contemporary implant debridement

Implant dentistry has become the standard of care for tooth

replacement in both fully and partially edentulous patients.

Due to this rapid evolution, the dental hygienist has been

thrust into the position of providing care for the peri-implant

environment. The long-term prognosis of an implant is

directly related to effective preventive care. The hygienist

must perform this care in a manner that is compatible with

contemporary implant restorative designs and is based on

the principles of maintaining soft tissue health.

IntroductionSince the introduction of osseointegrated implant dentistry,

numerous changes have occurred that challenge the clin-

ician. The rapid acceptance of implants and an increased

concern with achieving optimal aesthetics have resulted in

implant restorations that are frequently indistinguishable

from restored natural teeth. Indeed, radiographs are nec-

essary during the debridement process to differentiate

between implants and teeth. To understand which is the

appropriate instrument to be utilized, the hygienist must

become familiar with different restorative designs and where

the soft tissue restorative interface lies.

Soft Tissue InterfaceThe peri-implant tissues mimic those surrounding a natural

tooth in several aspects with some important differences.

A soft tissue crevice lined by sulcular epithelium sits just

coronal to a junctional epithelium that adheres to the

titanium surface and to a zone of connective tissue, which

merely adheres to the titanium (Figure 1).1,2 The zone of

connective tissue around a tooth, however, is attached by

gingival fibers that insert into the cemental surface.3 Another

difference exists apically. Each tooth is surrounded by a

periodontal ligament, a source of blood vessels and fibro-

blasts for the connective tissue attachment. The implant,

Valerie Sternberg-Smith, RDH, BS, has been a dental hygienist

and surgical assistant for 17 years in a practice limited to perio-

dontics and implant surgery. Ms. Smith is a faculty member in

both the Ashman Department of Implant Dentistry and the

Dental Hygiene Program at New York University, College of

Dentistry.

Robert N. Eskow, DMD, MScD, is a diplomate of the American

Board of Periodontolgy and Clinical Professor in the Ashman

Department of Implant Dentistry, New York University, College

of Dentistry. Dr. Eskow maintains a private practice limited to

periodontics, implant dentistry, and oral medicine in Livingston,

NJ and Clark, NJ.

ContemporaryImplant Debridement

Valerie Sternberg-Smith, RDH, BS

Robert N. Eskow, DMD, MScD

March /Apri l 2001 15

CECONTINUING EDUCATION

2

Figure 1. The soft tissue anatomy of the dental implant,abutment, and crown versus the natural tooth.

Crevice

SulcularEpithelium

JunctionalEpithelium

ConnectiveTissueAttachment

PeriodontalLigament

Root

Crown

Abutment

Crevice

SulcularEpithelium

Junctional Epithelium

ConnectiveTissueAdherence

Fixture

Bone

with its direct titanium-to-bone contact, lacks this soft tissue

reservoir (Figure 1). These differences explain why the peri-

implant mucosa has diminished capacity for self-repair in

the face of inflammation.4

Several experimental studies have demonstrated that

the destructive response to inflammation in the peri-implant

tissues is greater than in those tissues that surround the

natural tooth.4,5 Furthermore, the nature of the relationship

of the soft tissue to the restorative implant components

varies depending on the material employed. The soft-tissue-

to-titanium adhesions described in the aforementioned

studies do not occur in the presence of ceramic or gold

restorations.6 Due to the current interaction of peri-implant

tissues and bacteria, the emphasis must be on preventive

care to preclude the initiation of inflammation.

