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implantitis Flashcards

1
Q

What is the definition of peri implantitis

A

pathological condition occurring in tissues around dental implants, characterized by inflammation in the peri-implant CT and progressive loss of supporting bone

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2
Q

Characteristics of the peri implant mucosa

A

-Barrier epithelium with basal lamina and hemidesmosomes facing the implant or abutment
-CT fibers run parallel to implant
-implant tissues are less vascularized (plexus immediately lateral to barrier epi)
-epithelium attachment is only on the coronal region via hemidesmosomes
-CT has MORE collagen fibers and LESS fibroblasts and is LESS vascularized
– -biologic width 3mm
-peri implant tissues have a BW 1.5mm longer than teeth (Linkevicius 2008)

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3
Q

What is the biologic width around implants

A

JE 1.88
CT 1.05
BW 3.08
(Cochran 1997 dog study)

3m after implant placement (Tomasi 2014)
- 1.9 epi
- 1.7 CT
- Total 3.6mm

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4
Q

Diagnostic criteria for peri implantitis

A

-BOP or suppuration
-increased PD
-bone loss beyond crestal bone level changes
-may have recession

If no previous data:
-BOP or suppuration
-PD >=6mm
-Bone levels >=3mm apical to the coronal portion of the intraosseous part of the implant

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5
Q

How does the disease presentation compare to periodontitis

A

-larger (doubled) inflammatory cell infiltrate, more neutrophils and macrophages in peri implantitis
-not self-limiting
-both have plasma cells and lymphocytes
-disease accelerates faster

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6
Q

How important is keratinized mucosa around implants

A

lack of concensus around this
-may have advantages for patient comfort and hygiene
-Wennstrom 1994: no association between soft tissue health and lack of KM
-Lin 2013 systematic review:<2mm gingiva width associated worse worse perio parameters
-Monje 2019: erratic compliers more prone

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7
Q

What is the importance of maintenance for prevention of peri implantitis

A

5 year follow up study by Costa 2012
-no maintenance group had 44% peri implantitis
-maintenance group had 18% peri implantitis

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8
Q

Is probing safe around implants?

A

Yes, healing of the junctional epithelium after 5 days (Etter 2003)

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9
Q

What type of bone loss pattern is commonly seen?

A

Schwarz 2018: Usually circumferential pattern
Shatta 2019: vertical bone loss seen at grafted sites; horizontal bone loss seen between adjacent implants
Monje 2019: mostly type b defects (2-3 walls)

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10
Q

Classification system for implants

A

Monje 2019

Class 1 – infraosseous
Class 2 – horizontal
Class 3 – combined

A – dehiscence
B- 2-3 wall
C- circumferential

S-slight <25%
A-advanced 25-50%
M-moderate >50%

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11
Q

Prevalence of implantitis

A

55% mucositis
22% implantitis
Renvert et al 2018
26 year follow up study

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12
Q

Risk factors for peri implantitis

A

(Schwarz 2018)
-hx of periodontitis (x9 odds – Costa 2012)
-poor plaque control (x14 odds – Ferreira 2006)
-no regular maintenance

-may also be associated: smoking, DM, cement, lack of KM, malposition, overheating, prosthetic design

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13
Q

Does ridge preservation affect implant outcomes

A

Marconcini 2018: more MBL in the non-grafted group

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14
Q

Effect of periodontally compromised patients and dental implants

A

Roccuzzo
-PD and bone loss differed significantly in the groups

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15
Q

How effective is implantoplasty versus resective

A

Romeo 2005
Survival was better (100 versus 78%) and less MBL and improved PD and BOP scores

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16
Q

What type of bacteria is found at peri implantitis

A

P gingivalis
-P intermedius
-S aureus has been implicated and may be involved in the initiation of peri implantitis

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17
Q

How can the prosthesis affect implantitis

A

-emergence angle of >30 deg (Katafuchi 2018)
-convex profile
-need to be aware of the critical and subcritical zones
-cleasibility

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18
Q

Types of mechanical debridement

A

-titanium curettes
-SS curettes
-ultrasonic
-air flow
-titanium brushes

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19
Q

types of chemical debridements

A

-hydrogen peroxide: supported by evidence
-chlorhexidine: (not supported by evidence to promote implant decontamination or reosseointegration due to its osteoblast cytotoxicity; Muthukuru 2012 found it was not as effective as antibiotics, air polish, or lasers for BOP)
-citric acid: partially supported
-saline
-EDTA

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20
Q

types of pharmacological agents

A

-tetracycline: may further contribute to reducing bacterial load
-minocycline

Schwartz 2022 – not enough evidence for adjunctive systemic antibiotics

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21
Q

other adjuncts for decontamination

A

-lasers (might be beneficial for decreasing BOP and disinfecting but no consensus)
-photodynamic therapy
-galvosurg

