SlideShare une entreprise Scribd logo
1  sur  153
Télécharger pour lire hors ligne
Peri-Implantitis:
Prevalence, Practical Treatment and Prevention
Prevalence, Practical Treatment and Prevention
Dr. Scott K. Smith
November 13, 2013
Scott K. Smith
• Practicing Periodontist 20 years
• Placed over 10,000 implants
• HiOssen lecturer, teacher and Instructer
Objectivesand Peri• Define Peri-Implant Mucositis
Implantitis

• Prevalence of each
• Pathogenesis vs. Periodontal Disease
• Diagnostic Criteria
• Treatment for mucositis and implantitis
• Maintenance following treatment
Conflict of Interest
• HiOssen - Clinical practice support and
honorarium.
Dental Implant Success
• 400,000 implants placed per year in US
• 1 million implants placed per year in EU
• $6.5 billion US industry
• Failure Rate of Implants less than 5%
• Industry and Research Focus on Initial
Stabilization, enhancing supporting
structure and Initial Esthetics.
Peri implantitis
Peri implantitis
Peri implantitis
Peri implantitis
Peri implantitis
The Dark Side
• Incidence of Peri-implant mucositis and
Peri-implantitis is as much as 47%!!

• Failure of Implants by Chronic Inflammation
include Functional loss, Phonetic and
Esthetic Challenges

• Professional Challenge
Similarity with
Periodontal Diseases
• Host Response to Bacterial Insult
• Initial Event is Inflammation of Pocket
Epithelium without CT or Bone
Destruction - Reversible = Gingivitis

• Chronic Inflammation and Risk Factors =
Periodontitis
Implant Related Periodontal
Diseases
• Peri-Implant Mucositis
• Peri-Implantitis
Peri-Implant Mucositis
• The presence of inflammation

confined to the soft tissues around
the implant - No sign of bone loss.

• Presence of probing >4mm with
bleeding or suppuration

• Reversible
Peri-Implantitis
• Inflammatory process around and implant

including soft tissue and progressive loss of
supporting bone beyond biological bone
remodeling.

• Probing depth >4mm with bleeding,

suppuration and radiographic bone loss
Peri-Implantitis

Probing depths >4mm with bleeding, suppuration
Radiographic loss of bone beyond remodeling
Prevalence:
Peri-Implant Mucositis
Peri-Implant Mucositis
• Berglundh, Renvert:

48% of all implants over 9-14 yrs affected.

• Prevalence may be higher - Previous

Dogma of Not Probing around Implants
Reduced Identification
Prevalence:
Peri-Implantitis
Peri-Implantitis

• Wide Range: from 4.7% to 36.6%
• The Threshold used is Bone Loss. No
standarized radiographic analysis.

• Additionally Factors such as Smoking,

Diabetes, Previous Periodontal Disease
create subpopulations and complicate
comparisons of studies.
Periodontal Anatomy
Anatomy of a Tooth
• Junctional Epithelium has Hemidesmosomal
attachment to enamel

• Connective tissue array of 1mm thickness with
attachment to Cementum

• Alveolar Bone with Perpendicular Fibers attaching
to Cementum overlying Dentin

• Vast Source of Nutrients and Cells for

Regeneration of Ligament, CT, Cementum, Bone
Cementum
• Acellular and Cellular containing

cementoblasts provide support on the
tooth side to anchor sharpy’s fibers

• Periodontal Ligament space provides

nutrient supply and cells for Regeneration
Anatomy of an Implant

• Junctional Epithelium attached to titanium

surface by basal lamina and hemidesmosomes

• At apical portion of sulcus is only a few cell
layers thick and separated from bone by 12mm

• No Cementum - Bone to Implant Contact
• Connective tissue between JE and Bone few
vascular structures and few Fibroblasts
Pathogenesis
Peri-Implant Mucositis
• Plaque formation of titanium surface and
formation of biofilm. Gram (-) Anaerobic

• Inflammatory infiltration occurs in CT
• Neutrophils, lymphocytes, macrophages in
high numbers

• Adaptation of JE to Inflammation
Peri-Implantitis
Peri-Implantitis

• Inflammatory - bacterial driven destruction
of the implant supporting apparatus.

• Chronic Inflammation starting as PIM
• Inflammatory Cell Infiltrate more Severe
with Implants vs. Teeth

• Rate of Disease Progression Faster with
Implants
Peri-Implantitis
• The difference in collagen fiber orientation
(parallel to implant and perpendicular with
teeth) and less vasculature structure may
explain the faster pattern of tissue
destruction with peri-implantitis.
Influential Factors
• Patient Related - systemic diseases, history
of Periodontal Disease

• Social Factors - Poor OH, Smoker, Heavy
alcohol consumption

• Parafunctional Habits - Bruxism,
Malocclusion
Smoking
• Baig and Rajan found in smokers

significantly more marginal bone loss after
placement and higher Peri-Implantitis
percentages.
Previous Periodontitis
• Significant correlation with increased
prevalence of Peri-Implantitis
Genetic Factors
• Significant correlation with

Interleukin1gene polymorphism and PeriImplantitis.

