9 Year follow up showing how essential a CBCT is to prognosticate future treatment

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Posted on By Howard Gluckman In Anterior/Esthetic

This is now the full picture of the case previously posted and linked to and it is a great case for discussion. Most of us rely on PA X-rays to determine health and also to prognosticate future health and possible treatment. This case shows clearly how crucial a CBCT is and how a PA is really wholly inadequate as it shows only the 2D picture. How many clinicians show only PAs at conferences and claim success of either a bone graft or an implant placement. we need to see the full picture in 3D. This case also shows the importance that PET will start to play in the future. The lack of collapse if we had kept the tooth in the 22 area or if we had a socket shield in the 21 we would still have a healthy situation of that I have no doubt.
I am interested in your thoughts about this

Here are the 6, 7 ad 9 year buccal pics which show extensive buccal recession which is increasing as time goes bye and may indicate further loss of bone over time causing the recession.

CBCT showing nothing on the buccal of the implant and which now more accurately informs us of the state of the implant.
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28 Comments

Great case to learn from Howard,

I agree 100% that a CBCT is paramount for implant placement, specially in the front region and specially if it will be a post extraction case.

How many times I have taken a CBCT and found inadequate anatomy for immediate placement. This is impossible with periapical Xrays.

Also plays a key role to determine angulation. In a big percentage of cases we can't place immediate implants for screwed prosthesis due to the angulation we have to place the implant at.

When I see doctors in conferences show cases of immediate implant placements and just a periapical for the diagnosis, and say that they always aim to get a screw retained restoration by coming out in the cingulum, I wonder how many times they run into trouble.

Thanks for sharing


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Agreed Andoni. I think a lot of people are fooling themselves into thinking that their treatment protocols are successful when in fact they are total failures.


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If the result is maintained after 9 years we must consider how we evaluate success. Is labial bone a requirement? Or is thick KT acceptable?? Great discussion. Thanks Mo


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I think we still need to evaluate success the same way. This patient had thick gingiva and is slowly resorbed over time and got worse and worse. We may get away with it like in this case because he has a low lip line and is a low aesthetic value case but in other cases we won't be so lucky. "Bone sets the tone but tissue remains the issue" ---Team Atlanta


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Wow, that is an eye opener. The big question is what Maurice said. How do you interpretep this info now. Do you proceed with GBR or watch? Maybe absense or presence of clinical symptoms and Probing depth could help??

Yiannis


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Howie. This case represents the unavoidable ugly truth what happens overtime following extraction and loss of PDL. Placing an implant obviously didn't prevent continuous loss of bone and soft tissue. In reality implant placement only amplifies the impact upon us and our patients. So what choices do we have? IMO we need to treatment plan knowing continuous remodeling and loss of tissue is inevitable. Unless of course PET proves to be a long term viable solution. PERSONALLY,in the absence of PET, I tend to rely upon smaller diameter implants skewed toward the palate because palatal bone resorption is less than the facial. In addition, I rely upon the use of CTG early in treatment.IMO CTG is the most effective and resilient reparative tissue in the long run. Even though I find GBR to look best on a radiograph (even a CBCT) in the early years, It appears in the long run the "grafted bone" eventually converts to some form of tissue other than bone. Maybe we should work harder to save teeth or at least parts of them? Great case and documentation. Thank you for sharing. Best regards. Chuck.


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Yiannis I am not sure the future treatment is the issue here but rather the past treatment. These days we would leave the roots with PET and then this would not be an issue. This case will go on for many years of that I have no doubt and perhaps one day periimplantitis will set in and we will have to treat.


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Howard:

Excellent discussion case. I tend to see a similar remodeling pattern in several other implants with an "aggressive" thread pattern, especially in anterior implants. I use the Ankylose implants, and I love them, but I see more long term active buccal plate remodeling in comparison to other implants with less aggressive thread design. Maybe, it is not the bone to blame here. Maybe we need to rethink the more aggressive thread design.


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Howie

Mo, Charles and Salah- great comments and all valid points
My question is what role does hygiene and occlusion play in this?

9 years is a good period- a 3 unit anterior bridge bridge in a male- where could be parafunctional habits- constant protrusive and bit forces
could there be already Peri imp hidden? Questions like what does patient brush with? Could he brush away KT thickness- that's a question a OMS needs to look to all you cats about?m How often does go in for hygiene- Is he wearing a splint or night guard?

Chuck, I think PET works but do we have 9 year follow up in this same case? - who's to say we would not have PET exposure with thinning of KT? What is this bridge was 22-24 in mandible?

Salah- that's food for thought- and very valid- I used to use ankylosis an and Xive- and have a 10 yr full mouth case that comes to mind on a smoker That comes to mind with multiple bridges that I will try to find -where I've had issues but implants are solid- but as I write and think- we may have to classify aggressive threads when placed in a healed site vs immed placement where we always leave a gap to the plate- so no thread contact except for apically- That brings up another question I have about "densifying" and if this holds true- if we use your beautiful technique on immed #9- drills never touch buccal plate- so all palatal bone- if we PET in Immed case, doesn't drill run high chance of touching PET apically - Lastly- Salah- Take same situation Howie faced with 3 unit bridge- you think ODT ( osseodensification is just too dang long to type out each time so I am crowning it ODT if not taken already!) would have make a difference?

Cheers and for all those going to Xp- don't expect me to give a response like this in person!

