Dental implants: Perio-Prostho

symbiotic relation for long term

implant maintenance & sucess

DR.NITHIYANANDAM.P
DEPT OF PERIODONTOLOGY
CONTENTS
• Introduction
• Implant and Natural Teeth
• Diagnosis and history taking.
• Peri implant mucosa
• Implant and Periimplantitis
• AKUT protocol
• Prosthetic Design Factors Influencing Peri
Implant Disease.
• Implant Failure
• Maintenance
• Role in implant maintenance
• Conclusion
Introduction
• Oral implants have become an integral part of reconstructive dentistry.
• Implant devices, prosthetic devices and superstructures are different from the
normal gingival/ tooth contours and relationships.
• Permucosal seal of the soft tissue to the implant surface is important for the
success of implants.
• Failure to maintain this seal, will cause bacteria and their by-products have a
direct entry to the bone surrounding the implant.
• Poor oral hygiene is a documented risk factor associated with implant failures.
IMPLANT VS NATURAL TEETH
IMPLANT VS NATURAL TEETH
TAKE PROPER CASE HISTORY
Absolute contraindication
 Recent myocardial infarction
 Valvular prosthesis
 Severe renal disease
 Uncontrolled and treatment resistant diabetes
 Advanced and untreated osteoporosis
 Treatment resistant osteomalacia
 Endocrine disease
 AIDS
 Chemotherapy in progress
 Radiotherapy in progress
Relative contraindication

Inadequately controlled diabetes

Mild Renal disorder
Heavy smoking
Insufficient mouth opening
Hepatic disorder(hepatitis c)
Uncontrolled bruxism
 THE RULE OF 5 TRIANGLES
TO
DECISION-MAKING
PROCESS

Gracia et al 2014.
 There are 5 key aspects to follow in placing an implant
in order to reach favorable outcomes, these are the 5 triangles

1. Primary 3. Jumping
distance (Filling of
stability where 2. The presence of
there is existing buccal plate the gap between
apical buccal plate
bone and implant)

4. Tissue biotype 5. Implant design.

EXAMINATION AFTER IMPLANT PLACEMENT
• This is a mandatory component of the maintenance protocol and is
crucial in determining whether there presently exist any concomitant
conditions that would predispose the patient to peri-implant disease.
1.XEROSTOMIA
• It has been shown to affect the dental biofilm composition and
intraoral healing of the soft tissues.
• Immune cells are normally delivered and distributed in the oral
cavity through the saliva; therefore a lack of saliva may lead to
lowered antimicrobial components in the oral cavity.
• A patient with a soft tissue–borne implant prosthesis may
experience soft tissue irritation because of the lack of saliva.
AUTOIMMUNE DISEASES:
• Lichen planus causes the hemidesmosomal epithelial attachment to
the implant surface to become disabled, leading to periimplant
mucositis and possibly progressing to peri-implantitis.
• With many autoimmune diseases, patients may lose their manual
dexterity, thereby decreasing hygiene ability and also difficulty in
removing an attachment-dependent overdenture prosthesis.
BONE DISEASES:
• Altered bone physiology in conditions such as
osteoporosis/osteomalacia/osteopenia, Paget’s disease, and fibrous
dysplasia may significantly increase the risk for complications for
implant patients.
DIABETES:
• Patients with diabetes, are prone to acquire infections and vascular complications. The healing
process is affected by the impairment of vascular function, chemotaxis, and neutrophil
function.
• Protein metabolism is decreased, and healing of soft and hard tissue is delayed, which may lead
to the susceptibility of infection.
RADIATION TREATMENT TO THE ORAL CAVITY:
• Patients who receive radiation to the oral cavity after implant treatment may suffer from many
deficits including oral mucositis, xerostomia, compromised healing, and reduced angiogenesis.
• This is a direct result of changes in the vascularity and cellularity of hard and soft tissue,
damage to the salivary glands, and increased collagen synthesis that results in fibrosis.
SLEEP APNEA:
• Patients who are diagnosed with sleep apnea are often treated with continuous positive airway
pressure(CPAP).
• CPAP machines may place an increased force on the oral cavity.
• Therefore if patients are using a CPAP machine, the implant area should be monitored closely.
• Elderly patients: Postinsertion complications such as muscle control, hygiene difficulty, tissue
inflammation, and overdenture seating are significant in the older population study.
SMOKING:
• Studies have shown the detrimental effects of the gases and chemicals (e.g.,
nitrogen, carbon monoxide, carbon dioxide, ammonia, hydrogen cyanide,
benzene, nicotine) released in cigarette smoke. Multiple retrospective studies
have shown that smokers experience almost twice as many implant failures
compared with nonsmokers.
PHENYTOIN (DILANTIN):
• Dilantin is associated with a high incidence of gingival overgrowth of peri-
implant soft tissue, implant gingival hyperplasia, mucosal proliferation,
proliferative gingivitis, and implant-related tissue hyperplasia.
• These hyperplasia-induced pockets may harbor pathogenic anaerobic bacteria.
• The plaque biofilm colonization and maturation in implant pockets initiates
inflammation.
SOFT TISSUE ASSESSMENT
• An overview of the visual signs of gingival inflammation redness,
edema, alterations of tissue contour, fistula tracts should be
evaluated and documented.
• The most common bleeding gingival index used for implants is the
Loe and Silness gingival index.
ASSESSMENT OF HOME CARE
• Because the presence of microbial biofilm has been shown to be a
leading factor in the pathogenesis of peri-implant disease, the
routine assessment of plaque accumulation should be a priority of
each maintenance visit.
• High plaque scores have been shown to have a direct correlation
with peri-implant mucositis and increased probing depths.
PRESENCE OF KERATINIZED TISSUE
However, other reports have shown a lack of keratinized tissue is associated with bone loss,increased plaque

