Exam 1 Flashcards
1
Q
Osseointegration definition
A
A direct functional and structural connection between living bone and the surface of a load carrying implant
2
Q
Bone lost every time a flap is raised
A
about 0.7mm
3
Q
Implant healing stages
A
2 hours after placement the wound chamber area (the deepest areas of the threads) fills with blood clot
At 4 days the wound chamber area is filling with fibroblasts
At 1 week woven bone osteoids are starting to form in the wound area.
At 2 weeks bone formation is developing
At 4 weeks the boney structures are starting to connect through to the base bone
at 12 weeks the wound chamber area is mostly remodeled
4
Q
Contact osteogenesis
A
bone formation originating against the implant
5
Q
Distant osteogenesis
A
Bone formation from the existing bone towards the implant
6
Q
What healing stage are implants at their weakest point
A
4 weeks. Do not do anything to the implant at 4 weeks. Weaker than initial placement.
7
Q
Biocompatibility
A
The ability of a material to perform with an appropriate host response in a specific application
8
Q
Characteristics of mild implant failure
A
PD <4mm
Bleeding and purulent on gentle probing
Bone loss <25%
9
Q
Characteristics of moderate implant failure
A
PD <6mm
Bleeding and purulent on gentle probing
bone loss 25-50%
10
Q
Characteristics of Severe implant failure
A
PD >6mm
Bleeding and purulent on gentle probing
Bone loss >50%
11
Q
Low surface energy
A
Tefflon - no water sticks to it. No cellular attachment will occur
12
Q
High surface energy
A
Very hydrophylic. Will allow surface attachment of cells to this surface.
13
Q
SLActive treatment
A
plasma treatment used to create superclean circuits. increases surface energy
14
Q
Straumann loading time
A
SLActive claims to be able to load at 6 weeks rather than 8 weeks. Likely immediate loading is more successful as well
15
Q
Downsides of rough implant surfaces
A
Bacteria can get in if recession occurs
rough edges break microscopically when implant is inserted. Tapping more important
16
Q
type of attachment to implants
A
Hemidesmosomal
17
Q
Common type of attachment around implants
A
long epithelial attachment as opposed to short epithelial attachment with inserted fibers into the tooth
18
Q
Strength of epithelial attahcment around an implant
A
Much weaker, need to be much more careful probing around implants
19
Q
Surface type epithelial cells like
A
Polished surface, horizontal grooves should be less than 10 microns in depth. laser Lock is deeper than this
20
Q
Fibroblast movement
A
Move by themselves by grabbing a surface. Much better on a rough surface.
21
Q
macrophages that cause healing around an implant
A
M2 - similar to the process of athersclerosos
M1 cause failure
22
Q
Nobel implant surface
A
TiUnite
increases titanium oxide thickness
anodized surface
23
Q
AstraTech surface
A
Fluoride modified surface
Stimumate osteoblast differentiation
improves osseointegration and decreases marginal bone loss in immediate loading protocols
24
Q
Straumann implant surface
A
Acid etched
macrocraters overlayed with micropits
25
Risk factor definition
the probability of an individual developing a specific disease in a given period
Identified through longitudinal studies
26
Implant risk - Age
Does not seem to affect long term success rate
27
How to determine if a patient is done growing and can get their implant
lateral ceph 6 months apart. Still some debate if this means growth is fully stopped
28
Factors in considering success of an implant
```
bone levels
cosmetic concerns
complications with prosth
BOP
pt expectations
```
29
implant risk factors - smoking
considered the strongest modifiable risk factor
>10 cigarettes a day has more than 20% failure rate
20/day is the highest failure rate
smoking cessation 1 wk prior and 8 weeks after implant success rates similar
higher failure rate in maxilla than mandible in smokers
30
Smoking changes in bone
increases proinflammatory cytokines, inhibits fibroblasts, abnormal PMN phagocytosis, altered lymphocyte, decreases vascularity, delayd
31
Implant risk factor - diabetes
Poorly controlled diabetes (HbA1c >7%) negatively affects osseointegration
well controlled has no effect
Antiseptic mouth rinses and OH maintenance helps in achieving successful osseointegration
32
Diabetes effects on bone
impairs growth and regeneration of blood vessels, impair collagen metabolism, impaired bone metabolism, and advanced glycation end products
33
Risk factors for implants - osteoporosis
unclear relationship with periodontitis
No convincing data for osseointegration
T score less than -2.5
34
Implant risk factors - bisphosphonates
Higher risk of MRONJ with implant or any surgical procedure. Separate informed consent form. IV much higher risk than oral
35
Risk factor for implants - previous periodontal disease
substantial increase in peri-implantitis. 3X higher
| 14X higher risk of peri-implant mucocitis
36
implant risk factor - grafted vs host bone
A little ambiguous but seems to be similar survival rates
37
Implant risk factor - bone quality
Class 1-3 same survival, class 4 lower with rough implant surfaces
38
Implant risk factors - Keratinized tissue
<2mm peri-implant mucosa should increased GI, PIU, bone loss, and BOP
Some studies showed no difference
39
Socket preservation phases of healing
Inflammatory - Coagulation day 1, inflammatory cell and granulation tissue day 2-3
Proliferative - fibrogenesis/provisional matrix day 7, woven bone formation day 14, bone modeling day 30, bone remodeling day 90
40
Alveolar socket healing
clot breakdown 48-72 hours as granulation tissue infiltrates. Epithelium at socket periphery start at 3-4 days.
