Dental Press Implantology – ISSN 2237-650X
Dental Press Implantol.
v. 06, no. 4
October / November / December
César Arita in memoriam
Briefly, according to technical routines and recommendations, the editorial of a journal should present relevant opinions of the publishing team or board of directors about a topic of general interest for its readership. It may also specifically focus on the sequential organization of the topics or articles chosen for a certain issue.
Exceptionally in this issue, the Dental Press Implantology journal, represented by its chief-editors, Professor Carlos Eduardo Francischone and Professor Alberto Consolaro, has offered us space to express all our sadness and grief for the sudden and unexpected passing of a learned exponent of Brazilian dentistry (Sept 14, 2012). At the age of 45, with 24 years of professional experience, at the climax of his career and his life, Professor Dr. César Augusto Arita has left us.
A list of a considerable number of renowned professors and dentists that had the privilege of contacting him or the opportunity to know César Arita would certainly reveal a natural and predictable convergence towards the same conclusion: He was a diplomat of Dentistry! A skillful supporter and disseminator of scientific knowledge. A talented speaker. A sensitive and mordant critic of unprofessional ways and improvisations in our profession. An up-to-date, pragmatic and restless thinker. A man with a refined education. A qualified holder of sophisticate culture and incontestable intelligence, always framed by a subtle and highly refined sense of humor.
Uncountable friends and close relations would be much more capable and prepared to provide details and rich reports of all that was built under Professor César Arita’s influence and guidance, and that he has effectively influenced the evolution of Dentistry as a science, art and profession. In truth, it would be very easy and even bureaucratically simple to dwell on his exemplary and admirable professional resume, abundant and fully accessible in the Internet or social networks. However, the purpose of our editorial today, within the limits of only two characteristics of César Arita’s profile — humility and simplicity — is to report on a fact that occurred a very short time ago, during his last class, on September 10 of this year, in the São Leopoldo Mandic School of Dentistry, in Campinas, Brazil, where he had very recently joined the faculty of the Master’s and Doctorate Programs in Implantology. Without predicting, in any way, what was about to come four days later, he intuitively decided to change the direction of his class about the concepts of Occlusion, Dental Prosthesis and Oral Rehabilitation, which he knew in depth, and drew attention to the importance of social interactions and the richness of human values, exclusively on the basis of experience and free observation, definitively leaving a great, thoughtful lesson imprinted in the memories of all the students present on that day.
At a certain moment, in the middle of his technological and cybernetic class presentation, that born teacher made an abrupt stop and, after a quiet pause of seconds, started philosophically dwelling vehemently on the topic of the intense, true and legitimate essence of human relations that had blossomed exactly there, in the classroom, from the casual meeting of colleagues of all origins, where what really mattered was the reunion of multifaceted currents of thought, responsible for the immeasurable benefits of addition and multiplication, always by means of exchanging, sharing, constructively granting the gifts of personal, human, social and scientific interchange that undoubtedly consolidates positive knowledge and solid friendship. On that day, at a certain point, Professor Arita prophesied: “… we are discussing basic concepts of occlusion in a Doctorate class… therefore, you may think: What does that have to do with my course? What am I doing here? And the simple answer is: In a broad view, any concept, any principle is part of any trajectory. When you teach your classes, you’ll face a great challenge: to find a proper connection with your students. How can that connection work if we do not turn our eyes to what is simple, to what is basic? This is the key, and also the challenge! The world today and, above all, young people desire something special to catch their attention, so that they may connect to a specific topic. You have to find that, otherwise you will not be heard…”.
By sheer chance and fate, this playful outburst was casually recorded by the cell phone of a doctorate student, Ariádene Cristina Pértile Rosa, as she perceived the didactic and philosophical content of that message, and her sensitive feeling made her record that moment. In the next meeting, immediately after the professor passed away, Ariádene taught the master class with fragments extracted from those insights, bringing back to mind the memories and the awareness of all in the class, in a just and emotional tribute.
