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Maintenance protocol for implant supported restorations: An overview

Article in International Journal of Oral Health Dentistry · October 2018

DOI: 10.18231/2395-499X.2018.0032

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Review Article DOI: 10.18231/2395-499X.2018.0032

Maintenance protocol for implant supported restorations: An overview

Himanshu Aeran1,*, Varun Kumar2, Mudita Sood3, Lakshya Vishnoi4
1Director Principal and Head, 2Professor, 3PG 3rd Year, 4Intern, Dept. of Prosthodontics & Oral Implantology, Seema Dental
College & Hospital, Rishikesh, Uttarakhand, India

*Corresponding Author: Himanshu Aeran

Email: [email protected]

Abstract
In the recent years, implants have emerged as a very successful treatment modality to replace missing teeth. The success of
implant therapy depends upon adequate diagnosis and treatment planning. There is a direct relationship between the success of
implant therapy and oral hygiene maintenance of dental implants. A clear directive must be established by every clinician for the
implant maintenance protocol with routine clinical evaluation of implants. Clinicians must be well versed with the means to
assess and maintain implants along with the techniques and instruments to be used. The patients must be made aware to set up an
adequate home care ritual for long term success of dental implants. This article explains implant assessment, monitoring, and
home & in office maintenance protocol.

Keywords: Implants, Monitoring, Maintenance, Prosthesis.

Introduction damage has occurred. These include providing safe

“Over the past 30 years, research has validated the implant maintenance, and monitoring the tissue and the
success of osseointegrated implants as a viable bone level surrounding the implant. In-office
alternative to fixed or removable prosthetic maintenance protocols and home-care regime are both
restorations.”1 It is well-documented fact that the crucial for the success of implants. This requires the
success rate for single tooth endosteal implant clinician to be well versed with the protocols for
restorations is up to 97% after more than 10 years.2,3 assessment of implants at maintenance appointments,
Patient selection for implant therapy is based on a safe instrumentation of peri-implant tissues, and the
number of factors, including medical history, oral products that can be safely recommended for home
health, and hygiene status. care.6
In the presence of a tooth, tensile force is The signs and symptoms of failing implants must
transmitted to the surrounding bone through the be recognized as early as possible during the evaluation
periodontal ligament, which stimulates and helps in phase of maintenance therapy. Once implants have been
maintaining it. Implants also stimulate the bone and successfully placed, the patient must follow a proper
help to maintain it by transferring compressive forces, home-care regime which should be re evaluated each
if the forces are directed axially. There is an increase in time the patient presents for implant maintenance
bone density even in the absence of a natural tooth and therapy.
the periodontal ligament, due to osseoperception of the
forces transferred to the bone via the implant, which in Implant Home Care Following Surgery
turn can help in preserving the facial structure. The key A daily meticulous home-care routine is essential
benefits of implants are the restoration of function and for the maintenance of implants and demands proper
esthetics and preservation of the remaining oral compliance from the patient. A customized home-care
structures.4 regime must be developed for each patient that
considers the type of implant prosthesis and the
Peri-Implantitis is Different from Periodontitis patient’s dexterity. It should be effective and simple to
Peri-implantitis and periodontitis are similar in the understand and follow. Post-surgically, good oral
respect that they both involve alveolar bone loss. hygiene is necessary to maintain a healthy field and
However, there are some differences. Since there is no adequate healing. The patient should follow these
periodontal ligament, so the inflammatory lesion in points post surgically:
peri-implantitis always extends closer to the bone 1. Drink only clear liquids for the rest of the day
surface. Therefore, it progresses faster and it is 2. Take antibiotics and analgesics as prescribed
potentially a more aggressive disease and is very hard 3. Eat soft foods for the first few days of healing
to treat.5 4. Avoid wearing a removable temporary prosthesis
Nevertheless, tissue degradation may be a slow or denture to let the gingival tissue heal (if the
process in peri-implantitis, and a loading time of more implant was not immediately loaded)
than 5 years may be required to detect peri-implant 5. Use an extra soft toothbrush to clean the dentition,
complications. One must aim to take the steps preexisting implants and the gingiva (and do not
necessary to salvage the implant before an irreversible brush the incision area)
International Journal of Oral Health Dentistry, July-September 2018;4(3):139-142 139
Himanshu Aeran et al. Maintenance protocol for implant supported restorations: An overview

