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Building a Healthy Foundation for Dental Implants

Our article topic in this issue is achieving dental implant stability through guided bone regeneration. I wanted to take a look at the historical perspective of ‘where we've been’ and share some updates on where we are today. I hope you find this article informative and helpful as you work with your patients.

Today's dental implants are the recommendation of choice for a healthy patient with one or more missing teeth. Over the last 20 years, changes in the design and composition of the dental implant (surface, type, platform, coating), have decreased healing times and broadened restorative options. The expanding application and understanding of bone regeneration procedures continues to make implant restorations feasible for most replacement scenarios. (1)

Dr. Marco Brindis

Prosthodontist Dr. Marco Brindis presented ‘A Hopeless Tooth is Not a Useless Tooth’ at our October 26th RRSC meeting.

Osseointegration as the Goal

The road to successful osseointegration of dental implants is based on a series of small decisions. While we all strive to ‘begin with the end in mind’ the analysis, planning and patient collaboration in implant dentistry is a thoughtful process from the moment the decision is made to extract a tooth. (2)

How much bone do we need?

Implant site assessment is based on several interdependent factors; at the top of the list are bone height/width and the necessary implant length/diameter and crown-to-implant ratio for restorative success. (3)

  • Generally, a minimum implant length (and bone height) needed to achieve a favorable outcome is 8-10 mm, with a recommended 2mm margin from landmarks such as the mandibular canal, etc. (3)
  • Bone width is defined as the “distance between the buccal and lingual plates, measured at the crest”. (3)

Increasing the diameter of the implant reduces stress on the crestal bone; with that, each 1mm increase in implant diameter expands the necessary surface area by 20-30%. (3) Often bone width presents as the greater challenge over bone height in implant placement.

With implant selection, an oversized implant can impede blood flow and inhibit bone growth (as revealed by studies surrounding peri-implantitis in larger implants). (4) Balancing all the necessary criteria to accomplish osseointegration is key.

tooth extraction and bone graft

Guided Bone Regeneration Materials

The regenerative functions that bone grafting materials serve are 1) to provide a framework for continued growth (osteoconduction) or 2) to stimulate osteoblast cell growth (osteoinduction).

Most dental bone graft materials are bioresorbable and do not normally cause an antigen-antibody reaction. (5) In a 2015 survey of 100 patients on the use of bone grafts in dental treatments, Fernandez et al. reported that the highest rates of patient refusal occurred with allograft and xenograft. (6) The primary reason for rejection were concerns over disease transmission. The highest acceptance occurred with autogenous grafts, followed by alloplastic grafts. (5) In my practice we find that patients are generally accepting of allograft materials.

The term ‘guided bone regeneration’ (GBR) infers the use of a barrier membrane to assist with holding the graft in place, or, to help stabilize a blood clot. (3,7)

Resorbable membranes are collagen-based and are often used to assist in clinical management of tissue or grafting materials.(8) Nonresorbable membranes are available, however they do require a second surgery to remove them. Both have been found to be equally effective. (8)

Dr. Matthew Nejad

Our February 8th RRSC meeting featured hands-on instruction by Dr. Matthew Nejad ‘Advanced Adhesion Minimally Invasive Dentistry’

Dental Implant Stability

In 2017, Tettamanti et. al. cited primary implant stability as the main determinant of successful osseointegration. Bone quality/quantity and load, in addition to other health, tissue condition and technique factors influence primary implant stability at the time of placement. (9)

Implants Immediately after Extraction and Immediate Load Implants
Generally, immediate implant placement is more likely considered in anterior cases, stemming from the patient's esthetic concerns and the clinician's desire for clinical control of healing esthetics and prosthesis support.

Immediate implant placement is a popular and constantly evolving area of study. Current research is supportive of immediate implant placement at the time of extraction. One mention in the literature is a controlled study by Sabir et. al., in which 12 patients age 20-50 showed a 100% success rate of implant survival (all in anterior sites) at 30 months post-placement. (10)

Immediate load implants require careful case selection as they are at a higher risk of failure and complications than delayed implants. (9) Beyond esthetics, there is motivation for further research and development, as evidence supports that immediate placement of dental implants can assist with preservation of alveolar bone. (10)

tooth extraction and bone graft

All-on-Four and Full Arch Implant Restorations

All-on-four and full-arch implant restorations are also a growing area of practice that has tremendous patient appeal.

