From: Terry Pannkuk
To: ROOTS
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 couldn’t 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’ll 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 weren’t 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 I’m interpreting
the radiograph correctly, is a bulky poorly contoured crown margin, especially on the distal and I’ll
assume the labial from the photograph. - Henry Levant

That’s certainly plausible, but it’s interesting that the only one with problems is the one that’s 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 it’s 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.
Don’t 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 I’m 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 won’t 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!.
It’s all BP’s 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 isn’t 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 isn’t simple, and Oil Platform drilling isn’t 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