Restorative Dentistry

An in vitro and in vivo evalnation of varions implant-cleaning instrnments

Crawford A. Bain, BDS, DDS, MScEd, MBA*
Objective: The surface roughness caused by four implant sealers (Premier/Hawe-Neos, Advanced Implant Technologies. Hu-Friedy, and Nobel Biocare) on a titanium abutment was assessed in a standardized In vitro situation, und operators were asked to evaluate the clinical usefulness of each instrument. Method and materials: Twenty-four evaluator.K scored .^canning electron micrographs of abutment surfaces scaled for 5 minutes with each instrument. Twelve operators used each instrument on at least three implant retail patients and scored each for ease of access; efficacy in deposit removal: overall convenience; distance reached subgiiigivally; scaling time per abutment; and overall preference. Results: The Advanced Implant Technologies sealer created a .significantly rougher surface than all other instruments. The Premier/Hawe-Neos and Advanced Implant Technologies instruments were .significantly preferred in mast categories by the operators. There was no statisticaily significant difference in .scaling time per abutment. Conclusion: The Premier/Hawe-Neos instrument combines operator acceptance with ess damage to the abutments, and. of the instruments te.sted. is the sealer of choice. (Quintessence int 1998; 29:42 3^27) Key words: implant sealer, in vitro study, iti vivo study, scanning electron mic-roscopy, tjtaniutu abutment

Clinical relevance Previous studies have evaluated implant sealers only through scanning electron micrographs. This study combines in vitro with in vivo assessment by experienced clinicians and is more relevant to clinicians considering new products for practical use.

It is the purpose of this study to evaluate the surface roughness associated with four of these devices (HuFriedy, Advanced Implant Technologies, Nobel Biocare. and Premier/Hawe-Neos) and to evaluate operator acceptance of these instruments with respect to ease of u,w, access, convenience, and general effectiveness. Method and materials The method previously descrihed by Bain et al'' was used to evaluate the surface roughness caused by these devices in an in viiro simulation of 5 years" maintenance on the surface of new Brnemark abutment,s (Nobel Biocare) made of commercially pure titanium. Each instrument was used to scale the surface of a 10mm Brnemark abutment for 15 minutes. This was con,sidered to he equivalent to two professional cleanings per year for 5 years. The scaling procedures were carried out hy a research assistant who was unaware of sources of sponsorship for the study. Scanning electron micrographs of the treated surfaces were examined: representative surfaces were produced on photomicrographs at x 1,000 magnification, and these were ranked by 24 evaluators, on a single-blind basis, using a 4-point scale from "smoother" (score 1) to "much rougher" (score 4), compared to a new, untreated control abutment (score
423

he softness of commercially pure titanium has led to the development of various devices for the cleaning of implanl ahutments. The surface roughness caused hy traditional stainless steel instruments is well documented,'-^ so a variety of nonmetal cleaning instruments has been developed. Although previous studies have evaluated the effectiveness of some of these instruments on the titanium surface, there is littie information on operator acceptance of these instruments.

*Lecturer, Adult Dentl Care Unit, University of Glasgow, Glasgow Denial Hospital and Sthoiil, Glasgow, Scotland, Reprint requests: Dr Crawford A. Bain, Lecturer, Adult Dental Care Unit, university of Glasgow, Glasgow Dental Hospital and School, 378 Sauchiehall Street, Glasgow G2 3JZ, Scotland. E-mail: GZMA02@ UKAC,GLASGOW,VME

Quintessence International

Fig 1 Scanning eleotron micrograph of the control (untreated) abutment suttaoe.

Fig 2 Scanning eleotron miorogiaph of the abutment surface after treatment with the Premier/Hawe-Neos sealer.

Fig 3 Scanning electron micrograph of the abutment surface after treatment with the Hu-Friedy sealer.

Fig 4 Scann rig electron -mcrograpn of the abutment surface after treatment with the Nobel Biocare soaler.

B;^ ^i|ii^pjgAiUMi*i3aa3-a
Fig 5 Soanning electron micrograph of the abutment surface after treatment with the Advanced Implant Technologies soaler.

2). Means, standard deviations, and a Duncan's Multiple Range Test value were calculated, with a = .05 (Figs 1 to5. To evaluate operator acceptance of the instruments, a group of 12 clinicians with considerable experience in implant prosthesis maintenance were recruited from across Canada. They agreed to use each of the four instruments on at least three implant patients. This group of operators consisted of eight dentists and four dental hygienists. They were not informed of the source of the sponsorship of the study and were allowed to keep the instruments in return for their participation. Each participant answered a seven-question survey after using all instruments as prescribed. Duncan's Multiple Range Test was performed for each question, with a = .05.
Volume 29, Number ?,

424

TABLE 1 Distribution of ratings and mean rating for each sealer by 24 evaluators
Less rougfi (1] 5 2 6 0 Score Same as conlrol (2) Rougfier (3 3 1 1 0 16 15 9 2 Much rougher (d] 0 6 8 22 Mean SD 2.45 0B3 3.04 + 0 80 2791.18 3.91 0.28

