PERI-IMPLANT TISSUE EVALUATION AND

POST-PROSTHODONTIC CARE OF IMPLANTS

RESD 854
Tord M. Lundgren, DDS
Associate Professor, Advanced Periodontics
Loma Linda University
Loma Linda, California

Charles J. Goodacre, DDS, MSD

Professor, Restorative Dentistry
Loma Linda University
Loma Linda, California

INTRODUCTION

Teeth are anatomically unique because they are the only structures of the body that
penetrate a lining or covering epithelium. Dental implants, as a replacement of teeth, are
another example of structures that pierce the epithelium. While proper anchorage of an
implant in the bone is a prerequisite for its stability, long-term results1 also seem to
depend on the soft tissue attachment to the titanium surface which seals the bone from the
oral environment (reference 1).

COMPARISON OF PERI-IMPLANT TISSUES AND GINGIVA

The free marginal gingiva around teeth and the peri-implant mucosa around implants
have many clinical and histological features in common.

Color and Consistency

The clinical healthy soft tissues facing teeth and implants are pink and have a firm
consistency (figure 1A, figure 1B, figure 1C).

Histology
In experimental studies2 using beagle dogs (reference 2), histologic analysis was used to
compare the marginal gingiva and peri-implant mucosa (figure 2).

Vascular Topography
Regarding the vascular topography of the periodontium and the peri-implant tissues, it
has been observed that the periodontium around teeth is supported by supraperiosteal
vessels lateral to the alveolar process and vessels from the periodontal ligament. In
contrast, the peri-implant mucosal blood supply was provided by terminal branches of
larger vessels originating from the periosteum of the bone associated with the implant
site.

1
The vascular supply3 to the peri-implant mucosa is not as extensive and complete as that
present around teeth (reference 3). Fewer vessels in the supracrestal soft tissue zone
immediately lateral to the implant surface suggest that the peri-implant soft tissues might
have an impaired defense capacity against irritation.
Probing Depth
The probing depth around healthy gingival tissues and peri-implant mucosa has been
compared both in animal4 models (reference 4) and in humans5 (reference 5) and found
to be more advanced at implants than at teeth. Around implants the probe displaces the
junctional epithelium as well as the connective tissue and stops close to the bone.
Around teeth, the probe tip stops coronal to the apical portion of the junctional epithelium
(figure 3).

PERI-IMPLANT MUCOSITIS COMPARED TO GINGIVITIS

Over three decades ago, Le et al (J Periodontol 1965;36:177-187) presented convincing

evidence showing that bacterial plaque at the dento-gingival junction around teeth
resulted in gingival inflammation. In a similar model6 designed to compare gingivitis
with peri-implant mucositis, a group of patients with teeth and dental implants refrained
from all oral hygiene for a period of three weeks and thereafter oral hygiene was
reinstituted again (reference 6).

The ability of the peri-implant tissues to handle plaque-associated lesions was tested on
five dogs by placing cotton floss ligatures around the neck of both implants and teeth.7
The ligature was forced into the pocket and thereby a subgingival microbiota rapidly
formed resulting in periodontitis on teeth and peri-implantitis on implants (reference
7). These results indicate the peri-implant mucosa seems to be less effective than the
gingiva in encapsulating plaque-associated lesions. Examples of peri-implant mucositis
and peri-implantitis are shown in (figure 4A, figure 4B) and (figure 5A, figure 5B).

DATA REGARDING THE USE OF CONVENTIONAL METHODS

OF EVALUATING PERIODONTAL HEALTH WHEN THEY ARE
USED WITH IMPLANTS

Multiple clinical studies have investigated the relationship between implant loss/bone
loss and the factors conventionally used to evaluate the periodontal status of natural teeth
(presence of plaque, oral hygiene, gingivitis, probing depths, bleeding on probing,
presence of attached/unattached tissue, microbiotia present, crevicular fluid, prosthesis-
to-soft tissue distance). There is a difference in the conclusions of various authors. The
following material is designed to present available data from both sides of the issue so
readers can assess available evidence.