DebridementThe rationale for debridement is to control the bacterial

population, both quantitatively and qualitatively, in prox-

imity to the peri-implant mucosa. This is accomplished by

removing plaque and calculus while maintaining soft-tissue

adherance. Debridement is just as necessary for dental

implants as it is for the natural dentition, since peri-implant

disease has been demonstrated to result in bone loss and

ultimate loss of the implant fixture (Figure 2).7

Although implant dentistry became a well-established

clinical reality in the mid-1980s, it was not until several

years later that any mention of debridement was made in

the literature. Initial studies were observations utilizing a

scanning electron microscope (SEM) analysis of the effect

of various implements on titanium surfaces,8-10 but in subse-

quent discussions of clinical preventive care, there was

only nominal mention of the instrumentation process.11,12

Implant-supported restorations can range from single

crowns to attachments for overdentures to fixed-hybrid

dentures. The classic implant components the therapist

must be knowledgeable of during debridement are the

abutment and the prosthesis. In a restorative modification,

the abutment is absent, and the prosthesis attaches directly

to the implant fixture. Occasionally, the fixture is not com-

pletely encased in bone and is exposed to the oral cavity;

in such a case, it also requires debridement (Figure 3).

Contemporary Implant Debridement

16 The Journal of Practical Hygiene

Figure 3. The sheathed ultrasonic tip can be adaptedinto the crevice of an exposed implant fixture.

Figure 4. A metal curette is adapted to the pontic areaof this implant-supported bridge.

Figure 2. Implant-supported restorations resemblerestored natural teeth. The instrument is well-suited toenter a shallow peri-implant crevice and debride thelimited amount of abutment surface.

Instrument SelectionHistorically, preventive instrumentation in implant dentistry

has been discussed in universal terms.11-13 It may be more

appropriate to consider the specific components that require

debridement: the restoration, the transmucosal abutment,

and the fixture. Each component will influence the selec-

tion of instruments.

The Restoration

The basis for instrument selection is to leave the restoration

undamaged. The clinician can select an instrument based

strictly on the specific restorative material to be debrided; the

fact that the prosthesis is implant supported is irrelevant.

For example, if calculus is present on a porcelain-fused-

to-metal (PFM) crown, a metal curette may be used (though

the crown is implant supported), with care exercised

not to use this instrument apical to the restorative margin

(Figure 4). If soft debris alone is present on the restora-

tion (eg, crown, denture, attachments for overdentures), the

most effective way to deplaque is to polish with an appro-

priate prophy paste. When the restoration is a nonremov-

able hybrid denture, deplaquing the undersurface can be

accomplished with interdental brushes or tips, end-tuft

brushes, or floss materials.

For restorations that mimic crown-and-bridge dentistry

and have large embrasure areas, interdental brushes/tips

may be effective for gross plaque removal, but in most cases

the bristles do not penetrate into the peri-implant crevice.

Interdental brushes/tips should be used in a vigorous back-

and-forth motion against the walls of the restoration and

directed toward the tissue margin in an effort to reach into

the crevice. The depth of the crevice can be cleansed with

floss or a Perio-Aid™ (Marquis Dental Mfg, Aurora, CO).

A commonly placed implant in dentistry today is the

single-tooth replacement. Debridement of these restora-

tions requires an understanding of the peri-implant tissues

and the restorative components (Figure 5). Frequently, the

circumference of the crown is greater than the supporting

abutment. This results in a broad surface of restorative

material in contact with the soft tissue. Dental floss can be

adapted to the restoration and brought into the peri-implant

crevice, thus removing intracrevicular plaque (Figure 6).

Sternberg-Smith


Figure 5. Extensive crevicular depth is required to enabledevelopment of proper restorative contours. Instrumenta-tion of these deep crevices is limited in order to preventdamage to the soft tissues.

Figure 6. This posterior implant-supported restorationnecessitates deplaquing the abutment and the restora-tive material in contact with the soft tissue.

Fixture

Abutment

Crown

The Transmucosal Abutment

If a metal instrument is used during debridement of a

supra- and/or subgingival transmucosal titanium abutment,

it will roughen the surface,8-10 thus fostering bacterial

accumulation.14,15 The clinician must maintain the integrity

of the surface by using specially designed instruments.

Research has shown that scalers/curettes made of plastic and

plastic sonic and ultrasonic tips can be used without nega-

tively affecting the surface.16-18

The air syringe is an excellent tool that allows the

hygienist to deflect the tissue to view the peri-implant

crevice. In consideration of the vulnerability of peri-implant

tissue adherence, the scaler/curette should be delicately

placed into the crevice, positioned against the titanium sur-

face, and moved in a coronal direction toward the restora-

tion (Figure 7).

