Implants

Clinical aspect and evaluation of the implant patient:-
DR. ROOBAL BEHAL
(CONSULTANT)
DR. MEHRAJ KIRMANI
DR. FAYIZA YAQOOB KHAN
(REGISTRARS)

• W. R. Laney who served for a long time as the Editor in
Chief of the International Journal of Oral and Maxillofacial
Implants (JOMI), an implant is defined as “an artificial
material or tissue that shows biocompatibility upon its
surgical implantation”.

• TYPES & CLASSIFICATIONS OF DENTAL
IMPLANTS
– FIVECLASSIFICATIONS
1. Based on implant design.
2. Based on attachment mechanism.
3. Based on macroscopic body design.
4. Based on the surface of implant.
5. Based on the type of material

• COMPONENTS OF DENTAL IMPLANT

• Clinical aspect and evaluation of
the implant patient:-

• Clinical aspect and evaluation of the implant patient:-
• The main aim of dental implant therapy is to satisfy the patient's desire to
replace one or more missing teeth in an
• esthetic,
• secure,
• functional,
• and long-lasting manner.
• To achieve this , clinicians must accurately diagnose
– current dentoalveolar condition,
– overall mental and physical well-being of the patient.
– Local evaluation of potential jaw sites for implant placement (e.g.,
measuring available alveolar bone height, width, and jaw relationship)
and prosthetic restorability
• However, determine whether the patient is a good candidate for implants
• includes identifying factors that might increase the risk of failure or
complications,
• determining whether the patient's expectations are reasonable.

• Clinical aspect and evaluation of the implant patient:-
– pretreatment evaluation of potential implant patients
– possible risk factors and contraindications.
– posttreatment evaluation of patients with implants.
– implant maintenance.

• pretreatment evaluation of potential implant patients
• Case types and indications of implants:-
• Edentulous patient:-
• most benefited from dental implants are fully edentulous arches. These
patients can be effectively restored, both esthetically and functionally, with
an implant-assisted removable prosthesis or an implant-supported fixed
prosthesis.
• Original design for complete edentulous patients was a fixed-bone–
anchored bridge that used five to six implants in the anterior area of the
mandible or the maxilla to support a fixed, hybrid prosthesis.

The design is a denture-like complete arch of teeth attached
to a substructure (metal framework), which in turn is
attached to the implants with cylindrical titanium abutments.

The prosthesis is fabricated without flange extensions and
does not rely on any soft tissue support. It is entirely
implant supported
Usually, the prosthesis includes bilateral distal cantilevers,
which extend to replace posterior teeth (back to premolars
or first molars).

• Another design used to restore an edentulous arch is the
ceramic-metal fixed bridge .

• Patients prefer this because the ceramic restoration emerges
directly from the gingival tissues in a manner similar to the
appearance of natural teeth.
– One limitation of both hybrid and ceramometal implant-
supported fixed prostheses is that they provide very little lip
support and thus may not be indicated for patients who have
lost significant alveolar dimension. This is often more
problematic for maxillary reconstructions patients.
– some patients, there is lack of a complete seal (i.e., spaces
under the framework) allows air to escape during speech, thus
creating phonetic problems.

• Depending on the
– volume of existing bone,
– jaw relationship,
– lip support, and phonetics,
• patients may not be able to be rehabilitated with an implant-
supported fixed prosthesis.
• For them a removable, complete-denture type of prosthesis is a
better choice because
– provides a flange extension that can be adjusted and contoured
to support the lip,
– there are no spaces for unwanted air escape during speech.
• This type of prosthesis can be retained and stabilized by two or
more implants placed in the anterior region of the maxilla or
mandible.

• the stability of the implant-retained overdenture is not same as
rigidly attached, implant-supported fixed prosthesis,
• But there is increased retention and stability over conventional
complete dentures is an important advantage for denture wearers
(Zitzmann 1999)
• protect alveolar bone from additional bone loss caused by long-
term use of removable prostheses that are bearing directly on the
alveolar ridges.

