contemporary implant debridement
TRANSCRIPT
Implant dentistry has become the standard of care for tooth
replacement in both fully and partially edentulous patients.
Due to this rapid evolution, the dental hygienist has been
thrust into the position of providing care for the peri-implant
environment. The long-term prognosis of an implant is
directly related to effective preventive care. The hygienist
must perform this care in a manner that is compatible with
contemporary implant restorative designs and is based on
the principles of maintaining soft tissue health.
IntroductionSince the introduction of osseointegrated implant dentistry,
numerous changes have occurred that challenge the clin-
ician. The rapid acceptance of implants and an increased
concern with achieving optimal aesthetics have resulted in
implant restorations that are frequently indistinguishable
from restored natural teeth. Indeed, radiographs are nec-
essary during the debridement process to differentiate
between implants and teeth. To understand which is the
appropriate instrument to be utilized, the hygienist must
become familiar with different restorative designs and where
the soft tissue restorative interface lies.
Soft Tissue InterfaceThe peri-implant tissues mimic those surrounding a natural
tooth in several aspects with some important differences.
A soft tissue crevice lined by sulcular epithelium sits just
coronal to a junctional epithelium that adheres to the
titanium surface and to a zone of connective tissue, which
merely adheres to the titanium (Figure 1).1,2 The zone of
connective tissue around a tooth, however, is attached by
gingival fibers that insert into the cemental surface.3 Another
difference exists apically. Each tooth is surrounded by a
periodontal ligament, a source of blood vessels and fibro-
blasts for the connective tissue attachment. The implant,
Valerie Sternberg-Smith, RDH, BS, has been a dental hygienist
and surgical assistant for 17 years in a practice limited to perio-
dontics and implant surgery. Ms. Smith is a faculty member in
both the Ashman Department of Implant Dentistry and the
Dental Hygiene Program at New York University, College of
Dentistry.
Robert N. Eskow, DMD, MScD, is a diplomate of the American
Board of Periodontolgy and Clinical Professor in the Ashman
Department of Implant Dentistry, New York University, College
of Dentistry. Dr. Eskow maintains a private practice limited to
periodontics, implant dentistry, and oral medicine in Livingston,
NJ and Clark, NJ.
ContemporaryImplant Debridement
Valerie Sternberg-Smith, RDH, BS
Robert N. Eskow, DMD, MScD
March /Apri l 2001 15
CECONTINUING EDUCATION
2
Figure 1. The soft tissue anatomy of the dental implant,abutment, and crown versus the natural tooth.
Crevice
SulcularEpithelium
JunctionalEpithelium
ConnectiveTissueAttachment
PeriodontalLigament
Root
Crown
Abutment
Crevice
SulcularEpithelium
Junctional Epithelium
ConnectiveTissueAdherence
Fixture
Bone
with its direct titanium-to-bone contact, lacks this soft tissue
reservoir (Figure 1). These differences explain why the peri-
implant mucosa has diminished capacity for self-repair in
the face of inflammation.4
Several experimental studies have demonstrated that
the destructive response to inflammation in the peri-implant
tissues is greater than in those tissues that surround the
natural tooth.4,5 Furthermore, the nature of the relationship
of the soft tissue to the restorative implant components
varies depending on the material employed. The soft-tissue-
to-titanium adhesions described in the aforementioned
studies do not occur in the presence of ceramic or gold
restorations.6 Due to the current interaction of peri-implant
tissues and bacteria, the emphasis must be on preventive
care to preclude the initiation of inflammation.