The documented success of short/long implants and angling techniques to avoid anatomical structures (sinus, inferior alveolar canal, etc.) has pushed full-arch rehabilitation for the edentulous patient to the forefront of dentistry. And, as we know, the results can be life changing for the long-term denture patient. (11)

Bone Graft Procedures

Socket Grafting
We have all been there. A patient has a painful toothache in a non-restorable tooth. While it may not be the ideal time to introduce the concept of a bone graft and dental implant, we know that making the case for the bone graft is important while the opportunity exists.

Sometimes, however, the graft itself presents a challenge, especially when the level of horizontal and/or vertical bone loss is substantial. The question of ‘now’ vs. ‘later’ is a good one. After a tooth is extracted, the body's healing processes go to work. The healing cycle, from 1) blood clot, 2) granulation tissue, 3) collagen to 4) initial bone formation generally takes about 4-6 weeks. The epithelium stays active throughout this process and finishes the job to cover the extraction site. (8)

There are restorative challenges inherit to the natural healing process:

  • Bone resorption is inevitable due to the loss of normal mechanical bone strain. (12)
  • Agarwal et. al. reports that “the rate of post-extraction bone loss is rapid in the first 6 months, followed by gradual modeling and remodeling of the remaining bone with approximately 40% of the alveolar height and 60% of alveolar width lost in the first 6 months”. (13)
  • Simultaneous epithelium growth can actually impede bone regeneration as it fills the open space. (12)
  • The physiological healing response to tooth extraction does not necessarily create an esthetically pleasing or stable site for a dental implant, especially in the esthetic region. (13,15)
  • Bone loss or bone defects can occur for a wide variety of reasons, including: periodontal disease, systemic medical illness or medications, bruxism/clenching and issues with occlusion, as well as genetics. (5) Histology alone adds a wide range of healing considerations.

Clearly, the answer to ‘graft or not to graft’ lies within the difficulty to predict if the extraction site will be suitable for prosthesis placement if we just let nature take its course without intervention. Socket preservation is a preventive measure intended to avoid “alveolar bone and soft tissue collapse, which would cause unacceptable prosthesis esthetics.” (13)

While most peer research supports the practice of socket grafting to offset bone resorption and promote regeneration following a tooth extraction, comparable studies have shown that “bone generation can occur without socket grafting in extraction sockets with intact bony walls”. (8) Granted, this is a judgment call that might not be possible until after the tooth is removed.

If placement of a dental implant is an acceptable recommendation, generally both the patient and the provider would prefer to minimize surgical time and healing time by placing bone graft materials at the time of extraction. Bone, however, tends to be imperfect, even before the disruption of an extraction. (7)

Ridge Preservation
In 1988, periodontist and author E.S. Cohen defined the term socket preservation as a “surgical procedure in which graft material or a scaffold is placed in a fresh extraction socket to preserve the alveolar ridge for a future prosthesis”. (13) This was expanded in 2007 to delineate socket preservation as “specifically for the treatment of fresh extraction sockets with intact buccal bone walls” and ridge preservation in circumstances with “deficient buccal bone walls”.(13) The distinction came about because the buccal bone wall is “believed to have a relevant influence on bone healing”. (13)

Alveolar ridge preservation (ARP) generally involves a flap elevation procedure and placement of a bone graft with the goal of shoring up the midbuccal or midlingual height at the wall of the implant. Timing varies; depending on the extent of the bone deficiency, ARP can be performed in conjunction with the extraction, post-healing or at implant placement. (9)

Sinus lift procedures are frequently used to address vertical bone deficiency in pre-implant preparation of the maxillary posterior. The surgery itself includes gaining access to the sinus cavity, after which the sinus membrane is gently detached and lifted to create an area for placement of the bone graft.

