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ADI Focus Meeting 2018 - Post-Event Analysis

Dominic O’Hooley shares his experience of the ADI Focus Meeting 2019, focusing on each session presented and offering a glimpse into what the event was really like.

ADI Focus Meeting: Innovations in Dental Implantology Saturday 17 November 2018 ICC Birmingham

Introduction

Like ripples on a still pond as a stone plunges in after being thrown right to the far side, the heads of the those sitting in Hall 5 jerked in synchronicity as controversial comments came thick and fast at the most recent ADI Focus Meeting specifically covering innovations in implant dentistry. It certainly did what it said on the tin...

A truly international line-up of six speakers gave us the opportunity to hear insights at the forefront of our exciting branch of dental surgery. Delegates had the chance to ask questions both formally at two panel discussions and informally over coffee during the breaks. As one person who had a pocket full of thoughts to discuss in this second context, I was gratified at the selfless way that all the speakers obliged me. Much food for thought indeed. So, without further ado, let me provide a brief synopsis of my thoughts on all six presentations.

Ziv Mazor Ridge Atrophy Treatment Concepts Utilizing Osseodensification and Blood Derived Growth Factors

Chuckles immediately erupted in the hall at the amusing skits Ziv presented to delegates, who showed off his dancing and basketball skills as a way of warming us up for his self-proclaimed paradigm shift in dental implant surgical technique and outcomes.

He described the benefits of osseodensification using counter clockwise rotating drills with a reverse quasi-Archimedean screw principle. This serves to compact trabecular bone both radially and apically, whilst traumatic overheating can be avoided by using a cushion of irrigation fluid and appropriate rotational speeds. Ziv tied our historical osteotomy drills to those of carpenters and mechanical engineers – good at removing substrate whether that is wood or bone. I wondered if we were heading towards a sales pitch or whether I was going to see evidence-based validation...

Studies followed. Initially they focused on pig tibia in vitro studies, then animal studies with sheep and on to humans. The same messages coming through compared to traditional osteotomies: insertion torque up, a condensing layer, a slightly reduced osteotomy diameter due to the spring back effect and up to three times the percentage of initial bone to dental implant contact. Promising stuff. In humans, dental implant stability quotient (ISQ) was tested weekly and found no dip in primary dental implant stability at weeks four and five, maintaining the same primary implant stability all the way to week six. I was seeing some study-based validation and now I wanted to see clinical implications.

Ziv started with a ridge expansion case study, putting a 5.7mm diameter dental implant in an initially 4mm ridge with no buccal bone cracks and a nice chunky buccal plate. Case results were presented until five weeks post surgery. The second case considered immediate placement in mandibular molars. Osseodensification was used inter-radicularly to expand the septum without the ever-present risk of drill chatter and bye-bye septum, which we all know so well.

Increasingly complex indications followed, looking at a full maxillary arch with large pneumatised sinuses and a knife-edge ridge form. Osseodensification protocol with no buccal cracks was performed. Ziv contrasted this to our old favourite manual expanders. Further cases showing osseodensification of the poor bone of the maxillary tuberosities were demonstrated and then, a highlight for me, crestal sinus augmentation using osseodensification.

Ziv stated that the lateral window sinus lift is extinct for the vast majority of situations. Whilst I don’t agree that it has had its death knell just yet, I was impressed with the controlled combination ridge expansion/crestal lifting he was showing me. He screened a clip of a platelet-rich fibrin (PRF) membrane being lab tested to show how the Densah drills have atraumatic tips due to the cushion of irrigation, which don’t chew up the PRF. As we all know, Schneiderian membranes can be gossamer thin on occasion and so I baulked at the comparison. I wondered why the drills don’t have internal irrigation ports to further improve the apical irrigation cushion? Perhaps this is something for the future.

Ziv showed how he utilised decontaminated ground-up extracted tooth as augmentation substrate, a source of patient growth factors and green dentistry! He combined this with PRF and again, the limited results on display were impressive.

I’m by nature a sceptical person, but I am going to explore this technology and techniques in my clinical practice. No technique is a panacea, but as a paradigm shift I think osseodensification will be judged as one.