Richard



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Great discussion...it will continue and thee are MANY MANY cases walking around like this one Howie displays so nicely. What's next?? I think "PET", really born here on this Forum....in it's current form will be a KEY!! Aggressive threads to me not so much an issue, hygiene not an issue in thick KT cases, Trauma from occlusion ALWAYS an issue but most of uss do not have off axis forces on our implants......so.....See you all in Florida!! regards Mo


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Rich Thanks for your great response and reply. See my response to Salah about the thread design. With regards to PET I agree with Chuck but you are right who is to say what will happen with them long term. However I am very optimistic about them and even a little exposure can easily be managed easily. I do not believe at all that occlusal forces and bit have anything to do with either bone loss or soft tissue loss around implants and I do not believe there is much data around that and it is also very difficult to measure if there are. This is a simple fact of no buccal bone caused by loss of the tooth. I don't think there is another factors involved.

I may be wrong. But hey thats how I understand it at the moment.

See you soon my friend. Looking forward to it.


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Salah Im not sure that the thread design is the issue. I have many cases of perfect bone on implants with very heavy threads. See the case below 4 yrs post op bel active very heavy threads and the bone is good. The case you see in this post lost its bone almost immediately and it was only the KG that held it together. But this started going at a later stage.

4 years post op


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Wooow !! what great post !! This is so educational, thank you Howie.
Makes my mind wonder though..Was this implant placed in a more palatal position as you would do today?
Was a xenograft used in the gap?
I look at long term follow up studies by Dr Buser for the contour augmentation and wonder even more :) It may not be bone thats on the buccal, but do we need bone or is it sufficient to have the xenograft particles maintaining contours and tissue levels?
To me there is now no question, PET is king, and it is only through this forum that i have come to realize this. But what about those other situations when PET is not possible??

Thank you for this great discussion, see you soon :)

Best,

Ehab


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Gents,

I will have the PET -ODT convo over a nice 18 yr

Cheers,

RJM


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Thanks for the comments Ehab I completely agree with you. I do think that todays placement protocols would have helped with the bone but again with multiple extractions it was bound to collapse. PET is the answer I strongly believe that and if we had not extracted the tooth between the implants this would not have happened and if we had socket shielded then it would be perfect to this day. But then again RIchard Martin makes a valid point in that we have no 9 year data. So lets see in 4 years time. See you soon


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After reading though this discussion , I realized that there is no definite reason for such bone loss has been established. Is it true or may be I missed something?


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Anton. LOSS OF TOOTH AND LOSS OF PDL RESULTS IN LOSS OF BONE. DEFINATE CAUSE and EFFECT RELATIONSHIP.


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Thank you Charles for enlightenment , but how do you explain Thin labial bone around the teeth 6-11, dehiscences and fenestrations around healthy roots with healthy pdl?


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Anton. Regarding teeth #'s 6-11, I assume you are not referring to this case specifically. If so I am missing something. However, if your observations and questions are generalized, I believe the explanation is related to developmental factors associate with eruption and tooth position within the alveolar envelope. Some teeth (for example mandibular anteriors) never have nor had any buccal and/or lingual bone to begin with. The PDL will only maintain existing bundle bone so long as it is within the alveolar envelope. Hopefully this answers your question. Best regards. Chuck


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Anton read Chucks answer below. There is no confusion. and there is only one reason. Remove the tooth and the buccal bone disappears as simple as that. Preserve the buccal plate with PET and there is no collapse.


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IMO there is at least one more reason Why we do have buccal bone loss after teeth are extracted . PET WILL ONLY DELAY THIS LOSS.


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The important missing information in this case is the starting point . Did you have a CBCT at time of insertion? What was the thickness of labial bone over the implant fixture at time zero? What parafunctional habits and occlusal pattern are there, these are also very important factors to add into the equation, to help determine is this just the natural history of progression or the result of lessons already learned. Can PET prevent this type of bone loss or will we find different problems 9 years down the road with PET. Only tincture of time can tell.


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Jerome you make some good points as we know from Evans and Chen as well as others that the thickness of the buccal plate will determine the amount of plate resorption as well as recession. I don't have an initial one so can't say but one thing is for sure the bone went quickly. One area I do not agree with is that bite and occlusal forces played a part in the bone loss.


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Richard:

Osseodensification is a way to enhance bone thickness in the immediate area next to the implant thread. Our histological studies have showed; with osseodensification, a 1 mm of densified bone has remained vital next to implant thread at 10-12 wks of healing. But the study did not look at how that bone remodel under function or load. I honestly believe that biology still dictates the need for 2 mm of bone thickness next to a titanium thread regardless if it is densified or not. I do more socket shields now. It does make biological sense to save the dentin layer. After all, histologically, it is a densified bone layer with attached PDL :)

Jorge Campos, Chuck Schwimer and I have posted cases where we used the Densah bur to finish the preparation of the shield. The DB do not chatter as traditional drills do, so in my hands, there is a minimal effect on the shield stability.

Also, with immediate placement with or without a shield, Chuck Schwimer, and Ziv Mazor both have introduced the method of using the DB in CCW rotation to densify an allograft in the extraction socket before implant placement. Our initial findings have showed that this method does increase insertion torque and ISQ and may enhance initial stability. I will post a case soon from this study.

Below please find a link to:

1- The healing histology Study by Trisi, et al. It is due to be published in Feb.2016.
http://www.ncbi.nlm.nih.gov/pubmed/26584202

2- Link for the socket shield preparation using the Densah Burs.
http://forum.dentalxp.com/case/details/socket-shield-osseodensification/5094

IMHO, both PET and Osseodensification are ways to preserve nature to optimize the site for maybe more predictable outcome.

Salah


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Salah,

Don't get me wrong- I think ODT is genius and I need another set- I may have missed that post but will check it out- you gents post so much good stuff- I have to take a day off just to keep up


Cheers,

Richard


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Richard:

You are good, my friend. You got the "ODT". I like it. See you in Florida. Please join the Versah "Lunch and learn". Good cases presentation and discussions will take place.

Salah


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See you there!!!


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See you there!!! I'll be with Henry but I'll come by


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