05 September 2022

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The nightmare of peri-implant papilla - Interview with Prof. Giovanni Zucchelli

Paola Omini

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The city of Bologna will host the International Convention of the Italian Academy of Osseointegration Oct. 6 to 8, 2022. Event organizers have created an evocative and challenging theme, "The nightmare of peri-implant papilla." Internationally renowned speakers will address the issue from different perspectives, including hard tissue augmentation, soft tissue augmentation and prosthetic solutions. Moderators, speakers and attendees will discuss possible treatment alternatives.

Dentistry33 recently talked about the convention and related topics with Professor Giovanni Zucchelli, president of the Italian Academy of Osseointegration.

Q: Tell us about this important event. Why was this theme or topic selected, and what are the goals of the convention?

A: ”The nightmare of peri-implant papilla" is related to what we cannot still predictably achieve. When a patient has lost the papilla around teeth or has multiple edentulous sites, we need to reconstruct a papilla between implants. The most challenging aspect is to place two or more consecutive implants and create something that resembles a papilla between the implant-supported crowns. The papilla is made of soft tissue standing above the bone. 

The convention's main objective is to better understand how much we, as dentists, can achieve with hard tissue augmentation, soft tissue augmentation, and with prosthetic conditioning to reconstruct what was entirely lost or didn't exist at all. This is the peri-implant papilla.

Q. You’ve talked about the challenges in your leadership role with the Italian Academy of Osseointegration and bringing something new and valuable to dental professionals. What lies ahead in that realm at the October convention? 

A: The most important element will be facilitating an authentic discussion between panelists. There will not be traditional lectures where a speaker talks and shows a set of slides. Rather, most of the time will be reserved for discussion. Speakers will debate opposing concepts and operative approaches. Speakers will also explain why they would use one technique or another for the same patient's treatment. This is the only way for everyone to understand which surgical procedure works better to achieve the same result. 

The audience will be the other key element in these debates. We will pose questions to better understand the clinical and procedural advantages and benefits of one treatment choice versus another.

We started using this training method during the Covid-19 pandemic and lockdown, and we have conducted many similar interactive digital courses in the past few months. The training style also includes a roundtable discussion between experts and younger professionals. A small group of renowned key opinion leaders was given a topic and allowed to present a single image. Each webinar was an open discussion in which the clinicians explained the operative technique used and the clinical reasons behind the choice. In contrast, other leaders and course participants advocated different solutions.

In my role as president, I am leading an approach for clinicians to explain how they are approaching procedures and treatments. Professors teaching at colleges and universities need to show how they approach a case on a step-by-step basis, and they must support the reason for their treatment decision. Videos are used to support the discussion, since videos are the best tool for understanding a technique and the clinician's expertise. The convention will follow this same method.

Q: The challenge of implantology has always been osseointegration. But today, implant aesthetics is at the center of this challenge. How do you view these topics?

A: Osseointegration is no longer a problem. Of course, there is still room for advancement. Companies and researchers are studying surfaces less prone to peri-implantitis, materials that integrate more easily and quickly into the bone. But in general, the osseointegration problem is solved. 

When osseointegration therapy started, it was for completely edentulous patients. Dentures were moving all over the place. The goal was to make this prosthesis stay fixed in place. The purpose of osseointegration was utterly different. 

Today the goal is to integrate the implant-supported crown into the rest of the patient's existing dentition. The patient wants the crown to match adjacent teeth. Aesthetic appearance has become as crucial as functional performance. The shape of the crown should be identical to the adjacent natural teeth, otherwise, the patient will not accept the treatment. The shape of the crown is designed by the outline of the soft tissue, from the papilla tips to the buccal soft tissue margin; this is why soft tissue management is so critical to a successful outcome.

Q: New technologies are revolutionizing implantology. How will you explore the topic of technological advancement during the convention?

A: This is a significant part of the program. One of the main reasons for aesthetic failure is bad implant placement. Even if you demonstrate very highly skilled implantology, in the aesthetic part of the treatment, a small mistake can jeopardize the result of the entire implant therapy. Technology can support us. Thanks to it, we can now plan the implant ahead of time, reducing the risk of misplacement to almost zero. Technology guides us in the placement of the implant in the proper position. This is extremely critical considering the main topic of this convention when you are dealing with a double implant – one next to the other. The distance between the two implants is critical to having the papilla. If you do the procedure relying solely on your judgment, you will not achieve the perfect implant placement every time. Studying the correct position supported by advanced computer technology also gives the patient an idea of the aesthetic outcome of the treatment right away. Thanks to technology, you can also obtain more predictably primary stability of the implant even in the presence of minimal amount of residual bone, allowing you to place a temporary crown. This is another advantage to achieving the aesthetic result expected.

