Interview: It is all about soft-tissue management
Dr Giovanni Zucchelli is professor at the University of Bologna in Italy and president elect of the Italian Academy of Osseointegration. He specialises in the treatment of complex periodontal and peri-implant cases and in the aesthetic rehabilitation of gingival tissue around natural teeth and implants, applying the avant-garde procedures he himself devised. Zucchelli also offers courses at his private practice in Bologna and speaks regularly at major international congresses. Furthermore, he is an active researcher and regularly gives presentations internationally. He has published several books focusing on periodontal plastic surgery. Zucchelli was one of the lecturers at the MASTERMINDS2 conference, organised by OMNIPRESS, which took place in Athens in Greece on 17 and 18 May.
Dr Zucchelli, how would you describe yourself? What would you like people to know about you?
Most probably that what really made me choose this type of life was a desire to be a little different. I was small as a child, and this might have been the reason that I wanted to be different. I don’t mean better, rather I wanted more to think outside the box and try to think by myself without being too influenced by others. I am grateful to my mentors who introduced me to different topics while I was learning. They taught me how to lecture, to present and to do research. From that time, I decided not to look any more at the past and not to look so much at what had been done before, but rather to try to be innovative.
So, did this come from your mentors or was it from your own personality?
This is my personality. I am not happy to repeat things over and over; I always try to improve. In order to do better, you have to add to what you have already done to see if you can improve. The one positive thing I think I have done in my life is that I have tried to innovate, and not repeat what others have already done, rather, if possible, to improve what has been done and to add my own input. Sometimes I have succeeded and at other times I have not—that is life—but even if you succeed in improving even a small thing, I think it is good, and maybe, people appreciate that you are always trying to give them something new, something from yourself. We all have different talents and I think that is one of mine. I try to communicate what I know, what I have learnt, and the feedback I receive from dentists tells me that I have succeeded in sharing with them.
How did a career in dentistry come about for you?
My father was a nephrologist, and in my youth, I was not so keen on studying. After finishing high school, I had a discussion with him and asked him what he thought I should do. He told me that, since I did not want to study so much, I could become a dentist. For him, as a medical doctor, he thought that my becoming a dentist would allow me to make a decent living. He considered that dentistry was for people who were smart enough but not sufficiently intelligent to become medical doctors. I think that caused my conflict from the beginning. I always have had to prove something to myself. So, it is an incentive to push myself, but on the other hand, I have a tendency to never be completely satisfied. If you always want something more, once you get it, you find you need something new.
Why soft tissue? What appeals to you in periodontics that you decided to make it your specialty?
Soft tissue is what people see; they don’t see bone. I want to be appreciated and make people understand what I do. I am always afraid of things happening to what I can see rather than afflictions that are within the body. If I make a mistake treating the soft tissue, everybody can see it immediately. If one makes a mistake with bone, you only realise it later and, maybe, never. I want to succeed in working with soft tissue, because I know that patients will be really happy seeing the results immediately.
You are recognised as an opinion leader in your field and therefore have an influence on both dentists and students. What is your motivation in doing research and creating new soft-tissue plastic surgery techniques?
This is related to doing the best for our patients and being close to young people. I love to teach; I love my younger colleagues at the university; I love to see them grow and I get great satisfaction when they are called to speak at conferences all over the world. This makes me happier than being myself asked to speak at a conference. It means that I have done a good job. Sharing through teaching gives me great satisfaction. You teach and grow together with your students.
What criteria do you use to decide from which area of the palate you will harvest a connective tissue graft?
The choice depends on the advantages for the patient in terms of outcome, so you should harvest as posteriorly as possible, because the more posteriorly you go, the harder, denser the palate is and therefore the more stable the outcome is. Concurrently, the more posteriorly you harvest, the less the postoperative pain for the patient. Therefore, these are the two reasons that today I believe you should harvest as far posteriorly as possible and also very superficially.
If you have to choose what the most important thing is for both tooth and implant, the bony housing or the soft-tissue seal, which one do you believe has the greatest impact on prognosis and long-term survival?
There is no question about it. In terms of importance, especially when you are talking about aesthetics, the soft-tissue management is of vital importance for aesthetic appearance and its maintenance. If you don’t have bone you cannot place an implant. The issue is how much bone we really need and whether it is true that we are increasing the amount of bone needed too much, because we think the implant needs more bone than it actually does. Some of this missing bone, at least in the buccal area, can be compensated for with soft tissue.
Do you expect any significant advancements in implant geometry or surface in the next few years?
I think that we have a good level of advancement now; I think that research will result in even more improvements and I expect that we will be able to place very small implants in the future, so the need for bone augmentation will decrease. The smallest implant diameter we have at the moment is 3 mm. I expect that the quality of the surface will also improve to give us implants that have such a small diameter that they can also be placed in situations where the amount of available bone is not ideal.
The progress made in biomaterials has led to the manufacture of new collagen tissue grafts, mainly xenografts. What do you think about using them in the daily clinical routine and to what extent are they able to replace soft-tissue grafts now and in the future?
