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Clinical and radiographic evaluation of marginal periimplant tissue stability after buccal defect regeneration using porous titanium granules A protocol Submitted in Partial Fulfillment of The Requirement of the doctor Degree in Oral Medicine, Periodontology, Oral Diagnosis and Radiology. By

Mohamed Ismael As- Sa'daway Alwakel (B.D.S) (2003G) (M.D.S) (2013) Faculty of Dental Medicine (boys) Cairo Alazhar University Department of Oral Medicine, Periodontology, Oral Diagnosis and Radiology

Faculty of Dental Medicine Alazhar University Cairo (Boys) Egypt 2013G-1434H

Supervisors


Introduction Bone augmentation of the alveolar crest in implant dentistry has attracted a substantial interest in the maxillofacial literature (1). Bone substitutes represent an important contribution to this field as augmentation with autogenous bone has drawbacks such as morbidity for the patient as well as problems with various degrees of resorption of the grafted bone volume over time(2) After installation of dental implants, multifactorial conditions may all contribute to a peri-implant state of disease, for example, poor oral hygiene and a history of periodontitis, diabetes, or smoking. The mucosal status of attached or free gingiva at the fixture site is also of importance for long time success(3). soft tissue peri-implant mucositis may affect about 50% of the implant sites and bone-affecting peri-implantitis may be seen in as many as 12–40% of the implant sites according to a consensus report from a European group of workers

(3)

Implantology offers huge possibilities for patients and the


restorative team, but the potential problem that may arise around implants needs to be addressed and not neglected by the implant surgeon The stability of the soft tissue over time 12 months–10 years (4) have revealed a probing depth of 0.24 mm around implants to 0.27 mm around teeth.(4, 5) Clinical attachment levels varied from 0.37 mm around implant vs. 0.3 mm around teeth. Bengazi et al.(5) has observed 0.4 mm of gingival recession at 6 months at the augmented site vs. 0.7 mm at the non-augmented sites during the 24 months follow-up. Grunder (6) reported 0.6 mm shrinkage of the augmented soft tissue margin after prosthetic insertion. The possible reasons attributed to the dimensional changes observed are: Recession of the peri-implant soft tissue margin may be due to remodeling of the soft tissue to establish the biodimensions(7), bulking of the keratinized mucosa at the second-stage surgery compensates the future soft tissue shrinkage and improves the overall tissue profile, provisional prosthesis to be placed for 6 months after the abutment connection until a stable gingival margin is obtained, complete maturation of the tissues following second-stage surgery allows the tissue to be resistant to prosthetic manipulations and possible gingival recessions.(8) Porous titanium granule (PTG) represents a new alternative in augmenting osseous defects in maxillofacial surgery(9). Its earliest application was seen in orthopedics and used for stabilization of tibial plateau fractures and for prosthetic reoperations for femoral stem fixations. A case operated in 1995 where dental implants in a split-crest procedure were supported by PTG represents the earliest reported surgery in the literature(10) They imitated bone properties, stimulated osteoblasts colonization and Osseo integration, and kept their volume during the entire healing period which ensures mechanical stability (11). Thereafter, titanium granules have been widely used for sinus floor augmentation (12),


peri-implantitis related bone regeneration(13), furcation defects repair, onlay augmentation of deformed alveolar process(14), cystic cavities reconstruction, filling of extraction socket (15) Traditional viewpoint for bone graft is primarily that graft should guide and induce new bone regenerationas well as been absorbed completely by human body.(16) Nowadays, we mainly focus on the filling of bone deficiency, instead of new bone regeneration and osseointegration. Hence, we need to seek for novel approach to settle the problem of bone deficiency, and improve the success rate of dental implantation(17). During bone grafting, bone tissue competes with soft tissue for survival space(18)The integration between titanium and bone tissue is greater than that between titanium and soft tissue. Therefore, when titanium granules is implanted, titanium granules have priority to integrate with bone tissue. Thus, the implant height is maintained stable, like controlled tissue regeneration (CTR) technique and entry of soft tissue is prevented. Thereby, the success of dental implant is guaranteed. (19)

The bone-implant integration is a complex process, in which microenvironment around bone tissue definitely altered. However, the mechanisms involved are poorly understood. After implant placement, there is no obvious distinction between oxide layer surface and bone, even though the width of the interaction region of implant and periimplant bone is greater than 1 mm. H anawa had discovered a series of interesting alterations when observed implants with loading in clinic.(20) The formation of an inert titanium oxide layer, as thick as about 2000m was found on the implant surface 6 years after implantation. Analysis of this newly formed layer revealed that it contains organics and inorganics (Ca, P, S), indicating that the oxide layer on implant surface is very sensitive to the intake and rise of these mineral ions and can respond


to them, even though it is coated by a layer of protein. Moreover, exposure of the pure titanium or titanium alloy surface to the blood led to spontaneous formation of titanium phosphate and calcified compound containing hydroxyl groups on oxide layer surface, which suggested a reaction between titanium and water, mineral ions, and plasma had happened. Interestingly, it would accelerate calcium phosphate deposition on pure titanium surface in case of low PH at the implant area(17). The parameters used routinely during maintenance of patients treated with

implants

should

be

sensitive

enough

to

allow

discrimination of early changes. These parameters should be easy to measure and yield reliable and reproducible information(21, 22). Dental implants are usually placed by elevating a soft tissue flap, but in some instances, they can also be placed without flap elevation reducing postoperative discomfort. Several flap and suturing techniques have been proposed. Soft tissues are often manipulated and augmented for aesthetic reasons. It is often recommended that ‘firm’ (attached/keratinized) soft tissues rather than ‘movable’ mucosa to improve their long-term prognosis surround implants. (23) There is insufficient evidence to recommend a specific flap or suturing technique. There are not reliable trials indicating whether soft tissue correction/augmentation techniques. (24) Computer-assisted image analysis has been shown to improve the diagnostic accuracy (i.e. increased sensitivity) of detecting minimal periodontal tissue changes(25). Consequently, the use of digital image analysis has expanded into implant dentistry to monitor peri-implant bone healing and gain or loss of alveolar bone density


Patients and Methods Twenty

patients will be enrolled in the study from those attending at

outpatient clinic in Faculty of Dental Medicine- Alazhar University. The enrolled patients will have an edentulous area suitable for implant placemen.

