FAILING IMPLANT??

Todd C. Gerlach D.D.S. Diplomate, American Board of Oral and Maxillofacial Surgery

September 10, 2015

1

What is Failure?

• Main Entry: fail • ure

• Pronunciation: feyl-yer

• Function: noun

• 1) a : a failing to do or perform <failure to pass the test> b : neglect of an assigned or expected action <failure to pay on time> c : inability to perform a normal function well enough <heart failure>

• 2) a : a lack of success <failure in the campaign> b : BANKRUPTCY <a business failure>

• 3) a : a falling short : DEFICIENCY <crop failure> b : a breaking down <a failure of memory>

• 4) one that has failed <the scheme was a complete failure>

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What is Success?

• Osseointegrated implant with minimal to no bone loss over time

• Provides appropriate function

• Esthetically pleasing

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What is Failure?

• Biomechanical failure

• Esthetic failure

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Failure Types

• Surgical failure

• Restorative failure

• Peri-implant disease

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Surgical Failure

• Why didn’t we get integration?

• Inadequate bone volume

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Surgical Failure

• Inadequate bone quality

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Surgical Failure

• Thermal

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Surgical Failure

• Implant position

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Surgical Failure

• Unknown cause

• Patient selection

• Patient response

• Implant fracture

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Restorative Failure

• Cement

• Occlusal Forces

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Cement

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Occlusion

• Clenching and grinding

• Excursive forces

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Peri-Implant Disease

• Peri-implant mucositis

• inflammatory process limited to the soft tissue

• Peri-implantitis

• inflammatory process that includes the soft tissue as well as progressive bone loss

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Peri-implant Disease

• Prevalence

• 63.4% of patients and 30.7% of implants with peri-implant mucositis

• 18.8% of patients and 9.6% of implants with peri-implantitis

• M.A. Atieh, N.H. Alsabeeha, C.M. Faggion Jr., W.J. Duncan.The frequency of peri-implant diseases: a systematic review and meta-analysis. Journal of Periodontology, 84(11), 2013, 1586-1598.

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Ailing, Failing, Failed

• Ailing refers to an implant that is clinically stable but has soft tissue involvement

• Failing refers to an implant that is also stable but has bone loss

• Failed is either fractured or mobile

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Diagnosis

• Probing

• depth

• bleeding on probing

• Radiographs

• Mobility

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Treatment

• Nonsurgical

• Surgical

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Nonsurgical Treatment

• Debridement

• multiple studies have shown very limited benefit

• Surface decontamination

• chemical, laser, air abrasion

• almost all worked in vivo, but not nearly as well in vitro

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Nonsurgical Treatment

• Local antibiotics

• Arestin, Chlorhexidine, Doxycycline

• Limited reduction in pocket depth, but decreased bleeding on probing

• S. Renvert, J. Lessem, G. Dahlén, H. Renvert, and C. Lindahl, “Mechanical and repeated antimicrobial therapy using a local drug delivery system in the treatment of peri-implantitis: a randomized clinical trial,” Journal of Periodontology, vol. 79, no. 5, pp. 836–844, 2008.

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Nonsurgical Treatment

• Systemic antibiotics

• Not for long term use due to antibiotic resistance

• Useful only for acute phase of peri-implantitis

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Surgical Treatment

• Open flap debridement

• Has been shown to improve probing depths after treatment

• Studies have varied depending on the implant surface

• Variables include: bone contouring, apically positioned flap, surface decontamination and implantoplasty

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Surgical Treatment

• Regenerative techniques

• studies have shown improved probing depth and bone fill

• small studies and many varied grafting materials and bone defects make it nearly impossible to determine best course and if better than other treatments

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Surgical Treatment

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Surgical treatment

• Explantation

• removal

• attempt to save as much bone as possible and graft as needed

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Thank You

• Questions??

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WHAT IS THE PINHOLETECHNIQUE?

Douglas Petersen, DDS Diplomate American Board of Periodontology

The Dental Specialists, Edina

September 10, 2015

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TAKING CONTROL OF ENDODONTIC ANATOMICAL COMPLEXITY

Brent Rundquist, DDS, MS

September 10, 2015

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Goals

• Discuss gingival recession

• Traditional techniques, pros and cons

• Newer techniques, pros and cons and controversies

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Recession defectsInt J Periodontics Restorative Dent. 1985;5(2):8-13. A classification of marginal tissue recession. Miller PD Jr.