• Partially Edentulous Patients:-
• Multiple missing teeth
• Partially edentulous patients present another viable treatment option for
osseointegrated implants, but the remaining natural dentition (occlusal
periodontal health status, relationships, and esthetics) introduces additional
challenges for successful rehabilitation (Van Steenberghe et al. Int J Oral
Maxillofac Implants 1994)
– endosseous dental implants and its close proximity requires special attention
and planning (Belser UC et al Periodontol 2000 1998)

• major advantage of implant-supported restorations in partially
edentulous patients is.
– they replace missing teeth without invasion, alteration or
preparation of natural teeth
– larger edentulous spans (Kennedy Class I and II) can be restored
with implant-supported fixed bridges ( Key MC, et al Int J Oral
Maxillofac Implants 1992)

• Difficulty:-
• use of endosseous implants to replace missing teeth in the partially
edentulous patient were a challenge
 underestimation of the importance of treatment planning for implant-retained
restorations with an adequate number of implants to withstand occlusal loads.
 two implants could be used to support a multiunit fixed bridge in the posterior
area; complications or failures (mechanical or biologic)
• The use of stronger implants and better treatment planning (more
implants used to support more restorative units), particularly in areas
of poor-quality bone, has solved many of these problems.

• Single Tooth:-
• Patients with a missing single tooth (anterior or posterior) benefits greatly
from the success and predictability of endosseous dental implants.
• Replacement of a single missing tooth with an implant-supported crown is a
much more conservative approach than preparing two adjacent teeth for the
fabrication of a tooth-supported fixed partial denture
• success rates for single-tooth implants are excellent.[Hirsch JM J
Oral Sci 1998 ]

• Replacement of an individual missing posterior tooth with an
implant-supported restoration has been successful as well.
– greatest challenges to overcome with the single-tooth implant restorations
were screw loosening and implant or component fracture.
– Because of increased potential to generate forces in the posterior area, the
implants, components, and screws often failed.

• Esthetic Considerations:-
• Some cases are more esthetically challenging
• because of the nature of each individual's smile and display of teeth.
• The prominence and occlusal relationship of existing teeth,
• the patient's own psychologic perception of esthetics.
• Cases with good bone volume, bone height, and tissue thickness can be
predictable in terms of esthetic results.
• However patients with less-than-ideal tissue qualities poses difficult
challenges for the restorative and surgical team.[Belser UC Periodontol
2000 1998 ]
• patient with a high smile line, compromised or thin periodontium, inadequate
hard or soft tissues,
• and high expectations,

Pretreatment Evaluation:-
comprehensive evaluation is needed for any patient ,considered for
dental implant therapy.
 current health status, including a review the patient's past medical
history, medications, and medical treatments.
 parafunctional habits, such as clenching or grinding teeth.
 any substance use or abuse, including tobacco, alcohol, and
drugs.
The assessment also include an evaluation of the patient's motivations,
level of understanding, compliance, and overall behavior.

 Well organized, systematic history and examination is essential to obtaining an
accurate diagnosis and treatment plan
 treatment plan should be comprehensive and provide several treatment options
for the patient, including periodontal and restorative therapies.
 Information gathered throughout the process will help the clinician's decision
making and determination of whether a patient is a good candidate for dental
implants.
 can also reveal deficiencies and indicate what additional surgical procedures
may be necessary for therapy (e.g., localized ridge augmentation, sinus bone
augmentation).

• Chief Complaint:-
• What is the problem or concern in the patient's own words?
• What is the patient's goal of treatment, and how realistic are the
patient's expectations?
• The patient will measure implant success according to personal
criteria.
– overall comfort
– function of the implant restoration ,
– satisfaction with the appearance of the final restoration.
• Patients will evaluate, whether the treatment helped him to eat better,
look better, or feel better.

• Medical History:-
• Medical history is required for any patient in need of dental treatment,
regardless of whether implants are part of the plan (Hollender et al 2003).
• should be documented in writing on history form and verbally through an
interview with the treating clinician.
• Patients must be in reasonably good health to undergo surgical therapy for the
placement of dental implants.
 Any disorder that impair the normal wound-healing process, especially when it
relates to bone metabolism,
 physical examination is needed if questions arise about the health status of the patient (Branemark
1985).
 laboratory tests (e.g., coagulation tests who are receiving anticoagulant therapy).
 If any questions remain about the patient's health status, a medical clearance for
surgery should be obtained from the patient's treating physician ( Marx et al 2005
).

