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ADI Team Congress 2019 - Day 2 Morning Write Up

Friday Morning - 3rd May

The Evolution of Ceramics in Aesthetic Implant Dentistry – Markus B Blatz

Most material innovation in dentistry is industry based. I knew this but Markus provided a timely reminder that we have to use evidence-based techniques to act as de-facto fact checkers and combine the best scientific evidence, our clinical practice and what our patients prefer, to sort the wheat from the chaff. The role of digital allowing the latest milled PMMA provisional crowns to discussion of the 30-year journey from gold alloy implant abutments to full contour zirconia followed. Not a metal, not white steel, but a ceramic with very limited plastic deformation, high brittleness and a need for accurate design to give a minimum thickness for excellent longevity.

The present day, monolithic full contour chairside restorations bonded to titanium inserts and now, even non bonded inserts too, the screw providing the compression on the join. Markus then amazed us with discussion on Catalytic Antimicrobial Robots, magnetic iron nano-particles to remove bacterial biofilm. The importance of correct polishing of zirconia abutments to allow true epithelial attachment, medium grit, not fine or coarse. A true Goldilocks situation!

This presentation highlighted Markus’s acknowledgment of marginal gains. Everything counting towards enhanced soft tissue adherence in this age of younger patients with so much longer outcomes ahead of them. I was impressed. Deep knowledge combined with a true care for his and all our patients.

Peri-implantitis – Diagnosis, Prevalence, Risk Factors and Treatment – Tord Berglundh

This generic problem that faces us all. The 2017 World Workshop of Classification of Periodontal and Peri-implant Disease and subsequent 2018 consensus report providing the first time Peri-Implant diseases reached the World Workshop level of discussion and thus, a superb background for Tord’s talk.

Bone loss is not normal, an early point from the subsequent definition of peri-implant health (PIH), peri-implant mucositis (PIM) and peri-implantitis (PI). Implants with pre-existing bone loss having peri-implant health now, bleeding on probing but no bone loss as the most conspicuous clinical features of PIM. The plaque associated soft tissue disease PI, possibly progressing subtly and much sooner after implant placement than we used to think. Tord enhanced our understanding of the key differences between PI and periodontitis, the former being larger, non-encapsulated with biofilm in direct implant contact, with fairly specific differences in immune cell infiltration. He reiterated the key risk factors whilst emphatically stating the need for us to probe our implants. Probing implants – still contentious today but there was no doubt regarding Tord’s logical summation of the need to do this.

There is no generic implant, and all can be affected by PI. We should probe and take standardised radiographs both at baseline and review whilst remembering that according to the Gothenburg studies, 45% of implants have evidence of PI if we use the 0.5mm bone loss caveat. Our periodontal patients are at higher risk of PI. PI is common and we must step up to meet this challenge. A sobering presentation that left us all in no doubt about the challenges in our midst.

Three-Dimensional Engineering in Dentofacial Rehabilitation – Wael Att

“A modern disease – being afraid of missing out”. Wael started by reminding us of this age of smartphone addiction but also the ability to use digital technologies to create the virtual patient. Data fusion of two CBCTs, not just the patient but an imaging appliance, combined with static face scanning and intraoral scans to allow bespoke surgical guides, the implants driven by the fully realised virtual definitive prosthesis. Wael was clear that the state of the art was not accurate enough to justify blind full arch implant placement. I was pleased to hear his repudiation of flapless full arch. A personal bugbear of mine, the reliance on less than perfect accuracy means that my skin crawls when I see people presenting this.

A brief discussion of intra-oral scanners followed, the latest multi-functional third generation systems allowing both caries detection and time-lined patient monitoring of such variables as soft tissue horizontal dimension – one of the recurring themes of this congress and so relevant. What a tool for us to be able to take accurate serial images and really evaluate our own success (or otherwise) regarding our horizontal grafting protocols.

After further discussion of the relative issues with edentulous jaw intra-oral scanning, the relative accuracy of intra-oral scanned impressions with appropriate scan bodies and other techniques such as photogrammetry, Wael moved to virtual registration, the individual virtual articulation and the natural head position. Hilarious videos of chickens demonstrating this followed to much laughing from the audience.

A lovely case followed showing monolithic zirconia with the vital continued input of a master ceramist. The need for skilled artisans ameliorating my fear that a future digital consensus will negate these experts to the loss of us all. The presentation finished by touching on Artificial Intelligence (AI), big data and machine learning for the next generation of intra-oral scanners. My mind went back to a recent New Scientist article on machine learning, and how neural networks don’t see the big picture and can thus be confused by little discrepancies. Wael made me think and made me wonder about where we are truly going.

New Interdisciplinary Perspectives with All Ceramic Restorations – Anabell Bologna

This lecture was a technical tour de force. The degree of analysis displayed on the first case – a single tooth case with a width discrepancy showed mastery of diagnosis, planning, technical solutions and execution. The use of a partial no prep veneer (what Anabell termed a fragment), on the distal adjacent tooth showed consummate technical skill to create the illusion of cross arch symmetry where non really existed.

I could imagine dental technicians lapping this up, but for a room full of implant dentists, this was a little outside our comfortable frames of reference. It would be easy to discount its direct relevance to us, and I accept that the focus of the lecture was towards the margins of our own priorities when thinking of our daily practice. That being said, it is good to be reminded of just how detailed a top technician has to be to achieve the gold standard in the aesthetic zone. The second case showed the importance of the aesthetic and functional analysis for this 14-year old patient, too young for implants. Again, fragments were used combined with digital design, wax milling and lithium disilicate pressed prosthetics.

Final cases showcased occlusal table-top restorations and vertical preparations. Very in vogue at the moment. I was left feeling in awe of the quality of the team work on display but that I needed a fix of dental implants to get me back into my comfort zone.

Moderated Discussion – Franck Renouard; Markus B Blatz; Tord Berglundh; Wael Att; Anabell Bologna

A pithy collection of audience questions formed the cornerstone of this interesting exchange of viewpoints. Franck Renouard provided the sounding board, in his role as session moderator. Questions of probing around implants were prevalent! The discussion was continued on the ADI Members’ Only Facebook group and will likely continue beyond that.

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