Sinus Grafting with Concentrated Growth Factorsincreasingly the sinus floor elevation procedure. Method: A new and innovative tech-nique named “IPG” utilized for the place-ment

The Journal of Implant & Advanced Clinical Dentistry

Volume 6, No. 1 JaNuary 2014

Sinus Grafting with Concentrated

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The Journal of Implant & Advanced Clinical DentistryVolume 6, No. 1 • JaNuary 2014

Table of Contents

9 A Case-Study of Seven Dental Implants Placed in the Maxillary Sinus with Intentional Schneiderian Membrane Perforation Dr. Ioannis P. Georgakopoulos, Dr. Spyros N. Gialidis, Dr. Stavros Tsantis, Dr. Panagiotis Georgakopoulos, Dr. Paraskevi V. Itziou, Dr. George N. Gialidis, Dr. Ioanna Margoni

21 Laser and Air-Abrasive Therapies in the Nonsurgical Treatment of Peri-Implantitis: A Systematic Review Dr. Joannis D. Vouros, Dr. Christos Papadopoulos, Dr. George Menexes, Dr. Antonis Konstantinidis

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Table of Contents

39 Maintenance and Follow up of Dental Implants: Key to Long Term Success Dr. Sachin Mittal, Dr. Charu Gupta Mittal, Dr. Pankaj Kharade

51 The Accuracy of Casts made with and without Splinted Implant Impression Copings or Analogs Talal Alnassar, Louis DiPede, Gregory Lehnes



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Wilcko et al

Background: A growing number of eden-tulous patients are receiving treatment with dental implants. In cases of vertical alveolar ridge deficiencies of the posterior areas of the maxilla, the prevailing method of treatment is increasingly the sinus floor elevation procedure.

Method: A new and innovative tech-nique named “IPG” utilized for the place-ment of seven (7) implants in the posterior areas of the maxilla in a 50 year old female patient, is presented. The novelty of the pro-posed method is that the implants, which were placed in a flapless approach, entered both the sinus cavities with intentional perforation of the Schneiderian membrane. Concentrated

growth factors (CGF), as well as alloplas-tic bone grafting material were employed in this study, following an innovative protocol.

Results: Radiographs were examined at vari-ous stages during the process of osseointe-gration in order to assess the increase and maturation of bone structure formed around the implants and over the sinus floor. Healing was without incident and provided excellent results.

Conclusions: The promising results, derived from the “IPG” DentistEdu technique demon-strate that it can be considered as a reliable alternative to the sinus floor elevation procedure.

A Case-Study of Seven Dental Implants Placed in the Maxillary Sinus with Intentional Schneiderian Membrane Perforation

Dr. Ioannis P. Georgakopoulos1 • Dr. Spyros N. Gialidis2 • Dr. Stavros Tsantis3 Dr. Panagiotis Georgakopoulos4 • Dr. Paraskevi V. Itziou2

Dr. George N. Gialidis2 • Dr. Ioanna Margoni2

1. Department of Radiology, School of Medicine, University of Patras, 265 00 Patras, Greece

2. Dentist Education Institute, Akadimias 41, Athens 10672, Greece

3. Department of Medical Physics, School of Medicine, University of Patras, 265 00 Patras, Greece

4. University Alfonso X El Sabio, School of Dentistry, Madrid, Spain

Abstract

KEY WORDS: Dental implants, maxillary sinus, bone augmentation, membrane performation


10 • Vol. 6, No. 1 • January 2014

IntRODuCtIOnPartially or completely edentulous patients typi-cally have a preference for either tooth-supported or implant-supported fixed partial dentures. With removable dentures becoming less acceptable with modern patients, dental practitioners need considerably less effort to convince patients to receive treatment with dental implants than sev-eral years ago. In many occasions, during treat-ment planning, various procedures such as bone augmentation, bone transplantation, or both are considered necessary in order to acquire the desired alveolar ridge dimensions so as to achieve implant stability and long term aesthetic results.1

In cases of vertical alveolar ridge deficien-cies of the posterior areas of the upper jaw, either extensive bone transplantation techniques are uti-lized, or in most cases sinus floor elevation pro-cedures are undertaken in order to create the necessary bone height for implant stability to occur.2 Previous investigations have reported max-illary sinusitis in up to 20% of patients following Sinus Floor Elevation procedures (SFE).3 The most common complications of SFE procedures include disturbed and delayed wound healing, followed by haematoma, sequestration of bone, and transient maxillary sinusitis.4,5 In addition, postoperative acute maxillary sinusitis could even cause implant and graft failures. The aforemen-tioned limitations of the SFE procedures neces-sitate the implementation of new techniques that could provide us and the patient with more sta-ble and predictable results and relieve the latter from a painful and expensive surgical experience.

The rapid placement of implants in the sinus cavity with intentional perforation of the sinus membrane following a certain protocol – called the “IPG” DentistEdu technique – is introduced

in this article. The proposed technique combines the use of concentrated growth factors (CGF with stem cells CD34+), bone grafting and implant placement, in such a manner that the sinus can adapt to the new conditions and form new bone around the implants without the need to perform an SFE procedure. Implants can be placed either using a surgical approach, or by utilizing the flap-less technique which is greatly advocated by the authors and was also utilized for the patient pre-sented in this article.6 In this case-study presen-tation, seven (7) implants were placed in both sinuses followed by a radiographic (Panoramic radiography and Cone Bean Computed Tomog-raphy – CBCT scans) and clinical evaluation (by Osstell measurements) after an 8 month fol-low-up period showing good implant stability. To the best of our knowledge, the proposed tech-nique of intentional direct implant placement into the sinus with intentional sinus perforation has not been previously reported in the literature.

MAtERIAlS AnD MEthODSA 50 year old partially dentate, non-smoker female patient in good health condition and without any chronic diseases visited the Den-tist Education Institute postgraduate center in Athens–Greece, requesting an upper jaw reha-bilitation with a non-removable prosthesis. With only the anterior dentition present, the patient was having serious difficulties chewing her food. Since the patient had requested a non-remov-able prosthesis, the option of placing a total of 7 implants (4 in the left and 3 in the right side) was offered to the patient. After informing the patient in details the procedure that was going to be performed, a written consent was signed.

Cone Beam Computed Tomography (CBCT)

Georgakopoulos et al


scans confirmed the alveolar ridge deficiency in both sides with a highly resorbed and short ridge of 1–2 mm in height in the area of the upper right 1st molar (#3), and 2–3 mm in the area of the upper left 1st molar (#14), (Figure 1). Since no pathology was found in the pos-terior segments of the maxilla, the assessment of the CBCT scan allowed for a precise plan-ning of the sites for implant placement. These sites were decided to be at tooth area #5 (upper right first premolar), #4 (upper right second pre-molar), #3 (upper right first molar), #12 (upper left first premolar), #13 (upper left second pre-molar), #14 (upper left first molar), and #15 (upper left second molar). Implant placement was planned to be performed atraumatically using the flapless technique which was preferred over the traditional surgical approach in order to reduce the chance for postoperative infec-tions and provide less discomfort to the patient.7

Surgical Procedure and Concentrated Growth Factors (CGF)As part of the authors everyday clinical prac-tice for all surgical procedures, concentrated growth factors (CGF) with stem cells CD34+, in all its various forms was prepared.8 At first blood was drawn from the patient utilizing eight sterile tubes (9 ml each) and centrifuged in a special centrifuge device (Medifuge, Sil-fradent srl, St. Sofia, Italy) for approximately 13 minutes (Figure 2). For optimum quality of CGF matrices the blood samples were centri-fuged immediately after the blood was drawn. After centrifugation, in each sterile tube four components can be easily identified from top to bottom: (a) a superior phase represented by the serum (blood plasma without fibrinogen and coag-ulation factors), (b) an interim phase represented by a very large and dense polymerized fibrin buffy coat, (c) a liquid phase containing the white blood

Figure 1: Computed tomography scan of both sinuses in which the bilateral alveolar ridge deficiency is obvious.


12 • Vol. 6, No. 1 • January 2014

cells and (d) the lower red blood cell portion, a viscous and dense platelet-rich coagulation mass (Figure 3a).9 A large number of growth factors and stem cells CD34+ are aggregated in the mid-dle layer (between the dense polymerized fibrin buffy coat and the upper 3-4 mm of red blood cor-puscles mass of the bottom layer. This growth fac-tor-rich segment is separated from the rest of the red corpuscles using scissors (Figure 3b) in order to obtain the CGF-CD34+ matrix (Figure 3c).

Afterwards, Povidine-iodine solution (Beta-dine) was first employed extra-orally for disinfec-tion of the surgical site in order to reduce the probability of microbial contamination, and then

infiltration was performed using a 2% lidocaine solution containing a ratio of 1:100,000 epineph-rine. In each predetermined site, the osteotomy was extended all the way through the whole bone height available. Drilling did not stop only until the sinus membrane was intentionally per-forated. A CGF matrix, created in the previ-ous process of blood centrifugation, was then cut in half approximately. One half of the matrix was inserted through the osteotomy site and into the sinus through the membrane perforation using the fibrin injector (Silfradent-Italy – Fig-ure 4a), which proved to be a great tool for the swift insertion of the fibrin gel block (Figure 4b).

Figure 2: Special centrifuge for the preparation of CGF (Medifuge, Silfradent, Italy).

Figure 3a: Sterile tubes after centrifugation.



The remaining half of CGF matrix (highly con-centrated growth factors and stem cells) was then cut into small pieces and mixed with a small quantity of the alloplastic bone grafting mate-rial Combioss (0.5ml, by Silfradent-Italy – Figure 5a). This mixture is then placed within the oste-otomy site (Figure 5b). For faster osseointegra-tion of the implants, each implant was immersed into a Liquid Phase of the Concentrated Growth Factors (LPCGF) in order to create a “bioac-tive” membrane around it. The LPCGF was pre-pared by squeezing some of the remaining seven CGF-CD34+ matrices by means of the CGF-for-ceps (Silfradent, Italy – Figure 6a) and was col-

lected in a sterilized container. Each implant was carefully and fully immersed into the liquid phase CGF (Figure 6b). All implants were then placed using a hand wrench and the insertion torque was measured to be between 20-25 N/cm2. The low insertion torque values are expected due to the small bone heights at all the implant sites.

RESultSAll implants in-situ 8 months later are depicted in Figure 7. The proposed clinical protocol was evaluated be means of Panoramic radi-ography and CBCT scans and clinically in terms of Osstell readings and stability values.

Figure 3b: Separation of the dense platelet-rich coagulation sample from the CGF matrix using scissors.

Figure 3c: The CGF-CD34+ matrix.


14 • Vol. 6, No. 1 • January 2014

Figure 4a: Fibrin injector (Silfradent-Italy). Figure 4b: Insertion of the fibrin gel block within the osteotomy site.

Figure 5a: A mixture of highly concentrated growth factors, stem cells CD34+ and bone grafting material.

Figure 5b: Placement of the aforementioned mixture in the osteotomy site.



Radiographic EvaluationThe panoramic radiographs in Figure 8 shows the patient’s mouth before and after the implants placement following the proposed clinical protocol, whereas Figure 9 shows some of the CT scans showing new bone for-mation around the implants. The new bone formation within the sinus cavity and around the implant in tooth area #4 (middle implant in the right sinus) can be seen in Figure 10.

Clinical EvaluationFollowing implant placement, the primary stabil-ity of each implant was investigated by means of Resonance Frequency Analysis (RFA) using the Osstell device.10 The RFA technique is essentially a bending test of the bone-implant interface in which an extremely small bending force is applied by stimulating a transducer. It can provide valuable and reliable clinical infor-

Figure 6a: Process of LPCGF with CD34+ production utlizing the CGF-forceps.

Figure 6b: Implant immersions into LPCGF, towards the creation of a bioactive membrane around it.

Figure 7: Surgical site of all placed implants 8 months after.


16 • Vol. 6, No. 1 • January 2014

mation regarding the state of the bone-implant –interface since the use of the Osstell device provides the dental practitioner an Implant Stability Quotient (ISQ) value. The measure-ments can range from 0 to 100 ISQ units, where the higher the ISQ values the more stable the implant. To perform the RFA test, a

metal rod is first attached to the implant with a screw connection. The rod has a small mag-net incorporated to its top that is stimulated by magnetic pulses from a handheld electronic device. Analysis of the resonance frequency of the rod is then automatically performed by the device and an ISQ measurement is pro-

Figure 8a: Panoramic radiograph before implant placement.

Figure 8b: Panoramic radiograph after the implant placement.

Figure 9: Computed tomography scan of the surgical site 8 months after the procedure.



Figure 10a: Implant in tooth area #15 in which the ridge height did not exceed 2mm.

Figure 10b: The same site 8 months after the implant placement following the proposed protocol where the ridge now nearly covers the full length of the implant.

Figure 11: Osstell measurement.

vided (Figure 11). For all seven implants placed using the IPG-Dentist Edu technique, the ISQ range of values was between 61 and 69, which shows high stability for all implants placed.

DISCuSSIOnThe aesthetics and functional integrity of the periodontal tissues, as well as the verti-cal and horizontal dimensions of the alveo-lar processes are usually compromised following tooth loss. In such cases, various bone regenerative techniques are employed in order to restore the alveolar processes back to their original shape, allowing for a more predictable long term aesthetic and functional success of the implants placed.

For the posterior segments of the maxilla, a regenerative technique called the “sinus floor elevation procedure” (SFA), has spread widely and is taught extensively. A “sinus floor eleva-


18 • Vol. 6, No. 1 • January 2014

tion procedure” can be carried out before, or in the same day with implant placement depend-ing on each case, but nevertheless, it consti-tutes a more complex treatment plan and an unpleasant and longer surgical procedure for both the surgeon and the patient. Moreover, the predictability of the treatment outcome also depends on the operator’s experience performing this technically demanding surgi-cal procedure. Sinus elevation procedures also increase both the cost and time required for completion of each case. Despite the pro-found drawbacks, this procedure is generally accepted by patients when they are informed that it is the only way for the posterior areas of the maxilla to be restored with a functional and easily adaptable non-removable prosthesis. Without doubt, patients do not consider SFA as a “minor procedure” and probably would have chosen an alternative non-surgical, non-invasive and painless option if it was offered to them.

