AVOIDING AND MANAGING DENTAL IMPLANT COMPLICATIONS · to successful implant surgery? ... 2...

AVOIDING AND MANAGING DENTAL IMPLANT COMPLICATIONSDentsplySironaWorld 2017 Jay B. Reznick, DMD, MD Diplomate, American Board of Oral and Maxillofacial Surgery Tarzana, CA

Dentsply Sirona (aka Sirona Dental, Inc.) is designated as an approved AGD PACE program provider by the Academy of General Dentistry. The formal continuing education programs of the program provider are accepted by the AGD for fellowship, mastership, and membership maintenance credit. Approval does not imply acceptance by state or provincial boards of dentistry, or AGD endorsement. The current term of approval extends from 8/1/15 – 7/31/18. Provider #: 306440

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AVOIDING AND MANAGING DENTAL IMPLANT COMPLICATIONS

OVERHEARD…

“If you are a dentist, and can drill a hole, then you can do

implants.” - Anonymous, DDS

4

UNDERSTANDINGTHE TECHNICIAN UNDERSTANDS “THE HOW”

THE DOCTOR ALSO UNDERSTANDS… “THE WHY … THE WHY NOT…

AND THE WHAT IF…”5

IT’S NOT ENOUGH JUST TO RECOGNIZE A PROBLEM…

6


“IMPLANTS ARE EASY!” “EVERYONE SHOULD BE PLACING THEM!”

7

8

DON’T FORGET THIS…IMPLANT SURGERY IS…

SURGERY9

PRIMUM NON NOCERE“FIRST DO NO HARM”

10

Anyone who says they never have complications either doesn’t do much surgery, or is a damn liar!!

AVOIDING AND MANAGING DENTAL IMPLANT COMPLICATIONS 11

HOW DO WE AVOID THE MOST COMMON COMPLICATIONS IN IMPLANT DENTISTRY?

•Meticulous and complete pre-operative evaluation •Understand the procedure’s requirements and limitations •Have more training than you need •Be 100% prepared to complete the procedure


DR. REZNICK…

▸ “What did I do wrong?”

STRATEGY•MENTALLY VISUALIZE THE PROCEDURE FROM START TO FINISH •ANTICIPATE WHAT INSTRUMENTS WILL BE NEEDED, AND HAVE THEM READY/ READILY AVAILABLE •ANTICIPATE COMPLICATIONS •HEADLIGHT, LOUPES •“MEASURE TWICE, CUT ONCE”

14

WHAT ARE THE BASIC REQUIREMENTS TO SUCCESSFUL IMPLANT SURGERY?•RELATIVELY HEALTHY PATIENT

‣Systemic disease ‣Smoker ‣Parafunction ‣SSRI

•COMPLIANT PATIENT •GOOD QUALITY BONE/ SOFT TISSUE

IN ADDITION TO GOOD QUALITY BONE, WE ALSO NEED:

SUFFICIENT BONE VOLUME

INSUFFICIENT BONE VOLUMEINADEQUATE BONE WIDTH

4 -0.4 mm 5 0 mm

INSUFFICIENT BONE VOLUME• INADEQUATE BONE HEIGHT • INADEQUATE BONE WIDTH

HOW MUCH BONE DO WE NEED SURROUNDING AN IMPLANT FIXTURE?•INADEQUATE BONE THICKNESS LEADS TO RESORPTION DUE TO COMPROMISED BLOOD SUPPLY •2 mm buccal (facial) •2 mm lingual (palatal)

• Qahash M, et al. Bone healing dynamics at buccal peri-implant sites. Clin Oral Implants Res. 2008 Feb;19(2):166-72. • Spray JR et al. The influence of bone thickness of facial bone response: stage 1 placement through stage 2 uncovering. Ann

Periodontal 5(1): 119-128, 2000

TISSUE CONSIDERATIONS

•TISSUE BIOTYPE •BIOLOGIC WIDTH

SOFT TISSUE BIOTYPES•THICK ‣FLAT BONY ARCHITECTURE ‣DENSE, FIBROTIC SOFT TISSUE ‣LARGE AMOUNT OF ATTACHED GINGIVA ‣PRONE TO POCKET FORMATION •THIN ‣SCALLOPED BONY ARCHITECTURE ‣DELICATE, FRIABLE SOFT TISSUE ‣THIN ATTACHED GINGIVA ‣PRONE TO GINGIVAL RECESSION

SOFT TISSUE BIOTYPES•THICK •MINIMAL RIDGE ATROPHY •BONE/GINGIVAL CONTOURS MORE PREDICTABLE •THIN •APICAL/LINGUAL RIDGE RESORBTION •BONE/GINGIVAL HEALING LESS PREDICTABLE

SOFT TISSUE BIOTYPES - SO WHAT?•THICK

RIDGE MAY NOT NEED PRESERVATION GRAFT IMMEDIATE IMPLANTS MORE PREDICTABLE

•THIN ATRAUMATIC EXTRACTION/ RIDGE PRESERVATION ESSENTIAL IMMEDIATE IMPLANTS LESS PREDICTABLE

BIOLOGIC WIDTH•MINIMUM DIMENSION OF SOUND TOOTH STRUCTURE BETWEEN THE RESTORATIVE MARGIN AND THE ALVEOLAR CREST.

