Maintenance of Dental Implants

IMPLANT MAINTENANCE
Presentation By
Dr. Viral Gadhiya
1

CONTENTS
1. Introduction
2. Plaque biofilm and dental implant
3. Soft tissue interface
4. Instrument selection
5. Implant maintenance procedure
6. Criteria for implant success
2

7. Implant quality scale
8. Baseline data
9. Repair of ailing failing implant
10.Implant crown esthetic index
11.Summary
12.References
3

5
Charles A Babbush, Dental implants arts and science 3rd edition pg no. 423-700
5

PLAQUE BIO-FILM AND DENTAL
IMPLANTS
• Implants more susceptible to inflammation and bone loss.
• Plaque biofilm development and maturation have similarities for
natural teeth and dental implants.
• Lee et al in 1999 found a history of periodontitis had greater
impact on periimplant microbiota than implant loading time
1. Carl E Misch. Contemporary implant dentistry 3rd edition 2008; chapter no 42. pg
no.1073-1083
2. Lee KH, Maiden MF, Tanner AC, Weber HP. Microbiota of successful osseointegrated
dental implants. Journal of periodontology. 1999 Feb;70(2):131-8.
7
7

 In a study by Mombelli and Mericske - Stern 1987 of the
plaque from 18 edentulous patients with successful dental
implants, facultative anaerobic cocci ( 52.8 % ) and
facultative anaerobic rods (17.4%) were reported.
 However, the pathogens P. gingivalis and spirochetes were
absent, and minimal (7.3%) gram-negative rods were present.
8
1. Carl E Misch. Contemporary implant dentistry 3rd edition 2008; chapter no 42. pg
no.1073-1083
2. Charles A Babbush, Dental implants arts and science 3rd edition pg no. 423-700
8

According to
GOUD ET AL (1981) :
Reported that epithelial cells attach to the surface of titanium in same
manner as the epithelial cells attach to the surface of a natural tooth.
SCHROEDER ET AL (1981) :
Observed that if the post of the implant was situated in a region of
immobile , keratinized mucosa, a sign of adhesion of the epithelial
cells to the titanium-sprayed surface would be apparent.
12
12

WENNSTROM AND LINDHE (1983) :
Disagree with Schroeder by maintaining that lack of keratinized
gingiva is not necessarily a vulnerable situation and that a movable
mucosa around the neck of the implant, if maintained will allow for
success.
WENNSTROM ( 1982) :
theorized that keratinized gingiva, though desired, is not essential
for maintenance of peri-mucosal seal.
13Charles A Babbush, Dental implants arts and science 3rd edition pg no. 423-700

PERI-IMPLANTMUCOSITIS
• It is an inflammatory change of the soft tissue surrounding
an implant.
• Like gingivitis:
• The primary etiology is plaque biofilm, and reversible, no
loss of attachment apparatus.
• If allowed to progress
14
14
Periimplantitis

PERI-IMPLANTITIS
• An inflammatory process affecting the
tissues around an osseointegrated
implant in function, resulting in loss of
supporting bone.
• Peri - implant inflammation
• Deep pocket formation
and progressive bone loss.

STAGE
• EARLY
• MODERATE
• ADVANCED
PROBING
DEPTH
• > 4MM
• > 6 MM
• > 8MM
BONE LOSS
(ON RADIOGRAPH)
• <25% of
implant length
• <25-50% of
implant length
• > 50% implant
length
FROUM AND ROSEN’S CLASSIFICATION OF PERI –
IMPLANTITIS ( 2012)
16
16
Gulati M, Govila V, Anand V, Anand B. Implant maintenance: a clinical update. International scholarly
research notices. 2014;2014.

ETIOLOGY OF PERI IMPLANTITIS
1. Bacterial infection
2. Biomechanical factors.
17
17
1. Jan Lindhe Textbook of Clinical Periodontology ; 4th edition pg no. 98-
120, chapter no.3
2. Charles A Babbush, Dental implants arts and science 3rd edition pg no.