• Plagnat - proposed markers for Elastase

and alkaline phosphatase may be helpful in
future diagnosis of bone destruction.
Health Status
• Diabetes Type I and II if uncontrolled lend
to increased inflammatory Response and
Peri-Implantitis
Occlusion
• Non-axial forces, cantilevers, bruxism
• H.L.Wang et al - occlusal overload

positively associated with Peri-Implantitis

• Likely excess strain causes microfracture
within bone.
Additional Influential
Factors -You’re to Blame
• Implant Design
• Prosthetic Connection
• Mechanical Failures and Cement
Contamination

• Surgical Errors
Implant Design
• Smooth titanium vs. Roughened
surfaces

• Smooth Cervical collar vs. Surface
texture to coronal margin

• Thread Design - aggressive vs. passive
Implant Design Connection
• External Hex
• Internal Hex
• Morse Taper
• Platform Switch
Platform Design
• Crestal Bone loss begins when healing

abutment is attached to implant at second
stage surgery (Nobel implants - Ericsson J.
Clin. Perio 1995)

• Burglund and Lindhe identified 0.5mm

inflammation above and below Branemark
implants at abutment/implant junction after
2 weeks.
Peri implantitis
Microgap and Platform
Switching
• Move the microgap away from the implant
platform and hence away from the crestal
bone as a protective measure.
Peri implantitis
Restorative Problems
• Excessive Cantilever
• No Passive fit
• Improper fit of abutment
• Improper prosthetic design, occlusal scheme
• Premature Loading, Overtorquing
• Connecting implants to Natural teeth
Peri implantitis
Mehcanical Failures
Fractured Implants
Loosening of Screws
Retained Cement
Surgical Placement
• Off Axis Position - severe angulation,
• Lack of Initial Stabilization
• Infection from improper flap design
• Overheating bone
• Spacing too close to teeth or implants
• Inadequate bone or attached gingiva
• Too Buccal or Lingual and compromise bone
Inadequate Attached
Gingiva
Inadequate Buccal Bone
Space Between Teeth
and Implants
Head of Implant
ANGULATION
Buccally Positioned
Heat Generation
• Eriksson and Albrektsson reported the

critical temperature for implant placement
was 47C for 1 minute.

• Matthews and Hirsch demonstrated that

temperature elevation was more a result of
force applied rather than drill speed.
Diagnostic Criteria
• Probe all implants - Plastic or Metal
• Look for Bleeding and or Suppuration
• X-rays should be taken yearly first two

years and compared to base line placement

• Evaluate Occlusion, Prosthetic Stability
• Soft tissue evaluation - Attached Gingiva?
Probing
Probe Long Axis
Accessibility
• Adjust Prosthesis
• Plaque Control
• Biofilm Removal
How do you Probe
this?
Remove Prosthetic
Bone Level
Attached Gingiva?
Treatment Options
• Early Detection is Key to Success and
improved health!

• Non-surgical Intervention
• Surgical Intervention
Non-Surgical - Studies

• Mechanical Debridement with plastic instruments

and Chlorhexidine irrigation showed reduction of
pocket and bleeding at six months - Schwartz

• Antiseptic irrigation of pockets <4mm not

effective, but over 5mm it has added effect.
Renvert

• Adjunctive use of generalized antibiotics did not
improve the treatment results
Peri-Implant Mucositis Transmucosal
Transmucosal
Peri-Prosthetic
Peri-Prosthetic
Peri implantitis
Peri-implant Mucositis
• Application of Minocycline spheres along

with debridement provide some additional
benefit to reducing bleeding and probing,
but NEEDS TO BE REPEATED OFTEN.
Renvert
Clinical Treatment of PIM
• Mechanical Scaling of Implants with plastic or
titanium instruments or Ultrasonic Plastic
Tips. I-Brush if exposed threads.

• Apply exposed implant surface with 0.2%
Chlorhexidine gauze for 2 mins

• Subgingival irrigation with 0.2%
Chlorhexidine 5ml per implant

• Minocycline Spheres or Gel
Peri-Implantitis
Treatment Options
Treatment Options
• Visualization with open flap very effective
with cementitits!
Peri-Implantitis
• Treatment to be determined by amount of bone

loss and esthetic impact of the implant in question

• If minimal bone loss (3 threads or less) Proceed

with similar treatment as Peri-implant mucositis,
but decontaminate prosthetic components as well.
The use of various lasers has been suggested.

• If bone loss is advanced or progressive than

surgical access with resective or regenerative
components will need to be employed.
Peri-Implantitis
Non Surgical - Studies
Non Surgical - Studies

• 31 Subjects mean age 62
• One qualifying implant per patient
• PPD >4mm with bleeding or suppuration
• < 2.5mm bone loss
• J. Clin. Perio 2009 Renvert
Non-Surgical
• Titanium hand instrumentation
• Or Ultrasonic Debridement with plastic tip
• 6 month results - minimal change with PD
for either treatment modality
Laser Therapy Er:YAG
• SRP with plastic instruments and 0.2%

chlorhexidine followed by Er:YAG 20sec
disinfection per implant

• Control was only SRP and antiseptic rinse
• Six months later Equal Reduction of Pocket
and Clinical Attachment

• Twelve months later both groups lost effect
Peri-Implantitis with Er:YAG vs.
Air-Abrasive device

• 42 Patients mean age 69
• Laser 55 implants
• Perio Flow 45 implants
• PPD >5mm with bleeding or suppuration
• > 3mm bone loss
• J. Clin Perio 2011, Renvert
Results
• Remove Supra-Structure from Implants!
• Significant difference in PD bleeding and

Pus reduction for both groups at 6 months

• Both seem to have limited benefit in
advanced cases
Open Flap - Resective
• Surgical flap access and resection of 1 or 2 wall
defects combined with decontamination and
antibiotic treatment was effective in just over
half the cases over 5 years. Leonhardt 2003

• 2008 Hitz-Mayfield with flap surgery and

resection and antimicrobial treatment stopped
the progression of the disease in 90% of cases
up to one year - However, BOP continued in
50% of the lesions.
Regenerative Surgery
• Schwartz (2008) found combination bone

grafting debridement and antibiotics had
significant reduction of bone loss and BOP
after 2 years.

