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2. Branemark P, Zarb G, Albrektsson T. Tissue integrated prostheses. Chicago: Quintessence Publ, 19%X11-19,117-128,156-162. 3. Brunski J. Biomaterials and biomechanics. Calif Dent J 198&X66-77. 4. Branemark P. Osseointegration and its experimental back ground. J PROSTHET DENT 1983;50:399-410. 5. Adell R, Lekholm U, Branemark P-I. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;6:381-414. 6. Linder L, Carlsson A, Marsal L, Bjursten LM, Branemark P-I. Clinical aspects of osseointegration in joint replacement: a histologic study of titanium implants. J Bone Joint Surg [Br] 1988;70:550-551. 7. English CE. Implants. Part I. Cylindrical implants. CDAJ 1988;16:17. 8. Caputo A, Standlee JP. Biomechanics in clinical dentistry. Chicago: Quintessence Publ, 1987:216-S.

Effect of hygiene instrumentation A scanning electron microscopy Alan W. Homiak, DDS,a Phillip A. Cook, James DeBoer, DDSc U.S. Army Dental Activity, Fort Bliss, Texas

DDS,b

9. Davis D, Rimrott R, Zarb G. prostheses: part 2. The effect the occlusal superstructure. 10. Perren SM, Cordey J, Rahn rary porosis of bone induced Rel Res 1988;232:139-51.

Studies on frameworks for osseointegrated of adding acrylic resin or porcelain to form Int J Oral Maxillofac Surg 1988;3:275-280. BA, Gamier E, Schneider E. Early tempoby internal fixation implants. Clin Orthop

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on titanium study

abutments:

and

Implant abutments can be exposed to a variety of oral prophylaxis procedures. In this in vitro study, titanium abutments were subjected to five oral prophylaxis treatment modalities; a metal scaler, a plastic scaler, a rubber cup, a rubber cup with tin oxide, and an air-powder abrasive. The abutment surfaces were then examined under both light and scanning electron microscopes. The metal scaler was seen to roughen the titanium surface. All other modalities tested appeared to smooth the titanium surface by removing surface debris and rounding olY the sharp machined grooves present on the untreated abutment surface. (J PROSTHET DENT 1992;67:364-9.)

T

he useof dental implants hasincreasedin recent years. With the advent of the osseointegratedtitanium implant, many patients formerly unable to function with conventional dental prosthesesare now finding success through these implant systems. As with any dental procedure, home oral hygiene practices and professional recall are necessaryif a successful outcome is to be expected. During these visits, an assessment of the implants and surrounding tissues is made,’ and, if needed, the implant abutments receive a prophylaxis. Treatment modifications have been suggestedwhen The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. aMajor, U.S. Army, DC; Senior prosthodontic resident. bColonel, U.S. Army, DC; Director, Prosthodontic Residency Training Program. CColonel, U.S. Army, DC; Assistant Director, Prosthodontic Residency Training Program. 10/l/29672

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titanium abutments are cleanedcomparedwith the procedures followed when natural teeth are cleaned.For example, the useof metal instruments is contraindicated due to the danger of scratching the titanium surface.im3 Likewise, ultrasonic scalersare not recommendedfor fear that the abutment could be scratched or even loosened by the ultrasonic vibrations.le3 Certain instruments and procedureshave been recommendedfor cleaning titanium surfaces.Instruments made of plastic have beendevelopedto replacemetal scalersand curets.le3The useof a rubber cup, either with1 or without2 abrasives,has also been recommended.Air-powder abrasive systemshave also been mentioned, both in product advertisementsand in the literature, asone of a number of possibletreatment modalities.2 Hand scaling,a rubber cup and abrasive,and air-powder abrasiveshave all beenstudied with respect to the effects that they have upon various tissues and restorative materials.4-13 The effect of various prophylactic modalities on certain titanium implants, especiallyin the mucosalseal area, has also been studied.l4 However, there is currently

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a lack of research that describes the effect of these modalities on titanium abutment surfaces normally exposed to the intraoral environment. Before the titanium abutment is subjected to different forms of instrumentation, it is important to know what changes might occur in the titanium so procedures that pit, scratch, or otherwise degrade the surface could be avoided. This study evaluated in vitro the surface of titanium implant abutments using light and scanning electron microscopes, and also assessed the effects of various forms of hygienic prophylaxis instrumentation on the abutments.

