Esthetic and biological complications frequently lead to an unfavorable prognosis for dental implants. Often, these cannot be managed predictably to improve the condition or satisfy a patient’s demands. In such circumstances, implant removal needs to be considered. Minimally invasive methods based on reverse torque engineering are key to preserving peri-implant soft and hard tissues when compared to traditional methods such as burs or trephines. In a scenario where future implant placement is desired, simultaneous reconstructive approaches should be based upon defect morphology as well as soft and hard tissue characteristics. This article aims to review the strategies for implant removal and management of the residual alveolar bone defect.
Abstract
Introduction
Advances in material sciences contributed to the development of modified implant surfaces aimed at securing more rapid osseointegration with the goal of shortening treatment times and improving patient-reported outcomes. Overall, long-term cumulative survival rates between 85.5-100% have been reported (Jung et al. 2012). Similar outcomes have been reported in more complex scenarios such as immediate/early implant placement simultaneously with reconstructive interventions (Blanco et al. 2019; Chrcanovic et al. 2015; Graziani et al. 2019). However, implant survival alone is no longer regarded as an appropriate outcome measure; rather, a lack of technical/biological complications and patient satisfaction (including esthetic outcomes) have emerged as the outcomes of choice.
Peri-implantitis is regarded as a chronic inflammatory condition induced by bacterial biofilm in susceptible hosts (Schwarz et al. 2018). The definition is based on composite criteria including radiographic and clinical features such as progressive bone loss, increased probing pocket depth, erythema, tumor and profuse bleeding on gentle probing with or without suppuration (Renvert et al. 2018). It has been demonstrated that peri-implantitis progresses in an accelerating and non-linear manner (Derks et al. 2016) resulting in moderate severity (~50%) (Monje et al. 2019), with buccal plate bone loss being more pronounced than lingual plate bone loss (class IB) (Monje et al. 2019). These data reflect the complexity of the management of peri-implantitis and an unfavorable prognosis for dental implants under such conditions. Peri-implantitis is the leading cause of implant removal (Figs 1 – 2) (Gargallo-Albiol 2021).
Fig. 1: Implant removed from an advanced peri-implant infection site. Note granulation tissue attached to the contaminated implant surface and scanning electron microscopy (SEM) with debris and calculus attached
Fig. 2: Peri-implantitis sites exhibiting spontaneous suppuration are often associated with advanced bone loss defects
Satisfying esthetics in implant dentistry requires the reconstruction to reflect the natural appearance of the lost dentition and the adjacent soft tissues in a harmonious manner (Wittneben et al. 2018). Implant prosthetics are mainly dictated by implant positioning. In other words, implants positioned wrongly due to inadequate communication between the surgeon and the prosthodontist are more likely to result in esthetic failure. Despite advances in the esthetics of pink porcelain, certain situations are not manageable esthetically without implant removal even in situations where the implants are free of biological complications.