JICDRO is a UGC approved journal (Journal no. 63927)

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INVITED REVIEW
Year : 2015  |  Volume : 7  |  Issue : 3  |  Page : 160-179

Management of peri-implant infections


Department of Periodontics, College of Dental Sciences, Davangere, Karnataka, India

Date of Web Publication31-Dec-2015

Correspondence Address:
K L Vandana
Department of Periodontics, College of Dental Sciences, Davangere, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-0754.172931

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   Abstract 

The ever-increasing popularity of dental implants in recent years has been associated with the reported incidence of short-term and long-term complications such as peri-implant mucositis and peri-implantitis. Therapies proposed for treating peri-implantitis are based on the evidence available for the treatment of periodontitis, and are aimed at reducing the bacterial load within peri-implant pockets and decontaminating implant surfaces, and, in some cases, attempting afterward to bring about bone regeneration. The treatment of peri-implant infections comprises conservative (nonsurgical) and surgical approaches. This paper reviews various treatment strategies used for the treatment of peri-implant diseases. There are many approaches suggested by various authors for the treatment of peri-implant diseases, but there is no “ideal peri-implant therapy” that has been described in the literature. There is no consensus regarding the treatment protocol as the studies conducted so far have had varying study designs, small sample sizes, and short follow-up periods.

Keywords: Peri-implant disease, periodontal disease, peri-implantitis, peri-implantitis therapy


How to cite this article:
Vandana K L, Dalvi P, Nagpal D. Management of peri-implant infections. J Int Clin Dent Res Organ 2015;7, Suppl S1:160-79

How to cite this URL:
Vandana K L, Dalvi P, Nagpal D. Management of peri-implant infections. J Int Clin Dent Res Organ [serial online] 2015 [cited 2020 May 25];7, Suppl S1:160-79. Available from: http://www.jicdro.org/text.asp?2015/7/3/160/172931


   Introduction Top


An effective and reliable treatment for missing teeth with dental implants has shown predictable success rates. The ever-increasing popularity of dental implants in recent years has been associated with the reported incidence of short-term and long-term complications such as peri-implant mucositis and peri-implantitis.

Longitudinal prospective studies of peri-implant disease are needed to identify the real risk factors for peri-implant disease, but few have been published to date. There is no conclusive information relating to the issue of implant surface characteristics as a determining factor for peri-implantitis, and in the few studies that do exist, information is sometimes contradictory. It is not, therefore, surprising that the therapies proposed for treating peri-implantitis are based on the evidence available for the treatment of periodontitis, and are aimed at reducing the bacterial load within peri-implant pockets and decontaminating implant surfaces, and, in some cases, attempting afterward to bring about bone regeneration.[1]

Similar to gingivitis and periodontitis affecting the periodontium of natural teeth, inflammation and destruction of soft and hard tissues surrounding dental implants are termed as peri-implant mucositis and peri-implantitis [2] [Figure 1].[3] Thereby, transitions are often fluent and not clinically clearly separable. Peri-implant diseases present in two forms — peri-implant mucositis and peri-implantitis. Peri-implant mucositis has been described as a disease in which the presence of inflammation is confined to the soft tissues surrounding a dental implant, with no signs of loss of supporting bone following initial bone remodeling during healing.[4]Peri-implantitis has been characterized by an inflammatory process around an implant, which includes both soft tissue inflammation and progressive loss of supporting bone beyond biological bone remodeling.[4] [Figure 2].[5]The differences between peri-implantitis and peri-implant mucositis are presented in [Table A]. [Figure 3][6] [Figure 4][7] [Figure 5][6] [Figure 6][8] [Figure 7]a and [Figure 7]b[6]
Figure 1: tooth vs implant[3]

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Figure 2: periodontitis vs peri-implantitis[5]

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Figure 3: inflamed enlarged mucosa and bleeding on probing present[6]

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Figure 4: suppuration present[7]

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Figure 5: recession[6]

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Figure 6: increased pocket depth over a period of time from the baseline recording[8]

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Figure 7: (a) peri-implantitis, exposure of implant threads[6] (b) peri-implant mucositis[6]

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Table A: Differences between Peri-implant mucositis (PIM) and Peri-implantitis (PI) [Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7]

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Bacterial infections play the most important role in the failure of dental implants. Another factor that intervenes in peri-implantitis etiopathogeny is excessive mechanical stress.

