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Implants are becoming increasingly popular with low-cost offers pro- motingthisdevelopment.Thenumber of customers preferring implants to customary restorations is expanding. The variety of client demands, indi- vidualsettings,treatmentoptionsand risksrelatedtoinflammationandbone damage following implant treatment advocateevident,comprehensibleand durablesolutions. Safeguarding implant treatment commences with careful tooth re- moval, pre-implant treatment and implantplanningrespectingfourkey issues: 1.Early decision making to ensure implant bone support with limited number of implant placements. Sound tooth removal to protect bone loss by intraalveolar root dis- section. 2.Accuracy of implant diagnosis and implant placement by 3-D visuali- zation (DVT) of implant surgical access. 3.Minimal surgical involvement with short and low diameter im- plants while restricting augmen- tation to prosthetic relevant set- tings. Planning Early Decision Making Early implant decision making comprises anatomical, functional andeconomicissues: a)Anatomy:Treatedsevereperiodon- titis usually displays clinical stabil- ity with further drawbacks around implant supported bone at buccal plates or interapproximal sites by inflammation(Figs.1&2).1 b)Function:Followinguntreatedperi- odontal diseases or tooth removal, shifting of single tooth initiates due to myofunctional imbalance. By loss of front-canine equilibra- tion,agroupsideshiftemergeswith further bite reduction as result of ageandmisusage.2 c)Dues: Periodontal therapy of se- verely compromised teeth with bone loss >50% often results in a later date implant treatment that doubles dental efforts and bills. Economic issues should downreg- ulatethisstrategy. d)Oralcomfort:Stability,oralhygiene and esthetics become fostered by timely implant placement and optimizedimplantprosthetics. Clinical practice emphasizes a time-testedplanningwith(i)removal of severely compromised teeth, (ii) periodontal therapy securing the residual dentition, supplemented by (iii) microsurgical revision of deep intrabony pockets prior to implant placement to safeguard inflamma- tion (Figs. 3 & 4). Implant planning resides tentatively. A final quotation will be drawn after completion of functionalreliefand3-Ddigitalevalu- ationoftheimplantboneanatomy. Functional decompensation Fully and partially edentulous pa- tients frequently reveal a bite reduc- tionbyusage(wear)withlossoffront- canine equilibration and a resulting left and right grouped pemolar and molar side shift.3 Dysfunction and habits (pressing, grinding etc.) pro- mote further damage. In severe peri- odontitis,groupsideshiftaccelerates disease progression, impedes post therapyhealingandweakensalveloar boneassignedforlaterimplantplace- ment. Early implant planning in- cludesfollowingkeyissues: 1.Inspection of the oral cavity com- prisesevaluationofthemastication muscels (M. temporalis, M. mas- seter) and the temporomandibular joints (M. pterygoideus medialis und lateralis) with focus of tension, indurationandpainpressure. 2.Osteopathic examination of cran- iocaudal dysfunctions: initiated by body statics (inclined position), (mis-) posture, walk (activity) etc. should exclude somatic sources. If applicable supportive therapy. If applicable, manual osteopathic treatment to improve physiologic function, i.e. body alignment, sym- metry and support homeostasis that has been altered by somatic dysfunctions.4 3.Carefull reduction of prominent protrusivecontacts(front)andslid- ingbarsduringlaterotrusiononthe operatingside. 