•ACCOMMODATES THE CONNECTIVE TISSUE AND EPITHELIAL ATTACHMENT

BIOLOGIC WIDTHBiologic Width of Natural Tooth

1-2 mm Sulcus

1 mm Epithelial Attachment

1 mm Supra-Crestal Connective Tissue

Tissue Level at Placement

Biologic Width Established

Sulcus

Epithelial Attachment

Supra-Crestal Connective Tissue

KERATINIZED GINGIVA (KG)•BIOLOGIC WIDTH = CONNECTIVE TISSUE (1MM) + JUNCTIONAL EPITHELIUM (0.5 - 1.5MM) + SULCUS DEPTH

CTJES

BW1-2 mm

0.5 - 1 mm

1 mm

INADEQUATE KERATINIZED GINGIVA (KG)Violation of Biologic Width

KERATINIZED GINGIVA REQUIREMENTS•SIGNIFICANCE FOR DENTAL IMPLANTS:

✴ There must be a sufficient width and thickness of keratinized tissue around an implant.

•THIS VARIES FROM TOOTH TO TOOTH, BUT ABOUT 2MM IS A GOOD RULE OF THUMB.

“Since I have a CBCT-based surgical guide, does that mean that I can place the implant without a flap (tissue punch)?”

29AVOIDING AND MANAGING DENTAL IMPLANT COMPLICATIONS

IF YOU HAVE ENOUGH…•BONE •ATTACHED GINGIVA

ADEQUATE KG FOR PUNCH?•WHAT IF YOU ARE NOT SURE?

6 MONTH POSTOP

3D IMAGING- CBCTKNOWING THE PATIENT’S ANATOMY IN 3D IS CRITICAL TO:

• Accurate implant planning • Avoidance of complications • Long term implant success

IMPLANT SPACING/ POSITION•IDEALLY- - Parallel to adjacent teeth - Equally spaced between adjacent teeth - Aligned with occlusal tables of adjacent teeth

39

DISTANCE BETWEEN IMPLANTS

•TARNOW 2003 CLINICAL PERIODONTOLOGY, 11 ED.

HOW FAR APICALLY SHOULD THE CONTACT BE PLACED TO ENSURE COMPLETE FILL OF THE INTERDENTAL PAPILLA?• TARNOW DP, MAGNER AW, FLETCHERP: THE EFFECT OF DISTANCE FROM THE CONTACT POINT TO

THE CREST OF BONE ON THE PRESENCE OR ABSENCE OF THE INTERDENTAL PAPILLA. J PERIODONTOLOGY 1992; 63: 995-996

TARNOW 1992

•Contact points closer to bone crest are more predictable, but tooth form will look more square

DISTANCE IN MM FROM CONTACT POINT TO CREST TO BONE(N)3

(2)4

(11)5

(73)6

(112)7

(63)8

(21)9

(4)10 (2)

Papilla Present 2 11 72 63 17 2 1 0

Papilla Not Present

0 0 1 49 46 19 3 2

% Present 100 100 98 56 27 10 25 0

% Not Present 0 0 2 44 73 90 75 100

SALAMA 1998

•NOT BASED ON “PLATFORM-SWITCHED” IMPLANTS

Salama et al classification of predicted height of interdental papillae

Class Restorative Environment

Proximity Limitations

Vertical soft Tissue Limitations

1 Tooth-Tooth 1.0 mm 5.0 mm

2 Tooth-Pontic N/A 6.5 mm

3 Pontic-Pontic N/A 6.0 mm

4 Tooth-Implant 1.5 mm 4.5 mm

5 Implant-Pontic N/A 5.5 mm

6 Implant-Implant 3.0 mm 3.5 mm

IMPLANT SPACING GUIDELINES

• TARNOW DP, ET AL: THE EFFECT OF INTER-IMPLANT DISTANCE ON THE HEIGHT OF INTER-IMPLANT BONE CREST. J PERIODONTOLOGY 2000; 71:546-54

IMPLANT PLACEMENT IN THE ESTHETIC ZONE

“3-2 RULE”

Cooper LF. Objective criteria: guiding and evaluating dental implant esthetics. J Esthet Restor Dent. 2008;20(3):195-205.

MAINTENANCE OF INTERDENTAL PAPILLAE•THE MAXIMUM DISTANCE BETWEEN THE CRESTAL BONE AND THE CONTACT POINT SHOULD BE 4-5 MM IN ORDER TO MAINTAIN THE INTERDENTAL PAPILLAE FILLING THE EMBRASURE SPACE.