6. Use warm saline rinses or an antiseptic rinse as The Implant Maintenance Appointment
prescribed The implant maintenance appointment consists of:
1. Review of the patient’s medical history and general
Home Care for Implants health
Oral care for single-tooth implants involves a 2. Assessment of the implant(s)
number of steps. The patient should be instructed to 3. Proper instrumentation and polishing of the
brush the implant(s) twice a day with a low-abrasive implant(s)
dentifrice. Using a low-abrasive dentifrice ensures that 4. Reinforcement of home-care routine and specific
it will not scratch the surface or irritate the tissue cuff recommendations
surrounding the implant.7 An ultra soft toothbrush
should be used – options include a manual brush, Step 1: Review of the Patient’s Medical History and
electric or sonic brush, end tuft brush, or proxi-brush. General Health: The patient’s medical history should
There is a slim sonic brush that can fit under the bar or be documented from the beginning of the treatment and
ball attachments used with overdentures. The updated and reviewed at every routine oral evaluation
interdental brushes that have coated wires are also and implant maintenance appointment. The clinician
recommended to clean around single implants or under must check if there has been any change in the patient’s
a Hader bar. The end-tuft brushes clean the difficult-to- health status that could impact the implants or
reach areas around implants. Instruct the patient to floss treatment. If the patient has uncontrolled diabetes, it
once a day on the mesial and distal aspects. For increases the risk of implant failure. It will be necessary
implants, it is also recommended to floss implants on to consult with the patient’s physician and control the
the facial and lingual aspects. This is accomplished by blood sugar at the earliest.12 Overall good general
wrapping the floss around the tooth or looping the floss health is an important factor determining the success of
to remove all plaque on the implant surface. The implant(s) and may affect the length of time between
biological differences between an implant and a natural implant maintenance visits.13
tooth make the implant more susceptible to Step 2: Assessment of Implants: Implant assessment
inflammation and bone loss from bacterial plaque, starts with a visual soft tissue examination of the
making meticulous oral hygiene a prerequisite for perimucosal seal. Any signs of inflammation or
success.8 bleeding upon probing, including peri-mucositis (no
Generally a single-tooth implant can be flossed bone loss) or peri-implantitis (inflammation with bone
with the regular waxed floss. Alternatively, implant loss) should be recorded. Presence of any clinical
floss can be used. For bar-retained prostheses or wider symptoms such as pain or mobility must be noted.
interproximal spaces, thicker floss or one with a built-in These assessments must be performed at every
threader is recommended. Antimicrobial rinses may be maintenance appointment. Accurate radiographs are
recommended, especially if inflammation is present or necessary to monitor the crestal bone level.
the patient has dexterity problems with an area that is
difficult to clean. If the patient is prone to Visual Soft Tissue Assessment
inflammation, the use of chlorhexidine gluconate or The soft tissue should be visually examined for
another antimicrobial rinse, in conjunction with a color, texture, form, bleeding, and inflammation
rubber tip stimulator, is recommended.9 Water keeping the normal appearance in mind. The overall
irrigation units can be beneficial if used twice daily periodontal assessment and any tissue changes should
(following proper instruction to ensure that the be recorded in the patient’s records as well as with
perimucosal seal is not damaged). The water must be photography. These photographs can be used to help in
directed only interproximally and horizontally on a low educating the patient about his/her own oral hygiene
speed to avoid damaging the perimucosal seal. status. The patient can be motivated for better
compliance as images can be an excellent visual tool to
Implant Maintenance reinforce the importance of good home care.
After successful placement, osseointegration and
loading of implants, the patient is largely responsible Protocol for Proper Probing around the Implant
for its long term success and needs to understand the There are a number of considerations and
importance of proper on--time clinical appointments for guidelines that should be followed when probing the
maintenance therapy. A re-evaluation after every three tissue surrounding an implant. A plastic-coated probe
months is mandatory for the first year as it is helpful in should be used to reduce the risk of scratching the
preventing infection or failure of the implant.10 After implant surface. A plastic probe is more flexible,
one year the bone surrounding the implant maintains a enabling the clinician to follow the anatomy more
mature level of bone11 and the interval between closely for an accurate reading. The perimucosal seal is
maintenance visits should be based on the patient’s fragile and more susceptible to trauma and penetration
general health, assessment of the implant, and home during probing than the periodontal ligament around
care. teeth. It can allow the penetration of pathogens more
International Journal of Oral Health Dentistry, July-September 2018;4(3):139-142 140
Himanshu Aeran et al. Maintenance protocol for implant supported restorations: An overview

