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Restorative Dentistry

in vitro and in vivo evalnation of varionswford A. Bain, BD S, DDS, MScEd, MBA*

Objective: The surface rou ghness caused by four implant sealers Premier/Hawe-Neos,AdvancedImplantTechnologies. Hu-Friedy, and Nobel Biocare) on a titanium abutmentwasassessedinastandardized In vitrosituation, und operators were asked to evaluate the clinical usefulness of each instrument.Method and materials Twenty four evaluator.Kscored. canning electron micrographso fabutmentsurfacesscaled for 5 minutes w ith each instrument.Twelveoperators usedeach instrumenton at leastthreeimplantretail patients and scored each for ease of access; efficacy in depositremoval: overallconvenience;distancereachedsubgiiigivally;scalingtimeperabutment;and overall preference.Results:The Advanced ImplantTechnologies sealer created a.significantly roughersurfacethanall otherinstruments. The Premier/Hawe-Neos and Advanced ImplantTechnologies instrumentswere .significantlypre-ferred inmast categories by theoperators.There was no statisticailysignificant difference in.scaling timeperabutment.Conclusion The Premier/Hawe-Neos instrument combines operatoracceptancewithessdamage to the abut-ments, and. of the instrumentste 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 relevancePrevious studies have evaluated implant sealersonly through scanning electron micrographs. Thisstudy combines in vitro with in vivo assessment byexperienced clinicians and is more relevant to clini-cians considering new products for practical use.

he softness of commercially pure titanium has ledto the development of various devices for the clean-of implanl ahutments. The surface roughness caused

tiveness of some of these instruments

Dr Crawford A. Bain, Lecturer, Adult Dental Care

It is the purpose of this study to evaluate the surfaceroughness associated with four of these devices (Hu-Friedy, Advanced Implant Technologies, Nobel Biocare.and Premier/Hawe-Neos) and to evaluate operatoracceptance of these instruments with respect to ease ofu,w, access, convenience, and general effectiveness.Method and materialsThe method previously descrihed by Bain et al'' wasused to evaluate the surface roughness caused by thesedevices in an in viiro simulation of 5 years mainte-nance 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 10-mm Brnemark abutment for 15 minutes. This was con-,sidered to he equivalent to two professional cleaningsper year for 5 years. The scaling procedures were car-ried out hy a research assistant who was unaware ofsources of sponsorship for the study.

Scanning electron micrographs of the treatedsurfaces were examined: representative surfaces wereproduced on photomicrographs at x 1,000 magnifica-tion, and these were ranked by 24 evaluators, on asingle -blind bas is, using a 4-point scale from smo other (score 1) to much rough er (score 4),compared to a new, untreated control abutment (score

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i 1 Scanning eleotron microg raph of the control untreated)abutment suttaoe. i 2 Scanning eleotron miorogiaph of the abutment surfaceafter treatment with the Premier/Hawe-Neos sealer.

i 3 Scanning electron micrograph of the abutment surfaceafter treatment with the Hu-Friedy sealer. i 4 Scann rig electron -m crograpn of the abutm ent surfaceafter treatment with the Nobel Biocare soaler.

B;^ i|ii^pjgAiUMi*i3aa3-ai 5 Soanning electron micrograph of the abutment surfaceafter treatment with the Adva nced Implant Technologies soaler.

2). M eans , s tandard d eviat io ns , and a D uncan sMultiple Range Test value were calculated, with a =.05 (Figs to5 .To evaluate operator acceptance of the instruments,a group of 12 clinicians with considerable experiencein implant prosthesis maintenance were recruited fromacross Canada. They agreed to use each of the fourinstruments on at least three implant patients. Thisgroup of operators consisted of eight dentists and fourdental hygienists. They were not informed of thesource of the sponsorship of the study and wereallowed to keep the instruments in return for their par-ticipation. Each participant answered a seven-questionsurvey after using all instruments as prescribed.Dun can s Multiple Range Test was performed for eachquestion, with a = .05.