Complete infiltration of granulation tissue and replacement of a clot in 7 days
41
If you have 0.5mm facial bone post extraction
You will lose all the facial plate during healing. Socket preservation is much more important in these cases
If you have less than 2mm socket graft, if you have more you can get away without it
Socket preserve any endo treatment, especially apico
42
Soft tissue formation in augmented healing
You get more soft tissue thickness naturally than in augmented healing. Can do extraction, wait 4-5 weeks, then do bone augmentation
43
Osteoinduction
the process of stimulating osteogenesis (demineralized exposes the cells to try to get more osteoinduction)
44
Osteoconduction
actinv as a scaffold for bone to build off of, keeping soft tissue out
45
Autograft as a bone material
Osteoconductive, but resorbs very quickly
46
Demineralized allograft
better for osteoinduction, have lost most of their structure, better for small sockets
47
Freeze dried allograft
better for osteoconduction, better for larger sockets as it lasts longer
48
Xenograft as a bone material
osteoconductive scaffold, very slow resorption, still there even 10 years out
49
Alloplasts as a bone material
lab fabricated, biologically inert osteoconductive
50
Socket seal procedure
in a 4 wall defect, use a soft tissue graft over the socket to seal it
51
ePTFE vs dPDFE membrane
ePTFE is porous and needs to be sealed the entire time otherwise it will get infected, dPDFE can be left exposed, much less porous
52
Data collection for implants
```
CC
Medical History/medications/allergies/smoking
Extraoral Exam
Intraoral exam
Soft tissue assessment
Smile line
OH frequency/plaque score
Occlusal assessment
Periodontal assessment
spacing (height, width)
KT
```
53
Minimum spacing for an implant
1.5mm between teeth, 3mm between implants, 7mm occ height, 9 is better, 5 bare minimum
54
Worst placement for an implant prosthetically
Shallow and facial
55
3X3 rule
Implant head placement 3mm palatal, 3mm apical to the gingival zenith
56
Papilla heights
```
imp/imp - 3.5mm
imp-tooth - 4.5mm
tooth-tooth - 5mm
tooth-pontic - 5.5mm
pontic-pontic - 6mm
imp-pontic - 5.5mm
```
57
Junctional epithelium thickness
0.97mm
58
Connective tissue thickness
1.07mm
59
Fiber terms for connective tissue
```
Dentogingival
Dentoperiosteal
Alveologingival
Circumfrential
Semicircular
Transgingival
Intergingival
Transseptal
Interpapillary
```
60
Junctional epithelium around implants
About 2mm wide with wider intercellular spaces compared to teeth. Biological width on average is 3.5mm instead of 2
61
What is the anatomical shape of the sinus, and where are the walls
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pyramidal shaped cavity
Base - lateral nasal wall
apex - Zygomatic process
Ostium - 2/3 up the base
Superior - floor of orbit
Inferior - alveolar process
anterior/lateral - Cheek
Posterior - Infratermoral fossa/pterygopalatime fossa
```
62
Anatomical surgical considerations for the maxillary sinus
```
infraorbital foramen must be avoided (too high anyways)
Shape of sinus floor (door should follow shape, curved better than flat for indirect)
Sinus septum (impact window and more likely to perforate)
```
63
Sinus membrane perforation
```
Small perforations (<2mm) may come together when the membrane is folded
Medium (2-10mm) should be covered with a resorbable membrane/bioglues
Large >10mm perforation sutured, and sinus lift abandoned.
