Implant apical lesion

1. Implant apical lesion 가천의대 부속 길병원 보철과 R2.곽 재 호

2. Introduction • According to Meffert 1.ailing implant-bone loss with pocketing, but is static at maintenace checks. 2.failing implant-bone loss with poketing, Bleeding on probing, purulence, and evidence of continuing bone loss irrespective of therapy. 3.failed implant-mobility, dull sound on P/R, periimplant radiolucency.

3. Introduction • 1960년대에 Branemark이 “골유착” 개념을 발표한 이래 임프란트 시술은 지속적으로 발전. • 최근엔, 임프란트의 성공률이 높아졌지만 종종 실패도 보고. • 임프란트 실패의 정확한 기전은 임프란트의 실패에 직접 내지는 간접적으로 기여하는 다양한 인자때문에 명확하지 않다.

4. Introduction • 현재까지, implant apical lesion의 가능한 원인에 대해서는 충분히 논의되지 않았다. • 비록 implant apical lesion의 유병률이 알려져 있지 않지만, 발생빈도는 낮다. • 1995년에 Reiser와 Nevins는 3800개의 임프란트에서 10개의 periapically infected implant를 보고하였다.

5. Definition • Implant apical lesion is described as a periapical lesion which is located at the apex of a dental implant(Resier and Nevins) • Misch defined the implant periapical lesion, also termed a retrograde periimplantitis, as a retrograde implant failure possibly due to bone microfractures caused by premature implant loading, overloading, other trauma, or occlusal factors.

6. Classification 1.Inactive form-periapical scar without characterstic clinical symptom, resulting from a residual bone cavity created by placing an implant shorter than the prepared drill site. 2.Infected form-occurs when an implant apex is placed in proximity to an existing infection or when a contaminated implant is placed.

7. Etiology 1.Presence of pre-existing microbial pathology 2.Contamination of implant 3.Bone overheating during implant placement(surgical trauma) 4.Excess tightening the implant with compression of bone chips.

8. Etiology 5.Premature loading and/or overloading of implant. 6.Fenestration of vestibular bone. 7.Poor quality of the bone site. 8.Inadequate space between implants or between implant and tooth

9. Presence of pre-existing microbial pathology • Endodontic pathology can travel through marrow space and contaminate an adjacent implant. • Immediate implantation • McAllister et al. claimed that even with vigorous debridement, bacteria remaining in the socket can initiate infection.

10. Contamination of implant • Implant can be contaminated due to manufacturer errors, by the operator, from non-titanium instruments, or by intraoral microorganisms. A contaminated implant surface possibly could lead to early osseodisintegration.

11. Overheating • Eriksson and Albrektsson reported bone cell death when a temperature of 40C was applied for 7minutes or when a temperature of 47C was applied for 1minute to the bone. • Long implant를 식립시 더 주의해야 함- coolant가 bone의 근단부에 도달 하지 않을 수도 있기 때문.

12. Excessive tightening • Excessive tightening of the implant compress bone chips produced during bone site preparation, possibly resulting in subsequent bone ischemia and necrosis, and formation of a squestrum. • Placment of self-tapping implant in dense bone has demonstrated significantly higher degree of hard tissue trauma and is therefore not recommended.

13. Premature loading or overloading • Premature or overloading은 implant periapical lesion보다는 오히려 crestal bone loss나 골융합의 실패를 가져오게 된다. • 고로, 즉시 식립 임프란트에서의 미세동요가 이런 병소의 주된 원인이라고 고려될 수는 없다.

14. Fenestration of vestibular bone • Perforation in the facial or lingual alveolar cortical plate which does not communicate with the crestal marginal bone.

15. Poor quality of the bone site • Poor bone quality에 기인한 osteoprogenitor cell의 부족은 아마도 임프란트 주위의 mineralized tissue의 형성에 부정적인 영향을 미치는 것 같다.

16. Inadequate space • Tarnow et al. found less radiographic crestal bone loss on implants with more than 3mm of a distance between implants, as compared to implants with a distance of 3mm or less(0.45 vs 1.04mm). • Askary et al. stated that highly dense bone requires more space between implants,as compared to cancellous bone, in order to avoid overheating with subsequent death of bone cells.

17. Treatment • 임상적 증상이 없는 inactive form의 경우는 특별한 치료가 필요하지 않으며, Periodic radiograph로 F/U을 하면 됨. • Infected form의 경우는 antibiotics and surgical therapy를 병행해야 한다.

18. Treatment • Sussman stated that infected implant should be immediately removed to prevent an osteomyelitis. • Implant apicoectomy may be considered as a treatment modality for the treatment of the implant apical lesion if the lesion is localized to the apex.

19. Treatment • Implant apicoectomy의 indication 1.implant is stable(osseointegration) 2.infection이 근단부영역에 국한된 경우. 3.임프란트의 길이가 충분하여 resection한 후에 안정성에 문제가 없는 경우.

20. Treatment • After surgical treatment of the periapical lesion, a non-steroidal anti-inflammatory agent in combination with antibiotic therapy can be employed to the patient to further surpress the microbiota not removed by clinical procedures, and to reduce inflammation and enhance the host response.

21. Treatment • Implant apical area를 resection하는데 있어서 bur의 사용 -titanium은 diamond bur보다는 carbide bur를 사용한 것이 더 깨끗하게 제거될 수 있다.

22. 임프란트의 성공을 위한 기준 1.clinical mobility 2.lack of radiographic peri-implant radiolucency. 3.비가역적 증상의 부재 4.1년간의 골흡수가 1mm이내, 그 후는 매년 0.2mm이하. 5.5년 success rate는 85% 6.10년 success rate는 80%로 정의.

23. 임프란트의 성공을 위한 기준 • Implan success by Albrektsson et al included “that a radiograph does not demonstrate any evidence of peri-implant radiolucency.”

24. Case Presentation

25. Case I • Pt:노00 2001.2.16-#17,15,14,13,11,21,24,25,27 임프란트 식립 2001.8.24-2nd surgery(#17implant remove) 2002.1.25:#17 reimplantation #22-발치와 동시에 임프란트 식립 #21-labial fistula formation and bone defect Tx: curretage, TC powder, BG(from tuberosity)

26. Labial fistula

27. Crevicular incision

28. Dissection of flap

29. Granulation tissue remove

30. Implant detoxification

31. Closure

32. Radiograph

33. Final prosthesis

34. Case II • Pt:유00 2000.11.15-Chin bone grafting 2001.5.9-#13:implant placement 2001.9.3-#13: implant apicoectomy and granulation tissue removal

35. Chin bone

36. Bone defect

37. Bone graft

38. Bone maturation state

39. Implant placement

40. Labial fistula

41. Implant resection and granulation tissue remove

42. Implant detoxification

43. Radiograph

44. Final prosthesis

45. Conclusion • Little is known on the etiopathogenesis of the implant periapical lesion. • Based upon currently available literature, microbial involvement of pre-existing pathoses and surgical trauma such as bone overheating may be the most likely causes of the implant periapical lesion. • Appropriate endo. Tx and removal of potential sources shoud be performed prior to implant placement.

46. Conclusion • For the implant periapical lesion, various combined therapies can be utilized, including surgical exposure, degranulation of the defect, detoxification of the implant surface with chemotherapeutic agents, antibiotic usage, and GBR.