Dental Implant Trainers Advanced Concepts Course

Transcription

1 Dental Implant Trainers Advanced Concepts Course Anterior Implant Dentistry Foundation Variables Immediate Techniques When to Load Patient Assessment Tips Flap Designs Peri-implantitis

2 What is Esthetics? Defined as inspired by nature Esthetics are different for every person Younger Elderly Shade Tooth Shape Tooth visibility

3 Biological Principles Soft tissue around teeth vs around an implant Sulcus, junctional epithelium, connective tissue Perpendicular fibers Sulcus, junctional epithelium, connective tissue Parallel fibers Fewer blood vessels than natural teeth Peri implant tissue is really scar tissue A,B,C-Oral, sulcular and junctional epithelium D- Lack of perpendicular fibers E-no connective tissue attachment F-No PDL

4 Biological Principles Inter-implant distance 3mm is our magic number between implants At 3 mm even though the facial bone goes apically. The bone around the adjacent teeth stays coronal=a papilla If we place implants less than 3 mm apart, then the interproximal level will be apical or equal to the facial bone=no papilla Results in thinner soft tissue

5 Biological Principles Tarnow, 1992 Study Tarnow Study: 0.45mm loss when Implant Distance is >3mm 1.04mm loss when Implant Distance is <3mm

6 Biological Principles Clinical implications of the Tarnow study Peri-implant Bone loss occurs around the junction between the implant and the abutment Results from bacterial colonization in the inside of the implant We can move this interface coronally and solve this bone loss problem, but then it will not be covered by soft tissue Unacceptable in the anterior where we want all implant parts buried

7 Biological Principles Bone remodeling occurs. This is a fact

8 Biological Principles Bone remodeling occurs. This is a fact Minimum distance to preserve bone is 1.5 mm between implant and tooth Bone loss occurs in a vertical direction usually down to the first thread On a x-ray this looks like a crater This loss will not approach the natural tooth next to it if it is 1.5 mm away This will cause a loss in papilla height This makes a case for using a narrower diameter implant in esthetic areas

9 Biological Principles Bone remodeling Most coronal height of bone of a natural tooth determine papilla support Even though an implant is more apical than the adjacent tooth a papilla will still be present If the bone is lower than the adjacent natural teeth then the papilla will be vary in height as we move across the anterior area

10 Biological Principles At inter-implant distances of 5mm, we have the luxury of creating ideal bony architecture much like we do in perio surgery We can sculpt the bone and create depressions in the bone before we place an implant

11 Biological Principles 7mm diameter 4mm for implant diameter, 1.5mm either side of implant (for single implants) Prefer 2mm of labial bone Dentinal gingival fibers provide support for gingival tissues in natural teeth Periodontal healthy anterior tooth not greater than 5mm papilla height coronal to interproximal alveolar bone crest Implants must be submerged to create a higher interproximal bone height to support papilla Papilla morphology dependent on perio status ridge morphology dependent on quantity/shape of bone

12 Biological Principles At the same time we need to consider the buccal soft tissue thickness Third dimension At least 2 mm of buccal soft tissue is needed. 3-4mm is more ideal This will be outside the area of circumferential loss and ensure long term support of the papilla over a long time. Without the buccal thickness the soft tissue collapses and it looks dark This would appear to dictate buccal bone grafting on all cases or placement of the implant slightly palatal to get the desired thickness of soft tissue

13 Gingival Architecture Gingival biotype is described as the thickness of the gingiva in the facio-palatal/ facio-lingual dimension. Seibert and Lindhe categorized the gingiva into thick-flat and thin scalloped biotypes in 1989

14 Gingival Architecture Patients with thick and flat gingival biotypes exhibit short papillae Thin and scalloped biotypes represent long papillae.

15 Gingival Architecture Thick biotypes include flat soft tissue and bony architecture, denser and more fibrotic soft tissue with large amount of attached masticatory mucosa Thick biotype is more resistant to any acute trauma and respond to disease by pocket formation and infra bony defect This difference may be the cause of more papilla loss in the thin biotype. This affect on the treatment outcome may be because of the difference in the amount of blood supply to the underlying bone and susceptibility to resorption according to Manjunath, Rana, et al, J of Clinical and Diagnostic Research, 2015

16 Gingival Architecture Thick gingival biotype usually depicts broad zone of keratinized tissue. This coupled with flat gingival contour, which indicates thick underlying bony architecture, is more resilient to any inflammation or trauma. Thin gingival biotype is related with a thin band of the keratinized tissue and scalloped gingival contour which suggest thin bony architecture and is more sensitive to any inflammation or trauma. >2.0mm is defined as thick <1.5mm is defined as thin

