Apico implantectomy - Courtesy ROOTS
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From: Terry Pannkuk
Sent: Saturday, June 12, 2010 5:13 PM
Subject: [roots] apico-implantectomy
This was the quiz case I posed last November. We moved very slowly with this making
sure the patient accepted the plan and was ready due to her tragic implant esthetic problems.
Today I performed the apico on the maxillary lateral that had its apex into the max
central implant replacement. I couldnít apically resect the root too much
away from the implant without severely shortening it, but I presume we got the root
tip cut back enough from the implant to allow good debridement and clotting. I'íll take
another CT when I take the sutures out next week. Reverse-filled the root end with MTA
polished and debrided the implant surface with Metronidizole gel where the
root tip was in contact.
Do you think her percussion sensitivity will now go away? Las Vegas odds? - Terry
P.S. I previously posted the CBCT captures with the 5 year history /photos/ radiographs.
Great case Terry, did you graft over the threads of the implant? - Jose
Absolutely not. Why would I? Thanks, - Terry
Just because the area is expose to you and the threads had no bone over it,
I do not see any harm in trying to improve the condition of the implant - Jose
Jose, I believe it would be a significant risk and could make it worse.
Less is more in my opinion. The implant is integrated, the more coronal crestal
tissues have been previously grafted with stable tissue contours (reason I went with
a submarginal incision), and the rationale for treatment was to
remove a nidus of bacteria/potential space having no blood supply.
If I had placed a membrane I would have worried about it being a bacterial sponge
around the same area I just cleaned and debrided. I see absolutely no benefit to
adding anything artificial in that site and the most appropriate
biological rationale seemed to be simply re-establishing space for a natural clot,
formation of a new blood supply, and ultimately regeneration of healthy bone in an
area that harbored pathogens.
The biggest problems I see with implantology these days is the popular trend to
fill holes and cover it with membranes when not necessary. Most complications seem
to be a result of these unnecessary treatments.
How about this patient? Elderly guy with no maxillary gum tissue showing when he
smiles.three NBC Replace Selects replacing #12, 11, and 10. A different implantologist
placed the Astra (platform switch) with grafting/membrane to replace #9. This is 4 years
after restoration of the area. The platform-switched/grafted implant is the only one
with gingival inflammation/bleeding and the other three are as stable and healthy as can be.
Bottom-line: we have to respect biology, understand, and work with it. - Terry
P.S. As you can see dark triangles werenít a big concern for this guy, so esthetic goals
were greatly simplified
Terry, Rather than blame the implant design, I would bet that the problem with # 9,
if Iím interpreting the radiograph correctly, is a bulky poorly contoured crown margin,
especially on the distal and Iíll assume the labial from the photograph. - Henry Levant
Thatís certainly plausible, but itís interesting that the only one with problems is the
one thatís platform switched. All crowns emerging from a narrow neck are bulky, right? - Terry
NO. All crowns should have an emergence profile that mimics the natural tooth itís
replacing at the level of the gingival margin.
The crowns on the NDC implants you showed seem to do that. The one on the ASTRA implant
does not! - Henry
Henry, The central incisor crown you are referring to has natural tooth emergence at the
gingival margin. Donít you think it is simply a food trap because of the platform switching
which lies just apical to the gingival margin. I agree the distal crown contour comes out
a bit wide but it looks quite normal to me on the mesial. If you take this issue further,
you might conclude that the Astra Implant is simply not placed deep enough to give a proper
emergence. That is the problem with platform switching which Iím trying to show below with
the actual image and the same image Photoshopped to where I think the implant should have
been placed (for that type of implant).
Tell me what you see wrong with this concept:
All the benefits of having the bone protected to the level of the platform are essentially
negated by having to place a platform switched implant with a narrow neck deeper which may
actually create a deeper food trap/more potential space volume. A natural Bioform seems
more intuitive and less complicated to me. It was a great learning experience for me to
get myself into a heated discussion on the Akylos site. I ended up consulting
other non-Ankylos aligned implantologists and learned much about the opposing argument - Terry
Terry I think that the platform switching is a different concept that you are thinking
and showing in this case. That marginal inflammation can be due to so many factors and saying
that it is due to PS it is not accurate.
Another concept is that you can do PS with different implant systems and not only with Ankylos
and it's major advantage is to place the connector implant interface further from the implant
margin (preventing bacterial leakage and bone destruction).
If you read the literature it seams like a very nice concept.
The name of the game is prevention of bone loss at the implant connector interface and looks
like the PS is better than the conventional same diameter components system - Carlos Murgel CD, Dr.
Here is the answer to platform switching "phenomena" - see the RX and there is also a nice
study done by colleague of ours showing this is only a marketing hype.
( picture is from that study, too ) - Valeri
Valeri, Could you forward the study you referred to below regarding platform switching
marketing hype? - Henry C. Levant
Valeri, There are so many factors that affect implant success, bone level is just one of many.
If you lose a little bone down to the first thread but you have stable tissue height versus
bone maintained to the platform surface with chronic supracrestal gingival inflammation and a
food trap; which would you prefer as a practical clinical solution.
Most of the best prosthodontist and implantologists in my town are very critical of the platform
switching hype and view it as marketing fraud, or just more of the same in a long line of
commercial gimmicks corrupting science.
The clinical reality is that slight platform-switching might be better than extreme platform
switching or even better than a traditional bioform contour in some esthetically-sensitive
situations (certainly not mandibular overdentures), but we wonít really know as long as the
literature base is corrupted by economically-incentivized zealots functioning as faux experts
propped up by commercial interests.
We live in extraordinary times with extraordinary distortions of images to mold mass perception
to suit those who have the power and resources to manipulate interests. Just look at the blame
shifting going on with the oil spill!. Itís all BPís fault right? J BP is simply a corporation
that acts on behalf of its interest like the beast it is. There is nothing wrong with that
because it is natural and the way all powerful businesses behave. The fraud exists
when facts are grossly distorted. For instance. The Horizon Oil rig is 80 miles off US coast
line which is beyond 12 nautical miles and in international waters. There is an Extended
Economic Zone or (EEZ) which extends 200 miles functioning to control fisheries and similar
industries like the development of oil rigs, but the legal liability is much more limited
outside territorial waters and international waters requires some international cooperation when
considering legal liability such as the oil spill accident. What this means is simple but
certainly not discussed much in the press because of our current government propaganda machine:
If drilling had been allowed in shallow waters within territorial waters an oil spill could
have been capped immediately and any damage could have been legally restituted and enforced
more simply within US Federal laws. Of course this isnít being mentioned in the
liberal media or the current administration because it highlights their failed off-shore
drilling policies which forced deep water drilling.
There is always more to the story. Platform switching isnít simple, and Oil Platform drilling
isnít simple. When something goes wrong no one wants to admit what the reality is if it make
them look wrong, just bring in the commercial marketing clowns to make it look good. - Terry
Terry, I could not agree with you more. - Valeri