The IPG DentistEdu technique described in this study, involves the utilization of bone grafting material, implant placement and con-centrated growth factors-CGF (with stem cells CD34+) into the intentionally perforated sinus membranes. This allowed for all implants to be placed atraumatically in both sides of the max-illa and with no sinus elevation procedure. This protocol has demonstrated stable and reliable results with very high implant success rates. The IPG DentistEdu technique has proven to be an absolutely safe procedure without any what-so-ever post-operative complications. Neither of the sinuses presented any signs of infec-tion that affected the well-being of the patient.

Anchorage of the CGF matrix in the sinuses is achieved by platelets released after the

penetration and slight haemorrhage of the sinus membranes. Platelets also found in the CGF matrix allow for anchorage on the sur-face that they are placed on, or at the area where there is trauma. Therefore, when the CGF matrix is placed in the sinus cavities it will not be displaced away from where it is originally placed, forcing the bone to regen-erate locally and around the implants. Dur-ing new bone formation in the sinus cavities following sinus membrane penetration, it is believed by the authors, that the sinus mem-brane slowly repairs itself and covers the for-mer, while any parts of the sinus membrane under the bone grafting material slowly resorbs.

A metal-acrylic fixed partial denture (with an acrylic masticatory surface) was fabricated, and was preferred over a metal-ceramic because the masticatory forces are generally absorbed better. The fixed partial denture was inserted about 9 months after implant placement in order to allow enough time for new bone growth to occur around the implants. It is believed that a shorter osseointegration period before implant loading could be equally successful in simi-lar cases. Future case studies and research will provide us with the important informa-tion of the minimum amount of time that must be allowed before uncovering the implants. Future studies are also required to determine whether the observed augmentation in bone height will be maintained over the long term or, if there will be bone loss due to remodelling.

COnCluSIOnThe results of the proposed IPG Dentist-Edu technique support the concept of a one-stage, flapless implant placement with



intentional sinus membrane perforation when-ever there is ridge-height deficiency. It must be emphasized that the protocol should be carefully and precisely executed if the desired results are to be expected. There-fore, it is the authors’ belief, that adequate training on how to perform this technique has been completed first, before any attempt is made in utilizing this technique on patients. ●

Correspondence:

Dr. Stavros Tsantis

Department of Medical Physics, School of

Medicine, University of Patras, 265 00 Patras,

Greece

Email: [email protected], [email protected]

Tel.: +30 6977635864

Fax: +30 2132028608

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

References1. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in

the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants 2004;19 Suppl:43-61.

2. Santagata M, Guariniello L, Rauso R, Tartaro G. Immediate loading of dental implant after sinus floor elevation with osteotome technique: a clinical report and preliminary radiographic results. J Oral Implantol. 2010;36(6):485-9.

3. Summers RB. The osteotome technique: Part 3--Less invasive methods of elevating the sinus floor. Compendium 1994 Jun;15(6):698, 700, 702-4 passim; quiz 710.

4. Timmenga NM, Raghoebar GM, Boering G, van Weissenbruch R. Maxillary sinus function after sinus lifts for the insertion of dental implants. J Oral Maxillofac. Surg. 1997;55:936–939.

5. Timmenga NM, Raghoebar GM, van Weissenbruch R, Vissink A. Maxillary sinusitis after augmentation of the maxillary sinus floor: a report of 2 cases. J Oral Maxillofac Surg. 2001;59:200–204.

6. Campelo LD, Camara JR Flapless implant surgery: a 10-year clinical retrospective analysis. The International Journal of Oral & Maxillofacial Implants 2002; 17(2):271-276.

7. Toffler M. Minimally invasive sinus floor elevation procedures for simultaneous and staged implant placement. N Y State Dent J 2004 Nov;70(8):38-44.

8. Rodella LF, Favero G, Boninsegna R, Buffoli B, Labanca M, Scarì G, Sacco L, Batani T, Rezzani R. Growth Factors, CD34 positive cells and fibrin network analysis in concentrate growth factors fraction. Microsc Res Tech. 2011 Aug;74(8):772-7

9. Sohn DS, Heo JU, Kwak DH, Kim DE, Kim JM, Moon JW, Lee JH, Park IS. Bone regeneration in the maxillary sinus using an autologous fibrin-rich block with concentrated growth factors alone. Implant Dent. 2011 Oct;20(5):389-95.

10. Sennerby L, Meredith N. Implant stability measurements using resonance frequency analysis: biological and biomechanical aspects and clinical implications. Periodontol 2000 2008;47:51-66.

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Wilcko et al

Background: Numerous clinical trials and sys-tematic reviews have observed that mechanical debridement does not seem to be efficient in the treatment of peri-implantitis lesions. New tech-nology methods like air-abrasive devices and lasers have been proposed for biofilm removal and decontamination of implant surfaces. The aim of the present systematic review was to evaluate the effectiveness of lasers and air-abrasive methods when used as a monotherapy in the nonsurgical treatment of periimplantitis.

Material and methods: An electronic search, together with a complemented man-ual search, was conducted until March 2013 to identify available studies published in Eng-lish. A three-stage screening process was performed independently and in duplicate.

Results: The search strategy revealed 771 potentially relevant titles and sequential screen-

ing identified 5 articles fulfilling the inclusion criteria. Er:Yag laser irradiation and submuco-sal air-abrasion with glycin powder resulted in a more pronounced short-term reduction of bleeding on probing in periimplantitis lesions compared to mechanical debridement with plastic curettes and chlorhexidine (CHX). No significant differences were detected for any of the other investigated outcome variables between mechanical debridement followed by CHX and air-abrasion or Er:YAG laser.

Conclusions: ER:Yag laser, air-abrasion and mechanical debridement followed by CHX application seem equally efficacious in improv-ing clinical parameters in peri-implantitis cases. A trend for a significant reduction of bleed-ing tendency was observed after laser and air-polishing therapies over the traditional plastic curettes debridement. However this improve-ment was sustained for only a short time period.

Laser and Air-Abrasive Therapies in the Nonsurgical Treatment of Peri-Implantitis:

A Systematic Review

Dr. Joannis D. Vouros1 • Dr. Christos Papadopoulos1 Dr. George Menexes2 •Dr. Antonis Konstantinidis2

1. Department of Preventive Dentistry, Periodontology & Implant Biology, School of Dentistry, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece

2. Faculty of Agriculture, Laboratory of Agronomy, Aristotle University, 54124 Thessaloniki, Greece

Abstract

KEY WORDS: Orthodontics, periodontics, osteopenia, bone graft


22 • Vol. 6, No. 1 • January 2014

IntRODuCtIOnOver the last 30 years, restoration with den-tal endosseous implants has become a widely accepted treatment modality for the replace-ment of missing teeth with successful func-tional and esthetic results. A key factor for the long-term success of dental implants is the maintenance of healthy soft and hard peri-implant tissues since the microbial colonization of implant surfaces can lead to inflammatory changes in the surrounding tissues resembling the periodontal inflammatory conditions.1 Peri-implant mucositis is the reversible inflammatory reaction of the mucosa around dental implants while peri-implantitis is the inflammatory pro-cess affecting both soft and hard peri-implant tissues that results in the loss of supporting alveolar bone.1,2 The prevalence of peri-implant mucositis is approximately 80% on a subject and 50% on an implant basis while peri-implan-titis affects 28-56% of subjects and 12-43% of the implant sites.2-4 This has resulted in a number of treatment modalities being inves-tigated for the treatment of peri-implantitis.

Removal of the established bacterial bio-film from the implant surface is considered an essential factor in controlling peri-implant dis-eases5 and several anti-infective therapeu-tic approaches have been suggested for the resolution of inflammation in peri-implant tis-sues. A systematic review on the efficacy of anti-infective protocols for the treatment of peri-implantitis including 21 clinical and ani-mal studies reported the low methodologi-cal quality of the available publications and pointed out the lack of controlled clinical trials.6

More recent systematic reviews have dis-cussed the inadequacy of standard submuco-

sal mechanical debridement in the resolution of peri-implantitis and reported limited short-term clinical improvements with laser ther-apy.7-9 The apparent limitations of mechanical debridement in the treatment of peri-implantitis is attributed to the insufficiency of plastic, tita-nium, or carbon curettes to remove organized bacterial biofilms from threaded rough implant surfaces.9-12 However, the adjunctive use of chemical agents including local delivery of dis-infectants and local or systemic antibiotics seemed to improve bleeding on probing (BOP) and probing depth (PD).9,13-15 The drawbacks of mechanical debridement have spurred interest over the years in other nonsurgical therapeutic modalities for the treatment of peri-implantitis.

New air-abrasive devices have been used for biofilm removal from both infected tooth16 and implant surfaces.17 In these, glycine pow-der and water are sprayed under pressure via a thin flexible plastic nozzle onto the sub-mucosal environment. A recent report has confirmed the safety of this method and indi-cated an efficacy comparable to mechani-cal instrumentation when applied on teeth.18

Laser therapy is another therapeutic option for decontaminating both implant surfaces and peri-implant tissues. Diode, CO2, and erbium-doped yttrium, aluminum, and gar-net (Er:YAG) lasers are suitable for implant irradiation because the degree of energy absorption by titanium is low, and there is no significant temperature increase of the implant body.19-22 Whereas electron micros-copy has revealed extensive melting of the tita-nium surface with neodymium-doped:yttrium, aluminum, and garnet (Nd:YAG) laser appli-cation.19 Er:YAG and CO2 lasers exhibit

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bactericidal effects on implant surfaces in vitro without this drawback. In contrast to diode and CO2 lasers, the ability of Er:YAG laser to effectively ablate calculus from tita-nium surfaces has been demonstrated.23

The aim of the present study was to sys-tematically review the available dental lit-erature in order to critically evaluate the effectiveness of laser and air-abrasive therapies in the non-surgical treatment of peri-implantitis.

MAtERIAl AnD MEthODSStudy Design A comprehensive protocol was developed and approved by all the authors as an essen-tial part of the present systematic review. The detailed protocol clarified all aspects of the systematic review including the focused ques-tion, search strategy, inclusion/exclusion cri-teria, screening methodology, data extraction, outcome measures, data analysis/synthesis, and quality assessment of the included studies.

Focused QuestionWhat is the efficacy of Er:YAG laser and air-abrasive devices when used as a monotherapy in the nonsurgical treatment of peri-implanti-tis compared to each other and with standard submucosal mechanical debridement com-bined with chlorhexidine (CHX) application?

Search StrategyAn electronic search on MEDLINE (PubMed) was conducted from 1966 up to and including the 30th of March 2013 using a combination of MeSH terms and text words. The following key-words/search terms and their synonyms limited to clinical human studies were combined as

Population AND Intervention AND Outcome as follows: peri-implantitis OR peri implantitis OR peri-implant$ OR peri-implant infection OR peri-implant defect OR peri-implantitis treatment

AND non-surgical therapy OR non surgi-cal therapy OR non-surgical treatment OR non surgical treatment OR mechanical disinfec-tion OR mechanical treatment OR mechani-cal debridement OR ultrasonic treatment OR ultrasonic therapy OR carbon curette treat-ment OR plastic curette treatment OR car-bon curette therapy OR plastic curette therapy OR laser$ OR laser treatment OR Er:Yag laser OR Er-Yag laser OR Er: Yag laser OR air abrasion OR air abras$ OR air flow OR air-flow OR perio flow OR perio-flow OR amino acid glycin OR glycin powder

AND failing implant OR surviving implant OR implant failure OR implant loss OR implant survival OR alveolar bone loss OR bone resorption OR bone remodeling OR bone fill OR radiographic bone fill OR prob-ing pocket depth OR clinical attachment level.

In addition, a search by hand of the follow-ing peer-reviewed dental journals was per-formed from January 2002 to March 2013 for relevant publications: Clinical Oral Implants Research, the International Journal of Oral and Maxillofacial Implants, International Journal of Oral and Maxillofacial Surgery, Oral surgery Oral medicine Oral pathology Oral Radiology and Endodontics, The International Journal of Periodontics and Restorative Dentistry, The International Journal of Prosthodontics, The Journal of the American Dental Association, Journal of Prosthodontics, Journal of Clinical Periodontology, and Journal of Periodontology.

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Inclusion Criteria● Articles published in peer-reviewed journals in

the English language.● Human clinical prospective studies including

randomized controlled trials (RCTs), controlled clinical trials (CCTs), and cohort studies report-ing on patients treated for peri-implantitis with at least one of the three investigated therapeutic methods used as monotherapy.

● Controlled human studies had to report on at least 10 participating patients per treatment group and a follow up period of at least 3 months for all patients.

● Case series reporting on at least 10 con-secutive patients were also included.

● Only studies utilizing screw-type titanium endosseous dental implants with various surface modifications were included in the present systematic review.

Exclusion Criteria● Studies reporting on implants placed simul-

taneously or following any form of hard or soft tissue augmentation procedures.

● Case reports, reviews, editorials, and retrospective studies.

● Studies with patients suffering from medi-cal conditions affecting implant therapy.

● Studies with implants placed in extraoral sites.● Studies reporting on the treatment of peri-

implantitis with local or systemic antibiotics.