• Froum (2012) Significant reduction of BOP,

Pocket reduction, bone loss over 3-7 years.
Submerged Healing • 16 implants in 12 patients
• Open Flap and 3% Hydrogen Peroxide
• Bone Graft and Membrane
• Submerged healing
• Roos-Janasker J. Clin Perio 2007
Submerged Surgical
Results
• PD change
• Defect fill (threads)
• Defect Fill (mm)
• Recession (mm)

4.2mm
3.8
2.3
2.8
Implant Configuration
and Decontamination
• Implant contours and surface are a limitation
to remove the biofilm

• Surface treatments including - mechanical,
Er:YAG, photodynamic, air-abrasion,
implantoplasty

• Romeo (2005, 2007) implantoplasty improved
regenerative capability - reducing probings
from 5.5 - 3.6mm and BOP.
Implantoplasty
Regenerative Treatment for PeriImplantitis affected implant:
Stuart J. Froum Clin Adv Perio 2013
Stuart J. Froum Clin Adv Perio 2013

• 7 year follow up showed decrease pocket
depths

• Technique successful in 51 cases (IJPRD
2012:32:11-20)

• Believes if any Elements of protocol not
followed could compromise outcome
Protocol
• 1 month prior to surgery: SRP of natural
teeth; debride implant surface and OHI

• Requires 2 visits to accomplish this
Surgery:
Exposure and Debridement
Exposure and Debridement

• 2 gm Amox 1 hour prior to surgery
• FTF to expose area
• Debride defect with titanium and graphites
• Air-Power abrasives (Bicarbonate powder) for
60 secs

• 60 secs irrigation with sterile saline
• 60 secs application of Tetracycline strips
Surgical Protocol
• Second application of air-powder abrasive
for 60-90 secs

• Application of CHX for 30 secs
• 60-90 secs of sterile saline with air power
device no powder
Surgical Protocol
• EMD applied - avoid blood and saliva
• Defect filled with 1:1 Bioss/Puros
rehydrated with gem 21

• 2 ossix membranes placed to cover all
surfaces

• Flap released and coronally advanced and
sutured with Goretex and vicryl sutures
Post Surgery
• 2 weeks remove sutures and polish
• Pt to brush area 4x/day with 1:1 Peroxide
and rinse with salt water 4x/day

• Return monthly for 12 months for post op
and every 6-8 weeks for maintenance
Peri implantitis
Treating Peri-Implantitis
• Systemic Antibiotics for three days prior to
treatment

• 2 mins pre-operative rinse with
Chlorhexidine

• Full Thickness Mucoperiosteal Flap to one
tooth beyond diseased site

• Thorough Debridement circumfirentially with
plastic or titanium or Ultrasonic plastic tips
Treating Peri-Implantitis
• Pack Gauze Strips soaked with CHX around
implants and in defects for 5 mins

• Remove Gauze and irrigate with CHX or
Tetracycline 250mg/5cc

• Graft Defect with FDBA, BioOss
• Apply Collagen Membrane
• Closure of Flap and Regular Post op Intervals
Peri implantitis
Peri implantitis
Peri implantitis
Peri implantitis
Detoxify
• HCL Acid
• Tetracycline
• EDTA
• Hydrogen Peroxide
• Er:YAG and Diode
Graft Material
• Need OsteoInductive Material as there is
minimal Osteoprogenetor cells

• FDBA, DBA, Acel, OsteoCel, BMP2, Gem21, PRP, Emdogain

• Collagen Matrix Necessary
• Tacks to hold membrane if necssary
Peri implantitis
Peri implantitis
Peri implantitis
Mechanical
Debridement
I-Brush
Peri implantitis
Peri implantitis
Peri implantitis
Peri implantitis
Peri implantitis
Peri implantitis
Peri implantitis
Retrograde
Peri implantitis
Peri implantitis
Peri implantitis
Peri implantitis
Peri implantitis
Peri implantitis
Peri implantitis
LAPIP
• Nd:YAG laser with LANAP protocol to
address peri-implantitis

• Closed access
• First pass to decontaminate and selectively
eliminate infected tissue

• Debride with Piezon and CHX
• Second pass with laser to provide fibrin clot
LAP-IP
LAP-IP
LAP-IP
LAP-IP
Peri-Implantitis Effects
• Loss of implant and functioning prosthetics
• Esthetic Challenges
• Phonetic Challenges
• Maintenance Challenges
Peri implantitis
Peri implantitis
Prosthetic and
functional failure
Prevention Is The First
Step:

• Avoid conditions that contribute to poor
results

• Choose cases where you have excellent chance
for implant and prosthetic success.

• Anticipate and Diligently observe for implant
and restorative problems.

• Once Perio-Implant Disease identified act

quickly and with purpose to effectuate the
situation
What I see
• Retained Cement
• Inadequate attached gingiva
• Position of implant - Too Buccal
• Position of implant - Too Close to others
• Occlusal Overload
• Loss of Attached Gingiva Anterior
• Poor Oral Hygiene - Inability to get access
Peri implantitis
Peri implantitis
Hybrid Screw Retained
Vs. Implant Denture
Accessibility
Access for patient?
Peri implantitis
Peri implantitis
Proximity Issues
Peri implantitis
Peri implantitis
Peri implantitis
Implant Maintenance
• Needs to be Individually Determined
• Needs to be Enforced by Doctor and
Hygienist

• Patient Needs to assume Responsibility
Low Risk Patient
• Highly motivated
• Excellent Oral Hygiene
• One or Two implants
• No associated Risk Factors
Moderate Risk Patient
• Loss of Motivation
• Fair Oral Hygiene
• 3-6 implants
• Moderate Smoker (half pack)
• Controlled Medical Issues
High Risk Patient
• Unmotivated
• Poor Oral Hygiene
• Previous Periodontitis
• >6 implants
• Smokes more than half Pack
• Poorly Controlled Systemic Disease(s)
Maintenance Recall
• Low Risk Patients - every 6 months
• Moderate Risk - every 3 months
• High Risk - every 2-3 months
• Note - Oral Hygiene signficantly influences
the category the patient is placed.
Peri implantitis
Mechanical
Debridement
Hand Scalers and Ultrasonics
Maintenance

• Plastic, titanium, graphite instruments for
visual debridement from prosthetics and
sulcus.