Karl Ulrich Volz Bone Growing Implants – Update on the Latest Protocols and Shapes in Ceramic Implants

This piqued my interest straight away. Not because I have the urge to start offering zirconia instead of titanium, but because I genuinely believe that pre- and post-operative testing and optimisation protocols for certain essential nutrients involved with ideal bone metabolism and healing will become future best practice within the UK dental implant community. For me, Karl's presentation was about nuggets of gold within a path containing contentious opinions, strongly held subjective positions and a very different philosophy than what I have seen here in the UK. I did not agree with all positions he held, but I still found myself in animated thought as Karl managed to take me out of my comfort zone and into a very different dental implant worldview.

His presentation began with pre-operative protocols to help patients achieve optimised physiology and to promote predictable dental implant success. He reminded me of the association between distance from the equator and the incidence of chronic diseases such as diabetes. He flagged vitamin D3 and its widespread insufficiency as a main reason for this. Many of us are aware of D3 and its role in calcium homeostasis, and I am glad his slide showed how vitamin K2 is its vital partner. D3 on its own with low K2 levels is linked to arterial and other soft tissue calcification, and it is less known that many of us have low vitamin K2 levels. I strongly believe that at the right time and levels, both are vital to put calcium in bones and keep it out of coronary arteries and heart valves. I also think that correct levels assist with dental implant integration and long-term success.

Where I found things contentious here was his vouching for colonics, detoxification and saunas for potential dental implant patients. I also found his recommended vitamin D3 dosing protocol of up to one million units a day to be highly controversial, with underplay of the possible severe toxicity of this fat-soluble vitamin in excess. I am a believer of balance in all things. Karl presented a clip of clinician Alain Simonpieri, who offers a lifetime guarantee of his dental implants for patients who present optimised tested D3 levels during the winter months of the first six years. Faith indeed in the power of D3.

Now Karl moved towards the core of his talk. Ceramic dental implants and associated surgical techniques. Controversial is an understatement here as he discussed closely placed one-piece ceramic dental implants that use soft tissue adhesion and the tulip-like flair of the restorative portion to create pseudo papillae.

He seemed to be placing with minimal buccal bone, but not worrying as the rigidity of ceramic prevents bone loss, unlike that caused – in his view – by the micro movement of ductile titanium. He explored the soft tissue stability against ceramic, and thus its uses as a bone substitute rather than traditional buccal GBR.

I know of few cases of reported titanium allergy in the literature, and I would avoid using ceramic dental implants to treat people with a poorly defined fear of metals. What I noted on the slides was that many of the dental implants had dark marks after being placed with metal drivers. Was this nano deposition of metal due to its contact with the super hard ceramic, I wonder? It muddied the metal free waters for me.

Karl moved onto case after case with two-piece ceramic dental implants. He demonstrated lovely accurate placements every time, but I was struck by the size of the dental implants. They had bulky platforms, which I feel was partly to over-engineer the abutment connection in order to avoid fracture. There were also novel dental implants with integral apical disks to push up sinus linings. I felt that the cases shown did not demonstrate advantages of this specific feature and I wondered about explantation, should it be required. Karl repeatedly mentioned tension as a cause of failure. He covered everything from the contentious view that the sinus lining within certain cross-sectional sinus morphologies places tension on dental implants and contributes to failure by expulsive force, to the widely accepted need for tension free closure to allow optimised healing. Karl's presentation was certainly innovative, very thought provoking and I am sure that aspects of it will be adopted as best practice in the future. I was left with my comfortable positions either reinforced or destabilised. The mark of a great lecture.

Anas Aloum From Planning to Execution – Novel Concepts and Techniques in Rehabilitations

Anas works with his dad and began his presentation with some touching photographs of them together in one of their three surgeries in Abu Dhabi. Seventy employees including several laboratory technicians more than hinted at the size of their operation.

This presentation asked us early on – are we really going digital? Themes of true digital workflow, comparisons of model and model free protocols, full contour compared to layering, digital wax-ups and potential aesthetic compromises, were ever present.

Anas uses a great deal of full contour zirconia and he discussed chipping issues being due to the interfaces in layered zirconia techniques. There is nothing controversial about chipping issues associated with cutting back and layering zirconia, but to say that this is the main reason for chipping was harder for me to accept. Memories of bruxist patients reminded me of the enormous patient factors that we all face.

For Anas, aligning the face with the model and the digital wax-up is vital for a true digital workflow. I was struck by the need to accept that the 2D photo of the smile from the front means that digital design on the image uses distorted pictorial representations of the teeth that must be converted accurately to 3D. Test driving the virtual wax-up using prototypes gives both you and the patient a real chance to analyse potential outcomes and in Anas’ opinion, technicians do not make teeth longer when they have a fully integrated digital model, wax-up and face to work from.