SElECtIOn OF StuDIES AnD DAtA ExtRACtIOn

A three-stage screening process was per-formed independently by two independent reviewers (GM and CP) to increase the accu-racy of the procedure (Fig. 1). In the first stage,

the reviewers screened all the retrieved titles and excluded irrelevant and duplicate publica-tions. Screening of the accepted publications at the abstract level was based on the num-ber of patients, nature of the study, interven-tion and outcome characteristics. The third stage involved full-text reading and indepen-dent assessment by both reviewers utilizing a specially constructed data extraction form. During each stage, all disagreements were resolved by discussion and when no consen-sus was achieved, a third reviewer was con-sulted (IV). The level of agreement between the examiners for each screening stage was assessed by using the k-score. Whenever required, the corresponding author of the included articles was contacted by email for fur-ther clarifications or to obtain unpublished data.

types of InterventionThe following methods were considered for the non-surgical treatment of peri-implantitis: (a) ER:YAG laser and (b) air-abrasion ther-apy. These therapeutic approaches were con-sidered monotherapies and were performed without the utilization of surgical procedures.

types of Outcome MeasuresThe primary outcome variable in the present sys-tematic review was the PD changes observed around dental implants after the therapeutic inter-ventions being investigated. Changes of BOP, clinical attachment level (CAL), mucosal reces-sion (MR), and Plaque Index (PI) were considered as secondary outcomes. The outcome measures analysis was patient based on the qualification that the available data were processed accord-ingly by the authors of the included studies.

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Confounding FactorsAdjustment for a series of potential confound-ing factors such as smoking, medical his-tory and periodontal status in the original data analyses of the included trials has also been evaluated in the current systematic review.

Quality AssessmentMethodological quality assessment of the included studies was carried out independently by two reviewers (IV and CP). This assessment regarding RCTs was based on the recommen-dations of the CONSORT-statement24 and the criteria set by Esposito et al.25, taking into con-sideration seven basic criteria including sample size calculation, adequate statistical analysis, definition of inclusion/exclusion criteria, random-ization and allocation concealment, blindness of examiners, similarity of baseline character-istics between groups, and completeness of follow-up. Each study included in this system-atic review was assigned with a high, low, or medium risk of bias score depending on the quality assessment criteria fulfilled by each trial.

RESultSA total of 771 articles were identified by the electronic search on PubMed MEDLINE. The manual search did not retrieve any addi-tional publications. Screening of the titles provided 42 potentially relevant publications and abstract reading yielded 10 papers. At the final full-text stages of screening 5 stud-ies met the predetermined selection criteria and were included in the systematic review (Fig. 1). The inter-rater kappa values were 0.85 at the title level, 0.93 at the second stage, and 1.00 for the full-text evaluation with “good”

agreement between the reviewers for all the sequential steps of the literature search.26

From the 5 RCTs included in the pres-ent systematic review 2 compared Er:YAG laser therapy with mechanical debridement and the local application of CHX,27,28 2 com-pared Er:YAG laser with air-abrasion using gly-cine,29,30 and 1 study evaluated the efficacy of mechanical debridement and the local applica-tion of CHX against air-abrasion treatment.31 However, the 2 publications comparing Er:YAG

Figure 1: Flowchart of literature search and selection of relevant clinical trials.

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laser with air-abrasion reported clinical29 and microbiological30 outcomes on identical patient populations. Hence, only the clinical results from the Renvert et al. study29 were eventually considered in the present systematic review. The 3 RCTs27,28,31 were conducted by the same clinical group in Germany, while 2 RCTs 29,30 were performed by another group in Sweden.

Population and Intervention Characteristics (table 1)Overall, 215 implants with peri-implantitis

were treated with the three modes of ther-apy in the 4 RCTs 27-29, 31 included in this sys-tematic review. These implants were placed in 114 patients, 46 men and 68 women with a mean age ranging from 48 to 68.9 years between studies. In one study 2 patients were lost to follow-up, reducing the total number of participating patients to 112.31

The following 8 different implant systems were involved in the 5 publications that ful-filled the inclusion criteria of this system-atic review: Brånemark, Camlog, Frialit, IMZ,

Implant Type of Study Therapeutic # of Mean Age Manufacturer Implant peri-implant Clinical Follow-up Study Desgn Country Procedures Participants Gender (years) and surface Distribution Lesions Parameters (months)

Schwarz et al. 2005 RCT Germany Exp: Er:YAG Laser Exp: 10 Pts/116imp 12M, 8 W Exp: 48 SLA, TPS Exp: 9, SLA 7 TPS Moderate to PI, BOP, MR, 3, 6 Parallel Ctr: DBR/CHX 0.2% Ctr: 10 Pts/16 IMP Ctr: 51 Ctr: 8 SLA, 8 TPS Advanced PD, CAL

Schwarz et al. 2006a IMZ (SLA) Exp: 2, Ctr: 2 Exp: Er:YAG laser Exp: 10 pts/20imp Exp: 4 M, 6 W Exp: 56±14 Straumann (SLA, TPS) Exp: 6, Ctr: 2 a) moderate PI, BOP, MR RCT Germany Spine Twist (SLA) Exp: 6, Ctr: 8 b) advanced , PD, CAL 3, 6, 12 Parallel Ctr: DBR/CHX 0.2% Ctr: 10 Pts/20 Imp Ctr: 5M, 5W Ctr: 52±11 Carniog (SLA) Exp: 2, Ctr: 4 ZL-Duraplant (anodized) Exp: 4, Ctr:8

Renvert et al. 2011 RCT Sweden Exp: Er: YAG laser Exp: 21 Pts/55 Imp 13 M, 29 W Exp: 68.5±6.4 MAC, MED Exp: 41 MAC, 14 MED Severe PI, BOP, PD, 6 (Persson et al. 2011) Parallel Ctr: Air-abrasion Ctr: 21 Pts/45 Imp Ctr: 68.9±12.5 Ctr: 29 MAC, 16 MED suppuration, on bone level changes

Sahm et al. 2011 Branemark (MAC) Exp: 2, Ctr: 4 Exp: Air-abrasion Exp: 15 Pts/29 Imp Carnlog (SLA) Exp: 5, Ctr: 7 Frialift (SLA) Exp: 2, Ctr: 0 Initial to PI, BO{, MR 3, 6 RCT Germany Ctr: DBR/CHX 0.2% Ctr: 15 Pts/20 Imp 12 M, 20 W 60.6±38.6 Straumann (SLA) Exp: 5, Ctr: 4 moderate PD, CAL Parallel Screw Vent Exp: 6, Ctr: 3 (Microrough) Non-indentifiable Exp: 6, Ctr: 2

RCT: controlled clinical trial, Exp: experimental, Ctr: control, Pts: patients, Imp: Implants, M: men, W: women, DBR: mechanical debridement, CHX: chlorhexidine, SLA: sand-blasted and acid-etched, TPS: titanium plasma sprayed MAC: machined surface, MED: medium rough surface, PI: plaque index, BOP: bleeding or probing, MR: mucosal recession, PD: probing depth, CAL: clinical attachement

Table 1: Trial, Population, and Intervention Characteristics of the Clinical Trials Included in the Systematic Review.

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Screw Vent, Spline Twist, Straumann, and ZL-Duraplant. These implant systems pre-sented with a diverse surface microarchitec-ture including the machined, sand-blasted and acid-etched, titanium plasma sprayed, and anodized surfaces ranging from smooth, to medium-rough, to micro-rough topography.

Peri-implant lesions were moderate to advanced (PD 5,4-5,9mm) in one article,27 ini-tial to moderate (PD 3,8-4,0mm) in another one trial,31 and severe (5,9-6,2 mm) in another study.29 Finally, in one trial peri-implant lesions were

grouped into moderate or advanced based on initial PD and radiographic marginal bone loss.28

In 2 RCTs mechanical debridement of peri-implant defects with plastic curettes followed by CHX irrigation was compared with Er:YAG laser irradiation.27,28 The remaining 2 RCTs com-pared air-abrasion with glycine powder against Er:YAG laser29 and nonsurgical debridement in combination with local use of CHX.31 The follow-up period was 6 months for most tri-als.27,29,31 One study with 20 implants in each experimental group reported 1-year results.28

Implant Type of Study Therapeutic # of Mean Age Manufacturer Implant peri-implant Clinical Follow-up Study Desgn Country Procedures Participants Gender (years) and surface Distribution Lesions Parameters (months)

Schwarz et al. 2005 RCT Germany Exp: Er:YAG Laser Exp: 10 Pts/116imp 12M, 8 W Exp: 48 SLA, TPS Exp: 9, SLA 7 TPS Moderate to PI, BOP, MR, 3, 6 Parallel Ctr: DBR/CHX 0.2% Ctr: 10 Pts/16 IMP Ctr: 51 Ctr: 8 SLA, 8 TPS Advanced PD, CAL

Schwarz et al. 2006a IMZ (SLA) Exp: 2, Ctr: 2 Exp: Er:YAG laser Exp: 10 pts/20imp Exp: 4 M, 6 W Exp: 56±14 Straumann (SLA, TPS) Exp: 6, Ctr: 2 a) moderate PI, BOP, MR RCT Germany Spine Twist (SLA) Exp: 6, Ctr: 8 b) advanced , PD, CAL 3, 6, 12 Parallel Ctr: DBR/CHX 0.2% Ctr: 10 Pts/20 Imp Ctr: 5M, 5W Ctr: 52±11 Carniog (SLA) Exp: 2, Ctr: 4 ZL-Duraplant (anodized) Exp: 4, Ctr:8

Renvert et al. 2011 RCT Sweden Exp: Er: YAG laser Exp: 21 Pts/55 Imp 13 M, 29 W Exp: 68.5±6.4 MAC, MED Exp: 41 MAC, 14 MED Severe PI, BOP, PD, 6 (Persson et al. 2011) Parallel Ctr: Air-abrasion Ctr: 21 Pts/45 Imp Ctr: 68.9±12.5 Ctr: 29 MAC, 16 MED suppuration, on bone level changes

Sahm et al. 2011 Branemark (MAC) Exp: 2, Ctr: 4 Exp: Air-abrasion Exp: 15 Pts/29 Imp Carnlog (SLA) Exp: 5, Ctr: 7 Frialift (SLA) Exp: 2, Ctr: 0 Initial to PI, BO{, MR 3, 6 RCT Germany Ctr: DBR/CHX 0.2% Ctr: 15 Pts/20 Imp 12 M, 20 W 60.6±38.6 Straumann (SLA) Exp: 5, Ctr: 4 moderate PD, CAL Parallel Screw Vent Exp: 6, Ctr: 3 (Microrough) Non-indentifiable Exp: 6, Ctr: 2

RCT: controlled clinical trial, Exp: experimental, Ctr: control, Pts: patients, Imp: Implants, M: men, W: women, DBR: mechanical debridement, CHX: chlorhexidine, SLA: sand-blasted and acid-etched, TPS: titanium plasma sprayed MAC: machined surface, MED: medium rough surface, PI: plaque index, BOP: bleeding or probing, MR: mucosal recession, PD: probing depth, CAL: clinical attachement

Table 1: Trial, Population, and Intervention Characteristics of the Clinical Trials Included in the Systematic Review.

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Outcome Variables (table 2)The primary and secondary outcome vari-ables were provided in most studies incor-porated in this systematic review. However, in 2 instances the first author was contacted electronically in order to obtain primary data

in the form of mean ± SD.28,29 In the Schwarz et al. trial,28 only data from the advanced peri-implantitis lesions were incorporated in Table 2.

Implant Therapeutic Study Survival Procedure PI BOP MR PD CAL

Schwarz et al. Exp 0m: 1.1 ± Exp 0m: Exp 0m 0.4 ± Exp 0m: 5.4 ± Exp 0m: 5.8 ± Exp: Exp: Er YAG Exp 3m: 1.1 ± Exp 3m: Exp 3m 0.5 ± Exp 3m: 4.6 ± Exp 3m: 5.1 ± Exp 6m: 1.1 ± Exp 6m: Exp 6m 0.5 ± Exp 6m: 4.6 ± Exp 6m: 5.1 ± Ctr 0m: 1.1 ± Ctr 0m: Ctr 0m 0.7 ± Ctr 0m: 5.5 ± Ctr 0m: 6.2 ± Ctr: DBR/CHX Ctr 3m: 1.2 ± Ctr 3m: Ctr 3m 0.8 ± Ctr 3m: 4.9 ± Ctr 3m: 5.7 ± Ctr 6m: 1.0 ± Ctr 6m: Ctr 6m 0.8 ± Ctr 6m: 4.8 ± Ctr 6m: 5.6 ±

Schwarz et al. Exp 0.9 ± Exp 79.9 ± Exp 0.5 ± Exp 5.9 ± Exp 6.5 ± Exp: Exp: Er YAG Exp 0.9 ± Exp 41.6 ± Exp 0.9 ± Exp 3m:2 ± Exp 6.1 ± (advanced) Exp 0.9 ± Exp 39.9 ± Exp 6m ± Exp 5.2 ± Exp 6.1 ± Exp 1.4 ± Exp 12m: 55.0 ± Exp 0.9 ± Exp 5.4 ± Exp 6.3 ± Ctr 0.8 ± Ctr 88.3 ± Ctr 0.6 ± Ctr 5.9 ± Ctr 6.5 ± Ctr: DBR/CHX Ctr 0.7 ± Ctr 56.6 ± Ctr 0.7 ± Ctr 5.3 ± Ctr 6.1 ± (advanced) Ctr 0.8 ± Ctr53.3 ± Ctr 0.7 ± Ctr 5.4 ± Ctr 6.2 ± Ctr 1.3 ± Ctr 66.6 ± Ctr 0.7 ± Ctr 5.5 ± Ctr 6.3 ±

Renvert et al. Exp 0.3 ± Exp 0m: 5 ± Exp 5.9 ± Persson et al. 100 Exp: Er YAG Exp 0.2 ± Exp 6m: ± Exp 5.4 ± Ctr 0.2 ± Exp 0m: 5 ± N Ctr 6.2 ± 100 Ctr: Air- Ctr 0.1 ± Exp 6m: ± Ctr 5.5 ±

Sahm et al. Exp 1.2 ± Exp 94.6 ± Exp Om: ± Exp 3.8 ± Exp 4.8 ± Exp: Exp: Air- Exp 1.0 ± Exp 43.0 ± Exp 1.1 ± Exp 3m: ± Exp 4.1 ± Exp 1.1 ± Exp 51.1 ± Exp 1.2 ± Exp 3.2 ± Exp 4.4 ± Ctr 0m: 1.0 ± Ctr 0m: 95.3 ± Ctr 0m: 0.7 ± Ctr 0m: 4.0 ± Ctr 0M: 4.8 ± Ctr: Ctr: DBR/CHX Ctr 3m: 0.8 ± Ctr 3m: 70.4 ± Ctr 3m: 0.7 ± Ctr 3m: 3.2 ± Ctr 3m: 4.0 ± Ctr 6m: 0.8 ± Ctr 6m: 84.3 ± Ctr 6m: 0.7 ± Ctr 6m: 3.5 ± Ctr 6m: 4.3 ±

Exp: experimental, Ctr: control, DBR: mechanical depridement, CHX; chlorhexidine, PI: plaque index, BOP: bleeding on, MR: mucosal recession, PD: probing depth, CAL: attachment level, N: not applicable, month*, **: statistically significant difference between experimental and control

Table 2: Outcome Characteristics of the Clinical Studies Included in the Systematic Review

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Er:Yag laser versus Mechanical Debridement and ChlorhexidineTwo studies fulfilled the inclusion criteria and were considered for assessment of the treatment out-come.27,28 Even though both trials were conducted by the same research group, they provided suffi-cient information on randomization, allocation con-

cealment and blinding of the operators. One study reported clinical parameters 3 and 6 months after treatment and the other after 3, 6, and 12 months. A statistically significant greater reduction of BOP was detected 3 and 6 months following laser irradiation treatment in comparison to plastic curettes debridement combined with CHX (Table 2). Nevertheless a relapse of the initially improved BOP was recorded at the 12- month examina-tion, leading to similar long term values for both treatment modalities. All other clinical parameters showed a similar improvement at 3- an 6 months for both laser therapy and the conventional mechanical debridement followed by CHX.27,28

Air Abrasion versus Mechanical Debridement and ChlorhexidineOnly one study compared the clinical outcome after submucosal air abrasion with glycin powder against the standard plastic curettes debride-ment of periimplantitis lesions.31 At the 3- and 6 month examination a marked decrease of BOP values was observed for the air abrasion group in comparison to the mechanical debridement and CHX. PD and CAL values improved simi-larly for both investigated treatment modalities.

