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Plaque Accumulation Beneath Maxillary

All-on-4™ Implant-Supported Prostheses


Samer Abi Nader, DMD, MSc, FRCD (C);*†† Hazem Eimar, BDS, MSc;†,††
Moath Momani, BDS, MClinDent;‡ Ke Shang;§ Nach G. Daniel, DMD, BSc, MSc, FRCD(C);¶
Faleh Tamimi, BDS, MSc, PhD**

ABSTRACT
Background: Maxillary prostheses supported by four implants, following the All-on-4™ principles, have become an
accepted effective treatment for totally edentulous patients. Maintaining the hygiene of such fixed implant-supported
prostheses is challenging.
Purpose: The purpose of this clinical study was to evaluate the distribution of plaque on the fitting surface of All-on-4 fixed
prostheses in order to find new strategies for maintaining their hygiene.
Materials and Methods: Twenty All-on-4 maxillary fixed prostheses collected from 20 patients, 6 months after delivery, were
stained with methylene blue to disclose plaque accumulation at the fitting surfaces of the prostheses. Digital photographs
of the fitting surfaces of the prostheses were recorded and processed. The distribution of accumulated plaque was evaluated
statistically.
Results: The average percentage of area covered with plaque was 28 1 8% of the total area of the fitting surface of the
prostheses. The fitting surfaces of the prostheses had three times more plaque on the palatal area (52.5 1 7.33%) than on
the buccal area (17.3 1 7.33%, p < .05). The interimplant proximal areas of the fitting surface covered with plaque were high
when the distance between implants was short (r = −0.326, p = .014).
Conclusion: These findings suggest that the hygiene of the All-on-4 prostheses could be improved by maximizing the
distances between the inserted implants in the jaw, minimizing the prostheses’ palatal extension and guiding patients to
optimize their oral hygiene practices targeting the palatal area of their prostheses.
KEY WORDS: clinical study, fixed implant prosthesis, peri-implantitis, plaque accumulation, prosthesis hygiene

INTRODUCTION
The All-On-4™ fixed implant-supported prosthesis
(Nobel Biocare AB, Göteborg, Sweden) has been shown
*Associate professor, Division of Restorative Dentistry, Faculty of to be an effective clinical treatment for totally eden-
Dentistry, McGill University, Montreal, Quebec, Canada; †graduate tulous patients.1–6 This method of treatment aims to
student, Division of Restorative Dentistry, Faculty of Dentistry,
McGill University, Montreal, Quebec, Canada; ‡prosthodontist at restore adequate function and aesthetics with a fixed
Royal Medical Services, Jordanian Armed Forces, Amman, Jordan; prosthesis supported by four implants only.4,5 Clinical
§
undergraduate DMD student, Faculty of Dentistry, McGill Univer- studies report that this prosthesis has a good survival
sity, Montreal, Quebec, Canada; ¶oral and maxillofacial surgeon, East
Coast Oral Surgery Center (private practice), Moncton, New Bruns- and patient satisfaction rate and can be considered as an
wick, Canada; **assistant professor, Division of Restorative Dentistry, alternative treatment for fixed prostheses over dentures
Faculty of Dentistry, McGill University, Montreal, Quebec, Canada or conventional dentures.6,7 The success of any fixed
Corresponding Author: Faleh Tamimi, Faculty of Dentistry, McGill implant-supported prosthesis, such as All-on-4 pros-
University, 3640 University Street, Montreal, Quebec H3A 0C7, theses, relies mainly on osseointegration of the dental
Canada; e-mail: faleh.tamimimarino@mcgill.ca
implants.8 Osseointegration can be compromised by
††
Both authors contributed equally to this work.
the presence of peri-implantitis,9–11 an inflammatory
© 2014 Wiley Periodicals, Inc. process around the dental implant that leads to bone
DOI 10.1111/cid.12199 loss and can cause loss of implants in the long term.12

