Maintenance Sequences

Achieving a successful result with the treatment is only half the battle won. The main challenge is maintain that result over a long period of time more so as apart from the clinician's skills, patient's cooperation is a must.

Initial Maintenance Steps

It is very essential, that from the beginning of the patient interaction regarding the implant therapy, through the diagnosis and planning stages and then the treatment stage, some time included for counseling the patient to sensilizing them about the need of meticulous oral hygiene maintenance procedures.In general, in dental office, procedures for maintenance of patients with implants are similar to those with natural teeth with three differences.

1) Special instruments that will not scratch the implants are used for calculus removal on the implants.

2) Acidic Fluoride prophylactic agents are avoided.

3) Non abrasive prophy pastes are used.

During the phase after uncovering the implants, patients must use the following to keep the implants and the natural teeth clean.

• Brushes and Interdental Cleaning Aids
• Chemotherapeautic rinses: The use of 0.12 per cent chlorhexidine has been proven to be of therapeutic significance in maintaining periodontal health and treating periodontal pathology. However, generalized long term use is not recommended. However in implant patients use of dental floss, interdental tapes, interdental brushes or cotton swabs dipped in 0.12 per cent chlorhexidine around the implant supported prosthesis has been recommended.
• Irrigation devices.

Generally, patients are apprehensive to touch the implant areas during routine hygiene procedures, but should be motivated by the clinician to use the aids judiciously to maintain meticulous hygiene.Dental implants require special oral hygiene techniques. The particular technique chosen often depends upon the prosthesis. A removable prosthesis gives access to the implant-retained bar and an interdental brush and small cleaners are usually adequate because spaces are large. On the other hand, fixed restorations require floss and brushes. Metal tools, such as interproximal brushes with a stainless-steel core wire, must be avoided because they could damage the titanium.

1) Manual or Automatic Toothbrushes: Brushing is imperative and soft or medium toothbrushes are recommended. Small heads are useful because they allow better access. Automatic toothbrushes effectively disturb biofilm and are particularly useful for formerly edentulous patients. Patients need to reach towards the implants,which may be more lingual than the contour of a tooth. They also need to be made aware of the implant locations, which may not be obvious for multiple unit bridges.

2) Interdental Threaded Cleaners: The use of floss is recommended around any implant-supported bridge, crown, or bar. Instruct the patient to wrap the floss around the implant and move using both horizontal and vertical motions.

Interdental cleaning aids

• If patients find wrapping around the implant difficult, another option is to use floss in a “shoe-shine” fashion around implants, making an effort to clean 360 degrees around the prosthesis.

•  Instruct the patient to use the interdental brush in a back-and-forth motion to cover the entire proximal surface of the implant and restoration. For patients who cannot tolerate the bristles of interdental brushes because of the presence of little or no attached gingiva, sponge tips that attach to interdental handles may be useful. Cone-shaped interdental cleaners are available with replaceable tips similar to interdental brushes and are also useful.

Interdental and unitufted brushes

3) Oral irrigation Devices: The use of oral irrigation devices has been controversial due to concerns about incomplete plaque removal and potential separation of connective issue fibers. They may be useful when a prosthesis design does not allow the patient to gain proper access to peri-implant areas, or in other difficult maintenance situations. Short-term use of chlorhexidine solution in the irrigation device may be useful for reduction of severe inflammation.

Oral Irrigation Device

The following sequence is suggested for inculcating these habits and ensuring the patients compliance.On the day of the cementation/delivery of the implant supported prosthesis it is very important that the patient is shown all the home care aids and trained to use them.Check oral hygiene within one week. The prevalent status should be assessed to evaluate whether the patient is maintaining hygiene successfully or not. The patient who is adhering to the protocol should be appreciated and motivated while those who are not should be counseled further and the operator should adjust devices and techniques as necessary. Review oral hygiene in 1-2 weeks and then after 1 month. Adjust devices and techniques as necessary.

Maintenance in the Continuing Care Cycle

Patients should enter the continuing care cycle only after they have demonstrated good habits and techniques.

1) The Maintenance Visit— Systemic Evaluation

The revaluation of the patients systemic status is also critical in the maintenancesequence also as the patients health can undergo unfavourable changes due to disease or trauma and some of these as discussed below can adversely affect the existing implant supported prosthesis.

Impaired dexterity: Any impairment of dexterity, even if it is temporary, may be detrimental to dental implants because home maintenance care is complex. Make sure that caregivers understand all aspects of home care.

