View
10
Download
0
Category
Preview:
Citation preview
5/3/16
1
Implant Maintenance and
Soft Tissue Management
Juliette Reeves Dental Hygienist Nutrition Consultant
Certified Implant Auxiliary (USA)
Optident Implant Maintenance Masterclass
DirectorandDCPCommi/eeMember2012-14 ADIACer9fiedMember
• Implant Structure and Surface Characteristics
• Osseointegration
• Tissue Anatomy
• Peri-Mucositis / Peri-Implantitis
• Monitoring and Maintenance Protocols
• Risk Factors
• Probing / Instrumentation
• Clinical cases
• Home care
Aims and Objectives
Implant Classification
• Subperiosteal
• Transosteal
• Endosseous:
a) Plate/ Blade Form b) Pterygoid/ Zygomatic c) Root Form: i) One Piece ii) Two Piece
Variety of diameters: Regular 3.5-4.5mm Wide > 4.5mm Narrow < 3.5mm Mini < 3mm
Implant Classification
Endosseous Implants
Implant Structure and Surface Characteristics
Implant Classification
Zygomatic Implants
Implant Structure and Surface Characteristics Implant Structure and Surface Characteristics
Root Form Implants
5/3/16
2
Implant Structure and Surface Characteristics
Single Piece 2 Piece
Root Form Implants
Implant Structure and Surface Characteristics
Tissue Level Bone Level
Implant Structure and Surface Characteristics
Cement Retained
Implant Structure and Surface Characteristics
Screw Retained
Implant Structure and Surface Characteristics
Transmucosal Collar
• Transition between crestal bone soft tissue
• Highly polished
• Smooth finish
• Avoid bacterial colonisation
• Anatomy of peri-implant tissues compromised.
• Resistance to inflammation
Implant Structure and Surface Characteristics
Implant Body
• Screw Threads
• Variety surface finishes
• Increase surface roughness
• Aids osseointegration
5/3/16
3
Osseointegration
Initial Stages- threads locked into old bone
PrimaryStability(OldBone)
SecondaryStability(NewBone)
TotalStability
Time(weeks)
012345678
Stability
100%
50%
25%
Anatomy of Tissues
Tooth Anatomy
• Root Surface Cementum
• Attachment via Sharpey’s Fibres
• Periodontal Ligament
• Crevicular Fluid
• Immune function
• Increased vascular supply
• Absorbs occlusal forces
• Connective tissue has 13 groups fibres
Anatomy of Tissues
Direct Osseointegration into Bone•
No fibrous attachment•
No Periodontal Ligament•
Crevicular Fluid (increased IL1ß)•
Reduced Immune function•
Reduced vascularity•
No absorption occlusal forces•
More prone to occlusal overload•
Connective tissue has 2 group fibres•
Implant Tissue Anatomy
Anatomy of Tissues
Normal Tissue Anatomy
Complex fibre arrangements
Extend all directions
Circumferential
Horizontal
Vertical
Perpdendicular
! Increased vascularity
Better blood supply
Nutrient and Oxygen
Efficient Immune Function NormalTissue ImplantTissue
Anatomy of Tissues
Implant Tissue Anatomy
NormalTissue ImplantTissue
! Implant Tissue Compromised
! Weaker attachment/seal
! Poorer blood supply
! Compromised immune function
! Implant Junctional epithelium
! Not keratinised
! More fragile
probing, instrumentation
brushing OH techniques
Peri- Mucositis/Implantitis
Mucositis
• A reversible inflammatory process of the superficial soft tissues that surround implants in function.
• An inflammatory lesion that resides in the mucosa, while peri-implantitis also affects the supporting bone”
• (Lindhe J, Meyle J, 2008)
• As having clinical signs of inflammation, bleeding on probing and/or exudate, however the supporting bone remains intact.
• (Renvert S, Sanz M, Euro-Perio 7 2012)
5/3/16
4
Peri- Implantitis
! An inflammatory process affecting the tissues around an osseointegrated implant in function, resulting in loss of supporting bone.
! (Mombelli A, Lang NP, 1998)
! The term for inflammatory, pathological reactions in the surrounding soft and/or hard tissue of an osseointegrated implant involving bone loss which can lead to de-osseointegration.
! (3rd European Concensus Cologne, 2008)
Definitions
Peri- Mucositis/Implantitis
Implantitis
• Peri-implantitis involves bone loss, which does not always exhibit bleeding on probing.
• Mombelli Euro Perio 7, 2012
• The most important clinical feature in the diagnosis of peri-implantitis is the:
• Increase Peri-implant probing depths.
• Radiographic presence of bone loss
• ,Renvert S, Sanz M, Euro Perio 7, 2012
Differential Diagnosis
! Is there suppuration? ! Are there clinical signs of inflammation? ! Are there pocket depths >3mm?
If the answers to the above are all no, this indicates health. If any are yes then proceed to question 4.
! Does the pocket extend more than 3mm beyond the implant shoulder? ! Is there bone loss? ! Is there a plausible cause other than peri-implantitis? ! Is the pocket deeper than 5mm?