Sealer Premier/Hawe-Neos Hu-Friedy Nobei Biocare Advanced Implant Technologies

TABLE 2 Effectiveness in removing deposits*

Sealer Premier/Hawe-Neos Advanced Implanf Technologies Hu-Fnedy Nobel Biocare Mean effectiveness 4.00 3.50 3.08 2.58

TABLE 3 Ease of access without prosthesis retnoval*

Sealer Premier/Hawe-Neos Hu-Friedy Advanced Implant Tecfinologies hJobel Biocare 3.75 3.17 3.08 1,91

Ranked on a scale ot t to 5 (1 - not effeclive: 5 = very eflectiue}. Significant difference befnveen Premier/Hawe-Neos anO Nobel Biocare only (Duncan's Multiple Range Test),

Ranked an a scale of 1 to 5 [1 = not effective; 5 = very effective]. Significant difference between Nobel Biocare and otiier three sealer; (Duncan's Multiple frange Test).

TABLE 4 Overall convenience of handling'

Sealer Premier/Hawe-Neos Advanced Implant Technologies Hu-Fnedy Nobel Biocare Mean convenience 3.91 3.08 2.66 2,25

TABLE 5 Subgingival ettectiveness

Sealer Premie r/Hawe-Neos Advanced Implant Technologies Hu-Friedy Nobel Biocare
SI g nit leant difference between Nobel Bio sealers (Duncans Mulliple Range Test).

Mean subgingival effectiveness (mm) 3.58 2.50 2.17 0.42

nd Ihe olher tliiee

'Ranked on a scale o( 1 to 5 (1 = not convenient; 5 = very convenient). Significant difference between Premier/Hawe-Neos and all ttiree others, significant difference between Advanced Implant Technologies and HuFriedy [whicli were not significantly different from each other) and t^obe Biocare (Duncan's Multiple Range Test).

Results
In vitro study

The distribution of ratings and the mean rating for each sealer are shown in Table 1. Use of the Duncan's Multiple Range Test with a = .05 revealed that the Advaneed Implant Technologies sealer created significantly greater surface roughne.ss than the other three sealers and that the Premier/Hawe-Neos sealer created significantly less suiiace roughness than the Hu-Friedy instrument. n vivo operator evaluation Effectiveness in removing deposits (Table 2). The Premier/Hawe-Neos instrument was ranked signifiQuintessence international

cantly more effective in removing deposits than the Nohel Biocare instrument. No other significant differences were identified. Ease of access (Tabie 3). The Nobel Biocare in.strument was significantly le.ss effective in gaining acce,ss to the abutment surfaces than all other instruments. No significant difference was identified among the other three instruments. Overall convenience (Table 4). The Premier/HaweNeos instrument was considered significantly more convenient than all other instruments. The Advanced Implant Technologies and Hu-Friedy sealers were significantly more convenient than the Nobel Biocare instrument. Subgingival effectiveness (Table 5). The Nobel Biocare instrument was considered to have significantly less distance that was effective subgingivally. Operators
425

TABLE 6 lUlean scaling lime for one abutment on a cotnplete mandibular prosthesis Sealer Nobel Biocare Advanced Implant Technologies Hu-Friedy Premie r/Hawe-Neos
No significant ditference betw Test).

TABLE 7 Mean overall preference rankings (ranked 1st to 4th) Sealer Premier/Hawe-Neos Advanced Implant Technologies Hu-Friedy Nobel Biocare Overall preference ranking

Mean scaling time per abutment(s)

77,5 67.5 61.25 S2.5

1.42 2.08 3.16 3.33

calers (Duncan's Multiple Range

Significant dilferance between Ptemier/Hawe-Neos and Advanced Implant Technologies (which were not significantly different from each other] and the other two sealers Duncan's Multiple Range Test).

felt tliat it was effective to less than 0.5 mm subgingivally. while all oilier itisttTjmeiits were considered effective to between 2.2 and 2.6 mtn. Average scaling time per abutment (Table 6). Operators identified no significant differences in the time it took to clean one abutment. Overall preference (Table 7). Operators significantly preferred tbe Pretnier/Hawe-Neos and Advanced Implant Technologies instruments over tbe Nobel Biocare and Hu-Friedy instruments. Additional comments that occurred more tban once were tbat operators liked the shaipening properties and reusability of some products, and disliked the pan-disposable, part-sterilizable feature of tbe Hu-Friedy instrument. Tbe Nobel Biocare instrument was noted as effective in older-designed "higb and dry'" prosiheses but of little value with more estbetically designed prostbeses. Tbe Premier/Hawe-Neos sealer was reported to need only occasional resbarpening. Discussion It is clear that different insttuments, marketed for similar purposes, bave significantly different effects on the surface of commercially pure titanium. Previous studies have evaluated the roughness created by these and otber instruments, generally in statidardized in vitro situations, as was done in tbe first pail of tbis study. However, tbere seems to be no previous study that has evaluated both the surface roughness created in a specific time frame and tbe subjective operator appraisal of the instruments. Clearly, if an in.strument is easier to use effectively, providing good access to all surfaces of an implant abutment, it is likely to take less clinical time to achieve tbe same task. In addition to tbe obvious time savings lo tbe clinician, tbere is the added bonus of less surface wear lo tbe abutment when total scaling time is reduced. From the combined perspective oT minimal surface roughness and ease of effectiveness of use, the
426

