CE           2                                                           CONTINUING EDUCATION                             ...
Contemporary Implant Debridement     with its direct titanium-to-bone contact, lacks this soft tissue     reservoir (Figur...
Sternberg-Smith                                                             Instrument Selection                          ...
Contemporary Implant Debridement                                                                   Table                  ...
Sternberg-Smith                                                                      Implacare™ (Hu-Friedy, Chicago, IL) i...
Contemporary Implant Debridement     Figure 8. The Facial Scaler is ideal for removal of heavy         Figure 9. An SEM (o...
Sternberg-SmithFigure 10. An SEM (original magnification 500) reveals                          Figure 11. The Profin™ is i...
CONTINUING EDUCATION (CE) EXERCISE NO. 2                                                                                  ...
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Contemporary Implant Debridement


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Contemporary Implant Debridement

  1. 1. CE 2 CONTINUING EDUCATION Contemporary Implant Debridement Valerie Sternberg-Smith, RDH, BS Robert N. Eskow, DMD, MScDImplant dentistry has become the standard of care for tooth become familiar with different restorative designs and wherereplacement in both fully and partially edentulous patients. the soft tissue restorative interface lies.Due to this rapid evolution, the dental hygienist has beenthrust into the position of providing care for the peri-implant Soft Tissue Interfaceenvironment. The long-term prognosis of an implant is The peri-implant tissues mimic those surrounding a naturaldirectly related to effective preventive care. The hygienist tooth in several aspects with some important differences.must perform this care in a manner that is compatible with A soft tissue crevice lined by sulcular epithelium sits justcontemporary implant restorative designs and is based on coronal to a junctional epithelium that adheres to thethe principles of maintaining soft tissue health. titanium surface and to a zone of connective tissue, which merely adheres to the titanium (Figure 1).1,2 The zone ofIntroduction connective tissue around a tooth, however, is attached bySince the introduction of osseointegrated implant dentistry, gingival fibers that insert into the cemental surface.3 Anothernumerous changes have occurred that challenge the clin- difference exists apically. Each tooth is surrounded by aician. The rapid acceptance of implants and an increased periodontal ligament, a source of blood vessels and fibro-concern with achieving optimal aesthetics have resulted in blasts for the connective tissue attachment. The implant,implant restorations that are frequently indistinguishablefrom restored natural teeth. Indeed, radiographs are nec- Crownessary during the debridement process to differentiatebetween implants and teeth. To understand which is the Creviceappropriate instrument to be utilized, the hygienist must Abutment Crevice Sulcular Epithelium SulcularValerie Sternberg-Smith, RDH, BS, has been a dental hygienist Epithelium Junctionaland surgical assistant for 17 years in a practice limited to perio- Epithelium Junctionaldontics and implant surgery. Ms. Smith is a faculty member in Connective Epithelium Tissueboth the Ashman Department of Implant Dentistry and the Attachment Connective TissueDental Hygiene Program at New York University, College of Adherence PeriodontalDentistry. Ligament Fixture RootRobert N. Eskow, DMD, MScD, is a diplomate of the American BoneBoard of Periodontolgy and Clinical Professor in the AshmanDepartment of Implant Dentistry, New York University, Collegeof Dentistry. Dr. Eskow maintains a private practice limited toperiodontics, implant dentistry, and oral medicine in Livingston, Figure 1. The soft tissue anatomy of the dental implant,NJ and Clark, NJ. abutment, and crown versus the natural tooth. March /April 2001 15
