IMPLANT MAINTENANCE PROTOCOL

Robert Delie, DMD, MDS
 

• Recall Visit
  • One year
• Radiographic Exam
  • Evaluate Crestal Bone Loss
    • PA X-Ray Annually
    • 3-D ?
• Clinical Exam
  • Marginal Tissue Evaluation
    • Color
    • Consistency
    • Keratinization
  • Inflammation
    • Bleeding Evaluation
      • Probing (BOP)
      • Prophy brushes  (TePe)
      • Interproximal brushes
      • Tissue Stimulators
• Hygiene
  • Healthy Bone Level (without fixture exposure)
    • ProphyàWNL
    • Hand scalers/curettes
    • Ultrasonic
      • Supragingival or sulcular (abutment) margin
      • Home care products: TePe interproximal brushes, antiseptic rinses

• Bone Loss (exposed fixture surface)
  • Titanium Scalers
  • Plastic instrument
  • Graphite instruments
  • Irrigation
  • Locally-delivered anti-microbials
  • PerioChip (chlorhexidine gluconate)
    • Home care products: TePe interproximal brushes, anti-microbial rinses
  • Bone Loss (without exposed fixture surface)
    • Without Presence of Bleeding
      • Treat as a healthy site
      • Increase recall and radiographs to every 6 months
      • Presence of Bleeding
        • Subgingival Scaling
        • LAA’s (locally-applied anti-microbials)                               
          • PerioChip (chlorhexidine gluconate)
• Implant Complications & Intervention
  • Peri-implantitis
  • Criteria for failure

IMPLANT MAINTENANCE PROTOCOL

Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA

• Recall
  • 1 week post restoration (check occlusion)
  • 1 month post restoration (check occlusion)
  • 3 month post restoration (check occlusion and soft tissue as well as pt home care)
  • 6 month recall schedule (unless perio dictates more frequent)

• Radiographic Exam
  • Evaluate Crestal Bone Loss
    • PA radiograph annually (standardized radiographic positioner with bite to get exact position each recall)

• Clinical Exam
  • Marginal Tissue Evaluation
    • Color (pink, red, cyanotic)
    • Consistancy (firm, boggy, swollen)
    • Comparison to adjacent areas
    • Keratinization
    • Recession (stability of the gingival margin)
  • Inflammation
    • Bleeding Evaluation
      • Probing  (do not probe due to fiber orientation)
      • Digital palpation of gingival tissue to evaluate presence of bleeding or exudate
  • Mobilty
    • Prosthetics
    • Implant fixture

• Hygiene
  • Absence of inflammation with stable bone level (without fixture collar exposure)
    • Prophy
    • Hand scalers/curettes (plastic, graphite or titanium)
    • Ultrasonic with plastic tip (optional)
    • Do not probe around fixtures due to fiber orientation compared to natural teeth
    • Polish with prophy paste
    • Check occlusion
    • Recall 6 months

• Presence of inflammation with stable bone level (without fixture collar exposure)
  • Prophy
  • Hand scalers/curettes (plastic, graphite or titanium)
  • Ultrasonic with plastic tip
  • Do not probe around fixtures due to fiber orientation compared to natural teeth
  • Polish with prophy paste (avoid air polishers)
  • Check occlusion
  • Recall 3 months

• Presence of inflammation with fixture collar exposure
  • Prophy
  • Hand scalers/curettes (plastic, graphite or titanium)
  • Ultrasonic with plastic tip
  • Do not probe around fixtures due to fiber orientation compared to natural teeth
  • Polish with prophy paste (avoid air polishers)
  • Check occlusion
  • Recall 3 months (if inflammation present still at next recall may wish to flap to clean or refer to periodontist to have treated more aggressively)
  • Supplement home care with:
    • CHX rinse
    • Brush on FL2
    • Doxycycline 20mg 2x daily till next recall (Periostat or generic equivalent)

• Bone Loss with absence of inflammation
  • Prophy
  • Hand scalers/curettes (plastic, graphite or titanium)
  • Ultrasonic with plastic tip
  • Do not probe around fixtures due to fiber orientation compared to natural teeth
  • Polish with prophy paste (avoid air polishers)
  • Check occlusion
  • PA radiograph to monitor bone level
  • Recall 3 months (follow-up radiograph to check stability of bone level)

• Bone Loss with presence of inflammation (no mobility to fixture)

More aggressive approach needed to stop the bone loss progression, monitoring tends to allow progression and potential loss of the fixture.

• PA radiograph with reproducible bite on holder
• Flap procedure to eliminate any debris (calculus, cement etc) subgingivally)
• Hand scalers/curettes (plastic, graphite or titanium)
• Ultrasonic with plastic tip
• Treat exposed threads with Meffert technique for ailing implants*
• Osseous graft placed to cover all exposed threads (resorbable membrane recommended under flap before closure to allow better organization of the osseous graft)
• Close with resorbable sutures (PGA recommended)
• Check occlusion
• 2 week suture removal
• PA radiograph with reproducible bite on holder at 8 weeks to verify new bone level
• Recall 3 months
• Supplement home care with:
  • CHX rinse
  • Brush on FL2
  • Doxycycline 20mg 2x daily till next recall (Periostat or generic equivalent)

• Bone Loss with presence of inflammation and mobility to fixture

Poor prognosis, implant needs to be removed and site grafted before new fixture may be placed.

• Implant Complications & Intervention
  • Peri-implantitis defined as the presence of inflammation with or without bone loss at an implant fixture.
    • Unless the inflammation is controlled bone loss will progress with eventual failure of the fixture.  Watching and waiting only demonstrates increasing bone loss and a more aggressive approach is needed to stop the ongoing process
    • Ailing vs failing:
      • Ailing implant is defined as an implant that has some bone loss and inflammation but the absence of any mobility to the fixture with sufficient bone level to maintain the implant long term if the bone were to remain at the current level
      • Failing implant is defined as an implant that has mobility and/or sufficient bone loss that long term stability can not be maintained
      • Criteria for failure
        • Presence of any mobility to the fixture (need to differentiate fixture and prosthetic mobility) signifies a failing implant
        • Insufficient bone support to manage the occlusal loads present
        • Loss of bone level creating an esthetic issue that can not be grafted to restore the implant to proper esthetics

Avoid:

• Air polisher (may cause air embolism due to weaker connective tissue connection then found around natural teeth)
• Probing (can inoculate bacteria into sulcus due to weaker connective tissue connection and lack of fiber barrier allows probe to penetrate till bone encountered giving false reading on pocket depth)
• Stainless steel instruments (harder then implant surface will gouge the implant surface leading to rougher area which will trap plaque)
• Ultrasonic/piezo tips (the metal tips will gouge the implant surface, if used should have plastic tip)

*Meffert Technique for Ailing Implants

• Flap tissue to exposure all supracrestal exposed threads on the implant
• Remove all granulation tissue on the implant surface using titanium scalers
• Detoxify the exposed implant surface 
  • Make paste from a capsule of Doxycycline (add drop or two of saline to make paste)
  • Apply paste to implant surface only (acidic so avoid contact with bone if possible)
  • Allow to sit 1 minute then rinse
  • Repeat two times
  • Apply citric acid gel to implant surface and bone
  • Allow to sit 1 minute then rinse
  • Repeat two times
  • Modification may be to apply ozonated water to rinse and ozonated oil to the implant surface as final treatment
  • Site is ready for grafting.