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Implant Tribune Italian Edition

7Implant Tribune Italian Edition - Maggio 2014 Clinica & Pratica << pagina 6 - Patients with no personal pref- erences to comfort, esthetics and costs. - Patients willing to accept en- hanced tooth mobility, oc- casional food impaction and frequent professional tooth cleaning. - Individuals with chronic diseas- es and autoimmune disorders. The recommendation to replace affected teeth with implants is in- dicated in the following clinical situations and should be planned on-time after completion of per- iodontal therapy (three to six months): - Patients running a demand- ing business striving for fixed teeth. - Enhanced masticatory and cleaning comfort. - Long-term rehabilitation with low input in time, effort and ex- penses. Currently, the items above are effective at implant placements within the local bone, minor later- al hard and soft tissue deficiencies, following sinus floor elevation, in settings with sufficient implant abutment distances of 3 mm and after periodontal therapy. Extend- ed surgical protocols enhance treatment time (Fig. 3), render the case prognosis uncertain and may aggravate long-term success. Implant therapy in advanced periodontal disease The survival rates of teeth with se- vere periodontal damage published in evidence-based studies are rarely valid for patients inquiring treat- ment in dental offices (Fig. 4). Short- comings in oral hygiene, lack in supportive care, oral dysfunctions, stress, smoking and general disor- ders abbreviate the function times of periodontally-compromised teeth sustainably. The advice to replace affected teeth with implants in advanced perio- dontal settings within the maxilla implicates on-time patient informa- tion of the second and third molar removal: implant placement and prosthetic bridegworks are sched- uled in the functional masticatory area until to the first molar. In the mandible, the second molars can be preserved due to their beneficial root anatomy. They should be restored, but not included in implant planning. Fol- lowing the removal of the first mo- lar in the maxilla, implant therapy is often preceded (if the supporting bone is less than 4 mm) or accom- panied by a simultaneous sinus lift. The implant treatment plan in periodontally compromised pa- tients results in a reduced denti- tion (Fig. 5): - Fixed bridgeworks in the maxil- la and mandible up to the first molar. - Maxilla: preservation of pre- molars and first molars, tooth removal and implant therapy with sinus floor elevation at furcation involvement level III (Fig. 6). Inflammation and hygiene Clinical healthy and stable implants are completely covered within the alveolar bone by osseointegration. They also are attached to the periim- plant gingiva and thereby become functionally included into the body’s metabolism. This explains the high overall survival rates of oral implants between eight and more than 15 years. The combination of - a thin biotype gingiva with lack of soft tissue protection - functional overload due to stress, habits or a missing front-canine equilibration - loss of biofilm protection by peri- odontal diseases often causes mid-term damages (two years after functional loading) of the implant-to-bone interface. Like per- iodontally affected teeth with lack of hygiene access and enhanced bi- ofilm accumulation, implants devel- op a potential risk of inflammation when bacteria enter the implant-to- bone interface (Fig. 10). If the close hard and soft tissue sealing disappears irreversibly, for- eign-body infections occur with- in the oral cavity which are more harmful for the implant-support- ing bone and the body health than periodontal diseases. The best pro- tection against periimplant inflam- mation is not avoiding implants: a careful implant placement strategy with concomitant thickening of the surrounding tissues and relief from functional overload preceded by comprehensive periodontal therapy (hygiene) are the best therapeutic helpers for implant survival and oral health (Fig. 11). Summary In advanced periodontal diseases, the network between medical pro- gress and ever-expanding patient’s expectations requires a time-tested schedule with a grace period of three to six months to evaluate the affect- ed dentition for periodontal treat- ment outcomes. If patients anticipate immediately fixed and esthetic restorations, on- time implant therapy with minimal augmentative solutions is recom- mended. Preservation of periodon- tally compromised natural teeth is advised when patients display no preference for further comfort and esthetics. Periodontal therapy is continued, supplemented with sur- gery in advanced intrabony settings where oral hygiene is impaired. The long-term success for the natural dentition and implants similarly de- pends on patient’s medical and local risk factors that cannot be forecast- ed with any genetic or susceptibility test for sale. Fig. 7 - Volume thickening with a free gingival graft in an initial thin tissue with buccal perforation. Fig. 8 - Short implants are advised in critical anatomic situations when the alveolar bone width is sufficient. Functionally, they represent no alternative to classical augmentation protocols. (Photo: Kochhan) - Mandible: preservation of sec- ond molars, restoration, no in- clusion into bridgeworks. - Volume thickening with free autogenous gingival grafts in initial thin biotype settings (Fig. 7). - Short implants in both esthet- ically and functionally less de- manding situations as an alter- native to surgical augmentation (Fig. 8). Low bone quality (D3/D4), lateral hard-tissue deficiencies and in- creased mechanical loading are contraindications for short im- plants. According to conventional im- plant rehabilitation, the horizontal width of the alveolar bone crest is the fundament for functional sta- bilization, vascularization and nu- trition, thus for implant survival and clinical success (Fig. 9). Fig. 9 - Insertion of short implants close to the alveolar nerve in the mandible with sufficient alveolar bone width. (Photo: Kochhan) Fig. 10 - Implants require a comprehensive maintenance care. Periimplant inflam- mations display foreign body infections that are more harmful for the body health than periodontal diseases. Fig. 11 - Periodontal therapy lowers the inflammatory burden and promotes health while optimizing body metabolism with stimulating effects onto the vascular system.