Dental Tribune Indian Edition

18 Dental Tribune Indian Edition - September 2013Implantology Dr Georg Bach Rathausgasse 36 79098 Freiburg/Breisgau Germany Tel.: +49 761 22592 doc.bach@t-online.de Contact Info appeared to be in the lead, the healing times of some implant manufacturers were inflated. Values were corrected downwards almost on a daily basis. Some manufacturers went along with it, while others remained firm. Some participants felt they needed to be at the forefront, others stayed out of it. A short but remarkable ascent was followed by a rapid crash. A personal highlight for me was an article in a tabloid newspaper that said, “Extraction in the morning; directly followed by augmentation and implantation; a firmly seated supra-construction implemented at lunch time, and then endless servings of spare ribs”! As can be seen from this euphoric statement, some got carried away, while others had to painfully back-track. What remains is the realisation that, owing to improved surfaces and other conditions, the long healing times recommended in the early phase of implantology can in fact be reduced considerably, but not at any cost. _New options for improving the implant site The afore-mentioned dominance of prosthetic implantology was only possible because many new and safer augmentation procedures were established during the observation period, enabling dentists to design the osseous bed for the implant as desired. Revolutionary augmentation procedures in the area of the maxillary posterior teeth, which had been the focus of discussion in the first year of the period in question, constituted another important approach for real progress. Thanks to surgical techniques for sinus lifts, which underwent an incredible number of modifications also with regard to less invasive procedures, it was possible to treat areas of the jaw that had previously been considered impossible or that could only be restored for implantation by way of highly invasive orthodontic procedures. While initial sinus-lift procedures were generally reserved for highly specialised centres, they have now become common knowledge in implantology and are offered and performed extensively. _Establishing virtual im- plantology It seems easy to figure out what the old-school fraction must have thought about the new planning and placement options for oral implants. This fraction had already had a hard time accepting the development from surgical to prosthetic implantology, and they were strictly against the new digital procedures that were emerging incredibly quickly. With the rapid spread of dental volume tomography, which opened a new dimension to dental image diagnostics, a multitude of planning programs and aids were placed on the market. The suggestion by some opinion leaders to define validity and establish standards with regard to these new techniques, which are generally based on 3-D X-ray data, was especially frowned upon. I feel that a good compromise has been reached, owing to anticipatory and serious discussions held during consensus conferences and congresses, as well as at universities and within the dental associations. Thesenewtechniquesareimmensely helpful in the treatment of complex cases, and they are even indispensable for highly complex cases. The treatment of simple cases usually does not require the use of these techniques. In fact, they should not be used in such cases owing to the radiation exposure when obtaining 3-D data. _Of promises and realities Themes of the congresses during the first decade of the observation period contained generally positive statements and depicted new opportunities in implantology, which exceeded the then current options by far and express- ed a belief in boundless growth. This coincided with many positive statements and evaluations by implant ma nu facturers and distributors. However, all this changed considerably during the past five years. Suddenly, new topics were given priority, which shaped specialists’ conventions—topics that had previou- sly been partially suppressed if not negated. I remember only too well the implant congress held by a very important American implant manufacturer in Frankfurt/Main in 1998, where I reported on a concept for the treatment of peri-implantitis developed at the University of Freiburg and was then rebuked by the main speaker, who was from the USA, during the ensuing panel discussion. He asserted that he had “not seen one case of peri-implantitis in twenty years of implantology—this phenomenon does not exist and, if it occurs, it can only be attributed to a lack in skill on the part of the implantologists.” How times have changed. However, trouble-shooting and complications in implantology and even the word “failure” have been mentioned in the themes of many congresses held by leading professional associations of implantology in the past years. _Patients’ expectations While a consistently positive and at times even euphoric tone prevailed regarding the topic of implants for many years, a few critical voices and later increasing criticism emerged at the beginning of the observation period. This was—concurrent with a noticeable increase in the number of implants—based on the considerable increase in implantology failures and complications. The following images depict total implantological failure— the loss of a purely implantsupported complete maxillary restoration caused