TO BELIEVE OR NOT BELIEVE

I was watching a T.V. show on CNN where several political pundits were discussing, in an adversarial manner, United States policies relative to domestic and foreign affairs. They discussed the merits and/or demerits of the colour of money, conservation and environmental concerns, economic strategies, health care and the folly of U.S. increasing self-imposed international hegemony.

Each of these experts had their own solution to each problem and as I watched and listened I was intrigued by how much I was impressed by each argument despite the fact that each “solution” was diametrically opposed to the other.

I then thought of the recent Dental Implant Conference I attended where several pre-eminent implant clinicians were giving their respective points of view on various topics. Their “revelations” were perturbing to me because very often one person’s theory was in complete disagreement with the other and each argued with devout enthusiasm.

Varying opinions can be intellectually stimulating and can bring interest and excitement to the dullest of subjects. This is acceptable in philosophical discussions or interpretation of political, social and economic issues. But controversy should not be part of patient care. Science-based evidence and controlled treatment outcome studies should be what drives our treatment strategies. As dental practitioners treating trusting patients we should not be listening to experts debating with diverse points of view regarding:
- The best implant surface
-The best bone substitute material
- Immediate, early or delayed implant loading
- Wider is better than longer
- Longer is better than wider
- Cement your prosthesis
- Screw-retain your prosthesis
- Pre-implantitis exists and is more prevalent in unattached mucosa
- Implants placed in unattached mucosa is not a problem
- You can successfully treat osteoporotics
- You cannot successfully treat osteoporotics
- You must have patients on antibiotics
-Antibiotics are not necessary
- Brett Hull has a harder shot than Al McGiness


Why are we still grappling with these questions? Where are our evidence-based treatment protocols? In an ideal world we should only make decisions based on well-structured and well-documented evidence worthy of publication in respected, referred journals. In the real world it appears as if that is not happening as yet---at least insofar as clinical implant treatment is concerned.

Jack G. Zosky, D.D.S.,F.R.C.D.(C),F.I.C.D.
Editor

“The Relative Impact of Local and Endogenous Patient-related Factors on Implant Failure up to the Abutment Stage,” by D.van Steenberghe, R. Jacobs, M. Desnyder, et al. Clin Oral Implant Res, 13:617-622, 2002

This prospective study examined the factors that may influence early implant loss. The study group included 399 consecutive patients with a total of 1263 Branemark implants (Nobel Biocare, Goteborg, Sweden) placed over a period of 3 years in the same clinic. Various parameters involving intraoral factors (such as bone quality and quantity, the reason for tooth loss, implant location in the mouth and prior radiotherapy); systemic factors (disease states such as diabetes, hypertension, Crohn’s disease, etc); and smoking history were evaluated and compared statistically to implant failures. A total of 27 implants failed prior to abutment placement. Several factors were correlated to these failures. Prior traumatic tooth loss (vs caries, periodontal disease, etc) was significantly related to implant loss. Diseases such as cardiovascular, osteoporosis, and controlled diabetes were not associated with failures, whereas chemotherapy and prior radiotherapy of the oral tissues was. Those patients who had a breach of sterility during implant placement (because of claustrophobia) also had a significant correlation with failure. Heavy smokers (greater than 10 cigarettes per day) suffered increased failures. Local factors such as poor bone quality and quantity and arch location (maxillary posterior) were also related to failures. These results suggest that early implant loss can be related to several local and systemic factors.



BONE GRAFTING

“Maxillary Sinus Augmentation With Deproteinated Bovine Bone and Platelet Rich Plasma With Simultaneous Insertion of Endosseous Implants,” by A. Rodriguez, G. Anastassov, H. Lee, et al. J. Oral Maxillofac Surg, 61:157-163, 2003

This clinical study evaluated the efficacy of a combination of Bio-Oss (Osteohealth, Shirley, NY) and platelet-rich plasma (PRP) in sinus grafts. Fifteen patients who required sinus grafts in order to place dental implants in the posterior maxilla were included in the study (24 sinuses with less than 5mm of residual bone). The sinus lifts were performed using the traditional lateral wall approach. Implants were placed into the sinus after repositioning the schneiderian membrane but prior to the placement of the graft. PRP was prepared with the use of the Smart Prep (Harvest Technologies) and was mixed with the Bio-Oss prior to placement into the sinus. The access window was sprayed with residual PRP, and no membrane was placed prior to closure. The implants were uncovered after 4 months’ healing and later loaded. Follow-up was between 6 and 36 months. A biopsy was obtained in 1 patient at uncovery and graft density was compared with native bone using computed tomography (CT) and SIMPlant software (Columbia Scientific, Columbia, MD) in 3 patients. The results indicated that of the 70 implants placed, 5 were lost in 4 patients after loading (92.9% success). The biopsy demonstrated bone formation in close approximation to the Bio-Oss. The CT scan evaluation demonstrated that the graft was similar or greater than the surrounding bone. These results suggest that a PRP/Bio-Oss combination may be applicable to sinus grafts. The lack of controls limits the validity of these results.