! The most important clinical feature in the diagnosis of peri-implantitis is the peri-implant probing depths.
! Radiographic presence of bone loss
Professor Andrea Mombelli
Mombelli A: EuroPerio 7 differential diagnosis protocol
Comparisons with Periodontal Disease
• Mobility patterns
• Implants osseointegrate into cortical bone.
• Maintain stability with much less bone
• Mobile no apical bone
• Exfoliate
Bone Loss Pattern
Bone Loss/Remodeling
• Crestal Bone level at osseointegration higher before implant loaded
• Placement of restoration
• Results in the establishment of biologic width.
• Creation of peri-implant sulcus
• Biological seal
• Bone remodeling 1-2 screw threads in first year
Sulcus
BiologicalSeal
BiologicWidthEstablishedTissuelevelsatPlacement
Biologic Width
5/3/16
5
Bone Loss/Remodeling
• 1mm sulcus
• Biologic width about
2-3mm in implants:
• System Variation
• Tissue level/bone level
• Healthy pocket 3-5mm
Biologic Width
• 2.04 teeth
• 3.08-3.8mm including sulcus
Monitoring and Maintenance Protocols
Risk Factors
• Risk Factors
• Circulation
• Oxygen supply
• Nutrients
• Immune function
• Initial osseointegration
• Long term stability
Clot
PrecursorcellsDeadOsteocytes
SeveredCapillariesCircula9on
O2
Nutrients
Func9on
ImplantWoundBone
ISCHEMIA=SLOWHEALING
Contraindications - ADI• Radiotherapy to jaw
• Untreated intraoral pathology or malignanacy
• Untreated periodontal disease
• Uncontrolled drug or alcohol abuse
• Uncontrolled psychiatric disorders
• Recent MI, cerebrovascular accidentor valvular prosthesis surgery
• IV bisphosphonate therapy *
• Immunosupression – organ transplant or systemic disease*
• Inability to maintain high levels of plaque control e.g. –
• Reduced manual dexterity or mental capacity.
* Complications rather than outright contraindication
ADI White paper – small risk, dose and time related
www.adi.org.uk
• Smoking
• Alcohol abuse
• Poorly controlled diabetes
• Osteoporosis
• Chronic Inflammatory diseases –
elevated circulating pro-inflammatory mediators:
• RA, Sjögren's, Crohn’s, Lupus, autoimmune disease
• Previous history periodontal disease
• Occlusal overload/bruxism
• Lack manual dexterity/ impaired vision
• Prosthetic design – hygiene access
Risk Factors
• Oral health: • Good OH • Stable tissue status
• General health:
• Age – not a contraindication – risk factor • Ageing population • Decline in cognitive function • Parkinson’s, Alzheimer’s, stroke • Manual dexterity – complicated OH regimes
Risk Factors
5/3/16
6
• Hyper inflammatory response1
• 10-15% population worldwide2
• 20% of tissue response mediated by plaque levels.
• 80% tissue destruction mediated by host response.
• Tissue destruction occurs from
• Dysregulation of immune response
" Chapple ILC, Matthews JB. The role of reactive oxygen and antioxidant species in periodontal tissue destruction. Periodontol 2000 2007; 43:160-232. " Page RC, Kornman KS. The pathogenesis of human periodontitis: an introduction. Periodontol 2000 1997;14:9-11.
Risk Factors Risk Factors• Thin Bio-type
• narrow band of keratinised tissue • wavy mucogingival junction • thin transparent gingivae • Protruding / long teeth and long
papillae
• highly-scalloped gingival margin • Prone to gingival recession
• Implant: • Bone thinner - greater risk of
dehiscence • Greater risk recession • Interdental papillae less stable
• Tissues not so forgiving!
Risk Factors
• Thick Bio-type
• wide band of keratinised tissue
• thick gingivae, • short papillae • squarish teeth
• Restorative Design
• Emergence profile
• Anatomical emergence
• Molar Teeth
• Multi rooted tooth
• Single implant body
• Modified ridge lap:
• Adequate hygiene access
• Non keratinised tissue
Implant Restoration
Monitoring Protocols
• Soft and Hard Tissues
• Colour: pink, red, purple
• Texture: stippled, glossy
• Contour: tight, enlarged, cratered
• Consistency: keratinised/ non
• BOP, Inflammation/ exudate
Recording
• Mobility
• Prosthesis for stability
• Trans mucosal collar: measure exposure
• OH : Plaque and or calculus
• Bone loss
• Last radiographs
• Probing depths
5/3/16
7
Probing Protocols
Probes
Probing Protocols
• First step in effective management
• Routine probing not iatrogenic*
• Technique sensitive
• Collect baseline data: BOP
• Baseline probing depths
• Critical maintenance data
• From this measure future changes
• And/Or deterioration
*Not within 3 months of placement *Etter, Hakanson, Lang et al: Healing after Standardised Clinical Probing of the Peri-Implant Soft tissue Seal. Clin Oral Imp Res 2002 13:571-580
Probing Protocols
• Bone loss not always inflammatory in origin
• Occlusal overload
• Lateral pressure
• If wait for signs inflammation in tissues
• May be significant bone loss
Fu JH, Hsu YT, Wang HL. Identifying occlusal overload and how to deal with it to avoid marginal bone loss around implants. Eur J Oral Implantol. 2012;5 Suppl:S91-103.
