From: Terry Pannkuk
To: ROOTS
Sent: Wednesday, July 29, 2009 5:37 AM
Subject: [roots] Patience is a biologic virtue

I retreated these two lower anteriors a decade ago and one was suspected to be vertically fractured after
obturation when the sealer spread along what appears to be a fracture plane radiographically.
Since my ego is healthy and I'm not insecure, I never blame myself and assume the root was destined to crack
due to previous spreader loading and previous weakening from the other clinician's procedure as I applied
reasonable compaction force. :)

The perio didnt' blow out until 2007 but when it did the entire lingual plate was compromised and I was worried
about a knife edge contour profile complicating esthetic implant placement.  I graft as infrequently as I can
get away with because native bone is gold and graft isn't as good or as predictable. I extracted the tooth,
placed graft only down to the defect level, leaving a normal clot apically, then covered with Biomend, sutured,
then cut off the crown from the extracted tooth and ad libbed a Maryland bridge type temp bonded
to the adjacent teeth.

She stayed this way for 1 1/2 years, until I had the temp removed a couple weeks ago, made sure she had a
thorough dental cleaning, then placed the implant last week.  (3.5 S Astra..... I don't like tapered implants
and rarely place them).  The bone was solid and the BioOss integrated solidly into the peripheral native bone.

I thought I'd show this because it demonstrates a "poor man's CT" technique.  I placed the radiograph sensor
externally against the left jaw to get the saggital section angle showing that the implant is properly placed
within the labial bone and in ideal parallel alignment - Terry




Excellent as usual! -  Dr Sanjay Jamdade

Nicely managed terry.  You should go into the implant business!  nice documentation.  And of course I always
enjoy when you anti foo foo dust guys are forced to come over to the dark side - gary

I'd call it the gray side, not the dark side.  Ironically the dark side is when the entire socket is white.
:):):) -  Terry

Terry, why do you not like the tapered implants?  My surgeon does not either and his only answer is they integrate
as predictably.  Don’t get why not but it is on his dime.  What is your reason? - Guy

We went through this argument before, but most of the studies are with parallel sided implants going back to Branemark.
Tapered drilling creates less stability than a normal parallel drill; in fact most of the time those clinician's placing
tapered implants do not utilize the apical half of drilled bone to actually thread intimately with the screwed implant
and the primary stability is all at the cervical collar creating a greater risk for loosening and movement via
fulcruming if disrupted.

The geometry just doesn't theoretically satisfy any elegant logic and there is minimal evidence to suggest using them.
Tapered implants are just simply easier to place "sloppily" and slide into a fresh extraction socket giving the clinican
the the idea that it's easier and better.  Easier is not better. :)- Terry

	Tapered implants are better, but the implant bed in bone must be prepared with cylindrical shape and conical implant
	has to be with large threads and of course self tapping.  This makes things quite different from the situation when
	one is preparing conical shaped bone bed to insert a conical shaped implant with small threads - Valeri Stefanov

	Now how can you make that statement with absolutely no logic or evidence. :):):) - Terry

	I can make it, because of the dental implant sytem I myself developed back in 1990 based on these principles.
	(see attached case - single stage,self tapping ,conical shape, one piece implants with SLA rough surface after
	13 years of loading ) There are a number of Italian implant systems, too based on same principles. These have
	been developed back in 1980ies and are used with success till today. There was dental implantology long before
	Branemark has given the world the "great news" that Titanium made orthopaedic fixing screw replica osseointegrates -
	fact orthopaedic surgeons have known since 1959 !!! Branemark's clever marketing has played a decisive role for
	delaying the implant dentistry development for years. Remember when they were pretending that the machine surface
	is the best and even tried to patent it :-))). Now even NB uses rough surface on their implants - Valeri

	P.S. I was the first who applied SLA surface on dental implants clinically back in 1993 ( results reported during
	ICOI World Congress in Istanbul 1993 - then all others were using as machined, blasted with AlO, TPS or HA surfaces
	only  including Straumann )

	

Can't help weighing in on this...........unfortunate that TulsA HAS elected to be be so non-supportive in the online
community world re; ANKYLOS.

I started with the GROOVY and REPLACE SELECT and Astra Tech stuff..........but the reality is they lacked a progressive
thread design with apical primary stability...........the force vector studies done in Europe for lo these 20 + years
were very dramatic and convincing.......implant need to engage apically, not cervically

The lack of saucerization and dieback is simply a reflection of the fact that force distribution on the fixture by the
abutment is along the fixture length...NOT CERVICALLY...think of a well sized and designed post................

