Ailing failing implants.pdf

Ailing failing implants Prevalence Factors leading to peri-implant Chronic o *History of periodontitis o *Poor oral hygiene o *Tobacco smoking o *Uncontrolled diabetes Early healing o Bone topography o Tissue thickness o Tissue keratinization o Biologic width formation o Implant design and surface o...

Ailing failing implants Prevalence Factors leading to peri-implant Chronic o *History of periodontitis o *Poor oral hygiene o *Tobacco smoking o *Uncontrolled diabetes Early healing o Bone topography o Tissue thickness o Tissue keratinization o Biologic width formation o Implant design and surface o Immediate implant o Lacking healthy tissue is an issue Iatrogenic o *Poor treatment plan o *Excess cement o *Traumatic occlusion 5 years follow up Survival rate: 91.6% Peri-Implantitis Infectious disease: primary etiologic factor is bacterial insult. Mucositis: increase in cocci, spirochetes, and motile bacteria. Implantitis: Once above bacteria invade CT à bone loss (increase in gram-, anaerobic, motile flora just like periodontitis Implants are more vulnerable to bacterial insult because of the lack of a true connective tissue attachment and reduced blood supply. Periodontitis: inflammatory mediators: IL, MMP, TNF-a à bone destruction after a cascade of cell signaling Same thing with implants: not a self-limiting process, and lesion continue even after bacterial removed Goal: Decontaminate the implant surface and create environment for re-osseointegration of bone lost around implant threads. Peri-Implant mucositis: inflammation in the mucosa ONLY- no bone loss o Attached keratinized gingiva MUST be present o If not, a gingival graft may be needed. o Occurrence: 33% o Increased cocci, spirochetes and motile bacteria Peri-Implantitis: bone loss AND mucositis o Occurrence: 16% o Younger ages o Diabetes o Perio status at time of follow-up Implant failure o Diabetes o Immediate placement o Larger diameter fixture Other factors o Periodontal status at the time of placement o SMOKING o Poor oral hygiene o Bruxism (NG needed) o Hormones (pregnancy, menopause, hormone therapy, stress, etc. Thyroid-Graves disease or hyper-thyroid Etiology of marginal bone loss around an implant is a multi-factorial problem and not fully understood. Know the system used in a patient’s mouth for repair, abutment, crown change (whatimplantisthat.com -free) o 7 systems (Sulzer,Centerpulse,Straumann, NobelBiocare,Astra,SteriOss, BRANEMARK (earliest) o Platform switch can help prevent some issues Diagnosis of peri-implant diseases *peri-implant probing o Use Horizontal technique o Vertical technique creates a pocket (very little tissue around implant) *bleeding upon probing *suppuration *implant mobility** *radiographic bone loss Use titanium or plastic probes Check what is loose: abutment or crown o Xray required to identify where crown ends and abutment beings o Xray determines implant platform Peri-implant probing and scalers Results obtained with peri-implant probing cannot be interpreted same as the natural teeth because o Different in the surrounding tissues that support implant teeth o Probe inserts and penetrates differently o Healthy tissue: probe tip penetrates tissues around submerged implants to within 0.2mm of bone crest level. o Natural teeth: perio probe is resisted by supra-crestal connective tissue fibers into the cementum of root surface. o There is no equivalent fiber attachment around implants o Titanium scalers work great. Plastic and tephlon are also available- not as great! o ‘Scratching’ the fixtures is NOT as devastating as we initially thought. Implants are made of titanium o Fuses to jawbone o Great strength o Great stability o Contain various surface coatings made of § Hydroxyapatite § Plasma sprayed § Other proprietary surface rougheners (fine grit sandpaper) § Designed to increase microscopic surface area of implant surface § Older types have smooth surface o Body views titanium as NATURAL o Gum tissues will not attach to implants same way as natural roots § Natural teeth: CT embedded into cementum § Implant: Parallel CT allows gingival tissue to adhere to titanium o Gums adhere tightly like a suction around implant § Very little tissue along implant (resists even gentle probing) o Biological attachment via osseointegration § Occurs in gingiva-titanium oxide contact zone § Hemidesmosome anchor epithelial cells to the implant surface Non-surgical therapy Local delivery antibiotics o Slight improvement with (Actisite, Atridox, Arestin) Systemic antibiotics: o Some improvement o Will not last- doesn’t remove source of infection o Pt think they get better after antibiotics (False- they get worse when they return, similar to endo lesion) Mechanical debridement: o curettes scalers: titanium, plastic, tephlon o ultrasonics: metal tip, plastic tip Laser Air-powder projet Photodynamic therapy Dealing with extremely rough surfaces. Will get some improvement, but will not last. Surgical therapy Mechanical: o *Titanium brush o *Implantoplasy: Surface modification (smooth surface with handpiece) o *Ultrasonic o *Prophy jet o *Rubber cup pumice o *Laser o *Photodynamic therapy Chemotherapeutic: o *Tetracycline o *Hydrogen Peroxide o *Chlorhexidine o *Saline o *Phosphoric acid AND citric acid § Eliminate microorganisms § No histologic changes in gingiva § Increases ion release from implant surface § Suppresses fibroblast attachment Regeneration: 40-90% bone is gained o Decontaminate (all of previous) o Emdogain o Gem 21 (bone graft with periodontal growth factor) o Bone graft o Membrane (screwed onto implant) o Connective tissue If Endotoxins or other contaminants are left on the implant surface, there CANNOT be biologic repair or re-osseointegration Surgical protocol Remove restoration (must NOT see any cement around crown or abutment) Surgical approach Degranulate osseous defect Detox implant surface: o *implantoplasty o *chemotherapy (phosphoric acid, citric acid, TTC) o *saline rinse Regeneration or osseous resection Soft tissue enhancement Maintenance o 3 month recall (adjust according to patient) o Thorough removal of plaque, calculus o Motivate, educate patient re: home care o Evaluate soft and hard tissue o Assess occlusal forces, occlusal stability o Tell patients that implants ‘unzip’ 30% faster than a natural tooth (ex. bruxism can fracture an implant) o Suggest everything: water pik with pik pocket attachment, pipe cleaners, proxa brushes, post cleaners, yarn with a floss threader, dental tape o Implant or screw fracture: most companies have a special screw retrieval system for their implants. o Implants by oral surgeons do NOT do maintenance o Implants by periodontist DO maintenance o Implant surface is very difficult to keep clean § MORE vulnerable to bacterial insult Implant removal o Systems available to help remove internal threading of implant o Most implants are trephined out (part or entire implant may be osseointegrated) Creates bone loss beyond the fixture o Difficult to remove