While it is possible to place a dental implant immediately following the sinus lift procedure, Bortoluzzi et. al. concluded that greater success occurs with patients that have higher residual bone heights (>4mm). (14) Delayed placement with a healing period of approximately 6 months is the alternative.

Looking Ahead
Implant manufacturers and biologics companies are hot on the heels of solutions to provide both the clinician and patient with predictable outcomes and minimal surgery with shorter healing times.

And, interestingly, in the not-so-distant future, stem-cell research points to the possible implantation of tooth buds in sockets to regrow teeth or placement of a cellular scaffold in the socket to maintain the bone. (13)

References

1. Abraham, C. M. (2014). A Brief Historical Perspective on Dental Implants, Their Surface Coatings and Treatments. The Open Dentistry Journal, 8, 50–55. http://doi.org/10.2174/1874210601408010050

2. Covey, S. R. (2004). The 7 habits of highly effective people: Restoring the character ethic ([Rev. ed.].). New York: Free Press

3. Mittal, Y., Jindal, G., & Garg, S. (2016). Bone manipulation procedures in dental implants. Indian Journal of Dentistry, 7(2), 86–94. http://doi.org/10.4103/0975-962X.184650.

4. Flanagan, D. (2016). The Case for Smaller Diameter Implants, Journal of Oral Implantology. 2016;42(6):517-517. https://doi.org/10.1563/aaid-joi-D-16-00106

5. Prasanna Kumar, Belliappa Vinitha,1 and Ghousia Fathima. (2013). Bone Grafts In Dentistry. J Pharm Bioallied Sci. 2013 Jun; 5(Suppl 1): S125–S127. doi: 10.4103/0975-7406.113312, PMCID: PMC3722694, PMID: 23946565 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722694/

6. Fernández, R. F., Bucchi, C., Navarro, P., Beltrán, V., & Borie, E. (2015). Bone grafts utilized in dentistry: an analysis of patients' preferences. BMC Medical Ethics, 16, 71. http://doi.org/10.1186/s12910-015-0044-6

7. Horowitz R1, Holtzclaw D, Rosen PS. A Review On Alveolar Ridge Preservation Following Tooth Extraction. J Evid Based Dent Pract. 2012 Sep;12(3 Suppl):149-60. doi: 10.1016/S1532-3382(12)70029-5.

8. Termeie, D.A. Periodontal Review. 2013; Quintessence Publishing Co., Inc., Hanover Park, IL. IBSN 978-0-86715-591-4

9. Tettamanti, L., Andrisani, C., Bassi, M. A., Vinci, R., Silvestre-Rangil, J., & Tagliabue, A. (2017). Post Extractive Implant: Evaluation of the Critical Aspects. Oral & Implantology, 10(2), 119–128. http://doi.org/10.11138/orl/2017.10.2.119.

10. Sabir, M., & Alam, M. N. (2015). Survival of Implants in Immediate Extraction Sockets of Anterior Teeth: Early Clinical Results. Journal of clinical and diagnostic research : JCDR, 9(6), ZC58-61.

11. Hong, D. G. K., & Oh, J. (2017). Recent advances in dental implants. Maxillofacial Plastic and Reconstructive Surgery, 39(1), 33. http://doi.org/10.1186/s40902-017-0132-2

12. Hansson, S., & Halldin, A. (2012). Alveolar Ridge Resorption After Tooth Extraction: A Consequence Of A Fundamental Principle Of Bone Physiology. Journal Of Dental Biomechanics, 3, 1758736012456543. http://doi.org/10.1177/1758736012456543

13. Agarwal G, Thomas R, Mehta D. (2012). Postextraction Maintenance Of The Alveolar Ridge: Rationale And Review. Compend Contin Educ Dent. 2012 May;33(5):320-4, 326; quiz 327, 336. Review. PMID: 22616214. https://cced.cdeworld.com/courses/20903postextraction_Maintenance_of_the_Alveolar_Ridge:Rationale_and_Review

14. Bortoluzzi, M. C., Manfro, R., Fabris, V., Cecconello, R., & Derech, E. D. (2014). Comparative study of immediately inserted dental implants in sinus lift: 24 months of follow-up. Annals of Maxillofacial Surgery, 4(1), 30–33. http://doi.org/10.4103/2231-0746.133071

15. Elian, N., Cho, S., Froum, S., Smith, R.B., & Tarnow, D.P. (2007). A Simplified Socket Classification And Repair Technique. Practical Procedures & Aesthetic Dentistry : PPAD, 19 2, 99-104.