ANATOMICAL CONSIDERATIONS• MANDIBULAR NERVE • LINGUAL NERVE • MAXILLARY SINUSES • MYLOHYOID FOSSA


NERVE INJURY▸Nerve (IAN) injury - Drilling injury

▸ Drill extends 0.1 - 1.0 mm beyond fixture depth - Fixture injury

▸ Pressure on IAN ▸ Impingement on IAN

TOO LATE

PREVENTING IAN INJURY - 2MM SAFETY MARGIN

•2MM SAFETY MARGIN

SEDDON CLASSIFICATION➡NEUROPRAXIA •Blunt trauma or

stretching •Minor deficit •No loss of continuity

SEDDON CLASSIFICATION➡AXONOTMESIS •Nerve damaged

but not severed •Partial deficit

SEDDON CLASSIFICATION➡NEUROTMESIS •Nerve is severed •Axonal degeneration •Neuroma formation •May be painful - dysesthesia •Poor prognosis for resolution

NERVE INJURY PROTOCOL•DOCUMENT •DOCUMENT •DOCUMENT •FOLLOW CLINICAL PROGRESS •IF UNSURE, REFER

SOUTHERN CALIFORNIA CENTER FORORAL AND FACIAL SURGERY

PRELIMINARY NEUROLOGIC EXAM

Patient Name: _____________________________________ File #: ___________________ Date: _________________

Subj

Obj

Clinical Findings:Temperature (ice) + –Pain (pin prick- measure & diagram) + –

Pressure (pin prick, pinch reflex) + –Touch (brush) + –DirectionTwo Point Discrimination & Localization + – (normal = _______ mm) (test = ______ mm)Taste Sweet + – Salt + – Sour + – Bitter + –

Descriptive Findings:

Radiographs:

Comments:

Date of Surgery:Chief Complaint:

Subjective Symptoms:

Pt. given Nerve Injury Information sheet

Next F/U Visit:Consults:

NERVE INJURY PROTOCOL๏NEUROPRAXIA •Remove implant •Corticosteroids/ NSAIDs •May resolve in days to

weeks

๏AXONOTMESIS •Remove implant •Corticosteroids/ NSAIDs •Sensation returns in 2 - 6

months (0.1mm/d)

NERVE INJURY PROTOCOL๏NEUROTMESIS •Complete anesthesia >3 months •Consider surgery for continued anesthesia or dysesthesia

Dysesthesia:Neurontin (gabapentin)900-1200 mg TID

WITHOUT CT GUIDANCE•64 YEAR OLD WOMAN •MULTIPLE IMPLANTS PLACED •RIGHT LOWER LIP NUMB, PAINFUL (BURNING) •PERIAPICAL: #30 IMPLANT “CLOSE” TO MANDIBULAR NERVE

CT SCAN•IMPLANT FIXTURE WAS REMOVED •GABAPENTIN 300MG TID •PAIN IMPROVED OVER 6 MONTHS •GABAPENTIN TAPERED OFF •NERVE SENSATION IMPROVED 80%

ANATOMICAL CONSIDERATIONS•MANDIBULAR NERVE •Stay at least 2mm above canal •Watch anterior loop of mental nerve

BEWARE THE ANTERIOR LOOP

ANTERIOR LOOP OF MANDIBULAR NERVE•GREENSTEIN G AND TARNOW D. •THE MENTAL FORAMEN AND NERVE: CLINICAL

AND ANATOMICAL FACTORS RELATED TO DENTAL IMPLANT PLACEMENT: A LITERATURE REVIEW. J PERIODONTAL 77(12), P 1933-1943, 2006


RESULTS/ CONCLUSIONS

•Mental foramen location can vary from canine —1st molar

•CT scan more accurate than conventional radiographs •Incidence ranges between 0 - 88% •2mm “safety zone” should be kept from mandibular

nerve

GREENSTEIN G AND TARNOW D. J PERIODONTAL 77(12), P 1933-1943, 2006

LINGUAL NERVE•VERY VARIABLE LOCATION •MAY BE ABOVE OR BELOW THE MYLOHYOID MUSCLE •AVOID LINGUAL RETRACTION AND INSTRUMENTATION

MYLOHYOID FOSSA


SOFT TISSUE BLEEDING


BLEEDING FROM BONE•PLACE IMPLANT •IF DURING GRAFTING ➡APPLY PRESSURE


LOCAL MEASURES TO CONTROL BLEEDING

▸ Gauze pressure ▸ Pack site- gelatin sponge

(Gelfoam), absorbable oxycellulose (Surgicel)

▸ Topical thrombin ▸ Bone wax ▸ Local anesthetic

“ALL BLEEDING EVENTUALLY STOPS!”

