of Full-Arch Implant-Supported Restorations, Peri-implant and Prosthetic Considerations

Fig. 16.1

Data from the third EAO consensus conference

Implant failures can best be prevented if the causes of the failure are thoroughly understood and some of the factors that place some patients at high risk of peri-implantitis are addressed.

Among them are local factors such as previous aggressive or current periodontitis, residual subgingival cement, occlusal overload, foreign body reaction and poor oral hygiene [3]. Because patients’ peri-implant health is affected by systemic issues such as smoking, diabetes and generalized chronic inflammation, it is important to ensure a good patient medical history and referral to the right medical professional.

16.1.1 Home Care for Dental Implants

The available home care methods are forms of brushing, flossing and mouth rinses. The evidence is somewhat mixed on whether powered or manual toothbrushes are best for implants; however, there’s a trend towards electric brushes in reducing BOP and plaque level. Results of a 6-year multicentre study reported significant decrease in bleeding on probing (BOP) and plaque using counter-rotational electric brushes [4]. Another paper based on a systematic review of self-performed oral hygiene practices for dental implant-supported restorations reveals a lack of evidence to support best practices, but concluded that powered toothbrushes were found to perform better than manual toothbrushes [5]. Ultimately, the right tool depends most of all on the patient’s willingness and ability to use it properly. For patients with poor dexterity, an electric toothbrush is specifically recommended.

The literature on mouth rinses varies, due to the heterogeneity of the studies. For example, 0.12% chlorhexidine solution irrigation seems to be more effective in reducing plaque and bleeding than swishing it alone, and swishing Listerine mouthwash was also found to be better than saline with regard to reducing plaque and bleeding around dental implants. These findings from the Cochrane Database of Systemic Review done in 2010 found no difference between 0.12% chlorhexidine rinse and saline rinse [6].

There are numerous tools for interdental cleaning besides floss, such as different size and shape interdental brushes, rubber tips and oral irrigators. Interdental brushes can be helpful in patients who have implant-supported prostheses, but they must have the dexterity to use them properly (Fig. 16.2). Pulsating oral irrigato rs have been shown to be 80% more effective than string floss in reducing bleeding around dental implants after 30 days [7, 8]. A Tufts School of Dental Medicine study found that a water flosser with implant tip was 145% more effective than string floss around implants when used in conjunction with a manual toothbrush [9]. Significant reduction of gingival bleeding at 2 weeks and 30 days, respectively, was reported [9].

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Fig. 16.2

A tapered interdental brush can be used to clean an implant bar

Through electron microscopy, an oral health study from the University of Southern California’s Center for Biofilm Research verified the efficiency of the oral irrigator . A treatment with the water jet over the surface of the root of an extracted tooth removed 99.9% of mature plaque biofilm in only 3 s [10].

In conclusion, when recommending a home care protocol for dental implant patients, one should consider the individual—including dexterity, motivation and type of restoration. For full-arch restoration, the most practical and effective way to clean underneath the prosthesis is with a pulsated oral irrigator (Fig. 16.3a, b). Based on the literature, it is advised to have patients incorporate an electric toothbrush and oral irrigator, if inflammation around peri-implant tissues is present. Patients who are avid string flossers should be cautioned about the risk of injury to gingiva and peri-implant tissues using the floss because the attachment of the peri-implant tissues is not as diseases; patients have to be instructed on their personal oral hygiene with regular monitoring and reinforcement [11, 12].

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Fig. 16.3

Oral irrigator users. (a) Healthy gingival tissue around individual dental implants. This patient previously had inflammation which caused recession to expose the abutment. (b) Healthy gingival tissue around top and bottom full-arch prosthesis

16.1.2 In-Office Dental Implant Management

A 2015 consensus on preventing peri-implant diseases published guidelines for dental implant maintenance [13]. Bleeding on probing is considered as key clinical measure to distinguish between peri-implant health and disease, according to these guidelines. Therefore, probing around dental implants should be considered at least once a year. It is important to establish initial pocket depths at baseline (insertion of the restoration) and to monitor for changes over time. For this, a traditional periodontal probe should be used, exerting light force, 0.25 N. However, unlike bone loss, neither BOP nor probing depths—even as much as 6 mm—are correlated to bone loss around implants, according to the Estepona consensus on peri-implantitis 2012 [14].

Professionally administered plaque control procedures should include regular oral hygiene instructions and mechanical debridement employing different hand or powered instruments with or without polishing tools. The interval between hygiene visits should be personalized and based on the individual patient’s ability to perform good oral hygiene, and their history of previous periodontitis. There is no protocol established in the literature for the 6-month interval for implant patients; however, the 2015 consensus advises 3-, 6- or 12-month recall intervals with shorter intervals in patients with a history of aggressive periodontitis [13]. To prevent the development of peri-implantitis in a patient who has difficulty cleaning underneath the prosthesis, an interval of 1 or 2 months may also be appropriate.

Assessing the amount of keratinized tissue around an implant area is of great importance and should start prior to the implant being placed (Fig. 16.4). To facilitate personal oral hygiene, clinicians should consider having keratinized attached and unmovable tissue surrounding the transmucosal implant portion already during implant placement (for one-stage implant placement) or during abutment connection (for two-stage implant placement) [13].

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Fig. 16.4

(a) Adequate zone of keratinized mucosa around implant restorations replacing central incisors. (b) Inadequate zone of keratinized mucosa around implant

Whenever possible a screw-retained restoration should be employed. Other clinicians have utilized a friction fit telescopic prosthesis which is removable. The advantage of this type of restoration is that the patient is able to clean around the implants with visible access. If cementation is unavoidable due to the angle of the implant, then it is important to use a radio-opaque cement, which is visible on radiographs to facilitate complete removal.

The contours of the prosthesis can have a significant impact on the patient’s ability to maintain good oral hygiene at home and keeping healthy peri-implant tissues. The practitioner should be aware of this issue and make sure that restorations are as cleansable as possible. For example, a concave on the undersurface of a full-arch restoration is not conducive to good hygiene (Fig. 16.5a–c). In general, all intaglio surfaces of the prosthesis should be convex or flat, and buccolingual dimensions should be as narrow as possible, but not so thin that it is likely to break. The patient must be able to get the water flosser all the way through and underneath the prosthesis.

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Fig. 16.5

(ac) Inadequate contours of a full-arch implant-supported restoration, making it uncleansable

16.1.3 Record Keeping

Systemic health, medications and/or supplements should be regularly inquired about, because 68% of Americans today take some kind of supplements that can affect oral health (​newhope.​com/​news-analysis/​most-americans-take-and-trust-supplements). Nutritional deficiencies can affect oral health. Vitamin D deficiency for example increases the risk of osteoporosis, high blood pressure, allergies, colds and flu, mental health and heart problems. An adequate level, on the other hand, positively affects oral health by reducing inflammation and modulating cell growth and immune function. Vitamin D level has also been inversely associated with gingival bleeding and level of periodontal disease [15].

Baseline photographs, radiographs and probing depths should be taken at the time of implant placement and prosthesis delivery, so we can monitor changes over time. Radiographs should be taken once a year ideally. Inflammation and plaque levels should be reported at every appointment (Fig. 16.6a, b).

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Dec 6, 2018 | Posted by in General Dentistry | Comments Off on of Full-Arch Implant-Supported Restorations, Peri-implant and Prosthetic Considerations
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