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70 The Dentist March 2007 .implants. The ten commandments Stewart Harding highlights the keystone principles for treatment success. lFigs 1-4: Implantitis begins with inflammation of the peri-implant mucosa (mucositis) and is usually reversible. If left untreated the inflammation spreads apically, resulting in suppuration and bone loss. Early treatment has a good prognosis for this type of failing implant. This illustrates the importance of keystone principles six and ten. lFigs 5-6: Occlusal overload is one of the main causes of implant fracture and shows the importance of keystone principles six and seven. Occlusal trauma is defined as an injury to the attachment apparatus as a result of excessive occlusal force and, if persistent, can lead to bone loss. I f all dental implants available today boast high success rates and have been approved as safe and predicable to use, why does treatment go wrong? Is there a common factor involved and, if so, how can it be controlled or minimised? The ultimate success or failure of implant treatment is invariably the result of insufﬁcient adherence to the ten keystone principles during the early stages of the treatment planning process, and poor dentist training. The purpose of this article is to introduce the concept of training and explain its importance in the predictable delivery of implant treatment. Ten keystone principles There are ten principles that can be identiﬁed as fundamental for the safe and predictable treatment planning of osseointegrated implant dentistry. The importance of Stewart Harding has an MsC in implant dentistry and is an honarary associate professor at the University of Warwick. these principles is not dependent on the sequence in which they are considered, but they must be understood and applied appropriately to all stages of the treatment and planning process: 1. Good primary ﬁxation for integration. Implant failure has been classiﬁed as either early or late. Late failure refers to loss of osseointegration or mechanical failure after secondstage surgery. Early failure occurs when the implant does not osseointegrate before second-stage surgery. Research suggests that, if implants are going to fail, they tend to do so soon after they‹ 72 The Dentist March 2007 .implants. lFigs 7-8: Advanced peri-implantitis has resulted in bone loss to the first row of perforations. Although there is no mobility, explantation is indicated if further bone loss is to be prevented. This again shows the importance of keystone principles six and ten. lFig 9: The existing restoration has metal backing on the incisor teeth indicative of a heavy occlusion. Also, the lack of pink acrylic suggests that there will be sufficient soft tissue available to permit the formation of a soft tissue margin around the final implant restoration (keystone principle three). components will determine the €have been placed. The likelihood ﬁnal appearance and stability of of failure decreases from the time the soft tissues and restoration. of implantation through ﬁve years It is imperative that the clinician post-surgery. Early failure has been and technician understand the attributed to the poor mechanical restorative protocol of the system ﬁxation of an implant on insertion employed, together with its or poor primary ﬁxation. Primary limitations. Inappropriate abutment ﬁxation is dependent on good selection may induce soft tissue surgical technique and bone type. recession even in the absence of 2. Resorption changes anatomy other predisposing factors. Following tooth loss, the supporting 6. Early bone is A failing implant that has a poor intervention for gradually lost prognosis should be removed prevention. over time due sooner rather than later if The sooner to resorption, bone is to be preserved and an implant which not only unnecessarily prolonged patient complication is changes the suffering avoided. identiﬁed and dealt external shape with, the better of the bone but also its internal structure. The quality the eventual outcome of corrective treatment will be. A failing implant and quantity of the remaining bone that has a poor prognosis should has a direct bearing on primary be removed sooner rather than ﬁxation. Insufﬁcient bone and low later if bone is to be preserved and density reduces its mechanical unnecessarily prolonged patient properties and ability to anchor the suffering avoided. The long-term‹ implant sufﬁciently on insertion. 3. Space should be measured and the existing restoration looked at. There should be sufﬁcient threedimensional space available to accommodate the proposed implant restoration. This means that there must be space mesio-distally within the arch (intra-arch space) and occlusal clearance (inter-arch space), not overlooking the space between the roots and available bone. The existing restoration is invaluable in providing dimension information together with an occlusal history of the loading environment. 4. Soft tissue is the issue but bone sets the tone. Ultimately, regardless of technique, good soft tissue aesthetics depend on the underlying bony support. This prerequisite is reliant on keystones two and three, as there must be sufﬁcient bone and space to permit lFigs 10-11: A missing upper canine has left optimal implant placement. little space between the remaining teeth to allow 5. Abutment design and position placement of an implant. In addition, there is dictates emergence proﬁle. insufficient bone to support the insertion of an implant showing the importance of keystone The correct selection and principles two and three. appropriate use of implant 74 The Dentist March 2007 .implants. €use of antibiotics is not justiﬁable in such cases. 7. Sufﬁcient implants should be placed to meet occlusal demands. It is often tempting, especially when there are ﬁnancial constraints, to limit or optimise the number of implants required. It is not in the patient’s best long-term interests to under plan the case, as late failure will be the inevitable result and the ﬁnancial burden of putting it right will fall on the dentist who planned the case. Recognise this fact early and avoid the complication. 8. Plan for possible failure. The best-formulated treatment plans should always include provision for the unforeseen complication and incorporate risk management. This is primarily reliant on keystones six and ten. 9. Overdentures do not mean Implants are to last the patient’s life and so require long-term maintenance. fewer implants. The mechanical complexity of implant overdentures is often overlooked and insufﬁcient attention paid to their mechanics and long-term maintenance. When considering the provision of a removable implant restoration, additional attention should be given to keystones seven and ten. 10. Implants are not ‘ﬁt and forget’.Finally, it is important to remember that implants are to last the patient’s life and so require long-term maintenance. The patient must be made aware of his or her commitment to this long-term goal, and the dentist implementing the treatment should provide a maintenance and surveillance programme.n £60m modernisation package Primary care trusts are being awarded £60m to modernise dental premises and equipment, minister for delivery and reform, Andy Burnham, has announced. He said the capital injection for dental surgeries reﬂected the need to match the working environments of dentists with the high quality services that they were already providing. Primary care trusts can use the money to give greater ﬁnancial support to help dentists establish new surgeries or to upgrade existing ones. The money is part of an overall package of £382m of capital funding being allocated to PCTs for the next ﬁnancial year. This money represents a 30 per cent increase on the allocation last year. Mr Burnham said: ‘This funding will mean that patients will have better facilities and access to more sophisticated equipment which will beneﬁt the community for years to come.’n lAndy Burnham Dental face lift Dentists in America and Canada are cashing in on the multi billion dollar anti-aging business, by ﬁtting a device which gives patients a face lift. According to a report in the Ottawa Sun, the device called Angellift ﬁts above the gum lines, and lifts and supports the tissues around the face, so that it removes wrinkles and prevents further deepening of the wrinkles. The device is created with a mould designed to ﬁt the patient’s mouth. Using the mould the Angellift is then made using hard resin and ﬁtted in the mouth just above the gum line. Medical Matrix, the US-based company, which manufactures the Angellift, says about 500 North American dentists have currently been trained to ﬁt the device. Aaron Bruce, an ofﬁcial with Medical Matrix in San Diego, said the concept was used by European actors more than 25 years ago when they would put something behind their lips to change their appearance. The Angellift came about when Medical Matrix was building a prototype insert for a surgeon who wanted to give patients a preview before putting implants under their lips. ‘Then all of a sudden they realized, wow, this is not just a preview but you could wear this without any discomfort and it does manipulate the face,’ he said.n lAngellift...removes wrinkles.
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