PUBLISHED IN DUBAI www.dental-tribune.me November-December 2018 | No. 6, Vol. 8 Implants should only be inserted when periodontal conditions are stable SUBSCRIBE NOW https://me.dental-tribune.com/e-paper/ 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 nec- essary, treatment help in patients with this problem. The W&H No Implantology without Periodontol- ogy workﬂow 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 signiﬁcantly improve quality of life after tooth loss.1,2 The long-term prognosis is generally good, but biological com- plications are common.3 Peri-im- plantitis and its preliminary stage, mucositis, occur in a substantial pro- portion of patients.4 As is the case for periodontitis and gingivitis, oral bio- ﬁlm is the main cause.5,6 This micro- bial biocoenosis can also encourage the development of severe systemic disease in the event of pathological changes, such as endocarditis and inﬂammatory bowel disease.7 The only difference in the micro- bial ﬂora in periodontitis and peri- implantitis is in the detail.8 Com- pared 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 extensive defects than when it occurs around teeth.9 Accordingly, preventative care is advised even before implant treat- ment. Determining risks and pro- viding periodontal treatment Periodontitis is a key risk factor for peri-implant inﬂammation. This means untreated periodontitis pa- tients have an increased risk of peri- implant inﬂammation through to implant loss.10 The risk is also higher when patients who are initially treat- ed are not included in a supportive periodontitis treatment/recall pro- gramme.11 Leading periodontists therefore rec- ommend carrying out a screening procedure before implant treatment using, for example, the periodon- tal screening index or periodontal screening and recording.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 re- sults are abnormal.13 Taking a careful medical history, in- cluding previous systemic exposure, is also important.13 This provides im- portant information about increased risk of inﬂammation, for example in patients with diabetes that is not being optimally managed.14 Further- more, patients should be informed of the risks relating to implants. Where necessary, initial periodontal treatment is carried out. First, pro- fessional tooth cleaning establishes healthy gingival conditions. In this procedure, calculus (Fig. 1) and bio- ﬁlm (Fig. 2) are removed as far as the gingival sulcus. In combination with careful instruction on oral hygiene, this gives the patient the basis for long-term freedom from inﬂamma- tion.15 Removal of subgingival coatings (de- bridement) is carried out using sonic or ultrasonic devices and special periodontal tips as initial periodon- tal treatment (Fig. 3). Manual instru- ments can also be used. Further sur- gical and/or regenerative measures may be necessary, depending on the situation. Periodontal aftercare for long-term success In the periodontal aftercare sub- sequent to implantation, soft (bio- ﬁlm) and hard coatings are regularly professionally and mechanically removed.16,17 In the subgingival and supragingival areas, ultrasonic de- vices are generally used for this (Fig. 4), in combination with manual in- struments where necessary. Alterna- tively, subgingival air polishing can be used in combination with peri- odontal attachments and powders.18 Checking for individual risk factors, such as smoking and diabetes, and working towards a healthy lifestyle are also recommended for a good long-term prognosis after periodon- titis treatment.13,19 If the patient had severe periodontitis before the initial treatment, the recall frequency will be increased accordingly, partially to prevent peri-implant inﬂamma- tion.20 treatment, Proactive implant treatment If the patient has received good preventative treatment and where necessary has received preliminary periodontal implant treatment can be planned. A subop- timal implant-supported prosthesis increases the likelihood of bioﬁlm forming.21 In order to avoid this, the correct implant position, sufﬁcient distances from adjacent teeth and an ideal axial alignment should be con- sidered during the planning phase. A sufﬁciently sized bone site and soft tissue that is well supplied with blood are needed for successful im- plant healing and a good long-term prognosis. Prior or simultaneous augmentation may be needed to achieve this. In contrast to this, the time at which the implant is inserted and the treatment is provided plays a less signiﬁcant role.22,23 In order to support predictable and stable implant treatment, it is also necessary to prepare the implant bed using suitable methods and equipment. This can be achieved us- ing high-performance implantology motors in combination with surgical contra-angle handpieces. Using a low speed and an ample supply of ster- ile cooling ﬂuid is essential during preparation.24 Otherwise, the bone can overheat and affect the healing process. 