When only soft debris is present on the abutment, the

clinician needs to deplaque the surface. Supragingival abut-

ments can be polished using tin oxide or a prophy paste

specifically designed for polishing titanium surfaces. When

polishing the proximal area of the abutment is difficult, an

interdental brush/tip may be used. It is best to avoid those

with metal stems so as not to scratch the surface. Many imple-

ments include a plastic or nylon coating over the metal wire

that will prevent damage. A vigorous back-and-forth motion

against the titanium abutment surface will remove debris.



TableInstruments and Manufacturers

Hand Instruments ManufacturerImplacare™ Hu-Friedy (Chicago, IL)

Columbia 4R/4LAnterior Sickle H6/H7Posterior Sickle 204S

Implant-Prophy+™ Advanced Implant Technologies (Beverly Hills, CA)Gracey 5/6, 11/12, 13/14Columbia 13/14

HaweNeos™ (Graphite)Orofacial Scaler (Hoe) Premier (King of Prussia, PA)Columbia 4R/4L Implant Innovations Inc (Palm Beach Gardens, FL)

Nobel Biocare (Yorba Linda, CA)

Steri-Oss Implant Curettes™ (Graphite) Nobel Biocare (Yorba Linda, CA)Gracey 5/6, 11/12, 13/14Sickle

Power InstrumentsQuixonic Sonic Scaler SofTip™ Dentsply Professional (York, PA)Ultrasonic Tip Tony Riso Company, LLC (Miami Beach, FL)Profin™ Dentatus USA, Ltd (New York, NY)

Prophy PasteAbutment Glo™ Implant Innovations Inc (Palm Beach Gardens, FL)ImplantCleanic® Premier Dental Products Co (King of Prussia, PA)

Debridement AidsInterdental Brushes (coated wire) John O. Butler Co (Chicago, IL)Proxi-Tip™ (no wire center) Advanced Implant Technologies (Beverly Hills, CA)

Floss MaterialsSuper Floss® Oral-B Laboratories (Belmont, CA)Thornton’s Floss Thornton International Inc (Norwalk, CT)Proxi-Floss™ Advanced Implant Technologies (Beverly Hills, CA)Post Care® John O. Butler Co (Chicago, IL)Perio-Aid® Marquis Dental Mfg (Aurora, CO)

Frequently the abutment will be completely confined

within the peri-implant crevice so that optimal aesthetics can

be achieved. This area can be deplaqued with dental floss

with the clinician adapting the floss to the restoration and

continuing into the peri-implant crevice. Perio-Aid®, a device

made of a plastic handle that holds round wooden tooth-

picks, can be utilized as well. The wooden tips are placed

in the crevice at an oblique angle and moved 360 degrees

around the abutment surface. Each tip will splay as it is

moistened by saliva, creating a more efficient surface than

a plastic curette or scaler to remove soft debris or plaque.

When calculus is present on the abutment, it must also

be removed without altering the titanium surface. The instru-

ment selection for this purpose will depend on the access,

the location, the tenacity of the calculus, and the design of

the prosthesis. Many different plastic scalers/curettes can

clean a titanium surface and maintain its integrity. The clini-

cian needs to understand the advantages/disadvantages of

each instrument in order to make the appropriate selection.

Implacare™ (Hu-Friedy, Chicago, IL) instruments are

disposable plastic tips, available in presterilized packaging,

which screw into autoclavable metal handles. Small enough

to use in the peri-implant crevice, this instrument should

be placed apical to the calculus and moved in short strokes

in a coronal direction.

While these particular instruments are effective for

light calculus and crown-and-bridge-design restorations,

they can be too flexible to remove tenacious calculus. In

cases where a mandibular hybrid denture has been placed

in a mouth with severe ridge resorption, adaptation of

these tips is difficult due to shank length.