DORTBUDAK O, HAAS R, BERNHART T, MAILATH-POKORNY G. Inlay autograft of Intra-membranous bone for lateral alveolar ridge augmentation: A new surgical technique. J Oral Rehabil 2002;20(9):835-841

This study describes a new surgical technique for harvesting intra-membranous bone from the mandibular symphyseal region and using it as an inlay graft. The surgical technique of turning a complex-shaped defect into a defect of defined size by contour preparation and insertion of an appropriate inlay graft was used in 31 patients. At 4 months, 15 patients (48%) showed negligible graft resorption. Of 0.33 mm. At 5 to 8 months the resorption rate in the remaining 16 patients was around 1.22mm. All in all, a significant positive correlation was found between bone resorption and time (r=0.57;P <.001). All patients received an implant after the fixation screw was removed. A conservative interpretation of the results suggests that, on account of the flush fit and the early revascularization of the graft, implants may and should, in fact, be inserted earlier in order to prevent graft resorption. (DORTBUDAK/STANFORD)

Reprints: Dr. O. Dortbudak, University of Vienna, Dental School, Department of Oral Surgery, Wahringer Str 25A, A-1090 Vienna, Austria. E-mail: orhun.doertbudak@univie.ac.at



MORAIS JA, HEYDECKE G, PAWLIUK J, LUND JP, FEINE JS. The effects of mandibular two-implant overdentures on nutrition in elderly edentulous individuals. J Dent Res 2003;82(1)53-58.

It is unclear whether mandibular implant overdentures improve the nutritional state of edentulous patients better than conventional dentures. In a randomized clinical trial, we tested for post-treatment differences in nutritional status between patients with mandibular 2-implant retained overdentures and those with conventional complete dentures. Edentulous subjects (ages 65 to 75 years) received 2-implant mandibular overdentures (IOD, n=30) or conventional dentures (CD, n=30). Measures of nutritional state were gathered before and 6 months after treatment. Significant improvements in anthropometric parameters were detected in the IOD but no in the CD group, for percent body fat (P=.011) and skin-fold thickness at the biceps, subscapularis, and abdomen (P<.05), with significant decreases in waist circumference (P<.0001)and waist-hip ratio (P=.001). Significant increases were seen in concentrations of serum albumin (P=.015), hemoglobin (P=.01), and B12 (P=.01). NO significant between-group differences were found. These results suggest that low-cost IOD treatment may improve the nutritional state of edentulous people. (MORAIS/STANFORD)

Reprints: Nutrition and Food Science Centre, Royal Victoria Hospital, Faculty of Medicine, McGill University, Montreal, Quebec, Canada











NOCITI FH JR, CESAR NETO JB, CARVALHO MD, SALLUM EA, SALLUM AW. Intermittent cigarette smoke inhalation may affect bone volume around titanium implants in rats. J Periodontol 2002; 73:982-987.

Background: A negative influence of smoking on implant outcomes has been reported. This animal study investigated the influence of cigarette smoke on osseointegration and newly formed bone within implant threads. Methods: Male Wistar rats were included in the study. After anesthesia, the tibiae surface was exposed and a screw-shaped titanium implant (4.0mm in length; 2.2mm in diameter) was placed bilaterally. The animals were randomly assigned to group 1, control, or group 2, intermittent cigarette smoke inhalation. The animals were sacrificed after 60 days and undecalcified sections obtained. The degree of bone-to-implant contact (BIC) and the bone area (BA) within the implant threads were measured in the cortical (zone A) and cancellous bone (zone B) areas. Results: A slight difference in the BIC was noted between the groups, but this was not statistically significant either in zone A or in zone B (Mann-Whitney test, P>.05). In contrast, the BA close to the implant significantly decreased in both zones for group 2 (84.73%± 4.77 versus 79.85% ± 6.17, zone A in groups 1 and 2, respectively, and 32.01% ± 6.62 versus 20.71% ± 8.57, zone B in groups 1 and 2, respectively, P < .05). Conclusion: Within the limits of the present study, intermittent cigarette smoke inhalation may result in poor bone quality around titanium implants inserted in rats. (NOCITI/COCHRAN)

Reprints: Dr. Francisco H. Nociti, Jr, Av Limeira 901, Caixa Postal 052, CEP 13414-903, Piracicaba, SP, Brazil. Fax: 55 19 3412 5218. E-mail: nociti@fop.unicamp.br



BUSER D, INGIMARSSON S, DULA K, LUSSI A, HIRT HP, BELSER UC. Long-term stability of osseointegrated implants in augmented bone: A 5-year prospective study in partially edentulous patients. Int J Periodontics Restorative Dent 2002;22:109-117.

