essentials level ii handout - online oral surgery...implant surgical flap design implant surgery...

ESSENTIALS OF IMPLANTOLOGY AND CBCT-GUIDED IMPLANT SURGERY: LEVEL II

JAY B. REZNICK, D.M.D., M.D. DIPLOMATE, AMERICAN BOARD OF ORAL AND MAXILLOFACIAL SURGERY

TARZANA, CA

ESSENTIALS OF IMPLANTOLOGY - LEVEL II

COURSE OUTLINE▸ Implant surgical flap design ▸ Suturing techniques ▸ Anterior esthetic zone ▸ Extraction/ immediate implant

▸ Bone augmentation

▸ Indirect sinus lift

▸ 2nd molar implants

▸ Peri-implantitis!2


COURSE OUTLINE▸ Hands-On exercises

▸ Hands-on case planning

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INSTRUMENTS OF THE BETTER GRADE

Dr. Reznick is a Diplomate of the American Board of Oral and Maxillofacial Surgery. He received his undergraduate Biology degree from CAL-Berkeley, Dental degree from Tufts University, and his M.D. degree from the University of Southern California. He did his internship in General Surgery at Huntington Memorial Hospital in Pasadena and trained in Oral and Maxillofacial Surgery at L.A. County- USC Medical Center.

His special clinical interests are in the areas of facial trauma, jaw and oral pathology, dental implantology, sleep disorders medicine, laser surgery, and jaw deformities. He also has expertise in the integration of digital photography and imaging in clinical practice.

He frequently lectures at continuing education meetings, and has published articles in JADA, Journal of the California Dental Association, Oral Surgery-Oral Medicine-Oral Pathology, Compendium of Continuing Education in Dentistry, DentalTown Magazine, CE Digest, and Gastroenterology.

His advice and comments are frequently seen in DentalTown Magazine and on the website DentalTown.com. He is an Administrator of the DentalTown Message Boards and a Moderator of the Oral and Maxillofacial Surgery section. He was also one of the first contributors to DentalTown’s Online CE.

He is the Director of the Southern California Center for Oral and Facial Surgery, in Tarzana, California. (www.sccofs.com)

737 E. Elizabeth Ave.Linden, NJ 07036(800) 523-2427

�arl Schumacher is pleased to offercourse participants a �� savings on this

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Essentials of Implantology & Guided Implant Surgery

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Implant Surgical Flap Design

IMPLANT SURGERY SITE ACCESSINVASIVE

•FULL FLAP BUTTON HOLE

•FLAPLESS •TISSUE PUNCH

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CLINICAL EXAM• EVALUATION OF SOFT TISSUE AT

IMPLANT SITE ‣ Keratinized gingiva

• EVALUATION OF RIDGE HEIGHT/ WIDTH

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BIOLOGIC WIDTH• MINIMUM DIMENSION OF SOUND TOOTH

STRUCTURE BETWEEN THE RESTORATIVE MARGIN AND THE ALVEOLAR CREST.

• ACCOMMODATES THE CONNECTIVE TISSUE AND EPITHELIAL ATTACHMENT

• INADEQUATE BIOLOGIC WIDTH RESULTS IN INFLAMMATION

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VIOLATION OF BIOLOGIC WIDTH

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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

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

CTJES

BW

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1-2 mm

0.5 - 1 mm

1 mm

VIOLATION OF BIOLOGIC WIDTH

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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.

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WHAT DETERMINES TYPE OF ACCESS?

▸Amount of keratinized gingiva (KG) •Tissue punch: >2mm KG around implant

•Flap: <2mm KG

▸Grafting needed?

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EVALUATION OF KERATINIZED TISSUETISSUE PUNCH

VS. FLAP

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TISSUE PUNCH•2 MM OF KERATINIZED GINGIVA

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TISSUE PUNCH•THROUGH SURGICAL GUIDE •ASTRA TECH IMPLANT

SYSTEM EV

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BONE VOLUME EVALUATION▸ Need adequate width and height ▸ Both apical and occlusal ends of fixture should be in

bone

▸

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HOW MUCH BONE DO WE NEED SURROUNDING AN IMPLANT FIXTURE?BLOOD SUPPLY TO ALVEOLAR BONE COMES FROM: •Periosteum •Periodontal ligament

!19• 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

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)

!20• 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 PUNCH?

