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Maintenance of Dental Implants: Implant
Quality of Health Scale
CARL MISCH CHAPTER 42
PLAQUE BIOFILM AND DENTAL
IMPLANTS
 implants more susceptible to inflammation and bone loss
 Plaque biofilm development and maturation have similarities for
natural teeth and dental implants.
 The gingival sulcus in periodontal health and the peri mucosal
attachment of a successful dental implant are essentially sirnilar.
PLAQUE BIOFILM AND DENTAL
IMPLANTS
 In a study by Mombelli and Mericske-Stern 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. gingiva/is and spirochetes were absent,
and minimal (7.3%) gram-negative rods were present.
PLAQUE BIOFILM AND DENTAL
IMPLANTS
 Generally, pellicle adheres to the intraoral structure, whether it be a
tooth or an implant.
 Gram-positive cocci bacteria are the first "early colonizers,"
beginning with single cocci and progressing to streptococci forms.
 Without appropriate oral hygiene measures additional bacteria
colonies including gram-negative rod-shaped bacteria grow with
the established gram-positive bacteria.( late colonizers).(e.g.,
Bacteroides, Prevotelia, Porphyromonas, Fusobacterium).
PLAQUE BIOFILM AND DENTAL
IMPLANTS
 This finding suggests that staphylococci may be more significant in
developing peri-implantitis lesions than previously recognized.
 Natural dentitions with dental implants appear to increase the risk
for implant infections, compared with completely edentulous
patients.
 This suggests that natural teeth may serve as a reservoir for
periodontal pathogens that may extend their growth to contiguous
implants in the same oral cavity.
PLAQUE BIOFILM AND DENTAL
IMPLANTS
 Peri-implant mucositis 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, peri-implantitis may result, which includes loss
of osteointegration, similar to loss of attachment and bone with
periodontitis.
SOFT TISSUE INTERFACE
 If oral irrigation is used, the patient should be instructed to use the
lowest setting and direct the irrigation flow through the contacts to
avoid excessive pressure to the implant tissue cuff.
 Incorrect use could alter tissue adaptation and induce bacteremia
around the implant.
INSTRUMENT SELECTION
 tip designs :not bulky .
 Metallic ultrasonic and sonic scalers have been reported to gouge
titaniurn.
 A plastic or rubber sleeve over an ultrasonic scaler appears not to
alter titaniurn.
 Conventional ultrasonic scalers with a nonmetal tip also are suitable
for implant maintenance.
 Air polishers are effective and safe for maintenance procedures
around implants.
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.
IMPLANT MAINTENANCE PROCEDURES
 Unlike the attachment to the porosities of teeth, the adherence and
tenacity of calculus around implants are usually less binding.
 Because the perimucosal seal is more fragile than a normal tooth
sulcus, it is important to use short, exploratory working strokes with
light pressure.
 Depending on the location of the calculus, a horizontal, vertical, or
oblique stroke may need to be.
IMPLANT MAINTENANCE PROCEDURES
 When an instrument must be used subgingivally to remove calculus
or excess cement, insertion and instrumentation should be gentle
and light strokes should be in a semicircular pattern.
 Attention to placing the blade carefully under the deposit and
drying calculus or cement with compressed air may make
detection and removal easier and more comfortable for the
patient.
CHEMOTHERAPEUTIC AGENTS
 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 .
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.
 In the context of the foregoing, a success rate of 85% at the end of
a 5-year observation period and 80% at the end of a 1O-year
period are minimum criteria for success.