easily than the periodontal ligament and jeopardize the implant surface can cause bacteria to adhere more
success of the implant.14 Some clinicians may not easily, causing an increased risk of inflammation. The
recommend probing in the perimucosal seal in the first surface of the ball, bar or locator attachments must be
three months following abutment attachment to avoid protected from scratching, to avoid increased plaque
disrupting the biologic seal. A probe baseline formation and retention. Metal tipped subgingival
measurement at a specific location should be recorded, irrigators are also contraindicated.20
to establish a clinical parameter for re-evaluation on The appropriate instruments for implant
later appointments. This baseline should be recorded in maintenance are plastic, graphite, or solid titanium
the patient’s notes at the first maintenance appointment scalers and curettes. These have been proven to be safe
after three months.15 The measurement should ideally and effective for the removal of plaque and other
read 2.5 mm to 5.0 mm or less, depending on soft tissue deposits on titanium implants. If ultrasonic or sonic
depth, and there should be no signs of inflammation.16 scalers need to be used, caution is required to avoid
Measurements at appointments should be compared to damaging the perimucosal seal. They must have a
baseline, and if the probe depths change, this must be nonmetal tip or plastic sleeve to prevent scratching of
noted in the patient’s chart. the implant surface during use.21 Several manufacturers
have developed implant power scaler tips and silicone
Protocol for Radiographic Monitoring covers to be placed on the ultrasonic scaler tips, to
Bone level: A radiograph is taken to accurately monitor prevent possible scratching of the implant surface.
crestal bone level around the implant(s) and to verify Hand implant scalers and curettes are available in
the accurate seating of the prosthetic components. polycarbonate plastic and graphite. These can be
Subsequent radiographs at the maintenance sharpened and autoclaved. Implant scalers are also
appointment are used to determine any change in the available with a sturdy handle and single-use plastic
prosthetic components. Changes in the crestal bone disposable tips. Solid titanium scalers and curettes are
around the implant can also be monitored. Periapical or also now available that can be used to scale on “like
vertical bitewing radiographs for one to four implants, metal” titanium implants, are thinner than plastic or
and a panoramic radiograph for five or more implants is graphite instruments and provide more strength to
recommended to enable accurate determination of the dislodge calculus.22
crestal bone level.17 A measurement of 0.5 mm to 1 mm
horizontal bone loss is acceptable in the first year, with Protocol for Polishing
an anticipated 0.1 mm of bone loss each subsequent Coronal polishing around implants is done using a
year.18 If more than 1 mm of horizontal or vertical bone soft rubber tip, not brush, with a nonabrasive paste.
loss is detected in the first year, a referral to a Aluminum oxide, tin oxide, APF-free prophy paste, and
periodontist may be required. After carefully assessing low-abrasive dentifrice are all considered acceptable
the implant and recording the findings, evaluate for the polishing abrasives for implants. Coarse abrasive
presence of calculus on the implant or abutments. polishing pastes and airpolishing are contraindicated.21
Minimal or no instrumentation is necessary for an It should be noted that acidulated phosphate fluoride
implant with a healthy gingival attachment. If an (APF) products are also contraindicated, as they may
implant fails, it is generally due to bacterial infection, etch the surface of implants. It may be helpful to polish
occlusal overload or a poorly- designed prosthesis.19 first around implants to remove any plaque or debris
The cause of the failing implant and a treatment plan to present and then to determine deposits that need
accommodate the failure must be determined by the instrumentation.
dentist.
Conclusion
Step 3: Proper Instrumentation: Instruments must The professional implant maintenance and patient
effectively remove all plaque and calculus deposits home care are two critical factors for the long-term
without scratching the surface of the implant. Calculus success of dental implants. This further imvolves
deposits on implants are generally softer than on teeth assessment of the patient’s general and oral health. The
and are more often found supragingivally than use of specified maintenance protocol and materials by
subgingivally. Generally, proper hand instrumentation the clinician, are essential in today’s scenario of high
is sufficient to restore the periodontal health of patient expectations reagarding the longevity of the
implants. Excessive pressure or trauma to the implant restorations. All clinicians must educate their
perimucosal seal during instrumentation is patients regarding implant home care regime and insist
contraindicated to prevent pathogenic infiltration and on regular maintenance appointments after successful
scratching the surface of the implant or the abutment. implant restorations.
Stainless steel–tipped instruments, as well as metallic
sonic and ultrasonic scalers, have been found to gouge
titanium and are contraindicated for implant
instrumentation. The scratching or roughening of the
International Journal of Oral Health Dentistry, July-September 2018;4(3):139-142 141
 Himanshu Aeran et al. Maintenance protocol for implant supported restorations: An overview

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