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 sur- faces on teeth. It enables patients to check bioﬁlm effectively at home. (Photograph: W&H) Alternatively, the im- plant bed can be pre- pared with piezo-surgi- cal systems, for which special sets of instru- ments are available.25 Bone can be worked on in a gentle yet highly effective manner us- ing other special in- struments. Indications include alveolar ridge splitting, surgical tooth removal, and the prep- aration of bone blocks or lateral windows for augmentation.26 Highly advanced piezo-surgical devices are also mini- mally 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 resonance fre- quency analysis. The technology is available either separately or as an optional module in an implantology motor. If the ISQ (Implant Stability Quotient) value measured is 66 or higher, early intervention is possible, and if it is over 70, treatment must be provided immediately.27 An exposure protocol based on the ISQ value improves the prognosis of treatment. Simply measuring the torque resistance, however, 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 measurement can then be used to determine whether osseointegra- tion has been successful (secondary stability) and loading will be predict- able at this point.29 Hygiene-friendly prostheses The emergence region should be de- signed to ensure that it is atraumatic to the tissue for long-lasting implant restorations. The implant–abutment connection, material, surface and emergence proﬁle must be biocom- patible and mechanically resilient over the long term. The transgin- ÿPage D2 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)
D2 ◊Page D1 gival components should also be accessible for individual and profes- sional cleaning and for probing.20 Deﬁnitively integrating abutments or other components at implant lev- el immediately (“one abutment, one time”) has also proved to be effec- tive.30 In combination with good hy- giene and correspondingly healthy tissue, this concept can probably be used to achieve a more stable attach- ment of the implant to the oral cav- ity than if the components have to be replaced several times - a require- ment for peri-implant health. Whether it is with crowns, bridges, partial or complete prostheses, the implant-supported superstructure should be designed so that the pa- tient can maintain it without any difﬁculty.20 Additionally, a distance of at least 2 mm between the bone and the mucosal edge of the prosthe- sis appears to be advised to prevent infection and subsequent bone loss.31 Peri-implant aftercare Experts recommend treatment im- mediately after the initial occur- rence of symptoms of inﬂammation to avoid peri-implant bone loss from the start.20 Mucositis affects almost half of all implants, and since pa- tients often have several implants, it occurs in a high percentage of pa- tients.32 The prophylactic or perio- dontal recall programme established after the implant has been inserted should therefore be continued.20,33 At-home oral hygiene should be carefully tailored to the new pros- thesis and the patient accordingly instructed on this.34 In combination with professional bioﬁlm manage- ment, good preventative efﬁcacy can be achieved in this way.35 The risk of peri-implantitis decreases from 43.9 per cent (no recall) to 18.0 per cent if a patient receives a recall appointment carried out carefully each year, in other words by more than half.36 Ultrasonic systems with special instruments that do not af- fect the materials are suitable for this, such as those made of PEEK (Fig. 5), or appropriate manual instru- ments.37 recall Mechanically preventing mucositis As for periodontitis patients, peri- implant regular screening with a clinical check of both periodontal and peri-implant tissue for symptoms of inﬂamma- tion, probing and, where necessary, radiographic diagnosis.9 A frequen- includes IMPLANT TRIBUNE Dental Tribune