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)