There are multiple studies8-15(references 8, 9, 10, 11, 12, 13, 14, 15) showing no
relationship between these periodontal evaluation parameters and implant success. In

2
contrast, several other studies16-23 (references 16, 17, 18, 19, 20, 21, 22, 23) identified a
relationship between the factors used to evaluate the periodontium of natural teeth and
implant failures/bone loss.

A definitive conclusion appears to be lacking when attempting to determine what

relationship exists between the methods commonly used to assess periodontal health
around natural teeth and their application to implants. Most of the studies where no
relationship was found involved assessment of completely edentulous patients. The value
of using conventional periodontal parameters may be more apparent in partially
edentulous patients who have both teeth and implants.

Until more definitive data becomes available, it is proposed that oral hygiene is important
and the lack thereof may affect implant and prosthesis longevity. It is unclear whether
conventional methods of evaluating periodontal health are effective when evaluating
implants. While attached tissue is desirable, it does not appear to be necessary for
successful results as long as oral hygiene is adequate.

MAINTENANCE PROGRAM

There are three elements in the maintenance program for patients with dental implants.
First is the establishment of a home-care regimen that helps the patient achieve
acceptable plaque control. The second element is to give the patient periodic recall
appointments to evaluate the oral hygiene level and monitor the status of the implants and
the supporting tissues. The third element is to make the patient adopt a lifetime
maintenance program, which is an important factor24 in long-term implant treatment
success (reference 24).

The daily home-care program must be customized to the individual's ability to clean the
oral cavity. After placement of the implants at stage-one surgery, hygiene recall visits at
appropriate intervals will be needed to prevent the occurrence of an inflammatory
response around teeth (if present) and in the area of implant surgery. Uncovering the
implants and placing abutments during stage-two surgery necessitates additional home-
care considerations. The sutures used in the tissues around the abutment make it more
difficult to maintain oral hygiene and there is a tendency for the patient to be afraid of
damaging the implant treatment.

Oral hygiene instructions should be performed for each type of prosthesis using soft
toothbrushes, floss/yarn, end-tufted brushes, interproximal brushes, and other aids.

Implant Single Crowns

Oral hygiene procedures around implant single crowns are managed in the usual manner
with toothbrushes and dental floss.

3
 Implant Fixed Partial Dentures
In addition to brushing and flossing, fixed partial dentures require the use of floss
threaders (EEZ-THRU, John O. Butler Co., Chicago, IL 60630) to transport the floss
beneath connectors and through cervical spaces between the prosthesis units so those
areas can be cleansed. Braided nylon filaments are available in thin and regular sizes
(POSTCARE, John O. Bulter Co.) to clean around implants (figure 6). Super Floss
and ULTRA FLOSS (Oral-B Laboratories, Belmont, CA 94002) can also be threaded
into cervical embrasure areas and used to clean interproximal surfaces.

When there is sufficient cervical space between the prosthesis units, an interproximal
brush (PROXABRUSH, John O. Butler Co.; Interdental Brush System; Oral-B) can
be used in the same manner it is used with conventional tooth supported fixed partial
dentures (video 1). Interproximal brushes are available with inserts that snap into the
handle (PROXABRUSH SNAP-ONS, John O. Butler Co.). The bristles are coated
with chlorhexidine (figures 7A, 7B)(video 2).

Implant Overdentures
Overdentures are cleaned in the same manner as when the prostheses are
supported/retained by teeth. The prosthesis is removed so it can be cleaned with a
denture brush that reaches into the concave portions of the intaglio surface and around the
retentive mechanisms. Ultrasonic cleaners are also very helpful in cleaning the prosthesis
and removing surface stains.

Cleaning around individual ball abutments is accomplished using a toothbrush. Bars are
cleaned using a toothbrush and end tufted brush (End Tuft Brush, John O. Butler Co.)
for accessible areas. An interproximal brush, Super Floss, ULTRA FLOSS, or floss
threaders/floss can be used to clean the tissue surfaces of bars that cannot be reached by a
brush.

