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peri-implant mucositis
- implant gingivitis
- inflammation confined to the soft tissues
- bleeding on probing
- • Suppuration
- • usually associated with probing depths ≥4 mm*
- • no evidence of radiographic loss of bone beyond bone
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peri-implantitis
- implant periodontitis
- both bone/soft tissue
- If no baseline, a vertical distance of 2 mm from the expected marginal bone level following remodeling
- post-implant placement is recommended as the threshold for diagnosing peri-implantitis
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implant microbio
- G+ facultative cocci, rods
- G- anaerobes in small numbers(increase in disease)
- Red: P.ging, Treponema denticola and Tannerella forsythia
- Orange: Fusobacterium, Prevotella intermedia
- peri-implantitis: S. Aureus, Candida, enteric rods
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Peri-implantitis/periodontitis pathophys
- B-lymph, plasma cells
- cytokines IL-1B, 6,8,12, TNFa
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Implant bone susceptible because absence of ___
inserting collagen fibers
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peri-implantitis risk factors
- plaque, hygeine
- smoking
- residual cement
- diabetes
- occlusal overload
- increased loading time possibly one
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clinical consequences peri-implantitis, mucositis
- mucositis successful w/o surgery if early
- surgery for peri-implantitis unpredictable
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Phase I Therapy
- Oral Hygiene Instructions
- Subgingival Scaling & Root Planing
- Re-evaluation and Reassessing the Periodontal Status
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____ margin of mand posterior always generate plaque
lingual, gingival
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target hygiene
concave area, bass method
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OHI changes
- bleeding/tenderness for 2 weeks
- shrink in papilla
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Pocket sequelae
- as the pocket progresses apically
- localized areas of root resorption
- localized areas of hypomineralization
- cementum becomes soft
- toxic material gets incorporated into cementum (becoming “diseased cementum”)
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_____ has the shortest root trunk most likely tooth to have a furcation involvement
mandibular 1st molar
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maxillary molars and maxillary first bicuspids presents root trunk concavities and furcation openings facing the ____ which makes plaque removal difficult.
interdental areas
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Palatal concavity on
max lateral incisor
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Most Common Areas of Recurrent Pockets
- 1. maxillary first premolar (mesial aspect)
- 2. maxillary first molar (mesial aspect)
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Mandibular First Molar internal concavity
- mesial 0.7mm 100%
- distal 0.5mm 99%
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Maxillary First Molar internal concavities
- MB root presents a 0.3mm concavity in 94% of the extracted teeth studied.
- DB root presented insignificant amount of concavity in 31% of the extracted teeth studied.
- P presented insignificant amount of concavity in 17% of the extracted teeth studied.
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58% of these cases studied, both in the maxillary first molar (buccal) and the mandibular first molar (buccal), the standard Gracey curette blade does not fit into the furcation opening.
True
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Cervical Enamel Projections:
- An apical extension of the cemento-enamel junction in the area above the furcation opening
- These projections shortens the root trunk, therefore leading to an earlier furcation opening and predisposes the area to furcation lesions
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Intermediate Bifurcation Ridge:
- A narrow, uneven ridge of enamel which extends from the mesial to the distal root at the furcation opening. Found in 30% of cases studied.
- Conclusion: plaque and calculus can accumulate onto this ridge.
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Apical Fused Roots:
- The apical portion of the roots fuses creating a cul-de-sac like opening between the two roots. Found most often in the maxillary and mandibular second molars.
- Conclusion: plaque and calculus accumulates inside this opening, which is impossible to clean or instrument
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Accessory Canals in the Furcation Area:
- In numerous cases, caries involvement of the pulp can lead to bone loss in the furcation area via the accessory canal. If this bone loss communicates with the oral environment, a periodontal furcation defect can result.
- Conclusion: plaque and calculus can contaminate the root surfaces of the furcation area due to bone loss from the pulpal lesion.