16. Academy of Osseointegration. (2017). What is Osseointegration? http://whydentalimplants.org/what-is-osseointegration/

17. Biohorizons.com. (2018). About Allograft bone. http://www.biohorizons.com/bonegrafting-allograft.aspx

Periodontal Plastic Surgery and Soft Tissue Grafts

A Road Map for Assessment and Recommendation

My purpose for this article is to support your co-diagnostic process with an overview of soft tissue grafting procedures, as well as share a few tools and indicators to assist in the development of treatment recommendations for patients with gingival recession (GR).

Meet Patient A: (See Figure 1). As we would expect, Patient A presented with esthetic concerns and complained about sensitivity when brushing. It was fair to assume that this condition would worsen over time, with a reasonable risk of tooth loss. Developing a treatment plan and addressing the underlying cause was our mission for this patient, as I am sure it would be in your practice.

before and after soft tissue grafting

The Decision Process for Soft Tissue Grafts
The type of soft tissue grafting procedure selected is based on the diagnostic criteria and necessary healing to achieve the best outcome. Patient A clearly has severe gingival with no keratinized gingiva (KG) orattached tissue. In this case, a connective tissue graft with a coronally advanced flap was recommended. (See Figure 2).

Following are some of the methodologies used to arrive at this recommendation:

I. Miller Classification of Mucogingival Defects
In 1985, periodontist, author and clinical researcher Dr. P.D. Miller, Jr. developed a system that applies the criteria of both diagnosis and prognosis for classification of gingival recession defects. The Miller classification system is one of the most widely used evaluation tools today.

A key determinant of Miller classification is to assess the adjacent interproximal bone level for bone loss before any soft tissue grafting procedure. (1 See Table 1 below; note that root coverage is not expected with the presence of interproximal bone loss and predictability of root coverage diminishes with increased bone and tissue loss.

Miller Classification

Table 1. Miller Classification

Along with Miller classification, site specific factors are considered, including: depth of defect, presence of frenum attachment, root prominence, root-surface caries, presence of non-carious cervical lesion, vestibular depth and thin or thick tissue biotype. (2)

The problem with recession is…
The longer we wait to treat gingival recession defects, the less favorable the expected treatment outcome. In Patient A's case, if left untreated, neither you nor I would make any promises to this patient that they would not lose these teeth or develop an infection. Using Miller Classification, Patient A was Miller Class II.

gingival recession tissue graft gingival recession tissue graft

II. Treatment Planning

The treatment process begins with identifying the etiology of the gingival recession defect and plotting a course of action to prevent reoccurrence. Common etiologies include toothbrush trauma, abfraction, poor plaque control of subgingival restorations, high frenal attachment, tooth malalignment, calculus, gingival inflammation and orthodontic tooth movement. (1) Having addressed the etiology, the next step is to consider the objectives of soft tissue grafting, which may be a combination of root coverage, increased keratinized gingiva or increased tissue thickness. (See the decision tree diagram, Figure 5). (1)

  • For Miller Class I or II patients, if root coverage is required, soft tissue procedures may include connective tissue graft (CT), free gingival graft (FG), lateral pedicle graft, coronally advanced flap procedures, guided tissue regeneration (GTR), acellular dermal matrix (ADM), or a combination of procedures.
  • For Miller Class III or IV patients, root coverage is not predictable. The first choices are typically free gingival graft or connective tissue graft (CT) procedures. Other soft tissue procedures may be indicated. A restorative plan may also be needed to meet the patient's expectations. (2)
decision tree

