Case Presentation. Overall Health. Oral Hygiene. Chief Complaint. I hate my upper denture. I can t taste food. I want an implant solution

Transcription

1 Case Presentation Medical History Age & Gender 62 years old female Peri-implant Osteitis Overall Health Good Hx of Smoking 5 cigarets per day (Peri-implantitis) Oral Hygiene Fair Systemic Disease Osteoarthritis Chief Complaint Medication Celebrex (For a few years) Dr. Babak Shokati DDS, MSc., MSc. Prosthodontist, FRCD(c) Ontario Dental Association Annual Spring Meeting, May 2014, Toronto I hate my upper denture. I can t taste food. I want an implant solution Intra-oral Pictures Intra/Extra-oral Pictures Radiographic Findings Front View With Prosthesis Maxillary complete Denture: Fabricated 2 years ago Occlusal View Ridge resorption, pre-maxilla Adequate ridge width: posterior Front View Without Prosthesis Residual ridge resorption Pre-maxilla: flabby tissue Existing teeth: - heavily restored - plane of occlusion X Front View With Prosthesis Lack of adequate ridge support Radiographic Findings Possible Treatment Options Advantages vs. Disadvantages Implant-retained Overdenture Implant-supported Overdenture Detachable Implant-supported FDP Load bearing Implants Implants (and tissue ) Retention/stability Fixed (Fully secured) Removable (Partially secured) Occlusion Very high biting force Acceptable biting force Prosthetic space Less space required (15 mm) More space required (20mm) Tissue coverage Minimum tissue coverage Partial tissue coverage Maintenance Low maintenance High maintenance 1

2 Advantages vs. Disadvantages Treatment Planning Hygiene Fair (Maxilla: difficult) Good Cost High fabrication cost Lower fabrication cost Appearance Hard to replace atrophied ridge (O.H. problems) Possibility of replacing bone with full flanges Milled bar implant-supported overdenture Why an in this case? Lack of lip support: Excessive Residual Ridge Resorption. An extended buccal flange may make it difficult to observe oral hygiene if a fixed implant-supported prosthesis is planned. Surgery: Stage I Surgery: Stage II Stage II Surgery + GBR Radiographic stent Modified to surgical stent Implant placement surgery Osseointegration & bone loss on sites 12 and 22 Xenograft (Bio-oss collagen), GBR Stage II Surgery + GBR Four months after the second stage + GBR grafting: Prosthetic Treatment Healing abutments in place after the stage II surgery 2

3 Progressive Bone Loss Treatment: Phase I Antibiotic Therapy: The Outcome - Deep pockets around all of the implants (4 to 7 mm) - Discharge (with suppuration) on sites 16, 24, 26 - No bleeding on probing - No pain associated with the implant sites - Osstell ISQ values: between 68 to 72 Exception: site 12 with an ISQ value of 65 - The bars and prosthesis were removed - Antibiotics: Amoxicillin + Metronidazole - Oral rinse: Chlorhexidine - Old denture, tissue conditioned: Coe-soft Liner - Oral hygiene: Reinforced Following the Antibiotic Therapy - Deep Pockets, No Suppuration, No BOP, No Pain - Gingival Recession Peri-implant Osteitis (Peri-implantitis) From Marginal Bone Loss to Peri-implantitis Lisa Heitz-Mayfield & Andrea Mombelli Int J Oral Maxillofac Implants. 2014;29 Suppl: Definition An infectious condition of the tissues around osseointegrated implants with loss of supporting bone (>1.8 mm) and clinical signs of inflammation (bleeding and/or suppuration on probing) Prevalence 10% of implants, 20% of patients (5 to 10 years follow-ups) Etiology and Risk Factors What do we know about progressive marginal bone loss and peri-implantitis around osseointegrated implants? Etiology of marginal bone loss: Surgical Techniques: width of the peri-implant marginal bone Smoking and Oral Hygiene Implant design and Surface Topography Genetics and Bone Metabolism Medications (i.e. NSAIDs), effects on osteogenesis? Biomechanical concept: myth or truth? Etiology and Risk Factors - Serino & Ström Clin Ora Imp Res.20(2): Poor oral hygiene/plaque control - Ferreira et al, J Clin Perio.33(12): Diabetes & poor metabolic control - Ferreira et al, J Clin Perio.33(12): Laine et al. 2006, Clin Ora Impl Res.17(4):380-5 Genetic Traits: - Feloutzis et al, Clin Ora Impl Res.14(1): ) IL-1 gene (RN allele 2) - Gruica et al, Clin Ora Impl Res.15(4): ) Synergism of IL-1& smoking - Jansson et al, Clin Impl Den Rel Res.7(1):51-9 History of Periodontitis (teeth) - Heitz Mayfield, 2008 J Clin Perio.35(8): Strietzel et al, 2007.J Clin Perio.34(6): Smoking: a significant risk factor Systematic review including 35 papers Keratinized mucosa: Not a risk f. Roos-Jansåker et al, J Clin Perio.33(4): Rough implant surface: - Ellegaard et al,1997.clin Oral Impl Res.8(3):180-8: Y - Astrand et al,2004.clin Impl Den Rel Res.6(3):130-41: Y Is it a risk factor? - Wennström et al, J Clin Perio.31(9):713-24: NO Treatment Approaches Non-Surgical Surgical (1) Chlorhexidine: irrigation/ gel (2) Antibiotics: local and/or systemic (3) Debridement: manual, ultrasonic or air-abrasion (4) Laser therapy: ER:YAG Laser (5) Photodynamic Therapy (PDT): nm wavelength... (6) Resective surgery: pocket depth reduction (7) Implant surface smoothening: implantoplasty (burs) (8) Grafting approach: autograft, allograft, xenograft, HA (9) Implant removal: with or without further implant treatment Treatment Approaches Which approach is more effective? Surgical? Non-surgical? A combination of both? What are the success rates? Is there any evidence in the literature? A desperate attempt to save the affected implants! Studies Included Treatment Methods Esposito et al. Eur J Oral Implantol. 2008;1(2): The efficacy of interventions to treat peri-implantitis: A Cochrane systematic review 7 Randomized Controlled Trials 148 patients in total (1) Chlorhexidine: irrigation/ gel (2) Antibiotics: local and/or systemic (3) Debridement (sub g.): manual, ultrasonic or laser (4) Resective surgery and pocket depth reduction (5) Implant surface smoothening (6) Grafting: Nano-crystaline HA or Bio-Oss with barriers In 4 out of 7 RCTs The clinical outcome of mechanical debridement was similar to more complex therapies 3

