Interview: Promoting preservation and regeneration of the natural biology with the IDR technique
Dr. José Carlos Martins da Rosa has a Master of Science in Prosthodontics and a PhD in implantology, and specializes in periodontics and prosthodontics. He has developed new approaches to the treatment of compromised sockets and to the esthetic regeneration of soft and hard tissue around implants, among them the immediate dentoalveolar restoration technique. He is the owner of a pioneering dental center in Caxias do Sul, Brazil, equipped with modern facilities to work with biosafety and comfort and to achieve excellence using high technology to accomplish, for example, a fully digital treatment. Offering specially developed immersion courses, as well as study and research groups, the center is also a place for professional improvement. Dr. Martins da Rosa also offers courses at locations in South America, North America, Europe, the Middle East and Asia. He speaks regularly at major international congresses around the world, is an active researcher and has written many articles published in the international scientific literature. He has authored a book titled Immediate Dentoalveolar Restoration: Immediately Loaded Implants in Compromised Sockets (Quintessence, 2014) and has contributed to many chapters on the same topic in other books.
Dr. Rosa, what has been your path in dentistry?
I am passionate about dentistry and excellence in the outcomes for my patients. I crave new challenges and new ideas and have a need for innovation. When I was young, I used to spend my time with my older dentist brothers in their offices. I had the opportunity to learn about the functional, esthetic and psychological benefits of dentistry, and this helped me realize that my future lay there.
My family has always been supportive of my choices and encouraged me. My dream was to become a recognized person in the field of dentistry. I am very grateful to my mentors, who taught me to think differently and motivated me to study and pursue lifelong learning. The knowledge I acquired and the influences I have had over time helped set the path for my career, focusing on implantodontics, immediate implant function, esthetic periodontal plastic surgery and prostheses. At that time, I was thirsty for new things, always looking for teachers who were at the forefront. I was always seeking new perspectives. That is why I have pursued new approaches, concepts and techniques, because it gives the greatest benefits to the patients, which is to me the ultimate goal.
What appeals to you in treating compromised sockets?
In the past, when reading the international literature, I wasn’t happy with the final results obtained in treating compromised sockets. I decided to use all my clinical experience and knowledge to develop a completely different technique than what had been described in the literature.
I have been working on compromised sockets for more than 20 years, and 12 years ago, my team and I developed a simpler, more predictable, easy-to-reproduce technique, at less cost to the patient and entirely biological, to greatly facilitate treatment. We named this technique immediate dentoalveolar restoration (IDR). It gives the best esthetic results for long-lasting stability of the gingival tissue architecture and maintenance of the color, texture and volume of the soft tissue.
What is the main concept of the IDR technique in the treatment of compromised sockets?
The IDR is a surgical and prosthetic technique established to broaden indications for immediate loading on individual implants. In this way, lost tissue of varying extent is reconstructed in the same surgical session as implant placement and provisional crown installation, reducing the number of interventions and retaining predictability of the esthetic aspects. This technique uses autogenous bone graft harvested from the maxillary tuberosity. The IDR protocol was developed a little over 12 years ago because of the need to minimize the treatment time and the morbidity rate of reconstructive procedures used in these cases.
Why use autogenous bone grafts harvested from the maxillary tuberosity instead of using bone substitutes?
Soft- and hard-tissue management is of vital importance for an esthetic appearance and its maintenance. The maxillary tuberosity is an advantageous therapeutic choice because its bone tissue has great osteogenic potential and a low postoperative morbidity rate. The use of bone grafts harvested from the maxillary tuberosity may provide a superb source of autogenous bone to augment the alveolar ridges and sockets without the need for more invasive intraoral surgical harvesting procedures, in which bone tissue is obtained from the chin or the ramus.
The choice of the maxillary tuberosity as a donor site in bone reconstruction can be explained by examining the macro- and microscopic characteristics and graft incorporation principles at the receptor site. Using autogenous bone grafts for the remodeling and regeneration of new bone in the receptor bed occurs through three potential mechanisms, osteogenesis, osteoinduction and osteoconduction. That is why we chose the tuberosity as the main donor area instead of using other intraoral donor sites or bone substitutes. Bone substitutes only possess osteoconductivity. The maxillary tuberosity bone graft may effectively serve as a reliable, minimally invasive, easy-to-harvest intraoral source of osteoprogenitor cells. Adequate bone volumes can be obtained for dentoalveolar reconstruction during an immediate implant placement procedure, especially in the esthetic zone. This particular bone graft is effective as an autogenous self-scaffolding material in the repair of different bone defects. In my opinion, biomaterials cannot yet be considered bone substitutes, considering that a substitute means something that can be used instead of something else, and that is not the case at the moment. Biomaterials still need autogenous grafts, either bone or soft-tissue grafts, in order to obtain better outcomes.