Figure 5 - Decision Tree

III. Techniques and Materials

Free Gingival Grafts (FG)
Free gingival grafts (FG) have been in use since the 1960s with a good history of success. They are harvested from the patient's palatal tissue; the most prevalent use is in the lower anterior region for Miller Class I or II recession defects. In addition to treating recession, FG grafts may sometimes be used to increase keratinized tissue (KT) around a dental implant. (3)

FG grafts are generally best suited for non-esthetic areas because the grafted tissue often does not blend seamlessly with the surrounding areas; full root coverage should not be expected. (4)

Connective Tissue Grafts (CT)
Subepithelial connective tissue grafts (CT) provide the best outcomes for root coverage in Miller Class I and II defects for most patients, along with an increase in keratinized tissue. 2 CT grafts are limited to the amount of tissue that can be obtained from the palate or other intraoral site(s). They provide a better esthetic result than free gingival grafts as they tend to blend very well with surrounding tissues. For Miller Class III and IV GR defects, CT procedures provide significant benefits such as GR reduction and CAL (clinical attachment level) gain, however, root coverage is not predictable. (2)

Pedicle Grafts
A pedicle graft is a coronal flap tissue repositioning procedure. Site selection is the most critical factor with this type of soft tissue graft; if the connective tissue is thin, the graft can fail and make the recession worse. They are effective in cases of mild recession with no bone loss and adequate tissue height on adjacent teeth. (5)

Esthetic Crown Lengthening
Periodontal plastic surgery is probably best known for esthetic improvement in the anterior region. Crown lengthening procedures are used to reduce excessive gingiva, “gummy smile”, or to create a more symmetrical appearance in the gumline. Crown lengthening procedures may also be used to move the gingival margin apically and expose more of the anatomic crown, thus providing the opportunity for supragingival restoration margins.

Autogenous Grafts vs. Allografts
Using the patient's own tissue (autograft) is well supported in research for the benefits of healing and integration. Harvesting autograft tissue, however, does create an additional surgical site, so post-surgical discomfort is a common patient concern. Availability of adequate intraoral donor tissue must also be considered; treatment of multiple sites raises the question of alternative graft options.

Acellular dermal matrix or allograft (trade name Alloderm®, Dermis®, etc.) has been used for many years in medicine for graft treatment of burn victims and other reconstructive procedures. In recent years, it has taken a viable position for use in periodontal soft tissue procedures as an alternative to autogenous tissue.

Allograft tissue is increasing in use to meet patient comfort needs, and it is delivering comparable results to autograft procedures in well planned treatment cases, although the clinical data is not as extensive. (4)

soft tissue graft alloderm

IV. Patient Education & Medical History

Patient education to address plaque control and counseling to quit smoking help enhance the success of gingival surgical procedures. Smoking has been reported to be one of the most common reasons for failure after mucogingival surgery. (4)

Recall compliance is crucial for healing, studies show that poor plaque control contributes to less than optimal surgical outcomes and can lead to loss of clinical attachment, further gingival recession and infection.

Candidates for periodontal soft tissue grafting procedures should be medically screened for systemic health conditions that negatively affect wound healing, such as uncontrolled diabetes. Medical consultation is recommended for these patients. (4)

Conclusion

The goals of periodontal plastic surgery and soft tissue grafting procedures include improving the long term prognosis of tissue health, tooth stabilization, intervening and stopping future gingival recession and facial bone loss, and eliminating inflammation and recession for planned and existing subgingival restorations. The grafting approach selected is based on critical analysis of key factors, including Miller's Classification, surgical site condition, patient health and smoking habits, esthetic requirements and comfort.

Our objective as a periodontal specialty practice is to support these goals and to educate the patient in the importance of continual periodontal maintenance through professional hygiene visits and diligent home care. We strive to partner with the restorative dentist to achieve an oral health condition for our shared patients that is manageable, comfortable, functional and esthetically appealing.

If you have questions about periodontal plastic surgery procedures or possible outcomes, please do not hesitate to contact myself or my team.