4.Placementofarelaxationappliance in the maxilla (overbite and deep biteinthemandible)forfunctional decompensation with a frontal plateau allowing a front-canine equilibration and temporary relief inmolarsbyverticalreleaseof1mm (Fig.5). The primary objective is the de- compensation of use-related dys- functions to achieve relief, vascular- ization and mineralization of the alveolar bone prior to implant place- ment. Subsequent realization of the issues 1–4 ensures dispenses of the habitualusepatternsafterfourtosix weeks wearing. Due to hygiene and stabilization,theintraoralappliances are manufactured as strew splints in adimensionof1.5mmwithextension limitedtothefirstmolars. Digital imaging 3-D Digitization means information andsafeness.ThegenerationofaDVT in early implant planning harbors threevantages: •Commitment: The expenses of 120–180 euro depending to extent, areaofanalysisandinstitutedisplay a motivational factor ensuring con- sentwiththetreatmentplan.Young patients and IT employees ask for the benefit of 3-D imaging during the first or second visit of implant planningtosafeguardandminimize surgicalimplantplacement. •Anatomy: Additional information aboutvicinitytoN.alveolaris,extent of sinus maxillaris and anatomical septa, characteristics and mineral- ization of implant bone (following tooth removal) and implant posi- tioning related to adjacent teeth (Figs. 6 & 7). However, inclined DVT readings result in measurement errorsupto1mm.5,6 •Precision: The benefit of a time- intense 3-D implant evaluation is a more precise, controlled and risk- reducedplanning,andeasessurgical implant placement. These advan- tagesshouldbeutilizedbyalldental health care providers, even with longtermclinicalexpertiseeventhose withlong-termclinicalexpertise.» A time shift link How implant planning affects periimplant diseases By Rainer Buchmann1,2,DanielTorres-Lagares2,Guillermo Machuca-Portillo2 1 University of Düsseldorf,Germany;2 University of Seville,Spain IMPLANTTRIBUNE The World’s Implantology Newspaper · Asia Pacific Edition Published in Hong Kong www.dental-tribune.asia Vol. 13, No. 10 Fig. 1: Severe periodontitis, residual inflammation and bacteremia. Poor hygienic capability, comfort and esthetics with furcation caries.—Fig. 2: Drawn-out expectation period in advanced periodontal disease at # 15,16 with horizontal alveloar bone resorption at assigned implant site.—Fig.3: Surgical access to deep intrabony periodontal pockets securing the residual dentition and safeguarding inflammation prior to implantplacementfollowingcompletionofnon-surgicalperiodontaltherapy.—Fig.4: Microsurgicalrevisionusingavascularpedicleflaptomaintaininterdentalpapillaeandaugmentrestingperiodontalpockets with autogenous bone. Usage of Osteora (antiinflammatory) or Emdogain,if applicable.—Fig. 5: Relaxation appliance in the maxilla with a frontal plateau to decompensate age and use related bite reduction prior to final implant planning.—Fig.6: Advanced horizontal alveolar bone atrophy in the mandible with small ridge,vestibular sloping plateau,proximity to n.alveolaris and small keratinized gingiva.—Fig.7: Securing implant planning (implant length,positioning,diameter and surgery) by DVT review (Cranium Bonn,Germany,2014).—Fig.8: Interimplant distances of 7 mm at front and premolar sites with 11 mm in molars to safeguard vascularization and periimplant damage,assigned from prosthodontics.Surgery:Dr G.Kochhan.—Fig.9: Inadequate implant bone support with vestibular bony defect following tooth loss duetotraumaticcrossbiterelationshipintheleftuppermaxilla.—Fig.10:Promotionofperfusionandhealingbymicro-invasiveimplantsurgerywithimplantabutmentinsertionintovascularizedblood-supplied alveolarbone.—Fig.11:Sinuselevation#26withimplantplacementpriortoperiimplantenlargement.—Fig.12:Freegingivalgraftinsitupriortosuturing.—Fig.13:Unstableperiimplantgingivawithpoorhygiene capability, persistent inflammation # 34 and chronic sensitivity.—Fig. 14: Unobtrusive healing for 8 weeks posttherapy with functional relief by enlargement and periimplant stabilization.—Fig. 15: Long-cone implantoprosthetic abutments undergo no self-cleaning frequently initiating periimplant sensitivity. 6 7 8 9 10 11 12 13 14 15 1 2 3 4 5 DTAP1015_17-18_Buchmann 14.10.15 09:14 Seite 1 678910 1112131415 12345 DTAP1015_17-18_Buchmann 14.10.1509:14 Seite 1