank you for being bilingual so you could talk to me, since I'm not smart enough to be able to talk to you in Romanian.

Mihnea: Thank you very much.

Howard: All right. 

Mihnea: Thank you.

Howard: Thank you. Bye-bye. 

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