"Partial Extraction Therapy (PET) will become the default technique in the future." Dr Udatta Kher

Dr Udatta Kher graduated from Govt. Dental College and Hospital, Mumbai in 1991 and completed his post-graduation in Oral Surgery from the same institute in 1995. He practices in Mumbai and specializes in Implant Dentistry. He is the Director of ‘Impart Education’ an academy for training dentists in the field of Implant Dentistry and Full Mouth Rehabilitation. Dr Udatta is an Xpert on Dental XP, the largest portal in the world for Continuing Dental Education. He is also a registered ITI speaker. He is the Consultant Oral Surgeon and Implantologist to the Hon Governor of Maharashtra. He has the unique distinction of having lectured in all the continents of the world in the field of Oral Implantology. An avid traveller, trekker, and photographer, Dr Udatta knows how to maintain work-life balance. He can be contacted at www.drkher.com

1. For the esthetic areas, ITI guidelines recommend that immediate implants should be reserved only for the 'most ideal' cases to prevent the buccal tissue loss. Else, one should simply go for an 'early' placement. We know that you have been a strong proponent of 'Socket Shield.' So, nowadays, how many of your anterior implant esthetic cases, percentage-wise, go for socket shield vs immediate implants vs early implants?

The socket shield technique is the only procedure that can prevent the inevitable labial bone loss after extractions of teeth. In my practice, I perform a socket shield procedure for every tooth indicated for an extraction in the esthetic zone, provided the labial plate is intact.

In case the preoperative scan shows an absence of the labial bone, I choose the ‘Early Implant Placement’ strategy as per the ITI guidelines. I see very few indications for the conventional extraction and Dual Zone Grafting protocol in my practice.

2. What were the challenges you faced in your early days of implantology regarding implant placement and restoration in the anterior esthetic zone?

The biggest challenge I used to face, was getting an esthetic restoration from the laboratory. It was frustrating to build up peri-implant tissue, and still end up with an unaesthetic outcome because of a sub-standard restoration. Over the years the lab work in India has improved to such an extent that it matches the highest international standards.

It was also disappointing to see the results of some of the grafting procedures I performed in the initial days of my practice. Also, I didn’t pay much attention to building soft tissue around implants in the esthetic zone due to which I landed up with unsatisfactory results.

3. A lot of youngsters seek your advice. What's the most common mistake that you see in the implants restored in the esthetic zone nowadays? If there is one single important piece of advice you wish to give the youngsters regarding implants in the esthetic zone, what would that be?

If there is one key to success in the esthetic zone, it is the ‘3-D implant positioning’. Most errors in the aesthetic zone occur due to malposed implants. Hence my advice for youngsters is, irrespective of what surgical procedure is being executed, like post-extraction immediate placement, socket shield procedure, ridge-split procedure, ridge expansion of conventional placement, the ideal prosthetically-driven implant placement is sacrosanct.

4. How did your journey of Partial Extraction Therapy (PET), and more specifically, Socket Shield (SS) begin?

I was introduced to the socket shield procedure by my dear friend Dr T.V.Narayan in 2013.  It sounded absurd to me back then. I was truly inspired by the cases presented by Maurice Salama and Jorge Campos Aliaga on Dental XP and that led me to learn more about the procedure. I was astonished at the beautiful outcome of my very first case of socket shield. I waited for 1 year to see the follow-up before I performed the procedure again and I haven’t looked back! I am so convinced in my mind that the Partial Extraction Therapy/ Socket shield will become the default technique of placing implants in the future.

5. You were a part of the 1st international PET consensus #JTI2017 in Madrid? Can you share a few insights about the consensus meeting?

The first PET consensus saw a group of like-minded clinicians who were early adopters, getting together to brainstorm about the technique, indications and nuances of the socket shield procedure. Clinicians like Maurice Salama, Howard Gluckman, Micheal Pikos, Mitsias Miltiadis, Snjezana Pohl and others were a part of this unique event.

I am privileged to be a part of the PET research group which will assemble again in 2020 for the next PET consensus meeting. The objective will be to provide more specific guidelines for case selection, design of the shield, and management of complications. The interest in the field has grown exponentially and there is a need for clinicians to share their experiences.