Q: The program includes considerable time for international speakers and young professionals. What are the reasons behind those choices? 

A: It is not only young dentists. The right name to use is the next generation of dentists. We call them the NextGen, an expression you’ve heard before. A new generation of dentists are growing incredibly and fast. The Academy must give them the opportunity to show how good they are! On the other hand, it is equally important that leading names in world dentistry attend the event. This gives prestige to the convention and allows attendees to learn a great deal from the best.

In most cases, these professionals are also NextGen teachers. Sometimes NextGen are even better than their teachers. The convention provides an extraordinary opportunity to meet and grow as a result.

Q: A special invitation was given to dental hygienists who will have dedicated sections. How important is the collaboration between dentists and hygienists for the success of the treatments?

A: I can’t say enough about how important this collaboration is. Dental hygienists prepare the patient. Diseases such as periodontitis and gingivitis must be gone before we start any implant therapy. The hygienist's first extremely important task is to ensure the patient is in a healthy oral condition. The second task of equal importance is to teach the patient the proper maintenance and hygiene of the implant because preventing an implant disease is crucial. 

We cannot predict treating peri-implantitis, but we are far ahead in preventing this disease. The hygienist's role is to educate the patient on the correct hygiene of the implant, organize follow-up visits, and check the implant's status to detect if there is an inflammatory situation immediately. If caught in time, inflammation is easily resolved.

 If the inflammation reaches the bone, it becomes overly complex to treat and the outcome is less predictable. The hygienist is the key to the success of implant therapy.

The role of hygienists in maintaining the peri-implant papilla will be discussed in a specific session for dental hygienists at the Congress. We also encourage dentists to attend this session.

Q: In addition to being the president of the Italian Academy of Osseointegration, you are a highly experienced practitioner and researcher. What are the biggest successes in implant therapy in recent years, and what challenges remain?

A: The greatest success we’ve reached through implant therapy is the achievement of high patient acceptance, not only from the point of view of functional recovery but also for the high aesthetic success we can accomplish today. This can be achieved thanks to hard tissue augmentation, soft tissue augmentation, and prosthetic solutions. All these procedures need to be performed to have a successful result. Planning the treatment, which varies from patient to patient and soft and hard augmentation procedures coupled with the prosthetic must be considered together for optimal results. Prosthetics is another fundamental topic of this convention. 

The challenge we are still facing is the title of this convention: “The nightmare of peri-implant papilla.”

Q: What’s next for research in osseointegration? What might you discuss at the next convention?

A: The future direction of osseointegration is making implant surfaces easier to clean, reducing the risk of bacterial infection, and accelerating the healing process while still respecting biology. Technology and materials will need to improve functional and aesthetic outcomes continually.

The next convention will be in 2023. The chairman, who is also the incoming president of the Italian Academy of Osseointegration, is Dr. Massimo Simion, who works in private practice with a focus on periodontics and implant surgery, and at the University of Milan’s department of periodontology and implant therapy. He is an international lecturer on the topic of osseointegration and guided bone regeneration. 

About Professor Giovanni Zucchelli

Prof. Giovanni Zucchelli graduated in dentistry from the University of Bologna in 1988 at the top of his class. Today, he is the president of the Italian Academy of Osseointegration. 

Zucchelli is an active member of the European Academy of Esthetic Dentistry and of the Italian Society of Periodontology and Implantology (SIdP) and a member of the European Federation of Periodontology. He is also the only Italian dentist who is an honorary member of the American Academy of Periodontology and the coordinator of the Dental Hygiene school at the University of Bologna. As a professor, Zucchelli teaches periodontology and implantology at the School of Dentistry at the University of Bologna and is the director of several international master’s degree programs in periodontology and Implantology.

He has received multiple awards in Italy and around the world for scientific research in periodontology.

About the Italian Academy of Osseointegration

The Italian Academy of Osseointegration (IAO) is a scientific society founded on December 14, 2015. It was created from the confluence of two other important scientific societies - SICOI (Italian Society of Oral Surgery and Implantology) and SIO (Italian Society of Osseointegration) - united to meet the cultural demand of modern dentistry. IAO aims to organize congresses, courses, conferences and meetings, and establishes scholarships, awards, and competitions. The IAO is also dedicated to providing other initiatives that contribute to scientific progress in the osseointegrated implantology, oral surgery and aesthetic fields, and functional rehabilitation of the oral cavity.