1
2 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2014

Fixed implant-supported prostheses, such as All- polyvinylsiloxane impression materials (Express, 3M


on-4, are difficult to clean, and thus high levels of plaque ESPE, St. Paul, MN, USA), and a model was poured.
tend to accumulate on the surfaces of these pros- Implant-supported prostheses were then fabricated on
theses.13,14 Consequently, the possibility of peri-implant the model following the profile prosthesis concept
infection significantly increases with fixed implant- design, in which the prosthesis fitting surfaces are kept
supported prostheses, and this in return could limit in intimate contact with the alveolar ridge.17 Fitting of
the survival rate of the provided dental treatment.15,16 each prosthesis on the alveolar ridge was evaluated
Accordingly, we have conducted a clinical study to assess by visual inspection. The biting (occlusal) surface of
plaque accumulation and topographical distribution on the prosthesis was fabricated following the opposing
the fitting surfaces of All-on-4 prostheses. The results of mandibular teeth (n = 12) or prosthesis (n = 8). All
this study can be adapted to develop new strategies for prostheses were fabricated and seated by the same
better hygiene of fixed implant-supported prostheses, prosthodontist 3 to 4 hours after completion of the
including All-on-4 prostheses. surgery.
Upon completion of the surgical and prosthodontic
MATERIALS AND METHODS treatments, verbal and written oral hygiene instructions
The study was carried out in accordance with Decla- were provided to all patients. Patients were notified to
ration of Helsinki guidelines and was approved by avoid brushing and warm-water rinses for the first
the Research Ethics Committee of McGill University postoperative week. A cold or room-temperature soft
Health Center. This study included dental records of diet was recommended for the first 24 hours follow-
20 patients (9 males and 11 females), 50–77 years old ing surgery, followed by a semisolid diet for the
(mean = 61.8 1 7.6), treated by maxillary fixed implant- next 3 months. Patients were also instructed to use
supported prostheses following the All-on-4 concept. All chlorhexidine 0.12% mouthwash (Peridex, 3 M ESPE)
patients included in our study were medically fit and free three times a day for the first 10 days after the treatment.
of any systemic or local diseases that might contraindi- After day 10, patients were instructed to floss their
cate the placement of an implant. No patients were prostheses and alveolar ridge once a day using a dental
excluded or lost to follow-up over the course of the floss threader (GUM Eez-Thru Floss, Sunstar Americas,
study. Chicago, IL, USA) and an unwaxed dental floss (Johnson
The surgical procedure was done as described pre- & Johnson, New Brunswick, NJ, USA). Also, patients
viously by Malo et al.4,5 Briefly, a mucoperiosteal flap were instructed to brush both the prosthesis and the
was raised at the ridge crest, with a relieving incision on alveolar ridge with a soft toothbrush (Gum Delicate
the buccal aspect in the molar area. An antrostomy Post-Surgical Toothbrush, Oral B–Gillette, Redwood,
defect was created using a round bur for identification of CA, USA) using a low-abrasive toothpaste (Dentu-
the exact position of the sinus antrum. Implant place- Cream, Block Drug Co., Jersey City, NJ, USA) and
ment sites were assessed using the All-on-4 surgical mouth rinse (Crest Pro-Health Multi-Protection,
guide. All patients received four dental implants (Nobel Procter & Gamble Co., Cincinnati, OH, USA) three
Biocare AB) in their maxilla; two distally tilted implants times a day. Patients were recalled six weeks after surgery
in the posterior region were positioned just anterior to and instructed to use an oral irrigator (WaterPik®,
the maxillary sinus antrum, followed by two straight Teledyne Hanau, Buffalo, NY, USA) once a day to clean
anterior implants in the anterior maxilla. The length of beneath the prosthesis. These irrigators are water pumps
the immediately loaded implants ranged from 11.5 that gently flush out food, debris, and bacterial toxins
to 15 mm. The diameter of the inserted implants was from the surfaces of teeth, prostheses, and implants in a
4 mm. All surgeries were done by the same surgeon. highly efficient way.18–20
Immediately following surgery, straight 17-degree- Following 6 months of function, the cleanliness of
angled multiunit abutments and internal. 30-degree- the All-on-4 prostheses was examined as part of the
angled multiunit abutments (Nobel Biocare AB) were routine follow-up. Briefly, the prostheses were removed
used to achieve relative parallelism of the implants and washed with tap water for 60 seconds before being
so that a rigid prosthesis would be seated in a stained with a plaque-disclosing agent (methylene blue;
passive manner. An impression was taken with Henry Schine Company, Melville, NY, USA). Digital
Fixed Implant Prostheses and Plaque Accumulation 3

