Implant Maintenance: Long-term Implant Success










1192
42
Implant Maintenance:
Long-Term Implant Success
JON B. SUZUKI AND DIANA BRONSTEIN
T
he maintenance of endosseous implants has evolved over
many decades, from trial and error of various anecdotal
supportive therapy methods to evidence-based protocols.
ese newer maintenance protocols allow for the implant clini-
cian to implement individualized patient care of the peri-implant
tissues.
1,2
With patients understanding the benets of dental
implants, the dental profession is moving away from traditional
prosthetics and integrating the latest dental implant technologic
advances into treatment plans. erefore in the future, a greater
need will be required by the implant clinician to integrate a com-
prehensive systemic and supportive protocol to maintain the suc-
cess and longevity of the implant prosthesis.
3
Prevention of peri-implant disease is now an accepted funda-
mental cornerstone of eective and predictable treatment strate-
gies. e preventive approach commences with ideal and realistic
case selection, preoperative patient education, and control of risk
factors associated with increased implant complication incidence.
4
e lifelong professional implant maintenance protocol must be
communicated to and acknowledged by the patient as part of his
or her presurgical educational process. Patients at a higher risk
for the development of peri-implantitis need to be identied and
monitored with a stricter maintenance protocol. In addition,
because of the inherent dierences between implants and teeth,
patient education is crucial on the specics of hygiene with respect
to the dental implants and the type of prosthesis.
5
Anatomy of Peri-implant Hard and Soft
Tissues
e implant clinician must have a strong foundation for the rela-
tionship between the peri-implant tissues and the signs of disease
so that early detection and denitive treatment may be rendered.
If a disease process goes undiagnosed, hard and soft tissues com-
plications may lead to an increased morbidity of the implants or
associated prosthesis. When evaluating the hard and soft tissues
surrounding a dental implant, many dierences exist between the
natural teeth and dental implants. e support system of natural
teeth is much better designed to reduce biomechanical forces to
the crestal bone region, thereby reducing the possibility of peri-
implant disease. Because of the periodontal membrane, nerve and
blood vessel complex, and occlusal material (enamel), occlusal
overload is far less in comparison with dental implants.
6
Soft Tissue Differences
For a natural tooth the surrounding soft tissue has an average bio-
logical width of 2.04 mm between the depth of the sulcus and the
crest of the alveolar bone.
7
It should be noted that the biological
width” is actually a height dimension with a greater range in the
posterior region compared with the anterior and may be greater
than 4 mm in height.
8
With natural teeth the biologic width is
composed of a connective tissue attachment (1.07 mm average)
above the bone and a junctional epithelial attachment (0.97 mm
average) at the sulcus base, with the most consistent value among
individuals being the connective tissue attachment.
e connective tissue attachment zone of the “biological
width” around a tooth will prevent penetration into the sulcus
and allows gingival bers of the connective tissue attachment zone
to establish direct connection with the cementum of the natural
tooth. It acts as a physical barrier to the bacteria in the sulcus to
the underlining periodontal tissues. Eleven dierent gingival ber
groups comprise the connective tissue attachment zone observed
around a natural tooth and tissue: dentogingival (coronal, hori-
zontal, and apical), alveologingival, intercapillary, transgingival,
circular, semicircular, dentoperiosteal, transseptal, periosteogingi-
val, intercircular, and intergingival.
9
At least six of these gingival
ber groups insert into the cementum of the natural tooth: the
dentogingival (coronal, horizontal, and apical), dentoperiosteal,
transseptal, circular, semicircular, and transgingival bers. In addi-
tion, some crestal bers from the periodontal ber bundles also
insert into the cementum above the alveolar bone, forming a true
attachment to the tooth. Clinically this attachment will prevent a
periodontal probe from invading the periodontal ligament (PDL)
space and minimize the ingress of bacteria (Fig. 42.1).
In comparison, the sulcular regions around an implant are
very similar in many respects. e rete peg formation within the
attached gingiva and the histologic lining of the gingiva within the
sulcus are similar in implants and teeth.
10
A free gingival margin
forms around a tooth or implant, with nonkeratinized sulcular
epithelium and the epithelial cells. At the base, junctional epi-
thelial cells are present for both. However, a fundamental dier-
ence characterizes the base of the gingival complex around teeth.
Whereas a tooth has two primary regions that make up the bio-
logical width, an implant has only one (Fig. 42.2).
e biological seal for an implant, which is analogous to
the epithelial attachment of the tooth, is needed to protect

1193
CHAPTER 42 Implant Maintenance: Long-Term Implant Success
the implant-bone interface against bacterial irritants, as well
as mechanical trauma such as restorative materials, prosthesis
design, and occlusal forces. Cochran etal.
11
has reported the
biologic width to be 3.3 mm for dental implants, but unlike
the biological width dimension for teeth, they also included
the sulcus depth. In a typical implant gingival region, only
two of the gingival ber groups are found around a tooth (cir-
cular and periosteogingival bers), and no periodontal bers
are present.
12
ese bers do not insert into the implant body
below the abutment margin as they do into the cementum of
natural teeth.
13
Instead, the collagen bers around an implant
run parallel to the implant surface, not perpendicular, as with
natural teeth.
14
Hence the implant has only a junctional epi-
thelial “attachment” system. e gingival and periosteal ber
groups are responsible for the connective tissue attachment
component of the biological width around teeth, and these
are not present around the transosteal region of an implant.
e “biological width” around the abutment-implant connec-
tion should not be similarly compared with the connective tis-
sue attachment of a tooth. e biological seal around dental
implants may to some degree prevent the migration of bacteria
and endotoxins into the underlying bone. However, an attach-
ment component of the biological width similar to the one
found with natural teeth is not present with dental implants
(Fig. 42.3).
Tooth Versus Implant Movement
A natural tooth exhibits normal physiologic movements in verti-
cal, horizontal, and rotational directions. e amount of move-
ment of a natural tooth is related to its surface area and root
design. erefore the number and length of the roots; their diam-
eter, shape, and position; and the health of the PDL primarily
inuence a tooths mobility. A healthy tooth normally exhibits
zero clinical mobility in a vertical direction. Studies have shown
the actual initial vertical tooth movement to be approximately 28
μm and is the same for anterior and posterior teeth.
15
e vertical
movement of a rigid implant (i.e., integrated) has been measured
as 2 to 3 μm under a 10-lb force and is due mostly to the visco-
elastic properties of the underlying bone (i.e., bone density at the
bone-implant interface).
16
Muhlemann
17
found that horizontal tooth movement may be
divided into initial mobility and secondary movement. e initial
mobility is observed with a light force, occurs immediately, and
is a consequence of the PDL. Initial horizontal tooth mobility is
greater than initial vertical movement. A very light force (500 g)
horizontally moves the tooth. e initial horizontal mobility of a
healthy, “nonmobile” posterior tooth is less than that of an ante-
rior tooth and ranges from 56 to 75μm, which is two to nine times
the vertical movement of the tooth.
1mm
Sulcus
1mm
Epithelial
attachment
1mm
Connective
tissue
Fig. . The biologic width for a natural tooth is approximately 1 mm of connective tissue above the
bone and 1 mm of epithelial attachment between the sulcus and the connective tissue. (From Misch CE.
An implant is not a tooth: a comparison of periodontal indices. Dental Implant Prosthetics. 2nd ed. St.
Louis, MO: Mosby; 2015.)
F
CT
C
Fig. . The soft tissue around an implant (I) has a sulcular region very
similar to a tooth. A free gingival margin (F) with nonkeratinized sulcular
epithelium and cells at the base (C) has junctional epithelial attachment
above the bone (B). CT, Connective tissue.

1194
PART VIII Dental Implant Maintenance
Initial horizontal mobility is even greater in anterior teeth and
ranges from 70 to 108 μm in health
18
(Fig. 42.4).
e secondary tooth movement described by Muhlemann
17
occurs after the initial movement, when greater forces are applied.
When an additional force is applied to the tooth, a secondary
movement is also observed, which is related directly to the amount
of force. e secondary tooth movement is related to the viscoelas-
ticity of the bone and measures as much as 40 μm under consider-
ably greater force (Fig. 42.5).
When evaluating implant movement, “rigid xation” indicates
the absence of clinical mobility of an implant tested with vertical
or horizontal forces less than 500 g. Rigid xation is a clinical
term, and osseointegration is a histologic term. Osseointegration
is dened as bone in direct contact with an implant surface at the
magnication of a light microscope (Fig. 42.6). Over the years
these two terms have been used interchangeably, and implant
abutment support is most predictable with rigid xation. Lack
of implant mobility (IM) does not always coincide with a direct
bone-implant interface. However, when observed clinically, rigid
xation usually means that at least a portion of the implant is in
direct contact with bone, although the percentage of bone contact
cannot be specied. A mobile implant indicates the presence of
connective tissue between the implant and bone.
Increased tooth mobility may be caused by occlusal trauma or
bone loss. Increased tooth mobility alone is not a criterion of peri-
odontal health or pathology. Unlike a tooth, for which mobility
is not a primary factor for longevity, mobility is a primary deter-
mining factor for implant health. Rigid xation is also an excel-
lent indicator of the implant health status because it is an easy,
1 mm
0.5 mm
Bone
crest
FGM
Implant
platf
orm
CT
JE
Sulcus
Fig. . An implant has no connective tissue fibers in the connective
tissue zone that insert into the implant. The peri-implant probe penetrates
the sulcus, junctional epithelial attachment (JE), and most of the connec-
tive tissue zone. CT, Connective tissue; FGM, free gingival margin. (From
Misch CE. An implant is not a tooth: a comparison of periodontal indices.
Dental Implant Prosthetics. 2nd ed. St. Louis, MO: Mosby; 2015.)
0.108 mm
0.028 mm
Physiologic
movement
Fig. . The physiologic movement of a tooth has been measured as
28 μm in the apical direction and up to 108 μm in the horizontal direction.
(From Misch CE. An implant is not a tooth: a comparison of periodontal
indices. Dental Implant Prosthetics. 2nd ed. St. Louis, MO: Mosby; 2015.)
15
mm
100
10
5
0
100 g 500 g
AB
Fig. . A secondary horizontal movement of a tooth occurs after the
initial tooth movement when a greater force is applied and is related to
the deformation of the alveolar bone. (From Misch CE. An implant is not
a tooth: a comparison of periodontal indices. Dental Implant Prosthetics.
2nd ed. St. Louis, MO: Mosby; 2015.)
Fig. . Osseointegration is a histologic term that describes a direct
bone-implant contact at the level of magnification of a light microscope.

1195
CHAPTER 42 Implant Maintenance: Long-Term Implant Success
objective test. As such, rigid xation is usually the rst clinical cri-
terion and the most important when evaluating a dental implant.
Past techniques to evaluate primary stability and mobility of
dental implants have included percussion and mobility tests with
mirror handles. However, these techniques were very subjective
and were associated with inaccurate results. In implant dentistry
today, the most common technique to assess the stability of dental
implants is the use of resonance frequency analysis (RFA). Reso-
nance frequency analysis (RFA) is a non-invasive, reliable, and
clinically acceptable technique developed by Meredith in 1996.
19
is technique includes magnetic pulses being sent to a small
metal post that is temporarily attached to the implant. As the
post vibrates, the probe reads the resonance frequency which is
translated into a value termed implant stability quotient (ISQ).
e ISQ value is evaluated via a scale that ranges from 1 to 100,
with high values indicating increased stability. Usually, acceptable
ranges of stability lie between 55 – 85 ISQ, with values below
55 indicating possible mobility of the implant.
20
is technol-
ogy is advantageous as measurements may be taken at the time
of implant placement and used as a baseline for future measure-
ments in the evaluation of the health of the dental implant. e
Penguin RFA® (Glidewell Direct; Irvine, Calif.) is commercially
available which uses re-usable multi-pegs that are implant specic.
In addition, this device is cordless which is very user friendly for
the clinician. When evaluating mobility of the implant, ideally the
prosthesis should be removed, which allows for the multi-pegs to
be directly inserted into the implant body.
Evaluating the mobility of the prosthesis does not allow for
an accurate assessment of dental implant health as the associ-
ated mobility is most commonly from a loose abutment screw
(Box 42.1 and Fig. 42.7).
A natural tooth with primary occlusal trauma exhibits an
increase in clinical mobility and radiographic PDL space. After the
cause of trauma is eliminated, the tooth may return to zero clinical
mobility and a normal radiographic appearance. is scenario is
not predictable around an implant. e implant clinician should
not restore an implant with any clinical mobility, because the
risk for failure is great. However, after the prosthesis is completed
and IM-1 develops, the risk is small to evaluate the implant for a
few months and decrease almost all stress during this time frame.
Implants with slight detectable mobility of approximately 0.1 mm
of horizontal movement (IM-1), similar to the mobility of a healthy
central incisor, on occasion may return to rigid xation and zero
mobility. However, to reachieve rigid xation, the implant should
be taken completely out of occlusion for several months and strictly
monitored. e return of rigid xation of an implant is far greater
if no mobility is noted before the implant is placed into function.
An implant with horizontal movement greater than 0.5 mm
(IM-3) is at much greater risk than a tooth. A root form implant
with greater than 0.5 mm horizontal mobility (IM-3) or any vertical
mobility (IM-4) should be removed to avoid continued bone loss and
future compromise of the implant site or adjacent teeth (Table 42.1).
Maintenance Protocol
Medical and Dental Histories
e rst step in the maintenance protocol is to update the patients
medical and dental histories. is is a mandatory component of
the maintenance protocol and is crucial in determining whether
there presently exist any concomitant conditions that would pre-
dispose the patient to peri-implant disease.
Medical History
Medical conditions may change during the maintenance phase
(i.e., after implant prosthesis completion) of treatment that have
a direct impact on the morbidity and success of the implants or
prosthesis. It is imperative the patient relates any updates to his or
her medical history because many systemic conditions may aect
the long-term prognosis of dental implants and the prosthesis.
1. Xerostomia: e lack of saliva (i.e., dry mouth) is caused by
hypofunction of the salivary glands and may be caused by
numerous medications and systemic conditions. Most com-
monly, autoimmune conditions may result in xerostomia, as
well as many medications, especially if given concurrently.
A
B
Fig. . (A, B) Penguin Resonance Frequency Analysis Unit (Aseptico)
which measures the ISQ (Implant Stability Quotient) implant stability using
reusable, calibrated MulTipegs.
Scale Description
0 Absence of clinical mobility with 500 g in any direction
1 Slight detectable horizontal movement
2 Moderate visible horizontal mobility up to 0.5 mm
3 Severe horizontal movement greater than 0.5 mm
4 Moderate-to-severe horizontal and any visible vertical
movement
BOX
42.1
Mobility Measurements
97

1196
PART VIII Dental Implant Maintenance
Xerostomia has been shown to aect the dental biolm com-
position and intraoral healing of the soft tissues. Immune cells
(e.g., neutrophils) and immune factors (e.g., lysozyme, secre-
tory IgA) are normally delivered and distributed in the oral
cavity through the saliva; therefore a lack of saliva may lead to
lowered antimicrobial components in the oral cavity.
21-24
Prosthetically, patients who acquire xerostomia after completion of
treatment may become compromised. For example, a patient with
a soft tissue–borne implant prosthesis (i.e., RP-5 overdenture) may
experience soft tissue irritation because of the lack of saliva.
2. Autoimmune diseases: Selected autoimmune diseases have
been associated with peri-implantitis. For example, lichen
planus causes the hemidesmosomal epithelial attachment to
the implant surface to become disabled, leading to peri-
implant mucositis and possibly progressing to peri-implantitis.
25
However, long-term implant survival, according to current
research, does not seem to be aected.
26
With many auto-
immune diseases, patients may lose their manual dexterity,
thereby decreasing hygiene ability and also diculty in remov-
ing an attachment-dependent overdenture prosthesis. Some of
the more common autoimmune disorders and the associated
symptoms that may aect the oral cavity are as follows:
• Sjogrenssyndrome:xerostomia
• Systemiclupuserythematosus:corticosteroidtreatmentand
immunosuppressive medications
• Scleroderma: manual dexterity and immunosuppressive
medications
• Rheumatoid arthritis: manual dexterity and immunosup-
pressive medications
• HIV:compromised lymphocytes and immunosuppressive
medications
3. Bone diseases: Altered bone physiology in conditions such
as osteoporosis/osteomalacia/osteopenia, Paget’s disease, and
brous dysplasia may signicantly increase the risk for com-
plications for implant patients.
27
4. Diabetes: Poor diabetic control (i.e., > 7% A
1c
) correlates
the inammatory markers closer to patients with chronic
periodontitis when peri-implantitis is present. Patients with
diabetes, especially if uncontrolled, are prone to acquire
infections and vascular complications. e healing process is
aected by the impairment of vascular function, chemotaxis,
and neutrophil function, as well as an anaerobic milieu. Pro-
tein metabolism is decreased, and healing of soft and hard
tissue is delayed, which may lead to the susceptibility of
infection. Neuropathy and impaired nerve regeneration may
be altered, as well as angiogenesis.
28
5. Pregnancy: During the maintenance period, radiographs
should be delayed until after birth with pregnant patients.
Medical clearance should be obtained if radiographs or pro-
cedures need to be performed on an emergency basis.
Comprehensive Dierences Between Natural Teeth and Dental Implants
Natural Teeth Dental Implants
Interface Periodontal membrane Direct bone
Junctional epithelium Hemidesmosomes and basal lamina (lamina lucida and
lamina densa zones)
Hemidesmosomes and basal lamina (lamina lucida and lamina
densa, and sublamina lucida zones)
Connective tissue 12 groups: six insert perpendicular to tooth surfaces
Collagen, fibroblasts
Only two groups: parallel and circular fibers; no attachment to
the implant surface
Collagen, fibroblasts
Vascularity Greater; supraperiosteal and PDL Less; mainly periosteal
Biologic width 2.04–2.91 mm 3.08 mm
Mobility +
Pain +/− (tooth may be hyperemic)
Attrition + Wear facets, abfraction, fremitus − ( porcelain fracture, possible screw loosening)
Radiographic changes + Increased radiopacity and thickness of cribriform plate Crestal bone loss
Interference awareness + (Proprioception) − (Osseoperception)
Nonvertical forces Relatively tolerated Results in bone loss
Force-related movement Primary: movement of PDL
Secondary: osseous movement
Primary: osseous movement
Lateral force Apical third of root surface Crestal bone
Lateral movement 56–108 μm 10–50 μm
Apical movement 25–100 μm 3–5 μm
Tactile sensitivity High Low
Signs of overloading PDL thickening, fremitus, mobility, wear facets, pain Screw loosening, screw fracture, abutment fracture, implant
body fracture, bone loss
PDL, Periodontal ligament.
TABLE
42.1

1197
CHAPTER 42 Implant Maintenance: Long-Term Implant Success
6. Radiation treatment to the oral cavity: Patients who receive
radiation to the oral cavity after implant treatment may suf-
fer from many decits including oral mucositis, xerostomia,
compromised healing, and reduced angiogenesis. is is
a direct result of changes in the vascularity and cellularity
of hard and soft tissue, damage to the salivary glands, and
increased collagen synthesis that results in brosis. erefore
patients exhibiting these complications should be treated
symptomatically. Patients who presently wear a tissue-borne
prosthesis (RP-5) may benet from changing the nal pros-
thesis to a xed (non-tissue-bearing) prosthesis.
7. Sleep apnea: Patients who are diagnosed with sleep apnea are
often treated with continuous positive airway pressure(CPAP).
e CPAP machine uses a hose and mask that delivers constant
steady air pressure. CPAP machines may place an increased
force on the oral cavity. erefore if patients are using a CPAP
machine, the implant area should be monitored closely.
8. Elderly patients: Elderly patients have been shown to have
many issues with adapting to the nal implant prostheses.
Postinsertion complications such as muscle control, hygiene
diculty, tissue inammation, and overdenture seating are
signicant in the older population study. During maintenance
visits, patient education should be continuously reenforced.
9. Smoking: e use of tobacco should be closely monitored
with implant patients. Studies have shown the detrimental
eects of the gases and chemicals (e.g., nitrogen, carbon mon-
oxide, carbon dioxide, ammonia, hydrogen cyanide, benzene,
nicotine) released in cigarette smoke. Multiple retrospective
studies have shown that smokers experience almost twice as
many implant failures compared with nonsmokers, and there
exists a strong correlation with peri-implantitis.
29
e nega-
tive eects of smoking on the implants/prosthesis should be
reenforced at each maintenance visit.
10. Phenytoin (Dilantin): e most common medication to
cause peri-implant conditions is phenytoin (Dilantin). Dilan-
tin is associated with a high incidence of gingival overgrowth
(hyperplasia) of peri-implant soft tissue, implant gingival
hyperplasia, mucosal proliferation, proliferative gingivitis, and
implant-related tissue hyperplasia, and has been recognized as a
signicant clinical issue in implant dentistry today. If there is
no associated bone loss, the pockets are termed pseudopockets
or gingival pockets. ese hyperplasia-induced pockets may
harbor pathogenic anaerobic bacteria. e plaque biolm
colonization and maturation in implant pockets initiates
inammation. e resultant hyperplastic tissue is most com-
monly composed of compact collagenous bers, broblasts,
and inammatory cells. Management of peri-implant gingival
overgrowth should include the identication of the etiology
(e.g., medication or humoral). If the etiology is determined
to be medication induced, consultation with the patient’s
physician is recommended for possible alternative treatment.
11. Miscellaneous: Epidemiologic and longitudinal studies have
found an association of peri-implantitis prevalence with hepa-
titis and cardiovascular disease.
30
Cardiovascular disease is
associated with periodontitis and peri-implantitis through the
systemic-inammatory-mediator link and appears to be an
indirect cofactor in patients whose prole identies them as
being predisposed to inammatory diseases.
31
Interestingly, genetics has been implicated with aggressive peri-
odontal diseases, which appear to be correlated with peri-implantitis.
Studies associate peri-implant disease with the IL-1 gene polymor-
phism in smokers.
32
Dental History
e dental history update is crucial in determining any changes to
the patient’s oral condition. Changes in home care practices, along
with recent dental treatment, should be documented and evaluated
for any impact on the implant prostheses. Of special concern are
parafunctional habits (e.g., clenching, bruxism), which if present
or worsening may lead to peri-implant diseases or implant failure.
Clinical Evaluation of the Implant(s)/Prosthesis
Soft Tissue Assessment
An overview of the visual signs of gingival inammation (e.g.,
redness, edema, alterations of tissue contour, stula tracts)
should be evaluated and documented. Poor tissue tone (i.e.,
thin, friable, accid) surrounding an implant may harbor food,
plaque, and calculus, which increases the possibility of inam-
mation and infection. A gingival health index may be used to
evaluate the soft tissue health. e most common bleeding
gingival index used for implants is the Loe and Silness gingival
index. When used on teeth, this index scores gingival inamma-
tion from 0 to 3 on the facial, lingual, and mesial surfaces of all
teeth. e symptom of bleeding comprises a score of at least 2
(Box 42.2). e facial and lingual are already being probed to
evaluate bone loss that cannot be seen on a radiograph. Because
the bleeding index evaluates inammation, the Loe and Silness
index is adequate for implants, and because fewer implants typi-
cally are used to restore a region compared with the presence
of natural teeth, one also may evaluate the distal surface when
bleeding is present
33
(Fig. 42.8).
Assessment of Home Care
Because the presence of microbial biolm has been shown to be
a leading factor in the pathogenesis of peri-implant disease, the
routine assessment of plaque accumulation should be a priority
of each maintenance visit. is objective form of plaque monitor-
ing should ideally be performed and documented at each mainte-
nance visit. Consistent use of the same plaque index is paramount
because this will allow an easier determination of the presence of
a disease process. High plaque scores have been shown to have a
direct correlation with peri-implant mucositis and increased prob-
ing depths.
34
Mombelli etal.
35
and Lindquist etal.
36
have reported
implant-specic plaque indices to be used at dental implant main-
tenance appointments. Mombelli etal.
35
suggested a numerical
scale from 0 to 3, which is dependent on the amount of visible
plaque present or by running a probe over the implant surface.
Lindquist etal.
36
recommended a similar scale (i.e., 0–2) depen-
dent on the amount of visible plaque (Fig. 42.9 and Box 42.3).
Probing
Probing around dental implants is a controversial topic even
though it has been shown in the literature to be a reliable and
important factor in determining peri-implant health. e safety of
probing, once thought to be detrimental, has been well established
Normal
0 = mild inflammation, slight color change and edema, no bleeding
1 = moderate inflammation, redness, edema, bleeds on probing
2 = severe inflammation, marked redness and edema ulceration,
spontaneous bleeding
BOX
42.2
Loe and Silness Bleeding Index

1198
PART VIII Dental Implant Maintenance
and does not jeopardize the integrity of the implant system.
37,38
Etter etal.
39
reported after probing of the implant system, healing
of the epithelial attachment will occur approximately 5 days after
clinical probing.
e connective tissue zone for an implant has only two ber
groups, and neither of them inserts into the implant. As a result, with
an implant, the probe goes beyond the sulcus, through the junctional
epithelium attachment, and through the type III collagen connective
tissues and reaches closer to the bone.
40
Because the probe penetrates
deeper next to an implant compared with a tooth, one should take
care not to contaminate the implant sulcus with bacteria from a dis-
eased periodontal site. To prevent contamination, the dental probe tip
may be placed in chlorhexidine after each reading, thereby reducing
the possibility of inoculating the sulcular area of the next probed area.
In most cases probing depths of 2 to 4 mm have been established as a
healthy condition
41
(Figs. 42.10 and 42.11).
In addition, there exists controversy concerning the type of
periodontal probe to use with dental implants. Many authors
have advocated the use of plastic periodontal probes
42,43
; how-
ever, more recent articles have recommended conventional metal
A B
C
D
Fig. . Soft Tissue Assessment. (A) Edematous tissue surrounding dental implant. (B) Significant
gingival recession leading to exposure of the implant bodies allowing for plaque accumulation. (C) Poor tis-
sue quality resulting from facial bone loss. (D) Soft tissue recession resulting from apical positioned implant
which leads to soft tissue loss and resultant black triangles.
AB
Fig. . (A and B) Plaque accumulation as a result of recession and poor oral hygiene.

1199
CHAPTER 42 Implant Maintenance: Long-Term Implant Success
probes because they do not appear to damage the mucosal attach-
ment or mar the implant surface.
44,45
Ideally there should be baseline clinical probing depths acquired
after the initial insertion of the prosthesis. However, in some cases,
because of malpositioned implants or an overcontoured prosthe-
sis, obtaining true probing depths may be dicult. In these cases a
more routine radiographic evaluation is indicated to help ascertain
peri-implant health.
When bleeding on probing is present, usually this is indica-
tive of positive peri-implant disease. Studies have shown that simi-
lar to natural teeth, the absence of bleeding on probing may be
interpreted as highly predictive of stability of the peri-implant tis-
sues.
46,47
However, a positive correlation exists with bleeding on prob-
ing and histologic signs of inammation at peri-implant tissue levels.
48
Care should be exercised to avoid false-positive readings
for bleeding on probing depths. Gerber etal.
49
reported that a
pressure of approximately 0.15 N should be used to minimize
incorrect readings. Probing around dental implants has been
shown to be more sensitive to force variation in comparison with
natural teeth.
50
e thickness and the type of tissue may inuence the mucosa/
epitheliumsurroundingadentalimplant.VanSteenbergheetal.
51
determined that shallow (minimal) probing depths are associated
with keratinized tissue, and deeper probing depths are consis-
tent with alveolar mucosa (i.e., movable tissue) surrounding the
implant.
On probing the peri-implant tissues, if suppuration is pres-
ent, the implant clinician should be conscious of the strong
evidence of the presence of infection or peri-implant disease.
Radiographic evaluation should be immediately completed
to determine the etiology of the exudate and the infectious
origin.
When evaluating probing depths, greater than 3 mm is not a
denite sign of peri-implantitis; peri-implant tissue dimensions
are inuenced by the implant type and shape, the connections
of the multiple components (material and retention mode), and
the prosthetic restoration design and conguration. Coveted soft
tissue conditioning in the esthetic zone to simulate an interdental
papilla can lead to an increase in the distance from the implant
shoulder to the mucosal margin of up to 5 mm.
52
Clinical pre-
sentations may be misdiagnosed as peri-implantitis when factors
such as mucositis and marginal bone remodeling ensue from deep
positioning of the implant for more acceptable esthetic outcomes.
e diagnosis of peri-implantitis may also be caused by the local
anatomic variations.
53
Controversy surrounds the issue of using bleeding and gingi-
val health as an implant health indicator. Unlike a natural tooth,
implant success in the rst few years is related more often to bio-
mechanical equilibrium than to gingival health. Compared with a
natural tooth, the soft tissue inammation caused specically by
bacteria may be more restricted to above the crestal bone, because
of the lack of a periodontal membrane or brous tissue between
the implant and the bone interface. As a result the bleeding index
may not be as signicant when evaluating early implant health
status.
54
Presence of Keratinized Tissue
In recent literature, compelling clinical published reports have cor-
related peri-implantitis with keratinized gingiva and biotype thick-
ness. A few studies have shown a minimal correlation between
keratinized tissue and implant success. However, other reports
have shown a lack of keratinized tissue is associated with bone
loss,
55
increased plaque acculumlation,
56
increased gingival reces-
sion,
57
increased gingival inammation,
58
and a higher frequency
of bleeding on probing.
59
The soft tissue at the implant site has been recognized as a
crucial factor in long-term maintenance of healthy implant res-
torations. The soft tissue quality at the implant site, together
with the gingival biotype, is a predisposing factor in a patients
resistance to plaque accumulation and inflammatory-mediated
peri-implant disease.
60,61
Unattached, nonkeratinized muco-
sal tissue is more problematic because implants do not have
inserting supracrestal gingival fibers, which serve as a barrier
to bacterial insult; Sharpeys fibers run parallel to the implant,
leaving only the hemidesmosomal seal of the junctional epi-
thelium at the neck of the implant to protect underlying soft
and hard peri-implant structures. During the mastication pro-
cess, this seal may be broken when the vestibule is shallow
and frenum attachment is high, causing excess pressure on the
Lindquist Plaque Index
0 = no visible plaque
1 = local plaque accumulation
2 = general plaque accumulation (>25%)
Mombelli Plaque Index
0 = no visible plaque
1 = plaque recognized by probing over smooth margin of implant
2 = visible plaque
3 = abundance of soft matter
BOX
42.3
Plaque Index Evaluations
Bone crest
FGM
CT
JE
Sulcus
Fig. . A probe placed into the sulcus of a tooth goes through the
sulcus and the epithelial attachment. It is stopped by the connective tissue
attachment. The biological width of a natural tooth has a connective tissue
zone that inserts into the cementum of the tooth. A periodontal probe will
penetrate the sulcus and the junctional epithelial (JE) attachment. CT, Con-
nective tissue; FGM, free gingival margin. (From Misch CE. An implant is
not a tooth: a comparison of periodontal indices. Dental Implant Prosthet-
ics. 2nd ed. St. Louis, MO: Mosby; 2015.)

