Dental News - AAID: The great debates

Dental Tribune USA

Thu. 17 January 2013

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WASHINGTON, D.C., USA: When the American Academy of Implant Dentistry planned its 2012 annual scientific meeting in Washington, D.C., the scientific program chair, John Minichetti, DMD, and his committee decided to change the format from the AAID’s traditional main podium presentations to debate-style sessions in which experts would address contrasting positions on key issues in implant dentistry.

“With the meeting scheduled in Washington a month before the presidential election, we had the perfect venue to develop a series of provocative debates over the four days of the conference. It was a major departure from our usual format, but we believed it was worth the risk,” Minichetti said.

Based on the rounds of applause after many of the debate sessions and supportive comments buzzing around the meeting, held at the Washington Hilton, Minichetti’s hunch proved right. Not only were the 10 debate presentations informative and sometimes entertaining, they often shifted opinions on various issues among the dentists in attendance, according to the AAID.

At the beginning of each session, cases were presented with radiograph slides and the audience was given multiple-choice options for selecting their treatment and procedural preferences. After the speaker presentations, the audience was polled again, and results were displayed showing before-and-after opinion changes, some of which were significant.

Long vs. short implants

The debates began with presentations on the advantages and disadvantages of long and short implants. The speakers were Michael Pikos, DMD, and Marco Esposito, DDS. Pikos made the case for using longer implants, and Esposito covered the versatility of shorter implants. Before the talks, the audience was presented a case and asked to choose a treatment option. They also were polled on what they consider to be the length for a short implant and for their opinions regarding the optimal length of implants. Eighty-one percent of session attendees voted that longer implants are best if there is enough anatomic space and 45 percent considered a short implant to be less than 8 mm. For the case presented, 49 percent would choose to perform a lateral window sinus graft and place implants at the same time.

Pikos mentioned that the failure rate of short implants is as high as 30 percent in one study, and the key reasons for failures are crown height, bite force and insufficient bone density. He said some of the major advantages of longer implants are better primary stability, immediate loading, well-suited for patients with bone loss, less need for splinting and lower risk for peri-
implantitis. Pikos said in his career he has placed 15,000 implants with a success rate of 98 percent, and he added that more long-term data is needed on shorter implants.

Esposito focused much of his presentation on bone stability and said there is more bone loss around longer implants. Shorter implants, therefore, are preferred when bone grafting is necessary, and less bone is needed for shorter implants than is commonly thought.

Esposito and Pikos agreed that more long term data from randomized clinical studies are needed to improve understanding regarding the overall utility of shorter implants.

After the presentations, the audience vote showed no change in the treatment choice, a jump to 74 percent agreement that a short implant is less than 8 mm, and an even stronger preference (81 percent) for longer implants as the best choice if anatomic space is sufficient.

Guided surgery vs. freehand

Another debate topic covered the advantages of digital image guided surgery vs. freehand techniques. The speakers were Scott Ganz, DMD, and David Vassos, DDS. Before they spoke, attendees were asked to choose treatment preferences for two cases: a patient with a fully edentulous mandible requiring placement of five implants for a fixed prosthesis and an edentulous maxilla for which the patient wants a fixed prosthesis. For the first case, 33 percent of the audience chose flapless guided surgery with a CT created surgical guide and 66 percent favored free-hand flapless surgery, with and without guides. When asked to explain their choices, 28 percent said better outcomes and quicker recoveries are achieved with guided CT surgeries and 39 percent said flap surgeries give more consideration to soft tissue and allow for bone manipulation.

For the patient with an edentulous maxilla, freehand flap surgery with an unrestricted surgical guide was the choice of 47 percent of session attendees before the debate.

In his presentation, Ganz reported on the advantages of cone-beam, CT imaging and stressed that it is the best diagnostic tool to assure proper placement of implants and is becoming the standard of care.

Information from digital-imaging studies enables dentists to devise superior treatments. “It’s not the scan, it’s the plan,” Ganz said. He added that freehand surgery offers no guarantees that implants will be placed in ideal locations, and digital imaging reduces morbidity, surgical time and makes crown fitting easier for the restorative dentist.

Vassos maintained that dentists should first and foremost become highly skilled surgeons and then utilize technology. Excellent surgical skills are the best way to assure proper implant placements and high-quality outcomes.