ER:Yag laser versus Air ArasionAs mentioned above two publications reporting on the efficacy of Er:Yag laser against submucosal air abrasion with glycin powder on peri-implantitis lesions were retrieved. However, the two articles were presenting clinical data of the same patient population, so only one trial29 was incorporated in the present systematic review. Both approaches resulted in a reduction of both BOP and PD val-ues 6 months after therapy without a significant difference between treatment groups. In the

Implant Therapeutic Study Survival Procedure PI BOP MR PD CAL

Schwarz et al. Exp 0m: 1.1 ± Exp 0m: Exp 0m 0.4 ± Exp 0m: 5.4 ± Exp 0m: 5.8 ± Exp: Exp: Er YAG Exp 3m: 1.1 ± Exp 3m: Exp 3m 0.5 ± Exp 3m: 4.6 ± Exp 3m: 5.1 ± Exp 6m: 1.1 ± Exp 6m: Exp 6m 0.5 ± Exp 6m: 4.6 ± Exp 6m: 5.1 ± Ctr 0m: 1.1 ± Ctr 0m: Ctr 0m 0.7 ± Ctr 0m: 5.5 ± Ctr 0m: 6.2 ± Ctr: DBR/CHX Ctr 3m: 1.2 ± Ctr 3m: Ctr 3m 0.8 ± Ctr 3m: 4.9 ± Ctr 3m: 5.7 ± Ctr 6m: 1.0 ± Ctr 6m: Ctr 6m 0.8 ± Ctr 6m: 4.8 ± Ctr 6m: 5.6 ±

Schwarz et al. Exp 0.9 ± Exp 79.9 ± Exp 0.5 ± Exp 5.9 ± Exp 6.5 ± Exp: Exp: Er YAG Exp 0.9 ± Exp 41.6 ± Exp 0.9 ± Exp 3m:2 ± Exp 6.1 ± (advanced) Exp 0.9 ± Exp 39.9 ± Exp 6m ± Exp 5.2 ± Exp 6.1 ± Exp 1.4 ± Exp 12m: 55.0 ± Exp 0.9 ± Exp 5.4 ± Exp 6.3 ± Ctr 0.8 ± Ctr 88.3 ± Ctr 0.6 ± Ctr 5.9 ± Ctr 6.5 ± Ctr: DBR/CHX Ctr 0.7 ± Ctr 56.6 ± Ctr 0.7 ± Ctr 5.3 ± Ctr 6.1 ± (advanced) Ctr 0.8 ± Ctr53.3 ± Ctr 0.7 ± Ctr 5.4 ± Ctr 6.2 ± Ctr 1.3 ± Ctr 66.6 ± Ctr 0.7 ± Ctr 5.5 ± Ctr 6.3 ±

Renvert et al. Exp 0.3 ± Exp 0m: 5 ± Exp 5.9 ± Persson et al. 100 Exp: Er YAG Exp 0.2 ± Exp 6m: ± Exp 5.4 ± Ctr 0.2 ± Exp 0m: 5 ± N Ctr 6.2 ± 100 Ctr: Air- Ctr 0.1 ± Exp 6m: ± Ctr 5.5 ±

Sahm et al. Exp 1.2 ± Exp 94.6 ± Exp Om: ± Exp 3.8 ± Exp 4.8 ± Exp: Exp: Air- Exp 1.0 ± Exp 43.0 ± Exp 1.1 ± Exp 3m: ± Exp 4.1 ± Exp 1.1 ± Exp 51.1 ± Exp 1.2 ± Exp 3.2 ± Exp 4.4 ± Ctr 0m: 1.0 ± Ctr 0m: 95.3 ± Ctr 0m: 0.7 ± Ctr 0m: 4.0 ± Ctr 0M: 4.8 ± Ctr: Ctr: DBR/CHX Ctr 3m: 0.8 ± Ctr 3m: 70.4 ± Ctr 3m: 0.7 ± Ctr 3m: 3.2 ± Ctr 3m: 4.0 ± Ctr 6m: 0.8 ± Ctr 6m: 84.3 ± Ctr 6m: 0.7 ± Ctr 6m: 3.5 ± Ctr 6m: 4.3 ±

Table 2: Outcome Characteristics of the Clinical Studies Included in the Systematic Review

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30 • Vol. 6, No. 1 • January 2014

other publication, which was finally not included in this systematic review, microbiological out-comes of the two therapeutic approaches were presented. Lower counts of the potential patho-gens Pseudomonas aeruginosa, Staphylococcus aureus, and Staphylococcus anaerobius were detected in the air-abrasive group one month after therapy while reduced levels of Fusobacterium nucleatum were reported in the laser group.30

ComplicationsIn one study, 1 patient with 2 implants treated with mechanical debridement was dropped from the study because of persisting puru-lent discharge, 2 months after the interven-tion.27 For the same reason, 2 patients with 4 implants were withdrawn from the con-trol debridement group in another study.28

In one case, the application of the laser resulted in perforation of the buc-cal keratinized peri-implant mucosa.28 Heal-ing was uneventful after suturing but was

associated with an increased soft tissue reces-sion. In all other cases, the post-treatment period was generally uneventful for all the ther-apeutic approaches considered in this sys-tematic review without complications such as allergic reactions, swellings, abscesses or infections.

Subgingival application of glycine powder under pressure for the treatment of 68 implants with peri-implantitis in 36 patients was not asso-ciated with emphysema formation indicating a low risk for air embolism by air-abrasive treat-ment.29,31 However, timing of the instrumenta-tion with air-abrasive devices was according to the recommendations of the manufacturer.

Methodological Quality AssessmentData on the fulfillment of quality assessment criteria by the studies included in this system-atic review are critically presented in Table 3. The reviewers agreed that 2 studies27,28 were at medium risk of bias because they did not provide information on the sample size cal

Adequate Inclusion Randomization Completemess Sample Statistical Exclusion & Group of Estimate Calculation Analysis Criteria Concealment Maskin Standardization Followers Risk Study Study (0- (0- (0- (0- (0- (0- (0- of

Schwarz et al. RCT, 0 2 1 3 2 2 1 Medium


Renvert et al. RCT, 2 2 1 3 2 2 1 Low Persson et al.

Sahm et al. RCT, 2 2 2 1 3 2 2 1 Low

The score range for each quality assessment criterion is provided within parentheses in the respective column headings controlled clinical trial.

Table 3: Quality Assessent of the Clinical Studies Included in the Systematic Review

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culation in the protocol of the trials. How-ever, 2 RCTs29,31 were regarded as being at low risk because they both fulfilled all the dis-cussed quality assessment criteria (Table 3).

Confounding FactorsComparisons between treatment groups at baseline revealed no statistically signifi-cant differences for any of the investigated parameters in 2 studies.27,31 In another trial,29 statistical analysis failed to demonstrate differ-ences in years of smoking, medications used, and gender between treatment groups. The same investigators also failed to demonstrate differences in treatment outcomes as a result of implant surface characteristics within each group.

Even though periodontally involved teeth in partially edentulous patients were accord-ingly treated before enrolment in the included studies27,29,31 and received proper periodon-tal maintenance care,31 detailed periodon-tal status was not provided by any of the

trials. Hollow cylinder implants and smok-ers were excluded from 2 studies27,31 while occasional smokers were included in 1 trial because they were considered as nonsmokers.28

Based on these limited data, it is impos-sible to determine the effect of probable uncontrolled confounding factors such as smoking, periodontal condition, medical his-tory, or implant surface roughness on the efficacy of the investigated nonsurgical approaches in the treatment of peri-implantitis.

DISCuSSIOnAlthough a sequential therapeutic strategy termed “Cumulative Interceptive Supportive Therapy” was proposed in the late 90’s for the treatment of peri-implant diseases,32 there is very little reli-able evidence for the most effective and appropri-ate protocol for the treatment of peri-implantitis.33 The inadequacy of traditional mechanical debride-ment in removing microbial biofilms from the threaded and roughened titanium implant sur-faces has generated considerable interest over the years in other therapeutic approaches.7-9 This systematic review investigated the effec-tiveness of nonsurgical therapeutic modalities in the treatment of peri-implantitis based on human clinical studies. Even though the num-ber of available studies in the literature is cur-rently limited, the emerging need for treating peri-implant diseases and the growing interest in nonsurgical therapies will probably lead to an increase in the number of related publications.

The primary outcome variable of this system-atic review in evaluating the efficacy of these nonsurgical interventions was PD around dental implants. All the primary studies included in the systematic review provided relevant clinical data.

Adequate Inclusion Randomization Completemess Sample Statistical Exclusion & Group of Estimate Calculation Analysis Criteria Concealment Maskin Standardization Followers Risk Study Study (0- (0- (0- (0- (0- (0- (0- of



Renvert et al. RCT, 2 2 1 3 2 2 1 Low Persson et al.

Sahm et al. RCT, 2 2 2 1 3 2 2 1 Low

Table 3: Quality Assessent of the Clinical Studies Included in the Systematic Review

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32 • Vol. 6, No. 1 • January 2014

Survival rate is a common parameter for assessing success in implant therapy, but was not utilized in this systematic review because of the short-term follow-up times of the included publications.

The evaluation of PD scores presented by the two primary studies included in this system-atic review revealed no differences between Er:YAG laser and mechanical debridement fol-lowed by CHX in the treatment of moderate to advanced peri-implantitis (Table 2). Nevertheless there are certain difficulties and limitations asso-ciated with PD measurements of peri-implant lesions, especially when probing without remov-ing the suprastructures.29 After the 6-month examination, a slight relapse of PD and CAL was detected for both treatment modalities, especially in the initially advanced lesions.28 The observed deterioration was linked to insufficient oral hygiene and associated increases in PI val-ues from the 6- to the 12-month examination.28

BOP was also regarded as an important out-come measure in this systematic review. The reported 6-month BOP reduction ranged from 40 to 52% for the laser treatment and from 22 to 35% for the mechanical nonsurgical debride-ment.27,28 Clinical observations from the two pri-mary studies included in the present systematic review revealed a more favorable response in bleeding tendency for laser therapy compared to mechanical debridement and CHX. However, the observed difference between the two treatment modalities was apparently neither statistically significant nor long term. Decrease of BOP after Er:YAG laser therapy is attributed to the reported antimicrobial effects of laser irradiation against periodontal pathogens,22,34 leading to a reduction of inflammatory reaction and associated bleeding tendency of the surrounding tissues. Neverthe-

less, the observed relapse of BOP values, 1 year after an initial course of laser therapy, raises ques-tions about the long-term stability of this treatment modality28 and may indicate the need for repeated laser applications to achieve stable clinical results.

