A Review on Recommendations for the Maintenance of Implant Supported Restorations

Implant placement necessitates an interdisciplinary approach in which a team of dental implant specialists, including an oral surgeon, prosthodontist, periodontist, and oral radiologist, collaborate on the design, execution, and maintenance of the implants to provide the best possible result. Review Article Noorsaeed et al.; JPRI, 33(46A): 593-600, 2021; Article no.JPRI.74638 594 According to the data, the vast majority of the participating dentists provide implant-supported restorations to their patients on a regular basis. Surprisingly, the percentage of dentists who plan implant placement and employ backward planning methods was significantly lower. This finding implies that dentists do not always follow the current scientific consensus that the placement of an implant should be based on prosthetic principles.


INTRODUCTION
Implant placement necessitates an interdisciplinary approach in which a team of dental implant specialists, including an oral surgeon, prosthodontist, periodontist, and oral radiologist, collaborate on the design, execution, and maintenance of the implants to provide the best possible result. Routine maintenance, recall evaluations, and radiographs are required once the implants have been placed in the adventurous region, and this necessitates the team of dental implant specialists to be well versed in the implant maintenance procedures as well, as an implant failure would result in a debate, which would give the profession no credit. [1] With time, the emphasis for long-term implant success has shifted from surgical phase of therapy to osseointegration and, more recently, to the long-term preservation of the peri-implant hard and soft tissues' health. As the number of patients choosing dental implants as a treatment option to replace lost teeth continues to rise, the dental team must confront the challenges of maintaining these sometimescomplicated restorations [1][2][3][4].
Implant-supported single crowns and implantsupported FDPs have good long-term survival rates, but they have significant mechanical and biologic problems. Implant-supported single crowns had a ten-year survival rate of around 95 percent, whereas implant-supported FDPs had a 93 percent survival rate. The authors propose that patients be placed in a well-structured maintenance programme because 33.6 percent of the patients suffered a mechanical and/or biologic problem in the first 5 years. Over a 5year period, mechanical problems of implantsupported FDPs have been recorded, including veneering material fractures (13.5%), screw loosening (5.3%), loss of cemented FDP retention (4.7%), and screw fracture (1.3%) [5][6][7][8][9][10][11].
Dental implants feature a very high rate of success, which means that survival rates for dental implants range more than 90% after 10 years of clinical service.Nevertheless, technical and biological complications are regularly observed in implant-supported restorations. Technical complications include fractures of the implant or abutment or problems with the associated prosthetic superstructure such as chipping of the veneering, loosening or fracture of abutment screws, or wear and loss of retention in attachment systems [12][13][14][15].
With the growing popularity of implants, the most prevalent biological consequences, such as periimplant mucositis and peri-implantitis, have become a serious worry. Many studies are currently being conducted with the goal of determining the long-term effectiveness of various implant-supported rehabilitation regimens. Peri-implant mucositis is a reversible inflammation of the soft tissue around the implant, whereas peri-implantitis encompasses both soft-tissue inflammation and bone loss around the functioning implant [16].

EVALUATION
Clinical and radiographic parameters used to assess oral implants during maintenance care should have good sensitivity and specificity, be simple to quantify, and produce repeatable results [1].

-Oral radiology
Radiographs are an essential part of a dentist's or dental specialist's diagnostic toolkit. They help with the detection and characterisation of a variety of oral diseases and disorders, as well as treatment planning and follow-up. However, radiographic requirements should be adapted to the specific demands of each patient and assessed against the dangers of radiation exposure. As a result, the decision to get a radiograph is largely based on the clinical judgement of the dental practitioner, who should evaluate the patient's needs, medical/dental history, clinical findings, and overall health when determining the type and number of radiographs required [17][18][19][20]. -

Soft-Tissue Assessment
Checking for visible indicators of gingival inflammation, such as redness, swelling, changes in contour and consistency, aberrant gingival form, or the presence of fistulas, is part of the soft-tissue assessment. [21].
-Bleeding on Probing (BOP) Lang et al. (1994) found that healthy periimplant locations had no bleeding (0%), whereas peri-implant mucositis and periimplantitis sites had significantly higher BOP (67 percent and 91 percent, respectively). Luterbacher and colleagues later demonstrated that BOP alone provides better diagnostic accuracy at implant sites than at tooth sites [1,22,23].

-Plaque Index assessment
This index was designed to evaluate oral health and oral hygiene in groups of individuals, particularly in hospitals or at other institutions. MPS consists of the sum of a four-point mucosal score (MS) and a fourpoint plaque score (PS) [24]. -

Peri-Implant Probing Depth
In the longitudinal monitoring of peri-implant soft tissues, probing is a significant and reliable diagnostic measure. Probing around implant restorations has been proven to be safe, and it does not appear to impair the integrity of oral implants. [21,25,26,27,28,29,30,31,32].
The connective tissue zone has just two fiber groups, none of which is implanted into the implant, and the junctional epithelial attachment zone has decreased attachment strength to the implant. As a result, the probe extends beyond the peri-implant sulcus and into the bone, necessitating the use of a lower probing force (0.2-0.3 N) around implants. Successful implants typically have a probing depth of 3 mm, however pockets of 5 mm or higher provide a safe haven for germs and can cause peri-implantitis. [1,33,34] .

-Peri-Implant Sulcus Fluid Analysis (PISF)
Several biochemical mediators found in the PISF have been discovered as potential host markers for peri-implant disease activity and development, and their study provides a noninvasive way to assess the role of the host response in peri-implant disease [1].
-Suppuration is a solid indicator of disease activity and shows the necessity for antiinfective medication [1].

