periodontics 2 - weebly · periodontics 2 date of lecture 9-12-2018 sheet number 13 doctor dr.omar...

Faculty of Dentistry Batch of 2018

Periodontics 2

Date of Lecture 9-12-2018

Sheet Number 13

Doctor Dr.Omar

Karadsheh

Written By Rawan ALrejjal

Corrected by Dana AL-Foqaaha’a

Reference sheets in 2013

(if present) 12

University of Jordan Introduction to peri-implant diseases Sheet #13 Faculty of Dentistry

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Introduction:

What is the process of bone healing around implant? Osseointegration

➢ For better osteointegration surface treatment (micro,

macro -scoopicly rough) to increase the surface area

➢ Complications we may face with implants:

- mechanical porcelain fracture, screw loosening, implant

fracture

- biological peri-implant disease

Tooth VS implants: - how’s the soft tissue heal around the implant? -if you

compare the mucosa around the implant what’s the differences and

similarities?

There’s no PDL in implants, So no proprioception and no cushioning effect.

if you put anything in the oral cavity and it was biocompatible, the tissue

should heal somehow so the bacteria won’t get in and act like a barrier, in

implants we have junctional epithelium and it is longer. In teeth it is almost

1mm , connective tissue is 1mm and these together (junctional epithelium +

connective tissue) is called biological width.

In implants we have biological width too, but it doesn't have the same

dimensions, so in implants you don’t see PDL but you see long junctional

epithelium, a band of CT above the bone. let’s go into details;

-Do we have biological width in implants?! yes we do. the body always form

a biological width

around any structure

inside the body tissue

and going outside

any cavity, so there

has to be protection

so there’s biological

width.


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The main differences:

- junctional epithelium is longer in implants and we

call it epithelial barrier, because usually the

biological width is more in implants.

If you look at histology;

- you will see gingival fiber around the tooth it is going into bone and

gingiva in different directions -if you look at implant you have bone ,

collagen fiber going parallel to the implant surface they’re not inserting

inside, so the fibers are attached to tooth surface while in implant there is no

attachment with connective tissue that just adapt / heal around the implant.

this information is clinically significant

(TOOTH) (IMPLANT)


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Vascular supply:

-This is a tooth, you have rich vascularization coming to the PDL , you have

also dentogingival plexus and intr-abony vessels and subperiosteal vessels,

but when you extract the tooth you have only the subperiosteal and intra

osseous, so you don’t have this rich vascularity in the tooth so you will

expect that the healing in implants will be less , we don’t really have much

vascularity as in tooth.

Due to the lack of the vascular plexus of the periodontal ligament around the

implant after we extract the tooth what we have left is a scar tissue. but why?

Because you did a trauma when you extract the tooth and the scar tissue has

less blood vessels and has less cells and it has more collagen fibers.

And that makes the implants susceptible to infection

• What actually is attached is the

cuticle, proteins, lamina densa

• It’s like adhesion more than

attachment

Peri-implant mucosa Vs. Gingiva:

- The peri-implant mucosa is sealed, and not attached to the implant.

- A biological width is maintained, whatever the thickness of the mucosa.

- Compared to the gingiva, the peri-implant mucosa is a scar-like tissue, rich

in collagen fibers, poor in fibroblasts, and with limited blood supply.


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- Not keratinized just adapted around the crown which makes it easier to

remove.

- The potential for repair is more limited than with gingival tissue

The potential for repair is limited due to the:

A. Lack of periodontal ligament

B. Reduction of the cellular components of the mucosa

C. Reduced vascularization.

Implant Examination?

▪ Can we probe around implants? Normal PD? Is it the same

as teeth? Do you think the resistance for probing is more or

less in implants?

The CT fibres are parallel to the implant surface without attachment to

the metal body (adhesion). Consequently, the resistance to probing

around implants is decreased as compared to that around teeth.

➢ Actually, what is more important than probing depth is bleeding score

since it’s an indicator of the absence or presence of a disease.

So, when you examine an implant patient you are looking for:

1. PD

2. BOP

3. Suppuration

4. Plaque score

5. Mobility

6. Bone level


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1. PD

When probing in healthy tissues, the tip of the

probe seems to reach similar levels at the

implant and tooth sites if you use light force no

more than (0.25N).