How many times in our lives do we involuntarily test our real capacity to withstand hardship or great losses, no matter how old or how personally experienced? The more we can assimilate these hard, unexpected and unwanted blows that life now and then deals us, the more resistance we gain to survive and overcome them, contrary to what we might expect. For that, it is important to hold tight to the good examples left by all those that are extremely significant to us. It will certainly help us to improve and recover our strength faster in face of any possible adversity.
César Augusto Arita, as a human being, was special. Regardless of his oriental origin and his contagious happiness wherever he was, he also managed the feat of expressively “smiling” with his eyes. He had an emperor’s name, the physique and moral stature of a “great” man. Maybe to justify the captive shelter of a great heart full of goodness, as well as the strength and space to conquer and welcome endless new friends and discoveries. There was no time left…
However, it consoles us to know that he will remain among us for many years. Not physically any more, unfortunately. But in the living, germinating form of all the ideas that he sowed; in the seeds of knowledge and teachings that he planted, in the ethical position that he held, the examples and the memories that he left…
We dedicate these words and this issue of the Dental Press Implantology journal to this distinguished figure of the academic, scientific and professional circles of Brazilian dentistry, together with special and affectionate reference to his wife, Camila Arita, and his only son, Augusto Arita, equally important and fundamental living cells of his legacy.
Franklin Moreira Leahy
Ariádene Cristina Pértile Rosa
(PhD students of Implantology, São Leopoldo Mandic School of Dentistry).
With over 30 years of experience in osseointegration, more than 200 published articles, Professor Dr. Georg Watzek is divided — with remarkable skill — between university life, politics and his private clinic, proving to move comfortably and with great expertise from the scientific knowledge to clinical results, as shown in this interview to the Dental Press Implantology journal.
Committed researcher and professional acting since early 80’s, the carrier of Professor Georg Watzek is intertwined with the history of European Implantology. It features a large and experienced view of the entire universe involving osseointegration as a science.
Head of the Department of Oral Surgery of the University of Viena, the renowned professor is dedicated to multiple activities, closely related to the deep study of osseointegration and its applications.
Currently, he is a member of the scientific research committee of the Osteology Foundation in Switzerland, coeditor of the International Journal of Oral & Maxillofacial Implants, member of the Nobel Biocare directors board (Sweden), besides caring his private practice, in Viena.
Invited to lecture at the III International Congress of Implantology, he demonstrated the large experience he gained over the decades as an implantologist, where he discussed several issues related to his presentation, as well as other interesting issues that were a rich source of information to compose this interview.
Explanations and applications
Diagnosis of occlusal trauma: Extrapolations for peri-implant bone region can be done
Occlusal trauma. Occlusion. Gingival recession. Tooth trauma. Abfraction.
Images provide a language to describe the dynamics of bone and tissue. Bone density and space distribution vary and indicate greater or lower reaction and adaptation to functional demands, such as masticatory loads, on natural teeth or osseointegrated implants. In rehabilitation, load distributions have to be planned, and the remaining teeth and their relation with neighboring bone should be evaluated. The detection of bone responses to pre-existing occlusal trauma may provide a more accurate evaluation of masticatory conditions and parafunctional habits, that is, a true functional history of remaining teeth. Occlusal interference and overloads take months or years to induce classical signs and symptoms of occlusal trauma as a clinical entity. When a tooth has pulp necrosis and signs of occlusal trauma, the evaluation of history, as well as all tests, should be directed to the diagnosis of superposed dental trauma even when posterior teeth are affected. There is no scientific basis to confirm that occlusal interferences and overloads lead to pulp necrosis. A frequent question: Up to what point should orthodontic forces be applied to osseointegrated implants? Orthodontic forces are not greater, in any situation, than occlusal forces in terms of intensity, amplitude and variability. If an implant can bear masticatory loads, it may also receive orthodontic forces resulting from anchorage.
Ask the Expert
How to achieve long-term stability on bonding zirconia/alumina structures?
