CE Course Review 01/30/10
International Periodontal Implant Symposium
“THE AGE OF SPEED”
January 28-30, 2010
I attended the 35th Annual USC Periodontal and
Implant Symposium this last weekend. I found it to be very interesting and
informative. Its objective was to evaluate the materials and protocols that
have been designed to increase the speed of therapy. While some of these
materials and protocols have been well documented, others are not supported by
scientific data. Examples of some of the protocols developed include immediate
placement of implants into extraction sites, immediate or early loading of
implants and accelerated osteogenic orthodontics, computer-guided implant
placement and microsurgery, minimally invasive surgery for implant site development and
placement to reduce healing time. We were all cautioned that our ultimate objective in predictable
therapeutic outcomes rather than the speed with which therapy is developed.
I found that my general experience and instincts were generally reinforced as
well as being introduced to new ideas
The keynote speaker Lars Sennerby reviewed the controversy
of immediate (<72hrs) vs. early (6-8 wks) vs. conventional delayed (6mos)
loading of implants after placement. His general conclusion was that
immediate loading could be successful in fully edentulous cases in selected
patients, with dense bone, using rough surface implants, where good primary
stability can be achieved, by experienced clinicians. Cross arch stabilization is very important which may
not be present in partially edentulous cases.
Dr. Maurizio Tonetti spoke about acceleration of periodontal
regeneration procedures and cautioned that speed is not necessarily an
advantage. He emphasized the importance of limiting tissue trauma and close tissue
adaptation to accelerate healing through the use of microsurgical techniques.
He introduced his Modified Minimally Invasive Surgical Technique (Mod MIST),
which was very interesting. He stated that research does not support the
concept that any material is superior to others in terms of speeding healing.
Surgical technique is the most important. I have also found that to be true in
my practice over the years, which is why I have emphasized microsurgical
techniques in my practice. The most valuable part of his presentation was his
review of the comparison of Guided Tissue Regeneration (GTR -Traditional
Procedure), Enamel Matrix Derivative (EMD - a material), and Enamel Matrix
Derivative/Minimally Invasive Surgery (EMD+MIST - a Procedure) in terms of
patient comfort and regeneration results.
PAIN TABS USED
Intensity of pain
MIST + EMD
MIST + BONE
INITIAL DEFECT DEPTH
From these studies Dr. Tonetti concluded that the regenerative
materials are not as important as the surgical technique as illustrated by
the attachment gain and decreased morbidity shown. He stated that, over the last 15 years,
treatment, surgical technique development on flap design, execution and pre-
and post-operative care (microsurgical techniques) has been the major
contributing force to treatment outcomes. That is what I have experienced since
I started exclusively using microsurgical techniques in about 1996.
Drs. Seong-Hun Kim and Kevin Murphy spoke about the concept
of Accelerated Osteogenic Orthodontics and Periodontal Accelerated Osteogenic
Orthodontics, which used the concept of surgically creating a wound on the
cortical plate and bone ostectomies around teeth and then grafting before starting
orthodontic movement, which then allows faster and more aggressive tooth
movement than traditional orthodontic therapy. Examples were shown in which the time of treatment was decreased from an
average of 2 years to 6-12 mos. In fairly advanced and complex cases with less
complications! I have placed bone grafts on pre-orthodontic patients to
improve the ridge width horizontally to decrease the chances of bony
dehiscences successfully, but have not performed the alveolar wounding
technique. This is a very promising treatment concept, which is still in its
infancy in terms of the understanding of why and how it works. I think this concept
that merits close monitoring.
Dr. Ziv Mazor and Dr Hong Chan Lee discussed various sinus
grafting techniques. Again, the consensus was that the type of grafting
materials does not matter as much as the importance of using a barrier, if a
lateral window is performed and minimally invasive surgical techniques are used
in sinus lifts. The advantage of piezosurgery techniques were stressed and
the use of PRF (platelet rich fibrin). Dr. Lee introduced the alveolar approach
for sinus grafting performed at the time of implant placement. Their conclusions were similar to my
experience in the use of minimally invasive techniques, use of piezosurgery,
and growth enhancers such as PRP and PRF.
I have also found that the alveolar approach (I refer to it as a
localized sinus lift in my surgical reports), when indicated, allows for faster
completion of implant treatment with less patient discomfort. I first performed
the alveolar approach to sinus lifts about 15 years ago and have found it to be
very successful over the years in single implant cases with adequate bone for
stability. Dr. Lee has expanded the concept using it multiple implant
Dr. Uematsu reviewed the controversy of immediate implant
placement (<3days) in extraction sockets, delayed placement (6-8 wks), and late
placement (>6mos) in the esthetic zone in particular. His conclusion after reviewing
many studies was that though immediate placement had the advantage of
decreased treatment time, the unpredictability of the healing response
exhibited experimentally in terms of gingival recession and bone support was
not worth it. The delayed protocol showed good and predictable esthetic, as
well as bone regeneration, results. Late placement (> 6 moss) resulted
in more vertical bone loss but exhibited good esthetic predictability. The
esthetic outcome is similar to delayed placement (6-8wks). His preference
overall was delayed placement after tooth extraction with guided bone
regeneration. That has been my experience and general approach so I was glad to
have that confirmation of my approach clinically.
