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Dental Implant Maintenance and Prosthetic Preventive Care for Implant Longevity
Rafael Delgado‐Ruiz1, Fawad Javed2, and Georgios E. Romanos3
1 Department of Prosthodontics and Digital Technology, Stony Brook University, Stony Brook, NY, USA
2 Department of Orthodontics and Dentofacial Orthopedics, Eastman Institute for Oral Health, University of Rochester, Rochester, NY, USA
3 Department of Periodontics and Endodontics, Stony Brook University, Stony Brook, New York, USA
Introduction
During the delivery of implant–supported restorations, base reference values (BRVs) should be registered. These BRVs include different variables of the peri‐implant tissues, prosthetic parameters, and patient outcomes (Figure 30.1).
BRVs for the peri‐implant tissues:
- The soft tissue characteristics (thickness, height, location, color, gingival papilla, and attributes).
- Probing depths (measured with stable reference points in the implant or the prostheses).
- Bleeding on probing (evaluated with standardized periodontal probes).
- Mesial and distal radiographic bone levels (using as reference implant or prosthetic landmarks).
BRVs for the implant prostheses:
- The occlusal relationships (occlusal contacts and occlusal scheme)
- Interproximal relationships (interproximal contacts, embrasure spaces)
- Prostheses fit (implant–abutment/crown–abutment fit and emergence profile, both evaluated by clinical and radiographic methods)
- Integrity and quality of the implant restorations (presence of cracks, surface porosity, finishing, and contamination)
- Color matching and mimicking with the adjacent structures (including adjacent teeth and gingival tissue).
The BRVs for patient outcomes are subjective, usually measured through questionnaires filled by the patient, and can include some of the following:
- Patient satisfaction
- Patient function
- Patient’s quality of life
In addition to the BRVs recorded immediately after delivery, periodical follow‐ups can detect changes in the BRVs during the implants’ expected functional life. As consequence of the implant/prosthesis function and the exposure to multiple environmental factors, the health of the peri‐implant tissues as well as their survival can be impaired [1].
Local and general factors can alter the peri‐implant tissues’ health. Among the local factors that can affect the health of peri‐implant tissues can be included: plaque, bacteria, sub‐products (toxins), residual cement and foreign bodies, material surface porosity and chemistry, and maintenance protocols. General factors that can affect the health of the peri‐implant tissues are immune system status, medications, diabetes, and smoking [2]. Therefore, with long‐term implantable medical devices and prostheses, the periodical evaluation of the peri‐implant and prosthetic parameters is obligatory to detect and control as early as possible any alterations of the BRVs parameters [3].
When periodical evaluations are completed, any deviation from the original BRVs indicates a potential impairment of biological (mucositis, peri‐implantitis), prosthetic, or patient outcomes is in progress. These changes must be addressed to return the dental implants, the peri‐implant tissues, the implant restorations, and the patient to the baseline or stability (Figure 30.2).
The prevalence of biologic (mucositis and peri‐implantitis) (Table 30.1) and prosthetic complications (Table 30.2) are present in different percentages. Both increase with the time of implant service [3]. Given that fluctuations between health and disease occur and co‐exist over the long term, follow‐up evaluations are required to detect changes, and maintenance protocols are essential to support the health and longevity of implants and their restorations. Because it has been demonstrated that the incidence of peri‐implant diseases is significantly reduced, and implant survival is increased when maintenance protocols are applied [3].
Figure 30.1 Base Reference Values (BRVs) recorded immediately after the insertion of the implant restorations. Parameters will be recorded periodically during follow‐up visits or maintenance visits. Any changes and date of occurrence must be registered (By Delgado, Javed and Romanos).
Figure 30.2 Different factors can influence dental implants, where a thin line separates health and disease. The peri‐implant health and disease status are variable and adjacent to each other. Maintenance protocols can stabilize the line on the healthy side. Although health is considered the lack of disease, the disease can be present with different severity levels, which can mask the early stages of the disease. Severe disease conditions are away from health, and mild disease conditions are near to health status. The black dotted line indicates the equilibrium. The broken spaces in the line indicate periods of interruption or change. The oscillating line shows alternant health and disease. When the disease appears and is detected early, therapeutic and corrective actions are required to restore the equilibrium (By Delgado, Javed and Romanos).
Table 30.1 Compilation of the prevalence of peri‐implant diseases (mucositis and peri‐implantitis) upon a follow‐up period of 15 years presented in the most recent systematic reviews. Mucositis is more frequent than peri‐implantitis.
| Authors | Population patients/implants | Mucositis prevalence/frequency | Peri‐implantitis prevalence/frequency | Time of evaluation | Definitions | |
|---|---|---|---|---|---|---|
| Mucositis | Peri‐implantitis | |||||
| Atieh et al. [4] | 1,497 P/6,283 I | 63.4% of participants and 30.7% of implants | 18.8% of participants and 9.6% of implants | >5 Years | Inflamed mucosa that may have bleeding, and/or suppuration without bone loss | Inflamed mucosa bleeding, probing depth ±5 mm, radiographic bone loss ±2 mm and/or ǂ3 threads of implant |
| Derks et al. [5] | NA | Range from 19 to 65% Meta‐analysis 43% (CI: 32–54%) |
Range from 1 to 47% Meta‐analysis 22% (CI: 14–30%) |
1 Year to 24 Years | Bleeding on probing and absence of bone loss, or bone loss <0.05mm‐0.06mm | Bleeding on probing, probing depths >4–5 mm, bone loss, >3 threads exposed |
| Muñoz et al. [6] | 2,734 P/7,849 I | NA | For PPD ≥4 mm prevalence by subject was 34% and by implant 11%. For PPD ≥5 mm prevalence by subject was 12% and by implant 10%. For PPD ≥6 mm prevalence by subject was 18% and by implant 10% |
>6 months | NA | Bleeding on probing, probing depth |
| Natto et al. [7] | NA | NA | NA | 6 months to >5 Years | Bleeding on probing, with a crestal bone loss of 2 mm in the first year and 0.2 mm in each subsequent year and, probing depth of 5 mm | Bleeding on probing, suppuration, radiographic bone loss >3 mm |
The prevalence of both diseases appears to increase with the time of follow‐up. CI, Confidence Interval; I, Implants; NA, Not applicable; NR, Not reported; P, Patients; PPD, Peri‐implant probing depth.
