Post Insertion Maintenance

Prior to embarking on treatment with implants, it is important that the patient is fully aware of the commitment that is required, not only during treatment, but in the long term maintenance of the prosthesis. It is the role of the practitioner to emphasise the need for six monthly or annual visits. An assessment of the continuing viability of both the prosthesis and the implants, from both a clinical and radiographic perspective, should be carried out. There is some disagreement amongst clinicians as to whether or not there is a need to remove fixed prostheses on an annual basis, in order to assess the presence or absence of mobility of the supporting implants. Though there is some desire to do this, the removal of the prosthesis will often result in patient disapproval, which will occasionally prove well founded when, subsequent to prosthesis removal, problems occur in reseating the bridge-work in exactly the same way. Experience shows that in the absence of periimplant radiolucency and other clinical signs, mobility is unlikely. On balance it may prove wiser to remove the prosthesis only when clinical conditions dictate and not on an elective basis. A paralleling technique is advisable when taking intra-oral radiographs, so that the threads appear in focus (Fig 8 -1) since only then is it possible to determine a true periimplant radiolucency (Fig 8-2). Focusing on the marginal bone may demonstrate signs of crestal bone loss. Given that a radiograph is merely a picture in time, it is necessary to compare two or more radiographs over the first one to two years (Figs 8-3, 8 - 4a and 8-4b).

It is not unusual to have to re tighten bridge screws which may work loose during early functional loading of the bridge. This would seem to arise more commonly with those implants that utilise a butt joint interface. Bridge screws that continue to present loose on subsequent recall appointments should arouse concern for the accuracy of fit of the bridgework, or possibly for overloading of the prosthesis. However, the advantage of the bridge screws being the weakest link in the chain is that not only do they act to protect the

Fig 8-1 The use of a reproducible paralleling technique will ensure that the threads of the fixture are in focus. This is essential for accurate assessment of osseointegration or periimplant radiolucency

Fig 8-2 Periimplant radiolucency, seen here around two single crystal sapphire implants is characterised by a dark line that can be traced around the apex of the fixture, with no evidence of bone between the threads. This is a cardinal sign ol implant lailure.

Fig 8-3 Radiographs should be taken prior to Implant exposure to act as a baseline by which to compare future radiographs.

underlying implant/abutment complex but, being occlusally placed they are more easily accessed. Considering that the majority of prospective studies cited in this text report a 100% prosthetic success (as compared to implant success), it is clear that having passed the first annual recall, the number of failures take a dramatic drop, statistically. Expected failures fall even further after the three and five year recall with only occasional case reports of long standing prostheses being compromised by implant failures. The role of the hygienist may prove more critical during maintenance

Figa-4a This radiograph was taken approximately 8 months post insertion. Note the molar seen in figure 8-3 was extracted and no socket remnant is now visible. When comparing the two radiographs it is clear thai there has been a small crater-ing around the mesial aspecl of the mesial implant. Future radiographic monitoring will determine if this is "physiological" or "pathological".

Fig 8-4b This radiograph was taken 2 years post insertion. Careful study of the bone around the mesial implant clearly demonstrates that the vertical bone loss seen in figure 8 -4a has been stabilised and the crater filled with bone that is now visibly horizontal. This is indicative of a favourable load distribution by the prosthesis.

visits, bearing in mind that many implant patients lost their own teeth initially through poor dental health motivation. It Is perhaps surprising that, with all the physical and financial investment involved in implant therapy, some patients still persist in ignoring oral hygiene instruction. The presence of a plaque induced periimplant inflammatory response has been well documented 2 and shown to be potentially destructive,2 Studies show that it is not acceptable to clean the surface of abutments with standard metal scalers or ultrasonic instruments since these result in visual damage of the softer

Fig 8-5 G-Floss IITt! {3r™, implant innovations™. Palm Beach. Florida) is a type of ribbon floss which is very useful for cleaning around the necks of implants and in the interproximal spaces.

Fig 8-6 G-Floss llT« {3i™, Implant Innovations™. Palm Beach. Florida) is also useful for cleaning around the undersurface and the lingual surface of the bridgework.

titanium surfaced Instead the use of plastic scalers6-9 or gold alloy scalers (Implarette Scaler™, 3iT,j Implant Innovations™, Palm Beach, Florida) have been used to remove gross debris from abutment surfaces, without scratching or pitting the titanium.

In an effort to further remove debris, whilst leaving a polished surface, investigators have studied the effects of abrasive pastes applied by rubber cup;6-7 air-powder abrasive systems;5'6- ,D and flour of pumice, applied by rubber cup.s, 10 The flour of pumice applied intermittently, with light pressure, would seem to provide the best results with obliteration of the machine milling marks, leaving a smooth swirl pattern.10 This prophylactic technique is also easily accessible to the general practice hygienist.

The most important job for both dentist and hygienist is to convey a sense of encouragement to the patient. The role of the patient in his or her long term maintenance programme is of paramount importance. The use of soft tooth brushes and interdental brushes is to be recommended, though without the use of toothpaste, which can prove too abrasive for the softer titanium. The use of floss and super floss are of limited value around the larger gaps, and the bulky fixed bridge prosthesis. However, the introduction of G-Floss™ (3iImplant Innovations"", Palm Beach, Florida) allows more effective cleaning in those awkward nooks and crannies (Figs 8-5 and 8-6).

Above all the patient should be encouraged to possess a high level of awareness for the feel and function of the prosthesis. It should be abundantly clear that at the first sign of trouble or even concern, the patient should present for a checkup. The result of procrastination will often be that a minor complication is now more costly, in all respects!! Perhaps the most significant advantage of regular maintenance appointments is the constant reminder of both the predictability of implants and the total improvement in quality of life that such restorations can provide.

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