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The opinions within this web page are not ours. Authors have been credited
for the individual posts and photographs where they are. - www.rxroots.com

Buried polished collar

From: Terry Pannkuk To: ankylos@rxdentistry.com Sent: Wednesday, May 12, 2010 12:35 PM Subject: Today's buried polished collar. Hereís a Nobel BioCare Replace Select Straight that I buried flush to the osseous crest today (polished collar and all ). I think these are popular because they are easy to restore and most general dentists have the kits for NBC. They like what they are used to. There is certainly nothing wrong with NBC and it is what Iím asked to place 80% of the time.so I do it.- Terry

Ahhh...savor that pre prosthetic x-ray. Things will never look better with NBC! But, it is very easy to restore :-) - Arturo So is this artistic rendition of what to expect that bad or that far off? The adjacent teeth will hold up the tissue and bone. The bigger question is how much of a compromise it is to lose 3mm of bone down the polished collar and lose very little tissue? Ií've found the NBC to be extremely stable and if a referring dentist is comfortable restoring them, they are less likely to have future problems. Presuming Ankylos would hold the bone up to the platform a decade later. How unstable and much worse is the NBC compromise? Will the bone drop down on the adjacent natural teeth? Will the bone migrate down beyond the first thread? Is peri-implantitis risk greater? From what Iíve seen on single replacement implants between two natural healthy teeth, the bone isn'ít expected to go away is it? I like the idea of platform switching and the fact that bone/tissue is held up, but how big is the problem that is being solved by Ankylos in a nonesthetic site like this? Again, I donít use NBC in esthetic sites. - Terry Three questions. 1. You placed a polished collar flush with the osseous crest, even though that implant is indicated for supracrestal placement as the soft tissue prefers the polished Ti and the hard tissues prefer rough Ti. Where will the bone end up in 2 years? 2. What is the middle radiograph on the second page demonstrating? The paralleling pin is in the air. 3. The final photo makes the implant look like it is buccally placed. Good mesial/distal positioning. But remember it is all about 3D placement. or is it the angulation of the photograph? - Dwayne Dwayne, 1. I was taught to place these implants flush. Supracrestal would mean a tomato on a stick no emergence profile and a food trap. Bone should migrate to the first thread and stay there (I hope); I expect the tissue to hold up and the restoration to have natural emergence. Who places these implants supracrestal? their restorative dentists must hate them! When I consider the Ankylos design versus a traditional parallel design, I keep asking myself which is more of a problem?....a horizontal food trap or a vertical one? I donít really know but how easy is it for patients to clean the narrow neck? 2. The guide pin is a in my surgical guide which is radiolucent and shows the angulation of the pin as a check before drilling the osteotomy. 3. It is slightly toward the buccal, hopefully catching some native bone on the buccal. An oral surgeon in Israel had performed the extractions and grafted the sockets with mystery foo foo a couple years ago. I doní't know what the darker material is filling the socket; it didnítí penetrate with the needle during the injection, but I liked the idea of hugging the buccal and getting some contact with some of the dense buccal native bone. The mandibular nerve canal was also toward the lingual at 15mm depth. I placed a 11.5 x 5.0. The slight buccal placement was intentional, hereís the cross-sectional CTís: - Terry Terry Since we are all citing biology as our reasons for doing what we do there are some biological principles we should all be aware of - Bone does not like smooth Titanium. Fibroblasts and bone prefer rough Ti. Gingival connective tissue prefers the smooth Ti. This implant is specifically fabricated and its suggested usage is that the polished portion to be placed above the crest. If your submergence and emergence profile predilection/criteria does not fit this specific design then you are using the wrong implant. Might i suggest the NRS with TiUnite to the shoulder- "NRS Groovy". Know your systems and what they are designed for. - We are all taught to do certain things, but must change and adapt with the times/technology. "I never let schooling interfere with my education" Mark Twain - This is not a discussion of Ankylos vs NRS...but rather is NRS is your choosen system then use the bullets that go into your six shooter accurately and judiciously. - Why check angulation of the pin prior to initiating the osteotomy. So many variables can enter the equation after that in my opinion it is a moot point. And subjects the patient to unecessary radiation. Again, my personal opinion. A much better radiograph if you are so inclined is either half way through the initial osteotomy with the 2mm pilot drill or once this initial osteotomy is completed. - If you are so concerned about the submergence/emergence profile of the restoration the certainly purposefully engaging the buccal plate of bone with the NRS WP will cause the resulting