Entweder Oder. Entscheidungshilfen für die tägliche klinische Praxis. Graz, März Zahnerhaltung als Praxiskonzept?

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1 Entweder Oder Entscheidungshilfen für die tägliche klinische Praxis Graz, März 2014 Zahnerhaltung als Praxiskonzept? Dr. Wolfgang Westermann Fachzahnarzt für Parodontologie

2 Lindhe, J; Nyman, S. The effect of plaque control and surgical pocket elimination on the establishment and maintenance of periodontal health. A longitudinal study of periodontal therapy in cases of advanced disease. Journal of clinical periodontology; VOL: 2 (2); p /1975 The present clinical study was initiated in 1969 to test the hypothesis that microbial plaque is the cause of periodontal disease and that hence even advanced cases of periodontitis can be cured in patients willing to exercise optimal plaque control. The material consisted of 75 patients with severe destruction of the periodontal tissues. The patients were selected for the study because of their ability to maintain plaque-free dentition. Following an initial examination, a preliminary treatment plan was presented to the patients. This plan included detailed instructions in plaque control measures, scaling, root planning and emergency dental care, including endodontic therapy and extractions. Three to six months after the termination of the so-called presurgical treatment, surgical elimination of pathologically deepened pockets was performed. The patients were recalled every 3 to 6 months after the end of the treatment. At these reexaminations the following parameters were assessed: Plaque Index, Gingival Index, Pocket Depths, Marginal alveolar bone topography and height. The results demonstrate that it is possible to treat periodontal disease successfully, even in advanced stages, in patients willing to maintain plaque-free dentition.

3 Käyser AF Shortened dental arches and oral function. Journal of oral rehabilitation; VOL: 8 (5); (457-62) 1981 Cross-sectional clinical investigation was carried out among 118 subjects. They were classified into six classes, according to the degree and the symmetry of the shortened condition. Conclusion: there is sufficient adaptive capacity to maintain adequate oral function in shortened dental arches when at least four occlusal units are left, preferably in a symmetrical position.

4 Nyman S, Ericsson I The capacity of reduced periodontal tissues to support fixed bridgework J Clin Periodontol Sep;9(5): Despite the fact that the periodontal support for the restorations was dramatically reduced, all bridges have functioned properly for 8-11 years and the periodontal tissues around the abutment teeth have not suffered further loss of attachment during the period of maintenance care

5 Praxiskonzept Westermann Plaque-Kontrolle professionell individuell Kein Mensch benötigt 28 Zähne Reduziertes Attachment unproblematisch

6 ZIELE DER PAR-THERAPIE API/SBI < 25% Sondierungstiefen < 4 mm Keine Furk.-Beteiligung Nichtraucher (< 10 Zig.)

7 Das Praxiskonzept Westermann Ohne Plaque keine Destruktion Langfristige Motivation (Einsicht) ist Ausnahme Individuelle patho-physiologische Grenze (Risiko-Größe) Jeder Zahn ist potentiell gefährdet Kein Patient benötigt 28 Zähne Rest-Parodont --- Gegenbiss Behandle niemals einen Fremden (Historie beachten) Zahnerhalt ist Teamarbeit

8 Das Praxiskonzept Westermann REDUKTION DES THERAPIESPEKTRUMS Parodontologie Plastisch-rekonstruktive PAR-Chirurgie Mikrochirurgie Funktionsdiagnostik und -therapie Endodontologie Festsitzender ZE Implantologie

9 Behandlungsablauf: Befund - Diagnose (evtl. Schmerztherapie, akute Versorgung) Initialtherapie Reevaluation PAR-Chirurgie I Versorgung Hartgewebs-Defekte, Endo Reevaluation Korrektive PAR-Chirurgie II Reevaluation Zahnersatz Erhaltungstherapie

10 Pjetursson BE, Lang NP Prosthetic treatment planning on the basis of scientific evidence J Oral Rehabil Jan;35 Suppl 1:72-9 Meta-analysis of the studies included indicated an estimated 5-year survival of conventional tooth-supported FDP of 93.8%, cantilever FDP of 91.4%, solely implant-supported FDP of 95.2%, combined tooth-implant-supported FDP of 95.5% and implant-supported SC of 94.5% as well as resin-bonded bridges 87.7%. Moreover, after 10 years of function the estimated survival decreased to 89.2% for conventional FDP, to 80.3% for cantilever FDP, to 86.7% for implant-supported FDP, to 77.8% for combined tooth-implant-supported FDP, to 89.4% for implant-supported SC and to 65% for resin-bonded bridges. When planning prosthetic rehabilitations, conventional end-abutment tooth-supported FDP, solely implant-supported FDP or implant-supported SC should be the first treatment option. Only as a second option, because of reasons such as financial aspects patient-centered preferences or anatomical structures cantilever tooth-supported FDP, combined toothimplant-supported FDP or resin-bonded bridges should be chosen

11 Pjetursson BE, Lang NP Prosthetic treatment planning on the basis of scientific evidence 100% J Oral Rehabil Jan;35 Suppl 1: % SC 89,4 % T-T 89,2 % I-I 86,7 % 80% Cantil. 80,3 % T-I 77,8 % 70% RB 65 % 60% T - T I - I T - I SC Cantilever RB FDP

12 Erhalt des Originals 10 - Jahres Überleben (%) Zähne vs. Implantate Tonetti et al Lulic et al Jung et al Pjetursson et al.2004a Lang et al ,2 92,9 96,3 92,8 82,1 70 Paro Pat. Paro Pat. - wenige Pfeiler Einzelkronen auf Impla Impla - Impla I - I Rekonstr. Impla. - Zahn I - Z Rekonstr. Holm-Pedersen P. Lang NP. Müller F.: What are the longevities of teeth and oral implants? Clin Oral Impl Res. 18: review

13 Erhalt des Originals Zähne 10 - Jahres Überleben (%) Implantate vs.... oral implants after 10 years of service present with a longevity that does not surpass that of even compromised, but successfully treated teeth. Holm-Pedersen P. Lang NP. Müller F.: What are the longevities of teeth and oral implants? Clin Oral Impl Res. 18: review

14 DAN LUNDGREN, HARALD RYLANDER & LARS LAURELL To save or to extract, that is the question. Natural teeth or dental implants in periodontitis-susceptible patients: clinical decision-making and treatment strategies exemplified with patient case presentations Periodontology 2000, Vol. 47, 2008, 27-50

15 DAN LUNDGREN, HARALD RYLANDER & LARS LAURELL (2008)

16 DAN LUNDGREN, HARALD RYLANDER & LARS LAURELL (2008)

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19 Reevaluation nach Therapie Mech. + AB Mechanische Therapie Nein Erfolgskriterien:?? Ja OHI ok? Nein Erfolg? Ja BOP < 25% API < 25% ST < 5mm Raucher < 10 Zig. Nein Mehr Therapie erforderlich? Keine Furk-Beteilg Nicht Stabil Stabil Recall Ja Verschiedene Verfahren möglich

20 Das Praxiskonzept Westermann Recall (Erhaltungstherapie) in Abhängigkeit von Morbidität 3 Monate: Aggress. PAR; Umfangr. ZE; Implantate; Allgem.-Erkrankg 4 Monate: Prof. PAR; Schlechte MH; Implantate; ZE 6 Monate: Normal-Fälle ohne Probleme 12 Monate: Karies- u. PAR-Resistente