71AVOIDING AND MANAGING DENTAL IMPLANT COMPLICATIONS

ANATOMICAL CONSIDERATIONSMAXILLARY SINUSES

•LIGHTEN SKULL •WARM, MOISTEN AIR •PNEUMATIZE AFTER EXTRACTIONS

ANATOMICAL CONSIDERATIONS•MAXILLARY SINUSES: •“NORMAL” VS. “PATHOLOGICAL” PATHOLOGY •PENETRATING THE SINUS FLOOR

SINUS FLOOR VIOLATION

SINUS FLOOR VIOLATION

THIS IS A PROBLEM…

MAXILLARY BONE REQUIREMENT•NEED AT LEAST 5MM OF SOLID BONE AT FLOOR OF SINUS TO STABILIZE FIXTURE •SINUS LIFT FIRST

NASOPALATINE DUCT

DAMAGE TO ADJACENT TEETH

DAMAGE TO ADJACENT TEETH•IF MINOR - WATCH •ENDODONTIC TREATMENT •IMPLANT REMOVAL

SINUSITIS•AUGMENTIN 875MG BID X 14 DAYS •OTC ANTIHISTAMINES- CLARITIN, ALLEGRA •OTC NASAL STEROIDS- FLONASE, NASACORT

SINUSITIS•IF ALLERGIC TO AUGMENTIN (PCN) - Cipro (ciprofloxacin) 500 mg BID - Cleocin (clindamycin) 300 mg QID - Biaxin (clarithromycin) 500 mg BID

SINUSITIS• IF SINUSITIS FAILS TO RESOLVE:

➡ REMOVE IMPLANT ➡ DEBRIDE GRAFT (CALWELL-LUC)

• SURGICAL EVALUATION (ENT OR OMFS) IF PERSISTENT

TOOTH MOVEMENT•USE A SPACE MAINTAINER

- ESSIX BRIDGE - BONDED BRIDGE - STAYPLATE/ FLIPPER

•ORTHODONTIC EVALUATION IF SIGNIFICANT

•MAY RESULT IN REMOVAL OF TOOTH

TOOTH MOVEMENT•USE A SPACE MAINTAINER

- ESSIX BRIDGE - BONDED BRIDGE - STAYPLATE/ FLIPPER

•ORTHODONTIC EVALUATION IF SIGNIFICANT

•MAY RESULT IN REMOVAL OF TOOTH

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BROKEN ABUTMENT SCREW

BROKEN ABUTMENT SCREW•SALVIN IMPLANT RESCUE KIT

ASTRA TECH SCREW REMOVAL INSTRUMENTS

ASTRA TECH SCREW REMOVAL INSTRUMENTS

OTHER OPTIONS•ULTRASONIC - vibrate and loosen screw - back out with tip •COTTON APPLICATOR - break stick and engage screw - rotate counter-clockwise


CLINICAL FINDINGS WITH HEALTHY DENTAL IMPLANTS

▸ Firm pink peri-implant mucosa ▸ Shallow probing depths (≤ 3 mm) ▸ Absence of bleeding on probing ▸ Absence of purulence or suppuration ▸ Non-responsive to percussion ▸ High-pitched resonance with percussion ▸ Maintenance of bone level to 1st thread of

fixture

Vered Y, et al. Teeth and implant surroundings: clinical health indices and microbiologic parameters. Quinessence Int 42(4): 339-344, 2011

PERI-IMPLANT MUCOSITIS AND PERI-IMPLANTITIS

•DENTAL IMPLANTS ARE NOT SUSCEPTIBLE TO CARIES

•BUT THEY ARE SUSCEPTIBLE TO SOFT TISSUE INFLAMMATORY PROBLEMS, JUST LIKE NATURAL DENTITION

•CAN RESULT IN LOSS OF IMPLANTS

PERI-IMPLANT MUCOSITIS• 32 - 80% incidence • Inflammation during healing or in

function • BoP, ± suppuration • Probing depths up to 4mm • Biofilm harboring bacteria (Gram -

anaerobes) • Reversible inflammatory changes • No bone loss

Ziltman NU, Berglund T. Definition and prevalence of peri-implant disease. J Clin Periodontol 35(8):286-291, 2008


RISK FACTORS FOR PERI-IMPLANT MUCOSITIS AND PERI-IMPLANTITIS▸ Previous periodontal disease ▸ Poor plaque control/ inability to clean ▸ Smoking ▸ Genetic factors ▸ Diabetes ▸ Occlusal overload

▸ Residual cement

AAP Task Force on Peri-Implantitis. Peri-Implant Mucositis and Peri-Implantitis: A current Understanding of Their Diagnoses and Clinical Implications. J Periodontol 84(4): 436-443, 2013.


