Periodontal Considerations in Implant Site Preparation

1. PERIODONTAL CONSIDERATIONS
IN
IMPLANT SITE DEVELOPMENT

2. Advanced Periodontitis
Arch/FMR

3. AN IMPLANT IS NOT A
TOOTH
A tooth can survive if it still has disease
A dental implant with disease can hardly be called successful
Tooth substitute getting precedence over a tooth….

4. Criteria Flap Surgery Implant Placement
Initial Success • 0.2 t/y to 0.06 t/y*
• Flap surgery and regenerative
therapies were equally
effective in the short term
• The cumulative survival at 1-, 2-
and 5-years is 96%, 87%, and
81%⁑
Survival Rates • 0.007 t/y at 20 years**
• 10 years, attachment loss was
significantly more for the flap
surgery group than for the
regenerative group**
• 10-yr survival rate of implant-
supported single crowns is 95.2%
and that of implant-supported
FPD is 93.1%.
• Annular failure rate can be 0.3%
to 1.3%‡
*J Clin Periodontol. 2019;46:840–845. **Cortellini et al., 2017⁑ Int J Implant Dent 8, 15 (2022).‡J Oral Implantol (2022) 48 (4): 261–262.
‖J Clin Periodontol 2014; 41:1090-1097. ◦Kyle Summerford & Scott Froum, Feb. 27, 2015.⁋ Periodontol 2000. 2012;59(1):89-110.

5. IMPLANT SITE DEVELOPMENT Bartee (2011)
IMPLANT SITE DEVELOPMENT REFERS TO A VARIETY OF PROCEDURES
AIMED AT AUGMENTING AN EDENTULOUS RIDGE TO OPTIMIZE
IMPLANT POSITIONING FOR EXCELLENT PROSTHESIS AESTHETICS AND
FUNCTION.
Bartee BK. Implant Site Development and Extraction Site Grafting. 2011 by Osteogenics Biomedical, Inc

6. Ganz SD. Thetriangle of bone—a formula for successful implant placement and restoration. Article in The Implant Society: [periodical]· January 1995.
Garcia JJ et al. A new protocol for immediate implants. The rule of the 5 triangles: A case report – EAO 2014.
Biotype
Primary
stability
Implant
design
Jumping Gap
Buccal Plate
RULE OF FIVE TRIANGLES

7. PRIMARY STABILITY
Azoubel E, Freitas AC, Azoubel MCF, et al. Reabsorbable wire use for fixing membrane on bone graft surgery. MOJ Surg.
2016;3(4):90-92. DOI: 10.15406/mojs.2016.03.00051

8. PRIMARY STABILITY

9. PRIMARY STABILITY

10. ᴧInfection
ᴧ Heat production
˅ Blood Supply
˅ Porosity
Periodontal
Bone loss
Adequate
Bone Quantity
PRIMARY STABILITY
SITE WITH PERIODONTITIS

11. PRIMARY STABILITY
Dental Implants Fail at a Rate 10 Times That of Natural Teeth in
Patients with Treated Chronic Periodontitis*
*Guarnieri R, Di Nardo D, Di Giorgio G, Miccoli G, Testarelli L. Longevity of teeth and dental implants in patients treated for chronic periodontitis following periodontal maintenance therapy in a private specialist
practice: a retrospective study with a 10-year follow-up. Int J Periodontics Restorative Dent. 2021;41(1):89-98. **Ayangco L et al 2001, Marconcini S et al 2013, MM Abdulmunem 2022.
Infection reduces primary stability**
Implants should only be inserted when
periodontal conditions are stable (Koch
2018)
Granulomatous tissue left in infected
fresh sockets doesn’t impact dental
implant outcome (Crespi et al 2016)
Periodontitis affects bone quality
and quantity
Periodontitis transforms the alveolar
envelope (Zhang et al 2020)
Bone defects will impact implants and
restorative treatments (Papalexiou et
al 2006)

12. PRIMARY STABILITY
Elimination of Inflammation by PMPR
Implant success- and survival rate in periodontitis is determined by
microbiological and/or inflammation free tissue environment
Location of the implant abutment interface
Residual Granulomatous
Tissue