Ideal Clinical Conditions of Teeth
 Absence of pain
 Less than 0.1 mm initial horizontal mobility under lateral forces less
than 100 g
 Less than 0.15 mm secondary mobility with lateral forces of 500 g
 Absence of observed vertical mobility
 Periodontal probing depths less than 2.5 mm
 Radiographic crestal bone height 1.5 to 2.0 mm below cement-
enamel junction
 Intact lamina dura
 No bleeding on probing
 No exudate
 Absence of recession
 Absence of furcation involvement on multirooted teeth
Implant Quality Scale
 I. Success (optimum health)
 II. Survival (satisfactory health)
 III. Survival (compromised health)
 IV. Failure (clinical or absolute failure)
I. Success (optimum health)
 No pain or tenderness upon function
 0 mobility
 <2 mm radiographic bone loss from initial surgery
 Probing depth <5 mm
 No exudate history
 MANAGEMENT :Normal maintenance
II. Survival (satisfactory health)
 No pain
 0 mobility
 2-4 mm radiographic bone loss
 Probing depth 5 to 7 mm
 No exudate history
 Reduction of stresses
 Shorter intervals between hygiene appointments
 Gingivoplasty
 Yearly radiographs
III. Survival (compromised health)
 No pain upon functiona
 0 mobility
 Radiographic bone loss> 4 mm
 Probing depth> 7 mm
 May have exudate history
 Reduction of stresses
 Drug therapy (antibiotics, chlorhexidine)
 Surgical reentry and revision
 Change in prosthesis or implants
IV. Failure (clinical or absolute
failure)
 Any of the following:
 Pain upon function
 Mobility
 Radiographic bone loss >1/2 length of implant
 Uncontrolled exudate
 No longer in mouth
 Removal of implant
REPAIR OF THE AILING, FAILING DENTAL
IMPLANT
 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
 F. Leave the repaired implant out of function and "covered" for 10 to 12 weeks
REPAIR OF THE AILING, FAILING DENTAL
IMPLANT
 2. If no active infection is present and if an HA-coated implant is in place and the HA looks
intact without ongoing resorption (bone loss from traumatic occlusion, overloading, off-axis
loading, and so on):
 A. Reflect the tissue and degranulate the defect with metallic curettes.
 B. Detoxify the surface with citric acid (40%,pH 1) for 30 seconds per surface. Flush and irrigate
with sterile water or sterile saline to stop demineralization process of the citric acid. Thirty
seconds of citric acid application will detoxify and "freshen" the surface.
 C. Continue with grafting.
 Do not use tetracycline on intact HA because it changes the
calcium/phosphate ratio of HA.
 Do not leave citric acid on HA surface for more than 1 minute; it
continues to "remove".
IMPLANT CROWN ESTHETIC INDEX
 The nine selected items were as follows:
 Mesiodistal Dimension of the Crown. The mesiodistal dimension must be in harmony with
the adjacent and contralateral tooth; a judgment can be given on a 5-point rating
scale (grossly undercontoured, slightly undercontoured, no deviation, slightly
overcontoured,grossly overcontoured).
 Position of the Incisal Edge of the Crown. The position must be in harmony with the
adjacent and contralateral tooth; a judgment can be given on a 5-point rating scale
(grossly undercontoured, slightly undercontoured, no deviation, slightly overcontoured,
grossly overcontoured).
IMPLANT CROWN ESTHETIC INDEX
 Labial Convexity of the Crown. Convexity of the labial surface of the crown must be in
harmony withthe adjacent and contralateral tooth; a judgment can be given on a 5-point
rating scale (grossly undercontoured,slightly undercontoured, no deviation, slightly
overcontoured, grossly overcontoured).
 Color and Translucency of the Crown. Color and translucency of the crown must be in
harmony with the adjacent and contralateral tooth; a judgment can be given on a 3-
point rating scale (gross mismatch, slight mismatch, no mismatch).
IMPLANT CROWN ESTHETIC INDEX
 Surface of the Crown. Labial surface characteristics of the crown, such as roughness and
ridges, must be in harmony with the adjacent and contralateral tooth;a judgment can be
given on a 3-point rating scale (gross mismatch, slight mismatch, no mismatch).
 Position of the Labial Margin of the Peri-Implant Mucosa. The labial margin of the peri-
implant mucosa must be at the same level as the contralateral tooth and in harmony with
the adjacent teeth; a judgment can be given on a 3-point rating scale (deviation of 1.5
mm or more, deviation less than 1.5 rnrn, no deviationj).
IMPLANT CROWN ESTHETIC INDEX
 Position of Mucosa in the Approximal Embrasures. The interdental papillae must be in their
natural position; a judgment can be given on a 3-point rating scale (deviation of 1.5 mm or
more, deviation less than 1.5 mm, no deviation).
 Contour of the Labial Surface of the Mucosa. The contour of the mucosa at the alveolar bone
must be inharmony with the adjacent and contralateral tooth; a judgment can be given on a
5-point rating scale (grossly undercontoured, slightly undercontoured, no deviation, slightly
overcontoured, grossly overcontoured).