Middle East & Africa Edition | 6/2018 and professional bioﬁlm manage- ment where possible for every pa- tient. Ideally, this preventative workﬂow should start well before each restora- tive measure, before periodontitis can develop. It is essential if implant prosthetic treatment is planned or has already been integrated. Patients will be pleased with the long-term success of the treatment and will be pleased to return to a practice or clinic they trust. Editorial note: A list of references and information is available from the publisher by scanning this QR code using your mobile phone. More in- formation can be found at niwop. wh.com. cy of two to four times a year has proved to be effective.17 Deep prob- ing values and bleeding occur more commonly in patients with peri- implantitis than in those with mu- cositis; pus secretion only occurs in patients with peri-implantitis.38 If a patient has mucositis, profes- sional supragingival and subgingival bioﬁlm removal reduce the risk of the inﬂammation advancing to peri- implantitis. Local and systemic anti- biotics used as supportive measures or air polishing, however, show no additional beneﬁt.20,39 Treating peri-implantitis Peri-implant bone loss can develop even if good preventative care is pro- vided, for example if the patient’s oral hygiene is not sufﬁcient. Most minimal defects should be treated in a non-surgical manner using peri- implant debridement.37 Mechanical removal of coatings using suitable ultrasonic systems, supported by Er:YAG lasers, antibacterial photo- dynamic treatment, air polishing, or treatment with local or systemic antibiotics, where appropriate, has shown promising results.37 If closed treatment is no longer pos- sible, the defect must be surgically exposed and carefully decontami- nated. This is carried out after ﬂap preparation by removing inﬂamed tissue and cleaning the surface of the implant using, for example, ul- trasonic or piezo-surgical systems. Measures designed to regenerate the bone carried out after this procedure have been successful.40 Special pie- zosurgical instruments are available for the surgical treatment of peri- odontal defects. After treatment, the patient is once again intensively instructed on oral hygiene and made aware of the need for continual recall. If necessary, the frequency can be selected to be high- er than previously in line with peri- odontal aftercare. If bioﬁlm manage- ment is carried out consistently, the implantological results can remain stable for several years even after the periodontitis, mucositis or peri- implantitis has healed.33,39 No Implantology without Periodontology Successful implant treatment re- quires consistent, long-term preven- tative thinking. In each phase, this includes regular periodontal and peri-implant screening in combina- tion with individually tailored risk management, oral hygiene training Case report: Prosthetic procedure with Atlantis Anatomical shape, support and colour provided by the use of an Atlantis patient-speciﬁc abutment in gold-shaded titanium By Dr Fernando Rojas-Vizcaya & Mr Francisco Ortega, Spain Case 36 year-old patient with a vertical fracture of tooth 46. The treatment plan was to extract the tooth and replace it with a dental implant us- ing a conventional installation and loading protocol. The challenge was to restore the position of the gingival contour and the inter-proximal pa- pillae, as for a natural tooth. In order to achieve a long term natural result, an Atlantis Abutment was selected to provide the optimal anatomical shape, support and colour. Dr Fernando Rojas-Vizcaya, DDS, MS Department of Prosthodontics University of North Carolina, Chapel Hill, NC, USA Director of the Mediterranean Prostho- dontic Institute, Castellon, Spain www.prosthodontics.es Mr Francisco Ortega, CDT Labordent, Malaga, Spain Fig. 1: A vertical fracture of tooth 46. When probing, a distal narrow iso- lated pocket measuring more than 15 mm was detected. Fig. 2: In the radiograph, a radiolucency along the distal wall of the dis- tal root with the typical “J” shape seen in vertical root fractures could be observed. Fig. 3: Tooth extraction was performed without damaging the alveolar walls. The socket was scraped and sutured without using grafting mate- rial. Fig. 4: After 8 weeks of healing, the soft tissue over the extraction area was completely healed. Fig. 5: After 8 weeks, the amount of bone formation into the socket al- lowed for implant placement. Fig. 6: Using a surgical stent, the osteotomy could be performed in an ad- equate position in 3 dimensions, using the zenith of the cervical contour of the planned restoration as a reference point. ÿPage D3