• Ultrasonics with plastic tips at low to
moderate settings are excellent

• Individual or multiple implants with fixed
crowns or bridges screw or cemented
assess and debride as you would teeth.
Maintenance
• For Fixed Hybrid cases Remove at least
Twice a year and assess and debride
Transmucosal and Prosthetic underside

• O rings Remove Denture and address
abutments directly
Maintenance
• Polish with soft rubber tip and non-abrasive
paste - aluminum oxide, tin oxide, fine
pumice

• Irrigate with CHX with endodontic syringe
or piezon on low setting.
Ancillary Homecare
• Periostat - Doxycycline 20mg b.i.d.
• Evorapro - Especially for Dry Mouths
• Perio-science AO gel and rinse
• Listerene if no dry mouth 2x/day
• Biotene if dry mouth 2x/day
Likely Cause?
Peri implantitis
Etiology?
Thank You

Contenu connexe

Tendances

Guided tissue regeneration
Guided tissue regenerationGuided tissue regeneration
Guided tissue regenerationParth Thakkar
 
Periodontal plastic surgery
Periodontal plastic surgeryPeriodontal plastic surgery
Periodontal plastic surgeryRobert Cain
 
Implant failure , complications and treatment, management- Partha Sarathi Adhya
Implant failure , complications and treatment, management- Partha Sarathi AdhyaImplant failure , complications and treatment, management- Partha Sarathi Adhya
Implant failure , complications and treatment, management- Partha Sarathi AdhyaPartha Sarathi Adhya
 
Periodontal regeneration current concepts
Periodontal regeneration current conceptsPeriodontal regeneration current concepts
Periodontal regeneration current conceptsR Viswa Chandra
 
Genetic factors and periodontal disease
Genetic factors and periodontal diseaseGenetic factors and periodontal disease
Genetic factors and periodontal diseaseNavneet Randhawa
 
Periodontal flap surgeries by Dr. Jerry
Periodontal flap surgeries by Dr. JerryPeriodontal flap surgeries by Dr. Jerry
Periodontal flap surgeries by Dr. JerryDeepesh Mehta
 
Periodontal Medicine: Impact of periodontal disease on systemic health
Periodontal Medicine: Impact of periodontal disease on systemic healthPeriodontal Medicine: Impact of periodontal disease on systemic health
Periodontal Medicine: Impact of periodontal disease on systemic healthBinaya Subedi
 
Guided bone regeneration
Guided bone regenerationGuided bone regeneration
Guided bone regenerationBhaumik Thakkar
 
Regenerative osseous surgery
Regenerative osseous surgeryRegenerative osseous surgery
Regenerative osseous surgeryAlbert Augustinè
 
local drug delivery in periodontics
local drug delivery in periodonticslocal drug delivery in periodontics
local drug delivery in periodonticsAishwarya Hajare
 
8.periodontal dressing
8.periodontal dressing8.periodontal dressing
8.periodontal dressingpunitnaidu07
 
Role of occlusion in periodontal disease
Role of occlusion in periodontal diseaseRole of occlusion in periodontal disease
Role of occlusion in periodontal diseaseDr. Virshali Gupta
 

Tendances (20)

Guided tissue regeneration
Guided tissue regenerationGuided tissue regeneration
Guided tissue regeneration
 
Periodontal plastic surgery
Periodontal plastic surgeryPeriodontal plastic surgery
Periodontal plastic surgery
 
Ridge augmentation
Ridge augmentationRidge augmentation
Ridge augmentation
 
Implant failure , complications and treatment, management- Partha Sarathi Adhya
Implant failure , complications and treatment, management- Partha Sarathi AdhyaImplant failure , complications and treatment, management- Partha Sarathi Adhya
Implant failure , complications and treatment, management- Partha Sarathi Adhya
 
Periimplantitis
PeriimplantitisPeriimplantitis
Periimplantitis
 
Periodontal regeneration current concepts
Periodontal regeneration current conceptsPeriodontal regeneration current concepts
Periodontal regeneration current concepts
 
Root biomodification
Root biomodificationRoot biomodification
Root biomodification
 
Genetic factors and periodontal disease
Genetic factors and periodontal diseaseGenetic factors and periodontal disease
Genetic factors and periodontal disease
 
evidence based periodontology
 evidence based periodontology evidence based periodontology
evidence based periodontology
 
Periodontal regeneration
Periodontal  regenerationPeriodontal  regeneration
Periodontal regeneration
 
Periodontal flap surgeries by Dr. Jerry
Periodontal flap surgeries by Dr. JerryPeriodontal flap surgeries by Dr. Jerry
Periodontal flap surgeries by Dr. Jerry
 
Periodontal Medicine: Impact of periodontal disease on systemic health
Periodontal Medicine: Impact of periodontal disease on systemic healthPeriodontal Medicine: Impact of periodontal disease on systemic health
Periodontal Medicine: Impact of periodontal disease on systemic health
 
Guided bone regeneration
Guided bone regenerationGuided bone regeneration
Guided bone regeneration
 
Regenerative osseous surgery
Regenerative osseous surgeryRegenerative osseous surgery
Regenerative osseous surgery
 
Periodontal medicine
Periodontal medicinePeriodontal medicine
Periodontal medicine
 
Periodontal regeneration
Periodontal regeneration Periodontal regeneration
Periodontal regeneration
 
local drug delivery in periodontics
local drug delivery in periodonticslocal drug delivery in periodontics
local drug delivery in periodontics
 
8.periodontal dressing
8.periodontal dressing8.periodontal dressing
8.periodontal dressing
 
Non surgical periodontal therapy
Non surgical periodontal therapyNon surgical periodontal therapy
Non surgical periodontal therapy
 
Role of occlusion in periodontal disease
Role of occlusion in periodontal diseaseRole of occlusion in periodontal disease
Role of occlusion in periodontal disease
 