One case series not included in this sys-tematic review provided valuable histological observations from human peri-implant lesions revealing the formation of a loose fibrous tis-sue with poor attachment to the implant sur-faces. The microscopic findings confirmed the apparent lack of efficacy of a single course of laser treatment for the long-term mainte-nance of advanced peri-implantitis cases.35

The results of this systematic review are consistent with the descriptive findings of a previous systematic review.8 The authors also questioned the long-term efficacy of laser ther-apy in peri-implantitis and discussed the possibil-ity of repeated laser application or the adjunctive use of other therapeutic approaches. Similarly, the conclusion of the Consensus report of the 6th Workshop on Periodontology on the non-surgical laser therapy of peri-implant diseases was that “The outcome data on laser therapy is incomplete and do not show benefit as com-pared with conventional mechanical therapy”.9

The efficacy of air-abrasion in the treatment of peri-implantitis was compared to mechani-cal debridement followed by CHX in one study31 and to Er:YAG laser in another study29 included in this systematic review. A slightly more favor-able reduction of PD for the air-abrasion group over the standard mechanical treatment and CHX application was detected (Table 2). On the other hand, a marked decrease of BOP val-ues was recorded, favoring the air-abrasion ther-apy over the mechanical approach plus CHX

Vouros et al


application (Table 2). Apparently, air-abrasion is more efficient in the disruption of subgingival biofilms compared to mechanical debridement combined with CHX, leading to reduced bac-terial load and subsequently decreased bleed-ing tendency. In support of this, a very recent in vitro study observed a significant cleaning effect of glycine powder on implant surfaces.36 Using different angulations for sandblasting artificial peri-implant defects, a remarkable removal of stains from the greatest part of implant surfaces was observed in the larger defects. In the sec-ond study,29 PD reduction did not seem to differ between both Er:Yag laser irradiation and glycin powder air-abrasion. Similarly, no differences were detected between the two approaches in the treatment of severe peri-implantitis lesions for BOP, suppuration, and peri-implant bone loss.29

The importance of bacterial plaque biofilm in the initiation and progression of peri-implant dis-eases has been established and the disruption of subgingival microbial communities is considered a primary objective for the treatment of these con-ditions.5,33 Therefore, a significant drawback of all the controlled human studies included in this sys-tematic review was the lack of microbial monitor-ing in the investigated nonsurgical approaches for the treatment of peri-implantitis.27,28,31

Only one trial fulfilling the inclusion criteria of this systematic review presented microbiologi-cal outcomes comparing Er:YAG laser with air-abrasion.30 This study originated from the same Swedish group and was conducted on the same patient population29 but focused mainly on the impact of these therapeutic approaches on sub-gingival biofilms. Lower counts of Pseudomonas aeruginosa, Staphylococcus aureus, and Staphy-lococcus anaerobius were detected in the air-

abrasive group, 1 month after therapy. Although these species are not putative periopathogens, they have been associated with peri-implantitis lesions and seem to play a significant role in the development of biofilm on implant surfaces.37 Reduced levels of Fusobacterium nuclea-tum were detected in the laser group, respec-tively. However, a relapse was monitored at the 6-month evaluation, indicating the inability of both air-abrasion and laser treatments to sustain microbial suppression for longer time periods.30 The microbiological observations further con-firm the inadequacy of these nonsurgical meth-ods in the long term maintainance of the clinical improvements observed after a single applica-tion in moderate to severe peri-implantitis cases.

The results of one recent systematic review38 reporting on the efficacy of non-surgical ther-apy of periimplantitis are in agreement with the findings of the present trial. More specifically lower BOP scores were detected 6 months fol-lowing Er:Yag laser irradiation or air-abrasion with glycin powder in comparison with the tra-ditional plastic curettes debridement followed by CHX. No difference in the evaluated clini-cal parameters was reported 12 months post treatment between the investigated therapeutic approaches, indicating the short term advan-tage of laser and air-abrasion therapy over the standard mechanical therapy of periimplantitis.38

A very recent RCT compared the combina-tion of mechanical debridement, air-abrasion with glycine, and photodynamic therapy with phenothiazine chloride to the combination of mechanical debridement, air-abrasion, and local application of minocycline microspheres.39 In cases of initial peri-implantitis, adjunctive photody-namic therapy was equally effective as adjunctive

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34 • Vol. 6, No. 1 • January 2014

local delivery of the antibiotic in reducing BOP and PD. However, even though the treatments were repeated at sites with residual BOP, com-plete resolution of inflammation was not attained with either of the adjunctive approaches.39

The extent of response to alternative nonsur-gical treatments may be related to the severity of the disease. Renvert et al.29 noted that despite good levels of oral hygiene, patients presented clinically visible inflammation expressed with BOP and suppuration, indicating inadequacy of both laser and air-abrasion in the treatment of advanced peri-implantitis cases. The limited suc-cess was attributed to the inability of these non-surgical approaches to adequately control the microbial etiology because of disease severity. In accordance to this observation, improved clini-cal parameters were reported in moderate com-pared to advanced peri-implantitis defects for laser and mechanical debridement followed by CHX.28 However, Sahm et al.31 reported limited clinical efficacy of both air-abrasion and mechani-cal debridement to control disease progres-sion in initial to moderate peri-implantitis cases.

Single applications of alternative nonsur-gical treatments seem inadequate to control intense inflammation, especially in advanced peri-implantitis cases. Consequently, con-trolled clinical trials are needed to evaluate the results of a single compared to repeated appli-cations of these nonsurgical approaches. In addition, the short-term improvements in clini-cal parameters after nonsurgical methods in peri-implantitis cases may represent a ben-eficial step in the preparation of the inflamed tissues for treatment with regenerative proce-dures to improve the osseointegration levels.27,28

Because clinical improvements from these

nonsurgical treatments appear to be similar, another important issue is a cost-effectiveness analysis to maximize the level of benefits relative to the resources available.27,28 In addition, removal of the prosthetic suprastructures may be advanta-geous in providing adequate access for the laser tip or the air-abrasive nozzle to reach the deep-est parts of peri-implant lesion.29 Removal and repositioning of the suprastructures implies both increased treatment time and greater expense.

Two of the trials included fulfilled all the pre-determined quality assessment criteria and were judged to be at low risk of bias,29,31 two were graded at medium risk of bias because they did not provide data on power calculation of the opti-mal sample size.27,28 Furthermore the fact that the included studies in this systematic review originated from one German27,28,31 and one Swed-ish29,30 group represents a reduced risk of hetero-geneity because of the similar experimental design along with an increased risk of bias because of the small number of the involved centers.

The limited number of available clinical con-trolled studies on the efficacy of laser and air-abrasion therapies on peri-implantitis may be considered a potential drawback of the pres-ent systematic review. Additionally, the 5 studies included in this systematic review originated from one German27,28,31 and one Swedish29,30 research groups. However all the included studies are well designed, provide data on randomization, alloca-tion concealment and blinding of the operators and were judged to be at low to medium risk of bias. Therefore, more studies with larger sample sizes and longer follow-up periods are required to draw definitive conclusions on the long term effects of the two novel therapeutic approaches evaluated in the present systematic review.

Vouros et al


COnCluSIOnSEr:YAG laser irradiation, submucosal air-abrasion with glycin powder and mechani-cal debridement combined with CHX application seem to be equally effica-cious in the treatment of peri-implantitis.

Even though the two novel approaches inves-tigated in this systematic review resulted in simi-lar improvements in PD reduction, a trend for significant, albeit short-term decrease in BOP was observed when compared to traditional mechanical debridement followed by CHX application. Whereas a single application of alternative nonsurgical therapies induced only short-term clinical improvements, the impact of repeated use remains to be elucidated. ●

Correspondence:

Dr. Ioannis Vouros

Department of Preventive Dentistry

Periodontology and Implant Biology

School of Dentistry, Aristotle University of

Thessaloniki

54124 Thessaloniki, Greece

Phone: +30-2310999597

Fax: +30-2310999613

Email: [email protected]

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Vouros et al

36 • Vol. 6, No. 1 • January 2014

Vouros et al

DisclosureThe authors report no conflict of interest with anything mentioned in this article.

References1. Heitz-Mayfield LJ. Peri-implant diseases:

diagnosis and risk indicators. J Clin Periodontol 2008; (35)Suppl 8: 292-304.

2. Zitzmann NU, Berglundh T. Definition and prevalence of peri-implant diseases. J Clin Periodontol 2008; (35)Suppl 8: 286-291.

3. Roos-Jansaker AM, Lindahl C, Renvert H, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part II: presence of peri-implant lesions. J Clin Periodontol 2006; 33: 290-295.

4. Fransson C, Wennstrom J, Berglundh T. Clinical characteristics at implants with a history of progressive bone loss. Clin Oral Implants Res 2008; 19: 142-147.

5. Mombelli A, Lang NP. Microbial aspects of implant dentistry. Periodontol 2000 1994; 4: 74-80.

6. Klinge B, Gustafsson A, Berglundh T. A systematic review of the effect of anti-infective therapy in the treatment of peri-implantitis. J Clin Periodontol 2002; (29) Suppl 3: 213-225.

7. Claffey N, Clarke E, Polyzois I, Renvert S. Surgical treatment of peri-implantitis. J Clin Periodontol 2008; (35) Suppl 8: 316-332.

8. Kotsovilis S, Karoussis IK, Trianti M, Fourmousis I. Therapy of peri-implantitis: a systematic review. J Clin Periodontol 2008; 35: 621-629.

9. Renvert S, Roos-Jansaker AM, Claffey N. Non-surgical treatment of peri-implant mucositis and peri-implantitis: a literature review. J Clin Periodontol 2008; (35) Suppl 8: 305-315.

10. Fox SC, Moriarty JD, Kusy RP. The effects of scaling a titanium implant surface with metal and plastic instruments: an in vitro study. J Periodontol 1990; 61: 485-490.

11. Rühling A, Kocher T, Kreusch J, Plagmann HC. Treatment of subgingival implant surfaces with Teflon-coated sonic and ultrasonic scaler tips and various implant curettes. An in vitro study. Clin Oral Implants Res 1994; 5: 19-29.

12. Augthun M, Tinschert J, Huber A. In vitro studies on the effect of cleaning methods on different implant surfaces. J Periodontol 1998; 69: 857-864.

13. Mombelli A, Feloutzis A, Brägger U, Lang NP. Treatment of peri-implantitis by local delivery of tetracycline. Clinical, microbiological and radiological results. Clin Oral Implants Res 2001; 12: 287-294.

14. Persson GR, Salvi GE, Heitz-Mayfield LJ, Lang NP. Antimicrobial therapy using a local drug delivery system (Arestin) in the treatment of peri-implantitis. I: Microbiological outcomes. Clin Oral Implants Res 2006; 17: 386-393.

15. Renvert S, Lessem J, Dahlén G, Lindahl C, Svensson M. Topical minocycline microspheres versus topical chlorhexidine gel as an adjunct to mechanical debridement of incipient peri-implant infections: a randomized clinical trial. J Clin Periodontol 2006; 33: 362-369.

16. Petersilka GJ, Tunkel J, Barakos K, Heinecke A, Häberlein I, Flemmig TF. Subgingival plaque removal at interdental sites using a low-abrasive air polishing powder. J Periodontol 2003; 74: 307-311.

17. Duarte PM, de Mendonça AC, Máximo MB, Santos VR, Bastos MF Nociti FH. Effect of anti-infective mechanical therapy on clinical parameters and cytokine levels in human peri-implant diseases. J Periodontol 2009; 80: 234-243.

18. Moëne R, Décaillet F, Andersen E, Mombelli A. Subgingival plaque removal using a new air-polishing device. J Periodontol 2010; 8: 79-88.

19. Romanos GE, Everts H, Nentwig GH. Effects of diode and Nd:YAG laser irradiation on titanium discs: a scanning electron microscope examination. J Periodontol 2000; 71: 810-815.

20. Kreisler M, Al Haj H, Götz H, Duschner H, d’Hoedt B. Effect of simulated CO2 and GaAlAs laser surface decontamination on temperature changes in Ti-plasma sprayed dental implants. Lasers Surg Med 2002a; 30: 233-239.

21. Kreisler M, Götz H, Duschner H. Effect of Nd:YAG, Ho:YAG, Er:YAG, CO2, and GaAIAs laser irradiation on surface properties of endosseous dental implants. Int J Oral and Maxillofac Implants 2002b; 17: 202-211.

22. Kreisler M, Kohnen W, Marinello C, Götz H, Duschner H, Jansen B, d’Hoedt B. Bactericidal effect of the Er:YAG laser on dental implant surfaces: an in vitro study. J Periodontol 2002c; 73: 1292-1298.

23. Eberhard J, Ehlers H, Falk W, Açil Y, Albers HK, Jepsen S. Efficacy of subgingival calculus removal with Er:YAG laser compared to mechanical debridement: an in situ study. J Clin Periodontol 2003; 30: 511-518.

24. Schulz KF, Altman DG. Moher D. CONSORT 2010 Statement: Updated guidelines for reporting parallel group randomized trials. J Clin Epidemiol 2010; 63: 834-840.

25. Esposito M, Coulthard P, Worthington HV, Jokstad A. Quality assessment of randomized controlled trials of oral implants. Int J Oral and Maxillofac Implants 2001; 16: 783-792.

26. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159-174.

27. Schwarz F, Sculean A, Rothamel D, Schwenzer K, Georg T, Becker J. Clinical evaluation of an Er:YAG laser for nonsurgical treatment of peri-implantitis: a pilot study. Clin Oral Implants Res 2005; 16: 44-52.

28. Schwarz F, Bieling K, Bonsmann M, Latz T, Becker J. Nonsurgical treatment of moderate and advanced periimplantitis lesions: a controlled clinical study. Clin Oral Investig 2006a; 10: 279-288.

29. Renvert S, Lindahl C, Roos Jansåker AM, Persson GR. Treatment of peri-implantitis using an Er:YAG laser or an air-abrasive device: a randomized clinical trial. J Clin Periodontol 2011; 38: 65-73.

30. Persson GR, Roos-Jansåker AM, Lindahl C, Renvert S. Microbiologic results after non-surgical erbium-doped:yttrium, aluminum, and garnet laser or air-abrasive treatment of peri-implantitis: a randomized clinical trial. J Periodontol 2011; 82: 1267-1278.

31. Sahm N, Becker J, Santel T, Schwarz F. Non-surgical treatment of peri-implantitis using an air-abrasive device or mechanical debridement and local application of chlorhexidine: a prospective, randomized, controlled clinical study. J Clin Periodontol 2011; 38: 872-878.

32. Lang NP, Wilson TG, Corbet EF. Biological complications with dental implants: their prevention, diagnosis and treatment. Clin Oral Implants Res 2000; (11)Suppl 1: 146-155.

33. Esposito M, Grusovin MG, Coulthard P, Worthington HV. The efficacy of interventions to treat peri-implantitis: a Cochrane systematic review of randomised controlled clinical trials. European Journal of Oral Implantology 2008; 1: 111-125.

34. Folwaczny M, Mehl A, Aggstaller H, Hickel R. Antimicrobial effects of 2.94 microm Er:YAG laser radiation on root surfaces: an in vitro study. J Clin Periodontol 2002; 29: 73-78.

35. Schwarz F, Bieling K, Nuesry E, Sculean A, Becker J. Clinical and histological healing pattern of peri-implantitis lesions following non-surgical treatment with an Er:YAG laser. Lasers Surg and Med 2006b; 38: 663-671.