We are now at the beginning. We understand that finding a soft-tissue substitute is extremely important, most probably even more than finding a bone substitute, because it makes all the difference. Soft-tissue grafts are still not at the same level as bone grafts because soft tissue is much more difficult to find, and research into this only began recently. There are good prospects, but until now, there has been no material that can substitute for tissue taken from the body. There are some indications for the use of collagen matrix to increase the thickness of the tissue, but it cannot yet be considered a substitute, because a substitute means that something can be used instead of something else, and this is not the case at the moment. I hope that research will make great advancements in this area, because there is a real need.
You practice, do research, teach and write. Do you have a preference for any of these activities or do they just come together as a whole and are all necessary for you to feel complete and to progress in your specialty?
Well, you are really answering the question for me! I need everything. I need to teach and I enjoy doing it, but going back to what we discussed earlier, I need novelty; I need to challenge myself and innovate. I like to do research as well and can honestly say that all of what I do is linked. I don’t teach if I have nothing to do and, in order to have something to do, I do research, but I also do surgery, because 90 per cent of what I am is a surgeon and if you do not do surgery, it is difficult to judge how a surgical procedure should be changed, improved or modified. So, if I do not do any surgery for a few days, I feel I am losing the opportunity to improve something. I am here to share with people what I am doing.
You have authored and co-authored several books and are working on a new one. Do you decide to write a new book because of a feeling something is missing and needs to be addressed?
Indeed, my next book is almost finished. I feel a need to write when I think something is missing and my focus is really always the same topic: soft-tissue management around the implant. It tends to be considered as a procedure done only to improve an outcome that can be achieved with bone augmentation. I think it is exactly the opposite. By increasing the soft-tissue thickness and by improving the soft-tissue management, you can usually avoid bone augmentation and at the same time you are able to achieve the best aesthetic outcome. This is the subject of my book—how far we can go with soft-tissue management to reduce the need for bone augmentation. It is something which, at least in my opinion, is not as critical for aesthetic success.
Are you talking about soft-tissue management before implant placement or after placement as well?
The book is about soft-tissue management before, during or after implant placement, if the surgeon did not do it when placing the implant, and in that case, what you are able to do to improve the aesthetic appearance of an implant that has already been placed.
The first book, Mucogingival Esthetic Surgery, was an incredible success, maybe because very few dentists do mucogingival surgery. The great story, however, is that now mucogingival surgery is not only to treat recession, it is, I think, a work philosophy. You can apply it to recession problems, restorative work and implantology. I can say that my first book gave me great satisfaction because, although not linked to a company, there was a great demand for it and it indicated to me that people appreciate the need for what I am doing.
You will be the next President of the Italian Academy of Osseointegration (IAO). What is your vision and goal in accomplishing this new mission?
My goal is to make dentists who place implants appreciate and understand how soft-tissue management is critical. For many years, we focused on gaining a deeper understanding of osseointegration and bone augmentation, but most clinicians don’t understand the potential of soft-tissue management. My objective is to include soft-tissue management in implant therapy, thereby indicating the need to understand the importance of periodontics in placing implants for an optimal outcome.
I agree that at implantology congresses one still hears a lot about osseointegration but not so much about soft-tissue management.
True, only recently did we start hearing about soft-tissue management. I think it is another challenge to make implantologists consider soft tissue more. I love to speak with women in the many places around the world where implantology and periodontal therapies are carried out mainly by women. When you speak to them, you find that they are much more sensitive to soft-tissue management then men. I am not sure why, maybe because of the aesthetic aspect. I refer to aesthetics also when speaking about function. I think that, by improving the soft tissue, the patient can maintain better hygiene and, of course, will be happy with the successful aesthetic outcome.
What do you enjoy most about your job?
What do you enjoy outside of dentistry?
There is only one thing—soccer—and more than this, Bologna’s team. It is not such a good team, but it is my team and I have suffered and celebrated with this team since I was a child. I love soccer because it is a race and a continuous effort to survive. It is, I think, my only true passion. It is a troubled passion, because I always suffer, but when you win—what a feeling!
Of course, the time with my family is important as well, but I choose to avoid travelling. I just do too much of it for my work and don’t enjoy the places I go to, because I dread the travel involved in getting there. At the moment, I need to reduce all this travelling time and refocus my life a bit.
What advice would you give young periodontists?
I would advise them to study a lot, learn as much as they can and, once they have a good background, try to think for themselves. They should not continually re-evaluate what has already been done because it is easy. It is easy to publish today something that was published in the past, but to come up with an original article is very hard. If you only speak about the past, it is difficult to advance. I would like them to try to think a little more biologically. I had the good fortune to gain this type of experience when I attended the Department of Periodontology at University of Gothenburg in Sweden under the chairmanship of Prof. Jan Lindhe. The emphasis there was very biologically focused; everything was justified biologically more than scientifically. Science deals in numbers; biological concepts exist and will be the same for ever. So, you should not try to do something because someone told you to do it; you should try to understand why you are doing it, and if you don’t understand, then don’t try it.
I think that the problem is that many are afraid to question themselves and rather do something because someone else said they should.
Yes, this is the problem of young people. Of course, it is difficult, and my students are often confused when I tell them to do something in a certain way and somebody else tells them to do it in another way. This is the reason that they need the knowledge to think for themselves and evaluate the different options.