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22
Q

What is the effect of implantoplasty on your outcome

A

Khoury 2019:
Sig decrease in BOP and PD compared to mechanical debridement alone

(Engelzos 2018)
-stable MBL
-resolution of infection
-recession is expected

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23
Q

What is the effect of regeneration with bone grafts

A

Donos 2023 systematic review
-PD reduction of 2-4.5mm, reduction in BOP from 44-86%, and bone fill

But this paper concluded that there wasn’t a significant difference between OFD and regeneration

No evidence to support a specific bone graft or membrane

No difference with BG or BG+mem (and membrane often leads to exposures) (Renvert 2015)

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24
Q

What is the effect of non-surgical perio therapy for mucositis

A

Effective for mucositis: Renvert 2008 – chx + debridement can help reduce BOP and PD

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25
What factors will negatively affect your outcomes
initial bone loss > 7 mm PD> 8 mm Suppuration postoperative presence of biofilm smoking modified implant surface (Koldsland; De Waal)
26
What surgical treatment options are there
-OFD: decrease in BOP and PD; disease recurrence is high -resective with implantoplasty: decrease in BOP and PD; good disease resolution; good bone stability -regeneration: decrease PD and BOP; 2mm bone gain 50% success for all groups Implants still lost for all groups
27
What factors affect the success of regenerative approach
-implant location (in or out of bony housing) -morphology of the bone defect (contained defect and 3mm at least) -implant surface characteristics -presence of KM
28
What is the conversion from mucositis to implantitis
Costa: 31% of those w mucositis develop implantitis after 5 years -18% of those with SPT got implantitis -44% of those without SPT got implantitis
29
Differences between mucositis and implantitis
-<2mm of bone loss is acceptable -histologically in mucositis the infiltrate does NOT go apical to the JE but in implantitis it goes apical -both contain plasma cells and lymphocytes -larger lesion in implantitis -reversible versus irreversible
30
Periodontitis versus implantitis
1) the lesion is twice the size 2) implantitis is not self limiting and the lesion extends more apically to the bone 3) both have plasma cells and lymphocytes but implantitis has more neutrophils, plasma cells, lymphocytes, and macrophages (Carcuac and Berglundh) 4) implantitis has a circumferential defect 5)osteoclasts are found on the bone 6) both related to biofilm and irreversible 7) implantitis does not respond as well to insult removal
31
What factors contribute to hard tissue loss AFTER implant placement
-malposition -peri implantitis -soft tissue thickness -surgical trauma (high insertion torque) -supracrestal implant placement -infection -insufficient bone dimensions
32
what is the effect of implantoplasty on implant fracture
3.75mm diameter needed
33
healing of an FGG
(Gargiulo and Arrocha) 0-2: plasmatic circulation 2-4: vascular invasion 4-7: CT attachment, epithelium sloughs 10: bridge of vascular channels, complete epithelialization 21: well organized CT 28: keratinization of epithelium begins
34
How long does an FGG take to heal
-2.5m for thin graft (0.75mm) -4m for thick graft (1.75mm) (Gordon 1968)
35
Minimum amount of thickness for an FGG
minimum thickness of 0.75-1.25mm (epi is 0.34mm according to Soehren, lamina propria is around 1-1.5mm)
36
What layers do you have for an FGG
-epi 0.3mm -CT 1.0mm? -submucosal layer: capillaries, salivary glands, adipose tissue, periosteum
37
How much shrinkage do you expect
25% in 12m (Egli 1975), depends on thickness
38
What factors affect FGG healing
-amount of sutures? -mobility -thickness -infection -trauma -extent of host bed -thickness of blood clot
39
how does compliance affect implantitis
Costa 2012 – 44% incidence of peri implantitis for non compliers versus 18% for compliers
40
What is the effect of implantoplasty on the implant/abutment connection?
Chan 2013 -narrow implants failed (by fracture) and the bending strength was SS reduced by implantoplasty (narrow is 3.75mm) -IMPLANTOPLASTY DID NOT AFFECT THE STRENGTH OF WIDE IMPLANTS (4.7mm) -fracture failures occurred at the abutment screw
41
What are the components to NSPT for peri implantitis?
1) Hand instruments 2) Local antibiotics or antiseptics 3) Systemic antibiotics 4) Air polishing -reduce signs of inflammation after implantitis (Schwarz 2015) 5) Lasers 6) Modification of the prosthesis
42
What are the goals for NSPT with peri implantitis?
1) PD reduction <5 2) Reduce bacterial load 3) Help patient achieve good OH 4) Condition soft tissues 5) Reduce plaque and BOP
43
Indications for NSPT for peri implantitis?
1) Before surgical intervention 2) Well contained defects 3) Horizontal defects 4) Not good candidates for surgery (smoking)
44
Types of hand instruments