Probing Techniques
• Lateral displacement of tissues
• Disturbs biological seal
• Increases opportunity for
• infection from bacterial pathogens
• Technique critical
• To avoid iatrogenic damage
• Remove biofilm before probing
• Probe implants first
• Disinfect tip CHX
Probing Techniques
!
• Probe parallel to long axis
• Close to zero degrees as possible
• Use a maximum of 20g pressure
• Record depths at baseline
• 1,2, 4 or 6 points?
• NB: individual variations
in bone loss patterns
Probing Protocols
• Healthy reading
• 3- 5mm
• Abutment type
• Change in pocket depth more important
• Than baseline pocket depth itself
• Greater than 5mm
5/3/16
8
Probing Protocols
• Reading greater than 5mm
• Changes in baseline tissue record
• Inflammation Bleeding
• Radiographic assessment
• Loosening / mobility
• Refer to dentist/ implantologist
• Mobility patterns
Instrumentation
ADI Consensus 2012
• Literature review
• Questionnaire UK
• Reports key research Professors Europe
Implant Instrumentation
Instrument Selection
• What is being removed ?
• Plaque biofilm
• Supra gingival calculus
• Sub gingival calculus
• What part of the implant ?
• Collar
• Body
Instrument Selection
Prophy Polishing
• Paste Selection
• Low abrasive polishing paste
• Designed for implant surface
• Suitable for aesthetic restoration
• Kind to soft tissues
• Does not leave residue
! Thread
! Surface roughness
! Aid osseointegration
Implant Body
! Tenacious calculus
! Less affected by scratches
! More prone surface contamination/
! residue from plastic instrument tips
Instrument Selection
5/3/16
9
! Ultra Sonic Instrumentation
! Piezon Implant Tip
Implant Tip
! PEEK Plastic
! Does not leave residue behind
! High melting point
! Good sliding properties (very smooth)
! Good dimensional stability
! Very wear resistant
! Bonded onto tip Schwartz et al: Influence of plaque biofilm removal on re-establishment of the biocompatibility of titanium contaminated surfaces. J Biomed Mat Res 2006:77(a);437-444
Instrument Selection
Properties
• Autoclavable / disposable
• Don’t leave residue or scratch
• Suitable for implant collar (smooth surface)
• Implant body (rough surface)
• Narrow blade for atraumatic access
• Variety instrument tip patterns
• No damage to biological seal
Instrument Selection
• Air Polishing - Biofilm
• No contact with implant surface
• Debride trans mucosal collar
• Implant body/ exposed screw threads
• Debride subginigival screw threads
• Powder selection
• Glycine – 25ug
• Erythritol – 14ug
PowderSelec9on
Instrument Selection Glycine
! Non abrasive powder
! Kind to soft tissues
! No residue around margins
! Hydrophilic
! Does not affect cell viability of implant surface
Schwartz F, Ferrari D et al: Influence of different air-abrasive powders on cell viability at biologically contaminated titanium dental implant surfaces. J Bio M Res 2009;88(1):83-89
Glycine
• Glycine/ Erythritol Air Polishing
• Supra gingival
• Sub gingival
• Implant surface disinfection
• Without compromising soft tissue
• Implant surface
• Cell viability
Clinical Examples Mucositis? Implantitis?
Inflammation BOP PIPD 6mm
Rads?
Debridement:
Light hand instrument: check calc Polish : soft rubber point Irrigate Superfloss/implant floss CHX gel
PEEK Tip Airpolish
OHI, OHI, OHI
Re check 6/52
5/3/16
10
Clinical Examples Mucositis? Implantitis?
Inflammation BOP PIPD 8mm
Rads?
Debridement:
Ultra sonic debridement: Metal tip – light strokes High water – Low power
Irrigate: CHX, H2O2 CHX gel
Metal tip Airpolish : subgingival tip
OHI, OHI, OHI
Ref to implant surgeon
Home Care
Home Care
! Type of implant
! Type of restoration
! Access to implant
! Patient dexterity
Home Care
! Non Keratinised Tissue
! Fragile
! Enthusiastic plaque control
! Compromise surrounding tissue
! Brushing technique
! Implant specific brushes
! Flossing habits
! Careful use of interdental brushes
Home Care
! Biological seal
! No attachment
! Weak fibre arrangement
! Iatrogenic damage
! Bone loss
! Flossing technique
Flossing Techniques
Home Care
! Low power
! Biological seal
! Micro burst technology
! Irrigation
! Minimum contact with tissues
! Chemical adjuncts
Irrigation Techniques
5/3/16
11
Home Care
! Big enough to extend laterally
! Small enough not to traumatise
fragile tissues
! Wires need to be plastic coated
! Avoid scratching titanium
Interproximal Brushes
Thank You !
Any Questions?
Recommended