Implant Fixed Complete Dentures

Oral hygiene around these prostheses is more difficult than with other implant
prostheses(video A). Conventional toothbrushes can be used to clean the facial, lingual,
and occlusal surfaces of the prosthesis and to clean accessible facial surfaces of the
implant abutments. End tuft brushes25 are also effective when cleaning facial surfaces as
they adapt to the curved surfaces and they also can enter into the proximal surfaces
(reference 25) (video 3).

An end tuft brush can be bent (figure 8A) in a manner that customizes it for the patient
and allows the brush to reach the lingual portion of the implant abutments and prosthesis.
Bending is accomplished by placing the neck of the brush in a Bunsen burner flame until
the plastic becomes pliable and then the tufted portion is bent until the desired angle is
formed between the handle and brush. The neck is placed under running water to cool
the plastic and fix the handle in its bent position (video 4).

4
Bending facilitates cleaning the lingual surfaces of the prosthesis and implant abutments
(figure 8B) and also allows the brush to reach under the cantilever extension when there
is sufficient vertical space between the cantilever and residual ridge (video 5).

Interproximal brushes (John O. Butler Co.; Oral-B) or wireless soft foam points (Oral-
B) are effective in cleaning the poximal surfaces between adjacent implants since they
function by being wedged between 2 opposing surfaces (figure 9). The main precaution
when using an interproximal brush is the wire. The use of plastic-coated brushes or
wireless soft foam points avoids scratching the metal surfaces (video 6).
In addition to the brushes, Super Floss can be used to clean between the abutments
(figure 10). Space permitting, gauze can be used to clean between abutments (figure 11)
and it can also be folded and used to clean the tissue surface of cantilever extensions
(video 7). Other types of oral hygiene aids have included yarn to clean beneath the
cantilever extensions (video 8) and interproximally (figure 12), Q-tips (figure 13), and
tulle (netting available in fabric stores) (figure 14A, 14B).

Chlorhexidine is often prescribed as an oral rinse that can help reduce the plaque on
teeth and implants. The chlorhexidine can also be applied around the abutment with a
brush or a cotton-tipped swab to minimize risk of staining and bad taste and to maximize
the concentration of the agent at the implant surface.

RECALL SCHEDULE

During the first year of treatment, patients should be seen after 1 week, 2 weeks, 1 month,
3 months, 6 months, and then one year following prosthesis placement. After the first
year, the patient should be placed on a recall which meets individual patient needs.
However, 6 months between recall visits is proposed as an appropriate interval for most
patients with implants. If hygiene maintenance is poor, the patient should be placed on a
3-month recall schedule and they should receive further instructions until the level of
care is satisfactory.

Items To Be Evaluated
1. Responses of the patient to questions: It is important to ask the patient
about any changes they have noted. Ask them if they are having any
discomfort, problems in chewing or oral hygiene challenges.

2. Periapical radiographs: The marginal bone height should be evaluated

around the implants as well as the axial adaptation of the bone to the implant
around its perimeter. Some marginal bone loss may be noted, typically about
0.9 millimeter loss during the first year and about 0.1 millimeter per year after
that. Healthy stable implants will display normal trabeculations around the
implants (figure 15). It is recommended that radiographs be taken twice per
year during the first 2 years following prosthesis placement and once per year
thereafter.

5
 3. Soft tissue evaluation: The soft tissue around implants should be evaluated
for changes in color and consistency. The tissue should be palpated for
exudate and pain. The conditions most frequently seen during recall
appointments are peri-implant mucositis, hyperplasia, small fistulas, and
increased oral exposure of the implant components. The soft tissue can be
evaluated for its tendency to bleed by bringing a probe into gentle contact
with the marginal soft tissue and rubbing it across the tissue.

4. Probing: Some clinicians/researchers feel the probing depth should be

regularly evaluated. Others feel that probing should only be performed when
significant radiographic bone loss or pathology are noted. There are others
who feel probing is not necessary and does not provide valuable information.
When using a probe, it should be made of plastic to protect the metal
components from being scratched (video 9).