17 Biotype and Success Thin Decreased blood supply Complicates tissue response to surgical trauma Complicates suturing as it tears easily Show through of metal is an issue Patient needs to be informed of the challenge Thick Increase blood supply and support Esthetic success is predictable Downside is that bad incisions can create scars

18 Gingival Architecture In a study of 336 patients in India, the following was found: Thick biotype was more prevalent in the majority of the population Men 76.9% Women 55.3% Sex was not a difference Age was a difference for women(thin was more prevalent as women aged)

19 Gingival Architecture Drs. Fu and Lee, et all proposed the following in 2011 Create a thick biotype around implants as it is more conducive to implant health. Compared to a thin biotype it is preferred. Suggested a PDP management Implant Position Implant Design Design of Prosthetic

20 PDP Principals Implant position refers to depth and angle Implant design which includes diameter and platform can help prevent crestal bone loss Prosthetic design can provide additional space for soft tissue in growth creating a fuller tissue profile

21 PDP Principals Standard surgical guidelines mandate that an implant be placed with 2mm of buccal bone, 3mm apical to the CEJ of the adjacent tooth and 1.5mm from the tooth root and 3mm from an implant In situations where we need more facial soft tissue growth, placing an implant more apically and more palatal/lingual may be warranted. To deal with appropriate emergence, for every mm of palatal/lingual placement, the implant should be placed apically by an additional mm.

22 PDP Principals How do we accomplish the B-L bone requirement? Ridge expansion, implant position, or narrower implants can accomplish this. Platform switching will require the use of a narrower abutment over a wider body. This shift of the microgap toward the center of the implant, reducing crestal bone loss and fostering more soft tissue growth The use of a concave abutment or crown will create additional space for peri-implant tissue to occupy

23 PDP Principals Ridge expansion during osteotomy Densah auxillary burs which creates more bone on the facial surface of an implant

24 Gingival Architecture Clinical Applications of Biotype Determination Review Thick biotype is more resistant to recession, better at hiding metal and more forgiving to implant positional errors Thick biotype will handle trauma including prosthetic trauma better Utilize platform switching to increase tissue thickness

25 Let s discuss ''Biologic Width'' Sicher coined the term "dentogingival junction" in In 1961,Gargiulo et al., found out that the vertical dimension of the dentogingival junction comprising sulcus depth (SD), junctional epithelium (JE), and connective tissue attachment (CTA), is a physiologically formed and stable dimension, which forms at a level dependent on the location of the crest of the alveolar bone This protects the two most vulnerable structures of a tooth-the periodontal ligament and alveolar bone, which ultimately determine the survival and longevity of the dental elements

26 Biologic Width Gingival sulcus 0.69 mm Junctional epithelium 0.97 mm Connection tissue attachment coronal to bone 1.07 mm Gargiulo A., Wentz F., Orban F. Dimensions and Relations of the Dentogingival Junction in Humans. J. Periodontol :261

27 Where do we end our crowns with respect to the biological width Above the gingiva Best biological practice At crest of the gingiva Subgingival The most critical factor regarding the long-term gingival health is the relationship between the margin location, the location of the base of the sulcus and the supracrestal fiber attachment

28 Above the gingiva Preservation of tooth structure during tooth preparation. Impressions are more predictable, with minimal or no cord packing. Provisional restorations are easier to make, and the soft tissues will be healthier when the patient returns for cementation of the final restoration. Removing excess cement is much easier when the margin is visible.

29 Level with the gingiva Traditionally, not recommended as they were thought to retain more plaque than supragingival or subgingival margins and therefore cause greater gingival inflammation This plaque retention is typically true as patients did not clean as well. Older cements were relatively soluble Easier to take an impression blended with esthetic vigilance

30 Subgingival If the sulcus probes 1.5 mm or less, place the restoration margin 0.5 mm below the gingival tissue crest. This is especially important on the facial aspect. If the sulcus probes more than 1.5 mm, place the margin one half the depth of the sulcus below the tissue crest. This places the margin far enough below the tissue so that it still is covered if the patient is at higher risk of recession. Never place the margin closer than 2.5 mm to the bone level

31 Subgingival If we do place the margin closer than 2.5 mm to the bone level. We have now entered into the zone of the biologic width, and a very important biologic principle is being violated. When this happens an inflammatory response results in alveolar bone resorption, increased pocket depths, increased loss of periodontal support, exacerbation of accumulation of subgingival bacteria, increased chronic inflammation, and further localized periodontal breakdown. So if this is such a crucial area, why would we even consider going subgingival?