Anas's second case showed the digitised patient. The CT scan also tied into the other digital parameters to allow truely joined up planning with dental implant virtual placements linked to tooth and soft tissue positions. Obviously, accuracy of these separate digitised files must be excellent, which for me – particularly for full arch – is not something I think is consistent yet and makes me wince when I see guided full arch flapless surgery.

After showing some impressive aesthetic outcomes with the latest full contour zirconia veneers, Anas then started to discuss model versus model-less workflows, which he has been using in various forms for sixteen years. It’s not suitable for every full arch case and challenging anterior aesthetic cases still require models. Anas also felt that printed models were unreliable, costly, took ages to print and that many technicians didn’t like the feel of them to work on. These were all points I had heard from others and agreed with.

Anas still uses impressions for multiple cases of more than six units. He emphasised fit and showed another full contour veneer case where care on try-in and cementation was clear from the excellent photographs. These cases need neutral stump shades to avoid exposing the limitations of full contour zirconia.

Back onto dental implants and Anas discussed the advantages of angled screws with a ball connector dynamic abutment to allow screw-retained solutions with the dental implant optimally placed in the usual partially resorbed ridge. Whilst I accepted his point, I often feel that a palatally placed dental implant, or perhaps a coaxial connection, can offer similar opportunities. I do wish that a standard for angle screws and their drivers could be agreed upon! I have a big collection of angled drivers and when you get a case to dismantle, I worry that repeatedly trying drivers can affect the integrity of the angled screw head connection. Finally, we looked at flapless full arch procedures (wince), with Anas using stock trays and bite registration material to take open tray impressions. He went straight to delivery of the final restoration with no verification or framework try-in, which I feel are still required stages but Anas has stopped doing as everything was always correct. I didn’t like the fitting surface as it had concavities, which although highly polished, would be not easy to keep clean. This was an impressive presentation, with high skill and innovative techniques at the forefront. I think adopting the full digital workflow as demonstrated here is not for every dental implantologist. You need absolute faith in your support team, technology and audited outcomes. You need to be technology confident and for me, to ever go flapless for full arch remains contraindicated. That being said, Anas made me reflect on many aspects of my current workflows and contemplate new opportunities, which, for a self-confessed digital Luddite, spoke volumes about the quality of his presentation.

Costa Nicolopoulos Immediate Loading with Permanent Restorations within 7 Days – Fact or Myth?

Starting with a quote from our hero Per-Ingvar Brånemark, Costa emphasised how site-specific dental implants, high quality supporting studies and high primary stability support the reality that immediately loaded dental implants can be predictably successful. He then dismissed the widely reported minimum end insertion torque of 32ncm as too low for this and said that 45ncm with an ISQ of 68 was his accepted minimum to immediately load a dental implant. I got the feeling that torque values might creep up from this point during the talk, primarily because I was familiar with Costa's previous comments on this topic. I was proved right!

Images of broken dental implant drivers followed with chuckles from the hall, but then studies that seemed to refute high insertion torque leading to bone necrosis followed. I personally believe bone type, drill protocol, dental implant features and insertion protocol are more important than end torque in most cases, but I wasn’t convinced of the requirement for high torque values, particularly when dental implants are splinted immediately. As we all know, resistance to rotation on the axis of insertion is entirely different to resistance to lateral movement. To me, a wobbly dental implant is a different beast to one that perhaps didn’t quite get the insertion end torque I was looking for, but which remained laterally secure.

Costa didn’t mention a dental implant manufacturer by name during the presentation, but it was clear from the slides which company was being used. I think they are highly innovative and so I wasn’t surprised at all that this was the case in a lecture about site-specific dental implants.

Max dental implants with wide platforms of 9mm plus featured heavily in the first cases presented. A case on a rather forthright arms-dealer who wanted no sinus entry showed their use distal to the maxillary sinuses in what we know is usually soft D4 bone. This was immediately loaded with a 14-tooth bridge (again, at the patient's insistence). This was a very well executed case. Short and narrow dental implants then followed with emphasis on the external hex design of the narrow Piccolo implant to increase fatigue resistance at the coronal connection portion. I also noted how the titanium is cold worked to improve its strength, as this was obviously a worry with narrow platforms and emphasises their site-specific indications.