by an infaust peri-implantitis (Figs. 15– 17), leaving profound osseous defects. However, in line with the consistently positive evaluation of implants and the persisting promise that the use of implants would yield optimum results always—and often publicised by the lay press—our patients’ expectations have increased considerably in the past 15 years. Patients assumed that, regardless of the individual situation, he or she would always receive the optimum results. In this regard, it seems reasonable to maintain a self-critical attitude and to concede that we did not always contradict this general assumption vehemently enough. And then what was bound to happen, happened: at times, the result was not what the patient had expected. An awkward situation arises when the dentist, based on the initial diagnosis, considers the result to be successful and the patient considers it a failure. A long-time legal expert sums up this situation accurately by stating that, “Two-thirds of all pending court proceedings were filed by patients whose expectations were disappointed.” Rather unfortunately, the increasing number of court proceedings are mostly related to implantology. It cannot be by chance that the premiums for mandatory professional liability insurance have increased considerably. _Emerging criticism German periodontists Dr Thomas Kocher referred to implantology as “the red light district of dentistry”. Whether this evaluation is justified is a matter to be decided individually. Personally, I do not agree with this evaluation, but a grain of truth might be found in its reference to overtreatment. In this regard, the extraction of teeth in favour of implants, even when not indicated, is a concern voiced increasingly by periodontists and those in favour of conservative treatment. We have to address this issue by individual evaluation of each patient, as well as through academic discussion. Implant versus tooth preservation has been a frequent debate at conventions and implant symposia in recent years. In my opinion, this would not have been possible ten years ago. _Trouble-shooting concepts Unexpected complications, such as implant fracture and failure of implant supra-structure connections (Figs. 18–21), necessitated the development of surgical and prosthetic trouble- shooting concepts and modification of constructions in implant and abutment design. However, these were not readily available and have not yet been finally agreed upon. In other words, they cannot be said to be common knowledge in implantology, at least not in the treatment of peri- implantitis. Similar statements can be made with regard to pre-implantology arguments, where a pleasing variety of surgical techniques and materials is listed, but no generally valid scheme has been agreed upon. The fact that the need to develop and convey these trouble-shooting concepts is generally recognised today and that these concepts are yet widely supported by the participants on the implant market is gratifying. The specialist press has made a valuable contribution here and continues to do so—numerous articles that received a great deal of attention during the past 15 years are those that dealt with implantology and implant-prosthetic trouble-shooting. _Digital implantology I consider the establishment of 3-D diagnostic imaging, with all associated possibilities, to be the significant development during the 15-year obser- vation period. It is true that only implantologists used the new 3-D technology during the initial phase of dental volume tomography (because they made up the group of dentists who could actually afford this expensive equipment); nevertheless, 3-D techno- logy constituted a quantum leap for dental diagnostic imaging as a whole. Today, we have almost unbelievable possibilities at our disposal that even the greatest optimists would not have considered possible 15 years ago: highly complex patient cases can now receive minimally invasive treatment and have implants placed even without the need for augmentation. Our first case shows a highly atrophied mandible, in which four implants could be placed without any prior augmentation owing to 3-D data and planning (Figs. 22–24). Three- dimensional diagnostics are sometimes also employed to clarify facts when complications have arisen, for example neural lesions after implantation (Figs. 25 & 26) and bone necrosis after administration of bisphosphonates, and erroneously diagnosed as peri- implantitis (Fig. 27). _My personal conclusions It is difficult to draw a conclusion regarding the development of implantology over the past 15 years because it has been so multifaceted and rapid. To conclude, I would therefore like to quote my academic teacher and former supervisor, Prof. Wilfried Schilli, who, as a founding member of the International Team for Implantology, was undoubtedly among the pioneers of implantology and has contributed to improving implantology through his university work: “Who would have thought that implantology could develop like it did in less than twenty years.” This very true statement encom- passes many aspects: the admiration and appreciation of what has been achieved, the satisfaction with having initiated a procedure that is considered to be the safest in the entire field of medicine, and some criticism regarding any development in oral implantology that did not turn so well or went off course.DT