```
64
Maxillary sinus anatomy paper
Van Den Bergh 2000
65
primary septum maxillary sinus
septum that form when the sinuses are forming
66
secondary semtum maxillary sinus
sinuses that form after the teeth are removed
67
most common complication with osteotome other than membrane perforation
Benign paroxysmal positional vertigo - when the calcium carbonate crystals are dislodged by the hammer
68
vessel that runs along the lateral wall of the sinus
Extraosseous Anastomosis of the posterior superior artery
69
2 arteries that supply the maxillary sinus
inferior alveolar artery
| posterior superior artery (extraosseus nd intraosseous anastomosis)
70
Page 1976 - initial lesion
occurs 2-4 days after plaque accumulation
findings are subclinical (dilation of vessels, PMN migration, exudate from gingival sulcus is seen, serum proteins and extra-vascular fibrin, alteration of coronal JE
71
Page 1976 - early lesion
4-7 days following plaque formation
gingivitis stage
dense lymphoid infiltrate in gingival connective tissue, making up 65% of total infiltrate
fibroblasts are 3X larger, and collagen loss is 60-70%
crevicular leukocytes reach peak 6-12 days from onset of gingivitis
72
Page 1976 - established lesion
2-3 weeks after plaque accumulation
plasma cells are predominant with no significant bone loss
plasma cells are not restricted to reaction site any longer, and are clustered around blood vessels
proliferation and apical migration of JE may occur, and early pocket formation may be present
73
Page 1976 - advanced lesion
Transition from gingivitis to periodontitis
no specific timeline for this stage to occur
periodontal pocket formation, ulceration, suppuration, alveolar bone loss, PDL destruction
Lesion is no longer localized, and extends apically and laterally
bone marrow distant from lesion converts to fibrous CT
74
causes of sinus membrane damage
overfilling, infection, or perforation
75
sinus membrane perforation most likely to occur
Sharp angle such as a ridge line or septa/spine
76
pikos sinus perforation rate
20-60%
5-10mm repair with collagen membrane
10mm+ a cross-linked collagen membrane
85% of sinus membranes are closed within 48 hours
77
Carreno - antibiotic susceptibility for sinus bacteria
92% - ampicillin and amoxi/clav
90% cefoxitin
some studies indicate that prophylaxis does not provide any advantage
78
Kim 2006 primary vs secondary septum
primary occur when the sinus forms
secondary occur after extraction during pneumatization
septum present in 25% of sinuses, half in the middle 1/3 vs ant/post
79
Najm 2013
sinus perforation is generally well tolerated, and rarely causes sinusitis
80
Penarro 2008 - risks of osteotomes
paroxysmal positional vertigo
| referral to otoneurological specialist recommended
81
Pjetursson 2009 - indirect sinus lift success
grafting material produces more bone
implants placed with indirect sinus lift have similar success rates to conventional implants, however it is dependant on residual bone height
82
Pjetursson 2014 - indirect sinus lifts
2-3mm sinus bump bone material is optional
5mm bone with indirect sinus is more important
if residual bone height is <4mm then higher implant failure rate
5-8mm and flat sinus floor, implant with or without grafting is indicated
83
Aghaloo 2007
implant survival is 92% in aotogenous boe, and 95% in zenograft
84
Pjetursson 2008 - lateral window success rates
higher success when barrier membrane placed over the lateral window
rough implants had higher survivial
particulate grafts are better than block grafts
sinus perforation is 20%
85
sinus perforation - timing for reentry
6-8 weeks after first attempt
86
implant placement after sinus augmentation
Van Den Burgh 4-6 months
| my understanding 9 months
87
Solar 1999 - vessel position in the maxilla
vascular supply from PSA artery and Infraorbital artery
| the anterior/posterior boney window should be as small as possible
88
short implants - marginal bone loss
does not seem to be related to crown to implant ratio
89
tutak 2013 - short implant failure rates
lower in posterior maxilla
no evidence that splinting, length of cantilever, occlusal surface pattern, implant system, opposing arch dentition, bruxism influenced the outcome of any treatment
90
Queiroz 2014
short implants have a slightly higher failure rate so patients should be warned
most failures are within he first year
91
Bulagi 2015 - implant crown height
crown heights of 8mm-16mm
increased stress 34% at frame abutment
20% of off axis stress taken by the screw increasing the probability of fracture.