MANAGEMENT - FIRST 8 WEEKS•Avoid manipulating implant fixture for the first 6 weeks of integration

➡Light debridement

➡Chlorhexidine irrigation/ rinse

•Infected- antibiotics ➡amoxicillin

➡cephalosporin

➡clindamycin


MANAGEMENT AFTER 8 WEEKS•Elimination of biofilm from the implant surface is primary goal ➡Irrigation device

➡Chlorhexidine irrigation/ rinse

•Infected- antibiotics ➡amoxicillin

➡cephalosporin

➡clindamycin


SODIUM HYPOCHLORITE IRRIGATION▸ Oral rinse with 0.05% sodium hypochlorite resulted in significant reductions in

supragingival biofilm accumulation and gingival inflammation - De Nardo R, et al. Effects of 0.05% sodium hypochlorite oral rinse on supragingival biofilm and gingival

inflammation. Int Dent J 62(4): 208-212, 2012

▸ Twice-weekly oral rinsing with 0.25% sodium hypochlorite produced a significant reduction in bleeding on probing, even in deep unscaled pockets - Gonzales S, et al. Gingival bleeding on probing: a relationship to change in periodontal pocket depth

and effect of sodium hypochlorite oral rinse. J Periodontal Res 50(3): 387-402, 2015

▸ Sodium hypochlorite, hydrogen peroxide, chlorhexidine and Listerine showed a significant bactericidal effect against adhering bacteria - Gosau M, et al. Effect of six different peri-implantitis disinfection methods on in vivo human oral biofilm.

Clin Oral Impl Res 21(8): 866-872, 2010

PERI-IMPLANTITIS•10 - 40% INCIDENCE •INFLAMMATORY PROCESS •BIOFILM HARBORING PATHOLOGIC BACTERIA ‣TITANIUM AND ZIRCONIUM ABUTMENTS

SIMILARLY COLONIZED •IMPLANT IN FUNCTION •BONE LOSS

Rosen P, et al. Peri-implant mucositis abd peri-implantitis: a current understanding of their diagnoses and clinical implications. J Periodontol 84(4): 436-4443, 2013

PERI-IMPLANTITIS•Most commonly associated with implant-

supported overdentures •Incidence 11-32% (fixed 7-20%) • ARDEKIAN L, DODSON TB, COMPLICATIONS ASSOCIATED WITH THE PLACEMENT

OF DENTAL IMPLANTS; ORAL MAXILLOFACIAL CLINICS N AM15 (2003) 243-249

A MULTIFACTORIAL ANALYSIS TO IDENTIFY PREDICTORS OF IMPLANT FAILURE AND PERI-IMPLANT BONE LOSS

•TO IDENTIFY PREDICTORS OF IMPLANT FAILURE AND PERI-IMPLANT BONE LOSS

! RETROSPECTIVE COHORT, 376 PATIENTS WITH 1320 OSSEOSPEED IMPLANTS

! AT LEAST 2 YEARS FOLLOW-UP (24-65 MONTHS) ! STATISTICAL ANALYSES, AT A LEVEL OF SIGNIFICANCE OF 0.05 • - MULTIVARIATE ANALYSIS (COX PROPORTIONAL HAZARDS REGRESSION)

Aim

Vervaeke S, Collaert B, Cosyn J, Deschepper E, De Bruyn H.

Clin Implant Dent Rel Res 2013;E-pub Sep 4, doi:10.1111/cid.12149

Materials

&

Methods


SURVIVAL BONE LOSS

TREATMENT PROTOCOL NS NS • SMOKING STATUS P =0.001 P <0.001 • IMPLANT DESIGN NS NS • RECONSTRUCTION NS NS • TREATED JAW NS P <0.001 • OPPOSING JAW STATUS NS NS • RECALL COMPLIANCE P = 0.010 NS

Multivariate analysis

Results ➢ Cumulative implant survival 96.8% on patient level

➢ Mean bone loss 0.36 mm (SD ±0.68)

Results: Risk factors for bone loss were: - Being a smoker - Having an implant in the maxilla

Risk factors for implant failure were: - Being a smoker - High recall compliance (patients who experienced an implant failure of one of their implants were more prone to check their oral status than patients not having experienced any failures)

➢ Implant related factors did not affect marginal bone loss or implant survival ➢ Being a smoker was associated with implant failures and bone loss ➢ Implant in the maxilla was associated with more bone loss

Conclusion:



SELECTIVE SEROTONIN REUPTAKE INHIBITORS AND THE RISK OF OSSEOINTEGRATED IMPLANT FAILURE▸ SSRIs: Antidepressant- Prozac, Zoloft, Celexa, Paxil ▸ SSRIs reduce bone formation and increase risk of fracture ▸916 implants in 490 patients (94 implants in 51 patients on SSRSs) ▸ SSRI usage associated with an increased risk of dental implant

failure (10.6% vs. 4.6%) ▸ Implant diameter <4mm and smoking further increased the risk in

both groups

WU ET AL- J DENT RES 2014(11) NOV:1054-61


RISK FACTORS FOR IMPLANT FAILURE

▸ Smoking negatively affects healing and the outcome of implant treatment. - Chrcanovic BR, Albrektsson T, Wennerberg A. Smoking and dental implants:

a systematic review and meta-analysis. J Dent 43(5): 487-498, 2015.