 Color and Surface of the Labial Mucosa Color (redness) and surface characteristics (presence
of attached mucosa) must be in harmony with the adjacent and contralateral tooth and must
have a natural appearance; a judgment can be given on a 3-point rating scale (gross
mismatch, slight mismatch, no mismatch). It has been decided to use the adjacent
‫برد؟‬ ‫بکار‬ ‫ایمپلنت‬ ‫روی‬ ‫بر‬ ‫میتوان‬ ‫زمانی‬ ‫چه‬ ‫در‬ ‫حداکثر‬ ‫را‬ ‫سیتریک‬ ‫اسید‬
30‫ثانیه‬
1‫دقیقه‬
1.5‫دقیقه‬
2‫دقیقه‬
‫است؟‬ ‫شده‬ ‫پذیرفته‬ ‫موفق‬ ‫های‬ ‫ایمپلنت‬ ‫برای‬ ‫الست‬ ‫بون‬ ‫ورتیکال‬ ‫از‬ ‫میزان‬ ‫چه‬
0.1‫دوم‬ ‫سال‬ ‫در‬ ‫میلمتر‬
0.2‫میلمتر‬‫سال‬ ‫در‬‫دوم‬
0.5‫میلمتر‬‫سال‬ ‫در‬‫دوم‬
1‫دوم‬ ‫سال‬ ‫در‬ ‫میلیمتر‬
 ‫است؟‬ ‫ایمپلنت‬ ‫شکست‬ ‫نشاندهنده‬ ‫کدامیک‬
 ‫طول‬ ‫دوم‬ ‫یک‬ ‫از‬ ‫بیشتر‬ ‫الست‬ ‫بون‬
 ‫طول‬ ‫چهارم‬ ‫یک‬ ‫از‬ ‫بیشتر‬ ‫الست‬ ‫بون‬
 ‫طول‬ ‫سوم‬ ‫دو‬ ‫از‬ ‫بیشتر‬ ‫الست‬ ‫بون‬

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Maintenance of dental implants

  • 1. Maintenance of Dental Implants: Implant Quality of Health Scale CARL MISCH CHAPTER 42
  • 2. PLAQUE BIOFILM AND DENTAL IMPLANTS  implants more susceptible to inflammation and bone loss  Plaque biofilm development and maturation have similarities for natural teeth and dental implants.  The gingival sulcus in periodontal health and the peri mucosal attachment of a successful dental implant are essentially sirnilar.
  • 3. PLAQUE BIOFILM AND DENTAL IMPLANTS  In a study by Mombelli and Mericske-Stern 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. gingiva/is and spirochetes were absent, and minimal (7.3%) gram-negative rods were present.
  • 4. PLAQUE BIOFILM AND DENTAL IMPLANTS  Generally, pellicle adheres to the intraoral structure, whether it be a tooth or an implant.  Gram-positive cocci bacteria are the first "early colonizers," beginning with single cocci and progressing to streptococci forms.  Without appropriate oral hygiene measures additional bacteria colonies including gram-negative rod-shaped bacteria grow with the established gram-positive bacteria.( late colonizers).(e.g., Bacteroides, Prevotelia, Porphyromonas, Fusobacterium).
  • 5. PLAQUE BIOFILM AND DENTAL IMPLANTS  This finding suggests that staphylococci may be more significant in developing peri-implantitis lesions than previously recognized.  Natural dentitions with dental implants appear to increase the risk for implant infections, compared with completely edentulous patients.  This suggests that natural teeth may serve as a reservoir for periodontal pathogens that may extend their growth to contiguous implants in the same oral cavity.
  • 6. PLAQUE BIOFILM AND DENTAL IMPLANTS  Peri-implant mucositis 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, peri-implantitis may result, which includes loss of osteointegration, similar to loss of attachment and bone with periodontitis.
  • 7. SOFT TISSUE INTERFACE  If oral irrigation is used, the patient should be instructed to use the lowest setting and direct the irrigation flow through the contacts to avoid excessive pressure to the implant tissue cuff.  Incorrect use could alter tissue adaptation and induce bacteremia around the implant.