There are so many others who can weigh in here on the design, it's rationale.....it's "difference" from the design of
BioHorizon and Nobel and 3i et al.............Active is similar but still not capable of the progressive thread
capability of ANKYLOS, Astra Tech created a better collar with it's microthreads, but sizing was odd and restorative
issues abound...........

BONE SUPPORTS TISSUE and the narrow one size fits all abutment doesn't create a hygiene defect, it enables full
occlusion, not passive occlusion, it enables esthetics that are truly tissue "driven" et al.
I sound like an infomercial and I dislike it intensely.......I have supported Tulsa in the past, but have lost interest
as they persist in avoiding digital education in any format.......you can't compete one on one in this market and as
a result, the endodontist who brings this product into his service mix is woefully unsupported and must do his or her
own marketing with literally NO RESOURCES.  They have 10 designated implant specialists who can help on ROOTS or IMPLANTS
with OFF LABEL I grant you commentary based on their demographics which cover OS's and Perios from around the US.........

I choke everytime I hear a company say, we can't go OFF LABEL.........take 10 dentists who by the same product and the
minute the box is opened, the product is used OFF LABEL............the good done by encouraging that which is supported
and validated and verified with recognition of regulatory oversight is needed, the bad by avoiding it.....horrific.....
....think any carrier based obturation system........think Beruti and Cantatore, then think Joe Schmo in KOKOMO.

Ovidiu - would you be kind enough to send ONE low res image of ANKYLOS C/X - only academic representative I know is
Kurt Magnus who works with Fred at Einstein......

He is invited to weigh in on this topic........simply because it can be science based and in the absence of any
marketing resources, he has no choice but to speak logic and science.

Jose - you're running an endo/implant residency near Beantown.........step on board........granddaughter down for
her nap........................adieu.

OH BY THE WAY - August 1st, 2010............www.rootssummit2010.com...........you have a choice....make it a
resounding success and continue to discuss your scope needs et al.......

You all have databases and address books, know people around the world.......DTI and Dental India seem to have
no problem using ROOTS resources.........et al.......YOU can all make it a success.......if not..........
no threats, no diatribes, it ends because it simply isn't worth the time or trouble..........Kendo

	Valeri,

	I'm asking for evidence or at least a logical rationale.  What does that have to do with taper versus straight
	implant selection?  Granted, surfaces have improved dramatically.

	Ones mere invention doesn't construe validity otherwise the world would be littered with Rube Goldberg machines
	and a malfunctioning inefficient industry . :):):)

	Why do you insist that being first equates to being best?   Show me the evidence that tapered is better than
	straight.  At best, the very limited evidence shows that "tapered might be as good", but that's very speculative
	and not established well at all.  In the absence of evidential and compelling theoretical validity, "tried and true"
	rules - Terry

	Terry,

	It's a long discussion, if we start it now here on Roots. We have had this on Implantology list years ago back in 2001
	- 2002. The advantage of conical shaped self tapping ,large threads implants with rough surface is "visible" in
	cases with so called delayed immediate insertion. Inserting a self tapping conical implant with large threads into
	a cylindrically prepared bone hole with diameter slightly less than the body of the implant (not dia of threads )
	give an exceptional primary stability of such implants even in D5 bone / :-))) /  ( means inserting 3.6 - 3.7 mm dia
	implant into 2 mm cylindrical bone hole )

	I, for example, am not brave enough to place for example a single piece-single stage, non self tapping , cylinder
	shaped implant with low ( 0.25 - 0.30  mm high ) threads into D3-D4 bone. I will surely, with no doubt, place a
	conical self tapping implant with large threads into same qulaity  bone as one stage implant.

	Rough surface helps both - cylinder and conical shaped implants - there is no question about that. Macrodesign of
	the implants is what gives advantages on macro level.

	Here is another attached example - an SDV 1 implant developed myself - 8 years after loading. See bone loss around
	teeth and bone being nicely preserved around the conical, one piece, self tapping, single stage implant with SLA
	surface.

	One thing I agree with you - in so called routine cases ( enough bone volume, enough space between teeth,
	D1-D2 bone ) it will be hard to demonstrate significant difference between cylindrical and conical implants when
	placed with two stage surgery.