Similaire à Peri implantitis

Implant related complications and failure
Implant related complications and failureImplant related complications and failure
Implant related complications and failureJignesh Patel
 
Dental implant failure / /certified fixed orthodontic courses by Indian dent...
Dental implant failure  / /certified fixed orthodontic courses by Indian dent...Dental implant failure  / /certified fixed orthodontic courses by Indian dent...
Dental implant failure / /certified fixed orthodontic courses by Indian dent...Indian dental academy
 
Dental implant failure /certified fixed orthodontic courses by Indian dental...
Dental implant failure  /certified fixed orthodontic courses by Indian dental...Dental implant failure  /certified fixed orthodontic courses by Indian dental...
Dental implant failure /certified fixed orthodontic courses by Indian dental...Indian dental academy
 
Oral implantology
Oral implantologyOral implantology
Oral implantologySaleh Bakry
 
IMPLANT related complications
IMPLANT related complicationsIMPLANT related complications
IMPLANT related complicationsAfsana Kader A
 
Peri implantitis treatment with regenerative approach
Peri implantitis treatment with regenerative approachPeri implantitis treatment with regenerative approach
Peri implantitis treatment with regenerative approachajayashreep
 
Implant failure & its management.pptx
Implant failure & its management.pptxImplant failure & its management.pptx
Implant failure & its management.pptxDr.shiva sai vemula
 
Basic implantology (periodontology and implantology)
Basic implantology (periodontology and implantology)Basic implantology (periodontology and implantology)
Basic implantology (periodontology and implantology)KanchanMane4
 
Dental implants. surgical stages
Dental  implants. surgical stagesDental  implants. surgical stages
Dental implants. surgical stagesLinda Jenhani
 
Maintenance and failures
Maintenance and failuresMaintenance and failures
Maintenance and failuresR Viswa Chandra
 
IMPLANT FAILURES- A DENTIST'S NIGHT MARE
IMPLANT FAILURES- A DENTIST'S NIGHT MAREIMPLANT FAILURES- A DENTIST'S NIGHT MARE
IMPLANT FAILURES- A DENTIST'S NIGHT MARESneha Bobbireddy
 
911 krishnan ppt
911 krishnan ppt911 krishnan ppt
911 krishnan pptRafi Romano
 
Soft tissue management around dental implant
Soft tissue management around dental implantSoft tissue management around dental implant
Soft tissue management around dental implantrasmitasamantaray1
 
Peri-implant Diseases Classification, Cases Definition and Treatment.pdf
Peri-implant Diseases Classification, Cases Definition and Treatment.pdfPeri-implant Diseases Classification, Cases Definition and Treatment.pdf
Peri-implant Diseases Classification, Cases Definition and Treatment.pdfssuseraf61fb
 
Gingival recession
Gingival recessionGingival recession
Gingival recessionImen Kassoma
 
Dental Implant failures
Dental Implant failuresDental Implant failures
Dental Implant failuresRavi banavathu
 
implant failure
implant failure implant failure
implant failure a7madf
 

Similaire à Peri implantitis (20)

Implant related complications and failure
Implant related complications and failureImplant related complications and failure
Implant related complications and failure
 
Dental implant failure / /certified fixed orthodontic courses by Indian dent...
Dental implant failure  / /certified fixed orthodontic courses by Indian dent...Dental implant failure  / /certified fixed orthodontic courses by Indian dent...
Dental implant failure / /certified fixed orthodontic courses by Indian dent...
 
Dental implant failure /certified fixed orthodontic courses by Indian dental...
Dental implant failure  /certified fixed orthodontic courses by Indian dental...Dental implant failure  /certified fixed orthodontic courses by Indian dental...
Dental implant failure /certified fixed orthodontic courses by Indian dental...
 
Oral implantology
Oral implantologyOral implantology
Oral implantology
 
IMPLANT related complications
IMPLANT related complicationsIMPLANT related complications
IMPLANT related complications
 
Peri implantitis treatment with regenerative approach
Peri implantitis treatment with regenerative approachPeri implantitis treatment with regenerative approach
Peri implantitis treatment with regenerative approach
 
Wilckodontics.pptx
Wilckodontics.pptxWilckodontics.pptx
Wilckodontics.pptx
 
Implant failure & its management.pptx
Implant failure & its management.pptxImplant failure & its management.pptx
Implant failure & its management.pptx
 
Basic implantology (periodontology and implantology)
Basic implantology (periodontology and implantology)Basic implantology (periodontology and implantology)
Basic implantology (periodontology and implantology)
 
Dental implants. surgical stages
Dental  implants. surgical stagesDental  implants. surgical stages
Dental implants. surgical stages
 
Maintenance and failures
Maintenance and failuresMaintenance and failures
Maintenance and failures
 
IMPLANT FAILURES- A DENTIST'S NIGHT MARE
IMPLANT FAILURES- A DENTIST'S NIGHT MAREIMPLANT FAILURES- A DENTIST'S NIGHT MARE
IMPLANT FAILURES- A DENTIST'S NIGHT MARE
 
911 krishnan ppt
911 krishnan ppt911 krishnan ppt
911 krishnan ppt
 
911 krishnan
911 krishnan911 krishnan
911 krishnan
 
Soft tissue management around dental implant
Soft tissue management around dental implantSoft tissue management around dental implant
Soft tissue management around dental implant
 
Peri-implant Diseases Classification, Cases Definition and Treatment.pdf
Peri-implant Diseases Classification, Cases Definition and Treatment.pdfPeri-implant Diseases Classification, Cases Definition and Treatment.pdf
Peri-implant Diseases Classification, Cases Definition and Treatment.pdf
 
Gingival recession
Gingival recessionGingival recession
Gingival recession
 
Endodontic faiures
Endodontic faiuresEndodontic faiures
Endodontic faiures
 
Dental Implant failures
Dental Implant failuresDental Implant failures
Dental Implant failures
 
implant failure
implant failure implant failure
implant failure
 

Dernier

Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptPradnya Wadekar
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfDolisha Warbi
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu Medical University
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaSujoy Dasgupta
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologyDeepakDaniel9
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptxWINCY THIRUMURUGAN
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptxNIKITA BHUTE
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)kishan singh tomar
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdfHongBiThi1
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE Mamatha Lakka
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 

Dernier (20)

Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.ppt
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
 
Mental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil ThirusanguMental health Team. Dr Senthil Thirusangu
Mental health Team. Dr Senthil Thirusangu
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacology
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
 
High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)High-Performance Thin-Layer Chromatography (HPTLC)
High-Performance Thin-Layer Chromatography (HPTLC)
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 
Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...
 