Stress: Patients who are undergoing stressful periods may develop increased grinding or clenching habits. Although natural teeth adapt to increased force, in implants this can lead to mechanical fatigue, which can eventually cause component loosening or fracture. Night-guards, may help prevent future restorative and component failures.

Medication causing xerostomia: The patient should be referred back to the treating doctor in order to explore the possibility of alternative medication. The use of lozenges to stimulate salivation and the use of saliva substitute if necessary should be done to offset this condition.

2) Clinical Evaluation

Examination of gingival contours, along with mechanical evaluation of the prosthesis, implants, and implant components will allow you to detect emerging problems at an early state. The examination of gingiva, plaque assessment and probing depth should be assessed as we had discussed earlier.

3) Examination of the Prosthesis

It is important to examine the prosthesis thoroughly. This involves assessing mobility, checking screws, evaluating attachments and porcelain restorations.

a) Assess Mobility

All implant-supported prostheses must be stable. To detect mobility, place an explorer or scaler under the embrasures and apply gentle pressure in the buccolingual direction, as well as slight tension in the apicocoronal direction.When mobility is present, assume that it originates at the prosthetic or component level, rather than from the implant itself. It is often difficult to distinguish mobility of the prosthesis from mobility of the abutments. If the prosthesis is mobile and there is no separation between the prosthesis and the abutment, this is a sign of loosening or fracture of the abutment screws.In screw retained prostheses- two screws are involved: a screw attaching the prosthesis to the abutment and a screw retaining the abutment on the implant. Movement may be due to the loosening either or both screws.

b) Check Screws- Check screw access holes for closure.

If screw access holes are uncovered, such as the bar-retained dentures, make sure that are free from debris. If screws can be seen, gentle movement with a probe or an explorer will allow you to detect unscrewing or possible fracture. At least once a year, an appropriate screwdriver should be used to verify tightening. If you find a loose screw ideally replace it with a new one.

Inspect the connection between the prosthesis and the abutment when supragingival. Increased distance between these elements may be a sign of uncementing or unscrewing of the prosthesis.Note that in the presence of periosteal or blade implants, as well as some root-form implants that contain the abutment, any loosening is due to loss of osseointegration or fracture of the implant itself.

c) Evaluate Attachments

It is expected that the attachment parts of removable prostheses must be replaced regularly because of wear. The replacement part is most often in the prosthesis itself, and not on the implant attachment or bar.Evaluate retention by positioning the prosthesis and removing it. Also evaluate prosthetic stability by having the patient apply occlusal and lateral biting forces.Patients are often aware of loss of retention and will request a change of attachments.

d) Examine Porcelain Restorations:

When porcelain is present, it is also important to examine its integrity. Ceramic fractures or cracks are important signs of excessive forces that may need to be addressed. When porcelain fractures are found within 6 months of prosthesis delivery, failure may be due to a fabrication error or to the presence of excessive force (which may be damaging the implants as well as the prosthesis).

4) Radiographic Examination: Radiographs are an important tool to evaluate the bone levels, health and implant integrity. Annual radiographs following treatment are recommended in the maintenance protocol. The details we had discussed in the preceding section.

5) Scaling Instrumentation: Although stainless steel is generally the mosteffective material for removing calculus, it cannot be used with implants, because it scratches titanium and leaves a nidus for plaque retention. Implant scalers may be made of Plastic / nylon, gold-plated or titanium. The types vary slightly in shape, efficacy of calculus removal, and type of care required.

Plastic Scaler in use around implant supported crown

a) Plastic/ Nylon Scalers: These are available in a variety of shapes and are moderately effective in calculus removal. Can be Ultrasonically cleaned and autoclaved in the usual manner while some are available as reusable handle with disposable tips. The reusable types are not amenable to sharpening and are not very durable.

b) Gold-plated Curettes: These were recommended initially. However, gold plating can be easily removed, resulting in an instrument contraindicated for implants.Therefore they should not be placed in an ultrasonic cleaner or sharpened.These have been superseded by titanium instruments.

c) Titanium Instruments: Universal and Gracey curettes made of titanium alloy are available. These are effective and can be autoclaved. These are the instruments of choice, though currently very expensive.

d) Ultrasonic scaler: Its use around an implant is also controversial with varying views about their use with conventional tips. Many manufactures have introduced ultrasonic scaler tips which have a stainless steel core with plastic sheaths. The plastic (PEEK) used for this sheath is highly heat resistant and can be autoclaved.