He said guided surgery can provide function by stabilizing prosthesis, but for severely compromised patients, it can rarely meet expectations. Guided surgery, therefore, has its place, Vassos said, but will never be a replacement for surgical skills necessary to restore bone and papillae for optimal esthetics and patient satisfaction. He also said there is no substitute for knowing the patient’s medical and life histories to gain better insight regarding desired outcomes, healing issues and other factors that could influence treatment success and patient satisfaction.

After the presentations, the vote on the case of the fully edentulous mandible showed that just 19 percent of the audience opted for flapless guided surgery with a CT-created surgical guide and 81 percent chose freehand flapless surgery. Sixty-five percent explained their choice was made because flap surgeries give more consideration to soft tissues and allow for bone manipulation.

For the edentulous maxilla case, there was more support for guided surgery with 33 percent of the respondents supporting it, and 26 percent agreed that placing immediate provisionals is easier with guided surgery. The top treatment choice post-debate was osteotomes, drills and bone manipulation with an unrestricted guide and delayed function, which garnered 41 percent of the vote, and 53 percent agreed the two-stage option with free hand surgery is more predictable with delayed loading.

Bone-grafting options

Bone grafting was one of the other debates, and the speakers were Alfred “Duke” Heller, DDS, and Edgard El Chaar, DDS, MS.

Heller covered realities of additives and if these materials really make a difference. El Chaar spoke about the benefits of growth factors in ridge augmentation procedures.

The first case presented to the audience involved an extraction site with a facial defect for which site development was desired. A second case was a ridge defect with inadequate bucco-lingual width.

In the first case, two-thirds of the respondents chose a particulate graft with an allogenic graft and 21 percent said they would use growth factors. The preferred closure method for 40 percent of the audience was a resorbable membrane with primary closure, and 90 percent said they would wait at least four months before re-entering the site to place an implant.

Heller told the group that management of bone atrophy has created an entire discipline of bone-grafting techniques. Today, many additives are included in autogenous allografts and xenographs to help enhance bone growth. He showed evidence that bone-grafting materials, many in pure form, still are what dentists should consider for onlay bone grafting, sinus grafting and socket preservation. El Charr reviewed studies on the use of growth factors and said they have helped make socket preservation and ridge-augmentation procedures more predictable.

Following the talks, the audience vote showed that for the extraction site with facial defect case there was no significant shift in opinion, as 68 percent still preferred to use a particulate graft with an allogenic graft. More than half of the respondents (52 percent) said they would use a restorable membrane with primary closure vs. 39 percent pre-debate. Regarding re-entry time for implant placement, support for waiting just three months jumped from 10 percent to 19 percent, but the overwhelming majority still preferred waiting four months or longer.

Other debate topics

There were several other debatable issues presented on the main podium, such as:

“Vertical Augmentation: Vascularized Osteotomies vs. Guided Bone Regeneration” by O. Hilt Tatum, Jr., DDS, and Istvan Urban, DMD, MD,
“Prosthetics: Glass Ceramics vs. Metal Ceramics” between Christian Coachman, DDS, and Christian Stappart, DDS, PhD
“Esthetics: Ceramics vs. Gingiva,” by Sonia Lezey, DDS, and Braham Miller, DDS.
“Botox and Dermal Fillers for Facial Esthetics vs. Plastic Surgical Prosthetics” by Louis Malmacher, DDS, and Leo Keegan, MD .
“Treatment Planning: Bioengineering vs. Design Engineering,” featuring Carl Misch, DDS, MS, PhD, and Paulo Malo, DDS, PhD.

Other debate presenters included Drs. David Garber, Maurice Salama, Michael Sonick, Maurice Steigmann, John Russo and Fouad Khoury.

“A lot of audience members told me this was the best format for a meeting they have ever attended,” Minichetti said. “Dr. Shankar Iyer, Dr. Larry Bush and I really wanted to get the audience involved at this meeting, and I think the format worked well in that respect. We had people in the hallways raving about the presenters’ comments and ‘high fiving’ me for a job well done.”

Looking ahead

AAID’s 2013 Scientific Meeting is Oct. 23-26 in Phoenix, and the theme is “Technology and Biology Converge.” The scientific program will provide comparisons of various treatment options, and challenge dentists to think about the choices they make. Conference speakers will explore how biology and technology converge to improve treatment options for difficult and complex cases. Separate session tracks will enable attendees to choose the topics most beneficial to them in their own practice.

(Source: AAID)

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