DebridementThe rationale for debridement is to control the bacterial
population, both quantitatively and qualitatively, in prox-
imity to the peri-implant mucosa. This is accomplished by
removing plaque and calculus while maintaining soft-tissue
adherance. Debridement is just as necessary for dental
implants as it is for the natural dentition, since peri-implant
disease has been demonstrated to result in bone loss and
ultimate loss of the implant fixture (Figure 2).7
Although implant dentistry became a well-established
clinical reality in the mid-1980s, it was not until several
years later that any mention of debridement was made in
the literature. Initial studies were observations utilizing a
scanning electron microscope (SEM) analysis of the effect
of various implements on titanium surfaces,8-10 but in subse-
quent discussions of clinical preventive care, there was
only nominal mention of the instrumentation process.11,12
Implant-supported restorations can range from single
crowns to attachments for overdentures to fixed-hybrid
dentures. The classic implant components the therapist
must be knowledgeable of during debridement are the
abutment and the prosthesis. In a restorative modification,
the abutment is absent, and the prosthesis attaches directly
to the implant fixture. Occasionally, the fixture is not com-
pletely encased in bone and is exposed to the oral cavity;
in such a case, it also requires debridement (Figure 3).
Contemporary Implant Debridement
16 The Journal of Practical Hygiene
Figure 3. The sheathed ultrasonic tip can be adaptedinto the crevice of an exposed implant fixture.
Figure 4. A metal curette is adapted to the pontic areaof this implant-supported bridge.
Figure 2. Implant-supported restorations resemblerestored natural teeth. The instrument is well-suited toenter a shallow peri-implant crevice and debride thelimited amount of abutment surface.
Instrument SelectionHistorically, preventive instrumentation in implant dentistry
has been discussed in universal terms.11-13 It may be more
appropriate to consider the specific components that require
debridement: the restoration, the transmucosal abutment,
and the fixture. Each component will influence the selec-
tion of instruments.
The Restoration
The basis for instrument selection is to leave the restoration
undamaged. The clinician can select an instrument based
strictly on the specific restorative material to be debrided; the
fact that the prosthesis is implant supported is irrelevant.
For example, if calculus is present on a porcelain-fused-
to-metal (PFM) crown, a metal curette may be used (though
the crown is implant supported), with care exercised
not to use this instrument apical to the restorative margin
(Figure 4). If soft debris alone is present on the restora-
tion (eg, crown, denture, attachments for overdentures), the
most effective way to deplaque is to polish with an appro-
priate prophy paste. When the restoration is a nonremov-
able hybrid denture, deplaquing the undersurface can be
accomplished with interdental brushes or tips, end-tuft
brushes, or floss materials.
For restorations that mimic crown-and-bridge dentistry
and have large embrasure areas, interdental brushes/tips
may be effective for gross plaque removal, but in most cases
the bristles do not penetrate into the peri-implant crevice.
Interdental brushes/tips should be used in a vigorous back-
and-forth motion against the walls of the restoration and
directed toward the tissue margin in an effort to reach into
the crevice. The depth of the crevice can be cleansed with
floss or a Perio-Aid™ (Marquis Dental Mfg, Aurora, CO).
A commonly placed implant in dentistry today is the
single-tooth replacement. Debridement of these restora-
tions requires an understanding of the peri-implant tissues
and the restorative components (Figure 5). Frequently, the
circumference of the crown is greater than the supporting
abutment. This results in a broad surface of restorative
material in contact with the soft tissue. Dental floss can be
adapted to the restoration and brought into the peri-implant
crevice, thus removing intracrevicular plaque (Figure 6).
Sternberg-Smith
March /Apri l 2001 17
Figure 5. Extensive crevicular depth is required to enabledevelopment of proper restorative contours. Instrumenta-tion of these deep crevices is limited in order to preventdamage to the soft tissues.
Figure 6. This posterior implant-supported restorationnecessitates deplaquing the abutment and the restora-tive material in contact with the soft tissue.
Fixture
Abutment
Crown
The Transmucosal Abutment
If a metal instrument is used during debridement of a
supra- and/or subgingival transmucosal titanium abutment,
it will roughen the surface,8-10 thus fostering bacterial
accumulation.14,15 The clinician must maintain the integrity
of the surface by using specially designed instruments.
Research has shown that scalers/curettes made of plastic and
plastic sonic and ultrasonic tips can be used without nega-
tively affecting the surface.16-18
The air syringe is an excellent tool that allows the
hygienist to deflect the tissue to view the peri-implant
crevice. In consideration of the vulnerability of peri-implant
tissue adherence, the scaler/curette should be delicately
placed into the crevice, positioned against the titanium sur-
face, and moved in a coronal direction toward the restora-
tion (Figure 7).