  2. 2. Contemporary Implant Debridement with its direct titanium-to-bone contact, lacks this soft tissue reservoir (Figure 1). These differences explain why the peri- implant mucosa has diminished capacity for self-repair in the face of inflammation.4 Several experimental studies have demonstrated that the destructive response to inflammation in the peri-implant tissues is greater than in those tissues that surround the natural tooth.4,5 Furthermore, the nature of the relationship of the soft tissue to the restorative implant components Figure 2. Implant-supported restorations resemble varies depending on the material employed. The soft-tissue- restored natural teeth. The instrument is well-suited to to-titanium adhesions described in the aforementioned enter a shallow peri-implant crevice and debride the limited amount of abutment surface. studies do not occur in the presence of ceramic or gold restorations.6 Due to the current interaction of peri-implant tissues and bacteria, the emphasis must be on preventive care to preclude the initiation of inflammation. Debridement The rationale for debridement is to control the bacterial population, both quantitatively and qualitatively, in prox- imity to the peri-implant mucosa. This is accomplished by removing plaque and calculus while maintaining soft-tissue adherance. Debridement is just as necessary for dental implants as it is for the natural dentition, since peri-implant disease has been demonstrated to result in bone loss and ultimate loss of the implant fixture (Figure 2).7 Figure 3. The sheathed ultrasonic tip can be adapted Although implant dentistry became a well-established into the crevice of an exposed implant fixture. clinical reality in the mid-1980s, it was not until several years later that any mention of debridement was made in the literature. Initial studies were observations utilizing a scanning electron microscope (SEM) analysis of the effect of various implements on titanium surfaces,8-10 but in subse- quent discussions of clinical preventive care, there was only nominal mention of the instrumentation process.11,12 Implant-supported restorations can range from single crowns to attachments for overdentures to fixed-hybrid dentures. The classic implant components the therapist must be knowledgeable of during debridement are the abutment and the prosthesis. In a restorative modification, the abutment is absent, and the prosthesis attaches directly to the implant fixture. Occasionally, the fixture is not com- Figure 4. A metal curette is adapted to the pontic area pletely encased in bone and is exposed to the oral cavity; of this implant-supported bridge. in such a case, it also requires debridement (Figure 3).16 The Journal of Practical Hygiene
  3. 3. Sternberg-Smith Instrument Selection Historically, preventive instrumentation in implant dentistry has been discussed in universal terms.11-13 It may be more Fixture appropriate to consider the specific components that require debridement: the restoration, the transmucosal abutment, and the fixture. Each component will influence the selec- tion of instruments. The Restoration The basis for instrument selection is to leave the restoration undamaged. The clinician can select an instrument based strictly on the specific restorative material to be debrided; the fact that the prosthesis is implant supported is irrelevant. For example, if calculus is present on a porcelain-fused- to-metal (PFM) crown, a metal curette may be used (though the crown is implant supported), with care exercised not to use this instrument apical to the restorative margin (Figure 4). If soft debris alone is present on the restora- tion (eg, crown, denture, attachments for overdentures), the Abutment most effective way to deplaque is to polish with an appro- priate prophy paste. When the restoration is a nonremov- able hybrid denture, deplaquing the undersurface can be Crown accomplished with interdental brushes or tips, end-tuft brushes, or floss materials. For restorations that mimic crown-and-bridge dentistryFigure 5. Extensive crevicular depth is required to enabledevelopment of proper restorative contours. Instrumenta- and have large embrasure areas, interdental brushes/tipstion of these deep crevices is limited in order to prevent may be effective for gross plaque removal, but in most casesdamage to the soft tissues. the bristles do not penetrate into the peri-implant crevice. Interdental brushes/tips should be used in a vigorous back- and-forth motion against the walls of the restoration and directed toward the tissue margin in an effort to reach into the crevice. The depth of the crevice can be cleansed with floss or a Perio-Aid™ (Marquis Dental Mfg, Aurora, CO). A commonly placed implant in dentistry today is the single-tooth replacement. Debridement of these restora- tions requires an understanding of the peri-implant tissues and the restorative components (Figure 5). Frequently, the circumference of the crown is greater than the supporting abutment. This results in a broad surface of restorative material in contact with the soft tissue. Dental floss can beFigure 6. This posterior implant-supported restoration adapted to the restoration and brought into the peri-implantnecessitates deplaquing the abutment and the restora-tive material in contact with the soft tissue. crevice, thus removing intracrevicular plaque (Figure 6). March /April 2001 17
