optident handout slides

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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


Endosseous Implants

Implant Structure and Surface Characteristics


Zygomatic Implants

Implant Structure and Surface Characteristics Implant Structure and Surface Characteristics

Root Form Implants

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Single Piece 2 Piece

Root Form Implants


Tissue Level Bone Level


Cement Retained


Screw Retained


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 Body

•  Screw Threads

•  Variety surface finishes

•  Increase surface roughness

•  Aids osseointegration

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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)

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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

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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

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•  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

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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

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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


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


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! 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


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


• 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

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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

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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?

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