Implantology

**1. Many factors are taken into consideration before implant placement. Patients must have adequate bone level and density, adequate oral hygiene, and the absence of system disease that can delay healing. These factors must be present to facilitate success of an implant. MT #18** **2. Radiographs are detrimental in determining the amount of available bone support of an implant. When reevaluating the tissue, probing the area to determine the pocket depth of the implant during the healing phase more than 2 times during can have an effect on the surrounding tissue and decrease supporting tissue. Therefore during the healing phase probing should be limited. SR14**

===3. Straight implants had a greater accuracy with splint technique than non-splint, but when there were 4 or more implants there was greater accuracy with the pick-up technique. Both materials were recommended for the implant impressions. AP12===

After the patient has been place in the maintanace stage the patient can begin the surgical phase. In the surgical phase the patient receives implant placement. Not every patient is a candidate and the clinician will need to determine this as well as factors that can contribute to implant failure. One type of implant is tapered-end implant which are also referred to as screw-shaped implants. Tapered implants have been used because they require less space in the apical region. This advantage is relevant to partial edentulous patients and for implant placement in the anterior region. Tapered implant designs can help to minimize apical bone fenestration. In one study tapered implants were placed at the time of maxillary molar extractions along with demineralized freeze-dried bone allograft, osseous coagulum, and membranes. The results concluded that the implant design and the addition of the regenerative materials at the time of placement produced a more stable implant. However, currently there is no clinical data that supports that tapered has a higher success rate when compared to other implant designs. MC#3
 * 4. Tapered-end implants with a modified insertion technique provided a more stable implant.**


 * 5. The macro- and micro-structure of the implant enhances the osseointegration, and therefore increases the implant's survival rate. TL #8**

Plaque and calculus is the most important factor in periodontal diseases**,** which is why it is important for implant patients to receive cleanings regularly. Having a good implant prognosis depends on the patient and the clinican to remove these local factors. A clinical evaluation of an implant maintenance protocol for the prevention of peri-implant disease in patients treated with immediately loaded full-arch rehabilitations. The aim was to determine the outcomes of an implant maintenance protocol for implants supporting a full-arch rehabilitation. In the study was conducted on sixty-one patient (28 women and 33 men) treated with immediately loaded full-arch rehabilitation, both mandibular and maxillary, that were supported by a combo of two titled and two axial implants. These patients were scheduled for follow-up visits every 6 months for two years, then yearly up to four years. All patients received oral hygiene treatment and detailed oral hygiene instructions. During each visit, plaque index, bleeding index and probing depth were taken. Presence of peri-implant tissue inflammation was also evaluated. Results revealed plaque frequency decreased over time. Probing depths were stable. Only three implants were lost due to perio-implantitis. The incidence of peri-implant mucositis was less than 10% in each considered period. In conclusion the systemic hygiene protocol is effective in keeping a low incidence of peri-implant mucositis as well as controlling plaque and clinical attachment loss.
 * 6. Plaque and calculus are factors that can affect the outcome or prognosis of a dental implant.** **GE#6**

Corbella, S, Del Fabbro, M, Taschieri, S, De Siena, F, & Francetti, L. (2010). Clinical evaluation of an implant maintenance protocol for the prevention of peri-implant diseases in patients treated with immediately loaded full-arch rehabilitations. Pubmed, Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21356024

Risk factors that can interfere with the overall success rate of an implant placement is bone loss, poor oral hygiene, patient age, presences of systemic environmental factors and the patients current health status that can delay healing. For these reasons it is real important that a thorough discussion of the treatment plan and anticipated outcomes should be discussed with the patient.


 * 7. New technology has enabled more sophisticated ways of analyzing patients' anatomy for implant placement. MW 19**

With the advancements in technology in recent years dentistry has been able to use new techniques in order to evaluate patients. In the field of implantology some of the new technology that has been introduced includes computed tomography (CT) and software programs that analyze the images that are obtained through radiographs or CT scans. More recently CAD/CAM systems have been introduced to aid in the planning, placing, and manufacturing of implants. These technologies aide in the evaluation and assessment of the quality and quantity of bone, and are able to prepare a guide for the dentist to follow for placement, including if a bone graft is needed and how much bone needs to be augmented. The CAD/CAM system also fabricates the implant based on the analysis of the patient and what shape of implant is most suitable. These advancements have shown increased predictability and success of implants.