-Once you have inflammation: in teeth you

might get a little deeper pocket but in implants

it increases more because it has less resistance,

so you might get deep pocket in normal inflammation

(6mm).

-What is the normal probing depth of an implant?

Actually, there is no normal PD, but it depends on many

things like the position of the implant where probing depth

may reach up to 4mm.

- you must measure probing depth at baseline when you put the restoration,

if its 5 then it’s the normal, that’s why it’s important to record baseline for

implants because it’s not like teeth it’s different, so you always need to

record the baseline.

**We mean by baseline record is the probing depth we measure once the

implant is functioning **

So, probing in implants is not reliable and you need to compare to baseline

and you also need to have other signs of inflammation. so sometimes in

health, implants and teeth have the same probing depth, but in inflammation

the implants are less resistant, so you get a deeper pocket.

PLASTIC prob: to prevent scratching the implant + flexibility which is more

imp due to the huge difference in the ratio of crown~10 \ trunk~7 ,

crown~10 \ implant shoulder~5 between normal tooth

and implant

**So we need to look for other signs


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2. BOP:

-It's accurate with correct force (but you still have high risk of

bleeding) because the tissues are less resistant and the huge

supracrestal structures may lead you to couse trauma .

-If There is dot bleeding properly due trauma, But if it was drop or

line of bleeding that’s mean that the implant is diseased.

**radiographic examination is also important .

**Implants are not complaining (no pdl no proprioception ) so the

implant may get cracked .

**bone remodeling around implant happen during the first year ➔up

to the first thread or 2mm from the first thread or implant shoulder it

considered normal, if you don’t have base line data you can look at

first thread or implant shoulder

peri-implant disease

peri-implant health

-no bleeding

-no bone loss than expected remodling

-no progression

peri-implant mucositis

- no bone loss

-inflmmation

-resemble gigvaitits

peri-implantitis

-resamble peridontitis

-there is bone loss


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-Peri-implant Mucositis resemble gingivitis.

-Peri-implantitis resemble periodontitis.

-The difference between peri implant mucositis and peri implantitis is bone

loss whereas the difference between gingivitis and periodontitis is

attachment loss.

-You don’t have attachment in implant, you have bone.So, if you want to

define mucositis, it’s inflammatory lesion that resides in the mucosa, not

involving bone only soft tissue.

Etiology :

1. Plaque (poor OH )

2. Local factors:

A. Crown design (non-hygnic, difficult to clean around, no

embrasures) large bulbous crowns/poor denture designs: it’s easy

to happen in implants like in central incisors

B. Deep implant (hard to maintain it clean and cement removing also

difficult)

C. Ill-fitting component of the implant (-the junction of an ill-fitting

implant-abutment or abutment-crown connection).

D. Rough implant surface (its impossible to remove plaque from it so

sometimes we do implantoplasty if it was exposed (highly

textured, macroscopically rough implant surfaces: rough surface

implants are designed to be rough to integrate, if you have

recession and a part of the implant is exposed it will be hard to

clean).

E. Trapped excess sub mucosal cement: excess cement they call it

cementitis .

So for you to diagnose peri-implant mucositis you need to have:

1. Inflammation (redness, swelling,…)

2. Bleeding more than a dot

3. No bone loss

4. Might have increase probing depth


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NOTE: you can find abscesses around implants clinically but in radiographs

you can’t find bone loss, but you still can find that the junction between the

crown and the abutment is below the interproximal bone (apically) and the

cement can be trapped under the bone causing ➔abscess.

((this is an exaggerated proliferative reaction, this is a cement causes abscess

in the area. A, Clinical photograph of abscess caused by excess cement

trapped within the soft tissues.

B, Radiograph of implant with

cemented crown (same patient as in A).

Notice the subgingival depth of the

crown-abutment (cement line) junction,

which is below the level of the adjacent

interproximal bone and therefore

impossible to adequately access with

explorer to remove excess cement. we

*the staging in mucositis is the same as gingivitis (initial,established,…)

the only difference that it's larger (remember its less resistant)

There was a study done on doges for mucositis and they found:

• the same bacteriology as gingivitis (gram +\-)

• it's reversible


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Treatment:

A. OHI:( First we start with

prevention methods by

improving OH and good

prosthetic design)

** teach the pt how to use floss,

supra floss, the regular brushing,

interdental brushing below and

around the pontics side way. (so

it's favorable to have hygnic design to start with )

((sometimes when you put 4 implants to place overdenture for

example, and you don’t have access to clean, then whatever money

you paid for implants you are going to lose them, so you have to have

a good access to clean, so the design is very important.))