Sincerely, Kyle Trammell

References

1. The International Journal of Periodontics & Restorative Dentistry. A Decision Tree for Soft Tissue Grafting, Daylene Jack-Min Leong, BDS, Hom-Lay Wang, DDS, MSD, phd, Volume 31, Number 3, 2011. Quintessence Publishing Company.

2. Enhancing Periodontal Health Through Regenerative Approaches Periodontal Soft Tissue Root Coverage Procedures: Practical Applications From the AAP Regeneration Workshop Christopher R. Richardson,* Edward P. Allen,† Leandro Chambrone,‡ Burton Langer,x Michael K. Mcguire,‖ Ion Zabalegui,{ Homayoun H. Zadeh,# and Dimitris N. Tatakis* http://www.surgicalrestorative.com/content/dam/diq/online-articles/documents/2015/03/Periodontal%20Soft%20Tissue%20Root%20Coverage%20Procedures%20%20_%20Practical%20Applications.pdf

3. Is it time to retire the free gingival graft procedure in light of new alternative tissue grafting materials? By Alessandro Geminiani, DDS, MS 2013-05-06, Surgical Restorative Resource, online http://www.surgicalrestorative.com/articles/2013/05/is-it-time-to-retire-the-free-gingival-graft-procedure-in-light-.html

4. Periodontal Soft Tissue Non–Root Coverage Procedures: Practical Applications From the AAP Regeneration Workshop Vanchit John,* Laureen Langer,† Giulio Rasperini,‡ David M. Kim,x Rodrigo Neiva,‖ Henry Greenwell,{ Serge Dibart,# Mariano Sanz,** and E. Todd Scheyer†† 0051 Clinical Advances in Periodontics, Vol. 5, No. 1, February 2015 http://www.surgicalrestorative.com/content/dam/diq/online-articles/documents/2015/03/Periodontal%20Soft%20Tissue%20Non%C2%adroot%20Coverage%20Procedures%20_%20Practical%20Applications.pdf

5. Practical Periodontal Plastic Surgery Serge Dibart, Mamdouh Karima ISBN: 978-1-118-70493-6 May 2013, Wiley-Blackwell, Hoboken, NJ http://www.glustitch.com/periacryl/booktext-85-73.pdf Chapter 8: Pedicle Grafts: Coronally Advanced Flaps

Tissue Repair and Regeneration in Periodontics

While the first order of business in managing a patient's periodontal health is to eliminate infection and disease, the question of “how do we replace what has been lost?” is one that is pondered daily in our profession. The study of the periodontal repair and regeneration of soft tissue and bone has seen major changes over the last twenty years; surgical techniques have been taken to a new level through the development of regenerative products designed and tested specifically for the oral tissues.

CASE EXAMPLES: In Case Examples 1 and 2, these patients present with vertical intrabony defects. Assuming that all other oral health needs are stable and well-managed, the challenge becomes the inherent difficulties in repairing and rebuilding the bone, periodontal ligament and soft tissue to prevent further damage and tooth loss while also attempting to regenerate the lost alveolar bone, PDL and cementum.

guided bone regeneration

Guided Bone Regeneration (GBR) and Guided Tissue Regeneration (GTR):

We would agree that the treatment plan for these situations would likely include periodontal surgery for access and root surface debridement to reduce bacterial levels and promote healing. In these cases, each of the treating periodontists employed Guided Tissue Regeneration (GTR) surgical procedures to facilitate the growth of bone and fill the defect.

Beyond the surgery itself, GBR and GTR typically involve the use of membranes (filters), bone and tissue grafts or tissue-stimulating proteins that are designed to interact with the body's natural healing and regenerative processes. The strategic objective of these products is to retard the downgrowth of gingival tissues, provide space maintenance, and promote new cementum, alveolar bone, and periodontal ligament cells.

Where Repair and Regeneration Overlap

In dental practice, we address one patient at a time. When we achieve results as in the examples provided, we would describe these as successful outcomes and probably not argue “what is repair vs. regeneration”? In the scientific arena, analysts would tell us that the only way to verify “regeneration” would be to obtain tissue samples followed by histological studies. Katz describes guided tissue regeneration as verified by through histological analysis as a form of repair termed “new attachment” (2013). So, the claim that we can “grow tissue” is perhaps better stated that we can “repair loss of tissue and bone”. Semantics, maybe, but also an indication of how wide and vast this area of research has become.

