Implant success – not just about the bone… – Dr Boota Uhbi
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There are many factors that can affect the short- and long-term success of dental implants. Both biological and mechanical criteria are involved, including biocompatibility of materials, implant surface characteristics, cell growth and function, primary stability and success of osseointegration.[1]Today, much emphasis is placed on the need to manage and optimise the soft tissue surrounding an implant in order to encourage ideal treatment outcomes.
To get this right, it’s important to understand the biological differences between natural teeth and implants. A natural tooth has three methods of blood supply – supraperiostal vessels and blood vessels from the periodontal ligament and alveolar bone.[2]The main challenge for soft tissue around an implant is that it lacks the periodontal ligament. As this would evenly distribute forces applied to a natural tooth, in its absence, excessive stress can accumulate at the crestal region around an implant and lead to bone loss.[3]
There are various facets involved with managing the gingiva around implants. All factors should be considered during the planning stage of treatment, where the clinician will need to perform a full assessment in order to predict and subsequently reduce the risk of any complications occurring. Beyond designing the surgical procedure for optimal results in each individual case, on-going oral hygiene is key for continued soft tissue health and the patient must appreciate their role if they are to enjoy the long-term benefits of successful implant therapy.
Materials
The interface between the implant and soft tissue is influenced by the materials used. For example, peri-implant epithelium cells are believed to attach to titanium in much the same way that the junctional epithelium cells attach to natural tooth roots.[4]Zirconia has also been shown to promote a beneficial soft tissue response, with some research finding it to be superior to titanium in this area.[5]Biocompatibility of the materials employed therefore has a significant effect on the gingival stability and aesthetics following implant treatment. Employing a tried-and-trusted implant system that promotes primary stability and soft tissue healing will encourage better results post surgery.
Periodontal biotype
The soft tissue biotype can influence the success of implant treatment. As categorised by Olsson and Lindhe (1991),[6]there are two types of periodontal tissue – thin, scalloped and thick, flat periodontium. The two biotypes each react differently to inflammation, trauma and surgical intervention.[7]
With regards to implant surgery, the biotype should be considered during the treatment planning phase in order to optimise preparation of the site for good aesthetic outcomes. Thicker biotypes are associated with enhanced stability compared to thinner biotypes, so augmentation procedures are sometimes indicated where there is insufficient gingival tissue to allow for bone growth or an aesthetic outcome. Good long-term results can be achieved with such a procedure in the right cases, including with immediate implant placement and provisionalisation.[8]
Technique
Effective soft tissue management begins with proper tooth extraction. The removal of the tooth has been shown to cause rapid resorption of the alveolar ridge within the initial few months, which can affect the aesthetics of the soft tissue and consequently the treatment outcome. Atraumatic extraction has been shown to improve preservation of the alveolar bone and adjacent soft tissue,[9]and this should be the aim of every procedure.
Oral hygiene
Beyond extraction and surgical placement of the dental implant, on-going maintenance of the soft tissue is required for long-lasting results. Internal factors include the patient’s general health, periodontal condition and age, as well as the amount of keratinizing mucosa around the implant. External influences consist of the patient’s tobacco smoking habits, adequacy of soft tissue rest during the healing phase and preservation of the biological width of the soft tissue.[10]
Maintenance of oral health at home is particularly important for longevity of dental implants. A leading cause of complications in this field is peri-implant inflammation and good oral hygiene is a key issue in terms of prevention.[11]Patients should be sufficiently educated on how, when and why to look after their teeth, implant(s) and gingiva before surgery commences and resources made available to freshen their memory in the following months. Protocols should include brushing twice daily and interdental cleaning,[12]with products recommended that are specifically designed for and clinically proven to improve oral health around dental implants. This should be accompanied by professional supportive care at appropriate time intervals post surgery.[13]
Maximising chances of success
The aesthetics of the smile following implant surgery – especially where anterior implants are placed – can be a significant marker of a patient’s satisfaction with treatment. Effective management of the soft tissue surrounding an implant is crucial if aesthetics, as well as health and function, are to be optimised in the long-term. Ensuring you have sufficient knowledge and skills to achieve the best outcomes for your patients is key, so why not learn from one of the best in the business and attend a course by Dr Boota Singh Ubhi, Specialist Periodontist and renowned implantologist? He also accepts referrals at BPI Dental for complex cases where soft tissue management requires advanced intervention.
