Implant Tribune Italian Edition

20 Congresso Nazionale SICOI • Milano RELATORI Congresso Nazionale SICOI Dr. Khoury Fouad Efoss consensus conference on teeth versus implants: decision making criteria for correct treatment planning “Teeth vs. implants – single tooth replacement, regeneration or restoration?” What do you think is the main advantage of using a dental implant to replace a missing tooth as opposed to any other option? Dental implants are a replacement for missing teeth, not a tooth substitute, and they are not always better than teeth! The decision of whether to keep a tooth or remove it and place an implant can be too easy to make without due consideration - teeth are often removed when they could be retained. Likewise, continuing complicated and expensive restorative procedures may not have a good long-term predictability and so may be less favourable from a health eco- nomics point of view. Patients come to us looking for a solution – they want a tooth to fill the gap and are amenable to different solutions when we take the time to explain the options with their relative merits and costs. This is our responsibility. I think the main advantage of using an implant is when it is the option that involves least “dentistry” for other teeth; the only thing that can be guaranteed about any dentistry is that at some time, it will fail. Although studies show similar survival rates over 10 years for three-unit bridges or single tooth implants, after this a well-placed implant may outperform the bridge, which may fail due to caries or fracture of abutment teeth, or periodontal disease. This often then results in the loss of another tooth. Of course, implants can also fail due to periodontal disease, and so preoperative stabilization and ongoing maintenance care are essential. Indeed this can also enable us to keep a tooth, provided any required restorative work also has a good long-term prognosis. So, we have to look at all the factors involved in creating a stable long term result at both the tooth level and the individual patient level, and decide which option has the best chance of living up to our expectations and most importantly, those of the patient. So what do you think is the main problem with single tooth implant replacement? It is very technically demanding and very unforgiving of any error, however slight. If you don’t like a tooth-supported crown or bridge, it is possible to remove it and refine the result to some degree. If an implant is in the wrong place, even by 0,5 mm (which is a 10% error in a 5 mm gap), it can have a permanently adverse effect on the result and on the adjacent teeth. You normally cannot just unscrew a badly placed implant and put another one in – there is often a need for reconstruction of hard and/or soft tissue and the time and cost involved in correcting a problem is always more distressing and expensive for the patient than getting it right in the first place. We see a lot of commercial pressures for dentists to become involved with implant placement. Appropriate collaboration between the industry and academia can certainly provide excellent educational programmes to train clinicians, but I do not see this as being possible within short courses. Ten years ago I used to see two or three revision surgery cases every year; now I see three or four a week. There are some simple key factors that help generate (but cannot guarantee!) successful outcomes and I intend to cover this in my presentation. Gaetano Calesini “Stato dell’arte in protesi tradizionale e implanto supportata” Cosa è cambiato nel campo protesico grazie alle nuove tecnologie e ai nuovi materiali? Mai come in questo momento il team odontoiatrico ha avuto a disposi- zione materiali così raffinati e affidabili e informazioni scientifiche di così grande rilevanza. I materiali e le tecniche che usiamo giornalmente hanno raggiunto livelli di precisione e affidabilità tali che al confronto la precisione dell’operatore, per quanto raffinato esso sia, appare assolutamente approssimativa. Tuttavia la vastissima mole d’informazioni validate scientificamente prodotta dalle industrie e dai ricercatori indipendenti spesso non viene utilizzata adegua- tamente da medici e odontotecnici. Qual è il ruolo della evidence based dentistry nell’attività giorna- liera della pratica clinica? Negli anni recenti il tentativo di validazione dell’efficacia terapeutica, for- nita dell’evidence based dentistry ha prodotto, nell’attività clinica, un cam- biamento nella formulazione dei piani di trattamento e, paradossalmente, il trasferimento della responsabilità del risultato dall’operatore alla “evidenza” esistente in letteratura. Tuttavia, anche se è ragionevole essere orientati verso l’oggettivazione e la standardizzazione degli obiettivi terapeutici (forse fra qualche tempo le diagnosi e le terapie saranno rispettivamente formulate ed eseguite da com- puter e robot) è altrettanto ragionevole