5. Stability and fit of the prosthesis: The stability (lack of movement) of the
prosthesis should be evaluated. Movement of a prosthesis or a change in
marginal fit can be indicative of screw loosening/fracture. The prosthesis
should be evaluated for fracture of the prosthetic teeth, framework integrity,
occlusal contacts, etc. It is important to look for signs of bruxism (wear).

Oral Prophylaxis Modifications

Certain modifications in oral prophylactic procedures are necessary during recall
appointments of patients with implants. Conventional metal instruments and ultrasonic
cleaning devices may scratch the titanium components26 (reference 26). Plastic
instruments prevent scratches and abrasion of the titanium components and should be
used instead (figure 16)(video 10). Manual and mechanical scaler tips can be obtained
with Teflon coatings (E.A. Beck, Costa Mesa). Prophy-paste and similar substances
should be avoided since their abrasives damage the titanium surfaces. Sometimes when
screw-retained prostheses exhibit excessive amounts of calculus the prosthesis has to be
removed and cleaned outside the mouth. Cleaning the removed prosthesis is easily
accomplished using an ultrasonic cleaning device.

REFERENCES
1. Brnemark PI, Zarb GA, Albrektsson T. Tissue-Integrated Prostheses:
Osseointegration in Clinical Dentistry. Chicago; Quintessence Publishing Co., pp 65-
66.

In this early textbook about osseointegrated implants, all available knowledge at the time
was discussed. In the first chapter, Professor Brnemark introduced osseointegration and
discussed the criteria for clinical success or failure. He stated that the long-term healthy
state of the anchoring bone and the covering mucosa must be preserved both by precise
control of masticatory load distribution via a perfectly fitting prosthetic construction and
by maintaining the mucoperiosteal functional barrier toward the oral cavity at the
piercing abutments without persisting deep inflammatory processes.

6
2. Berglundh T, Lindhe J, Ericsson I, Marinello CP, Liljenberg B, Thomsen P. The soft
tissue barrier of implants and teeth. Clin Oral Impl Res 1991;2:81-90.

This study used 5 beagle dogs. Implants were placed in the edentulous mandibular
premolar area and, after 3 months, abutments were connected. After another 2 month
healing period, plaque control was initiated and maintained once a day for 8 weeks.
Clinical examinations were performed and then the implant area harvested for histologic
analysis. It was determined that both the marginal gingiva around the teeth and the peri-
implant mucosa had a keratinized oral epithelium. Both also had a junctional
epithelium with a length of approximately 2 millimeters. The height of the gingival
supracrestal connective tissue around teeth was approximately 1 millimenter. The
height of the connective tissue facing the implant surface was found to be approximately
2 millimeters i.e., two times that of the gingival supracrestal connective tissue (figure 2).
Orientation of the collagen fiber bundles around teeth was fan-shaped. The collagen
bundles in the peri-implant mucosa run mainly parallel with the implant surface. The
connective tissue portion around implants contains significantly more collagen (85% vs.
60%) and fewer fibroblasts (1-3% vs. 5-15%) than corresponding gingival connective
tissue.

3. Berglundh T, Lindhe J, Jonsson K, Ericsson I. The topography of the vascular

systems in the periodontal and peri-implant tissues in the dog. J Clin Periodontol
1994;21:189-193.

This histologic study involved 2 beagle dogs and two-stage implants. It was determined
that both the gingiva and peri-implant mucosa have a vascular plexus located lateral to
the junctional epithelium (a characteristic crevicular plexus). However, while the
supracrestal connective tissue located lateral to the cementum of teeth was richly
vascularized, the supracrestal connective tissue located lateral to the implant surface was
almost devoid of blood supply.

4. Ericsson I, Lindhe J. probing of implants and teeth. An experimental study in the

dog. J Clin Periodontol 1993;20:623-627.

The purpose of this study of 5 beagle dogs was to evaluate the resistance to probing
presented by the gingiva around the teeth and the peri-implant mucosa around implants.
The mean probing depth around teeth varied between 0.7 and 0.8 millimeters whereas the
mean depth around implants was 2.0 millimeters. At all the tooth sites, the probe tip was
found to be located a little (0.1 0.2 millimeters) coronal to the apical termination of the
junctional epithelium ( figure 2). With all the implant probing sites, the probe appeared
to have displaced the soft tissue and the probe tip was consistently located apical to the
apical termination of the junctional epithelium.