Implant-Prophy+™ (Advanced Implant Technologies,

Beverly Hills, CA) has slightly more bulk and is more rigid

than Implacare. The advantages of these autoclavable instru-

ments are rigidity; ability to be sharpened (with a special

stone), maintaining the effectiveness of the instrument over

time; and numerous blade configurations. Suitable for mod-

erate to heavy calculus, the instrument’s variety of config-

urations allows the clinician to select the most appropriate

one. A disadvantage is the bulk of the blade, which pre-

vents its utilization in the peri-implant crevice. This can be

corrected by reduction with the sharpening stone.

Plastic scalers/curettes reinforced with graphite are

the most rigid instruments available. They can be sharp-

ened, although a dedicated stone should be utilized for

this purpose. When a stone that previously sharpened a

metal instrument comes in contact with a plastic instrument,

metal filings can be embedded into the plastic cutting

blades, which may in turn roughen the titanium surface.

Different designs of this reinforced plastic are available: a

universal curette, a hoe, and various Gracey configurations.

All of these graphite instruments can be dry-heat sterilized

or autoclaved.

The blade of the universal curette is compact, similar

to that of a metal curette. Due to its thinness and rigidity,

the instrument can break, especially when utilized on tena-

cious calculus. This particular instrument is ideal for crown-

and-bridge-design restorations and is most suitable for light

to moderate calculus.

The hoe design has more bulk and is therefore ideal

for heavy calculus deposits. Effective on mandibular hybrid

denture designs in which access is difficult (Figure 8), this

Sternberg-Smith


Figure 7. An instrument is adapted to the abutmentsurface with minimal apical pressure to precludedisrupting the junctional epithelium.

Crown

Abutment

Fixture

Figure 9. An SEM (original magnification � 500) revealsno damage to the abutment surface following utilizationof a sheathed ultrasonic tip for 25 seconds on low power.

instrument is not appropriate for traditional posterior crown-

and-bridge designs.

The Gracey graphite configurations are smaller than

the Implant-Prophy+ curette, which in some limited-access

cases is beneficial. While these instruments can be sharp-

ened using a dedicated stone, the short blade face will limit

the number of times this can be done. The small Gracey

configurations can be advantageous in the posterior regions

with traditional crown-and-bridge restorations.

Power instruments can be used to remove plaque and

calculus from the titanium abutment surface as well. A plas-

tic sonic instrument has been shown to polish the titanium

surface in addition to removing debris.10 The autoclavable

metal tip attached to a disposable plastic sheath should be

held lightly against the surface and kept constantly mov-

ing to avoid damage.16

When an ultrasonic insert with an attached plastic

sheath (Tony Riso Co, Miami Beach, FL) is utilized on low

power with copious irrigation, no damage to the titanium

surface occurs (Figure 9). The ultrasonic insert and plastic

tip can be autoclaved without damage. As the tip is small

enough to fit into the crevice of the peri-implant tissues,

this instrument is very effective where there is limited access

and heavy calculus formation (Figure 3).

The newest power instrument available for implant

debridement is the Profin™ (Dentatus®, New York, NY). It

consists of a handpiece into which disposable nylon plas-

tic points are inserted. These tips move in a linear motion

and can remove both plaque and calculus. Scanning elec-

tron microscope examination revealed no damaging effects

on a titanium abutment surface after 25 seconds of appli-

cation (Figure 10). This tip contains no metal, which allows

for adaptation to the lateral walls of the abutment and

underside of the restoration, and is small enough to fit into

the peri-implant crevice. It can be used for heavy calculus

and difficult access areas typically associated with hybrid

designs (Figure 11).

Fixture

When the implant fixture is exposed within the peri-implant

crevice or supramarginally, debridement becomes both

necessary and challenging. The macro and micro architec-

ture of the fixture surface influences the quantity of plaque

and calculus,14,15 its retention, and the instrumentation neces-

sary to remove it. Whether the surface is machined, etched,

blasted, sprayed titanium, or hydroxyapatite coated is sig-

nificant. Plastic instruments previously described have been

shown to alter the abutment surface following utilization

on the surface of an implant fixture.17

The surface coating of the implant fixture is plaque

retentive, and the calculus that forms can be very tenacious,

as clinical experience has shown. Accordingly, a metal curette

or an ultrasonic tip seems the more appropriate choice.