1200
PART VIII Dental Implant Maintenance
tissue. Microbial colonization may then progress to the crestal
and peri-implant tissue, which may result in the early stages of
peri-implant disease. If plaque control is not adequate around
the implants lacking keratinized gingiva, tissue may cause irri-
tation and sensitivity, which may be uncomfortable for the
patient.
For the existing soft tissue the quality may be classied as either
a thin or a thick biotype. in gingival biotype is indicative of
thin underlying supporting bone. in structures are less vascular-
ized and more prone to recession and resorption in the presence
of inammation. erefore patients with a thin biotype are more
susceptible to peri-implant complications, especially if keratinized
tissue is compromised (Box 42.4).
In conclusion, there is increasing literature to support the advan-
tage of keratinized tissue over nonkeratinized tissue. Many authors
recommend keratinized mucosa more intensely than others.
In specic clinical instances, attached, keratinized gingiva is
more often desirable. For example, a xed prosthesis (FP-1) in the
esthetic zone (anterior maxilla) will require keratinized mucosa to
develop a soft tissue drape around the implant prosthesis. Another
prime example is with a mandibular overdenture, which benets
from a stable vestibule and a zone of nonmobile tissue around the
B
D
A
C
Fig. . Controversies related to probing include the material of the probe and the difficulty in obtaining
accurate measurements (A) probing around an implant retaining a bar overdenture; (B) if excessive prob-
ing pressure is used, probing depths will be inaccurate and traumatize the tissue; (C) if the prosthesis is
overcontoured, difficulty in probing will result; (D) difficulty probing with a plastic probe around the contours
of a fixed prosthesis.
1. Similar to natural teeth tissue in color, contour, and texture of the soft
tissue drape
2. More esthetic, especially when a high smile line exists
3. Keratinized tissue is more resistant to abrasion
4. Maintaining papillae is more predictable if keratinized tissue is present
4. Hygiene aids are more comfortable to use
5. Degree of gingival recession is proportional to the amount of keratinized
gingiva
6. Keratinized mucosa is more manageable during the retraction and
impression process
7. Long-term tissue stability is greater with keratinized tissue
8. With two-stage implant placement, wound dehiscence is less likely
BOX
42.4
Benets of Keratinized Tissue Around an
Implant

1201
CHAPTER 42 Implant Maintenance: Long-Term Implant Success
implant abutments. When these conditions exist, it is less likely
for patients to exhibit tissue sensitivity. Current recommendations
based on clinical experience and current systematic reviews are
to evaluate and, if possible, increase decient sites of inadequate
keratinized gingiva around implants prophylactically if peri-
implant disease exists
62,63
(Fig. 42.12).
Mobility of Implant/Prosthesis
At each maintenance appointment the mobility of the prosthesis
and implants should be evaluated. If mobility exists, the etiology
should be ascertained, specically if it is due to a loose screw
or implant failure. Usually if pain is present when the prosthe-
sis is moved in a buccal-lingual and apical direction, then it is
most likely due to an implant failure (i.e., unless the tissue is
impinging on the tissue, resulting in pain). When implant fail-
ure exists, pain will result because of the soft tissue interface. If
no pain exists, then usually this is indicative of screw loosening
(Fig. 42.13).
Pain/Sensitivity
A component of the maintenance protocol is the determination of
any possible subjective ndings of pain, tenderness, and sensitiv-
ity concerning the patient’s peri-implant tissues, implant body, or
implant prosthesis. Pain and tenderness are subjective criteria and
depend on the patient’s interpretation of the degree of discomfort.
Pain is dened as an unpleasant sensation ranging from mild dis-
comfort to excruciating agony. Tenderness is more an unpleasant
awareness of the region. An implant rarely is troubled by the sub-
jective criteria of pain or sensitivity after initial healing. In contrast
to a natural tooth an implant does not become hyperemic and
is not temperature sensitive. If a traumatic occlusion situation is
present, rarely will symptoms be present with an implant.
Implant-Related Pain. After the implant has achieved primary
healing, absence of pain under vertical or horizontal forces is a pri-
mary subjective criterion. Usually, but not always, pain does not
occur unless the implant is mobile and surrounded by inamed
tissue or has rigid xation but impinges on a nerve. e most
common condition that causes discomfort from an implant is
when a loose implant abutment is entrapping some of the soft
tissue in the abutment-implant connection. Usually, after the soft
tissue in the region is removed and the abutment is repositioned,
the discomfort or pain will subside.
When an implant is mobile, pain may occur early or late in
treatment. In either case the condition rarely improves. Pain on
loading of rigid implants has been observed more often on imme-
diately loaded implants compared with those healing unloaded
for an extended period. Implant sensitivity or mild tenderness
rather than pain in a rigid implant is also most unusual and sig-
nals a more signicant complication for an implant than for a
tooth. Tenderness during function or percussion usually implies
A
CD
B
Fig. . Inadequate Keratinized Tissue. (A) Lack of quality attached tissue on facial aspect of the
healing abutments. (B and C) Lack of keratinized tissue on facial of final prosthesis. (D) Bar overdenture
exhibiting compromised attached tissue because of the facial placement of the implants.

1202
PART VIII Dental Implant Maintenance
healing in the proximity of a nerve or, on rare occasions, bone
stress beyond physiologic limits.
On occasion an implant body may fracture from fatigue.
Fatigue is related to the amount of force, the number of cycles,
the strength of the material, the diameter of the component,
and the number of implants splinted together. is condition
is similar to a fractured root. In any case, radiographic evidence
of the fracture may be dicult to ascertain. Percussion and
forces up to 500 g (1.2 psi) with a bite stick are used clinically
to evaluate a tooth or implant for pain or discomfort. Percus-
sion and heavy biting on a wood stick associated with pain
are clinical indices. In these cases the implant is most often
removed, which especially in the mandible (i.e., dense bone)
may be dicult (Fig. 42.14).
Abutment-Related Pain. When the abutment-implant connec-
tion is not secure, pain may result because of tissue integration
into the void. is pain is usually persistent and occurs most often
during percussion or function. If this occurs, the prosthesis and
abutment should be removed, soft tissue excised, and components
repositioned (Fig. 42.15).
Infection-Related Pain. Especially in the early stages of peri-
implantitis, pain usually does not present as a primary clinical
symptom. Unless active infection with suppuration accompanies
sucient osseous destruction, patients do not experience pain.
Because dental implants do not have a PDL support and its sen-
sory apparatus, low-grade infections and bone resorption are not
detected by marginal gingiva. As the disease process begins around
an implant, the patient may feel slight irritation, but normally
not alarming pain.
64,65
It is recommended that the implant clini-
cian be proactive in evaluating the status of dental implants with
the incorporation of a routine maintenance protocol for implant
patients.
Occlusion
Ideally, in most xed implant cases an implant-protected occlu-
sion should be present. Implant-protected occlusion (i.e., canine
guidance) should be adhered to so the anterior teeth protect the
posterior teeth (i.e., protrusive movements) and the posterior
teeth protect the anterior (i.e., centric occlusion).
Traumatic occlusion has been shown to be an etiologic factor
in the loss of bone around the peri-implant region. A timed occlu-
sion should always be present, which includes the natural teeth
contacting rst before the contact of the implant (i.e., to compen-
sate for the PDL compression during occlusal contacts). During
light contact, extrathin articulating paper (e.g., shimstock) should
be easily pulled through the occlusal contact with an implant.
en during heavy contact, minimal resistance should be pres-
ent. Miyata etal.
66
reported with monkey studies that bone loss
AB
C D
Fig. . (A and B) Mobile implant prostheses diagnosed at the maintenance appointment. (C) Ill-fitting
and loose full-arch fixed prosthesis. (D) Ill-fitting prosthesis which may result from loose abutment screw.

1203
CHAPTER 42 Implant Maintenance: Long-Term Implant Success
may occur with an excess occlusal contact of 180 μm, even in the
absence of peri-implant inammation. erefore it is imperative
that the implant clinician evaluate and modify the existing occlu-
sion if necessary, at each appointment (Fig. 42.16).
In addition, the presence of parafunctional habits (e.g., clench-
ing, bruxism) should be documented and treated, most commonly
with an occlusal guard. A hard acrylic centric is most commonly
used.
Prosthesis
At each maintenance appointment the prosthesis should be evalu-
ated for not only mobility but also any fractures of the prosthesis
material (e.g., porcelain, acrylic, zirconia). If material fracture is
present, the occlusion should be immediately evaluated and the
possibility of replacement is determined. For a removable pros-
thesis, all implant attachments should be evaluated for mobility
and retention.
Radiographic Evaluation of the Implant and
Prosthesis
An accurate and thorough radiographic examination should be
performed as a routine adjunct to the clinical maintenance exami-
nation (Box 41.2). Ideally the radiographic modality used should
be able to standardize the evaluation of the implant interface and
bone level. e selection of the radiographic modality is dictated
by the number and position of implants, along with the type of
prosthesis.
Upon radiographic evaluation the crestal bone region is often
the most diagnostic for the ranges of optimum, satisfactory, and
compromised health conditions. Radiographic interpretation
is one of the easiest clinical tools to use to assess implant crestal
bone loss, but has many limitations. However, a two-dimensional
radiograph will illustrate only the mesial and distal crestal levels of
bone (Fig. 42.17).
When early bone loss occurs, it is most often present
on the facial aspect of the implant. e absence of radiolu-
cency around an implant does not indicate bone is pres-
ent at the interface. erefore two-dimensional radiographs
(i.e., periapical, bitewings, panographic lms) may often
be misleading on revealing the amount of bone loss. In the
mandibular anterior region, as much as a 40% decrease in
density is necessary to produce a traditional radiographic dif-
ference in this region because of the dense cortical bone.
67
When abundant bone width is present, a V-shaped crestal
defect around an implant may be surrounded by cortical bone
and, as a result, the radiograph is less diagnostic for bone
loss.
AB
C
D
Fig. . Implant Pain. (A and B) If pain is present with an implant, it is usually a failure because of a
soft tissue encapsulation; radiographs reveal significant radiolucency surrounding the implant bodies. (C
and D) If suppuration is present, usually the patient will be symptomatic.

1204
PART VIII Dental Implant Maintenance
Radiograph Type
e type of radiograph used in the evaluation of the implant
and prosthesis is dicult to generalize. Standardized periapi-
cal radiographs are usually recommended as the most com-
mon type of radiographic modality in evaluation of dental
implants. e long cone paralleling technique should be used
to minimize image distortion.
68
Panoramic radiographs exhibit
inherent disadvantages, including magnication, distortion,
overlapping images, and poor resolution. erefore panoramic
radiographs are not the most ideal radiograph in evaluating
bone loss (Fig. 42.18). However, in cases where periapical or
bitewing radiographs cannot be obtained, panoramic lms may
be used.
Cone beam computed tomography (CBCT) scans, although
superior to plain lm radiographs in the diagnosis and treat-
ment planning phases of implant dentistry, are usually not indi-
cated for routine maintenance unless complications are present.
Studies evaluating the visibility of the buccal plate showed that
if the amount of bone present is less than 0.6 mm in thick-
ness, the bone will be invisible on a CBCT image.
69
In addi-
tion, CBCT images suer from beam hardening, which leads to
the formation of a radiolucency surrounding the implant. is
occurs from a greater number of photons being absorbed (Fig.
42.19). In summary, the type of image modality should be spe-
cically tailored to each individual patient, according to clinical
and anatomic circumstances.
Radiograph Accuracy
It is often more dicult to obtain an accurate radiograph of the
implant body in comparison with a natural tooth. Most com-
monly, implants are placed more apical to the apex of the pre-
existing natural teeth. As a result the apex of the implant often is
located beyond muscle attachments or in regions almost impossible
to capture with a parallel radiographic method. A foreshortened
A B
C D
Fig. . Abutment-Related Pain. (A) An incomplete abutment seating will result in tissue growth with
resultant pain. (B) After implant is removed, tissue impingement is evident. (C and D) The excess tissue is
removed with a latch-type tissue punch.

1205
CHAPTER 42 Implant Maintenance: Long-Term Implant Success
image to encompass the apical portion of the implant results
in poor display of the crestal bone. An accurate radiograph will
show a clear depiction of the threads on the radiograph and a
proper angulation. If the implant threads are clear on one side
but blurry on the other, the angulation was incorrect by approxi-
mately 10%
70
(Fig. 42.20). If both sides of a threaded implant
are unclear, the radiograph is not diagnostic for crestal bone loss
assessment because of angulation issues. Ideally the abutment-
implant connection should appear as a clear line between the two
components. When the top of the implant is placed at the crest of
the regional bone, the amount of crestal bone loss is most easy to
evaluate (Fig. 42.21).
In addition, the prosthesis should be evaluated for any
radiographic changes from the baseline radiographs. Of
utmost importance is the fit of the prosthesis because an ill-
fitting or loose prosthesis may lead to peri-implant disease. If
a space is present between the prosthesis and the abutment,
the prosthesis should be immediately evaluated for passivity
and mobility.
Radiograph Timing
e most important radiograph for use in the maintenance phase
is the postprosthetic baseline radiograph. is radiograph is most
often taken at the prosthesis insertion appointment. By this time
the “biological width” most likely will have inuenced the implant
crest module bone level.
In general, implants with machined surfaces or external hex
connections are usually subject to an initial remodeling of the
bone level. Adell etal.
71
reported an average bone loss of 1.5 mm
during the rst year and 0.1 mm per year thereafter. However,
recent implant design changes have reduced this bone loss with
internal connections and platform switching.
72,73
In most cases an individualized radiographic protocol should
be developed based on the number and location of implants, type
of prosthesis, and any associated complications. A comprehensive
and generalized radiologic protocol was established by Resnik
74
in
2016 (Box 42.5).
Radiographic Crestal Bone Loss
e marginal bone around the implant crestal region is usually a
signicant indicator of implant health. e cause of crestal bone
loss around an implant is multifactorial and may occur at dierent
AB
B
Fig. . (A) Radiograph depicting significant bone loss surrounding the anterior implant; however, this
may be misleading because it depicts only the mesial and distal bone levels. (B) Vertical bitewing exhibiting
ideal angulation.
A
B
Fig. . Occlusal Contacts. (A) The occlusion should be checked
at each maintenance appointment to ensure lack of premature contacts.
(B) Ideal occlusion consists of primary contact (i.e., light occlusion) on the
natural teeth and light contact on implants during heavy occlusion.

1206
PART VIII Dental Implant Maintenance
time periods: surgical bone loss, initial “biologic width” bone loss,
early loading bone loss, intermediate-term bone loss, and long-
term bone loss. Each period may be associated with a dierent
cause for the bone loss. Most often the surgical trauma results in
minimal bone loss, but on occasion, bone loss may reach several
millimeters (Fig. 42.22).
When the abutment is attached to the implant body, approxi-
mately 0.5 to 1 mm of connective tissue forms apical to this
connection.
75
is associated bone loss may be caused by an
“implant biologic width.” Initial bone loss during the surgical
healing phase may vary for submerged and unsubmerged healing
protocols.
76
After the implant is connected with a permucosal element,
the marginal bone may be lost during the rst month from: (1)
the position of the abutment-implant connection or (2) the crest
module design of the implant. e abutment-implant connection
may cause 0.5 to 1.0 mm of bone loss when it is at or below
the bone. In addition, when smooth metal is present below the
abutment-implant connection, additional bone loss will occur in
direct relation to the smooth metal region. e bone levels will
most often reside at the rst thread or at a roughened surface after
the rst month after permucosal element placement (Fig. 42.23
and Box 42.6).
Diagnosis of Peri-implant Disease
After the clinical and radiographic maintenance examination is
complete, a diagnosis of the current peri-implant condition is war-
ranted. In the evaluation of the peri-implant tissues, three pos-
sible conditions may exist: (1) healthy condition, (2) peri-implant
mucositis, and (3) peri-implantitis.
Healthy Condition
If there exist no signs of inammation, bleeding, recession, bone
loss, or implant/prosthesis mobility, then the patient’s implants/
prosthesis is determined to be in a “healthy” state (Fig. 42.24 and
Box 42.7).
Treatment includes adherence to routine implant maintenance
(i.e., usually 3–6 months).
Peri-implant Mucositis
Peri-implant mucositis is dened as a localized inammation
within the soft tissue surrounding the implant bodies. In addi-
tion, redness and bleeding on probing may be present. However,
the bone level has not changed; therefore no hard tissue recession
(i.e., bone loss) has occurred. Peri-implant mucositis is similar to
gingivitis with respect to natural teeth (Fig. 42.25).
Fig. . Panoramic Image. The determination of the amount of bone
loss on a panoramic image is misleading because of the magnification,
distortion, overlapping images, and poor resolution.
AB
Fig. . Inherent Cone Beam Computed Tomography Disadvantages. (A) Beam hardening result-
ing in a radiolucency surrounding the implant. (B) Scatter that is caused by the presence metallic objects
(e.g., crowns, implants).

1207
CHAPTER 42 Implant Maintenance: Long-Term Implant Success
Treatment includes remediation of the causative factors of peri-
implant mucositis and associated follow-up care.
Peri-implantitis
Peri-implantitis is dened as localized inammation with concomi-
tant bone loss. In most peri-implantitis cases suppuration and clini-
cal probing depths are present, together with bleeding on probing.
On radiographic evaluation, marginal bone loss is present in com-
parison with the original baseline radiographs (Fig. 42.26).
Treatment includes remediation of the causative factors and
usually hard and soft tissue surgical intervention, followed by con-
tinued maintenance care.
Frequency of Maintenance Visits
Peri-implant disease may result from opportunistic infections that
lead to soft and hard tissue complications; therefore it is manda-
tory to monitor the peri-implant tissues at regular intervals. If early
signs of disease are diagnosed, aggressive intervention may prevent
the loss of hard tissue. Zitzman etal.
77
reported that peri-implant
mucositis may exhibit apical progression after only 3 months of
plaque buildup around implants. erefore a 3-month mainte-
nance regimen is recommended within the rst year of implant
placement to evaluate the tissue health and the patients home
care. If after the rst year the peri-implant tissues are healthy, then
the maintenance interval may be extended to 6 months. However,
a stricter recall protocol should be adhered to if the patient does
exhibit risk factors or comorbidities.
78
Patient Home Care
Ideally a home care assessment should be determined before the
initiation of dental implant treatment. In partially or completely
edentulous patients, usually compromised home care is already
present. In addition, during the postsurgical phase of treatment,
patients are often lax in their hygiene practices because of fear of
causing damage to the surgery site. erefore it is imperative that
the patient be educated on the necessity and need for a compre-
hensive home care regimen.
When educating patients on home care, various techniques
may be used, as long as they are safe and eective. Depending on
the type of implant, implant position, location in the oral cavity,
and type and size of the prosthesis, various devices along with the
frequency may be recommended. No single hygiene device has
been shown to be ideal in all situations. ere exists a full array of
Fig. . On this periapical radiograph the threads are clear. On the
right side only, the central ray was not directed completely perpendicular
to the implant body but was within 10 degrees. This film is not ideal to
ascertain the amount of bone loss.
A B
Fig. . (A) Poor angulation resulting in no threads of the implants being seen. (B) Ideal positioning as
implant threads on mesial and distal are easily seen.

1208
PART VIII Dental Implant Maintenance
brushes, oss threading systems, and other devices available to aid
patients in their hygiene protocols.
One common mistake often employed by clinicians is to add
too many oral hygiene devices for patient home care. Studies have
shown that when multiple devices are recommended, patients are
more apt to become discouraged and less motivated. However,
when a combination of toothbrushing devices, auxiliary aids, and
antimicrobial mouthrinses are used, an increased plaque inhibi-
tion is seen.
79
Specific Dentifrices
Manual and Electromechanical Devices
In general most exposed facial and lingual surfaces may be
cleaned with a soft, multitufted nylon toothbrush. e implant
clinician should recommend to each individual patient which
brush angle would be ideal to access all areas within the mouth.
e modied Bass technique should be used or a short, hori-
zontal, back-and-forth movement may be incorporated into the
hygiene regimen. e brush may be held at a 45-degree angle to
the gingival tissue.
80
Most commonly, patients often prefer electromechanical
devices, which have been shown to be superior to manual brush-
ing around dental implants.
81
When using electromechanical
devices (i.e., sonic toothbrushes, oscillating-rotating power tooth-
brushes), especially in dicult-to-access areas, end-tufted brushes
and tapered rotary brushes tend to be benecial. Studies have con-
rmed the benets of these devices.
82,83
Rasperini etal.
82
reported
a reduction in bleeding (50% in the rst year) and decrease in
probing depths (0.3 mm) with power toothbrushes.
Most manufactured power brushes have soft, interchangeable
bristle heads (attened, rubber cuplike, short and long pointed
Preoperative
Cone Beam Computed Tomography
• Allvitalstructuresidentied
• Sinus-relatedprocedures:mustconrmpatencyofostiumandlackof
pathology
Intraoperative
• Peri-apicalradiograph(PA)afterpilotdrillduringplacementtoconrm
positioning and proximity to vital structures and adjacent teeth
• PAofnalplacementwithcoverscreworhealingabutment
• PAbeforeuncoversurgery(stage2procedure)
Prosthetic
• PAtoconrmimplantisreadytorestore
• PAtoconrmabutmentisseatedproperly
• PAtoconrmproperseatingofprosthesis/cementremoval(willbe
baseline for future evaluation radiographs)
Postoperative
• PAonceannuallyfortherst3yearsafterimplantprostheticstomonitor
bone level
• Normal(acceptable):<0.2mmverticalbonelossperyearforrst3
years
• After3years,PAshouldbetakenevery2years
In addition to radiographic evaluation, the following should be evaluated:
• Presenceofpain,suppuration
• Implantand/orprosthesismobility
• Hyperocclusion
• Softtissuechanges(bleeding,recession,hyperplasia)
In some cases a periapical radiograph cannot be accurately obtained
because of positioning issues; therefore a panoramic radiograph may be used
as an alternative radiographic modality.
BOX
42.5
Radiograph Timing Protocol
A
B
Fig. . Postprosthetic Images. (A) Ideal radiograph showing no
signs of bone loss. (B) Image depicting significant early bone loss at first
maintenance appointment.
Fig. . When an implant is placed with the abutment connection
at the crest of the ridge (left side), after the permucosal abutment is con-
nected the bone is usually lost to the first thread, especially when the crest
module is machined or smooth (right side).

1209
CHAPTER 42 Implant Maintenance: Long-Term Implant Success
in shape) that may be used. e short and long pointed tips are
ideal for reaching proximal areas, wide embrasures, and pontic
areas under a splinted prosthesis. e hollowed rubber cup may
be used on the facial and lingual aspects of the implant and pros-
thesis (Fig. 42.27).
Toothpaste/Gel
e selection of a toothpaste should be low abrasive as to not
scratch the surface of the exposed implant. Dentifrices should be
avoided that contain harsh abrasive ingredients, including stain
removers and smokers toothpaste.
84
Selective uorides may result
in etching and roughness on implant surfaces.
85,86
Interproximal Brushes
With some types of prostheses (e.g., full-arch xed prosthesis),
interproximal brushes with small brush heads may be indicated to
gain easier access. Ideally these types of device should be plastic-
coated because metal may damage the implant surface.
79
e inter-
dental brush is used to massage the gingival tissue, which results
in increased blood ow and healthier tissue. Patients should be
instructed to insert the tip interproximally in an occlusal direction
and use a gentle rotary motion against the gingiva
80
(Fig. 42.28).
Floss Aids
Flossing around dental implants is also a controversial topic.
Most patients are resistant to ossing their natural teeth, espe-
cially if oss threaders are required. erefore ossing has an
inherent disadvantage in patient compliance and also dexter-
ity issues. When ossing around implants, it is often dicult
to manipulate and maneuver the oss around a malpositioned
implant or an overcontoured/atypical prosthesis. Floss is ideally
used interproximally, especially when a splinted prosthesis is
present. icker oss is available (e.g., “yarnlike”) that allows for
cleaning around abutments and prostheses, and ease of penetrat-
ing hard to reach interproximal areas. Floss may be used in con-
junction with chlorhexidine or other antimicrobials to decrease
plaque accumulation.
It is imperative that the patient is instructed on the proper
technique on ossing around dental implants. Improper or over-
aggressive ossing may lead to tissue trauma and resultant peri-
implant soft tissue lesions (Fig. 42.29).
Time Etiology
Surgery Trauma to bone
Uncovery “Implant biologic width” related to abutment location
and implant crest module design
Early Occlusal trauma
Intermediate Bacteria or occlusal trauma
Long term Bacteria
BOX
42.6
Etiology of Implant Crestal Bone Loss
Fig. . Healthy Implant Condition. No signs of inflammation, bleed-
ing, tissue recession, or bone loss (lateral incisors).
1. No signs of inflammation (pink, firm peri-implant mucosa)
2. Noprobingdepths(<4mm)
3. Absenceofbleedingongentleprobing(<15N)
4. No suppuration
5. No pain or sensitivity
6. No radiographic bone changes
BOX
42.7
Healthy Clinical Findings
Fig. . Periimplant Mucositis. Molar implant prosthesis exhibiting
signs of bleeding; however, no bone loss is present.
Fig. . Peri-implantitis. Anterior implant prosthesis exhibiting signs
of significant recession, inflamed gingival tissue, and plaque accumulation.