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Furcation therapy
- Early Lesions
- Specific biofilm removal (rubber tip, proximal, dry toothbrush)
- Scaling and root planing
- Moderate Lesions
- Soft tissue surgery
- Osseous recontouring
- Crown / Restoration recontouring
- Advanced Lesions
- Root resection
- Regenerative surgery
- Extraction and Implant placement
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demarco curettes
spoon looking for furca
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CAL (clinical attachment loss) and Radio correlation
- health = 0
- slight = 1-2mm
- moderate = 3-4mm
- severe >5mm
- Radio distance from crest to CEJ (mm)
- health 0-2
- slight 3-4
- moderate 5-6
- severe >7mm
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Goal of Perio therapy:
- plaque and calculus-free environment around the dentogingival area
- Instrumentation in furcation area is difficult, unpredictable and sometimes impossible
- Furcation Area: pocket bounded by root surfaces
- Removal of this pocket by resection or regeneration is very unpredictable
- 90% of perio abcesses associated with furcations
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Problems related to Furcation Lesions
- Plaque retention
- Calculus formation
- Inaccessibility for plaque/calculus removal
- Splinted restoration prove exceptionally challenging
- Caries in furcation area
- Routin home care usually not successful
- Furcation involvement: can lead to diagnosis of advanced periodontal disease and less favorable prognosis for the affected tooth/teeth
- i) Presents diagnostic and therapeutic dilemmas
- 3) Furcation Involvement
- a) ID the problem
- b) Anatomical Factors
- i) Description of root anatomy
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Root trunk length
- (a) Distance from CEJ to separation of the roots
- (b) Proportional to the time it takes for a lesion to reach the furcation opening
- (c) Buccal aspect of Mn M1 has shortest root trunk length
- (d) Crown margins extending past CEJ will shorten the root trunk length
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External Concavities
- (a) Location of concavities determines cleansibility
- (b) Interdental concavities are the most problematic
- (i) Maxillary molars (mesial) and maxillary 1st premolars (mesial) most commonly with recurrent pockets
- 1. Large lingual embrasure between canine and Mx PM1, between Mx PM 2 and Mx M1
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Internal Concavities
- (a) Maxillary 1st Molar
- (i) MB root: 0.3 mm in 94% of teeth
- (ii) DB root: Insignificant concavity in 31%
- (iii) P root: Insignificant concavity in 17%
- (b) Mandibular 1st Molar
- (i) M root: 0.7 mm in 100% of teeth
- (ii) D root: 0.5 mm in 99% of teeth
- (iii) Can only attempt to clean with a proxy brush
- (c) Dimension of Furcation Entrance
- (i) 81% are 1 mm or less
- (ii) 58% are 0.75 mm or less
- (iii) 58% of all teeth the standard Gracey curet does not fit
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Local Developmental Anomalies
- (a) Cervical Enamel Projections
- (i) Apical extension of CEJ in the area above furcation opening
- (ii) Shortens the root trunk and predisposes to perio disease
- (iii) Found in ~50% of teeth, leads to faster furcation involvement
- (iv) Can be “man-made” with apical crown margin
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Intermediate Bifurcation Ridge
- (i) Narrow, uneven ridge of enamel which extends from the mesial to distal root at the furcation opening
- (ii) 30% of Mn M1, allows for plaque accumulation
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Apical Fused Roots
- (i) Often found on 2nd molars
- (ii) Apical portion fuses creating a cul-de-sac opening
- (iii) If plaque accumulates here, it is impossible to clean. Tooth is usually hopeless
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Furcational Etiologic Factors
- i) Primary factor is the accumulation of bacteria and the long-term consequences of resulting inflammation
- ii) Local factors affect rate of plaque accumulation
- (1) Oral hygiene and perio recall
- iii) Increase furcation involvement with age
- iv) Dental Caries and Pulpal Involvement may also affect furcations
- (1) Accessory canals in the furcation area with pulpal infection can lead to bone loss and furcation involvement
- (2) If endo lesion: RCT should resolve pathology. Will only get healing if the lesion is endo-related
- (3) If needs endo and perio therapy, always do ENDO first
- v) Extent of attachment loss required to produce furcation involvement is variable, depending on:
- (1) Root trunk length
- (2) Root morphology
- (3) Local developmental anomalies (cervical enamel projections)
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Horizontal Classification (Classic, Glickmane)
- i) Grade I: Incipient or early lesion
- (1) Pocket is suprabony: slight bone loss and soft tissue involvemtn
- (2) Little to no radiographic bone loss
- ii) Grade II
- (1) Bone destroyed on one or more aspects of furcation, partial penetration into furca
- (a) Cul-de-sac lesion
- (b) Radiograph may or may not reveal much change
- iii) Grade III
- (1) Bone completed destroyed between roots, forming a tunnel
- (2) Orifice is occluded by soft tissue, so opening cannot be seen clinically
- (3) Radiograph shows through and through RL opening
- iv) Grade IV
- (1) Same as grade III except gingival has receded enough to expose the orifice of the furcation and it can be seen clinically
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Horizontal Classification: Lindhe and Nyman
- i) Grade 1
- (1) Loss of bone into furcation but portion of alveolar bone and PDL is intact.
- (2) Measures less than 3 mm
- ii) Grade II
- (1) Grade I but measures greater than 3 mm
- iii) Grade III
- (1) Through and through lesion
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Vertical Classification: determined by mm from roof of furca to probeable depth
- i) Subclass A: 0-3 mm
- ii) Subclass B: 4-6
- iii) Subclass C: 7 mm or greater
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Furcation Therapy
- a) Factors to consider
- i) Classification
- ii) Age
- iii) Tooth associated with lesion and furcation characteristics
- (1) Mn M1 or M2: B/L
- (2) Mx M1 or M2: B/M/D
- iv) Mobility
- v) Soft tissue
- vi) Bone environment
- vii) Vestibular depth
- viii) Endodontic factors
- ix) Restorative factors
- b) Early Lesions
- i) S/RP and plaque removal
- ii) Recontour restorations/soft tissue
- c) Moderate lesions
- i) Soft tissue surgery
- (1) Removal of gingival tissue apically to uncover furcation opening for instrumentation
- ii) Osseus recontouring
- iii) Crown/restoration recontouring
- iv) Resective root therapy
- (1) Most obvious choice is the DB root or Mx M1
- (2) Remaining root(s) must be viable and stable
- v) Regenerative therapy
- d) Advanced
- i) Root resections
- ii) Regenerative Surgery
- iii) Extractions
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Masticatory Mucosa
- i) Keratinized, attached
- ii) On palate, near the teeth
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Lining mucosa
i) Non-Keratinized, unattached
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