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T A B L E 1 Distribution of r tings nd me n r ting for each sealer by24 evaluators

SealerPremier/Hawe-NeosHu-FriedyNobei BiocareA dvanced Implant

Technologies

Lessrougfi (1]5260

ScoreSame asconlrol (2)

3110

Rougfier (3161 59

2

Muchrougher (d]068

Mean S D2 .4 5 0 B 33.04 + 0 802 7 9 1 . 1 83.91 0.28

2 E ffectiveness in removing deposits*ealer Mean effectivenessremier/Hawe-Neosdvanced Implanf Technologiesu-Fnedyobel B iocare

4.003.503.082.58

Ranked on a scale ot t to 5 (1 - not effeclive: 5 = very eflectiue}.ignificant difference befnveen Prem ier/Haw e-Ne os anO Nobel Biocarenly (Duncan s M ultiple Ra nge T est),

T A B L E 3 E ase of access withou t prosthesis retnoval*SealerPremier/Hawe-NeosHu-FriedyA dvanced Implant T ecfinologieshJobel Bioca re

3.753.173.081,91

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

A B L E 4 Overall convenience of ha ndl ingSealer Mean conveniencePremier/Hawe-NeosAdvanced Implant TechnologiesHu-FnedyNobel B iocare

3.913.082.662,25

Rankedon a scale o( 1 to 5 (1 = not convenient; 5 = very convenient).Significant difference between Premier/Hawe-Neos and all tt iree others,significant difference between A dvanced Implant Technologies and Hu-Friedy [whicli were not significantly different from each other) and t^obeB iocare (Duncan s Multiple Range T est).

TA B L E 5 Subging ival ettectivenessSealer Mean subgingivaleffectiveness (mm)Premier/Hawe NeosA dvanced Implant TechnologiesHu-FriedyNobel Biocare

3.582.502.170.42

g nit leant difference between Nobel Biosealers (Du ncans Mulliple Range T est). nd Ihe olher t l i iee

in Table 1. Use of the D un can sa = .05 revealed that the Ad-

vivo operator ev lu tionin removing dep osits (Table 2 . The

cantly more effective in removing deposits than theNohel Biocare instrument. No other significant differ-ences were identified.Ease of ccess (Tabie 3). The Nobel Biocare in.stru-ment was significantly le.ss effective in gaining acce,ssto the abutment surfaces than all other instruments. Nosignificant difference was identified among the otherthree instruments.Overall convenience (Table 4). The Premier/Hawe-Neos instrument was considered significantly more con-venient than all other instruments. The AdvancedImplant Technologies and Hu-Friedy sealers were sig-nificantly more convenient than the Nobel Biocareinstrument.Subgingivaleffectiveness (Table 5). The Nobel Bio-care instrument was considered to have significantlyless distance that was effective subgingivally. Operators

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T A B L E 6 lUlean scalin g l im e for one abutmen ton a cotnplete man dibular prosthes is

Sealer Mean scaling timeper abutment(s)Nobel BiocareAdvanced Implant TechnologiesHu-FriedyPremie r/Hawe-Neos

77,567.561.25S2.5No significant ditference betwTest). calers (Duncan s Multiple Range

T A B L E 7 Mean overall preference rankin gs ranked 1st to 4th)Sealer Overall preference rankingPremier/Hawe-NeosAdvanced Implant TechnologiesHu-FriedyNobel Biocare

1.422.083.163.33Significant dilferance between Ptemier/Hawe-Neos and AdvancedImplant Technologies (which were not significantly different from eachother] and the other two sealers Duncan s M ultiple Range Test).

felt tliat it was effective to less than 0.5 mm subgingi-vally. while all oilier itisttTjmeiits were considered effec-tive to between 2.2 and 2.6 mtn. verage sc lingtimeper butment(Table 6 ). Opera-tors identified no significant differences in the time ittook to clean one abutment.Overall preference(Table 7). Operators significantlypreferred tbe Pretnier/Hawe-Neos and Advanced Im-plant Technologies instruments over tbe Nobel Biocareand Hu-Friedy instruments.Additional comments that occurred more tban oncewere tbat operators liked the shaipening properties andreusability of some products, and disliked the pan-dis-posable, part-sterilizable feature of tbe Hu-Friedyinstrument. Tbe Nobel Biocare instrument was noted aseffective in older-designed higb and dry' prosihesesbut of little value with more estbetically designed pros-tbeses. Tbe Premier/Hawe-Neos sealer was reported toneed only occasional resbarpening.iscussiont is clear that different insttuments, marketed for simi-lar purposes, bave significantly different effects on thesurface of commercially pure titanium. Previous studieshave evaluated the roughness created by these and otberinstruments, generally in statidardized in vitro situa-tions, as was done in tbe first pail of tbis study. How-ever, tbere seems to be no previous study that has evalu-ated both the surface roughness created in a specifictime frame and tbe subjective operator appraisal of theinstruments.Clearly, if an in.strument is easier to use effectively,providing good access to all surfaces of an implantabutment, it is likely to take less clinical time to achievetbe same task. In addition to tbe obvious time savings lotbe clinician, tbere is the added bonus of less surfacewear lo tbe abutment when total scaling time is reduced.From the combined perspective oT minimal surfaceroughness and ease of effectiveness of use, the