01XP 11/16/09: Panorama

XS 11/16/09: Cross-sectional XS 11/16/09: Tangential XS 11/16/09: Axial (from above)

XV 11/16/09: 3D

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CLINICAL EVALUATION• ATROPHIC APPEARING

RIDGE • BUCCAL BONE LOSS

AFTER BRIDGE REMOVED • NOT MUCH BUCCAL KG

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SURGICAL FLAPS FOR DENTAL IMPLANTS•PURPOSE OF FLAP IS TO GAIN ACCESS TO SURGICAL SITE •TO PRESERVE KERATINIZED GINGIVA (KG) •TO FACILITATE BONE GRAFTING •TO ALLOW BONE REDUCTION/ CONTOURING

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SURGICAL FLAP DESIGN•SHOULD BE BASED ON ANATOMY, BLOOD SUPPLY

•BASE BROADER THAN APEX •FOR IMPLANTS - FULL THICKNESS

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SURGICAL FLAP DESIGNSize of flap depends on purpose

Releasing incision

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Suturing Techniques

SUTURING‣TO REAPPROXIMATE

SURGICAL FLAPS ‣TO HOLD MEMBRANE IN

PLACE

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SUTURING•SIZE

!3-0: BASIC !4-0: FINER

•NEEDLE TYPES •SUTURE TYPES

RESORBABLE NON-RESORBABLE

!28

RESORBABLE SUTURE•QUICK -Gut

•SLOW- PGA -Vicryl -Dexon

!29

NON-RESORBABLE•SILK •NYLON

•PTFE GORE-TEX CYTOPLAST

!30


GENERAL PRINCIPLES OF SUTURING▸ Suture should engage at least 2-3mm from wound

edge to avoid tearing

▸ Needle is held about 2/3 from the point

▸ If needle is dull, replace the suture

▸ Pass suture through more mobile tissue flap first, the more fixed

▸ Needle should enter tissue at 90 degrees

▸ Tissue should not blanch when the suture is tied - “approximate, don’t strangulate” !31


TYPES OF SURGICAL KNOTS

▸Square knot ▸Slip (Granny) knot ▸Surgeon’s knot

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SUTURE TYPES FOR IMPLANT SURGERY▸Simple interrupted ▸Continuous ▸Horizontal mattress ▸Vertical mattress ▸Figure-8 ▸Sling

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SUTURE TYPES FOR IMPLANT SURGERY

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▸Simple interrupted ▸Continuous

▸Horizontal mattress ▸Vertical mattress ▸Figure-8 ▸Sling



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▸Simple interrupted ▸Continuous ▸Horizontal mattress ▸Vertical mattress ▸Figure-8 ▸Sling



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▸Simple interrupted ▸Continuous

▸Horizontal mattress ▸Vertical mattress ▸Figure-8 ▸Sling

FULL THICKNESS FLAP•MUCOPERIOSTEAL

FLAP •ENVELOPE FLAP

➡ Sulcus ➡ Crestal

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

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6 MONTH POSTOP

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Considerations for Implants in the Anterior Esthetic Zone

ESSENTIALS OF IMPLANTOLOGY - LEVEL I


IMPLANT CONSIDERATIONS IN THE ESTHETIC ZONE▸ Esthetic Requirements

- Lip line

▸ Bone Requirements - Buccal/ lingual bone - Interproximal spacing - Adjacent teeth

▸ Soft Tissue Issues - Gingival Biotype - Keratinized gingiva/Biologic Width

▸ Angulation - Prothetic Plan

➡ Screw Retention ➡ Cement Retention

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LIP LINE

▸High vs. low lip line

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LIP LINE

▸High vs. low lip line

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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 mm4 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

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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

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IMPLANT PLACEMENT IN THE ESTHETIC ZONE

•“3-2 RULE”

!51

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


BONE LEVEL OF ADJACENT TEETH

▸The bone level of the adjacent teeth sets the bone level at the implant site

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INTEROCCLUSAL SPACE

▸Minimum of 7mm to accommodate abutment height plus restoration

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7mm

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

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

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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

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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.

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SCREW- VS. CEMENT-RETAINED: IMPLANT ANGULATION

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JOHN D.HEALTHY 26 YEAR OLD MALE EXTERNAL RESORPTION TOOTH #8

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TOOTH #8

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ANTERIOR CROWN RETENTION▸ Screw ▸ Cement

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Extraction With Immediate Implant Placement

ADVANTAGES OF DELAYED PLACEMENT•RIDGE IS COMPLETELY HEALED •BETTER BONE DENSITY •BETTER PRIMARY STABILITY •ALLOWS FOR EASIER PRIMARY CLOSURE

!63

DISADVANTAGES OF DELAYED PLACEMENT

•DELAYS OVERALL TREATMENT TIME BY >3 MO •RISK OF BONE/ GINGIVAL RECESSION

!64

•GREATLY SUPERIOR INITIAL IMPLANT STABILITY •MORE PREDICTABLE •LOWER FAILURE RATE

MYTHS OF DELAYED PLACEMENT

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IMMEDIATE IMPLANT PLACEMENTIMPLANT IS PLACED AT TIME OF TOOTH EXTRACTION