Dental Tribune Middle East & Africa Edition | 6/2018 IMPLANT TRIBUNE D3 ◊Page D2 Fig. 7: The implant was placed 3 mm apical to the cervical contour of the planned restoration, symmetrically from mesial to distal, and 2 mm to the lingual in order to preserve the buccal bone that will support the soft tissue. Fig. 8: A 7 mm healing abutment was placed to guide the soft tissue to an optimal healing situation. Fig. 9: The healing abutment was removed after 6 weeks and a ﬁnal im- pression of the implant position and the shape of the soft tissue was sent together with the opposing model to the dental laboratory. Fig. 10: The Atlantis Abutment was virtually designed with the emer- gence width of the replaced molar and manufactured in titanium with a titanium nitride coating. Fig. 11: The Atlantis Abutment in gold-shaded titanium, together with the Atlantis abutment screw, was sent to the dental laboratory. Fig. 12: The subgingival portion of the abutment will give the anatomi- cal shape, support and color to the surrounding soft tissue. The ﬁnal crown restoration in zirconia was fabricated. Fig. 13: Final implant restoration with the ﬁnishing line close to the gin- gival margin, allowing for easy removal of excess cement in the subgin- gival area. The restoration was ready to be delivered to the patient. Fig. 14: The Atlantis Abutment was placed with some pressure of the soft tissue. After a few minutes, the ischemia disappeared and the abutment was seated in the correct position. Fig. 15: Veriﬁcation of correct seating of the abutment using a radio- graphic image. Note that the transitional portion of the abutment fol- lows the contour of the bone. Fig. 16: The Atlantis Abutment in gold-shaded titanium was torqued according to the implant manufacturer’s recommendation of 25 Ncm. The screw head was covered and the crown was later cemented to the abutment. Fig. 17: After 8 years, radiograph is showing a perfect ﬁt of the restora- tion, the spaces created for the inter-proximal papillae, and the position of the bone at the level of the implant. Fig. 18: After 8 years, a perfect adjustment of soft tissue around the resto- ration (buccal view) was observed, ﬁlling the space for the inter-proximal papillae and giving a natural position of the soft tissue contour. The evolution of the Neoss implant system: A retrospective follow-up of three patient cohorts treated with three types of Neoss implants This article reports on three patient cohorts with three types of Neoss implants. The retrospective analysis shows excellent long-term results with the Neoss implant system. The results also indicate that the introduction of the ProActive implant surface led to improved clinical outcomes in difﬁcult cases. By Dr Thomas Zumstein, Switzer- land & Dr Herman Sahlin, Sweden factors change together with the change of implant design. effect of implant design changes in a more controlled manner. Introduction The effect of dental implant design changes on the clinical outcome is usually difﬁcult to study in a struc- tured way. When comparing study data from different studies, several Here we have a clinical material where the same surgical protocol has been used by the same surgeon at the same clinic but with three genera- tions of Neoss implants. That gives us a unique opportunity to study the For each new generation of Ne- oss implants - i.e. Bimodal Straight, ProActive Straight and ProActive Ta- pered - the clinical outcome of the ﬁrst 50 consecutive patients treated in one private ofﬁce has been ret- rospectively analysed. Data on the Bimodal and the ProActive Straight patient groups have been published earlier.1,2 Materials and methods Patients This retrospective study analyses three patient cohorts consisting of the ﬁrst 50 consecutive patients treated with three types of Neoss dental implants (Neoss Ltd, Harro- gate, UK): • Bimodal Straight implants • ProActive Straight implants • ProActive Tapered implants ÿPage D4