acculumlation, increased gingival recession, increased gingival inflammation, and a higher frequency of

bleeding on probing.
MOBILITY OF IMPLANT
• If mobility exists, the etiology should be ascertained, specifically if it is due to a
loose screw or implant failure.
• Usually if pain is present when the prosthesis is moved in a buccal-lingual and
apical direction, then it is most likely due to an implant failure
• When implant failure exists, pain will result because of the soft tissue interface.
• If no pain exists, then usually this is indicative of screw loosening.
PAIN/SENSITIVITY
• Pain and tenderness are subjective criteria and depend on the patient’s
interpretation of the degree of discomfort.
• In contrast to a natural tooth an implant does not become hyperemic and is
not temperature sensitive.
• If a traumatic occlusion situation is present, rarely will symptoms be present
with an implant.
DIAGNOSIS OF PERI-IMPLANT DISEASE
In the evaluation of the peri-implant tissues, three possible conditions may exist:
(1) healthy condition, (2) peri-implant mucositis, and (3) peri-implantitis.
Healthy Condition
• If there exist no signs of inflammation, bleeding, recession, bone loss, or
implant/prosthesis mobility, then the patient’s implants/prosthesis is
determined to be in a “healthy” state
• Treatment includes adherence to routine implant maintenance (i.e., usually 3–
6 months).
Peri-implant Mucositis
• Peri-implant mucositis is defined as a localized
inflammation within the soft tissue
surrounding the implant bodies. In addition,
redness and bleeding on probing may be
present.
• However, the bone level has not changed;
therefore no hard tissue recession (i.e., bone
loss) has occurred.
• Peri-implant mucositis is similar to gingivitis
with respect to natural teeth.
• Treatment includes remediation of the
causative factors of periimplant mucositis and
associated follow-up care.
PERI-IMPLANTITIS
• Peri-implantitis is defined as localized
inflammation with concomitant bone loss. In
most peri-implantitis cases suppuration and
clinical probing depths are present, together
with bleeding on probing.
• On radiographic evaluation, marginal bone loss
is present in comparison with the original
baseline radiographs.