BENIGN BREAST DISEASE
BENIGN BREAST DISEASE BENIGN BREAST DISEASE
BENIGN BREAST DISEASE
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...
 

Peri implantitis

  • 1. Peri-Implantitis: Prevalence, Practical Treatment and Prevention Prevalence, Practical Treatment and Prevention Dr. Scott K. Smith November 13, 2013
  • 2. Scott K. Smith • Practicing Periodontist 20 years • Placed over 10,000 implants • HiOssen lecturer, teacher and Instructer
  • 3. Objectivesand Peri• Define Peri-Implant Mucositis Implantitis • Prevalence of each • Pathogenesis vs. Periodontal Disease • Diagnostic Criteria • Treatment for mucositis and implantitis • Maintenance following treatment
  • 4. Conflict of Interest • HiOssen - Clinical practice support and honorarium.
  • 5. Dental Implant Success • 400,000 implants placed per year in US • 1 million implants placed per year in EU • $6.5 billion US industry • Failure Rate of Implants less than 5% • Industry and Research Focus on Initial Stabilization, enhancing supporting structure and Initial Esthetics.
  • 11. The Dark Side • Incidence of Peri-implant mucositis and Peri-implantitis is as much as 47%!! • Failure of Implants by Chronic Inflammation include Functional loss, Phonetic and Esthetic Challenges • Professional Challenge
  • 12. Similarity with Periodontal Diseases • Host Response to Bacterial Insult • Initial Event is Inflammation of Pocket Epithelium without CT or Bone Destruction - Reversible = Gingivitis • Chronic Inflammation and Risk Factors = Periodontitis
  • 13. Implant Related Periodontal Diseases • Peri-Implant Mucositis • Peri-Implantitis
  • 14. Peri-Implant Mucositis • The presence of inflammation confined to the soft tissues around the implant - No sign of bone loss. • Presence of probing >4mm with bleeding or suppuration • Reversible
  • 15. Peri-Implantitis • Inflammatory process around and implant including soft tissue and progressive loss of supporting bone beyond biological bone remodeling. • Probing depth >4mm with bleeding, suppuration and radiographic bone loss
  • 16. Peri-Implantitis Probing depths >4mm with bleeding, suppuration Radiographic loss of bone beyond remodeling
  • 17. Prevalence: Peri-Implant Mucositis Peri-Implant Mucositis • Berglundh, Renvert: 48% of all implants over 9-14 yrs affected. • Prevalence may be higher - Previous Dogma of Not Probing around Implants Reduced Identification
  • 18. Prevalence: Peri-Implantitis Peri-Implantitis • Wide Range: from 4.7% to 36.6% • The Threshold used is Bone Loss. No standarized radiographic analysis. • Additionally Factors such as Smoking, Diabetes, Previous Periodontal Disease create subpopulations and complicate comparisons of studies.
  • 20. Anatomy of a Tooth • Junctional Epithelium has Hemidesmosomal attachment to enamel • Connective tissue array of 1mm thickness with attachment to Cementum • Alveolar Bone with Perpendicular Fibers attaching to Cementum overlying Dentin • Vast Source of Nutrients and Cells for Regeneration of Ligament, CT, Cementum, Bone
  • 21. Cementum • Acellular and Cellular containing cementoblasts provide support on the tooth side to anchor sharpy’s fibers • Periodontal Ligament space provides nutrient supply and cells for Regeneration
  • 22. Anatomy of an Implant • Junctional Epithelium attached to titanium surface by basal lamina and hemidesmosomes • At apical portion of sulcus is only a few cell layers thick and separated from bone by 12mm • No Cementum - Bone to Implant Contact • Connective tissue between JE and Bone few vascular structures and few Fibroblasts
  • 24. Peri-Implant Mucositis • Plaque formation of titanium surface and formation of biofilm. Gram (-) Anaerobic • Inflammatory infiltration occurs in CT • Neutrophils, lymphocytes, macrophages in high numbers • Adaptation of JE to Inflammation
  • 25. Peri-Implantitis Peri-Implantitis • Inflammatory - bacterial driven destruction of the implant supporting apparatus. • Chronic Inflammation starting as PIM • Inflammatory Cell Infiltrate more Severe with Implants vs. Teeth • Rate of Disease Progression Faster with Implants
  • 26. Peri-Implantitis • The difference in collagen fiber orientation (parallel to implant and perpendicular with teeth) and less vasculature structure may explain the faster pattern of tissue destruction with peri-implantitis.
  • 27. Influential Factors • Patient Related - systemic diseases, history of Periodontal Disease • Social Factors - Poor OH, Smoker, Heavy alcohol consumption • Parafunctional Habits - Bruxism, Malocclusion
  • 28. Smoking • Baig and Rajan found in smokers significantly more marginal bone loss after placement and higher Peri-Implantitis percentages.
  • 29. Previous Periodontitis • Significant correlation with increased prevalence of Peri-Implantitis
  • 30. Genetic Factors • Significant correlation with Interleukin1gene polymorphism and PeriImplantitis. • Plagnat - proposed markers for Elastase and alkaline phosphatase may be helpful in future diagnosis of bone destruction.
  • 31. Health Status • Diabetes Type I and II if uncontrolled lend to increased inflammatory Response and Peri-Implantitis
  • 32. Occlusion • Non-axial forces, cantilevers, bruxism • H.L.Wang et al - occlusal overload positively associated with Peri-Implantitis • Likely excess strain causes microfracture within bone.
  • 33. Additional Influential Factors -You’re to Blame • Implant Design • Prosthetic Connection • Mechanical Failures and Cement Contamination • Surgical Errors
