Renfert

PRACTICE-INTEGRATED, EFFICIENT AFTERCARE CONCEPTS

AS THE BASIS FOR SUCCESS IN IMPLANT PROSTHETICS

The success of endosseous implants has been proven by comprehensive data in numerous clinical studies. Initially interest was focussed on the success rate of osseointegrated implants in different areas of indication and bone quality as well as the effect of various implant designs (Esposito et al. 1998). It was only later that implant failures, which occurred during the functional phase of the restoration, also became a focus of interest. Apart from technical complications, biological problems are an example of failure risks in the functional period of the restoration (Norowski and Bumgardner 2009). The main cause of biologically induced problems in the late phase is progressive peri-implant in-flammation, which leads to destruction of the peri-implant hard tissue and consequently implant loss in the final stage (Lang et al. 2001).

Infection pattern The development of peri-implant mucositis has been proven to have a close causal relationship with bacterial plaque, despite the anatomical differences between teeth and implants (Beikler et al.2005). The microbial colonisation and formation of a multispecies biofilm follow the same pat- tern as on natural teeth. The submucosal biofilm accumulation is also an important aetiological factor with periimplant diseases. The microflora associated with peri-im- plantitis consists of periodontal pathogen species, which resemble the spectrum of periodontitis (Luterbacher et al. 2000). It can be assumed that bacterial processes on dental implants follow the same pattern as periodontitis – through translocation of bacterial germs from ecological niches in the oral cavity (back of the tongue, tonsils, buccal mucosa) as well as the supragingival and subgingival environment of the existing dentition (Klinge et al. 2002). Limits in therapy require prevention Occasionally extensive dental interventions are required with peri-implant diseases in order to maintain the function of an implant. In addition, not all current therapy options have been scientifically validated, as they only partly enable restitutio ad integrum. Effective prevention of peri- implantitis is therefore in the interest of the patient and cost bearers as well as in that of the medical provider. Based on the knowledge that the aetiological infec- tion pattern on the teeth and implants progresses in a similar manner the basic diagnostic methods used in periodontology can be applied with implant patients (Beik- ler et al. 2005). To ensure early diagnosis of peri-implant complications, it is highly recommended that patients with implants are included in an integrated aftercare concept (Esposito et al. 1999). Recall intervals of 3 months have proven successful in the case of partially edentulous patients and patients treated with implants. The recall interval should be 3 to 5 months (depend- ing on the individual status of oral hygiene) for edentulous patients who have been treated with an implant-supported restoration (Lang et al. 2000). The peri-implant probe depth should be recorded regularly at six-month intervals using the clinical parameter bleeding on probing. To ensure optimal aftercare, these values should be compared with the initial findings when the implant was first loaded. Recording the pocket probing depth at implants using special plastic periodontal probes, which was a requirement for many years, is now no longer considered necessary. Conven- tional metal periodontal probes not only just alter the rough implant surface to an insignificant degree but also ensure more reliable and reproducible diagnoses due to their more slender diameter and greater inherent rigidity in comparison with plastic probes. The radiological check of the peri-implant bone site is also given greater significance; a radiological check is recommended after 1, 3, and 5 years of pros- thetic loading and if there is normal clinical progress, it should be completed every 5 years (Zitzmann el. 2006).

Peri-implant aftercare concept At this present point in time there are no generally accepted guidelines for cleaning implant surfaces. The use of a combined mechanical anti-infective therapy similar to periodontitis therapy seems practical (Beikler et al. 2005, Esposito et al. 1999, Zitzmann et al. 2006). Mechanical removal of the bacterial biofilm is mainly used in the routine aftercare of implant patients. Air-powder-water sprays with a minimally abrasive blasting agent and also silicone cups with polishing paste or specially developed sonic scalers with silicone tips are suitable for subgingival cleaning of the polished surfaces of implant shoulders and superstructures (Mombelli & Lang 2000). With periimplant bone loss any cleaning of the predominantly rough implant surface that is necessary can also be performed using conventional sonic scalers, as instrumentation only alters the property of the implant surface to an insignificant degree (Lang et al. 1999). At present, the minimally abrasive air polishing technique using a glycine-based agent seems to be the most efficient and gentle method for conditioning submucosal implant surfaces. Adjuvant procedures in the aftercare concept Operator-removable superstructures should be removed, if possible, during implantological aftercare. This not only cre- ates better access to the individual implants but also enables the superstructure to be cleaned separately. In the case of implant- retained overdentures separate cleaning of the attachments and overdenture is particularly important, as there could be accretion, discoloration or calculus on these units. In the majority of cases the use of ultrasonic cleaners alone is not adequate for producing a satisfactory result. Gener- ally in these instances further cleaning is required using rotary instruments and drills - a procedure that is very time consuming and that is not sufficiently cost-effective in terms of business management. Efficient, effective cleaning Needle-cleaning techniques have been recommended for cleaning dentures for some years. The term needle cleaning is derived from the metal pins, which are used as a second component in combination with liquid during cleaning. A rotary magnetic field sets the pins in motion, which then produce gentle mechanical removal of the surface accretion. The rotating needles heat up the cleaning solution to approx. 45 °C and so accelerate the chemical reaction. This technique allows dentures that have been in situ to be cleaned fully automati- cally. Stubborn discoloration and calculus can be eliminated without removing any material, even on areas that are difficult to access. Many years of clinical experience with these systems indicate that interdental spaces, fissures and complex structures of precision attachments and retentive ele- ments are also effectively cleaned using this technique. Needle cleaning can be provid- ed as a practical additional service within the parameters of a structured prophylaxis programme. Generally patients who under- go implant prosthetic treatment are more compliant than patients who undergo conventional prosthetic treatment. The primary target group for additional services in a prophylaxis programme is therefore to be found in this segment: these patients attend the practice regularly and they have already exhibited their willingness to pay by opting for a high-quality restoration. A newly developed unit (SYMPRO, Renfert) based on the needle cleaning technique was recently introduced to the market. This unit is much more efficient than previ- ously available units, as it is possible to clean a denture effectively within 15 to 20 minutes. This means that the full cleaning cycle for the restoration can be completed parallel to the prophylaxis appointment - when the peri-implant aftercare is complete, the removable restoration has also been cleaned.

Before cleaning After cleaning with SYMPRO

Before cleaning After cleaning with SYMPRO DR. SVEN RINKE Hanau and Alzenau, Germany