32 Reasons to go subgingival. Need to improve the resistance and retention form of a short clinical crown Presence of caries or restorations extending apical to the gingival margin Modification of the emergence profile Esthetics

33 Biological Principles Platform switching accident. Alters the horizontal position of the prosthetic-implant interface No solid guidelines on the exact nature of this technique Do surfaces make a difference Does thread position make a difference Does type of interface make a difference Bone loss was limited to 0.65 mm That being said 25-36% of the implants showed 1mm + bone loss Not a guarantee If 2 implants are close together then platform switching will help with bone loss around the implant, but the narrow space between the implants won t help with buccal papilla loss

34 Biological Principles Micro movement theory Reduce the movement and minimize bone loss around the implant No real studies to support it this At the end of the day, I utilize this concept as there is nothing to lose Morse taper

35 Biological Principles What should I do? Since Platform switching is not a guarantee of no bone loss around the implant, what s the right thing to do? At the same time there is no disadvantage to doing this As long as the larger implant does not reduce the mesio-distal distance As long as the larger implant does not result in a reduction of bone width on the buccal

36 Patient Assessment Lip line High line Low line when I pick up my lip, I see..

37 Patient Assessment Tooth shape Square tooth Triangular tooth

38 Patient Assessment Tooth shape Minimize a large black triangle by changing the tooth shape

39 Patient Assessment Jaw shape Convex jaw Thinner biotype May see a high lip line Lip pressure will cause thinning of buccal tissue Flat jaw Less tissue loss after extraction may favor an immediate implant Thicker biotype

40 Patient Assessment

41 Patient Assessment Diastema Very difficult to get a papilla Can t fake the papilla by lengthening the contact point Possibly suggest closing the diastema

42 Patient Assessment Mesial or Distal Tilt Tooth axis will determine the contact point If both centrals are tilted mesially then we have an incisal point contact If both centrals have are tilted distally then the contact point is shifted gingivally and can be broad Solutions: Ortho Bonding Crown both teeth

43 Patient Assessment Concavity on the adjacent tooth Emphasizes or creates a black triangle Discuss this prior to treatment showing them their issue After the fact it is a rationalization for failure

44 Patient Assessment Large frenum Remove it at the beginning Leaving it will leave mucosa around the implant Increase the possibility of recession

45 Patient Assessment Large Incisive canal Never place the implant in the incisive canal with live tissue Remove all nerves and vessels and graft the area Not a situation for immediate implant placement

46 Patient Assessment Replacing 2 teeth 2 implants=6-8mm Tooth to implants = 1.5x2=3mm Space between implants = 3mm or more Total needed is 12-15mm at least Bonded bridge may be a better esthetic choice

47 Temporary Restoration Fixed-bonded zirconia bridge Removable Essix Fuse abutment

48 Implant position Facio-lingual(palatal) Mesio-distal Apico-coronal

49 Facio-lingual(palatal) A 25% decrease this dimension occurs within the first year of tooth loss and rapidly evolves into a 30% to 40% decrease within 3 years. The bone width loss is primarily from the facial region, because the labial plate is very thin compared with the palatal plate, and facial undercuts are often found over the roots of the teeth. Darkness of the implant shows through the gingiva

50 Facio-lingual(palatal) The crestal bone should be at least 1.5 mm wider on the facial aspect of the implant and 0.5 mm on the palatal aspect. The thickness of bone on the facial aspect of a natural root is usually 0.5 mm thick. As a result, the implant is 1mm or more palatal than the facial emergence of the adjacent crowns at the free gingival margin. Best for screw retention

51 Mesio distal

52 Mesio distal The best implant position is under the incisal edge of the final crown, or slightly more palatal (A). The ideal mesio distal implant position for a central incisor is 0.5 to 1.0 mm more distal than the midtooth position. This decreases the risk of encroachment on the incisive canal (B). The best mesiodistal position for a cuspid is centered in the cuspid position.