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ADVANTAGES OF IMMEDIATE PLACEMENT•SAVES >3 MO OF TREATMENT TIME •HELPS MAINTAIN ALVEOLAR VOLUME •ALLOWS FOR IMMEDIATE PROVISIONALIZATION ‣Avoids need for flipper/ space maintainer ‣Psychologically better

!67

DISADVANTAGES OF IMMEDIATE PLACEMENT

•IMPLANT POSITION MAY BE DICTATED BY EXTRACTION SOCKET AND EXISTING ANATOMY

•MAY HAVE POORER INITIAL STABILIZATION •NON-GUIDED PLACEMENT IS NOT ADVISED

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EXTRACTION/ IMMEDIATE IMPLANT

HEALTHY 52 YEAR OLD MAN FRACTURED # 9

JBR


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Cooper LF, Reside GJ, Raes F, Garriga JS, Tarrida LG, Wiltfang J, Kern M and De Bruyn H. Int J Oral Maxillofac Implants 29(3): 709-717, 2014.

➢ 113 patients in need of anterior single implant rehabilitation were included ➢55 implants were placed in fresh extraction sockets ➢58 implants were placed in healed ridges

➢A provisional crown was delivered at the day of implant insertion ➢A permanent crown was cemented after 3 months ➢Peri-implant bone response i.e. marginal bone level/change, was

recorded at implant placement and yearly thereafter ➢Peri-implant mucosal response i.e. papilla index and gingival

zenith scores, were recorded yearly

Aim

Materials

&

Methods

To evaluate the 5-year clinical outcome of immediately provisionalized OsseoSpeed™ implants placed in extraction sockets or in healed ridges

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Results

Bone &

Mucosa

Peri-implant tissues were healthy around immediately provisionalized OsseoSpeed implants placed in both fresh extraction sockets and in healed ridges

Conclusion

➢ 94 patients (out of 113) attended the 5-year follow-up visit ➢45 patients in the extraction socket group, and 49 patients in the healed ridge group ➢ 4 implants failed, all during the first year ➢3 implants in the extraction socket group and 1 in the healed ridge group

➢ Bone levels did not differ between the groups after 5 years ➢ A mean gain was seen; 2.06 mm in the extraction socket group and 0.1 mm in the

healed ridge group ➢ Papilla index increased over time and did not differ between the groups

➢ Mucosal zenith scores were stable over time and were similar in both groups

IMMEDIATE PROVISIONALIZATION OF DENTAL IMPLANTS PLACED IN HEALED ALVEOLAR RIDGES AND EXTRACTION SOCKETS: A 5-YEAR PROSPECTIVE EVALUATION

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Cooper LF, Reside GJ, Raes F, Garriga JS, Tarrida LG, Wiltfang J, Kern M and De Bruyn H. Int J Oral Maxillofac Implants 29(3): 709-717, 2014.

MARGINAL BONE PRESERVATION IN SINGLE-TOOTH REPLACEMENT: A 5-YEAR PROSPECTIVE CLINICAL MULTICENTER STUDY

•TO EVALUATE THE CLINICAL AND RADIOLOGICAL OUTCOME OF IMMEDIATE PROVISIONALIZATION OF SINGLE OSSEOSPEED IMPLANTS IN THE ESTHETIC ZONE

!MULTICENTER STUDY (8 PRIVATE CLINICS) !151 PATIENTS WERE INCLUDED AND 140 PATIENTS WERE AVAILABLE AT THE 5 YEAR VISIT !RANDOMIZATION INTO GROUPS: • CONTROL – 2-STAGE SURGERY, CONVENTIONAL DRILLING (3 MONTHS HEALING) • TEST 1 – 1-STAGE SURGERY, CONVENTIONAL DRILLING AND IMMEDIATE PROVISIONAL • TEST 2 – 1-STAGE SURGERY, OSTEOTOME TECHNIQUE AND IMMEDIATE PROVISIONAL !RADIOGRAPHIC ASSESSMENT (BONE LEVEL CHANGE AND MULTIVARIATE ANALYSIS OF VARIABLES AFFECTING THE BONE LEVELS) !CLINICAL ASSESSMENT (PLAQUE, BOP, PPD, HEIGHT OF PAPILLA, WIDTH OF KERATINIZED TISSUE)

Aim

Materials

&

Methods

Donati M, La Scala V, Di Raimondo R, Speroni S, Testi M, Berglundh T.