BACTERIAL INFECTION
Bacterial plaque
Plaque products and inflammatory
mediators
Stimulate osteoclasts
18Jan Lindhe Textbook of Clinical Periodontology ; 4th edition pg no. 98-120, chapter no.3

BIOMECHANICAL FACTORS
• Experimental & clinical evidence by Hadeen et al. 1998, Lindhe et
al. 1992 supports the concept that excessive biomechanical forces
may lead to high stress or micro-fractures in the coronal bone to
implant contact and thus lead to loss of osseointegration around the
neck of the implant.
20
Jan Lindhe Textbook of Clinical Periodontology ; 4th edition pg no. 98-120, chapter no.3

The role of overloading is likely to increase in four
clinical situations:
1. The implant is placed in poor quality bone.
2. The implant’s position or the total amount of implants placed
does not favor ideal load transmission over the implant surface.
3. The patient has a pattern of heavy occlusal function associated
with parafunction.
4. The prosthetic superstructure does not fit the implants precisely.
21
21

Other etiological factors
• Traumatic surgical procedures
• Smoking
• Inadequate amount of bone at placement.
Compromised host response can act as co-factors in the
development of peri implant disease.
22

• Rosenlincht reports that a positive and passive seat must be
obtained clinically and radiographically to prevent soft and hard
tissue impingement.
• Clinical experience demonstrates a concomitant loss of crestal bone
when a soft or hard tissue impingement exists between the
abutment and implant fixture, allowing a macrogap to develop.
23

Microbiologic findings in periimplantitis
• Similar as that with periodontitis.
THE DISEASE PROCESS,
MICROORGANISMS,
SEQUENCE OF COLONIZATION
PLAQUE MATURATION

RETROGRADE
PERI-IMPLANTITIS
What is it and what causes it???
• Traumatic failure
• The bone loss may be due to microfractures in the bone caused
by premature implant loading or overloading, off long axis
loading, or lateral function loading
26

Cumulative Interceptive Supportive therapy
• The principle of this method is to detect peri implant
infections as early as possible and to intercept the
problems with appropriate therapy.
Jan Lindhe Textbook of Clinical Periodontology ; 4th edition pg no. 98-
120, chapter no.3
27

28

The major clinical parameters to be used:
1. Presence of a biofilm
2. Presence or absence of BoP
3. Presence or absence of suppuration
4. Increased peri-implant probing depth
5. Evidence and extent of radiographic alveolar bone loss
29

• Oral implants without plaque and calculus and surrounded by
healthy peri-implant tissues, as evidenced by
(1) Absence of BoP
(2) Absence of suppuration, and
(3) Probing depth usually not exceeding 3 mm, should be
considered clinically stable.
Optimally an implant should yield negative results for all these
parameters. In this case no therapy is needed and one may consider
increasing the length of recall interval.
30

Clinically stable implant with crown
(region 21) characterized by absence
of bleeding on probing, suppuration,
and a peri-implant probing depth not
exceeding 3 mm.
Peri-implant mucositis characterized
by presence of bleeding on probing,
absence of suppuration and a peri-
implant probing depth of 4 mm.

MICRO-GAP VERSUS MACRO-
GAP
To maintain optimal soft tissue health , the abutment must fit the
fixture - if does not fit
1. Charles A Babbush, Dental implants arts and science 3rd edition pg no. 423-700
Loss of osseous support and possibly the eventual loss of the
implant itself.
“open margin” ( allowing the harbouring of bacterial flora)
if microgap becomes macrogap
32
32
Left side –microgap Right side macrogap
between abutment
and fixture

CRESTAL BONE LOSS AROUND
IMPLANTS
• Initial breakdown of the implant – tissue interface generally begins at
the crestal region.
• Adell et al were the first to report crestal bone loss.
• They found greater crestal bone loss during the first year – averaging
1.2 mm(range of 0-3 mm)
• After 1st year --- 0.05 -0.13 mm /year .
• Other studies report an average first year bone loss of 0.93 mm ,with a
range from 0.4- 1.6 mm and a mean loss of 0.1 mm after 1st year.
Carl E Misch. Contemporary implant dentistry 3rd edition 2008; chapter no 42. pg no.1073-
1083
34