  4. 4. Contemporary Implant Debridement Table Instruments and Manufacturers Hand Instruments Manufacturer Implacare™ Hu-Friedy (Chicago, IL) Columbia 4R/4L Anterior Sickle H6/H7 Posterior Sickle 204S Implant-Prophy+™ Advanced Implant Technologies (Beverly Hills, CA) Gracey 5/6, 11/12, 13/14 Columbia 13/14 HaweNeos™ (Graphite) Orofacial Scaler (Hoe) Premier (King of Prussia, PA) Columbia 4R/4L Implant Innovations Inc (Palm Beach Gardens, FL) Nobel Biocare (Yorba Linda, CA) Steri-Oss Implant Curettes™ (Graphite) Nobel Biocare (Yorba Linda, CA) Gracey 5/6, 11/12, 13/14 Sickle Power Instruments Quixonic Sonic Scaler SofTip™ Dentsply Professional (York, PA) Ultrasonic Tip Tony Riso Company, LLC (Miami Beach, FL) Profin™ Dentatus USA, Ltd (New York, NY) Prophy Paste Abutment Glo™ Implant Innovations Inc (Palm Beach Gardens, FL) ImplantCleanic® Premier Dental Products Co (King of Prussia, PA) Debridement Aids Interdental Brushes (coated wire) John O. Butler Co (Chicago, IL) Proxi-Tip™ (no wire center) Advanced Implant Technologies (Beverly Hills, CA) Floss Materials Super Floss® Oral-B Laboratories (Belmont, CA) Thornton’s Floss Thornton International Inc (Norwalk, CT) Proxi-Floss™ Advanced Implant Technologies (Beverly Hills, CA) Post Care® John O. Butler Co (Chicago, IL) Perio-Aid® Marquis Dental Mfg (Aurora, CO) The Transmucosal Abutment placed into the crevice, positioned against the titanium sur- If a metal instrument is used during debridement of a face, and moved in a coronal direction toward the restora- supra- and/or subgingival transmucosal titanium abutment, tion (Figure 7). it will roughen the surface,8-10 thus fostering bacterial When only soft debris is present on the abutment, the accumulation. 14,15 The clinician must maintain the integrity clinician needs to deplaque the surface. Supragingival abut- of the surface by using specially designed instruments. ments can be polished using tin oxide or a prophy paste Research has shown that scalers/curettes made of plastic and specifically designed for polishing titanium surfaces. When plastic sonic and ultrasonic tips can be used without nega- polishing the proximal area of the abutment is difficult, an tively affecting the surface. 16-18 interdental brush/tip may be used. It is best to avoid those The air syringe is an excellent tool that allows the with metal stems so as not to scratch the surface. Many imple- hygienist to deflect the tissue to view the peri-implant ments include a plastic or nylon coating over the metal wire crevice. In consideration of the vulnerability of peri-implant that will prevent damage. A vigorous back-and-forth motion tissue adherence, the scaler/curette should be delicately against the titanium abutment surface will remove debris.18 The Journal of Practical Hygiene
  5. 5. Sternberg-Smith Implacare™ (Hu-Friedy, Chicago, IL) instruments are disposable plastic tips, available in presterilized packaging, Crown which screw into autoclavable metal handles. Small enough to use in the peri-implant crevice, this instrument should be placed apical to the calculus and moved in short strokes in a coronal direction. While these particular instruments are effective for Abutment light calculus and crown-and-bridge-design restorations, they can be too flexible to remove tenacious calculus. In cases where a mandibular hybrid denture has been placed in a mouth with severe ridge resorption, adaptation of Fixture these tips is difficult due to shank length. Implant-Prophy+™ (Advanced Implant Technologies, Beverly Hills, CA) has slightly more bulk and is more rigid than Implacare. The advantages of these autoclavable instru- ments are rigidity; ability to be sharpened (with a special stone), maintaining the effectiveness of the instrument over time; and numerous blade configurations. Suitable for mod- erate to heavy calculus, the instrument’s