After an implant or implants have integrated into the bone and the restorations have been placed, the soft tissues should be evaluated for the following: Quality of the peri-implant tissue; presence of plaque and calculus; radiographic appearance of implant; presence of suppuration in the peri-implant tissue; and mobility of the implant or prosthesis. When instrumenting implants the following points should be kept in mind: Calculus formation on implant surfaces is less tenacious than on natural teeth; Metal instruments have been shown to scratch titanium implant surfaces; Plastic, graphite and gold tipped instruments are appropriate for implants; Plastic probes are available for probing peri-implant tissue when necessary; Rubber tips and plastic interdental brushes may also be effective for deplaquing implant surfaces; Specially designed, plastic coated ultrasonic tips, may be safely used on dental implants; and Low abrasive polishing paste and cleaning agents can be used safely when polishing is indicated for stain removal.
 * 8. Improper instrumentation can effect the amount of plaque build up on implants RK 7**

In regards to the care and maintenance of implants the perio.org position paper states that Patients should be on a regular recall schedule to monitor the maintenance, including plaque control, of the implant-supported prostheses. Maintenance appointments for patients with an implant should be designed on an individual basis and the following should be considered: methods of plaque and calculus removal, and appropriate antimicrobial agents for maintenance around implants. Studies on the maintenance of implants state that steel curets should not be used to remove calculus because of the potential of scratching the abutments which would lead to further plaque accumulation. An Instrument that is approved for the maintenance of implants is a titanium-tipped curet. However, in conflicting studies these instruments have been indicated to produce rougher surfaces than those treated with steel instruments. On the other hand a literature review on dental implant maintenance determined that roughened implant abutment surfaces caused by different maintenance techniques have not been shown to increase implant complications. The study concluded that more research must be conducted in order to determine the best choice of instruments for treating an implant.

Reference: Iacono, V. (2000). Academy report: dental implants in periodontal therapy. Retrieved from http://www.perio.org/resources-products/pdf/31-implants.pdf

Many factors influence the outcome of the implant and should be considered prior to the implant being placed. These factors include quantity, quality and location of available bone, the patient's mental and physical health and possible risk factors and contraindications. Patients should always be presented with at least two treatment plans; one including implant placement and one without.
 * 9. Most patients, whether missing a single tooth, several teeth, or all their teeth, can be candidates for dental implant therapy. CE5**

**10. It is important to be able to discuss with patient risk factors and contraindications related to implant placement. KT4**
Conditions such as uncontrolled diabetes, bone disease, those immune compromised or under going radiation therapy are examples of some risk factors or contraindications for implant therapy. Diabetes is not a direct contraindication, but it is a risk factor. Some studies noted by Caranza stated that it was noted some later implant failures were higher in diabetic patients, but could not relate a direct correlation with the control or lack of blood glucose levels. Caranza suggests patient with AIDS or HIV should most likely not have implant placement due to delayed wound healing and their reduced resistance to infection. Implant placement for patients with past radiation treatment and osteoporosis are still under debate, there is no clear evidence for contraindication. It is important to be able to discuss with these patients treatment options as well as possible outcomes of implant placement.

11. Different specialists have different ways in placing implants. Some specialists would extract a tooth or teeth and place bone graft in the area before placing an implant in 3 or 6 months. The specialist wanted to see the integration and the increase in bone density and bone volume before placing an implant. Some specialists would choose to place an implant immediately after a tooth was extracted and placed graft material in the area. There's no right or wrong way to place an implant. The success rate of the implant could be base on different factors such as smoking, diabetes which delays the healing of the tissues, patients who have previously taken biophosphonate and patient maintenance and patient compliance to home care. As clinicians, we should reinforce the importance of 3 month re-care as part of implant maintenance and daily home care instructions for implants. LL#9.