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119242Implant Maintenance: Long-Term Implant SuccessJON B. SUZUKI AND DIANA BRONSTEINThe maintenance of endosseous implants has evolved over many decades, from trial and error of various anecdotal supportive therapy methods to evidence-based protocols. ese newer maintenance protocols allow for the implant clini-cian to implement individualized patient care of the peri-implant tissues.1,2 With patients understanding the benets of dental implants, the dental profession is moving away from traditional prosthetics and integrating the latest dental implant technologic advances into treatment plans. erefore in the future, a greater need will be required by the implant clinician to integrate a com-prehensive systemic and supportive protocol to maintain the suc-cess and longevity of the implant prosthesis.3Prevention of peri-implant disease is now an accepted funda-mental cornerstone of eective and predictable treatment strate-gies. e preventive approach commences with ideal and realistic case selection, preoperative patient education, and control of risk factors associated with increased implant complication incidence.4 e lifelong professional implant maintenance protocol must be communicated to and acknowledged by the patient as part of his or her presurgical educational process. Patients at a higher risk for the development of peri-implantitis need to be identied and monitored with a stricter maintenance protocol. In addition, because of the inherent dierences between implants and teeth, patient education is crucial on the specics of hygiene with respect to the dental implants and the type of prosthesis.5Anatomy of Peri-implant Hard and Soft Tissuese implant clinician must have a strong foundation for the rela-tionship between the peri-implant tissues and the signs of disease so that early detection and denitive treatment may be rendered. If a disease process goes undiagnosed, hard and soft tissues com-plications may lead to an increased morbidity of the implants or associated prosthesis. When evaluating the hard and soft tissues surrounding a dental implant, many dierences exist between the natural teeth and dental implants. e support system of natural teeth is much better designed to reduce biomechanical forces to the crestal bone region, thereby reducing the possibility of peri-implant disease. Because of the periodontal membrane, nerve and blood vessel complex, and occlusal material (enamel), occlusal overload is far less in comparison with dental implants.6Soft Tissue DifferencesFor a natural tooth the surrounding soft tissue has an average bio-logical width of 2.04 mm between the depth of the sulcus and the crest of the alveolar bone.7 It should be noted that the biological “width” is actually a height dimension with a greater range in the posterior region compared with the anterior and may be greater than 4 mm in height.8 With natural teeth the biologic width is composed of a connective tissue attachment (1.07 mm average) above the bone and a junctional epithelial attachment (0.97 mm average) at the sulcus base, with the most consistent value among individuals being the connective tissue attachment.e connective tissue attachment zone of the “biological width” around a tooth will prevent penetration into the sulcus and allows gingival bers of the connective tissue attachment zone to establish direct connection with the cementum of the natural tooth. It acts as a physical barrier to the bacteria in the sulcus to the underlining periodontal tissues. Eleven dierent gingival ber groups comprise the connective tissue attachment zone observed around a natural tooth and tissue: dentogingival (coronal, hori-zontal, and apical), alveologingival, intercapillary, transgingival, circular, semicircular, dentoperiosteal, transseptal, periosteogingi-val, intercircular, and intergingival.9 At least six of these gingival ber groups insert into the cementum of the natural tooth: the dentogingival (coronal, horizontal, and apical), dentoperiosteal, transseptal, circular, semicircular, and transgingival bers. In addi-tion, some crestal bers from the periodontal ber bundles also insert into the cementum above the alveolar bone, forming a true attachment to the tooth. Clinically this attachment will prevent a periodontal probe from invading the periodontal ligament (PDL) space and minimize the ingress of bacteria (Fig. 42.1).In comparison, the sulcular regions around an implant are very similar in many respects. e rete peg formation within the attached gingiva and the histologic lining of the gingiva within the sulcus are similar in implants and teeth.10 A free gingival margin forms around a tooth or implant, with nonkeratinized sulcular epithelium and the epithelial cells. At the base, junctional epi-thelial cells are present for both. However, a fundamental dier-ence characterizes the base of the gingival complex around teeth. Whereas a tooth has two primary regions that make up the bio-logical width, an implant has only one (Fig. 42.2).e biological seal for an implant, which is analogous to the epithelial attachment of the tooth, is needed to protect 1193CHAPTER 42 Implant Maintenance: Long-Term Implant Successthe implant-bone interface against bacterial irritants, as well as mechanical trauma such as restorative materials, prosthesis design, and occlusal forces. Cochran etal.11 has reported the biologic width to be 3.3 mm for dental implants, but unlike the biological width dimension for teeth, they also included the sulcus depth. In a typical implant gingival region, only two of the gingival ber groups are found around a tooth (cir-cular and periosteogingival bers), and no periodontal bers are present.12 ese bers do not insert into the implant body below the abutment margin as they do into the cementum of natural teeth.13 Instead, the collagen bers around an implant run parallel to the implant surface, not perpendicular, as with natural teeth.14 Hence the implant has only a junctional epi-thelial “attachment” system. e gingival and periosteal ber groups are responsible for the connective tissue attachment component of the biological width around teeth, and these are not present around the transosteal region of an implant. e “biological width” around the abutment-implant connec-tion should not be similarly compared with the connective tis-sue attachment of a tooth. e biological seal around dental implants may to some degree prevent the migration of bacteria and endotoxins into the underlying bone. However, an attach-ment component of the biological width similar to the one found with natural teeth is not present with dental implants (Fig. 42.3). Tooth Versus Implant MovementA natural tooth exhibits normal physiologic movements in verti-cal, horizontal, and rotational directions. e amount of move-ment of a natural tooth is related to its surface area and root design. erefore the number and length of the roots; their diam-eter, shape, and position; and the health of the PDL primarily inuence a tooth’s mobility. A healthy tooth normally exhibits zero clinical mobility in a vertical direction. Studies have shown the actual initial vertical tooth movement to be approximately 28 μm and is the same for anterior and posterior teeth.15 e vertical movement of a rigid implant (i.e., integrated) has been measured as 2 to 3 μm under a 10-lb force and is due mostly to the visco-elastic properties of the underlying bone (i.e., bone density at the bone-implant interface).16Muhlemann17 found that horizontal tooth movement may be divided into initial mobility and secondary movement. e initial mobility is observed with a light force, occurs immediately, and is a consequence of the PDL. Initial horizontal tooth mobility is greater than initial vertical movement. A very light force (500 g) horizontally moves the tooth. e initial horizontal mobility of a healthy, “nonmobile” posterior tooth is less than that of an ante-rior tooth and ranges from 56 to 75μm, which is two to nine times the vertical movement of the tooth.1mmSulcus1mmEpithelialattachment1mmConnectivetissue• Fig. . The biologic width for a natural tooth is approximately 1 mm of connective tissue above the bone and 1 mm of epithelial attachment between the sulcus and the connective tissue. (From Misch CE. An implant is not a tooth: a comparison of periodontal indices. Dental Implant Prosthetics. 2nd ed. St. Louis, MO: Mosby; 2015.)FCTC• Fig. . The soft tissue around an implant (I) has a sulcular region very similar to a tooth. A free gingival margin (F) with nonkeratinized sulcular epithelium and cells at the base (C) has junctional epithelial attachment above the bone (B). CT, Connective tissue. 1194PART VIII Dental Implant MaintenanceInitial horizontal mobility is even greater in anterior teeth and ranges from 70 to 108 μm in health18 (Fig. 42.4).e secondary tooth movement described by Muhlemann17 occurs after the initial movement, when greater forces are applied. When an additional force is applied to the tooth, a secondary movement is also observed, which is related directly to the amount of force. e secondary tooth movement is related to the viscoelas-ticity of the bone and measures as much as 40 μm under consider-ably greater force (Fig. 42.5).When evaluating implant movement, “rigid xation” indicates the absence of clinical mobility of an implant tested with vertical or horizontal forces less than 500 g. Rigid xation is a clinical term, and osseointegration is a histologic term. Osseointegration is dened as bone in direct contact with an implant surface at the magnication of a light microscope (Fig. 42.6). Over the years these two terms have been used interchangeably, and implant abutment support is most predictable with rigid xation. Lack of implant mobility (IM) does not always coincide with a direct bone-implant interface. However, when observed clinically, rigid xation usually means that at least a portion of the implant is in direct contact with bone, although the percentage of bone contact cannot be specied. A mobile implant indicates the presence of connective tissue between the implant and bone.Increased tooth mobility may be caused by occlusal trauma or bone loss. Increased tooth mobility alone is not a criterion of peri-odontal health or pathology. Unlike a tooth, for which mobility is not a primary factor for longevity, mobility is a primary deter-mining factor for implant health. Rigid xation is also an excel-lent indicator of the implant health status because it is an easy, 1 mm0.5 mmBonecrestFGMImplantplatformCTJESulcus• Fig. . An implant has no connective tissue fibers in the connective tissue zone that insert into the implant. The peri-implant probe penetrates the sulcus, junctional epithelial attachment (JE), and most of the connec-tive tissue zone. CT, Connective tissue; FGM, free gingival margin. (From Misch CE. An implant is not a tooth: a comparison of periodontal indices. Dental Implant Prosthetics. 2nd ed. St. Louis, MO: Mosby; 2015.)0.108 mm0.028 mmPhysiologicmovement• Fig. . The physiologic movement of a tooth has been measured as 28 μm in the apical direction and up to 108 μm in the horizontal direction. (From Misch CE. An implant is not a tooth: a comparison of periodontal indices. Dental Implant Prosthetics. 2nd ed. St. Louis, MO: Mosby; 2015.)15mm1001050100 g 500 gAB• Fig. . A secondary horizontal movement of a tooth occurs after the initial tooth movement when a greater force is applied and is related to the deformation of the alveolar bone. (From Misch CE. An implant is not a tooth: a comparison of periodontal indices. Dental Implant Prosthetics. 2nd ed. St. Louis, MO: Mosby; 2015.)• Fig. . Osseointegration is a histologic term that describes a direct bone-implant contact at the level of magnification of a light microscope. 1195CHAPTER 42 Implant Maintenance: Long-Term Implant Successobjective test. As such, rigid xation is usually the rst clinical cri-terion and the most important when evaluating a dental implant.Past techniques to evaluate primary stability and mobility of dental implants have included percussion and mobility tests with mirror handles. However, these techniques were very subjective and were associated with inaccurate results. In implant dentistry today, the most common technique to assess the stability of dental implants is the use of resonance frequency analysis (RFA). Reso-nance frequency analysis (RFA) is a non-invasive, reliable, and clinically acceptable technique developed by Meredith in 1996.19 is technique includes magnetic pulses being sent to a small metal post that is temporarily attached to the implant. As the post vibrates, the probe reads the resonance frequency which is translated into a value termed implant stability quotient (ISQ). e ISQ value is evaluated via a scale that ranges from 1 to 100, with high values indicating increased stability. Usually, acceptable ranges of stability lie between 55 – 85 ISQ, with values below 55 indicating possible mobility of the implant.20 is technol-ogy is advantageous as measurements may be taken at the time of implant placement and used as a baseline for future measure-ments in the evaluation of the health of the dental implant. e Penguin RFA® (Glidewell Direct; Irvine, Calif.) is commercially available which uses re-usable multi-pegs that are implant specic. In addition, this device is cordless which is very user friendly for the clinician. When evaluating mobility of the implant, ideally the prosthesis should be removed, which allows for the multi-pegs to be directly inserted into the implant body.Evaluating the mobility of the prosthesis does not allow for an accurate assessment of dental implant health as the associ-ated mobility is most commonly from a loose abutment screw (Box 42.1 and Fig. 42.7).A natural tooth with primary occlusal trauma exhibits an increase in clinical mobility and radiographic PDL space. After the cause of trauma is eliminated, the tooth may return to zero clinical mobility and a normal radiographic appearance. is scenario is not predictable around an implant. e implant clinician should not restore an implant with any clinical mobility, because the risk for failure is great. However, after the prosthesis is completed and IM-1 develops, the risk is small to evaluate the implant for a few months and decrease almost all stress during this time frame. Implants with slight detectable mobility of approximately 0.1 mm of horizontal movement (IM-1), similar to the mobility of a healthy central incisor, on occasion may return to rigid xation and zero mobility. However, to reachieve rigid xation, the implant should be taken completely out of occlusion for several months and strictly monitored. e return of rigid xation of an implant is far greater if no mobility is noted before the implant is placed into function.An implant with horizontal movement greater than 0.5 mm (IM-3) is at much greater risk than a tooth. A root form implant with greater than 0.5 mm horizontal mobility (IM-3) or any vertical mobility (IM-4) should be removed to avoid continued bone loss and future compromise of the implant site or adjacent teeth (Table 42.1). Maintenance ProtocolMedical and Dental Historiese rst step in the maintenance protocol is to update the patient’s medical and dental histories. is is a mandatory component of the maintenance protocol and is crucial in determining whether there presently exist any concomitant conditions that would pre-dispose the patient to peri-implant disease.Medical HistoryMedical conditions may change during the maintenance phase (i.e., after implant prosthesis completion) of treatment that have a direct impact on the morbidity and success of the implants or prosthesis. It is imperative the patient relates any updates to his or her medical history because many systemic conditions may aect the long-term prognosis of dental implants and the prosthesis. 1. Xerostomia: e lack of saliva (i.e., dry mouth) is caused by hypofunction of the salivary glands and may be caused by numerous medications and systemic conditions. Most com-monly, autoimmune conditions may result in xerostomia, as well as many medications, especially if given concurrently. AB• Fig. . (A, B) Penguin Resonance Frequency Analysis Unit (Aseptico) which measures the ISQ (Implant Stability Quotient) implant stability using reusable, calibrated MulTipegs.Scale Description0 Absence of clinical mobility with 500 g in any direction1 Slight detectable horizontal movement2 Moderate visible horizontal mobility up to 0.5 mm3 Severe horizontal movement greater than 0.5 mm4 Moderate-to-severe horizontal and any visible vertical movement • BOX 42.1 Mobility Measurements97 1196PART VIII Dental Implant MaintenanceXerostomia has been shown to aect the dental biolm com-position and intraoral healing of the soft tissues. Immune cells (e.g., neutrophils) and immune factors (e.g., lysozyme, secre-tory IgA) are normally delivered and distributed in the oral cavity through the saliva; therefore a lack of saliva may lead to lowered antimicrobial components in the oral cavity.21-24Prosthetically, patients who acquire xerostomia after completion of treatment may become compromised. For example, a patient with a soft tissue–borne implant prosthesis (i.e., RP-5 overdenture) may experience soft tissue irritation because of the lack of saliva. 2. Autoimmune diseases: Selected autoimmune diseases have been associated with peri-implantitis. For example, lichen planus causes the hemidesmosomal epithelial attachment to the implant surface to become disabled, leading to peri-implant mucositis and possibly progressing to peri-implantitis.25 However, long-term implant survival, according to current research, does not seem to be aected.26 With many auto-immune diseases, patients may lose their manual dexterity, thereby decreasing hygiene ability and also diculty in remov-ing an attachment-dependent overdenture prosthesis. Some of the more common autoimmune disorders and the associated symptoms that may aect the oral cavity are as follows: • Sjogren’ssyndrome:xerostomia • Systemiclupuserythematosus:corticosteroidtreatmentandimmunosuppressive medications • Scleroderma: manual dexterity and immunosuppressivemedications • Rheumatoid arthritis: manual dexterity and immunosup-pressive medications • HIV:compromised lymphocytes and immunosuppressivemedications 3. Bone diseases: Altered bone physiology in conditions such as osteoporosis/osteomalacia/osteopenia, Paget’s disease, and brous dysplasia may signicantly increase the risk for com-plications for implant patients.27 4. Diabetes: Poor diabetic control (i.e., > 7% A1c) correlates the inammatory markers closer to patients with chronic periodontitis when peri-implantitis is present. Patients with diabetes, especially if uncontrolled, are prone to acquire infections and vascular complications. e healing process is aected by the impairment of vascular function, chemotaxis, and neutrophil function, as well as an anaerobic milieu. Pro-tein metabolism is decreased, and healing of soft and hard tissue is delayed, which may lead to the susceptibility of infection. Neuropathy and impaired nerve regeneration may be altered, as well as angiogenesis.28 5. Pregnancy: During the maintenance period, radiographs should be delayed until after birth with pregnant patients. Medical clearance should be obtained if radiographs or pro-cedures need to be performed on an emergency basis. Comprehensive Dierences Between Natural Teeth and Dental ImplantsNatural Teeth Dental ImplantsInterface Periodontal membrane Direct boneJunctional epithelium Hemidesmosomes and basal lamina (lamina lucida and lamina densa zones)Hemidesmosomes and basal lamina (lamina lucida and lamina densa, and sublamina lucida zones)Connective tissue 12 groups: six insert perpendicular to tooth surfaces↓ Collagen, ↑ fibroblastsOnly two groups: parallel and circular fibers; no attachment to the implant surface↑ Collagen, ↓ fibroblastsVascularity Greater; supraperiosteal and PDL Less; mainly periostealBiologic width 2.04–2.91 mm 3.08 mmMobility + −Pain +/− (tooth may be hyperemic) −Attrition + Wear facets, abfraction, fremitus − (∼ porcelain fracture, possible screw loosening)Radiographic changes + Increased radiopacity and thickness of cribriform plate Crestal bone lossInterference awareness + (Proprioception) − (Osseoperception)Nonvertical forces Relatively tolerated Results in bone lossForce-related movement Primary: movement of PDLSecondary: osseous movementPrimary: osseous movementLateral force Apical third of root surface Crestal boneLateral movement 56–108 μm 10–50 μmApical movement 25–100 μm 3–5 μmTactile sensitivity High LowSigns of overloading PDL thickening, fremitus, mobility, wear facets, pain Screw loosening, screw fracture, abutment fracture, implant body fracture, bone lossPDL, Periodontal ligament. TABLE 42.1 1197CHAPTER 42 Implant Maintenance: Long-Term Implant Success 6. Radiation treatment to the oral cavity: Patients who receive radiation to the oral cavity after implant treatment may suf-fer from many decits including oral mucositis, xerostomia, compromised healing, and reduced angiogenesis. is is a direct result of changes in the vascularity and cellularity of hard and soft tissue, damage to the salivary glands, and increased collagen synthesis that results in brosis. erefore patients exhibiting these complications should be treated symptomatically. Patients who presently wear a tissue-borne prosthesis (RP-5) may benet from changing the nal pros-thesis to a xed (non-tissue-bearing) prosthesis. 7. Sleep apnea: Patients who are diagnosed with sleep apnea are often treated with continuous positive airway pressure(CPAP). e CPAP machine uses a hose and mask that delivers constant steady air pressure. CPAP machines may place an increased force on the oral cavity. erefore if patients are using a CPAP machine, the implant area should be monitored closely. 8. Elderly patients: Elderly patients have been shown to have many issues with adapting to the nal implant prostheses. Postinsertion complications such as muscle control, hygiene diculty, tissue inammation, and overdenture seating are signicant in the older population study. During maintenance visits, patient education should be continuously reenforced. 9. Smoking: e use of tobacco should be closely monitored with implant patients. Studies have shown the detrimental eects of the gases and chemicals (e.g., nitrogen, carbon mon-oxide, carbon dioxide, ammonia, hydrogen cyanide, benzene, nicotine) released in cigarette smoke. Multiple retrospective studies have shown that smokers experience almost twice as many implant failures compared with nonsmokers, and there exists a strong correlation with peri-implantitis.29 e nega-tive eects of smoking on the implants/prosthesis should be reenforced at each maintenance visit. 10. Phenytoin (Dilantin): e most common medication to cause peri-implant conditions is phenytoin (Dilantin). Dilan-tin is associated with a high incidence of gingival overgrowth (hyperplasia) of peri-implant soft tissue, implant gingival hyperplasia, mucosal proliferation, proliferative gingivitis, and implant-related tissue hyperplasia, and has been recognized as a signicant clinical issue in implant dentistry today. If there is no associated bone loss, the pockets are termed pseudopockets or gingival pockets. ese hyperplasia-induced pockets may harbor pathogenic anaerobic bacteria. e plaque biolm colonization and maturation in implant pockets initiates inammation. e resultant hyperplastic tissue is most com-monly composed of compact collagenous bers, broblasts, and inammatory cells. Management of peri-implant gingival overgrowth should include the identication of the etiology (e.g., medication or humoral). If the etiology is determined to be medication induced, consultation with the patient’s physician is recommended for possible alternative treatment. 11. Miscellaneous: Epidemiologic and longitudinal studies have found an association of peri-implantitis prevalence with hepa-titis and cardiovascular disease.30 Cardiovascular disease is associated with periodontitis and peri-implantitis through the systemic-inammatory-mediator link and appears to be an indirect cofactor in patients whose prole identies them as being predisposed to inammatory diseases.31Interestingly, genetics has been implicated with aggressive peri-odontal diseases, which appear to be correlated with peri-implantitis. Studies associate peri-implant disease with the IL-1 gene polymor-phism in smokers.32 Dental Historye dental history update is crucial in determining any changes to the patient’s oral condition. Changes in home care practices, along with recent dental treatment, should be documented and evaluated for any impact on the implant prostheses. Of special concern are parafunctional habits (e.g., clenching, bruxism), which if present or worsening may lead to peri-implant diseases or implant failure. Clinical Evaluation of the Implant(s)/ProsthesisSoft Tissue AssessmentAn overview of the visual signs of gingival inammation (e.g., redness, edema, alterations of tissue contour, stula tracts) should be evaluated and documented. Poor tissue tone (i.e., thin, friable, accid) surrounding an implant may harbor food, plaque, and calculus, which increases the possibility of inam-mation and infection. A gingival health index may be used to evaluate the soft tissue health. e most common bleeding gingival index used for implants is the Loe and Silness gingival index. When used on teeth, this index scores gingival inamma-tion from 0 to 3 on the facial, lingual, and mesial surfaces of all teeth. e symptom of bleeding comprises a score of at least 2 (Box 42.2). e facial and lingual are already being probed to evaluate bone loss that cannot be seen on a radiograph. Because the bleeding index evaluates inammation, the Loe and Silness index is adequate for implants, and because fewer implants typi-cally are used to restore a region compared with the presence of natural teeth, one also may evaluate the distal surface when bleeding is present33 (Fig. 42.8). Assessment of Home CareBecause the presence of microbial biolm has been shown to be a leading factor in the pathogenesis of peri-implant disease, the routine assessment of plaque accumulation should be a priority of each maintenance visit. is objective form of plaque monitor-ing should ideally be performed and documented at each mainte-nance visit. Consistent use of the same plaque index is paramount because this will allow an easier determination of the presence of a disease process. High plaque scores have been shown to have a direct correlation with peri-implant mucositis and increased prob-ing depths.34 Mombelli etal.35 and Lindquist etal.36 have reported implant-specic plaque indices to be used at dental implant main-tenance appointments. Mombelli etal.35 suggested a numerical scale from 0 to 3, which is dependent on the amount of visible plaque present or by running a probe over the implant surface. Lindquist etal.36 recommended a similar scale (i.e., 0–2) depen-dent on the amount of visible plaque (Fig. 42.9 and Box 42.3). ProbingProbing around dental implants is a controversial topic even though it has been shown in the literature to be a reliable and important factor in determining peri-implant health. e safety of probing, once thought to be detrimental, has been well established Normal0 = mild inflammation, slight color change and edema, no bleeding1 = moderate inflammation, redness, edema, bleeds on probing2 = severe inflammation, marked redness and edema ulceration, spontaneous bleeding • BOX 42.2 Loe and Silness Bleeding Index 1198PART VIII Dental Implant Maintenanceand does not jeopardize the integrity of the implant system.37,38 Etter etal.39 reported after probing of the implant system, healing of the epithelial attachment will occur approximately 5 days after clinical probing.e connective tissue zone for an implant has only two ber groups, and neither of them inserts into the implant. As a result, with an implant, the probe goes beyond the sulcus, through the junctional epithelium attachment, and through the type III collagen connective tissues and reaches closer to the bone.40 Because the probe penetrates deeper next to an implant compared with a tooth, one should take care not to contaminate the implant sulcus with bacteria from a dis-eased periodontal site. To prevent contamination, the dental probe tip may be placed in chlorhexidine after each reading, thereby reducing the possibility of inoculating the sulcular area of the next probed area. In most cases probing depths of 2 to 4 mm have been established as a healthy condition41 (Figs. 42.10 and 42.11).In addition, there exists controversy concerning the type of periodontal probe to use with dental implants. Many authors have advocated the use of plastic periodontal probes42,43; how-ever, more recent articles have recommended conventional metal A BCD• Fig. . Soft Tissue Assessment. (A) Edematous tissue surrounding dental implant. (B) Significant gingival recession leading to exposure of the implant bodies allowing for plaque accumulation. (C) Poor tis-sue quality resulting from facial bone loss. (D) Soft tissue recession resulting from apical positioned implant which leads to soft tissue loss and resultant black triangles.AB• Fig. . (A and B) Plaque accumulation as a result of recession and poor oral hygiene. 