variety of config- urations allows the clinician to select the most appropriateFigure 7. An instrument is adapted to the abutment one. A disadvantage is the bulk of the blade, which pre-surface with minimal apical pressure to preclude vents its utilization in the peri-implant crevice. This can bedisrupting the junctional epithelium. corrected by reduction with the sharpening stone. Plastic scalers/curettes reinforced with graphite are Frequently the abutment will be completely confined the most rigid instruments available. They can be sharp-within the peri-implant crevice so that optimal aesthetics can ened, although a dedicated stone should be utilized forbe achieved. This area can be deplaqued with dental floss this purpose. When a stone that previously sharpened awith the clinician adapting the floss to the restoration and metal instrument comes in contact with a plastic instrument,continuing into the peri-implant crevice. Perio-Aid , a device ® metal filings can be embedded into the plastic cuttingmade of a plastic handle that holds round wooden tooth- blades, which may in turn roughen the titanium surface.picks, can be utilized as well. The wooden tips are placed Different designs of this reinforced plastic are available: ain the crevice at an oblique angle and moved 360 degrees universal curette, a hoe, and various Gracey configurations.around the abutment surface. Each tip will splay as it is All of these graphite instruments can be dry-heat sterilizedmoistened by saliva, creating a more efficient surface than or autoclaved.a plastic curette or scaler to remove soft debris or plaque. The blade of the universal curette is compact, similar When calculus is present on the abutment, it must also to that of a metal curette. Due to its thinness and rigidity,be removed without altering the titanium surface. The instru- the instrument can break, especially when utilized on tena-ment selection for this purpose will depend on the access, cious calculus. This particular instrument is ideal for crown-the location, the tenacity of the calculus, and the design of and-bridge-design restorations and is most suitable for lightthe prosthesis. Many different plastic scalers/curettes can to moderate calculus.clean a titanium surface and maintain its integrity. The clini- The hoe design has more bulk and is therefore idealcian needs to understand the advantages/disadvantages of for heavy calculus deposits. Effective on mandibular hybrideach instrument in order to make the appropriate selection. denture designs in which access is difficult (Figure 8), this March /April 2001 19
  6. 6. Contemporary Implant Debridement Figure 8. The Facial Scaler is ideal for removal of heavy Figure 9. An SEM (original magnification 500) reveals calculus from mandibular anterior lingual surfaces. no damage to the abutment surface following utilization of a sheathed ultrasonic tip for 25 seconds on low power. instrument is not appropriate for traditional posterior crown- and can remove both plaque and calculus. Scanning elec- and-bridge designs. tron microscope examination revealed no damaging effects The Gracey graphite configurations are smaller than on a titanium abutment surface after 25 seconds of appli- the Implant-Prophy+ curette, which in some limited-access cation (Figure 10). This tip contains no metal, which allows cases is beneficial. While these instruments can be sharp- for adaptation to the lateral walls of the abutment and ened using a dedicated stone, the short blade face will limit underside of the restoration, and is small enough to fit into the number of times this can be done. The small Gracey the peri-implant crevice. It can be used for heavy calculus configurations can be advantageous in the posterior regions and difficult access areas typically associated with hybrid with traditional crown-and-bridge restorations. designs (Figure 11). Power instruments can be used to remove plaque and calculus from the titanium abutment surface as well. A plas- Fixture tic sonic instrument has been shown to polish the titanium When the implant fixture is exposed within the peri-implant surface in addition to removing debris. The autoclavable 10 crevice or supramarginally, debridement becomes both metal tip attached to a disposable plastic sheath should be necessary and challenging. The macro and micro architec- held lightly against the surface and kept constantly mov- ture of the fixture surface influences the quantity of plaque ing to avoid damage. 