▸ Smoking and antidepressant use were statistically significant predictors of implant failure

- Chrcanovic BR, et al. Factors influencing early dental implant failures. J Dent Res 95(9): 995-1002, 2016

PERI-IMPLANTITIS•MINOR •Scale with titanium

curette •Home irrigator/ HClO

•Intrasulcular antibiotics

EXPOSED FIXTURE- Expect further

exposure as inflammation reduces

- Pocket depth improves - May be maintainable

for long term

MODERATE PERI-IMPLANTITIS•Further radiographic bone

loss/ pocketing •Increased probing depths •Bleeding on probing •Gingival erythema •Purulent drainage •Gram - anaerobes •No mobility

PERI-IMPLANTITIS•Surgical debridement •Citrate, CHX •Bone graft •Infuse (rBMP) •Barrier membrane -

PerioDerm •Primary closure

CEMENT SEPSIS•MANAGED LIKE PERI-IMPLANTITIS •CEMENT MUST BE COMPLETELY DEBRIDED •BEST TO AVOID- KEEP MARGINS ≤ 1MM SUBGINGIVAL


CAN AN IMPLANT HAVE A PERIAPICAL LESION?

▸ Inactive - probable apical scar from osteotomy longer than implant

▸ Infected - Implant placed in proximity to focus of infection

- Contaminated implant was placed

Reiser GM, Nevins M. The implant periodical lesion: etiology, prevention, and treatment. Compend Contin Educ Dent 16(8): 768-772, 1995



SUCCESS RATES OF OSSEOINTEGRATION FOR IMPLANTS PLACED UNDER STERILE VERSUS CLEAN CONDITIONS Tarnow D, J Periodontol 1993 Oct;64(10)954-6

▸ Retrospective study ▸ “Sterile” - 61 pts/ 273 implants - OR/ strict sterile protocol

▸ “Clean” - 31 cases/ 113 implants - Clinic setting

▸ Evaluated at Stage 2 ▸ Sterile group: 98.9% implant success/ 95.1% case success

▸ Clean group: 98.2% implant success/ 93.5 case success

▸ No statistical difference between study groups ▸ Implant surgery can be performed under “clean” conditions


IT DOESN’T REALLY MAKE A DIFFERENCE UNLESS YOU TOUCH OUTSIDE OF THE ASEPTIC FIELD

▸ So, if you are new to surgery, maintaining a “OR sterile” environment is a good insurance policy

J Oral Maxillofac Surg 1996


CAN AN IMPLANT HAVE A PERIAPICAL LESION?

▸ Inactive - probable apical scar from osteotomy longer than implant

▸ Infected - Implant placed in proximity to focus of infection

- Contaminated implant was placed

- Bony necrosis due to overheating

Reiser GM, Nevins M. The implant periodical lesion: etiology, prevention, and treatment. Compend Contin Educ Dent 16(8): 768-772, 1995

DRILLING FOR SUCCESS•IT IS CRITICAL THAT THE BONE BE RESPECTED WHEN PREPARING THE IMPLANT OSTEOTOMY SITES. THIS MEANS: •Light pressure on the drill •Slowest drilling speed for the job •Drill speed decreases as drill diameter increases

120

•HIGHER DRILL SPEED IS MORE EFFICIENT AND ACTUALLY CAUSES LESS HEAT GENERATION.

•INCREASING SPEED AND LOAD TOGETHER DOES NOT INCREASE HEAT GENERATION.

•SHARAWY M, MISCH CE, ET AL. HEAT GENERATION DURING IMPLANT DRILLING: THE SIGNIFICANCE OF MOTOR SPEED. JOMS 60 (10), 1160-1169, 2002. •BRISMAN DL. THE EFFECT OF SPEED, PRESSURE, AND TIME ON BONE TEMPERATURE DURING THE DRILLING OF IMPLANT SITES. INT J OMF IMPLANTS 11(1), 35 - 37, 1996. •ABOUZGIA NB, SYMINGTON JM. EFFECT OF DRILL SPEED ON BONE TEMPERATURE. INT J ORAL MAXILLOFAC SURG 1996; 25:394-399.

121

INTERMITTENT VERSUS CONTINUOUS DRILLING•CONTINUOUS DRILLING RESULTS IN HIGHER TEMPERATURES IN BONE DUE TO: • CLOGGING EFFECT OF BONE DEBRIS • INABILITY OF IRRIGATION TO REACH SITE

•DECREASES CUTTING EFFICIENCY AND INCREASES TIME REQUIRED

✴ WATCHER R, STOLL P. INCREASE IN TEMPERATURE DURING OSTEOTOMY. IN VITRO AND IN VIVO INVESTIGATIONS. INT J ORAL MAXILLOFAC SURG 1991; 20: 245-249.