MATERIAL

AND

METHODS

Five new 10 mm titanium implant abutments (Nobelpharma, Nobel Industries, Gothenburg, Sweden) were used in this study. They were removed from the original packaging and were stored, individually wrapped in gauze, when not actually being subjected to the test conditions. The abutments were handled by the abutment screw or by the ends of the cylinder. In this manner the portion of the titanium surface subjected to test conditions was otherwise untouched. Each of the abutments was assigned a number, 1 to 5. On each of the cylinder’s surface two small lines were scribed as orientation marks. The lines were approximately 2 mm long and 2 mm apart. The titanium surface was instrumented in this space and the surface was also examined in this area. Each of the abutments was examined by an optical microscope (Olympus Microscopes, Tokyo, Japan) and scanning electron microscope (SEM) (DS-130 SEM, International Scientific Instruments, Inc., Pleasanton, Calif.) before any instrumentation to rule out any preexisting surface defects and to obtain a pretreatment surface image. The abutments were then instrumented as follows in an attempt to simulate one recall visit for routine prophylaxis. Abutment 1 was scraped three times with a stainless steel scaler (American Dental Mfg. Co., Missoula, Mont.) using moderate finger pressure. Abutment 2 was scraped three times with a plastic scaler (Nobelpharma, Nobel Industries) using moderate finger pressure. Abutment 3 was polished using a slow-speed handpiece and prophy angle with a screw-type rubber cup (Densco Prophy Cup, Teledyne Getz, Elkgrove Village, Ill.). Moderate pressure was used over the entire 10 mm length for 5 seconds. Abutment 4 was treated the same as abutment 3 except that a tin oxide slurry (Oxide of Tin Polishing Putty, S. S. White Co., Philadelphia, Pa.) was used as an abrasive agent. Abutment 5 was treated with an air-powder abrasive unit (Cavi-Jet, Dentsply International, York, Pa.) adjusted to 40 to 60 ml/min. A spray of air, water, and sodium bicarbonate was applied to the abutment for 5 seconds. In keeping with the manufacturer’s instructions, the instru-

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ment tip was kept 4 to 5 mm from the abutment surface at a 60-degree angle to it. The spray was centered on the target area and a constant circular motion was used.15 All abutments were rinsed with distilled water and were allowed to dry in air. The abutments were then examined visually with an optical microscope and with the SEM. A second phase of the study simulated 10 additional recall visits for oral prophylaxis. The effects of 10 prophylaxes seen on the titanium surface were examined. The five abutments were treated as before, with the following changes: (1) Abutments 1 and 2 received 30 instrument strokes and (2) abutments 3, 4, and 5 were treated for 50 seconds. Again, all abutments were examined visually and with both an optical microscope and the SEM. Differences, if any, in the quality of the titanium surfaces were noted. Comparisons were made among the untreated, treated (one “recall visit”), and treated (10 additional “recall visits”) groups, and among the five types of instrument modalities used.

RESULTS Upon visual examination of the abutments without magnification, all specimens appeared smooth before treatment. The only sample whose unmagnified appearance changed with treatment was abutment 1 (treated with a metal scaler). After both 1 and 10 treatments, some slight scratches could be observed. Under the optical microscope (15 to 80 power magnification), it was evident that the surface of the untreated abutments was not smooth. Definite machined grooves could be seen circumferentially. For the treated samples, abutment 1 again displayed the scratches caused by the metal scaler, both after 1 and 10 simulated treatments. The only other abutment that showed a noticeable change was abutment 4 (rubber cup with tin oxide) after 10 treatments. This abutment gave the impression of being “shinier” than the others. When the abutments were examined under the SEM (199 to 201 power magnification), the machined grooves of the untreated specimens could be clearly seen (Fig. 1). Photomicrographs of the abutment surfaces after the various treatments showed differences depending upon the treatment given. The use of a stainless steel scaler clearly resulted in scraping of the abutment surface, both after 1 treatment (Fig. 2) and after 10 treatments (Fig. 3). The plastic scaler did not appear to significantly affect the titanium surface, especially after one treatment (Fig. 4). After 10 treatments (Fig. 5), however, some smoothing of the titanium surface appears to have occurred. Polishing with a plain rubber cup also seems to have had a limited effect. The machined grooves were still clearly present, both after one treatment (Fig. 6) and after 10 treatments (Fig. 7). However, there did appear to have been some rounding of the sharp and ragged edges of some of the grooves. Adding tin oxide to the rubber cup treatment did seem

365

HOMIAK,

Fig. 1. Examples of untreated nal magnification X200.)

abutment

Fig. 2. Surface after one treatment ment. (Original magnification X200.)

with

surface. (Origi-

metal

instru-

to change the titanium surface after the treatments. One treatment (Fig. 8) seems to have rounded the machined grooves to approximately the same extent as 10 treatments of the rubber cup without tin oxide. The photomicrograph showing the abutment surface after 10 simulated treatments (Fig. 9) with tin oxide clearly indicates that there has been a decrease in the depth and sharpness of the surface grooves. The air-powder abrasive also created changes in the titanium surface. One treatment (Fig. 10) appears to have rounded many of the sharp edges, and after 10 treatments (Fig. 11) further smoothing of the machined grooves was apparent.