Your interest in studying and developing the IDR protocol made you well known nationally and internationally. It also motivated you to do research and write about implantodontics. Because of the ease of using the technique, its low morbidity rate and its proven efficiency, IDR is considered by many as an extremely important technique in modern implantodontics. It should certainly be part of the therapeutic arsenal of any implantologist who aims at optimizing rehabilitation results, especially when working with implants placed in compromised sockets in esthetic zones. In this context and based on your experience, do you believe that the IDR technique is able to replace classical techniques such as autografts, guided bone regeneration, biomaterials or xenografts?
No surgical technique is universally indicated for all cases. My opinion is that all techniques have advantages as well as disadvantages. Whenever more than one technique is indicated for a given case, the clinician must choose the one he is skilled at performing, the technique that is feasible to him and that is affordable for the patient.
IDR is a surgical technique used to treat compromised sockets, combining bone reconstruction, immediate implant placement and immediate provisionalization. Its main advantages are the maintenance of gingival architecture, because it is a flapless procedure, the reduction in the number of interventions, because it is a single procedure, and the reduction in treatment costs, because it uses autografts.
The use of autografts harvested from the maxillary tuberosity, a structure rich in cancellous bone, improves the treatment results. With proper handling, cancellous bone has osteoconductive, osteoinductive and osteogenic properties, all of which are needed to optimize bone repair. Our team has treated more than 500 cases and has clinically, radiographically and tomographically monitored them with great results. Photomicrographic analysis and scanning electron microscopy of repaired bone allow us to deeply understand the results, not only in terms of quicker bone repair but also regarding bone stability over time. Owing to the large amount of feasible osteoprogenitor cells found in this type of bone, I would go so far as to say that it can be considered a bone transplant.
In order to achieve it, strict criteria for harvest from the donor site and handling, as well as for inserting it into the receptor site, must be accurately met. Proper training on how to employ the technique allows us to fully benefit from its essential properties. Credit must be given to mother nature. Today, based on my own and my study group’s experience, as well as on the results produced by other research groups, students, peers and friends, using the IDR technique is my first choice, provided that its indications and contraindications are respected. Several groups, linked or not to universities, have been conducting research on the IDR technique, looking to include it in their therapeutic arsenal as another treatment option available for dentists and especially for patients.
What is your opinion about the current status of biomaterials used as a therapeutic resource to treat esthetic cases? Can biomaterials be used with the methods employed in IDR cases?
There have been significant developments in biomaterials, and except for a few marketing exaggerations, it can be credited with important achievements. Whenever necessary, it can be used as a therapeutic resource, especially in intact sockets, in combination with soft-tissue grafting. However, it is not universally applicable for all cases.
In cases of loss in a buccal bone wall, it has been proven that subepithelial connective tissue grafting, when used in combination with guided bone regeneration, yields more predictable results, which minimizes potential morphological changes in the gingival tissue, but it still entails two or three surgical procedures. Thus, in cases of loss in a buccal bone wall, I prefer to use an autogenous bone graft from the maxillary tuberosity and take advantage of the properties this type of graft has to offer.
Cases with defects in two or more bone walls, for which the use of biomaterials is needed, require that we treat in different stages using guided bone regeneration and late implant placement. Should there be a donor site available, I prefer to use it and consider immediate implant function to be more advantageous. Additionally, whenever necessary, I use autografts, with or without connective tissue grafts, depending on whether or not there is gingival recession. Autogenous grafts are the key to the success of the IDR technique.
In response to your question, when biomaterials are used, I do not recommend that the concepts related to the IDR technique be used; for example, with flapless surgery, graft stabilization, a single surgical procedure and immediate implant function. From my point of view, the post-extraction area should never become an edentulous area for late implantation, as this would increase the number of surgical procedures, the cost, the treatment time and the unpredictability of the results. Hence, it is important to manage everything in a single surgical procedure, without flap elevation, which avoids a reduction in volume, as well as apical migration of the gingival margin or papillae. This is the main concept of the IDR technique.
Have you observed that implant surface treatment affects bone repair and, as a consequence, the positive results yielded by the IDR technique?
Implant surface treatment significantly affects how the implant behaves inside the bone. For this reason, this procedure plays an important role when implants are placed in areas of low bone density, as well as in grafted areas, including IDR-treated sites. From my point of view, since the IDR technique uses essentially cancellous bone, it generates a great number of cells, favoring bone incorporation and osseointegration. If the implant surface facilitates great cell proliferation and adhesion, bone matrix synthesis onset time is reduced and so is its association with the implant, which is significantly favorable for IDR. The IDR technique favors immediate implant function. For this reason, it requires an implant surface that speeds up bone repair and, as a result, increases treatment predictability. Nevertheless, similar attention must be given to the macro-geometry of the implant, which must significantly favor primary stability. Despite being a process of paramount importance for IDR repair, implant surface treatment should not be considered essential. Several other factors affect the positive results yielded by the IDR technique, namely the flapless procedure, which maintains nutrition of the periosteum in the receptor site; the macro- and microstructure of the tuberosity bone used for grafting; the implant primary stability; the controlled and low-intensity stimulus promoted by immediate placement of the provisional crown; and the anatomically shaped provisional crown, with a slightly concave emergence profile, allowing proper fitting of the periimplant tissue.
In which cases can you apply the IDR technique?
