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Implant Inflammatory and Destructive Diseases

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Implant Inflammatory and Destructive Diseases PERI-IMPLANT INFLAMMATORY AND DESTRUCTIVE DISEASES (PERI-IMPLANT MUCOSITIS AND PERI- IMPLANTITIS) Prof. Dr Christina Popova, DDS, PhD Two pioneers in implant dentistry: P.-I. Bränemark (University of Gothenburg, Sweden) and A. Schroeder (University of Berne, Switzerland), who first put forth the concept of osseointegration or functional ankylosis, respectively (Branemark et al., 1969, 1977; Schroeder et al., 1976, 1978, 1981). OSSEOINTEGRATION Both researchers described this biologic phenomenon as: "DIRECT BONE DEPOSITION UPON THE IMPLANT SUFACE" (Brånemark et al. 1969) (Albrektsson et al. (1981) “A PROCESS WHEREBY CLINICALLY ASYMPTOMATIC RIGID FIXATION OF ALLOPLASTIC MATERIALS IS ACHIEVED AND MAINTAINED IN BONE DURING FUNCTIONAL LOADING” (Zarb and Albrektsson (1991) OSSEOINTEGRATION (Brånemark et al. 1969) The primary goal of implant installation is to achieve and maintain a stable bone-to-implant connection (i.e., osseointegration). Histologically, osseointegration is defined as the direct structural and functional connection between ordered, living bone and the surface of a load- bearing implant without intervening soft tissues Clinically, osseointegration is the asymptomatic rigid fixation of an alloplastic material (implant) in bone with the ability to withstand occlusal forces. The hard tissue interface is a fundamental requirement for and an essential component of implant success. Osseointegration represents a direct bone to implant contact Osseointegration represents a direct connection between bone and implant without interposed soft tissue layers Three-dimensional diagram of the tissue and titanium interrelationship showing an overall view of the intact interfacial zone around the osseointegrated implant IN ORDER TO ACQUIRE PROPER CONDITIONS FOR HEALING, THE IMPLANT FOLLOWING INSTALLATION MUST EXHIBIT GOOD MECHANICAL STABILITY OSSEOINTEGRATION IS A TIME-RELATED PHENOMENON Chr. Popova OSSEOINTEGRATION Dynamic process Healing phase: 0 - 12 months Remodeling phase: 3 - 18 months Steady state: 18 months --- OSSEOINTEGRATION a dynamic process HEALINGREMODELING DYNAMIC EQUILIBRIUM HEALING DYNAMIC REMODELING EQUILIBRIUM After insertion of an implant, slight tissue necrosis may result from surgical trauma. This tissue or the interposed blood clot is removed by the multinucleated osteoclasts and is replaced by osteoid (poorly mineralized) bone, which will then become woven and later lamellar bone. Carranza’s Clinical Periodontology NB BONE MATURATION Pre-existing bone (PB) extends into threads providing stability. New Bone (NB) in close PB apposition to the implant New Bone deposition approximately 1um/day A, AFTER INITIAL HEALING, WOVEN BONE, AS CHARACTERIZED BY ITS IRREGULAR PATTERN, IS LAID DOWN. B, AFTER WEEKS OR MONTHS, PROGRESSIVELY A LAMELLAR BONE IS LAID DOWN, WITH REGULAR CONCENTRIC LAMELLAE. (PROF. T. ALBREKTSSON, GOTHENBURG, SWEDEN.) Carranza’s Clinical Periodontology IMPLANT - SOFT TISSUE INTERFACE Healthy NORMAL GINGIVAL ARCHITECTURE MINIMAL INFLAMMATORY INFILTRATE CONNECTIVE TISSUE CLOSELY ADAPTED TO THE IMPLANT SOFT TISSUE RELATIONSHIP SIMILAR TO TEETH NO SHARPEYS FIBERS HEMIDESMOSOMAL ATTACHMENTS CIRCUMFERENTIAL AND PARALLEL CONNECTIVE TISSUE FIBERS Implant, abutment (Ab), and crown within alveolar bone and soft tissues. Im, Endosseous part of implant; MR, margin of gingiva/alveolar mucosa; Bo, marginal bone level; 1, implant crown; 2, vertical alveolar-gingival connective tissue fibers; 3, circular gingival connective tissue fibers; 4, circular gingival connective tissue fibers; 5, periosteal-gingival connective tissue fibers; a, junctional epithelium; b, sulcular epithelium; c, oral epithelium; A/ I, abutment/implant junction; aAE, apical (point) of attached epithelium. Mauricio G. Araujo, Jan Lindhe J Periodontol. 2018;89(Suppl 1):S249–S256. The aim is to define clinical and histologic characteristics of peri-implant tissues in health and describe the mucosa–implant interface. An understanding of the characteristics of healthy peri-implant tissues facilitates the recognition of disease (i.e., departure from health). The healthy peri-implant mucosa is, at the microscopic level, comprised of a core of connective tissue covered by either a keratinized (masticatory mucosa) or non-keratinized epithelium (lining mucosa). The peri-implant mucosa averages about 3 to 4 mm high, and presents with an epithelium (about 2 mm long) facing the implant surface. Small clusters of inflammatory cells are usually present in the connective tissue lateral to the barrier epithelium. Most of the intrabony part of the implant appears to be in contact with mineralized bone (about 60%), while the remaining portion faces bone