• Dental History:-
• patient's past dental experiences are valuable part of the overall
evaluation.
– recurrent or frequent abscesses, which may indicate a susceptibility to
infections or diabetes?
– Does the patient have many restorations?
– How compliant has the patient been with previous dental
recommendations?
– What are the patient's current oral hygiene practices?
– previous experiences with surgery and prosthetics.

• If patient has various problems and difficulties with past
dental care, including dissatisfaction, the patient may have
similar difficulties with implant therapy.
• It is essential to identify past problems and to elucidate any
contributing factors.
• The clinician must also assess the .
– patient's dental knowledge and
– understanding of the proposed treatment,
– patient's attitude and motivation toward implants.

• Local examination:-
• Intraoral examination:-
• performed to assess the current health and condition of oral hard
and soft tissues.
Any pathologic conditions
Any oral lesions, especially infections:-should be diagnosed and
appropriately treated before implant therapy.
 Additional criterias include;
 the patient's habits,
 level of oral hygiene,
 overall dental and periodontal health,
 occlusion,
 jaw relationship,
 temporomandibular joint condition,
 ability to open wide mouth;

• After intraoral examination, the clinician should evaluate potential
implant sites.
– measure available space in the bone for the placement of implants and
in the dental space for prosthetic tooth replacement
– The mesial-distal and buccal-lingual dimensions of edentulous spaces
can be approximated with a periodontal probe or other measuring
instrument.

• The orientation or tilt of adjacent teeth and their roots should
be noted as well.
– There may be enough space in the coronal area for the restoration
but not enough space in the apical region for the implant if roots
are directed into the area of interest
– there may be adequate space between roots, but the coronal
aspects of the teeth may be too close for emergence and
restoration of the implant.

Ultimately, edentulous areas need to be precisely
measured using diagnostic study models and imaging
techniques to determine whether space is available and
whether adequate bone volume exists to replace missing
teeth with implants and implant restorations.

• Alveolar Bone:-
 Before 1981; implant 4 mm in diameter and 10 mm long were used ; the minimal
width of the jawbone needs to be 6 to 7 mm, and the minimal height should be 10
mm (minimum of 12 mm in the posterior mandible, where an additional margin of
safety is required over the mandibular nerve.
 The Branemark screw type implant body and osseointegrated approach was
provided only in 3.75mm width and 9mm length.

• Interocclusal Space:-
• The restoration consists of the abutment, the abutment screw, and the crown (
also include a screw to secure the crown to the abutment if it is not cemented).
• Restorative “stack” is the total of all the components used to attach the crown to
the implant.
• The dimensions of the restorative stack vary slightly depending on the type of
abutment and the implant-restorative interface (i.e., internal or external
connection).
• The minimum amount of interocclusal space required for the restorative “stack”
of implant is 7 mm.
7mm

• Diagnostic Study Models:-
• Mounted study models are an excellent means of assessing potential
sites for dental implants.
• Properly articulated models with diagnostic wax-up of the proposed
restorations allow the clinician to evaluate the available space and
to determine potential limitations of the planned treatment.
• This is particularly useful when multiple teeth are to be replaced
with implants or when a malocclusion is present.

• Hard Tissue Evaluation:-
• The amount of available bone is the next criterion to evaluate.
• Wide variations in jaw anatomy ; it is therefore important to analyze the
anatomy of the dentoalveolar region of interest both clinically and
radiographically.
• A visual examination can immediately identify deficient areas ,
• Clinical examination of the jawbone consists of palpation to feel for
anatomic defects and variations in the jaw anatomy, such as concavities
and undercuts.

• Some areas that appear to have good ridge width
require further evaluation
• If desired, it is possible with local anesthesia to
probe through the soft tissue (intraoral bone
mapping) to assess the thickness of the soft tissues
and measure the bone dimensions at the proposed
surgical site.