prendere atto che attualmente i pro- tocolli operativi e la scelta dei materiali in odontoiatria protesica rimangono in grandissima parte legati a un approccio empirico-pragmatico personale ereditato da chi professionalmente ci ha preceduto. In altre parole, nonostante lo sviluppo merceologico e cognitivo attua- le, anche nelle “linee guida protesiche” ufficiali che dovrebbero orientare i professionisti sono riconoscibili protocolli operativi tortuosi messi a punto decine di anni orsono per compensare i limiti e le deficienze di materiali inadeguati e ormai caduti in disuso. Tali procedure influenzano ancora oggi, negativamente, sia la qualità sia la quantità delle terapie erogate. Il nostro lavoro è influenzato, nel bene e nel male, da variabili inerenti i materiali e le tecniche utilizzate ma è soprattutto l’esperienza, la competen- za e il talento dell’operatore a fare la differenza poiché, sia materiali che le tecniche sono scelte dagli operatori e quindi tutti i problemi che odontotec- nici e clinici affrontano giornalmente sono a essi correlabili. Infine, quale consiglio pratico darebbe ai giovani colleghi? Parafrasando il titolo del congresso Sicoi “criteri decisionali per un atteg- giamento terapeutico di successo” il consiglio è semplificare e standardiz- zare le procedure operative cliniche e di laboratorio e, soprattutto, ricordarsi che non esistono materiali, tecnologie o evidenze scientifiche che ci sollevi- no dalle responsabilità derivanti dalle nostre scelte, dalle nostre azioni e/o dalle nostre omissioni. Egon Euwe “Come ottenere l’eccellenza estetica nei casi complessi” What are key elements to obtain an optimal esthetic result with an implant supported single tooth restoration? First of all we have to divide the single tooth replacement cases into different categories; I work with the following classification: - Immediate post extraction - Post extraction with early placement (5-7 weeks) - Healed sites continua >> Jose Luis Calvo Guirado Gap treatment n immediate post-extraction implants The purpose of my lecture is to answer the following questions: - Do immediate implants have a significant effect on soft tissue recession outcomes? - Does the gap treatment minimize crestal bone loss? - Does the biomaterial play an important role in crestal bone preservation? Nowadays advances in clinical techniques and biomaterials have facilitated a great expansion in the indications for dental implant treatment options. Teeth replacement using dental implants has proven to be a successful and predict- able treatment procedure; different placement and loading protocols have evolved from the first protocols in order to achieve quicker and easier surgical treatment times. Over time, clinical experience has provided the criteria for imme- diate implant treatment success: atraumatic tooth extraction, sterilization and minimal invasive surgical approach, as well as implant primary stability. Reductions in the number of surgical interventions, a shorter treatment time, an ideal three dimensional implant posi- tioning, the presumptive preservation of alveolar bone at the side of the tooth extraction and soft tissue aesthetics have been claimed as the potential advantages of this treatment approach. The survival rates of post- extraction implants are high and comparable to those of implants placed in healing sites, like many authors. On the other hand, the morphology of the side, the presence of periapical pathology, the absence of keratinized tissue, thin tissue biotype and lack of complete soft tissue closure over the extraction socket have been reported to adversely affect in immediately placed implants. The first classification described the timing of implant placement as mature, recent, delayed or immediate depending on soft tissue healing and predictability of Guided Bone Regeneration (GBR) procedures, however further classifications based on hard and soft tissue healing and treatment time approach were subsequently described by many authors. Several reviews reported that the immediate implant treatment using autogenous bone grafts or xenografts may improve the process of bone formation between the implant and the surrounding socket walls as well as survival rates. They observed that several studies have suggested that small gaps between implants and extraction sockets would fill with bone grafting procedures or without them. The efficacy of GBR therapy employing autogenous and non-autogenous particulate materials combined with vari- ous membranes to regenerate alveolar bone at the time of tooth extraction has also been demonstrated. Concomitant placement of regenerative materials has been shown to result in predictable, high levels of osseointegration with the use of porcine bone. With regard to the gap between the socket wall and the implant, it was reported that if the jumping distance is over 2 mm, grafting is recom mended. Smaller distances could heal spontaneously.