This prospective clinical study evaluated the 5-year survival and success rates of 66 titanium implants placed in bone that has been previously augmented with autografts and nonresorbable barrier membranes. During the observation period, 3 patients with 5 implants dropped out of the study. None of the remaining 61 implants were lost during the follow-up period (implant survival rate of 100%). One implant exhibited a peri-implant infection, whereas 60 implants were considered clinically successful at the 5-year examination, resulting in a 5-year success rate of 98.3%. It can be concluded that the clinical results of implants in regenerated bone are comparable to those of implants in nonregenerated bone. (BUSER/COCHRAN)

Reprints: Dr. Daniel Buser, Department of Oral Surgery and Stomatology, PO Box 56, Freiburgstrasse 7, CH-3010 Berne, Switzerland. E-mail: Daniel.buser@zmk.unibe.ch












MARCHETTI C, DEGIDI M, SCARANO A, PIATTELLI A. Vertical distraction osteogenesis of fibular free flap in mandibular prosthetic rehabilitation: A case report. Int J Periodontics Restorative Dent 2002;22:251-257

A 17 year old boy underwent 3 cycles of chemotherapy and a subsequent mandibular resection for a Ewing’s sarcoma of the left body and ramus. The mandible was immediately reconstructed with a microvascular osteomuscular fibular flap. One year after the mandibular reconstruction, distraction osteogenesis of the anterior portion of the fibula was performed using a Martin distractor according to the Hoffmeister technique. Bone lengthening was achieved at a rate of 1mm/day by turning the device twice each day for 12 days. Subsequently, the authors waited for 70 days for bone consolidation to occur. After 6 additional weeks, 5 Maestro implants were placed into the distracted fibula. Bone specimens were retrieved with a trephine bur during implant placement. Mature bone was present after 70 days and after 6 months. The bone height increase was 12mm. (MARCHETTI/COCHRAN)

Reprints: Dr Adriano Piattelli, Via F. Sclucchi 63, 66100 Chieti, Italy. E-mail: aplattelli@unich.it.

GELFOAM - Pharmacia Mississauga, On. Absorbable gelatin
sponge(methylcellulose). Scaffold for blood clot
formation. Place into socket and retain in ploace with
suture.

SURGICEL (Johnson & Johnson, Gelph On. Oxidized
regenerated methylcellulose. Binds platelets and
chemically preciptates fibrin through low PH. Place
into socket (Note: cannot be mixed with throbin)

COLLATAPE (Sulzer Dental, Carlsbad, Calif.) Highly cross-linked collagen. Stimulates platelet adherence and stabilizes clot; dissolves in 4-6 weeks. Place into socket

COLLAPLUG (Sulzer Dental, Carlsbad, Calif.) Preshaped highly cross-linked collagen plugs. Stimulates platelet adherence and stabalizes clot; dissolves in 4-6 weeks

AVITENE (Davol, Cranston, Rhode Island) Microfibrillar collagen. Stimulates platelet adherence and stabilizes clot; dissolves in 4-6 weeks

THROMBIN (Bovine thrombin (5000 or 10,000 units) Causes cleavage of fibrinogen to fibrin and positive feedback to coagulation cascade. Mix fine powdere with CaCl 2 and spray into aarea; alternatively ,mix with Gelfoam before application

GLYNNS GLUE ( Toronto General Hospital Dental Formulary.) Thrombin, Gelfoam, CaCl 2 and sucralfate. Combination of Gelfoam and Thrombin plus sucralfate's adherent properties. Mix and pack into socket; suture in place

TISSEEL ( Baxter, Misissauga On.) Bovine thrombin, human fibrin, CaCl 2 and aprotinin. Antifbrinolytic action of aprotinin. Requires specialized heating, mixing and delivery system; inject into socket.

By Dr. Michael R. Norton

As an increasing number of peer-reviewed articles are published on immediate loading, I am drawn by the sense of apparent mental confusion of authors and referees alike. They often seem unable to recognize the dichotomy that exists when the term immediate loading is use din a title, but the materials and methods clearly state that the temporary restoration is kept clear of functional occlusal contacts, as with single-tooth or short span restorations.

As if that contrast were not clear enough, it seems that immediate loading can also refer to placement of a restoration, in or out of functional occlusion, either on the same day as implant placement or up to one month after implant placements.

The term immediate restoration apparently denotes a sense of the definitive as compared to the temporary. We can appropriately apply this term to the so-called Same Day Teeth™ technique marketed by Nobel Biocare, in which a definitive restoration is secured to the implants on the same day the implants are placed. In contrast, many immediate loading studies have used all-acrylic temporary restorations to be replaced in due course, typically after the osseointegration period.