7
5. Adell R, Lekholm U, Rockler B, Brnemark PI, Lindhe J, Eriksson B, Sbordone L.
Marginal tissue reactions at osseointegrated titanium fixtures. Int J Oral Maxillofac
Surgery 1986;15:39-52.

The marginal hard and soft tissue reactions around implants placed in 16 completely
edentulous patients (95 implants) were studied. The examinations occurred at baseline
and after 6, 12, 21, 30 and 39 months. The mean probing depth was 2.9 millimeters at
the final examination. Seventy-two percent of the probing depths were less than 3
millimeters and 28% were found to be between 4 and 5 millimeters.

6. Pontoriero R, Tonelli MP, Carnevale G, Mombelli A, Nyman SR, Lang NP.

Experimentally induced peri-implant mucositis. A clinical study in humans. Clin
Oral Impl Res 1994;5:254-259.

This study involved partially edentulous patients. Following completion of active

periodontal therapy, implants were placed in posterior edentulous areas. Implants and
adjacent natural teeth were examined and compared.

A three week period of no oral hygiene resulted in gingivitis around teeth. Conversely,
the reinstitution of optimal oral hygiene resulted in re-establishment of gingival health.
The period of no oral hygiene demonstrated a similar cause-effective relationship
between the accumulation of bacterial plaque and the development of peri-implant
mucositis as established for the gingival units using the experimental gingivitis model
developed by Le. There was no significant difference between the amount of plaque or
gingivitis around implants compared to tooth sites.

7. Berglundh T, Lindhe J, Marinello C, Ericsson I., Liljenberg B. Soft tissue reactions

to de novo plaque formation at implants and teeth. An experimental study in the dog.
Clin Oral Impl Res 1992;3:1-8.

After a plaque control period of 6 months in the dogs, a baseline clinical and radiographic
examination was performed on both teeth and implants. Plaque was then allowed to
accumulate for 6 weeks and the ligatures were removed. One month later, clinical and
radiographic examinations were performed and biopsies obtained.

Results obtained from the clinical and histologic examinations indicated that the signs of
tissue destruction (clinical and radiographic) were greater around implants than teeth, and
the implant lesions extended into the bone marrow but did not with teeth.

8. Adell R, Lekholm U, Rockler B, Brnemark PI, Lindhe J, Eriksson B, Sbordone L.

Marginal tissue reaction at osseointegrated titanium fixtures. I. A 3-year longitudinal
prospective study. Int J Oral Maxillofac Surg 1986;15:39-52.

8
The authors determined the conventional clinical periodontal examination methods did
not appear to give a full comprehension of the conditions in the soft tissues adjacent to
fixture abutments.

9. Lekholm U, Adell R, Lindhe J, Brnemark PI, Eriksson B, Rockler B, Lindvall AM,

Yoneyama T. Marginal tissue reaction at osseointegrated titanium fixtures. II. A
cross-sectional retrospective study. Int J Oral Maxillofac Surg 1986;15:53-61.
These researchers indicated the presence of gingivitis and deep pockets were not
correlated with marginal bone loss nor the general presence of pathologic changes in the
marginal gingiva.

10. Apse P, Zarb GA, Schmitt A, Lewis DW. The longitudinal effectiveness of
osseointegrated dental implants. The Toronto study: Peri-implant mucosal response.
Int J Periodont Rest Dent 1991;11:95-111.

This study found no evidence to support a correlation between poor oral hygiene and
either implant loss or mucosal health.

11. Mombelli A, van Oosten MAC, Schurch E, Lang NP. The microbiota associated with
successful or failing osseointegrated titanium implants. Oral Microbiol Immunol
1987;2:145-151.

No significant difference was found between the plaque index of failed and successful
implants.

12. Quirynen M, Naert I, van Steenberghe D, Teerlinck J, Dekeyser C, Theuniers G.

Periodontal aspects of osseointegrated fixtures supporting an overdenture. A 4-year
retrospective study. J Clin Periodontol 1991;18:719-728.