• Classification System for Available Bone:-
• In 1985, Misch and Judy classified available bone with
treatment options for each category. The basic four divisions
have been further expanded to following categories:-
– Division A
– Division B
i) Division B +
ii) Division B - w (width)
– Division C
i) Division C - w (width)
ii) Division C - h (height)
iii) Division C - a (angulation)
– Division D

• Division A (Abundant Bone)
• This category of bone volume is available soon after tooth loss and is abundant in all
dimensions.
• Division A bone is mainly observed in the anterior regions
• Based on the available dimensions, use of Division A root-form implants with height
> 12 mm and width > 4 mm. Their advantages include:
– Greatest surface area
– Improved stress distribution
– Greatest range of prosthetic options
– Less fracture of implant and components
– Less abutment screw loosening

• Division B (Adequate Bone)
• Slight to moderate atrophy characterized by reduced bone width in
comparison to Division A bone and is mostly observed in the posterior
regions.
• Two subtypes (B + and B - w) exist depending on the extent of
resorption
A Division B ridge
converted to Division A
by osteoplasty
Placement Division B implantRidge augmentation

• Division C (Compromised Bone):-
• Moderate to advanced atrophy; bone may be deficient in one or more
dimensions.
• With continued resorption, the Division C - w bone changes to a
Division C - h bone which is commonly observed in the posterior
regions because the maxillary sinus or mandibular canal limits the
vertical height .
• Division C - a bone is found most often in the anterior maxilla and
mandible with facial undercut regions, or the mandibular second
molar with a severe lingual undercut.

• Treatment Options for Division C Bone
• A) Division C - w
• 1) Osteoplasty
• This converts the Division C - w bone to a Div C - h category The treatment protocol of
Division C - h bone is then followed.
• 2) Augmentation
• Augmentation of Division C - w preferred in the posterior maxilla or mandible.
• B) Division C - h
• 1) Augmentation
• This is advocated in the posterior maxilla and mandible.
• 2) Root-form implants
• Additional implants are required to increase the overall implant-bone surface area to
counteract the unfavorable force multiplier of increases crown height. For the same
reason RP-5 prosthesis is considered to reduce the cantilever action.
• C) Division C - a
• 1) Augmentation to improve the angulation
• 2) Subperiosteal implants

• Division D (Deficient Bone)
• Severe atrophy; is the most difficult to treat.
• Fixed restorations are almost always contraindicated due to
significant crown height.
• Idiopathic fractures during surgery or implant failure or
removal are likely complications.
•
• Treatment Options for Division D Bone
• Augmentation
– Autogenous bone grafts are indicated to upgrade the
division.
– Endosteal or subperiosteal implants may be inserted
depending on the division of bone attained.

• Bone classification based on density:-
• Linkow in 1970, classified bone density inn to three categories
– Class I bone structure:- ideal bone type consists of evenly spaced
trabeculae with small cancellated spaces.
– Class II bone structure:- slightly larger cancellated spaces with less
uniformity of osseous pattern.
– Class III bone structure:- large marrow filled spaces exist between
bone trabeculae.

• 1985, lekholm and Zarb classification based on quality in the anterior
region:-
– Quality I:- composed of homogeneous compact bone.
– Quality 2:- thick layer of compact bone surrounding a core of dense
trabecular bone.
– Quality 3:- thin layer of compact bone surrounding a core of dense
trabecular bone.
– Quality 4:- thin layer of compact bone surrounding a core of low density
trabecular bone.
– Jaffin and Berman reported 10% difference in implant survival
between Quality I and quality 2 and 22% lower survival in quality
4 type of bone

• 1988 Misch classification on bone density:-
• He classified it in to 4 groups independent of region of the jaw, based on
microscopic structure of bone.
D5 Immature, nonmineralized bone

• Anatomic location of bone density types ( % of occurrence)

• Radiographic Examination:-
• Assessment of the quantity, quality, and location of available alveolar bone in
implant site to determine whether a patient is a candidate for implants or
implant site needs bone augmentation.
• Radiographic procedures,
• Standard projections
– Periapical radiographs,
– panoramic projections,
– Occlusal radiographs
– Lateral cephalometric radiographs
• Cross- sectional imaging:-
– Conventional x-ray tomographic
– Computed tomography;
– Cone Beam Computed tomography
– Dual Energy X-Ray Absorptiometry (DEXA)

 Imaging helps to identify vital structures such as the floor of the
nasal cavity, maxillary sinus, mandibular canal, and mental
foramen.
 In addition it gives absolute dimensional measurement of the
alveolar bone,
 it also determines whether the volume of bone radiographically
(as well as clinically) is located in a position to allow for the
proper position of the implant.
 The best way to evaluate the relationship of available bone to the
dentition is to image the patient with a diagnostically accurate
guide using radiopaque markers that accurately represent the
proposed prosthetic contours

