A conceptual review on reconstructive peri-implantitis therapy: Challenges and opportunities

Abstract

Objectives: The current strategies to reconstruct lost peri-implant tissues due to the disease have been largely unpredictable. The aim of this conceptual review is to discuss relevant biological and biomechanical challenges of applying reconstructive means to treat peri-implantitis. Additionally, opportunities to improve treatment predictability are presented.

Material and methods: A narrative review was conducted to fulfill the aim.

Results: The four interrelated negative conditions hampering effective reconstruction are: inferior tissue perfusion, unfavorable bone topography, ineffective surface treatment, and unstable wound. First, peri-implant tissues resemble scars with reduced cellularity and vascularity, coupled with the absence of the periodontal ligament plexuses and the avascular implant and biomaterials, maintaining primary closure is a challenge, which is critical for regeneration. Second, defect morphology and bone topography surrounding implants determine the reconstructive potential. Unfortunately, noncontained defects are frequently encountered, with a combination of suprabony (horizontal bone loss) and infrabony (vertical usually involving circumferential bone loss) defects. Third, current attempts for implant surface decontamination are insufficient due to inaccessible macrostructure and rough surfaces in the micro-scale. Histologic evaluation has shown bacteria aggregation and calcified deposits around implants. Lastly, wound stability is difficult to achieve due to inherent soft tissue biomechanical quality and quantity deficiencies and mobile bone particulates. Opportunities to tackle the abovementioned challenges include the use of novel imaging technologies, such as high-frequency dental ultrasound and laser speckle imaging to evaluate tissue perfusion, soft tissue quality/quantity, and bone topography pre-surgically. The use of the operating microscope could allow better visualization and removal of etiologic factors. Strategies to improve soft tissue quality may include preoperative control of soft tissue inflammation and the potential use of biologics. Methods such as fixation to stabilize the biomaterials could be beneficial.

Conclusions: A more nuanced understanding of the current challenges and opportunities can lead to more effective preoperative and postoperative care protocols, ultimately improving the success rate of reconstructive procedures.

Keywords: microsurgery; peri-implantitis; ultrasonography; wound healing.

Figure 1

Tissue perfusion in the peri‐implant tissues. Arterioles have an apico‐coronal direction and they can be intraosseous, supraperiosteal, and in the peri‐implant soft tissue. The vessel dimension and density decrease when they pass to the mucogingival junction. They have a parallel orientation with the implant. Only small anastomoses of the arterioles reach the mucosal margin and the peri‐implant crestal bone.

Figure 2

Bony topography surrounding infected implants. The left image shows a vertical defect with an infrabony component and a small suprabony component (a cyan arrow shows the space between the implant platform and the bone crest). The right image shows a horizontal defect without an infrabony component (a cyan arrow shows the suprabony defect above the bone crest).

Figure 3

Clinical situation of a peri‐implant defect after degranulation and cleaning (left), along with a biopsy fragment overview and histology (middle). The right image focuses on a detailed view of foreign material using light‐optical birefringence.

Figure 4

Histologic image capturing an excised sample from another case, revealing the presence of bone fragments (dark staining).

Figure 5

Histological example demonstrating the accumulation and aggregation of bacteria resembling actinomycosis.

Figure 6

Preoperative ultrasound image (Right) before crown removal that can be used for treatment planning regarding the defect type, amount of facial bone loss, and soft tissue quality. In this case, a relative horizonal facial defect (H‐defect) was found, with exposed implant threads (Exp‐threads), peri‐implant lesion (PI‐lesion) and thick peri‐implant tissue (PI‐ST). The image was confirmed during open surgery (Left).

Figure 7

Preoperative ultrasound image (Right) before crown removal that can be used for surgical planning. Facial bone has a small infrabony component, more amenable for regeneration. Clinical intra‐surgical photo confirmed the vertical defect on the buccal wall (Left). Exp‐threads, Exposed implant threads; PI‐lesion, peri‐implant lesion; PI‐soft tissue, peri‐implant soft tissue.