Following a discussion on Co-Axis dental implants with his protocol for cases avoiding the sinus (using a very narrow initial lance drill of 1.2mm with careful checking and a periodontal probe to get the initial osteotomy just right), Costa showed papers supporting the use of angled dental implants before continuing with case studies. These cases had common features – very accurate placements but extremely high insertion torques of 100ncm plus. In one case in the upper premolar region, a dental implant at 45ncm and good position was removed and replaced with a 6mm platform one to 100ncm. Controversial indeed, but the patient had a very wide bony table, so the width at least looked acceptable. I have not reconciled the need for these very high insertions torques and would love to see failure rates for total placements per year with reference to these insertion levels.

The cases shown had reviews at two, four and up to 10 years. These reviews looked great.

There was much I agreed with here:

• Using one clean abutment one time in an internally clean dental implant and avoiding repeatedly removing and replacing it. • Drilling thorough molar teeth to create accurate initial osteotomies rather than damaging thin bony septums. • Ensuring abutment seating using bone milling where required. • Using beta TCP (which works well in my hands). • Using osseodensification drills.

What I struggled with were the extremely high insertion torques and the assertion that the precise fit of modern external hex abutments precludes bacterial ingress into the gap (perhaps, but endotoxin can get in). Again, this controversial lecture was fantastic at taking me out of my comfortable working patterns and making me think again about what I do.

Rana Al-Falaki Light at the End of the Tunnel: Are Lasers the Answer to Peri-implantitis?

All of us have experienced peri-implantitis disease first hand in our practices with the associated lowering of mood! With this in mind, I was keen to hear what Rana had to say.

She opened (after a good-natured dig at removing teeth aimed at the previous presenters), by discussing the new classification of peri-implant (PI) status for 2018 and then specifically how to classify PI – mentioning Froum & Rosen 2012 as the most widely used classification – then moving on to some latest findings including some controversial ones...

Smoking and diabetes, for example, can only be regarded as inconclusive indicators of risk. Advanced Periodontitis is always a strong indicator. Less than ideal placement circumstances (when compared to the gold standard often seen in cases used for scientific papers), may also be an increased indicator of risk.

Rana then took us through treatment modalities for PI, including non-surgical and surgical options. It is clear that an “everything but the kitchen sink” approach predominates, and this led me to one issue I had with the central tenet of the lecture. More on that later. Rana now started on the core of her talk, lasers. No one type of laser can do everything and this is usually to do with the specific wavelength of light involved. This presentation really had to be literature heavy but I didn’t find it heavy going; Rana succeeded in explaining topics that are outside most of our day-to-day experience, in a way that allowed me, anyway, to grasp the salient points easily.

After a brief summary of why the current American Academy of Periodontology review of lasers for treatment of PI is limited, there followed a synopsis of the lasers she doesn’t use much. Having seen lots, particularly from across the pond about LANAP (Laser Assisted New Attachment Procedure) and LAPIP (Laser Assisted Peri-Implantitis Procedure), I was intrigued to hear that the laser involved – Nd:YAG – melts titanium, including the surface of dental implants. It seems to be growing in popularity, but this made me sceptical of it. The talk now moved to Rana's primary laser modalities – Erbium:YAG and Erbium, chromium:YSGG – and how she uses these in her daily practice. The Erbium:YAG removes the contaminated titanium oxide layer and also P. gingivalis, which she reminded us, is associated with particularly aggressive PI. She uses a radial firing tip, which, when vertical entry to the site can be achieved, allows 85% of the laser to emit radially onto the dental implant and pocket lining. She follows the internal treatment with external epithelium removal to inhibit re-epithelisation of the site, manual debridement and then the Diode laser to biostimulate healing and reduce post-operative pain. Rana showed her study of 28 dental implant cases, which demonstrated review at two and six months, with convincing evidence of bone regeneration. She mentioned she has four-year data on some cases, which continues to be positive.

A discussion of a novel new delivery tip – the dual tip – followed, and also the Erbium, chromium:YSGG laser. Again, case after case showed undoubted bone regeneration and big reductions in probing depths. My reservations, as mentioned earlier, are that manual debridement was used concurrently in all cases (as well as intermittent use of other adjuncts), and this muddied the waters for me with regard to the direct effects of the laser within this justified but “kitchen sink” approach. Additionally, I wondered how many of my patients would accept the significant recession and metal show that featured in many of these outcomes.

