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Sep 27, 2023 // 16 min read

Non-surgical and Surgical Management of Peri-implantitis

Kristina Bertl

Andreas Stavropoulos

DOI: 10.3290/iti.fi.45715

diagnosis non-surgical treatment supportive peri-implant care surgical treatment peri-implantitis

Abstract

Prevention and treatment of peri-implantitis is challenging and there is no "gold standard" treatment that provides predictable positive results comparable to those after treatment of periodontitis. Thus, once peri-implantitis is diagnosed, it is recommended to follow a strict treatment concept, including: 1) reduction of local and systemic risk factors, 2) fast initiation of non-surgical treatment, 3) early evaluation of non-surgical treatment and, 4) if unsuccessful, fast transition to the surgical treatment phase, provided that the patient is compliant, 5) treatment should always be followed by stringent supportive peri-implant care with an individualized interval, and 6) if needed, correction of peri-implant soft tissue deficiencies should be considered. In the current article, this concept is presented along with several clinical examples, including an overview of current scientific knowledge.

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Introduction

Dental implants are an integral part of modern daily clinical practice and, as such, the prevalence of peri-implantitis has also increased dramatically. Prevention and treatment of peri-implantitis are challenging and there is no "gold standard" treatment that provides predictable positive results comparable to those after treatment of periodontitis. Prevalence rates of peri-implantitis vary greatly in the literature, depending on the population studied and the diagnostic criteria applied for case definition (i.e., pocket depth and bone loss thresholds), but approximately every fifth to fourth patient is affected by peri-implantitis (Derks & Tomasi 2015). This high prevalence rate, in combination with the fact that the number of implants placed is increasing annually (Klinge et al. 2018), means that the actual number of cases is very large and common. Recently, the European Federation of Periodontology (EFP) produced S3 level clinical practice guidelines for prevention and treatment of peri-implant diseases (Herrera et al. 2023), and these are discussed and summarized herein.

Fig. 1: Implant in position #43 diagnosed with peri-implantitis (a - d). Clinical signs of inflammation, deeper probing depths, and bleeding on probing are present (a - c); in addition, the radiograph shows bone loss exceeding what can be expected due to marginal bone remodeling (d)

Fig. 2: Although the primary treatment plan was to keep the implants in position #24 and #25 (a - b), it became obvious during surgery that explantation was a more favorable treatment option due to extensive peri-implant bone loss in combination with malpositioning of the implants (c - d)

Fig. 3: Full-arch restoration in the upper jaw with peri-implant mucositis at the implants on the right. The design of the prosthesis did not allow the patient to use an interdental brush (a). Modification of the prosthesis (b - c) enabled the patient to clean under the bridge and around the implants with greater ease (d)

Fig. 4: Patient case with peri-implantitis at the implants in position #25 and #26 (a - b) treated by a non-augmentative approach. A paramarginal incision palatally and a sulcular incision buccally were performed (c) and after flap elevation primarily horizontal bone loss with a minor bone peak between the implants was recognized (d). Implantoplasty and bone re-contouring were performed (e), the palatal flap was thinned and both the buccal and the palatal flaps were apically positioned and sutured (f). The procedure resulted in a stable post-operative result (g - i), although the patient refused an additional surgery to increase the width of keratinized, attached peri-implant mucosa (g)

Fig. 6: Patient case with peri-implantitis at the implants in position #14 and #15 (a - b) treated by a combined approach. After flap elevation a class Ic defect was recognized at both implants (c) and implantoplasty was performed at the buccal bone dehiscences (d). The vertical components were grafted with autologous bone (e) and the defects covered with a resorbable membrane (f - g). The procedure resulted in a stable post-operative result (h) with a significant improvement in the crestal peri-implant bone level especially at the implant in position #15 (i)

Fig. 7: Patient case presented in Fig. 5 showing the need for oral hygiene instructions prior to any treatment (a - c) as well as the need to adapt oral hygiene measures after surgical treatment, i.e., a significantly larger interdental brush was required post-operatively (d)

Fig. 8: Patient case with peri-implantitis at the implant in position #15 (most likely initiated by a cement remnant at the distal aspect) and peri-implant mucositis at the implant in position #16 (a - b) treated by a non-augmentative approach combined with a free gingival graft due to the lack of keratinized, attached peri-implant mucosa especially at the implant in position #15 (c). Minor flap elevation allowing access for surface decontamination (d) was combined with an apically positioned flap (e) and placement of a free gingival graft (f - g). The procedure resulted in a stable post-operative result with a significant increase in the width of keratinized, attached peri-implant mucosa (h - i)

Fig. 9: Patient case with peri-implantitis at the implant in position #45 (a) successfully treated with a reconstructive approach (b), but remaining bleeding on probing at the buccal aspect with a minor amount of keratinized, attached peri-implant mucosa (c). An apically positioned flap (d) and placement of a free gingival graft was performed (e-f); at suture removal a well-integrated soft tissue graft was observed (g). The procedure resulted in a stable post-operative result with a significant increase in the width of keratinized, attached peri-implant mucosa (h - i)