	Advantages of conical self tapping implants with large threads where the reason for  NB to purchase Israeli
	Alpha Bio company adding an implant with large threads implants to their line ( called "Nobel Active"  now ).
	They, however were not brave enough to offer the single piece version of  Alpha Bio implant  :-) !

	Implants like BICON or QUANTUM with their unique design also have certain advantages for particular cases -
	especially when short implants are needed - Valeri

	I repeat: Where's the research validity?  You're talking products not studies - Terry

	I am talking implant's macrodesign and biomechanics and I'm talking experience - Valeri

	I've placed some tapered implants as well, but only when anatomy dictates it (i.e. safer vital structures and
	when the ridge is knife edge).  I've viewed it as an occasional necessary compromise (like grafting).

	Tapers are easier to self-tap and tend to fit the shape of extraction sockets, easier for immediate placements
	many times.

	My eyebrows raise everytime someone insists something is better with no evidence or rationale.  How in the world
	can someone be positive that tapered implants are better when there are no comparison long-term results versus
	straight?   That's ludicrous. Straights have been used longer and have a successful history.  Tapered implants
	do not have the same long history of use.

	The most appropriate thing you can say is that they "seem' to be similarly successful as straights at this point.
	Change should be dictated by need, not novelty.  - Terry

	Placement of well designed tapered implants is definetely NOT a compromise. Placing tapered NB implant
	( beside Alpha Bio aka "Nobel Active" implant ) is a compromise due to lack of real threads in half of implant's
	lenght !

	There is a vast difference in biomechanics of  tapered implants, which are not self tapping, have low threads
	( less than 0.30 mm high ) and are inserted into tapered bone hole and tapered implants which are self tapping,
	have a large threads ( over 0.5 , usually 0.7 - 1 mm high ) and are inserted into a cylindrically shaped bone
	hole having a smaller diameter than at least upper two thirds of the  implant body  ( not threads ).

	These type of tapered implants are virtually unknown to dentists in USA ( beside Bicortical screw which was sold
	in US for a short while and one USA made implant, which I do not know, if it is still on sale in USA) and most
	EU countries. May be hundred of thousands of such implants have been placed with success in Italy and Germany
	through last 30 - 35 years. Significant portion of these have been immediately loaded or more often placed with
	delayed immediate placement technique.

	Simply said -  tapered implants will work in all cases where one can use cylindrical implants, but cylindrical
	implants will not work in cases where tapered implants will perform very well. That's the logic to say tapered,
	self tapping and with large threads is better than cylindrical, non self tapping  and with small height threads.
	- Valeri

	I find this thread interesting for several reasons - one - the lessons learned in endo in terms of deep shaping
	and gauging, the lessons learned from the endodontic restorative continuum do relate to orthobiologics and
	biomimetics.

	Photo-elastic stress studies may be soft science to some, but they test cars, bullet trains and airplanes in wind
	tunnels for a reason.................

	Please visit www.ovidiu.ca/example032 for a moment.......

	as I suggested before, I won't reiterate my perspective on ANKYLOS - having placed at least one or two of the
	top 5 implants in N. America, after much due diligence I chose ANKYLOS in spite of some restorative deficiencies
	such as CAD/CAM.  Bone supports tissue, even on the most elemental level, bone over the platform makes sense and
	saucerization does not.

	IMPLANT engagement in the apical 1/3 rather than the cervical or coronal 1/3 makes infinitely more sense. and
	Ankyolos is a tapered and a parallet implant you need to look carefully at the configuration and unlike Activ
	with the screw threads, the threads are squared off, more surface area..........

	There are many things happening with ROOTS.........not discussable, suffice it to say the linkage to cbCT is
	underway........anyone practising endo or implants without immediate access to cbCT is simply not in the
	21st century...it's like 2D flat field graphics, 2D flat field radiographs are yesterday's news.........and
	in some ways suberting standard of care.

	Placing implants next to one another is always difficult unless you can keep the bone - think Tarnow........
	you really can't cantilever off a fixture/abutment using IKEA design, that is internal hex........anon.

	I am working on what I hope will be the ability to bring these kinds of text messages into graphics and animations
	you will see on the link and attach them to a mechanism for content renewal that will include cbCT avi files.....
	as well......like the last 11 years on ROOTS, always a CRUCIBLE of the non-Arthur Miller variety........