• Soft Tissue Evaluation:-
• Evaluation of the quality, quantity, and location of soft tissue present in the
implant site helps to know the type of tissue that will surround the implant(s)
after treatment is completed (keratinized versus nonkeratinized mucosa).
• In some cases, depending on the clinician's view of keratinized tissue, may need
soft tissue augmentation.
– Keratinized mucosa is thicker and denser than alveolar mucosa (nonkeratinized).
– forms a strong seal around the implant with a cuff of circular (parallel) fibers
around the implant, abutment, or restoration that is resistant to retracting with
mastication forces and oral hygiene procedures.
– Implants with coated surfaces (i.e., hydroxyapatite [H] or titanium plasma spray
[TPS] coating) demonstrate greater periimplant bone loss and failures in the
absence of keratinized mucosa.(Beckler 1996)
• Additionally, any mucogingival concerns, such as frenum attachments or pulls,
should be thoroughly evaluated.

• Risk Factors and Contraindications:-
• In this era of high implant success and predictability and
complacency, it is imperative for clinicians to recognize risk factors
and contraindications to implant therapy so that problems can be
minimized and patients can be accurately informed about risks.
• the clinician must be knowledgeable in this area and inform patients
about risk factors and contraindications before initiating treatment.
• Some conditions are probably best described as “risk factors”
rather than “contraindications” to treatment because implants can
be successful in almost all patients;
• Ultimately, it is the clinician's responsibility to make decisions as to
when implant therapy is not indicated.

• Medical and Systemic Health–Related Issues:-
• The clinician must see the medical and health-related conditions that affect
bone metabolism or any aspect of the patient's capacity to heal
normally(Beikler T 2003)
• Includes conditions such as
– diabetes,
– osteoporosis, and
– immune compromise, medications, and
– medical treatments such as chemotherapy and irradiation.

• Diabetes :-
• Diabetes is a metabolic disease that can have significant effects on the patient's
ability to heal normally and resist infections ,particularly patients when not well
controlled.
• Poorly controlled diabetics often have impaired wound healing and a
predisposition to infections,
• whereas diabetic patients whose disease is well controlled experience few, if any,
problems.
• Several studies have reported moderate failure rates in diabetic patients, with
implant success ranging from 85.6% to 94.3%.(Balshi TJ 1999).
• A prospective study demonstrated 2.2% early failures and 7.3% late failures in
diabetic patients.(Shernoff AF 1994)
•

• After 5 years, the overall success rate for this group of
diabetic patients was 90% (Olson JW 2000)
• Diabetic patients experience slightly more late failures,
related to less tissue integrity caused by reduced tissue
turnover and impaired tissue perfusion.
• These results suggest that diabetes may be a risk factor for
implants, particularly for late failures. However, the risk does
not appear to be high.

• Bone Metabolic Disease
• Osteoporosis is a skeletal condition characterized by decreased
mineral density.
• classifications are
– primary (three types)
– secondary (many types) osteoporosis.
• Primary osteoporosis has been
– menopausal changes (type I),
– age-related changes (type II),
– idiopathic causes (type III).
• Secondary osteoporosis has been attributed to many different diseases
and conditions, including diabetes, alcoholism, malnutrition, and
smoking(Glaser DL 1997)

In osteoporosis there is decreased bone mineral density, so impair
the patient's ability to achieve and maintain implant osseointegration.
 osseointegration depends on bone formation adjacent to the implant surface
and success rates are highest in dense bone and lowest in poor-quality, loose
trabecular bone.
 longer healing time for osseointegration to occur before loading the implants in
patients with osteoporosis.[Mellstrom D,2001]
• Aging adults (men over 50 years and postmenopausal women) their bone
mass decreaseses at demineralization rate of 1% to 2% per year and in
some individuals as much as 5% to 8% per year throughout their later
life so the chance of implant failure also increases in the same
rate.[Hildebolt CF1997]

• Medications:-
• Medications, including steroids and bisphosphonates, cause of
concern for implant patient.
• Corticosteroid therapy, used for hormone replacement, and
cancer treatment,or immune suppression suppresses the
– immune response,
– impair wound healing or
– compromise the normal adrenal response to stressress.