A fascinating lecture which left me feeling very intrigued about how these safe lasers can assist us with the scourge of peri-implant disease.

Howard Gluckman Partial Extraction Therapies

Howard’s talk may have been last on the agenda, but both the topic and his great delivery style ensured rapt attention from the hall.

He stated what is true for everyone – we look for exceptional results but we find that they are not predictable every time. The themes today were thus predictability and reproducibility. Reproducibility for us, for average oral surgeons and not just the giants of the world stage who show exceptional and inspirational cases. One of my bugbears is this exact topic: “Joe Average” leaving a conference with inspiration but unfortunately not the technical skills. Patients with suboptimal outcomes and a discouraged clinician are the result. I hoped Howard could help me see how these worries could be ameliorated, particularly regarding Socket Shield (SS).

Partial Extraction Therapies (PET) cover three specific modalities – Submerged Root Techniques (SRT), Pontic Shield (PS) and the aforementioned Socket Shield (SS). Whilst all demand high levels of technical skill, there is a gradient in my opinion with SS as the pinnacle. I have been aware of various dental implant dentists attempting this treatment option with mixed results. My concern has been that the evidence base is been slim, the fine surgical skillset has to be excellent and the devil really is in the details. Howard made it clear he wanted reproducibility for not just the top 10% of implant dentists. He also reminded us all that regarding the stability of the pink/white transition zone, low lip line patients are not get out of jail free cards, but can be just as particular!

Howard now started reminding us of the caveats necessary to allow consideration of an immediate dental implant. He stated the prevalence of a 1mm plus intact buccal plate at less than 10%. I think that there are studies to suggest a higher percentage dependent on the measurement techniques employed, but I agreed that they are in the minority. Howard discussed how he was going to show his failures and I found this refreshing. I love to see a confident clinician who appreciates that failures and sub-optimal outcomes happen to us all and are usually the best opportunity for learning. He called them his “bottom drawer cases” and showed several with respect to various historical methods to preserve buccal bone in immediates, and keep the white/pink transition stable.

Howard felt that multiple dental implant cases compound the problems and that in his experience, about seven years is when things can often start deteriorating so five-year reviews are not representative. Case after case, after case was shown with varying degrees of aesthetic failure. Dental implant shine through the gingivae, visible scarring and cases with post-operative CTs showing great buccal bone, but still collapsed appearing gingivae due to the palatally placed, fairly narrow platform dental implants. There was good bone but they still looked horizontally collapsed. Perhaps patients need to do the pink aesthetic scoring!

Howard discussed PS and RST techniques, but then concentrated on his step-by-step technique for SS.

The key points were: • A smile shaped fragment is needed to allow support of the medial and distal interdental bone. • Never use a stock abutment and an S-shaped cross-sectional root fragment profile to stop contact between the custom abutment/provisional crown and the root. • Ensure the root is at at bone level to allow bone to grow over the root. • Shield must be solid. • No periodontal disease locally must be present. • No fracture or displacement of the shield is important. • The dental implant should not touch, or at least exert no pressure on, the internal portion of the shield. • A gap is needed between crown margin and shield.

Howard showed his complications and that the most common ones could be predictably sorted. He finished the presentation with a full arch example combining all three PET techniques, which was extremely impressive. So for me, this was a technically brilliant presentation from a man who is so highly regarded in the dental implant sphere and gave me so much to think about. He did dispel some of my very great doubts about SS. I could not get away from the fact, though, that the skill level required to do this is not at the mean of dental implant surgeons, but is very much to the right on the bell curve. I think that these concepts are exciting and present novel ways to preserve bundle bone. I think that in the right hands (and this is the crux), they may provide a way to achieve the panacea of white/pink transitional stability, but I also think that as a larger number of long-term studies become available, further refinement, limitations and unexpected happenings will be reported. As implant dentists in a country with rigorous regulation, it was refreshing to see six innovative presentations. My mind was opened, much knowledge was gained, many questions burst forth and I was left intellectually stimulated and very proud of my friends at the ADI for organising this exceptional day.

Author:

Dominic has been placing and restoring dental implants for over 11 years and works peripatetically in West Yorkshire. He is particularly interested in full arch reconstructions, guided bone regeneration, soft tissue optimisation and the use of short dental implants. He finds dental implantology to be an endlessly fascinating sphere within dentistry. He is currently recovering after a serious bicycle accident and is looking forward to starting work again very soon.

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