Biomechanical failure resulting in loss of osseointegration without clinically detectable pocket formation or signs of inflammation mimicking peri-implantitis

Excessive overload may result in complete disintegration and implant failure. Occlusal overload has been reported to be of minor significance, whereas factors such as poor oral hygiene and smoking have been associated with bone resorption around implants. Overload does not cause peri-implantitis. Overload along with plaque-induced inflammation induced bone resorption in an animal model.[9]

The treatment of peri-implant infections comprises conservative (nonsurgical) and surgical approaches. The classification of the treatment of peri-implant diseases is presented in [Table B] [Figure 8].[10]
Figure 8: osseous defect morphology[10]

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Table B: Classification of treatment strategies for peri-implant diseases

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Primary goals of the treatment:

  • Elimination of peri-implant mucosal inflammation.
  • Cessation of peri-implant disease progression.
  • Maintenance of functionality of implant with healthy peri-implant tissues.
  • Regeneration of lost peri-implant tissues.
  • Restoring peri-implant esthetics such as treatment of mucosal recession, inadequate width, and thickness of peri-implant mucosa.



   Treatment Strategies Top


  • Most of the published strategies for peri-implantitis therapy are mainly based on the treatments used for teeth with periodontitis.
  • The extant treatment strategies for peri-implant diseases are based on the Cumulative Interceptive Supportive Therapy (CIST)[11],[12] protocol. The major drawback of this proposal is dependence on the implant pocket depth, which is found to be variable even in healthy status.
  • There is a lack of any standardized classification to differentiate the various degrees of peri-implantitis, which has led to confusion in interpreting the results of studies evaluating the prevalence, treatment, and outcomes of therapy.
  • Froum et al. 2012[13] proposed a classification for peri-implantitis based on the severity of the disease. A combination of bleeding on probing and/or suppuration, probing depth, and extent of radiographic bone loss around the implant were used to classify the severity of peri-implantitis into early, moderate, and advanced categories. Again this classification considered pocket depth as a clinical parameter, hence a modified treatment strategy based on the clinical, radiologic, and diagnostic criteria and the prognosis has been introduced for the first time [Table C]. The use of greater than or less than 2 mm of peri-implant probing depth is eliminated as there is no specific normal peri-implant probing depth/sulcus depth, which depends on the level of implant placement.
Table C: Classification of peri-implant disease based on the clinical, radiolographical, and diagnostic criteria and prognosis

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Various peri-implant disease treatments are as follows:


   Emergency Therapy Top


  • Treatment of peri-implant abscess with/without surgical drainage under systemic antimicrobial coverage.



   Nonsurgical Therapy Top


Patient education, motivation and oral hygiene instructions

  • Treatment plan should be understood by the patient before the active treatment is initiated.
  • Home care plaque control measures, e.g., interdental aids and oral irrigation devices should be instituted.
  • The patient must be taught how to maintain oral hygiene.
  • The patient should understand from the beginning of treatment that the responsibility of maintaining the implant is primarily his or hers.


[TAG:2]Management of Risk Factors for Peri-Implant Diseases [14] [Table D][14][/TAG:2]
Table D: Risk indicators and their management[14]

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  • Local risk factorsmay influence the bacterial composition and bacterial load at a specific site, whereas the general risk factor may influence the patient's susceptibility to infection. There are limited scientific data confirming these factors as true risk indicators of peri-implant disease.


[TAG:2]Peri-Implant Scaling [15][/TAG:2]

[Figure 9]a[16] [Figure 9]b[17] [Figure 10][18] [Figure 11][19] [Figure 12][20] [Figure 13][21] [Figure 14].[22]
Figure 9: (a) carbon fiber curettes[16] (b) carbon fiber curettes[17]

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Figure 10: plasteel (Hu-Friedy)[18]

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Figure 11: SofTip implant insert (dentsply): ultrasonic scaling of implant surfaces[19]

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Figure 12: gold-tipped curettes for peri-implant scaling[20]

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Figure 13: airborne-particle abrasion device Air-N-Go satelec, acteon[21]

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Figure 14: bionikTM titanium curettes[22]

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Objective

The object is removal of plaque and plaque-retentive features without altering the implant surface so that the biocompatibility of the implant surface is not affected.