• Determines predictability of root coverage procedures

• Class 1-4

• Based on extent of recession tooth position and status of interproximal hard and soft tissue

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Miller Class I Defects

• Intact interproximal tissues

• Recession not past mucogingival junction

• 100% root coverage likely

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Miller Class II Defects• Recession past the

mucogingival junction

• Interproximal tissues intact

• 100% coverage expected

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Miller Class III Defects• Recession past

mucogingival junction

• Some loss of interproximal tissues

• <100% root coverage likely

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Miller Class IV Defects

• Substantial loss of interproximal tissues

• Root coverage unpredictable

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Connective Tissue Grafts• Gold standard in treating gingival recession

• Originally described by Bernimoulin in 1975

• Technique has been studied and improved significantly over the years through world wide collaboration.

• This has improved the technique and patient outcomes.

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Connective Tissue Graft

• Pre-op • Miller grade 1 • Good root

coverage expected

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Connective Tissue Graft

• Root scaled and root planed

• Recipient bed prepared

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Connective Tissue Graft

Epithelium reflected from palate.

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Connective Tissue Graft

Graft harvested

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Connective Tissue Graft

Closed with sutures

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Connective Tissue Graft

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Connective Tissue Graft

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Connective Tissue Graft • Flap advanced to cover

graft, closed with sutures.

• Post op

• Ibuprofen, soft diet, Peridex, suture removal in a week, Risk of bleeding post operatively.

• Pain 3-4/10

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Connective Tissue Graft

• One week post op

• Good root coverage

• Some swelling

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Connective Tissue Graft

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Connective Tissue Graft • 2 week post op • Still a little bulky • Will likely do

some gingivoplasty in 6-8 weeks

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Pinhole Technique• New root coverage

technique.

• Aggressive marketing campaign

• General dentists

• Periodontists

• Patients

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Pinhole Technique

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Pinhole Technique

• Described by John Chao DDS

• General DDS and JD

• IJPRD 2012

• For root coverage

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Pinhole Technique

• Advantages • Less invasive

• No palatal donor site required

• Quicker

• Suture free?

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Pinhole Technique

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Pinhole Technique

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Pinhole Technique

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Study

• 121 recession sites • 85 sites Miller Class I or II • Assessment period 18 months • Used bioresorbable membrane or

acellular dermal matrix

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Results• Class I or II sites • Complete root coverage 81.2%

• Defect reduction 94%

• All Sites • Complete root coverage 69.4%

• Defect reduction 88.4%

• Treatment Time - 22 minutes

• Patients reported minimal discomfort

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Controversy• Patented

• Not taught and cannot be taught in periodontal residencies

• New technique which does not have a body of evidence in the scientific literature

• No independent clinical research

• No research in the pipeline

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Pinhole Technique• Marketing

campaign

• email to general dentists

• Direct to consumer marketing

• The Doctors

• TV appearances.

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Pinhole Technique

• To become “qualified” you must attend a seminar with Dr Chao

• Seminar fee is $5000

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Pinhole Contract• Must sign non-disclosure

contract if you attend technique seminar.

• Can’t take photos of technique and display on a website

• Can’t share seminar materials

• Cannot re-create instruments

• Can only use instruments purchased from Chao

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Pinhole Technique

• Patented instrument kit $4000

• $307 per instrument.

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Pinhole Contract

• Cannot teach anyone else the technique

• Any improvements developed by attendee of seminar belong to Chao

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Pinhole Technique

• Chao’s perspective

• Trying to protect patients and ensure they are well treated and doctors are well trained.

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My Opinions

• I like less invasive techniques

• The pinhole technique has promise as well as other techniques such as tunneling

• I don’t like it when research and advances in medical treatment are stymied by lawyers and contracts.

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My Opinions• Independent research is lacking

• Are his results reproducible?

• Will the treatment hold up over time?

• Is this treatment approach appropriate for all areas? Mental nerve?