• Bisphosphonate used in cancer therapy cause great concern about risk of
bisphosphonate-related osteonecrosis of the jaw (BRONJ),
• In general, the risk of BRONJ is 1 in 100,000 but may increase to 1 in
300 after an oral surgical procedure. The majority of BRONJ occur in
patient using intravenouly with having Co-factors, such as smoking,
steroid use, anemia, hypoxemia, diabetes, infection, and immune
deficiency[Marx RE 2007]
•
• Procedures that contributed to the development of BRONJ include
extractions, periodontal surgery, root canal treatment, and dental implant
surgery.[Marx RE, and Fortin M 2005]
• Dental implant therapy, as well as other surgical procedures, should be
avoided in individuals who have been treated with intravenous (IV)
bisphosphonate therapy for more than 3 years (Assael LA 2009).

• Immune Compromise and Immune Suppression:-
• Individuals undergoing chemotherapy or taking medications that impair
healing (e.g., steroids) and increases infection chances are not good
candidates for implant therapy.
• Patients with very low or undetectable viral loads and normal (T cell
counts) immune function may be candidates for implant therapy.
• Past history of chemotherapy or immunosuppressive therapy are not
problematic if the patient has recovered from the side effects of treatment.
• Patients with an immunocompromising disease, such as human
immunodeficiency virus (HIV) infection or acquired immunodeficiency
syndrome (AIDS), are not good candidates for implants, especially when
their immune system is seriously impaired.

• Radiation Therapy:-
• Patients with a history of radiation treatment to the head and neck
region may not heal well after surgery.
• Soft tissue dehiscence may follow surgical manipulation, which
may lead to osteoradionecrosis (ORN).
• This is especially problematic for patients who have received
radiation dosages greater than 60 Gy.
• Surgical procedures, or any procedure that may initiate a wound,
are generally avoided in patients with a history of radiation
therapy.
• If deemed necessary, surgical procedures can be done in
conjunction with hyperbaric oxygen (HBO) therapy to reduce the
risk of ORN.

• Studies have documented poor success rates for implants
in patients with a history of radiation therapy.[Granstrom
G 1999]
• Sennerby and Roos1998 found irradiation to be associated
with high failure rates.
• Beumer et al 1995 reported success rates as low as 60.4%
in the irradiated maxilla.
• Granstrom et al 1993 reported a significant improvement
in survival rates for implants in patients treated with HBO.

• Habits and Behavioral Considerations:-
• Smoking, clenching or grinding of teeth, and drug or alcohol
abuse are among the most well-known habits that should be
identified because of the increased risk for implant failure or
complications.

• Smoking and Tobacco Use:-
• Moderate to heavy smoking has been documented to result in higher
rates of early implant failure and adversely affect the long-term
prognosis of dental implant restorations.[Bain CA 1993]
• particularly when implant is placed in poor quality bone such as the
posterior maxilla (Han TJ 2007).
• Becouse effect of smoking
– on white blood cells,
– vasoconstriction,
– wound healing,
– Osteoporosis (Ericsson I 1993)
• . Smoking cessation improves the success rate of implants.[Bain CA
1996]

• Parafunctional Habits:-
• Parafunctional habits, such as clenching or grinding of teeth
(consciously or unconsciously) have increased rate of implant failure.
• Repeated lateral forces (i.e., parafunctional habits) applied to implants
can be detrimental to the osseointegration process, especially during the
early healing period..
• Bain 1996 considered bruxism as contraindication to implant treatment,
especially in the case of a short-span, fixed partial denture or a single-
tooth implant.
• If implants are planned for a patient with parafunctional habits,
protective measures should be employed, such as creating a narrow
occlusal table with flat cusp angles, protected occlusion, and the regular
use of occlusal guards

• Posttreatment Evaluation:-
• Periodic posttreatment examination of implants, the retained prosthesis,
and the condition of the surrounding periimplant tissue is an important
part of successful treatment.
• Aberrations and complications can often be treated if discovered early,
but many problems will go unnoticed by the patient.
• Thus periodic examination is essential to discovering problems early.
• Several parameters are available to evaluate the condition of the
prosthesis,
– stability of the implant(s),
– health of surrounding periimplant tissues after implant integration and
prosthetic restoration.
• other clinical measures are clinical inspection, probing, and radiographic
examination.