Advantage

The advantage is removal of plaque and calculus to achieve long-term success.

Disadvantage

Scaling procedure may alter the oxide layer on the implant surface, which can result in decreased corrosion resistance.

Instruments

Plastic scaler tips (Implacare H6/H7 © 2015 Hu-Friedy Mfg. Co., LLC, USA), titanium alloy curettes (Maxil®, Chicago, USA), plastic modified ultrasonic point (SofTip implant insert by Dentsply, USA), and air polishing systems (Air-N-Go® Satelec, Acteon, USA) were used.

Studies have attempted to evaluate the different materials regarding cleaning efficacy, the potential of alteration of the implant surface, and the prosthetic component. All these factors can affect implant biocompatibility, biofilm formation, and therefore the implant longevity [Table 1].[23],[24],[25]
Table 1: Clinical efficacy for implant surface debridement

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Conclusions from studies [15] [Table 1]

  • The metallic instruments are more adequate in cases where there would be the need of either removing the implant coverage or making the surface smoother.
  • When the treatment goal is to maintain implant surface integrity, the treatment of choice involves nonmetallic instruments, rubber cups, and air abrasion.
  • Metallic instruments cause important superficial alterations and should not, therefore, be indicated for the routine scaling of implants.
  • The results of air polishing systems depend on the medium used. The results are significantly better in the following order of use: Hydroxylapatite/tricalcium phosphate > hydroxylapatite > glycine > titanium dioxide > water and air (control group) > phosphoric acid.
  • On the other hand, nonmetallic instruments such as plastic curettes, rubber cups, air abrasion, and some ultrasonic systems seem to be better choices for removing the biofilm and calculus of the supra- and submucosal peri-implant area.
  • It is noteworthy that further studies evaluating the clinical efficacy of these methods are necessary to define the best practices to be used in the treatment of patients with dental implants.


[TAG:2]Local and Systemic Antibiotics in Nonsurgical Treatment of Peri-Implantitis:[26] [Figure 15][27][/TAG:2]

The composition of the submucosal biofilm in peri-implantitis lesions resembles the subgingival biofilm in chronic periodontitis with high proportions of motile rods and spirochetes, Porphyromonas gingivalis, Tannerella forsythia, Fusobacterium spp, Treponema spp, and Prevotella intermedia.
Figure 15: peri-implant local drug delivery[27]

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The combination of peri-implant scaling with a systemic antimicrobial therapy can improve the clinical parameters of peri-implantitis lesions.

There are numerous in vitro andin vivo studies on the application of medicaments as part of the treatment of peri-implant mucositis and peri-implantitis. However, due to differences in the designs of all studies, comparison of these studies is difficult.

The following therapies can be distinguished:

  • Antiseptic rinses, e.g., 3% hydrogen peroxide (H2O2) and chlorhexidine (CHX) 0.2%.
  • Application of systemic and locally delivered antibiotics, e.g., tetracycline fibers and minocycline microspheres.


Lang et al.[28] suggested the following antibiotic regimes:

  • Systemic ornidazole 500 mg bis die (BD) for 10 days, or
  • Metronidazole 250 mg ter die sumendus (TDS) for 10 days, or
  • Omni die (OD) combination of metronidazole 500 mg and amoxicillin 375 mg for 10 days.


Conclusions from studies[26][Table 2][29],[30] [Table 3][31],[32]
Table 2: Treatment of PI using local drug delivery

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Table 3: Treatment of PI using systemic antimicrobials

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  • The scientific information on the clinical efficacy of antibiotics in controlling peri-implantitis is by far not sufficient to provide an evidence-based approach to create clinical guidelines for treating these peri-implant infections. The treatment protocols originate from the field of periodontology. Nonsurgical treatment involves mechanical debridement of the implant surface and surrounding tissues with curettes, pocket irrigation with disinfectants such as CHX (0.2%) or H2O2(3-10%), and the use of local or systemically administered antibiotics.
  • For most systems, the surface and geometry of the implant do not allow proper removal of biofilm deposits using periodontal instruments. This is probably the reason that nonsurgical treatment of peri-implantitis showing bleeding and/or pus on probing with titanium curettes or with an ultrasonic device provides very limited clinical improvement. In such cases, antimicrobial therapy serves as a good adjunct.