When only soft debris is present on the abutment, the
clinician needs to deplaque the surface. Supragingival abut-
ments can be polished using tin oxide or a prophy paste
specifically designed for polishing titanium surfaces. When
polishing the proximal area of the abutment is difficult, an
interdental brush/tip may be used. It is best to avoid those
with metal stems so as not to scratch the surface. Many imple-
ments include a plastic or nylon coating over the metal wire
that will prevent damage. A vigorous back-and-forth motion
against the titanium abutment surface will remove debris.
Contemporary Implant Debridement
18 The Journal of Practical Hygiene
TableInstruments and Manufacturers
Hand Instruments ManufacturerImplacare™ Hu-Friedy (Chicago, IL)
Columbia 4R/4LAnterior Sickle H6/H7Posterior Sickle 204S
Implant-Prophy+™ Advanced Implant Technologies (Beverly Hills, CA)Gracey 5/6, 11/12, 13/14Columbia 13/14
HaweNeos™ (Graphite)Orofacial Scaler (Hoe) Premier (King of Prussia, PA)Columbia 4R/4L Implant Innovations Inc (Palm Beach Gardens, FL)
Nobel Biocare (Yorba Linda, CA)
Steri-Oss Implant Curettes™ (Graphite) Nobel Biocare (Yorba Linda, CA)Gracey 5/6, 11/12, 13/14Sickle
Power InstrumentsQuixonic Sonic Scaler SofTip™ Dentsply Professional (York, PA)Ultrasonic Tip Tony Riso Company, LLC (Miami Beach, FL)Profin™ Dentatus USA, Ltd (New York, NY)
Prophy PasteAbutment Glo™ Implant Innovations Inc (Palm Beach Gardens, FL)ImplantCleanic® Premier Dental Products Co (King of Prussia, PA)
Debridement AidsInterdental Brushes (coated wire) John O. Butler Co (Chicago, IL)Proxi-Tip™ (no wire center) Advanced Implant Technologies (Beverly Hills, CA)
Floss MaterialsSuper Floss® Oral-B Laboratories (Belmont, CA)Thornton’s Floss Thornton International Inc (Norwalk, CT)Proxi-Floss™ Advanced Implant Technologies (Beverly Hills, CA)Post Care® John O. Butler Co (Chicago, IL)Perio-Aid® Marquis Dental Mfg (Aurora, CO)
Frequently the abutment will be completely confined
within the peri-implant crevice so that optimal aesthetics can
be achieved. This area can be deplaqued with dental floss
with the clinician adapting the floss to the restoration and
continuing into the peri-implant crevice. Perio-Aid®, a device
made of a plastic handle that holds round wooden tooth-
picks, can be utilized as well. The wooden tips are placed
in the crevice at an oblique angle and moved 360 degrees
around the abutment surface. Each tip will splay as it is
moistened by saliva, creating a more efficient surface than
a plastic curette or scaler to remove soft debris or plaque.
When calculus is present on the abutment, it must also
be removed without altering the titanium surface. The instru-
ment selection for this purpose will depend on the access,
the location, the tenacity of the calculus, and the design of
the prosthesis. Many different plastic scalers/curettes can
clean a titanium surface and maintain its integrity. The clini-
cian needs to understand the advantages/disadvantages of
each instrument in order to make the appropriate selection.
Implacare™ (Hu-Friedy, Chicago, IL) instruments are
disposable plastic tips, available in presterilized packaging,
which screw into autoclavable metal handles. Small enough
to use in the peri-implant crevice, this instrument should
be placed apical to the calculus and moved in short strokes
in a coronal direction.
While these particular instruments are effective for
light calculus and crown-and-bridge-design restorations,
they can be too flexible to remove tenacious calculus. In
cases where a mandibular hybrid denture has been placed
in a mouth with severe ridge resorption, adaptation of
these tips is difficult due to shank length.
