Implant Maintenance and Management

Patient Journey - The Role of the GDP (**and Dental Therapist)

• Patient assessment and advice on tooth replacement

• Establishing oral health**

• Referral

• Detailed planning*

• Implant surgery*

• Implant restoration*

• Monitoring implant health and function, providing supportive care**

* Training required

Survival vs Success

Success Criteria

Albrektsson et al 1986

• Clinical immobility of the implant

• No peri-implant radiolucency

• Vertical bone loss of less than 0.2mm annually after the first year

• Absence of pain, infection, neuropathy, etc

• In the context of the above, minimum success rates of 85% after 5 years and 80% after 10 years.

Success → Failure

Success → Complications → Failure

• Biological

• Mechanical

• Aesthetic

• Multifactorial

Monitoring Implant Health

• Symptoms

• Visual inspection of peri-implant soft tissues

• Probing depth

• Bleeding

• Suppuration

• Mobility

Peri-Implant Soft Tissues

• Normal healthy gingiva

• No inflammation, no recession, etc

Probing

• No collagen fibres are attached to the implant surface, they run parallel

• No PDL, there is a direct connection between the bone and the implant

• Can have equal probing depths all the way around the implant depending ont he implant design

Interpreting Clinical Signs

• “Normal” probing depths around anterior implants can be deeper than expected around teeth

• Increasing probing depth is significant

• Small amounts of BOP are not uncommon, however brisk BOP should be regarded as a sign of inflammation

• Suppuration is always significant

• Implants should be immobile

• Clinical mobility may be due to loss of implant integration or a prosthetic failure

Biological Complications

• Peri-implant mucositis

  • Inflammation in the peri-implant soft tissues, no bone loss

• Peri-implantitis

  • Inflammation in the peri-implant soft tissues, bone loss

These conditions result from the presence of biofilm adjacent to the peri-implant mucosa

• It doesn’t always occur but is very common

Peri-Implantitis

• Use the threads to measure bone loss

Prevention of Peri-Implant Disease

• Control of risk factors

  • Oral hygiene

  • Periodontal disease

  • Smoking

• Regular supportive visits

• Prosthesis design

• Cement

• Keratinised tissue?

“Implants placed in patients treated for periodontal disease are associated with a higher incidence of biological complications and lower success and survival rates than those placed in periodontally healthy patients. Severe forms of periodontal disease are associated with higher rates of implant loss.”

• Impossible to clean

• A large gap between restorations that increases the risk of caries and bone loss

Management of Peri-Implant Mucositis

• Patient-performed plaque control

• Professional debridement

• Restoration modification

Which Instrument?

• Not steel?

  • Can scratch

• Plastic tip

• Specific implant instruments

• Titanium instruments

Management of Peri-Implnantitis

• Surgical access

• Granulation tissue removal

• Implant surface decontamination

• Implant surface modification?

• Bone regeneration?

• Implant removal

Implant Surface Decontamination

• Titanium brush

• Damp gauze

Implantoplasty

• Smooth the surface

  • Reduced its thickness which may reduce its strength

  

Bone Regeneration

Implant Removal

• Unscrew

• Trephine Bur

Mechanical Complications

• The implant breaks (not often)

• The screw breaks

• The abutment breaks

Aesthetic Complications

• Soft tissue deficiencies

  • Pre-existing

  • Labial recession/uneven contour

  • Lack of papillae

• Prosthetic errors

• 3D implant position

  • Has to be completely surrounded by bone, especially on the labial surface

    • Can bulk out the labial surface with Bio-Oss (a bone replacement material) for stabilising this bone

Black Triangle

• Have sufficient distance between the implant and the adjacent tooth

  • >1.5mm means the remodelling will not extend through the full thickness of the bone and you will retain that bone on the adjacent tooth

    • Supports the interdental papilla

  • <6mm between the bone crest height and the contact point, there’s a good chance that it will fill up with papilla.

    • It may take several years in some cases

Failure of Integration

• Rapid and complete loss of integration

• Early (before loading)

  • Intra-operative trauma?

• Later

  • Overload?

  • Host factors?

Conclusions

• Implant complications are common

• Mechanical complications are a nuisance but can usually be managed

• The peri-implant disease can be prevented with excellent plaque control and regular supportive care

• Peri-implant mucositis can often be managed with simple measures

• Peri-implantitis requires specialist input