This lecture, presented by Dr. Thomas Wiser, is divided into two parts: "Extraordinary Implantology and Case Reports" and "Implantology and Radiology." The first part focuses on complex implantological treatments for exceptional patients, including those with cancer, severe trauma, congenital defects (like cleft palate and ectodermal dysplasia), and neurocyclic diseases (like Parkinson’s). Dr. Wiser stresses the necessity of an interdisciplinary approach for these cases, showcasing successful long-term rehabilitation using implants to stabilize both conventional prosthetics (bars/telescopic bridges) and specialized craniofacial prostheses (often utilizing magnetic abutments).
The second part addresses the risks and advancements in digital radiology. It compares the use of standard OPGs (Orthopantomograms) with Cone Beam CT (CBCT), emphasizing the importance of correct indication, low-dose protocols, and accurate patient positioning due to the potential for diagnostic artifacts and radiation-related health risks (particularly in children). Dr. Wiser also provides a detailed technical demonstration of CBCT analysis and concludes by discussing the future role of non-ionizing radiation techniques like Magnetic Resonance Imaging (MRI) and Artificial Intelligence (AI) in oral and maxillofacial surgery.
Extraordinary Implantology and Radiology: Advanced Techniques and Digital Diagnostics
Part 1: Extraordinary Implantology and Case Reports
0:30 Aim and Indication: The aim of implantology is to improve function and aesthetics, extending quality of life, particularly for "exceptional patients" (e.g., status after cancer, radiation therapy, congenital defects).
1:26 Insurance Coverage (Germany): Common health insurance in Germany pays for implantology only when conventional prosthetic restoration is impossible.
2:12 Interdisciplinary Approach: Complex cases (shown in the reports) require strong collaboration between the implantologist, maxillofacial surgeons, general dentists, and other specialists.
3:00 Case: Cleft Palate: A 54-year-old patient with hypoplasia of the midface resulting in a difficult intermaxillary relationship. Despite complexity, sufficient occlusion was achieved using two implants per jaw (the limit paid by insurance).
5:24 Exoral Defects (Craniofacial Prostheses): Implants are crucial for stabilizing prostheses resulting from trauma, cancer, or malformation, aiding in psychological and social rehabilitation.
6:17 Magnetic Abutments Preferred: For stabilizing craniofacial prostheses (e.g., orbital or nasal), magnetic abutments (6:21) are the favored choice due to ease of handling, stability, and patient hygiene compared to bars or telescopic abutments.
7:26 Survival Rates in Exoral Areas: Implants in irradiated bone have a reduced survival rate compared to native bone. Survival rates vary by location (orbital area < nasal area < ear area).
8:43 Long-Term Success: The clinic reported an 88% survival rate after 12 years for orbital implants (in irradiated/non-irradiated patients) and 100% survival for the craniofacial prostheses (due to placing 4 implants where only 2 were needed for stability).
9:53 Surgical Technique Demonstration: Demonstration of placing exoral implants in the orbital area using careful, layer-by-layer preparation and short (4.0/4.1mm) implants placed in a non-parallel position for improved stability.
27:17 Complex Trauma Cases: Case example of an elderly patient with extreme mandibular resorption requiring iliac grafting, where implants were successfully placed between the horizontal screws of the osteosynthesis plate.
30:36 Treating Parkinson's Patients: Patients with Parkinson’s disease require extra precautions (e.g., an additional nurse to fix the head, careful aspiration control) due to movement and aspiration risks.
33:51 Combination Prosthetics: Case involving congenital missing teeth used a "Her Bridge"—a superstructure fixed on implants via screws and connected to a cemented superstructure on natural teeth.
37:53 Guideline Adaptation: In irradiated cancer patients, the ideal prosthetic position must often be compromised for a risk-reduced or prognostically better surgical position.
43:29 Maxilla Defect Occlusion Rule: In patients with large posterior maxillary defects, the prosthesis must only have occlusion in the posterior area; contact in the middle or anterior areas will overload and cause early failure of the posterior implants.
44:38 Critical Risk: A warning is issued regarding the risk of secondary squamous cell carcinoma developing around implants in cancer patients, which can be misdiagnosed as peri-implantitis.
47:37 Immediate Implants: Immediate implant placement in selected irradiated patients, although outside standard guidelines, has been successfully performed following detailed preparation (curettage, antimicrobial photodynamic therapy).
Part 2: Implantology and Digital Radiology
53:50 Radiation Concerns: Although dental X-rays (43% of medical X-rays) only contribute 0.4% to the total radiation dosage, there is scientific evidence linking exposure to an increased risk of thyroid cancer.
56:19 Digital Image Manipulation Risk: Digital X-rays are defined by a sequence of numbers (histogram). Changing these can easily alter the image, posing a risk if the changed (wrong) image is used as the basis for therapy.
1:00:51 The Correlation Principle: It is mandatory that radiological findings, the clinical situation, and patient complaints always correlate to avoid false diagnoses (e.g., misinterpreting an artifact as a fracture).
1:04:47 CBCT Advancements: Over 200 CBCT machines are on the market. New generations (Photon Counting Detector CTs) promise improved visualization and reduced scanning time/radiation.
1:06:04 CBCT Analysis: Detailed steps on analyzing a CBCT scan, focusing on moving through axial, coronal, and cross-sectional layers to confirm bony structure, nerve paths (canalis mandibularis), and sinus condition.
1:13:41 Navigation Planning: CBCT is essential for navigation-supported implant surgery, matching CT data with optical scans of diagnostic wax-ups to create accurate surgical guides.
1:18:43 CBCT Dosage Warning: The effective dosage of a CBCT is typically 10 times higher than that of an OPG. The effective dose is also significantly higher in children, warranting careful indication.
1:22:34 CBCT Indications: CBCT is necessary for complex anatomical assessment (e.g., placing implants in reconstructed grafts), quantifying bone quantity/quality, and localizing structures or foreign bodies (e.g., detecting a root tip in the sinus before elevation).
1:37:45 The Future: MRI: MRI is increasingly popular in dentistry and oral surgery due to no radiation exposure, high reliability, and the ability to visualize both bone and soft tissue simultaneously. Small, portable MRI machines are currently being developed.
1:39:33 MRI Disadvantages: Current drawbacks include long scan times (risk of patient movement) and high cost.
1:41:40 Role of AI: Artificial intelligence will play a supporting role in radiological diagnostics (e.g., analyzing OPGs), but clinical information remains mandatory for accurate treatment decisions.