122

IMPLANT DRILLING SPEEDSTISSUE PUNCH: OSTEOTOMIES:

THREAD TAPPING: IMPLANT DELIVERY:

COVER SCREW/ABUTMENT:

800 rpm 1200 - 1500 rpm 15 - 50 rpm/ 45 Ncm 15 - 50 rpm/ 35 - 45 Ncm 10 - 15 rpm/ 10 -20 Ncm

123

DRILL SHARPNESS

•Matthews LS, Hirsch C. Temperatures measured in human cortical bone when drilling. J Bone Joint Surg 1972;54:297–308. •Yacker M, Klein M. The effect of irrigation on osteotomy depth and bur diameter. Int J Oral Maxillofac Implants 1996;11:634–638. • Andrianne Y, Wagenknecht M, Donkerwolcke M, Zurbuchen C, Burny F. External fixation pin: An in vitro general investigation. Orthopedics 1987;10:1507–1516. •Sutter F, Krekeler G, Schwammerger AE, Sutter FJ. Atraumatic surgical technique and implant bed

A sharp drill creates less heat!

124

IMPLANT PERIAPICAL LESION•IF INFECTED, REQUIRES SURGICAL INTERVENTION - If not mobile: apical resection

and debridement - If mobile: removal and grafting

Penarrocha-Diago M, et al. Implant periodical lesion: diagnosis and treatment. Oral Med Oral Path Oral Surg 17(6): 1023-1027, 2012


IMPLANT PERIAPICAL LESION








SALVAGE OF AN AILING IMPLANT▸ The fixed dental prosthesis supported by the implant does not require

replacement unless the implant is removed ▸ Esthetics is not a factor ▸ Adequate access for peri-implantitis treatment is available ▸ The implant is causing an esthetic problem that can be predictably treated by

surgical and/or prosthetic means (excludes poor implant placement) ▸ Removal cannot be done by reverse torquing the fixture (would require trephine

or drill) ▸ The patient has psychological or emotional attachment to the implant ▸ Financial considerations are an issue

Tarnow DP, Chu SJ, Fletcher PD. Clinical decision: Determining when to save or remove an ailing implant. CDE World April 2016


▸ The fixed dental prosthesis supported by the ailing implant requires replacement

▸ The implant is causing an esthetic problem that cannot be predictably treated by surgical or prosthetic means (includes poor implant placement)

▸ There is existing attachment loss in combination with poor position ▸ The implant can be reverse torqued out with out damaging the surrounding

periodontium and adjacent teeth ▸ Prosthetic components are no longer manufactured for the specific existing

implant system

Tarnow DP, Chu SJ, Fletcher PD. Clinical decision: Determining when to save or remove an ailing implant. CDE World April 2016

REMOVAL OF AN AILING IMPLANT


FAILING IMPLANT•Refractory to treatment •Continues to get worse ‣Bone loss progresses ‣Continued suppuration ‣Continued pain ‣Mobility

IMPLANT FAILURE

PROTOCOL•CHLORHEXIDINE RINSE- BID •AMOXICILLIN 875MG BID •START 2 DAYS PRIOR •CONTINUE 5 DAYS POST-OP


RITZER J., ET AL. NATURE COMMUNICATIONS 8:264, AUG 15, 2017

▸ Standard testing: matrix metaloproteins (MMP-8) in sulcular fluid in peri-implant pockets

▸ Developed a chewing gum test for peri-implantitis - Attached bitter peptide denatonium fragment

to chewing gum - MMP-8 cleaves off denatonium, resulting in a

bitter taste - Intensity of bitterness related to level of MMP-8

▸ Good correlation between home chewing gum test and chair side sulcular fluid assay

ARTICLE

Diagnosing peri-implant disease using the tongueas a 24/7 detectorJ. Ritzer1, T. Lühmann1, C. Rode2, M. Pein-Hackelbusch3, I. Immohr3, U. Schedler4, T. Thiele4, S. Stübinger5,

B.v. Rechenberg5, J. Waser-Althaus6, F. Schlottig6, M. Merli7, H. Dawe7, M. Karpíšek8, R. Wyrwa2,

M. Schnabelrauch2 & L. Meinel1

Our ability of screening broad communities for clinically asymptomatic diseases critically

drives population health. Sensory chewing gums are presented targeting the tongue as 24/7

detector allowing diagnosis by “anyone, anywhere, anytime”. The chewing gum contains

peptide sensors consisting of a protease cleavable linker in between a bitter substance and a

microparticle. Matrix metalloproteinases in the oral cavity, as upregulated in peri-implant

disease, specifically target the protease cleavable linker while chewing the gum, thereby

generating bitterness for detection by the tongue. The peptide sensors prove significant

success in discriminating saliva collected from patients with peri-implant disease versus

clinically asymptomatic volunteers. Superior outcome is demonstrated over commercially

available protease-based tests in saliva. “Anyone, anywhere, anytime” diagnostics are within

reach for oral inflammation. Expanding this platform technology to other diseases in the

future features this diagnostic as a massive screening tool potentially maximizing impact on

population health.

