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ADI Team Congress 2019 - Day 2 Afternoon Write Up

Friday Afternoon – 3rd May

Primary Stability: What Do We Know and What is ‘Truly’ Important for Success? – Barry P Levin

Stability, whether implant, prosthetic or biological tissues. All three needed for success… So started Barry’s critique of our current tenets of received wisdom. Did we need high initial torque values at placement? How closely are our common measurement parameters linked? Can low initial values still lead to predictable successes?

After dismantling the direct link between Initial Torque Value (ITV) and ISQ with cases showing low values for both at placement, but patience and a judgement call leading to some stress but eventual success, he discounted the need for high initial torque when placing the implant with evidence that excessive high torque values set us up for bone loss. Multinucleated giant cells leading to more crestal bone loss at 1-2 years than lower torques at placement.

The ‘Dermal Apron Technique’ was demonstrated, using connective tissue draping in low torque value immediate placements as a valid alternative to traditional CTG techniques. I hadn’t seen this demonstrated before. Very intriguing.

A novel implant design with a narrower coronal portion above a wider tapered body was now shown. Clinical trials are ongoing of this concept, the ‘Facial Palatal Bone Chamber’ created by the narrow coronal region combined with co-axis angulation and the Dermal Apron. This new implant design really intrigued me and combined together these concepts appear to provide exceptional early clinical results. Avoiding the trauma of excessive coronal pressure on the bone is surely a vital area of continued study and innovation.

New Perspectives on Osseointegration – John E Davies

Per-Ingvar Brånemark’s seminal work on vascular biology provided a moving historical but also incredibly prescient counterpoint to John’s fascinating presentation on this central tenet of our implant lives - osseointegration.

One of the latest purported definitions of osseointegration describes it as a defence reaction, the body using bone to wall off a foreign body. John categorically dismissed this viewpoint. A restoration of homeostasis being far more elegant and logical in his opinion.

From 1991 where Buser described rough implant surfaces having higher bone to implant contact, to 2015 when secondary stability was computer modelled for the first time, we now know how both micro and nano-textured surfaces get to the same end point of stability, but nano does so quicker. What we didn’t know was details of the first growth phase of bone. Tiny initial increases in implant stability during the first 60 minutes after placement due to blood clotting was followed by detailed pictorial illustration of mouse model experiments using a glass cranial window to directly view a star shaped skull implant and see how surface alterations affect both distance and contact osseointegration. Fluorescent dye via the living mouse tail vein clearly showed enhanced ordered angiogenesis with the nano surface. By day 7, Brånemark’s open capillary theory being proved correct as blood leaking was clearly shown.

A final dismantling of the foreign body reaction hypothesis of osseointegration via clarification of the reparative and not inflammatory nature of the multinucleate giant cells seen, provided a fitting ending to this cutting-edge presentation on a topic at the very core of what we do.

Selecting Treatment Strategies in the Era of Evidence Based Medicine – Markus B Hürzeler

Without doubt one of the most anticipated presentations of the congress, this certainly lived up to expectations. Markus said he wanted to simplify implant therapy… for the patient, not us!

A questioning of concepts that we hold dear came quick and fast. Platform Switching, does it maintain bone better or not? How do we probe platform switched implants properly anyway?

Do we need a roughened implant surface in the coronal portion? Should we use angulated abutments? A resounding no to the latter two. The control of plaque retention factors being compromised both when we get bone loss after subcrestal placement or around our angled connections meaning that the ‘All on 4’ concept was not acceptable to Markus.

His views can be encapsulated by using biologically rather than prosthetically driven implant treatment providing true modern implant therapy. The ‘All in 2’ concept of treatment meaning two visits for reduced morbidity and cost, with improved function, aesthetics and stability. Rather than extracting posterior multirooted teeth prior to immediate placement, drilling through the roots to provide a guide, thus allowing septal placement and much increased bone to implant contact. Upper and lower teeth, combining with crestal sinus lifting, case after case showing ideal control and position.

Using the scan body at placement to create the customised individual abutment, avoiding socket sealing due to scar formation and the same with labial incisions in the aesthetic zone. Not relying on the Pink Aesthetic Score which he views as crude but looking at imaging to give a true sequential 3D analysis of the tissues.

Markus repeatedly warned us about thinking we are good. These thoughts lead to complacency and I certainly realised the journey I need to continue on after this inspiring presentation. Beautiful cases, questioning everything, care about the tiniest details. A lesson in excellence for us all.

Moderated Discussion – Moderator Joseph Kan; Barry P Levin; John E Davies; Markus B Hürzeler

Some interesting questions to the panel by both the audience via the bespoke link, and also from Joseph Kan. A great end to Friday’s Plenary programme, with the excitement and spectacle of the Congress Dinner, held at the beautiful National Museum of Scotland, to follow!

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