Summary on nonsurgical therapy

In nonsurgical treatment of peri-implantitis, mechanical therapy on its own would appear to be insufficient; used in combination with CHX, it improves the clinical and microbiological parameters slightly, and the addition of local or systemic administration of antibiotics reduces bleeding on probing and probing depth.

Nonsurgical treatment should be limited to the treatment of peri-implant mucositis, as it will not resolve inflammatory lesions in cases of bone loss.

For peri-implantitis treatment, surgical access is recommended in order to achieve complete removal of granulation tissue and to obtain access for the decontamination of the implant surface.

In peri-implantitis lesions, nonsurgical therapy was not found to be effective. Adjunctive CHX application had only limited effects on clinical and microbiological parameters. However, adjunctive local or systemic antibiotics were shown to reduce bleeding on probing and probing depths. Minor beneficial effects of laser therapy on peri-implantitis have been shown, and this approach needs to be further evaluated.[33]


   Revaluation Top


At the individual level, clinical peri-implant revaluation is necessary to appreciate clinical response to therapeutic intervention.

Pre- and postoperative plaque levels and the tendency for bleeding on probing should be noted in the revaluation.

Periodic maintenance:[34] [Table K][34]
Table J: Treatment outcome measure

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Treatment of peri-implant mucositis

  • Nonsurgical therapy:
    • Patient education and motivation.
    • Institution of home care plaque control measures (mechanical/chemical). Use of oral irrigation devices, dental floss, and interdental aids encouraged.
    • Management of risk factors for peri-implant diseases [Table D].[14]
    • Manual peri-implant scaling intruments e.g. plastic/Teflon-coated/titanium alloys curettes or power-driven peri-implant scaling instruments: e.g. plastic ultrasonic point.
    • Systemic antimicrobials.
    • Peri-implant local delivery of drugs using local antiseptic medication for implant debridement (0.2% or 0.12% CHX gluconate, 3-10% H2O2, sodium percarbonate, povidone-iodine) to support the antimicrobial therapy.
    • Occlusal therapy when indicated.
    • Revaluation.
    • Periodic maintenance.


Studies have attempted to evaluate the effect of nonsurgical therapy in peri-implant mucositis [Table 4].
Table E: Decontamination procedures[1]

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Conclusions from studies [Table 4][35],[36]

Mechanical nonsurgical therapy could be effective in the treatment of peri-implant mucositis lesions.

The adjunctive use of antimicrobial mouth rinses enhanced the outcome of mechanical therapy for peri-implant mucositis.[33]


   Surgical Therapy Top


Prior to surgical therapy, the acute and chronic inflammation must be resolved and proper oral hygiene should be instituted. Following surgical exposure of the contaminated implant surface, mechanical, chemical, or photodynamic measures and combinations of all three can be used to attempt to eliminate infection, resolve inflammation, and render the surface conducive to bone regeneration and reosseointegration.

Decontamination procedures

Decontamination is an extended process of scaling and appears to be analogous to root planing within periodontal treatment. The word decontamination refers to the removal of an infective agent from the affected surface, by gaining access to and visibility of the implant surface during surgical therapy. There is a possibility of this procedure being mistaken for the use of local and systemic antimicrobials during a nonsurgical procedure.

With reference to the treatment of implant diseases, decontamination includes both mechanical and chemical means, similar to root planing. Hence, the term “decontamination” needs to be replaced by the term “implant planing” as most of the terms have developed from periodontal treatment procedures.

Decontamination is performed during surgical therapy.

Various methods have been advocated with no definitive “gold standard,” e.g., air powder abrasion, saline wash, citric acid treatment, laser therapy, peroxide treatment, ultrasonic and manual debridement, andapplication of topical medication [Table E].[1]{Table 9}

Mechanical [1] (implantoplasty)

Objective

The mechanical removal of biofilm from the implant surface is considered a priority for the etiological treatment of peri-implantitis. Its objective is the elimination of toxins from the implant surface in order to produce a surface compatible with health, to promote reosseointegration [Figure 16].[37]
Figure 16: Straumann® TiBrush™ physical decontamination[37]

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Implantoplasty is the mechanical elimination of surface roughness together with the implant thread.