92
Slotte 2014 - ultra short implants
4mm implants had a 92% survival after 5 years
| no significant bone loss after 5 years
93
Nissand 2014 - short implants vs vertically augmented bone
much less morbidity with short implants
| argued that they are more prone to issues in the case of bone loss, but that is not proven
94
Chapelle 2018 - gingival health
clinical gingival health on an intact periodontum
clinical gingival health on a reduced periodontium
BOP <10%, PD 3mm or less
95
Chapelle 2018 - gingivitis classes
Gingivitis on an intact periodontum
Gingivitis on a reduced periodontium in a non-periodonitis patient (recession, crown lengthening)
Gingivitis on a successfully treated periodontitis patient
96
modifyable gingivitis risk factors
```
overhanging margins
oral dryness
smoking
diabetes
malnutrition
sex hormones
drug induced
```
97
Trombelli 2018 gingivitis definition
localized gingivitis 10-30% BOP
| generalized gingivitis 30% + BOP
98
Trombelli 2018 - gingival index
0 - no inflammation
1 - slight inflammation/edema, no BOP
2 - moderate infalmmation/edema with BOP
3 - severe inflammation, spontaneous BOP
99
Lang and Bartold 2018 - 4 categories of gingival health
Crest of bone to CEJ height range 1-3mm
1 - pristine periodontal health (very rare)
2 - well maintained clinical periodontal health on an intact periodontium
3 - clinical periodontal health on a reduced periodontium (successful treatment)
4 - periodontal disease remission/control with a reduced periodontum (incomplete resolution of disease or control of local factors)
5 - non-periodontitis reduced periodontium (recession, crown lengthening)
100
Holmstrup 2018 - non-plaque induced gingival diseases
| hereditary
hereditary gingival fibromatosis
| rare - based on the som of sevenless gene
101
Holmstrup 2018 - non-plaque induced gingival diseases
| bacteria
necrotizing periodontal diseases (gingivitis, periodontitis, stomatitis)
stomatitis extends beyond the MGJ and >1cm
localized bacterial infections (gonorrhea, syphilis, TB - rare)
102
Holmstrup 2018 - non-plaque induced gingival diseases
| Viral
Coxsakie virus (hand/foot/mouth)
HSV1/2 - herpetic gingivastomatitis and recurrant herpes simplex lesions
varicella-zoster - during chicken pox, later in life shingles, unilateral trigeminal nerve
HPV - oral lesions benign and asymptomatic, may persist or spontaneously regress
103
Holmstrup 2018 - non-plaque induced gingival diseases
| Fungal
Candidosis - opportunistic
| gingiva red with a granular surface
104
Holmstrup 2018 - non-plaque induced gingival diseases
| inflammatory immune conditions
```
hypersensitivity reactions (contact allergy, plasma cell gingivitis, erythema multiforme)
auto-immune disease (pemphigus vulgaris, pemphigoid, lichen planus, lupus erythematous)
Granulomatous inflammatory conditions (TB, chrons, sarcoidosis)
```
105
Holmstrup 2018 - non-plaque induced gingival diseases
| reactive processes
Epiludes (fibroma, peripheral ossifying fibroma, pyogenic granuloma, peripheral giant cell granuloma (most prevalent))
106
Holmstrup 2018 - non-plaque induced gingival diseases
| neoplasms
pre-malignant (leukoplakia, Erythroplakia)
| Malignant (SSC, Leukemia, Lymphoma)
107
Holmstrup 2018 - non-plaque induced gingival diseases
| endocrine
scurvy - vitamin C deficiency
108
Holmstrup 2018 - non-plaque induced gingival diseases
| Traumatic lesions
Frictional keratosis
tooth brushing induced gingival ulceration (differentiate between necrotizing)
self-harm
109
Holmstrup 2018 - non-plaque induced gingival diseases
| chemical insults
```
Etching
theramal insults
Gingival pigmentation (drug induced/addisons/heavy metals etc)
smokers melanosis
drug induced pigmentation
amalgam tattoo
```
110
Fan and Caton 2018 - occlusal trauma
NCCL may be occlusal trauma
occlusal trauma does not cause periodontitis
no strong evidence to support routine occlusal adjustments
111
Cortellini and Bassada 2018 gingival biotypes
thin scalloped - triangular crown, low contacts to incisal edges, narrow KT