1199CHAPTER 42 Implant Maintenance: Long-Term Implant Successprobes because they do not appear to damage the mucosal attach-ment or mar the implant surface.44,45Ideally there should be baseline clinical probing depths acquired after the initial insertion of the prosthesis. However, in some cases, because of malpositioned implants or an overcontoured prosthe-sis, obtaining true probing depths may be dicult. In these cases a more routine radiographic evaluation is indicated to help ascertain peri-implant health.When bleeding on probing is present, usually this is indica-tive of positive peri-implant disease. Studies have shown that simi-lar to natural teeth, the absence of bleeding on probing may be interpreted as highly predictive of stability of the peri-implant tis-sues.46,47 However, a positive correlation exists with bleeding on prob-ing and histologic signs of inammation at peri-implant tissue levels.48Care should be exercised to avoid false-positive readings for bleeding on probing depths. Gerber etal.49 reported that a pressure of approximately 0.15 N should be used to minimize incorrect readings. Probing around dental implants has been shown to be more sensitive to force variation in comparison with natural teeth.50e thickness and the type of tissue may inuence the mucosa/epitheliumsurroundingadentalimplant.VanSteenbergheetal.51 determined that shallow (minimal) probing depths are associated with keratinized tissue, and deeper probing depths are consis-tent with alveolar mucosa (i.e., movable tissue) surrounding the implant.On probing the peri-implant tissues, if suppuration is pres-ent, the implant clinician should be conscious of the strong evidence of the presence of infection or peri-implant disease. Radiographic evaluation should be immediately completed to determine the etiology of the exudate and the infectious origin.When evaluating probing depths, greater than 3 mm is not a denite sign of peri-implantitis; peri-implant tissue dimensions are inuenced by the implant type and shape, the connections of the multiple components (material and retention mode), and the prosthetic restoration design and conguration. Coveted soft tissue conditioning in the esthetic zone to simulate an interdental papilla can lead to an increase in the distance from the implant shoulder to the mucosal margin of up to 5 mm.52 Clinical pre-sentations may be misdiagnosed as peri-implantitis when factors such as mucositis and marginal bone remodeling ensue from deep positioning of the implant for more acceptable esthetic outcomes. e diagnosis of peri-implantitis may also be caused by the local anatomic variations.53Controversy surrounds the issue of using bleeding and gingi-val health as an implant health indicator. Unlike a natural tooth, implant success in the rst few years is related more often to bio-mechanical equilibrium than to gingival health. Compared with a natural tooth, the soft tissue inammation caused specically by bacteria may be more restricted to above the crestal bone, because of the lack of a periodontal membrane or brous tissue between the implant and the bone interface. As a result the bleeding index may not be as signicant when evaluating early implant health status.54 Presence of Keratinized TissueIn recent literature, compelling clinical published reports have cor-related peri-implantitis with keratinized gingiva and biotype thick-ness. A few studies have shown a minimal correlation between keratinized tissue and implant success. However, other reports have shown a lack of keratinized tissue is associated with bone loss,55 increased plaque acculumlation,56 increased gingival reces-sion,57 increased gingival inammation,58 and a higher frequency of bleeding on probing.59The soft tissue at the implant site has been recognized as a crucial factor in long-term maintenance of healthy implant res-torations. The soft tissue quality at the implant site, together with the gingival biotype, is a predisposing factor in a patient’s resistance to plaque accumulation and inflammatory-mediated peri-implant disease.60,61 Unattached, nonkeratinized muco-sal tissue is more problematic because implants do not have inserting supracrestal gingival fibers, which serve as a barrier to bacterial insult; Sharpey’s fibers run parallel to the implant, leaving only the hemidesmosomal seal of the junctional epi-thelium at the neck of the implant to protect underlying soft and hard peri-implant structures. During the mastication pro-cess, this seal may be broken when the vestibule is shallow and frenum attachment is high, causing excess pressure on the Lindquist Plaque Index0 = no visible plaque1 = local plaque accumulation2 = general plaque accumulation (>25%) Mombelli Plaque Index0 = no visible plaque1 = plaque recognized by probing over smooth margin of implant2 = visible plaque3 = abundance of soft matter • BOX 42.3 Plaque Index EvaluationsBone crestFGMCTJESulcus• Fig. . A probe placed into the sulcus of a tooth goes through the sulcus and the epithelial attachment. It is stopped by the connective tissue attachment. The biological width of a natural tooth has a connective tissue zone that inserts into the cementum of the tooth. A periodontal probe will penetrate the sulcus and the junctional epithelial (JE) attachment. CT, Con-nective tissue; FGM, free gingival margin. (From Misch CE. An implant is not a tooth: a comparison of periodontal indices. Dental Implant Prosthet-ics. 2nd ed. St. Louis, MO: Mosby; 2015.) 1200PART VIII Dental Implant Maintenancetissue. Microbial colonization may then progress to the crestal and peri-implant tissue, which may result in the early stages of peri-implant disease. If plaque control is not adequate around the implants lacking keratinized gingiva, tissue may cause irri-tation and sensitivity, which may be uncomfortable for the patient.For the existing soft tissue the quality may be classied as either a thin or a thick biotype. in gingival biotype is indicative of thin underlying supporting bone. in structures are less vascular-ized and more prone to recession and resorption in the presence of inammation. erefore patients with a thin biotype are more susceptible to peri-implant complications, especially if keratinized tissue is compromised (Box 42.4).In conclusion, there is increasing literature to support the advan-tage of keratinized tissue over nonkeratinized tissue. Many authors recommend keratinized mucosa more intensely than others.In specic clinical instances, attached, keratinized gingiva is more often desirable. For example, a xed prosthesis (FP-1) in the esthetic zone (anterior maxilla) will require keratinized mucosa to develop a soft tissue drape around the implant prosthesis. Another prime example is with a mandibular overdenture, which benets from a stable vestibule and a zone of nonmobile tissue around the BDAC• Fig. . Controversies related to probing include the material of the probe and the difficulty in obtaining accurate measurements (A) probing around an implant retaining a bar overdenture; (B) if excessive prob-ing pressure is used, probing depths will be inaccurate and traumatize the tissue; (C) if the prosthesis is overcontoured, difficulty in probing will result; (D) difficulty probing with a plastic probe around the contours of a fixed prosthesis. 1. Similar to natural teeth tissue in color, contour, and texture of the soft tissue drape 2. More esthetic, especially when a high smile line exists 3. Keratinized tissue is more resistant to abrasion 4. Maintaining papillae is more predictable if keratinized tissue is present 4. Hygiene aids are more comfortable to use 5. Degree of gingival recession is proportional to the amount of keratinized gingiva 6. Keratinized mucosa is more manageable during the retraction and impression process 7. Long-term tissue stability is greater with keratinized tissue 8. With two-stage implant placement, wound dehiscence is less likely • BOX 42.4 Benets of Keratinized Tissue Around an Implant 1201CHAPTER 42 Implant Maintenance: Long-Term Implant Successimplant abutments. When these conditions exist, it is less likely for patients to exhibit tissue sensitivity. Current recommendations based on clinical experience and current systematic reviews are to evaluate and, if possible, increase decient sites of inadequate keratinized gingiva around implants prophylactically if peri-implant disease exists62,63 (Fig. 42.12). Mobility of Implant/ProsthesisAt each maintenance appointment the mobility of the prosthesis and implants should be evaluated. If mobility exists, the etiology should be ascertained, specically if it is due to a loose screw or implant failure. Usually if pain is present when the prosthe-sis is moved in a buccal-lingual and apical direction, then it is most likely due to an implant failure (i.e., unless the tissue is impinging on the tissue, resulting in pain). When implant fail-ure exists, pain will result because of the soft tissue interface. If no pain exists, then usually this is indicative of screw loosening (Fig. 42.13). Pain/SensitivityA component of the maintenance protocol is the determination of any possible subjective ndings of pain, tenderness, and sensitiv-ity concerning the patient’s peri-implant tissues, implant body, or implant prosthesis. Pain and tenderness are subjective criteria and depend on the patient’s interpretation of the degree of discomfort. Pain is dened as an unpleasant sensation ranging from mild dis-comfort to excruciating agony. Tenderness is more an unpleasant awareness of the region. An implant rarely is troubled by the sub-jective criteria of pain or sensitivity after initial healing. In contrast to a natural tooth an implant does not become hyperemic and is not temperature sensitive. If a traumatic occlusion situation is present, rarely will symptoms be present with an implant.Implant-Related Pain. After the implant has achieved primary healing, absence of pain under vertical or horizontal forces is a pri-mary subjective criterion. Usually, but not always, pain does not occur unless the implant is mobile and surrounded by inamed tissue or has rigid xation but impinges on a nerve. e most common condition that causes discomfort from an implant is when a loose implant abutment is entrapping some of the soft tissue in the abutment-implant connection. Usually, after the soft tissue in the region is removed and the abutment is repositioned, the discomfort or pain will subside.When an implant is mobile, pain may occur early or late in treatment. In either case the condition rarely improves. Pain on loading of rigid implants has been observed more often on imme-diately loaded implants compared with those healing unloaded for an extended period. Implant sensitivity or mild tenderness rather than pain in a rigid implant is also most unusual and sig-nals a more signicant complication for an implant than for a tooth. Tenderness during function or percussion usually implies ACDB• Fig. . Inadequate Keratinized Tissue. (A) Lack of quality attached tissue on facial aspect of the healing abutments. (B and C) Lack of keratinized tissue on facial of final prosthesis. (D) Bar overdenture exhibiting compromised attached tissue because of the facial placement of the implants. 1202PART VIII Dental Implant Maintenancehealing in the proximity of a nerve or, on rare occasions, bone stress beyond physiologic limits.On occasion an implant body may fracture from fatigue. Fatigue is related to the amount of force, the number of cycles, the strength of the material, the diameter of the component, and the number of implants splinted together. is condition is similar to a fractured root. In any case, radiographic evidence of the fracture may be dicult to ascertain. Percussion and forces up to 500 g (1.2 psi) with a bite stick are used clinically to evaluate a tooth or implant for pain or discomfort. Percus-sion and heavy biting on a wood stick associated with pain are clinical indices. In these cases the implant is most often removed, which especially in the mandible (i.e., dense bone) may be dicult (Fig. 42.14). Abutment-Related Pain. When the abutment-implant connec-tion is not secure, pain may result because of tissue integration into the void. is pain is usually persistent and occurs most often during percussion or function. If this occurs, the prosthesis and abutment should be removed, soft tissue excised, and components repositioned (Fig. 42.15). Infection-Related Pain. Especially in the early stages of peri-implantitis, pain usually does not present as a primary clinical symptom. Unless active infection with suppuration accompanies sucient osseous destruction, patients do not experience pain. Because dental implants do not have a PDL support and its sen-sory apparatus, low-grade infections and bone resorption are not detected by marginal gingiva. As the disease process begins around an implant, the patient may feel slight irritation, but normally not alarming pain.64,65 It is recommended that the implant clini-cian be proactive in evaluating the status of dental implants with the incorporation of a routine maintenance protocol for implant patients. OcclusionIdeally, in most xed implant cases an implant-protected occlu-sion should be present. Implant-protected occlusion (i.e., canine guidance) should be adhered to so the anterior teeth protect the posterior teeth (i.e., protrusive movements) and the posterior teeth protect the anterior (i.e., centric occlusion).Traumatic occlusion has been shown to be an etiologic factor in the loss of bone around the peri-implant region. A timed occlu-sion should always be present, which includes the natural teeth contacting rst before the contact of the implant (i.e., to compen-sate for the PDL compression during occlusal contacts). During light contact, extrathin articulating paper (e.g., shimstock) should be easily pulled through the occlusal contact with an implant. en during heavy contact, minimal resistance should be pres-ent. Miyata etal.66 reported with monkey studies that bone loss ABC D• Fig. . (A and B) Mobile implant prostheses diagnosed at the maintenance appointment. (C) Ill-fitting and loose full-arch fixed prosthesis. (D) Ill-fitting prosthesis which may result from loose abutment screw. 1203CHAPTER 42 Implant Maintenance: Long-Term Implant Successmay occur with an excess occlusal contact of 180 μm, even in the absence of peri-implant inammation. erefore it is imperative that the implant clinician evaluate and modify the existing occlu-sion if necessary, at each appointment (Fig. 42.16).In addition, the presence of parafunctional habits (e.g., clench-ing, bruxism) should be documented and treated, most commonly with an occlusal guard. A hard acrylic centric is most commonly used. ProsthesisAt each maintenance appointment the prosthesis should be evalu-ated for not only mobility but also any fractures of the prosthesis material (e.g., porcelain, acrylic, zirconia). If material fracture is present, the occlusion should be immediately evaluated and the possibility of replacement is determined. For a removable pros-thesis, all implant attachments should be evaluated for mobility and retention. Radiographic Evaluation of the Implant and ProsthesisAn accurate and thorough radiographic examination should be performed as a routine adjunct to the clinical maintenance exami-nation (Box 41.2). Ideally the radiographic modality used should be able to standardize the evaluation of the implant interface and bone level. e selection of the radiographic modality is dictated by the number and position of implants, along with the type of prosthesis.Upon radiographic evaluation the crestal bone region is often the most diagnostic for the ranges of optimum, satisfactory, and compromised health conditions. Radiographic interpretation is one of the easiest clinical tools to use to assess implant crestal bone loss, but has many limitations. However, a two-dimensional radiograph will illustrate only the mesial and distal crestal levels of bone (Fig. 42.17).When early bone loss occurs, it is most often present on the facial aspect of the implant. e absence of radiolu-cency around an implant does not indicate bone is pres-ent at the interface. erefore two-dimensional radiographs (i.e., periapical, bitewings, panographic lms) may often be misleading on revealing the amount of bone loss. In the mandibular anterior region, as much as a 40% decrease in density is necessary to produce a traditional radiographic dif-ference in this region because of the dense cortical bone.67 When abundant bone width is present, a V-shaped crestaldefect around an implant may be surrounded by cortical bone and, as a result, the radiograph is less diagnostic for bone loss.ABCD• Fig. . Implant Pain. (A and B) If pain is present with an implant, it is usually a failure because of a soft tissue encapsulation; radiographs reveal significant radiolucency surrounding the implant bodies. (C and D) If suppuration is present, usually the patient will be symptomatic. 1204PART VIII Dental Implant MaintenanceRadiograph Typee type of radiograph used in the evaluation of the implant and prosthesis is dicult to generalize. Standardized periapi-cal radiographs are usually recommended as the most com-mon type of radiographic modality in evaluation of dental implants. e long cone paralleling technique should be used to minimize image distortion.68 Panoramic radiographs exhibit inherent disadvantages, including magnication, distortion, overlapping images, and poor resolution. erefore panoramic radiographs are not the most ideal radiograph in evaluating bone loss (Fig. 42.18). However, in cases where periapical or bitewing radiographs cannot be obtained, panoramic lms may be used.Cone beam computed tomography (CBCT) scans, although superior to plain lm radiographs in the diagnosis and treat-ment planning phases of implant dentistry, are usually not indi-cated for routine maintenance unless complications are present. Studies evaluating the visibility of the buccal plate showed that if the amount of bone present is less than 0.6 mm in thick-ness, the bone will be invisible on a CBCT image.69 In addi-tion, CBCT images suer from beam hardening, which leads to the formation of a radiolucency surrounding the implant. is occurs from a greater number of photons being absorbed (Fig. 42.19). In summary, the type of image modality should be spe-cically tailored to each individual patient, according to clinical and anatomic circumstances. Radiograph AccuracyIt is often more dicult to obtain an accurate radiograph of the implant body in comparison with a natural tooth. Most com-monly, implants are placed more apical to the apex of the pre-existing natural teeth. As a result the apex of the implant often is located beyond muscle attachments or in regions almost impossible to capture with a parallel radiographic method. A foreshortened A BC D• Fig. . Abutment-Related Pain. (A) An incomplete abutment seating will result in tissue growth with resultant pain. (B) After implant is removed, tissue impingement is evident. (C and D) The excess tissue is removed with a latch-type tissue punch. 1205CHAPTER 42 Implant Maintenance: Long-Term Implant Successimage to encompass the apical portion of the implant results in poor display of the crestal bone. An accurate radiograph will show a clear depiction of the threads on the radiograph and a proper angulation. If the implant threads are clear on one side but blurry on the other, the angulation was incorrect by approxi-mately 10%70 (Fig. 42.20). If both sides of a threaded implant are unclear, the radiograph is not diagnostic for crestal bone loss assessment because of angulation issues. Ideally the abutment-implant connection should appear as a clear line between the two components. When the top of the implant is placed at the crest of the regional bone, the amount of crestal bone loss is most easy to evaluate (Fig. 42.21).In addition, the prosthesis should be evaluated for any radiographic changes from the baseline radiographs. Of utmost importance is the fit of the prosthesis because an ill-fitting or loose prosthesis may lead to peri-implant disease. If a space is present between the prosthesis and the abutment, the prosthesis should be immediately evaluated for passivity and mobility. Radiograph Timinge most important radiograph for use in the maintenance phase is the postprosthetic baseline radiograph. is radiograph is most often taken at the prosthesis insertion appointment. By this time the “biological width” most likely will have inuenced the implant crest module bone level.In general, implants with machined surfaces or external hex connections are usually subject to an initial remodeling of the bone level. Adell etal.71 reported an average bone loss of 1.5 mm during the rst year and 0.1 mm per year thereafter. However, recent implant design changes have reduced this bone loss with internal connections and platform switching.72,73In most cases an individualized radiographic protocol should be developed based on the number and location of implants, type of prosthesis, and any associated complications. A comprehensive and generalized radiologic protocol was established by Resnik74 in 2016 (Box 42.5). Radiographic Crestal Bone Losse marginal bone around the implant crestal region is usually a signicant indicator of implant health. e cause of crestal bone loss around an implant is multifactorial and may occur at dierent ABB• Fig. . (A) Radiograph depicting significant bone loss surrounding the anterior implant; however, this may be misleading because it depicts only the mesial and distal bone levels. (B) Vertical bitewing exhibiting ideal angulation.AB• Fig. . Occlusal Contacts. (A) The occlusion should be checked at each maintenance appointment to ensure lack of premature contacts. (B) Ideal occlusion consists of primary contact (i.e., light occlusion) on the natural teeth and light contact on implants during heavy occlusion. 1206PART VIII Dental Implant Maintenancetime periods: surgical bone loss, initial “biologic width” bone loss, early loading bone loss, intermediate-term bone loss, and long-term bone loss. Each period may be associated with a dierent cause for the bone loss. Most often the surgical trauma results in minimal bone loss, but on occasion, bone loss may reach several millimeters (Fig. 42.22).When the abutment is attached to the implant body, approxi-mately 0.5 to 1 mm of connective tissue forms apical to this connection.75 is associated bone loss may be caused by an “implant biologic width.” Initial bone loss during the surgical healing phase may vary for submerged and unsubmerged healing protocols.76After the implant is connected with a permucosal element, the marginal bone may be lost during the rst month from: (1) the position of the abutment-implant connection or (2) the crest module design of the implant. e abutment-implant connection may cause 0.5 to 1.0 mm of bone loss when it is at or below the bone. In addition, when smooth metal is present below the abutment-implant connection, additional bone loss will occur in direct relation to the smooth metal region. e bone levels will most often reside at the rst thread or at a roughened surface after the rst month after permucosal element placement (Fig. 42.23 and Box 42.6). Diagnosis of Peri-implant DiseaseAfter the clinical and radiographic maintenance examination is complete, a diagnosis of the current peri-implant condition is war-ranted. In the evaluation of the peri-implant tissues, three pos-sible conditions may exist: (1) healthy condition, (2) peri-implant mucositis, and (3) peri-implantitis.Healthy ConditionIf there exist no signs of inammation, bleeding, recession, bone loss, or implant/prosthesis mobility, then the patient’s implants/prosthesis is determined to be in a “healthy” state (Fig. 42.24 and Box 42.7).Treatment includes adherence to routine implant maintenance (i.e., usually 3–6 months). Peri-implant MucositisPeri-implant mucositis is dened as a localized inammation within the soft tissue surrounding the implant bodies. In addi-tion, redness and bleeding on probing may be present. However, the bone level has not changed; therefore no hard tissue recession (i.e., bone loss) has occurred. Peri-implant mucositis is similar to gingivitis with respect to natural teeth (Fig. 42.25).• Fig. . Panoramic Image. The determination of the amount of bone loss on a panoramic image is misleading because of the magnification, distortion, overlapping images, and poor resolution.AB• Fig. . Inherent Cone Beam Computed Tomography Disadvantages. (A) Beam hardening result-ing in a radiolucency surrounding the implant. (B) Scatter that is caused by the presence metallic objects (e.g., crowns, implants). 1207CHAPTER 42 Implant Maintenance: Long-Term Implant SuccessTreatment includes remediation of the causative factors of peri-implant mucositis and associated follow-up care. Peri-implantitisPeri-implantitis is dened as localized inammation with concomi-tant bone loss. In most peri-implantitis cases suppuration and clini-cal probing depths are present, together with bleeding on probing. On radiographic evaluation, marginal bone loss is present in com-parison with the original baseline radiographs (Fig. 42.26).Treatment includes remediation of the causative factors and usually hard and soft tissue surgical intervention, followed by con-tinued maintenance care. Frequency of Maintenance VisitsPeri-implant disease may result from opportunistic infections that lead to soft and hard tissue complications; therefore it is manda-tory to monitor the peri-implant tissues at regular intervals. If early signs of disease are diagnosed, aggressive intervention may prevent the loss of hard tissue. Zitzman etal.77 reported that peri-implant mucositis may exhibit apical progression after only 3 months of plaque buildup around implants. erefore a 3-month mainte-nance regimen is recommended within the rst year of implant placement to evaluate the tissue health and the patient’s home care. If after the rst year the peri-implant tissues are healthy, then the maintenance interval may be extended to 6 months. However, a stricter recall protocol should be adhered to if the patient does exhibit risk factors or comorbidities.78 Patient Home CareIdeally a home care assessment should be determined before the initiation of dental implant treatment. In partially or completely edentulous patients, usually compromised home care is already present. In addition, during the postsurgical phase of treatment, patients are often lax in their hygiene practices because of fear of causing damage to the surgery site. erefore it is imperative that the patient be educated on the necessity and need for a compre-hensive home care regimen.When educating patients on home care, various techniques may be used, as long as they are safe and eective. Depending on the type of implant, implant position, location in the oral cavity, and type and size of the prosthesis, various devices along with the frequency may be recommended. No single hygiene device has been shown to be ideal in all situations. ere exists a full array of • Fig. . On this periapical radiograph the threads are clear. On the right side only, the central ray was not directed completely perpendicular to the implant body but was within 10 degrees. This film is not ideal to ascertain the amount of bone loss.A B• Fig. . (A) Poor angulation resulting in no threads of the implants being seen. (B) Ideal positioning as implant threads on mesial and distal are easily seen. 1208PART VIII Dental Implant Maintenancebrushes, oss threading systems, and other devices available to aid patients in their hygiene protocols.One common mistake often employed by clinicians is to add too many oral hygiene devices for patient home care. Studies have shown that when multiple devices are recommended, patients are more apt to become discouraged and less motivated. However, when a combination of toothbrushing devices, auxiliary aids, and antimicrobial mouthrinses are used, an increased plaque inhibi-tion is seen.79Specific DentifricesManual and Electromechanical DevicesIn general most exposed facial and lingual surfaces may be cleaned with a soft, multitufted nylon toothbrush. e implant clinician should recommend to each individual patient which brush angle would be ideal to access all areas within the mouth. e modied Bass technique should be used or a short, hori-zontal, back-and-forth movement may be incorporated into the hygiene regimen. e brush may be held at a 45-degree angle to the gingival tissue.80Most commonly, patients often prefer electromechanical devices, which have been shown to be superior to manual brush-ing around dental implants.81 When using electromechanical devices (i.e., sonic toothbrushes, oscillating-rotating power tooth-brushes), especially in dicult-to-access areas, end-tufted brushes and tapered rotary brushes tend to be benecial. Studies have con-rmed the benets of these devices.82,83 Rasperini etal.82 reported a reduction in bleeding (∼50% in the rst year) and decrease in probing depths (∼0.3 mm) with power toothbrushes.Most manufactured power brushes have soft, interchangeable bristle heads (attened, rubber cuplike, short and long pointed PreoperativeCone Beam Computed Tomography• Allvitalstructuresidentied• Sinus-relatedprocedures:mustconrmpatencyofostiumandlackofpathology Intraoperative• Peri-apicalradiograph(PA)afterpilotdrillduringplacementtoconrmpositioning and proximity to vital structures and adjacent teeth• PAofnalplacementwithcoverscreworhealingabutment• PAbeforeuncoversurgery(stage2procedure)Prosthetic• PAtoconrmimplantisreadytorestore• PAtoconrmabutmentisseatedproperly• PAtoconrmproperseatingofprosthesis/cementremoval(willbebaseline for future evaluation radiographs) Postoperative• PAonceannuallyfortherst3yearsafterimplantprostheticstomonitorbone level• Normal(acceptable):<0.2mmverticalbonelossperyearforrst3years• After3years,PAshouldbetakenevery2yearsIn addition to radiographic evaluation, the following should be evaluated:• Presenceofpain,suppuration• Implantand/orprosthesismobility• Hyperocclusion• Softtissuechanges(bleeding,recession,hyperplasia)In some cases a periapical radiograph cannot be accurately obtained because of positioning issues; therefore a panoramic radiograph may be used as an alternative radiographic modality. • BOX 42.5 Radiograph Timing ProtocolAB• Fig. . Postprosthetic Images. (A) Ideal radiograph showing no signs of bone loss. (B) Image depicting significant early bone loss at first maintenance appointment.• Fig. . When an implant is placed with the abutment connection at the crest of the ridge (left side), after the permucosal abutment is con-nected the bone is usually lost to the first thread, especially when the crest module is machined or smooth (right side). 1209CHAPTER 42 Implant Maintenance: Long-Term Implant Successin shape) that may be used. e short and long pointed tips are ideal for reaching proximal areas, wide embrasures, and pontic areas under a splinted prosthesis. e hollowed rubber cup may be used on the facial and lingual aspects of the implant and pros-thesis (Fig. 42.27). Toothpaste/Gele selection of a toothpaste should be low abrasive as to not scratch the surface of the exposed implant. Dentifrices should be avoided that contain harsh abrasive ingredients, including stain removers and smoker’s toothpaste.84 Selective uorides may result in etching and roughness on implant surfaces.85,86 Interproximal BrushesWith some types of prostheses (e.g., full-arch xed prosthesis), interproximal brushes with small brush heads may be indicated to gain easier access. Ideally these types of device should be plastic-coated because metal may damage the implant surface.79 e inter-dental brush is used to massage the gingival tissue, which results in increased blood ow and healthier tissue. Patients should be instructed to insert the tip interproximally in an occlusal direction and use a gentle rotary motion against the gingiva80 (Fig. 42.28). Floss AidsFlossing around dental implants is also a controversial topic. Most patients are resistant to ossing their natural teeth, espe-cially if oss threaders are required. erefore ossing has an inherent disadvantage in patient compliance and also dexter-ity issues. When ossing around implants, it is often dicult to manipulate and maneuver the oss around a malpositioned implant or an overcontoured/atypical prosthesis. Floss is ideally used interproximally, especially when a splinted prosthesis is present. icker oss is available (e.g., “yarnlike”) that allows for cleaning around abutments and prostheses, and ease of penetrat-ing hard to reach interproximal areas. Floss may be used in con-junction with chlorhexidine or other antimicrobials to decrease plaque accumulation.It is imperative that the patient is instructed on the proper technique on ossing around dental implants. Improper or over-aggressive ossing may lead to tissue trauma and resultant peri-implant soft tissue lesions (Fig. 42.29). Time EtiologySurgery Trauma to boneUncovery “Implant biologic width” related to abutment location and implant crest module designEarly Occlusal traumaIntermediate Bacteria or occlusal traumaLong term Bacteria • BOX 42.6 Etiology of Implant Crestal Bone Loss• Fig. . Healthy Implant Condition. No signs of inflammation, bleed-ing, tissue recession, or bone loss (lateral incisors). 1. No signs of inflammation (pink, firm peri-implant mucosa)2. Noprobingdepths(<4mm)3. Absenceofbleedingongentleprobing(<15N) 4. No suppuration 5. No pain or sensitivity 6. No radiographic bone changes • BOX 42.7 Healthy Clinical Findings• Fig. . Periimplant Mucositis. Molar implant prosthesis exhibiting signs of bleeding; however, no bone loss is present.• Fig. . Peri-implantitis. Anterior implant prosthesis exhibiting signs of significant recession, inflamed gingival tissue, and plaque accumulation. 1210PART VIII Dental Implant MaintenanceABC• Fig. . (A) Manual brushing around a dental implant (Procter & Gamble, Cincinnati, Ohio). (B) Electro-mechanical toothbrush around a dental implant Philips Sonicare. (C) AirFloss Pro (Philips).A B• Fig. . (A) Interproximal brush (Sunstar Butler, Chicago, Ill.). (B) Hu-Friedy EMS Piezo implant tip, PIEZON® TECHNOLOGY. 