abutment and crown to have too prominent a buccal contour. OVER contour of a restoration has terrible biological consequences. It would be much more prudent to center the osteotomy on the central grooves (assuming they are in ideal relationship) of the adjacent teeth. This was the implant is centered and the resulting crowns profile will be ideal... The current thought with implants (especially in the anterior) is to avoid the buccal plate of bone. I know this is not an anterior case, but i follow the principle through. - If you had measured on a CBCT the distance to the Mand nerve was 15mm and you are not countersinking the implant and presuming you want maximal bone/implant contact why not place a 13mm implant...what is your rationale for a 11.5mm implant? The CBCT that you show...what stage of the procedure is that? - Dwayne On May 12, 2010, at 9:24 AM, Terry Pannkuk wrote: 1. How much radiation do you think a digital radiograph exposes a patient to? I like to validate the buccolingual position using the stent in the mouth before drilling and figure the patient wonít get lymphoma from that event. I take several radiographs along the way to check for drill shifting in soft bone. Radiation exposure is a non-issue as far as Iím concerned but I only take radiographs I think that will help me. 2. Fibroblasts may not like smooth titanium but neither does plaque/bacteria biofilm which love rough surfaces having pores ideal for colonization. 3. How far buccal off center do you think I placed this? The patient had excellent ridge width and there is well over 1mm of dense buccal plate covering the buccal portion of the implant. I know you wouldnít want me to take a scan (exposing the patient to more radiation) of the case post op but I donít mind when the patient comes in for a check visit next week figuring it would be good validation of my placement. J 4. Do you really think a 11.5 mm deep implant in mandibular bone with excellent primary stability has any negative significance compared to a 13mm deep one? I personally like 3mm safety space from vital structures if possible. A 13 mm brings me potentially within 2mm and if there is any CBCT distortion which does occur, it could be problematic. You are clearly more concerned with things like radiation exposure, length of implant, junctional epithelial attachment on smooth surface titanium, and other issues which I am not. Iím concerned about the mystery foo foo, vital structure proximity, and not creating a conflict with the restorative follow-up (i.e. being compatible and on board with the restorative dentistís plan to the extent it doesnít compromise the case. I just havenít seen your concerns that you are raising being a problem with the clinical results Iíve had. Iím open to the possibility that maybe I should be concerned with the things you are saying, but I just havenít seen any evidence of it being necessary yet.- Terry When the bone does not attach to the smooth Ti ( and resorbs as it will).. this give more surface area for the biofilm to adhere to...including the abutment. All radiogaphic exposure is additive. Thus anything which is redundant is unecessary (opinion). Do you take radiographs of your Endo files before you enter the pulp chamber? To my knowledge there is no distortion (or if any it is minimal) in a CBCT. that is why we can accurately measure tenths of millimeters. However, i will confirm this with a Oral-Maxillo Facial Radiologist at UTHSCSA. Certainly not enough distortion for concern regarding 2mm. Why do you not then do a CBCT with a measuring gauge, say a 5mm ball bearing, like we used to do with Pans. Buccal bone is sacred...the sanctum sanctorum so to speak... always stay 2mm away. if your philosophy was to engage this for greater stability, then i think you should go longer with your implant, and have more centrally placed. again assuming you are desiring more stability and bone/implant interface. If the mystery foo foo is of concern then call or email the doc in Israel....I have delt with docs in Israel, Russia, Hong Kong, Taiwan, Brazil, Iran and Phillipines...and others. The internet is a powerful tool if you choose to use it. If you cannot get an answer then perhaps you should remove it as you do not know its biologic consequence. What if it is Bioplant (acrylic beads with HA coating...god forbid) used the socket. What would you do if a patient presented to you with Sargenti Paste or Silver points???? If you do not know then it is wrong to place an implant into it. Remove it, regraft and place the implant at a later date. This is the biologically sound thought process.- Dwayne Good point on the mystery foo foo and removal consideration. It may have been a bit blind faithish to place an implant into the unknown. The bone that came out during drilling looked pretty normal, no Bioplant, so the main concern was just that it wasnít native bone. BMP is the only real good stuff that becomes real bone. The buccal plate is solid as a rock. I suppose you arenít going to be satisfied until I get a CBCT from this guy and measure the remaining buccal width. Iíll do it when he comes in. I have well over a mm, maybe didn'ít even engage it, weíll see with the CBCT. I didnít need greater stability, I had to unwind, wind a few time to lessen the torque! I did take radiographs during the process:- Terry