Thick scalloped - thick fibrotic gingiva, slender teeth, narrow KT, pronounced scalloping
Thick flat - square shaped teeth, broad contacts, broad KT, thick bone
Average width of KT for thick 5.72mm
Average width of KT for thin 4.15mm
112
Cortellini and Brasada 2018 - gingival recession
Ortho 5-12% liklehood
thicker gingiva biotypes augmented by grafting are more stable than thin
if recession is untreated it will likely progress even with good OH
NCCL reduces root coverage probability
113
Ercoli and Caton 2018 - dental prosthesis factors
```
Subgingival class 2 fillings have more inflammation, and 0.2mm crestal bone loss
subgingival direct margins associated with localized gingivitis and increased PD
```
114
Ercoli and Caton 2018
| cervical enamel projections
found in 25-35% of mandibular nd 8-17% of maxillary molars
| 82.5% of molars with furcation involvement
115
Papapanou 2018
reasons for new periodontitis classification
substantial overap between agressive and chronic, with no difference in etiology noted
features of periodontitis
interproximal CAL 2+mm at 2+ non-adjacent teeth.
116
Tonetti 2018 - goals of staging and grading
staging - classify severity and extent, and assess complexity
grading - estimate future risk, estimate potential impact of patient's health
117
Tonetti 2018 - stages of periodontitis
I - very early attachment loss, borderland between gingivitis and periodontitis
II - established perio, but management still simple
III - significant damage and tooth loss will occur without treatment. masticatory function preserved, management complicated by intrabony defects/furcation/history of periodontal tooth loss/ridge defects complicating implant replacement
IV - significant damage and tooth loss has occured, loss of masticatory function, complicated by hypermobility (secondary occlusal trauma), posterior bite collapse, drifting, requires stabilization
118
Tonetti 2018 - grading periodontitis
disease severity at presentation is an indirect assessment
CAL must be adjusted in some way based on number of missing teeth (unclear how we do this?)
risk factor will shift grade higher (smoking/diabetes)
119
Berglundh and Armitage 2018
| peri-implant health
PD usually greater than adjacent teeth, stable.
| peri-implant epithelium is longer with no inserting CT onto the implant
120
Berglundh and Armitage 2018
| Peri-implant mucositis
BOP on simple probing
strong evidence of plaque etiology
3 weeks for resolution
plasma cells and lymphocytes which do not extend apical of the junctional epithelium
121
Berglundh and Armitage 2018
| Peri-implantitis
BOP +/- suppuration, progressive bone loss radiographically,
strongly associated with periodontitis
122
Araujo and Lindhe 2018
| peri-implant attachment
3-4mm height (margin to crest of peri-implant bone) JE 2mm, CT 1-2mm
most fibers are parallel to implant restoration
fibroblasts concentrated at the surface of the implant
123
Heitz-Mayfield and Salvi 2018
| peri-implant mucositis
peri-implant mucositis inflammatory infiltrate does not extend apical to the barrier epithelium. infiltration of B and T cells within 21 days
These sites are an increased risk of peri-implantitis
124
Heitz-Mayfield and Salvi 2018
| peri-implant mucositis risk factors
Biofilm acumulation, complaince with SPT, excess cement, improper restoration
Improved home care and mechanical debridement resolved 38% of peri-implant mucositis
125
Schwarz 2018
| peri-implantitis
requires radiographic confirmation
dominated by plasma cells and lymphocytes
peri-implant lesions are twice as wide as periodontitis (3.5mm2 vs 1.5mm2)
lesions tend to evolve circumfrentially
126
Schwartz 2018
| risk factors of peri-implantitis
```
history of periodontitis
lack of SPT
Smoking is not
Diabetes is not
Excess cement is a potential risk factor
poor placement may lead to poor OH, but not a risk factor
occlusal overload is not conclusive
titanium particles is not conclusive
<2mm KT leads to more plaque but not changes in bone level
```