53 Mesio distal Two-piece implant should be at least 1.5 mm from an adjacent tooth. When the implant is closer than this to an adjacent tooth bone loss related to the microgap, and biological width violation. Use a Mini

54 Mesio distal in Narrow Space Megagen just like standard sizes except narrower Don t need to buy a separate kit

55 Apico coronal Midcrest position of the edentulous site should be 2 mm below the facial CEJ of the adjacent teeth. The interproximal bone should be scalloped 3 mm more incisal than the midcrest position. Becker et al classified the rang of interpoximal bone height above the midfacial scallop from less than 2.1 mm (flat) to scalloped 2.8 mm to pronounced scalloped < 4.1 mm. flat anatomy scalloped-anatomy square-shaped tooth ovoid-shaped tooth

56 Implant Angulation 3 Choices: Facial angulation so that emergence of the final crown will be similar to adjacent teeth. Under the incisal edge of the final restoration. Within the cingulum position of the implant crown.

57 Ideal position A. Position below the incisal edge is best used for a cemented crown in the esthetic zone. A. An implant is in the place of the natural root of the tooth. Although this makes sense, it places the implant too facial, and an angled abutment is usually necessary B. In the cingulum position when a screw-retained crown is the treatment of choice. This position requires a facial ridge lap of porcelain when used for FP-l prostheses

58 Immediate placement

59 Immediate placement

60 Flap Design Incision facts: We need to end up with tension free closure. Incisions will scar. If we add bone, the volume that must be covered by the flap has increased.

61 Flap Design Small minimal incision with or without verticals Makes a tension free incision impossible Makes grafting impossible Papilla preservation technique 1.5-2mm away from adjacent tooth

62 Flap Design Vertical Incisions in the Anterior Avoid in a visible esthetic zone If this must be done, then place them at the distal portion of the adjacent teeth as the highest portion of the gingiva is usually at the distal and your eye is used to going upward

63 Flap Design Ideal Flap Design Wide flap Only use 1 vertical incision Place the vertical outside the esthetic zone Circumferential incision in esthetic sensitive areas

64 Delayed/Immediate placement Incisions Use an Endodontic flap design Semi-trapezoidal Sling suture to close

65 Immediate placement

66 Immediate placement Remember the patient amidst all of you planning

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74 Position

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80 Immediate/Grafting

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82 Immediate/Grafting

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84 Immediate/Grafting

85 Implantitis A New Battleground in Implant Dentistry

86 Implantitis Prevalence Difficult to assess as definitions vary Bone loss Pocket appearance This is important as we try to diagnose a problem early Requires a radiograph to confirm the diagnosis >5mm has been defined as Stage 1 peri-implantitis >6mm is called Stage 2 A 2012 study showed that 22% of implants placed in approx. 28 out of 70 patients after 8 years

87 Implantitis Risk factors Smoking Previous perio Current perio in other areas of the mouth should be a red flag Hard to clean restorations Residual cement Guide our choice of screw vs cement retained Removal of cement fixes the problem

88 Implantitis Incubation period Swiss Study 5-10 years after implantation, 20% of all patients showed peri-implant disease

89 Implantitis Early Diagnosis Perio probe 4 sites Watch for increased depths Deep implant placement could give 5-6mm without inflammation Observe redness or swelling No bleeding is an indication of health Radiographs must be done in conjunction with a visual exam Use the bone level at the time of uncovery or restoration as a baseline Mobility means we have no osseointegration. If no signs or bleeding with probing, or bone loss is an indication of overloading

90 Implantitis Risk Factors General perio yields poorer results Have 3 month recall Smoking Success rate goes down about 30% Encourage smoking cessation Poor Oral Hygiene Demonstrate, provide and document aids Poor access Try to design the restoration with convex sufaces Residual cement Removal will usually resolve the issue Gingiva vs Alveolar mucosa At least 2 mm of gingiva is associated with reduced plaque accumulation

91 Implantitis Microbiology Similar to general perio? Fusobacteria, Prevotella, Porphyromanas, Spirochetes These are same bacteria that we find in perio around teeth These are all anaerobes The difference occurs as we see Staphylococci at times as the predominate bacteria on an implant This is also seen in general orthopedic implants and catheter infections BOTTOM LINE: The infection is populated by a mix of bacteria that are present in the mouth. Poor hygiene, for example, around an implant may allow one bug to increase in number

92 Implantitis Based on what we just said, we can not eradicate a certain type of bacteria to solve this problem as the entire mouth is populated with these types. Consequently, there is no special bacterial test to diagnose peri-implantitis. Use radiographs Use probing depths Visual exam

