March 201416 Perio Tribune United Kingdom Edition page 15DTß food impaction and frequent pro- fessional tooth cleaning • Individuals with chronic diseas- es and autoimmune disorders The recommendation to re- place affected teeth with im- plants is indicated in the following clinical situations and should be planned on-time after completion of periodontal therapy (three to six months): • Patients running a demanding business striving for fixed teeth • Enhanced masticatory and cleaning comfort •Long-termrehabilitationwithlow input in time, effort and expenses Currently, the items above are effective at implant placements within the local bone, minor lateral hard and soft tissue defi- ciencies, following sinus floor el- evation, in settings with sufficient implant abutment distances of 3mm and after periodontal ther- apy. Extended surgical protocols enhance treatment time (Fig 3), render the case prognosis uncer- tain and may aggravate long-term success. Implant therapy in advanced periodontal disease The survival rates of teeth with severe periodontal damage pub- lished in evidence-based stud- ies are rarely valid for patients inquiring treatment in dental of- fices (Fig 4). Shortcomings in oral hygiene, lack in supportive care, oral dysfunctions, stress, smoking and general disorders abbreviate the function times of periodontally compromised teeth sustainably. The advice to replace affected teeth with implants in advanced periodontal settings within the maxilla implicates on-time pa- tient information of the second and third molar removal: implant placement and prosthetic bridge- works are scheduled in the func- tional masticatory area until to the first molar. In the mandible, the second molars can be preserved due to their beneficial root anat- omy. They should be restored, but not included in implant plan- ning. Following the removal of the first molar in the maxilla, im- plant therapy is often preceded (if the supporting bone is less than 4mm) or accompanied by a si- multaneous sinus lift. The implant treatment plan in periodontally compromised patients results in a reduced dentition (Fig 5): • Fixed bridgeworks in the maxilla and mandible up to the first molar • Maxilla: preservation of pre- molars and first molars, tooth re- moval and implant therapy with sinus floor elevation at furca- tion involvement level III (Fig 6) • Mandible: preservation of sec- ond molars, restoration, no inclu- sion into bridgeworks • Volume thickening with free au- togenous gingival grafts in initial thin biotype settings (Fig 7) • Short implants in both aestheti- callyandfunctionallylessdemand- ing situations as an alternative to surgical augmentation (Fig 8). Low bone quality (D3/D4), lateral hard-tissue deficiencies and increased mechanical load- ing are contraindications for short implants. According to conven- tional implant rehabilitation, the horizontal width of the alveolar bone crest is the fundament for functional stabilisation, vasculari- sation and nutrition, thus for im- plant survival and clinical success (Fig 9). Inflammation and hygiene Clinical healthy and stable im- plants are completely covered within the alveolar bone by os- seointegration. They also are at- tached to the peri-implant gingiva and thereby become functionally included into the body’s metabo- lism. This explains the high over- all 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 periodontal diseases often causes mid-term damages (two years after functional loading) of the implant-to-bone interface. Like periodontally affected teeth with lack of hygiene access and en- hanced biofilm accumulation, implants develop a potential risk of inflammation when bacteria enter the implant-to-bone inter- face (Fig 10). If the close hard and soft tissue sealing disappears irreversibly, foreign-body infec- tions occur within the oral cavity, which are more harmful for the implant-supporting bone and the body health than periodontal dis- eases. The best protection against peri-implant inflammation is not avoiding implants: a careful im- plant placement strategy with concomitant thickening of the surrounding tissues and relief from functional overload preced- ed by comprehensive periodontal therapy (hygiene) are the best therapeutic helpers for implant survival and oral health (Fig 11). Summary In advanced periodontal diseas- es, the network between medi- cal progress and ever-expanding patient’s expectations requires a time-tested schedule with a grace period of three to six months to evaluate the affected dentition for periodontal treatment outcomes. If patients anticipate immediately fixed and aesthetic restorations, on-time implant therapy with minimal augmentative solutions is recommended. Preservation of periodontally compromised natu- ral teeth is advised when patients display no preference for further comfort and aesthetics. Periodon- tal therapy is continued, supple- mented with surgery in advanced intra-bony settings where oral hy- giene is impaired. The long-term success for the natural dentition and implants similarly depends on patient’s medical and local risk factors that cannot be forecasted with any genetic or susceptibility test for sale. DT About the author Prof Dr Rainer Buchmann Practice limited to Periodontics Königsallee 12, 40212 Düsseldorf, Germany Tel.: +49 211 8629120 E-Mail: info@rainer-buchmann.de www.rainer-buchmann.com Fig. 1 Treatment of advanced periodontal disease with implants replacing the natural dentition is recommended “time-tested” 3-6 months following periodontal therapy (SRP). Fig. 2 Exclusion criteria for implants with continuation of saving natural teeth after comprehensive periodontal therapy. Fig. 3 Implant therapy should be performed with minimal augmentation. Extended surgical therapy prolongs treatment time, renders case prognosis unsafe and may ag- gravate long-term success. Fig. 4 Unexpected life-events half cut the survival rates of teeth with advanced periodontal bone loss in daily practice down to 5–7 years. Fig. 5 Guidelines to a safe implant treat- ment protocol in advanced periodontal disease. Fig. 6 The piezosurgical access to the lat- eral sinus is the best approach to promote implant supported bone in the maxilla. plants are not advocated, internal lifts technique-sensitive. Fig. 7 Volume thickening with a free gin- gival 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. Func- tionally, they represent no alternative to classical augmentation protocols. (Photo: Kochhan) Fig. 9 Insertion of short implants close to the alveolar nerve in the mandible with sufficient alveolar bone width. (Photo: Kochhan) Fig. 11 Periodontal therapy lowers the inflammatory burden and promotes health while optimizing body metabolism with stimulating effects onto the vascular system. Fig. 10 Implants require a comprehensive maintenance care. Peri-implant inflamma- tions display foreign body infections that are more harmful for the body health than periodontal diseases. 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