If I hear constantly the story about comprehensive treatment planning Terry.....how do you rate the progress of the crown and its margins distal to the implant. Do you anticipate another implant crown needed in 1 year. The margins again look suspicious - Glenn So youíre presuming it isnít recorded and on the bucket list of prioritized items to be treated? You presume that I dictate the sequence of executed treatment options to the general dentist; i.e. quarterback? Yep, youíre right itís a crap crown requiring replacement. So? - Terry Dwayne: If I am correct you have a dual degree in Periodontics and Prosthodontics. Am I correct in this. If so , I would imagine that you spent a vast amount of time in your education in the USA ( was it Columbia university) learning about implants and the issues you relate here to us. Its amazing that anyone would not sit and think a long time before defending their opinions in my mind unless they have a similar degree of training. I guess some people just love to argue about everything and never take the time to sit quietly and take advice from someone else or constructive criticism on their concepts. I for one have learned A LOT from your comments. Please continue to educate us as your background in this topic is beyond reproach. I am sure that others could learn as well some from your vast knowledge. Thanks for sharing.- Glenn Glenn, I am sure that this opinion is a bit contaminated with your previous discussion with Terry on Roots. Not disrespecting Dwayne, but one is not measured by its degrees and titles. You are an example of this since you are a GP and teaches all over the world about different topics with a great expertise. Terry has the write to disagree about this topic or any other, and he has a knowledge basis to do that even do he is not an specialist. We leave in a democracy and a forum like this should be a place for education not for its killing. I strongly believe that if Dwayne presents some solid literature all of us will learn and progress, in the contrary if one can not "challenge" the current status quo of or a "big" shot all of us will leave as prisoners of imaginary boundaries. I learned a great deal from you and many others with out of a formal degree. Just let the past goes and lets focus in the future. - Dr. Carlos Murgel Carlos, yes terry had the right to diagree. however, his arguement was not supported by the lit. merely opinion. what i have stated is supported. it has been my mistake not to give references, however, in a busy implant practice i do not have time to look them up. where i am not an authority in a subject i have outsourced my material. i am still awaiting a response to Terrys comment about distortion in CBCT (he is wrong BTW)...this rebuttal is coming from the department head of OMFR at University of Texas San Antonio... i am told i will have it later today. but everyone is busy and sometimes in blogs you cannot reference properly. i do not know how Ken does it. catch my presentation in Barcelona, everything will be referenced.. - Dwayne Carlos: A very well written and thoughtful post. I have learned more from people on ROOTS about endo over the years than anywhere else. If I do lecture and provide any information it is basically on two topics- 1. Lasers 2. Microscopes I do have 13 years of clinical experience and 3 DVDs in the microscope field. I have a mastership in lasers. I guess that allows me to present some useful information on both topics. I also know my place and that is that I am not an endodontist or an implantologist. I realize that I am in no position to argue with "expert" or those who have gained a foundational background in these topics like you have in grad school. I have no problem at all with formal , professional debate. I see no reason why personal shots must be levelled at someone with a different viewpoint. That has no basis in personal communication be it online or face to face. We can maturely agree to disagree. So when these issues keep cropping up and never are started by me , well then it is disappointing to me to see. I am beyond it and looking forward . I too will see you in Barcelona and looking at the speaker list , I am absolutely honored to be invited. All the best - Glenn van As Terry this is exactly my experience with extractions: why we need to place something inside the socket if we have bone there? - Carlos Murgel

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