93 Implantitis If we decide to employ antibiotics, which one? International Journal of Oral Maxillofacial Impl, 2014 Heitz-Mayfield and Mombelli Amoxicillin Metronidazole(Flagyl) The treatment regime for all peri-implant infections is that they should be treated with 500mg Amoxicillin and 375 mg capsules Metronidazole for 7 days. Coumadin patients need to monitor INR with Metronidazole Peri-implantitis cannot be treated solely by meds Requires cleaning the implant surface to totally remove the biofilm which allows the bugs to grow

94 Implantitis Let s get organized Assessment which results in prosthetic fixes Screw loosening Cement Poor fit Poor contours Assessment which involves behaviour fixes Smoking Poor oral hygiene Bruxism Treating adjacent perio

95 Implantitis Let s get organized Non-surgical debridement Anitibiotics Laser Improved home care Re-assess 4 weeks later Resolution results in going to proper maintenance therapy Non-resolution will take us to surgery

96 Implantitis Let s get organized Surgical approach Full thickness flap Remove any cement Remove any granulation tissue Decontaminate the surface Rubbing with saline gauze Rubbing with citric acid gauze Rubbing with hydrogen peroxide gauze Mechanical cleaning with acurrette Mechanical cleaning with a brush Laser treatment

97 Implantitis Let s get organized Surgical approach If bone loss is circumferential and there is an outside wall, aka an infrabony defect, then we could regrow bone If not our goal is to stop inflammation and further loss of attachment In not esthetic areas then bone elevations can be reduced to allow apical flap adaptation Must be associated with implantoplasty to allow oral hygiene following healing Analagous to the long root on natural teeth Regeneration as opposed to resection Fill infrabony defect Membrane use Used very often with early bone loss(ie before loading)

98 Implantitis Let s get organized Post surgical protocol Antibiotics Chlorhexidine Implant removal if no improvement Maintenance for Frequent recalls Proper oral hygiene

99 Implantitis Bone Loss Class 1 Usually found at Second Stage Surgery No exudate Located at the coronal surface Managed by Debridement Decorticate bone Graft Membrane Classification is Based on text from Louie Al-Faraje, DDS

100 Implantitis Bone Loss Class 2 Usually found at Second Stage Surgery No exudate Located at the mid-buccal surface No exposure to the oral environment Cause: Narrow Ridge Managed by Soft tissue graft to prevent showing through thin gingival tissue CT graft or Alloderm Adding a bone Graft Membrane

101 Implantitis Bone Loss Class 3 Usually found at Second Stage Surgery No exudate Located at the coronal surface circumferentially No exposure to the oral environment Cause: Narrow Ridge/Possible pressure from provisional restoration Managed by Raise buccal and lingual/palatal flap Debridement Adding a bone Graft after decorticated Membrane

102 Implantitis Bone Loss Class 4 Usually found at recall visit Exudate present Located at the coronal surface circumferentially No exposure to the oral environment Cause: Infection Managed by Raise buccal and lingual/palatal flap Debridement Adding a bone Graft after decorticated Membrane OR Removal and Grafting

103 Implantitis Bone Loss Class 5 Gross bone and soft tissue loss Infection present Part of the implant is exposed to the oral cavity Cause: Prolonged history of infection Managed by Remove implant Grafting and healing for 6 months Replace the implant

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106 Implantitis R-Brush I-Brush

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110 Implantitis Success and predictability of dental implants have been well documented throughout the years with purported success rates of more than 90%. These success rates, however, have been established according to an older criteria. An implant without pain, mobility, radiolucency, or 1 mm of bone loss during the first year and.2 mm thereafter was considered a success. A recent review that considered excessive bone loss as an additional criteria of implant failure suggested that "implant survival and success rates in general dental practices may be lower than those reported in studies conducted in academic or specialty settings" and quoted an 80% success rate.(3) Two systematic reviews and metaanalyses reported that the prevalence of peri-implantitis was present in approximately 10% of implants and 20% of patients eight to 10 years after implant placement

111 Implantitis Early implant complications arise prior to dental implant integration and often are the result of intraoperative or short-term postoperative problems. Early complications during implant placement include overpreparation of the implant osteotomy or underpreparation of the implant osteotomy. Underpreparing an implant site can result in surgically overheating the bone and bone necrosis if the critical threshold of greater than 47 C is reached by the surgical drills or dental implant. Contamination of the surgical site and/or the dental implant surface from bacteria is also possible during fixture placement, which can result in the failure of the implant to integrate. Lack of primary stability, stability of the implant when it is first placed into the alveolus, can result in implant micro-motion above 100 microns and loss of the implant due to fibrous tissue bonding to the implant surface instead of bone.