• Acording to these findings Albrektsson has included “vertical
bone loss less that 0.2 mm annually after first year of service of
the implant” as one of the criteria for implant success.
• The early crestal bone loss has been observed so frequently that
proposed criteria for successful implants do not include 1st year
bone loss .
Carl E Misch. Contemporary implant dentistry 3rd edition 2008; chapter
no 42. pg no.1073-1083 35
35

Effects of crestal bone loss
• Effect on esthetics
• Implant failure
36

Implant failures
LATEEARLY
37

Early implant failures are the result of:
• Bacterial contamination and extensive inflammation of the wound
that may delay healing of the soft & hard tissues.
• Improper mechanical stability of the implant following its
insertion.
• Premature loading of the implant.
Jan Lindhe Textbook of Clinical Periodontology ; 4th edition pg no. 98-120,
chapter no.3 38

• Late failures occur in situations during which osseointegration
of a previously stable & properly functioning implant is lost.
• Flemming & Renvert 1999 suggested that late failures are the
result of excessive load and/or infection.
39

BASELINE DATA
• Documentation – important
• Indicates a problem
40
Charles A Babbush, Dental implants arts and science 3rd edition pg no. 423-
700

PROSTHESIS DESIGN
• Varies from patient to patient
• Understanding the type of restoration and its design
To recommend oral hygiene aids suitable to the patients needs.
• Design should allow- access by the patient and clinician to keep
areas free of plaque.
41
Charles A Babbush, Dental implants arts and science 3rd edition pg no.
423-700

Post-care can be inserted mesial and distal to a ridge lapped crown
and gently pulled lingually to debride the restoration.
42

If a contact is tight or an embrassure
space is inadequate
Difficult or painful to cleanse with
floss
Patient may omit this part of an
oral hygiene routine.

If patient has retrievable superstructure
Should be removed every 18-24
months and placed in ultrasonic
cleaning solution.
44

• Connector bars and overdentures - to be cleansed
thoroughly.
45

POST SURGICAL HYGIENE
Tissues are tender
Difficulty in achieving adequate
hygiene.
Gentle and thorough
• Visits to the dentist- weekly
for approximately 1 month
(for evaluation and
education)
• If good oral hygiene cannot
be achieved - subsequent
phases are delayed.
• Proceeding with restorative
phase of treatment
46

The Implant Maintenance Appointment
To Probe Or Not To Probe?
47

Should the doctor probe the dental implant???
Its controversial
As there is no true attachment of soft tissue to the implant surface.
.

• Some clinicians believe that inserting a probe in an implant sulcus can
cause an introduction of bacteria to the implant-bone interface.
• Dipping the tip of the non metallic probe into chlorhexidine before
probing around an implant may be performed to prevent seeding of peri-
implant tissue with bacteria.
• It is advocated to probe the dental implant only if pathology is present.

• If a light probing pressure is
applied during probing , the
epithelial attachment of the
transmucosal tissue seal will be
disrupted but will heal within 5-7
days.

OCCLUSION
• An implant is similar to an ankylosed tooth.
• Periodontal ligament is not present.
• Hence biting forces are transmitted to the surrounding bone
through implant.
• Excessive occlusal forces ( bruxism or improper contact)
• Too much stress leading to non infective bone loss.
• Therefore occlusion should be checked periodically.
51
53

HARD TISSUE EVALUATION
• Longetivity of implant requires good osseous support.
• Bone loss may be caused by-
 Bacterial invasion and infection
 Traumatic occlusion
 Inaccurate fit of the prosthesis
 Breakdown of cement seal or
 Micromovement due to screw loosening
52

IMPLANT MOBILITY
• Sign of a more serious problem
• Requires a more complicated assessment, diagnosis and repair.
• If the mobility exists within the abutment- prosthesis connection , it
is often easy to repair with screw tightening , re-cementation or
occlusal adjustment.

P. Apse, G. A. Zarb, A. Schmitt, and D. W. Lewis, “The longitudinal effectiveness of
osseointegrated dental implants. The Toronto study: peri-implant mucosal response,”
The International Journal of Periodontics & Restorative Dentistry, vol. 11, no. 2, pp. 95–
111, 1991. 54

BASELINE RADIOGRAPHS
• Key in diagnosing radiolucencies and can act as an aid in
evaluating bone loss.
• Some implants with bone loss may not exihibit any clinical
tissue problems or symptoms.
• Radiographs should be taken annually for the first 3 years after
the placement and for the life of the implant after completion of
the case.