B. Non surgical treatment \scaling :( Second thing is mechanical

debridement with plastic or titanium curette (instruments hardness

should be less or similar to titanium hardness in order to avoid

scratching of implant surface that will enhance plaque accumulation)

,stainless steel are harder so we don't use them.)

1. Ti scalers: because it has the same hardness of implants (hardness: the

resistance to scratch )

2. Ultrasonic scalers with carbon fiber tip/gold tip.

3. Adjunctive measures (antiseptics, local + systemic antibiotics + air

abrasive devices)

4. YAG Laser: There is no studies or proof that it treats mucositis.

*It is only marketing.

*It is good for mucositis, but it is not better and not more effective

than mechanical debridement and it is more expensive.

*No effect on periimplantitis

Note: Don't do vertical motion when you do debridement because in this

way you will stuck with first thread only, you should do it in circular

manner.


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Also there are titanium brushes for recession areas or we can do

Implantoplasty : if threads are exposed , can't be treated any more , we don’t

want to remove the implant , 50% of the implant inside the bone and in non-

aesthetic areas (posterior implant) ,we just smoothen the surface by

removing these threads with a bur

Nobody knows which choice is better but combination of these can work.

Peri-implantitis : inflammation around implant with increasing PD and

bone loss ( if you don't have date ) 3mm loss from where it supposed to

be it's considered implantitis or PD more 6mm.

-suppuration is very common here

-mobility is not sensitive


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-radiographic bone loss ➔saucer shape following the threads

(circumferential)

-in the normal tooth it's either horizontal or vertical.

- usually start from excess cement.

How it's different from periodontitis?

In a study they bring up doges and they place in them implants in 1

quadrant and they Couse attachment loss by pushing sutures in the

sulcus.

In the histological section:

there was inflammation getting closer to the bone but there was

connective tissue capsule (healthy 1mm of CT from bone in a normal

tooth)teeth were always have 1mm CT between the inflammation and the

bone ( they will never met together )


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in implants : there is no 1mm CT and it progress faster and more

dangerous , the inflammation was closer to the bone because there was

no CT capsule .

Prevalence:

Peri-implant Mucositis: up to 50% of implants

Peri-implantitis: 15-20% of implants

It is very important to detect Peri-implant Mucositis before it progresses

to Peri-implantitis which is difficult to treat. To examine, we can use our

perio probe (without scratch just insert it into the pocket) or plastic probe

that can bend and insert easily to get accurate reading. Nowadays they

find that no difference between using of two probes.

Risk factors:

1. Poor OH

2. Poor supracrestal structure (huge)

3. History of periodontitis ;if pt of periodontitis decided to extract and

place an implant and he wasn't well motivated and wasn't treated

well from periodontitis he is contraindicated

4. Smoking\DM (there is no enough evidence )


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Treatment :

-we can start as mucositis but studies have shown that peri-implantitis

doesn't respond well to non-surgical therapy , so most of the time you will

go for surgical therapy:

1. open--<

2. clean\disinfect \decontaminate by CHX or tetracycline in the study

there was no difference as long as you use them correctly .

3. Then you can graft it if it was nice defect (some studies says that

bone can osteo-re-integrate again (grow again ) but still you have to

have 3 wall defect .

4. Sometimes the bone all over the implant goes down ,we can't graft it

vertically (sometime you need implantoplasty)

5. Surgery :it can Couse rescission-so in anterior areas it's better to

remove it and do a new one because sometime it won't heal (dead

surface)

It's not predictable (very high chance of having relapse again )


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This is how you should design the

crown …with open embrasures

like this picture and the patient

should be able to remove the

entrapped food by suctioning the

air through it.

The End

periodontics 2 - weebly · periodontics 2 date of lecture 9-12-2018 sheet number 13 doctor dr.omar...

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