Table 30.2 Compilation of technical/mechanical/prosthetic complications upon a follow‐up period of 15 years collated from recent systematic reviews. Two frequent complications were described in all the reviews (Screw loosening and material fractures); prosthetic designs were responsible for the variability. The complication rates increase with the time of prosthesis use, which can be related to material fatigue. Finally, cemented restorations will present higher biological complications, and screw‐retained restorations will develop more mechanical complications.
| Authors | Prosthetic complications | Incidence | Time of evaluation | Type of implant restoration |
|---|---|---|---|---|
| Jung et al. [8] | Screw/abutment loosening Ceramic/veneer fracture Screw/abutment fracture Implant fracture |
12.7% 4.5% 0.35% 0.14% |
5 Years | Implant–supported single crowns |
| Romeo et al. [9] | Veneer fractures Screw loosening Restoration debonding Abutment screw fractures Implant fractures |
10.1% 7.9% 5.9% 1.6% 0.7% |
5+ Years | Cantilevered prosthesis on implants |
| Papaspyridakos et al. [10] | Prosthetic screw fracture Chipping/fracture of veneering material |
10.4% (5Y) 20.8% (10Y) 33.3% (5Y) 66.6% (10Y) |
5 Years and 10 Years | Full mouth rehabilitations on implants |
| Rabel et al. [11] | Chipping Framework fractures |
9% (5Y) 2.7% (10Y) |
5 Years and 10 Years | All ceramic single crowns supported by implants |
| Pieralli et al. [12] | Chipping of the veneering ceramic Fracture of the framework Decementation Screw loosening |
22.8% (partial) 34.8% (full arch) <1% <1% <1% |
Calculated complications at 5 Years | Partial and full arch all‐ceramic implant–supported prostheses |
| Gaddale R et al. [13] | Cemented Screw‐retained |
+Biological complications (>2 mm marginal bone loss) +Technical complications (Screw loosening, material fractures, and screw fracture) |
1 Year up to 15 Years | Screw versus cemented full arch restorations |
Definition of Implant Health, Maintenance, and Patient’s General Health
Peri‐implant health was defined as the absence of inflammation, bleeding on probing, swelling, suppuration, or bone loss at the Proceedings of the World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions [14]. The health of the peri‐implant tissues can be sustained through implant maintenance therapy [15]. Thus, implant maintenance can be defined as all these procedures that measure the peri‐implant soft and hard tissue parameters, detect and remove plaque and other risk factors, apply corrective actions, educate the patient to perform correct home care, and attempt to improve the patient’s compliance [15].
Although there are different ways to describe implant maintenance, like supportive peri‐implant therapy (SPIT) [16] and cumulative interceptive supportive therapy (CIST) [17], the goals are the same. They are comparable to conventional supportive periodontal treatment (SPT). Essential implant maintenance includes the following steps analog to SPT: clinical examination, radiographic evaluation, oral hygiene instructions, plaque control, and mechanical debridement [18].
Beyond peri‐implant health is general health, defined by the World Health Organization (WHO) as a “state of complete physical, psychological, and social well‐being and not merely the absence of disease or infirmity.” Therefore, not just the peri‐implant tissues but also the patient’s general health, prostheses integrity, prosthesis’s function, and patient’s quality of life (evaluated through specific questionnaires) should be included within the goals of the implant maintenance and patient’s health maintenance procedures [1].
Implant Maintenance Protocols
Since the middle of the ’90s, different approaches have been recommended for the maintenance of dental implants; this occurred because some of the first long‐term follow‐up studies on dental implants demonstrated that a small percentage of implants could fail [20, 21]. Wilson T., in 1996, described a list of seven aspects that should be evaluated in the maintenance visit for patients restored with dental implants (Figure 30.3).
As can be observed, the maintenance visit included more than the simple evaluation of the peri‐implant tissues but extended far to cover prostheses, the patient’s health, and preventive and corrective steps. Regarding the examination of the peri‐implant tissues, the method of probing was not described. However, the assessment of the soft tissues included bleeding on probing and detecting the presence of suppuration (Figure 30.4–30.6).
In addition, the occlusal examination evaluated, among others, the screening for evidence of wear, the evaluation of screws (looking for loosening or fractures of implants and parts), and recording patient complaints. The implant stability was also included in the evaluations when permitted by the type of restoration.
Figure 30.3 List of evaluations proposed by Wilson [22]. Evaluations were covering the general and oral health, implant, peri‐implant tissues, hygiene, patient’s behavior toward oral hygiene, evaluation of bone levels, cleaning the prostheses, and setting the maintenance intervals.
Figure 30.4 Peri‐implant tissue health after abutment connection (a). The peri‐implant mucosa with good tissue stability presents capillary formation without any inflammatory reaction (b).
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