	The only thing that is relevant re; WORDS is the song by the BEEGEES.......believe nothing of what you read,
	half of what you hear and ALL YOU SEE IN THREE D if it is time stamped and follows DICOM.....

	Bone sets the tone, tissue is the issue but an implant design that factors bone preservation into is biomechanics,
	that because of the fixture abutment connection doesn't mandate a 5.0 mm fixture diameter.....now that would
	interest me.

	Endudes doing implants is SERIOUSLY late to the dance.........y'all better have more than words to justify a)
	why you should be chosen rather than a PERIO OR OS who has been doing them for 20 years, b) how to ensure that
	they appreciate your choice as being not more of the same - you do NBC, so does Joe Schmo and he's done hundreds
	and thousands, and c) you better have a team of people who walk the walk and talk the talk........otherwise,
	it's a very expensive and risky gamble..............dazzle them with science, graphics, animations........
	cbCT for your endo and implants........you need to rock their worlds................not just advise them of the
	addition to your service mix - Kendo

	

	Baumgarten presented some research on this at the AAE all day course...don't know if you saw him. Stated that
	obtaining primary stability with immediate placement was easier and greater with tapered implants - Tim Bachman

	Here's a recent study that suggests the opposite (although not statistically significant). Most of the studies
	I've seen by proponents of tapered implants are very low level evidence and mostly opinion. It's clear that tapered
	implants might be technically easier to place in some cases.  There may even be some cases where they may decrease
	the risk of buccal or lingual plate perforation, but to say they are inherently better and more stable doesn't seem
	to jive with the established evidence.  I'm always happy to change my opinion when the evidence and rationale is
	there, but I just don't see it being presented on this topic - Terry

		J Oral Rehabil. 2009 Apr;36(4):279-83. Epub 2009 Feb 10. 

		Reliability and validity of the instrumental assessment of implant stability in dry human mandibles.
		Brouwers JE, Lobbezoo F, Visscher CM, Wismeijer D, Naeije M.
		Department of Prosthetic Dentistry & Oral Implantology, Academic Centre for Dentistry (ACTA) Amsterdam,
		The Netherlands.

		The aim of this study was to determine the intra- and interobserver reliability and validity of the instrumental
		assessment of primary dental implant stability, using resonance frequency analysis (RFA). Sixteen tapered implants
		and 16 cylindrical implants were installed in eight unfixed dry human mandibles (Cawood classification IV/V).
		Implant stability quotients (ISQ; the outcome variable of RFA) and peak removal torque were determined. Both the
		intra-observer reliability and the interobserver reliability of the RFA measurements were fair-to-good, while no
		significant correlations between the ISQ values and removal torque were found. The removal torque of the cylindrical
		implants was higher than that of the tapered implants. The smallest detectable difference was almost nine ISQ units.
		Within the limitations of the present dry cadaver study, it was concluded that (i) primary dental implant stability
		can be assessed reliably with RFA measurements, (ii) the concurrent validity between RFA measurements and removal
		torque is poor, (iii) cylindrical implants may be more stable than tapered ones and (iv) two subsequent readings
		of RFA measurements need to differ at least nine ISQ units before the difference between the two measurements can
		be considered statistically significant. More research is needed to see whether these conclusions can be
		extrapolated to the clinical situation, including the assessment of implants during function (secondary stability).

	Do you know the literature citings?  - Terru Pannkuk

	I tend to agree with you, but there is little research in this arena.  one thing I do believe in, however, is I do
	a parallel wall osteotomy even with a tapered fixture, allowing it to expand the osteotomy.  Very easy to overprep
	and strip out a tapered prep with a tapered bur.  And better primary fixation at the crest, where occlusal forces
	in lateral movements are the greatest - gary

	Hi Terry..I will look through my notes. I enjoyed his lecture quite a bit. Gave a really good bit on Biotype as well.
	I have used only Astra straight implants as well but after his lecture I decided to give some tapered larger thread
	implants a try. I dont think they are necessarily easier to place technically...not sure why you say that.  Both
	types are going to work well but I  have found it easier to control the osteotomy and get greater primary stability
	in immediate sites with the tapered implants.

	In an edentulous non-immediate site I would probably still prefer the straight every time if no anatomical concerns

	Baumgarten was going for insertion torques of 75-100 NCM with tapered implants in immediate sites. 25-50 less with
	the straight - Tim

	Tim:  astra is not straight, it flares in the coronal 1/3 - Gary L Henkel