Clin Impl Dent Rel Res 2013;E-pub July 25, doi:10.1111/cid.12117

!75

Donati M, La Scala V, Di Raimondo R, et al. Marginal bone preservation in single-tooth replacement: A 5-year prospective clinical multicenter study. Clin Impl Dent Rel Res 2013;E-pub July 25, doi:10.1111/cid.12117

Radiographic Findings

➢No significant difference in bone loss was found between the groups

➢Mean marginal bone loss (mm ± SD) from implant placement to 5-year follow-up

Control = -0.26 (±1.22) Test 1 = -0.30 (±0.91) Test 2 = -0.29 (±1.31)


!76

➢NO SIGNIFICANT DIFFERENCE IN CLINICAL VARIABLES WERE FOUND BETWEEN THE GROUPS AT EITHER TIME POINTS

➢PLAQUE, BOP AND PPD INCREASED BETWEEN 1 AND 5 YEAR ➢PAPILLA HEIGHT INCREASED BETWEEN 1 AND 5 YEAR ➢WIDTH OF KERATINIZED TISSUE DECREASED BETWEEN 1 AND 5 YEARS

Clinical Findings

Immediately provisionalized single tooth OsseoSpeed implants in the esthetic zone had similar good long-term clinical outcome as conventionally loaded OsseoSpeed implants

Conclusion:

Donati M, La Scala V, Di Raimondo R, et al. Marginal bone preservation in single-tooth replacement: A 5-year prospective clinical multicenter study. Clin Impl Dent Rel Res 2013;E-pub July 25, doi:10.1111/cid.12117


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FLAPLESS POSTEXTRACTION SOCKET IMPLANT PLACEMENT IN THE ESTHETIC ZONE: PART 1. THE EFFECT OF BONE GRAFTING AND/OR PROVISIONAL RESTORATION ON THE FACIAL-PALATAL RIDGE DIMENSION- A RETROSPECTIVE COHORT STUDY Tarnow D P et al: Int J Perio Rest Dent 34(3) 2014

➢Bone grafting at immediate implant placement with provisional or contoured healing abutment resulted in the least ridge contour changes

➢Soft tissue height and thickness was greater in grafted sites with provisional restoration FLAPLESS POSTEXTRACTION SOCKET IMPLANT PLACEMENT: PART 2. THE EFFECTS OF BONE GRAFTING AND PROVISIONAL RESTORATION ON THE PERI-IMPLANT SOFT TISSUE HEIGHT AND THICKNESS — A RETROSPECTIVE STUDY Chu S J et al: Int J Perio Rest Dent 35(6) 2016

IMMEDIATE TOOTH REPLACEMENT

GRAFTING AROUND AN IMMEDIATE IMPLANT•Some bone loss occurs around an immediate implant, even if atraumatic techniques are used •Loss of PDL blood supply •Bone loss- facial > palatal •Gap <2 mm will fill in, but not completely (Araujo 2005, 2006)

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ATRAUMATIC FLAPLESS EXTRACTION/ IMMEDIATE IMPLANT PLACEMENT•Bone grafting into the gap around an implant at the time of flapless extraction minimizes ridge contour change. •Further improved by using contoured healing abutment or provisional restoration

Tarnow DP, et al. Flapless postextraction socket implant placement in the esthetic zone: part 1. The effect of bone grafting and/or provisional restoration on facial-palatal ridge dimensional change- a retrospective cohort study. Int J Periodontics Restorative Dent 34(3): 323-31, 2014

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SYMBIOS™ DBX® PUTTYDemineralized Bone Matrix▸ Starts as cortical bone (212 – 850µ)

- Demineralization exposes natural BMP in bone

- Demineralized bone mixed with biologic carrier

▸ Sodium Hyaluronate – synthetic material: Chemically identical to the sodium hyaluronate produced by the human body

- End result is a DBM

- Integrates in approximately 3-4 months

- 2-year shelf life

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ATRAUMATIC TOOTH EXTRACTION•-PROXIMATORS

- “Turbo periotomes” •-APICAL RETENTION FORCEPS

•THIN BEAKS •TAPERED PROFILE •ALLOW INSTRUMENT TO PASS

DEEPER ONTO ROOT SURFACE

!82

ATRAUMATIC TOOTH EXTRACTION

!83

SYMBIOS™ OSTEOSHIELD® PTFENON-RESORBABLE

!84

PERIACRYL• COLLAPLUG • GUT FIG-8

SUTURE • PERIACRYL

!85

SALVIN POCKET PACKER

!86

IMMEDIATE PROVISIONALIZATION• MINIMAL INSERTION TORQUE SHOULD BE

30-35N/CM2

• Gazelles J, WismeijerD: Early and immediately restored and loaded dental implants for single tooth and partial arch

applications. The International Journal of Oral and Maxillofacial Implants. Vol. 19 Supplement, 2004, page 99.

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CRITERIA FOR IMMEDIATE PLACEMENT/ PROVISIONAL•GOOD INITIAL STABILIZATION** •NO SIGNIFICANT INFECTION •ADEQUATE BONY VOLUME •BUCCAL PLATE REASONABLY INTACT •OUT OF FUNCTION/OCCLUSION •*COMPLIANT PATIENT*

Hammerle CHF, et al.: Concensus Statement and Recommended Clinical Procedures Regarding the Placement of Implants in Extraction Sockets. Int J Oral and Maxillofacial Implants. Vol 19 Suppl; pp26-28.

