- Email: [email protected]
PRESERVING THE OSSEOUS TISSUE-Authors’ response
COMMENTARIES
Robert Delcanho, BDSc, MS, Cert Orofacial Pain, FFPMANZCA, FICD Clinical Associate Professor School of Dentistry University of Western Australia Perth Australia Elizabeth Moncada, DDS, MS, Private practice limited to orofacial pain Redwood City, Calif. Tara Renton, BDS, MDSc, PhD Professor in Oral Surgery King’s College London 1. Esposito M, Hirsch J, Lekholm U, Thomsen P. Differential diagnosis and treatment strategies for biologic complications and failing oral implants: a review of the literature. Int J Oral Maxillofac Implants 1999;14(4):473–490. 2. Delcanho RE, Moncada E. Persistent pain after dental implant placement: a case of implant-related nerve injury. JADA 2014;145(12):1268-1271. 3. Renton T, Yilmaz Z. Profiling of patients presenting with posttraumatic neuropathy of the trigeminal nerve. J Orofac Pain 2011;25(4): 333-344. 4. Khawaja N, Renton T. Case studies on implant removal influencing the resolution of inferior alveolar nerve injury. Br Dent J 2009; 206(7):365-370. 5. Renton T, Dawood A, Shah A, Searson L, Yilmaz Z. Post-implant neuropathy of the trigeminal nerve: a case series. Br Dent J 2012; 212(11):E17. 6. Rodríguez-Lozano FJ, Sanchez-Pérez A, Moya-Villaescusa MJ, Rodríguez-Lozano A, Sáez-Yuguero MR. Neuropathic orofacial pain after dental implant placement: review of the literature and case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109(4): e8-e12.
Authors’ response: Our article addressed the usual causes of dental implant loss and signs manifested by ailing or failed dental implants. A major focus of the article was to discuss criteria that could be used to decide when an ailing implant that was not mobile should be considered failed, and this would dictate its removal to avoid further bone loss. We also thought it was important to discuss the rates of success of dental reimplantations at sites where implants had failed. Implant failures due to neuropathies caused by faulty placement were not addressed. Therefore, we appreciate the letter from Dr. Delcanho and his colleagues bringing this issue to readers’ attention. Gary Greenstein, DDS, MS Clinical Professor
Department of Periodontology College of Dental Medicine Columbia University New York City and Private Practitioner Surgical Implantology and Periodontics Freehold, N.J. John Cavallaro, DDS Clinical Associate Professor Department of Prosthodontics College of Dental Medicine Columbia University New York City and Private Practitioner Surgical Implantology and Prosthodontics Brooklyn, N.Y.
PRESERVING THE OSSEOUS TISSUE
I read with great interest Dr. Gary Greenstein and Dr. John Cavallaro’s excellent August JADA article, “Failed Dental Implants: Diagnosis, Removal and Survival of Reimplantations” (JADA 2014;145[8]:835-842). While this report was well done, the authors recommend “360 degrees” of bone removal for explantation. This method may remove precious facial cortical bone. A method using a 330 bur that removes bone from the mesial, lingual and distal surfaces may be a better choice. This may preserve the facial osseous tissue that is needed for osteogenesis and subsequent implant replacement. The bur is taken to a depth of about one-half to threequarters of the implant length. A fixture mount then can be attached and the implant rotated or luxated out of the osteotomy, away from the intact facial bone. Titanium shavings may be introduced into the bone during the removal of titanium and bone. The bur may remove material at the expense of the implant, rather than the bone, thus preserving the osseous tissue for osteogenesis. Dennis Flanagan, DDS, MSc Willimantic, Conn.
