PUBLISHED IN DUBAI www.dental-tribune.me July-August 2018 | No. 4, Vol. 8 Neoss ScanPeg - Simpliﬁed intra-oral scanning SUBSCRIBE NOW https://me.dental-tribune.com/e-paper/ issn 1868-3207 Vol. 18 • Issue 4/2017 implants international magazine of oral implantology 4 2017 By Dr. Jakob Zwaan, Italy Patient 60 year old woman. Non-smoker in good general health. Clinical situation Missing lower ﬁrst molar. Part of a complex case with multiple recon- structions in both jaws. Treatment plan Placement of Aesthetic Heal- ing Abutment at time of implant placement. Digital impression us- ing the Neoss ScanPeg. CAD/CAM CoCr single crown with angulated screw hole. A 4.0 x 11 mm Neoss ProActive® Tapered implant was placed in the lower ﬁrst molar position follow- ing 3D radiological examination. A minimal ﬂap was raised to split the small amount of keratinized soft tissue. Excellent primary stability was obtained, insertion torque >50 Ncm and 76 ISQ. An Aesthetic Healing Abutment Pre-molar was placed and the soft tissue closed with single sutures (Fig. 1). Note the buccal orientation of the groove, which functions as a direction feature, to ensure proper anatomical transgingival shape. The screw channel was ﬁlled with PTFE material (Fig. 2). At time of scanning, the PTFE ma- terial was removed, the push-in ScanPeg was seated inside the Heal- ing Abutment (Figs. 3 & 4), and an intra-oral scan was taken. The as- research Titanium and its alloys in dental implantology case report Rehabilitation of edentulous patients industry Digital workﬂ ow: From planning to restoration sembly allows the digital impression of the implant position and soft tissue (Fig. 5) to be taken without un- screwing the abutment, thereby leaving the healing of ÿPage D2 Fig. 1 Fig. 2 Fig. 3 Fig. 4
D2 ◊Page D3 IMPLANT TRIBUNE Dental Tribune Middle East & Africa Edition | 4/2018 the soft tissue completely undisturbed. Final restoration with matching transgingival shape in place (Fig. 8) Since there was no need for a temporary crown for esthetic reasons, and the soft tissue was conditioned by the healing abutment, it was decided to immediately produce the de- ﬁnitive restoration. A CAD crown was designed by the labora- tory with a minor correction of axis (12°). A library of preset transgingival shapes in the CAD library that matched the shape of the healing abutment simpliﬁed the design work. A Cobalt Chromium restoration was milled (Arc Solutions, Helsingborg, Sweden). The milled abutment was mounted in the stone model and occlusion was tested before layering the framework with porcelain (Fig. 6). At time of placement of the ﬁnal restoration, the Esthetic Healing Abutment was removed, revealing a mucosa around the implant anatomically shaped by the Healing Abutment (Fig. 7). Dr. Jakob Zwaan, The Netherlands Born in 1962 in the Netherlands. Graduated in dentistry in 1987 at the University of Utrecht, NL and emigrated to Italy in the same year. Oper- ating in a private dental ofﬁce at Calusco d’Adda(BG, Italy) since 1990 as a general practitioner. First approach to periodontal and implant surgery and implant supported prosthodontics in 1993, continuously updat- ing professional knowledge and skills following lectures and attending courses. Professor and Director, Department of Orthodontics, Dental School, Uni- versity of Brescia, Brescia, Italy. Fig. 5 Fig. 6 Fig. 7 Fig. 8 When to avoid implants By DTI Located in the Salamanca district of Madrid, Spain’s capital, Clínica Vila- boa was founded more than 30 years ago by Drs Beatriz and Débora Vila- boa. With polished hardwood ﬂoors and a stylishly minimalist in terior, the practice’s aesthetic emphasis is immediately evident. A pioneer in aesthetic dentistry when ﬁrst estab- lished, the multilingual clinic has since expanded its focus to two dis- ciplines, implantology and prophy- laxis—which may at ﬁrst seem con- tradictory. prevention spoke with practice dentists Drs Amparo Llor- ente and José Manuel Reuss about the clinic’s approach to prevention in implantology. Why did you choose implantology? Dr José Manuel Reuss: I was always very interested in prosthetics and re- placing what was missing. I am very motivated by the fact of giving back what patients have lost. The com- bination of prosthetics and surgery makes implantology perfect for me. Dr Amparo Llorente: I am a trained periodontist and I am wholly dedi- cated to it. I look more at periodontal disease and prevention of implants [laughs]. However, I think I also have a good understanding of implants, so we make a good team. Reuss: You deﬁnitely have a very good