4 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): Consensus 2008 non-surgical treatments By: Renvert, Roos-Jansaker, Claffey 1) Non-surgical therapy is not very effective. 2) Laser treatments show minor beneficial effects. 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): Consensus 2008, surgical treatments By: Renvert, Roos-Jansaker, Claffey - Bone graft techniques with/without membranes resulted in various degrees of success. - Such techniques do not address disease resolution but rather merely attempt to fill the osseous defect. - No single method of surface decontamination (chemical agents, air-abrasives and lasers) was found to be superior. Non-Surgical Interventions Local Antibiotics Renvert et al., 2006 Manual Debridement 30 patients (12 months) Local Antibiotics (Minocycline) Probing depth reduction 0.0 mm 0.3 mm Reduction of BoP 10% 17% Renvert et al., 2008 Manual Debridement 32 patients (12 months) Tx was repeated in 30 & 90 days Local Antibiotics (Minocycline) Tx was repeated in 30 & 90 days Probing depth reduction 0.2 mm 0.3 mm Reduction of BoP 25% 39% Non-Surgical interventions ER:YAG Laser Schwrz et al., 2006 Manual Debridement, and 20 patients (12 months) Subgingival Chlorhexidine YAG:ER Laser Probing depth reduction 0.4 mm 0.4 mm Reduction of BoP Less improvement Greater improvement Renvert et al., 2011 Debridement with 42 patients (6 months) Air-abrasive Device YAG:ER Laser Probing depth reduction 0.9 mm 0.8 mm Reduction of BoP 25% 30% Non-Surgical Interventions Photodynamic Therapy (PDT) Bassetti et al., patients (12 months) Local Antibiotics (Minocycline) Photodynamic Therapy (PDT) Probing depth reduction 0.7 mm 0.1 mm Reduction of BoP 65% 57% Surgical Interventions Grafting with/without membrane Roos-Jansaker et al., 2007 Flap Surgery, Xenograft Flap Surgery, Xenograft 36 patients (12 months) without membrane with membrane (resorbable) Probing depth reduction 3.4 mm 2.9 mm Reduction of BoP 71% 57% Bone gained (after 12 months) 1.4 mm 1.5 mm After Manual Debridement and systemic Antibiotics (Amoxicillin+Metronidazol) Surgical Interventions Flap + instrumentation of bony defects Plastic Instrument vs. ER:YAG Laser Schwarz et al., patients (12 months) Bony defect debridement with: Plastic instrument Bony defect debridement with: ER: YAG Laser Probing depth reduction 2.0 mm 1.7 mm Reduction of BoP 60% 45% Bone gained (after 12 months) 1.5 mm 1.3 mm Flap surgery + implantoplasty + xenograft + collagen membrane Expected results from interventions: Non-surgical Interventions: Not effective Surgical Interventions: 1 to 2 mm of bone gain Summary Surgical vs. Non-surgical (12 months) Non-Surgical Intervention Surgical Intervention Suppuration Fully Controlled Fully Controlled Probing depth reduction mm mm Reduction of BoP 10-50% 45-70% Bone gain 0.0 mm mm Factors influencing the treatment outcomes: Initial severity of disease Patient s oral hygiene Periodontitis of the existing teeth Configuration of bony defects (vertical vs. horizontal) Macro / Micro-structure of implant s surface Position of the implant within the arch 4

5 Success Criteria Heitz-Mayfield LJ, Mombelli A. The therapy of peri-implantitis: a systematic review. Int J Oral Maxillofac Implants. 2014;29 Suppl: Implant survival with: 1) Probing depth (PD) of less than 5 mm 2) Absence of bleeding on probing (BoP) 3) Absence of suppuration 4) No further bone loss Flap Surgery, Allograft Particulate Bone Grafting One implant (22) failed prior to the grafting surgery GBR grafting procedure with resorbable membrane Six months submerged healing period Three Years After Surgical Intervention Clinically stable and asymptomatic condition: No Bleeding on Probing No Suppuration Reduced Probing Depth (2-3 mm of reduction) Surgical Intervention resulted in a stable condition; HOWEVER: it could not significantly improve the clinical situation of the implants. - Patient is satisfied with her - She meticulously maintains her oral hygiene - Interestingly, pockets are still shallow after 3 years - There s no signs and symptoms Prognosis of the Treatment? Compromised Survival How long the implants would be able to survive with such a compromised condition? 5