Advantage

Implantoplasty allows optimization of maintenance and facilitates oral hygiene in the patient when implant threads are exposed.

There have been a few studies showing the clinical and radiological long-term outcomes of implantoplasty [Table 5].[38],[39],[40]
Table 5: Clinical studies: Decontaminations procedures in treatment of peri-implant osteitis

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Sandblasting systems [1]

Sandblasting systems using different abrasive particles [specially processed sodium bicarbonate (SPSB)] have been used for the surgical treatment of peri-implantitis in animals and humans without producing adverse effects.

Air abrasion using SPBS is the method of choice for decontamination of implants.[41]

Objective

The use of this technique on smooth or roughened surfaces makes them less susceptible to bacterial adhesion, possibly because of the modification of the surface texture and because of the presence of abrasive deposits.

It is not recommended for the elimination of supramucosal calculus from titanium posts in supportive therapy.

Decontamination using laser [1] [Table 6][42],[43]
Table 6: Decontamination using lasers and PDT

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Principle

Decontamination via laser is based on its thermal effect, which denatures proteins and causes cellular necrosis.

The use of Er:YAG lasers has been widely studied in recent years and has been shown to be effective for biofilm removal, having bactericidal effects that do not damage implant surfaces. Er:YAG laser use in nonsurgical peri-implantitis treatments brings improvements to the clinical parameters.

Studies have attempted to evaluate the effect of laser and photodynamic therapy (PDT) in the treatment of peri-implantitis [Table 6][42],[43]

Conclusions from studies [1] [Table 6][42],[43]

Application of both CO2 and diode lasers with different wavelengths is effective for eliminating bacteria without producing alterations to the surfaces treated. Additionally, they do not cause significant rise in temperature that can be detected in the implant body.

Photodyanamic therapy [1] [Table 6][42],[43]

Photodyanamic therapy (PDT) is a technique that uses a photosensitizing substance, e.g., tricyclic dye, that fixes itself to the bacteria of the biofilm, and when irradiated with laser, cytotoxic singlet oxygen is produced that is able to destroy the bacterial cells.

PDT appears to be more efficient for eliminating bacteria from implant surfaces than laser irradiation alone [Table 6].[42],[43]

Chemical decontamination [1] [Table 5][38],[39],[40]

Chemical decontamination involves the localized use of antimicrobial solutions such as topical CHX, tetracycline or minocycline, citric acid, H2O2, or 35% phosphoric acid gel, in combination with mechanical debridement for eliminating hard and soft deposits.

Comparisons of the decontaminating efficacy of these chemical agents have been made mainly by means of in vitro studies on different types of implant surface.

Reviews made by various authors conclude that 40% citric acid with pH 1 for 30-60 s has proved the most effective agent for the reduction of bacterial growth on hydroxyapatite (HA) surfaces, although clinical application at a more acidic pH could affect the peri-implant tissues, and that if the time of application is prolonged this can affect the union between the HA and the implant body.

Studies have attempted to evaluate the effect of chemical decontamination in the treatment of peri-implantitis [Table 5][38],[39],[40]

Conclusions from studies from [Table 5][38],[39],[40]

CHX has been seen to be ineffective on HA surfaces.

Machined titanium decontaminates more effectively than other surface types, with topical applications of tetracycline as the antibiotic of choice.[1]

  • Steps for surgical technique:
    • Selection of surgical site.
    • Profound local anesthesia.
    • Intrasulcular incision preferred to conserve as much as tissue possible.
    • Full-thickeness mucoperiosteal flap raised to expose the implant surface and to visualize the underlying bony defect.
    • Implant surface decontamination using specialized instruments.
    • Resective or regenerative osseous surgery wherever indicated.
    • Suturing and postoperative care.


