Periodontitis & Implants

Transcription

1 Objectives Periodontitis & Implants Dr Simon Hinckfuss D.C.D (Melb), Cert.Perio, MS (Minn, USA) Diplomat of the American Board of Periodontology Diagnose common types of periodontal disease Describe the likely outcome of periodontal treatment Discuss implant treatment options for periodontal patients w Chronic Periodon?ts w E?ologic/risk factors are propor?onal to the amount of aeachment loss w Localized or generalized w Slight, moderate or severe w Includes Type II diabe?cs and smokers (Armitage 1999) w Aggressive Periodon?ts w aeachment loss that is not consistent with the amount of plaque/calculus present w No contribu?ng systemic illness w Usually pa?ents under 35 w Can be localized or generalized (Armitage 1999) Less Common w Others w Gene?c or aquired immune system defects (eg cyclic neutropenia, AIDS, chemo) w Connec?ve?ssue defects w Type I Diabe?cs w Muco- cutanous disorders Evidence Supporting efficacy of Periodontal treatment Natural Progression (Neely) Randomized controlled trials Lindhe, Pihlstrom, Ramfjord, Kaldahl, Loma Linda Long-term Private Practice Fewer studies for Aggressive Periodontitis. 1

2 Clinical Outcomes-Perio Tx Hirschfeld and Wasserman (1978) 22 Year private practice retrospective study McGuire and Nunn (1996) Prognosis Biologic Outcome of Perio Tx w Host status not changed w Reduc?on in pathogens (Shiloah 1996) rebound occurs in deep pockets (Magnusson 1996) % of sites infected Microbial analysis of sites with progressive a7achment loss (Shiloah 1996) Baseline 1 week 12 months P.g A.a P.i What about Implants and periodontitis? Karoussis IK, Salvi GE, Heitz-Mayfield LJ, Brägger U, Hämmerle CH, Lang NP. Long-term implant prognosis in patients with and without a history of chronic periodontitis: a 10-year prospective cohort study of the ITI Dental Implant System. Clin Oral Implants Res Jun;14(3): First study to raise the alarm. Survival 90.5% vs 96.5% Peri-implantitis 28% vs 5% difference only apparent after 6 years Confounding factor of more smokers in the perio group First systematic review Schou S, Holmstrup P, Worthington HV, Esposito M. Outcome of implant therapy in patients with previous tooth loss due to periodontitis. Clin Oral Implants Res Oct;17 Suppl 2: Systematic review- Only identified 2 studies with 5 and 10 year follow-up! No difference in survival of implants or superstructures Risk ratio of 9 for peri-implantitis in perio group Extra 0.5mm mean bone loss in perio group after 5 years Karoussis rebutts himself Karoussis Cochrane style review. 15 studies including seven short-term and eight long-term Only 3 studies with aggressive perio but short term No difference in survival but deeper pockets, more bone loss and more peri-implantitis. Because of considerable discrepancies among these studies, metaanalysis was not performed Only included studies up to This has become a hot topic since and the number of published studies has escalated since Adequate study size to find a difference N required to show a difference Control Group success rate Test group with 98% success Assume Type I error rate 0.05 and 90% power (chance that a true difference will be correctly reported) 2

