October 12, 2014

Teeth in a Day- immediate full arch loading. Fairytales frequently end in tears! – Dr Anthony Summerwill 

  • Immediate implant placement is defined as extraction and immediate placement of implants on the same day.
  • An implant is a replacement for a missing tooth, not a tooth.
  • Evidence for maintaining teeth – survival rates of teeth were higher than implants in well-maintained patients (Tomasi). Only extract teeth if they have a hopeless prognosis (Zitzmann).
  • Implant placement should be prosthodontically driven.
  • The available evidence for immediate placement and loading is strong in terms of implant survival (Lang). A Cochrane review by Esposito shows it is a predictable approach although more evidence is required.
  • Alveolectomy is not advised as alveolar height is important in terms of prosthetic rehabilitation. Also consider the prosthetic space to decide if grafting required.
  • Tilted implants allows for the use of extra long implants, shorter cantilevers and avoidance of anatomical structures.
  • All on 4 concept – Rosen 2007 considers patient complications including mucositis, paraesthesia, sinusitis, speech, aesthetics.
  • Ping 2013 looks at complications. Biological complications include – sinus membrane perforation, peri-implant mucositis and fistula. Prosthetic complications included screw loosening.
  • Implant maintenance is essential to ensure long-term success of the reconstruction
  • Is fixed really the right option for maxilla? Sequelae of tooth loss can be difficult to correct with a fixed option. Speech and hygiene are a major issues for full arch maxillary reconstructions. An over denture can be more satisfactory, particularly in the older patient.
  • Sinus augmentation has a high success rate and low complication rate (Raghoebar 2001).
  • The overriding measure likely to embrace all aspects of surgical and prosthodontic implant treatment is patient reported outcomes.
  • No single treatment modality can treat cater for all requirements
  • Think carefully before you extract a tooth and consider all treatment options
  • Informed consent is an essential pre-requisite for treatment. The principles of prosthodontic treatment is the ability of the prosthodonist to make the correct diagnostic and treatment decisions. Treatment should then be undertaken within a culture of scholarship and patient mediated outcomes.

How do we Maintain Implants and Salvage the Failures? – Professor Frank Schwarz 

Useful reference

  • Peri-implant diseases – consensus report of the sixth European workshop on periodontology (Lindhe and Meyle 2008).

Diagnosis

  • Following the observation of the clinical signs of disease, probing is essential for the diagnosis peri-implantitis. Furthermore, when the clinical signs indicate the presence of peri-implantitis then it is advised to take a radiograph.
  • Peri-mucositis indicated by bleeding on probing. Peri-implantitis indicated by bleeding on probing, possibly suppuration, pocketing and bone loss.
  • Aetiology of peri-implant disease – primarily due bacterial plaque biofilms. Bacteria closely adhere to implant surface and it is a challenge to remove them.