[TAG:2]Resective Osseous Surgery [Table 7][38],[44] [Figure 17]a, [Figure 17]b,[Figure 17]c[45][/TAG:2]
Table 7: Resective osseous surgery in treatment of peri-implant disease

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Similar to peridontitis, resective surgery in treatment of peri-implant infection has been to be effective in the reduction of clinical signs of inflammation, bleeding on probing, and probing depths. The basic principles include the elimination of the peri-implant osseous defect using ostectomy and osteoplasty, and bacterial decontamination. Additionally, smoothening and polishing of the supracrestal implant surface (implantoplasty) may be done.[2],[46],[47]{Table 7}
Figure 17: (a) preoperative radiograph[45] (b) mucoperiosteal flap reflection[45] (c) follow-up measurements[45]

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Indications

Reshaping of the bulbous alveolar bone margin which prevents recurrence of the pocket and helps in enhances flap adaptation:

  • Contraindications:
    • In anterior esthetic areas.
    • Deep osseous craters.
    • Three-wall osseous defects.
    • Moderate to deep circumferential defects.
  • Advantage:
    • Reduction of peri-implant pocket depth.


  • Disadvantages:


    • Mucosal recession.
    • Questionable reosseointegration.


Studies have attempted to evaluate the effectiveness of resective osseous surgery in the treatment of peri-implantitis [Table 7].[38],[44]

Conclusions from studies [Table 7][38],[44]

Resective surgical therapy for peri-implantitis is a recommendable therapy option. Ostectomy and osteoplasty combined with implantoplasty represent an effective therapy to reduce or even stop peri-implantitis progression.

Nevertheless, due to the increased postoperative recessions, this procedure is not suitable for every situation, especially in highly esthetically sensitive areas.[2]

[TAG:2]Regenerative Osseous Surgery [Table 8][48],[49][/TAG:2]
Table 8: Regenerative implant surgery with grafting materials and barrier membranes

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  • Indications:


    • Three-wall and two-wall defects.
    • Bony dehiscence.


  • Advantages:


    • Reosseointegration possible.


  • Disadvantage:


    • Mucosal recession


Guided bone regeneration

Based on Melcher's concept,[50] selective cell repopulation membranes, osseous grafts, and substitutes used for guided bone regeneration have been classified [Table F][51] and [Table G].[52]
Table F: Membranes used for guided bone regeneration[51]

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Resective surgical therapy may result in reosseointegration in only minor superficial defects. From the functional, esthetic, and long-time-survival points of view, full regeneration and reosseointegration should be achieved.[46],[47]

Various osseous grafts and their substitutes are used in isolation [Figure 18]a,[Figure 18]b,[Figure 18]c[53] or with membrane for guided bone regeneration [Figure 19]a,[Figure 19]b,[Figure 19]c,[Figure 19]d.[54]
Figure 18: (a) preoperative radiograph[53] (b) placement of bone graft material[53] (c) postoperative follow-up radiograph[53]

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Figure 19: (a) preoperative radiograph[54] (b) mucoperiosteal flap elevation, debridement, and placement of bone graft[54] (c) placement of barrier membrane[54] (d) bone fill seen on follow-up radiograph[54]

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Studies have attempted to evaluate the effectiveness of regenerative surgery in the treatment of peri-implantitis [Table 8][48],[49]

Conclusions from studies [Table 8][48],[49]

Regarding a “regenerative” approach, autologous, allogenic, and xenogenic bone replacement materials are often used for augmentation in bone defects used with or without collagen membrane.

Allogenic and xenogenic grafts may be almost equivalent to autogenous material.


   Peri-Implant Esthetic Surgeries Top


Peri-implant plastic surgery focuses on harmonizing peri-implant structures by means of hard tissue and soft tissue engineering, and includes:

  • Bone structure enhancement.
  • Soft tissue enhancement.
  • Precision in implant placement.
  • Quality of the prosthetic restoration.


Peri-implant plastic surgery is important for creating peri-implant keratinized mucosa and interimplant soft tissue height in order to avoid food impaction, interimplant airflow, and speech problems.[55]

Peri-implant plastic surgery includes:[55],[56]

  • Enhancement of keratinized width and thickness.
  • Treatment of mucosal recession.
  • Frenotomy/frenectomy.
  • Vestibuloplasty.
  • Ridge augmentation.


Indications of peri-implant esthetic surgery:[55],[56]

  • Implant soft tissue dehiscences.
  • Thin soft tissue around implant.
  • Minimal width of keratinized tissue.
  • Mucosal recession around implants.
  • Abnormal frenum attachment.
  • Shallow vestibule.
  • Vestibuloplasty.
  • Papillary deficiency around implant.