3 Updated review Is there a difference between Chronic and Aggressive Perio? Schou S. Implant treatment in periodontitis-susceptible patients: a systematic review. J Oral Rehabil Jan;35 Suppl 1:9-22. Wider inclusion criteria so 23 studies. Included studies as short as 1 year, retrospective and prospective, minimum 5 patients Prosthesis survival: Only 1 study>5 years. 2/25 lost in perio patients and none lost in non-perio. Implant Survival: Only 1 study at 10 years. 90% in perio, 96.5% non-perio Peri-implantitis: 2 short term studies show no diff. 10 year study by Karoussis showed 38% vs 5%. More frequent in aggressive perio vs chronic perio One 3-year study showing attachment loss around implants is greater than teeth for aggressive, chronic and healthy patients. (Jannson 2005) De Boever AL, Quirynen M, Coucke W, Theuniers G, De Boever JA. Clinical and radiographic study of implant treatment outcome in periodontally susceptible and non-susceptible patients: a prospective long-term study. Clin Oral Implants Res Dec;20(12): Epub 2009 Sep healthy (nsp), 68 chronic perio (cgp), 16 aggressive perio (agp) (patients) (513 Implants) 48 +/-25 months Implant Survival: nsp (97%), cgp (96%), agp (85%) Twice as much bone loss in gap, but nsp and cgp similar Smoking only an issue in agp group (survival reduced to 63%) Study did include TPS implants early on that had more failure that SLA surface) Risk Minimization Consider concept of multiple small risks adding together Smoking, poor plaque control, diabetes, periodontitis, lack of maintenance, obesity, chronic steroid use, immediate placement, osteoporosis, immediate restoration, grafted bone, simultaneous implant in grafted sinus, short implant, inferior implant design What about the bugs? De Boever and De Boever. Early colonization of nonsubmerged dental implants in patients with a history of advanced aggressive periodontitis Aggressive Perio pts: SPT for months at implant surgery (68 implants). Plq < 20% BOP<20% 10 days post-op 17/22 patients had similar pathogens around teeth and implants. did not hamper osseointegration and did not lead to periimplantitis, mucositis or initiation of bone destruction (6 months). What about the bugs? Peri-implantitis Quirynen M, Van Assche N. Microbial changes after full-mouth tooth extraction, followed by 2-stage implant placement. J Clin Peridontol 2011 Microbial sampling prior to edentulation, 1 week post exo s, 3 and 12 months. Sulci, tongue and saliva. Prior to exo s, pockets were heavily colonized by pathogens. Presence of pathogens in saliva and tongue did not change after exo s or over 12 month period, but the numbers reduced significantly, especially in saliva. A.a was exception. After one week, all pathogens were present around implants but total numbers much lower by log factor (except for A.a). Numbers remained stable up to 12 months. Lindhe J, Meyle J; Group D of European Workshop on Periodontology Peri-implant diseases: Consensus Report of the Sixth European Workshop on Periodontology. J Clin Periodontol Sep;35(8 Suppl): Peri-implant mucosotis in 50% of implants Peri-implantitis in 12-40% of implants Risk factors are poor oral hygiene, Hx of perio, diabetes, smoking 3

4 Lang NP, Berglundh T; Working Group 4 of Seventh European Workshop on Periodontology. Periimplant diseases: where are we now?--consensus of the Seventh European Workshop on Periodontology. J Clin Periodontol Mar;38 Suppl 11: Mucositis is reversible (Salvi 2011) Mucositis will convert to peri-implantitis more easily than gingivitis converts to periodontitis Calculus formation on implants appears to be lower than on teeth TPS implants are more likely to develop peri-implantitis than minimally rough implants. -Tissue trauma and fungal infection from denture -Horizontal ridge atrophy #14 site, #11 site. -Horizontal and vertical ridge deficiency UL. -Steep and deep palate 4

5 Treatment Plan Phase I Full mouth scaling and root planing, re-evaluate plaque control. Effect of SRP Phase II GTR LL. Phase III UR,UL direct sinus lift & ridge augmentation.(scarano 1996) Extraction of hopeless teeth & ridge augmentation Augmentation of edentulous sites Phase IV Implants #16,14,11, 25,26, 44,45,32,42,46 Sinus Li` UL Sinus Li` UL w Bluish/Purple membrane exposed w In this case, en?re buccal window osseous removed. w Bacterial control cri?cal w Ver?cal incision distal to 25 high into sulcus w Crestal incisions going distal w Ver?cal incisions into sulcus around 27 site Sinus Li` UL Ext 32, 31, 42 and ridge augmentation w Membrane elevated. Medial wall visible w FDBA placed firmly but not packed. w Membrane trimmed to cover lateral window. 5