Implant-Prophy+™ (Advanced Implant Technologies,
Beverly Hills, CA) has slightly more bulk and is more rigid
than Implacare. The advantages of these autoclavable instru-
ments are rigidity; ability to be sharpened (with a special
stone), maintaining the effectiveness of the instrument over
time; and numerous blade configurations. Suitable for mod-
erate to heavy calculus, the instrument’s variety of config-
urations allows the clinician to select the most appropriate
one. A disadvantage is the bulk of the blade, which pre-
vents its utilization in the peri-implant crevice. This can be
corrected by reduction with the sharpening stone.
Plastic scalers/curettes reinforced with graphite are
the most rigid instruments available. They can be sharp-
ened, although a dedicated stone should be utilized for
this purpose. When a stone that previously sharpened a
metal instrument comes in contact with a plastic instrument,
metal filings can be embedded into the plastic cutting
blades, which may in turn roughen the titanium surface.
Different designs of this reinforced plastic are available: a
universal curette, a hoe, and various Gracey configurations.
All of these graphite instruments can be dry-heat sterilized
or autoclaved.
The blade of the universal curette is compact, similar
to that of a metal curette. Due to its thinness and rigidity,
the instrument can break, especially when utilized on tena-
cious calculus. This particular instrument is ideal for crown-
and-bridge-design restorations and is most suitable for light
to moderate calculus.
The hoe design has more bulk and is therefore ideal
for heavy calculus deposits. Effective on mandibular hybrid
denture designs in which access is difficult (Figure 8), this
Sternberg-Smith
March /Apri l 2001 19
Figure 7. An instrument is adapted to the abutmentsurface with minimal apical pressure to precludedisrupting the junctional epithelium.
Crown
Abutment
Fixture
Figure 9. An SEM (original magnification � 500) revealsno damage to the abutment surface following utilizationof a sheathed ultrasonic tip for 25 seconds on low power.
instrument is not appropriate for traditional posterior crown-
and-bridge designs.
The Gracey graphite configurations are smaller than
the Implant-Prophy+ curette, which in some limited-access
cases is beneficial. While these instruments can be sharp-
ened using a dedicated stone, the short blade face will limit
the number of times this can be done. The small Gracey
configurations can be advantageous in the posterior regions
with traditional crown-and-bridge restorations.
Power instruments can be used to remove plaque and
calculus from the titanium abutment surface as well. A plas-
tic sonic instrument has been shown to polish the titanium
surface in addition to removing debris.10 The autoclavable
metal tip attached to a disposable plastic sheath should be
held lightly against the surface and kept constantly mov-
ing to avoid damage.16
When an ultrasonic insert with an attached plastic
sheath (Tony Riso Co, Miami Beach, FL) is utilized on low
power with copious irrigation, no damage to the titanium
surface occurs (Figure 9). The ultrasonic insert and plastic
tip can be autoclaved without damage. As the tip is small
enough to fit into the crevice of the peri-implant tissues,
this instrument is very effective where there is limited access
and heavy calculus formation (Figure 3).
The newest power instrument available for implant
debridement is the Profin™ (Dentatus®, New York, NY). It
consists of a handpiece into which disposable nylon plas-
tic points are inserted. These tips move in a linear motion
and can remove both plaque and calculus. Scanning elec-
tron microscope examination revealed no damaging effects
on a titanium abutment surface after 25 seconds of appli-
cation (Figure 10). This tip contains no metal, which allows
for adaptation to the lateral walls of the abutment and
underside of the restoration, and is small enough to fit into
the peri-implant crevice. It can be used for heavy calculus
and difficult access areas typically associated with hybrid
designs (Figure 11).
Fixture
When the implant fixture is exposed within the peri-implant
crevice or supramarginally, debridement becomes both
necessary and challenging. The macro and micro architec-
ture of the fixture surface influences the quantity of plaque
and calculus,14,15 its retention, and the instrumentation neces-
sary to remove it. Whether the surface is machined, etched,
blasted, sprayed titanium, or hydroxyapatite coated is sig-
nificant. Plastic instruments previously described have been
shown to alter the abutment surface following utilization
on the surface of an implant fixture.17
The surface coating of the implant fixture is plaque
retentive, and the calculus that forms can be very tenacious,
as clinical experience has shown. Accordingly, a metal curette
or an ultrasonic tip seems the more appropriate choice.
