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Check-up parameters

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Introduction

Some patients believe that the treatment is over when the final replacement has been incorporated on the implants. Long-term success is especially dependant on the motivation and instruction of the patient for a careful oral and prosthesis hygiene. Regular check-ups are necessary.
Recalls are an integral part of therapy. A recall after three months during which the transgingival and subgingival calculus is removed can prevent subgingival colonization with bacteria associated with peri-implant complications (Fleming et al. 1990).
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Recall intervals

After the insertion of the suprastructure, the patient is called in for pre-determined intervals.
Then the adequate instruments for oral hygiene are selected and their use demonstrated.
  • 1 week after insertion of the suprastructure
    • Check of oral hygiene
    • Demonstration of plaque by disclosing agents
    • Re-motivation and re-instruction, if necessary
    • Check of suprastructure


  • 3 weeks
  • 6 weeks
  • 3 months
  • 6 months
Some patients have extensive and quickly developing calculus. These patients are recalled quarterly.

Normally, the recall appointments are every 6 months.

Check of oral hygiene, re-motivation, re-instruction

Use of plaque indicators to illustrate deficiencies in cleaning

If cleaning is deficient
  • The patient demonstrates the technique used at home
  • The treating person demonstrates better tools and/or techniques
  • The patient practices these methods

Radiographic control of the peri-implant bone situation

Compared with the probing depth, the radiological bone level shows a statistically significant correlation to the actual histological bone height of oral implants (Isidor 1997).

The recall check-ups should be performed according to a standardized protocol, if possible.

  1. X-ray is performed post-operatively immediately after the implantation

    Depending on the scope of the treatment, an orthopanthomogram (OPG), or 1/2 OPG is made. For single-tooth replacement, a dental radiographic film is sufficient.

  2. After prosthodontic treatment (insertion of the abutment or the suprastructure), a reference X-ray is taken.

    The geometric resolution should be as optimal as possible and it should be possible to adapt the beam direction. Panoramic radiography cannot meet these requirements. Intra-oral dental films are more suitable for this purpose.
    The bone level is shown and the exact fit between the abutment and the implant as well as between the abutment and the suprastructure are documented.

    #pic#
    Regarding beam geometry, the central beam should be vertical to the longitudinal axis of the implant and aligned to the film level.

  3. There should be a radiological check at every recall appointment.
    The bone level is compared to the reference X-ray following the insertion of the suprastructure. Therefore, the highest requirements for the reproducibility of the recordings (geometry, density, contrast) must be met. Density and contrast are set during the film development. The geometric resolution of intra-oral pictures is better than that of extra-oral pictures.
    The central beam should always be aligned in the same manner (see figure.)
Bone loss
  • Healing period
  • Loading phase
Tolerated horizontal bone loss
  • 0.4 - 1.6 mm within the first year after healing is complete
  • In the following years: 0 - 0.2 mm
In a review, 13 studies examining bone loss were evaluated in the first year. The average bone loss was 0.93 mm in the first year, ranging from 0.4 to 1.6 mm. In the following years, the average bone loss per year was 0.1 mm, the values ranged from 0 to 0.2 mm (Goodacre et al. 1999).

When the bone surrounding the implant shows progressive resorption, then there is a risk of implant loss.

Necessity of treatment

Treatment is necessary once the limits of tolerated bone loss are exceeded. In other words, with increased horizontal and vertical bone loss (wedge-shaped defects).

Manual mobility check

The check of the implant mobility is meaningful when the implant is close to loosing its bony connection (Teerlinck et al. 1991).

Assessment of gingival inflammation status

Gingival index

The meaningfulness of this parameter, which is very subjective, is very limited.

Sulcus fluid flow rate (SFFR)

A connection between the increase in the pocket depth and the SFFR values have been described (Spörlein et al. 1986, Günay et al. 1990)

Bleeding during probing

This clinical parameter is defined by the careful probing of the peri-implant sulcus or a pocket with a periodontal probe.
The diameter of the tip of the probe as well as the force used should be standardized.
The probing force is 0.25 N and the diameter of the tip of the probe should be 0.45 mm (Mombelli et al. 1992).

Probing depth

  • Based on the initial value
  • Determination with plastic probes (no damage to the titanium surface)
  • Measurements are often not possible with screw-shaped implants
  • Disadvantage: Bacterial transfer and partial damage to the peri-implant tissue

Check of suprastructure

The goal is a reduction of possible overloads that could put osseointegration at risk.

Pure implant-supported constructions

Control of
  • Screw fixation
  • Fitting without clefts or tension
  • Static and dynamic occlusion
Implant-supported dentures

Control of
  • Congruence
  • Static and dynamic occlusion
  • Fit of suprastructure
  • Stress check (tip test)
  • Retention of holding elements
Signs of overload
  • Fractures of the meso-structure
  • Repeated loosening of screws
  • Extensive grinding facets


sources

  • Flemmig TF, Berwick RHF, Newman MG, Kenney EB, Beumer J, Nachnani S, Nep R (1990)   Effekt des Recalls auf die subgingivale Mikroflora von osseointegrierten Implantaten   Z Zahnärztl Implantol 6: 45-51
  • Goodacre CJ, Kan JY, Rungcharassaeng K (1999)   Clinical complications of osseointegrated implants   J Prosthet Dent 1999 May;81(5):537-52
  • Isidor F (1997)   Histological evaluation of peri-implant bone at implants subjected to occlusal overload or plaque accumulation   Clin Oral Implants Res 8:1-9
  • Isidor F (1997)   Clinical probing and radiographic assessment in relation to the histologic bone level at oral implants in monkeys.   Clin Oral Implants Res 8:255-64
  • Mombelli A, Muhle T, Frigg R (1992)   Depth-force patterns of periodontal probing. Attachment-gain in relation to probing force   J Clin Periodontol 19:295-300
  • Teerlinck J, Quirynen M, Darius P, van Steenberghe D (1991)   Periotest: an objective clinical diagnosis of bone apposition toward implants   Int J Oral Maxillofac Implants 6:55-61