36. Sahrmann P, Ronay V, Sener B, Jung RE, Attin T, Schmidlin PR. Cleaning potential of glycine air-flow application in an in vitro peri-implantitis model. Clin Oral Implants Res 2013; 24: 666-670.

37. Heitz-Mayfield LJ, Lang NP. Comparative biology of chronic and aggressive periodontitis vs. peri-implantitis. Periodontol 2000 2010; 53: 167-181.

38. Muthukuru M, Zainvi A, Esplugues E, Flemmig T. Non-surgical therapy for the management of peri-implantitis: a systematic review. Clin Oral Implants Res 2013. In press.

39. Schär D, Ramseier CA, Eick S, Arweiler NB, Sculean A, Salvi GE. Anti-infective therapy of peri-implantitis with adjunctive local drug delivery or photodynamic therapy: six-month outcomes of a prospective randomized clinical trial. Clin Oral Implants Res 2013; 24: 104-110.

Vouros et al

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Wilcko et al

Dental implants have become routine therapy for the replacement of miss-ing teeth and have an excellent success

rate. Proper patient selection prior to implant therapy and home-care are crucial to this suc-cess. The direct impact of oral hygiene mainte-nance by the patient will determine long-term prognosis and success of the dental implant. An implant maintenance protocol with routine in-

office implant evaluation and maintenance should be established for each implant patient. Clini-cians must know how to assess and maintain implants and which techniques and instruments to use and also make awareness in the patient to set up a proper home care for long term success of dental implants. The overall goal of this article is to explain about implant assessment, moni-toring, home & in office maintenance protocol.

Maintenance and Follow up of Dental Implants: Key to Long Term Success

Dr. Sachin Mittal1 • Dr. Charu Gupta Mittal2 • Dr. Pankaj Kharade3

1. Oral and Maxillofacial Surgeon, Hisar, Haryana, India.

2. Dental Surgeon, Haryana India.

3. Prosthodontist and Fellow, Department of Dental & Prosthetic Surgery & Oncology, Tata Memorial Hospital, Mumbai, India.

Abstract

KEY WORDS: Dental implants, maintenance, home care


40 • Vol. 6, No. 1 • January 2014

INTRODUCTION“Over the past 30 years, research has validated the success of osseointegrated implants as a viable alternative to fixed or removable pros-thetic restorations.”1 It is now well-accepted that the success rate for single tooth end-osteal implant is up to 97% over 10 years.2,3 Since implants have become a routine ther-apy, the entire team needs to understand how implants are placed and restored in order to be able to confidently talk to patients about implants as an option for tooth replacement.

Patient selection for implant therapy is based on a number of factors, including medical his-tory, oral health, and hygiene status. Endosteal implants are placed in the bone, an abutment is attached to the implant, and the prosthesis is then placed on the abutment.4 In the pres-ence of a tooth, force is transmitted to the sur-rounding bone, which stimulates and helps maintain it. Implants also stimulate bone and help to maintain and increase bone density in the absence of a natural tooth, which in turn can help preserve facial structure. The key ben-efits of implants are functional and esthetic: to enhance appearance, restore normal eat-ing, improve removable denture retention, and in the case of single implants, replace teeth without the need for a bridge that may involve preparing virgin or minimally restored teeth.

Does peri-implantitis progress faster than periodontitis?5 Peri-implantitis is similar to peri-odontitis. They both involve alveolar bone loss. However, there are some differences. There is a zone of connective tissue being attached to the root surface in periodontitis. But in peri-implantitis, the connective tissue does not attach directly onto implants and there is no periodontal ligament, so the inflammatory lesion

in peri-implantitis always extends closer to the bone surface. Therefore, it progresses faster and it is potentially a more aggressive disease and it is very hard to treat. Nevertheless, tis-sue degradation may be a slow process, as in chronic periodontitis, a function time exceed-ing 5 years for implants may be required to detect biological peri-implant complications.

Finally, the steps necessary for success-ful peri-implant maintenance must be taken: provide safe implant maintenance, and moni-tor the tissue and the bone level surrounding the implant. In-office maintenance protocols and home-care recommendations are crucial for the success of implants. This requires clini-cal knowledge on how to assess implants at maintenance appointments, how to safely instrument implants, and which products can safely be recommended for home care.6

The signs and symptoms of failing implants must be recognized during the evaluation phase of maintenance. Once implants have been suc-cessfully placed, the patient must follow a proper home-care program and an implant main-tenance protocol must be developed for the patient. Home-care recommendations should begin at the time of implant placement and should be reevaluated each time the patient presents for implant maintenance therapy.

IMPLANT HOME CAREA daily meticulous home-care routine is essential for the long-term success of implants. An individ-ual home-care routine should be developed that considers the type of implant prosthesis and the patient’s dexterity, and should be kept as sim-ple and as effective as possible for the patient. Post-surgically, good oral hygiene is necessary to maintain a healthy field as well as to help with

Mittal et al


healing, and the patient should do the following:● Drink only clear liquids for the rest of the day● Take antibiotics and analgesics as prescribed

and recommended● Eat soft foods for the first few days of healing● Avoid wearing a temporary prosthesis or

denture to let the gum tissue heal (if the implant was not immediately loaded)

● Use an extra soft toothbrush to clean the denti-tion, preexisting implants and the gingiva (and do not brush the incision area)

● Use warm saline rinses or an antiseptic rinse if prescribed or recommended.

ORAL CARE FOR IMPLANTSOral care for single-tooth implants involves a number of steps. The patient should be instructed to brush the implant(s) twice a day with a low-abrasive dentifrice. Using a low-abra-sive dentifrice ensures that it will not scratch the surface or irritate the tissue cuff surround-ing the implant.7 A soft toothbrush should be

used – options include a manual brush, elec-tric or sonic brush (e.g., Sonicare®, Oral-B® Sonic, or Pulsonic), end tuft brush, or proxa-brush. The Oral-B® Pulsonic has a slim sonic brush that can fit under bar-retained implants or around ball implants used with overdentures. The interdental brushes that have coated wires are also recommended to clean around single implants or under a Hader bar. The end-tuft brushes clean around hard-to-reach implants and around bar-retained or ball-implant abutments.

Instruct the patient to floss once a day on the mesial and distal aspects. For implants, it is also recommended to floss implants on the facial and lingual aspects. This is accomplished by wrap-

Figure 1: Natural teeth versus implants.

Figure 2: Periodontitis.

Mittal et al

42 • Vol. 6, No. 1 • January 2014

ping the floss around the tooth or looping the floss to remove all plaque on the implant sur-face. The biological differences between an implant and a natural tooth make the implant more susceptible to inflammation and bone loss from bacterial plaque, making meticulous oral hygiene essential.8 There are many types of floss in the market today, and generally a single-tooth implant can be flossed with the patient’s regular floss. Alternatively, implant floss can be used (e.g., Thornton’s bridge and implant interdental floss). For bar-retained prostheses or wider interproximal spaces, thicker floss or one with a built-in threader (e.g., Oral-B® Super

Floss; Butler® Postcare) is recommended.Antimicrobial rinses may be recommended,

especially if inflammation is present or the patient has dexterity problems with an area that is difficult to clean. If the patient is prone to inflammation, the use of chlorhexidine gluconate or another antimicrobial rinse, in conjunction with a rubber tip stimulator, is recommended.9 Water irrigation units (e.g., Hydro Floss) can be beneficial if used twice daily (following proper instruction to ensure that the perimucosal seal is not damaged). The water must be directed only interproximally and horizontally on a low speed to avoid damaging the perimucosal seal.

Figure 3: Peri-implantitis. Figure 4: Oral B.

Mittal et al


IMPLANT MAINTENANCEAfter osseointegration has been confirmed and the final prosthesis or restoration is complete, the patient is largely responsible for the suc-cess of an implant and needs to understand the importance of proper in-office implant main-tenance appointments every three months for the first year, to help prevent infection or failure of the implant.10 After one year the bone sur-rounding the implant maintains a mature level of bone11 and the interval between maintenance visits should be based on the patient’s general health, assessment of the implant, and home care.

THE IMPLANT MAINTENANCE APPOINTMENT

The implant maintenance appointment consists of the following: 1) Review of the patient’s medi-cal history and general health; 2) Assessment of the implant(s); 3) Proper instrumentation and polishing of the implant(s); 4) Reinforcement of home-care routine and specific recommendations.

Step 1: Review of the patient’s medical his-tory and general health. The patient’s medi-

cal history should be updated and reviewed at every routine oral evaluation and implant mainte-nance appointment, to check if there has been any change in the patient’s health status that could impact the implants or treatment. If the patient has uncontrolled diabetes, increasing the risk of peri-implantitis and ultimately implant failure, it will be necessary to work in collabora-tion with the patient’s physician and the patient to gain control of the diabetes. 12 Overall good general health is one of the keys to the suc-cess of implant(s) and may affect the length of time between implant maintenance visits.13

Step 2: Assessment of implants. Implant assessment starts with a visual soft tissue exam-ination of the perimucosal seal. Any signs of inflammation or bleeding upon probing, including peri-mucositis (a reversible inflammatory reac-tion with no bone loss) or peri-implantitis (an irreversible inflammation with bone loss) should be recorded as well as any clinical symp-toms present such as pain and mobility. These assessments must be performed at every main-tenance appointment. Accurate radiographs

Figure 5: Proxabrush interdental system.

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44 • Vol. 6, No. 1 • January 2014

are necessary to monitor the crestal bone level.Visual soft tissue assessment: The soft tis-

sue should be visually examined for color, texture, form, bleeding, and inflammation. The assessment and any tissue changes should be recorded in the patient’s charts as well as with a regular intra-oral or digital camera. This photograph or digital image can be used to help educate the patient on the appearance of healthy tissue and, if pres-ent, the patient can be shown the inflamed tis-sue. Images can also be an excellent visual tool to reinforce the importance of good home care.

Protocol for proper probing around the implant: There are a number of considerations and guidelines that should be followed when prob-ing the tissue surrounding an implant. A plastic-coated probe (e.g., PDT EasyView; Hu-Friedy Colorvue®) should be used to reduce the risk of scratching the implant’s surface; plastic probes are also more flexible enabling them to follow the anatomy for a more accurate clinical reading. The perimucosal seal is fragile and more susceptible to trauma and penetration during probing than the periodontal ligament around teeth, which could introduce pathogens and jeopardize the success

of the implant.14 Probing in the perimucosal seal may not be recommended by some clinicians in the first three months following abutment attach-ment to avoid disrupting the biologic seal. Guide-lines for proper implant probing are described below. A probe baseline measurement at a spe-cific location should be recorded, to establish a clinical parameter for the patient’s record. This baseline should be recorded in the patient’s notes at the first maintenance appointment after three months.15 The measurement should ideally read 2.5 mm to 5.0 mm or less, depending on soft tis-sue depth, and there should be no signs of inflam-mation.16 Measurements at appointments should be compared to baseline, and if the probe depths change, this must be noted in the patient’s chart.

Figure 6: Dental flossing.

Figure 7: Antimicrobial rinse.

Mittal et al


Figure 8: Plastic and metal probe.

Figure 9: How to probe.

PROTOCOL FOR RADIOgRAPHIC MONITORINg

(Bone level): This final step is a critical one. A radiograph is taken to accurately monitor crestal bone level around the implant(s) using a measurable device and to verify that the pros-thesis is seated properly on the implant follow-ing placement of the prosthesis. Subsequent radiographs are used to determine if any crestal bone loss around the implant has occurred and, if so, to measure this. Periapical or vertical bite-wings for one to four implants and a panoramic or full mouth series for five or more implants is recommended to enable accurate determina-tion of the crestal bone level.17 Radiographs should show indentations in the implant or the screw clearly in focus to help visual confirma-tion that the X-ray is the correct way round.A measurement of 0.5 mm to 1 mm horizontal bone loss is acceptable in the first year, with an anticipated 0.1 mm of bone loss each subse-quent year.18 If more than 1 mm of horizontal or vertical bone loss is detected in the first year, a referral to the periodontist may be given. Any signs of peri-mucositis, mobility, peri-implantitis, or

bone loss need to be recorded at each appoint-ment and appropriately treated. After carefully assessing the implant and recording the find-ings, evaluate if calculus is present on the implant or abutments. Minimal or no instrumentation is necessary for an implant with a healthy gingival attachment. If an implant does fail with loss of osseointegration it is generally due to bacterial infection, occlusal overload or a poorly designed prosthesis.19 The cause of a failing implant and a treatment plan must be determined by the dentist.

Step 3: Proper Instrumentation: Selecting instruments that will effectively remove all plaque and calculus deposits without scratching the sur-face of the implants is essential. Calculus deposits on implants are generally softer than on teeth and are more often found supragingivally than subgin-givally. Generally, proper hand instrumentation is all that is needed.20 Excessive pressure or trauma to the perimucosal seal during instrumentation is contraindicated to avoid damaging it, the surface

Mittal et al

46 • Vol. 6, No. 1 • January 2014

Figure 10: Implant scalers with disposable plastic tips. Figure 11: Plastic scaler in use around implant-ball abutment.

of the implant, or any exposed abutment surface. Stainless steel–tipped instruments, as well as metallic sonic and ultrasonic scalers, have been found to gouge titanium21,22,23 and are contraindi-cated for implant instrumentation as scratching or roughening the implant surface can cause bacte-ria to adhere more easily, with an increased risk of inflammation.24 Clinicians also need to avoid damaging the surfaces of ball, bar-retained or locator abutments as this can result in increased plaque formation and retention.25 Metal tipped sub-gingival irrigators are also contraindicated.

The appropriate instruments for implant main-tenance are plastic, graphite, or solid titanium scalers and curettes. These have been proven to be safe and effective for the removal of plaque and other deposits on titanium implants.26,27 If ultrasonic or sonic scalers need to be used, cau-tion is required to avoid damaging the perimu-cosal seal and they must have a nonmetal tip or plastic sleeve to prevent scratching of the implant surface during use.28 Several manufacturers have developed implant power scaler tips and silicone

covers to place on ultrasonic scaler tips to prevent possible scratching of the implant surface (Cavi-tron® SofTip™; GentleCLEAN™; EMS Piezon® Implant cleaning tip; Periosoft™ carbon compos-ite mini-tip; SensiTips®). Plastic sleeve tips may become loose in the patient’s mouth and should be used with caution to avoid the risk of aspiration.