ORAL HYGIENE AND
IMPLANT MAINTENANCE
• The importance of good oral hygiene should be stressed even
before implants are placed.
• Oral hygiene instructions for plaque control should begin as early
as possible.

Team Approach For Implant Maintenance

Roles In Implant Maintenance
Patient ‘s role
Hygienist’s role
Dentist’s clinical role
58
58

HYGIENIST’S ROLE
• Check plaque control effectiveness(85%)
• Check for inflammatory changes.
• If pathologic condition exists, probe gently with plastic probe.
• Scale supragingivally only (or slightly subgingivally) with impla-care or
similar device.
• Check for problems such as loose suprastructure, broken screws and sore
spots.
• No need to probe if no pathologic condition is present.
60

DENTIST’S CLINICAL ROLE
• Check patient every 3-4 months.
• Check for 85% plaque control effectiveness.
• Expose radiographs every 12-18 months if no pathologic
condition is present and as needed if pathologic condition is
present.
• If implant needs repair, degranulate, detoxify, and graft with
guided bone regeneration if necessary.
• Wait 10-12 weeks before placing implant back in full function.
Check to see whether implant needs to be repaired.
61
Carl E Misch. Contemporary implant dentistry 3rd edition 2008; chapter no 42. pg no.1073-
1083

• Some patients with good oral hygiene and minimal deposits, will
require infrequent professional hygiene maintenance, whereas
others with heavy deposits will require more frequent follow-up
care.
• The use of plastic and gold curettes has been advocated to protect
the titanium implant surface and the titanium abutment from
contamination.
• These curettes were also used to reduce the likelihood of scratching
the surface.
62
62
Carl E Misch. Contemporary implant dentistry 3rd edition 2008; chapter no 42. pg
no.1073-1083

• The gold alloy or ceramic surfaces can be debrided with most
scalers and curettes without damaging the surface.
• Rotary instruments (prophy cup) can be used to remove plaque or
biofilms and polish surfaces.
• The use of sonic instruments (CAVITRON) should be avoided
because of the irregularities that can easily be created in the surface
which can contribute to plaque and calculus accumulation.
63
63
no.1073-1083

• Titanium-tipped curettes produced parallel grooves with
overlapping strokes.
• Stainless steel curettes produced random grooving, with a marked
pitting on the surface.
• The soft titanium surface was pitted in a random fashion with the
air abrasive instrument.
64
no.1073-1083
64

INSTRUMENT SELECTION
• A variety of nonmetallic, plastic, graphite, nylon, or Teflon-coated
instruments are available and have been proven to be safe to use on
titanium implant surfaces.
• A titanium curette and a rubber cup with flour of pumice are
suitable for cleaning implant surfaces.
65
65

SELECTION OF INSTRUMENTS
Depends on –
 Tip designs that are not bulky and the designs should be easy
to use by the hygienist.
 Instruments should be disposable or able to be sterilized and
cost effective.
 Location and tenacity of the deposit to be removed.
 Prosthesis design
66

Products for Implant Maintenance
Instruments for implant maintenance are available from several
manufacturers. The following list serves as a guide.

Implant-Prophy + Plastic Dental Instrument System-
Plastic polymer curettes with the Gracey design (5/6, 11/12, 13/14,
and the Columbia 13/14). The instruments are designed to be
resharpened with a sharpening stone included with this system.
Instruments are effective with up to 75 autoclave cycles.
70Charles A Babbush, Dental implants arts and science 3rd edition pg no. 423-

• ITS implant scaler- ultrasonic implant scaler with disposable
plastic tips.
• Quixonic sonic scaler with soft tip disposable tips- sonic scaler tip
used with disposable plastic tips
71
71

• Perioguard- 0.12% chlorhexidine gluconate
• Pro-Select 3- 0.12% chlorhexidine gluconate
• Rota-Dent toothbrush
• Rota-Point Interdental Cleaners- Plastic interdental stimulators
• G-Floss-Wide flat floss designed for implants
• Abutment Glo- Very fine prophy paste for implant abutments
• Thorton Bridge & Implant Interdental Cleaners- 2.5 inch
plastic threader connected to a 5 inch spongy filament floss.
72