Perhaps we all think we know what we mean, but there is a danger when, for example, with single-tooth implants, we use the term immediate loading, and mean immediate temporization out of functional occlusion. Misunderstood by the ill formed, this could result in unnecessary implant failures.

Perhaps I am debating semantics, but in any and every specialist field, nomenclature is and should be clear and unambiguous, leaving no one in any doubt as to the intent and meaning. I would, therefore, like to propose for future clarity that implantology adopt a rational approach to defining this small group of terms. Perhaps the following definitions may help in attaining that goal:

Immediate Restoration: The insertion of a definitive prosthesis directly supported by implants and in full functional occlusion, on the same day as the implants themselves are placed, as with the Same Day Teeth™ technique.

Immediate Loading: The insertion of a temporary prosthesis, directly supported by implants and in full functional occlusion, on the same day as the implants themselves are placed. In this case, the definitive restoration will not be placed until after the osseointegration phase.

Immediate Temporization: This insertion of a temporary prosthesis on the same day as the implants themselves are placed, but kept clear of all occlusal contacts. The subsequent definitive restoration will then be placed after the osseointegration phase, and in full functional occlusion.

Early Loading: The insertion of either a temporary or definitive prosthesis directly supported by implants and in full functional occlusion, within a period of not more than eight weeks after the implants themselves are placed.

You may feel I am only complicating the issue, but the fact remains that one cannot include the words immediate loading in a title and then clearly express in the materials and methods section that the restorations were kept clear of functional contacts during the osseointegration phase. This is unambiguously misleading!

Michael R. Norton is an editorial board member of Academy News and the immediate past president of the British Association of Dental Implantology (UK). He is registered with the General Dental Council of Great Britain as a specialist in Surgical Dentistry.

FEBRUARY 19-22, 2004
CHICAGO DENTAL SOCIETY MIDWINTER MEETING
CHICAGO, ILLINOIS
INFORMATION:
CDS
FAX: +1 312 836 7337
www.chicagodentalsociety.org


FEBRUARY 20-21, 2004
AMERICAN ACADEMY OF FIXED PROSTHODONTICS
CHICAGO, ILLINOIS
INFORMATION:
DR. ROBERT STAFFANOU
SECRETARY, AAFP
FAX: +1 707 875 2927
E-MAIL: secaafp@worldnet.att.net
www.prosthodontics.org/forum/aafp


MARCH 18-20, 2004
ACADEMY OF OSSEOINTEGRATION
SAN FRANCISO, CALIFORNIA
INFORMATION:
AO
FAX: + 1 847 709 3029
www.osseo.org


JUNE 10-13, 2004
8TH INTERNATIONAL SYMPOSIUM ON PERIODONTICS AND RESTORATIVE DENTISTRY
BOSTON, MASSACHUSETTS
INFORMATION:
QUINTESSENCE PUBLISHING CO INC
FAX: + 1 630 682 3288
E-MAIL: service@quintbook.com
www.quintpub.com


JUNE 22-26, 2004
MEDITERRANEAN DENTAL IMPLANT CONGRESS
CORFU, GREECE
INFORMATION:
MDIC 2004
FAX: + 30 21 06 42 39 56
E-MAIL: info@medcongr.org
www.medcongr.org




AUGUST 4-7, 2004
AMERICAN ACADEMY OF ESTHETIC DENTISTRY
ALBERTA, CANADA
AAED
FAX: + 312 673 6952
E-MAIL: aaed@sba.com
http://www.estheticacademy.org


SEPTEMBER 10-13, 2004
FDI WORLD DENTAL CONGRESS
NEW DELHI, INDIA
INFORMATION:
FDI
FAX: +33 4 50 40 55 55
E-MAIL: congress@fdiworldental.org
www.fdlworldental.org



SEPTEMBER 16-18, 2004
EUROPEAN ASSOCIATION FOR OSSEOINTEGRATION
PARIS, FRANCE
INFORMATION:
FAX: + 4420 7290 2989
E-MAIL: eao-office@rsm.ac.uk
www.eao.org



OCTOBER 27-30, 2004
AMERICAL COLLEGE OF PROSTHODONTISTS
OTTAWA, ONTARIO, CANADA
INFORMATION:
ACP
FAX: + 1 312 573 8792
E-MAIL: acp@prosthodontics.org
www.proshodontics.org


NOVEMBER 3-7, 2004
AMERICAN ACADEMY OF IMPLANT DENTISTRY
NEW YORK, NEW YORK
INFORMATION:
FAX: + 1 312 335 9090
E-MAIL: aald@aaid-implant.org
www.aaid-implant.org