  • 34. Implant Design • Smooth titanium vs. Roughened surfaces • Smooth Cervical collar vs. Surface texture to coronal margin • Thread Design - aggressive vs. passive
  • 35. Implant Design Connection • External Hex • Internal Hex • Morse Taper • Platform Switch
  • 36. Platform Design • Crestal Bone loss begins when healing abutment is attached to implant at second stage surgery (Nobel implants - Ericsson J. Clin. Perio 1995) • Burglund and Lindhe identified 0.5mm inflammation above and below Branemark implants at abutment/implant junction after 2 weeks.
  • 38. Microgap and Platform Switching • Move the microgap away from the implant platform and hence away from the crestal bone as a protective measure.
  • 40. Restorative Problems • Excessive Cantilever • No Passive fit • Improper fit of abutment • Improper prosthetic design, occlusal scheme • Premature Loading, Overtorquing • Connecting implants to Natural teeth
  • 46. Surgical Placement • Off Axis Position - severe angulation, • Lack of Initial Stabilization • Infection from improper flap design • Overheating bone • Spacing too close to teeth or implants • Inadequate bone or attached gingiva • Too Buccal or Lingual and compromise bone
  • 53. Heat Generation • Eriksson and Albrektsson reported the critical temperature for implant placement was 47C for 1 minute. • Matthews and Hirsch demonstrated that temperature elevation was more a result of force applied rather than drill speed.
  • 54. Diagnostic Criteria • Probe all implants - Plastic or Metal • Look for Bleeding and or Suppuration • X-rays should be taken yearly first two years and compared to base line placement • Evaluate Occlusion, Prosthetic Stability • Soft tissue evaluation - Attached Gingiva?
  • 57. Accessibility • Adjust Prosthesis • Plaque Control • Biofilm Removal
  • 58. How do you Probe this?
  • 62. Treatment Options • Early Detection is Key to Success and improved health! • Non-surgical Intervention • Surgical Intervention
  • 63. Non-Surgical - Studies • Mechanical Debridement with plastic instruments and Chlorhexidine irrigation showed reduction of pocket and bleeding at six months - Schwartz • Antiseptic irrigation of pockets <4mm not effective, but over 5mm it has added effect. Renvert • Adjunctive use of generalized antibiotics did not improve the treatment results
  • 68. Peri-implant Mucositis • Application of Minocycline spheres along with debridement provide some additional benefit to reducing bleeding and probing, but NEEDS TO BE REPEATED OFTEN. Renvert
  • 69. Clinical Treatment of PIM • Mechanical Scaling of Implants with plastic or titanium instruments or Ultrasonic Plastic Tips. I-Brush if exposed threads. • Apply exposed implant surface with 0.2% Chlorhexidine gauze for 2 mins • Subgingival irrigation with 0.2% Chlorhexidine 5ml per implant • Minocycline Spheres or Gel
  • 70. Peri-Implantitis Treatment Options Treatment Options • Visualization with open flap very effective with cementitits!
  • 71. Peri-Implantitis • Treatment to be determined by amount of bone loss and esthetic impact of the implant in question • If minimal bone loss (3 threads or less) Proceed with similar treatment as Peri-implant mucositis, but decontaminate prosthetic components as well. The use of various lasers has been suggested. • If bone loss is advanced or progressive than surgical access with resective or regenerative components will need to be employed.
  • 72. Peri-Implantitis Non Surgical - Studies Non Surgical - Studies • 31 Subjects mean age 62 • One qualifying implant per patient • PPD >4mm with bleeding or suppuration • < 2.5mm bone loss • J. Clin. Perio 2009 Renvert
  • 73. Non-Surgical • Titanium hand instrumentation • Or Ultrasonic Debridement with plastic tip • 6 month results - minimal change with PD for either treatment modality
  • 74. Laser Therapy Er:YAG • SRP with plastic instruments and 0.2% chlorhexidine followed by Er:YAG 20sec disinfection per implant • Control was only SRP and antiseptic rinse • Six months later Equal Reduction of Pocket and Clinical Attachment • Twelve months later both groups lost effect
  • 75. Peri-Implantitis with Er:YAG vs. Air-Abrasive device • 42 Patients mean age 69 • Laser 55 implants • Perio Flow 45 implants • PPD >5mm with bleeding or suppuration • > 3mm bone loss • J. Clin Perio 2011, Renvert
  • 76. Results • Remove Supra-Structure from Implants! • Significant difference in PD bleeding and Pus reduction for both groups at 6 months • Both seem to have limited benefit in advanced cases
  • 77. Open Flap - Resective • Surgical flap access and resection of 1 or 2 wall defects combined with decontamination and antibiotic treatment was effective in just over half the cases over 5 years. Leonhardt 2003 • 2008 Hitz-Mayfield with flap surgery and resection and antimicrobial treatment stopped the progression of the disease in 90% of cases up to one year - However, BOP continued in 50% of the lesions.
  • 78. Regenerative Surgery • Schwartz (2008) found combination bone grafting debridement and antibiotics had significant reduction of bone loss and BOP after 2 years. • Froum (2012) Significant reduction of BOP, Pocket reduction, bone loss over 3-7 years.
  • 79. Submerged Healing • 16 implants in 12 patients • Open Flap and 3% Hydrogen Peroxide • Bone Graft and Membrane • Submerged healing • Roos-Janasker J. Clin Perio 2007
  • 80. Submerged Surgical Results • PD change • Defect fill (threads) • Defect Fill (mm) • Recession (mm) 4.2mm 3.8 2.3 2.8