When the exposed implant fixture consists of machined

threads, the clinician should take care not to increase the

roughness. Although it is difficult to remove calculus from



Figure 8. The Facial Scaler is ideal for removal of heavycalculus from mandibular anterior lingual surfaces.

the threads, this can be accomplished with one of the

power instruments with plastic tips previously described.

If only plaque is present, a soft-bristle brush can be

utilized to remove it. An end-tuft brush frequently is ideal

for this situation. This brush should be rotated in a small

circular motion around the fixture and abutment. It is much

easier to deplaque the fixture surface with a brush than

other plaque-control aids.

ConclusionImplant dentistry has demanded that practitioners acquire

new knowledge and techniques. Understanding the rela-

tionship of the peri-implant mucosa to the implant restora-

tion and the vulnerability of the tissue helps guide the

clinician in the debridement process and in the selection

of appropriate instruments. This selection should be based

on tip design and rigidity, consideration of the tenacity of

the calculus, the type of prosthesis, and the individual com-

ponent (ie, the fixture, abutment, or restoration) being

instrumented. The ultimate challenge facing the hygienist

is to preserve the bone supporting the implant.

References1. Buser D, Weber HP, Donath K, et al. Soft tissue reactions to non-

submerged unloaded titanium implants in beagle dogs. J Periodontol1992;63(3):225-235.

2. Schroeder A, van der Zypen E, Stich H, Sutter F. The reactions of bone,connective tissue, and epithelium to endosteal implants with titanium-sprayed surfaces. J Maxillofac Surg 1981;9(1):15-25.

3. Berglundh T, Lindhe J, Ericsson I, et al. The soft tissue barrier atimplants and teeth. Clin Oral Impl Res 1991;2:81-90.

Sternberg-Smith


Figure 11. The Profin™ is ideal for hybrid restorativedesigns and for the removal of heavy deposits from thefixture, abutments, and restoration.

Figure 10. An SEM (original magnification � 500) revealsno damage to the abutment surface using the Profin™with the Eva 123 tip for 25 seconds.

4. Lindhe J, Berglundh T, Ericsson I, et al. Experimental breakdown ofperi-implant and periodontal tissues. A study in the beagle dog. ClinOral Impl Res 1992;3:9-16.

5. Ericsson I, Berglundh T, Marinello C, et al. Long-standing plaque andgingivitis at implants and teeth in the dog. Clin Oral Impl Res1992;3(3):99-103.

6. Abrahamsson I, Berglundh T, Glantz PO, Lindhe J. The mucosal attach-ment at the different abutments. An experimental study in dogs. J ClinPeriodontol 1998;25(9):721-727.

7. Albrektsson T, Insidor F. Consensus report of session IV. In: Lang NP,Karring T, eds. Proceedings of the 1st European Workshop onPeriodontology. London, England: Quintessence Publishing; 1994:365-369.

8. Thomson ND, Evans GH, Meffert RM. Effects of various prophylactictreatments of titanium, sapphire, and hydroxyapatite-coated implants:An SEM study. Int J Perio Rest Dent 1989;9(4):300-311.

9. Rapley JW, Swan RH, Hallmon WW, Mills MP. The surface character-istics produced by various oral hygiene instruments and materialson titanium implant abutments. Int J Oral Maxillofac Impl 1990;5(1):47-52.

10. Gantes BG, Nilveus R. The effects of different hygiene instrumentson titanium surfaces: SEM observations. Int J Perio Rest Dent 1991;11(3):225-239.

11. Garber DA. Implants—the name of the game is still maintenance.Compend 1991;12(12):876,878,880 passim.

12. Koutsonikos A, Federico J, Yukna RA. Implant maintenance. J PracHyg 1996;5(2):11-15.

13. Orton GS, Steele DL, Wolinsky LE. Dental professional’s role in mon-itoring and maintenance of tissue-integrated prostheses. Int J OralMaxillofac Impl 1989;4(4):305-310.