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TOOTH #13- M-D SPLIT

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IMMEDIATE MOLAR IMPLANT

IMMEDIATE MOLAR IMPLANT

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IMMEDIATE IMPLANT - HOW TO DECIDE

-Esthetic Zone -Patient Desires -Patient Compliance -Bone volume/ quality

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PEARL•HAVE A BACK-UP PLAN IN CASE IMPLANT IS NOT STABLE ENOUGH FOR PLACEMENT OR IMMEDIATE PROVISIONAL

•FLIPPER •ESSIX •FIXED PARTIAL DENTURE “MARYLAND BRIDGE”

!99

JBR

FAILING TOOTH #8

VIDEO OF PLANNING WORKFLOW

GARNER- #8

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Planning Report — Overview

GALILEOS Implant

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Printed: 8/10/2012 12:43 Page 1 / 2This report is intended for documentation only. For diagnosis and implant planning use GALAXIS/GALILEOS Implant.

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IMPLANT ANALOG SET IN MODEL - ASTRA TECH TX

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IMPLANT ANALOG SET IN MODEL - ASTRA TECH USING GUIDED IMPLANT MOUNT

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Bone Augmentation Around Implants

•MAJOR CHANGES TO EXTRACTION SITE OCCUR IN FIRST 12 MONTHS AFTER EXTRACTION. •2/3 OF THE RESORPTION OCCURS WITHIN THE FEW MONTHS•SCHROPP L ET AL. BONE HEALING AND SOFT TISSUE CONTOUR CHANGES FOLLOWING SINGLE-TOOTH EXTRACTION: A CLINICAL AND RADIOGRAPHIC 12-MONTH PROSPECTIVE STUDY. INT J PERIODONTICS RESTORATIVE DENT 23(4); 313-23, 2003

!108

RIDGE RESORPTION•REVIEW OF ALL ENGLISH LANGUAGE DENTAL LITERATURE •3954 TITLES / 238 ABSTRACTS —> 104 FULL TEXT ARTICLE ANALYSIS •6 MONTHS AFTER EXTRACTION - 3.79mm (29-63%) horizontal - 1.24mm (B)/ 0.84mm (L) vertical avg. bone loss (11-22%)

Tan WL, et al. Clin Oral Implants Res; 23 Suppl 5: 1-21, 2012!109

POST-EXTRACTION RESORPTIONSLOPED RIDGES ARE A COMMON CLINICAL SITUATION OSSEOSPEED™ PROFILE EV IS DESIGNED FOR SLOPED RIDGE SITUATIONS THAT PRESERVES THE MARGINAL BONE AND SUPPORTS THE SOFT TISSUE ALL AROUND THE IMPLANT

EFFICIENT USE OF AVAILABLE BONE REDUCED NEED FOR AUGMENTATION SOFT TISSUE ESTHETICS

!110

!111

2.5 mm

3.1 mm

IMPLANT DESIGN AND ASSORTMENT- OSSEOSPEED™ PROFILE EV

3.1 mm 3.7

mm

!112

Noelken R., Donati M., Fiorellini J., Gellrich N.C., Parker W., Wada K., and Berglundh T. Clin Oral Implants Res 2012;E-pub Dec 5, doi:10.1111/clr.12079

0 WEEK OSSEOSPEED™ PROFILE IMPLANT PLACEMENT AND HEALING ABUTMENT 4.0/5.0 CONNECTION

16 WEEKS RE-ENTRY AND CLINICAL MEASUREMENTS 21 WEEKS FINAL ABUTMENT AND CROWN INSTALLATION (LOADING) 1 YEAR LAST FOLLOW-UP

• 2.2 MM PROBING POCKET DEPTH AT THE 21-WEEK FOLLOW-UP • 2.5 MM PROBING POCKET DEPTH AT THE 1-YEAR FOLLOW-UP • SMALL CHANGES IN CLINICAL ATTACHMENT LEVELS BETWEEN 21-

WEEK AND 1-YEAR FOLLOW-UP (-0.1 TO +0,1 MM)

STUDY

OVERVIEW

RESULTS:

SOFT TISSUE

SOFT AND HARD TISSUE ALTERATIONS AROUND IMPLANTS PLACED IN AN ALVEOLAR RIDGE WITH A SLOPED CONFIGURATION

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SOFT AND HARD TISSUE ALTERATIONS AROUND IMPLANTS PLACED IN AN ALVEOLAR RIDGE WITH A SLOPED CONFIGURATION

NO IMPLANT FAILURES STABLE MARGINAL BONE LEVELS

- BUCCAL BONE ALTERATIONS (16 W): - 0.3 MM - LINGUAL BONE ALTERATIONS (16 W): - 0.02 MM - PROXIMAL BONE ALTERATION (1 YEAR): - 0.54 MM

