Six years of schooling with Professor Khoury
Dr Roman d'Olive, dentist and oral surgeon with practices in Mulhouse and Neuenburg am Rhein, studied in France and gained his doctorate in 2008. Because there was no structured further training in oral surgery there, he first went to observe the renowned surgeon Jean-Pierre Gardella in Marseille, who took him along to an EAO congress in Monaco. There he saw Professor Fouad Khoury on stage and at first considered what was shown to be unattainable – he feared he would have to study all over again for it, until somebody told him that Khoury was a dentist. Through contacts, among them Pierre Keller from Strasbourg, he eventually became an assistant doctor with Professor Khoury in Olsberg – and stayed for six years. On the podcast Queens & Sons of Dentistry he recounts that in the first year, lacking a German licence to practise, he was not allowed to do anything on patients: for a whole year he stood on a stool and filmed the operations while bringing his German up to the required level.
A long learning curve to confidence
The surgical training with Khoury followed a fixed sequence. At the beginning stood the apically repositioned flap; d'Olive openly describes how he was at first 'super bad' at it and was sent back to the pig jaw to practise – an experience that makes one feel very small indeed. The next big step was the harvesting of bone blocks, a procedure in which the feeling of confidence takes a long time to set in. Implant placement itself came right at the end, because with Khoury it was above all the position of the implant that counted: the distances to neighbouring teeth and neighbouring implants, the depth, the trained eye. There was plenty of criticism – rightly so in d'Olive's view; anyone who had not worked precisely had to go back into theatre. His conclusion: only at the end of the six years did he feel genuinely confident in freehand implant placement in complex cases; with the single implant it went faster.
The turning point: when the prosthetics do not fit
The impetus to rethink came by way of the prosthetics. For complete full-arch restorations there were as yet no printing options at the time; the temporary was prepared and connected to the implant abutments in the mouth, or an impression was taken. If an implant did not stand exactly in the intended position, the connection became an enormous and complicated undertaking. D'Olive describes the sobering moment: he believed he had placed the implants perfectly – and then saw on the panoramic radiograph that the result was 'rubbish'. His thought: there must be another way, and a digital one. In France digitalisation is a step ahead in any case, because twilight sedation may not be offered in private practices there and minimally invasive work is therefore even more pressing than in Germany.
The impulse from Harvard – and the misguided purchase
The decisive push came from his brother Simon, likewise a dentist, who completed a three-year, extremely digitally oriented programme at Harvard. In constant exchange he urged that work could not continue in this way – either a camera should be acquired or the laboratory should digitalise the impressions, since a surgical guide had by now become easy to produce. For d'Olive something 'clicked' – and he made a mistake that he now recounts openly: he bought everything at once. A scanner, the first printer, a new camera and more – 'a lot of money', and above all too much at one time, because in that way it is impossible to follow how the individual systems work. He expressly advises against this approach.
First cases between success and disaster
His first navigated case with the Navident system went well: a first molar in the lower jaw, sufficient bone, no complexity – honestly, says d'Olive, he would not have needed the device for it at all. The planning was carried out directly on the screen, then a cone beam CT with a marker in the mouth, followed by the procedure. The way of working was unfamiliar: not bringing the head between camera and marker, and looking at the screen instead of into the mouth during the drilling. The second case, a complete full arch, by contrast turned into a 'disaster': the reference helmet on the patient's head slipped slightly, and with that the reference was lost – added to which was the tension of a procedure completely new to practitioner and team. D'Olive removed everything and continued to implant freehand.
The Rubicon: no way back
He describes the moment of no return on the podcast with the image of the Rubicon – the river whose crossing by Caesar was irreversible. For him this moment came with the combination of immediate implant placement, augmented bone and the requirement of high primary stability: once it was clear that, according to the literature, navigated work is just as precise as the static guide while the tactile feel for bone and tissue is retained, there was no going back. Today not a single full-arch case is operated on in his practice without navigation. The foundation nevertheless remains in place for him: being able to operate freehand is a prerequisite – if the system no longer matches reality or the computer crashes, the camera comes off and work continues freehand.