DOI: 10.1038/s41467-017-00340-x OPEN

1 Institute for Pharmacy and Food Chemistry, Universität Würzburg, Am Hubland, 97074 Würzburg, Germany. 2 Biomaterials Department, Innovent e.V.,Prüssingstraße 27B, 07745 Jena, Germany. 3 Institute for Pharmaceutics, Universität Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf, Germany. 4 PolyAnGmbH, Rudolf-Baschant-Straße 2, 13086 Berlin, Germany. 5Musculoskeletal Research Unit, Center for Applied Biotechnology and Molecular Medicine,Universität Zürich, Winterthurerstrasse 270, 8057 Zurich, Switzerland. 6 Thommen Medical AG, Neckarsulmstrasse 28, 2540 Grenchen, Switzerland.7 Indent—International Dental Research and Education srl, Via Settembrini 17/o, 47923 Rimini, Italy. 8 BioVendor—Laboratorni medicina AS and Departmentof Human Pharmacology and Toxicology, University of Veterinary and Pharmaceutical Sciences, Palackého 1-3, 61242 Brno, Czech Republic. J. Ritzer andT. Lühmann contributed equally to the work. Correspondence and requests for materials should be addressed to L.M. (email: [email protected])

NATURE COMMUNICATIONS |8: �264� |DOI: 10.1038/s41467-017-00340-x |www.nature.com/naturecommunications 1

Biomaterials Dept., Univ. of Würzburg, Germany

BROKEN IMPLANT

FIXTURE REMOVAL•SALVIN IMPLANT RESCUE KIT

IMPLANT REMOVAL TREPHINE

ASTRA TECH EV IMPLANT REMOVAL

IMPLANT REMOVAL TREPHINE


CLOSING THOUGHTS…

▸Once an issue is recognized- manage immediately. ▸ Implant problems will not get better on their own.

▸ If you are not comfortable managing the most common complications, don’t attempt the procedure. ▸Get the education you need to get comfortable!


“WHEN THINGS DON’T SEEM RIGHT…

…there’s a good chance that something’s wrong!”

JBR 1990

g y g

IITTEEMM NNUUMMBBEERR 111100 “Essentials of Implantology” Course

Receive 14 CE Credits as well as extensive knowledge about the Essentials of Implantology and Guided Implant Surgery Utilizing the Industry’s Most Advanced Techology. The

featured speaker, Jay Reznick, DMD,MD is the Director of the Southern California Center for Oral and Facial Surgery and has published numerous articles in JADA, DentalTown, and more. This course aims to educate general dentists in the foundations

of surgical principles and implant surgery. Donated by Dr. Jay Reznick

TTHHAANNKK YYOOUU FFOORR SSUUPPPPOORRTTIINNGG TTHHEE CCHHIILLDDRREENN’’SS DDEENNTTAALL CCEENNTTEERR OOFF GGRREEAATTEERR LLOOSS AANNGGEELLEESS!!

Essentials of Implantology and Guided Implant Surgery

Course Description: This course aims to educate general dentists in the foundations of surgical principles and dental implant surgery, to elevate the general dentist to be able to deliver predictable care to their patients. Doctors are encouraged to bring to this course their staff member who will be primarily responsible for assisting in implant surgical and restorative cases.

At the conclusion of this course, attendees will:

Dr. Reznick is the Director of the Southern California Center for Oral and Facial Surgery in Tarzana, California and a Diplomat of the American Board of Oral and Maxillofacial Surgery. A frequent lecturer, he has published numerous articles in JADA, Journal of the California Dental Association, Oral Surgery-Oral Medicine-Oral Pathology and Compendium of Continuing Education in Dentistry, Dentaltown Magazine, CE Digest and Gastroenterology.

• Understand the fundamentals of safe surgery and implantology

• Be familiar with atraumatic extraction techniques and ridge preservation

• Understand the potential risks and complications which accompany dental implant surgery, and know how to prevent and manage them

• Understand the concept of prosthetically-based implant planning to determine the proper position and orientation of each implant fixture for ideal restoration

• Become familiar with using software to plan implant surgery and understand how to order a surgical guide

• Gain hands-on experience utilizing guided surgery to place implants accurately and efficiently using custom surgical guides

• Understand which cases are appropriate to tackle and which cases are best to do in collaboration with a surgical specialist

Speaker Jay Reznick, DMD, MD

Registration: For complete information and/or to register, please go to www.OnlineOralSurgery.com. Space is limited. Credit Details: This program half live lecture and half self-participation, designated for 14 hours of CE credit by Online Oral Surgery. AGD Codes: 704 (8 hours) and 719 (8 hours). Cancellation Policy: Full refund over 60 days from event minus $25 administrative fee. Refunded 50% 30-60 days from event. No refunds, cancellations, or transfers under 30 days from event.

Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. 09/01/2016 to 08/31/2018. Provider ID# 371806

LOCATIONS San Diego, CA September 22-23, 2017

St. Louis, MO October 20-21, 2017

Charlotte, NC November 6-7, 2017

Tampa, FL December 15-16, 2017

DISCOUNT CODES $250 off Doctor Registration: “DSworldDoc” $50 off Staff Registration: “DSworldStaff”

THANK YOU!

AVOIDING AND MANAGING DENTAL IMPLANT COMPLICATIONS · to successful implant surgery? ... 2...

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