Premier/Hawe-Neos linplant Curette was clearly supe-rior to tbe otber sealers tested. All sealers, except for tbeNobel Biocare instrument, were considered to be effec-tive to between 2.0 and 3.0 mm subgingivally. TheNobel Biocare in.strument was considered le.ss effectivein removing deposits, as well as poorest witb regard toaccess and overall convenience; bowever, it was,together with tbe Premier/Hawe-Neos instrument, leastdamaging to tbe abutment .surface.Tbe Premier/Hawe-Neos instrument was ranked firstor second overall by II of 12 ope rato rs, and theAdvanced Implant Technologies received eight first orsecond rankings. Tbe latter instrument did. however,create significantly more surface rougbness tban all theotbers and cannot be recommended. The scanning elec-tron micrographs of tbe abutments treated with theAdvanced Implant Technologies sbowed considerablymore plastic debris than the other instruments.

As implant dentistry reaches maturity, more andmore emphasis is placed on esthetically designed pros-theses combined with longevity of prosthesis survival.Because poor oral hygiene has been identified as a fac-tor that contributes to premature implant failure andbecause many implant patients, particularly tbe com-pletely edentulous, bave already demonstrated aninability to preserve natural teeth, tbe role of profes-sional tnaintenance is of paramoutit itnportance.Mucb research time bas been devoted to implant andprostbesis design and surgical atid prostbetic tecbnique.To date, little attention has been devoted to long-termimplant maintenance. Altbougb tbe in vitro part of thisstudy did evaluate the surface rougbness created by newinstruments, it did not assess the use of resharpenedinstruments. Because two of the instruments tested arerecommended for resbarpening. future researcb sbotildalso assess their continued effectiveness. Future studiesshould also investigate wbetber patients wbo lost teetbto periodontal diseases require different implant recallregimens from those wbo lost teetb to caries. Tbe effectsof cbemical plaque and calculus control around implants

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as well as the cost-beneftt ratioitb ultrasotiic as well as mechanical methods.Ultimately a customized implant maintenance pro-

ifically established rather tban empirical param eters.

rument but also the potential lotig-term damage tbat four implant sealers. Although the original Nobel

ge to the abutmen ts and of the instruments testedclearly tbe sealer of choice.

cknowledgmentsThe partial support of Nobel Biocare Canada and Premier DentalProducts Co/Haw e-Neos in this study i s aeknowledged as is theinvaluabie aisi.itance of Laura Ham ilton-Whitman DDS in the roleof research assistant.References1 Thom son-Neal DM Evans GH Meffert RM . Effects of variousprophylactic Ireatrnents on titanium sapphire and hydroxyapalitecoated implantsAn SEM study int J Periodont Resi Dent1989:9:301-3112. Eox SC Moriarty JD Kusy RP. The effects of scaling titaninmimplant surfaces with nieta] and plastic instruments; an in vitrostudy. J Periodontol iyy il;6 L4 85 ^9 .3. Rapley JW Swan RH Hallmon WW Millis MP The surfacecharacteristics produeed by various oral hygiene instruments andmaterials on titanium implant abutments. Int J Oral and Maxillo-fac Implants I99O;5:47-5I4. Homiak AW. Cook PA De Boer J Effects of hygiene on tita-n ium abutmenls; A scanning electron microscopy s tudy. JProsthet Dent 1992;67:364-369. Speelmiin ]A. Collaert B Klinge B. Evaluation of differentmethods of cleaning titanium abutments; a scanning electron.itudy Clin Oral Implant Res I992;3:120-127d Bain CA Green S. Bain GGB Price D. Effects of various clean-ing devices on dental implanls [abstract 193] J Dent Res 1993;72:2}7.

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