• Clinical Examination:-
Clinical examination includes visual inspection and probing.
Visual evaluation of the tissue include
 Color
 contour
 consistency,
 They can also be palpated to detect areas of edema, tenderness
and exudate for any inflammation or swelling .

• Periimplant Probing:-
• Periodontal probing around natural teeth is very useful to
assess the health of periodontal tissues, the sulcus or pocket
depth, and the level of attachment(Bragger U 1997)
• Clinicians should use caution during periimplant probing
because of distinct differences in the surrounding tissues that
support implants compared to those that support teeth.
• Around teeth, the periodontal probe is resisted by the health
of the periodontal tissues by the insertion of supracrestal
connective tissue fibers into the cementum of the root
surface.
• These fibers are unique to teeth, are the primary source of
resistance to the probe (Armitage GC 1997)

• Connective tissue fibers around implants generally run parallel to the
implant or restorative surface and do not have perpendicular or inserting
fibers (Ericsson I 1993)
• At noninflamed sites, the probe will be resisted by the most coronal
aspect of connective tissue adhesion to the implant. At inflamed sites, the
probe tip consistently penetrates farther into the connective tissue until
less inflamed connective tissue is encountered, which is often close to or
at the level of bone.
• However, periimplant probing is affected by several conditions, including
the size of the probe, the force and direction of insertion, the health and
resistance of periimplant tissues, the level of bone support, and the
features of the implant, abutment, and prosthesis design.

• Probing around implants is likely to be more variable than
around teeth; studies have shown that change in probing force
around implants results in more loss of tissue than around teeth
(Mombelli A 1997).
• 3 mm of probing depth around implants presumed to be
“healthy” (and without bleeding)(Adell R 1981)
• The absence of bleeding on probing around teeth has been
established as an indicator of health and a predictor of
periodontal stability (Lang NP 1990).
• Microbiologic studies suggest that greater probing depth or
“pockets” around implants harbor higher levels of pathogenic
microorganisms (Mombelli A 1987)

• Microbial Testing:-
 Studies have demonstrated the development of periimplant mucosal
inflammation in response to the accumulation of bacterial plaque
(Berglundh T, Lindhe J 1992)
 similarities in the microbial composition of plaque in healthy
periodontal sites compared with healthy periimplant sites (Mombelli A
2000)
 microbiota of inflamed periimplant sites (periimplantitis) harbors the
same periodontal pathogenic microorganisms as those observed in
diseased periodontal pockets(Sanz M 1990) .
 The usefulness of microbial testing may be limited to the evaluation of
periimplant sites that are showing signs of infection and bone loss, so
the clinician can prescribe appropriate antibiotics.

• Stability Measures:-
• The assessment of implant stability (or mobility) is an important
measure for determining whether osseointegration is being maintained.
• however, this measure has extremely low sensitivity but high
specificity.
– That is, a large amount of bone loss can occur around an implant, but the
implant remains stable .
– On the other hand, if significant mobility is detected, the implant has likely
failed.
• So evaluating the stability of the bone-to-implant contact in a non
invasive manner. Two techniques that have been used are:-
– impact resistance (e.g., Periotest) and
– resonance frequency analysis (RFA).

• periotest
• Periotest (Gulden, Bensheim, Germany) is a noninvasive, electronic
device that provides measurement of the reaction of the
periodontium to a defined impact load applied to the tooth crown.
• The Periotest value depends to some extent on tooth mobility but
mainly on the damping characteristics of the periodontium.
• Despite the dependence on the periodontium, the Periotest has been
used to evaluate implant stability as well.
• However, unlike teeth, the movement of implants and the
surrounding bone is very little, and therefore the Periotest values
fall within a much smaller range compared to the range found with
teeth.
• Used for detection of horizontal mobility because it is more
sensitive to horizontal movement than by other means, such as
manual assessment (Lekholm U 1998)