6 Ext 32, 31, 42 and ridge augmentation Tenting screw is placed no higher than line drawn between crestal bone on mesial of 22 and weeks post- op GTR 35, 36 What type of implants? No great evidence that one system is better than others for perio patients progression of untreated peri-implantitis, is greater with a moderately rough surface than at implants with a polished surface (Berglundh et al 2007) Abutment seal and stability? Position of microgap? 6

7 Abutment/Fixture connections Bicon 4 Degrees Ankylos: 6 degrees Straumann Tissue level: 8 degrees Astra 11 Degrees Straumann Bone Level: 15 degrees NobelActive: 20+ degrees Ext #25. Implant #25, 26 Sinus lift has now been healing for 6 months Ext #25 and Implant #25, 26 # 11 Par?culate Allogra` 7

8 # 11 Par?culate Allogra` Implants #32,42,44,45 Implants #32,42,44,45 32, 42 44, 45 Consider mesio-distal position. Can a 4mm implant be placed in the middle of a lateral incisor space? Not really. 8

9 Implants #16,14 and 11 Radiographic Re- eval #36,35,34 Pre treatment 6.5months postgrafting 9

10 Success of GTR v.s Exo &Implants FMX second stage Stability of grafted bone: (Flemmig et al, J.Periodontol 1998) Stability of long junctional epithelium (Beaumont J.Periodontol 1984) Consider complications associated with nonrestored tooth vs. combined surgical prosthetic complications associated with implants (Samet & Jotkowitz et al,quintessence,2009) 10

11 How important is maintenance? Roccuzzo M, De Angelis N, Bonino L, Aglietta M. Ten-year results of a threearm prospective cohort study on implants in periodontally compromised patients. Part 1: implant loss and radiographic bone loss. Clin Oral Implants Res May;21(5): Epub 2010 Mar patients in private practice (healthy, moderate and severe perio). Implant survival 97%, 93%, 90% respectively For healthy pts, 2/24 patients who adhered to SPT lost an implant whereas 0/4 who did not adhere lost an implant. For moderate perio, 1/26 patients who adhered to SPT lost an implant whereas 5/11 who did not adhere lost an implant. For severe perio, 3/29 patients who adhered to SPT lost an implant whereas 4/7 who did not adhere lost an implant. 11

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13 Left-Right Side Right-MIP 13

14 Maintenance - Critical Roccuzzo M, De Angelis N, Bonino L, Aglietta M. Ten-year results of a three-arm prospective cohort study on implants in periodontally compromised patients. Part 1: implant loss and radiographic bone loss. Clin Oral Implants Res May;21 (5): Epub 2010 Mar 11. If no bleeding leave alone If bleeding and deep pocket but no attachment loss, debride If bleeding, deep pocket and attachment loss, open debridement Non-surgical treatment of Periimplantitis Persson et al. Mechanical non-surgical treatment of peri-implantitis: a single-blinded randomized longitudinal clinical study. I Clinical results. J.Clin.Perio 2009, II Microbiological results 2010 Treated sites with bone loss>2.5mm, pocket and bleeding. Method 1) Titanium currettes and prophy Method 2) Ultrasonic debridement using special implant tip. Results: Both methods were ineffective at reducing pockets or bacterial loads Schwarz F, Sahm N, Iglhaut G, Becker J. lmpact of the method of surface debridement following combined surface treatment of peri-implantitis: a randomized controlled clinical study. J Clin Periodontol 2011;38: Grafted intrabony defects with Bio-Oss after cleaning surface with plastic curette, rubbing with cotton and saline. Just as good as using a laser to decontaminate. Did implantolplasty on suprabony exposed surfaces. Results similar to grafting teeth. 3mm PD reduction and CAL gain % reduction in bop. Surgical treatment of Periimplantitis Flap, debride with currettes, chlorhexidine and saline on gauze. Graft with Bio-Oss Probably doesn t re-osseointegrate much. Defect fill, PD reductions and reductions in BOP can be maintained for 3 years (Roos- Jansaker et al. J Clin Perio 20011) Thank you 14