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ADI Team Congress 2019 - Day 1 Write Up

My anticipation had distilled itself into a fine single malt by the time I arrived in Edinburgh for what I consider to be the premier biennial dental event in the UK. Surrounded by close friends and colleagues, the thought of super education, vigorous debate and loads of fun, boded well for a well-balanced spirit, just the right amount of each ingredient to leave good memories but minimal hangover. I was privileged to have been asked to write up the Plenary Programme for the ADI. I arrived stocked well with paper and pens and I am so glad I did! My notes at the end filled two pads and my second pen was nearly smoking!

Thursday afternoon started with ADI President Abid Faqir conducting the opening ceremony and also moderating the world class ‘master distillers’ about to take the stage. I don’t think it could possibly have started better than with the first speaker.

Thursday Afternoon – 2nd May

Perspectives on Vertical and Horizontal Augmentation – Istvan Urban Istvan started by putting up a photo of a massive posterior mandible bony defect. “Over the years, the age of my patients has come down as the size of the defects has increased, sometimes massively.” He christened this, ‘The New Enemy,’ the ‘Extreme Vertical Defect’. Literature seemed to concentrate on 5mm or less vertical augmentation, but he stated that they are pioneering more than 5mm. Sometimes more than 10mm!

Another shocking taster of a case came up on screen. No nasal floor on the left side... We were asked to wait in anticipation until the end of the lecture to see what happened.

After this introduction, a synopsis of his clinic protocols over time showed both their evolution regarding bone grafts (initially fully autogenous, moving to 50/50 with bovine xenograft), but their consistency regarding particulates. Still favouring these and this mix to the present day. As a foundation for his present day practice, precise anatomical dissections of the posterior mandible provided the opportunity to define 3 key zones for the lingual flap and also to identify both mylohyoid border relationships and the dense protective fibrous connective tissue surrounding the lingual artery, providing reassurance of the relative safety of his proposed extensive lingual releases. His delicate blunt dissection of these layers was demonstrated via close up video.

Using titanium reinforced PTFE membranes and tight packed particulates was a precursor to his trade mark, The Sausage Technique. Pioneering resorbable collagen membranes tacked over tight packed bone with extensive but delicate lingual and buccal release to give a drum skin tight immobile vertical augmentation but with tension free closure. He showed 13-year reviews of big vertical augmentations. I was impressed but reflected on the Dunning Kruger effect and how most of us in the hall were perhaps not located quite at the same point on the horizontal axis of the bell curve as Istvan.

Istvan went on to show periosteoplasty to improve tissue quality in scarring whilst exploring shallow vestibule cases. A disaster with CTG contraction leading to the paradigm shift of always doing soft tissue reconstruction before uncovering implants, then a crestal mini sausage technique at uncovering. This led to the use of collagen matrixes and then micro strips of connective tissue to use cells to give beautiful soft tissue matching and consistency. Again, state of the art soft tissue manipulation added to the exceptional vertical and horizontal bone gain from the Sausage and Mini Sausage protocols.

And so, came the floor of the nose case! A superb panoply of all his current techniques with a fabulous result. I found this presentation very stimulating indeed. The need for high levels of surgical skill are mandatory as is a super knowledge of anatomy, combined with an experienced team to ensure meticulous diagnosis and planning. What a start to the day.

Comprehensive Therapies for Single Tooth Replacement: What is Enough? – Lyndon F Cooper

An amusing start... “Following Istvan, hair to no hair... big cases to small cases,” got the crowd chuckling, but then it got serious as Lyndon discounted biotype and recounted how his 2003/4 statement that peri-implant response to implant placement can be predictable flowed against the tide until his later 2010 study showed reviews with 80% plus stability at 7 year review.

Zenith Orientated Displacement, creation of thick architecture via implant positioning and thus negating to a degree, the rigorous biotype definition so loved by us implant dentists. By 2008, Lyndon had fully quantified the gingival zenith as the key landmark for implant 3D positioning. The 3/2 rule. 3mm apical and 2mm palatal.

Using the comprehensive aesthetic diagnosis to aid the still difficult challenge on horizontal mucosal stability. The evolution of his soft tissue grafting protocols at the time of implant placement with jump gap GBR, tunnelling CT grafting with an extensive digital workflow, delivering the one-piece crown and abutment (with pucker factor!) and case after case of entirely predictable results.

The utter importance of implant positioning, how the digital workflow can assist planning, design, manufacture and delivery, the predictability of vertical soft tissue stability but the continued challenges of horizontal stability were key messages I got from this fascinating presentation. Lots to think about indeed.

Making Contact and Staying in Touch – Mark Montana

From Hominidae to black rats, all of us share the phenomena of mesial drift. From pre-industrial revolution humans eating stone ground rough bread, grit potentiated interstitial wear and low levels of third molar impaction, to us latte-supping metrosexuals with increasing impaction generation on generation, our soft diets not wearing our contacts to the same extent, this talk was fascinating and so relevant.

Mark’s next point alluded to this era of implants next to teeth. No surprises that up to 50% see open contacts develop. Mesial drift but also distal spacing due to deflective, non-axial contacts via our predilection for the ‘implant protected occlusion’, our implant crowns not in contact during initial tooth to tooth contact as we try to protect our expensive prosthetics.

Craniofacial growth throughout life. When is the youngest age we can place our implants? Mark showed examples of vertical discrepancies developing from 21 to 69 years old. It made me reflect on the rough tools we try to use to inform our decisions.

The next section was on unintended consequences of our contact positions, adjustments, areas and shapes. Our implant prostheses influencing their natural neighbours over countless chewing cycles and contacts being lost, teeth intruding or extruding. Unsupported thick sections of porcelain moving out of contact and fracturing, food packing, caries and aesthetic loss. The need to inform our patients, identify the many cases in our practices, monitor and sometimes, actively replace our prostheses to regain that lost contact, this talk opened my eyes to a complex subject that has been historically under-reported, and which happens to us all. I could see much animated discussion in the hall as Mark left the stage.

Surgical Veneer Grafting (SVG) Protocol: An Approach for the Immediate Implants in the Aesthetic Zone – Alessandro Agnini & Andrea Agnini

I confess to some cynicism, as yet another bespoke acronym attempted to enter to lexicon of implantology, SVG. Was this just two established techniques being bundled together, the dual zone of slow resorbing/fast resorbing particulate bone grafting, tied to labial connective tissue veneer grafting? Beautiful cases, exceptional photography and real passion from both presenters attempted to persuade me otherwise. They were at least partially successful.

A masterclass in current aesthetic zone best practice followed, with case after case highlighting everything from the flapless minimally traumatic extraction to not compromise periosteal blood supply, through ideal implant placement parameters, polished, ideal contoured provisional crowns, envelope flapped CTGs and the duel zone into the jump gap. The need for thick dense connective tissue from the donor site rather than thin vascular CT, to improve long term predictability and even cases showing tissue creep with time, rather than the slow inexorable loss of tissue that seemed to be the historical norm.

This presentation was as polished as one of their meticulous provisional crowns. I am not convinced that SVG is really a ground-breaking new technique, but is really more of an insightful bringing together of disparate techniques for a net gain in outcomes. A valuable and visually stimulating showcase all the same.

Moderated Discussion – Abid Faqir; Istvan Urban; Lyndon F Cooper; Mark Montana; Alessandro Agnini; Andrea Agnini

This lively discussion focused on questions submitted from the floor via the bespoke link. The vigorous discussion was navigated expertly by the session moderator, Abid Faqir, whose own interest in digital implant case planning was very apt!

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