The loss in marginal bone height did not clearly correlate with parameters such as the
plaque index, the gingival index, the presence or absence of attached gingiva around the
abutment, or the implant length.

13. Zarb GA, Schmitt A. Osseointegration for ederly patients: the Toronto study. J
Prosthet Dent 1994;72:559-568.

Successful osseointegration can be maintained irrespective of a patients oral hygiene

performance.

9
14. Wismeijer D, van Waas MA, Mulder J, Vermeeren JI, Kalk W. Clinical and
radiological results of patients treated with three treatment modalities for
overdentures on implants of the ITI Dental Implant System. A randomized controlled
clinical trial. Clin Oral Impants Res 1999;10:297-306.

No significant correlations were found between plaque and bleeding indices and bone
loss.

15. Weber HP, Crohin CC, Fiorellini JP. A 5-year prospective clinical and radiographic
study of non-submerged dental implants. Clin Oral Implants Res 2000;11:144-153

This prospective 5-year study not only calculated implant success by life table analysis,
but also evaluated the correlation between observed bone level changes and clinical
parameters such as suppuration, plaque indices, bleeding indices, probing depth,
attachment level and mobility.

A total of 112 ITI dental implants were inserted in different areas of the jaws. The low
levels of correlation between the individual and cumulative clinical periodontal
parameters with radiographically measured bone loss suggest that these parameters are of
limited clinical value in assessing and predicting future peri-implant bone loss.

16. Kirsch A, Mentag P. The IMZ endosseous two phase implant system: a complete
oral rehabilitation treatment concept. J Oral Implantol 1986;12:576-589.

Seventy-five percent of the implants lost in this study were associated with poor oral
hygiene or the lack of attached gingiva.

17. Mombelli A, van Oosten MAC, Schurch E, Lang NP. The microbiota associated with
successful or failing osseointegrated titanium implants. Oral Microbiol Immunol
1987;2:145-151.

This article was already cited as a study showing no relationship between periodontal
evaluation parameters and implant success since there was no significant difference in the
plaque index of failed and successful implants. However, the article also presented data
indicated there could be a relationship since sites with failing implants were found to be
associated with high proportions of microorganisms associated with periodontally
diseased states.

18. Henry PJ, Tolman DE, Bolender C. The applicability of osseointegrated implants in
the treatment of partially edentulous patients: Three-year results of a prospective
multi-center study. Quintessence Int 1993;24:123-129.

10
Implant failures were concentrated in patients with more plaque accumulation.

19. Block MS, Kent JN. Long-term follow-up on hydroxyapatite-coated cylindrical

dental implants: A comparison between developmental and recent periods. J Oral
Maxillofac Surg 1994;52:937-943.

The lack of keratinized gingiva and poor oral hygiene were some of the most common
reasons for implant loss.

20. Teixeira ER, Sato Y, Akagawa Y, Kimoto T. Correlation between mucosal

inflammation and marginal bone loss around hydroxyapatite-coated implants: A 3-
year cross-sectional study. Int J. Oral Maxillofac Implants 1997;12:74-81.

A statistical correlation was identified between bone loss and both the gingival index and
crevicular fluid volume.

21. Salonen MA, Oikarinen K, Virtanen K, Pernu H. Failures in the osseointegration of

endosseous implants. Int J Oral Maxillofac Implants 1993;8:92-97.

204 endosseous implants were (TPS, ITI, Bonefit, or Biolox) followed for 22.5 months in
this study (from 4 to 60 months). Fourteen implants were lost. Possible causes of failure
included advanced age and poor general health of the patient, complications in the
surgical procedures, and compromised oral hygiene.

22. Lindquist LW, Carlsson GE, Jemt T. A prospective 15-year follow-up study of
mandibular fixed prostheses supported by osseointegrated implants. Clinical results
and marginal bone loss. Clin Oral Implants Res 1996;7;329-336.

Smoking and poor oral hygiene had a significant influence on bone loss.