1211CHAPTER 42 Implant Maintenance: Long-Term Implant SuccessBA• Fig. . (A and B) Floss aids. (B) Microdroplets of air and liquid with AirFloss Pro (Philips).Oral Irrigatore oral irrigator (e.g., Air Floss Pro, Philips) may be benecial in removing supragingival debris, especially when dicult access exists because of the prosthesis type. Numerous studies have shown an oral irrigator to be superior in reducing gingival bleed-ing, inammation, and plaque in comparison with string oss.87-89 Magnuson etal.90 found oral irrigators to reduce bleeding around implants by 81% in contrast with 33% for ossing. However, cau-tion must be exercised in using an oral irrigator because excessive force (i.e., high pressure) may damage the junctional epithelium, which may lead to a bacteremia.91 To minimize complications, patients should be instructed on the proper use of these devices, mainly using a low to medium speed and angulating the tip to be perpendicular to the long axis of the implant body.Patients should be instructed to use a nonmetal tip once to twice daily.An antimicrobial (e.g., chlorhexidine, cetylpyridinium chlo-ride) may be used as an irrigant that decreases the bacterial count in the oral cavity.92 Studies comparing rinsing with 0.12% chlorhexi-dine with irrigating with 0.06% chlorhexidine showed the irri-gation group to be 87% more eective in reducing gingivitis in comparison with the rinsing group93 (Fig. 42.30 and Box 42.8). AB C• Fig. . Hu-Friedy AIRFLOW® DEVICES, EMS Dental (A) AIRFLOW® HANDY 3.0 PERIO. (B) AirFlow interdental and supragingival. (C) Ideal placement of Hu-Friedy PerioFlow tip into subgingival areas. 1212PART VIII Dental Implant MaintenanceBA• Fig. . Subgingival irrigation therapeuticals. (A) AIRFLOW PERIO POWDER for Hu-Friedy EMS AIRFLOW® THERAPY SYSTEM, prophylaxis powder. (B) Irrigation with Chlorhexidine gluconate in monojet syringe interproximally and subgingivally.Antimicrobial Rinsese regular use of chemotherapeutic agents such as antimi-crobial rinses may be used as an adjunct in plaque control. Chlorhexidine gluconate is the most commonly used antimi-crobial rinse in implant dentistry because it is safe, inexpensive, and nontoxic. It is very eective because of its substantivity, which is the binding of the medication to the soft tissues and implant surfaces. Studies have shown that a 30-second rinse of chlorhexidine inhibits 90% of oral bacteria for more than 5 hours.92 Chlorhexidine or cetylpyridinium chloride may be locally applied with a cotton swab or may be used as a rinse twice daily (Fig. 42.31 (B)). In-Office DebridementIn certain situations a maintenance visit will lead to the need for in-oce debridement. When excessive dental plaque and calcu-lus are present, the dental professional must use instruments for proper removal. However, care should be exercised in not dam-aging the implant or prosthesis. Older implant systems made of commercially pure titanium, which is a softer metal, are eas-ily damaged with conventional instruments. If surface damage results, the titanium oxide surface layer will be altered, which may cause surface corrosion.94 However, more recent implant designs use titanium alloy, which is far more resistant to surface alteration.e use of ultrasonic instrumentation is not recommended with dental implants, unless the stainless steel tips are covered with a protective sleeve. Fig. 42.28 (B) these scalers may dis-rupt the titanium dioxide surface, which leads to plaque accu-mulation. ese scratches and gouges may be detrimental to long-term health and hygiene practices.95 Air polishers with bicarbonate particles (e.g., Prophy-Jet) may also be detrimen-tal to the implant surface. Studies have shown alteration of the implant surface may result because random pitting and irregu-larities within the surface may occur. erefore air polishers with bicarbonate particles should not be used around implants or the prosthesis.96Low-abrasive amino acid glycine powder has been shown to be an eective treatment for removing biolm with-out damaging the implant surface or hard and soft tissues. is piezo instrument (Hu-Friedy, Chicago, Ill.) uses a spe-cial handpiece with a plastic tube nozzle with three orthogo-nally oriented holes. An air-powder mixture with reduced pressure is expelled through the nozzle, which prevents the formation of air emphysema complications. e nozzle is moved in a circumferential movement around the implant surface Fig. 42.30 (A), (B), (C) and Fig. 42.31 (A).Although more extensive studies need to be conducted as to technique ecacy, glycine powder can be incorporated into a treatment regimen. e clinician should be careful to use the powder only in areas where access is available and a posttreatment rinse can remove any residue. is modality is best used in cases with buccal dehiscence and/or horizontal bone loss without crater or infrabony pocketing.After debridement procedures a follow-up visit should be scheduled approximately 1 month later. At this appointment the health of the peri-implant tissues should be evaluated together with home care reinforcement. Usually after the 1-month follow-up the patient should be seen on a 3-month recall. If peri-implant health is normal, patients can usually be placed on a 3- to 6-month recall system. • Maycleansupragingival,subgingival,andinterdentalareas• Mayremovesupragingivalandsubgingivalplaque(biolm)• Hasbeenshowntobemoreeffectivethanstringossfordentalimplants• Moreeffectivethanchlorhexidinewithimplantcare• Hasbeenshowntobesafeifusedproperly• Easytouse • BOX 42.8 Benets of Oral Irrigator3 1213CHAPTER 42 Implant Maintenance: Long-Term Implant SuccessConclusione ongoing maintenance of dental implants is one of the most important factors for long-term health. With increasing numbers of implants being placed each year, it is evident that the preven-tion of peri-implant disease is paramount to success. An individu-alized implant maintenance program needs to be implemented that is tailored to the specic patient, the implants, and the pros-thesis. Successful implant maintenance depends on many factors, most importantly communication and collaboration between the dental professional and the patient. Peri-implant disease is a preva-lent disease; therefore a comprehensive maintenance program is essential to decrease complications. e implant clinician must understand the factors and the need for a systematic maintenance protocol, along with informing his or her patients of the most updated information to ensure longevity of their implants and prosthesis.References 1. Corbella S, Del Fabbro M, Taschieri S, etal. Clinical evaluation of an implant maintenance protocol for the prevention of peri-implant diseases in patients treated with immediately loaded full-arch reha-bilitations. Int J Dent Hyg. 2011;9:216–222. 2. Silverstein L, Garg A, Callan D, Shatz P. e key to success: main-taining the long-term health of implants. Dent Today. 1998;17: 104, 106, 108–111. 3. Lyle DM. Implant maintenance: is there an ideal approach? Com-pend Contin Educ Dent. 2013;34(5):386–390. 4. Sanz M, Chapple IL. Clinical research on periimplant diseases: Con-sensus report of Working Group 4. J Clin Periodontol. 2012;39:202–206. 5. Glavind L, Attström R. Periodontal self-examination. A motiva-tional tool in periodontics. J Clin Periodontol. 1979;6:238–251. 6. Bidez MW, Misch CE. Force transfer in implant dentistry: basic concepts and principles. J Oral Implantol. 1992;18:264–274. 7. Gargiulo A, Wentz F, Orban B. Dimensions and relations of the dentogingival junction in humans. J Periodontol. 1961;32:261–268. 8. Vacek JS, Gher ME, Assad DA, et al. e dimensions of the human dentogingival junction. Int J Periodontics Restorative Dent. 1994;14:154–165. 9. Rateitschak KH. Periodontology. In: Rateitschak KH, Rateitschak EM, Wolf HF, etal., eds. Color Atlas of Dental Medicine. 2nd ed. New York: ieme; 1989. 10. James RA, Schultz RL. Hemidesmosomes and the adhesion of junc-tional epithelial cells to metal implants: a preliminary report. J Oral Implantol. 1974;4:294. 11. Cochran DL, Herman JS, Schenk RK, etal. Biologic width around titanium implants: a histometric analysis of the implanto-gingival junction around unloaded and loaded submerged implants in the canine mandible. J Periodontol. 1997;68:186–198. 12. Schroeder A, Pohler O, Sutter F. Tissue reaction to a titanium hol-low cylinder implant with titanium plasma sprayed surface. Schweiz Monatsschr Zahnmed. 1976;86:713–727. 13. Ericsson I, Lindhe J. Probing at implants and teeth: an experimental study in the dog. J Clin Periodontol. 1993;20:623–627. 14. Abrahamsson I, Berglundh T, Lindhe J. e mucosal barrier follow-ing abutment disreconnection: an experimental study in dogs. J Clin Periodontol. 1997;24:568–572. 15. Partt GS. Measurement of the physiologic mobility of individual teeth in an axial direction. J Dent Res. 1960;39:608–612. 16. Sekine H, Komiyama Y, Hotta H, et al. Mobility characteristics and tactile sensitivity of osseointegrated xture-supporting systems. In:VanSteenbergheD, ed. Tissue Integration in Oral Maxillofacial Reconstruction. Amsterdam: Excerpta Medica; 1986. 17. Muhlemann HR. Tooth mobility: a review of clinical aspects and research ndings. J Periodontol. 1967;38:686–708. 18. Rudd KD, O’Leary TJ, Stumpf AJ. Horizontal tooth mobility in carefully screened subjects. Periodontics. 1964;2:65–68. 19. Meredith N, Alleyne D, Cawley P. Quantitative determination of the stability of the implant-tissue interface using resonance fre-quency analysis. Clin Oral Implant Res 1996;7:261-7. 20. Sennerby L, Meredith N. Implant stability measurements using res-onance frequency analysis: biological and biomechanical aspects and clinical implications. Periodontology. 2000, 2008. 21. Antoniazzi RP, Miranda LA, Zanatta FB, et al. Periodontal con-ditions of individuals with Sjögren’s syndrome. J Periodontol. 2009;80:419–435. 22. Habbab KM, Moles DR, Porter SR. Potential oral manifestations of cardiovascular drugs. Oral Dis. 2010;16:769–773. 23. Smidt D, Torpet LA, Nauntofte B, Heegaard KM, Paedersen AM. Associations between oral and ocular dryness, labial and whole salivary ow rates, systemic diseases and medications in a sam-ple of older people. Community Dent Oral Epidemiol. 2011;39: 276–288. 40. 24. Fejerskov O, Escobar G, Jøssing M,BaelumV. A functional natural dentition for all- and for life? e oral healthcare system needs revi-sion. J Oral Rehabil. 2013;40:707–722. 25. Hernández G, Lopez-Pintor RM, Arriba L, Torres J,deVicenteJC. Implant treatment in patients with oral lichen planus: a prospective-controlled study. Clin Oral Implants Res. 2012;23:726–732. 26. López-Jornet P, Camacho-Alonso F, Sánchez-Siles M. Dental implants in patients with oral lichen planus:a cross-sectional study. Clin Implant Dent Relat Res. 2014;16:107–115. 27. Dvorak G, Reich KM, Tangl S, Goldhahn J, Haas R, Gruber R. Cortical porosity of the mandible in an osteoporotic sheep model. Clin Oral Implants Res. 2011;22:500–505. 28. March and F, Raskin A, Dionnes-Hornes A, etal. Dental implants and diabetes: conditions for success. Diabetes Metab. 2012;38:14–19. 29. Cavalcanti R, Oreglia F, Manfredonia MF, et al. e inuence of smoking on the survival of dental implants: a 5-year pragmatic multicenter retrospective cohort study of 1727 patients. Eur J Oral Implantol. 2010;4(1):39–45. 30. Marrone A, Lasserre J, Bercy P, Brecx MC. Prevalence and risk fac-tors for peri-implant disease in Belgian adults. Clin Oral Implants Res. 2013;24:934–940. 31. Renvert S, Aghazadeh A, Hallstrom H, Persson GR. Factors related to peri-implantitis - a retrospective study. Clin Oral Implants Res. 2014;25(4):522–529. 32. Bormann KH, Stühmer C, Z’Graggen M, etal. IL-1 polymorphism and periimplantitis. A literature review. Schweiz Monatsschr Zahn-med. 2010;120:510–520. 33. Löe H. e gingival index, the plaque index and the retention index systems. J Periodontol. 1967;38(6):610–616, ISSN 0022- 3492. 34. Lekholm R, Adell R, Lindhe J, etal. Marginal tissue reactions at osseointegrated titanium xtures (II). A cross-sectional study. Int J Oral Maxillofac Surg. 1986;15:53–61. 35. Mombelli A, Marxer M, Gaberthuel T, et al. e microbiota of osseointegrated implants in patients with a history of periodontal disease. J Clin Periodontol. 1995;22:124–130. 36. Lindquist LW, Rocker B, CarlsonGE. Bone resorption around x-tures in edentulous patients treated with mandibular xed tissue-integrated prostheses. J Prosthet Dent. 1988;59:59–63. 37. Newman MG, Flemmig TF. Periodontal considerations of implants and implant associated microbiota. Int J Oral Implantol. 1988;5(1):65–70. 38. Orton GS, Steele DL, Wolinsky LE. e dental professional’s role in monitoring and maintenance of tissue-integrated prostheses. Int J Oral Maxillofac Implants. 1989;4(4):305–310. 39. Etter TH, Håkanson I, Lang NP, Trejo PM, Caesse RG. Heal-ing after standardized clinical probing of the perlimplant soft tis-sue seal: a histomorphometric study in dogs. Clin Oral Implants Res. 2002;13(6):571–580. 40. Ericsson I, Lindhe J. Probing at implants and teeth: an experimental study in the dog. J Clin Periodontol. 1993;20:623–627. 1214PART VIII Dental Implant Maintenance 41. Lang NP, Berglundh T, Heitz-Mayeld LJ, Pjetursson BE, Salvi GE, Sanz M. Consensus statements and recommended clinical pro-cedures regarding implant survival and complications. Int J Oral Maxillofac Implants. 2004;19(l):150–154. 42. Heitz-Mayeld LJ. Peri-implant diseases: diagnosis and risk indica-tors. J Clin Periodontol. 2008;35(8 l):292–304. 43. Humphrey S. Implant maintenance. Dent Clin North Am. 2006;50(3):463–478. 44. Lindhe J, Meyle J, Group D of European Workshop on Periodontol-ogy. Peri-implant diseases: Consensus report of the Sixth European Workshop on Periodontology. J Clin Periodontol. 2008;35(8):282–285. 45. Lang NP, Berglundh T. Working group 4 of the Seventh European Workshop on Periodontology. Periimplant diseases: where are we now? – Consensus of the Seventh European Workshop on Periodon-tology. J Clin Periodontol. 2011;38(11):178–181. 46. Jepsen S, Rühling A, Jepsen K, etal. Progressive peri-implantitis. Incidence and prediction of peri-implant attachment loss. Clin Oral Implants Res. 1996;7(2):133–141. 47. Luterbacher, Mayeld L, Bragger U, Land NF. Diagnostic cheracter-istics of clinical and microbiological tests for monitoring periodontal and peri-implant mucosal tissue conditions during supportive peri-odontal therapy (SPT). Clin Oral Implants Res. 2000;11(6):521–529. 48. Luterbacher S, Mayeld L, Bragger U, etal. Diagnostic characteris-tics of clinical and microbiological tests for monitoring periodontal and periimplant mucosal tissue conditions during supportive peri-odontal therapy (SPT). Clin Oral Implants Res. 2000;11:52–59. 49. Gerber JA, Tan WC, Balmer TE, etal. Bleeding on probing and pocket probing depth in relation to probing pressure and mucosal health around oral implants. Clin Oral Impl Res. 2009;20(1):75–78. 50. Mombelli A, Buser D, Lang NP, etal. Comparison of periodontal and peri-implant probing by depth force pattern analysis. Clin Oral Implants Res. 1997;8:448–454. 51. van Steenberghe D. Periodontal aspects of osseointegrated oral implants modum Branemark. Dent Clin North Am. 1988;32:355–370. 52. Gallucci GO, Grütter L, Chuang SK, Belser UC. Dimensional changes of peri‐implant soft tissue over 2 years with single‐implant crowns in the anterior maxilla. J Clin Periodontol. 2011;38:293–299. 53. Mombelli A, Müller N, Cionca N. e epidemiology of peri-implantitis. Clin Oral Implants Res. 2012;23(6):67–76. 54. Misch CE, Resnik R. Misch’s Avoiding Complications in Oral Implan-tology-E-Book. Elsevier Health Sciences; 2017. 55. Ross-Jansaker AM, Renvert H, Lindahl C, Renvert S. Nine-to four-teen-year follow-up of implant treatment. Part III: factors associated with peri-implant lesions. J Clin Periodontol. 2006;33(4):296–301. 56. Bouri Jr A, Bissada N, Al-Zahrani MS, Fadoul F, Nounen I. Width of keratinized gingiva and the health status of the support-ing tissues around dental implants. Int J Oral Maxillofac Implants. 2008;23(2):323–326. 57. Schrott AR, Jimenez M, Hwang JW, Fiorellini J, Weber HP. Five-year evaluation of the inuence of keratinized mucosa on peri-implant soft-tissue health and stability around implants sup-porting full-arch mandibular xed prostheses. Clin Oral Implants Res. 2009;20(10):1170–1177. 58. Adibrad M, Shahabuei M, Sahabi M. Signicance of the width of keratinized mucosa on the health status of the supporting tis-sue around implants supporting overdentures. J Oral Implantol. 2009;35(5):232–237. 59. Chung DM, Oh TJ, Shotwell JL, Misch CE, Wang HL. Signicance of keratinized mucosa in maintenance of dental implants with dier-ent surfaces. J Periodontol. 2006;77(8):1410–1420. 60. Lin GH, Chan HL, Wang HL. e signicance of keratinized mucosa on implant health: a systematic review. J Periodontol. 2013;84:1755–1767. 61. Gobbato L, Avila-Ortiz G, Sohrabi K, Wang CW, Karimbux N. e eect of keratinized mucosa width on peri-implant health: a system-atic review. Int J Oral Maxillofac Implants. 2013;28:1536–1545. 62. Bronstein D, Suzuki K, Garashi M, Suzuki JB. Contemporary esthetic periodontics. StomaEduJ. 2016;3(2):26–36. 63. Esposito M, Maghaireh H, Grusovin MG, Ziounas I, Worthing-ton HV. Soft tissue management for dental implants: what are the most eective techniques? A Cochrane systematic review. Eur J Oral Implantol. 2012;5:221–238. 64. Lang PL, Berglundh T. Working group 4 of the VII E.W.o.P.Peri-implant diseases: where are we now? Consensus of the Sev-enth European Workshop on Periodontology. J Clin Periodontol. 2011;38(11):178–181. 65. Froum S, Rosen P. A Proposed Classication for peri-implantitis. Int J Periodontics Restorative Dent. 2012;32(5):533–540. 66. Miyata T, Kobayashi Y, Araki H, Ohto T, Shin K. e inu-ence of controlled occlusal overload on peri-implant tissue. Part 3: a histological study in monkeys. Int J Oral Maxillofac Implants. 2000;15(3):415–431. 67. White SC, Pharoah M. Oral Radiology: Principles and Interpretation. 5th ed. St Louis: Mosby; 2004. 68. Friedland B. e clinical evaluation of dental implants: a review of the literature, with emphasis on the radiographic aspects. Oral Implantol. 1987;13:101–111. 69. Naitoh M. Labial bone assessment surrounding dental implant using cone-beam computed tomography:. Clin. Oral Impl. Res. 2012;23:970–974. 70. Gröndahl K, Ekestubbe A, Gröndahl HG. Radiography in Oral Endosseous Prosthetics. Goteborg, Sweden: Nobel Biocare AB; 1996. 71. Adell R, Lekholm U, Rockler B, Brånemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg. 1981;10(6):387–416. 72. Shin YK, Han CH, Heo SJ, Kim S, Chun HJ. Radiographic evalu-ation of marginal bone level around implants with dierent neck designs after 1 year. Int J Oral Maxillofac Implants. 2006;21(5):789–794. 73. Lazzara RJ, Porter SS. Platform switching: a new concept in implant dentistry for controlling postrestorative crestal bone levels. Int J Peri-odontics Restorative Dent. 2006;26(1):9–17. 74. Resnik RR. Personal Communication; 2017. 75. Quirynen M, Naert I, Teerlinck J, etal. Periodontal indices around osseointegrated oral implants supporting overdentures. In: Schepers E, Naert J, eunier G, eds. Overdentures on Oral Implants. Leuwen, Belgium: Leuwen University Press; 1991. 76. Herrmann JS, Cochran DL, Nummikoski PV, etal. Crestal bone changes around titanium implants: a radiographic evaluation of unloaded non-submerged and submerged implants in the canine mandible. J Periodontol. 1997;68:1117–1130. 77. Zitzmann N, Berglundh T, Marinello CP, etal. Experimental peri-implant mucositis in man. J Clin Periodontol. 2001;28:517–523. 78. Humphrey S. Implant maintenance. Dental Clin North Am. 2006;50(3):463–478. 79. Biesbrock AR, Bartizek RD, Gerlach RW, Terézhalmy GT. Oral hygiene regimens, plaque control, and gingival health: a two-month clinical trial with antimicrobial agents. J Clin Dent. 2007;18(4):101–105. 80. Kracher CM, Smith WS. Oral health maintenance of dental implants. Dent Assist. 2010;79(2):27–35. 81. Esposito M, Worthington H, Coulthard P, et al. Maintaining and reestablishing health around osseointegrated oral implants: a Cochrane systematic review comparing the ecacy of various treat-ments. Periodontology. 2003;33:204–212. 82. Rasperini G, Pellegrini G, Cortella A, etal. e safety and accept-ability mucosa in patients with oral implants in aesthetic areas: a prospective. Implantol. 1(3):221–228.83. VandekerckhoveB, Quirynen M, Warren PR, etal. e safety and ecacy of a powered toothbrush on soft tissues in patients with 1215CHAPTER 42 Implant Maintenance: Long-Term Implant Successimplant-supported xed prostheses. Clin Oral Investig. 2004;8(4). 26–10. 84. Wingrove S. Focus on implant home care: before, during, and after restoration. RDH. 2013;33(9):52–58. 85. Nakagawa M, Matsuya S, Shiraishi T, Ohta M. Eect of uoride concentration and pH on corrosion behavior of titanium for dental use. J Dent Res. 1999;78(9):1568–1572. https://doi.org/10.1177/00220345990780091201. 86. Matono Y, Nakagawa M, Matsuya S, Ishikawa K, Terada Y. Corro-sion behavior of pure titanium and titanium alloys in various con-centrations of acidulated phosphate uoride (APF) solutions. Dent Mat J. 2006;25(1):104–112. 87. Barnes CM, Russell CM, Reinhardt RA, etal. Comparison of irri-gation to oss as an adjunct to tooth brushing: eect on bleeding, gingivitis, and supragingival plaque. J Clin Dent. 2005;16(3):71–77. 88. Rosema NA, Hennequin-Hoenderdos NL, Berchier CE, et al. e eect devices on gingival bleeding. J Int Acad Periodontol. 2011;13(1):2–10. 89. Sharma NC, Lyle DM, Qaqish JG, etal. Eect of a dental water jet with bleeding in adolescent patients with xed orthodontic appli-ances. Am J. 2008;133(4):565–571. 90. Magnuson B, Harsono M, Silberstein J, etal. Water Flosser Vs. Floss: Comparing Reduction in Bleeding Around Implants [Abstract]. Seattle WA: Presented at the International Association for Dental Research Meeting; March 23, 2013. 91. Brough Muzzin KM, Johnson R, Carr P, Daron P. e den-tal hygienist’s role in the maintenance of osseointegrated dental implants. J Dent Hyg. 1988;62(9):448–453. 92. Friedman LA. Oral hygiene for dental implant patients. Tex Dent J. 1991;108(5):21–23. 93. Felo A, Shibly O, Ciancio SC, et al. Eects of subgingival chlorhexidine irrigation on peri-implant maintenance. Am J Dent. 1997;10(2):107–110. 94. Meert RM. e soft tissue interface in dental implantology. J Dent Educ. 1988;52(12):810–811. 95. Koumjian JH, Kerner J, Smith RA. Implants: hygiene maintenance of dental implants. Ill Dent J. 1991;60(1):54–59. 96. omson-Neal D, Evans GH, Meert RM. Eects of various pro-phylactic treatments on titanium, sapphire, and hydroxyapatite-coated implants: an SEM study. Int J Periodontics Restorative Dent. 1989;9(4):300–311. 97. Misch CE. Implant quality scale: a clinical assessment of the health-disease continuum. Oral Health. 1998;88:15–25. 1216Edentulous Maxilla 1. No treatmentDisadvantage: Diculty in eating/speaking, continued bone loss, maintain current prosthesis (ill-tting) 2. Complete upper dentureAdvantage: Minimal treatment, fastDisadvantage: Removable prosthesis disadvantages, diculty in eating/speaking, palate coverage, continued bone loss 3. Implant-supported overdenture (Removable, RP5)Advantage: Removable prosthesis that “clips” in, added reten-tion, soft tissue supportDisadvantage: Full denture with palate, needs to be removed some-time each day removable, clips need changed on a regular basis (additional cost), may have associated mobility of prosthesis 4. Implant-supported overdenture (removable, RP4)Advantage: Removable prosthesis that clips in, horseshoe shaped (no full palate), no soft tissue coverage, totally implant supportedDisadvantage: needs to be removed sometime each day removable prosthesis, clips need changed on a regular basis (additional cost) 5. Implant-supported xed prosthesis (xed)Advantage: Fixed prosthesis (Non-Removable) increased biting force, Closest prosthesis to natural teethDisadvantage: Usually will require extensive bone grafting and more implants, possible need for pink porcelain or acrylic because of the amount of bone loss, teeth will be larger (FP-2/FP-3), may not be able to increase soft tissue support, increased expense Edentulous Mandible 1. No treatmentDisadvantage: Diculty in eating/speaking, continued bone loss, maintain current prosthesis (ill-tting) 2. Complete lower dentureAdvantage: Minimal treatment, fastDisadvantage: Removable prosthesis, diculty in eating/speak-ing, continued bone loss 3. Implant-supported overdenture (Removable, RP5)Advantage: Removable prosthesis that clips in, less implants re-quired, soft tissue supportDisadvantage: Full denture, needs to be removed sometime each day removable, clips need changed on a regular basis (additional cost),May have associated mobility 4. Implant-supported overdenture (removable, RP4)Advantage: Removable prosthesis that clips in, no soft tissue coverageDisadvantage: needs to be removed sometime each day, remov-able, clips need changed on a regular basis (additional cost) 5. Implant-supported xed prosthesis (xed), Requires more implants than RP-5Advantage: Fixed prosthesis (Non-Removable) increased biting force, Closest prosthesis to natural teethDisadvantage: Usually will require more implants, increased ex-pense, possible need for pink porcelain or acrylic because of the amount of bone loss, teeth will be larger (FP-2/FP-3), may not be able to increase soft tissue support Single Tooth Missing 1. No treatmentDisadvantage: Esthetics, adjacent teeth may move (tilting), su-praeruption, decreased mastication, food impaction, con-tinued bone loss, occlusal force 2. Removable Partial dentureAdvantage: Minimal treatment, fastDisadvantage: Removable prosthesis, diculty in eating/speak-ing, extensive pressure on adjacent teeth/soft tissue which leads to additional tooth loss, poor long-term success rate, increased bone loss, tissue soreness 3. Fixed partial dentureAdvantage: Fast, esthetic, usually no need for hard/soft tissue graftingDisadvantage: Alteration of adjacent teeth, higher incidence of decay, increased endodontic treatment (~15%), hygiene dif-culty 4. Implant-supported crownAdvantage: No alteration of adjacent teeth, higher success rate than xed partial denture (most studies >90% suc-cess rate)Disadvantage: Longer treatment time, requires bone quality and quantity, esthetic issues possible Multiple Missing Teeth 1. No treatmentDisadvantage: Esthetics, adjacent teeth will move (tilting), su-praeruption, decreased mastication, continued bone loss, food impaction, occlusal force 2. Removable Partial dentureAdvantage: Minimal treatment, fastDisadvantage: Removable prosthesis, diculty in eating/speak-ing, tissue soreness, places extensive pressure on adjacent teeth/soft tissue which leads to additional tooth loss, poor long-term success rate 3. Fixed partial denture (if indicated)Advantage: Fast, estheticDisadvantage: Alteration of adjacent teeth, higher incidence of decay, increased endodontic treatment (~ 15%), hygiene diculty 4. Implant-supported prosthesisAdvantage: No alteration of adjacent teeth, higher success rate than xed partial denture (most studies >90% success rate)Disadvantage: Longer treatment time, requires bone quality and quantity, esthetic issues possibleAppendixTreatment Plan Options 1217IndexAAATB. See American Association of Tissue BanksAbsorbable sutures, 622–623, 625, 628t–629t, 630fAbutment(s)angled, 43, 43f, 141for cement-retained restorations, 547, 548fcustom, 33f–34f, 36, 547, 548fexternal mechanism of, 100–101for xed partial denture, 13, 534forces on, 9healing. See Healing abutmentheight of, 509intermediary, 167internal mechanism of, 101, 103fmodication of, 1175multiunit, 39f, 549f, 881fnatural, 513b, 521–524options for, 514pain related to, 1202, 1204fperiodontal health of, 13permucosal, 32, 1208fpier, 520–521, 520f–521ffor removable partial denture, 13root surface area of, 523scanning, 34, 38ffor screw-retained restorations, 548–551size of, 521–522temporary, 36, 41fterminal, 167, 469fAbutment-level impressions, 34Abutment screwcomposition of, 804description of, 51–52diameter of, 804fracture of, 154–155, 156fimplant number and, 514loosening of, 152–153, 155f, 477, 801–807movement of, 806–807removal of, 810f–811fAccessory foramen, 293, 293f, 757, 759fAcellular dermal matrix, 925, 978f, 1169, 1171fAcetaminophendrug interactions, 379t–380tnonsteroidal antiinammatory drugs and, 371pain management uses of, 370, 370bAcid etching, 198, 201tAcute rhinosinusitis, 307–308, 308f, 1001–1002, 1002f, 1040t, 1041Addison’s disease, 242Adenocarcinoma, 310Adolescents, implants in, 258, 259fAdrenal gland disorders, 241–242, 243tAge-related macular degeneration, 264Agger nasi cells, 299, 303, 303fAggressive periodontitis, 347, 347fAging populationforecasted growth of, 2, 3fimplant demand aected by, 2–4life expectancy, 2, 3f–4f, 4tooth loss in, 4Air emphysema, 775–776, 777fAir space, 313Alanine aminotransferase, 223, 224t–226tAlbumin, 224t–226tAlcohol, 259–260Aldosterone, 242Alkaline phosphatase, 223, 224t–226tAll-on-four protocol, 584–585, 585f, 586b, 594, 876, 877bAllergic rhinosinusitis, 308, 308f, 1002–1003Allergiesimplant-related, 268–269, 270ftitanium, 269, 794, 795fAlloDerm, 957Allograftsdenition of, 917, 969bdescription of, 28, 29t, 917, 968–969distribution of, 921–922freeze-dried bone, 923–925layering of, 966–967modication of, 930osteoconductive, 969bosteoinductive, 969bparticle form and size, 969processing of, 921–922Allografts (Continued)source of, 921–922types of, 923–925, 929t, 968–969Alloplastsdenition of, 917description of, 28, 29t, 969distribution of, 923production of, 923types of, 925–926, 929t, 969–970Allowash XG process, 919–920Aluminum oxide ceramics, 114, 114t, 126Alveolar boneformation of, 7, 7fheight of, losses in, 8, 8fimaging of, 316–318implant-supported prostheses eect on, 15, 15floss of, 7, 8f, 933maintenance of, 7remodeling and resorption of, 8Alveolar ridgeatrophic, mucosa thickness on, 9–10augmentation of, 962classication of, 944contours of, 955fdefects of, 944–946deciency of, 415edentulous, treatment planning in, 937f, 941–946expansion of, 30preservation of, 939fresorption of, 939, 953fAmerican Association of Tissue Banks, 918, 921American Society of Anesthesiologists physical status classication, 227, 227b, 360, 361tAminotransferases, 223Amoxicillin, 362, 364t, 1159bAmoxicillin/clavulanic acid, 362, 364tAnalgesics, 369–371, 369t–370t, 369b–370b, 373b, 1010Anchorageexternal abutment mechanism for, 100–101internal abutment mechanism for, 101, 103fNote: Page numbers followed by f indicate gures; t, tables; b, boxes 1218IndexAnchorage (Continued)mini-implants for, 101–103, 105fretromolar implant as, 100, 100f, 104ftitanium implants for, 98, 99fAndrogens, 90–93Anemia, 244–245, 247tAngina pectoris, 229–233, 234tAngiogenesis, 96fAngled abutmentsdescription of, 43, 43fforce generated by, 141Angled implants, 49Angular cheilitis, 1135–1136Ankylosing spondylitis, 264Anodontiaillustration of, 873fsingle-tooth implant for, 535–536, 726–727Anterior loop, 292–293, 292f, 757, 760fAnterior mandible, 737–738, 739f, 741f, 743fbone density in, 649description of, 295, 296fextraosseous vessels in, 780–781radiographic imaging of, 1107fsurgical specimen of, 1108fAnterior nasal spine, 725Anterior superior alveolar nerve, 334, 813Anterior superior iliac spine, 1094–1095Anterior teethbiting force of, 193maxillaryevaluation of, 706–710position of, 495–496, 496fshape of, 707–708, 708fsize of, 707–708soft tissue drape of, 708–710Anteroposterior distance/spread, 149, 468, 469f, 513, 567–568, 568f, 577, 862Antibioticsallergic reactions to, 361bacterial resistance to, 361beta-lactam, 362, 362f, 362bcommonly used, 364tcomplications of, 361locally applied, 1159, 1159fpenicillin, 362, 362b, 379t–380tprophylactic use of, 353, 359–361, 365, 1008–1009selection of, 361systemic, 1159therapeutic use of, 365Anticoagulants, 219–221, 238, 267tAntihistamines, 379t–380tAntihypertensive medicationsnonsteroidal antiinammatory drugs and, 229Antimicrobialsantibiotics. See Antibioticsperi-implant mucositis treated with, 1148, 1159prophylaxis, 1008–1010rinses, 1212, 1212fAntinuclear antibody test, 256Antiseptics, 1148Antithrombotics, oral, 266–268Antroliths, maxillary sinus, 1006–1007, 1007fApatites, 115Apical peri-implantitis, 793Apicocoronal (Z-axis) positioning, 689–695, 692fApicoectomy, 510Apnea, 228, 257Appliance, 385bArachidonic acid, 367, 370, 791Archaea, 345Aromatase inhibitors, 263Arthritis mutilans, 264Articaine, 373–374, 373t–374tArtifacts, 286–288, 287f–288f“As low as reasonably achievable”, 276Aseptic technique, 360, 620–622, 621b–622b, 621t, 623f–627fAspartate aminotransferase, 223, 224t–226tAspirin, 266–268, 