14. Quirynen M, Bollen CM, Willems G, van Steenberghe D. Comparisonof surface characteristics of six commercially pure titanium abutments.Int J Oral Maxillofac Impl 1994;9(1):71-76.

15. Quirynen M, Papaioannou W, van Steenberghe D. Intraoral trans-mission and the colonization of oral hard surfaces. J Periodontol 1996;67:986-993.

16. Hollmon W, Waldrop T, Meffert R, Wade B. A comparative study ofthe effects of metallic, nonmetallic, and sonic instrumentation on tita-nium abutment surfaces. Int J Oral Maxillofac Impl 1996;11(1):96-100.

17. Rühling A, Kocher T, Kreusch J, Plagmann HC. Treatment of subgin-gival implant surfaces with Teflon®-coated sonic and ultrasonic scalertips and various implant curettes. An in vitro study. Clin Oral Impl Res1994;5:19-29.

18. Kwan JY, Zablotsky MH, Meffert RM. Implant maintenance using amodified ultrasonic instrument. J Dent Hyg 1990;64(9):422,424-425,430.


1. The soft tissue crevice around an implant islined with:A. Connective tissue.B. Gingival fibers.C. Sulcular epithelium.D. Bone.

2. What structure is absent in the soft tissuesurrounding an implant?A. Junctional epithelium.B. Periodontal ligament.C. Sulcular epithelium.D. Bone.

3. The destructive inflammatory response aroundan implant is __________ that around a tooth.A. Less than.B. Equal to.C. Unlike. D. Greater than.

4. What is the most effective way to removeplaque from the undersurface of a non-removable hybrid denture?A. Interdental brush.B. Floss.C. End tuft brush.D. All of the above.

5. Instrument selection is based on:A. The feel of the instrument.B. The component needing debridement.C. The type of instrument.D. The patient’s health history.

6. Which instrument is the most appropriate whenheavy calculus on the abutment is present andaccess is difficult? A. 4R/4L graphite instrument.B. Metal instrument.C. Hoe graphite.D. Implacare™ 4R/4L.

7. The ultrasonic insert with plastic sheath shouldbe used on a titanium abutment surface with:A. High power.B. Medium power.C. No irrigation.D. Low power.

8. What is the instrument of choice on an exposedcoated implant fixture with heavy calculus? A. Metal curette.B. Implacare™.C. Prophy+™.D. Graphite reinforced curette.

9. What is the instrument of choice when anexposed machine-threaded implant fixture hasonly plaque and soft debris?A. Plastic instrument.B. Floss.C. Perio-Aid™.D. End-tuft brush.

10. The most rigid plastic instruments are reinforcedwith the following:A. Silicone.B. Graphite.C. Metal.D. Acrylic.

To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and complete it

as follows: 1) Identify the article; 2) Place an X in the appropriate box for each question; 3) Clip the answer sheet from the page and

mail it to the CE Department at Montage Media Corporation. For further instructions, please refer to the CE Editorial Section.

Answers to the 10 multiple-choice questions for this CE exercise are based on the article “Contemporary Implant Debridement” by

Valerie Sternberg-Smith, RDH, BS and Robert N. Eskow, DMD, MScD. Answers will be mailed to all subscribers on a per test basis

within one month of the exam deadline.

WARNING: The Journal of Practical Hygiene encourages its readers to pursue further education when necessary beforeimplementing any new procedures expressed in this article. Reading an article in The Journal of Practical Hygiene doesnot fully qualify you to incorporate these new techniques or procedures into your practice.

Learning Outcomes:• Review the relationship between the peri-implant mucosa and implant-supported restorations.

• Understand the various factors that influence instrument selection for implant debridement.

• Examine the features of different instruments and consider their appropriateness for the task at hand.

CONTINUING EDUCATION (CE) EXERCISE NO. 2 CECONTINUING EDUCATION

2

contemporary implant debridement

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