Authors’ response: We thank Dr. Flanagan for his kind remarks concerning our article. There are many nuances regarding implant removal
JADA 145(12)
that were not discussed in the article. Rather, a succinct methodology was presented that is effective. As indicated, a reverse-torque device to remove an implant is the most conservative method for explanting an implant and results in no additional bone loss caused by burring bone. This device can be employed in the maxilla or the mandible. However, there may be denser bone in the mandible, which may provide additional resistance to explantation. Therefore, in the mandible, it was suggested that a bur could be used to reduce bone-to-implant contact to facilitate implant removal. If the bone is thick around an implant, circumferentially using a bur to half the height of the implant is an effective adjunctive procedure. On the other hand, when using a reverse torque device, if the buccal plate of the bone is thin, we agree that the bur should not be used on the buccal aspect. Avoiding buccal bone damage and subsequent bone resorption and recession is desirable. We also concur that, when using a bur around an implant, it should be pressed against the implant to remove more titanium and less bone. One additional point: if a reversetorque device is not used to remove an implant, it is a good idea to go circumferentially around an implant with a bur prior to its removal with an elevator or a forcep. This is recommended because the buccal or lingual plate may fracture upon explantation if there is a high degree of bone-to-implant contact. This result would be worse than thinning the internal aspect of the buccal or lingual bony plates. In conclusion, there are various factors that need to be considered prior to removing an implant: available equipment, efficacy and predictability of procedures, thickness of bone and potential consequences of buccal or lingual plate fractures adjacent to an implant site. Gary Greenstein, DDS, MS Clinical Professor
http://jada.ada.org
December 2014
1213
COMMENTARIES
Department of Periodontology College of Dental Medicine Columbia University New York City and Private Practitioner Surgical Implantology
and Periodontics Freehold, N.J. John Cavallaro, DDS Clinical Associate Professor Department of Prosthodontics College of Dental Medicine
Columbia University New York City and Private Practitioner Surgical Implantology and Prosthodontics Brooklyn, N.Y.
Little things can be a big pain Even with well-fitting dentures Dentures are put through a lot during the day, and trapped food can often cause discomfort. In fact, up to 86% of denture wearers experience this discomfort, making it their #1 complaint.1,2
Super Poligrip® denture adhesive Clinically proven with well-fitting dentures to: Seal out up to 74% more irritating food particles *3 Significantly improve denture satisfaction, comfort & confidence *4
Recommend Super Poligrip® with their well-fitting denture
© 2014 GlaxoSmithKline Consumer Healthcare
1214
* Based on food particle migration vs. no adhesive (1) TNS Info Plan, Usage and Attitude Study, Japan 2009. (2) Chapman Group, Denture care quality of life research; Canada 2005. (3) The Use of Soluble Denture Adhesives to Prevent Food Particles From Becoming Trapped Under Full Upper and Lower Dentures, Study L3920658, 2010. (4) A Study of Denture Adhesives in Well-Fitting Dentures, Study L3510566, 2008.
JADA 145(12) http://jada.ada.org
December 2014
Robert Delcanho, BDSc, MS, Cert Orofacial Pain, FFPMANZCA, FICD Clinical Associate Professor School of Dentistry University of Western Australia Perth Australia Elizabeth Moncada, DDS, MS, Private practice limited to orofacial pain Redwood City, Calif. Tara Renton, BDS, MDSc, PhD Professor in Oral Surgery King’s College London 1. Esposito M, Hirsch J, Lekholm U, Thomsen P. Differential diagnosis and treatment strategies for biologic complications and failing oral implants: a review of the literature. Int J Oral Maxillofac Implants 1999;14(4):473–490. 2. Delcanho RE, Moncada E. Persistent pain after dental implant placement: a case of implant-related nerve injury. JADA 2014;145(12):1268-1271. 3. Renton T, Yilmaz Z. Profiling of patients presenting with posttraumatic neuropathy of the trigeminal nerve. J Orofac Pain 2011;25(4): 333-344. 4. Khawaja N, Renton T. Case studies on implant removal influencing the resolution of inferior alveolar nerve injury. Br Dent J 2009; 206(7):365-370. 5. Renton T, Dawood A, Shah A, Searson L, Yilmaz Z. Post-implant neuropathy of the trigeminal nerve: a case series. Br Dent J 2012; 212(11):E17. 6. Rodríguez-Lozano FJ, Sanchez-Pérez A, Moya-Villaescusa MJ, Rodríguez-Lozano A, Sáez-Yuguero MR. Neuropathic orofacial pain after dental implant placement: review of the literature and case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109(4): e8-e12.
Authors’ response: Our article addressed the usual causes of dental implant loss and signs manifested by ailing or failed dental implants. A major focus of the article was to discuss criteria that could be used to decide when an ailing implant that was not mobile should be considered failed, and this would dictate its removal to avoid further bone loss. We also thought it was important to discuss the rates of success of dental reimplantations at sites where implants had failed. Implant failures due to neuropathies caused by faulty placement were not addressed. Therefore, we appreciate the letter from Dr. Delcanho and his colleagues bringing this issue to readers’ attention. Gary Greenstein, DDS, MS Clinical Professor
Department of Periodontology College of Dental Medicine Columbia University New York City and Private Practitioner Surgical Implantology and Periodontics Freehold, N.J. John Cavallaro, DDS Clinical Associate Professor Department of Prosthodontics College of Dental Medicine Columbia University New York City and Private Practitioner Surgical Implantology and Prosthodontics Brooklyn, N.Y.