  • 81. Implant Configuration and Decontamination • Implant contours and surface are a limitation to remove the biofilm • Surface treatments including - mechanical, Er:YAG, photodynamic, air-abrasion, implantoplasty • Romeo (2005, 2007) implantoplasty improved regenerative capability - reducing probings from 5.5 - 3.6mm and BOP.
  • 83. Regenerative Treatment for PeriImplantitis affected implant: Stuart J. Froum Clin Adv Perio 2013 Stuart J. Froum Clin Adv Perio 2013 • 7 year follow up showed decrease pocket depths • Technique successful in 51 cases (IJPRD 2012:32:11-20) • Believes if any Elements of protocol not followed could compromise outcome
  • 84. Protocol • 1 month prior to surgery: SRP of natural teeth; debride implant surface and OHI • Requires 2 visits to accomplish this
  • 85. Surgery: Exposure and Debridement Exposure and Debridement • 2 gm Amox 1 hour prior to surgery • FTF to expose area • Debride defect with titanium and graphites • Air-Power abrasives (Bicarbonate powder) for 60 secs • 60 secs irrigation with sterile saline • 60 secs application of Tetracycline strips
  • 86. Surgical Protocol • Second application of air-powder abrasive for 60-90 secs • Application of CHX for 30 secs • 60-90 secs of sterile saline with air power device no powder
  • 87. Surgical Protocol • EMD applied - avoid blood and saliva • Defect filled with 1:1 Bioss/Puros rehydrated with gem 21 • 2 ossix membranes placed to cover all surfaces • Flap released and coronally advanced and sutured with Goretex and vicryl sutures
  • 88. Post Surgery • 2 weeks remove sutures and polish • Pt to brush area 4x/day with 1:1 Peroxide and rinse with salt water 4x/day • Return monthly for 12 months for post op and every 6-8 weeks for maintenance
  • 90. Treating Peri-Implantitis • Systemic Antibiotics for three days prior to treatment • 2 mins pre-operative rinse with Chlorhexidine • Full Thickness Mucoperiosteal Flap to one tooth beyond diseased site • Thorough Debridement circumfirentially with plastic or titanium or Ultrasonic plastic tips
  • 91. Treating Peri-Implantitis • Pack Gauze Strips soaked with CHX around implants and in defects for 5 mins • Remove Gauze and irrigate with CHX or Tetracycline 250mg/5cc • Graft Defect with FDBA, BioOss • Apply Collagen Membrane • Closure of Flap and Regular Post op Intervals
  • 96. Detoxify • HCL Acid • Tetracycline • EDTA • Hydrogen Peroxide • Er:YAG and Diode
  • 97. Graft Material • Need OsteoInductive Material as there is minimal Osteoprogenetor cells • FDBA, DBA, Acel, OsteoCel, BMP2, Gem21, PRP, Emdogain • Collagen Matrix Necessary • Tacks to hold membrane if necssary
  • 117. LAPIP • Nd:YAG laser with LANAP protocol to address peri-implantitis • Closed access • First pass to decontaminate and selectively eliminate infected tissue • Debride with Piezon and CHX • Second pass with laser to provide fibrin clot
  • 118. LAP-IP
  • 119. LAP-IP
  • 120. LAP-IP
  • 121. LAP-IP
  • 122. Peri-Implantitis Effects • Loss of implant and functioning prosthetics • Esthetic Challenges • Phonetic Challenges • Maintenance Challenges
  • 126. Prevention Is The First Step: • Avoid conditions that contribute to poor results • Choose cases where you have excellent chance for implant and prosthetic success. • Anticipate and Diligently observe for implant and restorative problems. • Once Perio-Implant Disease identified act quickly and with purpose to effectuate the situation
  • 127. What I see • Retained Cement • Inadequate attached gingiva • Position of implant - Too Buccal • Position of implant - Too Close to others • Occlusal Overload • Loss of Attached Gingiva Anterior • Poor Oral Hygiene - Inability to get access
  • 130. Hybrid Screw Retained Vs. Implant Denture
  • 139. Implant Maintenance • Needs to be Individually Determined • Needs to be Enforced by Doctor and Hygienist • Patient Needs to assume Responsibility
  • 140. Low Risk Patient • Highly motivated • Excellent Oral Hygiene • One or Two implants • No associated Risk Factors
  • 141. Moderate Risk Patient • Loss of Motivation • Fair Oral Hygiene • 3-6 implants • Moderate Smoker (half pack) • Controlled Medical Issues
  • 142. High Risk Patient • Unmotivated • Poor Oral Hygiene • Previous Periodontitis • >6 implants • Smokes more than half Pack • Poorly Controlled Systemic Disease(s)
  • 143. Maintenance Recall • Low Risk Patients - every 6 months • Moderate Risk - every 3 months • High Risk - every 2-3 months • Note - Oral Hygiene signficantly influences the category the patient is placed.
  • 146. Maintenance • Plastic, titanium, graphite instruments for visual debridement from prosthetics and sulcus. • Ultrasonics with plastic tips at low to moderate settings are excellent • Individual or multiple implants with fixed crowns or bridges screw or cemented assess and debride as you would teeth.
  • 147. Maintenance • For Fixed Hybrid cases Remove at least Twice a year and assess and debride Transmucosal and Prosthetic underside • O rings Remove Denture and address abutments directly
  • 148. Maintenance • Polish with soft rubber tip and non-abrasive paste - aluminum oxide, tin oxide, fine pumice • Irrigate with CHX with endodontic syringe or piezon on low setting.
  • 149. Ancillary Homecare • Periostat - Doxycycline 20mg b.i.d. • Evorapro - Especially for Dry Mouths • Perio-science AO gel and rinse • Listerene if no dry mouth 2x/day • Biotene if dry mouth 2x/day