When the exposed implant fixture consists of machined
threads, the clinician should take care not to increase the
roughness. Although it is difficult to remove calculus from
Contemporary Implant Debridement
20 The Journal of Practical Hygiene
Figure 8. The Facial Scaler is ideal for removal of heavycalculus from mandibular anterior lingual surfaces.
the threads, this can be accomplished with one of the
power instruments with plastic tips previously described.
If only plaque is present, a soft-bristle brush can be
utilized to remove it. An end-tuft brush frequently is ideal
for this situation. This brush should be rotated in a small
circular motion around the fixture and abutment. It is much
easier to deplaque the fixture surface with a brush than
other plaque-control aids.
ConclusionImplant dentistry has demanded that practitioners acquire
new knowledge and techniques. Understanding the rela-
tionship of the peri-implant mucosa to the implant restora-
tion and the vulnerability of the tissue helps guide the
clinician in the debridement process and in the selection
of appropriate instruments. This selection should be based
on tip design and rigidity, consideration of the tenacity of
the calculus, the type of prosthesis, and the individual com-
ponent (ie, the fixture, abutment, or restoration) being
instrumented. The ultimate challenge facing the hygienist
is to preserve the bone supporting the implant.
References1. Buser D, Weber HP, Donath K, et al. Soft tissue reactions to non-
submerged unloaded titanium implants in beagle dogs. J Periodontol1992;63(3):225-235.
2. Schroeder A, van der Zypen E, Stich H, Sutter F. The reactions of bone,connective tissue, and epithelium to endosteal implants with titanium-sprayed surfaces. J Maxillofac Surg 1981;9(1):15-25.
3. Berglundh T, Lindhe J, Ericsson I, et al. The soft tissue barrier atimplants and teeth. Clin Oral Impl Res 1991;2:81-90.
Sternberg-Smith
March /Apri l 2001 21
Figure 11. The Profin™ is ideal for hybrid restorativedesigns and for the removal of heavy deposits from thefixture, abutments, and restoration.
Figure 10. An SEM (original magnification � 500) revealsno damage to the abutment surface using the Profin™with the Eva 123 tip for 25 seconds.
4. Lindhe J, Berglundh T, Ericsson I, et al. Experimental breakdown ofperi-implant and periodontal tissues. A study in the beagle dog. ClinOral Impl Res 1992;3:9-16.
5. Ericsson I, Berglundh T, Marinello C, et al. Long-standing plaque andgingivitis at implants and teeth in the dog. Clin Oral Impl Res1992;3(3):99-103.
6. Abrahamsson I, Berglundh T, Glantz PO, Lindhe J. The mucosal attach-ment at the different abutments. An experimental study in dogs. J ClinPeriodontol 1998;25(9):721-727.
7. Albrektsson T, Insidor F. Consensus report of session IV. In: Lang NP,Karring T, eds. Proceedings of the 1st European Workshop onPeriodontology. London, England: Quintessence Publishing; 1994:365-369.
8. Thomson ND, Evans GH, Meffert RM. Effects of various prophylactictreatments of titanium, sapphire, and hydroxyapatite-coated implants:An SEM study. Int J Perio Rest Dent 1989;9(4):300-311.
9. Rapley JW, Swan RH, Hallmon WW, Mills MP. The surface character-istics produced by various oral hygiene instruments and materialson titanium implant abutments. Int J Oral Maxillofac Impl 1990;5(1):47-52.
10. Gantes BG, Nilveus R. The effects of different hygiene instrumentson titanium surfaces: SEM observations. Int J Perio Rest Dent 1991;11(3):225-239.
11. Garber DA. Implants—the name of the game is still maintenance.Compend 1991;12(12):876,878,880 passim.
12. Koutsonikos A, Federico J, Yukna RA. Implant maintenance. J PracHyg 1996;5(2):11-15.
13. Orton GS, Steele DL, Wolinsky LE. Dental professional’s role in mon-itoring and maintenance of tissue-integrated prostheses. Int J OralMaxillofac Impl 1989;4(4):305-310.
