Surgical treatment of peri-implantitis

Abstract

As utilisation of dental implants continues to rise, so does the incidence of biological complications. When peri-implantitis has already caused extensive bone resorption, the dentist faces the dilemma of which therapy is the most appropriate to maintain the implant. Since non-surgical approaches of peri-implantitis have shown limited effectiveness, the present paper describes different surgical treatment modalities, underlining their indications and limitations. The primary goal in the management of peri-implantitis is to decontaminate the surface of the infected implant and to eliminate deep peri-implant pockets. For this purpose, access flap debridement, with or without resective procedures, has shown to be effective in a large number of cases. These surgical treatments, however, may be linked to post-operative recession of the mucosal margin. In addition to disease resolution, reconstructive approaches also seek to regenerate the bone defect and to achieve re-osseointegration.

Fig. 1

Reconstructive treatment of peri-implantitis: diagnosis. a) Radiograph taken in September 2010, three years after delivery of the prosthesis, reveals optimal peri-implant bone levels. b) Radiograph taken in December 2014 depicts advanced marginal bone loss at implant 4.6. c) Bleeding on gentle probing and/or suppuration are the main clinical characteristics of mucositis and peri-implantitis. d) Peri-implantitis sites exhibit clinical signs of inflammation, increased probing depths, in addition to radiographic bone loss compared to previous examinations. There is some evidence linking peri-implantitis to the lack of keratinised mucosa

Fig. 2

Reconstructive treatment. a) A linear crestal incision was performed leaving the mesial papilla into place in order to facilitate the stabilisation of the flap over the grafted defect. b) The exposed implant surface was thoroughly cleaned using an ultrasonic device with a Teflon-coated tip, under continuous saline irrigation. c) After the removal of granulation tissue the implant surface is decontaminated with ethylenediaminetetraacetic acid (EDTA) 24% and chlorhexidine 1% gel. d) Deproteinised bovine bone mineral with 10% collagen is applied in the infrabony defect. e) A connective tissue graft is taken from the maxillary tuberosity and U-shaped. f) The connective tissue graft is adapted around the collar of the implant and over the entire defect to ensure stability of the graft. g) 4/0 Vycril suture of the flap ensures an optimal not-submerged healing. h) Optimal one-year healing. No signs of inflammation. A keratinised tissue band is now visible around the implant

Fig. 3

Follow-up (supportive periodontal care). a) Radiograph taken in May 2019 reveals complete bone fill of the defect. b) After the surgical treatment, the patient was asked to follow an individualised supportive care program including oral hygiene measures, biofilm removal and monitoring risk indicators. c) Clinical picture in November 2021 demonstrates healthy peri-implant tissues. The probing reveals shallow pocket and the absence of bleeding. d) Radiograph taken in March 2023, 16 years after implant placement, shows optimal interproximal bone levels

Fig. 4

Access flap debridement. a) Radiograph taken one year after delivery of the prosthesis reveals optimal peri-implant bone levels. b) Bleeding on gentle probing and pocket depth of 6 mm, five years after implant placement. c) Radiograph taken in December 2014 depicts marginal bone loss at implant 4.4. d) The elevation of a full thickness flap revealed the bone loss at the level of the second thread. Due to the thin bone crest with no infrabony component, a reconstructive approach was not selected, but an open flap debridement was preferred

Fig. 5

a) After the removal of granulation tissue, the implant surface was decontaminated with EDTA 24% for two minutes. b) After saline irrigation, chlorhexidine 1% gel was applied for two minutes. c) 4/0 Vycril suture of the flap ensures an optimal not-submerged healing. d) Healing proceed with no complications

Fig. 6

a) Radiograph taken in September 2020, ten years after implant placement, shows stable bone defect. b) Clinical picture in September 2020 shows peri-implant soft tissues free from inflammation. c) Radiograph taken in January 2024 confirm the absence of additional bone loss distally, and minimal improvement on the mesial aspect. d) Clinical picture in January 2024 demonstrates a minimal soft tissue recession, 14 years after placement. The probing reveals stable, even if not ideal, pocket depth