Detail matters - manifesto

Detail matters

“Bone, pixels, prosthetics… and a near FBI arrest. This is not a case report — it’s a manifesto. Detail matters. “

manifesto in 4 parts

Yesterday, Easter day, I left the clinic at 6 in the evening. Christmas Eve. Very hollow and joyful at the same time, to be with lab tech Sofia, planning a case and sharing knowledge with her. She doesn’t know anything — in fact, neither do I, I think. I can only share my insights, which are a mixture of what others have taught me and my own expertise.

Some of the things that I thought I knew are wrong, and some other things that I already suspected that people had taught me differently prove that they don’t work.

Note that I was humble enough to choose my words in the last sentence. It’s not that they taught me wrong; it’s what they knew at that time. And so, with a mix of biological plausibility, they turned something with absolutely no evidence into the standard of care.

I’m in Porto right now, in a dark room on the 15th floor of Porto Palácio, after 40 minutes of circling, seated in a chair so as not to wake the kids and my wife, who are still asleep. It’s 8 in the morning, and I’m just hearing the bells of the Lapa church just behind me.

And here — who would have thought that the TLX NT would behave like that in the case of Catarina and in the case of Princess Jasmin’s father? The bone seems to like that smooth surface after all. I remember a discussion between Tarnow and Michael Norton about the polished collar from Straumann, on a cold Tuesday in the Marion marquee (moments before I was almost arrested in the subway, showing off to Elena… but that’s another story to be told). Dennis defended that bone cannot attach to smooth surfaces, and Michael would argue that it will. Then, after some years, Tarnow and Buser changed the name of the polished collar from “tissue level” to “polished / machined,” saying that it’s not quite polished. But the evidence from Hermann and Buser articles is there… it will lose bone when subcrestal.

Years later, Straumann changed pure titanium for a titanium–ceramic alloy, and a couple of years later, with the TLX line, they changed the macrogeometry on the platform and neck, leaving the tulip shape for a straight shape, allowing the clinician to place these implants subcrestally. But with any subcrestal implant, you need an emergence profile, so the components of the traditional tissue level would no longer make sense for these implants. We clinicians advised this to Straumann from the beginning, and they continued to deny that possibility until eventually science and clinical expertise won the battle, and finally the portfolio was complete.

Having said this, it’s exciting times in the way protocols, ideas, and research are changing in implant dentistry. It’s about implant biomaterial evolution, changing concepts, but also a digital disruption of the system.

Detail matters more and more at this stage. I found myself planning an FP1 with Sofia in a totally different way than in the past.

The image and photo acquisition were top. We used Smile Cloud to show the patient; the patient approved, and we picked the digital set of teeth and exported it to exocad. Then Sofia made a first removable try-in in exocad. I tried it and made the changes. We went back to exocad and changed tooth morphology and position. Another try-in, and it was perfect. We made videos and photos, placed the markers, did a CBCT, and merged everything in the coDiagnostiX program.

We planned the implants, the intermediate abutments, and the anchor pins according to the planned prosthesis — made from the try-in but already adapted to receive the implants.

It’s here where detail matters: carving the teeth outline, imagining where my flap would be, creating the pontic according to the biological width. The software lets you see bone, gum, and prosthesis in the same space, and you can design according to your needs. Sofia initially designed a classic round pontic, and we corrected it to the proper profile.

Detail matters in the merging procedures between the prosthesis and the CBCT. Take time preparing the patient with cotton rolls to displace the cheek and clearly visualize the soft tissue profile. Take time to reach a holistic prosthetic design. Take time to fit and critically evaluate the merging process in coDiagnostiX.

Draw the prosthesis as if it were the final one, but with characteristics that help the surgery. Place the anchor pins correctly to guarantee guide stability.

And then, when everything is ready, perform at your best.

My friends, this is the gateway post to talk about:

1 – the structural and biological behavior of polished / machined collar implants

2 – image acquisition and software merging

3 – FP1 provisional fabrication

4 – my almost FBI arrest in New York

Let’s eat all the bacalhau.

Merry Christmas 2025!!!