photographs of the fitting surfaces of the prostheses


before and after staining were recorded and shown to
patients (as an educational tool for the patients) to iden-
tify plaque accumulation areas at the fitting surfaces that
needed special attention during the cleaning process.
The photos were processed with ImageJ 1.45s software
(National Institutes of Health, Bethesda, MD, USA). The
photographs were converted to monochromatic binary
images (Figure 1). Specific standardized thresholds were
established in order to distinguish the pixels that con-
tained plaque (blue) from those that did not (pink).
Average percentage of plaque covering the fitting
surface of the prostheses was calculated. Topographical
plaque distribution on the fitting surface of the prosthe-
ses was examined by measuring plaque covering the
following specific areas of the prosthesis fitting surface:
buccal, palatal, anterior, posterior, and interimplant Figure 2 A, Monochrome image of the fitting surface of the
proximal areas. The buccal and palatal areas of the pros- prosthesis, delineating buccal and palatal areas. B, Negative
image of A, showing plaque in black. C, Box-plot graph
thesis fitting surface were identified by drawing a curved comparing percentage area of plaque covering the buccal semi-
line that crossed the center of all implants and bisected arch of the prosthesis to that covering the palatal semi-arch.
the fitting surface (Figure 2, A and B). Anterior and pos-
erior interimplant proximal areas; the anterior inter-
terior areas of the prosthesis fitting surface were identi-
implant proximal area was the area between the most
fied as areas mesial and distal, respectively, to the centers
anterior implants (blue area, Figure 4, A and B), and the
of the most posterior implants (Figure 3, A and B). The
posterior interimplant proximal areas were the areas
interimplant proximal area was defined as the area of
the fitting surface within two curved tangent lines that
intersected all implants at the most buccal and palatal
points, respectively. The interimplant proximal area of
the fitting surface was divided into anterior and post-

Figure 3 A, Monochrome image of the fitting surface of the


Figure 1 A, Original dental digital image of the fitting surface prosthesis indicating the anterior areas (distal to the posterior
of an All-on-4 fixed implant-supported prosthesis. B, Cropped implants) and posterior areas (mesial to the posterior
image of A. C, Colorized image of B to facilitate thresholding. implants). B, Negative image of A, showing plaque in black. C,
D, Establishing the threshold for plaque recognition. E, Binary Box-plot graph comparing percentage area of plaque covering
image of D, showing plaque in black. the anterior and posterior areas of the prosthesis fitting surface.
4 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2014

RESULTS
The average percentage of area covered with plaque
was 28.3 1 8.4% of the total area of the prosthesis fitting
surface. Plaque accumulation at the fitting surface of
the prostheses was not correlated with participants’ age
(r = 0.211, p = .488) or gender (p = 0.597, power = 0.075).
Plaque accumulation was significantly different on
the buccal and palatal areas of the prosthesis fitting
surface (p < 0.001, Figure 2C). The fitting surface area
covered with plaque was three times higher on the
palatal half of the prostheses (41.3 1 17.7%) than on the
buccal half (22.3 1 8.3%, power = 0.994, Figure 2C). No
significant differences were observed between the per-
centage of plaque on the posterior area of the prosthesis
fitting surface (33.4 1 17.1%) and that on the rest of
the prosthesis (28.4 1 11.8%, power = 0.167; Figure 3C).
The results also showed no significant differences
between the accumulated plaque on the anterior
(33.8 1 12.2%) and posterior (31.2 1 9.9%) inter-
Figure 4 A, Monochrome image of the fitting surface of the
prosthesis indicating anterior interimplant proximal area and implant proximal areas of the prosthesis fitting surface
posterior interimplant proximal areas. B, Negative image of A, (power = 0.212, Figure 4C).
showing plaque in black. C, Box-plot graph comparing
percentage of plaque area covering anterior interimplant The percentages of plaque accumulated inter-
proximal area and posterior interimplant proximal areas of the proximally to the implants were significantly associated
prosthesis fitting surface. with the distance between implants (Figure 5). This
association indicated that the shorter the distance
between implants, the more plaque accumulation
between anterior and posterior implants (red areas, (r = 0.3345, p < .05).
Figure 4, A and B).
The average percentage of plaque covering the DISCUSSION
examined areas was calculated. Differences between
In this study we provide the first clinical evidence for
examined areas were conducted by paired Student’s
plaque distribution on the fitting surface of All-on-4
two-tailed t-test: the buccal area of the prosthesis fitting
fixed implant-supported prostheses. Based on our
surface versus the palatal area of the prosthesis fitting
surface (Figure 2, A and B); the anterior area of the
prosthesis fitting surface versus posterior areas of the
prosthesis fitting surface (Figure 3, A and B); and, finally,
the anterior interimplant proximal area of the prosth-
esis fitting surface versus the posterior interimplant
proximal area of the prosthesis fitting surface (Figure 4,
A and B).
The relationship between the percentages of plaque
coverage and the interimplant distance (shortest
distance between adjacent implants) was tested for
Pearson correlation. The correlation coefficient (r) and
the significance of the correlation (P) were calculated.
The statistical significance was set at p < .05. All the
Figure 5 Linear regression analysis that illustrates the relation
statistical analyses were done with Origin 7.0 software between the interimplant distance and the accumulated plaque
(Origin Lab Co; Northampton, MA, USA). on the fitting surface of All-on-4 prostheses.
Fixed Implant Prostheses and Plaque Accumulation 5