Hand implant scalers and curettes are available in polycarbonate plastic (e.g., Pro-phy+™, Advanced Implant Technologies) and graphite (e.g., Premier Dental), can be sharp-ened and are autoclavable. Implant scal-ers are also available with a sturdy handle and plastic disposable tips (Implacare™, Hu-Friedy) - these are single-use and must be disposed of after one use. Solid titanium scal-ers and curettes are also now available that can be used to scale on “like metal” titanium implants, are thinner than plastic or graphite instruments and provide more strength to dis-lodge calculus.26, 27 (Nordent ImplaMate™). Tita-nium instruments have been adapted with a shorter radius blade length and rounded tips

Mittal et al


Table 1: Dental Implants Versus Natural Teeth

Natural Teeth Implants

Surface: Cementum Titanium or coated

Held in by periodontal ligament Osseonintegrated directly with bone

Heat sensitive: pulpitis possible No sense of temperature

Mobility occur due to periodontitis Mobility occure due to peri-impantitis

Susceptible to decay No decay possi

specifically for peri-implant therapy (Paradise Dental Technologies), as well as with replace-able titanium tips (ImplantPro™, Brasseler).

Protocol for Polishing: Basic steps for proper coronal polishing around implants include using a soft rubber tip, not brush, with appropriate nonabrasive paste. Alumi-num oxide, tin oxide, APF-free prophy paste, and low-abrasive dentifrice are all considered acceptable polishing abrasives for implants.29 Coarse abrasive polishing pastes are contrain-dicated, as is airpolishing.30 It should be noted that acidulated phosphate fluoride (APF) prod-ucts are also contraindicated, as they may etch the surface of implants.31 It may be help-ful to polish first around implants to remove any plaque or debris present and then to determine deposits that need instrumentation.

CONCLUSION During the infancy years of dental implantology, the emphasis for long-term success of osseo-integrated implants was the surgical phase

of dental implantology. In the years that fol-lowed, the emphasis for success has switched from a purely surgical influence to focusing more on the proper fixture placement which would be dictated by the prosthetic and aes-thetic needs of each particular case. In more recent years, the dental professional has rec-ognized professional implant maintenance and patient home care as two critical factors for the long-term success of dental implants. ●

Correspondence:Dr. Sachin MittalC/o Sarvodaya multispecialty hospital below dabra bridge hisar-125001 haryana Mob. No. : 9996468881E-mail: [email protected]: 01662-231010

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48 • Vol. 6, No. 1 • January 2014

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References1. Committee of the American Academy of Periodontology. J Periodontol. 2000;

71:1934-1942.2. Misch CE. Contemporary Implant Dentistry. 3rd ed. St. Louis: Mosby; 2008:7.3. Fugazzotto PA. Success and failure rates of osseointegrated implants in

function in regenerated bone for 72 to 133 months. Int J Oral Maxillofac Imp. 2005; 20:77-83.

4. Babbbush CA. Master planning the implant case: Sequential analysis. In: Babbush CA (ed.): Dental implants: The Art and Science. Philadelphia, W.B. Sunders, 2001, 3-18.

5. Gualini F, Berglundh T. (2003) Immuno histochemical characteristics of inflammatory lesions at implants. J Clin Perio 30, 14-18.

6. Misch CE. Contemporary Implant Dentistry. 3rd ed. St. Louis: Mosby; 2008:457.

7. Yukna R. Optimizing clinical successes with implants: maintenance and care. Compend Contin Educ Dent. 1993; 15:S554-S561.

8. Berglundh T, Lindhe J, Ericsson I, et al. The soft tissue barrier at implants and teeth. Clin Oral Impl Res. 1991; 2(2):81-90.

9. Esposito M, Worthington HV, Thomsen P, Coulthard P. Interventions for replacing missing teeth: maintaining health around dental implants. Cochrane Database Syst Rev. 2004; 3:CD003069.

10. Palmer RM, Pleasance C. Maintenance of osseointegrated implant prosthesis. Dent Update. 2006; 33:84-86.

11. Albrektsson T, Zarb G, Worthington P, Erikson AR. The long-term efficacy of currently used dental implants: a review and proposed criteria of success. Int J Oral Maxillofac Implants. 1986:11-25.

12. Fiorellini JP, Chen PK, Nevins M, Nevins ML. A retrospective study of dental implants in diabetic patients. Int J Periodontics Restorative Dent. 2000; 20:366-373.

13. Berglundh T, Lindhe J, Lang NP, et al. Mucositis and peri-implantitis. In: Clinical Periodontology and Implant Dentistry. 4th ed. Copenhagen; Blackwell Publishing Co/Munksgaard; 2003.

14. Bauman GR, Mills M, Rapley J, et al. Clinical parameters of the evaluation during implant maintenance. Int J Oral Maxillofac Implants. 1992; 7:220-227.

15. Mombellli A, Muhle T, Bragger U, et al. Comparison of periodontal and peri-implant probing by depth-force pattern analysis. Clin Oral Implant Res. 1997; 8:448-454.


17. Lekholm U, van Steenberghe D, Hermann I, et al. Osseointegrated implants in the treatment of partially edentulous jaws; a prospective 5-year multicenter study. Int J Oral Maxillofac Implants. 1994; 9:627- 635.


19. Paquette DW, Brodala N, Williams RC. Risk factors for endosseous dental implant failure. Dent Clin North Am. 2006; 50:361-374.

20. Darby ML, Walsh MM. Dental Hygiene Theory and Practice. 1st ed. Philadelphia, PA: WB Saunders Co; 1995.

21. Meschenmoser A, d’Hoedt B, Menyle J, et al. Effects of various hygiene procedures on the surface characteristics of titanium abutments. J Periodontol. 1996; 67(3);229-235.

22. Hallmon W, Waldrop T, Meffert R, Wade BW. A comparative study of the effects of metallic, nonmetallic, and sonic instrumentation on titanium abutment surfaces. Int J Oral Maxillofac Impl. 1997; 11(1):96-100.

23. Sato S, Kishida M, Ito K. The comparative effect of ultrasonic scalers on titanium surfaces: an in vitro study. J Periodontol. 2004; 75(9):1269- 1273.

24. Committee of the American Academy of Periodontology. J Periodontol. 2000; 71:1934-1942.

25. Romeo E, Ghisolfi M, Carmagnola D. Peri-implant disease. Minerva Stomatol. 2004; 53:215-230.

26. Brough Muzzin KM, Johnson R, Carr P, Daffron P. The dental hygienist’s role in the maintenance of osseointegrated dental implants. J Dent Hyg. 1988; 62(9):448-453.

27. Rapley JW, Swan RH, Hallomon WW, Mills MP. The surface characteristics produced by various oral hygiene instruments. Int J Oral Maxillofac Impl. 1990; 5(1):47-52.

28. Yukan R. Optimizing clinical success with implants: maintenance and care. Compend Contin Educ Dent. 1993:15:S554-S561.

29. Matarasso S, Wuaremba G, Coraggio F, Vaia E, Cafiero C, Lang NP. Maintenance of implants: an in vitro study of titanium implant surface modifications subsequent to the application of different prophylaxis procedures. Clin Oral Imlpl Res. 1996;7(1):64-72.

30. Bergendal T, Forsgren L, Kvint S, Lowstedt E. The effects of air abrasive instrument on soft and hard tissues around osseointegrated implants. Swed Dent J. 1990;14:219-223.

31. Matono Y, Nakagawa M, Matsuya S, Isikawa K, Terada Y. Corrosion behavior of pure titanium and titanium alloys in various concentrations of Acidulated Phosphate Fluoride (APF) solutions. Dent Mater J. 2006;25(1):104-112.

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Wilcko et al

Backgrond: There currently exists neither a clini-cal measure defining an acceptable level of fit between the mating surfaces of an implant pros-thesis and its intended implant or abutment plat-form, nor which clinical procedures are best to optimize that fit. Several techniques using resin to splint implant components have been sug-gested in order to improve the accuracy of impressions and working casts in the fabrica-tion of an implant prosthesis. These include: the use of resin to splint adjacent impression cop-ings before impressioning, or laboratory analogs before pouring a working cast; or lastly, the use of resin to splint both impression copings and laboratory analogs. The purpose of this article is to determine the effect of splinting impression copings and/or implant analogs compared to non-splinting on the accuracy of the resulting cast.

Materials and methods: A control standard was fabricated by incorporating implant rep-licas secured to a CAD/CAM milled titanium framework into a cast of Type V dental stone that served as the control for the present inves-tigation. The interface between the framework and the analogs were positioned above the stone in the control cast to allow visual access. Standardized impressions and working casts

of the control were made using six techniques: Group N: neither copings nor analogs splinted, Group A: splinted analogs, Group C: splinted copings, Group CA: splinted copings, and ana-logs, with two additional groups involving a pre-made resin splint that was sectioned and then reconnected on the control: Group S: sectioned splint reconnected on the control, and Group SA: sectioned splint reconnected on the control, with splinted analogs. The resulting working casts were evaluated and measurements of the frame-work-analog interface gap were made using pho-tographs under high magnification. The incidence of the framework having all four analog interface gaps less than 150 microns was also noted.

Results: Group A had significantly larger gaps than all the other groups. There was no statistically significant differ-ence found between any other groups.

Conclusion: Within the limitations of the pres-ent investigation’s study design, it was found that: 1) Splinting analogs with resin resulted in a working cast with significantly diminished accuracy; 2) There was no significant differ-ence in working cast accuracy if impression copings were unsplinted or splinted with resin.

The Accuracy of Casts made with and without Splinted Implant Impression Copings or Analogs

Talal Alnassar BDS, MDS, FACP1 • Louis DiPede DMD, FACP2 Gregory Lehnes DMD, MDS3

1. Faculty, Department of Prosthetic Dental Science, College of Dentistry, King Saud University, Riyadh, Saudi Arabia

2. Assistant Professor and Interim Chair, Department of Restorative Dentistry, New Jersey Dental School.

3. Assistant Clinical Professor, Department of Restorative Dentistry, New Jersey Dental School.

Abstract

KEY WORDS: Dental implants, prosthetics, impression accuracy, analog


52 • Vol. 6, No. 1 • January 2014

BACKgROunDA dental impression is defined as a negative imprint of an oral structure used to produce a positive replica of the structure for use as a per-manent record or in the production of a dental restoration or prosthesis.1 Achieving an accurate fit between a prosthesis framework and its’ sup-porting implants is related to the accuracy of the impression.2,3 An inaccurate impression would result in an inaccurate working cast as well as the prosthesis made from it. Misfit of an implant prosthesis’ framework may induce strain causing mechanical or biologic complications. Mechani-cal complications may include screw loosening, screw fracture, or implant fracture.4 Biological complications may include plaque accumulation, gingival inflammation and bone loss.5 Therefore, framework must fit as precisely and passively as possible to minimize interface gaps and strain.

Some authors have attempted to define pas-sivity of fit for an implant prosthesis. Brånemark in 1983 defined a passive fit as minimum of 10 µm between the implant platform and the superstruc-ture.6 Klineberg et al considered a passive fit to be unacceptable if the gap between the implant and the abutment is greater than 30 µm for more than 10% of the interface circumferentially.7 The

results of a prospective study by Jemt et al. sug-gests that misfit should be less than 150 µm.8

Complications in dental implant treatments occur for a variety of reasons, and some of these have been attributed to poor prostheses fit.4, 9 Production of a prosthesis that fits pas-sively and precisely is dependent on an accu-rate transfer of the intraoral position of implants to the working cast. Because dimensional change is inherent in materials used for impres-sion making and the production of a working cast, numerous techniques involving variety impression trays, materials, or copings, have been suggested in order to reduce this error.10

Included in these are techniques that involve splinting impression copings or laboratory ana-logs, with auto polymerizing resin. However resins are subject to a potentially significant dimensional change upon polymerization. Poly-methylmethacrylate (PMMA) has been shown to shrink 6.5% by volume.11 At room tempera-ture, PMMA continues to shrink up to 24 hours after mixing power and liquid.11 Eighty per cent (80%) of the total shrinkage occurs in the first 17 minutes, with no significant shrinkage after 24 hours.11 Therefore, when using a technique that directly splints impression copings with resin, it

Figure 1: Frontal view of titanium framework. Figure 2: Implant analogs attached to titanium framework.

Alnassar et al


is unclear if this continued shrinkage will affect the fidelity of that impression given the common clinical practice of delayed working cast fabrica-tion. In an attempt to overcome this, it has also been suggested that the resin splint be made indirectly on a preliminary working cast well in advance of the definitive impressioning proce-dure. That premade resin splint would then be sectioned and reconnected intraorally with a minimal volume of additional PMMA. By resplint-ing a preformed resin pattern, the volume of resin used in this approach significantly minimizes polymerization shrinkage when compared to a bulk application. A systematic review by Lee H. et al compared the accuracy of implant impres-sions.10 Seven studies advocated the splinting technique, seven studies reported no difference between the splinting and non-splinting, and 3 studies advocated the non-splinting technique as being the most accurate technique.10,11,12,13,14

The purpose of the present investigation was to record impressions of a standard with prepos-tioned implant replicas to measure the effect of splinting impression copings or analogs com-

pared to not splinting. The null hypothesis is there would be no statistically significant differ-ences between unsplinted impression copings or analogs compared to those that are splinted.

MAtERiAlS AnD MEthODSFour implant analogs (Replace Select nar-row platform, Nobelbiocare, Mahwah, NJ)

Figure 3: Control platform with carved channels. Figure 4: Control platform with triad for positioning.

Figure 5: Positioning of tray.