[TAG:2]Role of Keratinized Mucosa in Relation To implant [Figure 20][57][/TAG:2]

Both the width and the thickness of keratinized mucosa are important to maintain the health of the peri-implant mucosa.
Figure 20: absence of keratinized tissue around implant[57]

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The minimal zone of keratinized mucosa to maintain peri-implant soft tissue health is a topic of debate.

No scientific data have been provided to support that inadequate lack of keratinized mucosa is more prone/susceptible to plaque-induced destruction.

There is no evidence indicating that a specific zone of keratinized mucosa is needed to maintain mucosal health or to prevent peri-implantitis.[55],[56],[58]

Conclusions from studies [Table 9][59],[60]
Table 9: Role of keratinized mucosa around implant

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It has been argued that there is a need for an adequate zone of keratinized mucosa around the implant to prevent recession, to facilitate oral hygiene measures, and to prevent peri-implant mucositis and peri-implantitis.

Gingival thickness plays a vital role in the development of gingival recession around implants.

[TAG:2]Treatment of Peri-Implant Recession [56] [Figure 21]A,[Figure 21]B,[Figure 21]C[61][/TAG:2]

As with teeth, the occurrence of facial soft tissue dehiscence is a common finding following implant-supported restorations in patients with a high standard of oral hygiene, and it may be secondary to peri-implantitis.
Figure 21: (a) treatment of mucosal recession, preparation of recipient bed[61] (b) placement of free gingival graft[61] (c) follow-up[61]

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Peri-implant recession defects are subject to the same principles that apply to root coverage around natural teeth. However, peri-implant tissues differ from those around natural teeth in that peri-implant tissues have poorer blood supply due to the absence of the periodontal ligament.

Objective

The objective is complete resolution of the recession defect, with minimal probing depths after treatment, along with an esthetic outcome that shows complete blending of tissue color and texture of the treated area with the adjacent soft tissues.

Several factors have been described that negatively influence the stability of the peri-implant mucosa of the facial aspect, presented in [Table H].[56]
Table H: Factors that affect the influence the stability of the peri-implant mucosa of the facial aspect[56]

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Peri-implant soft tissue recession occurs, and the same surgical coverage technique proposed for recession around teeth may be indicated. Surgical procedures with different root coverage [Table I][56] have been described over the years with well-reported results in the literature, but soft tissue dehiscence coverage (STDC) around endosseous implants has been studied much less. Treatment of high frenum attachment and shallow vestibule secondary to mucosal recession may be taken into consideration.
Table I: Various root coverage procedures[56]

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Studies describing treatment of mucosal recession around implants have been described in [Table 10].[62],[63]
Table 10: Peri-implant esthetic surgeries

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Conclusions of studies on treatment of mucosal recession around implant [Table 10][62],[63]

It is well known that there is a difference in anatomy between teeth and implants: The absence of a supracrestal fiber insertion into the cementum and of a periodontal ligament, with its dense vascular network, characterizes the peri-implant mucosa.

All the available knowledge on this topic, including the approaches described in this paper, is based on very limited literature support and should therefore be addressed with caution. These concerns should encourage long-term good clinical trials for better assessment of the relevant issues.

Summary of peri-implant esthetic surgeries

Site-related factors such as the dimensions of the recession defect, the depth of the vestibulum, and the level of interdental or interimplant papilla should be considered.

Miller (1985)[64] classified oral mucosal recession by marginal soft tissue level and interproximal bone loss. Based on the literature, complete root coverage can be expected in classes 1 and 2.

However, there are no reports on the classification of soft tissue recession in dental implants. Soft tissue dehiscence of plural implants is more complicated and technically sensitive.

Therefore, site-related factors, surgical methods, and the patient's expectations should be taken into account.

Outcome measures [Table J][4],[65],[66]{Table 20}

Outcome measures are those measurements of clinical signs of inflammation that are assessed using indices at baseline and will be compared postoperatively to evaluate the treatment's effectiveness. They are as follows:

  1. Evaluation of oral hygiene standard (plaque assessment).
  2. Clinical signs of mucosal inflammation.
  3. Bleeding on probing.
  4. Suppuration.
  5. Mucosal marginal position.
  6. Peri-implant probing depth.
  7. Mobility.
  8. Peri-implant sulcus fluid analysis.
  9. Radiographic assessment.