14. Quirynen M, Bollen CM, Willems G, van Steenberghe D. Comparisonof surface characteristics of six commercially pure titanium abutments.Int J Oral Maxillofac Impl 1994;9(1):71-76.
15. Quirynen M, Papaioannou W, van Steenberghe D. Intraoral trans-mission and the colonization of oral hard surfaces. J Periodontol 1996;67:986-993.
16. Hollmon W, Waldrop T, Meffert R, Wade B. A comparative study ofthe effects of metallic, nonmetallic, and sonic instrumentation on tita-nium abutment surfaces. Int J Oral Maxillofac Impl 1996;11(1):96-100.
17. Rühling A, Kocher T, Kreusch J, Plagmann HC. Treatment of subgin-gival implant surfaces with Teflon®-coated sonic and ultrasonic scalertips and various implant curettes. An in vitro study. Clin Oral Impl Res1994;5:19-29.
18. Kwan JY, Zablotsky MH, Meffert RM. Implant maintenance using amodified ultrasonic instrument. J Dent Hyg 1990;64(9):422,424-425,430.
22 The Journal of Practical Hygiene
1. The soft tissue crevice around an implant islined with:A. Connective tissue.B. Gingival fibers.C. Sulcular epithelium.D. Bone.
2. What structure is absent in the soft tissuesurrounding an implant?A. Junctional epithelium.B. Periodontal ligament.C. Sulcular epithelium.D. Bone.
3. The destructive inflammatory response aroundan implant is __________ that around a tooth.A. Less than.B. Equal to.C. Unlike. D. Greater than.
4. What is the most effective way to removeplaque from the undersurface of a non-removable hybrid denture?A. Interdental brush.B. Floss.C. End tuft brush.D. All of the above.
5. Instrument selection is based on:A. The feel of the instrument.B. The component needing debridement.C. The type of instrument.D. The patient’s health history.
6. Which instrument is the most appropriate whenheavy calculus on the abutment is present andaccess is difficult? A. 4R/4L graphite instrument.B. Metal instrument.C. Hoe graphite.D. Implacare™ 4R/4L.
7. The ultrasonic insert with plastic sheath shouldbe used on a titanium abutment surface with:A. High power.B. Medium power.C. No irrigation.D. Low power.
8. What is the instrument of choice on an exposedcoated implant fixture with heavy calculus? A. Metal curette.B. Implacare™.C. Prophy+™.D. Graphite reinforced curette.
9. What is the instrument of choice when anexposed machine-threaded implant fixture hasonly plaque and soft debris?A. Plastic instrument.B. Floss.C. Perio-Aid™.D. End-tuft brush.
10. The most rigid plastic instruments are reinforcedwith the following:A. Silicone.B. Graphite.C. Metal.D. Acrylic.
To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and complete it
as follows: 1) Identify the article; 2) Place an X in the appropriate box for each question; 3) Clip the answer sheet from the page and
mail it to the CE Department at Montage Media Corporation. For further instructions, please refer to the CE Editorial Section.
Answers to the 10 multiple-choice questions for this CE exercise are based on the article “Contemporary Implant Debridement” by
Valerie Sternberg-Smith, RDH, BS and Robert N. Eskow, DMD, MScD. Answers will be mailed to all subscribers on a per test basis
within one month of the exam deadline.
WARNING: The Journal of Practical Hygiene encourages its readers to pursue further education when necessary beforeimplementing any new procedures expressed in this article. Reading an article in The Journal of Practical Hygiene doesnot fully qualify you to incorporate these new techniques or procedures into your practice.
Learning Outcomes:• Review the relationship between the peri-implant mucosa and implant-supported restorations.
• Understand the various factors that influence instrument selection for implant debridement.
• Examine the features of different instruments and consider their appropriateness for the task at hand.
CONTINUING EDUCATION (CE) EXERCISE NO. 2 CECONTINUING EDUCATION
2