371Asthma, 249tAsymmetric psoriatic arthritis, 264Atopic dermatitis, 264–265Atraumatic tooth extractionbiomechanics of, 896, 896fforceps for, 896–899, 898fperiotomes in, 896–899, 897froot tip retention after, 911fsocketdebridement of, 899, 899f–900ffour-wall defect, 902, 903fsocket graftingcomplications of, 909–911, 910f–911fcontraindications for, 908–909, 909fhealing after, 908, 908finfection, 908, 909fmandibular canal proximity, 908–909, 909fmandibular ramus donor site for, 902–905, 904f–905fmaxillary sinus considerations, 909, 910fmaxillary tuberosity donor site for, 905–906, 905f–906fAtraumatic tooth extraction (Continued)overlling of socket, 909, 911fprovisional restorations after, 907, 908fseal surgery for, 906, 907ftechnique for, 899–907technique for, 893–907, 894f–903ftheory of, 893Atrial brillation, 215–216Autogenous bone grafts, 28, 29t, 969bblock graft, 1074–1076, 1076f–1077f, 1080–1082complications of, 1077–1082, 1078f–1082fdenition of, 917, 969bdescription of, 28, 29tdonor sitescomparison of, 1076–1077, 1077textraoral, 1088–1111intraoral, 1054–1087mandibular ramus, 293–294, 294f, 902–905, 904f–905f, 980f, 1064–1071, 1070f–1072f, 1071b, 1077t, 1079–1080mandibular symphysis, 1056–1064, 1056f–1066f, 1063b–1064b, 1077tmaxillary tuberosity, 905–906, 905f–906f, 1021, 1071–1073, 1072f–1073f, 1077tharvesting of, 1021, 1022fhistory of, 1054–1055iliac crest, 430, 431f, 869fimplant placement, 1082–1083mandibular ramus donor site for, 293–294, 294f, 902–905, 904f–905f, 980f, 1064–1071, 1070f–1072f, 1071bmandibular symphysis donor site for, 1056–1064, 1056f–1066f, 1063b–1064bmaxillary tuberosity donor site for, 905–906, 905f–906f, 1021, 1071–1073, 1072f–1073fmobility of, 1082fpostoperative care and instructions, 1077recipient site for, 1055–1056, 1056f–1057fAutografts, 963, 966Autoimmune diseasesperi-implantitis and, 1196rheumatoid arthritis, 256scleroderma, 256Sjögren syndrome, 255–256systemic lupus erythematosus, 256 1219IndexAutoradiographyof bone, 76, 80fdescription of, 72Available boneangulation of, 420, 421f, 836density of, 647–650, 649f, 649bDivision A, 420–422, 422f, 422b, 432–433Division B, 422–425, 423f–424f, 423b, 425b, 432–433Division C, 426–429, 426b, 427f–429f, 428b, 433Division D, 430–433, 430f–433f, 430bheight of, 419, 419fideal amount of, 698for immediate implant placement, 834–839length of, 420, 421f, 836measurement of, 418–420in posterior maxilla, 554width of, 419–420, 419f, 834–836Axonotmesis, 817–818, 819fAzithromycin, 364tBBackscatter emission, 73Backscatter emission imaging, 75–76, 79fBacterial endocarditis, 236–237, 237bBactericidal antibiotics, 361Bacteriostatic antibiotics, 361Band of Büngner, 340Barium sulfate, 385, 386fBarrier membranes. See also Membranesguided bone regeneration, 28, 957–969ideal characteristics of, 957bnonresorbable, 28, 957–961resorbable, 28, 960–961selection and placement of, 962–963Basal bone, 7–8, 9fBasic multicellular units, 913Basophils, 218, 224t–226tBeam hardening artifact, 286–287, 287fBenzodiazepines, 375–376, 379t–380tBeta-lactam antibiotics, 362, 362f, 362b, 1038Beta-tricalcium phosphate, 116tBIC. See Bone-to-implant contactBig-nose variant, 305, 305f, 312f, 1000Biguanides, 239bBilirubin, 223, 224t–226tBio-Oss, 923Bioactive ceramics, 114–119, 116tBioactive glass, 926, 969Biochemical proles, 221–224BioCleanse process, 920Biolmdescription of, 353in peri-implant mucositis, 1143–1144in peri-implantitis, 1149Biologic width, 24–25, 1192, 1193faverage, 159, 159fmarginal bone loss and, 159–160, 159f–160fBiologics, 263b, 264–266, 352Biomaterials. See also Implant materialsbiocompatibility of, 108biodegradation of, 110compatibility of, 108corrosion of, 110deformation of, 143design of, 108–109elastic strain of, 108fatigue behavior of, 150, 150fforces on, 109history of, 108–109mechanical properties of, 109physical properties of, 109research and development of, 109stiness of, 143stress corrosion cracking of, 110, 111ftoxicity of, 110–111Bisphosphonatesdrug-induced osteonecrosis of the jaw caused by, 261, 261timplant surfaces with, 201–202osteoporosis treated with, 252, 252b, 261–262, 261tBite force, 141t, 174, 176t, 192–193Bitewing radiographs, 317Biting forceimplant-supported prosthesis eects on, 16in posterior maxilla, 555–556, 556fBlack triangles, 694f, 1129, 1129f–1130fBlade implants, 22–23, 22f–23f, 48, 49tBleeding-related complications, 778–785, 779f–784fBleeding tests, 218–221, 219fBleeding time, 220, 224t–226tBlock grafts, 1074–1076, 1076f–1077f, 1080–1082, 1097–1099, 1099fBlood pressureclassication of, 233televated. See Hypertensionmanagement of, 214–215Blood urea nitrogen, 224, 224t–226tBody temperature, 216Boneandrogens’ eect on, 90–93apposition of, 86fautoradiography of, 76, 80favailable. See Available boneBone (Continued)backscatter emission imaging of, 75–76, 79fbundle, 79, 82fcalcium inconservation of, 87–93homeostasis of, 84–85, 89fmetabolism of, 84, 88fparathyroid hormone and, 84–85classication of, 76–79, 416, 417f, 453–454composite, 78–79, 82fcortical. See Cortical boneuorescent labels of, 73–74functions of, 69implant surface and, interactions between, 198flamellar, 78, 165loss of. See Bone lossmacroscopic structure of, 454fmechanical properties of, 868, 868fmetabolism of, 84–87, 88f–89fmicrocomputed tomography of, 75–76, 79f–80fmicroindentation of, 75–76microradiography of, 74–75, 75f–78fmineralization of, 74mineralized sections of, 73, 75fmodeling of, 79–84, 83f, 87tmorphology of, 69–71, 70fnuclear volume morphometry of, 76, 81foverload zones for, 452–453physiology of, 72–79, 164–165polarized light of, 73, 75fprimary mineralization of, 74properties of, 69remodeling ofcell signaling for, 913cell types in, 913control factors for, 87bdenition of, 893b, 913, 937bfunctional loading of implants and, 82histology of, 864fmicrocomputed tomography of, 76, 80foverview of, 79–81, 251parathyroid hormone eects on, 87primary stability in, 21purpose of, 69self-tapping implant and, 863strain and, 161, 452stress and, 161trabecular bone, 452resorption ofAtwood’s stages of, 8f 1220IndexBone (Continued)in edentulous arches, 8fin maxillary sinus, 989in posterior maxilla, 554f–555fsecondary mineralization of, 74, 78sex hormones’ eect on, 90–93skeletal adaptation of, 79–81strength of, 458, 460ftissue classication for, 76–79trabecular. See Trabecular boneturnover of, 75f, 80–81, 82fwoven, 78, 165Bone augmentationceramics for, 114–115in crown height space, 189denition of, 28description of, 913guided bone regeneration, 28prosthetic replacement versus, 506socket-shield technique for, 30, 30f–31fsurgical techniques for, 30techniques for, 28–30, 28fvertical, 742–744, 746fBone dehiscence, 288, 288fBone densityfor bone regeneration, 967bone strength based on, 458, 460fbone-to-implant contact and, 460–461, 462f–463fclassication of, 453–454, 454t, 648, 649fcone beam computerized tomography of, 286, 393, 393f, 393b, 457, 458f, 458bof cortical bone, 459fD1, 454–455, 454t–455t, 456f, 462fD2, 454–455, 454t–455t, 457f, 462fD3, 454–455, 454t–455t, 457f, 463fD4, 454–455, 454t–455t, 456f–457f, 463f, 553fD5, 454, 454t–455tdescription of, 162, 167determination of, 454–458, 649bHounseld units and, 457, 649bimmediate implant placement and, 837–838for immediate loading, 861implant positioning and, 700–701implant success rates aected by, 450, 451flocation dierences in, 455–457Misch classication of, 454, 454t, 648, 649fin posterior maxilla, 532–535radiographic evaluation of, 457–458stress transfer and, 461, 463fBone density (Continued)tactile sensation and, 458, 459ftreatment planning based on, 461–464, 464bvariable, 450–453, 451fBone diseasescemento-osseous dysplasia, 254, 255tectodermal dysplasia, 254, 255tbrous dysplasia, 252multiple myeloma, 253osteitis deformans, 253osteogenesis imperfecta, 254osteomalacia, 252–253, 255tosteomyelitis, 254osteoporosis. See OsteoporosisBone le, 612, 613fBone xation screws, 960, 962–967, 972f–973f, 976, 1082, 1083fBone graft(s)allografts, 28, 29t, 969bapplication of, 962–963autogenous. See Autogenous bone graftscalvarial. See Calvarial graftsclassication of, 935bextraoral, 1088–1111healing times for maturation of, 974–980indications for, 28infection, 985intraoral. See Autogenous bone graftsmaterials for, 28, 28f, 29tosteoconduction of, 30osteogenesis of, 30osteoinduction of, 30postoperative treatment of, 970–980properties of, 30provisional restoration, 973–974simulation of, 393, 395fsite preparation for, 28suturing of, 969–970tibial, 1099–1102, 1101f, 1101bvascularized composite graft, 1102–1105, 1103b–1104b, 1104f–1106fxenografts, 28, 29t, 969bBone graft substitutescharacteristics of, 927–928classication of, 917denition of, 913end-user responsibilities, 920–921future of, 928–930handling of, 920–921ideal, 917oversight of, 917–918single-patient uses for, 921for socket grafting, 909–911Bone graft substitutes (Continued)sterility of, 919summary of, 930Bone graftingcomplications of, 974incision line opening, 796–797, 980incisions for, 951b, 960findications for, 933–935inlay, 30mandibular ramus donor site for, 902–905, 904f–905fmaxillary tuberosity donor site for, 905–906, 905f–906fonlay, 30tooth extraction socket, 899–907Bone healingdescription of, 245, 258surgical trauma eects on, 862–863triad of, 917fBone-implant interface, 51, 453fBone-level implantcollar for, 54, 55fdescription of, 24–25, 24fplacement of, 55fBone lossAtwood classication of, 416fdescription of, 935ffactors aecting the rate of, 8bin mandible, 8, 12fmarginal. See Marginal bone, loss ofin maxilla, 9, 12fmechanical stress as cause of, 164fprostheses as cause of, 7, 8fin women, 90–93Bone mass, 251Bone modeling, 893b, 914, 937bBone morphogenetic proteins, 202–203, 224t–226t, 915, 962Bone regenerationbone density for, 967cellular process, 937–939denition of, 893bguided. See Guided bone regenerationmechanisms of, 915–917PASS principles for, 950bterminology associated with, 937bBone repair, 914–917, 937bBone scrapers, 961, 981f, 983fBone spreading, 425Bone-supported guides, 398, 398f, 879b–880bBone-to-implant contact, 17, 198, 200bone density based on, 460–461, 462f–463f, 553, 989for D1 bone, 654fdenition of, 21 1221IndexBone-to-implant contact (Continued)immediate loading eects on, 861of zirconia implants, 203Bone turnover, 863, 914Bone volume, 415, 416fBone wax, 790, 790fBone–implant interface, 154fBony defects, 840–841, 900–901, 942–949Bosker implant, 40Botulinum toxin injectionsbotulinum toxin type A, 1112–1114, 1114t, 1115fcomplications of, 1124–1125contraindications for, 1124duration of action, 1114gummy smile treated with, 1120–1124, 1121f–1126fhistory of, 1112masseter muscle hypertrophy treated with, 1114–1118, 1116f–1118fmechanism of action, 1112, 1130fparafunctional habits treated with, 1114–1118postoperative instructions for, 1124preparation of, 1112–1114temporalis muscle treated with, 1118, 1119ftemporomandibular joint syndrome/temporomandibular dysfunction treated with, 1119–1124, 1121fBotulinum toxin type A, 1112–1114, 1114t, 1115fBrain natriuretic peptide, 236Brånemark, Per-Ingvarimplants designed by, 20, 23, 23f, 27, 197–198, 544, 544f, 581, 860photograph of, 21fBreast cancer, 265–266Bromodeoxyuridine immunocytochemistry, 76Bronchodilators, 248Bruising, 792f, 793Brushite, 116tBruxismbiting forces created by, 175cervical erosion associated with, 181characteristics of, 184tdescription of, 167diagnosis of, 175–178, 176f–177fengram pattern of, 177, 177fincisal guidance in, 178, 178fmasticatory forces aected by, 177occlusal guards for, 179–180, 180f, 184signs and symptoms of, 175–176treatment planning for, 183–184, 184twear patterns associated with, 176–177, 176f–177f, 179fBuccal artery, 748, 783, 783fBuccal plate, 893, 894f, 940fBuccinator muscleanatomy of, 332–333, 336–337attachments of, 11Buccolingual (“Y-axis”) positioning, 682–687, 684f–687fBUN. See Blood urea nitrogenBundle bone, 79, 82fBupivacaine, 373t–374t, 374Burs, 611, 612f, 650, 824, 826f, 1061fButt-joint, 27Buttress threads, 26f, 51f, 59, 60fCCAD/CAM technologychairside systems, 405custom abutments created using, 36, 39fdigital scanner process, 405, 406f–409fdigital systems, 405immediate prosthesis fabrication, 1107flaboratory implant applications of, 405materials, 405optical impressions, 404–405, 405brestorative implant applications of, 405treatment planning uses of, 405workow for, 404Calcied carotid artery atheroma, 306, 307fCalcitonin, 87Calciumin boneconservation of, 87–93homeostasis of, 84–85, 89fmetabolism of, 84, 88fparathyroid hormone and, 84–85daily expenditure of, 87dietary recommendations for, 92tfood sources of, 92tmetabolism of, 84, 88fparathyroid hormone and, 84–85, 89f, 250–251recommended daily allowance of, 87–90, 251serum, 87, 222, 222t, 224t–226tsupplementation of, 90, 251Calcium channel blockers, 229Calcium phosphateceramics, 114–119, 115b, 116timplant surface treated with, 203Calcium sulfate, 923, 926Caldwell-Luc procedure, 558, 1010Calvarial graftsanatomy of, 1090, 1090f–1091fcase study of, 1092, 1093f–1094fcomplications of, 1090–1092Calvarial grafts (Continued)description of, 1089–1092harvesting of, 1090fincision for, 1091ftechnique for, 1090, 1091fCanalis sinuosus, 306, 307f, 813fCancellous compaction, 78–79Candida albicans, 1148Caninesxed prostheses for, 469–471, 470f–471fmaxillary, 707Cantilever length, 147f–148f, 149, 163Cantilevers, 468, 468f, 514–516, 516f, 584, 802Carbon compounds, 119Carbon dioxide, 224t–226tCarbon silicon compounds, 119Carbonate apatite, 969Cardiovascular diseasesangina pectoris, 229–233, 234tbacterial endocarditis, 236–237, 237bcerebrovascular accident, 238congestive heart failure, 235–236, 235b–236bhypertension, 227–229, 229b, 233tmyocardial infarction, 234–235, 235tvalvular heart disease, 236–237Cariesxed partial denture and, 534prevalence of, 4removal of, 523restoration for, 510statistics regarding, 4Carotid artery atheromas, calcied, 306, 307fCefadroxil, 364tCefuroxime axetil, 1008–1009Celecoxib, 370bCell-based products, 930Cell culture technology, 928Cell kinetics, 72Cement, retained, 1172–1179, 1173fCement-enamel junction, 420, 514, 691Cement-retained crown, 36, 545–546, 545fCement-retained restorationsabutments for, 547angulation of, 688fscrew loosening with, 805–806tooth replacement uses of, 36, 545–546, 545fCemento-osseous dysplasia, 254, 255tCentric occlusion, 504Centric relation occlusion, 504–505, 507Centripetal circulation, 338Cephalexin, 364t 1222IndexCephalosporins, 362, 363b, 364tCeramicsaluminum oxide, 114, 114t, 126bioactive, 114–119, 116tbiodegradable, 114–119, 116tbone augmentation and replacement uses of, 114–115calcium phosphate, 114–119, 115b, 116tcarbon, 119carbon silicon compounds, 119conductivity of, 118–119denition of, 114density of, 118–119discoloration of, 130engineering properties of, 114tsolubility of, 118–119surface of, 126titanium oxide, 114, 114tzirconium oxide, 114, 114tCerebrovascular accident, 238Cervical abfraction, 181fCervical erosion, 181Chemotaxis, 915Chewing eciency, implant-supported prosthesis eects on, 16CHF. See Congestive heart failureChlorhexidine, 240, 348, 365, 365b, 1148, 1148f, 1212, 1212fCholecalciferol, 90Christensen phenomenon, 499Chronic bronchitis, 246–248Chronic obstructive pulmonary disease, 216–217, 246–248, 248tChronic periodontitis, 347–348Chronic rhinosinusitis, 308, 1002CHS. See Crown height spaceCigarette smoking. See SmokingCiprooxacin, 363–364, 379t–380tCirrhosis, 248–249Citric acid, 365, 366fClarithromycin, 364tClass II malocclusion, 73fClavulanic acid, 362Clearant process, 920Clenchingcervical erosion associated with, 181characteristics of, 184tdescription of, 167diagnosis of, 180–181, 181fmasseter hypertrophy associated with, 181, 182fmuscle evaluation for, 181signs of, 180tongue scalloping associated with, 181, 182ftreatment planning for, 183–184, 184tClindamycindescription of, 363, 364t, 1038–1039drug interactions, 379t–380tClopidogrel, 268Closed-tray technique, for impressions, 34, 38fClotting, 219Coagulation cascade, 218, 219fCobalt alloys, 125–126Cobalt-chromium-molybdenum–based alloydescription of, 113mechanical properties of, 144tCodeine, 371Collagen, 788t, 789–790, 790fCollagen membranes, 925, 926f, 927, 961, 971fColumella-philtrum angle, 11, 12fCombination prosthesis, 547, 547fCombination syndrome, 498–499, 499fComplete blood cell count, 217–218Complete denturedental adhesives for, 14–15masticatory function and, 14maxillary, 14–15morbidity of, 14–15negative eects of, 15bpatient dissatisfaction with, 14Complete edentulismclassication of, 489–494, 490f–493fxed prosthesis for, 422bimmediate loading of implants in, 873f, 874–876, 875f–876fprosthesis design for, 436–437, 437fComplete-limiting surgical template, 397, 398f, 702, 702fComplicationsbleeding-related, 778–785, 779f–784fintraoperative, 771–785neurosensory impairment, 811–821Composite beam analysis, 161–162Composite bone, 78–79, 82fComposites, 122–123Compound annual growth rate, for implants, 17Compressive force, 141–142, 142tComputed tomographyalveolar bone changes evaluated using, 317–318cone beam. See Cone beam computerized tomographyinteractivedescription of, 384ideal implant position evaluations and determination, 384–388, 385f–386f, 385bComputed tomography (Continued)magnetic resonance imaging versus, 278–279scanners used in, 280–286, 281f, 282tConcha bullosa, 302, 302f, 312f, 999Cone beam computerized tomographyartifacts, 286–288, 287f–288fbit depth of, 286bone dehiscence on, 288, 288fbone density on, 286, 393, 393f, 393b, 457, 458f, 458bbone graft simulation, 393, 395fbone quality on, 281bbone-supported guides, 398, 398f, 703fcomplication prevention, 289contrast resolution of, 286dataset from, 389–390, 390fdescription of, 17disadvantages of, 1206fDivision C available bone on, 427fdose range of, 282–286double scan, 386–387, 389fdrill guidance, 399, 399feective dose, 282, 285feld of view, 282, 284f, 289apless full arch technique, 386–387, 389ffocal spot of, 282, 284fimage acquisition, 279–280, 280f, 283f, 388, 390fimage detection, 388images using, 320f–328fin immediate implant placement, 840fimplant applications ofmaintenance, 1204, 1206fplacement, 418f, 840fincidental ndings, 288–289incisive canal on, 291–292, 292flegal issues, 318–319mandible on, 753, 753f, 756fmandibular canal on, 290–291, 290f–291f, 390–391, 391b, 392fmandibular symphysis on, 294, 296f, 1059fmaxillary sinus on, 997noise associated with, 287–288, 288fosseous defects on, 952fpanoramic curve, 390, 391fpilot guide, 399, 399fpresurgical uses of, 275–276prosthetic plan created with, 939radiology report of, 289radiopaque prosthesis worn during, 385, 386fradiopaque template, 385–386, 386f–387f, 386b–387b 1223IndexCone beam computerized tomography (Continued)safety zone, 393, 395fscanners, 280–286, 281f–282f, 282tscanning technique with, 286, 388sensors used in, 282soft tissue-supported guides, 398, 399f, 703fspatial resolution of, 282–286surgical templates. See Surgical templatetooth-supported guides, 397, 398f, 703ftreatment planning uses of, 279, 328, 406f–409funiversal guide, 399, 399fvirtual implant placement using, 393, 394fvirtual teeth, 386, 388f, 388bCongestive heart failure, 235–236, 235b–236bConnective tissue attachment, 24–25Conscious sedation, 375Continuous positive airway pressure, 257, 1197Continuous sutures, 630, 637fConventional loading, of implants, 33, 37tCOPD. See Chronic obstructive pulmonary diseaseCopings, 512Coralline grafts, 925Coronal incision, 951Cortical boneD1, 454, 454t–455t, 653–657, 654f, 655b, 656f–657f, 667tD2, 454, 454t–455t, 657–658, 659f, 659b, 667tD3, 454, 454t–455t, 658–661, 660f–661f, 661b, 667tD4, 454, 454t–455t, 661–663, 662f–663f, 662b–663b, 667tD5, 454, 454t–455tdensity of, 459fgrowth of, 81–84harvesting of, 960, 1055maturation of, 81–84metabolic fraction of, 83–84, 88fmodeling and remodeling of, 80–81remodeling of, 70fstrength of, 142tstructural fraction of, 83–84Cortical onlay grafts, 1093fCorticocancellous bone grafts, 1055, 1092, 1096f, 1097–1099Corticosteroids, inhaled, 248Cortisol, 242Cortisone, 367t, 792tCosmetic smile, 1121Coughing, 249tCoumadin, 220Coupling factors, 81Cover screw, 28, 31, 33f, 666f, 850f–851fCOX-1, 369COX-2, 369COX-2 inhibitors, 371COX-3, 369CPAP. See Continuous positive airway pressureCraniofacial complexgrowth cessation, 258osteology of, 69–71Creatinine, 223, 224t–226tCreatinine clearance, 224t–226tCreep, 181, 182f, 899“Creeping substitution”, 915, 916fCrest, 25fCREST syndrome, 256Crestal boneheight of, 348loss of, 155, 157b, 163, 1143, 1205–1206, 1208f, 1209bocclusal force transfer across, 50Crestal sinus lift, 30Crohn’s disease, 250Crownangled load to, 187cement-retained, 36, 39ffailure rate for, 4screw-retained, 36, 39fsplinting of, 477, 803Crown height, 187–188Crown height spacebiomechanics of, 186b, 506bone augmentation in, 189in bone measurements, 418, 418fdenition of, 186–187, 505–506in edentulous patients, 500, 590–591excessive, 187–191, 187f, 190f–191f, 190b, 194f, 505f–507f, 506–507, 506bxed prosthesis considerations for, 190, 192ffor hybrid prosthesis, 444ideal, 187, 189in maxilla, 591, 591fmeasurement of, 186f, 505–506, 505focclusal vertical dimension and, 496osteoplasty eects on, 426foverdentures aected by, 509in posterior maxilla, 554, 555freduced, 507–509, 508frestoration material selection based on, 442Crown-implant ratio, 694f, 1012fCrown/root ratio, 522Cryotherapy, 368, 368b, 792–793, 1010CT number, 280CTx test, 261–262Cupping artifacts, 287Curettes, 612, 613f, 620, 621f, 1146–1147, 1146fCurve of Spee, 420, 500Curve of Wilson, 500Cushing syndrome, 242Custom abutments, 33f–34f, 36Cutting cones, 82–84, 157CVA. See Cerebrovascular accidentCyclooxygenases, 366, 369fCylinder implantsdescription of, 23, 23fdesign of, 417long-term success rates for, 49tmoment of inertia of, 151surface area of, 169Cytostatics, 263–264DDabigatran, 220Danger space infections, 344Debridement, in-oce, 1212Decongestants, 1009–1010, 1040Decortication, 955Defective hydroxyapatite biomaterials, 116tDeformation, 143, 145Delayed loading, of implants, 33, 37tDelayed occlusal loading, 861bDemineralized freeze-dried bone allografts, 29t, 967, 1019Denosumab, 263Densah burs, 650Dense polytetrauoroethylene membrane, 955, 966fDental adhesives, 14–15Dental archedentulous, bone resorption in, 8fform of, 512–513, 512fmandibular, 568f–569fmolar teeth for maintenance of, 4opposing, force aected by, 193–194partially edentulous. See Partially edentulous archesposition of, force aected by, 193Dentifrices, 1208–1212, 1210f–1211fDentistryfuture of, 17goals of, 2Denturescomplete. See Complete denturexed partial. See Fixed partial denture 1224IndexDentures (Continued)phonetics aected by, 16removable partial. See Removable partial denturesoft tissue changes caused by long-term use of, 11fDermal llersangular cheilitis treated with, 1135–1136black triangles treated with, 1129, 1129f–1130fcomplications of, 1136–1137duration of action, 1128facial applications of, 1131–1136hyaluronic acid, 1126–1127indications for, 1128injection techniques for, 1128, 1129flips treated with, 1130–1131, 1131f, 1134fmarionette lines treated with, 1134, 1136fmechanism of action, 1127nasolabial folds/crease treated with, 1134, 1135fpermanent llers, 1129preparation of, 1127–1128reversals for, 1136supply of, 1127–1128, 1127ftypes of, 1125–1129, 1127tDeviated septum, 302, 303f, 312f, 999, 999fDexamethasone, 367–368, 367t, 368b, 792t, 820fDiabetes mellitus, 238–240, 239b, 240t, 1146, 1149Diazepam, 375Dierentiation, 915Digestive system disordersinammatory bowel disease, 250liver disease, 248–249stomach ulcers, 249–250Digital Imaging and Communication in Medicine format, 390, 702–704Digital impressions, 410f–411f1,25-Dihydroxy-cholecalciferol, 90DIONJ. See Drug-induced osteonecrosis of the jawDip coating, of hydroxyapatite coating, 200tDirect bone apposition, 98–99Distal psoriatic arthritis, 264Ditching, 156Divine proportions, 497–498, 498fDivision A bone, 420–422, 422f, 422bDivision B bone, 422–425, 423f–424f, 423b, 425bDouble-barrel bula graft, 1105, 1110f–1111fDouble foramen, 293, 293f, 757, 759fDoxycycline, 1039Drilling, 645–647, 645f–646f, 650, 650f, 814–816Drivers, 31, 33fDrug-induced lupus, 256Drug-induced osteonecrosis of the jaw, 261, 261t, 351Drug interactions, 379t–380tDry mouth. See XerostomiaDysphagia, 250tDyspnea, 249tEEarly loading, of implants, 33, 37tEarly loading failure, 153, 467Early occlusal loading, 861bEcchymosis, 792f, 793, 1034–1035, 1035fEctodermal dysplasia, 254, 255tEczema, 264–265Edema, postoperative, 791–794, 792tEdentulismbone density in, 193free-end, 5partial. See Partial edentulismsite assessment, 941–946total. See Total edentulismEdentulous jawbiomechanical sections of, 167bone loss classication in, 416fearly loading of implants in, 874xed prosthesis for, 568f, 579–585, 579b, 580f–585f, 586bfree-end, 5, 5fimmediate loading of implants in, 874, 875fimplant-supported overdenture for, 570–579, 570b, 571f, 573t, 574f–578f, 577b–579bremovable prosthesis for, 568fresorption of, 10ftreatment planning principles for, 567–570Edentulous space, 953fElderlyimplants in, 257–258tooth loss in, 4, 7total edentulism in, 6–7Electrocautery/electrocauterization, 786–787, 786fElectrophoretic deposition, of hydroxyapatite coating, 200tElectrospinning, 930Embolic stroke, 238Emergency implants, 28Emphysema, 246–248Empyema, 308Enameloplasty, 184, 500–501Endodontic therapy, 510–511Endosseous anastomosis, 1017Endosseous implantsblade implants, 22–23, 22f–23f, 48, 49tcylinder implants, 23, 23fdescription of, 22design of, 22, 22fimpingement of, 100fmacrostructure of, 22microstructure of, 22transmandibular implants versus, 40Endosteal implantsmarginal bone loss around, 159occlusal awareness with, 16root form, 431–432Endosteal plexus, 338Endurance limit, 150, 178fEngineering strain, 143Entresto, 235Envelope aps, 606, 607f, 607bEosinophilic fungal rhinosinusitis, 308–309, 309f, 1003Eosinophils, 218, 224t–226tEpinephrine, 787Eposteal implantsdescription of, 37–40ramus frame of, 40, 42fsubperiosteal implants, 37–40ePTFE. See Expanded polytetrauoroethylene membraneErythrocyte sedimentation rate, 224t–226tErythrocytic disorders, 244Erythromycin, 362–363, 364tEsophageal reux, 250tEssential thrombocythemia, 246Essix appliances, 970, 800, 800fEsthetics, total edentulism eects on, 11–12, 11f, 12bEstimated glomerular ltration rate, 223–224Estrogen replacement therapy, 93Ethmoid bullae, 299Ethmoid sinus, 299Expanded polytetrauoroethylene membrane, 28, 927, 955External hex, 27, 27fExtraoral examination, 211–214FFaceage-related changes in, 11fascial spaces of, 342ller injections applied to, 1131–1136inferior third of, 11f, 15 1225IndexFacial artery, 750, 780–781Facial measurements, 497–498Facial prole, 15Facial sutures, 95–98, 95f–97fFascia lata, 925Fatigue curve, 178–179, 178fFatigue failure, 150, 150fFatigue fracturesbruxism as cause of, 178–179description of, 63fFatigue strength, 62–64Fentanyl, 376Ferritin, 224t–226tFever, 216Fibrin, 199–200Fibrinogen, 789Fibromyalgia, 265Fibrous dysplasia, 252Fibula graft, double-barrel, 1105, 1110f–1111fField of view, 282, 284f, 289, 319Figure-eight suture, 626, 635fFillers, injectableangular cheilitis treated with, 1135–1136black triangles treated with, 1129, 1129f–1130fcomplications of, 1136–1137duration of action, 1128facial applications of, 1131–1136hyaluronic acid, 1126–1127indications for, 1128injection techniques for, 1128, 1129flips treated with, 1130–1131, 1131f, 1134fmarionette lines treated with, 1134, 1136fmechanism of action, 1127nasolabial folds/crease treated with, 1134, 1135fpermanent llers, 1129preparation of, 1127–1128reversals for, 1136supply of, 1127–1128, 1127ftypes of, 1125–1129, 1127tFilling cones, 82–84Finite-element modeling, 72Five-walled bony defect, 901, 901f510(k), 917–918Fixed partial dentureabutment teeth for, 13failure of, 13, 152illustration of, 13flife span of, 13, 13bmandibularblade implant supporting, 22fmorbidity of, 12–13Fixed partial denture (Continued)single-tooth replacement using, 533–534, 534f, 534bthree-unit, 12–13, 13fFixed prosthesesadvantages of, 422bcantilevers in, 468, 468f, 514–516classication of, 438tcrown height space and, 190, 192ffor edentulous mandible, 568f, 579–585, 579b, 580f–585f, 586bfor edentulous maxilla, 591–594, 592f–594f, 592t, 592b–593bfailure of, 514ve- to seven-unit, 470fFP-1, 438, 438t, 439f–440f, 448fFP-2, 438–440, 438t, 442f, 448fFP-3, 440–445, 442f–443f, 448ffull-arch, 471, 474fimplant-supported overdenture versus, 437key implant positions guidelines for, 467–471, 467bmovement of, 518opposing arch of, 194fporcelain-metal, 442, 443t, 444fporcelain thickness for, 192fpretreatment, 525, 525bsingle-tooth replacement using, 533–534, 534f, 534bFixed provisional prostheses, 880–881, 884fFlap(s)access using, 603, 603fblood supply to, 602–603design of, 602–605, 602b, 603f–605f, 644envelope, 606, 607f, 607bfull-thickness reection, 603, 603fguided bone regeneration, 949–969incision technique for, 607–610, 608f–609fmobility of, 604–605, 604ftrapezoidal, 606–607, 607f, 607btrauma minimization, 603–604triangular, 606–607, 607f, 607btypes of, 605–607, 606f–607fvestibular, 607, 607bFlapless full arch technique, 386–387, 389fFlapless incision, 605, 606f, 606bFloss aids, 1209, 1211fFlumazenil, 376Fluoroquinolonesdescription of, 363–364, 364bdrug interactions, 379t–380tFocal spot, 282, 284fForceangled abutments, 141bite, 141t, 174, 176t, 192–193compressive, 141–142, 142tconversion factors for, 141bdenition of, 140deformation caused by, 143delivery of, 146mastication, 9, 174mechanical stress, 143moment of, 146–147, 146focclusal. See Occlusal forcesparafunctional. See also Parafunctional habitsbruxism, 175–180, 176f–180f, 183–184, 184tcategories of, 175characteristics of, 174–175clenching, 180–184, 184ttongue thrust and size, 184–186, 185fpatient factorsarch position, 193bite force, 141t, 174, 176tbruxism, 175–180, 176f–180f, 183–184clenching, 180–184crown height space, 186–191, 186f–191f, 186bdescription of, 167masticatory muscle dynamics, 191–193, 192fsummary of, 194–195tongue thrust and size, 184–186, 185fshear, 142, 142ttensile, 141–142, 142t, 144ftypes of, 141–146, 142fvector quantities, 140–141Forceps, 896–897Four-wall bony socket, 902, 903fFP-1angulation of, 687–689description of, 422, 438, 438t, 439f–440f, 448fexcessive depth of, 693FP-2angulation of, 687–689description of, 422, 438–440, 438t, 442f, 448fexcessive depth of, 693FP-3, 440–445, 442f–443f, 448f, 592f, 688, 693Free-end edentulism, 5Free gingival graft, 1171fFree-standing implants, 36Freeze-dried bone allograft, 900, 923–925, 967, 1019 1226IndexFrenum attachment, 959fFretting corrosion, 110Frontal sinus, 299Functional cross-sectional area, 143Functional endoscopic sinus surgery, 1043fFungal rhinosinusitis, 308–309, 309f, 1003Furcation treatment, 511GGalvanic corrosion, 110GBR. See Guided bone regenerationGeneric terminology, 20Genial tubercles, 332fGenioglossus muscle, 336Gerdy tubercle, 1101fGilbert syndrome, 223Gingivahyperplasia of, 1175–1179, 1179f, 1179bkeratinized, lack of, 1168–1172, 1169f–1172frecession of, 1169total edentulism eects on, 9Gingival bers, 159–160, 1192Gingival pockets, 1197Gingivitis, 347, 1143, 1144fGlomerular ltration ratein elderly, 257estimated, 223–224Gloving, 622b, 626f–627fGlucocorticoidsadrenal suppression caused by, 367contraindications to, 368description of, 263, 366edema treated with, 791–792, 792timplant dentistry uses of, 367–368mechanism of action, 367sinus grafting uses of, 1009, 1009bsynthetic, 366–368, 367tGlucose, serum, 221–222, 222t, 224t–226tGold alloy, 126, 549, 551fGolden ratio, 727Gowning, 622b, 626f–627fGranulomatous rhinosinusitis, 308Growth cessation, 258, 259fGuided bone regenerationbarrier membranes used in, 28, 957–969clinical application of, 949–969denition of, 914–915description of, 28, 935ap design for, 949–969history of, 915illustration of, 936fGuided bone regeneration (Continued)incisions for, 949–969indications for, 917membranes used in, 966protocol for, 973bspace maintenance for, 967Guided surgery, 33, 35f–37f, 644, 754fGuided tissue regeneration, 915Gummy smile, 502–503, 1120–1124, 1121f–1126fGut sutures, 622–623, 628t–629tH3H-thymidine, 76HA. See HydroxyapatiteHahn guided surgery kit, 33, 35f–36fHahn implant, 33f, 36, 40f, 199fHahn implant surgery kit, 32fHaller cells, 299, 302–303Halo formation, 561Halsted, William