Who are Candidates for Guided Tissue Regeneration Procedures?

Patients that would likely benefit from regenerative periodontal surgical procedures are those that present with vertical bony defects evident on radiographs and localized deep probing depths. As with any dental treatment, healthy patients have a better treatment prognosis than those with systemic medical conditions, but certainly this will vary on a case by case basis. Also, smokers have much less predictable regenerative results than do non-smokers. A combined radiographic and clinical examination is needed to determine potential sites for regeneration; however, sites that are potential candidates are usually confirmed intrasurgically when the defect can be fully visualized.

regenerative procedures terms

How are Regenerative Procedures Different from Conventional Treatment?

In comparison, surgical bone and tissue regenerative procedures are closely related to soft tissue grafting procedures for addressing gingival recession, but are generally more invasive and require longer healing times.

Post-surgical healing is also different - in traditional surgical and non-surgical therapy, tissue response and growth is limited to the most apical portion of the defect along the root surface. A positive response to regenerative periodontal surgery will stimulate differential tissue response, which increases bone levels, clinical Attachment levels and reduces pocket probing depths. Humphrey states, “the use of regenerative periodontal procedures that include bone graft materials and membranes generally produce greater intrabony bone defect fill than flap debridement alone” (2014).

The Future of Periodontal Regeneration

Future efforts in the study of regeneration will likely focus on controlling this process to create predictable outcomes. As we continue to manage the oral health of our aging “baby boomer” population, the demand for services that help patients keep their teeth and support an enjoyable quality of life will continue to inspire researchers and practitioners alike in this area of practice.

References

American Academy of Periodontology (2001). Glossary of Periodontal Terms. 4th Edition. Online version retrieved 10/20/14: http://www.perio.org/sites/default/files/files/PDFs/Publications/GlossaryOfPeriodontalTerms2001Edition.pdf

Cochran, D. (2014). Periodontal regeneration: a look at the current and future landscape. Penwell Dentistry IQ: Online article retrieved 11/10/14: http://www.dentistryiq.com/articles/2014/01/periodontal-regeneration-a-look-at-the-current-and-future-landscape.html Gruber R., et. al. (2013). Enamel Matrix Derivative Inhibits Adipocyte Differentiation of 3T3-L1 Cells via Activation of TGFKinase Activity. PLOS ONE: http://www.plosone.org, 8-8. Retrieved online 11/10/14: http://boris.unibe.ch/40394/1/__ubnetapp02.unibe.ch_profile$_debmeier_Desktop_PlosOne.pdf

Hempton, T.J., Wilkins, E. , Lancaster, D. (1998). Periodontal Regeneration. Dental Economics, RDH Dentistry IQ: online article retrieved 10/20/14: http://www.rdhmag.com/articles/print/volume-17/issue-10/feature/periodontal-regeneration.html

Humphrey, S.P., Huja, P.E. (2014). Regenerative Periodontal Therapy: A Focus on Periodontal Maintenance. Dental Economics, RDH Dentistry IQ: online article retrieved 10/20/14: http://www.rdhmag.com/articles/print/volume-34/issue-4/features/regenerative-periodontal-therapy.html Katz, B. (2013). Guided Tissue Regeneration: Background to Current Indications and Applications. Penwell Dentistry IQ: Online article retrieved 11/10/14: http://www.surgicalrestorative.com/articles/2013/11/guided-tissue-regeneration-background-to-current-indications-and-applications.html

Hygiene Maintenance of Dental Implants

Protecting your patient's investment in their dental implant is important to you. For this edition of our newsletter, we reviewed articles that highlight current philosophies of care in preventive and periodontal maintenance procedures for dental implants.

