How AO got S.M.A.R.T. first
Editorial by Harriet K. McGraw, DDS,
Editor, Academy News
One thing that stands out in Dr. Ernesto Lee’s presentations is his meticulous attention to detail. From the beautifully photographed images, to the evidence-based content, there is a consistently high quality to every aspect of the presentation. His lectures are learning experiences showing the planning, management, and treatment of complex cases, accomplished by blending the artistry and science of dentistry.
Dr. Harriet K. McGraw
Dr. Ernesto Lee
At the 2017 AO meeting in Orlando this past March, Dr. Lee formally introduced S.M.A.R.T. (Subperiosteal Minimally Invasive Aesthetic Ridge Augmentation Technique). It is a groundbreaking procedure, which piqued a great deal of interest. Dr. Lee graciously agreed to be interviewed by Academy News on the particulars of the procedure.
HKM: Dr. Lee, what was the genesis of the S.M.A.R.T. technique:
Dr. Lee: I have dedicated most of my career to treating complex cases, and was lucky enough to develop the S.M.A.R.T. approach to solve challenging clinical issues in the esthetic zone. One of the early cases was a young man who had a hopeless central incisor adjacent to an implant-supported crown. To complicate matters further, he had a very high smile line and CBCT imaging revealed an absence of facial bone. Rather than subjecting the patient to the traditional staged grafting approach and risk ending up with soft tissue defects and missing papillae, I elected to graft the site using a laparoscopic tunneling technique. From the work of Michael Block, Camelo, Marc Nevins, Massimo Simion, and others, I knew this was a possibility. Not opening a flap was very advantageous. Healing was improved and it allowed me to preserve the gingival architecture. Treatment moved faster and patients were happy. The results from these early cases were very positive, encouraging further development of the technique and its use in other applications.
HKM: Where and by whom were the surgeries you presented performed?
Dr. Lee: I performed all the surgeries presented at AO in my private practice.
HKM: Can you give another example of situations that would benefit from the technique?
Dr. Lee: The technique is especially advantageous for horizontal augmentation of narrow of knife-edge edentulous ridges. Currently, site development techniques for those areas involve block grafting or GBR. Compare a S.M.A.R.T. bone graft, which requires no tenting screws or membranes and can be completed in 45 minutes, with minimal discomfort and reduced morbidity versus the more invasive block grafting/GBR procedures. Another application with tremendous potential is bone grafting over implants with exposed threads, resulting from loss of the buccal plate.
HKM: As far as biotype, is there a threshold where you won’t use S.M.A.R.T.?
Dr. Lee: Yes, a minimum tissue thickness of 2mm is required, and my preference is to have keratinized gingiva. If the tissue is thinner than 2mm, I will place a soft tissue graft prior to augmenting the bone using the S.M.A.R.T. approach.
HKM: Is there special instrumentation required to perform the technique?
Dr. Lee: While developing S.M.A.R.T., I found that existing instruments were inadequate and actually limited the potential of the technique. New instruments had to be developed. Over 100 prototypes were tested prior to arriving at the current designs.
HKM: At the time of the S.M.A.R.T. publication (IJPRD March, 2017), 21 patients and 60 sites had been treated. How many sites have been treated to date? Will you be publishing or presenting current data anytime soon?
Dr. Lee: To date, I have treated over 100 sites. I am waiting to get more follow-up on specific applications – horizontal and vertical augmentations and coverage of exposed implant threads – prior to publishing the data. At this point, some of the colleagues I have trained have also started compiling their cases, and we may publish some of this work collectively.
HKM: Have you encountered any complications?
Dr. Lee: So far, there have been very few. You could have graft exposure or migration, but these are usually related to technique issues.
HKM: I understand an application has been made to patent the procedure. Why patent a procedure?
Dr. Lee: S.M.A.R.T. is a technique sensitive procedure. It offers the potential to help many of our patients and change the way we do GBR. But this will only happen if it is developed in a safe and ethical manner. A patent has been applied for to ensure that the proper training protocol is followed.
HKM: Are you teaching the technique at this time?
Dr. Lee: Currently, the technique is being taught at our education center adjacent to my practice in Bryn Mawr, PA. As mentioned previously, S.M.A.R.T. is very technique sensitive. For that reason, the course is only open to clinicians with documented surgical expertise. I want the technique done with proper training to make sure patients are protected. Education is also particularly important at this early stage, because we want to develop S.M.A.R.T.’s full potential as a minimally invasive treatment alternative. In fact, instruments are not available to anyone who has not taken the course.
HKM: Do participants in the course operate on models?
Dr. Lee: Yes, and every effort has been made to simulate clinical situations as closely as possible. CT scans were taken and models created to give participants a realistic experience. We even tested models with and without periosteum. Mimicking the handling characteristics of gingival tissue posed the biggest challenge. We continue to test new silicone formulations to further refine our soft tissue models.
HKM: It is no surprise that you are being very meticulous and careful in promoting S.M.A.R.T. Can you share any final thoughts on the technique?
Dr. Lee: My clinical experience with S.M.A.R.T. has been very rewarding. It has been a game changer. In my mind, the procedure has the potential to impact the future of implant dentistry/GBR pretty much in the same way angioplasties and stents changed the field of open-heart surgery.
HKM: Thank you for sharing your thoughts with AO membership. We look forward to further updates.
In interviewing Dr. Lee, his passion for S.M.A.R.T. and its impact on implant dentistry was evident. During the course of our conversation, it became clear he was not seeking personal accolades. Instead, he showed great humility in emphasizing the procedure’s benefits for patients.
Having taken continuing education courses for decades, I’ve found that individuals on the lecture circuit are motivated by ego, money or a sincere desire to teach and share their knowledge with the profession. Dr. Lee falls into the last category. He is a credit to us all. How fortunate he considers AO a premier implant organization with which to share his expertise.