16 and calculus,14,15 its retention, and the instrumentation neces- When an ultrasonic insert with an attached plastic sary to remove it. Whether the surface is machined, etched, sheath (Tony Riso Co, Miami Beach, FL) is utilized on low blasted, sprayed titanium, or hydroxyapatite coated is sig- power with copious irrigation, no damage to the titanium nificant. Plastic instruments previously described have been surface occurs (Figure 9). The ultrasonic insert and plastic shown to alter the abutment surface following utilization tip can be autoclaved without damage. As the tip is small on the surface of an implant fixture.17 enough to fit into the crevice of the peri-implant tissues, The surface coating of the implant fixture is plaque this instrument is very effective where there is limited access retentive, and the calculus that forms can be very tenacious, and heavy calculus formation (Figure 3). as clinical experience has shown. Accordingly, a metal curette The newest power instrument available for implant or an ultrasonic tip seems the more appropriate choice. debridement is the Profin™ (Dentatus , New York, NY). It ® When the exposed implant fixture consists of machined consists of a handpiece into which disposable nylon plas- threads, the clinician should take care not to increase the tic points are inserted. These tips move in a linear motion roughness. Although it is difficult to remove calculus from20 The Journal of Practical Hygiene
  7. 7. Sternberg-SmithFigure 10. An SEM (original magnification 500) reveals Figure 11. The Profin™ is ideal for hybrid restorativeno damage to the abutment surface using the Profin™ designs and for the removal of heavy deposits from thewith the Eva 123 tip for 25 seconds. fixture, abutments, and restoration.the threads, this can be accomplished with one of the 4. Lindhe J, Berglundh T, Ericsson I, et al. Experimental breakdown of peri-implant and periodontal tissues. A study in the beagle dog. Clinpower instruments with plastic tips previously described. Oral Impl Res 1992;3:9-16. If only plaque is present, a soft-bristle brush can be 5. Ericsson I, Berglundh T, Marinello C, et al. Long-standing plaque and gingivitis at implants and teeth in the dog. Clin Oral Impl Resutilized to remove it. An end-tuft brush frequently is ideal 1992;3(3):99-103. 6. Abrahamsson I, Berglundh T, Glantz PO, Lindhe J. The mucosal attach-for this situation. This brush should be rotated in a small ment at the different abutments. An experimental study in dogs. J Clincircular motion around the fixture and abutment. It is much Periodontol 1998;25(9):721-727. 7. Albrektsson T, Insidor F. Consensus report of session IV. In: Lang NP,easier to deplaque the fixture surface with a brush than Karring T, eds. Proceedings of the 1st European Workshop on Periodontology. London, England: Quintessence Publishing; 1994:other plaque-control aids. 365-369. 8. Thomson ND, Evans GH, Meffert RM. Effects of various prophylactic treatments of titanium, sapphire, and hydroxyapatite-coated implants:Conclusion An SEM study. Int J Perio Rest Dent 1989;9(4):300-311.Implant dentistry has demanded that practitioners acquire 9. Rapley JW, Swan RH, Hallmon WW, Mills MP. The surface character- istics produced by various oral hygiene instruments and materialsnew knowledge and techniques. Understanding the rela- on titanium implant abutments. Int J Oral Maxillofac Impl 1990; 5(1):47-52.tionship of the peri-implant mucosa to the implant restora- 10. Gantes BG, Nilveus R. The effects of different hygiene instruments on titanium surfaces: SEM observations. Int J Perio Rest Dent 1991;tion and the vulnerability of the tissue helps guide the 11(3):225-239.clinician in the debridement process and in the selection 11. Garber DA. Implants —the name of the game is still maintenance. Compend 1991;12(12):876,878,880 passim.of appropriate instruments. This selection should be based 12. Koutsonikos A, Federico J, Yukna RA. Implant maintenance. J Pracon tip design and rigidity, consideration of the tenacity of Hyg 1996;5(2):11-15. 13. Orton GS, Steele DL, Wolinsky LE. Dental professional’s role in mon-the calculus, the type of prosthesis, and the individual com- itoring and maintenance of tissue-integrated prostheses. Int J Oral Maxillofac Impl 1989;4(4):305-310.ponent (ie, the fixture, abutment, or restoration) being 14. Quirynen M, Bollen CM, Willems G, van Steenberghe D. Comparisoninstrumented. The ultimate challenge facing the hygienist of surface characteristics of six commercially pure titanium abutments. Int J Oral Maxillofac Impl 1994;9(1):71-76.is to preserve the bone supporting the implant. 