Dental Tribune Middle East & Africa Edition | 6/2018 ◊Page D3 IMPLANT TRIBUNE D4 supracrestal with half of the collar above bone level. In the two Pro- Active cohorts, all implants were placed with the implant-abutment connection at bone level. Healing protocol Three different healing protocols were utilized: Two-stage healing, one-stage healing with delayed load- ing and immediate loading. Prosthetics Implants were restored with sin- gle crowns, partial bridges, ﬁxed full bridges, or overdentures (Figure 1). All restorations were fabricated using conventional prosthetic tech- niques on NeoLink abutments (Ne- oss Ltd). Frameworks were made of titanium or gold, and both porce- lain and acrylate were used as ve- neering materials. Bimodal 50 patients 183 implants Bone grafting 2003 2005 2010 2015 Implant surgeries 10 year follow-up 31 f 19 m 76 full jaw 79 partial 28 single GBR: 126 No GBR: 57 ProActive Straight 50 patients 159 implants Bone grafting 2005 2010 2015 Implant surgeries 5 year follow-up 28 f 22 m 37 full jaw 96 partial 26 single GBR: 91 No GBR: 68 ProActive Tapered 51 patients 101 implants Bone grafting 2005 2010 2015 Implant surgeries 3 year follow-up Fig. 1: Overview of studies 33 f 18 m 15 full jaw 50 partial 36 single GBR: 66 No GBR: 35 Bimodal ProActive Straight ProActive Tapered 100% 98.9% 98.5% 100% 100% 100% ) R S C ( e t a r l a v i v r u s e v i t a l u m u C 100% 95% 90% 85% 80% 98.2% 93.5% 100% 95% 90% 85% 80% 95% 90% 85% 80% 0 5 10 0 1 2 3 4 5 0 1 2 3 Follow-up (years) Follow-up (years) Follow-up (years) Fig. 2: Implant survival rates over time for the three study groups. The Bimodal GBR group showed lower survival rate than the other groups. Figure 2: Implant survival rates over time for the three study groups. The Bimodal GBR group showed lower survival rate than the 95% 90% 85% 80% No GBR GBR The Bimodal implant had a straight implant body with a blasted surface. The ProActive Straight implant has exactly the same implant geom- etries as the Bimodal implant, but with the blasted and etched hydro- philic ProActive implant surface. The ProActive Tapered implant has the same ProActive surface, the same prosthetic connection and cutting features as the ProActive Straight implants but with a tapered implant body. The patients were examined clini- cally and radiographically before treatment. They were thoroughly informed of the surgical and fol- low-up procedures and gave their written consent before treatment. All treatment steps were part of the routine procedures at the clinic, and no extra measures were taken for the cause of the study. The study was conducted in full accordance with ethical principles, including the World Medical Association Dec- laration of Helsinki. Surgical protocol Patients were given antibiotics (Da- lacin, 300 mg, Pﬁzer AG, Zurich, Switzerland) prior to the proce- dure, and the implant surgery was performed under local anaesthesia (Ultracain D-S Forte, Sanoﬁ-Aventis, Geneva, Switzerland). In cases of localized horizontal and vertical defects, a guided bone re- generation (GBR) procedure using BioOss and a resorbable BioGide membrane (Geistlich, Switzerland) was performed simultaneously with implant placement. Larger de- fects were treated using a staged GBR procedure. First, either an au- tologous bone block and a resorb- able membrane (BioGide) or a bone substitute material (BioOss) and a non-resorbable ePTFE membrane (Gore-Tex Regenerative Membrane, Gore Medical, Flagstaff, AZ, USA) were used. Implants were placed af- ter a healing period of 6 months. ePTFE membranes were removed in the same operation. In some cas- es, sinus ﬂoor augmentations were made simultaneous with implant placement either by the use of a se- ries of osteotomes or by using a lat- eral window technique. Flapped surgery was used. Implant sites were prepared and implants were placed in accordance with the manufacturer’s guidelines. Implant placement depth varied between the different treatment groups: In the Bimodal treatment cohort 59% of the implants were placed with the implant platform at bone level and 41% were placed ) m m ( l e v e l e n o b i l a n g r a M 0.5 1.0 1.5 Follow-up The patients were scheduled for annual check-ups with clinical and radiographic examination. Follow- up data was collected from the 1-, 3-, 5-, and 10-year visits. Survival analysis was performed, and marginal bone levels were measured from periapical radio- graphs. Mesial and distal bone lev- els were measured and an average was calculated. Baseline measure- ments were taken at time of im- plant placement for the ProActive groups and at time of prosthesis de- livery for the Bimodal group. Results Baseline data, treatment schedule and follow-up status for each