[TAG:2]Prevention and Maintenance [34][/TAG:2]

A maintenance program should be undertaken after successful implant therapy.

Aims:

  • Should be tailored to the individual.
  • Should include regular recalls to enable optimal disease prevention.


Before a patient is enrolled in a maintenance program, one should ensure that baseline data have been established. Probing pocket depths and mucosal margin positions must be noted and radiographic crestal bone levels established.

The decision process for peri-implantitis maintenance and treatment should be a rational and evidence-based approach.

Maintenance visits protocol are provided [Table K][34] [Figure 22]a,[Figure 22]b,[Figure 22]c.[67]
Figure 22: (a) interdental oral hygiene aids for implants[67] (b) dental floss for implant[67] (c) flossing implant-supported prosthesis[67]

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Table K: Maintenance protocol[34]

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   Proposed Improvements by This Paper Top


The nomenclature “peri-implantitis” appears to be a misnomer: The addition of the suffix “itis” is used to signify inflammation of living tissues, e.g., mucos “itis”; the addition of “itis” to a nonliving implant remains highly questionable scientifically. The natural bone that integrates around the implant, peri-implant bone, is inflamed during the disease process. The obvious sign of osteitis is loss of bone appreciated radiographically. Hence, the term “peri-implant osteitis” is recommended instead of “peri-implantitis.


   Some Terminology Top


Early peri-implantitis has been defined as the presence of an inflammatory lesion of infective etiology when osseointegration is being established and the implant is mechanically stable.

Retrograde peri-implantitis [68] refers to the presence of a lesion at the apex of the implant. A condition known as retrograde peri-implantitis may also be associated with implant failure. Retrograde implant failure may be due to bone microfractures caused by premature implant loading or overloading, other trauma, or occlusal factors. Implant failures from retrograde peri-implantitis are characterized by periapical radiographic bone loss without, at least initially, gingival inflammation. The distinction between implant failure due to infection with periodontal pathogens (infective failure) and implant failure associated with retrograde peri-implantitis (traumatic failure) is also reflected in the microflora.

Other terms that appear in the literature with minimum explanation are:

  • Early peri-implantitis.
  • Chronic implantitis, the slowly progressive form of the disease.
  • Aggressive form of peri-implantitis, a rapidly progressive form of the disease.
  • Necrotizing form of peri-implantitis.
  • Early implantitis.
  • Retrograde implantitis.


There is a lack of consistency across definitions of peri-implantitis in the literature, and the diagnostic criteria are not clear. Most of the published strategies for peri-implantitis therapy are mainly based on treatments used for teeth with periodontitis. The differences between peri-implant tissue and periodontal tissue have been well discussed by Dhir et al.[69]


   Conclusion Top


There are many approaches suggested by various authors for the treatment of peri-implant diseases, but there is no “ideal peri-implant therapy” that has been described in the literature. There is no consensus regarding the treatment protocol as the studies conducted so far have had varying study designs, small sample sizes, and short follow-up periods. Therefore, prevention is the most important aspect, along with appropriate treatment planning, periodic check-ups, and management of risk factors. In nonsurgical therapy, combinations of mechanical cleaning with curettes and air polishing systems are recommendable. Adjuvant antiseptic rinses and local or systemic antimicrobials are effective for short-term eradication of bacteria; laser therapy and PDT are additional treatment options. However, results supporting the long-term benefits of these methods are missing. Surgical treatment of peri-implantitis seems feasible. More long-term studies in humans, involving sufficient numbers of subjects, are needed to provide a solid basis for recommendations regarding the surgical treatment of peri-implantitis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17], [Table 18], [Table 19], [Table 20], [Table 21]



 

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  In this article
    Abstract
   Introduction
   Treatment Strategies
   Emergency Therapy
   Nonsurgical Therapy
    Management of Ri...
    Peri-Implant Sca...
    Local and System...
   Revaluation
   Surgical Therapy
    Resective Osseou...
    Regenerative Oss...
    Peri-Implant Est...
    Role of Keratini...
    Treatment of Per...
    Prevention and M...
    Proposed Improve...
   Some Terminology
   Conclusion
    References
    Article Figures
    Article Tables

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