SCALING
Because of the delicacy of the perimucosal seal,
Short working strokes with light pressure
(BEST METHOD FOR REMOVING CALCULUS)

PLASTIC SCALER
74

GOLD TIPPED SCALER
GRAPHITE SCALER
75

• Plastic or teflon coated curettes that can treat the subgingival area
effectively without changing the surface topography of implants.
• These Surfaces treated with plastic and titanium currettes showed
greater numbers of attached cells than stainless steel currette treated
surfaces.
• vitro results theoretically suggest that implant maintenance could
affect tissue attachment integrity.
76
76

CURETTES
77
• Depending on the
location of the
calculus,
• a horizontal, vertical,
or oblique stroke may
be used and
• should be performed
with an exploratory-
type stroke to avoid
tissue trauma.
77

• Tufted brush easily maneuvers in hard to reach areas and may be
bent to accommodate patient needs.
• Especially useful in posterior lingual regions where a conventional
tooth brush might not reach.
78
END TUFTED BRUSH

Proxi-Tip Interproximal Brush and Stimulator- brush has
plastic bristles and a plastic core with no metal wire to
contact the implant surface.

INTERDENTAL
BRUSH
80
Brush designs- straight and
cone-shaped.
Embrasure size and shape
considered to prevent brush
bending and tissue trauma.
Proxi tip- interdental brush
and stimulator.
80

POWERED BRUSH
(ROTO DENT)
81
SIMPLE SOFT
BRUSH

• Foam tips – used to apply chemotherapeutic agents interdentally
and site specifically.
82

TUFTED FLOSS
83

• Gentle insertion and motion to avoid trauma to the tissue.
• Woven flosses with threaders – to help access and cleanse larger
embrassure spaces and under connector bars.
84

YARN
85
Yarns can be used as same as flosses
but if there is the possibility of fibers
being retained on rough surfaces or
around restorations they are not to be
considered.
Yarns are a cost-effective alternative to
woven floss.

• ULTRASONIC BRUSH
• SONI CARE , PHILLIPS
86

ORAL IRRIGATION
• Patients are to be instructed to use at the
lowest setting possible to avoid undue
pressure to the implant tissue cuff.
• The flow should be aimed to pass through
the contacts and never be directed into the
tissue.
• Incorrect use- - trauma - bacteremia
87
87
ORAL IRRIGATOR

CHEMOTHERAPEUTICAGENTS
 Chlorhexidine gluconate has
proved to be a useful irrigant.
 It is also wise to use a neutral
sodium fluoride in a patient
with dental implants because
certain acidic fluorides can
alter titanium .
89

CRITERIA FOR IMPLANT
SUCCESS
 An individual, unattached implant is immobile when tested
clinically.
 A radiograph does not demonstrate any evidence of periimplant
radiolucency.
 Vertical bone loss is less that 0.2 mm annually after the first year of
service of the implant.
 Individual implant performance is characterized by an absence of
persistent or irreversible signs and symptoms such as pain,
infections, neuropathies, paresthesia, or violation of the mandibular
canal. 90

IMPLANT HEALTH QUALITY
SCALE
• Helps the clinician in evaluation, classification and in deciding
further treatment protocol in any implant case.
• Proposed by Carl Misch.
91
Carl E Misch. Contemporary implant dentistry 3rd edition 2008; chapter no 42. pg no.1073-1083

ImplantQuality Scale
I. Success (optimum health)
II. Survival (satisfactory health)
III. Survival (compromisedhealth)
IV. Failure (clinical or absolutefailure)
92
no.1073-1083
92

I.Success (optimumhealth)
 No pain or tenderness upon
function
 0mobility
 < 2 mm radiographic bone loss
from initial surgery
 Probing depth <5mm
 No exudatehistory
 MANAGEMENT :Normal
maintenance
93
II.Survival(satisfactoryhealth)
 No pain
 0mobility
 2-4mm radiographic boneloss
 Probing depth 5to7mm
 No exudatehistory
Management: Reduction ofstresses
 Shorter intervals between hygiene
appointments
 Gingivoplasty
 Yearly radiographs