Exam, Assessment & Monitoring

As with any procedure in dentistry, there is not a single hygiene maintenance technique for dental implants that is universal. Clearly the experts agree that a thorough assessment of the oral condition and consideration of the patient's overall health are the first steps we must always take before treatment. We know, for example, that systemic health issues such as diabetes can affect the patient's ability to heal.

A general rule of thumb is to avoid periodontal probing of the dental implant site for the first three months after placement to avoid disturbing the perimucosal seal. The standing theory is that probing too soon could introduce pathogens and compromise success of the implant. An exception would be if evidence of peri-implantitis, such as bleeding, inflammation, bone loss, pain or mobility exists which warrants further investigation.

When circumstances justify probing, a plastic probing instrument is recommended to reduce the risk of scratching the implant surface and potential trauma to the perimucosal seal.

Recording and monitoring probing depths after the initial three months and in 3-month intervals is standard. Principles of co-diagnostic dentistry apply in managing the health of the bone and soft tissue and their role in dental implant success.

Did You Know?

Acidulated Phosphate Fluoride (APF) products are contraindicated for use with dental implant patients as they may etch the surface of the implants.

Our typical recommendation for dental implant patients is to maintain a 3-month hygiene recall schedule to monitor progress, healing and implant integration. This is especially true in the presence of risk factors or home care and plaque control challenges. We usually continue the 3-month recall cycle for 18-24 months; the patient can return to 6 month recall if healing and periodontal assessments appear normal.

dental implants x ray

Instrumentation

Identify the type of implant and level of exposure. This combined data and assessment is critical to determining your approach to care. Is the implant abutment smooth or rough? What area of the implant is visible upon examination? Until recent years, the primary approach to debridement of the implant and restoration was to use plastic instruments. The goal here was to avoid scratching or gouging the implant surface, which would make the implant surface more conducive for plaque growth.

Many implant systems now have a completely roughened surface extending to most of the coronal portion of the implant fixture, making a case for metal instrumentation with the strength to remove calculus deposits. Since the majority of dental implants are made of titanium, titanium instruments and titanium-coated instruments are certainly stronger and some would argue are more bio-compatible than plastic instruments, which may introduce plastic debris or residue into the site. I personally prefer gold-tipped instruments or titanium; I have also found that plastic instruments are not strong enough to do an adequate job in removing hard deposits.

Ultrasonic Scalers
When used with proper precautions and a plastic covering that prevents gouging of the implant surface, ultrasonic scalers may be used to debride exposed supragingival and subgingival areas of the dental implant in most cases.

Air Polishing
Debridement of the implant prosthesis with air abrasion is acceptable, with caution to avoid trauma to the soft tissue. Note that repeated use can alter the surface of the dental implant.

Conclusion

The long term success of a dental implant relies heavily on the combination of timely periodontal maintenance, effective home care and good overall patient health. As dental health care providers, we have a professional stake in supporting our patients not only with clinical procedures, but with education and resources to help them maintain their oral health and protect their investment. A well-rounded approach to examination, protocols and instrumentation supported by continual learning has become the current competency for management of dental implants in periodontics today.

References

American Academy of Periodontology. Academy Report. Dental Implants in Periodontal Therapy. Volume 71, Number 12. http://www.joponline.org/doi/pdf/10.1902/jop.2000.71.12.1934

Bains VK, Bains R, Gupta S. Maintaining the dental implants: Importance in long-term success. J Dent Implant 2013;3:62-6. http://www.jdionline.org/downloadpdf.asp?issn=0974-6781;year=2013;volume=3;issue=1;spage=62;epage=66;aulast=Bains;type=2

Hempton, Timothy. et. al. Implant Maintenance. Techniques and tools for effective debridement of artificial anatomy. Dimensions of Dental Hygiene; January 2011; 9(1): 58-61.http://www.dimensionsofdentalhygiene.com/print.aspx?id=10235

Wingrove, Susan S. Dental implant maintenance: the role of the Dental Hygienist and Therapist. Dental Health September 2011; Volume 50 No 5 of 6. http://www.pdtdental.com/documents/2012Gen/Dental-implant-maintenance-the-role-of-the-Dental-Hygienist-and-Therapist.pdf