DISCUSSION The quality of home care to implant prostheses is important, since it is obvious that plaque and calculus can

Fig. 3. Surface after 10 additional instrument. (Original magnification

Fig. 4. Surface after one treatment (Original magnification X200.)

COOK.

AND

treatments X200.)

with

DEBOER

with metal

plastic

scaler.

accumulate on the titanium abutment surfaces. Therefore any treatment provided that attempts to improve oral hygiene should clearly not change the abutment surface so as to make it more plaque-retentive. On the contrary, it would seem advantageous to attempt to alter the abutment surface so as to make it less susceptible to plaque and calculus accumulation. This study examined the texture of a titanium implant abutment surface and then noted the changes that might occur as a result of various oral prophylactic procedures. Procedures that lead to increased surface roughness might be expected to produce deleterious effects with respect to plaque and calculus retention, while smoothing the surface might be expected to create the opposite effect. It was clear that abutment cylinders, as supplied by the manufacturer, were not highly polished when viewed under magnification. Machined grooves were clearly visible, both

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Fig. 5. Surface after 10 additional treatments with plastic scaler (sample rotated 90 degrees). (Original magnification X200.)

Fig. 7. Surface after 10 additional treatments ber cup. (Original magnification x200.)

Fig. 6. Surface after one treatment (Original magnification X200.)

Fig. 8. Surface after one treatment with rubber cup with tin oxide. (Original magnification x200.)

with

rubber

cup.

under the light and electron microscopes. While there might be certain advantages to having a smoother surface, possible risks and benefits would need to be carefully weighed. For example, the system examined here is clinically noted for its high quality control and the precision to which its implant system components conform to one another. Unless a system of polishing could be used that would maintain these precise tolerance levels, further treatment of the titanium surface by the manufacturer could be counterproductive. It is also possible that the surface roughness may be beneficial in some manner, such as to help create a better soft tissue-implant interface. If this were the case, it is doubtful that any benefit gained from a smoother surface would outweigh the problems created by it. Regardless of home care, recall visits are needed for professional evaluation and treatment. The results of this

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study suggest that prophylactic procedures differ markedly in their effect on the titanium abutment surface. As mentioned previously, it has been recommended in the literature that metal instruments not be used to clean the titanium surfaces. It has clearly been shown here that the metal scaler produces a gouging effect on the titanium surface, and that definite damage can be done by using these instruments on the implant abutment. Of the four other treatments studied here, two seem to have had only a limited effect on the abutment surface, whereas two appear to have caused a more significant change. Both the plastic scaler and the plain rubber cup seem to have rounded off the extremely sharp edges of the grooves and to have removed some of the debris created by the machining process. While the results of these two procedures were not extremely dramatic, they do appear to produce some smoothing of the titanium surface. 367

HOMIAK,

Fig. 9. Surface after 10 additional treatments with rubber cup with tin oxide. (Original magnification x201.)

COOK,

AND

DEBOER

Fig. 11. Surface after 10 additional treatments with airpowder abrasive. (Original magnification x200.)

vitro. How surface changesmight actually affect plaque and calculusretention, for example,needsto be studied. It should alsobe mentioned that use of the air-powder abrasive systembrings with it the possibility of air embolism/ emphysemaeffectsif it isnot properly used.15Sincethe soft tissue attachment apparatus is different between natural teeth and implant material, further study isrequired in this area as well. CLINICAL

IMPLICATIONS

In an effort to keep plaque and calculusaccumulation on titanium abutments to a minimum, oral prophylaxis proceduresshouldmake implant surfacessmoother,or at least should not add roughness.The findings discussedsuggest which forms of treatment could be used to improve or at least not harm the titanium surface. 10. Surface after one treatment with air-powder abrasive. (Original magnification x199.)