23. Tang Z, Sha Y, Lin Y, Zhang G, Wang X, Cao C. Peri-implant mucosal

inflammation and bone loss: clinical and radiographic evaluation of 108 dental
implants after 1-year loading. Chin J Dent Res 2000;3:15-20.

A significant positive correlation was found between mucosal inflammation and bone
loss (P < 0.05). One of the etiologic factors of alveolar bone loss around implants seems
to be plaque-associated marginal inflammation.

24. Koumjian JH, Kerner J, Smith RA. Hygiene maintenance of dental implants. Calif
Dent Assoc J 1990;18:29-33.

11
The authors make the following profound statement: patients must comprehend, from the
very beginning, that their compliance is very much a factor in the successful outcome of
their implant. The authors stress the importance of bringing the patient to an acceptable
level of oral hygiene before implant surgery and the use of chlorhexidine after surgery.

They illustrate angled brushes, use of a Q-tip, flossing, rotary electric brush,
interproximal brush, and plastic scalers. It is recommended that a copy of this paper be
made as it illustrates use of a variety of oral hygiene devices.

25. Balshi TJ. Hygiene maintenance procedures for patients treated with the tissue
integrated prosthesis (osseointegration). Quintessence Int 1986;17:95-102.

This article should be copied and used as a reference. It shows patient use of an end-
tufted brush, gauze, soft nylon mesh, superfloss, interproximal brush, and plastic hand
instrument use by a dental professional.

26. Gantes BG, Nilveus R. The effects of different hygiene instruments on titanium
surfaces: SEM observations. Int J Perio Rest Dent 1991;11:225-239.

This paper used a scanning electron microscope to evaluate the changes occurring on
titanium surfaces as a result of using different hygiene instruments. A ridge (0.55
millimeter wide and 0.11 millimeter high) was machined into 5 millimeter cylindrical
bars of pure titanium. The bars were subjected to a Gracey curet, plastic hand scaler, air-
slurry polisher, rubber cup and coarse pumice, and a sonic scaler with both a metal and
plastic tip.

The use of a Gracey curet for 15 seconds removed the vertical portion of the metal ridge.
The sonic scaler with a metal tip removed the entire metal ridge in 15 seconds. A rubber
cup and coarse pumice rounded the edge of the ridge in 15 seconds. No morphologic
changes were noted from either 15 or 30 seconds with the air-slurry polisher, the plastic
hand scaler, or the plastic tipped sonic instrument.

REFERENCE LIST
1. Brnemark PI, Zarb GA, Albrektsson T. Tissue-Integrated Prostheses:
Osseointegration in Clinical Dentistry. Chicago; Quintessence Publishing Co., pp 65-
66.
2. Berglundh T, Lindhe J, Ericsson I, Marinello CP, Liljenberg B, Thomsen P. The soft
tissue barrier of implants and teeth. Clin Oral Impl Res 1991;2:81-90.
3. Berglundh T, Lindhe J, Jonsson K, Ericsson I. The topography of the vascular systems
in the periodontal and peri-implant tissues in the dog. J Clin Periodontol 1994;21:189-
193.