1. Early: PD ≤ 3mm
2. Moderate: PD 4-5mm
3. Advanced: > 5mm
Cumulative Interceptive SupportiveTherapy (CIST)
• Mombelli developed the Cumulative Interceptive SupportiveTherapy (CIST)
protocol for maintenance of the dental implant and management of peri-
implantitis
AKUT PROTOCOL BY LANG ET AL IN
2004
Prosthetic Design Factors Influencing Peri
Implant Disease:
Etiology and Risk Factors
• Poor oral hygiene:
• Smoking
• Systemic health conditions:
Prosthetic factors:
Role of Prosthetic Components in Peri-Implant Health
• The materials and design decisions made during the prosthetic phase of
implant dentistry can exert profound effects on the long-term stability of the
implant and the health of the peri-implant tissues
• Biocompatible materials resistant to corrosion and wear are pivotal for
minimizing adverse reactions and tissue irritation, which can contribute to peri-
implant complications.
• The selection of materials for crowns, abutments, and other components must
be guided by an understanding of their compatibility with the patient's oral
environment and systemic health
• Furthermore, the design of prosthetics, such as the emergence profile,
contours, and occlusal scheme,profoundly influences peri-implant health.
• Poorly designed prosthetics can create areas prone to food impaction and
bacterial colonization, making patients more susceptible to periimplant
mucositis and subsequently, peri-implantitis
Crown Design and Its Impact on Peri-Implant Health
• Occlusal forces play a pivotal role in the success of dental implant
procedures.
• When the crown is poorly designed and does not distribute forces
evenly, it can lead to excessive stress concentrations at specific
points in the implant-bone interface.
• One important strategy to mitigate these force-related issues is
platform switching
• Platform switching involves using an abutment with a smaller
diameter than the implant fixture. This configuration creates a
horizontal mismatch between the implant and the abutment,which
can help redistribute occlusal forces more favorably.
• A well-designed crown can further ensure that occlusal forces are
distributed evenly across the implant site by incorporating platform
switching, significantly reducing the risk of force-related
complications.
• Emergence profile: The emergence profile, which is how the crown emerges
from the soft tissue, is another vital element in crown design. An optimal
emergence profile should promote healthy soft tissue contours and facilitate
easy access for oral hygiene.
• Inadequate emergence profiles may create challenges in maintaining proper
oral hygiene, as it can lead to food impaction areas and bacterial colonization.
• Crown-to-implant ratio: The proportion of the crown to the implant fixture,
known as the crown-to-implant ratio, plays a role in peri-implant health.
• Ideally, the ratio between the crown and the root should be 1:2, and a
minimum of 1:1 for a tooth abutment is recommended
• Imbalances in this ratio, particularly in cases with excessive crown height, can
result in an uneven distribution of forces. This can lead to mechanical
complications and increased strain on the implant-bone interface, which may
accelerate bone loss and peri-implant disease.
Abutment Design and Its Influence on Peri-Implant Disease
• Emergence profile: The emergence profile created by
the abutment design plays a pivotal role in determining
peri-implant health. This profile defines how implant-
supported restoration emerges from the soft tissues,
and it has both functional and esthetic implications.
• An optimal emergence profile supports the formation
of healthy and natural soft tissue contours around the
implant. This not only enhances the esthetic
appearance of the restoration but also aids in
maintaining the health of the peri-implant soft tissues.
• Irregular emergence profiles are more likely to trap
debris and bacteria, making them a risk factor for soft
tissue complications
SOFT TISSUE CONTOURS:
• Ideally, abutments should encourage the formation
of well-adapted and healthy soft tissue around
the implant.
• When abutment design fails to support these
favorable soft tissue contours, it can result in soft
tissue recession.
• This recession creates pockets or crevices in the
peri-implant area, where bacteria can readily
accumulate.
• Bacterial biofilm within these recesses increases
the risk of inflammation and infection,which is a
characteristic of peri-implant disease. Therefore,
an abutment design that promotes proper soft
tissue contours is essential for maintaining peri-
implant health.
Considerations of Implant Abutment and Crown Contour: Critical
Contour
and Subcritical Contour Huan Su, DDSOscar González-Martín,
DDSArnold Weisgold, DDSErnesto Lee, DMD
Accessibility for oral hygiene:

• Effective oral hygiene maintenance is a cornerstone of peri-implant

disease prevention.
• Poorly designed abutments can impede the patient's ability to
clean around the implant supported prosthesis effectively. There
are several reasons for this.
• Irregular abutment contours can create challenges in accessing
certain areas around the implant, making it difficult for the patient
to reach and clean these spots.
• Additionally, the presence of undercuts or areas that are
challenging to reach with dental instruments can trap debris,
making proper cleaning even more problematic. When patients
struggle to maintain proper oral hygiene due to these design-
related issues, the risk of peri-implant mucositis and peri implantitis
significantly increases.
• Inadequate cleaning can result in the accumulation of microbial
biofilm,inflammation, and the progression of peri-implant disease.
Mechanical Stress and Its Effect on Peri-Implant
Tissues
• Prosthetic design factors significantly influence the management and distribution of
occlusal forces in implant-supported restorations.
• These factors encompass the design of the crown, the implant's angulation,and the
choice of materials. In cement-retained prostheses, the crown's design plays a critical
role, as it must be carefully engineered to ensure it can withstand and evenly distribute
occlusal forces.
• Additionally, the angulation of the implant is vital to align with the patient's natural
occlusion, preventing any misdirected forces.
• The choice of materials also becomes pivotal, as it should consider their strength and
their ability to withstand mechanical stress. For screw-retained prostheses, similar
principles apply.
• The crown's design is paramount to effectively managing occlusal forces.
Implications for Prosthetic Modifications and
Adjustments
• Prosthetic component modifications:
Prosthetic component modifications represent a proactive approach to
managing peri-implant disease. These adjustments involve a meticulous assessment
of the contours and materials of crowns and abutments, aiming to optimize oral
hygiene access and reduce the risk of bacterial colonization.
• reshaping
• reshaping
• smooth and well-contoured prosthetic components
• These modifications contribute to the overall maintenance of peri-implant health
and prevent the onset or progression of peri-implant disease, fostering a
favorable environment for the long-term stability of the implant-supported
restoration.
Potential Advancements in Prosthetic Design to
Mitigate Peri-Implant Disease
• Advanced prosthetic materials:
• Digital technologies and precision prosthetics:
• Evaluation of emerging prosthetic solutions:
FREQUENCY OF MAINTENANCE
VISITS
• Zitzman et al. reported that peri-implant mucositis may exhibit apical
progression after only 3 months of plaque buildup around implants. Therefore
a 3-month maintenance regimen is recommended within the first year of
implant placement to evaluate the tissue health and the patient’s home care.
• If after the first year the peri-implant tissues are healthy, then the
maintenance interval may be extended to 6 months.
CONCLUSION
• Daily self-care (oral hygiene) and adherence to a maintenance recall schedule
is absolutely required for long term success.This is best discussed and
conveyed to the patient at the consultation visit.
• Recall maintenance visit should always include the evaluation of soft and hard
tissue health, patient’slevel of oral hygiene compliance and plaque control
and the prosthesis integrity and stability.
• Long term success of both periodontal and implant therapy depends on an
effective partnership between the patient and practioner.
RECIPE FOR SUCCESSFUL IMPLANTS

Anatomy Technique

Hygiene Prosthesis
REFERENCES
• Maintenance protocols for implant-supported dental prostheses: A scoping review
Pablo Machado Soares, DDS, MSciD,a Gabriela do Amaral Silveira, DDS
Student,bLuciano de Souza Gonçalves, DDS, MScid, PhD,c Atais Bacchi, DDS, MSciD,
PhD,d and Gabriel Kalil Rocha Pereira, DDS, MScid, PhDe
• Maintenance of dental implants: A way to long term success: A reviewDr. Hema
Kanathila, Dr. Ashwin Pangi, Dr. Veena Benakatti and Dr. Suvidha Patil
• Maintenance therapy for teeth and implantsAndrea Mombelli
• The influence of crown-to-implant ratio on marginal bone loss: a narrative review
Adolfo Di Fiore, Francesco Maniero, Edoardo Stellini
• Considerations of Implant Abutment and Crown Contour: Critical Contour and
Subcritical Contour
• Implant Maintenance: A Clinical Update Minkle Gulati,1 Vivek Govila,2 Vishal Anand,3
and Bhargavi Anand
• Misch's Contemporary Implant Dentistry 4th Edition