understanding! What is your approach to implantology and prevention? Reuss: It is very difﬁcult to be able to tell a patient that something should last for a lifetime, but this is our goal, our wish and our belief. Plac- ing an implant should naturally be our last solution once we have done everything to save the natural tooth. When we do the treatment, we do not want to have the implant last for only ten years. That is not really as the patient’s oral care mindset cannot be changed easily. Llorente: Prophylaxis is the main way that conditions like peri-im- plantitis can be prevented. We know that implant treatment requires follow-up; implants need to be taken care of continuously, so it is very im- portant to instruct and motivate pa- tients to have regular check-ups that are complemented by a good home oral hygiene routine. As a periodontist and implan- tologist, how do you work to- gether? Reuss: In cases of severe periodon- tal disease, such as aggressive peri- odontitis, we try to delay the implant placement as far as possible. I am not talking about weeks or months, but even years. If we need ten years for a patient with periodontitis to have the necessary oral health for implant placement, then we wait. Sometimes, it depends on the pa- tient; sometimes, it is the wrong ap- proach to oral hygiene; sometimes, it is genetics. At the same time, we have seen implant failure without any clear reason. Llorente: The major risk factors in- clude bacterial contamination, a his- tory of periodontitis and habits such as smoking. This means that we need to look at the patient’s habits and anatomy and the surgical protocol. These factors are more related to early loss. Another factor is the pros- thetic design. What role does poor oral hy- giene play in terms of implant success? Reuss: When we see a patient with very poor oral hygiene, we do not place the implants. We are that radi- cal. We tell our patients that the peri- ÿPage D3 Drs Amparo Llorente and José Manuel Reuss in talks with Dental Tribune. a success. We want to provide a treat- ment that lasts for a lifetime. Llorente: The great thing about Dr Reuss is that, as an implantologist, he is devoted to restoration and replac- ing. However, whenever he sees a tooth that still has the potential to be maintained, he does everything to maintain it. That is very important. Nowadays, implantology is so fash- ionable. Everybody wants to place implants. Some dentists see the im- plants only, but we should look at oral health ﬁrst. The patient needs to have an implant for a lifetime. This involves good initial oral health and a wellplanned treatment. So, you argue that implants should be avoided as much as possible? Reuss: Well, implants are a great treatment modality and we are very thankful for this invention. How- ever, implants should be delayed as far as possible. If we can preserve the tooth for ten more years and then place the implant, that is the way forward. Patients should not have their teeth removed and replaced with implants instead. After implant treatment, patients need to be twice as careful with their mouths. There is no way to go back to another solu- tion. The dentist needs to communi- cate this as far as possible. Llorente: An implant is the best solu- tion for a missing tooth, but it is not an alternative for a tooth that can still be saved. An implant is more ex- pensive than maintaining the natu- ral tooth, so we try to preserve the tooth if we still can. Do you think that implantolo- gy and prevention of implants can work side by side? Reuss: Prevention is the best thing one can do for one’s patient in the long run. If we can get our patients to believe in prevention and therefore come to the dentist more regularly, it will be beneﬁcial for all of us. How- ever, this is a long and bumpy road,
D3 ◊Page D2 IMPLANT TRIBUNE Dental Tribune Middle East & Africa Edition | 4/2018 odontal tissue needs to be strong. In the case of poor oral hygiene, the implant will fall out eventually. We need to make sure that the patient has good oral health habits. Eden- tulous patients with a lack of good oral hygiene are not good candidates for implants. We have to do several hygiene appointments ﬁ rst before continuing with implant placement. mindset that patients only come when they are in pain. Now, we are moving in this direction of coming at least every year. From a periodon- tal perspective, I would like to see my patients every three to six months, especially during maintenance ther- apy. During the dental appointment, they already look forward to the next appointment. How can