After 12 years of experience, our group has reached a consensus with regard to the two critical characteristics of cases that make the use of the IDR technique unfeasible: the absence of gingival papillae above 3 mm in height, and recession above the mucogingival line. For these types of cases, it is recommended to use slow orthodontic treatment procedures prior to applying the IDR technique. Besides these two contraindications, the IDR technique can be applied in all cases of compromised sockets, regardless of the severity of the bone loss. Furthermore, this technique can be used in cases with gingival recession of around 4–5 mm with bone loss.
In some extreme cases, with defects involving three or four alveolar bone walls, implants are stabilized as a result of the presence of residual bone in the apical region of the socket in combination with osseodensification, with satisfactory results. The main aim of using IDR is to achieve tissue stability over the years. We never recommend raising a flap, and the main goal is to insert the implant right after the extraction of the condemned tooth, in combination with bone reconstruction and immediate provisionalization, in a single procedure.
What is the current status of the first cases treated with the IDR technique? How long have they been monitored for? Are they considered stable from an esthetic point of view?
The IDR technique was first employed in October 2006. We adapted our treatment protocol developed for intact sockets and used it with compromised sockets. Although it was a case of total buccal bone loss, we performed extraction, implant placement, bone reconstruction and immediate fabrication of provisional crowns. All procedures were flapless and carried out in a single session, which partially refuted the literature at the time.
Today, after a follow-up of more than 12 years, the case has proved to be stable from an esthetic and functional point of view, similarly to other cases treated shortly after the first case. Stability of the gingival margin, papillary height and tissue volume have been constant in the cases treated with the IDR technique. Few complications were observed during the development of the technique protocol. However, after establishing a strict protocol, we are able to avoid and properly solve even these.
What criteria do you use to decide which area of the maxillary tuberosity to harvest the graft from?
It is important to locally examine the area through clinical evaluation and palpation, in addition to periapical, panoramic and CBCT imaging. CBCT is the most important exam for accurate evaluation of the amount of bone and soft tissue available in the maxillary tuberosity, the best area for the bone to be harvested, and the relationship between the maxillary tuberosity and the maxillary sinus. Pneumatization of the maxillary sinus and the presence of third molars are not considered contraindications to harvesting bone from the maxillary tuberosity. CBCT enables the surgeon to determine the exact location of available bone and guide the correct insertion position of the chisels to remove the maxillary tuberosity graft. Although limited mouth opening may make harvesting difficult, buccal or palatal access may be used to remove the lateral portion of the maxillary tuberosity. The choice depends on the advantages for the patient in terms of outcome and where we can find the best area of hard and, sometimes, soft tissue to be harvested. We usually use chisels to harvest bone from the tuberosity. We never use drills or trephines.
Is training necessary to apply the IDR technique?
Sure. The IDR technique is a sensitive procedure that requires proper knowledge and training, as well as the correct use of instruments, which must be of high quality and, in some cases, have delicate and precise active tips. That is why we created a global hands-on training course, to allow our peers around the world to apply the IDR technique. Very special IDR models were developed, in which participants can not only follow the technique step by step but also reproduce the whole sequence of the procedure. The main goal of this course is to first train people to respect the protocol and then learn the steps of this reconstruction technique, using either a cortico-cancellous graft or a triple graft (cortical, cancellous and connective tissue in a single piece) harvested from the maxillary tuberosity. In these courses, all members of my team (Drs. Ariádene Cristina Pértile de Oliveira Rosa, Marcos Alexandre Fadanelli and Luis Antonio Violin Pereira) are responsible for teaching the participants in the simplest and easiest way possible.
How do you promote the IDR technique?
Nowadays I am involved in many projects in order to spread the IDR technique worldwide. The IDR team has been traveling all around the world to give lectures and courses. I usually give three or four courses a year in my office and many courses worldwide annually. My goal is to reach as many dental professionals as possible and to teach and train them to apply, in the easiest way possible, the IDR technique in their patients’ mouths. Another way to spread the technique is through online webinars.
Are you working on other research projects at the moment?
I really like to get involved in new projects and things that nobody has done before. I am at the moment involved in several research projects at my center and in several universities in Brazil and North America, and in a multicenter study worldwide.
My interest is to develop new approaches, protocols and techniques in quite challenging situations, in order to make life easier for dentists around the world and to find the best solution for their patients. My satisfaction lies in sharing knowledge and experience with my peers. I intend to develop other projects inside and outside the field of dentistry, activities that will contribute to our growth as human beings, helping people in need or difficulty.
Can you tell me about your book?
My book has been a great success. Its aim is to help dentists better understand the IDR treatment philosophy and to inspire those who apply IDR and followers of IDR around the world. The book gave me incredible satisfaction because, although not supported by any implant company, there was a great demand for it, indicating to me that people appreciate the need for what I am doing.
What is the most satisfying part of your job?
Surgery. I am a fan of hard- and soft-tissue augmentation. I think that, by improving the soft and hard tissue, the patient can maintain better oral hygiene and will, of course, be happy with the successful esthetic outcome.