marrow, vascular structures, or fibrous tissue. During healing following implant installation, bone modeling occurs that may result in some reduction of the marginal bone level. Peri-implant mucosa. Peri-implant tissues are those that occur around osseointegrated dental implants. They are divided into soft and hard tissue compartments. The soft tissue compartment is denoted “peri- implant mucosa” and is formed during the wound healing process that follows implant/abutment placement. The hard tissue compartment forms a contact relationship to the implant surface to secure implant stability. Due to their histologic and anatomic features, peri- implant tissues carry out two basic functions: the mucosa protects the underlining bone, while the bone supports the implant. Indeed, the destruction of peri-implant tissues can jeopardize the implant success and survival, and the understanding of the characteristics of healthy peri- implant tissues allows the recognition of disease. NORMAL PERI-IMPLANT MUCOSA THE STRUCTURE AND FUNCTION OF THE MUCOSA THAT SURROUNDS IMPLANTS MADE OF COMMERCIALLY PURE TITANIUM HAS BEEN EXAMINED IN MAN AND SEVERAL ANIMAL MODELS (Berglundh 1999) In an early study in the dog, Berglundh et al. (1991) compared some anatomical features of the gingiva (at teeth) and the mucosa at implants. The mandibular premolars in one side of the mandible were extracted, leaving the teeth in the contralateral jaw quadrant. After 3 months of healing following tooth extraction implants made of titanium were installed Another 3 months later, abutment connection was performed in a second stage procedure and the animals were placed in a careful plaque control program. Berglundh et al. 1991 After 4 months of careful plaque control the gingiva and the peri-implant mucosa are clinically healthy. Four months subsequent to abutment connection, The clinically healthy gingiva and peri-implant mucosa, have several Berglundh et al. 1991 features in common. BIOLOGIC WIDTH - EPITHELIAL ATTACHMENT + CONNECTIVE TISSUE ATTACHMENT BIOLOGIC WIDTH DEFINED VOLUME OF SOFT TISSUES THAT ARE ATTACHED TO THAT PART OF THE TOOTH / IMPLANT THAT IS CORONARY TO ALVEOLAR BONE CREST Garguilo et al. 1961 – 2.04mm Vacek et al. 1994 – 1.91mm NORMAL PERI-IMPLANT MUCOSA The clinically healthy gingiva and peri-implant mucosa, have common features – keratinized oral epithelium, The junctional epithelium is about 2 mm long and the supracrestal connective tissue portion about 1 mm high THE POSITION OF THE SOFT TISSUE MARGIN 2 mm long junctional epithelium THE APICAL CELLS OF THE JUNCTIONAL EPITHELIUM 1.5mm high of connective tissue in direct contact with the implant THE CREST OF THE ALVEOLAR BONE Berglundh et al. 1991 COMPARISON STRUCTURE OF PERIODONTAL TISSUE Higher magnification of the supracrestal connective tissue portion Note the direction of the principal fibers IMPLANT / CONNECTIVE TISSUE INTERFACE Microphotograph of a section (buccal/lingual) of the implant/connective tissue interface of the peri-implant mucosa. The collagen fibers invest in the periosteum of the bone and project in directions parallel to the implant surface towards the margin of the soft tissue. Abrahamsson et al. 1996 IMPLANTS OF THREE SYSTEMS INSTALLED IN THE MANDIBLE OF A BEAGLE DOG.: Astra Tech Implants Dental System (left) Branemark System (center) и ITI Dental Implant System (right) Astra Tech Implants Branemark System ITI Dental Implant System Dental System THE TRANSMUCOSAL ATTACHMENT AT ALL IMPLANTS INCLUDES: ONE BARRIER EPITHELIUM THAT WAS 2 mm LONG AND ONE ZONE OF CONNECTIVE TISSUE ATTACHMENT THAT WAS 1-1.5 mm HIGH THE BIOLOGICAL HEIGHT OF THE TRANSMUCOSAL ATTACHMENT WAS FURTHER EXAMINED IN A DOG EXPERIMENT BY Berglundh & Lindhe (1996). In biopsies obtained after 6 months of careful plaque control, it was observed that the transmucosal attachment at all implants IN THE LEFT SIDE OF THE MANDIBLE included one barrier epithelium that was 2mm THE VOLUME OF THE RIDGE MUCOSA long and one zone of connective tissue WAS MAINTAINED WHILE IN THE attachment that was 1-1.5mm high. RIGHT JAW THE VERTICAL At sites where the mucosa prior to abutment DIMENSION OF THE MUCOSA WAS connection was made thin (2mm), disclosed REDUCED TO ≤2mm that wound healing consistently had included marginal bone resorption to establish a mucosa that was 3mm high. Microphotograph illustrating the peri-implant mucosa of a normal dimension (left) and reduced dimension (right). Note the angular bone loss that had occurred at the site with the thin mucosa. Berglundh & Lindhe 1996 NORMAL PERI-IMPLANT MUCOSA Soft Tissue Relationship between oral mucosa and titanium implants comprises junctional epithelium a height of about 2mm and an area of connective tissue of ≥1mm height Is assumed that this attachment provide protection of an area of osseointegration by factors of plaque and
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