13. PRIMARY STABILITY
Prosthesis-centric Implant Positioning
A 0.75 mm thick inflammatory/Connective tissue cell infiltrate at implant-abutment area
Human biopsy shows a 0.35mm inflammatory infiltrate in the same region (Luongo et al)
Inflammation α Bone Loss α Loss of Stability

14. IMPLANT DESIGN
K3Pro® Adin® K3Pro® Short

15. IMPLANT DESIGN
Why does the extraction socket have a different implant design?
Why is it necessary to do so?

16. ≠
IMPLANT DESIGN

17. Bad
BONE
Good
BONE RESPONSE
IMPLANT DESIGN

18. IMPLANT DESIGN

19. IMPLANT DESIGN
SINGLE-
PIECE
ZIRCONIA
IMPLANT
TITANIUM
IMPLANT
STABILITY HIGHER ISQ VALUES OVER
TITANIUM IMPLANT
COLOR TOOTH LIKE
COLOR THAT
CAN AID IN
AESTHETIC
BENEFITS
GREY COLOR
PLAQUE AFFINITY LOW HIGHER
BIOCOMPATIBILITY HIGH AS IT
IS METAL
FREE
COMPARATIVELY
LOW AS IT IS
METALLIC IN
NATURE
Memè et al 2022, Arlucea N et al 2021, Calvo-Guirado et al 2015

20. JUMPING DISTANCE

21. Compensating for osteogenic jumping distance
LARGER DIAMETER IMPLANT
BUCCAL POSITIONING
GRAFTING ON BUCCAL BONE
X Bone response?
X Loss of prosthetic centre
X More Bone loss
M. G. Araujo, F. Sukekava, J. L. Wennstrom, and J. Lindhe, Clinical Oral Implants Research, vol. 17, no. 6, pp. 615 –624, 2006.
JUMPING DISTANCE

22. Type III
(Semilunar defect)
No Grafting Needed
Type II (Palatal Defect)
Overgrafting and Palatal Side Grafting advised
Deporter D, Khoshkhounejad AA, Khoshkhounejad N, Ketabi M. A new classification of peri implant gaps based on gap location (A case series of 210 immediate implants). Dent Res J (Isfahan). 2021 Apr 6;18:29.
PMID: 34249255; PMCID: PMC8248266.
Type I (Buccal Defect)
Implant will hold the clot
Type IV
(Implant placed in septa)
No Grafting Needed
JUMPING
DISTANCE

23. Type VI
(Mesial and distal)
Interseptal
Placement
Type VII
(Mesial and distal)
Socket Placement
Type V
Palatal
Socket Placement
JUMPING
DISTANCE

24. BUCCAL PLATE
LOSS OF BUCCAL PLATE
BIOLOGICAL
BONE
›Bone Quality
›Bone Quantity
MECHANICAL
SOFT TISSUE
›Biotype
›Flap Design
IMPLANT SIZE
›Diameter
›Length
IMPLANT DESIGN
›Macrosurface
›Microsurface
Hämmerle CH. et al., Int J Oral Maxillofac Implants. 2004;19 Suppl:26-8.

25. Immediate Implant
Metal Show
(IIM)
Delayed Implant
Shadow Show
(DISS)
Delayed Implant
Actual Show
(DIAS)
Mazen Almasri. Surgical Science. 2013:4;110-113.
Signs of a “losing or lost buccal plate”

26. Managing the Plate of Bone Greenstein and Cavallaro (2013)
NO ADDITIVE
TREATMENT
BONE GRAFT
+/-
GROWTH
FACTORS
BARRIER
ONLY
BARRIER
+
BONE GRAFT
›Flap
positioned
over defect
›Flap Placed at
crest
›Flap
positioned
over defect
›Flap Placed at
crest
›With Flap
Advancement
›Without Flap
Advancement
›With Flap
Advancement
›Without Flap
Advancement
Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant Placement.
Continuing Education . Course Number: 159 2013

27. No additive treatment
Flap positioned at bone crest
Gaps < 2 mm usually heal without allografts, xenografts,
and barriers when implants are submerged
Juodzbalys G, Wang HL. Soft and hard tissue assessment of immediate implant placement: a case series. Clin Oral Implants Res. 2007;18:237-243.