Nothing seems to be more frustrating for dentists than the often recurrent displacement of an indirect restoration. Such clinical setback leads to self-criticism about their professional skills, which may also be silently questioned by their patients at the same time and raise serious concerns. For this reason, questions about which cementing techniques and agents are more appropriate for each particular clinical situation have always been raised during the phase of crown and prosthesis cementing. The desire to make retention last and to ensure that they are kept attached to the posts has led several authors and clinicians to constantly seek procedures and materials that are more reliable and adequate for that purpose.
Both dentists and the dental industry systematically seek alternatives to optimize esthetics in dental treatments. This is confirmed by the interest in adhesive systems and techniques that may ensure a better performance of composite resin restorations, or the special attention that has been paid to gingiva surrounding prosthetic crowns, either supported by implants or not. This latter has even gained the status of pink esthetics and is currently the focus of special attention.
The demand for better esthetic results is growing, and the use of densely sintered oxide-based structures, particularly alumina and zirconia, as replacements for metal copings in the traditional metal-ceramic crowns is irreversible. Such change has effectively translated into a substantial esthetic gain, so that it has become the first choice when the aim is to have crowns and restorations that respond to esthetic appeals. This is a fact! However, at the last moment of crown placement, questions about the ideal way to cement crowns haunt most of those that use such technology. The relevance of this question deserves a more profound analysis. [...]
Image and Science
Initial phase of repairing
Behavior of peri-implant soft tissue in the interface with titanium: A literature review
Dental implants. Titanium. Oral mucosa.
The soft tissue’s adhesion to titanium, biologically capable to preserve and protect the peri-implant structures contributes to peri-implant mucosa’s stability and maintenance of pink esthetics. Thus, the object of this study was, through a literature review, to describe the interaction between the titanium used in the prosthetic and implant components and the soft tissue to the maintenance of the stability and health of peri-implant tissues. It was concluded that the peri-implant soft tissue’s stability is one of the criteria of success to rehabilitation with implants, once the establishment of an intimate relation between the soft tissue and the titanium of the implant, as well as the prosthetic components, promote a protective barrier to penetration of bacteria and its metabolic products, favoring the implant’s long-term performance.
Immediate loading in anterior region using the clinical crown of the lost natural tooth: A case report
Dental implants. Immediate loading. Tooth fracture. Single implant.
One of the major current challenges in Dentistry is oral rehabilitation after tooth loss due to trauma. Esthetic and functional results, together with periodontal health, define success and prognosis. Implant dentistry provides the resources for the placement of osseointegrated screw-retained implants or cemented prostheses to replace missing teeth. Careful use of provisional prostheses preserves the harmonious architecture of gingival tissues and affects final treatment results positively. This study describes a clinical case of root fracture of the right maxillary central incisor (tooth #11) due to dental trauma. The tooth was extracted, an immediate implant was placed and the provisional prosthesis was fabricated using the clinical crown of the fractured tooth. The use of a fractured tooth for provisional restorations is a viable technique that has good esthetic and functional results and preserves gingival and dental balance.
Surgical maxillary expansion anchored on dental implants: Case report
Orthodontic anchorage. Dental implants. Rapid maxillary expansion.
One of the most common transverse discrepancies and a frequent dentofacial abnormality is the transverse maxillary deficiency. Rapid maxillary expansion (RME) is the indicated treatment in these cases, but satisfactory anchorage is difficult to obtain in partially edentulous adult patients, which is a frequent contraindication for this type of orthodontic treatment. This study reviewed previous researches about surgically assisted methods of orthopedic expansion of the maxilla using dental implants as anchorage, and described a clinical case, in which two titanium implants were placed in the edentulous segment and a Hyrax expander was cemented to the provisional crowns, following a protocol described in the literature. Titanium implants remained stable and osseointegrated when forces were applied, which suggests that they may be suitable for orthodontic anchorage and support for maxillary expansion.
Root coverage with laterally positioned flap
Gingival recession. Periodontics. Dentin sensitivity.
