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ePaper created 2015-11-13, 09:39:45 | version 1.38.0
2015 Pakistan Edition DENTAL TRIBUNE 7CLINICAL PRACTICE November the planned 3-D implant position we make the decision to do open or closed surgery. If possible we will do a tissue punch because it is faster and less traumatic to the tissue and the patient. Our patients love the flapless insertion of implants. There is virtually no post operative bleeding, swelling, sutures or pain compared to raising a flap. I admit that we often have to do some type of grafting but when I am able to do a flapless procedure, I will do it. (It is a fast procedure and a great internal marketing opportunity.) At this point we make a decision whether we want a customised Atlantis titanium abutment, a customized titanium/zirconia abutment or a screw- retained crown. We always use customised abutments for cemented solutions to make sure the risk of cement residuals is minimal. The customised abutments are designed with a preparation margin of 0.5mm, subgingivally facially and aproximally. On the oral surface, the margin is placed 1mm above the gingiva. This is impossible with stock abutments. Implant Direct has some implants that are delivered with a stock abutment. This abutment can be modified and scanned with an intraoral scanner and with CAD/CAM technology we can mill a customised zirconia abutment part that will be glued to the stock abutment. The gingiva will establish a strong hemidesmosome attachment to the zirconia and thereby create a better seal to the surrounding environment. Furthermore, it will allow us to produce every prosthetic part inhouse and save time. Screw-retained crowns are primarily used in the posterior and only in selected cases when we think we need easy retrievability. I admit there are many different philosophies about this subject. And I admit it is harder to remove excess cement in the posterior. We use a semi-permanent composite cement or tempbond to cement all our restorations. We want all restorations to be retrievable in case of future complications. At this point we know how the final result will look like?the abutment design and the position of the implant. We know whether or not we need grafting and if it is going to be an open or closed procedure. We know the exact type and size of implant and what surgical kit we will be using. Now we just have to order the surgical guide. In our practice we let In2Guide design and produce our guides, since it is a laboratory at KaVo that does all the work under strict quality control. We are confident in the precision and quality of the product. It takes about 7–10 days from placing the order online until we receive the guide. We do not charge our patients extra for the surgical guides since the time we save during surgery more than covers the costs of the guide. And after the placement of the implant we always have an ideal position of the implant in regards to the final prosthetic outcome. Placing a crown in harmony with the functional occlusion has improved the aesthetic results and reduced our prosthetic failure rate, including the amount of periimplantitis. It is my belief that a lot of so-called periimplantitis we see today is related to occlusal problems rather than biofilm. But that is a totally different issue. Before doing any surgery, we need to think about a provisional restoration. The function of the provisional is primarily to prevent tooth migrations and to shape the soft tissue. This can be a fixed or a removable solution; direct or indirect. Among the removable solutions, we have the partial denture, the Essix retainer, bite splints with teeth mounted as provisionals, etc. (Figs. 5a-c). Among the fixed solutions there is the Maryland bridge and the immediate loaded implant crown. The immediate crown is usually made directly but can be made in advance utilizing the In2Guide software and the CAD/CAM team at KaVo. It requires a scanned model of the opposing arch and a bite registration (the two models held together). Once again we can use a lab-scanner or the cone beam scanner to acquire these data. This way we receive a surgical guide and a screw- retained provisional implant crown to be placed immediately after surgery. It is tricky but doable and removes the problem with bis-acrylics in the wound. The whole treatment planning protocol can seem a little overwhelming. But in reality it is fast and saves a lot of chair time. The implant planning in In2Guide for a single implant takes approximately five minutes once you get accustomed to the software. In our practice, we have been working with surgical guides since 2010. They were introduced because we saw too many implants placed in a less than ideal prosthetic position. It was a problem faced with more than six different experienced surgeons. There seemed to be a paradigm among a lot of surgeons saying ‘We place the implants where the bone is’. In such cases, we do not want to do the final prosthetic work because it will always be a compromise. Every step in implant surgery has to be planned and executed exquisitely with the final prosthetic solution in mind. It is the only way to a predictable and good result