• Appropriate for all biotypes?

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Thank You!

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Endodontic anatomical complexity plays a significant role in success or failure of root canal treatment?

True or False?

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True or False?

Leaving undebrided tissue behind in the pulp space is one of the most common reasons for persistent, non-healing pathosis following NSRCT

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Undebrided Tissue: Would it have healed?

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True or False?

The more anatomically aberrant the pulp space and canal system, the more unfavorable the long term prognosis following NSRCT

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True or False?

Being aware of which teeth harbor the most anatomical variability is the first step towards being able to manage pulp space complexity

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Mx central, lateral, canineINCREASING

ANATOMICAL

COMPLEXITY

100% one canalMn 2nd premolarMx 2nd premolarMn centralMn lateralMn canineMx second molarMn Second molar

Mx 1st premolarMn 1st premolar

Mn 1st molar

Mx 1st molar

88% one canal75% one canal70% one canal45% two canals30% two canals30% four canals

8% four canals, “C” shaped

90% 2canals, 6% 3canals

14% “C”, 24% 2 or more cls

20-46% have middle mesial30% two distal canals

42-71% have two MB canals

1.4% two palatal canals/rts

Sources: Vertucci, Cleghorn, Peikoff, Nosrat, Azim, Baisden

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Mn 1st premolar

Cleghorn et al, J Endod 2007;33:509-516

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Cleghorn et al.

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Nallapati J Endod 2005;31:474-476

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The Three Rooted Mn 1st Premolar

Cleghorn et al.

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Look for:

Evidence of a “fast break”

Evidence of multiple PDLs on PA

Cleghorn et al.

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Nallapati, J Endod 2005;31:474-476

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The “C” shaped Mn 1st PremolarFan et al, J Endod 2008;34:1337-1341

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Mn Incisors

Bianchi Leoni et al, J Endod 2014;40:710-716

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The “Middle Mesial” in Mn Molars

20-46%

Nosrat et al, J Endod 2015;41: 28-32

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Trough through developmental groove to locate or rule out “middle mesial”

The younger the patient, the more likely you are to locate a middle mesial canal. >40 = significantly more hard tissue in canals and developmental groove

Azim et al, J Endod 2015;41:164-168

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Baugh and Wallace J Endod 2004;30:185-186

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Baugh and Wallace

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Baugh and Wallace

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Rundquist

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The Mx First Molar “The Demon”

Gu et al, J Endod 2009;35: 353-356

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3D micro CTLee et al, J Endod 2006;32:941-945

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4 canals 41-72% of cases

Gu et al, J Endod 2009;35: 353-356

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Mx 1st molar

Anatomy at the apex of the MB root

Peters et al, J Endod 2004;30: 559-567

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Two palatal roots/canals

Incidence = 1.4%

Barbizam et al, J Endod 2004;30: 668-671

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Negotiating dilacerated canals

Use small, short file (#6) until you run out of usable file length

Use generous amount of canal lubricant (EDTA or RC Prep etc.)

Increase file size gradually. If the file stops advancing with light teasing motion, go back to smaller file

Rotary files may or may not negotiate curvature. Use hand instrumentation in curvature as needed and rotaries within the “safe zone”

Straight line access is an absolute necessity

Pre-bend small instruments with “pig tail” and orient in direction of curvature when inserted into orifice

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Locating small canals

Use some kind of enhanced magnification. Scope is ideal

Use your pre-op PA as a road map. Pre-op PA must be of high quality, and additional angle may be helpful

Look for multiple PDLs. The more PDLs you can trace, the more complicated the radicular architecture to be expected

Look for “fast break” as indication of branching in canal system

Assume more canals are present until you prove otherwise

Thoroughly trough through developmental grooves to uncover hidden canals

Respect anatomical complexity

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Calcified Canals

Canals obliterated with hard tissue will be found along the boundary between the darker, irregular, secondary dentin and the lighter, primary dentin that was present when the tooth developed

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Canal Location Tricks

Use longshank halfround burhigh speed

Look for effervescing bubbles of

chlorine gasover orifice

Use ultrasharp endoexplorer

Trough until you reach

the bottomof the

developmentalgroove

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Questions?

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