Dental Tribune Indian Edition

17Dental Tribune Indian Edition - September 2013 Implantology Author_Dr Georg Bach, Germany _Introduction It all started with an inquiry from a well-known professional journal of implantology asking for a contribution to acknowledge their having been in business for 15 years. Then there was the incidental telephone call by an academic teacher who had accompanied and supported me in my first steps in implantology. When I asked him about the upcoming publication project, I received a both spontaneousandsurprisingreply,“The last 15 years—those were the most important years in implantology”! This from a renowned university professor who was instrumental in establishing implantology—I was impressed. Later on I had to ask myself, “Is this really true?” The result of my tracing this development is this article—a personal retrospective. _Phases of implantology If one considers oral implantology with regard to its major developments, three phases are evident: (i) the empirical and experimental phase; (ii) the arrival of implantology in universities and science; (iii) the mass phenomenon of implantology. I would like to add that this is a rough and probably superficial division to some extent. Please, however, allow me to apply it within the scope of this personal—and not exhaustive—review. Looking back at these past fifteen years, I will barely touch on phase II, but will discuss phase III fully. This entails different directions and priority areas that colleagues working in implantology experienced. When I browsed through implantology text- books and journals from this period, I realised even more that implantology had undergone considerable change in this relatively short period of 15 years. I would like to recount my highlights of implantology from this period in the following paragraphs. _Farewell to the tristesse of papers A seemingly minor issue to start with: the variety and quality of dentistry- specific print media and of digital media, particularly print layout, has developed substantially during the past 15 years. This holds true not only for implantology, but also for dentistry as a whole. The appearance of some professional journals up until the mid-1990s was reminiscent of an official legal amendment, but amazing things have happened since. The quality of colour printing (which is the norm now, but used to be subject to a surcharge for authors who wanted to include colour images), the accuracy of images, the paper—all of these make for a high quality appearance and leave a lasting impression on the reader. This has clearly been an advantage also for implantology because now highly complex correlations can be more easily conveyed and “sometimes a picture is worth a thousand words”. Ideally, e-learning and electronic professional journals supplement the current training needs of the younger generation of dentists especially. _The end of dogmas While implantology was marked by many dogmas from its beginning and the mid-1990s, this had changed at the time when our 15-year observation period begins. However, implantology was later called into question in its entirety. Whether it was healing times, waiting times after augmentation or prosthetic concepts—everything underwent scru ti ny. On the one hand, some of these dogmas did in fact prove to be no longer sustainable because of remarkable developments, especially improvements in implant surfaces. On the other hand, the mark was at times overshot in the elimination of other dogmas, creating the need to back- track. This was a painful experience for both patients and implantologists. One dogma that we encountered in the observation period was that of a strict refusal of immediate implant placement. There is general consensus today, however, that under suitable conditions an immediate implant placement can be a high quality and sustainable alternative to established procedures. One clinical case shows an immediate implant placement in the maxillary anterior teeth: the extraction and the immediate implant placement of a maxillary anterior tooth that was not worth preserving under the guidance of a drilling template and implant position (Fig. 1), transfer into the oral cavity (Fig. 2), and the condition immediately after insertion of the implant crown (Fig. 3). _The prospering of the implant market A welcome variety of new implants, implant forms and prosthetic options has become a reality in the past 15 years. Special implants were developed for special indications so that now even a mandibular molar can be replaced by a corresponding sized implant, followed by insertion of a corresponding sized implant crown. Figures 4 to 7 show the clinical and dental appearance of these in a patient. Implantologists who placed several hundred implants annually were considered the big players on the implant market in the 1990s. Achieving the mark of 100,000 implants placed per year in Germany signified that the peak had been reached. This was not the case, since the one-million mark was also reached within the scope of a rapid, almost unimpeded development. While the increase has been slower in recent years and global economic developments even caused a brief decline, today we can assume that the implant market will continue to grow. The maximum growth phase falls into our observed period. _Development in the eyes of implant manufacturers From manufacturer to global player— this would be an accurate description of the development of some implant manufacturers. The development of some of these companies over the past 15 years, the size of their companies and the number of their employees today are indeed impressive. And these prosperous companies share other characteristics as well: the acquisition of products and entire firms in order to expand or supplement their product port -folio and their pressing on to the field of digital dentistry (CAD/CAM, planning, etc.), into which these global players invest large sums of money. Revenues must be generated so that these investments can be made—and they are still made, albeit declining owing to the economic crisis. Still, the implant market is booming. Although the consistently two-digit annual growth rates some implant manufacturers had started to become used to have become more moderate today, a great deal of money can be made with implants. As a result, an ever-increasing number of implant suppliers and systems make it impossible for the individual user to keep track. Aside from new systems, an increasing number of generics are being launched on the market. _Focus on red-white aesthetics The President of the German Society for Dental Implantology (Deutsche Gesellschaft für Zahn ärzt liche Implan- tologie), Prof. Frank Palm, aptly remarked, “What was celebrated as a triumph for some colleagues 20 years ago is today taken to court.” Dentists who practised implantology were not prepared to find themselves confronted with a debate that had spread from North America to Europe: that of red–white aesthetics. This new focus on achieving the highest possible aesthetics for implant-prosthetic treat- ments was linked to implantology and distanced itself from surgery, which had been dominant up until that time. In the early phase of implantology, the main focus was on safe placement and the best possible placement in the bone, sometimes even at the expense of subsequent prosthesis treatment owing to unfavourable placement of the artificial abutment teeth. Now, however, prosthetic standards and issues have become the centre of the discussion. Placement techniques were modified and new techniques were established in order to satisfy these requirements. Patients no longer, or only occasionally, accept demanding and complex cases like the following case. Both implants in the anterior maxillary region were placed too far buccally, and there was a gap of 5.5 mm between the implant shoulder and the cemento-enamel junction of the adjacent teeth (Figs. 8–10). Treatment with a long-term temporary restoration would only have yielded an unsatisfactory aesthetic result. However, under certain surgical and dental conditions—as shown in our second example—superior results and stability for a period of ten years can be achieved even with challenging initial situations. In 1999, an immediate implant was placed in region 12. The following images show the steps of treatment (Figs. 11–13). The last image shows the condition after ten years (Fig. 14). This development was made possible mainly by massive improve- ments in the area of augmentations, which can now be performed with significantlyhigherpredictability.This development was further enhanced by a considerable improvement in the training of implantologists. These improvements are significant for both undergraduate study and postgraduate training. Thus, the universities and professional associations who have contributed immensely in this area deserve much credit in this respect. _The battle of healing times It was but an episode, yet one that caused an incredible furor at the time: the debate about shortened healing times. Stimulated by a media hype in which the specialised press only played second fiddle and the lay press The most important years in implantology A very personal retrospect