06 CLINICAL Dental Tribune Asia Pacific Edition | 12/2018 Implants should only bh inshrthd whhn phriodontal conditions arh stablh By Dr Jan H. Koch, Germany Biofilm is the most significant cause of inflammatory bone loss around teeth and implants. Diagnostics, bio- film management and, where neces- sary, treatment help in patients with this problem. The W&H No Implan- tology without Periodontology work- flow should provide stable tissue prior to implantation through prevention, and implant success in the long term through aftercare – something that is advantageous to both the patient and the treatment team. Implant treatment can signifi- cantly improve quality of life after tooth loss.1, 2 The long-term prog- nosis is generally good, but biolog- ical complications are common.3 Peri-implantitis and its preliminary stage, mucositis, occur in a substan- tial proportion of patients.4 As is the case for periodontitis and gin- givitis, oral biofilm is the main cause.5, 6 This microbial biocoenosis can also encourage the develop- ment of severe systemic disease in the event of pathological changes, such as endocarditis and inflam- matory bowel disease.7 The only difference in the mi- crobial flora in periodontitis and peri-implantitis is in the detail.8 Compared with healthy conditions, the quantity and aggressiveness of the pathogenic microorganisms change in both diseases.5, 6 Bone loss around implants is generally more rapid and leads to more ex- tensive defects than when it occurs around teeth.9 Accordingly, pre- ventative care is advised even be- fore implant treatment. This means untreated periodonti- tis patients have an increased risk of peri-implant inf lammation through to implant loss.10 The risk is also higher when patients who are initially treated are not included in a supportive periodontitis treat- ment/recall programme.11 Leading periodontists there- fore recommend carrying out a screening procedure before im- plant treatment using, for exam- ple, the periodontal screening index or periodontal screening and re- cording.12 Bleeding on probing and pocket depths are determined at selected positions. An extensive check of the periodontal status should be carried out if the results are abnormal.13 Taking a careful medical his- tory, including previous systemic exposure, is also important.13 This provides important information about increased risk of inflamma- tion, for example in patients with diabetes that is not being optimally managed.14 Furthermore, patients should be informed of the risks relating to implants. Where necessary, initial peri- odontal treatment is carried out. First, professional tooth cleaning establishes healthy gingival condi- tions. In this procedure, calculus (Fig. 1) and biofilm (Fig. 2) are re- moved as far as the gingival sulcus. In combination with careful in- struction on oral hygiene, this gives the patient the basis for long-term freedom from inflammation.15 Determining risks and providing periodontal treatment Periodontitis is a key risk fac- tor for peri-implant inflammation. Removal of subgingival coat- ings (debridement) is carried out using sonic or ultrasonic devices and special periodontal tips as ini- tial periodontal treatment (Fig. 3). Manual instruments can also be used. Further surgical and/or re- generative measures may be nec- essary, depending on the situation. Periodontal aftercare for long-term success In the periodontal aftercare subsequent to implantation, soft (biofilm) and hard coatings are regularly professionally and me- chanically removed.16, 17 In the sub- gingival and supragingival areas, ultrasonic devices are generally used for this (Fig. 4), in combina- tion with manual instruments where necessary. Alternatively, subgingival air polishing can be used in combination with peri- odontal attachments and powders.18 Checking for individual risk factors, such as smoking and dia- betes, and working towards a healthy lifestyle are also recommended for a good long-term prognosis after periodontitis treatment.13, 19 If the patient had severe periodontitis before the initial treatment, the re- call frequency will be increased ac- cordingly, partially to prevent peri-implant inflammation.20 Proactive implant treatment If the patient has received good preventative treatment and where necessary has received prelimi- nary periodontal treatment, im- plant treatment can be planned. A suboptimal implant-supported prosthesis increases the likelihood of biofilm forming.21 In order to avoid this, the correct implant po- sition, sufficient distances from adjacent teeth and an ideal axial alignment should be considered during the planning phase. A suf- ficiently sized bone site and soft tissue that is well supplied with blood are needed for successful implant healing and a good long- term prognosis. Prior or simulta- neous augmentation may be needed to achieve this. In contrast to this, the time at which the implant is inserted and the treatment is pro- vided plays a less significant role.22, 23 In order to support predictable and stable implant treatment, it is also necessary to prepare the im- plant bed using suitable methods and equipment. This can be achieved using high-performance implan- tology motors in combination with surgical contra-angle handpieces. Using a low speed and an ample supply of sterile cooling fluid is es- sential during preparation.24 Oth- erwise, the bone can overheat and affect the healing process. Alternatively, the implant bed can be prepared with piezo-surgi- cal systems, for which special sets of instruments are available.25 Bone can be worked on in a gentle yet highly effective manner using other special instruments. Indications include alveolar ridge splitting, sur- gical tooth removal, and the prepa- ration of bone blocks or lateral win- dows for augmentation.26 Highly advanced piezo-surgical devices are also minimally invasive in soft tissue. Stability measurement and bone surgery Once the implant has been screwed into its final position, the primary stability can be safely and precisely determined using reso- nance frequency analysis. The tech- nology is available either separately or as an optional module in an im- plantology motor. If the ISQ (Im- plant Stability Quotient) value mea- sured is 66 or higher, early inter- vention is possible, and if it is over 70, treatment must be provided immediately.27 An exposure protocol based on the ISQ value improves the prog- nosis of treatment. Simply mea- suring the torque resistance, how- ever, does not provide the same level of clinical safety.28 If reduced ISQ values are measured after the implant has been inserted, a two- phase protocol is generally chosen. After exposure, a new measure- ment can then be used to deter- mine whether osseointegration has been successful (secondary stability) and loading will be pre- dictable at this point.29 Hygiene-friendly prostheses The emergence region should be designed to ensure that it is at- raumatic to the tissue for long-last- ing implant restorations. The im- plant–abutment connection, ma- terial, surface and emergence pro- file must be biocompatible and mechanically resilient over the long term. The transgingival com- ponents should also be accessible for individual and professional cleaning and for probing.20 Definitively integrating abut- ments or other components at im- plant level immediately (“one abut- ment, one time”) has also proved to be effective.30 In combination with good hygiene and correspond- ingly healthy tissue, this concept can probably be used to achieve a more stable attachment of the im- plant to the oral cavity than if the components have to be replaced several times - a requirement for peri-implant health. 1 3 2 4 5 Fig. 1: Calculus removal using an ultrasound (W&H Tigon (+) with a 3U tip) is a key part of professional tooth cleaning. (Photograph: W&H) Fig. 2: Rotary cleaning with prophylaxis polishing cups and brushes (W&H Proxeo prophylaxis contra-angle handpiece) ensures smooth surfaces on teeth. It enables patients to check biofilm effectively at home. (Photograph: W&H) Fig. 3: If marginal periodontitis is diagnosed, the initial debridement can be carried out very efficiently with an air scaler (sonar technology, W&H Proxeo with 1AP tip). (Photograph: W&H) Fig. 4: Ultrasound devices are particularly suitable for UPT, for example in combination with periodontal tips (W&H Tigon (+) with 1P tip). (Photograph: W&H) Fig. 5: Implants and suprastructures are routinely cleaned, for example using ultrasound devices and special plastic instruments (W&H Tigon (+) with 1I tip). (Photograph: W&H)