Dr. Igarashi reviewed his experiences with full arch implant
restorations with immediate loading. He stressed the importance of cross
arch stabilization and maximizing the anterior-posterior spread of implants.
His guidelines were that the distal extension of a cantilever full arch splint
be less than 15mm, Implants should be at least 3.5 x 10 mm in favorable bone
with at least a torque value at placement of 35ncm.
Dr. Romanos reviewed the histological bone response to
immediate and early loading vs. delayed loading suggesting loading during the
early phase of bone remodeling improves bone density. He suggested placing
implants 4 mos. after augmentation and loading no earlier than 6 wks after
placement. He cautioned that this is not recommended in the esthetic zone,
however due to esthetic risks and the importance of good initial implant
stability at placement.
Dr. Lyndon Cooper reviewed the parameters required for immediate
loading of implants. He also stressed the importance of primary implant
stability, using rough surface, threaded, and tapered implants. He also stressed that a minimum of 4-5 mm
of bone is required apical to the socket and placement should be 3mm apical to
the gingival crest and 2mm lingual to the ideal zenith of the tooth. He also
cautioned not to place immediate implants if there is a buccal plate dehiscence
citing studies showing significant recession in those types of situations. He
emphasized, “If in doubt, graft and wait 6 mos. for implant placement."
Dr. Gunder reviewed the limitations of papilla regeneration
and maintenance. He emphasized the importance of bone support in long term
gingival height maintenance stating that the bone dictated gingival levels.
He feels the maximum gain of soft tissue augmentation that can be expected is
in the 3.5-4.5mm range, greater depth will eventually recede. Gingival grafting
success can’t be claimed for at least 3 years long since initial success may
begin to recede over time. He also stated that autogenous bone was not the
best graft material for GBR procedures citing studies showing to its
tendency for loss (50%) later on.
Dr. Marchak reviewed his experience with placing full arch
zirconium-porcelain fixed hybrid dentures on implants. He claims good success
with milled frameworks but his major problem has been porcelain fracture (3-5%).
He suggests bringing the zirconium close to the contact surface or even
replacing the occlusal surface in areas of high stress.
Dr. Rojao-Vizcaya reviewed a complex case of utilizing
computer modeling to plan and carry out a treatment plan. He was able to
maximize the esthetic and functional restoration in relation to implant
placement with computer modeling. He was
able to anticipate and avoid potential problems prior to implant placement. In
addition he was able to plan and construct temporary restorations prior to
implant placement. This was a very impressive treatment of a complex case which
showed the importance of the use of 3-D planning implant placement and the
use of surgical guides in implant placement. He confirmed my belief in the value of 3-D computer
modeling techniques and utilizing guided implant placement. I have been using
this technique on virtually all implant cases since about 1993.
Dr. Moy reviewed the use of BMPr-2 in bone augmentation
cases and cautioned that rushing treatments are not necessarily the best for
outcomes and our patients. There are certain basic biologic principals that
should be respected. Pushing the envelope may result in unnecessary risks and
can lead to problems. He reviewed situations where he was able to “save”
previously failed augmentation cases. In association with this there was a
“live” demonstration of a ridge augmentation of a severely atrophic mandibular
defect by Dr. Jovanovic which was very interesting.
Dr.’s Yang Chai and Songtao Shi reviewed basic biologic
research being done on stem cell research in relation to bone tooth growth and
maturation and the role different growth
factors such as BMP, TGIF, EMD, that are available to us, have in bone and
tooth dynamics. They also gave us a brief view of potential technologies that
may be available in the future.
Overall the symposium was very valuable and was a good
review of the current “state of the art” in periodontics and implant dentistry.
It confirmed many of the approaches I have been taking and I picked up some
“gems” to fine tune my treatment techniques and approaches. I also got a
glimpse promising future possibilities in treatment.
In summary, there seems to be agreement that the best approach is
not necessarily the fastest approach. Biologic principals and predictable
outcomes are more important than shorter treatment times which may be more
risky. In implant placement initial implant stability (20-35ncm) must be
established before considering anything else. Controlling stresses on implants
during the healing phase is also critical to success. Implant placement in the esthetic
zone, in particular, ideally should be done with 3-D evaluation (CT scans) and
surgical guides. The general rule of implant placement was mentioned several
times, “3mm apical to the gingival margin, 2mm lingual to the tooth zenith.”
The best results seem to be with delayed implant placement (4-6 wks),
particularly in augmented sites (4 mos.) and delayed loading (4-6 wks). In
surgery, microsurgery and minimally invasive treatment procedures were superior
to traditional procedures in terms of outcomes as well as patient morbidity.