• STABLE HARD AND SOFT TISSUES • PRESERVED DIFFERENCES BETWEEN BUCCAL AND LINGUAL

BONE LEVELS

RESULTS:

HARD TISSUE

CONCLUSIONS

Noelken R., Donati M., Fiorellini J., Gellrich N.C., Parker W., Wada K., and Berglundh T. Clin Oral Implants Res 2012;E-pub Dec 5, doi:10.1111/clr.12079

!114

SURVIVAL AND TISSUE MAINTENANCE OF AN IMPLANT WITH A SLOPED CONFIGURED SHOULDER IN THE POSTERIOR MANDIBLE-A PROSPECTIVE MULTI CENTER STUDY24 CENTERS/ 184 PATIENTS/ 238 PROFILE OS TX IMPLANTS ASSESSMENT TIMES

•BEFORE PLACEMENT •AFTER PLACEMENT •PROSTHETIC DELIVERY •6, 12, 24 MONTHS AFTER PLACEMENT

Schiegnitz E at al. Clin Oral Implants Res 2016 May

!115

• AVG 2.4 (±0.4) YEARS - 99.2% SURVIVAL • INCREASED PERI-IMPLANT KERATINIZED MUCOSA • GREATEST DIFFERENCE IN ≤2MM KG AT POST-OP • MEAN INTER PROXIMAL BONE LOSS 0.30±0.6MM • SLOPED SHOULDER CONFIGURATION SUPPORTS

REGAIN OF KG

SURVIVAL AND TISSUE MAINTENANCE OF AN IMPLANT WITH A SLOPED CONFIGURED SHOULDER IN THE POSTERIOR MANDIBLE-A PROSPECTIVE MULTI CENTER STUDY

Schiegnitz E at al. Clin Oral Implants Res 2016 May

!116

• Flapless and immediate implant installation in the anterior maxilla (socket grafting with autogenous bone was performed if needed)

• OsseoSpeed Profile implants with a conical neck design (length 15 mm, 4.5 or 5.0 mm wide)

• Immediate provisionalization (temporary crown splinted to neighboring teeth, for 8 weeks) • Permanent zirconia crowns cemented on zirconia abutments (3 months after surgery) • Outcome variables: implant survival, interproximal and buccal bone levels, buccal bone

thickness, pink esthetic score (PES) and implant success

Aim

Noelken R, Oberhansl F, Kunkel M and Wagner W. Clin Oral Implant Res E-pub August 2015, doi:10.1111/clr.12651

Materials

&

Methods

To prospectively evaluate the clinical outcome of OsseoSpeed Profile implants placed in fresh extraction sockets and immediately provisionalized

IMMEDIATELY PROVISIONALIZED OSSEOSPEED PROFILE IMPLANTS INSERTED INTO EXTRACTION SOCKETS: 3-YEAR RESULTS

!117

Results

A positive clinical outcome was found for OsseoSpeed Profile when placed in fresh extraction sockets and immediately provisionalized

Conclusion

➢ 21 OsseoSpeed Profile single implants were placed in 16 patients ➢ 19 implants were evaluated after 3 years (mean follow-up time 43±3.5 months) ➢ Implant survival rate 95% (1 implant loss at 10 weeks) ➢ Marginal bone remodeling: interproximal bone level changed from 0.8 to -0.2 mm buccal bone level changed from -0.38 to 0.30 mm ➢ PES changed from 10.58 to 11.89 mm

Noelken R, Oberhansl F, Kunkel M and Wagner W. Clin Oral Implant Res E-pub August 2015, doi:10.1111/clr.12651

IMMEDIATELY PROVISIONALIZED OSSEOSPEED PROFILE IMPLANTS INSERTED INTO EXTRACTION SOCKETS: 3-YEAR RESULTS

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SYMBIOS™ REGENERATIVE PRODUCTS

!120

MY STANDARD GRAFTING TECHNIQUE❖SYMBIOS mineralized

corticocancellous granules

❖SYMBIOS OsteoShield PTFE membrane

❖Cytoplast suture

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SYMBIOS™ CORTICAL/CANCELLOUS GRANULES• A COMBINATION OF CORTICAL HUMAN BONE (80%) AND CANCELLOUS

HUMAN BONE (20%) • LARGE PARTICLE RANGE

- Mineralized: 1.0 mm – 2.0 mm

- Demineralized: 0.5 mm – 3.0 mm • INTEGRATES IN APPROXIMATELY 4-5 MONTHS • 3-YEAR SHELF LIFE

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OSTEOGRAF®/NNATURAL BOVINE ANORGANIC BONE MATRIX (ABM) – MICROPOROUS HYDROXYLAPATITE DENSE, HIGH-HEAT STERILIZED BOVINE PARTICLES AVAILABLE IN 2 PARTICLE RANGES:

