JUST ENOUGH IS THE WAY TO GO

K. F. Chow BDS., FDSRCS November 16th, 2010

“Wolff’s law” states that bone models and remodels in response to the mechanical stresses it experiences so as to produce a minimal-weight structure that is ‘adapted’ to its applied stresses. The behaviour of bone according to Wolff’s law mirrors a fundamental trait of mother nature, i.e. optimal economic use of substance in the performance of a function.

Thus to use a wide diameter implant because there is a wide hole seems to contradict this fundamental. A living organism deserves to be treated according to living rules of life, not static non-living engineering presumptions.

Granted that we need to use a titanium screw, since the tooth germ implant is not yet available….. it does make more organic living sense to use the optimal titanium necessary to allow maximal living tissue around it and thus also minimize the perio pocket that inevitably forms around all dental implants.

Minimized and optimized diameter implants should be the trend and not large diameter dental implants. If we have to put something foreign into the living body, put in the smallest you can. That is what the “GREEN MOVEMENT” is all about…… to use just enough and leave the rest alone and we will save the world !

After all, are we not living in the narrow sweet zone between bleeding to death and clotting to death. And if our beloved earth is 10,000 Km nearer or further from the sun, we will either burn or freeze. Just enough is the way to go.

THE TRANSMUCOSAL PASSAGE OF THE DENTAL IMPLANT AND THE THREE CRITICAL MARGINS

You can see and hear the lecture on the three critical margins of implant dentistry..... boring though !!
http://www.youtube.com/watch?v=N1GF_82dY1g


Every dental implant ever placed has created an iatrogenic  periodontal pocket. Yap! Has created a pathology in the mouth that has a certain amount of inflammatory infiltrate around it that ranges from a low grade perimucositis to a full fledged peri-implantitis.


This fact does militate against  the use of large and extra-large diameter implants. The periodontal pocket that accompanies every dental implant we place is a reality that every implant dentist must accept and manage as an acceptable evil for the sake of the greater benefit of being able to replace a lost tooth almost as good as before.

 The issue at hand is what is the best approach to managing this compromise for the sake of the larger good. The best replacement for a lost tooth of course is another tooth, and that will likely come in the future in the form of a tooth germ implant or stimulation of germ cells already present but dormant. As that may take another generation or so before we can bypass all the barriers involved, we are stuck with titanium screws for the forseable future with its accompanying perio pocket and the management issues involved.

KAI FOO'S THREE CRITICAL MARGINS

The transmucosal passage of the dental implant is a poor imitation of that of the tooth. The tooth has a very sophisticated self-renewing living cuff around the neck of the tooth as it emerges into a bacteria filled environment.

There have been some claims of hemidesmosomes between the connective tissue and the surface of the implant but they are at best a far cry from the original ! Let us look at a study on the inflammation present around dental implants.

"PERSISTENT ACUTE INFLAMMATION AT THE IMPLANT-ABUTMENT INTERFACE"
is the title of this study. The conclusion suggests that,  "these findings may motivate a clinician to place an implant shoulder above the alveolar crest or to utilize a one-piece implant to minimize potential inflammation and/or possible hard or soft-tissue loss".


I would like to further add that narrow diameter dental implants will give a smaller transmucosal passage and therefore arguably lower the amount of inflammation and therefore the chances of peri-implantitis in the long run, provided that satisfactorily hygienic prostheses( read the BUDDY SYSTEM in this blog) are delivered at the same time. This is assuming that narrow diameters are strong enough...... and time is beginning to indicate that it is, when used in the right way and context.

http://smalldentalimplants.blogspot.com/2010_05_01_archive.html


http://smalldentalimplants.blogspot.com/2010_05_01_archive.html


http://smalldentalimplants.blogspot.com/2010/05/buddy-system.html

http://smalldentalimplants.blogspot.com/2010_05_01_archive.html

BONE CLIMBING UP MINI DENTAL IMPLANT

I think I am seeing things.........but my patient is not complaining and is happily biting away.

The upper right did not have that much bone, so I did a sinus lift .....what.
Hoping to develop and innovate to the point that I can use all minis and still lift the sinus ......or avoid it like some 3 rooted upper molars do....2 buccal roots in the buccal sinus wall and 1 palatal root in the sinus palatal wall.......what?!  You canna do that you....... well if He can, why not little me? Will keep ya allll posted.

Oh, this guy did not wanna his lower right bridge yanked and thrown away. So we salvaged it with a mini right through the pontic. Told 'im that its temporary......but now its almost 3 years and he thinks its permanent. Anyways.... I never promised him its permanent!

BONE CLIMBING UP MINI DENTAL IMPLANT

Immediate extraction and implantation. Bone level is definitely higher than when the implant was first placed.

Well what do you think? Nah........ can't be bone climbing up the implant. Its a camera trick!
Whatever it is, I am really glad and I guess I will continue to do this "miracle" as long as the miracles keep coming and not run out.

Not very scientific, but my patient is not complaining.

BONE CLIMBING UP MINI DENTAL IMPLANT

A case of immediate extraction and implantation, followed by PFM bridge within 3 weeks. Follow-up xrays showed healthy bone growing around the minis. Not only did the bone seem to have climbed up the second implant from the left, there is also a layer of healthy cortical bone around it and between the minis.

There was a study that claimed that bone remodels around the minis at much higher rates than around a conventional, indicating the possibility that the bone around the mini maybe mainly woven bone and therefore not as good and sound as that around a conventional. Looking at this series of xrays, I am not sure that is true and if so, is it a disadvantage or advantage?

 There is also the possibility that the bone that seemed to have climbed up the mini may not be in close intimate contact with the surface of the implant, and therefore may not be osseointegrated. Alright then, I am going to CBVT this one as soon as I think it is necessary enough to buy one.

BONE CLIMBING UP MINI DENTAL IMPLANT

This young girl avulsed her tooth. It was reimplanted and splinted. Endodontics was done, but eventually the tooth had to be extracted due to external resorption of the root. A mini was subsequently placed with a composite crown in place. About 13 years old then, orthodontic treatment was commenced and completed. By then, she was about 16, so we placed in a PFM. If we compare the 2 Xrays closely, it can be seen that the bone level has climbed or risen up to match that of the adjacent teeth. Thus in young children, where bone maturity has not been reached, an adjustable composite tooth built on a mini may be an option in order to compensate for bone growth and obviate submergence that may result. Treatment of choice?

Bone has climbed up along the mini implant and even up and around the base of the PFM.