IIISURVIVAL(COMPROMISED
HEALTH)
 No pain upon function
 0mobility
 Radiographic bone loss>4mm
 Probing depth > 7mm
 May have exudate history
Management : Reduction of
stresses
 Drug therapy (antibiotics,
chlorhexidine)
 Surgical reentry andrevision
 Changein prosthesis or implants
94
IV.Failure (clinical orabsolute failure)
Any of thefollowing:
 Pain uponfunction
 Mobility
 Radiographic bone loss >1/2
length of implant Uncontrolled
exudate
 No longer inmouth
 Management: Removal of
implant

TERMINOLOGIES
• A Failed Implant is described as one that is clinically mobile, and that
shows peri implant radiolucency and probing depths greater than 6mm.
• A Failing Implant, in contrast, is one that shows progressive loss of
supporting bone, but that is clinically immobile.
• Problems limited to the soft tissues surrounding implants & not
involving the supporting bone have seen defined as “ailing implants”
and more recently as ‘biological complication’.
95

REPAIROFTHEAILING, FAILING DENTAL
IMPLANT
96
I. If an active infection (purulence, bleeding, swelling) is present
with radiographically visible bone loss and the disease process is
continuing, the following steps should be implemented:
A. Reflect the tissue and degranulate the defect (metallic curettes are
acceptable)
B. If the implant is hydroxyapatite (HA) coated and the HA is
undergoing resorption and has changed color and texture, remove all
the HA until the metallic surface is visible.

 Use of ultrasonics such as Cavitron is best; use of hand curettes
is too slow, and use of air abrasives is dangerous because of
danger of air emboli in marrow spaces.
C. Detoxify the dental implant with citric acid applied with cotton
pledget or camel's hair brush. Thirty seconds per surface is
sufficient.
D.Graft
E. Leave the repaired implant out of function and "covered" for 10
to 12 weeks
97

IMPLANT CROWN ESTHETIC INDEX
 Developed by HENNY ET AL esthetics can be rated in a subjective
and an objective manner.
 A subjective method is the use of questionnaires, which must be
completed by the patient
 The total score is 8 points on the index, which means poor esthetics
Esthetic Scale
0 points = Excellent esthetics
1 or 2 points = Satisfactory esthetics
3 or 4 points = Moderate esthetics
5 or more points = Poor esthetics
98

1. Mesiodistal Dimension of the Crown
2. Position of the Incisal Edge of the Crown.
3. Labial Convexity of the Crown
4. Color and Translucency of the Crown
5. Surface of the Crown
6. Position of the Labial Margin of the Peri-Implant Mucosa
7. Position of Mucosa in the Approximal Embrasures
8. Contour of the Labial Surface of the Mucosa
9. Color and Surface of the Labial Mucosa
99

CONCLUSION
• Daily self-care(oral hygiene) and adherence to a maintenance
recall schedule is absolutely required for long term success.
• This is best discussed and conveyed to the patient at the
consultation visit.
• Long term success of both periodontal and implant therapy
depends on an effective partnership between the patient and
practioner.
101

REFERENCES
1. Carl E Misch. Contemporary implant dentistry 3rd edition
2008; chapter no 42. pg no.1073-1083
2. Ajay vikram singh:clinical implantology: 1st edition
chapter no.19-22,pg no.423-500.
3. Charles A Babbush, Dental implants arts and science 3rd
edition pg no. 423-700
4. Lee KH, Maiden MF, Tanner AC, Weber HP. Microbiota
of successful osseointegrated dental implants. Journal of
periodontology. 1999 Feb;70(2):131-8. 102

5) Chen S, Darby I. Dental implants: Maintenance,
care and treatment of peri‐implant infection.
Australian dental journal. 2003 Dec;48(4):212-20.
6) Gulati M, Govila V, Anand V, Anand B. Implant
maintenance: a clinical update. International
scholarly research notices. 2014;2014.
7) Jan Lindhe Textbook of Clinical Periodontology ;
4th edition pg no. 98-120, chapter no.3
103

Maintenance of Dental Implants

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