SUMMARY

The surfacescreated by the rubber cup with tin oxide and by the air-powder abrasivesystem were more dramatically altered. In both instances, especially after the lotreatment simulations, the machined grooveswere much lessprominent and machining debris seemsto have been removed. In both instances, significant smoothing of the titanium surface seemsto have occurred. From the standpoint of surface texture alone, it would appear that these last four methodsof prophylaxis would be acceptable. Before recommending these modalities, however, further study is needed.For example,it would be helpful to know how much titanium is removed asthe surface modification is taking place. Obviously, if a significant massof titanium were removed to achieve the smoothing effect, certain problems could be created. In addition, it must be rememberedthat this study was done strictly in

Five treatment modalities usedin oral prophylaxis procedureswereperformed in vitro on titanium implant abutment surfaces.The surfaceswere then studied visually and with both a light microscopeand a SEM. The study indicated that: 1. The abutment surfacestudied had an inherent roughness,apparently due to the machining process. 2. The stainlesssteelinstrument had a gougingeffect on the titanium surface, creating a much rougher texture. 3. The useof plastic scalers,a rubber cup both with and without a tin oxide polishing agent, and an air-powder abrasivesystemall seemedto producea somewhatsmoother abutment surface. The rubber cup with tin oxide and the air-powder abrasive system seemedto produce the most significant polishing effect. 4. Further study is required to correlate these findings with in vivo effects, and to confirm the safety of usingthese proceduresintraorally.

Fig.

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We thank Dr. John McClure and Mr. Melvin DeSilva of the Department of Metallurgical Engineering, University of Texas at El Paso, for their assistance and technical expertise.

REFERENCES 1. Brough Muzzin KM, Johnson R, Carr P, Daffron P. The dental hygienist’s role in the maintenance of osseointegrated dental implants. J Dent Hyg 1988;62:448-53. 2. Stefani LA. The care and maintenance of the dental implant patient. J Dent Hyg 1988;62:447-66. 3. Balshi TJ. Hygiene maintenance procedures for patients treated with the tissue integrated prosthesis (osseointegration). Quintessence Int 1986;17:95-102. 4. Mishkin DJ, Engler WO, Javed T, Darby TD, Cobb RL, Coffman MA. A clinical comparison of the effect on the gingiva of the Prophy-Jet and the rubber cup and paste techniques. J Periodontol 1986,57:151-4. 5. Berkstein S, Reiff RL, McKinney JF, Killoy WJ. Supragingival root surface removal during maintenance procedures utilizing an air-powder abrasive system or hand scaling: an in vitro study. J Periodontol 1987;58:327-30. 6. Pameijer CH, Stallard RE, Hiep N. Surface characteristics of teeth following periodontal instrumentation: a scanning electron microscopic study. J Periodontol 1972;43:628-33. 7. Wilkinson RF, Maybury JE. Scanning electron microscopy of the root surface following instrumentation. J Periodontol 1973;44:559-63.

Availability

8. Galloway SE, Pashley DH. Rate of removal of root structure by the use of the Prophy-Jet device. J Periodontol 1987;58:464-9. 9. Kontturi-Narhi V, Markkanen S, Markkanen H. The gingival effects of dental airpolishing as evaluated by scanning electron microscopy. J Periodontol 1989;60:19-22. 10. Atkinson DR, Cobb CM, Killoy WJ. The effect of an air-powder abrasive system on in vitro root surfaces. J Periodontol 1984;55:13-8. 11. Cooley RL, Lubow RM, Patrissi GA. The effect of an air-powder ahrasive instrument on composite resin. J Am Dent Assoc 1986;112:362-4. 12. Lubow RM, Cooley RL. Effect of air-powder abrasive instrument on restorative materials. J PROSTHET DENT 1986;55:462-5. 13. Cooley RL, Lubow RM, Brown FH. Effect of air-powder abrasive instrument on porcelain. J PROSTHET DENT 1988;60:440-3. 14. Thomson-Neal D, Evans GH, Meffert RM. Effects of various prophylactic treatments on titanium, sapphire, and hydroxyapatite-coated implants: an SEM study. Int J Periodont Restor Dent 1989;9:301-11. 15. Dentsply/Cavitron. Instruction manual. Cavi-Jet 30 dental prophylaxis unit. York Pa: Dentsply International Inc, 1988.

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Effect of hygiene instrumentation on titanium abutments: a scanning electron microscopy study.

Implant abutments can be exposed to a variety of oral prophylaxis procedures. In this in vitro study, titanium abutments were subjected to five oral p...
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