-Occlusal Evaluation
The implant's and prosthesis' occlusal condition must be checked on a regular basis. Occlusal disharmonies, such as early contacts or interferences, should be recognised and addressed to avoid occlusal overload, which can lead to a variety of issues, including abutment screw loosening, implant failure, and prosthesis failure [1].

-Keratinized Tissue
The literature is divided on whether the presence or absence of keratinized tissue affects the long-term health of implants. Lack of keratinized tissue has been linked to modest bone loss, higher plaque formation, increased soft-tissue recession, increased probing bleeding, and increased gingival inflammation in some studies. Another study, on the other hand, found no link between keratinized tissue breadth and implant survival [21,[35][36][37][38][39]. -

Evaluation of Implant Stability/Mobility
Unlike a tooth, for which mobility is not a primary factor for longevity, mobility is a primary determining factor for implant health. Rigid fixation is usually the first clinical criterion evaluated for a dental implant . The techniques to assess rigid fixation are similar to those used for natural tooth mobility [1].

DIAGNOSIS
The patient's implants are classified as healthy if there are no clinical signs of inflammation. -

Implant Mucositis
Apart from the original 0.2-2 mm cratering that happens quickly after abutment connection surrounding some osseointegrated implants, mucositis is described as a localised inflammatory lesion within the soft tissue with no progressive bone loss. Redness and bleeding on gentle probing (pressure 0.15 N) can be used to diagnose mucositis.
-Peri-implantitis A localised inflammatory lesion accompanied by bone loss around an osseointegrated implant is known as peri-implantitis. The mucosal lesion in peri-implantitis is frequently linked with suppuration or a deepening of clinical probing depths, and it is invariably followed by bleeding on probing and loss of supporting marginal bone beyond the original bone loss [21].

MAINTENANCE
The long-term success of an implant is largely dependent on the long-term health of the periimplant hard and soft tissues. A typical maintenance visit for patients with dental implants should include a review of the patient's medical and dental history, a clinical and radiographic examination of the implants and peri-implant tissues, evaluating implant stability, removing any implant-retained plaque and calculus, and setting maintenance intervals. This maintenance visit should last one hour and be done every three months [1].
In dentistry, maintenance programmes have traditionally concentrated on younger patient groups and on diagnosing and controlling chronic conditions including caries and periodontal disease. The American Academy of Dental Science recommended for the standard 6-month patient recall interval utilised by dentists around the world as early as 1879. In its inaugural oral health patient pamphlet, the American Dental Association (ADA) also campaigned for the 6month recall. In the 1930s, a prominent dentifrice commercial (Ipana; Bristol-Meyers Company, New York, NY) advocated the 6-month interval for dental appointments, which eventually gained widespread acceptance as a standard in the dental insurance market [5,40,41,42,43].

Home Maintenance
In the one-stage system, the patient must begin the implant care regimen immediately after surgical installation, in the two-stage system, following implant site exposure, and in the two-stage system, upon premature exposure of the implant healing screw. Chemical plaque control (e.g., chlorhexidine) should be utilised during healing times when mechanical plaque control is not possible [1].
This classification summarize all maintenance techniques that can be used by patient as well as medical care practitioner

Home Care Steps Includes:
-

Adjustment of the Occlusion
Traumatic occlusion, in addition to peri-implant inflammation, is another possible cause of bone collapse around the implant. As a result, an occlusal examination should be performed during the implant maintenance consultation. Even in the absence of inflammation in the peri-implant tissue, studies in monkeys revealed that bone resorption around implants with 180 m of excess superstructure height could occur [21].

DISCUSSION
Patients with implant-borne removable and fixed restorations require lifelong professional recall regimes to offer biological and mechanical maintenance that is individualised for each patient, according to a substantial body of data. The use of particular oral topical agents and oral hygiene aids can also improve professional and at-home care of implant-borne restorations, according to current research. Because of variances in prosthetic materials and designs, there is evidence of disparities in mechanical and biological maintenance requirements. Due to gaps in available evidence, clinical practise guidelines for recall and maintenance of patients with implant-borne dental restorations are being developed [5].
There is a scarcity of research on how to execute effective and optimal oral care around dental implants. At the moment, home care suggestions are based on what is currently known about natural tooth cleaning. It becomes clear that academic institutions and industry must launch and support high-quality randomised controlled clinical trials on this topic as soon as possible [44].
According to the data, the vast majority of the participating dentists provide implant-supported restorations to their patients on a regular basis. Surprisingly, the percentage of dentists who plan implant placement and employ backward planning methods was significantly lower [45,46]. This finding implies that dentists do not always follow the current scientific consensus that the placement of an implant should be based on prosthetic principles. In this regard, it has lately been stated that dental technicians play an important part in decision-making, implying that dentists' prosthetic expertise should be constantly expanded [47].
Mechanical plaque removal is the foundation of successful periimplant therapy; patient-and professionally administered plaque control has been shown to reduce periimplant inflammation, though complete resolution of inflammation is not always apparent [46,48]. Moreover the use of adjunctive chemical agents in maintaining periimplant health is still unknown; and d) regular periimplant mammography is recommended [47].

CONCLUSION
Professional implant maintenance is essential for the long-term success of dental implants. This also includes an evaluation of the patient's general and dental health. In today's context of high patient expectations about the lifespan of implant restorations, the clinician's utilisation of prescribed maintenance routine and materials is critical. After successful implant restorations, all doctors must educate their patients about implant home care and insist on frequent maintenance checkups.

CONSENT
It is not applicable.

ETHICAL APPROVAL
It is not applicable.