112 Late implant complications occur after the implant has integrated and the final prosthesis has been placed. Recognition of these complications via radiographic and clinical analysis is extremely important since many of these problems can be corrected if detected early. On the other hand, if allowed to progress, a minor complication can often result in loss of the implant and/or prosthesis. Late complications of the dental implant fall into the category of biologic or mechanical complications. Late biologic complications are those in which the peri-implant soft and hard tissues are affected. Peri-implant mucositis describes a reversible inflammatory reaction in the mucosa adjacent to an implant,(8) a term that has become known as implant gingivitis. Studies show that the prevalence of peri-implant mucositis can be as high as 50% to 80% of implants in function(9) with the etiology of peri-implant mucositis being bacterial plaque. Typical clinical presentation includes erythema, edema, swelling, and redness Although bleeding upon probing and increased probing depths are not always indicative of peri-implant mucositis, the absence of these two factors usually means implant health.

113 Finances: Fee-for-service with no insurance involvement is the preferable method of payment. Insurance reimbursements and involvement are often solutions to help patients have access to peri-implant disease treatment. Insurance submissions and obtaining approvals are often confusing when it comes to peri-implant treatment. The first step in understanding the tangled web of insurance is to understand that insurance companies have created their own definition and standard of treatment for periimplant disease. Insurance companies do not recognize peri-implant mucositis, only peri-implantitis. In addition, most insurance companies will only accept treatment in the form of surgical access, debridement, and flap replacement without the use of regenerative treatment

114 Implantitis Aetna Policy Despite large numbers of publications available regarding peri-implantitis treatments, there are no long term studies which indicate that the uses of osseous contouring, placement of barriers or bone grafts are superior to flap reflection with debridement. Therefore, Aetna considers flap reflection with debridement as the accepted clinical protocol for peri-implantitis treatment. Background Peri-implantitis is defined as an inflammatory process affecting the tissues around an osseointergrated implant in function resulting in loss of supporting bone. Clinical signs are deep probing depth (> 5 mm) bleeding and/or suppuration on probing. Loss of supporting bone usually forms a circumferential crater defect. Large scale studies detected peri-implantitis in 12% of implants in function for at least 5 years and 43% of implants in function for 9-14 years. Biofilms consist predominately of gram negative anaerobes and are similar to those found in chronic periodontits, but bone loss is more rapid in peri-implantitis. Risk factors include poor oral hygiene, smoking, diabetes and a history of chronic periodontitis.

115 Implantitis Codes D Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant D Debridement of a peri-implant defect and surface cleaning of exposed implant surfaces, including flap entry and closure D Debridement and osseous contouring of a peri-implant defect; includes surface cleaning of exposed implant surfaces and flap entry and closure D Bone graft for repair of peri-implant defect - not including flap entry and closure or, when indicated, placement of a barrier membrane or biologic materials to aid in osseous regeneration D Bone graft at time of implant placement D Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure. This procedure is not performed in conjunction with D1110 or D4910.

116 Implantitis Diagnosed with severe peri-implantitis. The patient was in a financial crisis at the time and asked that we submit to his primary insurance and secondary insurance. Treatment approved by primary insurance (Delta Dental): D debridement of peri-implant defect and surface cleaning of exposed implant surfaces, including flap entry and closure Treatment denied by primary insurance (Delta Dental): D bone graft for repair of peri-implant defect - not including flap entry and closure or, when indicated, placement of a barrier membrane or biological material to aid in osseous regeneration Treament approved by secondary insurance (Aetna Dental): D implant-maintenance procedures, including removal of prosthesis, cleansing of prosthesis, and abutments and reinsertion of prosthesis Treatment denied by secondary insurance (Aetna Dental): D debridement of a peri-implant defect and surface cleaning of exposed implant surfaces, including flap entry and closure D bone graft for repair of peri-implant defect - not including flap entry closure or, when indicated, placement of a barrier membrane or biological material to aid in osseous regeneration

117 Implantitis January 2018-Not much has changed Recently, a regenerative surgical protocol that uses both mechanical and chemical means for implant surface detoxification together with a bone graft and/or substitute including coverage with a barrier membrane and a two- to 10-year follow-up period has been shown to have a 98.8% implant survival rate. The results of this study were based on peri-implantitis treatment of 170 consecutive dental implants in 100 patients. (13) In that specific study, an air powder abrasive was utilized as part of the surface decontamination. The authors of two of the more complete reviews could not identify any one protocol as being more predictable or superior than the others in terms of treatment outcomes