Perspectives - Group 3

Perspectives
September 2003
Kraut, Richard A. DDS
Implant Dentistry: Volume 12(3) September 2003 pp 196-197
Lippincott Williams & Wilkins
Dental Implant Center
Montefiore Medical Center
111 East 210th Street
Bronx, NY 10467
Richard A. Kraut says...
The surgical phase of endosteal-implant surgery can appropriately be divided into simple and complex surgery. The placement of an implant anterior to the mental foramina where ample bone exists is surgically less challenging than surgery that requires osseous augmentation, or one that requires nerve repositioning. In the maxilla, implants placed in the anterior esthetic zone in patients with a high lipline, are more surgically challenging than those placed in patients with low liplines with ample osseous volume for implant placement. A major advancement in implant surgery over the past 10 years is the ability to increase bone volume in the posterior maxilla via the use of allografts enhanced with growth factors from the patient's platelets. There are now a variety of techniques utilized for augmenting the posterior maxilla that take advantage of this relatively simple surgical procedure and provide the patient with more predictable, allograft-supported implants.
In the past 10 years, the surfaces of implants have improved, enabling the implants to achieve integration earlier; perhaps even more importantly, integration in less dense bone appears to have become more predictable. The future of bone augmentation will involve minor modification of the use of allograft and platelet-rich plasma, as well as the use of autogenous bone, in those cases in which either a cortical cancellous graft or a bone marrow graft is needed because of the severity of the atrophy present at the time the patient presents.
The future of surgery will be enhanced when bone morphogenic protein becomes available to implant surgeons. Because of marketing priorities, the drug company that has developed bone morphogenic protein has chosen to introduce it only into the spine surgery market. When bone morphogenic protein becomes available for implant dentistry, there will be considerable research necessary to determine the appropriate carrier for this protein to ensure that the protein will have ample time to stimulate bone growth and adequate volume will result to support the endosteal implant reconstruction that the patient is ultimately seeking.
Understanding and Differentiating
The most significant surgical advance in implant dentistry over the past 10 years has become the common acceptance of CT scanning as part of implant treatment planning. Through the use of CT scanning, one can clearly identify those cases that are going to be surgically and prosthetically challenging and differentiate them from those that are surgically routine and restoratively less challenging. It is this ability to understand the osseous and soft tissue foundation on which the restoration will be built that has enabled us to differentiate those cases that are routine from those cases that are challenging. I function in a tertiary care center in which 85% of our patients who receive endosteal implants are classified as surgically less challenging patients compared with the 15% that truly are surgically and prosthodontically challenging.
As an oral and maxillofacial surgeon who is very interested in implant placement and reconstruction, I have followed the prosthodontic evolution of implant dentistry with great interest. Our industry partners have offered us a variety of new abutments that simplify implant restorations. They have continued to offer the full diversity of implant componentry that is necessary for the more challenging cases. However, they have recognized that there are many cases that can be restored quite simply with a minimum number of parts and screws, making implant dentistry comparable with conventional crown and bridge. This is a natural evolution in the implant dentistry arena and one that should be welcomed. The companies still provide the diversity of abutments needed to restore the most challenging cases; yet, those cases that can be more simply and successfully managed with fewer components should certainly be managed in that way.
Who is Treating What
Change in health care is inevitable. We have been fortunate that over the past 10 years, implant dentistry has become well established as part of American dental care. Implant dentistry is no different than any other form of dentistry. The well-trained generalist may take out numerous teeth, yet will refer the difficult impaction to an oral and maxillofacial surgeon. A similar situation should exist with regard to the surgery for placing implants. If a generalist feels that a patient has adequate bone and soft tissue, and he or she feels comfortable in placing an implant, I see no reason why the generalist should not go ahead and treat the patient. Those cases that the generalist believes to present more of a surgical challenge than he or she wishes to undertake can and should be referred to either an oral and maxillofacial surgeon or a periodontist who has greater experience in the surgical phases of implant dentistry, such as distraction osteogenesis or complex grafting. A similar situation exists with the restoration of implants. Well-trained generalists can restore many implants quite eloquently. However, there are cases that are extremely challenging to restore where the added training and expertise of a prosthodontist are truly critical to the long-term success of a case.
The American Dental Association has made it clear that in the United States, we are not going to see a specialty called implant dentistry. The majority of American dentists are general dentists and serve the American public well. It is for the generalist to decide which cases are appropriate for referral. The current dental specialties are ready and able to meet the needs of those patients who need specialty care, be it the surgical or restorative phase of implant dentistry.
ий 2003 Lippincott Williams & Wilkins, Inc.