For more information on the referral service available from Birmingham Periodontal & Implant (BPI) Dental, visit www.bpidental.co.uk, call 0121 427 3210 or email info@bpidental.co.uk
[1]Alias CN. Factors affecting the success of dental implants. Implant Dentistry – A rapidly evolving practice. Chapter 14. Pages 356-357. Intechopen. Pub August 2011 https://www.intechopen.com/books/implant-dentistry-a-rapidly-evolving-practice/factors-affecting-the-success-of-dental-implants[Accessed August 2018]
[2]Bhatavadekar N. Peri-implant soft tissue management: Where are we? Journal of Indian Society of Periodontology. 2012;16(4):623-627. doi:10.4103/0972-124X.106938.
[3]Gulati M, Anand V, Govila V, et al. Periodontio-integrated implants: A revolutionary concept. Dental Research Journal. 2014;11(2):154-162.
[4]Gould, T.R., Westbury, L., and Brunette, D.M. Ultrastructural study of the attachment of human gingiva to titanium in vivo. J Prosthet Dent. 1984; 52: 418–420
[5]Blaschke C, Volz U. Soft and hard tissue response to zirconium dioxide dental implants–a clinical study in man.Neuro Endocrinol Lett. 2006 Dec;27 Suppl 1:69-72.
[6]Olsson M, Lindhe J. Periodontal characteristics in individuals with varying form of the upper central incisors. J Clin Periodontol. 1991;18:78–82.
[7]Abraham S, Deepak KT, Ambili R, Preeja C, Archana V. Gingival biotype and its clinical significance – A review. The Saudi Journal for Dental Research. January 2014;(5)1: 3-7
[8]Rojo R, Prados-Frutos JC, Manchon A, Rodriguez-molinero J, Sammartino G, Guirado JLC, Gomez-de Diego R. Soft tissue augmentation techniques in implants placed and provisionalized immediately: A systematic review. BioMed Research International. vol. 2016, Article ID 7374129, 12 pages, 2016. https://doi.org/10.1155/2016/7374129.
[9]M Kubilius, R Kubilius, A Gleiznys. The preservation of alveolar bone ridge during tooth extraction. Stomatologija. 2012;14(1):3–11
[10]Talwar BS. A Focus on Soft Tissue in Dental Implantology. The Journal of the Indian Prosthodontic Society. 2012;12(3):137-142. doi:10.1007/s13191-012-0133-x.
[11]Smeets R, Henningsen A, Jung O, Heiland M, Hammacher C, Stein JM. Definition, etiology, prevention and treatment of peri-implantitis – a review. Head & Face Medicine. 2014;(10)34 https://doi.org/10.1186/1746-160X-10-34[Accessed August 2018]
[12]Gulati M, Govila V, Anand V, Anand B. Implant Maintenance: A Clinical Update. International Scholarly Research Notices. 2014;2014:908534. doi:10.1155/2014/908534.
[13]European Federation of Periodontology. Guidelines for effective prevention of peri-implant diseases. Guidance for dental professionals. https://www.bsperio.org.uk/publications/downloads/84_092940_efp-prevention-workshop-guidelines-implants.pdf[Accessed August 2018]
Author biography:
Boota graduated in 1992 and later gained an MSc in Periodontology from Liverpool University. He became a lecturer at the University and passed his Membership in Restorative Dentistry form the Royal College of Surgeons of England in 2000 to become a registered Specialist in Periodontology. Since then, Boota has lectured at universities and educational events in the field of periodontics, dental implantology and bone / soft tissue augmentation, running his own implant training programme for colleagues as well. He is also an active member of the British Society of Periodontology, the Association of Dental Implantology and the American Academy of Periodontology.
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