  • 8. INSTRUMENT SELECTION  tip designs :not bulky .  Metallic ultrasonic and sonic scalers have been reported to gouge titaniurn.  A plastic or rubber sleeve over an ultrasonic scaler appears not to alter titaniurn.  Conventional ultrasonic scalers with a nonmetal tip also are suitable for implant maintenance.  Air polishers are effective and safe for maintenance procedures around implants.
  • 9. 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.
  • 10. IMPLANT MAINTENANCE PROCEDURES  Unlike the attachment to the porosities of teeth, the adherence and tenacity of calculus around implants are usually less binding.  Because the perimucosal seal is more fragile than a normal tooth sulcus, it is important to use short, exploratory working strokes with light pressure.  Depending on the location of the calculus, a horizontal, vertical, or oblique stroke may need to be.
  • 11. IMPLANT MAINTENANCE PROCEDURES  When an instrument must be used subgingivally to remove calculus or excess cement, insertion and instrumentation should be gentle and light strokes should be in a semicircular pattern.  Attention to placing the blade carefully under the deposit and drying calculus or cement with compressed air may make detection and removal easier and more comfortable for the patient.
  • 12. CHEMOTHERAPEUTIC AGENTS  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 .
  • 13. 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.  In the context of the foregoing, a success rate of 85% at the end of a 5-year observation period and 80% at the end of a 1O-year period are minimum criteria for success.
  • 14. Ideal Clinical Conditions of Teeth  Absence of pain  Less than 0.1 mm initial horizontal mobility under lateral forces less than 100 g  Less than 0.15 mm secondary mobility with lateral forces of 500 g  Absence of observed vertical mobility  Periodontal probing depths less than 2.5 mm  Radiographic crestal bone height 1.5 to 2.0 mm below cement- enamel junction  Intact lamina dura  No bleeding on probing  No exudate  Absence of recession  Absence of furcation involvement on multirooted teeth
  • 15. Implant Quality Scale  I. Success (optimum health)  II. Survival (satisfactory health)  III. Survival (compromised health)  IV. Failure (clinical or absolute failure)
  • 16. I. Success (optimum health)  No pain or tenderness upon function  0 mobility  <2 mm radiographic bone loss from initial surgery  Probing depth <5 mm  No exudate history  MANAGEMENT :Normal maintenance
  • 17. II. Survival (satisfactory health)  No pain  0 mobility  2-4 mm radiographic bone loss  Probing depth 5 to 7 mm  No exudate history  Reduction of stresses  Shorter intervals between hygiene appointments  Gingivoplasty  Yearly radiographs
  • 18. III. Survival (compromised health)  No pain upon functiona  0 mobility  Radiographic bone loss> 4 mm  Probing depth> 7 mm  May have exudate history  Reduction of stresses  Drug therapy (antibiotics, chlorhexidine)  Surgical reentry and revision  Change in prosthesis or implants
  • 19. IV. Failure (clinical or absolute failure)  Any of the following:  Pain upon function  Mobility  Radiographic bone loss >1/2 length of implant  Uncontrolled exudate  No longer in mouth  Removal of implant
  • 20. REPAIR OF THE AILING, FAILING DENTAL IMPLANT  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  F. Leave the repaired implant out of function and "covered" for 10 to 12 weeks
  • 21. REPAIR OF THE AILING, FAILING DENTAL IMPLANT  2. If no active infection is present and if an HA-coated implant is in place and the HA looks intact without ongoing resorption (bone loss from traumatic occlusion, overloading, off-axis loading, and so on):  A. Reflect the tissue and degranulate the defect with metallic curettes.  B. Detoxify the surface with citric acid (40%,pH 1) for 30 seconds per surface. Flush and irrigate with sterile water or sterile saline to stop demineralization process of the citric acid. Thirty seconds of citric acid application will detoxify and "freshen" the surface.  C. Continue with grafting.
  • 22.  Do not use tetracycline on intact HA because it changes the calcium/phosphate ratio of HA.  Do not leave citric acid on HA surface for more than 1 minute; it continues to "remove".