PRESERVING THE OSSEOUS TISSUE
I read with great interest Dr. Gary Greenstein and Dr. John Cavallaro’s excellent August JADA article, “Failed Dental Implants: Diagnosis, Removal and Survival of Reimplantations” (JADA 2014;145[8]:835-842). While this report was well done, the authors recommend “360 degrees” of bone removal for explantation. This method may remove precious facial cortical bone. A method using a 330 bur that removes bone from the mesial, lingual and distal surfaces may be a better choice. This may preserve the facial osseous tissue that is needed for osteogenesis and subsequent implant replacement. The bur is taken to a depth of about one-half to threequarters of the implant length. A fixture mount then can be attached and the implant rotated or luxated out of the osteotomy, away from the intact facial bone. Titanium shavings may be introduced into the bone during the removal of titanium and bone. The bur may remove material at the expense of the implant, rather than the bone, thus preserving the osseous tissue for osteogenesis. Dennis Flanagan, DDS, MSc Willimantic, Conn.
Authors’ response: We thank Dr. Flanagan for his kind remarks concerning our article. There are many nuances regarding implant removal
JADA 145(12)
that were not discussed in the article. Rather, a succinct methodology was presented that is effective. As indicated, a reverse-torque device to remove an implant is the most conservative method for explanting an implant and results in no additional bone loss caused by burring bone. This device can be employed in the maxilla or the mandible. However, there may be denser bone in the mandible, which may provide additional resistance to explantation. Therefore, in the mandible, it was suggested that a bur could be used to reduce bone-to-implant contact to facilitate implant removal. If the bone is thick around an implant, circumferentially using a bur to half the height of the implant is an effective adjunctive procedure. On the other hand, when using a reverse torque device, if the buccal plate of the bone is thin, we agree that the bur should not be used on the buccal aspect. Avoiding buccal bone damage and subsequent bone resorption and recession is desirable. We also concur that, when using a bur around an implant, it should be pressed against the implant to remove more titanium and less bone. One additional point: if a reversetorque device is not used to remove an implant, it is a good idea to go circumferentially around an implant with a bur prior to its removal with an elevator or a forcep. This is recommended because the buccal or lingual plate may fracture upon explantation if there is a high degree of bone-to-implant contact. This result would be worse than thinning the internal aspect of the buccal or lingual bony plates. In conclusion, there are various factors that need to be considered prior to removing an implant: available equipment, efficacy and predictability of procedures, thickness of bone and potential consequences of buccal or lingual plate fractures adjacent to an implant site. Gary Greenstein, DDS, MS Clinical Professor
http://jada.ada.org
December 2014
1213
COMMENTARIES
Department of Periodontology College of Dental Medicine Columbia University New York City and Private Practitioner Surgical Implantology
and Periodontics Freehold, N.J. John Cavallaro, DDS Clinical Associate Professor Department of Prosthodontics College of Dental Medicine
Columbia University New York City and Private Practitioner Surgical Implantology and Prosthodontics Brooklyn, N.Y.
Little things can be a big pain Even with well-fitting dentures Dentures are put through a lot during the day, and trapped food can often cause discomfort. In fact, up to 86% of denture wearers experience this discomfort, making it their #1 complaint.1,2
Super Poligrip® denture adhesive Clinically proven with well-fitting dentures to: Seal out up to 74% more irritating food particles *3 Significantly improve denture satisfaction, comfort & confidence *4
Recommend Super Poligrip® with their well-fitting denture
© 2014 GlaxoSmithKline Consumer Healthcare
1214
* Based on food particle migration vs. no adhesive (1) TNS Info Plan, Usage and Attitude Study, Japan 2009. (2) Chapman Group, Denture care quality of life research; Canada 2005. (3) The Use of Soluble Denture Adhesives to Prevent Food Particles From Becoming Trapped Under Full Upper and Lower Dentures, Study L3920658, 2010. (4) A Study of Denture Adhesives in Well-Fitting Dentures, Study L3510566, 2008.
JADA 145(12) http://jada.ada.org
December 2014