• Resonance frequency analysis (RFA) :-
• another noninvasive method used to measure the stability of implants
(Meredith N 1996)
• Uses a transducer that is attached to the implant or abutment. A steady-
state signal is applied to the implant through the transducer, and a
response is measured.
• The RFA value is a function of the stiffness of the implant in the
surrounding tissues.
• The stiffness is influenced by the implant, the interface between the
implant ,bone, soft tissues as well as the surrounding bone, height of the
implant or abutment above the bone

• Unlike the Periotest, the RFA is not dependent on movement in only one
direction.
• Absolute RFA values vary from one implant design to another and from
one site to another, but there is high consistency for any one implant or
location.
• it is very sensitive to changes in the bone-implant interface. Small changes
in tissue support can be detected using RFA.
• An increase in RFA value indicates increased implant stability, whereas a
decrease indicates loss of stability.
• However, this is a relative measure and it has not been determined
whether RFA is capable of detecting impending failure before the implant
actually fails.
• Mobility remains the cardinal sign of implant failure, and detecting
mobility is therefore an important parameter.

• Radiographic Examination:-
• Intraoral radiographs should be taken at the time of
– placement (baseline),
– abutment connection (confirm seating and serve as another
baseline),
– final restoration delivery (loading),
– subsequently to monitor marginal or periimplant bone changes.
• Periapical radiographs have excellent resolution and provide
adequate details for evaluating bone support around implants if
taken at a perpendicular direction.
• The limitation of periapical radiographs is that they are difficult
to standardize, and great variability in the acquisition process
• Periapical films are relatively simple, inexpensive, and readily
available in the dental office.

• The objective of the radiographic examination is to measure the height of
bone adjacent to implant(s) and evaluate the presence and quality of bone
along the length of the implant.
• Finally, the periimplant areas are assessed for any radiolucent lesions
around the implant.
• Although the predictive value of assessing implant stability with radiographs
is low, but offer a reasonable method to measure changes in bone levels
(Sunden S 1995)
 Radiographic identification of unstable implants is reliable when performed
as part of frequent examinations (Lekholm U 1997).
• Friberg B 1991 demonstrated much higher predictive value for radiographic
diagnosis of implant failure and concluded that it is most important factors
for making an accurate radiographic diagnosis but depends on
– quality of the radiograph
– experience of the clinician (Lekholm U 1997)

• Oral Hygiene and Implant Maintenance:-
• The long-term success of dental implants requires the maintenance of
healthy periimplant tissues because the soft tissue “seal” around
implants is best when the surrounding mucosa is not inflamed.
• The importance of good oral hygiene should be stressed even before
implants are placed, and oral hygiene instructions for plaque control
should begin as early as possible.
• The patient's ability to maintain good oral hygiene should be monitored
and reinforced at each visit, and the patient should be given instructions
specific to individual needs

• Implant superstructures, frameworks, and restorations should be
fabricated to facilitate oral hygiene (e.g., embrasure spaces
should be made to allow the passage of a proxy brush).
• Initially, for the first year after treatment is completed, recall
maintenance visits should be scheduled at 3-month intervals and
then adjusted to suit the patient's individual needs.
• Some patients, with good oral hygiene and minimal deposits, will
require infrequent professional hygiene maintenance, whereas
others, with poor oral hygiene and heavy deposits, will require
more frequent follow-up care.

Plastic and gold-coated curettes should be used to protect the
titanium implant surface and the titanium abutment from
contamination and scratching by other metals.
 Plastic curettes do not work very well, and gold-coated curettes
cannot be sharpened.
 Most current implant prostheses are made with gold alloys or
ceramic materials, can be debrided with most scalers and
curettes (plastic, gold coated, stainless steel) without damaging
the surface.
 Rotary instruments (e.g., prophy cup) can be used to remove
plaque or biofilms and polish surfaces.
 The use and sonic instruments (e.g., Cavitron) should be
avoided because of irregularities that can easily be created in
the surface, which can contribute to plaque and calculus
accumulation.

 One advantage of using screw-retained implant restorations (e.g., super
structures, overdenture bars, fixed prosthesis, etc.) is that they can be removed,
cleaned outside the mouth, and replaced.
• Recall maintenance visits should include an
– evaluation of soft and hard tissue health,
– level of oral hygiene compliance and plaque control,
– prosthesis integrity and stability, and implant stability.
– Implant stability can be evaluated with a combination of mobility testing and radiographic
assessment.

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