 

6. What's your take on socket grafting? How many of your socket grafted cases need grafting again at the time of implant placement?

I do not perform socket grafting routinely in my practice. Actually, I am against the procedure because of its inconsistencies. There is no assurance of volume maintenance after socket grafting and very often there is a need for a second round of grafting during implant placement. My preference is to enter the site early at 6-8 weeks post-extraction before the collapse has set in and perform the grafting at the time of implant placement. The only 2 occasions that I have performed a socket grafting procedure in my practice is on adolescent patients for whom an implant placement had to be delayed.

7. Coming to sinus lift, the Minimally Invasive Transcrestal Sinus Augmentation technique, popularly known as MITSA, is a great technique developed by you. People feel it's a real game-changer. How did you come up with this technique? How many of your own sinus lift cases have moved from the lateral window approach to MITSA?

Something close to my heart. I chanced upon the technique when I discovered that the 3mm diameter an osteotome coincides with the diameter of the Novabone (Calcium Phosphosilicate) cartridge nozzle. The hydraulic pressure exerted by the viscous putty provided the right amount of sinus elevation through a minimally invasive crestal approach.

The original technique was developed for the osteotome, but over the years it has been used with crestal drills and Densah drills. However, I feel for a country like India, where the cost of equipment and drills is prohibitive, the original osteotome technique still has a place in many practices. It is the most economical and effective technique of doing a crestal sinus grafting.

In my practice, any case with a residual bone height of over 2.5mm is managed with the MITSA protocol. Hence the number of lateral window sinus lifts has dropped drastically.

8. Where do you see a place for cortical - basal implants?

I see a place for this treatment modality is highly resorbed jaws where conventional treatment modalities are not easily possible without extensive grafting. However, the prosthetic management of the cases is way below what we see in conventional implant dentistry. For that reason, I don’t fancy that option in my practice. However, for cases like post-cancer resections and reconstructions, this can be a good tool to improve the quality of life for patients.

9. What is your take on All-on-4 and All-on-6?

Very good options for the right indications. I routinely perform All-on-4 procedures for geriatric patients who are edentulous. In patients who are rendered edentulous at a younger age, I opt for the All-on-6 option. In very young patients, I prefer to graft and place more implants to provide a long term solution. So the decision for me based on the age of the patient. and functional needs. However, I am very selective while performing immediate loading for full arches. Many of these cases receive conventional loading protocols

10. What's your take on social media dentistry? How is it influencing the dental practitioners?

In my opinion, it is the best thing that has happened to Indian dentistry. I am a big proponent of social media as a means of sharing clinical work and ideas, with a large population across the globe. It is a great tool to inspire young clinicians to improve their knowledge and clinical work. Needless to say, it does not substitute the need for attending continuing education programs to upgrade one's skillsets. It acts as an adjunct to old and time tested methods of learning. Never before have we seen so many wonderful clinicians from India, showcasing their work on an international platform. I believe social media has a big role to play in this transition.

11. What's your take on mushrooming of academies and courses in dentistry and Implantology?

I see that as a healthy sign of progress. Every aspiring educator needs to sharpen his/her skills if he/she has to start teaching. As more clinicians choose to share their knowledge and start teaching, they need to enhance their own skills if they are to remain relevant. This has a positive impact on the number of clinicians who rise above the rest and inspire others to do excel in their craft. There will always be a few academies and courses which are below par. But the clinician is smart enough to recognise that, due to social media exposure. Such academies and courses will cease to exist very soon.

12. What are your new areas of interest that you are working upon currently?

I am currently working on techniques for simplifying Implant Prosthodontics for clinicians. That has remained a challenge for many practices. The Fast Tracking technique that we recently published in The Compendium is an example. There are a few more concepts in the pipeline.

I am also working on some protocols to amalgamate MITSA and Densah. Since the osteotome is not a very elegant tool for surgeries, clinicians have moved towards drills for improving the patient experience. I am working at further refining those protocols.

Also in the pipeline are some publications on PET. This is a golden era for Implant dentistry in India and I feel privileged to be a part of these exciting times!

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