JCDA Express Issue 1 2013

Excess Cement and Peri-implant Disease

Welcome to JCDA Express for 2013!

In this first installment of JCDA Express, Dr. Tom Wierzbicki, a recent graduate of the graduate periodontics program at the University of Manitoba, and Dr. Anastasia Kelekis-Cholakis, director of the graduate periodontics program at the University of Manitoba, bring forward 3 articles that examine the relationship between implant restorative margin placement, residual subgingival cement, and development of peri-implant disease.

How deep should the abutment margin be placed? An in vitro analysis.

Linkevicius T, Vindasiute E, Puisys A, Peciuliene V. The influence of margin location on the amount of undetected cement excess after delivery of cement-retained implant restorations. Clin Oral Implants Res. 2011;22(12):1379-84. Epub 2011 Mar 8.

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JCDA Clinical Pearl: Greater amounts of residual cement are retained around implant abutments with subgingivally placed restoration margins. Clinicians should strive to keep the margins no deeper than 1 mm subgingivally in esthetic areas, and take extra care to ensure no residual cement is left in the subgingival tissues after prosthesis cementation.

Key Points:

• This in vitro study examined the influence of restoration margin location on the amount of subgingivally retained cement after implant restoration.
• The study authors found that complete removal of retained cement is difficult for margins located up to 1 mm subgingivally, and highly unlikely for margins placed greater than 1 mm in depth. In contrast, restorations with visible margins had almost all the cement removed.

Reasons for Recommending this Article: This in vitro study demonstrates that even under ideal benchtop conditions the detection and complete removal of subgingivally retained restorative cement is highly unlikely. Therefore, clinicians should exercise caution when considering subgingival placement of the implant restoration margin.

How deep should the abutment margin be placed? A clinical analysis.

Linkevicius T, Vindasiute E, Puisys A, Linkeviciene L, Maslova N, Puriene A. The influence of the cementation margin position on the amount of undetected cement. A prospective clinical study. Clin Oral Implants Res. 2013;24(1):71-6. Epub 2012 Apr 8.

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JCDA Clinical Pearl: Greater amounts of residual cement are retained around subgingivally placed implant abutment margins. The excess cement is frequently undetected during radiographic examination. Clinicians should avoid placement of subgingival restoration margins whenever possible, and not rely solely on radiographic examination to confirm complete cement removal.

Key Points:

• This clinical study examined whether the location of the restoration margin, as modified by the treating clinician, has an impact on the amount of excess cement extruded into the subgingival tissues after prosthesis cementation.
• The authors verified that in a clinical setting, complete removal of subgingivally located cement around an implant abutment after prosthesis cementation is not possible. The amount of retained residual cement increases with the subgingival depth at which the restoration margin is placed.
• This study confirmed that radiographs do not consistently detect subgingivally retained restorative cement, and should not be relied on as the sole means of ensuring that all subgingival cement has been removed.

Reasons for Recommending this Article: This is the first clinical study to confirm previously published in vitro findings^5,6 demonstrating the effect of subgingival restoration margin placement on retention of excess restorative cement.

Is excess subgingival cement associated with peri-implant disease?

Wilson TG Jr. The positive relationship between excess cement and peri-implant disease: a prospective clinical endoscopic study. J Periodontol. 2009;80(9):1388-92.

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JCDA Clinical Pearl: A strong correlation seems to exist between retained subgingival restorative cement and peri-implant disease. Clinicians should exercise caution to minimize cement extrusion into the subgingival tissues when cementing implant-supported prosthetics, and should routinely monitor restored implants for peri-implant disease.

Key Points:

• This study examined the relationship between retained subgingival restorative cement, as determined by dental endoscopy, and clinical signs of peri-implant disease.
• Implants exhibiting healthy peri-implant tissues were used as controls.
• Within the scope of the study the author was able to show that excess restorative cement was associated with signs of peri-implant disease in the majority (81%) of cases.
• Signs of peri-implant disease appeared as early as 4 months and more than 9 years after prosthesis cementation.
• Careful and complete removal of excess subgingival restorative cement from around affected implants resulted in disease resolution in 76% of cases.
• There was no correlation between the type of cement used and the prevalence of peri-implant disease.

Reasons for Recommending this Article: This case-controlled study completed by an experienced clinician is the first to examine and demonstrate the possible link between retained subgingival restorative cement and signs of peri-implant disease.

References

1. Belser UC, Buser D, Hess D, Schmid B, Bernard JP, Lang NP. Aesthetic implant restorations in partially edentulous patients—a critical appraisal. Periodontol 2000. 1998;17:132-50.
2. Andersson B, Odman P, Lindvall AM, Brånemark PI. Cemented single crowns on osseointegrated implants after 5 years: results from a prospective study on CeraOne. Int J Prosthodont. 1998;11(3):212-8.
3. Reeves WG. Restorative margin placement and periodontal health. J Prosthet Dent. 1991;66(6):733-6.
4. Reitemeier B, Hänsel K, Walter MH, Kastner C, Toutenburg H. Effect of posterior crown margin placement on gingival health. J Prosthet Dent. 2002;87(2):167-72.
5. Agar JR, Cameron SM, Hughbanks JC, Parker MH. Cement removal from restorations luted to titanium abutments with simulated subgingival margins. J Prosthet Dent. 1997;78(1):43-7.
6. Linkevicius T, Vindasiute E, Puisys A, Peciuliene V. The influence of margin location on the amount of undetected cement excess after delivery of cement-retained implant restorations. Clin Oral Implants Res. 2011;22(12):1379-84. Epub 2011 Mar 8.