Howard Speaks: An Epic Implantologist by Howard Farran, DDS, MBA, publisher, Dentaltown Magazine

Howard Farran: It's beyond a pleasure and an honor. I just can't tell you how touched I am to be talking to my idol, my mentor—everybody's idol, Carl Misch. How are you doing?

Carl E. Misch: Well, I'm very happy that I get up every morning so far. It has made me appreciate this past year step by step, rather than taking it for granted.

Howard: I've got to tell you my first meeting of you. I live here in Phoenix and I flew all the way to Pittsburgh. I was in my 20s.

Carl: I remember you coming up to me saying, "You know, I've learned more in the past two days than I did in all of dental school. Every dentist should take this program."

Howard: I told everybody it was like seeing Beethoven play the piano. What blew my mind was that you'd be doing these surgeries while you were looking up at dentists, talking to them. I'd never seen so many implants placed so seamlessly, so easily.

Carl: It very much is like somebody playing the piano, in that you can't learn how to play by watching somebody play—you have to practice the piano yourself. It's the same in implant dentistry.

Howard: You started first in removable, though. That's where you cut your teeth, wouldn't you say? Prosthodontics?

Carl: In those days, people were still doing three-unit bridges, because the primary way to replace a tooth was with a three-unit bridge. Because I had an implant-restricted practice, the community would send me completely edentulous patients that traditional dentistry had trouble fulfilling. For example, a single-tooth implant for a central incisor, many patients would tell their general dentist, "I don't want a bridge," and the dentist would say, "OK, Misch, here's an implant and a lower denture." There wasn't anything in traditional dentistry that would solve the problem of a lower denture, so they'd say, "Go see Misch."

In some circles in that era, I was the crazy guy from Dearborn, Michigan, who was putting titanium in people's jaws, and who knows where this would lead in the future? Maybe I'll end up giving cancer to all these patients. There was quite a bit of discussion about the bacteria, what happens at the implant's softest—does it directly go in the blood stream? Are you putting your patients at risk? The institutions of dentistry were telling their students to stay away from implants.

But by 1985, Nobel Pharma had enough money to come in and market to the dental schools, starting with oral surgery programs, and almost overnight everybody started talking about and referring patients for dental implants.

Unfortunately, the dental school faculty had no experience or knowledge in it, so what was taught was what's perceived as easier, faster, simpler. Like any discipline, usually the things that are simpler or easier or faster don't directly correspond with the best method to do something, or what lasts the longest, or what has the fewest complications. Rarely are those on the same page.

The all-on-four concept is perfect for the environment in which implant dentistry is being taught. It can be used in selective cases, but the threshold of problems is risky. People forget that the restorations are screw-retained; an abutment screw or a prosthetic screw loosening is a common complication. Those screws are only 1½ millimeters in diameter and have just seven threads. If one breaks or gets loose—which occurs more than 28 percent of the time—now it's all on two. All-on-two blows out one or two of the implants.

You've got this $10,000 treatment—some people are charging as much as $20,000—all based on a metal component 1.5mm in diameter and seven threads touching metal. It doesn't make sense to balance a treatment plan so perfectly that if one thing happens, the whole case breaks down. Faster, easier, cheaper usually is not the best thing to do. It's better to have some backup so if you have a complication, it doesn't automatically lead to a catastrophic failure.

A couple of years ago I opened an implant-complication practice in Chicago. I was never so busy in all my life! All of these problems started flooding the gates, many because a local treatment center had begun offering all-on-four. They give the impression that it can be a lifetime device, but when it doesn't last a lifetime the practitioner is forced to do it again for free—and they don't know how to treat it again. The second time is worse than the first. There's usually less bone. There's more of a complication associated with it.

For more "Epic Implantology," turn to page 76.

Learn more from Carl Misch online, through CE
Dr. Carl Misch shares his implant expertise in three online CE courses now available on Dentaltown.com. In them, you'll learn about the rationale for implants to replace single teeth or for completely edentulous patients, as well as the most common causes for implant success (or failure). Go to dentaltown.com/misch-on-implants.

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