- 250 – 420µ (OsteoGraf N-300) - 420 – 1000µ (OsteoGraf N-700)

RESORBS IN APPROXIMATELY 9 – 12 MONTHS 5-YEAR SHELF LIFE

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OSTEOGRAF®/NFeatures Benefits

Dense bovine bone particulate Provides dimensional stability

Hydrophilic Easy to use and place

High heat processing Safe

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Indications for use: • Extraction sites • Ridge augmentation* • Periodontal (peri-implant)

defects* • Sinus elevations

Four-pack configuration

1 gram

3 grams

OSTEOGRAF®/N

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MIXING BONE WITH SALINE VERSUS BLOOD

•SALINE AND BLOOD ARE BOTH ISOTONIC •BLOOD CONTAINS FIBRIN, PROTEINS, STEM CELLS •PARTICULATE GRAFT IS MORE COHESIVE WHEN MIXED WITH BLOOD VERSUS SALINE •MIXING WITH BLOOD REQUIRES DRAWING BLOOD (APPROX. EQUAL VOLUMES) •CLINICAL ADVANTAGE??

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• PROPRIETARY 100% POLYTETRAFLUOROETHYLENE SHEET • BIOLOGICALLY INERT AND TISSUE COMPATIBLE • MESH APPEARANCE IS “DIMPLES”, NOT HOLES – MAKES MEMBRANE

VIRTUALLY IMPERVIOUS TO BACTERIAL AND SOFT TISSUE PENETRATION (SMOOTH SIDE IS PLACED ON BONE)

• 4-YEAR SHELF LIFE

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Features Benefits

Primary closure is not required • By avoiding releasing incisions the membrane maintains soft tissue architecture and preserves keratinized mucosa

• Easily, non-surgical removal after 21-28 daysMedical grade PTFE • Biocompatible and non-reactive

• Can be trimmed with sharp sterile scissors for easier handling

Micro-machined surface texture • Facilitates cell adhesion • Enhances membrane stability • Reduces flap retraction • Increases pull-out strength


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Indications for use:

• Socket grafting

• When primary closure after grafting cannot be achieved

• Large bony defects

• Temporary implantable material for space-making barrier in periodontal defects

Multi-pack configuration

12 mm x 24 mm (10 pack)

25 mm x 30 mm (4 pack)

SYMBIOS™ OSTEOSHIELD® PTFENON-RESORPABLE

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SYMBIOS™ REGENERATIVE PRODUCTS

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SYMBIOS™ OSTEOSHIELD® COLLAGENRESORBABLE

• RESORBABLE TISSUE MATRIX DERIVED FROM HIGHLY-PURIFIED TYPE-I BOVINE ACHILLES TENDON FOR SAFETY AND PREDICTABILITY

• GBR BARRIER FUNCTION • INTEGRATES IN APPROXIMATELY 6-9 MONTHS • 3-YEAR SHELF LIFE

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Features Benefits

Multi layer construction Guides healing of bone and tissue – inner layers help prevent cellular and bacterial down growth

Unique fiber orientation Provides tensile strength to accommodate sutures or tacks

Excellent wet handling characteristics and either side may be placed on site

Ease of use


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Indications for use:

• Around dental implants

• Bony defects

• Ridge reconstruction

• GBR/GTR

Two-pack configuration

15 mm x 20 mm

20 mm x 30 mm

30 mm x 40 mm


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Indirect Sinus Lift (Sommer’s Technique)

Making it easy…

INDIRECT SINUS LIFT

1 / 1

DQMFB035; Rev. 2014-06-09

Prior to using the surgical guide, visually evaluate the position of the master cylinder and/or pilot sleeve to ensure it is placed according to your treatment plan.

Clinician judgment, as related to individual patient presentations, must always supersede recommendations in any BioHorizons or SICAT Instructions for Use (IFU). Additional technical information is available upon request from BioHorizons or SICAT, or may be viewed and/ or downloaded at www.biohorizons.com or

Patient ID: Murata,Akiko *5/30/1949 Case ID: 74943 Contact Person: Jay Reznick

Date of Order: 30.11.2015

Tooth Position–ADA 3 Item Number TLXP5807

Implant length (mm) 7.5

Guide Site Complete

Implant Site Preparation

Drill Length (mm) 21

Drill Guide / Drill B / 2.0







Guided Implant Placement

Depth Position SP4

Implant Driver 5.8/4.5

Green-Blue

* If attempting to use BioHorizons mounted implants, the 3inOne®abutment will have to be removed prior to implant delivery.