15. Quirynen M, Papaioannou W, van Steenberghe D. Intraoral trans- mission and the colonization of oral hard surfaces. J Periodontol 1996; 67:986-993.References 16. Hollmon W, Waldrop T, Meffert R, Wade B. A comparative study of 1. Buser D, Weber HP, Donath K, et al. Soft tissue reactions to non- the effects of metallic, nonmetallic, and sonic instrumentation on tita- submerged unloaded titanium implants in beagle dogs. J Periodontol nium abutment surfaces. Int J Oral Maxillofac Impl 1996;11(1):96-100. 1992;63(3):225-235. 17. Rühling A, Kocher T, Kreusch J, Plagmann HC. Treatment of subgin- 2. Schroeder A, van der Zypen E, Stich H, Sutter F. The reactions of bone, gival implant surfaces with Teflon®-coated sonic and ultrasonic scaler connective tissue, and epithelium to endosteal implants with titanium- tips and various implant curettes. An in vitro study. Clin Oral Impl Res sprayed surfaces. J Maxillofac Surg 1981;9(1):15-25. 1994;5:19-29. 3. Berglundh T, Lindhe J, Ericsson I, et al. The soft tissue barrier at 18. Kwan JY, Zablotsky MH, Meffert RM. Implant maintenance using a implants and teeth. Clin Oral Impl Res 1991;2:81-90. modified ultrasonic instrument. J Dent Hyg 1990;64(9):422,424-425,430. March /April 2001 21
  8. 8. CONTINUING EDUCATION (CE) EXERCISE NO. 2 CE 2 CONTINUING EDUCATION To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and complete it as follows: 1) Identify the article; 2) Place an X in the appropriate box for each question; 3) Clip the answer sheet from the page and mail it to the CE Department at Montage Media Corporation. For further instructions, please refer to the CE Editorial Section. Answers to the 10 multiple-choice questions for this CE exercise are based on the article “Contemporary Implant Debridement” by Valerie Sternberg-Smith, RDH, BS and Robert N. Eskow, DMD, MScD. Answers will be mailed to all subscribers on a per test basis within one month of the exam deadline. WARNING: The Journal of Practical Hygiene encourages its readers to pursue further education when necessary before implementing any new procedures expressed in this article. Reading an article in The Journal of Practical Hygiene does not fully qualify you to incorporate these new techniques or procedures into your practice. Learning Outcomes: • Review the relationship between the peri-implant mucosa and implant-supported restorations. • Understand the various factors that influence instrument selection for implant debridement. • Examine the features of different instruments and consider their appropriateness for the task at hand. 1. The soft tissue crevice around an implant is 6. Which instrument is the most appropriate when lined with: heavy calculus on the abutment is present and A. Connective tissue. access is difficult? B. Gingival fibers. A. 4R/4L graphite instrument. C. Sulcular epithelium. B. Metal instrument. D. Bone. C. Hoe graphite. D. Implacare™ 4R/4L. 2. What structure is absent in the soft tissue 7. The ultrasonic insert with plastic sheath should surrounding an implant? be used on a titanium abutment surface with: A. Junctional epithelium. A. High power. B. Periodontal ligament. B. Medium power. C. Sulcular epithelium. C. No irrigation. D. Bone. D. Low power. 3. The destructive inflammatory response around 8. What is the instrument of choice on an exposed an implant is __________ that around a tooth. coated implant fixture with heavy calculus? A. Less than. A. Metal curette. B. Equal to. B. Implacare™. C. Unlike. C. Prophy+™. D. Greater than. D. Graphite reinforced curette. 9. What is the instrument of choice when an 4. What is the most effective way to remove exposed machine-threaded implant fixture has plaque from the undersurface of a non- only plaque and soft debris? removable hybrid denture? A. Plastic instrument. A. Interdental brush. B. Floss. B. Floss. C. Perio-Aid™. C. End tuft brush. D. End-tuft brush. D. All of the above. 10. The most rigid plastic instruments are reinforced 5. Instrument selection is based on: with the following: A. The feel of the instrument. A. Silicone. B. The component needing debridement. B. Graphite. C. The type of instrument. C. Metal. D. The patient’s health history. D. Acrylic.22 The Journal of Practical Hygiene