results, we discuss new strategies to improve the hygiene of the prosthesis fitting surface was influenced by the
level of these prostheses. In this study, plaque accumu- distance between the inserted implants. These results are
lation on the fitting surfaces of All-on-4 prostheses was aligned with previous clinical studies, in which it has
identified using a disclosing solution. This method has been shown that the wider the distance between inserted
previously been used to evaluate and monitor hygiene implants, the less plaque accumulates on the surfaces of
level of removable complete prostheses21–23; however, these implants.28–30
this study is the first one to use this method in fixed These findings are of great relevance in dentistry, as
implant-supported prostheses. they have surgical, prosthetic, and hygienic implications.
We found that around one-third of the fitting Surgically, the results of this study highlight the im-
surface area of the prostheses was covered by plaque. portance of wide distances between the implants that
This high percentage of plaque accumulation on the support fixed implant-supported prostheses in order to
fitting surfaces of the prostheses might badly affect facilitate oral hygiene. Prosthetically, our findings on
the condition of the nearby soft tissues, promoting plaque emphasize the importance of minimizing the
their infection.24–26 Soft tissue infection might reach palatal extension of fixed implant-supported prostheses
tissues surrounding the implants, causing peri-implant in order to facilitate the cleaning process. Hygienically,
mucositis, which could subsequently develop into our results can be adapted as an educational tool to
peri-implantitis.27 Accordingly, keeping prostheses at guide patients in order to optimize their oral hygiene
the optimum hygiene level is an essential preventative practices targeting the palatal area of their prostheses.
procedure in order to minimize the probability of
peri-implant tissue infection. CONCLUSION
Our study revealed that more plaque accumulates
One-third of the fitting surface in All-on-4 implant-
on the palatal areas of the prosthesis fitting surface than
supported prostheses was covered with plaque. Plaque
on the buccal areas (Figure 2C). This difference might be
accumulates more on the palatal areas of the fitting
related to the anatomy of the maxilla, in which the cur-
surface of the prostheses than on the buccal areas.
vatures of the upper jaw and the palate produce hidden
Plaque accumulation was influenced by the distance
areas that are difficult to clean and consequently favor
between implants. These findings suggest that the
plaque accumulation.22,23 Another problem that might
hygiene of the All-on-4 prostheses could be improved by
exacerbate the observed poor hygiene at the palatal area
maximizing the distances between implants, minimizing
of the fitting surface is the substantial difficulty in reach-
prostheses’ palatal extension, and guiding patients to
ing the palatal semi-arch when cleaning the maxillary
optimize their oral hygiene practices targeting the
prosthesis.23 Another factor that might increase plaque
palatal area of the prostheses.
accumulation in palatal areas of the fitting surface is the
use of oral irrigators. Oral irrigators are usually used
ACKNOWLEDGMENTS
from the buccal side during the cleaning process, and
this might force the plaque to accumulate on the palatal The authors would like to acknowledge the McGill
area of the prosthesis fitting surface. However, future Faculty of Dentistry’s Summer Research Scholarship
research will have to be performed in order to confirm (KS), Le Réseau de recherche en santé buccodentaire et
these hypotheses. osseuse (FT, HE), the Jordanian Armed Forces (MM),
Comparing results for plaque accumulation Fondation de l’Ordre des dentistes du Québec (FT),
between the other examined areas of the fitting surface the Faculty of Dentistry of McGill University and the
did not reveal significant differences within the 20 Natural Sciences and Engineering Research Council
samples analyzed (Figure 3 and 4). Although this might of Canada (FT), and Ministère du Développement
indicate that wearers of All-on-4 prostheses have good Économique, Innovation et Exportation (FT) for their
cleaning access to these areas of the fitting surface, financial support.
further studies with a greater pool of fixed implant-
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