treat- ment group is presented in Figure 1. In the Bimodal group, all followed patients have attended the 10 year check-up. In the ProActive Straight group, the patients have complet- ed the 5 year follow-up, and in the ProActive Tapered group, the 3 year follow-up is completed (Figure 1). Implant survival is shown in Fig- ure 2. In the Bimodal group, the cumulative survival rate after 10 years was 93.2% for augmented sites (8 implant failures) and 98.2% for non-augmented sites (1 failure). In the ProActive Straight group, the cumulative survival rate after 5 years was 98.5% for augmented sites (1 failure) and 98.9% for non- augmented sites (1 failure). In the ProActive Tapered group, no failures occurred, resulting in cumulative survival rates after 3 years of 100% for augmented sites as well as non- augmented sites. Marginal bone levels over time are shown in Figure 3. In the Bimodal group, the bone resorption from prosthesis delivery to 10 years was 0.4 ± 1.2 mm. In the ProActive Straight group, the bone resorption from implant placement to 5 years was 0.7 ± 0.6 mm. In the ProActive Tapered group, the bone resorption from implant placement to 3 years was 0.5 ± 0.6 mm. All groups showed stable bone lev- els after the ﬁrst year. None of the patients in any of the study groups showed any signs of peri-implantitis. Discussion The three patient cohorts were treat- ed according to the same clinical protocol. Hence, the groups were similar in gender distribution and percentage of sites requiring bone grafting. However, as clearly seen in Figure 1, the number of implants decreased for each new group. This most likely reﬂects a shift in the general implant population over time where the percentage of full arch restorations has decreased and the percentage of single crown res- toration has increased over the last 10-15 years. The results indicate excellent long- term clinical results with the Neoss implant system. The bone levels are maintained on a stable level after one year in all groups with an aver- age long-term bone level change in the Bimodal group between 5 and 10 years is less than 0.1 mm. The Bimodal implant showed lower survival rate in augmented sites (93.2% vs. 98.2%). No differ- ence in implant survival between augmented and non-augmented sites were seen for the ProActive implants. This indicates that im- plants with the ProActive surface experience less complications than implants with the Bimodal surface. This ﬁnding is in line with earlier studies showing that ProActive im- plants performed better than Bimodal implants when placed directly after total extraction of remaining teeth and loaded with a ﬁxed bridge within 3 days.3 No case of peri-implantitis was recorded in the studied patient population during the 3-10 years of follow-up. This is an interesting and encouraging ﬁnding. However, ad- ditional studies and larger patient populations are needed to establish whether this is due to the studied patient population, the surgical and prosthetic protocol, the meticulous follow-up schedule or the implant properties. In conclusion, the studies show ex- cellent long-term results with the Neoss implant system. The results also indicate that the introduction of the ProActive implant surface led to improved clinical outcomes in dif- ﬁcult cases. References 1. Zumstein T, Billstrom C, Sennerby L. A 4- to 5-year retrospective clini- cal and radiographic study of Ne- oss implants placed with or with- out GBR procedures. Clin Implant Dent Relat Res. 2012;14:480-90. 2. Zumstein T, Sennerby L. A 1-Year Clinical and Radiographic Study on Hydrophilic Dental Implants Placed with and without Bone Augmenta- tion Procedures. Clin Implant Dent Relat Res. 2016;18:498-506. 3. Andersson P, Degasperi W, Verroc- chi D, Sennerby L. A Retrospective Study on Immediate Placement of Neoss Implants with Early Loading of Full-Arch Bridges. Clin Implant Dent Relat Res. 2015;17:646-57. About the Authors Dr Thomas Zumstein Private Practice, Luzern, Switzerland Dr Herman Sahlin Neoss Ltd, Gothenburg, Sweden 0 2 4 6 8 10 Follow-up (years) ProActive Tapered ProActive Straight Bimodal Fig. 3: Marginal bone levels. All groups showed bone resorption less than 0.7 mm to the longest follow-up timepoint. The bone levels in the Bimodal group is lower than the other groups, partly due to differences in placement depth. A Neoss 4.0 mm straight implant is outlined to show the bone levels in reference to the implant collar.