The age of subjects will range from 18 -55years old. Written

consent will be attained from all patients. Inclusion criteria: It will include patients with adequate bone for securing primary implant stabilization.

Exclusive criteria included patients with a history of the following: -

Heart disease.

-

Connective tissue disorders.

-

Metabolic bone diseases.

-

Uncontrolled diabetes.

-

smokers Clinical evaluation: It will include visual inspection of the tissue

color, contour and consistency. Gingival index(12), and probing depth, Modified Sulcus Bleeding Index,(26) Level of the mucosal margin(21),papillary presence index(27) will be recorded., mobility , effect on the adjacent teeth , presences of infection, quality of life score (28) will be measured . Radiographic assessment: Prospective standard periapical radiographic imaging will be carried out to evaluate the bone healing and


crestal bone changes. Each patient will have full mouth preparation. Standard periapical and cone beam computerize tomography will be done before the surgical procedure .Standard periapical at two months (base line)

and then repeated at four and six months . Computer-assisted

image analysis to measure marginal bone changes will be used.

Aim of study The aim of present study is to evaluate clinically and radiographicaly marginal periimplant tissue stability after buccal defect regeneration using porous titanium granules


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11. Barbas A, Bonnet AS, Lipinski P, Pesci R, Dubois G. Development and mechanical characterization of porous titanium bone substitutes. Journal of the Mechanical Behavior of Biomedical Materials. 2012;9(0):34-44. 12. Lambert F, Lecloux G, Léonard A, Sourice S, Layrolle P, Rompen E. Bone Regeneration Using Porous Titanium Particles versus Bovine Hydroxyapatite: A Sinus Lift Study in Rabbits. Clinical implant dentistry and related research. 2013;15(3):412-26. 13. Mijiritsky E, Yatzkaier G, Mazor Z, Lorean A, Levin L. The use of porous titanium granules for treatment of peri-implantitis lesions: preliminary clinical and radiographic results in humans. British dental journal. 2013;214(5):E13-E. 14. Steveling HG, Mertens C. Titanium granules for contour enhancement of the alveolar process. 15. Wohlfahrt JC, Lyngstadaas SP, Heijl L, Aass AM. Porous Titanium Granules in the Treatment of Mandibular Class II Furcation Defects: A Consecutive Case Series. Journal of periodontology. 2011;83(1):61-9. 16. springfield. Autogenous bone grafts : nonvascular and vascular. Thorofare, NJ, ETATS-UNIS: Slack; 1992. 17. Fu X, Wu Y, Gu Y, Yang Y, Zhou Y. A new view on bone graft in dental implantation: Autogenous bone mixed with titanium granules 2013. 18. Karring T, Nyman S, Gottlow JAN, Laurell L. Development of the biological concept of guided tissue regeneration — animal and human studies. Periodontology 2000. 1993;1(1):26-35. 19. Llambés F, Silvestre F-J, Caffesse R. Vertical Guided Bone Regeneration With Bioabsorbable Barriers. Journal of periodontology. 2007;78(10):2036-42. 20. Park J-W, Jang J-H, Lee CS, Hanawa T. Osteoconductivity of hydrophilic microstructured titanium implants with phosphate ion chemistry. Acta Biomaterialia. 2009;5(6):2311-21. 21. Narula S, Garg D, Pamecha S, Asopa V. Clinical evaluation and diagnostic parameters for monitoring the prognosis of implants. Journal of Advanced Oral Research. 2012;3(1). 22. Mombelli A, Lang NP. Clinical parameters for the evaluation of dental implants. Periodontology 2000. 1994;4(1):81-6. 23. Esposito M, Grusovin MG, Maghaireh H, Coulthard P, Worthington HV. Interventions for replacing missing teeth: management of soft tissues for dental implants. Cochrane Database Syst Rev. 2007(3):CD006697. Epub 2007/07/20. 24. Esposito M, Maghaireh H, Grusovin MG, Ziounas I, Worthington HV. Interventions for replacing missing teeth: management of soft tissues for dental implants. Cochrane Database Syst Rev. 2012;15(2). 25. Brägger U, Pasquali L, Rylander H, Carnes D, Kornman KS. Computer-assisted densitometric image analysis in periodontal radiography. Journal of clinical periodontology. 1988;15(1):27-37. 26. Mombelli A, van Oosten MAC, Schürch E, Lang NP. The microbiota associated with successful or failing osseointegrated titanium implants. Oral microbiology and immunology. 1987;2(4):145-51. 27. Jemt T. Regeneration of gingival papillae after single-implant treatment. The International journal of periodontics & restorative dentistry. 1997;17(4):326-33. 28. Parkerson Jr GR, Broadhead WE, Tse C-KJ. Quality of life and functional health of primary care patients. Journal of Clinical Epidemiology. 1992;45(11):1303-13.



Clinical and radiographic of marginal periimplant tissue stability after buccal defect regeneration