Gingival recession is a common clinical condition that brings esthetic discomfort, sensitivity, among other problems. Looking for a satisfactory outcomes both esthetically and functionally, several techniques have been proposed to root coverage, including the laterally positioned flap — which is a pedicle graft technique that, despite some limitations and a few indications, may achieve good outcomes in some cases. Due to the lack of predictability, the treatment of class III gingival recession is considered a major challenge for dental professionals; thus in the case reported in this paper, we aimed the root coverage in a class III by means of the laterally positioned flap technique.
Switching platform on esthetic area: Case report
Implants. Tooth structure. Prosthesis. Supporting tooth. Bone resorption.
The cervical bone remodeling around implants with conventional platform, known as saucerization, may compromise the maintenance of peri-implant hard and soft tissues, leading to esthetic impairments such as recessions and/or loss of papillae. The concept of platform switching with an inner placement of the implant-abutment junction, increasing the distance between bone and prosthetic platform, seems to minimize and/or block this bone resorption. The present paper has the purpose of presenting a clinical case report of previous esthetic rehabilitation using a platform switching implant associated to peri-implant plastic resources and peri-implants prosthesis that would maximize the final result. The clinical and radiographic results show preservation of proximal bone crest and papillae, maintenance of the soft tissue thickness and appropriate final esthetic result. Choosing implants with these characteristics of platform switching may be favorable in esthetic areas.
Peri-implant tissues health and its association to the gingival phenotype
Mucositis. Peri-implantitis. Keratinized mucosa
Peri-implant tissue is an adaptation of the masticatory mucosa to the different implant systems placed in the oral cavity. The lack of root cement to anchor gingival fibers to the surface of the implant is responsible for the parallel direction of the fibers around it. The absence of connective attachment between the mucosa and the implant may suggest a deficiency of the structural defenses in the region and may be associated with the more rapid progression of peri-implantitis than of periodontitis. Several studies have evaluated the importance of epithelial connections to form an adequate seal around implants. Other discussions have focused on the evaluation of whether peri-implant gingival health may be correlated with the presence of a specific amount (height and thickness) of keratinized mucosa. This study evaluated the association of the structural role of the soft tissue and the effect of gingiva phenotype on periimplant health. The studies that were reviewed stressed the importance of a good biological seal around the implant system, the protective function that the structures of this tissue provide to the bone-implant interface, and the discussion about the need to have a band of keratinized mucosa around tooth implants to ensure a better prognosis. Current studies point to the need to conduct further investigations to evaluate the effect of the clinical characteristics of soft peri-implant tissues so that peri-implant health may be ensured and preserved.
Zirconia dental implants: An alternative for today or for the future? (Part II)
Osseointegration. Allergy and immunology. Biomedical materials. Materials test. Dental Implants. Experimental implants.
Introduction: Recent research suggests that titanium (Ti) dental implants may have more side effects than previously believed. In addition to the fact that metals compromise esthetics, emerging technologies involving zirconia (Zr) ceramics were recently introduced in dentistry, which are proving as effective as Ti, but in metal-free rehabilitation. The clinical/histological outcomes of ceramics (ZrO2), driven by the awareness of patients seeking esthetics without metals, have increased their demand.
Objective: To find a viable alternative to Ti implants and identify the ceramic systems amenable to use by humans, taking into account biocompatibility and longevity, while pointing out their advantages and disadvantages.
Methods: Extensive and detailed literature review.
Conclusions: Although ISO standards need to be reviewed, it has been found that zirconia (Y-TZP) dental implants show a promising future. Zirconia increases the longevity of oral rehabilitation given its diminished bacterial adhesion. The following Zr implant systems were found in the studies: CeraRoot, Sigma, Z-Systems, Ziterion Zit-Z, Easy-Kon, Zeramex, White Sky, Denti Circon Implants, Zimplant-Biosyr, Omnis-Creamed, White Implants and Ziraldent. Among the disadvantages are a high production cost, the need for protectors during healing, and potential hydrothermal degradation of the material. Based on international scientific publications, it was concluded that Zr (Y-TZP) dental implants are now a viable substitute for Ti, although not yet recommended for routine clinical practice.