we motivate the pa- tient to use oral care products more effectively and regularly? Reuss: First of all, we have a growing awareness of oral health among our patients. That helps a lot in the gen- eral predisposition of patients. When they come to our practice, they have changed their dietary attitude and work out more. They are starting to believe more in prevention. They also come in every six months, while we only saw them every two years in the past. Llorente: In Spain, we still have this Reuss: We understand now that we have to work with patients as a team. We can no longer simply provide treatment. We have to spend extra time educating them, motivating them on how they can maintain and preserve their oral health, which is ultimately their responsibility. Do you also instruct your pa- tients on how to use tooth- brushes, interdental cleaning tools and toothpaste? Reuss: Our dental hygienists focus more on oral care instructions. Their role in prevention is crucial. They es- tablish a close relationship with the patient and make sure that every pa- tient gets the individual tools he or she needs, be it toothbrushes, inter- dental brushes or ﬂ oss. Everything in our ofﬁ ce is teamwork. Llorente: Every patient is differ- ent, no doubt, but everyone needs interdental brushes, for example. I brush interdentally every day. As dentists, we need to make sure that we reinforce oral hygiene measures every time the patient visits. With improving oral health habits comes greater satisfaction for the patient. The best thing in dentistry is that we can see the change. We can see how the bleeding stops. And the patient feels it. What do you think about CURAPROX products? Reuss: Products that are easy to use help us progress in our treat- ments quicker and provide patients with the tools to easily establish a positive home care dental regimen. CURAPROX’s products are often gentler than other products, and this meant that it went against the gen- eral trend of the market for the past few years. However, this softness is extremely beneﬁ cial, as it helps to prevent damage to tissue and teeth. What role does the implant design play for oral hygiene? Reuss: Implant prostheses are not easy to clean. The implant has a very thin cylinder compared with the anatomy of the tooth. The design of the implant needs to accommodate the structure of the overall anatomy, as well as the neighbouring teeth. In the case of missing periodontal tissue or of full-arch restorations, we need to have a different implant design. In any case, we use the design most suitable for oral hygiene measures, especially in non-aesthetic areas. 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That is not possible in the upper arch. But we want to have implant surfaces that can be polished easily. Interdental brushes and dental ﬂ oss also need to be used regularly. We work very closely with the laboratory and have clear in- structions. Tissue contact continues to be crucial. Finally, optimal prevention and oral health require an inter- disciplinary partnership. How do you work with other medi- cal doctors towards achieving overall health for your patients? Reuss: As healthcare profession- als, we see patients every day who are sent to us by heart specialists, endocrinologists, and so on. This is because there is an intrinsic relation- ship, proved by many studies, be- tween oral health and overall health. For example, we have patients who have been referred by cardiologists who have detected some form of car- diovascular disease and want their patients to be orally healthy as soon as possible. We also have diabetics referred to us by endocrinologists, often straight out of the hospital. This is because, if they have anything wrong with their mouths, an infec- tion or anything that needs to be addressed, it is essential that this is- sue is resolved so that the diabetes- related issues may also be resolved. Patients need to know about these relationships. Llorente: We always have to contact doctors if the patient has a special need. Interestingly, medical doctors send us their patients with immu- nosuppression and other conditions to get rid of the dental problems. In comparison with other medical dis- ciplines, we can quickly manage to control the inﬂ ammation and regain the microbial balance in the mouth, thereby helping the overall immune system. The dental knowledge of general medical doctors is growing, as they understand the need for a healthy mouth for general health. The interview was originally pub- lished in Prevention International Magazine for Oral Health 1/18.