  • 23. IMPLANT CROWN ESTHETIC INDEX  The nine selected items were as follows:  Mesiodistal Dimension of the Crown. The mesiodistal dimension must be in harmony with the adjacent and contralateral tooth; a judgment can be given on a 5-point rating scale (grossly undercontoured, slightly undercontoured, no deviation, slightly overcontoured,grossly overcontoured).  Position of the Incisal Edge of the Crown. The position must be in harmony with the adjacent and contralateral tooth; a judgment can be given on a 5-point rating scale (grossly undercontoured, slightly undercontoured, no deviation, slightly overcontoured, grossly overcontoured).
  • 24. IMPLANT CROWN ESTHETIC INDEX  Labial Convexity of the Crown. Convexity of the labial surface of the crown must be in harmony withthe adjacent and contralateral tooth; a judgment can be given on a 5-point rating scale (grossly undercontoured,slightly undercontoured, no deviation, slightly overcontoured, grossly overcontoured).  Color and Translucency of the Crown. Color and translucency of the crown must be in harmony with the adjacent and contralateral tooth; a judgment can be given on a 3- point rating scale (gross mismatch, slight mismatch, no mismatch).
  • 25. IMPLANT CROWN ESTHETIC INDEX  Surface of the Crown. Labial surface characteristics of the crown, such as roughness and ridges, must be in harmony with the adjacent and contralateral tooth;a judgment can be given on a 3-point rating scale (gross mismatch, slight mismatch, no mismatch).  Position of the Labial Margin of the Peri-Implant Mucosa. The labial margin of the peri- implant mucosa must be at the same level as the contralateral tooth and in harmony with the adjacent teeth; a judgment can be given on a 3-point rating scale (deviation of 1.5 mm or more, deviation less than 1.5 rnrn, no deviationj).
  • 26. IMPLANT CROWN ESTHETIC INDEX  Position of Mucosa in the Approximal Embrasures. The interdental papillae must be in their natural position; a judgment can be given on a 3-point rating scale (deviation of 1.5 mm or more, deviation less than 1.5 mm, no deviation).  Contour of the Labial Surface of the Mucosa. The contour of the mucosa at the alveolar bone must be inharmony with the adjacent and contralateral tooth; a judgment can be given on a 5-point rating scale (grossly undercontoured, slightly undercontoured, no deviation, slightly overcontoured, grossly overcontoured).  Color and Surface of the Labial Mucosa Color (redness) and surface characteristics (presence of attached mucosa) must be in harmony with the adjacent and contralateral tooth and must have a natural appearance; a judgment can be given on a 3-point rating scale (gross mismatch, slight mismatch, no mismatch). It has been decided to use the adjacent
  • 27. ‫برد؟‬ ‫بکار‬ ‫ایمپلنت‬ ‫روی‬ ‫بر‬ ‫میتوان‬ ‫زمانی‬ ‫چه‬ ‫در‬ ‫حداکثر‬ ‫را‬ ‫سیتریک‬ ‫اسید‬ 30‫ثانیه‬ 1‫دقیقه‬ 1.5‫دقیقه‬ 2‫دقیقه‬ ‫است؟‬ ‫شده‬ ‫پذیرفته‬ ‫موفق‬ ‫های‬ ‫ایمپلنت‬ ‫برای‬ ‫الست‬ ‫بون‬ ‫ورتیکال‬ ‫از‬ ‫میزان‬ ‫چه‬ 0.1‫دوم‬ ‫سال‬ ‫در‬ ‫میلمتر‬ 0.2‫میلمتر‬‫سال‬ ‫در‬‫دوم‬ 0.5‫میلمتر‬‫سال‬ ‫در‬‫دوم‬ 1‫دوم‬ ‫سال‬ ‫در‬ ‫میلیمتر‬
  • 28.  ‫است؟‬ ‫ایمپلنت‬ ‫شکست‬ ‫نشاندهنده‬ ‫کدامیک‬  ‫طول‬ ‫دوم‬ ‫یک‬ ‫از‬ ‫بیشتر‬ ‫الست‬ ‫بون‬  ‫طول‬ ‫چهارم‬ ‫یک‬ ‫از‬ ‫بیشتر‬ ‫الست‬ ‫بون‬  ‫طول‬ ‫سوم‬ ‫دو‬ ‫از‬ ‫بیشتر‬ ‫الست‬ ‫بون‬