Alnassar et al

54 • Vol. 6, No. 1 • January 2014

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were attached to a milled titanium framework, and the assembly was embedded into a mold filled with a Type V high strength, low expan-sion dental stone, (Silky Rock, Whip Mix, Lou-isville, KY) to create a control platform (Figures 1 and 2). The interface between the framework

and analogs was positioned 5 millimeters above the level of the stone in order for the frame-work analog interface to be visually accessible.

A stock resin impression tray (Benco dispos-able, Benco dental, Pittston, PA) with holes drilled to access impression coping guide pins was placed on the control platform, and an outline of the tray borders was traced. After removing the tray, 2 channels were made 3 to 4 millimeters wide buccolingually at a depth of 2 millimeters. Light polymerized resin (Triad tray VLC, Dentsply Inc., York, PA) was placed in this channel, and the rim of the stock impression tray was reseated into the unpolymerized resin. The assembly was placed into a light polymerization unit (Triad 2000 curing unit, Dentsply Inc., York, PA) for ten min-utes to polymerize the resin following the manu-facturer’s instructions. This channel allowed subsequent stock impression trays to be posi-tioned in a standardized manner (Figures 3-5).

Impressions of the control platform were then made with a variety of techniques: Group N: No splinted copings, no splinted analogs;

Figure 6: Floss wrapped around impression copings. Figure 7: Impression separated from control platform with analogs attached to impression copings.

Figure 8: Interface of implant analog and titanium framework.


Alnassar et al

group C: Splinted copings, no splinted ana-logs; group A: No Splinted copings, splinted analogs; group CA: Splinted copings, splinted analogs; group S: Sectioned splint recon-nected on the control platform, no splinted ana-logs; group SA: Sectioned splint reconnected on the control platform, and splinted analogs.

A template was made of the first stock tray in order to standardize the position of these holes for subsequent trays. All techniques used the same size stock trays with 4 openings to allow access to the impression coping guide pins. A fast set vinyl polysiloxane (VPS) impression material (Exa-fast NDS Monophase, GC America, Alsip, Il) was used for all impressions. For the techniques that included a polymethylmethacrylate (PMMA) splint, a floss scaffold (Glide, Proctor and Gamble, Cin-cinnati, OH) was overlaid with autocuring PMMA (Pattern resin, GC America, Alsip, Il) (Figure 6). For Groups S and SA, impression copings were connected in the same manner and then sec-tioned. The individual sections in Groups S and SA were placed into water at 100 degrees cen-tigrade for 20 minutes in order to minimize the residual monomer content and ongoing setting reaction of the set polymer.15, 16 After 5 minutes of bench cooling, these individual sections were then reconnected with additional pattern resin on the stone platform and an impression was made.

Twelve impressions were made for each of the various techniques after hand-tightening impres-sion copings onto the implant replicas imbedded into the control platform. This sample size was chosen based on a pilot study (n= 10) which was conducted and showed that at least 12 samples would be required for each group to satisfy the constraints of a = 0: 01, power, 0.80, and a dif-ference of 20% between means. In addition to

that, one way ANOVA power analysis was used to determine the new sample size (n=12) of the six groups. Twelve samples for each of the six groups ensured a power over 0.80 accord-ing to a one way ANOVA of power analysis. After the impression material had completely polymerized according to manufacturer instruc-tions, the impression coping guide pins were unscrewed and the impression was separated from the control standard. Implant analogs were then carefully hand-tightened to the impres-sion copings maintaining their position within the impression (Figure 7). Each of the impres-sions with attached analogs were placed into the same base forming mold and working casts were poured using the same stone used to make the control platform, following the manufacturer instructions. After the stone was set, the guide pins were unscrewed, and the working casts were recovered from their impressions and base form-ing mold. A single operator attached the refer-ence framework to each working cast by using a single screw hand tightened to the posterior left analog. To assess the accuracy of the work-ing cast, a previously described method was used to measure the vertical gap between the framework and analogs.17, 18 Each working cast was positioned in a reproducible manner on the stage of a photographic microscope (Olympus SZX12, Olympus America, Valley, PA) (Figure 8) using a silicone putty matrix (Sil-Tech Super, Ivo-clar vivadent, Amherst, NY) for consistent posi-tioning. Photographs were taken at each of the 4 framework and analog interfaces at 100X magnification at a set distance from the stage. Measurements of the vertical gap between the framework and each analog were made using imaging software (Bioquant image analysis soft-

56 • Vol. 6, No. 1 • January 2014

Alnassar et al

ware, Bioquant Corp., Nashville, TN). A single operator made measurements of each mesial, distal and midfacial gap for each interface and recorded the average of those three measure-ments. In addition, the average of the 4 interfaces for each framework were calculated and recorded.

Means and standard deviations were deter-mined for each study group (Table I). An analysis of variance was performed to test for significant differences among the different groups and a chi-square test was used to determine if those per-centages were significant (Table II). This analysis was followed by a Tukey HSD post hoc test to determine which groups were statistically differ-ent from each other (Table III). The percentage of casts which had no implant framework gap greater than 150 µm at any site was also noted.

RESultSThe mean and standard deviation was calculated for each study group [Table I]. Group A had the highest mean framework analog gap of 183.19 µm, which an ANOVA test revealed to be statisti-cally significant. The remaining Groups N, C, CA,

S and SA were not statistically different from each other. The Tukey HSD post hoc test showed that Group A had statistically larger gaps than all the other groups, and there was no statistically sig-nificant difference in the other groups (Table III).

Working casts with all 4 gaps at the frame-work analog interface of less than 150 µm was considered to be a clinical threshold for a working cast. It was noted that Group C had the highest number of casts were all frame-work analog interfaces were less than 150 µm.

DiSCuSSiOnThe results of the present study show a significant decrease in the fidelity of a working cast when implant analogs alone were splinted compared to all other techniques studied. Of the remain-ing techniques, there was no statistically signifi-cant difference found. Only Group A was shown to have a significantly larger mean gap between the framework and the analogs compared to all other groups (183.19 µm). In this study, splint-ing the analogs alone caused a significantly increased gap between the framework and the

Table 1: Mean and Standard Deviation for Each Study Group

Technique N Mean SD P Value Post Hoc

N 12 66.01 21.61 B

C 12 43.32 14.2 B

A 12 183.19 44.79 <.001 A

CA 12 102.44 21.35 B

S 12 46.05 10.51 B

SA 12 99.74 23.09 B


Alnassar et al

working cast analogs, and therefore appears to be counterproductive. The elastomeric nature of the impression material allows movement of the analog and coping. It would appear that in the course of splinting the analogs, the floss that was used as a scaffold for resin placed a force on those analogs that altered the position of the analogs and impression copings to a significant degree. The results indicate that this technique is to be avoided. In Groups CA and SA the resin that splinted the impression copings was appar-ently able to counteract that force that the floss had applied to the analogs in Group A. Group C showed the smallest mean gap of 43.32 µm between the framework and the analogs, how-ever, an analysis of variance with post hoc test showed that the mean of the average gaps between Groups N, C, CA, S, and SA were not significant. In Groups S and SA the use of pre-polymerized resin sections greatly reduced the volume of resin needed to directly splint the impression copings compared to Groups C and CA. The use of prepolymerized resin sections did not significantly improve the fidelity of a working cast compared to direct placement of the entire volume of resin (Group C) or the group that had non-splinted impression copings (Group N). Overall, splinting impression copings whether directly or with the use of prepolymerized sec-tions was not shown to be an effective method for improving the accuracy of working casts.

In addition to analyzing the mean gap among the different techniques, the authors noted the num-ber of times that a particular technique resulted in a mean gap of less than 150 µm for each of the 4 implant positions. If all gaps were less than 150 µm for each of the framework analog inter-faces of any individual working cast, that cast was

considered to be able to produce a framework that would not need to be corrected or remade. If any of individual framework analog interfaces were greater than 150 µm, the authors consid-ered the working cast would produce a frame-work that would need to be corrected or remade.

It was interesting to note that Group C showed the highest percentage of implant frameworks that fit (83.3%) followed by Group N (75%). This difference amounted to only one framework between the groups. Although the sample size is too low to apply meaningful sta-tistical analysis to this observation, it does help to support the conclusion that splinting impres-sion copings with either method described was not shown to be an effective method for signifi-cantly improving the accuracy of working casts.

One limitation of the study was the varia-tion in the overall volume resin used for splint-ing as well as variation in the liquid to powder ratio of the resin used. A larger volume of resin would presumably have a greater amount of dimensional change, as would an increased liquid to powder ratio. Although care was taken to use a minimum of resin, the degree of dimensional change could have been different between samples, albeit within a limited range.

Additionally, the stock plastic impression trays used are not as rigid as custom made impression trays. However, because the control platform was flat, no meaningful force was required to recover the impressions from it or the working casts. Therefore, the rigidity of the stock resin impression trays was adequate for the present investigation.

Additional research is needed to better estab-lish the level of misfit beyond which, one can expect a significant increase in clinical complica-tions. Current research lacks focus on an upper

58 • Vol. 6, No. 1 • January 2014

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Yes or No

Technique Y N Total

N Count 3 19 12

% within Technique 25.0% 75.0% 100.0%

% within Yes or No 8.6% 24.3% 16.7%

% of Total 4.2% 12.5% 16.7%

C Count 2 10 12


% within Yes or No 5.7% 27.0% 16.7%

% of Total 2.8% 13.9% 16.7%

A Count 11 1 12


% within Yes or No 31.4% 2.7% 16.7%

% of Total 15.3% 1.4% 16.7%

Table 2: Analysis of Variance for Different Groups


Alnassar et al

Yes or No

Technique Y N Total

CA Count 8 4 12


% within Yes or No 22.9% 10.8% 16.7%

% of Total 11.1% 5.6% 16.7%

S Count 4 8 12


% within Yes or No 11.4% 21.6% 16.7%

% of Total 5.6% 11.1% 16.7%

SA Count 11 1 12


% within Yes or No 20.0% 13.5% 16.7%

% of Total 9.7% 6.9% 16.7%

Total Count 35 37 72


% within Yes or No 100.0% 100.0% 100.0%

% of Total 48.6% 51.4% 100.0%

Table 2: Analysis of Variance for Different Groups

60 • Vol. 6, No. 1 • January 2014

Alnassar et al

limit of acceptable misfit. An equally important question for future research would be how best to determine that upper limit in a clinical set-ting. Studies that compare the ability of various clinical techniques to provide accurate measure-ments of misfit would give clinicians valuable information. These two questions are interrelated, as knowing that threshold of misfit is of limited value if it cannot be reliably measured clinically.

COnCluSiOnWithin the limitations of the present study design, it was found that: 1) splinting ana-logs with resin resulted in a working cast with significantly diminished accuracy; 2) there was no significant difference in working cast accuracy if impression copings remained individual, or were splinted with resin. ●

Value df Asymp. Sig (2 sided)

Pearson Chi-Square 19.626 5 0.001

Likelihood Ratio 21.711 5 0.001

N of Valid Cases 72

Table 3: Percentage of Casts which had No Implant Framework Gap Greater than 150µm

Correspondence:Dr. Talal Alnassar411 bon air driveAugusta, GA 30907Phone# 551-580-9050E-mail: [email protected]

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

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Quintessence; 1985. p. 199-209.3. Laney WL, Tolman DE, Keller EE, Desjardins RP, Van Roekel NB. Dental

implants: tissue-integrated prosthesis utilizing the osseointegration concept. Mayo Clin Proc 1986;61:91-7.

4. Skalak R. Biomechanical considerations in osseointegrated prostheses. J.Prosthet Dent 1983;49:843-8.

5. Kan J.et al, Clinical methods for evaluating implant framework fit, J. prosthet Dent, 1999:88(3): 329-36.

6. Brånemark PI. Osseointegration and its experimental background. J Prosthet Dent 1983; 50:399-410.

7. Klineberg IJ, Murray GM. Design of superstructures for osseointegrated fixtures. Swed Dent J 1985;28:63-9.

8. Jemt T. Failures and complications in 391 consecutively inserted fixed prostheses supported by Brånemark implant in the edentulous jaw: a study of treatment from the time of prostheses placement to the first annual check up. Int J Oral Maxillofac Implants 1991; 6:270-6.

9. Zarb GA, Schmitt A. The longitudinal clinical effectiveness of osseointegrated dental implants: the Toronto Study. Part II: The prosthetic results. J Prosthet Dent 1990; 64:53-61.

10. Lee H. The accuracy of implant impressions: A systematic review, J. prosthet Dent, 2008;100:4;285-91.

11. Mojon P. et al, Polymerization shrinkage of index and pattern acrylic resins, J. Prosthet. Dent, 1990:64(6);684-88.

12, Lindhe J, Berglundh T, Ericsson I, Liljenberg B, Marinello C. Experimental breakdown of periimplant and periodontal tissues. A study in the beagle dog. Clin Oral Implants Res 1992; 3:9-16.

13. Lekholm U, van Steenberghe D, Herrmann I, et al. Partially edentulous jaws: a prospective 5 year multicenter study. Int J Oral Maxillofac Implants 1994;9:627-35.

14. Assif D, Fenton A, Zarb G, et al. Comparative accuracy of implant impression procedures. Int J Periodontics Restorative Dent. 1992;12:112-121.

15. Vallittu PK, Ruyter IE, Buykuilmaz S, Effect of polymerization temperature and time on the residual monomer content of denture base polymers, Eur J Oral Sci, 1998 Feb;106(1):588-93.

16. Bayraktar G, Guvener B, Bural C, Uresin Y, Influence of polymerization method, curing process, and length of time of storage in water on the residual methyl methacrylate content in dental acrylic resins, J Biomed Mater Res B Appl Biomater, 2006 Feb;76(2):340-5.

17. Wise M, Fit of implant-supported fixed prostheses fabricated on master casts made from a dental stone and a dental plaster. J Prosthet Dent 2001; 86: 532-538.

18. Romero GG, Engelmeier R, Powers JM, Canterbury AA, Accuracy of three corrective techniques for implant bar fabrication. J Prosthet Dent 2000;84:602-607.

Alnassar et al

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