12
4. Ericsson I, Lindhe J. probing of implants and teeth. An experimental study in the dog.
J Clin Periodontol 1993;20:623-627.
5. Adell R, Lekholm U, Rockler B, Brnemark PI, Lindhe J, Eriksson B, Sbordone L.
Marginal tissue reactions at osseointegrated titanium fixtures. Int J Oral Maxillofac
Surgery 1986;15:39-52.
6. Pontoriero R, Tonelli MP, Carnevale G, Mombelli A, Nyman SR, Lang NP.
Experimentally induced peri-implant mucositis. A clinical study in humans. Clin Oral
Impl Res 1994;5:254-259.
7. Berglundh T, Lindhe J, Marinello C, Ericsson I., Liljenberg B. Soft tissue reactions to
de novo plaque formation at implants and teeth. An experimental study in the dog.
Clin Oral Impl Res 1992;3:1-8.
8. Adell R, Lekholm U, Rockler B, Brnemark PI, Lindhe J, Eriksson B, Sbordone L.
Marginal tissue reaction at osseointegrated titanium fixtures. I. A 3-year longitudinal
prospective study. Int J Oral Maxillofac Surg 1986;15:39-52.
9. Lekholm U, Adell R, Lindhe J, Brnemark PI, Eriksson B, Rockler B, Lindvall AM,
Yoneyama T. Marginal tissue reaction at osseointegrated titanium fixtures. II. A
cross-sectional retrospective study. Int J Oral Maxillofac Surg 1986;15:53-61.
10. Apse P, Zarb GA, Schmitt A, Lewis DW. The longitudinal effectiveness of
osseointegrated dental implants. The Toronto study: Peri-implant mucosal response.
Int J Periodont Rest Dent 1991;11:95-111.
11. Mombelli A, van Oosten MAC, Schurch E, Lang NP. The microbiota associated with
successful or failing osseointegrated titanium implants. Oral Microbiol Immunol
1987;2:145-151.
12. Quirynen M, Naert I, van Steenberghe D, Teerlinck J, Dekeyser C, Theuniers G.
Periodontal aspects of osseointegrated fixtures supporting an overdenture. A 4-year
retrospective study. J Clin Periodontol 1991;18:719-728.
13. Zarb GA, Schmitt A. Osseointegration for ederly patients: the Toronto study. J
Prosthet Dent 1994;72:559-568.
14. Wismeijer D, van Waas MA, Mulder J, Vermeeren JI, Kalk W. Clinical and
radiological results of patients treated with three treatment modalities for
overdentures on implants of the ITI Dental Implant System. A randomized controlled
clinical trial. Clin Oral Impants Res 1999;10:297-306.
15. Weber HP, Crohin CC, Fiorellini JP. A 5-year prospective clinical and radiographic
study of non-submerged dental implants. Clin Oral Implants Res 2000;11:144-153
16. Kirsch A, Mentag P. The IMZ endosseous two phase implant system: a complete
oral rehabilitation treatment concept. J Oral Implantol 1986;12:576-589.
17. Mombelli A, van Oosten MAC, Schurch E, Lang NP. The microbiota associated with
successful or failing osseointegrated titanium implants. Oral Microbiol Immunol
1987;2:145-151.
18. Henry PJ, Tolman DE, Bolender C. The applicability of osseointegrated implants in
the treatment of partially edentulous patients: Three-year results of a prospective
multi-center study. Quintessence Int 1993;24:123-129.
19. Block MS, Kent JN. Long-term follow-up on hydroxyapatite-coated cylindrical
dental implants: A comparison between developmental and recent periods. J Oral
Maxillofac Surg 1994;52:937-943.

13
20. Teixeira ER, Sato Y, Akagawa Y, Kimoto T. Correlation between mucosal
inflammation and marginal bone loss around hydroxyapatite-coated implants: A 3-
year cross-sectional study. Int J. Oral Maxillofac Implants 1997;12:74-81.
21. Salonen MA, Oikarinen K, Virtanen K, Pernu H. Failures in the osseointegration of
endosseous implants. Int J Oral Maxillofac Implants 1993;8:92-97.
22. Lindquist LW, Carlsson GE, Jemt T. A prospective 15-year follow-up study of
mandibular fixed prostheses supported by osseointegrated implants. Clinical results
and marginal bone loss. Clin Oral Implants Res 1996;7;329-336.
23. Tang Z, Sha Y, Lin Y, Zhang G, Wang X, Cao C. Peri-implant mucosal
inflammation and bone loss: clinical and radiographic evaluation of 108 dental
implants after 1-year loading. Chin J Dent Res 2000;3:15-20.
24. Koumjian JH, Kerner J, Smith RA. Hygiene maintenance of dental implants. Calif
Dent Assoc J 1990;18:29-33.
25. Balshi TJ. Hygiene maintenance procedures for patients treated with the tissue
integrated prosthesis (osseointegration). Quintessence Int 1986;17:95-102.
26. Gantes BG, Nilveus R. The effects of different hygiene instruments on titanium
surfaces: SEM observations. Int J Perio Rest Dent 1991;11:225-239.

14