28. No additive treatment
Flap placed over the defect
Extraction socket like defects with
respect to height and width could
be eliminated without the use of a
membrane and/or a bone graft.
Chen ST, Darby IB, Adams GG, et al. A prospective clinical study of bone augmentation techniques at immediate implants. Clin Oral Implants Res. 2005;16:176-184.

29. BONE GRAFT
+/-
GROWTH
FACTORS
›Flap
positioned
over defect
›Flap Placed at
crest
Managing the Plate of Bone Greenstein and Cavallaro (2013)

30. Graft with or without Growth Factors
With Flap at the crest
RhBMP-2
Del Fabbro M, Tommasato G, Pesce P, Ravidà A, Khijmatgar S, Sculean A, Galli M, Antonacci D, Canullo L. Sealing materials for post-extraction site: a
systematic review and network meta-analysis. Clin Oral Investig. 2022 Feb;26(2):1137-1154. doi: 10.1007/s00784-021-04262-3. Epub 2021 Nov 25.
PMID: 34825280; PMCID: PMC8816783

31. Graft with or without Growth Factors with Flap over the defect
Korsch M, Peichl M. Retrospective Study: Lateral Ridge Augmentation Using Autogenous Dentin Tooth-Shell Technique vs.
Bone-Shell Technique. Int J Environ Res Public Health. 2021 Mar 19;18(6):3174. doi: 10.3390/ijerph18063174. PMID:
33808616; PMCID: PMC8003557

32. *RONALD E. JUNG,ALEXIS IOANNIDIS,CHRISTOPH H. F. H€AMMERLE & DANIEL S. THOMA. Periodontology 2000, Vol. 0, 2018, 1–11.
Turchi JL. Dent Today. 2008 Jun;27(6):112, 114.
If the endpoint is high quality bone, use Autografts and
Bioactive glasses

33. BARRIER
ONLY
›With Flap
Advancement
›Without Flap
Advancement
Managing the Plate of Bone Greenstein and Cavallaro (2013)

34. Barrier only without Flap advancement
Preservation of Vital Landmarks
Sbricoli L, Guazzo R, Annunziata M, Gobbato L, Bressan E, Nastri L. Selection of Collagen Membranes for
Bone Regeneration: A Literature Review. Materials (Basel). 2020 Feb 9;13(3):786. doi:
10.3390/ma13030786. PMID: 32050433; PMCID: PMC7040903.

35. Barrier only with Flap advancement
MacBeth ND, Donos N, Mardas N. Alveolar ridge preservation with guided bone regeneration or socket seal
technique. A randomised, single-blind controlled clinical trial. Clin Oral Implants Res. 2022 Jul;33(7):681-699. doi:
10.1111/clr.13933. Epub 2022 Jun 22. PMID: 35488477; PMCID: PMC9541021.

36. BARRIER
ONLY
BARRIER
+
BONE GRAFT
›With Flap
Advancement
›Without Flap
Advancement
›With Flap
Advancement
›Without Flap
Advancement
Managing the Plate of Bone Greenstein and Cavallaro (2013)

37. Barrier placed over graft without Flap advancement
Dentine block
+
Roll Technique
Bassetti RG, Stähli A, Bassetti MA, Sculean A. Soft tissue augmentation procedures at second-stage surgery: a systematic review. Clin Oral Investig. 2016 Sep;20(7):1369-87. Li Y, Zhou
W, Li P, Luo Q, Li A, Zhang X. Comparison of the osteogenic effectiveness of an autogenous demineralised dentin matrix and Bio-Oss® in bone augmentation: a systematic review and
meta-analysis. Br J Oral Maxillofac Surg. 2022 Sep;60(7):868-876.

38. Barrier placed over graft with Flap advancement
Urban I, Montero E, Sanz-Sánchez I, Palombo D, Monje A, Tommasato G, Chiapasco M. Minimal invasiveness in vertical
ridge augmentation. Periodontol 2000. 2023 Feb;91(1):126-144. doi: 10.1111/prd.12479. Epub 2023 Jan 26. PMID:
36700299.

39. BIOTYPE

40. “Learn to do common things uncommonly well.”
― George Washington Carver

41. viswachandra@hotmail.com