Treatment

  • Consensus statement suggests mucositis can be treated with non-surgical mechanical debridement but this has limited efficacy with peri-implantitis.
  • No surgical treatment has some limitations. ErYag laser improves the outcome improved but this is expensive. Adjunctive treatment may improve outcome but over time reinfection may occur.
  • Schwarz – non-surgical treatment using mechanical debridement alone may not always be the treatment of choice and any additional procedure may have limitations in the long term. Surgical therapy is usually necessary for the treatment of peri-implantitis.
  • Surgical approaches – open flap debridement, resective therapy, regenerative therapy, combined therapy. All 4 approaches supported by clinical data.
  • Always initially treat non-surgical to control the infection and reduce signs of inflammation.
  • Open flap debridement – metal curettes – decontamination of surface to reduce biofilm removal.
  • Resective therapy – smoothing of the implant surface (implantoplasty), excise pocket soft tissue component around implant. Reduce macro design of implant using diamond burs and stone. Promising procedure but exposure of significant parts of the implant and causes mucosal recession so may limit to the non-aesthetic zone. Resective superior to implant open flap debridement (Romeo 2005/7).
  • Regenerative therapy – augmentation therapy – different materials available, case reports show improvements in clinical parameters. We need randomised clinical trials. Options: bovine bone, nano hydroxyapatite, xenografts, porous titanium granules, autogenous bone – bovine bone superior to autogenous bone. Surface itself plays a role so SLA more promising than TPS. Barrier membrane did not seem to have an impact. Defect configuration plays a part. Circumferential defect more appropriate for augmentation therapy.
  • Combined resective and regenerative therapy – implantoplasty with augmentation therapy – combination seems to be a promising procedure and data approaching 6 year follow up (Schwarz). Re-entry following combined approach shows new hard tissue formation in former defect area (Schwarz 2014).
  • Implantoplasty – beyond envelope or exposed at buccal or oral site – class 1 defect. Exceeding 1 mm less predicable for GBR. Bony support then use augmentation. Note that implantoplasty causes weakening of the implant which may cause fracture so limit to screw area and avoid any extension to the core diameter of implant.
  • Carefully consider the thickness of the mucosa – always get mucosal recession – any elevation of a flap causes 1.5 mm recession. Thin mucosa has the highest the risk of recession.
  • Combined with connective tissue graft to support tissue and decrease recession. Used overlying a barrier membrane. Mandatory in aesthetic zone.
  • No clear evidence as of yet for specific protocols for the treatment of peri-implantitis.

Implant Survival, The Truth – Professor Stefan Renvert 

  • Peri-implantitis may be expected to occur in 20% of cases (Klinge 2012).
  • However, when considering and comparing studies, we find there are a variety of definitions of peri-implantitis, which is a problem. Patient selection also differs and the majority of the studies are in university settings. There is also a lack of long term follow up studies on presently used implant surfaces. 25-35% of individuals are lost during follow up and this may include those that are not healthy and not complying. So the available data are most likely to be too positive as it is based on reasonably healthly, complying individuals who are attending for maintenance.
  • Local risk factors – poor oral hygiene, foreign body e.g. cement, periodontitis, endodontics lesions, peri-implant pocket depth, poor soft tissue conditions, implant surface structure, roughness of transmucosal surface.
  • Poor oral hygiene – 48% of implants with peri-implantitis had no accessibility for oral hygiene measures compared to 4% with accessibility (Serino 2009).
  • Foreign body e.g. cement. Cement remnants were found in 69% of implants with biological complications. Peri-implantitis was found in 85% of cases with cementum remnants (Linkevicius 2012).
  • Lack of keratinised tissue associated with more plaque accumulation, tissue inflammation, mucosal recession. Not with bleeding on probing, pocket depth or radiographic bone loss (Lin et al). Using the available data on keratinised tissue – if oral hygiene is good then keratinised tissue is not a prerequisite to maintain health around implants.
  • Revert 2012 – TiOblast vs machined – no statistical difference in occurrence of peri-implantitis between the implant systems.
  • Systematic review by Ong 2008 showed there is some evidence that periodontitis patients may experience more implant loss and complications than non periodontitis patients.
  • Revert 2013 – Peri-implantitis was associated with a history of systemic disease, periodontitis and smoking habits. More people in the peri-implantitis group were not very healthy (cardiovascular disease). After adjustment for age, smoking and gender there was an odds ratio of 8.7 for cardiovascular disease
  • Five years after loading, smokers experienced almost twice as many failures compared to non-smokes (Calvacanti).
  • Taking into account the limitations, after 10 years approximately 93% of the implants will still be in place. But 20% of those patients with remaining implants are likely to have peri-implantitis and will need care. Clinically we find that implant loss and peri-implantitis tend to cluster within individuals. Completing surgical procedures on peri-implantitis patients is more difficult than ordinary periodontitis as it is less predicable.
  • Measures to reduce risk of peri-implantitis and implant loss – treat periodontal disease before installing implants, design the prosthesis for oral hygiene accessibility, offer a smoking cessation program, use screw retained prosthesis when you can, individuals with poor metabolic control and cardiovascular diseases should be considered as risk patients, monitor and give maintenance therapy frequently (patients with an incidence of periimplantitis require appointments at least every 3 months).

Periodontology

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