Stewart, 602, 602bHandpieces/motors, 618, 619f, 776–777Hard tissue, 7f–9f, 7bHashimoto’s thyroiditis, 241Haversian canals, 914fHead and neckfascial spaces of, 344infections of, 341–344Healing abutmentcustom, 33f–34fdenition of, 32illustration of, 33f–34f, 666ftemporary, 28Healing collar, 32Healing cu, 32Height, 217Helix angle, 25f, 58fHematocrit, 218, 224t–226tHemoglobin, 218, 224t–226tHemoglobin A1c, 224t–226t, 239–240Hemophilia A, 219Hemophilia B, 219Hemoptysis, 249tHemostasisdescription of, 219, 219f, 799mechanical methods of, 785–787pharmacologic agents and techniques for, 787–791, 789f–790fHemostat forceps, 786Hemostats, 612–615, 615fHepatitis, 250tHepatitis C, 249Herbal supplements, 268, 269bHertwig root sheath, 7Hiatal hernia, 250tHigh lip line, 502–503, 503f, 528Home carefor implant maintenance, 1207–1212, 1210f–1212ffor peri-implant mucositis, 1148Hooke’s law, 145Horizontal mattress suture, 630–631, 638fHot isostatic pressing, of hydroxyapatite coating, 200tHounseld units, 281, 281b, 286, 286f, 393b, 457, 649bHourglass mandible, 737Human cellular and tissue-based products, 918Hyaluronic acid llers, 1126–1127Hybrid prosthesescrown height space for, 444, 507fFP-3, 179f, 443f, 445fmetal framework for, 192fHydrocodone, 371, 379t–380tHydrocortisone, 367t, 792tHydroxyapatitecoating of, on implant surface, 128–129, 128f, 199, 200t, 203crystallinity of, 118description of, 116, 116t, 925–926, 967particulate, 116–117, 117fsolubility of, 118–119, 118fsurface of, 126–127Hyperalgesia, 369–370Hyperbaric oxygen, for osteoradionecrosis, 255Hypercalcemia, 84–85, 87, 222Hyperglycemia, 222, 239Hyperparathyroidism, 242–243, 253Hypertension, 227–229, 229b, 233tHyperthyroidism, 241Hyperventilation, 217Hypodontia, 535Hypoglycemia, 222Hypomineralization, of mandibular canal, 293, 293fHypothyroidism, 241Hypoventilation, 217IIBD. See Inammatory bowel diseaseIbuprofen, 370–371, 370bIdeal load-bearing zone, 865Idiopathic thrombocytopenic purpura, 246Iliac crest bone grafts, 430, 431f, 869f, 1092–1099, 1094f–1097f, 1094t, 1095b, 1104f 1227IndexImagingcomputed tomography. See Computed tomographycone beam computerized tomography. See Cone beam computerized tomographyimportance of, 328intraoperative, 314, 317fmandibular anatomy, 289–296maxilla anatomy, 296–302, 298f–301fobjectives for, 275postprosthetic, 314–318postsurgical, 314presurgical, 275–276, 276bradiographic. See Radiographic imagingImmediate implant placement, 830–859in active infection site, 346–347, 346fadvantages of, 830–832, 830banatomic location and, 838anterior, 950available bone for, 834–839bone density and, 837–838buccal bone thickness and, 838–839complications of, 849–853, 856fcone beam computerized tomography in, 840fdescription of, 28, 346–347, 346f, 411f, 764–767disadvantages of, 832–834, 832bwith double-barrel bula graft, 1105, 1110f–1111fideal positioning for, 842–845implant indesign of, 845–846stability of, 846–848in infected sites, 849in mandible, 855fin maxilla, 854fin periodontal disease, 348requirements for, 839studies of, 834technique for, 839–849tissue-supported, 884ftissue thickness and, 838treatment planning for, 834–839Immediate loading, of implantsadvantages of, 860–861, 861bbenet/risk ratio, 886bone microstrain and, 865, 866fin completely edentulous arches, 873f, 874–876, 875f–876fdescription of, 33, 37tdisadvantages of, 861bula reconstruction with, 1104–1105, 1107fforce conditions and, 866f–867f, 867–868Immediate loading, of implants (Continued)histologic evaluation of, 864–865implant overdentures, 881–884, 885fin partially edentulous patients, 868–870, 869b, 871f–872fpostoperative complications of, 885postoperative instructions for, 884prerequisites for, 861–862, 863frationale for, 862–863, 886summary of, 886surface area and, 865–868, 866f–867fsurvival rates, 886terminology of, 860trauma caused by, 863Immediate occlusal loading, 861bImmunosuppressive drugs, 263–266, 263bImpact, 145Implant(s). See also specic implantallergy to, 268–269, 270fapical region of, 61, 61f–62f, 65apically positioned, 515fappointments necessary for, 7attachment of, to teeth, 516–524available bone for. See Available bonebone grafts for. See Bone graft(s)bone loss around, 1205f, 1209bclinical evaluation of, 1197–1206complications ofabutment-screw loosening, 153, 155fmechanical, 187components ofbiomechanical complications of, 154–155description of, 31–34, 33f–34ft of, 804occlusal overload eects on, 153–155swallowing/aspiration of, 775, 776fcompound annual growth rate for, 17conical connection, 57, 64connections for, 27, 27f, 57, 57fconnective tissue zone for, 1198custom components of, 33–34design ofbiomechanics of, 165–166bone loss aected by, 165–166diameter, 50–52, 52f, 54, 55fendosseous implants, 22, 22ffailure rates, 48, 49tfunctional basis for, 64–65length, 52–54occlusal forces and, 48–49, 165–166progression of, 48, 64screw loosening aected by, 804–805shape, 49–50, 64success rates for, 48, 49tsurface area aected by, 169Implant(s) (Continued)diameter of, 50–52, 52f, 54, 55f, 416–417early loading failure of, 153, 467emergency, 28endosseous. See Endosseous implantsendosteal. See Endosteal implantsengaging components of, 34explantation of, 824–825factors aecting demand forage-related tooth loss, 4aging population, 2–4esthetics, 4partial edentulism, 4–6social activity, 4total edentulism, 6–12failure ofbiomechanical overload as cause of, 152–153bone density and, 450, 648diabetes mellitus as cause of, 239–240early loading, 153fatigue, 150, 150fforce delivery and, 146after immediate implant placement, 833implant diameter eects on, 51infections as cause of, 341, 347lack of keratinized tissue as cause of, 1168–1169overheating of bone as cause of, 154f, 773parafunctions as cause of, 174–175, 181–183. See also Parafunctional habitsretained cement as cause of, 1172surgical, 152–153, 154ffeatures of, 54–61fracture ofetiology of, 821–822, 823ffatigue as cause of, 63f, 178–179prevention of, 822treatment of, 822free-standing, 36future of, 17geometry of, 49–54, 51f–53f, 150global prevalence of, 2, 3fhealthy, 1209f, 1209bheight of, 417–418ideal position evaluations, 384–388, 385f–386f, 385bimmediate loading of. See Immediate loading, of implantsimmediate placement of, 28impingement trauma, 816findications for, 7, 48 1228IndexImplant(s) (Continued)industry growth of, 2joining of, to teeth, 519–520keratinized tissue around, 1199–1201, 1200b, 1201fkey positions for, 167–169length of, 417–418, 418f, 556, 847floading ofearly loading failure, 153marginal bone loss after, 48progressive, 528types of, 33, 37tloads applied todeformation caused by, 143description of, 140impact, 145–146macrostructure of, 20–22, 25–26macrothreads of, 25–26, 26fmaintenance of. See Implant maintenancemalpositioned, 671f, 857f, 936fmicrostructure of, 22, 26microthreads of, 26, 55–56, 56fmigration of, into maxillary sinus, 1044–1045, 1045t, 1046f–1049fmobility of, 518–519, 806, 824, 1193–1195, 1195f, 1195b, 1201, 1202fmovement of, 517–518, 518f, 1193–1195nonengaging components of, 34number of, 471–475, 474f, 514, 556–557, 581f, 865occlusion, 1202–1203one-stage, 27–28osteotomy preparation for. See Osteotomyplaque accumulation around, 1197, 1198f, 1199bplatform-matched, 27, 27fplatform shifting, 56platform-switched, 27, 27fprevalence of, 2probing around, 1197–1199, 1199f–1200fradiographic evaluation of, 1203–1206radiology report ndings for, 314screw-shaped. See Screw-shaped implantsshape of, 49–50single-tooth. See Single-tooth implantsize of, 168–169, 416–418, 866soft tissue aroundassessment of, 1197ber groups, 160fsplinting of, 476–477standardized components of, 33–34Implant(s) (Continued)surface area of, 52f, 61t, 168, 168f, 183–184, 464, 865–868, 866f–867fsurface of. See Implant surfacesurgical instrumentation for, 30–33, 32f–33fsurgical protocols for, 27–30survival rates for, 48technological advances in, 17teeth and, dierences between, 1196tteeth replaced with, 2, 3fthreads ofbuttress, 26f, 51f, 59, 60fdepth of, 60–61, 61fdescription of, 25–26, 25f–26f, 57–58pitch, 58–59, 58fprimary stability uses of, 57–58, 65reverse buttress, 26f, 59, 60fshape of, 59–60, 60fsquare, 26f, 51f, 59–60, 60fV-threads, 26, 59–60, 60ftreatment planning for, 48two-stage, 27–28wide, 51–52, 53fwidth of, 416–417Implant analog, 33–34, 38fImplant bodyabutment connection to, 159, 160f, 1206angulation of, 686–687design of, 866–867force on, 463fracture of, 154–155, 156f, 187, 821–822, 1202load transfer by, 142radiographs of, 1204–1205Implant collar, 54–57, 55f–56f, 64, 165–166Implant drills, 31Implant-level impression coping, 33–34Implant-level impressions, 33–34Implant-level prosthesis, 34Implant maintenancedental history for, 1197dentifrices used in, 1208–1212, 1210f–1211ffrequency of visits for, 1207home care, 1207–1212, 1210f–1212fin-oce debridement, 1212medical history for, 1195–1197overview of, 1142pain/sensitivity assessments, 1201–1202, 1203fprotocol for, 1195–1206Implant materials. See also Biomaterials; specic materialbiocompatibility of, 62, 108biodegradation of, 110corrosion of, 110corrosion resistance of, 64modulus of elasticity, 64overview of, 61–65standardization of, 111titanium. See Titaniumtoxicity of, 110–111Implant mounts, 31Implant overdentures. See also Implant-supported overdenturedenition of, 36immediate loading of, 881–884, 885fin limited crown height space, 509Implant placementautogenous bone grafts, 1082–1083bone density factors involved in, 647–650, 649f, 649bcone beam computerized tomography image of, 418fdenition of, 844tfacial dehiscence after, 771–772, 772fguided surgery in, 33, 35f–37fimmediate. See Immediate implant placementin inadequate bone, 950finfection before, 346–348, 346fnavigational systems for, 400, 402fone-stage, 665–666, 666bosseodensication for, 649–650osteotomy preparation for, 645–647, 645f–646f, 648b, 650–653, 650f–652fpressure necrosis caused by, 774primary stability assessments, 663–664, 664f–665f, 665bprotocolsfor D1 bone, 653–657, 654f, 655b, 656f–657f, 667tfor D2 bone, 657–658, 659f, 659b, 667tfor D3 bone, 658–661, 660f–661f, 661b, 667tfor D4 bone, 661–663, 662f–663f, 662b–663b, 667tdescription of, 644–645after radiotherapy, 255surgical approaches for, 644–645surgical template used in, 394–398thread pitch and, 59two-stage, 665–666, 666f, 666bvirtual, 393, 394f 1229IndexImplant position/positioningapicocoronal (Z-axis), 689–695, 692fbuccolingual (“Y-axis”), 682–687, 684f–687fexcessive depth, 691–695, 693f–694f, 695bexcessive implant–tooth distance, 677–679, 678f–680f, 680bideal, 670–705, 704bimmediate loading aected by, 867–868inadequate depth, 695–696, 695f–696finsucient implant–tooth distance, 670–676, 671f–674flack of implant–implant distance, 679–682, 680f–683f, 684bverication of, 650vital structures and, 698“X”-axis, 670–682, 671f–681fImplant quality scale, 1179–1183, 1180t, 1181f–1183fImplant stability quotient, 17, 22Implant-supported overdenture. See also Implant overdenturesdescription of, 437for edentulous mandible, 570–579, 570b, 571f, 573t, 574f–578f, 577b–579bfor edentulous maxilla, 594–596, 595f–598f, 595t, 596b, 598bImplant-supported prosthesesadvantages of, 15–17, 15balveolar bone maintenance using, 15, 15fbiting force aected by, 16chewing eciency with, 16general health benets of, 16masticatory eciency using, 16nutritional benets of, 16occlusal awareness with, 16occlusion stability using, 16phonetics aected by, 16psychological health aected by, 16–17, 17bsuccess rate for, 16Implant surfaceacid etching of, 198, 201tadditive processes, 199anodization of, 199, 201tantibiotic coating on, 202biological responses, 199–201bisphosphonate, 201–202blasting techniques for, 198–199bone and, interactions between, 198fcalcium phosphate, 203chemical cleaning of, 129cleanliness of, 129Implant surface (Continued)coatings on, 127–129energy of, 129functionalization of, with biologically active substances, 202–203hydroxyapatite coatings on, 128–129, 128f, 199, 200t, 203laser treatment of, 199modications to, 129in osseointegration, 197oxidation of, 199, 201tperi-implantitis and, 1170porous coatings on, 127–129for press-t implants, 23resorbable blast media, 26, 26f, 127f, 198, 199freview of, 197–199roughening/roughness of, 126–127, 197, 200t, 201statins on, 202sterilization of, 130subtractive processes, 26, 198–199titanium plasma-sprayed, 127–128, 127f, 199types of, 23zirconia implants, 202Implant systems, 30–31Implant verication jig, 34, 38fImplant–abutment connection, 666designs for, 57, 57fexternal, 27, 27f, 57internal, 27, 27f, 57Impressionsabutment-level, 34closed-tray technique for, 34, 38fdigital, 410f–411fimplant-level, 33–34open-tray technique for, 34, 38foptical, 404–405, 405btechniques for, 34, 38fIMZ implant, 27In-oce debridement, 1212Incision line opening, 794–801, 795f–800f, 795b, 801t, 980, 1030–1032, 1077–1078, 1080, 1081fIncisions, for aps, 607–610, 608f–609fIncisive artery, 748, 779–780Incisive canal, 291–292, 292f, 748, 780f, 974Incisive foramen, 297–298, 298f, 721–725, 724fIncisive nerve, 757, 760f, 1079Incisivus labii superioris muscle, 332Independent prosthesis, 475–476, 476fInfections. See also specic infectionantibiotic prophylaxis for, 353, 359–361apical, 909fInfections (Continued)aseptic technique and, 360biolm associated with, 353bone graft, 985causes of, 346head and neck, 341–344before implant placement, 346–348, 346fmicrobiology of, 341, 344–346overview of, 341–344pain caused by, 1202periodontal disease, 347–348, 347fperisurgical, 348postsurgical, 349–352, 349f–350frisks of, 346, 360, 360bsigns and symptoms of, 341, 365in socket-grafting site, 908, 909fspread of, 342–344, 343fInferior alveolar artery, 338–339, 748, 779Inferior alveolar canal, 289–290, 754–755, 765fInferior alveolar nerve, 337, 698, 752, 754f–755f, 811Inferior meatus, 300Inferior turbinate and meatus pneumatization, 305, 305f, 1000Inammationcryotherapy for, 368, 368bglucocorticoids for. See Glucocorticoidspostoperative, 365–368Inammatory bowel disease, 250Informed consent, 920–921Infraorbital artery, 334, 338, 994Infraorbital foramen, 298–299, 299fInfraorbital nerve, 299, 299f, 334, 813–814, 1032Injectable botulinum toxin. See Botulinum toxin injectionsInjectable llersangular cheilitis treated with, 1135–1136black triangles treated with, 1129, 1129f–1130fcomplications of, 1136–1137duration of action, 1128facial applications of, 1131–1136hyaluronic acid, 1126–1127indications for, 1128injection techniques for, 1128, 1129flips treated with, 1130–1131, 1131f, 1134fmarionette lines treated with, 1134, 1136fmechanism of action, 1127nasolabial folds/crease treated with, 1134, 1135f 1230IndexInjectable llers (Continued)permanent llers, 1129preparation of, 1127–1128reversals for, 1136supply of, 1127–1128, 1127ftypes of, 1125–1129, 1127tInlay grafting, 30Inner diameter, 25Insertion torque, 647, 861Inserts, 123Instruments. See also specic instrumentbone compaction, 663fbone-grafting, 612handpieces/motors, 618, 619f, 776–777for holding drapes, 618, 618ffor holding mouth open, 615–618, 617f–618fosteotomes, 620, 620fscalpel, 608–610, 610fsurgical blades, 610, 610ffor suturing, 640, 640f–641ftissue forceps, 611, 611ffor tissue reection, 611, 611ffor tissue removal, 611–620for tissue retraction, 615, 616f–617fInteractive computed tomographydescription of, 384ideal implant position evaluations and determination, 384–388, 385f–386f, 385bInterarch distance, 186, 505–506Interdental papillae, 503f, 709f, 719f, 720–721Interimplant distance, 680fInterleukin-12, 264Interleukin-17 inhibitors, 264Intermediary abutments, 167International normalized ratio, 220, 220tInterocclusal distance, 497Interocclusal space, 424f, 444f–445f, 555, 590–591, 697f–699fInterproximal bone, 954fInterproximal brushes, 1209, 1210fIntramobile elements, 123Intraoperative imaging, 314, 317fIntraoral examination, 211–214Intraoral scanning, 17Intraosseous anastomosis, 306, 306f, 1033fInvestigational device exemption, 918Ion beam-assisted deposition, of hydroxyapatite coating, 200tIron, 224t–226tIron alloys, 125–126Iron-chromium-nickel–based alloys, 113–114Isolated systolic hypertension, 258IVJ. See Implant verication jigJJaundice, 250tJaw. See also Mandiblebone density in, 451drug-induced osteonecrosis of, 261, 261tedentulous. See Edentulous jawosteomyelitis of, 349–351, 349f–350fJunctional epithelium, 24–25KKeratinized tissuearound implants, 1199–1201, 1200b, 1201flack of, 1168–1172, 1169f–1172fKey implant positionsdescription of, 167–169rst molar, 471, 473ffor xed prostheses, 467–471, 467bKidney, calcium conservation in, 87LLabiomental angle, 11Laboratory evaluationbiochemical proles, 221–224bleeding tests, 218–221, 219fcomplete blood cell count, 217–218hematocrit, 218hemoglobin, 218overview of, 217–224red blood cell count, 218urinalysis, 217white blood cell count, 218Lactic dehydrogenase, 223Lamellar bone, 78, 165LANAP. See Laser-assisted new attachment procedureLAPIP. See Laser-assisted peri-implantitis protocolLaser(s)hemostatic uses of, 787implant surface treated with, 199Laser-assisted new attachment procedure, 1157, 1160fLaser-assisted peri-implantitis protocol, 1156–1157, 1158f, 1159Lateral access drilling tube, 412fLateral incisors, congenitally missing, 727–732Lateral pharyngeal space, 344Lateral pterygoid muscle, 336Lateral tongue thrust, 185Left-sided congestive heart failure, 236Leukemia, 247tLeukocyte disorders, 245–246Leukocyte platelet-rich brin, 1166Leukocytosis, 245–246Leukopenia, 246Levator anguli oris muscle, 333Levator labii superioris muscle, 333Levooxacin, 364tLichen planus, 1196Lidocaine, 373–375, 373t–374t, 379t–380tLife expectancy, 2, 3f–4f, 4Lindemann drill, 844, 845fLingual artery, 780Lingual canal, 295–296Lingual concavities, 294, 295fLingual ap, 963fLingual foramen, 295–296Lingual nerve, 337, 750–752, 751f, 811–813Lingual tori, 72f, 960, 983fLingual undercut, 746–748, 749f, 782–783, 783fLinkow blades, 22–23Lip(s)anatomy of, 1130–1131anesthesia of, 1131, 1131fller injections applied to, 1130–1131, 1131f–1134fvermilion border of, 11Lip lines, 501–504, 502f–503fLip support, 590, 590fLipoprotein lipase, 224t–226tLithium disilicate, 549, 550f–551fLithium silicate, 549Liver disease, 248–249Liver function tests, 224t–226tLoading, of implants, 33, 37tLocal anesthetics, 373–375, 373t–374t, 373b–374b, 814Locally applied antibiotics, 1159, 1159fLoe and Silness bleeding index, 1197, 1197bLong buccal nerve, 338Low-abrasive amino acid glycine powder, 1156, 1157f, 1212Lymphocytes, 218, 224t–226tMMacrolides, 362–363, 363b, 379t–380t, 1038Macroporosity, 916, 916fMacrostructure, 20–22, 25–26Macrothreads, implant, 25–26, 26fMagnetic resonance imagingcomputed tomography versus, 278–279description of, 278–279treatment planning uses of, 278–279 1231IndexMandible. See also Jawanatomy of, 289–296, 335–338, 572, 572f, 738fanterior, 737–738, 739f, 741f, 743fbone density in, 649description of, 295, 296fextraosseous vessels in, 780–781radiographic imaging of, 1107fsurgical specimen of, 1108fatrophy of, 10fblood supply to, 338–340body of, pathologic fracture of, 8bone height losses in, 8, 8fbone loss in, 8, 12f, 415–416, 416fcone beam computed tomography of, 753, 753f, 756fdeformation of, 744–746edentulousbiomechanical sections of, 167early loading of implants in, 874xed prosthesis for, 568f, 579–585, 579b, 580f–585f, 586bfree-end, 5, 5fimmediate loading of implants in, 874, 875fimplant-supported overdenture for, 570–579, 570b, 571f, 573t, 574f–578f, 577b–579bremovable prosthesis for, 568fresorption of, 10ftreatment planning principles for, 567–570exure of, 569f–570f, 569, 744–746, 747ffree-end edentulism in, 5, 5fhourglass, 737immediate implant placement in, 855finnervation of, 337–338, 750–752, 751flack of bone height in, 742–748lack of keratinized tissue in, 739lingual nerve of, 750–752, 751flingual undercut of, 746–748, 749f, 782–783, 783fmedial movement of, 569, 569fmedian vascular canal of, 296, 297f, 738, 741f, 779muscle attachment to, 335–338neurosensory complications of, 760–767osteology of, 69osteoplasty of, 742, 745fposterior, 742, 746f, 937fradiographic anatomy of, 289–296resorption stages in, 8fseverely angled, 738–739three-dimensional radiography of, 753–754, 753fMandible (Continued)torsion of, 569–570, 744two-dimensional radiography of, 752–753, 752fMandibular canalcone beam computerized tomography of, 390–391, 391b, 392fhypomineralization of, 293, 293fimplant placement in, 780fradiographic anatomy of, 289–291, 290f–291fsocket-grafting proximity to, 908–909, 909fMandibular condyle, 75Mandibular incisors, 499–500Mandibular lip line, 504Mandibular premolars, congenitally missing, 535–536Mandibular ramusanatomy of, 293–294, 294f, 1064–1067autogenous bone grafts from, 293–294, 294f, 902–905, 904f–905f, 980f, 982f, 1064–1071, 1070f–1072f, 1071b, 1079–1080radiographic anatomy of, 293–294, 294fMandibular symphysisanatomy of, 294–296, 296f, 949f, 1056, 1058fautogenous bone grafts from, 1056–1064, 1056f–1066f, 1063b–1064b, 1077–1079bone grafting from, 1054–1055, 1055fbone loss in, 415radiographic anatomy of, 294–296, 296fMarginal boneloss ofanimal studies of, 162, 163fautoimmune response of host as cause of, 158–159bacteria as cause of, 158–159biological width as cause of, 159–160, 159f–160fcantilevers and, 164fcellular biomechanics, 161clinical reports on, 163–164hygiene as cause of, 159imaging of, 158fafter implant loading, 48implant osteotomy as cause of, 157–158occlusal trauma as cause of, 155–157, 161periosteal reection as cause of, 157, 158fmaintenance of, 48Marionette lines, 1134, 1136fMass, 140, 141bMasseter muscleanatomy of, 337, 1114blood supply to, 1114botulinum toxin injection in, 1114–1118, 1116f–1118fhypertrophy of, 181, 182f, 509–510, 1114–1118, 1116f–1118finnervation of, 1114Masseteric space infections, 342Masticationcomplete denture and, 14forces generated by, 9, 174implant-supported prosthesis eects on, 16tooth loss eects on, 14Masticatory musclesforce aected by dynamics of, 191–193, 192fpalpation of, in clenching examination, 180Material safety data sheets, 921Maxillaanatomy of, 296–302, 298f–301f, 331–335, 331f, 589farterial supply to, 334–335, 334fblood supply to, 338–340bone loss in, 9, 12f, 415–416, 416fcrown height space in, 591, 591fedentulousearly loading of implants in, 874xed prostheses for, 591–594, 592f–594f, 592t, 592b–593bimmediate loading of implants in, 874implant overdenture for, 594–596, 595f–598f, 595t, 596b, 598bregions of, 168removable prostheses for, 594–596, 595f, 595t, 596b, 598btreatment planning for, 589–591esthetic zone in, 438free-end edentulism in, 5, 5fimmediate implant placement in, 854flateral wall/nasal bleeding, 783–785lymphatic drainage of, 335muscles to, 332–333, 332f–333fosteology of, 69palatal resorption pattern of, 504premaxilla, 296–297, 298f, 305–306, 305fradiographic anatomy of, 296–302, 298f–301fradiology report ndings for, 312sensory innervation of, 333–334, 333fsurgical anatomy of, 331–335, 331fvenous drainage of, 335 1232IndexMaxillary anterior implantanatomic challenges for, 710–715angulation of, 714–717body angulation of, 714–715bone height, 710–711bone width, 713fcomplications of, 720–721for congenitally missing lateral incisors, 727–732diameter of, 714bfaciopalatal width, 711–712ideal angulation of, 716–717mesiodistal space, 711nasopalatine canal, 721–732placement of, 706–725position of, 714size of, 712–714soft tissue closure, 719soft tissue incision, 717–719, 718bstudies of, 706transitional prosthesis, 719–720Maxillary anterior teethevaluation of, 706–710position of, 495–496, 496fshape of, 707–708, 708fsize of, 707–708soft tissue drape of, 708–710Maxillary arch, edentulous, 15Maxillary artery, 334, 992Maxillary complete denture, 14–15Maxillary incisorscongenitally missing, 535–536, 536fextraction of, 896fMaxillary nerve, 333Maxillary sinusanatomical variants of, 998–1000anatomy of, 299, 300f, 332f, 987–997, 988fanterior wall of, 990, 997tantroliths of, 310–311, 311f–312f, 1006–1007, 1007fbacterial ora of, 996blood supply to, 992–995, 993fbone density in, 989bone resorption process in, 989bony walls of, 990–992, 990f–991fclinical assessment of, 996–997cone beam computed tomography of, 997cyst of, 309–310, 310fcystic lesions of, 1003–1007development of, 987–989, 988fexpansion of, 987–989, 988f–989fextraosseous anastomosis of, 993foreign bodies in, 1006–1007, 1007fMaxillary sinus (Continued)grafting of, 558–564, 559f–563f, 559t, 560b–561b, 563b, 1008–1010, 1016–1024, 1019b, 1020fhypoplasia of, 304–305, 304f, 999–1000, 1000fimplant migration, 1044–1045, 1045t, 1046f–1049fimplant penetration into, 1043–1044, 1044fimplant placement near, 698, 701finferior oor of, 304finferior wall of, 992, 997tintraosseous anastomosis of, 306, 306f, 993–994lateral wall of, 992, 1016–1024medial wall of, 991–992, 991f, 997tmild mucosal thickening of, 1001, 1001fmucocele of, 309, 310f, 1005, 1006fmucociliary clearance of, 994–995, 995fmucosa of, 994ostiomeatal complex of, 300–302, 313, 992, 998ostium of, 301, 301f, 991–992overlling of, 1044, 1045fpathology of, 557, 557f, 1000–1007physical examination of, 997, 997tpneumatization of, 554, 554f, 987posterior wall of, 990–991, 991f, 997tpostoperative cyst of, 309–310, 310fprimary mucocele of, 309, 310f, 1005, 1005fpseudocysts of, 1003–1004, 1004fradiographic evaluation of, 997retention cysts of, 1004Schneiderian membrane of, 300, 300f, 333, 992, 995f, 997sensory innervation of, 992–995septa of, 304, 304fsmoking eects on, 1007socket grafting considerations, 909, 910fsquamous cell carcinoma of, 311fsuperior wall of, 990, 991f, 997tsurgical treatment of, 1010Maxillary sinus oor augmentation, 30Maxillary tuberosityanatomy of, 1072bone grafting from, 905–906, 905f–906f, 1021, 1071–1073, 1072f–1073f, 1074bdescription of, 44–45harvesting of, 1073fMaxillomandibular arch relationship, 504Maximal intercuspation, 504–505, 505fMean corpuscular volume, 224t–226tMechanical stress, 143Mechanostat concept, 94, 94fMedial pterygoid muscle, 336Median vascular canal, 296, 297f, 738, 741f, 779Medical consultation and clearance, 269, 270fMedical historyextraoral examination, 211–214form for, 211f–214fintraoral examination, 211–214overview of, 210–217vital signs. See Vital signsMedication-related osteonecrosis of the jaw, 351. See also Drug-induced osteonecrosis of the jawMedullary plexus, 338Membranes. See also Barrier membranescharacteristics of, 927–928classication of, 917future of, 928–930in guided bone regeneration, 955ideal, 917layering of, 966–967oversight of, 917–918resorbable, 927single-patient uses for, 921sterility of, 919summary of, 930Mental foramen, 278, 291, 291f, 392f, 698, 755–757, 756f, 835f, 908–909, 1058Mental nerve, 755–757Mental protuberance, 336Mentalis muscle, 11, 336–337Meperidine, 371Mepivacaine, 373, 373t–374tMetabolic bone disease, 93–94Metabolic screening, 221Metal-ceramic restorations, 549, 551fMetals and alloyscobalt-chromium-molybdenum, 113engineering properties of, 112tiron-chromium-nickel, 113–114overview of, 111–114surfaces of, 123–124titanium. See TitaniumMethotrexate, 256Metronidazole, 364, 364t, 379t–380t, 1039–1040, 1159, 1159bMicrocomputed tomographybone on, 75–76, 79f–80fdescription of, 73Microindentation, 75–76Microindentation testing, 73Microporosity, 916, 916f 1233IndexMicroradiography, 72, 74–75of bone, 74–75, 75f–78fMicrosieverts, 282, 285fMicrostrain, 865, 866fMicrostructure, implant, 22, 26Microthreads, 26, 55–56, 56fMidazolam, 375Middle meatus, 300Middle superior alveolar nerve, 334Middle turbinate, 999Mild pain, 372Mineralized allografts, 29tMineralocorticoids, 366Mini-implantsdescription of, 23–24, 24forthodontic anchorage uses of, 101–103, 105fMinocycline, 1159, 1159bMisch classication, of bone density, 454, 454t, 648, 649fMisch occlusal analyzer, 501fMitosis, 915Model, 385bModerate pain, 372Modulus of elasticity, 64, 143, 161–162, 162f, 460, 868fModulus of rigidity, 145Molarsbiting force of, 569fdental arch maintained by, 4rst, single-tooth implant for, 539–541, 540ffurcation treatment of, 511loss of, 5, 5fsecond, single-tooth implant for, 541–542, 542f, 542tMolt periosteal elevator, 611Moment armscantilever length as, 147f–148f, 149denition of, 146–147occlusal height as, 147, 147f–148focclusal width as, 149Moment loads, 146–147, 146f, 188f, 188tMoment of force, 898Moment of inertia, 151Monetite, 116tMonoclonal antibodies, 262–263Monocytes, 218, 224t–226tMonolithic zirconia, 442–444, 443tMonopolar electrosurgery units, 777, 777fMotion-related artifacts, 287, 287fMoxioxacin, 364tMucocele, 309, 310f, 1005Mucositis, peri-implant. See Peri-implant mucositisMucous retention cyst, 309, 312f, 1003–1004Multiple myeloma, 253Multiple sclerosis, 265Multiple-teeth replacementimplant-supported multiple crowns, 543–544, 543fno treatment, 542–543recommendations for, 551tMylohyoid muscleanatomy of, 335–336nerve to, 337Myocardial infarction, 234–235, 235tNN-FIT, 870N-terminal-pro-brain natriuretic peptide, 236Naloxone, 376Nasal cavityanatomy of, 299–300, 999, 999fimplant position, 698, 725–732radiology report ndings for, 313Nasal turbinates, 998Nasolabial crease, 1134, 1135fNasolabial folds, 1134, 1135fNasolabial groove, 11Nasopalatine canal, 297–298, 298f, 715f, 721–725Nasopalatine nerve, 334, 813National Center for Health Statistics, 2, 4Navigational systems, 400, 402f, 645Necrotizing periodontal diseases, 347Needle holders, 640, 641fNeuropraxia, 817, 819f, 1078Neurosensory impairment, 811–821, 853, 857fNeurotmesis, 818, 819fNeutrophils, 218, 224t–226tNew York Heart Association congestive heart failure classication, 236, 236bNewton’s laws of motion, 140Nicotine, 260tNight guardsfor bruxism, 179–180, 180f, 184for clenching, 181, 182f, 184Noise, 287–288, 288fNon-ST segment elevation myocardial infarction, 234Nonabsorbable sutures, 623–624, 631fNonfunctional early prosthesis, 861bNonfunctional immediate prosthesis, 861b, 871fNonfunctional immediate teeth, 869b, 872bNonlimiting surgical template, 394–395, 701, 702fNonocclusal loading, 861bNonresorbable membranes, 28Nonrigid connectors, 519–520Nonsteroidal antiinammatory drugs (NSAIDs)acetaminophen and, 371antihypertensive medications aected by, 229classes of, 370, 370tdrug interactions, 379t–380tedema treated with, 791gastrointestinal complications of, 370tmechanism of action, 366, 366fpain management uses of, 370–371, 370tNovaSterilis, 920Novel oral anticoagulants, 220, 268Nuclear volume morphometry, 76, 81fNutrition, implant-supported prostheses eects on, 16OObesity, 90Obsidian, 549Obstructive sleep apnea, 228, 257Occlusal awareness, 16Occlusal contacts, 1202–1203, 1205fOcclusal forcesbone response to, 49direction of, 49duration of, 49immediate loading and, 866f–867f, 867–868magnitude of, 49marginal bone aected by, 152–153nonaxial, 49transfer of, to bone, 48–50, 51ftype of, 49Occlusal guardsfor bruxism, 179–180, 180ffor clenching, 181, 182f, 184Occlusal height, 147, 147f–148fOcclusal loading, 861bOcclusal overloadimmediate, 863, 864fmechanical components aected by, 153–155Occlusal planes, 500–501, 500fOcclusal stress, 1149Occlusal traumadenition of, 161marginal bone loss caused by, 155–157, 161tooth mobility caused by, 1194–1195Occlusal vertical dimensionbruxism eects on, 177–178correlations, 498b 1234IndexOcclusal vertical dimension (Continued)crown height space and, 496denition of, 496with denture, 9fdenture eects on, 11fevaluation of, 497–499, 498bexisting, 496–500facial height aected by, 11facial measurements and, 497–498implant loading aected by, 496–497, 497fmodication of, 497radiographic assessment of, 498transitional prosthesis for restoration of, 527Occlusal width, 149Occlusioncentric, 504implant-supported prosthesis for stability of, 16load direction established with, 141in preimplant prosthodontics evaluation, 504–505, 505fOctacalcium phosphate, 116tOdontogenic rhinosinusitis, 306–307, 307f, 1000–1001, 1001fOset loading, 142–143One-piece implants, 23, 24fOnlay grafting, 30Onodi cells, 299Open bite, 91bOpen-tray technique, for impressions, 34, 38fOpioidsdrug interactions, 379t–380tmechanism of action, 369pain management uses of, 371Optical impressions, 404–405, 405bOral anticoagulants, 220–221Oral irrigator, 1211, 1211f, 1212bOrbicularis oris muscle, 332Organ procurement organizations, 921–922Oroantral stulae, 1035–1036, 1037fOrthodontics, implant-anchored, 98–103Osseodensication, 649–650Osseointegrationbone-to-implant contact, 21denition of, 