for the patient. Isn’t that what it is all about? Editorial note: This article was published in cone beam – international magazine of cone beam dentistry No. 03/2015. Where periodontology has advanced his afternoon, Prof. Mark Barthold from the University of Adelaide in Australia will be presenting a paper on periodontal medicine as part of the Asia Pacific session at EuroPerio8 in London. In this editorial, written exclusively for Dental Tribune Online, he discusses some of the myriad major advances in periodontology in recent times. Over the past 20 years, there have been some exceptional advances made in periodontology. Many of these have led to changes in our thinking and our approach to periodontal therapy. In 1999, the American Academy of Periodontology devised a new classification system for periodontal diseases. From this, some 50 different types of periodontal conditions were identified that were considered worthy of individual classification. Clearly, this was an unwieldy system and in reality it was distilled down to three main types of plaque-associated periodontal diseases: gingivitis, chronic periodontitis and aggressive periodontitis. While the appropriateness of the terms “chronic” and aggressive” has been debated, they have served as a framework for both clinicians and researchers to define specific types of periodontitis with identifiable clinical parameters. They have also provided a framework for understanding management protocols and outcomes. Nonetheless, over time, it has become evident that such a classification system (chronic and aggressive) may be too simplistic because of the heterogeneity of periodontal diseases. Therefore, it may be timely to revisit such a classification system and determine whether current understanding of the epidemiology and pathology of these diseases can be used to better define them. However, it is worth noting that in the past 25 years there have been at least ten different classification systems proposed, none of which have been fully adopted. Clearly, there remain a number of important challenges in this field. Since chronic and aggressive periodontitis are heterogeneous groups of diseases, for example, there will be unique subcategories based on their multifactorial nature on the basis of microbial, host response and environmental components.At present, apart from a plaque-associated designation, the current American Academy of Periodontology classification is not based on cause- related criteria. Recognition that bacteria are necessary, but not sufficient for periodontitis to develop During the 1990s, a very important conceptual advance occurred in our understanding of dental plaque and its interaction within the subgingival environment. The recognition that subgingival plaque existed as a biofilm with its own micro-regulatory and communicative properties changed our thinking of how the subgingival microbiota interacted not only with itself, but also with the host. Notwithstanding this, research through the 1990s and 2000s began to question the role of the biofilm and its component bacterial consortia in the overall process of the development of periodontitis. While it was very clear that periodontitis cannot, and will not, develop in the absence of bacteria, it was becoming increasingly obvious that clinically there were some patients who, despite the presence of considerable plaque deposits, did not develop periodontitis. Conversely, it was also evident that there were individuals who had very minor visible deposits of plaque yet developed very advanced and destructive periodontitis. These observations led to a major paradigm shift in periodontology, in which it was agreed that, although plaque was necessary for periodontitis to develop, it was not sufficient for it to develop. Indeed, it became evident that, in addition to dental plaque, environmental and host response factors were critical for the clinical manifestation of periodontitis. With this, came a new, more informed management process for our patients that dictated that, in addition to management of oral hygiene, patients must be assessed for other factors that would lead to the development of periodontitis and these must be controlled in order for treatments to be successful. Indeed, it is now recognised that dental plaque (and its constitutive elements) accounts for only 20% of the risk of developing periodontitis and thus the other 80% of modifying and predisposing factors must be taken into account when diagnosing and treating periodontal diseases. Development of the subdiscipline of periodontal medicine The term “periodontal medicine” was first proposed by Offenbacher in 1997 as “A broad term that defines a rapidly emerging branch of periodontology focusing on new data establishing a strong relationship between periodontal health or disease and systemic health or disease”. It arose with the emerging evidence suggesting that a number of systemic conditions and periodontal diseases were interrelated. By 2000, the evidence that oral health and systemic health should not be separated had become very compelling. Indeed, the relevance of oral health to overall Continued on page 14 T By Prof. Mark Bartold, Australia