-plastic: limited effectiveness -titanium: effective without damage to the surface because of similar hardness (Louroupoulou) -SS: harder than titanium and scratch surface: only use infraosseous
45
What is the effect of hand instrumentation with or without adjuncts?
-not effective on its own -slightly better PD reduction with combined treatments
46
how effective is NSPT for mucositis
Renvert 2008 – NSPT + chx was good for mucositis
47
how effective is NSPT for peri implantitis
- NSPT was not effective, chx had limited effects, adjunctive local or systemic antibiotics helped with reducing BOP and PD (Renvert 2008) - NSPT IS BENEFICIAL FOR THE IMPROVEMENT OF PERI IMPLANT PARAMETERS BUT INSUFFICIENT TO COMPLETELY RESOLVE THE DISEASE
48
Goals of resective sx
1) Reduce PD <6mm – PD is associated with disease progression 2) Eliminate deep PD with BOP 3) Reduce bacterial load 4) OH at home
49
rationale for implantoplasty
- REDUCE PLAQUE ADHESION BY SMOOTHENING THREADS - FACILITATE AT HOME HYGIENE - MECHANICAL DETOXIFICATION
50
Indications for resective surgery
-controlled perio condition (full mouth bop and pi low) -nspt didn’t work -<10 cig/day smoker, controlled systemic -defect uncontained -low esthetic demand -implant outside of envelope
51
benefits of implantoplasty:
-less biofilm attachment (as long as the surface roughness is <20 microns according to bollen 1996) -mechanical detoxification
52
disadvantages of implantoplasty:
- implant is weakened (biomechanical complications) – must have 3.75mm - particles are released - notches that can harbour biofilm - not for esthetic region
53
Goals for reconstructive therapy:
1) Reduce PD <6mm – PD is associated with disease progression 2) Eliminate deep PD with BOP 3) Reduce bacterial load 4) OH at home -gain in bone fill and CAL -idea that you want re-osseointegration but cannot confirm clinically or radiographically ** re-osseointegration was confirmed histologically by Schou et al
54
drawback of chx
Chx as a irrigant can prevent osteoblast attachment and proliferation; it was found that sodium hypochlorite was better than chx
55
Is KM needed around implants?
- Controversy around this topic - Wennstrom 1994 mentioned that it does not have an influence on peri implant health - Lin 2013: systematic review says has worse outcomes for PI, GI, recession, and attachment loss - Monje and Blasi 2019: found that if you had <2mm and erradic compliance then you had worse perio parameters compared to if you had >2mm KM and were an erradic complier.
56
Thickness for bone resorption
- Berglundh and Linde (1996) found that <2mm had more bone resorption and angular defects compared to thicker >2mm (2.1mm and 1.8mm) - Ideally the thickness should be equivalent to the biologic width to prevent bone resorption - Biologic width around implants is 3.6mm so the soft tissue should be the dimension of the biologic width
57
Types of STA around implants:
- ARF - ARF + FGG - ARF+CTG - ARP + collagen matrix (volume collapse) - Pedicle flap (less shrinkage)
58
What is the effect of soft tissue augmentation on your outcomes?
Thoma 2018: -gain in KM improves GI and MBL -MBL was less in the ARF+autogenous graft group (compared to ARF alone or ARF with collagen matrix or maintenance group) -gain in thickness did NOT improve BI but improved MBL overtime
59
How much gain in KM do you expect?
Ranges from 1.5-4 depends on study
60
How much shrinkage do you expect?
- Monje 2020 after 12m found FGG had 42% shrinkage around implants
61
how does bone or periosteum effect your FGG
- James and McFall 1978: 25% shrinkage for bone and 50% for periosteum, but you have delayed revascularization and healing for bone Mormann 1981: -thick grafts on bone had delayed healing -if you are on periosteum you have fast revascularization (esp for uniform thin-thick grafts)
62
How does FGG thickness affect outcome - shrinkage and contraction?
Mormann 1981: -thicker grafts had less shrinkage (30% thick, 38% intermediate, 44% thin) -Thicker grafts have more primary contraction (43%), thin grafts have more secondary contraction
63
what is the ideal thickness of an FGG
1.5mm to guarantee you have epi and lamina propria 0.3+ 1 = 1.3mm
64
how much graft shrinkage for an FGG around implant
42% after 12m (and most shrinkage in the first 3m) Monje 2020
65
why FGG over CTG?
- Thoma 2018 found FGG helps with MBL and GI; CTG helps with MBL only - Thoma 2014 o ARF + autogenous was the best (1.4-3.3 mm increase in KT) o CTG was good for esthetics and thickness
66
when is the best time to do STA around implants
second stage surgery (Thoma 2022)
67
risk factors for peri mucositis
-biofilm -smoking -radiation (Heitz-Mayfield 2018)
68
What is the effect of soft tissue thickness on MBL
Linkevicius 2009 -thin mucosa <2mm had more MBL than thick mucosa >2mm 1.5mm vs 0.3mm
69
How much is probe penetration
0.52 mm past the CT level (Lang 1994) Schou found that inflammation causes the probe to exceed much

Treatment Planning Notes (15 decks)

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