Surgical Protocol for

BioHorizons Guided Surgery Kit


Challenges With 2nd Molar Implants

JBR

ESSENTIALS OF IMPLANTOLOGY - LEVEL I

DRILL LOGICS- STANDARD VS. GUIDED DRILLS


!145

TEXT

J.K.

▸ Healthy 44 year old male

▸ Pain, swelling adjacent to tooth #18

▸ Endodontic treatment 12 years before

TEXT

J.K.

▸ Saw the Endodontist

▸ Diagnosed as fracture/ non-restorable

▸ Had atraumatic extraction/ ridge preservation graft

▸ 4 months healing

TEXT

CLINICAL EXAM - 4 MO

▸ Site fully healed

▸ Abundant healthy keratinized gingiva

▸ Wide clinical ridge, mildly sloped to buccal

▸ Minimal hyper-eruption of opposing teeth

▸ Unrestricted mandibular opening

TEXT

▸ Astra Implant System EV

▸ 4.8 x 11 mm Profile S implant

▸ EV Guided kit placement

TREATMENT PLAN


VERTICAL SPACE REQUIREMENTS FOR GUIDED IMPLANT SURGERY▸ Drill ▸ Handpiece ▸ Astra Tech EV 4.8 x 13mm fixture - Drill length: 27mm

- Handpiece head: 16mm

- TOTAL: 47mm

!150

WHAT IF THE PATIENT HAS LIMITED OPENING?

STRATEGIES • SLEEVE ON DRILL- MOVE DOWN • DRILL SHORT, THEN LENGTHEN • DRILL FREEHAND WITH STANDARD KIT

!151

TEXT

A CLINICAL PEARL

Go with the longer implant!153


Peri-Implantitis


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!155

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 AND BONE LOSS, JUST LIKE NATURAL DENTITION

•CAN RESULT IN LOSS OF IMPLANTS!156

PERI-IMPLANT MUCOSITIS•32 - 80% INCIDENCE •INFLAMMATION DURING HEALING •BIOFILM HARBORING BACTERIA (GRAM -) •REVERSIBLE INFLAMMATORY CHANGES •NO BONE LOSS

!157

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.


RISK FACTORS FOR PERI-IMPLANT MUCOSITIS AND PERI-IMPLANTITIS

▸ Inadequate diagnostic work-up • Adjacent odontogenic disease, pathology

▸ Poor treatment planning • Inadequate spacing

▸ Improper surgical technique

▸ Inexperienced clinician

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•Avoid manipulating implant fixture for the first 6 weeks of integration

➡Light debridement

➡Chlorhexidine irrigation/ rinse

•Infected- antibiotics ➡amoxicillin

➡cephalosporin

➡clindamycin!160


MANAGEMENT•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!162

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

SIMILARLY COLONIZED •IMPLANT IN FUNCTION •BONE LOSS

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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

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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

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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)

!166

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:


!167

PERI-IMPLANTITIS•MINOR •Scale with titanium

curette •Intrasulcular antibiotics •Home irrigator/ HClO

!168

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

!169

EXPOSED FIXTURE- Expect further

exposure as inflammation reduces

- Pocket depth improves - May be maintainable

for long term

!170

MODERATE IMPLANTITIS•Mild radiographic bone loss/

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

!171

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

PerioDerm •Primary closure

!172

NEWER TECHNOLOGIES TO TREAT PERI-IMPLANT DISEASE

•ER,CR:YSGG LASER - Removes biofilm and Ti Oxide - Removes granulation tissue - Sterilizes sulcus/pocket - May promote bony regrowth

!173

NEWER TECHNOLOGIES TO TREAT PERI-IMPLANT DISEASE

•ER,CR:YSGG LASER - Removes biofilm and Ti Oxide - Removes granulation tissue - Sterilizes sulcus/pocket - May promote bony regrowth •GLYCINE POLISHING - Peri-implant mucositis - Adjuunct to laser

!174

ULTRASONIC IMPLANT DEBRIDEMENTNo peer-reviewed articles showing lack of damage to implant surface

!175


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

!176Reiser GM, Nevins M. The implant periodical lesion: etiology, prevention, and treatment. Compend Contin Educ Dent 16(8): 768-772, 1995


IMPLANT PERIAPICAL LESION

▸ If infected, requires surgical intervention - If not mobile: apical resection and debridement

- If mobile: removal and grafting

!177

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



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!179



!180



!181


FAILING IMPLANT▸ 71 year old female

▸ PMH: HTN, “heart murmur”

▸ Synthroid, lisinopril, Fosamax (3y)

▸ Implant #14 placed 3 years ago

▸ Recurrent sinus infections, OAF

▸ Seen by ENT —> abx

▸ + BOP!182


!183


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

!184

IMPLANT FAILURE

!185

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

!186


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

!187


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

!188

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

!189

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


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

!190

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

THANK YOU!

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essentials level ii handout - online oral surgery...implant surgical flap design implant surgery...

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