Premier/Hawe-Neos linplant Curette was clearly superior to tbe otber sealers tested. All sealers, except for tbe Nobel Biocare instrument, were considered to be effective to between 2.0 and 3.0 mm subgingivally. The Nobel Biocare in.strument was considered le.ss effective in removing deposits, as well as poorest witb regard to access and overall convenience; bowever, it was, together with tbe Premier/Hawe-Neos instrument, least damaging to tbe abutment .surface. Tbe Premier/Hawe-Neos instrument was ranked first or second overall by II of 12 operators, and the Advanced Implant Technologies received eight first or second rankings. Tbe latter instrument did. however, create significantly more surface rougbness tban all the otbers and cannot be recommended. The scanning electron micrographs of tbe abutments treated with the Advanced Implant Technologies sbowed considerably more plastic debris than the other instruments. As implant dentistry reaches maturity, more and more emphasis is placed on esthetically designed prostheses combined with longevity of prosthesis survival. Because poor oral hygiene has been identified as a factor that contributes to premature implant failure and because many implant patients, particularly tbe completely edentulous, bave already demonstrated an inability to preserve natural teeth, tbe role of professional tnaintenance is of paramoutit itnportance. Mucb research time bas been devoted to implant and prostbesis design and surgical atid prostbetic tecbnique. To date, little attention has been devoted to long-term implant maintenance. Altbougb tbe in vitro part of this study did evaluate the surface rougbness created by new instruments, it did not assess the use of resharpened instruments. Because two of the instruments tested are recommended for resbarpening. future researcb sbotild also assess their continued effectiveness. Future studies should also investigate wbetber patients wbo lost teetb to periodontal diseases require different implant recall regimens from those wbo lost teetb to caries. Tbe effects of cbemical plaque and calculus control around implants
Volume 29, Number 7,

should be investigated, as well as the cost-beneftt ratio of periodic prosthesis removal for extraoral professional cleaning witb ultrasotiic as well as mechanical methods. Ultimately, a customized implant maintenance program should be establi.shed for each patient based on scietitifically established, rather tban empirical, parameters. Conclusion In selecting an instrument to be used for the professiotial maintenance of implant-supported prostheses, the operator tnust assess not only the ease of use of the instrument, but also the potential lotig-term damage tbat any instrument may cause to the titanium abutment. This study evaluated the effectiveness and ease of use of four implant sealers. Although the original Nobel Biocare instruments were clearly effective in supragitigival scaling of tbe earlier high and dry prosthesis design, they cannot be considered the insirument of choice where esthetic and/or phonetic considerations have created more limited access for maintenance. The Advanced Implant Technologies was ranked highly by the operators but caused significantly rougber abutment surfaces. In this situation, the Premier/Hawe-Neos instrument combines operator acceptance with less damage to the abutments, and, of the instruments tested, is clearly tbe sealer of choice.

Acknowledgments
The partial support of Nobel Biocare Canada and Premier Dental Products Co/Hawe-Neos in this study i,s aeknowledged, as is the invaluabie aisi.itance of Laura Hamilton-Whitman, DDS, in the role of research assistant.

References
1 , Thomson-Neal DM, Evans GH, Meffert RM. Effects of various prophylactic Ireatrnents on titanium, sapphire and hydroxyapalite coated implantsAn SEM study, int J Periodont Resi Dent 1989:9:301-311, 2. Eox SC, Moriarty JD, Kusy RP. The effects of scaling titaninm implant surfaces with nieta] and plastic instruments; an in vitro study. J Periodontol iyyil;6L485^9. 3. Rapley JW, Swan RH, Hallmon WW, Millis MP, The surface characteristics produeed by various oral hygiene instruments and materials on titanium implant abutments. Int J Oral and Maxillofac Implants I99O;5:47-5I, 4. Homiak AW. Cook PA, De Boer J, Effects of hygiene on titanium abutmenls; A scanning electron microscopy study. J Prosthet Dent 1992;67:364-369. 5. Speelmiin ]A. Collaert B, Klinge B. Evaluation of different methods of cleaning titanium abutments; a scanning electron .itudy Clin Oral Implant Res I992;3:120-127, d. Bain CA, Green S. Bain GGB, Price D. Effects of various cleaning devices on dental implanls [abstract 193], J Dent Res 1993; 72:2}7.

Quintessence Internalional

427