20–22, 913determinants of, 197illustration of, 21f, 1194fimplant surface in, 197secondary stability created by, 21stages of, 199–200zirconia implants, 121Osseous defects, 951fOsteitis deformans, 253Ostene, 790–791, 791fOsteoblasts, 80f, 913Osteocel, 925Osteoclasts, 203, 913Osteoconduction, 30, 915Osteoconductive grafts, 935bOsteocutaneous grafts, 1105fOsteocytes, 914, 914fOsteogenesisdenition of, 30, 915growth factors in, 202Osteogenesis imperfecta, 254Osteogenic grafts, 935bOsteoinduction, 30, 915Osteoinductive grafts, 935bOsteology, of craniofacial complex, 69–71Osteomalacia, 252–253, 255tOsteomyelitis, 254, 349–351Osteonecrosis of the jaw, drug-induced/medication-related, 261, 261t, 351OsteonsOsteopenia, 94fOsteoplasty, 423f–424f, 470, 742, 745f, 1011Osteoporosisbisphosphonates for. See Bisphosphonatesdenition of, 93, 251estrogen therapy for, 251, 252bin jaw, 251medications for, 252bmonoclonal antibodies for, 262–263obesity and, 90risk factors for, 93treatment of, 252bvitamin D and, 251–252Osteopromotion, 916–917Osteoradionecrosis, 254–255Osteotomes, 620, 620fOsteotomybone overheating during, 645–647, 645f–646f, 773, 773f–774fdrilling, 645–647, 645f–646f, 650, 650f, 814–816heat generated during, 645–647, 645f–646ffor immediate implant placement, 842inferior, 1065f–1066fmalpositioned site for, 771, 772fmandibular symphysis technique, 1064bmarginal bone loss caused by, 157–158sinus elevation and, 1013, 1014fsuperior cuts, 1070ftechnique for, 645–647, 645f–646f, 648bOstiomeatal complex, 300–302, 313, 992, 998Outer diameter, 56fOverdenture(s)denition of, 36immediate loading of, 881–884, 885fin limited crown height space, 509Overdenture attachments, 36, 41f, 189Overdenture bars, 509Oxycodone, 371Oxygen supplementationfor chronic obstructive pulmonary disease, 248for congestive heart failure, 236PPaget disease, 253Painabutment-related, 1202, 1204fanalgesics for, 369–371, 369t–370t, 369b–370b, 373bdenition of, 1201implant-related, 1201–1202local anesthetics for, 373–375, 373t–374t, 373b–374bmechanism of, 368–369postsurgical, 368–372protocol for controlling, 372–375, 373t–374t, 373b–374bPalatine bone, 331Palatine nerve, 334Panoramic curve, 390, 391fPanoramic radiographsalveolar bone changes evaluated using, 317disadvantages of, 1204limitations of, 277–278, 277f–278fmagnication from, 277, 277fvital structures on, 277–278Papilla-sparing incision, 605–606, 606f, 798–799, 961f, 1057fParadoxical middle turbinate, 302, 303fParafunctional habits, 1012fbotulinum toxin injections for, 1114–1118, 1116f–1118fbruxism. See Bruxismcategories of, 175characteristics of, 174–175clenching, 180–184, 184timplant-supported overdenture aected by, 571–572masseter muscle hypertrophy, 1114–1118, 1116f–1118fscrew loosening caused by, 802–803in temporalis muscle, 1118, 1119ftongue thrust and size, 184–186, 185f 1235IndexParallel-sided screw-shaped implants, 25, 25f, 50Paranasal sinuses. See also specic sinusanatomy of, 299, 300f, 998fpathologic conditions in, 306–311, 997radiology report ndings for, 312–313squamous cell carcinoma of, 310, 311fParapharyngeal space, 344Parathyroid hormonecalcium and, 84–85, 89f, 250–251hyperparathyroidism, 242–243phosphorus regulation by, 222Partial denture. See Fixed partial denture; Removable partial denturePartial edentulismfactors associated with, 5free-end, 5implant demand aected by, 4–6prevalence of, 4–6prosthesis design for, 437–446Partial-limiting surgical template, 397Partial thromboplastin time, 220–221, 224t–226tPartially edentulous archesClass I, 480–483, 481f–483fClass II, 483–485, 484f–485fClass III, 485–487, 486f–487fClass IV, 487–489, 488f–489fclassication of, 480history-taking, 480immediate loading of implants in, 868–870, 869b, 871f–872fKennedy classication of, 480Particulate grafts, 974b, 976–977Particulate hydroxyapatite, 116–117, 117fPassivation, 129Pathologic fracture, of mandibular body, 8, 1109fPathologic overload zone, 865Patientheight of, 217laboratory evaluation of. See Laboratory evaluationmedical evaluation of, 210medical history of. See Medical historyrisk assessment of, 210bvital signs of. See Vital signsweight of, 217PDL. See Periodontal ligamentPenicillin V, 362Penicillins, 362, 362b, 379t–380tPeptic ulcers, 249–250Percussion testing, 22, 846–847, 847fPeri-implant diseasebiolm associated with, 1143–1144denition of, 36–37description of, 1143–1144diabetes mellitus and, 1146diagnosis of, 1206–1207, 1209fillustration of, 41fimplant surface roughness and, 201prevention of, 1192protocol for, 1184f–1185fretained cement, 1172–1179, 1173fPeri-implant mucosal hyperplasia, 1175–1179, 1179f, 1179bPeri-implant mucositisantimicrobials for, 1148, 1159bacteria associated with, 1145bdenition of, 1143–1145, 1206description of, 36–37, 352–353etiology of, 1145, 1146fhome care for, 1148illustration of, 1145f, 1209fmanagement of, 1146–1148, 1147f–1148f, 1159, 1159fmechanical debridement of, 1146–1147prevalence of, 1145prevention of, 1145–1146prosthesis-related, 1146ftreatment of, 1167tultrasonic devices for, 1147–1148, 1148fPeri-implant tissue, 1192–1195, 1193f–1195fPeri-implantitisapically repositioned surgical technique for, 1162autoimmune diseases associated with, 1196biolm associated with, 1149, 1166cement-retained, 1172–1179, 1173fdenition of, 1143, 1148–1149, 1207description of, 36–37, 41f, 252, 259, 352–353, 352f, 793–794, 794fdiabetes mellitus and, 1149etiology of, 1149–1155human studies on, 1151t–1155tillustration of, 1150f, 1209fimplant surface and, 1170laser treatment of, 1156–1167, 1158fmanagement of, 1155–1167occlusal stress as cause of, 1149pathogens associated with, 1148–1149periodontitis and, 1149platelet concentrate growth factors for, 1162–1166predictive proles associated with, 1156tPeri-implantitis (Continued)prevalence of, 1149prevention of, 1149–1155regenerative procedures for, 1161–1162, 1161fsmoking and, 1149studies of, 1151t–1155tsurgical management of, 1159–1172symptoms of, 1149btreatment of, 1163f–1166f, 1167tPeriapical lesions, 793–794, 794fPeriapical mucositis, 306–307, 307f, 1000–1001Periapical radiograph, 276–279, 276f, 317, 318fPericardium membranes, 961, 971fPeriodontal diseasedescription of, 347–348, 347fgingivitis, 347, 1143, 1144fimmediate loading in, 348tooth extractions because of, 511–512Periodontal ligament, 1193bundle bone with, 79, 82fdenition of, 74Periodontitis, 347, 347f, 1143, 1149Periosteal implant, 22Periosteal reection, 157, 158fPeriosteal release, 965fPeriosteal releasing incisions, 955, 964f–965fPeriotest, 663, 664f, 847, 847fPeriotomes, 896–899, 897fPerisurgical infection, 348Permucosal abutment, 32, 1208fPermucosal extension, 32Petechiae, 219–220PGA sutures, 623Pharmacologyanalgesics, 369–371, 369t–370t, 369b–370b, 373bantibiotics. See Antibioticsdrug interactions, 379t–380tglucocorticoids. See Glucocorticoidslocal anesthetics, 373–375, 373t–374t, 373b–374bprotocol for, 376, 377tsedatives, 375–376Phenytoin, 1197Philtrum, 1131, 1131fPhonetics, implant-supported prosthesis eects on, 16Phosphorus, inorganic, 222–223Physics Forceps, 898–899, 898fPick-up technique, for impressions, 34, 38fPier abutments, 520–521, 520f–521fPiezosurgery units, 980, 980f, 618, 619f 1236IndexPiezotome surgery, 1060, 1061fPilot drill, 650, 650fPilot guide, 399, 399fPitchdenition of, 25fthread, 58–59, 58fPixels, 279–280, 280fPlaque, 1197, 1198f, 1199bPlasma-spraying techniquehydroxyapatite, 128–129, 128f, 200ttitanium, 127–128, 127f, 199Platelet count, 220, 224t–226tPlatelet-derived growth factor-B, 202–203Platelet disorders, 246Platelet-rich brin, 961–969, 972f, 1024, 1102, 1166Platelet-rich plasma, 202, 1162Platform-matched implants, 27, 27fPlatform-switched implants, 27, 27fPneumatization, of maxillary sinus, 554, 554fPocket depths, 1143bPolycythemia, 244Polymers, 121–123engineering properties of, 122, 122tber-reinforced, 121–122Polymethylmethacrylate prosthesis, 526–527, 526f–527f, 527b, 551, 551f, 551t, 884fPolymyalgia rheumatica, 264–265Polyposis, 308, 308f, 312fPolypropylene sutures, 624Polytetrauoroethylene membrane, 968f, 970fPolytetrauoroethylene sutures, 624Pontics, 468–469Porcelain-metal xed prostheses, 442, 443t, 444fPosterior implantsin maxilla, 51surgical template for placement of, 411, 412fPosterior lateral nasal artery, 784–785, 784f, 994Posterior maxilla, edentulousaccess-related issues, 555, 556fanatomic location of, 555, 556farterial supply to, 994bavailable bone in, 554biting force in, 555–556, 556fbone density in, 532–535bone resorption in, 554f–555fcrown height space in, 554, 555fimplants in, 557–558, 698, 701flingual oriented ridge position in, 554–555Posterior maxilla, edentulous (Continued)maxillary sinus pneumatization, 554, 554fMisch-Resnik classication, 558–564, 559f–563f, 559t, 560b–561b, 563bsinus grafting for, 558–564, 559f–563f, 559t, 560b–561b, 563bsubantral treatment options for, 558–564, 559f–563f, 559t, 560b–561b, 563b, 1011–1028surface area requirements, 556–557, 557ftreatment classications for, 1010–1028, 1011f–1013fPosterior superior alveolar artery, 338Posterior superior alveolar nerve, 333–334Posterior teeth, 4, 5fPosterior tongue thrust, 185Postoperative maxillary cyst, 309–310, 310fPostsurgical periodbleeding control in, 785–794edema in, 791–794, 792timaging in, 314infections in, 349–352, 349f–350fpain management in, 368–372Potassium, 224t–226tPrednisolone, 367t, 792tPrednisone, 367t, 792tPreemptive analgesia, 369–370, 370bPregnancy, 244Preload, 153Premature ventricular contraction, 216Premaxillabuccal thickness of bone in, 305–306, 305fradiographic anatomy of, 296–297, 298fPremolarscongenitally missing, 535–536immediate implants, 765fsingle-tooth implant for, 538–542, 538fPreosteoblasts, 76, 80fPress-t cylinders, 48Press-t implantsdescription of, 23, 23fplacement of, 48Pressure necrosis, 774Primary hyperparathyroidism, 243Primary maxillary sinus mucocele, 309, 310fPrimary mineralization, 74Primary osteons, 78–79Primary spongiosa, 74–75Primary stabilityassessment of, 663–664, 664f–665f, 665b, 846–848denition of, 21determination of, 21–22, 862implant threads for, 57–58, 65inability to obtain, 849–852insertion torque, 21resonance frequency analysis of, 21threads for, 57–58Probing, 1197–1199, 1199f–1200fProphylactic antibiotics, 353, 359–361, 365Propofol, 376Proprietary terminology, 20Prostate specic antigen, 224t–226tProsthesesbone loss caused by, 7, 8ffracture of, 157fimplant-supported. See Implant-supported prosthesesmaintenance of, 1203mobility of, 1201, 1202fradiographic evaluation of, 1203–1206removable. See Removable prosthesessplinting of, 168, 168fProsthodontics evaluation, preimplantarch form, 512–513crown height space, 505–509, 505f–508f, 506b–507bexisting prostheses, 512extraction of teeth with hopeless or guarded prognosis, 510–512lip lines, 501–504, 502f–503fmandibular incisor edge position, 499–500maxillary anterior tooth position, 495–496, 496fmaxillomandibular arch relationship, 504natural teeth adjacent to implant site, 513–516, 515focclusal planes, 500–501, 500focclusal vertical dimension, 496–500occlusion, 504–505, 505foverall evaluation, 495sequence of, 496bsoft tissue support, 524–525temporomandibular joint, 509–510Prothrombin time, 220–221, 224t–226tProvisional implantsall-on-four surgical protocol, 876–884, 877f, 877bdenition of, 874–876xed, 880–881fully guided immediate placement, 876–884, 879b–880b 1237IndexProvisional prosthesesbone grafts, 967, 973–974denition of, 861bsingle-tooth, 872fProvisional restorationafter socket grafting, 907, 908fPseudocysts, 309, 309fPseudomembranous colitis, 361, 362tPseudoperiodontium, 79Pseudopockets, 1197Psoriatic arthritis, 264Psychological disorders, 260–261Psychological health, 16–17, 17bPterygoid implants, 990–991advantages of, 43–44description of, 40–45disadvantages of, 43–44origin of, 44–45zygoma implant and, 44–45, 44fPulse, 215–216Pulse oximeter, 217Pulse rate, 215–216Pulse rhythm, 216Pulse strength, 216Pulsed laser deposition, of hydroxyapatite coating, 200tPyocele, 308RRa, 26, 197Radiation therapy, 254–255, 255bRadiofrequency glow discharge technique, 130Radiographic imaging“as low as reasonably achievable” principle for, 276bitewing radiographs, 317crestal bone loss, 1205–1206, 1208fimplants, 1203–1206magnetic resonance imaging, 278–279overview of, 275panoramic radiograph. See Panoramic radiographsperiapical radiograph, 276–279, 276f, 317, 318fprostheses, 1203–1206Radiographic template, 384–386Radiology reports, 289, 311–312, 315f–316fRadiopaque template, 385–386, 386f–387f, 386b–387bRaloxifene, 93Ramus frame, 40, 42fRanulas, 778, 778fRaynaud phenomenon, 256Reactive woven bone, 863Reclast, 262Recombinant human bone morphogenetic proteins, 202–203, 915, 967Red blood cell count, 218, 224t–226tRed blood cell disorders, 244Red blood cells, 217Regional acceleratory phenomenon, 82, 862–863, 865, 1021, 1074Remodeling, of bonecell signaling for, 913cell types in, 913control factors for, 87bdenition of, 893b, 913, 937bfunctional loading of implants and, 82histology of, 864fmicrocomputed tomography of, 76, 80foverview of, 79–81, 251parathyroid hormone eects on, 87primary stability in, 21purpose of, 69self-tapping implant and, 863strain and, 161, 452stress and, 161trabecular bone, 452Removable partial dentureabutment teeth for, 13bone loss associated with, 7morbidity of, 13–14negative eects of, 14bsingle-tooth replacement using, 532–533, 533f, 533bRemovable prosthesesdescription of, 445for edentulous maxilla, 594–596, 595f, 595t, 596b, 598bRP-4, 445–446, 446f, 448fRP-5, 446, 447f–448fRemovable soft tissue–borne partial denturesacceptance rates for, 13force transmission in, 193morbidity of, 13–14Removable soft tissue–borne prosthesisin partial edentulism, 9pretreatment, 525–526Renal osteodystrophy, 87Repair bone, 863Resin-bonded prosthesis, for single-tooth replacement, 533, 533f, 533bResnik technique, 1175, 1176b, 1177fResonance frequency analysis, 17denition of, 847–848devices used in, 22, 22f, 665f, 848fprimary stability determination using, 663–664, 665f, 862Resorbable blast media, 26, 26f, 127f, 198, 199fResorbable collagen membranes, 925, 926fResorbable membranes, 28, 927Respiration, 216–217Retained cement peri-implant disease, 1172–1179, 1173fRete peg formation, 159Retention cysts, 309Retrograde peri-implantitis, 793–794, 794fRetromolar canal, 294, 295fRetromolar foramen, 294, 295fRetromolar implant, 100, 100f, 104fRetromolar triangle, 336Retropharyngeal space, 344Retrovisceral space, 344Reverse buttress threads, 26f, 59, 60fReverse screw technique, 825fReverse torque testing, 22RFA. See Resonance frequency analysisRFGDT. See Radiofrequency glow discharge techniqueRheumatoid arthritis, 256Rheumatoid factor, 224t–226tRhinosinusitisacute, 307–308, 308f, 1001–1002, 1002f, 1040t, 1041allergic, 308, 308f, 1002–1003chronic, 308, 1002clinical examination for, 997fungal, 308–309, 309f, 1003odontogenic, 306–307, 307f, 1000–1001Ridge expansion, 30Right-sided congestive heart failure, 236Rivaroxaban, 220–221Rongeur forceps, 611–612, 612fRoot form implantsanterior, 432fdesign of, 416–417moment of inertia of, 151smaller-diameter, 424Root resection, 511fRoot tip retention, after tooth extraction, 911fRP-4angulation of, 689description of, 186, 445–446, 446f, 448ffor edentulous maxilla, 595, 596bpositioning of, 696–698, 698f–699fRP-5angulation of, 689description of, 186, 446, 447f–448ffor edentulous mandible, 570–579, 570b, 571ffor edentulous maxilla, 595–596loading of, 881positioning of, 696–698, 698f–699f 1238IndexSSa, 26, 197SA-4, 1027f, 1027bSaline rinses, 1040–1041Salivary gland injury, 778, 778fSalvin implant rescue kit, 812fSaucerization, 156Scaolds, 928Scalers, 1147, 1148fScalpel, 608–610, 610fScanning abutments, 34, 38fScanning template, 384–386SCC. See Stress corrosion crackingSchneiderian membrane, 300, 300f, 333, 992, 995f, 997, 1033Schwann cell column, 340Scissors, 612, 614f, 640, 641fScleroderma, 256Screw(s). See also Abutment screwfracture of, 154–155, 155f, 807–809, 809floosening of, 152–153, 155f, 477, 801–807removal of, 810f–811fScrew-cementable prosthesis, 547, 547fScrew-retained crowndescription of, 36illustration of, 39f, 544fScrew-retained restorations, 544–545, 544f–545f, 545b, 591, 688f, 803f, 805–806Screw-shaped implantsbone-level implants, 24–25, 24fdenition of, 23macrostructure of, 25, 25fone-piece, 23, 24fparallel-sided, 25, 25fparallel-walled design of, 23small diameter implants, 23–24, 24ftapered screw design of, 23, 24f–25f, 25thread characteristics of, 58ftissue-level implants, 24–25, 24ftwo-piece, 23, 24fScrew tap instrument, 26SDIs. See Small diameter implantsSecond molar implants, 767fSecond-stage surgery, 28Secondary hyperparathyroidism, 243Secondary maxillary sinus mucocele, 1005, 1006fSecondary mineralization, 74, 78Secondary osteons, 82, 98fSecondary stabilitybiomechanical concept of, 21denition of, 20–21, 848osseointegration as, 20–21Sedatives, 375–376Segmental degeneration, 817, 818fSelective serotonin reuptake inhibitors, 268Self-tapping implants, 26Serum glucose, 221–222, 222tSevere pain, 372Sharpey’s bers, 79, 1199–1200Shear force, 142, 142tSickle cell anemia, 244–245, 247tSilk sutures, 623–624Simple interrupted suture, 626–630, 633f–634f, 637fSimple loop suture, 626–630, 633f–634fSingle-tooth implantadvantages of, 534–535, 535banodontia treated with, 535–536anterior teeth, 551tmandibular, 536–537, 537fmaxillary, 537–538, 720disadvantages of, 535, 535billustration of, 534fimmediate loading of, 868–870, 872findications for, 535–536posterior teeth, 551trst molar, 539–541, 540fpremolars, 538–542, 538fsecond molar, 541–542, 542f, 542tsize of, 536–542Single-tooth replacementxed partial denture for, 533–534, 534f, 534bimplant for. See Single-tooth implantno treatment for, 532, 532foptions for, 531–532, 532bprevalence of, 531removable partial denture for, 532–533, 533f, 533bresin-bonded prosthesis for, 533, 533f, 533bthree-unit xed partial denture for, 12–13, 13f, 13bSinus augmentation, 30, 319fSinus bump, 30Sinus curettes, 620, 621fSinus graft surgery, 558–564, 559f–563f, 559t, 560b–561b, 563b, 1008–1010, 1016–1026, 1019b, 1020fantibiotic prophylaxis for, 1008–1010, 1009bbleeding, 1030, 1032fbottom layer, 1021complications of, 1008–1010contraindications for, 1007–1008, 1008becchymosis after, 1034–1035, 1035fedema after, 1034Sinus graft surgery (Continued)implant insertion, 1027–1028infections after, 1036–1041, 1042f, 1045intraoperative complications of, 1028–1030lateral wall approach, 1016–1024layered approach, 1018–1021, 1019bmembrane perforations, 1028–1029, 1028boroantral stulae after, 1035–1036, 1037fpain after, 1035postoperative complications of, 1030–1032postoperative instructions for, 1026–1027, 1028brevision surgery of, 1033, 1035fSA-1, 1011SA-2, 1012–1014, 1014fSA-3, 1014–1024SA-4, 1024–1028, 1027f, 1027bsecond layer, 1021vascular healing of, 1025–1026Sinus membrane perforations, 1028–1029, 1028bSjögren syndrome, 255–256Skeletal systembiomechanics of, 94–95compromise of, 93–94mechanical loading of, 94metabolic bone disease of, 93–94regulatory mechanisms of, 93Small diameter implants, 23–24, 24f, 51Small intestine, calcium absorption in, 87Smile, gummy, 502–503, 1120–1124, 1121f–1126fSmile line, 589–590, 590fSmiling, 502Smoking, 258–259, 260t, 1007, 1146, 1149, 1197Smooth Staple implant, 40SNAP-25, 1112, 1113fSocial smile, 1121Socket graftingcomplications of, 909–911, 910f–911fcontraindications for, 908–909, 909fhealing after, 908, 908finfection, 908, 909fmandibular canal proximity, 908–909, 909fmandibular ramus donor site for, 902–905, 904f–905fmaxillary sinus considerations, 909, 910fmaxillary tuberosity donor site for, 905–906, 905f–906f 1239IndexSocket grafting (Continued)overlling of socket, 909, 911fprovisional restorations after, 907, 908fseal surgery for, 906, 907ftechnique for, 899–907Socket preservation/restoration, 937bSocket seal surgery, 906, 907fSocket-shield technique, 30, 30f–31fSodium, 224t–226tSoft tissue, 946biological width of, 1192biotypes, 949–950, 957f–958fperi-implant, 1192–1193reduction of, 508–509reection of, 814–816total edentulism eects on, 9–10, 10bSoft tissue grafts, 930Soft tissue-supported guides, 398, 399fSol-gel, 200tSphenoid sinus, 299Sphenopalatine artery, 994Sphenopalatine nerve, 333–334Spirochetes, 345Splinting, 168, 168f, 476–477, 477fSpondylitis, 264Sputter coating, of hydroxyapatite coating, 200tSquamous cell carcinoma, 310Square threads, 26f, 51f, 59–60, 60fSSRIs. See Selective serotonin reuptake inhibitorsST segment elevation myocardial infarction, 234Stabilitydetermination of, 21–22insertion torque of, 647, 861percussion testing of, 22primaryassessment of, 663–664, 664f–665f, 665b, 846–848denition of, 21determination of, 21–22, 862implant threads for, 57–58, 65inability to obtain, 849–852insertion torque, 21resonance frequency analysis of, 21threads for, 57–58resonance frequency analysis of, 22freverse torque testing of, 22secondarybiomechanical concept of, 21denition of, 20–21, 848osseointegration as, 20–21Stability dip, 21Stackable guides, 403f–404fStaged occlusal loading, 861bStainless-steel curettes, 1147Stainless-steel fracture xation screw, 111fStaple bone implant system, 40Statins, 202Stent, 385bStereolithographic guide, 404bStereolithographic models, 400, 401fStereolithography, 400Sterile eld, 620–622, 623fSterility assurance level, 919Stomach ulcers, 249–250Strain, 143, 145fbone remodeling and, 161, 452denition of, 161Streak artifacts, 287, 288fStressbone remodeling and, 161crown height space and, 190implant surface area and, 168, 168fmagnitude of, 143, 174mechanical, 143treatment planning aected by, 166–167Stress corrosion cracking, 110, 111fStress-strain relationship, 143–145Stress treatment theorem, 152–173, 153b, 169bStroke, 238Subacute bacterial endocarditis, 236–237, 237bSubantral implants, 558–564, 559f–563f, 559t, 560b–561b, 563b, 996–997, 996f, 1011–1028Subcondylar fractures, 71Sublingual artery, 780, 781fSublingual hematoma, 782fSublingual space, 343fSubmandibular space, 343fSubmental artery, 780–781, 781fSubmental space, 343fSubmucosal space technique, 604–605, 605b, 799, 799bSubperiosteal implantsdescription of, 37–40illustration of, 42flong-term success rates for, 49tSubtractive processes, 26Sulcular incisions, 1060fSulcus depth, 24–25Sulfonamides, 1039Superior meatus, 300Supragingival implant, 54, 55fSurface. See also Implant surfaceof ceramics, 126of cobalt alloys, 125–126of hydroxyapatite, 126–127of iron alloys, 125–126of titanium alloys, 123–124Surgical blades, 610, 610fSurgical burs, 611, 612fSurgical guide, 33, 35f–36f, 702–704Surgical scrub, 622, 624f–627fSurgical templatesaccess inadequacies with, 411, 411f–412fbone overheating concerns, 411complete-limiting, 397, 398f, 702, 702fcomplications of, 411–413denition of, 394, 701description of, 33, 35f–36fdiculty in template seating, 413, 413ffabrication of, 393–394, 400–401fully guided, 399, 400fillustration of, 395fimplant placement using, 394–398nonlimiting, 394–395, 701, 702fpartial-limiting, 397, 701as pilot guide, 399, 399fin posterior implant placement, 411, 412frequirements of, 399–400summary of, 399fas universal guide, 399, 399fSuture needle, 626, 632fSutures/suturingabsorbable, 622–623, 625, 628t–629t, 630fatraumatic removal of, 800bleeding control using, 785continuous, 630, 637ffacial, 95–98, 95f–97fgure-eight, 626, 635fhorizontal mattress, 630–631, 638finstruments for, 640, 640f–641finterrupted, 626–630, 633f–635fknots for, 640–641, 642fnonabsorbable, 623–624, 631fprinciples of, 640bqualities of, 625–626simple loop, 626–630, 633f–634fsize of, 626, 632ftechniques for, 626–631types of, 628t–629tvertical mattress, 630–631, 639fSuzuki-Misch-Hsaio implant health scale, 1180, 1180tSymmetric psoriatic arthritis, 264Systemic lupus erythematosus, 256TT3, 224t–226t, 241T4, 224t–226t, 241T-cell inhibitors, 264Tamoxifen, 93, 263 1240IndexTapered screw-shaped implantsdescription of, 23, 24f–25f, 25illustration of, 417f, 856flong-term performance of, 50T C P. See Tricalcium phosphateTeeth. See also Anterior teeth; Posterior teeth; specic toothadjacent, injury to, 774implants and, dierences between, 1196tmesiodistal width of, 676tmovement of, 1193–1195, 1194fTemplate, 385b. See also Surgical templatesTemporal fossa, 74–75Temporalis musclebotulinum toxin injections in, 1118, 1119fdescription of, 336Temporary abutments, 36, 41fTemporary healing abutment, 28Temporomandibular jointdescription of, 70–71dysfunction of, 509–510radiology report ndings for, 313Temporomandibular joint syndrome/temporomandibular dysfunction, 1119–1120, 1121fTensile force, 141–142, 142t, 144fTension-free incision closure, 799, 799fTenting screws, 974–976Terminal abutments, 167, 469fTerminologygeneric, 20proprietary, 20Tertiary hyperparathyroidism, 243Tetracyclines, 363, 364t, 1039, 1159alassemia, 247te Joint Commission, 918ermal spraying, of hydroxyapatite coating, 200termometers, 216read pitch, 58–59, 58freadformer, 26reads, implantbuttress, 26f, 51f, 59, 60fdepth of, 60–61, 61f, 867description of, 25–26, 25f–26f, 57–58geometry of, 867loading of, 166fpitch, 58–59, 58fprimary stability uses of, 57–58, 65reverse buttress, 26f, 59, 60fshape of, 59–60, 60fsquare, 26f, 51f, 59–60, 60fV-threads, 26, 59–60, 60f3D printers, 393–394, 396f–397frombin, 787–789, 788t, 789frombin time, 220rombocytopenia, 246rombotic stroke, 238rombotic thrombocytopenic purpura, 246yroid disorders, 240–241, 241tyroid-stimulating hormone, 224t–226tyroid storm, 241yroxine, 224t–226t, 241Tibial bone graft, 1099–1102, 1101f, 1101bTissue forceps, 611, 611fTissue-level implants, 24–25, 24fTissue pickups, 640, 640fTissue sterilization, 919Titaniumacid etching of, 198allergy to, 269, 794, 795fbiocompatibility of, 62corrosion of, 113, 125engineering properties of, 112, 112tfatigue strength of, 62–64hypersensitivity to, 794, 795fintegration with, 124–125mechanical properties of, 64t, 144tmodulus of elasticity of, 161–162properties of, 112–113strength of, 62–64, 804surfaces of, 123–124tissue interactions, 124Titanium-6 aluminum-4 vanadiumdescription of, 112–113, 112tmechanical properties of, 144tTitanium curettes, 1146–1147, 1146fTitanium implantsacid-etching of, 126fanchorage uses of, 98, 99fsurface etching of, 126fsurface of, 26Titanium mesh, 926, 927f, 960–961, 970fTitanium nitride, 129Titanium oxide ceramics, 114, 114tTitanium plasma-sprayed surface, 127–128, 127f, 199TMJ. See Temporomandibular jointTonguein edentulous ridges, 10scalloping of, 181, 182fTongue thrust, 184–186, 185fTooth extractionatraumatic. See Atraumatic tooth extractionbuccal plate in, 893, 894fendodontic therapy versus, 510Tooth extraction (Continued)with hopeless or guarded prognosis, 510–512indications for, 511tsocket healing after, 892–893, 894fTooth lossage-related, 4, 7alveolar bone remodeling and resorption caused by, 8bone loss after, 415, 416fin elderly, 7masticatory eciency aected by, 14molars, 5, 5fin posterior regions, 4, 5fstatistics regarding, 4three-unit xed partial denture for, 12–13, 13fTooth mobility, 517–518, 518fTooth replacementcement-retained crown for, 36, 545–546, 545fglobal strategies for, 3fmultiple teeth. See Multiple-teeth replacementscrew-retained restorations for, 544–545, 547single. See Single-tooth replacementstatistics regarding, 531–532, 531fTooth-supported guides, 397, 398fToothbrush abrasion, 181, 181fTori, lingual, 72f, 960, 983fTorquedenition of, 146–147insertion, 647, 861Torque controller, 31Torque wrench, 31Torsades de pointes, 363Torsional load, 146–147Total edentulismage-related prevalence of, 6, 6fanatomic consequences of, 7–12, 7bcomplications of, 9bconsequences of, 7bin elderly, 6–7esthetic consequences of, 11–12, 11f, 12bglobal prevalence of, 6hard tissue loss caused by, 7f–9f, 7bimplant demand aected by, 6–12prevalence of, 6, 6fpsychological eects of, 14socioeconomic factors, 6soft tissue consequences of, 9–10, 10bTrabecular boneadaptability of, 450–451calcium reserves in, 83–84density of, 165 1241IndexTrabecular bone (Continued)in dentate mandible, 451fmodeling and remodeling of, 80–81, 452occlusal force transfer across, 50variations of, 451f–452fTrabeculation, 15Tramadol, 370b, 371, 379t–380tTranexamic acid, 787, 788fTransfer technique, for impressions, 34, 38fTransient ischemic attacks, 238Transitional prosthesis, 526–528, 526f–527f, 527b, 719–720, 800, 857fTransmandibular implantsdenition of, 40endosseous implants versus, 40Transosteal implants, 22, 40, 43fTransplant, 917Trapezoidal aps, 606–607, 607f, 607bTreatment planningbiomechanical stress eects on, 166–167bone density in, 455–457, 461–464, 464bfor bruxism, 183–184, 184tCAD/CAM systems in, 405for clenching, 183–184, 184tcone beam computerized tomography for, 279, 328description of, 48hard tissue considerations, 935bimmediate implant placement, 834–839magnetic resonance imaging applications for, 278–279stress treatment theorem of, 167bfor tongue thrust and size, 186Trephine burs, 903–904Treponema denticola, 345Triangular aps, 606–607, 607f, 607bTriazolam, 376Tricalcium phosphate, 116, 926, 969Triiodothyronine, 224t–226t, 241Trimethoprim/sulfamethoxazole, 364tTubero-pterygo-maxillary implants. See Pterygoid implantsTuberosity implantsdescription of, 44–45illustration of, 45fTutoplast process, 919Two-piece implants, 23, 24fType IV hypersensitivity reaction, 270fUUlcerative colitis, 250Ulcers, stomach, 249–250Ultracet, 370bUltram, 370bUltrasonic devicesfor peri-implant mucositis, 1147–1148, 1148ffor peri-implantitis, 1156Uncinate process, 301–302, 312f, 999Universal guide, 399, 399fUnstable angina, 229–233Urinalysis, 217VV-thread(s), 26, 59–60, 60fV-thread implantsdescription of, 48force transmission of, 51fsurvival rate of, 50tVacuum-formed radiopaque template, 388Valvular heart disease, 236–237Vascular endothelial growth factors, 264Vascularized composite graft, 1102–1105, 1103b–1104b, 1104f–1106fVasoconstrictors, 234, 379t–380tVector quantities, 140–141Vermilion zone, 1130–1131, 1131fVertical bone augmentation, 742–744, 746fVertical dimension of the dentogingival junction, 24–25Vertical mattress suture, 630–631, 639fVertical release incisions, 604, 604f, 797, 798f, 951, 953–954Vestibular aps, 607, 607bVestibular incisions, 1060f, 1078fVirtual teeth, 386, 388f, 388bVital signsblood pressure, 214–215body temperature, 216pulse, 215–216respiration, 216–217Vitamin Dactive metabolite of, 84–85description of, 90disorders involving, 252–253osteoporosis and, 251–252von Mises stress, 58–59Voxels, 278, 280, 280f, 282WWallerian degeneration, 340, 817, 819fWarfarin sodium, 266Weight, 140, 217Wheezing, 249tWhite blood cell count, 218, 224t–226tWhitlockite, 116tWol ’s law, 7Women, bone loss in, 90–93World Health Organization analgesic ladder, 372, 373bWound classication, 360bWoven bone, 78, 165, 863, 915Wrenches, 31XXenograftsdenition of, 921, 969bdescription of, 28, 29t, 917, 969distribution of, 921–922processing of, 921–922source of, 922–923types of, 925–926, 929tXerostomia, 4, 243–244, 243b, 1195–1197YYankauer suction, 618fYonsei point, 1121–1123, 1123fYttria-stabilized tetragonal zirconia polycrystal, 202ZZinc phosphate cement, 155Zirconiaadvantages of, 17chemical composition of, 119–120description of, 119–121nal prosthesis, 876fmonolithic, 442–444, 443t, 548–549, 550forthopedic uses of, 119physical properties of, 120surface roughness of, 120Zirconia implantsadvantages of, 122bbone-to-implant contact of, 203description of, 119disadvantages of, 122bfabrication of, 119fracture of, 121ffracture resistance of, 120–121one-piece, 120, 202osseointegration of, 121success rates for, 121surface modication of, 202–203two-piece, 120types of, 120–121, 120fZirconia restorations, 548–549, 550fZirconium ceramic, 64Zirconium dioxide, 64Zirconium oxide ceramics, 114, 114tZygomatic implantsdescription of, 40–45illustration of, 43f This page intentionally left blank This page intentionally left blank This page intentionally left blank This page intentionally left blank This page intentionally left blank This page intentionally left blank This page intentionally left blank Evidence-based answers, continually updatedConf idenceis ClinicalKeyA subscription to ClinicalKey draws content fromcountless procedural videos, peer-reviewed journals,patient education materials, and books authored bythe most respected names in medicine.Your patients trust you. 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